Epidemiology of stroke in Europe and trends for the 21st century

The relationship between ambient temperature and acute respiratory and cardiovascular diseases in Shenyang, China

The purpose of this study was to analyze the acute effect of ambient temperature on hospitalization due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD), stroke, and myocardial infarction (MI) in Shenyang, China. We used the distributed delayed nonlinear model to evaluate the impact of ambient temperature on respiratory and cardiovascular diseases. The study population was divided into four groups: < 65 group and ≥ 65 age groups, female and male groups. The < 65 age group of AECOPD patients was more likely to be affected by high ambient temperature, while the ≥ 65 age group of AECOPD patients was more sensitive to low ambient temperature. The hospitalization risk of MI admission increased in the ≥ 65 age group at 1-8 days delay under low ambient temperature conditions.

An investigation into the critical role of fibre orientation in the ultimate tensile strength and stiffness of human carotid plaque caps

The development and subsequent rupture of atherosclerotic plaques in human carotid arteries is a major cause of ischaemic stroke. Mechanical characterization of atherosclerotic plaques can aid our understanding of this rupture risk. Despite this however, experimental studies on human atherosclerotic carotid plaques, and fibrous plaque caps in particular, are very limited. This study aims to provide further insights into atherosclerotic plaque rupture by mechanically testing human fibrous plaque caps, the region of the atherosclerotic lesion most often attributed the highest risk of rupture. The results obtained highlight the variability in the ultimate tensile stress, strain and stiffness experienced in atherosclerotic plaque caps. By pre-screening all samples using small angle light scattering (SALS) to determine the dominant fibre direction in the tissue, along with supporting histological analysis, this work suggests that the collagen fibre alignment in the circumferential direction plays the most dominant role for determining plaque structural stability. The work presented in this study could provide the basis for new diagnostic approaches to be developed, which non-invasively identify carotid plaques at greatest risk of rupture. STATEMENT OF SIGNIFICANCE: Mechanical characterisation of the atherosclerotic plaque cap is of utmost importance for understanding the mechanisms that govern the rupture strength of this tissue in-vivo. Studies has shown that plaque tissue is heterogenous and comprises of many structural components, each of which exhibits a varying mechanical response. However, rupture generally is located to the plaque cap, whereby the stress exerted on this location exceeds its mechanical strength causing failure. This work shows, for the first time, that the underlying collagen fibre architecture of carotid plaque caps governs their strength and stiffness. This study shows that plaque caps with collagen fibres aligned in the predominately circumferential direction experience higher stresses and lower strains before failure while those with predominately axial fibres display the opposite trend. Furthermore, total collagen content was found not to play a dominant role in determining the mechanical response of the tissue. The present study provides critical insights into human atherosclerotic plaque tissue mechanics and offers clinically relevant insights for mechanically sensitive imaging techniques, such as strain-based ultrasound or MRI.

High incidence of stroke in young adults in Tartu, Estonia, 2013 to 2017: A prospective population-based study

BACKGROUND AND PURPOSE

Previous studies conducted elsewhere in the world have demonstrated an increase in the incidence of ischemic stroke (IS) in younger ages. We sought to determine stroke incidence and 28-day case-fatality rates in 15- to 54-year-old residents of Tartu, Estonia from 2013 to 2017.

METHODS

All stroke cases that were the first ever in a lifetime (IS, nontraumatic intracerebral hemorrhage [ICH], and subarachnoid hemorrhage [SAH]) in 15- to 54-year-old residents of Tartu, Estonia were prospectively registered from January 1, 2013 to December 31, 2017. Several additional overlapping data sources were used for case ascertainment including other departments of the Tartu University Hospital and outpatient clinic, Estonian Cause of Death Registry, and the Estonian Electronic Health Record. All cases were thoroughly validated before inclusion.

RESULTS

We identified 110 cases (43.6% female) of first-ever stroke (IS 72.7%, ICH 12.7%, SAH 14.6%), out of which 85.5% were included prospectively. The mean age at onset was 44.3 ± 8.5 (SD) years. The mean age at onset was higher for men than for women (p = 0.046). The incidence of stroke standardized to the 1976 European standard population (EUR) was 46.1/100,000 (95% confidence interval [CI]: 37.4-54.8). IS incidence was 33.4/100,000 EUR (95% CI: 26-40.7). The total stroke incidence was higher in 45- to 54-year-old men than in women in the same age group (rate ratio, 2.24; 95% CI: 1.35-3.71). There were no more significant differences between sexes or age groups. The 28-day case-fatality rate was 10.9% for all strokes.

CONCLUSIONS

Our study shows higher crude incidence and case fatality of stroke in the young compared to studies from other high-income countries.

Association of Barriers, Fear of Falling and Fatigue with Objectively Measured Physical Activity and Sedentary Behavior in Chronic Stroke

Understanding the fostering factors of physical activity (PA) and sedentary behavior (SB) in post-stroke chronic survivors is critical to address preventive and health interventions. This cross-sectional study aimed to analyze the association of barriers to PA, fear of falling and severity of fatigue encountered by stroke chronic survivors with device-measured PA and SB. Ambulatory community-dwelling post-stroke subjects (≥six months from stroke onset) were evaluated and answered the Barriers to Physical Activity after Stroke Scale (BAPAS), Short Falls Efficacy Scale-International (Short FES-I) and Fatigue Severity Scale (FSS). SB and PA were measured with an Actigraph GT3X+ accelerometer for ≥seven consecutive days. Stepwise multiple linear regression analysis was employed to identify factors associated with PA and SB. Fifty-seven participants (58.2 ± 11.1 years, 37 men) met the accelerometer wear–time criteria (three days, ≥eight h/day). The physical BAPAS score explained 28.7% of the variance of the prolonged sedentary time (β = 0.547; p < 0.001). Additionally, the walking speed (β = 0.452) together with physical BAPAS (β = −0.319) explained 37.9% of the moderate-to-vigorous PA time (p < 0.001). In chronic post-stroke survivors, not only the walking speed but, also, the perceived physical barriers to PA are accounted for the SB and PA. Interventions to reverse SB and to involve subjects post-stroke in higher levels of PA should consider these factors.

Single-Nucleotide Polymorphisms in Oxidative Stress-Related Genes and the Risk of a Stroke in a Polish Population-A Preliminary Study

The present preliminary case-control study was undertaken to detect the potential association of six single nucleotide polymorphisms (SNPs) in oxidative stress-related genes: SOD2 (c.47T > C; rs4880), CAT (c.-89A > T; rs7943316), GPX4 (c.660T > A; rs713041), NOS1 (g.117803515C > T; rs1879417) and NOS2 (c.1823C > T; rs2297518 and c.-227G > C; rs10459953) and the occurrence of a stroke. The SNPs were determined using the TaqMan^® Allelic Discrimination Assay in 107 patients with strokes and 107 age- and sex-matched individuals who had not experienced cerebrovascular accidents. The T alleles of the rs4880 were positively correlated with a stroke (bootstrap OR 1.31; 1.07-1.59 95% CI). In the case of the rs713041, an association with the T allele was found (bootstrap OR 1.36; 1.12-1.67). In addition, the occurrence of a stroke was associated with the presence of the C allele of the rs1879417 (bootstrap OR 1.32; 1.09-1.61). We also found that the C/C genotype and C allele of the rs2297518 increased the risk of a stroke (bootstrap ORs 7.00; 4.34-11.29 and 4.96; 3.88-6.34, respectively). Moreover, the C allele of the rs10459953 was associated with an increased occurrence of this disease (bootstrap OR 1.31; 1.08-1.60). These results indicated that genetics variants in the SOD2, GPX4, NOS1 and NOS2 might be associated with susceptibility to strokes in the Polish population.

Targeting the Autonomic Nervous System for Risk Stratification, Outcome Prediction and Neuromodulation in Ischemic Stroke

Ischemic stroke is a worldwide major cause of mortality and disability and has high costs in terms of health-related quality of life and expectancy as well as of social healthcare resources. In recent years, starting from the bidirectional relationship between autonomic nervous system (ANS) dysfunction and acute ischemic stroke (AIS), researchers have identified prognostic factors for risk stratification, prognosis of mid-term outcomes and response to recanalization therapy. In particular, the evaluation of the ANS function through the analysis of heart rate variability (HRV) appears to be a promising non-invasive and reliable tool for the management of patients with AIS. Furthermore, preclinical molecular studies on the pathophysiological mechanisms underlying the onset and progression of stroke damage have shown an extensive overlap with the activity of the vagus nerve. Evidence from the application of vagus nerve stimulation (VNS) on animal models of AIS and on patients with chronic ischemic stroke has highlighted the surprising therapeutic possibilities of neuromodulation. Preclinical molecular studies highlighted that the neuroprotective action of VNS results from anti-inflammatory, antioxidant and antiapoptotic mechanisms mediated by α7 nicotinic acetylcholine receptor. Given the proven safety of non-invasive VNS in the subacute phase, the ease of its use and its possible beneficial effect in hemorrhagic stroke as well, human studies with transcutaneous VNS should be less challenging than protocols that involve invasive VNS and could be the proof of concept that neuromodulation represents the very first therapeutic approach in the ultra-early management of stroke.

Blood Biomarker Panels for the Early Prediction of Stroke-Associated Complications

Background Acute decompensated heart failure (ADHF) and respiratory tract infections (RTIs) are potentially life-threatening complications in patients experiencing stroke during hospitalization. We aimed to test whether blood biomarker panels might predict these complications early after admission. Methods and Results Nine hundred thirty-eight patients experiencing ischemic stroke were prospectively recruited in the Stroke-Chip study. Post-stroke complications during hospitalization were retrospectively evaluated. Blood samples were drawn within 6 hours after stroke onset, and 14 biomarkers were analyzed by immunoassays. Biomarker values were normalized using log-transformation and Z score. PanelomiX algorithm was used to select panels with the best accuracy for predicting ADHF and RTI. Logistic regression models were constructed with the clinical variables and the biomarker panels. The additional predictive value of the panels compared with the clinical model alone was evaluated by receiver operating characteristic curves. An internal validation through a 10-fold cross-validation with 3 repeats was performed. ADHF and RTI occurred in 19 (2%) and 86 (9.1%) cases, respectively. Three-biomarker panels were developed as predictors: vascular adhesion protein-1 >5.67, NT-proBNP (N-terminal pro-B-type natriuretic peptide) >4.98 and d-dimer >5.38 (sensitivity, 89.5%; specificity, 71.7%) for ADHF; and interleukin-6 >3.97, von Willebrand factor >3.67, and d-dimer >4.58 (sensitivity, 82.6%; specificity, 59.8%) for RTI. Both panels independently predicted stroke complications (panel for ADHF: odds ratio [OR] [95% CI], 10.1 [3-52.2]; panel for RTI: OR, 3.73 [1.95-7.14]) after adjustment by clinical confounders. The addition of the panel to clinical predictors significantly improved areas under the curve of the receiver operating characteristic curves in both cases. Conclusions Blood biomarkers could be useful for the early prediction of ADHF and RTI. Future studies should assess the usefulness of these panels in front of patients experiencing stroke with respiratory symptoms such as dyspnea.

Antiplatelet Therapy in the Secondary Prevention of Non-cardioembolic Ischemic Stroke and Transient Ischemic Attack: A Mini-Review

The aim of this mini-review is to discuss the main antiplatelet agents that have been successfully used in the secondary prevention of non-cardioembolic ischemic stroke and transient ischemic attacks (TIA). The methodology is based on a literature review of available peer-reviewed English studies listed in PubMed. The findings reveal that aspirin remains a reliable antiplatelet agent in the secondary prevention of acute non-cardioembolic ischemic stroke and TIA. Nevertheless, currently, there are also other agents, i.e., ticagrelor, clopidogrel, and cilostazol, that can be applied. In addition, the results indicate that time is significant not only in severe stroke but also in non-severe stroke and TIA, which suggests that antiplatelet therapy should be applied within 24 h after the first symptoms because early treatment can lead to an improvement in neurological outcomes and reduce the chance of an early subsequent stroke.

Temporal trends in stroke incidence and case-fatality rates in Arcadia, Greece: A sequential, prospective, population-based study

BACKGROUND

Stroke incidence and case-fatality are reported to decline in high-income countries during the last decades. Epidemiological studies are important for health services to organize prevention and treatment strategies.

AIMS

The aim of this population-based study was to determine temporal trends of stroke incidence and case-fatality rates of first-ever stroke in Arcadia, a prefecture in southern Greece.

METHODS

All first-ever stroke cases in the Arcadia prefecture were ascertained using the same standard criteria and multiple overlapping sources in three study periods: from November 1993 to October 1995; 2004; and 2015-2016. Crude and age-adjusted to European population incidence rates were compared using Poisson regression. Twenty-eight days case fatality rates were estimated and compared using the same method.

RESULTS

In total, 1315 patients with first-ever stroke were identified. The age-standardized incidence to the European population was 252 per 100,000 person-years (95% CI 231-239) in 1993/1995, 252 (95% CI 223-286) in 2004, and 211 (192-232) in 2015/2016. The overall age- and sex-adjusted incidence rates fell by 16% (incidence rates ratio 0.84, 95% CI: 0.72-0.97). Similarly, 28-day case-fatality rate decreased by 28% (case fatality rate ratio = 0.72, 95% CI: 0.58-0.90).

CONCLUSIONS

This population-based study reports a significant decline in stroke incidence and mortality rates in southern Greece between 1993 and 2016.

Risk factors among stroke subtypes and its impact on the clinical outcome of patients of Northern Portugal under previous aspirin therapy

BACKGROUND

In Western European countries, acute ischemic stroke (AIS) remains the third leading cause of death. Among the risk factors for cerebrovascular disease, some have more influence than others in certain stroke subtypes. The aim of this study was to evaluate the impact of risk factors among Stroke Subtypes on the clinical outcome of Portuguese patients under previous aspirin therapy.

MATERIALS AND METHODS

We studied a cohort of 371 patients diagnosed with AIS and a clinical follow-up protocol was set up.The patients were admitted in a Department of Internal Medicine of a major hospital. Standardized data assessment and stroke subtype classification (Oxfordshire Community Stroke Project) were used.

RESULTS

Arterial hypertension (80.4 %), overweight (72.6 %) and dyslipidemia (62.0 %) were the most prevalent risk factors with no statistical differences among the group's subtypes. Current smoking was more prevalent in POCI(62.9 %) with differences among subtypes (p = 0.002). Atrial fibrillation was more commonly reported in TACI (39.3 %) and less common in POCI (8.1 %) (p < 0.001).Comparing TACI vs Non TACI Stroke Subtypes demonstrated major differences in cumulative survival,among the cases with no previous aspirin treatment, after 3 years (51.9 % vs 88.8 %).The increased risk of mortality at 12 months is consistently observed for the presence of a previous atrial fibrillation (OR 3.01 95 %CI 1.69-5.39), TACI subtype (OR 10.4 95 %CI 4.83-22.6) and NIHSS over 10 (OR 9.33 95 % CI 4,49-19.4). When we analyze the impact of previous aspirin treatment in the risk for a new stroke event, it seems to have a protective effect in a time frame of 12 months, but this protection is lost extending at 24 months (p = 0.094 vs p = 0.005).

DISCUSSION

Our results indicate that smoking, atrial fibrillation and age have different relevance in their distribution among ischemic stroke subtypes at the time of diagnosis. Concerning the influence of the main stroke risk factors on the clinical outcome, our results present a strong influence of atrial fibrillation and of age. Severity of disease at diagnosis, represented by TACI subtype is clearly associated to decreased survival among patients with no record of previous aspirin therapy. Our results reinforce the relevance cohort studies of different populations, to achieve a more comprehensive knowledge of the impact of risk factors on stroke subtypes and on its clinical outcome.

Factors Associated with Level of Physical Activity After Minor Stroke

OBJECTIVES

To explore factors from the acute phase, and after three and 12 months, associated with level of self-reported physical activity 12 months after a minor ischemic stroke with National Institutes of Health Stroke Scale (NIHSS) score ≤ 3 in persons 70 years or younger.

MATERIALS AND METHOD

In this longitudinal cohort study patients were recruited consecutively from two stroke units. Activity level were measured with three sets of questions addressing the average number of frequency (times exercising each week), the average intensity, and duration (the average time), and a sum score was constructed. The association between physical activity 12 months after stroke and sociodemographic factors, NIHSS, body mass index, balance, and neuropsychiatric symptoms were explored using multiple linear regression.

RESULTS

This study included 101 patients, with mean age (SD) 55.5 (11.4) years, NIHSS median (Q₁, Q₃) 0.0 (0.0, 1.0), and 20 % were female. Multiple linear regression analyses showed sick leave status at stroke onset, balance at three and 12 months, and anxiety, depression, apathy, and fatigue at 12 months to be factors associated with physical activity at 12 months after stroke.

CONCLUSION

We found that pre-stroke sick leave, post-stroke balance, and neuropsychiatric symptoms were associated with the level of physical activity one year after minor stroke. This might be of importance when giving information about physical activity and deciding about post-stroke follow-up.

Gender difference of geographic distribution of the stroke incidence affected by socioeconomic, clinical and urban-rural factors: an ecological study based on data from the Brest stroke registry in France

Background

Mapping the spatial distribution of disease occurrence is a strategy to identify contextual factors that could be useful for public health policies. The purpose of this ecological study was to examine to which extent the socioeconomic deprivation and the urbanization level can explain gender difference of geographic distribution in stroke incidence in Pays de Brest, France between 2008 and 2013.

Methods

Stroke cases aged 60 years or more were extracted from the Brest stroke registry and combined at the census block level. Contextual socioeconomic, demographic, and geographic variables at the census block level come from the 2013 national census. We used spatial and non-spatial regression models to study the geographic correlation between socioeconomic deprivation, degree or urbanization and stroke incidence. We generated maps using spatial geographically weighted models, after longitude and latitude smoothing and adjustment for covariates.

Results

Stroke incidence was comparable in women and men (6.26 ± 3.5 vs 6.91 ± 3.3 per 1000 inhabitants-year, respectively). Results showed different patterns of the distribution of stroke risk and its association with deprivation or urbanisation across gender. For women, stroke incidence was spatially homogeneous over the entire study area, but was associated with deprivation level in urban census blocks: age adjusted risk ratio of high versus low deprivation = 1.24, [95%CI 1.04–1.46]. For men, three geographic clusters were identified. One located in the northern rural and deprived census blocks with a 9–14% increase in the risk of stroke. Two others clusters located in the south-eastern (mostly urban part) and south-western (suburban and rural part) with low deprivation level and associated with higher risk of stroke incidence between (3 and 8%) and (8.5 and 19%) respectively. There were no differences in profile of cardiovascular risk factors, stroke type and stroke severity between clusters, or when comparing clusters cases to the rest of the study population.

Conclusions

Understanding whether and how neighborhood and patient’s characteristics influence stroke risk may be useful for both epidemiological research and healthcare service planning.

SMASH-U classification: a tool for aetiology-oriented management of patients with acute haemorrhagic stroke

Intracerebral haemorrhage (ICH) is responsible for disproportionately high morbidity and mortality rates. The most used ICH classification system is based on the anatomical site. We used SMASH-U, an aetiological based classification system for ICH by predefined criteria: structural vascular lesions (S), medication (M), amyloid angiopathy (A), systemic disease (S), hypertension (H), or undetermined (U). We aimed to correlate SMASH-U classification of our patients to the intra-hospital mortality rates. We performed a single centre retrospective study at the Santa Maria Della Misericordia Hospital, Perugia (Italy) including consecutive patients between January 2009 and July 2017 assigned with 431 ICD-9 (International Classification of Diseases-9). We classified the included patients using SMASH-U criteria, and we analysed the association between SMASH-U aetiology and ICH risk factors to the outcome defined as intra-hospital mortality, using multivariable logistic regression analysis. The higher intra-hospital mortality rate was detected in the systemic disease (36.1%), medication (31.5%), and undetermined (29.4%) groups. At multivariable analysis, medication and systemic disease groups resulted associated with the outcome (odds ratio 3.47; 95% CI 1.15-10.46; P = 0.02 and 3.64; 95% CI 1.47-9.01; P = 0.005, respectively). Furthermore, age and high NIHSS at admission resulted significantly associated with intra-hospital mortality (odds ratio 1.01; 95% CI 1-1.03; P = 0.04 and 1.12; 95% CI 1.03-1.22; P = 0.008, respectively). In our retrospective study, the aetiology-oriented classification system SMASH-U showed to be potentially predictive of intra-hospital mortality of acute haemorrhagic stroke patients and it may support clinicians in the acute ICH management.

Deep learning reconstruction versus iterative reconstruction for cardiac CT angiography in a stroke imaging protocol: reduced radiation dose and improved image quality

Background

To assess the radiation dose and image quality of cardiac computed tomography angiography (CCTA) in an acute stroke imaging protocol using a deep learning reconstruction (DLR) method compared to a hybrid iterative reconstruction algorithm.

Methods

Retrospective analysis of 296 consecutive patients admitted to the emergency department for stroke suspicion. All patients underwent a stroke CT imaging protocol including a non-enhanced brain CT, a brain perfusion CT imaging if necessary, a CT angiography (CTA) of the supra-aortic vessels, a CCTA and a post-contrast brain CT. The CCTA was performed with a prospectively ECG-gated volume acquisition. Among all CT scans performed, 143 were reconstructed with an iterative reconstruction algorithm (AIDR 3D, adaptive iterative dose reduction three dimensional) and 146 with a DLR algorithm (AiCE, advanced intelligent clear-IQ engine). Image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and subjective image quality (IQ) scored from 1 to 4 were assessed. Dose-length product (DLP), volume CT dose index (CTDIvol) and effective dose (ED) were obtained.

Results

The radiation dose was significantly lower with AiCE than with AIDR 3D (DLP =106.4±50.0 vs. 176.1±37.1 mGy·cm, CTDIvol =6.9±3.2 vs. 11.5±2.2 mGy, and ED =1.5±0.7 vs. 2.5±0.5 mSv) (P<0.001). The median SNR and CNR were higher [9.9 (IQR, 8.1-12.3); and 12.6 (IQR, 10.5-15.5), respectively], with AiCE than with AIDR 3D [6.5 (IQR, 5.2-8.5); and 8.4 (IQR, 6.7-11.0), respectively] (P<0.001). SNR and CNR were increased by 51% and 49%, respectively, with AiCE compared to AIDR 3D. The image quality was significantly better with AiCE (mean IQ score =3.4±0.7) than with AIDR 3D (mean IQ score =3±0.9) (P<0.001).

Conclusions

The use of a DLR algorithm for cardiac CTA in an acute stroke imaging protocol reduced the radiation dose by about 40% and improved the image quality by about 50% compared to an iterative reconstruction algorithm.

Quantifying Pathological Synergies in the Upper Extremity of Stroke Subjects With the Use of Inertial Measurement Units: A Pilot Study

BACKGROUND

Stroke is one of the main causes of disability in the world, causing loss of motor function on mainly one side of the body. A proper assessment of motor function is required to help to direct and evaluate therapy. Assessment is currently performed by therapists using observer-based standardized clinical assessment protocols. Sensor-based technologies can be used to objectively quantify the presence and severity of motor impairments in stroke patients.

METHODS

In this work, a minimally obstructive distributed inertial sensing system, intended to measure kinematics of the upper extremity, was developed and tested in a pilot study, where 10 chronic stroke subjects performed the arm-related tasks from the Fugl-Meyer Assessment protocol with the affected and non-affected side.

RESULTS

The pilot study showed that the developed distributed measurement system was adequately sensitive to show significant differences in stroke subjects' arm postures between the affected and non-affected side. The presence of pathological synergies can be analysed using the measured joint angles of the upper limb segments, that describe the movement patterns of the subject.

CONCLUSION

Features measured by the system vary from the assessed FMA-UE sub-score showing its potential to provide more detailed clinical information.

A Novel Point-in-Polygon-Based sEMG Classifier for Hand Exoskeleton Systems

In the early 2000s, data from the latest World Health Organization estimates paint a picture where one-seventh of the world population needs at least one assistive device. Fortunately, these years are also characterized by a marked technological drive which takes the name of the Fourth Industrial Revolution. In this terrain, robotics is making its way through more and more aspects of everyday life, and robotics-based assistance/rehabilitation is considered one of the most encouraging applications. Providing high-intensity rehabilitation sessions or home assistance through low-cost robotic devices can be indeed an effective solution to democratize services otherwise not accessible to everyone. However, the identification of an intuitive and reliable real-time control system does arise as one of the critical issues to unravel for this technology in order to land in homes or clinics. Intention recognition techniques from surface ElectroMyoGraphic (sEMG) signals are referred to as one of the main ways-to-go in literature. Nevertheless, even if widely studied, the implementation of such procedures to real-case scenarios is still rarely addressed. In a previous work, the development and implementation of a novel sEMG-based classification strategy to control a fully-wearable Hand Exoskeleton System (HES) have been qualitatively assessed by the authors. This paper aims to furtherly demonstrate the validity of such a classification strategy by giving quantitative evidence about the favourable comparison to some of the standard machine-learning-based methods. Real-time action, computational lightness, and suitability to embedded electronics will emerge as the major characteristics of all the investigated techniques.

Characterizing Multiple Patterns of Motor Intent Using Spatial-Temporal Information for Intuitively Active Motor Training in Stroke Survivors

Upper extremity motor function loss severely affects stroke survivors during daily life activities. Different rehabilitation robotic systems have been developed to allow stroke survivors regain their motor function. Meanwhile, most of the robots only operate in a passive mode and restrict the users to navigate predefined trajectories which may not align with their motion intent, thus limiting motor recovery. One way to resolve this issue would be to utilize a decoded movement intent to trigger intuitively active motor training for patients. In this direction, this study proposed and investigated the use of spatial-temporal neuromuscular descriptor (STD) for optimal decoding of multiple patterns of movement intents in patient to provide inputs for active motor training in the rehabilitation robotic systems. The STD performance was validated using High-Density surface electromyogram recordings from five stroke survivors who performed 21 limb movements. Experimental results show that the STD achieved a significant reduction in limb movement classification error (13.36%) even in the presence of the inevitable White Gaussian Noise compared to other methods (p<0.05). The STD also showed obvious class separability for individual movement. Findings from this study suggest that the STD may provide potential inputs for intuitively active motor training in stroke rehabilitation robotic systems.Clinical Relevance- This study showed that spatial-temporal neuromuscular information could aid adequate decoding of movement intents upon which intuitively active motor training could be achieved in stroke rehabilitation robotic systems.

The Role of Resolvins: EPA and DHA Derivatives Can Be Useful in the Prevention and Treatment of Ischemic Stroke

INTRODUCTION

Most ischemic strokes develop as a result of atherosclerosis, in which inflammation plays a key role. The synthesis cascade of proinflammatory mediators participates in the process induced in the vascular endothelium and platelets. Resolvins are anti-inflammatory mediators originating from eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which may improve the prognosis related to atherosclerosis by inhibiting the production of proinflammatory cytokines, limiting neutrophil migration, or positively influencing phagocytosis. Although clinical trials with resolvin in humans after stroke have not been realized, they may soon find application.

AIM

The aim of the study was to review the available literature on the scope of the possibilities of the prevention and treatment of stroke with the use of resolvins, EPA and DHA derivatives.

MATERIALS AND METHODS

The review features articles published until 31 January 2020. The search for adequate literature was conducted using the keywords: stroke and resolvins. Over 150 articles were found. Studies not written in English, letters to the editor, conference abstracts, and duplicate information were excluded.

RESULTS

In several studies using the animal model, the supplementation of resolvin D2 decreased brain damage caused by myocardial infarction, and it reversed the neurological dysfunction of the brain. A decrease in the concentration of proinflammatory cytokines, such as TNF-α, Il-6, and Il-1β, was also observed, as well as a decrease in the scope of brain damage. In the context of stroke in animals, the treatment with resolvin D2 (RvD2) (injection) has a better effect than supplementation with DHA.

CONCLUSIONS

Resolvins are characterised by strong anti-inflammatory properties. Resolvins improve prognosis and decrease the risk of developing cardiovascular disease, consequently lowering the risk of stroke, and may find application in the treatment of stroke.

Transesophageal Echocardiography - Dysphagia Risk in Acute Stroke (TEDRAS): a prospective, blind, randomized and controlled clinical trial

BACKGROUND AND PURPOSE

Dysphagia is common in acute stroke and leads to worse overall outcome. Transesophageal echocardiography (TEE) is used in the diagnostic evaluation of stroke with regard to its etiology and is a known cause of postoperative dysphagia in cardiac surgery. The prevalence of dysphagia in acute stroke patients undergoing TEE remains unknown. The aim of the Transesophageal Echocardiography - Dysphagia Risk in Acute Stroke (TEDRAS) study was to assess the influence of TEE on swallowing among patients who have experienced acute stroke.

METHODS

The TEDRAS study was a prospective, blind, randomized, controlled trial that included two groups of patients with acute stroke. Simple unrestricted randomization was performed, and examiners were blinded to each other's results. Swallowing was tested using flexible endoscopic evaluation of swallowing (FEES) at three different time points in the intervention group (24 h before, immediately after and 24 h after TEE) and in the control group (FEES on three consecutive days and TEE earliest after the third FEES). Validated scales were used to assess dysphagia severity for all time points as primary outcome measures.

RESULTS

A total of 34 patients were randomized: 19 to the intervention group and 15 to the control group. The key findings of the repeated-measures between-group comparisons were significant increases in the intervention group for the following dysphagia measures: (1) secretion severity score (immediately after TEE: P < 0.001; 24 h after TEE: P < 0.001) and (2) Penetration-Aspiration Scale score for saliva (immediately after TEE: P < 0.001; 24 h after TEE: P = 0.007), for small (immediately after TEE: P = 0.009) and large liquid boli (immediately after TEE: P = 0.009; 24 h after TEE: P = 0.025).

CONCLUSION

The results indicate a negative influence of TEE on swallowing in acute stroke patients for at least 24 hours.

Is limited-coverage CT perfusion helpful in treatment decision-making in patients with acute ischemic stroke?

Background

The initial core infarct volume predicts treatment outcome in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). According to the literature, CT perfusion (CTP) is able to evaluate cerebral parenchymal viability and assess the initial core in AIS. We prospectively studied whether limited-coverage CTP with automated core calculation correlates with the final infarct volume on follow-up non-enhanced CT (NECT) in patients successfully treated by mechanical thrombectomy.

Methods

We enrolled 31 stroke patients (20 women aged 74.4±12.9 years and 11 men aged 66±15.4 years; median initial NIHSS score 15.5) with occlusion of the medial cerebral artery and/or the internal carotid artery that were treated by successful mechanical thrombectomy. CTP performed in a 38.6 mm slab at the level of basal ganglia was included in the CT stroke protocol, but was not used to determine indication for mechanical thrombectomy. The infarction core volume based on CTP was automatically calculated using dedicated software with a threshold defined as cerebral blood flow <30% of the value in the contralateral healthy hemisphere. The final infarction volume was measured on 24-hour follow-up NECT in the same slab with respect to CTP. Pearson and Spearman correlation coefficients and robust linear regression were used for comparison of both volumes, P values <0.05 were considered as statistically significant.

Results

The median time from stroke onset to CT was 77 minutes (range, 31-284 minutes), and the median time from CT to vessel recanalization was 95 minutes (range, 55-215 minutes). The mean CTP-calculated core infarct volume was 24.3±19.2 mL (median 19 mL, range 1-79 mL), while the mean final infarct volume was 21.5±39.5 mL (median 8 mL; range 0-210 mL). Only a weak relationship was found between the CTP-calculated core and final infarct volume [Pr₍₂₉₎ =0.32, P=0.078; rho =0.40, P=0.028]. Regression analysis showed CTP significantly overestimated lower volumes.

Conclusions

In our prospective study, the infarction core calculated using limited-coverage CTP only weakly correlated with the final infarction volume measured on 24-hour follow-up NECT; moreover, CTP significantly overestimated lower volumes. Our results do not support the use of limited-coverage CTP for guiding treatment recommendations in patients with AIS.

Trends in mortality from stroke in the European Union, 1996-2015

BACKGROUND AND PURPOSE

Stroke is the second largest single cause of death in Europe, responsible for 9% and 13% of all deaths in men and women, respectively. There have been large overall declines in stroke mortality rates in the majority of European countries in recent decades. The aim of this study was to analyse trends in mortality caused by stroke in the 28 member countries of the European Union (EU) over the last two decades.

METHODS

We extracted data for age-standardized stroke mortality rates per 100 000 in the EU for the period 1996-2015 from the World Health Organization database. Joinpoint regression analysis was used to analyse the trends and compute the annual percent change (APC) in the EU as a whole and by country. Analyses were conducted by gender and by European region.

RESULTS

Mortality from stroke has decreased in the EU over the study period by an average APC of 4.2%. All countries showed downward trends, with the sharpest decreases in Estonia, Portugal and Austria. We recorded statistically significant decreases of 4.2% and 4.3% in mortality rates in men and women, respectively, in the whole EU. Southern and western countries showed the steepest decreases, whereas mortality has increased in northern countries in recent years.

CONCLUSIONS

Stroke mortality has decreased in the EU, in both sexes, especially in southern and western European countries. Our results could be a reference for the development of primary prevention and acute management of stroke policies focused on countries with higher mortality.

The Prevalence of Cognitive Impairment on Admission to Nursing Home among Residents with and without Stroke: A Cross-Sectional Survey of Nursing Homes in Ireland

Post-stroke cognitive impairment (PSCI) is a common consequence of stroke. Epidemiological evidence indicates that, with an ageing population, stroke and PSCI are likely to increase in the coming decades. This may have considerable implications for the demand for nursing home placement. As prevalence estimates of both cognitive impairment and dementia on admission to nursing home among residents with and without stroke have not yet been compared, they were estimated and compared in this study. We performed a cross-sectional survey to establish the admission characteristics of 643 residents in 13 randomly selected nursing homes in Ireland. The survey collected data on resident's stroke and cognitive status at the time of nursing home admission. The survey found, among nursing home residents that experienced stroke prior to admission, prevalence estimates for cognitive impairment (83.8%; 95% CI = 76.9-90.6%) and dementia (66.7%; 95% CI = 57.9-75.4%) were significantly higher compared to residents that had not experienced stroke prior to admission (cognitive impairment: 56.6%; 95% CI = 52.4-60.8%; X2 (1) = 28.64; p < 0.001; dementia: 49.8%; 95% CI = 45.6-54.1%; X2 (1) = 10.47; p < 0.01). Since the prevalence of PSCI is likely to increase in the coming decades, the findings highlight an urgent need for health service planning for this increased demand for nursing home care to meet the care needs of these stroke survivors.

Specificities of acute phase stroke management in the elderly

Health professionals are currently facing the challenge of managing an increasing number of old patients presenting with acute stroke, due to rapid aging of the population. Compared to their younger counterparts, elderly patients differ in many ways in the setting of acute stroke. Apart from a striking high stroke incidence, which increases exponentially as age increases, cardioembolism also becomes, as patients age, the main cause of ischemic stroke. Delirium, which can challenge the diagnosis, is frequent at the acute phase of stroke, and may be related to an underlying dementia, which is almost exclusively observed in the elderly during stroke. At all levels, management of elderly stroke patients is suboptimal, especially when they are cognitively impaired, with insufficiencies including admission to stroke units, applying standards of care and investigation, reperfusion therapy for ischemic stroke, and finally transfer to rehabilitation centers. A paradigm shift must take place to limit age-related discrimination for acute-phase management of stroke.

An assessment of annual procedure volumes and therapy adoption of transcatheter closure of patent foramen ovale in four European countries

Introduction

Patent foramen ovale closure reduces recurrence of cryptogenic ischaemic stroke compared to anti-platelet therapy. Our goal was to determine procedure volumes and closure utilisation as a proportion of candidates in four large European countries.

Patients and methods

National statistics were obtained for Germany, England, France, and Italy for the last available five years (2014-2018). Eligibility was aligned to the enrolment criteria of pivotal trials and current consensus documents. Stroke and transient ischaemic attack incidences were obtained from epidemiological registries and claims data. The eligible candidate pool for analysis included current year candidates plus untreated patients from the prior two years. Absolute strokes avoided assumed the hazard ratio for ischaemic stroke recurrence from a recent meta-analysis.

Results

In 2018, closure incidence rates were 5.64, 0.53, 2.94 and 5.26 per 100,000 in Germany, England, France and Italy, respectively. This reflects five-year increases of 128% in Germany, 462% in France and 36% in Italy (p < 0.05 for all), and a decline of 37% in England. The proportions of treated patients versus candidates for the combined stroke and transient ischaemic attack pool were 55%, 30%, 80%, and 6%, respectively.

Discussion

Patent foramen ovale closure volumes increased after the 2017 announcement of positive trial results but still differ substantially across large European countries. If all closure candidates in 2018 with prior ischaemic stroke were treated, the resulting absolute reduction of recurrent ischaemic strokes, compared to anti-platelet therapy alone, would be between 782 and 2295 across the four countries over five years.

Conclusion

Many eligible patients at risk for a recurrent cryptogenic event might remain untreated due to regional practice variations.

White-matter hyperintensities in patients with carotid artery stenosis: An exploratory connectometry study

BACKGROUND

White-matter lesions (WMLs) are frequently found in magnetic resonance imaging (MRi), and the WML load tends to be higher in patients affected by cervical internal carotid artery (cICA) stenosis.

PURPOSE

This study aimed to investigate whether and how WMLs influence cerebral networking in patients with asymptomatic cICA stenosis eligible for carotid endarterectomy (CEA) by exploiting the connectometry technique.

METHODS

The study was designed as a cross-sectional exploratory investigation, and 28 patients with cICA stenosis eligible for CEA were enrolled. All patients received an MRI scan, including a T1-weighted, a FLAIR and a diffusion-weighted (DW) sequence. The T1 and FLAIR sequences were analysed for quantification of WML burden (WMLB) and total number of WMLs (TNWMLs). The DW data were reconstructed in the MNI space using q-space diffeomorphic reconstruction, and were grouped to create a connectometry database. The connectometry analysis evaluated the influence of both the WMLB and TNWMLs to local connectivity in a multiple regression model that included age, WMLB and TNWMLs, adopting three different T-score thresholds (1, 2 and 3). A p-value corrected for false discovery rate of <0.05 was adopted as a threshold to identify statistically significant results.

RESULTS

The connectometry analysis identified several white-matter bundles negatively correlated with WMLB; no statistically significant correlation was found for TNWMLs.

CONCLUSION

Results of our study suggest that WMLs influence brain connectivity measured by the connectometry technique in patients with cICA stenosis eligible for CEA. Further studies are warranted to understand the role of WMLs better as a marker of disease in patients with cICA stenosis.

Stroke risk, phenotypes, and death in COVID-19: Systematic review and newly reported cases

OBJECTIVES

To investigate the hypothesis that strokes occurring in patients with coronavirus disease 2019 (COVID-19) have distinctive features, we investigated stroke risk, clinical phenotypes, and outcomes in this population.

METHODS

We performed a systematic search resulting in 10 studies reporting stroke frequency among patients with COVID-19, which were pooled with 1 unpublished series from Canada. We applied random-effects meta-analyses to estimate the proportion of stroke among COVID-19. We performed an additional systematic search for cases series of stroke in patients with COVID-19 (n = 125), and we pooled these data with 35 unpublished cases from Canada, the United States, and Iran. We analyzed clinical characteristics and in-hospital mortality stratified into age groups (<50, 50-70, >70 years). We applied cluster analyses to identify specific clinical phenotypes and their relationship with death.

RESULTS

The proportions of patients with COVID-19 with stroke (1.8%, 95% confidence interval [CI] 0.9%-3.7%) and in-hospital mortality (34.4%, 95% CI 27.2%-42.4%) were exceedingly high. Mortality was 67% lower in patients <50 years of age relative to those >70 years of age (odds ratio [OR] 0.33, 95% CI 0.12-0.94, p = 0.039). Large vessel occlusion was twice as frequent (46.9%) as previously reported and was high across all age groups, even in the absence of risk factors or comorbid conditions. A clinical phenotype characterized by older age, a higher burden of comorbid conditions, and severe COVID-19 respiratory symptoms was associated with the highest in-hospital mortality (58.6%) and a 3 times higher risk of death than the rest of the cohort (OR 3.52, 95% CI 1.53-8.09, p = 0.003).

CONCLUSIONS

Stroke is relatively frequent among patients with COVID-19 and has devastating consequences across all ages. The interplay of older age, comorbid conditions, and severity of COVID-19 respiratory symptoms is associated with an extremely elevated mortality.

Can miRNAs Be Considered as Diagnostic and Therapeutic Molecules in Ischemic Stroke Pathogenesis?-Current Status

Ischemic stroke is one of the leading causes of death worldwide. Clinical manifestations of stroke are long-lasting and causing economic burden on the patients and society. Current therapeutic modalities to treat ischemic stroke (IS) are unsatisfactory due to the intricate pathophysiology and poor functional recovery of brain cellular compartment. MicroRNAs (miRNA) are endogenously expressed small non-coding RNA molecules, which can act as translation inhibitors and play a pivotal role in the pathophysiology associated with IS. Moreover, miRNAs may be used as potential diagnostic and therapeutic tools in clinical practice; yet, the complete role of miRNAs is enigmatic during IS. In this review, we explored the role of miRNAs in the regulation of stroke risk factors viz., arterial hypertension, metabolic disorders, and atherosclerosis. Furthermore, the role of miRNAs were reviewed during IS pathogenesis accompanied by excitotoxicity, oxidative stress, inflammation, apoptosis, angiogenesis, neurogenesis, and Alzheimer's disease. The functional role of miRNAs is a double-edged sword effect in cerebral ischemia as they could modulate pathological mechanisms associated with risk factors of IS. miRNAs pertaining to IS pathogenesis could be potential biomarkers for stroke; they could help researchers to identify a particular stroke type and enable medical professionals to evaluate the severity of brain injury. Thus, ascertaining the role of miRNAs may be useful in deciphering their diagnostic role consequently it is plausible to envisage a suitable therapeutic modality against IS.

Identification of health behaviour clusters among people at high risk of stroke: A latent class profile analysis

AIMS

To identify the possible latent classes of health behaviour reported by people at high risk of stroke and to explore the predictors of these different classes of health behaviour.

DESIGN

A cross-sectional survey study.

METHODS

A stratified cluster random sampling method was used to collect data from 2,500 individuals at high risk of stroke who were from Henan Province, China, from January 2018-January 2019. A latent class profile analysis was used to identify the health behaviour clusters and multinomial logistic regression was used to determine which factors predicted the emergent latent classes of health behaviour.

RESULTS

High-risk individuals (N = 2,236) at high risk of stroke replied to the survey (89.44% response rate). Model fit indices (AIC = 257,509.610, BIC = 260,228.733, Entropy = 0.956) supported a three-class model of health behaviours. The latent classes were Class 1 (a good level of adaptive health behaviour, 31%, N = 693), Class 2 (a moderate level of adaptive health behaviour, 36%, N = 805) and Class 3 (a poor level of adaptive health behaviour, 33%, N = 738); Based on physical and belief, behaviour and clinical profiles, the three classes were further labelled self-realization deficiency subgroup, social contact anxiety subgroup and health responsibility absence subgroup respectively. Older age, male gender, no spouse, lower education and household income were risk factors associated with good health behaviour. After controlling these socio-demographic variables, high levels of health-related knowledge and attitude were the main positive predictors of health behaviour.

CONCLUSIONS

This study has identified three different latent classes of health behaviour and their predictive factors in people at high risk of stroke in the Chinese setting.

IMPACT

This study has significance for the promotion of adaptive health behaviour in individuals at high risk of stroke. It has allowed the identification of specific clusters of health behaviour that vary in terms of their adaptiveness and forms the basis for the development of a targeted intervention to promote health behaviour for each different subgroup.

Consensus-Based Core Set of Outcome Measures for Clinical Motor Rehabilitation After Stroke-A Delphi Study

Introduction: Outcome measures are key to tailor rehabilitation goals to the stroke patient's individual needs and to monitor poststroke recovery. The large number of available outcome measures leads to high variability in clinical use. Currently, an internationally agreed core set of motor outcome measures for clinical application is lacking. Therefore, the goal was to develop such a set to serve as a quality standard in clinical motor rehabilitation poststroke.

Methods: Outcome measures for the upper and lower extremities, and activities of daily living (ADL)/stroke-specific outcomes were identified and presented to stroke rehabilitation experts in an electronic Delphi study. In round 1, clinical feasibility and relevance of the outcome measures were rated on a 7-point Likert scale. In round 2, those rated at least as “relevant” and “feasible” were ranked within the body functions, activities, and participation domains of the International Classification of Functioning, Disability, and Health (ICF). Furthermore, measurement time points poststroke were indicated. In round 3, answers were reviewed in reference to overall results to reach final consensus.

Results: In total, 119 outcome measures were presented to 33 experts from 18 countries. The recommended core set includes the Fugl–Meyer Motor Assessment and Action Research Arm Test for the upper extremity section; the Fugl–Meyer Motor Assessment, 10-m Walk Test, Timed-Up-and-Go, and Berg Balance Scale for the lower extremity section; and the National Institutes of Health Stroke Scale, and Barthel Index or Functional Independence Measure for the ADL/stroke-specific section. The Stroke Impact Scale was recommended spanning all ICF domains. Recommended measurement time points are days 2 ± 1 and 7; weeks 2, 4, and 12; 6 months poststroke and every following 6th month.

Discussion and Conclusion: Agreement was found upon a set of nine outcome measures for application in clinical motor rehabilitation poststroke, with seven measurement time points following the stages of poststroke recovery. This core set was specifically developed for clinical practice and distinguishes itself from initiatives for stroke rehabilitation research. The next challenge is to implement this clinical core set across the full stroke care continuum with the aim to improve the transparency, comparability, and quality of stroke rehabilitation at a regional, national, and international level.

Sex differences of ischemic stroke in young adults-A single-center Chinese cohort study

BACKGROUND AND OBJECTIVE

Stroke at a young age is a societal challenge with a rising incidence. Our aim was to investigate sex differences in risk factors, etiology, and diagnostic process of ischemic stroke in Chinese young adults.

METHODS

We retrospectively recruited 411 consecutive patients with first-ever ischemic stroke who were 18 to 50 years of age (mean age, 38.2 ± 8.1 years, women 31.4%), admitted to Peking Union Medical College Hospital from 2007 to 2018. Sex differences in demographics, risk factors, etiology, and diagnostic testing were analyzed.

RESULTS

Females were significantly younger than males (36.9 versus 38.7 years, P<0.05). Hypertension (43.0%), smoking (41.1%), hyperlipidemia (37.2%), and hyperhomocysteinemia (27.9%) were common risk factors, statistically higher among males than females (P<0.05). Stroke etiology showed a significant sex difference that large-artery atherosclerosis and small-vessel diseases were more common among males than females (48.6% versus 19.4%, P<0.001; 9.9% versus 3.1%, P<0.05, respectively). Stroke of other determined etiology was more common among females (50.4% versus 19.1%, P<0.001). Relevant abnormality rates were higher among females on screening for autoimmune diseases and thrombophilia (23.3% versus 11.1%, P<0.05 and 50.0% versus 16.7%, P<0.001, respectively).

CONCLUSIONS

A high rate of the traditional stroke risk factors and etiological subtype of large artery atherosclerosis in males were found, as well as prominent sex differences in relevant diagnostic testing abnormality rates, providing useful information for developing sex-specific strategies in stroke evaluation and prevention in young adults.

Factors Associated with Severe Carotid Artery Stenosis in a Population with One of the Highest Incidences of Ischemic Stroke in Europe - Single National Center Analysis

Introduction: Despite significant advances in its prevention and acute-phase treatment, stroke is still one of the leading causes of disability and death worldwide. Ischemic stroke accounts for 80 to 87% of all strokes, with 15-30% of cases being caused by extracranial carotid artery (CA) stenosis. Methods: This is an observational, cross-sectional, single-center, prospective, registry-based study. The current research presents the preliminary results after analyzing the demographic features, biological data, and cardio- and cerebro-vascular risk factors of the first 74 patients included in the first "Romanian registry for cervical and cerebral arterial stenosis." Results: In our group of patients, the severity of carotid artery stenosis was related to fibrinogen, total cholesterol, and triglyceride blood levels. Moreover, patients who underwent carotid artery stenosis were more prone to having peri-procedural complications if they had a low blood platelet count. Concerning the associated pathologies of patients with severe carotid atheromatosis, the risk of having lower cognitive abilities was higher in subjects with atrial fibrillation, regardless of the severity of carotid artery stenosis. Conclusions: The presented study brings essential information about a population more prone to cerebral ischemic events than that of most other countries. All data obtained until this moment and which will further result from analyzing the clinical, demographic, and biological features of patients included in this registry should be used for implementing populational strategies for preventing further strokes.

High Frequency and Intensity Rehabilitation in 641 Subacute Ischemic Stroke Patients

OBJECTIVES

To determine the effects of exergaming on quality of life (QoL), motor, and clinical symptoms in subacute stroke patients.

DESIGN

A pseudorandomized controlled trial, using a before-after test design.

SETTING

University hospital.

PARTICIPANTS

Subacute, ischemic stroke outpatients (N=3857), 680 of whom were randomized and 641 completed the study.

INTERVENTIONS

We determined the effects of 5 times a week twice daily (EX2; 50 sessions; n=286) and once daily (EX1; 25 sessions; n=272) exergaming and low-intensity standard care (control [CON]; 25 sessions; n=83) on clinical, mobility, blood pressure (BP), and QoL outcomes.

MAIN OUTCOME MEASURES

The primary outcome was Modified Rankin Scale. Secondary outcomes were activities of daily living, 5 aspects of health-related QoL, Beck Depression Inventory, 6-minute walk test (6MWT), Berg Balance Scale (BBS), and static balance (center of pressure).

RESULTS

During exercise, the peak heart rate was 134, 134, and 126 beats per minute in the EX2, EX1, and CON groups, respectively. mRS improved similarly in the EX2 (-1.8; effect size, d=-4.0) and EX1 (-1.4; d=-2.6) groups, but more than in the CON group (-0.7; d=-0.6). QoL, Barthel Index, BBS, 6MWT, and standing posturography improved more in the EX2 group and the same in the EX1 and CON groups. Systolic and diastolic resting BP decreased more in the EX2 and EX1 groups than in the CON group. The intervention effects did not differ between men (n=349) and women (n=292).

CONCLUSIONS

Twice daily compared with once daily high-intensity exergaming or once daily lower intensity standard care produced superior effects on clinical and motor symptoms, BP, and QoL in male and female subacute ischemic stroke participants.

Stroke care and outcomes in the Department of Neurology in Parakou, Benin: Retrospective cohort study

Introduction

Stroke is one of the most common causes of high mortality rates in Africa with many unknown aspects around its prognosis. In this study we aim to describe stroke characteristics and in-hospital mortality of stroke in Parakou.

Methods

This is a retrospective cohort study including all stroke patients admitted to the Department of Neurology at Parakou Teaching Hospital from January 1, 2013 through to December 31, 2019. Clinical data, vascular risk factors, stroke subtype and outcome data were recorded. The in-hospital case-fatality and its associated factors were determined. The study was approved by the Local Ethics Committee of Biomedical research and has been registered under the unique indentifying number researchregistry5687 and is available at https://www.researchregistry.com/browse-the-registry#home/.

Results

Stroke cases represented 51.5% of all patients. There were 372 patients included in the study with a mean age of 58.2 ± 14.2 years. The sex ratio was 1:3. Ischemic stroke accounted for 40.3%, intracerebral hemorrhage 30.4%, and unknown 29.3%. The main vascular risk factors were hypertension (69.1%), alcoholism (23.9%) and diabetes mellitus (16.9%). The mean NIHSS at admission was 9.4 ± 5.7 and the length of hospital stay was 9.0 ± 7.3. The most common complications recorded during the acute phase were swallowing disorders (10.2%), pneumonia (9.1%) and urinary tract infections (8.3%). The in-hospital case fatality was 6.2% and was associated with loss of consciousness (p = 0.0001), high NIHSS on admission (p = 0.001), fever (p = 0.0001), swallowing disorders (p = 0.001) and leukocytosis (p = 0.021). On discharge, 27.6% were independent and 97.8% were on antihypertensive drugs.

Conclusion

The in-hospital stroke mortality was close to that reported by other studies in Africa.

Moderator Role of Mutuality on the Association Between Depression and Quality of Life in Stroke Survivor-Caregiver Dyads

BACKGROUND

Authors of previous research have not yet analyzed the role of potential moderators in the relationship between depressive symptoms and quality of life (QOL).

AIMS

The aim of this study was to examine the moderating effect of mutuality between depressive symptoms and QOL in stroke survivor and caregiver dyads.

METHODS

This study used a longitudinal design with 222 stroke survivor-caregiver dyads enrolled at survivor discharge from rehabilitation hospitals. Data collection was performed for 12 months. We examined survivor and caregiver QOL dimensions (physical, psychological, social, and environmental), depression, and mutuality at baseline and every 3 months. Hierarchical linear modeling was used to test 4 longitudinal dyadic moderation models (1 for each QOL domain).

RESULTS

Survivors (50% male) and caregivers (65% female) were 70.8 (SD, 11.9) and 52.5 (SD, 13.1) years old, respectively. We observed no significant moderating effects of mutuality for survivors across the 4 dimensions of QOL over time. However, higher survivor mutuality was significantly associated with higher survivor psychological and social QOL at baseline. Regarding caregivers, caregiver mutuality significantly moderated the association between caregiver depressive symptoms and caregiver physical (B = 0.63, P < .05), psychological (B = 0.63, P < .01), and social (B = 0.95, P < .001) QOL at baseline, but not in environmental QOL. Higher caregiver mutuality was significantly associated with less improvement in caregiver physical QOL over time.

CONCLUSIONS

Mutuality is a positive variable on the association between depression and QOL for both members of the dyad at discharge but may lead to declines in physical health for caregivers over time. Further work is needed to understand the role of mutuality on long-term outcomes and associations with increased care strain.

Temporal Asynchrony but Not Total Energy Nor Duration Improves the Judgment of Numerosity in Electrotactile Stimulation

Stroke patients suffer from impairments of both motor and somatosensory functions. The functional recovery of upper extremities is one of the primary goals of rehabilitation programs. Additional somatosensory deficits limit sensorimotor function and significantly affect its recovery after the neuromotor injury. Sensory substitution systems, providing tactile feedback, might facilitate manipulation capability, and improve patient's dexterity during grasping movements. As a first step toward this aim, we evaluated the ability of healthy subjects in exploiting electrotactile feedback on the shoulder to determine the number of perceived stimuli in numerosity judgment tasks. During the experiment, we compared four different stimulation patterns (two simultaneous: short and long, intermittent and sequential) differing in total duration, total energy, or temporal synchrony. The experiment confirmed that the subject ability to enumerate electrotactile stimuli decreased with increasing the number of active electrodes. Furthermore, we found that, in electrotactile stimulation, the temporal coding schemes, and not total energy or duration modulated the accuracy in numerosity judgment. More precisely, the sequential condition resulted in significantly better numerosity discrimination than intermittent and simultaneous stimulation. These findings, together with the fact that the shoulder appeared to be a feasible stimulation site to communicate tactile information via electrotactile feedback, can serve as a guide to deliver tactile feedback to proximal areas in stroke survivors who lack sensory integrity in distal areas of their affected arm, but retain motor skills.

Burden of Stroke in Europe: Thirty-Year Projections of Incidence, Prevalence, Deaths, and Disability-Adjusted Life Years

BACKGROUND AND PURPOSE

Prediction of stroke impact provides essential information for healthcare planning and priority setting. We aim to estimate 30-year projections of stroke epidemiology in the European Union using multiple modeling approaches.

METHODS

Data on stroke incidence, prevalence, deaths, and disability-adjusted life years in the European Union between 1990 and 2017 were obtained from the global burden of disease study. Their trends over time were modeled using 3 modeling strategies: linear, Poisson, and exponential regressions-adjusted for the gross domestic product per capita, which reflects the impact of economic development on health status. We used the Akaike information criterion for model selection. The 30-year projections up to 2047 were estimated using the best fitting models, with inputs on population projections from the United Nations and gross domestic product per capita prospects from the World Bank. The technique was applied separately by age-sex-country groups for each stroke measure.

RESULTS

In 2017, there were 1.12 million incident strokes in the European Union, 9.53 million stroke survivors, 0.46 million deaths, and 7.06 million disability-adjusted life years lost because of stroke. By 2047, we estimated an additional 40 000 incident strokes (+3%) and 2.58 million prevalent cases (+27%). Conversely, 80 000 fewer deaths (-17%) and 2.31 million fewer disability-adjusted life years lost (-33%) are projected. The largest increase in the age-adjusted incidence and prevalence rates are expected in Lithuania (average annual percentage change, 0.48% and 0.7% respectively), and the greatest reductions in Portugal (-1.57% and -1.3%). Average annual percentage change in mortality rates will range from -2.86% (Estonia) to -0.08% (Lithuania), and disability-adjusted life years' from -2.77% (Estonia) to -0.23% (Romania).

CONCLUSIONS

The number of people living with stroke is estimated to increase by 27% between 2017 and 2047 in the European Union, mainly because of population ageing and improved survival rates. Variations are expected to persist between countries showing opportunities for improvements in prevention and case management particularly in Eastern Europe.

Incidence of stroke among Saudi population: a systematic review and meta-analysis

BACKGROUND AND AIMS

Stroke is a leading cause of death and disability worldwide. However, our knowledge of the incidence of stroke for Saudi Arabian population is not known. Thus, we aimed to determine the pooled annual incidence of stroke in Saudi Arabia. We conducted a comprehensive literature search of PubMed, Web of Science, and SCOPUS, without language or publication year limits. Outcomes of interest were stroke incidence rate for both first and recurrent. A total of five studies met the inclusion criteria for this review. The pooled annual incidence of stroke in Saudi Arabia was 0.029% (95% CI: 0.015 to 0.047) equivalent of 29 strokes per 100,000 people annually (95% CI: 15 to 47).

CONCLUSION

The findings indicate that there are 29 stroke cases for every 100,000 people annually for individuals residing Saudi Arabia. Our values were lower than those of other high-income countries. Establishing a nationwide stroke registry is warranted for monitoring and improving healthcare services provided to stroke survivors.

Balance and Gait After First Minor Ischemic Stroke in People 70 Years of Age or Younger: A Prospective Observational Cohort Study

BACKGROUND

Two-thirds of patients with stroke experience only mild impairments in the acute phase, and the proportion of patients <70 years is increasing. Knowledge about balance and gait and predictive factors are scarce for this group.

OBJECTIVE

The objective of this study was to explore balance and gait in the acute phase and after 3 and 12 months in patients ≤70 years with minor ischemic stroke (National Institutes of Health Stroke Scale score ≤3). This study also explored factors predicting impaired balance after 12 months.

DESIGN

This study was designed as an explorative longitudinal cohort study.

METHODS

Patients were recruited consecutively from 2 stroke units. Balance and gait were assessed with the Mini-Balance Evaluation Systems Test (Mini-BESTest), Timed Up and Go, and preferred gait speed. Predictors for impaired balance were explored using logistic regression.

RESULTS

This study included 101 patients. Mean (SD) age was 55.5 (11.4) years, 20% were female, and mean (SD) National Institutes of Health Stroke Scale score was 0.6 (0.9) points. The Mini-BESTest, gait speed, and Timed Up and Go improved significantly from the acute phase to 3 months, and gait speed also improved from 3 to 12 months. At 12 months, 26% had balance impairments and 33% walked slower than 1.0 m/s. Poor balance in the acute phase (odds ratio = 0.92, 95% confidence interval = 0.85-0.95) was the only predictor of balance impairments (Mini-BESTest score ≤22) at 12 months poststroke.

LIMITATIONS

Limitations include lack of information about pre-stroke balance and gait impairment and poststroke exercise. Few women limited the generalizability.

CONCLUSION

This study observed improvements in both balance and gait during the follow-up; still, about one-third had balance or gait impairments at 12 months poststroke. Balance in the acute phase predicted impaired balance at 12 months.

Trends in Stroke Incidence in High-Income Countries in the 21st Century: Population-Based Study and Systematic Review

Background and Purpose- Population-based studies provide the most reliable data on stroke incidence. A previous systematic review of population-based studies suggested that stroke incidence in high-income countries decreased by 42% between the 1970s and early 2000s. However, it is uncertain whether this trend of steady decline has been maintained in more recent periods. Methods- Data from OCSP (Oxfordshire Community Stroke Project; 1981-1986) and OXVASC (Oxford Vascular Study; 2002-2017) along with other published population-based stroke incidence studies that reported temporal trends of stroke incidence since 1990 in high-income countries were included. Age-standardized relative incidence rate ratios were calculated for each study and then pooled with inverse-variance weighted random-effects meta-analysis. Projection estimates were calculated for the number of incident stroke patients in the United Kingdom from year 2015 to 2045. Results- In Oxfordshire, stroke incidence fell by 32% from OCSP to OXVASC, with a similar trend before or after year 2000. With the projected aging population, if the age-specific stroke incidence continued to decrease at its current rate (6% every 5 years), there would still be a 13% increase of the number of first-ever strokes in the United Kingdom up to year 2045. Incorporating the Oxfordshire data with other 12 population-based studies, stroke incidence declined steadily between the 1990s and 2010s within each study, resulting in a 28% decline over an average period of 16.5 years (pooled incidence rate ratio, 0.72 [95% CI, 0.66-0.79]; P<0.0001). The trend was the same for men (0.69 [95% CI, 0.61-0.77]; P<0.0001) and women (0.66 [95% CI, 0.59-0.74]; P<0.0001) and remained consistent after year 2010 in OXVASC. Proportion of disabling or fatal stroke also decreased over time (early versus later period, 53.6% versus 46.1%; P=0.02). Conclusions- Stroke incidence is continuing to decline with steady rate in Oxfordshire and in other high-income settings. However, the absolute number of strokes occurring is not falling.

Short- and Long-Term Outcomes Following Biological Pericardium Patches Versus Prosthetic Patches for Carotid Endarterectomy: A Retrospective Bicentric Study

BACKGROUND

Currently, there are various types of patches available on the market for carotid endarterectomy (CEA) with enlargement angioplasty, prosthetic, and biological patches including bovine pericardial patches. Despite the increasing use of these biological patches, there are little data in the literature comparing the results of these 2 types of patch. The purpose of this study is to compare the short- and long-term results of bovine pericardium patches (BPPs) with prosthetic patches (PPs) in carotid thromboendarterectomy.

METHODS

This study presents a retrospective analysis of all CEAs performed at Montpellier and Nîmes University Hospitals (France) in 2014 and 2015. Patients who underwent eversion were excluded. Preoperative, peroperative, and postoperative clinical and Doppler ultrasound results were collected and analyzed. The primary end point was the comparison of the restenosis rate between the BPP and the PP group. Secondary end points were the analysis of restenosis risk factors (type of patch, gender, renal failure, smoking, diabetes, arterial hypertension, dyslipidemia, and redo surgery were analyzed); the comparison of morbidity-mortality and infection between the BPP and the PP group and the comparison of morbidity-mortality between symptomatic and asymptomatic stenosis.

RESULTS

In total, 342 CEAs were performed: 168 (49%) with BPP and 174 (51%) with PP. Median follow-up was 30 months (interquartile range = 24). The stroke rate at day 30 was 3.22% and mortality at day 30 was 1.86%. There was no significant difference between groups concerning anyone of the variables of interest. At the end of follow-up, the restenosis rate >50% was 7.31% (6.45% for the BPP group vs. 8.22% for the PP group, P = 0.55). The severe restenosis rate (>70%) was 4.65% (5.16% for the BPP group vs. 4.11% for the PP group, P = 0.79). The univariate analysis identified renal failure (odds ratio = 2.69) as the main risk factor. The postoperative infection rate was 1.17% (0.59% for the BPP group vs. 1.75% for the PP group, P = 0.62).

CONCLUSIONS

The rates of stroke and postoperative death, bleeding, infection, and restenosis are comparable between BPPs and PPs in our study. The use of prosthetic or biological patches seems to deliver comparable outcomes. Further studies on larger samples are required.

Impairments in spatial navigation during walking in patients 70 years or younger with mild stroke

Background: Spatial navigation, the ability to determine and maintain a route from one place to another, is needed for independence in everyday life. Knowledge about impairments in spatial navigation in people with mild stroke is scarce.Objectives: To explore impairments in spatial navigation in patients ≤70 years after first-ever mild ischemic stroke (NIHSS≤3) and to explore which variables are associated with these impairments 12 months later.Methods: Patients were examined in the acute phase, and after 3 and 12 months. To assess impairments in spatial navigation, we used the Floor Maze Test (FMT), with time and FMT-errors as outcomes. Patients' perceived navigational skills were collected using self-report. Logistic regression was used to explore which variables (sociodemographic data, stroke characteristics, cognition, and mobility) were associated with impaired navigation ability.Results: Ninety-seven patients (20 females) were included. The mean (SD) age was 55.5 (11.4) years. Timed FMT improved significantly from the acute phase to 12 months (p = <.001). At 12 months, 24 (24.7%) of the participants walked through the maze with errors, and 22 (22.7%) reported spatial navigational problems. The Trail Making Test (TMT)-B was the only variable from the acute phase associated with FMT-errors at 12 months, and being female was the only variable associated with self-reported navigational problems at 12 months.Conclusion: Nearly one in four patients experienced spatial navigation problems 12 months after a mild stroke. Executive function (TMT-B), measured in the acute phase, was associated with navigational impairments (FMT-errors) at 12 months, and being female was associated with self-reported navigational problems.

"Invisible" visual impairments. A qualitative study of stroke survivors` experience of vision symptoms, health services and impact of visual impairments

BACKGROUND

Visual impairments (VIs) have a negative impact on life and affect up to 60% of stroke survivors. Despite this, VIs are often overlooked. This paper explores how persons with VIs experience vision care within stroke health services and how VIs impact everyday life the first 3 months post stroke.

METHODS

Individual semi-structured interviews were conducted with 10 stroke survivors 3 months post stroke, and analyzed using qualitative content analysis.

RESULTS

The main theme, "Invisible" visual impairments, represents how participants experience VIs as an unknown and difficult symptom of stroke and that the lack of attention and appropriate visual care leads to uncertainty about the future. VIs were highlighted as a main factor hindering the participants living life as before. The lack of acknowledgement, information, and systematic vision rehabilitation leads to feelings of being unsupported in the process of coping with VIs.

CONCLUSION

VIs are unknown symptoms pre stroke and sequelas after stroke that significantly affect everyday life. VIs and vision rehabilitation needs more attention through all phases of stroke health services. We request a greater awareness of VIs as a presenting symptom of stroke, and that visual symptoms should be included in stroke awareness campaigns. Further, we suggest increased competence and standardized evidence-based clinical pathways for VIs to advance all stroke health services including rehabilitation in order to improve outcomes and adaptation to future life for stroke survivors with VIs.

Assessment of the manifestations of atrial fibrillation in patients with acute cerebral stroke - a single-center study based on 998 patients

Aim of the Study: Cardioembolic stroke accounts for approximately 15-25% of ischemic strokes and is characterized by a poor prognosis. Atrial fibrillation (AF) is more commonly diagnosed in the elderly.The aim of the study was the assessment of the manifestations of AF in patients hospitalized due to cerebral stroke, with particular attention paid to newly diagnosed AF.Methods: A retrospective analysis was performed on 998 cerebral stroke patients. The data were analyzed for sex, age, cerebral stroke risk factors, drugs, NIHSS, RANKIN scores and ECG recordings on admission and at discharge.Results: The mean age of disease onset was 73 ± 16 years. Women accounted for 50.8% of patients. AF prior to hospital admission was diagnosed in 20.1% of patients, while de novo AF in 26.3% of patients during hospitalization. Hypercholesterolemia, hypertriglyceridemia and smoking were more commonly reported in ischemic stroke patients without AF compared to patients with ischemic stroke and AF. Ischemic heart disease, more frequent deaths, and a worse prognosis were more frequently observed in patients with ischemic stroke and AF compared to patients without AF. The first manifestation of AF in 25% of stroke patients was related to the period of the first 10 days of hospitalization.Discussion: The above data should prompt neurologists, cardiologists and family doctors to try to detect AF as a risk factor for ischemic stroke which worsens patient prognosis, prolongs hospital stay and contributes to increase in mortality, especially when more effective drug treatment is currently possible.

Ischemic stroke and mitochondria: mechanisms and targets

Stroke is one of the main causes of mortality and disability in most countries of the world. The only way of managing patients with ischemic stroke is the use of intravenous tissue plasminogen activator and endovascular thrombectomy. However, very few patients receive these treatments as the therapeutic time window is narrow after an ischemic stroke. The paucity of stroke management approaches can only be addressed by identifying new possible therapeutic targets. Mitochondria have been a rare target in the clinical management of stroke. Previous studies have only investigated the bioenergetics and apoptotic roles of this organelle; however, the mitochondrion is now considered as a key organelle that participates in many cellular and molecular functions. This review discusses the mitochondrial mechanisms in cerebral ischemia such as its role in reactive oxygen species (ROS) generation, apoptosis, and electron transport chain dysfunction. Understanding the mechanisms of mitochondria in neural cell death during ischemic stroke might help to design new therapeutic targets for ischemic stroke as well as other neurological diseases.