Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life

The significance of the oxidative stress markers in the one-year prognosis of patients with acute ischemic stroke: a case-control study

Background

Stroke is a major cause of mortality and morbidity. Also, free radicals and oxidative stress are deleterious factor in the stroke progression. We aimed to evaluate the association between oxidative stress markers and odds of having risk factor for stroke or developing stroke.

Methods

The present case-control study was conducted on 556 participants in Imam-Reza hospital, Tabriz, Iran. Subjects were divided into three group, including individuals with acute ischemic stroke, those who were at risk of stroke, and healthy controls. All enrolled participants except for controls underwent neurological examinations and brain magnetic resonance imaging (MRI). Stroke-related disability and stroke severity were evaluated by modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS), respectively. Serum malondialdehyde (MDA) level and total antioxidant capacity (TAC) were measured within 48 h of the initiation of stroke. One-way ANOVA and Chi-square tests were used for comparing characteristics between groups. Multivariable logistic regression was implemented for odds of stroke based on MDA and TAC quartiles. Also, Spearman’s correlation was utilized.

Results

Serum MDA, systolic and diastolic blood pressure, cholesterol, and triglyceride were significantly higher in the stroke group than controls. High levels of MDA were associated with increased development of stroke (P-value < 0.001), however TAC and MDA were not associated with having risk factors for stroke (P-value = 1.00 and 0.27, respectively). Also, TAC level was negatively associated with baseline (ρ = − 0.28; P-value = 0.04) and follow-up (ρ = − 0.31; P-value = 0.03) NIHSS scores. Moreover, MDA was correlated with mRS score at follow-up (ρ = − 0.26; P-value = 0.04).

Conclusions

The balance between antioxidants and oxidants markers might reveal a new approach in this context. Further studies are warranted to identify the source of oxidative stress as well as cessation of the production of oxygen radicals in stroke.

Effect of prehospital workflow optimization on treatment delays and clinical outcomes in acute ischemic stroke: A systematic review and meta-analysis

BACKGROUND

The prehospital phase is critical in ensuring that stroke treatment is delivered quickly and is a major source of time delay. This study sought to identify and examine prehospital stroke workflow optimizations (PSWOs) and their impact on improving health systems, reperfusion rates, treatment delays, and clinical outcomes.

METHODS

The authors conducted a systematic literature review and meta-analysis by extracting data from several research databases (PubMed, Cochrane, Medline, and Embase) published since 2005. We used appropriate key search terms to identify clinical studies concerning prehospital workflow optimization, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

The authors identified 27 articles that looked at the impact of prehospital workflow optimizations on time and treatment parameters; 26 were included in the meta-analysis. The PSWO were subgrouped into three categories: improved intravenous thrombolysis (IVT) triage, large-vessel occlusion (LVO) bypass, and mobile stroke unit (MSU). The salient findings are as follows: improved IVT triage led to significantly improved rates of IVT (relative risk [RR] = 1.80, 95% confidence interval [CI] = 1.18 to 2.75); however, MSU did not (RR = 1.22, 95% CI = 0.98 to 1.52). Improved IVT triage (standard mean difference [SMD] = -0.82, 95% CI = -1.32 to -0.32), LVO bypass (SMD = -0.80, 95% CI = -1.13 to -0.47), and MSU (SMD = -0.87, 95% CI = -1.57 to -0.17) were found to significantly reduce door-to-needle time for IVT. MSU was found to significantly reduce call-to-needle (SMD = -1.41, 95% CI = -1.94 to -0.88) and onset-to-needle (SMD = -1.15, 95% CI = -1.74 to -0.56) times for IVT. MSU additionally demonstrated significant reduction in door-to-perfusion (SMD = -0.72, 95% CI = -1.32 to -0.12) as well as call-to-perfusion (SMD = -0.73, 95% CI = -1.08 to -0.38) times for EVT. Finally, PSWO did not demonstrate significant improvements in rates of good functional outcome (RR = 1.04, 95% CI = 0.97 to 1.12) or mortality at 90 days (RR = 1.00, 95% CI = 0.76 to 1.31).

CONCLUSIONS

This systematic review and meta-analysis found that PSWO significantly improves several time metrics related to stroke treatment leading to improvement in IVT reperfusion rates. Thus, the implementation of these measures in stroke networks is a promising avenue to improve an often-neglected aspect of the stroke response. However, the limited available data suggest functional outcomes and mortality are not significantly improved by PSWO; hence, further studies and improvement strategies vis-à-vis PSWOs are warranted.

Monitoring Dysfunction after Stroke Sequelae in Patients undergoing Hydro-/ Thermo-/ Kinesio-Therapy

Stroke is an important health problem generating a set of musculoskeletal and cognitive consequences that significantly affect the patient’s clinical-functional status and quality of life, as well as the effectiveness of the recovery treatment. Hydro-/ thermo-/ kinesio-therapy with water from Lake Techirghiol, known for its special properties, is also used for patients with neurological disorders and consists in immersing the patient in the therapeutic pool with specific exercises under the strict supervision of specialized medical staff. The aim of this study is to analyze the effects of Lake Techirghiol water on the functional deficit in patients with post-stroke sequelae. In this sense, 200 patients who were hospitalized in the Balneal Rehabilitation Sanatorium of Techirghiol, Constanta County, Romania during 2018-2020 were included in the study and they were divided into two groups: patients from group 1 performed on a daily basis, for 12 days, hydro-/ thermo-/ kinesiotherapy and other physical-kinetic procedures, and the patients from group 2 performed on a daily basis, for 12 days, only physical-kinetic procedures, without hydro-/ thermo-/ kinesio-therapy. Patients’ assessment was made based on the Functional Independence Measure scale and a better evolution was observed in the patients who performed hydro-/ thermo-/ kinesio-therapy as compared to those who did not perform this procedure, in the sense of a diminution of the functional deficit by making self-service activities easier and by improving gait disorders and transfers. We consider appropriate that we extend the period of patients’ treatment and follow-up in our next research so as to highlight, if relevant, any notable changes in terms of increasing functional independence also in the case of patients undergoing land-based kinesiotherapy.

Habitual flavonoid intake and ischemic stroke incidence in the Danish Diet, Cancer, and Health Cohort

BACKGROUND

Flavonoid-rich foods have antiinflammatory, antiatherogenic, and antithrombotic properties that may contribute to a lower risk of ischemic stroke.

OBJECTIVES

We aimed to investigate the relationship between habitual flavonoid consumption and incidence of ischemic stroke in participants from the Danish Diet, Cancer and Health Study.

DESIGN

In this prospective cohort study, 55,169 Danish residents without a prior ischemic stroke [median (IQR) age at enrolment of 56 y (52-60)], were followed for 21 y (20-22). We used Phenol-Explorer to estimate flavonoid intake from food frequency questionnaires obtained at study entry. Incident cases of ischemic stroke were identified from Danish nationwide registries and restricted cubic splines in Cox proportional hazards models were used to investigate relationships with flavonoid intake.

RESULTS

During follow-up, 4237 individuals experienced an ischemic stroke. Compared with participants in Q1 and after multivariable adjustment for demographics and lifestyle factors, those in Q5-for intake of total flavonoids, flavonols, and flavanol oligo + polymers-had a 12% [HR (95% CI): 0.88 (0.81, 0.96)], 10% [0.90 (0.82, 0.98)], and 18% [0.82 (0.75, 0.89)] lower risk of ischemic stroke incidence, respectively. Multivariable (demographic and lifestyle) adjusted associations for anthocyanins and flavones with risk of ischemic stroke were not linear, with moderate but not higher intakes associated with lower risk [anthocyanins Q3 vs. Q1 HR (95% CI): 0.85 (0.79, 0.93); flavones: 0.90 (0.84, 0.97)]. Following additional adjustment for dietary confounders, similar point estimates were observed; however, significance was only retained for anthocyanins and flavanol oligo + polymers [anthocyanins Q3 vs. Q1 HR (95% CI): 0.86 (0.79, 0.94); flavanol oligo + polymers Q5 vs. Q1 0.86 (0.78, 0.94)].

CONCLUSIONS

These findings suggest that moderate habitual consumption of healthy flavonoid-rich foods is associated with a lower risk of ischemic stroke and further investigation is therefore warranted.

Neuroprotective Effects of Guanosine in Ischemic Stroke-Small Steps towards Effective Therapy

Guanosine (Guo) is a nucleotide metabolite that acts as a potent neuromodulator with neurotrophic and regenerative properties in neurological disorders. Under brain ischemia or trauma, Guo is released to the extracellular milieu and its concentration substantially raises. In vitro studies on brain tissue slices or cell lines subjected to ischemic conditions demonstrated that Guo counteracts destructive events that occur during ischemic conditions, e.g., glutaminergic excitotoxicity, reactive oxygen and nitrogen species production. Moreover, Guo mitigates neuroinflammation and regulates post-translational processing. Guo asserts its neuroprotective effects via interplay with adenosine receptors, potassium channels, and excitatory amino acid transporters. Subsequently, guanosine activates several prosurvival molecular pathways including PI3K/Akt (PI3K) and MEK/ERK. Due to systemic degradation, the half-life of exogenous Guo is relatively low, thus creating difficulty regarding adequate exogenous Guo distribution. Nevertheless, in vivo studies performed on ischemic stroke rodent models provide promising results presenting a sustained decrease in infarct volume, improved neurological outcome, decrease in proinflammatory events, and stimulation of neuroregeneration through the release of neurotrophic factors. In this comprehensive review, we discuss molecular signaling related to Guo protection against brain ischemia. We present recent advances, limitations, and prospects in exogenous guanosine therapy in the context of ischemic stroke.

Targeting Common Signaling Pathways for the Treatment of Stroke and Alzheimer's: a Comprehensive Review

Neurodegenerative diseases such as stroke and Alzheimer's disease (AD) are two inter-related disorders that affect the neurons in the brain and central nervous system. Alzheimer's is a disease by undefined origin and causes. Stroke and its most common type, ischemic stroke (IS), occurs due to the blockade of cerebral blood vessels. As an important feature, both of disorders are associated with irreversible damages to the brain and nervous system. In this regard, finding common signaling pathways and the same molecular origin between these two diseases may be a promising way for their solution. On the basis of literature appraisal, the most common signaling cascades implicated in the pathogenesis of AD and stroke including notch, autophagy, inflammatory, and insulin signaling pathways were reviewed. Furthermore, current therapeutic strategies including natural and synthetic pharmaceuticals aiming modulation of respective signaling factors were scrutinized to ameliorate neural deficits in AD and stroke. Taken together, digging deeper in the common connections and signal targeting can be greatly helpful in understanding and unified treating of these disorders.

Neuroinflammation in Ischemic Stroke: Inhibition of cAMP-Specific Phosphodiesterases (PDEs) to the Rescue

Ischemic stroke is caused by a thromboembolic occlusion of a major cerebral artery, with the impaired blood flow triggering neuroinflammation and subsequent neuronal damage. Both the innate immune system (e.g., neutrophils, monocytes/macrophages) in the acute ischemic stroke phase and the adaptive immune system (e.g., T cells, B cells) in the chronic phase contribute to this neuroinflammatory process. Considering that the available therapeutic strategies are insufficiently successful, there is an urgent need for novel treatment options. It has been shown that increasing cAMP levels lowers neuroinflammation. By inhibiting cAMP-specific phosphodiesterases (PDEs), i.e., PDE4, 7, and 8, neuroinflammation can be tempered through elevating cAMP levels and, thereby, this can induce an improved functional recovery. This review discusses recent preclinical findings, clinical implications, and future perspectives of cAMP-specific PDE inhibition as a novel research interest for the treatment of ischemic stroke. In particular, PDE4 inhibition has been extensively studied, and is promising for the treatment of acute neuroinflammation following a stroke, whereas PDE7 and 8 inhibition more target the T cell component. In addition, more targeted PDE4 gene inhibition, or combined PDE4 and PDE7 or 8 inhibition, requires more extensive research.

The Effectiveness of Additional Core Stability Exercises in Improving Dynamic Sitting Balance, Gait and Functional Rehabilitation for Subacute Stroke Patients (CORE-Trial): Study Protocol for a Randomized Controlled Trial

Background: Trunk impairment produces disorders of motor control, balance and gait. Core stability exercises (CSE) are a good strategy to improve local strength of trunk, balance and gait. Methods and analysis: This is a single-blind multicenter randomized controlled trial. Two parallel groups are compared, and both perform the same type of therapy. A control group (CG) (n = 110) performs conventional physiotherapy (CP) (1 h per session) focused on improving balance. An experimental group (EG) (n = 110) performs CSE (30 min) in addition to CP (30 min) (1 h/session in total). EG is divided in two subgroups, in which only half of patients (n = 55) perform CSE plus transcutaneous electrical nerve stimulation (TENS). Primary outcome measures are dynamic sitting, assessed by a Spanish version of Trunk Impairment Scale and stepping, assessed by Brunel Balance Assessment. Secondary outcomes are postural control, assessed by Postural Assessment Scale for Stroke patients; standing balance and risk of fall assessed by Berg Balance Scale; gait speed by BTS G-Walk (accelerometer); rate of falls, lower-limb spasticity by Modified Ashworth Scale; activities of daily living by Barthel Index; and quality of life by EQ-5D-5L. These are evaluated at baseline (T0), at three weeks (T1), at five weeks (end of the intervention) (T2), at 17 weeks (T3) and at 29 weeks (T4). Study duration per patient is 29 weeks (a five-week intervention, followed by a 24-week post-intervention).

Aquatic Therapy for improving Lower Limbs Function in Post-stroke Survivors: A Systematic Review with Meta-Analysis

BACKGROUND

Lower limb disability is common in chronic stroke patients, and aquatic therapy is one of the modalities used for the rehabilitation of these patients.

OBJECTIVES

To summarize the evidence of the effects of aquatic therapy on lower limb disability compared to land-based exercises in post-stroke patients.

METHODS

MEDLINE, PsycInfo, CENTRAL, SPORTDiscus, PEDro, PsycBITE, and OT Seeker were searched from inception to January 2019. The search included only randomized clinical trials. Two reviewers independently examined the full text and conducted study selection, data extraction, and quality assessment. Data synthesis was applied to summarize information from the included studies. The quantitative analysis incorporated fixed-effect models.

RESULTS

Of the 150 studies identified in the initial search, 17 trials (629 participants) satisfied the eligibility criteria. Aquatic therapy improved balance based on the Berg Balance Scale (BBS) (standardized mean difference [SMD], 0.72; 95% confidence interval [CI], 0.50-0.94; I² = 67%) compared with land-based exercises (control). Also, aquatic therapy had a small positive effect on walking speed (SMD, -0.45; 95% CI {-0.71 - (-0.19)}; I² = 57%), based on the results of the 10-m walking test, compared to controls. Aquatic therapy had a small positive effect on mobility (based on Timed Up and Go), (SMD, -0.43; 95% CI {-0.7-(- 0.17)}; I² = 71%) compared to land-based exercise (control).

CONCLUSIONS

Aquatic therapy had a more positive effect on walking speed, balance, and mobility than land-based exercises. Further research is needed to confirm the clinical utility of aquatic therapy for patients following stroke in the long term.

Effects of CNS Injury-Induced Immunosuppression on Pulmonary Immunity

Patients suffering from stroke, traumatic brain injury, or other forms of central nervous system (CNS) injury have an increased risk of nosocomial infections due to CNS injury-induced immunosuppression (CIDS). Immediately after CNS-injury, the response in the brain is pro-inflammatory; however, subsequently, local and systemic immunity is suppressed due to the compensatory release of immunomodulatory neurotransmitters. CIDS makes patients susceptible to contracting infections, among which pneumonia is very common and often lethal. Ventilator-acquired pneumonia has a mortality of 20–50% and poses a significant risk to vulnerable patients such as stroke survivors. The mechanisms involved in CIDS are not well understood. In this review, we consolidate the evidence for cellular processes underlying the pathogenesis of CIDS, the emerging treatments, and speculate further on the immune elements at play.

Cognitive impairment in a patient with COVID-19 on hemodialysis: Too dangerous to neglect!

Neurological manifestations of coronavirus disease 2019 (COVID-19) often have tragic repercussions. Although many reports of neurological complications of severe acute respiratory syndrome coronavirus 2 infection exist, none of them are of patients on hemodialysis, who have a fivefold greater risk of stroke than the general population. In this report, we emphasize the importance of being vigilant for mild stroke in high risk populations-such as patients on hemodialysis-with COVID-19, since these conditions have overlapping symptoms.

A Digital Twins Machine Learning Model for Forecasting Disease Progression in Stroke Patients

Background: Machine learning methods have been developed to predict the likelihood of a given event or classify patients into two or more diagnostic categories. Digital twin models, which forecast entire trajectories of patient health data, have potential applications in clinical trials and patient management. Methods: In this study, we apply a digital twin model based on a variational autoencoder to a population of patients who went on to experience an ischemic stroke. The digital twin’s ability to model patient clinical features was assessed with regard to its ability to forecast clinical measurement trajectories leading up to the onset of the acute medical event and beyond using International Classification of Diseases (ICD) codes for ischemic stroke and lab values as inputs. Results: The simulated patient trajectories were virtually indistinguishable from real patient data, with similar feature means, standard deviations, inter-feature correlations, and covariance structures on a withheld test set. A logistic regression adversary model was unable to distinguish between the real and simulated data area under the receiver operating characteristic (ROC) curve (AUCadversary = 0.51). Conclusion: Through accurate projection of patient trajectories, this model may help inform clinical decision making or provide virtual control arms for efficient clinical trials.

Pre-stroke cognitive impairment is associated with vascular imaging pathology: a prospective observational study

BACKGROUND

Chronic brain pathology and pre-stroke cognitive impairment (PCI) is predictive of post-stroke dementia. The aim of the current study was to measure pre-stroke neurodegenerative and vascular disease burden found on brain MRI and to assess the association between pre-stroke imaging pathology and PCI, whilst also looking for potential sex differences.

METHODS

This prospective brain MRI cohort is part of the multicentre Norwegian cognitive impairment after stroke (Nor-COAST) study. Patients hospitalized with acute ischemic or hemorrhagic stroke were included from five participating stroke units. Visual rating scales were used to categorize baseline MRIs (N = 410) as vascular, neurodegenerative, mixed, or normal, based on the presence of pathological imaging findings. Pre-stroke cognition was assessed by interviews of patients or caregivers using the Global Deterioration Scale (GDS). Stroke severity was assessed with the National Institute of Health Stroke Scale (NIHSS). Univariate and multiple logistic regression analyses were performed to investigate the association between imaging markers, PCI, and sex.

RESULTS

Patients' (N = 410) mean (SD) age was 73.6 (±11) years; 182 (44%) participants were female, the mean (SD) NIHSS at admittance was 4.1 (±5). In 68% of the participants, at least one pathological imaging marker was found. Medial temporal lobe atrophy (MTA) was present in 30% of patients, white matter hyperintensities (WMH) in 38% of patients and lacunes in 35% of patients. PCI was found in 30% of the patients. PCI was associated with cerebrovascular pathology (OR 2.5; CI = 1.4 to 4.5, p = 0.001) and mixed pathology (OR 3.4; CI = 1.9 to 6.1, p = 0.001) but was not associated with neurodegeneration (OR 1.0; CI = 0.5 to 2.2; p = 0.973). Pathological MRI markers, including MTA and lacunes, were more prevalent among men, as was a history of clinical stroke prior to the index stroke. The OR of PCI for women was not significantly increased (OR 1.2; CI = 0.8 to 1.9; p = 0.3).

CONCLUSIONS

Pre-stroke chronic brain pathology is common in stroke patients, with a higher prevalence in men. Vascular pathology and mixed pathology are associated with PCI. There were no significant sex differences for the risk of PCI.

TRIAL REGISTRATION

NCT02650531 , date of registration: 08.01.2016.

Motor coordination and grip strength assessed after the break and in various positions of the upper limb in patients after stroke in relation to healthy subjects. An observational study

BACKGROUND

Stroke patients often have weakness of the shoulder (scapular) stabilizers, which may contribute to motor impairment of the hand and wrist.

AIM

of the study was to analyze the effect of stabilization of the affected upper limb and the break in the examination on hand motor coordination and grip strength in patients after stroke in relation to healthy subjects.

DESIGN

An observational study.

SETTING

A hospital Rehabilitation Department.

POPULATION

Eighty post-stroke patients mean, 62 ± 17 years, and 77 healthy individuals mean, 25,7 ± 6,5 years.

METHODS

A Hand Tutor device and manual dynamometer were used to measure hand motor coordination parameters. Subjects were assessed in two positions: supine with the tested upper extremity extended perpendicularly to the vertical axis of the body (i.e., passive stabilization of the trunk; no stabilization of the shoulder), and supine with the tested upper extremity held close to the body (i.e., passive stabilization of the trunk and shoulder).

RESULTS

Stabilization of the shoulder improved the motor coordination parameters of the fingers and the wrist, and resulted in greater grip strength in post-stroke patients and healthy subjects (P ˂ .001). Local stabilization of the shoulder was particularly beneficial for improving hand motor coordination in females and non-dominant hands.

CONCLUSIONS

A stable position of the upper extremity can improve motor coordination and grip strength during stroke rehabilitation.

CLINICAL REHABILITATION IMPACT

Placing subjects in a supine position and stabilizing their affected upper limb may help restore motor coordination of the hand and wrist following stroke.

Design and In Vitro Study of a Dual Drug-Loaded Delivery System Produced by Electrospinning for the Treatment of Acute Injuries of the Central Nervous System

Vascular and traumatic injuries of the central nervous system are recognized as global health priorities. A polypharmacology approach that is able to simultaneously target several injury factors by the combination of agents having synergistic effects appears to be promising. Herein, we designed a polymeric delivery system loaded with two drugs, ibuprofen (Ibu) and thyroid hormone triiodothyronine (T3) to in vitro release the suitable amount of the anti-inflammation and the remyelination drug. As a production method, electrospinning technology was used. First, Ibu-loaded micro (diameter circa 0.95–1.20 µm) and nano (diameter circa 0.70 µm) fibers were produced using poly(l-lactide) PLLA and PLGA with different lactide/glycolide ratios (50:50, 75:25, and 85:15) to select the most suitable polymer and fiber diameter. Based on the in vitro release results and in-house knowledge, PLLA nanofibers (mean diameter = 580 ± 120 nm) loaded with both Ibu and T3 were then successfully produced by a co-axial electrospinning technique. The in vitro release studies demonstrated that the final Ibu/T3 PLLA system extended the release of both drugs for 14 days, providing the target sustained release. Finally, studies in cell cultures (RAW macrophages and neural stem cell-derived oligodendrocyte precursor cells—OPCs) demonstrated the anti-inflammatory and promyelinating efficacy of the dual drug-loaded delivery platform.

Effect of comorbidities on ischemic stroke mortality: An analysis of the National Inpatient Sample (NIS) Database

Background

Stroke risk has been attributed to many pathological and behavioral conditions. Various modifiable and non-modifiable risk factors have been recognized and found consistent throughout epidemiological studies. Herein, we investigate the effect of comorbidities seen with patient's suffering from ischemic stroke and its effect on in-hospital mortality.

Methods

We identified patients >18 year old in the National Inpatient Sample database with diseases of interest utilizing the tenth International Classification of Disease 10 diagnostic codes from the years 2016 to 2018. Interval data were analyzed using one-way ANOVA. Post hoc analysis was performed using Bonferroni correction methods. To determine independent predictors of in-hospital mortality, odds ratios were calculated using binary logistic regression for each comorbidity. Descriptive and numerical statistics, imputation, and logistic regression were calculated using SPSS software version 25.

Results

Patients hospitalized with ischemic stroke were found to have the following comorbidities: atrial fibrillation (7.5%), carotid artery stenosis (1.1%), diabetes mellitus type 2 (11.4%), congestive heart failure (CHF) (7.5%), essential hypertension (21.2%), and ischemic heart disease (IHD) (2.3%). In-hospital mortality rates were higher in patients hospitalized with ischemic stroke and concomitant IHD (28.2%, P < 0.001). Hospital length of stay was longest in patients with concomitant CHF (5.96 days, P < 0.001). Similarly, patients with CHF accrued the greatest in-hospital costs (69,174 USD, P < 0.001).

Conclusion

Patients hospitalized from ischemic stroke suffered from the coexistence of other comorbidities. Of the comorbidities studied, IHD was identified as having the most significant impact on in-hospital mortality.

Telerehabilitation of Post-Stroke Patients as a Therapeutic Solution in the Era of the Covid-19 Pandemic

(1) Background: Due to the pandemic caused by the SARS-CoV-2 virus, rehabilitation centres have become less available for neurological patients. This is the result of efforts to physically distance society, to try to slow the spread of the pathogen. Health care facilities were mainly restricted to urgent cases, while most physiotherapy treatments, mainly for patients with chronic conditions, were suspended. Some countries have seen a reduction in acute stroke hospital admissions of from 50% to 80%. One solution to the above problem is the use of telerehabilitation in the home environment as an alternative to inpatient rehabilitation. (2) Aim of the study: The purpose of this review is to analyse the benefits and limitations of teletherapy in relation to the functional condition of post-stroke patients. (3) Methods: Selected publications from 2019 to 2021 on the telerehabilitation of stroke patients were reviewed. The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. (4) Results: Studies have proven that teletherapy significantly improves the functional condition of post-stroke patients, resulting in improved quality of life and faster return to independence (while maintaining maximum possible precautions related to the SARS-CoV-2 virus pandemic). (5) Conclusions: Analysis of the study results showed comparable effectiveness of rehabilitation in the tele system to inpatient therapy. However, it should be emphasised that patients undergoing telerehabilitation must meet strict conditions to be eligible for this type of treatment program. However, the strength of the evidence itself supporting the effectiveness of this method ranks low due to the limited number of randomised control trials (RCT), small number of participants, and heterogeneous trials.

Societal Cost of Ischemic Stroke in Romania: Results from a Retrospective County-Level Study

BACKGROUND

Health policies in transitioning health systems are rarely informed by the economic burden of disease due to scanty access to data. This study aimed to estimate direct and indirect costs for first-ever acute ischemic stroke (AIS) during the first year for patients residing in Cluj, Romania, and hospitalized in 2019 at the County Emergency Hospital (CEH).

METHODS

The study was conducted using a mixed, retrospective costing methodology from a societal perspective to measure the cost of first-ever AIS in the first year after onset. Patient pathways for AIS were reconstructed to aid in mapping inpatient and outpatient cost items. We used anonymized administrative and clinical data at the hospital level and publicly available databases.

RESULTS

The average cost per patient in the first year after stroke onset was RON 25,297.83 (EUR 5226.82), out of which 80.87% were direct costs. The total cost in Cluj, Romania in 2019 was RON 17,455,502.7 (EUR 3,606,505.8).

CONCLUSIONS

Our costing exercise uncovered shortcomings of stroke management in Romania, particularly related to acute care and neurorehabilitation service provision. Romania spends significantly less on healthcare than other countries (5.5% of GDP vs. 9.8% European Union average), exposing stroke survivors to a disproportionately high risk for preventable and treatable post-stroke disability.

Clinical and Microbiological Analysis of Hospital-Acquired Pneumonia Among Patients With Ischemic Stroke: A Retrospective Outlook

Background Hospital-acquired pneumonia (HAP) is a leading cause of morbidity and mortality in patients with ischemic stroke. Our study aims to explore the clinical and microbiological aspects (culture and sensitivity) of stroke patients with a confirmed diagnosis of HAP. Methodology This retrospective cross-sectional study included a total of 232 patients with a confirmed diagnosis of HAP following ischemic stroke. HAP was diagnosed based on the timing of onset of symptoms and chest X-ray. Patients were evaluated for their demographic details and a myriad of clinical parameters including dysphagia, mechanical ventilation, mortality, spontaneous pneumothorax, and Glasgow coma scale (GCS) score. The frequencies of different microorganisms isolated from the tracheal secretions were reported. Thereafter, the percentages of resistant isolates against a plethora of antimicrobial agents were tabulated. Results Out of 232 patients, 110 were males and 122 were females with a mean age of 58.79 ± 8.62 years. Dysphagia and mechanical ventilation were present in 66.4% and 72%, respectively. The mortality rate was 30.6%. Klebsiella pneumoniae was the most frequently isolated organism (28.9%), followed by Escherichia coli (24.5%), and Pseudomonas aeruginosa (23.3%). The antimicrobial resistance patterns of most of the isolates against different antibiotics were alarmingly high. Conclusions Dysphagia and mechanical ventilation are frequently present in patients of ischemic stroke with associated HAP. The antimicrobial resistance patterns of the isolated organisms are a cause of major concern. This necessitates the need for proper sanitation and the careful use of antibiotics.

Changes in Muscle Tone, Function, and Pain in the Chronic Hemiparetic Shoulder after Dry Needling Within or Outside Trigger Points in Stroke Patients: A Crossover Randomized Clinical Trial

OBJECTIVES

To investigate the effects of applying dry needling into a trigger point (TrP) or non-TrP area in people who have suffered a stroke and to investigate if the effects of dry needling are maintained at six-week follow-up.

METHODS

A controlled, repeated-measures, crossover, double-blinded randomized trial was conducted. Nineteen patients with hemiparetic shoulder pain after a stroke event were randomly assigned to receive a single multimodal treatment session combined with TrP dry needling or non-TrP dry needling. The neuro-rehabilitation session included modulatory interventions targeting the central nervous system. Spasticity (Modified Ashworth Scale), shoulder pain intensity (numerical pain rate scale, 0-10), and upper extremity function (Motor Evaluation Scale for Upper Extremity in Stroke [MESUPES], Reaching Performance Scale [RPS]) were assessed before (baseline) and one, two, three, four, five, and six weeks after the treatment session by a blinded assessor. All participants received both sessions in a randomized order where they were followed up for six weeks before receiving the opposite treatment and then followed up for another six weeks.

RESULTS

Changes in muscle tone (all P > 0.266) and upper extremity function (MESUPES: F = 0.544, P  = 0.465; RPS close task: F = 0.820, P = 0.371; RPS far task: 0.830, P  = 0.368) were similar after both interventions at all follow-up periods. The decrease in shoulder pain was higher within the TrP dry needling group as compared with the non-TrP dry needling group, particularly at two and four weeks (P  = 0.01).

CONCLUSIONS

The effect of dry needling on muscle tone (spasticity) and upper extremity function is not related to its application in or outside of a TrP area. The effect of dry needling on shoulder pain was slightly superior when applied over a TrP in poststroke people. These effects were maintained six weeks after treatment.

Ten-year risk of cerebrovascular accidents in incident rheumatoid arthritis: a population-based study of trends over time

OBJECTIVE

To evaluate secular trends in 10-year risk of incident cerebrovascular accidents (CVA), in incident RA relative to the general population.

METHODS

We conducted a retrospective study of a population-based incident cohort with RA onset from 1997 to 2004 in British Columbia, Canada, with matched general population controls (2:1), using administrative health data. RA and general population cohorts were divided according to year of RA onset, defined according to the first RA visit of the case definition. Incident CVA was defined as the first CVA occurring within 10 years from the first RA visit. Secular trend was assessed using delayed-entry Cox models with a two-way interaction term between the year of RA onset and indicator of RA vs general population. Linear, quadratic and spline functions of year of RA onset were compared with assess non-linear effects. The model with the lowest Akaike Information Criterion was selected.

RESULTS

Overall, 23 545 RA and 47 090 general population experienced 658 and 1220 incident CVAs, respectively. A spline Cox model with a knot at year of onset 1999 was selected. A significant decline in risk of CVA was observed in individuals with RA onset after 1999 [0.90 (0.86, 0.95); P = 0.0001]. The change in CVA risk over time differed significantly in RA with onset from 1999 onwards compared with the general population (P-value of interaction term = 0.03), but not before 1999 (P = 0.06).

CONCLUSION

Our findings suggest that people with RA onset from 1999 onwards, had a significantly greater decline in 10-year risk of CVA compared with the general population.

Transient Receptor Potential Channel Ankyrin 1: A Unique Regulator of Vascular Function

TRPA1 (transient receptor potential ankyrin 1), the lone member of the mammalian ankyrin TRP subfamily, is a Ca²⁺-permeable, non-selective cation channel. TRPA1 channels are localized to the plasma membranes of various cells types, including sensory neurons and vascular endothelial cells. The channel is endogenously activated by byproducts of reactive oxygen species, such as 4-hydroxy-2-noneal, as well as aromatic, dietary molecules including allyl isothiocyanate, a derivative of mustard oil. Several studies have implicated TRPA1 as a regulator of vascular tone that acts through distinct mechanisms. First, TRPA1 on adventitial sensory nerve fibers mediates neurogenic vasodilation by stimulating the release of the vasodilator, calcitonin gene-related peptide. Second, TRPA1 is expressed in the endothelium of the cerebral vasculature, but not in other vascular beds, and its activation results in localized Ca²⁺ signals that drive endothelium-dependent vasodilation. Finally, TRPA1 is functionally present on brain capillary endothelial cells, where its activation orchestrates a unique biphasic propagation mechanism that dilates upstream arterioles. This response is vital for neurovascular coupling and functional hyperemia in the brain. This review provides a brief overview of the biophysical and pharmacological properties of TRPA1 and discusses the importance of the channel in vascular control and pathophysiology.

Remote Ischemic Conditioning With Exercise (RICE)-Rehabilitative Strategy in Patients With Acute Ischemic Stroke: Rationale, Design, and Protocol for a Randomized Controlled Study

Objective: Exercise rehabilitation is an effective therapy in reducing the disability rate after stroke and should be carried out as early as possible. However, very early rehabilitation exercise exacerbates brain injury and is difficult to conduct in stroke patients due to their weakened and potentially disabled state. It is valuable to explore additional early rehabilitation strategies. Remote Ischemic Conditioning (RIC) is a novel therapy designed to protect vital organs from severe lethal ischemic injury by transient sublethal blood flow to non-vital organs, including the distal limbs, in order to induce endogenous protection. RIC has previously been conducted post-stroke for neuroprotection. However, whether combined early RIC and exercise (RICE) therapy enhances stroke rehabilitation remains to be determined.

Methods: This is a single-center, double-blinded, randomized controlled trial that will enroll acute ischemic stroke patients within 24 h of symptom onset or symptom exacerbation. All enrolled patients will be randomly assigned to either the RICE group (exercise with RIC) or the control group (exercise with sham RIC) at a ratio of 1:1, with 20 patients in each group. Both groups will receive RIC or sham RIC within 24 h after stroke onset or symptom exacerbation, once a day, for 14 days. All patients will begin exercise training on the fourth day, twice a day, for 11 days. Their neurological function [Modified Rankin Scale (mRS) score, National Institutes of Health Stroke Scale (NIHSS) score, Barthel Index, and walking ability], infarct volume (nuclear magnetic resonance, MRI), and adverse events will be evaluated at different time points in their post-stroke care.

Results: The primary outcome is safety, measured by the incidence of any serious RICE-related adverse events and decreased adverse events during hospitalization. The secondary outcome is a favorable prognosis within 90 days (mRS score < 2), determined by improvements in the mRS score, NIHSS score, Barthel Index, walking ability after 90 days, and infarct volume after 12 ± 2 days.

Conclusion: This study is a prospective randomized controlled trial to determine the rehabilitative effect of early RIC followed by exercise on patients with acute ischemic stroke.

Trial Registration:www.chictr.org.cn, identifier: ChiCTR2000041042

Presence of Extra-Criteria Antiphospholipid Antibodies Is an Independent Risk Factor for Ischemic Stroke

Background: Ischemic stroke is the most common and severe arterial thrombotic event in Antiphospholipid syndrome (APS). APS is an autoimmune disease characterized by the presence of thrombosis and antiphospholipid antibodies (aPL), which provide a pro-coagulant state. The aPL included in the classification criteria are lupus anticoagulant, anti-cardiolipin (aCL) and anti-β2-glycoprotein-I antibodies (aB2GPI) of IgG and IgM isotypes. Extra-criteria aPL, especially IgA aB2GPI and IgG/IgM anti-phosphatidylserine/prothrombin antibodies (aPS/PT), have been strongly associated with thrombosis. However, their role in the general population suffering from stroke is unknown. We aim (1) to evaluate the aPL prevalence in ischemic stroke patients, (2) to determine the role of aPL as a risk factor for stroke, and (3) to create an easy-to-use tool to stratify the risk of ischemic stroke occurrence considering the presence of aPL and other risk factors.

Materials and Methods: A cohort of 245 consecutive ischemic stroke patients was evaluated in the first 24 h after the acute event for the presence of classic aPL, extra-criteria aPL (IgA aB2GPI, IgG, and IgM aPS/PT) and conventional cardiovascular risk factors. These patients were followed-up for 2-years. A group of 121 healthy volunteers of the same age range and representative of the general population was used as reference population. The study was approved by the Ethics Committee for Clinical Research (Reference numbers CEIC-14/354 and CEIC-18/182).

Results: The overall aPL prevalence in stroke patients was 28% and IgA aB2GPI were the most prevalent (20%). In the multivariant analysis, the presence of IgA aB2GPI (OR 2.40, 95% CI: 1.03–5.53), dyslipidemia (OR 1.70, 95% CI: 1.01–2.84), arterial hypertension (OR 1.82, 95% CI: 1.03–3.22), atrial fibrillation (OR 4.31, 95% CI: 1.90–9.78), and active smoking (OR 3.47, 95% CI: 1.72–6.99) were identified as independent risk factors for ischemic stroke. A risk stratification tool for stroke was created based on these factors (AUC: 0.75).

Conclusions: IgA aB2GPI are an important independent risk factor for ischemic stroke. Evaluation of aPL (including extra-criteria) in cardiovascular risk factor assessment for stroke can potentially increase the identification of patients at risk of thrombotic event, facilitating a decision on preventive treatments.

Effect of the Acoustic Impedance Mismatch at the Bone-Soft Tissue Interface as a Function of Frequency in Transcranial Ultrasound: A Simulation and In Vitro Experimental Study

The transcranial Doppler (TCD) ultrasound is a method that uses a handheld low-frequency (2-2.5 MHz), pulsed Doppler phased array probe to measure blood velocity within the arteries located inside the brain. The problem with TCD lies in the low ultrasonic energy penetrating inside the brain through the skull, which leads to a low signal-to-noise ratio. This is due to several effects, including phase aberration, variations in the speed of sound in the skull, scattering, the acoustic impedance mismatch, and absorption of the three-layer medium constituted by soft tissues, the skull, and the brain. The goal of this article is to study the effect of transmission losses due to the acoustic impedance mismatch on the transmitted energies as a function of frequency. To do so, wave propagation was modeled from the ultrasonic transducer into the brain. This model calculates transmission coefficients inside the brain, leading to a frequency-dependent transmission coefficient for a given skin and bone thickness. This approach was validated experimentally by comparing the analytical results with measurements obtained from a bone phantom plate mimicking the skull. The average position error of the occurrence of the maximum amplitude between the experiment and analytical result was equivalent to a 0.06-mm error on the skin thickness given a fixed bone thickness. The similarity between the experimental and analytical results was also demonstrated by calculating correlation coefficients. The average correlation between the experimental and analytical results came out to be 0.50 for a high-frequency probe and 0.78 for a low-frequency probe. Further analysis of the simulation showed that an optimized excitation frequency can be chosen based on skin and bone thicknesses, thereby offering an opportunity to improve the image quality of TCD.

Long Noncoding RNA SNHG14 Promotes Ischemic Brain Injury via Regulating miR-199b/AQP4 Axis

BACKGROUND

Ischemic stroke is the leading cause of disability worldwide. Long noncoding RNAs (lncRNAs) play important roles in the pathogenesis of cerebral ischemia. This study aimed to investigate the role and mechanism of lncRNA small nucleolar RNA host gene 14 (SNHG14) in ischemic brain injury.

METHODS

Cerebral ischemia was induced by middle cerebral artery occlusion (MCAO) in mice. The expression of SNHG14 in MCAO mouse model was detected by quantitative real-time PCR (qRT-PCR). The levels of SNHG14, microRNA-199b (miR-199b) and aquaporin 4 (AQP4) in oxygen-glucose deprivation (OGD)-stimulated BV2 cells were determined by qRT-PCR or western blot assay. Cell proliferation and apoptosis were assessed by Cell Counting Kit-8 (CCK-8) assay and flow cytometry. The levels of pro-inflammatory cytokines were measured by enzyme-linked immunosorbent assay (ELISA). The levels of oxidative stress markers were examined using commercial kits. The relationships among SNHG14, miR-199b and AQP4 were confirmed by dual-luciferase reporter assay, RNA immunoprecipitation assay and RNA pull-down assay.

RESULTS

SNHG14 was up-regulated in MCAO mouse model. Depletion of SNHG14 lessened cerebral ischemia in MCAO mouse model. SNHG14 silencing inhibited inflammation and oxidative stress in OGD-exposed BV2 cells. MiR-199b level was decreased, while AQP4 level was increased in OGD-treated BV2 cells. Knockdown of miR-199b reversed the effect of SNHG14 knockdown on ischemic damage in OGD-stimulated BV2 cells. Moreover, AQP4 overexpression abolished the effect of miR-199b on ischemic injury in OGD-treated BV2 cells. Furthermore, SNHG14 indirectly regulate AQP4 expression by sponging miR-199b.

CONCLUSIONS

Knockdown of SNHG14 attenuated ischemic brain injury by inhibiting inflammation and oxidative stress through the miR-199b/AQP4 axis.

[Indicators of stroke morbidity and mortality from stroke in the territories included in the Federal program of caring for patients with stroke]

OBJECTIVE

To study and analyze the dynamics of stroke morbidity and mortality rates among men and women in the territories included in the Federal program for the reorganization of care for stroke patients.

MATERIAL AND METHODS

The study was based on data from the territorial-population register of strokes. The study included the following territories: Ivanovo region, Stavropol territory, the Republic of Bashkortostan, Sverdlovsk region, Irkutsk region, Sakhalin region, and the Republic of Tatarstan. Research period was from 2009 to 2016. A total of 29 779 stroke cases were analyzed. The age of the examined people was 25 years and older.

RESULTS AND CONCLUSION

In the study areas, a 2.2 - fold decrease in stroke mortality among men and a 3-fold decrease among women was found. The values of morbidity and mortality from stroke over the entire study period were higher among men. It was also revealed that in 2015-2016, the mortality rate was in a narrow range of values, which demonstrates the impact of comprehensive measures to reduce stroke mortality in all the studied territories. The results of cluster analysis of stroke incidence rates obtained from seven territories over an 8-year period indicate similar measures for primary stroke prevention among men. Among women, there are also similarities in primary stroke prevention measures, with the exception of two regions - the Stavropol territory (4.8 cases per 1000 population) and the Republic of Tatarstan (4.5 cases per 1000 population), where the highest values of the stroke incidence rate were found. The results of cluster analysis of stroke mortality rates among men indicate a fairly large variation in the indicator values. The dominant value of the stroke mortality rate among men was found in the Sakhalin region (1.61 per 1000 population). The significance of stroke mortality rates among women in the regions was similar: six territories with similar levels of values were identified. The exception was the Stavropol territory (2.48 cases per 1000 population), where the highest death rate from stroke was revealed.

Neuroprotective Phytochemicals in Experimental Ischemic Stroke: Mechanisms and Potential Clinical Applications

Ischemic stroke is a challenging disease with high mortality and disability rates, causing a great economic and social burden worldwide. During ischemic stroke, ionic imbalance and excitotoxicity, oxidative stress, and inflammation are developed in a relatively certain order, which then activate the cell death pathways directly or indirectly via the promotion of organelle dysfunction. Neuroprotection, a therapy that is aimed at inhibiting this damaging cascade, is therefore an important therapeutic strategy for ischemic stroke. Notably, phytochemicals showed great neuroprotective potential in preclinical research via various strategies including modulation of calcium levels and antiexcitotoxicity, antioxidation, anti-inflammation and BBB protection, mitochondrial protection and antiapoptosis, autophagy/mitophagy regulation, and regulation of neurotrophin release. In this review, we summarize the research works that report the neuroprotective activity of phytochemicals in the past 10 years and discuss the neuroprotective mechanisms and potential clinical applications of 148 phytochemicals that belong to the categories of flavonoids, stilbenoids, other phenols, terpenoids, and alkaloids. Among them, scutellarin, pinocembrin, puerarin, hydroxysafflor yellow A, salvianolic acids, rosmarinic acid, borneol, bilobalide, ginkgolides, ginsenoside Rd, and vinpocetine show great potential in clinical ischemic stroke treatment. This review will serve as a powerful reference for the screening of phytochemicals with potential clinical applications in ischemic stroke or the synthesis of new neuroprotective agents that take phytochemicals as leading compounds.

Effects of Hemispheric Stroke Localization on the Reorganization of Arm Movements within Different Mechanical Environments

This study investigated how stroke’s hemispheric localization affects motor performance, spinal maps and muscle synergies while performing planar reaching with and without assistive or resistive forces. A lesion of the right hemisphere affected performance, reducing average speed and smoothness and augmenting lateral deviation in both arms. Instead, a lesion of the left hemisphere affected the aiming error, impairing the feedforward control of the ipsilesional arm. The structure of the muscle synergies had alterations dependent on the lesion side in both arms. The applied force fields reduced the differences in performance and in muscle activations between arms and among populations. These results support the hypotheses of hemispheric specialization in movement control and identify potential significant biomarkers for the design of more effective and personalized rehabilitation protocols.

The Effectiveness of Massage Therapy for Improving Sequelae in Post-Stroke Survivors. A Systematic Review and Meta-Analysis

Objective: To assess the effect of therapeutic massage for improving sequelae in stroke survivors. Methods: A systematic review of the nine medical databases from January 1961 to December 2020 was carried out. The bibliography was screened to identify randomized controlled clinical trials (RCTs). Two reviewers independently screened references, selected relevant studies, extracted data and assessed the risk of bias using the PEDro scale. The primary outcome was upper and lower limb motor function and spasticity. Results: A total of 3196 studies were identified and 18 RCT were finally included (1989 individuals). A meta-analysis of RCTs in the comparison of Chinese massage (Tuina) plus conventional physiotherapy versus conventional physiotherapy was performed. The mean difference (MD) in the subacute stage on upper limb motor-function using the Fugl Meyer Assessment was 2.75; (95% confidence interval (CI) from 0.97 to 4.53, p = 0.002, I² = 36%). The MD on upper limb spasticity using modified Ashworth scale was −0.15; (95% CI from −0.24 to −0.06, p < 0.02, I² = 0%).The MD on lower limb spasticity was −0.59; (95% CI from −0.78 to −0.40, p < 0.001, I² = 0%) in the endpoint. Conclusions: Therapeutic massage, especially Tuina, in addition to conventional therapy is effective for improving motor function and for reducing spasticity in stroke survivors.

Machine learning analysis to predict the need for ankle foot orthosis in patients with stroke

We investigated the potential of machine learning techniques, at an early stage after stroke, to predict the need for ankle–foot orthosis (AFO) in stroke patients. We retrospectively recruited 474 consecutive stroke patients. The need for AFO during ambulation (output variable) was classified according to the Medical Research Council (MRC) score for the ankle dorsiflexor of the affected limb. Patients with an MRC score of < 3 for the ankle dorsiflexor of the affected side were considered to require AFO, while those with scores ≥ 3 were considered not to require AFO. The following demographic and clinical data collected when patients were transferred to the rehabilitation unit (16.20 ± 6.02 days) and 6 months after stroke onset were used as input data: age, sex, type of stroke (ischemic/hemorrhagic), motor evoked potential data on the tibialis anterior muscle of the affected side, modified Brunnstrom classification, functional ambulation category, MRC score for muscle strength for shoulder abduction, elbow flexion, finger flexion, finger extension, hip flexion, knee extension, and ankle dorsiflexion of the affected side. For the deep neural network model, the area under the curve (AUC) was 0.887. For the random forest and logistic regression models, the AUC was 0.855 and 0.845, respectively. Our findings demonstrate that machine learning algorithms, particularly the deep neural network, are useful for predicting the need for AFO in stroke patients during the recovery phase.

Prevalence and Effect of Cerebral Small Vessel Disease in Stroke Patients With Aspirin Treatment Failure-A Hospital-Based Stroke Secondary Prevention Registry

Background: Breakthrough strokes during treatment with aspirin, termed clinical aspirin treatment failure (ATF), is common in clinical practice. The burden of cerebral small vessel disease (SVD) is associated with an increased recurrent ischemic stroke risk. However, the association between SVD and ATF remains unclear. This study investigated the prevalence and clinical characteristics of SVD in stroke patients with ATF.

Methods: Data from a prospective, and multicenter stroke with ATF registry established in 2018 in Taiwan were used, and 300 patients who developed ischemic stroke concurrent with regular use of aspirin were enrolled. White matter lesions (WMLs) and cerebral microbleeds (CMBs) were identified using the Fazekas scale and Microbleed Anatomical Rating Scale, respectively. Demographic data, cardiovascular comorbidities, and index stroke characteristics of patients with different WML and CMB severities were compared. Logistic regression analyses were performed to explore the factors independently associated with outcomes after ATF.

Results: The mean patient age was 69.5 ± 11.8 years, and 70.0% of patients were men. Among all patients, periventricular WML (PVWML), deep WML (DWML), and CMB prevalence was 93.3, 90.0, and 52.5%, respectively. Furthermore, 46.0% of the index strokes were small vessel occlusions. Severe PVWMLs and DWMLs were significantly associated with high CMB burdens. Patients with moderate-to-severe PVWMLs and DWMLs were significantly older and had higher cardiovascular comorbidity prevalence than did patients with no or mild WMLs. Moreover, patients with favorable outcomes exhibited significantly low prevalence of severe PVWMLs (p = 0.001) and DWMLs (p = 0.001). After logistic regression was applied, severe WMLs predicted less favorable outcomes independently, compared with those with no to moderate PVWMLs and DWMLs [odds ratio (OR), 0.47; 95% confidence interval (CI), 0.25–0.87 for severe PVWMLs; OR, 0.40; 95% CI, 0.21–0.79 for severe DWMLs].

Conclusions: SVD is common in stroke patients with ATF. PVWMLs and DWMLs are independently associated with functional outcomes in stroke patients with ATF. The burden of SVD should be considered in future antiplatelet strategies for stroke patients after ATF.

Dynamics of Stroke Incidence and Mortality Indicators over Eight-Year Period in the Territories Included into the Federal Program of Reorganization of Care for Patients with Stroke

Background. Stroke is a severe medical, social and economic burden for all countries of the world. The leading indicators characterizing the “epidemiological picture” of stroke are the incidence and mortality rates from stroke.

Aims. Analyze the dynamics of stroke incidence and mortality rates in the regions of Russia that were included in the federal program for reorganizing care for patients with stroke for the period from 2009 to 2016.

Material and methods. The study was based on the data of the territorial-population register for seven study areas in the regions of Russia that were included in the federal program for reorganizing care for patients with stroke (Republic of Bashkortostan, Sverdlovsk region, Republic of Tatarstan, Sakhalin region, Stavropol Territory, Ivanovo Region and Irkutsk Region). The age of the examined persons was 25 years and older.

Results. In the period from 2009 to 2016, in the studied territories, there was a consistent stable decrease in the value of the stroke incidence rate. Stroke mortality rates fluctuated with a single increase in 2012. When comparing the average incidence of stroke and mortality from it between 2009 and 2016, we discovered a statistically significant decrease in the incidence of stroke – by 1.4 times and in the rate of mortality from stroke – by 2.3 times. According to the results of the cluster analysis, we revealed a significant conformity (similarity) of mortality rates between regions by 2016 and the absence of monotony (stability) of the rate of stroke incidence.

Conclusion. In all the regions under study, an almost systematic annual decrease in the incidence and mortality rates from stroke among the adult population was revealed in seven studied territories. The results of cluster analysis of the “picture” of stroke incidence and mortality from it also demonstrate a positive trend by 2016 in all studied territories. Only one of the studied territories – the Republic of Tatarstan – despite the presence of a positive dynamics of stroke incidence over an eight-year period, in 2016 belonged to the rank with a high integral incidence rate.

Comparison of Hemodynamic Visualization in Cerebral Arteries: Can Magnetic Resonance Imaging Replace Computational Fluid Dynamics?

A multimodality approach was applied using four-dimensional flow magnetic resonance imaging (4D flow MRI), time-of-flight magnetic resonance angiography (TOF-MRA) signal intensity gradient (SIG), and computational fluid dynamics (CFD) to investigate the 3D blood flow characteristics and wall shear stress (WSS) of the cerebral arteries. TOF-MRA and 4D flow MRI were performed on the major cerebral arteries in 16 healthy volunteers (mean age 34.7 ± 7.6 years). The flow rate measured with 4D flow MRI in the internal carotid artery, middle cerebral artery, and anterior cerebral artery were 3.8, 2.5, and 1.2 mL/s, respectively. The 3D blood flow pattern obtained through CFD and 4D flow MRI on the cerebral arteries showed reasonable consensus. CFD delivered much greater resolution than 4D flow MRI. TOF-MRA SIG and CFD WSS of the major cerebral arteries showed reasonable consensus with the locations where the WSS was relatively high. However, the visualizations were very different between TOF-MRA SIG and CFD WSS at the internal carotid artery bifurcations, the anterior cerebral arteries, and the anterior communicating arteries. 4D flow MRI, TOF-MRA SIG, and CFD are complementary methods that can provide additional insight into the hemodynamics of the human cerebral artery.

Repurposing Immunomodulatory Imide Drugs (IMiDs) in Neuropsychiatric and Neurodegenerative Disorders

Neuroinflammation represents a common trait in the pathology and progression of the major psychiatric and neurodegenerative disorders. Neuropsychiatric disorders have emerged as a global crisis, affecting 1 in 4 people, while neurological disorders are the second leading cause of death in the elderly population worldwide (WHO, 2001; GBD 2016 Neurology Collaborators, 2019). However, there remains an immense deficit in availability of effective drug treatments for most neurological disorders. In fact, for disorders such as depression, placebos and behavioral therapies have equal effectiveness as antidepressants. For neurodegenerative diseases such as Parkinson's disease and Alzheimer's disease, drugs that can prevent, slow, or cure the disease have yet to be found. Several non-traditional avenues of drug target identification have emerged with ongoing neurological disease research to meet the need for novel and efficacious treatments. Of these novel avenues is that of neuroinflammation, which has been found to be involved in the progression and pathology of many of the leading neurological disorders. Neuroinflammation is characterized by glial inflammatory factors in certain stages of neurological disorders. Although the meta-analyses have provided evidence of genetic/proteomic upregulation of inflammatory factors in certain stages of neurological disorders. Although the mechanisms underpinning the connections between neuroinflammation and neurological disorders are unclear, and meta-analysis results have shown high sensitivity to factors such as disorder severity and sample type, there is significant evidence of neuroinflammation associations across neurological disorders. In this review, we summarize the role of neuroinflammation in psychiatric disorders such as major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, and bipolar disorder, as well as in neurodegenerative disorders, such as Parkinson's disease and Alzheimer's disease, and introduce current research on the potential of immunomodulatory imide drugs (IMiDs) as a new treatment strategy for these disorders.

Evaluation of the Anatomical Locations of Stroke Events From Computed Tomography Scan Examinations in a Tertiary Facility in Ghana

Introduction Stroke events are leading causes of mortalities globally and currently increasing alarmingly in low- and middle-income nations including Ghana, thus overburdening national healthcare delivery sectors. This trend is predicted to ultimately have an impact on the socio-economic development of these countries, thus gaining the attention of policy-makers and implementers. This study was therefore conducted to evaluate the anatomical locations of stroke events from CT scan examinations and the possibly associated variables to assist in managing this non-communicable pandemic. Methods All computed tomography (CT) scans performed for stroke events at the Cape Coast Teaching Hospital from June 2016 to June 2020 were retrieved and reviewed for this study. The socio-demographics and the presence of hypertensive risk factor were also retrieved. Data were then collated, grouped, coded, inputted, and used for analysis. Chi-square test of independence was employed for assessing possible associations, and logistic regression analysis was performed to predict the anatomical locations of stroke events using sex and hypertension. Statistical significance level was specified at p ≤ 0.05. Results A total of 1,750 stroke cases were recorded during the study period, comprising 1,237 (70.7%) ischemic strokes and 513 (29.3%) hemorrhagic strokes. Majority (54.3%) of the patients were males. The average age of participants was 62.46±14.74 years. Basal ganglia (43.0%), parietal lobe (26.7%), and frontal lobe (6.9%) were the commonest anatomical locations. The elderly (≥ 60 years) were significantly affected at the basal ganglia (p=0.006), parietal lobe (p=0.005), frontal lobe (p=0.013), temporal lobe (p=0.048), and cerebellum (p=0.049). Basal ganglia lesions were significantly recorded in men, whereas lesions located at the pons were significantly seen in females. The regression model revealed that the risk of stroke at the pons increased by 2.155-folds in males (p=0.043; 95% CI=1.026-4.528). Generally, gender and hypertension were not significant predictors of stroke lesion locations. Conclusions The basal ganglia area, which falls under the middle cerebral artery territory, was the commonest anatomical location for stroke events in our setting. Knowing the anatomical locations of these stroke events has an impact on the type of interventions needed, especially at the early stages of these stroke events. CT perfusion, CT angiography, and magnetic resonance imaging (MRI) with MR angiography (MRA) when available can further assist in determining the exact cause so that urgent interventions such as endovascular treatments can be offered.

Risk factors and outcomes of hospitalized stroke patients in Lusaka, Zambia

BACKGROUND

Limited data exists about stroke risk factors and outcomes in sub-Saharan African countries, including Zambia. We aim to fill this gap by describing features of hospitalized stroke patients at University Teaching Hospital (UTH), the national referral hospital in Lusaka, Zambia.

METHODS

We conducted a retrospective study of consecutive adults with stroke admitted to UTH's inpatient neurology service from October 2018 to March 2019. Strokes were classified as ischemic or hemorrhagic based on CT scan results and unknown if CT scan was not obtained. Chi-square analyses and t-tests were used to compare characteristics between cohorts with differing stroke subtypes.

RESULTS

Adults with stroke constituted 43% (n = 324) of all neurological admissions, had an average age of 60 ± 18 years, and 62% of the cohort was female. Stroke subtypes were 58% ischemic, 28% hemorrhagic, and 14% unknown. Hypertension was present in 80% of all strokes and was significantly associated with hemorrhagic stroke (p = 0.03). HIV was present in 18% of all strokes and did not significantly differ by stroke subtype. Diabetes (16%), heart disease (34%), atrial fibrillation (9%), and past medical history of stroke (22%) were all significantly more common in patients with ischemic stroke (p < 0.05). In-hospital mortality was 24% overall and highest among individuals with hemorrhagic strokes (33%, p = 0.005).

CONCLUSIONS

This Zambian stroke cohort is notable for its young age, significant HIV burden, high in-hospital mortality, and high rates of uncontrolled hypertension. Our results demonstrate Zambia's substantial stroke burden, significant contribution of HIV to stroke, and the need to improve primary stroke prevention.

Intra-arterial infusion of autologous bone marrow mononuclear cells combined with intravenous injection of cerebrolysin in the treatment of middle cerebral artery ischemic stroke: Case report

We present a patient with severe middle cerebral artery occlusion who received an intra-arterial infusion of autologous bone marrow stem cells combined with Cerebrolysin IV. The patient was evaluated before and after treatment using the National Institutes of Health Stroke Scale, the Medical Research Council Muscle Scale, Modified Brunnstrom Classification, Barthel Index and modified Rankin Scale. After the therapy, the patient showed good outcome with functional as well as neurological improvements especially in terms of functional motor recovery without any side effects. Further controlled studies are needed to find possible side effects and establish net efficacy.

Left Ventricular Diastolic Dysfunction as Predictor of Unfavorable Prognosis After ESUS

Objective

Identification of echocardiographic, hemodynamic and biochemical predictors of unfavorable prognosis after embolic strokes of undetermined etiology (ESUS) in patients at age <65.

Patients and Methods

Out of 520 ischemic stroke patients we selected 64 diagnosed with ESUS and additional 36 without stroke but with similar risk profile. All patients underwent echocardiography, non-invasive assessment of hemodynamic parameters using SphygmoCor tonometer and measurements of selected biomarkers. Follow-up time was 12 months.

Results

Nine percent of patients died, and recurrent ischemic stroke occurred in 9% of patients only in the ESUS group. Atrial fibrillation (AF) occurred in 10% of patients and the ESUS group had a significantly poorer outcome of AF in the first 2 months after hospitalization. The outcome of re-hospitalization was 28% in the ESUS group and 17% in the control group. In the multivariate analysis mean early diastolic (E’) mitral annular velocity (OR 0.75, 95% CI: 0.6–0.94; p=0.01) was significantly associated with cardiovascular hospitalizations. The only independent predictor of recurrent stroke was the ratio of peak velocity of early diastolic transmitral flow to peak velocity of early diastolic mitral annular motion (E/E’) (OR 0.75, 95% CI: 0.6–0.94; p=0.01). E/E’ was independently associated with composite endpoint (death, hospitalization and recurrent stroke) (OR 1.90, 95% CI 1.1–3.2, p=0.01).

Conclusion

The indices of diastolic dysfunction are significantly associated with unfavorable prognosis after ESUS. There is a robust role for outpatient cardiac monitoring especially during the first 2 months after ESUS to detect potential AF.

Therapeutic Potential of Saffron (Crocus sativus L.) in Ischemia Stroke

Stroke is the second leading cause of death and a main cause of disability worldwide. The majority (approximately 80%) of strokes are ischemic. Saffron (Crocus sativus L.) has been considered for medicinal purposes since ancient times. Pharmacological effects of saffron are attributed to the presence of crocin, crocetin, picrocrocin, and safranal. In the present review, we summarized the reported neuroprotective effects of saffron and its active constituents against cerebral ischemia stroke. Saffron and its components exert its beneficial effects as an antioxidant, anti-inflammatory, and antiapoptotic agent though inhibition of biochemical, inflammatory, and oxidative stress markers. Taken together, this review indicates that saffron and its ingredients could be a potent candidate in the process of new drug production for the treatment of ischemia stroke.

Knowledge of Risk Factors and Warning Signs of Stroke Among Patients with Heart Disease at Tikur Anbessa Specialized Hospital

BACKGROUND

Stroke is a leading cause of mortality and disability worldwide and the economic costs of treatment and post-stroke care are extensive. The inability to identify stroke warning signs accurately is an important cause of delay in seeking medical attention, leading to potential ineligibility for acute intervention and which leads to secondary complications.

PURPOSE

To identify cardiac patients' knowledge of stroke risk factors and warning signs.

PATIENTS AND METHODS

The institutional based cross-sectional study design was employed. Participants were selected using systematic random sampling. Close-ended questionnaires were pre-tested and validated for consistency before data collection. Then after data collection, data were checked and entered into Epi-data 4.6. Finally, the cleaned data were exported to SPSS version 25 for analysis. Statistical analysis using binary logistic regression was done and Predictors with a p-value of <0.05 were considered statistically significant.

RESULTS

A total of 227 patients were included in the study, of which 140 (61.7%) of them identified physical inactivity, followed by hypertension126 (55.5%) as stroke risk factor while 15.4% of them did not know any risk factor of stroke. Amongst the study participants, 45.81% of them had adequate knowledge of stroke risk factors. Regarding stroke warning signs the most identified sign was sudden unilateral weakness 142 (62.6%) while 46 (20.26%) of them did not know at least one warning sign of a stroke. Based on multivariable logistic regression analysis, higher education level AOR 3.05 (95% CI 1.62-5.74) and Urban residence area AOR 2.07 (95% CI 1.05-4.1) were significantly associated with knowledge of stroke risk factors with p-value<0.05.

CONCLUSION

Study participants had inadequate knowledge of stroke risk factors and warning signs. Educational status and information about stroke are significantly associated with adequate knowledge of stroke risk factors, raising stroke awareness is the mainstay to reduce stroke burden.

Burden of stroke in the Kingdom of Saudi Arabia: A soaring epidemic

Stroke is a key cerebrovascular disease that is related to high morbidity and mortality in the globe. The Kingdom of Saudi Arabia (KSA) is not an exception where stroke is fast developing into a serious challenge due to the high mortality rate. Additionally, stroke presents a tremendous economic burden and has a devastating effect on the quality of lives of individuals. The number of stroke cases are increasing yearly, thus posing a major challenge to the health care system. Therefore, it is crucial to implement primary and secondary prevention strategies in the KSA. Nevertheless, as compared with developed countries, information on the prevalence, socio-demographic properties and prevention of stroke remains scarce that could be attributed to the shortage of research conducted in this specified region. The review is written to address the various aspects of stroke in the KSA, based on current literatures search using PubMed, Scopus, Web of Science and Google Scholar databases, to identify studies published since inception to Dec 2020.

Isoquercetin Improves Inflammatory Response in Rats Following Ischemic Stroke

Inflammatory response contributes to brain injury after ischemia and reperfusion (I/R). Our previous literature has shown isoquercetin plays an important role in protecting against cerebral I/R injury. The present study was conducted to further investigate the effect of isoquercetin on inflammation-induced neuronal injury in I/R rats with the involvement of cyclic adenosine monophosphate (cAMP)/protein kinase A (PKA) and inhibitor of NF-κB (I-κB)/nuclear factor-kappa B (NF-κB) signaling pathway mediated by Toll-like receptor 4 (TLR4) and C5a receptor 1 (C5aR1). In vivo middle cerebral artery occlusion and reperfusion (MCAO/R) rat model and in vitro oxygen-glucose deprivation and reperfusion (OGD/R) neuron model were used. MCAO/R induced neurological deficits, cell apoptosis, and release of cytokines such as tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 in ischemic brain in rats. Simultaneously, the expression of TLR4 and C5aR1 was significantly up-regulated in both MCAO/R rats and OGD/R neurons, accompanied with the inhibition of cAMP/PKA signaling and activation of I-κB/NF-κB signaling in the cortex of MCAO/R rats. Over-expression of C5aR1 in neurons induced decrease of cell viability, exerting similar effects with OGD/R injury. Isoquercetin acted as a neuroprotective agent against I/R brain injury to suppress inflammatory response and improve cell recovery by inhibiting TLR4 and C5aR1 expression, promoting cAMP/PKA activation, and inhibiting I-κB/NF-κB activation and Caspase 3 expression. TLR4 and C5aR1 contributed to inflammation and apoptosis via activating cAMP/PKA/I-κB/NF-κB signaling during cerebral I/R, suggesting that this signaling pathway may be a potent therapeutic target in ischemic stroke. Isoquercetin was identified as a neuroprotective agent, which maybe a promising therapeutic agent used for the treatment of ischemic stroke and related diseases.

A porous circulation model of the human brain for in silico clinical trials in ischaemic stroke

The advancement of ischaemic stroke treatment relies on resource-intensive experiments and clinical trials. In order to improve ischaemic stroke treatments, such as thrombolysis and thrombectomy, we target the development of computational tools for in silico trials which can partially replace these animal and human experiments with fast simulations. This study proposes a model that will serve as part of a predictive unit within an in silico clinical trial estimating patient outcome as a function of treatment. In particular, the present work aims at the development and evaluation of an organ-scale microcirculation model of the human brain for perfusion prediction. The model relies on a three-compartment porous continuum approach. Firstly, a fast and robust method is established to compute the anisotropic permeability tensors representing arterioles and venules. Secondly, vessel encoded arterial spin labelling magnetic resonance imaging and clustering are employed to create an anatomically accurate mapping between the microcirculation and large arteries by identifying superficial perfusion territories. Thirdly, the parameter space of the problem is reduced by analysing the governing equations and experimental data. Fourthly, a parameter optimization is conducted. Finally, simulations are performed with the tuned model to obtain perfusion maps corresponding to an open and an occluded (ischaemic stroke) scenario. The perfusion map in the occluded vessel scenario shows promising qualitative agreement with computed tomography images of a patient with ischaemic stroke caused by large vessel occlusion. The results highlight that in the case of vessel occlusion (i) identifying perfusion territories is essential to capture the location and extent of underperfused regions and (ii) anisotropic permeability tensors are required to give quantitatively realistic estimation of perfusion change. In the future, the model will be thoroughly validated against experiments.

The Antioxidant Enzyme PON1: A Potential Prognostic Predictor of Acute Ischemic Stroke

OBJECTIVE

Paraoxonase 1 (PON1) is an antioxidant enzyme, which has been proved to be involved in the pathophysiological process of oxidative stress and various neurological diseases in recent years. Although reduced PON1 activity has been reported in patients with acute ischemic stroke (AIS), the prognostic value of PON1 in AIS has not been clearly established. The purpose of this study was to determine whether the baseline serum PON1 activity level is related to the functional outcome of AIS patients.

METHODS

From July 2017 to June 2020, AIS patients within 3 days of symptom onset were continuously prospectively included in the study. On admission, clinical and laboratory data were recorded, and serum PON1 activity was tested. The National Institute of Health Stroke Scale (NIHSS) score was used to evaluate the initial neurologic deficit at admission, and the modified Rankin scale (mRS) was used to evaluate the functional outcome at 3 months. A multiple logistic regression model was used to analyze the relationship between the baseline PON1 activity level and the prognosis of AIS.

RESULTS

A total of 336 AIS patients were finally included in this study. The serum PON1 activity of AIS patients with good outcomes was significantly higher than that of patients with poor outcomes (193.4 ± 16.3 U/mL vs. 127.2 ± 14.9 U/mL, p < 0.001). However, the comparison of other clinical and laboratory data between AIS patients with good and poor outcomes was not significant (p > 0.05). There was a significant decrease in the mRS score in patients with AIS across serum PON1 quartiles (3.0 ± 1.6, 2.6 ± 1.5, 2.4 ± 1.4, and 2.4 ± 1.3, p = 0.007). Multivariate logistic regression analysis showed that the 3-month functional outcome of AIS patients was significantly correlated with the quartile of serum PON1 activity.

CONCLUSIONS

This study suggests that the serum PON1 activity may be an independent predictor of the functional outcome of AIS patients.

Is Dry Needling Effective for the Management of Spasticity, Pain, and Motor Function in Post-Stroke Patients? A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effects of muscle dry needling alone or combined with other interventions on post-stroke spasticity (muscle tone), related pain, motor function, and pressure sensitivity.

DATABASES AND DATA TREATMENT

Electronic databases were searched for randomized controlled trials including post-stroke patients where at least one group received dry needling and outcomes were collected on spasticity and related pain. Secondary outcomes included motor function and pressure pain sensitivity. Data were extracted by two reviewers. The risk of bias was assessed with the Cochrane Risk of Bias tool, methodological quality was assessed with the Physiotherapy Evidence Database score, and the quality of evidence was assessed by the Grading of Recommendations Assessment, Development, and Evaluation approach. Between-groups mean differences (MDs) and standardized mean differences (SMDs) were calculated.

RESULTS

Seven studies (three within the lower extremity, four in the upper extremity) were included. The meta-analysis found significantly large effect sizes of dry needling for reducing spasticity (SMD: -1.01, 95%confidence interval [CI] -1.68 to -0.34), post-stroke pain (SMD -1.01, 95%CI -1.73 to -0.30), and pressure pain sensitivity (SMD 1.21, 95% CI: 0.62 to 1.80) as compared with a comparative group at short-term follow-up. The effect on spasticity was found mainly in the lower extremity (MD -1.05, 95% CI: -1.32 to -0.78) at short-term follow-up. No effect on spasticity was seen at 4 weeks. No significant effect on motor function (SMD 0.16, 95% CI: -0.13 to 0.44) was observed. The risk of bias was generally low, but the imprecision of the results downgraded the level of evidence.

CONCLUSION

Moderate evidence suggests a positive effect of dry needling on spasticity (muscle tone) in the lower extremity in post-stroke patients. The effects on related pain and motor function are inconclusive.

Hyperhomocysteinemia is an emerging comorbidity in ischemic stroke

Hyperhomocysteinemia or systemic elevation of the amino acid homocysteine is a common metabolic disorder that is considered to be a risk factor for ischemic stroke. However, it is still unclear whether predisposition to hyperhomocysteinemia could contribute to the severity of stroke outcome. This review highlights the advantages and limitations of the current rodent models of hyperhomocysteinemia, describes the consequence of mild hyperhomocysteinemia on the severity of ischemic brain damage in preclinical studies and summarizes the mechanisms involved in homocysteine induced neurotoxicity. The findings provide the premise for establishing hyperhomocysteinemia as a comorbidity for ischemic stroke and should be taken into consideration while developing potential therapeutic agents for stroke treatment.

Neuroprotective effects of human amniotic fluid stem cells-derived secretome in an ischemia/reperfusion model

Stem cells offer the basis for the promotion of robust new therapeutic approaches for a variety of human disorders. There are still many limitations to be overcome before clinical therapeutic application, including a better understanding of the mechanism by which stem cell therapies may lead to enhanced recovery. In vitro investigations are necessary to dissect the mechanisms involved and to support the potential development in stem cell-based therapies. In spite of growing interest in human amniotic fluid stem cells, not much is known about the characteristics of their secretome and regarding the potential neuroprotective mechanism in different pathologies, including stroke. To get more insight on amniotic fluid cells therapeutic potential, signal transduction pathways activated by human amniotic fluid stem cells (hAFSCs)-derived secretome in a stroke in vitro model (ischemia/reperfusion [I/R] model) were investigated by Western blot. Moreover, miRNA expression in the exosomal fraction of the conditioned medium was analyzed. hAFSCs-derived secretome was able to activate pro-survival and anti-apoptotic pathways. MicroRNA analysis in the exosomal component revealed a panel of 16 overexpressed miRNAs involved in the regulation of coherent signaling pathways. In particular, the pathways of relevance in ischemia/reperfusion, such as neurotrophin signaling, and those related to neuroprotection and neuronal cell death, were analyzed. The results obtained strongly point toward the neuroprotective effects of the hAFSCs-conditioned medium in the in vitro stroke model here analyzed. This can be achieved by the modulation and activation of pro-survival processes, at least in part, due to the activity of secreted miRNAs.

Temporally distinct myeloid cell responses mediate damage and repair after cerebrovascular injury

Cerebrovascular injuries can cause severe edema and inflammation that adversely affect human health. Here, we observed that recanalization after successful endovascular thrombectomy for acute large vessel occlusion was associated with cerebral edema and poor clinical outcomes in patients who experienced hemorrhagic transformation. To understand this process, we developed a cerebrovascular injury model using transcranial ultrasound that enabled spatiotemporal evaluation of resident and peripheral myeloid cells. We discovered that injurious and reparative responses diverged based on time and cellular origin. Resident microglia initially stabilized damaged vessels in a purinergic receptor-dependent manner, which was followed by an influx of myelomonocytic cells that caused severe edema. Prolonged blockade of myeloid cell recruitment with anti-adhesion molecule therapy prevented severe edema but also promoted neuronal destruction and fibrosis by interfering with vascular repair subsequently orchestrated by proinflammatory monocytes and proangiogenic repair-associated microglia (RAM). These data demonstrate how temporally distinct myeloid cell responses can contain, exacerbate and ultimately repair a cerebrovascular injury.