Burden of stroke in the Kingdom of Saudi Arabia: A soaring epidemic

The utility of serum glucose potassium ratio as a predictive factor for haemorrhagic transformation, stroke recurrence, and mortality among ischemic stroke patients

Background and Objective

Glucose-Potassium Ratio (GPR) has emerged as a biomarker in several pathophysiological conditions. However, the association between GPR and long-term outcomes in stroke patients has not been investigated. Our study evaluated the applicability of baseline GPR as a predictive prognostic tool for clinical outcomes in ischemic stroke patients.

Methods

The multicenter retrospective cohort study included acute-subacute adult ischemic stroke patients who had their baseline serum GPR levels measured. Eligible patients were categorized into two sub-cohorts based on the baseline GPR levels (<1.67 vs. ≥ 1.67). The primary outcome was the incidence of 30-day hemorrhagic transformation, while stroke recurrence, and all-cause mortality within twelve months, were considered secondary.

Results

Among 4083 patients screened, 1047 were included in the current study. In comparison with GPR < 1.67 group, patients with ≥ 1.67 GPR had a significantly higher ratio of all-cause mortality within twelve months (aHR 2.07 [95 % CI 1.21-3.75] p = 0.01), and higher ratio of 30-day hemorrhagic transformation but failed to reach the statistical significance (aHR 1.60 [95 % CI 0.95-2.79], p = 0.08).

Conclusion

Overall, baseline GPR serum is an independent predictor of all-cause mortality within twelve months in patients with acute and subacute ischemic stroke. Further clinical studies are necessary to validate these findings.

Characteristics and outcomes of large artery occlusion-related stroke due to intracranial atherostenosis: An experience from a single center in Saudi Arabia

BACKGROUND

Literature on the frequency, response to treatment, and outcomes of acute ischemic stroke (AIS) due to intracranial atherostenosis (ICAS)-related intracranial large artery occlusion (ILAO) from Saudi Arabia is scarce. The aim of this study was to identify the percentage, describe the characteristics, and observe the treatment response in patients with AIS attributed to ICAS-related ILAO.

MATERIALS AND METHODS

This cross-sectional study included all adult patients from 2017-2021 who fulfilled the inclusion criteria for the diagnosis of ICAS-related AIS. Patients were dichotomized based on ILAO. Mortality and functional outcomes (FOCs) based on 90 days' dependence level were compared between the two groups. The association between ILAO and other variables was assessed using the Chi-squared test, odds ratios (OR), and 95% confidence interval (CI).

RESULTS

ILAO was found in 38.7% of patients with ICAS-related AIS. Men comprised three-fourths of the cohort and were more frequent in the ILAO group. Smoking was associated with increased (P = 0.04) likelihood of ILAO. Patients with ILAO had more severe strokes (P ≤ 0.001) than patients without. Middle cerebral artery was the most common occluded vessel (52%). Functional dependence (P = 0.003, OR = 2.87, CI = 1.42-5.77), malignant transformation (P = 0.001, OR = 8.0, CI = 1.82-35.9), and mortality (P ≤ 0.001, OR = 7.67, CI = 2.40-24.5) were significantly higher among ILAO group. Patients with ILAO with unfavorable FOC were older than those who achieved better FOC (P ≤ 0.001). Thrombolysis (P = 0.02, OR = 2.50, CI = 1.15-5.41) and mechanical thrombectomy (MT) improved FOC in patients with ILAO (P = 0.04, OR = 2.33, CI = 1.10-4.92).

CONCLUSION

ILAO is common in patients with ICAS-related AIS. Timely hyperacute stroke treatment can help improve the FOC of otherwise disabling stroke due to ILAO. Raising awareness of the community about stroke is needed, so that a higher number of patients can arrive at hospital within the golden hours. Further data from the region are required to recognize the efficacy of MT in ICAS-related ILAO.

Characterization of Demographic, Clinical, and Laboratory Risk Factors for Stroke in a Tertiary Hospital in Riyadh, Saudi Arabia

Background Stroke is a major cause of death and long-term disability worldwide, with varying incidence and risk factors across different populations. This study aims to analyze demographic, clinical, and laboratory risk factors for stroke among the Saudi Arabian population to enhance the understanding of its behavior and associated mortality. Methods In this retrospective cohort study, we analyzed data from 3586 patients diagnosed with hemorrhagic or non-hemorrhagic stroke at King Fahad Medical City from January 1, 2020, to November 11, 2022. We collected data on demographic variables, past medical history, social history, nationality, and laboratory components. Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 27.0. (Armonk, NY: IBM Corp.), with significance set at p<0.05. Results The study population was predominantly male (57.86%) and within the age group of 51 to 80 years (58.8%). A significant portion of patients were Saudi nationals (99.6%), with hypertension (50.2%) and diabetes (40.4%) being the most common comorbidities. Laboratory abnormalities related to sodium and potassium levels were strongly linked to mortality rates. Notably, ischemic stroke was the most common type across all age groups, except for patients under age 16, where hemorrhagic stroke was more prevalent. Conclusions Our findings reveal significant associations between stroke risk factors and mortality within the Saudi Arabian population, highlighting the impact of hypertension, diabetes, and electrolyte imbalances. The study underscores the need for targeted stroke prevention and management strategies in Saudi Arabia, aligning with global trends to mitigate the burden of this disease.

Spiral strapping for improving upper extremity motor functions in individuals with stroke: A randomized controlled trial

BACKGROUND

The rehabilitation process for the upper extremities of individuals with stroke requires therapists to use splints for supportive and corrective purposes. The aim of this study was to assess the effectiveness of spiral strapping in inhibiting spasticity and improving the upper extremity motor functions of individuals with chronic stroke.

METHODS

Forty Saudi individuals aged 50-60 years with chronic stroke participated in this study. Their degrees of spasticity according to the Modified Ashworth Scale ranged across grades 1, 1+, and 2. Participants were randomly assigned to experimental and control groups. Participants in both groups received 1 h of conventional physical therapy for 3 d/wk to improve the motor functions of their upper extremities. In addition, participants in the experimental group wore an upper-limb spiral strapping with a hand splint 10 h/d for 6 d/wk. The treatment program for both groups was delivered for 4 weeks. Changes in the scores of Action Research Arm Test for elbow joint spasticity, active range of motion of the shoulder, elbow, and forearm joints, and hand grip strength were evaluated before and after treatment in both groups.

RESULTS

Significant improvements in all measured variables after treatment were reported in both groups, except for elbow joint spasticity in the control group. The experimental group showed significant post-treatment improvement in the scores for all measured variables compared with the control group.

CONCLUSIONS

Spiral strapping was beneficial in inhibiting mild degrees of spasticity and improving the motor functions of the upper extremities of stroke patients.

HbA1c and risk factors' prevalence in patients with stroke: a retrospective study in a tertiary care hospital in Saudi Arabia

OBJECTIVES

To determine the relationship between hemoglobin A1c (HbA1c) and different types of stroke, and how different comorbidities and risk factors are related to the occurrence of stroke in a Saudi Arabian tertiary care hospital.

METHODS

This retrospective study was conducted at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia. The study included patients who experienced either hemorrhagic stroke (HS), ischemic stroke (IS), or transient ischemic attack (TIA) between 2015 and 2020.

RESULTS

In total, 976 patients were included, of whom 670 were males (68.6%). The incidence of HS was significantly higher in males compared to females (14.2% vs. 6.9%), whereas the incidence of IS was higher in females (76.8% vs. 74.6%) (p=0.001). Ischemic stroke was significantly higher in the 65 years or older age group, whereas HS was comparatively higher among those aged <65 years. The means HbA1c levels in all three types of stroke were abnormally high. However, HbA1c levels were significantly higher in IS than in the other 2 stroke types (p=0.017). The HbA1c levels showed statistically significant differences between the different types of stroke, where the estimated marginal means were higher in patients with IS with a small effect size. Heart disease was also more prevalent in the IS group. Stroke-related mortality was reported in 16 patients and was significantly higher in the IS group than in the HS group.

CONCLUSION

The HbA1c levels were elevated in all types of stroke, significantly in IS. Controlling patients' HbA1c and other modifiable risk factors could significantly reduce the risk of stroke.

Primordial and Primary Prevention of Ischemic Stroke in Saudi Arabia: A Combination Approach and Evolving Concepts

Ischemic stroke is a considerable public health hazard and a significant cause of disability and mortality in Saudi Arabia. Primary prevention strategies in the country are currently limited. With the health sector transformation program that depends on the principles of value-based care and applying the new model of care in disease prevention, aggressive and serious steps for primary stroke prevention are expected to be implemented. This article reviews primordial and primary prevention of ischemic stroke in Saudi Arabia and suggests a combination approach and framework for implementation. We provide a pragmatic solution to implement primordial and primary stroke prevention in Saudi Arabia and specify the roles of the government, health professionals, policymakers, and the entire population. Currently, there are several key priorities for primordial and primary stroke prevention in Saudi Arabia that should target people at different levels of risk. These include an emphasis on a comprehensive approach that includes both individual and population-based strategies and establishing partnerships across health-care providers to share responsibility for developing and implementing both strategies. This is an urgent call for action to initiate different strategies suggested by experts for primary stroke prevention in Saudi Arabia.

The Association between Sleep Quality and Depressive Symptoms among Stroke Survivors and Caregivers

BACKGROUND

Stroke is a serious health problem that can lead to the development of depressive symptoms, sleep disturbances, and functional dependence in stroke survivors. The change in stroke survivors' quality of life results in negative health outcomes for stroke survivors and caregivers. This study aims to investigate the association between sleep quality and depressive symptoms among stroke survivors and caregivers in Saudi Arabia.

METHODS

A cross-sectional design was used to collect data from 100 stroke survivors and 80 caregivers using the patient health questionnaire and Pittsburgh Sleep Quality Index.

RESULTS

43% of the stroke survivors reported depressive symptoms and 65% had poor sleep quality; 21% of the caregivers reported depressive symptoms and 46% reported poor sleep quality. A strong association between sleep quality and depressive symptoms was detected for the stroke survivors and caregivers: (r = 0.885, p < 0.001); (r = 0.669, p < 0.001), respectively. A strong association was found between caregivers' depressive symptoms and patient post-stroke depressive symptoms (r = 0.502, p < 0.001). A moderate association was found between stroke survivors' sleep quality and caregivers' sleep quality (r = 0.407, p < 0.001). There was a moderate association between stroke survivors' depressive symptoms and caregivers' sleep quality (r = 0.456, p < 0.001). Moreover, there was a moderate association between stroke survivors' sleep quality and caregivers' depressive symptoms (r = 0.492, p < 0.001).

CONCLUSION

Poor sleep quality and depressive symptoms are common among stroke survivors and caregivers. This study found an association between the two variables. Therefore, depressive symptoms and sleep disturbances in stroke survivors and caregivers should receive more attention. Future research should focus on an interventional study to enhance sleep quality and decrease the risk of depressive symptoms.

Knowledge and awareness of stroke and associated factors in the Saudi general population: a cross-sectional study

Introduction

Stroke is a major cause of death and disability globally and in Saudi Arabia as well. Prevention and management of stroke depend highly on raising knowledge and awareness about the disease.

Purpose

The purpose of this study was to evaluate Saudi adult's knowledge and awareness about stroke and determine the associated factors.

Materials and methods

A cross-sectional online survey was conducted in May-July 2022 among Saudi citizens. Assessments of stroke knowledge about risk factors, symptoms, and response to stroke symptoms were evaluated. Logistic regression was conducted to assess the association between the socio-demographic characteristics and knowledge.

Results

A total of 389 participants were enrolled with the majority (81.7%) being male participants. Less than half of the study subjects (43.3%) identified four out of five correct answers related to general knowledge about stroke. Almost all the participants were able to identify at least one risk factor associated with stroke. The majority of the participants (81.2%) believed that physical inactivity was the most common risk factor associated with stroke. Approximately three-quarters of participants considered difficulty speaking and understanding speech, followed by the sudden loss of consciousness as the most common stroke manifestation. Participants with a history of hypertension, dyslipidemia, and obesity had significantly higher odds of identifying at least one early stroke symptom (OR 2.271 [95% CI 1.402 3.677], 2.059 [95% CI 1.273 3.328], and 2.665 [95% CI 1.431 4.963], respectively).

Conclusion

Our study revealed that participants have good knowledge about stroke. Nonetheless, further efforts are required to raise awareness and educate the public to optimize and ensure better treatment outcomes.

Nursing Care for Stroke Patients: Current Practice and Future Needs

BACKGROUND

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Stroke nurses play an important role in the care of patients living with stroke by using best practices and adhering to stroke-management guidelines. This study aims at examining the current nursing practice for stroke patients in Saudi Arabia.

METHOD

A cross-sectional descriptive design was used to collect data from nurses working in the stroke unit and intensive care unit between the period of February and June 2022 using electronic self-administered questionnaires.

RESULTS

A convenience sample of 131 nurses who provided care for stroke patients was enrolled. Significant differences in nursing practice were found between the stroke units and the intensive care units regarding the activation of the stroke code, X2 (4, N = 131) = 48.34, p < 0.001; transferring stroke patients to a designated bed, X2 (4, N = 131) = 48.74, p = 0.002; applying the NIHSS, X2 (4, N = 131) = 70.11, p < 0.001; using the modified Rankin scale, X2 (4, N = 131) = 61.24, p < 0.001; providing intervention for neglect syndrome, X2 (4, N = 131) = 44.72, and hemianopsia, X2 (4, N = 131) = 39.22; screening for poststroke depression, X2 (4, N = 131) = 101.59, p < 0.001; assessing for psychosocial needs, X2 (4, N = 131) = 74.44, p < 0.001, and encouraging patients to express their feelings, X2 (4, N = 131) = 58.64, p < 0.001; educating patients and families about stroke prevention, X2 (4, N = 131) = 40.51, p < 0.001.

CONCLUSION

As per the results of the study, there is an urgent need for stroke units run by specialized stroke nurses to provide early stroke management and improve survivors' outcomes. Structured stroke-care programs are needed to improve nursing practice and meet the international standard of stroke care.

Evaluation of Physicians' Compliance With Secondary Prevention Among Ischemic Stroke Patients: A Retrospective Study

BACKGROUND

Stroke is a leading cause of disability and death worldwide. Globally, stroke affects 13.7 million individuals every year. Several studies have shown an increase in the rehospitalization rate among stroke patients caused by non-adherence to secondary prevention as recommended by the American Heart Association/American Stroke Association (AHA/ASA) guideline. The aim of this study was to evaluate physicians' compliance with secondary prevention of stroke upon patients' discharge.

METHODS

A retrospective chart review study was conducted at King Fahad Medical City. The primary outcome of this study was the number of patients discharged with the recommended medications for the secondary prevention of ischemic stroke (IS). The data were collected from the patient's medical record files and analyzed using the Statistical Package for the Social Sciences (SPSS).

RESULTS

Of the 675 patients who were screened for eligibility, 507 were included and 168 were excluded. The mean age of the patients was 59.5 (± 15.6) years. Of the 507 patients, 181 (35.7%) had a history of previous stroke. Overall, 376 (74%) stroke patients were discharged with appropriate secondary prevention recommendation per AHA/ASA guideline.

CONCLUSIONS

This study stresses the importance of compliance with the AHA/ASA guideline for secondary stroke prevention and highlights the role of pharmacists in the stroke unit in which it is necessary to ensure that all stroke patients are discharged with the recommended medications to reduce recurrent stroke.

Frequency, Risk Factors, and Outcomes of Intracranial Atherosclerotic Stenosis in Stroke Patients From the Southern Region of Saudi Arabia

Background Intracranial Atherosclerotic Stenosis (ICAS) represents a noteworthy cerebrovascular pathology linked to ischemic stroke, contributing to a considerable burden of morbidity and mortality on a global scale. The present study was undertaken with the primary objective of investigating the frequency, risk factors, and outcomes of ICAS in stroke patients within the Southern Region of Saudi Arabia. Methods This was a descriptive cross-sectional study conducted at a tertiary care hospital located in the southern region of Saudi Arabia, from June 2022 to December 2022. The study population consisted of patients aged 18 years and above who were diagnosed with acute ischemic stroke during the designated research period. Patients with hemorrhagic stroke, transient ischemic attack (TIA), or incomplete medical records were excluded from the analysis. Data pertaining to the patients were retrieved from their respective medical records. Results Out of 201 patients admitted with stroke, 92 (45.77%) were found to have intracranial stenosis. The majority of patients were female (52.2%) and aged over 55 years (60.9%). The presence of hypertension exhibited a statistically significant correlation with varying degrees of stenosis (p=0.02), as did ischemic heart disease and obesity (p=0.04) and active smoking (p=0.01). Hypertension displayed a marginal association with intracranial stenosis, with an odds ratio of 1.01 (95% CI: 0.25, 4.11) and a p-value of 0.02. Similarly, dyslipidemia showed a potential correlation, with an odds ratio of 1.16 (95% CI: 0.44, 3.03) and a p-value of 0.014. On the other hand, obesity showed a stronger association, with an odds ratio of 4.53 (95% CI: 1.05, 19.51) and a p-value of 0.04. Among the patients, 25 (27.17%) underwent revascularization procedures, while 44 (47.83%) were not eligible for such intervention. During the three-month follow-up, 4 (16%) experienced an ipsilateral stroke, and 3 (12%) suffered from a contralateral transient ischemic attack (TIA). Encouragingly, 18 (72%) of the treated patients showed no recurrence during the follow-up period. Conclusion This study concludes that approximately half (45.77%) of stroke patients had intracranial stenosis, and significant associations were found between varying degrees of stenosis and hypertension, ischemic heart disease, obesity, and active smoking. Hypertension demonstrated a marginal correlation, while obesity exhibited a stronger association with intracranial stenosis.

Hyperlipidemia and Hypertension Are Associated With Intracerebral Hemorrhage Incidence: A Retrospective Study

Introduction Stroke places a huge burden on the socioeconomic systems. Hemorrhagic stroke (HS) is the second most common type of stroke and the second leading cause of disability and death. The updated data on the prevalence of intracerebral hemorrhage (ICH) stroke and related physiological risk factors in Saudi Arabia were limited. The aim of this study was to identify the prevalence of ICH stroke and the related physiological risk factors. Methods This was a retrospective, hospital-based, and chart review study that utilized the BESTCare system at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. Patients who attended the neurology department (inpatient/outpatient) between 2015 and 2020 were studied. The statistical tool JMP (JMP Inc., Cary, NC, USA) was used for data entry and analysis. Results Patient data (N = 1,870, 58.6 ± 13.87 years old) were screened for comorbidities, hypertension (66.1%), diabetes mellitus (DM) (57.7%), hyperlipidemia (28.4%), and history of an old stroke (22.3%). Ischemic stroke (IS) was more dominant than ICH stroke with ratios of 94.5% (n = 1767) versus 5.5% (n = 103), respectively. The prevalence of ICH stroke among the patients (n = 103) was 10.6%, 20.3%, 24.2%, and 28.1% in the age groups of <40, 41-50, 51-60, and 61-70 years old, respectively. There was a significant gender effect on the distribution of both IS and ICH (p = 0.003). ICH strokes were more prevalent in males than in females. Body mass index (BMI) has no significant effect on the prevalence of IS and ICH stroke (p = 0.081). ICH stroke was significantly associated with DM (p = 0.032), hypertension (p = 0.01), and hyperlipidemia (p = 0.002). Regression analyses show that only hypertension (positive association) and hyperlipidemia (negative association) were significantly associated with the incidence of ICH stroke. Conclusion IS was more prevalent than ICH stroke. ICH strokes were more prevalent in males than in females. Also, hypertension was the most common factor leading to ICH stroke, unlike hyperlipidemia, which was revealed to be protective against ICH stroke.

Correlation Between Pre-treatment Collateral Status and Short-Term Functional Outcome in Patients With Mild to Moderate Stroke After Reperfusion Therapy in a Local Primary Stroke Center in the Southwestern Part of Saudi Arabia

Background Stroke is a substantial cause of disability and mortality worldwide and is characterized by the sudden onset of acute neurological deficit. During acute ischemia, cerebral collateral circulations are crucial in preserving blood supply to the ischemic region. Recombinant tissue plasminogen activator (r-tPA) and endovascular mechanical thrombectomy (MT) are the primary standards of care for acute recanalization therapy. Methodology From August 2019 through December 2021, we enrolled patients treated in our local primary stroke center with anterior circulation acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT) with or without MT. Only patients diagnosed with mild to moderate anterior ischemic stroke, as measured by the National Institutes of Health Stroke Scale (NIHSS), were included in the study. The candidate patients underwent non-contrast CT scanning (NCCT) and CT angiography (CTA) at admission. The modified Rankin scale (mRS) was used to assess the functional outcome of the stroke. The modified Tan scale, graded on a scale of 0-3, was used to determine the collateral status. Results This study comprised a total of 38 patients who had anterior circulation ischemic strokes. The mean age was 34. 8±13. All patients received IVT; eight patients (21.1%) underwent MT following r-tPA. In 26.3% of cases, hemorrhagic transformation (HT), both symptomatic and asymptomatic, was evident. Thirty-three participants (86.8%) had a moderate stroke, whereas five participants (13.2%) had a minor stroke. With a P-value of 0.003, a poor collateral status on the modified Tan score is substantially associated with a short, poor functional outcome. Conclusion In our study, patients with mild to moderate AIS with good collateral scores at admission had better short-term outcomes. Patients with poor collaterals tend to present with a disturbed level of consciousness more than patients with good collaterals.

Pharmacological Inhibition of Class III Alcohol Dehydrogenase 5: Turning Remote Ischemic Conditioning Effective in a Diabetic Stroke Model

The restoration of cerebral blood flow (CBF) to achieve brain tissue oxygenation (PbtO₂) is the primary treatment for ischemic stroke, a significant cause of adult mortality and disability worldwide. Nitric oxide (NO) and its bioactive s-nitrosylated (SNO) reservoirs, such as s-nitrosoglutathione (GSNO), induce hypoxic vasodilation to enhance CBF during ischemia. The endogenous pool of SNOs/GSNO is enhanced via the activation of endothelial NO synthase (eNOS/NOS3) and by the suppression of class III alcohol dehydrogenase 5 (ADH5), also known as GSNO reductase (GSNOR). Remote ischemic conditioning (RIC), which augments NOS3 activity and SNO, is an emerging therapy in acute stroke. However, RIC has so far shown neutral effects in stroke clinical trials. As the majority of stroke patients are presented with endothelial dysfunctions and comorbidities, we tested the hypothesis that NOS3 dysfunction and diabetes will abolish the protective effects of RIC therapy in stroke, and the prior inhibition of GSNOR will turn RIC protective. Our data demonstrate that RIC during thrombotic stroke failed to enhance the CBF and the benefits of thrombolysis in NOS3 mutant (NOS3^+/−) mice, a genetic model of NOS3 dysfunction. Interestingly, thrombotic stroke in diabetic mice enhanced the activity of GSNOR as early as 3 h post-stroke without decreasing the plasma nitrite (NO₂⁻). In thrombotic stroke, neither a pharmacological inhibitor of GSNOR (GRI) nor RIC therapy alone was protective in diabetic mice. However, prior treatment with GRI followed by RIC enhanced the CBF and improved recovery. In a reperfused stroke model, the GRI–RIC combination therapy in diabetic mice augmented PbtO₂, a translatory signature of successful microvascular reflow. In addition, RIC therapy unexpectedly increased the inflammatory markers at 6 h post-stroke in diabetic stroke that were downregulated in combination with GRI while improving the outcomes. Thus, we conclude that preexisting NOS3 dysfunctions due to comorbidities may neutralize the benefits of RIC in stroke, which can be turned protective in combination with GRI. Our findings may support the future clinical trial of RIC in comorbid stroke. Further studies are warranted to test and develop SNO reservoirs as the blood-associated biomarker to monitor the response and efficacy of RIC therapy in stroke.

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.

Nebulization of Low-Dose S-Nitrosoglutathione in Diabetic Stroke Enhances Benefits of Reperfusion and Prevents Post-Thrombolysis Hemorrhage

The COVID-19 pandemic has escalated the occurrence of hypoxia including thrombotic stroke worldwide, for which nitric oxide (NO) therapy seems very promising and translatable. Therefore, various modes/routes of NO-delivery are now being tested in different clinical trials for safer, faster, and more effective interventions against ischemic insults. Intravenous (IV) infusion of S-Nitrosoglutathione (GSNO), the major endogenous molecular pool of NO, has been reported to protect against mechanical cerebral ischemia-reperfusion (IR); however, it has been never tested in any kind of “clinically” relevant thromboembolic stroke models with or without comorbidities and in combination with the thrombolytic reperfusion therapy. Moreover, “IV-effects” of higher dose of GSNO following IR-injury have been contradicted to augment stroke injury. Herein, we tested the hypothesis that nebulization of low-dose GSNO will not alter blood pressure (BP) and will mitigate stroke injury in diabetic mice via enhanced cerebral blood flow (CBF) and brain tissue oxygenation (PbtO2). GSNO-nebulization (200 μg/kgbwt) did not alter BP, but augmented the restoration of CBF, improved behavioral outcomes and reduced stroke injury. Moreover, GSNO-nebulization increased early reoxygenation of brain tissue/PbtO2 as measured at 6.5 h post-stroke following thrombolytic reperfusion, and enervated unwanted effects of late thrombolysis in diabetic stroke. We conclude that the GSNO-nebulization is safe and effective for enhancing collateral microvascular perfusion in the early hours following stroke. Hence, nebulized-GSNO therapy has the potential to be developed and translated into an affordable field therapy against ischemic events including strokes, particularly in developing countries with limited healthcare infrastructure.