Meyer, Dawn

Background: In younger patients (<60 years) with cryptogenic stroke presumed to be patent foramen ovale (PFO)-related, the standard approach involves transcatheter PFO closure combined with antithrombotic therapy (ATA). However, due to their exclusion from randomized clinical trials, no formal recommendations exist for patients ≥60 years. This study investigates whether PFO closure benefits patients ≥60 years with prior cryptogenic stroke or if ATA remains the preferred option. Methods: We searched the PubMed, Embase, Web of Science, and ScienceDirect databases to obtain articles in all languages from January 2004 until July 2025. The primary outcome was a risk of recurrent stroke during follow-up and secondary outcomes were risk of new-onset atrial fibrillation (AF), all-cause mortality and in-hospital complications. PROSPERO registration ID: CRD420250652870. Results: One post hoc evaluation of the DEFENSE-PFO trial and eleven observational studies were included. Compared to ATA, PFO closure was associated with a reduced risk of recurrent stroke (HR=0.60; 95% CI: 0.45 to 0.80, p<.001) and mortality (HR=0.41; 95% CI: 0.19 to 0.90, p=.02; I2 = 43.8%) with no difference in risk of new-onset AF (HR=1.13, 95%CI: 0.53 to 2.44, p=.74). When compared with patients <60 years, individuals ≥60 years had a higher risk of recurrent stroke (HR = 2.68; 95% CI 1.40–5.13; p=.002), new-onset AF (HR = 4.12; 95% CI 1.90–8.95; p<0.001) and mortality during follow-up (HR = 8.24; 95% CI 3.49–19.46; p<.0001). In-hospital complications after PFO closure were comparable between two age groups. Conclusion: While PFO closure may reduce ischemic stroke risk in older patients with cryptogenic stroke, this benefit is offset by higher absolute risks for recurrent stroke, new-onset AF, and mortality. Therefore, highly individualized patient selection and age-specific risk tools are crucial. Further long-term randomized trials are essential to optimize PFO closure in this population.

Background: In younger patients (<60 years) with cryptogenic stroke (CS) presumed to be patent foramen ovale (PFO)-related, the standard approach involves transcatheter PFO closure combined with antithrombotic therapy. However, due to their exclusion from randomized clinical trials (RCTs), no formal recommendations exist for patients ⩾60 years. This study had two objectives (1) to compare the efficacy and safety of PFO closure versus antithrombotic therapy alone (ATA) exclusively in older patients (⩾60 years) and (2) to assess the outcomes of PFO closure in patients ⩾ 60 years versus < 60 years. Methods: We searched PubMed, Embase, Web of Science, and ScienceDirect databases to obtain articles in all languages from January 2004 until July 2025. The primary outcome was risk of recurrent stroke during follow-up. Secondary outcomes were risk of new-onset atrial fibrillation (AF), all-cause mortality, and in-hospital complications. PROSPERO registration ID: CRD420250652870. Results: Only one RCT (post hoc evaluation of the DEFENSE-PFO trial) and 11 observational studies were included. In patients aged ⩾ 60 years, risk of recurrent stroke was lower when PFO was closed compared with ATA (5.48% vs 10.05%, respectively, hazard ratio (HR) = 0.56, 95% confidence interval (CI) = 0.45–0.80, p < 0.001, I 2 = 45.6%). All-cause mortality was also lower for PFO closure versus ATA (1.73% vs 7.59%, respectively, HR = 0.41; 95% CI = 0.19–0.90, p = 0.02; I 2 = 43.8%). There was no difference between PFO closure and ATA in risk of new-onset AF (HR = 1.13, 95% CI = 0.53–2.44, p = 0.74). Compared with patients < 60 years, individuals ⩾ 60 years who underwent PFO closure had a higher risk of recurrent stroke (2.94% vs 1.04%, respectively, HR = 3.47; 95% CI = 1.61–7.48; p = 0.001), new-onset AF (4.86% vs 1.01%, respectively, HR = 4.12; 95% CI = 1.90–8.95; p < 0.001), and all-cause mortality during follow-up (8.32% vs 0.39%, respectively, HR = 8.24; 95% CI = 3.49–19.46; p < 0.0001). In-hospital complications after PFO closure were comparable between two age groups. Due to insufficient data, we were not able to perform a subgroup analysis based on anatomic features of PFO, antithrombotic regimen, or occluder devices. Conclusion: Based on available data, which is predominantly derived from observational studies, PFO closure is associated with a reduced risk of recurrent stroke compared to ATA in patients over 60 years. However, these findings are subjected to limitations, including the potential for selection bias, unmeasured confounding, and insufficient long-term follow-up. Furthermore, long-term randomized trials are essential to definitively confirm efficacy and establish clinical guidelines for PFO closure in this older population.

Introduction: Mechanical thrombectomy (MT) is a primary treatment for acute ischemic stroke due to large vessel occlusions. While effective, 20-40% of patients experience hemorrhagic transformation (HT), and around 50% fail to achieve favorable functional outcomes. Transcranial Doppler (TCD) is a non-invasive and cost-effective method for real-time monitoring of hemodynamic status following MT. However, the prognostic value of TCD parameters in predicting HT and poor functional outcome is unclear. We performed a systematic review and meta-analysis of 4 TCD parameters (mean flow velocity (MFV), MFV index, peak systolic velocity (PSV), and pulsatility index (PI) in patients with and without HT and favorable vs poor functional recovery (modified Rankin Scale (mRS) 0-2 vs 3-6). Methods: PubMed, Embase, and Scopus were searched on July 25, 2024 to identify observational studies in which TCD parameters were measured within 48 hours from successful MT (Thrombolysis in Cerebral Infarction 2b–3) of anterior circulation. Risk of bias assessment was performed using a standardized tool tailored for TCD studies. The standardized mean difference (Hedges’ g) with 95% CI and risk ratios (RRs) with 95% CI were calculated using random-effects models. The review was prospectively registered on PROSPERO (registration number CRD42024575381). Results: Eleven studies met inclusion criteria. No study had high risk of bias. MFV and MFV index were higher in patients with HT+ compared with HT- (Hedges' g = 0.42 and 0.54, p = 0.015 and 0.005, respectively). Patients with MFV index ≥1.3 showed a higher risk of all HT (RR = 2.01, 95% CI = 1.27–3.17, p = 0.003), symptomatic HT (RR, 4.68; 95% CI,1.49–14.65, p=0.008), and poor functional recovery at 90 days (RR, 1.66; 95% CI,1.32–2.08, p<0.001), respectively. There was no difference in mean PSV (p=0.1) and PI (p=0.3) among groups with and without HT. Conclusion: Our study highlights the prognostic value of TCD parameters, particularly MFV index, in predicting HT, symptomatic HT, and poor functional recovery after successful MT in the anterior circulation. Our findings were limited by low number of studies. Large-scale and multi-center studies are needed to confirm these findings and validate the MFV index as a reliable predictor to improve post-thrombectomy care.

Introduction: Embolic Stroke of Undetermined Source (ESUS) represents about 25% of ischemic strokes, with patent foramen ovale (PFO) involved in roughly 25% of those cases. Recent studies (REDUCE, CLOSE, RESPECT) indicate that PFO closure may benefit select patients. Accurate PFO diagnosis is crucial for treatment decisions but current methods, such as transcranial Doppler (TCD) with bubble study, transthoracic echocardiography with bubble study (TTE), transesophageal echocardiography (TEE), and cardiac computed tomography (CT), vary in accuracy. This study aims to assess the diagnostic performance of TCD compared to TTE, TEE, and cardiac CT, to determine the most reliable modality for detecting PFO in patients with ESUS. Methods: We conducted a retrospective analysis of ESUS patients aged 18 and older referred to our vascular lab between July 2023 and September 2024. Each patient underwent at least two PFO detection methods: TCD with bubble study, TTE with bubble study, TEE, and cardiac CT. PFO presence was confirmed if identified by at least two detection methods. Patients with extracardiac shunts were excluded. Sensitivity, specificity, and overall test performance were evaluated using the Area Under the Curve (AUC) of a Receiver Operating Characteristic (ROC) curve, with higher AUC values indicating better performance. Differences in AUCs were assessed using DeLong’s test. Statistical analysis was performed using Analyse-it for Microsoft Excel (version 2.30). Results: Of 187 enrolled patients, 63 (33.7%) had evidence of right-to-left shunt. The mean age of the cohort was 63 ± 18 years, with 51% being male. PFO was confirmed in 36 patients. Sensitivity was highest for TCD (93.1%), followed by TTE (87.1%), TEE (86.7%), and cardiac CT (42.9%). Specificity was highest for cardiac CT (87.5%), followed by TTE (84%), TCD (59.1%), and TEE (47.1%). The AUC was highest for TTE (AUC: 0.85, 95% CI: 0.76–0.95), followed by TCD (AUC: 0.75, 95% CI: 0.64–0.87), TEE (AUC: 0.66, 95% CI: 0.50–0.81), and cardiac CT (AUC: 0.65, 95% CI: 0.42–0.88). No statistically significant differences in diagnostic performance across pairwise comparisons were found (p > 0.05). Conclusion: TCD with bubble study is highly sensitive for screening right-to-left shunt, while cardiac CT is highly specific for detecting PFO in ESUS patients. Further studies with larger sample sizes are needed to confirm these findings and refine diagnostic strategies.

Background Transcranial Doppler (TCD) is a non-invasive, bedside tool that allows for real-time monitoring of the patient’s hemodynamic status following mechanical thrombectomy (MT). This systematic review and meta-analysis aims to evaluate the predictive value of TCD parameters following successful MT (Thrombolysis in Cerebral Infarction 2b–3). Methods In July 2024, we searched PubMed, Embase, and Scopus, to identify observational studies in which TCD parameters were measured within 48 hours of MT. Using random-effects models, we compared four TCD parameters (mean flow velocity (MFV), MFV index, pulsatility index (PI), and peak systolic velocity (PSV) among groups with vs without hemorrhagic transformation (HT) and favorable vs poor functional recovery (modified Rankin Scale 0–2 vs 3–6). Results Eleven studies comprising 1432 patients (59% male; mean age range: 63–73 years) were included. The MFV and MFV index were higher in patients with HT (Hedges' g=0.42 and 0.54, P=0.015 and 0.005, respectively). Patients with MFV index ≥1.3 showed a higher risk of all HT (RR 1.97; 95% confidence interval (CI) 1.28 to 3.03, P=0.002), symptomatic HT (RR 4.68; 95% CI 1.49 to 14.65, P=0.008), and poor functional status at 90 days (RR 1.65; 95% CI 1.27 to 2.14, P=0.029), respectively. There was no difference in mean PSV (P=0.1) and PI (P=0.3) among groups with and without HT. Conclusion This study underscores the prognostic value of the MFV index in predicting HT, symptomatic HT, and poor functional recovery after successful MT in the anterior circulation. Large-scale, multi-center studies are necessary to confirm these findings and to validate the MFV index as a reliable predictor for improving post-thrombectomy care.

AbstractBackgroundCervical artery dissection (CAD) is a common cause of ischemic stroke in young adults. Local blood clot formation and distal emboli are the key mechanisms for the development of stroke in patients with CAD. Microemboli distal to the dissection point can be detected as high‐intensity transient signals (HITS) using transcranial Doppler (TCD). Despite this unique capability, TCD is used inconsistently in the management of CAD. In this international survey, we aim to explore the frequency and potential barriers to TCD use in CAD.MethodThis study was an international electronic survey, based on the Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection (STOP‐CAD) study, aiming at evaluating the use of TCD in diagnosing and managing CAD patients. A comprehensive questionnaire was developed to gather insights into the current practices, perceptions, and potential barriers to the effective use of TCD in participating centers. The collected data was then analyzed.ResultsFifty‐eight medical centers with advanced stroke care capabilities from Europe and United States participated in this study. Half (29 out of 58) of the sites routinely perform TCD on CAD patients, particularly in the presence of carotid or vertebral artery stenosis, complete carotid occlusion, and early neurologic deterioration. The primary reason for participating institutions not performing TCD was because its results would not change their practice. The protocol for TCD monitoring and managing HITS‐positive CAD patients varied among centers but transitioning from antiplatelet to anticoagulant was the most common practice in this patient population.ConclusionHalf of the stroke centers in our survey routinely perform TCD monitoring for CAD patients. The detection of HITS in CAD patients is a warning sign for providers, which may prompt a change in secondary stroke prevention management. However, a standard protocol for performing TCD in CAD and treatment recommendations for HITS‐positive CAD are not currently available, which warrants further research.

Introduction: "Mild" stroke is not well defined, but is a relative contraindication for the administration of IV rtPA. Advances in telemedicine have allowed for specialized practitioners to observe the examination, rather than rely on the on-scene examiner. We investigated whether there were differences in rates of identification, treatment, and outcomes of mild stroke patients in the phone compared to the video arms of a telestroke network. Methods: The STRokE DOC trials were prospective, randomized, outcome-blinded trials comparing video telemedicine to phone-only evaluations, which assessed eligibility for IV rtPA and correctness of decision-making for 2 hubs and 6 spokes. This analysis included all adult acute ischemic stroke patients from the STRokE DOC trials who were defined as “mild” using a recent definition from the TREAT Task Force. Rates of ICH, mortality, and dichotomized 90-day mRS scores were compared between the video and phone arms. Results: Mild stroke accounted for 32% and 29% of the video and phone arms, respectively. The two groups had similar baseline characteristics except hypertension (higher rate in video arm). Of the video mild stroke patients, 13% had poor outcome (mRS>1) compared to 24% of the phone arm (p=0.45). There were no symptomatic ICH or deaths. Among IV rtPA treated mild stroke patients, all of the video arm had good outcome, versus 25% of the phone arm. Of 100 non-treated patients, 34 were excluded because of "too mild" a deficit (TMT). In the phone arm, 7 of these did not meet the TREAT-derived criteria for mild stroke (p=0.03). One TMT patient in the phone arm had poor outcome. Conclusions: Mild stroke made up a third of the patients in each group. Some TMT patients in the phone arm did not meet the criteria for mild stroke; their subtle findings may not have been conveyed adequately over the phone. Among IV rtPA treated patients, the phone arm had worse outcomes. The results raise concern regarding accuracy of predicting outcomes for mild stroke patients, especially when based on a phone description. The study numbers were small, so conclusions cannot be definitively made. Future studies are necessary to determine decision making factors within the telemedicine process that influence treatment outcomes among mild stroke patients.