Intracranial aneurysms in patients with acute ischemic stroke prevalence and influence on mechanical thrombectomy over 14 years in a tertiary-care center

INTRODUCTION

The prevalence of intracranial aneurysms (IA) in patients with acute ischemic stroke (AIS) requiring mechanical thrombectomy (MT) is unclear.

OBJECTIVE

To describe the prevalence of IA in patients with AIS and their influence on MT.

MATERIALS & METHODS

This is a retrospective cohort study on all patients admitted with a diagnosis of AIS from January 2008 to March 2022 at a tertiary academic center. The records were reviewed for demographic, clinical, imaging, and outcomes data. Only patients who had CTA at admission were included in this analysis.

RESULTS

Among 2265 patients admitted with AIS, this diagnosis was confirmed in 2113 patients (93.3 %). We included 1111 patients (52.6 %) who had head CTA and 321 (28.9 %) who underwent MT. The observed prevalence of aneurysms on CTA was 4.5 % (50/1111 patients), and 8 (16 %) had multiple aneurysms. MT was performed in 7 patients harboring IAs: 6 ipsilateral (5 proximal and 1 distal to the occlusion)and 1 contralateral aneurysm.. The patient with a contralateral aneurysm had a TICI 2B score In patients with ipsilateral aneurysms, TICI 2B or 3 was achieved in 3 cases (50 %), which is significantly lower than historical control of MT (91.6 %) without IA (p = 0.01). No aneurysms ruptured during MT. The aneurysm noted distal to the occlusion was mycotic.

CONCLUSION

In this analysis, the observed prevalence of IA in patients with AIS was 4.5%. Ipsilateral aneurysms (proximal or distal to the occlusion site) deserve particular attention, given the potential risk of rupture during MT. Aneurysms located distal to the occlusion were mycotic and the rate of recanization in patients with ipsilateral aneurysms was low compared to historical controls. Further studies are needed to improve the outcomes in patients with IA requiring MT.

p39 Affects Myelin Formation in Cerebral Ischemic Injury

Stroke is a significant public health issue, and research has consistently focused on studying the mechanisms of injury and identifying new targets. As a CDK5 activator, p39 plays a crucial role in various diseases. In this article, we will explore the role and mechanism of p39 in cerebral ischemic injury. We measured the level of p39 using western blot and QPCR at various time points following cerebral ischemia-reperfusion (I/R) injury. The results indicated a significant reduction in the level of p39. TTC staining and behavioral results indicate that the knockout of p39 (p39KO) provides neuroprotection in the short-term. Interestingly, the behavioral dysfunction in p39KO mice was exacerbated after the repair phase of I/R. Further study revealed that this deterioration may be due to demyelination induced by elevated p35 levels. In summary, our study offers profound insights into the significance of p39 in both the acute and repair stages of ischemic injury recovery and a theoretical foundation for future therapeutic drug exploration.

Cocaine-related ischemic priapism. Systematic review and presentation of a single center series

INTRODUCTION

Ischemic priapism is a medical emergency that, if not treated, could lead to permanent erectile dysfunction. The association between cocaine and priapism is well-known; however, data on patient characteristics, treatment, and outcomes is missing. This work aimed to answer the research question: What are the characteristics, management strategies, and erectile prognosis of patients consuming cocaine and presenting with priapism?

METHODS

We conducted a systematic review according to PRISMA guidelines and described our case series.

RESULTS

Eight studies were selected for qualitative synthesis, presenting information on ten patients. In our case series, we showed information regarding four patients. From the systematic review, the mean presentation time was 42.6 h, and the mean number of procedures to solve priapism was 2,4; in our case series was 42.75 h and 2, respectively.

CONCLUSION

Cocaine-related priapism might present with a delayed diagnosis, need more procedures to be managed, and have a worse prognosis. More extensive and prospective studies are required.

Tenecteplase Versus Alteplase in Medium Vessel Occlusion Ischemic Stroke: A Secondary Analysis of the Alteplase Compared to Tenecteplase Randomized Trial

BACKGROUND AND PURPOSE

The safety and efficacy of tenecteplase in patients with ischemic stroke due to medium vessel occlusion (MeVO) are not well studied. We aimed to compare tenecteplase with alteplase in stroke due to MeVO.

METHODS

Patients with baseline M2-middle cerebral artery (MCA), M3/M4-MCA, P2/P3/P4-posterior cerebral artery (PCA), A2/A3/A4-anterior cerebral artery (ACA) occlusions from the Alteplase Compared to Tenecteplase (AcT) trial were included. Primary outcome was the proportion of 90-day modified Rankin Scale (mRS) 0-1. Secondary outcomes were 90-day mRS 0-2, ordinal mRS, mortality, quality of life measures (EuroQol 5-Dimension 5-Level, EuroQol visual analog scale), and symptomatic intracerebral hemorrhage (sICH). Initial and final successful reperfusion were reported in patients undergoing endovascular thrombectomy (EVT).

RESULTS

Among 1,558 patients with available baseline computed tomography angiography; 455 (29.2%) had MeVO of which 27.5% (125/455) were proximal M2; 16.3% (74/455) were distal M2; 35.2% (160/455) were M3/M4; 7.5% (34/455) were A2/A3/A4; and 13.6% (62/455) were P2/P3/P4 occlusions. EVT was performed in 87/455 (19.1%) patients. mRS 0-1 at 90 days was achieved in 37.9% in the tenecteplase versus 34.7% in the alteplase group (adjusted risk ratio [aRR] 1.07; 95% confidence interval [CI] 0.91-1.25). Rates of 90-day mRS 0-2, sICH, and mortality were similar in both groups. No statistical difference was noted in initial successful reperfusion rates (13.0% vs. 7.5%) among the 87 patients who underwent endovascular thrombectomy. However, final successful reperfusion was higher in the tenecteplase group (71.7% vs. 60.0%, aRR 1.29, 95% CI 1.04-1.61).

CONCLUSION

Intravenous tenecteplase had comparable safety, functional outcomes and quality of life compared to intravenous alteplase among patients with MeVO. Among those treated with EVT, tenecteplase was associated with higher successful reperfusion rates than alteplase.

TGR5 signalling in heart and brain injuries: focus on metabolic and ischaemic mechanisms

The heart and brain are the core organs of the circulation and central nervous system, respectively, and play an important role in maintaining normal physiological functions. Early neuronal and cardiac damage affects organ function. The relationship between the heart and brain is being continuously investigated. Evidence-based medicine has revealed the concept of the "heart- brain axis," which may provide new therapeutic strategies for certain diseases. Takeda protein-coupled receptor 5 (TGR5) is a metabolic regulator involved in energy homeostasis, bile acid homeostasis, and glucose and lipid metabolism. Inflammation is critical for the development and regeneration of the heart and brain during metabolic diseases. Herein, we discuss the role of TGR5 as a metabolic regulator of heart and brain development and injury to facilitate new therapeutic strategies for metabolic and ischemic diseases of the heart and brain.

Frequency & factors associated with elevated lipoprotein-a among Ghanaian stroke survivors

BACKGROUND

Indigenous Africans are genetically predisposed to elevated lipoprotein-a (Lp(a)), a veritable risk factor for ischemic stroke. Recent studies have demonstrated the promising efficacy of therapeutic interventions for addressing elevated Lp(a) among patients at high risk of atherosclerotic cardiovascular events. It is important to assess the burden of elevated Lp(a) among stroke survivors of African ancestry aimed at addressing potential unmet therapeutic gaps for optimal secondary prevention.

PURPOSE

To assess the frequency of elevated lipoprotein-a among Ghanaian stroke survivors and factors associated with it.

METHODS

A prospective study conducted at the Neurology clinic of the Komfo Anokye Teaching Hospital among ischemic stroke survivors aged ≥18 years. Serum lipoprotein-a concentrations were measured using ELISA kits. A multivariate regression analysis was fitted to identify factors independently associated with elevated lipoprotein-a concentration > 30 mg/dl.

RESULTS

Among 116 stroke survivors, 35 (30.2%) had elevated Lp(a). The adjusted odds ratio (95% CI) of factors associated with elevated Lp(a) were female sex 3.09 (1.05-9.12), p = 0.04, diabetes mellitus 3.52 (1.32-9.40), p = 0.01, urban dwelling 4.64 (1.61-13.39), p = 0.005 and total cholesterol 1.85 (1.28-2.67), p = 0.001. Whereas the LDL cholesterol significantly decreased from baseline to month 12 among a subset of participants, the Lp(a) levels significantly increased from a baseline value of 29.38 ± 15.32 mg/dl to 40.97 ± 29.72 mg/dl, p = 0.032.

CONCLUSION

Approximately 1 in 3 Ghanaian ischemic stroke survivors harbor an elevated Lp(a) associated with female sex, urban residence, diabetes mellitus and raised cholesterol. This burden highlights an unmet therapeutic gap in secondary risk reduction in this resource-limited setting.

Challenges to Thrombolysis in A Resource-Poor Setting- A Case Report

A major complication of acute ischemic stroke is death and disability. The emergence of reperfusion therapy in form of thrombolysis and endovascular thrombectomy has led to the reversal of this trend in high-income countries. Low- and middle-income countries are yet to benefit maximally from these time-bound treatment options due to some limitations. We intend to highlight some of these in this report. We report an 80-year-old male patient with hypertension and firstdegree AV block admitted 3 hours after the onset of stroke with National Institutes of Health Stroke Scale (NIHSS) score of 13 and Medical Research Council (MRC) muscle power grade 3 in both the left upper and lower limb. Urgent non-contrast brain CT revealed no evidence of hemorrhage. Intravenous tissue plasminogen activator (tPA) was administered at a dose of 0.6 mg/kg 9 hours after symptom onset. He made significant improvement afterward and was discharged. The challenges encountered in his management include prehospital and intrahospital delay, and unavailability of tissue plasminogen activator. There is a need for an improved healthcare delivery system in order to reduce the morbidity associated with acute ischemic stroke.

Do Triglyceride-Rich Lipoproteins Equal Low-Density Lipoproteins in Risk of ASCVD?

PURPOSE OF REVIEW

Recent large clinical trials have failed to show that triglyceride-rich lipoprotein-lowering therapies decrease the risk of atherosclerotic cardiovascular disease (ASCVD). In this review, we reconcile these findings with evidence showing that elevated levels of triglyceride-rich lipoproteins and the cholesterol they contain, remnant cholesterol, cause ASCVD alongside low-density lipoprotein (LDL) cholesterol.

RECENT FINDINGS

Results from observational epidemiology, genetic epidemiology, and randomized controlled trials indicate that lowering of remnant cholesterol and LDL cholesterol decrease ASCVD risk by a similar magnitude per 1 mmol/L (39 mg/dL) lower non-high-density lipoprotein cholesterol (remnant cholesterol+LDL cholesterol). Indeed, recent guidelines for ASCVD prevention recommend the use of non-high-density lipoprotein cholesterol instead of LDL cholesterol. Current consensus is moving towards recognizing remnant cholesterol and LDL cholesterols as equals per 1 mmol/L (39 mg/dL) higher levels in the risk assessment of ASCVD; hence, triglyceride-rich lipoprotein-lowering therapies should also lower levels of non-HDL cholesterol to reduce ASCVD risk.

Association of electrocardiographic and echocardiographic variables with neurological outcomes after ischemic Stroke

Background

Cardiac dysfunction is often seen following neurological injury. Data regarding cardiac involvement after ischemic stroke is sparse. We investigated the association of electrocardiographic (ECG) and echocardiographic variables with neurological outcomes after an acute ischemic stroke.

Methods

We retrospectively collected baseline characteristics, stroke location, National Institute of Health Stroke Scale (NIHSS) at the time of admission, acute reperfusion treatment, ECG parameters, and echocardiographic data on 174 patients admitted with acute ischemic stroke. Outcomes of the stroke were based on cerebral performance category (CPC) with a CPC score of 1-2 indicating a good outcome and a CPC score of 3-5 indicating a poor outcome.

Results

Older age (75.31 ± 11.89 vs. 65.16 ± 15.87, p < 0.001, OR = 1.04, 95 % CI 1.01-1.07), higher heart rate (80.63 ± 18.69 vs. 74.45 ± 17.17 bpm, p = 0.024, OR = 1.02, 95 % CI 1.00-1.05) longer QTc interval (461.69 ± 39.94 vs. 450.75 ± 35.24, p = 0.024, OR = 1.01, 95 % CI 0.99-1.02), NIHSS score (60.9 % vs. 17.8 %, p < 0.001, OR = 14.90, 95 % CI 3.83-69.5), and thrombolysis (15 % vs. 5 %, p = 0.049, OR = 0.55, 95 % CI 0.10-2.55) were associated with poor neurological outcomes. However, when adjusted for age and NIHSS, heart rate and QTc were no longer statistically significant. None of the other ECG and echocardiographic variables were associated neurological outcomes.

Conclusions

Elevated heart rate and longer QTc intervals may potentially predict poor neurological outcomes. Further studies are needed for validation and possible integration of these variables in outcome predicting models.

Perinatal hypoxic-ischemic brain injury: What's behind the "ribbon effect"?

Ribbon effect describes a perceived macroscopic color reversal of the gray and white matter, characterized by a pale cortex and diffusely dusky underlying white matter. This finding is thought to be unique to the perinatal period and indicative of hypoxic-ischemic injury. However, the clinical and microscopic correlates of this macroscopic finding have not been clearly defined. A 21-year retrospective study of autopsies was performed. Ribbon effect was seen in 190 subjects, ages 20 weeks gestation to 9.5 months adjusted age. Clinical associations and radiographic findings were similar in ribbon effect cases and controls. A variety of histologic findings were observed including acute neuronal injury, diffuse white matter gliosis, and white matter necrosis. Only white matter vascular congestion was significantly correlated to the macroscopic severity of ribbon effect; the severity of white matter injury and acute neuronal injury were not significantly correlated to ribbon effect. While hypoxic-ischemic changes were present in nearly all cases of ribbon effect, the location, severity, and chronicity of these changes varied considerably, and similar findings were observed in controls. The presence of ribbon effect therefore does not predict microscopic findings apart from vascular congestion, highlighting the importance of microscopic examination in perinatal brain autopsies.

Stroke: Hospital Nursing Management Within the First 24 Hours

Within the United States, someone will have a stroke approximately every 40 seconds. Eighty-five percent of strokes are ischemic, with 15% classified as either intracranial or subarachnoid hemorrhage. Stroke care is complex, and nurses play a critical role in identification, assessment, management, and coordination throughout the stroke continuum of care. This article will explore the nursing care of the patient with ischemic and hemorrhagic stroke during the first 24 hours.

Mechanical Thrombectomy for Pediatric Large Vessel Occlusions : A Systematic Review and Meta-analysis

BACKGROUND

Acute intracranial large vessel occlusion (LVO) is an important cause of morbidity and mortality among children; however, unlike in adults, no clinical trial has investigated the benefit of mechanical thrombectomy (MT) in pediatric LVO. Thus, MT remains an off-label procedure for pediatric stroke.

PURPOSE

To investigate the efficacy and safety of MT in pediatric LVO.

METHODS

A systematic literature search was conducted in Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, and Cochrane Central Register of Clinical Trials databases. Studies reporting safety and efficacy outcomes for endovascular treatment of pediatric LVO were included. Data regarding recanalization, functional outcome, symptomatic intracranial hemorrhage (sICH), and mortality were extracted from the included studies. Functional outcome was assessed with the modified Rankin scale (mRS). A fixed or random-effects model was used to calculate pooled event rates and 95% confidence intervals (CI).

RESULTS

In this study 11 studies comprising 215 patients were included. The successful recanalization rate was 90.3% (95% CI = 85.77-95.11%), and complete recanalization was achieved in 52.7% (95% CI = 45.09-61.62%) of the cases. The favorable (mRS = 0-2) and excellent (mRS = 0-1) outcome rates were 83.3% (95% CI = 73.54-94.50%) and 59.5% (95% CI = 44.24-80.06%), respectively. The overall sICH prevalence was 0.59% (95% CI = 0-3.30%) and mortality rate was 3.2% (95% CI = 0.55-7.38%).

CONCLUSION

In our meta-analysis, MT demonstrated a promising safety and efficacy profile for pediatric patients, with consistently high efficacy outcomes and low complication rates. Our results support the utilization of MT in pediatric LVOs; however, prospective studies are still needed to further establish the role of pediatric MT as a first-line treatment strategy.

Postoperative vasospasm and cerebral infarction in a patient with large pituitary adenoma and cerebral superficial siderosis

BACKGROUND

Cerebral vasospasm and infarction are rare complications of transsphenoidal surgery for pituitary adenoma. Cerebral superficial siderosis may result from subarachnoid hemorrhage from a pituitary adenoma. The constellation of cerebral superficial siderosis, cerebral vasospasm, and pituitary adenoma is rare. We describe an extremely rare clinical constellation of immediately postoperative cerebral vasospasm and consequent cerebral infarction in a case with a large pituitary adenoma and cerebral superficial siderosis.

CASE DESCRIPTION

A 70-year-old man presented with a pituitary adenoma causing a worsening headache. Preoperative magnetic resonance (MR) images revealed cerebral superficial siderosis, suggesting subarachnoid hemorrhage from pituitary apoplexy. MR angiography (MRA) showed no vasospasm. During the transsphenoidal surgery, an intratumoral hematoma was found. The arachnoid membrane was partially torn and intratumoral hematoma entered the subarachnoid space. Intraoperatively, the intracranial vessels remained intact. The suprasellar tumor was almost entirely resected; however, the patient remained comatose postoperatively. Computed tomography revealed ischemic lesions in the bilateral insular and frontotemporal cortex. MRA revealed cerebral vasospasm in the bilateral middle cerebral arteries. The patient was treated with levetiracetam for nonconvulsive status epilepticus and underwent a lumbar peritoneal shunt surgery for secondary hydrocephalus. However, the patient remained listless.

CONCLUSION

Postoperative cerebral vasospasm and infarction are severe but rare complications for a pituitary adenoma after transsphenoidal surgery. Preoperative and intraoperative subarachnoid hemorrhage might have been a risk factor in our case. Similar cases should be warranted to analyze whether cerebral superficial siderosis may also indicate the risk of severe postoperative vasospasm immediately after transsphenoidal surgery for pituitary adenoma.

Multi-Organ System Screening, Care, and Patient Support in Systemic Sclerosis

Systemic sclerosis (SSc) is a heterogenous systemic autoimmune disease of complex multi-organ manifestations with a disease-specific mortality of >50%. The patient journey is fraught with severe, diverse, and diffuse physical impairment, psychological burden, and diminishing health-related quality of life. SSc remains unfamiliar to many clinicians. Delayed/misdiagnosis, inadequate screening, and attention for common complications with potentially preventable disability/death contribute to patients feeling isolated and unsupported. We present actionable standards including screening, anticipatory guidance, and counseling in patient-centered SSc-care emphasizing psycho-social health as the central goal, whereas robust vigilance and efforts to improve biophysical health and survival are imperatives that support this goal.

Higher mold levels found in in the deteriorated housing in the Sun Valley neighborhood of Denver, Colorado compared to other Denver housing and higher rates of health insurance claims for some diseases documented for the Sun Valley residents compared to other Denver residents

The Sun Valley Homes public housing in Denver, Colorado (CO) will be replaced because of its deteriorated condition. Our goal was to document the mold contamination and particulate matter (PM2.5) concentrations in Sun Valley homes and the circulatory and respiratory health of Sun Valley compared to all Denver residents (total 2761 and 1,049,046, respectively) based on insurance claims data for 2015 to 2019. Mold contamination in Sun Valley homes (n = 49) was quantified using the Environmental Relative Moldiness Index (ERMI) scale. Indoor PM2.5 concentrations were measured in Sun Valley homes (n = 11) using time-integrated, filter-based samples and quantified using gravimetric analysis. Outdoor PM2.5 concentrations data were obtained from a near-by United States Environmental Protection Agency monitoring station. In Sun Valley homes, the average ERMI value was 5.25 compared to -1.25 for other Denver homes. The PM2.5 median concentration inside Sun Valley homes was 7.6 μg/m3 (interquartile range - 6.4 μg/m3). The ratio of indoor to outdoor concentrations of PM2.5 was 2.3 (interquartile range - 1.5). In the last five years, ischemic heart disease was significantly more likely for Denver compared to Sun Valley residents. However, acute upper respiratory infections, chronic lower respiratory diseases and asthma were all significantly more likely for Sun Valley than Denver residents. Since the process of replacing and occupying the new housing will take several years, the next phase of the study will not occur until that process is complete.

Stroke: Molecular mechanisms and therapies: Update on recent developments

Stroke, a neurological disease, is one of the leading causes of death worldwide, resulting in long-term disability in most survivors. Annual stroke costs in the United States alone were estimated at $46 billion recently. Stroke pathophysiology is complex, involving multiple causal factors, among which atherosclerosis, thrombus, and embolus are prevalent. The molecular mechanisms involved in the pathophysiology are essential to understanding targeted drug development. Some common mechanisms are excitotoxicity and calcium overload, oxidative stress, and neuroinflammation. In addition, various modifiable and non-modifiable risk factors increase the chances of stroke manifolds. Once a patient encounters a stroke, complete restoration of motor ability and cognitive skills is often rare. Therefore, shaping therapeutic strategies is paramount for finding a viable therapeutic agent. Apart from tPA, an FDA-approved therapy that is applied in most stroke cases, many other therapeutic strategies have been met with limited success. Stroke therapies often involve a combination of multiple strategies to restore the patient's normal function. Certain drugs like Gamma-aminobutyric receptor agonists (GABA), Glutamate Receptor inhibitors, Sodium, and Calcium channel blockers, and fibrinogen-depleting agents have shown promise in stroke treatment. Recently, a drug, DM199, a recombinant (synthetic) form of a naturally occurring protein called human tissue kallikrein-1 (KLK1), has shown great potential in treating stroke with fewer side effects. Furthermore, DM199 has been found to overcome the limitations presented when using tPA and/or mechanical thrombectomy. Cell-based therapies like Neural Stem Cells, Hematopoietic stem cells (HSCs), and Human umbilical cord blood-derived mesenchymal stem cells (HUCB-MSCs) are also being explored as a treatment of choice for stroke. These therapeutic agents come with merits and demerits, but continuous research and efforts are being made to develop the best therapeutic strategies to minimize the damage post-stroke and restore complete neurological function in stroke patients.

Motor sequela of adult and pediatric stroke: Imminent losses and ultimate gains

Stroke is the leading cause of neurological disability in the United States and worldwide. Remarkable advances have been made over the past 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in the understanding and clinical approaches to neurological recovery after stroke. This chapter reviews the epidemiology, bedside examination, localization approaches, and classification of stroke, with an emphasis on motor stroke presentations and management, and promising research approaches to enhancing motor aspects of stroke recovery.

SARS-CoV-2 Infection and Increased Risk for Pediatric Stroke

BACKGROUND

There is an increased risk of stroke in adults with severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) infection, but whether there is a similar association with stroke in children is unclear. Our objective was to determine whether there is a correlation between COVID-19 infection, multisystem inflammatory syndrome in children (MIS-C), and pediatric ischemic stroke.

METHODS

This was a retrospective, population-based cohort analysis between March 1, 2020, and June 30, 2021, conducted at a children's hospital. Pediatric patients with a diagnosis of ischemic stroke were identified using ICD-10 diagnoses of ischemic stroke, cerebrovascular accident, or cerebral infarction.

RESULTS

We identified 16 patients, seven male and nine female, with ischemic stroke. Ages were 8 months to 17 years (median 11.5 years). More Asian (6%) and black (13%) patients had strokes compared with population prevalence (2% each, respectively). No patients had active COVID-19 infection. COVID-19 antibodies were identified in five of 11 patients tested (45%), of whom three were diagnosed with MIS-C. 82% of the strokes occurred between February and May 2021. The peak incidence was in February 2021, which was two months after peak incidence of pediatric cases of COVID-19 and one month after the peak of MIS-C cases.

CONCLUSIONS

Our study suggests that prior COVID-19 infection, but not acute infection, is correlated with a risk for stroke in the pediatric population. The risk for stroke appears to be distinct from the risk for MIS-C.

Acute symptomatic seizures and hippocampal sclerosis: the major contributor for post-stroke epilepsy?

OBJECTIVE

Hippocampal sclerosis (HS) is a prominent biomarker of epilepsy. If acquired later in life, it usually occurs in the context of degenerative or acute inflammatory-infectious disease. Conversely, acute symptomatic seizures (ASS) are considered a risk factor for developing post-stroke epilepsy, but other factors remain unrecognized. Here, we hypothesize that silent hippocampal injury contributes to the development of post-stroke epilepsy.

METHODS

We performed a retrospective observational study of patients hospitalized between 1/2007 and 12/2018 with an acute stroke in the Stroke Center of the Geneva University Hospital. Patients were included if they had a documented normal hippocampal complex at onset and a control MRI at ≥ 2 year interval without new lesion in the meantime.

RESULTS

162 patients fulfilled our inclusion criteria. ASS during the first week (p < 0.0001) and epileptiform abnormalities in electroencephalography (EEG; p = 0.02) were more frequently associated with the development of epilepsy. Hemorrhagic stroke was strongly associated to both ASS and future focal epilepsy (p = 0.00097). Three patients (1.8%) developed hippocampal sclerosis ipsilateral to the cerebrovascular event between 2 and 5 years, all with ASS and hemorrhagic stroke.

INTERPRETATION

ASS and epileptiform EEG abnormalities are strong predictors of post-stroke epilepsy. HS develops in a minority of patients after hemorrhagic lesions, leading to focal epilepsy. Prospective studies are required, including follow-up with EEG and if characterized by epileptiform discharges, with MRI, to determine the true frequency of HS and to better understand predictors of post-stroke epilepsy (AAS, stroke type, and HS), and their impact on stroke recovery.

Targeting Nrf2 in ischemia-reperfusion alleviation: From signaling networks to therapeutic targeting

The nuclear factor erythroid 2-related factor 2 (Nrf2) is a master regulator of redox balance and it responds to various cell stresses that oxidative stress is the most well-known one. The Nrf2 should undergo nuclear translocation to exert its protective impacts and decrease ROS production. On the other hand, ischemic/reperfusion (I/R) injury is a pathological event resulting from low blood flow to an organ and followed by reperfusion. The I/R induces cell injury and organ dysfunction. The present review focuses on Nrf2 function in alleviation of I/R injury. Stimulating of Nrf2 signaling ameliorates I/R injury in various organs including lung, liver, brain, testis and heart. The Nrf2 enhances activity of antioxidant enzymes to reduce ROS production and prevent oxidative stress-mediated cell death. Besides, Nrf2 reduces inflammation via decreasing levels of pro-inflammatory factors including IL-6, IL-1β and TNF-α. Nrf2 signaling is beneficial in preventing apoptosis and increasing cell viability. Nrf2 induces autophagy to prevent apoptosis during I/R injury. Furthermore, it can interact with other molecular pathways including PI3K/Akt, NF-κB, miRNAs, lncRNAs and GSK-3β among others, to ameliorate I/R injury. The therapeutic agents, most of them are phytochemicals such as resveratrol, berberine and curcumin, induce Nrf2 signaling in I/R injury alleviation.

Development and validation of a composite score to predict severe forms of ischemic colitis

OBJECTIVE

To develop a simple scoring system in order to predict the risk of severe (death and/or surgery) ischemic colitis METHODS: In this retrospective study, 205 patients diagnosed with ischemic colitis in a tertiary hospital were consecutively included over a 6-year period. The study sample was sequentially divided into a training cohort (n = 103) and a validation cohort (n = 102). In the training cohort, multivariable analysis was used to identify clinical, biological, and CT variables associated with poor outcome and to build a risk scoring system. The discriminative ability of the score (sensitivity, specificity, positive predictive value, negative predictive value) was estimated in the two cohorts to externally validate the score, and a receiver operating characteristic curve was established to estimate the area under the curve of the score. Bootstrapping was used to validate the score internally.

RESULTS

In the training cohort, four independent variables were associated with unfavorable outcome: hemodynamic instability (2 pts), involvement of the small bowel (1 pt), paper-thin wall pattern (3 pts), no stratified enhancement pattern (1 pt). The score was used to categorize patients into low risk (score: 0, 1), high risk (score: 2-3), and very high risk (score: 4-7) groups with sensitivity and specificity of 97% and 67%, respectively, and a good discriminating capability, with a C-statistic of 0.94. Internal and external validation showed good discrimination capability (C-statistics of 0.9 and 0.84, respectively).

CONCLUSION

A simple risk score can stratify patients into three distinct prognosis groups, which can optimize patient management.

CLINICAL TRIAL NUMBER

NCT04662268 KEY POINTS: • Simple scoring system predicting the risk of severe ischemic colitis • First study to include CT findings to the clinical and biological data used to determine a severity score.

Sex differences in the association between diabetes and hypertension and the risk of stroke: cohort of the Tehran Lipid and Glucose Study

Background

We assessed the sex differences in the association between blood pressure categories and glucose intolerance status with overall and ischemic stroke among Iranian adults.

Methods

This prospective study was conducted on 5349 individuals (2446 men) aged ≥ 40 years. Cox models were used to estimate adjusted hazard ratios (HRs) and men-to-women ratios of HRs (RHRs) of overall and ischemic stroke for systolic (SBP) and diastolic (DBP) blood pressure, pre-hypertension, hypertension, fasting plasma glucose (FPG), pre-diabetes and type 2 diabetes (T2D).

Results

Each 0.55 mmol/L increase in FPG was associated with a higher HR of overall stroke in men than women [RHRs 1.05 (1.01–1.09)]. The associations between each 10 mmHg increase in DBP and stroke events were stronger in men than women, with RHRs of 1.20 (1.00–1.45) and 1.29 (1.04–1.60) for overall and ischemic stroke, respectively. Hypertension was associated with a higher HR of overall [RHRs: 2.41 (1.21–4.8)] and ischemic stroke [2.37 (1.12–5.01)] in men than women. We also found that T2D was associated with higher risks of overall and ischemic stroke in men than women: the RHRs were 2.16 (1.24–3.75) and 1.93 (1.05–3.55) for overall and ischemic stroke, respectively.

Conclusion

Hypertension and T2D induced higher risk of overall and ischemic stroke in men than women among Iranian population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13293-022-00421-7.

The associations between diastolic blood pressure and stroke events were stronger in men than women.

The fasting blood plasma level was associated with higher risk of stroke events in men than women.

Hypertension and diabetes were associated with higher risk of stroke events in men than women.

The association between systolic blood pressure with ischemic stroke was higher in men than women.

Outcomes of Mechanical Thrombectomy for Ischemic Stroke in Nonagenarians: A 10-Year Institutional Experience

BACKGROUND

Nonagenarians have been underrepresented in stroke trials that established endovascular treatment as the standard for acute ischemic stroke (AIS). Evidence remains inconclusive regarding the efficacy of thrombectomy in this population.

OBJECTIVES

To report our experience with thrombectomy in nonagenarians with stroke, and to identify predictors of mortality. We further investigated the effects of first-pass reperfusion and the addition of intravenous thrombolysis (IVT) on achieving better outcomes.

MATERIALS AND METHODS

Data was collected for consecutively treated patients at three affiliated comprehensive stroke centers from 2010 to 2021. We included patients ≥90 years-old with AIS secondary to large vessel occlusion. Bivariate analyses were performed using the Mann-Whitney U test for continuous variables, and χ² and Fisher's exact tests, respectively, for nominal and ordinal variables.

RESULTS

Thirty-two nonagenarians underwent thrombectomy, of whom 25 (81%) had prestroke mRS ≤2. Thrombectomies were performed using stents (2, 6.7%), aspiration (8, 26.7%), or a combination of both (20, 66.7%). Successful recanalization was achieved in 97%. Procedural complications occurred in 2 (6.3%) and intracranial hemorrhage in 3 (9.4%). Sixteen patients (50%) were discharged home or to rehabilitation, 9 (28.2%) to nursing home or hospice, and 7 (21.9%) died during hospitalization. Only 2 (6%) patients had mRS ≤2 at discharge. No independent predictors of in-hospital mortality were identified, and neither first-pass reperfusion nor the addition of IVT correlated with improvement in clinical outcome.

CONCLUSIONS

Although thrombectomy is safe for nonagenarian stroke and can achieve excellent recanalization, high mortality and poor functional status remain high given the advanced age and frailty of this population.

Healthcare Resource Utilization, Cardiovascular Event Rate and Use of Lipid-Lowering Therapies in Secondary Prevention of ASCVD in Hospitalized Patients in Italy

Introduction

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality in Italy, accounting for 22% of total deaths. Lowering low-density lipoprotein cholesterol (LDL-C) levels reduces the risk of cardiovascular (CV) events; thus, lipid-lowering therapy (LLT) is the first-line treatment for patients with ASCVD and hypercholesterolaemia. However, many patients with ASCVD fail to reach LDL-C treatment thresholds, leaving them at greater risk of CV events. Inpatient care accounts for 51% of total expenditure on cardiovascular disease in the European Union, but healthcare resource utilization (HCRU) data for ASCVD in Italy is limited.

Methods

The study analysed healthcare claims data for 17,881 patients with acute coronary syndrome, ischemic stroke or peripheral artery disease from the Umbria 2 and Marche regions of Italy. LLT treatment patterns and CV event rates were collected and HCRU estimated in the year before and after the index event.

Results

High-intensity LLTs were prescribed to 44.3% of patients and 49.6% received moderate-/low-intensity LLTs during the 6 months after the index event. The first year CV event rate was 18.0/100 patient-years for patients receiving high-intensity LLTs and 17.2/100 patient-years for those on moderate-/low-intensity LLTs. Higher costs were associated with patients untreated with LLT 6 months post-index event (€8323) than patients prescribed high-intensity (€6278) or moderate-/low-intensity LLTs (€6270). Hospitalization accounted for most of the total costs.

Conclusions

This study found that CV events in secondary prevention Italian patients are associated with substantial HCRU and costs. More intensive LDL-C lowering can prevent CV events, easing the financial burden on the healthcare system.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01960-y.