Background: China is one of the countries with the highest burden of stroke. Implementing multidimensional management guidelines will help clinicians practise evidence-based care, improve patient outcomes and alleviate societal burdens. This update of the 2019 edition will provide the latest comprehensive recommendations for the diagnosis and treatment of ischaemic cerebrovascular diseases. Methods: We conducted a comprehensive search on MEDLINE (via PubMed) up to 31 August 2023. The writing team established the recommendations through multiple rounds of online and offline discussions. Each recommendation was graded using the evidence grading algorithm developed by the Chinese Stroke Association (CSA). The draft was reviewed and finalised by the CSA Stroke Guidelines Writing Committee. Results: This update included revisions of 15 existing recommendations and 136 new recommendations in the following areas of stroke care: emergency assessment and diagnosis of ischaemic cerebrovascular disease, acute-phase reperfusion therapy, evaluation of underlying mechanisms, antithrombotic therapy, prevention and treatment of complications, and risk factor management. Conclusions: This guideline updated the recommendations for the clinical management of ischaemic cerebrovascular disease from 2019.

: Introduction: Stroke etiology may affect the prognosis of acute basilar artery occlusion (BAO). This study aimed to estimate the efficacy and safety of endovascular treatment (EVT) in BAO strokes due to the underlying stroke etiologies of large artery atherosclerosis (LAA) and cardioembolism (CE). Patients and methods: Patients with LAA and CE subtypes from the registry EVT for Acute Basilar Artery Occlusion Study (BASILAR) were selected for this analysis. We estimated the EVT treatment effect relative to standard medical treatment (SMT) in these patients by using a propensity score approach with inverse probability of treatment weighted estimation. Outcomes included 90-day favorable functional outcomes (modified Rankin scale (mRS) 0–3), functional independence (mRS 0–2), all-cause mortality, and symptomatic intracranial hemorrhage (sICH). Results: A total of 744 patients were included in the final analysis. After weighting with inverse probability of treatment estimation, the patients who, based on their characteristics, were treated with EVT rather than SMT, demonstrated higher rates of favorable functional outcomes in both the LAA (29.2% vs 11.7%, adjusted OR with 95% CI: 4.34 [2.15–8.78], p < 0.001) and the CE subtype (36.0% vs 8.1%, adjusted OR with 95% CI: 9.14 [1.96–42.55], p = 0.005). A similar finding was also observed for functional independence. EVT patients also demonstrated lower rates of mortality than SMT. Among EVT patients, no significant difference was observed in mortality or sICH between LAA and CE groups, but LAA patients had lower rates of favorable functional outcome and functional independence (29.2% vs 37% and 24.2% vs 32.9%, respectively), where the latter remained significant after adjustment for imbalances in baseline data (p = 0.04). Conclusions: In acute BAO strokes, both LAA and CE patients who, based on their characteristics, were treated with EVT rather than SMT, demonstrated better outcomes. Among EVT patients, LAA and CE subtypes displayed important baseline and treatment differences, and LAA patients were less likely to achieve functional independence at 3 months, but mortality and sICH were similar between LAA or CE subtypes. These results need to be confirmed in future clinical trials.

Background: It is unclear whether infarct location affects stroke recurrence after index ischemic stroke. We aimed to compare the risk of stroke recurrence and the responses to dual antiplatelets with ticagrelor-aspirin versus clopidogrel-aspirin between patients with posterior circulation infarct (PCI) and those with anterior circulation infarct (ACI) after minor stroke or transient ischemic attack. Methods: Data were obtained from the double-blind CHANCE-2 trial (Ticagrelor or Clopidogrel With Aspirin in High-Risk Patients With Acute Nondisabling Cerebrovascular Events II), which was conducted across 202 centers in China from September 2019 to March 2021. Patients with positive diffusion-weighted imaging were included and classified into PCI and ACI groups according to the hyperintense lesions on diffusion-weighted imaging. The primary efficacy and safety outcomes were a new stroke and severe or moderate bleeding within 90 days, respectively. Results: A total of 4168 patients were included in this substudy, with 1427 PCI and 2741 ACI. During the 90-day follow-up, the risk of stroke recurrence in patients with PCI was similar to that with ACI (7.4% versus 8.3%; adjusted hazard ratio, 1.01 [95% CI, 0.79–1.29]; P =0.94). In comparison with clopidogrel-aspirin, ticagrelor-aspirin significantly reduced the risk of stroke recurrence in both the PCI (hazard ratio, 0.59 [95% CI, 0.40–0.89]; P =0.01) and ACI groups (hazard ratio, 0.65 [95% CI, 0.50–0.85]; P =0.002). There was no treatment-by-infarct location interaction ( P value for interaction, 0.92). The risk of severe or moderate bleeding was similar between PCI and ACI patients ( P =0.19). However, the risk of any bleeding increased on ticagrelor-aspirin than clopidogrel-aspirin treatment in PCI and ACI patients ( P =0.02 and 0.002, respectively). Conclusions: Our study demonstrated that stroke recurrence was similar between PCI and ACI in patients with minor stroke or transient ischemic attack. Additionally, ticagrelor-aspirin was superior to clopidogrel-aspirin in reducing the risk of stroke within 90 days in both PCI and ACI patients. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04078737.

Background and Objectives: Single small subcortical infarction (SSSI) is an important stroke subtype. The optimal antiplatelet medication for ischemic stroke patients with an SSSI is still unclear. We aimed to test the efficacy and safety of ticagrelor-aspirin in preventing stroke recurrence among SSSI patients in the Ticagrelor or Clopidogrel with Aspirin in High-Risk Patients with Acute Nondisabling Cerebrovascular Events II (CHANCE-2) trial. Methods: In the CHANCE-2 trial, patients with a minor stroke or transient ischemic attack (TIA) who carried CYP2C19 loss-of-function (LOF) alleles were randomly assigned within 24 hours after symptom onset, to either ticagrelor-aspirin (placebo clopidogrel plus a 180 mg loading dose of ticagrelor on Day 1, followed by 90 mg twice daily on Days 2–90) or clopidogrel-aspirin (placebo ticagrelor plus a 300 mg loading dose of clopidogrel on Day 1, followed by 75 mg daily on Days 2–90). Aspirin was applied during the first 21 days. Patients who had an SSSI (diffusion-weighted imaging lesion diameter ≤20 mm) were included in this analysis and further categorized into two types according to whether they had the responsible intracranial artery stenosis (ICAS): SSSI+ICAS and SSSI-ICAS. The primary efficacy outcome was a new stroke at 90 days. Results: Among 2,143 eligible patients, 340 had the responsible ICAS and 1,803 did not. Ticagrelor-aspirin reduced stroke recurrence among all SSSI patients (HR: 0.54; 95% CI: 0.38-0.79; P=0.001) compared to clopidogrel-aspirin. Stroke recurrence occurred in 35/901 (3.9%) patients with SSSI-ICAS on ticagrelor-aspirin and in 72/902 (8.0%) on clopidogrel-aspirin (HR: 0.45; 95% CI: 0.29-0.68; P<0.001). In patients with SSSI+ICAS, the corresponding event rates were 14/176 (8.2%) and 13/164 (7.9%), respectively (HR: 1.20; 95% CI: 0.45-3.23; P=0.71; P for interaction=0.08). The risk of moderate to severe bleeding only occurred in SSSI-ICAS patients (5/901 [0.6%] vs. 5/902 [0.6%]). Conclusions: In this prespecified substudy, ticagrelor-aspirin was superior to clopidogrel-aspirin in reducing the risk of stroke at 90 days among SSSI patients who carried CYP2C19 LOF allele(s). Although there was no treatment-by-heterogeneous etiology interaction, a greater absolute risk reduction of stroke was observed in patients with SSSI-ICAS than in those with SSSI+ICAS.