Epidemiology and the global burden of stroke

Bibliometric Analysis of the Role of Occludin in the Pathogenesis of Stroke

Over the past decade, there has been a notable surge in research dedicated to unraveling the intricate role of tight junction proteins in blood-brain barrier (BBB) damage associated with ischemic stroke. This bibliometric analysis explores the expansive landscape of occludin research, a key tight junction protein, during the years 2000-2023, shedding light on the global scientific contributions, collaborations, and emerging trends in this critical area of stroke pathogenesis. China and the United States emerge as significant contributors, underscoring their prominence in advancing our understanding of tight junction proteins. Occludin, identified as a linchpin in regulating BBB integrity, proves to be a pivotal player, with implications extending to the diagnosis of hemorrhagic transformation in ischemic stroke. This study identifies occludin as a potential biomarker, offering promise for early diagnosis and paving the way for novel diagnostic strategies. The analysis highlights the necessity for a more comprehensive exploration of tight junction proteins, including occludin and claudin-5, particularly in the context of acute cerebral ischemia. The unique healthcare landscape in Kazakhstan adds urgency to the call for further scientific research in this region, emphasizing the need for tailored investigations to address specific regional challenges. This comprehensive overview not only delineates the current state of occludin research but also signals the direction for future investigations. The identified knowledge gaps and emerging trends provide a roadmap for researchers and policymakers alike, with implications for both scientific discourse and clinical practice. Moving forward, a deeper understanding of tight junction proteins, informed by the insights gleaned from this study, holds the potential to shape targeted therapeutic interventions and diagnostic strategies, ultimately contributing to advancements in global stroke care.

The link between Alzheimer's disease and stroke: A detrimental synergism

Being age-related disorders, both Alzheimer's disease (AD) and stroke share multiple risk factors, such as hypertension, smoking, diabetes, and apolipoprotein E (APOE) Ɛ4 genotype, and coexist in patients. Accumulation of amyloid-β plaques and neurofibrillary tangled impair cognitive potential, leading to AD. Blocked blood flow in the neuronal tissues, causes neurodegeneration and cell death in stroke. AD is commonly characterized by cerebral amyloid angiopathy, which significantly elevates the risk of hemorrhagic stroke. Patients with AD and stroke have been both reported to exhibit greater cognitive impairment, followed by multiple pathophysiological mechanisms shared between the two. The manuscript aims to elucidate the relationship between AD and stroke, as well as the common pathways and risk factors while understanding the preventive therapies that might limit the negative impacts of this correlation, with diagnostic modalities and current AD treatments. The authors provide a comprehensive review of the link and aid the healthcare professionals to identify suitable targets and risk factors, that may retard cognitive decline and neurodegeneration in patients. However, more intricate research is required in this regard and an interdisciplinary approach that would target both the vascular and neurodegenerative factors would improve the quality of life in AD patients.

Exoskeleton-assisted upper limb rehabilitation after stroke: a randomized controlled trial

OBJECTIVES

The upper-limb exoskeleton training program which is repetetive and task-specific therapy can improve motor functions in patients with stroke. To compare the effect of an upper-limb exoskeleton training program with Bobath concept on upper limb motor functions in individuals with chronic stroke.

METHODS

Participants were randomly assigned to exoskeleton group (EG, n = 12) or to Bobath group (BG, n = 12). Interventions were matched in terms of session duration and total number of sessions and performed 2 times per week for 6-weeks. Primary outcome was Fugl-Meyer-Upper Extremity (FMA-UE). Secondary outcomes were Modified Ashworth Scale (elbow and wrist flexor muscles), Motor Activity Log-30 which is consist of two parts as an amount of use (AOU) and quality of movement (QOM), and The Nottingham Extended Activities of Daily Living (NEADL) index.

RESULTS

After 12-sessions of training, the mean (SD) FMA-UE score increased by 5.7 (2.9) in the EG, and 1.9 (1.5) points in the BG (p < .05). In total, 40% of participants (5/12) demonstrated a clinically meaningful improvement (≥5.25 points) in the FM-UE, while none of the participants reached MCID score in the bobath group. Changes in the AOU, QOM, and NEADL were significantly larger in the EG compared to BG (p < .05). 7/12 (58.33%) of participants for AOU and 5/12 (42%) of participants for QOM in the EG showed that clinically meaningful change. 5/12 of participants (42%) in the EG demonstrated ≥4.9-point increase in NEADL score.

DISCUSSION

High-intensity repetitive arm and hand exercises with an exoskeleton device was safe and feasible. Exoskeleton-assisted training demonstrated significant benefits in improving upper limb functions and quality of life in individuals after stroke.

The IC87201 (a PSD95/nNOS Inhibitor) Attenuates Post- Stroke Injuries

N-methyl-D-aspartate receptor-dependent excitotoxicity is one of the most important mechanisms underlying stroke injury and the resulting neuronal death. In the present study, in order to reduce post-stroke brain injury and improve behavioral performance, a new molecule named IC87201, which acts as an inhibitor of PSD95/nNOS interaction in the intracellular signaling pathway of NMDA receptors, was administered. Using the middle cerebral artery occlusion (MCAO) technique, 24 adult male rats were subjected to one hour of cerebral ischemia. Animals were randomly divided into sham, MCAO, MCAO + DXM, and MCAO + IC87201 groups, and in the last two groups, intraperitoneal injection of dextromethorphan hydrobromide monohydrate (DXM), as an NMDA antagonist, and IC87201 was performed after ischemia. Neurobehavioral scores were evaluated for seven days, and on the last two days, the rats' memory performance was appraised using the passive avoidance test. On seventh day, the brain tissue was properly prepared for stereological analysis. Stereological studies of the hippocampus CA1 and CA3 regions revealed that changes in the total and infarcted volumes, total number of neurons, non-neurons, and dead neurons are the consequences of cerebral ischemia. Also, following cerebral ischemia, neurobehavioral and memory function impairments which were assessed by modified neurological severity scores (mNSS) and passive avoidance test, were observed. The aforementioned impairments were recovered after administration of IC87201 significantly and more potently than DXM. Based on our findings, IC87201 successfully attenuated post-ischemia damages. Therefore, this molecule can be considered as a new therapeutic approach in future research.

Team functioning in Neurorehabilitation: a mixed methods study

The objective of this study was to enhance understanding of team functioning in a neurorehabilitation team by identifying the factors that impede and facilitate effective interprofessional team collaboration. We focused on team identification, psychological safety, and team learning, and conducted the research at a neurorehabilitation center treating young patients with severe acquired brain injury in the Netherlands. A mixed-methods approach was employed, integrating quantitative data from questionnaires (N = 40) with qualitative insights from a focus group (n = 6) and in-depth interviews (n = 5) to provide a comprehensive perspective on team dynamics. Findings revealed strong team identification among participants, denoting a shared sense of belonging and commitment. However, limited psychological safety was observed, which negatively affected constructive conflict and team learning. Qualitative analysis further identified deficiencies in shared mental models, especially in shared decision-making and integrated care. These results highlight the crucial role of psychological safety in team learning and the development of shared mental models in neurorehabilitation settings. Although specific to neurorehabilitation, the insights gained may be applicable to enhancing team collaboration in various healthcare environments. The study forms a basis for future research to investigate the impact of improvements in team functioning on patient outcomes in similar settings.

The Role of Neurosurgical Techniques in Management of Acute and Chronic Stroke: A Comprehensive Literature Review

Stroke is a medical condition that results from a decreased or completely diminished supply of blood to the brain, and it is considered one of the major causes of morbidity and mortality globally. Stroke is categorized as ischemic and hemorrhagic stroke, both of which demand prompt and particular timely intervention. This extensive review is done to investigate the precise management of acute and chronic manifestations of stroke in relation to neurosurgical interventions, ultimately providing a thorough analysis regarding indications, procedures, outcomes, and complications that are associated with it. In this regard, a pervasive review of literature was carried out, which was primarily sourced from literature databases such as PubMed. This paper particularly outlines a sound relative analysis of anticipating the competence of each neurosurgical technique in use. Endovascular clot retrieval (ECR) has been particularly highlighted, as its effectiveness has been profoundly observed when selected as a treatment option within a time period of 6-24 hours following an ischemic stroke. In less than a time frame of 48 hours, decompressive hemicraniectomy (DH) is usually considered the most suitable treatment for cases of intracranial hypertension resulting from middle cerebral artery (MCA) infarction. Hemorrhages that occur due to ruptured aneurysms are most commonly dealt with clipping and neuroendovascular techniques. Additionally, considering that revascularization surgery is time-sensitive, the results can ultimately vary. Competent results have been linked with stereotactic surgery, which includes deep brain stimulation (DBS) and focused ultrasound ablation (FUSA), which are also famous for being minimally invasive in nature. However, the broader application of these techniques is hindered by the absence of established protocols. This review highlights the importance of timely interventions, advanced equipment, and precise medical protocols to optimize treatment outcomes.

Association between deep neural network-derived electrocardiographic-age and incident stroke

Background

Stroke continues to be a leading cause of death and disability worldwide despite improvements in prevention and treatment. Traditional stroke risk calculators are biased and imprecise. Novel stroke predictors need to be identified. Recently, deep neural networks (DNNs) have been used to determine age from ECGs, otherwise known as the electrocardiographic-age (ECG-age), which predicts clinical outcomes. However, the relationship between ECG-age and stroke has not been well studied. We hypothesized that ECG-age is associated with incident stroke.

Methods

In this study, UK Biobank participants with available ECGs (from 2014 or later). ECG-age was estimated using a deep neural network (DNN) applied to raw ECG waveforms. We calculated the Δage (ECG-age minus chronological age) and classified individuals as having normal, accelerated, or decelerated aging if Δage was within, higher, or lower than the mean absolute error of the model, respectively. Multivariable Cox proportional hazards regression models adjusted for age, sex, and clinical factors were used to assess the association between Δage and incident stroke.

Results

The study population included 67,757 UK Biobank participants (mean age 65 ± 8 years; 48.3% male). Every 10-year increase in Δage was associated with a 22% increase in incident stroke [HR, 1.22 (95% CI, 1.00-1.49)] in the multivariable-adjusted model. Accelerated aging was associated with a 42% increase in incident stroke [HR, 1.42 (95% CI, 1.12-1.80)] compared to normal aging. In addition, Δage was associated with prevalent stroke [OR, 1.28 (95% CI, 1.11-1.49)].

Conclusions

DNN-estimated ECG-age was associated with incident and prevalent stroke in the UK Biobank. Further investigation is required to determine if ECG-age can be used as a reliable biomarker of stroke risk.

Pharmacotherapy to Improve Cognitive Functioning After Acquired Brain Injury: A Meta-Analysis and Meta-Regression

Cognitive impairments, common sequelae of acquired brain injury (ABI), significantly affect rehabilitation and quality of life. Currently, there is no solid evidence-base for pharmacotherapy to improve cognitive functioning after ABI, nevertheless off-label use is widely applied in clinical practice. This meta-analysis and meta-regression aims to quantitatively aggregate the available evidence for the effects of pharmacological agents used in the treatment of cognitive impairments following ABI. We conducted a comprehensive search of Embase, Medline Ovid, and Cochrane Controlled Trials Register databases for randomized controlled and crossover trials. Meta-analytic effects were calculated for each pharmaceutical agent and targeted neuromodulator system. Cognitive outcome measures were aggregated across cognitive domains. Of 8,216 articles, 41 studies (4,434 patients) were included. The noradrenergic agent methylphenidate showed a small, significant positive effect on cognitive functioning in patients with traumatic brain injury (TBI; k = 14, d = 0.34, 95% confidence interval: 0.12-0.56, P = 0.003). Specifically, methylphenidate was found to improve cognitive functions related to executive memory, baseline speed, inhibitory control, and variability in responding. The cholinergic drug donepezil demonstrated a large effect size, albeit based on a limited number of studies (k = 3, d = 1.68, P = 0.03). No significant effects were observed for other agents. Additionally, meta-regression analysis did not identify significant sources of heterogeneity in treatment response. Our meta-analysis supports the use of methylphenidate for enhancing cognitive functioning in patients with TBI. Although donepezil shows potential, it warrants further research. These results could guide clinical decision making, inform practice guidelines, and direct future pharmacotherapeutic research in ABI.

Turning brain MRI into diagnostic PET: 15O-water PET CBF synthesis from multi-contrast MRI via attention-based encoder-decoder networks

Accurate quantification of cerebral blood flow (CBF) is essential for the diagnosis and assessment of a wide range of neurological diseases. Positron emission tomography (PET) with radiolabeled water (15O-water) is the gold-standard for the measurement of CBF in humans, however, it is not widely available due to its prohibitive costs and the use of short-lived radiopharmaceutical tracers that require onsite cyclotron production. Magnetic resonance imaging (MRI), in contrast, is more accessible and does not involve ionizing radiation. This study presents a convolutional encoder-decoder network with attention mechanisms to predict the gold-standard 15O-water PET CBF from multi-contrast MRI scans, thus eliminating the need for radioactive tracers. The model was trained and validated using 5-fold cross-validation in a group of 126 subjects consisting of healthy controls and cerebrovascular disease patients, all of whom underwent simultaneous 15O-water PET/MRI. The results demonstrate that the model can successfully synthesize high-quality PET CBF measurements (with an average SSIM of 0.924 and PSNR of 38.8 dB) and is more accurate compared to concurrent and previous PET synthesis methods. We also demonstrate the clinical significance of the proposed algorithm by evaluating the agreement for identifying the vascular territories with impaired CBF. Such methods may enable more widespread and accurate CBF evaluation in larger cohorts who cannot undergo PET imaging due to radiation concerns, lack of access, or logistic challenges.

Does Self-Reported BMI Modify the Association Between Stroke and Depressive Symptoms?

BACKGROUND

Depressive symptoms are common in stroke survivors. While obesity has been associated with stroke and depression, its influence on the association between stroke and depressive symptoms is unknown.

METHODS

Cross-sectional data from 2015 to 2016 Canadian Community Health Survey was used. History of stroke was self-reported and our outcome of interest was depressive symptoms in the prior 2 weeks, measured using the 9-item Patient Health Questionnaire. Self-reported body mass index (BMI) was modeled as cubic spline terms to allow for nonlinear associations. We used multivariable logistic regression to evaluate the association between stroke and depressive symptoms and added an interaction term to evaluate the modifying effect of BMI.

RESULTS

Of the 47,521 participants, 694 (1.0%) had a stroke and 3314 (6.5%) had depressive symptoms. Those with stroke had a higher odds of depressive symptoms than those without (aOR = 3.13, 95% CI 2.48, 3.93). BMI did not modify the stroke-depressive symptoms association (P interaction = 0.242) despite the observed variation in stroke-depressive symptoms association across BMI categories,: normal BMI [18.5-25 kg/m2] (aOR† = 3.91, 95% CI 2.45, 6.11), overweight [25-30 kg/m2] (aOR† = 2.63, 95% CI 1.58, 4.20), and obese [>30 kg/m2] (aOR† = 2.76, 95% CI 1.92, 3.94). Similar results were found when depressive symptoms were modeled as a continuous measure.

CONCLUSION

The association between stroke and depressive symptoms is not modified by BMI, needing additional work to understand the role of obesity on depression after stroke.

The Activation of GABAAR Alleviated Cerebral Ischemic Injury via the Suppression of Oxidative Stress, Autophagy, and Apoptosis Pathways

Ischemic stroke is a devastating disease leading to neurologic impairment. Compounding the issue is the very limited array of available interventions. The activation of a γ-aminobutyric acid (GABA) type A receptor (GABAAR) has been reported to produce neuroprotective properties during cerebral ischemia, but its mechanism of action is not yet fully understood. Here, in a rat model of photochemically induced cerebral ischemia, we found that muscimol, a GABAAR agonist, modulated GABAergic signaling, ameliorated anxiety-like behaviors, and attenuated neuronal damage in rats suffering cerebral ischemia. Moreover, GABAAR activation improved brain antioxidant levels, reducing the accumulation of oxidative products, which was closely associated with the NO/NOS pathway. Notably, the inhibition of autophagy markedly relieved the neuronal insult caused by cerebral ischemia. We further established an oxygen-glucose deprivation (OGD)-induced PC12 cell injury model. Both in vivo and in vitro experiments demonstrated that GABAAR activation obviously suppressed autophagy by regulating the AMPK-mTOR pathway. Additionally, GABAAR activation inhibited apoptosis through inhibiting the Bax/Bcl-2 pathway. These data suggest that GABAAR activation exerts neuroprotective effects during cerebral ischemia through improving oxidative stress and inhibiting autophagy and apoptosis. Our findings indicate that GABAAR serves as a target for treating cerebral ischemia and highlight the GABAAR-mediated autophagy signaling pathway.

Brain endothelial CD200 signaling protects brain against ischemic damage

Ischemic stroke induced inflammatory responses contribute significantly to neuronal damage and stroke outcomes. CD200 ligand and its receptor, CD200R, constitute an endogenous inhibitory signaling that is being increasingly recognized in studies of neuroinflammation in various central nervous system disorders. CD200 is a type 1 membrane glycoprotein that is broadly expressed by endothelia and neurons in the brain. In the present study, we have examined the role of endothelial CD200 signaling in acute ischemic stroke. Endothelial CD200 conditional knock out (CKO) mice were generated by breeding CD200 gene floxed mice with Cdh5Cre mice. The mice were subjected to a 60-min transient middle cerebral artery occlusion (MCAO). Flow cytometry, Immunohistochemical staining, and Western blotting were performed to assess the post-stroke inflammation; stroke outcomes (infarct volume and neurobehavioral deficits) were evaluated at 72 h after MCAO. We found CD200R was near-null expressed on microglia at 24 h after stoke. Endothelial CKO of CD200 had no impact on peripheral immune cell development. Immunohistochemical staining confirmed CD200 was expressed on CD200 floxed but not on CD200 CKO endothelia. CD200 CKO mice exhibited larger infarct size, worse neurological deficit scores (NDS), and more deficits in the adhesive removal when compared with control mice, 72 h after MCAO. Western blot results showed that endothelial CKO of CD200 did not change BBB protein expression. Together it suggests that endothelial CD200 signaling protects brains against ischemic injury through a mechanism not directly related to microglial activation.

Comparison of a single session of tDCS on cerebellum vs. motor cortex in stroke patients: a randomized sham-controlled trial

OBJECTIVE

The purpose of this study was to determine whether a single session of trans-cranial direct current stimulation (tDCS) of the cerebellum and M1 has any advantages over one another or sham stimulation in terms of balance, gait and lower limb function.

METHODS

A total of 66 patients who had experienced their first ever stroke were recruited into three groups for this double-blinded, parallel, randomized, sham-controlled trial: cerebellar stimulation group (CbSG), M1 stimulation group (MSG) and sham stimulation group (SSG). A single session of anodal tDCS with an intensity of 2 mA for a duration of 20 min was administered in addition to gait and balance training based on virtual reality using an Xbox 360 with Kinect. Balance, gait, cognition and risk of fall were assessed using outcome measures before intervention (T0), immediately after intervention (T1) and an hour after intervention (T2).

RESULTS

Across group analysis of all outcome measures showed statistically non-significant results (p > .05) except for Six Minute Walk Test (p value T0 = .003, p value T1 = .025, p value T2 = .016). The training effect difference showed a significant difference in balance, gait and cognition, as well as cerebral and cerebellar stimulation, in comparison to sham stimulation (p < .05). The risk of falls remained unaffected by any stimulation (p > .05).

CONCLUSIONS

In addition to Xbox Kinect-based rehabilitation training, a single session of anodal tDCS to the M1 or cerebellum may be beneficial for improving lower limb function, balance and gait performance.

Responsiveness of Section GG Scores in Tracking Post-Stroke Functional Recovery From Inpatient Rehabilitation Admission to 90-Day Follow-Up

OBJECTIVE

To evaluate the responsiveness and scale-to-sample targeting of Section GG of the Inpatient Rehabilitation Facility-Patient Assessment Instrument in measuring the trajectory of functional recovery in patients with stroke from inpatient rehabilitation admission to 90 days after discharge.

DESIGN

Retrospective cohort study.

SETTING

150-bed inpatient rehabilitation facility.

PARTICIPANTS

Patients with stroke (N=1087) discharged between December 2019 to April 2021.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Admission and discharge self-care and mobility scores from Section GG were analyzed for the Inpatient Only group (n= 817). Admission, discharge and 90-day post-discharge Section GG scores from telephone interviews with patients or caregivers were analyzed for the Follow-Up group (n=270). Standardized response means (SRM) determined responsiveness of the tool for each group and time interval. Score means, standard deviations, and floor/ceiling effects illustrated scale-to-sample targeting of the tool.

RESULTS

Self-care and mobility scores improved significantly from admission to discharge (P<.001) for both groups and from discharge to 90 days (P<.001) for the Follow-Up group. Large SRM existed from admission to discharge for self-care and mobility scores in both groups. ​A small-to-moderate SRM was seen from discharge to 90 days for self-care (0.46) and a moderate SRM was observed for mobility (0.68). Overall floor effects were minor at admission for self-care (9.8%) and mobility (7.2.%). Overall ceiling effects were minor at discharge for self-care (11.2%) and mobility (4.6%)​ and significant at follow-up for both self-care (45.2%) and mobility (32.2%).

CONCLUSIONS

Section GG is responsive to change and appropriately measures patients' functional ability during inpatient rehabilitation. More study is required for telephone follow-up after discharge from inpatient rehabilitation.

Are Ischemic Stroke and Alzheimer's Disease Genetically Consecutive Pathologies?

Complex diseases that affect the functioning of the central nervous system pose a major problem for modern society. Among these, ischemic stroke (IS) holds a special place as one of the most common causes of disability and mortality worldwide. Furthermore, Alzheimer's disease (AD) ranks first among neurodegenerative diseases, drastically reducing brain activity and overall life quality and duration. Recent studies have shown that AD and IS share several common risk and pathogenic factors, such as an overlapping genomic architecture and molecular signature. In this review, we will summarize the genomics and RNA biology studies of IS and AD, discussing the interconnected nature of these pathologies. Additionally, we highlight specific genomic points and RNA molecules that can serve as potential tools in predicting the risks of diseases and developing effective therapies in the future.

Impact of stroke on people that receive rehabilitation and are living in Ankara, Turkey

Background

Clinical guidelines for stroke rehabilitation and practices vary between high and low/middle-income countries (LMICs). Knowledge of the perceived impact of stroke in Turkey is limited. Understanding these perceptions can serve as a basis for developing rehabilitation.

Design and methods

The aim was to investigate and compare the perceived impact of stroke in two groups of people living in Ankara. A cross-sectional study with 150 participants divided by stroke onset (Group I: stroke onset <12 months; Group II: >12 months) was conducted. The Barthel Index was used to describe the level of independence in daily living activities and stroke severity. The Stroke Impact Scale (SIS 3.0) was used to investigate the perceived impact of stroke.

Results

The proportion of mild strokes was 78 and 82%, respectively, and 46% of participants in the total sample were moderately dependent. The impact of stroke was high; mean domain scores were below 50 in six of the eight SIS domains.

Conclusions

Turkish stroke survivors perceived a higher impact of stroke regardless of the time passed since stroke onset, compared to survivors from other countries, including other LMICs. The high impact among survivors with mostly mild stroke indicates that Turkish survivors might not receive adequate rehabilitation. The content of rehabilitation services needs to be developed, and an evaluation of individually tailored interventions, preferably with a multidisciplinary approach, is warranted to find ways to decrease the perceived impact of stroke among Turkish stroke survivors.

Predictors of quality of life at 6 months in patients with mild stroke: A prospective observational cohort study

OBJECTIVES

This study aimed to analyze the factors affecting the long-term quality of life of patients with mild stroke and evaluate the differences according to age and sex.

MATERIALS AND METHODS

The Korean Stroke Cohort for functioning and rehabilitation data was used, and patients with mild stroke with a National Institute of Health Stroke Scale score of < 5 were included. Quality of life after 6 months was analyzed using EuroQol-5 dimensions. Demographic and clinical characteristics were evaluated, and factors affecting the quality of life at 6 months were analyzed.

RESULTS

Age, current drinking, marital status, length of stay, and modified Rankin Scale, Fugl-Meyer assessment, Functional Independence Measure, and Geriatric Depression Scale scores affected the quality of life at 6 months in patients with mild stroke. Fugl-Meyer assessment score was a predictor for those aged < 65 years, while the functional ambulatory category was a predictor for those aged ≥ 65 years. Predictors of quality of life, excluding alcohol consumption, were comparable between male and female.

CONCLUSIONS

Among patients aged <65 years, individuals who consumed alcohol, and those who showed better motor function and fewer comorbidities had a higher quality of life. Among patients aged ≥65 years, quality of life was higher in males, younger age, married individuals, those with diabetes, and those with a better walking ability. Among male, individuals who consumed alcohol had a higher quality of life. Rehabilitation treatment should prioritize improving modifiable factors to enhance the quality of life in patients with mild stroke.

Serum amyloid A-dependent inflammasome activation and acute injury in a mouse model of experimental stroke

Serum amyloid A (SAA) proteins increase dramatically in the blood following inflammation. Recently, SAAs are increased in humans following stroke and in ischemic animal models. However, the impact of SAAs on whether this signal is critical in the ischemic brain remains unknown. Therefore, we investigated the role of SAA and SAA signaling in the ischemic brain. Wildtype and SAA deficient mice were exposed to middle cerebral artery occlusion and reperfusion, examined for the impact of infarct volumes, behavioral changes, inflammatory markers, TUNEL staining, and BBB changes. The underlying mechanisms were investigated using SAA deficient mice, transgenic mice and viral vectors. SAA levels were significantly increase following MCAo and mice deficient in SAAs showed reduced infarct volumes and improved behavioral outcomes. SAA deficient mice showed a reduction in TUNEL staining, inflammation and decreased glial activation. Mice lacking acute phase SAAs demonstrated a reduction in expression of the NLRP3 inflammasome and SAA/NLRP3 KO mice showed improvement. Restoration of SAA expression via SAA tg mice or adenoviral expression reestablished the detrimental effects of SAA. A reduction in BBB permeability was seen in the SAA KO mice and anti-SAA antibody treatment reduced the effects on ischemic injury. SAA signaling plays a critical role in regulating NLRP3-induced inflammation and glial activation in the ischemic brain. Blocking this signal will be a promising approach for treating ischemic stroke.

Home-based rehabilitation versus hospital-based rehabilitation for stroke patients in post-acute care stage: Comparison on the quality of life

BACKGROUND

This study focused on the integrated post-acute care (PAC) stage of stroke patients, and employed a retrospective study to examine the satisfaction with life quality in two groups, one that received home-based rehabilitation and one that received hospital-based rehabilitation. A secondary purpose was to analyze the correlations among the index and components concerning their quality of life (QOL) and compare the advantages and disadvantages of these two approaches to PAC.

METHODS

This research was a retrospective study of 112 post-acute stroke patients. The home-based group received rehabilitation for one to two weeks, and two to four sessions per week. The hospital-based group received the rehabilitation for three to six weeks, and 15 sessions per week. The home-based group mainly received the training and guidance of daily activities at the patients' residence. The hospital-based group mainly received physical facilitation and functional training in the hospital setting.

RESULTS

The mean scores of QOL assessment for both groups were found to be significantly improved after intervention. Between-group comparisons showed that the hospital-based group had better improvement than the home-based group in mobility, self-care, pain/discomfort and depression/anxiety. In the home-based group, the MRS score and the participant's age can explain 39.4% of the variance of QOL scores.

CONCLUSION

The home-based rehabilitation was of lower intensity and duration than the hospital-based one, but it still achieved a significant improvement in QOL for the PAC stroke patients. The hospital-based rehabilitation offered more time and treatment sessions. Therefore hospital-based patients responded with better QOL outcomes than the home-based patients.

Contemporary Treatment of the Asymptomatic Carotid Patient

Stroke is a persistent leading cause of morbidity and mortality, and carotid artery atherosclerosis remains a treatable cause of future stroke. Although most patients with asymptomatic carotid artery disease may be at a relatively low risk for future stroke, most completed strokes are unheralded; thus, the identification and appropriate treatment of patients with asymptomatic carotid artery disease remains a critical part of overall stroke prevention. Select patients with asymptomatic carotid artery stenosis with an increased risk of future stroke based on the degree of stenosis and other imaging or patient-related characteristics are appropriate to consider for carotid artery intervention.

Depressive Symptoms and Its Associated Factors Among Primary Caregivers of Stroke Survivors at Amhara Regional State Tertiary Hospitals: Multicenter Study

Background

Stroke is one of the leading causes of severe disability and functional limitation, which are reasons for being dependent on their family for daily activities and participation in social affairs. After discharge from the hospital, most stroke survivors require physical, psychosocial, and financial support from caregivers at home, which is one of the most stressful events for families. The stroke survivors and their caregivers may influence each other during the caregiving process and social life. The stroke survivor's disability and depressive symptoms affect the quality of life of the survivor and their caregivers. Therefore, the purpose of this study was to assess the prevalence and associated factors of depression among caregivers of stroke survivors.

Methods

An institution-based, cross-sectional study was conducted in Amhara regional state tertiary hospitals. A systematic random sampling technique was employed to select 424 participants. The data were collected using an interviewer-administered and chart-reviewed structured questionnaire. The Patient Health Questionnaire-9 (PHQ-9) was used to assess depression. Univariable and multivariable logistic regression analyses were performed to identify factors associated with depression. Adjusting the odds ratio with the corresponding 95% confidence interval and variables with a P-value < 0.05 was considered significantly associated with depression.

Results

The overall prevalence of depressive symptoms was 65.6% (95% CI: 60.8-69.8). Being female, older than 40, having no formal education, having a low family monthly income, being the son or daughter, and spending more than six hours per day were associated with depression.

Conclusion

We found that depression was prevalent among primary caregivers of stroke survivors. To reduce the risk of developing depression, policymakers should fully recognize the role of caregivers in caring for stroke patients. More attention should be given to caregivers who are female, elderly, have a low income, are sons or daughters, and spend a long time caring per day.

Circadian Rhythm Disturbance in Acute Ischemic Stroke Patients and Its Effect on Prognosis

INTRODUCTION

Poststroke sleep disturbances are common and can affect stroke outcomes, but the clinical studies mainly focus on breathing-related sleep disorders, while the bidirectional impact of circadian rhythm dysfunction in ischemic stroke remains unknown. This study observed the characteristics of melatonin secretion in acute ischemic stroke patients and evaluated whether melatonin rhythm impacts the prognosis after stroke by assessing the neurological function, cognition, emotion, and quality of life 3 months after stroke.

METHODS

Acute ischemic stroke patients were selected from the Department of Neurology Inpatients of the Second Hospital affiliated with Soochow University from October 2019 to July 2021. Healthy control subjects were recruited at the same time. Demographic and clinical data were collected, and relevant scale scores (including neurological function, cognition, emotion, and sleep) were assessed within 2 weeks of onset and followed up 3 months later. All participants collected salivary melatonin samples on the 4th day of hospitalization and dim light melatonin onset (DLMO) was calculated according to melatonin concentration. Stroke patients were then divided into three groups based on their DLMO values.

RESULTS

A total of 74 stroke patients and 33 control subjects were included in this analysis. Compared with healthy controls, stroke patients exhibited a delayed melatonin rhythm during the acute phase of stroke (21:36 vs. 20:38, p = 0.004). Stroke patients were then divided into three groups, namely normal (n = 36), delayed (n = 28), or advanced DLMO (n = 10), based on their DLMO values. A χ2 test showed that there were significant differences in the rate of poor prognosis (p = 0.011) and depression tendency (p = 0.028) among the three groups. A further pairwise comparison revealed that stroke patients with delayed DLMO were more likely to experience poor short-term outcomes than normal DLMO group (p = 0.003). The average melatonin concentration of stroke patients at 5 time points was significantly lower than that of the control group (3.145 vs. 7.065 pg/mL, p < 0.001). Accordingly, we split stroke patients into three groups, namely low melatonin level (n = 14), normal melatonin level (n = 54), or high melatonin level (n = 6). Unfortunately, there were no great differences in the clinical characteristics, cognition, emotion, sleep quality, and short-term outcome among groups.

CONCLUSIONS

This is a preliminary study, and our results indicate that changes in melatonin secretion phase of stroke patients may have effect on their short-term prognosis.

The relationship of income on stroke incidence in Finland and China

BACKGROUND

Stroke incidence has continued to increase recently in most countries. The roles of individual-level income on the incidence of overall stroke and its subtypes are still unknown, especially in low- and middle-income countries and the cross-national evidence is also limited. We explored the association between individual-level income and stroke incidence in Finland and China.

METHODS

Changde Social Health Insurance Database (N=571 843) and Finnish population register (N=4 046 205) data were used to calculate standard stroke incidence rates, which were employed to assess the absolute incidence difference between income quintiles. Cox regression was used to compare income differences in first-ever stroke incidence.

RESULTS

The highest income quintile had lower overall and subtype stroke incidence when compared to lower-income quintiles. The relative difference was more evident in hemorrhagic stroke incidence. After adjusting for age and employment status, the disparity of stroke incidence between the lowest and highest income quintiles was high among both men and women and in Finland and China. The disparity was particularly notable among men: in Finland, the hazard ratio (HR) for hemorrhagic stroke was 0.633 [95% confidence interval (95% CI) 0.576-0.696] and HR 0.572 (95% CI 0.540-0.606) for ischemic stroke. The respective figures were HR 0.452 (95% CI 0.276-0.739) and HR 0.633 (95% CI 0.406-0.708) for China.

CONCLUSIONS

Individual-level income is related to overall and subtype stroke incidence. Future studies should explore the causal relationship between individual-level income and stroke incidence.

Exploring the Therapeutic Effect of Neurotrophins and Neuropeptides in Neurodegenerative Diseases: at a Glance

Neurotrophins and neuropeptides are the essential regulators of peripheral nociceptive nerves that help to induce, sensitize, and maintain pain. Neuropeptide has a neuroprotective impact as it increases trophic support, regulates calcium homeostasis, and reduces excitotoxicity and neuroinflammation. In contrast, neurotrophins target neurons afflicted by ischemia, epilepsy, depression, and eating disorders, among other neuropsychiatric conditions. Neurotrophins are reported to inhibit neuronal death. Strategies maintained for "brain-derived neurotrophic factor (BDNF) therapies" are to upregulate BDNF levels using the delivery of protein and genes or compounds that target BDNF production and boosting BDNF signals by expanding with BDNF mimetics. This review discusses the mechanisms of neurotrophins and neuropeptides against acute neural damage as well as highlighting neuropeptides as a potential therapeutic agent against Parkinson's disease (PD), Huntington's disease (HD), Alzheimer's disease (AD), and Machado-Joseph disease (MJD), the signaling pathways affected by neurotrophins and their receptors in both standard and diseased CNS systems, and future perspectives that can lead to the potent application of neurotrophins and neuropeptides in neurodegenerative diseases (NDs).

The Aldose Reductase Inhibitor Epalrestat Maintains Blood-Brain Barrier Integrity by Enhancing Endothelial Cell Function during Cerebral Ischemia

Excessive activation of aldose reductase (AR) in the brain is a risk factor for aggravating cerebral ischemia injury. Epalrestat is the only AR inhibitor with proven safety and efficacy, which is used in the clinical treatment of diabetic neuropathy. However, the molecular mechanisms underlying the neuroprotection of epalrestat remain unknown in the ischemic brain. Recent studies have found that blood-brain barrier (BBB) damage was mainly caused by increased apoptosis and autophagy of brain microvascular endothelial cells (BMVECs) and decreased expression of tight junction proteins. Thus, we hypothesized that the protective effect of epalrestat is mainly related to regulating the survival of BMVECs and tight junction protein levels after cerebral ischemia. To test this hypothesis, a mouse model of cerebral ischemia was established by permanent middle cerebral artery ligation (pMCAL), and the mice were treated with epalrestat or saline as a control. Epalrestat reduced the ischemic volume, enhanced BBB function, and improved the neurobehavior after cerebral ischemia. In vitro studies revealed that epalrestat increased the expression of tight junction proteins, and reduced the levels of cleaved-caspase3 and LC3 proteins in mouse BMVECs (bEnd.3 cells) exposed to oxygen-glucose deprivation (OGD). In addition, bicalutamide (an AKT inhibitor) and rapamycin (an mTOR inhibitor) increased the epalrestat-induced reduction in apoptosis and autophagy related protein levels in bEnd.3 cells with OGD treatment. Our findings suggest that epalrestat improves BBB function, which may be accomplished by reducing AR activation, promoting tight junction proteins expression, and upregulating AKT/mTOR signaling pathway to inhibit apoptosis and autophagy in BMVECs.

Special Issue "Genomics of Stroke" 2022

Stroke is one of the greatest medical threats to human health and quality of life in modern society [...].

Video augmented mirror therapy for upper extremity rehabilitation after stroke: a randomized controlled trial

PURPOSE

To investigate the effects of mirror therapy using a newly developed video augmented wearable reflection device on reach-to-grasp motor control and upper extremity motor function.

METHODS

Participants were randomly allocated to one of three groups: mirror therapy using a video augmented wearable reflection device group (MTVADG), n = 12; traditional mirror therapy group (TMTG), n = 12; and control group (CG), n = 12. Participants in the MTVADG and TMTG received conventional rehabilitation in addition to mirror therapy. Motor control during the reach-to-grasp movement was assessed using kinematic analysis. Each participant's upper extremity motor function was assessed using the Fugl-Meyer Assessment, Manual Function Test, and Box and Block Test.

RESULTS

While both the MTVADG and TMTG showed significantly improved reach-to-grasp movement. The MTVADG showed greater efficiency in kinematic performance than the TMTG. Moreover, while both the MTVADG and TMTG showed improved upper extremity motor function, the MTVADG showed significantly greater improvement in proximal upper limb function compared to the TMTG.

CONCLUSION

Our results suggested that mirror therapy using a video augmented wearable reflection device is more efficient compared to traditional mirror therapy for patients with stroke.

CLINICAL TRIAL REGISTRATION UNIQUE IDENTIFIER

KCT0003047.

Differential gene expression in the contralateral hemisphere of the rat brain after focal ischemia

Ischemic stroke is one of the most severe polygenic brain diseases. Here, we performed further functional genetic analysis of the processes occurring in the contralateral hemisphere (CH) after ischemia-reperfusion injury in rat brain. Comparison of RNA sequencing data for subcortical samples from the ipsilateral hemisphere (IH) and CH after 90 min of transient middle cerebral artery occlusion (tMCAO) and corresponding sham-operated (SO) controls showed four groups of genes that were associated with ischemic processes in rat brain at 24 h after tMCAO. Among them, 2672 genes were differentially expressed genes (DEGs) for IH but non-DEGs for CH, 34 genes were DEGs for CH but non-DEGs for IH, and 114 genes had codirected changes in expression in both hemispheres. The remaining 16 genes exhibited opposite changes at the mRNA level in the two brain hemispheres after tMCAO. These findings suggest that the ischemic process caused by a focal ischemia induces complex bilateral reactions at the transcriptome level in the rat brain. We believe that specific genome responses in the CH and IH may provide a useful model for the study of the potential for brain repair after stroke.

Predictors of in-hospital mortality in stroke patients

In-hospital mortality is a good indicator to assess the efficacy of stroke care. Identifying the predictors of in-hospital mortality is important to advance the stroke outcome and plan the future strategies of stroke management. This was a prospective cohort study conducted at a tertiary referral center in Sri Lanka to identify the possible predictors of in-hospital mortality. The study included 246 confirmed stroke patients. The diagnosis of stroke was established on the clinical history, examination and neuroimaging. The differentiation of stroke in to haemorrhagic type and ischaemic type was based on the results of computed tomography. In all patients, demographic data, comorbidities, clinical signs (pulse rate, respiratory rate, systolic blood pressure, diastolic blood pressure, on admission Glasgow Coma Scale (GCS) score) and imaging findings were recorded. All patients were followed up throughout their hospital course and the in-hospital mortality was recorded. In hospital mortality was defined as the deaths which occurred due to stroke after 24 hours of hospital admission. The incidence of in-hospital mortality was 11.7% (95% confidence interval: 8-16.4). The mean day of in-hospital deaths to occur was 5.9 days (SD ± 3.8 Min 2 Max 20). According to multivariate logistic regression analysis on admission GCS score (Odds Ratio (OR)-0.71) and haemorrhagic stroke type (OR-5.12) predict the in-hospital mortality. The area under the curve of receiver operating curve drawn for the on admission GCS score was 0.78 with a sensitivity of 96.31% and specificity of 41.38% for a patient presented with the GCS score of <10. On admission GCS and haemorrhagic stroke are independent predictors of in-hospital mortality. Thus, a special attention should be given to the patients with low GCS score and haemorrhagic strokes for reducing rates of in-hospital mortality.

Comparison of imaging findings on three-dimensional black-blood enhanced MR imaging between intracranial atherosclerotic occlusion and thrombotic occlusion

PURPOSE

The purpose of this study was to compare the imaging findings on three-dimensional (3D) black-blood (BB) contrast-enhanced MR imaging between intracranial atherosclerotic occlusion (IAO) and thrombotic occlusion (TO) of the middle cerebral artery (MCA) territory.

MATERIALS AND METHODS

From August 2020 to September 2021, we retrospectively reviewed the BB contrast-enhanced MR imaging of patients visiting the emergency room for evaluation of acute ischemic stroke. In total, 77 patients with complete occlusion of the MCA territory on 3D BB contrast-enhanced MR imaging and cerebral angiography were enrolled in this study. We divided the IAO and TO groups according to occlusion causes based on angiography findings.

RESULTS

Of 77 patients, 44 (57.1%) had an IAO in the M1 and M2 and 33 had a TO. Lesion length contrast enhancement (CE) in patients with a TO was significantly longer than that in patients with an IAO (18.95 mm [IQR: 20.91] vs. 7.1 mm [8.92], p <0.001). Overall, 38 (39.4%) patients showed a disconnection of CE on 3D BB contrast-enhanced MR imaging, and 35 showed CE before and after the stenotic or thrombotic lesion. Symptomatic lesions on diffusion-weighted imaging in the TO group were significantly higher than that of the IAO group (97.0% vs, 70.5%, p = 0.003).

CONCLUSION

The long segment CE on 3D BB contrast-enhanced MR imaging was related to TO of MCA. CE before and after a stenotic or thrombotic lesion is a common finding on 3D BB contrast-enhanced MR imaging.

Clustering and prediction of long-term functional recovery patterns in first-time stroke patients

Objectives

The purpose of this study was to cluster long-term multifaceted functional recovery patterns and to establish prediction models for functional outcome in first-time stroke patients using unsupervised machine learning.

Methods

This study is an interim analysis of the dataset from the Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO), a long-term, prospective, multicenter cohort study of first-time stroke patients. The KOSCO screened 10,636 first-time stroke patients admitted to nine representative hospitals in Korea during a three-year recruitment period, and 7,858 patients agreed to enroll. Early clinical and demographic features of stroke patients and six multifaceted functional assessment scores measured from 7 days to 24 months after stroke onset were used as input variables. K-means clustering analysis was performed, and prediction models were generated and validated using machine learning.

Results

A total of 5,534 stroke patients (4,388 ischemic and 1,146 hemorrhagic; mean age 63·31 ± 12·86; 3,253 [58.78%] male) completed functional assessments 24 months after stroke onset. Through K-means clustering, ischemic stroke (IS) patients were clustered into five groups and hemorrhagic stroke (HS) patients into four groups. Each cluster had distinct clinical characteristics and functional recovery patterns. The final prediction models for IS and HS patients achieved relatively high prediction accuracies of 0.926 and 0.887, respectively.

Conclusions

The longitudinal, multi-dimensional, functional assessment data of first-time stroke patients were successfully clustered, and the prediction models showed relatively good accuracies. Early identification and prediction of long-term functional outcomes will help clinicians develop customized treatment strategies.

Contribution of participation and resilience to quality of life among persons living with stroke in Sweden: a qualitative study

PURPOSE

Resilience contributes to positive adaptation after many health conditions, but little is known about its contribution to long-term recovery after stroke. This study investigated the lived experience of resilience and participation and their relationship to quality of life after stroke in Sweden.

MATERIAL AND METHOD

Semi-structured telephone interviews were conducted with 19 informants (10 male, 9 female), aged from 44-89 years and between 1 and 19 years post-stroke. Stroke severity ranged from mild (n = 8), moderate (n = 9) to severe (n = 2). Interviews were analysed using content analysis.

RESULTS

The analysis resulted in an overarching theme; Life with stroke has been adapted to but not accepted, built on five subthemes: 1) Adapting and adjusting life, 2) Meaningful values in life, 3) Inner resources, 4) Support and treatment from social relations, and 5) Support and treatment from external resources.

CONCLUSION

Participants described a tension between adapting and accepting life after stroke. Resilience was a useful framework, highlighting the contribution of inner, social and societal resources to recovery and quality of life, both directly and as enhanced through increased participation. Important factors for adaptation are meaningful values in life, individual strategies for adaptation and support from both social relationship and the society.

Long-term air pollution exposure and incident stroke in American older adults: A national cohort study

Aims

Stroke is a leading cause of death and disability for Americans, and growing evidence suggests that air pollution may play an important role. To facilitate pollution control efforts, the National Academy of Sciences and the World Health Organization have prioritized determining which air pollutants are most toxic. However, evidence is limited for the simultaneous effects of multiple air pollutants on stroke.

Methods and results

We constructed a nationwide population-based cohort study, using the Medicare Chronic Conditions Warehouse (2000-2017) and high-resolution air pollution data, to investigate the impact of long-term exposure to ambient PM2.5, NO2, and ground-level O3 on incident stroke. Hazard ratios (HR) for stroke incidence were estimated using single-, bi-, and tri-pollutant Cox proportional hazards models. We identified ~2.2 million incident stroke cases among 17,443,900 fee-for-service Medicare beneficiaries. Per interquartile range (IQR) increase in the annual average PM2.5 (3.7 μg/m3), NO2 (12.4 ppb), and warm-season O3 (6.5 ppb) one-year prior to diagnosis, the HRs were 1.022 (95% CI: 1.017-1.028), 1.060 (95% CI: 1.054-1.065), and 1.021 (95% CI: 1.017-1.024), respectively, from the tri-pollutant model. There was strong evidence of linearity in concentration-response relationships for all three air pollutants in single-pollutant models. This linear relationship remained robust for NO2 and O3 in tri-pollutant models while the effect of PM2.5 attenuated at the lower end of concentrations.

Conclusion

Using a large nationwide cohort, our study suggests that long-term exposure to PM2.5, NO2, and O3 may independently increase the risk of stroke among the US elderly, among which traffic-related air pollution plays a particularly crucial role.

Supervised Myoelectrical Hand Gesture Recognition in Post-Acute Stroke Patients with Upper Limb Paresis on Affected and Non-Affected Sides

In clinical practice, acute post-stroke paresis of the extremities fundamentally complicates timely rehabilitation of motor functions; however, recently, residual and distorted musculoskeletal signals have been used to initiate feedback-driven solutions for establishing motor rehabilitation. Here, we investigate the possibilities of basic hand gesture recognition in acute stroke patients with hand paresis using a novel, acute stroke, four-component multidomain feature set (ASF-4) with feature vector weight additions (ASF-14NP, ASF-24P) and supervised learning algorithms trained only by surface electromyography (sEMG). A total of 19 (65.9 ± 12.4 years old; 12 men, seven women) acute stroke survivors (12.4 ± 6.3 days since onset) with hand paresis (Brunnstrom stage 4 ± 1/4 ± 1, SIAS 3 ± 1/3 ± 2, FMA-UE 40 ± 20) performed 10 repetitive hand movements reflecting basic activities of daily living (ADLs): rest, fist, pinch, wrist flexion, wrist extension, finger spread, and thumb up. Signals were recorded using an eight-channel, portable sEMG device with electrode placement on the forearms and thenar areas of both limbs (four sensors on each extremity). Using data preprocessing, semi-automatic segmentation, and a set of extracted feature vectors, support vector machine (SVM), linear discriminant analysis (LDA), and k-nearest neighbors (k-NN) classifiers for statistical comparison and validity (paired t-tests, p-value < 0.05), we were able to discriminate myoelectrical patterns for each gesture on both paretic and non-paretic sides. Despite any post-stroke conditions, the evaluated total accuracy rate by the 10-fold cross-validation using SVM among four-, five-, six-, and seven-gesture models were 96.62%, 94.20%, 94.45%, and 95.57% for non-paretic and 90.37%, 88.48%, 88.60%, and 89.75% for paretic limbs, respectively. LDA had competitive results using PCA whereas k-NN was a less efficient classifier in gesture prediction. Thus, we demonstrate partial efficacy of the combination of sEMG and supervised learning for upper-limb rehabilitation procedures for early acute stroke motor recovery and various treatment applications.

Assessment of incidence and trends in cerebrovascular disease in the healthcare district of Lleida (Spain) in the period 2010-2014

OBJECTIVES

This study aimed to determine the incidence and trends of cerebrovascular disease (CVD) in the healthcare district of Lleida.

MATERIAL AND METHODS

We performed a population-based prospective cohort study including the entire population of the healthcare district of Lleida (440 000 people). Information was gathered from the minimum basic data set from the emergency department and hospital discharges for the period from January 2010 to December 2014. All types of stroke were included. We evaluated crude and age-standardised rates using the world population as a reference. Patients without neuroimaging confirmation of the diagnosis were excluded.

RESULTS

We identified 4397 patients: 1617 (36.8%) were aged 80 years or over; 3969 (90.3%) presented ischaemic stroke, and 1741 (39.6%) were women. The crude incidence rate ranged from 192 (95% confidence interval [CI], 179-205) to 211 (95% CI, 197-224) cases per 100 000 population, in 2012 and 2013, respectively. Age-standardised rates ranged from 93 (95% CI, 86-100) to 104 (95% CI, 96-111) cases per 100 000 population, in 2012 and 2013, respectively. For all years, incidence rates increased with age, and were significantly higher among men than among women.

CONCLUSION

The impact of CVD in Lleida is comparable to that observed in other European regions. However, population ageing induces a high crude incidence rate, which remained stable over the five-year study period.

Reducing care time after implementing protocols for acute ischemic stroke: a systematic review

Background The treatment of acute ischemic stroke with cerebral reperfusion therapy requires rapid care and recognition of symptoms.

Objective To analyze the effectiveness of implementing protocols for acute ischemic stroke in reducing care time.

Methods Systematic review, which was performed with primary studies in Portuguese, English, and Spanish published between 2011 and 2020. Inclusion criteria: study population should comprise people with acute ischemic stroke and studies should present results on the effectiveness of using urgent care protocols in reducing care time. The bibliographic search was conducted in June 2020 in the LILACS, MEDLINE, Embase, Scopus, CINAHL, Academic Search Premier, and SocINDEX databases. The articles were selected, and data were extracted by two independent reviewers; the synthesis of the results was performed narratively. The methodological quality of articles was evaluated through specific instruments proposed by the Joanna Briggs Institute.

Results A total of 11,226 publications were found, of which 35 were included in the study. Only one study reported improvement in the symptoms-onset-to-door time after protocol implementation. The effectiveness of the therapeutic approach protocols for ischemic stroke was identified in improving door-to-image, image-to-needle, door-to-needle and symptoms-onset-to-needle times. The main limitation found in the articles concerned the lack of clarity in relation to the study population.

Conclusions Several advances have been identified in in-hospital care with protocol implementation; however, it is necessary to improve the recognition time of stroke symptoms among those who have the first contact with the person affected by the stroke and among the professionals involved with the prehospital care.

Non-invasive brain stimulation as therapeutic approach for ischemic stroke: Insights into the (sub)cellular mechanisms

Although spontaneous recovery can occur following ischemic stroke due to endogenous neuronal reorganization and neuroplastic events, the degree of functional improvement is highly variable, causing many patients to remain permanently impaired. In the last decades, non-invasive brain stimulation (NIBS) techniques have emerged as potential add-on interventions to the standard neurorehabilitation programs to improve post-stroke recovery. Due to their ability to modulate cortical excitability and to induce neuroreparative processes in the brain, multiple studies have assessed the safety, efficacy and (sub)cellular mechanisms of NIBS following ischemic stroke. In this review, an overview will be provided of the different NIBS techniques that are currently being investigated in (pre)clinical stroke studies. The NIBS therapies that will be discussed include transcranial magnetic stimulation, transcranial direct current stimulation and extremely low frequency electromagnetic stimulation. First, an overview will be given of the cellular mechanisms induced by NIBS that are associated with enhanced stroke outcome in preclinical models. Furthermore, the current knowledge on safety and efficacy of these NIBS techniques in stroke patients will be reviewed.

Comparative Use of Contralateral and Sham-Operated Controls Reveals Traces of a Bilateral Genetic Response in the Rat Brain after Focal Stroke

Ischemic stroke is a multifactorial disease with a complex etiology and global consequences. Model animals are widely used in stroke studies. Various controls, either brain samples from sham-operated (SO) animals or symmetrically located brain samples from the opposite (contralateral) hemisphere (CH), are often used to analyze the processes in the damaged (ipsilateral) hemisphere (IH) after focal stroke. However, previously, it was shown that focal ischemia can lead to metabolic and transcriptomic changes not only in the IH but also in the CH. Here, using a transient middle cerebral artery occlusion (tMCAO) model and genome-wide RNA sequencing, we identified 1941 overlapping differentially expressed genes (DEGs) with a cutoff value >1.5 and Padj < 0.05 that reflected the general transcriptome response of IH subcortical cells at 24 h after tMCAO using both SO and CH controls. Concomitantly, 861 genes were differentially expressed in IH vs. SO, whereas they were not vs. the CH control. Furthermore, they were associated with apoptosis, the cell cycle, and neurotransmitter responses. In turn, we identified 221 DEGs in IH vs. CH, which were non-DEGs vs. the SO control. Moreover, they were predominantly associated with immune-related response. We believe that both sets of non-overlapping genes recorded transcriptome changes in IH cells associated with transhemispheric differences after focal cerebral ischemia. Thus, the specific response of the CH transcriptome should be considered when using it as a control in studies of target brain regions in diseases that induce a global bilateral genetic response, such as stroke.

Risk Factors of Asymptomatic Carotid Artery Disease in Geriatric Evaluated Using Carotid Intima-Media Thickness (IMT) Measurement, the First Indonesian Population Study

Introduction Carotid artery disease in geriatric is one of the important etiologies of stroke, which topped the cause of mortality in Indonesia. Specific prevention should be done as early as asymptomatic disease occurred. Initial assessment can be performed using ultrasound by measuring the intima-media thickness (IMT) of carotid artery, which can evaluate earlier progression of the atherosclerosis process. Unfortunately, we do not have risk factors categorization that show us which geriatric population fall under high-risk stratification to be screened.

Method Study was done to Indonesian geriatric population. Asymptomatic carotid disease was tested positive if IMT was > 0.9 mm without any previous neurological symptoms. Correlation of the result was statistically tested with risk factors of atherosclerotic process, such as sex, body mass index, presence of hypertension, diabetes mellitus, and hypercholesterolemia

Results Study obtained 104 subjects and showed the prevalence of asymptomatic carotid disease was 37.5%. Two risk factors: diabetes mellitus and hypercholesterolemia were statistically significant (p = 0.01) with odds ratio (OR) 3.56 (1.31–9.64, 95% confidence interval [CI]) and OR 2.85 (1.25–6.51, CI 95%), respectively. Logistic regression showed the risk was 69.2% by having two of these comorbidities, 47.2 or 42.5% if diabetes mellitus or hypercholesterolemia was present.

Conclusion As diabetes mellitus and hypercholesterolemia were proved to be significant risk factors for asymptomatic carotid artery disease, we recommend performing ultrasound screening to measure carotid artery IMT for geriatric population who had diabetes mellitus and/or hypercholesterolemia for asymptomatic carotid artery disease to be diagnosed and further treated.

Citicoline in acute ischemic stroke: A randomized controlled trial

Introduction

Two pharmacological possibilities exist for an acute ischemic stroke (AIS): recanalization of the occluded artery and neuroprotection from ischaemic injury, the latter’s efficacy being debatable. We sought to determine whether administration of Citicoline immediately after recanalization therapy for AIS would improve clinical and radiological outcome at three months compared to standard treatment alone.

Patients and methods

CAISR was a single centre, randomized, placebo-controlled, parallel-group trial with blinded endpoint assessment. It was approved by the All India Institute of Medical Sciences Institutional ethics committee and registered at the Clinical Trial Registry of India (CTRI/2018/011900). We recruited participants with AIS undergoing recanalization therapy and randomly assigned them to receive either Citicoline or placebo in 1:1 ratio. Citicoline arm patients received Citicoline 1gm BD intravenously for three days, followed by oral citicoline 1gm BD for 39 days. Placebo arm patients received 100ml intravenous normal saline for three days, followed by multivitamin tablet BD for 39 days. All patients received standard of care.

Outcome

Blinded assessors did the follow-up assessment at six weeks (MRI Brain-stroke volume) and three months (NIHSS 0–2, mRS 0–2 and Barthel index> = 95).

Results

The infarct volume decreased from week 1 to week 6 by 2.6 cm³ on placebo versus 4.2 cm³ on Citicoline (p-0.483). The OR for achieving NIHSS 0–2, mRS 0–2 and Barthel index> = 95 with Citicoline was found to be 0.96(95%CI 0.39–2.40), 0.92(95%CI 0.40–2.05) and 0.87(95%CI 0.22–2.98) respectively.

Conclusion

CAISR was the first to evaluate the role of Citicoline, when used immediately after recanalization therapy, when the penumbral tissue is the most susceptible either to be protected from injury or become ischemic. We did not find any significant difference between the Citicoline or placebo arms with respect to either our primary or secondary outcomes.

Effects of the home-based exercise program with an augmented reality system on balance in patients with stroke: a randomized controlled trial

PURPOSE

To investigate the therapeutic potentials of the home-based exercise program (HEP) with an augmented reality (AR) system to improve balance in patients with stroke.

METHODS

Sixty-eight patients with stroke were recruited in this randomized controlled study with blind observer. Patients in the smart-rehab group underwent HEP with an AR system for four weeks, whereas patients in the control group underwent the written and pictorial HEP. Assessments of balance and fear of falling were performed three times: at baseline (T0), immediately (T1), and four weeks (T2) after cessation of HEP.

RESULTS

The change in balance from T0 to T1 was significantly higher in the smart-rehab group than in the control group (p < 0.017). The change in fear of falling from T0 to T1 and T2 was significantly higher in the smart-rehab group than in the control group, respectively (p < 0.017). One participant with vertebral artery dissection in the smart-rehab group discontinued participation due to a transient ischemic attack which resolved during the study period.

CONCLUSIONS

The results of this study suggest that the HEP with the AR system might be effective to improve balance in patients with stroke. However, more careful precautions for the HEP using the AR system are also required. Implications for rehabilitationBalance was modestly improved in both home-based exercise programs, slightly more in AR home exercise group.AR home-based program was significantly better in reducing fear of falling compared to the control group.No falls were recorded, however, safety for patients with arterial dissection needs to be carefully considered due to the possibility of adverse effects.

Shared Inflammatory Pathology of Stroke and COVID-19

Though COVID-19 is primarily characterized by symptoms in the periphery, it can also affect the central nervous system (CNS). This has been established by the association between stroke and COVID-19. However, the molecular mechanisms that cause stroke related to a COVID-19 infection have not been fully explored. More specifically, stroke and COVID-19 exhibit an overlap of molecular mechanisms. These similarities provide a way to better understand COVID-19 related stroke. We propose here that peripheral macrophages upregulate inflammatory proteins such as matrix metalloproteinases (MMPs) in response to SARS-CoV-2 infection. These inflammatory molecules and the SARS-CoV-2 virus have multiple negative effects related to endothelial dysfunction that results in the disruption of the blood-brain barrier (BBB). Finally, we discuss how the endothelial blood-brain barrier injury alters central nervous system function by leading to astrocyte dysfunction and inflammasome activation. Our goal is to elucidate such inflammatory pathways, which could provide insight into therapies to combat the negative neurological effects of COVID-19.

Clock Gene Bmal1 Disruption in Vascular Smooth Muscle Cells Worsens Carotid Atherosclerotic Lesions

BACKGROUND

Clock system disruptions are associated with cardiovascular diseases. We previously demonstrated Bmal1 (brain muscle aryl nuclear translocase like-1) expression is significantly attenuated in plaque-derived vascular smooth muscle cells (VSMCs). However, the influence of Bmal1 disruption in VSMCs and its molecular targets are still unclear. Here, we aim to define how Bmal1 disruption in VSMCs influences the atherosclerosis lesions.

METHODS

The relationship among Bmal1, neurological symptoms, and plaque stability was investigated. VSMC Bmal1^-/- and VSMC Bmal1^+/+mice were generated and injected with adeno associated virus encoding mutant proprotein convertase subtilisin/kexin type 9 to induce atherosclerosis. Carotid artery ligation and cuff placement were performed in these mice to confirm the role of Bmal1 in atherosclerosis progression. The relevant molecular mechanisms were then explored.

RESULTS

Bmal1 expression in the carotid plague was significantly lower in symptomatic patients as well as in unstable plaques. Moreover, Bmal1 reduction is an independent risk factor for neurological symptoms and plaque instability. Besides, VSMC Bmal1^-/- mice exhibit aggravated atherosclerotic lesions. Further study demonstrated that Bmal1 downregulation in VSMCs increased VSMC migration, monocyte transmigration, reactive oxygen species levels, and VSMCs apoptosis. As for the mechanism, we revealed that Bmal1 suppresses VSMCs migration by inhibiting RAC1 activity in 2 ways: by activating the transcription of RhoGDIα and by interacting with RAC1. Besides, Bmal1 was shown to preserve antioxidant function in VSMCs by activating Nrf2 (nuclear factor erythroid 2-related factor 2) and Bcl-2 transcription.

CONCLUSIONS

Bmal1 disruption in VSMCs worsens atherosclerosis by promoting VSMC migration and monocyte transmigration and impairing antioxidant function. Therefore, Bmal1 may be a potential therapeutic target and biomarker of atherosclerosis in the future.

Mitigated Oxidative Stress and Cognitive Impairments in Transient Global Ischemia using Niosomal Selegiline-NBP delivery

Stroke is the most common reason for adult disabilities and the second ground for death worldwide. Our previous study revealed that selegiline serves as an alternative candidate in transient hypoxia-ischemia. However, aggressive and restless behavior was observed in stroke-induced rats receiving 4 mg/kg selegiline. In comparison, 1 mg/kg selegiline could induce negligible therapeutic effects on mitochondrial dysfunction and histopathological changes. Therefore, we designed oral noisome-based selegiline attached to 4-(4-nitrobenzyl) pyridine to improve transient global ischemia by attenuating cognitive impairments, oxidative stress, and histopathological injury. The investigation was performed in transient hypoxia-ischemia-induced rats by oral administration of nanoformulation containing selegiline (0.25-1 mg/kg) for 4 weeks (3 times a week). Novel object recognition (NOR) was considered to evaluate their cognitive dysfunction. Oxidative stress parameters and brain histopathological assessments were determined following the scarification of rats. Outstandingly, our data demonstrated slower selegiline release from niosomes relative to free drug, which was also in a controlled manner. Our data confirmed significant improvement in cognitive behavior in the NOR test, an increase in glutathione level and total antioxidant power, a decline in MDA and protein carbonyl level, as well as a decreased number of dead cells in histopathological assessment after being exposed to (0.5-1 mg/kg) selegiline-NBP nanoformulation. These data manifested that the selegiline-NBP nanoformulation (0.5-1 mg/kg) could significantly reduce oxidative damage, cognitive dysfunction, and histopathological damage compared to transient hypoxia-ischemia rats, which is 20 times lower than the therapeutic dose in humans. Therefore, the proposed nanoformulation would be capable as an alternative candidate without side effects in stroke.

Measurement Feedback System for Intensive Neurorehabilitation after Severe Acquired Brain Injury

Outcome of acquired brain injury (ABI) and the potential for neurorehabilitation are subject to distinct heterogeneity between patients. Limited knowledge of the complex constellation of determinants at play interferes with the possibility to deploy precision medicine in neurorehabilitation. Measurement Feedback Systems (MFS) structure clinical data collection and deliver the measurement results as feedback to clinicians, thereby facilitating progress monitoring, promoting balanced patient-centered discussion and shared decision making. Accumulation of clinical data in the MFS also enables data-driven precision rehabilitation medicine. This article describes the development and implementation of a MFS for neurorehabilitation after ABI. The MFS consists of specialized measurement tracks which are developed together with representatives of each discipline in the multidisciplinary team. The MFS is built into a digital platform that automatically distributes measurements among clinicians, at predetermined time points during the inpatient treatment, outpatient treatment and follow-up. The results of all measurements are visualized in individual patient dashboards that are accessible for all clinicians involved in treatment. Since step-wise implementation, 124 patients have been registered on the MFS platform so far, providing an average of more than 200 new measurements per week. Currently, more than 15,000 clinical measurements are captured in the MFS. The current overall completion rate of measurements is 86,4%. This study shows that structured clinical assessment and feedback is feasible in the context of neurorehabilitation after severe ABI. The future directions are discussed for MFS data in our Health Intelligence Program, which aims at periodic care evaluation and the transition of neurorehabilitation care towards precision medicine.

Biomechanical Assessment of Post-Stroke Patients' Upper Limb before and after Rehabilitation Therapy Based on FES and VR

Stroke is a medical condition characterized by the rapid loss of focal brain function. Post-stroke patients attend rehabilitation training to prevent the degeneration of physical function and improve upper limb movements and functional status after stroke. Promising rehabilitation therapies include functional electrical stimulation (FES), exergaming, and virtual reality (VR). This work presents a biomechanical assessment of 13 post-stroke patients with hemiparesis before and after rehabilitation therapy for two months with these three methods. Patients performed two tests (Maximum Forward Reach and Apley Scratching) where maximum angles, range of motion, angular velocities, and execution times were measured. A Wilcoxon test was performed (p = 0.05) to compare the variables before and after the therapy for paretic and non-paretic limbs. Significant differences were found in range of motion in flexion–extension, adduction–abduction, and internal–external rotation of the shoulder. Increases were found in flexion–extension, 17.98%, and internal–external rotation, 18.12%, after therapy in the Maximum Forward Reach Test. For shoulder adduction–abduction, the increase found was 20.23% in the Apley Scratching Test, supporting the benefits of rehabilitation therapy that combines FES, exergaming, and VR in the literature.