Association between endothelial function and early neurological improvement in atrial fibrillation-related ischemic stroke

'Associations' DO NOTHING FOR SURVIVOR RECOVERY! Are you that blitheringly stupid you don't know that survivors would like recovery rather than a completely fucking useless 'association'?  By not writing a protocol on this, you were actually WORSE THAN USELESS! You're all fired!

 Association between endothelial function and early neurological improvement in atrial fibrillation-related ischemic stroke

So Young Yang^1,2Sung Hee Ahn³Jeonggeun Moon²Yeong-Bae Lee⁴Dae-il Chang⁴Sang Hee Ha^4*

• ¹Department of Cardiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
• ²Department of Cardiology, Gil Medical Center, Gacheon University, Incheon, Republic of Korea
• ³Department of Big Data Management and Engineering, Namseoul University, Chungcheongnam-do, Republic of Korea
• ⁴Department of Neurology, Gil Medical Center, Gacheon University, Incheon, Republic of Korea

Background: Understanding the factors related to early neurological improvement (ENI) is crucial in managing atrial fibrillation-related ischemic stroke (AF-stroke), as ENI indicates better long-term outcomes. We investigated the association between endothelial function, measured via flow-mediated dilation (FMD), and the occurrence of ENI in patients with AF-stroke.

Methods: We reviewed patients with acute AF-stroke within 7 days of FMD between April 2019 and April 2025. ENI was defined as a ≥2-point decrease in National Institutes of Health Stroke Scale (NIHSS) or ≥1-point reduction in motor NIHSS items within 24 h in non-thrombolysis patients. For thrombolysis patients, ENI was a ≥8-point reduction or NIHSS 0–1 at 24 h. FMD was measured during hospitalization and expressed as %FMD = (peak diameter − baseline diameter) / Baseline diameter × 100. Multivariable analysis identified the factors associated with ENI and explored their relationship with FMD.

Results: Among the 169 patients diagnosed with AF-stroke, 77 (44.4%) experienced ENI. Those with ENI had higher NIHSS (7 [4–13] vs. 2 [1–5], p < 0.001), more confluent (38.7% vs. 25.5%) and scattered with confluent pattern (29.3% vs. 18.1%, p = 0.007), and higher %FMD (6.5% ± 2.5% vs. 5.3 ± 2.2%, p = 0.001). Multivariable analysis revealed a higher initial NIHSS score (adjusted odds ratio [aOR]: 1.329, p < 0.001) and a history of smoking (aOR: 4.532, p = 0.004), and higher %FMD score (aOR: 1.179; p = 0.043) were independently associated with ENI. Subgroup analysis demonstrated a stronger association between high %FMD and ENI in patients with concomitant vascular risk factors, such as hypertension and dyslipidemia.

Conclusion: Endothelial function was associated with ENI in patients with AF-stroke.

1 Introduction

More than 20% of stroke cases are caused by cardiac embolism attributable to atrial fibrillation (AF) (1). Compared to strokes of other etiologies, AF-related ischemic stroke (AF-stroke) is associated with greater severity and a higher risk of disability and mortality (2). This may be due to large infarct volumes resulting from the abrupt occlusion of blood flow by a clot originating in the heart, often without sufficient time for collateral circulation to compensate (3). Numerous studies have shown that AF-stroke is associated with a lower likelihood of early neurological improvement (ENI) (2, 4, 5). Nevertheless, ENI can still occur in a subset of patients with AF-stroke and is associated with favorable functional outcomes (6).

Several factors have been linked to ENI, including successful recanalization, collateral status, and smaller infarct core size (6–8). Additionally, the endothelium plays multiple roles in stroke pathophysiology and recovery by regulating vascular tone, maintaining blood–brain barrier (BBB) integrity, modulating inflammatory responses, and influencing thrombotic and fibrinolytic balance (9–11). Patients who have experienced acute ischemic stroke (AIS) with impaired FMD are associated with early neurological deterioration and poor long-term outcome (12). Furthermore, endothelial function is associated with the development of AF and AF-stroke by promoting atrial remodeling, thrombogenesis, and hemodynamic alterations (13, 14). However, whether endothelial function influences the capacity for early neurological recovery in patients with AF-stroke remains unclear.

Brachial artery flow-mediated dilation (FMD), assessed using high-resolution ultrasonography, is a widely used tool to evaluate endothelial function (15). In this study, we aimed to identify the factors associated with ENI in patients with AF-stroke, with a particular focus on the role of endothelial function as measured by FMD.

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