Mortality and recurrent vascular events after first incident stroke: a 9-year community-based study of 0·5 million Chinese adults

Ginkgo diterpene lactone meglumine for functional recovery in patients with acute ischemic stroke: A systematic review and meta-analysis

ETHNOPHARMACOLOGICAL RELEVANCE

The clinical efficacy of ginkgo diterpene lactone meglumine (GDLM), a Chinese patent medicine, in acute ischemic stroke (AIS) has garnered attention. However, the impact of GDLM on functional recovery in AIS patients has not been systematically reviewed or meta-analyzed.

AIM OF THE STUDY

To evaluate the functional outcomes of GDLM in AIS patients.

MATERIALS AND METHODS

We conducted a search of seven databases from inception to July 10, 2024, for pertinent randomized controlled trials (RCTs). We performed trial selection, data extraction, and bias assessment. Meta-analysis was conducted to evaluate functional and safety outcomes. Quality of evidence was assessed.

RESULTS

We included eight RCTs involving 4041 patients. Compared to those receiving only conventional treatments (CTs), patients treated with GDLM in combination with CTs exhibited a significantly higher proportion of patients achieving excellent (modified Rankin Scale [mRS] 0-1) or favorable functional outcomes (mRS 0-2) (risk ratio [RR] for excellent functional outcome = 1.16, 95% confidence interval [CI] 1.08 to 1.24, p < 0.001; RR for favorable functional outcome = 1.21, 95% CI 1.17 to 1.26, p < 0.001) and had lower mRS scores (mean difference [MD] = -0.66, 95% CI -0.73 to -0.59, p < 0.001) at 90 days. The evidence supporting GDLM's role in restoring functional independence was rated as moderate in certainty. Additionally, the incidences of adverse events and reactions did not differ significantly between the two groups.

CONCLUSION

Moderate-certainty evidence suggests that GDLM may be a beneficial adjunct therapy for improving functional outcomes in AIS patients. Nonetheless, further validation of GDLM's efficacy and safety in real-world settings is warranted through future practice.

Salt Substitution and Recurrent Stroke and Death: A Randomized Clinical Trial

Importance

The direct effect of consumption of salt substitutes on recurrent stroke and mortality among patients with stroke remains unclear.

Objective

To evaluate the effects of salt substitutes vs regular salt on the incidence of recurrent stroke and mortality among patients with stroke.

Design, Setting, and Participants

The Salt Substitute and Stroke Study (SSaSS), an open-label, cluster randomized clinical trial, was conducted in 600 northern Chinese villages (clusters). Patients who self-reported a hospital diagnosis of stroke were included in this prespecified subgroup analysis. Data were analyzed from November 2023 to August 2024.

Interventions

Participants were assigned to use either a salt substitute, consisting of 75% sodium chloride and 25% potassium chloride by mass, or regular salt.

Main Outcomes and Measures

The primary outcome was recurrent stroke.

Results

After excluding 5746 persons without a baseline history of stroke, 15 249 patients with stroke (mean [SD] age, 64.1 [8.8] years; 6999 [45.9%] female; 8250 male [54.1%]) were included. Over a median (IQR) follow-up of 61.2 (60.9-61.6) months, the mean difference in systolic blood pressure was -2.05 mm Hg (95% CI, -3.03 to -1.08 mm Hg). A total of 2735 recurrent stroke events (691 fatal and 2044 nonfatal) and 3242 deaths were recorded. Recurrent stroke was significantly lower in the salt substitute vs regular salt group (rate ratio [RR], 0.86; 95% CI, 0.77-0.95; P = .005), with larger effects on hemorrhagic stroke (relative reduction, 30%; P = .002). Death rates were also significantly lower (RR, 0.88; 95% CI, 0.82-0.96; P = .003), with larger effects on stroke-related deaths (relative reduction 21%; P = .01). No significant difference was observed for hyperkalemia (RR, 1.01; 95% CI, 0.74-1.38; P = .96).

Conclusions and Relevance

Results of this cluster trial demonstrate that salt substitution was safe, along with reduced risks of stroke recurrence and death, which underscores large health gains from scaling up this low-cost intervention among patients with stroke.

Trial Registration

ClinicalTrials.gov Identifier: NCT02092090.

Cost-Effectiveness of Endovascular Thrombectomy in Patients with Large Ischemic Stroke

OBJECTIVES

Whereas highly cost-effective and cost-saving for patients with small infarcts, whether endovascular thrombectomy (EVT) remains cost-effective in patients with extensive ischemic injury is uncertain.

METHODS

We conducted a model-based cost-effectiveness analysis from the United States, Australian, and Spanish societal perspectives, using a 7-state Markov model, with each state defined by the modified Rankin Scale (mRS) score. Initial probabilities at 3 months were derived from the SELECT2 trial. All other model inputs, including transition probabilities, health care and non-health care costs, and utility weights, were sourced from published literature and government websites. Our analysis included extensive sensitivity and subgroup analyses.

RESULTS

EVT in patients with large ischemic stroke improved health outcomes and was associated with lower costs from a societal viewpoint. EVT was cost-effective with a mean between-group difference of 1.24 quality-adjusted life years (QALYs), and a cost-saving of $23,409 in the United States, $10,691 in Australia, and $30,036 in Spain, in addition to uncosted benefits in productivity for patients and carers. Subgroup analyses were directionally consistent with the overall population, notably with preserved cost-effectiveness in older patients (≥ 70 years) and those with more severe strokes (National Institutes of Health Stroke Scale [NIHSS] ≥ 20). Sensitivity analyses were largely consistent with the base-case results.

INTERPRETATION

EVT demonstrated cost-effectiveness in patients with large core across different settings in the United States, Australia, and Spain, including older patients and those with more severe strokes. These results further support adaptation of systems of care to accommodate the expansion of thrombectomy eligibility to patients with large cores and maximize EVT benefits. ANN NEUROL 2025;97:222-231.

Incidence, case fatality, and functional outcome of intracerebral haemorrhage, according to age, sex, and country income level: a systematic review and meta-analysis

Background

Intracerebral haemorrhage (ICH) accounts for approximately 28% of all strokes worldwide. ICH has a high case fatality, and only few survivors recover to independent living. Over the past decades, demographic changes, and changes in prevalence and management of risk factors may have influenced incidence. Widespread implementation of stroke units and improved care in general may have affected case fatality and outcome. We aimed to update the evidence on incidence, case fatality, and functional outcome of ICH, according to age, sex, and country income level.

Methods

We systematically searched PubMed and Embase from 2008 to April 2023 for prospective population-based studies on incidence, case fatality, or functional outcome of first-ever ICH. We excluded studies in which less than 80% of cases was confirmed with imaging or autopsy. Quality of the studies was assessed based on the used case finding methods. We used inverse variance-based random-effects meta-analyses to pool the crude incidence, case fatality at 1 month, and the percentage of patients with good functional outcome after 3, 6, or 12 months, as defined by the authors of the individual studies. Time trends were assessed using weighted linear meta-regression. Funnel plots were constructed to study publication bias. The review was registered on PROSPERO (CRD42023413314).

Findings

We identified 70 eligible studies, describing 19,470 ICH patients from 26 different countries. Of these, 62 studies reported on crude incidence, 41 on case fatality, and 10 on functional outcome. Overall crude incidence was 29.2 per 100,000 person-years (95% CI 23.3-36.4; I2 = 100%). Incidence was lower in women than in men and increased with age. Incidence was highest in lower-middle income countries, followed by high and upper-middle income countries. Case fatality at 1 month was 35.5% (95% CI 32.3-38.9; I2 = 90%). The percentage of patients with good functional outcome (mRS 0-2 in nine studies, mRS 0-3 in one) after 3-12 months was 31.2% (95% CI 24.7-38.6; I2 = 76%). We found no time trends in incidence, case fatality, or functional outcome.

Interpretation

Our results demonstrate the persistently high burden and devastating consequences of ICH, stressing the need for better preventive strategies and acute treatments.

Funding

None.

Progress of research on short-chain fatty acids, metabolites of gut microbiota, and acute ischemic stroke

Acute ischemic stroke (AIS) significantly impacts the well-being and quality of life of individuals within our population. Short-chain fatty acids (SCFAs), metabolites produced by the intestinal microbiota, are integral to the bidirectional regulatory pathway linking the gut and the brain. SCFAs may significantly influence the risk, prognosis, recurrence, and management of complications associated with AIS. Potential mechanisms underlying these effects include the facilitation of brain-gut barrier repair, the mitigation of oxidative stress, the reduction of neuroinflammatory responses, and the inhibition of autophagy and apoptosis. Consequently, SCFAs hold promise as a prospective target for AIS intervention, with the potential to significantly impact AIS prevention and treatment strategies.

A comprehensive analysis of stroke risk factors and development of a predictive model using machine learning approaches

Stroke is a leading cause of death and disability globally, particularly in China. Identifying risk factors for stroke at an early stage is critical to improving patient outcomes and reducing the overall disease burden. However, the complexity of stroke risk factors requires advanced approaches for accurate prediction. The objective of this study is to identify key risk factors for stroke and develop a predictive model using machine learning techniques to enhance early detection and improve clinical decision-making. Data from the China Health and Retirement Longitudinal Study (2011-2020) were analyzed, classifying participants based on baseline characteristics. We evaluated correlations among 12 chronic diseases and applied machine learning algorithms to identify stroke-associated parameters. A dose-response relationship between these parameters and stroke was assessed using restricted cubic splines with Cox proportional hazards models. A refined predictive model, incorporating age, sex, and key risk factors, was developed. Stroke patients were significantly older (average age 69.03 years) and had a higher proportion of women (53%) compared to non-stroke individuals. Additionally, stroke patients were more likely to reside in rural areas, be unmarried, smoke, and suffer from various diseases. While the 12 chronic diseases were correlated (p < 0.05), the correlation coefficients were generally weak (r < 0.5). Machine learning identified nine parameters significantly associated with stroke risk: TyG-WC, WHtR, TyG-BMI, TyG, TMO, CysC, CREA, SBP, and HDL-C. Of these, TyG-WC, WHtR, TyG-BMI, TyG, CysC, CREA, and SBP exhibited a positive dose-response relationship with stroke risk. In contrast, TMO and HDL-C were associated with reduced stroke risk. In the fully adjusted model, elevated CysC (HR = 2.606, 95% CI 1.869-3.635), CREA (HR = 1.819, 95% CI 1.240-2.668), and SBP (HR = 1.008, 95% CI 1.003-1.012) were significantly associated with increased stroke risk, while higher HDL-C (HR = 0.989, 95% CI 0.984-0.995) and TMO (HR = 0.99995, 95% CI 0.99994-0.99997) were protective. A nomogram model incorporating age, sex, and the identified parameters demonstrated superior predictive accuracy, with a significantly higher Harrell's C-index compared to individual predictors. This study identifies several significant stroke risk factors and presents a predictive model that can enhance early detection of high-risk individuals. Among them, CREA, CysC, SBP, TyG-BMI, TyG, TyG-WC, and WHtR were positively associated with stroke risk, whereas TMO and HDL-C were opposite. This serves as a valuable decision-support resource for clinicians, facilitating more effective prevention and treatment strategies, ultimately improving patient outcomes.

The feasibility and effectiveness of telecare consultations in a nurse-led post-acute stroke clinic

BACKGROUND

Telecare may provide an alternative to maintaining post-acute stroke care services in making benefit to both the providers and the stroke survivors, although study is needed to investigate its feasibility and effectiveness in integrating this innovative delivery mode into a routine.

OBJECTIVES

The objectives of this study are to assess the feasibility and effectiveness of telecare consultations in a nurse-led post-acute stroke clinic.

METHODS

A pre- and post-test one group quasi-experimental design was adopted. Subjects were recruited in the clinic and received three secondary stroke care consultations in 3 months via telecare from stroke nurses. Data were collected at pre- and post-intervention. A Wilcoxon signed-rank test was used to compare the two time-points for differences in effectiveness.

RESULTS

Ninety-two stroke survivors participated. The drop-out rate was 27%. The majority perceived the programme as time-friendly and cost-saving and as alleviating their health-related worries. At the 3-month follow-up, notable improvements were observed in the activities of daily living and the strength domain of stroke-specific quality of life.

CONCLUSIONS

Integrating telecare consultations within nurse-led stroke clinics is a feasible and acceptable strategy for monitoring the health and fostering the self-care abilities of individuals following their discharge from hospital after an acute stroke episode.

Newly developed DWI hyperintensities and changes in cerebral blood flow after carotid stent placement for unilateral symptomatic carotid artery stenosis

This study aimed to evaluate changes in cerebral blood flow and perioperative outcomes in patients with unilateral symptomatic carotid artery stenosis before and after carotid artery stenting (CAS), providing insights to guide surgical decision-making. Ninety-six patients with moderate to severe unilateral symptomatic carotid artery stenosis (>50%) admitted to the Neurology Department of the Second Affiliated Hospital of Zhejiang University from June 2023 to April 2024 were included. All patients underwent CAS and magnetic resonance imaging, including diffusion-weighted imaging (DWI) and 3D quasi-continuous arterial spin-labeled perfusion imaging, within 3 days preoperatively and on the third postoperative day. Patients were categorized into microembolic and non-embolic groups based on the presence of new diffusion-weighted imaging hyperintensities. Newly developed diffusion-weighted imaging hyperintensities were detected in 68 patients (70.8%), with a total of 704 lesions, though only 4 cases exhibited symptoms. Most lesions were localized to the frontal-parietal cortex and subcortical areas on the affected side (60.8%) and were <3 mm in size (92.6%). Postoperatively, cerebral blood flow in the frontal-parietal lobe was significantly higher than in the temporal lobe on both the affected (50.49 ± 8.02 vs 47.94 ± 9.08, t = 2.179, P < .05) and healthy sides (50.16 ± 5.79 vs 48.00 ± 5.98, t = 3.835, P < .05). Additionally, cerebral blood flow in the affected frontal and temporal lobes significantly increased after surgery (P < .05). Preoperative frontal-parietal cerebral blood flow was lower in the microembolic group compared to the non-embolic group (P < .05). Microemboli are common after CAS but are unlikely to result from immediate hemodynamic changes. Instead, they appear to be associated with chronic preoperative hypoperfusion, which impairs cerebral blood flow regulation.

Effects of a Behavior Intervention Based on the Recurrence Risk Perception and Behavioral Decision Model for Ischemic Stroke Patients: A Randomized Controlled Trial

Behavioral management is essential to preventing recurrence after stroke, but its adherence is limited worldwide. We aimed to assess the impact of the behavior intervention based on the Recurrence risk perception and Behavioral decision Model for ischemic stroke patients' health behavior. This study was a single-blind, randomized, controlled trial with a 3-month follow-up. The outcome measures were the perception of the risk of stroke recurrence, behavioral decision, and health behavior. A total of seventy participants were randomized to the intervention group (n = 35) or control group (n = 35). The former received a twelve-week theory-based intervention in addition to the routine education, while the control group received only the routine education. The generalized estimating equations results indicated that the intervention group had significantly greater improvements in perception of the risk of stroke recurrence compared to the control group at all T1 (B = 0.13, 95% CI: 0.03 to 0.23), T2 (B = 0.18, 95% CI: 0.07 to 0.28), and T3 (B = 0.16, 95% CI: 0.07 to 0.25) after adjusting for stroke frequency. Statistically significant improvements were found in behavioral decision for the intervention group compared with the control group at T2 (B = 0.25, 95% CI: 0.09 to 0.41) and T3 (B = 0.26, 95% CI: 0.10 to 0.43). Results also showed a significantly higher increase in health behavior at T1 (B = 0.29, 95% CI: 0.09 to 0.48) and T2 (B = 0.22, 95% CI: 0.04 to 0.40). The intervention can improve the perception of the risk of stroke recurrence, behavioral decision, and health behavior in ischemic stroke patients. IMPLICATIONS: This study provides a reference point for promoting healthy behaviors in patients with ischemic stroke. A recurrence risk perception and behavioral decision model-based intervention was deemed to be feasible and useful in practice. PATIENT OR PUBLIC CONTRIBUTION: Patients and their caregivers agreed to participate in the study and shared their experiences of participating in research with us.

Safety and efficacy of staged coiling followed by flow diverter in the treatment of ruptured intracranial aneurysms

To evaluate the safety and efficacy of staged coiling followed by flow diverter (FD) in the treatment of ruptured intracranial aneurysms(RIAs). A retrospective analysis was conducted on 20 patients with RIAs treated with staged coiling followed by FD at a single center, between April 2015 and September 2024. Patient demographics, aneurysm characteristics, clinical and imaging outcomes were reviewed. Aneurysm occlusion was determined using the O'Kelly-Marotta (OKM) grading system. All 20 RIAs underwent successful first-stage coiling. In the second stage, 21 FD were deployed, achieving a 100% success rate. The mean maximum diameter of aneurysms was 10.2 (6.3, 20.7) mm, with a neck width of 6.1 (4.2, 7.8) mm. The interval between the first and second stages was 33.3 ± 23 days. One patient (5%) experienced ischemic complications during the first-stage coiling, but no hemorrhagic complications occurred. In the second stage, FD placement was performed without any hemorrhagic or ischemic complications. All 20 patients (100%) received clinical follow-up with a median follow-up time of 182(172.5,190.5) days.14 patients(70%) underwent available DSA follow-up with a median follow-up time of 184 (158.3, 194.8) days, and the OKM grade B was reported in 1 case (7.1%), grade C in 1 case (7.1%), and grade D in 12 cases (85.7%). No aneurysm recurrence was observed. At the last follow-up, all 20 patients had an mRS score of ≤ 1. Staged coiling followed by FD placement for the treatment of RIAs is a safe and effective approach, with a high technical success rate, low perioperative complication rate, and high aneurysm occlusion rate during follow-up.

Metabolic pathway and genetically causal links of 1,400 circulating metabolites on the risk of intracranial aneurysms and aneurysmal subarachnoid hemorrhage

BACKGROUND

The rupture of intracranial aneurysms (IAs) leads to aneurysmal subarachnoid hemorrhage (aSAH), which is associated with significant disability and mortality rates. This study aims to identify metabolic markers causally linked to the occurrence of IAs and aSAH through Mendelian randomization (MR), thereby offering novel predictive and therapeutic targets.

METHODS

We conducted a genome-wide association study (GWAS) on IAs and aSAH, analyzing 1,400 metabolomic indices from the Canadian Longitudinal Study on Aging (CLSA) cohort (n = 8,299). Subsequently, we employed two-sample Mendelian randomization to ascertain potential causal relationships between each metabolite and the conditions IAs and aSAH by various MR methodologies, including MR Egger, Weighted median, Inverse variance weighted (IVW), MR-PRESSO, Simple mode, and Weighted mode. The heterogeneity of instrumental variables was assessed using Cochran's Q statistics, and metabolic pathway analyses were performed via the Metaconflict 5.0 platform.

RESULTS

Our analysis found that 87 metabolites/metabolic ratios were associated with IAs, and 85 metabolites/metabolic ratios were associated with aSAH. After false discovery rate (FDR) correction and sensitivity analyses, nine metabolites/metabolic ratios were significantly causally associated with aSAH. Conversely, while 87 metabolites and their ratios initially showed potential causal links with IA, none demonstrated significant causal associations post-FDR correction. The study also pinpointed eight significant metabolic pathways implicated in both IAs and aSAH.

CONCLUSION

This study found that nine circulating metabolites and their ratios with significant causal associations to aSAH, while no metabolites and their ratios were causally linked to IAs. These results suggest possible mechanisms and predictive molecular targets for IAs and aSAH.

High-quality targeted temperature management combined with decompressive craniectomy in patients with poor-grade aneurysmal subarachnoid hemorrhage: a secondary analysis of a multicenter prospective study

Background

The effect of targeted temperature management (TTM) combined with decompressive craniectomy (DC) on poor-grade aneurysmal subarachnoid hemorrhage (aSAH) has not been previously addressed in the literature. This study aims to investigate the therapeutic outcomes of the combination of TTM and DC in patients with poor-grade aSAH.

Methods

This study represents a secondary analysis of the Multicenter Clinical Research on Targeted Temperature Management of Poor-grade Aneurysmal Subarachnoid Hemorrhage (High-Quality TTM for PaSAH), a multicenter prospective study conducted in China. The High-Quality TTM for PaSAH study enrolled patients aged 18 years and older who were transported to the intensive care units (ICU) of three tertiary care hospitals in China between April 2022 and April 2024. Among these patients, those who underwent DC were included in the present analysis. Patients were divided into two groups: the DC-alone group and the TTM combined with the DC (TTM-DC) group. The DC-alone group maintained normothermia. The TTM-DC group used automated devices with a temperature feedback system (TFS). TTM was initiated with core temperatures between 36°C-37°C immediately after diagnosing poor-grade aSAH, and concurrent emergency aneurysm repair. This was followed by a rapid induction to 34°C-35°C, maintained for a minimum of 72 h. Subsequently, a slow rewarming process reached 36°C-37°C, which was maintained for at least 48 h. Primary outcomes were evaluated using the Modified Rankin Scale (mRS) score at 3 months. Secondary outcomes included the Glasgow Coma Scale (GCS) at discharge, ICU stay duration, length of hospitalization, proportion of external ventricular drainage (EVD), mechanical ventilation time, tracheostomy, midline shift, hydrocephalus, and delayed cerebral ischemia (DCI) on the 7th day. Safety outcomes comprised the incidence of pneumonia, myocardial infarction, stress hyperglycemia, thrombocytopenia, acute liver injury, hypokalemia, hypoproteinemia, and death at 90 days.

Results

Of the 141 patients enrolled in the High-Quality TTM for PaSAH study, 43 (25 in the TTM-DC group and 18 in the DC-alone group) were eligible for this secondary analysis. The TTM-DC group had a higher proportion of favorable outcomes (mRS 0-3: 56% vs. 22%, aOR 5.97, 95%CI 0.96-52.2, p = 0.071). After propensity score matching, the TTM combined with DC improved favorable outcome at 3 months (mRS 0-3: 61% vs. 22%, OR 5.50, 95%CI 1.36-26.3, p = 0.022). In addition, the TTM-DC group increased GCS score at discharge compared with the DC-alone group (9 vs. 3, β 2.58, 95%CI 0.32-4.84, p = 0.032). The incidence of safety outcomes was not increased in the TTM-DC group.

Conclusion

TTM combined with DC can improve clinical conditions at discharge and ameliorate short-term neurological outcomes in poor-grade aSAH patients. TTM should be considered one of the main treatments for poor-grade aSAH patients who underwent DC.

Association between prognostic nutritional index and stroke: A nationally representative cross-sectional study from NHANES

BACKGROUND

The correlation between the prognostic nutritional index (PNI) and the risk of stroke has become a hot spot within the medical research community. The available evidence from a large sample regarding the correlation between PNI and stroke is inadequate. There is also a need for more research analysis from national surveys.

OBJECTIVE

The principal goal of this research is to improve our understanding of the relationship between PNI and the risk of stroke. This study also intends to investigate the potential synergistic influence of PNI on stroke in combination with other interacting variables.

METHODS

A cross-sectional study was conducted with 35,549 participants selected from the National Health and Nutrition Examination Survey (NHANES) 2005-2018 cycle. Information was gathered from all participants regarding the following: lymphocyte count, albumin levels, stroke occurrence, age, sex, race/ethnicity, education level, poverty income ratio (PIR), marital status, body mass index (BMI), smoking habits, drinking status, physical activity measured in total metabolic equivalents (PA_total_MET), diabetes status, glycohemoglobin levels, total cholesterol, direct high-density lipoprotein cholesterol(direct HDL-cholesterol), hypertension, and coronary heart disease. Curve fitting, subgroup analysis, and multifactor weighted logistic regression analysis were used to examine the relationship between PNI and stroke.

RESULTS

The overall prevalence of stroke was found to be 3.9%, PNI quartile 4(Q4) had an increased prevalence of stroke than quartile 1, 2, and 3(Q1,2,3). Our research suggested a negative association between PNI and the risk of stroke, as indicated by the odds ratio (OR=0.98) with a 95% confidence interval (CI=0.97∼0.99) and a p-value <0.05 (P=0.005), even after adjusting for all confounders. Subsequent subgroup analysis indicated a significant difference in the impact of PNI on stroke between individuals with different body mass index(BMI) levels (p for interaction = 0.02).

CONCLUSION

Our findings underscore that lower PNI in US adults is associated with an increased stroke risk, shedding light on a potential interrelationship between nutrition, inflammatory parameters, and stroke.

Identification of Key Genes Mediated by N6-Methyladenosine Methyltransferase METTL3 in Ischemic Stroke via Bioinformatics Analysis and Experiments

The N6-methyladenosine (m6A) methyltransferase METTL3 has been demonstrated to function in mediating m6A modification, but its role in ischemic stroke (IS) has not been fully elucidated. This study aimed to explore the downstream mechanism of METTL3-mediated m6A modification in IS. GSE16561 and GSE22255 were downloaded from the Gene Expression Omnibus database for analysis of differentially expressed genes (DEGs), and it was found that METTL3 mRNA was downregulated in IS. Then quantitative real-time polymerase chain reaction was used to verify the downregulation of METTL3 mRNA in the peripheral blood of IS patients and the cortexes of transient middle cerebral artery occlusion mice. By combining DEGs with the m6A-downregulated genes in GSE142386 which performed methylated RNA immunoprecipitation sequencing (MeRIP-seq) on METTL3-deficient and control endothelial cells, a total of 131 genes were identified as the METTL3-mediated m6A-modified genes in IS. Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis showed that the genes were mainly involved in cytokine-cytokine receptor interaction, MAPK signaling pathway and NF-kappa B signaling pathway. CTSS and SBK1 were further screened as the key METTL3-mediated m6A-modified genes by random forest model and PCR validation. The ROC curve analysis showed that the combination with CTSS and SBK1 was of good diagnostic value for IS, with the AUC of 0.810, sensitivity of 0.780, and specificity of 0.773. Overall, we found that METTL3-mediated m6A modification may influence the occurrence and development of IS by participating in inflammation-related biological processes, and two key m6A-modified genes mediated by METTL3 (CTSS and SBK1) can be used as diagnostic biomarkers for IS.

Advancements of Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage

OBJECTIVE

Spontaneous intracerebral hemorrhage (sICH) is a severe cerebrovascular disease with high mortality and disability. And its treatment strategies have always been a hotspot in clinical research. Endoscopic surgery (ES) is widely used for treating sICH. A comprehensive review of ES for sICH is warranted to provide better understanding and guidance for clinicians. We provide an updated overview of the surgical equipment, surgical indications and timing, and technical advancements, as well as therapeutic effects and future directions.

METHODS

A narrative review of current literature in ES for sICH was performed based on publications from the databases of PubMed, Scopus, and Google Scholar databases up to December 2023.

RESULTS

ES has shown promising safety and efficacy, emerging as a favorable minimally invasive alternative to conventional craniotomy. It reduces perioperative risks associated with long procedures and significant intraoperative bleeding. Recent advancements in ES techniques have led to superior outcomes in mortality reduction and functional recovery. Scholars' systematic studies and summaries underscore ES's role in improving long-term outcomes for sICH patients. However, its limitations, including reduced depth perception, difficulty in managing deep hematomas, and reduced ability to control rapid bleeding control, should be noted.

CONCLUSIONS

ES represents a significant advancement in the treatment of sICH. Its minimally invasive features, coupled with continuous methodological refinement, contribute to a lower mortality rate and better functional recovery compared to traditional methods. ES should be considered a significant option in the surgical management of sICH, necessitating further research and standardization to enhance patient care and outcomes.

Associations of NETs with inflammatory risk and clinical predictive value in large artery atherosclerosis stroke: a prospective cohort study

Background and objective

Neutrophil extracellular traps (NETs) with inflammatory risk are important contributors to cardiovascular disease, but no definitive information is available in large artery atherosclerotic (LAA) stroke. This study aims to investigate the association between NETs with related inflammatory biomarkers and prognosis of LAA stroke in the Chinese population.

Methods

A prospective study involving 145 LAA stroke cases and 121 healthy controls was conducted. Serum levels of MPO-DNA, PAD4, HMGB1, C1q, AIM2, ASC, Caspase-1, IL-1β, IL-6, and IL-8 were determined in all participants. The biomarkers were detected at three time points after stroke onset (24 hours: T1, 48 hours: T2, 7 days: T3) for LAA stroke patients and once for controls. Patients were followed up for 2 years after the ischemic event.

Results

The serum MPO-DNA, PAD4, C1q, IL-1β, IL-6 and IL-8 reach their peak at 24 hours after stroke onset and show a decreasing trend during acute phase. MPO-DNA, AIM2 and IL-1β at baseline were associated with poor outcome at 3 months, further GMDR analysis revealed that the combination of MPO-DNA, AIM2 and IL-1β exert a synergistic effect on the prognosis of LAA stroke (OR: 8.75 95%CI (2.10-32.42)). For time-to-event analysis, MPO-DNA, Caspase-1 and IL-1β at baseline were predictors of MVEs after stroke (HR:4.04 (95%CI 1.28-12.70), 2.33 (95%CI 1.06-5.12) and 4.09 (95%CI 1.39-11.99), respectively).

Conclusions

NETs and related inflammatory biomarkers at baseline predicted outcome at 3 months and late major vascular events following LAA stroke, supporting a rationale of randomized trials for targeted therapy directed at high-risk patients with elevated baseline NETs and related inflammatory biomarkers.

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.

Design, green synthesis, and anti-glutamate damage screening of chalcone derivatives with spiro-heterocyclic structures as potential anti-ischemic brain and eye damage agents

Antagonizing excessive glutamate-induced neuroexcitatory toxicity is one of the treatments for brain and retinal nerve damage in ischemic stroke patients. In this work, a series of 3-benzoyl-4-phenyl-spiropyrrolidone (spiroheterocyclic) compounds were designed and synthesized by modifying the Michael receptor of chalcone to reduce its toxicity. Several compounds with superior protective effects on PC12 cells were screened through an experimental model of glutamate-induced damage, and a quantitative evaluation of the structure-activity relationship (QSAR) model with a regression coefficient of R2 = 0.90723 was established through the random forest (RF) algorithm. Among these compounds, E38 significantly increased the survival rate of damaged cells, promoted colony formation, and inhibited LDH release and apoptosis, and the protective effect of E38 was possibly partly through the HO-1/SIRT1 pathway. More importantly, in mice model of middle cerebral artery occlusion (MCAO), E38 decreased cerebral infarct size, improved neurological scores, and mitigated retinal damage. In conclusion, this work presents a novel class of chalcone derivatives with neuroprotective activity and offers potential compounds for the treatment of ischemic stroke.

Influencing Factors Associated with Psychological Capital Among Ischemic Stroke Patients: A Latent Profile Analysis

BACKGROUND

China has the highest incidence of stroke worldwide because of a high rate of recurrence of ischemic stroke, which has significant negative impacts on the physical and mental health of patients. However, little research has been devoted to the psychological capital of ischemic stroke patients.

PURPOSE

To investigate the psychological capital of ischemic stroke patients, and uses latent profile analysis to identify the potential profiles of the psychological capital among patients as well as to explore heterogeneity within subgroups and the factors influencing it.

METHODS

A survey was distributed among and completed by 427 ischemic stroke patients from November 2023 to March 2024. Four types of questionnaires were administered: the Psychological Capital Questionnaire (PCQ-26), Perceived Stress Scale (CPSS), Athens Insomnia Scale (AIS), and a general information questionnaire.

RESULTS

Three latent profiles of the psychological capital of ischemic stroke patients were identified: the deficient psychological capital group(19.7%), medium psychological capital group(52.5%), and affluent psychological capital group(27.9%). Compared with the deficient psychological capital group, the results of a disordered multi-classification logistic regression analysis showed that the factors influencing the participants of the medium psychological capital group were their marital status (married OR = 1.081, 95% CI: 1.163-7.468, p = 0.023), perceived stress (OR = -0.2, 95% CI: 0.769-0.872, p < 0.001), and insomnia (OR = -0.273, 95% CI: 0.696-0.833, p < 0.001). The factors influencing the affluent psychological capital group were perceived stress (OR = -0.334, 95% CI: 0.664-0.773, p < 0.001) and insomnia (OR = -0.46, 95% CI: 0.56-0.712, p < 0.001).

CONCLUSION

Three potential categories of psychological capital in ischemic stroke patients were identified. Sex, marital status, education, perceived stress, and insomnia were found to be associated with psychological capital in stroke patients. Future research should explore other determinants of psychological capital in ischemic stroke patients to formulate interventions that can improve their psychological capital.

Untargeted metabolomics to detect and identify plasma metabolic signatures associated with intracranial aneurysm and its rupture

The biological basis for metabolic differences between unruptured and ruptured intracranial aneurysm (UIA and RIA) populations and their potential role in triggering IA rupture remain unclear. The aim of this study was to analyze the plasma metabolic profiles of patients with UIA and RIA using an untargeted metabolomic approach and to develop a model for early rupture classification. Plasma samples were analyzed using an ultra-high-performance liquid chromatography high-resolution tandem mass spectrometry-based platform. Least absolute shrinkage and selection operator regression and random forest machine learning methods were employed for metabolite feature selection and predictive model construction. Among 49 differential plasma metabolites identified, 31 were increased and 18 were decreased in the plasma of RIA patients. Five key metabolites-canrenone, piperine, 1-methyladenosine, betaine, and trigonelline-were identified as having strong potential to discriminate between UIA and RIA patients. This combination of metabolites demonstrated high diagnostic accuracy, with an area under the curve exceeding 0.95 in both the training and validation datasets. Our finding highlights the significance of plasma metabolites as potential biomarkers for early detection of IA rupture risk, offering new insights for clinical practice and future research on IA management.

Multiple omics reveal link between the microbiota-gut-brain axis and intracranial aneurysm rupture

Intracranial aneurysms (IAs) are benign cerebrovascular maladies characterized by wall dilatation in the intracranial arteries. Nevertheless, spontaneous aneurysmal rupture can cause a life-threatening spontaneous subarachnoid hemorrhage (SAH). Emerging evidence indicates potential associations between gut dysbiosis and IAs pathogenesis, though the relationship with IA rupture remains unclear. This research analyzed 124 fecal samples for microbiomics and 160 for metabolomics, with the discovery and validation sets established for cross-validation. We identified differential gut microbiota and metabolites associated with ruptured intracranial aneurysms (RIAs) and developed a superior risk assessment model. Subsequent integrative analyses and validation revealed a significant link between disrupted unsaturated fatty acid and essential amino acid metabolic pathways and IA rupture, driven by alterations in gut microbiota. This study underscores the potential association between the gut-brain axis and IA rupture, while also highlighting gut microbiota dysbiosis as a potential risk factor for IA rupture and providing biomarkers for assessment.

A Systematic Review and Meta-Analysis Assessing the Accuracy of Blood Biomarkers for the Diagnosis of Ischemic Stroke in Adult and Elderly Populations

This study aims to elucidate the methodology and compare the accuracy of different blood biomarkers for diagnosing ischemic stroke (IS). We reviewed 29 articles retrieved from PubMed, MEDLINE, Web of Science, and CINAHL Plus with Full Text. Among these, 23 articles involving 3,494 participants were suitable for meta-analysis. The pooled area under the curve (AUC) of all studies for meta-analysis was 0.89. The pooled sensitivity and specificity were 0.76 (0.74-0.78) and 0.84 (0.83-0.86), respectively. Blood biomarkers from noninpatient settings demonstrated better diagnostic performance than those in inpatient settings (AUC 0.91 vs 0.88). Smaller sample sizes (<100) showed better performance than larger ones (≥100; AUC 0.92 vs 0.86). Blood biomarkers from acute IS (AIS) patients showed higher diagnostic values than those from IS and other stroke types (AUC 0.91 vs 0.87). The diagnostic performance of multiple blood biomarkers was superior to that of a single biomarker (AUC 0.91 vs 0.88). The diagnostic value of blood biomarkers from Caucasians was higher than that from Asians and Africans (AUC 0.90 vs 0.89, 0.75). Blood biomarkers from those with comorbidities (AUC 0.92) showed a better diagnostic performance than those not reporting comorbidities (AUC 0.84). All the subgroups analyzed, including setting, sample size, target IS population, blood biomarker profiling, ethnicity, and comorbidities could lead to heterogeneity. Blood biomarkers have demonstrated sufficient diagnostic accuracy for diagnosing IS and hold promise for integration into routine clinical practice. However, further research is recommended to refine the optimal model for utilizing blood biomarkers in IS diagnosis.

Correlation and predictive value of platelet biological indicators and recurrence of large-artery atherosclerosis type of ischemic stroke

Large-artery atherosclerosis type of ischemic stroke happens when a blood clot forms in a major artery that carries blood to the brain. This causes a blockage and a decrease in blood flow to the brain tissue making up approximately 15-20% of all cases. This type of stroke is more prevalent in older adults and those with risk factors such as high blood pressure, high cholesterol, diabetes, smoking, and a family history of stroke. To investigate the correlation and predictive value of platelet-related biological indicators with recurrence of large-artery atherosclerosis type of ischemic stroke (LAA-IS)2. The patients were divided into a relapse group (R, n = 40) and non-relapse group (NR, n = 45). Platelet-related biological indicators were collected from both groups to analyze their correlation with neurological impairment score (NIHSS score). Risk factors were analyzed using binary logistic regression and a survival curve (ROC) was drawn to evaluate the predictive effect of clinical platelet-related biological indicators on LAA-IS recurrence. This study confirmed that PAg-ADP, PAg-COL, and FIB are closely related to the formation of LAA-IS due to carotid atherosclerosis, and the combined PAg-ADP, PAg-COL, and FIB index levels are the most promising for assessing the prognostic development of recurrence in patients with LAA-IS. Combined monitoring of platelet aggregation rate and FIB index is of important evaluation value in judging the recurrence prognosis of LAA-IS patients.

Major vascular events after first incident stroke: a population-based study

Background

Recent advances in stroke care have led to improvements in survival and rates of stroke recurrence. However, there is a lack of data on trends of major vascular events, and risk factors associated with non-fatal and fatal outcomes. We aim to identify demographical and clinical factors leading to incidence of subsequent major vascular events after the first-ever stroke.

Methods

6051 patients' records with first-ever stroke between 1995 and 2018 in South London, UK were analysed. Semicompeting risks models were constructed to estimate factors affecting time to incidence of recurrent stroke, myocardial infarction (MI), mortality and transitions from poststroke recurrence/MI to mortality (indirect mortality). Cumulative incidence functions were plotted for each major vascular event, stratified by stroke subtypes. All models were adjusted for age, sex, socioeconomic status, comorbidities, stroke severity and stroke subtype.

Results

Five years of cumulative incidences were 9.2% (95% CI (8.4% to 10.0%)) for recurrent stroke, 4.4% (95% CI 3.9% to 5.0%) for MI, and 45% (95% CI 44% to 47%) for mortality. Prior atrial fibrillation was associated with 47% increased risk of mortality (HR=1.47 (95% CI 1.23 to 1.75)) and a previous diagnosis of MI was the strongest risk factor for poststroke MI (HR=9.17 (95% CI 6.28 to 13.39)). Stroke unit was associated with a 40% lower hazard of mortality without having a recurrent stroke/MI (HR=0.60 (95% CI 0.50 to 0.72)) and a 39% lower hazard of indirect mortality (HR=0.57 (95% CI 0.37 to 0.87)).

Conclusion

Major vascular events are prevalent after stroke, particularly among those with concurrent vascular conditions. The rate of stroke recurrence plateaued in the last decade, yet MI incidence increased. Targeted strategies to control risk factors are required to reduce the incidence of a second vascular event and prevent progression to mortality in these high-risk groups.

Reduced circulating CD63+ extracellular vesicle levels associate with atherosclerosis in hypercholesterolaemic mice and humans

AIMS

The association and co-isolation of low-density lipoproteins (LDL) and extracellular vesicles (EVs) have been shown in blood plasma. Here we explore this relationship to better understand the role of EVs in atherogenesis.

METHODS AND RESULTS

Wild type (WT), PCSK9-/-, and LDLR-/- C57BL/6 mice were used in this study. Eleven week-old male mice were fed high-fat diet (HFD) for 12 weeks or kept on normal diet until old age (22-months). Cardiac function was assessed by ultrasound, cholesterol was quantified with a colorimetric kit and circulating EVs were measured using flow cytometry. Plaques were analysed post-mortem using Oil-Red-O staining of the aortic arch. EVs were measured from platelet free blood plasma samples of normal and hypercholesterolaemic clinical patients. Based on annexin V and CD63 staining, we found a significant increase in EV levels in LDLR-/- and PCSK9-/- mice after HFD, but CD81 showed no significant change in either group. There was no significant change in plaque formation after HFD. PCSK9-/- mice show a favourable cardiac function after HFD. Blood cholesterol levels progressively increased during HFD, with LDLR-/- mice showing high levels while PCSK9-/- were significantly lowered compared to WT animals. In mice at old age, similar cholesterol levels were observed as in young mice. In old age, LDLR-/- mice showed significantly increased plaques. At old age, ejection fraction was decreased in all groups of mice, as were CD63+ EVs. Similarly to mice, in patients with hypercholesterolaemia, CD63+ EVs were significantly depleted.

CONCLUSIONS

This research demonstrates an inverse relationship between circulating EVs and cholesterol, making EVs a potential marker for cardiovascular disease (CVD). HFD causes reduced cardiac function, but atherosclerotic development is slowly progressing in hypercholesterolaemic models and only observed with old animals. These results also bring further evidence for the benefit of using of PCSK9 inhibitors as therapeutic agents in CVD.

Advanced vascular aging and outcomes after acute ischemic stroke: a systematic review and meta-analysis

Pulse wave velocity (PWV) is as a reliable marker of arterial stiffness and vascular aging, surpassing traditional risk factors in predicting detrimental cardiovascular events. The present meta-analysis aims to investigate PWV thresholds and assess its prognostic value in outcomes of acute ischemic stroke (AIS). A search was conducted in PubMed, Cochrane, Web of Science, and Scopus for studies published up to January 2024, focusing on patients admitted with AIS, wherein arterial stiffness was assessed through PWV measurements during hospitalization. Identified studies reported PWV values in individuals with both favorable and unfavorable outcomes at the end of follow-up. Initially, 35 eligible studies provided data for weighted mean baPWV (11,953 AIS patients) and cfPWV (2,197 AIS patients) calculations. The average age was 67 years, with approximately 60% male, 67% hypertensive, 30% diabetic and 30% smoker participants. The weighted mean systolic blood pressure was approximately 150 mmHg. In AIS patients, the mean PWV was 10 m/s for standard cfPWV and 20 m/s for baPWV. Nine cohort studies (6,006 AIS patients) were included in the quantitative analysis of clinical outcomes. Higher PWV levels were associated with poorer functional outcomes (2.3 m/s higher, 95%CI:1.2-3.4, p < 0.001; I2 = 87.4%). AIS patients with arterial stiffness/vascular aging (higher PWV) had approximately 46.2% increased risk of poor functional outcome, 12.7% higher risk of mortality, 13.9% greater risk of major adverse cardiovascular events, and 13.9% greater risk of stroke recurrence over the long term compared to those without arterial stiffness. Advanced vascular aging, as indicated by PWV, significantly predicts adverse outcomes in AIS patients. Integrating the assessment of vascular aging into clinical practice can improve risk perception in these patients.

Females with diabetes have a higher risk of ischemic stroke readmission: a retrospective cohort study

BACKGROUND

There are significant sex differences in the incidence of stroke or diabetes mellitus. However, little is known about sex differences in stroke rehospitalization among diabetic patients.

OBJECT

To explore the sex differences in short-term and long-term rehospitalization of ischemic stroke patients with Type 2 diabetes mellitus.

METHODS

A retrospective cohort study was conducted from 2017 to 2021. The rehospitalization events of ischemic stroke patients with diabetes mellitus were identified by the national unified Electronic Health Record. Propensity score matching was applied to adjust for multiple covariates, and LASSO regression was used to screen for independent variables. Cox proportional hazards model was utilized to analyze the different sex in short-term (90 days, 1 year) and long-term (5 years) rehospitalization in ischemic stroke patients with type 2 diabetes mellitus.

RESULT

A total of 10,724 ischemic stroke patients were included in this study, of whom 5,952 (55.5%) were males. After a 1:1 propensity score matching, there were 3,460 males and 2,772 females. After adjusting for confounding factors, female patients with type 2 diabetes had an increased risk of ischemic stroke rehospitalization at 90 days (HR: 1.94, 95%CI: 1.13-3.33, P < 0.05), 1 year (HR: 1.65, 95%CI:1.22-2.23, P = 0.001), and 5 years (HR: 1.58, 95%CI: 1.26-1.97, P < 0.001). However, there was no significant relationship between male patients with type 2 diabetes and the risk of ischemic stroke rehospitalization, either in the short or long term.

CONCLUSION

Females with type 2 diabetes mellitus have a higher risk of ischemic stroke rehospitalization in both the short-term and long-term.

Acute Myocardial Injury in Spontaneous Intracerebral Hemorrhage: A Secondary Observational Analysis of the FAST Trial

BACKGROUND

Acute myocardial injury is associated with poor outcomes in patients with acute ischemic stroke, but its prognostic significance in patients with spontaneous intracerebral hemorrhage remains unclear. We investigated whether acute myocardial injury and the direction of the cardiac troponin I (cTnI) change (rising versus falling) affect post-intracerebral hemorrhage outcomes.

METHODS AND RESULTS

We re-analyzed the FAST (Factor-Seven-for-Acute-Hemorrhagic-Stroke) trial. Acute myocardial injury was defined as at least 1 cTnI value above the upper reference limit with a rise/fall of >20%. Logistic regression tested for associations (1) between acute myocardial injury (presence versus absence) and poor outcome (modified Rankin Scale 4-6) and mortality at 15 and 90 days; (2) among 3 groups (rising versus falling versus no acute myocardial injury) and outcomes. Among the 841 FAST participants, 785 patients were included. Acute myocardial injury was detected in 29% (n=227); 170 had rising cTnI. At 15 and 90 days, respectively, those with acute myocardial injury had higher odds of poor outcome (adjusted odds ratio) ([aOR] 2.3 [95% CI, 1.3-3.9]); and adjusted odds ratio 2.5 [95% CI, 1.6-3.9];, and higher odds of mortality (adjusted odds ratio 2.4 [95% CI, 1.4-4.3]; and adjusted odds ratio 2.2 [CI, 1.3-3.6]) than patients without. There was no interaction between FAST group assignment and myocardial injury, and associations between myocardial injury and outcomes were consistent across group assignments. Rising cTnI was associated with the highest risk of poor outcomes and mortality.

CONCLUSIONS

In this secondary analysis of the FAST trial, acute myocardial injury was common and associated with poor outcomes. The direction of the cTnI change might provide additional risk stratification after intracerebral hemorrhage.

Association of clopidogrel resistance and ABCD-GENE score with long-term clinical prognosis in patients with ischemic stroke or TIA

BACKGROUND

Clopidogrel resistance (CR) is associated with adverse clinical outcomes in acute ischemic stroke or transient ischemic attack (TIA) patients. However, whether CR affects the long-term clinical prognosis remains to be clarified. The ABCD-GENE score is a novel risk model that identifies CR in cardiovascular disease patients; its diagnostic ability and application in ischemic stroke or TIA remain to be studied. This study aimed to investigate the diagnostic ability of the ABCD-GENE score for CR and analyze the relationship between CR and long-term clinical prognosis in patients with ischemic stroke or TIA.

METHODS

From January 2018 to January 2021, 251 ischemic stroke or TIA patients who were treated with clopidogrel for more than three months after onset and maintained the medication until the follow-up time were enrolled, and platelet reactivity was detected by thromboelastography. CYP2C19 gene analysis was performed. Adverse clinical outcomes were recorded from 3months after onset. The median follow-up time was 878days.

RESULTS

The prevalence of CR was 33.9%. The proportion of CYP2C19 loss-of-function carriers was 62.2%. The ABCD-GENE score≥10 was independently associated with CR (OR=1.82, 95% CI: 1.02-3.24, P=0.041), and the C-statistic value of the score (as a binary and integer variable) on CR was 0.58 and 0.63, respectively. The risk of long-term adverse clinical outcomes was not significantly different between CR and clopidogrel sensitive groups (12.94% vs. 11.44%, HR=1.22, 95% CI: 0.57-2.62, P=0.603). A similar result was observed between ABCD-GENE score≥10 and ABCD-GENE score<10 groups (10.38% vs. 12.64%, HR=1.19, 95% CI: 0.55-2.60, P=0.666).

CONCLUSIONS

In ischemic stroke or TIA patients, the ABCD-GENE score could identify the risk of CR. CR was not associated with long-term adverse clinical outcomes.

Impaired glucose metabolism and the risk of vascular events and mortality after ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Diabetes mellitus (DM), prediabetes, and insulin resistance are highly prevalent in patients with ischemic stroke (IS). DM is associated with higher risk for poor outcomes after IS.

OBJECTIVE

Investigate the risk of recurrent vascular events and mortality associated with impaired glucose metabolism compared to normoglycemia in patients with IS and transient ischemic attack (TIA).

METHODS

Systematic literature search was performed in PubMed, Embase, Cochrane Library on 21st March 2024 and via citation searching. Studies that comprised IS or TIA patients and exposures of impaired glucose metabolism were eligible. Study Quality Assessment Tool was used for risk of bias assessment. Covariate adjusted outcomes were pooled using random-effects meta-analysis.

MAIN OUTCOMES

Recurrent stroke, cardiac events, cardiovascular and all-cause mortality and composite of vascular outcomes.

RESULTS

Of 10,974 identified studies 159 were eligible. 67% had low risk of bias. DM was associated with an increased risk for composite events (pooled HR (pHR) including 445,808 patients: 1.58, 95% CI 1.34-1.85, I2 = 88%), recurrent stroke (pHR including 1.161.527 patients: 1.42 (1.29-1.56, I2 = 92%), cardiac events (pHR including 443,863 patients: 1.55, 1.50-1.61, I2 = 0%), and all-cause mortality (pHR including 1.031.472 patients: 1.56, 1.34-1.82, I2 = 99%). Prediabetes was associated with an increased risk for composite events (pHR including 8,262 patients: 1.50, 1.15-1.96, I2 = 0%) and recurrent stroke (pHR including 10,429 patients: 1.50, 1.18-1.91, I2 = 0), however, not with mortality (pHR including 9,378 patients, 1.82, 0.73-4.57, I2 = 78%). Insulin resistance was associated with recurrent stroke (pHR including 21,363 patients: 1.56, 1.19-2.05, I2 = 55%), but not with mortality (pHR including 21,363 patients: 1.31, 0.66-2.59, I2 = 85%).

DISCUSSION

DM is associated with a 56% increased relative risk of death after IS and TIA. Risk estimates regarding recurrent events are similarly high between prediabetes and DM, indicating high cardiovascular risk burden already in precursor stages of DM. There was a high heterogeneity across most outcomes.

Monocyte Chemoattractant Protein-1, Inflammatory Biomarkers, and Prognosis of Patients With Ischemic Stroke or Transient Ischemic Attack: Fndings From a Nationwide Registry Study

BACKGROUND

Recent Mendelian randomization and meta-analysis highlight the relevance of MCP-1 (monocyte chemoattractant protein-1) in stroke. We aimed to investigate the associations between MCP-1 and clinical outcomes in patients with ischemic stroke or transient ischemic attack and test whether inflammation mediates or jointly contributes to the relationships.

METHODS AND RESULTS

A total of 10 700 patients from the Third China National Stroke Registry study were included. Multivariable Cox regression was used for recurrent stroke and all-cause death, and logistic regression was used for poor functional outcome. Mediation analyses were performed to clarify whether inflammation mediates the associations. After adjusting for potential confounders, low MCP-1 level (<337.6 pg/mL) was associated with a reduced risk of all-cause death (hazard ratio [HR], 0.65 [95% CI, 0.51-0.82]) and poor functional outcome (odds ratio, 0.81 [95% CI, 0.70-0.94]) but was not associated with recurrent stroke (HR, 1.10 [95% CI, 0.95-1.27]), compared with high MCP-1 level (≥337.6 pg/mL). The association between MCP-1 and all-cause death was partially mediated by highly sensitive C-reactive protein, interleukin-6, and YKL-40 (Chitinase-3-like protein 1; mediated proportion: 7.4%, 10.5%, and 7.4%, respectively). The corresponding mediated proportion for poor functional outcome was 9.9%, 17.1%, and 7.1%, respectively. Patients with combined high levels of MCP-1 and inflammatory biomarkers had the highest risks of all-cause death and poor functional outcome.

CONCLUSIONS

Low plasma MCP-1 level was associated with decreased risks of all-cause mortality and poor functional outcome after ischemic stroke or transient ischemic attack. Inflammation partially mediated and jointly contributed to the associations.

Conventional and genetic associations of BMI with major vascular and non-vascular disease incidence and mortality in a relatively lean Chinese population: U-shaped relationship revisited

BACKGROUND

Higher body mass index (BMI) is associated with higher incidence of cardiovascular and some non-cardiovascular diseases (CVDs/non-CVDs). However, uncertainty remains about its associations with mortality, particularly at lower BMI levels.

METHODS

The prospective China Kadoorie Biobank recruited >512 000 adults aged 30-79 years in 2004-08 and genotyped a random subset of 76 000 participants. In conventional and Mendelian randomization (MR) analyses, Cox regression yielded adjusted hazard ratios (HRs) associating measured and genetically predicted BMI levels with incident risks of major vascular events (MVEs; conventional/MR 68 431/23 621), ischaemic heart disease (IHD; 50 698/12 177), ischaemic stroke (IS; 42 427/11 897) and intracerebral haemorrhage (ICH; 7644/4712), and with mortality risks of CVD (15 427/6781), non-CVD (26 915/4355) and all causes (42 342/6784), recorded during ∼12 years of follow-up.

RESULTS

Overall, the mean BMI was 23.8 (standard deviation: 3.2) kg/m2 and 13% had BMIs of <20 kg/m2. Measured and genetically predicted BMI showed positive log-linear associations with MVE, IHD and IS, but a shallower positive association with ICH in conventional analyses. Adjusted HRs per 5 kg/m2 higher genetically predicted BMI were 1.50 (95% CI 1.41-1.58), 1.49 (1.38-1.61), 1.42 (1.31-1.54) and 1.64 (1.58-1.69) for MVE, IHD, IS and ICH, respectively. These were stronger than associations in conventional analyses [1.21 (1.20-1.23), 1.28 (1.26-1.29), 1.31 (1.29-1.33) and 1.14 (1.10-1.18), respectively]. At BMIs of ≥20 kg/m2, there were stronger positive log-linear associations of BMI with CVD, non-CVD and all-cause mortality in MR than in conventional analyses.

CONCLUSIONS

Among relatively lean Chinese adults, higher genetically predicted BMI was associated with higher risks of incident CVDs. Excess mortality risks at lower BMI in conventional analyses are likely not causal and may reflect residual reverse causality.

Relationships between obesity and functional outcome after ischemic stroke: a Mendelian randomization study

BACKGROUND AND OBJECTIVES

Most previous studies suggested obesity deteriorates the functional outcome after ischemic stroke. But there are researches claiming that obesity is associated with lower mortality, recurrence, and readmission rates, which is known as the obesity paradox. Our current research aimed to investigate the correlation between genetically obesity and the post-stroke outcome with the Mendelian randomization (MR) method.

METHODS

The UK Biobank and the GIANT consortium provided instrumental variables for body mass index (BMI, 806,834 individuals) and waist-to-hip ratio (WHR, 697,734 individuals). Data of functional outcome after ischemic stroke were obtained from the Genetics of Ischemic Stroke Functional Outcome network (6012 individuals). Inverse-variance weighted approach was utilized as the primary analyses. Sensitivity analyses involved the utilization of different MR methods. The heterogeneity among genetic variants was assessed by I2 and Q value statistics.

RESULTS

In univariable analysis, there was a significant connection between genetic susceptibility to WHR and worse functional outcome (modified Rankin Scale 3) after ischemic stroke (OR [95%CI] = 1.47 [1.07, 2.02], P = 0.016). Genetic liability to BMI and was not associated with post-stroke functional outcome (all P > 0.05). The overall patterns between genetic liability to WHR and functional outcome post-ischemic outcome no longer existed in the multivariable MR analysis after adjusting for BMI (OR [95%CI] = 1.26[0.76,1.67], P = 0.56).

CONCLUSION

The current MR study provided evidence that WHR was correlated to unfavorable outcome post-ischemic stroke. Exploring interventions against obesity may potentially improve recovery after ischemic stroke.

The incidence of stroke and contribution of risk factors for stroke in high-risk stroke population in southwestern China

OBJECTIVE

To estimate the incidence of stroke and determine the role that risk factors play in the high-risk stroke populace in southwest China.

METHODS

This research employed a prospective cohort design that focused on the community. Eight communities in southwest China were selected randomly for this study. The residents aged 40 years and older who volunteered to participate were surveyed through face-to-face interviews. Those with a history of stroke or at least three of the eight stroke-related risk factors were categorized as the high-risk stroke population. A total of 2698 high-risk individuals were included in the study after a 4.7-year follow-up period. The incidence of stroke and the association between risk variables and stroke occurrence were estimated.

RESULTS

During 4.7-year follow-up, the incidence of total stroke, ischemic stroke, and hemorrhagic stroke in high-risk stroke population were 5.0 %, 4.4 % and 0.9 % respectively. It should be noted that some participants experienced both cerebral infarction and cerebral hemorrhage during the follow-up period. The multivariate analytic model revealed that a personal history of stroke (OR=3.397, 95 % CI 2.365-4.878, p<.001) was substantially linked with an elevated risk of overall stroke. This correlation remained consistent for both ischemic and hemorrhagic stroke.

CONCLUSIONS

This study revealed a high prevalence and incidence of stroke among a high-risk group in southwestern China. Furthermore, it demonstrated that individuals with a personal history of stroke are at an elevated risk of future stroke, suggesting the need for additional precautions in this population.

Recurrent cerebrovascular events after recent small subcortical infarction

BACKGROUND

Recent small subcortical infarcts (RSSI) are the neuroimaging hallmark feature of small vessel disease (SVD)-related acute lacunar stroke. Long-term data on recurrent cerebrovascular events including their aetiology after RSSI are scarce.

PATIENTS AND METHODS

This retrospective study included all consecutive ischaemic stroke patients with an MRI-confirmed RSSI (in the supply area of a small single brain artery) at University Hospital Graz between 2008 and 2013. We investigated associations between clinical and SVD features on MRI (STRIVE criteria) and recurrent cerebrovascular events, using multivariable Cox regression adjusted for age, sex, vascular risk factors and MRI parameters.

RESULTS

We analysed 332 consecutive patients (mean age 68 years, 36% women; median follow-up time 12 years). A recurrent ischaemic cerebrovascular event occurred in 70 patients (21.1%; 54 ischaemic strokes, 22 transient ischaemic attacks) and was mainly attributed to SVD (68%). 26 patients (7.8%) developed intracranial haemorrhage. In multivariable analysis, diabetes (HR 2.43, 95% CI 1.44-3.88), severe white matter hyperintensities (HR 1.97, 95% CI 1.14-3.41), and cerebral microbleeds (HR 1.89, 95% CI 1.32-3.14) on baseline MRI were related to recurrent ischaemic stroke/TIA, while presence of cerebral microbleeds increased the risk for intracranial haemorrhage (HR 3.25, 95% CI 1.39-7.59). A widely used SVD summary score indicated high risks of recurrent ischaemic (HR 1.22, 95% CI 1.01-1.49) and haemorrhagic cerebrovascular events (HR 1.57, 95% CI 1.11-2.22).

CONCLUSION

Patients with RSSI have a substantial risk for recurrent cerebrovascular events-particularly those with coexisting chronic SVD features. Recurrent events are mainly related to SVD again.

Crosstalk between ferroptosis and necroptosis in cerebral ischemia/reperfusion injury and Naotaifang formula exerts neuroprotective effect via HSP90-GCN2-ATF4 pathway

BACKGROUND

Cerebral ischemia/reperfusion injury (CIRI) is a sequence of pathophysiological processes after blood recanalization in the patients with ischemic stroke, and has become the hinder for the rehabilitation. Naotaifang formula (NTF) has exhibited the clinical effectiveness for this disease. However, its action effects and molecular mechanisms against CIRI are not fully elucidated.

PURPOSE

The research was to clarify the crosstalk between ferroptosis and necroptosis in CIRI, and uncover the mechanism underlying the neuroprotection of NTF.

METHODS

This study established MCAO/R rat models with various reperfusion times. Western blot, transmission electron microscope, laser speckle imaging, immunofluorescence, immunohistochemistry and pathological staining were conducted to detect and analyze the obtained results. Subsequently, various NTF doses were used to intervene in MCAO/R rats, and biology experiments, such as western blot, Evans blue, immunofluorescence and immunohistochemistry, were used to analyze the efficacy of NTF doses. The effect of NTF was further clarified through in vitro experiments. Eventually, HT22 cells that suffered OGD/R were subjected to pre-treatment with plasmids overexpressing HSP90, MLKL, and GPX4 to indicate the interaction among ferroptosis and necroptosis.

RESULTS

There was a gradual increase in the Zea Longa score and cerebral infarction volume following CIRI with prolonged reperfusion. Furthermore, the expression of factors associated with pro-ferroptosis and pro-necroptosis was upregulated in the cortex and hippocampus. NTF alleviated ferroptosis and necroptosis in a dose-dependent manner, downregulated HSP90 levels, reduced blood-brain barrier permeability, and thus protected nerve cells from CIRI. The results in vitro research aligned with those of the in vivo research. HSP90 and MLKL overexpression promoted necroptosis and ferroptosis while activating the GCN2-ATF4 pathway. GPX4 overexpression had no effect on necroptosis or the associated signaling pathway. The administration of NTF alone, as well as its combination with the overexpression of HSP90, MLKL, or GPX4 plasmids, decreased the expression levels of factors associated with pro-ferroptosis and pro-necroptosis and reduced the protein levels of the HSP90-GCN2-ATF4 pathway. Moreover, the regulatory effects of the NTF alone group on GSH, ferrous iron, and GCN2 were more significant compared with those of the HSP90 overexpression combination group.

CONCLUSION

Ferroptosis and necroptosis were gradually aggravated following CIRI with prolonged reperfusion. MLKL overexpression may promote ferroptosis and necroptosis, while GPX4 overexpression may have little effect on necroptosis. HSP90 overexpression accelerated both forms of cell death via the HSP90-GCN2-ATF4 pathway. NTF alleviated ferroptosis and necroptosis to attenuate CIRI by regulating the HSP90-GCN2-ATF4 pathway. Our research provided evidence for the potential of drug development by targeting HSP90, MLKL, and GPX4 to protect against ischemic stroke.

Diverging Trends in Survival and Functional Outcome between Males and Females after Intracerebral Hemorrhage

BACKGROUND

Compared to ischemic stroke, sex differences in patient outcomes following intracerebral hemorrhage (ICH) are underreported. We aimed to determine sex differences in mortality and functional outcomes in a large, unselected Swedish cohort.

METHODS

In this observational study, data on 22,789 patients with spontaneous ICH registered in the Swedish Stroke Register between 2012 and 2019 were used to compare sex differences in 90-day mortality and functional outcome using multivariable Cox and logistic regression analyses, adjusting for relevant confounders. Multiple imputation was used to impute missing data.

RESULTS

The crude 90-day mortality rate was 36.7% in females (3,820/10,405) and 31.7% in males (3,929/12,384) (female hazard ratio [HR] 1.20 95% confidence interval [CI]: 1.15-1.25). In multivariable analysis, the HR for 90-day mortality following ICH in females was 0.89 (95% CI: 0.85-0.94). Age was an important driving factor for the effect of sex on mortality. After adjustment for age, vascular risk factors, and stroke severity, the 90-day functional outcome in pre-stroke independent patients was worse in females compared to males (odds ratio: 1.27 95% CI: 1.16-1.40).

CONCLUSION

In this large observational study, despite lower 90-day mortality, the female sex was independently associated with a worse functional outcome compared to males after ICH, even after adjusting for significant covariates. These diverging trends have not been previously reported for ICH. Given the observational design, our findings should be interpreted with caution, thus further external validation is warranted.

Multicenter Validation of lncRNA and Target mRNA Diagnostic and Prognostic Biomarkers of Acute Ischemic Stroke From Peripheral Blood Leukocytes

BACKGROUND

Long noncoding RNA (lncRNA) and mRNA profiles in leukocytes have shown potential as biomarkers for acute ischemic stroke (AIS). This study aimed to identify altered lncRNA and target mRNA profiles in peripheral blood leukocytes as biomarkers and to assess the diagnostic value and association with AIS prognosis.

METHODS AND RESULTS

Differentially expressed lncRNAs (DElncRNAs) and differentially expressed target mRNAs (DEmRNAs) were screened by RNA sequencing in the discovery set, which consisted of 10 patients with AIS and 20 controls. Validation sets consisted of a multicenter (311 AIS versus 303 controls) and a nested case-control study (351 AIS versus 352 controls). The discriminative value of DElncRNAs and DEmRNAs added to the traditional risk factors was estimated with the area under the curve. NAMPT-AS, FARP1-AS1, FTH1, and NAMPT were identified in the multicenter case-control study (P<0.05). LncRNA NAMPT-AS was associated with cis-target mRNA NAMPT and trans-target mRNA FTH1 in all validation sets (P<0.001). Similarly, AIS cases exhibited upregulated lncRNA FARP-AS1 and FTH1 expression (P<0.001) in the nested case-control study (P<0.001). Furthermore, lncRNA FARP1-AS1 expression was upregulated in AIS patients at discharge with an unfavorable outcome (P<0.001). Positive correlations were found between NAMPT expression level and NIHSS scores of AIS patients (P<0.05). Adding 2 lncRNAs and 2 target mRNAs to the traditional risk factor model improved area under the curve by 22.8% and 5.2% in the multicenter and the nested case-control studies, respectively.

CONCLUSIONS

lncRNA NAMPT-AS and FARP1-AS1 have potential as diagnostic biomarkers for AIS and exhibit good performance when combined with target mRNA NAMPT and FTH1.

Low Remnant Cholesterol and In-Hospital Bleeding Risk After Ischemic Stroke or Transient Ischemic Attack

BACKGROUND

Bleeding risk brought by intensive lipid-lowering therapy and low low-density lipoprotein cholesterol is concerning, while evidence regarding the relationship between remnant cholesterol and bleeding is frightening. This study aimed to investigate the association between remnant cholesterol at admission and an in-hospital bleeding event after acute ischemic stroke or transient ischemic attack (TIA).

METHODS AND RESULTS

A total of 3222 eligible patients admitted to Shanghai Huashan Hospital between 2015 and 2021 with complete lipid data were analyzed. Patients were classified into low (<20.0 mg/dL), moderate (20.0-29.9 mg/dL), and high (≥30 mg/dL) groups by remnant cholesterol. The mean age of patients was 63.0± 13.1 years, including 2301 (71.4%) men and 651 (20.2%) with TIA. The median (interquartile range) of remnant cholesterol was 18.6 (13.5-25.9) mg/dL. After adjustment for confounding variables, patients with low remnant cholesterol had a higher risk of bleeding events (odds ratio, 2.56 [95% CI, 1.12-6.67]) than those with moderate remnant cholesterol. The high remnant cholesterol group was not significantly associated with bleeding risk. Combined assessment of low-density lipoprotein cholesterol and remnant cholesterol further identified patients with the highest risk of bleeding events.

CONCLUSIONS

Low remnant cholesterol levels were associated with bleeding events during the acute stage of ischemic stroke and TIA. The assessment of remnant cholesterol could inform the bleeding risk during hospitalization both for patients and physicians in clinical practice.

Using status of secondary prevention medications in post-stroke dysphagia patients: time to raise awareness and develop special formulations

Post-stroke dysphagia (PSD) is an increasingly common complication of stroke. Despite its intuitively unfavorable impact on secondary prevention medication use, limited awareness is available regarding this issue. Herein, a cross-sectional survey was conducted to determine the current use, patient-perceived needs and preferences for secondary prevention medications among PSD patients. To emphasize the unique context related to dysphagia, we recruited Chinese stroke patients with a duration of less than 5 years. These patients were initially categorized into PSD respondents with and without dysphagia. Among the 3490 eligible respondents, 42.7% reported experiencing dysphagia after stroke. Those PSD respondents were more likely to consume multiple medications and suffer from anticoagulants-associated gastrointestinal bleeding as compared to non-PSD ones (p < 0.001). More crucially, 40.2% of them had frequent difficulty in swallowing pills, 37.1% routinely crushed solid oral dosage forms (SODFs), and 23.5% coughed frequently when taking SODFs. In consequence, 87.4% responded a need for PSD-specific formulations where safe swallowing, easy swallowing, and reduced medication frequency were preferred pharmaceutical factors. These findings demonstrate an unsatisfactory situation and definite needs for PSD patients in using secondary prevention medications. Awareness should be increased to develop PSD-specific formulations for safe and effective secondary prevention.

Stroke

Stroke affects up to one in five people during their lifetime in some high-income countries, and up to almost one in two in low-income countries. Globally, it is the second leading cause of death. Clinically, the disease is characterised by sudden neurological deficits. Vascular aetiologies contribute to the most common causes of ischaemic stroke, including large artery disease, cardioembolism, and small vessel disease. Small vessel disease is also the most frequent cause of intracerebral haemorrhage, followed by macrovascular causes. For acute ischaemic stroke, multimodal CT or MRI reveal infarct core, ischaemic penumbra, and site of vascular occlusion. For intracerebral haemorrhage, neuroimaging identifies early radiological markers of haematoma expansion and probable underlying cause. For intravenous thrombolysis in ischaemic stroke, tenecteplase is now a safe and effective alternative to alteplase. In patients with strokes caused by large vessel occlusion, the indications for endovascular thrombectomy have been extended to include larger core infarcts and basilar artery occlusion, and the treatment time window has increased to up to 24 h from stroke onset. Regarding intracerebral haemorrhage, prompt delivery of bundled care consisting of immediate anticoagulation reversal, simultaneous blood pressure lowering, and prespecified stroke unit protocols can improve clinical outcomes. Guided by underlying stroke mechanisms, secondary prevention encompasses pharmacological, vascular, or endovascular interventions and lifestyle modifications.

Investigation of vascular risk factor control and secondary prevention medication compliance in acute ischemic stroke

Objectives

This study aimed to investigate the management of vascular risk factors, with a specific focus on understanding the various factors affecting risk factor control through an in-depth analysis of clinical data and a longitudinal follow-up of patients who have experienced ischemic strokes.

Methods

A total of 1,572 participants were included in the analysis. We assessed thresholds for blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), and glycated hemoglobin (HbA1c) levels to uncover the contextual conditions and factors affecting vascular risk factor control. Moreover, the study also scrutinized medication compliance at intervals of 3, 6, and 12 months post-onset. Logistic regression was used to adjust for confounding factors.

Results

At 3, 6, and 12 months, BP,LDL, hemoglobin control targets were achieved in 50.7, 51.8, and 50.6%; 51.5, 59.4, and 50.6%; 48.1, 44.0, and 48.4%,respectively. Notably, age was associated with the achievement of BP control (odds ratio [OR], 0.96; 95% confidence intervals [CI], 0.94-0.98; p < 0.0001). Ethnic minorities (OR, 4.23; 95% CI, 1.19-15.09; p = 0.02) and individuals with coronary heart disease (OR, 0.5; 95% CI, 0.3-1.0; p = 0.05) experienced decreased BP control ratios. A previous history of stroke (OR, 1.7; 95% CI, 1.0-2.8; p = 0.03) and unrestricted alcohol consumption (OR, 3.3; 95% CI, 1.0-11.1; p = 0.05) was significantly associated with the achievement of lipid control. Furthermore, lifestyle modifications were significantly correlated with the achievement of BP control (OR, 0.19; 95% CI, 0.12-0.30; p < 0.01), blood glucose control (OR, 0.03; 95% CI, 0.01-0.08; p < 0.01), and blood lipid control (OR, 0.26; 95% CI, 0.16-0.42; p < 0.01). The absence of regular physical activity was associated with lower rates of glycemic (OR, 0.14; 95% CI, 0.06-0.36; p < 0.01) and lipid controls (OR, 0.55; 95% CI, 0.33-0.90; p = 0.01). Over time, overall medication compliance declined.

Conclusion

Within the cohort of patients under medication, the compliance rate concerning vascular risk factors remains unsatisfactory. Attention should be paid to compliance with secondary prevention medications and enhance the control of vascular risk factors, as compliance emerges as the key to effective prevention.

Long-term outcomes among ischemic stroke TOAST subtypes: A 12-year Cohort study in China

BACKGROUND

Disparities in short-term ischemic stroke (IS) prognosis among Trial of Org 10172 in Acute Stroke Treatment (TOAST) subtypes were observed. Notably, little is known about the long-term prognosis of different subtypes in China. We aim to investigate the long-term outcome in IS patients and try to explore the potential interactive effects between IS subtypes and antithrombotic therapy.

METHODS

This is a prospective cohort of stroke survivors. Patients diagnosed with first-ever IS at the Department of Neurology, West China Hospital, Sichuan University from January 2010 to December 2019 were recruited. They were followed until September 2022 to assess recurrence, mortality, and functional recovery. The multivariate Fine-Gray model assessed stroke recurrence, while Cox regression estimated hazard ratios. Modified Rankin Scale scores(mRS) were analyzed using the generalized linear mixed effects model.

RESULTS

At baseline, 589 of 950 participants (62.00 %) were male. The longest follow-up was 150 months, the shortest was 1.5 months, and the median follow-up was 81.0 months. Cardio-embolism (CE) bore the highest mortality risk compared to large artery atherosclerosis (LAA) (HR=4.43,95 %CI 1.61-12.23). Among survivors on anticoagulant therapy, CE exhibited a reduced risk of mortality (HR = 0.18, 95 % CI 0.04-0.80). In function recovery, small artery occlusion (SAO) demonstrated more favorable prognostic outcomes (β=-2.08, P<0.01, OR=0.13,95 %CI 0.03-0.47). Among survivors taking antiplatelet drugs, SAO demonstrated a slower pace of functional recovery compared to LAA (β=1.39, P=0.05, OR=3.99,95 %CI 1.01-15.74).

CONCLUSIONS

Long-term outcomes post-first IS vary among TOAST subtypes. Anticoagulant therapy offers long-term benefits among patients of the CE. However, prolonged administration of antiplatelet drugs among SAO patients may be limited in improving function recovery. Physicians should carefully consider treatment options for different IS subtypes to optimize patient outcomes and stroke care effectiveness.

Determinants influencing health-promoting behaviors in individuals at high risks of stroke: a cross-sectional study

Background

Quit smoking, moderate drinking, exercise, and healthy eating habits are all known to decrease the risk of stroke. As a result, understanding the health behaviors of high risk groups for stroke is crucial. Health behavior is influenced by knowledge, social environment, and health beliefs. However, little research has been done on these relationships. For a better grasp of the relationships mentioned above, consider using the COM-B model (capability, opportunity, motivation, and behavior). The purpose of this study was to investigate the variables related to health behavior and to test the mediating effect of health beliefs.

Methods

The cross-sectional study was carried out at a physical examination center of a tertiary hospital in Shanghai, China. 986 high-risk populations of stroke have been tested using the Health Behavior Scale (HBS-SP), Stroke Knowledge Questionnaire (SKQ), Health Beliefs Questionnaire (HBS), and Multidimensional Scale of Perceived Social Support (MSPSS). The structural equation modeling was used in this study.

Results

The scores for MSPSS, SKQ, HBS, and HBS-SP were 60.64 ± 13.72, 26.60 ± 9.77, 157.71 ± 34.34, and 2.46 ± 0.41, respectively. The revised model fits well (approximate root mean square error = 0.042; comparative fit index = 0.946). The health behavior was obviously and positively correlated to social Support, stroke knowledge, and health beliefs. Moreover, health belief has a mediating effect on the relation of social support, stroke knowledge, and health behavior.

Conclusion

Chinese high risk groups for stroke have a mediate level of health behaviors. Factors associated with health behaviors are knowledge of stroke, health beliefs, and social support. The COM-B-based model can be used to explain the health behavior of individuals at risk of stroke and to guide the formulation of effective health management programs.

Early sexual activity lowers the incidence of intracranial aneurysm: a Mendelian randomization investigation

Objective

Investigate the potential correlation between the age of initial sexual contact, the lifetime accumulation of sexual partners, and the occurrence of intracranial aneurysm (IA) employing a two-sample Mendelian randomization approach.

Methods

This research aims to elucidate the causal relationship between intracranial aneurysm (IA) and sexual variables. Two distinct sexual variables, specifically the age had first sexual intercourse (n = 406,457) and the lifetime number of sexual partners (n = 378,882), were employed as representative parameters in a two-sample Mendelian randomization (MR) study. Outcome data from 23 cohorts, comprising 5,140 cases and 71,934 controls, were gathered through genome-wide association studies (GWAS). To bolster analytical rigor, five distinct methodologies were applied, encompassing MR-Egger technique, weighted median, inverse variance weighted, simple modeling, and weighted modeling.

Results

Our investigation unveiled a causal relationship between the age first had sexual intercourse and the occurrence of intracranial aneurysm (IA), employing the Inverse Variance Weighted (IVW) approach [Odds Ratio (OR): 0.609, p-value: 5.684E-04, 95% Confidence Interval (CI): 0.459-0.807]. This association was notably significant in the context of unruptured intracranial aneurysms (uIA) using the IVW approach (OR: 0.392, p-value: 6.414E-05, 95% CI: 0.248-0.621). Conversely, our findings did not reveal any discernible link between the lifetime number of sexual partners and the occurrence of IA (IA group: OR: 1.346, p-value: 0.415, 95% CI: 0.659-2.749; SAH group: OR: 1.042, p-value: 0.943, 95% CI: 0.338-3.209; uIA group: OR: 1.990, p-value: 0.273, 95% CI: 0.581-6.814).

Conclusion

The two-sample Mendelian Randomization (MR) study presented herein provides evidence supporting a correlation between the age of initial engagement in sexual activity and the occurrence of intracranial aneurysm (IA), with a noteworthy emphasis on unruptured intracranial aneurysms (uIA). Nevertheless, our investigation failed to establish a definitive association between IA and the cumulative lifetime number of sexual partners.

Red blood cell count in cerebrospinal fluid was correlated with inflammatory markers on the seventh postoperative day and all associated with the outcome of aneurysmal subarachnoid hemorrhage patients

Background

Exploring factors associated with the outcome of patients with aneurysmal subarachnoid hemorrhage (aSAH) has become a hot focus in research. We sought to investigate the associations of inflammatory markers and blood cell count in cerebrospinal fluid with the outcome of aSAH patients.

Methods

We carried a retrospective study including 200 patients with aSAH and surgeries. The associations of neutrophil, lymphocyte, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), systemic immune inflammation index (SII), system inflammation response index (SIRI), and blood cell count in cerebrospinal fluid on the 1st and 7th postoperative days with the outcome of aSAH patients were investigated by univariate analysis and multivariate logistic regression model.

Results

According to the modified Rankin scale (mRS) score, there were 147 patients with good outcome and 53 patients with poor outcome. The neutrophil, NLR, SIRI, and SII levels on the seventh postoperative day in patients with poor outcome were all significantly higher than patients with good outcome, P < 0.05. The multivariate logistic regression model including inflammatory markers and blood cell counts in cerebrospinal fluid on the 1st postoperative day confirmed that red blood cell count in cerebrospinal fluid (≥177 × 109/L; OR: 7.227, 95% CI: 1.160-45.050, P = 0.034) was possibly associated with poor outcome of aSAH patients, surgical duration (≥169 min), Fisher grade (III-IV), hypertension, and infections were also possibly associated with the poor outcome. The model including inflammatory markers and blood cell counts in cerebrospinal fluid on the 7th postoperative day confirmed that red blood cell count in cerebrospinal fluid (≥54 × 109/L; OR: 39.787, 95% CI: 6.799-232.836, P < 0.001) and neutrophil-lymphocyte ratio (≥8.16; OR: 6.362, 95% CI: 1.424-28.428, P = 0.015) were all possibly associated with poor outcome of aSAH patients. The NLR (r = 0.297, P = 0.007) and SIRI (r = 0.325, P = 0.003) levels were all correlated with the count of red blood cells in cerebrospinal fluid.

Discussion

Higher neutrophil-lymphocyte ratio and higher red blood cell count in cerebrospinal fluid were all possibly associated with poor outcome of patients with aneurysmal subarachnoid hemorrhage. However, we need a larger sample study.

A bibliometric analysis of acupuncture for cerebral infarction from 1993 to 2023

Objective

This research aims to explore the trends and knowledge domain of acupuncture for cerebral infarction through bibliometrics.

Methods

Publications related to acupuncture for cerebral infarction were retrieved from the Web of Science core collection database from 1993 to December 31, 2023. A domain knowledge graph was then constructed using VOSviewer, CiteSpace, GraphPad Prism, and Scimago Graphica.

Results

The cumulative publication trend shows a steady increase over the years, with China being the most productive country. Notably, Europe exhibits significant close collaboration. Institutional cooperation is primarily observed among Chinese universities specializing in traditional Chinese medicine. Tao Jing is the most prolific author, with his highest number of publications is in "Stroke" journal, and Acupuncture Electro Therapeutics Research is the significant journal. Zhang SH is the most cited author, and Si QM is a prominent author in this field. Rehabilitation treatment after cerebral infarction emerges as a prevalent research focus, with nerve regeneration being a keyword. Long EZ's 1989 paper, published in the journal Stroke, holds significant importance. The prominent papers are Donnan et al. and Wu et al., which covers the following topics: "population-based study," "Baihui Acupoint," "memory deficits," "neurotrophic factor," and "randomized trial."

Conclusion

This bibliometric analysis of acupuncture for cerebral infarction offers insights into the Web of Science database, delineates a knowledge map of countries, authors, institutions, cited authors, keywords, cited references in the field of acupuncture for cerebral infarction, which has a momentous guiding significance for quickly and accurately positioning the key information in the field.

Mechanism of ameliorating cerebral ischemia/reperfusion injury by antioxidant inhibition of autophagy based on network pharmacology and experimental verification

Cerebral ischemia-reperfusion injury (CIRI) is one of the most difficult challenges in cerebrovascular disease research. It is primarily caused by excessive autophagy induced by oxidative stress. Previously, a novel compound X5 was found, and the excellent antioxidant activity of it was verified in this study. Moreover, network pharmacological analysis suggested that compound X5 was closely associated with autophagy and the mTOR pathway. In vitro, X5 could significantly inhibit the expression of autophagy proteins Beclin-1 and LC3-β, which are induced by H2O2, and promote the expression of SIRT1. In vivo, compound X5 significantly reduced the infarct size and improved the neurological function scores in the middle cerebral artery occlusion (MCAO) model of rats. In conclusion, ROS-induced autophagy is closely related to mTOR, SIRT1 and others, and X5 holds promise as a candidate for the treatment of CIRI.

Effects of a Planned Web-Based Educational Intervention Based on the Health Belief Model for Patients With Ischemic Stroke in Promoting Secondary Prevention During the COVID-19 Lockdown in China: Quasi-Experimental Study

Background

Some common modified vascular risk factors remain poorly controlled among stroke survivors, and educational programs may help improve these conditions.

Objective

This study aimed to evaluate the effect of a planned web-based educational intervention based on the health belief model (HBM) in promoting secondary prevention among patients with ischemic stroke.

Methods

An evaluation-blinded quasi-experimental trial with a historical control group was conducted. Patients admitted from March to June 2020 were assigned to the historical control group, and patients admitted from July to October 2020 were assigned to the intervention group. The control group received routine health management. The intervention group received 6 additional sessions based on the HBM via Tencent Meeting, an audio and video conferencing application, within 3 months after discharge. Sessions were held every 2 weeks, with each session lasting approximately 40 minutes. These sessions were conducted in small groups, with about 8 to 10 people in each group. The primary outcomes were changes in blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), hemoglobin A1c (HbA1c), and the proportion of patients achieving the treatment target. The secondary outcomes were medication adherence, assessed with the Morisky Medicine Adherence Scale (MMAS), and disability, assessed with the modified Rankin scale.

Results

In total, 315 patients experiencing their first-ever stroke were analyzed. More patients in the intervention group had controlled BP (41.9% vs 28.4%; adjusted odds ratio [aOR] 1.93; P=.01), LDL-C (83.1% vs 67.7%; aOR 2.66; P=.001), and HbA1c (91.9% vs 83.9%; aOR: 3.37; P=.04) levels as well as a significant postintervention decrease in the systolic BP (adjusted β -3.94; P=.02), LDL-C (adjusted β -0.21; P=.008), and HbA1c (adjusted β -0.27; P<.001), compared with control groups. Significant between-group differences were observed in medication adherence (79.4% vs 63.2%; aOR 2.31; P=.002) but not in favorable functional outcomes.

Conclusions

A web-based education program based on the HBM may be more effective than current methods used to educate patients having strokes on optimal vascular risk factors and medication adherence.