1
|
Hameed S, Karim N, Wasay M, Venketasubramanian N. Emerging Stroke Risk Factors: A Focus on Infectious and Environmental Determinants. J Cardiovasc Dev Dis 2024; 11:19. [PMID: 38248889 PMCID: PMC10816862 DOI: 10.3390/jcdd11010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
This review focuses on emerging risk factors for stroke, including air pollution and climate change, gut microbiota, high altitude, and systemic infection. Up to 14% of all stroke-associated mortality is attributed to air pollution and is more pronounced in developing countries. Fine particulate matter and other air pollutants contribute to an increased stroke risk, and this risk appears to increase with higher levels and duration of exposure. Short term air pollution exposure has also been reported to increase the stroke risk. The gut microbiota is a complex ecosystem of bacteria and other microorganisms that reside in the digestive system and affect multiple body systems. Disruptions in the gut microbiota may contribute to stroke development, possibly by promoting inflammation and atherosclerosis. High altitudes have been associated with erythrocytosis and cerebrovascular sinus thrombosis, but several studies have reported an increased risk of thrombosis and ischemic stroke at high altitudes, typically above 3000 m. Systemic infection, particularly infections caused by viruses and bacteria, can also increase the risk of stroke. The risk seems to be greatest in the days to weeks following the infection, and the pathophysiology is complex. All these emerging risk factors are modifiable, and interventions to address them could potentially reduce stroke incidence.
Collapse
Affiliation(s)
- Sajid Hameed
- Department of Neurology, University of Virginia, Charlottesville, VA 22903, USA;
| | - Nurose Karim
- Department of Neurology, East Carolina University, Greenville, NC 27834, USA;
| | - Mohammad Wasay
- Department of Neurology, Aga Khan University, Karachi 74800, Pakistan;
| | | |
Collapse
|
2
|
Wang P, Feng W, Luo S, Cheng S, Gong M, Li Y, Liu Y. Cleaner outdoor air diminishes the overall risk of intracerebral hemorrhage but brings differential benefits to subpopulations: a time-stratified case-crossover study. BMC Public Health 2023; 23:1303. [PMID: 37420171 PMCID: PMC10327021 DOI: 10.1186/s12889-023-16232-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 07/02/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Short-term air pollution exposure and intracerebral hemorrhage (ICH) risk are related. However, the impact of the pollutant levels decline on this relationship, which attributes to clean air policy implementation and the COVID-19 pandemic lockdown, is unclear. In the present research, we explored the influence of different pollutant levels on ICH risk during eight years in a southwestern China megacity. METHODS Our research used a time-stratified case-crossover design. We retrospectively analyzed ICH patients in a teaching hospital from January 1, 2014, to December 31, 2021, and divided 1571 eligible cases into two groups (1st group: 2014-2017; 2nd group: 2018-2021). We observed the trend of every pollutant in the entire study period and compared the pollution levels in each group, using air pollutants data (PM2.5, PM10, SO2, NO2, CO, and O3) documented by the local government. We further established a single pollutant model via conditional logistic regression to analyze the association between short-term air pollutants exposure and ICH risk. We also discussed the association of pollution levels and ICH risk in subpopulations according to individual factors and monthly mean temperature. RESULTS We found that five air pollutants (PM2.5, PM10, SO2, NO2, CO) exhibited a continuous downward trend for the whole duration, and the daily concentration of all six pollutants decreased significantly in 2018-2021 compared with 2014-2017. Overall, the elevation of daily PM2.5, SO2, and CO was associated with increased ICH risk in the first group and was not positively associated with risk escalation in the second group. For patients in subgroups, the changes in the influence of lower pollutant levels on ICH risk were diverse. In the second group, for instance, PM2.5 and PM10 were associated with lower ICH risk in non-hypertension, smoking, and alcohol-drinking participants; however, SO2 had associations with increased ICH risk for smokers, and O3 had associations with raised risk in men, non-drinking, warm month population. CONCLUSIONS Our study suggests that decreased pollution levels diminish the adverse effects of short-term air pollutants exposure and ICH risk in general. Nevertheless, the influence of lower air pollutants on ICH risk in subgroups is heterogeneous, indicating unequal benefits among subpopulations.
Collapse
Affiliation(s)
- Peng Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
- Department of Neurosurgery, Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Wentao Feng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Shuang Luo
- Department of Neurosurgery, Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Shuwen Cheng
- Department of Neurosurgery, Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Min Gong
- Department of Neurosurgery, Cancer Prevention and Treatment Institute of Chengdu, Chengdu Fifth People's Hospital (The Second Clinical Medical College, Affiliated Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Yaxin Li
- West China Fourth Hospital/West China School of Public Health, Sichuan University, Chengdu, China
| | - Yanhui Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China.
| |
Collapse
|
3
|
Liao KH, Chan TC, Wu CC, Huang WC, Hsu CW, Chuang HC, Wiratama BS, Chiu WT, Lam C. Association between short-term air pollution exposure and traumatic intracranial hemorrhage: pilot evidence from Taiwan. Front Neurol 2023; 14:1087767. [PMID: 37234787 PMCID: PMC10208221 DOI: 10.3389/fneur.2023.1087767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/17/2023] [Indexed: 05/28/2023] Open
Abstract
Introduction The detrimental effects of air pollution on the brain are well established. However, few studies have examined the effect of air pollution on traumatic brain injury (TBI). This pilot study evaluated the association between short-term air pollution exposure and traumatic intracranial hemorrhage (TIH). Methods Hospital data of patients with TBI following road traffic accidents were retrospectively collected from the electronic medical records at five trauma centers in Taiwan between 1 January and 31 December 2017. TIH was employed as an outcome measure. All road accident locations were geocoded, and air quality data were collected from the nearest monitoring stations. Air pollutants were entered into five multivariable models. A sensitivity analysis was performed on patients who are vulnerable to suffering TBI after road accidents, including motorcyclists, bicyclists, and pedestrians. Results Among 730 patients with TBI, 327 had TIH. The ages of ≥65 [odds ratio (OR), 3.24; 95% confidence interval (CI), 1.85-5.70], 45-64 (OR, 2.61; 95% CI, 1.64-4.15), and 25-44 (OR, 1.79; 95% CI, 1.13-2.84) years were identified as significant risk factors in the multivariable analysis. In the best-fit multivariable model, exposure to higher concentrations of particulate matter ≤ 2.5 μm in aerodynamic diameter (PM2.5) was associated with an elevated TIH risk (OR, 1.50; 95% CI, 1.17-1.94). The concentration of nitrogen oxides (NOX) did not increase the risk of TIH (OR, 0.45; 95% CI, 0.32-0.61). After categorizing the air pollution concentration according to quartile, the trend tests in the multivariate model showed that the concentrations of PM2.5 and NOX were significant (p = 0.017 and p < 0.001, respectively). There was a negative borderline significant association between temperature and TIH risk (OR, 0.75; 95% CI, 0.56-1.00, p = 0.05). Notably, the single-vehicle crash was a significant risk factor (OR, 2.11; 95% CI, 1.30-3.42) for TIH. Discussion High PM2.5 concentrations and low temperatures are risk factors for TIH in patients with TBI. High NOX concentrations are associated with a lower TIH risk.
Collapse
Affiliation(s)
- Kuo-Hsing Liao
- Department of Neurosurgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Critical Medicine, Department of Emergency and Critical Care Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Neurotraumatology and Intensive Care, Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
- Division of Neurosurgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ta-Chien Chan
- Research Center for Humanities and Social Sciences, Academia Sinica, Taipei, Taiwan
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Chieh Wu
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wen-Cheng Huang
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Emergency Department, Department of Emergency and Critical Care Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Center for Education in Medical Simulation, Taipei Medical University, Taipei, Taiwan
- Department of Education and Humanities in Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chin-Wang Hsu
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Emergency Department, Department of Emergency and Critical Care Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hsiao-Chi Chuang
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
- Cell Physiology and Molecular Image Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Bayu Satria Wiratama
- Department of Biostatistics, Epidemiology, and Population Health, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Wen-Ta Chiu
- Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei, Taiwan
- AHMC Health System, Alhambra, CA, United States
| | - Carlos Lam
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
4
|
Leira EC, Latorre JG. Ambient Pollution and Stroke: Time to Clear the Air on Causal Mechanisms. Neurology 2022; 98:1003-1004. [PMID: 35613932 DOI: 10.1212/wnl.0000000000200801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/13/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Enrique C Leira
- From the Departments of Neurology, Neurosurgery, and Epidemiology (E.C.L.), University of Iowa, Iowa City; and Departments of Neurology and Neurosurgery (J.G.L.), Upstate Medical University, Syracuse, NY.
| | - Julius G Latorre
- From the Departments of Neurology, Neurosurgery, and Epidemiology (E.C.L.), University of Iowa, Iowa City; and Departments of Neurology and Neurosurgery (J.G.L.), Upstate Medical University, Syracuse, NY
| |
Collapse
|
5
|
Ho AFW, Lim MJR, Zheng H, Leow AST, Tan BYQ, Pek PP, Raju Y, Seow WJ, Yeo TT, Sharma VK, Aik J, Ong MEH. Association of ambient air pollution with risk of hemorrhagic stroke: A time-stratified case crossover analysis of the Singapore stroke registry. Int J Hyg Environ Health 2021; 240:113908. [PMID: 34974273 DOI: 10.1016/j.ijheh.2021.113908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/06/2021] [Accepted: 12/15/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Haemorrhagic stroke (HS) is a major cause of mortality and disability. Previous studies reported inconsistent associations between ambient air pollutants and HS risk. OBJECTIVE We evaluated the association between air pollutant exposure and the risk of HS in a cosmopolitan city in the tropics. METHODS We performed a nationwide, population-based, time-stratified case-crossover analysis on all HS cases reported to the Singapore Stroke Registry from 2009 to 2018 (n = 12,636). We estimated the risk of HS across tertiles of air pollutant concentrations in conditional Poisson models, adjusting for meteorological confounders. We stratified our analysis by age, atrial fibrillation and smoking status, and investigated the lagged effects of each pollutant on the risk of HS up to 5 days. RESULTS All 12,636 episodes of HS were included. The median (1st-to 3rd-quartile) daily pollutant levels from 22 remote stations deployed across the island were as follows: (PM2.5 = 15.9 (12.7-20.5), PM10 = 27.3 (22.7-33.4), O3 = 22.5 (17.3-29.8), NO2 = 23.3 (18.8-28.4), SO2 = 10.2 (5.6-14.4), CO = 0.5 (0.5-0.6). The median (1st-to 3rd-quartile) temperature (°C) was 27.9 (27.1-28.7), that of relative humidity (%) was 79.4 (75.6-83.2), and that of total rainfall (mm) was 0.0 (0.0-4.2). Higher levels of CO were significantly associated with an increased risk of HS (3rd tertile vs 1st tertile: Incidence Rate Ratio (IRR) = 1.06, 95% CI = 1.01-1.12). The increased risk of HS due to CO persisted for at least 5 days after exposure. Individuals under 65 years old and non-smokers had a higher risk of HS when exposed to CO. O3 was associated with increased risk of HS up to 5 days (3rd tertile vs 1st tertile: IRRday 1 = 1.07, 95% CI = 1.02-1.12; IRRday 5 = 1.07, 95% CI = 1.02-1.13). CONCLUSION Short-term exposure to ambient CO levels was associated with an increased risk of HS. A reduction in CO emissions may reduce the burden of HS in the population.
Collapse
Affiliation(s)
- Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Pre-hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore.
| | - Mervyn Jun Rui Lim
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Huili Zheng
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | | | | | - Pin Pin Pek
- Pre-hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Yogeswari Raju
- Environmental Quality Monitoring Department, Environmental Monitoring and Modelling Division, National Environment Agency, Singapore
| | - Wei-Jie Seow
- National Registry of Diseases Office, Health Promotion Board, Singapore; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Joel Aik
- Pre-hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore; Environmental Epidemiology and Toxicology Division, National Environment Agency, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Pre-hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
| |
Collapse
|
6
|
Ambient particulate matter, ozone, and neurologic symptoms in U.S. Gulf states adults. Environ Epidemiol 2021; 5:e160. [PMID: 34414344 DOI: 10.1097/ee9.0000000000000160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/01/2021] [Indexed: 01/24/2023] Open
Abstract
Research on neurologic effects of air pollution has focused on neurodevelopment or later-life neurodegeneration; other effects throughout adulthood have received less attention. We examined air pollution levels and neurologic symptoms among 21,467 adults in US Gulf Coast states. We assigned exposure using Environmental Protection Agency estimates of daily ambient particulate matter 2.5 (PM2.5) and ozone. Gulf Long-term Follow-up Study participants reported neurologic symptoms at enrollment (2011-2013). We estimated cross-sectional associations between each air pollutant and prevalence of "any" neurologic, central nervous system (CNS), or peripheral nervous system (PNS) symptoms. Ambient PM2.5 was consistently associated with prevalence of neurologic symptoms. The highest quartile of 30-day PM2.5 was associated with any neurologic symptom (prevalence ratio [PR] = 1.16; 95% confidence interval [CI] = 1.09, 1.23) and there were increasing monotonic relationships between 30-day PM2.5 and each symptom category (P-trend ≤ 0.01). Associations with PM2.5 were slightly stronger among nonsmokers and during colder seasons. The highest quartile of 7-day ozone was associated with increased prevalence of PNS symptoms (PR = 1.09; 95% CI = 1.00, 1.19; P-trend = 0.03), but not with other outcomes. Ozone concentrations above regulatory levels were suggestively associated with neurologic symptoms (PR = 1.06; 95% CI = 0.99, 1.14). Mutual adjustment in co-pollutant models suggests that PM2.5 is more relevant than ozone in relation to prevalence of neurologic symptoms.
Collapse
|
7
|
Verhoeven JI, Allach Y, Vaartjes ICH, Klijn CJM, de Leeuw FE. Ambient air pollution and the risk of ischaemic and haemorrhagic stroke. Lancet Planet Health 2021; 5:e542-e552. [PMID: 34390672 DOI: 10.1016/s2542-5196(21)00145-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 03/30/2021] [Accepted: 05/14/2021] [Indexed: 05/26/2023]
Abstract
Stroke is a leading cause of disability and the second most common cause of death worldwide. Increasing evidence suggests that air pollution is an emerging risk factor for stroke. Over the past decades, air pollution levels have continuously increased and are now estimated to be responsible for 14% of all stroke-associated deaths. Interpretation of previous literature is difficult because stroke was usually not distinguished as ischaemic or haemorrhagic, nor by cause. This Review summarises the evidence on the association between air pollution and the different causes of ischaemic stroke and haemorrhagic stroke, to clarify which people are most at risk. The risk for ischaemic stroke is increased after short-term or long-term exposure to air pollution. This effect is most pronounced in people with cardiovascular burden and stroke due to large artery disease or small vessel disease. Short-term exposure to air pollution increases the risk of intracerebral haemorrhage, a subtype of haemorrhagic stroke, whereas the effects of long-term exposure are less clear. Limitations of the current evidence are that studies are prone to misclassification of exposure, often rely on administrative data, and have insufficient clinical detail. In this Review, we provide an outlook on new research opportunities, such as those provided by the decreased levels of air pollution due to the current COVID-19 pandemic.
Collapse
Affiliation(s)
- Jamie I Verhoeven
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | - Youssra Allach
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ilonca C H Vaartjes
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands.
| |
Collapse
|
8
|
Nzwalo H, Logallo N. Addressing Stroke Admissions During COVID-19 Pandemic Beyond Fear and Constraining Health Factors. J Stroke Cerebrovasc Dis 2021; 30:105693. [PMID: 33685785 PMCID: PMC7908875 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/16/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Hipólito Nzwalo
- Faculty of Medicine and Biomedical Sciences of Algarve, Algarve, Portugal; Stroke Unit, University Hospital Center of Algarve, Algarve, Portugal.
| | - Nicola Logallo
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Norway
| |
Collapse
|