This is a protocol for a Cochrane review (prognosis). The objectives are as follows: Primary objective To systematically review and critically appraise multivariable prognostic models developed for adults (≥ 18 years) with carotid stenosis in which imaging biomarkers (e.g. plaque characteristics derived from magnetic resonance imaging (MRI), computed tomography (CT), or ultrasound) constitute the core predictors. The primary focus is to evaluate the predictive performance of these models for cerebrovascular complications - specifically ipsilateral ischaemic stroke and transient ischaemic attack (TIA) - which are the clinical outcomes to be predicted. Where feasible, we will summarise and compare the models' discrimination (C‑statistic/area under the curve (AUC)) and calibration (calibration‑in‑the‑large, calibration slope, observed‑to‑expected ratio) across studies, and assess their potential for clinical application and external validation. For the purpose of defining symptomatic carotid stenosis as an eligibility criterion and subgroup variable, we will include studies that also considered retinal ischaemia (e.g. retinal embolism, amaurosis fugax) as a qualifying event. Secondary objectives To describe the combinations of imaging markers, modelling techniques, sample sizes, and variable‑selection strategies used in the development of the included models To evaluate the performance of these models for additional secondary clinical outcomes: plaque progression or regression, incident high‑risk imaging features, and the transition from asymptomatic to symptomatic disease To explore whether predictive performance differs according to imaging modality (MRI versus CT versus contrast‑enhanced ultrasound (CEUS)) or technical protocol (e.g. 3 T versus 1.5 T, spectral CT versus conventional CT) For studies that report both cerebrovascular and broader cardiovascular outcomes (major adverse cardiovascular events, myocardial infarction, etc.), we will only extract the performance metrics relating to cerebrovascular events for the primary analysis. Performance metrics for cardiovascular outcomes will be considered exploratory and will not form part of the main synthesis.

Background and Aims Current guidelines advocate for indefinite direct oral anticoagulant (DOAC) therapy after successful catheter ablation for atrial fibrillation (AF), based on the CHA 2 DS 2 -VASc score. This strategy is challenged by the inherent bleeding risk of DOAC versus the potentially reduced stroke risk post-ablation. We aimed to compare long-term antithrombotic strategies in patients with durable freedom from AF recurrence. Methods We conducted a meta-analysis of the ALONE-AF and OCEAN trials enrolling 2124 patients with no documented AF recurrence for ≥1 year after ablation. The trials compared DOAC continuation versus DOAC discontinuation. We calculated pooled risk ratios (RRs) with 95% confidence intervals (CIs) for primary efficacy (thromboembolic events/all-cause mortality) and safety (bleeding events) outcomes. Results The meta-analysis found no statistically significant difference between DOAC continuation and DOAC discontinuation for all stroke or systemic embolism (RR 1.36; 95% CI: 0.16-11.38), transient ischemic attack (RR 0.20; 95% CI: 0.03-1.15), myocardial infarction (RR 0.08; 95% CI: 0.00-1.37), and all-cause mortality (RR 1.43; 95% CI: 0.55-3.74). In contrast, DOAC continuation was associated with a significantly higher risk of major bleeding (RR 3.07; 95% CI: 1.05-8.96) and clinically relevant non-major bleeding (RR 2.47; 95% CI: 1.01-6.00). Subgroup analysis confirmed consistent treatment effects. Conclusion In patients who achieve durable freedom from AF recurrence for at least 1 year following catheter ablation, the absolute risk of thromboembolic events was very low. Strategies involving the discontinuation of DOACs were associated with a statistically lower risk of bleeding without significant risk of stroke.

Posterior circulation ischemic vertigo (PCIV) denotes vertigo attributable to ischemia in the vertebrobasilar territory. It overlaps with the vascular vertigo categories of the Bárány Society diagnostic criteria and may indicate posterior circulation stroke or transient ischemic attack, so timely vascular evaluation is essential. In traditional Chinese medicine (TCM) theory, phlegm-dampness is regarded as a principal pathological product in vertigo, and pattern-based prescribing frequently targets it; whether phlegm-dampness pattern in PCIV corresponds to a biologically defined patient subgroup is unknown. This narrative review critically appraises the evidence behind that possibility. We searched PubMed, Embase, Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang from inception to June 30, 2026. Direct clinical evidence in PCIV is limited to trials and meta-analyses of low certainty indicating that acupuncture, alone or as an adjunct, increases vertebrobasilar blood-flow velocity and improves symptom scores; transcranial Doppler velocity is not equivalent to tissue perfusion, and the composite "clinical effective rate" is a non-standardized outcome. Biomarker studies link phlegm-dampness constitution-assessed in non-PCIV cohorts-to dyslipidemia, low-grade inflammation, and gut microbiome alterations including depletion of Flavonifractor plautii and its product phytosphingosine. Mechanistic studies, conducted almost entirely in healthy volunteers or animal models, suggest that acupuncture can modulate cerebrovascular hemodynamics, inflammatory and oxidative-stress signaling, and gut-brain communication. Integrating these strands, we propose a candidate metabolic-microbial endotype framework as a hypothesis-generating model rather than an established entity: the proposed abnormalities have not been shown to coexist in pattern-defined PCIV patients, nor to predict differential response to acupuncture. Pattern-stratified trials with pre-specified biomarker panels are needed to test the framework.

Patent foramen ovale (PFO) is a highly prevalent cardiac abnormality, affecting approximately 25% of the population worldwide. Although a PFO may be discovered incidentally and remain asymptomatic throughout life, it can also be a conduit for paradoxical emboli or vasoactive substances and has been associated with neurological disorders, including cryptogenic stroke, transient ischemic attack, migraine, epilepsy, as well as systemic embolism, hypoxemic disorders, and decompression sickness, particularly in individuals with high-risk anatomy or traditional cardiovascular risk factors. However, accurate identification of pathogenic PFO remains a challenge in current clinical practice, and the indications, timing, and long-term safety of PFO closure remain controversial. In this review, we summarize the epidemiology, risk factors, pathophysiological mechanisms, clinical manifestations, diagnostic strategies, and management of PFO, with particular emphasis on risk stratification, emerging imaging tools, novel closure devices, procedure-related complications, and the application of closure in special populations. In addition, we focused on the current evidence regarding when and who may benefit from PFO intervention and the surveillance of postprocedural complications. Overall, this review provides a comprehensive overview of the current findings and future perspectives for the management of PFO.

Dabigatran is widely used for stroke prevention in atrial fibrillation (AF), but concerns remain regarding its effectiveness in patients with Class III obesity (BMI ≥40 kg/m2.) We evaluated the association between dabigatran use in patients with AF and ischaemic stroke (IS) or transient ischaemic attack (TIA) across body mass index (BMI) categories in a multiethnic New Zealand population. In this retrospective nested case-control study, cases with incident IS/TIA were identified from the fifth Auckland Regional Community Stroke Study (1st September 2020-31st August 2021), and event-free controls were randomly selected from the National Minimum Dataset. Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) for IS/TIA, and effect modification by BMI catergory (< 30, 30-39.9, ≥40 kg/m[2]) was assessed using an interaction term. Among 1,854 patients with AF (295 cases, 1,559 controls), dabigatran use was associated with lower odds of IS/TIA (adjusted odds ratio [aOR] 0.50, 95% CI 0.38-0.68). After multivariable adjustment, BMI was not independently associated with IS/TIA risk. The association between dabigatran use and lower IS/TIA risk was similar in patients with BMI <30 and 30-39.9 kg/m[2], but the point estimate shifted towards the null in patients with BMI ≥40 kg/m[2] and was imprecise. There was no statistical evidence of effect modification by BMI (p-interaction=0.49), although clinically important attenuation in Class III obesity could not be excluded. In this real-world nested case-control study, there was no clear statistical evidence of BMI-related effect modification; however, the study had limited power in patients with BMI ≥40 kg/m[2], and clinically important attenuation, including the possibility of no reduction in IS/TIA odds with dabigatran use in Class III obesity cannot be excluded.

ObjectiveTo summarise evidence on the intervention design, safety, feasibility, acceptability, and effectiveness of a cardiac rehabilitation-based intervention for people who have had a stroke or transient ischaemic attack (TIA).Data sourcesMedline, PsycINFO, Embase, and CINAHL were searched between inception and 2026 for experimental or observational English-language studies that evaluated a cardiac rehabilitation-based intervention delivered to people with a history of stroke or TIA.Review methodsData were synthesised descriptively.ResultsNineteen studies were included (1951 participants), nine included people who had had a TIA, one exclusively. Most studies specified that participants had to have minimal or no stroke-associated disability. Reported time since stroke or TIA ranged from four weeks to more than one year. The interventions varied considerably in dose and components, though all included aerobic exercise training. Adverse event reporting was inconsistent; no study concluded that their interventions were unsafe, and one study stopped exercise testing. All 14 studies that measured feasibility reported that their study or intervention was feasible, though one concluded that it may not be feasible to enrol people with moderate stroke severity into existing cardiac rehabilitation programmes. Eight studies examined acceptability, all concluding that the interventions were acceptable and positively received. One powered randomised controlled trial found improvements were not sustained at 1-year follow-up.ConclusionsThe evidence suggests that cardiac rehabilitation after stroke and TIA is safe, feasible and acceptable. There are limited data relating to the inclusion of people with moderate or severe disability after stroke, or from trials regarding effectiveness.