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Acute Ischemic Stroke: Current Status and Future Challenges
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Acute Ischemic Stroke: Current Status and Future Challenges

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Clinical Neurology".

Deadline for manuscript submissions: 28 February 2025 | Viewed by 6561

Special Issue Editor

Dr. Lucio D'Anna

E-Mail Website
Guest Editor
1. Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London W6 8RF, UK
2. Department of Brain Sciences, Imperial College London, London SW7 2AZ, UK
Interests: stroke; cryptogenetic stroke; atrial fibrillation

Special Issue Information

Dear Colleagues,

Stroke is a leading cause of mortality and the primary cause of disability worldwide, with ischemic stroke accounting for approximately 70% of all cases globally. Acute stroke treatment has enjoyed two major successes over the past 30 years, both involving the early reperfusion of the ischemic brain. Both thrombolytic drug treatment and endovascular thrombectomy, after some initial stutters, hit upon successful strategies for patient selection and trial design that yielded a large treatment effect when compared with that of control groups. Recent advancements in brain imaging techniques have significantly expanded the treatment window for reperfusion therapies in carefully selected patients, resulting in improved functional outcomes in the short and long term. Despite significant advancements, several controversies persist in the field of ischemic stroke management. These controversies encompass various topics, including determining the actual effectiveness of endovascular thrombectomy in patients with large ischemic core, distal vessel occlusion, mild stroke syndromes, or high baseline disability. Additionally, the safety of intravenous thrombolysis was determined in patients with a recent ingestion of direct oral anticoagulants. Moreover, these controversies include various topics, including the determination of the optimal secondary prevention strategies. By examining the latest evidence in ischemic stroke management, this Special Issue aims to explore recent advancements, challenges, and ongoing debates throughout the entire spectrum of ischemic stroke management, including prevention strategies, diagnostic techniques, and acute treatment approaches. The studies included in this Special Issue will endeavor to contribute to the ongoing efforts for enhancing the clinical practice, improving patient outcomes, and guiding the future direction of stroke care.

This Special Issue welcomes original research articles and reviews.

Dr. Lucio D'Anna
Guest Editor

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Keywords

  • acute ischemic stroke
  • atrial fibrillation
  • endovascular thrombectomy
  • intravenous thrombolysis
  • direct oral anticoagulants

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Published Papers (5 papers)

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Research

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12 pages, 475 KiB  
Article
The Usefulness of Outpatient Cardiac Telemetry in Patients with Cryptogenic Stroke
by Anetta Lasek-Bal, Adam Konka, Przemysław Puz, Joanna Boidol, Katarzyna Kosarz-Lanczek, Agnieszka Puz, Anna Wagner-Kusz, Andrzej Tomasik and Sebastian Student
J. Clin. Med. 2024, 13(13), 3819; https://doi.org/10.3390/jcm13133819 - 28 Jun 2024
Viewed by 1047
Abstract
Introduction: Atrial fibrillation (AF), apart from non-stenotic supracardiac atherosclerosis and neoplastic disease, is the leading cause of cryptogenic stroke, including embolic stroke of un-determined source (ESUS). The aim of our study was to determine the prevalence of AF in ESUS patients based [...] Read more.
Introduction: Atrial fibrillation (AF), apart from non-stenotic supracardiac atherosclerosis and neoplastic disease, is the leading cause of cryptogenic stroke, including embolic stroke of un-determined source (ESUS). The aim of our study was to determine the prevalence of AF in ESUS patients based on 30-day telemetric heart rate monitoring initiated within three months after stroke onset. Another aim was to identify factors that increase the likelihood of detecting subsequent AF among ESUS patients. Material and Methods: patients with first-ever stroke classified as per the ESUS definition were eligible for this study. All patients underwent outpatient 30-day telemetric heart rate monitoring. Results: In the period between 2020 and 2022, 145 patients were included. The mean age of all qualified patients was 54; 40% of eligible patients were female. Six patients (4.14%), mostly male patients (4 vs. 2), were diagnosed with AF within the study period. In each case, the diagnosis related to a patient whose stroke occurred in the course of large vessel occlusion. Episodes of AF were detected between day 1 and 25 after starting ECG monitoring. Out of the analyzed parameters that increase the probability of, A.F.; only supraventricular extrasystoles proved to be an independent factor regarding an increased risk of AF [OR 1.046, CI 95% 1.016–1.071, p-value < 0.01]. Conclusions: The use of telemetry heart rhythm monitoring in an outpatient setting can detect AF in 4% of ESUS patients who have undergone prior diagnostic procedures for cardiogenic embolism. Supraventricular extrasystoles significantly increases the likelihood of AF detection in patients with ESUS within three months following stroke. Comorbid coronary artery disease, diabetes and hypertension, rather than a single-factor clinical burden, increase the likelihood of AF detection in older ESUS patients. ESUS in the course of large vessel occlusion is probably associated with an increased likelihood of cardiogenic embolism. Full article
(This article belongs to the Special Issue Acute Ischemic Stroke: Current Status and Future Challenges)
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10 pages, 391 KiB  
Article
Age and Stroke Severity Matter Most for Clinical Outcome in Acute Arteriosclerotic Tandem Lesions
by Cyrill Huber, Jatta Berberat, Renske Sassenburg, Stefanie Pflugi, Javier Anon, Michael Diepers, Lukas Andereggen, Timo Kahles, Andreas R. Luft, Krassen Nedeltchev, Luca Remonda and Philipp Gruber
J. Clin. Med. 2024, 13(8), 2315; https://doi.org/10.3390/jcm13082315 - 17 Apr 2024
Viewed by 966
Abstract
Background: Tandem lesions (TLs) cause up to 15–30% of all acute ischemic strokes (AISs). Endovascular treatment (EVT) is regarded as the first-line treatment; however, uncertainties remain with respect to the treatment and predictive outcome parameters. Here, we aimed to identify the clinical [...] Read more.
Background: Tandem lesions (TLs) cause up to 15–30% of all acute ischemic strokes (AISs). Endovascular treatment (EVT) is regarded as the first-line treatment; however, uncertainties remain with respect to the treatment and predictive outcome parameters. Here, we aimed to identify the clinical and demographic factors associated with functional short- and long-term outcomes in AIS patients with arteriosclerotic TLs undergoing EVT. Methods: This was a retrospective, mono-centric cohort study of 116 consecutive AIS patients with arteriosclerotic TLs who were endovascularly treated at a stroke center, with analysis of the relevant demographic, procedural, and imaging data. Results: A total of 116 patients were included in this study, with a median age of 72 years (IQR 63–80), 31% of whom were female (n = 36). The median NIHSS on admission was 14 (IQR 7–19), with a median ASPECT score of 9 (IQR 8–10) and median NASCET score of 99% (IQR 88–100%). A total of 52% of the patients received intravenous thrombolysis. In 77% (n = 89) of the patients, an antegrade EVT approach was used, with a good recanalization (mTICI2b3) achieved in 83% of patients (n = 96). Symptomatic intracerebral hemorrhage occurred in 12.7% (n = 15) of patients. A favorable outcome (mRS0–2) and mortality at 3 months were obtained for 40% (n = 47) and 28% of patients (n = 32), respectively. Age and NIHSS on admission were strongly associated with outcome parameters. Diabetes mellitus and previous neurological disorders were independently associated with long-term mortality (median 11 months, IQR 0–42). Conclusions: Younger age, lower stroke severity, and good recanalization were found to be independently associated with a favorable outcome. In contrast, older age, higher stroke severity, previous neurological disorders, and diabetes were correlated with mortality. The endovascular treatment of acute arteriosclerotic tandem lesions is feasible and relatively safe. Full article
(This article belongs to the Special Issue Acute Ischemic Stroke: Current Status and Future Challenges)
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Review

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24 pages, 21479 KiB  
Review
Advancements in 3D Transoesophageal Echocardiography (TOE) and Computed Tomography (CT) for Stroke Prevention in Left Atrial Appendage Occlusion Interventions
by Reza Hajhosseiny, Ben Ariff, Graham Cole, Michael Koa-Wing, Punam Pabari, Nilesh Sutaria, Norman Qureshi, Prapa Kanagaratnam and Bushra Rana
J. Clin. Med. 2024, 13(22), 6899; https://doi.org/10.3390/jcm13226899 - 16 Nov 2024
Viewed by 440
Abstract
Left atrial appendage occlusion (LAAO) has emerged as a highly effective alternative to oral anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation. Precise pre-procedural planning and meticulous post-procedural follow-up are essential for achieving successful LAAO outcomes. This review explores the latest [...] Read more.
Left atrial appendage occlusion (LAAO) has emerged as a highly effective alternative to oral anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation. Precise pre-procedural planning and meticulous post-procedural follow-up are essential for achieving successful LAAO outcomes. This review explores the latest advancements in three-dimensional (3D) transoesophageal echocardiography (TOE) and computed tomography (CT) imaging modalities, which have considerably improved the planning, intra-procedural guidance, and follow-up processes for LAAO interventions. Innovations in 3D TOE and CT imaging have transformed the approach to LAAO by providing a more detailed and accurate assessment of the left atrial appendage, enabling clinicians to acquire comprehensive anatomical and morphological information, crucial for optimising device selection and positioning, thus reducing the risk of complications and enhancing the overall safety and efficacy of the procedure. Post-procedurally, CT and TOE imaging are invaluable in the monitoring of patients, ensuring that the device is correctly positioned and functioning as intended. Early detection of any complications (e.g., device-related thrombus and peri-device leaks) can help to risk-stratify patient at increased risk of stroke and initiate timely interventions, thereby improving long-term outcomes for patients. Full article
(This article belongs to the Special Issue Acute Ischemic Stroke: Current Status and Future Challenges)
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14 pages, 285 KiB  
Review
Endovascular Treatment for Basilar Artery Occlusion
by Devansh Gupta, Lucio D’Anna, Piers Klein, Robert Araujo-Contreras, Artem Kaliaev, Mohamad Abdalkader, Wei Hu and Thanh N. Nguyen
J. Clin. Med. 2024, 13(14), 4153; https://doi.org/10.3390/jcm13144153 - 16 Jul 2024
Viewed by 1978
Abstract
Basilar artery occlusion (BAO) is a neurological emergency associated with a high risk for adverse outcomes. This review provides evidence on the therapeutic efficacy of intravenous thrombolysis (IVT) and endovascular therapy (EVT) in the treatment of BAO. Historically considered the primary intervention for [...] Read more.
Basilar artery occlusion (BAO) is a neurological emergency associated with a high risk for adverse outcomes. This review provides evidence on the therapeutic efficacy of intravenous thrombolysis (IVT) and endovascular therapy (EVT) in the treatment of BAO. Historically considered the primary intervention for acute ischemic stroke, IVT has been progressively combined with EVT, which has emerged from recent studies demonstrating clinical benefits, notably in patients presenting with severe stroke. Several randomised controlled trials have shown that EVT improves patient outcomes in select clinical contexts. Future research directions could address therapeutic treatment thresholds, combination strategies, and long-term outcomes. Full article
(This article belongs to the Special Issue Acute Ischemic Stroke: Current Status and Future Challenges)

Other

Jump to: Research, Review

9 pages, 1069 KiB  
Systematic Review
Mechanical Thrombectomy in Ischemic Stroke with a Large Infarct Core: A Meta-Analysis of Randomized Controlled Trials
by Michele Romoli, Lucia Princiotta Cariddi, Marco Longoni, Gianluca Stufano, Sebastiano Giacomozzi, Luca Pompei, Francesco Diana, Lucio D’Anna, Simona Sacco and Simone Vidale
J. Clin. Med. 2024, 13(15), 4280; https://doi.org/10.3390/jcm13154280 - 23 Jul 2024
Cited by 1 | Viewed by 1194
Abstract
Background/Objectives: Endovascular treatment (EVT) is recommended for acute ischemic stroke due to large-vessel occlusion (LVO) and an Alberta Stroke Program Early CT Score (ASPECTS) ≥ 6. Randomized controlled trials (RCTs) have recently become available on EVT effects in people with LVO-related large core [...] Read more.
Background/Objectives: Endovascular treatment (EVT) is recommended for acute ischemic stroke due to large-vessel occlusion (LVO) and an Alberta Stroke Program Early CT Score (ASPECTS) ≥ 6. Randomized controlled trials (RCTs) have recently become available on EVT effects in people with LVO-related large core stroke (ASPECTS 0–5). Here, we provide an updated meta-analysis of the EVT effect on functional neurological status in people with large-core stroke. Methods: The study followed the PRISMA guidelines. PubMed, EMBASE and Cochrane Central were searched for RCTs comparing EVT vs. best medical treatment (BMT) in large-core LVO stroke. The primary outcome was functional independence at 90 days (modified Rankin Scale; mRS 0–2). The secondary outcomes were symptomatic intracranial hemorrhage (sICH), good functional outcome (mRS 0–3) and excellent functional outcome (mRS 0–1). EVT vs. BMT was compared through random effect meta-analysis. Heterogeneity was assessed with the I2 and Q test and risk of bias reported according to the RoB2 tool. Results: Six RCTs were included (n = 1656 patients). All studies had a moderate risk of bias, with blinding bias due to the nature of the intervention, potential allocation bias and incomplete outcome reporting. Functional independence was significantly more frequent in the EVT vs. BMT group (OR = 2.47, 95% CI = 1.52–4.03, p < 0.001). sICH rates (OR = 1.77, 95% CI = 1.01–3.11, p = 0.04) and good functional outcome (OR = 2.20; 95% CI = 1.72–2.81, p < 0.001) were more frequent in the EVT vs. BMT group, while the rates of mRS 0–1 did not differ. Conclusions: In patients with large-core stroke and LVO, EVT plus BMT as compared to BMT alone carries a significant increase in independent ambulation and good functional outcome at 3 months despite the marginal increase in sICH. Full article
(This article belongs to the Special Issue Acute Ischemic Stroke: Current Status and Future Challenges)
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