Stroke systems of care in low-income and middle-income countries: challenges and opportunities

Honduran nurses' perceptions among the quality of care for stroke patients: a qualitative study

OBJECTIVE

to explore the nurses' perceptions among the quality of care to stroke patients in a public hospital in Northern Honduras.

METHOD

a descriptive phenomenological study was carried out. The data collection was conducted by means of depth- interviews to 20 general nurses from the emergency and clinical medicine departments from the Atlántida General Hospital. Data analysis was by thematic technique.

RESULTS

the research found three key themes, and 10 subthemes, which illustrated the quality of stroke patients care in a general hospital from Honduras. The finding points up the theme "negative outcomes regarding the structure dimension of the patient care units", which means the failure to improve or maintain the quality of healthcare. Likewise, "positive outcomes regarding the nursing process", defined as pleasant and helpful among the care of stroke patients, such as ethical and humanized caring, and activities on promoting patient self-care with involvement of the relatives.

CONCLUSION

the results indicate that Honduran nurses do not have qualified graduate training in critical care, which is a limitation that compromises the quality of care. Therefore, it is recommended to have clear organization structures and better resources managing, consequently, it may increase user satisfaction, as well as reducing hospital stays.

PhenoAge and PhenoAgeAccel in the context of dyslipidemia: association with stroke and potential as a new predictor in the US general population

BACKGROUND

The challenges posed by an aging society are increasingly recognized, particularly regarding the potential impacts of high-fat diets and the trend toward younger ages of disease onset. The purpose of this study was to clarify the relationships between the prevalence of stroke in the general US population and PhenoAge (PA) and PhenoAgeAccel (PAA).

METHODS

Key methods included a correlation heatmap to explore linear relationships between some of the variables and weighted multivariable logistic regression to assess associations between PA, PAA, and stroke. Restricted cubic spline (RCS) analysis was used to investigate nonlinear relationships and dose-response effects. The ability of the PAA to predict stroke risk was assessed by a nomogram model and a receiver operating characteristic curve.

RESULTS

After adjusting for confounding variables, both continuous and categorical PA and PAA were significantly associated with stroke prevalence. RCS analysis revealed a significant nonlinear relationship between PA and stroke prevalence. Further subgroup RCS analysis indicated that maintaining PA below 31.6 could provide greater benefits across all races and genders, specifically for individuals aged 40-80 years and those who are overweight or obese.

CONCLUSION

This study highlights the importance of stroke prevention in overweight and obese populations. Monitoring intermediary factors such as high-density lipoprotein cholesterol and waist circumference may reduce stroke risk. Additionally, PA and PAA may serve as novel markers for stroke, offering new directions for health management in an aging society.

Implementation of a goal-directed Care Bundle for intracerebral hemorrhage: Results of embedded process evaluation in the INTERACT3 trial

The third, stepped-wedge, cluster-randomized, Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT3), has shown that a goal-directed multi-faceted Care Bundle incorporating protocols for the management of physiological variables was safe and effective for improving functional recovery in a broad range of patients with acute intracerebral hemorrhage (ICH). The INTERACT3 Care Bundle included time- and target-based protocols for the management of early intensive lowering of systolic blood pressure (SBP, target <140mmHg), glucose control (target 6.1-7.8 mmol/L in those without diabetes and 7.8-10.0 mmol/L in those with diabetes), anti-pyrexia treatment (target body temperature ≤37.5°C), and the rapid reversal of warfarin-related anticoagulation (target international normalized ratio <1.5). An embedded process evaluation was conducted to allow a better understanding of how the Care Bundle was implemented in different countries to enhance the transferability of this evidence in the international context. This study used a mixed-methods approach involving interviews, focus group discussions, and surveys to evaluate the implementation outcomes included fidelity, dose, reach, acceptability, appropriateness, adoption, and sustainability. Interviews (n = 27), focus group discussions (n = 3), and quantitative surveys (n = 48) were conducted in 7 low- and middle-income countries (LMICs) and 1 high-income country during 2019-2022. The Care Bundle was generally delivered as planned and well accepted by stakeholders, although some difficulties were reported in reaching the SBP and glycemic targets. Contextual factors including staff shortage, limited availability of antihypertensive drugs, and delayed systems of care processes, were common barriers to implementing the Care Bundle. Facilitating factors included good communication and collaboration with staff in emergency departments, the development of pathways within available resources, and regular training and monitoring. Our process evaluation provides useful insights into the contextual barriers which need to be addressed for effective scale up of the Care Bundle implementation in a global context. Trial registration: INTERACT3 is registered at Clinicaltrials.gov (NCT03209258) and the Chinese Clinical Trial Registry (ChiCTR-IOC-17011787).

Projections of the Stroke Burden at the Global, Regional, and National Levels up to 2050 Based on the Global Burden of Disease Study 2021

BACKGROUND

Stroke is a pressing public health issue worldwide. This study aimed to forecast the future temporal trends and distribution characteristics of the global stroke burden.

METHODS AND RESULTS

Global data on stroke incidence, prevalence, deaths, and disability-adjusted life years between 1990 and 2021 were obtained from the GBD (Global Burden of Disease) Study 2021. The temporal trends of stroke burden were estimated using various regression models. Gross domestic product per capita was adopted as a predictor in the model to consider the impact of economic development on stroke burden. Projections of stroke burden up to 2050 were generated using the optimal model selected based on the Akaike information criterion, encompassing global, World Bank income levels, national levels, and sex-age groups. In 2050, we projected 21.43 million stroke cases, 159.31 million survivors, 12.05 million deaths, and 224.86 million disability-adjusted life years due to stroke globally. From 2021 to 2050, there was a declining trend in the global age-adjusted stroke rates, with -7% in incidence, -4% in prevalence, -28% in deaths, and -28% in disability-adjusted life years. Upper-middle-income countries were projected to have the most severe stroke burden, followed by lower-middle-income countries, low-income countries, and high-income countries. The stroke burden in over half of the 204 countries and territories was expected to be alleviated from 2022 to 2050. Men and older women worldwide bear higher burden.

CONCLUSIONS

Stroke remains a serious global health challenge, especially in low-income and middle-income countries. Targeted implementation of prevention and interventions is imperative across diverse demographic groups.

Telehealth interventions for stroke management and rehabilitation in low- and middle-income countries: A scoping review

INTRODUCTION

The burden of stroke is higher in low- and middle-income countries (LMICs) than in high-income countries due to the lack of stroke care centers, stroke specialist, and rehabilitation access. One way to increase access to stroke care in LMICs is through the use of telehealth.

MATERIAL & METHOD

We performed a scoping review to summarize the evidence on telehealth in LMICs. We searched Medline, SCOPUS, and Web of Science through February 18th, 2022. Reviewers screened for studies reporting on health outcomes following telehealth interventions (imaging, thrombolysis, and rehabilitation) in LMICs. We included all study designs.

RESULTS

Out of 259 studies, 10 studies met the eligibility criteria. Nine reported on functional or disability measures, 6 reported on cerebral infarction or intracerebral hemorrhage, 5 reported on door-to-needle time to thrombolysis, and 6 reported on mortality rate. Out of 9 studies, 8 reported that the use of telehealth for stroke management and rehabilitation in LMICs has led to a decrease in the degree of post-stroke disability. However, the comparison group may have received no rehabilitation treatment at all in LMICs. All 5 studies that measured administration of thrombolytic therapy in respective telehealth interventions were within the recommended 3-hour time window. Studies with a comparison arm found that there was no significant difference in mortality and cerebral infarction/intracerebral hemorrhage rates between telehealth and control.

CONCLUSION

Evidence from this review suggests that telehealth may improve post-stroke disability and facilitate the timely administration of thrombolytics therapy within the 3-hour window by allowing remote access to distant tertiary stroke care center in situations where it would otherwise be delayed in LMICs due to logistical barriers such as an extended travel time. Further research using randomized and quasi-experimental studies are needed in LMICs to determine the overall effectiveness of telehealth intervention for stroke management and rehabilitation.

Mendelian randomization studies of lifestyle-related risk factors for stroke: a systematic review and meta-analysis

Objective

Stroke risk factors often exert long-term effects, and Mendelian randomization (MR) offers significant advantages over traditional observational studies in evaluating the causal impact of these factors on stroke. This study aims to consolidate and evaluate the relationships between potential causal factors and stroke risk, drawing upon existing MR research.

Methods

A comprehensive search for MR studies related to stroke was conducted up to August 2023 using databases such as PubMed, Web of Science, Embase, and Scopus. This meta-analysis examines the relationships between potential causative factors and stroke risk. Both random-effects and fixed-effects models were utilized to compile the dominance ratios of various causative elements linked to stroke. The reliability of the included studies was assessed according to the Strengthening the Reporting of Observational Studies in Epidemiology incorporating Mendelian Randomization (STROBE-MR) guidelines.

Results

The analysis identified several risk factors for stroke, including obesity, hypertension, low-density lipoprotein cholesterol (LDL-C), chronic kidney disease (CKD), and smoking. Protective factors included high-density lipoprotein cholesterol (HDL-C), estimated glomerular filtration rate (eGFR), and educational attainment. Subgroup analysis revealed that type 2 diabetes mellitus (T2DM), diastolic blood pressure (DBP) are risk factors for ischemic stroke (IS).

Conclusion

This study confirms that variables such as obesity, hypertension, elevated LDL-C levels, CKD, and smoking are significantly linked to the development of stroke. Our findings provide new insights into genetic susceptibility and potential biological pathways involved in stroke development.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42024503049.

World Federation of Neurology Needs Registry Survey 2021

The WFN Needs Registry survey was developed and conducted over two and a half years commencing in 2020 to investigate the accessibility and affordability of neurological services and therapeutics and the most urgent needs.

METHOD

An experienced neurologist responded in each of 118 societies to an online electronic survey comprising 13 questions. General data sought comprised the respondent's training, place of practice, duration in practice, number of neurologists in the society, health care system and types of neurological practice available. Specific data collected comprised neurological facilities, specialist services available, resources, therapeutics accessibility, challenges and three most urgent needs.

RESULTS

Responding neurologists spent a median of 26 years in practice and represented a median of 225 neurologists per society. Of 13 classes of neuromedicines deemed readily available to 70% of the population, 41 societies listed ≥1 and 14 societies ≥3 unavailable. The three most frequent unavailable neuromedicines were second level AEDs, Dopamine agonists and MS DMTs. Of 14 neurological services, 15 societies had all services accessible and affordable, 13 had none and 72 had ≥1 services either inaccessible or unaffordable. EEG, Epilepsy, Headache and EMG services were most available; Neurogenetics, Neuropsychology, Neurorehabilitation and Neurodevelopmental services were least available. Of 13 specified challenges, lack of subspecialists and specialty centers were both identified by 61% of societies followed by costs of neurological care, neuromedicines availability and stigma. Ten societies had no challenges.

CONCLUSION

A unique insight into the inequities of neurological care globally and a potential tool to assist their remedy.

Predictive etiological classification of acute ischemic stroke through interpretable machine learning algorithms: a multicenter, prospective cohort study

BACKGROUND

The prognosis, recurrence rates, and secondary prevention strategies varied significantly among different subtypes of acute ischemic stroke (AIS). Machine learning (ML) techniques can uncover intricate, non-linear relationships within medical data, enabling the identification of factors associated with etiological classification. However, there is currently a lack of research utilizing ML algorithms for predicting AIS etiology.

OBJECTIVE

We aimed to use interpretable ML algorithms to develop AIS etiology prediction models, identify critical factors in etiology classification, and enhance existing clinical categorization.

METHODS

This study involved patients with the Third China National Stroke Registry (CNSR-III). Nine models, which included Natural Gradient Boosting (NGBoost), Categorical Boosting (CatBoost), Extreme Gradient Boosting (XGBoost), Random Forest (RF), Light Gradient Boosting Machine (LGBM), Gradient Boosting Decision Tree (GBDT), Adaptive Boosting (AdaBoost), Support Vector Machine (SVM), and logistic regression (LR), were employed to predict large artery atherosclerosis (LAA), small vessel occlusion (SVO), and cardioembolism (CE) using an 80:20 randomly split training and test set. We designed an SFS-XGB with 10-fold cross-validation for feature selection. The primary evaluation metrics for the models included the area under the receiver operating characteristic curve (AUC) for discrimination and the Brier score (or calibration plots) for calibration.

RESULTS

A total of 5,213 patients were included, comprising 2,471 (47.4%) with LAA, 2,153 (41.3%) with SVO, and 589 (11.3%) with CE. In both LAA and SVO models, the AUC values of the ML models were significantly higher than that of the LR model (P < 0.001). The optimal model for predicting SVO (AUC [RF model] = 0.932) outperformed the optimal LAA model (AUC [NGB model] = 0.917) and the optimal CE model (AUC [LGBM model] = 0.846). Each model displayed relatively satisfactory calibration. Further analysis showed that the optimal CE model could identify potential CE patients in the undetermined etiology (SUE) group, accounting for 1,900 out of 4,156 (45.7%).

CONCLUSIONS

The ML algorithm effectively classified patients with LAA, SVO, and CE, demonstrating superior classification performance compared to the LR model. The optimal ML model can identify potential CE patients among SUE patients. These newly identified predictive factors may complement the existing etiological classification system, enabling clinicians to promptly categorize stroke patients' etiology and initiate optimal strategies for secondary prevention.

The Principles of Home Care for Patients with Stroke: An Integrative Review

Background

Patients With Stroke (PWS), like patients with other chronic health conditions, need long-term care in home settings. Patient transfer from hospital to home is associated with challenges such as care quality impairment and ineffective patient need fulfillment. The aim of this study was to assess the principles of Home Care (HC) for PWS.

Materials and Methods

This integrative review was conducted in 2023 using the method recommended by Whittemore and Knafl. The Web of Science, Google Scholar, ScienceDirect, ProQuest, Scopus, Cumulative Index to Nursing and Allied Health Literature, PubMed, and specific databases for stroke care guidelines were searched to find relevant articles published between 2010 and 2023. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used for document screening and selection. The data were analyzed using the constant comparison method.

Results

Primarily, 2608 documents were retrieved, and 22 of them were included in data analysis. The principles of HC for PWS were categorized into six main categories: principles of transition from hospital care to HC, principles of assessment for HC, principles of education for HC, principles of designing an HC plan, principles of HC measures, and principles of discharge from HC centers.

Conclusions

The present study provides a detailed overview of the principles of HC for PWS, which can be used to develop standard guidelines and improve the quality of HC for PWS.

Stroke Rehabilitation in India: Addressing Gender Inequities

Gender inequality has a significant and complex impact on stroke recovery and rehabilitation outcomes. Moreover, the influence of gender on post-stroke recovery is multifactorial, primarily biological, social, and behavioral issues. The recovery paths for men and women may have different outlines in relation to stroke occurrence, injury sites, and hormonal effects. These collectively influence the effective summarization of recovery strategies and outcomes. Furthermore, societal and cultural elements play a significant role in shaping access to resources, social support networks, and participation in rehabilitation programs, which consequently affect the outcomes. Considering the gender-specific nuances is important in developing effective rehabilitation strategies. Furthermore, effective stroke rehabilitation programs are needed to achieve equitable and improved recovery outcomes for all stroke survivors and to create inclusive interventions that consider these differences.

Stroke rehabilitation: from diagnosis to therapy

Stroke remains a significant global health burden, necessitating comprehensive and innovative approaches in rehabilitation to optimize recovery outcomes. This paper provides a thorough exploration of rehabilitation strategies in stroke management, focusing on diagnostic methods, acute management, and diverse modalities encompassing physical, occupational, speech, and cognitive therapies. Emphasizing the importance of early identification of rehabilitation needs and leveraging technological advancements, including neurostimulation techniques and assistive technologies, this manuscript highlights the challenges and opportunities in stroke rehabilitation. Additionally, it discusses future directions, such as personalized rehabilitation approaches, neuroplasticity concepts, and advancements in assistive technologies, which hold promise in reshaping the landscape of stroke rehabilitation. By delineating these multifaceted aspects, this manuscript aims to provide insights and directions for optimizing stroke rehabilitation practices and enhancing the quality of life for stroke survivors.

The Capacitated Maximal Covering Location Problem Improves Access to Stroke Treatment: A Cross-Sectional Simulation Study

Disparities in accessing advanced stroke treatment have been recognized as a policy challenge in multiple countries, including Japan, necessitating priority solutions. Nevertheless, more practical healthcare policies must be implemented due to the limited availability of healthcare staff and financial resources in most nations. This study aimed to evaluate the supply and demand balance of mechanical thrombectomy (MT) and identify areas with high priority for enhancing stroke centers. The target area of this study was Hokkaido, Japan. We adopted the capacitated maximal covering location problem (CMCLP) to propose an optimal allocation without increasing the number of medical facilities. Four realistic scenarios with varying levels of total MT supply capacity for Primary stroke centers and assuming a range of 90 minutes by car from the center were created and simulated. From scenarios 1 to 4, the coverage increased by approximately 53% to 85%, scenarios 2 and 3 had 5% oversupply, and scenario 4 had an oversupply of approximately 20%. When the supply capacity cap was eliminated and 8 PSCs received 31 or more patients, they became priority enhancement targets. The CMCLP estimates demand coverage considering the supply and demand balance and indicates areas and facilities where MT supply capacity enhancement is a priority.

Artificial Intelligence-based automated CT brain interpretation to accelerate treatment for acute stroke in rural India: An interrupted time series study

In resource-limited settings, timely treatment of acute stroke is dependent upon accurate diagnosis that draws on non-contrast computed tomography (NCCT) scans of the head. Artificial Intelligence (AI) based devices may be able to assist non-specialist physicians in NCCT interpretation, thereby enabling faster interventions for acute stroke patients in these settings. We evaluated the impact of an AI device by comparing the time to intervention (TTI) from NCCT imaging to significant intervention before (baseline) and after the deployment of AI, in patients diagnosed with stroke (ischemic or hemorrhagic) through a retrospective interrupted time series analysis at a rural hospital managed by non-specialists in India. Significant intervention was defined as thrombolysis or antiplatelet therapy in ischemic strokes, and mannitol for hemorrhagic strokes or mass effect. We also evaluated the diagnostic accuracy of the software using the teleradiologists' reports as ground truth. Impact analysis in a total of 174 stroke patients (72 in baseline and 102 after deployment) demonstrated a significant reduction of median TTI from 80 minutes (IQR: 56·8-139·5) during baseline to 58·50 (IQR: 30·3-118.2) minutes after AI deployment (Wilcoxon rank sum test-location shift: -21·0, 95% CI: -38·0, -7·0). Diagnostic accuracy evaluation in a total of 864 NCCT scans demonstrated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) in detecting intracranial hemorrhage to be 0·89 (95% CI: 0·83-0·93), 0·99 (0·98-1·00), 0·96 (0·91-0·98) and 0·97 (0·96-0·98) respectively, and for infarct these were 0·84 (0·79-0·89), 0·81 (0·77-0·84), 0·58 (0·52-0·63), and 0·94 (0·92-0·96), respectively. AI-based NCCT interpretation supported faster abnormality detection with high accuracy, resulting in persons with acute stroke receiving significantly earlier treatment. Our results suggest that AI-based NCCT interpretation can potentially improve uptake of lifesaving interventions for acute stroke in resource-limited settings.

Multiwavelength laser diode based portable photoacoustic and ultrasound imaging system for point of care applications

Vascular diseases are a leading cause of death and disability worldwide. Despite having precursor conditions like peripheral arterial disease (PAD), they are often only diagnosed after the onset of stroke or heart attack. Low-cost, portable, noninvasive, point-of-care (POC), label-free assessment of deep vascular function benefits PAD diagnosis, especially in resource poor settings of the world. Doppler ultrasound-based blood flow measurements can diagnose PAD, albeit with limited sensitivity and specificity. To overcome this, here, we propose the first-of-its-kind dual-modality photoacoustic-and-ultrasound (PAUS) imaging system that integrates a multiwavelength pulsed laser diode (PLD) with a compact ultrasound data acquisition unit. The mesoscopic imaging depth of the portable PLD-PAUS system was validated using tissue phantoms, and its multispectral photoacoustic imaging capabilities were validated using an atherosclerosis-mimicking phantom. Furthermore, we demonstrated high-contrast volumetric in vivo photoacoustic imaging of rodent abdominal vasculature and quantified vessel reactivity due to hypercapnia stimulation. The multiparametric functional and molecular imaging capabilities of the PLD-PAUS system holds promise for POC applications.

Enhancing stroke care in Ghana: A systematic review of stroke rehabilitation services

OBJECTIVE

In Ghana, the shifting demographics of stroke incidence towards young adults have prompted the expansion of stroke care and rehabilitation efforts. Nevertheless, the precise impact of stroke rehabilitation remains unclear. We conducted a systematic review to explore the landscape and effects of stroke rehabilitation in Ghana.

METHOD

We identified articles on stroke rehabilitation services in Ghana through searches of PubMed, Scopus, Embase, and Web of Science from inception until February 2024. The Critical Appraisal Skills Programme (CASP) Qualitative Checklist was employed to assess the risk of bias in the included studies, supplemented by qualitative synthesis.

RESULTS

Among the 213 articles screened, 8 were deemed suitable for review. These studies primarily focused on two groups: stroke survivors (n = 335) and healthcare professionals (HCPs) (n = 257). Many stroke survivors reported significant benefits from telerehabilitation, with increased participation in rehabilitation activities correlating with improved physical and cognitive outcomes. The findings also underscored a lack of knowledge about stroke rehabilitation among HCPs, alongside variations in the availability of protocols and guidelines for stroke management across different hospital levels.

CONCLUSIONS

The review reveals several challenges in stroke rehabilitation in Ghana, including disparities in HCPs' perceptions and utilization of rehabilitation services. The findings emphasize the need for comprehensive, patient-centered approaches, standardized training for HCPs, improved resource allocation, and the integration of telehealth to overcome barriers and enhance stroke rehabilitation in Ghana. These insights hold significance not only for Ghana but also for guiding strategies in similar contexts worldwide, aiming to improve stroke rehabilitation outcomes.

Stroke Demographics, Risk Factors, Subtypes, Syndromes, Mechanisms and Inter-Ethnic Differences between Chinese, Malays and Indians in Singapore-A Hospital-Based Study

Disparities in stroke may be due to socioeconomics, demographics, risk factors (RF) and ethnicity. Asian data are scant. This retrospective hospital-based study aimed to explore demographics, RF, stroke subtypes and mechanisms among the Chinese, Malays and Indians in Singapore. Stroke was subtyped into haemorrhagic stroke (HS) and ischaemic stroke (IS). For IS, the clinical syndrome was classified using the Oxfordshire Community Stroke Project (OCSP) classification while the stroke mechanism was categorised using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. During the study period 1 June 2015 to 31 December 2023, data were collected on 1165 patients, with a mean age of 65.6 ± 12.9 yr; 47.4% were female, 83% were Chinese and hypertension (63.5%) and hyperlipidaemia (60.3%) were the most common RF. HS comprised 23.5% (95%CI 21.1-26.1%) (intracerebral 21.7%, subarachnoid 1.3%) of the patients, while IS comprised 76.5% (95%CI 73.9-78.9%) (small artery occlusion 29.0%, cardioembolism 13.3%, large artery atherosclerosis 9.4%, stroke of other determined aetiology 6.2%, stroke of undetermined aetiology 18.6%); 55% of patients had lacunar syndrome. A multivariable analysis showed that HS was associated with ethnicity (p = 0.044), diabetes mellitus (OR 0.27, 95%CI 0.18-0.41, p < 0.001) and smoking (OR 0.47, 95%CI 0.34-0.64, p < 0.001). There were no significant inter-ethnic differences by the OCSP (p = 0.31) or TOAST (p = 0.103) classification. While differences in stroke subtype in Asia may be due to RF, ethnicity has a role. More studies are needed to further explore this.

Ethical Considerations in Endovascular Thrombectomy for Stroke

INTRODUCTION

Stroke is a leading cause of morbidity and mortality globally. Endovascular mechanical thrombectomy is considered for patients with large vessel occlusion stroke presenting up to 24 hours from onset and is being increasingly utilized across diverse clinical contexts. Proactive consideration of distinctive ethical dimensions of endovascular thrombectomy (EVT) can enable stroke care teams to deliver goal-concordant care to appropriately selected patients with stroke but have been underexplored.

METHODS

A narrative review with case examples was conducted.

RESULTS

We explain and critically evaluate the application of foundational bioethical principles and narrative ethics to the practice of EVT, highlight key ethical issues that may emerge in neuroendovascular practice and develop an ethical framework to aid in the responsible use of EVT for people with large-vessel occlusive ischemic stroke.

CONCLUSIONS

EVT for stroke introduces important ethical considerations. Salient challenges include decision-making capacity and informed consent, the telos of EVT, uncertainty, access to care, and resource allocation. An ethical framework focusing on combining patient values and preferences with the best available evidence in the context of a multidisciplinary care team is essential to ensure that the benefits of EVT are responsibly achieved and sustained.

Addressing disparities in the global epidemiology of stroke

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.

Biochemical, biomechanical and imaging biomarkers of ischemic stroke: Time for integrative thinking

Stroke is one of the leading causes of adult disability affecting millions of people worldwide. Post-stroke cognitive and motor impairments diminish quality of life and functional independence. There is an increased risk of having a second stroke and developing secondary conditions with long-term social and economic impacts. With increasing number of stroke incidents, shortage of medical professionals and limited budgets, health services are struggling to provide a care that can break the vicious cycle of stroke. Effective post-stroke recovery hinges on holistic, integrative and personalized care starting from improved diagnosis and treatment in clinics to continuous rehabilitation and support in the community. To improve stroke care pathways, there have been growing efforts in discovering biomarkers that can provide valuable insights into the neural, physiological and biomechanical consequences of stroke and how patients respond to new interventions. In this review paper, we aim to summarize recent biomarker discovery research focusing on three modalities (brain imaging, blood sampling and gait assessments), look at some established and forthcoming biomarkers, and discuss their usefulness and complementarity within the context of comprehensive stroke care. We also emphasize the importance of biomarker guided personalized interventions to enhance stroke treatment and post-stroke recovery.

Developing Systems of Care for Stroke in Resource-limited Settings

Although stroke prevention and treatment strategies have significantly advanced in recent years, implementation of these care elements in resource-limited settings can be challenging, since the burden of stroke is higher and access to stroke care is lower. Barriers to stroke care in resource-limited settings include insufficient prevention, reduced awareness of stroke symptoms, limited prehospital care and lack of triage systems, limited access to comprehensive stroke centers, inadequate personnel education, lack of staff and resources, as well as limited access to neuroimaging, thrombolytics, mechanical thrombectomy, neurosurgical care, and rehabilitation. Here, we suggest strategies to improve stroke care in these settings, including public health campaigns, protocols for prehospital notification, organized flow to specialized stroke centers, development of dedicated stroke units, and utilization of telemedicine and telerehabilitation. We also highlight the role of international organizations and governments in reducing the global burden of stroke.

Mounting Stroke Crisis in India: A Systematic Review

Stroke, a neurological disorder, has emerged as a formidable health challenge in India, with its incidence on the rise. Increased risk factors, which also correlate with economic prosperity, are linked to this rise, including hypertension, diabetes, obesity, sedentary lifestyle, and alcohol intake. Particularly worrisome is the impact on young adults, a pivotal segment of India's workforce. Stroke encompasses various clinical subtypes and cerebrovascular disorders (CVDs), contributing to its multifaceted nature. Globally, stroke's escalating burden is concerning, affecting developing nations. To combat this trend effectively and advance prevention and treatment strategies, comprehensive and robust data on stroke prevalence and impact are urgently required. In India, these encompass individuals with elevated BMIs, and those afflicted by hypertension, diabetes, or a familial history of stroke. Disparities in stroke incidence and prevalence manifest across India, with differences in urban and rural settings, gender-based variations, and regional disparities. Early detection, dietary changes, effective risk factor management, and equitable access to stroke care are required to address this issue. Government initiatives, like the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) 2019, provide guidelines, but effective implementation and awareness campaigns are vital. Overcoming barriers to stroke care, especially in rural areas, calls for improved infrastructure, awareness campaigns, and support systems. Data standardization and comprehensive population studies are pivotal for informed public health policies.

IMPETUS Stroke: Assessment of hospital infrastructure and workflow for implementation of uniform stroke care pathway in India

BACKGROUND

India accounts for 13.3% of global disability-adjusted life years (DALYs) lost due to stroke with a relatively younger age of onset compared to the Western population. In India's public healthcare system, many stroke patients seek care at tertiary-level government-funded medical colleges where an optimal level of stroke care is expected. However, there are no studies from India that have assessed the quality of stroke care, including infrastructure, imaging facilities, or the availability of stroke care units in medical colleges.

AIM

This study aimed to understand the existing protocols and management of acute stroke care across 22 medical colleges in India, as part of the baseline assessment of the ongoing IMPETUS stroke study.

METHODS

A semi-structured quantitative pre-tested questionnaire, developed based on review of literature and expert discussion, was mailed to 22 participating sites of the IMPETUS stroke study. The questionnaire assessed comprehensively all components of stroke care, including human resources, emergency system, in-hospital care, and secondary prevention. A descriptive analysis of their status was undertaken.

RESULTS

In the emergency services, limited stroke helpline numbers, 3/22 (14%); prenotification system, 5/22 (23%); and stroke-trained physicians were available, 6/22 (27%). One-third of hospitals did not have on-call neurologists. Although non-contrast computed tomography (NCCT) was always available, 39% of hospitals were not doing computed tomography (CT) angiography and 13/22 (59%) were not doing magnetic resonance imaging (MRI) after routine working hours. Intravenous thrombolysis was being done in 20/22 (91%) hospitals, but 36% of hospitals did not provide it free of cost. Endovascular therapy was available only in 6/22 (27%) hospitals. The study highlighted the scarcity of multidisciplinary stroke teams, 8/22 (36%), and stroke units, 7/22 (32%). Lifesaving surgeries like hematoma evacuation, 11/22 (50%), and decompressive craniectomy, 9/22 (41%), were performed in limited numbers. The availability of occupational therapists, speech therapists, and cognitive rehabilitation was minimal.

CONCLUSION

This study highlighted the current status of acute stroke management in publicly funded tertiary care hospitals. Lack of prenotification, limited number of stroke-trained physicians and neurosurgeons, relatively lesser provision of free thrombolytic agents, limited stroke units, and lack of rehabilitation services are areas needing urgent attention by policymakers and creation of sustainable education models for uniform stroke care by medical professionals across the country.

Big Data-Enabled Analysis of Factors Affecting Medical Expenditure in the Cerebral Infarction of a Developing City in Western China

Purpose

Cerebral infarction (CI) has been one of the leading causes of death in China since 2017, and controlling the medical expenses of this disease is an urgent issue for the Chinese government. This study aims to explore the important factors that affect the hospitalization expenses of CI patients and to provide a scientific basis for establishing a reasonable reimbursement mechanism and hospitalization expense standard for CI patients.

Methods

Data from 109,314 inpatients from the Healthcare Security Administration of Chengdu in western China from January 2016 to December 2018 were utilized. Descriptive statistical analysis was used for variable characteristic analysis. The Mann-Whitney test and Kruskal-Wallis test were used for single-factor analysis, and multiple linear stepwise regression was used for single-factor analysis and multiple-factor analysis.

Results

This study found that the average direct economic burden of CI in Chengdu was approximately 10,569 Chinese yuan (CNY), about 1450 US dollars, the average length of stay (LOS) was 14.47 days, the indirect economic burden was approximately 2817 CNY, and the total economic burden was 13,386 CNY for a CI inpatient. Gender, insurance type, grade of medical institution, the level of payment type, age, LOS, and complications and comorbidities (CCs) are the most important factors affecting CI medical costs.

Conclusion

Citizens should improve their lifestyle habits to reduce disease risk to avoid the associated medical and economic burdens. Hospitals should improve their medical technology to decrease the LOS and reduce direct medical costs. The government should actively promote the hierarchical diagnosis and treatment policy to reduce the waste of medical resources caused by low-acuity patients going to high-level hospitals for treatment. The National Healthcare Security Administration should optimize the medical insurance payment method and establish a corresponding mechanism to reduce the occurrence of excessive medical treatments such as overuse.

Secondary prevention by structured semi-interactive stroke prevention package in INDIA (SPRINT INDIA): Findings from the process evaluation of a randomized controlled trial

INTRODUCTION

Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in INDIA Trial delivered secondary stroke awareness intervention to sub-acute stroke patients in form of workbook, videos and SMS across 31 centres in 12 languages. Trial was stopped for futility due to fewer vascular outcomes than anticipated. Trial results indicated that trial intervention, did not lead to reduction in vascular events. We carried out process evaluation, to evaluate trial implementation and participant's perspectives, to comprehend the trial's futile outcomes.

MATERIALS AND METHODS

Using mixed methods approach, qualitative interviews and quantitative data from case report forms, workbooks and questionnaires were analysed to measure intervention fidelity and contamination. Using purposive sampling, 115 interviews of patient-caregiver dyads and health professionals at 11 centres and 2 focus group discussions were held.

RESULTS AND DISCUSSION

Iterative thematic analysis of qualitative data was done with RE-AIM and realist models. There was good fidelity to intervention and adherence to protocol; however, there was dilution of inclusion criteria by randomly enrolling uneducated and caregiver-dependent patients. Centre coordinators provided counselling to both arms, not specified by protocol, causing bias. Coordinators found it difficult to keep patients motivated to view intervention which was corroborated by fidelity questionnaire showing decreased viewing of intervention for a year. Cardiovascular protection improved in routine care by virtue of participating in trial. No contamination of intervention was reported.

CONCLUSION

The intervention was acceptable by patients and caregivers, which could be made a community-based programme. Reasons identified for decreased viewing were repetitive content and non-availability of personal cellular device.

Author Response: Factors Requiring Improvement for Timely and Effective Treatment of Acute Stroke

How to cite this article: Shah A, Diwan A. Author Response: Factors Requiring Improvement for Timely and Effective Treatment of Acute Stroke. Indian J Crit Care Med 2023;27(12):949-950.

Implementing stroke care in a lower-middle-income country: results and recommendations based on an implementation study within the Nepal Stroke Project

Background

Globally, the majority of strokes affect people residing in lower- and lower-middle-income countries (LMICs), but translating evidence-based knowledge into clinical practice in regions with limited healthcare resources remains challenging. As an LMIC in South Asia, stroke care has remained a healthcare problem previously unaddressed at a national scale in Nepal. The Nepal Stroke Project (NSP) aims to improve acute stroke care in the tertiary healthcare sector of Nepal. We hereby describe the methods applied and analyze the barriers and facilitators of the NSP after 18 months.

Methods

The NSP follows a four-tier strategy: (1) quality improvement by training healthcare professionals in tertiary care centers; (2) implementation of in-hospital stroke surveillance and quality monitoring system; (3) raising public awareness of strokes; and (4) collaborating with political stakeholders to facilitate public funding for stroke care. We performed a qualitative, iterative analysis of observational data to analyze the output indicators and identify best practices.

Results

Both offline and online initiatives were undertaken to address quality improvement and public awareness. More than 1,000 healthcare professionals across nine tertiary care hospitals attended 26 stroke-related workshops conducted by Nepalese and international stroke experts. Monthly webinars were organized, and chat groups were made for better networking and cross-institutional case sharing. Social media-based public awareness campaigns reached more than 3 million individuals. Moreover, live events and other mass media campaigns were instituted. For quality monitoring, the Registry of Stroke Care Quality (RES-Q) was introduced. Collaboration with stakeholders (both national and international) has been initiated.

Discussion

We identified six actions that may support the development of tertiary care centers into essential stroke centers in a resource-limited setting. We believe that our experiences will contribute to the body of knowledge on translating evidence into practice in LMICs, although the impact of our results must be verified with process indicators of stroke care.

Modern Prehospital Screening Technology for Emergent Neurovascular Disorders

Stroke is a serious neurological disease and a significant contributor to disability worldwide. Traditional in-hospital imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) remain the standard modalities for diagnosing stroke. The development of prehospital stroke detection devices may facilitate earlier diagnosis, initiation of stroke care, and ultimately better patient outcomes. In this review, the authors summarize the features of eight stroke detection devices using noninvasive brain scanning technology. The review summarizes the features of stroke detection devices including portable CT, MRI, transcranial Doppler ultrasound , microwave tomographic imaging, electroencephalography, near-infrared spectroscopy, volumetric impedance phaseshift spectroscopy, and cranial accelerometry. The technologies utilized, the indications for application, the environments indicated for application, the physical features of the eight stroke detection devices, and current commercial products are discussed. As technology advances, multiple portable stroke detection instruments exhibit the promising potential to expedite the diagnosis of stroke and enhance the time taken for treatment, ultimately aiding in prehospital stroke triage.

Stroke systems of care in South-East Asia Region (SEAR): commonalities and diversities

The Southeast Asia Region (SEAR) accounts for nearly 50% of the developing world's stroke burden. With various commonalities across its countries concerning health services, user awareness, and healthcare-seeking behavior, SEAR still presents profound diversities in stroke-related services across the continuum of care. This review highlights the numerous systems and challenges in access to stroke care, acute stroke care services, and health care systems, including rehabilitation. The paper has also attempted to compile information on the availability of stroke specialized centers, Intravenous thrombolysis (IVT) ready centers, Endovascular therapy (EVT) ready centers, rehabilitation centers, and workforce against a backdrop of each country's population. Lastly, the efforts of WHO (SEARO)-CMCL (World Health Organization-South East Asia region, Christian Medical College & Hospital Ludhiana) collaboration towards improving stroke services and capacity among the SEAR have been described.

Surveillance of stroke: a South-East Asia Region (SEAR) perspective

Surveillance of stroke is critical to track its burden and assess progress in prevention and treatment. We reviewed the literature to evaluate stroke surveillance efforts in the South-East Asia Region (SEAR) countries, identify progress and assess gaps. Epidemiological data on all the major parameters such as the incidence, prevalence and mortality of stroke were available for India and Thailand but for none of the other SEAR countries. Most of the epidemiological data came from investigator-initiated studies. National stroke surveillance was present only in India in the form of a National Stroke Registry Programme and Thailand has a national database that was used to obtain epidemiological data for stroke. Research on novel methods for stroke registration, such as using information technology, was absent. This review identified serious gaps in the monitoring and surveillance of stroke in SEAR countries. Systematic efforts are needed to fill those gaps.

Tenecteplase vs. Alteplase for Intravenous Thrombolytic Therapy of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

INTRODUCTION

In recent years, as one of the drugs for the treatment of acute ischemic stroke (AIS), the clinical application of tenecteplase is still controversial. Therefore, we aimed to evaluate the safety and efficacy of tenecteplase versus alteplase to guide clinical practice.

METHODS

A search of PubMed, MEDLINE, EMBASE, Cochrane Library, and Web of Science databases until February 15, 2023 was conducted to identify eligible articles. The quality of the included studies was assessed using the Cochrane Risk of Bias tool. RevMan 5.3 and Stata 17 were used to perform the meta-analysis and detect publication bias, and risk ratios (RRs) with 95% confidence intervals (95% CIs) were reported for each outcome measure.

RESULTS

A total of 1326 records were retrieved in this meta-analysis. As a result of the limited reports on tenecteplase in patients with AIS and the lack of high-quality randomized controlled trials (RCTs), and considering the impact of publication bias, we did not include any of these studies published before 2015. Ultimately we included 16 RCTs with a total of 7508 patients, including 3940 patients treated with alteplase and 3568 patients treated with tenecteplase. Tenecteplase was associated with better early neurological improvement (RR 0.10; 95% CI 0.00-0.19; P = 0.04), recanalization of blood vessels (RR 0.24; 95% CI 0.07-0.40; P = 0.01), and 90-day excellent neurological recovery (RR 0.12; 95% CI 0.01-0.24; P = 0.04). In addition, there were no significant differences in other efficacy and safety outcomes between the two groups. The funnel plot and Begg's as well as Egger's tests showed no significant publication bias.

CONCLUSIONS

This meta-analysis showed that tenecteplase was not inferior to alteplase in early thrombolytic therapy in patients with AIS, and was even better than alteplase on some efficacy outcomes with no significant differences in safety. However, as a result of some inherent limitations of this study, more high-quality prospective clinical studies are needed to confirm these results.

CNN-Res: deep learning framework for segmentation of acute ischemic stroke lesions on multimodal MRI images

BACKGROUND

Accurate segmentation of stroke lesions on MRI images is very important for neurologists in the planning of post-stroke care. Segmentation helps clinicians to better diagnose and evaluation of any treatment risks. However, manual segmentation of brain lesions relies on the experience of neurologists and is also a very tedious and time-consuming process. So, in this study, we proposed a novel deep convolutional neural network (CNN-Res) that automatically performs the segmentation of ischemic stroke lesions from multimodal MRIs.

METHODS

CNN-Res used a U-shaped structure, so the network has encryption and decryption paths. The residual units are embedded in the encoder path. In this model, to reduce gradient descent, the residual units were used, and to extract more complex information in images, multimodal MRI data were applied. In the link between the encryption and decryption subnets, the bottleneck strategy was used, which reduced the number of parameters and training time compared to similar research.

RESULTS

CNN-Res was evaluated on two distinct datasets. First, it was examined on a dataset collected from the Neuroscience Center of Tabriz University of Medical Sciences, where the average Dice coefficient was equal to 85.43%. Then, to compare the efficiency and performance of the model with other similar works, CNN-Res was evaluated on the popular SPES 2015 competition dataset where the average Dice coefficient was 79.23%.

CONCLUSION

This study presented a new and accurate method for the segmentation of MRI medical images using a deep convolutional neural network called CNN-Res, which directly predicts segment maps from raw input pixels.

Global and Regional Estimate of HIV-Associated Stroke Burden: A Meta-Analysis and Population Attributable Modeling Study

BACKGROUND

This study aimed to determine the correlation between human-immunodeficiency-virus (HIV) infection and stroke, as well as to estimate the global, regional, and national burden of HIV-associated stroke.

METHODS

A registered meta-analysis was performed by searching PubMed, Embase, and Web of Science for relevant literature up to October 31, 2022. The pooled relative risk of stroke in HIV-infected people was calculated using a random-effects model. HIV prevalence and disability-adjusted life years (DALYs) datasets were obtained from the Joint United Nations Program on HIV and AIDS, and the Global Health Data Exchange, respectively. The population attributable fraction was estimated and delivered to calculate the HIV-associated DALYs of stroke from 1990 to 2019, at the global, regional, and national levels. Pearson correlation analysis were conducted to assess the correlation between the age-standardized rate or estimated annual percentage changes and the sociodemographic index.

RESULTS

Out of 10 080 identified studies, 11 were included in this meta-analysis. Compared with individuals without HIV-infection, the pooled relative risk of stroke in HIV-infected individuals was 1.40 (95% CI, 1.18-1.65). From 1990 to 2019, the global population attributable fraction of HIV-associated stroke increased almost 3-fold, while the HIV-associated DALYs increased from 18 595 (95% CI, 7485-31 196) in 1990 to 60 684 (95% CI, 24 281-101 894) in 2019. Meanwhile, HIV-associated DALYs varied by region, with Eastern and Southern Africa having the highest value of 126 160 in 2019. Moreover, countries with middle social development index were shouldering the highest increase trend of the HIV-associated DALYs age-standardized rates.

CONCLUSIONS

HIV-infected individuals face a significantly higher risk of stroke, and the global burden of HIV-associated stroke has increased over the past 3 decades, showing regional variations. Eastern and Southern Africa bear the highest burden, while Eastern Europe and Central Asia have seen significant growth. Health care providers, researchers, and decision-makers should give increased attention to stroke prevention and management in HIV-endemic areas.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: CRD42022367450.

Trends in deaths and disability-adjusted life-years of stroke attributable to high body-mass index worldwide, 1990-2019

Background

High body mass index (HBMI) is an independent risk factor for stroke. Previous studies on the incremental burden of the rapid growth of stroke attributable to HBMI are incomplete and lag behind. We aim to assess the global burden of stroke attributable to HBMI based on a public database online.

Materials and methods

Study data were taken from the Global Burden of Disease, Injuries, and Risk Factors Study; deaths, the Disability-Adjusted Life-Years (DALYs), and their age-standardized rates were screened. The join point regression was used, wherein age-standardized rates were referred to as temporal trends in disease burden.

Results

Deaths from stroke attributable to HBMI worldwide were on the rise during 1990-2019, with an increase of 88.75%. Age-standardized DALYs were on the rise during 1990-2003 but declined during 2003-2013, with a turning point in 2013 and an increasing trend since then [the Annual Percentage Change (APC) = 0.30%, p < 0.05]. China, India, Indonesia, the Russian Federation, and the United States of America shared in sequence the rate of leading deaths and DALYs in 2019. The Socio-Demographic Index (SDI) was associated with an increasing trend in age-standardized deaths (R = -0.24, p < 0.001) and age-standardized DALYs (R = -0.22, p = 0.0018).

Conclusion

A range of indicators for the global burden of stroke attributable to HBMI have been on the rise for the past three decades. Tremendous efforts worldwide should be in place to control and treat stroke attributable to HBMI, especially in regions with high-middle and middle SDIs and among middle-aged and aged populations.

Secondary prevention with a structured semi-interactive stroke prevention package in INDIA (SPRINT INDIA): a multicentre, randomised controlled trial

BACKGROUND

There is a high burden of stroke, including recurrent stroke, in India. We aimed to assess the effect of a structured semi-interactive stroke prevention package in patients with subacute stroke to reduce recurrent strokes, myocardial infarction, and death.

METHODS

This was a multicentre, randomised, clinical trial conducted in 31 centres of the Indian Stroke Clinical Trial Network (INSTRuCT). Adult patients with first stroke and access to a mobile cellular device were randomly allocated (1:1) to intervention and control groups by the research coordinators at each centre using a central, in-house, web-based randomisation system. The participants and research coordinators at each centre were not masked to group assignment. The intervention group received regular short SMS messages and videos that promoted risk factor control and medication adherence and an educational workbook, in one of 12 languages, and the control group received standard care. The primary outcome was a composite of recurrent stroke, high-risk transient ischaemic attack, acute coronary syndrome, and death at 1 year. The outcome and safety analyses were done in the intention-to-treat population. The trial is registered with ClinicalTrials.gov, NCT03228979 and Clinical Trials Registry-India (CTRI/2017/09/009600) and was stopped for futility after interim analysis.

FINDINGS

Between April 28, 2018, and Nov 30, 2021, 5640 patients were assessed for eligibility. 4298 patients were randomised to the intervention group (n=2148) or control group (n=2150). 620 patients were not followed up at 6 months and a further 595 patients were not followed up at 1 year because the trial was stopped for futility after interim analysis. 45 patients were lost to follow-up before 1 year. Acknowledgment of receipt of the SMS messages and videos by the intervention group patients was low (17%). The primary outcome occurred in 119 (5·5%) of 2148 patients in the intervention group and 106 (4·9%) of 2150 patients in the control group (adjusted odds ratio 1·12; 95% CI 0·85-1·47; p=0·370). Among the secondary outcome measures, alcohol cessation and smoking cessation were higher in the intervention group than in the control group (alcohol cessation 231 [85%] of 272 in the intervention group vs 255 [78%] of 326 in the control group; p=0·036; smoking cessation 202 [83%] vs 206 [75%]; p=0·035). Medication compliance was better in the intervention group than in the control group (1406 [93·6%] of 1502 vs 1379 [89·8%] of 1536; p<0·001). There was no significant difference between the two groups in other secondary outcome measures at 1 year: blood pressure, fasting blood sugar (mg/dL), low-density lipoprotein cholesterol (mg/dL), and triglycerides (mg/dL), BMI, modified Rankin Scale, and physical activity.

INTERPRETATION

A structured semi-interactive stroke prevention package did not reduce vascular events when compared with standard care. However, there was an improvement in some lifestyle behavioural factors, including adherence to medication, which might have long-term benefits. There was a possibility of type 2 error owing to reduced power since there were fewer events and a high number of patients could not be followed up.

FUNDING

Indian Council of Medical Research.

Screening diagnosis of executive dysfunction after ischemic stroke and the effects of transcranial magnetic stimulation: A prospective functional near-infrared spectroscopy study

BACKGROUND

Post-ischemic stroke executive impairment (PISEI) is a serious obstacle for patients to returning to their society and is currently difficult to screen early and clinically ineffective.

AIM

The aim of the study was to clarify whether functional near-infrared spectroscopy (fNIRS) can be used as a rapid screening tool for PISEI and to explore the efficacy of transcranial magnetic stimulation (TMS) in PISEI patients and the changes in brain function.

METHODS

A single-blind, randomized controlled study design was used to detect hemodynamic differences by fNIIRS in 16 PISEI patients and 16 healthy subjects during the resting state and Stroop task, respectively. After 3 days, all subjects received a single TMS intervention and underwent simultaneous fNIRS testing for the Stroop task before and 3 days after the TMS intervention.

RESULTS

PISEI patients had significantly higher HbO₂ content in the left dorsolateral prefrontal cortex (DLPFC), the right pre-motor cortex (PMC) and the right primary sensorimotor cortex (SM1) during the Stroop task compared to the resting state (F = 141.966, p < 0.001), but significantly lower than healthy subjects (T = -3.413, p = 0.002). After TMS intervention, PISEI patients' time and error number scores on the Stroop test were significantly enhanced, and the functional activity of the above-mentioned brain regions was significantly more active than at baseline, while the strength of their functional connections with each other was markedly increased.

CONCLUSIONS

fNIRS helped screen and diagnose PISEI. A single TMS session benefited PISEI patients with effects lasting 3 days, which may be attributed to activation of the left DLPFC, right PMC and right SM1 brain regions.

Characteristics of stroke service implementation in Armenia

Background

Acute stroke care service in Armenia was established in 2019 after the implementation of the National Stroke Program (NSP). This study aimed to provide an up-to-date account of the current image and clinical characteristics of acute stroke service implementation at a tertiary hospital in Armenia by analyzing the quality of care and identifying the areas that need improvement.

Methods

We analyzed patient data from a single hospital in 1 year after the establishment of acute stroke care service (February 2021-January 2022). We selected patients who were within 0-24 h from symptom onset at admission and included patients who benefited from reperfusion therapies (intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT)). A favorable outcome was defined as a drop in the National Institutes of Health Stroke Scale (NIHSS) by more than four points at discharge and a modified Rankin score (mRS) of 0-2 at 90 days.

Results

Of the total 385 patients, 155 underwent reperfusion therapies, 91% of patients (141/155) arrived by ambulance, 79.2% (122/155) had neurological improvement at discharge, and 60.6% (94/155) had an mRS of 0-2 at 3 months. Less than 5% of patients had early direct access to the rehabilitation center.

Conclusion

Our study demonstrated that the implementation of NSP with organized protocol-driven inpatient care led to significant advancement in acute stroke service performance. We believe that our report will serve as a model for achieving advanced and structured stroke care in a resource-limited context and contribute to the future development of the healthcare system in our country.

Research Hotspots and Global Trends of Transcranial Direct Current Stimulation in Stroke: A Bibliometric Analysis

Purpose

Transcranial direct current stimulation has been widely used in the clinical treatment of stroke. The purpose of this study was to perform a bibliometric analysis of scientific literature in this field.

Methods

Articles and reviews regarding transcranial direct current stimulation in stroke from January 01, 2004 to May 31, 2022 were identified from the Science Citation Index-Expanded of the Web of Science Core Collection database. CiteSpace 6.1.R2, Bibliometrix and the Bibliometric Online Analysis Platform were used to analyze data.

Results

A total of 905 papers were obtained, with the highest number of publications coming from the USA. The institutions and authors with the most publications were Harvard Medical School and Fregni F respectively. Nitsche MA had the most co-citations, followed by Fregni F. Neurosciences was the most fruitful research area and Brain Stimulation had the highest H-index. The research topics could be divided into three sections: mechanisms of treatment, comparison of efficacy with transcranial magnetic stimulation, clinical application of post-stroke dysfunction. The field of "walking", "strength" and "virtual reality therapy" are the future research hotspots of transcranial direct current stimulation.

Conclusion

The overall research showed a slow growth trend, and the outstanding contribution of the USA in this field cannot be ignored. Relevant researchers are suggested to focus on international collaboration and actively conduct high-quality randomized controlled clinical trials on research hotspots and frontiers in order to identify the optimal stimulation paradigm for clinical purposes.

Loureirin C ameliorates ischemia and reperfusion injury in rats by inhibiting the activation of the TLR4/NF-κB pathway and promoting TLR4 degradation

Ischemic stroke is a leading cause of death and disability worldwide. Post-ischemia, microglia respond immediately to the alternations in neuronal activity and mediate inflammation. Toll-like receptor 4 (TLR4) plays a key role in this phenomenon. To explore the effect of loureirin C, an effective compound from Chinese Dragon's blood, on ischemic stroke, Sprague-Dawley rats were subjected to middle cerebral artery occlusion/reperfusion (MCAO/R) with/without intragastric administration of loureirin C (7, 14, and 28 mg/kg). Loureirin C alleviated MCAO/R-induced brain impairment evaluated by neurological scores (p < 0.001), brain water content (p < 0.001), and cerebral infarct volume (p = 0.001). The neuroprotective (p < 0.001) and inhibitory effects on microglial activation (p < 0.001) of loureirin C were revealed by immunofluorescence. Rescue studies with TLR4 overexpression in BV-2 microglia showed that the antiinflammatory effect of loureirin C was attributable to the inhibition of TLR4 protein expression. Moreover, co-immunoprecipitation assays showed that the binding of Triad3A, an E3 ubiquitin ligase of TLR4, was increased by loureirin C (p = 0.003). Our study demonstrates that loureirin C could be a promising therapeutic agent for the management of ischemic stroke by inhibiting microglial activation, potentially by Triad3A-mediated promotion of TLR4 ubiquitination and degradation.

One-year recurrence of stroke and death in Lebanese survivors of first-ever stroke: Time-to-Event analysis

BACKGROUND

To date, despite the application of secondary prevention worldwide, first-ever stroke survivors remain at imminent risk of stroke recurrence and death in the short and long term. The present study aimed to assess the cumulative risk rates and identify baseline differences and stroke characteristics of Lebanese survivors.

METHODS

A prospective longitudinal study was conducted among survivors ≥18 years old who were followed-up for 15 months through a face-to-face interview. Kaplan-Meier method was used to calculate the cumulative rates of stroke mortality and recurrence. Cox-regression univariate and multivariable analyses were performed to identify the predictors of both outcomes.

RESULTS

Among 150 subjects (mean age 74 ± 12 years; 58.7% men vs. 44.3% women; 95.3% with ischemic stroke vs. 4.3% with intracerebral hemorrhage), high cumulative risk rates of stroke recurrence (25%) and death (21%) were highlighted, especially in the acute phase. Survival rates were lesser in patients with stroke recurrence compared to those without recurrence (Log rank test p < 0.001). Older age was the main predictor for both outcomes (p < 0.02). Large artery atherosclerosis was predominant in patients with stroke recurrence and death compared to small vessel occlusion (p < 0.02). Higher mental component summary scores of quality of life were inversely associated with stroke recurrence (p < 0.01). Lebanese survivors exhibited the highest percentages of depression and anxiety; elevated Hospital Anxiety and Depression Scale (HADS) scores were seen in those with stroke recurrence and those who died (≥80% with mean HADS scores ≥8). Lower Mini-Mental State Examination scores at the acute phase increased the risk of both outcomes by 10% (p < 0.03). Three out of 13 mortalities (23.1%) were presented with early epileptic seizures (p = 0.012). High educational level was the protective factor against stroke recurrence (p = 0.019). Administration of intravenous thrombolysis decreased the risk of both outcomes by 10% (p > 0.05).

CONCLUSION

Higher rates of stroke recurrence and death were observed in the first year following a stroke in Lebanon. Various factors were identified as significant determinants. Thus, health care providers and officials in Lebanon can use these findings to implement effective preventive strategies to best address the management of these factors to reduce the stroke burden and improve the short and long-term prognosis of stroke survivors.

Incidence, lethality, and post-stroke functional status in different Brazilian macro-regions: The SAMBA study (analysis of stroke in multiple Brazilian areas)

Background

Stroke is the second leading cause of death in Brazil. The social and financial burden of stroke is remarkable; however, the epidemiological profile remains poorly understood.

Objective

The aim of this study was to report the incidence, lethality, and functional status at 30 and 90 days post-stroke in the cities of different Brazilian macro-regions.

Methods

This is an observational, prospective, and population-based study, led in Canoas (South), Joinville (South, reference center), Sertãozinho (Southeast), and Sobral (Northeast) in Brazil. It was developed according to the three-step criteria recommended by the World Health Organization to conduct population-based studies on stroke. Using different sources, all hospitalized and ambulatory patients with stroke were identified and the same criteria were kept in all cities. All first events were included, regardless of sex, age, or type of stroke. Demographic and risk factor data were collected, followed by biochemical, electrocardiographic, and radiological test results. Functional status and lethality were obtained using the mRankin scale through telephonic interview (validated Brazilian version).

Results

In 1 year, 932 stroke cases were registered (784 ischemic stroke, 105 hemorrhagic stroke, and 43 subarachnoid hemorrhage). The incidence rates per 100,000 inhabitants, adjusted for the world population, were 63 in Canoas, 106 in Joinville, 72 in Sertãozinho, and 96 in Sobral. The majority (70.8%) were followed for 90 days. Kaplan-Meier curves showed that 90-day survival was different among cities. Sobral, which has the lowest socioeconomic indexes, revealed the worst results in terms of lethality and functional status.

Conclusion

This study expands the knowledge of stroke epidemiology in Brazil, a middle-income country with enormous socioeconomic and cultural diversity. The discrepancy observed regarding the impact of stroke in patients from Joinville and Sobral highlights the need to improve the strategic allocation of resources to meet the health priorities in each location.

Thrombolysis experience in Costa Rica compared against individual patient data from two randomized controlled trials

OBJECTIVES

We sought to compare thrombolysis outcomes from the Costa Rican Stroke Registry Program (CRSRP) with published individual patient data from NINDS and CLOTBUST-ER trials using matching and outcome modeling from randomized clinical trials (RCTs).

MATERIALS AND METHODS

A retrospective observational study matching subjects on baseline characteristics, from the CRSRP, the control arm of CLOTBUST-ER, and the interventional arm of NINDS trials. Day 7-10/discharge modified Rankin Score (mRS), and early mortality was compared between matched subjects. A mortality model derived from RCTs was developed, and outcomes were compared at similar baseline NIHSS scores. CRSRP symptomatic hemorrhage (SICH) rate was compared with an Ibero-American cohort (IAC).

RESULTS

Of 540 CRSRP patients, 351 received rt-PA under 3 hours and were matched with NINDS subjects yielding 292 pairs; 161 CRSRP subjects treated within 4.5 hours were matched with CLOTBUST-ER subjects resulting in 151 pairs. The proportion of patients achieving excellent outcomes (mRS 0-1) did not differ between CRSRP and either NINDS or CLOTBUST-ER (CRSRP vs NINDS: 36.6% vs 32.9%, p=0.3; CRSRP vs CLOTBUST-ER: 26.5% vs 24.5%, p=0.8). Mortality was higher for CRSRP vs CLOTBUST-ER (7.3% vs 0.7%, p=0.006), but not vs NINDS (6.5% vs 4.5%, p=0.4). A pooled mortality model derived from 15 RCTs representing 4410 patients (R²=0.39) showed CRSRP and NINDS within expected mortality, while CLOTBUST-ER showed lower than expected mortality. CRSRP SICH rate equaled IAC (5.7% vs 5.7%; p=0.9).

CONCLUSIONS

Functional outcomes and SICH of thrombolysed Costa Rican patients compared favorably with published datasets, with a potential increase in early mortality.

Exploring the poststroke experiences and unmet needs of South Asian communities in high-income countries: a scoping review protocol

INTRODUCTION

South Asian groups experience a higher burden of stroke and poorer functional outcomes after stroke than their White counterparts. However, within the stroke literature, there has been little focus on the unique poststroke needs of the South Asian community and opportunities for community-based services to address these needs.

RESEARCH QUESTION

What is the current knowledge base related to the experiences and needs, including unmet needs of people living with stroke and their caregivers from South Asian communities living in high-income countries?

AIMS

This is a protocol for a review that intends to synthesise existing studies of the poststroke experiences and needs of individuals from South Asian communities to uncover opportunities for community-based resources to address these needs.

METHODS AND ANALYSIS

This scoping review methodology will be guided by modified Arksey and O'Malley (2005) and Joanna Briggs Institute frameworks. A search on OVID Medline, OVID Embase, OVID PsycINFO, EBSCO CINAHL, the Cochrane Library, Scopus and Global Index Medicus will be conducted to synthesise existing peer-reviewed literature (all study designs). Grey literature will be searched through detailed hand searching. Literature focusing on the poststroke experiences and needs of South Asian groups impacted by stroke residing in high-income countries will be included. Study descriptors will be extracted (eg, study location, type, methodology). Data will be analysed descriptively and thematically. Team meetings will provide opportunities for peer debriefing, thereby enhancing analytic rigour.

CONCLUSION AND IMPLICATIONS

Findings will enhance knowledge of the poststroke experiences and needs of South Asian communities living in high-income countries and identify actionable opportunities for community-based resources to address needs.

ETHICS AND DISSEMINATION

Ethics approval was not required for this scoping review protocol. Community-based organisations will be consulted to provide insights into the analysis and assist with dissemination. Dissemination of findings will also occur through a publication and academic presentations.

Causative Classification of Ischemic Stroke by the Machine Learning Algorithm Random Forests

Background

Prognosis, recurrence rate, and secondary prevention strategies differ by different etiologies in acute ischemic stroke. However, identifying its cause is challenging.

Objective

This study aimed to develop a model to identify the cause of stroke using machine learning (ML) methods and test its accuracy.

Methods

We retrospectively reviewed the data of patients who had determined etiology defined by the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) from CASE-II (NCT04487340) to train and evaluate six ML models, namely, Random Forests (RF), Logistic Regression (LR), Extreme Gradient Boosting (XGBoost), K-Nearest Neighbor (KNN), Ada Boosting, Gradient Boosting Machine (GBM), for the detection of cardioembolism (CE), large-artery atherosclerosis (LAA), and small-artery occlusion (SAO). Between October 2016 and April 2020, patients were enrolled consecutively for algorithm development (phase one). Between June 2020 and December 2020, patients were enrolled consecutively in a test set for algorithm test (phase two). Area under the curve (AUC), precision, recall, accuracy, and F1 score were calculated for the prediction model.

Results

Finally, a total of 18,209 patients were enrolled in phase one, including 13,590 patients (i.e., 6,089 CE, 4,539 LAA, and 2,962 SAO) in the model, and a total of 3,688 patients were enrolled in phase two, including 3,070 patients (i.e., 1,103 CE, 1,269 LAA, and 698 SAO) in the model. Among the six models, the best models were RF, XGBoost, and GBM, and we chose the RF model as our final model. Based on the test set, the AUC values of the RF model to predict CE, LAA, and SAO were 0.981 (95%CI, 0.978-0.986), 0.919 (95%CI, 0.911-0.928), and 0.918 (95%CI, 0.908-0.927), respectively. The most important items to identify CE, LAA, and SAO were atrial fibrillation and degree of stenosis of intracranial arteries.

Conclusion

The proposed RF model could be a useful diagnostic tool to help neurologists categorize etiologies of stroke.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [NCT01274117].

Nitrate Metabolism and Ischemic Cerebrovascular Disease: A Narrative Review

Inorganic and organic nitrates are present in vivo and in vitro. Inorganic nitrate is considered a pool of nitric oxide (NO), but it can be converted into nitrite and NO through various mechanisms. It plays an important role in the regulation of complex physiological and biochemical reactions, such as anti-inflammatory processes and the inhibition of platelet aggregation, which are closely related to the pathology and treatment of cerebrovascular disease. Ischemic cerebrovascular disease is characterized by high incidence, recurrence, and disability rates. Nitrate, nitrite, and NO were recently found to be involved in cerebrovascular disease. In this review, we describe the relationship between cerebrovascular disease and nitrate metabolism to provide a basis for further advances in laboratory and clinical medicine.

Maintaining Stroke Care During the COVID-19 Pandemic in Lower- and Middle-Income Countries: World Stroke Organization Position Statement Endorsed by American Stroke Association and American Heart Association

For more than a year, the SARS-CoV-2 pandemic has had a devastating effect on global health. High-, low, and middle-income countries are struggling to cope with the spread of newer mutant strains of the virus. Delivery of acute stroke care remains a priority despite the pandemic. In order to maintain the time-dependent processes required to optimize delivery of intravenous thrombolysis and endovascular therapy, most countries have reorganized infrastructure to optimize human resources and critical services. Low-and-middle income countries (LMIC) have strained medical resources at baseline and often face challenges in the delivery of stroke systems of care (SSOC). This position statement aims to produce pragmatic recommendations on methods to preserve the existing SSOC during COVID-19 in LMIC and propose best stroke practices that may be low cost but high impact and commonly shared across the world.

Younger age of stroke in low-middle income countries is related to healthcare access and quality

Stroke is the second leading cause of mortality globally with higher burden and younger age in low‐middle income countries (LMICs) than high‐income countries (HICs). However, it is unclear to what extent differences in healthcare access and quality (HAQ) and prevalence of risk factors between LMICs and HICs contribute to younger age of stroke in LMICs. In this systematic review, we conducted meta‐analysis of 67 articles and compared the mean age of stroke between LMICs and HICs, before and after adjusting for HAQ index. We also compared the prevalence of main stroke risk factors between HICs and LMICs. The unadjusted mean age of stroke in LMICs was significantly lower than HICs (63.1 vs. 68.6), regardless of gender (63.9 vs. 66.6 among men, and 65.6 vs. 70.7 among women) and whether data were collected in population‐ (64.7 vs. 69.5) or hospital‐based (62.6 vs. 65.9) studies (all p < 0.01). However, after adjusting for HAQ index, the difference in the mean age of stroke between LMICs and HICs was not significant (p ≥ 0.10), except among women (p = 0.048). In addition, while the median prevalence of hypertension in LMICs was 23.4% higher than HICs, the prevalence of all other risk factors was lower in LMICs than HICs. Our findings suggest a much larger contribution of HAQ to the younger mean age of stroke in LMICs, as compared with other potential factors. Additional studies on stroke care quality and accessibility are needed in LMICs.

OUP accepted manuscript

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management:

A: Appropriate Antithrombotic therapy.

B: Better functional and psychological status.

C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).