Stroke in the young in the northern Manhattan stroke study

Stroke prevalence among the Turkish population in a rural area of Istanbul: A community-based study

Background

The population-based information on the prevalence of stroke from rural areas of Middle East countries including Turkey is unknown. Our aim is to evaluate the prevalence of stroke in those ⩾18 years in the Turkish population in a rural area of Istanbul.

Methods

A cross-sectional door-to-door study was conducted in a rural area of Istanbul between 1 March and 30 March 2013. A research protocol recommended by World Health Organization for developing countries was used. Each screening teams consisted of one neurologist, one local nurse, and five surveyors. Teams were trained about the survey and questionnaire. The patients, who claimed to have suffered a stroke, were examined, and the diagnosis was confirmed by a neurologist on site. The findings and medical records were documented.

Results

In total, 2906 people ⩾18 years were screened. 50 stroke cases were detected. 80% of those were found to have had an ischemic stroke, 14% of those were hemorrhagic cases, and 6% of those had an unclassified stroke type. The overall prevalence rate in those ⩾ 18 years was 1.7%. The male/female ratio was 0.92. Young (<45) stroke prevalence was found to be 0.6%.

Conclusion

This study was the first of its kind to show the stroke prevalence among Turkish population ⩾ 18 years in a rural area of Istanbul. When compared to other studies which investigate people ⩾45 years from Turkey, the result (in the same age group) was moderate high. The male/female ratio was low compared to many other studies.

Risk factor profile in patients with stroke at a young age

Background The distribution of risk factors for stroke is related to gender and age. The main objective of study was to determine the type and frequency of stroke risk factors in patients with first-in-life stroke before the age of 50. Methods Our study included patients under the age of 50 with first-in-life stroke. The following data obtained from all participants were analyzed: a neuroimaging of the head, wide panel of blood tests, electrocardiogram, transesophageal echocardiography, ultrasound of the carotid/cerebral arteries. 24-hour ECG monitoring and angio-MRI of head were performed in most patients. Results One hundred and eighty-four patients were qualified into the study; mean age - 39 years (female 45%). The female gender was significantly more often associated with diabetes, carotid/cerebral artery stenosis, myocardial infarction, cardiomyopathy and risk factors associated with lifestyle. More than half of the patients presented at least two risk stroke factors. The most frequent categories of risk factors were related to arteries and metabolic diseases. Vascular risk factors were among the most frequent in individual age categories. Hereditary stroke-burden was significant in the patient before the age of 20.15% of the patients haven't got known stroke risk factor. Conclusions Angiopathy is the most common risk factor for stroke at a young age. More than half of the patients with stroke at a young age have at least two independent risk factors for stroke. In the first two decades of life, the most frequent risk factors for stroke are heart diseases; arterial diseases play a dominant role in the consecutive three decades.

Influenza-like illness as a trigger for ischemic stroke

Objective

We hypothesized that ILI is associated with risk of incident stroke, and that the risk would be highest closest in time to the event.

Methods

This case‐crossover analysis utilized data obtained from the California State Inpatient Database of the Healthcare Cost and Utilization Project (HCUP). The outcome of interest was ischemic stroke. Exposure was defined as a visit to the emergency department or hospitalization for influenza‐like illness (ILI) 365, 180, 90, 30, or 15 days before stroke (risk period) or similar time intervals exactly 1 or 2 years before stroke (control period). Conditional logistic regression was used to calculate the odds ratio and 95% confidence interval (OR, 95% CI).

Results

In 2009, 36,975 hospitalized ischemic strokes met inclusion criteria, and of these strokes, 554 (1.5%) had at least 1 episode of ILI in the 365‐day risk period prior to their stroke. Using non‐overlapping time intervals from ILI to stroke, the odds of ischemic stroke was greatest in the first 15 days post ILI (OR: 2.88, 95% CI: 1.86–4.47). The strength of the relationship decreased as the time from ILI increased, and was no longer significant after 60 days. There was a significant interaction (P = 0.017) with age and ILI; the odds of stroke associated increased 7% with each 10‐year decrease in age (OR per 10‐year age decrease 1.07, 95% CI: 1.03–1.35).

Interpretation

We found that ILI increases short‐term risk of stroke, particularly in people under the age of 45, and therefore may be considered to act as a trigger for stroke.

Nontraumatic intracerebral haemorrhage in young adults

Nontraumatic intracerebral haemorrhage (ICH) is a common subtype of stroke with a poor prognosis, high mortality and long-term morbidity. The incidence of ICH increases with age. ICH has not been widely investigated in young adults (herein defined as aged ∼18-50 years) despite an annual incidence of ∼5 per 100,000 individuals. Furthermore, ICH characteristics differ between young and elderly patients. Risk factors for ICH are surprisingly common in young adults, in whom ICH is often caused by structural lesions or hypertension, and only rarely by anticoagulation therapy and cerebral amyloid angiopathy (which are common predisposing factors in elderly patients). High short-term mortality (17% at 3 months) and long-term mortality (>25% at 10 years) persist even in contemporary series from high-income countries, and long-term disability is very common. Thus, an aggressive approach to identifying treatable underlying conditions and preventing ICH recurrence is indicated in young patients, although treatment strategies have generally not been investigated specifically in this age group. This narrative Review summarizes existing knowledge on the epidemiology, risk factors, causes, diagnosis, treatment and outcomes of ICH in young adults. We provide comparisons with the population of elderly patients with ICH and discuss challenges for future research.

The Impact of Pregnancy on Hemorrhagic Stroke in Young Women

BACKGROUND

Pregnancy is a sex-specific risk factor for causing hemorrhagic stroke (HS) in young adults. Unique physiological characteristics during pregnancy may alter the relative risk for HS in pregnant/postpartum (PP) women compared to HS in other young women. We compared patient characteristics and HS subtypes between young non-pregnant and PP women.

METHODS

We reviewed the medical records of all women 18-45 years old admitted to our center with HS from October 15, 2008 through March 31, 2015, and compared patient characteristics and stroke mechanisms using logistic regression.

RESULTS

Of the 130 young women with HS during the study period, 111 were non-PP women, and 19 PP women. PP women had lower proportions of vascular risk factors such as hypertension, prior stroke, and smoking, and a higher proportion of migraine (36.8 vs. 14.4%, p = 0.01). After adjusting for hypertension, smoking, migraine, prior stroke and prior myocardial infarction, PP women had lower odds of having an underlying vascular lesion (OR 0.14, 95% CI 0.04-0.44, p = 0.0009) and a higher proportion of the reversible cerebral vasoconstriction syndrome (RCVS) as cause of their HS.

CONCLUSIONS

Women with pregnancy-associated HS had fewer cerebrovascular risk factors, lower odds of having -underlying vascular lesions, and higher proportion of -migraine and RCVS compared with similar-aged non--pregnant women. Pregnancy-associated HS appears to represent a unique pathophysiological process, requiring targeted study.

A Diagnostic Approach to Stroke in Young Adults

OPINION STATEMENT

Optimal diagnosis and management of stroke in young adults benefit from a multidisciplinary team, including a vascular neurology specialist. In addition to the "standard" vascular risk factors including smoking, hypertension, diabetes, and hyperlipidemia, one needs to consider alternative etiologies including substance abuse, carotid/vertebral artery dissections, and rare genetic conditions among others. Once a young patient is determined to have had a stroke, the next question a clinician should ask is why did this patient have a stroke? A "heart to head" diagnostic approach is recommended. A thorough history is performed, including a detailed family history with specific annotations on each family member. A thorough physical examination is necessary including a careful evaluation of the patient's general appearance, noting any joint laxity, and/or abnormalities of the skin, eyes, and heart. Findings across multiple organ systems in the patient and/or their family may indicate a genetic etiology. After an initial head CT rules out hemorrhagic stroke, additional testing should include a brain MRI, neck and cerebral vascular imaging (e.g., CTA for head and neck), transthoracic echocardiogram with a bubble study, telemetry monitoring, basic risk factor blood work (e.g., lipid panel, hemoglobin A1c, TSH, ESR, CRP, RPR, HIV, and toxicology screen), and, when appropriate, sickle screen and pregnancy test. There should be a low threshold to obtain blood cultures or a lumbar puncture. The acute treatment of ischemic stroke in young adult patients does not differ from treatment of older adults, using intravenous alteplase within 4.5 h, assuming no contraindications. In suspected proximal large artery occlusive disease, interventional clot extraction procedures should be employed in patients deemed eligible. Long-term secondary prevention strategies aimed to reduce recurrent stroke risk by targeting and modifying vascular risk factors should be instituted. The mainstay of preventative therapy is aspirin for most etiologies; however, for atrial fibrillation, anticoagulation is recommended. Statin therapy is another pharmacologic intervention recommended in most stroke patients. Other measures employed are blood pressure reduction, smoking cessation, optimal glucose control in diabetic patients, the initiation of a healthy diet and regular exercise, and lastly, substance abuse counseling in appropriate patients.

Controversies and evidence for cardiovascular disease in the diverse Hispanic population

OBJECTIVE

Hispanics account for approximately 17% of the U.S.

POPULATION

They are one of the fastest growing racial/ethnic groups, second only to Asians. This heterogeneous population has diverse socioeconomic conditions, making the prevention, diagnosis, and management of vascular disease difficult. This paper discusses the cultural, racial, and social aspects of the Hispanic community in the United States and assesses how they affect vascular disease within this population. Furthermore, it explores risk factors, medical and surgical treatments, and outcomes of vascular disease in the Hispanic population; generational evolution of these conditions; and the phenomenon called the Hispanic paradox.

METHODS

A systematic search of the literature was performed to identify all English-language publications from 1991 to 2014 using PubMed, which draws from the National Institutes of Health and U.S. National Library of Medicine, with the words "cardiovascular disease," "prevalence," "vascular," and "Hispanic." An additional search was performed using "cardiovascular disease and Mexico," "cardiovascular disease and Cuba," "cardiovascular disease and Puerto Rico," and "cardiovascular disease and Latin America" as well as for complications, management, outcomes, surgery, vascular disease, and Hispanic paradox. The resulting publications were queried for generational data (spanning multiple well-defined age groups) regarding cardiovascular disease, and cross-references were obtained from their bibliographies. Results are segmented by country of origin.

RESULTS

Compared with non-Hispanic whites, Hispanics face higher risks of cardiovascular diseases because of a high prevalence of high blood pressure, obesity, diabetes mellitus, and ischemic stroke. However, the incidence of peripheral arterial disease and carotid disease appears to be significantly lower than in whites. The Hispanic paradox (lower mortality in spite of higher cardiovascular risk factors) may relate to challenges in ascribing life expectancy and cause of death in this diverse population. Low socioeconomic status and high prevalence of concomitant diseases negatively influence the outcomes of all patients, independent of being Hispanic.

CONCLUSIONS

Understanding the cultural diversity in Hispanics is important in terms of targeting preventive measures to modify cardiovascular risk factors, which affect development and outcomes of vascular disease. The available literature regarding vascular disease in the Hispanic population is limited, and further longitudinal study is warranted to improve health care delivery and outcomes in this group.

Epidemiology of Ischemic Stroke

Ischemic stroke is a heterogeneous multifactorial disorder recognized by the sudden onset of neurologic signs related directly to the sites of injury in the brain where the morbid process occurs. The evaluation of complex neurologic disorders, such as stroke, in which multiple genetic and epigenetic factors interact with environmental risk factors to increase the risk has been revolutionized by the genome-wide association studies (GWAS) approach. This article reviews salient aspects of ischemic stroke emphasizing the impact of neuroepidemiology and GWAS.

Comparison of the Time Course of Return to Work After Stroke Between Two Cohort Studies in Japan

The conditions for stroke rehabilitation such as individual therapeutic procedure and medical treatment system in Japan have drastically changed over the past decade: increasing incidence of ischemic stroke, the use of intravenous recombinant tissue plasminogen activator, hospital specialization, introduction of convalescent rehabilitation wards, and public long-term care insurance. However, it is not known whether these changes have influenced the time course of return to work (RTW) after stroke. In this study we compared the time course of RTW after stroke in Japan that was reported in two cohort studies performed 20 years apart. The cumulative rate of RTW after first stroke was similar in the two studies, even though they were separated by an interval of two decades. This shows that advances in stroke rehabilitation have not impacted RTW, and we suggest that the social security system, particularly sickness benefit, has a strong influence on RTW.

Cryptogenic Stroke: Research and Practice

BACKGROUND

Cryptogenic stroke accounts for 30% to 40% of ischemic stroke. It is essential to determine the possible culprit because this will improve secondary stroke prevention strategies.

METHODS

We performed a narrative nonsystematic review of the literature that included randomized trials, exploratory comparative studies, and case series on cryptogenic stroke.

RESULTS

There are several possible mechanisms implicated in cryptogenic stroke, including occult paroxysmal atrial fibrillation, patent foramen ovale, aortic arch atherosclerosis, atrial cardiopathy, and substenotic atherosclerosis. The heterogeneity of these mechanisms leads to differences in stroke prevention strategies among cryptogenic stroke patients.

CONCLUSIONS

A thorough diagnostic evaluation is essential to determine the pathogenesis in cryptogenic stroke. This approach, in addition to risk factor management and lifestyle modifications, will lead to improved stroke prevention strategies in patients with cryptogenic stroke. This will allow for targeted clinical trials to improve stroke prevention strategies in this patient population.

Tale of 2 Health-care Systems: Disparities in Demographic and Clinical Characteristics between 2 Ischemic Stroke Populations in Los Angeles County

BACKGROUND

Individuals who present to the emergency departments of safety-net systems often have poorly controlled risk factors due to lack of primary care. Little is known about potential differences in presenting characteristics, discharge medications, and discharge destinations of patients with acute ischemic stroke (AIS) who present to safety-net settings versus university medical centers (UMCs).

METHODS

Demographic characteristics, medical history, premorbid medication use, stroke severity, discharge medications, and discharge destination were assessed among consecutive admissions for AIS over a 2-year period at a UMC (n = 385) versus 2 university-affiliated safety-net hospitals (SNHs) (n = 346) in Los Angeles County.

RESULTS

Compared with patients presenting to the UMC, individuals admitted to the SNHs were younger, more frequently male, nonwhite, current smokers, hypertensive, and diabetic; they were less likely to take antithrombotics and statins before admission, and had worse serum lipid and glycemic markers (all P < .05). Patients admitted to the UMC trended toward more cardioembolic strokes and had higher stroke severity scores (P < .0001). At discharge, patients admitted to the SNHs were more likely to receive antihypertensive medications than do patients admitted to the UMC (P < .001), but there were no differences in prescription of antiplatelet medications or statins.

CONCLUSIONS

Individuals with AIS admitted to SNHs in Los Angeles County are younger and have poorer vascular risk factor control than their counterparts at a UMC. Discharge treatment does not vary considerably between systems. Early and more vigorous efforts at primary vascular risk reduction among patients seen at SNHs may be warranted to reduce disparities.

Sex differences in the presentation of stroke

Stroke affects both men and women of all ages, although the condition is more common among the elderly. Stroke occurs at an older age among women than among men; although the incidence is lower among women than among men, as women have a longer life expectancy their lifetime risk is slightly higher. Ischemic stroke is the most common type of stroke; and reperfusion treatment is possible if the patient reaches hospital early enough. Thrombolysis and thrombectomy are time-sensitive treatments - the earlier they are initiated the better is the chance of a positive outcome. It is therefore important to identify a stroke as soon as possible. Medical personnel can readily identify typical stroke symptoms but the presentation of non-traditional stroke symptoms, such as impaired consciousness and altered mental status, is often associated with a significant delay in the identification of stroke and thus delay in or inability to provide treatment. Non-traditional stroke symptoms are reported to be more common in women, who are thereby at risk of delayed recognition of stroke and treatment delay.

Risk of Acute Stroke After Hospitalization for Sepsis: A Case-Crossover Study

BACKGROUND AND PURPOSE

Infections have been found to increase the risk of stroke over the short term. We hypothesized that stroke risk would be highest shortly after a sepsis hospitalization, but that the risk would decrease, yet remain up to 1 year after sepsis.

METHODS

This case-crossover analysis utilized data obtained from the California State Inpatient Database of the Healthcare Cost and Utilization Project. All stroke admissions were included. Exposure was defined as hospitalization for sepsis or septicemia 180, 90, 30, or 15 days before stroke (risk period) or similar time intervals exactly 1 or 2 years before stroke (control period). Conditional logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (95% CI) for the association between sepsis/septicemia and ischemic or hemorrhagic stroke.

RESULTS

Ischemic (n=37 377) and hemorrhagic (n=12 817) strokes that occurred in 2009 were extracted where 3188 (8.5%) ischemic and 1101 (8.6%) hemorrhagic stroke patients had sepsis. Sepsis within 15 days before the stroke placed patients at the highest risk of ischemic (OR, 28.36; 95% CI, 20.02-40.10) and hemorrhagic stroke (OR, 12.10; 95% CI, 7.54-19.42); however, although the risk decreased, it remained elevated 181 to 365 days after sepsis for ischemic (OR, 2.59; 95% CI, 2.20-3.06) and hemorrhagic (OR, 3.92; 95% CI 3.29-4.69) strokes. There was an interaction with age (P=0.0006); risk of developing an ischemic stroke within 180 days of hospitalization for sepsis increased 18% with each 10-year decrease in age.

CONCLUSIONS

Risk of stroke is high after sepsis, and this risk persists for up to a year. Younger sepsis patients have a particularly increased risk of stroke after sepsis.

[Juvenile stroke - what is important?]

Stroke in young adults is a diagnostic and therapeutic challenge for all persons involved. Approximately 15% of ischemic strokes occur in young adults. Lack of awareness of the symptoms in emergency departments often results in delayed diagnosis and access to specific therapeutic options, such as revascularization. The causes are often heterogeneous and necessitate specific investigations. The etiology of juvenile stroke includes drug abuse, vasculitis and arteriopathies, such as reversible vasoconstriction syndrome and posterior reversible encephalopathy syndrome, although the prevalence of classical vascular risk factors is high. The most frequent causes of ischemic stroke in young adults are cardioembolism and microangiopathy; furthermore, dissection of vessels of the neck are more frequent compared to older patients. According to the results of currently available studies reperfusion strategies, such as intravenous fibrinolysis and mechanical thrombectomy are efficacious and safe in young patients.

Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism

Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations.

Dyslipidaemia as a risk factor in the occurrence of stroke in Nigeria: prevalence and patterns

INTRODUCTION

Stroke is a major public health problem worldwide. Hypertension, diabetes mellitus, dyslipidaemia and smoking are some of the common modifiable risk factors in the occurrence of stroke. Therefore, this study was designed to assess the prevalence and patterns of dyslipidaemia among individuals with acute stroke.

METHODS

This is a retrospective descriptive cross-sectional study, carried out in the Departments of Medicine at the LAUTECH Teaching hospital, Ogbomoso and General Hospital, Orile-Agege, Lagos, South-West, Nigeria, over a 18-month period between September 2012 and February 2014. One hundred and six (106) patients with acute stroke confirmed with computed tomography (CT) brain scan were recruited. Clinical features, risk factors, lipid profiles and stroke patterns were identified.

RESULTS

Mean age was significantly higher in ischaemic stroke compared to haemorrhagic (64.08±10.87 Vs, 56.21±12.38years, p=0.001). There was slight male preponderance in both stroke types (1.3:1). Out of 106 patients, 65 (61.3%) had ischaemic stroke, 38 (35.8%) intracerebral haemorrhage and 3 (2.9%) with subarachnoid haemorrhage. Dyslipidaemia is the most frequent risk factor (85.9%), followed by hypertension (66.0%) and diabetes mellitus (15.1%). Dyslipidaemia was significantly higher in the ischaemic stroke compared to haemorrhagic. Reduced HDL-cholesterol is the most prevalent fraction of lipid abnormalities (74.5%).

CONCLUSION

Dyslipidaemia, particularly low HDL-C, was the most frequent risk factor in our patients with stroke. Hence, prevention of dyslipidaemia as well as other risk factors is key to reducing the burden of stroke in our country.

Cardiovascular diseases in patients 65 years and younger with non-cardiogenic stroke

INTRODUCTION

Approximately 10-15% of patients with stroke are under 65 years of age. The aim of the study was to determine types of stroke In people below 65. We analysed the incidence and types of associated cardiovascular diseases in patients with non-cardiogenic stroke.

MATERIAL AND METHODS

In this prospective study patients (aged ≤ 65) with stroke underwent physical examination, computed tomography of the head, blood tests, electrocardiogram, echocardiography, and transcranial and carotid artery ultrasound. Classification of stroke was performed according to the ASCOD scale. Analysis considered the incidence of heart diseases in patients with non-cardiogenic stroke and the incidence of heart diseases recognised as a cause of cerebral embolism in patients with cardiogenic stroke.

RESULTS

The study included 611 patients with stroke at the age of 27-65 (mean: 57.2 ±6.7; M/F 380/231). Stroke of heterogeneous aetiology was observed in 321 patients, cardiogenic stroke in 78, and stroke caused by small vessel and carotid artery disease in 73 and 72 patients, respectively. The most common heart diseases in non-cardiogenic stroke patients included persistent foramen ovale, coronary heart disease and past myocardial infarction. The most common causes of cardiogenic embolism were cardiomyopathy, atrial fibrillation and interatrial septal defect.

CONCLUSIONS

Aetiologically heterogeneous stroke and cardiogenic stroke are the most commonly observed among young stroke patients. Cardiomyopathy and atrial fibrillation are the most common sources of cerebral embolism in young patients with cardiogenic stroke. Nearly 1/5 of patients with a non-cardiogenic stroke have congenital or acquired structural changes in the heart.

Ischemic stroke in the young: Current perspectives on incidence, risk factors, and cardiovascular prognosis

About one-fourth of ischemic strokes occur in working-aged individuals in the high-income countries, with worldwide increasing incidence in this age group from 1980s to present. Recent evidence suggests that traditional vascular risk factors are more prevalent than previously suggested in young adult stroke patients and they accumulate with age particularly in men. Accordingly, relatively high rates of atherosclerotic changes have been detected in these patients. The strength of association of vascular risk factors has gone poorly studied, however. Many young patients with ischemic stroke have, in turn, no traditional risk factors, while they may harbor other conditions with weak or uncertain association with the stroke alone. These individual conditions often represent a risk factor that may be strictly young-age specific, more prevalent in younger than older stroke patients (e.g. patent foramen ovale), or more prevalent among the young in the population. Despite high rates of vascular risk factors and atherosclerotic changes, these findings do not translate to higher frequencies of identified classical stroke mechanisms. In fact, cryptogenic causes are markedly common and even more frequent among the very young patients. Limited randomized trial evidence exists to support secondary prevention decision-making in patients, yet they face an increased risk of death and future vascular events for years to come-dependent on risk factor profile and cause of the stroke. This review provides an overview of recent data on epidemiology, risk factors, and their strength of association in ischemic stroke in the young. Furthermore, the relationship between with the risk factors and cardiovascular outcomes and key features on the evidence related to secondary prevention will be discussed.

Fifty years of stroke researches in India

Currently, the stroke incidence in India is much higher than Western industrialized countries. Large vessel intracranial atherosclerosis is the commonest cause of ischemic stroke in India. The common risk factors, that is, hypertension, diabetes, smoking, and dyslipidemia are quite prevalent and inadequately controlled; mainly because of poor public awareness and inadequate infrastructure. Only a small number of ischemic stroke cases are able to have the benefit of thrombolytic therapy. Benefits from stem cell therapy in established stroke cases are under evaluation. Presently, prevention of stroke is the best option considering the Indian scenario through control and/or avoiding risk factors of stroke. Interventional studies are an important need for this scenario.

Development of epilepsy after ischaemic stroke

For about 30% of patients with epilepsy the cause is unknown. Even in patients with a known risk factor for epilepsy, such as ischaemic stroke, only a subpopulation of patients develops epilepsy. Factors that contribute to the risk for epileptogenesis in a given individual generally remain unknown. Studies in the past decade on epilepsy in patients with ischaemic stroke suggest that, in addition to the primary ischaemic injury, existing difficult-to-detect microscale changes in blood vessels and white matter present as epileptogenic pathologies. Injury severity, location and type of pathological changes, genetic factors, and pre-injury and post-injury exposure to non-genetic factors (ie, the exposome) can divide patients with ischaemic stroke into different endophenotypes with a variable risk for epileptogenesis. These data provide guidance for animal modelling of post-stroke epilepsy, and for laboratory experiments to explore with increased specificity the molecular 'mechanisms, biomarkers, and treatment targets of post-stroke epilepsy in different circumstances, with the aim of modifying epileptogenesis after ischaemic stroke in individual patients without compromising recovery.

Ethnic differences in ischemic stroke subtypes in young-onset stroke: the Stroke Prevention in Young Adults Study

Background

Prior studies indicate that young African-Americans (AA) have a greater frequency of ischemic stroke than similarly aged European-Americans (EA). We hypothesized that differences in stroke subtype frequency mediated through sex and differing risk factor profiles may play a role in ethnicity-specific stroke. Utilizing our biracial young-onset stroke population, we explored these relationships.

Methods

Fifty nine hospitals in the Baltimore-Washington area participated in a population-based study of young-onset stroke in men (218-AA, 291-EA) and women (219-AA, 222-EA) aged 16–49. Data on age, sex, ethnicity and stroke risk factors (hypertension (HTN) and smoking) were gathered through standardized interview. A pair of vascular neurologists adjudicated each case to determine TOAST subtype. Logistic regression analyses evaluating for differences in stroke risk factors by TOAST subtype were performed.

Results

Analyses controlling for age and sex demonstrated that AA were more likely to have a lacunar stroke than EA (OR = 1.61; 95 % CI = 1.12–2.32; p = 0.011) when utilizing the other TOAST subtypes as the reference group. This effect was mediated by HTN, which increases the risk of lacunar stroke (OR = 2.03; 95 % CI = 1.38–2.98; p = 0.0003) and large artery stroke (OR = 1.70; 95 % CI = 1.01–2.88; p = 0.048) when controlling for sex, ethnicity, and age. Cases below age 40 were more likely to have a cardioembolic stroke than those above age 40 (OR = 1.62; 95 % CI = 1.15–2.27; p = 0.006), controlling for sex and ethnicity. Lastly, current smokers were more likely to have a large artery stroke than non-smokers (OR = 1.79; 95 % CI = 1.08–2.98; p = 0.024).

Conclusions

Our population-based data demonstrate ethnic differences in ischemic stroke subtypes. These findings may help clarify mechanisms of stroke in young adults which may in part be driven by ethnic-specific differences in early-onset traditional risk factors, thereby indicating differing emphasis on workup and prevention.

Comparative evaluation of risk factors, outcome and biomarker levels in young and old acute ischemic stroke patients

Background

Stroke is the third leading cause of death and disability worldwide accounting for 400-800 strokes per 100,000 individuals each year.

Purpose

In the present study, we compared risk factors, clinical outcome, and prognostic biomarkers NSE, S-100 ßß and ITIH4 levels in young and old acute ischemic stroke (AIS) patients.

Methods

We compared the risk factors and clinical outcomes in young (n = 38) and old (n = 66) AIS patients admitted to tertiary health care centre in Central India. In addition, we also evaluated NSE, S100ββ & ITIH4 levels in admission and discharge samples of young and old AIS patients with different clinical outcome.

Results

Hypertension was a major risk factor in 45% of young and 80% of old AIS patients. Hospital outcome was less favorable in young AIS patients with higher dependent rates of 24% as compared to 12% in old AIS patients. Whereas long term outcome at 12 and 18 months after discharge was more favorable in young AIS patients with low dependency rates of 16% and 11% as compared to 41% and 24% in older AIS patients respectively. Similarly, serum NSE, S100ββ and ITIH4 levels showed a distinct pattern of expression at discharge time in AIS patients with improved and dependent outcome in both the age groups.

Conclusion

Young males with hypertension and smoking habits are at a high risk of AIS while old AIS patients are at a greater risk of worse long term outcome. Serum levels of NSE and S100ββ are independent predictors of outcome in AIS patients. Similarly, it also suggests that serum ITIH4 levels could be used as a potential biomarker for predicting the outcome in AIS patients.

Risk factors, aetiology and outcome of ischaemic stroke in young adults: the Swiss Young Stroke Study (SYSS)

Ischaemic stroke (IS) in young adults has been increasingly recognized as a serious health condition. Stroke aetiology is different in young adults than in the older population. This study aimed to investigate aetiology and risk factors, and to search for predictors of outcome and recurrence in young IS patients. We conducted a prospective multicentre study of consecutive IS patients aged 16-55 years. Baseline demographic data, risk factors, stroke aetiology including systematic genetic screening for Fabry disease and severity were assessed and related to functional neurological outcome (modified Rankin Scale, mRS), case fatality, employment status, place of residence, and recurrent cerebrovascular events at 3 months. In 624 IS patients (60% men), median age was 46 (IQR 39-51) years and median NIHSS on admission 3 (IQR 1-8). Modifiable vascular risk factors were found in 73%. Stroke aetiology was mostly cardioembolism (32%) and of other defined origin (24%), including cervicocerebral artery dissection (17%). Fabry disease was diagnosed in 2 patients (0.3%). Aetiology remained unknown in 20%. Outcome at 3 months was favourable (mRS 0-1) in 61% and fatal in 2.9%. Stroke severity (p < 0.001) and diabetes mellitus (p = 0.023) predicted unfavourable outcome. Stroke recurrence rate at 3 months was 2.7%. Previous stroke or TIA predicted recurrent cerebrovascular events (p = 0.012). In conclusion, most young adults with IS had modifiable vascular risk factors, emphasizing the importance of prevention strategies. Outcome was unfavourable in more than a third of patients and was associated with initial stroke severity and diabetes mellitus. Previous cerebrovascular events predicted recurrent ones.

Strokes in young adults: epidemiology and prevention

Strokes in young adults are reported as being uncommon, comprising 10%-15% of all stroke patients. However, compared with stroke in older adults, stroke in the young has a disproportionately large economic impact by leaving victims disabled before their most productive years. Recent publications report an increased incidence of stroke in young adults. This is important given the fact that younger stroke patients have a clearly increased risk of death compared with the general population. The prevalence of standard modifiable vascular risk factors in young stroke patients is different from that in older patients. Modifiable risk factors for stroke, such as dyslipidemia, smoking, and hypertension, are highly prevalent in the young stroke population, with no significant difference in geographic, climatic, nutritional, lifestyle, or genetic diversity. The list of potential stroke etiologies among young adults is extensive. Strokes of undetermined and of other determined etiology are the most common types among young patients according to TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Prevention is the primary treatment strategy aimed at reducing morbidity and mortality related to stroke. Therefore, primary prevention is very important with regard to stroke in young adults, and aggressive treatment of risk factors for stroke, such as hypertension, smoking, and dyslipidemia, is essential. The best form of secondary stroke prevention is directed toward stroke etiology as well as treatment of additional risk factors. However, there is a lack of specific recommendations and guidelines for stroke management in young adults. In conclusion, strokes in young adults are a major public health problem and further research, with standardized methodology, is needed in order to give us more precise epidemiologic data. Given the increasing incidence of stroke in the young, there is an objective need for more research in order to reduce this burden.

Do Hispanic Children Need to Know About Stroke Prevention?

When compared to Hispanics in their native countries, the frequency of stroke in the Hispanic American population is higher. This has been linked to an increase in smoking, inactivity, and obesity. Initially these health issues were thought to affect only Hispanic adults, but research confirms that first- and second-generation adolescents and young adults continue to demonstrate these habits. Education has been shown to be an effective method of stroke prevention by increasing an individual's knowledge base. As demonstrated in a previous study performed in the Hispanic community, when educational material is presented in a familiar environment and offers lifestyle options that are culturally realistic, there is an increase in knowledge and compliance with lifestyle changes. The focus of education for stroke prevention has always been placed on older adults, but little has been done to alter the cultural risk factors found in the young adult and adolescent population in order to prevent stroke in the future.

Predictors of cholesterol and lipoprotein(a) testing in children with arterial ischemic stroke

BACKGROUND

Professional societies recommend screening lipids in healthy children. Dyslipidemia and elevated lipoprotein(a) are risk factors for adult cardiovascular disease and stroke. Their role in childhood arterial ischemic stroke is unexplored. Inconsistencies in testing limit analysis of existing lipid data. The objective of this study is to identify predictors and modifiable barriers to lipid testing in pediatric stroke.

METHODS

In this cross-sectional analysis, children (28 days-18 years) with arterial ischemic stroke were identified from the International Pediatric Stroke Study registry (January 2003-April 2012). Analyzed predictors of recorded lipid or lipoprotein a (Lp(a)) testing were age, sex, race, ethnicity, body mass index (BMI) category, other stroke risk factors, country, US region, and recurrent thrombosis.

RESULTS

Among 1652 participants (median, 6 years [interquartile range, 1.7-12.7]; 59.0% male; 40.8% white; 7.0% black), at least 1 lipid parameter or Lp (a) was available for 461 (27.9%). Compared with infants, testing was incrementally higher for older age categories. Compared with whites, testing was lower in blacks (adjusted odds ratio [OR], .5; 95% confidence interval [CI], .4-.5; P < .0001). Hispanic ethnicity only predicted testing within the United States (OR, 2.2; 95% CI, 1.4-3.4; P = .001]. Testing was lower in the United States and Australia and higher in Chile. Any thrombotic recurrence and recurrent symptomatic arterial ischemic stroke were associated with testing, unlike male sex, BMI, other stroke risk factors, and region in the United States.

CONCLUSIONS

Only a quarter of children with stroke had recorded lipid testing. Older age, white race, and recurrence predicted testing. In future study adjusting for these predictors may be necessary. Standardized lipid testing in children with arterial ischemic stroke may further our understanding of this potential risk factor.

Red blood cell distribution width in patients with cryptogenic stroke

BACKGROUND

There is no information about a possible association of red blood cell distribution width (RDW) with cryptogenic stroke (CS). We aimed to analyze the association of RDW with CS.

PATIENTS AND METHODS

One hundred and sixty-three patients with CS were included along with 186 healthy controls. Fibrinogen, leukocytes, hemoglobin, and erythrocyte indices were evaluated.

RESULTS

Patients showed higher RDW, leukocyte count, and body mass index (BMI) than controls (P < .05). No differences were observed in the erythrocyte indices or in glucose, cholesterol, and triglycerides levels (P > .05). When patients with anemia were excluded from the study (6 controls and 5 cases), the differences between cases and controls persisted (P = .005). Multivariate logistic regression revealed that, after adjusting for potential confounders (anemia, age > 40 years, gender, and fibrinogen >382 mg/dL, total cholesterol >240 mg/dL, and BMI > 28.7 kg/m(2)), RDW >14% was the only parameter that independently increased the risk of CS.

CONCLUSION

The RDW >14% increased the risk of CS by 2.5-fold, irrespectively of anemia, inflammation, and lipidic profile.

Persistent racial disparity in stroke hospitalization and economic impact in young adults in the buckle of stroke belt

BACKGROUND AND PURPOSE

Mounting evidence points to a decline in stroke incidence. However, little is known about recent patterns of stroke hospitalization within the buckle of the stroke belt. This study aims to investigate the age- and race-specific secular trends in stroke hospitalization rates, inpatient stroke mortality rates, and related hospitalization charges during the past decade in South Carolina.

METHODS

Patients from 2001 to 2010 were identified from the State Inpatient Hospital Discharge Database with a primary discharge diagnosis of stroke (International Classification of Diseases, Ninth Revision codes: 430-434, 436, 437.1). Age- and race-stroke-specific hospitalization rates, hospital charges, charges associated with racial disparity, and 30-day stroke mortality rates were compared between blacks and whites.

RESULTS

Of the 84,179 stroke hospitalizations, 31,137 (37.0%) were from patients aged<65 years and 29,846 (35.5%) were blacks. Stroke hospitalization rates decreased in the older population (aged≥65 years) for both blacks and whites (P<0.001) but increased among the younger group (aged<65 years; P=0.004); however, this increase was mainly driven by a 17.3% rise among blacks (P=0.001), with no difference seen among whites (P=0.84). Of hospital charges totaling $2.77 billion, $453.2 million (16.4%) are associated with racial disparity (79.6% from patients aged<65 years). Thirty-day stroke mortality rates decreased in all age-race-stroke-specific groups (P<0.001).

CONCLUSIONS

The stroke hospitalization rate increased in the young blacks only, which results in a severe and persistent racial disparity. It highlights the urgent need for a racial disparity reduction in the younger population to alleviate the healthcare burden.

The growing problem of stroke among young adults

Although overall stroke incidence has been declining in developed countries, there is evidence that stroke in the young is increasing. Increasing incidence may be particularly pronounced among minorities in whom historically a higher burden of stroke has been reported. Compared with older adults, time spent with disability is longer for those affected at younger ages, and new data suggests that among 30-day young adult stroke survivors, increased mortality persists for as long as 20 years. Stroke in young adults is often missed by less experienced clinicians due to its unexpectedness, leading to lost opportunities for intervention. The causes and risk factors for stroke in the young are often rare or undetermined, but young adults with stroke also have a high burden of traditional cardiovascular risk factors, including hypertension, diabetes, obesity, and substance abuse. Disseminating awareness and promoting research on young adult stroke are steps towards reducing the burden of stroke.

Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

The aim of this statement is to summarize data on stroke risk factors that are unique to and more common in women than men and to expand on the data provided in prior stroke guidelines and cardiovascular prevention guidelines for women. This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through May 15, 2013. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

We provide current evidence, research gaps, and recommendations on risk of stroke related to preeclampsia, oral contraceptives, menopause, and hormone replacement, as well as those risk factors more common in women, such as obesity/metabolic syndrome, atrial fibrillation, and migraine with aura.

CONCLUSIONS

To more accurately reflect the risk of stroke in women across the lifespan, as well as the clear gaps in current risk scores, we believe a female-specific stroke risk score is warranted.

Factor V Leiden does not have a role in cryptogenic ischemic stroke among Iranian young adults

BACKGROUND

Different risk factors have been suggested for ischemic stroke in young adults. In a group of these patients despite of extensive diagnostic work-up, the primary cause remains unknown. Coagulation tendency is accounted as a possible cause in these patients. Previous studies on factor V Leiden (FVL) as the main cause of inherited thrombophilia for clarifying the role of FVL in stroke have resulted in controversial findings. The current study investigates the role of this factor in ischemic stroke among Iranians.

MATERIALS AND METHODS

This case-control study was performed between September 2007 and December 2008 in Isfahan, Iran. The case group comprised of 22 patients of which 15 were males and 7 were females with age range of ≤50 years, diagnosed as ischemic stroke without classic risk factors and the control group consisted of 54 healthy young adults. After filling consent form, venous blood samples were obtained and sent to the laboratory for genetic examination.

RESULTS

No FVL mutation was found in the case group. There was one carrier of the mutation as heterozygous in the control group (relative frequency = 1.85%).

CONCLUSIONS

Based on our study, FVL might not be considered as an independent risk factor for ischemic stroke in Iranian individuals who are not suffering from other risk factors of ischemic stroke.

Age and ethnic disparities in incidence of stroke over time: the South London Stroke Register

BACKGROUND AND PURPOSE

Data on continuous monitoring of stroke risk among different age and ethnic groups are lacking. We aimed to investigate age and ethnic disparities in stroke incidence over time from an inner-city population-based stroke register.

METHODS

Trends in stroke incidence and before-stroke risk factors were investigated with the South London Stroke Register, a population-based register covering a multiethnic population of 357 308 inhabitants. Age-, ethnicity-, and sex-specific incidence rates with 95% confidence intervals were calculated, assuming a Poisson distribution and their trends over time tested by the Cochran-Armitage test.

RESULTS

Four thousand two hundred forty-five patients with first-ever stroke were registered between 1995 and 2010. Total stroke incidence reduced by 39.5% during the 16-year period from 247 to 149.5 per 100 000 population (P<0.0001). Similar declines in stroke incidence were observed in men, women, white groups, and those aged>45 years, but not in those aged 15 to 44 years (12.6-10.1; P=0.2034) and black groups (310.1-267.5; P=0.3633). The mean age at stroke decreased significantly from 71.7 to 69.6 years (P=0.0001). The reduction in prevalence of before-stroke risk factors was mostly seen in white patients aged>55 years, whereas an increase in diabetes mellitus was observed in younger black patients aged 15 to 54 years.

CONCLUSIONS

Total stroke incidence decreased during the 16-year time period. However, this was not seen in younger age groups and black groups. The advances in risk factor reduction observed in white groups aged>55 years failed to be transferred to younger age groups and black groups.

Quality of life amongst young adults with stroke living in Kenya

BACKGROUND

The world has been experiencing an increase of stroke among young adults. Occurrence of stroke in young adults dramatically affects the quality of life of the individuals.

OBJECTIVES

To investigate the quality of life amongst young adults who experienced a stroke living in Kenya.

METHODS

A cross-sectional study was carried out on a conveniently selected sample of 161 young adults with stroke drawn from three tertiary hospitals in Kenya. The Short-Form 36-item second version (SF-36v2) was used to collect the data. Descriptive and association statistical analysis using Mann-Whitney U, and Kruskal Wallis tests were calculated on the data using SPSS.

RESULTS

In relation to a total score of 100, when expressed as a percentage the mean quality of life scores, ranged from 30% to 48% for each of the SF-36v2 domains. The results showed that males scored higher than females in all the domains except in physical functioning and that the scores decline with advance in age in most domains.

CONCLUSION

The quality of life scores for this group were low meaning that that they were experiencing more challenges with physical functioning, psychological and emotional functioning and fulfilling previous roles.

Effect of task-based mirror therapy on motor recovery of the upper extremity in chronic stroke patients: a pilot study

BACKGROUND AND AIMS

Mirror therapy (MT) is an alternative therapeutic intervention that uses the interaction of visuomotor-proprioception inputs to enhance movement performance of the impaired limb. Despite strong evidence for task-specific training in stroke, MT has been investigated using nontask movements. The aim of this pilot study was to assess the effectiveness of task-based MT on motor recovery of the upper extremity in chronic stroke patients.

METHOD

In a pretest-posttest single-group design, a convenience sample of 13 chronic stroke patients at an occupational therapy department of a rehabilitation institute was assessed on a task-based MT intervention. Participants received a task-based MT program, performing various tasks by the less affected upper extremity and observing in the mirror box along with conventional management, 4 days per week for 4 weeks. Fugl-Meyer Assessment (FMA), which includes subsection upper extremity (FMA-UE) and subpart upper arm (FMA-UA) and hand (FMA-WH), was used as an outcome measure.

RESULTS

Participants showed no significant improvement for FMA-UE and FMA-UA at postassessment. FMA-UE changed from 43% to 51%. Post FMA-UA score showed only 2% improvement. However, there was statistically significant improvement on mean scores of FMA-WH at postassessment (16.21 ± 3.06) as compared with the prescores (12.29 ± 3.1; P < .05). FMA-WH improved from 41% to 54%.

CONCLUSIONS

The preliminary findings suggest that task-based MT is effective in improving wrist and hand motor recovery in chronic stroke patients. Further studies in the form of randomized trials are needed to validate its effectiveness.

Recognition and management of stroke in young adults and adolescents

Approximately 15% of all ischemic strokes (IS) occur in young adults and adolescents. To date, only limited prior public health and research efforts have specifically addressed stroke in the young. Early diagnosis remains challenging because of the lack of awareness and the relative infrequency of stroke compared with stroke mimics. Moreover, the causes of IS in the young are heterogeneous and can be relatively uncommon, resulting in uncertainties about diagnostic evaluation and cause-specific management. Emerging data have raised public health concerns about the increasing prevalence of traditional vascular risk factors in young individuals, and their potential role in increasing the risk of IS, stroke recurrence, and poststroke mortality. These issues make it important to formulate and enact strategies to increase both awareness and access to resources for young stroke patients, their caregivers and families, and health care professionals. The American Academy of Neurology recently convened an expert panel to develop a consensus document concerning the recognition, evaluation, and management of IS in young adults and adolescents. The report of the consensus panel is presented herein.

The ethnic differences of stroke in Yakutia

Background

In Yakutia, the morbidity and mortality from stroke increased in the past 2 decades. Stroke share in the total mortality structure increased significantly. According to the autopsies, haemorrhagic stroke (HS) was more common in indigenous patients.

Objective

The aim of the study was to examine ethnic features of stroke patients of indigenous and non-indigenous ethnicity admitted to Regional Vascular Center (RVC), Yakutsk.

Design

The study used data from a hospital stroke registry, which took into account the cases of acute stroke in 2011. Stroke type and aetiology were determined by clinical examination, computed tomography and magnetic resonance imaging studies, cerebral angiography and ultrasound of cerebral vessels.

Results

A total of 1,108 patients were hospitalized (51.4% male, n=569) in 2011. The mean age was 60.5±12.9 years, male: 59.1±12.8, female: 61.9±13.05. Five hundred and ninety-two ischemic strokes (IS; 53.4%), 236 HS (21.3%), 280 transient ischemic attacks (TIA; 25.3%) were diagnosed. Patients who had a stroke were divided into 3 groups according to their ethnicity: native (n=411; 49.6%), Russians (n=347; 41.9%) and other nationalities (n=70; 8.5%). When comparing the incidence of HS in different ethnic groups, it was found that indigenous patients had more cases of HS than Russians (38% vs. 20.2%, p<0.05; adjusted odds ratio=2.42; 95% confidence interval: 1.72–3.41). Mean age of IS and HS indigenous patients had no significant differences compared with the average age of Russian ethnicity patients (p=0.69; p=0.201, respectively).

Conclusions

The data from this study suggest that among the patients who suffered from stroke in the indigenous population, the share of a haemorrhagic form washigher than those of non-indigenous Caucasians. At the same time, the average age of patients, both having IS and HS had no significant differences by ethnicity. Further studies are needed to establish the causes of ethnic differences of stroke in Yakutia.

The brain's heart - therapeutic opportunities for patent foramen ovale (PFO) and neurovascular disease

Patent foramen ovale (PFO), a common congenital cardiac abnormality, is a connection between the right and left atria in the heart. As a "back door to the brain", PFO can serve as a conduit for paradoxical embolism, allowing venous thrombi to enter the arterial circulation, avoiding filtration by the lungs, and causing ischemic stroke. PFO-related strokes affect more than 150,000 people per year in the US, and PFO is present in up to 60% of migraine patients with aura, and in one out of four normal individuals. So, in such a highly prevalent condition, what are the best treatment and prevention strategies? Emerging studies show PFO-related neurovascular disease to be a multi-organ condition with varying individual risk factors that may require individualized therapeutic approaches - opening the field for new pharmacologic and therapeutic targets. The anatomy of PFO suggests that, in addition to thrombi, it can also allow harmful circulatory factors to travel directly from the venous to the arterial circulation, a concept important in finding novel therapeutic targets for PFO-related neurovascular injury. Here, we: 1) review emerging data on PFO-related injuries and clinical trials; 2) discuss potential mechanisms of PFO-related neurovascular disease in the context of multi-organ interaction and heart-brain signaling; and 3) discuss novel therapeutic targets and research frontiers. Clinical studies and molecular mapping of the circulatory landscape of this multi-organ disease will both be necessary in order to better individualize clinical treatment for a condition affecting more than a quarter of the world's population.

Etiology of first-ever ischaemic stroke in European young adults: the 15 cities young stroke study

BACKGROUND AND PURPOSE

Risk factors for IS in young adults differ between genders and evolve with age, but data on the age- and gender-specific differences by stroke etiology are scare. These features were compared based on individual patient data from 15 European stroke centers.

METHODS

Stroke etiology was reported in detail for 3331 patients aged 15-49 years with first-ever IS according to Trial of Org in Acute Stroke Treatment (TOAST) criteria: large-artery atherosclerosis (LAA), cardioembolism (CE), small-vessel occlusion (SVO), other determined etiology, or undetermined etiology. CE was categorized into low- and high-risk sources. Other determined group was divided into dissection and other non-dissection causes. Comparisons were done using logistic regression, adjusting for age, gender, and center heterogeneity.

RESULTS

Etiology remained undetermined in 39.6%. Other determined etiology was found in 21.6%, CE in 17.3%, SVO in 12.2%, and LAA in 9.3%. Other determined etiology was more common in females and younger patients, with cervical artery dissection being the single most common etiology (12.8%). CE was more common in younger patients. Within CE, the most frequent high-risk sources were atrial fibrillation/flutter (15.1%) and cardiomyopathy (11.5%). LAA, high-risk sources of CE, and SVO were more common in males. LAA and SVO showed an increasing frequency with age. No significant etiologic distribution differences were found amongst southern, central, or northern Europe.

CONCLUSIONS

The etiology of IS in young adults has clear gender-specific patterns that change with age. A notable portion of these patients remains without an evident stroke mechanism according to TOAST criteria.

Pharmaco-proteomics opportunities for individualizing neurovascular treatment

Neurovascular disease often involves multi-organ system injury. For example, patent foramen ovale (PFO) related ischemic strokes involve not just the brain, but also the heart, the lung, and the peripheral vascular circulation. For higher-risk but high-reward systemic therapy (e.g., thrombolytics, therapeutic hypothermia (TH), PFO closure) to be implemented safely, very careful patient selection and close monitoring of disease progression and therapeutic efficacy are imperative. For example, more than a decade after the approval of therapeutic hypothermic and intravenous thrombolysis treatments, they both remain extremely under-utilized, in part due to lack of clinical tools for patient selection or to follow therapeutic efficacy. Therefore, in understanding the complexity of the global effects of clinical neurovascular diseases and their therapies, a systemic approach may offer a unique perspective and provide tools with clinical utility. Clinical proteomic approaches may be promising to monitor systemic changes in complex multi-organ diseases - especially where the disease process can be 'sampled' in clinically accessible fluids such as blood, urine, and CSF. Here, we describe a 'pharmaco-proteomic' approach to three major challenges in translational neurovascular research directly at bedside - in order to better stratify risk, widen therapeutic windows, and explore novel targets to be validated at the bench - (i) thrombolytic treatment for ischemic stroke, (ii) therapeutic hypothermia for post-cardiac arrest syndrome, and (iii) treatment for PFO related paradoxical embolic stroke. In the future, this clinical proteomics approach may help to improve patient selection, ensure more precise clinical phenotyping for clinical trials, and individualize patient treatment.

Long-term cognitive impairment after first-ever ischemic stroke in young adults

BACKGROUND AND PURPOSE

Up to 14% of all ischemic strokes occur in young adults (<50 years). Poststroke cognitive performance is a decisive determinant of their quality of life. However, virtually no studies report on cognition after young stroke, especially not on the long term. This long-term perspective is important because young patients have a long life expectancy during which they start forming a family, have an active social life, and make decisive career moves. We aimed to evaluate the long-term cognitive outcome.

METHODS

All consecutive patients between January 1, 1980, and November 1, 2010, with a first-ever young ischemic stroke were recruited for cognitive assessment, using a matched stroke-free population as a reference. Composite Z scores for 7 cognitive domains were calculated and the ANCOVA model was used (Bonferroni correction). A below average performance was defined as >1.0 SD below the age-adjusted mean of the controls and cognitive impairment as >1.5 SD.

RESULTS

Two hundred seventy-seven patients and 146 matched controls completed cognitive assessment (mean follow-up, 11.0 years, SD, 8.2; age, 50.9 years, SD, 10.3). Long-term cognitive outcome after an ischemic stroke was worse in most cognitive domains compared with a nonstroke population. Up to 50% of the patients had a below average performance or cognitive impairment. Deficits in processing speed, working memory, and attention were most common.

CONCLUSIONS

Even 11 years after ischemic stroke in young adults, a substantial proportion of patients must cope with permanent cognitive deficits. These results have implications for information given to patients and rehabilitation services.

Age at stroke: temporal trends in stroke incidence in a large, biracial population

OBJECTIVES

We describe temporal trends in stroke incidence stratified by age from our population-based stroke epidemiology study. We hypothesized that stroke incidence in younger adults (age 20-54) increased over time, most notably between 1999 and 2005.

METHODS

The Greater Cincinnati/Northern Kentucky region includes an estimated population of 1.3 million. Strokes were ascertained in the population between July 1, 1993, and June 30, 1994, and in calendar years 1999 and 2005. Age-, race-, and gender-specific incidence rates with 95 confidence intervals were calculated assuming a Poisson distribution. We tested for differences in age trends over time using a mixed-model approach, with appropriate link functions.

RESULTS

The mean age at stroke significantly decreased from 71.2 years in 1993/1994 to 69.2 years in 2005 (p < 0.0001). The proportion of all strokes under age 55 increased from 12.9% in 1993/1994 to 18.6% in 2005. Regression modeling showed a significant change over time (p = 0.002), characterized as a shift to younger strokes in 2005 compared with earlier study periods. Stroke incidence rates in those 20-54 years of age were significantly increased in both black and white patients in 2005 compared to earlier periods.

CONCLUSIONS

We found trends toward increasing stroke incidence at younger ages. This is of great public health significance because strokes in younger patients carry the potential for greater lifetime burden of disability and because some potential contributors identified for this trend are modifiable.