Lifestyle Risk Factors for Ischemic Stroke and Transient Ischemic Attack in Young Adults in the Stroke in Young Fabry Patients Study

The association between smoking and unfavorable outcomes in acute ischemic stroke patients with mechanical thrombectomy

INTRODUCTION

Little is known about the relationship between smoking and clinical outcomes in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT). The outcomes could depend on different stroke subtypes. The aim of this study was to investigate whether smoking affected differently the outcomes in patients with different stroke subtypes who received MT.

METHODS

AIS patients who underwent MT were prospectively enrolled from three hospitals between January 2014 and December 2018. Smokers were defined as current users of cigarettes. The stroke subtypes were classified according to TOAST criteria. Outcome measurements included treatment effects, intracerebral hemorrhage (ICH), and functional outcomes at 3 months. The effects of smoking on outcomes were assessed by logistic regression analysis.

RESULTS

A total of 128 AIS patients with MT were enrolled, including 64 smokers and 64 non-smokers. Logistic regression analysis indicated that smoking was related to higher risk of In-hospital ICH (OR=4.31; 95% CI: 1.10–16.96; p=0.036) in patients with cardioembolism subtype. Furthermore, smoking was also associated with lower rates of mild stroke at discharge (OR=0.07; 95% CI: 0.02–0.31; p<0.001) and functional independence (OR=0.13; 95% CI: 0.03–0.56; p=0.006) in patients with cardioembolism subtype.

CONCLUSIONS

In AIS patients undergoing MT, smoking could be related to a higher risk of In-hospital ICH and lower rates of mild stroke at discharge and functional independence if their stroke subtype is cardioembolism.

Ischaemic stroke in young adults: a global perspective

Ischaemic stroke at young age is an increasing problem in both developing and developed countries due to rising incidence, high morbidity and mortality and long-term psychological, physical and social consequences. Compared with stroke in older adults, stroke in young adults is more heterogeneous due to the wide variety of possible underlying risk factors and aetiologies. In this review, we will provide an overview of the global variation in the epidemiology of stroke in young adults, with special attention to differences in geography, ethnicity/race and sex, as well as traditional and novel risk factors for early-onset ischaemic stroke, such as air pollution. Understanding global differences is an important prerequisite for better region-specific prevention and treatment of this devastating condition.

AMPKα2 Deficiency Does Not Affect the Exercise-Induced Improvements in Glucose Tolerance and Metabolic Disorders in Mice Fed a High-Fat Diet

Exercise can improve obesity and metabolic disorders in mice fed a high-fat diet (HFD), but the role of AMPKα2 in the process remains unclear. The aim of this study was to investigate the role of AMPKα2 in the exercise-induced improvements in glucose tolerance and metabolic turnover in obesity mice. Male wild-type mice (n=12) and AMPKα2 knockout (AMPKα2 KO) mice (n=12) were fed a HFD for 16 wk and were then randomly divided into four groups: WT HFD group (WT HF), AMPKα2 KO HFD group (AMPKα2 KO HF), WT HFD exercise group (WT HE), and AMPK HFD exercise group (AMPKα2 KO HE). The HF groups continue to be fed a HFD from 16 wk to 24 wk, and the HE groups were fed a HFD and performed exercise training. After 8 wk of exercise, all mice were placed in an energy metabolism chamber to test their metabolic turnover, include locomotor activity, food intake, oxygen consumption (VO₂), carbon dioxide production (VCO₂), energy expenditure (EE) and respiratory exchange ratio (RER), over a period of 3 d. Exercise improved glucose tolerance, VO₂, VCO₂ and EE in mice fed a HFD (p<0.05). The VO₂, VCO₂ and EE in AMPKα2 KO HE group were lower than these in WT HE group (p<0.05). Our findings revealed exercise improved glucose tolerance and metabolic disorders in C57 and AMPKα2 KO mice fed a HFD. AMPKα2 is not essential for exercise-induced improvements in glucose tolerance and metabolic disorders.

Risk Factors for Recurrent Arterial Ischemic Stroke in Children and Young Adults

Arterial ischemic stroke (AIS) experienced at a young age is undoubtedly a serious medical problem. AIS very rarely occurs at a developmental age, whereas in young adults, it occurs with a higher frequency. The etiologic mechanisms of AIS occurring in childhood and adulthood differ. However, for both age populations, neurological consequences of AIS, including post-stroke seizures, motor disability, and recurrence of the disease, are connected to many years of care, rehabilitation, and treatment. Recurrent stroke was observed to increase the risk of patients' mortality. One of the confirmed risk factors for recurrent stroke in children is the presence of vasculopathies, especially Moyamoya disease and syndrome, and focal cerebral arteriopathy of childhood (FCA). FCA causes a 5-fold increase in the risk of recurrent stroke in comparison with idiopathic AIS. In turn, young adults with recurrent stroke were found to more often suffer from hypertension, diabetes mellitus, or peripheral artery disease than young patients with first-ever stroke. Some reports also indicate relationships between specific genetic polymorphisms and AIS recurrence in both age groups. The aim of the present literature review was to discuss available data regarding the risk factors for recurrent AIS in children and young adults.

Analysis of young ischemic stroke patients in northeast China

Background

Limited research has been conducted to address stroke etiology in young patients in developing countries. We aimed to analyze risk factors and etiology of ischemic stroke (IS) in young patients of northeast China.

Methods

We retrospectively analyzed ischemic stroke patients aged 15-49 years in a single-center study from January 2013 to December 2017. Demographics and clinical information, including imaging studies, were retrieved for all patients. Patients were first compared according to sex and age. They were then divided into the first-ever and recurrent stroke groups; risk factors and stroke etiology between the two groups were compared.

Results

Of the 956 patients (median age 45 years) included, 78.9% were males. The most frequent risk factors were hypertension (60.0%), dyslipidemia (55.3%), smoking (54.1%), and alcohol consumption (49.6%). The most common etiology of stroke was large-artery atherosclerosis (LAA, 43.7%). In total, 789 patients experienced first-ever stroke and 167 patients experienced recurrent stroke. Recurrent stroke patients more often suffered from hypertension (70.7% versus 57.8%, P=0.002), diabetes (35.3% versus 24.8%, P=0.005), and coronary heart disease (10.2% versus 5.1%, P=0.011), and were less likely to be smokers (44.3% versus 56.1%, P=0.005) and consume alcohol (38.3% versus 52.0%, P=0.001). Recurrent strokes were more frequently caused by LAA (42.1% versus 52.5%, P=0.026) and less often by small-vessel disease (40.9% versus 29.9%, P=0.008).

Conclusions

LAA is the most common etiology in Chinese young stroke patients, especially in those with recurrent stroke. Our data highlight the need of screening of LAA and prevention and management of conventional stroke risk factors in young people of China.

Risk Factors for Early-Onset Ischemic Stroke: A Case-Control Study

Background

Recent studies have shown an increasing prevalence of vascular risk factors in young adults with ischemic stroke (IS). However, the strength of the association between all vascular risk factors and early‐onset IS has not been fully established.

Methods and Results

We compared 961 patients with a first‐ever IS at 25 to 49 years to 1403 frequency‐matched stroke‐free controls from a population‐based cohort study (FINRISK). Assessed risk factors included an active malignancy, atrial fibrillation, cardiovascular disease, current smoking status, a family history of stroke, high low‐density lipoprotein cholesterol, high triglycerides, low high‐density lipoprotein cholesterol, hypertension, and type 1 and type 2 diabetes mellitus. We performed subgroup analyses based on age, sex, and IS etiology. In a fully adjusted multivariable logistic regression analysis, significant risk factors for IS consisted of atrial fibrillation (odds ratio [OR], 10.43; 95% confidence interval [CI], 2.33–46.77], cardiovascular disease (OR, 8.01; 95% CI, 3.09–20.78), type 1 diabetes mellitus (OR, 6.72; 95% CI, 3.15–14.33), type 2 diabetes mellitus (OR, 2.31; 95% CI, 1.35–3.95), low high‐density lipoprotein cholesterol (OR, 1.81; 95% CI, 1.37–2.40), current smoking status (OR, 1.81; 95% CI, 1.50–2.17), hypertension (OR, 1.43; 95% CI, 1.17–1.75), and a family history of stroke (OR, 1.37; 95% CI, 1.04–1.82). High low‐density lipoprotein cholesterol exhibited an inverse association with IS. In the subgroup analyses, the most consistent associations appeared for current smoking status and type 1 diabetes mellitus.

Conclusions

Our study establishes the associations between 11 vascular risk factors and early‐onset IS, among which atrial fibrillation, cardiovascular disease, and both type 1 and 2 diabetes mellitus in particular showed strong associations.

Role of PFO Closure in Ischemic Stroke Prevention

PURPOSE OF REVIEW

To highlight recent advancements in the management of acute ischemic stroke patients with patent foramen ovale (PFO).

RECENT FINDINGS

One significant recent development was publication of long-term follow-up data from the RESPECT trial demonstrating evidence in favor of PFO closure over medical management. This data subsequently led to FDA approval for AMPLATZER™ septal occluder in the treatment of patients aged 18 to 60 years with both PFO and no other determined etiology for ischemic stroke, otherwise referred to as embolic stroke of undetermined source. Several subsequent closure trial results have recently been published, which also demonstrated benefit of PFO closure over medical management for ischemic stroke risk reduction in select patients. Based on the results of the more recently published REDUCE trial, the FDA granted approval for the GORE™ septal occluder. There is current, well-established evidence that PFO closure for secondary stroke prevention is effective in select cases.

Acute phase serum cathepsin S level and cathepsin S/cystatin C ratio are the associated factors with cerebral infarction and their diagnostic value for cerebral infarction

Cathepsin S plays an important role in the pathogenesis of several cardiovascular diseases; however, the relationship between serum cathepsin S and cerebral infarction (CI) is still unknown. This study aimed to investigate the relationship between acute phase serum cathepsin S level and cerebral infarction. A total of 202 stroke patients were enrolled into this study, and were divided into cerebral infarction (n = 140) group and non-cerebral infarction group (non-CI, n = 62). Fifty healthy individuals were recruited as the control group. Serum levels of cathepsin S and cystatin C were measured at days 1, 7, and 14 posthospitalization. Compared to the non-CI group, the CI group had significantly higher rates of hypertension, dyslipidemia, and smoking (all P < 0.05). The CI group had significantly higher cathepsin S levels and cathepsin S to cystatin C ratio (CatS/CysC) at both days 1 and 7 posthospitalization (both P < 0.05). Multivariate logistic regression analysis demonstrated that cathepsin S level (day 7) and CatS/CysC (days 1 and 7) were the associated factors with CI (all P < 0.05). Receiver operating characteristic (ROC) curve analysis revealed that the Area Under Curve (AUC) value of CatS-day7, CatS/CysC-day1, and CatS/CysC-day7 were 0.726 (95% CI: 0.652-0.800, P < 0.001), 0.641 (95% CI: 0.559-0.723, P = 0.001), and 0.721 (95% CI: 0.645-0.797, P = 0.039), respectively. Cathepsin S and CatS/CysC were associated with acute CI, and may have the potential to be the diagnostic biomarkers for CI. Our findings help to better understand the role of serum cathepsin S level in CI.

Prevalence and risk factors of ischaemic stroke in the young: a regional Australian perspective

BACKGROUND

There is no universally accepted age cut-off for defining young strokes.

AIMS

We aimed to determine, based on the profile of young stroke patients in our regional centre, an appropriate age cut-off for young strokes.

METHODS

A retrospective analysis of all ischaemic stroke patients admitted to our centre from 2015 to 2017. We identified 391 ischaemic stroke patients; 30 patients between the ages of ≤50, 40 between 51-60 inclusive and 321 ≥ 61 years of age. We collected data on demographic profiles, risk factors and stroke classification using the Trial of Org 10 172 in Acute Stroke Treatment criteria.

RESULTS

We found significant differences between the ≤50 and ≥61 age groups for most of the risk factors and similarities between the 51-60 inclusive and ≥ 61 age groups. At least one of the six risk factors assessed in the study was present in 86.7% of the youngest group, 97.5% of the intermediate age group and 97.2% in the oldest group. In terms of the mechanisms of stroke, the youngest and oldest age groups in our study differed in the prevalence of cryptogenic, cardioembolic and other causes of stroke. The middle and older age groups had similar mechanisms of stroke.

CONCLUSIONS

The prevalence of vascular risk factors and mechanisms of stroke likewise differed significantly across age groups. This study suggests that 50 years is an appropriate age cut-off for defining young strokes and reinforces the importance of primary prevention in all age groups.

Discover high-risk factor combinations using Bayesian network from cohort data of National Stoke Screening in China

BACKGROUND

In recent years, the increasing incidence and prevalence of stroke has brought a heavy economic burden on families and society in China. The Ministry of Health of the Peoples' Republic of China initiated the national stroke screening and intervention program in 2011 for stroke prevention and control. In the screening, only those who have been classified to "potential high-risk" group in preliminary screening need further examination and physician confirmation to determine the risk level of stroke in rescreening. However, at the beginning of the program, the "potential high-risk" classification method in the preliminary screening are determined by experts based on their experience. The primary aim of this study is to study the causality of stroke and risk factors in middle-aged population using the cohort data, and to explore whether the stroke screening and intervention program should include more precise "potential high-risk" evaluation criteria for this age group in preliminary screening.

METHOD

We use the cohort data of screening between 2013 and 2017 in this study. After data cleaning, the cohort consists of 48,007 people aged from 40 to 59 who are free of stroke at baseline. We use Bayesian networks to develop models.

RESULT

The results show that the stroke incidence in middle-aged population with certain two risk factors is higher than some of that with three factors, which is in keeping with our previous study results. We can take the ratio of the stroke incidence with combinations of risk factors and incidence without any of the risk factors as a variable threshold. By adjusting the threshold, we can get precise stroke preliminary screening criteria to achieve a balance between economy and efficiency.

CONCLUSION

We find that the criteria used in preliminary screening are not reasonable enough. There is a need for national stroke screening and intervention program to further include some more important risk factors or combinations of two risk factors as classification criteria in the preliminary screening. The results of the study can directly guide stroke screening program in China to make the screening more accurate and efficient.

Extended Risk Factors for Stroke Prevention

Stroke causes disability and high mortality, while it can be prevented by increasing public awareness of risk factors. The common known risk factors are hypertension, atrial fibrillation, heart failure, smoking, alcohol consumption, low physical activity, overweight and hypercholesterolemia. However, the deep understanding of risk factors is limited. Moreover, more risk factor emerges in recent years. To further increase the awareness of risk factors for stroke prevention, this review indicates the reasonable application of antihypertensive agents according to the age-dependent changes of hypertension, and some new risk factors including chronic kidney disease, obstructive sleep apnea, migraine with aura, working environment, genetic factors and air pollution. Therefore, internal risk factors (e.g. heredity, hypertension, hyperglycemia) and external risk factors (e.g. working environment, air pollution) are both important for stroke prevention. All of these are reviewed to provide more information for the pre-hospital prevention and management, and the future clinical studies.

Body mass index and fatal stroke in young adults: A national study

Rates of stroke and obesity have increased in recent years. This study aimed to determine the body mass index (BMI) of fatal stroke cases amongst young adults, their clinical characteristics and the association with BMI with risk factors. All cases aged 15-44 years where death was attributed to stroke for whom BMI was available were retrieved from the National Coronial Information System (1/1/2009-31/12/2016). 179 cases were identified: haemorrhagic (165), ischaemic (5), thrombotic (6), mycotic (3), embolic (0). Proportions in each BMI category were: underweight (5.6%), normal weight (37.4%), overweight (27.4%), obese (29.6%). There was a significant linear trend in the proportion of subarachnoid haemorrhages as BMI increased (p < 0.05), and between higher BMI and hypertension (p < 0.001). There were no group differences in cardiomegaly or left ventricular hypertrophy where known causes were other than hypertension, cardiomyopathy, severe coronary artery atherosclerosis, endocarditis or cerebral arteries atherosclerosis. A history of alcoholism (p < 0.01) was less likely with higher BMI. There was no association between BMI and previous stroke, diabetes, vasculitis, gravid/post-partum, tobacco use, psychostimulant use or injecting drug use. Overweight and obese cases were prominent among young fatalities of stroke. Reducing rates of obesity, and associated hypertension, would be expected to reduce the escalating stoke rates among young adults.

Risks associated with the stroke predisposition at young age: facts and hypotheses in light of individualized predictive and preventive approach

Stroke is one of the most devastating pathologies of the early twenty-first century demonstrating 1-month case-fatality rates ranging from 13 to 35% worldwide. Though the majority of cases do occur in individuals at an advanced age, a persistently increasing portion of the patient cohorts is affected early in life. Current studies provide alarming statistics for the incidence of "young" strokes including adolescents. Young stroke is a multifactorial disease involving genetic predisposition but also a number of modifiable factors, the synergic combination of which potentiates the risks. The article analyzes the prevalence and impacts of "traditional" risk factors such as sedentary lifestyle, smoking, abnormal alcohol consumption, drug abuse, overweight, hypertension, abnormal sleep patterns, and usage of hormonal contraceptives, among others. Further, less explored risks such as primary vascular dysregulation and associated symptoms characteristic for Flammer syndrome (FS) are considered, and the relevance of the FS phenotype for the stroke predisposition at young age is hypothesized. Considering the high prevalence of known genetic and modifiable risk factors in the overall predisposition to the young stroke, the risk mitigating measures are recommended including innovative screening programs by application of specialized questionnaires and biomarker panels as well as educational programs adapted to the target audiences such as children, adolescents, and young adults.

Genetic risk, incident stroke, and the benefits of adhering to a healthy lifestyle: cohort study of 306 473 UK Biobank participants

OBJECTIVE

To evaluate the associations of a polygenic risk score and healthy lifestyle with incident stroke.

DESIGN

Prospective population based cohort study.

SETTING

UK Biobank Study, UK.

PARTICIPANTS

306 473 men and women, aged 40-73 years, recruited between 2006 and 2010.

MAIN OUTCOME MEASURE

Hazard ratios for a first stroke, estimated using Cox regression. A polygenic risk score of 90 single nucleotide polymorphisms previously associated with stroke was constructed at P<1×10^-5 to test for an association with incident stroke. Adherence to a healthy lifestyle was determined on the basis of four factors: non-smoker, healthy diet, body mass index <30 kg/m², and regular physical exercise.

RESULTS

During a median follow-up of 7.1 years (2 138 443 person years), 2077 incident strokes (1541 ischaemic stroke, 287 intracerebral haemorrhage, and 249 subarachnoid haemorrhage) were ascertained. The risk of incident stroke was 35% higher among those at high genetic risk (top third of polygenic score) compared with those at low genetic risk (bottom third): hazard ratio 1.35 (95% confidence interval 1.21 to 1.50), P=3.9×10^-8. Unfavourable lifestyle (0 or 1 healthy lifestyle factors) was associated with a 66% increased risk of stroke compared with a favourable lifestyle (3 or 4 healthy lifestyle factors): 1.66 (1.45 to 1.89), P=1.19×10^-13. The association with lifestyle was independent of genetic risk stratums.

CONCLUSION

In this cohort study, genetic and lifestyle factors were independently associated with incident stroke. These results emphasise the benefit of entire populations adhering to a healthy lifestyle, independent of genetic risk.

A Hospital-Based Study of Stroke in Young from North East India

Introduction:

A study of stroke among young adults and children has recently become a subject of interest. This is because it has a major impact on the individual and society. Studies of stroke in young can lead to therapeutical results affecting both short- and long-term outcomes.

Methods:

This paper is based on a hospital-based retrospective study, of stroke in young, for a duration of 1 year.

Results:

The study revealed stroke in young in 31.38% of all strokes, with cerebral infarction in 50.66%, followed by intracerebral hemorrhage in 41.33%, subarachnoid hemorrhage in 4.66%, and cerebral venous thrombosis in 3.33%. The most common presenting symptom was hemiparesis. The most prevalent risk factor for stroke in young was alcohol consumption, followed by traditional risk factors such as hypertension and smoking. Diabetes was detected less in our study.

Conclusion:

Although traditional risk factors are associated with stroke in young, unfavorable behavioral pattern such as alcohol abuse may cause and promote development stroke in young.

Prevalence of Stroke Risk Factors and Their Distribution Based on Stroke Subtypes in Gorgan: A Retrospective Hospital-Based Study-2015-2016

Background

Stroke is a leading cause of death and disability worldwide. According to the Iranian Ministry of Medical Health and Education, out of 100,000 stroke incidents in the country, 25,000 lead to death. Thus, identifying risk factors of stroke can help healthcare providers to establish prevention strategies. This study was conducted to investigate the prevalence of stroke risk factors and their distribution based on stroke subtypes in Sayad Shirazi Hospital, Gorgan, Northeastern Iran.

Material and Methods

A retrospective hospital-based study was conducted at Sayad Shirazi Hospital in Gorgan, the only referral university hospital for stroke patients in Gorgan city. All medical records with a diagnosis of stroke were identified based on the International Classification of Diseases, Revision 10, from August 23, 2015, to August 22, 2016. A valid and reliable data gathering form was used to capture data about demographics, diagnostics, lifestyle, risk factors, and medical history.

Results

Out of 375 cases, two-thirds were marked with ischemic stroke with mean ages (standard deviation) of 66.4 (14.2) for men and 64.6 (14.2) for women. The relationship between stroke subtypes and age groups (P=0.008) and hospital outcome (P=0.0001) was significant. Multiple regression analysis showed that hypertension (Exp. (B) =1.755, P=0.037), diabetes mellitus (Exp. (B) =0.532, P=0.021), and dyslipidemia (Exp. (B) =2.325, P=0.004) significantly increased the risk of ischemic stroke.

Conclusion

Overall, hypertension, diabetes mellitus, and dyslipidemia were the major risk factors of stroke in Gorgan. Establishment of stroke registry (population- or hospital-based) for the province is recommended.

Role of autophagy in a model of obesity: A long‑term high fat diet induces cardiac dysfunction

Obesity may induce end-organ damage through metabolic syndrome, and autophagy serves a vital role in the pathogenesis of metabolic syndrome. The purpose of the present study was to define the roles of autophagy and mitophagy in high fat diet (HFD)-induced cardiomyopathy. Male, 8 week-old C57BL/6 mice were fed either a HFD (60% kcal) or a diet of normal chow (NC; 10% kcal) for 42 weeks. Glucose tolerance tests were performed during the feeding regimes. Blood samples were collected for assaying serum triglyceride with the glycerol-3-phosphate oxidase phenol and aminophenazone (PAP) method and total cholesterol was tested with the cholesterol oxidase-PAP method. Myocardial function was assessed using echocardiography and hemodynamic analyses. Western blot analysis was employed to evaluate endoplasmic reticulum stress (ERS), autophagy and mitochondrial function. Electron microscopy was used to assess the number of lipid droplets and the degree of autophagy within the myocardium. The body weight and adipose tissue weight of mice fed the HFD were increased compared with the NC mice. The serum levels of blood glucose, total cholesterol and triglyceride were significantly increased following 42 weeks of HFD feeding. The results of the glucose tolerance tests additionally demonstrated metabolic dysregulation in HFD mice. In addition, HFD mice exhibited hemodynamic and echocardiographic evidence of impaired diastolic and systolic function, including alterations in the cardiac output, end-diastolic pressure, end-diastolic volume and left ventricular relaxation time constant (tau) following HFD intake. Furthermore, a HFD resulted in increased ERS, and a downregulation of the autophagy and mitophagy level. The present study investigated cardiac function in obese HFD-fed mice. These results aid the pursuit of novel therapeutic targets to combat obesity-associated cardiomyopathy.

Aerobic Exercise Increases Meteorin-Like Protein in Muscle and Adipose Tissue of Chronic High-Fat Diet-Induced Obese Mice

Upregulated meteorin-like (Metrnl) protein in peripheral tissues because of exercise-induced increases in intramuscular Metrnl may effectively alleviate obesity by improving metabolism in whole-body tissues. The objective was to analyse the effects of regular treadmill exercise on Metrnl levels in muscle and peripheral tissues of chronic high-fat diet- (HFD-) induced obese mice. Forty-eight-week-old male C57BL/6 mice were first divided equally into normal-diet (CO) and high-fat diet (HF) groups. Following 16 weeks of a HFD, each group was again split equally into control (CO, HF) and training groups (COT, HFT). The HFT group expressed significantly higher phospho-AMP-activated protein kinase (AMPK), AMPK activity, and peroxisome proliferator-activated receptor gamma coactivator-1α (PGC-1α) in muscle tissue than the HF group (p < 0.05). Similar to muscle energy sensing network protein levels, the HFT group also expressed significantly higher muscle, plasma, and adipose tissue Metrnl (p < 0.05). Moreover, regular exercise increased acyl-CoA oxidase 1 (ACOX-1) and monoglyceride lipase (MGL) expression in adipose tissue (p < 0.05) and significantly decreased abdominal fat mass (p < 0.05). This study suggests that exercise-induced muscle Metrnl effectively reduces fat accumulation through the increase of Metrnl in adipose tissue, which may be a therapeutic target for chronic obesity.

Smoking and Risk of Ischemic Stroke in Young Men

BACKGROUND AND PURPOSE

There is a strong dose-response relationship between smoking and risk of ischemic stroke in young women, but there are few data examining this association in young men. We examined the dose-response relationship between the quantity of cigarettes smoked and the odds of developing an ischemic stroke in men under age 50 years.

METHODS

The Stroke Prevention in Young Men Study is a population-based case-control study of risk factors for ischemic stroke in men ages 15 to 49 years. The χ² test was used to test categorical comparisons. Logistic regression models were used to calculate the odds ratio for ischemic stroke occurrence comparing current and former smokers to never smokers. In the first model, we adjusted solely for age. In the second model, we adjusted for potential confounding factors, including age, race, education, hypertension, myocardial infarction, angina, diabetes mellitus, and body mass index.

RESULTS

The study population consisted of 615 cases and 530 controls. The odds ratio for the current smoking group compared with never smokers was 1.88. Furthermore, when the current smoking group was stratified by number of cigarettes smoked, there was a dose-response relationship for the odds ratio, ranging from 1.46 for those smoking <11 cigarettes per day to 5.66 for those smoking 40+ cigarettes per day.

CONCLUSIONS

We found a strong dose-response relationship between the number of cigarettes smoked daily and ischemic stroke among young men. Although complete smoking cessation is the goal, even smoking fewer cigarettes may reduce the risk of ischemic stroke in young men.

Insulin resistance in ischemic stroke

Insulin resistance often refers to a pathological condition in which cells fail to respond to the normal actions of insulin. Increasing literature has noted a critical role of insulin resistance in the pathogenesis of ischemic stroke. Insulin resistance plays an important role in the pathogenesis of ischemic stroke via enhancing advanced changes of atherosclerosis. A variety of literature indicates that insulin resistance enhances platelet adhesion, activation and aggregation which are conducive to the occurrence of ischemic stroke. Insulin resistance also induces hemodynamic disturbances and contributes to the onset of ischemic stroke. In addition, insulin resistance may augment the role of the modifiable risk factors in ischemic stroke and induce the occurrence of ischemic stroke. Preclinical and clinical studies have supported that improving insulin resistance may be an effective measure to prevent or delay ischemic stroke.

Characteristics and Outcomes of Young Patients with First-Ever Ischemic Stroke Compared to Older Patients: The National Acute Stroke ISraeli Registry

Background

Nationwide data on the clinical profile and outcomes of ischemic stroke in younger adults are still scarce. Our aim was to analyze clinical characteristics and outcomes of young patients with first-ever ischemic stroke compared to older patients.

Methods

The National Acute Stroke ISraeli registry is a nationwide prospective hospital-based study performed triennially. Younger adults, aged 50 years and younger, were compared with patients, aged 51–84 years regarding risk factors, clinical presentation, stroke severity, stroke etiology, and outcomes. A logistic model for stroke outcome was fitted for each age group.

Results

336 first-ever ischemic strokes were identified among patients aged 50 years and younger and 3,243 among patients 51–84 years. Younger adults had lower rates of traditional vascular risk factors, but 82.7% had at least one of these risk factors. Younger adults were more likely to be male (62.8%), current smokers (47.3%), and to have a family history of stroke (7.4%). They tended to have less common stroke presentation such as sensory disturbances or headache and were more likely to arrive at the hospital independently by car. The majority of young adults (70%) had a favorable outcome (modified Ranking Scale; mRS ≤ 1) at discharge, but 11.7% had poor outcome (mRS > 3) and 18.2% had an in-hospital complication. According to a multivariable regression model, in young adults, only baseline stroke severity (National Institute of Health Stroke Scale > 5) was associated with poor outcome at discharge (p < 0.001), whereas in older adults, stroke severity (p < 0.001), female gender (OR = 1.35, CI 95% 1.03–1.76), older age (OR = 1.08, CI 95% 1.01–1.16), atrial fibrillation (OR = 1.62, CI 95% 1.16–2.26), and anterior circulation territory (OR = 2.10, CI 95% 1.50–2.94) were all significantly associated with poor outcome.

Conclusion

Our findings, in this nationwide registry, demonstrate the relatively high rate of smoking and family history of stroke, and the lower rate of hospital arrival by ambulance among young adults. This calls for increasing awareness to the possibility of stroke among young adults and for better prevention, especially smoking cessation.

Dolichoectasia and Small Vessel Disease in Young Patients With Transient Ischemic Attack and Stroke

BACKGROUND AND PURPOSE

We evaluated whether basilar dolichoectasia is associated with markers of cerebral small vessel disease in younger transient ischemic attack and ischemic stroke patients.

METHODS

We used data from the SIFAP1 study (Stroke in Young Fabry Patients), a large prospective, hospital-based, screening study for Fabry disease in young (<55 years) transient ischemic attack/stroke patients in whom detailed clinical data and brain MRI were obtained, and stroke subtyping with TOAST classification (Trial of ORG 10172 in Acute Stroke Treatment) was performed.

RESULTS

Dolichoectasia was found in 508 of 3850 (13.2%) of patients. Dolichoectasia was associated with older age (odds ratio per decade, 1.26; 95% confidence interval, 1.09-1.44), male sex (odds ratio, 1.96; 95% confidence interval, 1.59-2.42), and hypertension (odds ratio, 1.39; 95% confidence interval, 1.13-1.70). Dolichoectasia was more common in patients with small infarctions (33.9% versus 29.8% for acute lesions, P=0.065; 29.1% versus 16.5% for old lesions, P<0.001), infarct location in the brain stem (12.4% versus 6.9%, P<0.001), and in white matter (27.8% versus 21.1%, P=0.001). Microbleeds (16.3% versus 4.7%, P=0.001), higher grades of white matter hyperintensities (P<0.001), and small vessel disease subtype (18.1% versus 12.4%, overall P for differences in TOAST (P=0.018) were more often present in patients with dolichoectasia.

CONCLUSIONS

Dolichoectasia is associated with imaging markers of small vessel disease and brain stem localization of acute and old infarcts in younger patients with transient ischemic attack and ischemic stroke.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00414583.

Previously undiagnosed risk factors and medication nonadherence are prevalent in young adults with first-ever stroke

PURPOSE

The incidence of stroke and prevalence of traditional vascular risk factors (VRFs) in young adults (age < 55 y) are both increasing. Young patients tend to be unaware of their VRFs and to have lower medication adherence. We examined how age affects the prevalence of previously undiagnosed VRFs and the extent of medication nonadherence among stroke patients.

METHODS

Using Taiwan's National Health Insurance Research Database, we identified consecutive adult patients with first-ever stroke between 2000 and 2013. Diagnosis of hypertension, diabetes, and hyperlipidemia was ascertained using validated methods. We investigated (1) the proportion of patients who had undiagnosed VRFs within 3 years before stroke and (2) the proportion of nonadherence to medications among patients who had a previously diagnosed VRF.

RESULTS

Among stroke patients with hypertension (n = 9722), diabetes (n = 4751), and hyperlipidemia (n = 4486), 24.9%, 20.8%, and 55.0%, respectively, had not been diagnosed before stroke, whereas 56.0%, 66.7%, and 32.5%, respectively, had been diagnosed at least 1 year before stroke. The proportions of medication nonadherence were 71.5%, 64.3%, and 88.4% in patients with previously diagnosed hypertension, diabetes, and hyperlipidemia, respectively. In multivariate analysis, younger age was independently associated with undiagnosed hypertension before stroke as well as medication nonadherence in patients with previously diagnosed hypertension or diabetes.

CONCLUSIONS

Previously undiagnosed hypertension and nonadherence to treatment of hypertension and diabetes were more prevalent in young adult patients with first-ever stroke in Taiwan. Interventions targeting young people to promote early detection and adequate control of VRFs should be encouraged.

Risk Factors and Etiology of Young Ischemic Stroke Patients in Estonia

Objectives

Reports on young patients with ischemic stroke from Eastern Europe have been scarce. This study aimed to assess risk factors and etiology of first-ever and recurrent stroke among young Estonian patients.

Methods

We performed a retrospective study of consecutive ischemic stroke patients aged 18–54 years who were treated in our two hospitals from 2003 to 2012.

Results

We identified 741 patients with first-ever stroke and 96 patients with recurrent stroke. Among first-time patients, men predominated in all age groups. The prevalence of well-documented risk factors in first-time stroke patients was 83% and in the recurrent group 91%. The most frequent risk factors were hypertension (53%), dyslipidemia (46%), and smoking (35%). Recurrent stroke patients had fewer less well-documented risk factors compared to first-time stroke patients (19.8 versus 30.0%, P = 0.036). Atrial fibrillation was the most common cause of cardioembolic strokes (48%) and large-artery atherosclerosis (LAA) was the cause in 8% among those aged <35 years. Compared to first-time strokes, recurrent ones were more frequently caused by LAA (14.3 versus 24.0%, P = 0.01) and less often by other definite etiology (8.5 versus 1.0%, P = 0.01).

Conclusions

The prevalence of vascular risk factors among Estonian young stroke patients is high. Premature atherosclerosis is a cause in a substantial part of very young stroke patients.

Contribution of Established Stroke Risk Factors to the Burden of Stroke in Young Adults

BACKGROUND AND PURPOSE

As stroke in young adults is assumed to have different etiologies and risk factors than in older populations, the aim of this study was to examine the contribution of established potentially modifiable cardiovascular risk factors to the burden of stroke in young adults.

METHODS

A German nationwide case-control study based on patients enrolled in the SIFAP1 study (Stroke In Young Fabry Patients) 2007 to 2010 and controls from the population-based GEDA study (German Health Update) 2009 to 2010 was performed. Cases were 2125 consecutive patients aged 18 to 55 years with acute first-ever stroke from 26 clinical stroke centers; controls (age- and sex-matched, n=8500, without previous stroke) were from a nationwide community sample. Adjusted population-attributable risks of 8 risk factors (hypertension, hyperlipidemia, diabetes mellitus, coronary heart disease, smoking, heavy episodic alcohol consumption, low physical activity, and obesity) and their combinations for all stroke, ischemic stroke, and primary intracerebral hemorrhage were calculated.

RESULTS

Low physical activity and hypertension were the most important risk factors, accounting for 59.7% (95% confidence interval, 56.3-63.2) and 27.1% (95% confidence interval, 23.6-30.6) of all strokes, respectively. All 8 risk factors combined explained 78.9% (95% confidence interval, 76.3-81.4) of all strokes. Population-attributable risks of all risk factors were similar for all ischemic stroke subtypes. Population-attributable risks of most risk factors were higher in older age groups and in men.

CONCLUSIONS

Modifiable risk factors previously established in older populations also account for a large part of stroke in younger adults, with 4 risk factors explaining almost 80% of stroke risk.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00414583.

Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Triggers, Causes, and Outcome (SECRETO): Rationale and design

BACKGROUND

Worldwide, about 1.3 million annual ischaemic strokes (IS) occur in adults aged <50 years. Of these early-onset strokes, up to 50% can be regarded as cryptogenic or associated with conditions with poorly documented causality like patent foramen ovale and coagulopathies.

KEY HYPOTHESES/AIMS

(1) Investigate transient triggers and clinical/sub-clinical chronic risk factors associated with cryptogenic IS in the young; (2) use cardiac imaging methods exceeding state-of-the-art to reveal novel sources for embolism; (3) search for covert thrombosis and haemostasis abnormalities; (4) discover new disease pathways using next-generation sequencing and RNA gene expression studies; (5) determine patient prognosis by use of phenotypic and genetic data; and (6) adapt systems medicine approach to investigate complex risk-factor interactions.

DESIGN

Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO; NCT01934725) is a prospective multi-centre case-control study enrolling patients aged 18-49 years hospitalised due to first-ever imaging-proven IS of undetermined etiology. Patients are examined according to a standardised protocol and followed up for 10 years. Patients are 1:1 age- and sex-matched to stroke-free controls. Key study elements include centralised reading of echocardiography, electrocardiography, and neurovascular imaging, as well as blood samples for genetic, gene-expression, thrombosis and haemostasis and biomarker analysis. We aim to have 600 patient-control pairs enrolled by the end of 2018.

SUMMARY

SECRETO is aiming to establish novel mechanisms and prognosis of cryptogenic IS in the young and will provide new directions for therapy development for these patients. First results are anticipated in 2019.

Age-Specific Vascular Risk Factor Profiles According to Stroke Subtype

BACKGROUND

Ischemic and hemorrhagic stroke are increasingly recognized as heterogeneous diseases with distinct subtypes and etiologies. Information on variation in distribution of vascular risk factors according to age in stroke subtypes is limited. We investigated the prevalence of vascular risk factors in stroke subtypes in relation to age.

METHODS AND RESULTS

We studied a prospective multicenter university hospital-based cohort of 4033 patients. For patients with ischemic stroke caused by large artery atherosclerosis, small vessel disease, or cardioembolism and for patients with spontaneous intracerebral hemorrhage or aneurysmal subarachnoid hemorrhage, we calculated prevalences of vascular risk factors in 4 age groups: <55, 55 to 65, 65 to 75, and ≥75 years, and mean differences with 95% CIs in relation to the reference age group. Patients aged <55 years were significantly more often of non-white origin (in particular in spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage patients) and most often smoked (most prominent for aneurysmal subarachnoid hemorrhage patients). Patients aged <55 years with ischemic stroke caused by large artery atherosclerosis or small vessel disease more often had hypertension, hyperlipidemia, and diabetes mellitus than patients with ischemic stroke of cardiac origin. Overall, the frequency of hypertension, hyperlipidemia, and diabetes mellitus increased with age among all stroke subtypes, whereas smoking decreased with age. Regardless of age, accumulation of potentially modifiable risk factors was most pronounced in patients with ischemic stroke caused by large artery atherosclerosis or small vessel disease.

CONCLUSIONS

The prevalence of common cardiovascular risk factors shows different age-specific patterns among various stroke subtypes. Recognition of these patterns may guide tailored stroke prevention efforts aimed at specific risk groups.

Arterial Ischemic Stroke in Children and Young Adults

PURPOSE OF REVIEW

This article reviews risk factors, recurrence risk, evaluation, management, and outcomes of arterial ischemic stroke in children and young adults.

RECENT FINDINGS

The risk for recurrence and mortality appear to be low for neonatal and childhood stroke. Most children have relatively mild deficits, but those who have greater neurologic deficits, poststroke epilepsy, or strokes early in life are at risk for lower overall cognitive function. Stroke recurrence and long-term mortality after stroke in young adults are greater than originally thought. Cognitive impairments, depression, and anxiety are associated with higher levels of poststroke unemployment and represent targets for improved poststroke care. Poststroke care in young adults involves more than medical management. Self-reported memory and executive function impairments may be more severe than what is detected by objective measures. Assessment of possible cognitive impairments and appropriate management of psychological comorbidities are key to maximizing the long-term functional outcome of stroke survivors.

SUMMARY

Childhood and young adult stroke survivors survive for many more years than older patients with stroke. To ensure that these survivors maximize the productivity of their lives, neurologists must not only optimize medical management but also recognize that impairments in cognition and mood may be remediable barriers to long-term functional independence.

Association of eNOS and Cav-1 gene polymorphisms with susceptibility risk of large artery atherosclerotic stroke

Endothelial nitric oxide synthase (eNOS) is localized in caveole and has important effects on caveolar coordination through its interaction with caveolin-1 (Cav-1), which supports normal functioning of vascular endothelial cells. However, the relationship between genotypic polymorphisms of e-NOS and Cav-1 genes and ischemic stroke (IS) remains lesser reported. This hospital-based case-control study aimed to determine the genetic polymorphisms of the eNOS (Glu298Asp) and Cav-1 (G14713A and T29107A) genes in association with susceptibility risk in patients who had suffered from a large artery atherosclerotic (LAA) stroke. Genotyping determination for these variant alleles was performed using the TaqMan assay. The distributions of observed allelic and genotypic frequencies for the polymorphisms were in Hardy-Weinberg equilibrium in healthy controls. The risk for an LAA stroke in the Asp298 variant was 1.72 (95% CI = 1.09–2.75) versus Glu298 of the eNOS. In the GA/AA (rs3807987) variant, it was 1.79 (95% CI = 1.16–2.74) versus GG and in TA/AA (rs7804372) was 1.61 (95% CI = 1.06–2.43) versus TT of the Cav-1, respectively. A tendency toward an increased LAA stroke risk was significant in carriers with the eNOS Glu298Asp variant in conjunction with the G14713 A and T29107A polymorphisms of the Cav-1 (aOR = 2.03, P-_trend = 0.002). A synergistic effect between eNOS and Cav-1 polymorphisms on IS risk elevation was significantly influenced by alcohol drinking, heavy cigarette smoking (P-_trend<0.01), and hypercholesterolemia (P-_trend < 0.001). In conclusion, genotypic polymorphisms of the eNOS Glu298Asp and Cav-1 14713A/29107A polymorphisms are associated with the elevated risk of LAA stroke among Han Chinese in Taiwan.

Age-related small vessel disease: a potential contributor to neurodegeneration in multiple sclerosis

Multiple sclerosis (MS) is a chronic inflammatory demyelinating disorder of the central nervous system wherein, after an initial phase of transient neurological defects, slow neurological deterioration due to progressive neuronal loss ensues. Age is a major determinant of MS progression onset and disability. Over the past years, several mechanisms have been proposed to explain the key drivers of neurodegeneration and disability accumulation in MS. However, the effect of commonly encountered age-related cerebral vessel disease, namely small vessel disease (SVD), has been largely neglected and constitutes the aim of this review. SVD shares some features with MS, that is, white matter demyelination and brain atrophy, and has been shown to contribute to the neuronal damage seen in vascular cognitive impairment. Several lines of evidence suggest that an interaction between MS and SVD may influence MS-related neurodegeneration. SVD may contribute to hypoperfusion, reduced vascular reactivity and tissue hypoxia, features seen in MS. Venule and endothelium abnormalities have been documented in MS but the role of arterioles and of other neurovascular unit structures, such as the pericyte, has not been explored. Vascular risk factors (VRF) have recently been associated with faster progression in MS, though the mechanisms are unclear since very few studies have addressed the impact of VRF and SVD on MS imaging and pathology outcomes. Therapeutic agents targeting the microvasculature and the neurovascular unit may impact both SVD and MS and may benefit patients with dual pathology.

Stroke and Hypertension in Children and Adolescents

Hypertension is the single most important modifiable risk factor for adult stroke. Stroke mortality has significantly decreased over the last 5 decades; this decline has been mainly associated to improved blood pressure control. Though much less prevalent than in adults, stroke is an increasingly recognized cause of morbidity and mortality in children. Although hypertension has not been strongly identified as a risk factor in childhood stroke yet, there is preliminary evidence that suggests that elevated blood pressure may be associated with stroke in children. This review summarizes the literature that may link elevated blood pressure to the development of childhood ischemic and hemorrhagic stroke. The authors suggest that elevated blood pressure may be a significant risk factor that, alone or in combination with other multiple risk factors, leads to the development of stroke in childhood. It is therefore recommend that blood pressure be measured and assessed carefully in every child presenting with acute stroke.

[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.

Posterior versus Anterior Circulation Stroke in Young Adults: A Comparative Study of Stroke Aetiologies and Risk Factors in Stroke among Young Fabry Patients (sifap1)

BACKGROUND

Although 20-30% of all strokes occur in the posterior circulation, few studies have explored the characteristics of patients with strokes in the posterior compared to the anterior circulation so far. Especially data on young patients is missing.

METHODS

In this secondary analysis of data of the prospective multi-centre European sifap1 study that investigated stroke and transient ischemic attack (TIA) patients aged 18-55 years, we compared vascular risk factors, stroke aetiology, presence of white matter hyperintensities (WMH) and cerebral microbleeds (CMB) between patients with ischaemic posterior circulation stroke (PCS) and those having suffered from anterior circulation stroke (ACS) based on cerebral MRI.

RESULTS

We diagnosed PCS in 612 patients (29.1%, 407 men, 205 women) and ACS in 1,489 patients (70.9%). Their age (median 46 vs. 47 years, p = 0.205) and stroke severity (modified Rankin Scale: both 2, p = 0.375, Barthel Index 90 vs. 85, p = 0.412) were similar. PCS was found to be more frequent among the male gender (66.5 vs. 60.1% with ACS, p = 0.003). Vertebral artery (VA) dissection was more often the cause of PCS (16.8%) than was carotid artery dissection of ACS (7.9%, p < 0.001). Likewise, small vessel disease (Trial of Org 10172 in Acute Stroke Treatment [TOAST] = 3, PCS: 14.7%, ACS: 11.8%) and stroke of other determined aetiology (TOAST = 4, PCS: 24.5%, ACS: 16.0%) were more frequent in those with PCS. Furthermore, patent foramen ovale (PFO; PCS: 31.1%, ACS: 25.4%, p = 0.029) was more often detected in patients with PCS. In contrast, large-artery atherosclerosis (TOAST = 1, PCS: 15.4%, ACS: 22.2%) and cardio-embolic stroke (TOAST = 2, PCS: 15.6%, ACS: 18.0%) were less frequent in those with PCS (p < 0.001) as were preceding cerebrovascular events (10.1 vs. 14.1%, p = 0.014), TIA (4.8 vs. 7.7%, p = 0.016) and smoking (53.2 vs. 61.0%, p = 0.001). The presence, extent, and location of WMH and CMB did not differ between the 2 groups.

CONCLUSIONS

Our data suggested a different pattern of aetiology and risk factors in young patients with PCS compared to those with ACS. These findings especially call for a higher awareness of VA dissection and potentially for more weight of a PFO as a risk factor in young patients with PCS. Clinical trial registration-URL: http://www.clinicaltrials.gov; NCT00414583.

Modeling of in hospital mortality determinants in myocardial infarction patients, with and without stroke: A national study in Iran

Background:

The data and determinants of mortality due to stroke in myocardial infarction (MI) patients are unknown. This study was conducted to evaluate the differences in risk factors for hospital mortality among MI patients with and without stroke history.

Materials and Methods:

This study was a retrospective, cohort study; 20,750 new patients with MI from April, 2012 to March, 2013 were followed up and their data were analyzed according to having or not having the stroke history. Stroke and MI were defined based on the World Health Organization's definition. The data were analyzed by logistic regression in STATA software.

Results:

Of the 20,750 studied patients, 4293 had stroke history. The prevalence of stroke in the studied population was derived 20.96% (confidence interval [CI] 95%: 20.13–21.24). Of the patients, 2537 (59.1%) had ST-elevation MI (STEMI). Mortality ratio in patients with and without stroke was obtained 18.8% and 10.3%, respectively. The prevalence of risk factors in MI patients with and without a stroke is various. The adjusted odds ratio of mortality in patients with stroke history was derived 7.02 (95% CI: 5.42–9) for chest pain resistant to treatment, 2.39 (95% CI: 1.97–2.9) for STEMI, 3.02 (95% CI: 2.5–3.64) for lack of thrombolytic therapy, 2.2 (95% CI: 1.66–2.91) for heart failure, and 2.17 (95% CI: 1.6–2.9) for ventricular tachycardia.

Conclusion:

With regards to the factors associated with mortality in this study, it is particularly necessary to control the mortality in MI patients with stroke history. More emphasis should be placed on the MI patients with the previous stroke over those without in the interventions developed for prevention and treatment, and for the prevention of avoidable mortalities.

Incidence and Risk Factors for Stroke Among 14 European Countries

Background This study compared the risk factors for and incidence of stroke among 14 European countries by using the Survey of Health, Aging, and Retirement in Europe (SHARE). Methods The analysis was based on data collected during 2006 to 2007 from Wave 2 of SHARE and panel data from respondents interviewed during 2004 to 2005. Results and Conclusion The highest stroke incidence rates were found in Denmark, Poland, and Sweden; these incidence rates were more than double that of Spain. Stroke was mostly associated with elderly people (age, ≥65 years) in Sweden, France, Switzerland, the Czech Republic, and Greece. In addition, stroke incidence was high among young males (age, <65 years) in Italy and elderly males in Germany and Switzerland. A negative association was found between stroke and vigorous exercise for younger people in Sweden and elderly people in Poland, whereas moderate exercise was significantly associated with stroke only for elderly Belgians, Greeks, and Irish.

The effects of Risk Factor-Targeted Lifestyle Counselling Intervention on working-age stroke patients' adherence to lifestyle change

INTRODUCTION

Since a history of stroke or transient ischaemic attack is a major risk factor for a recurrent event, lifestyle counselling during the hospital phase is an essential component of treatment and may increase the probability of lifestyle change.

AIMS AND OBJECTIVES

To study the effect of risk factor-targeted lifestyle counselling intervention on working-age stroke patients' adherence to lifestyle changes.

DESIGN

A quasi-experimental, nonequivalent control group pretest-post-test design.

METHODS

Stroke patients in an acute neurological unit were divided into a control group (n = 75) receiving standard counselling and an experimental group (n = 75) receiving risk factor-targeted counselling. Lifestyle data and clinical outcomes were collected at hospital between January 2010 and October 2011, while data on adherence to lifestyle changes 3, 6, and 12 months after discharge.

RESULTS

The baseline lifestyle habits did not differ significantly other than in alcohol behaviour. Both groups increased their intake, but the intervention group to a lesser degree. However, the experimental group significantly lost their weight for the first 3 and 6 months; at 3 months reduction in cigarette consumption and at 6 months significant increases in smoking cessation were also achieved. All improved some of their lifestyle habits. Intervention was associated with support from nurses as well as from family and friends. Adherence scores were higher in the experimental group.

CONCLUSION

Some short-term advantages in lifestyle habits due to the intervention were noted. Participants in both groups improved some of their lifestyle habits.

Young ischemic stroke in Tunisia: a multicentric study

PURPOSE

There is wanting data regarding young ischemic stroke in developing countries, especially in Tunisia. The purpose of this study was to investigate risk factors and etiologies of young ischemic stroke in Tunisian and make a comparison with previous reports.

MATERIALS AND METHODS

A total of 102 young ischemic stroke patients (15-45 years old) were admitted, between January 1996 and August 2007, to 11 departments of internal medicine in different Tunisian hospitals. The risk factors for stroke were documented and assessed. Diagnosis workup consisted of anamnesis, complete physical examination and extensive laboratory, radiologic, immunologic, neurologic and cardiologic examination. Stroke etiologies were classified according the Trial of ORG 10172 in acute stroke treatment.

RESULTS

There were 42 men (41.2%) and 60 women (58.89%) with a mean age at onset of 35.7 years. As regards stroke subtype, large-artery atherosclerosis was diagnosed in 6.9% of cases, cardioembolism in 11.8%, small-vessel occlusion in 8.8%, other determined etiology in 37.3% and undetermined etiology in 35.3%. Concerning the traditional risk factors, smoking (31.4%), hypertension and diabetes mellitus (12.7% for each one) and a family history of stroke (10.8%) were the most common. The mean follow-up period was 30.5 months.

CONCLUSIONS

In our study, traditional risk factors were not-so-uncommon in young adults with ischemic stroke suggesting that prevention can go through controlling these factors. Stroke of other determined etiology was the most common among our patients, so that a broad and detailed diagnostic workup is crucial to puzzle out the etiology for more and better stroke prevention.

Stroke in young adults: Incidence rate, risk factors, treatment and prognosis

OBJECTIVES

To analyse the incidence, risk factors, aetiology, treatment and clinical evolution of young patients with stroke.

PATIENTS AND METHODS

Retrospective registry of patients aged 55 years or younger hospitalised in a stroke unit during 2014. We recorded the incidence rate for all strokes and analysed demographic data, risk factors, degree of stress, stroke type and aetiology, reperfusion treatments and clinical evolution.

RESULTS

The study included 110 patients, the majority of whom were men (60.9%, 1.6:1 ratio). The incidence rate was 13.3% (110 of 830 strokes). Most of the patients had cardiovascular risk factors. Smoking was the most common risk factor (56.4%), followed by arterial hypertension (50%), dyslipidaemia (42.7%), obesity (33%), diabetes (18.2%) and emboligenic heart disease (12.7%). Some 64.3% of the heart disease cases and 51.1% of the dyslipidaemia cases were discovered during hospitalisation. Some 57.2% of the patients experienced psychosocial stress in the stage prior to the stroke. Some 83.6% of the stroke cases were ischaemic, 12.7% were haemorrhagic and 3.6% were venous sinus thrombosis. Of the ischaemic stroke cases, 30.4% were cryptogenic, 23.9% were lacunar, 16.3% were from uncommon causes, 15.2% were atherothrombotic and 14.1% were cardioembolic. Some 78.6% of the cerebral haemorrhage cases were hypertensive. Some 23.3% of the ischaemic stroke cases underwent reperfusion treatments in the acute phase, achieving levels of functional independence at 3 months of 62.5%.

CONCLUSIONS

The majority of stroke events in patients 55 years of age or younger appear to be related to a high prevalence of classical cardiovascular risk factors and possibly to psychosocial stress.

Age dependency of ischaemic stroke subtypes and vascular risk factors in western Norway: the Bergen Norwegian Stroke Cooperation Study

OBJECTIVES

Age dependency of acute ischaemic stroke aetiology and vascular risk factors have not been adequately evaluated in stroke patients in Norway. Aims of this study were to evaluate how stroke subtypes and vascular risk factors vary with age in a western Norway stroke population.

MATERIALS AND METHODS

Patients aged 15-100 years consecutively admitted to our neurovascular centre with acute ischaemic stroke between 2006 and 2012 were included. The study population was categorized as young (15-49 years), middle-aged (50-74 years) or elderly (≥ 75 years). Stroke aetiology was defined by TOAST criteria. Risk factors and history of cardiovascular disease were recorded.

RESULTS

In total, 2484 patients with acute cerebral infarction were included: 1418 were males (57.3%). Mean age was 70.8 years (SD ± 14.9), 228 patients were young, 1126 middle-aged, and 1130 were elderly. The proportion of large-artery atherosclerosis and of small-vessel occlusion was highest among middle-aged patients. The proportion of cardioembolism was high at all ages, especially among the elderly. The proportion of stroke of other determined cause was highest among young patients. Some risk factors (diabetes mellitus, active smoking, angina pectoris, prior stroke and peripheral artery disease) decreased among the elderly. The proportions of several potential causes increased with age.

CONCLUSION

The proportion of stroke subtypes and vascular risk factors are age dependent. Age 50-74 years constitutes the period in life where cardiovascular risk factors become manifest and stroke subtypes change.

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.

Distribution of ischemic infarction and stenosis of intra- and extracranial arteries in young Chinese patients with ischemic stroke

Background

The distribution of cerebral ischemic infarction and stenosis in ischemic stroke may vary with age-group, race and gender. This study was conducted to understand the risk factors and characteristics of cerebral infarction and stenosis of vessels in young Chinese patients with ischemic stroke.

Methods

This was a retrospective study, from January 2007 to July 2012, of 123 patients ≤50 years diagnosed with acute ischemic stroke. Patient characteristics were compared according to sex (98 males and 25 females) and age group (51 patients were ≤45 years and 72 patients were 46–50 years). Characteristics of acute ischemic infarction were studied by diffusion weighted imaging. Stenosis of intra- and extracranial arteries was diagnosed by duplex sonography, head magnetic resonance angiography (MRA) or cervical MRA.

Results

Common risk factors were hypertension (72.4 %), dyslipidemia (55.3 %), smoking (54.4 %) and diabetes (33.3 %). Lacunar Infarction was most common in our patients (41.5 %). Partial anterior circulation infarction was predominant in females (52.0 vs 32.7 %; P = 0.073) and posterior circulation infarction in males (19.8 vs 4 %; P = 0.073). Multiple brain infarctions were found in 38 patients (30.9 %). Small artery atherosclerosis was found in 54 patients (43.9 %), with higher prevalence in patients of the 46–50 years age-group. Intracranial stenosis was more common than extracranial stenosis, and middle cerebral artery stenosis was most prevalent (27.3 %). Stenosis in the anterior circulation was more frequent than in the posterior circulation (P < 0.001).

Conclusions

In these young patients, hypertension, smoking, dyslipidemia and diabetes were common risk factors. Intracranial stenosis was most common. The middle cerebral artery was highly vulnerable.

Intravenous Thrombolysis is Effective in Young Adults: Results from the Baden-Wuerttemberg Stroke Registry

Background

The efficacy of intravenous thrombolysis (IVT) is sufficiently proven in ischemic stroke patients of middle and older age by means of randomized controlled trials and large observational studies. However, data in young stroke patients ≤50 years are still scarce. In this study, we aimed to evaluate the effectiveness and safety of IVT in young adults aged 18–50 years. Data from a consecutive and prospective stroke registry was analyzed that covers a federal state with 10.8 million inhabitants in southwest Germany.

Methods

Our analysis comprises 51,735 ischemic stroke patients aged 18–80 years and hospitalized from January 2008 to December 2012. Of these, 4,140 (8%) were aged 18–50 years and 7,529 (15%) underwent IVT. Data on 8,439 patients (16% of the study population) were missing for National Institutes of Health stroke severity score at admission and/or modified Rankin Scale (mRS) at discharge and were excluded from outcome analysis. In sensitivity analysis, patients with incomplete data were also examined. Binary logistic regression models were used adjusted for patient, hospital, and procedural parameters and stratified by age group (18–50 and 51–80 years, subgroup analyses 18–30, 31–40, and 41–50 years) to assess the relationship between IVT and mRS at discharge.

Results

IVT appears equally effective in young adults 18–50 years (adjusted odds ratio 1.40, 95% confidence interval 1.12–1.75; p = 0.003), compared to patients 51–80 years of age (1.33, 1.23–1.43; p < 0.001). Age-stratified analyses suggest an inverse relation of age and effectiveness, which appears to be highest in very young patients 18–30 years of age (2.78, 1.10–7.05; p = 0.03).

Discussion

Ischemic stroke etiology, vascular dynamics, and recovery in young patients differ from those of middle and older age. The evidence from routine hospital care in Germany indicates that IVT in young stroke patients appears to be at least equally effective as in the elderly.