Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission

Association between C-reactive protein-triglyceride glucose index and stroke risk in different glycemic status: insights from the China Health and Retirement Longitudinal Study (CHARLS)

OBJECTIVE

C-reactive protein-triglyceride-glucose index (CTI) has been proposed as a novel biomarker for insulin resistance and inflammation. However, the association between CTI and the risk of stroke, particularly in individuals with different glycemic status, remains unclear.

METHODS

A total of 10,443 middle-aged and elderly participants were enrolled from the China Health and Retirement Longitudinal Study (CHARLS). The primary endpoint was the occurrence of stroke events. The CTI was calculated using the formula 0.412* Ln (CRP [mg/L]) + Ln (TG [mg/dl] × FPG [mg/dl])/2. The Kaplan-Meier curves, Cox proportional hazard models, and restricted cubic spline analysis were applied to explore the association between CTI and the risk of stroke according to gender, age and glycemic status.

RESULTS

During a median follow-up of 9 years, 960 (9.2%) participants experienced a stroke. Our findings revealed a significant positive linear relationship between CTI and the occurrence of stroke. The association was similar between male and female, despite the HR tended to be higher in females (HR 1.22, 95% CI 1.09, 1.36) than males (HR 1.15, 95% CI 1.02, 1.29), and similar in middle-aged (HR 1.25, 95% CI 1.11, 1.41) and elderly participants (HR 1.12, 95% CI 1.00, 1.26). In different glycemic status, high levels of CTI were found to be linked to an increased risk of stroke in individuals with normal glucose regulation (NGR) (HR 1.33, 95% CI 1.11, 1.59) and prediabetes mellitus (Pre-DM) (HR 1.20, 95% CI 1.04, 1.39). However, this association was not observed in individuals with diabetes mellitus (DM).

CONCLUSIONS

Our findings revealed a significant positive linear relationship between CTI and the occurrence of stroke. The association between CTI and stroke was similar between male and female, and similar in middle-aged and elderly participants. In different glycemic status, the association was significant in individuals with NGR and Pre-DM.

The Naples prognostic score as a nutritional and inflammatory biomarkers of stroke prevalence and all-cause mortality: insights from NHANES

BACKGROUND

Stroke is a complex neurological condition characterized by high rates of incidence, recurrence, disability, and mortality, making it one of the leading causes of death and disability worldwide. The Naples prognostic score (NPS), an index that combines markers of inflammation and nutritional status, has demonstrated prognostic value in various diseases. This research investigated the relationships among NPS, stroke prevalence, and overall mortality in stroke individuals, drawing on data from the National Health and Nutrition Examination Survey from 2007 to 2018.

METHODS

The cross-sectional analysis included 20,798 participants aged beyond 40 years with 1155 persons with stroke analyzed for mortality. Stroke prevalence was self-reported, and the NPS was derived from serum albumin, total cholesterol, the neutrophil-to-lymphocyte ratio, and the lymphocyte-to-monocyte ratio (Galizia et al. in Cancer 60:1273-1284, 2017). Weighted Logistic regression and Cox models assessed associations among NPS, stroke, and mortality, adjusting for demographic and clinical factors.

RESULTS

Higher NPS scores were linked to increased stroke prevalence (OR 3.573, 95% CI 2.745-4.652, P < 0.001) and elevated all-cause mortality risk (HR 3.281, 95% CI 1.978-5.442, P < 0.001) in stroke individuals. The triglyceride-glucose index (TYG) significantly modified the relationship between the NPS and stroke prevalence.

CONCLUSION

This study supports the clinical utility of the NPS as a predictor of both stroke prevalence and all-cause mortality. The NPS may serve as a valuable tool for risk stratification in stroke prevention and long-term prognosis.

Cross-sectional study on smoking types and stroke risk: development of a predictive model for identifying stroke risk

Background

Stroke, a major global health concern, is responsible for high mortality and long-term disabilities. With the aging population and increasing prevalence of risk factors, its incidence is on the rise. Existing risk assessment tools have limitations, and there is a pressing need for more accurate and personalized stroke risk prediction models. Smoking, a significant modifiable risk factor, has not been comprehensively examined in current models regarding different smoking types.

Methods

Data were sourced from the 2015-2018 National Health and Nutrition Examination Survey (NHANES) and the 2020-2021 Behavioral Risk Factor Surveillance System (BRFSS). Tobacco use (including combustible cigarettes and e-cigarettes) and stroke history were obtained through questionnaires. Participants were divided into four subgroups: non-smokers, exclusive combustible cigarette users, exclusive e-cigarette users, and dual users. Covariates such as age, sex, race, education, and health conditions were also collected. Multivariate logistic regression was used to analyze the relationship between smoking and stroke. Four machine-learning models (XGBoost, logistic regression, Random Forest, and Gaussian Naive Bayes) were evaluated using the area under the receiver-operating characteristic curve (AUC), and Shapley's additive interpretation method was applied for feature importance ranking and model interpretation.

Results

A total of 273,028 individuals were included in the study. Exclusive combustible cigarette users had an elevated stroke risk (β: 1.36, 95% CI: 1.26-1.47, P < 0.0001). Among the four machine-learning models, the XGBoost model showed the best discriminative ability with an AUC of 0.794 (95% CI = 0.787-0.802).

Conclusion

This study reveals a significant association between smoking types and stroke risk. An XGBoost-based stroke prediction model was established, which has the potential to improve the accuracy of stroke risk assessment and contribute to personalized interventions for stroke prevention, thus alleviating the healthcare burden related to stroke.

Machine learning-based scoring model for predicting mortality in ICU-admitted ischemic stroke patients with moderate to severe consciousness disorders

Background

Stroke is a leading cause of mortality and disability globally. Among ischemic stroke patients, those with moderate to severe consciousness disorders constitute a particularly high-risk subgroup. Accurate predictive models are essential for guiding clinical decisions in this population. This study aimed to develop and validate an automated scoring system using machine learning algorithms for predicting short-term (3- and 7-day) and relatively long-term (30- and 90-day) mortality in this population.

Methods

This retrospective observational study utilized data from the MIMIC-IV database, including 648 ischemic stroke patients with Glasgow Coma Scale (GCS) scores ≤12, admitted to the ICU between 2008 and 2019. Patients with GCS scores indicating speech dysfunction but clear consciousness were excluded. A total of 47 candidate variables were evaluated, and the top six predictors for each mortality model were identified using the AutoScore framework. Model performance was assessed using the area under the curve (AUC) from receiver operating characteristic (ROC) analyses.

Results

The median age of the cohort was 76.8 years (IQR, 64.97-86.34), with mortality rates of 8.02% at 3 days, 18.67% at 7 days, 33.49% at 30 days, and 38.89% at 90 days. The AUCs for the test cohort's 3-, 7-, 30-, and 90-day mortality prediction models were 0.698, 0.678, 0.724, and 0.730, respectively.

Conclusion

We developed and validated a novel machine learning-based scoring tool that effectively predicts both short-term and relatively long-term mortality in ischemic stroke patients with moderate to severe consciousness disorders. This tool has the potential to enhance clinical decision-making and resource allocation for these patients in the ICU.

Leveraging machine learning for enhanced and interpretable risk prediction of venous thromboembolism in acute ischemic stroke care

BACKGROUND

Venous thromboembolism (VTE) is a life-threatening complication commonly occurring after acute ischemic stroke (AIS), with an increased risk of mortality. Traditional risk assessment tools lack precision in predicting VTE in AIS patients due to the omission of stroke-specific factors.

METHODS

We developed a machine learning model using clinical data from patients with acute ischemic stroke (AIS) admitted between December 2021 and December 2023. Predictive models were developed using machine learning algorithms, including Gradient Boosting Machine (GBM), Random Forest (RF), and Logistic Regression (LR). Feature selection involved stepwise logistic regression and LASSO, with SHapley Additive exPlanations (SHAP) used to enhance model interpretability. Model performance was evaluated using area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

Among the 1,632 AIS patients analyzed, 4.17% developed VTE. The GBM model achieved the highest predictive accuracy with an AUC of 0.923, outperforming other models such as Random Forest and Logistic Regression. The model demonstrated strong sensitivity (90.83%) and specificity (93.83%) in identifying high-risk patients. SHAP analysis revealed that key predictors of VTE risk included elevated D-dimer levels, premorbid mRS, and large vessel occlusion, offering clinicians valuable insights for personalized treatment decisions.

CONCLUSION

This study provides an accurate and interpretable method to predict VTE risk in patients with AIS using the GBM model, potentially improving early detection rates and reducing morbidity. Further validation is needed to assess its broader clinical applicability.

Association of Life's Crucial 9 with all-cause and cardiovascular mortality in stroke survivors and predictive value for mortality compared with Life's Essential 8: evidence from NHANES 2005-2018

Background

There is evidence of a positive correlation between depressive disorders and poor cardiovascular health (CVH). Recently, the inclusion of psychological health assessments into Life's Essential 8 (LE8) has been put forward to enhance the foundation of CVH. We aimed to investigate the probable link between the innovative CVH assessment framework, Life's Crucial 9 (LC9), and overall mortality as well as mortality associated with cardiovascular disease (CVD) among stroke survivors, while also assessing its prognostic relevance regarding mortality in comparison to LE8.

Methods

This study draws on a cohort of stroke survivors identified from the National Health and Nutrition Examination Survey (NHANES), spanning survey cycles from 2005 to 2018. The LE8 was assessed by the approach recommended by the American Heart Association. The LC9 framework incorporated an additional depression score, measured by Patient Health Questionnaire-9, into the LE8 assessment. To investigate the associations between LE8 and LC9 with all-cause and cardiovascular mortality in stroke survivors, we employed multivariable Cox proportional hazards regression analyses.

Results

After adjusting for covariates, each 10-point increase in LC9 was associated with a 24.5 and 30.1% reduction in all-cause and CVD mortality in stroke survivors, respectively. Participants in the highest quartile (Q4) of LC9 exhibited significantly lower mortality rates compared to those in the lowest quartile (Q1) (all-cause mortality: HR 0.412, p < 0.0001; CVD mortality: HR 0.327, p < 0.001). Similar associations were observed for LE8. Restricted cubic spline analysis indicated that both LC9 and LE8 demonstrated linearly associations with mortality post-stroke. Physical activity score, nicotine exposure score, and blood glucose score were significantly linked to all-cause and CVD mortality in stroke survivors. Adding depression score to LE8 significantly enhanced the prediction of all-cause mortality in stroke survivors (net reclassification improvement index = 9.6%, p = 0.033; ΔC index = 0.002, p = 0.0009; integrated discrimination improvement = 0.01, p = 0.007). The NRI of 9% (p = 0.086) for CVD mortality, while not statistically significant, suggests a trend toward improved classification.

Conclusion

LC9 exhibited both linear and inverse correlations with all-cause and cardiovascular mortality among stroke survivors. Adding a depression score to the LE8 framework may improve the predictive accuracy for all-cause mortality in stroke survivors.

Association between triglyceride glucose-waist height ratio and stroke: a population-based study

Background

Stroke poses a substantial threat to global public health. The triglyceride glucose-waist height ratio (TyG-WHtR), which incorporates the TyG metric with obesity-related WHtR, has demonstrated superior diagnostic and predictive value compared to the TyG index alone. Nevertheless, there is still a lack of in-depth exploration into the relationship between TyG-WHtR and stroke. This study seeks to address this gap by extracting information from the National Health and Nutrition Examination Survey (NHANES) to elucidate the potential association between TyG-WHtR levels and stroke.

Methods

This study included 8,757 individuals from four research cycles conducted between 2011 and 2018. To examine the potential relationship between TyG-WHtR and stroke, we conducted multivariable logistic regression analysis. In addition, smooth curve fitting was applied to display the nonlinear association. Subgroup analyses and sensitivity analyses contributed to examining the robustness and consistency of the relationship between TyG-WHtR and stroke. The receiver operating characteristic (ROC) curves were employed to evaluate the diagnostic capability of TyG-WHtR and TyG.

Results

After adjusting for relevant covariates, a positive association between TyG-WHtR levels and stroke occurrence was observed (OR: 1.26, 95% CI: 1.02-1.55). Specifically, each unit increase in TyG-WHtR was associated with a 26% higher likelihood of stroke. The findings of sensitivity analysis further demonstrated the stability of this positive relationship. Subgroup analysis revealed that this association was significant among participants who did not engage in moderate exercise and those without coronary heart disease or angina pectoris. ROC analysis demonstrated that TyG-WHtR exhibited superior predictive value compared to TyG.

Conclusion

This study identified an association between elevated TyG-WHtR levels and an increased prevalence of stroke, suggesting that TyG-WHtR may serve as a valuable predictive tool for stroke risk, with potential implications for clinical prevention and early intervention.

The role of glucose disposal efficiency in predicting stroke among older adults: a cohort study

Background

Glucose disposal rate (eGDR) has recently been validated as a surrogate marker of insulin resistance, providing a novel approach to assess metabolic health. However, the relationship between changes in eGDR levels and stroke incidence remains underexplored. The current study aims to investigate the impact of eGDR control on stroke incidence and related events.

Methods

Data were obtained from the China Longitudinal Study on Health and Retirement (CHARLS). The analysis included 6,375 participants aged 45 and above with complete stroke and eGDR data from the CHARLS for 2011, 2013, and 2015. Logistic multivariable regression examined the relationship between eGDR and stroke, using threshold analysis to identify inflection points. we categorized participants into distinct subgroups based on sociodemographic variables to see the relationship between stroke and other variables.

Results

Out of the 8,060 individuals analyzed in the cohort, 821 were diagnosed with new-onset stroke. There was a notable negative correlation found between new-onset risk of stroke and eGDR, with each Interquartile Range (IQR) increment in eGDR leading to a 38% risk reduction [OR: 0.62; 95% CI: (0.45,0.84)]. Stratified analyses revealed age as a potential modifier in the age-stroke relationship (P for interaction = 0.01).

Conclusion

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.

Rehabilitation training robot using mirror therapy for the upper and lower limb after stroke: a prospective cohort study

BACKGROUND

This prospective cohort study was designed to investigate and compare the effectiveness of rehabilitation training robots versus conventional rehabilitation training on stroke survivors by monitoring alterations in brain network of stroke patients before and after robot intervention.

METHODS

Between September 2020 and November 2021, stroke patients at four grade-A tertiary hospitals underwent limb rehabilitation training. Of the total of participants, 117 patients received conventional limb rehabilitation, 93 patients participated in upper-limb robot training, and 103 patients underwent lower-limb robot training. The measured outcomes included modified Barthel Index (MBI), Fugl-Meyer assessment subscale (FMA), and manual muscle testing (MMT). Functional magnetic resonance imaging (fMRI) was conducted on 30 patients to assess changes in the brain network. Data were mainly analyzed based on the Intention-to-Treat (ITT) principle.

RESULTS

Post-interventional analysis utilizing linear mixed models in ITT analysis revealed that the robot training group had greater enhancements compared to the conventional limb rehabilitation training group. Notably, the shoulder flexor strength (P = 0.043) was significantly higher in the upper-limb group. On the other hand, hip flexor strength (P < 0.001), hip extensor strength (P < 0.001), knee extensor strength (P = 0.013), ankle dorsiflexion strength (P < 0.001) and ankle plantarflexor strength (P < 0.001) were significantly higher in the lower-limb group. In the upper-limb group, region-of-interest (ROI) -to-ROI analysis revealed enhanced functional connectivity between the left hemisphere's motor control region and the auditory network. ROI-to-ROI analysis primarily showed enhanced interhemispheric functional connectivity in the lower-limb group, specifically between right the hemisphere's motor control region (central opercular cortex) and left hemisphere's primary motor area in the precentral gyrus.

CONCLUSIONS

According to our research findings, upper- and lower-limb rehabilitation robots demonstrated great potential in promoting motor function recovery in stroke patients. Robot-assisted training offers an alternative treatment method with comparable efficacy to traditional rehabilitation. Large-scale randomized controlled trials are needed to confirm these results.

TRIAL REGISTRATION

The study was registered on the Chinese Clinical Trial Registry (ChiCTR1800019783).

Global, regional, and national burden and trends of stroke among youths and young adults aged 15-39 years from 1990 to 2021: findings from the Global Burden of Disease study 2021

Background

Stroke is a leading cause of disability and mortality worldwide, with rising incidence rates among youths and young adults aged 15-39 years. However, comprehensive assessments of stroke burden in this age group at global, regional, and national levels are limited. This study examines trends in stroke incidence, mortality, and disability-adjusted life years (DALYs) from 1990 to 2021 using data from the Global Burden of Disease (GBD) study.

Methods

Data from the GBD study (1990-2021) were analyzed to assess the age-standardized incidence, mortality, and DALYs related to stroke in individuals aged 15-39 years. The relationship between stroke burden and the Socio-Demographic Index (SDI) was explored across 204 countries and 21 regions. Trends were analyzed using the estimated annual percentage change (EAPC) and average annual percentage change (AAPC).

Results

This study reveals global, regional, and national trends in stroke burden among youths and young adults (15-39 years) from 1990 to 2021. In 2021, the global age-standardized stroke incidence was 757,234.61 cases, with 8.72 million DALYs and 122,742 stroke-related deaths. Although global incidence increased by 19.09%, age-standardized rates (ASRs) declined by 0.67% annually. DALYs and mortality rates also decreased globally. Notably, stroke burden increased in low and low-middle SDI regions. South Asia had the highest number of cases, while Oceania reported the highest mortality rate. These findings underscore regional disparities in stroke trends. Globally, metabolic risks (46.2%) and high systolic blood pressure (37.87%) are major contributors to stroke-related mortality.

Efficacy and safety of brain-computer interface for stroke rehabilitation: an overview of systematic review

Background

Stroke is a major global health challenge that significantly influences public health. In stroke rehabilitation, brain-computer interfaces (BCI) offer distinct advantages over traditional training programs, including improved motor recovery and greater neuroplasticity. Here, we provide a first re-evaluation of systematic reviews and meta-analyses to further explore the safety and clinical efficacy of BCI in stroke rehabilitation.

Methods

A standardized search was conducted in major databases up to October 2024. We assessed the quality of the literature based on the following aspects: AMSTAR-2, PRISMA, publication year, study design, homogeneity, and publication bias. The data were subsequently visualized as radar plots, enabling a comprehensive and rigorous evaluation of the literature.

Results

We initially identified 908 articles and, after removing duplicates, we screened titles and abstracts of 407 articles. A total of 18 studies satisfied inclusion criteria were included. The re-evaluation showed that the quality of systematic reviews and meta-analyses concerning stroke BCI training is moderate, which can provide relatively good evidence.

Conclusion

It has been proven that BCI-combined treatment can improve upper limb motor function and the quality of daily life for stroke patients, especially those in the subacute phase, demonstrating good safety. However, its effects on improving speech function, lower limb motor function, and long-term outcomes require further evidence. Multicenter, long-term follow-up studies are needed to increase the reliability of the results.

Clinical Trial Registration

https://www.crd.york.ac.uk/PROSPERO/view/CRD42024562114, CRD42023407720.

Risk and impact of stroke across 38 countries and territories of the Americas from 1990 to 2021: a population-based trends analysis from the Global Burden of Disease Study 2021

Background

Despite substantial declines in burden over time, stroke remains a public health threat in the Americas. This study aimed to assess the current magnitude, trends, and disparities in the estimates of stroke burden by sex and age in the Americas from 1990 to 2021.

Methods

Estimates from the Global Burden of Disease, Injuries and Risk Factors Study 2021 were used to analyze incidence, prevalence, mortality, years of life lost due to premature death, years lived with disabilities, and disability-adjusted life years (DALYs) caused by stroke and its major subtypes stratified by age, and sex in the Americas from 1990 to 2021. We used Joinpoint regression analysis to estimate the average annual percent change (AAPC) of stroke mortality and disease burden outcomes and assessed trends.

Findings

In 2021, there were 1.1 million (95% uncertainty interval: 1.0-1.2) new cases, 12.9 million (12.3-13.7) prevalent cases, 0.5 million (0.5-0.6) deaths, and 11.4 million (10.6-12.1) DALYs due to stroke in the Americas. The absolute number of stroke burden outcomes increased from 1990 to 2021, but their corresponding age-standardized rates significantly declined. A deceleration in reduction rates of burden outcomes for all strokes and most stroke subtypes occurred over the last decade, with pronounced difference between sexes mainly in incidence among younger groups. From 2015 to 2021, trends in incidence rates from all stroke and stroke subtypes reversed to increase in most age groups, and strikingly, trends in mortality and DALY rates from ischemic stroke among younger populations reversed to upward with AAPC over 1.4%. A substantial number of countries contributed to these increasing trends.

Interpretation

Regionally, the annual number of stroke cases and deaths significantly increased from 1990 to 2021, despite reductions in age-standardized rates. The declining pace in age-standardized stroke rates has decelerated in recent years, while trends in incidence, and ischemic stroke mortality and DALY among middle-aged adults and adults, reversed towards upward in the period 2015-2021. Further studies are needed to understand the determinants of this recent pattern and identify the most cost-effective interventions to stem this alarming trend.

Funding

There was no funding source for this study.

SIRT1 Alleviates Mitochondrial Fission and Necroptosis in Cerebral Ischemia/Reperfusion Injury via SIRT1-RIP1 Signaling Pathway

Programmed cell death, including necroptosis, plays a critical role in the pathogenesis of cerebral ischemia/reperfusion injury (CIRI). Silent information regulator 1 (SIRT1) has been identified as a potential therapeutic target for CIRI, yet its precise role in regulating necroptosis remains controversial. Furthermore, the potential interaction between SIRT1 and receptor-interacting protein kinase 1 (RIP1) in this context is not fully understood. Sanpian Decoction (SPD), a classical traditional herbal formula, was previously shown to enhance SIRT1 expression in our studies. Our findings demonstrated that, both in vivo and in vitro, CIRI was associated with a decrease in SIRT1 levels and phosphorylated dynamin-related protein 1 (p-DRP1) at Ser637, alongside an increase in RIP1 and other necroptosis-related proteins. Co-immunoprecipitation and immunofluorescence analyses revealed a weakened interaction between SIRT1 and RIP1. Furthermore, abnormal mitochondrial fission and dysfunction were mediated through the phosphoglycerate mutase 5-DRP1 pathway. Notably, SPD treatment improved neurological outcomes and reversed these pathological changes by enhancing the SIRT1-RIP1 interaction. In conclusion, this study suggests that SIRT1 is a promising therapeutic target for CIRI, capable of inhibiting necroptosis and mitigating mitochondrial fission via the SIRT1-RIP1 pathway. SPD exhibits therapeutic potential by activating SIRT1, thereby attenuating necroptosis and mitochondrial fission during CIRI.

Oxygen-glucose-deprived peripheral blood mononuclear cells act on hypoxic lesions after ischemia-reperfusion injury

BACKGROUND

Despite advances in reperfusion therapies, ischemic stroke remains a major cause of long-term disability due to residual hypoxic lesions persisting after macrovascular reperfusion. These residual hypoxic lesions, caused by microvascular dysfunction, represent an important therapeutic target. We previously demonstrated that oxygen-glucose-deprived peripheral blood mononuclear cells (OGD-PBMCs) migrate to ischemic brain regions and promote functional recovery after stroke. This recovery occurs through mechanisms involving hypoxia-inducible factor-1α, exosomal miR-155-5p, and vascular endothelial growth factor (VEGF). However, it remains unclear whether OGD-PBMCs target hypoxic regions.

METHODS

We evaluated cerebral blood flow using a laser speckle flow imaging system. Next, we utilized pimonidazole to investigate the presence of hypoxic lesions after ischemia-reperfusion injury in a rat suture occlusion model in immunohistochemical analyses. We also compared levels of a cell surface receptor in human PBMCs by flow cytometric analysis under normoxic and OGD conditions.

RESULTS

We found persistent pimonidazole-positive hypoxic lesions at 10- and 28-days post-reperfusion despite restored gross cerebral perfusion. Treatment with the C-X-C motif chemokine receptor 4 (CXCR4) inhibitor AMD3100 before and after OGD-PBMCs administration reduced the number of OGD-PBMCs in the brain parenchyma compared to the control group (P = 0.018). Administered OGD-PBMCs localized within these hypoxic regions via the stromal cell-derived factor-1/CXCR4 chemotactic axis. OGD-PBMCs enhanced VEGF expression, specifically within hypoxic lesions, compared to the phosphate-buffered saline group (P < 0.01). Furthermore, OGD-PBMCs reduced the number of pimonidazole-positive hypoxic cells in the ischemic core on 28 days. These findings demonstrate that OGD-PBMCs selectively migrate to and modulate the microenvironment of hypoxic lesions following cerebral ischemia-reperfusion injury.

CONCLUSION

Targeting these residual hypoxic regions may underline the therapeutic effects of OGD-PBMC treatment and represent a promising strategy for improving stroke recovery despite successful recanalization.

Trends in stroke incidence, death, and disability outcomes in a multi-ethnic population: Auckland regional community stroke studies (1981-2022)

Background

Reliable data on trends of stroke incidence and outcomes over time are necessary for assessing the effectiveness of public health and clinical strategies, and for allocating healthcare resources. We assessed the levels and trends in incidence, mortality, early case fatality and disability for stroke in a defined, ethnically mixed population over 40 years.

Methods

To analyse data from five population-based stroke incidence studies in adult residents (age ≥15 years) of the Greater Auckland Region of New Zealand (NZ) (1.35 million) over 12-month calendar periods for 1981-1982, 1991-1992, 2002-2003, 2011-2012, and 2021-2022. Fatal and non-fatal, hospitalised and non-hospitalised stroke events (first-ever and recurrent) were identified through multiple overlapping sources using clinical World Health Organization (WHO) diagnostic criteria and neuroimaging to define three major pathological types of stroke: ischaemic stroke (IS), primary intracerebral haemorrhage (PICH), subarachnoid haemorrhage (SAH), and stroke of undetermined type (SUT). Crude and age-standardised annual incidence, mortality, 28-day case fatality and disability level, and 40-year trends were calculated by age, sex, and ethnicity assuming a Poisson distribution. For comparison of our findings, we carried out a pooled analysis of methodologically comparable population-based stroke epidemiology estimates in high-income countries over the last two decades.

Findings

Overall, there were 7462 first-ever strokes (9917 events) over the 40-year period (4,682,012 person-years). From 1981-1982 to 2021-2022, age-standardised stroke incidence rates decreased from 156/100,000 (95% confidence interval [CI] 143; 170) to 124/100,000 (119; 130) and mortality rates from 98/100,000 (88; 110) to 28/100,000 (26; 31) in nearly all age, sex, and ethnic groups. Moreover, from 2002-2003 to 2021-2022, there was an increase in stroke incidence of 1.28% per year (95% CI 0.38-2.17) in people aged 15-54 years, with the mean age of people with stroke decreasing from 73.0 (SD ± 13.8) in 2002-2003 to 71.6 (SD ± 14.9) in 2011-2012 and 70.7 (SD ± 15.2) years in 2021-2022 (p for trend <0.0001). The risk of stroke in Māori and Pacific people in 2021-2022 was almost 1.5 and 2.0 times greater than that in NZ Europeans. Ethnic disparities in the risk of stroke and age of stroke onset remained stable over the study period. From 1981-1982 to 2021-2022, 28-day stroke case fatality declined from 33.1% to 12.1% (p < 0.0001). There was a trend towards reducing 28-day case-fatality (from 31.6% [95% CI 27.6; 35.7] in 1981-1982 to 11.4% [10.0; 12.7] in 2021-2022) and an increasing proportion of stroke survivors with good functional outcome at discharge/28-days post-stroke (increased from 45.7% (95% CI 41.3; 50.0) in 1981-1982 to 60.2% (58.1; 62.3) in 2021-2022).

Interpretation

Stroke incidence, 1-year mortality and 28-day case-fatality and disability have decreased in Auckland, NZ over the last 4 decades. However, over the last decade (2011-2022) there was a stagnation in the decline in the age-standardised stroke incidence rates. The absolute numbers of people with strokes, and those who have died or remained disabled from stroke, have significantly increased from 1981 to 2022. Ethnic disparities in the risk and burden of stroke persist. Effective prevention strategies for stroke must remain a high priority.

Funding

Health Research Council of New Zealand.

Global, regional and national trends in the burden of intracranial hemorrhage, 1990-2021: Results from the Global Burden of Disease study

Intracerebral hemorrhage (ICH) is a significant global public health issue that is characterized by a rapid start, severe symptoms, and a poor prognosis. It is the most common type of hemorrhagic stroke. We analyzed global intracranial hemorrhage incidence, mortality, disability-adjusted life years (DALYs), and corresponding age-standardized rates (ASRs) and estimated annual percentage changes (EAPCs) by using GBD 2021 data. The data were further stratified by age, sex, and region to assess the global burden of ICH from 1990 to 2021, providing the most up-to-date epidemiologic reference data for public health prevention and treatment strategies. In 2021, there were 3,444,300 (95 % UI, 305.30 to 381.20) new cases, 3,308,400 (302.11-359.47) deaths and 79,457,400 (7230.45-8548.02) DALYs. The burden of intracranial hemorrhage was higher in Oceania and Southeast Asia (Age-standardized DALY rates of 2582.46 per 100,000 and 1976.78 per 100,000), but lower in Australasia (126.59), high-income North America (221.19), and Western Europe (161.23). Of the 204 countries and territories globally, the burden of intracranial hemorrhage is higher in countries such as Nauru, Solomon Islands and Marshall Islands. From 1990 to 2021, global age-standardized incidence rates (ASIR), age-standardized mortality rates (ASMR), and age-standardized DALY rates (ASDR) declined, corresponding to EAPCs of -1.52, -1.63 and -1.75, with females declining more than males. In 2021, the most significant risk factor for ICH was high systolic blood pressure, accounting for 56.4 % of total DALYs for intracranial hemorrhage. Other major risk factors include: ambient particulate matter pollution, smoking, solid fuel pollution of household air, high sodium diet, and renal dysfunction. We need to target interventions at relevant risk factors, such as hypertension management, environmental particulate management, smoking cessation campaigns, focusing on high-risk groups and high-burden areas, and continue to deepen the implementation of the universal primary prevention strategy.

Cerebrovascular events induced by venomous snake bites: A systematic review

Snake bites represent a critical public health issue, affecting approximately 2.7 million people globally each year. Around 20 % of snake species are venomous, and their venom contains a complex array of toxins that can cause multi-organ damage, particularly affecting the nervous system, leading to both ischemic and hemorrhagic cerebrovascular events. This systematic review aims to compile and analyze data on cerebrovascular events associated with venomous snakebites. A comprehensive literature search was conducted using Scopus, PubMed, SciELO, and LILACS databases, with search terms including ("snake bite" OR "viper bite") AND ("stroke" OR "hemorrhagic stroke" OR "ischemic stroke"). Studies in English, Spanish, French and Portuguese were reviewed, yielding 52 eligible articles reporting 73 cases of stroke following snakebites. Most cases were attributed to snakes from the Viperidae family, with 67.12 % of cases occurring in males. Ischemic strokes were the most frequent, comprising 73.97 % of reported cases. The most affected systems were the nervous, cardiovascular, and respiratory systems. Snakes from the Bothrops genera and Daboia russelii specie caused the widest range of symptoms, including altered consciousness, ptosis, hypertension, drowsiness, aphasia, and tachycardia. Stroke is a severe complication of snakebite envenomation. Regarding treatment, the articles included emphasize the use of antivenom serum; however, they do not go into detail about the specific management of cutaneous stroke due to a snakebite, whether ischemic or hemorrhagic It is crucial to develop standardized protocols for the management of snakebite-induced strokes and to conduct further research to identify the snake species whose venom poses the highest risk for cerebrovascular complications.

Effects of a Self-Management Program on Adults with Stroke: A Quasi-Experimental Study

BACKGROUND

Stroke is a leading cause of death and disability, underscoring the importance of effective self-management programs to improve the quality of life for survivors.

OBJECTIVES

This study investigates the impact of the ComVida (Bridges-PT) self-management program on self-efficacy, physical function, health-related quality of life, and emotional state of stroke survivors in Portugal.

METHODS

A quasi-experimental study was conducted with 28 participants from hospital and community settings. The ComVida program, combining personalized rehabilitation sessions and the use of a self-management workbook was implemented. Assessments were conducted at baseline, 6 weeks, and 12 weeks using the Stroke Self-Efficacy Questionnaire (SSEQ), the Stroke Impact Scale (SIS-16), Hospital Anxiety and Depression Scale (HADS), and Short Form Questionnaire-12 (SF-12v2).

RESULTS

Significant improvements were observed in self-efficacy, physical function, emotional state, and health-related quality of life over the study period. The SSEQ scores increased from 23.3 at baseline to 33.3 at 12 weeks, while SIS-16 scores improved from 47.5 to 67.2. Anxiety and depression levels, measured by HADS, also showed significant reductions, as did health-related quality of life, evaluated by the SF-12v2.

CONCLUSIONS

The results suggest that the program may enhance self-efficacy, physical function, and emotional well-being in stroke survivors, highlighting its potential as a valuable component of post-stroke care in Portugal.

How perceived risk of recurrence strengthens health management awareness in stroke patients: the chain mediating role of risk fear and health literacy

Background

Prior research has found that perceived risk in stroke patients motivates health behaviors in visitors. However, the role that perceived risk of recurrence in stroke patients plays in reinforcing health management awareness during the motivation phase is unclear.

Objective

This study explores this issue by examining the effects of risk fear and health literacy on health management awareness due to perceived risk of recurrence in stroke patients.

Methods

We validated the effect of perceived risk of recurrence on health management awareness and its internal mechanism by constructing a structural equation model and including 763 stroke patients, extending the relevant literature and application of the Healthy Behavior Procedural Approach (HAPA) model.

Result

The results suggest that perceived risk of recurrence in stroke patients can effectively reinforce and improve health management awareness, with risk fear and health literacy having a chain-mediated role in this group relationship.

Conclusion

This study reveals the differential effects of perceived risk of recurrence, risk fear, and health literacy in stroke patients on health management awareness at the individual level, providing valuable guidance for healthcare practitioners and families to improve patients' health outcomes and health well-being.

Dietary index for gut microbiota is associated with stroke among US adults

Aims: Emerging evidence underscores the diet-microbiota-gut-brain axis as vital to brain health. The dietary index for gut microbiota (DI-GM), quantifying diet quality linked to gut microbiota diversity, reflects healthier gut microbiota with higher scores. Therefore, this study was designed to explore the unclear association between DI-GM and stroke. Methods: A cross-sectional analysis was conducted using data from 48 677 participants aged ≥20 years in the National Health and Nutrition Examination Survey (NHANES). Demographic and dietary data were collected, and multivariable weighted logistic regression analysis was performed to evaluate the association between the DI-GM and stroke. Additionally, restricted cubic spline (RCS), subgroup analyses, and receiver operating characteristic (ROC) curve were conducted. Results: In participants aged ≥20 years, the odds ratio (OR) was 0.96 (95% CI: 0.92-1.00, P = 0.075) in the crude model, but after adjustment, the OR was 0.93 (95% CI: 0.89-0.98, P = 0.003), while higher beneficial to gut microbiota scores were consistently associated with lower stroke prevalence with ORs of 0.87 (95% CI: 0.83-0.90, P < 0.001) in the crude model and 0.88 (95% CI: 0.83-0.93, P < 0.001) after adjustment. Among participants aged 20-29 years, no significant association was observed. For those aged ≥30 years, higher DI-GM and beneficial to gut microbiota scores were associated with lower stroke prevalence, with DI-GM showing ORs of 0.93 (95% CI: 0.89-0.97, P < 0.001) in the crude model and 0.93 (95% CI: 0.89-0.98, P = 0.003) after adjustment, and beneficial to gut microbiota scores showing ORs of 0.82 (95% CI: 0.79-0.86, P < 0.001) in the crude model and 0.88 (95% CI: 0.83-0.93, P < 0.001) after adjustment. RCS indicated a linear relationship between DI-GM and stroke. Conclusion: The DI-GM was inversely and linearly associated with stroke prevalence, particularly in adults aged 30 years and above.

Associations between ambient benzene and stroke, and the mediating role of accelerated biological aging: Findings from the UK biobank

Benzene can cause respiratory diseases. However, the associations between benzene and stroke are unclear. A total of 13,116 patients with stroke and 377,120 controls from the UK Biobank were included. The benzene exposure concentrations were matched on the basis of the address information of each participant via a data form from the UK Department for Environment, Food and Rural Affairs. Weighted Cox regression was used to investigate the association between benzene and stroke risk. The polygenic risk score (PRS) was used to observe the joint effects of benzene exposure and genetic factors on stroke risk. We conducted a mediation analysis to investigate the mediating role of accelerated biological aging in this cohort study. After adjusting for covariates, every 1 μg/m3 increase in benzene exposure increased the risk of stroke by 70%, which may be mediated by accelerated biological aging. The population with high benzene exposure concentrations and high PRSs had a 44% greater risk of stroke than did those with low benzene exposure concentrations and low PRSs. Benzene exposure and the PRS have joint effects on the risk of stroke. Benzene exposure was associated with stroke risk, possibly through increased biological aging, and the PRS modified this association.

Estimated pulse wave velocity is associated with all-cause and cardiovascular mortality in individuals with stroke: A national-based prospective cohort study

Extensive evidence underscores the potential of estimated pulse wave velocity (ePWV) as a robust tool for predicting disease prevalence and mortality. However, its comparative effectiveness in forecasting all-cause and cardiovascular disease (CVD) mortality, particularly among stroke populations, remains inadequately characterized in relation to the traditional Framingham Risk Score (FRS) model. This prospective study included 1202 individuals with stroke from the National Health and Nutrition Examination Survey conducted between 1999 and 2014, with comprehensive follow-up data. Survey-weighted Cox regression models were employed to examine the association between ePWV and the risks of all-cause and CVD mortality. Subgroup analyses were performed to evaluate the stability of ePWV in predicting these outcomes. A generalized additive model was utilized to explore the dose-response relationship between ePWV and mortality risk. Receiver operating characteristic curves were then used to assess and compare the prognostic capabilities of ePWV and FRS models for 10-year all-cause and CVD mortality. After adjustment for relevant covariates, each 1 m/s increase in ePWV was associated with a 44% and 65% increase in all-cause and CVD mortality, respectively. ePWV demonstrated consistent prognostic performance across the majority of stroke subpopulations. Notably, ePWV exhibited a nonlinear relationship with all-cause mortality (P for nonlinearity = .045) while maintaining a linear association with CVD mortality (P for nonlinearity = .293). Furthermore, ePWV outperformed the FRS model in predicting 10-year all-cause (Integrated Discrimination Improvement = 0.061, 95% confidence interval: 0.031-0.095, P = .007) and CVD mortality (95% confidence interval: 0.005-0.083, P = .02). ePWV is an independent risk factor for both all-cause and CVD mortality in individuals with stroke, demonstrating superior predictive value compared to the traditional FRS model for forecasting these outcomes.

Association Between Liver Fibrosis and Risk of Incident Stroke and Mortality: A Large Prospective Cohort Study

BACKGROUND

There is a well-established relationship between liver conditions and cardiovascular diseases. However, uncertainty persists regarding the contribution of liver fibrosis to major stroke types including ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage at the population level.

METHODS

In this large prospective cohort study, participants without previous stroke or coronary heart disease at baseline from the UK Biobank were included. We identified participants at high probability of advanced liver fibrosis using the Fibrosis-4 index >2.67 or aspartate aminotransferase to platelet ratio index ≥1.0. Multivariable Cox proportional hazard regression analyses were conducted to estimate hazard ratios (HRs) for liver fibrosis with the incidence of major stroke types, stroke-related death, and all-cause death.

RESULTS

Among 379 953 participants (mean age, 56.2 [SD, 8.1] years; 44.6% men), 7396 (1.9%) had a Fibrosis-4 index >2.67 at baseline. During a median follow-up of 12.75 (interquartile range, 12.03-13.48) years, 7143 (1.9%) incident stroke cases were documented. Advanced liver fibrosis assessed by the Fibrosis-4 index was associated with an increased risk of ischemic stroke (HR, 1.94 [95% CI, 1.70-2.22]), intracerebral hemorrhage (HR, 2.14 [95% CI, 1.63-2.81]), subarachnoid hemorrhage (HR, 1.90 [95% CI, 1.27-2.84), stroke-related death (HR, 2.20 [95% CI, 1.73-2.80]), and all-cause death (HR, 2.59 [95% CI, 2.46-2.73]). Using the aspartate aminotransferase to platelet ratio index as an alternative score, liver fibrosis was correlated with magnified risk of intracerebral hemorrhage (HR, 3.76 [95% CI, 2.38-5.93]) and subarachnoid hemorrhage (HR, 3.05 [95% CI, 1.51-6.13]) compared with ischemic stroke (HR, 1.58 [95% CI, 1.17-2.14]). Restricted cubic spline analysis showed nonlinear associations of the Fibrosis-4 index and aspartate aminotransferase to platelet ratio index with stroke incidence and all-cause death.

CONCLUSIONS

Liver fibrosis is associated with increased risk of incident stroke and death among people without previous stroke or cardiovascular events, with particularly greater risk of intracerebral hemorrhage and subarachnoid hemorrhage. Noninvasive indices of liver fibrosis may serve as an easily accessible marker to detect individuals facing elevated risk of stroke and death in the primary prevention settings.

Global challenges in the access of endovascular treatment for acute ischemic stroke (global MT access)

BACKGROUND

Mechanical thrombectomy (MT) is the standard of care for eligible acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) since 2015.

AIM

Our aim was to determine the key challenges for MT implementation and access worldwide.

METHODS

We conducted an international online survey consisting of 37 questions, distributed through the World Stroke Organization network and as invited by co-authors between December 2022 and March 2023. The survey included a preamble outlining its purpose, questions on respondent demographics, imaging availability, MT service availability, MT selection criteria, barriers to MT, and training status in each country.

RESULTS

We received 526 responses from 89 countries distributed across 7 continents. One hundred and sixteen (22.1%) respondents did not have available MT service, 43 (8.2%) had available MT only during working hours, 362 (68.8%) had 24/7 MT availability. Regarding neuroimaging protocols, 13.5% used non-contrast computed tomography (NCCT) only, 40.1% used NCCT/CT angiography, 37.5% used NCCT/CT angiography/CT perfusion), 0.4% used magnetic resonance imaging (MRI) only, and 7.8% used MRI/MR angiography. The most common reasons for not receiving MT were cost, late presentation, and lack of availability of qualified neurointerventional services within reasonable distance. There were 59.1% of respondents who reported having a well-structured MT training program. Lack of qualified trainers, financial support, support from higher authorities, and lack of collaboration between departments were the most common obstacles against developing a training program.

CONCLUSION

Our study highlights significant variations in MT availability, accessibility, patient selection criteria, and MT service training programs worldwide. Financial costs and a shortage of trained neurointerventionalists were the main challenges in low- and middle-income countries.

Somatosensory-Thalamic Functional Dysconnectivity Associated With Poststroke Motor Function Rehabilitation: A Resting-State fMRI Study

BACKGROUND

The thalamus plays a pivotal role in functional brain networks, yet its contribution to motor function recovery following stroke remains elusive. We aim to explore changes in thalamocortical functional connectivity poststroke and its correlation with motor function.

METHODS

Thirty-nine subacute ischemic stroke patients and 32 healthy individuals underwent resting-state functional magnetic resonance imaging (MRI). The Fugl-Meyer Assessment (FMA) was employed to evaluate upper and lower extremity motor function before and 1 year after stroke rehabilitation. The ipsilesional thalamus and contralesional thalamus were parceled into functional regions of interest (ROIs) based on connectivity with six cortical ROIs: prefrontal, motor, temporal, posterior parietal, somatosensory, and occipital cortex. Functional connectivity between each cortical ROI and its corresponding thalamic ROI was calculated and compared between groups. Differences identified in the ROI-to-ROI analysis were further investigated through seed-to-voxel whole-brain connectivity analyses to pinpoint thalamic dysconnectivity. Correlations with upper and lower extremity motor function were also analyzed.

RESULTS

Significant changes in thalamocortical functional connectivity were observed after stroke in ROI-to-ROI analysis, with bilateral somatosensory-thalamic connectivity decreased and ipsilesional temporal-thalamic and bilateral occipital-thalamic connectivity increased. Seed-to-voxel analysis localized ipsilesional thalamic hypoconnectivity to the ipsilesional rolandic operculum and ipsilesional precentral gyrus. Ipsilesional somatosensory-thalamic connectivity was positively correlated with baseline upper extremity FMA scores and negatively correlated with upper extremity motor function change rate at 1-year postdischarge.

CONCLUSIONS

This study provides new insights into the role of the thalamus in motor function recovery after stroke, offering preliminary evidence for its potential as a therapeutic target in poststroke rehabilitation.

Mendelian randomization and mediation examination of the immune cell-mediated link between sphingomyelin and stroke

OBJECTIVE

The study established a direct link between stroke and sphingomyelin. The precise biology underlying this connection is yet unknown, though. As a result, we decided to investigate the potential causal relationship between Sphingomyelin and genetic vulnerability to stroke, as well as the potential mediating function that immune cells may play in this process, using Mendelian randomization (MR) approaches.

METHODS

A published genome-wide association study (GWAS) dataset of European populations served as the foundation for the MR Study. The inverse variance weighting (IVW) model is the main technique. Four additional statistical techniques (MR Egger, Weighted median, Simple mode, and Weighted mode) were also employed to enhance the verification process. Reverse MR Analysis was utilized to reinforce the findings, and heterogeneity and horizontal pleipotency were assessed. Additionally, this study looked into potential immune cell mediating roles in the causal link between sphingomyelin and stroke using two-step MR techniques.

RESULT

The IVW metod's results indicated that sphingomyelin genetic susceptibility was linked to a high risk of stroke (OR = 1.045 [95 %CI, 1.004-1.087; P = 0.031). Additionally, the statistical result of SSC-A on CD8br and stroke was IVW [P = 0.007, OR(95 % CI) 1.020 (1.005-1.034)], which was proportionate to the increased risk of stroke. A lower incidence of stroke IVW is linked to CD45 on CD8br [P = 0.004, OR(95 % CI) 0.993 (0.988-0.998)]. Furthermore, our results imply that SSC-A on CD8br and CD45 on CD8br contribute to the causative relationship between sphingomyelin and stroke. The percentages of conciliation are 5.38 %, 22.7 %, 33.5 %), and 0.000999, 0.0152, 0.0132, respectively.

CONCLUSION

We confirmed the effect of sphingomyelin on stroke and conducted in-depth studies. SSC-A on CD8br and CD45 on CD8br is latent stroke mediators associated with sphingomyelin. Through two-step mediated Mendelian randomization analysis, we provide new insights into the etiology and treatment of stroke.

A colorimetric and SERS-based LFIA for sensitive and simultaneous detection of three stroke biomarkers: An ultra-fast and sensitive point-of-care testing platform

Stroke ranks as the second leading cause of disability and mortality globally. Biomarker detection represents a promising avenue for predicting disease severity and prognosis. The expression levels of metalloproteinase-9 (MMP-9), neuron-specific enolase (NSE), and N-terminal pro-brain natriuretic peptide (NT-pro BNP) in blood correlate with stroke severity. Hence, monitoring these biomarkers is crucial for stroke diagnosis and management. Point-of-care testing (POCT) offers on-site diagnostic capabilities, with lateral flow immunoassay (LFIA) being the most widely used method currently. However, traditional LFIA sensitivity requires enhancement. This study introduces an ultra-sensitive surface-enhanced Raman scattering-based lateral flow immunoassay (SERS-based LFIA) strip for simultaneous detection of the three stroke biomarkers using SERS immune tags. Bimetallic core-shell structured SERS immune tags leverage the advantages of two metals, ensuring stability and enhancing Raman signals through plasmon resonance. This development of a POCT based on SERS-based LFIA strips offers rapid, sensitive, and multiplex detection of stroke biomarkers. The limits of detection (LODs) for MMP-9, NSE, and NT-pro BNP were 0.00020 ng mL-1, 0.00016 ng mL-1, and 0.00012 ng mL-1, respectively. Furthermore, enzyme-linked immunosorbent assay (ELISA) validated the accuracy of SERS-based LFIA. Clinical sample analysis demonstrated consistency between outcomes obtained by SERS-based LFIA and ELISA. Thus, SERS-based LFIA presents a novel POCT approach for stroke diagnosis.

Race/ethnicity-specific association between the American Heart Association's new Life's Essential 8 and stroke in US adults with nonalcoholic fatty liver disease: Evidence from NHANES 2005-2018

BACKGROUND

The Life's Essential 8 (LE8) is a recently introduced assessment of cardiovascular health (CVH) by the American Heart Association (AHA). Nonalcoholic fatty liver disease (NAFLD) is currently the most common chronic liver disease and is associated with an increased risk of stroke. We aimed to explore the association of LE8 with stroke in NAFLD using a national cross-sectional study.

METHODS

Eligible participants with NAFLD aged 20-85 years in NHANES 2005-2018 were included. LE8 was assessed according to AHA criteria and categorized into metabolic and behavioral factors. US Fatty Liver Index (USFLI) ≥ 30 and exclusion of other chronic liver diseases suggested NAFLD. Stroke was diagnosed according to self-report on standardized questionnaires.

RESULTS

After adjusting for all confounders, each point increase in LE8, LE8 metabolic factors, and LE8 behavioral factors was associated with a 4.4 %, 1.8 %, and 2.5 % reduction in stroke prevalence in NAFLD, respectively. Both moderate and high CVH assessed by LE8 and LE8 behavioral factors were associated with reduced odds of stroke compared with low CVH. Stroke prevalence declined progressively with increasing number of ideal LE8 components, with the lowest odds of stroke at 3 + ideal LE8 components for both LE8 metabolic and behavioral factors. Restricted cubic spline suggested dose-response associations. Race/ethnicity was a significant effect modifier, and this association was present only among non-Hispanic white population and other Hispanic population. FLI as a diagnostic indicator of NAFLD yielded generally consistent results.

CONCLUSIONS

Higher LE8 score, especially LE8 behavioral factors, was associated with reduced prevalence of stroke in NAFLD, especially among non-Hispanic white population and other Hispanic population. The odds of stroke declined progressively with increased ideal LE8 component number. These findings underscore the preventive value of adherence to high CVH for stroke prevention in NAFLD.

Enhancing Neuron Activity Promotes Functional Recovery by Inhibiting Microglia-Mediated Synapse Elimination After Stroke

BACKGROUND

Activating glutamatergic neurons in the ipsilesional motor cortex can promote functional recovery after stroke. However, the underlying molecular mechanisms remain unclear. Clarifying key molecular mechanisms involved in recovery could help understand the development of neuromodulation strategies after stroke.

METHODS

Adeno-associated virus 2/9-CamKIIa-hM3Dq-mCherry was injected into ipsilesional motor cortex by stereotaxic in the photothrombotic stroke model. Starting from the third day after the stroke, male mice were injected intraperitoneally with clozapine-N-oxide every day to activate excitatory neurons. C1q-blocking antibody and annexin V were used to inhibit C1q and exposed phosphatidylserine (EPS), respectively. The cylinder test and grid-walking test were performed to evaluate functional recovery. The potential molecular mechanisms of excitatory neuronal activation on microglia-mediated synaptic pruning after stroke by immunofluorescence, real-time polymerase chain reaction, Western blotting, and RNA sequencing.

RESULTS

Activating excitatory neurons significantly promoted functional recovery and inhibited microglia-mediated synaptic pruning after stroke. Furthermore, it decreased EPS and C1q levels in synapses. On the contrary, inhibiting excitatory neurons aggravated functional defects, promoted microglia-mediated synaptic pruning, and increased EPS and C1q levels in synapses. Selective blocking of EPS repressed C1q tagging of synapses and microglia-mediated synaptic pruning and improved functional recovery. Meanwhile, blocking EPS markedly rescued synaptic density, and motor function deteriorated by chemogenetic inhibition. In addition, C1q-blocking antibody prevented phosphatidylserine engulfment by microglia.

CONCLUSIONS

Together, these data provide mechanistic insight into microglia-mediated synapse pruning after neuronal activation after stroke and identify the role of C1q binding to EPS in stroke treatment during the repair phase.

Acute stroke care in low and middle-income countries

PURPOSE OF REVIEW

The purpose of this article is to discuss the global impact of stroke, the disparities and barriers to implement stroke care, and the global efforts to improve access to acute treatments in low and middle-income countries (LMICs).

RECENT FINDINGS

Disparities in access to stroke care are influenced by socioeconomic inequalities, geographic disparities, and limited healthcare infrastructure, particularly in LMICs. Effective stroke care requires a coordinated approach involving emergency services, rapid diagnosis, timely treatment, and early rehabilitation. However, there are significant delays in implementing evidence-based practices, particularly in areas where stroke care resources are scarce.Key barriers include geographic disparities, economic constraints, insufficient healthcare infrastructure, low public awareness, and weak policy frameworks. Addressing these challenges requires strengthening health systems, promoting universal health coverage, enhancing public and healthcare provider education, leveraging technology like telemedicine, and fostering international collaboration. Global efforts, including initiatives by the World Stroke Organization, focus on improving stroke care through infrastructure development, workforce training, and policy advocacy.

SUMMARY

These recommended strategies aim to make stroke care accessible and effective for everyone, regardless of location or socioeconomic status, ultimately helping to reduce the global burden of stroke.

World Stroke Organization: Global Stroke Fact Sheet 2025

BACKGROUND

Among non-communicable disorders (NCDs), stroke remains the second leading cause of death and the third leading cause of death and disability combined (as expressed by disability-adjusted life-years lost-DALYs) in the world.

AIMS

The study was aimed to estimate global, regional and nationa burden of stroke and its risk factors from 1990 to 2021.

METHODS

Finding presented in this paper were derived mainly from the Global Burden of Disease 2021 Study on stroke burden published in The Lancet Neurology 2024:23:973-1003.

RESULTS

The estimated global cost of stroke is over US$890 billion (0.66% of the global GDP). From 1990 to 2021, the burden (in terms of the absolute number of cases) increased substantially (70.0% increase in incident strokes, 44.0% deaths from stroke, 86.0% prevalent strokes, and 32% DALYs), with the bulk of the global stroke burden (87.0% of deaths and 89.0% of DALYs) residing in lower-income and lower-middle-income countries (LMICs). Stroke attributable to metabolic risks constituted 69.0% of all strokes, environmental risks constituted 37.0%, and behavioral risks constituted 35.0%.

CONCLUSION

This World Stroke Organization (WSO) Global Stroke Fact Sheet 2025 provides the most updated information that can be used to inform communication with all internal and external stakeholders; all statistics have been reviewed and approved for use by the WSO Executive Committee and leaders from the Global Burden of Disease research group.

Association of aspirin use with risk of intracerebral hemorrhage in patients without history of stroke or transient ischemic attack in the UK Biobank

BACKGROUND

The association between aspirin use and the risk of intracerebral hemorrhage (ICH) among individuals without previous stroke events is inconclusive.

AIM

We investigated the association between regular aspirin use and ICH risk in middle-aged and older adults without previous stroke or transient ischemic attack (TIA).

METHODS

This prospective population-based study included participants older than 40 years with no history of stroke or TIA from the UK Biobank. The main exposure was regular aspirin use. Cox regression analyses and propensity score matching analyses estimated the hazard ratios (HRs) for aspirin use for incident fatal and non-fatal ICH. We conducted pre-specified subgroup analyses for selecting individuals at high risk of ICH when using aspirin. Multiple sensitivity analyses were performed to test the robustness of our results.

RESULTS

A total of 449,325 participants were included into final analyses (median (IQR) age 58 (50-63) years, 54.6% females), of whom 58,045 reported aspirin use. During a median follow-up of 12.75 (IQR: 12.03-13.47) years, 1557 (0.3%) incident ICH cases were identified, of which 399 (25.6%) were fatal. Aspirin was not associated with increased risk of overall (hazard ratio (HR): 1.11, 95% confidence interval (CI): 0.95-1.27, P = 0.188), fatal (HR: 1.03, 95% CI: 0.78-1.36, P = 0.846) and non-fatal (HR: 1.12, 95% CI: 0.95-1.33, P = 0.186) ICH. Propensity score matching analysis showed similar results. Subgroup analysis indicated that aspirin use in individuals older than 65 years or with concurrent anticoagulant use was correlated with increased risk of ICH.

CONCLUSION

In this large cohort study of middle-aged and older adults without stroke or TIA events, there was no significant association between aspirin use and ICH risk in the real-world setting. However, it is possible that aspirin use in those aged over 65 years and concurrent anticoagulant treatment may increase the risk of ICH.

Piceatannol-3'-O-β-D-glucopyranoside inhibits neuroexcitotoxicity and ferroptosis through NMDAR/NRF2/BACH1/ACSL4 pathway in acute ischemic stroke

BACKGROUND

Neuronal protection is a well-established method of acute ischemic stroke (AIS) treatment. The pharmacodynamic effect of Piceatannol-3'-O-β-D-glucopyranoside (Chinese name: Hartigan, QZZG) on AIS has been reported, but the molecular mechanism of this effect remains unknown.

PURPOSE

The purpose of this study is to elucidate the pharmacodynamic effects and mechanisms of QZZG in the treatment of AIS.

METHODS

A combined network pharmacology and metabolomics approach was used to predict the key targets and pathways of QZZG in the treatment of AIS and to elucidate the mechanism of QZZG through experimental validation.

RESULTS

In this study, QZZG improved histopathologic features and reduced infarct volume and neurologic deficit scores. Integrated network pharmacology and metabolomics revealed that QZZG may protect neurons by regulating glutamate and its receptors, and that glutamate is closely related to NMDAR1, NRF2, and Caspase-3. Pathway analysis results suggested that NMDAR-mediated Ca2+ inward flow is one of the critical pathways. In terms of neuroexcitotoxicity QZZG inhibited glutamate content, reduced Ca2+ inward flow, protected mitochondrial function, and reduced ROS, as well as being able to effectively inhibit the expression of NMDAR1, Caspase-3, Bax, and promote the expression of Bcl-2, NMDAR2A. In terms of ferroptosis QZZG promoted NRF2, HO-1, GPX4 and nuclear-NRF2, inhibited the expression of BACH1 and ACSL4, and suppressed Fe2+ accumulation and lipid peroxidation. Silencing of BACH1 resulted in elevated expression of NRF2 and decreased expression of ACSL4, which inhibited the sensitivity of neurons to ferroptosis. QZZG was able to further increase NRF2 expression under conditions of silencing BACH1. QZZG induced NRF2 and inhibited BACH1, ACSL4 was inhibited by ML385, and inhibition of NRF2 induced the expression of BACH1 and ACSL4, QZZG protects neurons in an NRF2-dependent manner.

CONCLUSION

In summary, QZZG inhibited neuroexcitotoxicity and ferroptosis by regulating the NMDAR/NRF2/BACH1/ACSL4 pathway. The study provided a relatively novel perspective on the mechanism of traditional Chinese medicine (TCM) treatment of the disease.

A comprehensive analysis of stroke risk factors and development of a predictive model using machine learning approaches

Stroke is a leading cause of death and disability globally, particularly in China. Identifying risk factors for stroke at an early stage is critical to improving patient outcomes and reducing the overall disease burden. However, the complexity of stroke risk factors requires advanced approaches for accurate prediction. The objective of this study is to identify key risk factors for stroke and develop a predictive model using machine learning techniques to enhance early detection and improve clinical decision-making. Data from the China Health and Retirement Longitudinal Study (2011-2020) were analyzed, classifying participants based on baseline characteristics. We evaluated correlations among 12 chronic diseases and applied machine learning algorithms to identify stroke-associated parameters. A dose-response relationship between these parameters and stroke was assessed using restricted cubic splines with Cox proportional hazards models. A refined predictive model, incorporating age, sex, and key risk factors, was developed. Stroke patients were significantly older (average age 69.03 years) and had a higher proportion of women (53%) compared to non-stroke individuals. Additionally, stroke patients were more likely to reside in rural areas, be unmarried, smoke, and suffer from various diseases. While the 12 chronic diseases were correlated (p < 0.05), the correlation coefficients were generally weak (r < 0.5). Machine learning identified nine parameters significantly associated with stroke risk: TyG-WC, WHtR, TyG-BMI, TyG, TMO, CysC, CREA, SBP, and HDL-C. Of these, TyG-WC, WHtR, TyG-BMI, TyG, CysC, CREA, and SBP exhibited a positive dose-response relationship with stroke risk. In contrast, TMO and HDL-C were associated with reduced stroke risk. In the fully adjusted model, elevated CysC (HR = 2.606, 95% CI 1.869-3.635), CREA (HR = 1.819, 95% CI 1.240-2.668), and SBP (HR = 1.008, 95% CI 1.003-1.012) were significantly associated with increased stroke risk, while higher HDL-C (HR = 0.989, 95% CI 0.984-0.995) and TMO (HR = 0.99995, 95% CI 0.99994-0.99997) were protective. A nomogram model incorporating age, sex, and the identified parameters demonstrated superior predictive accuracy, with a significantly higher Harrell's C-index compared to individual predictors. This study identifies several significant stroke risk factors and presents a predictive model that can enhance early detection of high-risk individuals. Among them, CREA, CysC, SBP, TyG-BMI, TyG, TyG-WC, and WHtR were positively associated with stroke risk, whereas TMO and HDL-C were opposite. This serves as a valuable decision-support resource for clinicians, facilitating more effective prevention and treatment strategies, ultimately improving patient outcomes.

Unraveling the Synergistic Neuroprotective Mechanism of Natural Drug Candidates Targeting TRPV1 and TRPM8 on an Ischemic Stroke

The development of multitargeted drugs is urgent for ischemic stroke. TRPV1 and TRPM8 are important targets of ischemic stroke. Previous drug candidate screening has identified that muscone, l-borneol, and ferulic acid may target TRPV1 and TRPM8 for ischemic stroke. However, the mechanisms of these drug candidates on targets were ill-informed. Therefore, firstly, a tongue-tissue biosensor was constructed. It explored the activation or inhibition mechanisms of drug candidates targeting TRPV1 and TRPM8 in a near-physiological environment. It was found that muscone could specifically inhibit TRPM8 and selectively activate TRPV1, while l-borneol exhibited the opposite effect. It suggested a synergistic network between these two drug candidates. Furthermore, more selective protein biosensors were developed to delve deeper into the synergistic mechanisms. A strong synergistic effect of muscone and l-borneol was proved. Molecular docking revealed that the synergistic effect was caused by different action sites, respectively. Subsequently, the synergistic effect of muscone and l-borneol was further confirmed by hypoxic nerve injury models of Caenorhabditis elegans (C. elegans) and antithrombus and anti-ischemic models of zebrafish. Ultimately, through nontargeted metabolomics, it was found that muscone and l-borneol mainly regulated Ca2+ concentration and energy metabolism by pathways such as purine and amino acid metabolisms. In conclusion, this research identified critical targets and synergistic drug candidates for multitarget neuroprotection of ischemic stroke. In addition, it has systemically demonstrated the feasibility of the integration of tissue/protein biosensors and metabolomics for the research and development of multitarget drugs. Compared to other screening and validation methods for drugs and targets, the biosensors we developed not only achieved higher sensitivity and specificity in complex physiological environments, ensuring a wider detection range, but also greatly saved biological samples. Simultaneously, they could be extended to other complex systems, such as biomarker screening in clinical samples and exosomes isolated from stem cells.

Molecular Hydrogen Modulates T Cell Differentiation and Enhances Neuro-Regeneration in a Vascular Dementia Mouse Model

This study explores whether molecular hydrogen (H2) administration can alleviate cognitive and immunological disturbances in a mouse model of vascular dementia (VaD). Adult male C57BL/6 mice underwent bilateral common carotid artery stenosis to induce VaD and were subsequently assigned to three groups: VaD, VaD with hydrogen-rich water treatment (VaD + H2), and Sham controls. Behavioral assessments using open field and novel object recognition tests revealed that VaD mice exhibited anxiety-deficient behavior and memory impairment, both of which were reversed by H2 treatment. Histological examinations showed pyknotic neuronal morphologies and elevated reactive oxygen species (ROS) in the VaD hippocampus, whereas H2 administration mitigated these alterations. Furthermore, VaD-induced downregulation of BCL2 was reversed in the VaD + H2 group, in parallel with increased IL-4 expression. Flow cytometric analyses revealed that VaD disrupted T regulatory cell homeostasis by significantly increasing their proportion, an effect reversed by H2 treatment, thereby restoring immunological balance. Transcriptomic evaluations confirmed that VaD suppressed key neuroprotective and anti-inflammatory genes, while H2 treatment restored or enhanced their expression. Collectively, these findings highlight the neuroprotective and immuno-modulatory potential of molecular hydrogen, suggesting that H2 supplementation may promote neuronal resilience, modulate T cell differentiation, and support cognitive recovery in vascular dementia.

Association of the triglyceride glucose index with obesity indicators and hypertension in American adults based on NHANES 2013 to 2018

This cross-sectional study aimed to investigate the association between the TyG index and both obesity indicators and hypertension among American adults. Data were drawn from 4,813 adults in the 2013-2018 National Health and Nutrition Examination Survey (NHANES). Multivariate logistic regression models indicated significant associations between TyG and obesity-related indices with hypertension. Using Cox regression analysis, we examined the relationship between TyG and obesity-related indices in relation to hypertensive prognosis, employing threshold effect analysis and fitted smoothed curves for consistency. Subgroup analyses and interaction tests were conducted. Results showed strong correlations between TyG, TyG-BMI, TyG-WHtR, TyG-WC and hypertension, with odds ratios (ORs) of hypertension rising across TyG quartiles (Q1-Q4). Cardiovascular mortality analysis revealed that TyG (HR = 1.89, 95% CI (1.03,3.51), P < 0.05) and the Q2 group (HR = 4.93, 95% CI (1.29,18.80), P < 0.05) were significantly associated with increased risk. A positive correlation between TyG and hypertension was noted below a threshold of 8.1, with inverse associations beyond this point. The TyG-BMI, TyG-WHtR, and TyG-WC exhibited positive correlations with hypertension, although weakened after reaching a certain threshold. These findings suggested that TyG and related indices are associated with hypertension and may aid in understanding risk stratification in this context.

Combined 25-hydroxyvitamin D concentrations and physical activity on mortality in US stroke survivors: findings from the NHANES

BACKGROUND

25-hydroxyvitamin D [25(OH)D] concentrations and physical activity (PA) are linked and both are associated with changes in mortality. We examined the association of 25(OH)D and PA with all-cause or cause-specific mortality risk in stroke survivors.

METHODS

The analysis included 677 stroke survivors from National Health and Nutrition Examination Survey (NHANES) 2007-2008 to 2017-2018. Independent and joint associations of 25(OH)D, PA and mortality among stroke survivors were analyzed using weighted Cox regression.

RESULTS

We identified 133 all-cause deaths [major adverse cardiovascular events (MACE), 34; non-MACE, 79] with a median follow-up of 5.8 years (interquartile, 2.8-8.9 years). In a range of adjusted models, high 25(OH)D was observed with lower all-cause mortality compared to low 25(OH)D (HR, 0.376; 95% CI, 0.233-0.607) and non-MACE (HR, 0.265; 95% CI, 0.143-0.490) mortality was consistently associated. At the same time, compared with no PA, PA was associated with a lower all-cause (HR, 0.280; 95%CI, 0.107-0.733) and non-MACE (HR, 0.266; 95%CI, 0.087-0.810) was associated with a lower risk of death. In addition, pooled analyses showed that stroke survivors with high 25(OH)D and PA had the lowest risk of all-cause death (HR, 0.132; 95%CI, 0.038-0.460) and non-MACE (HR, 0.092; 95%CI, 0.023-0.363), there is an additive interaction between 25(OH)D and PA in non-MACE.

CONCLUSION

In conclusion, this study found that combining high 25(OH)D levels and PA showed an enhanced protective effect which demonstrated a synergistic effect between them in reducing mortality among stroke survivors. These findings provide new ideas and possibilities for the prevention and treatment of cardiovascular and cerebrovascular diseases, offering a reference for development of clinical practice guidelines in the future.

Time to consider health services dedicated for adults living with cerebral small vessel disease: Report of a ESO scientific seminar

PURPOSE

Cerebral small vessel disease (cSVD) is a highly prevalent disorder leading to physical, cognitive and functional decline. We report key barriers in the management of individuals with cSVD, the potential benefit of cSVD-dedicated health services, and evidence from existing models of care for adults with cSVD.

METHODS

We examined information from a scientific seminar developed between seven experts in cSVD during the eighth European Stroke Organisation Conference that discussed the optimal health care for adults with cSVD and what health services dedicated to cSVD should include.

FINDINGS

Barriers in cSVD care include unrecognised symptoms and modifiable risk factors, heterogeneity of clinical presentations, inefficient inter/intra-clinical services communication/organisation, and uncertainties regarding what assessments/treatments should be routinely done, when and by whom. However, existing health services and research studies suggest models of care in cSVD. Multi-step approaches can be used for identification and aetiological workup in individuals with cSVD, including basic and selected advanced evaluations, for example, monogenic cSVD testing. Although current guidelines for management of cSVD illlustrate limitations, there are recommendations on risk factors and lifestyle considerations, as well as pharmacological and non-pharmacological interventions for people with cSVD.

DISCUSSION AND CONCLUSION

Existing healthcare models do not provide optimal care for individuals with cSVD. Lack of awareness of heterogeneous clinical presentations and uncertainty in threshold of cSVD 'burden' for referral to specialist multidisciplinary services, are key challenges for health services to overcome. Creating cSVD-dedicated services may prevent underdiagnosing and achieve standardised holistic management to improve outcomes in people with cSVD. However, adequate prevention and early management should be offered at all levels of care.

Relationship between physical activity and depressive symptoms in stroke survivors: a cross-sectional study of 1,140 individuals

OBJECTIVES

To investigate the relationship between physical activity and depressive symptoms in stroke survivors.

DESIGN

A cross-sectional study utilizing National Health and Nutrition Examination Survey (NHANES) 2007-2018 data, employing propensity score matching to control for confounders.

PATIENTS

1,140 stroke survivors from NHANES, assessing depressive symptoms through the Patient Health Questionnaire-9 (PHQ-9) conducted via family interview or a mobile examination centre examination.

METHODS

PA was surveyed concurrently with the PHQ-9, categorized into vigorous, moderate, and moderate-to-vigorous intensities. Propensity score matching was used to match participants based on their activity levels, and the relationship between physical activity and depressive symptoms was analysed by logistic regression.

RESULTS

Among all the subjects, 225 individuals had significant depressive symptoms. If vigorous-intensity PA duration is longer than 75 min (odds ratio [OR] = 0.41, 95% CI 0.21-0.75) or longer than 150 min (OR = 0.42, 95% CI 0.19-0.85), and moderate-intensity physical activity duration is longer than 150 min (OR = 0.59, 95% CI 0.38-0.90) or between 150 and 300 min (OR = 0.36, 95% CI 0.15-0.77), and moderate-to-vigorous PA duration is greater than 150 min (OR = 0.61, 95% CI 0.40-0.91) or exceeding 300 min (OR = 0.50, 95% CI 0.31-0.78), this might be associated with lower depressive symptoms.

CONCLUSION

Regular physical activity, particularly of moderate or higher intensity, is associated with milder depressive symptoms in stroke survivors, suggesting the potential for non-pharmacological intervention.

Associations of reverse triiodothyronine serum levels with anxiety, depression, and health related quality of life after experiencing acute ischemic stroke

Aim

This study intended to explore associations of reverse triiodothyronine (rT3) with emotional disturbances and health-related quality of life (HRQoL) after experiencing acute ischemic stroke (AIS).

Materials and methods

Serum samples from individuals with AIS were collected on admission to three Lithuania stroke centers and investigated for free tetraiodothyronine, free triiodothyronine (fT3), rT3, and thyroid stimulating hormone levels. At discharge, emotional disturbance was evaluated using the Hospital Depression and Anxiety Scale (HADS), and HRQoL using the EQ-5D-5L scale.

Results

Analyses included 159 individuals (59.7% male and 40.3% female; mean (SD) aged 66.4 [10.3] years), 52.83% of which showed increased rT3 levels upon admission. After adjustment for age, sex, National Institutes of Health Stroke Scale scores, previous stroke, modified Rankin Scale before AIS ≤ 2, and diabetes mellitus, multivariable linear regression revealed negative associations of rT3 with HADS total score (β = -0.163; p = 0.046) and HADS-D subscale score (β = -0.187; p = 0.019). Analyses supported a positive relationship between the fT3 ratio to rT3 with HADS-D score (β = 0.157; p = 0.046) and rT3, rT3 × fT3 product with EQ-5D index score (β = 0.157; p = 0.044 and β = 0.179; p = 0.023, respectively).

Conclusion

We found that individuals who experienced AIS and had higher levels of rT3 at hospital admission had less emotional disturbance and better HRQoL when discharged.

Association between the systemic immunity-inflammation index and stroke: a population-based study from NHANES (2015-2020)

Background The systemic immunity-inflammation index(SII) is a new indicator of composite inflammatory response. Inflammatory response is an important pathological process in stroke. Therefore, this study sought to investigate the association between SII and stroke. Methods We collected data on participants with SII and stroke from the 2015-2020 cycle of National Health and Nutrition Examination Survey (NHANES) for the cross-sectional investigation. Multivariate linear regression models were used to test the association between SII and stroke. Fitted smoothing curves and threshold effect analysis were applied to describe the nonlinear relationship. Results A total of 13,287 participants were included in our study, including 611 (4.598%) participants with stroke. In a multivariate linear regression analysis, we found a significant positive association between SII and stroke, and the odds ratio (OR) [95% CI] of SII associating with prevalence of stroke was [1.02 (1.01, 1.04)] (P < 0.01). In subgroup analysis and interaction experiments, we found that this positive relationship was not significantly correlated among different population settings such as age, gender, race, education level, smoking status, high blood pressure, diabetes and coronary heart disease (P for trend > 0.05). Moreover, we found an nonlinear relationship between SII and stroke with an inflection point of 740 (1,000 cells /µl) by using a two-segment linear regression model. Conclusions This study implies that increased SII levels are linked to stroke. To confirm our findings, more large-scale prospective investigations are needed.

Longitudinal changes in remnant cholesterol and the risk of cardiovascular disease

BACKGROUND AND AIM

The analyses of longitudinal changes in remnant cholesterol (RC) and cardiovascular disease (CVD) remains are limited. The objective of the study was to investigate the associations of longitudinal changes in RC with the risks of CVD and its subtypes (myocardial infarction [MI] and stroke).

METHODS AND RESULTS

The participants were enrolled in the Kailuan study. The RC short-term change pattern was defined by RC cutoff points according to equivalent percentiles for low-density lipoprotein cholesterol of 2.6 mmol/L at visits in 2006 and 2008. The RC long-term change pattern was defined as the RC trajectories from 2006 to 2010. Multivariate Cox proportion models were used to calculate hazard ratios (HRs) and their 95% confidence intervals (CIs). The cutoff values of RC were 0.52 mmol/L at the 2006 visit and 0.51 mmol/L at the 2008 visit. In the RC short-term change analysis, the participants in the high stable group had a 31% increased risk of CVD (HR 1.31; 95% CI 1.22-1.41), 73% increased risks of MI (HR 1.73; 95% CI 1.47-2.03), and 21% increased risks of stroke (HR 1.21; 95% CI 1.12-1.31) compared with participants in the low stable group. Three RC trajectories were employed in the RC long-term change analysis. Compared with the low stable group, the high stable group had a 1.34-fold risk of CVD (HR 1.34; 95% CI 1.17-1.53), 1.66-fold risk of MI (HR 1.66; 95% CI 1.24-2.21), and 1.22-fold risk of stroke (HR 1.22; 95% CI 1.05-1.42).

CONCLUSIONS

The stable high RC was associated with a higher risk of CVD. Maintaining optional RC levels could reduce the lifetime risk of CVD and prolong the year of life free from CVD.

Biomimetic Nanomotors for Deep Ischemia Penetration and Ferroptosis Inhibition in Neuroprotective Therapy of Ischemic Stroke

Nerve injury represents the primary reason of mortality and disability in ischemic stroke, but effective drug delivery to the region of cerebral ischemia and hypoxia poses a significant challenge in neuroprotective treatment. To address these clinical challenges, a biomimetic nanomotor, Pt@LF is designed, to facilitate deep delivery of neuroprotective agents and inhibit ferroptosis in ischemic stroke. Pt@LF traverses the blood-brain barrier (BBB) and penetrates into deep cerebral ischemic-hypoxic areas due to the active targeting capacity of apo-lactoferrin (Apo-LF) and the self-propelling motion properties of nanomotors. Subsequently, Pt@LF loosens thrombus and alleviates the "no reflow" phenomenon via mechanical thrombolysis. Thanks to the various enzyme-like abilities and multi-target ferroptosis inhibition capability, Pt@LF ameliorates the inflammatory microenvironment and rescues dying neurons. In conclusion, Pt@LF demonstrates efficiently deep penetration and neuroprotective effects in vitro and vivo. And this study provides a promising therapeutic platform for the treatment of ischemic stroke.

Cost evaluation of acute ischemic stroke in Latin America: a multicentric study

Background

Current literature highlights a gap in precise stroke cost data for Latin America. This study measures the real costs associated with acute ischemic stroke care in Latin America using Time-Driven Activity-Based Costing (TDABC). The findings aim to lay a solid foundation for adopting value-based healthcare (VBHC) strategies in the region.

Methods

The study is an observational, multicenter, international analysis of direct costs and outcomes for patients hospitalised with acute ischemic stroke from December 2021 to December 2022. Data from stroke centres in Argentina, Brazil, Chile, Colombia, Costa Rica, Mexico, Peru, and Uruguay were analysed. Costs were stratified by country. Factors such as favourable outcomes based on the modified Rankin Scale (mRS 0-2), clinical risk levels, and treatment interventions were considered for the analysis. Generalized Estimating Equation (GEE) models were utilised to assess the relationship of clinical variables with the total cost per patient.

Findings

A total of 1106 patients were included in the study. Among these patients, 74% received medical treatment alone, 18% received intravenous thrombolysis (IVT), 4% underwent mechanical thrombectomy (MT), and 3% received combined IVT plus MT. The mean cost per patient was I$ 12,203 (SD I$ 15,055), with 49% achieving a favourable functional outcome. Compared to medical treatment alone, MT incurred costs 3.1 times higher, with an incremental cost of I$ 20,418 per patient (p < 0.0001). Across all countries, costs increased according to patients' clinical risk and treatment options, with length of hospital stay emerging as the primary cost driver.

Interpretation

Our study highlights significant disparities in stroke costs across healthcare services in Latin America, influenced by variations in treatment accessibility, patient outcomes, and clinical risk profiles. These findings offer essential insights for shaping health policy decisions to enhance the long-term sustainability of stroke care in the region.

Funding

The project received funding from the World Stroke Organization and Boehringer Ingelheim (BI) IS 0135-0352.

Enhancing stroke-associated pneumonia prediction in ischemic stroke: An interpretable Bayesian network approach

Background

Stroke-associated pneumonia (SAP) is a major cause of mortality following ischemic stroke (IS). However, existing predictive models for SAP often lack transparency and interpretability, limiting their clinical utility. This study aims to develop an interpretable Bayesian network (BN) model for predicting SAP in IS patients, focusing on enhancing both predictive accuracy and clinical interpretability.

Methods

This retrospective study included patients diagnosed with IS and admitted to the Second Affiliated Hospital of Nanchang University between January and December 2019. Clinical data collected within 48 h of admission and SAP occurrences within 7 days were analyzed. Dimensionality reduction was performed using Least Absolute Shrinkage and Selection Operator regression, while data imbalances were addressed using synthetic minority oversampling technique. A BN model was trained using a hill-climbing algorithm and compared to logistic regression, decision trees, deep neural networks, and existing risk-scoring systems. Decision curve analysis was used to assess clinical usefulness.

Results

Of the 1252 patients, 165 (13.18%) patients had SAP within 7 days of admission. The BN model identified age, risk of pressure injury (PI), National Institutes of Health Stroke Scale (NIHSS) score, and C-reactive protein (CRP) as significant prognostic factors. The BN model achieved an area under the curve of 0.85(95% CI: 0.78-0.92) on the test set, outperforming other models and demonstrating a greater net benefit in clinical decision-making.

Conclusions

Age, risk of PI, NIHSS score, and CRP are significant predictors of SAP in IS patients. The interpretable BN model demonstrates superior predictive performance and interpretability, suggesting its potential as an effective and interpretable tool for clinical decision support in SAP risk assessment.

The Power of Advocacy in Global Neurosurgery

Advocacy, one of the five domains of global neurosurgery, represents a powerful avenue to influence public policy to expand access to safe, timely, and affordable neurosurgical care. In this manuscript, we characterize advocacy in global neurosurgery, describe specific neurosurgeon-led initiatives, and delineate how neurosurgeons can become involved in global neurosurgery advocacy efforts. Advocacy in global neurosurgery involves working together in organized neurosurgery with organizations focused on clinical provisions, training, and policy initiatives. Effective advocacy uses a data-driven approach with myriad facilitators, including collaboration and approach strategies for sharing information and a variety of contextual, ideological, and practical barriers. The main action fronts for global neurosurgery include identifying needs, broadening access, and assuring quality. Neurosurgery-led initiatives transforming public policy have occurred on regional and global scales and accelerated since 2019. Folate fortification of staple foods to prevent neural tube defects represents a recent and notably successful area of advocacy and remains in progress. Neurosurgeons who aspire to become involved in advocacy efforts must obtain competencies and skills distinct from, yet complementary to, the traditional neurosurgical training curriculum.