You might be interested in…Stroke (Part 2) – Clinical Issues

Dr Ray O’Connor continues his look at recent clinical papers on stroke, including clinical symptoms or signs associated with significantly lower odds of haemorrhagic stroke

Valid discrimination of ischemic and haemorrhagic stroke relies exclusively on neuroimaging. Novel biomarkers in acute stroke present an opportunity to reconsider combination diagnostic approaches with standardized clinical assessment.

This systematic review1 evaluated diagnostic properties of acute clinical features in determining primary stroke aetiology. PubMed and EMBASE were searched from inception to March 6, 2025. Eligibility criteria included cohort, cross-sectional, case-control, or randomised controlled trials; consecutive adults with an acute stroke confirmed by neuroimaging; and one or more acute stroke symptom(s) or sign(s) recorded by stroke subtype. A random-effects model was used to pool odds ratios.

Dr Ray O’Connor

A total of 60 studies, (n = 12,879,006; ischemic stroke = 10,814,474; haemorrhagic stroke = 2,064,532), were eligible. Mean age was 70.45 ± 14.36 years and 51.9 per cent were women. Clinical presenting symptoms/signs associated with significantly higher odds of haemorrhagic stroke (compared to ischemic stroke) included coma (odds ratio 8.81), neck stiffness (5.21), Glasgow Coma Scale ≤8 (4.37), vomiting (3.86), altered consciousness (3.55), headache (3.49), syncope (2.74), seizure (2.67), abnormal plantar response (1.94) and vertigo/dizziness (1.32).

Clinical symptoms/signs associated with significantly lower odds of haemorrhagic stroke included morning onset (0.41), facial weakness (0.66), hemiplegia (0.68), and ataxia (0.73). The authors conclude that the review reports substantive differences in prevalence of stroke symptoms and signs between ischemic and haemorrhagic stroke subtypes.

The therapeutic efficacy and safety of IV thrombolysis (IVT) for patients with minor strokes remain a subject of significant debate and uncertainty. This meta-analysis2 aimed to assess the comparative effectiveness and safety of IVT vs nonthrombolytic standard of care (NT-SC) in minor strokes, focusing exclusively on data from randomized controlled trials (RCTs).

The authors conducted a comprehensive literature search to identify RCTs evaluating IVT in minor stroke, defined as a NIH Stroke Scale (NIHSS) score ≤5. The primary outcome was excellent functional recovery, defined as a modified Rankin Scale (mRS) score of 0-1 at 90 days. Secondary outcomes included functional independence (mRS 0-2 at 90 days) and safety end points, including 90-day mortality, recurrent stroke, symptomatic intracranial haemorrhage (sICH), and any ICH.

The primary analysis included data from four RCTs that exclusively enrolled patients with minor stroke (N = 3,364; age range: 56-80 years). In the primary analysis, IVT was not significantly associated with higher odds of excellent functional recovery at 90 days compared with NT-SC. IVT was significantly associated with lower odds of achieving 90-day functional independence and higher odds of both sICH and 90-day mortality (OR 2.40) compared with NT-SC. The authors concluded that IVT does not confer improved functional outcomes among patients with minor strokes and can be associated with higher odds of sICH and mortality at 90 days compared with NT-SC.

This study was a multicentre, cluster randomised clinical trial3 that took place in 77 hospitals across China. The objective was to evaluate the efficacy of a clinical decision support system (CDSS) on stroke care quality and clinical outcomes among patients with acute ischaemic stroke. Among the 77 hospitals, 38 were randomised to intervention group, 39 to control group. They enrolled 21,603 patients with acute ischaemic stroke admitted to hospital within seven days after symptom onset.

Hospitals in the intervention group received stroke CDSS support including artificial intelligence assisted imaging analysis, classification of stroke causes, and evidence based treatment recommendations. Hospitals in the control group provided usual care.

The primary outcome was a new vascular event (composite of ischaemic stroke, haemorrhagic stroke, myocardial infarction, and vascular death) within three months after initial symptom onset. Secondary outcomes included the composite measure and all-or-none measure of evidence based performance measures for acute ischaemic stroke care quality, a new vascular event at six and 12 months, and disability and all cause mortality at three, six, and 12 months. Safety outcomes were moderate or severe bleeding events and all bleeding events at three, six, and 12 months.

The results were as follows: 11,054 patients in the intervention group and 10,549 patients in the control group were enrolled. New vascular events at three months occurred in 2.9 per cent (320/11,054) in the intervention group compared with 3.9 per cent (416/10,549) in the control group (adjusted hazard ratio 0.74). The CDSS intervention effect remained significant in the cluster level analysis. New vascular events were significantly lower in the intervention group at 12 months (4.0 per cent (440/11 054) v 5.5 per cent (576/10 549), adjusted hazard ratio 0.73).

No significant differences were found in disability and all-cause mortality. Moderate or severe bleeding, and all bleeding did not differ significantly between the two groups. The authors’ conclusion was that use of the stroke CDSS in patients with acute ischaemic stroke in China led to a significant decrease in new vascular events at three months. The stroke CDSS intervention was also effective in improving stroke care quality and decreasing long term vascular events.

This systematic review4 documented the occurrence of stroke following Percutaneous Coronary Intervention (PCI) in patients with Acute Coronary Syndrome (ACS). A systematic search of PubMed and EMBASE identified 2,369 articles. After full-text screening, 109 articles were included in the systematic review, with 55 articles selected for meta-analysis. Data from 18,466,823 patients across 109 studies were analysed. Among these, 202,999 patients (1.1 per cent) experienced post-PCI stroke.

The participants’ ages ranged from 49.0 to 87.6 years (mean 64.3). The incidence of early post-PCI stroke within 30 days was 1.1 per cent, while the incidence of stroke occurring >30 days post-PCI was 1.8 per cent, predominantly ischemic strokes. Predictors of stroke following PCI in ACS patients included traditional risk factors (i.e. female sex, older age, diabetes mellitus, hypertension, prior stroke or transient ischemic attack); comorbidities (i.e. chronic kidney disease, atrial fibrillation, anaemia, high bleeding risk); and procedural factors (i.e. thrombus aspiration and Clopidogrel use).

The authors concluded that there is a relatively low prevalence of stroke following PCI, estimated at approximately one per cent of the studied population. These findings emphasize the critical need for continued vigilance in identifying and managing risk factors associated with post-PCI stroke in ACS patients.

This was a two armed, randomised trial5that aimed to investigate the effectiveness of a multidisciplinary, home based, tailored intervention to reduce falls after stroke. It was based in three states in Australia. Participants were people within five years of stroke, aged >50 years, discharged from formal rehabilitation to the community, and able to walk 10 m across flat ground with or without an aid. Those with moderate-to-severe receptive aphasia or walking speed >1.4 m/s without falls in the previous year were excluded.

Over six months, the experimental group received a habit forming functional exercise, home fall hazard reduction, and goal directed community mobility coaching; the control group received usual care. Physiotherapist and occupational therapist dyadic teams worked collaboratively to deliver the intervention. The primary outcome was rate of falls over 12 months. Secondary outcomes were proportion of participants having a fall, community participation, self-efficacy, balance, mobility, physical activity, activities of daily living, depression, and health related quality of life. 370 people with stroke were enrolled.

At 12 months, a significant between group difference was seen in the rate of falls in favour of the experimental group, representing a 33 per cent reduction in falls. No significant between group difference was seen in the number of participants having a fall. The main between group differences in favour of the experimental group were in community participation, self-efficacy, mobility and balance. The authors concluded that a tailored intervention prevented falls in community dwelling, ambulatory people with stroke. The decrease in the rate of falls was underpinned by clinically worthwhile improvements in self-efficacy, mobility, community participation, and balance.

References:

McDermott C et al. Discrimination of ischemic versus hemorrhagic stroke type by presenting symptoms or signs: A systematic review and meta-analysis. Journal of Stroke and Cerebrovascular Diseases 34 (2025) 108413. https://doi.org/10.1016/j.jstrokecerebrovasdis.2025.108413.
Doheim M et al. Meta-Analysis of Randomized Controlled Trials on IV Thrombolysis in Patients With Minor Acute Ischemic Stroke. Neurology. 2025 Aug 12;105(3):e213863. doi:10.1212/WNL.0000000000213863. Epub 2025 Jul 17.
Zhang X et al. Effect of a clinical decision support system on stroke care quality and outcomes in patients with acute ischaemic stroke (GOLDEN BRIDGE II): cluster randomised clinical trial. BMJ 2026;392:e085810. http://dx.doi.org/10.1136/bmj-2025‑085810.
Qanitha A et al. Determinants of stroke following percutaneous coronary intervention in patients with acute coronary syndrome: a systematic review and meta-analysis. Annals of Medicine 2025, VOL. 57, NO. 1, 2506481. https://doi.org/10.1080/07853890.2025.2506481.
Clemson L et al. Home based, tailored intervention to reduce rate of falls after stroke (FAST): randomised trial. BMJ 2026;392:e085519. http://dx.doi.org/10.1136/bmj-2025‑085519.