Temporal trend and attributable risk factors of stroke burden in China, 1990–2019: an analysis for the Global Burden of Disease Study 2019

A review: Carrier-based hydrogels containing bioactive molecules and stem cells for ischemic stroke therapy

Ischemic stroke (IS), a cerebrovascular disease, is the leading cause of physical disability and death worldwide. Tissue plasminogen activator (tPA) and thrombectomy are limited by a narrow therapeutic time window. Although strategies such as drug therapies and cellular therapies have been used in preclinical trials, some important issues in clinical translation have not been addressed: low stem cell survival and drug delivery limited by the blood-brain barrier (BBB). Among the therapeutic options currently sought, carrier-based hydrogels hold great promise for the repair and regeneration of neural tissue in the treatment of ischemic stroke. The advantage lies in the ability to deliver drugs and cells to designated parts of the brain in an injectable manner to enhance therapeutic efficacy. Here, this article provides an overview of the use of carrier-based hydrogels in ischemic stroke therapy and focuses on the use of hydrogel scaffolds containing bioactive molecules and stem cells. In addition to this, we provide a more in-depth summary of the composition, physicochemical properties and physiological functions of the materials themselves. Finally, we also outline the prospects and challenges for clinical translation of hydrogel therapy for IS.

Association between particulate matter exposure and acute ischemic stroke admissions in less-polluted areas: a time-series study using a distributed lag nonlinear model

Purpose

China has experienced a heavy public health burden due to the increasing incidence of ischemic stroke (IS). Few studies have evaluated the relationship between particulate matter (PM) exposure and acute ischemic stroke (AIS) in relatively less-polluted areas, and the results have been inconsistent. As a result, this study aimed to investigate and evaluate the association between PM exposure and hospitalizations for AIS in an area with less air pollution.

Methods

Through collecting daily AIS hospitalizations, air pollution data and meteorological data from July 1, 2017 to June 30, 2020 in Nanning, this paper explored the association between short-term exposure to PM (PM2.5, PM10 and PMc) and daily hospital admissions for AIS using a distributed lag non-linear model based on time-series. To further identify the susceptible populations, stratified analyses were performed by age and gender.

Results

During the study period, a total of 2382 patients were admitted to hospital with AIS, with the ratio of male to female reached 2.03: 1. No statistical association was found between PM exposure and AIS admissions in the total population. Subgroup analysis showed that PM2.5, PM10 and PMc exposures were significantly associated with AIS admissions in male at lag29-lag30, lag27-lag30 and lag25-lag27, respectively. In addition, PMc exposure was also relevant to admissions for AIS with aged < 65 years at lag18-lag23.

Conclusions

Short-term exposure to ambient PM was not associated with hospital admissions for AIS in the general population, but males and young adults (aged < 65 years) were more susceptible to PM exposure. Even in areas with relatively low air pollution, appropriate measures should be adopted to intervene in the adverse effects of air pollution on vulnerable populations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40201-024-00926-w.

Depressive symptoms changes in the new-onset stroke patients: A cross-lagged panel network analysis

BACKGROUND

Each year, there are approximately 10.3 million new stroke cases worldwide, with 2 million occurring in China. Post-stroke depression (PSD) is a common complication that negatively affects rehabilitation outcomes and increases long-term mortality.

OBJECTIVE

This study used network analysis to investigate the cross-sectional and longitudinal networks between depressive symptoms in new-onset stroke patients with PSD, aiming to identify the key symptoms and predictive relationships among distinct symptoms during the acute phase and 6 months after the stroke.

METHODS

This longitudinal descriptive study collected data from October 2022 to December 2023, including eligible new-onset stroke patients. Depressive symptoms were assessed using the CES-D scale, and network analysis was used to analyze the interactions between symptoms.

RESULTS

613 participants completed the data collection. The study found that D3 (Felt sadness) emerged as the central depressive symptom at both baseline and follow-up (EI value = 1.215 and 1.168, respectively). In the longitudinal network analysis, D7 (Sleep quality) displayed the strongest out-Expected Influence (value = 1.728), while D4 (Everything was an effort) showed the strongest in-Expected Influence (value = 1.322).

LIMITATIONS

The self-report measure is adopted for all depressive symptoms in the study, and there may be some deviation.

CONCLUSION

These symptom-level associations at cross-sectional and longitudinal networks extend our understanding of PSD symptoms in new-onset stroke patients by pointing to specific key depressive symptoms that may aggravate PSD. Recognizing these symptoms is imperative for the development of targeted interventions and treatments aimed at addressing PSD in new-onset stroke patients.

Metabolic diseases in the East Asian populations

East Asian populations, which account for approximately 20% of the global population, have become central to the worldwide rise of metabolic diseases over the past few decades. The prevalence of metabolic disorders, including type 2 diabetes mellitus, hypertension and metabolic dysfunction-associated steatotic liver disease, has escalated sharply, contributing to a substantial burden of complications such as cardiovascular disease, chronic kidney disease, cancer and increased mortality. This concerning trend is primarily driven by a combination of genetic predisposition, unique fat distribution patterns and rapidly changing lifestyle factors, including urbanization and the adoption of Westernized dietary habits. Current advances in genomics, proteomics, metabolomics and microbiome research have provided new insights into the biological mechanisms that might contribute to the heightened susceptibility of East Asian populations to metabolic diseases. This Review synthesizes epidemiological data, risk factors and biomarkers to provide an overview of how metabolic diseases are reshaping public health in East Asia and offers insights into biological and societal drivers to guide effective, region-specific strategies.

Interactive Effect of Air Temperature and Fine Particulate Matter on the Hospital Admissions for Stroke in Shenzhen, China

BACKGROUND

Stroke is a major health challenge in China. Numerous studies have linked stroke with temperature and fine particulate matter (PM2.5), but findings varied by stroke subtypes and regions, and few explored the interactive effects of air temperature and PM2.5. This study examines the association between air temperature, PM2.5, and stroke hospital admissions in Shenzhen, a subtropical monsoon city in southern China.

METHODS AND RESULTS

We applied time-series generalized additive models to estimate the individual and interactive effects of air temperature and PM2.5 on stroke hospital admissions using daily records from 2015 to 2016. Subgroup analysis by sex, age, and education level was conducted, assessing admissions for hemorrhagic (n=8752) and ischemic (n=33 233) stroke separately. For hemorrhagic stroke, a 1 °C increase in temperature was significantly associated with a 2.3% (95% CI, -3.2% to -1.3%) decrease in hospital admissions, whereas higher levels of PM2.5 indicated an increased risk, though not significant. Conversely, for ischemic stroke, a 1 °C rise was significantly associated with a 1.0% (95% CI, 0.4%-1.6%) increase in admissions. The impact PM2.5 on stroke was more pronounced at higher concentrations, while showing no evident effects at lower levels. Interaction effects between temperature and PM2.5 were statistically significant for both stroke types, with stronger effects observed at 10 to 20 °C and PM2.5 concentration around 80 to 100 μg/m3.

CONCLUSIONS

This study suggests lower air temperature may increase hemorrhagic stroke risk, whereas higher temperature and higher PM2.5 exposure may increase ischemic stroke risk. Interactive effects between temperature and PM2.5 were observed for both stroke types in Shenzhen.

Electrolyte Levels in Poor Prognosis and Early Neurological Deterioration in Patients With Acute Ischemic Stroke

Discrepancies in serum electrolyte levels have been observed between stroke patients and healthy individuals. Previous studies have indicated an association between electrolytes and all-cause mortality as well as cardiovascular events in stroke patients. However, there still lacks comprehensive analysis on the connection between electrolytes and negative outcomes in hypertensive individuals with early neurological deterioration (END). Totally 1341 patients treated with thrombolysis for acute ischemic stroke at the First Affiliated Hospital of Wenzhou Medical University were included. Outcomes included END, 3-month, 6-month, and 1-year poor prognosis. Logistic regression assessed the correlation and restricted cubic spline analysis examined dose-response relationships. Subgroup analysis validated the relationship between electrolytes and prognosis in hypertensive patients. A total of 242 patients exhibited a 3-month poor prognosis. Significant differences were observed in Cl-, Ca2+, and Mg2+ levels between mRS binary classification. Logistic regression identified Cl- as the strongest predictor for 3-month, 6-month, and 1-year mRS score and Ca2+ for END. Restricted cubic spline analysis revealed relationships between higher concentrations of Na+ and poorer prognosis. In the hypertension subgroup, a higher concentration of Na+ indicated worse 6-month and 1-year outcomes and a lower concentration of Ca2+ was linked to a higher risk of END. The concentration of Na+ is related to adverse clinical outcomes, while that of Cl- and Ca2+ are associated with END. Among hypertensive patients, elevated levels of Na+ and Ca2+ concentration are respectively associated with 6-month poor prognosis and END. Monitoring the electrolytes may promote the early identification of individuals at high risk of poor functional outcomes.

Steatotic Liver Disease Prevalence in China: A Population-Based Study and Meta-Analysis of 17.4 Million Individuals

BACKGROUND

Steatotic liver disease (SLD), including metabolic dysfunction-associated SLD (MASLD), has emerged as a leading cause of chronic liver disease in China.

AIMS

We aimed to provide a comprehensive and updated description of SLD prevalence in China.

METHODS

We described the prevalence, subgroup distribution, and clinical characteristics of SLD in the Taizhou Study of Liver Diseases (T-SOLID). Additionally, we searched for studies reporting SLD prevalence in five databases. Eligible data were analysed using a generalised linear mixed model. Linear regression was applied to estimate the annual average percentage change (AAPC).

RESULTS

Of the 28,623 participants in T-SOLID, 30.8% were diagnosed with SLD, among which 83.8% were classified as MASLD. Prevalence of SLD increased from 22.1% in 2018 to 36.7% in 2021. The meta-analysis included 792 publications and 17,404,296 subjects. Nationwide, the pooled SLD prevalence rose from 23.8% (95% CI 21.9%-25.9%) during 2001-2010 to 27.9% (26.0%-29.8%) during 2016-2023 in the general population (AAPC = 2.56, p < 0.0001), equating to approximately 402.0 million cases. An increase in SLD prevalence was observed in subpopulations by region, sex, and age, and in high-risk groups. Northeast China had the highest prevalence (35.0%). Males had a higher prevalence rate than females (35.0% vs. 20.6%). SLD prevalence increased with age, ranging from 8.1% in children and adolescents to 31.8% in the elderly. Meta-regression identified calendar period, age, sex, geographical area, and residence area as significant determinants of SLD prevalence.

CONCLUSION

The ubiquitously rising prevalence of SLD in Chinese populations underscores the urgent need for targeted public health interventions.

Sex-Specific Impact of Serum Calcium Levels on Acute Coronary Syndrome Risk: A 19-Year Cohort Study in Korea

Background: This study aims to investigate the association between serum calcium levels and acute coronary syndrome (ACS) risk, examining whether this relationship differs by sex, given the known differences in calcium metabolism and hormonal influences between males and females. Methods: Utilizing the Korean Genome Epidemiology Study (KoGES) prospective cohort data, our primary exposure variables were serum calcium level and sex. The incidence of ACS served as the main outcome of interest. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression analysis. An interaction analysis was conducted to assess the interaction effect of calcium level and sex on ACS incidence. Results: After adjusting for confounding variables, high calcium intake did not significantly increase ACS incidence, with a hazard ratio (HR) of 1.07 (95% CI: 0.90-1.26). There was also no significant difference in ACS risk between females and males (HR: 0.81, 95% CI: 0.61-1.04). However, interaction effect analysis revealed that higher calcium levels were associated with an increased risk of ACS only in females (HR: 1.24, 95% CI: 1.07-1.58), whereas the association in males was not statistically significant (HR: 0.90, 95% CI: 0.71-1.15). Conclusion: Our study results indicate that elevated serum calcium levels alone did not independently increase the risk of ACS; however, high serum calcium levels were associated with an increased risk of ACS in females but not in males, underscoring the importance of sex-specific factors in assessing and managing ACS risk and highlighting the necessity for personalized medical approaches to improve cardiovascular health outcomes for women.

Association between C-reactive protein-triglyceride glucose index and stroke risk in different glycemic status: insights from the China Health and Retirement Longitudinal Study (CHARLS)

OBJECTIVE

C-reactive protein-triglyceride-glucose index (CTI) has been proposed as a novel biomarker for insulin resistance and inflammation. However, the association between CTI and the risk of stroke, particularly in individuals with different glycemic status, remains unclear.

METHODS

A total of 10,443 middle-aged and elderly participants were enrolled from the China Health and Retirement Longitudinal Study (CHARLS). The primary endpoint was the occurrence of stroke events. The CTI was calculated using the formula 0.412* Ln (CRP [mg/L]) + Ln (TG [mg/dl] × FPG [mg/dl])/2. The Kaplan-Meier curves, Cox proportional hazard models, and restricted cubic spline analysis were applied to explore the association between CTI and the risk of stroke according to gender, age and glycemic status.

RESULTS

During a median follow-up of 9 years, 960 (9.2%) participants experienced a stroke. Our findings revealed a significant positive linear relationship between CTI and the occurrence of stroke. The association was similar between male and female, despite the HR tended to be higher in females (HR 1.22, 95% CI 1.09, 1.36) than males (HR 1.15, 95% CI 1.02, 1.29), and similar in middle-aged (HR 1.25, 95% CI 1.11, 1.41) and elderly participants (HR 1.12, 95% CI 1.00, 1.26). In different glycemic status, high levels of CTI were found to be linked to an increased risk of stroke in individuals with normal glucose regulation (NGR) (HR 1.33, 95% CI 1.11, 1.59) and prediabetes mellitus (Pre-DM) (HR 1.20, 95% CI 1.04, 1.39). However, this association was not observed in individuals with diabetes mellitus (DM).

CONCLUSIONS

Our findings revealed a significant positive linear relationship between CTI and the occurrence of stroke. The association between CTI and stroke was similar between male and female, and similar in middle-aged and elderly participants. In different glycemic status, the association was significant in individuals with NGR and Pre-DM.

Associations between short-term exposure to fine particulate matter with ischemic stroke mortality and the role of green space: a time-series study in Zibo, China

Background

Previous studies on associations between short-term exposure to fine particulate matter (PM2.5) and ischemic stroke (IS) mortality reported inconclusive results. Additionally, whether and how PM2.5 and green space interact to precipitate IS deaths remains unclear. We aimed to examine the impacts of short-term exposure to PM2.5 on IS mortality and the role of green space in the association.

Methods

We collected data on daily IS deaths, daily PM2.5 concentrations, and monthly normalized difference vegetation index (NDVI) in Zibo City from 2015 to 2019. Generalised additive models were adopted to investigate the short-term impacts of PM2.5 on IS mortality, and subgroup analyses were used to examine effect modification by population characteristics. Stratified analyses by green space levels and joint effect model were conducted to test the interactions of PM2.5 and green space on IS mortality.

Results

A total of 10 799 IS deaths were included in our study. Exposure to PM2.5 was associated with an increased risk of IS mortality, with odds ratios (ORs) of 1.0263 (95% confidence interval (CI) = 1.0017, 1.0516) for each interquartile range (IQR) increase in PM2.5 on lag0 and 1.0317 (95% CI = 1.0016, 1.0627) on lag01. The links between PM2.5 and IS mortality were not significantly different across genders, ages, or PM2.5 zones. Furthermore, our results showed that the effects of PM2.5 on IS mortality were higher in low levels of green space. Specifically, for each IQR increase in PM2.5, the ORs (95% CIs) of IS death in the low level and the high level of NDVI were 1.0287 (95% CI = 1.0019, 1.0563) and 0.9934 (95% CI = 0.9296, 1.0615), respectively. In addition, PM2.5 and NDVI exhibited significant interactive effects on IS mortality, with relative excess odds due to interaction (REOI) of greater than 0.

Conclusions

Our findings showed that PM2.5 was significantly associated with increasing odds of IS mortality. Furthermore, there were synergetic impacts between PM2.5 and lack of greenness on IS mortality. Our results suggest that expanding green spaces, such as increasing park coverage and street greening, along with regulating industrial emissions to reduce PM2.5 levels, can help prevent premature deaths from IS.

Temporal trends of ischemic stroke attributable to diet high in sodium in China from the global burden of disease study 2021

Background

Ischemic stroke is a significant global health burden, with high sodium intake recognized as a key risk factor. This study aimed to assess the disease burden of ischemic stroke attributable to diet high in sodium in China from 1990 to 2021. Additionally, we analyzed the influence of age, period, and cohort effects on the trends in ischemic stroke burden and projected the disease burden from 2022 to 2036.

Methods

Data from the Global Burden of Disease Study 2021 (GBD 2021) were used to analyze the ischemic stroke burden among high-risk populations in China. Annual average percent change (AAPC) was calculated using Joinpoint regression models to evaluate trends in ischemic stroke burden from 1990 to 2021. Age-period-cohort models were employed to estimate the independent effects of age, period, and cohort on the ischemic stroke burden, and to project the burden from 2022 to 2036 using Bayesian age-period-cohort models.

Results

From 1990 to 2021, ischemic stroke mortality attributable to diet high in sodium in China showed a continuous increase, while the age-standardized mortality and disability-adjusted life years (DALYs) significantly declined. In the age-period-cohort analysis, the age effect on ischemic stroke burden increased steadily over the study period. Period effects revealed an initial decline in the relative risk (RR) of ischemic stroke mortality and DALY rates, followed by an increase in cohorts born before 2004-2009, and a gradual decline in cohorts born after that period. Cohort effects demonstrated a continuous decline in the relative risk of ischemic stroke mortality and DALY rates from 1990 to 2021.

Conclusion

This study found that ischemic stroke attributable to a diet high in sodium in China fluctuated from 1990 to 2021, with a declining trend observed in recent years. Projections indicate that this downward trend will continue. Age and birth period are key factors influencing the disease burden, with older adults and men being particularly affected. Future policy efforts should focus on enhancing health management in high-risk populations to further reduce the burden of ischemic stroke linked to high sodium intake.

The immunomodulatory effects of GLP-1 receptor agonists in neurogenerative diseases and ischemic stroke treatment

Glucagon-like peptide-1 (GLP-1) receptor is widely distributed in the digestive system, cardiovascular system, adipose tissue and central nervous system. Numerous GLP-1 receptor-targeting drugs have been investigated in clinical studies for various indications, including type 2 diabetes and obesity (accounts for 70% of the total studies), non-alcoholic steatohepatitis, Alzheimer's disease, and Parkinson's disease. This review presented fundamental information regarding two categories of GLP-1 receptor agonists (GLP-1RAs): peptide-based and small molecule compounds, and elaborated their potential neuroprotective effects by inhibiting neuroinflammation, reducing neuronal apoptosis, and ultimately improving cognitive function in various neurodegenerative diseases. As a new hypoglycemic drug, GLP-1RA has a unique role in reducing the concurrent risk of stroke in T2D patients. Given the infiltration of various peripheral immune cells into brain tissue, particularly in the areas surrounding the infarct lesion, we further investigated the potential immune regulatory mechanisms. GLP-1RA could not only facilitate the M2 polarization of microglia through both direct and indirect pathways, but also modulate the quantity and function of T cell subtypes, including CD4, CD8, and regulatory T cells, resulting into the inhibition of inflammatory responses and the promotion of neuronal regeneration through interleukin-10 secretion. Therefore, we believe that the "Tregs-microglia-neuron/neural precursor cells" axis is instrumental in mediating immune suppression and neuroprotection in the context of ischemic stroke. Given the benefits of rapid diffusion, favorable blood-brain barrier permeability and versatile administration routes, these small molecule compounds will be one of the important candidates of GLP-1RA. We look forward to the further clinical evidence of small molecule GLP-1RA intervention in ischemic stroke or T2D complicated by ischemic stroke.

Tenecteplase for ischemic stroke at 4.5 to 24 hours without thrombectomy: a cost-utility analysis from the perspective of Chinese healthcare system

Background

Tenecteplase improves functional outcomes in acute ischemic stroke (AIS) patients treated 4.5 to 24 h after symptom onset who do not undergo thrombectomy. However, its cost-utility remains unexamined.

Methods

A hybrid model combining a short-term decision tree and a long-term Markov model was developed to simulate the costs and quality-adjusted life years (QALYs) for Chinese patients with AIS at 4.5 to 24 h, who did not undergo thrombectomy. Clinical data were sourced from the TRACE-III trial, while cost data were obtained from the China National Stroke Registry and the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China database. The primary outcome was the incremental cost-effectiveness ratio (ICER). Secondary outcomes included total costs, total QALYs and remaining life expectancy, as well as the incremental cost, incremental QALYs, and incremental remaining life expectancy. One-way sensitivity analysis, probabilistic sensitivity analysis (PSA), and scenario analysis were conducted to test the robustness of the results.

Results

For a Chinese patient with AIS treated within 4.5 to 24 h after symptom onset without thrombectomy, adding tenecteplase to standard care resulted in an incremental cost of 2,536 Chinese Yuan (CNY) and an increase of 0.40 QALYs, yielding an ICER of 6,386 CNY per QALY. One-way sensitivity analysis revealed that the most significant factors influencing the ICER were the efficacy and cost of tenecteplase. PSA and scenario analyses confirmed the robustness of these results.

Conclusion

Compared to standard medical treatment alone, administering intravenous tenecteplase between 4.5 and 24 h after onset for Chinese patients with AIS who did not undergo thrombectomy, is highly cost-effective.

Impact of sodium butyrate on stroke-related intestinal injury in diabetic mice: Interference with Caspase-1/GSDMD pyroptosis pathway and preservation of intestinal barrier

Diabetic stroke-associated acute intestinal injury is characterized by high mortality, disability, and poor prognosis due to the lack of effective therapies. Our prior research demonstrated that administration of 300 mg/kg sodium butyrate (NaB) can improve neurological outcomes post-diabetic stroke. Nonetheless, whether the effect of NaB is related to intestinal regulation, along with its underlying mechanisms, remains uncertain. This study aims to investigate the effects and mechanistic pathways of NaB on diabetic stroke-associated acute intestinal injury. A middle cerebral artery occlusion/reperfusion model was established in mice with streptozotocin-induced diabetes. The results demonstrated that NaB alleviated colonic injury 24 h after reperfusion in diabetic stroke. Pyroptosis-related protein levels in colonic tissues were significantly elevated following diabetic stroke but were markedly reduced with NaB treatment. NaB also improved gut barrier integrity and reduced inflammation, promoting epithelial barrier self-repair. In the NaB combined with lipopolysaccharide group, lipopolysaccharide administration induced a significant inflammatory response in the colonic tissue. Conversely, treatment with NaB and VX-765 (an inhibitor for Caspase-1) led to a notable alleviation in intestinal inflammation. These findings suggest that NaB mitigates colonic injury and enhances barrier function following diabetic stroke, potentially through the Caspase-1/Gasdermin D pyroptosis pathway. This study may provide a novel strategy and direction for intestinal rehabilitation in diabetic stroke patients.

Clinical factors influencing intravenous thrombolysis in patients with cerebral infarction: a retrospective cohort study comparing private car and ambulance transport in Jiaxing, China

OBJECTIVES

This study aims to evaluate and compare the clinical differences in intravenous thrombolytic therapy among patients with cerebral infarction transported to the hospital by private cars versus ambulances in Jiaxing, a non-supersized city in China. It also sought to examine the impact of different transportation methods on emergency department arrival times, delays in initiating thrombolytic therapy and final clinical prognosis. The findings aim to provide a basis for optimising emergency treatment protocols and improving outcomes for patients with cerebral infarction.

DESIGN

Data on age, gender, height, weight, body mass index, season, time of day (day vs night), modified Rankin Scale scores, door-to-needle time (DNT) and onset-to-needle time (ONT) were retrospectively collected from 808 patients admitted to the emergency department of the Affiliated Hospital of Jiaxing University for intravenous thrombolysis between January 2019 and September 2022. The data were analysed and compared.

SETTING

A retrospective cohort study conducted in Jiaxing, China.

OUTCOME MEASURES

The primary outcomes were DNT and ONT.

RESULTS

Among the 808 eligible patients, 279 (34.53%) were transported by ambulance, and 529 (65.47%) arrived by private car. Patients in the private car group were younger on average than those in the ambulance group (aged 64.70 vs 68.41 years). Although ambulance transport resulted in shorter prehospital transportation times (113.89 vs 127.38 min), patients arriving by private car had shorter thrombolytic therapy initiation times (39.90 vs 36.30 min). At admission, the National Institutes of Health Stroke Scale scores were higher in the ambulance group (4 vs 2), indicating more severe conditions and a greater proportion of patients requiring bridging thrombectomy after thrombolysis (7.53% vs 3.02%).

CONCLUSION

In non-supersized cities, private car transportation for acute patients with cerebral infarction may lead to shorter DNT and ONT compared with those in ambulance transport. However, patients transported by ambulance tended to have more severe conditions, highlighting the importance of tailored emergency response strategies.

Heart Failure Is Associated With Increased Stroke Severity, In-Hospital Mortality, Major Adverse Cardiovascular Events, and Complications: Insights From the Chinese Stroke Center Alliance

BACKGROUND

Heart failure (HF) constitutes the source of various damaging pathophysiological mechanisms in acute ischemic stroke (AIS). The effect of a previous HF on the in-hospital outcomes for patients with AIS still lacks effective research. We aimed to evaluate the severity of stroke, in-hospital mortality, major adverse cardiovascular events, and complications associated with a previous HF in these patients.

METHODS AND RESULTS

This cross-sectional study was conducted at 1476 hospitals in the Chinese Stroke Center Alliance. Multivariable logistic regression and propensity score-matched analyses were used to evaluate the association between a history of HF and in-hospital outcomes. Of 836 885 patients with AIS, 1.1% (n=8950) patients had a history of HF. Patients with a history of HF had a higher National Institutes of Health Stroke Scale score at admission (6.0 versus 3.0) than those without a history of HF. Multivariable analysis revealed that a history of HF was associated with an 80% higher risk of all-cause mortality (odds ratio [OR], 1.80 [95% CI, 1.54-2.10]), a 34% higher risk of major adverse cardiovascular events (OR, 1.34 [95% CI, 1.26-1.43]), and a 92% higher risk of complications (OR, 1.92 [95% CI, 1.83-2.02]). Further propensity score matching showed that patients with a history of HF had higher risks of adverse in-hospital outcomes (all-cause mortality: OR, 1.62 [95% CI, 1.30-2.02]; major adverse cardiovascular events: OR, 1.39 [95% CI, 1.26-1.53]; complications: OR, 1.70 [95% CI, 1.58-1.82]).

CONCLUSIONS

Patients with AIS and a history of HF have increased risks of severe stroke, in-hospital mortality, major adverse cardiovascular events, and complications. Systematic cardiovascular evaluation and integrated multidisciplinary care for patients with AIS in clinical practice are warranted.

Advancements in the investigation of gut microbiota-based strategies for stroke prevention and treatment

Stroke represents a predominant cause of mortality and disability on a global scale, impacting millions annually and exerting a considerable strain on healthcare systems. The incidence of stroke exhibits regional variability, with ischemic stroke accounting for the majority of occurrences. Post-stroke complications, such as cognitive impairment, motor dysfunction, and recurrent stroke, profoundly affect patients' quality of life. Recent advancements have elucidated the microbiota-gut-brain axis (MGBA), underscoring the complex interplay between gut health and brain function. Dysbiosis, characterized by an imbalance in gut microbiota, is significantly linked to an elevated risk of stroke and unfavorable outcomes. The MGBA plays a crucial role in modulating immune function, neurotransmitter levels, and metabolic byproducts, which may intensify neuroinflammation and impair cerebral health. This review elucidates the role of MGBA in stroke pathophysiology and explores potential gut-targeted therapeutic strategies to reduce stroke risk and promote recovery, including probiotics, prebiotics, pharmacological interventions, and dietary modifications. However, the current prevention and treatment strategies based on intestinal flora still face many problems, such as the large difference of individual intestinal flora, the stability of efficacy, and the long-term safety need to be considered. Further research needs to be strengthened to promote its better application in clinical practice.

Estimation of hypoperfused tissue volume in large vessel occlusions: pseudo-continuous arterial spin labeling versus dynamic susceptibility contrast perfusion-weighted imaging

Background

Currently, the selection of patients with acute anterior large vessel occlusions (LVOs) for endovascular thrombectomy (EVT) is primarily based on dynamic susceptibility contrast perfusion-weighted imaging (DSC-PWI) or computed tomography (CT) perfusion imaging. This study investigated the consistency between hypoperfused tissue (HPT) (time to maximum >6 s, Tmax >6 s) volumes estimated by corrected and uncorrected multidelay pseudo-continuous arterial spin labeling (pCASL) and DSC-PWI in patients with anterior LVOs and also evaluated the diagnostic performances in selecting patients with acute LVOs for EVT.

Methods

This retrospective study enrolled patients with acute (n=108) and symptomatic chronic (n=90) LVOs. Shapiro-Wilk tests and receiver operating characteristic (ROC) analyses were used. Intraclass correlation coefficient (ICC) compared the consistency of HPT volume calculated by DSC-PWI and multidelay pCASL.

Results

Multidelay pCASL with different thresholds in acute LVOs were 128.8 [interquartile range (IQR), 76.2-181.1] mL in uncorrected relative cerebral blood flow (rCBF) <40%, 84.1 (IQR, 36.8-133.9) mL in uncorrected CBF <20 mL·100 g-1·min-1 , and 74.4 (IQR, 26.2-118.0) mL in corrected CBF <20 mL·100 g-1·min-1, which were comparable to the volume of 69.5 (IQR, 20.0-121.4) mL automatically determined by Tmax >6 s in DSC-PWI, and showed substantial consistency after correction (ICC =0.742). Multidelay pCASL with different thresholds in symptomatic chronic LVOs was 78.3 (IQR, 53.5-129.4) mL, 59.8 (IQR, 16.6-98.5) mL and 36.4 (IQR, 10.1-85.3) mL, which were comparable to the volume of 0 (IQR, 0-36.4) mL in DSC-PWI, and showed substantial consistency after correction (ICC =0.617). Using DEFUSE 3 as the reference standard, the CBF corrected by arterial transit time (ATT) showed good performance in selecting patients for EVT (area under the curve 0.804, 95% confidence interval: 0.717-0.891).

Conclusions

The volume of HPT defined by corrected CBF <20 mL·100 g-1·min-1 is consistent with that of DSC-PWI in acute and chronic symptomatic LVOs patients. Multidelay pCASL adjusted by ATT is more applicable to clinical routine.

Quantitative Electroencephalogram Might Improve the Predictive Value of Prognosis 6 Months After Discharge in Acute Ischemic Stroke

Background: As a leading cause of severe morbidity, acute ischemic stroke (AIS) necessitates precise prognostic evaluation to inform critical treatment strategies. Recent advancements have identified quantitative electroencephalography (qEEG) as a pivotal instrument in refining prognostic accuracy for AIS. This investigation aimed to construct a robust prognostic model, anchored in qEEG parameters, to enhance the precision of clinical prognosis 6 months after discharge in AIS patients. Methods: In a retrospective observational study, we analyzed AIS cases from January 2022 to March 2023. Data encompassing demographic profiles, clinical manifestations, qEEG findings, and modified Rankin Scale (mRS) assessments were evaluated for 109 patients with AIS. These metrics were instrumental in developing prognostic models, segregating outcomes into either favorable (mRS: 0-2) or unfavorable categories (mRS: 3-6) at 6 months post-discharge. Prognostic models were developed using clinical and qEEG parameters. Results: The formulation of two distinct prognostic models was predicated on an integration of baseline clinical data (age, unilateral limb weakness, ataxia and red blood cell count) and specific qEEG metrics (T3-P3 (TAR) and T4-P4 (TAR)). The synthesis of these models culminated in the Prognostic Model 3, which exhibited a marked enhancement in prognostic accuracy, as evidenced by an area under the curve (AUC) of 0.8227 (95% CI: 0.7409-0.9045), thereby signifying a superior prediction of AIS prognosis 6 months after discharge relative to the individual models. Conclusion: Quantitative EEG, especially increased theta/alpha power ratio (TAR), might improve the prediction of prognosis 6 months after discharge of acute ischemic stroke in clinical practice.

Gender-specific effects of delay in cardiology consultation following primary care physician referral in atrial fibrillation patients: Impact on one-year outcomes

BACKGROUND AND OBJECTIVES

Over the last two decades, reductions in cardiovascular (CV) and cerebrovascular events for patients with atrial fibrillation (AF) have been observed, but the non-cardiovascular rates have increased. Early initiation of oral anticoagulation helps reduce AF complications; however, the impact of delayed cardiology care after referral by a Primary Care Physician (PCP) is unknown. The aim of our study is to investigate the association between the elapsed time to cardiology care following a PCP referral and one-year outcomes among patients with AF and analyses gender-specific differences in these outcomes.

METHODS

All PCP referrals with previous AF diagnoses to cardiology consultation from 2010 to 2021 (N = 15,224) were analysed. The outcomes analysed were all-cause, CV, and stroke mortality and hospitalizations rates at one-year. Cox regression adjusted for age, sex, diabetes mellitus, hypertension, atrial fibrillation, peripheral arterial disease, and stroke analysed the risk associated with elapsed time. Odds ratios and 95 % confidence interval (OR [95 % CI]) were calculated.

RESULTS

Delay time from PCP referral to cardiology care was associated with an increase per day of delay in all-cause (0.25 %), CV (0.13 %), HF (0.11 %) and stroke (0.14 %) mortality rates. Multivariate analyses showed that elapsed time was associated with a higher risk of all-cause (1.005 [1.003-1.007]), CV-mortalities (1.006 [1.005-1.007]), all-cause (1.005 [1.003-1.006]), and CV-hospitalizations (1.009 [1.006-1.012]). Gender-specific analyses revealed that men had higher all-cause mortality (5.3 % vs. 4.0 %, p < 0.001), while women exhibited higher stroke mortality (2.7 % vs. 1.5 %, p = 0.005) and haemorrhagic mortality (4.7 % vs. 3.2 %, p = 0.012). AF complications also increased with the delay time: stroke (1007 [1001-1013]), and cerebral haemorrhage (1008 [1005-1011]).

CONCLUSIONS

Elapsed time for cardiology care was associated with an increase in AF complications (stroke and haemorrhage), all-cause, CV-related mortality and hospitalizations rates at one-year. Gender differences were evident, with women demonstrating higher stroke and haemorrhagic mortality rates despite similar delays in care. These findings underscore the need for gender-tailored risk stratification and timely cardiology care to optimise outcomes.

Diagnostic significance of serum hsa_circ_0000745 and hsa_circ_0001459 in ischemic stroke and its role in the prognosis of interventional therapy

OBJECTIVE

We aimed to identify hsa_circ_0000745 and hsa_circ_0001459 expression, value as biomarkers in ischemic stroke (IS), and functions in BV2 cells.

METHODS

RNA sequencing datasets in the GEO database were retrieved. The expression of circulating hsa_circ_0000745 and hsa_circ_0001459 was validated by RT-qPCR. The predictive values of hsa_circ_0000745 and hsa_circ_0001459 in the diagnosis and outcome of acute IS were evaluated using receiver operator characteristic curve analysis. BV2 cells were treated with lipopolysaccharide, followed by hsa_circ_0000745 or hsa_circ_0001459 downregulation and subsequent migration and apoptosis assay. The downstream miR-1287-5p was detected using the luciferase reporter gene assay.

RESULTS

Hsa_circ_0000745 or hsa_circ_0001459 were upregulated in acute IS. Hsa_circ_0000745 or/and hsa_circ_0001459 differentiated between healthy control subjects and patients with IS, resulting in areas under curve (AUC) of 0.85 and 0.83, respectively. Hsa_circ_0000745 or hsa_circ_0001459 was positively correlated with serum pro-inflammatory cytokines and the NIHSS (P<0.001). Longitudinal and ROC analyses of hsa_circ_0001459 and hsa_circ_0000745 expression levels revealed the 90-day-outcome-predicting potential after stroke. Hsa_circ_0001459 and hsa_circ_0000745 promoted the apoptosis and inhibited the migration of LPS-induced BV2 cells. Hsa_circ_0001459 and hsa_circ_0000745 commonly sponged miR-1287-5p.

CONCLUSIONS

Hsa_circ_0001459 and hsa_circ_0000745 showed upregulations in IS and might have clinical utility as a diagnostic and outcome-predicting marker.

Piceatannol upregulates USP14-mediated GPX4 deubiquitination to inhibit neuronal ferroptosis caused by cerebral ischemia-reperfusion in mice

Ischemic stroke is a very common brain disorder. This study aims to assess the neuroprotective effects of piceatannol (PCT) in preventing neuronal injury resulting from cerebral ischemia and reperfusion (I/R) in mice. Additionally, we investigated the underlying mechanisms through which PCT inhibits neuronal ferroptosis by modulating the USP14/GPX4 signaling axis. In vitro and in vivo experiments were conducted. In vitro, oxygen-glucose deprivation followed by reoxygenation (OGD/R) was used to simulate ischemic injury in neuronal cells. We utilized various techniques, including DCFH-DA staining, FeRhoNox-1 staining, MDA and GSH determination, immunofluorescence, Western blotting, co-immunoprecipitation, plasmid and siRNA transfection, to evaluate the therapeutic efficacy of PCT and elucidate its mechanism of action. For vivo studies, we established a mouse model of I/R by ligating the bilateral common carotid arteries. The efficacy of PCT in mitigating brain injury and cognitive dysfunction were assessed through behavioral tests, histological analysis, Western blotting, and immunohistochemistry. PCT treatment significantly enhanced cell viability under OGD/R and reduced lipid peroxidation by decreasing levels of ROS, MDA. Furthermore, PCT effectively inhibited neuronal ferroptosis by modulating the expression of key ferroptosis-related proteins, including GPX4, ACSL4, FPN1, and Ferritin. Mechanistically, PCT was found to prevent GPX4 degradation through USP14-mediated deubiquitination. Notably, silencing USP14 reversed the ferroptotic effects of PCT, whereas overexpressing of USP14 amplified these effects. In vivo, PCT significantly reduced pathological damage of brain tissue and improved cognitive dysfunction. Piceatannol exerts neuroprotective effects by regulating ferroptosis through the USP14/GPX4 axis, thereby preventing cerebral ischemia/reperfusion injury.

Enhancing Outcome Prediction in Intracerebral Hemorrhage Through Deep Learning: A Retrospective Multicenter Study

RATIONALE AND OBJECTIVES

This study aimed to employ deep learning techniques to analyze and validate an automatic prognostic biomarker for predicting outcomes following intracerebral hemorrhage (ICH).

MATERIALS AND METHODS

This study included patients with ICH whose onset-to-imaging time (OIT) was less than 6 h. Patients were randomly divided into training and test sets at a 7:3 ratio. Using the Resnet50 deep learning method, we extracted features from the hematoma and perihematomal edema (PHE) areas and constructed a 90-day prognosis prediction model using logistic regression. To evaluate predictive efficacy and clinical significance, we employed logistic regression to train three models: Clinical, Deep Score, and the combined Clinical-Deep Learning (Merge).

RESULTS

Our study comprised 1098 patients (652 male, 446 female), with a mean Glasgow Coma Scale (GCS) score of 10. Univariate and multivariate analyses identified age, intraventricular hemorrhage (IVH), hematoma and PHE volume, and admission GCS score as independent prognostic factors. Additionally, 15 deep learning features were retained through LASSO regression. In the training set, the AUC values for the three models were as follows: Clinical model (0.88), Deep Score (0.91), and Merge model (0.94). In the test set, the Merge model exhibited a significantly higher AUC value than the other models. Calibration curves revealed satisfactory calibration of the Merge model nomogram in both training and test sets.

CONCLUSION

Our Merge model nomogram is an objective and effective prognostic tool, offering personalized risk assessments for 90-day functional outcomes in patients with ICH.

Long-term mortality outcome of a primary care-based mobile health intervention for stroke management: Six-year follow-up of a cluster-randomized controlled trial

BACKGROUND

Despite growing evidence of primary care-based interventions for chronic disease management in resource-limited settings, long-term post-trial effects remain inconclusive. We investigated the association of a 12-month system-integrated technology-enabled model of care (SINEMA) intervention with mortality outcomes among patients experiencing stroke at 6-year post-trial.

METHODS AND FINDINGS

This study (clinicltiral.gov registration number: NCT05792618) is a long-term passive observational follow-up of participants and their spouse of the SINEMA trial (clinicaltrial.gov registration number: NCT03185858). The original SINEMA trial was a cluster-randomized controlled trial conducted in 50 villages (clusters) in rural China among patients experiencing stroke during July 2017-July 2018. Village doctors in the intervention arm received training, incentives, and a customized mobile health application supporting monthly follow-ups to participants who also received daily free automated voice-messages. Vital status and causes of death were ascertained using local death registry, standardized village doctor records, and verbal autopsy. The post-trial observational follow-up spanned from 13- to 70-months post-baseline (up to April 30, 2023), during which no intervention was requested or supported. The primary outcome of this study was all-cause mortality, with cardiovascular and stroke cause-specific mortality also reported. Cox proportional hazards models with cluster-robust standard errors were used to compute hazard ratios (HRs) and 95% confidence intervals (95% CIs), adjusting for town, age, and sex in the main analysis model. Analyses were conducted on an intention-to-treat basis. Of 1,299 patients experiencing stroke (mean age 65.7 years, 42.6% females) followed-up to 6 years, 276 (21.2%) died (median time-to-death 43.0 months [quantile 1-quantile 3: 26.7-56.8]). Cumulative incidence of all-cause mortality was 19.0% (121 among 637) in the intervention arm versus 23.4% (155 among 662) in the control arm (HR 0.73; 95% CI 0.59, 0.90; p = 0.004); 14.4% versus 17.7% (HR 0.73; 95% CI 0.58, 0.94; p = 0.013) for cardiovascular cause-specific mortality; and 6.0% versus 7.9% (HR 0.71; 95% CI 0.44, 1.15; p = 0.16) for stroke cause-specific mortality. Although multisource verification was used to verify the outcomes, limitations exist as the survey- and record-matching-based nature of the study, unavailability of accurate clinical diagnostic records for some cases and the potential confounders that may influence the observed association on mortality.

CONCLUSIONS

Despite no observed statistically difference on stroke cause-specific mortality, the 12-month SINEMA intervention, compared with usual care, significantly associated with reduced all-cause and cardiovascular cause-specific mortality during 6 years of follow-up, suggesting potential sustained long-term benefits to patients experiencing stroke.

Potential profiles of caregivers' benefit finding in ischaemic stroke: The role of personality traits and coping styles

OBJECTIVE

To investigate the different categories of benefit finding among caregivers of patients with ischemic stroke and the mechanisms of personality and coping styles using an individual-centered approach.

METHODS

A cross-sectional survey was conducted among 235 caregivers of patients with ischemic stroke in the neurology departments of three tertiary hospitals in Bengbu using the revised Inventory of Illness Benefit, the Short Form of the Chinese Big Five Personality Inventory, and the Simplified Coping Style Questionnaire.

RESULTS

The benefit finding of caregivers of patients with ischemic stroke could be categorized into three latent classes: "Low sense of benefit-low personal growth group " (n = 58, 24.68 %), "Moderate sense of benefit-healthy behaviors group " (n = 117, 49.78 %), and "High Sense of Benefit-Family Cohesion Group " (n = 60, 25.53 %). Neuroticism positively predicted the low benefit group, while conscientiousness, agreeableness, openness, and extraversion positively predicted the moderate and high benefit groups, all acting as mediators across different benefit categories.

CONCLUSION

Caregivers of patients with ischemic stroke exhibit significant classification characteristics in benefit finding. Healthcare providers can develop targeted intervention measures based on the specific characteristics of the caregivers.

Associations of triglyceride glucose-body mass index with short-term mortality in critically ill patients with ischemic stroke

BACKGROUND

The triglyceride glucose-body mass index (TyG-BMI) has been established as a convenient and reliable marker for assessing insulin resistance (IR) and has been shown to be significantly correlated with stroke. However, only a few studies have been conducted in this field, with conflicting conclusions.

METHODS

This study based on the eICU database, investigated the association between TyG-BMI and 28-day mortality in critically ill ischemic stroke (IS) patients. Multivariate Cox regression models were employed to analyze the impacts of the TyG-BMI on 28-day hospital and ICU mortality. Restricted cubic splines (RCS) were applied to explore the nonlinear relationship between the TyG-BMI and 28-day mortality. K‒M curves were utilized for outcome comparisons among different TyG-BMI groups. Additionally, interaction and subgroup analyses were performed to validate the robustness of the results.

RESULTS

A total of 1,362 critically ill patients with IS were enrolled, with a mean age of 68.41 ± 14.16 years; 47.50% were male. Multivariate Cox regression analysis revealed that, the high TyG-BMI group had significantly higher 28-day hospital mortality(HR = 1.734, P = 0.032) and ICU mortality (HR = 2.337, p = 0.048). RCS analysis showed a nonlinear positive correlation between the TyG-BMI and 28-day hospital mortality. Below the inflection point of the TyG-BMI = 380.37, each increase of 1 standard deviation (SD) (approximately 25.5 units) in the TyG-BMI was associated with a 37.3% increase in 28-day hospital mortality (HR = 1.373, P = 0.015), and above 380.376, each 1-SD increase in the TyG-BMI resulted in an 87.9% decrease in 28-day hospital mortality (HR = 0.121, P = 0.057). The log-likelihood ratio test P value = 0.004. For 28-day ICU mortality, the TyG-BMI exhibited a significant positive linear correlation in RCS.

CONCLUSIONS

Elevated TyG-BMI is significantly associated with an increased risk of short-term all-cause mortality in patients with critically ill IS in the United States. This result provides compelling evidence to address the existing discrepancies in this research domain, indicating that the TyG-BMI could serve as a straightforward and efficient biomarker for identifying critically ill IS patients at high risk of mortality.

Frequency-Dependent Changes in Wavelet-ALFF in Patients With Acute Basal Ganglia Ischemic Stroke: A Resting-State fMRI Study

Background and Purpose: Motor impairment is a common occurrence in patients with acute basal ganglia (BG) ischemic stroke (ABGIS). However, the underlying mechanisms of poststroke motor dysfunction remain incompletely elucidated. In this study, we employed multifrequency band wavelet transform-based amplitude of low-frequency fluctuations (Wavelet-ALFFs) to investigate the alterations of spontaneous regional neural activity in patients with ABGIS. Methods: A total of 39 ABGIS patients with motor dysfunction and 45 healthy controls (HCs) underwent resting-state functional magnetic resonance imaging. Wavelet-ALFF values were calculated in the conventional frequency band (0.01-0.08 Hz), slow-5 frequency band (0.01-0.027 Hz), and slow-4 frequency band (0.027-0.073 Hz). A two-sample t-test was performed to compare the Wavelet-ALFF values between the two groups with sex as a covariate and Gaussian random field (GRF) theory (voxel p < 0.001, cluster p < 0.05, two-tailed) was used for the multiple corrections. Furthermore, spearman correlation analysis was performed to assess the relationship between alterations in regional neural activity between Fugl-Meyer Assessment (FMA) and National Institutes of Health Stroke Scale (NIHSS) scores. Results: In comparison to HCs, patients with ABGIS showed significantly increased Wavelet-ALFF in the left middle temporal gyrus (MTG) and decreased Wavelet-ALFF in the right inferior frontal operculum (IFO) across all three frequency bands (conventional, slow-4, and slow-5). In the left superior occipital gyrus (SOG), Wavelet-ALFF was decreased in the conventional frequency band but increased in the slow-4 frequency band. Additionally, patients with ABGIS demonstrated reduced Wavelet-ALFF in the right superior temporal gyrus (STG) in the conventional and slow-4 frequency bands. In the slow-5 frequency band, increased Wavelet-ALFF was observed in the left calcarine cortex (CC), left middle frontal gyrus (MFG), left supramarginal gyrus (SMG), and left postcentral gyrus (PCG), while decreased Wavelet-ALFF was noted in the right precuneus (PCu). Correlation analysis revealed that increased Wavelet-ALFF in the left CC in the slow-5 frequency band was positively correlated with the FMA score. No other correlations were detected in the conventional and slow-4 frequency bands. Conclusions: The altered spontaneous neural activity was frequency-specific in patients with ABGIS, and the slow-5 frequency band exhibited better results. Furthermore, the relationship between spontaneous brain activity and clinical characteristics highlighted patterns of neural alterations associated with motor dysfunction. These findings may provide novel insights into the neural mechanisms underlying motor dysfunction in ABGIS.

Subnational Evidence for the Attributable Burden of Respiratory Infections in China's Population under 20: Challenges from Particulate Matter Pollution

Respiratory infections and tuberculosis ranked as the second leading global causes of mortality in 2021. Following the methodology from the Global Burden of Disease Study (GBD) 2021, we aimed to estimate the attributable burden and risk factors of respiratory infections and tuberculosis among China's population under 20 from 1990 to 2021. In 2021, there were 652 million new cases and 12 699 deaths of respiratory infections and tuberculosis among people under 20 years old in China. We estimated 9054 (71.2%) deaths and 818 498 (54.6%) disability-adjusted life years (DALYs) from respiratory infections attributed to all evaluated risk factors. Mortality rates were the highest in Xizang, Xinjiang, and Qinghai in 2021, while they constantly decreased since 1990. Ambient particulate matter pollution was the second leading cause of death among males and first among females, accounting for nearly 1/5 of deaths from respiratory infections and tuberculosis in 2021. In 23 of 33 provinces, ambient particulate matter pollution was the first leading cause of death and DALY, while in Xizang and Gansu, it was not the major contributor to the burden. From 1990 to 2021, the burden from household air pollution declined remarkably in all 33 provinces except for Xizang and Gansu, while the population attributable fraction (PAF) of ambient particulate matter pollution continuously increased. The overall burden of respiratory infections and tuberculosis showed a declining trend, while it remained a fatal threat to infants in relatively less developed regions. The raised hazard of ambient particulate matter pollution underscored the necessity of the shift into the formulation of prevention and intervention strategies.

Temporal trends in the burden of vertebral fractures caused by falls in China and globally from 1990 to 2021: a systematic analysis of the Global Burden of Disease Study 2021

BACKGROUND

This study aimed to estimate temporal trends in the burden of vertebral fractures (VFs) caused by falls by gender and age in China and globally from 1990 to 2021.

METHODS

Data concerning the characteristics of VFs caused by falls in China and worldwide, with a focus on metrics in incidence, prevalence and years lived with disability (YLDs) and their age-standardised rates, were sourced from the Global Burden of Disease (GBD) Study 2021. Joinpoint regression analysis was used to identify periods with significant changes. The average annual percentage change (AAPC) was calculated to reflect the temporal trends from 1990 to 2021. We utilised the age-period-cohort (APC) model to assess the effects of age, period, and cohort on the burden of VFs in China.

RESULTS

From 1990 to 2021, the age-standardised incidence rate (ASIR), age-standardised prevalence rate (ASPR) and age-standardised YLD rate (ASYR) of VFs caused by falls exhibited an overall increase in China, whereas a general decline was observed globally. Furthermore, the ASIR, ASPR and ASYR were higher for males than females in China and worldwide. In 2021, across all age groups, the disease burden of VFs was primarily observed among the elderly population, particularly in the older female population, both in China and globally. The impact of age, period, and cohort on the incidence, prevalence, and YLDs exhibited variations in China.

CONCLUSION

The burden of VFs in China remains significant, particularly among older females. Given the considerable size of the elderly population and the ageing of the Chinese population, VFs remain critical public issues. Therefore, continued efforts must be made to address the health consequences of VFs caused by falls.

Unveiling synergies: Integrating TCM herbal medicine and acupuncture with conventional approaches in stroke management

This review explores the mechanisms and treatment strategies of ischemic stroke, a leading cause of morbidity and mortality worldwide. Ischemic stroke results from the obstruction of blood flow to the brain, leading to significant neurological impairment. The paper categorizes ischemic stroke into subtypes based on etiology, including cardioembolism and large artery atherosclerosis, and discusses the challenges of current therapeutic approaches. Conventional treatments like tissue plasminogen activator (tPA) and surgical interventions are limited by narrow windows and potential complications. The review highlights the promise of acupuncture, which offers neuroprotective benefits by promoting cerebral ischemic tolerance and neural regeneration. Integrating acupuncture with conventional treatments may enhance patient outcomes. Emphasis is placed on understanding the pathophysiology to develop targeted therapies that mitigate neuronal damage and enhance recovery.

Abducens nerve palsy in patients with spontaneous intraventricular hemorrhage: A case report

RATIONALE

The purpose of this case report is to describe the process of the patient developing abductor nerve paralysis, analyze the causes of this symptom, provide new diagnostic and treatment ideas for patients with spontaneous intraventricular hemorrhage who develop abductor nerve paralysis, and be alert to the occurrence of abductor nerve paralysis in such patients.

PATIENT CONCERNS

A 49-year-old man was admitted to our hospital with a spontaneous intraventricular hemorrhage. After performing digital subtraction angiography of the whole brain under local anesthesia, his eyes were limited in abduction, accompanied by hemorrhage and exudation of the optic papilla. Edema is an extremely rare condition.

DIAGNOSES

Transient intracranial hypertension was considered after reexamination with computed tomography.

INTERVENTIONS

The application of mannitol and the release of cerebrospinal fluid were used to reduce intracranial pressure and provide patient-related symptomatic treatment.

OUTCOMES

After 1 month, the patient's eyes had no abduction limitation and showed good activity.

LESSONS

Abducens nerve palsy is a common condition. Owing to its complex etiology, a careful and comprehensive examination is necessary. In particular, patients with spontaneous cerebral hemorrhage who undergo digital subtraction angiography should pay more attention to the abducens nerve.

Analyzing the correlation between acute ischemic stroke and triglyceride-glucose index based on ordered logistic regression

Objective

To investigate the association between insulin resistance, measured by the triglyceride-glucose (TyG) index, and clinical outcomes in patients with acute ischemic stroke who underwent intravenous thrombolysis with alteplase.

Methods

This retrospective study included 165 patients with acute ischemic stroke treated with intravenous alteplase. Insulin resistance was evaluated using the TyG index, and its relationship with the modified Rankin Scale (mRS) scores was analyzed. The analysis was conducted using R software (version R 4.1.3) to evaluate the correlation between the TyG index and functional outcomes at 14, 30, and 90 days post-stroke.

Results

The study found that each unit increase in the TyG index significantly raised the risk of poor functional outcomes at 14 days (OR 9.86; 95% CI: 3.32-32.21; P < 0.001), 30 days (OR 5.82; 95% CI: 2.08-17.45; P = 0.001), and 90 days (OR 9.79; 95% CI: 3.33-31.66; P < 0.001) following a stroke. Higher TyG index values were associated with worse neurological outcomes. Although male gender, older age, and smoking were also linked to poorer outcomes, these associations did not reach statistical significance.

Conclusion

The findings suggest that a higher TyG index, indicating greater insulin resistance, is associated with worse neurological outcomes in stroke patients. Early intervention targeting insulin resistance may improve clinical outcomes in ischemic stroke patients, and further research is needed to explore additional factors affecting neurological recovery.

Berberine enhances autophagic flux to alleviate ischemic neuronal injury by facilitating N-ethylmaleimide-sensitive factor-mediated fusion of autophagosomes with lysosomes

Our previous study demonstrated that Berberine (BBR) significantly enhances autophagic flux, alleviating ischemic neuronal injury by restoring autolysosomal function, but how BBR augmented autolysosomal functions remained elusive. N-ethyl-maleimide sensitive factor (NSF) is considered as a major ATPase to reactivate soluble NSF attachment protein receptors (SNAREs), which directly mediate autophagosome-lysosome fusion. However, NSF was dramatically inactivated by ischemia to hamper membrane-membrane fusion, leading to autophagic/lysosomal dysfunction in neurons. This study was to investigate whether BBR-ameliorated autophagic flux was exerted by reinforcing NSF activity, which subsequently boosted autophagosome-lysosome fusion in ischemic neurons. Rat model of ischemic stroke and neuronal ischemia model of HT22 cells were prepared by middle cerebral artery occlusion (MCAO) and oxygen-glucose deprivation (OGD), respectively. BBR was intraperitoneally administrated with 100 mg/Kg/d for 3 days before MCAO and was treated with 90 μM in HT22 neurons for 12 h, respectively. The results illustrated that NSF activity was markedly reinforced to facilitate autophagosome-lysosome fusion in penumbral cells and OGD HT22 neurons by BBR treatment. Consequently, the ischemia-created autophagic/lysosomal dysfunction was greatly restored to alleviate ischemic injury. Thereafter, NSF activity in OGD HT22 neurons was altered by transfection with NSF-overexpressing lentiviruses and siRNA-mediated knockdown, respectively. The data showed that BBR-enhanced autophagic flux and it-induced neuroprotection were greatly counteracted by NSF knockdown. By contrast, NSF overexpression synergistically boosted autophagosome-lysosome fusion and further attenuated neuronal death upon BBR treatment. Therefore, our study indicates that BBR-conferred neuroprotection against ischemic stroke is induced through facilitating autophagosome-lysosome fusion, by which enhancing autophagic flux in ischemic neurons.

Global Trends of Mechanical Thrombectomy in Acute Ischemic Stroke Over the Past Decade: A Scientometric Analysis Based on WOSCC and GBD Database

OBJECTIVE

To present a global overview of the current research landscape and emerging trends in mechanical thrombectomy for acute ischemic stroke (AIS) over the past decade.

METHODS

A thorough search was conducted on the Web of Science on May 20, 2024, focusing on original articles and reviews in English. Bibliometric tools were employed to make a network analysis and visual representation. Additionally, data on disability-adjusted life years, prevalence, and incidence of ischemic strokes were extracted from the Global Burden of Disease database.

RESULTS

A total of 7776 papers were included, indicating a steady increase from 169 to 1311 between 2014 and 2023. The United States led in core publications with 2887 papers. The incidence and disability-adjusted life years of ischemic stroke have continued to rise in Asia but have recently declined in North America and European countries. The University of Calgary emerged as the leading institution and Mayank Goyal was the most prolific author. Neurointerventional Surgery was the top contributing journal with 790 articles. The analysis identified 6332 keywords forming 5 clusters, with "mechanical thrombectomy" serving as the largest cluster, focusing mainly on interventional thrombectomy techniques for AIS. The term "tissue plasminogen activator" exhibited strong burst strength of 46.58. Keywords such as "injury", "diagnosis", "posterior circulation", and "severity" burst in 2020 and lasted until 2024.

CONCLUSIONS

Interest in mechanical thrombectomy for AIS was progressively increasing. Future research directions may include minimizing intraoperative injuries, refining diagnostic techniques, investigating interventions for posterior circulation, and tailoring thrombectomy strategies based on stroke severity and large vessel occlusion etiology.

Development and Validation of a Fusion Model Based on Carotid Plaques and White Matter Lesion Burden Imaging Characteristics to Evaluate Ischemic Stroke Severity in Symptomatic Patients

BACKGROUND

The diagnostic value of carotid plaque characteristics based on higher-resolution vessel wall MRI (HRVW-MRI) combined with white matter lesion (WML) burden for the risk of ischemic stroke is unclear.

PURPOSE

To combine carotid plaque features and WML burden to construct a hybrid model for evaluating ischemic stroke severity and prognosis in patients with symptomatic carotid artery stenosis.

STUDY TYPE

Retrospective.

SUBJECTS

One hundred and ninty-three patients with least one confirmed carotid atherosclerotic stenosis ≥30% and cerebrovascular symptoms within the last 2 weeks (136 in the training cohort and 57 in the test cohort).

FIELD STRENGTH/SEQUENCE

3.0T, T2-weighted fluid attenuated inversion recovery (T2-FLAIR) and diffusion-weighted imaging (DWI); HRVW-MRI: 3D T1-weighted variable flip angle fast spin-echo sequences (VISTA), T2-weighted VISTA, simultaneous noncontrast angiography and intraplaque hemorrhage (SNAP), and contrast-enhanced T1-VISTA.

ASSESSMENT

The following features of the plaques or vessel wall were assessed by three MRI readers independently: calcification (CA), intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), ulceration, plaque enhancement (PE), maximum vessel diameter (Max VD), maximum wall thickness (Max WT), total vessel area (TVA), lumen area (LA), plaque volume, and lumen stenosis. WMLs were graded visually and categorized as absent-to-mild WMLs (Fazekas score 0-2) or moderate-severe WMLs (Fazekas score 3-6). WML volumes were quantified using a semiautomated volumetric analysis program. Modified Rankin scores (mRS) were assessed at 90 days, following an outpatient interview, or by telephone.

STATISTICAL TESTS

LASSO-logistic regression analysis was performed to construct a model. The performance of the model was evaluated using receiver operating characteristic (ROC) curve analyses, calibration curves, decision curve analyses, and clinical imaging curves. Conditional logistic regression analysis was used to explore the associations between the hybrid model-derived score and the modified Rankin Scale (mRS) score at 90 days.

RESULTS

The model was constructed using five selected features, including IPH, plaque enhancement, ulceration, NWI, and total Fazekas score in deep WMLs (DWMLs). The hybrid model yielded an area under the curve of 0.92 (95% confidence interval [CI] 0.87-0.97) in the training cohort and 0.88 (0.80-0.96) in the test cohort. Furthermore, the hybrid model-derived score (odds ratio = 1.28; 95% CI 1.06-1.53) was independently associated with the mRS score 90 days after stroke.

DATA CONCLUSIONS

The hybrid model constructed using MRI plaque characteristics and WML burden has potential to be an effective noninvasive method of assessing ischemic stroke severity. The model-derived score has promising utility in judging neurological function recovery.

LEVEL OF EVIDENCE: 4

TECHNICAL EFFICACY

Stage 2.

The Relationship Between Muscle Metabolic Index (Cr/CysC) Levels and Short-Term Prognosis with Acute Ischemic Stroke: Findings from a Cohort Study

OBJECTIVE

Sarcopenia significantly impacts prognosis in patients with acute ischemic stroke (AIS). This study investigates the relationship between serum creatinine/serum cystatin C (Cr/CysC) levels and short-term prognosis in AIS patients, aiming to inform post-treatment strategies.

METHODS

We analyzed AIS patients at the First Affiliated Hospital of the University of Science and Technology of China from January 2022 to January 2024. Baseline data were collected through interviews and medical records, with a 3-month follow-up for prognosis assessment. 265 were included in the final analysis. Cr/CysC levels were categorized into quartiles (Q1-Q4). Logistic regression and restricted cubic spline analysis were employed to evaluate the association between Cr/CysC and prognosis.

RESULTS

Among the 265 patients, the average age was 66.18 ± 12.41 years, and 129 (48.68%) had poor short-term prognosis. Multivariate logistic regression showed that patients in the lowest quartile of Cr/CysC (Q1) had a significantly lower risk of poor prognosis compared to those in the highest quartile (Q4) (odds ratio = 0.287, 95% confidence interval: 0.090-0.917, P = 0.035). A linear relationship was identified between Cr/CysC and prognosis (P overall<0.001, P nonlinear = 0.571).

CONCLUSIONS

This study establishes a significant linear correlation between Cr/CysC levels and poor short-term prognosis in AIS patients. Encouraging muscle function exercises may enhance patient outcomes.

Factors Affecting the Readmission of Patients with Stroke

BACKGROUND

Incidence of stroke is increasing annually in China, the readmission rate of patients with stroke remains high.

METHODS

In total, 441 patients were enrolled in this study. We described the incidence of stroke readmissions. Furthermore, we used the Andersen-Gill model to explore the factors affecting all-cause readmission and cardio-cerebrovascular-related readmission of patients with stroke. Identification of these predictors can help reduce the readmission rate of patients with stroke.

RESULTS

1) In total, 441 patients with stroke were included. Among them, 163 (40%) had readmission records. Among them, 44 patients had readmission due to cardiovascular and cerebrovascular diseases, accounting for 10.70%. 2) The Modified Rankin Scale (mRs scale) score affected all-cause readmission of patients with stroke. Patients with stroke and a score of 5 were 5.46 times more likely to be readmitted than those with a score of 0 (HR = 5.46, 95% CI: 1.59∼18.7, P < 0.1). 3) Patients with college degree or above were 2.48 times more likely to have cardio-cerebrovascular-related readmission compared to those with junior high school education or below (HR = 2.48, 95% CI: 1.11∼5.54, P < 0.1). Patients with chronic diseases were 3.68 times more likely to have cardio-cerebrovascular-related readmission compared to those without chronic diseases (HR = 3.68, 95% CI: 1.61∼8.39, P < 0.1).

CONCLUSIONS

The readmission of patients with stroke may be related to their physical activity function, chronic diseases, and socioeconomic status. When considering the factors predicting the readmission of patients with stroke, we cannot blindly draw on the results of relevant foreign studies.

An interpretable machine learning scoring tool for estimating time to recurrence readmissions in stroke patients

BACKGROUND

Stroke recurrence readmission poses an additional burden on both patients and healthcare systems. Risk stratification aims to accurately divide patients into groups to provide targeted interventions at reducing readmission. To accurately predict short and intermediate-term risks of readmission and provide information for further temporal risk stratification, we developed and validated an interpretable machine learning risk scoring tool.

METHODS

In this retrospective study, all stroke admission episodes from January 1st 2015 to December 31st 2019 were obtained from the Shanghai Health and Health Development Research Centre database, which covers medical records of all patients hospitalized in 436 medical institutes in Shanghai. The outcome was time to stroke recurrence readmission within 90 days post discharge. The Score for Stroke Recurrence Readmission Prediction (SSRRP) tool was derived via an interpretable machine learning-based system for time-to-event outcomes. SSRRP as six-variable survival score includes sequelae, length of stay, type of stroke, random plasma glucose, medical expense payment, and number of hospitalizations.

RESULTS

A total of 339,212 S admission episodes were finally included in the whole cohort. Among them, 217,393 episodes were included in the training dataset, 54,347 episodes in the internal validation dataset, and 67,472 in the temporal validation dataset. Readmission within 90 days was documented in 33922(9.97 %) episodes, with a median time to emergency readmission of 19 days (Interquartile range: 8-43). In the temporal validation dataset, the SSRRP achieved an integrated area under the curve of 0.730(95 % CI, 0.724-0.737). In addition, SSRRP demonstrated good calibration and clinical benefit rate.

CONCLUSIONS

In this retrospective cohort study, the SSRRP, a parsimonious and point-based scoring tool, was developed to predict the risk of recurrent readmission for stroke. It also provided accurate information on the time to stroke readmission, enabling further temporal risk stratification and informed clinical decision-making.

Prognostic Value of Apparent Diffusion Coefficient for Mechanical Thrombectomy in Patients with Acute Posterior Ischemic Stroke

BACKGROUND

This study investigates the prognostic value of the apparent diffusion coefficient (ADC) in magnetic resonance imaging for patients with acute posterior circulation stroke (PCS) undergoing endovascular therapy (EVT).

METHODS

A retrospective analysis was conducted of patients with acute PCS from January 2017 to December 2021, confirmed by diffusion-weighted imaging (DWI)-ADC within 24 hours of onset. Patients were categorized based on their 3-month modified Rankin Scale score after EVT. Data on the National Institutes of Health Stroke Scale at admission, ADC value, and 3-month modified Rankin Scale score were collected. Multivariable logistic regression analyzed the impact of various factors on ADC values. The receiver operating characteristic curve assessed predictive indices.

RESULTS

Among 94 patients, 47 had a good prognosis and 47 had a poor prognosis. Univariate analysis showed that factors significantly associated with a good prognosis included lower National Institutes of Health Stroke Scale at admission, higher ADC values, smaller infarct areas, unilateral infarction, basilar artery occlusion, lower pons-midbrain-thalamus scores, intravenous thrombolysis, intra-arterial thrombolysis, and fewer perioperative complications (P < 0.05). Multivariable logistic regression identified high ADC values (P = 0.002) and unilateral infarction (P = 0.017) as independent predictive factors for prognosis. An ADC value >549 × 10-6 mm2/second was associated with a higher rate of good prognosis. Combining ADC values with unilateral infarction resulted in the highest area under the curve and Youden Index of 0.766, with sensitivity and specificity of 89.36% and 87.23%, respectively (P < 0.05).

CONCLUSIONS

High ADC values and unilateral infarction are independent predictive factors for the prognosis of patients with PCS after EVT. Combining these factors provides the highest predictive accuracy, aiding in clinical decision making for PCS treatment.

Xiaoxuming decoction enhanced neuroprotection after cerebral ischemia/reperfusion via the JAK2/STAT3 signaling pathway based on UPLC/HRMS, network pharmacology and experimental validation

ETHNOPHARMACOLOGICAL RELEVANCE

Xiao-xu-ming decoction (XXMD), a prominent traditional Chinese medicinal formula historically revered for stroke treatment, demonstrates pronounced efficacy in ameliorating ischemic stroke injury.

AIM OF THE STUDY

This study aims to investigate the effects and mechanisms of XXMD on neuroprotection subsequent to cerebral ischemia/reperfusion in vivo and in vitro.

MATERIALS AND METHODS

Neurobehavioral test, TTC staining, HE staining and nissl staining were used to examine the neuroprotective effect of XXMD on cerebral ischemia-reperfusion injury induced by middle cerebral artery occlusion (MCAO) in rats. Additionally, we assessed cell viability and injury with CCK8 and lactate dehydrogenase (LDH) assays. The changes in neuronal ultra-structure were observed after oxygen-glucose deprivation and reoxygenation (OGD/R) by transmission electron microscopy (TEM). Network analysis combined with ultrahighperformance liquid chromatography-high resolution mass spectrometry (UPLC-HRMS) predicted the mechanism of XXMD on ischemic stroke injury. Furthermore, the expression of neuroplasticity-related proteins neurofilament 200 (NF200), microtubule-associated protein 2 (MAP2), postsynaptic density protein 95 (PSD95), synaptophysin (SYN), phosphorylated Janus kinase2 (p-JAK2), and phosphorylated signal transduction and activator of transcription 3 (p-STAT3) was evaluated by immunofluorescence staining and Western blot analyses.

RESULTS

XXMD significantly improved Ethology, infarct area and pathological changes after MCAO and reperfusion, reducing morphological and ultrastructural alterations and decreased cell viability in HT22 cells induced by OGD/R. Network pharmacology showed that 1153 compounds of XXMD were matched. The Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis demonstrated that XXMD treated ischemia stroke mainly regulating inflammation reaction-related signaling pathways, atherosclerosish-related signaling pathways. Molecular docking results showed that TP53, AKT1, STAT3, and IL6 are closely bound to the corresponding active ingredients. XXMD treatment significantly reversed the above alternations. XXMD or AG490 up-regulated the expression of neuroplasticity-associated proteins, and reduced phosphorylation of JAK2, STAT3 expression following OGD/R.

CONCLUSION

XXMD exerts neuroprotective effects by promoting neural plasticity via regulating the JAK2/STAT3 pathway, indicating a promising alternative therapeutic strategy for ischemic stroke.

Epidemiological status, development trends, and risk factors of disability-adjusted life years due to diabetic kidney disease: A systematic analysis of Global Burden of Disease Study 2021

BACKGROUND

Approximately 40% of individuals with diabetes worldwide are at risk of developing diabetic kidney disease (DKD), which is not only the leading cause of kidney failure, but also significantly increases the risk of cardiovascular disease, causing significant societal health and financial burdens. This study aimed to describe the burden of DKD and explore its cross-country epidemiological status, predict development trends, and assess its risk factors and sociodemographic transitions.

METHODS

Based on the Global Burden of Diseases (GBD) Study 2021, data on DKD due to type 1 diabetes (DKD-T1DM) and type 2 diabetes (DKD-T2DM) were analyzed by sex, age, year, and location. Numbers and age-standardized rates were used to compare the disease burden between DKD-T1DM and DKD-T2DM among locations. Decomposition analysis was used to assess the potential drivers. Locally weighted scatter plot smoothing and Frontier analysis were used to estimate sociodemographic transitions of DKD disability-adjusted life years (DALYs).

RESULTS

The DALYs due to DKD increased markedly from 1990 to 2021, with a 74.0% (from 2,228,000 to 3,876,000) and 173.6% (from 4,123,000 to 11,279,000) increase for DKD-T1DM and DKD-T2DM, respectively. In 2030, the estimated DALYs for DKD-T1DM surpassed 4.4 million, with that of DKD-T2DM exceeding 14.6 million. Notably, middle-sociodemographic index (SDI) quintile was responsible for the most significant DALYs. Decomposition analysis revealed that population growth and aging were major drivers for the increased DKD DALYs in most GBD regions. Interestingly, the most pronounced effect of positive DALYs change from 1990 to 2021 was presented in high-SDI quintile, while in low-SDI quintile, DALYs for DKD-T1DM and DKD-T2DM presented a decreasing trend over the past years. Frontiers analysis revealed that there was a negative association between SDI quintiles and age-standardized DALY rates (ASDRs) in DKD-T1DM and DKD-T2DM. Countries with middle-SDI shouldered disproportionately high DKD burden. Kidney dysfunction (nearly 100% for DKD-T1DM and DKD-T2DM), high fasting plasma glucose (70.8% for DKD-T1DM and 87.4% for DKD-T2DM), and non-optimal temperatures (low and high, 5.0% for DKD-T1DM and 5.1% for DKD-T2DM) were common risk factors for age-standardized DALYs in T1DM-DKD and T2DM-DKD. There were other specific risk factors for DKD-T2DM such as high body mass index (38.2%), high systolic blood pressure (10.2%), dietary risks (17.8%), low physical activity (6.2%), lead exposure (1.2%), and other environmental risks.

CONCLUSIONS

DKD markedly increased and varied significantly across regions, contributing to a substantial disease burden, especially in middle-SDI countries. The rise in DKD is primarily driven by population growth, aging, and key risk factors such as high fasting plasma glucose and kidney dysfunction, with projections suggesting continued escalation of the burden by 2030.

Chinese stroke association guidelines on reperfusion therapy for acute ischaemic stroke 2024

BACKGROUND

Stroke remains a major global health challenge, with China experiencing a significant burden due to its high incidence and severe outcomes. Reperfusion therapies, such as intravenous thrombolysis and endovascular thrombectomy, have shown substantial benefits in improving early outcomes for ischaemic stroke. Recent clinical trials have validated the safety and efficacy of a broader range of thrombolytic agents and expanded the eligible patient populations for both intravenous thrombolysis and mechanical thrombectomy. This guideline aims to provide the latest evidence-based insights in the field of reperfusion therapy.

METHODS

The Chinese Stroke Association (CSA) established a writing group to develop updated guidelines on reperfusion therapy for acute ischaemic stroke. A comprehensive search of MEDLINE (via PubMed) was conducted up to 30 September 2024. Experts in the field of stroke engaged in extensive discussions, both online and offline, to evaluate the latest evidence. Each recommendation was graded using the CSA's class of recommendation and level of evidence in the Guideline Development Manual of the CSA.

RESULTS

This guideline, reviewed and approved by the CSA Guidelines Writing Group, outlines the criteria for patient selection for thrombolysis and thrombectomy and summarises the latest evidence on various thrombolytic drug options to support decision-making in reperfusion therapy. Additionally, the guideline includes green channel flow charts for intravenous thrombolysis and mechanical thrombectomy, designed to assist clinicians in optimising their clinical decisions.

CONCLUSION

This guideline updates the latest advancements in the field of reperfusion therapy for acute ischaemic stroke. It is anticipated that future clinical research will further advance areas such as innovative thrombolytic agents, expanded indications for thrombolysis and mechanical thrombectomy.

Stroke Subtypes Mortality Attributable to Smoking in China: A Study Based on the Global Burden of Disease Database 2021

BACKGROUND

The objective of this study was to analyze long-term trends in ischemic stroke (IS), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) mortality from smoking in China from 1992 to 2021, to provide scientific advice on stroke prevention and treatment in China.

METHODS

The mortality data of smoking-related stroke and its subtypes in China during 1992-2021 were collected from the Global Burden of Disease 2021. Joinpoint regression model and Age-period-cohort (APC) model were used for trend analysis.

RESULTS

The age-standardized mortality rate of stroke and subtypes caused by smoking showed a decreasing trend in China from 1992 to 2021. The decline was greater for women than for men. According to APC model analysis, the age effect showed that ICH and IS showed an increasing trend, while SAH increased first and then decreased. The results of the cohort effect were similar to those of the period effect, with relative risk decreasing for all subtypes. The local drift showed that the stroke and subtypes in males showed a "U" shaped trend, a relatively stable trend for stroke and is in females, and a downward trend for SAH and ICH.

CONCLUSIONS

Over the past 30 years, the burden of stroke and stroke subtype deaths attributable to smoking in China has decreased. However, future efforts should focus on preventing ICH. Strengthening tobacco control legislation, particularly targeting older men and young people, is crucial for further reducing smoking-related stroke risk.

The role of di-(2-ethylhexyl) phthalate in cancer initiation and progression: Mechanisms and health implications

The increasing prevalence of cancer has been linked to various environmental factors associated with modern industrial and societal advancements. Di-(2-ethylhexyl) phthalate (DEHP), a commonly used plasticizer, is one such environmental contaminant with potential carcinogenic effects. While epidemiological studies have suggested a positive association between DEHP exposure and cancer risk, the specific role of DEHP in cancer initiation and progression requires further clarification. This review systematically examines the relationship between DEHP exposure and cancer, highlighting key mechanisms involved in tumorigenesis. DEHP has been found to influence several critical aspects of cancer biology, including cell proliferation, apoptosis, metastasis, invasion, epithelial-mesenchymal transition, angiogenesis, drug resistance, immune regulation, and cancer stem cell maintenance. These carcinogenic effects are mediated through multiple pathways, such as the PI3K/AKT signaling pathway, estrogen receptor activation, epigenetic modifications, oxidative stress, and inflammation. By elucidating the molecular mechanisms underlying DEHP's role in cancer, this review aims to contribute to the development of targeted prevention and intervention strategies to mitigate the cancer risks associated with DEHP exposure.

Metabolomic and transcriptomic analyses revealed potential mechanisms of Anchusa italica Retz. in alleviating cerebral ischemia-reperfusion injury via Wnt/β-catenin pathway modulation

Anchusa italica Retz. (AIR), a traditional herbal remedy, is commonly applied in managing heart and brain disorders. However, its specific function and mechanism in acute cerebral ischemia-reperfusion injury (CIRI) are not fully understood. This research focused on the interventional effects and potential mechanisms of AIR extract (AIRE) in a rat model of CIRI. The model was established using the filament occlusion method, which involved blocking the middle cerebral artery for 1.5 h and then removing the filament to restore blood flow. Transcriptomic and metabolomic analyses were conducted to explore the molecular pathways and metabolites affected by AIRE. ATP level was measured using an ATP assay kit. Additionally, RT-qPCR and western blot tests were conducted to evaluate the influence of AIRE on the Wnt signaling pathway and mitochondrial function. Transcriptomic and metabolomic analyses indicated that AIRE regulated the Wnt signaling pathway in CIRI and modulated metabolites associated with mitochondrial energy metabolism, such as citrate and succinate. ATP assay result demonstrated that AIRE enhanced ATP production in CIRI. Further, RT-qPCR and western blot analyses revealed that AIRE activated the Wnt/β-catenin signaling pathway and corrected mitochondrial dysfunction. These results proposed that AIRE mitigated mitochondrial energy metabolism deficits in CIRI via the Wnt/β-catenin pathway. By restoring the balance of mitochondrial function and energy metabolism, AIRE might offer a potentially therapeutic strategy for addressing CIRI.

The combined effects of cardiometabolic index and high-sensitivity C-reactive protein on the risk of new onset stroke in a Chinese national prospective longitudinal cohort study

BACKGROUND

The Cardiometabolic Index (CMI) represents a novel anthropometric measurement, which combines characteristics of adiposity and lipids. Since obesity, lipid metabolism, and inflammation may collectively facilitate the occurrence of stroke, we hypothesize that a combination of elevated levels of the CMI and high-sensitivity C-reactive protein (hs-CRP) increases the risk of future stroke among middle-aged and older Chinese adults.

METHODS

This study included 8,973 participants aged 45 years or older from the China Longitudinal Study on Health and Retirement (CHARLS), who were stroke-free and underwent baseline evaluations between 2011 and 2012, with followed-up at 2013, 2015 and 2018. The exposures were CMI and hs-CRP, with CMI calculated using the formula [waist circumference (cm)/height (cm)] × [triglycerides (mmol/L)/HDL-C (mmol/L)]. The primary outcome was the occurrence of new-onset stroke events. Cox proportional hazards models and restricted cubic spline (RCS) analyses were conducted to examine the associations between CMI, hs-CRP, and their combined effects on stroke risk. Sensitivity analysis was further implemented to verify the robustness of the results.

RESULTS

A total of 629 participants (7.01%) suffered new-onset stroke during follow-up. The risk for stroke increased with each elevating quartile of baseline CMI levels, with adjusted HRs and 95% CIs being 1.27 (0.98-1.66), 1.41 (1.08-1.83), and 1.46 (1.09-1.96) for Q2, Q3, and Q4, respectively. Moreover, participants with levels of hs-CRP ≥ 2 mg/L also had significantly higher stroke incidence compared to those with CRP levels < 2 mg/L (adjusted HR 1.24, 95% CI 1.05-1.47, p = 0.012). Specifically, those concurrently with the highest CMI quartile and levels of hs-CRP ≥ 2 mg/L had the highest risk of stroke (adjusted HR 1.90, 95% CI 1.32-2.74). The subsequent sensitivity analyses yielded consistent results, further corroborating the initial findings.

CONCLUSIONS

The combination of CMI and hs-CRP exhibited a significant association with stroke risk among middle-aged and older Chinese adults, highlighting the importance of joint assessments of these biomarkers for refining risk stratification and enhancing primary prevention strategies for stroke.

Liangxue Tongyu Prescription exerts neuroprotection by regulating the microbiota-gut-brain axis of rats with acute intracerebral hemorrhage

Liangxue Tongyu Prescription (LTP) is a classic herbal formula for treating acute intracerebral hemorrhage (AICH) in China. Previous studies have shown that LTP significantly ameliorates neurological impairments and gastrointestinal dysfunction in patients with AICH. However, the underlying molecular mechanism remains unclear. The aim of this study is to investigate whether LTP exerts its neuroprotective effect on AICH rats through the microbiota-gut-brain axis and explore its potential underlying mechanism. In the current study, AICH models were established by injecting autologous whole blood into the right caudate nucleus of rats. Behavioural and pathological evaluations demonstrated that LTP ameliorated neuronal and intestinal damage in AICH rats. Analysis via western blot, quantitative real-time PCR, immunohistochemistry (IHC) and tunel staining indicated that LTP upregulated the expression of brain-derived neurotrophic factor (BDNF) and nerve growth factor(NGF) and reduced neuronal cell apoptosis. Additionally, 16S rDNA sequencing revealed that LTP mitigated dysbiosis of intestinal microbiota in AICH rats. LTP increased the levels of noradrenaline (NA), dopamine (DA), glutamate (GLU) and modulated brain-gut peptides such as gastrin (GAS), motilin (MTL), ghrelin in AICH rats. Furthermore, LTP enhanced vagus nerve discharge. In summary, this research provides evidence suggesting that LTP's influence on AICH may involve modulation of the microbiota-gut-brain axis, offering a potential scientific rationale for its therapeutic efficacy in improving outcomes of AICH.

Efficacy of Auricular Therapy for Motor Impairment After Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

A high number of stroke patients cannot recover fully from motor impairment despite early rehabilitation. Auricular therapies, usually given by acupuncture doctors or nurses, have been widely used among these post-stroke patients. Potential benefits of auricular therapies were shown in recent clinical trials.

OBJECTIVES

The purpose of this review was to systematically evaluate the clinical effects of auricular therapy in the treatment of post-stroke motor impairment.

METHODS

PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Chinese Biological Medicine (CBM), Chinese National Knowledge Infrastructure (CNKI) and Wanfang databases were searched from their inception to May 2023. Randomised controlled trials of auricular therapy for the treatment of post-stroke motor impairment met the screening criteria. The primary outcome was the Fugl-Meyer Assessment Scale (FMA). The secondary outcomes included the Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE), Chinese Stroke Scale (CSS), clinical efficacy and the Barthel Index Scale (BI). Meta-analysis was carried out using RevMan software 5.3.

RESULTS

Twenty-eight RCTs with 1993 patients were included. The meta-analysis results suggested that compared with conventional treatment, auricular therapy combined with conventional treatment significantly improved the FMA score (MD: 15.07, 95% CI, 12.56 to 17.59), the FMA-UE score (MD: 6.49, 95% CI, 5.54 to 7.45), the clinical efficacy (RR: 1.20, 95% CI, 1.12 to 1.29) and the BI score (MD: 10.26, 95% CI, 9.11 to 11.40), while the combination treatment significantly decreased the CSS score (MD: -2.98, 95% CI, -4.38 to -1.59).

CONCLUSION

Auricular therapy, as an adjunctive treatment to the conventional treatment, improved post-stroke motor impairment and self-care ability. Early auricular therapy of the patients in the early disease stage may lead to better improvement. Further well-designed, large-size clinical studies are needed.

IMPLICATIONS FOR PRACTICE

This study suggested that auricular therapy could be used as a complementary therapy with conventional treatment for improving motor impairment and self-care ability among post-stroke patients with motor impairment in hospitals, long-term care facilities and homes.

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.

Trends and burden of cardiovascular diseases among children and adolescents in China from 1990 to 2021

BACKGROUND AND AIM

There are currently no reports on the burden and trends of cardiovascular disease among children and adolescents in China. This study aims to investigate the burden and epidemiological characteristics of Cardiovascular Diseases (CVD) within the Chinese population by analyzing the trends and burden of CVD among children and adolescents of different genders and age groups in China from 1990 to 2021.

METHODS AND RESULTS

Utilizing data from the Global Burden of Diseases Study 2021, we estimated the incidence, mortality, and disability-adjusted life years (DALYs) associated with CVD among children and adolescents aged 0-19 years in China from 1990 to 2021. During this period, both the rate of death and exhibited a declining trend, while incidence rate showed a slowly declining trend. The incidence rate of CVD increased with age, especially in the population aged ≥5years. Various diseases demonstrated different the estimated annual percent change (EAPC) during 1990-2021 and almost all diseases had a decreasing trend. The ranking of incident cases, deaths and DALYs of CVD and changes indicated that stroke, rheumatic heart disease were the most important diseases.

CONCLUSIONS

Despite a consistent decline in the incidence, mortality, and DALY rates of CVD over the past three decades, children and adolescents in China continue to face substantial cardiovascular health challenges. We need to focus on CVD in children and adolescents continuously and develop health policies and practical strategies based on the current trends to address this health challenge.