Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

Mirror therapy combined with neuromuscular electrical stimulation for poststroke lower extremity motor function recovery: a systematic review and meta-analysis

The combination of mirror therapy (MT) and neuromuscular electrical stimulation (NMES) has been devised as an intervention method in stroke rehabilitation; however, few studies have investigated its efficacy in lower extremity motor function recovery. In this systematic review and meta-analysis, we examined the effectiveness of combined MT and NMES therapy in improving poststroke walking speed, spasticity, balance and other gait parameters. Randomized controlled trials (RCTs) were selected from PubMed, Cochrane Library, EMBASE, and Scopus databases. In total, six RCTs which involving 181 participants were included. Our findings indicate that MT combined with NMES elicits greater improvement relative to control group in walking speed (SMD = 0.67, 95% confidence interval [CI] 0.26-1.07, P = 0.001), Berg Balance Scale (SMD = 0.72; 95% CI 0.31-1.13; P = 0.0007), cadence (SMD = 0.59, 95% CI 0.02-1.16, P = 0.04), step length (SMD = 0.94, 95% CI 0.35-1.53, P = 0.002), and stride length (SMD = 0.95, 95% CI 0.36-1.54, P = 0.002) but not in modified Ashworth scale (SMD =  - 0.40, 95% CI - 1.05 to 0.26, P = 0.23). Our findings suggest that MT combined with NMES may be a suitable supplemental intervention to conventional therapy in stroke survivors.

The role of the kynurenine pathway in cognitive functioning after stroke: A prospective clinical study

BACKGROUND

The kynurenine pathway is the main metabolic pathway of tryptophan degradation and has been associated with stroke and impaired cognitive functioning, but studies on its role in post-stroke cognitive impairment (PSCI) are scarce. We aimed to investigate associations between metabolites of the kynurenine pathway at baseline and post-stroke cognitive functioning over time.

METHODS

Baseline plasma kynurenines were quantified in 198 stroke patients aged 65.4 ± 10.8 years, 138 (69.7%) men, who were followed up over a period of three years after stroke. Baseline and longitudinal associations of kynurenines with PSCI and cognitive domain scores were investigated using linear mixed models, adjusted for several confounders.

RESULTS

No evidence of associations between kynurenines and odds of PSCI were found. However, considering individual cognitive domains, higher plasma levels of anthranilic acid (AA) were associated with better episodic memory at baseline (β per SD 0.16 [0.05, 0.28]). Additionally, a linear-quadratic association was found for the kynurenic acid/ quinolinic acid ratio (KA/QA), a neuroprotective index, with episodic memory (Wald χ2 = 8.27, p = .016). Higher levels of KA were associated with better processing speed in women only (pinteraction = .008; β per SD 0.15 [95% CI 0.02, 0.27]). These associations did not change over time.

CONCLUSIONS

Higher levels of KA, AA and KA/QA were associated with better scores on some cognitive domains at baseline. These associations did not change over time. Given the exploratory nature and heterogeneity of findings, these results should be interpreted with caution, and verified in other prospective studies.

Higher oxidative balance score decreases risk of stroke in US adults: evidence from a cross-sectional study

Background

The oxidative balance score (OBS) can be used to represent the overall burden of oxidative stress in an individual. This study aimed to explore the association between the risk of stroke and OBS.

Methods and materials

The National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018 was used to extract a series of variables for participants who took the stroke questionnaire. The construction of OBS relied on diet and lifestyle components, which included 16 nutrients and 4 lifestyle factors. Weighted multivariable-adjusted logistic regression was performed to investigate the association between stroke risk and OBS. A stratified analysis was also conducted. The dose-response relationship between stroke risk and OBS was elucidated by performing a restricted cubic spline function.

Results

A total of 20,680 participants were included for analysis, 768 of whom suffered from stroke. Based on weighted multivariable logistic regression analysis, we discovered that the stroke prevalence decreased by 2% for each OBS unit added [OR: 0.98 (0.97-1.00), P < 0.01]. For the OBS subgroup, we also discovered that higher OBS was related to a reduction in the risk of stroke [Q4 vs. Q1: OR:0.65 (0.46-0.90), P < 0.01]. The prevalence of stroke declined by 3% with every OBS unit added to the diet component [OR: 0.97 (0.96-0.99), P < 0.01]. For the dietary OBS subgroup, higher OBS in diet components was associated with a decrease in the prevalence of stroke [Q4 vs. Q1: OR: 0.65, (0.47-0.91), P < 0.05]. Further stratified analysis showed that every OBS unit raised was associated with a decline in stroke prevalence, which was statistically significant in participants in subgroups of ≥60 years, female, no-diabetes mellitus and no-hypertension. OBS and stroke prevalence were correlated in a linear manner.

Conclusion

The study found that a higher OBS was associated with a decrease in stroke prevalence, which could be a significant indicator for evaluating stroke risk.

Infection with COVID-19 is a risk factor for poor prognosis in patients with intracranial hemorrhage: A prospective observational cohort study

This research aimed to explore the COVID-19 infection in the prognosis of patients with intracerebral hemorrhage (ICH), as well as analyzed the risk factors of the poor prognosis. This present prospective observational cohort study enrolled 136 patients with ICH who were admitted in our hospital during May 2020 to July 2022. The diagnosis of COVID-19 was confirmed by reverse transcriptase polymerase chain reaction. All patients were collected demographic and clinical data and were followed up for 3 months, and we used the modified Rankin scale (mRS) to assess the prognosis of ICH patients, mRS score ≥ 3 indicated a bad prognosis and mRS score ≤ 2 indicated a good prognosis. All data used SPSS 18.0 for statistical analyses. The mRS score after 3 months of patients in COVID-19 group were also remarkably elevated than that in the patients in control group (P < .05). The levels of fasting plasma glucose (FPG), D-dimer (D-D) were remarkably enhanced in the ICH patients in COVID-19 group compared to the control group (P < .05). The national institutes of health stroke scale scores, hematoma volume, the serum levels of white blood cell, FPG, D-D and the proportion of patients with diabetes were significantly higher while the Glasgow coma scale scores were significantly lower in bad prognosis group (P < .05). In addition, we found a significantly higher rate of COVID-19 infections in ICH patients with poor prognosis (P < .05). Infection of COVID-19, FPG, white blood cell, national institutes of health stroke scale, Glasgow coma scale and hematoma volume were the risk factors for poor prognosis in patients with ICH. This study showed that the proportion of patients with diabetes, the mRS score after 3 months and the levels of FPG, D-D were remarkably elevated in the ICH patients in COVID-19 group compared to the control group. This study may provide the effective preventive and treatment measures for the burden of ICH on families and society.

[Inclisiran in patients with acute ischemic stroke: first data]

AIM

To evaluate the effect of inclisiran therapy on parameters of lipid metabolism in hospitalized patients with acute ischemic stroke.

MATERIAL AND METHODS

A prospective, observational, non-randomized study was performed. The study included 12 patients with acute ischemic stroke prescribed with a combination lipid-lowering therapy with inclisiran (284 mg as a single dose). At 15 days after the start of therapy, changes in blood lipid composition were assessed. For quantitative variables, median, maximum and minimum values were determined. The significance of differences between related samples in quantitative variables was assessed using the Mann-Whitney test.

RESULTS

Before the start of combination lipid-lowering therapy, total cholesterol (TC) was 7.33 mmol/l and low-density lipoprotein C (LDL-C) was 5.23 mmol/l. At 15 days after the start of inclisiran therapy, TC significantly decreased by 52.1 % and LDL-C decreased by 71.1 %. The proportion of patients who reached the LDL-C goal was 66.7 %. There were no adverse events considered by the investigators to be related with the therapy.

CONCLUSION

The strategy of early administration of inclisiran (or its combination with a statin) in patients with ischemic stroke allows safe achievement of a significant reduction in LDL-C already in 15 days after the start of therapy.

Pathogenesis-adaptive polydopamine nanosystem for sequential therapy of ischemic stroke

Ischemic stroke is lethal cerebrovascular disease, and reperfusion as the main strategy of blood supply restoration can cause severe ischemic brain damage. Considered as the major obstacle in medication for stroke, neuroinflammation after reperfusion undergoes dynamic progression, making precision treatment for stroke a Herculean task. In this work, we report a pathogenesis-adaptive polydopamine nanosystem for sequential therapy of ischemic stroke. Intrinsic free radical scavenging and tailored mesostructure of the nanosystem can attenuate oxidative stress at the initial stage. Upon microglial overactivation at the later stage, minocycline-loaded nanosystem can timely reverse the pro-inflammatory transition in response to activated matrix metalloproteinase-2, providing on-demand regulation. Further in vivo stroke study demonstrates a higher survival rate and improved brain recovery of the sequential strategy, compared with mono-therapy and combined therapy. Complemented with satisfactory biosafety results, this adaptive nanosystem for sequential and on-demand regulation of post-stroke neuroinflammation is a promising approach to ischemic stroke therapy.

Effects of Jiawei Yiqihuoxue decotion for the treatment of post stroke depression and anxiety

This study retrospectively assessed the effects of Jiawei Yiqihuoxue decotion (JWYQHXD) for the treatment of post stroke depression and anxiety (PSDA). This retrospective study included 72 patients who had undergone PSDA. All patients received flupentixol and melitracen and were divided into treatment (n = 36) and control (n = 36) groups. In addition, all the patients in the treatment group underwent JWYQHXD treatment. All patients in both groups were treated for 8 weeks. The primary outcomes were depression (assessed by Hamilton Depression Scale scores) and anxiety (evaluated by Hamilton anxiety scale scores). The secondary outcomes were quality of life (assessed using the 36-item short form health survey) and adverse events. We collected and analyzed the outcome data before and after treatment. After treatment, patients in the treatment group did not show greater relief on depression (Hamilton depression scale, P > .05) or anxiety (Hamilton anxiety scale, P > .05) than those in the control group. However, there were significant differences in quality of life 36-item short form health survey (physical function, P = .02; physical role, P = .01; and general health, P = .04) between the 2 groups after treatment. This study found that the JWYQHXD may help improve the quality of life of patients with PSDA. Future prospective studies are warranted to confirm these findings.

Effectiveness of acupuncture treatment for stroke and stroke complications: a protocol for meta-analysis and systematic review based on randomized, single-blind, controlled trials

Introduction

The treatment and rehabilitation of stroke and its complications have become major global health issues. Acupuncture is widely used as a complementary and alternative treatment for stroke. Many clinical studies have evaluated the efficacy and safety of acupuncture, but the research results need to be more consistent. The quality of research based on previously published meta-analyzes is uneven, leading to unstable conclusions. This study aims to provide a comprehensive and systematic analysis of the efficacy of high-quality, randomized controlled trials (RCTs) based on blinded designs for treating stroke and its complications. It also aims to review the characteristics of blinded designs and the current use of sham/placebo acupuncture controls in treating stroke.

Methods and analysis

This study will be conducted under the reporting guidelines for systematic reviews and meta-analyzes. Randomized controlled trials using acupuncture as the primary measure for stroke will be searched in databases such as China National Knowledge Infrastructure (CNKI), Chongqing VIP (CQVIP), Wan-fang, PubMed, Embase, Cochrane Library, and Web of Science. To evaluate high-quality research based on a blind design, if the trial evaluates the efficacy of any acupuncture intervention by including a sham/placebo acupuncture control, it will be included. The primary outcome indicator will be the ability to perform daily activities. Secondary outcome indicators include evaluating quality of life and related functions in stroke-related sequelae. We will assess the quality of evidence, reporting quality, and risk of bias for the acupuncture intervention in the literature included in this study using the GRADE system, the STRICTA 2010 checklist, and ROB2.0, respectively. RevMan 5.4 software will be used to conduct the meta-analysis, and Stata 15.0 software will be used for sensitivity analysis and publication bias testing.

Discussion

By analyzing high-quality, well-designed, randomized controlled trials of acupuncture, the results of this study may contribute to a more objective and standardized evaluation of acupuncture efficacy in treating stroke and its complications.Systematic review registration: PROSPERO, Identifier (CRD42023378930).

Ruscogenin timing administration mitigates cerebral ischemia-reperfusion injury through regulating circadian genes and activating Nrf2 pathway

BACKGROUND

Ruscogenin (Rus), a steroidal sapogenin extracted from Ophiopogon japonicus (L. f.) Ker-Gawl., has the effect of alleviating cerebral ischemia-reperfusion injury (IRI), acute lung injury. At present, the chronopharmacological effects of Rus are still unknown.

PURPOSE

This study explored the alleviating effect and mechanism of Rus timing administration on mice cerebral IRI.

METHODS

The animals in different groups were administrated Rus (10 mg/kg) by gavage at four time points (23:00-01:00, 05:00-07:00, 11:00-13:00, 17:00-19:00) respectively for 3 days. On the 4th day, middle cerebral artery occlusion (MCAO) surgery was operated during 5:00-7:00. Behavioral tests were executed and the brain was collected for infarct volume, qPCR and immunoblot detection. The levels of tumor necrosis factor-α (TNF-α), interleukin 6 (IL-6), interleukin-1beta (IL-1β) and inducible nitric oxide synthase (iNOS) were detected by qPCR. Glutathione (GSH), superoxide dismutase (SOD) activity and malondialdehyde (MDA) content in serum and cerebral cortex were detected. The clock genes were tested by western blot. Based on these results, 17:00-19:00 was selected to administrate Rus for further mechanism study and Nrf2 blocker group was administrated all-trans-retinoic acid (ATRA) at 14:00 for 3 days.

RESULTS

Administration of Rus reduced cerebral infarcted volume, ameliorated the behavior score and upregulated the mRNA and protein expression of Per1, Bmal1, Clock, Rev-erbα, transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2), heme oxygenase-1 (HO-1), quinone oxidoreductase 1 (NQO1). Administration of Rus during 17:00-19:00 had better preventive effect than other three time points. Combined administration of ATRA blunted the preventive effect of Rus.

CONCLUSION

The preventive effect of Rus is affected by the time of administration, which was regulated by Nrf2 pathway. Taken together, we provide solid evidence to suggest that different administration time point affect the effectiveness of Rus in alleviating IRI.

Early Intubation in Endovascular Therapy for Basilar Artery Occlusion: A Post Hoc Analysis of the BASICS Trial

BACKGROUND

The optimal anesthetic management for endovascular therapy (EVT) in patients with posterior circulation stroke remains unclear. Our objective was to investigate the impact of early intubation in patients enrolled in the BASICS trial (Basilar Artery International Cooperation Study).

METHODS

BASICS was a multicenter, randomized, controlled trial that compared the efficacy of EVT compared with the best medical care alone in patients with basilar artery occlusion. In this post hoc analysis, early intubation within the first 24 hours of the estimated time of basilar artery occlusion was examined as an additional covariate using regression modeling. We estimated the adjusted relative risks (RRs) for favorable outcomes, defined as modified Rankin Scale scores of 0 to 3 at 90 days. An adjusted common odds ratio was estimated for a shift in the distribution of modified Rankin Scale scores at 90 days.

RESULTS

Of 300 patients in BASICS, 289 patients were eligible for analysis (151 in the EVT group and 138 in the best medical care group). compared with medical care alone, EVT was related to a higher risk of early intubation (RR, 1.29 [95% CI, 1.09-1.53]; P<0.01), and early intubation was negatively associated with favorable outcome (RR, 0.61 [95% CI, 0.45-0.84]; P=0.002). Whereas there was no overall treatment effect of EVT on favorable outcome (RR, 1.22 [95% CI, 0.95-1.55]; P=0.121), EVT was associated with favorable outcome (RR, 1.34 [95% CI, 1.05-1.71]; P=0.018) and a shift toward lower modified Rankin Scale scores (adjusted common odds ratio, 1.63 [95% CI, 1.04-2.57]; P=0.033) if adjusted for early intubation.

CONCLUSIONS

In this post hoc analysis of the neutral BASICS trial, early intubation was linked to unfavorable outcomes, which might mitigate a potential benefit from EVT by indirect effects due to an increased risk of early intubation. This relationship may be considered when assessing the efficacy of EVT in patients with basilar artery occlusion in future trials.

Low vitamin B12 levels may predict the risk of ischemic stroke: A cross-sectional study

BACKGROUND

To examine serum vitamin B12 concentrations in relation to the risk of ischemic stroke among hospitalized patients in the Department of Neurology.

METHODS

We performed a cross-sectional study involving 2,212 inpatients discharged from the Department of Neurology of the First Affiliated Hospital of Chongqing Medical University, from January 2020 to January 2022. The results of laboratory assays such as serum vitamin B12, homocysteine, and folate levels were measured. Logistic regression analysis was used to investigate the association between serum vitamin B12 concentrations and ischemic stroke, with adjustment for a number of relevant demographic and lifestyle factors and comorbidities.

RESULTS

A total of 961 (43.4%) patients had an ischemic stroke. In the fully adjusted model, logistic regression analysis suggested a positive association between serum vitamin B12 levels<150 pg/mL (aOR: 1.42; 95% CI 1.02-1.97; p = 0.035), serum vitamin B12 150-300 pg/mL (aOR: 1.37; 95% CI 1.11-1.68; p = 0.003) and the prevalence of ischemic stroke. Furthermore, an inverse association was observed between serum vitamin B12 levels ≥ 900 pg/mL (aOR: 0.38; 95% CI: 0.19-0.77; p =0.007) and the prevalence of ischemic stroke. Moreover, the cut-off value of vitamin B12 concentration was 316.4 pg/mL and the discrimination power of the score evaluated by AUC-ROC was 0.71 (95%CI 0.68-0.73, p<0.001) in the vitamin B12 and ischemic stroke.

CONCLUSION

Findings suggest that low vitamin B12 levels may predict the risk of ischemic stroke, early and timely supplementation of vitamin B12 can improve the short-term prognosis of ischemic stroke patients.

Feasibility of using the Cognitive Orientation to daily Occupational Performance in a population of Danish stroke survivors: Adaptation and study protocol

BACKGROUND

A need was identified for an occupational therapy intervention for stroke survivors in a Danish municipal healthcare setting with emphasis on its ability to transfer and generalise what is learned in occupational therapy to everyday life post therapy. Being a possible candidate, the Cognitive Orientation to daily Occupational Performance (CO-OP) approach needed to be adapted to the target group and context, and its feasibility needed examination regarding reach, dose, intervention components, fidelity, perceived value, benefits, harms, and potential outcomes.

AIM

To adapt the CO-OP to a Danish healthcare setting and present a protocol for examining its feasibility.

MATERIAL AND METHODS

The Adapting interventions to new contexts (ADAPT) guidance was followed to (1) Assess the rationale for intervention and consider intervention-context fit, (2) Plan and undertake adaptations, and (3) Plan a feasibility study.

RESULTS

Intervention materials and procedures were translated and adapted for home-based occupational therapy with people in the subacute phase of stroke. A protocol was developed to examine feasibility aspects. Quantitative and qualitative evaluations were planned and measurements chosen.

CONCLUSIONS AND SIGNIFICANCE

The planned feasibility study will contribute to further developing and refining the intervention before performing a possible large-scale effectiveness study.

Phenothiazines reduced autophagy in ischemic stroke through endoplasmic reticulum (ER) stress-associated PERK-eIF2α pathway

BACKGROUND

Neuroprotective effects have been the main focus of new treatment modalities for ischemic stroke. Phenothiazines, or chlorpromazine plus promethazine (C + P), are known to prevent the generation of free radicals and uptake of Ca2+ by plasma membrane; they have a potential as a treatment for acute ischemic stroke (AIS). This study aims to investigate the role of endoplasmic reticulum (ER) stress-associated PERK-eIF2α pathway underlying the phenothiazine-induced neuroprotective effects after cerebral ischemia/reperfusion (I/R) injury.

METHODS

A total of 49 male Sprague Dawley rats (280-320 g) were randomly divided into 4 groups (n = 7 per group): (1) sham, (2) I/R that received 2 h of middle cerebral artery occlusion (MCAO), followed by 6 or 24 h of reperfusion, (3) MCAO treated by C + P without temperature control and (4) MCAO treated by C + P with temperature control. Human neuroblastoma (SH-SY5Y) cells were used in 5 groups: (1) control, (2) oxygen-glucose deprivation (OGD) for 2 h followed by reoxygenation (OGD/R), (3) OGD/R with C + P; (4) OGD/R with PERK inhibitor, GSK2656157, and (5) OGD/R with C + P and GSK2656157. The molecules of ER stress, unfolded protein response (UPR) (Bip, PERK, p-PERK, p-PERK/PERK, eIF2α, p-eIF2α, p-eIF2α/eIF2α), autophagy (ATG12, LC3II/I), and apoptosis (BAX, Bcl-XL) were measured at mRNA levels by real time PCR and protein levels by Western blotting.

RESULTS

In ischemic rats followed by reperfusion, expression of Bip, p-PERK/PERK, p-eIF2α/eIF2α, ATG12, and LC3II/I, as well as BAX were all significantly increased. These markers were significantly reduced by C + P at both 6 and 24 h of reperfusion. Anti-apoptotic Bcl-XL expression was increased, while pro-apoptotic BAX expression was decreased by C + P. In SH-SY5Y cell lines, both C + P and GSK2656157 significantly reduced the level of autophagy and apoptosis after I/R, respectively. The combination of GSK2656157 and C + P did not promote the same effect, suggesting that C + P did not induce any neuroprotective effect by inhibiting autophagy and apoptosis through the PERK-eIF2α pathway when this pathway was already blocked by GSK2656157. In general, the reduction in body temperature by phenothiazines was associated with better neuroprotection but it did not reach significant levels.

CONCLUSION

The combined treatment of C + P plays a crucial role in stroke therapy by inhibiting ER stress-mediated autophagy, thereby leading to reduced apoptosis and increased neuroprotection. Our findings highlight the PERK-eIF2α pathway as a central mechanism through which C + P exerts its beneficial effects. The results from this study may pave the way for the development of more targeted and effective treatments for stroke patients.

Biomechanical characteristics in the carotid artery: Noninvasive assessment using subharmonic emissions from microbubbles

BACKGROUND

Stroke is closely related to carotid atherosclerotic plaques, which tend to occur in specific parts of the arteries, especially at the bifurcations, and are considered to be caused by biomechanical factors. Quantitative analysis of hemodynamic stress characteristics of the carotid sinus in vivo provides a mechanical basis for the development of atherosclerotic plaque in the carotid sinus. Previous studies found that ultrasound (US) contrast agent microbubbles would vibrate nonlinearly under the excitation of sound pressure, generating subharmonics (transmission fundamental frequency, i.e., f0 and subharmonic frequency at f0 /2), which have the highest sensitivity to pressure changes and exhibit an inverse linear relationship with environmental pressure.

PURPOSE

This study employed subharmonic aided pressure estimation (SHAPE) technology to reflect carotid artery hydrodynamic characteristics in the carotid lumen.

METHODS

From May 2021 to December 2021, this prospective study reviewed a total of 26 normal carotid arteries of 13 participants, all of whom received bilateral carotid artery routine US and SHAPE US examinations. During this study, the lumen of the bilateral distal segment of the common carotid artery (Distal-CCA), carotid artery bifurcation (CAB), and carotid bulb (CB) were scanned section by section from bottom to top in longitudinal and transverse sections. Subsequently, the subharmonic amplitudes in the lumen of normal carotid arteries were collected and analyzed.

RESULTS

This study found that the amplitude of subharmonic amplitude in the carotid was distributed unevenly, with the amplitudes of subharmonic at the CAB being higher. Specifically, the subharmonic gradient of the carotid artery bifurcation apex plane was maximum (9.72 ± 4.31 dB), while the average subharmonic amplitude of the outer lateral layer of the carotid artery was higher (-56.40 ± 6.31 dB) (p < 0.001).

CONCLUSION

The SHAPE technique is capable of indirectly reflecting the pressure changes of vascular system tissues, which may provide a new monitoring method for evaluating mechanical characteristics obviating invasion.

Perilesional and contralesional brain activations related to associative encoding of unfamiliar face-names pairs in adults with left chronic stroke with or without ischemic infarct on left inferior frontal gyrus

The study of an Ischemic stroke infarction allows verifying how the lesion produces alterations in the neuronal networks resulting in cognitive deficits. It also allows the verification of adaptive and maladaptive cerebral reorganization related to the injury. In our previous fMRI study, we found that patients without ischemic vascular lesions in left inferior frontal gyrus showed an efficient compensation mechanism during the associative encoding of face name pairs, by the increased activation of ventrolateral and dorsolateral areas of contralesional hemisphere associated with better memory performance. While patients with ischemic vascular lesions on left inferior frontal gyrus (IFG) demonstrated worse memory performance and no signs of compensation mechanism. The present study explores more of these findings by analyzing perilesional and contralesional activations related to unfamiliar face name associative encoding in adults with chronic ischemic stroke, with or without left IFG lesion, compared to healthy controls. The main results showed that stroke survivors without lesions in IFG demonstrated increased activation in perilesional and contralesional prefrontal regions associated with better associative memory recognition, which are indicative of adaptive compensatory mechanisms. However, they also showed a negative correlation between the activation of right anterior prefrontal and inferior parietal regions and the associative memory performance, which may indicate the presence of maladaptive interhemispheric disinhibition. On the other hand, stroke survivors with IFG lesions demonstrated negative correlations in activations of the ipsilesional inferior parietal cortex and positive correlations in activations of the left middle frontal gyrus and left precentral cortex, which demonstrate the simultaneous occurrence of adaptive and maladaptive brain reorganization mechanisms in this group. However, the increase in perilesional prefrontal regions, associated with bilateral activation of the hippocampus and amygdala, was not enough to compensate for the inefficiency of associative memory performance. Finally, the differences in activation observed in stroke survivors reflect their clinical heterogeneity and demonstrate that adaptive or maladaptive compensatory mechanisms can coexist in the same group of patients. Furthermore, they reinforce the importance of the left IFG in the associative encoding of unfamiliar face name pairs and may suggest a deficit in associative memory related to injury in this region.

Non-contrast computed tomography features predict intraventricular hemorrhage growth

OBJECTIVES

Non-contrast computed tomography (NCCT) markers are robust predictors of parenchymal hematoma expansion in intracerebral hemorrhage (ICH). We investigated whether NCCT features can also identify ICH patients at risk of intraventricular hemorrhage (IVH) growth.

METHODS

Patients with acute spontaneous ICH admitted at four tertiary centers in Germany and Italy were retrospectively included from January 2017 to June 2020. NCCT markers were rated by two investigators for heterogeneous density, hypodensity, black hole sign, swirl sign, blend sign, fluid level, island sign, satellite sign, and irregular shape. ICH and IVH volumes were semi-manually segmented. IVH growth was defined as IVH expansion > 1 mL (eIVH) or any delayed IVH (dIVH) on follow-up imaging. Predictors of eIVH and dIVH were explored with multivariable logistic regression. Hypothesized moderators and mediators were independently assessed in PROCESS macro models.

RESULTS

A total of 731 patients were included, of whom 185 (25.31%) suffered from IVH growth, 130 (17.78%) had eIVH, and 55 (7.52%) had dIVH. Irregular shape was significantly associated with IVH growth (OR 1.68; 95%CI [1.16-2.44]; p = 0.006). In the subgroup analysis stratified by the IVH growth type, hypodensities were significantly associated with eIVH (OR 2.06; 95%CI [1.48-2.64]; p = 0.015), whereas irregular shape (OR 2.72; 95%CI [1.91-3.53]; p = 0.016) in dIVH. The association between NCCT markers and IVH growth was not mediated by parenchymal hematoma expansion.

CONCLUSIONS

NCCT features identified ICH patients at a high risk of IVH growth. Our findings suggest the possibility to stratify the risk of IVH growth with baseline NCCT and might inform ongoing and future studies.

CLINICAL RELEVANCE STATEMENT

Non-contrast CT features identified ICH patients at a high risk of intraventricular hemorrhage growth with subtype-specific differences. Our findings may assist in the risk stratification of intraventricular hemorrhage growth with baseline CT and might inform ongoing and future clinical studies.

KEY POINTS

• NCCT features identified ICH patients at a high risk of IVH growth with subtype-specific differences. • The effect of NCCT features was not moderated by time and location or indirectly mediated by hematoma expansion. • Our findings may assist in the risk stratification of IVH growth with baseline NCCT and might inform ongoing and future studies.

Rhein attenuates cerebral ischemia-reperfusion injury via inhibition of ferroptosis through NRF2/SLC7A11/GPX4 pathway

BACKGROUND

Ischemic stroke, a major cause of death and disability worldwide, results from reduced blood flow to the brain, leading to irreversible neuronal damage. Recent evidence suggests that ferroptosis, a form of regulated cell death, plays a critical role in the pathogenesis of ischemic stroke. Rhein, a natural anthraquinone compound, has demonstrated neuroprotective effects; However, its role in ferroptosis and the underlying mechanisms remain unclear. Here, we investigated the protective effects of Rhein against ischemia/reperfusion (I/R) injury in a rat model of middle cerebral artery occlusion (MCAO) and oxygen-glucose deprivation/reperfusion (OGD/R)-induced HT22 cells. Rhein treatment dose-dependently ameliorated neurological deficits, reduced infarct volume, and attenuated blood-brain barrier (BBB) disruption in the MCAO model. Furthermore, Rhein suppressed oxidative stress, intracellular ROS generation, and ferroptosis-related protein expression in both in vivo and in vitro models. Mechanistically, Rhein protected against OGD/R-induced HT22 cell injury by regulating the NRF2/SLC7A11/GPX4 signaling pathway. This effect was abolished upon NRF2 inhibition, suggesting that Rhein's neuroprotective action is NRF2-dependent. Molecular docking and microscale thermophoresis analyses further supported the direct interaction between Rhein and the ferroptosis-related protein NRF2. Collectively, our findings reveal that Rhein confers neuroprotection against cerebral I/R injury by inhibiting ferroptosis via the NRF2/SLC7A11/GPX4 axis, providing a potential therapeutic avenue for ischemic stroke.

AIMS

To investigate the neuroprotective effects of Rhein, a natural anthraquinone compound, against ischemia/reperfusion (I/R) injury and elucidate the underlying mechanisms involving ferroptosis and the NRF2/SLC7A11/GPX4 pathway.

METHODS

A rat model of middle cerebral artery occlusion (MCAO) was employed for in vivo assessments, while oxygen-glucose deprivation/reperfusion (OGD/R)-induced HT22 cells were used as an in vitro model. Comprehensive analyses, including neurological score assessment, triphenyl tetrazolium chloride staining, Evans Blue leakage assay, intracellular ROS detection, MTT assay, dual-luciferase reporter assay, oxidative stress and Fe2+ content assessment, immunofluorescence, Western blot, flow cytometry, molecular docking, and microscale thermophoresis, were performed to evaluate the effects of Rhein on I/R injury and ferroptosis.

RESULTS

Rhein conferred dose-dependent neuroprotection against cerebral I/R injury, reducing infarct volume and blood-brain barrier (BBB) disruption in the MCAO model. In both in vivo and in vitro models, Rhein suppressed oxidative stress, intracellular ROS generation, and ferroptosis-related protein expression. Furthermore, Rhein protected HT22 cells from OGD/R-induced injury by regulating the NRF2/SLC7A11/GPX4 signaling pathway, with NRF2 inhibition abolishing these therapeutic effects. Molecular docking and microscale thermophoresis analyses supported a direct interaction between Rhein and NRF2, a ferroptosis-related protein.

CONCLUSION

Rhein attenuates cerebral I/R injury by inhibiting ferroptosis via the NRF2/SLC7A11/GPX4 axis, highlighting its potential as a therapeutic agent for ischemic stroke.

Global Trends in Atherosclerotic Cardiovascular Disease

PURPOSE

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality, affecting over 523 million people globally. Atherosclerotic diseases, particularly ischemic heart disease (IHD) and stroke, are the primary mediators of CVD burden and trends, with half of CVD deaths attributed to IHD, and another quarter to ischemic stroke. The aim of this review was to provide an overview of world-wide trends in the burden of atherosclerotic CVD.

METHODS

A literature review of published studies reporting regional or global trends or burden of CVD was undertaken, with a specific focus on atherosclerotic-mediated CVDs.

FINDINGS

While long-term trends in age-standardized rates of CVD mortality and incidence indicate substantial declines in disease burden, the impact of population growth and ageing has contributed to a continued increase in the absolute number of people living with CVD. Additionally, when data are restricted to the most recent decade, there are indications that even declines in age-standardized CVD rates may have attenuated. Trends are also heterogeneous across countries and regions, with a relative increase in CVD burden in developing countries and differing trends within countries. The impact of the COVID-19 pandemic resulted in substantial short-term reductions in hospitalization rates for major atherosclerotic CVDs including acute coronary syndromes and heart failure in some countries.

IMPLICATIONS

Recent attenuation of declines in atherosclerotic CVDs with increasing absolute burden has significant implications for health systems and resource availability, with the impact of the COVID-19 pandemic on longer-term trends in CVD yet to be clearly established.

The Role of Lipid-Lowering Therapy in Post-Stroke Patients: Update and Recommendations

PURPOSE OF REVIEW

Stroke is the second leading cause of death and disability-adjusted life years worldwide, and the global lifetime risk of stroke is rising. Moreover, patients with a prior stroke are at high risk of recurrent events. We aimed at reviewing the evidence supporting aggressive secondary prevention strategies for lipid-lowering treatment in this population.

RECENT FINDINGS

Statins are the key players in such aggressive management; however, stroke survivors remain at significant residual risk suggesting the need for both better implementation of statin use as well as additional lipid lowering therapies. Newer drugs have become available and represent important tools in the management of patients with prior ischemic stroke. The role of lipid lowering treatment in hemorrhagic stroke is more controversial, given epidemiological data linking low lipid levels with increased risk of first and recurrent events. Aggressive secondary prevention strategies, including lipid lowering treatments, have proven to mitigate the risk of recurrent events in post-stroke patients. The tools available for treating such high-risk population have expanded beyond statins, and clinicians should familiarize themselves with them.

The auditory function in migraine model rats induced by postauricular nitroglycerin injection

Objective

The mechanism by which migraines produce inner ear-related symptoms is not well understood. Previous studies have found that the latency of auditory brainstem response (ABR) in animal models of migraine has changed, but the threshold has not changed significantly. Therefore, it is necessary to establish a better animal model with both migraine and hearing loss to explore the relationship between migraine and auditory function deeply.

Methods

In this study, the rat model of migraine was induced by postauricular injection of nitroglycerin (NTG), and the effect on the auditory function of the inner ear was explored by comparing with intraperitoneal injection of nitroglycerin. The rats were given the drug repeatedly on alternate days, a total of 5 dosing, with the body weight monitored during the drug administration. The tactile threshold of the rats' forepaw was measured using von-Frey filaments and auditory function was assessed by ABR.

Results

The results showed that the baseline tactile threshold of rats gradually decreased during the modeling process, and hyperalgesia appeared. Postauricular injection of NTG did not affect the weight gain of rats, while intraperitoneal injection of NTG showed slow or even negative weight gain. The ABR threshold of Click, 4 and 8 kHz of postauricular NTG injection rats increased, the latency was prolonged, and the ABR threshold in the right ear was higher than that in the left ear.

Conclusions

We demonstrated that postauricular injection of nitroglycerin may be safer and more effective than intraperitoneal injection of nitroglycerin in the process of creating rat migraine model without affecting the weight gain. Postauricular injection of nitroglycerin has more damage to the auditory function of rats. Therefore, the migraine model rat induced by postauricular injection of nitroglycerin may be a new model of cochlear migraine.

Impact of COVID-19 outbreak on stroke admission in Thailand: a quasi-experimental, ecological study on national database

This study aimed to evaluate the effect of COVID-19 outbreak on stroke admission by using a national database. A quasi-experimental, ecological study using the national database of Thailand was conducted. The study period was between January 2017 and August 2020 before and after COVID-19 outbreak starting from March 2020. Numbers of stroke admission were evaluated before and after the COVID-19 outbreak by an interrupted time series analysis for both pre- and post-COIVD-19 outbreak. There were 381,891 patients admitted throughout Thailand. Of those, 292,382 patients (76.56%) were admitted due to thrombotic stroke followed by hemorrhagic stroke (73,130 patients; 19.15%) and embolic stroke (16,379 patients; 4.29%). During pre-COVID-19 outbreak, all stroke subtypes had an increasing trend with a coefficient of 0.076 (p value < 0.001) for thrombotic stroke, 0.003 (p value < 0.001) for embolic stroke and 0.012 (p value = 0.025) for hemorrhagic stroke. The COVID-19 outbreak had significantly effect on reductions of incidence rates of thrombotic and hemorrhagic stroke with a coefficient of -2.412 (p value < 0.001) and -0.803 (p value = 0.023). The incidence rates of three stroke subtypes were increasing prior to the COVID-19 outbreak. The COVID-19 outbreak significantly impacts hospital admission rates of both thrombotic and hemorrhagic stroke subtypes.

Comparative efficacy and safety of Chinese patent medicines of acute ischemic stroke: A network meta-analysis

BACKGROUND

Acute ischemic stroke (AIS) is characterized by high morbidity, disability, mortality, recurrence, and economic burden. Clinical trials have demonstrated that the clinical efficacy of combining oral Chinese patent medicines (CPMs) with chemical drugs (CDs) is better than that of CDs alone. In this study, we performed a network meta-analysis (NMA) of RCTs to assess the efficacy of different CPMs in combination with CDs in the treatment of AIS.

METHODS

Search 6 databases from the beginning to January 10, 2023. The Cochrane Risk of Bias tool assessed the methodological quality of the included studies. The NMA was then performed using the STATA 13.0 program. The surface under the cumulative ranking curve (SUCRA) probability values were applied to rank the studied treatments, and cluster analysis was used to compare the effects of CPMs between 2 different outcomes.

RESULTS

A total of 94 eligible RCTs, involving 9581 participants, were included in this analysis. Nine CPMs, including Nao-mai-li granule (NML), Nao-mai-tai granule (NMT), Qi-long granule (QL), Long-sheng-zhi capsule (LSZ), Nao-xin-tong capsule (NXT), Nao-xue-shu oral liquid (NXS), Tong-xin-luo capsule (TXL), Xiao-shuan-chang-rong capsule (XSCR), and Xue-shuan-xin-mai-ning capsule (XSXMN) were included. Regarding the clinical effective rate, all types of CPMs + CDs treatments were significantly better than CDs treatments alone, with significant differences among the 9 selected CPMs. Compared with CDs, results showed that NXS + CDs performed best in improving clinical effective rate [OR = 4.73; 95% CI: 1.26-17.78; (SUCRA: 76.1%)]. TXL + CDs showed the most effective effect in alleviating National Institutes of Health Stroke Scale (NIHSS) [MD = -3.84; 95% CI: -5.23, -2.45; (SUCRA: 81.6%)]; NXT + CDs were most effective in improving Barthel index [MD = 13.05; 95% CI: 3.98-22.12; (SUCRA: 63.5%)]. Combined with other outcome indicators and the results of cluster analysis, NXS + CDs may assist in the potential optimal treatment regimen for AIS.

CONCLUSION

In conclusion, CPMs were found to be beneficial as adjuvant therapy in patients with AIS. Taking into account the clinical effective rate and other outcomes, NXS + CDs may be the most effective option to improve the condition of AIS patients.

Glial Fibrillary Acidic Protein Levels in Post-Stroke Depression: A Prospective Ischemic Stroke Cohort

Background and Purpose

Increased glial fibrillary acidic protein (GFAP) levels were found in cerebrovascular disease patients. The pathogenesis of depression after ischemic stroke remains largely unknown. Here, we aim to determine whether GFAP concentrations were associated with post-stroke depression (PSD) at 3 months.

Methods

From March 2022 to September 2022, patients with first-ever ischemic stroke were prospectively recruited. GFAP concentrations were detected within 24 h using an enzyme-linked immunosorbent assay. The PSD was defined as a Hamilton Depression Rating Scale 24-Item score ≥ 8.

Results

A total of 206 subjects with ischemic stroke (mean age: 63.6 years; 49.0% female) were enrolled. During the 90-day follow-up, 57 participants (27.7%) were observed in PSD. The median serum GFAP concentrations were 0.67 ng/mL. After adjustment for the covariates, higher increased GFAP levels were associated with increased risk of PSD (odds ratio [OR], 7.12; 95% confidence interval [CI], 3.29-15.44; P < 0.001). Also, the multivariate-adjusted OR of PSD associated with the fourth quartile of GFAP was 10.89 (95% CI, 3.53-33.60; P < 0.001) compared with the first quartile. Furthermore, the restricted cubic spline confirmed a linear association between GFAP and the risk of PSD (P for linearity < 0.001).

Conclusion

Our results indicated that increased circulating GFAP concentrations were significantly correlated with the risk of PSD at 3 months. Measuring the GFAP levels after ischemic stroke may add some values for the risk stratifying of PSD.

Shedding Light on Lysosomal Malondialdehyde Affecting Vitamin B12 Transport during Cerebral Ischemia/Reperfusion Injury

Cerebral ischemia-reperfusion injury (CIRI) is often accompanied by upregulation of homocysteine (Hcy). Excessive Hcy damages cerebral vascular endothelial cells and neurons, inducing neurotoxicity and even neurodegeneration. Normally, supplementation of vitamin B12 is an ideal intervention to reduce Hcy. However, vitamin B12 therapy is clinically inefficacious for CIRI. Considering oxidative stress is closely related to CIRI, the lysosome is the pivotal site for vitamin B12 transport. Lysosomal oxidative stress might hinder the transport of vitamin B12. Whether lysosomal malondialdehyde (lysosomal MDA), as the authoritative biomarker of lysosomal oxidative stress, interferes with the transport of vitamin B12 has not been elucidated. This is ascribed to the absence of effective methods for real-time and in situ measurement of lysosomal MDA within living brains. Herein, a fluorescence imaging agent, Lyso-MCBH, was constructed to specifically monitor lysosomal MDA by entering the brain and targeting the lysosome. Erupting the lysosomal MDA level in living brains of mice under CIRI was first observed using Lyso-MCBH. Excessive lysosomal MDA was found to affect the efficacy of vitamin B12 by blocking the transport of vitamin B12 from the lysosome to the cytoplasm. More importantly, the expression and function of the vitamin B12 transporter LMBD1 were proved to be associated with excessive lysosomal MDA. Altogether, the revealing of the lysosomal MDA-LMBD1 axis provides a cogent interpretation of the inefficacy of vitamin B12 in CIRI, which could be a prospective therapeutic target.

Prevalence and characteristics of comorbid stroke and traumatic brain injury in a real-world population: findings from a nationally representative cross-sectional survey in China

BACKGROUND

In China, data on the prevalence and characteristics of comorbid stroke and traumatic brain injury (TBI) in real-world populations are still lacking but of paramount importance for the evidence-based prevention and control of the comorbidity of the two diseases. This study aimed to investigate the prevalence and characteristics of comorbid stroke and TBI in a real-world population.

METHODS

In 2013, a nationally representative, door-to-door survey on stroke and TBI using a complex, multistage, probability sampling design was conducted among approximately 600,000 participants from 155 urban and rural areas in China (Ethic ID: KY2013-006-01). The weighted prevalence of comorbid stroke and TBI was estimated using individuals' final weight. A Poisson regression analysis was used to compare the rate ratio of the comorbidity prevalence among different subgroups of the population, including age, sex, place of residence, and geographic location subgroups. For analyses of associations between the comorbidities and predictors of interest, all other variables were adjusted for in a multinomial logistic regression model.

RESULTS

Among the 596,536 people, 219 patients with comorbid stroke and TBI were identified. The point prevalence of comorbid stroke and TBI weighted to the China 2010 census population was 29.30 (95% CI: 22.69-37.84) per 100,000 population in China. The adjusted prevalence of post-TBI stroke in patients with previous TBI was significantly higher than that of post-stroke TBI in patients with previous stroke (6021.3 vs. 811.1 per 100,000 people; rate ratio: 11.001; 95% CI: 8.069-14.998). Patients with nonconcussion had significantly higher rates of both pre-stroke TBI (odds ratio: 4.694; 95% CI: 3.296-6.687) and post-stroke TBI (odds ratio: 6.735; 95% CI: 3.719-12.194) than patients with concussion. Compared to patients with ischaemic stroke, patients with subarachnoid haemorrhage (odds ratio: 2.044; 95% CI: 1.097-3.809) and intracerebral haemorrhage (odds ratio: 1.903; 95% CI: 1.296-2.795) had significantly higher rates of post-TBI stroke.

CONCLUSIONS

The high prevalence of stroke among TBI patients is becoming a new public health issue. TBI patients, especially those with nonconcussion TBI, are more likely to develop comorbid stroke and TBI than stroke patients, especially ischaemic stroke patients.

Advance directives among community-dwelling stroke survivors

OBJECTIVE

Advance directives (ADs) are integral to health care, allowing patients to specify surrogate decision-makers and treatment preferences in case of loss of capacity. The present study sought to identify determinants of ADs among stroke survivors.

METHODS

In this cross-sectional study (Care Attitudes and Preferences in Stroke Survivors [CAPriSS]), community-dwelling stroke survivors were surveyed on ADs; validated scales were used to query palliative care knowledge and attitudes towards life-sustaining treatments. Logistic regression was used to determine variables associated with ADs.

RESULTS

Among 562 community-dwelling stroke survivors who entered the survey after screening questions confirmed eligibility, 421 (74.9%) completed survey components with relevant variables of interest. The median age was 69 years (IQR 58-75 years); 53.7% were male; and 15.0% were Black. Two hundred and fifty-one (59.6%) respondents had ADs. Compared to stroke survivors without ADs, those with ADs were more likely to be older (median age 72 vs. 61 years; p<0.001), White (91.2% vs. 75.9%, p<0.001), and male (58.6% vs. 46.5%, p = 0.015), and reported higher education (p<0.001) and income (p = 0.011). Ninety-eight (23.3%) participants had "never heard of palliative care". Compared to participants without ADs, participants with ADs had higher Palliative Care Knowledge Scale (PaCKS) scores (median 10 [IQR 5-12] vs. 7 [IQR 0-11], p<0.001), and lower scores on the Attitudes Towards Life-Sustaining Treatments Scale (indicating a more negative attitude towards life-sustaining treatments; median 23 [IQR 18-28] vs. 29 [IQR 24-35], p<0.001). Multivariable logistic regression identified age (OR 1.62 per 10 year increase, 95% CI 1.30-2.02; p<0.001), prior advance care planning discussion with a physician (OR 1.73, 95% CI 1.04-2.86; p = 0.034), PaCKS scores (OR 1.06 per 1 point increase, 95% CI 1.01-1.12; p = 0.018), and Attitudes Towards Life-Sustaining Treatments Scale scores (OR 0.91 per 1 point increase, 95% CI 0.88-0.95; p<0.001) as variables independently associated with ADs.

CONCLUSIONS

Age, prior advance care planning discussion with a physician, palliative care knowledge, and attitudes towards life-sustaining treatments were independently associated with ADs.

Cerebrolysin for acute ischaemic stroke

BACKGROUND

Cerebrolysin is a mixture of low-molecular-weight peptides and amino acids derived from porcine brain, which has potential neuroprotective properties. It is widely used in the treatment of acute ischaemic stroke in Russia, Eastern Europe, China, and other Asian and post-Soviet countries. This is an update of a review first published in 2010 and last updated in 2020.

OBJECTIVES

To assess the benefits and harms of Cerebrolysin or Cerebrolysin-like agents for treating acute ischaemic stroke.

SEARCH METHODS

We searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, Web of Science Core Collection, with Science Citation Index, and LILACS in May 2022 and a number of Russian databases in June 2022. We also searched reference lists, ongoing trials registers, and conference proceedings.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing Cerebrolysin or Cerebrolysin-like agents started within 48 hours of stroke onset and continued for any length of time, with placebo or no treatment in people with acute ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Three review authors independently applied the inclusion criteria, assessed trial quality and risk of bias, extracted data, and applied GRADE criteria to the evidence.

MAIN RESULTS

Seven RCTs (1773 participants) met the inclusion criteria of the review. In this update we added one RCT of Cerebrolysin-like agent Cortexin, which contributed 272 participants. We used the same approach for risk of bias assessment that was re-evaluated for the previous update: we added consideration of the public availability of study protocols and reported outcomes to the selective outcome reporting judgement, through identification, examination, and evaluation of study protocols. For the Cerebrolysin studies, we judged the risk of bias for selective outcome reporting to be unclear across all studies; for blinding of participants and personnel to be low in three studies and unclear in the remaining four; and for blinding of outcome assessors to be low in three studies and unclear in four studies. We judged the risk of bias for generation of allocation sequence to be low in one study and unclear in the remaining six studies; for allocation concealment to be low in one study and unclear in six studies; and for incomplete outcome data to be low in three studies and high in the remaining four studies. The manufacturer of Cerebrolysin supported three multicentre studies, either totally, or by providing Cerebrolysin and placebo, randomisation codes, research grants, or statisticians. We judged two studies to be at high risk of other bias and the remaining five studies to be at unclear risk of other bias. We judged the study of Cortexin to be at low risk of bias for incomplete outcome data and at unclear risk of bias for all other domains. All-cause death: Cerebrolysin or Cortexin probably result in little to no difference in all-cause death (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.65 to 1.41; 6 trials, 1689 participants; moderate-certainty evidence). None of the included studies reported on poor functional outcome, defined as death or dependence at the end of the follow-up period, early death (within two weeks of stroke onset), quality of life, or time to restoration of capacity for work. Only one study clearly reported on the cause of death: cerebral infarct (four in the Cerebrolysin and two in the placebo group), heart failure (two in the Cerebrolysin and one in the placebo group), pulmonary embolism (two in the placebo group), and pneumonia (one in the placebo group). Non-death attrition (secondary outcome): Cerebrolysin or similar peptide mixtures may result in little to no difference in non-death attrition, but the evidence is very uncertain, with a considerable level of heterogeneity (RR 0.72, 95% CI 0.38 to 1.39; 6 trials, 1689 participants; very low-certainty evidence). Serious adverse events (SAEs): Cerebrolysin probably results in little to no difference in the total number of people with SAEs (RR 1.16, 95% CI 0.81 to 1.66; 3 trials, 1335 participants; moderate-certainty evidence). This comprised fatal SAEs (RR 0.90, 95% CI 0.59 to 1.38; 3 trials, 1335 participants; moderate-certainty evidence) and an increase in the total number of people with non-fatal SAEs (RR 2.39, 95% CI 1.10 to 5.23; 3 trials, 1335 participants; moderate-certainty evidence). In the subgroup of dosing schedule 30 mL for 10 days (cumulative dose 300 mL), the increase was more prominent (RR 2.87, 95% CI 1.24 to 6.69; 2 trials, 1189 participants). Total number of people with adverse events: Cerebrolysin or similar peptide mixtures may result in little to no difference in the total number of people with adverse events (RR 1.03, 95% CI 0.92 to 1.14; 4 trials, 1607 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Moderate-certainty evidence indicates that Cerebrolysin or Cerebrolysin-like peptide mixtures derived from cattle brain probably have no beneficial effect on preventing all-cause death in acute ischaemic stroke. Moderate-certainty evidence suggests that Cerebrolysin probably has no beneficial effect on the total number of people with serious adverse events. Moderate-certainty evidence also indicates a potential increase in non-fatal serious adverse events with Cerebrolysin use.

Clinical outcomes associated with speech, language and swallowing difficulties post-stroke

BACKGROUND

 There is a lack of prospective research in South Africa's speech therapy private sector, specifically, in the acute stroke population. There is a need to understand the quality of speech therapy services and outcomes post-stroke in the private sector.

OBJECTIVES

 This prospective cohort study investigated associations between speech, language, and swallowing conditions (i.e. dysarthria, apraxia of speech, aphasia, dysphagia), and outcomes post-stroke (i.e. length of hospital stay [LOS], degree of physical disability according to the Modified Rankin Scale [mRS], functional level of oral intake according to the Functional Oral Intake Scale [FOIS], dehydration, weight loss, aspiration pneumonia, mortality).

METHOD

 A prospective design was used to determine the incidence of speech, language, and swallowing conditions post-stroke. Convenience sampling was used to select participants (N = 68). Various statistical tests were used and the alpha level was set at Bonferroni correction p  0.01.

RESULTS

 Co-occurring speech, language, and swallowing conditions frequently occurred post-stroke (88%). Participants who were referred to speech therapy later than 24 h post-admission (52.94%) stayed in hospital for a median of 3 days longer than those who were referred within 24 h (p = 0.042). Dysphagia was significantly associated with moderate to severe physical disability (p  0.01). Dysphagia with aspiration was significantly associated with poor functional level of oral intake, at admission and at discharge (p  0.01). At discharge, aspiration pneumonia was significantly associated with severe physical disability (p  0.01, r = 0.70).

CONCLUSION

 In South Africa's private sector, co-occurring speech, language, and swallowing conditions commonly occurred post-stroke, and dysphagia was strongly associated with physical disability and poor functional level of oral intake. Length of hospital stay was increased by delayed speech therapy referrals.Contribution: This article contributes data on speech therapy services, communication and swallowing disorders post-stroke, and outcomes in South Africa's private sector.

Association of severity and prognosis with elevated blood pressure and heart rate levels in patients with intracerebral hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) has a high mortality and morbidity in the world. Elevated blood pressure (BP) and heart rate (HR) have been identified as independent risk factors, with potential to predict prognosis and recurrence of cardiovascular diseases. Our study aimed to elucidate the association between BP and HR levels and the severity, as well as prognosis, of patients diagnosed with ICH.

METHODS

The basic characteristics of patients and laboratory examination results, inclusive of BP and HR levels upon admission, were recorded as baseline data. The modified Rankin Scale and living status were taken into account for all patients at a 1-year follow-up. The relationship between various BP and HR levels and clinical outcome was analyzed using logistic regression and the Kaplan-Meier survival method.

RESULTS

A total of 1,416 patients with acute ICH from 13 hospitals in Beijing were enrolled in our study. Logistic regression analysis indicated that patients with higher HR and BP (group 4), along with those with higher HR but lower BP (group 2), exhibited a poorer prognosis compared to those with lower BP and HR (group 1). This result was particularly pronounced in younger, male subgroups (OR (95% CI) = 4.379(2.946-6.508), P < 0.0001 for group 4; OR (95% CI) = 1.819 (1.219-2.714), P = 0.0034 for group 2). At the 1-year follow-up, group 4 patients demonstrated a significantly higher rate of fatal incidence compared to other groups (P < 0.01).

CONCLUSIONS

Higher HR and BP levels, suggestive of an autonomic dysfunction, were independently associated with a poorer 1-year prognosis and reduced survival rate in ICH patients. Our findings underscore the need for early intervention to modulate these physiological parameters in patients with ICH.

Global, regional and national burden of traumatic brain injury and spinal cord injury, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

OBJECTIVES

To evaluate the most up-to-date burden of traumatic brain injury (TBI) and spinal cord injury (SCI) and analyse their leading causes in different countries/territories.

DESIGN

An analysis of Global Burden of Disease (GBD) data.

SETTING

The epidemiological data were gathered from GBD Results Tool (1 January, 1990─31 December 2019) covering 21 GBD regions and 204 countries/ territories.

PARTICIPANTS

Patients with TBI/SCI.

MAIN OUTCOMES AND MEASURES

Absolute numbers and age-standardised rates/estimates of incidence, prevalence and years lived with disability (YLDs) of TBI/SCI by location in 2019, with their percentage changes from 1990 to 2019. The leading causes (eg, falls) of TBI/SCI in 204 countries/territories.

RESULTS

Globally, in 2019, TBI had 27.16 million new cases, 48.99 million prevalent cases and 7.08 million YLDs. SCI had 0.91 million new cases, 20.64 million prevalent cases and 6.20 million YLDs. Global age-standardised incidence rates of TBI decreased significantly by -5.5% (95% uncertainty interval -8.9% to -3.0%) from 1990 to 2019, whereas SCI had no significant change (-6.1% (-17.3% to 1.5%)). Regionally, in 2019, Eastern Europe and High-income North America had the highest burden of TBI and SCI, respectively. Nationally, in 2019, Slovenia and Afghanistan had the highest age-standardised incidence rates of TBI and SCI, respectively. For TBI, falls were the leading cause in 74% (150/204) of countries/territories, followed by pedestrian road injuries (14%, 29/204), motor vehicle road injuries (5%, 11/204), and conflict and terrorism (2%, 4/204). For SCI, falls were the leading cause in 97% (198/204) of countries/territories, followed by conflict and terrorism (3%, 6/204).

CONCLUSIONS

Global age-standardised incidence rates of TBI have decreased significantly since 1990, whereas SCI had no significant change. The leading causes of TBI/SCI globally were falls, but variations did exist between countries/territories. Policy-makers should continue to prioritise interventions to reduce falls, but priorities may vary between countries/territories.

Mesenchymal Stem Cells Overexpressing FGF21 Preserve Blood-Brain Barrier Integrity in Experimental Ischemic Stroke

Blood-brain barrier (BBB) disruption is a prominent pathophysiological mechanism in stroke. Transplantation of mesenchymal stem cells (MSCs) preserves BBB integrity following ischemic stroke. Fibroblast growth factor 21 (FGF21) has been shown to be a potent neuroprotective agent that reduces neuroinflammation and protects against BBB leakage. In this study, we assessed the effects of transplantation of MSCs overexpressing FGF21 (MSCs-FGF21) on ischemia-induced neurological deficits and BBB breakdown. MSCs-FGF21 was injected into the rat brain via the intracerebroventricular route 24 h after middle cerebral artery occlusion (MCAO) surgery. The behavioral performance was assessed using modified neurological severity scores and Y-maze tests. BBB disruption was measured using Evans blue staining, IgG extravasation, and brain water content. The levels of tight junction proteins, aquaporin 4, and neuroinflammatory markers were analyzed by western blotting and immunohistochemistry. The activity of matrix metalloproteinase-9 (MMP-9) was determined using gelatin zymography. At day-5 after MCAO surgery, intraventricular injection of MSCs-FGF21 was found to significantly mitigate the neurological deficits and BBB disruption. The MCAO-induced loss of tight junction proteins, including ZO-1, occludin, and claudin-5, and upregulation of the edema inducer, aquaporin 4, were also remarkably inhibited. In addition, brain infarct volume, pro-inflammatory protein expression, and MMP-9 activation were effectively suppressed. These MCAO-induced changes were only marginally improved by treatment with MSCs-mCherry, which did not overexpress FGF21. Overexpression of FGF21 dramatically improved the therapeutic efficacy of MSCs in treating ischemic stroke. Given its multiple benefits and long therapeutic window, MSC-FGF21 therapy may be a promising treatment strategy for ischemic stroke.

Carotid calcium burden derived from computed tomography angiography as a predictor of all-cause mortality after carotid endarterectomy

OBJECTIVE

Carotid endarterectomy (CEA) aims to reduce the risk of stroke in patients with atherosclerotic carotid disease. Preoperative risk assessments that predict complications are needed to optimize the care in this patient group. The current approach, namely relying solely on symptomatology and degree of stenosis, is outdated and calls for innovation. The Agatston calcium score was applied in several vascular specialties to assess cardiovascular risk profile but has been little studied in carotid surgery. It is hypothesized that a higher calcium burden at initial presentation equates to a worse prognosis attributable to an increased cerebrovascular and cardiovascular risk profile. The aim was to investigate the association between preoperative ipsilateral calcium score and postoperative all-cause mortality in patients undergoing CEA.

METHODS

This single-center retrospective cohort study included 89 patients who underwent CEA at a tertiary referral center between 2010 and 2018. Preoperative calcium scores were measured on contrast-enhanced computed tomography images with patient-specific Hounsfield thresholds at the level of the carotid bifurcation. The association between these calcium scores and all-cause mortality was analyzed using multivariable adjusted Cox proportional hazard analysis.

RESULTS

Cox proportional hazard analysis demonstrated a significant association between preoperative ipsilateral carotid calcium score and all-cause mortality (hazard ratio, 1.10; 95% confidence interval, 1.03-1.16; P = .003). After adjusting for age, preoperative estimated glomerular filtration rate, and diabetes mellitus, a significant association remained (hazard ratio, 1.07; 95% confidence interval, 1.00-1.15; P = .05).

CONCLUSIONS

A higher calcium burden was predictive of worse outcome, which might be explained by an overall poorer health status. These results highlight the potential of calcium measurements in combination with other traditional risk factors, for preoperative risk assessment and thus for improved patient education and care.

Trends and patterns in stroke incidence, mortality, DALYs and case-fatality by sociodemographic index worldwide: an age-period-cohort analysis using the Global Burden of Disease 2019 study

OBJECTIVES

Stroke is a significant public health burden worldwide. This study aimed to explore the trends and patterns of stroke incidence, mortality, disability-adjusted life years (DALYs) and case-fatality percent (CFP) worldwide from 1990 to 2019.

STUDY DESIGN

Age-period-cohort analysis.

METHODS

Trends in stroke burden worldwide were evaluated using data from the Global Burden of Disease 2019 study. In addition, the relationship between the burden of stroke and sociodemographic index (SDI) was examined by quantile regression. Age, period and cohort patterns in stroke burden across different SDI groups were estimated using age-period-cohort analysis.

RESULTS

Between 1990 and 2019, the age-standardised rates (ASRs) of stroke incidence, mortality and DALYs declined significantly worldwide, with decreases of -16.89% (95% uncertainty interval [UI]: -18.41 to -15.29), -36.43% (95% UI: -41.65 to -31.20) and -35.23% (95% UI: -40.49 to -30.49), respectively. Regions with ASRs in the 75th percentile and below experienced significant decreases in ASRs with increasing SDI. After 2014, there was a stable or slightly increased period effect for stroke incidence in all groups, while mortality, DALYs and CFP increased only in the high SDI group. The cohort effect of stroke incidence remained constant in the high SDI group from the 1960-1964 cohort onwards.

CONCLUSIONS

Although high SDI regions had a lower stroke burden and a faster overall decline in burden, the recent relative risk data suggest a potential deceleration in the progress of reducing stroke burden in these areas. There is a need for more active measures to reduce the stroke burden in areas with the highest incidence, mortality and DALYs, as increasing SDI alone cannot lower the burden in these regions.

USP25 Inhibits Neuroinflammatory Responses After Cerebral Ischemic Stroke by Deubiquitinating TAB2

Cerebral ischemic stroke is a leading cause of morbidity and mortality globally. However, the mechanisms underlying ischemic stroke injury remain poorly understood. Here, it is found that deficiency of the ubiquitin-specific protease USP25 significantly aggravate ischemic stroke injury in mice. USP25 has no impact on neuronal death under hypoxic conditions, but reduced ischemic stroke-induced neuronal loss and neurological deficits by inhibiting microglia-mediated neuroinflammation. Mechanistically, USP25 restricts the activation of NF-κB and MAPK signaling by regulating TAB2. As a deubiquitinating enzyme, USP25 removeds K63-specific polyubiquitin chains from TAB2. AAV9-mediated TAB2 knockdown ameliorates ischemic stroke injury and abolishes the effect of USP25 deletion. In both mouse and human brains, USP25 is markedly upregulated in microglia in the ischemic penumbra, implying a clinical relevance of USP25 in ischemic stroke. Collectively, USP25 is identified as a critical inhibitor of ischemic stroke injury and this data suggest USP25 may serve as a therapeutic target for ischemic stroke.

Reliability of the Modified Frenchay Scale for the Assessment of Upper Limb Function in Adults With Hemiparesis

OBJECTIVES

To investigate the reliability of the Modified Frenchay Scale (MFS) in adults with hemiparesis.

DESIGN

Prospective analysis of videos.

SETTING

Study conducted in a Neurorehabilitation Unit of a University Hospital.

PARTICIPANTS

Fifty-one patients (17 women [33%], age 46±15, time since injury 5.2±6.7 years) with hemiparesis secondary to stroke (N=47), tumor (N=3), or spinal cord injury (N=1) were enrolled.

INTERVENTION

The MFS measures active upper limb function in spastic hemiparesis based on a video recording of 10 daily living tasks, each rated from 0 to 10. Six tasks are bimanual and 4 are unimanual with the paretic hand. MFS videos performed in routine care of patients with hemiparesis between 2015 and 2021 were collected. After a 3-hour group training session, each MFS video was assessed twice, 1 week apart by 4 rehabilitation professionals with various levels of experience in using the scale.

MAIN OUTCOME MEASURES

Internal consistency was determined using Cronbach's alpha. Intra- and inter-rater reliability was measured using intraclass correlation coefficients (ICC, mean [95% CI]), mean differences between ratings and minimal detectable change (MDC). Bland-Altman plots were also performed for inter-rater assessments.

RESULTS

The mean overall MFS score was 4.95±1.20 with no floor or ceiling effect. Cronbach's α was 0.97. For the overall MFS score, intra- and inter-rater ICCs were 0.99[0.99;1.00] and 0.97[0.95;0.98], respectively; mean intra- and inter-rater differences were 0.10±0.04 and 0.24±0.12, respectively; and MDC were 0.17 and 0.37, respectively.

CONCLUSIONS

The MFS is an internally consistent and reliable scale to assess upper limb function in adults with hemiparesis.

Characteristics, clinical practice patterns, and outcomes of strokes in India: INSPIRE-A multicentre prospective study

BACKGROUND

India has a high burden of stroke, but there are limited data available on the characteristics of patients presenting with stroke in India.

AIMS

We aimed to document the clinical characteristics, practice patterns, and outcomes of patients presenting with acute stroke to Indian hospitals.

METHODS

A prospective registry study of patients admitted with acute clinical stroke was conducted in 62 centers across different regions in India between 2009 and 2013.

RESULTS

Of the 10,329 patients included in the prescribed registry, 71.4% had ischemic stroke, 25.2% had intracerebral hemorrhage (ICH), and 3.4% had an undetermined stroke subtype. Mean age was 60 years (SD = 14) with 19.9% younger than 50 years; 65% were male. A severe stroke at admission (modified-Rankin score 4-5) was seen in 62%, with 38.4% of patients having severe disability at discharge or dying during hospitalization. Cumulative mortality was 25% at 6 months. Neuroimaging was completed in 98%, 76% received physiotherapy, 17% speech and language therapy (SLT), 7.6% occupational therapy (OT), with variability among sites; 3.7% of ischemic stroke patients received thrombolysis. Receipt of physiotherapy (odds ratio (OR) = 0.41, 95% confidence interval (CI): 0.33-0.52) and SLT (OR = 0.45, 95% CI: 0.32-0.65) was associated with lower mortality, while a history of atrial fibrillation (OR = 2.22, 95% CI: 1.37-3.58) and ICH (OR = 2.00, 95% CI: 1.66-2.40) were associated with higher mortality.

CONCLUSION

In the INSPIRE (In Hospital Prospective Stroke Registry) study, one-in-five patients with acute stroke was under 50 years of age, and one-quarter of stroke was ICH. There was a low provision of thrombolysis and poor access to multidisciplinary rehabilitation highlighting how improvements are needed to reduce morbidity and mortality from stroke in India.

Cognitive and Motor Therapy After Stroke Is Not Superior to Motor and Cognitive Therapy Alone to Improve Cognitive and Motor Outcomes: New Insights From a Meta-analysis

OBJECTIVE

To evaluate whether cognitive and motor therapy (CMT) is more effective than no therapy, motor therapy, or cognitive therapy on motor and/or cognitive outcomes after stroke. Additionally, this study evaluates whether effects are lasting and which CMT approach is most effective.

DATA SOURCES

AMED, EMBASE, MEDLINE/PubMed, and PsycINFO databases were searched in October 2022.

STUDY SELECTION

Twenty-six studies fulfilled the inclusion criteria: randomized controlled trials published in peer-reviewed journals since 2010 that investigated adults with stroke, delivered CMT, and included at least 1 motor, cognitive, or cognitive-motor outcome. Two CMT approaches exist: CMT dual-task ("classical" dual-task where the secondary cognitive task has a distinct goal) and CMT integrated (where cognitive components of the task are integrated into the motor task).

DATA EXTRACTION

Data on study design, participant characteristics, interventions, outcome measures (cognitive/motor/cognitive-motor), results and statistical analysis were extracted. Multilevel random effects meta-analysis was conducted.

DATA SYNTHESIS

CMT demonstrated positive effects compared with no therapy on motor outcomes (g=0.49; 95% confidence interval [CI], 0.10, 0.88) and cognitive-motor outcomes (g=0.29; 95% CI, 0.03, 0.54). CMT showed no significant effects compared with motor therapy on motor, cognitive, and cognitive-motor outcomes. A small positive effect of CMT compared with cognitive therapy on cognitive outcomes (g=0.18; 95% CI, 0.01, 0.36) was found. CMT demonstrated no follow-up effect compared with motor therapy (g=0.07; 95% CI, -0.04, 0.18). Comparison of CMT dual-task and integrated revealed no significant difference for motor (F1,141=0.80; P=.371) or cognitive outcomes (F1,72=0.61, P=.439).

CONCLUSIONS

CMT was not superior to monotherapies in improved outcomes after stroke. CMT approaches were equally effective, suggesting that training that enlists a cognitive load per se may benefit outcomes.

Overground Robotic Exoskeleton Training for Patients With Stroke on Walking-Related Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This review aims to evaluate the effectiveness of solely overground robotic exoskeleton (RE) training or overground RE training with conventional rehabilitation in improving walking ability, speed, and endurance among patients with stroke.

DATA SOURCES

Nine databases, 5 trial registries, gray literature, specified journals, and reference lists from inception until December 27, 2021.

STUDY SELECTION

Randomized controlled trials adopting overground robotic exoskeleton training for patients with any phases of stroke on walking-related outcomes were included.

DATA EXTRACTION

Two independent reviewers extracted items and performed risk of bias using the Cochrane Risk of Bias tool 1 and certainty of evidence using the Grades of Recommendation Assessment, Development, and Evaluation.

DATA SYNTHESIS

Twenty trials involving 758 participants across 11 countries were included in this review. The overall effect of overground robotic exoskeletons on walking ability at postintervention (d=0.21; 95% confidence interval [CI], 0.01, 0.42; Z=2.02; P=.04) and follow-up (d=0.37; 95% CI, 0.03, 0.71; Z=2.12; P=.03) and walking speed at postintervention (d=0.23; 95% CI, 0.01, 0.46; Z=2.01; P=.04) showed significant improvement compared with conventional rehabilitation. Subgroup analyses suggested that RE training should combine with conventional rehabilitation. A preferable gait training regime is <4 times per week over ≥6 weeks for ≤30 minutes per session among patients with chronic stroke and ambulatory status of independent walkers before training. Meta-regression did not identify any effect of the covariates on the treatment effect. The majority of randomized controlled trials had small sample sizes, and the certainty of the evidence was very low.

CONCLUSION

Overground RE training may have a beneficial effect on walking ability and walking speed to complement conventional rehabilitation. Further large-scale and long-term, high-quality trials are recommended to enhance the quality of overground RE training and confirm its sustainability.

S100B and brain ultrasound: Novel predictors for functional outcome in acute ischemic stroke patients

OBJECTIVE

Stroke is a leading cause of mortality and disability worldwide. This study aimed to assess the prognostic value of serum S100B protein, transcranial color-coded duplex sonography (TCCD), and optic nerve sheath diameter (ONSD) in predicting functional outcomes in critically ill patients with acute ischemic stroke (AIS).

METHODS

In this prospective observational study, 80 adult AIS patients were evaluated. Serum S100B protein levels, ONSD, and middle cerebral artery pulsatility index (MCA PI) were measured on days 1 and 3. Functional outcomes at 90 days were assessed using the modified Rankin Scale (mRS) and categorized into favourable (mRS 0-2) or unfavourable (mRS 3-6) groups. The association of demographic, clinical, laboratory, and imaging parameters with mRS outcomes was analyzed.

RESULTS

Poor mRS outcomes occurred in 82.5 % of patients. Factors significantly associated with poor outcomes were female sex, higher National Institutes of Health Stroke Scale (NIHSS) scores on days 1, 3, and 7, and larger stroke size. Receiver Operating Characteristic (ROC) curve analysis revealed that ONSD at days 1 and 3, serum S100B levels at day 1, and right MCA PI at day 1 had significant predictive value for poor mRS outcome. Multivariate analysis identified female sex, S100B on day 1, and NIHSS on days 1, 3, and 7 as independent predictors of poor mRS outcomes.

CONCLUSIONS

The combination of S100B, ONSD, and MCA PI improved the prediction of functional outcomes in critically ill AIS patients. Early S100B measurement and brain ultrasound evaluation may serve as valuable prognostic tools for guiding therapeutic decision-making. This study provides novel insights into the role of S100B and brain ultrasound in stroke outcome prediction, particularly in critically ill AIS patients.

The multifaceted aspects of sleep and sleep-wake disorders following stroke

Sleep-wake disorders (SWD) are acknowledged risk factors for both ischemic stroke and poor cardiovascular and functional outcome after stroke. SWD are frequent following stroke, with sleep apnea (SA) being the most frequent SWD affecting more than half of stroke survivors. While sleep disturbances and SWD are frequently reported in the acute phase, they may persist in the chronic phase after an ischemic stroke. Despite the frequency and risk associated with SWD following stroke, screening for SWD remains rare in the clinical setting, due to challenges in the assessment of post-stroke SWD, uncertainty regarding the optimal timing for their diagnosis, and a lack of clear treatment guidelines (i.e., when to treat and the optimal treatment strategy). However, little evidence support the feasibility of SWD treatment even in the acute phase of stroke and its favorable effect on long-term cardiovascular and functional outcomes. Thus, sleep health recommendations and SWD treatment should be systematically embedded in secondary stroke prevention strategy. We therefore propose that the management of SWD associated with stroke should rely on a multidisciplinary approach, with an integrated diagnostic, treatment, and follow-up strategy. The challenges in the field are to improve post-stroke SWD diagnosis, prognosis and treatment, through a better appraisal of their pathophysiology and temporal evolution.

Diagnosis and treatment of dehydration after stroke: A synthesis of existing evidence

Dehydration after stroke is associated with poor health outcomes, increased mortality, and poses a significant economic burden to health services. Yet research suggests that monitoring and assessment of hydration status is not routinely undertaken. In this commentary, we critically appraise a systematic review which aimed to synthesise the existing evidence regarding diagnosis and treatment of dehydration after stroke. The review discusses common measures of dehydration, describes studies evaluating rehydration treatments, and highlights the link between dehydration and poorer health outcomes in both human and animal studies. The reviewers suggest, future research should focus on determining a single, validated, objective measure to clinically diagnose dehydration in stroke patients. Research designs should include clearly defined patient characteristics, type and severity of stroke, and type and time point of dehydration measurement, to enable comparison between studies. Management of hydration status is a crucial element of acute stroke care which should be routinely practiced.

Trajectories of post-stroke quality of life and long-term prognosis: Results from an eleven-year prospective study

PURPOSE

The relationship between quality of life (QoL) and long-term prognosis in stroke patients is still unclear. We explored physical and mental QoL trajectories during the first six months after stroke and determined the associations between trajectories and long-term prognosis in patients with first-ever ischemic stroke.

METHODS

Included were 733 participants from a prospective study. QoL was assessed with the 12-item Short Form Survey (SF-12) at baseline, 3 and 6 months. Patients' prognoses (stroke recurrence and death) were identified from 2010 to 2021. The latent class growth model (LCGM) was used to identify distinct trajectories of physical and mental QoL measured over the first 6 months. We employed the Cox model or Fine-Gray model for prognoses to examine the associations between QoL trajectories and prognosis.

RESULTS

Five trajectories of physical QoL and five trajectories of mental QoL were identified. For physical QoL of the Poor-Improved, and Moderate-Impaired trajectory versus Moderate-Improved trajectory, the hazard ratio (HR) for death was 2.39 (1.14 to 5.02), and 2.03(0.93 to 4.44); the HR for recurrence was 1.56 (0.83 to 2.94) and 2.33 (1.28 to 4.24). For mental QoL of the Moderate-Impaired trajectory versus the Moderate-Improved trajectory, the HR for death was 2.48 (1.21 to 5.07). The results were robust in the sensitivity analysis.

CONCLUSION

QoL during the first six months after ischemic stroke can be categorized into distinct groups. Change in QoL was associated with long-term survival. Secondary prevention of recurrent strokes might rely more on improving patients' physical QoL.

Stroke vs. Preeclampsia: Dangerous Liaisons of Hypertension and Pregnancy

Stroke during pregnancy and preeclampsia are two distinct but interrelated medical conditions, sharing a common denominator-blood control failure. Along with cardiovascular diseases, diabetes, dyslipidemia, and hypercoagulability, hypertension is undoubtedly a major risk factor associated with stroke. Even though men have higher age-specific stroke rates, women are facing higher life-long stroke risk, primarily due to longer life expectancy. Sex hormones, especially estrogen and testosterone, seem to play a key link in the chain of blood pressure control differences between the genders. Women affected with stroke are more susceptible to experience some atypical stroke manifestations, which might eventually lead to delayed diagnosis establishment, and result in higher morbidity and mortality rates in the population of women. Preeclampsia is a part of hypertensive disorder of pregnancy spectrum, and it is common knowledge that women with a positive history of preeclampsia are at increased stroke risk during their lifetime. Preeclampsia and stroke display similar pathophysiological patterns, including hypertension, endothelial dysfunction, dyslipidemia, hypercoagulability, and cerebral vasomotor reactivity abnormalities. High-risk pregnancies carrying the burden of hypertensive disorder of pregnancy have up to a six-fold higher chance of suffering from stroke. Resemblance shared between placental and cerebral vascular changes, adaptations, and sophisticated auto-regulatory mechanisms are not merely coincidental, but they reflect distinctive and complex cardiovascular performances occurring in the maternal circulatory system during pregnancy. Placental and cerebral malperfusion appears to be in the midline of both of these conditions; placental malperfusion eventually leads to preeclampsia, and cerebral to stoke. Suboptimal performances of the cardiovascular system are proposed as a primary cause of uteroplacental malperfusion. Placental dysfunction is therefore designated as a secondary condition, initiated by the primary disturbances of the cardiovascular system, rather than an immunological disorder associated with abnormal trophoblast invasion. In most cases, with properly and timely applied measures of prevention, stroke is predictable, and preeclampsia is a controllable condition. Understanding the differences between preeclampsia and stroke in pregnancy is vital for healthcare providers to enhance their clinical decision-making strategies, improve patient care, and promote positive maternal and pregnancy outcomes. Management approaches for preeclampsia and stroke require a multidisciplinary approach involving obstetricians, neurologists, and other healthcare professionals.

Cerebrovascular risk factors and their time-dependent effects on stroke survival in the EMMA cohort study

To investigate the time-dependent effects of traditional risk factors on functional disability in all-cause mortality post-stroke, we evaluated data from a long-term stroke cohort. Baseline cerebrovascular risk factors (CVRF) and functionality at 1 and 6 months were evaluated in survivors from a prospective stroke cohort using the modified Rankin scale (m-RS), which classifies participants as improvement of disability, unchanged disability (at least moderate), and worsening disability. Cox regression models considering baseline risk factors, medication use, and functionality 6 months after stroke were fitted to identify their time-dependent effects up to 12 years of follow-up. Adjusted hazard ratios (HR) with 95% confidence intervals (CI) are presented. Among 632 survivors (median age 68, 54% male, 71% first-ever episode), age and functional disability (unchanged and worsening) 6 months after ischemic stroke had time-dependent effects on all-cause mortality risk up to 12 years of follow-up. The most impacting risk factors were unchanged (at least moderate) (HR, 2.99; 95%CI: 1.98-4.52) and worsening disability (HR, 2.85; 95%CI: 1.26-6.44), particularly in the first two years after a stroke event (Time 1: ≥6 mo to <2.5 y). Worsening disability also impacted mortality in the period from ≥2.5 to <7.5 years (Time 2) of follow-up (HR, 2.43 (95%CI: 1.03-5.73). Other baseline factors had a fixed high-risk effect on mortality during follow-up. Post-stroke and continuous medication use had a fixed protective effect on mortality. Functional disability was the main contributor with differential risks of mortality up to 12 years of follow-up.

Factors Contributing to Life-Change Adaptation in Family Caregivers of Community-Dwelling Individuals with Acquired Brain Injury

Acquired brain injury (ABI) is a public health issue that affects family caregivers, because individuals with ABI often require semi-permanent care and community support in daily living. Identifying the characteristics of family caregivers and individuals with ABI and examining life-change adaptation may provide valuable insights. The current study sought to explore the factors contributing to life-change adaptation in family caregivers of community-dwelling individuals with ABI. As a secondary analysis, a cross-sectional study was conducted using data obtained in a previous study of 1622 family caregivers in Japan. We hypothesized that life-change adaptation in family caregivers of individuals with ABI would also be related to family caregivers' characteristics and the characteristics of individuals with ABI. In total, 312 valid responses were analyzed using Poisson regression analysis. The results revealed that life-change adaptation in family caregivers of individuals with ABI was related to sex (prevalence ratio [PR]: 0.65, confidence interval [CI]: -0.819;-0.041) and mental health (PR: 2.04, CI: 0.354; 1.070) as family caregivers' characteristics, and topographical disorientation (PR: 1.51, CI: 0.017; 0.805) and loss of control over behavior (PR: 1.61, CI: 0.116; 0.830) as the characteristics of individuals with ABI, after adjusting for the effects of the caregiver's age, sex, and the duration of the caregiver's role. The current study expands existing knowledge and provides a deeper understanding to enhance the development of specific policies for improving caregiving services and supporting families.

Clinical applications of smart wearable sensors

Smart wearable sensors are electronic devices worn on the body that collect, process, and transmit various physiological data. Compared to traditional devices, their advantages in terms of portability and comfort have made them increasingly important in the medical field. This review takes a unique clinical physician's standpoint, diverging from conventional sensor-type-based classifications, and provides a comprehensive overview of the diverse clinical applications of wearable sensors in recent years. In this review, we categorize these applications according to different diseases, encompassing skin diseases and injuries, cardiovascular diseases, abnormal human motion, as well as endocrine and metabolic disorders. Additionally, we discuss the challenges and perspectives hindering the development of sensors for clinical use, emphasizing the critical need for interdisciplinary collaboration between medical and engineering professionals. Overall, this review would serve as an important reference for the future direction of sensor devices in clinical use.

Multi-Level Biomarkers for Early Diagnosis of Ischaemic Stroke: A Systematic Review and Meta-Analysis

Blood biomarkers hold potential for the early diagnosis of ischaemic stroke (IS). We aimed to evaluate the current weight of evidence and identify potential biomarkers and biological pathways for further investigation. We searched PubMed, EMBASE, the Cochrane Library and Web of Science, used R package meta4diag for diagnostic meta-analysis and applied Gene Ontology (GO) analysis to identify vital biological processes (BPs). Among 8544 studies, we included 182 articles with a total of 30,446 participants: 15675 IS, 2317 haemorrhagic stroke (HS), 1798 stroke mimics, 846 transient ischaemic attack and 9810 control subjects. There were 518 pooled biomarkers including 203 proteins, 114 genes, 108 metabolites and 88 transcripts. Our study generated two shortlists of biomarkers for future research: one with optimal diagnostic performance and another with low selection bias. Glial fibrillary acidic protein was eligible for diagnostic meta-analysis, with summary sensitivities and specificities for differentiating HS from IS between 3 h and 24 h after stroke onset ranging from 73% to 80% and 77% to 97%, respectively. GO analysis revealed the top five BPs associated with IS. This study provides a holistic view of early diagnostic biomarkers in IS. Two shortlists of biomarkers and five BPs warrant future investigation.

Age-Associated Changes in Endothelial Transcriptome and Epigenetic Landscapes Correlate With Elevated Risk of Cerebral Microbleeds

Background Stroke is a leading global cause of human death and disability, with advanced aging associated with elevated incidences of stroke. Despite high mortality and morbidity of stroke, the mechanisms leading to blood-brain barrier dysfunction and development of stroke with age are poorly understood. In the vasculature of brain, endothelial cells (ECs) constitute the core component of the blood-brain barrier and provide a physical barrier composed of tight junctions, adherens junctions, and basement membrane. Methods and Results We show, in mice, the incidents of intracerebral bleeding increases with age. After isolating an enriched population of cerebral ECs from murine brains at 2, 6, 12, 18, and 24 months, we studied age-associated changes in gene expression. The study reveals age-dependent dysregulation of 1388 genes, including many involved in the maintenance of the blood-brain barrier and vascular integrity. We also investigated age-dependent changes on the levels of CpG methylation and accessible chromatin in cerebral ECs. Our study reveals correlations between age-dependent changes in chromatin structure and gene expression, whereas the dynamics of DNA methylation changes are different. Conclusions We find significant age-dependent downregulation of the Aplnr gene along with age-dependent reduction in chromatin accessibility of promoter region of the Aplnr gene in cerebral ECs. Aplnr is associated with positive regulation of vasodilation and is implicated in vascular health. Altogether, our data suggest a potential role of the apelinergic axis involving the ligand apelin and its receptor to be critical in maintenance of the blood-brain barrier and vascular integrity.

Effects of a digital learning platform on health behaviours in stroke patients from baseline to 6 months after discharge: a randomized controlled trial

AIMS

Improving the health behaviour can help prevent stroke recurrence. The existing health education interventions require more human resource. There is a lack of constructing a low-cost, highly universal, and easy-to-use stroke secondary prevention platform based on the existing medical resources.

METHODS AND RESULTS

This was a randomized controlled trial to test the effects of a digital learning platform on the health knowledge, beliefs, and behaviours of stroke patients from baseline to 6 months after discharge. The control group received routine health education while the intervention group received health belief education during hospitalization and used a digital learning platform for 6 months after discharge. The health knowledge was assessed by The Stroke Health Knowledge Questionnaire, health beliefs by The Short Form Health Belief Model Scale for Stroke Patients, and health behaviours by the Stroke Health Behavior Scale. A total of 90 patients were included: 45 each in the intervention group and the control group, of whom 38 and 37 completed the study, respectively. At 6 months after discharge, (1) the health knowledge score of the intervention group was insignificantly higher than that of the control group, (2) the health belief score of the intervention group was significantly higher than that of the control group, and (3) the intervention group had higher health behaviour scores especially in physical activity than that of the control group. Other health behaviour dimensions have time effect, but not significant.

CONCLUSIONS

The digital learning platform can improve health behaviours of stroke patients 6 months after discharge, especially in physical activity.

REGISTRATION

ChiCTR1800019936.

Individual trigger factors for hemorrhagic stroke: Evidence from case-crossover and self-controlled case series studies

BACKGROUND

Hemorrhagic stroke (HS) is a sudden-onset disease with high mortality and disability rates, and it is crucial to explore the triggers of HS. In this study, we analyzed individual triggers for HS to provide a basis for HS prevention and intervention.

METHODS

A systematic search of five databases was conducted until December 2022. Studies on HS-related individual triggers conducted using a case-crossover study or self-controlled case series design were included in the descriptive summary and comprehensive evidence synthesis of each trigger.

RESULTS

A total of 39 studies were included after the screening, and 32 trigger factor categories were explored for associations. Potential trigger factors for HS were as follows: Antiplatelet (odd ratio (OR), 1.10; 95% confidence interval (CI), 1.00-1.21) and anticoagulant (OR, 5.43; 95% CI, 2.04-14.46) medications, mood stabilizers/antipsychotics (OR, 1.33; 95% CI, 1.07-1.65), infections (OR, 2.15; 95% CI, 1.73-2.67), vaccinations (relative risk, 1.11; 95% CI, 1.02-1.21), physical exertion (OR, 2.08; 95% CI, 1.58-2.74), cola consumption (OR, 5.45; 95% CI, 2.76-10.76), sexual activity (OR, 7.49; 95% CI, 2.23-25.22), nose blowing (OR range, 2.40-56.40), defecation (OR, 16.94; 95% CI, 3.40-84.37), and anger (OR, 3.59; 95% CI, 1.56-8.26). No associations were observed with illicit drug use (OR, 2.05; 95% CI, 0.52-8.06) or cigarette smoking (OR, 0.81; 95% CI, 0.52-1.24) and HS.

CONCLUSIONS

Individual triggers, including several medications, infections, vaccinations, and behaviors, may trigger HS onset. Direct control measures for behavioral triggers can play a crucial role in preventing HS. High-risk populations should receive personalized therapies and monitoring measures during the medication treatment to balance the risk of acute HS and the basic diseases.