Sex influence in ischemic stroke severity and outcome among metabolically unhealthy overweight patients

Hemodynamic Characteristics of Intracranial Atherosclerotic Stenosis: A Pilot Study of Contrast Enhancement Time-Density Curves Based on Regions of Interest

OBJECTIVE

The present study aimed to analyze the hemodynamic characteristics of occluded vessels responsible for acute ischemic stroke and to diagnose the occlusion types.

METHODS

Multimodal computed tomography (CT) was used to accurately identify the range of occlusion of large intracranial vessels. Regions of interest (ROI 1-3 ) were manually delineated at sites 2 mm away from the proximal, middle, and distal portions of each occlusion, generating 3 contrast enhancement time-density curves. The peak CT attenuation values, or Hounsfield units (H 1-3 ), and time-to-peak values (T 1-3 ) were extracted from each curve. H 0 and T 0 of the time-density curve, based on ROI 0 of the automatically recognized input artery, were used as the baseline values with which the odds ratios of each parameter, H 1-3/0 and T 1-3/0 , were obtained. The present study aimed to establish prediction models for intracranial atherosclerotic stenosis (ICAS) based on each ROI's time-density curve.

RESULTS

Among the 33 acutely occluded intracranial vessels, 10 were found to have ICAS, whereas 23 did not, based on the diagnostic criteria. Significant differences were observed in patient sex, neutrophil-to-lymphocyte ratio upon admission, Alberta Stroke Program Early CT Score 24-48 hours after reperfusion therapy, and H 1/0 , H 3/0 , and T 3/0 between the ICAS and non-ICAS groups ( P < 0.05). The prediction model (model 3) based on the ROI 3 time-density curve showed the best performance for the diagnosis of ICAS (area under the curve, 0.944; 95% confidence interval, 0.854-1.000). The prediction models based on ROI 1 (model 1) and ROI 2 (model 2) showed moderate diagnostic performance (area under the curve, 0.817 vs 0.822, respectively). The best visualization for proximal occlusions was in the first phase (arterial phase) of multiphase CT angiography, and in the second phase (early venous phase) for distal occlusions.

CONCLUSIONS

The contrast enhancement time-density curves of the ROIs at all evaluated portions of the acute ischemic stroke occlusions provided a visual display of the blood flow characteristics of the responsible vessels. The time-density curve of the ROI placed 2 mm from the distal occlusion was a combined effect of residual blood flow and collateral establishment, thus providing good performance for the diagnosis of ICAS.

Sex-dependent outcomes of recanalization-treated acute ischemic stroke patients at Shamir (Assaf Harofeh) medical center, Israel, 2011-2020

BACKGROUND/OBJECTIVES

Sex-based differences in incidence, etiologies, severity and recanalization treatment outcomes of patients with acute ischemic stroke (AIS) have been studied extensively. We set out to determine if there were sex-based differences in outcomes among AIS patients who received recanalization treatments at Shamir (Assaf Harofeh) Medical Center (SMC), Israel, between 2011 and 2020.

METHODS

This was a single-center, retrospective chart review. The primary analysis compared outcomes for men and women, overall and stratifying by disease severity. We compared also demographics, risk factors and workflow data.

RESULTS

Eight hundred and eleven patients received recanalization treatment between 2011 and 2020: 472 (58.1%) men and 339 (41.8%) women. Mean age, NIHSS score and proportion with an NIHSS score ≥ 6 were higher for women. Cerebrovascular risk factors were more prevalent in women, particularly atrial fibrillation, except that current smoking was more prevalent in men. Six hundred and twenty patients (78.1%) were treated with TPA alone, 89 (11.2%) with TPA and endovascular treatment (EVT), and 85 (10.7%) with EVT alone. Fifty percent of patients were discharged home, 41% to a rehabilitation hospital or nursing home, and 9% did not survive. Twenty-four patients (3%) sustained symptomatic bleeds. Outcomes were worse in patients with NIHSS score ≥ 6. Outcomes did not differ by sex.

CONCLUSIONS

While treated women presented with more severe AIS and more risk factors, we did not find significant sex-related differences in outcomes. Meticulous adherence to risk factor modification remains the best strategy to reduce stroke incidence, morbidity, and mortality in women and in men.

Stroke in women between 2006 and 2018: Demographic, socioeconomic, and age disparities

BACKGROUND

Black Americans have a higher prevalence of stroke and stroke-related deaths than any other racial group. Racial disparities in stroke outcomes are even wider among women than men. Conventional studies have cited differences in lifestyle (i.e. smoking, alcohol consumption, etc.) and vascular risk factors between races as the source of these disparities. However, these studies fail to account for the higher prevalence of minoritized populations at the lower end of the socioeconomic distribution.

OBJECTIVES

This study explores differences in stroke risk factors across age and socioeconomic cohorts to determine whether comorbidities can sufficiently explain disparities at all ages and income levels.

DESIGN

Using the 2006-2018 National Health Interview Survey data, statistical analysis evaluated differences in risk factors among a full sample cohort (aged 18-85 years; n = 131,091) and a "young" subsample cohort (aged 18-59 years; n = 6183) of women.

METHODS

Logistics and unconditional quantile regression models assessed the relationship between stroke and comorbid, demographic, and behavioral characteristics across socioeconomic classes.

RESULTS

Results suggest that Black women had a 1.415-fold (confidence interval = 1.259, 1.591) higher likelihood of stroke compared with White women after controlling for age, behavior, and comorbidities. Racial disparities were not statistically significant at the higher income ranges for either the full (odds ratio = 1.404, p = 0.3114) or young samples (odds ratio = 1.576, p = 0.7718). However, Blacks had significantly higher odds of stroke in the lower quartiles (lower odds ratio: 1.329, p = 0.0242; lower middle odds ratio: 1.233, p = 0.0486; and upper middle odds ratio: 1.994, p = 0.0005). Disparities were larger among young women (odds ratio = 1.449, confidence interval = 1.211, 1.734).

CONCLUSION

While comorbidities were highly associated with stroke prevalence in all socioeconomic cohorts, Blacks only had higher relative odds in the lower income classes. Lack of biological or behavioral explanations for these findings suggests that unobserved or uncontrolled factors such as systemic racism, prejudicial institutions, or differential treatment may contribute to this.

Ambient air pollution and the risk of acute myocardial infarction and stroke: A national cohort study

We used a large national cohort in Canada to assess the incidence of acute myocardial infarction (AMI) and stroke hospitalizations in association with long-term exposure to fine particulate matter (PM_2.5), nitrogen dioxide (NO₂), and ozone (O₃). The study population comprised 2.7 million respondents from the 2006 Canadian Census Health and Environment Cohort (CanCHEC), followed for incident hospitalizations of AMI or stroke between 2006 and 2016. We estimated 10-year moving average estimates of PM_2.5, NO₂, and O₃, annually. We used Cox proportional hazards models to examine the associations adjusting for various covariates. For AMI, each interquartile range (IQR) increase in exposure was found to be associated with a hazard ratio of 1.026 (95% CI: 1.007-1.046) for PM_2.5, 1.025 (95% CI: 1.001-1.050) for NO₂, and 1.062 (95% CI: 1.041-1.084) for O₃, respectively. Similarly, for stroke, an IQR increase in exposure was associated with a hazard ratio of 1.078 (95% CI: 1.052-1.105) for PM_2.5, 0.995 (95% CI: 0.965-1.030) for NO₂, and 1.055 (95% CI: 1.028-1.082) for O₃, respectively. We found consistent evidence of positive associations between long-term exposures to PM_2.5, and O₃, and to a lesser degree NO₂, with incident AMI and stroke hospitalizations.

Influence of BMI on adenosine deaminase and stroke outcomes in mechanical thrombectomy subjects

Background

Emergent Large Vessel Occlusion (ELVO) strokes are ischemic vascular events for which novel biomarkers and therapies are needed. The purpose of this study is to investigate the role of Body Mass Index (BMI) on protein expression and signaling at the time of ELVO intervention. Additionally, we highlight the protein adenosine deaminase (ADA), which is a deaminating enzyme that degrades adenosine, which has been shown to be neuroprotective in ischemia. We investigate the relationship between ADA and BMI, stroke outcomes, and associated proteomic networks which might aid in personalizing prognosis and future treatment of ELVO stroke.

Methods

The Blood And Clot Thrombectomy And Collaboration (BACTRAC) study is a continually enrolling tissue bank (clinicaltrials.gov NCT03153683) and registry from stroke patients undergoing mechanical thrombectomy (MT). N ​= ​61 human carotid plasma samples were analyzed for inflammatory and cardiometabolic protein expression by Olink Proteomics. Statistical analyses used t-tests, linear, logistic, and robust regressions, to assess the relationship between BMI, proteomic expression, and stroke-related outcomes.

Results

The 61 subjects studied were broken into three categories: normal weight (BMI 18.5–24.9) which contained 19 subjects, overweight (BMI 25–30) which contained 25 subjects, and obese (BMI ≥30) which contained 17 subjects. Normal BMI group was a significantly older population (mean 76 years) when compared to overweight (mean 66 years) and obese (mean 61 years) with significance of p ​= ​0.041 and p ​= ​0.005, respectively. When compared to normal weight and overweight categories, the obese category had significantly higher levels of adenosine deaminase (ADA) expression (p ​= ​0.01 and p ​= ​0.039, respectively). Elevated levels of ADA were found to have a significant positive correlation with both infarct volume and edema volume (p ​= ​0.013 and p ​= ​0.041, respectively), and were associated with a more severe stroke (NIHSS on discharge) and greater stroke related disability (mRS on discharge) with significance of p ​= ​0.053 and p ​= ​0.032, respectively.

Conclusions

When examined according to BMI, subjects undergoing MT for ELVO demonstrate significant differences in the expression of certain plasma proteins, including ADA. Levels of ADA were found to be significantly higher in the obese population when compared to normal or overweight groups. Increased levels of ADA in the obese group were predictive of increased infarct volume, edema volume, and worse NIHSS scores and mRS at discharge. These data provide novel biomarker candidates as well as treatment targets while increasing the personalization of stroke prognosis and treatment.

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Adenosine deaminase is minimally reported on in the stroke literature.

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In our cohort of ischemic ELVO stroke patients treated with mechanical thrombectomy:

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Subjects with higher BMI had higher ADA expression.

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Higher ADA is predictive of larger infarct volume, edema volume, and increased mRS and NIHSS on discharge.

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ADA and related proteins may serve as novel and personalized prognostic biomarkers as well as potential therapeutic targets.

Association of Ischemic Stroke Incidence, Severity, and Recurrence With Dementia in the Atherosclerosis Risk in Communities Cohort Study

IMPORTANCE

Ischemic stroke is associated with increased risk of dementia, but the association of stroke severity and recurrence with risk of impaired cognition is not well known.

OBJECTIVE

To examine the risk of dementia after incident ischemic stroke and assess how it differed by stroke severity and recurrence.

DESIGN, SETTING, AND PARTICIPANTS

The Atherosclerosis Risk in Communities (ARIC) study is an ongoing prospective cohort of 15 792 community-dwelling individuals from 4 US states (Mississippi, Maryland, Minnesota, and North Carolina). Among them, 15 379 participants free of stroke and dementia at baseline (1987 to 1989) were monitored through 2019. Data were analyzed from April to October 2021. Associations between dementia and time-varying ischemic stroke incidence, frequency, and severity were studied across an average of 4.4 visits over a median follow-up of 25.5 years with Cox proportional hazards models adjusted for sociodemographic characteristics, apolipoprotein E, and vascular risk factors.

EXPOSURES

Incident and recurrent ischemic strokes were classified by expert review of hospital records, with severity defined by the National Institutes of Health Stroke Scale (NIHSS; minor, ≤5; mild, 6-10; moderate, 11-15; and severe, ≥16).

MAIN OUTCOMES AND MEASURES

Dementia cases adjudicated through expert review of in-person evaluations, informant interviews, telephone assessments, hospitalization codes, and death certificates. In participants with stroke, dementia events in the first year after stroke were not counted.

RESULTS

At baseline, the mean (SD) age of participants was 54.1 (5.8) years, and 8485 of 15 379 participants (55.2%) were women. A total of 4110 participants (26.7%) were Black and 11 269 (73.3%) were White. A total of 1378 ischemic strokes (1155 incident) and 2860 dementia cases were diagnosed 1 year or more after incident stroke in participants with stroke, or at any point after baseline in participants without stroke, were identified through December 31, 2019. NIHSS scores were available for 1184 of 1378 ischemic strokes (85.9%). Risk of dementia increased with both the number and severity of strokes. Compared with no stroke, risk of dementia by adjusted hazard ratio was 1.76 (95% CI, 1.49-2.00) for 1 minor to mild stroke, 3.47 (95% CI, 2.23-5.40) for 1 moderate to severe stroke, 3.48 (95% CI, 2.54-4.76) for 2 or more minor to mild strokes, and 6.68 (95% CI, 3.77-11.83) for 2 or more moderate to severe strokes.

CONCLUSIONS AND RELEVANCE

In this study, risk of dementia significantly increased after ischemic stroke, independent of vascular risk factors. Results suggest a dose-response association of stroke severity and recurrence with risk of dementia.

The Long-Term Functional Effect of Thrombectomy on Patients with Middle Cerebral Artery Occlusion Who Exhibit Moderate to Severe Disability

Background and Objectives: Endovascular thrombectomy (EVT is an emerging gold standard treatment for acute cerebral infarction and may allow functional improvement after subacute cerebral infarction. However, the long-term functional benefits of EVT in patients with moderate to severe disability remain unclear. We investigated the effects of EVT on the activities of daily living (ADL), handicap, gait, and eating in patients with middle cerebral artery (MCA) occlusion who exhibited moderate to severe disability (score of 3-5 on the modified Rankin scale (mRS)) due to stroke, up to six months after onset. Materials and Methods: This retrospective longitudinal case-control study assessed 45 patients with MCA occlusion who exhibited moderate to severe disability (mRS score ≥ 3): 15 underwent EVT and 30 served as controls. Clinical assessments were conducted at two weeks (12-16 days), four weeks (26-30 days), and six months (180-210 days) after stroke onset. Functional assessments comprised the Korean version of the modified Barthel index (MBI), mRS, functional ambulation category (FAC), and dysphagia outcome severity scale (DOSS) to assess disability, handicap, gait, and eating. Results: The MBI, mRS, FAC, and DOSS scores all improved significantly (all p < 0.05) in the EVT group, compared to the controls. Conclusions: EVT has favorable effects on performing routine ADL, the handicap itself, walking, and eating. Therefore, EVT is recommended for patients with acute MCA occlusion, including those with severe disability at the initial assessment.