Search Results (383)

Background/Objectives: Parent artery disease (PAD) is a significant yet often overlooked contributor to ischemic strokes, particularly affecting the perforating arteries. This study aims to evaluate the impact of PAD on endovascular treatment outcomes in patients with intracranial atherosclerosis. Methods: A narrative review was conducted, synthesizing the existing literature on PAD and its relationship with endovascular interventions. Key studies were analyzed to assess the effectiveness of imaging techniques like high-resolution Magnetic Resonance Imaging (MRI) and the implications of plaque morphology on treatment strategies. Results: The findings indicate that PAD significantly complicates endovascular procedures, often leading to perforating artery occlusions and increased rates of stroke recurrence. Patients with PAD-related strokes demonstrated larger lesion volumes and more severe neurological deficits compared to those with small vessel disease. The review highlights the challenges of accurately diagnosing PAD using conventional imaging techniques, emphasizing the need for advanced modalities to identify atheromatous plaques that may not cause significant stenosis. Conclusions: The study underscores the necessity for a shift in clinical practice towards recognizing and managing PAD in patients with ischemic strokes. Enhanced imaging techniques and tailored endovascular strategies are essential to improve patient outcomes and minimize the risk of recurrent strokes. Further research is needed to establish comprehensive guidelines for addressing PAD in acute stroke management. Full article

Objectives: Although sex differences have been emphasized in stroke and congenital heart disease, there has been limited investigation into their role in patent foramen ovale (PFO) closure for secondary prevention of stroke. We aimed to explore differences by sex in baseline profiles, procedural characteristics, and short-term outcomes of patients undergoing transcatheter PFO closure. Methods: A retrospective analysis was conducted on 458 consecutive patients (265 women and 193 men) treated with PFO closure at Centro Cardiologico Monzino in Milan between 2006 and 2011. Baseline information included demographic characteristics, medical history, diagnostic and procedural information, and periprocedural complications. Post-closure outcomes were assessed at index hospitalization and during the first follow-up. Results: The indications for PFO closure were as follows: cryptogenic stroke/TIA in 78% of women vs. 88% of men (p = 0.04). Positive thrombophilic screening was observed in 16% of women vs. 19% of men (non-significant). We observed age-matched (mean age 44 ± 12 years) patients without sex-related differences in baseline and procedural characteristics, with the exception of greater arterial hypertension in women. The mean follow-up time was 13 years for both groups. Recurrent stroke was observed in 0.1% and TIA observed in 0.4% of the ‘cryptogenic stroke/TIA’ group; in the ‘other indications’ group, 1.4% experienced stroke and no TIA was reported. No significant differences were present between sexes. Conclusions: There were no differences in procedural and short-term outcomes between males and females undergoing transcatheter PFO closure, but significant baseline differences in risk factors were identified. There is a critical need for long-term, systematic studies to understand sex and gender differences in the PFO population. Full article

Atrial fibrillation (AF) is the most common sustained heart rhythm disorder. It is estimated that AF affects over 52 million people worldwide, with its prevalence expected to double in the next four decades. AF significantly increases the risk of stroke and heart failure, contributing to 340,000 excess deaths annually. Beyond these life-threatening complications, AF results in limitations in physical, emotional, and social well-being causing significant reductions in quality of life and resulting in 8.4 million disability-adjusted life-years per year, highlighting the wide-ranging impact of AF on public health. Moreover, AF is increasingly recognized for its association with cognitive decline and dementia. AF is a chronic and progressive disease characterized by rapid and erratic electrical activity in the atria, often in association with structural changes in the heart tissue. AF is often initiated by triggered activity, often from ectopic foci in the pulmonary veins. These triggered impulses may initiate AF via: (1) sustained rapid firing with secondary disorganization into fibrillatory waves, or (2) by triggering micro re-entrant circuits around the pulmonary venous-LA junction and within the atrial body. In each instance, AF perpetuation necessitates the presence of a vulnerable atrial substrate, which perpetuates and stabilizes re-entrant circuits through a combination of slowed and heterogeneous conduction, as well as functional conduction abnormalities (e.g., fibrosis disrupting tissue integrity, and abnormalities in the intercalated disks disrupting effective cell-to-cell coupling). The re-entry wavelength, determined by conduction velocity and refractory period, is shortened by slowed conduction, favoring AF maintenance. One major factor contributing to these changes is the disruption of the extracellular matrix (ECM), which is induced by atrial fibrosis. Fibrosis-driven disruption of the ECM, especially in the heart and blood vessels, is commonly caused by conditions such as aging, hypertension, diabetes, smoking, and chronic inflammatory or autoimmune diseases. These factors lead to excessive collagen and protein deposition by activated fibroblasts (i.e., myofibroblasts), resulting in increased tissue stiffness, maladaptive remodeling, and impaired organ function. Fibrosis typically occurs when cardiac fibroblasts are activated to myofibroblasts, resulting in the deposition of excessive collagen and other proteins. This change in ECM interferes with the normal electrical function of the heart by creating irregular, fibrotic regions. AF and atrial fibrosis have a reciprocal relationship: AF promotes fibrosis through fibroblast activation and extracellular matrix buildup, while atrial fibrosis can sustain and perpetuate AF, contributing to higher rates of AF recurrence after treatments such as catheter ablation or cardioversion. Full article

Background: Sex-based disparities in the presentation, management, and outcomes of infective endocarditis (IE) remain insufficiently characterized despite their growing recognition. This study systematically evaluates current evidence on sex differences in the presentation, treatment, and outcomes of IE. Methods: A systematic review and meta-analysis were conducted according to PRISMA and Cochrane guidelines. EMBASE, MEDLINE, PubMed, the Cochrane Library, and Google Scholar were searched up to October 2024. Twenty-four studies including 139,952 patients (79,698 men and 60,254 women) were analyzed. Primary outcomes were mortality (in-hospital, 30-day, and 1-year), stroke, and treatment modality (medical vs. surgical). Secondary outcomes included complications, procedural characteristics, and hospital course. Results: Men were younger at diagnosis and had higher rates of substance abuse and coronary artery disease, while women more often had hypertension, diabetes, chronic lung disease, and prior valvular pathology. Men more frequently had aortic and prosthetic valve IE, whereas women had mitral and tricuspid involvement. Men were about 65% more likely to undergo surgery for infective endocarditis than women, while women were predominantly managed medically. Men had lower in-hospital (OR 0.81, 95% CI 0.72–0.92) and 1-year mortality (OR 0.76, 95% CI 0.61–0.94), though 30-day mortality did not differ significantly. Women experienced shorter hospital stays but longer ICU admissions and more heart failure, whereas men had more recurrent IE. Conclusions: Men underwent surgery more often and had better short- and long-term survival. Women presented later, with greater comorbidity and higher complication rates. Enhanced recognition of sex-specific risk and equitable surgical referral may improve IE outcomes. Full article

Background/Objectives: After the negative results of the SAMMPRIS trial, the indication for endovascular treatment of atherosclerotic intracranial artery stenosis (ICAS) was widely restricted. It was the aim of our study to report whether intracranial arterial percutaneous transluminal angioplasty and stenting (PTAS) as ultima ratio therapy is still effective and safe enough. Methods: Between February 2011 and June 2019, 63 consecutive patients with and without emergent large vessel occlusion (ELVO) who received PTAS for symptomatic ICAS in the anterior or vertebrobasilar circulation were included in our study. Results: A total of 32 patients had ELVO. In the remaining 31 patients, a known ICAS was treated with PTAS either because of recurrent stroke despite aggressive medical therapy with dual antiplatelet inhibition (n = 24) or due to progressive hemodynamic ischemia (n = 7). Stenting was successful in all 63 cases. Successful reperfusion was achieved in 94% of ELVO patients. Complications with new neurologic deficits, including dissection, subarachnoid hemorrhage, intracerebral hemorrhage (PH2), and stent thrombosis, were seen in five ELVO patients (16%). At discharge, neurological status improved in 16 patients (50%) and deteriorated in 7 patients (22%). In-hospital mortality happened in 5 of 32 ELVO cases (16%), and all of them had lesions in the vertebrobasilar circulation. Regarding non-ELVO cases, two patients (6%) developed new neurologic deficits due to perforator strokes. There was no in-hospital mortality in this group. Conclusions: Even in unfavorable situations with acute atherothrombotic occlusions or recurrent strokes under aggressive medical therapy of known ICAS, PTAS remains a treatment option with reasonable effectiveness. This should be balanced against other treatment options, taking into account the complication rate, which is not negligible. Full article

Background and Clinical Significance: Deficiency of Adenosine Deaminase 2 (DADA2) is a rare monogenic vasculopathy characterised by systemic inflammatory and immunodeficiency features. Although neurological and haematological manifestations are well-documented, hepatic vascular involvement remains underappreciated. This report aims to describe the clinical and imaging characteristics of hepatic vascular involvement in a patient with DADA2 and to illustrate the evolution of hepatic lesions during long-term Etanercept therapy. In addition, we provide a synthesis of the available evidence on hepatic manifestations in DADA2, emphasising vascular pathology, clinical presentation, and therapeutic implications. Case Presentation: We describe a girl with early-onset DADA2 presenting with recurrent systemic inflammation, hypogammaglobulinaemia, vasculopathy, and two childhood strokes, followed by the development of multiple FNH-like hepatic nodules on CEUS and MRI with persistently elevated GGT. Genetic testing confirmed biallelic ADA2 mutations, and treatment with Etanercept led to sustained clinical stabilisation and marked regression of liver lesions over a nine-year follow-up period. Her older sister, carrying the same mutations, showed a milder phenotype without hepatic involvement but experienced a mesenteric vascular event. Conclusions: Large regenerative nodules with an FNH-like appearance on CEUS or MRI have not been previously reported in this setting. In our patient, Etanercept therapy produced a favourable hepatic response, reflected by a significant reduction in both the number and size of the lesions. Our case contributes to the understanding of liver disease in DADA2 and the influence of imaging and treatment on the hepatic manifestations of the condition. Full article

Patent foramen ovale (PFO) is present in roughly one quarter of adults and is over-represented among younger patients with cryptogenic ischemic stroke. The past decade has produced compelling evidence from randomized trials showing that PFO closure is beneficial than medical therapy in preventing recurrent ischemic stroke in appropriately selected patients. Despite this, anticoagulation continues to be used when closure is not feasible, declined, contraindicated, or considered after recurrent events. The observation that some patients experience “breakthrough” stroke or transient ischemic attack (TIA) despite therapeutic anticoagulation raises a critical question: why does medical therapy fail in PFO-associated stroke, and why does closure appear superior? This narrative review synthesizes the latest evidence on the pathophysiology of PFO-associated stroke, with attention to mechanisms that remain incompletely addressed by anticoagulation. It analyzes randomized trial data comparing antiplatelet therapy, anticoagulation, and transcatheter closure. It examines the role of high-risk PFO anatomical characteristics, the Risk of Paradoxical Embolism (RoPE) score, and the PFO-Associated Stroke Causal Likelihood (PASCAL) classification in understanding medical therapy failure. Additionally, the review explores whether PFO “type” predicts anticoagulation failure and highlights future research directions needed to further optimize therapy. In conclusion, in appropriately selected patients with high-risk PFO features, closure provides greater stroke risk reduction than medical therapy alone, albeit with small absolute risk differences and a procedural risk of atrial fibrillation. Full article

Background: Guidelines recommend patent foramen ovale (PFO) closure for secondary prevention after cryptogenic stroke in patients aged 18–65 years, but there is limited evidence to guide management of elderly adults. This research aims to assess the efficacy, safety and methodological quality of trials comparing secondary prevention PFO closure with medial therapy alone (MTA) in patients aged ≥ 60 years. Methods: A PubMed search identified four studies comparing PFO closure with MTA in elderly patients—PFOSK (South Korea), PT (Taiwan), DEFENSE (South Korea) and PFOG (Germany). Primary analyses evaluated study quality—patient selection, allocation, crossover and adherence. Secondary analyses compared recurrent cerebral ischaemia, mortality, new-onset atrial fibrillation (AF) and disability. Results: In 644 patients ≥ 60 years old, PFO closure was associated with a 45% (95% CI 0.35–0.86, p = 0.0091) reduction in recurrent cerebral ischaemia and an 85% (95% CI 0.05–0.49, p = 0.0016) reduction in mortality. Lower disability scores and increased incidence of new-onset AF (RR 2.15, 95% CI 1.07–4.32, p = 0.0306) was observed in closure groups. Study quality was limited by heterogeneity in medical regimens and closure protocols, crossover between treatment arms and imbalances in baseline characteristics, with closure groups generally younger and possessing larger shunt sizes. Conclusions: In patients aged ≥ 60 years, PFO closure appears to reduce the risk of the recurrence of ischaemic events and mortality, particularly in those with ‘high-risk’ PFO features. However, variability in study designs and low event rates limit certainty. Large, standardised trials are warranted to provide evidence for guideline recommendations in this population. Full article

Background: Intracranial atherosclerotic disease (ICAD) remains a major global cause of ischemic stroke—particularly in Asian, Black, and Hispanic populations—and is characterized by high recurrence rates despite advances in intensive medical management. Objectives: This review synthesizes current evidence on surgical and endovascular approaches for ICAD, including extracranial–intracranial bypass, encephaloduroarteriosynangiosis, angioplasty, and hybrid revascularization strategies. Methods: We performed a structured narrative literature search of PubMed and Scopus. Searches were conducted up to 1 October 2025 using combinations of subject headings and keywords, including “intracranial atherosclerotic disease”, “ICAD”, “intracranial stenosis”, “bypass”, “encephaloduroarteriosynangiosis”, “angioplasty”, “stenting”, “revascularization”, and “stroke”. We also scanned reference lists of key articles and relevant reviews. Non-English language articles were excluded. Results: While randomized trials such as SAMMPRIS, VISSIT, and CASSISS reaffirm intensive medical management as first-line therapy, emerging data suggest that surgical revascularization may benefit select patients with hemodynamic compromise refractory to medical therapy. Recent studies incorporating physiologic imaging—such as PET, SPECT, and perfusion MRI—have refined patient selection, reducing perioperative risk and improving long-term outcomes. Innovations in indirect revascularization, hybrid procedures, and intraoperative imaging continue to expand therapeutic possibilities. However, evidence remains heterogeneous, underscoring the need for well-powered randomized trials integrating modern surgical techniques, objective hemodynamic endpoints, and AI-enhanced imaging analytics. Conclusions: While intensive medical management remains the first-line standard of care, select patients with refractory, hemodynamically significant ICAD may benefit from direct, indirect, or hybrid surgical revascularization. Future directions emphasize personalized, physiology-based management frameworks that combine medical, surgical, and technological advances to optimize stroke prevention and long-term vascular outcomes in ICAD. Full article

Background/Objectives: Post-varicella arteriopathy (PVA) is a significant cause of pediatric arterial ischemic stroke (AIS) that typically involves previously healthy children within 12 months of primary varicella infection, mostly with a monophasic course. Diagnosis is based on clinical and imaging findings, and cerebrospinal fluid analysis may confirm it; treatment is empirical and heterogeneous. We describe a typical case of PVA and present a systematic review of its clinical, radiological, therapeutic, and outcome features. Methods: Following PRISMA 2020 and AMSTAR-2 guidelines, data on demographics, clinical presentation, imaging, laboratory confirmation, treatment, and outcomes were extracted across databases (PubMed, Embase, Scopus). Results: Forty-seven studies, encompassing 312 pediatric patients, were included. Mean age was 4 years with a median latency of 3.82 months from varicella to neurologic symptoms. Common presentation included hemiparesis, language impairment, and seizures. Imaging findings showed unilateral focal involvement of anterior circulation arteries, basal ganglia infarctions, and, rarely, bilateral or posterior circulation involvement. CSF VZV-DNA PCR and anti-VZV IgG were positive in 39% and 48% of tested patients. Treatment included intravenous acyclovir (34%), corticosteroids (20%), and low-dose aspirin (77%); two patients underwent acute reperfusion therapy (rt-PA or thrombectomy). Outcomes tended to be moderately favorable: 43% achieved full recovery, 45% had residual deficit, and 11% experienced recurrence. Prothrombotic state was reported, and it may influence disease severity. Conclusions: PVA is a rare distinct cause of pediatric stroke, with a generally favorable prognosis quoad vitam. Standardized guidelines and prospective studies are needed to establish evidence-based management. Clinicians should maintain a high suspicion for its diagnosis. Full article

Background/Objectives: Secondary stroke prevention is a cornerstone of long-term recovery and healthy aging among older adults, yet adherence to preventive strategies remains suboptimal. This global systematic review aimed to synthesize evidence from randomized controlled trials evaluating interventions that support sustained secondary prevention in older adults after stroke. Methods: A systematic search of PubMed and Scopus databases was conducted up to April 2025, following PRISMA 2020 guidelines and registered in PROSPERO (CRD420251177501). Eligible studies included randomized controlled trials targeting adults aged 60 years or older and assessing pharmacological, behavioral, educational, rehabilitative, or technology-assisted interventions for stroke recurrence prevention. Data were narratively synthesized due to study heterogeneity, and methodological quality was appraised using the Cochrane RoB 2 tool. Results: Seventeen randomized trials involving approximately 17,000 participants met the inclusion criteria. Multicomponent programs integrating medication management, behavioral education, exercise, cognitive rehabilitation, and digital support consistently improved adherence, vascular risk control, and quality of life. Pharmacological strategies alone showed limited or transient benefits, underscoring the importance of patient education and sustained follow-up. Common barriers included low motivation, cognitive decline, and technological challenges, while key facilitators were personalized education, multidisciplinary coordination, and culturally adapted implementation. Conclusions: Effective secondary stroke prevention in older adults depends on integrated, person-centered models that combine education, behavioral reinforcement, and technology-assisted monitoring. Structured, continuous educational programs, embedded within rehabilitation and primary care, emerge as the most promising pathway to improve adherence, reduce recurrence, and promote active, autonomous aging. Full article

Background/Objectives: The optimal timing for initiating oral anticoagulants (OACs) after acute ischemic stroke (AIS) in patients with atrial fibrillation (AF) remains uncertain due to potential risks of recurrent stroke and bleeding. This meta-analysis compares early versus late OAC initiation for recurrent ischemic stroke, major bleeding, intracranial hemorrhage (ICH), systemic embolism, and all-cause mortality. Methods: We conducted a meta-analysis of randomized controlled trials (RCTs), prospective, and retrospective observational studies. Data were pooled using random-effects models, and subgroup analyses were performed to assess outcomes by study design. Heterogeneity was quantified using I² statistics. Results: A total of 17 studies were included. Early OAC initiation was associated with a significantly lower risk of recurrent ischemic stroke compared to late initiation (OR = 0.74, 95% CI [0.58, 0.95], p = 0.02), with moderate heterogeneity (I² = 36%, p = 0.08). No significant difference was observed in ICH rates (OR = 0.74, 95% CI [0.41, 1.33], p = 0.32), major bleeding (OR = 1.48, 95% CI [0.51, 4.30], p = 0.47), or systemic embolism (OR = 0.65, 95% CI [0.33, 1.25], p = 0.20). All-cause mortality showed no difference between early and late initiation (OR = 1.00, 95% CI [0.72, 1.39], p = 0.99). Subgroup analyses were consistent with overall findings, and heterogeneity ranged from low to moderate across outcomes. Conclusions: Early initiation of OACs post-AIS in AF patients significantly reduces ischemic stroke recurrence without increasing risks of ICH, major bleeding, systemic embolism, or mortality. These findings support early anticoagulation strategies for selected patients. Full article

Motion cueing algorithm (MCA) aims to reproduce the dynamic motion experience of real vehicles for users of driving simulators. Under rough or irregular road conditions, vehicles are subjected to severe shocks and vibrations. However, due to the inherent response delay and limited capability of motion platforms in reproducing high-frequency components, conventional MCA often suffers from slow response and poor tracking accuracy. This mismatch leads to dynamic inconsistency between the visual feedback and the motion cues provided to the driver, which can easily induce discomfort or even aggravate simulator sickness. To address these issues, this study proposes a route-preview MCA based on adaptive model predictive control (RPAMPC). A CNN–LSTM-based vehicle trajectory prediction model is developed by integrating convolutional and recurrent neural networks to exploit forward terrain information. Subsequently, a motion cueing prediction model incorporating actuator stroke and velocity states is formulated, and an AMPC-based MCA is designed to optimize the simulator platform motion under physical constraints. Experimental results on a Stewart motion simulation platform demonstrate that, compared with traditional MCA, the proposed algorithm achieves higher-quality motion cues and significantly reduces sensory errors under complex road conditions. Full article

Background: Circulating microRNAs (miRNAs) have emerged as potential biomarkers of platelet reactivity and thrombotic risk. Among them, miR-223-3p regulates P2Y12 receptor expression and may influence response to antiplatelet therapy. This study aimed to evaluate the prognostic value of selected circulating miRNAs in post-stroke patients receiving antiplatelet treatment. Methods: Sixty ischemic stroke survivors were prospectively enrolled and followed for 18 months for recurrent vascular events (stroke, transient ischemic attack, or myocardial infarction). Plasma levels of miR-126-3p, miR-223-3p, miR-24-3p, and miR-199a-5p were quantified using reverse transcription real-time PCR. Clinical data, antiplatelet regimen, statin use, and Essen Stroke Risk Scores (ESRS) were recorded. Logistic regression was applied to identify independent predictors of thrombotic events. Results: Expression of all examined miRNAs differed significantly across treatment groups. The dual antiplatelet therapy (DAPT) group showed the highest levels of miR-126-3p and miR-199a-5p (p < 0.01). Within the statin-naïve DAPT subgroup, lower miR-199a-5p levels (p < 0.001) were observed among patients who experienced ischemic events (n = 7/60; 12%; stroke = 4, TIA = 2, ACS = 1) during 18 months of follow-up. In multivariate analysis, reduced miR-223-3p remained the only independent predictor of recurrent thrombotic events (OR 1.18, 95% CI 1.01–1.37, p = 0.036), independent of ESRS and platelet reactivity. Elevated miR-126-3p and miR-199a-5p were associated with favorable treatment response, particularly among statin users. Conclusions: This study identifies low circulating miR-223-3p as an independent biomarker of thrombotic risk in post-stroke patients, potentially reflecting enhanced platelet activation via P2Y12 signaling. In contrast, higher miR-126-3p and miR-199a-5p levels may indicate more effective antiplatelet response. These findings support the potential utility of miRNA profiling for individualized antiplatelet therapy and long-term risk stratification after ischemic stroke. Full article

Background: This study aimed to evaluate the efficacy and safety of off-label use of non-vitamin K antagonist oral anticoagulants (NOACs) compared with antiplatelet therapy (APT) in patients with AF-related acute ischemic stroke (AIS) and a glomerular filtration rate (GFR) below 15 mL/min/1.73 m². Methods: We used a multicenter prospective stroke registry to identify patients with AF-related AIS and GFR < 15 mL/min/1.73 m² who were treated with either APT alone or NOAC alone at discharge. Primary outcomes were ischemic stroke recurrence, major bleeding, and all-cause mortality within one year. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression. Results: Among 311 eligible patients, 135 (43.4%) received APT and 176 (56.6%) received low-dose NOACs. Compared to APT, NOAC use was associated with a significantly lower risk of ischemic stroke recurrence (aHR 0.54, 95% CI 0.29–0.99) but higher risks of major bleeding (aHR 3.25, 95% CI 1.84–5.73) and all-cause mortality (aHR 2.65, 95% CI 1.60–4.38). The most common causes of death were non-vascular events such as sepsis and respiratory failure. Conclusions: In patients with AF-related stroke and ultra-low GFR, off-label use of NOACs may offer a benefit in stroke prevention but is associated with increased risks of bleeding and mortality. These findings suggest the need for individualized treatment strategies and careful monitoring when prescribing NOACs in this vulnerable population. Full article