Non-nystagmus hyperkinetic eye movement disorders

BACKGROUND

While nystagmus is an involuntary ocular movement relatively frequent, well described, and easily recognized by most practitioners, non-nystagmus hyperkinetic eye movement disorders (NHEMD) are less obvious and can be overlooked. NHEMD may arise from intrinsic abnormalities in ocular muscles and oculomotor nerves, brain and brainstem lesions, systemic diseases, dysimmune disorders, drugs or can even be functional in nature. Given that some treatable disorders initially manifest with NHEMD, their knowledge becomes crucial.

AIMS

This review aims to offer a practical and comprehensive guide to recognize specific types of NHEMD, to choose the appropriate diagnostic tests and treatments.

RESULTS

The review approaches individual NHEMD based on the location of anatomical lesions and the underlying pathophysiological mechanisms; therefore, it begins with those arising from abnormalities in extraocular muscles or oculomotor nerves (as for example, superior oblique myokymia and ocular neuromyotonia), then moves to NHEMD due to brainstem and brain involvement (as for example, ocular bobbing, opsoclonus, and tonic downward gaze deviation). Lastly, functional NHEMD and nonnystagmus ocular hyperkinesias associated with specific neurological disorders, such as Parkinson's disease or blepharospasm will be considered.

CONCLUSION

Overall, the review offers a comprehensive reappraisal of hyperkinetic disorders of eye motility.

Lipocalin 2 mediates kidney function abnormalities induced by ischemic stroke in mice: Involvement of neural pathways

BACKGROUND

Kidney function abnormalities is a common complication following ischemic stroke. Lipocalin 2 (LCN2) is currently a well-recognized specific biomarker of tubular injury. However, the role of LCN2 in kidney function abnormalities following stroke remains elusive. The sympathetic nervous system plays a crucial role in linking the brain and kidney. However, whether the kidney sympathetic nervous system regulates the expression of LCN2 following ischemic stroke has not been identified.

METHODS

In this study, we established a middle cerebral artery occlusion (MCAO) model to induce ischemic stroke in mice. Renal function was assessed 24 h after cerebral ischemia-reperfusion injury. Transcriptomic sequencing of kidney tissue was performed to identify potential pathological mechanisms. The role of LCN2 in post-stroke renal injury was investigated using renal tubule-specific LCN2 knockout mice and a combination of qPCR, western blotting, immunofluorescence, and transmission electron microscopy. In addition, renal denervation (RDN) was used to explore the relationship between sympathetic nerves and the expression of renal LCN2.

RESULTS

Ischemic stroke significantly exhibits renal functional impairment 24 h after reperfusion. Notably, RNA sequencing and Western blotting revealed a markedly increased expression of renal LCN2 following ischemic stroke. Renal tubular Lcn2-specific knockout significantly ameliorated the occurrence of kidney function abnormalities after stroke. Subsequently, we observed that the activation of renal sympathetic nerves upregulates LCN2 and induces kidney function abnormalities after stroke.

CONCLUSIONS

These findings reveal a neural pathway in which the sympathetic nervous system upregulates LCN2, providing potential therapeutic strategies for renal protection following ischemic stroke.

Indole lactic acid derived from Akkermansia muciniphila activates the aryl hydrocarbon receptor to inhibit ferroptosis in ischemic stroke

Ischemic stroke concurrent with gut microbiome dysbiosis induces intestinal damage, which exacerbates cerebral infarction. Probiotic or prebiotic interventions that reverse gut microbiome dysbiosis can promote recovery after ischemic stroke. Akkermansia muciniphila (AKK) safeguards intestinal health and is a promising probiotic; however, its role in ischemic stroke remains unclear. In this study, we found that live AKK, but not pasteurized AKK, mitigated ischemic-stroke-induced neurological injury, reduced cerebral infarction, and enhanced both blood-brain and intestinal barrier integrity. Moreover, the AKK supernatant reduced intestinal and cerebral injury, demonstrating efficacy comparable to that of live AKK. Metabolomic analysis revealed that the AKK supernatant was significantly enriched in indole lactic acid (ILA), a tryptophan metabolite. ILA levels were elevated in the serum and brains of pseudo-germ-free stroke rats administered AKK. Exogenous gavage with ILA mitigated ischemic-stroke-induced brain and intestinal damage. Mechanistically, ILA activated the aryl hydrocarbon receptor (AhR) and the nuclear transcription factor Nrf2, leading to the upregulation of SLC7A11 and GPX4 protein expression. This attenuated lipid peroxidation and intracellular iron accumulation triggered by ischemic stroke. Notably, intervention with the AhR inhibitor CH223191 abrogated the protective effects of ILA in ischemic stroke rats. These findings suggest that the therapeutic efficacy of AKK in ischemic stroke is at least partially attributable to ILA-mediated ferroptosis inhibition via AhR activation. AKK was selectively enriched by Puerariae lobatae Radix-resistant starch (PRS), promoting ILA generation more effectively than inulin and β-glucan. AKK and PRS synergistically alleviated ischemic-stroke-induced impairments, outperforming monomicrobial or prebiotic treatment alone. These findings reveal the unique mechanisms of AKK in ischemic stroke and provide a viable strategy for the clinical treatment of ischemic stroke through a novel synbiotic combination.

Portable ultra-low-field MRI in acute stroke care: A pilot study

INTRODUCTION

Neuroimaging is a prerequisite for treatment of stroke patients, but it is not available all over the globe. Portable ultra-low field (pULF) MRI has the potential to improve access to neuroimaging and thus stroke care worldwide. In a pilot study, we were the first to utilise pULF-MRI in a European tertiary stroke centre and to evaluate its diagnostic value compared to high-field (HF) MRI.

PATIENTS AND METHODS

Consecutive patients admitted for suspected ischaemic stroke underwent pULF-MRI using the 0.064 Tesla Swoop® portable MR imaging system in addition to standard imaging. HF-MRI and pULF-MRI scans were blindly assessed to compare the diagnostic accuracy and imaging-based therapeutic decisions based on pULF-MRI to HF-MRI.

RESULTS

Seventeen patients underwent pULF-MRI, 12 of whom had ischaemic lesions on HF-MRI. Ischaemic lesions were detected on pULF-MRI in 8/12 cases. The four infarcts not identified on pULF-MRI were all smaller than 6 mm in diameter. In all cases, a virtual treatment decision based on pULF-MRI by a blinded team matched the actual clinical decisions.

CONCLUSION

This single-centre study demonstrates that pULF-MRI is a promising tool in acute stroke care, providing reliable imaging for treatment decision and follow-up monitoring. pULF-MRI may support acute stroke care if HF-MRI is unavailable and may be particularly helpful in resource-limited settings. Limitations of pULF-MRI include long acquisition times and the lack of vessel imaging and haemorrhage-sensitive sequences.

Mining the risk factors for stroke occurrence and dietary protective factors based on the NHANES database: Analysis using SHAP

BACKGROUND

Stroke has a high morbidity and mortality rate and its incidence is rising. This study aimed to identify risk factors for stroke, develop an accurate prediction model and scoring system, thereby providing novel primary prevention strategies for stroke and post-stroke depression.

METHODS

Data from 49,491 participants in the National Health and Nutrition Examination Survey (NHANES) (1999-2016) were analyzed. A training cohort of 3972 individuals was created. Logistic regression was applied for univariate and multivariate analyses to identify risk factors. SHAP values analyzed the impact of these factors, leading to the development of a prediction model and scoring scale. Model performance was validated using DCA, ROC, and calibration curves.

RESULTS

A prediction model with an AUC of 82 % was developed, alongside a scoring scale with an AUC of 79 %. Key risk factors were identified as "age(OR = 1.061, 95%CI:1.055-1.066, P<0.001)", "income level(OR= 0.812, 95%CI:0.777-0.85, P<0.001)", "cholesterol(OR = 0.845, 95%CI:0.793-0.901, P<0.001)", "albumin(OR = 0.614, 95%CI:0.497-0.757, P<0.001)", "lymphocyte percentage(OR= 1.045, 95%CI:1-1.091, P=0.048)", "alkaline phosphatase(OR= 1.005, 95%CI:1.002-1.002, P<0.001)", " Glucose(OR= 1.059, 95%CI:1.026-1.093, P<0.001)", "triglycerides(OR = 1.061, 95%CI:1.004-1.123, P = 0.037)", and "neutrophil percentage(OR= 1.058, 95%CI:1.015-1.102, P=0.008)".

CONCLUSION

In this study, a simple scoring scale was successfully developed based on the research findings. The scale demonstrates excellent clinical usability and operational convenience, providing a novel self-screening tool for the occurrence of stroke and post-stroke depression.

The Relationship Between Flavonols Intake and Stroke in the Elderly: a cross-sectional study from NHANES (2007-2010 and 2017-2018)

BACKGROUND

Stroke is a common fatal and disabling disease in the elderly. We investigated the correlation and potential benefits of dietary intake of flavonoid compounds and their subclasses in elderly stroke patients.

METHODS

This study analyzed data from the National Health and Nutrition Examination Survey (NHANES) for the cycles 2007-2010 and 2017-2018. Dietary flavonoids intake was calculated based on food frequency questionnaires (FFQ) through a 24-hour dietary recall. To explore the relationship between flavonoids intake and their subclasses with stroke prevalence, we employed multivariable logistic regression models, adjusting for relevant covariates. Restricted cubic splines (RCS) and generalized additive models (GAMs) were applied to explore potential nonlinear relationships between flavonols subclasses and stroke prevalence. Multivariable logistic regression models were conducted both for the overall population and stratified by flavonols subclasses intake. Additionally, we utilized Bayesian kernel machine regression (BKMR) to evaluate the overall effect of flavonols intake levels on stroke status, accounting for potential interaction and correlation between subclasses. Given the high correlation among flavonols subclasses, we incorporated a hierarchical variable selection approach using a Markov Chain Monte Carlo (MCMC) algorithm. Finally, we analyzed the XGBoost model by applying SHAP (SHapley Additive exPlanations) values to assess the specific contribution of different flavonoids intake to stroke.

RESULTS

Including 3,806 elderly stroke patients, the study revealed an inverse relationship between dietary flavonoids and their subclasses and stroke prevalence. After adjusting for potential confounders, it was found that higher quartiles of flavonols intake were associated with lower stroke prevalence. Specifically, with each unit increase in flavonols (Q4) intake, the odds of stroke in the elderly decreased by 61% (OR=0.390, 95% CI [0.209-0.728]; P = 0.005). Similar results were observed for the subclasses of flavonols. Subgroup analyses indicated that age and poverty index ratio (PIR) were effect modifiers in the relationship between flavonols intake and stroke. We further examined the intake levels of dietary flavonols subclasses such as isorhamnetin, kaempferol, myricetin, and quercetin and their association with stroke status stratified by population characteristics. In addition to age and PIR, hyperlipidemia and body mass index (BMI) were found to be the most common significant influencing factors in the relationship between flavonols subclasses and stroke prevalence. Furthermore, RCS revealed a "U"-shaped nonlinear relationship between flavonols, including their quercetin and kaempferol subclasses, and stroke, whereas the relationship between stroke and myricetin was linear. Our study also assessed the overall impact of dietary flavonols subclasses on stroke in the elderly and the interrelationships among these subclasses. The results consistently indicated a negative joint effect of flavonols subclass mixtures on the stroke status in the elderly. When evaluating the impact of individual flavonols subclasses on stroke status, a potential dose-response relationship was observed, with increasing intake of myricetin being associated with a decreased risk of stroke. Furthermore, SHAP plots show that flavonols intake is predominantly associated with negative SHAP values, indicating that higher dietary flavonols intake corresponds to a lower predicted stroke risk.

CONCLUSION

These results emphasize that adhering to an increased dietary intake of flavonoid compounds, particularly flavonols and their subclasses such as myricetin, is inversely associated with the prevalence of stroke among the U.S. elderly population. This offers potential benefits for stroke patients, especially among elderly individuals aged 60-70 and those with higher incomes.

PErioperative respiratory care aNd outcomes for patients underGoing hIgh risk abdomiNal surgery (PENGUIN): a randomised international internal pilot trial

Background

Infections are a common complication of abdominal surgery in low- and middle-income countries (LMICs). The role of a high fraction of inspired oxygen (FiO2) and chlorhexidine mouthwash in preventing post-operative infections is unconfirmed.

Methods

Internal pilot phase of an international outcome assessor-blinded, 2x2 factorial randomised trial of patients aged ≥10-years undergoing midline laparotomy in LMIC hospitals. The main trial objectives are to compare the clinical effectiveness of preoperative 0.2% chlorhexidine mouthwash in preventing pneumonia versus no mouthwash, and 80-100% perioperative FiO2 to prevent surgical site infection (SSI) versus 21-35% FiO2. This 12-month internal pilot assessed feasibility of hospital site opening, patient recruitment, intervention adherence, patient follow-up and safety. Patients were randomised in a 1:1:1:1 ratio to the four intervention group combinations and followed up for 30 days.

Results

We recruited 927 patients from seven hospitals in India and South Africa over 12 months from November 2020. There were 907 adults (97.8%) and 20 children aged ten or over (2.2%): 89/927 (9.6%) patients died. Site opening reached 70% of our target (7/10) hospitals, and patient recruitment 107% (927/870). 917/927 (99%) patients in the mouthwash arm, and 840/927 (91%) patients in the oxygen arm received the allocated intervention. Lower adherence to the oxygen intervention related mainly to clinically necessary FiO2 increases in the 21-35% FiO2 arm. 30-day follow-up was completed appropriately for 924/927 (99%) patients. and was performed by a masked assessor for all patients. There were no reported safety events.

Conclusion

This pilot showed the feasibility and safety of a major phase III trial in post-operative infection prevention in LMICs.

Trial registration

ClinicalTrials.gov NCT04256798.

Association between estimated cardiorespiratory fitness trajectory and stroke and its subtypes: A prospective cohort study

BACKGROUND AND AIMS

The association between estimated cardiorespiratory fitness (eCRF) and stroke is ethnically heterogeneous, and conclusions are inconsistent among different stroke subtypes. The aim was to examine the relationship between eCRF trajectory and stroke and its subtypes in the Chinese population.

METHODS AND RESULTS

37,881 participants from the Kailuan Study (2006-2021) who underwent three waves survey and were free of cancer and stroke before or during 2010 were included in this study. The main outcome was stroke, involving ischemic stroke (IS) and intracerebral hemorrhage (ICH). The relationships were assessed using the Cox proportional hazard model. Three distinct eCRF trajectories were identified during 2006-2010: low, moderate, and high. A total of 2150 stroke events, including 1944 cases of IS and 231 cases of ICH, were reported during a median follow-up of 11.04 (interquartile range: 10.65-11.33) years. Compared to the low eCRF trajectory group, participants in the high eCRF trajectory group were associated with a 31 % lower risk of stroke (hazard ratio [HR] [95 % CI], 0.69 [0.60-0.81]), a 30 % lower risk of IS (0.70 [0.59-0.82]), and a 43 % lower risk of ICH (0.57 [0.36-0.91]). Notably, the association between the high eCRF trajectory and IS (Pinteraction = 0.0270) was stronger among women than men.

CONCLUSION

A long-term high eCRF level is associated with a decreased risk of stroke, especially ICH. Therefore, achieving or sustaining a high eCRF level over time could be a beneficial strategy for decreasing the risk of stroke.

Global trends, disparities, and future projections of ischemic stroke burden attributed to low-fiber diets: An analysis based on GBD 2021

OBJECTIVE

This study aims to analyze the disease burden attributed to ischemic stroke related to low-fiber diets (IFD-IS) from 1990 to 2021, utilizing data from the Global Burden of Disease (GBD) database to identify trends and influencing factors of the disease burden.

METHODS

We conducted a comprehensive analysis of the number of deaths, Disability-Adjusted Life Years (DALYs), Years of Life Lost (YLLs), and Years Lost due to Disability (YLDs) associated with IFD-IS, covering various regions and populations. Statistical methods, including breakpoint regression, decomposition analysis, health inequality analysis, and forecasting analysis, were employed to assess trends and their correlation with the Sociodemographic Index (SDI).

RESULTS

The findings indicate that deaths, DALYs, YLLs, and YLDs related to IFD-IS have gradually increased globally, with a significantly higher burden in males compared to females. Notable regional disparities were observed, particularly with heavier burdens in China and sub-Saharan Africa. Higher SDI regions demonstrated better control over disease burdens, while aging and population growth were the primary factors contributing to the increase. Additionally, the trend of health inequality related to IFD-IS has slightly diminished, although it is projected that the disease burden will continue to rise by 2040.

CONCLUSION

This study underscores the necessity of implementing targeted public health interventions for IFD-IS, particularly in low SDI regions. Enhancing dietary education and resource allocation can significantly mitigate the rising trend of IFD-IS. Ongoing monitoring and research are crucial for formulating effective health policies to address this public health challenge.

Joint effect of modifiable risk factors and genetic susceptibility on ischaemic stroke

PURPOSE

To investigate the effects of modifiable risk factors and genetic susceptibility on ischaemic stroke (IS).

METHODS

A total of 490365 participants from the UK Biobank, with a 17-year follow-up, were included in this study. Data on 115 modifiable exposures were collected from five domains: early life, environment, lifestyle, socioeconomic status, and physical measures. Additionaly, genetic data were collected. An exposure-wide association analysis was conducted to identify potential risk factors. Risk scores for each domain and genes were calculated. The effect of each domain score on IS and the joint effects among the five domains were analyzed using multi-variate Cox models. The population attributable fraction was estimated to quantize the impact of eliminating unfavorable factors.

RESULTS

Sixty-four of the 115 modifiable exposures were found to be significantly associated with the risk of IS (P < 4.35 × 10-4 for Bonferroni correction). Newly identified factors included maternal smoking and being either overweight or underweight at age 10, which could significantly increase the risk of IS by 4.78 % to 14.74 %, 11.01 % to 23.75 %, and 3.29 % to 12.80 %, respectively. Additionally, exposure to hard water was associated with a decreased risk of IS by 6.96 % to 11.48 % compared to exposure to soft water. The associations varied across domains, with socioeconomic factors accounting for 5.2 % of IS cases, lifestyle accounting for 2.8 %, and physical measures accounting for 2.5 %, representing the top three contributing factors. Overall, it was estimated that 10.6 % to 11.3 % of IS cases could be prevented by eliminating the identified risks.

CONCLUSIONS

Interactions between risk factors and genetic susceptibility elevated the risk of IS. Risk factors from different domains contributed variably to IS, with socioeconomic factors accounting for the largest proportion.

The Association of the Distance to the Hospital, Hospital Reputation, and Hospitalization Outcomes Among Patients with Stroke in China

Background: Both distance to the hospital and hospital reputation influence patient choice of hospital; but the combined effect of these factors and how they relate to hospitalization outcomes has yet to be determined. The purpose of this study was to assess the combined influence of distance to hospital and hospital reputation on the hospitalization outcomes in patients with stroke. Methods: This retrospective observational study utilized data from 69,107 stroke patients hospitalized in southern Chinese megacity between 2019 and 2021. A generalized linear model was used to assess the association between hospital reputation, distance to the hospital, hospitalization costs, and the length of stay. Multivariate logistic regression was used to estimate the combined effect on in-hospital mortality. Results: Compared with patients who chose hospitals without a good reputation and close to home, those who chose hospitals with a good reputation had lower hospitalization costs (-0.05; 95% CI: -0.08 to -0.02), a shorter length of stay (-0.18; 95% CI: -0.20 to -0.16), and lower in-hospital mortality (0.52; 95% CI: 0.40 to 0.67). However, patients who chose hospitals with a good reputation but farther distance experienced higher hospitalization costs (0.20; 95% CI: 0.17 to 0.23). Conclusions: A shorter distance to the hospital and a higher reputation of the hospital are associated with lower costs and better outcomes. Our study indicates that improving outcomes for patients with stroke requires equitable distribution of quality medical resources.

Preferences for long-termcare among elderly patients who had a stroke with disabilities in Eastern China: protocol for a ditscrete choice experiment study

BACKGROUND

Stroke is a leading cause of disability among older adults worldwide, often resulting in significant physical, cognitive and emotional impairments that require long-term care. With ageing populations and increasing stroke prevalence, the demand for appropriate and sustainable long-term care is growing. However, designing care models that align with the complex needs and preferences of elderly patients who had a stroke remains a challenge. This study employs a discrete choice experiment (DCE) to measure and quantify patients' preferences for long-term care. The primary objectives of this study are as follows: (1) identify and examine the key attributes and levels of long-term care that are most valued by this patient population, (2) assess patients' preferences for long-term care and explore the role of each attribute on overall preference and (3) explore heterogeneity in preferences based on participants' characteristics through subgroup analyses.

METHODS

The research was conducted in accordance with the design programme of the DCE study. Seven attributes were developed through a systematic literature review, in-depth interviews and experts consultation. A partial factorial survey design was generated through an orthogonal experimental design to optimise the choice scenario sets. We plan to conduct a DCE questionnaire survey in Suzhou, Jiangsu Province, China, and recruit at least 500 participants. The final data will be analysed through a mixed logit model and a latent class model to explore the preference of elderly patients who had a stroke with disabilities for long-term care.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of Nanjing Medical University-Affiliated Suzhou Hospital (K-2024-096 K01). All participants will be required to provide informed consent. The findings of this study will be disseminated and shared with interested patient groups and the general public through a variety of channels, including online blogs, policy briefs, national and international conferences, and peer-reviewed journals.

A scoping review of the utilization of mobile stroke units in low and lower middle-income countries: current evidence, implications and future direction

BACKGROUND

Low and Lower-Middle-Income Countries (LMICs) have the highest stroke incidence, prevalence, and case fatality rates globally. Current evidence suggests Mobile Stroke Units (MSUs) outperform traditional Emergency Medicine Services (EMS) in time metrics, cost-effectiveness, and long-term outcomes. MSUs could potentially improve stroke outcomes in resource-constrained settings by addressing critical challenges related to prehospital delays, health-seeking behavior, and access to expertise.

PURPOSE

This scoping review aims to assess the existing literature and knowledge gaps on the utilization of mobile stroke units in LMICS, their impact on stroke outcomes, and cost-effectiveness.

MATERIALS AND METHODS

We conducted a detailed search of PubMed, Scopus, CINAHL, African Index Medicus, and Publicly Available Content Database (ProQuest) inception to April 15, 2024. Google Scholar and TRIP Pro were also searched to identify Grey literature. African Journals Online, references were also hand-searched.

RESULTS

Seven hundred and eighty-five studies were screened; only two met the eligibility criteria. Cherian et al. report the first use of a mobile stroke unit (MSU) in India, detailing its operations during the first year and the challenges encountered. According to the authors, fewer patients utilize MSUs in India compared to other parts of the world due to challenges such as a lack of awareness and affordability. Osuegbu et al. also report the absence of both fixed and mobile stroke units in Rivers State, Nigeria.

CONCLUSION

There is currently very limited data to support the contextual suitability of MSU or implementation strategies to guide its integration into stroke care systems in LMICs. Further research is needed to examine the utilization, barriers, impact, and cost-effectiveness of Mobile Stroke Units (MSUs) in low- and middle-income countries. This could inform stakeholders and policymakers about the potential role and value of MSUs within stroke care systems in these settings.

Combined effect of heatwaves and residential greenness on the risk of stroke among Chinese adults: A national cohort study

Heatwaves have been associated with an increased risk of stroke, while residential greenness may offer protective benefits. This prospective cohort study examined 22,702 participants aged 35 years or older, with no prior history of cardiovascular disease (CVD), from the China Hypertension Survey (CHS) conducted between 2012 and 2015. Participants were followed up between 2018 and 2019. Heatwaves were defined as daily maximum temperatures exceeding the 92.5th percentile of the warm season for at least three consecutive days. Residential greenness was quantified using the Normalized Difference Vegetation Index (NDVI) within buffers of 300, 500, and 1000 m from participants' residences. Multivariable Cox proportional hazards models evaluated the independent and combined effects of heatwaves and greenness on stroke risk, while restricted cubic spline analyses explored nonlinear relationships. Interaction effects were assessed using both multiplicative and additive Cox regression models. During follow-up, 597 stroke events occurred. Each additional 3-day increase in heatwave days was associated with an increased stroke risk (HR: 1.19, 95 % CI: 1.08-1.31). Interaction analyses demonstrated a synergistic effect between heatwaves and lower residential greenness (NDVI300 m, NDVI500 m and NDVI1000 m) on stroke risk, with significant additive(RERI > 0, P < 0.05) and multiplicative interactions (HR > 1, P < 0.05). The strongest protective effects of greenness were observed within a 500 m buffer zone, particularly for individuals under 60 years, rural residents, and those with higher educational attainment. This study highlights the potential benefits of enhancing greenness for cardiovascular health and provides valuable insights for environmental governance and public health policy in China.

Proximal Single Subcortical Infarction, Left Ventricular Fractional Shortening, and Risk Prediction Model Development for Neurological Deterioration in Patients With Anterior Circulation Single Subcortical Infarction

BACKGROUND

With different infarct morphological characteristics included, the relationship between single subcortical infarction type and neurological deterioration (ND) remains unclear. Similarly, the diagnostic value of the known risk factors is also uncertain.

METHODS

We conducted a prospective observational study at a tertiary teaching hospital affiliated with Fudan University, enrolling patients with anterior circulation single subcortical infarction within 24 hours of symptom onset from 2017 to 2018. Clinical data, magnetic resonance imaging infarct characteristics, and echocardiographic indices were analyzed using a multivariable logistic regression model to identify independent ND predictors. The receiver operating characteristic curve with multiple testing corrections was performed to assess the discriminatory abilities of different models and the calibration curve for the accuracy of the optimal model.

RESULTS

The study included 298 patients, with 80 (26.85%) experiencing ND. Multivariate analysis identified admission National Institutes of Health Stroke Scale score (odds ratio [OR], 1.197 [95% CI, 1.067-1.343], P=0.002), proximal single subcortical infarction (OR, 3.311 [95% CI, 1.608-6.817], P=0.001), maximal diameter on axial DWI (OR, 1.651 [95% CI, 1.042-2.617], P=0.033), and left ventricular fractional shortening (OR, 0.001 [95% CI, 0.000-0.282], P=0.021) as independent predictors of ND. The optimal model, including the independent predictors and parent artery disease, demonstrated improved discrimination (area under the curve=0.762) and good calibration (Hosmer-Lemeshow P=0.51). left ventricular fractional shortening contributed positively to this model's performance (net reclassification improvement: 24.8%, P=0.051; integrated discrimination index: 2.1%, P=0.018).

CONCLUSIONS

When considering different infarct morphological characteristics simultaneously, SSI type remains an independent predictor of ND in patients with anterior circulation SSI. Furthermore, our research indicated left ventricular fractional shortening as a novel predictor, which can improve the discriminative ability of the prediction model.

Navigational difficulties after stroke: A systematic review and meta-analysis

OBJECTIVE

Navigation, the ability to find one's way from one place to another, is an important cognitive skill for maintaining autonomy in daily life. Several findings indicate that navigational ability can be impaired after stroke. However, navigation is rarely assessed in clinical practice, and evidence-based recommendations for suitable diagnostic tools are lacking. Furthermore, the scientific literature does not provide a meta-analytic estimation of the prevalence of post-stroke navigational impairments. This systematic review aims to provide an overview of the tools to assess navigational difficulties after stroke, including their psychometric properties, and determine the prevalence of post-stroke navigational difficulties.

METHOD

Three investigators independently and systematically searched publications performing assessments of navigation in the stroke population, with a fourth independent investigator consulted when discrepancies were present. References of the retrieved articles were hand searched for relevant articles.

RESULTS

The systematic review included 19 studies, reporting on 19 different approaches to assess objective and/or subjective navigation skills, each with different psychometric properties. The pooled effect size, using a random-effects model including data from a subset of 8 out of the 19 included studies, demonstrated a prevalence of post-stroke navigation impairments of 35% (95% CI: 0.29-0.42). However, this model was significantly heterogeneous.

CONCLUSIONS

Navigational difficulties are a common neuropsychological deficit after stroke. However, navigation is a broad construct and a subdivision to reduce heterogeneity in navigation ability is recommended, e.g. by categorizing navigation into landmark-, location-, and path-based navigation impairment. The inclusion of objective and subjective assessments of navigation is recommended in clinical practice.

REGISTRATION

The protocol was registered at the PROSPERO international prospective register of systematic reviews (PROSPERO ID: CRD42023491346).

Associations between dietary index for gut microbiota and stroke, and the mediating role of inflammation: a prospective cohort study

Background: There has been a growing focus on the link between diet, gut microbiota, and stroke. The dietary index for gut microbiota (DI-GM), a novel indicator reflecting the effect of diet on gut microbiota diversity, has not been extensively studied in relation to stroke. This study aimed to examine the association between DI-GM and stroke, and to explore the potential mediating role of inflammatory biomarkers. Methods: We included 124 943 participants from the UK Biobank without stroke at baseline. The DI-GM was calculated using 24-hour dietary assessments. Cox proportional hazard models were employed to analyze the longitudinal associations of DI-GM with stroke and its subtypes. Restricted cubic spline (RCS) and subgroup analyses were also performed. Additionally, mediation analyses were conducted to explore the potential mediating role of inflammatory biomarkers between DI-GM and stroke risk. Results: During a median follow-up of 11.08 years, 3741 participants experienced a stroke, including 1626 ischemic strokes and 536 hemorrhagic strokes. After adjusting for covariates in the main model, higher DI-GM was significantly associated with reduced risks of stroke (HR = 0.97, 95% CI, 0.95-0.99, P < 0.001) and ischemic stroke (HR = 0.96, 95% CI, 0.94-0.99, P = 0.008), but not hemorrhagic stroke. No significant non-linear association was observed in the RCS analysis. Mediation analyses indicated that inflammatory biomarkers, including C-reactive protein, neutrophils, monocytes, leukocytes, neutrophil-to-lymphocyte ratio, and INFLA-score, partially mediated the association, accounting for 2.82% to 10.40% of the total effect. Conclusions: Higher DI-GM was associated with a reduced risk of stroke, particularly ischemic stroke. This protective association may be partially mediated by reductions in serum inflammatory biomarkers.

Atherogenic index of plasma and triglyceride-glucose index mediate the association between stroke and all-cause mortality: insights from the lipid paradox

BACKGROUND

The "lipid paradox" describes the counterintuitive observation that traditionally unfavorable lipid profiles may be associated with improved outcomes in stroke patients. Non-traditional lipid markers such as the atherogenic index of plasma (AIP) and the triglyceride-glucose (TyG) index have been proposed to better reflect the complex metabolic disturbances following stroke. This study aims to investigate the mediating role of AIP and TyG index in the association between stroke and all-cause mortality and elucidate the potential mechanisms underlying the lipid paradox.

METHODS

This cohort study used data from the China Health and Retirement Longitudinal Study (CHARLS), including 10,220 participants enrolled from 2011 to 2020, with a maximum follow-up of 10 years. AIP and TyG index were calculated from baseline serum measurements. U-test, chi-square test, restricted cubic spline analysis (RCS), cox proportional hazards regression and mediation model were used to analyze the relationship between baseline AIP, TyG index, stroke and all-cause mortality.

RESULTS

A total of 1,421 deaths (13.90%) occurred during an average follow-up of 9.21 years. Compared to survivors, non-survivors were older, had a higher prevalence of stroke, and lower AIP levels (P < 0.05), while TyG index showed no significant group difference. RCS analysis revealed a nonlinear association between the TyG index and mortality, but no significant nonlinearity for AIP. Cox regression analysis identified age, gender, marital status, smoking history, hypertension, diabetes, lung disease, stroke, AIP, and the highest TyG quartile (Q4) as independent predictors of all-cause mortality (all P < 0.05). Notably, AIP showed a negative association with mortality (HR = 0.87, 95% CI: 0.77-0.98),demonstrating a lipid paradox phenomenon. Furthermore, in the chain mediation model, both AIP (β=-0.03, 95%CI: -0.072 to -0.002) and TyG index (β=-0.016, 95%CI: -0.036 to -0.002) independently mediated the association between stroke and all-cause mortality in a negative manner. However, the positive chain mediating effect of AIP through TyG index (β = 0.028, 95%CI: 0.003-0.066) offset this negative mediation, rendering the overall mediating effect insignificant.

CONCLUSIONS

AIP and the TyG index independently or jointly influence the risk of all-cause mortality after stroke. Notably, AIP demonstrates a significant lipid paradox phenomenon. Moreover, the chain mediating effect of AIP and TyG significantly increases post-stroke mortality risk. These findings highlight the complex interplay between lipid and glucose metabolism in stroke prognosis and offer a novel perspective for post-stroke metabolic management.

Pragmatic strategies for improving prevention, diagnosis, and treatment of epilepsy in low- and middle-income countries

Epilepsy poses a major public health challenge in low- and middle-income countries (LMICs), where prevention, diagnosis, and treatment must be tailored to local resources, infrastructure, and cultural contexts. Despite their diversity, LMICs commonly experience a pronounced urban-rural disparity in epilepsy care, with rural communities facing limited healthcare infrastructure, a shortage of specialists, and pervasive stigma. Prevention efforts should focus on modifiable risk factors. Neurocysticercosis, a leading preventable cause of epilepsy in endemic regions, can be addressed through improved sanitation, access to clean water, and timely treatment supported by low-cost diagnostics. Enhancing perinatal care, injury prevention, and stroke management is also essential to reduce epilepsy incidence. Stigma continues to hinder care. Targeted education campaigns aimed at schools, community leaders, and the general public are vital to improving awareness and reducing discrimination. Bridging diagnostic gaps requires accessible, cost-effective tools such as portable EEGs, smartphone-based seizure recordings, and mobile diagnostic applications. Integration of these technologies into community health systems, and their use by trained primary care providers and community health workers, enables earlier detection and ongoing monitoring, particularly in underserved areas. Treatment strategies should prioritize "easy-to-use," well-tolerated medications such as levetiracetam. Improving the affordability of antiseizure medications involves promoting generic alternatives, revising patent laws, regulating drug prices, setting price ceilings for essential medicines, and enabling bulk procurement. National health insurance schemes are crucial to ensure access for low-income populations. Expanding access through home-based care by community health workers, mobile outreach clinics, telemedicine, and collaboration with traditional healers can further improve treatment adherence and outcomes. Finally, training primary care physicians in epilepsy care is essential, as they are often the first point of contact for patients in rural and resource-limited settings.

Exploring the homecoming: a qualitative multimethod approach to understanding stroke survivors and their caregivers' experience

PURPOSE

To explore and compare the experiences and perceptions of stroke survivors and caregivers during the transition period from hospital to home.

MATERIALS AND METHODS

A qualitative study was conducted involving face-to-face interviews with 19 stroke survivors and 18 caregivers, to explore their experience with the transition from hospital to home, adopting Automatic Analysis of Textual Data for data analysis. The sample was recruited from neurology wards in Italy. Data collection focused on participants' experiences, needs, and challenges of participants during the transition period. Ethical approval and participant consent were obtained.

FINDINGS

The findings revealed distinct but interconnected experiences of stroke survivors and caregivers. Stroke survivors primarily expressed physical and emotional struggles, while caregivers highlighted the need for preparation and support. Key themes included the critical role of pre-discharge planning, the impact of social support on recovery, and the shared burden of transitioning to new routines. Hierarchical descending classification identified eight thematic domains, underscoring the complexity of transition care needs.

CONCLUSION

This study emphasizes the importance of individualized and integrated transitional care interventions that address the diverse needs of stroke survivors and caregivers. The innovative use of AATD provided deeper insight into their shared and unique experiences, advocating for tailored strategies to enhance recovery and quality of life.

Global, regional, and national burden of ischemic stroke in older adults (≥60 years) from 1990 to 2021 and projections to 2030

Background

Ischemic stroke is a leading cause of disability and mortality among adults worldwide, particularly in the older population (≥60 years). With the accelerating global aging population, it is crucial to analyze the trends and influencing factors of the global, regional, and national burden of ischemic stroke and forecast future trends. These insights are essential for informing the formulation of public health policies.

Methods

Using data from the Global Burden of Disease (GBD) 2021 database, this study examined the age-standardized incidence, age-standardized prevalence, age-standardized mortality, and age-standardized disability-adjusted life years (DALYs) of ischemic stroke in individuals aged 60 years and above from 1990 to 2021. A combination of variables, including the socio-demographic index (SDI), sex, and age groups, was applied in regression analyses and Bayesian predictive models to examine trends and forecast the burden of ischemic stroke up to 2030.

Results

From 1990 to 2021, despite global population growth among older adults, the age-standardized incidence, age-standardized prevalence, age-standardized mortality, and age-standardized disability-adjusted life years of ischemic stroke demonstrated an overall declining trend (all EAPCs were negative). The decline in disease burden was most pronounced in high-SDI regions, while low-SDI regions faced a significantly higher disease burden and exhibited notable regional disparities. The overall burden of ischemic stroke was higher in males than in females; however, in the 80-84 age group, females exceeded males in disease burden. Projections indicate that by 2030, the burden of ischemic stroke in older adults globally will continue to decline. Nevertheless, due to the aging population, the absolute number of patients is expected to increase.

Conclusion

The global burden of ischemic stroke has significantly decreased, particularly in high-SDI regions with abundant healthcare resources. However, low-SDI regions face more substantial public health challenges. It is recommended to enhance the control of high-risk factors such as hypertension, smoking, and high BMI, and to optimize healthcare services in low-income regions to further reduce the burden of ischemic stroke and improve the quality of life for older adults.

Modified microcatheter first-pass effect: Enhancing diagnostic accuracy and treatment strategies for ICAS in acute ischemic stroke

OBJECTIVES

To evaluate the effectiveness of the modified microcatheter first-pass effect in guiding treatment decisions for ICAS-related occlusions during endovascular therapy (EVT) for AIS.

METHODS

This study analyzed data from 31 AIS patients with a positive modified microcatheter first-pass effect from the OCEAN-AIS-EVT REGISTRY collected between July 2023 and January 2024. We evaluated diagnostic accuracy, procedural efficiency, recanalization rates, and safety.

RESULTS

ICAS was confirmed in all cases. The median age was 69 years, with 61.29 % males. The median NIHSS score was 9, and ASPECTS was 9. Stenosis primarily occurred in the M1 segment of the middle cerebral artery (74.19 %). The median puncture-to-recanalization time was 18.92 min. Successful recanalization (eTICI grade 3) was achieved in 87.10 % of cases. Post-procedural hemorrhage occurred in 12.90 % of patients, with symptomatic hemorrhage in 3.23 %. At 90-day follow-up, 80.64 % had an mRS score of 0-2.

CONCLUSION

The modified microcatheter first-pass effect may serve as a promising preliminary tool for guiding EVT strategy in ICAS-related AIS. By confirming distal vessel patency, it enables direct angioplasty without prior thrombectomy, simplifying the procedure and reducing mechanical manipulation. While this exploratory approach has shown potential to enhance treatment efficiency and improve clinical outcomes, larger-scale prospective studies are needed to further validate these preliminary findings.

Pharmacological therapies for early and long-term recovery in disorders of consciousness: current knowledge and promising avenues

INTRODUCTION

Disorders of consciousness (DoC) are characterized by impaired arousal and/or awareness, ranging from coma to unresponsive wakefulness syndrome, minimally conscious state, and cognitive motor dissociation. Pharmacological treatment options remain limited, complicated by the heterogeneity of etiologies, such as traumatic brain injury, stroke, and infections. The lack of rigorous clinical trials has led to off-label use of treatments, often without clear mechanistic understanding, posing challenges for effective patient care.

AREAS COVERED

In this perspective, the authors report on key studies concerning the effectiveness of pharmacological interventions, including dopaminergic and GABAergic agents, antidepressants, statins, and anticonvulsants, in promoting recovery of consciousness in DoC.

EXPERT OPINION

Robust longitudinal clinical trials are needed, with priority given to early subacute phase intervention. Outcomes should be better defined, considering immediate responses to medication while also increasing the emphasis on long-term quality of life. Unified functional and mechanistic frameworks are needed to guide research and foster collaboration. Furthermore, a shift toward personalized medicine would benefit this heterogeneous population. Moving forward, assessing the efficacy of more unconventional or 'paradoxical' pharmacological options in treatment plans will be essential. The authors also expect an increased use of AI tools to identify factors that best predict treatment responses.

Successful Surgical Management of Giant, Shamblin III Carotid Body Tumor (CBT) on a Male With 5 Years of Follow-Up: Case Report and Literature Review on Giant CBT

BackgroundCarotid body tumor (CBT) is a rare neoplasm that arises from the chemoreceptor cells located at the carotid bifurcation. Giant CBTs are extremely rare, with only 16 cases reported to date.Case SummaryA 63-year-old male with an unremarkable medical history presented with a right-sided, giant, Shamblin III CBT. For 20 years, he had been suffering from progressive dyspnea, dysphonia, and pain with left neck rotation. A computed tomography scan confirmed its dimension of 89 × 61 × 60 mm (height × width × depth). We performed our routine retrocarotid dissection technique (RCDT) without preoperative embolization. Histopathology reported an encapsulated, non-epithelial neuroendocrine neoplasm with architectural Zellballen pattern. His postoperative period was uneventful and was discharged home on day 2. At 5 years, he remains symptom-free without neoplasm recurrence.ConclusionThis case illustrates the atypical clinical presentation and the successful treatment of a giant, Shamblin III CBT with the RCDT without preoperative embolization.

ArmVR: Innovative Design Combining Virtual Reality Technology and Mechanical Equipment in Stroke Rehabilitation Therapy

The rising incidence of stroke has created a significant global public health challenge. The immersive qualities of virtual reality (VR) technology, along with its distinct advantages, make it a promising tool for stroke rehabilitation. To address this challenge, developing VR-based upper limb rehabilitation systems has become a critical research focus. This study developed and evaluated an innovative ArmVR system that combines VR technology with rehabilitation hardware to improve recovery outcomes for stroke patients. Through comprehensive assessments, including neurofeedback, pressure feedback, and subjective feedback, the results suggest that VR technology has the potential to positively support the recovery of cognitive and motor functions. Different VR environments affect rehabilitation outcomes: forest scenarios aid emotional relaxation, while city scenarios better activate motor centers in stroke patients. The study also identified variations in responses among different user groups. Normal users showed significant changes in cognitive function, whereas stroke patients primarily experienced motor function recovery. These findings suggest that VR-integrated rehabilitation systems possess great potential, and personalized design can further enhance recovery outcomes, meet diverse patient needs, and ultimately improve quality of life.

Co-occurrence patterns and related risk factors of ischaemic heart disease and ischaemic stroke across 203 countries and territories: a spatial correspondence and systematic analysis

BACKGROUND

Ischaemic heart disease (IHD) and ischaemic stroke are leading causes of death worldwide. Although extensively studied, previous research has predominantly addressed these two diseases in isolation. Comorbidity research faces challenges both at the patient level and in terms of study methods. We aimed to characterise the global co-occurrence pattern of IHD and ischaemic stroke from a spatial perspective and to identify the corresponding risk factors of the comorbidity.

METHODS

Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 database, we extracted incidence rates of IHD and ischaemic stroke and exposure rates of the 68 most detailed risk factors among individuals aged 25 years or older from 203 countries and territories. Based on the four quartiles of global incidence rates for both diseases, we proposed the comorbidity's co-occurrence patterns and classified the 203 countries or territories into three distinct regions (consistent, IHD-dominant, and ischaemic stroke-dominant areas). We used machine learning and negative binomial regression to screen and quantify the effects of corresponding risk factors and computed the population-attributable fraction and composite risk index to evaluate the global disease burden of IHD and ischaemic stroke.

FINDINGS

89 countries were classified as consistent, 59 as IHD-dominant, and 55 as ischaemic stroke-dominant. The spatial distribution of the three co-occurrence patterns overlapped with exposure to environmental, dietary, and behavioural risk factors. Nine risk factors were identified and functionally classified into common and specific features. Most countries are simultaneously exposed to the combined effects of multiple risk factors. Overall, 45·43% of IHD incidence and 38·53% of ischaemic stroke incidence is attributable to cumulative exposure to the respective risk factors, with specific combinations and variations of these factors greatly influencing the global disparities and patterns of incidence.

INTERPRETATION

The comorbidity of IHD and ischaemic stroke is a pervasive global health issue. Intervening corresponding modifiable risk factors can fundamentally reduce the global burden of these diseases.

FUNDING

National High Level Hospital Clinical Research Funding.

Post-stroke cognitive impairment and dementia research in Southeast Asia: A scoping review

INTRODUCTION

The incidence of stroke remains high in Southeast Asia (SEA), according to the 2021 Global Burden of Disease study. Stroke can lead to cognitive impairments and dementia, highlighting the need for evidence-based management.

AIM

To chart the research on post-stroke cognitive impairment and dementia (PSCID) in SEA.

METHODS

The review was conducted and reported using the PRISMA-ScR. A comprehensive search was performed across six databases: CINAHL, Scopus, Embase, PubMed, Web of Science, and APA PsycINFO. The last search date was September 15, 2024.

RESULTS

9118 references were identified, and 103 articles (from 78 studies) published between 1992 and 2024 were included. Singapore contributed 42 articles, followed by Indonesia with 28, Malaysia with 17 and Thailand with 15. 35 articles each were from cohort and cross-sectional studies, and 13 were case-control design articles. In Indonesia, the prevalence of post-stroke cognitive impairment (PSCI) ranged from 27.6 % to 81.2 %. In Malaysia, it was between 21.6 % and 76 %; in Singapore, it varied from 12 % to 57.2 %; and in Thailand, between 50.3 % and 55 %. The prevalence of post-troke dementia varied between 2.8 % and 48.4 % in the sources. The most risk factors associated with PSCID included increasing age and low levels of education. Mixed findings on the effectiveness of the limited management strategies for PSCI were reported. The region lacks research from low- and lower-middle-income countries (LLMICs). Moreover, thorough research on how PSCID affects survivors' quality of life (QoL) is deficient.

CONCLUSION

PSCID is common in SEA, requiring urgent interventions for improved QoL for survivors. More research focusing on low- and middle-income countries is needed.

Molecular imaging-guided diagnosis and treatment integration for brain diseases

In practical clinical scenarios, improved diagnostic methods have been developed for the precise visualization of molecular targets using molecular imaging in brain diseases. Recently, the introduction of innovative molecular imaging modalities across both macroscopic and mesoscopic dimensions, with remarkable specificity and spatial resolution, has expanded the scope of applications beyond diagnostic testing, with the potential to guide therapeutic interventions, offering real-time feedback in the context of brain therapy. The molecular imaging-guided integration of diagnosis and treatment holds the potential to revolutionize disease management by enabling the real-time monitoring of treatment responses and therapy adjustments. Given the vibrant and ever-evolving nature of this field, this review provides an integrated picture on molecular image-guided diagnosis and treatment integration for brain diseases involving the basic concepts, significant breakthroughs, and recent trends. In addition, based on the current achievements, some critical challenges are also discussed.

PA System in the Pathogenesis of Ischemic Stroke

Ischemic stroke remains a leading cause of morbidity and mortality worldwide, driven by complex pathophysiological mechanisms that make finding effective treatments challenging. PAs (plasminogen activators) play a critical role in fibrinolysis and vascular homeostasis and as such are important factors affecting stroke outcome. This review examines the complex relationships between ischemic stroke and PAs, highlighting their physiological, pathological, and therapeutic effects on ischemic stroke. We focus on recombinant tissue-type PA as the only Food and Drug Administration-approved thrombolytic agent, describing its clinical impact and associated obstacles impacting its wide-scale use, such as blood-brain barrier disruption and inflammation. Furthermore, emerging PA-based therapies and combination strategies are explored to address the limitations of recombinant tissue-type PA. By integrating mechanistic information with clinical developments, this review aims to provide insights for the advancement of PA-centered approaches to improve the safety and efficacy of stroke treatments.

Multimorbidity in acute ischemic stroke and its impact on short-term mortality: A Chilean nationwide database analysis

BACKGROUND

Multimorbidity predicts a worse prognosis for various diseases but its impact in people after an acute ischemic stroke (AIS) in developing societies is not well established. We aimed to characterize the pattern of multimorbidity and determine its association with in-hospital mortality after AIS in the nationwide Chilean database.

METHODS

A retrospective analysis of the Diagnosis-Related Groups database for hospitalized adult patients in Chile in 2019 was conducted. Association of multimorbidity, defined as the presence of ≥2 health conditions, in patients with AIS (ICD-10 code I63) on in-hospital mortality was determined in logistic regression models adjusted for confounding variables.

RESULTS

Of 1,048,575 recorded ICD-10 codes, there were 10,440 AIS episodes in whom 7,696 (73.7 %) patients had multimorbidity. Age, female sex, and low socioeconomic status were associated with a higher multimorbidity, and the combination of comorbidities differed across age groups. Cardiometabolic multimorbidity was associated with higher in-hospital mortality (odds ratio [OR] 1.39, 95 % confidence interval [CI] 1.16-1.66; p<0.001). Stage 5 chronic kidney disease combined with ischemic heart disease was the comorbidity with the highest risk of death (OR 4.20, 95 %CI 1.58-11.16; p = 0.004). Obesity, which exhibited a predominance in early to mid-life, had the highest association with mortality when combined with other conditions.

CONCLUSIONS

Multimorbidity is common in patients with AIS and its components vary by age and sex. Cardiometabolic multimorbidity increases the likelihood of in-hospital mortality. Adopting a multimorbidity-focused approach to stroke care could improve outcomes.

Association Between Dietary Fiber Intake and Stroke Among US Adults: From NHANES and Mendelian Randomization Analysis

BACKGROUND

There is debate on the link between dietary fiber intake and stroke risk. The purpose of this study was to look at how it impacts dietary fiber intake and stroke risk, as well as mortality among stroke survivors. Two-sample Mendelian randomization was also used to investigate the causal relationship.

METHODS

This research examined information from 1453 patients with stroke participating in the National Health and Nutrition Examination Survey from 1999 to 2018. To assess the incidence of stroke, we conducted a survey-weighted multivariate logistic regression analysis and subgroup analysis. To evaluate the mortality associated with stroke, we used Kaplan-Meier survival analysis combined with survey-weighted Cox regression models. Using 2-sample Mendelian randomization and inverse-variance weighted method, we established a causal relationship between dietary fiber intake and stroke. The article was organized according to Strengthening the Reporting of Observational Studies in Epidemiology and Strengthening the Reporting of Observational Studies in Epidemiology Using Mendelian Randomization guidelines.

RESULTS

In the fully adjusted model, dietary fiber intake was negatively associated with stroke (odds ratio, 0.98 [95% CI, 0.97-0.99]; P<0.0001; T3 versus T1; odds ratio, 0.71 [95% CI, 0.57-0.88]; P=0.002). A stable linear negative relevance was confirmed between dietary fiber intake and stroke risk (nonlinear P=0.566) by the multivariate adjusted spline regression model. According to the survey-weighted multivariate Cox regression model, dietary fiber intake significantly reduced all-cause mortality (T3 versus T1; odds ratio, 0.68 [95% CI, 0.47-0.97]; P=0.04). Further Kaplan-Meier survival analysis indicated that higher intake of dietary fiber improved the survival of patients with stroke (P=0.02325). The 2-sample Mendelian randomization analysis showed that genetic prediction supported a causal relationship between increased dietary fiber intake and reduced risk of small vessel stroke (odds ratio, 0.8326 [95% CI, 0.7051-0.9833]; P=0.0309).

CONCLUSIONS

There is a stable negative correlation between dietary fiber intake and stroke risk. High fiber intake is associated with reduced all-cause mortality among stroke survivors. Additionally, genetic prediction further demonstrates a causal relationship between dietary fiber and reduced risk of small vessel stroke.

Association of the triglyceride glucose-waist height ratio with asymptomatic intracranial arterial stenosis

BACKGROUND AND OBJECTIVE

This study evaluated the associations of the triglyceride-glucose (TyG) index or its attendant parameters, known as reliable measures of insulin resistance, with asymptomatic intracranial arterial stenosis (aICAS), along with their value for distinguishing individuals with a notable aICAS burden.

METHODS

This study enrolled 2000 participants (aged ≥ 40 years) based on the Rose asymptomatic IntraCranial Artery Stenosis study. Transcranial Doppler ultrasound combined with magnetic resonance angiography was utilized to confirm aICAS. Logistic regression was applied to assess the associations between TyG or TyG-related indices (TyG-body mass index, TyG-waist circumference [TyG-WC], TyG-waist-to-hip ratio [TyG-WHR], or TyG-waist-to-height ratio [TyG-WHtR]) and aICAS. The diagnostic potential of them was investigated using receiver operating characteristic (ROC) analysis.

RESULTS

Among the 2000 participants, 146 (7.3%) had a diagnosis of aICAS. TyG-WC, TyG-WHR, or TyG-WHtR were independently related to the prevalence of aICAS (TyG-WC: OR 1.26, 95%CI 1.03-1.54; TyG-WHR: OR 1.29, 95%CI 1.07-1.55; TyG-WHtR: OR 1.25, 95%CI 1.04-1.51). ROC analysis disclosed that TyG-WHtR had significant superior performance in identifying aICAS compared with other parameters (all P < 0.05). Subgroup analysis revealed that higher TyG-WHtR values showed a positive association with a heightened prevalence of aICAS observed in elderly participants aged ≥ 65 years (OR 1.69, 95%CI 1.20-2.38), and hypertensive patients (OR 1.30, 95%CI 1.06-1.59).

CONCLUSION

The association of TyG-WHtR with aICAS showed that TyG-WHtR might be a more effective indicator for identifying populations with early-stage aICAS.

Comparing the impact of cumulative insulin resistance surrogates exposure on stroke: optimizing prevention strategies

BACKGROUND

Insulin resistance (IR) plays a major role in increasing the risk of stroke. The objective of this research is to systematically evaluate and compare the impact of cumulative exposure over time to four commonly used IR surrogates-triglyceride-glucose (CumTyG) index, metabolic score for IR (CumMetS-IR), estimated glucose disposal rate (CumeGDR) and triglyceride to high-density lipoprotein cholesterol (CumTG/HDL-C) ratio-on stroke risk, providing insights for optimizing monitoring strategies for primary stroke prevention.

METHODS

The study population was sourced from the China Health and Retirement Longitudinal Study (CHARLS2011-2018). Cumulative exposure to IR (CumIR) surrogates was calculated as the mean value of IR surrogates measured in the first and third waves of CHARLS, multiplied by the total exposure duration. The primary endpoint was incident stroke, determined through questionnaires in the third and fourth waves of CHARLS. Multivariable Cox regression models were applied to estimate and compare HRs and 95% CIs for stroke across quartiles of CumIR surrogates.

RESULTS

A total of 4,669 participants with no history of stroke at baseline were included. During a median follow-up of 6 years, 347 new stroke events (7.43%) were recorded. The incidence rates of stroke in the highest quartiles of CumTyG index, CumTG/HDL-C ratio, and CumMetS-IR, as well as the lowest quartile of CumeGDR, were 9.67%, 9.93%, 10.45%, and 13.02%, respectively. In terms of risk assessment, the multivariable Cox regression analysis showed that the highest quartiles of CumTyG index, CumTG/HDL-C ratio, and CumMetS-IR and the lowest quartile of CumeGDR were associated with stroke risk, with corresponding HR (95% CI) of 1.48(1.05-2.10), 1.61(1.15-2.24), 1.72(1.21-2.43), and 3.57(2.25-5.68), respectively. In terms of event prediction, receiver operating characteristic analysis revealed that CumeGDR had the highest predictive accuracy for incident stroke compared with other common IR surrogates.

CONCLUSIONS

In assessing stroke risk and predicting events in middle-aged and elderly populations, cumulative exposure to eGDR demonstrates significant advantages over other common IR surrogates. Incorporating eGDR as an IR monitoring marker is recommended for primary stroke prevention.

Sphingosine-1-Phosphate Modulation in Neurological Disorders: Insights from MS and Stroke

Multiple sclerosis is a chronic autoimmune disease in which the immune system attacks the protective sheath or myelin that covers nerve fibers, impacting the brain's ability to communicate with other areas of the body. This abnormal immune response recruits inflammatory substances, which appear as lesions on the brain and spinal cord. A stroke is characterized by a sudden impairment of neurological function resulting from the loss or restriction of blood flow due to acute damage to a localized area of the central nervous system, including the brain, retina, or spinal cord. While strokes, both ischemic and hemorrhagic, are different in terms of their pathogenesis to MS, mechanisms such as neuroinflammation and neurodegeneration are common denominators among these conditions. Recent studies highlight the involvement of the sphingosine-1-phosphate receptor in the treatment of strokes and how fingolimod, an S1P receptor modulator employed in MS treatment, may play a role in the treatment of stroke-like symptoms. This review aims to explore the potential link between stroke and MS, providing a comprehensive analysis of the existing evidence. It will also shed light on the role of S1P receptors in the pathophysiology of stroke, offering insights into their mechanistic contributions. Furthermore, the review will examine recent studies investigating the therapeutic potential of the S1P modulator, fingolimod, in acute stroke patients, highlighting its efficacy and potential clinical applications. Through this multifaceted approach, we hope to contribute to the development of a deeper understanding of these interconnected neurological conditions and their treatment strategies.

Efficacy of immediate anti-hypertensive treatment in patients with acute ischaemic stroke stratified by mean arterial pressure and pulse pressure: a secondary analysis of the China Antihypertensive Trial in Acute Ischemic Stroke trial

BACKGROUND

Whether mean arterial pressure (MAP) and pulse pressure (PP), two indicators of cerebral perfusion, could guide the selection of anti-hypertensive strategies after acute ischaemic stroke remains uncertain. Our study was to explore the impact of early anti-hypertensive intervention on adverse clinical outcomes following ischaemic stroke stratified by the levels of MAP and PP based on the China Antihypertensive Trial in Acute Ischemic Stroke (CATIS).

METHODS

The trial randomised 4071 acute ischaemic stroke patients with elevated systolic blood pressure (SBP) to receive anti-hypertensive treatment (targeting a 10%-25% reduction in SBP during the 24 hours postrandomisation, reaching a BP level <140/90 mm Hg in 7 days, further keeping these levels throughout hospitalisation) or discontinue anti-hypertensive treatment during hospitalisation. The primary outcome was death or major disability at 14 days or hospital discharge. Study outcomes were analysed by comparing the BP-lowering intervention group and control group, stratified by tertiles of MAP or PP levels.

RESULTS

No significant difference was observed in the primary outcome between the intervention and control groups across all MAP (p=0.69 for homogeneity) and PP (p=0.78 for homogeneity) categories. The corresponding odds ratios (95% CIs) were 1.08 (0.85-1.36), 0.92 (0.74-1.15) and 1.00 (0.81-1.25) for participants with low, intermediate, and high MAP and were 0.99 (0.79-1.25), 1.06 (0.84-1.34) and 0.95 (0.77-1.18) for participants in PP subgroups, respectively. Furthermore, early anti-hypertensive intervention was not associated with secondary outcomes (including neurological deterioration, recurrent stroke, vascular events and all-cause mortality) by MAP and PP (all p>0.05).

CONCLUSIONS

Early anti-hypertensive therapy neither decreased nor increased the odds of major disability, mortality, recurrent stroke or vascular events in patients with acute ischaemic stroke regardless of different MAP and PP levels.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT01840072.

Challenges in studying neuroanatomy in sub-Saharan Africa: The case of Cameroon

Introduction

Quality education is key in addressing the skilled neurological workforce gap in Africa. However, many medics are scared of the neurological sciences because of the challenges faced in medical schools in studying the neurosciences. Understanding its state and educational challenges is crucial for fostering interest in neurosurgery and related specialities on the continent.

Research question

What are the current state, challenges, and solutions to improve neuroanatomy education in Cameroon, Africa in miniature?

Materials and methods

A cross-sectional study using an 11-item electronic survey was conducted among medical students from all nine medical schools in Cameroon. Data were analysed using descriptive statistics and independent t-tests, with significance set at p < 0.05.

Results

Among 220 respondents, 40.1 % and 35.0 % respectively, reported cranial nerves/brainstem and neurovascular anatomy to be the most challenging, with a mean comprehension score of 5.83/10. Faculty predominantly relied on PowerPoint lectures (83.2 %), while most students supplemented learning with YouTube videos (77.7 %). 63.9 % of the respondents perceived classroom teaching alone to limit their understanding of neuroanatomy, and 85.8 % of students reported the time allocated for neuroanatomy teaching to be inadequate. The usage of cadaver dissection (69.5 %), and neurosimulation practicals (66.4 %) were the most recommended tools by students to improve neuroanatomy teaching.

Discussion and conclusion

Challenges in neuroanatomy education in Cameroon are perceived to arise from insufficient hands-on learning, time constraints, and limited access to specialised faculty. These suggest interactive teaching, increased curriculum time, and diverse resources as potential improvements, though further research is needed to assess their effectiveness and ultimately improve understanding, fostering a stronger neurological workforce.

A Systematic Review of MicroRNAs in Hemorrhagic Neurovascular Disease: Cerebral Cavernous Malformations as a Paradigm

Hemorrhagic neurovascular diseases, with high mortality and poor outcomes, urge novel biomarker discovery and therapeutic targets. Micro-ribonucleic acids (miRNAs) are potent post-transcriptional regulators of gene expression. They have been studied in association with disease states and implicated in mechanistic gene interactions in various pathologies. Their presence and stability in circulating fluids also suggest a role as biomarkers. This review summarizes the current state of knowledge about miRNAs in the context of cerebral cavernous malformations (CCMs), a disease involving cerebrovascular dysmorphism and hemorrhage, with known genetic underpinnings. We also review common and distinct miRNAs of CCM compared to other diseases with brain vascular dysmorphism and hemorrhage. A systematic search, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, queried all peer-reviewed articles published in English as of January 2025 and reported miRNAs associated with four hemorrhagic neurovascular diseases: CCM, arteriovenous malformations, moyamoya disease, and intracerebral hemorrhage. The PubMed systematic search retrieved 154 articles that met the inclusion criteria, reporting a total of 267 unique miRNAs identified in the literature on these four hemorrhagic neurovascular diseases. Of these 267 miRNAs, 164 were identified in preclinical studies, while 159 were identified in human subjects. Seventeen miRNAs were common to CCM and other hemorrhagic diseases. Common and unique disease-associated miRNAs in this systematic review motivate novel mechanistic hypotheses and have potential applications in diagnostic, predictive, prognostic, and therapeutic contexts of use. Much of current research can be considered hypothesis-generating, reflecting association rather than causation. Future areas of mechanistic investigation are proposed alongside approaches to analytic and clinical validations of contexts of use for biomarkers.

Targeting the Ischemic Core: A Therapeutic Microdialytic Approach to Prevent Neuronal Death and Restore Functional Behaviors

Ischemic stroke leads to cerebral ionic imbalance, increases acidosis, oxidative stress and release of glutamate and inflammatory mediators. Removing solute or stimulants from the ischemic core may block cell-damaging events and confer neuroprotection. In this study, we developed a minimally invasive therapeutic microdialysis (tMD) method, choosing to include serum albumin in the buffer because it is a multifunctional protein with osmotic properties. Aiming at the ischemic core, continuous perfusion of buffer supplemented with osmotic agents removes mediators of inflammation/cell damage/death from the lesion. This tMD treatment significantly removed the glutamate and zinc ions from the core, thereby reducing infarct volumes and affording high-grade neurobehavioral protection against ischemic stroke. The tMD treatment effectively protected neurons and reduced microglial activation. Furthermore, this tMD approach extended the therapeutic window to protect beyond 6 h after stroke onset. These findings support the potential clinical feasibility of applying tMD to patients with ischemic stroke, potentially without adverse effects.

Glucose-to-potassium ratio as a predictor for early post-traumatic epilepsy: a retrospective cohort study

Background

Post-traumatic epilepsy (PTE) is a common complication following traumatic brain injury (TBI). Early PTE refers to the appearance of seizure symptoms within 7 days of the injury. The glucose-to-potassium ratio (GPR) has emerged as a potential biomarker for predicting Early PTE risk. This study aimed to evaluate the association between GPR and the risk of Early PTE, and to assess the predictive value of GPR through various analyses.

Methods

A total of 2,049 TBI patients were included in the analysis, with the GPR evaluated both as a continuous and categorical variable. Logistic regression, trend tests, and Kaplan-Meier (KM) curve analyses were performed to assess the relationship between GPR and Early PTE. Subgroup analyses were conducted to explore potential effect modifiers, and restricted cubic spline (RCS) analyses were used to examine non-linear associations. Adjustments were made for demographic, clinical, and biochemical factors.

Results

The GPR demonstrated a significant non-linear association with Early PTE risk, with a turning point at GPR = 2.835. Patients with a GPR > 2.835 exhibited a higher risk of epilepsy, as indicated by KM curve analysis (P < 0.0001). Logistic regression analysis revealed that GPR was an independent predictor of Early PTE in both unadjusted and adjusted models. In the fully adjusted model, GPR remained significantly associated with early epilepsy (OR: 1.499, 95% CI: 1.188-1.891, P < 0.001). Subgroup analyses identified gender, hypertension, and diabetes as significant effect modifiers. Trend tests revealed a dose-response relationship between GPR quartiles and epilepsy risk, with the highest quartile showing a significantly higher risk in both unadjusted and partially adjusted models (P = 0.017).

Conclusions

The GPR is a robust and independent predictor of Early PTE, with higher GPR levels strongly associated with an increased risk of epilepsy. The non-linear relationship and variations across subgroups underscore the clinical utility of GPR in risk stratification and personalized management of TBI patients.

Nomogram combined neuron-specific enolase and NIHSS for prediction of post stroke depression

OBJECTIVE

The National Institutes of Health Stroke Scale (NIHSS) is a known risk factor for post-stroke depression (PSD). However, more objective indicators are needed. The role of neuron-specific enolase (NSE) in PSD development remains unclear. This study aimed to ascertain the correlation of NIHSS score and NSE with PSD risk, and establish a novel nomogram combining NSE and NIHSS for early PSD prediction.

METHODS

A total of 172 patients with acute ischemic stroke (AIS) were involved. Baseline clinical data including NSE and NIHSS were collected. At 3-month follow-up, patients were categorized into PSD and non-PSD groups. Logistic models and restricted cubic spline curve were used to investigate the correlation between NIHSS, NSE and PSD. A corresponding nomogram was formulated.

RESULTS

Among 172 patients with AIS, 63 (36.63%) were diagnosed with PSD, while 109 (63.37%) were non-PSD. The baseline NIHSS and NSE were positively correlated with the risk of 3-month PSD (P < 0.05). Multivariate logistic regression revealed that sex (OR= 2.168, 95% CI 1.038 ∼ 4.526), age (OR= 1.035, 95% CI 1.002 ∼ 1.070), NIHSS (OR= 1.164, 95% CI 1.022 ∼ 1.325) and NSE (OR= 1.180, 95% CI 1.037 ∼ 1.343) were independently associated with 3-month PSD (all P < 0.05). The nomogram constructed using sex, age, baseline NIHSS score and NSE showed good discrimination, calibration, and clinical utility.

CONCLUSION

NSE is a valuable tool for early identification of PSD risk. A combined prediction model incorporating NIHSS and NSE has been established for the personalized prevention and intervention of PSD.

Implementation considerations of aquatic therapy post-stroke: A qualitative study from Ontario, Canada

BACKGROUND AND PURPOSE

Aquatic therapy is an effective alternative approach to therapy on land in facilitating mobility and independence after a stroke. Despite the evidence reporting on the effectiveness of many aquatic interventions, there is a lack of studies elucidating essential implementation factors for aquatic therapy post-stroke.

MATERIALS AND METHODS

A purposive sample of people with lived experience of stroke and healthcare providers participated in semi-structured interviews about their experiences with aquatic therapy. A deductive content analysis approach using the Consolidated Framework for Implementation Research (CFIR) was used to identify the essential aspects of aquatic therapy implementation post-stroke.

RESULTS

Twenty-three participants (9 people with stroke experience and 14 healthcare providers) participated in the study, from across the province of Ontario in Canada. The interview data were all relevant to the five main CFIR constructs and to some of the sub-constructs. Although participants were highly favorable to aquatic therapy, several implementation considerations in terms of costs, program structure, provider qualifications, and pool access were identified at the patient, provider, and system level.

CONCLUSION

The CFIR proved valuable in identifying contextual factors relevant to implementing aquatic therapy with the stroke population. These factors included the importance of education, barriers to accessing aquatic therapy in rehabilitation and community settings, and internal and external factors influencing the application of aquatic therapy post-stroke.

Young stroke in Bangladesh: addressing rare cases with diagnostic challenges and much-needed solutions

Stroke is a leading cause of mortality and morbidity in Bangladesh, and young adults are increasingly affected. Common risk factors include hypertension, diabetes, dyslipidaemia, obesity and smoking, whereas rare causes include haematologic disorders, premature atherosclerosis, vasculopathy and arteritis. Treatment barriers include inadequate infrastructure, a lack of trained staff and high intervention costs. Bangladesh faces a scarcity of neurologists and well-equipped hospitals, necessitating strategies to mitigate the burden of stroke among young people. This editorial summarises the current knowledge regarding the aetiology, pathophysiology and challenges in diagnosing and treating stroke in young people in Bangladesh, while addressing rare vasculopathy. Initiatives to support young stroke survivors and their families were also discussed. Prospective cohort studies, such as the Norwegian Stroke in the Young Study, provide insights into optimising prevention and early intervention by assessing family history and subclinical vascular diseases, which have also been highlighted. Recommendations include advanced neuroimaging for risk assessment, incorporating patient care and rehabilitation into medical education, conducting relevant research and promoting healthy lifestyles through campaigns and training of the healthcare staff.

Pulmonary and functional hallmarks after SARS-CoV-2 infection across three WHO severity level-groups: an observational study

Background

The manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection range from flu-like symptoms to severe lung disease. The consequences of this inflammatory process impact overall function, which can be detected through both short- to long-term assessments. This study aimed to assess the pulmonary functional and structural characteristics of post-SARS-CoV-2 infection in patients with mild/moderate, severe, and critical clinical presentations.

Methods

An observational, analytical, and cross-sectional study was conducted between 2020 and 2022, including participants with a confirmed diagnosis of coronavirus disease (COVID)-19, with mild/moderate (G1), severe (G2), and critical (G3) clinical presentations, all evaluated at least 3 months after acute infection. Spirometry, impulse oscillometry, fractional exhaled nitric oxide (FeNO), chest computed tomography, the 6-min walk test (6MWT), hand grip strength, maximum inspiratory pressure, and maximum expiratory pressure were assessed.

Results

We enrolled 210 participants aged 18-70 years, 32.6% of whom were male, with older age observed in G3. The participants were grouped as follows: G1 (42.3%), G2 (25.7%), and G3 (31.9%). Percentage of predicted X5 differed between G1 and G2, being higher in G1. The percentage of predicted forced vital capacity (FVC) according to the Global Lung Function Initiative and its z-score were higher in G1. The FVC by Pereira was lower in G3 compared to G1. The percentage of predicted forced expiratory volume in 1 s (FEV1) by Pereira was also lower in G3. The Tiffeneau (FEV1/FVC) index was different among groups, increasing with disease severity. The percentage of predicted forced expiratory flow rate at 25-75% (FEF25-75%) of the FVC and FeNO were both higher in G2 than G1. Chest computed tomography revealed the presence of interstitial abnormalities, associated with disease severity. The respiratory muscle strength evaluation showed an association between higher maximum expiratory pressure values in G3 compared to G1, but no association with maximum inspiratory pressure was observed. The 6MWT distance covered decreased with increasing severity, with a lower percentage of predicted values in G3 compared to G1. The right-hand grip strength was also lower in G3 compared to G1.

Conclusion

Alterations in pulmonary and functional markers were observed in post-COVID-19 evaluations, increasing with disease severity, as seen in G2 and G3. These findings highlight the complexity of post-COVID-19 functional assessments, given the long-term pulmonary sequelae and the consequent impairment of functional capacity.

Cardiovascular events and biochemically negative paragangliomas: a systematic review

OBJECTIVE

To study cardiovascular morbidity in patients with biochemically inactive pheochromocytomas/paragangliomas.

METHODS

PubMed, Cochrane, and Scopus databases were searched by two independent reviewers to identify relevant studies. Twenty-four case reports (n = 24 patients) met the inclusion criteria providing data on the cardiovascular status of biochemically negative pheochromocytomas/paragangliomas patients. Methodological quality was assessed by the Grading of Recommendations, Assessment, Development and Evaluations system, and all included studies were assessed for the risk of bias. This systematic review was conducted in conformance with the PRISMA statement and registered to PROSPERO (ID: CRD42024530601).

RESULTS

Almost half of patients (46%) presented objective abnormal findings on noninvasive cardiovascular examination performed routinely before surgery, whereas 67% complained of pheochromocytoma/paraganglioma-related symptoms (angina, headache, diaphoresis, shortness of breath, palpitations) and exhibited relevant clinical signs (hypertension, tachycardia, tachypnea, pallor). Preoperatively, only 38% of patients with biochemically negative pheochromocytomas/paragangliomas were treated with alpha-blockers, 25% did not receive any pharmaceutical preparation whereas data were not available for the remaining 37% of patients. Following an uneventful surgery, 70% of patients exhibited resolution of the preoperatively detected cardiovascular symptoms and signs.

CONCLUSION

The high occurrence of cardiovascular abnormalities in patients with pheochromocytomas/paragangliomas characterized as "biochemically negative" based on routine biochemical analyses highlights the difficulty in the appropriate classification of these tumors regarding their secretory profile and thus the risk of missing cardiovascular system involvement with potentially deleterious effects.

Two decades of vagus nerve stimulation for stroke: a bibliometric analysis

Background

Stroke is a major global health concern, imposing significant medical and social burdens. Vagus nerve stimulation (VNS), an emerging neuromodulation technology, has shown potential in the treatment of stroke. This bibliometric analysis aims to explore the knowledge structure and research trends in the field of VNS for stroke from 2004 to 2024.

Methods

Publications were retrieved from the Web of Science Core Collection. CiteSpace and VOSviewer were used to conduct bibliometric analyses, including author productivity, institutional contributions, and emerging research themes etc.

Results

A total of 191 eligible publications were analysed. Kilgard, M. P., and Hays, S. A. were the most prolific authors, each contributing 26 publications. The USA (96 publications), China (69 publications), and Scotland (17 publications) were the most prolific countries. The University of Texas at Dallas (33 publications) was the most prolific institution, followed by Chongqing Medical University (19 publications) and the University of Glasgow (15 publications). Future research is expected to focus on: (1) neurophysiological mechanisms of VNS in stroke recovery; (2) synergistic effects of VNS with other rehabilitation therapies; (3) comparative efficacy of non-invasive transauricular VNS versus invasive VNS; (4) safety and effectiveness of VNS for post-stroke functional impairments beyond motor rehabilitation; and (5) optimisation of VNS parameters for stroke treatment.

Conclusion

The field of VNS for stroke has experienced steady growth over the past two decades. This bibliometric analysis provides valuable insights to guide future research, clinical applications, and policy developments.

Telehealth intervention involving the HEARTS Technical Package and the additional use of an activity monitor to increase physical activity level post-stroke: Protocol for a feasibility randomized controlled trial

BACKGROUND

Low physical activity level is a common risk factor for recurrent stroke. Feasibility studies show behavior change interventions can increase physical activity participation, but face barriers (e.g., home visits or internet access). Low-cost telehealth approaches, like telephone calls, may overcome these challenges. Another low-cost strategy involves motivational tools supporting "Behavioral Regulation," such as physical activity monitors. However, evidence is insufficient to support their use in increasing physical activity levels post-stroke. A systematic review suggests integrating these devices into multifaceted behavior change interventions (e.g., the 5As brief intervention outlined in the HEARTS Technical Package) may enhance their effectiveness. Combined with physical activity monitors and telephone follow-up, this approach has proven feasible for individuals post-stroke. These findings underscore the need to explore combining the 5As brief intervention with physical activity monitors to assess potential added benefits. This feasibility randomized controlled trial (RCT) study will investigate whether the telehealth intervention (by telephone call) combining the 5As brief intervention, as outlined in the HEARTS Technical Package, and physical activity monitoring, compared to a control group receiving only the 5As brief intervention, is feasible and supports a fully powered RCT.

METHODS

A feasibility RCT study, with blinded assessment, will assign 24 individuals post-stroke (diagnosed ≥ 6 months), aged ≥ 18 years, inactive, able to walk 10 meters independently, and medically approved for physical activity, to experimental (n = 12) or control group (n = 12). Both groups will undergo the 5As brief intervention (Ask, Advise, Assess, and Assist delivered face-to-face, and Arrange via telephone call follow-up), for 12 weeks, with the experimental group also using a physical activity monitor. Outcomes include feasibility of recruitment, intervention, measurement, and blinding the outcome assessor, cost and clinical outcomes.

DISCUSSION

The intervention aligns with stroke secondary prevention recommendations and utilizes low-cost telehealth approaches. This study will contribute to defining future RCT phases.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06068036.

U-shaped association between the glycemic variability and prognosis in hemorrhagic stroke patients: a retrospective cohort study from the MIMIC-IV database

Background

Elevated glycemic variability (GV) is commonly observed in intensive care unit (ICU) patients and has been associated with clinical outcomes. However, the relationship between GV and prognosis in ICU patients with hemorrhagic stroke (HS) remains unclear. This study aims to investigate the association between GV and short- and long-term all-cause mortality.

Methods

Clinical data for hemorrhagic stroke (HS) patients were obtained from the MIMIC-IV 3.1 database. GV was quantified using the coefficient of variation (CV), calculated as the ratio of the standard deviation to the mean blood glucose level. The association between GV and clinical outcomes was analyzed using Cox proportional hazards regression models. Additionally, restricted cubic spline (RCS) curves were employed to examine the nonlinear relationship between GV and short- and long-term all-cause mortality.

Results

A total of 2,240 ICU patients with HS were included in this study. In fully adjusted models, RCS analyses revealed a U-shaped association between the CV and both short- and long-term all-cause mortality (P for nonlinearity < 0.001 for all outcomes). Two-piecewise Cox regression models were subsequently applied to identify CV thresholds. The thresholds for all-cause mortality in ICU, during hospitalization, and at 30, 90, and 180 days were determined to be 0.14, 0.16, 0.155, 0.14, and 0.14, respectively. These findings were consistent in sensitivity and subgroup analyses.

Conclusions

In HS patients, higher GV is associated with an increased risk of both short- and long-term all-cause mortality. Our findings suggest that stabilizing GV may improve the prognosis of HS patients.

Association of neutrophil-to-lymphocyte ratio with stroke morbidity and mortality: evidence from the NHANES 1999-2020

Background

Stroke is closely linked to inflammation, with the neutrophil-to-lymphocyte ratio (NLR) emerging as a promising inflammatory marker. This study aims to investigate the association between NLR and both morbidity and mortality in stroke patients.

Methods

Data from the National Health and Nutrition Examination Survey (NHANES) 1999-2020 were analyzed, including adults with complete neutrophil and lymphocyte count records. Multivariate logistic regression was used to examine the relationship between NLR and both stroke morbidity and all-cause mortality. Restricted cubic spline regression was employed to assess potential nonlinearity in these associations. Subgroup analyses were performed to identify influencing factors.

Results

After adjusting for confounders, the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for stroke in the higher NLR quartiles, compared to the lowest quartile, were 1.28 (1.07-1.52) and 1.36 (1.12-1.65), respectively. The restricted cubic spline curve indicated a nonlinear positive association between NLR and stroke risk. Additionally, an elevated NLR was positively associated with an increased risk of all-cause mortality.

Conclusion

The findings underscore the potential use of NLR in stratifying and predicting mortality risk in stroke patients, suggesting its relevance in clinical practice.