What is the role of dual antiplatelet therapy after high risk transient ischaemic attack or minor stroke? Specifically, does dual antiplatelet therapy with a combination of aspirin and clopidogrel lead to a greater reduction in recurrent stroke and death over the use of aspirin alone when given in the first 24 hours after a high risk transient ischaemic attack or minor ischaemic stroke? An expert panel produced a strong recommendation for initiating dual antiplatelet therapy within 24 hours of the onset of symptoms, and for continuing it for 10-21 days. Current practice is typically to use a single drug

Objective To examine rates of intravenous thrombolysis (IVT), mechanical thrombectomy (MT), door‐to‐needle (DTN) time, door‐to‐puncture (DTP) time, and functional outcome between patients with admission magnetic resonance imaging (MRI) versus computed tomography (CT). Methods An observational cohort study of consecutive patients using a target trial design within the nationwide Swiss‐Stroke‐Registry from January 2014 to August 2020 was carried out. Exclusion criteria included MRI contraindications, transferred patients, and unstable or frail patients. Multilevel mixed‐effects logistic regression with multiple imputation was used to calculate adjusted odds ratios with 95% confidence intervals for IVT, MT, DTN, DTP, and good functional outcome (mRS 0–2) at 90 days. Results Of the 11,049 patients included (mean [SD] age, 71 [15] years; 4,811 [44%] women; 69% ischemic stroke, 16% transient ischemic attack, 8% stroke mimics, 6% intracranial hemorrhage), 3,741 (34%) received MRI and 7,308 (66%) CT. Patients undergoing MRI had lower National Institutes of Health Stroke Scale (median [interquartile range] 2 [0–6] vs 4 [1–11]), and presented later after symptom onset (150 vs 123 min, p < 0.001). Admission MRI was associated with: lower adjusted odds of IVT (aOR 0.83, 0.73–0.96), but not with MT (aOR 1.11, 0.93–1.34); longer adjusted DTN (+22 min [13–30]), but not with longer DTP times; and higher adjusted odds of favorable outcome (aOR 1.54, 1.30–1.81). Interpretation We found an association of MRI with lower rates of IVT and a significant delay in DTN, but not in DTP and rates of MT. Given the delays in workflow metrics, prospective trials are required to show that tissue‐based benefits of baseline MRI compensate for the temporal benefits of CT. ANN NEUROL 2022;92:184–194

Background and Purpose Knowledge about different etiologies of non-traumatic intracerebral hemorrhage (ICH) and their outcomes is scarce.Methods We assessed prevalence of pre-specified ICH etiologies and their association with outcomes in consecutive ICH patients enrolled in the prospective Swiss Stroke Registry (2014 to 2019). Results We included 2,650 patients (mean±standard deviation age 72±14 years, 46.5% female, median National Institutes of Health Stroke Scale 8 [interquartile range, 3 to 15]). Etiology was as follows: hypertension, 1,238 (46.7%); unknown, 566 (21.4%); antithrombotic therapy, 227 (8.6%); cerebral amyloid angiopathy (CAA), 217 (8.2%); macrovascular cause, 128 (4.8%); other determined etiology, 274 patients (10.3%). At 3 months, 880 patients (33.2%) were functionally independent and 664 had died (25.1%). ICH due to hypertension had a higher odds of functional independence (adjusted odds ratio [aOR], 1.33; 95% confidence interval [CI], 1.00 to 1.77; <i>P</i>=0.05) and lower mortality (aOR, 0.64; 95% CI, 0.47 to 0.86; <i>P</i>=0.003). ICH due to antithrombotic therapy had higher mortality (aOR, 1.62; 95% CI, 1.01 to 2.61; <i>P</i>=0.045). Within 3 months, 4.2% of patients had cerebrovascular events. The rate of ischemic stroke was higher than that of recurrent ICH in all etiologies but CAA and unknown etiology. CAA had high odds of recurrent ICH (aOR, 3.38; 95% CI, 1.48 to 7.69; <i>P</i>=0.004) while the odds was lower in ICH due to hypertension (aOR, 0.42; 95% CI, 0.19 to 0.93; <i>P</i>=0.031).Conclusions Although hypertension is the leading etiology of ICH, other etiologies are frequent. One-third of ICH patients are functionally independent at 3 months. Except for patients with presumed CAA, the risk of ischemic stroke within 3 months of ICH was higher than the risk of recurrent hemorrhage.

A lthough the degree of lumen obstruction is a relevant marker of the risk of stroke, the recognition of the role of the vulnerable plaque has opened new insights in the field of atherothrombotic stroke. [1][2][3][4] Vulnerability is dictated in part by plaque morphology, which, in turn, is influenced by pathophysiologic mechanisms at the cellular and molecular level. Thus, a certain number of features of plaque morphology may play an important role in the occurrence of cerebrovascular events. [5][6][7] An unstable plaque, on the one hand, has a thin fibrous cap that contains large numbers of macrophages and T lymphocytes and a small number of smooth muscle cells. A stable plaque, on the other hand, has a thicker cap with larger numbers of smooth muscle cells and less inflammation. [8][9][10] Intensive research has been performed aimed at optimizing different imaging modalities to precisely analyze the arterial wall morphology, plaque composition, and degree of local inflammation. Among them, positron emission tomography (PET) using 18 fluoro-2-deoxy-d-glucose (18FdG) as a radiotracer has shown promise for detection of local inflammation in atherosclerotic plaques.11 Indeed, high levels of glucose metabolism are typically seen in tissue with inflammatory activity. 12 Moreover, significant positive correlations between histopathologic findings and degree of plaque inflammation depicted by 18FdG uptake have been documented. [13][14][15][16][17][18] Accordingly, a few clinical studies suggested a potential role of 18FdG-PET-computed tomography (CT) for the diagnosis of high-risk carotid plaques. Rudd et al 13 showed that PET-CT might be used to image inflammatory cell activity within the carotid plaque. The study involved only 8 patients but was capable to demonstrate that 18FdG uptake was significantly higher within the symptomatic as compared with the contralateral plaque. Another study showed in a retrospective analysis Background and Purpose-We investigated whether uptake of 18 fluoro-2-deoxy-d-glucose (18FdG) positron emission tomography-computed tomography (PET-CT) correlated to clinical symptoms and presence of microembolic signals (MES) detected by transcranial doppler in patients with carotid stenosis. Methods-18FdG-PET-CT and MES detection was performed in consecutive patients with 50% to 99% symptomatic or asymptomatic carotid stenoses. Uptake index was defined by a target to background ratio (TBR) between maximum standardized uptake value of the carotid plaque and the mean standardized uptake value of the jugular veins. End points for analysis were presence of symptoms and presence of MES. 22,23 A recent study showed a correlation between 18FdG-PET-MRI and presence of MES in 16 patients presenting with recent transient ischemic attack or minor stroke and 50% to 99% stenosis of the ipsilateral carotid bifurcation. There was a significant difference in the target to background ratio (TBR) values between MES positive (+) and MES negative (−) patients, reinforcing the notion that embolization occurring dist...