Twenty-Year Change in Severity and Outcome of Ischemic and Hemorrhagic Strokes

Role of triggering receptor expressed on myeloid cells 1/2 in secondary injury after cerebral hemorrhage

Intracerebral hemorrhage (ICH) is a common severe emergency in neurosurgery, causing tremendous economic pressure on families and society and devastating effects on patients both physically and psychologically, especially among patients with poor functional outcomes. ICH is often accompanied by decreased consciousness and limb dysfunction. This seriously affects patients’ ability to live independently. Although rapid advances in neurosurgery have greatly improved patient survival, there remains insufficient evidence that surgical treatment significantly improves long-term outcomes. With in-depth pathophysiological studies after ICH, increasing evidence has shown that secondary injury after ICH is related to long-term prognosis and that the key to secondary injury is various immune-mediated neuroinflammatory reactions after ICH. In basic and clinical studies of various systemic inflammatory diseases, triggering receptor expressed on myeloid cells 1/2 (TREM-1/2), and the TREM receptor family is closely related to the inflammatory response. Various inflammatory diseases can be upregulated and downregulated through receptor intervention. How the TREM receptor functions after ICH, the types of results from intervention, and whether the outcomes can improve secondary brain injury and the long-term prognosis of patients are unknown. An analysis of relevant research results from basic and clinical trials revealed that the inhibition of TREM-1 and the activation of TREM-2 can alleviate the neuroinflammatory immune response, significantly improve the long-term prognosis of neurological function in patients with cerebral hemorrhage, and thus improve the ability of patients to live independently.

The efficacy and feasibility of an immersive virtual reality game to train spatial attention orientation after stroke: A stage 2 report

Spatial neglect is a post-stroke attention deficit for which there is no evidence-based intervention. Immersive virtual reality (IVR) may increase treatment efficacy, as it allows to train spatial attention in a rich environment. This study evaluated the efficacy and feasibility of an IVR patient-tailored training (HEMIRehApp). Using a cross-over design, an active (spatially biased) and placebo (spatially unbiased) IVR intervention were compared. We aimed to recruit 8 per-protocol left-sided neglect patients. The primary outcome was response times on the Posner cueing task. To evaluate feasibility, we documented the number of recruited patients, cybersickness and patients' experience with HEMIRehApp. After 2 years of recruitment, we were able to enrol 6 patients, of whom 2 completed the full protocol. The target sample size was not feasible due to a lower than expected prevalence of left-sided neglect and a higher than expected drop-out rate. The planned group-level analysis was therefore replaced by a single-case analysis. The results in the 2 per-protocol cases suggest a superior effect of spatially biased IVR training than unbiased IVR training inside IVR. IVR training was feasible as all 6 enrolled patients were able to complete 10 IVR training sessions, but the cross-over protocol itself was unfeasible. While the low sample size prevented us from conclusively evaluating the efficacy of HEMIRehApp, our preliminary single-case results suggest that neglect patients were able to improve attentional orientation towards eccentric target locations in IVR. Follow-up studies are needed to further validate these findings.

Patient flow analysis with fast-track MRI for suspected stroke in the emergency department and associated non-comprehensive stroke center

Background

Good outcomes in stroke care require swift diagnostics, for which magnetic resonance imaging (MRI) as first-line brain imaging is superior to computed tomography scans. Reduced length of stay (LOS) in hospital and emergency departments (ED) may optimize resource use. Fast-track stroke MRI was implemented as the primary imaging technique for suspected stroke, in the ED at Copenhagen University Hospital-Herlev and Gentofte in 2020.

Objectives

We aimed to describe and compare LOS, MRI utilization, and the rate of strokes versus stroke-mimicking conditions on the stroke ward, before and after the implementation of fast-track MRI.

Design and method

In this cross-sectional study, we used data from admissions to the neurologic ED and associated non-comprehensive stroke unit. We compared two time periods, that is, January 1-December 31, 2019, and January 1-December 31, 2020, before and after the implementation of fast-track stroke MRI.

Results

There were 6650 admissions before and 7201 after implementation of fast-track stroke MRI. After implementation, we observed reductions in average LOS in hospitals from 56.0 to 38.6 h (p < 0.001), and LOS in ED from 9.17 to 8.63 h (p < 0.001). The use of inpatient MRI increased significantly, and the rate of acute ischemic stroke patients on the ward increased yet the rate of non-strokes remained unchanged. The association between shorter admissions and access to MRI remained (odds ratio 1.81, p < 0.001), after adjusting for sex, age, weekend admissions, and lockdown periods.

Conclusion

Fast-track stroke MRI in ED associated with reduced LOS in hospital.

Association of Vascular Risk With Severe vs Non-Severe Stroke: An Analysis of the INTERSTROKE Study

BACKGROUND AND OBJECTIVES

Acute stroke is associated with a spectrum of functional deficits. The objective of this analysis was to explore whether the importance of individual risk factors differ by stroke severity, which may be of relevance to public health strategies to reduce disability.

METHODS

INTERSTROKE is an international case-control study of risk factors of first acute stroke (recruitment 2007-August 2015) in 32 countries. Stroke severity was measured using the modified Rankin Scale (mRS) score within 72 hours of admission to hospital. Severe stroke is defined as mRS scores of 4-6 (and non-severe stroke, score of 0-3). We used multinomial logistic regression to estimate comparative odds ratios (ORs; 95% CIs) for severe and non-severe stroke and tested for heterogeneity (pheterogeneity). We also conducted a matched case-case analysis (matched for age, sex, country, and primary stroke subtype) to determine whether the prevalence of risk factors differed significantly between severe and non-severe stroke. A significant difference in the association of a risk factor of severe stroke compared with non-severe stroke was defined as p < 0.05 for both pheterogeneity and pcase-case.

RESULTS

Of patients with acute stroke (n = 13,460), 64.0% (n = 8,612) were reported to have mRS scores of 0-3 and 36.0% (n = 4,848) scores of 4-6. The mean age was 61.7 years for patients with non-severe stroke and 62.9 years for patients with severe stroke (p = 0.72). 38.1% (n = 3,278) of patients with non-severe stroke and 44.6% (n = 2,162) of patients with severe stroke were female. Hypertension (OR 3.21; 95% CI 2.97-3.47 for severe stroke, OR 2.87; 95% CI 2.69-3.05 for non-severe stroke; pheterogeneity = 0.03; pcase-case < 0.001), atrial fibrillation (OR 4.70; 95% CI 4.05-5.45 for severe stroke, OR 3.61; 95% CI 3.16-4.13 for non-severe stroke; pheterogeneity = 0.009; pcase-case < 0.001), and smoking (OR 1.87; 95% CI 1.72-2.03 for severe stroke, OR 1.65; 95% CI 1.54-1.77 for non-severe stroke; pheterogeneity = 0.02; pcase-case < 0.001) had a stronger association with severe stroke, compared with non-severe stroke. The waist-to-hip ratio had a stronger association with non-severe stroke compared with severe stroke (pheterogeneity < 0.001; pcase-case < 0.001).

DISCUSSION

Hypertension, atrial fibrillation, and smoking had a stronger magnitude of association with severe stroke (compared with non-severe stroke) while the increased waist-to-hip ratio had a stronger magnitude of association with non-severe stroke.

Mediation Analysis of Serum Fibroblast Growth Factor 20 and Poor Prognosis After Ischemic Stroke

BACKGROUND

We aimed to examine the relationship between serum FGF20 (fibroblast growth factor 20) levels and stroke prognosis in a multicenter cohort study.

METHODS AND RESULTS

Patients with ischemic stroke/transient ischemic attack were prospectively recruited from 5 participating centers and followed up at 3 months and 1 year. FGF20 levels were measured using the ELISA method. The primary outcome was poor stroke functional outcome (modified Rankin Scale score of 3-6), and secondary outcomes included death and composite vascular events. Multivariable logistic regression analysis or Cox proportional hazards regression analysis was employed to estimate the relationship between FGF20 and study outcomes. Mediation analysis was conducted to examine the mediating effects of traditional risk factors on the association between FGF20 and stroke outcomes. A total of 1011 patients with ischemic stroke were included in the study. After adjusting for potential confounding factors, an elevated serum FGF20 level was associated with a reduced risk of the poor outcome and death. Multivariable adjusted spline regression analysis demonstrated a linear correlation between serum FGF20 levels and the stroke outcomes. The incorporation of FGF20 alongside conventional risk factors marginally enhanced the reclassification of adverse outcomes. Renal function and white blood cell count partially mediated the relationship between FGF20 and the prognosis of ischemic stroke.

CONCLUSIONS

Elevated FGF20 level is associated with decreased risks of adverse outcomes after ischemic stroke, which was partially mediated by renal function and white blood cells with a modest amount, indicating that serum FGF20 might serve as a promising biomarker for predicting stroke prognosis.

REGISTRATION

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR2100051104.

Phase I/II trial of intracerebral transplantation of autologous bone marrow stem cells combined with recombinant peptide scaffold for patients with chronic intracerebral haemorrhage: a study protocol

INTRODUCTION

Intracerebral haemorrhage (ICH) stands as a leading global cause of death and disability, posing a significant challenge with limited treatment options, especially for chronic patients. Recent advances in stem cell therapies have opened new avenues for therapeutic potential. Our previous preclinical research has demonstrated that intracerebral transplantation of bone marrow stromal cells (BMSCs) combined with a recombinant human collagen type I scaffold enables higher cell survival and engraftment and holds promising potential. In this article, we present the protocol for a novel clinical trial, named 'Research on Advanced Intervention using Novel Bone MarrOW stem cells for chronic intracerebral haemorrhage' (RAINBOW-Hx).

METHODS AND ANALYSIS

RAINBOW-Hx is a phase I/II, open-label, uncontrolled study with the primary objective of assessing the safety and efficacy of intracerebral transplantation of autologous BMSCs combined with the scaffold (HUFF-01) in patients with chronic ICH. Eight patients, experiencing moderate to severe neurological deficits for 12 months or longer, will be enrolled. The haemorrhage location will be limited to the basal ganglia and thalamus. Approximately 50 mL of bone marrow will be extracted from the iliac bone of each patient, and BMSCs will be cultured using autologous platelet lysate. 3 days before transplantation, BMSCs will be combined with the scaffold to generate HUFF-01. Each patient will receive a 50 000 HUFF-01 dose, containing approximately 50 million BMSCs, through stereotactic transplantation into the haemorrhagic cavity. Neurological assessments, MRI, 18F-fluorodeoxyglucose positron emission tomography and 123I-Iomazenil single-photon emission CT will be performed for 1 year after administration.

ETHICS AND DISSEMINATION

The trial protocols were reviewed and approved by the Institutional Review Board of the Hokkaido University Hospital (R5-11), and this study is conducted according to Good Clinical Practice guidelines and the principles of the Declaration of Helsinki. The results of this trial will be submitted for publication in a peer-reviewed scientific journal.

TRIAL REGISTRATION NUMBER

jRCT2013230053, Japan Registry of Clinical Trials.

CHA2DS2-VASc score and prior oral anticoagulant use on endovascular treatment for acute ischemic stroke

OBJECTIVE

We evaluated the effect of CHA2DS2-VASc score and prior use of oral anticoagulants (OACs) on endovascular treatment (EVT) in patients with acute ischemic stroke and atrial fibrillation (AF).

METHODS

Patients with AF who received EVT in 353 centers in Japan (2018-2020) were included. The outcomes were symptomatic intracerebral hemorrhage (sICH), in-hospital mortality, functional independence, and successful and complete reperfusion. The effects of CHA2DS2-VASc score, its components, and prior use of OACs were assessed via a multiple logistic regression model.

RESULTS

Of the 6984 patients, 780 (11.2%) used warfarin and 1168 (16.7%) used direct oral anticoagulants (DOACs) before EVT. Based on the CHA2DS2-VASc score, 6046 (86.6%) presented a high risk (≥2 for males and ≥3 for females) while 938 (13.4%) had intermediate to low risks. Higher CHA2DS2-VASc scores were associated with increased sICH, in-hospital mortality, and decreased functional independence, regardless of prior OACs. For patients with a high-risk category, prior DOACs increased the odds of successful and complete reperfusion (adjusted odds ratio [95% confidence interval (CI)], 1.27 [1.00-1.61] and 1.30 [1.10-1.53]). For those with integrated intermediate to low risks, neither prior warfarin nor DOAC affected the outcomes. Regardless of total CHA2DS2-VASc scores, patients with congestive heart failure or left ventricular dysfunction, hypertension, age >75 years, or female benefited similarly from prior DOAC use.

INTERPRETATION

Prior DOAC use for patients with high- and selected intermediate-risk CHA2DS2-VASc scores increased prevalence of successful and complete reperfusion. These findings may provide supplemental evidence to introduce preventive DOAC for patients with AF.

Site-specific skeletal muscle mass and functional prognosis in geriatric stroke patients

BACKGROUND

Evidence is scarce regarding prognostic value of site-specific muscle mass in geriatric stroke survivors. We aim to assess the association between four measures of muscle mass, namely the skeletal muscle mass index of the limbs (SMI), upper limb SMI (USMI), lower limb SMI (LSMI), and trunk muscle mass index (TMI), and the functional prognosis in stroke patients.

METHODS

This study conducted a retrospective cohort analysis involving post-acute stroke inpatients. Muscle mass data were obtained through bioelectrical impedance analysis and computed by dividing each muscle mass by the square of the height. The study outcomes included the Functional Independence Measure (FIM) motor at discharge and FIM-motor gain. Multiple regression analysis was conducted to assess the association between SMI, USMI, LSMI, and TMI with outcomes, while adjusting for confounding factors.

RESULTS

A total of 701 patients (mean age 72.8 years, 374 males) were analyzed. As a result, LSMI (β = 0.089, P = 0.003) and SMI (β = 0.083, P = 0.008) were significantly associated in the FIM-motor at discharge, with LSMI showing a stronger association. USMI (β = 0.019, P = 0.521) and TMI (β = 0.035, P = 0.231) showed no significant association. LSMI (β = 0.124, P = 0.003) and SMI (β = 0.116, P = 0.008) were significantly associated with FIM-motor gain; however, USMI (β = 0.027, P = 0.521) and TMI (β = 0.049, P = 0.231) showed no significant association with FIM-motor gain.

CONCLUSIONS

Differential associations were observed between site-specific muscle mass and functional prognosis in post-stroke patients. Among these, lower limb muscle mass was most strongly associated with activities of daily living (ADL) recovery.

Medical Management of Acute Stroke based on Japan Stroke Society Guidelines and the Japan Stroke Data Bank

Stroke is a leading cause of death and disability in Japan, necessitating standardized treatment guidelines. The Japan Stroke Society (JSS) periodically revises its guidelines to incorporate new research. This review provides a short overview of acute stroke management based on JSS Guideline 2021 (revised 2023) and the Japan Stroke Data Bank (JSDB), and discusses future directions in stroke management. Acute stroke management emphasizes systemic support and complication management. Risk factor control during acute hospitalization is also crucial for preventing recurrent strokes in the chronic phase.In ischemic stroke, super-acute recanalization therapies, including intravenous thrombolysis and mechanical thrombectomy, are the most important and effective. Antiplatelet therapy, particularly aspirin and clopidogrel, is recommended for noncardiogenic stroke and high-risk transient ischemic attack. In cardioembolic stroke, early initiation of direct oral anticoagulants might be considered according to stroke severity.For brain hemorrhage, early blood pressure management is recommended. Specific reversal agents are advised for patients on anticoagulant therapy. Minimally invasive hematoma removal may improve outcomes for intracerebral hemorrhage.Subarachnoid hemorrhage treatments reported from Japan include intravenous drugs to prevent vasospasm.The JSDB revealed improvements in functional outcomes in patients with ischemic stroke over the past 20 years, although patients with hemorrhagic stroke showed no clear improvement. The evolving guidelines and research underscore the importance of stratified and timely intervention in stroke care.

Incidence and prognosis of first-ever intracerebral hemorrhage on antiplatelet therapy over 10 years in a population-based stroke registry

The use of antiplatelet therapy (APT) is prevalent among the general population, sometimes without clear indications. We provided updated figures on the incidence and prognosis of first-ever intracerebral hemorrhage occurring on APT (APT-ICH) over 10 years in a population-based stroke registry and investigated the rates of inappropriate APT prescription. We included all cases of first-ever ICH not on anticoagulants from January 2011 to December 2020 in the district of L'Aquila (Southern Italy). Indication to APT was adjudicated according to 2021 European Society of Cardiology (ESC) guidelines for cardiovascular prevention. We included 606 first-ever ICHs, of whom 251 (41.4%) were APT-related. One-hundred-forty-two APT-ICHs (56.6%) occurred in patients without clear indications to APT. While the incidence of non-APT-ICH decreased over time, the incidence of APT-ICH was stable. APT-ICH showed higher 30-day and 1-year case-fatality rates versus non-APT-ICH (44.7% versus 25.6%, 50.6% versus 34.4%; p < 0.001). APT intake was independently associated with higher 30-day case-fatality (HR 1.51, 95%CI 1.03-2.14; p = 0.023). Our findings suggest that APT-ICH exhibits sustained incidence over time and elevated mortality. Urgent initiatives are needed to enhance adherence to established guidelines for APT use. This effort has the potential to mitigate the risk of ICH and to reduce the associated mortality.

Predictors of upper limb motor recovery in stroke survivors: a pre-post test study design

OBJECTIVES

The study aimed to assess the predictors of upper limb motor recovery in stroke survivors.

DESIGN

Pre-post test study design.

SETTING

Conducted in two centres (First Level Hospital and University Teaching Hospital in Lusaka).

PARTICIPANTS

Patients living with stroke accessing physiotherapy services at the two public hospitals. A total of 52 patients were recruited at the start of the study, 6 were lost to follow-up and 46 completed the study.

INTERVENTION

Conventional physiotherapy for 8 weeks (5 September 2022-28 October 2022).

PRIMARY OUTCOME

Motor function measured using a Fugl-Meyer assessment of the upper extremity.

RESULTS

Analysis was conducted on 46 participants. A significant difference was observed between the level of motor function at baseline and after 8 weeks of treatment (p=0.0183). At baseline, 50% of participants had mild motor function, which improved after 8 weeks, with 69.6% having mild motor function. Stroke patients with severe motor function impairment at baseline were associated with 0.01 times likelihood of having mild motor function impairment after 8 weeks of physiotherapy treatment (AOR 0.01; 95 % CI 0.00 to 0.16; p=0.002).

CONCLUSION

The motor function of stroke patients continues to improve over time. This study demonstrated that initial upper limb motor function impairment could be used as a predictor for upper limb motor function.

Outcomes in ischemic and hemorrhagic stroke patients with cancer: The Japan Stroke Data Bank

INTRODUCTION

Data on the impact of malignancy on outcomes in patients with stroke, especially hemorrhagic stroke, are limited. We aimed to clarify the association between cancer and outcomes for each stroke type (ischemic/hemorrhagic) using a hospital-based multicenter stroke registration database.

PATIENTS AND METHODS

Study participants were adult patients within 7 days of the onset of ischemic stroke (IS) or hemorrhagic stroke (HS) between 2000 and 2020 in the Japan Stroke Data Bank (JSDB). The patients were categorized into two groups according to whether they had a history of cancer. Outcomes included good functional outcomes, representing a modified Rankin Scale score of 0-2 at discharge and in-hospital mortality.

RESULTS

Of the 203,983 patients analyzed in this substudy, 152,591 (women, 39.9 %; median age, 75 years) had IS, and 51,392 (48.6 %; 69 years) had HS. Of these, 6409 IS (4.2 %) and 1560 HS (3.0 %) patients had any cancer. IS patients with cancer had a lower frequency of good functional outcomes (47.5 % vs. 56.3 %; adjusted odds ratio [aOR] 0.85, 95 % confidence interval [CI] 0.79-0.91) and a higher incidence of in-hospital mortality (6.7 % vs. 4.5 %; aOR 1.59, 95 % CI 1.41-1.80) than those without cancer. HS patients with cancer showed a lower frequency of good functional outcome (24.9 % vs. 35.7 %; aOR 0.88, 95 % CI 0.78-0.99) and higher incidence of in-hospital mortality (20.1 % vs. 16.0 %; aOR 1.26, 95 % CI 1.04-1.52) than those without cancer.

CONCLUSIONS

Both IS and HS patients with cancer had significantly lower good functional outcomes and more in-hospital mortality.

Bioactive Self-Assembled Nanoregulator Enhances Hematoma Resolution and Inhibits Neuroinflammation in the Treatment of Intracerebral Hemorrhage

Hematoma and secondary neuroinflammation continue to pose a significant challenge in the clinical treatment of intracerebral hemorrhage (ICH). This study describes a nanoregulator formed through the self-assembly of Mg2+ and signal regulatory protein α (SIRPα) DNAzyme (SDz), aimed at enhancing hematoma resolution and inhibiting neuroinflammation in the treatment of ICH. The structure of SDz collapses in response to the acidic endo/lysosomal microenvironment of microglia, releasing Mg2+ and the SIRPα DNAzyme. The Mg2+ then acts as a cofactor to activate the SIRPα DNAzyme. By blocking the CD47-SIRPα signaling pathway, microglia can rapidly and effectively phagocytose red blood cells (RBCs), thereby promoting the clearance of the hematoma. Simultaneously, Mg2+ reset the microglia to the M2 phenotype by inhibiting the MYD88/MAPK/NF-κB signaling pathway, thereby modulating the inflammatory microenvironment of ICH. This co-delivery and synergistic strategy resulted in a significant reduction in hematoma size, decreasing from 11.90 to 5.84 mm3, and promoted recovery from ICH with minimal systemic side effects. This simple yet highly effective nanoplatform, which involves complex synergistic mechanisms, proves to be effective for ICH therapy and holds great promise for introducing novel perspectives into clinical and translational approaches for ICH.

A gender perspective on diet, microbiome, and sex hormone interplay in cardiovascular disease

A unique interplay between body and environment embeds and reflects host-microbiome interactions that contribute to sex-differential disease susceptibility, symptomatology, and treatment outcomes. These differences derive from individual biological factors, such as sex hormone action, sex-divergent immune processes, X-linked gene dosage effects, and epigenetics, as well as from their interaction across the lifespan. The gut microbiome is increasingly recognized as a moderator of several body systems that are thus impacted by its function and composition. In humans, biological sex components further interact with gender-specific exposures such as dietary preferences, stressors, and life experiences to form a complex whole, requiring innovative methodologies to disentangle. Here, we summarize current knowledge of the interactions among sex hormones, gut microbiota, immune system, and vascular health and their relevance for sex-differential epidemiology of cardiovascular diseases. We outline clinical implications, identify knowledge gaps, and place emphasis on required future studies to address these gaps. In addition, we provide an overview of the caveats associated with conducting cardiovascular research that require consideration of sex/gender differences. While previous work has inspected several of these components separately, here we call attention to further translational utility of a combined perspective from cardiovascular translational research, gender medicine, and microbiome systems biology.

Poststroke seizures and epilepsy increase the risk of dementia among stroke survivors: A population-based study

OBJECTIVE

With global aging, the occurrence of stroke and associated outcomes like dementia are on the rise. Seizures and epilepsy are common poststroke complications and have a strong connection to subsequent dementia. This study examines the relationship between poststroke seizures (PSS) or poststroke epilepsy (PSE) and dementia using a national health care database.

METHODS

We conducted a retrospective study using data from the Taiwan National Health Insurance Research Database from 2009 to 2020. We identified acute stroke patients from 2010 to 2015, excluding those with pre-existing neurological conditions. Based on age, sex, stroke severity level, and the year of index stroke, patients with PSS or PSE were matched to those without. The main outcome was incident dementia.

RESULTS

This study included 62 968 patients with an average age of 63 years, with males accounting for 62.9%. Of them, 60.3% had ischemic strokes, and 39.7% had hemorrhagic strokes. After an average follow-up period of 5.2 years, dementia developed in 15.9% of patients who had PSS or PSE, as opposed to 8.4% of those without these conditions. A time-dependent Fine and Gray competing risk analysis showed that PSS and PSE were significantly associated with dementia across all stroke types. Subgroup analyses revealed significantly increased risk of dementia across all age groups (<50, 50-64, and ≥65 years), sexes, and various stroke severity levels. The link between PSS or PSE and dementia was particularly pronounced in men, with a less distinct correlation in women.

SIGNIFICANCE

The risk of incident dementia was higher in patients with PSS or PSE. The potential for therapeutic interventions for seizures and epilepsy to reduce poststroke dementia underscores the importance of seizure screening and treatment in stroke survivors.

Tongue Pressure and Grip Strength as Indicators of Persistent Dysphagia After Acute Stroke

This study aimed to identify the independent predictors of postacute stroke dysphagia at discharge using sarcopenia-related parameters. This single-center prospective observational study assessed consecutive inpatients diagnosed with cerebral infarction or cerebral hemorrhage upon admission to the stroke unit. Tongue pressure, grip strength, and body composition were evaluated within 48 h. Dysphagia was defined by a functional oral intake scale of ≤ 5. Patient characteristics were compared between non-dysphagia and dysphagia groups using Mann-Whitney or chi-squared tests. Logistic regression analysis was performed using age, sex, tongue pressure, grip strength, skeletal muscle mass index (SMI), and National Institutes of Health Stroke Scale (NIHSS) scores as explanatory variables, with dysphagia at discharge as the objective variable. A total of 302 patients (mean age: 69.4 ± 13.8 years, 67.5% male) were analyzed, with 64 having dysphagia at discharge (21.2%). The dysphagia group was significantly older (p<0.001), had higher NIHSS scores on admission (p<0.001), lower SMI (p = 0.002), lower grip strength (p<0.001), and lower tongue pressure (p<0.001) than the non-dysphagia group. Logistic regression revealed that age (OR: 1.042, p = 0.018), tongue pressure (OR: 0.954, p = 0.010), and grip strength (OR: 0.943, p = 0.048) on admission were independent predictors of dysphagia at discharge, while NIHSS scores (OR: 1.403, p = 0.106), sex, and SMI (OR: 1.403, p = 0.150) were not. Older age, reduced tongue pressure, and reduced grip strength are strong predictors of persistent poststroke dysphagia at discharge. Thus, muscle strength is a more valuable parameter than muscle mass in predicting persistent poststroke dysphagia.

Maximising the Quality of Stroke Care: Reporting of Data Collection Methods and Resourcing in National Stroke Registries: A Systematic Review

Stroke registries are tools for improving care and advancing research. We aim to describe the methodology and resourcing of existing national stroke registries. We conducted a systematic search of the published, peer-reviewed literature and grey literature examining descriptions of data collection methods and resourcing of national stroke registries published from 2012 to 2023. The systematic review was registered in PROSPERO (CRD42023393841). 101 records relating to 21 registries in 19 countries were identified. They universally employed web-based platforms for data collection. The principal profession of data collectors was nursing. All included the acute phase of care, 28% (6) registered the pre-hospital (ambulance) phase and 14% (3) included rehabilitation. 80% (17) collected outcome data. The registries varied in their approach to outcome data collection; in 9 registries it was collected by hospitals, in 2 it was collected by the registry, and 7 had linkage to national administrative databases allowing follow-up of a limited number of end points. Coverage of the total number of strokes varies from 6 to 95%. Despite widespread use of Electronic Health Records (EHRs) the ability to automatically populate variables remained limited. Governance and management structures are diverse, making it challenging to compare their resourcing. Data collection for clinical registries requires time and necessary skills and imposes a significant administrative burden on the professionals entering data. We highlight the role of clinical registries as powerful instruments for quality improvement. Future work should involve creating a central repository of stroke registries to enable the development of new registries and facilitate international collaboration.

Basilar Stenosis Reduces the Impact of Successful Recanalization on Outcome in Basilar Artery Occlusion

BACKGROUND

Evidence from randomized controlled trials has shown a benefit for endovascular treatment in basilar artery occlusion. We aimed to show the effect of the recanalization result on outcome and determine the role of underlying basilar stenosis in a real-world setting.

METHODS

A retrospective, single-center study of patients who received endovascular treatment for basilar artery occlusion from March 2008 to June 2022 was conducted. Clinical and outcome characteristics were gathered. Multivariate logistic regression analysis was performed to predict poor outcomes (post-treatment mRS 5 or 6). MRS shift analysis was performed.

RESULTS

This study includes 210 patients (mean age, 71.4 years +/- 13.3 [standard deviation]; 124 men). The variables age (OR, 1.04; 95% CI: 1.01-1.08; p = 0.014), underlying basilar stenosis (OR: 4.86; 95% CI: 2.15-10.98; p < 0.001), admission NHISS (OR: 1.09; 95% CI: 1.04-1.13; p < 0.001), and TICI (OR: 1.89; 95% CI: 1.09-3.25; p = 0.022) independently predicted a poor outcome. Patients with occlusions due to underlying stenosis had significantly worse recanalization rates. Median post-treatment mRS in all patients with embolic occlusion was 4; IQR, 2-5 (only patients with embolic occlusion: mTICI 0-2a, median: 5 [IQR, 4-5.5]; mTICI 2b, median: 4 [IQR, 2.5-6]; mTICI 3, median: 3 [IQR, 1-5]; p = 0.037). Median post-treatment mRS in all patients with occlusions due to underlying stenosis was 5; IQR, 4-6 (only patients with embolic occlusions: mTICI 0-2a, median: 6 [IQR, 4.5-6]; mTICI 2b, median: 6 [IQR, 4.25-6]; mTICI 3, median: 5 [IQR, 3.5-5.25]; p = 0.059).

CONCLUSIONS

Successful recanalization is essential for preventing poor outcomes in basilar artery occlusion. Underlying basilar stenosis diminishes the effect of successful recanalization on the overall outcome.

Stroke severity and outcomes in patients with intracerebral hemorrhage on anticoagulants and antiplatelet agents: An analysis from the Japan Stroke Data Bank

BACKGROUND AND AIM

Some patients with intracerebral hemorrhage are on antithrombotic agents at the time of the event and these may worsen outcome, but the relative risk of different oral anticoagulants and antiplatelet agents is uncertain. We determined associations between pre-onset intake of antithrombotic agents and initial stroke severity, and outcomes, in patients with intracerebral hemorrhage.

METHODS

Patients with intracerebral hemorrhage admitted within 24 h after onset between January 2017 and December 2020 and recruited to the Japan Stroke Data Bank, a hospital-based multicenter prospective registry, were included. Enrolled patients were classified into four groups based on the type of antithrombotic agents being used on admission. The outcomes were the National Institutes of Health Stroke Scale (NIHSS) score on admission and modified Rankin Scale (mRS) of 5-6 at discharge.

RESULTS

Of a total 9810 patients with intracerebral hemorrhage (4267 females; mean age = 70 ± 15 years), 77.1% were classified into the no-antithrombotic group, 13.2% into the antiplatelet group, 4.0% into the warfarin group, and 5.8% into the direct oral anticoagulant (DOAC) group. Median (interquartile range) NIHSS score on admission was 12 (5-22), 13 (5-26), 15 (5-30), and 13 (6-24), respectively, in the four groups. In multivariable analysis, the prestroke warfarin use was associated with higher NIHSS score (adjusted incidence rate ratio = 1.09 (95% confidence interval (CI) = 1.06-1.13), with the no-antithrombotic group as the reference), but the antiplatelet group (1.00 (95% CI = 0.98-1.02)) and DOAC group (0.98 (95% CI = 0.95-1.01)) were not. The rate of mRS 5-6 at discharge was 30.8%, 41.9%, 48.6%, and 41.5%, respectively, in the four groups. In multivariable analysis, prestroke warfarin use was associated with mRS 5-6 (adjusted odds ratio = 1.90 (95% CI = 1.28-2.81), with the no-antithrombotic group as the reference), but the antiplatelet group (1.12 (95% CI = 0.91-1.37)) and DOAC group (1.25 (95% CI = 0.88-1.77)) were not.

CONCLUSION

Patients who were taking warfarin prior to intracerebral hemorrhage onset suffered more severe intracerebral hemorrhage as evidenced by higher admission NIHSS and higher discharge mRS. In contrast, no increase in severity was seen with antiplatelet agents.

Clinical impact of body mass index on outcomes of ischemic and hemorrhagic strokes

BACKGROUND AND AIM

To investigate the prognostic implication of body mass index (BMI) on clinical outcomes after acute ischemic and hemorrhagic stroke.

METHODS

The subjects of the study included adult patients with available baseline body weight and height data who had suffered an acute stroke and were registered in the Japan Stroke Data Bank-a hospital-based, multicenter stroke registration database-between January 2006 and December 2020. The outcome measures included unfavorable outcomes defined as a modified Rankin Scale (mRS) score of 5-6 and favorable outcomes (mRS 0-2) at discharge, and in-hospital mortality. Mixed effects logistic regression analysis was conducted to determine the relationship between BMI categories (underweight, normal weight, overweight, class I obesity, class II obesity; <18.5, 18.5-23.0, 23.0-25.0, 25-30, ⩾30 kg/m2) and the outcomes, after adjustment for covariates.

RESULTS

A total of 56,230 patients were assigned to one of the following groups: ischemic stroke (IS, n = 43,668), intracerebral hemorrhage (ICH, n = 9741), and subarachnoid hemorrhage (SAH, n = 2821). In the IS group, being underweight was associated with an increased likelihood of unfavorable outcomes (odds ratio, 1.47 (95% confidence interval (CI):1.31-1.65)) and in-hospital mortality (1.55 (1.31-1.83)) compared to outcomes in those with normal weight. Being overweight was associated with an increased likelihood of favorable outcomes (1.09 (1.01-1.18)). Similar associations were observed between underweight and these outcomes in specific IS subtypes (cardioembolic stroke, large artery stroke, and small-vessel occlusion). Patients with a BMI ⩾30.0 kg/m2 was associated with an increased likelihood of unfavorable outcomes (1.44 (1.01-2.17)) and in-hospital mortality (2.42 (1.26-4.65)) in large artery stroke. In patients with ICH, but not those with SAH, being underweight was associated with an increased likelihood of unfavorable outcomes (1.41 (1.01-1.99)).

CONCLUSIONS

BMI substantially impacts functional outcomes following IS and ICH. Lower BMI consistently affected post-stroke disability and mortality, while higher BMI values similarly affected these outcomes after large artery stroke.

Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke

Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.

Stroke Research Using Administrative Claims Database in Japan: A Narrative Review

AIMS

Although administrative claims databases have recently been used for clinical research in Japan, no detailed description of their utilization in stroke research is available. We reviewed stroke studies using the Diagnosis Procedure Combination (DPC), the National Database of Health Insurance Claims and Specific Health Checkups (NDB), and several commercial databases sourced from social health insurance associations, focusing on their applications and limitations.

METHODS

Original articles on stroke published by April 2024 using the DPC, NDB, and commercial databases were identified in Ovid MEDLINE. The characteristics of each database were compared in terms of comprehensiveness, traceability, baseline information, and outcome assessment in stroke research.

RESULTS

A total of 114 studies were included (83 for DPC, 6 for NDB, and 25 for commercial databases). The number of stroke studies using administrative databases in Japan is still approximately 10 per year, although there is a slowly increasing trend. The DPC database was utilized for short-term outcome studies because of its detailed baseline and outcome information, although the inability to track patients once they changed facilities limits their use in long-term studies. The NDB database is potentially useful for long-term studies because of its comprehensiveness and traceability, but difficulties in data access restrict its usage. The most commonly used commercial database utilizes baseline information on lifestyle and blood test data, although the lack of coverage for those over 75 years old may limit its generalizability.

CONCLUSIONS

Administrative claims databases are beginning to be used in stroke research in Japan but are not yet fully utilized. Researchers need to understand their applications and limitations.

The beneficial health effects of puerarin in the treatment of cardiovascular diseases: from mechanisms to therapeutics

Cardiovascular diseases (CVDs) are the leading causes of death globally that seriously threaten human health. Although novel western medicines have continued to be discovered over the past few decades to inhibit the progression of CVDs, new drug research and development for treating CVDs with less side effects and adverse reactions are continuously being desired. Puerarin is a natural product found in a variety of medicinal plants belonging to the flavonoid family with potent biological and pharmacological activities. Abundant research findings in the literature have suggested that puerarin possesses a promising prospect in treating CVDs. In recent years, numerous new molecular mechanisms of puerarin have been explored in experimental and clinical studies, providing new evidence for this plant metabolite to protect against CVDs. This article systematically introduces the history of use, bioavailability, and various dosage forms of puerarin and further summarizes recently published data on the major research advances and their underlying therapeutic mechanisms in treating CVDs. It may provide references for researchers in the fields of pharmacology, natural products, and internal medicine.

Post-stroke cognitive impairment remains highly prevalent and disabling despite state-of-the-art stroke treatment

BACKGROUND

State-of-the-art stroke treatment significantly reduces lesion size and stroke severity, but it remains unclear whether these therapeutic advances have diminished the burden of post-stroke cognitive impairment (PSCI).

AIMS

In a cohort of patients receiving modern state-of-the-art stroke care including endovascular therapy, we assessed the frequency of PSCI and the pattern of domain-specific cognitive deficits, identified risk factors for PSCI, and determined the impact of acute PSCI on stroke outcome.

METHODS

In this prospective monocentric cohort study, we examined patients with first-ever anterior circulation ischemic stroke without pre-stroke cognitive decline, using a comprehensive neuropsychological assessment ⩽10 days after symptom onset. Normative data were stratified by demographic variables. We defined PSCI as at least moderate (<1.5 standard deviation) deficits in ⩾2 cognitive domains. Multivariable regression analysis was applied to define risk factors for PSCI.

RESULTS

We analyzed 329 non-aphasic patients admitted from December 2020 to July 2023 (67.2 ± 14.4 years old, 41.3% female, 13.1 ± 2.7 years of education). Although most patients had mild stroke (median National Institutes of Health Stroke Scale (NIHSS) 24 h = 1.00 (0.00; 3.00); 87.5% with NIHSS ⩽ 5), 69.3% of them presented with PSCI 2.7 ± 2.0 days post-stroke. The most severely and often affected cognitive domains were verbal learning, episodic memory, executive functions, selective attention, and constructive abilities (39.1%-51.2% of patients), whereas spatial neglect was less frequent (18.5%). The risk of PSCI was reduced with more years of education (odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.23-0.99) and right hemisphere lesions (OR = 0.47, 95% CI = 0.26-0.84), and increased with stroke severity (NIHSS 24 h, OR = 4.19, 95% CI = 2.72-6.45), presence of hyperlipidemia (OR = 1.93, 95% CI = 1.01-3.68), but was not influenced by age. After adjusting for stroke severity and depressive symptoms, acute PSCI was associated with poor functional outcome (modified Rankin Scale > 2, F = 13.695, p < 0.001) and worse global cognition (Montreal Cognitive Assessment (MoCA) score, F = 20.069, p < 0.001) at 3 months post-stroke.

CONCLUSION

Despite modern stroke therapy and many strokes having mild severity, PSCI in the acute stroke phase remains frequent and associated with worse outcome. The most prevalent were learning and memory deficits. Cognitive reserve operationalized as years of education independently protects post-stroke cognition.

Cerebral small vessel disease markers and long-term prognosis in spontaneous intracerebral hemorrhage: the HAGAKURE-ICH study

We investigated the effects of individual and cumulative cerebral small vessel disease (SVD) markers on long-term clinical outcomes in spontaneous intracerebral hemorrhage (sICH) patients. This prospective, single-center cohort study was conducted from 2012 to 2019. SVD markers, including lacunae, cerebral microbleeds, white matter hyperintensity (WMH), and perivascular spaces in the basal ganglia, were assessed to calculate a summary SVD score. Patients were categorized into severe (score ≥3) and non-severe (score 0-2) SVD burden groups. Functional prognosis was defined as recovery, no change, or decline based on modified Rankin Scale changes at 2 years after discharge, excluding death. Associations of SVD burden and individual SVD markers with outcomes were evaluated using Cox proportional hazards modeling for recurrent stroke and all-cause mortality, and using ordinal logistic regression for functional prognosis. Among 155 sICH patients who underwent MRI, 98 showed severe SVD burden. Recurrent stroke and all-cause mortality rates were 2.2 and 8.3 per 100 patient-years, respectively, over a median 2.1-year follow-up. In terms of functional prognosis, 57 patients (51.8%) recovered, 32 (29.1%) showed no change, and 21 (19.1%) declined. A significant association was apparent between severe SVD burden and poorer functional prognosis (odds ratio [OR] 2.48, 95% confidence interval [CI] 1.04-6.04; p = 0.042), particularly with moderate-to-severe WMH (OR 2.54, 95%CI 1.02-6.54; p = 0.048). The cumulative effects of SVD markers inhibited long-term functional recovery in sICH patients. Severe SVD burden, as well as moderate-to-severe WMH, can be indicators of long-term prognosis after sICH.

Multi-therapeutic-activity selenium nanodot toward preventing brain injury and restoring neurobehavioral functions following hemorrhagic stroke

Intracerebral hemorrhage is a lethal cerebrovascular disease, and the inevitable secondary brain injury (SBI) is responsible for serious disability and death. Perfect therapeutic goal is to minimize SBI and restore neurobehavioral functions. Recently, neuroprotection is highlighted to reduce SBI, but it still faces "Neuronal survival but impaired functions" dilemma. Herein, this work further proposes a novel combinational therapeutic strategy of neuroprotection and neurogenesis toward this goal. However, appropriate therapeutic agents are rarely reported, and their discovery and development are urgently needed. Selenium participates in various physiological/pathological processes, which is hypothesized as a potential targeting molecule. To explore this effect, this work formulates an ultra-small selenium nanodot with a seleno-amino acid derived carbon dot domain and a hydrophilic PEG layer, surprisingly finding that it increases various selenoproteins levels at perihematomal region, to not only exert multiple neuroprotective roles at acute phase but promote neurogenesis and inhibit glial scar formation at recovery phase. At a safe dose, this combinational strategy effectively prevents SBI and recovers neurobehavioral functions to a normal level. Furthermore, its molecular mechanisms are revealed to broaden application scopes in other complex diseases.

Contemporary Statistics of Acute Ischemic Stroke and Transient Ischemic Attack in 2021: Insights From the CRCS-K-NIH Registry

This report presents the latest statistics on the stroke population in South Korea, sourced from the Clinical Research Collaborations for Stroke in Korea-National Institute for Health (CRCS-K-NIH), a comprehensive, nationwide, multicenter stroke registry. The Korean cohort, unlike western populations, shows a male-to-female ratio of 1.5, attributed to lower risk factors in Korean women. The average ages for men and women are 67 and 73 years, respectively. Hypertension is the most common risk factor (67%), consistent with global trends, but there is a higher prevalence of diabetes (35%) and smoking (21%). The prevalence of atrial fibrillation (19%) is lower than in western populations, suggesting effective prevention strategies in the general population. A high incidence of large artery atherosclerosis (38%) is observed, likely due to prevalent intracranial arterial disease in East Asians and advanced imaging techniques. There has been a decrease in intravenous thrombolysis rates, from 12% in 2017-2019 to 10% in 2021, with no improvements in door-to-needle and door-to-puncture times, worsened by the coronavirus disease 2019 pandemic. While the use of aspirin plus clopidogrel for non-cardioembolic stroke and direct oral anticoagulants for atrial fibrillation is well-established, the application of direct oral anticoagulants for non-atrial fibrillation cardioembolic strokes in the acute phase requires further research. The incidence of early neurological deterioration (13%) and the cumulative incidence of recurrent stroke at 3 months (3%) align with global figures. Favorable outcomes at 3 months (63%) are comparable internationally, yet the lack of improvement in dependency at 3 months highlights the need for advancements in acute stroke care.

Safety of Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage in the Registry of Intracerebral Hemorrhage Treated by Endoscopic Hematoma Evacuation in Japan

OBJECTIVE

The long history of treatment for intracerebral hemorrhage (ICH) includes the development of surgical procedures. However, few studies have demonstrated that surgery improved the functional outcome. The present study used the prospective Registry of Intracerebral hemorrhage treated by endoscopic hematoma evacuation of the outcomes in endoscopic surgery, which is widely followed in Japan, to try to establish clinical evidence.

METHODS

The Registry of Intracerebral hemorrhage treated by endoscopic hematoma evacuation is a multicenter, prospective registry in Japan, and included 143 surgical cases treated by certified neurosurgeons. The etiology and the location of ICH was evaluated by univariate and multivariate analyses as follows: deep, surface, intraventricular hemorrhage, cerebellum, and surgical outcome.

RESULTS

Hematoma location was deep in 44.8% of cases, intraventricular hemorrhage in 19.6%, surface in 21.7%, and cerebellum in 14.0%. Most cases were treated in the ultraearly stage within 8 hours. Mean hematoma evacuation rate was 83.6% and median residual hematoma volume was 3.0 ml. Duration of surgery was median 78 minutes. Rebleeding as a complication was observed in 6.7%, but only 2.9% were symptomatic. 2 cases required reoperation. Favorable outcome at 6 months was achieved in 35.8% of cases, with a mortality rate of 5.6%.

CONCLUSIONS

Endoscopic surgery for spontaneous ICH is safe and comparable to conventional surgery. The time required for the procedure was significantly reduced, demonstrating the minimally invasive character of the surgical burden. However, this study did not establish whether minimally invasive surgery is superior to conservative treatment. Future randomized controlled trials should clarify the effectiveness of the treatment.

Association of Age and Neurological Severity at Intensive Care Unit Admission With Driving Resumption Within 30 Days of Stroke: A Single-Center Historical Cohort Study

Objectives Guidelines in several countries recommend against driving soon after a stroke; however, some patients resume driving within one month after onset. This study aimed to examine the relationship between neurological and social background factors at intensive care unit (ICU) admission and resumption of motor vehicle driving within 30 days of the first acute stroke/cerebral hemorrhage. Materials and methods Data were extracted from medical records of a single center linked to the National Cerebral and Cardiovascular Center Administration Office for Stroke Data Bank in Japan. The data included age, sex, Japan Coma Scale (JCS), National Institutes of Health Stroke Scale (NIHSS), employment status, family situation, and outcomes of driving resumption in patients with a valid driving license transported to the ICU within 24 hours of stroke onset. Time-to-event analysis was used to explore the associations between these factors and driving resumption, with data censored 30 days from onset. Results In total, 239 patients had complete medical records, of whom 66 resumed driving. A multivariate Cox proportional hazards analysis showed that fewer patients aged ≥65 years resumed driving than those aged <65 years (hazard ratio 0.46; 95% confidence interval: 0.25-0.84; p=0.009). Patients with NIHSS scores ≥5 and JCS scores ≥1 were also less likely to resume driving compared with those with scores <5 (0.22; 0.08-0.56; p=0.008) and 0 (0.13; 0.04-0.37; p<0.001), respectively. Conclusions Age, NIHSS score, and JCS score at ICU admission are independently associated with the likelihood of resuming driving within 30 days of stroke onset. These findings may aid with the provision of support and education to facilitate the efficient resumption of driving after an acute event.

Addressing the Evidence Gap in Aneurysmal Subarachnoid Hemorrhage: The Need for a Pragmatic Randomized Trial Platform

Aneurysmal subarachnoid hemorrhage (aSAH) occurs less often than other stroke types but affects younger patients, imposing a disproportionately high burden of long-term disability. Although management advances have improved outcomes over time, relatively few aSAH treatments have been tested in randomized clinical trials (RCTs). One lesson learned from COVID-19 is that trial platforms can facilitate the efficient execution of multicenter RCTs even in complex diseases during challenging conditions. An aSAH trial platform with standardized eligibility criteria, randomization procedures, and end point definitions would enable the study of multiple targeted interventions in a perpetual manner, with treatments entering and leaving the platform based on predefined decision algorithms. An umbrella institutional review board protocol and clinical trial agreement would allow individual arms to be efficiently added as amendments rather than stand-alone protocols. Standardized case report forms using the National Institutes of Health/National Institute of Neurological Disorders and Stroke common data elements and general protocol standardization across arms would create synergies for data management and monitoring. A Bayesian analysis framework would emphasize frequent interim looks to enable early termination of trial arms for futility, common controls, borrowing of information across arms, and adaptive designs. A protocol development committee would assist investigators and encourage pragmatic designs to maximize generalizability, reduce site burden, and execute trials efficiently and cost-effectively. Despite decades of steady clinical progress in the management of aSAH, poor patient outcomes remain common, and despite the increasing availability of RCT data in other fields, it remains difficult to perform RCTs to guide more effective care for aSAH. The development of a platform for pragmatic RCTs in aSAH would help close the evidence gap between aSAH and other stroke types and improve outcomes for this important disease with its disproportionate public health burden.

Severity, Outcomes, and their Secular Changes in 33,870 Ischemic Stroke Patients with Atrial Fibrillation in a Hospital-Based Registry: Japan Stroke Data Bank

AIM

Severity, functional outcomes, and their secular changes in acute atrial fibrillation (AF)-associated stroke patients were determined.

METHODS

Acute ischemic stroke patients with AF in a hospital-based, multicenter, prospective registry from January-2000 through December-2020, were compared with those without AF. The co-primary outcomes were the initial severity assessed by the NIH Stroke Scale (NIHSS) score and favorable outcome assessed by the modified Rankin Scale scores 0-2 at hospital discharge.

RESULTS

Of the 142,351 patients studied, 33,870 had AF. AF patients had higher NIHSS scores (median 9 vs. 3, adjusted coefficient 5.468, 95% CI 5.354-5.582) than non-AF patients. Favorable outcome was less common in AF patients than in non-AF patients in the unadjusted analysis (48.4% vs. 70.4%), but it was more common with adjustment for the NIHSS score and other factors (adjusted OR 1.110, 95% CI 1.061-1.161). In AF patients, the NIHSS score decreased throughout the 21-year period (adjusted coefficient -0.088, 95% CI -0.115 - -0.061 per year), and the reduction was steeper than in non-AF patients (P＜0.001). In AF patients, favorable outcome became more common over the period (adjusted OR 1.018, 95% CI 1.010-1.026), and the increase was steeper than in non-AF patients (P＜0.001); the increase was no longer significant after further adjustment by reperfusion therapy.

CONCLUSIONS

Initial stroke severity became milder and functional outcomes improved in AF patients over the 21-year period. These secular changes were steeper than in non-AF patients, suggesting that AF-associated stroke seemed to reap more benefit of recent development of stroke care than stroke without AF.

A qualitative study of stressors faced by older stroke patients in a convalescent rehabilitation hospital

This study aimed to explore the stressors experienced by older patients with stroke in convalescent rehabilitation wards in Japan. Semi-structured interviews were conducted with four stroke patients aged > 65 years who experienced a stroke for the first time in their lives. The interviews were analyzed using the Steps for Coding and Theorization method for qualitative data analysis. The results of the qualitative analysis demonstrated that patients experienced specific stressors, such as, difficulty in movement of the paralyzed hand, fear of stroke recurrence, and dietary problems. Some stressors were manageable through healthcare professionals' active and sensitive communication strategies. These stressors were derived from the theoretical framework of "stressors related to hospitalization" and "stressors related to the illness". Additional stressors emerged from the interaction between these two types within the theoretical framework. The results of this study contribute to a deeper understanding of the specific stressors experienced by older stroke patients during the recovery process.

Caregiver burden after stroke: a 10-year follow-up study of Polish caregivers for stroke patients

BACKGROUND

A long-term assessment of stroke outcomes from the perspectives of patients and their caregivers is important for optimising long-term post-stroke care. The extended effects of stroke caregiving, particularly caregiver burden beyond 5 years since stroke, remain to be determined. Hence, this study aimed to determine caregiver burden at 10 years after stroke, compare the burden severity at 10 years with its levels at 5 years and 6 months after stroke, and identify predictors of the burden severity at 10 years post-stroke.

METHODS

A longitudinal follow-up study including a group of first-ever stroke patients/informal continuous caregivers pairs was followed for 10 years and interviewed face-to face at their home setting. Caregiver burden was evaluated with the Caregiver Burden Scale. Potential predictors were examined using standardised measures and identified by applying the Classification and Regression Tree.

RESULTS

A total of 40 caregiver/patient pairs participated in the study. At 10 years, 47.5% of the caregivers experienced a considerable burden. This was more than after 5 years (17.5%) and comparable to that after 6 months (37.5%), p < 0.003. Longer time spent caregiving, caregivers' weaker sense of coherence, more severe stroke, and caregivers' anxiety were the independent predictors of considerable burden 10 years after stroke.

CONCLUSIONS

Caregivers' burden in the late chronic post-stroke phase is a significant problem, as nearly half of the caregivers experience a substantial burden. This problem mainly concerns individuals who spend at least 7 h daily caregiving and have a lower Sense of Coherence. The long-term evaluation of stroke consequences reported by stroke patients and their caregivers can be an important source of information for healthcare professionals in order to optimise the care and support they provide at various stages of life after stroke.

Low hemoglobin causes hematoma expansion and poor intracerebral hemorrhage outcomes

Objectives

Although lower hemoglobin levels associate with worse intracerebral hemorrhage (ICH) outcomes, causal drivers for this relationship remain unclear. We investigated the hypothesis that lower hemoglobin relates to increased hematoma expansion (HE) risk and poor outcomes using human observational data and assessed causal relationships using a translational murine model of anemia and ICH.

Methods

ICH patients with baseline hemoglobin measurements and serial CT neuroimaging enrolled between 2010-2016 to a multicenter, prospective observational cohort study were studied. Patients with systemic evidence of coagulopathy were excluded. Separate regression models assessed relationships of baseline hemoglobin with HE (≥33% and/or ≥6mL growth) and poor long-term neurological outcomes (modified Rankin Scale 4-6) after adjusting for relevant covariates. Using a murine collagenase ICH model with serial neuroimaging in anemic vs. non-anemic C57/BL6 mice, intergroup differences in ICH lesion volume, ICH volume changes, and early mortality were assessed.

Results

Among 1190 ICH patients analyzed, lower baseline hemoglobin levels associated with increased odds of HE (adjusted OR per -1g/dL hemoglobin decrement: 1.10 [1.02-1.19]) and poor 3-month clinical outcomes (adjusted OR per -1g/dL hemoglobin decrement: 1.11 [1.03-1.21]). Similar relationships were seen with poor 6 and 12-month outcomes. In our animal model, anemic mice had significantly greater ICH lesion expansion, final lesion volumes, and greater mortality, as compared to non-anemic mice.

Conclusions

These results, in a human cohort and a mouse model, provide novel evidence suggesting that anemia has causal roles in HE and poor ICH outcomes. Additional studies are required to clarify whether correcting anemia can improve these outcomes.

Fasudil hydrochloride and ozagrel sodium combination therapy for patients with aneurysmal subarachnoid hemorrhage: a cross-sectional study using a nationwide inpatient database

BACKGROUND

Fasudil and ozagrel are drugs with the same indications for the treatment of cerebral vasospasm in Japan. However, there have been no definitive conclusions on the clinical efficacy of fasudil hydrochloride and ozagrel sodium monotherapy or their combination. Therefore, we aimed to investigate the effectiveness of the combined administration of fasudil hydrochloride and ozagrel sodium in Japanese patients with subarachnoid hemorrhage (SAH).

METHODS

This cross-sectional study used Diagnosis Procedure Combination data to assess patients who were hospitalized with SAH and received fasudil hydrochloride or ozagrel sodium between April 2016 and March 2020 (n = 17,346). The participants were divided into three groups based on the treatment received: fasudil hydrochloride monotherapy (F group, n = 10,484), ozagrel sodium monotherapy (O group, n = 465), and fasudil hydrochloride and ozagrel sodium combination therapy (FO group, n = 6,397). The primary outcome was in-hospital mortality. Multivariable adjusted logistic regression analysis (significance level, 5%) was used for data analyses.

RESULTS

The results of the multivariable analysis, adjusted for factors considered to impact prognosis, showed that the adjusted odds ratio (OR) with the F group as the reference for in-hospital mortality was 0.94 in the FO group (95% confidence interval [CI]: 0.81-1.08, p = 0.355), with no differences compared to the F group.

CONCLUSION

Fasudil hydrochloride and ozagrel sodium had different mechanisms of action, suggesting a synergistic effect of combination therapy. However, a comparison of fasudil hydrochloride monotherapy and combination therapy of fasudil hydrochloride and ozagrel sodium showed no difference in the prognostic effect. Therefore, it was suggested that fasudil hydrochloride monotherapy may be sufficient.

Gender-specific prognosis models reveal differences in subarachnoid hemorrhage patients between sexes

BACKGROUND

Subarachnoid hemorrhage (SAH) represents a severe stroke subtype. Our study aims to develop gender-specific prognostic prediction models derived from distinct prognostic factors observed among different-gender patients.

METHODS

Inclusion comprised SAH-diagnosed patients from January 2014 to March 2016 in our institution. Collected data encompassed patients' demographics, admission severity, treatments, imaging findings, and complications. Three-month post-discharge prognoses were obtained via follow-ups. Analyses assessed gender-based differences in patient information. Key factors underwent subgroup analysis, followed by univariate and multivariate analyses to identify gender-specific prognostic factors and establish/validate gender-specific prognostic models.

RESULTS

A total of 929 patients, with a median age of 57 (16) years, were analyzed; 372 (40%) were male, and 557 (60%) were female. Differences in age, smoking history, hypertension, aneurysm presence, and treatment interventions existed between genders (p < 0.01), yet no disparity in prognosis was noted. Subgroup analysis explored hypertension history, aneurysm presence, and treatment impact, revealing gender-specific variations in these factors' influence on the disease. Screening identified independent prognostic factors: age, SEBES score, admission GCS score, and complications for males; and age, admission GCS score, intraventricular hemorrhage, treatment interventions, symptomatic vasospasm, hydrocephalus, delayed cerebral ischemia, and seizures for females. Evaluation and validation of gender-specific models yielded an AUC of 0.916 (95% CI: 0.878-0.954) for males and 0.914 (95% CI: 0.885-0.944) for females in the ROC curve. Gender-specific prognostic models didn't significantly differ from the overall population-based model (model 3) but exhibited robust discriminative ability and clinical utility.

CONCLUSION

Variations in baseline and treatment-related factors among genders contribute partly to gender-based prognosis differences. Independent prognostic factors vary by gender. Gender-specific prognostic models exhibit favorable prognostic performance.

The Capacitated Maximal Covering Location Problem Improves Access to Stroke Treatment: A Cross-Sectional Simulation Study

Disparities in accessing advanced stroke treatment have been recognized as a policy challenge in multiple countries, including Japan, necessitating priority solutions. Nevertheless, more practical healthcare policies must be implemented due to the limited availability of healthcare staff and financial resources in most nations. This study aimed to evaluate the supply and demand balance of mechanical thrombectomy (MT) and identify areas with high priority for enhancing stroke centers. The target area of this study was Hokkaido, Japan. We adopted the capacitated maximal covering location problem (CMCLP) to propose an optimal allocation without increasing the number of medical facilities. Four realistic scenarios with varying levels of total MT supply capacity for Primary stroke centers and assuming a range of 90 minutes by car from the center were created and simulated. From scenarios 1 to 4, the coverage increased by approximately 53% to 85%, scenarios 2 and 3 had 5% oversupply, and scenario 4 had an oversupply of approximately 20%. When the supply capacity cap was eliminated and 8 PSCs received 31 or more patients, they became priority enhancement targets. The CMCLP estimates demand coverage considering the supply and demand balance and indicates areas and facilities where MT supply capacity enhancement is a priority.

Crosstalk between ferroptosis and necroptosis in cerebral ischemia/reperfusion injury and Naotaifang formula exerts neuroprotective effect via HSP90-GCN2-ATF4 pathway

BACKGROUND

Cerebral ischemia/reperfusion injury (CIRI) is a sequence of pathophysiological processes after blood recanalization in the patients with ischemic stroke, and has become the hinder for the rehabilitation. Naotaifang formula (NTF) has exhibited the clinical effectiveness for this disease. However, its action effects and molecular mechanisms against CIRI are not fully elucidated.

PURPOSE

The research was to clarify the crosstalk between ferroptosis and necroptosis in CIRI, and uncover the mechanism underlying the neuroprotection of NTF.

METHODS

This study established MCAO/R rat models with various reperfusion times. Western blot, transmission electron microscope, laser speckle imaging, immunofluorescence, immunohistochemistry and pathological staining were conducted to detect and analyze the obtained results. Subsequently, various NTF doses were used to intervene in MCAO/R rats, and biology experiments, such as western blot, Evans blue, immunofluorescence and immunohistochemistry, were used to analyze the efficacy of NTF doses. The effect of NTF was further clarified through in vitro experiments. Eventually, HT22 cells that suffered OGD/R were subjected to pre-treatment with plasmids overexpressing HSP90, MLKL, and GPX4 to indicate the interaction among ferroptosis and necroptosis.

RESULTS

There was a gradual increase in the Zea Longa score and cerebral infarction volume following CIRI with prolonged reperfusion. Furthermore, the expression of factors associated with pro-ferroptosis and pro-necroptosis was upregulated in the cortex and hippocampus. NTF alleviated ferroptosis and necroptosis in a dose-dependent manner, downregulated HSP90 levels, reduced blood-brain barrier permeability, and thus protected nerve cells from CIRI. The results in vitro research aligned with those of the in vivo research. HSP90 and MLKL overexpression promoted necroptosis and ferroptosis while activating the GCN2-ATF4 pathway. GPX4 overexpression had no effect on necroptosis or the associated signaling pathway. The administration of NTF alone, as well as its combination with the overexpression of HSP90, MLKL, or GPX4 plasmids, decreased the expression levels of factors associated with pro-ferroptosis and pro-necroptosis and reduced the protein levels of the HSP90-GCN2-ATF4 pathway. Moreover, the regulatory effects of the NTF alone group on GSH, ferrous iron, and GCN2 were more significant compared with those of the HSP90 overexpression combination group.

CONCLUSION

Ferroptosis and necroptosis were gradually aggravated following CIRI with prolonged reperfusion. MLKL overexpression may promote ferroptosis and necroptosis, while GPX4 overexpression may have little effect on necroptosis. HSP90 overexpression accelerated both forms of cell death via the HSP90-GCN2-ATF4 pathway. NTF alleviated ferroptosis and necroptosis to attenuate CIRI by regulating the HSP90-GCN2-ATF4 pathway. Our research provided evidence for the potential of drug development by targeting HSP90, MLKL, and GPX4 to protect against ischemic stroke.

Anemia From Inflammation After Intracerebral Hemorrhage and Relationships With Outcome

BACKGROUND

Baseline anemia is associated with poor intracerebral hemorrhage (ICH) outcomes. However, underlying drivers for anemia and whether anemia development after ICH impacts clinical outcomes are unknown. We hypothesized that inflammation drives anemia development after ICH and assessed their relationship to outcomes.

METHODS AND RESULTS

Patients with serial hemoglobin and iron biomarker concentrations from the HIDEF (High-Dose Deferoxamine in Intracerebral Hemorrhage) trial were analyzed. Adjusted linear mixed models assessed laboratory changes over time. Of 42 patients, significant decrements in hemoglobin occurred with anemia increasing from 19% to 45% by day 5. Anemia of inflammation iron biomarker criteria was met in 88%. A separate cohort of 521 patients with ICH with more granular serial hemoglobin and long-term neurological outcome data was also investigated. Separate regression models assessed whether (1) systemic inflammatory response syndrome (SIRS) scores related to hemoglobin changes over time and (2) hemoglobin changes related to poor 90-day outcome. In this cohort, anemia prevalence increased from 30% to 71% within 2 days of admission yet persisted beyond this time. Elevated systemic inflammatory response syndrome was associated with greater hemoglobin decrements over time (adjusted parameter estimate: -0.27 [95% CI, -0.37 to -0.17]) and greater hemoglobin decrements were associated with poor outcomes (adjusted odds ratio per 1 g/dL increase, 0.76 [95% CI, 0.62-0.93]) independent to inflammation and ICH severity.

CONCLUSIONS

We identified novel findings that acute anemia development after ICH is common, rapid, and related to inflammation. Because anemia development is associated with poor outcomes, further work is required to clarify if anemia, or its underlying drivers, are modifiable treatment targets that can improve ICH outcomes.

REGISTRATION

https://www.clinicaltrials.gov Unique identifier: NCT01662895.

Admission Viscoelastic Hemostatic Assay Parameters Predict Poor Long-Term Intracerebral Hemorrhage Outcomes

BACKGROUND

Viscoelastic hemostatic assays (VHAs) provide more comprehensive assessments of coagulation compared with conventional coagulation assays. Although VHAs have enabled guided hemorrhage control therapies, improving clinical outcomes in life-threatening hemorrhage, the role of VHAs in intracerebral hemorrhage (ICH) is unclear. If VHAs can identify coagulation abnormalities relevant for ICH outcomes, this would support the need to investigate the role of VHAs in ICH treatment paradigms. Thus, we investigated whether VHA assessments of coagulation relate to long-term ICH outcomes.

METHODS

Patients with spontaneous ICH enrolled into a single-center cohort study receiving admission Rotational Thromboelastometry (ROTEM) VHA testing between 2013 and 2020 were assessed. Patients with previous anticoagulant use or coagulopathy on conventional coagulation assays were excluded. Primary ROTEM exposure variables were coagulation kinetics and clot strength assessments. Poor long-term outcome was defined as modified Rankin Scale ≥ 4 at 6 months. Logistic regression analyses assessed associations of ROTEM parameters with clinical outcomes after adjusting for ICH severity and hemoglobin concentration.

RESULTS

Of 44 patients analyzed, the mean age was 64 years, 57% were female, and the median ICH volume was 23 mL. Poor 6-month outcome was seen in 64% of patients. In our multivariable regression models, slower, prolonged coagulation kinetics (adjusted odds ratio for every second increase in clot formation time 1.04, 95% confidence interval 1.00-1.09, p = 0.04) and weaker clot strength (adjusted odds ratio for every millimeter increase of maximum clot firmness 0.84, 95% confidence interval 0.71-0.99, p = 0.03) were separately associated with poor long-term outcomes.

CONCLUSIONS

Slower, prolonged coagulation kinetics and weaker clot strength on admission VHA ROTEM testing, not attributable to anticoagulant use, were associated with poor long-term outcomes after ICH. Further work is needed to clarify the generalizability and the underlying mechanisms of these VHA findings to assess whether VHA-guided treatments should be incorporated into ICH care.

Prevalence and outcome of pre-onset frailty in patients with acute stroke

BACKGROUND

Frailty in older individuals is an underappreciated condition that affects the incidence and/or prognosis of stroke.

OBJECTIVES

We evaluated the prevalence of pre-onset frailty in patients with acute first-onset and recurrent strokes and association between pre-onset frailty and functional disability at hospital discharge.

METHODS

This prospective cohort study included 210 acute stroke patients admitted to the Stroke Unit of Nippon Medical School Hospital during November 2021-June 2022. The mean participant age was 79.2 ± 7.4 years. Age, sex, pre-onset frailty, body mass index (BMI), stroke type, medical history, and National Institutes of Health Stroke Scale (NIHSS) score at admission were evaluated. Frailty was defined as a clinical frailty scale (CFS) score ≥ 5. Frailty prevalence was calculated for all patients, and scores of functional disabilities at discharge were evaluated using modified Rankin scale.

RESULTS

Overall frailty prevalence was 31% in all stroke patients, with 24% and 47% of first-onset and recurrent strokes, respectively. Pre-onset frailty, NIHSS score at admission, age, stroke type, previous stroke, sex, BMI, dyslipidemia, and atrial fibrillation were significantly associated with functional disability at discharge. Logistic regression analysis revealed that CFS score, NIHSS score at admission, and previous stroke were independent predictors of functional disability at discharge.

CONCLUSIONS

Approximately one-fourth of patients with first-onset stroke had pre-onset frailty; the rate doubled in recurrent stroke; these rates appear to be much larger than rate in healthy individuals. Pre-onset frailty, a negative independent factor affecting functional disability at discharge, is important for pre-onset frailty evaluation and rehabilitation intervention in acute stroke patients.

Research progress of prodrugs for the treatment of cerebral ischemia

It is well-known that pharmacotherapy plays a pivotal role in the treatment and prevention of cerebral ischemia. Nevertheless, existing drugs, including numerous natural products, encounter various challenges when applied in cerebral ischemia treatment. These challenges comprise poor brain absorption due to low blood-brain barrier (BBB) permeability, limited water solubility, inadequate bioavailability, poor stability, and rapid metabolism. To address these issues, researchers have turned to prodrug strategies, aiming to mitigate or eliminate the adverse properties of parent drug molecules. In vivo metabolism or enzymatic reactions convert prodrugs into active parent drugs, thereby augmenting BBB permeability, improving bioavailability and stability, and reducing toxicity to normal tissues, ultimately aiming to enhance treatment efficacy and safety. This comprehensive review delves into multiple effective prodrug strategies, providing a detailed description of representative prodrugs developed over the past two decades. It underscores the potential of prodrug approaches to improve the therapeutic outcomes of currently available drugs for cerebral ischemia. The publication of this review serves to enrich current research progress on prodrug strategies for the treatment and prevention of cerebral ischemia. Furthermore, it seeks to offer valuable insights for pharmaceutical chemists in this field, offer guidance for the development of drugs for cerebral ischemia, and provide patients with safer and more effective drug treatment options.

Ten-year national trends in in-hospital mortality and functional outcomes after intracerebral hemorrhage by age in Japan: J-ASPECT study

INTRODUCTION

National-level data on trends in the prognosis of age-stratified patients with intracerebral hemorrhage (ICH) are lacking. This study aimed to assess time trends in in-hospital mortality and functional outcomes of ICH patients by sex and age, and to explore factors associated with changes in in-hospital mortality trend.

PATIENTS AND METHODS

Using the largest nationwide, J-ASPECT stroke database in Japan, this serial cross-sectional study included ICH patients aged ⩾18 years who were hospitalized for non-traumatic ICH from April 2010 to March 2020. We examined trends in in-hospital mortality and functional outcomes using the modified Rankin Scale at discharge, as well as differences in in-hospital mortality change between age groups.

RESULTS

Among 262,399 ICH patients from 934 hospitals, crude in-hospital mortality showed a significant decreasing time trend (from 19.5% to 16.7%), and this trend was consistent across sex and age groups. In addition, differences in in-hospital mortality change over the 10-year study period were significant between male patients aged ⩾75 years and those aged ⩽64 years (-3.9% [95% confidence interval, -5.4 to -2.4] for 75-84 years; -4.1% [-6.3 to -1.9] for ⩾85 years). On the other hand, the proportion of dependent patients (mRS 3-5) at discharge increased from 52.0% to 54.9% over the 10-year study period.

CONCLUSION

The in-hospital mortality of ICH patients improved, whereas the proportion of patients with dependent functional outcome at discharge increased, over the 10-year study period. Elucidating the mechanism underlying differences in in-hospital mortality reduction in men may provide insights into effective interventions in the future.

Low phase angle: A predictor of functional status and discharge disposition in acute stroke older patients

BACKGROUND & AIMS

This study aimed to investigate the effects of low phase angle (PhA) on functional status and discharge disposition during the acute phase in older patients with acute stroke.

METHODS

We included consecutive patients who experienced acute stroke between October 2021 and December 2022. The exclusion criteria included: age<65 years, admission from other than home, death during hospitalization, inability to measure bioelectrical impedance analysis owing to implantation, and missing data. We defined low PhA (<5.28° for male and <4.62° for female) and categorized them into the low PhA group and normal group. The clinical outcomes were functional independence by the modified Rankin Scale (mRS) score (0-2, independence; 3-5, nonindependence) and discharge disposition (home or others). We used multivariate logistic regression analysis to examine the effect of low PhA on the mRS score at discharge and discharge disposition.

RESULTS

Ultimately, a total of 205 patients were included in this analysis. More patients in the low PhA group were unable to be independent (27.7% vs. 66.7%, P < 0.001) and were unable to be discharged home (53.4% vs. 82.5%, P < 0.001) than in the normal group. Logistic regression analysis of the mRS scores showed that baseline low PhA decreased the likelihood of functional independence (odds ratio [OR] = 0.275, P = 0.003) and home discharge (OR = 0.378, P = 0.044).

CONCLUSIONS

Low PhA is a risk factor for low functional status at hospital discharge; it decreases the likelihood of home discharge in older patients with acute stroke.

Factors associated with SARS-CoV-2 vaccine hesitancy after stroke: a cross-sectional study

BACKGROUND

The vaccination status of post-stroke patients, who are at high risk of severe outcomes from Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), is a significant concern, yet it remains unclear. We aimed to explore the vaccination status, factors associated with vaccine hesitancy, and adverse effects after vaccination among post-stroke patients.

METHODS

This multi-center observational study enrolled hospitalized post-stroke patients from six Chinese hospitals (Oct 1, 2020 - Mar 31, 2021), examining vaccine uptake and self-reported reasons for vaccine hesitancy, utilizing logistic regression to investigate risk factors for vaccine hesitancy, and recording any adverse reactions post-vaccination.

RESULTS

Of the total 710 post-stroke patients included in the study, 430 (60.6%) had completed the recommended full-3 dose SARS-CoV-2 vaccination, with 176 (24.8%) remaining unvaccinated. The most common reasons for vaccine hesitancy were concerns about vaccine side effects (41.5%) and impaired mobility (33.9%). Logistic regression identified advanced age (aOR = 1.97, 95%CI: 1.36-2.85, P = 0.001), lower Barthel Index score (aOR = 0.88, 95%CI: 0.82-0.93, P = 0.018), higher Modified Rankin Scale score (aOR = 1.85, 95%CI: 1.32-2.56, P = 0.004), and poorer usual activity level of EuroQol 5-Dimension (aOR = 2.82, 95%CI: 1.51-5.28, P = 0.001) as independent risk factors for vaccine hesitancy. Approximately 14.8% reported minor adverse reactions, mainly pain at the injection site.

CONCLUSION

We found that post-stroke patients have insufficient SARS-CoV-2 vaccination rates, with key risk factors for vaccine hesitancy including concerns about side effects, advanced age, and functional impairments. No severe adverse reactions were observed among the vaccinated population.

Favorable prognosis in posterior circulation ischemic stroke: Insights from a nationwide stroke databank

INTRODUCTION

Clinical trials have historically underrepresented patients with posterior circulation ischemic stroke (PCIS). This study aimed to comprehensively assess the clinical characteristics and outcomes of PCIS patients compared to those with anterior circulation ischemic stroke (ACIS).

METHODS

A retrospective analysis was conducted using data from the Japan Stroke Data Bank, encompassing 20 years across 130 stroke centers. The study focused on patients diagnosed with PCIS or ACIS.

RESULTS

Among 37,069 patients reviewed, 7425 had PCIS, whereas 29,644 had ACIS. PCIS patients were younger and had a lower female representation than ACIS patients. Notably, PCIS patients had more favorable outcomes: 71% achieved a modified Rankin Scale of 0-2 or showed no deterioration at discharge (17 days at the median after admission), compared to 60% for ACIS patients (p < 0.001). Factors associated with an unfavorable outcome in the PCIS subgroup were older age, female sex (assigned at birth), history of hypertension, and higher National Institute of Health Stroke Scale (NIHSS) scores at admission. In both sexes, older age and higher NIHSS scores were negatively associated with favorable outcomes.

CONCLUSIONS

PCIS patients demonstrated a more favorable prognosis than ACIS patients. Factors like older age, female sex, and higher NIHSS scores at admission were identified as independent predictors of unfavorable outcomes in PCIS patients. Older age and higher NIHSS scores at admission were common independent negative factors for a favorable outcome regardless of sex.

Clinical characteristics of heavy alcohol consumption in young and middle-aged acute cerebral infarction: A 12-month follow-up study

Objective

To investigate the clinical characteristics and prognosis of heavy alcohol consumption among young and middle-aged patients with acute cerebral infarction (ACI).

Methods

A total of 263 young and middle-aged ACI patients were included in the study from June 2018 to December 2020 and classified into heavy drinkers and non-heavy drinkers. Multivariate logistic regression analysis was conducted to assess the association between ACI and heavy alcohol consumption, considering clinical characteristics and one-year post-discharge prognosis.

Results

Among the patients, 78 were heavy drinkers. Heavy drinkers were more likely to consume alcohol 24 h before ACI onset (OR 4.03, 95 % CI 2.26-7.20), especially in the form of liquor (OR 3.83, 95 % CI 1.59-9.20), and had a higher risk of diastolic blood pressure ≥90 mmHg upon admission (OR 2.02, 95 % CI 1.12-3.64). In the one-year post-discharge prognosis, heavy drinkers had a greater likelihood of poor prognosis at 3 months (OR 2.31, 95 % CI 1.01-5.25), were less likely to quit drinking after discharge (OR 0.36, 95 % CI 0.19-0.66), and had a higher risk of recurrent cerebral infarction (OR 2.79, 95 % CI 1.14-6.84).

Conclusions

Over the 12-month follow-up, young and middle-aged ACI patients with heavy alcohol consumption exhibited worse short-term prognosis. Controlling alcohol consumption levels may improve the prognosis of these patients.

Symptoms at stroke onset as described by patients: a qualitative study

BACKGROUND

Stroke is a common and severe disease that requires prompt care. Symptom expressions as one-sided weakness and speech difficulties are common and included in public stroke campaigns. For some patients stroke can present with subtle and less common symptoms, difficult to interpret. The symptom severity assessed by the National Institutes of Health Stroke Scale has decreased, and symptoms at onset may have changed. Therefore, we aimed to investigate how patients describe their symptoms at the onset of a first-time stroke.

METHODS

The study used a qualitative descriptive design and conventional content analysis. Data were collected through recorded interviews with 27 patients aged 18 years and older hospitalised with a first-time stroke between October 2018 and April 2020. Data were analysed on a manifest level.

RESULTS

Symptoms at stroke onset were presented in two themes: Altered Reality and Discomfort and Changed Body Functions and described in five categories. Various types of symptoms were found. All symptoms were perceived as sudden, persistent, and never experienced before and this appear as a "red thread" in the result. Regardless of symptom expressions, no specific symptom was described as more severe than another.

CONCLUSIONS

Stroke symptoms were described with a variety of expressions. Many described complex symptoms not typical of stroke, which can make it difficult to recognise the symptoms as a stroke and delay medical care. Public stroke campaigns should emphasize the importance of seeking medical care at the slightest suspicion of stroke and could be designed to help achieve this.

TAK1 inhibition mitigates intracerebral hemorrhage-induced brain injury through reduction of oxidative stress and neuronal pyroptosis via the NRF2 signaling pathway

Introduction

Intracerebral hemorrhage (ICH) often triggers oxidative stress through reactive oxygen species (ROS). Transforming growth factor-β-activated kinase 1 (TAK1) plays a pivotal role in regulating oxidative stress and inflammation across various diseases. 5Z-7-Oxozeaenol (OZ), a specific inhibitor of TAK1, has exhibited therapeutic effects in various conditions. However, the impact of OZ following ICH and its underlying molecular mechanisms remain elusive. This study aimed to explore the possible role of OZ in ICH and its underlying mechanisms by inhibiting oxidative stress-mediated pyroptosis.

Methods

Adult male Sprague-Dawley rats were subjected to an ICH model, followed by treatment with OZ. Neurobehavioral function, blood-brain barrier integrity, neuronal pyroptosis, and oxidative stress markers were assessed using various techniques including behavioral tests, immunofluorescence staining, western blotting, transmission electron microscopy, and biochemical assays.

Results

Our study revealed that OZ administration significantly inhibited phosphorylated TAK1 expression post-ICH. Furthermore, TAK1 blockade by OZ attenuated blood-brain barrier (BBB) disruption, neuroinflammation, and oxidative damage while enhancing neurobehavioral function. Mechanistically, OZ administration markedly reduced ROS production and oxidative stress by facilitating nuclear factor-erythroid 2-related factor 2 (NRF2) nuclear translocation. This was accompanied by a subsequent suppression of the NOD-like receptor protein 3 (NLRP3) activation-mediated inflammatory cascade and neuronal pyroptosis.

Discussion

Our findings highlight that OZ alleviates brain injury and oxidative stress-mediated pyroptosis via the NRF2 pathway. Inhibition of TAK1 emerges as a promising approach for managing ICH.

Prospero Homeobox 1 and Doublecortin Correlate with Neural Damage after Ischemic Stroke

OBJECTIVE

Markers of neuroinflammation during ischemic stroke are well characterized, but additional markers of neural damage are lacking. The study identified associations of behavioral disorders after stroke with histologic neural damage and molecular biological change.

METHODS

Eight-week-old, 25 g male mice of the C57BL/6J strain were subjected to middle cerebral artery occlusion (MCAO) to induce ischemic stroke. The control group was a healthy wild type (WT), and the experimental group were designed as a low severity MCAO1 and a high severity MCAO2 based on post-stroke neurological scoring. All groups underwent behavioral tests, realtime polymerase chain reaction, triphenyltetrazolium chloride (TTC) staining and Hematoxylin and Eosin staining. One-way analysis of variance was used to analyze statistical significance between groups.

RESULTS

In TTC staining, MCAO1 showed 29.02% and MCAO2 showed 38.94% infarct volume (p<0.0001). The pro-inflammatory cytokine interleukin (IL)-1β was most highly expressed in MCAO2 (WT 0.44 vs. MCAO1 2.69 vs. MCAO2 5.02, p<0.0001). From the distance to target in the Barnes maze test, WT had a distance of 178 cm, MCAO1 had a distance of 276 cm, and MCAO2 had a distance of 1051 (p=0.0015). The latency to target was 13.3 seconds for WT, 27.9 seconds for MCAO1, and 87.9 seconds for MCAO2 (p=0.0007). Prospero homeobox 1 (Prox1) was most highly expressed in MCAO2 (p=0.0004). Doublecortin (Dcx) was most highly expressed in MCAO2 (p<0.0001).

CONCLUSION

The study demonstrated that histological damage to neural cells and changes in brain mRNA expression were associated with behavioral impairment after ischemic stroke. Prox1 and Dcx may be biomarkers of neural damage associated with long-term cognitive decline, and increased expression at the mRNA level was consistent with neural damage and long-term cognitive dysfunction.