Ischemic stroke in the elderly: an overview of evidence

Expression and clinical significance of 25-hydroxyvitamin D, insulin-like growth factor 1, and beta-2 microglobulin in cognitive dysfunction after ischemic stroke in the elderly

We aimed to unveil the clinical significance of serum 25-hydroxyvitamin D (25-OH-VD), insulin-like growth factor 1 (IGF-1), and beta-2 microglobulin (β2-MG) levels in cognitive dysfunction after ischemic stroke (IS) in the elderly. A total of 160 geriatric IS patients admitted to our hospital were retrospectively collected. The patients' serum 25-OH-VD, IGF-1, and β2-MG levels were detected, and the correlation between the three levels and the patients' National Institutes of Health Stroke Scale (NIHSS) and Montreal Cognitive Assessment (MoCA) scores was tested by the Pearson test. The diagnostic values of 25-OH-VD, IGF-1, and β2-MG for cognitive dysfunction and risk factors inducing cognitive dysfunction in the elderly after IS were evaluated. NIHSS score was negatively correlated with serum 25-OH-VD and IGF-1 levels, and positively correlated with serum β2-MG levels; MoCA score exhibited an inverse correlation. Diabetes, years of education <12 years, age, and serum high-sensitive C-reactive protein, cystatin C, 25-OH-VD, IGF-1, and β2-MG levels were independent factors for the development of cognitive dysfunction after IS in the elderly. The detection of 25-OH-VD, IGF-1, and β2-MG may be important for assessing the occurrence of cognitive dysfunction and the severity of the disease in patients.

Bacterial and bacterial derivatives-based drug delivery systems: a novel approach for treating central nervous system disorders

INTRODUCTION

Bacteria and their derivatives show great potential as drug delivery systems due to their unique chemotaxis, biocompatibility, and targeting abilities. In CNS disease treatment, bacterial carriers can cross the blood-brain barrier (BBB) and deliver drugs precisely, overcoming limitations of traditional methods. Advances in genetic engineering, synthetic biology, and nanotechnology have transformed these systems into multifunctional platforms for personalized CNS treatment.

AREAS COVERED

This review examines the latest research on bacterial carriers for treating ischemic brain injury, neurodegenerative diseases, and gliomas. Bacteria efficiently cross the blood-brain barrier via active targeting, endocytosis, paracellular transport, and the nose-to-brain route for precise drug delivery. Various bacterial drug delivery systems, such as OMVs and bacterial ghosts, are explored for their design and application. Databases were searched in Google Scholar for the period up to December 2024.

EXPERT OPINION

Future developments in bacterial drug delivery will rely on AI-driven design and high-throughput engineering, enhancing treatment precision. Personalized medicine will further optimize bacterial carriers for individual patients, but challenges such as biosafety, immune rejection, and scalability must be addressed. As multimodal diagnostic and therapeutic strategies advance, bacterial carriers are expected to play a central role in CNS disease treatment, offering novel precision medicine solutions.

Neurodegenerative Diseases: What Can Be Learned from Toothed Whales?

Neurodegeneration involves a wide range of neuropathological alterations affecting the integrity, physiology, and architecture of neural cells. Many studies have demonstrated neurodegeneration in different animals. In the case of Alzheimer's disease (AD), spontaneous animal models should display two neurohistopathological hallmarks: the deposition of β-amyloid and the arrangement of neurofibrillary tangles. However, no natural animal models that fulfill these conditions have been reported and most research into AD has been performed using transgenic rodents. Recent studies have also demonstrated that toothed whales - homeothermic, long-lived, top predatory marine mammals - show neuropathological signs of AD-like pathology. The neuropathological hallmarks in these cetaceans could help to better understand their endangered health as well as neurodegenerative diseases in humans. This systematic review analyzes all the literature published to date on this trending topic and the proposed causes for neurodegeneration in these iconic marine mammals are approached in the context of One Health/Planetary Health and translational medicine.

Clinical outcomes of reperfusion therapy in patients with site-specific basilar artery occlusion

BACKGROUND

Despite its low incidence, basilar artery occlusion (BAO) remains a major therapeutic challenge since severe disability and death occur in about 80% of patients. Specific site of BAO (proximal, middle, or distal) has rarely been reported as a prognostic factor in reperfusion therapy. We aimed to explore the relationship between site-specific BAO and clinical outcomes in patients treated with reperfusion therapies.

METHODS

We performed a single-centre retrospective study of all consecutive patients with acute BAO admitted to the University Medical Centre Ljubljana between January 2013 and August 2022 who were treated with reperfusion therapies. Patients were grouped according to the location of BAO and compared for baseline characteristics, differences in stroke aetiology, type of reperfusion therapy, success of recanalization, and clinical outcome after 90 days evaluated by the modified Rankin Scale (mRS) score. Statistical analysis was performed with the two-sided ANOVA t-tests for continuous measures, Chi-squared (χ2) tests for categorical measures and a multivariate ordinal logistic regression analysis.

RESULTS

The study included 103 patients (47% females, median age 74 years; confidence interval (CI) 72 to 98). Proximal BAO was found in 13%, middle in 13%, and distal in 74% of patients. Cardioembolic etiology was more common in distal (=0.01), and atherosclerotic etiology in proximal and middle BAO occlusions (P=0.02). While distal BAO was more likely to be recanalized using intravenous thrombolysis (IVT) compared with other sites of occlusion (P=0.05), we found no difference between different occlusion sites and the success of endovascular treatment (EVT). Lower age (odds ratio (OR) 0.89; CI 0.84 to 0.95; P<0.01) and shorter time to intervention (OR 0.71; CI 0.53 to 0.95; P=0.02), regardless of it being IVT or EVT, were predictors of an excellent clinical outcome (mRS 0-2). Distal occlusion (OR 28; CI 2.7 to 300; p<0.01) was a strong predictor of a favorable clinical outcome (mRS 0-3).

CONCLUSION

Prompt reperfusion, regardless of it being IVT or EVT, increases the chance of excellent clinical outcomes in patients with acute BAO. Distal BAO is more often associated with a favorable clinical outcome compared with the proximal and middle segments.

Mechanical thrombectomy in elderly stroke patients with low ASPECTS: insights from STAR

BACKGROUND

The elderly population (≥80 years) were underrepresented in recent trials of endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion acute ischemic stroke (LVO-AIS) with low Alberta Stroke Program Early CT Score (ASPECTS) (≤5).

METHODS

This study analyzed data from a prospectively maintained database of 37 thrombectomy centers. The primary cohort of the study comprised patients with LVO-AIS aged ≥80 who underwent EVT with ASPECTS≤5 from 2013 to 2023. The primary outcome was favorable modified Rankin Scale (mRS) score of 0-3. Propensity score matching (PSM) and multivariate regression were applied.

RESULTS

In a study of 14 233 patients undergoing EVT, 1741 patients were 80 or older, with 122 presenting with low ASPECTS. While successful recanalization rates were similar between age groups, patients aged ≥80 had significantly lower favorable 90-day mRS scores and higher mortality before propensity score matching (PSM). After PSM, differences in mortality and symptomatic intracranial hemorrhage (sICH) were no longer significant. Among all elderly patients, higher ASPECTS was an independent predictor of a 90-day favorable outcome but was not associated with 90-day mortality. For patients aged ≥80 years with low ASPECTS, favorable outcomes were associated only with lower rates of atrial fibrillation, baseline functioning (mRS 0-1), fewer thrombectomy passes, and higher likelihood of first-pass reperfusion within 30 min of puncture.

CONCLUSION

While age ≥80 increases mortality and disability in patients with AIS and low ASPECTS, select elderly patients may still benefit from EVT when clinical factors are considered, supporting individualized treatment and better patient selection for future trials.

The pathobiology of neurovascular aging

As global life expectancy increases, age-related brain diseases such as stroke and dementia have become leading causes of death and disability. The aging of the neurovasculature is a critical determinant of brain aging and disease risk. Neurovascular cells are particularly vulnerable to aging, which induces significant structural and functional changes in arterial, venous, and lymphatic vessels. Consequently, neurovascular aging impairs oxygen and glucose delivery to active brain regions, disrupts endothelial transport mechanisms essential for blood-brain exchange, compromises proteostasis by reducing the clearance of potentially toxic proteins, weakens immune surveillance and privilege, and deprives the brain of key growth factors required for repair and renewal. In this review, we examine the effects of neurovascular aging on brain function and its role in stroke, vascular cognitive impairment, and Alzheimer's disease. Finally, we discuss key unanswered questions that must be addressed to develop neurovascular strategies aimed at promoting healthy brain aging.

Proteomic Spectrum of Serum Exosomes in Ischemic Stroke Patients Is Associated with Cognitive Impairment in the Post-Stroke Period

Ischemic stroke (IS) and subsequent neuropsychiatric disorders are among the leading causes of disability worldwide. Several strategies have been previously proposed to utilize exosomes for assessing the risk of IS-related diseases. The aim of this work was to evaluate serum exosomal proteins in IS patients during the chronic post-stroke period and to search for their associations with the development of post-stroke mild cognitive impairment (MCI). Comparative quantitative proteomic analysis of serum exosomes of patients without post-stroke MCI (19 patients mean age 52.0 ± 8.1 years) and patients with post-stroke MCI (11 patients, mean age 64.8 ± 5.6 years) revealed significant differences in the levels of 62 proteins out of 186 identified. Increased levels of the proteins associated with immune system and decreased levels of the proteins involved in lipid metabolism were observed in the patients with MCI compared to the patients without MCI in the chronic post-stroke period. The obtained data suggest that the higher level of immune system activation in the patients during a relatively long period after IS may be one of the risk factors for the development of post-stroke cognitive disorders and suggest participation of exosomal transport in these processes.

Development of a Predictive Nomogram for Intra-Hospital Mortality in Acute Ischemic Stroke Patients Using LASSO Regression

Background and Purpose

Ischemic stroke is a leading cause of mortality and disability globally, necessitating accurate prediction of intra-hospital mortality (IHM) for improved patient care. This study aimed to develop a practical nomogram for personalized IHM risk prediction in ischemic stroke patients.

Methods

A retrospective study of 422 ischemic stroke patients (April 2020 - December 2021) from Chongqing Medical University's First Affiliated Hospital was conducted, with patients divided into training (n=295) and validation (n=127) groups. Data on demographics, comorbidities, stroke risk factors, and lab results were collected. Stroke severity was assessed using NIHSS, and stroke types were classified by TOAST criteria. Least absolute shrinkage and selection operator (LASSO) regression was employed for predictor selection and nomogram construction, with evaluation through ROC curves, calibration curves, and decision curve analysis.

Results

LASSO regression and multivariate logistic regression identified four independent IHM predictors: age, admission NIHSS score, chronic obstructive pulmonary disease (COPD) diagnosis, and white blood cell count (WBC). A highly accurate nomogram based on these variables exhibited excellent predictive performance, with AUCs of 0.958 (training) and 0.962 (validation), sensitivities of 93.2% and 95.7%, and specificities of 93.1% and 90.9%, respectively. Calibration curves and decision curve analysis validated its clinical applicability.

Conclusion

Age, admission NIHSS score, COPD history, and WBC were identified as independent IHM predictors in ischemic stroke patients. The developed nomogram demonstrated high predictive accuracy and practical utility for mortality risk estimation. External validation and prospective studies are warranted for further confirmation of its clinical efficacy.

Role of microglia in stroke

Microglia play key roles in the post-ischemic inflammatory response and damaged tissue removal reacting rapidly to the disturbances caused by ischemia and working to restore the lost homeostasis. However, the modified environment, encompassing ionic imbalances, disruption of crucial neuron-microglia interactions, spreading depolarization, and generation of danger signals from necrotic neurons, induce morphological and phenotypic shifts in microglia. This leads them to adopt a proinflammatory profile and heighten their phagocytic activity. From day three post-ischemia, macrophages infiltrate the necrotic core while microglia amass at the periphery. Further, inflammation prompts a metabolic shift favoring glycolysis, the pentose-phosphate shunt, and lipid synthesis. These shifts, combined with phagocytic lipid intake, drive lipid droplet biogenesis, fuel anabolism, and enable microglia proliferation. Proliferating microglia release trophic factors contributing to protection and repair. However, some microglia accumulate lipids persistently and transform into dysfunctional and potentially harmful foam cells. Studies also showed microglia that either display impaired apoptotic cell clearance, or eliminate synapses, viable neurons, or endothelial cells. Yet, it will be essential to elucidate the viability of engulfed cells, the features of the local environment, the extent of tissue damage, and the temporal sequence. Ischemia provides a rich variety of region- and injury-dependent stimuli for microglia, evolving with time and generating distinct microglia phenotypes including those exhibiting proinflammatory or dysfunctional traits and others showing pro-repair features. Accurate profiling of microglia phenotypes, alongside with a more precise understanding of the associated post-ischemic tissue conditions, is a necessary step to serve as the potential foundation for focused interventions in human stroke.

Bifidobacterium bifidum supplementation improves ischemic stroke outcomes in elderly patients: A retrospective study

This retrospective study aimed to explore the therapeutic potential of Bifidobacterium bifidum supplementation on elderly ischemic stroke patients. We retrospectively analyzed electronic medical records from 153 elderly ischemic stroke patients. Patients were stratified into 2 groups: those receiving B bifidum supplementation (Intervention group, n = 73) and those receiving standard treatment without any additional supplementation (Control group, n = 80). Outcomes were assessed using the National Institutes of Health Stroke Scale (NIHSS), Montreal Cognitive Assessment (MoCA), Self-Rating Depression Scale (SDS), and Self-Rating Anxiety Scale (SAS). Inflammatory markers, immunological indicators, neurotrophic factor, and gut-brain axis (GBA)-related markers were also evaluated at baseline and during 4-week follow-up. Compared to the control group, the intervention group exhibited significant improvements in the NIHSS, MoCA, SDS and SAS scores (P < .001). Enhanced levels of brain-derived neurotrophic factor (BDNF) and reduced levels of NPY were observed in the intervention group. Additionally, inflammatory markers, including IL-6, IL-8, IL-1β, and TNF-α, were significantly reduced in the intervention group, as well as significant increases in immunoglobulin levels (Ig A, Ig G, and Ig M) (P < .001). Besides, lower incidences of diarrhea and constipation were observed in the intervention group (P < .001), while the incidence of abdominal pain was no significant changed. B bifidum supplementation offers promising therapeutic benefits in improving neurological, cognitive, and psychological outcomes in elderly ischemic stroke patients, which may be achieved by regulating the GBA, reducing inflammation and promoting immune function. These findings highlight the importance of integrating gut health strategies in stroke management.

Revisiting the relevance of Hirano bodies in neurodegenerative diseases

AIMS

Hirano bodies (HBs) are eosinophilic pathological structures with two morphological phenotypes commonly found in the hippocampal CA1 region in Alzheimer's disease (AD). This study evaluated the prevalence and distribution of HBs in AD and other neurodegenerative diseases.

METHODS

This cross-sectional study systematically evaluated HBs in a cohort of 193 cases with major neurodegenerative diseases, including AD (n = 91), Lewy body disease (LBD, n = 87), progressive supranuclear palsy (PSP, n = 36), multiple system atrophy (MSA, n = 14) and controls (n = 26). The prevalence, number and morphology of HBs in the stratum lacunosum (HBL) and CA1 pyramidal cell layer were examined. In addition, we investigated the presence of HBs in five additional hippocampal subregions.

RESULTS

The morphological types of HBs in CA1 were divided into three, including a newly discovered type, and were evaluated separately, with their morphology confirmed in three dimensions: (1) classic rod-shaped HB (CHB), (2) balloon-shaped HB (BHB) and the newly described (3) string-shaped HB (SHB). The prevalence of each HB type differed between disease groups: Compared with controls, for CHB in AD, AD + LBD, PSP and corticobasal degeneration, for BHB in AD + LBD and PSP, and SHB in AD + LBD and PSP were significantly increased. Regression analysis showed that CHBs were independently associated with higher Braak NFT stage, BHBs with LBD and TDP-43 pathology, SHBs with higher Braak NFT stage, PSP and argyrophilic grain disease and HBLs with MSA.

CONCLUSIONS

This study demonstrates that HBs are associated with diverse neurodegenerative diseases and shows that morphological types appear distinctively in various conditions.

4-Hydroxysesamin, a Modified Natural Compound, Attenuates Neuronal Apoptosis After Ischemic Stroke via Inhibiting MAPK Pathway

Background

The 4-hydroxysesamin (4-HS, a di-tetrahydrofuran lignin) is a modified sesamin that was prepared in the laboratory. This preclinical study was designed to preliminarily investigate the neuroprotective properties of 4-HS.

Methods

In vitro, neuronal injury and inflammation were simulated by oxygen-glucose deprivation and lipopolysaccharide (LPS) exposure in mouse hippocampal neuronal HT22 cell line, and treated with 4-HS and/or metformin (MET, MAPK pathway activator for exploring mechanism). CCK-8, flow cytometry, and enzyme-linked immunosorbent assay were performed to evaluate cell viability, apoptosis, and inflammation. Apoptosis- and pathway-related proteins were detected by Western blotting. Middle cerebral artery occlusion (MCAO) was constructed as a stroke model and treated with 4-HS for in vivo confirmation. Histological staining was used for in vivo evaluation of 4-HS properties.

Results

The 4-HS showed similar anti-inflammatory activity to sesamin but did not affect the cell viability of HT22 cells. In vitro, 4-HS improved the cell viability, ameliorated neuronal apoptosis, along with the reversion of apoptotic proteins (Bax, cleaved-caspase 3/9, Bcl-2) expression and inflammatory cytokines (IL-6, TNF-α, IL-10) in LPS-treated HT22 cells. The 4-HS suppressed the phosphorylation of ERK, JNK, and p38 but the addition of MET reversed 4-HS-induced changes of phenotype and protein expression in LPS-treated cells. In vivo, 4-HS showed apparent improvement in cerebral infarction, brain tissue morphology, neuronal architecture, apoptosis, and inflammation of MCAO mice, and also showed inhibiting effects on the phosphorylation of ERK, JNK, and p38, confirming in vivo results.

Conclusion

In this first pre-clinical study on 4-HS, we preliminarily demonstrated the neuroprotective properties of 4-HS both in cell and animal models, and proposed that the underlying mechanism might be associated with the MAPK pathway.

The effect of the interaction of sleep onset latency and age on ischemic stroke severity via inflammatory chemokines

Objective

Prolonged sleep onset latency (PSOL) and age have been linked to ischemic stroke (IS) severity and the production of chemokines and inflammation, both of which contribute to IS development. This study aimed to explore the relationship between chemokines, inflammation, and the interplay between sleep onset latency (SOL) and age in influencing stroke severity.

Methods

A cohort of 281 participants with mild to moderate IS was enrolled. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and SOL was recorded. Serum levels of macrophage inflammatory protein-1alpha (MIP-1α), macrophage inflammatory protein-1beta (MIP-1β), monocyte chemoattractant protein-1 (MCP-1), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) were measured.

Results

NIHSS scores of middle-aged participants with PSOL were significantly higher than those with normal sleep onset latency (NSOL) (p = 0.046). This difference was also observed when compared to both the elderly with NSOL (p = 0.022), and PSOL (p < 0.001). Among middle-aged adults with PSOL, MIP-1β exhibited a protective effect on NIHSS scores (β = -0.01, t = -2.11, p = 0.039, R2 = 0.13). MIP-1α demonstrated a protective effect on NIHSS scores in the elderly with NSOL (β = -0.03, t = -2.27, p = 0.027, R2 = 0.12).

Conclusion

This study reveals a hitherto undocumented association between PSOL and IS severity, along with the potential protective effects of MIP-1β in mitigating stroke severity, especially among middle-aged patients.

Elevated lipoprotein(a) increases risk of subsequent major adverse cardiovascular events (MACE) and coronary revascularisation in incident ASCVD patients: A cohort study from the UK Biobank

BACKGROUND AND AIMS

Elevated lipoprotein(a) [Lp(a)] is a genetic driver for atherosclerotic cardiovascular disease (ASCVD). We aimed to provide novel insights into the associated risk of elevated versus normal Lp(a) levels on major adverse cardiovascular events (MACE) in an incident ASCVD cohort.

METHODS

This was an observational cohort study of incident ASCVD patients. MACE counts and incidence rates (IRs) per 100-person-years were reported for patients with normal (<65 nmol/L) and elevated (>150 nmol/L) Lp(a) within the first year after incident ASCVD diagnosis and overall follow-up. Cox proportional hazard models quantified the risk of MACE associated with a 100 nmol/L increase in Lp(a).

RESULTS

The study cohort included 32,537 incident ASCVD patients; 5204 with elevated and 22,257 with normal Lp(a). Of those with elevated Lp(a), 41.2% had a subsequent MACE, versus 35.61% with normal Lp(a). Within the first year of follow-up, the IRs of composite MACE and coronary revascularisation were significantly higher (p < 0.001) in patients with elevated versus normal Lp(a) (IR difference 6.79 and 4.66). This trend was also observed in the overall follow-up (median 4.7 years). Using time to first subsequent MACE, a 100 nmol/L increase in Lp(a) was associated with an 8.0% increased risk of composite MACE, and 18.6% increased risk of coronary revascularisation during the overall follow-up period.

CONCLUSIONS

The association of elevated Lp(a) with increased risk of subsequent MACE and coronary revascularisation highlights a population who may benefit from earlier and more targeted intervention for cardiovascular risk including Lp(a), particularly within the first year after ASCVD diagnosis. Proactive Lp(a) testing as part of routine clinical practice can help identify and better manage these higher-risk individuals.

Age-Period-Cohort Analysis of Long-Term Trends in Ischemic Stroke Mortality in China Caused by Specific Risk Factors from 1990 to 2019

OBJECTIVE

The objective of this study was to study the primary risk factors for the long-term trends of mortality rates in ischemic stroke (IS) in China.

METHODS

Using the Global Burden of Disease Study 2019 (GBD 2019) database, research was conducted on the 11 primary risk factors for the mortality rates of IS in China from 1990 to 2019. This study employed joinpoint regression software and the age-period-cohort method to evaluate the trends of mortality rates divided by age, period, and cohort over time.

RESULTS

From 1990 to 2019, the age-standardized mortality rate (ASMR) caused by a diet high in red meat and high body mass index in China showed an upward trend. ASMR increased first and then decreased due to smoking, diet high in sodium, particulate matter pollution, high fasting plasma glucose, and high systolic blood pressure. Low-density lipoprotein cholesterol (LDL-C), kidney dysfunction, low temperature, and lead exposure remained relatively stable during this period. In the 35-45 age group, the mortality rate of IS due to high LDL-C was up to about 60%, and smoking affected men more than women. Overall, high LDL-C, high systolic blood pressure, and particulate matter pollution were the most common risk factors in patients with IS. The risk of death rose with age. The period and cohort relative risks showed that metabolic risk factors had the greatest impact on the mortality of IS.

CONCLUSION

Metabolic risk factors have become the primary risk factors for the ASMR of IS in China. Relevant authorities should pay attention to their long-term effects on IS. Effective public health policies and interventions should be implemented to reduce the burden of IS.

Disparity in risk factors of ischemic stroke in four coastal-area hospitals in China

Background

Currently, ischemic stroke is the leading cause of death in China. To compare regional differences of ischemic stroke, we analyzed the clinical characteristics of patients with ischemic stroke in four regionally representative hospitals in China.

Methods

We conducted a retrospective study at four tertiary hospitals in east China, with regionally representative patients. The associated factors include hypertension, diabetes mellitus, coronary heart disease, hyperlipidemia and a combination of these factors. The standardized ratio (SR), estimated as the observed number divided by the expected number, computed as the sum of predicted probabilities from a multivariable logistic regression model derived using data from all other cities, was used to compare to average levels.

Results

A total of 34,707 patients were included. The number of patients increased with age in all four hospitals and patients were predominantly male. The number of ischemic stroke cases with related factors increased with age, except for hyperlipidemia. There was no significant gender difference when multiple related factors existed simultaneously. Coronary heart disease had a more significant impact on ischemic stroke in Qingdao Municipal Hospital and the First Hospital of Qinhuangdao, while hyperlipidemia had a significant influence on ischemic stroke in the First Hospital of Qinhuangdao.

Conclusions

At four hospitals in east China, with the increase of age, the risk factors associated with ischemic stroke increased, and the distribution of ischemic stroke-related factors showed regional differences.

Predictive Value of Nutritional Risk for All-Cause Death and Functional Outcomes in Chinese Elderly Patients with Acute Stroke: A 3-Year Follow-Up Study

Purpose

To explore the predictive value of nutritional risk for all-cause death and functional outcomes among elderly acute stroke patients.

Patients and Methods

A total of 479 elderly acute stroke patients were enrolled in this study. The nutritional risk of patients was screened by the GNRI and NRS-2002. The primary outcome was all-cause death, and the secondary outcome was poor prognosis defined as a modified Rankin Scale (mRS) score ≥3.

Results

Based on the NRS-2002, patients with nutritional risk had a higher risk of all-cause death at 3 months (adjusted OR: 3.642, 95% CI 1.046~12.689) and at 3 years (adjusted OR: 2.266, 95% CI 1.259~4.076) and a higher risk of adverse functional outcomes at 3 months (adjusted OR: 2.748, 95% CI 1.518~4.972. Based on the GNRI, compared to those without nutritional risk, patients with mild malnutrition also had a higher risk of all-cause death at 3 months (adjusted OR: 7.186, 95% CI 1.550~33.315) and at 3 years (adjusted OR: 2.255, 95% CI 1.211~4.199) and a higher risk of adverse functional outcomes at 3 months (adjusted OR: 1.947, 95% CI 1.030~3.680), so patients with moderate and severe malnutrition had a higher risk of all-cause death at 3 months (adjusted OR: 6.535, 95% CI 1.380~30.945) and at 3 years (adjusted OR: 2.498, 95% CI 1.301~4.799) and a higher risk of adverse functional outcomes at 3 months (adjusted OR: 2.213, 95% CI 1.144~4.279).

Conclusion

Nutritional risk increases the risk of poor short-term and long-term outcomes in elderly patients with acute stroke. For elderly stroke patients, we should pay attention to early nutritional risk screening, and effective intervention should be provided to improve the prognosis of such patients.

Clinical decision support systems for 3-month mortality in elderly patients admitted to ICU with ischemic stroke using interpretable machine learning

Background

Elderly patients are more likely to suffer from severe ischemic stroke (IS) and have worse outcomes, including death and disability. We aimed to develop and validate predictive models using novel machine learning algorithms for the 3-month mortality in elderly patients with IS admitted to the intensive care unit (ICU).

Methods

We conducted a retrospective cohort study. Data were extracted from Medical Information Mart for Intensive Care (MIMIC)-IV and International Stroke Perfusion Imaging Registry (INSPIRE) database. Ten machine learning algorithms including Categorical Boosting (CatBoost), Random Forest (RF), Support Vector Machine (SVM), Neural Network (NN), Gradient Boosting Machine (GBM), K-Nearest Neighbors (KNNs), Multi-Layer Perceptron (MLP), Naive Bayes (NB), eXtreme Gradient Boosting (XGBoost) and Logistic Regression (LR) were used to build the models. Performance was measured using area under the curve (AUC) and accuracy. Finally, interpretable machine learning (IML) models presenting as Shapley additive explanation (SHAP) values were applied for mortality risk prediction.

Results

A total of 1826 elderly patients with IS admitted to the ICU were included in the analysis, of whom 624 (34.2%) died, and endovascular treatment was performed in 244 patients. After feature selection, a total of eight variables, including minimum Glasgow Coma Scale values, albumin, lactate dehydrogenase, age, alkaline phosphatase, body mass index, platelets, and types of surgery, were finally used for model construction. The AUCs of the CatBoost model were 0.737 in the testing set and 0.709 in the external validation set. The Brier scores in the training set and testing set were 0.12 and 0.21, respectively. The IML of the CatBoost model was performed based on the SHAP value and the Local Interpretable Model-Agnostic Explanations method.

Conclusion

The CatBoost model had the best predictive performance for predicting mortality in elderly patients with IS admitted to the ICU. The IML model would further aid in clinical decision-making and timely healthcare services by the early identification of high-risk patients.

Neutrophil-to-albumin Ratio as a Prognostic Factor in Patients with Acute Ischemic Stroke

BACKGROUND

Neutrophil-To-Albumin Ratio (NAR) is a novel inflammatory biomarker. However, the potential prognostic value of NAR in acute ischemic stroke (AIS) remains unclear. This study aimed to evaluate whether NAR levels correlated with the 3-month modified Rankin scale (mRS) in patients with AIS.

METHODS

AIS patients were included in this retrospective study. NAR was calculated as the ratio of absolute neutrophil count to serum albumin level. Logistic regression analyses were used to investigate the effect of NAR on 3-month mRS of AIS. The predictive values of NAR, albumin level, and neutrophil count were compared utilizing receiver operating characteristic (ROC) curves. Moreover, subgroup analyses and interaction tests were conducted to evaluate the consistency of NAR's effect on AIS prognosis.

RESULTS

Of the 780 patients included, 403 (51.67%) had a poor clinical outcome (mRS 3-6) at 3 months. NAR was independently correlated to 3-month poor functional outcome after adjusting for confounders (Odds ratios (OR), 9.34; 95% confidence intervals (CI), 1.09 to 80.13; p =0.0417). Subgroup analysis showed a relative effect consistent with the overall population results, and no statistical interactions were found in the subgroups (all p for interaction > 0.05). The ROC curve showed that the prognosis-related cutoff value for NAR was 0.123, with corresponding specificity and sensitivity of 53.55% and 63.94%, respectively. When comparing the predictive power, NAR (0.590; 95%CI 0.549-0.630) exhibited the highest area under the curve (AUC) of ROC compared to neutrophils (0.584; 95%CI 0.543-0.624) and albumin (0.540; 95%CI 0.500-0.581).

CONCLUSION

There is a positive relationship between NAR levels and 3-month poor functional outcomes in AIS patients, supporting the potential of NAR as a readily available and economic serum biomarker for the early identification of AIS prognosis. Further studies are required to validate the prognostic value and clinical utility of the NAR.

CD8+ T cells in brain injury and neurodegeneration

The interaction between the peripheral immune system and the brain is increasingly being recognized as an important layer of neuroimmune regulation and plays vital roles in brain homeostasis as well as neurological disorders. As an important population of T-cell lymphocytes, the roles of CD8+ T cells in infectious diseases and tumor immunity have been well established. Recently, increasing number of complex functions of CD8+ T cells in brain disorders have been revealed. However, an advanced summary and discussion of the functions and mechanisms of CD8+ T cells in brain injury and neurodegeneration are still lacking. Here, we described the differentiation and function of CD8+ T cells, reviewed the involvement of CD8+ T cells in the regulation of brain injury including stroke and traumatic brain injury and neurodegenerative diseases, such as Alzheimer's disease (AD) and Parkinson's disease (PD), and discussed therapeutic prospects and future study goals. Understanding these processes will promote the investigation of T-cell immunity in brain disorders and provide new intervention strategies for the treatment of brain injury and neurodegeneration.

The impact of DRG on resource consumption of inpatient with ischemic stroke

Background

Diagnosis-related group (DRG) payments were gradually introduced and used in 12 public hospitals in L city. Given the high incidence and burden of ischemic stroke, the study aimed to assess the impact of DRG payment reform on inpatient medical resource utilization.

Methods

Data were obtained from the DRG local database of the new Chinese cooperative medical program in L city. The study used interrupted time series analysis to examine changes in length of stay and medical costs before and after the reform, and also assessed changes in different subgroups.

Results

There were 763 and 4,731 ischemic stroke patients in tertiary hospitals and 1953 and 10,439 patients in secondary hospitals before and after the DRG payment reform, respectively. After the reform, LOS was reduced 0.047 and 0.47 days in tertiary and secondary hospitals, respectively. Medical expenses decreased by 30.189 yuan in tertiary hospitals, but those increased by 44.918 yuan in secondary hospitals monthly. For gender, the average LOS reduced by 0.462 and 0.471 days for male and female in secondary hospitals. The change in medical expenses for male patients in tertiary hospitals and female in secondary hospitals were more significant, with a decrease of 65.396 yuan and increase of 56.257 yuan. The most pronounced change in resource consumption was seen for patients aged 85 years and older, with an increase in average LOS and medical expenses by 0.394 days and 382.422 yuan in tertiary hospitals. They showed a reduction in the average LOS by 1.480 days, and increase in the average medical expenses by 133.485 yuan in secondary hospitals monthly. Regarding disease severity, the most significant changes were seen in MCC patients. The average LOS decreased by 0.197 and 0.928 days and the average medical expenses decreased by 131.526 and 21.631 yuan in tertiary and secondary hospitals, respectively.

Conclusion

The implementation of DRG payment system has led to a reduction in the LOS in various levels of hospitals, which would save in bed resources. However, DRG payment reform can help to control medical expenses for ultra-high cases, but it may not be useful to control the overall increase in medical expenses.

Pathogenesis-adaptive polydopamine nanosystem for sequential therapy of ischemic stroke

Ischemic stroke is lethal cerebrovascular disease, and reperfusion as the main strategy of blood supply restoration can cause severe ischemic brain damage. Considered as the major obstacle in medication for stroke, neuroinflammation after reperfusion undergoes dynamic progression, making precision treatment for stroke a Herculean task. In this work, we report a pathogenesis-adaptive polydopamine nanosystem for sequential therapy of ischemic stroke. Intrinsic free radical scavenging and tailored mesostructure of the nanosystem can attenuate oxidative stress at the initial stage. Upon microglial overactivation at the later stage, minocycline-loaded nanosystem can timely reverse the pro-inflammatory transition in response to activated matrix metalloproteinase-2, providing on-demand regulation. Further in vivo stroke study demonstrates a higher survival rate and improved brain recovery of the sequential strategy, compared with mono-therapy and combined therapy. Complemented with satisfactory biosafety results, this adaptive nanosystem for sequential and on-demand regulation of post-stroke neuroinflammation is a promising approach to ischemic stroke therapy.

Efficacy, safety, and predictors for functional outcomes of mechanical thrombectomy in patients aged over 90 years with acute ischemic stroke and literature review

BACKGROUND

No evidence supports the efficacy and safety of mechanical thrombectomy (MT) in patients aged ≥ 90 years with acute ischemic stroke (AIS). This study clarifies the efficacy, safety, and predictors of MTs in patients aged ≥ 90 years by investigating our results and reviewing previous studies.

METHODS

We retrospectively investigated data from 80 consecutive patients who underwent MT at our hospital between 2018 and 2021. We analyzed outcomes using the modified Thrombolysis in the Cerebral Infarction (mTICI) scale and modified Rankin Scale (mRS). Functional outcomes were investigated at 90 days or discharge.

RESULTS

We obtained functional outcomes mRS ≤ 3 patients in 41.6%. The mortality rate was 16.6%. The rate of successful recanalization was 75%. Comparison mRS ≤ 3 and mRS ≥ 4 at 90 days or discharge showed statistical significance in the National Institute of Health Stroke Scale, the location of occluded vessels, and mTICI ≥ 2b at the first pass. Univariable logistic regression analysis indicated that the Alberta Stroke Program Early Computed Tomography Score was a predictor of mRS ≤ 3.

CONCLUSIONS

The efficacy is lower than that of patients aged < 90; however, MT is effective even in patients aged ≥ 90 years. The safety of MT in patients aged ≥ 90 years was similar to that in those aged < 90 years. Neuro-interventionalists should consider predictors and take the best strategies to achieve successful recanalization in patients aged ≥ 90 years with AIS.

Mesenchymal-derived extracellular vesicles enhance microglia-mediated synapse remodeling after cortical injury in aging Rhesus monkeys

Understanding the microglial neuro-immune interactions in the primate brain is vital to developing therapeutics for cortical injury, such as stroke or traumatic brain injury. Our previous work showed that mesenchymal-derived extracellular vesicles (MSC-EVs) enhanced motor recovery in aged rhesus monkeys following injury of primary motor cortex (M1), by promoting homeostatic ramified microglia, reducing injury-related neuronal hyperexcitability, and enhancing synaptic plasticity in perilesional cortices. A focal lesion was induced via surgical ablation of pial blood vessels over lying the cortical hand representation of M1 of aged female rhesus monkeys, that received intravenous infusions of either vehicle (veh) or EVs 24 h and again 14 days post-injury. The current study used this same cohort to address how these injury- and recovery-associated changes relate to structural and molecular interactions between microglia and neuronal synapses. Using multi-labeling immunohistochemistry, high-resolution microscopy, and gene expression analysis, we quantified co-expression of synaptic markers (VGLUTs, GLURs, VGAT, GABARs), microglia markers (Iba1, P2RY12), and C1q, a complement pathway protein for microglia-mediated synapse phagocytosis, in perilesional M1 and premotor cortices (PMC). We compared this lesion cohort to age-matched non-lesion controls (ctr). Our findings revealed a lesion-related loss of excitatory synapses in perilesional areas, which was ameliorated by EV treatment. Further, we found region-dependent effects of EVs on microglia and C1q expression. In perilesional M1, EV treatment and enhanced functional recovery were associated with increased expression of C1q + hypertrophic microglia, which are thought to have a role in debris-clearance and anti-inflammatory functions. In PMC, EV treatment was associated with decreased C1q + synaptic tagging and microglia-spine contacts. Our results suggest that EV treatment may enhance synaptic plasticity via clearance of acute damage in perilesional M1, and thereby preventing chronic inflammation and excessive synaptic loss in PMC. These mechanisms may act to preserve synaptic cortical motor networks and a balanced normative M1/PMC synaptic function to support functional recovery after injury.

Preserving and enhancing mitochondrial function after stroke to protect and repair the neurovascular unit: novel opportunities for nanoparticle-based drug delivery

The neurovascular unit (NVU) is composed of vascular cells, glia, and neurons that form the basic component of the blood brain barrier. This intricate structure rapidly adjusts cerebral blood flow to match the metabolic needs of brain activity. However, the NVU is exquisitely sensitive to damage and displays limited repair after a stroke. To effectively treat stroke, it is therefore considered crucial to both protect and repair the NVU. Mitochondrial calcium (Ca2+) uptake supports NVU function by buffering Ca2+ and stimulating energy production. However, excessive mitochondrial Ca2+ uptake causes toxic mitochondrial Ca2+ overloading that triggers numerous cell death pathways which destroy the NVU. Mitochondrial damage is one of the earliest pathological events in stroke. Drugs that preserve mitochondrial integrity and function should therefore confer profound NVU protection by blocking the initiation of numerous injury events. We have shown that mitochondrial Ca2+ uptake and efflux in the brain are mediated by the mitochondrial Ca2+ uniporter complex (MCUcx) and sodium/Ca2+/lithium exchanger (NCLX), respectively. Moreover, our recent pharmacological studies have demonstrated that MCUcx inhibition and NCLX activation suppress ischemic and excitotoxic neuronal cell death by blocking mitochondrial Ca2+ overloading. These findings suggest that combining MCUcx inhibition with NCLX activation should markedly protect the NVU. In terms of promoting NVU repair, nuclear hormone receptor activation is a promising approach. Retinoid X receptor (RXR) and thyroid hormone receptor (TR) agonists activate complementary transcriptional programs that stimulate mitochondrial biogenesis, suppress inflammation, and enhance the production of new vascular cells, glia, and neurons. RXR and TR agonism should thus further improve the clinical benefits of MCUcx inhibition and NCLX activation by increasing NVU repair. However, drugs that either inhibit the MCUcx, or stimulate the NCLX, or activate the RXR or TR, suffer from adverse effects caused by undesired actions on healthy tissues. To overcome this problem, we describe the use of nanoparticle drug formulations that preferentially target metabolically compromised and damaged NVUs after an ischemic or hemorrhagic stroke. These nanoparticle-based approaches have the potential to improve clinical safety and efficacy by maximizing drug delivery to diseased NVUs and minimizing drug exposure in healthy brain and peripheral tissues.

Feasibility of the Perceive, Recall, Plan and Perform system of intervention for persons with brain injury in community-based rehabilitation: a pilot for a multiple-baseline design study

OBJECTIVES

This paper describes a pilot study investigating the feasibility of the Perceive, Recall, Plan and Perform (PRPP) system for persons with cognitive impairments after acquired brain injury in the context of community-based rehabilitation for older individuals.

DESIGN

The feasibility, acceptability and practicability of the research procedures were evaluated by exploring the effectiveness of the PRPP intervention with non-concurrent multiple baseline designs.

SETTING AND PARTICIPANTS

Three participants (63+years of age) from two health centres were included.

INTERVENTION

In the PRPP intervention, the occupational therapist (OT) supports the participant in applying cognitive strategies in everyday activities to enhance task mastery, with nine sessions of 45-60 min over 3 weeks.

PRIMARY AND SECONDARY OUTCOME MEASURES

The participants completed measurements of five everyday tasks in each phase as dependent variables. PRPP assessment stages 1 and 2 served as the primary and secondary outcome measures, respectively. The percentage of mastery of the tasks and the participants' application of cognitive strategies at baseline acted as a control and was therefore compared with the other phases within the participant. The Goal Attainment Scale and Barthel Index served as generalisation measures. The uncertainties and acceptability of the procedures were also investigated with a procedural checklist and qualitative statements reported in the procedures or noted in dialogue meetings with the conducting OTs.

RESULTS

The procedures were acceptable for the OT and the participants and were feasible if the steps in the research procedure were clearly understood. The target behaviour should be changed to the use of one task with five measurement points instead of measuring five tasks. This can enable the application of recommended analysis methods.

CONCLUSIONS

The outcomes of this study led to a change in the target behaviour and clarification of the research procedure for the planned PRPP intervention study.

TRIAL REGISTRATION NUMBER

NCT05148247.

Association between population changes and the number of endovascular thrombectomies

Background

Randomized controlled trials have demonstrated the efficacy of mechanical thrombectomy (MT) for acute ischemic stroke. However, few studies indicate an association between the number of mechanical thrombectomies and population changes. We aimed to clarify the association between population changes and the number of mechanical thrombectomies for proper allocation of limited medical resources.

Methods

We retrospectively analyzed data from 162 patients who underwent MT for large vessel occlusion at our hospitals and compared the number of mechanical thrombectomies per 100,000 person/year to population changes in five regions covered by our hospitals within 2015-2016 and 2017-2019. We performed a simple linear regression analysis to determine the association between population changes and the number of mechanical thrombectomies.

Results

Overall, the number of mechanical thrombectomies increased from 15.1 to 19. However, a significant decrease was noted in Toya Lake and Sobetsu/Toyoura. Furthermore, there was a significant negative linear correlation between the overall population reduction rate and the number of mechanical thrombectomies and a positive linear correlation between the increased proportion of the population aged >65 years and the number of mechanical thrombectomies.

Conclusion

The number of mechanical thrombectomies may decrease in areas where the overall population reduction rate exceeds 8% or the increased rate of the population aged >65 years is <4%. However, it is necessary to continue establishing a system for MT in areas that have yet to reach these levels.

Biomarkers and the outcomes of ischemic stroke

Biomarkers are measurable substances that could be used as objective indicators for disease diagnosis, responses to treatments, and outcomes predictions. In this review, we summarized the data on a number of important biomarkers including glutamate, S100B, glial fibrillary acidic protein, receptor for advanced glycation end-products, intercellular adhesion molecule-1, von willebrand factor, matrix metalloproteinase-9, interleukin-6, tumor necrosis factor-a, activated protein C, copeptin, neuron-specific enolase, tau protein, gamma aminobutyric acid, blood glucose, endothelial progenitor cells, and circulating CD34-positive cells that could be potentially used to indicate the disease burden and/or predict clinical outcome of ischemic stroke. We examined the relationship between specific biomarkers and disease burden and outcomes and discussed the potential mechanisms underlying the relationship. The clinical significance and implications of these biomarkers were also discussed.

Asialo-rhuEPO as a Potential Neuroprotectant for Ischemic Stroke Treatment

Neuroprotective drugs to protect the brain against cerebral ischemia and reperfusion (I/R) injury are urgently needed. Mammalian cell-produced recombinant human erythropoietin (rhuEPOM) has been demonstrated to have excellent neuroprotective functions in preclinical studies, but its neuroprotective properties could not be consistently translated in clinical trials. The clinical failure of rhuEPOM was thought to be mainly due to its erythropoietic activity-associated side effects. To exploit its tissue-protective property, various EPO derivatives with tissue-protective function only have been developed. Among them, asialo-rhuEPO, lacking terminal sialic acid residues, was shown to be neuroprotective but non-erythropoietic. Asialo-rhuEPO can be prepared by enzymatic removal of sialic acid residues from rhuEPOM (asialo-rhuEPOE) or by expressing human EPO gene in glycoengineered transgenic plants (asialo-rhuEPOP). Both types of asialo-rhuEPO, like rhuEPOM, displayed excellent neuroprotective effects by regulating multiple cellular pathways in cerebral I/R animal models. In this review, we describe the structure and properties of EPO and asialo-rhuEPO, summarize the progress on neuroprotective studies of asialo-rhuEPO and rhuEPOM, discuss potential reasons for the clinical failure of rhuEPOM with acute ischemic stroke patients, and advocate future studies needed to develop asialo-rhuEPO as a multimodal neuroprotectant for ischemic stroke treatment.

Rhythms in barriers and fluids: Circadian clock regulation in the aging neurovascular unit

The neurovascular unit is where two very distinct physiological systems meet: The central nervous system (CNS) and the blood. The permeability of the barriers separating these systems is regulated by time, including both the 24 h circadian clock and the longer processes of aging. An endogenous circadian rhythm regulates the transport of molecules across the blood-brain barrier and the circulation of the cerebrospinal fluid and the glymphatic system. These fluid dynamics change with time of day, and with age, and especially in the context of neurodegeneration. Factors may differ depending on brain region, as can be highlighted by consideration of circadian regulation of the neurovascular niche in white matter. As an example of a potential target for clinical applications, we highlight chaperone-mediated autophagy as one mechanism at the intersection of circadian dysregulation, aging and neurodegenerative disease. In this review we emphasize key areas for future research.

Circvrk1 downregulation attenuates brain microvascular endothelial cell damage induced by oxygen-glucose deprivation through modulating the miR-150-5p/MLLT1 axis

The pivotal regulatory role of circular RNAs (circRNAs) in ischemic stroke (IS) has been expounded. The study aimed to probe the exact role and underlying mechanism of circVRK1 in oxygen-glucose deprivation (OGD)-induced human brain microvascular endothelial cells (HBMECs) injury. HBMECs challenged by OGD were used as in vitro models of IS. Quantitative real-time PCR was used to examine the levels of circVRK1, vaccinia-related kinase 1 (VRK1), miR-150-5p and MLLT1 mRNA. Cell viability, migration angiogenesis ability and death were evaluated by Cell counting kit-8 assay, transwell assay, wound-healing assay, tube formation assay and flow cytometry analysis. All the protein levels were monitored by western blot assay. Enzyme-linked immunosorbent assay was conducted for examining cell oxidative stress. Dual-luciferase reporter assay, RIP assay and RNA pull-down assay were performed to verify the combination between miR-150-5p and circVRK1 or MLLT1. CircVRK1 was upregulated in OGD-treated HBMECs. CircVRK1 knockdown alleviated OGD-caused effects on HBMECs migration, angiogenesis, death, inflammatory response and oxidative stress. Furthermore, circVRK1 could sponge miR-150-5p, and miR-150-5p silencing also mitigated the impact of circVRK1 deficiency on OGD-evoked injury. Besides, MLLT1 acted as a molecular target of miR-150-5p, and the protective influence of miR-150-5p on OGD-induced cell damage was overturned by MLLT1 introduction. CircVRK1 knockdown weakened OGD-evoked injury in HBMECs through modulating miR-150-5p/MLLT1 pathway, and this might supply new insights and probable targets for IS treatment.

Aged lipid-laden microglia display impaired responses to stroke

Microglial cells of the aged brain manifest signs of dysfunction that could contribute to the worse neurological outcome of stroke in the elderly. Treatment with colony-stimulating factor 1 receptor antagonists enables transient microglia depletion that is followed by microglia repopulation after treatment interruption, causing no known harm to mice. We tested whether this strategy restored microglia function and ameliorated stroke outcome in old mice. Cerebral ischemia/reperfusion induced innate immune responses in microglia highlighted by type I interferon and metabolic changes involving lipid droplet biogenesis. Old microglia accumulated lipids under steady state and displayed exacerbated innate immune responses to stroke. Microglia repopulation in old mice reduced lipid-laden microglia, and the cells exhibited reduced inflammatory responses to ischemia. Moreover, old mice with renewed microglia showed improved motor function 2 weeks after stroke. We conclude that lipid deposits in aged microglia impair the cellular responses to ischemia and worsen functional recovery in old mice.

Fibrinogen as a Predictor of Early Neurological Deterioration in Acute Ischemic Stroke - Evidence From the Indian Population

Background

Early neurological deterioration (END) is a common occurrence in ischemic stroke and contributes significantly to poor outcomes. Although multiple factors that predict END have already been identified, the role of fibrinogen - a key component of the coagulation pathway, is controversial.

Objective

To assess the role of fibrinogen in predicting END and poor hospital outcome in patients with acute ischemic stroke.

Design

Single-centre prospective observational study.

Methods

141 patients with acute ischemic stroke were analyzed in this prospective observational study from a single tertiary-care hospital in East India. END was defined as a worsening of ≥2 points on the National Institutes of Health Stroke Scale (NIHSS) within 7 days of admission. A score of 3-5 on the Modified Rankin Scale (mRS), a stroke recurrence event or death during hospital stay was considered poor hospital outcome. We performed univariate analysis using age, sex, body-mass index (BMI), hypertension, diabetes, NIHSS scores, stroke etiology, blood glucose and lipid parameters and plasma fibrinogen to develop a logistic regression model to establish the independent predictors of END and poor outcome.

Results

Age (Odds Ratio (OR) 1.034 [95% CI 1.001-1.069], P = .046), NIHSS score at admission (OR 1.152 [95% CI 1.070-1.240], P < .001) and fibrinogen (OR 1.011 [95%CI 1.006-1.015], P < .001) were independent predictors of END in patients with acute ischemic stroke. Factors independently associated with poor outcome were NIHSS score at admission (OR 1.257 [95% CI 1.150-1.357], P < .001), fasting plasma glucose (OR 1.007 [95% CI 1.001-1.013], P = .020), and fibrinogen [OR 1.004 [95% CI 1.000-1.007], P = .038).

Conclusion

The significant role of fibrinogen in determining neurological worsening and subsequent poor outcomes in patients with acute ischemic stroke may help in early prognostication and guided therapeutic interventions.

Impaired dynamics of precapillary sphincters and pericytes at first-order capillaries predict reduced neurovascular function in the aging mouse brain

The microvascular inflow tract, comprising the penetrating arterioles, precapillary sphincters and first-order capillaries, is the bottleneck for brain blood flow and energy supply. Exactly how aging alters the structure and function of the microvascular inflow tract remains unclear. By in vivo four-dimensional two-photon imaging, we reveal an age-dependent decrease in vaso-responsivity accompanied by a decrease in vessel density close to the arterioles and loss of vascular mural cell processes, although the number of mural cell somas and their alpha smooth muscle actin density were preserved. The age-related reduction in vascular reactivity was mostly pronounced at precapillary sphincters, highlighting their crucial role in capillary blood flow regulation. Mathematical modeling revealed impaired pressure and flow control in aged mice during vasoconstriction. Interventions that preserve dynamics of cerebral blood vessels may ameliorate age-related decreases in blood flow and prevent brain frailty.

Neutrophil dynamics and inflammaging in acute ischemic stroke: A transcriptomic review

Stroke is among the leading causes of death and disability worldwide. Restoring blood flow through recanalization is currently the only acute treatment for cerebral ischemia. Unfortunately, many patients that achieve a complete recanalization fail to regain functional independence. Recent studies indicate that activation of peripheral immune cells, particularly neutrophils, may contribute to microcirculatory failure and futile recanalization. Stroke primarily affects the elderly population, and mortality after endovascular therapies is associated with advanced age. Previous analyses of differential gene expression across injury status and age identify ischemic stroke as a complex age-related disease. It also suggests robust interactions between stroke injury, aging, and inflammation on a cellular and molecular level. Understanding such interactions is crucial in developing effective protective treatments. The global stroke burden will continue to increase with a rapidly aging human population. Unfortunately, the mechanisms of age-dependent vulnerability are poorly defined. In this review, we will discuss how neutrophil-specific gene expression patterns may contribute to poor treatment responses in stroke patients. We will also discuss age-related transcriptional changes that may contribute to poor clinical outcomes and greater susceptibility to cerebrovascular diseases.

Mesencephalic astrocyte-derived neurotrophic factor (MANF): Structure, functions and therapeutic potential

Mesencephalic astrocyte-derived neurotrophic factor (MANF) is a novel evolutionarily conserved protein present in both vertebrate and invertebrate species. MANF shows distinct structural and functional properties than the traditional neurotrophic factors (NTF). MANF is composed of an N-terminal saposin-like lipid-binding domain and a C-terminal SAF-A/B, Acinus and PIAS (SAP) domain connected by a short linker. The two well-described activities of MANF include (1) role as a neurotrophic factor that plays direct neuroprotective effects in the nervous system and (2) cell protective effects in the animal models of non-neuronal diseases, including retinal damage, diabetes mellitus, liver injury, myocardial infarction, nephrotic syndrome, etc. The main objective of the current review is to provide up-to-date insights regarding the structure of MANF, mechanisms regulating its expression and secretion, physiological functions in various tissues and organs, protective effects during aging, and potential clinical applications. Together, this review highlights the importance of MANF in reversing age-related dysfunction and geroprotection.

Effectiveness of the Perceive, Recall, Plan and Perform intervention for persons with brain injury in community-based rehabilitation: protocol for a single-case experimental design with multiple baselines

INTRODUCTION

There is a need for standardised interventions in community-based rehabilitation to improve everyday performance for older adults with cognitive challenges due to acquired brain injury (ABI). The Perceive, Recall, Plan and Perform System (PRPP) of intervention has a growing research base. The intervention is suitable for any client with decreased performance in everyday tasks due to ineffective cognitive strategy application to enhance mastery in performance of needed or desired activities. There is no current evidence on the effectiveness of the PRPP intervention for this population.

PURPOSE

To describe a protocol for a clinical trial that investigates the effectiveness of the PRPP intervention in the context of community-based rehabilitation for persons (65+ years) with difficulties in task performance due to cognitive challenges after ABI.

METHODS AND ANALYSIS

A non-concurrent multiple baseline design across participants with systematic replications (n=6) will be used. Nine sessions of PRPP intervention will be applied by trained occupational therapists in two community-based rehabilitation units. The participants will complete five repeated measurements of everyday tasks as target behaviours. PRPP Assessment stages 1 and 2 serve as outcome measures at baseline, in the intervention period, in the postintervention period and in the follow-up phase. Mastery percentage of the tasks and the participants' application of cognitive strategies at baseline acts as a control and will be compared with the following phases within the participant. Delayed intervention phases act as a control between participants. Goal Attainment Scaling and the Barthel Index will serve as generalisation measures. Data will be analysed using systematic visual inspection of graphical data, descriptions of clinical significance and descriptive statistical analysis.

ETHICS AND DISSEMINATION

This trial, including the data management plan, is approved by The Norwegian Regional Ethics Committee (215391). Results will be published in congresses and scientific journals.

TRIAL REGISTRATION NUMBER

NCT05148247.

Contribution and Effectiveness of Laboratory Testing in the Diagnostic Assessment of Juvenile Ischemic Stroke and Transient Ischemic Attack

Introduction

Strokes in young people require an extensive diagnostic workup to detect their possible several etiopathogenetic mechanisms. There is no consensus indicating what and when it should be tested. The clinical benefit and cost-effectiveness ratio of laboratory tests is unclear as well.

Methods

In one series of 104 consecutive juvenile ischemic stroke patients, under 45 years old, admitted between January 1, 2012, and December 31, 2017, we considered a wide panel of laboratory biomarkers exploring both the patient’s basal status and specific risk factors for thrombotic disorders. To combine conventional and unconventional risk factors, structural defects, and other stroke-related diseases, we defined four categories of etiologic probability. We then studied the contribution of laboratory testing in changing the rate of “definite or probable stroke etiology” and the “proportion of patients with at least one additional risk factor” for stroke.

Results

The mere clinical assessment clarified stroke etiopathogenesis in 31% of cases. Abnormal values of the panel of biomarkers we considered were found in 30.1% of young ischemic strokes, while 11.5% of patients had unclear or borderline values. The benefit of laboratory assessment consisted of a relevant 14% gain in patients with a “definite or probable stroke etiology.”

Conclusion

Several areas of uncertainty are still pending and herein discussed, such as the low re-testing rate during follow-up and the neglect of some relevant biomarkers. However, our results support the importance of laboratory testing in this setting. An improvement of diagnostic protocols in juvenile ischemic stroke would even increase their effectiveness, and this is still an unsolved issue in the field of cerebrovascular diseases. The same age limit, conventionally considered for juvenile stroke, could be better defined according to the effectiveness of both laboratory and clinical assessment in identifying unconventional stroke risk factors.

Clinical outcomes of tranexamic acid in acute hip hemiarthroplasties in frail geriatric patients

BACKGROUND

Tranexamic acid (TXA) has shown to significantly reduce perioperative blood loss in elective orthopedic joint replacement surgery but is yet not implemented in acute hip fracture surgery for elderly patients who are particularly vulnerable to perioperative blood loss and postoperative anemia. Aim of this study is to answer the following questions: 1. Does TXA reduce bleeding associated complications in elderly patients? 2. Does TXA induce thromboembolic complications in elderly patients?

HYPOTHESIS

TXA reduces perioperative blood loss and associated complications in acute hip fracture surgery in geriatric patients.

PATIENTS AND METHODS

In this observational cohort study with prospectively enrolled patients over 65 years of age who received an acute hip hemiarthroplasty, the primary outcome was blood loss, also described as Δ hemoglobin. Secondary outcomes were bleeding associated complications as hematomas. Also, the occurrence of thromboembolic events and mortality were examined.

RESULTS

In total 864 geriatric patients were included of which 235 received TXA and 629 did not. Multivariable analysis showed reduced Δ hemoglobin loss [-0.24 (-0.39; -0.09), p=0.002] and hematomas (OR 0.44 (0.21; 0.91), p=0.026). Pulmonary embolism were diagnosed more frequently after administration of TXA (2% versus 0.3%, p=0.008), without an association with increased 30-day mortality rate (6% versus 8%, p=0.3).

DISCUSSION

TXA reduced perioperative blood loss and associated complications. However, adverse effects of TXA as pulmonary embolisms were found more frequently without effecting postoperative mortality rates. More research is needed to assess adverse effects of intravenous TXA and topical TXA as an alternative for systemic TXA to prevent systemic adverse effects.

LEVEL OF EVIDENCE

III, Observational cohort study.

The trajectories of depressive symptoms and subsequent incident dementia, coronary heart diseases, stroke and all-cause mortality

BACKGROUND

Evidence suggests the occurrence of depressive symptoms in mid- to late-life inflates the risk for ageing-related morbidity compared to people without depressive symptoms. The eventual association between depressive symptoms in mid- to late-life and long-term (over 10-year) risks for incident dementia, coronary heart disease (CHD), stroke, and morbidity is to be established.

METHODS

This longitudinal cohort study utilized Health and Retirement Study (HRS) of U.S residents aged ≥ 50 years who were interviewed every 2-year during follow-up (average follow-up: 11.6 ± 2.85 years). Trajectories of depressive symptoms were assessed by the Center for Epidemiologic Studies Depression (CES-D) scale from 1994 to 2000 at baseline. Incident dementia, CHD, stroke and all-cause mortality were determined from 2000 to 2018.

RESULTS

Among 7810 individuals who were free from dementia, CHD and stroke, five trajectories of depressive symptoms were identified: non-depressed (36.7 %), mild (48.8 %), worsening (7.8 %), improving (4.1 %) and persistent (2.7 %). Compared with those in the non-depressed group, participants with mild, worsening and persistent depressive symptoms had significantly greater hazards of incident dementia (multivariable adjusted hazard ratios and 95 % confidence intervals: 1.32 [1.17-1.48], 1.58 [1.30-1.93], 2.82 [2.17-3.67], respectively), CHD (1.13 [1.03-1.24], 1.47 [1.25-1.73], 1.34 [1.03-1.74], respectively), stroke (1.30 [1.12-1.52], 1.58 [1.23-2.04], 1.71 [1.16-2.53], respectively) and all-cause mortality (1.17 [1.07-1.27], 1.46 [1.27-1.68], 1.66 [1.35-2.06], respectively). The hazards of incident events, except for CHD, were not significantly greater in individuals with improving depressive symptoms.

CONCLUSIONS

The present findings suggest even sub-clinical threshold depressive symptoms were associated with the hazards of ageing related diseases while such associations were not significant with managed depressive symptoms.

Pharmacotherapeutic potential of pomegranate in age-related neurological disorders

Age-related neurological disorders [AND] include neurodegenerative diseases [NDDs] such as Alzheimer's disease [AD] and Parkinson's disease [PD], which are the most prevalent types of dementia in the elderly. It also includes other illnesses such as migraine and epilepsy. ANDs are multifactorial, but aging is their major risk factor. The most frequent and vital pathological features of AND are oxidative stress, inflammation, and accumulation of misfolded proteins. As AND brain damage is a significant public health burden and its incidence is increasing, much has been done to overcome it. Pomegranate (Punica granatum L.) is one of the polyphenol-rich fruits that is widely mentioned in medical folklore. Pomegranate is commonly used to treat common disorders such as diarrhea, abdominal pain, wound healing, bleeding, dysentery, acidosis, microbial infections, infectious and noninfectious respiratory diseases, and neurological disorders. In the current review article, we aimed to summarize the data on the pharmacotherapeutic potentials of pomegranate in ANDs.

SK, Kshetri R, Regmi P, Gyawali P. Dyslipidemia among Patients with Ischemic Stroke in the Department of Medicine of a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

Stroke is a leading cause of morbidity and disability in Asian population. Dyslipidemia is considered a major risk factor for various cardiovascular diseases. The study aimed to find the prevalence of dyslipidemia among patients with ischemic stroke in the Department of Medicine of a tertiary care centre.

Methods

This is a descriptive cross-sectional study conducted among 150 diagnosed cases of ischemic stroke admitted in the Department of Medicine from 1st October, 2020 to 1st October, 2021. The ethical clearance was taken from the Institutional Review Committee (Reference number: 358/2077/78). Fasting blood samples were collected from the patients, serum lipids were measured and atherogenic indices of plasma were calculated. Demographic, anthropometric and cardiovascular risk factors related data were collected. Data were entered in Microsoft Excel 2010 and analysis was using the Statistical Package for the Social Sciences version 22.0. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data, and mean and standard deviation for continuous data.

Results

The prevalence of dyslipidemia among the ischemic stroke patients was 120 (80.00%) (73.60-86.40 at 95% Confidence Interval). High total cholesterol was found in 64 (53.33%) patients, high triglycerides in 70 (58.33%), high low-density lipoprotein cholesterol in 54 (45.00%) and low high-density lipoprotein cholesterol in 51 (42.50%) patients.

Conclusions

The prevalence of dyslipidemia among ischemic stroke patients was higher than the studies done in similar settings.

Keywords

dyslipidemia; ischemic stroke; lipid; prevalence.

Rapid triage for ischemic stroke: a machine learning-driven approach in the context of predictive, preventive and personalised medicine

BACKGROUND

Recognising the early signs of ischemic stroke (IS) in emergency settings has been challenging. Machine learning (ML), a robust tool for predictive, preventive and personalised medicine (PPPM/3PM), presents a possible solution for this issue and produces accurate predictions for real-time data processing.

METHODS

This investigation evaluated 4999 IS patients among a total of 10,476 adults included in the initial dataset, and 1076 IS subjects among 3935 participants in the external validation dataset. Six ML-based models for the prediction of IS were trained on the initial dataset of 10,476 participants (split participants into a training set [80%] and an internal validation set [20%]). Selected clinical laboratory features routinely assessed at admission were used to inform the models. Model performance was mainly evaluated by the area under the receiver operating characteristic (AUC) curve. Additional techniques-permutation feature importance (PFI), local interpretable model-agnostic explanations (LIME), and SHapley Additive exPlanations (SHAP)-were applied for explaining the black-box ML models.

RESULTS

Fifteen routine haematological and biochemical features were selected to establish ML-based models for the prediction of IS. The XGBoost-based model achieved the highest predictive performance, reaching AUCs of 0.91 (0.90-0.92) and 0.92 (0.91-0.93) in the internal and external datasets respectively. PFI globally revealed that demographic feature age, routine haematological parameters, haemoglobin and neutrophil count, and biochemical analytes total protein and high-density lipoprotein cholesterol were more influential on the model's prediction. LIME and SHAP showed similar local feature attribution explanations.

CONCLUSION

In the context of PPPM/3PM, we used the selected predictors obtained from the results of common blood tests to develop and validate ML-based models for the diagnosis of IS. The XGBoost-based model offers the most accurate prediction. By incorporating the individualised patient profile, this prediction tool is simple and quick to administer. This is promising to support subjective decision making in resource-limited settings or primary care, thereby shortening the time window for the treatment, and improving outcomes after IS.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13167-022-00283-4.

Potential Variables for Improved Reproducibility of Neuronal Cell Grafts at Stroke Sites

Interest is growing in using cell replacements to repair the damage caused by an ischemic stroke. Yet, the usefulness of cell transplants can be limited by the variability observed in their successful engraftment. For example, we recently showed that, although the inclusion of donor-derived vascular cells was necessary for the formation of large grafts (up to 15 mm3) at stroke sites in mice, the size of the grafts overall remained highly variable. Such variability can be due to differences in the cells used for transplantation or the host environment. Here, as possible factors affecting engraftment, we test host sex, host age, the extent of ischemic damage, time of transplant after ischemia, minor differences in donor cell maturity, and cell viability at the time of transplantation. We find that graft size at stroke sites correlates with the size of ischemic damage, host sex (females having graft sizes that correlate with damage), donor cell maturity, and host age, but not with the time of transplant after stroke. A general linear model revealed that graft size is best predicted by stroke severity combined with donor cell maturity. These findings can serve as a guide to improving the reproducibility of cell-based repair therapies.

The Role of miR-20 in Health and Disease of the Central Nervous System

Current understanding of the mechanisms underlying central nervous system (CNS) injury is limited, and traditional therapeutic methods lack a molecular approach either to prevent acute phase or secondary damage, or to support restorative mechanisms in the nervous tissue. microRNAs (miRNAs) are endogenous, non-coding RNA molecules that have recently been discovered as fundamental and post-transcriptional regulators of gene expression. The capacity of microRNAs to regulate the cell state and function through post-transcriptionally silencing hundreds of genes are being acknowledged as an important factor in the pathophysiology of both acute and chronic CNS injuries. In this study, we have summarized the knowledge concerning the pathophysiology of several neurological disorders, and the role of most canonical miRNAs in their development. We have focused on the miR-20, the miR-17~92 family to which miR-20 belongs, and their function in the normal development and disease of the CNS.

Sex differences in global disability-adjusted life years due to ischemic stroke: findings from global burden of diseases study 2019

To investigate the sex differences in disability-adjusted life years (DALYs) due to ischemic stroke (IS) by year, location and age. We extracted sex-specific data on DALYs number, age-standardized DALYs rate (ASDR) and all-age DALYs rate of IS by year, location and age from the Global Burden of Diseases study 2019. The estimated annual percentage changes (EAPC) were calculated to evaluate the temporal trend of ASDR. For both sexes, although the ASDR of IS slightly decreased from 1990 to 2019, there has been an 60.3% increase in DALYs number worldwide. Sex difference in DALYs number (men minus women) decreased from − 2.83 million in 1990 to 0.14 million in 2019, while the men to women’s ASDR ratio slightly increased from 1.10 in 1990 to 1.21 in 2019. The sex differences in IS DALYs showed remarkable regional variation. The largest sex differences in DALYs number and ASDR were in China and Vietnam. Middle-aged men had a higher IS DALYs than their age-matched counterparts. High systolic blood pressure accounted for the highest DALYs number in 2019, but the top three attributable risk factors that had the greatest sex differences were tobacco, dietary risk, and alcohol use. Sex differences in IS DALYs varied by year, location and age, mostly attributed to the disproportion of cardiovascular risk factors between sexes. Considering the population growth and aging, it is necessary to monitor the sex difference in IS DALYs in different populations and thus provide evidence for local administration to improve current preventive and management strategies of IS.

Safety and Efficacy of Tenecteplase in Older Patients With Large Vessel Occlusion: A Pooled Analysis of the EXTEND-IA TNK Trials

BACKGROUND AND OBJECTIVES

Detailed study of tenecteplase (TNK) in patients older than 80 years is limited. The objective of our study was to assess the safety and efficacy of TNK at 0.25 and 0.40 mg/kg doses in patients older than 80 years with large vessel occlusion.

METHODS

We performed a pooled analysis of the EXTEND-IA TNK randomized controlled trials (n = 502). Patients were adults presenting with ischemic stroke due to occlusion of the intracranial internal carotid, middle cerebral, or basilar artery presenting within 4.5 hours of symptom onset. We compared the treatment effect of TNK 0.25 mg/kg, TNK 0.40 mg/kg, and alteplase 0.90 mg/kg, stratifying for patient age (>80 years). Outcomes evaluated include 90-day modified Rankin Scale (mRS) score, all-cause mortality, and symptomatic ICH. Treatment effect was adjusted for baseline NIH Stroke Score, age, and time from symptom onset to puncture via mixed effects proportional odds and logistic regression models.

RESULTS

In patients >80 years (n = 137), TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs 4, adjusted common odds ratio (acOR) 2.70, 95% CI 1.23-5.94) and reduced mortality (acOR 0.34, 95% CI 0.13-0.91) vs 0.40 mg/kg. TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs 4, acOR 2.28, 95% CI 1.03-5.05) vs alteplase. No difference in 90-day mRS or mortality was detected between alteplase and TNK 0.40 mg/kg. Symptomatic ICH was observed in 4 patients treated with TNK 0.40 mg/kg, 1 patient treated with alteplase, and 0 patients treated with TNK 0.25 mg/kg. In patients ≤80 years, no differences in 90-day mRS, mortality, or symptomatic ICH were observed among TNK 0.25 mg/kg, alteplase, and TNK 0.40 mg/kg.

DISCUSSION

TNK 0.25 mg/kg was associated with improved 90-day mRS and lower mortality in patients older than 80 years. No differences among the doses were observed in younger patients.

TRIAL REGISTRATION INFORMATION

NCT02388061, NCT03340493.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that tenecteplase 0.25 mg/kg given before endovascular therapy in patients >80 years old with large vessel occlusion stroke is associated with better functional outcomes at 90 days and reduced mortality when compared to tenecteplase 0.40 mg/kg or alteplase 0.90 mg/kg.

Malnutrition and the Risk of Early Neurological Deterioration in Elderly Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

This study aimed to investigate the relationship between malnutrition and early neurological deterioration (END) in elderly patients with acute ischemic stroke in China.

METHODS

We used the registry data in the Third Affiliated Hospital of Nantong University and Nanjing Brain Hospital from June 2019 to January 2021. Malnutrition risk was evaluated by controlling nutritional status score (CONUT), geriatric nutritional risk index (GNRI) and prognostic nutritional index (PNI) score, respectively. END was defined as an increment of at least two points in the total NIHSS score within three days after admission. We evaluated the relationship between malnutrition and END with multivariable logistic regression models and reclassification indexes.

RESULTS

A total of 732 elderly patients with first-ever acute ischemic stroke were included in the study. 243 patients developed END. 5.7%, 21.4%, 4.6% patients were classified as moderate to severe malnutrition by CONUT, GNRI and PNI, respectively. Malnutrition was associated with the risk of END for CONUT (odds ratio [OR], 1.210; 95% confidence interval [CI] 1.092-1.341; P < 0.001), for GNRI (OR, 0.943; 95% CI, 0.919-0.967; P < 0.001), and for PNI (OR, 0.936; 95% CI, 0.908-0.965; P < 0.001) in multivariable logistic regression models using the back-ward selection method. The discriminative ability was 0.763 (95% CI, 0.727-0.798) for CONUT, 0.769 (95% CI, 0.733-0.805) for GNRI and 0.769 (95% CI, 0.733-0.805) for PNI after adjusting for confounders. Besides, adding malnutrition indexes into models made the prediction of END more accurate.

CONCLUSION

Malnutrition was associated with END in elderly Chinese patients with acute ischemic stroke.