The edition · Neurology
Factor XIa inhibitors cut recurrent stroke without a clear bleeding signal, but one trial carries the result; stroke in young adults keeps rising
A meta-analysis of three trials of factor XIa inhibitors after noncardioembolic stroke, population data on stroke in people under 55, preliminary evidence for PCSK9 inhibitors in acute stroke, and what the Parkinson's exercise literature can and cannot say.
The edition in brief
A Neurology meta-analysis pooled three randomised trials (14,239 participants) of factor XIa inhibitors against placebo after noncardioembolic ischaemic stroke or TIA, on top of standard antiplatelet therapy. Any stroke fell (RR 0.75, 95% CI 0.66 to 0.84), as did ischaemic stroke (0.74, 0.66 to 0.84), with no clear increase in major bleeding (RR 1.12, 0.87 to 1.44); one phase 3 trial of 12,327 people drove the estimates. A population-based study in a five-county US region found stroke incidence in adults aged 20 to 54 rose from 33.90 to 62.18 per 100,000 person-years between 1993/4 and 2020 while falling in older adults, alongside rising hypertension, diabetes, atrial fibrillation and substance use; 30-day case fatality eased from 11.7% to 9.4%. A meta-analysis of PCSK9 inhibitors added to statins in acute ischaemic stroke suggested better functional independence and fewer recurrences, but the authors rate the evidence preliminary, with low certainty for recurrence. A Bayesian network meta-analysis of 173 Parkinson's exercise trials found mind-body exercise had the largest effect on UPDRS III (g 0.65) but confidence in the evidence was low or very low, and no best modality or dose was established. The pearl is on recording last known well.
Factor XIa inhibitors reduced recurrent stroke after noncardioembolic stroke or TIA in pooled trials
Factor XIa inhibitors look promising for recurrent stroke prevention, but the result rests largely on one trial and bleeding safety is not settled; continue current antithrombotic therapy.
Stroke incidence in adults under 55 nearly doubled over three decades in a US population study
Treat young stroke as a common vascular condition first: check blood pressure, glucose, rhythm and substance use before pursuing rare causes.
PCSK9 inhibitors added to statins in acute ischaemic stroke: promising but preliminary
Hold off on using PCSK9 inhibitors specifically for acute stroke; the evidence is small and awaits larger trials.
Record the last known well, not the time the patient was found
Document the last known well as a clock time in every suspected stroke and pass it on.
Exercise helps Parkinson's motor symptoms on average, but no best type or dose is established
Encourage regular exercise in Parkinson's disease and let the patient's preference guide the type, since no modality or dose was shown to be best.
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