Stroke in the Young: a Global Update

Association of the High-Sensitivity C-Reactive Protein-to-Albumin Ratio with Carotid Atherosclerotic Plaque: A Community-Based Cohort Study

Background

The inflammatory response is a pivotal factor in accelerating the progression of atherosclerosis. The high-sensitivity C-reactive protein-to-albumin ratio (CAR) has emerged as a novel marker of systemic inflammation. However, few studies have shown the CAR to be a promising prognostic marker for carotid atherosclerotic disease. This study aimed to analyse the predictive role of the CAR in carotid atherosclerotic disease.

Methods

This community-based cohort study recruited 2003 participants from the Rose asymptomatic IntraCranial Artery Stenosis (RICAS) study who were free of stroke or transient ischemic attack. Carotid atherosclerotic plaques and their stability were identified via carotid ultrasound. Logistic regression models were utilized to investigate the association between CAR and the presence of carotid atherosclerotic plaques.

Results

The prevalence of carotid atherosclerotic plaques was 38.79% in this study. After adjusting for clinical risk factors, including sex, age, dyslipidemia, hypertension, diabetes mellitus (DM), and smoking and drinking habits, a high CAR-level was independently associated with carotid plaque (odds ratio [OR] of upper: 1.46, 95% confidence interval [CI]: 1.13-1.90, P = 0.004; P for trend = 0.011). The highest CAR tertile was still significantly associated with carotid plaques among middle-aged (40-64 years) or female participants. Notably, an elevated CAR may be an independent risk factor for vulnerable carotid plaques (OR of upper: 2.06, 95% CI: 1.42-2.98, P < 0.001; P for trend <0.001).

Conclusion

A high CAR may be correlated with a high risk of carotid plaques, particularly among mildly aged adults (40-64 years) or females. Importantly, the CAR may be associated with vulnerable carotid plaques, suggesting that the CAR may be a new indicator for stroke prevention.

The association between declining lung function and stroke risk: insights from an observational study and Mendelian randomization

Background

Stroke, prevalent globally, particularly impacts low- and middle-income countries. Decreased lung function is one of the risk factors for stroke, and there is a lack of sufficient research on the association between the two, especially based on evidence from representative large samples. We aimed to explore the association between lung function and stroke incidence.

Methods

We collected data from 13,371 participants from the 2007-2012 U.S. national cross-sectional study and 11,192 participants from the Chinese national cohort study during the 2011-2018 follow-up period. Multivariate logistic regression and Cox proportional hazards regression were used to assess cross-sectional and longitudinal associations of peak expiratory flow with stroke risks. Additionally, we used publicly available GWAS data from a European population to conduct Mendelian randomization analysis, further exploring the potential causal relationship.

Results

The results of the cross-sectional study suggest that a decline in peak expiratory flow may be associated with an increased risk of stroke. The cohort study revealed that, compared to the first tertile group, the risk of stroke incidence in the second and third tertile groups of PEF decreased by 19% (hazard ratio (HR) = 0.810, 95%CI = 0.684-0.960) and 21.4% (HR = 0.786, 95%CI = 0.647-0.956), respectively. Mendelian randomization analysis clarified that higher PEF levels are significantly associated with a reduced risk of stroke (OR = 0.852, 95%CI = 0.727-0.997).

Conclusion

Decreased lung function is a risk factor for stroke. As a simple and accurate indicator of lung function, PEF can be used to monitor lung function in community populations and patients for primary stroke prevention.

Network meta-analysis of non-pharmacological interventions for cognitive impairment after an ischemic stroke

Objective

This study aims to evaluate the effectiveness of non-pharmacological interventions in improving cognitive function in patients with ischemic stroke through network meta-analysis.

Methods

We searched databases including the Cochrane Library, PubMed, EmBase, and Web of Science for randomized controlled trials (RCTs) on non-pharmacological treatments to improve cognitive impairment following ischemic stroke. The publication date was up to 15 March 2023. Due to the insufficiency of included studies, supplementary searches for high-quality Chinese literature were performed in databases such as CNKI, WanFang Data, and VIP Chinese Science Journals Database. Two reviewers independently went through the literature, extracted data, and assessed the risk of bias in the included studies using the risk of bias assessment tool recommended by the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0. By utilizing R 4.2.3 RStudio software and the GeMTC package, a Bayesian network meta-analysis was conducted to assess the improvement in Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores under a variety of non-pharmacological interventions.

Results

A total of 22 RCTs involving 2,111 patients and 14 different non-pharmacological treatments were included. These interventions were transcranial direct current stimulation (tDCS), reminiscence therapy (RT), remote ischemic conditioning (RIC), physical fitness training (PFT), intensive patient care program (IPCP), moderate-intensity continuous training + high-intensity interval training (MICT + HIIT), medium intensity continuous training (MICT), grip training (GT), acupuncture, cognitive behavioral therapy (CBT), cognitive rehabilitation training (CRT), high pressure oxygen (HPO), moxibustion, and repetitive transcranial magnetic stimulation (rTMS). The results of the network meta-analysis indicated that rTMS had the highest likelihood of being the most effective intervention for improving MMSE and MoCA scores.

Conclusion

The evidence from this study suggests that rTMS holds promise for improving MMSE and MoCA scores in patients with cognitive impairment following ischemic stroke. However, further high-quality research is needed to confirm and validate this finding.

Outcome after Intracerebral Haemorrhage and Decompressive Craniectomy in Older Adults

OBJECTIVE

There is a relationship between the incidence of spontaneous intracerebral haemorrhage (ICH) and age. The incidence increases with age. This study aims to facilitate the decision-making process in the treatment of ICH. It therefore investigated the outcome after ICH and decompressive craniectomy (DC) in older adults (>65 years of age).

METHODS

Retrospective, multicentre, descriptive observational study including only consecutive patients who received DC as the consequence of ICH. Additive evacuation of ICH was performed after the individual decision of the neurosurgeon. Besides demographic data, clinical outcomes both at discharge and 12 months after surgery were evaluated according to the Glasgow Outcome Scale (GOS). Patients were divided into age groups of ≤65 and >65 years and cohorts with favourable outcome (GOS IV-V) and unfavourable outcome (GOS I to III).

RESULTS

56 patients were treated. Mean age was 53.3 (SD: 16.13) years. There were 41 (73.2%) patients aged ≤65 years and 15 (26.8%) patients aged >65 years. During hospital stay, 10 (24.4%) patients in the group of younger (≤65 years) and 5 (33.3%) in the group of older patients (>65 years) died. Mean time between ictus and surgery was 44.4 (SD: 70.79) hours for younger and 27.9 (SD: 41.71) hours for older patients. A disturbance of the pupillary function on admission occurred in 21 (51.2%) younger and 2 (13.3%) older patients (p = 0.014). Mean arterial pressure was 99.9 (SD: 17.00) mmHg for younger and 112.9 (21.80) mmHg in older patients. After 12 months, there was no significant difference in outcome between younger patients (≤65 years) and older patients (>65 years) after ICH and DC (p = 0.243). Nevertheless, in the group of younger patients (≤65 years), 9% had a very good and 15% had a good outcome. There was no good recovery in the group of older patients (>65 years).

CONCLUSION

Patients >65 years of age treated with microsurgical haematoma evacuation and DC after ICH are likely to have a poor outcome. Furthermore, in the long term, only a few older adults have a good functional outcome with independence in daily life activities.

Melatonin Inhibits Hypoxia-Induced Alzheimer's Disease Pathogenesis by Regulating the Amyloidogenic Pathway in Human Neuroblastoma Cells

Stroke and Alzheimer's disease (AD) are prevalent age-related diseases; however, the relationship between these two diseases remains unclear. In this study, we aimed to investigate the ability of melatonin, a hormone produced by the pineal gland, to alleviate the effects of ischemic stroke leading to AD by observing the pathogenesis of AD hallmarks. We utilized SH-SY5Y cells under the conditions of oxygen-glucose deprivation (OGD) and oxygen-glucose deprivation and reoxygenation (OGD/R) to establish ischemic stroke conditions. We detected that hypoxia-inducible factor-1α (HIF-1α), an indicator of ischemic stroke, was highly upregulated at both the protein and mRNA levels under OGD conditions. Melatonin significantly downregulated both HIF-1α mRNA and protein expression under OGD/R conditions. We detected the upregulation of β-site APP-cleaving enzyme 1 (BACE1) mRNA and protein expression under both OGD and OGD/R conditions, while 10 µM of melatonin attenuated these effects and inhibited beta amyloid (Aβ) production. Furthermore, we demonstrated that OGD/R conditions were able to activate the BACE1 promoter, while melatonin inhibited this effect. The present results indicate that melatonin has a significant impact on preventing the aberrant development of ischemic stroke, which can lead to the development of AD, providing new insight into the prevention of AD and potential stroke treatments.

Experience of financial toxicity and coping strategies in young and middle-aged patients with stroke: a qualitative study

BACKGROUND

While financial toxicity (FT) is prevalent in patients with cancer, young and middle-aged patients with stroke are also affected by FT, which can exacerbate their physical and psychological challenges. Understanding the patient's experience and response measures can further understand the impact of FT on patients with stroke, to help alleviate FT. However, little is known concerning the experience of patients with stroke with FT or their coping strategies. Therefore, this study aimed to describe the experiences of FT in young and middle-aged patients with stroke and their coping strategies.

METHODS

A phenomenological method was utilized. Semi-structured interviews were conducted with 21 young and middle-aged stroke patients (aged 18-59) between October 2022 and March 2023. The participants were recruited from a tertiary hospital in Shanghai, China. The research team used NVivo 12.0 software. Giorgi's phenomenological analysis method was used to analyse the interview data.

RESULTS

The interview results were divided into two categories in terms of patients' experiences of FT and their coping strategies. Nine subthemes were constructed. The experience category included four subthemes: (1) taking on multifaceted economic pressure, (2) dual choice of treatment, (3) decline in material living standards, and (4) suffering from negative emotions such as anxiety and depression. The coping strategy category included five subthemes: (1) reducing expenses, (2) improving living habits, (3) proactive participation in medical decision-making, (4) making a job position choice, and (5) seeking social support.

CONCLUSIONS

FT in young and middle-aged patients with stroke, which affected their physical and mental health, led them to implement strategies for dealing with FT. The Chinese government needs to broaden the reach of health insurance coverage and advance the fairness of healthcare policies. Healthcare professionals must pay active attention to FT in such patients in terms of strengthening their health education and considering their needs and preferences. Patients need to improve their sense of self-efficacy, actively reintegrate into society, and adhere to rehabilitation and treatment. Individuals at a high risk of stroke are recommended to purchase health insurance. Multifaceted efforts are needed to reduce the impact of FT in young and middle-aged patients with stroke.

Characteristics and predictors of stroke mimics in young patients in the norwegian tenecteplase stroke trial (NOR-TEST)

BACKGROUND

Several studies have shown that stroke mimics occur more often among young patients. Our aims were to identify the common mimics in young patients under the age of 60 years who received thrombolysis, to analyze the risk of hemorrhage after treatment with thrombolysis, and to identify risk factors and clinical parameters that might identify mimics in this group.

METHODS

Norwegian Tenecteplase Stroke Trial was a phase-3 trial investigating safety and efficacy of tenecteplase vs. alteplase in patients with acute ischemic stroke. Patients diagnosed with either acute cerebral ischemia or transient ischemic attack were categorized as stroke group, and patients with any diagnosis other than ischemic stroke or transient ischemic attack as mimics group. Patients were grouped post-hoc into young (< 60 years) and old (≥ 60 years). Logistic regression analyses were performed with mimics vs. stroke as dependent variable to identify predictors of mimics.

RESULTS

Of the 1091 patients included in the trial, 211 patients (19.3%) were under the age of 60 years. Out of the 1091 patients, 434 (39.8%) were female, median age 77 years (18-99 years), and median NIHSS was 4. Sixty-nine patients (32.7%) out of the 211 patients under the age of 60 were diagnosed as mimic. Mimics were significantly more frequent among the young (OR = 3.3, 32.7% vs. 12.8%, p = < 0.001). The most frequent mimics diagnoses among patients under 60 years of age were migraine (11.8%), no definite diagnosis (11.4%) and peripheral vertigo (3.3%). Mimics were independently associated with age < 50 years (OR = 4.97, p = < 0.001), not currently working/studying (OR = 3.38, p = 0.002) and not having aphasia on admission (OR = 2.95, p = 0.025). None of the mimics under the age of 60 years had symptomatic or asymptomatic intracerebral hemorrhage as a complication to thrombolysis.

CONCLUSION

We found significantly more mimics in the young, of which migraine was the most predominant diagnosis. Thrombolysis with alteplase or tenecteplase did not cause ICH in any mimics under 60 years.

Microbiota Metabolites and Immune Regulation Affect Ischemic Stroke Occurrence, Development, and Prognosis

The gut microbiota are not only related to the development and occurrence of digestive system disease, but also have a bidirectional relationship with nervous system diseases via the microbiota-gut-brain axis. At present, correlations between the gut microbiota and neurological diseases, including stroke, are one of the focuses of investigation and attention in the medical community. Ischemic stroke (IS) is a cerebrovascular disease accompanied by focal neurological deficit or central nervous system injury or death. In this review, we summarize the contemporary latest research on correlations between the gut microbiota and IS. Additionally, we discuss the mechanisms of gut microbiota implicated in IS and related to metabolite production and immune regulation. Moreover, the factors of gut microbiota that affecting IS occurrence, and research implicating the gut microbiota as potential therapeutic targets for IS, are highlighted. Our review highlights the evidential relationships and connections between the gut microbiota and IS pathogenesis and prognosis.

Resveratrol: a potential medication for the prevention and treatment of varicella zoster virus-induced ischemic stroke

BACKGROUND

Infection rate of varicella zoster virus (VZV) is 95% in humans, and VZV infection is strongly associated with ischemic stroke (IS). However, the underlying molecular mechanisms of VZV-induced IS are still unclear, and there are no effective agents to treat and prevent VZV-induced IS.

OBJECTIVE

By integrating bioinformatics, this study explored the interactions between VZV and IS and potential medication to treat and prevent VZV-induced IS.

METHODS

In this study, the VZV and IS datasets from the GEO database were used to specify the common genes. Then, bioinformatics analysis including Gene Ontology, Kyoto Encyclopedia Genes Genomes and Protein-Protein Interaction network analysis was performed. Further, the hub genes, transcription factor (TF) gene interactions, TF-miRNA co-regulatory network and potential drug were obtained. Finally, validation was performed using molecular docking and molecular dynamics simulations.

RESULTS

The potential molecular mechanisms of VZV-induced IS were studied using multiple bioinformatics tools. Ten hub genes were COL1A2, DCN, PDGFRB, ACTA2, etc. TF genes and miRNAs included JUN, FOS, CREB, BRCA1, PPARG, STAT3, miR-29, etc. A series of mechanism may be involved, such as inflammation, oxidative stress, blood-brain barrier disruption, foam cell generation and among others. Finally, we proposed resveratrol as a potential therapeutic medicine for the prevention and treatment of VZV-induced IS. Molecular docking and molecular dynamics results showed that resveratrol and hub genes exhibited strong binding score.

CONCLUSIONS

Resveratrol could be an alternative for the prevention and treatment of VZV-IS. More in vivo and in vitro studies are needed in the future to fully explore the molecular mechanisms between VZV and IS and for medication development.

Associations of effort-reward imbalance at work and quality of life among workers after stroke: a one-year longitudinal study in Thailand

Stroke incidence is increasing among working-age population, but the role of psychosocial stress in the workplace in predicting quality of life (QoL) after stroke onset is understudied. This longitudinal study aimed to investigate the relationship between work stress, measured by the effort-reward imbalance (ERI) model, and QoL over one-year period among 103 Thai workers who had experienced a stroke. The study evaluated the effort (E)-reward (R) ratio and over-commitment, the extrinsic and intrinsic components of the ERI model, before discharge; QoL was repeatedly measured at baseline, six months, and 12 months after discharge, respectively, using the Short Form Version 2 (SF-12v2) indicators of physical and mental health composite scores. Generalized estimating equations were used to examine longitudinal relationships between work stress at baseline and QoL over one year by testing the hypotheses that E-R ratio and over-commitment would have direct effects on QoL, and potential moderating effects of over-commitment on E-R ratio and QoL. The results supported the ERI model partially, as over-commitment was significantly associated with poor mental health (coefficient - 8.50; 95% CI: -13.79, -3.20) after adjusting baseline sociodemographic, behavioral, and clinical characteristics, while the E-R ratio was not significantly associated with physical or mental health; the interaction between the E-R ratio and over-commitment was also not significant. These findings suggest that more attention should be paid to workers' personal coping skills and ability to handle work-related problems and prioritize interventions that address over-commitment to promote long-term mental health among workers with stroke.

Disparities in transitions of acute stroke care: The transitions of care stroke disparities study methodological report

OBJECTIVE

The Transitions of Stroke Care Disparities Study (TCSD-S) is an observational study designed to determine race-ethnic and sex disparities in post-hospital discharge transitions of stroke care and stroke outcomes and to develop hospital-level initiatives to reduce these disparities to improve stroke outcomes.

MATERIALS AND METHODS

Here, we present the study rationale, describe the methodology, report preliminary outcomes, and discuss a critical need for the development, implementation, and dissemination of interventions for successful post-hospital transition of stroke care. The preliminary outcomes describe the demographic, stroke risk factor, socioeconomic, and acute care characteristics of eligible participants by race-ethnicity and sex. We also report on all-cause and vascular-related death, readmissions, and hospital/emergency room representations at 30- and 90-days after hospital discharge.

RESULTS

The preliminary sample included data from 1048 ischemic stroke and intracerebral hemorrhage discharged from 10 comprehensive stroke centers across the state of Florida. The overall sample was 45% female, 22% Non-Hispanic Black and 21% Hispanic participants, with an average age of 64 ± 14 years. All cause death, readmissions, or hospital/emergency room representations are 10% and 19% at 30 and 90 days, respectively. One in 5 outcomes was vascular-related.

CONCLUSIONS

This study highlights the transition from stroke hospitalization as an area in need for considerable improvement in systems of care for stroke patients discharged from hospital. Results from our preliminary analysis highlight the importance of investigating race-ethnic and sex differences in post-stroke outcomes.

The Role of the Low-Density Lipoprotein/High-Density Lipoprotein Cholesterol Ratio as an Atherogenic Risk Factor in Young Adults with Ischemic Stroke: A Case-Control Study

Dyslipidemia is a major atherogenic risk factor for ischemic stroke. Stroke patients tend to have high levels of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) and low levels of high-density lipoprotein cholesterol (HDL-C). Therefore, it is noteworthy that there has been an increase in ischemic stroke cases in young and elderly individuals in recent years. This study investigated the TC/HDL-C ratio and the LDL-C/HDL-C ratio, which may be more specific and common lipid parameters in young patients with ischemic stroke. This study aimed to demonstrate the sensitivity and specificity of TC/HDL-C and LDL-C/HDL-C ratios as atherogenic markers for young adult ischemic strokes. This trial was conducted as a retrospective case-control study. A total of 123 patients (patient group) and 86 healthy individuals (control group) aged 18-50 years were randomly selected from four different hospitals. Lipid parameters and TC/HDL-C and LDL-C/HDL-C ratios were compared between these two groups. The mean age was 38.8 ± 7.3 years in patients and 37.7 ± 9 years in controls (p > 005). The HDL-C levels were 39.1 ± 10.8 mg/dL in patients and 48.4 ± 13.8 mg/dL in controls (p < 0.001). LDL-C/HDL-C ratios were 3.23 ± 1.74 and 2.38 ± 0.87, and TC/HDL-C ratios were 5.24 ± 2.31 and 4.10 ± 1.25 in the patient and control groups, respectively (p < 0.001). The LDL-C/HDL-C and TC/HDL-C cutoff values in ROC analyses were 2.61 and 4.40 respectively; the AUCs (95% CI) were determined to be 0.680 (0.608-0.753) and 0.683 (0.610-0.755) (p < 0.001), respectively. An increased risk of stroke was observed in those with a high LDL-C/HDL-C ratio (OR = 1.827; 95% CI = 1.341-2.488; p < 0.001). Our study obtained similar results when we compared the mean TC and LDL-C levels between the two groups. However, considering the TC/HDL-C and LDL-C/HDL-C ratios, it is noteworthy that there was a significant difference between the patient and control groups.

Cerebellar Stroke in a Young Adult Following an Amusement Park Ride

The incidence of stroke in young individuals has been showing an increasing trend. In such cases, atypical mechanisms of stroke should be considered. Here, we report a case of a 37-year-old healthy female who presented with complaints of right-sided ataxia and clumsiness that started after an amusement park ride where she was swung rapidly. Imaging revealed an infarct in the right cerebellar hemisphere. This case report highlights certain mechanisms that can cause a stroke in this situation, with special emphasis on recognition, timely medical management, public awareness of such risk factors, and the prevention of complications.

Etiologies, mechanisms, and risk factors of ischemic stroke in a young Asian adult cohort

OBJECTIVES

Risk factors and causes of acute ischemic stroke (AIS) are more diverse in young adults, and traditional stroke classifications may be inadequate. Precise characterisation of AIS is important for guiding management and prognostication. We describe stroke subtypes, risk factors and etiologies for AIS in a young Asian adult population.

MATERIALS AND METHODS

Young AIS patients aged 18-50 years admitted to two comprehensive stroke centres from 2020-2022 were included. Stroke etiologies and risk factors were adjudicated using Trial of Org 10172 in Acute Stroke Treatment (TOAST) and International Pediatric Stroke Study (IPSS) risk factors. Potential embolic sources (PES) were identified in a subgroup with embolic stroke of undetermined source (ESUS). These were compared across sex, ethnicities and age groups (18-39 years versus 40-50 years).

RESULTS

A total of 276 AIS patients were included, with mean age 43±5.7 years and 70.3% male. Median duration of follow-up was 5 months (IQR: 3-10). The most common TOAST subtypes were small-vessel disease (32.6%) and undetermined etiology (24.6%). IPSS risk factors were identified in 95% of all patients and 90% with undetermined etiology. IPSS risk factors included atherosclerosis (59.5%), cardiac disorders (18.7%), prothrombotic states (12.4%) and arteriopathy (7.7%). In this cohort, 20.3% had ESUS, of which 73.2% had at least one PES, which increased to 84.2% in those <40 years old.

CONCLUSIONS

Young adults have diverse risk factors and causes of AIS. IPSS risk factors and ESUS-PES construct are comprehensive classification systems that may better reflect heterogeneous risk factors and etiologies in young stroke patients.

Stroke in Young Adults

Stroke in young adults is associated with significant morbidity, and its prevalence is rising in the United States. This is partly attributed to a rise in the prevalence of traditional risk factors including hypertension, hypercholesterolemia, obesity, diabetes mellitus, smoking and heart disease. In addition, there are non-modifiable risk factors comprising migraine, pregnancy and postpartum state, illicit drug use, oral contraceptives and hypercoagulable state. The mechanisms causing stroke in young adults are unique and include cervical dissection, cardioembolic phenomenon, vasculitis and vasculopathy, connective tissue disease, patent foramen ovale and cerebral venous thrombosis. The diagnosis of stroke in the young population can be challenging given its myriad clinical presentations. In this document, we provide an overview of the epidemiology of stroke in young adults, explore mechanisms that may explain increasing rates of stroke in this population, and provide a critical updated overview of the existing literature on the management and prevention of stroke in young adults.

Risk Factors, Incidence, and Outcome of Stroke: A Retrospective Cross-Sectional Hospital-Based Study Comparing Young Adults and Elderly

A noticeable increase of up to 40% in the incidence of stroke among young population over the past decade has been noted. This study aimed to investigate the incidence, risk factors, and outcomes of stroke and its subtypes in young adults compared to older population. A retrospective study of patients which included patients with confirmed diagnosis of stroke based on the International Classification of Diseases 10th Revision (ICD-10) classification between the years 2018 and 2020 was conducted. The results indicated that patients less than 45 years of age had a higher incidence of hemorrhagic stroke as compared to the other age groups (p=0.011). Hypertension leading to hemorrhagic stroke was higher in patients less than 45 years of age as compared to other groups (18 years {19.4%} versus 33 years {7.5%}, p=0.001). Hypertension was noted to be the leading risk factor for stroke among the younger population.

Defining the Age of Young Ischemic Stroke Using Data-Driven Approaches

Introduction: The cut-point for defining the age of young ischemic stroke (IS) is clinically and epidemiologically important, yet it is arbitrary and differs across studies. In this study, we leveraged electronic health records (EHRs) and data science techniques to estimate an optimal cut-point for defining the age of young IS. Methods: Patient-level EHRs were extracted from 13 hospitals in Pennsylvania, and used in two parallel approaches. The first approach included ICD9/10, from IS patients to group comorbidities, and computed similarity scores between every patient pair. We determined the optimal age of young IS by analyzing the trend of patient similarity with respect to their clinical profile for different ages of index IS. The second approach used the IS cohort and control (without IS), and built three sets of machine-learning models—generalized linear regression (GLM), random forest (RF), and XGBoost (XGB)—to classify patients for seventeen age groups. After extracting feature importance from the models, we determined the optimal age of young IS by analyzing the pattern of comorbidity with respect to the age of index IS. Both approaches were completed separately for male and female patients. Results: The stroke cohort contained 7555 ISs, and the control included 31,067 patients. In the first approach, the optimal age of young stroke was 53.7 and 51.0 years in female and male patients, respectively. In the second approach, we created 102 models, based on three algorithms, 17 age brackets, and two sexes. The optimal age was 53 (GLM), 52 (RF), and 54 (XGB) for female, and 52 (GLM and RF) and 53 (RF) for male patients. Different age and sex groups exhibited different comorbidity patterns. Discussion: Using a data-driven approach, we determined the age of young stroke to be 54 years for women and 52 years for men in our mainly rural population, in central Pennsylvania. Future validation studies should include more diverse populations.

ALDH2 rs671 Polymorphism Likely a Risk Factor for Hemorrhagic Stroke: A Hospital-Based Study

Background

Hypertension is the main risk factor for hemorrhagic stroke. Aldehyde dehydrogenase 2 (ALDH2) may inhibit the occurrence of hypertension by anti-oxidative stress and vascular dilation. The purpose was to investigate the relationship of ALDH2 polymorphisms with hemorrhagic stroke in Hakka Chinese.

Methods

A total of 329 patients with hemorrhagic stroke and 515 controls were enrolled, and medical records (smoking and drinking history, hypertension, and diabetes) were collected. The genotypes of ALDH2 rs671 of the two groups were detected and analyzed.

Results

The proportion of the ALDH2 rs671 G/G, G/A, and A/A genotype in patients with hemorrhagic stroke was 55.9%, 37.4%, and 6.7%, respectively, while those were 65.0%, 30.7%, and 4.3% in controls, respectively. There was statistically significant difference in ALDH2 rs671 genotypes distribution (P=0.021) and alleles distribution (P=0.005) between patients and controls. Among hemorrhagic stroke patients, no statistically significant differences were observed between patients with ALDH2 different genotypes. Logistic regression analysis showed that there was significantly high risk of hemorrhagic stroke in men (male vs female: adjusted OR 1.711, 95% CI 1.154-2.538, P=0.008), the presence of hypertension (with vs without hypertension: adjusted OR 16.095, 95% CI 10.958-23.641, P<0.001), and the presence of ALDH2 rs671 G/A genotype (G/A vs G/G: adjusted OR 1.679, 95% CI 1.151-2.450, P=0.007) or A/A genotype (A/A vs G/G: adjusted OR 2.516, 95% CI 1.132-5.591, P=0.024).

Conclusion

ALDH2 rs671 polymorphism likely a risk factor for hemorrhagic stroke.

Kinematic Studies of the Go/No-Go Task as a Dynamic Sensorimotor Inhibition Task for Assessment of Motor and Executive Function in Stroke Patients: An Exploratory Study in a Neurotypical Sample

Inhibition of reaching and grasping actions as an element of cognitive control and executive function is a vital component of sensorimotor behaviour that is often impaired in patients who have lost sensorimotor function following a stroke. To date, there are few kinematic studies detailing the fine spatial and temporal upper limb movements associated with the millisecond temporal trajectory of correct and incorrect responses to visually driven Go/No-Go reaching and grasping tasks. Therefore, we aimed to refine the behavioural measurement of correct and incorrect inhibitory motor responses in a Go/No-Go task for future quantification and personalized rehabilitation in older populations and those with acquired motor disorders, such as stroke. An exploratory study mapping the kinematic profiles of hand movements in neurotypical participants utilizing such a task was conducted using high-speed biological motion capture cameras, revealing both within and between subject differences in a sample of healthy participants. These kinematic profiles and differences are discussed in the context of better assessment of sensorimotor function impairment in stroke survivors.

Fasting blood glucose as a predictor of progressive infarction in men with acute ischemic stroke

Objective

Blood glucose is related to early neurological deterioration in acute ischemic stroke, but multiple mechanisms are involved in early neurological deterioration, such as progressive infarction. This study aimed to determine whether fasting blood glucose (FBG) is an independent predictor of progressive infarction.

Methods

From April 2017 to December 2020, we retrospectively enrolled 477 patients with acute ischemic stroke within 48 hours of onset. Demographic characteristics, clinical information, neuroimaging characteristics, and laboratory data were collected after admission.

Results

We found that 147 (30.8%) patients had progressive infarction. Multiple regression analysis showed that high FBG concentrations (>7.66 mmol/L) were independently associated with progressive infarction. Sex subgroup analysis showed that high FBG concentrations were an independent predictor of progressive infarction in male patients (odds ratio, 2.559; 95% confidence interval, 1.279–5.121). In a receiver operating characteristic curve analysis, FBG concentrations were a predictor of progressive infarction in all cases, especially in male patients. The cutoff value of FBG in all patients and men was 7.155 mmol/L.

Conclusions

FBG is an independent predictor of progressive infarction in patients with acute ischemic stroke within 48 hours of onset, especially in men. Patients with FBG concentrations ≥7.155 mmol/L are more likely to develop progressive infarction.

Adenomyosis-Associated Ischemic Stroke: Pathophysiology, Detection and Management

Female-specific risk factors for stroke have gradually received attention. The relationship between ischemic stroke and adenomyosis, a benign uterine disorder commonly present in parous women, is underrecognized. We aimed to provide an overview of the epidemiology, pathophysiological mechanisms, clinical characteristics, diagnostic considerations, and potential therapeutic strategies of adenomyosis-associated ischemic stroke. We shared our experience with the diagnosis and management of a patient, and summarized current findings and knowledge gaps of this disease based on previous literature. The relevant studies were searched in English and Chinese databases up to April 2022 using the keywords "ischemic stroke", "cerebral infarction" and "adenomyosis". Then, we provided a narrative review of the retrieved articles. Finally, the data of 32 cases were analyzed. We found that increased levels of carbohydrate antigen 125 and D-dimer and decreased level of hemoglobin are biomarkers of adenomyosis-associated ischemic stroke. In addition, hypercoagulability might be a key mechanism leading to thromboembolism in the cerebrovascular system. Additional studies are needed to find optimal prevention strategies for the disease. A better understanding of this "rare" pathogenesis of ischemic stroke may inform a more precise diagnosis and effective prevention strategy in middle-aged women with embolic stroke of undetermined source.

Relationship between the stroke mechanism of symptomatic middle cerebral artery atherosclerotic diseases and culprit plaques based on high-resolution vessel wall imaging

Purpose

For patients with symptomatic middle cerebral artery (MCA) atherosclerotic stenosis, identifying the potential stroke mechanisms may contribute to secondary prevention. The purpose of the study is to explore the relationship between stroke mechanisms and the characteristics of culprit plaques in patients with atherosclerotic ischemic stroke in the M1 segment of the middle cerebral artery (MCA) based on high-resolution vessel wall imaging (HR-VWI).

Methods

We recruited 61 patients with acute ischemic stroke due to MCA atherosclerotic stenosis from Shenzhen Bao'an District People's Hospital. According to prespecified criteria based on infarct topography and magnetic resonance angiography, possible stroke mechanisms were divided into parent artery atherosclerosis occluding penetrating artery (P), artery-to-artery embolism (A), hypoperfusion (H), and mixed mechanisms (M). The correlation between the characteristics of MCA M1 culprit plaque and different stroke mechanisms was analyzed using HR-VWI. The indicators included plaque surface irregularity, T1 hyperintensity, location, plaque burden (PB), remodeling index (RI), enhancement rate, and stenosis rate.

Results

Parental artery atherosclerosis occluding penetrating artery was the most common mechanism (37.7%). The proposed criteria showed substantial to excellent interrater reproducibility (κ, 0.728; 0.593–0.863). Compared with the P group, the surface irregularity, T1 hyperintensity, and obvious enhancement of the culprit plaque in the A group were more common (p < 0.0125). Compared with the other stroke mechanisms, positive remodeling of culprit plaques was more common (p < 0.0125), the RI was greater (p < 0.05), and the PB was the smallest (p < 0.05) in the P group. The enhancement ratio (ER) was smaller in the P group (p < 0.05). Compared with the A group, T1 hyperintensity of the culprit plaque was more common in the H group (p < 0.0125), and the stenosis rate was greater (p < 0.05). After adjustment for clinical demographic factors in the binary logistic regression analysis, the enhancement level (odds ratio [OR] 0.213, 95% CI (0.05–0.91), p = 0.037) and PB of culprit plaque (OR 0, 95% CI (0–0.477), p = 0.034) were negatively associated with P groups.

Conclusion

The culprit plaque characteristics of patients with symptomatic MCA atherosclerotic in different stroke mechanisms may be evaluated using HR-VWI. The plaque characteristics of different stroke mechanisms may have clinical value for the selection of treatment strategies and prevention of stroke recurrence.

Clinical trial registration

Identifier: ChiCTR1900028533.

Clinical Characteristics and Risk Factors of First-Ever Stroke in Young Adults: A Multicenter, Prospective Cohort Study

Stroke in young adults has catastrophic consequences and has increased in prevalence, contrary to the trends of most other diseases. This study aimed to determine the major characteristics and risk factors for stroke in younger adults compared with older adults. From the Korean Stroke Cohort for Functioning and Rehabilitation, 10,584 patients with first-ever stroke between August 2012 and March 2015 were enrolled retrospectively and divided into younger (age ≤ 45) and older groups (age > 45). The clinical characteristics and risk factors of stroke were compared between the younger and older groups. The younger group comprised 915 patients (8.6%). The proportion of hemorrhage strokes in the younger group (42.3%) was significantly higher than in the older group (20.0%) (p < 0.001). Obesity, current smoking, and heavy alcohol consumption were significantly more common risk factors in the younger group than in the older group for all stroke types, whereas hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation, and coronary heart disease were significantly more frequent in the older group (both p < 0.001). The major risk factors in the younger group may be lifestyle-related. Therefore, increasing awareness of lifestyle-related risk factors may be necessary to prevent stroke in young adults.

Spontaneous internal carotid artery pseudoaneurysm complicated with ischemic stroke in a young man: A case report and review of literature

BACKGROUND

Carotid artery pseudoaneurysm (PSA) is infrequently encountered in clinical settings. Internal carotid artery (ICA) PSA complicated with ischemic stroke is rare. PSAs are typically caused by iatrogenic injury, trauma, or infection. The underlying mechanisms of spontaneous PSA formation are not well characterized. We report a healthy young man who presented with stroke as a complication of spontaneous PSA of the left ICA.

CASE SUMMARY

A 30-year-old man working as a ceiling decoration worker was hospitalized due to sudden-onset speech disorder and right lower extremity weakness. Medical history was unremarkable. Brain computed tomography revealed ischemic stroke. Digital subtraction angiography showed a left ICA PSA with mild stenosis. The patient was conservatively managed with oral anticoagulation and antiplatelet therapy. He recovered well and was discharged. The patient was in good condition during follow-up.

CONCLUSION

The occupational history of patient should be taken into consideration while evaluating the etiology of spontaneous ICA PSA in young people with stroke.

Prediction Model of Hemorrhage Transformation in Patient with Acute Ischemic Stroke Based on Multiparametric MRI Radiomics and Machine Learning

Intravenous thrombolysis is the most commonly used drug therapy for patients with acute ischemic stroke, which is often accompanied by complications of intracerebral hemorrhage transformation (HT). This study proposed to build a reliable model for pretreatment prediction of HT. Specifically, 5400 radiomics features were extracted from 20 regions of interest (ROIs) of multiparametric MRI images of 71 patients. Furthermore, a minimal set of all-relevant features were selected by LASSO from all ROIs and used to build a radiomics model through the random forest (RF). To explore the significance of normal ROIs, we built a model only based on abnormal ROIs. In addition, a model combining clinical factors and radiomics features was further built. Finally, the models were tested on an independent validation cohort. The radiomics model with 14 All-ROIs features achieved pretreatment prediction of HT (AUC = 0.871, accuracy = 0.848), which significantly outperformed the model with only 14 Abnormal-ROIs features (AUC = 0.831, accuracy = 0.818). Besides, combining clinical factors with radiomics features further benefited the prediction performance (AUC = 0.911, accuracy = 0.894). So, we think that the combined model can greatly assist doctors in diagnosis. Furthermore, we find that even if there were no lesions in the normal ROIs, they also provide characteristic information for the prediction of HT.

Thrombolysis, time-to-treatment and in-hospital outcomes among young adults with ischaemic stroke in China: findings from a nationwide registry study in China

BACKGROUND AND PURPOSE

We aimed to determine whether young adults (<50 years) with acute ischaemic stroke (AIS) are more likely to receive intravenous tissue plasminogen activator (IV tPA) and have shorter time to treatment than older patients with stroke.

METHODS

We analysed data from the Chinese Stroke Center Alliance registry for patients with AIS hospitalised between August 2015 and July 2019. Patients were classified into two groups according to age: young adults (<50 years of age) and older adults (≥50 years of age).

RESULTS

Of 793 175 patients with AIS admitted to 1471 hospitals, 9.1% (71 860) were young adults. Compared with older adults, a higher proportion of young adults received IV tPA among patients without contraindicaitons (7.2% vs 6.1%, adjusted OR (aOR) 1.13, 95% CI 1.10 to 1.17) and among patients without contraindications and with onset-to-door time ≤3.5 hours (23.6% vs 19.3%, aOR 1.20, 95% CI 1.15 to 1.24). We did not observe differences in onset-to-needle time (median hours 2.7 hours) or door-to-needle time (DNT) (median minutes 60 min) between young and older adults. The proportion of DNT ≤30 min, DNT ≤45 min and DNT ≤60 min in young and older IV tPA-treated patients were 16.9% vs 18.8%, 30.2% vs 32.8% and 50.2% vs 54.2%, respectively. Compared with older adults, young adults treated with IV tPA had lower odds of in-hospital mortality (0.5% vs 1.3%, aOR 0.54, 95% CI 0.35 to 0.82) and higher odds of independent ambulation at discharge (61.0% vs 53.6%, aOR 1.15, 95% CI 1.08 to 1.22), and the associations may be partly explained by stroke severity measured by the National Institutes of Health Stroke Scale score.

CONCLUSION

Young adults with AIS were more likely to receive IV tPA than older adults, although there was no difference between the two groups in time to treatment. Compared with older adults, young adults may had better in-hospital outcomes.

The Role of Doctors in Ambulance Management of Stroke Patients in Emergency Medical Services

BACKGROUND: Strokes are one of the most common of all neurological diseases and can be found in all genders and ages. Emergency medical services (EMS) are the first line of care with access to stroke patients from on the scene assessment to initial treatment. However, currently there are no studies regarding the role doctors play in initial ambulance contact to assess stroke patients. AIM: To analyze the role of doctors in ambulances managing stroke patients in EMS. METHODS: This was a retrospective study over a five-year period (2017-2021) at Srinagarind Hospital EMS units. The information from the EMS database was transferred completely into the data record form and imported into the computer system for further data analysis. RESULTS: A total of 10,329 EMS operations were examined. The mean age of the patients was 52.10 ± 10.24 years. A total of 64.4% (n = 6650) of them were male. The afternoon shift was the most common time for EMS operations with doctors in the stroke group (42.9%) and non-stroke group (59.3%). The distance from hospital to the scene in the stroke group was 12.6 ± 3.2 km. The average response time for stroke group and non-stroke group were 7.05 minutes and 9.50 minutes, respectively CONCLUSIONS: The role of doctors in the ambulance to manage stroke patients in EMS directly resulted in a decrease in time in arriving at the scene to diagnose, arriving at the laboratory, and arriving at the scene to activate the special team.

Understanding the priorities in life beyond the first year after stroke: Qualitative findings and non-participant observations of stroke survivors and service providers

ABSTRACTLong-term unmet health needs are associated with a lower quality of life in stroke survivors. Survivors' priorities in living their lives and health professionals' recognition influence survivors' perceptions of their needs. From the perspectives of survivors and service providers, this study investigated survivors' long-term priorities for continuing their lives after stroke. A qualitative study was conducted with a convenience sample of 40 stroke survivors and a purposive sample of 11 providers who had worked with survivors for more than five years and were currently managers of community-based stroke care services or leaders of volunteer groups. Following the survivors' interviews, non-participant observations of a random day's activities were conducted. Data were transcribed verbatim. Survivors' and providers' data were analyzed separately and then together thematically. Five themes emerged: healing the mind in order to move forward, optimizing adaptations and maintaining physical function, living a safe and cost-effective life, returning to work, and giving back to society. Community-based services can be improved to offer more at-home, technology-supported psychological and self-management interventions, barrier-free and one-stop services, and opportunities for employment and volunteering. It would be worthwhile to invest in conducting public education to promote social inclusion and strengthening collaboration between academic and community organizations.

Circular noncoding RNA circ_0007865, serves as a competing endogenous RNA, targeting the miR-214-3p/FKBP5 axis to regulate oxygen-glucose deprivation-induced injury in brain microvascular endothelial cells

BACKGROUND

Ischemic stroke (IS) is a major cause of permanent morbidity and lifelong disability worldwide. Circular RNA (circRNA) circ_0007865 has been reported to be upregulated in acute ischemic stroke (AIS) patients. Also, AIS patients exhibited increased death of human brain microvascular endothelial cells (HBMECs). This study is designed to explore the role and mechanism of circ_0007865 in the oxygen-glucose deprivation (OGD)-induced cell damage in AIS.

METHODS

Circ_0007865, microRNA-214-3p (miR-214-3p), and FK506-binding protein 5 (FKBP5) levels were detected by real-time quantitative PCR. Cell proliferative angiogenesis, migration, and apoptosis were assessed by Cell Counting Kit-8, 5-ethynyl-2'-deoxyuridine, colony formation, tube formation, wound healing, transwell, and flow cytometry assays. B-cell lymphoma-2 (Bcl-2), Bcl-2-related X protein (Bax), cleaved caspase-3, and FKBP5 protein levels were determined by western blot assay. The binding relationship between miR-214-3p and circ_0007865 or FKBP5 was predicted by StarBase, and verified by a dual-luciferase reporter, RNA pull-down assay.

RESULTS

Circ_0007865 and FKBP5 were increased, and miR-214-3p was decreased in OGD-treated HBMECs. Furthermore, the silencing of circ_0007865 could promote cell proliferative angiogenesis, migration, and inhibit apoptosis in OGD-triggered HBMECs in vitro. Mechanically, circ_0007865 acted as a sponge of miR-214-3p to regulate FKBP5.

CONCLUSION

According to these results, circ_0007865 deficiency could attenuate OGD-induced HBMEC damage by modulating the miR-214-3p/FKBP5 axis, hinting at a promising therapeutic target for future acute IS therapy.

Young adults with nonalcoholic fatty liver disease, defined using the fatty liver index, can be at increased risk of myocardial infarction or stroke

AIM

To investigate the relationship between nonalcoholic fatty liver disease (NAFLD) and cardiovascular events among a nationally representative sample of young adults in Korea.

METHODS AND RESULTS

This population-based cohort study from the Korean National Health Insurance Service included adults who were aged 20 to 39 years when they underwent a health examination between 2009 and 2012. NAFLD was defined as a fatty liver index (FLI) ≥60, and participants were divided into three groups according to FLI (<30, 30-59 and ≥60) to investigate the dose-dependent effect of FLI score. Among 5 324 410 participants, 9.8% had an FLI ≥60. There were 13 051 myocardial infarctions (MIs; 0.39%) and 8573 strokes (0.26%) during a median follow-up of 8.4 years. In multivariable analysis, NAFLD was associated with a higher risk of MI and stroke (hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.61-1.77 and HR  1.73, 95% CI 1.63-1.84, respectively). MI and stroke had dose-dependent relationships with FLI (HR 1.28 in participants with FLI 30-59 and 1.73 in those with FLI ≥60 for MI and HR 1.18 in participants with FLI 30-59 and 1.41 in those with FLI ≥60 for stroke, respectively).

CONCLUSIONS

Nonalcholic fatty liver disease was an independent predictor of MI and stroke in young adults. These results suggest that primary prevention of cardiovascular disease should be emphasized in young adults with NAFLD.

Systematic Review of Sex Differences in Ischemic Strokes Among Young Adults: Are Young Women Disproportionately at Risk?

BACKGROUND AND PURPOSE

Recent evidence suggests that young women (18-45 years) may be at higher risk of ischemic strokes than men of the same age. The goal of this systematic review is to reconcile and synthesize existing evidence of sex differences among young adults with ischemic strokes.

METHODS

We searched PubMed from January 2008 to July 2021 for relevant articles and reviews and consulted their references. We included original studies that (1) were population based and (2) reported stroke incidence by sex or sex-specific incidence rate ratios of young adults ≤45 years. We excluded studies that (1) omitted measurements of error for incidence rates or incidence rate ratios, (2) omitted age adjustment, and (3) were not in English. Statistical synthesis was performed to estimate sex difference by age group (≤35, 35-45, and ≤45) and stroke type.

RESULTS

We found 19 studies that reported on sex-specific stroke incidence among young adults, including 3 that reported on overlapping data. Nine studies did not find a statistically significant sex difference among young adults ≤45 years. Three studies found higher rates of ischemic stroke among men among young adults ≥30 to 35 years. Four studies found more women with ischemic strokes among young adults ≤35 years. Overall, in young adults ≤35 years, the estimated effect size favored more ischemic strokes in women (incidence rate ratio, 1.44 [1.18-1.76], I²=82%) and a nonsignificant sex difference in young adults 35 to 45 years (incidence rate ratio, 1.08 [0.85-1.38], I²=95%).

CONCLUSIONS

Overall, there were 44% more women ≤35 years with ischemic strokes than men. This gap narrows in young adults, 35 to 45 years, and there is conflicting evidence whether more men or women have ischemic strokes in the 35 to 45 age group.

Drug-Coated Balloon-Oriented Angioplasty for Severe Symptomatic Atherosclerotic MCA Stenosis in Young Adults

Purpose

The clinical significance of endovascular therapy in young patients with symptomatic intracranial atherosclerotic stenosis is not clear. We aimed to report our preliminary findings on the safety and effectiveness of a new endovascular treatment strategy, drug-coated balloon (DCB)-oriented angioplasty for young adults with severe symptomatic atherosclerotic middle cerebral artery (MCA) stenosis.

Methods

We retrospectively retrieved the data of seven young patients aged 21–32 years old with severe symptomatic atherosclerotic MCA stenosis treated with DCB-oriented angioplasty from January 2018 to October 2020. We collected clinical presentations, perioperative complications, and clinical and radiological outcomes.

Results

The DCB was successfully dilated at the lesions in all seven patients and good antegrade perfusion was achieved in five. The other two patients underwent remedial stent implantation due to residual stenosis >50% and unstable antegrade perfusion after DCB dilatation. However, none of the patients had perioperative complications. There were no recurrent ischemic symptoms after a mean clinical follow-up period of 15.4 ± 6.9 months. Repeat vascular images of the patients showed no restenosis at 3- or 6-month imaging follow-up periods. High-resolution MRI (HRMRI) was completed in all the patients before the angioplasty procedure and at follow-up. Focal eccentric wall thickening was present at the site of stenosis preoperatively; however, the plaques had disappeared by the time of follow-up for all patients.

Conclusion

DCB-oriented angioplasty may be safe and effective for young patients with severe symptomatic atherosclerotic MCA stenosis.

Medical Data Acquisition and Internet of Things Technology-Based Cerebral Stroke Disease Prevention and Rehabilitation Nursing Mobile Medical Management System

This research was aimed at exploring the application value of a mobile medical management system based on Internet of Things technology and medical data collection in stroke disease prevention and rehabilitation nursing. In this study, on the basis of radio frequency identification (RFID) technology, the signals collected by the sensor were filtered by the optimized median filtering algorithm, and a rehabilitation nursing evaluation model was established based on the backpropagation (BP) neural network. The performance of the medical management system was verified in 32 rehabilitation patients with hemiplegia after stroke and 6 healthy medical staff in the rehabilitation medical center of the hospital. The results showed that the mean square error (MSE) and peak signal-to-noise ratio (PSNR) of the median filtering algorithm after optimization were significantly higher than those before optimization (P < 0.05). When the number of neurons was 23, the prediction accuracy of the test set reached a maximum of 89.83%. Using traingda as the training function, the model had the lowest training time and root mean squared error (RMSE) value of 2.5 s and 0.29, respectively, which were significantly lower than the traingd and traingdm functions (P < 0.01). The error percentage and RMSE of the model reached a minimum of 7.56% and 0.25, respectively, when the transfer functions of both the hidden and input layers were tansig. The prediction accuracy in stages III~VI was 90.63%. It indicated that the mobile medical management system established based on Internet of Things technology and medical data collection has certain application value for the prevention and rehabilitation nursing of stroke patients, which provides a new idea for the diagnosis, treatment, and rehabilitation of stroke patients.

Fasting Blood-Glucose Level and Clinical Outcome in Anterior Circulation Ischemic Stroke of Different Age Groups After Endovascular Treatment

OBJECTIVE

We aimed to analyze the association between fasting blood-glucose (FBG) level and 3-month functional outcome in anterior circulation ischemic stroke in different age groups after endovascular treatment (EVT).

METHODS

We retrospectively analyzed the consecutive patients with acute ischemic stroke (AIS) receiving EVT from our department between July 2015 and March 2021. The patients were categorized into the older (≥60 years) and younger (<60 years) groups, and patients in each age group were dichotomized into favorable versus unfavorable outcomes according to the 3-month modified Rankin Scale (mRS) score.

RESULTS

A total of 504 patients (286 males and 218 females) were included in our study. Three hundred ninety-two patients (77.8%) belonged to the group aged ≥60 years, and 112 (22.2%) belonged to the group aged <60 years. At the end of the study, 222 (56.6%) patients developed unfavorable outcomes in the older group and 31 (27.7%) showed unfavorable outcomes in the younger group. FBG level of the younger patients was significantly lower than that of older patients. In the older group, FBG level independently predicted a 3-month clinical unfavorable outcome with an odds ratio of 1.242 (95% confidence interval, 1.096-1.407; p = 0.001). However, the association was not found in the younger group (p = 0.376).

CONCLUSION

Higher FBG level is an independent risk factor for 3-month unfavorable outcome in the AIS patients aged ≥60 years receiving EVT, but no similar effect was seen in the group aged <60 years.

Ischemic Stroke in Young Adults Caused by Cervical Artery Dissection-A Retrospective Study

Background  Ischemic stroke is one of the most common causes of death and disability. The most common independent cause is cervical artery dissection, which represents around 20% of all cases of ischemic stroke in young adults. Risk factors for dissection include male gender, migraine (particularly with aura), hyperhomocysteinemia, recent infection, recent history of minor cervical trauma, young age, current smoking status, increased leucocyte count, and shortened activated partial thromboplastin time, whereas hypercholesterolemia and being overweight appear protective. Patients and Methods  This retrospective study was based on data of all patients aged 18 to 49 who were hospitalized in the University Medical Centre Maribor for ischemic stroke between 2010 and 2019 inclusive. The results of the research were analyzed by IBM SPSS Statistics 28 software. For statistical significance, a cut-off value of p  < 0.05 was used. Results  The study includes 196 patients with 198 events of ischemic stroke. Dissection of cervical arteries was presented in 16 (8.2%) cases. The presence of arterial hypertension proved to have a relation with the presence of a dissection; patients with dissection are less likely to suffer from arterial hypertension. Duration of hospitalization in the group with dissection lasted significantly longer than in the group without dissection. Conclusions  Dissection of cervical or intracranial artery is an important cause of ischemic stroke, especially in young adults. Therefore, it should be considered in young adults with presentation of stroke who lack traditional and modifiable risk factors.

Efficiency of Leg Exoskeleton Use in Rehabilitation of Cerebral Stroke Patients

The study aimed to evaluate the effectiveness of functional and motor activity restoration, including the walking function, in patients after an ischemic stroke using the ExoAtlet lower limb exoskeleton.

Patients and methods. A clinical study was carried out on 42 patients who had undergone a cerebral infarction in the mid cerebral artery system with a post-stroke paresis of the leg, and who had undergone a rehabilitation course in a round-theclock hospital during the early recovery period. Patients were randomized into two equal groups comparable in terms of the stroke severity: the patients in group 1 were receiving a standard rehabilitation program (control group), the patients in group 2 were additionally receiving a course of gait rehabilitation using the ExoAtlet exoskeleton - 10 sessions, 5 sessions per week for 14 days.

Results. The study demonstrated the effectiveness of the ExoAtlet exoskeleton used in the rehabilitation of stroke patients over the standard course of rehabilitation. The advantages include a decrease in the hemiparesis degree, an increase in the muscle strength of the paretic limb, an improvement in balance, an improvement and acceleration of the walking process. The obtained results of the instrumental study confirmed the benefits of physical training on the Exoskeleton, which was demonstrated through an increase in stability and balance, as well as through a decrease in the energy consumption index for maintaining the stable verticalization.

Conclusion. The usage of the ExoAtlet exoskeleton increases the effectiveness of rehabilitation measures and improves motor and functional activities of patients who have suffered a cerebral stroke.

The Predictive Role of Systemic Inflammation Response Index (SIRI) in the Prognosis of Stroke Patients

Purpose

Stroke is a disease associated with high mortality. Many inflammatory indicators such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR) and red blood cell distribution width (RDW) have been documented to predict stroke prognosis, their predictive power is limited. A novel inflammatory indicator called systemic inflammatory response index (SIRI) has been advocated to have an essential role in the prognostic assessment of cancer and infectious diseases. In this study, we attempted to assess the prognosis of stroke by SIRI. Moreover, we compared SIRI with other clinical parameters, including NLR, PLR, LMR and RDW.

Methods

This was a retrospective cohort study. We obtained data of 2450 stroke patients from the Multiparametric Intelligent Monitoring in Intensive Care III database. We used the Cox proportional hazards models to evaluate the relationship between SIRI and all-cause mortality and sepsis. Receiver operating curve (ROC) analysis was used to assess the predictive power of SIRI compared to NLR, PLR, LMR and RDW for the prognosis of stroke. We collected data of 180 patients from the First Affiliated Hospital of Wenzhou Medical University, which used the Pearson’s correlation coefficient to assess the relationship between SIRI and the National Institute of Health stroke scale (NIHSS).

Results

After adjusting multiple covariates, we found that SIRI was associated with all-cause mortality in stroke patients. Rising SIRI accompanied by rising mortality. Besides, ROC analysis showed that the area under the curve of SIRI was significantly greater than for NLR, PLR, LMR and RDW. Besides, Pearson’s correlation test confirmed a significant positive correlation between SIRI and NIHSS.

Conclusion

Elevated SIRI was associated with higher risk of mortality and sepsis and higher stroke severity. Therefore, SIRI is a promising low-grade inflammatory factor for predicting stroke prognosis that outperformed NLR, PLR, LMR, and RDW in predictive power.

Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions

PURPOSE OF THE REVIEW

To provide an up-to-date review of the incidence of stroke and large vessel occlusion (LVO) around the globe, as well as the eligibility and access to IV thrombolysis (IVT) and mechanical thrombectomy (MT) worldwide.

RECENT FINDINGS

Randomized clinical trials have established MT with or without IVT as the usual care for patients with LVO stroke for up to 24 hours from symptom onset. Eligibility for IVT has extended beyond 4.5 hours based on permissible imaging criteria. With these advances in the last 5 years, there has been a notable increase in the population of patients eligible for acute stroke interventions. However, access to acute stroke care and utilization of MT or IVT is lagging in these patients.

SUMMARY

Stroke is the second leading cause of both disability and death worldwide, with the highest burden of the disease shared by low- and middle-income countries. In 2016, there were 13.7 million new incident strokes globally; ≈87% of these were ischemic strokes and by conservative estimation about 10%-20% of these account for LVO. Fewer than 5% of patients with acute ischemic stroke received IVT globally in the eligible therapeutic time window and fewer than 100,000 MTs were performed worldwide in 2016. This highlights the large gap among eligible patients and the low utilization rates of these advances across the globe. Multiple global initiatives are underway to investigate interventions to improve systems of care and bridge this gap.

Prevalence of Walking Limitation After Acute Stroke and Its Impact on Discharge to Home

OBJECTIVE

The purpose of this study was to provide contemporary estimates of the prevalence of lower extremity motor impairment and walking limitation after first-ever stroke and to characterize the predictive nature of early walking ability for being discharged home after acute hospitalization.

METHODS

In this cohort study, data were collected from a metropolitan acute care hospital in Canada at admission for 487 adults with first-ever acute ischemic or hemorrhagic stroke. Lower extremity motor impairment and walking limitation were measured using the National Institutes of Health Stroke Scale and AlphaFIM, respectively. Parallel multivariable logistic regression models were built to predict discharge home after acute hospitalization compared with further hospitalization.

RESULTS

For patients surviving a first-ever stroke, 44.1% presented with some degree of lower extremity motor impairment and 46.0% were unable to walk. In a multivariable model built around a binary classification of walking (Nagelkerke R2 = 0.41), those with any ability to walk at admission (with or without therapist assistance) had 9.48 times greater odds of being discharged home (odds ratio = 9.48, 95% CI = 6.11-14.92) than those who were unable. In a parallel multivariable model built around an ordinal classification of walking (Nagelkerke R2 = 0.49), patients had 2.07 times greater odds (odds ratio = 2.07, 95% CI = 1.82-2.38) of being discharged home for each increment on a 6-point walking scale (total dependence to complete independence) assessed at acute admission.

CONCLUSION

Approximately one-half of patients with first-ever stroke present with lower extremity weakness and walking limitation. Early walking ability is a significant predictor of returning home after acute hospitalization, independent of stroke severity. Discharge planning may be facilitated early after stroke with the familiar assessment of walking ability.

IMPACT

An early assessment of walking function within days of stroke admission can help to streamline discharge planning.

LAY SUMMARY

Nearly one-half of all individuals who experience a first-time stroke have walking difficulty when they arrive at the hospital. The severity of the walking limitation can predict whether a patient will eventually be discharged home or go on to further hospitalization.

Stroke and Athletes: A Scoping Review

Stroke (i.e., cerebrovascular accident) affects one in 10,000 people between the ages of 14 and 45; however, very little is known about the frequency and type of stroke that occurs in athletes. The risk of injury to the neurovascular structures may depend on the type of sport involvement, although, sport-specific incidence rates are not known. Therefore, the goal of our scoping review was to provide some guidance to better inform the development of a context-fit stroke model by summarizing studies on a broad research topic related to stroke or cerebrovascular accident in sport based on a strict athlete definition. We used the guidance of Arksey and O’Malley’s five-stage-process for a scoping review. Databases included MEDLINE(R) Epub Ahead of Print, In-Process & Other Non- Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), and Embase (OVID databases); CINAHL Plus with Full Text, SportDiscus with Full Text (Ebsco databases); and Scopus. Publication dates were from 1979–2020 across nine different countries resulting in 39 individual cases of stroke with an athlete age range of 14–56 years (95% male). The major inciting event(s) prior to stroke onset were headaches (38.4%), head trauma (30.7%), and neck injury and/or vertebral artery dissection (20.5%). Several sporting activities were represented with American football as the most prevalent (30.7%). In summary, we found that sports with an aspect of impact, collision, or microtrauma can lead to subsequent stroke. These sport-related traumatic events were often difficult to diagnose because of the longer interval before ischemia occurred. Therefore, health care providers should be particularly attuned to the possibility of stroke when evaluating athletes presenting with or without neurological deficit.

Depletion of microglia mitigates cerebrovascular dysfunction in diet-induced obesity mice

Obesity is frequently associated with cerebrovascular dysfunction; however, the underlying mechanism remains less well understood. In this study, by using pharmacological approaches, we show that neuroinflammation involving microglia plays an important role in obesity-related cerebrovascular dysfunction. PLX3397 treatment, which leads to depletion of microglia, reduced the wall thickness and collagen deposition in the basilar artery of diet-induced obesity (DIO) mice. Besides, the phosphorylation of endothelial nitric oxide synthase (eNOS) at Ser1177 was enhanced, suggesting improved endothelial function of the basilar artery. The wire myography data show that acetylcholine-elicited relaxation of basilar artery isolated from DIO mice was improved after the treatment with PLX3397. Moreover, our data demonstrate that brain administration of IL-18 impaired cerebrovascular function in mice with normal body weight. Together, these data suggest that neuroinflammation involving microglia is important in obesity-related vascular dysfunction in the brain.NEW & NOTEWORTHY We reported that microglia, the resident immune cells in the brain, contribute to obesity-related cerebrovascular dysfunction in mice. Moreover, we showed that excessive IL-18 can lead to vascular dysfunction in mouse brain.

Verification and comparison of three prediction models of ischemic stroke in young adults based on the back propagation neural networks

This work aims to explore risk factors for ischemic stroke in young adults and analyze the Traditional Vascular Risk Factors Model based on age, hypertension, diabetes, smoking history, and drinking history. Further, the Lipid Metabolism Model was analyzed based on lipoprotein a [LP (a)], high-density lipoprotein (HDL), low-density lipoprotein (LDL), apolipoprotein AI (apo AI), apolipoprotein B (apo B), and the Early Renal Injury Model based on urinary microalbuminuria/creatinine ratio (UACR). Besides, we estimated glomerular filtration rate (eGFR), cystatin C (Cys-C), homocysteine (Hcy), β2 microglobulin (β2m), and validated their predictive efficacy and clinical value for the development of ischemic stroke in young adults.We selected and retrospectively analyzed the clinical data of 565 young inpatients admitted to Zhejiang Provincial Hospital of Chinese Medicine between 2010 and 2020, 187 of whom were young stroke patients. A single-factor analysis was used to analyze the risk factors for stroke in young people and developed a traditional vascular risk factors model, a lipid metabolism model, and an early kidney injury model based on backpropagation (BP) neural networks technology to predict early stroke occurrence. Moreover, the prediction performance by the area under the receiver operating characteristics (ROC) curve (AUC) was assessed to further understand the risk factors for stroke in young people and apply their predictive role in the clinical setting.Single-factor analysis showed that ischemic stroke in young adults was associated with hypertension, diabetes, smoking history, drinking history, LP(a), HDL, LDL, apo AI, apo B, eGFR, Cys-C, and β2m (P < .05). The BP neural networks technique was used to plot the ROC curves for the Traditional Vascular Risk Factors Model, the Lipid Metabolism Model, and the Early Kidney Injury Model in enrolled patients, and calculated AUC values of 0.7915, 0.8387, and 0.9803, respectively.The early kidney injury model precisely predicted the risk of ischemic stroke in young adults and exhibited a certain clinical value as a reference for morbidity assessment. Whereas the prediction performance of the Traditional Vascular Risk Factors Model and the Lipid Metabolism Model were inferior to that of the early kidney injury model.

Incidence of hospitalization and mortality due to stroke in young adults, residents of developed regions in Brazil, 2008-2018

Introduction

We evaluated trends in hospitalization incidence and mortality due to hemorrhagic and ischemic stroke in young adults, according to gender and developed regions in Brazil.

Methods

Between 2008–2018, we performed a population-based time-series study using official hospitalization and death data due to stroke, in individuals aged 10–49 years, from Southeast and South, Brazil. Data were based on reports from the Unified Health System of Hospital Information System and Mortality Information System. Stroke was defined by the International Classification of Diseases, 10^th revision (I60–I63). A Prais-Winsten regression model was performed and the Annual Percentage Change was calculated.

Results

In total, 78,123 hospitalizations of individuals aged 10–49 years were recorded, of which 59,448 (76%) resulted from hemorrhagic stroke (HS). The hospitalizations for HS was significantly decreased (- 4.37%) among men and women in both regions. The hospitalizations for ischemic stroke (IS) was flat, except between 2011 and 2018, when IS hospitalization rates increased. In the analysis by states, HS hospitalizations declined across all states, except for Espírito Santo, where it remained unchanged (p > 0.05). IS flat hospitalizations were observed in all states, except Espírito Santo, where it increased by 24.93%. In terms of mortality, 28,625 deaths were recorded, of which 26,548 (92.7%) resulted from HS. HS mortality decreased significantly by -3.48%and IS mortality by -3.84%. Decreases also occurred in all Southeast and South states (p < 0.05). IS remained unchanged across all states, except Minas Gerais, where it decreased by -14.95%.

Conclusions

We identified a decline in the hospitalizations and mortality of HS and a flat trend for IS in developed regions of Brazil. The recent period (2011–2018) demonstrated increasing rates in the hospitalizations of IS in both regions and genders. The mortality rates for HS and IS decreased between 2008–2018 in Southeast and South Brazil for both genders.

Large Vessel Occlusion Secondary to COVID-19 Hypercoagulability in a Young Patient: A Case Report and Literature Review

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) initially most appreciated for its pulmonary symptoms, is now increasingly recognized for causing multi-organ disease and stroke in the setting of a hypercoagulable state. We report a case of 33-year-old African American woman with COVID-19 who developed acute malignant middle cerebral artery infarction due to thromboembolic occlusion of the left terminal internal carotid artery and middle cerebral artery stem. Mechanical thrombectomy was challenging and ultimately unsuccessful resulting in limited reperfusion of <67% of the affected vascular territory, and thrombectomized clot was over 50 mm in length, at least three times the average clot length. The final stroke size was estimated at 224 cubic centimeters. On admission her D-dimer level was 94,589 ng/mL (normal 0-500 ng/ml). Throughout the hospitalization D-dimer decreased but never reached normal values while fibrinogen trended upward. Hypercoagulability panel was remarkable for mildly elevated anticardiolipin IgM of 16.3 MPL/mL (normal: 0-11.0 MPL/mL). With respect to remaining stroke workup, there was no evidence of clinically significant stenosis or dissection in the proximal internal carotid artery or significant cardioembolic source including cardiomyopathy, atrial fibrillation, cardiac thrombus, cardiac tumor, valvular abnormality, aortic arch atheroma, or patent foramen ovale. She developed malignant cytotoxic cerebral edema and succumbed to complications. This case underscores the importance of recognizing hypercoagulability as a cause of severe stroke and poor outcome in young patients with COVID-19 and highlights the need for further studies to define correlation between markers of coagulopathy in patients with COVID-19 infection and outcome post stroke.

Stroke in young adults: Current trends, opportunities for prevention and pathways forward

Cardiovascular disease remains a major contributor to morbidity and mortality in the US and elsewhere, and stroke is a leading cause of disability worldwide. Despite recent success in diminishing stroke incidence in the general US population, in parallel there is now a concerning propensity for strokes to happen at younger ages. Specifically, the incidence of stroke for US adults 20-44 years of age increased from 17 per 100,000 US adults in 1993 to 28 per 100,000 in 2015. Occurrence of strokes in young adults is particularly problematic as these patients are often affected by physical disability, depression, cognitive impairment and loss of productivity, all of which have vast personal, social and economic implications. These concerning trends among young adults are likely due to increasing trends in the prevalence of modifiable risk factors amongst this population including hypertension, hyperlipidemia, obesity and diabetes, highlighting the importance of early detection and aggressive prevention strategies in the general population at early ages. In parallel and compounding to the issue, troublesome trends are evident regarding increasing rates of substance abuse among young adults. Higher rates of strokes have been noted particularly among young African Americans, indicating the need for tailored prevention and social efforts targeting this and other vulnerable groups, including the primordial prevention of risk factors in the first place, reducing stroke rates in the presence of prevalent risk factors such as hypertension, and improving outcomes through enhanced healthcare access. In this narrative review we aim to emphasize the importance of stroke in young adults as a growing public health issue and increase awareness among clinicians and the public health sector. For this purpose, we summarize the available data on stroke in young adults and discuss the underlying epidemiology, etiology, risk factors, prognosis and opportunities for timely prevention of stroke specifically at young ages. Furthermore, this review highlights the gaps in knowledge and proposes future directions moving forward.

Racial disparities in post-stroke functional outcomes in young patients with ischemic stroke

BACKGROUND AND PURPOSE

Recent studies show rising incidence of stroke in the young, for which risk factors are not well characterized. There is evidence of increased risk in certain racial and ethnic groups. We assessed racial differences in risk factors, stroke etiology, and outcomes among young stroke patients.

METHODS

Using data from our inpatient registry for ischemic stroke, we reviewed patients aged 18-50 who were admitted 01/2013 to 04/2018. Race/ethnicity were characterized as non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic (HIS). For univariate comparisons Chi-square and Kruskal-Wallis tests were performed as appropriate. Multivariable logistic regression was used to assess impact of race on day seven modified Rankin score (mRS).

RESULTS

Among 810 patients with race and outcome data who were admitted in the study period, median age was 43, 57.1% were male, and 36.5% NHW, 43.2% NHB, 20.2% HIS. History of hypertension (HTN), type II diabetes (DM II), smoking, heart failure (CHF), prior stroke, and end-stage renal disease varied significantly by race. Compared to NHW, NHB had higher odds of HTN (OR 2.28, 1.65-3.15), CHF (OR 2.17, 1.06-4.46), and DM II 1.92 (1.25-2.94) while HIS had higher odds of DM II (OR 2.52, 1.55-4.10) and lower odds of smoking (OR 0.56, 0.35-0.90). Arrival NIHSS was higher in NHB, but etiology and rates of tpA treatment and thrombectomy did not vary by race. Compared to NHW patients, NHB (OR 0.50 CI (0.31-0.78)) and HIS (OR 0.37 CI (0.21-0.67)) were less likely to have good functional outcome (mRS <2) at day 7 in adjusted analyses.

CONCLUSIONS

In this study, there was a higher prevalence of several modifiable risk factors in NHB and HIS young stroke patients and early functional outcome was worse in these groups. Our study suggests a need for targeted prevention efforts for younger populations at highest risk for stroke.