World Stroke Organization (WSO): Global Stroke Fact Sheet 2022

Cholesterol metabolism: physiological versus pathological aspects in intracerebral hemorrhage

Cholesterol is an important component of plasma membranes and participates in many basic life functions, such as the maintenance of cell membrane stability, the synthesis of steroid hormones, and myelination. Cholesterol plays a key role in the establishment and maintenance of the central nervous system. The brain contains 20% of the whole body's cholesterol, 80% of which is located within myelin. A huge number of processes (e.g., the sterol regulatory element-binding protein pathway and liver X receptor pathway) participate in the regulation of cholesterol metabolism in the brain via mechanisms that include cholesterol biosynthesis, intracellular transport, and efflux. Certain brain injuries or diseases involving crosstalk among the processes above can affect normal cholesterol metabolism to induce detrimental consequences. Therefore, we hypothesized that cholesterol-related molecules and pathways can serve as therapeutic targets for central nervous system diseases. Intracerebral hemorrhage is the most severe hemorrhagic stroke subtype, with high mortality and morbidity. Historical cholesterol levels are associated with the risk of intracerebral hemorrhage. Moreover, secondary pathological changes after intracerebral hemorrhage are associated with cholesterol metabolism dysregulation, such as neuroinflammation, demyelination, and multiple types of programmed cell death. Intracellular cholesterol accumulation in the brain has been found after intracerebral hemorrhage. In this paper, we review normal cholesterol metabolism in the central nervous system, the mechanisms known to participate in the disturbance of cholesterol metabolism after intracerebral hemorrhage, and the links between cholesterol metabolism and cell death. We also review several possible and constructive therapeutic targets identified based on cholesterol metabolism to provide cholesterol-based perspectives and a reference for those interested in the treatment of intracerebral hemorrhage.

Robotic mirror therapy for stroke rehabilitation through virtual activities of daily living

Mirror therapy is a standard technique of rehabilitation for recovering motor and vision abilities of stroke patients, especially in the case of asymmetric limb function. To enhance traditional mirror therapy, robotic mirror therapy (RMT) has been proposed over the past decade, allowing for assisted bimanual coordination of paretic (affected) and contralateral (healthy) limbs. However, state-of-the-art RMT platforms predominantly target mirrored motions of trajectories, largely limited to 2-D motions. In this paper, an RMT platform is proposed, which can facilitate the patient to practice virtual activities of daily living (ADL) and thus enhance their independence. Two similar (but mirrored) 3D virtual environments are created in which the patients operate robots with both their limbs to complete ADL (such as writing and eating) with the assistance of the therapist. The recovery level of the patient is continuously assessed by monitoring their ability to track assigned trajectories. The patient's robots are programmed to assist the patient in following these trajectories based on this recovery level. In this paper, the framework to dynamically monitor recovery level and accordingly provide assistance is developed along with the nonlinear controller design to ensure position tracking, force control, and stability. Proof-of-concept studies are conducted with both 3D trajectory tracking and ADL. The results demonstrate the potential use of the proposed system to enhance the recovery of the patients.

Effects of intravenous rtPA in patients with minor stroke

BACKGROUND

Whether minor ischemic stroke (MIS) patients can benefit from intravenous thrombolysis (IVT) remains controversial. The association between the efficacy of IVT and baseline National Institute of Health Stroke Scale (NIHSS) score is unclear in MIS, while the association in moderate and severe stroke is known. This study aimed to explore the effect of IVT in patients with MIS and analyze its efficacy in patients with different baseline NIHSS scores.

METHODS

Patients with a NIHSS score ≤5 within 4.5 h of stroke onset were screened in 32 centers. Patients with and without IVT were matched to a ratio of 1:1 with propensity scores. An excellent outcome was defined as a modified Rankin Scale (mRS) score ≤1 at three months after stroke onset. Safety outcomes included mortality and symptomatic intracranial hemorrhage (sICH). Multivariate analysis was used to compute the adjusted odds ratio (OR) for excellent outcomes. The effect of IVT was further analyzed in subgroups according to the baseline NIHSS score.

RESULTS

Of the 23,853 screened, 3336 patients with MIS who arrived at the hospital within 4.5 h of onset were included. The 1163 patients treated with IVT were matched with 1163 patients without IVT. IVT in minor strokes generated an adjusted OR of 1.38 (95% CI: 1.09-1.75, p = 0.009) for excellent outcomes. There were no significant differences in mortality (0.17% vs. 0.09%, p = 1.000) and sICH (0.69% vs. 0.86%, p = 0.813) between patients with and without IVT. Subgroup analysis showed that there was no significant effect of IVT in the baseline NIHSS 0-1 or 2-3 subgroups, with adjusted OR of 0.816 (95% CI 0.437-1.53, p = 0.525) and1.22 (95% CI 0.845-1.77, p = 0.287), respectively. In patients with NIHSS score of 4-5, IVT was significantly effective, with an adjusted OR of 1.53 (95% CI 1.02-2.30, p = 0.038).

CONCLUSION

IVT can improve MIS outcomes. The risks of sICH and mortality did not increase, especially in patients with NIHSS scores 4 to 5, who could benefit from IVT significantly.

FHIR Implementation Guide for Stroke: A dual focus on the patient's clinical pathway and value-based healthcare

BACKGROUND

Stroke management requires a coordinated strategy, adhering to clinical pathways (CP) and value-based healthcare (VBHC) principles from onset to rehabilitation. However, the discrepancies between these pathways and actual patient experiences highlight the need for ongoing monitoring and addressing interoperability issues across multiple institutions in stroke care. To address this, the Fast Healthcare Interoperability Resource (FHIR) Implementation Guide (IG) standardizes the information exchange among these systems, considering a specific context of use.

OBJECTIVE

Develop an FHIR IG for stroke care rooted in established stroke CP and VBHC principles.

METHOD

We represented the stroke patient journey by considering the core stroke CP, the International Consortium for Health Outcomes Measurement (ICHOM) dataset for stroke, and a Brazilian case study using the Business Process Model and Notation (BPMN). Next, we developed a data dictionary that aligns variables with existing FHIR resources and adapts profiling from the Brazilian National Health Data Network (BNHDN).

RESULTS

Our BPMN model encompassed three critical phases that represent the entire patient journey from symptom onset to rehabilitation. The stroke data dictionary included 81 variables, which were expressed as questionnaires, profiles, and extensions. The FHIR IG comprised nine pages: Home, Stroke-CP, Data Dictionary, FHIR, ICHOM, Artifacts, Examples, Downloads, and Security. We developed 96 artifacts, including 7 questionnaires, 27 profiles with corresponding example instances, 3 extensions, 18 value sets, and 14 code systems pertinent to ICHOM outcome measures.

CONCLUSION

The FHIR IG for stroke in this study represents a significant advancement in healthcare interoperability, streamlining the tracking of patient outcomes for quality enhancement, facilitating informed treatment choices, and enabling the development of dashboards to promote collaborative excellence in patient care.

Investigating functional connectivity related to stroke recovery: A systematic review

INTRODUCTION

Stroke recovery is a complex process influenced by various factors, including specific neural reorganization. The objective of this systematic review was to identify important functional connectivity (FC) changes in resting-state fMRI data that were often correlated with motor, emotional, and cognitive outcome improvement.

METHOD

A systematic search using PubMed and SCOPUS databases was conducted to identify relevant studies published between 2010 and 2023.

RESULTS

A total of 766 studies were identified, of which 20 studies (602 S individuals) met the inclusion criteria. Fourteen studies focussed on motor recovery while six on cognitive recovery. All studies reported interhemispheric FC to be strongly associated with motor and cognitive recovery. The preservation and changes of M1-M1 (eight incidences) and M1-SMA (nine incidences) FC were found to be strongly correlated with motor function improvement. For cognitive recovery, restoration and preservation of FC with and between default mode network (DMN)-related regions were important for the process.

CONCLUSIONS

This review identified specific patterns of FC that were consistently reported with recovery of motor and cognitive function. The findings may serve in refining future management strategies to enhance patient outcomes.

Tirofiban mediates neuroprotective effects in acute ischemic stroke by reducing inflammatory response

Growing evidence suggests that neuroinflammation is a critical driver of the development, worsening, and cell death observed in acute ischemic stroke (AIS). While prior research has demonstrated that tirofiban enhances functional recovery in AIS patients by suppressing platelet aggregation, its impact and underlying mechanisms in AIS-related neuroinflammation remain elusive. The current study established an AIS mouse model employing photochemical techniques and assessed neurological function and brain infarct size using the modified neurological severity scale (mNSS) and 2,3,5-Triphenyltetrazolium chloride (TTC) staining, respectively. Tirofiban significantly reduced the volume of cerebral infarction in AIS mice, accompanied by an enhancement in their neurological functions. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assays along with experiments assessing oxidative stress showed that tirofiban mitigated oxidative damage and apoptosis in the ischemic penumbra post-AIS. Additionally, DNA microarray analysis revealed alterations in gene expression patterns in the ischemic penumbra after tirofiban treatment. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis showed that most gene-level downregulated signaling pathways were closely related to the inflammatory response. Moreover, the protein microarray analysis revealed that tirofiban diminished the expression levels of inflammatory cytokines, such as interleukin-1 (IL-1), IL-6, and tumor necrosis factor-alpha, in the ischemic penumbra. Additionally, immunofluorescence staining showed that tirofiban regulated inflammatory responses by altering the state and phenotype of microglia. In conclusion, this study suggests that tirofiban reduces inflammatory response by regulating microglial state and phenotype and lowering the levels of inflammatory factors, providing neuroprotection in acute ischemic stroke.

Pathophysiology of carotid atherosclerosis: Calcification, intraplaque haemorrhage and pulse pressure as key players

PURPOSE

Intraplaque haemorrhage (IPH) is a well-known risk factor for faster plaque progression (volume increase); however, its etiology is unclear. We aimed at determining what other local plaque- and systemic factors contribute to plaque progression and to the development and progression of IPH.

METHODS

We examined 98 asymptomatic participants with carotid plaque using serial multi-contrast magnetic resonance imaging. We measured the percent of wall volume (%WV=100 x [wall volume] / [total vessel volume]) and measured IPH and calcification volumes. We used generalized estimating equations-based regression to analyze predictors of %WV change and new IPH while accounting for covariates (sex, age and statin use), and multiple non-independent observations per participant.

RESULTS

Total follow-up was 1.8 ± 0.8 years on average. The presence of IPH (β: 0.6 %/y, p = 0.033) and calcification (β: 1.2 %/y, p = 0.028) were each associated with faster plaque progression. New IPH, detected on a subsequent scan in 4 % of arteries that did not initially have IPH, was associated with larger calcification (odds ratio [OR]: 2.6 per 1-SD increase, p = 0.038) and higher pulse pressure (OR: 2.3 per 1-SD increase, p = 0.016). Larger calcification was associated with greater increases in pulse pressure (β: 1.4 mm Hg/y per 1-SD increase, p = 0.040).

CONCLUSIONS

IPH and calcification are each independently associated with faster plaque progression. The association of carotid calcification to increased pulse pressure and new IPH development suggests a possible mechanism by which calcification drives IPH development and plaque progression.

Validity and intra- and inter-rater reliability of the Tinetti performance-oriented mobility assessment balance subscale using different tele-assessment methods in patients with chronic stroke

INTRODUCTION

Balance assessments are an important component of rehabilitation. Considering the increasing use of telemedicine to meet rehabilitation needs, it is important to examine the feasibility of such assessments. This study aimed to examine the reliability and validity of the Tinetti Performance-Oriented Mobility Assessment Balance Subscale (POMA-B) when applied via synchronous and asynchronous tele-assessment.

METHODS

Twenty-five patients with chronic stroke were included in the study. The first physiotherapist assessed the patients on the first day in a face-to-face clinical setting. Synchronous or asynchronous tele-assessment was applied the next day. The assessments were performed in the same time zone, with an interval of one day. The synchronous tele-assessment was done online in real time by the first and second physiotherapists. A reference assessment video was sent to the patients for asynchronous tele-assessment. They were asked to make a video recording while performing the evaluation activities according to the reference video. Then the first and second physiotherapists assessed these video recordings separately. All the tests were repeated 10 days later to determine the intra-rater reliability of the tele-assessment methods.

RESULTS

The intra-class correlation coefficients ranged from 0.96 to 0.98 for inter-rater reliability and from 0.97 to 0.98 for intra-rater reliability for both tele-assessment methods. Both asynchronous and asynchronous tele-assessment methods were medium correlated with the face-to-face versions.

CONCLUSIONS

We demonstrated the validity and reliability of the POMA-B in chronic stroke patients with different tele-assessment methods, typically using the internet and available devices.

Association of traditional and novel obesity indicators with stroke risk: Findings from the Rural Chinese cohort study

BACKGROUND AND AIMS

Few researchers have compared the effectiveness of traditional and novel obesity indicators in predicting stroke incidence. We aimed to evaluate the associations between six obesity indices and stroke risk, and to further identify the optimal indicator.

METHODS AND RESULTS

A total of 14,539 individuals from the Rural Chinese Cohort Study were included in the analyses. We used the Cox proportional hazards regression models to evaluate the association between six obesity indices (including body mass index [BMI], waist circumference [WC], conicity index [C-index], lipid accumulation product [LAP], visceral adiposity index [VAI], and Chinese visceral adiposity index [CVAI]) and stroke risk. Receiver operating characteristic curves were employed to compare their predictive ability on stroke risk. During a median follow-up period of 11.13 years, a total of 1257 cases of stroke occurred. In the multiple-adjusted Cox regression model, WC, BMI, C-index, and CVAI were positively associated with ischemic stroke (P < 0.01) rather than hemorrhagic stroke risk. Dose-response analyses showed a linear correlation of WC, BMI, C-index, and LAP (Poverall <0.05, and Pnonlinear >0.05), but a non-linear correlation of CVAI (Poverall <0.05, and Pnonlinear <0.05) with the risk of ischemic stroke. CVAI demonstrates the highest areas under the curves (AUC: 0.661, 95% CI: 0.653-0.668), indicating a superior predictive ability for ischemic stroke occurrence compared to other five indices (P < 0.001).

CONCLUSION

WC, BMI, C-index, LAP, and CVAI were all positively related to the risk of ischemic stroke, among which CVAI exhibited stronger predictive ability for ischemic stroke.

Identification of endoplasmic reticulum stress genes in human stroke based on bioinformatics and machine learning

After ischemic stroke (IS), secondary injury is intimately linked to endoplasmic reticulum (ER) stress and body-brain crosstalk. Nonetheless, the underlying mechanism systemic immune disorder mediated ER stress in human IS remains unknown. In this study, 32 candidate ER stress-related genes (ERSRGs) were identified by overlapping MSigDB ER stress pathway genes and DEGs. Three Key ERSRGs (ATF6, DDIT3 and ERP29) were identified using LASSO, random forest, and SVM-RFE. IS patients with different ERSRGs profile were clustered into two groups using consensus clustering and the difference between 2 group was further explored by GSVA. Through immune cell infiltration deconvolution analysis, and middle cerebral artery occlusion (MCAO) mouse scRNA analysis, we found that the expression of 3 key ERSRGs were closely related with peripheral macrophage cell ER stress in IS and this was further confirmed by RT-qPCR experiment. These ERS genes might be helpful to further accurately regulate the central nervous system and systemic immune response through ER stress and have potential application value in clinical practice in IS.

Hypertension Severity as Quantified by Hypertension Daily Dose and Blood Pressure With Risk of Stroke in REGARDS

BACKGROUND

It is unknown how blood pressure (BP) relates to stroke risk across levels of hypertension daily dose (HDD)-quantified antihypertensive medication intensity.

METHODS AND RESULTS

The REGARDS (Reasons for Geographic and Racial Differences in Stroke) study enrolled 30 239 participants from the 48 contiguous US states in 2003 to 2007 with in-person follow-up in 2013 to 2016 (Visit 2). We included those without prior stroke at Visit 2, treating this visit as T0. Biannual phone calls and medical record review ascertained incident stroke events. Cox proportional hazard models estimated the hazard ratio (HR) of incident stroke by treatment intensity defined by systolic BP stages and HDD groupings. There were 344 stroke events over a median 5.5 years. Relative to systolic BP <120 mm Hg and no antihypertensive medications, the stroke HR was 2.86 (95% CI, 1.68-4.85) for systolic BP 140 to 159 mm Hg and HDD tertile 2, 2.33 (1.37-3.97) for systolic BP 140 to 159 mm Hg and HDD tertile 3, 3.08 (1.20-7.88) for systolic BP ≥160 mm Hg and HDD tertile 2, and 3.66 (1.61-8.30) for systolic BP ≥160 mm Hg and HDD tertile 3. Stroke risk was similar across HDD levels for people with systolic BP <140 mm Hg.

CONCLUSIONS

Among adults without prior stroke, systolic BP ≥140 mm Hg and HDD tertile ≥2 was associated with greater stroke risk. For adults with BP <140 mm Hg, stroke risk was similar despite cumulative dose of antihypertensive medications used. These findings support the practice of BP-lowering medications to mitigate stroke risk.

The State of Stroke Research in Malawi: Results from a Mapping Review Study

Introduction

Stroke is one of the leading causes of death and disability globally, and low-income countries such as Malawi bear a heavy burden. Tailored, high-quality research is essential for bridging existing gaps and improving the healthcare provided in low-resource settings while maximizing available resources.

Aim

This mapping study aimed to synthesize the current state of stroke research in Malawi.

Methods

Six databases were thoroughly searched: CINAHL complete, Ovid MEDLINE and EMBASE, Web of Science Core Collection, PubMed, and Google Scholar.

Results

The search retrieved 598 references and identified 20 studies published between 2005 and 2023. Of these, 70% were conducted at Queen Elizabeth Central Hospital only; open-access journals published 95% of the studies. Cross-sectional studies were the most common (50%), followed by case-control studies (20%). The Malawi-Liverpool-Wellcome Trust Clinical Research Program authors contributed the most articles as main authors (25%). The number of citations per article ranged from 0 to 168 on Google Scholar, and the number of authors per article ranged from 1 to 15. Authors from thirty-five different institutions from 11 other countries partnered with Malawi on stroke articles, and England contributed 45.7% of the institutions. Most articles focused on pathophysiology (30%), followed by diagnosis (20%) and stroke management (15%). The highest number of participants included in the analysis was 739 and the highest number of stroke participants was 222. The identified challenges included the need for more infrastructure and under-utilization of available services. The Wellcome Trust has emerged as the primary funding agency for stroke research in Malawi.

Conclusion

The study found limited collaboration among local institutions in Malawi, with most research focused in Blantyre District. There is a critical need for increased interdisciplinary teamwork to boost nationwide research.

Hyper-Acute Stroke Systems of Care and Workflow

PURPOSE OF REVIEW

Recent stroke treatment advances have necessitated agile, broad-scale healthcare system redesign, to achieve optimal patient outcomes and access equity. Optimised hyperacute stroke care requires integrated pre-hospital, emergency department, stroke specialist, radiology, neurosurgical and endovascular neurointervention services, guided by a population-wide needs analysis. In this review, we survey system integration efforts, providing case studies, and identify common elements of successful initiatives.

RECENT FINDINGS

Different regions and nations have evolved varied acute stroke systems depending on geography, population density and workforce. However, common facilitators to these solutions have included stroke unit care as a foundation, government-clinician synergy, pre-hospital pathway coordination, service centralisation, and stroke data guiding system improvement. Further technological advantages will minimize the geographical distance disadvantages and facilitate virtual expertise redistribution to remote areas. Continued treatment advances necessitate an integrated, adaptable, population-wide trans-disciplinary approach. A well-designed clinician-led and government-supported system can facilitate hyperacute care and scaffold future system enhancements.

Beyond boundaries: The therapeutic potential of exosomes in neural microenvironments in neurological disorders

Neurological disorders are a diverse group of conditions that can significantly impact individuals' quality of life. The maintenance of neural microenvironment homeostasis is essential for optimal physiological cellular processes. Perturbations in this delicate balance underlie various pathological manifestations observed across various neurological disorders. Current treatments for neurological disorders face substantial challenges, primarily due to the formidable blood-brain barrier and the intricate nature of neural tissue structures. These obstacles have resulted in a paucity of effective therapies and inefficiencies in patient care. Exosomes, nanoscale vesicles that contain a complex repertoire of biomolecules, are identifiable in various bodily fluids. They hold substantial promise in numerous therapeutic interventions due to their unique attributes, including targeted drug delivery mechanisms and the ability to cross the BBB, thereby enhancing their therapeutic potential. In this review, we investigate the therapeutic potential of exosomes across a range of neurological disorders, including neurodegenerative disorders, traumatic brain injury, peripheral nerve injury, brain tumors, and stroke. Through both in vitro and in vivo studies, our findings underscore the beneficial influence of exosomes in enhancing the neural microenvironment following neurological diseases, offering promise for improved neural recovery and management in these conditions.

Artificial nutrition in cerebrovascular disease, necessity or futility: Case report

Introduction

Stroke is one of the leading causes of mortality and disability in the world, with clinical manifestations and severe complications that they negatively affect the patient's recovery, contributing to an uncertain prognosis and difficult decisions with bioethical dilemmas such as artificial nutrition in the context of severe stroke.

Presentation of the case

A 49-year-old patient with a Cerebrovascular Accident in a chronic vegetative state, tracheostomy, and gastrostomy user, admitted for infectious complications, whom, under therapeutic proportionality, the decision is made, shared by medical staff and family, to withdraw artificial nutrition.

Conclusions

Difficult decision-making involves multiple challenges for both the health personnel and the patient and his or her environment. It must be guided by bioethical principles and proportionality in favor of the quality of life and the patient's benefit.

Racial disparities in functional outcomes following mechanical thrombectomy in a cohort of patients with ischemic stroke

BACKGROUND

Non-Hispanic Black (NHB) patients experience increased prevalence of stroke risk factors and stroke incidence compared with non-Hispanic White (NHW) patients. However, little is known about >90-day post-stroke functional outcomes following mechanical thrombectomy.

OBJECTIVE

To describe patient characteristics, evaluate stroke risk factors, and analyze the adjusted impact of race on long-term functional outcomes to better identify and limit sources of disparity in post-stroke care.

METHODS

We retrospectively reviewed 326 patients with ischemic stroke who underwent thrombectomy at two centers between 2019 and 2022. Race was self-reported as NHB, NHW, or non-Hispanic Other. Stroke risk factors, insurance status, procedural parameters, and post-stroke functional outcomes were collected. Good outcomes were defined as modified Rankin Scale score ≤2 and/or discharge disposition to home/self-care. To assess the impact of race on outcomes at 3-, 6-, and 12-months' follow-up, we performed univariate and multivariate logistic regression.

RESULTS

Patients self-identified as NHB (42%), NHW (53%), or Other (5%). 177 (54.3%) patients were female; the median (IQR) age was 67.5 (59-77) years. The median (IQR) National Institutes of Health Stroke Scale score was 15 (10-20). On univariate analysis, NHB patients were more likely to have poor short- and long-term functional outcomes, which persisted on multivariate analysis as significant at 3 and 6 months but not at 12 months (3 months: OR=2.115, P=0.04; 6 months: OR=2.423, P=0.048; 12 months: OR=2.187, P=0.15). NHB patients were also more likely to be discharged to rehabilitation or hospice/death than NHW patients after adjusting for confounders (OR=1.940, P=0.04).

CONCLUSIONS

NHB patients undergoing thrombectomy for ischemic stroke experience worse 3- and 6-month functional outcomes than NHW patients after adjusting for confounders. Interestingly, this disparity was not detected at 12 months. Future research should focus on identifying social determinants in the short-term post-stroke recovery period to improve parity in stroke care.

Electroacupuncture improves the learning and memory abilities of rats with PSCI by attenuating the TLR4/NF-κB/NLRP3 signaling pathway on the hippocampal microglia

This study aims to investigate how electroacupuncture regulates the learning and memory abilities of poststroke cognitive impairment (PSCI) rats through the TLR4/NF-κB/NLRP3 signaling pathway on the hippocampal microglia. Thirty male rats were randomly divided into three groups: sham surgery group, PSCI model group, and electroacupuncture group, with 10 rats in each group. Middle cerebral artery occlusion was used to establish the PSCI model. The Zea Longa method was used to score the rats' neurological function. Electroacupuncture was utilized for 21 days to improve PSCI. The learning and memory abilities of rats were tested using the Morris water maze. Hematoxylin-eosin staining and immunofluorescence were used to find the hippocampus' pathological changes. The concentration of interleukin-1β, interleukin-6, tumor necrosis factor-α, and interleukin-18 were detected by ELISA. The mRNA expression levels of associated inflammatory corpuscles were measured by quantitative real-time PCR. The protein expression levels of TLR4, MyD88, NF-κB, and NLRP3 were measured using western blotting. Electroacupuncture improved not only the learning and memory abilities of PSCI rats but also hippocampal morphology. Electroacupuncture inhibited the activation of microglia and the TLR4/NF-κB/NLRP3 signaling pathway. Electroacupuncture also reduced proinflammatory factors and restrained the mRNA levels of NLRP3-associated inflammatory cytokines. Its mechanism was related to inhibiting the expression of the TLR4/NF-κB/NLRP3 signaling pathway, attenuating the release of inflammatory factors, and regulating the activation of hippocampal microglia in the brain.

Assessment approaches for hemiplegic shoulder pain in people living with stroke - A scoping review

PURPOSE

Hemiplegic shoulder pain (HSP) is reported in up to 40% of people with stroke. Causes of HSP are often multifactorial. To inform appropriate treatment, reliable/valid assessments are critical. The aim of this scoping review was to collate assessment approaches used in studies where the primary outcome was HSP, and to identify how frequently each assessment approach was used.

METHODS

A systematic search, including studies from 2000-2023 was conducted of the MEDLINE, EMBASE, CINAHL, AMED, Biomed Central, and Cochrane Library databases, with four key terms used: "assess", "stroke", "pain" and "shoulder". All primary studies published in English language fulfilling the reviews inclusion criteria were included. Six reviewers extracted the data.

RESULTS

A total of 29 assessment methods for HSP were identified from 124 studies. The common assessments were: Visual Analogue Scale (n = 75, 60%), Passive Range of Movement (n = 65, 52%), Fugl-Meyer Assessment (n = 32, 26%), glenohumeral subluxation (n = 30, 24%) and Numerical Rating Scale (n = 27, 22%).

CONCLUSION

A wide range of assessment approaches was identified for HSP, and some are used more than others. A fully comprehensive assessment that considers different aspects of pain including severity and timing, functioning, and the psychological burden, is needed in this area of practice to be able to guide appropriate treatment.

Caregiver burden, hopelessness, and anxiety: Association between sociodemographic and clinical profiles of patients with stroke

OBJECTIVES

This study aimed to evaluate the association between the sociodemographic characteristics of caregivers and patients with stroke, clinical data on stroke, and disability with caregiver burden, hopelessness, and anxiety.

MATERIALS AND METHODS

This cross-sectional study included patients with stroke of either sex, aged >18 years. Data were collected between January 2020 and July 2021. Patient demographic included age, sex, stroke type, severity, etiology, topography, treatment, and stroke recurrence. Stroke disability was assessed using the modified Rankin Scale and Barthel Index at 90 days post-discharge. Additionally, caregiver burden, hopelessness, and anxiety were evaluated during patient consultations using the Zarit Burden Interview (ZBI), Beck Hopelessness Scale (BHS), and Beck Anxiety Inventory (BAI).

RESULTS

We included 104 patients with stroke and their caregivers. Overall caregiver burden was moderate (ZBI: 24 [25]), with mild hopelessness (BHS: 4 [4]) and minimal to mild anxiety (BAI: 8 [13]). The linear regression model presented in Table 3 showed that female caregivers scored up to 11 points higher on the Zarit Burden Interview (p = 0.011). Additionally, increased patient age was associated with a higher caregiver burden (p = 0.002) on the Zarit Burden Interview. Posterior circulation stroke and total anterior circulation stroke were also associated with higher Zarit Burden Interview scores compared to lacunar stroke (p = 0.017). Age was not associated with caregiver burden in the entire sample. However, an association between age and caregiver burden was found only in the female group. Furthermore, women aged 65 years and older experienced a more severe burden than women aged 18 to 64 years (p<0.001). Stroke disability was not associated with caregiver burden.

CONCLUSIONS

Older female caregivers were significantly affected when caring for stroke patients. Total anterior circulation stroke and Posterior circulation stroke increased Zarit Burden Interview scores. However, no association was observed between stroke disability and the caregiver burden.

Astrocyte modulation in cerebral ischemia-reperfusion injury: A promising therapeutic strategy

Cerebral ischemia-reperfusion injury (CIRI) poses significant challenges for drug development due to its complex pathogenesis. Astrocyte involvement in CIRI pathogenesis has led to the development of novel astrocyte-targeting drug strategies. To comprehensively review the current literature, we conducted a thorough analysis from January 2012 to December 2023, identifying 82 drugs aimed at preventing and treating CIRI. These drugs target astrocytes to exert potential benefits in CIRI, and their primary actions include modulation of relevant signaling pathways to inhibit neuroinflammation and oxidative stress, reduce cerebral edema, restore blood-brain barrier integrity, suppress excitotoxicity, and regulate autophagy. Notably, active components from traditional Chinese medicines (TCM) such as Salvia miltiorrhiza, Ginkgo, and Ginseng exhibit these important pharmacological properties and show promise in the treatment of CIRI. This review highlights the potential of astrocyte-targeted drugs to ameliorate CIRI and categorizes them based on their mechanisms of action, underscoring their therapeutic potential in targeting astrocytes.

Return to work for stroke survivors with aphasia: A quantitative scoping review

The international incidence of stroke in people of working age is rising. As such, meaningful work return is a major rehabilitation goal for many individuals, including those with aphasia. This scoping review aimed to outline the post-stroke aphasia evidence related to work outcomes, factors influencing employment along with contemporary vocational-language and communication rehabilitation practice. The review employed terms related to aphasia, stroke, rehabilitation, and return to work in publications preceding 25.6.2023. Data were descriptively analysed, and vocational outcomes were summarized at defined timepoints. Of the 908 articles reviewed, 31 papers were included. Individuals with post-stroke aphasia consistently have lower rates of return to work than those post-stroke without aphasia. Employment at one year was 34.29% for those with aphasia compared to 58.46% for people without aphasia. No literature reported vocational-language assessment practices and there were minimal work-focused aphasia interventions identified. There was insufficient evidence to clearly identify person-related, rehabilitation, workplace or other factors influencing work return. This scoping review has identified that there are gaps in knowledge about the factors that influence work return and targeted vocational rehabilitation for this group. Future research to optimize return to work for individuals with aphasia is recommended.

Obstructive sleep apnea exaggeration as predictor of poor outcome post thrombolytic stroke

Obstructive sleep apnea (OSA) is a common sleep disordered breathing in stroke patients. This case report aimed to show the presence of OSA in stroke can contribute to the increasing chance of mortality and morbidity. We presented a case of first-time stroke in a 64-year-old female with a history of pre-stroke OSA. She underwent intravenous thrombolysis as main therapy within the time limit under 4.5 hours since the stroke onset. She had prolonged hospital stay due to complications from OSA, even though she only had a small ischemic core (9 mL) in follow-up radiological imaging and was discharged with a greater National Institutes of Health Stroke Scale (NIHSS) score than admission (5 to 10). OSA can be one of warning signs for poor prognosis in stroke patients. Understanding the presence of OSA not only can be beneficial toward choosing the next steps of therapy, but also important for the rehabilitation and recovery period of stroke patients.

Stroke awareness in a Brazilian Northeastern capital city and the burden of the COVID-19 pandemic

BACKGROUND

 The delay in recognizing stroke symptoms is a significant obstacle to receiving acute treatment. Therefore, it is essential to understand the gaps in the knowledge about stroke among the general population and promote campaigns based on these gaps.

OBJECTIVE

 To investigate the general knowledge about stroke in a capital in Northeastern Brazil in a sample of individuals who attended a public hospital and the impacts of the coronavirus disease 2019 (COVID-19) pandemic on the use of emergency services.

METHODS

 We included patients older than 18 years of age and their family members and/or companions. After obtaining consent, the researcher presented a typical case of stroke, and the participants filled out a questionnaire divided into 2 sections: sociodemographic data and 15 questions about stroke detection and seeking health services and treatment.

RESULTS

 We included 154 individuals with a mean age of 44.45 ± 16.21 years. After presenting the case, 60.4% mentioned the acronym AVC (acidente vascular cerebral, or cerebrovascular accident [stroke], in Portuguese) as a possible explanation, and 54.5% reported that they would call the Mobile Emergency Care Service. However, 62.9% provided the incorrect telephone number for the Mobile Emergency Care Service or lacked knowledge of the accurate number. Regarding the risk factors for stroke, 27.9% did not know any of them, 65.5% were unaware of any treatment, and no reference was made to thrombolytic therapy. About their chosen conduct in the same case in the context of the COVID-19 pandemic, 98.1% of the participants would not change their behavior.

CONCLUSION

 These results can assist in the planning of public policies and campaigns emphasizing the issue of risk factors and how to access emergency medical services in the state of Alagoas, Brazil.

'A Meaningful Difference, but Not Ultimately the Difference I Would Want': A Mixed-Methods Approach to Explore and Benchmark Clinically Meaningful Changes in Aphasia Recovery

INTRODUCTION

Outcome measurement instruments (OMIs) are used to gauge the effects of treatment. In post-stroke aphasia rehabilitation, benchmarks for meaningful change are needed to support the interpretation of patient outcomes. This study is part of a research programme to establish minimal important change (MIC) values (the smallest change above which patients perceive themselves as importantly changed) for core OMIs. As a first step in this process, the views of people with aphasia and clinicians were explored, and consensus was sought on a threshold for clinically meaningful change.

METHODS

Sequential mixed-methods design was employed. Participants included people with post-stroke aphasia and speech pathologists. People with aphasia were purposively sampled based on time post-stroke, age and gender, whereas speech pathologists were sampled according to their work setting (hospital or community). Each participant attended a focus group followed by a consensus workshop with a survey component. Within the focus groups, experiences and methods for measuring meaningful change during aphasia recovery were explored. Qualitative data were transcribed and analysed using reflexive thematic analysis. In the consensus workshop, participants voted on thresholds for meaningful change in core outcome constructs of language, communication, emotional well-being and quality of life, using a six-point rating scale (much worse, slightly worse, no change, slightly improved, much improved and completely recovered). Consensus was defined a priori as 70% agreement. Voting results were reported using descriptive statistics.

RESULTS

Five people with aphasia (n = 4, > 6 months after stroke; n = 5, < 65 years; n = 3, males) and eight speech pathologists (n = 4, hospital setting; n = 4, community setting) participated in one of four focus groups (duration: 92-112 min). Four themes were identified describing meaningful change as follows: (1) different for every single person; (2) small continuous improvements; (3) measured by progress towards personally relevant goals; and (4) influenced by personal factors. 'Slightly improved' was agreed as the threshold of MIC on the anchor-rating scale (75%-92%) within 6 months of stroke, whereas after 6 months there was a trend towards supporting 'much improved' (36%-66%).

CONCLUSION

Our mixed-methods research with people with aphasia and speech pathologists provides novel evidence to inform the definition of MIC in aphasia rehabilitation. Future research will aim to establish MIC values for core OMIs.

PATIENT OR PUBLIC CONTRIBUTION

This work is the result of engagement between people with lived experience of post-stroke aphasia, including people with aphasia, family members, clinicians and researchers. Engagement across the research cycle was sought to ensure that the research tasks were acceptable and easily understood by participants and that the outcomes of the study were relevant to the aphasia community. This engagement included the co-development of a plain English summary of the results. Advisors were remunerated in accordance with Health Consumers Queensland guidelines. Interview guides for clinicians were piloted by speech pathologists working in aphasia rehabilitation.

Neutralizing RGMa with Elezanumab Promotes Cerebroprotection and Recovery in Rabbit Middle Cerebral Artery Occlusion

Repulsive guidance molecule A (RGMa) is an inhibitor of neuronal growth and survival which is upregulated in the damaged central nervous system following acute spinal cord injury (SCI), traumatic brain injury, acute ischemic stroke (AIS), and other neuropathological conditions. Neutralization of RGMa is neuroprotective and promotes neuroplasticity in several preclinical models of neurodegeneration and injury including multiple sclerosis, AIS, and SCI. Given the limitations of current treatments for AIS due to narrow time windows to intervention (TTI), and restrictive patient selection criteria, there is significant unmet need for therapeutic agents that enable tissue survival and repair following acute ischemic damage for a broader population of stroke patients. In this preclinical study, we evaluated whether elezanumab, a human anti-RGMa monoclonal antibody, could improve neuromotor function and modulate neuroinflammatory cell activation following AIS with delayed intervention times up to 24 h using a rabbit embolic permanent middle cerebral artery occlusion model (pMCAO). In two replicate 28-day pMCAO studies, weekly intravenous infusions of elezanumab, over a range of doses and TTIs of 6 and 24 h after stroke, significantly improved neuromotor function in both pMCAO studies when first administered 6 h after stroke. All elezanumab treatment groups, including the 24 h TTI group, had significantly less neuroinflammation as assessed by microglial and astrocyte activation. The novel mechanism of action and potential for expanding TTI in human AIS make elezanumab distinct from current acute reperfusion therapies, and support evaluation in clinical trials of acute CNS damage to determine optimal dose and TTI in humans.

Current practice of outpatient rehabilitation services in patients with mobility-impaired paralysis due to stroke or spinal cord injury: a qualitative interview study in Germany

PURPOSE

When mobility deficits persist after stroke or spinal cord injury (SCI), outpatient neurorehabilitation services are required. This study aimed to explore the current practice of German outpatient neurorehabilitation services and identify factors associated to this practice.

METHODS

This was a qualitative observational study in which semi-structured interviews were conducted with professionals from outpatient neurorehabilitation services and mobility-impaired patients. A qualitative content analysis with a data-driven coding process was used.

RESULTS

Three general practitioners, five physical, five occupational, and one speech therapist, one neuropsychologist, two outpatient nurses, one rehabilitation technician, one social worker, two patient advocates (long-term survivors, each stroke and SCI), and 20 patients (10 after stroke, 10 after SCI, all first-ever affected since approximately one year) participated. The reported experiences ranged from high satisfaction to perceived deficits in participation-oriented, evidence-based, and coordinated care. Identified associated factors were: (a) availability of specialised therapists and professional education, (b) outpatient service catalogue, (c) cost coverage, (d) setting rehabilitation goals, and (e) physician as care coordinator.

CONCLUSION

Areas of improvement identified focused on: setting rehabilitation goals towards participation, training therapists on evidence-based treatments and shared decision-making, updating the outpatient service catalogue, and implementing coordination actions. Implementation of these recommendations should be evaluated.

Ten Priorities for Research Addressing the Intersections of Brain Injury, Mental Health and Addictions: A Stakeholder-Driven Priority-Setting Study

OBJECTIVES

The purpose of this study was to engage key stakeholders in a health research priority-setting process to identify, prioritize and produce a community-driven list of research questions addressing intersectional issues on mental health and addictions (MHA) in acquired brain injury (ABI).

METHODS

A multiphasic health research priority-setting process was co-designed and executed with community-based stakeholders, including researchers, health professionals, clinicians, service providers, representatives from brain injury associations, policy makers and people with lived experience of ABI and MHA, including patients and their family members. Stakeholders' ideas led to the generation of research questions, which were prioritized at a 1-day workshop.

RESULTS

Fifty-nine stakeholders participated in the priority-setting activity during the workshop, which resulted in a rank-ordered list of the top 10 questions for research addressing the intersections of ABI and MHA. Questions identified touched on several pressing issues (e.g., opioid crisis, homelessness), encompassed multiple subtypes of ABI (e.g., hypoxic-ischaemic, mild traumatic), and involved different domains (e.g., identification, intervention) of health research.

CONCLUSIONS

This community-driven health research priority-setting study identified and prioritized research questions addressing the intersections of ABI and MHA. Researchers and funding agencies should use this list to inform their agendas and address stakeholders' most urgent needs, fostering meaningful improvements to clinical services.

PATIENT OR PUBLIC CONTRIBUTION

An 11-person working group comprised of people with lived experience, service providers, researchers, healthcare professionals and other key stakeholders collaboratively developed and informed the scope, design, methodology and interpretation of this study. Over 50 community-based stakeholders contributed to the research priority-setting activity. One co-author is a person with lived experience.

Pharyngeal Cavity Electrical Stimulation-Assisted Swallowing for Post-stroke Dysphagia: A Systematic Review and Meta-analysis of Randomized Controlled Studies

Stroke is the leading cause of death and disability among adults. The incidence of stroke per 100, 000 patient-years was 2875. As many as 37% to 78% of patients with acute strokes suffer dysphagia. Dysphagia can easily lead to inhalation pneumonia, dehydration, malnutrition, and other serious complications, affecting the quality of life of stroke patients and increasing their mortality. Effective prevention and treatment of post-stroke dysphagia are of great significance to improving the prognosis and quality of life of patients. Some studies have shown that Pharyngeal cavity electrical stimulation-assisted swallowing (PCES-assisted swallowing) has a positive effect on patients with post-stroke dysphagia. This study will evaluate the effects of PCES-assisted swallowing on post-stroke dysphagia, including swallowing function, withdrawal rate of nasal feeding tubes, duration of hospitalization, and so on. Randomized controlled trials (RCTs) of PCES-assisted swallowing in the treatment of post-stroke dysphagia were searched in eight databases, including Cochrane Library, Embase, PubMed, Web of Science, Chinese Biomedical Literature Database, VIP Information Resource System, CNKI, and Wanfang Medical Science. The retrieval time was from the database establishment to June 2022. Rayyan was used to screen the retrieved literature risk of bias for included studies and was calculated using ROB2.0. The RevMan 5.3 software was used for the meta-analysis with the standard mean difference (SMD) and 95% confidence interval (CI). The model type was a random effect model, The risk ratio (RR) was used as the effect size for the two categorical variables. The swallowing function scores, withdrawal rate of nasal feeding tubes, and Length of stay (LOS) of the intervention and control groups were extracted, and the results of the meta-analysis were presented using a forest plot. Six studies from 2010 to 2018 with a total of 341 people were included in the meta-analysis. All studies reported quantitative outcome measures for the severity of dysphagia, and some reported the withdrawal rate of nasal feeding tubes, LOS, and penetration-aspiration-scale (PAS). The overall swallowing function of the PCES group was better than that of the control group (SMD = - 0.20, 95%CI - 0.38 to - 0.03, P = 0.02). In terms of the severity of dysphagia, there was a statistically significant difference in the Dysphagia Severity Rating scale (DSRS) between the Pharyngeal cavity electrical stimulation (PCES) group and the control group (SMD = - 0.24, 95%CI - 0.48 to 0, P = 0.05). The PCES group nasal feeding withdrawal rate of nasal feeding tubes was higher than the control group (RR = 2.88, 95% CI 1.15 to 7.26, P = 0.02). There was no significant difference in the LOS between the PCES group and the control group (SMD = - 0.19, 95%CI - 0.44 to 0.07, P = 0.15). This systematic review and meta-analysis provide reasonably reliable evidence that PCES-assisted swallowing can improve nasogastric feeding swallowing function and the withdrawal rate of nasal feeding tubes in patients with post-stroke dysphagia. However, the evidence for reducing oral feeding, aspiration, and length of hospitalization stay is lacking, and further studies are needed.

Efficacy of Cerebellar Transcranial Magnetic Stimulation for Post-stroke Balance and Limb Motor Function Impairments: Meta-analyses of Random Controlled Trials and Resting-State fMRI Studies

This study aimed to investigate the potential therapeutic effects of cerebellar transcranial magnetic stimulation (TMS) on balance and limb motor impairments in stroke patients. A meta-analysis of randomized controlled trials was conducted to assess the effects of cerebellar TMS on balance and motor impairments in stroke patients. Additionally, an activation likelihood estimation (ALE) meta-analysis was performed on resting-state functional magnetic resonance imaging (fMRI) studies to compare spontaneous neural activity differences between stroke patients and healthy controls using measures including the amplitude of low frequency fluctuation (ALFF), fractional ALFF (fALFF), and regional homogeneity (ReHo). The analysis included 10 cerebellar TMS studies and 18 fMRI studies. Cerebellar TMS treatment demonstrated significant improvements in the Berg Balance Scale score (p < 0.0001) and the Fugl-Meyer Assessment lower extremity score (p < 0.0001) compared to the control group in stroke patients. Additionally, spontaneous neural activity alterations were identified in motor-related regions after stroke, including the precentral gyrus, putamen, thalamus, and paracentral lobule. Cerebellar TMS shows promise as a therapeutic intervention to enhance balance and lower limb motor function in stroke patients. It is easy for clinical application and addresses the limitations of insufficient direct stimulation depth on the leg area of the cortex. However, further research combining neuroimaging outcomes with clinical measurements is necessary to validate these findings.

Multistrain Probiotics with Fructooligosaccharides Improve Middle Cerebral Artery Occlusion-Driven Neurological Deficits by Revamping Microbiota-Gut-Brain Axis

Recent burgeoning literature unveils the importance of gut microbiota in the neuropathology of post-stroke brain injury and recovery. Indeed, ingestion of prebiotics/probiotics imparts positive effects on post-stroke brain injury, neuroinflammation, gut dysbiosis, and intestinal integrity. However, information on the disease-specific preference of selective prebiotics/probiotics/synbiotics and their underlying mechanism is yet elusive. Herein, we examined the effect of a new synbiotic formulation containing multistrain probiotics (Lactobacillus reuteri UBLRu-87, Lactobacillus plantarum UBLP-40, Lactobacillus rhamnosus UBLR-58, Lactobacillus salivarius UBLS-22, and Bifidobacterium breve UBBr-01), and prebiotic fructooligosaccharides using a middle cerebral artery occlusion (MCAO) model of cerebral ischemia in female and male rats. Three weeks pre-MCAO administration of synbiotic rescinded the MCAO-induced sensorimotor and motor deficits on day 3 post-stroke in rotarod, foot-fault, adhesive removal, and paw whisker test. We also observed a decrease in infarct volume and neuronal death in the ipsilateral hemisphere of synbiotic-treated MCAO rats. The synbiotic treatment also reversed the elevated levels/mRNA expression of the glial fibrillary acidic protein (GFAP), NeuN, IL-1β, TNF-α, IL-6, matrix metalloproteinase-9, and caspase-3 and decreased levels of occludin and zonula occludens-1 in MCAO rats. 16S rRNA gene-sequencing data of intestinal contents indicated an increase in genus/species of Prevotella (Prevotella copri), Lactobacillus (Lactobacillus reuteri), Roseburia, Allobaculum, and Faecalibacterium prausnitzii, and decreased abundance of Helicobacter, Desulfovibrio, and Akkermansia (Akkermansia muciniphila) in synbiotic-treated rats compared to the MCAO surgery group. These findings confer the potential benefits of our novel synbiotic preparation for MCAO-induced neurological dysfunctions by reshaping the gut-brain-axis mediators in rats.

Association between estimated glucose disposal rate control level and stroke incidence in middle-aged and elderly adults

BACKGROUND

To estimate glucose disposal rate (eGDR) as a newly validated surrogate marker of insulin resistance. Few studies have explored the association between changes in eGDR levels and stroke incidence. This study aims to explore the effect of the level of eGDR control on stroke and events.

METHODS

Data were obtained from the China Longitudinal Study on Health and Retirement (CHARLS). The eGDR control level was classified using K-means cluster analysis. Logistic regression analysis was used to explore the association between different eGDR control levels and incident stroke. Restrictive cubic spline regression was used to test the potential nonlinear association between cumulative eGDR and stroke incidence.

RESULTS

Of the 4790 participants, 304 (6.3%) had a stroke within 3 years. The odds ratio (OR) was 2.34 (95% confidence interval [CI], 1.42-3.86) for the poorly controlled class 4 and 2.56 (95% CI, 1.53-4.30) for the worst controlled class 5 compared with class 1 with the best controlled eGDR. The OR for well-controlled class 2 was 1.28 (95% CI, 0.79-2.05), and the OR for moderately controlled class 3 was 1.95 (95% CI, 1.14-3.32). In restrictive cubic spline regression analysis, eGDR changes are linearly correlated with stroke occurrence. Weighted quartile and regression analysis identified waist circumference and hypertension as key variables of eGDR for predicting incident stroke.

CONCLUSIONS

Poorly controlled eGDR level is associated with an increased risk of stroke in middle-aged and elderly people. Monitoring changes in eGDR may help identify individuals at high risk of stroke early.

Investigating the Added Value of Beck's Depression Inventory in Atherosclerosis Prediction: Lessons from Paracelsus 10,000

Background: Depression is the most common mental illness worldwide and generates an enormous health and economic burden. Furthermore, it is known to be associated with an elevated risk of arteriosclerotic cardiovascular diseases (ASCVD), particularly stroke. However, it is not a factor reflected in many ASCVD risk models, including SCORE2. Thus, we analysed the relationship between depression, ASCVD and SCORE2 in our cohort. Methods: We analysed 9350 subjects from the Paracelsus 10,000 cohort, who underwent both a carotid artery ultrasound and completed a Beck Depression Inventory (BDI) screening. Patients were categorised binomially based on the BDI score. Atherosclerotic carotid plaque or absence was dichotomised for logistic regression modelling. Odds ratios and adjusted relative risks were calculated using Stata. Results: Subjects with an elevated BDI (≥14) had higher odds for carotid plaques compared to subjects with normal BDI, especially after adjusting for classical risk factors included in SCORE2 (1.21; 95%CI 1.03-1.43, p = 0.023). The adjusted relative risk for plaques was also increased (1.09; 95%CI 1.01-1.18, p = 0.021). Subgroup analysis showed an increased odds of plaques with increases in depressive symptoms, particularly in women and patients ≤55 yrs. Conclusions: In our cohort, the BDI score is associated with subclinical atherosclerosis beyond classical risk factors. Thus, depression might be an independent risk factor which may improve risk stratification if considered in ASCVD risk prediction models, such as SCORE2. Furthermore, reminding clinicians to take mental health into consideration to identify individuals at increased atherosclerosis risk may provide added opportunities to address measures which can reduce the risk of ASCVD.

Bottom-up versus Top-down designed rehabilitation sessions in chronic stroke survivors: a pilot randomized controlled trial

PURPOSE

The present study aimed to compare the effectiveness of Top-down and Bottom-up approaches on levels of the International Classification of Functioning, Disability and Health Framework (ICF), including impairments, activities, and participation.

MATERIALS AND METHODS

Thirty-nine chronic stroke survivors were recruited for this single-blinded randomized clinical trial. Participants were assigned to Top-down, Bottom-up interventions, or control group, and received a 6-week intervention. They were assessed before/after treatments and at follow-up (6 weeks later). Impairments were measured through kinematic analysis, Trail Making Tests (TMT), and Fugl-Meyer Assessment (FMA). Activity and participation were evaluated via Box and Block Test, Motor Activity Log (MAL), and Canadian Occupational Performance Measure (COPM), respectively.

RESULTS

We found significant improvements in impairment (FMA) and participation (COPM) in all groups, however, COPM scores improved beyond the MCID only in the Top-down, and FMA scores exceeded the MCID in Top-down and Bottom-up groups. Use of the upper limb in daily activities (MAL) enhanced in the Top-down group, although was not clinically significant.

CONCLUSION

In most of the outcome measures, no significant difference was observed between groups. It seems that Top-down, Bottom-up, and traditional interventions have relatively comparable effectiveness in chronic stroke survivors.

TRIAL REGISTRATION

IRCT20150721023277N2.

Electroacupuncture protects against cerebral ischemia-reperfusion injury through mitochondrial dynamics

Background

Electroacupuncture (EA) has been shown to promote functional recovery after cerebral ischemia-reperfusion (I/R) injury. However, the contribution of mitochondrial dynamics to recovery remains unclear. The aim of this study was to investigate whether mitochondrial dynamics are involved in the effects of EA on cerebral I/R injury.

Methods

The rats with cerebral I/R injury were established by the middle cerebral artery occlusion/reperfusion. Subsequently, EA was applied to Baihui (GV20) and Dazhui (GV14) acupoints, with 2 Hz/5 Hz in frequency, 1.0 mA in intensity, 20 min each time, once a day for seven consecutive days. The therapeutic outcomes were assessed by modified neurological severity score (mNSS), 2,3,5-Triphenyte-trazolium chloride (TTC) staining, and hematoxylin-eosin (HE) staining. Mitochondrial morphology was observed under transmission electron microscopy. Adenosine triphosphate (ATP) content and ATP synthases (ATPases) activity were evaluated to measure mitochondrial function using ELISA. Finally, mitochondrial dynamics-related molecules, including dynamin-related protein 1 (Drp1), fission 1 (Fis1), mitofusin 1 (Mfn1), mitofusin 2 (Mfn2), and optic atrophy 1 (OPA1), were detected by Western blot and immunofluorescence staining.

Results

Cerebral I/R injury induced neurological dysfunction, cerebral infarction and neuronal injury, all of which were ameliorated by EA. And EA improved mitochondrial morphology and function. Moreover, EA altered the balance of mitochondrial dynamics. Specifically, the data showed a significant decrease in the expression of Drp1 and Fis1, leading to the inhibition of mitochondrial fission. Additionally, Mfn1, Mfn2 and Opa1, which are related to mitochondrial fusion, were effectively promoted after EA treatment. However, sham EA did not show any neuroprotective effects in rats with cerebral I/R injury.

Conclusions

In summary, our study indicates that the balance of mitochondrial dynamics is crucial for EA therapy to treat cerebral I/R injury.

Spiritual needs and influencing factors among people with stroke in China: a cross-sectional study

BACKGROUND

Stroke is one of the primary causes of disability in China and around the world, having an impact on the health and well-being of stroke patients. The importance of spiritual needs for stroke patients has always been a controversial topic internationally, partly because related research was mostly qualitative and may not directly reflect the degree of spiritual needs. In addition, most studies focus on the same cultural background, there is a lack of research that delves into the nuances of Chinese culture and background. The goal of this study is to evaluate the level of spiritual needs and influencing factors in Chinese stroke patients and to explore the mediating role and pathways of these variables on spiritual needs.

METHODS

From August 2022 to January 2023, we conducted a cross-sectional questionnaire survey of 422 stroke patients in the affiliated hospitals of Hunan University of Chinese Medicine in Changsha Province by cluster sampling. We measured the patient's spiritual needs, quality of life, anxiety and depression levels, and family support using the Spiritual Needs Questionnaire (SPNQ), the MOS36 item Short Form Health Survey (SF-36), the Hospital Anxiety and Depression Scale (HADS), and the Family Support Self Rating Scale (PSS-Fa). We used the General Information Questionnaire to gain insight into the sociodemographic characteristics of the patients. Nonparametric tests and multiple linear regression models were used to analyze the independent relationship between spiritual needs and quality of life, anxiety, depression, and family support. The mediation model in AMOS 24.0 software was used to analyze the mediating role among the five variables.

RESULTS

The score of spiritual needs of people with stroke included in this study was 37 points [IQR 33 to 40)]. The influencing factors of spiritual needs included primary economic sources for disease-related expenditures (p = 0.044), number of stroke occurrences (p = 0.001), duration of illness (p = 0.023), activities of daily living (p = 0.006), depression scores(p = 0.034), and family support scores(p = 0.008). Anxiety (β = 0.347, p = 0.004), depression (β = 0.368, p = 0.005), and family support (β = 0.167, p = 0.023) had directly or indirectly affected the spiritual needs of people with stroke. Quality of life (β=-0.202, p = 0.017) had a direct effect on spiritual needs.

CONCLUSIONS

The spiritual needs of people with stroke were at an intermediate level. Our findings highlight that the SPNQ score is associated with anxiety, depression, quality of life, and family support. Therefore, nurses should identify the spiritual needs of patients and provide them with effective and comprehensive spiritual care by reducing negative emotions and enhancing social support, promoting the development and progress of spiritual care in China. This study offers a theoretical basis for the spiritual care of clinical people with stroke and constructing a stroke spiritual care model.

Primary Health Care in transitional care of people with stroke

OBJECTIVES

to understand the role of Primary Health Care teams in caring for people with stroke after hospital discharge.

METHODS

single case study, with integrated units of analysis, with a qualitative approach. Data triangulation occurred through interviews with professionals and family caregivers involved in transition of care, in addition to direct observations in rounds and document analysis. For the analyses, the analytical strategies of theoretical propositions and construction of explanations were used, with the help of ATLAS.ti®.

RESULTS

the importance of counter-referral, the role of community health workers and the multidisciplinary team, health promotion, secondary prevention, home visits as a visceral attribute and nurses as care managers are evident.

FINAL CONSIDERATIONS

the high demand on teams and the Social Determinants of Health interfere with adequate continuity of care. Transitional care programs that enable continuity of care are recommended.

Vagus nerve stimulation (VNS) inhibits cardiac mast cells activation and improves myocardial atrophy after ischemic stroke

BACKGROUND

Ischemic stroke is one of the leading causes of chronic disability worldwide, and stroke-induced heart damage can lead to death. According to research, patients with a variety of brain disease have good clinical results after vagus nerve stimulation (VNS). After ischemic stroke, mast cells (MCs) degranulate and release a large number of mediators, which may cause systemic inflammation. Chymase secreted by MCs can increase the levels of pathological angiotensin II (AngⅡ), which plays a crucial role in the deterioration of heart disease. Our goal was to develop a minimally invasive, targeted, and convenient VNS approach to assess the impact of VNS and to clarify the relationship between VNS and MCs in the prognosis of patients with myocardial atrophy after acute ischemic stroke.

METHODS

In this study, we verified the role of VNS in the treatment of myocardial atrophy after stroke and its molecular mechanism using a rat model of middle cerebral artery occlusion (MCAO/r). Behavioral studies were assessed using neurobehavioral deficit scores. Enzyme-linked immunosorbent assays, immunofluorescence staining, Western blotting and qRT-PCR were used to analyze the expression levels of myocardial atrophy, MC and inflammatory markers in rat hearts.

RESULTS

VNS improved myocardial atrophy in MCAO/r rats, inhibited MC activation, reduced the expression of chymase and AngⅡ, and inhibited the expression of proinflammatory factors. The chymase activator C48/80 reversed these effects of VNS. Chymase activation inhibited the effect of VNS on myocardial atrophy in MCAO/r rats, increased AngⅡ expression and aggravated inflammation and autophagy. The myocardial atrophy of MCAO/r rats was improved after chymase inhibition, and AngⅡ expression, inflammation and autophagy were reduced. Our results suggest that VNS may reduce the expression of chymase and AngⅡ by inhibiting MC activation, thereby improving myocardial atrophy and reducing inflammation and autophagy in MCAO/r rats. Inhibition of MC activation may be an effective strategy for treating myocardial atrophy after stroke.

CONCLUSIONS

VNS inhibits MC activation and reduces the expression of chymase and AngII, thereby alleviating myocardial atrophy, inflammation and autophagy after stroke.

ATP-sensitive potassium channel opener, Nicorandil, inhibits NF-κB/AIM2/GSDMD pathway activation to protect against neuroinflammation in ischemic stroke

The absent in melanoma 2 (AIM2) inflammasome contributes to ischemic brain injury by inducing cell pyroptosis and inflammatory responses. Our research group has previously demonstrated that ATP-sensitive potassium channels (KATP channels) openers can modulate neuronal synaptic plasticity post-ischemic stroke for neuroprotection. However, the specific mechanisms of KATP channels in the inflammatory response following ischemic stroke remain unclear. Here, we assessed cellular damage by observing changes in BV-2 morphology and viability. 2,3,5-Triphenyl tetrazolium chloride (TTC) staining, mNSS scoring, Nissl staining, and TdT-mediated dUTP nick end labeling (TUNEL) staining were used to evaluate behavioral deficits, brain injury severity, and neuronal damage in mice subjected to middle cerebral artery occlusion (MCAO). Quantitative real-time polymerase chain reaction (qRT-PCR), Western blotting, immunofluorescence, and enzyme-linked immunosorbent assay (ELISA) were used to measure cell pyroptosis and nuclear factor-kappaB (NF-κB) activation in vivo and in vitro. We observed that AIM2 protein expression was upregulated and localized within the cytoplasm of BV-2 cells. Notably, low-dose Nicorandil treatment reduced inflammatory cytokine secretion and pyroptosis-related protein expression, including AIM2, cleaved cysteinyl aspartate-specific protease-1 (cleaved caspase-1), and Gasdermin D N-terminal (GSDMD-NT). Further investigations revealed that the KATP channel inhibitor 5-HD upregulated p-NF-κB p65, NF-κB p65, and p-IκBα expression, reversing Nicorandil's neuroprotective effect in vivo. In summary, our results suggest that Nicorandil may serve as a potential therapeutic option for ischemic stroke. Targeting AIM2 and NF-κB represents effective strategies for inhibiting neuroinflammation.

Improving Movement Behavior in People after Stroke with the RISE Intervention: A Randomized Multiple Baseline Study

Objective: High amounts of sedentary behavior increase the risk of cardiovascular disease. This study aimed to determine the preliminary effectiveness and feasibility of the RISE intervention to support community-dwelling people with stroke, who are highly sedentary, to reduce and interrupt sedentary time. Additionally, the added value of including participatory support was determined. Methods: A randomized, multiple-baseline study was conducted including 14 participants. All received the RISE intervention, a 15-week blended behavioral intervention in which a primary care physiotherapist provided personalized coaching in the home setting by using behavior-change techniques and the RISE eCoaching system, including an activity monitor and app to provide real time feedback. Half of the participants (randomly allocated) received participatory support from someone from their social network (e.g., partner or close friend) who joined them in the intervention. Preliminary effectiveness was determined with significant changes in total sedentary time and fragmentation (interruption) of sedentary time using a randomization test. Feasibility was assessed by adherence with the intervention protocol, safety, and satisfaction with the intervention. Results: Participants significantly reduced total sedentary time (p = 0.01) by 1.3 h on average and increased their fragmentation (p < 0.01). Subgroup analyses showed significant improvements in both outcomes only in the group with participatory support. Thirteen (92.9%) participants completed the intervention, no related adverse events occurred, and the reported participant satisfaction was sufficient. Conclusions: The RISE intervention appears promising to support people with stroke who are highly sedentary to reduce and interrupt their sedentary time. Participatory support appears to contribute to greater results. Trial registration: ISRCTN international trial registry, 10694741.

Developing a nomogram model for 3-month prognosis in patients who had an acute ischaemic stroke after intravenous thrombolysis: a multifactor logistic regression model approach

OBJECTIVES

This study is to establish a nomination graph model for individualised early prediction of the 3-month prognosis of patients who had an acute ischaemic stroke (AIS) receiving intravenous thrombolysis with recombinant tissue plasminogen activator.

DESIGN

For the period from January 2016 through August 2022, 991 patients who had an acute stroke eligible for intravenous thrombolysis were included in the retrospective analysis study. The study was based on multifactor logistic regression.

PARTICIPANTS

Patients who received treatment from January 2016 to February 2021 were included in the training cohort, and those who received treatment from March 2021 to August 2022 were included in the testing cohort.

INTERVENTIONS

Each patient received intravenous thrombolysis within 4.5 hours of onset, with treatment doses divided into standard doses (0.9 mg/kg).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was a 3-month adverse outcome (modified Rankin Scale 3-6).

RESULTS

The National Institutes of Health Stroke Scale Score after thrombolysis (OR=1.18; 95% CI: 1.04 to 1.36; p = 0.015), door-to-needle time (OR=1.01; 95% CI: 1.00 to 1.02; p = 0.003), baseline blood glucose (OR=1.08; 95% CI: 1.00 to 1.16; p=0.042), blood homocysteine (OR=7.14; 95% CI: 4.12 to 12.71; p<0.001), monocytes (OR=0.05; 95% CI: 0.01 to 0.043; p=0.005) and monocytes/high-density lipoprotein (OR=62.93; 95% CI: 16.51 to 283.08; p<0.001) were independent predictors of adverse outcomes 3 months after intravenous thrombolysis, and the above six factors were included in the nominated DGHM2N nomogram. The area under the receiver operating characteristic curve value of the training cohort was 0.870 (95% CI: 0.841 to 0.899) and in the testing cohort was 0.822 (95% CI: 0.769 to 0.875).

CONCLUSIONS

A reliable nomogram model (DGHM2N model) was developed and validated in this study. This nomogram could individually predict the adverse outcome of patients who had an AIS receiving intravenous thrombolysis with alteplase for 3 months.

Single-belt vs. split-belt treadmill symmetry training: is there a perfect choice for gait rehabilitation post-stroke?

Post-stroke gait asymmetry leads to inefficient gait and a higher fall risk, often causing limited home and community ambulation. Two types of treadmills are typically used for training focused on symmetry: split-belt and single belt treadmills, but there is no consensus on which treadmill is superior to improve gait symmetry in individuals with stroke. To comprehensively determine which intervention is superior, we considered multiple spatial and temporal gait parameters (step length, stride time, swing time, and stance time) and their symmetries. Ten individuals with stroke underwent a single session of split-belt treadmill training and single belt treadmill training on separate days. The changes in step length, stride time, swing time, stance time and their respective symmetries were compared to investigate which training improves both spatiotemporal gait parameters and symmetries immediately after the intervention and after 5 min of rest. Both types of treadmill training immediately increased gait velocity (0.08 m/s faster) and shorter step length (4.15 cm longer). However, split-belt treadmill training was more effective at improving step length symmetry (improved by 27.3%) without sacrificing gait velocity or step length. However, this step length symmetry effect diminished after a 5-min rest period. Split-belt treadmill training may have some advantages over single belt treadmill training, when targeting step length symmetry. Future research should focus on comparing the long-term effects of these two types of training and examining the duration of the observed effects to provide clinically applicable information.

Temporal trends of sex differences in acute reperfusion therapy and early outcomes of acute ischemic stroke in South Korea: 10-year analysis of the nationwide stroke registry

BACKGROUND

Sex differences in stroke outcomes are notable, with women experiencing higher incidence rates, greater disability-adjusted life years, and poorer recovery compared to men, even after adjusting for age and comorbidities. Despite the disproportionate burden in women, studies have reported that women are less likely to receive appropriate stroke treatment than men.

AIM

This study investigated temporal trends of sex differences in acute reperfusion therapy and early outcomes in patients with acute ischemic stroke over 10 years in South Korea.

METHODS

A retrospective analysis of Korean Stroke Registry included patients with acute ischemic stroke from 2012 to 2021. The study outcomes were the temporal trends of acute reperfusion therapy and early outcomes over 10 years in men and women, respectively. In addition, this study analyzed the temporal trends of sex differences in these parameters during the same period. Early outcomes include the proportions of favorable functional outcomes at discharge, discharge patterns, and in-hospital mortality.

RESULTS

A total of 93,692 patients (68.4 years, 40.1% women) with acute ischemic stroke were finally enrolled. Women had a higher age at stroke onset, a higher prevalence of atrial fibrillation, and more severe strokes than men. Women had lower proportion of favorable functional outcomes at discharge and higher proportion of in-hospital mortality compared to men each year. The proportion of patients who received intravenous thrombolysis was lower or similar in women compared to men in most years, and the proportion of patients who received endovascular thrombectomy did not significantly differ between sexes annually. Sex differences in acute reperfusion therapy remained unchanged over 10 years.

CONCLUSION

Women have received acute reperfusion therapy at similar or lower rates than men and experienced poorer outcomes, despite having more stroke risk factors and often more severe strokes.

Association between fibrinogen levels and stroke-associated pneumonia in acute ischemic stroke patients

PURPOSE

Prior research had indicated a relationship between fibrinogen and stroke-associated pneumonia (SAP), yet the nature of this relationship had not been thoroughly investigated. Therefore, this study was designed to elucidate the prognostic value of fibrinogen levels in forecasting the occurrence of SAP among patients with acute ischemic stroke (AIS).

PATIENTS AND METHODS

In this retrospective cross-sectional analysis, we included 1092 patients who had experienced AIS and were admitted to our facility within 72 h of the onset of their symptoms. Based on the SAP diagnostic criteria, patients were classified into two groups: SAP and non-SAP. The correlation between serum fibrinogen concentration and SAP was examined using univariate analysis. Curve fitting and multivariable logistic regression model were utilized for statistical evaluation.

RESULTS

Out of the ischemic stroke patients included in the study, SAP was identified in 112 (10.26%) patients. A direct correlation was observed between fibrinogen levels and the incidence of SAP. An increase in fibrinogen levels corresponded with a heightened incidence of SAP. Multivariable logistic regression revealed a significant positive association between fibrinogen levels and SAP incidence (OR = 1.53, 95% confidence interval [CI]: 1.18, 1.99)).

CONCLUSION

A linear relationship between serum fibrinogen levels and the incidence of SAP in ischemic stroke patients was shown. The serum fibrinogen levels were positively and linearly correlated to SAP risk.

Predictive Validity of Motor Assessment Scale on Poststroke Discharge Destination

Background: Stroke frequently leads to hospital admission and subsequent rehabilitation in order to overcome poststroke sequelae, such as motor impairments. Efficient planning of the steps following hospital admission includes early prediction of whether the patient can be discharged home or not. Early assessment of motor performance in patients with stroke-induced motor deficits may be able to function as a predictor of discharge destination but is less explored. Objective: The primary objective was to assess the predictive validity of the Motor Assessment Scale (MAS) on discharge destination both regarding total score and regarding subscores (transfer-mobility items and upper extremity items). Design: The study was designed as a prospective cohort study. Subjects: Thirty-seven consecutively recruited patients with stroke are the subjects of the study. Methods: Logistic regression model was used to calculate the odds of being discharged to own home upon hospital admittance. The predictive ability was examined with a receiving operator characteristic (ROC) curve, and cut-points from the curve were employed in Cox regression. Results: A one-unit higher score on the total MAS significantly increased the odds of being discharged home upon hospital admittance (odds ratio (OR) 1.14, 95% CI 1.04-1.25). The same pattern was observed with the summed items of 1-5 and 6-8. The total MAS showed sensitivity of 91.7% and specificity of 68.0%. Patients having a total MAS score ≥ 24 were 17 times more likely to be discharged home (HR 17.64, 95% CI 2.23-139.57) compared to patients with a lower score. Conclusion: Motor function measured by the MAS can be applied as a predictor of discharge destination upon hospital admission after stroke in Danish setting.

Immediate and long-term brain activation of acupuncture on ischemic stroke patients: an ALE meta-analysis of fMRI studies

Background

Acupuncture, as an alternative and complementary therapy recommended by the World Health Organization for stroke treatment, holds potential in ameliorating neurofunctional deficits induced by ischemic stroke (IS). Understanding the immediate and long-term effects of acupuncture and their interrelation would contribute to a better comprehension of the mechanisms underlying acupuncture efficacy.

Methods

Activation likelihood estimation (ALE) meta-analysis was used to analyze the brain activation patterns reported in 21 relevant functional neuroimaging studies. Among these studies, 12 focused on the immediate brain activation and 9 on the long-term activation. Single dataset analysis were employed to identify both immediate and long-term brain activation of acupuncture treatment in IS patients, while contrast and conjunction analysis were utilized to explore distinctions and connections between the two.

Results

According to the ALE analysis, immediately after acupuncture treatment, IS patients exhibited an enhanced cluster centered around the right precuneus (PCUN) and a reduced cluster centered on the left middle frontal gyrus (MFG). After long-term acupuncture treatment, IS patients showed an enhanced cluster in the left PCUN, along with two reduced clusters in the right insula (INS) and hippocampus (HIP), respectively. Additionally, in comparison to long-term acupuncture treatment, the right angular gyrus (ANG) demonstrated higher ALE scores immediately after acupuncture, whereas long-term acupuncture resulted in higher scores in the left superior parietal gyrus (SPG). The intersecting cluster activated by both of them was located in the left cuneus (CUN).

Conclusion

The findings provide initial insights into both the immediate and long-term brain activation patterns of acupuncture treatment for IS, as well as the intricate interplay between them. Both immediate and long-term acupuncture treatments showed distinct patterns of brain activation, with the left CUN emerging as a crucial regulatory region in their association.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, CRD42023480834.

Cross-prevalence of multiple sclerosis and stroke evaluated on cohorts of four independent specialty medical centers

BACKGROUND

Numerous sources reported the increased risk of cerebrovascular accidents (CVA) in individuals with multiple sclerosis (MS), without a single study thus far challenging the conclusion. Before addressing hypothesis on potential cause-effect relationships, a question whether there are indeed frequent comorbidities between MS and CVA needed to be answered.

METHODS

Authors designed a study to evaluate substantial populations of four independent neurology centers with the purpose to assess the prevalence of CVA diagnosis in patients with MS, and vice versa. Data of subjects meeting enrollment criteria were entered into a single database. Authors compared obtained data with the MS and CVA prevalences in the populations of specific countries.

RESULTS

Of the 1881 subjects' records, the main diagnosis was MS for 51.5% and CVA for 48.5%. The CVA prevalence as a secondary diagnosis among MS subjects was 1.47% in USA cohort and 1.65% in combined USA+ Russian Federation (RF) cohorts, which is lower than known prevalence of stroke in adult population of these regions. The prevalence of MS as a secondary diagnosis among subjects with stroke in USA cohort was 0.4% and in combined USA+RF cohorts was 0.33%, which is higher, but not statistically different from calculated MS prevalence in both USA and RF populations combined.

CONCLUSION

Thus, authors found that prevalence of CVA in cohorts with MS of 2 independent centers was at least not higher, than that in general population, which differs from previously published data.

Sex Disparity in Stroke Mortality among Adults: A Time Series Analysis in the Greater Vitoria Region, Brazil (2000-2021)

The disparity between the sexes in stroke mortality has been demonstrated in people from different locations. The objective of this study was to analyze the disparity between sexes in stroke mortality in adults in the metropolitan area of Greater Vitoria between 2000 and 2021. Ecological time series design was conducted with a database of the Brazilian Health System Informatics Department. The annual percentage change and average annual percentage change were calculated through joinpoint regression. Pairwise comparisons using parallelism and coincidence tests were applied to compare temporal trends between men and women. Men had higher mortality rates in most years between 2000 and 2021. In contrast, women had higher proportional mortality values in all years evaluated from 2000 to 2021. The paired comparison revealed a disparity between the sexes in the proportional mortality time series (parallelism test: p = 0.003; coincidence test: p < 0.001). However, the time series of the mortality rates showed no disparity between the sexes (parallelism test: p = 0.114; coincidence test: p = 0.093). From 2000 to 2021, there was a disparity in proportional mortality from stroke between the sexes of the population in the metropolitan area of Greater Vitoria, Brazil. However, the time series of mortality rates between the sexes did not reveal any disparity in the study period.

The Contribution of the Triage Nurse in the Optimisation of Door-to-Computed-Tomography Time in Stroke

A stroke is a time-sensitive emergency, so diagnosing and treating the victim promptly is extremely important. Therefore, the purpose of this study was to identify the influence of the Stroke Code Protocol's activation on the door-to-computed-tomography (door-to-CT) time and determine whether factors such as previous Modified Rankin Scale (mRS), age, and gender influence its activation. A retrospective study was conducted in a Medical-Surgical Emergency Department in the centre of Portugal from 1 January 2021 to 31 December 2022. The sample was selected according to the diagnosis assigned at the time of clinical discharge from the Emergency Department and the Stroke Code Protocol activation criteria. It was observed that 113 (50%) suspected stroke victims who met the activation criteria for the Stroke Code Protocol did not have the protocol activated, which had a highly significant influence (p < 0.001) on door-to-CT time. It was determined that activation at triage has an average door-to-CT time of 35 ± 18 min, post-triage activation has an average door-to-CT time of 38 ± 26 min, and non-activation has an average door-to-CT time of 1 h 04 ± 45 min. The need to implement an institutional protocol for activating the Stroke Code Protocol and provide specialised training for the multidisciplinary team is reiterated.

Neurological outcomes and mortality of hyperoxaemia in patients with acute brain injury: protocol for a systematic review and meta-analysis

INTRODUCTION

Oxygen is frequently prescribed in neurocritical care units. Avoiding hypoxaemia is a key objective in patients with acute brain injury (ABI). However, several studies suggest that hyperoxaemia may also be related to higher mortality and poor neurological outcomes in these patients. The evidence in this direction is still controversial due to the limited number of prospective studies, the lack of a common definition for hyperoxaemia, the heterogeneity in experimental designs and the different causes of ABI. To explore the correlation between hyperoxaemia and poor neurological outcomes and mortality in hospitalised adult patients with ABI, we will conduct a systematic review and meta-analysis of observational studies and RCTs.

METHODS AND ANALYSIS

The systematic review methods have been defined according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and follow the PRISMA-Protocols structure. Studies published until June 2024 will be identified in the electronic databases MEDLINE, Embase, Scopus, Web of Science, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov. Retrieved records will be independently screened by four authors working in pairs, and the selected variables will be extracted from studies reporting data on the effect of 'hyperoxaemia' versus 'no hyperoxaemia on neurological outcomes and mortality in hospitalised patients with ABI. We will use covariate-adjusted ORs as outcome measures when reported since they account for potential cofounders and provide a more accurate estimate of the association between hyperoxaemia and outcomes; when not available, we will use univariate ORs. If the study presents the results as relative risks, it will be considered equivalent to the OR as long as the prevalence of the condition is close to 10%. Pooled estimates of both outcomes will be calculated applying random-effects meta-analysis. Interstudy heterogeneity will be assessed using the I2 statistic; risk of bias will be assessed through Risk Of Bias In Non-Randomised Studies of Interventions, Newcastle-Ottawa or RoB2 tools. Depending on data availability, we plan to conduct subgroup analyses by ABI type (traumatic brain injury, postcardiac arrest, subarachnoid haemorrhage, intracerebral haemorrhage and ischaemic stroke), arterial partial pressure of oxygen values, study quality, study time, neurological scores and other selected clinical variables of interest.

ETHICS AND DISSEMINATION

Specific ethics approval consent is not required as this is a review of previously published anonymised data. Results of the study will be shared with the scientific community via publication in a peer-reviewed journal and presentation at relevant conferences and workshops. It will also be shared key stakeholders, such as national or international health authorities, healthcare professionals and the general population, via scientific outreach journals and research institutes' newsletters.

Targeting TRPM channels for cerebral ischemia-reperfusion injury

Transient receptor potential melastatin (TRPM) channels have emerged as potential therapeutic targets for cerebral ischemia-reperfusion (I/R) injury. We highlight recent findings on the involvement of TRPM channels in oxidative stress, mitochondrial dysfunction, inflammation, and calcium overload. We also discuss the challenges and future directions in targeting TRPM channels for cerebral I/R injury.