Introduction: Currently, evidence regarding risk factors for 10-year cardiovascular mortality after ischemic stroke remains limited. This study aimed to develop and evaluate a robust predictive model for 10-year cardiovascular mortality in ischemic stroke patients. Methods: The predictive model was derived from the Acute Ischemic Stroke Intervention and Secondary Prevention Registry (AISISPR), in which eligible patients were randomly divided into derivation (60%) and validation (40%) cohorts. We identified 10-year cardiovascular mortality risk factors by analyzing comprehensive clinical data, including (1) medical histories, (2) demographic characteristics, (3) laboratory parameters, and (4) imaging findings. The area under the receiver operating characteristic curve (AUROC) and the calibration curve were used to assess model discrimination and calibration. Results: A total of 4,574 participants were included, with a mean age of 64.3 years. The model showed excellent discrimination for 10-year cardiovascular mortality across derivation (AUROC = 0.839; 95% CI: 0.822–0.856), validation (AUROC = 0.841; 95% CI: 0.820–0.862) cohort. Patients with carotid artery stenosis had a 19% higher cardiovascular mortality risk than those without stenosis (hazard ratio [HR] 1.19, 95% CI 1.01–1.40). Previous stroke was associated with a 44% increased risk of mortality (HR 1.44, 95% CI 1.24–1.68). In addition, among the subtypes of ischemic stroke, the large-artery atherosclerotic subtype and the modified Rankin Scale (mRS) score at discharge significantly increased the risk of cardiovascular mortality, while the use of standardized secondary prevention medications reduced the risk of cardiovascular mortality. Conclusion: The current prediction model demonstrates accurate prognostic performance for 10-year cardiovascular mortality following ischemic stroke. However, further validation in diverse populations and larger cohorts is warranted.

Introduction: Orolingual angioedema is a recognized adverse effect of thrombolytic treatment for acute ischemic stroke (AIS). Although it is generally mild with a relatively low incidence (1–5%), orolingual angioedema may trigger life-threatening airway occlusion necessitating rapid intubation. This population-based, retrospective study is the first to examine differences in complications, management, and outcomes of AIS in patients with and without thrombolysis-induced angioedema. Methods: The National Inpatient Sample (NIS) was queried by International Classification of Disease Ninth and Tenth Revision diagnostic and procedural codes (ICD-9-CM/ICD-10-CM) to identify AIS patients treated with thrombolysis who experienced subsequent angioedema. Baseline characteristics, treatment, complications, and functional outcomes were analyzed through multivariate regression and compared through a propensity-score matching (PSM) analysis. Results: We examined 99,935 patients diagnosed with AIS and administered thrombolytics between 2010 and 2019. AIS patients with thrombolytic-induced angioedema were younger (67.44 years vs. 69.32 years, p < 0.01), less likely to be white (53.83% vs. 66.48%, p < 0.01), and presented with higher acute stroke severity scores (0.69 vs. 0.63, p < 0.01) than non-angioedema AIS patients. Following PSM analysis, patients with angioedema had higher rates of tracheostomy (5.7% vs. 0.49%, p < 0.01) and lower rates of endovascular mechanical thrombectomy (4.72% vs. 9.63%, p < 0.01). Though patients who developed angioedema were observed to have longer length of stay (LOS) (7.34 days vs. 5.41 days, p < 0.01), they demonstrated similar rates of adverse complications, poor functional outcome (p = 0.25), and in-hospital mortality (p = 0.32) compared to their non-angioedema AIS counterparts. Conclusion: Although angioedema increased the likelihood of tracheostomy and prolonged hospitalization, outcomes were comparable to those of patients without this complication. These findings are hypothesis-generating and may help guide discussions with families when angioedema occurs, demonstrating that while the need for airway intervention is more likely, the overall prognosis remains reassuring. Future studies should further clarify acute management strategies and long-term outcomes in this patient population.

Introduction: Existing guidelines lack comprehensive recommendations for stroke prevention. This network meta-analysis aimed to evaluate the comparative efficacy of non-pharmacological interventions in preventing total stroke and fatal stroke in high-risk adults. Methods: We pooled only randomized controlled trials (RCTs). Relative risks (RRs), 95% confidence intervals (CIs), and P scores were computed to compare and rank the efficacy of interventions in preventing stroke. Results: 50 RCTs with 673,624 participants were pooled in this study. Compared with the control group, Exercise + Education may decrease stroke risk (RR = 0.23; 95% CI: 0.07–0.73; low strength of evidence [SOE]), followed by Exercise (RR = 0.40; 95% CI: 0.28–0.57; moderate SOE), Mediterranean diet (RR = 0.70; 95% CI: 0.50–0.97; low SOE), and Vitamin B6 combined with B12 and folic acid (Vitamin B6 + B12 + folic acid) (RR = 0.86; 95% CI: 0.77–0.95; moderate SOE). Only Salt substitute showed significantly reduced fatal stroke risk (RR = 0.78; 95% CI: 0.68–0.90; high SOE). Exercise + Education (low SOE) and Exercise alone (moderate SOE) showed short-term benefits on preventing stroke, while Salt substitute had long-term effects on reducing fatal stroke risk (high SOE). Carotid endarterectomy (moderate SOE) and Vitamin C (high SOE) were significantly effective in preventing ischemic stroke, and Salt substitute (high SOE) showed significantly reduced hemorrhagic stroke and fatal hemorrhagic stroke risks. Vitamin B6 + B12 + folic acid may lower hemorrhagic stroke and transient ischemic attack risks (moderate SOE). Conclusion: Future studies should prioritize high-quality RCTs with large sample sizes, different follow-up durations and specific stroke types to confirm the efficacy of these non-pharmacological interventions.

Introduction: This study provides a comprehensive assessment of the geographic distribution and accessibility of stroke care resources in Mexico’s public health system. The World Stroke Organization (WSO) roadmap criteria classifies centers offering only intravenous thrombolysis as Essential Stroke Centers (ESCs) and those providing both thrombolysis and mechanical thrombectomy as Advanced Stroke Centers (ASCs). Despite recent progress, substantial disparities in access have persisted, particularly between the remote and underserved areas. Methods: This cross-sectional study evaluated institutional resources for acute stroke care across public hospitals in Mexico. A structured online survey developed by the Deputy Secretariat for Health Policy and Population Well-Being in collaboration with experts was based on the WSO Roadmap and aligned with institutional protocols. The instrument was validated by healthcare professionals and distributed via institutional email to the medical directors of IMSS, ISSSTE, IMSS-Bienestar (including the National Institutes of Health), PEMEX, and SEMAR. Data were collected between December 5, 2024, and January 25, 2025. Duplicate entries, nonhospital responses, and uncertified neurointerventional specialists were excluded. The analysis was restricted to general and regional hospitals, and eligible facilities were identified and validated against the Ministry of Health’s Catalogue of Health Establishments. All hospitals were georeferenced using the CLUES code and classified as ESCs or ASCs according to the WSO Roadmap criteria. Results: In total, 1,032 facilities across 32 federal entities completed the survey. Hospitals without a diagnostic or therapeutic capacity for stroke were excluded from further analysis. Isochrones were generated using national road network data and the estimated average travel speeds for different road types under normal conditions. Eighty-five percent of at-risk individuals reside within 60 min of an ESC, ensuring access to fibrinolytic therapy. In contrast, 14% of the individuals aged ≥40 years (6,312,370 people) lived for more than 60 min from the nearest ESC. Despite advances in acute ischemic stroke care, more than half of the population aged ≥40 years remains over 1 h away from an ASC, highlighting critical “stroke care deserts,” particularly in access to thrombectomy, most notably in Colima, Nayarit, Oaxaca, Guerrero, Veracruz, and Sinaloa. Conclusion: Strengthening universal stroke care through interinstitutional collaboration, standardized protocols, certification programs, and optimization of referral networks could enable up to 85% of the at-risk population to access effective treatment at certified stroke centers. Our analysis highlights the major infrastructural and logistical barriers that impede equitable access to life-saving endovascular therapies. Addressing these gaps is essential to reducing mortality and disability in Mexico’s heterogeneous public health system.

Introduction: This study aimed to evaluate the potential association of intracranial pressure (ICP) monitoring on postoperative outcomes among patients with spontaneous intracerebral hemorrhage (ICH). Methods: This study conducted a systematic review and meta-analysis of relevant literature retrieved across the Cochrane Library, PubMed, Embase, and Web of Science from their inception to July 1, 2025. The primary efficacy outcome was unfavorable functional outcome (modified Rankin Scale 4–5 or Glasgow Outcome Scale 1–3). The primary safety outcome was mortality. Secondary outcomes included hospital stay, hematoma clearance rate, operative time, recurrent hemorrhage, and infection rates. Subgroup analyses were performed based on surgical intervention, hematoma type, and follow-up duration. Results: A total of 551 patients who underwent surgical treatment for spontaneous ICH were included in the analysis, based on five observational studies. Compared with the non-ICP group, patients who received ICP monitoring were associated with lower rates of unfavorable functional outcome (OR = 0.27, 95% CI: 0.15 to 0.46) and shorter hospital stays (MD = −3.90 days, 95% CI: –5.09 to −2.71). No significant differences were observed in mortality (OR = 1.24, 95% CI: 0.71 to 2.17), hematoma clearance rate, operative time, or complication rates. Subgroup analyses further indicated that, among patients with hypertensive ICH undergoing minimally invasive surgery, the use of adjunctive ICP monitoring was associated with a lower incidence of unfavorable functional outcome without a corresponding increase in mortality. Conclusion: The use of ICP monitoring was associated with improved functional outcomes in surgically treated patients with spontaneous ICH, without an observed increase in mortality or complications. These findings suggest a potential role of ICP monitoring in postoperative management, which warrants further validation in prospective studies.

Introduction: The Optimal Post-rtPA-IV Monitoring in Ischemic Stroke Trial (OPTIMISTmain) was an international, pragmatic, stepped-wedge, cluster-randomized, non-inferiority trial designed to compare a low-intensity protocol to standard high-intensity monitoring in patients with mild-to-moderate acute ischemic stroke treated with thrombolysis. The results showed the safety, feasibility, and non-inferiority efficacy of the low-intensity monitoring protocol, supporting hospitals to consider adopting this approach in stroke care depending on local resources and circumstances. An embedded process evaluation was undertaken to explore factors influencing implementation and impact of the intervention in Latin America. Methods: A convergent mixed-methods design was used to combine quantitative data and qualitative interviews with implementers and patients (or family members) at participating hospitals in Chile and Mexico. Purposive sampling ensured that a diverse range of experiences and discourses were captured, and normalization process theory (NPT) guided the identification of factors facilitating or hindering the incorporation of low-intensity monitoring. The analysis focused on key implementation outcomes. Results: Low-intensity monitoring was widely accepted by clinicians who found it efficient, straightforward to implement, and potentially cost saving for hospital services. Patients and families expressed acceptance, emphasizing the protocol’s potential to support continuous improvements in healthcare. Implementation challenges included staff turnover across shifts and hospital units, reliance on external contractors, and resistance to changing established care routines. Factors enabling successful implementation included strong team communication, dedicated stroke units, and ongoing feedback. Overall, the intervention demonstrated high acceptability, adoption and appropriateness, fidelity (median of 17 assessments in both countries), and sustainability. Feasibility outcomes were more variable, reflecting organizational challenges at the healthcare system level, such as initial resistance of nursing teams and high workloads in emergency services. Conclusions: Implementation of a novel low-intensity monitoring protocol was well accepted by healthcare staff and offers potential benefits to patients with mild-to-moderate acute ischemic stroke admitted to hospitals in Latin America. Embedding a process evaluation into the main trial provided valuable insights into the challenges of implementing a complex intervention. A comprehensive understanding of the factors influencing organization change is critical to improving health outcomes.

Plain Language SummaryPatients with acute stroke due to occlusion of large head blood vessels ideally have the occlusion removed via a surgical procedure (endovascular thrombectomy). They often need transfer between a peripheral and central hospital for this standard of care. Some patients will improve their occlusion while en-route and not need this surgical procedure. Predicting these patients is important in preventing unnecessary surgery. Our last study found that an improvement in National Institute of Health Stroke Scale of one-third or more was an excellent predictor of occlusion resolution. This study assessed this phenomenon in a separate group of patients and again found that a one-third or more improvement in stroke score correlated very well with occlusion resolution before surgical procedure at the central hospital. However, practically using this improvement threshold in a cost model saves only 34 dollars per patient and, for this reason, may be of higher use in areas that have higher logistic, financial, or geographic barriers to access endovascular thrombectomy.

Plain Language SummaryMoyamoya disease (MMD) is a cerebrovascular disorder characterized by the formation of hazy, smoke-like collateral vessels at the base of the skull. It can lead to ischemic or hemorrhagic stroke, headaches, seizures, or transient ischemic attacks. The clinical manifestations of MMD in children differ significantly from those in adults, with pediatric patients primarily presenting with cerebral ischemia while adults predominantly experience intracranial hemorrhage. MMD exhibits marked geographical and ethnic disparities in incidence, showing the highest prevalence in Asian populations. Its familial clustering suggests genetic factors play a significant role in pathogenesis. Cerebral angiography remains the gold standard for diagnosis, though advancements in noninvasive imaging techniques are increasingly enabling accurate evaluation of MMD. Surgical revascularization, particularly through intracranial-extracranial bypass procedures, has become the mainstay of treatment with demonstrated benefits for patients. This review highlights recent advances in MMD management, encompassing diagnostic approaches, pathophysiological mechanisms, therapeutic strategies, and outcome assessments, with the goal of optimizing long-term prognosis and informing clinical decision-making.

Introduction: Females have a higher incidence of aneurysmal subarachnoid hemorrhage and a higher prevalence and rupture risk of unruptured intracranial aneurysms than men. Underrepresentation of females in clinical trials would, therefore, limit their generalizability. The study aimed to evaluate sex disparities in aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysm trial enrollment and identify factors influencing female representation. Methods: The authors searched Ovid Medline, Embase, Cochrane Central, Clinicaltrials.gov, and International Clinical Trials Registry for clinical trials on aneurysmal subarachnoid hemorrhage or unruptured intracranial aneurysms, published before June 2023, with ≥100 adult patients, requiring informed consent for participation. The primary outcome was the proportion of female patients enrolled. Random effects meta-analysis was performed, and multivariate beta-regression was used to assess the impact of trial characteristics and predefined subgroups on female participation. Results: A total of 134 trials were included, with a total of 38,042 patients. Meta-analysis of the proportions of female participants resulted in a pooled proportion of 0.64 (95% CI: 0.63–0.66). Female participation was higher in trials on endovascular treatment (beta-estimate 1.32; 95% CI: 1.01–1.71) and in multicenter studies (beta-estimate 1.16; 95% CI: 1.01–1.33) but lower in Asian (beta-estimate 0.80; 95% CI: 0.67–0.95) and South American trials (beta-estimate 0.67; 95% CI: 0.47–0.97). Recruitment and consent procedures, sex of primary investigator, or burden of trial participation had no significant impact on female representation. Time trend analysis showed no statistically significant change in female participation over time. Conclusion: Females are not underrepresented in clinical trials for aneurysmal subarachnoid hemorrhage and unruptured intracranial aneurysms. Female participation is higher in trials on endovascular treatment and in multicenter studies and has regional differences, but other factors did not influence female representation. Our findings imply a good generalizability regarding sex distribution of the study results, strengthening the evidence guiding current clinical practice.