The epidemiology of stroke in the Middle East and North Africa

Health-Related Quality of Life Among Patients With Stroke: A Cross-Sectional Study

PURPOSE

To assess levels and predictive factors of health-related quality of life (HRQOL) among stroke patients.

METHODS

The study employed a cross-sectional predictive correlational design. Levels of HRQOL were assessed using the Stroke-Specific Quality of Life (SS-QOL) scale, and the Hospital Anxiety and Depression Scale was employed to assess psychological aspects among 209 Saudi stroke patients. The analysis included demographic and medical variables to comprehensively explore influencing factors.

RESULTS

A two-step hierarchical multiple regression analysis was performed. The overall SS-QOL summary score (49 items) showed a mean score of 94.4 (SD = 8.1), indicating poor functioning. Nine predictor variables were found to significantly predict HRQOL levels, including age (β = -0.212, p ≤ .001), female (β = -5.33, p ≤ .001), unmarried (β = 2.48, p ≤ .001), low gross monthly income (GMI) (β = -9.02, p ≤ .001), medium GMI (β = -8.36, p ≤ .001), having a medical history of hypertension (β = 2.7, p ≤ .01), time since stroke (β = 3.26 p ≤ .001), and being a probable case of anxiety (β = -4.29, p ≤ .001) and/or depression (β = -2.75, p ≤ .001). These variables collectively explained ~76% of the variance in HRQOL scores (adjusted R2 = .762, F (16,192) = 42.6, p ≤ .001).

CONCLUSIONS

Stroke patients exhibited poor HRQOL levels influenced by various factors. Clinicians should consider these predictors and intervene early to enhance HRQOL among patients at risk, emphasizing the importance of optimizing patient outcomes.

Clinical characteristics, Risk factors, and outcomes of Posterior circulation stroke: A retrospective study between younger and older adults in Saudi Arabia

INTRODUCTION

Posterior circulation stroke (PCS) may be less prevalent than its anterior counterpart but contributes to substantial morbidity and mortality. The aim was to characterize PCS's demographics, clinical presentation, management, and outcomes between younger and older adults in Saudi Arabia.

METHODS

This retrospective cohort study was conducted at two tertiary medical centers in Saudi Arabia between March 2016 and December 2020. All patients who presented with symptoms of posterior circulation stroke and had positive brain imaging were included.

RESULTS

The study involved 160 posterior circulation stroke patients, stratified into two age groups: 71 patients aged 18-59 years and 89 patients aged 60 years and above. The mean age of the entire cohort was 60.9 years, and 77 % were males. Hypertension was more prevalent in the older age group (88 % vs. 69 %, p=0.005), and smoking was significantly higher among younger patients (38 % vs. 15 %; p=0.0009). Only 22.4 % received thrombolysis and/or thrombectomy. Most strokes involved the posterior cerebral artery (45.6 %). Large artery atherosclerosis was the most common subtype. At discharge, younger patients had higher NIHSS compared to older patients.

CONCLUSION

Our investigation of 160 PCS patients in Saudi Arabia uncovers notable trends: a mere 22.4 % received thrombolysis and/or thrombectomy and a significant prevalence of posterior cerebral artery involvement due to large artery atherosclerosis. The study further reveals younger patients disproportionately had severe outcomes. Highlighting the need for improved stroke care and heightened awareness, this research contributes vital data to an underexplored domain, urging further study to optimize care and understand PCS dynamics in Saudi Arabia.

Incidence, clinical features, and outcomes of posterior circulation ischemic stroke: insights from a large multiethnic stroke database

Background

Posterior cerebral circulation ischemic stroke (PCS) comprises up to 25% of all strokes. It is characterized by variable presentation, leading to misdiagnosis and morbidity and mortality. We aim to describe PCS in large multiethnic cohorts.

Methods

A retrospective review of a large national stroke database from its inception on the 1st of January 2014 till 31 December 2020. Incidence per 100,000 adult population/year, demographics, clinical features, stroke location, and outcomes were retrieved. We divided the cohort into patients from MENA (Middle East and North Africa) and others.

Results

In total, 1,571 patients were identified. The incidence of PCS was observed to be rising and ranged from 6.3 to 13.2/100,000 adult population over the study period. Men were 82.4% of the total. The mean age was 54.9 ± 12.7 years (median 54 years, IQR 46, 63). MENA patients comprised 616 (39.2%) while others were 954 (60.7%); of these, the majority (80.5%) were from South Asia. Vascular risk factors were prevalent with 1,230 (78.3%) having hypertension, 970 (61.7%) with diabetes, and 872 (55.5%) having dyslipidemia. Weakness (944, 58.8%), dizziness (801, 50.5%), and slurred speech (584, 36.2%) were the most commonly presenting symptoms. The mean National Institute of Health Stroke Score (NIHSS) score was 3.8 ± 4.6 (median 3, IQR 1, 5). The overall most frequent stroke location was the distal location (568, 36.2%). The non-MENA cohort was younger, less vascularly burdened, and had more frequent proximal stroke location (p < 0.05). Dependency or death at discharge was seen in 39.5% and was associated with increasing age, and proximal and multilocation involvement; while at 90 days it was 27.4% and was associated with age, male sex, and having a MENA nationality (p < 0.05).

Conclusion

In a multiethnic cohort of posterior circulation stroke patients from the MENA region and South Asia, we noted a rising incidence over time, high prevalence of vascular risk factors, and poor outcomes in older men from the MENA region. We also uncovered considerable disparities between the MENA and non-MENA groups in stroke location and outcome. These disparities are crucial factors to consider when tailoring individualized patient care plans. Further research is needed to thoroughly investigate the underlying reasons for these variations.

Associations of stroke with all-cause and cause-specific mortality: A population-based matched cohort study

BACKGROUND

This study aimed to assess the specific associations between stroke and all-cause and cause-specific mortality among Korean adults.

METHODS

We used data extracted from the Korean National Health Insurance claims database from 2002 to 2013, including information on individuals with or without stroke aged 20 years and older. Patients with intracerebral hemorrhage, ischemic stroke or unspecified stroke were classified as stroke patients, while a reference population matched in terms of sex and age were also selected. The outcomes were all-cause mortality, natural causes of death (i.e. all natural causes, death by stroke and death by other diseases) and suicide. Survival analysis was performed using the Cox proportional hazards model.

RESULTS

Of the 73 150 eligible participants-including 14 630 stroke patients and 58 520 age- and sex-matched controls-11 121 (15.2%) died during the study period. Of them, 10 513 participants (94.5%) died of natural causes, including 1653 (14.5%) who died due to stroke and 8860 (79.7%) who died due to other diseases. Two hundred and fifty patients (2.2%) died by suicide. Stroke patients showed higher adjusted hazard ratios (HR) for all-cause (HR = 6.48, 95% CI, 3.87-10.86), all-natural-cause (HR = 2.68, 95% CI, 2.53-2.84), stroke (HR = 21.16, 95% CI, 17.49-25.61), other disease (HR = 1.69, 95% CI, 1.58-1.81) and suicide mortality (HR = 3.34, 95% CI, 2.24-4.98) than those without stroke. The effect size of stroke for suicide mortality was greater than that for other causes of mortality (except stroke mortality).

CONCLUSIONS

Stroke was associated with a higher risk of all-cause, natural cause and suicide mortality; stroke was more strongly associated with risk of suicide mortality than with any mortality for any other causes. From a policy standpoint, these results suggest the need for greater supportive care to prevent unnatural deaths among stroke patients.

Predictive Factors and Interventional Modalities of Post-stroke Motor Recovery: An Overview

Stroke is the most common cause of motor impairment worldwide. Therefore, many factors are being investigated for their predictive and facilitatory effects on recovery of motor function after stroke. Motor recovery can be predicted through several factors, such as clinical assessment, clinical biomarkers, and gene-based variations. As for interventions, many methods are under experimental investigation that aim to improve motor recovery, including different types of pharmacological interventions, non-invasive stimulation, and rehabilitation training by inducing cortical reorganization, neuroplasticity, angiogenesis, changing the levels of neurotransmitters in the brain, and altering the inflammatory and apoptotic processes occurring after stroke. Studies have shown that clinical biomarkers combined with clinical assessment and gene-based variations are reliable factors for predicting motor recovery after stroke. Moreover, different types of interventions such as pharmacological agents (selective serotonin reuptake inhibitors {SSRI}, noradrenaline reuptake inhibitors {NARIs}, levodopa, and amphetamine), non-invasive stimulation, and rehabilitation training have shown significant results in improving functional and motor recovery.

Global Burden of Ischemic Stroke in Young Adults in 204 Countries and Territories

BACKGROUND AND OBJECTIVES

To estimate the rates of incidence, death, and disability-adjusted life years (DALYs) of ischemic stroke in young adults aged 15-49 years and the relevant risk factors by sex, age group, and sociodemographic index (SDI) in 204 countries and territories.

METHODS

Data from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2019 study were used. The estimated annual percentage changes (EAPCs) were calculated to evaluate the temporal trends from 1990 to 2019. We also estimated the risk factors contributing to DALYs resulting from ischemic stroke.

RESULTS

From 1990 to 2019, the global age-standardized incidence (EAPC = -0.97), death (EAPC = -0.11), and DALYs rates (EAPC = -0.55) of ischemic stroke in young adults decreased. The largest increases in age-standardized incidence, death, and DALYs rates were observed in the low and low-middle SDI quintiles. At the regional level, North Africa and the Middle East and Southeast Asia showed the largest increases in the age-standardized incidence, death, and DALYs rates of ischemic stroke. The age-standardized incidence rate was higher among young women than among young men in 2019. Globally, a high environmental temperature, high body mass index (BMI), and a high fasting plasma glucose contributed to the largest increases in age-standardized DALYs rates between 1990 and 2019. In the same period, the largest increases in the age-standardized DALYs rates in high-SDI and low-SDI regions were attributable to high environmental temperatures and alcohol use, respectively.

DISCUSSION

The burden of ischemic stroke in young adults continues to increase in low-SDI regions such as North Africa and the Middle East and Southeast Asia. There were differences in the primary risk factors related to the burden of ischemic stroke in different SDI regions. Targeted implementation of cost-effective policies and interventions is an urgent need to reduce the burden of ischemic stroke in young adults.

The Incidence of Aphasia, Cognitive Deficits, Apraxia, Dysarthria, and Dysphagia in Acute Post Stroke Persian Speaking Adults

Stroke is a major cause of serious disabilities in adults. While communication deficits post stroke are prevalent and disabling, early detection of them is important during acute phase. There is limited data published on the incidence of communication disorders in Persian speaking adults following post stroke to our knowledge. The present study aims to determine the incidence and associated factors of aphasia, cognitive deficits, motor speech disorders (apraxia and dysarthria) as well as dysphagia following acute post stroke in Persian speaking adults. 100 stroke patients were assessed using P-WAB, MMSE, Oral Apraxia test, Informal Dysarthria assessment, and MASA. The data was collected from 2 hospitals in Tehran using convenient sampling for the duration of 1 year. Based on our findings, the incidence of aphasia, cognitive deficits, oral apraxia, dysarthria, and dysphagia was in respectively 61.8%, 76%, 30%, 61%, and 39% of stroke patients during the acute phase. Patients with aphasia were significantly older (mean age, 59.29 vs. 64.95), and had fewer education years (9.21 vs. 5.45) compared to individuals without aphasia (p < .05). Co-occurrence of aphasia and dysarthria, dysphasia, cognitive deficits, and apraxia was in respectively 40%, 31%, 55%, and 25%. Due to the high incidence of neurogenic communication disorders and dysphagia during the acute post stroke, especially in the elderly and the less educated patients, prompt and rapid detection of these deficits and rehabilitation is essential to ameliorate patients' quality of life and social participation, and reduce the comorbidities risk.

Receptor for Advanced Glycation End Product, Organ Crosstalk, and Pathomechanism Targets for Comprehensive Molecular Therapeutics in Diabetic Ischemic Stroke

Diabetes mellitus, a well-established risk factor for stroke, is related to higher mortality and poorer outcomes following the stroke event. Advanced glycation end products(AGEs), their receptors RAGEs, other ligands, and several other processes contribute to the cerebrovascular pathomechanism interaction in the diabetes-ischemic stroke combination. Critical reappraisal of molecular targets and therapeutic agents to mitigate them is required to identify key elements for therapeutic interventions that may improve patient outcomes. This scoping review maps evidence on the key roles of AGEs, RAGEs, other ligands such as Leukotriene B4 (LTB4), High-mobility group box 1 (HMGB1) nuclear protein, brain-kidney-muscle crosstalk, alternate pathomechanisms in neurodegeneration, and cognitive decline related to diabetic ischemic stroke. RAGE, HMGB1, nitric oxide, and polyamine mechanisms are important therapeutic targets, inflicting common consequences of neuroinflammation and oxidative stress. Experimental findings on a number of existing-emerging therapeutic agents and natural compounds against key targets are promising. The lack of large clinical trials with adequate follow-up periods is a gap that requires addressing to validate the emerging therapeutic agents. Five therapeutic components, which include agents to mitigate the AGE-RAGE axis, improved biomarkers for risk stratification, better renal dysfunction management, adjunctive anti-inflammatory-antioxidant therapies, and innovative neuromuscular stimulation for rehabilitation, are identified. A comprehensive therapeutic strategy that features all the identified components is needed for outcome improvement in diabetic stroke patients.

Stroke services in the Middle East and adjacent region: A survey of 34 hospital-based stroke services

Background

Acute stroke care is complex and requires multidisciplinary networking. There are insufficient data on stroke care in the Middle East and adjacent regions in Asia and Africa.

Objective

Evaluate the state of readiness of stroke programs in the Middle East North Africa and surrounding regions (MENA+) to treat acute stroke.

Method

Online questionnaire survey on the evaluation of stroke care across hospitals of MENA+ region between April 2021 and January 2022.

Results

The survey was completed by 34/50 (68%) hospitals. The median population serviced by participating hospitals was 2 million. The median admission of patients with stroke/year was 600 (250–1,100). The median length of stay at the stroke units was 5 days. 34/34 (100%) of these hospitals have 24/7 CT head available. 17/34 (50%) have emergency guidelines for prehospital acute stroke care. Mechanical thrombectomy with/without IVT was available in 24/34 (70.6%). 51% was the median (IQR; 15–75%) of patients treated with IVT within 60 min from arrival. Thirty-five minutes were the median time to reverse warfarin-associated ICH.

Conclusion

This is the first large study on the availability of resources for the management of acute stroke in the MENA+ region. We noted the disparity in stroke care between high-income and low-income countries. Concerted efforts are required to improve stroke care in low-income countries. Accreditation of stroke programs in the region will be helpful.

Post-stroke Anxiety Among Patients in Jordan: A Multihospital Study

This study aimed to assess the prevalence, correlates, and significant associated factors of anxiety among patients with stroke. A cross-sectional, correlation design was utilized. The Hospital Anxiety and Depression scale was used to detect and assess the severity of anxiety and depression among mentally well patients at general hospital settings. Among the 226 patients with stroke, 45.6% had clinically significant levels of anxiety to be considered as a definite case. Having a short duration since the stroke onset, being a definite case of depression, being unable to perform self-care activities, having an insufficient monthly income, and having visual problems due to stroke were the significantly associated factors. The high prevalence of anxiety among patients with stroke highlights the need for interventions of early detection and management to enhance recovery. Patients who have any of the significant traits predicted post-stroke anxiety required special attention.

Analysis of the demographic characteristics and clinical profile of acute ischemic strokes admitted to the emergency centre in the Somalia population

Background

Stroke is a leading cause of death and chronic disability worldwide. In Sub-Saharan Africa (SSA), which includes Somalia, stroke represents a significant part of the chronic disease burden. However, there is relatively little data on risk factors, demographics, and clinical profiles. This study aimed to define the etiological, demographic characteristics, classification of stroke and functional status of patients with acute ischemic stroke (AIS) admitted to the emergency centre, and to create projections to evaluate the incidence and genetic aspects of stroke.

Methods

The study population consisted of patients who applied to the emergency centre between 1 May 2017 and 1 May 2021 and were diagnosed with acute ischemic stroke (AIS). Patient demographics, season of onset, risk factors, laboratory data, imaging results, infarct location, AIS subtype and treatment outcomes were collected, and compared.

Results

A total of 3,968 patients diagnosed with ischemia stroke were included in the study. The mean age was 51.12 ± 16.43 years, and we reported male predominance (65.7%). While hypertension, hyperlipidaemia, Diabetes mellitus (DM) were more frequent among the risk factors, smoking history and alcohol consumption history were very low. HIV-infected ischemic stroke was detected at a high rate (20.9%) and was common in a relatively young age group (31.8 ± 14.3). Large-artery atherosclerosis (LAA) subtype was detected with a high rate of 67.7%. The most common clot localization was in Supratentorial location (74.3%), and according to OSCP classification, partial anterior circulation infarcts (PACI) subtype (56.3%) was the most common. And these results were again different from other studies.

Discussion

While the incidence of stroke and especially HIV-associated youthful ischemic stroke continues to increase rapidly in developing countries such as Somalia, with the addition of inadequate primary health care services, stroke has become a major public health problem in African countries regarding its costs at social, psychological, and economic levels.

Ischemic stroke demographics, clinical features and scales and their correlations: an exploratory study from Jordan

Aims:

The authors aimed to assess the ischemic stroke risk factors and scales.

Materials & methods:

A retrospective cohort study was conducted on patients with acute ischemic stroke (from January 2017 to December 2018). The scores of the National Institutes of Health Stroke Scale (NIHSS) at admission and discharge and of the modified Rankin Scale (mRS) and Barthel Index (BI) scale post-month of the stroke were collected.

Results:

Out of 376 patients, 359 were included, with a mean (standard deviation) age of 67.8 (12.2) years and male predominance (56.2%). Hyperlipidemia and hypertension were the most prevalent comorbidities (91.1% and 80.5%, respectively). The NIHSS, BI and mRS scores were worse among women, with no significant effects for comorbidities. The NIHSS scores at admission and discharge were significantly correlated with the post-month BI and mRS scores.

Conclusion:

The study findings suggest a complex interplay of gender, strict control and prevention of the modifiable stroke risk factors, as well as the association of neurological deficits' intensity with the functional outcomes.

This study aimed to explore the demographics, the clinical risk factors and the scores of the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Barthel Index (BI) scale at different points of time among the survivors of acute ischemic stroke at a tertiary hospital in Jordan. Also, the study aimed to investigate the differences in the scales' scores by the patients' characteristics and the correlations between these scales. Out of 376 screened patients, 359 were included. Their mean (standard deviation) age was 67.8 (12.2) years, and 56.2% were men. Compared with male participants, women scored significantly worse on the NIHSS at admission (7.61 [5.51] vs 9.47 [6.64]; p = 0.048), NIHSS at discharge (5.57 [4.72] vs 7.40 [5.88]; p = 0.028) and BI scale 1 month post-event (78.68 [28.33] vs 66.03 [35.86]; p = 0.011). The mean (standard deviation) mRS score post-month of stroke was lower in men (2.4 [1.7]) than in women (2.9 [1.9]), with a lack of statistical significance (p = 0.097). Thus, despite the male predominance in the cohort, women tended to have a more severe stroke, worse neurological impairment and poorer functional outcomes. Hyperlipidemia had the highest prevalence, sensitivity, positive predictive value and negative predictive value rates, followed by hypertension. No statistically significant differences existed in the comorbidities' NIHSS, BI scale and mRS scores. Strong and significant correlations were observed between the scores of NIHSS at admission and discharge and the BI scale and mRS scores at 1 month post-event. Thus, the authors concluded that neurological deficit severity has a potential role in predicting functioning outcomes and vice versa.

Burden of stroke in North Africa and Middle East, 1990 to 2019: a systematic analysis for the global burden of disease study 2019

BACKGROUND

While several studies investigated the epidemiology and burden of stroke in the North Africa and Middle East region, no study has comprehensively evaluated the age-standardized attributable burden to all stroke subtypes and their risk factors yet.

OBJECTIVE

The aim of the present study is to explore the regional distribution of the burden of stroke, including ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage, and the attributable burden to its risk factors in 2019 among the 21 countries of North Africa and Middle East super-region.

METHODS

The data of the Global Burden of Disease Study (GBD) 2019 on stroke incidence, prevalence, death, disability-adjusted life years (DALYs), years of life lost (YLLs), years lived with disability (YLDs) rates, and attributed deaths, DALYs, YLLs, and YLDs to stroke risk factors were used for the present study.

RESULTS

The age-standardized deaths, DALYs, and YLLs rates were diminished statistically significant by 27.8, 32.0, and 35.1% from 1990 to 2019, respectively. Attributed deaths, DALYs, and YLLs to stroke risk factors, including high systolic blood pressure, high body-mass index, and high fasting plasma glucose shrank statistically significant by 24.9, 25.8, and 28.8%, respectively.

CONCLUSION

While the age-standardized stroke burden has reduced during these 30 years, it is still a concerning issue due to its increased burden in all-age numbers. Well-developed primary prevention, timely diagnosis and management of the stroke and its risk factors might be appreciated for further decreasing the burden of stroke and its risk factors and reaching Sustainable Development Goal 3.4 target for reducing premature mortality from non-communicable diseases.

Health outcomes after acute ischemic stroke:retrospective and survival analysis from Oman

BACKGROUND

Stroke mortality and related functional disability have been declining over the last two decades, but stroke continues to represent the second leading cause of cardiovascular death worldwide and the number one cause for acquired long-term disability.

OBJECTIVES

Assess short- and long-term health outcomes after acute ischemic stroke and analyze factors associated with poor survival and functional outcomes.

DESIGN

Retrospective and survival analysis SETTING: Inpatient unit at a tertiary care referral hospital.

PATIENTS AND METHODS

All patients admitted with acute ischemic stroke from 1 January 2017 to 31 August 2018 were included in the study. Functional status was assessed using the modified Rankin Scale (mRS). Other demographic and clinical variables were obtained from medical records. Data were analyzed by multivariable logistic regression, Cox proportional hazards, and the Kaplan-Meier method. Long-term follow-up data, including mortality and mRS was collected by follow-up phone call.

MAIN OUTCOME MEASURES

Functional dependency and factors associated with mortality.

SAMPLE SIZE AND CHARACTERISTICS

110 with mean age of 67.0 (14.7) years; 59 patients (53.6%) were males.

RESULTS

Hypertension (75.5%), diabetes mellitus (54.6%), and dyslipidemia (29.1%) were common. Sixty-five patients (59.1%) had mRS >2 upon discharge including 18 patients (16.4%) who died during the hospital stay. The cumulative mortality rate was 25.4% (28/110) at 12 months and 30.0% (33/110) at 24 months. Twenty-nine stroke survivors (29/70, 41.4%) remained physically dependent (mRS >2) at the end of follow-up. Old age, atrial fibrillation, history of prior stroke, chronic kidney disease, and peripheral arterial disease were associated with increased mortality and functional dependence.

CONCLUSIONS

Patients in Oman with acute ischemic stroke tend to have a high comorbidity burden, and their functional dependency and mortality are higher compared to patients from developed countries. Therefore, evidence-based measures such as establishing stroke units are essential to improve the health outcomes of patients with acute ischemic stroke.

LIMITATIONS

Retrospective at single center.

CONFLICT OF INTEREST

None.

Fourty years of descriptive epidemiology of stroke

NA.

National and subnational burden of stroke in Iran from 1990 to 2019

BACKGROUND

Data on the burden of stroke and changing trends at national and subnational levels are necessary for policymakers to allocate recourses appropriately. This study presents estimates of the stroke burden from 1990 to 2019 using the results of the Global Burden of Disease (GBD) 2019 study.

METHODS

For the GBD 2019, verbal autopsy and vital registration data were used to estimate stroke mortality. Cause-specific mortality served as the basis for estimating incidence, prevalence, and disability-adjusted life years (DALYs). The burden attributable to stroke risk factors was calculated by a comparative risk assessment. Decomposition analysis was applied to determine the contribution of population aging, population growth, and changes in the age-specific incidence rates.

RESULTS

In 2019, the number of prevalent cases, incident cases, and deaths due to stroke in Iran were 963,512; 102,778; and 40,912, respectively. The age-standardized incidence rate (ASIR) and the age-standardized death rate (ASDR) decreased from 1990 to 2019. Of national stroke ASDRs in 2019, 44.7% (35.7-54.7%) were attributable to hypertension and 28.8% (15.2-57.4) to high fasting plasma glucose. At the subnational level, the trend of the stroke incidence and mortality rate decreased in all provinces. Stroke was responsible for 4.48% of total DALYs in 2019 (3.38% due to ischemic stroke, 0.87% due to intracerebral hemorrhage, and 0.22% due to subarachnoid hemorrhage).

CONCLUSION

ASIR and ASDR of stroke are decreasing nationally and subnationally; however, the number of incident cases and deaths are increasing in all SDI quintiles, possibly due to population growth.

CircFUNDC1 knockdown alleviates oxygen-glucose deprivation-induced human brain microvascular endothelial cell injuries by inhibiting PTEN via miR-375

BACKGROUND

The maintenance of human brain microvascular endothelial cell (HBMEC) function is crucial to improve the outcomes of ischemic stroke (IS). Emerging evidence shows that circular RNAs (circRNAs) are involved in IS progression. This study aimed to investigate the role of circRNA FUN14 domain containing 1 (circFUNDC1) in oxygen-glucose deprivation (OGD)-treated HBMECs.

METHODS

The expression of circFUNDC1, miR-375 and phosphatase and tensin homolog (PTEN) mRNA was detected by quantitative real-time PCR (qPCR). Cell viability, apoptosis, migration and angiogenesis were determined by CCK-8 assay, flow cytometry assay, transwell assay and tube formation assay. The protein level of PTEN was detected by western blot. The relationship between miR-375 and circFUNDC1 or PTEN was confirmed by pull-down assay, dual-luciferase reporter assay and RIP assay. Exosomes were identified by transmission electron microscopy (TEM) and nanoparticle tracking analysis (NTA).

RESULTS

CircFUNDC1 expression was increased in peripheral blood of IS patients and OGD-treated HBMECs. CircFUNDC1 knockdown alleviated OGD-induced cell apoptosis and promoted OGD-blocked cell viability, migration and angiogenesis of HBMECs. MiR-375 was a target of circFUNDC1, and miR-375 restoration played similar effects with circFUNDC1 knockdown. The inhibition of miR-375 reversed the effects of circFUNDC1 knockdown. In addition, PTEN was a downstream target of miR-375, and PTEN overexpression abolished the effects of miR-375 restoration. The expression of circFUNDC1 was elevated in serum-derived exosomes of IS patients, and circFUNDC1 harbored diagnostic values.

CONCLUSION

CircFUNDC1 knockdown alleviates OGD-induced HBMECs injuries by inhibiting PTEN via enriching miR-375.

Evaluation of platelets activity and reactivity as risk factors for acute ischemic non-embolic stroke in young adults

Background

Ischemic stroke (IS) constitutes a relevant health concern recently in younger population causing permanent cognitive and function-limiting disability and ranks as the 3rd cause of death in Egypt after cardiac and hepatic diseases. Platelet activation has a crucial mechanism in arterial thrombogenesis, thus in pathophysiology of IS. Surface expression of P-selectin (CD62P) reflects platelet activation and measured by flowcytometry. The purpose of the study is to evaluate whether platelet activity and reactivity are considered risk factors for IS so more restrict antiplatelet protocols could be implemented for management and recurrence prevention.

Results

Study population was 60 IS patients and 60 apparently healthy age and gender-matched controls. Patients were subdivided into 37 patients without classical risk factors, aged 46.1 ± 8.2, and 23 patients with > 1 vascular risk factors, aged 52 ± 9.9. The percentage of platelets expressing CD62P reflecting ex vivo baseline activity was significantly higher in stroke patients to controls (p = 0.001), also platelet reactivity (CD62P expression after ADP provocation) was statistically significantly elevated in patients than in controls (p < 0.0001) and was significantly higher in IS patients with vascular risk factors compared to patients without risk factors (p = 0.02).

Conclusion

Both baseline platelet activity and reactivity were significantly higher in IS patients, and were also higher in IS patients with other vascular risk factors than in cryptogenic stroke and considered risk factors for IS.

Study of correlations between CT properties of retrieved cerebral thrombi with treatment outcome of stroke patients

Background

All the patients with suspected stroke are directed to whole-brain CT scan. The purpose of this scan is to look for early features of ischemia and to rule out alternative diagnoses than stroke. In case of ischemic stroke, CT diagnostics (including CT angiography) is used mainly to locate the occlusion and its size, while the Hounsfield Units (HU) values of the thrombus causing the stroke are usually overlooked on CT scan or considered not important. The aim of this study was to demonstrate that the HU value is relevant and can help in better treatment planning.

Patients and methods

There were 25 patients included in the study, diagnosed with ischemic stroke in the middle cerebral artery (MCA) territory. In all patients, systemic thrombolysis was not successful and the mechanical recanalization was needed. The retrieved thrombi were also analyzed histologically for the determination of red blood cells (RBC) proportion. CT of the proximal MCA (M1) segment was analyzed for average HU value and its variability both in the occluded section and the symmetrical normal site. These CT parameters were then statistically studied for the possible correlations with different clinical, histological and procedure parameters using the Linear Regression and the Pearson correlation coefficient.

Results

Relevant positive correlations were found between average HU value of thrombus and outcome modified Rankin Scale (mRS), initial mRS, number of passes with thrombectomy device as well as RBC proportion.

Conclusions

Results of the present study suggest that measured HU values in CT images of the cerebral thrombi may help in the assessment of thrombus compaction and therefore better treatment planning.

Secondary Cerebellar Cortex Injury in Albino Male Rats after MCAO: A Histological and Biochemical Study

The present study focused on secondary injury following the middle cerebral artery (MCA) occlusion in rats not linked to the MCA’s feeding zone. This entity has been very rarely studied. Additionally, this study investigated the rates of expression of five fundamental angiogenic biomarkers called endoglin, vascular endothelial growth factors-A (VEGF-A), endothelin-1 (ET-1), 2granulocyte colony-stimulating factor (G-CSF), and angiopoietin-using the MCA occlusion (MCAO) model. The random allocation of twelve adult male albino rats was in two groups. As a sham control group, six rats were used. This group was subjected to a sham operation without MCAO. The MCAO group consisted of six rats that were subjected to MCAO operation. After three days, the rats were sacrificed. The cerebellar specimens were immediately processed for light microscopic examination. An angiogenic biomarkers multiplex assay from multiplex was used to assess endoglin levels, VEGF-A, ET-1, angiopoietin-2, and G-CSF in serum samples. Hematoxylin and eosin-stained sections showed that the cerebellar cortex of rats of the MCAO group was more affected than the sham control group. Furthermore, Nissl stain and immunohistochemical analysis revealed an apparent increase in the number of positive immunoreactive in the cerebellar cortex and an evident decrease in Nissl granules in Purkinje cells of the MCAO rats, in contrast to the control rats. In addition, there was a significant increase in angiogenic factors VEGF-A, ET-1, angiopoietin-2, and endoglin. Interestingly, there was an increase in the G-CSF but a non-significant in the MCAO rats compared to the control rats. Furthermore, there was a significant correlation between the angiopoietin-2 and ET-1, and between G-CSF and ET-1. VEGF-A also exhibited significant positive correlations with the G-CSF serum level parameter, Endoglin, and ET-1. Rats subjected to MCAO are a suitable model to study secondary injury away from MCA’s feeding zone. Additionally, valuable insights into the association and interaction between altered angiogenic factors and acute ischemic stroke induced by MCAO in rats.

Ischemic stroke in Morocco: Prehospital delay and associated factors

OBJECTIVES

This study aimed to estimate prehospital delay and to identify the factors associated with the late arrival of patients with ischemic stroke at the Souss Massa Regional Hospital Center in Morocco.

PATIENTS AND METHODS

An observational, prospective, cross-sectional study was conducted from March 2019 to September 2019 in the Souss Massa regional hospital center, which is a public hospital structure. A questionnaire was administered to patients with ischemic stroke and to bystanders (family or others), while clinical and paraclinical data were collected from medical records. Univariate and multivariate logistic regression analyses were used to identify the factors associated with delayed arrival at emergency department.

RESULTS

A total of 197 patients and 197 bystanders who fulfilled the criteria for the study were included. The median time from symptom onset to hospital arrival was 6hours (IQR, 4-16). Multiple regression analysis showed that illiteracy (OR 38.58; CI_95%: 3.40-437.27), waiting for symptoms to disappear (patient behavior) (OR 11.24; CI_95%: 1.57-80.45), deciding to go directly to the hospital (patient behavior) (OR 0.07; CI_95%: 0.01-0.57), bystander's knowledge that stroke is a disease requiring urgent care within a limited therapeutic window (OR 0.005; CI_95%: 0.00-0.36), and direct admission without reference (OR 0.005; CI_95%: 0.00-0.07), were independently associated with late arrival (>4.5hours) of patients with acute ischemic stroke. In addition, illiteracy (OR 24.62; CI_95%: 4.37-138.69), vertigo and disturbance of balance or coordination (OR 0.14; CI_95%: 0.03-0.73), the relative's knowledge that stroke is a disease requiring urgent care and within a limited therapeutic window (OR 0.03; CI_95%: 0.00-0.22), calling for an ambulance (relative's behavior) (OR 0.16; CI_95%: 0.03-0.80), distance between 50 and 100km (OR 10.16; CI_95%: 1.16-89.33), and direct admission without reference (OR 0.03; CI_95%: 0.00-0.14), were independently associated with late arrival (>6hours) of patients with acute ischemic stroke.

CONCLUSION

Patient behavior, bystander knowledge and direct admission to the competent hospital for stroke care are modifiable factors potentially useful for reducing onset-to-door time, and thereby increasing the implementation rates of acute stroke therapies.

Public Stroke Knowledge, Awareness, and Response to Acute Stroke in Isfahan Iran: What is Less or Misinterpreted in Developing Countries

BACKGROUND

Considering the high burden of stroke in developing countries, it is important for the community to have adequate information and awareness of this disease. In this study, the baseline knowledge of an Iranian population towards stroke has been evaluated.

METHOD

This study was conducted in a governmental hospital in Isfahan, Iran. The participants were selected from the companions of non-cardio-vascular hospitalized patients. A self-administered questionnaire was designed for gathering information RESULTS: A total of 630 questionnaires were analysed. Hypertension and stress were the most frequently identified risk factors (recognised by 83.7% and 75.8% respectively), while pregnancy, oral contraceptives, and anti-coagulants were the least (recognised by 3.5%, 14.2% and 15.8% respectively). Knowledge of other important risk factors such as cardiac diseases was also relatively low (39.4%). Sudden visual difficulties and irrelevant speech were the least identified warning signs of stroke (45.3% and 34.6% respectively), however, knowledge towards all other warning signs was moderately good (each identified by 60-70%). Importantly only 44.2% of respondents were aware that stroke treatment should be started within the first 3 hours. Participants tended to have moderately good insight of most stroke complications and rehabilitation (60-70%). Urban residence, high level of education and knowing someone with a history of stroke were significant predictors of a higher level of stroke awareness.

CONCLUSION

The findings of this study indicate that there is a need to improve general knowledge of cardiac and hypercoagulable related risk factors. Furthermore, understanding of the importance of time critical stroke management and the ineffectiveness of traditional medicine needs to be raised in the general community.

Public Awareness of Ischemic Stroke in Medina city, Kingdom of Saudi Arabia

Objectives:

To assess social awareness of ischemic stroke amongst Saudi citizens in Medina city.

Methods:

In a cross-sectional study conducted between February and September 2019, we used a validated questionnaire to conduct face-to-face interviews and collect data, at 4 shopping malls and 5 supermarkets in Medina city, KSA.

Results:

Five hundred and nineteen participants completed the questionnaire. Of the respondents, 57.4% correctly defined stroke, 42.6% correctly chose ≥2 stroke signs and made ≤one mistake, 23.1% knew of blood clot-dissolving drugs, 32.8% correctly identified ≥ 4 risk factors with ≤ one mistake, 85.93% knew that going to the Emergency Room (ER) was the correct action, and 35.84% identified ≥ 3 post-discharge requirements, with ≤one mistake. Most participants (65.77%) cited internet and social media as information sources. In the univariate comparison, older age (p<0.001) and family history of stroke (p=0.001) better predicted stroke knowledge. In a multivariate logistic regression, the only predictor for stroke recognition was the educational level. The gender and family history were predictors for stroke signs knowledge. Educational level and the family history of stroke were predictors for risk factors knowledge respectively.

Conclusion:

We observed a significant stroke knowledge deficit in our Saudi cohort, thus there is a need to increase public awareness about stroke risk factors, warning signs and emphasizing prevention approaches.

Low frequency transcranial magnetic stimulation in subacute ischemic stroke: Number of sessions that altered cortical excitability

BACKGROUND

Cortical reorganization between both cerebral hemispheres plays an important role in regaining the affected upper extremity motor function post-stroke.

OBJECTIVES

The purpose of the current study was to investigate the recommended number of contra-lesion low frequency repetitive transcranial magnetic stimulation (LF-rTMS) sessions that could enhance cortical reorganization post-stroke.

METHODS

Forty patients with right hemiparetic subacute ischemic stroke with an age range between 50-65 yrs were randomly assigned into two equal groups: control (GA) and study (GB) groups. Both groups were treated with a selected physical therapy program for the upper limb. Sham and real contra-lesion LF-rTMS was conducted for both groups daily for two consecutive weeks. Sequential changes of cortical excitability were calculated by the end of each session.

RESULTS

The significant enhancement in the cortical excitability was observed at the fourth session in favor of the study group (GB). Sequential rate of change in cortical excitability was significant for the first eight sessions. From the ninth session onwards, no difference could be detected between groups.

CONCLUSION

The pattern of recovery after stroke is extensive and not all factors could be controlled. Application of LF-rTMS in conjugation with a selected physical therapy program for the upper limb from four to eight sessions seems to be efficient.

Level of Knowledge on Stroke and Associated Factors: A Cross-Sectional Study at Primary Health Care Centers in Morocco

Background:

Stroke is increasingly becoming a major cause of disability and mortality. However, it can be prevented by raising awareness about risk factors and early health care management of patients.

Objective:

The aim of this study is to assess the level of knowledge on stroke, its risk factors, and warning signs in the population attending urban primary health care centers in the city of Agadir, Morocco.

Methods:

This is a multicentric cross-sectional study with a descriptive and analytical purpose. The study was conducted at five urban primary health care centers in Agadir in centralwest Morocco. All persons over the age of 18 years who consulted the health centers and who agreed to fill in the questionnaire were recruited, except for the foreign population and health workers. An interview questionnaire was used to assess the level of knowledge on stroke.

Findings:

A total of 469 participants were involved in the study. The median knowledge score was 8 (Interquartile range 4–13). High blood pressure (55.7%), depression and stress (48.8%) were the most well-known risk factors. Sudden weakness of the face, arms or legs (37.3%) was the main warning sign cited by the participants. Multivariate analysis revealed that illiteracy (OR 1.92; CI_95%: 1.08–3.44) primary education (OR 3.43; CI_95%: 1.63–7.21), rural residential (OR 1.67; CI_95%: 1.07–2.59), no history of stroke among respondents (OR 16.41; CI_95%: 4.37–61.59) and no history of stroke among relatives, acquaintances, or neighbors (OR 4.42; CI_95%: 2.81–6.96), were independently associated with a lower level of knowledge of stroke (Table 4).

Conclusions:

The low level of knowledge on stroke among this Moroccan population indicates the importance of implementing stroke education initiatives in the community. More specifically, proximity education and awareness programs ought to be considered to anchor lifestyle preventive behaviors along with appropriate and urgent actions regarding the warning signs of stroke.

Incidence of stroke among Saudi population: a systematic review and meta-analysis

BACKGROUND AND AIMS

Stroke is a leading cause of death and disability worldwide. However, our knowledge of the incidence of stroke for Saudi Arabian population is not known. Thus, we aimed to determine the pooled annual incidence of stroke in Saudi Arabia. We conducted a comprehensive literature search of PubMed, Web of Science, and SCOPUS, without language or publication year limits. Outcomes of interest were stroke incidence rate for both first and recurrent. A total of five studies met the inclusion criteria for this review. The pooled annual incidence of stroke in Saudi Arabia was 0.029% (95% CI: 0.015 to 0.047) equivalent of 29 strokes per 100,000 people annually (95% CI: 15 to 47).

CONCLUSION

The findings indicate that there are 29 stroke cases for every 100,000 people annually for individuals residing Saudi Arabia. Our values were lower than those of other high-income countries. Establishing a nationwide stroke registry is warranted for monitoring and improving healthcare services provided to stroke survivors.

Impact of Mild Hypothermia on Final Outcome of Patients with Acute Stroke: A Randomized Clinical Trial

Background and Aim Stroke is a sudden neurological disorder caused by disturbances in the brain blood flow and loss of normal brain function. Stroke is also the second leading cause of death worldwide. In the last two decades, among the various treatment options for stroke, hypothermia has shown the promise of improving the final outcome. This study aimed to investigate the effect of noninvasive hypothermia on the final outcome of patients with an acute stroke in Iran.

Methods In a randomized clinical trial, 60 Iranian patients diagnosed with acute stroke were enrolled in 2018. Patients were selected by convenience sampling method and then randomized in two groups as experimental (n = 30) and control (n = 30). Mild hypothermia was applied using a cooling device for 72 hours on the patients’ heads and intervention results were compared with the control group. Data were collected by using Acute Physiology and Chronic Health Evaluation III (APACHE III), Full Outline of Un-Responsiveness (FOUR), and National Institutes of Health Stroke Scale (NIHSS), and later analyzed by Statistical Package for the Social Sciences (SPSS) software version 22.

Results No significant difference was found in the mean scores of all three scales before and after the intervention in control group (p > 0.05) but statistically significant difference was found in the mean scores of all three scales for the intervention group (p < 0.05). The intervention group had an increased mean score in FOUR, while APACHE and NIHSS values dropped. Researchers found statistically significant difference between the mean scores after the intervention in the experimental group compared with the control group in all three scales (p < 0.05).

Conclusion The findings of this study indicate that hypothermia has a significant statistical and clinical effect on the acute stroke outcome and it can be argued that hypothermia therapy can increase the level of consciousness and reduce the risk of death in stroke patients.

Can Emergency Medical Services (EMS) Shorten the Time to Stroke Team Activation, Computed Tomography (CT), and the Time to Receiving Antithrombotic Therapy? A Prospective Cohort Study

INTRODUCTION

Stroke is a major emergency that can cause a significant morbidity and mortality. Advancement in stroke management in recent years has allowed more patients to be diagnosed and treated by stroke teams; however, stroke is a time-sensitive emergency that requires a high level of coordination, particularly within the prehospital phase. This research is to determine whether patients received by Emergency Medical Services (EMS) at a tertiary health care facility had shorter stroke team activation, time to computed tomography (CT), or time to receive intravenous thrombolytics.

METHODS

This research is a prospective cohort study of adults with stroke symptoms who required stroke team activation at a tertiary medical facility. The study included all patients received from September 1, 2017 through August 31, 2018. The primary outcome was the time difference to stroke team activation between patients received by EMS compared to patients that arrived by a private method of transportation. The secondary outcomes were the difference in time to CT scan and the time to receive intravenous recombinant tissue plasminogen activator (rtPA).

RESULTS

There were 75 (34.1%) patients who had been received by EMS, while 145 (65.9%) patients arrived via private transportation method (private car or by a friend/family member). The mean time to stroke team activation, time to CT, and time to receive thrombolytic therapy for the EMS group were: 8.19 (95% CI, 6.97 - 9.41) minutes; 18 (95% CI, 15.9 - 20.1) minutes; and 13.1 (95% CI, 6.95 - 19.3) minutes, respectively. Those for the private car group, on the other hand, were: 16 (95% CI, 12.4 - 19.6) minutes; 23.39 (95% CI, 19.6 - 27.2) minutes; and nine (95% CI, 4.54 -13.5) minutes, respectively. There was a significantly shorter time to stroke team activation for patients arriving via EMS compared to private car (P ≤ .00), but no significant difference was found on time to CT (P = .259) or time to receive rtPA (P = .100).

CONCLUSION

Emergency Medical Service transportation of stroke patients can significantly shorten the time to stroke team activation, leading to shorter triage and accelerated patient management. However, there was no statistical difference in time to CT or time to receive rtPA. Patients with stroke symptoms may benefit more from EMS transportation compared to private methods of transportation.

Saudi neurology residents' knowledge and attitudes toward intravenous thrombolysis in patients with acute ischemic stroke

Background

Although intravenous (IV) thrombolysis is an effective treatment for patients with acute ischemic stroke (AIS), it remains underused by neurologists worldwide. This study assessed the knowledge and attitudes toward IV thrombolysis in patients with AIS among neurology residents in Saudi Arabia.

Materials and Methods

An online survey was conducted using a sample of 81 neurology residents in and around Saudi Arabia. Statistical analysis included descriptive studies and Chi-square or Fisher's exact test.

Results

Of the 81 respondents, 50 (61.7%) were males and 31 (38.3%) females. Regarding IV thrombolysis use in AIS patients; 61.7% thought that they would consider it, a vast majority about 72.8% showed positive attitudes toward performing IV thrombolysis for AIS patients, 69.1% thought that IV thrombolysis is safe, 79.0% did not think that they have good knowledge about IV thrombolysis, and 53.1% felt not confident about their ability to employ IV thrombolysis. Confidence with knowledge was associated with the residency stage (P = 0.000). Attitudes toward IV thrombolysis was found associated with sex (P = 0.044) and residency stage (P = 0.002). Residents from the central region were more likely to have positive attitudes (P = 0.043).

Conclusion

The surveyed neurology residents showed a positive attitude towards the safety and use of IV thrombolysis for AIS patients. However, knowledge and confidence along with knowledge about the treatment are lacking. Therefore, theoretical and practical training is warranted to improve knowledge about IV thrombolysis.

Ischemic stroke in Morocco: a systematic review

Background

The aim of this systematic review is to determine the epidemiological and etiological profiles, the influential factors of the prehospital delay, thrombolysis management, the acute and 3-month mortality rate and the genetic aspect of ischemic stroke in Morocco.

Methods

The present work is a systematic review that was conducted according to the recommendations of the “Preferred reporting items for systematic reviews and meta-analysis”. We used Pubmed, Sciencedirect, Scopus, Clinicalkey, and Google scholar databases for the raking of the gray literature during the time frame 2009 and 2018. The protocol of the review was registered in the PROSPERO register (CRD42018115206).

These studies were analyzed based on: Age, sex ratio, risk factors, etiological profile according to Trial of ORG classification 10,172 in Acute Stroke Treatment, prehospital delay average and its influential factors, thrombolyzed patients’ proportion, acute and 3-month mortality and the genetic factors of ischemic stroke in Morocco.

Results

Twenty-nine (n = 29) studies were selected. The average age ranged from 49 ± 15.2 to 67.3 ± 9.9 years old. Moreover, we reported male predominance within all ages in 13 studies. High blood pressure, diabetes, smoking and heart disease were the four identified main risk factors by the prementioned studies. Atherosclerosis and cardioembolic were the main described etiologies of cerebral ischemia, and the average prehospital time ranged from 26 to 61.9 h. The proportion of thrombolysed patients ranged from 1.8% to 2.9%, the mortality rate varied in the acute phase from 3 to 13%, and the 3-month mortality ranged from 4.3 to 32.5%. It is also important to highlight that most of these studies, which were conducted in hospital environment, have a reduced sample size and no confidence interval.

Conclusions

Ischemic stroke is affecting more likely the young population with male predominance. Moreover, the long prehospital delay and the low proportion of thrombolysed patients are alarming. This indicates the need to investigate in depth the key factors influencing the access to care for Moroccan patients in order to improve the management of this neurologic deficit in Morocco.

Presentation, Management, and Outcomes of Acute Stroke in Palestine

Background Stroke is a leading cause of death and disability in the Middle East. Data on the uptake of evidence-based practices are limited in the region. We aimed to examine patterns of stroke presentation, management, and outcomes at public Palestinian hospitals. Methods and Results Comprehensive data from all patients with acute stroke admitted to 2 public hospitals in the West Bank of Palestine were prospectively collected. Acute stroke presentation patterns, in-hospital evaluation and management, mortality, and stroke complications were evaluated. Data were available for 150 patients with acute stroke between September 2017 and May 2018. The mean ( SD ) age was 65 (14) years and 49% were women. Only 25% of patients utilized ambulance services for transportation to the hospital. All patient received head computed tomography scans, although few received other investigations such as magnetic resonance imaging (8%) or carotid Doppler (4%). Most patients with ischemic stroke received antiplatelet therapy (98%), although none received thrombolysis. Only 17% received physical therapy evaluation. In-hospital mortality was 12%, 23% of patients had at least 1 poststroke complication, and the median modified Rankin Score at discharge was 4 (interquartile range, 2-5). Conclusions We identified high stroke mortality and discharge disability rates in Palestine. Key evidence-based gaps were highlighted, suggesting opportunities for quality improvement.

Risk factors and types of recurrent stroke: a Saudi hospital based study

[Purpose] To identify the risk factors and the stroke types in recurrent stroke patients of Madinah Al-Munawarah city. [Participants and Methods] A prospective research hospital based study was conducted through the year of 2014. The patients were entered in the study when they had recurrent cerebrovascular accident led to hospital admission. All details of patients were obtained include history, demographic data, risk factors and stroke types. [Results] Ninety-four (83.9%) ischaemic strokes, 12 (10.7%) intercerebral hemorrhage strokes and 6 (5.4%) undefined out of 112 patients had recurrent stroke found in this study. Hypertension was the most prevalent risk factors (90.2%) followed by diabetes mellitus (62.5%) and ischaemic heart disease (51.8%). [Conclusion] Hypertension, diabetes, and ischaemic heart disease in particular were exhibited to be crucial risk factors for stroke recurrence in this study. Future studies are needed for secondary prevention planning.

Stroke in the Middle-East and North Africa: A 2-year prospective observational study of intravenous thrombolysis treatment in the region. Results from the SITS-MENA Registry

BACKGROUND AND METHODS

Intravenous thrombolysis for acute ischemic stroke in the Middle-East and North African (MENA) countries is still confined to the main urban and university hospitals. This was a prospective observational study to examine outcomes of intravenous thrombolysis-treated stroke patients in the MENA region compared to the non-MENA stroke cohort in the SITS International Registry.

RESULTS

Of 32,160 patients with ischemic stroke registered using the SITS intravenous thrombolysis protocol between June 2014 and May 2016, 500 (1.6%) were recruited in MENA. Compared to non-MENA (all p < 0.001), median age in MENA was 55 versus 73 years, NIH Stroke Scale score 12 versus 9, onset-to-treatment time 138 versus 155 min and door-to-needle time 54 min versus 64 min. Hypertension was the most reported risk factor, but lower in MENA (51.7 vs. 69.7%). Diabetes was more frequent in MENA (28.5 vs. 20.8%) as well as smoking (20.8 vs. 15.9%). Hyperlipidemia was less observed in MENA (17.6 vs. 29.3%). Functional independence (mRS 0-2) at seven days or discharge was similar (53% vs. 52% in non-MENA), with mortality slightly lower in MENA (2.3% vs. 4.8%). SICH rates by SITS-MOST definition were low (<1.4%) in both groups.

CONCLUSIONS

Intravenous thrombolysis patients in MENA were younger, had more severe strokes and more often diabetes. Although stroke severity was higher in MENA, short-term functional independency and mortality were not worse compared to non-MENA, which could partly be explained by younger age and shorter OTT in MENA. Decreasing the burden of stroke in this young population should be prioritized.

Concurrent Effects of Dry Needling and Electrical Stimulation in the Management of Upper Extremity Hemiparesis

Stroke is one of the leading causes of disability in western countries. A variety of rehabilitation programs for the treatment of patients after stroke have been proposed. We describe the outcomes of a 49-year-old female patient with a 5-year history of right upper extremity hemiparesis after stroke. Physical examination revealed a right wrist extensor strength grade of 1 according to the Medical Research Council Manual Muscle Testing scale, Stage 4 according to the Brunnstrom hand functional recovery, and Grade 1 in finger flexor and in wrist flexor according to the Modified Modified Ashworth Scale system of muscle spasticity. Magnetic resonance imaging taken immediately after the stroke was indicative of an abnormal signal in the left paraventricular and lentiform nucleus. After receiving a single session of dry needling and electrical stimulation, the patient had significant improvement including a strength grade of 3 for the right wrist extensor muscles, Stage 6 according to the Brunnstrom hand functional recovery, and Grade 0 in finger flexor and in wrist flexor according to the Modified Modified Ashworth Scale system of muscle spasticity. This case report found that dry needling combined with electrical stimulation may be effective in hand function recovery, wrist extensor muscles strength, and decreased wrist and finger spasticity.

Stroke in the Middle-East and North Africa: A 2-year prospective observational study of stroke characteristics in the region-Results from the Safe Implementation of Treatments in Stroke (SITS)-Middle-East and North African (MENA)

BACKGROUND AND METHODS

Stroke incidence and mortality are reported to have increased in the Middle-East and North African (MENA) countries during the last decade. This was a prospective observational study to examine the baseline characteristics of stroke patients in the MENA region and to compare the MENA vs. the non-MENA stroke cohort in the Safe Implementation of Treatments in Stroke (SITS) International Registry.

RESULTS

Of the 13,822 patients with ischemic and hemorrhagic stroke enrolled in the SITS-All Patients Protocol between June 2014 and May 2016, 5897 patients (43%) were recruited in MENA. The median onset-to-door time was 5 h (IQR: 2:20-13:00), National Institutes of Health Stroke Scale (NIHSS) score was 8 (4-13) and age was 65 years (56-76). Hypertension (66%) and diabetes (38%) were the prevailing risk factors; large artery stenosis > 50% (25.3%) and lacunar strokes (24.1%) were the most common ischemic stroke etiologies. In comparison, non-MENA countries displayed an onset-to-door time of 5:50 h (2:00-18:45), a median of NIHSS 6 (3-14), and a median age of 66 (56-76), with other large vessel disease and cardiac embolism as the main ischemic stroke etiologies. Hemorrhagic strokes (10%) were less common compared to non-MENA countries (13.9%). In MENA, only a low proportion of patients (21%) was admitted to stroke units.

CONCLUSIONS

MENA patients are slightly younger, have a higher prevalence of diabetes and slightly more severe ischemic strokes, commonly of atherosclerotic or microvascular etiology. Admission into stroke units and long-term follow-up need to be improved. It is suspected that cardiac embolism and atrial fibrillation are currently underdiagnosed in MENA countries.

Current status of stroke in Qatar: Including data from the BRAINS study

BACKGROUND

Qatar is located on the north-eastern coast of the Arabian Peninsula. Qatari natives account for less than 15% of the population while the largest migrant group comprising 60% derives from South Asia. Despite projections that stroke burden in Qatar will increase with population ageing, epidemiological studies focusing on stroke in Qatar are relatively scarce.

METHOD

We reviewed the available epidemiological publications relating to Qatar. In addition, we have added to this knowledge by incorporating Qatari data from the on-going Bio-Repository of DNA in Stroke, an independent multinational database of stroke patients.

RESULTS

Qatar has low reported incidence and mortality rates of 58 and 9.17 per 100,000 per year, respectively, which may be explained by its middle-aged migrant worker majority population. Correspondingly, South Asian migrants in Qatar suffered younger strokes than Qatari natives (48.7 vs 63.4 years, P < 0.001). Among the most common risk factors identified in stroke patients were hypertension (77.9%), diabetes (43.8%) and hypercholesterolemia (28.5%). Ischaemic stroke was the most frequent subtype amongst migrant South Asians (71.1%). The majority of stroke cases had computed tomography and/or magnetic resonance imaging scans, but only 11.1% of ischaemic strokes were thrombolysed. Qataris on one-year follow up were more often found to have died (6.5% vs 0.3%) and had further stroke/transient ischaemic attack events (17.4% vs 6.4%, P = 0.009) compared to South Asians.

CONCLUSION

The burden of stroke is increasing in Qatar, and considerable disparities are observed between the native and migrant populations which likely will require different approaches to management by its healthcare system.

Stroke Outcome and Determinants among Patients with and without Diabetes in a Tertiary Hospital in Ghana

BACKGROUND

Diabetes mellitus, a well-established independent risk factor for stroke, has varied association with stroke outcome from previous studies. This study investigated stroke outcome and determinants among patients with and without diabetes in a tertiary hospital in Ghana.

METHODS

A prospective study conducted among stroke patients with and without diabetes admitted in a Ghanaian tertiary hospital. Baseline clinical and biochemical data were documented. Functional stroke outcome was evaluated at 1, 3, and 6 months after stroke using the modified Rankin Scale.

RESULTS

Number of participants enrolled were 326 and 105 (32.20%) had diabetes. Higher proportions of diabetes patients had poor functional stroke outcome at 1, 3, and 6 months (79%, 75.23%, 73.33%) compared with those without diabetes (70.13%, 65.16, 61.99) (p>0.05). Stroke patients with diabetes had lower survival compared with those without diabetes (p=0.0745). Mortality at 6 months was more likely among ischaemic stroke patients with diabetes compared with those without diabetes (Odds Ratio 2.037; CI: 1.058-3.923). Determinants of poor functional stroke outcome for diabetes patients were older age (Adjusted Odds Ratio (AOR)-1.07; CI-1.03-1.12), female gender (AOR-3.74; CI-1.26-12.65), and pneumonia (AOR-11.32; CI-1.93-220.05) whereas the determinants for those without diabetes were unemployment (AOR-4.19; CI-1.24-19.50), speech abnormalities (AOR-1.99; CI1.08-3.73), and pneumonia (AOR-4.05; CI-1.83-9.77). High fasting plasma glucose (HR-1.15; CI-1.07-1.23), elevated temperature (HR-1.41; CI-1.11-1.79), and pneumonia (HR-2.25; CI-1.44-3.50) were determinants of low survival among all stroke patients.

CONCLUSION

Trends towards poorer functional outcome and reduced survival were found among Ghanaian stroke patients with diabetes compared with those without diabetes. Older age, female gender, pneumonia, elevated temperature, and fasting plasma glucose were determinants of adverse outcome in stroke patients with diabetes.

Care and Discharge Outcome of Acute Stroke in Lebanon: A Hospital-Based Study

The present study was conducted to assess stroke care and outcomes in two Lebanese hospitals. Patients admitted in 2012 and 2013 were retrospectively selected. Data were extracted from medical records for time to hospital arrival, stroke severity, management, and discharge outcomes. A Cox regression analysis was then conducted to predict time to in-hospital death. A total of 201 patients were included (mean age = 69.2 years), among whom 50% arrived within a delay of 3.75 hours. Half underwent brain imaging in the first hour, and nine patients received an acute intervention. Forty-four patients died at the hospital; 142 were discharged home, among whom 98 patients were dependent in their daily activities. Stroke severity on admission and time from onset to arrival were found to be significantly associated to the time to in-hospital death (adjusted hazard ratio [HRa] = 1.13 and HRa = 0.98 respectively; p < 0.05). The study sheds light on high case fatality and dependency rates at discharge among stroke patients in Lebanese hospitals.

Risk factors of acute ischemic stroke in patients presented to Beni-Suef University Hospital: prevalence and relation to stroke severity at presentation

BACKGROUND

Acute ischemic stroke is one of the major causes of disability and death worldwide. Effective prevention remains the best approach for reducing the burden of stroke. The aim of this work was to study the prevalence of stroke risk factors and the possible relation between such risk factors and the disease severity at presentation in a sample of stroke patients presented to Beni-Suef University Hospital, north Upper Egypt.

METHODS

A sample of 167 patients of acute ischemic stroke recruited from Beni-Suef University Hospital was included in this cross-sectional descriptive study. All subjects were subjected to history taking, clinical, laboratory, and radiological evaluation. Stroke severity and disability were evaluated by National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) respectively.

RESULTS

Hypertension was detected in 104 patients (62.3%), dyslipidemia was detected in 79 patients (58.1%), and 69 patients (41.3%) were smokers. Diabetes mellitus was detected in 58 patients (34.7%) with high prevalence of cardio-embolic risk factor, 36 patients (21.6%) had rheumatic heart, and 44 patients (26.3%) had atrial fibrillation.NIHSS score was significantly higher in hypertensive patients (P value = 0.023) and in patients who had carotid stenosis ≥ 50% (P value = 0.011), whereas there was no significant relation between NIHSS score and diabetes mellitus (P = 0.221), dyslipidemia (P = 0.834), patients with history of cardio-embolic stroke (P = 0.085), previous ischemic stroke (P = 0.316), or sex (P = 0.343).mRS score was significantly higher in patients with age > 45 years old (P < 0.001), hypertension (P < 0.001), cardio-embolic risk factor (P = 0.044), and carotid stenosis ≥ 50% (P = 0.017), whereas there was no significant relation between mRS score and diabetes mellitus, previous ischemic stroke, or sex.

CONCLUSIONS

The most common risk factor for stroke was hypertension followed by dyslipidemia and then smoking with higher incidence of rheumatic heart diseases due to lowered living conditions. Age, hypertension, cardio-embolic risk factors, and carotid stenosis ≥ 50% have negative impact on stroke severity and disability.

Stroke epidemiology in Karabük city Turkey: Community based study

Introduction

Stroke has been projected to increase in developing countries like Turkey. Information about the prevalence of stroke may uncover the etiology of stroke and overcome its impact burden. However, data is limited due to a lack of studies based in Turkey and neighboring regions. We aimed to investigate the prevalence and risk factors of stroke in the Turkish city of Karabük and to pave the way for future epidemiological studies in Turkey.

Methods

The study was designed as a cross-sectional, door-to-door survey. The questionnaire was completed by a trained team in the presence of the participants according to their answers. Patients who had been diagnosed with stroke prior to the survey were re-examined by a neurologist.

Results

3131 persons who were above 44 years old were screened. 129 of them were found to have had a stroke previously. The prevalence rate of stroke above 44 years was found to be 4.12% (98% confidence level and ± 2% margin of error). 72.1% of stroke patients had hypertension. Male/female ratio was 0.72.

Conclusion

This study showed a high prevalence rate of stroke in Karabük Turkey with a low male/female ratio when compared to other studies.

Exploring risk patterns for incident ischemic stroke during more than a decade of follow-up: A survival tree analysis

BACKGROUND AND PURPOSE

The burden of stroke is increasing in low to middle income countries. Identifying risk patterns for ischemic stroke (IS) can help develop individualized preventive measures for at risk populations.

METHODS

The study population included 3088 Iranian subjects (1426 men) aged ≥50 years, free of cardiovascular diseases at baseline. The risk factors for ischemic stroke were identified by multivariate Cox analysis. A survival tree model was used to explore interactions between risk factors.

RESULTS

During 12years of follow-up, 106 cases of IS occurred. Age (hazard ratio (HR): 1.08), male gender (HR: 1.69), diastolic blood pressure (DBP) (HR: 1.04), fasting plasma glucose (HR: 1.10), waist circumference (WC) (HR: 1.03) and smoking (HR: 1.96), were associated with increased risk and estimated glomerular filtration rate (eGFR) (HR: 0.97) and wrist circumference (HR: 0.68) decreased the risk of IS (all P-values <0.05). The survival tree identified six risk patterns. The highest and lowest risks were related to subjects ≥60.5years with DBP ≥100mmHg and subjects <60.5years with DBP<97mmHg, respectively. In subjects ≥60.5years with DBP <100mmHg, risk of ischemic stroke was determined by WC ≥96.5cm or (eGFR) <60.87ml/min/1.73m².

CONCLUSION

By applying survival tree as a complementary method to the conventional Cox-analysis, for the first time, we identified risk patterns of ischemic stroke and explored the interactions between risk factors of the disease. DBP was the most important predictor of ischemic stroke in middle-aged and old subjects. In elderly subjects with DBP <100mmHg, abdominal obesity was associated with high risk; however, among non-obese subjects, kidney dysfunction increased the risk of ischemic stroke. Wrist circumference was reported as a novel predictor.

Risk factors and subtypes of acute ischemic stroke. A study at King Fahd Hospital of the University

Objective:

To identify the different subtypes of acute ischemic stroke, and estimate the frequency of various risk factors among these patients.

Methods:

In this retrospective, cross-sectional study, we reviewed the medical records of patients admitted with the diagnosis of acute ischemic stroke at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia from March 2008 till December 2015. The demographic characteristics, subtypes of stroke, risk factors (hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, atrial fibrillation, valvular heart disease) and other relevant data were documented on pre-defined data sheets.

Results:

The records of 343 patients were included in the study; 64.4% were male and 35.6% were female. The mean age was 59.3+13.6 (mean+SD) years for males, and 66.8+14.9 years for females. Small vessel occlusion was the most common etiologic subtype of ischemic stroke (32.1%), followed by cardio embolic (21.9%), and large artery atherosclerosis (14.6%). The middle cerebral artery was the most commonly affected territory. Hypertension was found in 78.1%, diabetes mellitus in 62.7%, hyperlipidemia in 54.8%, and ischemic heart disease in 24.2% of patients.

Conclusion:

Small vessel occlusion was the most common etiology in our cohort. The onset of stroke at a relatively younger age group in the male population is of great concern and needs to be verified by further epidemiological studies. Adequate control of modifiable risk factors may help in reducing the disease burden caused by stroke.

Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Stroke: South Asian Experience

BACKGROUND

The randomized trials showed improved outcome and reduced mortality in malignant middle cerebral artery (MMCA) undergoing Decompressive hemicraniectomy (DHC) within 48 hours of stroke onset. Despite high prevalence of stroke, especially in younger individuals, high and short-term mortality from stroke in South Asian and Middle East, there is little published data on DHC in patients with MMCA stroke.

METHODS

This is a retrospective, multicenter cross-sectional study to measure outcome following DHC using the modified Rankin Scale (mRS) and dichotomized as favorable (mRS ≤ 4) or unfavorable (mRS > 4), at 3 months.

RESULTS

In total, 137 patients underwent DHC. At 90 days, mortality was 16.8%; 61.3% of patients survived with an mRS of 4 or less and 38.7% had an mRS greater than 4. Age (55 years), diabetes (P = .004), hypertension (P = .021), pupillary abnormality (P = .048), uncal herniation (P = .007), temporal lobe involvement (P = .016), additional infarction (MCA + anterior cerebral artery, posterior cerebral artery) (P = .001), and infarction growth rates (P = .025) were significantly higher in patients with unfavorable prognosis in univariate analysis. Multivariate analysis showed age, additional infarction, septum pellucidum deviation greater than 1 cm, and uncal herniation to be associated with a significantly poor prognosis. Time to surgery had no impact on outcome (P = .109).

CONCLUSIONS

Similar to the results of the studies from the West, DHC Improves functional outcome in predominantly South Asian patients with MMCA Stroke.

Management of post-stroke depression in the Middle East and North Africa: Too little is known

Stroke is among the most common disabilities among adults and most stroke victims live in developing countries. However, little is known about services delivered in these countries for post-stroke depression, a common comorbidity that influences functional outcomes of stroke. In this paper, a physician from Syria reviews the literature on post-stroke depression among patients living in countries of the Middle East and North Africa region in order to examine whether current practices can be improved. Studies of prevalence were found in six of the region's countries and only four studies described interventions for stroke patients with clinical depression. The limited studies on prevalence confirmed that stroke incidence and post-stroke depression are common although diagnosed depression appears to vary depending on the economic environment of the country. Hence, additional interventions in MENA countries may be warranted to increase recognition of depression in stroke patients and to ensure health professionals are prepared to deliver appropriate services to stroke patients and their family-caregivers for depression when it occurs.

Specificities of Ischemic Stroke Risk Factors in Arab-Speaking Countries

BACKGROUND

Stroke is largely preventable, and therefore, a better understanding of risk factors is an essential step in reducing the population stroke rate and resulting disease burden in Arab countries.

SUMMARY

We performed 2 separate analyses in 2 similar populations of patients with noncardioembolic ischemic stroke. This first involved 3,635 patients in the Outcomes in Patients with TIA and Cerebrovascular disease (OPTIC) registry (followed for 2 years), with baseline collection of the usual risk factors and 5 socioeconomic variables (unemployment status, residence in rural area, living in fully serviced accommodation, no health-insurance coverage, and low educational level). The second involved patients in the PERFORM trial (n = 19,100 followed up for 2 years), with baseline collection of the usual risk factors and 1 socioeconomic variable (low educational level). The primary outcome was a composite of nonfatal stroke, nonfatal myocardial infarction, or cardiovascular death. Stroke risk factors were more prevalent in patients in Arab countries. The incidence of major cardiovascular events (MACE; age- and gender-adjusted) was higher in Arab countries (OPTIC, 18.5 vs. 13.3%; PERFORM, 18.4 vs. 9.7%; both p ≤ 0.0001). These results remained significant after adjustment on risk factors and were attenuated in OPTIC after further adjustment on socioeconomic variables (hazard ratio 1.24; 95% CI 0.98-1.55; p = 0.07). Key Messages: Patients with ischemic stroke living in Arab countries had a lower mean socioeconomic status, a much higher prevalence of diabetes mellitus, and a higher rate of MACE compared with patients from non-Arab countries. This finding is partly explained by a higher prevalence of risk factors and also by a high prevalence of poverty and low educational level.

Incidence of First Time Stroke: A Saudi Experience

BACKGROUND

Stroke is one of the major causes of morbidity and mortality throughout the world. A number of studies were conducted in Saudi Arabia. However, there were no studies conducted in Al-Madinah Al-Munawarah city.

OBJECTIVE

The aim of this study was to ascertain the incidence rate of first time stroke and the age-specific incidence in both genders in Al-Madinah Al-Munawarah city.

METHODS

A prospective hospital based study was conducted over a 1-year period (2014). The cases were included in the study when they were admitted with a diagnosis of cerebrovascular accident.

RESULTS

A total 164 patients (91 men and 73 women) who had first time stroke were found in this study with no significant difference between them (p = 0.565). The crude incidence rate of stroke was 13.89 per 100,000 persons. The age-specific incidence rate increased with age in the current study, where the peak was in the age group of more than 75 years old for men and women.

CONCLUSIONS

Total crude and the age-specific rates for first time stroke patients revealed in this study were markedly lower than the range reported from the developed countries. However, they were within the range that showed previously in Saudi Arabia and Arabian Peninsula countries.