Risk factors for ischaemic stroke

Risk of Ischemic Stroke in Relation to Helicobacter pylori Infection and Eradication Status: A Large-Scale Prospective Observational Cohort Study

Background/Aims

: A few studies have suggested the association between Helicobacter pylori (HP) infection and ischemic stroke. However, the impact of HP eradication on stroke risk has not been well evaluated. This study aimed to assess the influence of HP eradication on the incidence of ischemic stroke, considering the potential effect of sex.

Methods

: This prospective observational cohort study was conducted at Seoul National University Bundang Hospital, from May 2003 to February 2023, and involved gastroscopy-based HP testing. Propensity score (PS) matching was employed to ensure balanced groups by matching patients in the HP eradicated group (n=2,803) in a 3:1 ratio with patients in the HP non-eradicated group (n=960). Cox proportional hazard regression analysis was used to evaluate the risk of ischemic stroke.

Results

: Among 6,664 patients, multivariate analysis after PS matching indicated that HP eradication did not significantly alter the risk of ischemic stroke (hazard ratio, 0.531; 95% confidence interval, 0.221 to 1.270; p=0.157). Sex-specific subgroup analyses, both univariate and multivariate, did not yield statistically significant differences. However, Kaplan-Meier analysis revealed a potential trend: the females in the HP eradicated group exhibited a lower incidence of ischemic stroke than those in the HP non-eradicated group, although this did not reach statistical significance (p=0.057).

Conclusions

: This finding suggests that HP eradication might not impact the risk of ischemic stroke. However, there was a trend showing that females potentially had a lower risk of ischemic stroke following HP eradication, though further investigation is required to establish definitive evidence.

Spontaneous spinal cord infarction: a systematic review

Background and objectives

Spontaneous spinal cord infarction (SCInf) is a rare condition resulting in acute neurological impairment. Consensus on diagnostic criteria is lacking, which may present a challenge for the physician. This review aims to analyse the current literature on spontaneous SCInf, focusing on epidemiology, the diagnostic process, treatment strategies and neurological outcomes.

Methods

The study was performed in accordance with a previously published protocol. PubMed, Web of Science and Embase were searched using the keywords 'spontaneous', 'spinal cord', 'infarction' and 'ischaemic'. The eligibility of studies was evaluated in two steps by multiple reviewers. Data from eligible studies were extracted and systematically analysed.

Results

440 patients from 33 studies were included in this systematic review. Analysis of vascular risk factors showed that hypertension was present in 40%, followed by smoking in 30%, dyslipidaemia in 29% and diabetes in 16%. The severity of symptoms at admission according to the American Spinal Injury Association (ASIA) Impairment Scale was score A 19%, score B14%, score C36% and score D32%. The mean follow-up period was 34.8 (±12.2) months. ASIA score at follow-up showed score A 11%, score B 3%, score C 16%, score D 67% and score E 2%. The overall mortality during the follow-up period was 5%. When used, MRI with diffusion-weighted imaging (DWI) supported the diagnosis in 81% of cases. At follow-up, 71% of the patients were able to walk with or without walking aids.

Conclusion

The findings suggest a significant role for vascular risk factors in the pathophysiology of spontaneous SCInf. In the diagnostic workup, the use of DWI along with an MRI may help in confirming the diagnosis. The findings at follow-up suggest that neurological recovery is to be expected, with the majority of patients regaining ambulation. This systematic review highlights gaps in the literature and underscores the necessity for further research to establish diagnostic criteria and treatment guidelines.

Hyperglycaemia perturbs blood-brain barrier integrity through its effects on endothelial cell characteristics and function

Breakdown of blood-brain barrier (BBB) represents a key pathology in hyperglycemia-mediated cerebrovascular damage after an ischemic stroke. As changes in the level and nature of vasoactive agents released by endothelial cells (ECs) may contribute to BBB dysfunction, this study first explored the specific impact of hyperglycemia on EC characteristics and secretome. It then assessed whether secretome obtained from ECs subjected to normoglycaemia or hyperglycemia might regulate pericytic cytokine profile differently. Using a triple cell culture model of human BBB, composed of brain microvascular EC (BMEC), astrocytes and pericytes, this study showed that exposure to hyperglycemia (25 mM D-glucose) for 72 h impaired the BBB integrity and function as evidenced by decreases in transendothelial electrical resistance and increases in paracellular flux of sodium fluorescein. Dissolution of zonula occludens-1, a tight junction protein, and appearance of stress fibers appeared to play a key role in this pathology. Despite elevations in angiogenin, endothelin-1, interleukin-8 and basic fibroblast growth factor levels and a decrease in placental growth factor levels in BMEC subjected to hyperglycemia vs normoglycaemia (5.5 mM D-glucose), tubulogenic capacity of BMECs remained similar in both settings. Similarly, pericytes subjected to secretome obtained from hyperglycemic BMEC released higher quantities of macrophage migration inhibitory factor and serpin and lower quantities of monocyte chemoattractant protein-1, intercellular adhesion molecule, interleukin-6 and interleukin-8. Taken together these findings indicate the complexity of the mechanisms leading to BBB disruption in hyperglycemic settings and emphasize the importance of endothelial cell-pericyte axis in the development of novel therapeutic strategies.

Mendelian randomization of chronic hepatitis B and cardiovascular disease

Background

Evidence from observational studies suggests that chronic hepatitis B (CHB) is associated with cardiovascular disease (CVD). However, results have been inconsistent and causality remains to be established. We utilized two-sample Mendelian randomization (MR) to investigate potential causal associations between CHB and CVD, including atherosclerosis, coronary heart disease, hypertension, and ischemic stroke.

Methods

The analysis was conducted through genome-wide association studies (GWAS), considering chronic hepatitis B as the exposure and cardiovascular disease as the endpoint. The primary method for evaluating causality in this analysis was the inverse-variance weighted (IVW) technique. Additionally, we employed the weighted median, MR-Egger regression, weighted mode, and simple mode methods for supplementary analyses. Finally, heterogeneity tests, sensitivity analyses, and multiple effects analyses were conducted.

Results

In a random-effects IVW analysis, we found that genetic susceptibility to chronic hepatitis B was associated with an increased risk of atherosclerosis [OR = 1.048, 95% CI (1.022-1.075), P = 3.08E-04], as well as an increased risk of coronary heart disease [OR = 1.039, 95% CI (1.006-1.072), P = 0.020]. However, it was found to be inversely correlated with ischemic stroke risk [OR = 0.972, 95% CI (0.957-0.988), P = 4.13E-04]. There was no evidence that chronic hepatitis B was associated with hypertension [OR = 1.021, 95% CI (0.994-1.049), P = 0.121].

Conclusion

Our research indicates that chronic hepatitis B has a correlation with an elevated risk of developing atherosclerosis and coronary heart disease, while it is associated with a decreased risk of experiencing an ischemic stroke.

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.

Association of thrombopoietin-related drugs with thromboembolic events: Mendelian randomization and a real-world study

Background

Studies have shown conflicting results when using thrombopoietin-related drugs (TPORD) for thromboembolic events (TEEs). Our study aimed to explore the correlation between TPORDs and TEEs.

Method

Drug-targeted Mendelian randomization (MR) and multivariate MR (MVMR) analysis were used to explore the causal relationship between TPORDs and TEEs such as venous thromboembolism (VTE), deep vein thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI) and ischemic stroke (STR). At the same time, a real-world study was conducted by extracting adverse events (AEs) from the FDA Adverse Event Reporting System database included in AERSMine to further validate our findings.

Outcome

In drug-target MR, TPORDs were associated with VTE (OR = 1.193, 95% confidence interval (CI): 1.001-1.423, p = 0.049], DVT (OR = 1.321, 95% CI: 1.027-1.700, p = 0.030), MI (OR = 1.216, 95% CI: 1.010-1.464, p = 0.039), STR (OR = 1.224, 95% CI: 1.021-1.468, p = 0.029). VTE/DVT/STR remained stable in MVMR (VTE: OR = 1.3, 95% CI: 1.187-1.422, p < 0.001; DVT: OR = 1.465,95% CI:1.285-1.671, p < 0.001; STR: OR = 1.119, 95% CI: 1.018-1.229, p = 0.019) and real-world studies [lower bound of proportional reporting ratio (ROR) greater than 1]. The significance of myocardial infarction disappeared in MVMR (OR = 0.996, 95% CI: 0.894-1.109, p = 0.942) and in real-world studies (lower ROR lower than 1). There was no evidence of a causal relationship between TPORD and PE (OR = 1.244, 95% CI: 0.969-1.597, p = 0.087), but it generated a signal from a real-world study (lower bound of ROR greater than 1).

Conclusion

This study suggests that TPORDs may be associated with an increased risk of TEEs, particularly AEs leading to VTE/DVT/STR. In addition, the relationship between TPORDs and PE/MI is debatable and requires more research.

Providing clinical context to the spatio-temporal analysis of 4D CT perfusion to predict acute ischemic stroke lesion outcomes

Acute ischemic stroke is a leading cause of mortality and morbidity worldwide. Timely identification of the extent of a stroke is crucial for effective treatment, whereas spatio-temporal (4D) Computed Tomography Perfusion (CTP) imaging is playing a critical role in this process. Recently, the first deep learning-based methods that leverage the full spatio-temporal nature of perfusion imaging for predicting stroke lesion outcomes have been proposed. However, clinical information is typically not integrated into the learning process, which may be helpful to improve the tissue outcome prediction given the known influence of various factors (i.e., physiological, demographic, and treatment factors) on lesion growth. Cross-attention, a multimodal fusion strategy, has been successfully used to combine information from multiple sources, but it has yet to be applied to stroke lesion outcome prediction. Therefore, this work aimed to develop and evaluate a novel multimodal and spatio-temporal deep learning model that utilizes cross-attention to combine information from 4D CTP and clinical metadata simultaneously to predict stroke lesion outcomes. The proposed model was evaluated using a dataset of 70 acute ischemic stroke patients, demonstrating significantly improved volume estimates (mean error = 19 ml) compared to a baseline unimodal approach (mean error = 35 ml, p< 0.05). The proposed model allows generating attention maps and counterfactual outcome scenarios to investigate the relevance of clinical variables in predicting stroke lesion outcomes at a patient level, helping to provide a better understanding of the model's decision-making process.

Predicting infarction growth rate II using ANFIS-based binary particle swarm optimization technique in ischemic stroke

Ischemic stroke, a severe medical condition triggered by a blockage of blood flow to the brain, leads to cell death and serious health complications. One key challenge in this field is accurately predicting infarction growth - the progressive expansion of damaged brain tissue post-stroke. Recent advancements in artificial intelligence (AI) have improved this prediction, offering crucial insights into the progression dynamics of ischemic stroke. One such promising technique, the Adaptive Neuro-Fuzzy Inference System (ANFIS), has shown potential, but it faces the 'curse of dimensionality' and long training times as the number of features increased. This paper introduces an innovative, automatic method that combines Binary Particle Swarm Optimization (BPSO) with ANFIS architecture, achieves reduction in dimensionality by reducing the number of rules and training time. By analyzing the Pearson correlation coefficients and P-values, we selected clinically relevant features strongly correlated with the Infarction Growth Rate (IGR II), extracted after one CT scan. We compared our model's performance with conventional ANFIS and other machine learning techniques, including Support Vector Regressor (SVR), shallow Neural Networks, and Linear Regression. •Inputs: Real data about ischemic stroke represented by clinically relevant features.•Output: An innovative model for more accurate and efficient prediction of the second infarction growth after the first CT scan.•Results: The model achieved commendable statistical metrics, which include a Root Mean Square Error of 0.091, a Mean Squared Error of 0.0086, a Mean Absolute Error of 0.064, and a Cosine distance of 0.074.

Protective effect of MitoTEMPO against cardiac dysfunction caused by ischemia-reperfusion: MCAO stroke model study

PURPOSE

Neurological impairments are the leading cause of post-stroke mortality, while stroke-related cardiovascular diseases rank second in significance. This study investigates the potential protective effects of MitoTEMPO (2,2,6,6-tetramethyl-4-[[2-(triphenylphosphonio) acetyl] amino]-1-piperidinyloxy, monochloride, monohydrate), a mitochondria-specific antioxidant, against cardiac and neurological complications following stroke. The objective is to assess whether MitoTEMPO can be utilized as a protective agent for individuals with a high risk of stroke.

MATERIALS AND METHODS

Seventeen-week-old male Wistar Albino rats were randomly assigned to three groups: SHAM, ischemia-reperfusion and MitoTEMPO + ischemia-reperfusion (MitoTEMPO injection 0.7 mg/kg/day for 14 days). The SHAM group underwent a sham operation, while the ischemia-reperfusion group underwent 1-h middle cerebral artery occlusion followed by three days of reperfusion. Afterwards, noninvasive thoracic electrical bioimpedance and electrocardiography measurements were taken, and sample collection was performed for histological and biochemical examinations.

RESULTS

Our thoracic electrical bioimpedance and electrocardiography findings demonstrated that MitoTEMPO exhibited a protective effect on most parameters affected by ischemia-reperfusion compared to the SHAM group. Furthermore, our biochemical and histological data revealed a significant protective effect of MitoTEMPO against oxidative damage.

CONCLUSIONS

The findings suggest that both ischemia-reperfusion-induced cardiovascular abnormalities and the protective effect of MitoTEMPO may involve G-protein coupled receptor-mediated signaling mechanisms. This study was conducted with limitations including a single gender, a uniform age group, a specific stroke model limited to middle cerebral artery, and pre-scheduled only one ischemia-reperfusion period. In future studies, addressing these limitations may enable the implementation of preventive measures for individuals at high risk of stroke.

Cynaropicrin Averts the Oxidative Stress and Neuroinflammation in Ischemic/Reperfusion Injury Through the Modulation of NF-kB

Cerebral ischemia and successive reperfusion are the prevailing cause of cerebral stroke. Currently cerebral stroke is considered to be one of the prior causes for high mortality, disability, and morbidity. Cynaropicrin, a sesquiterpene lactone, exhibits various pharmacologic properties and also has an anti-inflammatory property associated with the suppression of the key pro-inflammatory NF-κB pathway. The protective effect of cynaropicrin against oxidative stress and neuroinflammation during CIR injury through the modulation of NF-κB pathway was studied in the current investigation. The experimental rats split into 5 groups as sham-operated control group (group 1), middle cerebral artery occlusion (MCAO)-induced rats (group 2), MCAO rats treated with cynaropicrin (diluted in saline) immediately 2 h after MCAO with 5, 10, and 25 mg/kg administration orally were designated as groups 3, 4, and 5, respectively. In MCAO-induced animals, the severity of ischemic was evident by the elevated level nitrate, MDA, MMPs, inflammatory mediators, Bax, caspase-3, and NF-κB. The level of Nrf-2, antioxidant enzymes, Bcl-2, and IL-10 was reduced in the MCAO-induced animals. Treatment with cynaropicrin in dosage-based manner increased the level of antioxidant enzymes, IL-10, Nrf-2, and Bcl-2 in the animals which indicates the antioxidative effect of cynaropicrin. The level of nitrate, MDA, MMPs, proinflammatory cytokines, inflammatory mediators, Bax, caspase-3, and NF-κB was reduced in the rats treated with cynaropicrin in a dosage-based manner. Experimental animals treated with cynaropicrin in a dosage-dependent way showed a defensive mechanism against oxidative stress and neuroinflammation by inhibiting the NF-κB pathway.

Potential enhancement of post-stroke angiogenic response by targeting the oligomeric aggregation of p53 protein

Tumor suppressor gene p53 and its aggregate have been found to be involved in many angiogenesis-related pathways. We explored the possible p53 aggregation formation mechanisms commonly occur after ischemic stroke, such as hypoxia and the presence of reactive oxygen species (ROS). The angiogenic pathways involving p53 mainly occur in nucleus or cytoplasm, with one exception that occurs in mitochondria. Considering the high mitochondrial density in brain and endothelial cells, we proposed that the cyclophilin D (CypD)-dependent vascular endothelial cell (VECs) necrosis pathway occurring in the mitochondria is one of the major factors that affects angiogenesis. Hence, targeting p53 aggregation, a key intermediate in the pathway, could be an alternative therapeutic target for post-stroke management.

Unveiling the Burden of Miscoding and Misclassification in Stroke Mortality: Analysis of Multiple Cause-of-Death Data in Mexico

BACKGROUND

The prevalence of risk factors for cerebrovascular diseases in Mexico is increasing although stroke mortality declined from 1990 to 2010, without meaningful changes afterward. While improving access to adequate prevention and care could explain this trend, miscoding and misclassification in death certificates need to be assessed to unveil the true burden of stroke in Mexico. Practices in death certification along with the presence of multi-morbidity could contribute to this distortion. Analyses of multiple causes of death could reveal ill-defined stroke deaths, providing a glimpse of this bias.

METHODS

Cause-of-death information from 4,262,666 death certificates in Mexico from 2009 to 2015, was examined to determine the extent of miscoding and misclassification on the true burden of stroke. Age-standardized mortality rates per 100,000 inhabitants (ASMR) were calculated for stroke as underlying and multiple causes of death, by sex and state. Deaths were classified following international standards as ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and unspecified, which were kept as an independent category to measure miscoding. To approximate misclassification, we compared ASMR under three misclassification scenarios: (1) current (the status quo); (2) moderate, which includes deaths from selected causes mentioning stroke; and (3) high which includes all deaths mentioning stroke. National and subnational data were analyzed to search for geographical patterns.

RESULTS

The burden of stroke in Mexico is underreported due to miscoding and misclassification. Miscoding is an important issue since almost 60% of all stroke deaths are registered as unspecified. Multiple cause analysis indicates that stroke ASMR could increase 39.9%-52.9% of the current ASMR under moderate and high misclassification scenarios, respectively. Both problems indicate the need to improve death codification procedures and cause-of-death classification.

CONCLUSIONS

Miscoding and misclassification lead to underestimation of the burden of stroke in Mexico. Stroke deaths are underreported when other important causes coexist, being diabetes the most frequent.

Measures to ensure safety during telerehabilitation of people with stroke: A scoping review

BACKGROUND

Measures used to prevent adverse events during the implementation of exercise sessions delivered via telerehabilitation can be varied, ranging from simple telephone monitoring to synchronous therapist-led sessions. However, this information is scattered in the literature, as evidence synthesis studies have only addressed the safety, satisfaction, and effectiveness aspects of exercise delivered via telerehabilitation.

AIMS

This scoping review aims to describe that measures are used to ensure safety during exercise sessions delivered to people with stroke through telerehabilitation, as reported by authors of primary studies. Secondarily, it describes the designs most frequently used to notify the effects of telerehabilitation and evidence level, the characteristics of the participants and type of stroke, and the characteristics of telerehabilitation.

SUMMARY OF REVIEW

A scoping review was conducted according to the Joana Briggs Institute (JBI) recommendations. A systematic search of MEDLINE (Ovid), Embase (Ovid), CENTRAL, and CINHAL was conducted from inception to August 2022, and a review of systematic review references on the topic. We included primary studies that enrolled adults with stroke who underwent exercise delivered via telerehabilitation. Two independent reviewers performed study selection and data extraction, and disagreements were resolved by consensus or a third reviewer. A qualitative analysis of the information was performed. One hundred seven primary studies (3991 participants) published between 2002 and 2022 were included. Most studies were case series (43%) and rated with an Oxford level of evidence of "4" (55.3%). Regarding randomized clinical trials, half included 53 or more participants (IQR 26.75 to 81). Most studies applied the exercises via asynchronous telerehabilitation (55.1%), of which only ten reported measures to avoid adverse events. Some of the measures included assessing the location where exercises are to be performed, only using a seated position, and using live warning systems that prevent or stop exercises when they are risky.

CONCLUSIONS

Reporting of measures implemented to prevent adverse events during exercise delivery via asynchronous telerehabilitation is scarce. Future primary studies should always consider reporting adverse events related to exercise delivery via telerehabilitation and strategies implemented to decrease the incidence of these unwanted safety events.

REGISTRATION NUMBER

INPLASY202290104.

Red blood cell distribution width combined with age as a predictor of acute ischemic stroke in stable COPD patients

Aim

This retrospective study aimed to investigate the independent clinical variables associated with the onset of acute cerebral ischemic stroke (AIS) in patients with stable chronic obstructive pulmonary disease (COPD).

Method

A total of 244 patients with COPD who had not experienced a relapse within 6 months were included in this retrospective study. Of these, 94 patients hospitalized with AIS were enrolled in the study group, and the remaining 150 were enrolled in the control group. Clinical data and laboratory parameters were collected for both groups within 24 h after hospitalization, and the data of the two groups were statistically analyzed.

Results

The levels of age, white blood cell (WBC), neutrophil (NEUT), glucose (GLU), prothrombin time (PT), albumin (ALB), and red blood cell distribution width (RDW) were different in the two groups (P < 0.01). Logistic regression analysis showed that age, WBC, RDW, PT, and GLU were independent risk factors for the occurrence of AIS in patients with stable COPD. Age and RDW were selected as new predictors, and the receiver operating characteristic curves (ROC) were plotted accordingly. The areas under the ROC curves of age, RDW, and age + RDW were 0.7122, 0.7184, and 0.7852, respectively. The sensitivity was 60.5, 59.6, and 70.2%, and the specificity was 72.4, 86.0, and 60.0%, respectively.

Conclusion

The combination of RDW and age in patients with stable COPD might be a potential predictor for the onset of AIS.

Voiding Dysfunction Due to Urethral Sphincter Dysfunction Might Be an Early Neurological Presentation of Central Nervous System Disorders in Aged Patients

PURPOSE

To investigate the incidence of central nervous system (CNS) diseases in adult patients with voiding dysfunction and videourodynamics (VUDS) proven urethral sphincter dysfunction.

METHODS

This retrospective analysis reviewed the medical charts of patients aged > 60 years who underwent VUDS for non-prostatic voiding dysfunction from 2006 to 2021. A chart review was performed to search for the occurrence and treatment of CNS diseases after the VUDS examination up to 2022. The diagnosis of CNS disease, such as cerebrovascular accidents (CVA), Parkinson's disease (PD), and dementia, by neurologists was also retrieved from the charts. Based on the VUDS findings, patients were divided into the following subgroups: dysfunctional voiding (DV), poor relaxation of the external sphincter (PRES), and hypersensitive bladder (HSB) and coordinated sphincter subgroups. The incidence of CVA, PD, and dementia in each subgroup was recorded and compared among them using one-way analysis of variance (ANOVA).

RESULTS

A total of 306 patients were included. VUDS examinations revealed DV in 87 patients, PRES in 108, and HSB in 111. Among them, 36 (11.8%) patients had CNS disease, including CVA in 23 (7.5%), PD in 4 (1.3%), and dementia in 9 (2.9%). Among the three subgroups, the DV group had the highest incidence rate of CNS disease (n = 16, 18.4%), followed by PRES (n = 12, 11.1%) and HSB (n = 8, 7.2%). However, no significant difference was noted in the incidence of CNS disease across the three subgroups. Nevertheless, the incidence of CNS disease was higher in patients with DV and PRES than that in the general population.

CONCLUSIONS

The incidence of CNS diseases was high in patients aged > 60 years with voiding dysfunction due to urethral sphincter dysfunction. Patients with VUDS-confirmed DV had the highest incidence of CNS disease among the three subgroups.

COVID-19, Blood Lipid Changes, and Thrombosis

Although there is increasing evidence that oxidative stress and inflammation induced by COVID-19 may contribute to increased risk and severity of thromboses, the underlying mechanism(s) remain to be understood. The purpose of this review is to highlight the role of blood lipids in association with thrombosis events observed in COVID-19 patients. Among different types of phospholipases A₂ that target cell membrane phospholipids, there is increasing focus on the inflammatory secretory phospholipase A₂ IIA (sPLA₂-IIA), which is associated with the severity of COVID-19. Analysis indicates increased sPLA₂-IIA levels together with eicosanoids in the sera of COVID patients. sPLA₂ could metabolise phospholipids in platelets, erythrocytes, and endothelial cells to produce arachidonic acid (ARA) and lysophospholipids. Arachidonic acid in platelets is metabolised to prostaglandin H2 and thromboxane A₂, known for their pro-coagulation and vasoconstrictive properties. Lysophospholipids, such as lysophosphatidylcholine, could be metabolised by autotaxin (ATX) and further converted to lysophosphatidic acid (LPA). Increased ATX has been found in the serum of patients with COVID-19, and LPA has recently been found to induce NETosis, a clotting mechanism triggered by the release of extracellular fibres from neutrophils and a key feature of the COVID-19 hypercoagulable state. PLA2 could also catalyse the formation of platelet activating factor (PAF) from membrane ether phospholipids. Many of the above lipid mediators are increased in the blood of patients with COVID-19. Together, findings from analyses of blood lipids in COVID-19 patients suggest an important role for metabolites of sPLA₂-IIA in COVID-19-associated coagulopathy (CAC).

Outgrowth Endothelial Cell Conditioned Medium Negates TNF-α-Evoked Cerebral Barrier Damage: A Reverse Translational Research to Explore Mechanisms

Improved understanding of the key mechanisms underlying cerebral ischemic injury is essential for the discovery of efficacious novel therapeutics for stroke. Through detailed analysis of plasma samples obtained from a large number of healthy volunteers (n = 90) and ischemic stroke patients (n = 81), the current study found significant elevations in the levels of TNF-α at baseline (within the first 48 h of stroke) and on days 7, 30, 90 after ischaemic stroke. It then assessed the impact of this inflammatory cytokine on an in vitro model of human blood-brain barrier (BBB) and revealed dramatic impairments in both barrier integrity and function, the main cause of early death after an ischemic stroke. Co-treatment of BBB models in similar experiments with outgrowth endothelial cell-derived conditioned media (OEC-CM) negated the deleterious effects of TNF-α on BBB. Effective suppression of anti-angiogenic factor endostatin, stress fiber formation, oxidative stress, and apoptosis along with concomitant improvements in extracellular matrix adhesive and tubulogenic properties of brain microvascular endothelial cells and OECs played an important role in OEC-CM-mediated benefits. Significant increases in pro-angiogenic endothelin-1 and monocyte chemoattractant protein-1 in OEC-CM compared to the secretomes of OEC and HBMEC, detected by proteome profiling assay, accentuate the beneficial effects of OEC-CM. In conclusion, this reverse translational study identifies TNF-α as an important mediator of post-ischemic cerebral barrier damage and proposes OEC-CM as a potential vasculoprotective therapeutic strategy by demonstrating its ability to regulate a wide range of mechanisms associated with BBB function. Clinical trial registration NCT02980354.

Meta-Analysis and Multivariate GWAS Analyses in 80,950 Individuals of African Ancestry Identify Novel Variants Associated with Blood Pressure Traits

High blood pressure (HBP) has been implicated as a major risk factor for cardiovascular diseases in several populations, including individuals of African ancestry. Despite the elevated burden of HBP-induced cardiovascular diseases in Africa and other populations of African descent, limited genetic studies have been carried out to explore the genetic mechanism driving this phenomenon. We performed genome-wide association univariate and multivariate analyses of both systolic (SBP) and diastolic blood pressure (DBP) traits in 80,950 individuals of African ancestry. We used summary statistics data from six independent cohorts, including the African Partnership for Chronic Disease Research (APCDR), the UK Biobank, and the Million Veteran Program (MVP). FUMA was used to annotate, prioritize, visualize, and interpret our findings to gain a better understanding of the molecular mechanism(s) underlying the genetics of BP traits. Finally, we undertook a Bayesian fine-mapping analysis to identify potential causal variants. Our meta-analysis identified 10 independent variants associated with SBP and 9 with DBP traits. Whilst our multivariate GWAS method identified 21 independent signals, 18 of these SNPs have been previously identified. SBP was linked to gene sets involved in biological processes such as synapse assembly and cell-cell adhesion via plasma membrane adhesion. Of the 19 independent SNPs identified in the BP meta-analysis, only 11 variants had posterior probability (PP) of > 50%, including one novel variant: rs562545 (MOBP, PP = 77%). To facilitate further research and fine-mapping of high-risk loci/variants in highly susceptible groups for cardiovascular disease and other related traits, large-scale genomic datasets are needed. Our findings highlight the importance of including ancestrally diverse populations in large GWASs and the need for diversity in genetic research.

Effects of comorbidity on post-acute outcomes in acquired brain injury: ABI-RESTaRT 1991-2020

BACKGROUND

Current understanding of comorbidities associated with acquired brain injury (ABI) and the effects on post-acute ABI outcomes is poor.

OBJECTIVE

To describe the prevalence, severity and patterns of comorbidity for the pre-injury, acute and post-acute phases, and to examine the effects of post-acute comorbidities on functional independence and length of stay (LOS) at discharge from post-acute care.

METHODS

Retrospective whole-population cohort study of n = 1,011 individuals with traumatic (TBI) or non-traumatic brain injury (NTBI), or eligible neurologic conditions admitted to a post-acute neurorehabilitation and disability support service in Western Australia (WA) between 1991 and 2020. Comorbidities were ascertained from internal electronic medical records and linked hospital and emergency department data from the WA Data Linkage System. We measured comorbidities across 14 body systems using the Cumulative Illness Rating Scale (CIRS) and Elixhauser Comorbidity Index (ECI), and functional independence with the UK Functional Independence Measure and Functional Assessment Measure (UK FIM+FAM). We used multilevel mixed-effect regression models to determine the effects of comorbidity on post-acute outcomes.

RESULTS

NTBI was the most common diagnosis (54%), followed by TBI (34%) and neurologic conditions (10%). Pre-injury comorbidities were present in over half the cohort. Comorbidity prevalence increased significantly from 57% to 84% (∆+27%) and severity (mean ECI score) increased significantly from 2.1 to 13.8 (∆+11.7) between pre-injury and the acute phase and remained elevated at admission to post-acute services (82%, mean ECI score 7.3). Psychiatric comorbidity was the most prevalent (56%) and was associated with significantly poorer functional outcomes at discharge and an increase in LOS of 6.5 months. Genitourinary, musculoskeletal, eye, ear nose and throat, and renal comorbidities also had significant effects on post-acute outcomes.

CONCLUSIONS

ABI has a long-term impact on multiple body systems. Identification and management of comorbidities is critical to maximize functional outcomes and reduce the cost of post-acute care.

Molecular mechanisms underlying some major common risk factors of stroke

Ischemic and hemorrhagic strokes are the most common known cerebrovascular disease which can be induced by modifiable and non-modifiable risk factors. Age and race are the most common non-modifiable risk factors of stroke. However, hypertension, diabetes, obesity, dyslipidemia, physical inactivity, and cardiovascular disorders are major modifiable risk factors. Understanding the molecular mechanism mediating each of these risk factors is expected to contribute significantly to reducing the risk of stroke, preventing neural damage, enhancing rehabilitation, and designing suitable treatments. Abnormalities in the structure of the blood-brain barrier and blood vessels, thrombosis, vasoconstriction, atherosclerosis, reduced cerebral blood flow, neural oxidative stress, inflammation, and apoptosis, impaired synaptic transmission, excitotoxicity, altered expression/activities of many channels and signaling proteins are the most knows mechanisms responsible for stroke induction. However, the molecular role of risk factors in each of these mechanisms is not well understood and requires a lot of search and reading. This review was designed to provide the reader with a single source of information that discusses the current update of the prevalence, pathophysiology, and all possible molecular mechanisms underlying some major risk factors of stroke namely, hypertension, diabetes mellitus, dyslipidemia, and lipid fraction, and physical inactivity. This provides a full resource for understanding the molecular effect of each of these risk factors in stroke.

Fishing for health: Neighborhood variation in fish intake, fish quality and association with stroke risk among older adults in the Cardiovascular Health Study

BACKGROUND AND AIMS

Fish consumption has been associated with better health outcomes. Dietary patterns may vary substantially by neighborhood of residence. However, it is unclear if the benefits of a healthy diet are equivalent in different communities. This study examines associations of fish consumption with stroke incidence and stroke risk factors, and whether these differ by neighborhood socioeconomic status (NSES).

METHODS AND RESULTS

We studied 4007 participants in the Cardiovascular Health Study who were 65 years or older and recruited between 1989 and 1990 from 4 US communities. Outcomes included fish consumption type (bakes/broiled vs. fried) and frequency, stroke incidence, and stroke risk factors. Multilevel regressions models were used to estimate fish consumption associations with clinical outcomes. Lower NSES was associated with higher consumption of fried fish (aOR = 1.47, 95% CI: 1.10-1.98) and lower consumption of non-fried fish (0.64, 0.47-0.86). Frequent fried fish (11.9 vs. 9.2 person-years for at least once weekly vs. less than once a month, respectively) and less frequent non-fried fish (17.7 vs. 9.6 person-years for less than once a month vs. at least once weekly, respectively) were independently associated with an increased risk of stroke (p-values < 0.05). However, among those with similar levels of healthy fish consumption, residents with low NSES had less benefit on stroke risk reduction, compared with high NSES.

CONCLUSION

Fish consumption type and frequency both impact stroke risk. Benefits of healthy fish consumption differ by neighborhood socioeconomic status.

Role of Uncoupling Protein 2 Gene Polymorphisms on the Risk of Ischemic Stroke in a Sardinian Population

The mitochondrial uncoupling protein 2 (UCP2) acts as an anion transporter and as an antioxidant factor able to reduce the reactive oxygen species level. Based on its effects, UCP2 prevents the membrane lipids, proteins, and DNA damage while preserving normal cellular functions. Many variants have been identified within the human UCP2. Some of them were associated with a higher risk of obesity, diabetes and cardiovascular diseases in different populations. UCP2 appears a suitable candidate also for the risk of ischemic stroke. In the current study, we investigated the possible association between few variants of UCP2 (rs659366, rs660339, rs1554995310) and the risk of ischemic stroke in a genetically homogenous cohort of cases and controls selected in Sardinia Island. This population has been previously analysed for other candidate genes. A total of 250 cases of ischemic stroke and 241 controls were enrolled in the study. The allelic/genotypic distribution of the 3 UCP2 variants was characterized and compared among cases and controls. The results of our study confirmed known risk factors for ischemic stroke: age, history of smoking, hypertension, hypercholesterolemia, and atrial fibrillation. No association was found between the 3 UCP2 variants and the risk of ischemic stroke in our Sardinian cohort.

A Systemic Review of the Integral Role of TRPM2 in Ischemic Stroke: From Upstream Risk Factors to Ultimate Neuronal Death

Ischemic stroke causes a heavy health burden worldwide, with over 10 million new cases every year. Despite the high prevalence and mortality rate of ischemic stroke, the underlying molecular mechanisms for the common etiological factors of ischemic stroke and ischemic stroke itself remain unclear, which results in insufficient preventive strategies and ineffective treatments for this devastating disease. In this review, we demonstrate that transient receptor potential cation channel, subfamily M, member 2 (TRPM2), a non-selective ion channel activated by oxidative stress, is actively involved in all the important steps in the etiology and pathology of ischemic stroke. TRPM2 could be a promising target in screening more effective prophylactic strategies and therapeutic medications for ischemic stroke.

Post-Stroke Outcomes of Patients with Chronic Obstructive Pulmonary Disease

Introduction: Research has shown that patients with ischemic stroke and coexisting obstructive respiratory disorders have worse clinical status on admission and increased long-term mortality. Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of stroke, and the risk is even greater after exacerbation of COPD. Moreover, COPD and stroke share major risk factors, which are advancing age and smoking. The aim of this study was to analyze the incidence of complications and mortality in acute ischemic stroke (AIS) patients with and without COPD. Material and methods: We analyzed prospectively collected data of 1022 patients with acute is-chemic stroke hospitalized in a district general hospital. The patients were divided into two groups—with coexisting COPD and without COPD. Results: Logistic regression analysis, which allowed for potential confounders, showed an association between coexisting COPD and the fol-lowing complications in acute ischemic stroke patients: heart failure (OR = 1.879, p = 0.048), atrial fibrillation (OR = 4.746, p = 0.012), delirium (OR = 2.803, p < 0.001), pneumonia (OR = 2.424, p = 0.005), bronchospasm (OR = 3.400, p = 0.023), and out-hospital mortality (OR = 2.656, p = 0.001). Conclusion: Patients presenting with acute ischemic stroke and coexisting COPD significantly more often had cardiac and pulmonary complications, as well as delirium following stroke. In a long-term follow-up, the probability of one-year survival was significantly lower in AIS patients with co-existing COPD.

Relationship Between Sleep Duration and Stroke History in Middle-Aged and Elderly in Guiyang: A Cross-Sectional Survey

BACKGROUND

With over 2 million new cases annually, stroke is associated with the higher amount of disability-adjusted life-years lost than any other disease in China; however, the relationship between sleep time and stroke has not been concluded yet. Aim of this study was to analyze the relationship between sleep duration and stroke history in middle-aged and elderly people in Guiyang, China.

METHODS

This study was a cross-sectional survey carried out in 40-99-years-old permanent residents of Guiyang. Yunyan, Wudang, and Baiyun districts and Xiuwen County were selected by stratified multilevel sampling for a face-to-face survey. Demographics, history of stroke, and self-reported sleep behavior data were collected, and multivariable logistic regression models were used to gradually adjust possible confounding factors.

RESULTS

A total of 5065 participants were included, of them 126 (2.5%) had a history of stroke. Short sleep (<7 h) was observed in 11.0%, sufficient sleep (7-9 h) in 69.4%, and long sleep (>9 h) in 19.6%. Sleep duration and stroke prevalence showed a U-shaped distribution. When taking the sleep duration of 7-9 h as a reference, sleep duration >9 h was associated with stroke (all P < 0.05) in the univariable model (OR = 2.68, 95% CI: 1.83-3.93) and in the multivariable models 1 (OR = 2.35, 95% CI: 1.59-3.47), 2 (OR = 2.27, 95% CI: 1.53-3.37), 3 (OR = 2.25, 95% CI: 1.51-3.33), and 4 (OR = 2.11, 95% CI: 1.39-3.19). There were no significant differences between the <7 and 7-9 h groups (P > 0.05).

CONCLUSION

Thus, long sleep duration (>9 h) is independently associated with history of stroke in middle-aged and elderly people in Guiyang.

Tramadol versus codeine and the short-term risk of cardiovascular events in patients with non-cancer pain: A population-based cohort study

AIMS

The effect of tramadol on the cardiovascular system is largely unknown. There is concern that, with its multimodal mechanism of action to increase serotonin and norepinephrine levels in the body, it could increase the risk of arterial ischaemia and cardiovascular events. We aimed to compare the short-term risk of cardiovascular events with the use of tramadol to that of codeine among patients with non-cancer pain.

METHODS

We conducted a retrospective population-based cohort study using data from the Clinical Practice Research Datalink (CPRD) with new users of tramadol or codeine from April 1998 to March 2017. Exposure was defined using an approach analogous to an intention-to-treat, with a maximum follow-up of 30 days. The primary endpoint was myocardial infarction, and secondary endpoints were unstable angina, ischaemic stroke, coronary revascularization, cardiovascular death and all-cause mortality. Hazard ratios (HRs) were estimated using Cox proportional hazards models, adjusted for high-dimensional propensity score.

RESULTS

The final cohort included 123 394 tramadol users and 914 333 codeine users. When tramadol was compared to codeine, the adjusted hazard ratio (HR) of myocardial infarction was 1.00 (95% CI 0.81-1.24). There was also no evidence of elevated risks of unstable angina (0.92; 95% CI 0.67-1.27), ischaemic stroke (0.98; 95% CI 0.82-1.17), coronary revascularization (0.97; 95% CI 0.69-1.38), cardiovascular death (1.07; 95% CI 0.93-1.23) or all-cause mortality (1.03; 95% CI 0.94-1.14) when tramadol was compared to codeine.

CONCLUSIONS

Short-term use of tramadol, compared with codeine, was not associated with an increased risk of cardiac events among patients with non-cancer pain.

Improvement of automatic ischemic stroke lesion segmentation in CT perfusion maps using a learned deep neural network

Acute ischemic stroke is one of the leading causes of death and long-term disability worldwide. It occurs when a blood clot blocks an artery that supplies blood to the brain tissue. Segmentation of acute ischemic stroke lesions plays a vital role to improve diagnosis, outcome assessment, and treatment planning. The current standard approach of ischemic stroke lesion segmentation is simply thresholding the Computed Tomography Perfusion (CTP) maps, i.e., quantitative feature maps created by summarizing CTP time sequence scans. However, this approach is not precise enough (its Dice similarity score is only around 50%) to be used in practice. Numerous machine learning-based techniques have recently been proposed to improve the accuracy of ischemic stroke lesion segmentation. Although they have achieved remarkable results, they still need to be improved before they can be used in actual practice. This paper presents a novel deep learning-based technique, MutiRes U-Net, for the segmentation of ischemic stroke lesions in CTP maps. MultiRes U-Net is a modified version of the original U-Net that is re-designed to be robust to segment the objects in different scales and unusual appearances. Additionally, in this paper, we propose to enrich the input CTP maps by using their contra-lateral and corresponding Tmax images. We evaluated the proposed method using the ISLES challenge 2018 dataset. As compared to the state-of-the-art methods, the results show an improvement in segmentation task accuracy. The dice similarity score (DSC) was 68%, the Jaccard score was 57.13%, and the mean absolute volume error was 22.62(ml).

Oxytocin improves ischemic stroke by reducing expression of excitatory amino acid transporter 3 in rat MCAO model

Various molecular mechanisms are activated in neurons during ischemic stroke. Extracellular glutamate secretion into brain tissue causes neurotoxicity and brain damage. Excitatory amino acid transporter 3 (EAAT3) could remove the extracellular glutamate. Neuroprotective activity of oxytocin (OT) in ischemia of various tissues has been reported. This study investigates the neuroprotective effect of OT in an animal model of middle cerebral artery occlusion (MCAO) and the possible role of EAAT3. Transient MCAO was performed as a model of ischemic stroke in male rats and then OT was administrated intra-nasally. Infarct volume was measured by 2, 3, 5-triphenyl tetrazolium chloride staining. Nissl staining method was performed for the evaluation of neuronal cell morphology. Immunohistochemistry assay was performed to analyze the EAAT3 expression in the ischemic region. OT significantly reduced the infarct volume in the cerebral cortex and striatum after ischemia (P< .05). In addition, OT reduces the number of neurons with pyknotic nuclei that are significantly increased in the ischemic region (P< .01) Immunohistochemistry results showed that although EAAT3 expression increased after ischemia, OT therapy increased EAAT3 expression further (P< .05). Therefore, increased EAAT3 expression could be one of the neuroprotective mechanisms of OT after MCAO.

Eye Movement Technique to Improve Executive Function in Patients With Stroke: A Randomized Controlled Trial

Objective: To investigate the efficacy of eye movement technique for the treatment of executive dysfunction of patients with stroke.

Methods: This was a prospective, single-blinded, randomized, controlled, single-center clinical trial conducted from June 2018 to December 2019 in patients with stroke. The patients were randomized 1:1 to the routine (conventional management) and eye-move group (routine management plus eye movement technique: 5-min goal management training, 5-min computer-aided working memory, and 10 min of inhibitory control training and set conversion training). The intervention lasted 6 weeks, followed by a 4-week follow-up. The primary endpoint was the Behavioral Assessment of the Dysexecutive Syndrome (BADS) score. The secondary endpoints mainly included the Montreal Cognitive Assessment (MoCA), Wisconsin Card Sorting Test (WCST), and modified Barthel Index (MBI) scores.

Results: Sixty-four patients were enrolled (32/group). After the 6-week intervention, the BADS and WCST scores of the eye-move group were significantly improved than those of the routine group (all P < 0.05), but the effects were attenuated in certain subscores after follow-up (all P > 0.05). The MoCA and MBI scores of the eye-move group were significantly higher, and the reaction time was significantly lower than those of the routine group at 4 weeks after the intervention (all P < 0.05). After follow-up, the MBI scores of the eye-move group were still higher than that of the routine group (P < 0.001), but there were no differences for MoCA scores and reaction time (both P > 0.05).

Conclusion: The eye movement technique could improve the executive function of patients with stroke. These results have to be confirmed.

This was a prospective, single-blinded, randomized, controlled, single-center clinical trial (ChiCTR2000036393).

Clinical Trial Registration: [www.chictr.org.cn], identifier [ChiCTR2000036393].

Secondary dyslipidemia: its treatments and association with atherosclerosis

Dyslipidemia is classified into primary and secondary types. Primary dyslipidemia is basically inherited and caused by single or multiple gene mutations that result in either overproduction or defective clearance of triglycerides and cholesterol. Secondary dyslipidemia is caused by unhealthy lifestyle factors and acquired medical conditions, including underlying diseases and applied drugs. Secondary dyslipidemia accounts for approximately 30-40% of all dyslipidemia. Secondary dyslipidemia should be treated by finding and addressing its causative diseases or drugs. For example, treatment of secondary dyslipidemia, such as hyperlipidemia due to hypothyroidism, by using statin without controlling hypothyroidism, may lead to myopathy and serious adverse events such as rhabdomyolysis. Differential diagnosis of secondary dyslipidemia is very important for safe and effective treatment. Here, we describe an overview about diseases and drugs that interfere with lipid metabolism leading to secondary dyslipidemia. Further, we show the association of each secondary dyslipidemia with atherosclerosis and the treatments for such dyslipidemia.

Prevalence, Patterns, and Predictors of Multimorbidity in Adults With Acquired Brain Injury at Admission to Staged Community-Based Rehabilitation

OBJECTIVES

To describe the prevalence, patterns, and predictors of multimorbidity in adults with an acquired brain injury (ABI) on presentation to a community-based neurorehabilitation service.

DESIGN

Retrospective cohort study using routinely collected admissions and clinical data.

SETTING

Community-based neurorehabilitation.

PARTICIPANTS

Individuals (N=263) with non-traumatic brain injury (NTBI; n=187 [71.1%]) versus traumatic brain injury (TBI; n=76 [28.9%]).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Comorbidity was defined as the co-occurrence of at least one chronic condition in conjunction with a primary diagnosis of ABI. Multimorbidity was defined as the co-occurrence of 2 or more chronic conditions across 2 or more body systems, in conjunction with a primary diagnosis of ABI.

RESULTS

Comorbidity was present in 72.2% of participants overall, whereas multimorbidity was present in 35.4% of the cohort. The prevalence of comorbidity (76% vs 63%; P=.036) and multimorbidity (40% vs 24%; P=.012) was higher in NTBI compared with participants with TBI. Participants with NTBI had a higher prevalence of physical health multimorbidities, including cardiovascular (44% vs 6%; P<.001) and endocrine (34% vs 10%; P=.002) disease, whereas participants with TBI had a higher prevalence of mental health conditions (79% vs 48%; P<.001). Depression (36.3%) and hypertension (25.8%) were the most common diagnoses. Increasing age was the only significant predictor of multimorbidity.

CONCLUSIONS

Most participants experienced multimorbidity. Effective management of multimorbidity should be included as part of individual rehabilitation for ABI and planning of resource allocation and service delivery. The results of this study can help guide the provision of treatment and services for individuals with ABI in community-based rehabilitation. Our study highlights access to mental health, cardiovascular, endocrine, and neurology services as essential components of rehabilitation for ABI.

Risk Factors and Subtyping of Ischemic Stroke in Young Adults in the Indian Population

Objective: To evaluate the risk factors and etiological subtyping of ischemic stroke in young adults in the Indian population.

Methods: This is a retrospective study of 160 patients, in the age group of 18 to 45 years with ischemic stroke, registered at a tertiary care hospital in Delhi, India between March 2014 and January 2018. Hypertension, diabetes mellitus, dyslipidemia, smoking, alcohol consumption, previous history of stroke, valvular heart disease, coronary artery disease (CAD), atrial fibrillation, family history, and migraine were considered as the identifiable risk factors. Stroke subtyping was done according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria.

Results: The mean age of the patients was 36.2 years with 74% being males. Headache, vomiting, difficulty in speech, and hemiparesis were the common complaints at presentation. Common risk factors identified were hypertension (50%), prior stroke or transient ischemic attack (TIA; 32%), dyslipidemia (25%), family history of stroke (18%), and smoking (15%). The most common TOAST subtype was undetermined (64%), followed by other determined cause (ODC; 20%), and cardioembolism (15%).

Conclusion: There is a certain dissimilarity in the risk factors for ischemic stroke in young adults living in developing countries compared to those belonging to developed nations. Primary and secondary prevention targeted at the modifiable risk factors of ischemic stroke is necessary. Cerebral artery dissection, being a prevalent cause of ischemic stroke in young adults, should be carefully evaluated. A more appropriate stroke classification system specifically tailored for younger patients is needed.

Endothelial progenitor cells, potential biomarkers for diagnosis and prognosis of ischemic stroke: protocol for an observational case-control study

Ischemic stroke is a devastating, life altering event which can severely reduce patient quality of life. Despite years of research there have been minimal therapeutic advances. Endothelial progenitor cells (EPCs), stem cells involved in both vasculogenesis and angiogenesis, may be a potential therapeutic target. After a stroke, EPCs migrate to the site of ischemic injury to repair cerebrovascular damage, and their numbers and functional capacity may determine patients’ outcome. This study aims to determine whether the number of circulating EPCs and their functional aspects may be used as biomarkers to identify the type (cortical or lacunar) and/or severity of ischemic stroke. The study will also investigate if there are any differences in these characteristics between healthy volunteers over and under 65 years of age. 100 stroke patients (50 lacunar and 50 cortical strokes) will be recruited in this prospective, observational case-controlled study. Blood samples will be taken from stroke patients at baseline (within 48 hours of stroke) and days 7, 30 and 90. EPCs will be counted with flow cytometry. The plasma levels of pro- and anti-angiogenic factors and inflammatory cytokines will also be determined. Outgrowth endothelial cells will be cultured to be used in tube formation, migration and proliferation functional assays. Primary outcome is disability or dependence on day 90 after stroke, assessed by the modified Rankin Scale. Secondary outcomes are changes in circulating EPC numbers and/or functional capacity between patient and healthy volunteers, between patient subgroups and between elderly and young healthy volunteers. Recruitment started in February 2017, 167 participants have been recruited. Recruitment will end in November 2019. West Midlands - Coventry & Warwickshire Research Ethics Committee approved this study (REC number: 16/WM/0304) on September 8, 2016. Protocol version: 2.0. The Bayraktutan Dunhill Medical Trust EPC Study was registered in ClinicalTrials.gov (NCT02980354) on November 15, 2016. This study will determine whether the number of EPCs can be used as a prognostic or diagnostic marker for ischemic strokes and is a step towards discovering if transplantation of EPCs may aid patient recovery.

Cigarette smoke extract exacerbates hyperpermeability of cerebral endothelial cells after oxygen glucose deprivation and reoxygenation

Cigarette smoking is a risk factor for stroke and is linked to stroke severity. Previous studies have shown that cigarette smoke extract (CSE) triggers endothelial dysfunction in vitro by initiating oxidative stress and/or an inflammatory response. In addition, cerebral endothelial dysfunction (particularly at the level of the blood-brain barrier [BBB]) contributes to stroke pathogenesis. Therefore, we hypothesized that cigarette smoking may influence stroke, at least in part, by exacerbating ischaemia-induced BBB disruption. To test this, we examined the effect of CSE on the permeability of cerebral endothelial cells exposed to oxygen glucose deprivation and reoxygenation (OGD + RO). We found that the loss of BBB integrity following ischaemic/reperfusion-like conditions was significantly worsened by CSE. Despite this being associated with increased mRNA expression of Nox catalytic subunits, reactive oxygen species (ROS) levels were however markedly lower. Furthermore, this occurred in association with elevated expression of antioxidant enzymes (SOD1, SOD2, and Gpx-1), suggesting an antioxidant defence response. Lastly, we found that CSE significantly upregulated mRNA expression of cytokines (IL-6 and TGF-β). Collectively, these results show that acute exposure to CSE worsens BBB disruption caused by OGD + RO, however, this is not linked to elevated ROS levels but may involve inflammatory mechanisms.

Exploring the effects of Gastrodia elata Blume on the treatment of cerebral ischemia-reperfusion injury using UPLC-Q/TOF-MS-based plasma metabolomics

Gastrodia elata Blume (Orchidaceae, GEB) is a medicinal plant that has been widely used in the treatment of cerebrovascular disease. This study explored the protective effects of GEB against cerebral ischemia-reperfusion using Information-Dependent Acquisition (IDA)-mediated UPLC-Q/TOF-MS-based plasma metabolomics. Cerebral ischemia-reperfusion (IR) injury was induced in male Wistar rats using the Zea Longa method. Biochemical and histological assays were performed to evaluate the therapeutic effects of GEB on IR rats. We found that the neurobehavioral scores and infarction areas of GEB and nimodipine treated groups were dramatically lower than those of the IR groups. Hematoxylin and Eosin (HE) staining and TdT-mediated dUTP Nick-End Labeling (TUNEL) showed that GEB significantly improved neuronal injury and prevented neuronal apoptosis. Biochemical analysis revealed that GEB prevented cerebral ischemia-reperfusion injury by regulating inflammation and oxidative injury. Through ultra-high-performance liquid chromatography-quadrupole time-of-flight mass spectrometry-metabolomics-based approaches, 43 plasma metabolites related to GEB treatment were detected, 6 of which significantly differed (p < 0.05) between the model and GEB groups. The levels of l-histidine, sphinganine, thymine, spermidine and deoxycytidine in the IR group were significantly higher than those in the sham group, but decreased following GEB treatment. Arachidonic acid levels were lower in the IR group, but dramatically increased in response to GEB. Pharmacodynamics and metabolomics confirmed that the mechanism of GEB in the treatment of cerebral ischemia was not only related to the reduction of inflammation, oxidation, neurotoxicity, and apoptosis, but also mediated through arachidonic acid metabolism, histidine metabolism, pyrimidine metabolism, arginine and proline metabolism, sphingolipid metabolism, and glycerophospholipid metabolism in vivo.

Imaging Functional Recovery Following Ischemic Stroke: Clinical and Preclinical fMRI Studies

Disability and effectiveness of physical therapy are highly variable following ischemic stroke due to different brain regions being affected. Functional magnetic resonance imaging (fMRI) studies of patients in the months and years following stroke have given some insight into how the brain recovers lost functions. Initially, new pathways are recruited to compensate for the lost region, showing as a brighter blood oxygen‐level‐dependent (BOLD) signal over a larger area during a task than in healthy controls. Subsequently, activity is reduced to baseline levels as pathways become more efficient, mimicking the process of learning typically seen during development. Preclinical models of ischemic stroke aim to enhance understanding of the biology underlying recovery following stroke. However, the pattern of recruitment and focusing seen in humans has not been observed in preclinical fMRI studies that are highly variable methodologically. Resting‐state fMRI studies show more consistency; however, there are still confounding factors to address. Anesthesia and method of stroke induction are the two main sources of variability in preclinical studies; improvements here can reduce variability and increase the intensity and reproducibility of the BOLD response detected by fMRI. Differences in task or stimulus and differences in analysis method also present a source of variability. This review compares clinical and preclinical fMRI studies of recovery following stroke and focuses on how refinement of preclinical models and MRI methods may obtain more representative fMRI data in relation to human studies.

Effects of Tai Chi on Cerebral Hemodynamics and Health-Related Outcomes in Older Community Adults at Risk of Ischemic Stroke: A Randomized Controlled Trial

This study investigated the effects of Tai Chi compared with no exercise control on the cerebral hemodynamic parameters and other health-related factors in community older adults at risk of ischemic stroke. A total of 170 eligible participants were randomly allocated to Tai Chi or control group. The cerebral hemodynamic parameters and physical fitness risk factors of cardiovascular disease were measured at baseline, 12 weeks, and 24 weeks. After the 12-week intervention, Tai Chi significantly improved the minimum of blood flow velocity (BFVmin); BFVmean; pulsatility index and resistance index of the right anterior cerebral artery; and BFVmax, BFVmin, and BFVmeanparameters of the right middle cerebral artery. Tai Chi training also decreased triglyceride, fasting blood glucose, and homocysteine levels, and improved balance ability. Therefore, the supervised 12-week Tai Chi exercise had potential beneficial effects on cerebral hemodynamics, plasma risk factors, and balance ability in older community adults at risk of ischemic stroke.

A 2-Min Transient Ischemia Confers Cerebral Ischemic Tolerance in Non-Obese Gerbils, but Results in Neuronal Death in Obese Gerbils by Increasing Abnormal mTOR Activation-Mediated Oxidative Stress and Neuroinflammation

A brief episode of transient ischemia (TI) can confer cerebral ischemic tolerance against a subsequent severer TI under standard condition. The brain under obesity’s conditions is more sensitive to ischemic injury. However, the impact of a brief episode of TI under obesity’s conditions has not been fully addressed yet. Thus, the objective of this study was to determine the effect of a brief TI in the hippocampus of high-fat diet (HFD)-induced obese gerbils and related mechanisms. Gerbils were maintained on HFD or normal diet (ND) for 12 weeks and subjected to 2 min TI. HFD gerbils were heavier, with higher blood glucose, serum total cholesterol, triglycerides, and leptin levels. Massive loss of pyramidal neurons occurred in the hippocampal cornu ammonis 1 (CA1) field of HFD animals at 5 days after 2 min of TI, but 2 min of TI did not elicit death of pyramidal neurons in ND gerbils. The HFD group showed significantly increased levels of oxidative stress indicators (dihydroethidium and 4-hydroxynonenal) and proinflammatory cytokines (tumor necrosis factor-α and interleukin-1β) and microglial activation in pre- and/or post-ischemic phases compared to the ND group. Levels of mammalian target of rapamycin (mTOR) and phosphorylated-mTOR in the CA1 field of the HFD group were also significantly higher than the ND group. On the other hand, inhibition of mTOR activation by rapamycin (an allosteric mTOR inhibitor) significantly attenuated neuronal death induced by HFD, showing reduction of HFD-induced increases of oxidative stress indicators and proinflammatory cytokines, and microglia activation. Taken together, a brief episode of TI can evoke neuronal death under obesity’s conditions. It might be closely associated with an abnormal increase of mTOR activation-mediated, severe oxidative stress and neuroinflammation in pre- and/or post-ischemic phases.

Study of the association between gait variability and gene expressions in a mouse model of transient focal ischemic stroke

Purpose: Gait variability analysis has been clinically adopted to characterize the presentation of various neurological diseases. However, literature and practice lack a comprehensive murine model assessment of the gait deficits that result from transient focal ischemic stroke. Further, correlations between gait parameters and the gene expression profiles associated with brain ischemia have yet to be identified. This study quantitatively assesses gait deficits through a murine model of transient focal cerebral ischemia on day 7 to determine associations between gait deficits and ischemia-related gene expressions.Methods: A total of 182 dynamic and static gait parameters from the transient middle cerebral artery occlusion (MCAO) murine model for simulating human transient focal ischemic stroke on day 7 were measured using the CatWalk system. Pearson's correlation analysis and genes associated with ischemia were identified from the existing literature to aid the investigation of the relationship between gait variability and gene expression profiles.Results: Thirty-nine gait parameters and the mRNA expression levels of four of the eight ischemia-associated genes exhibited more significant change in the MCAO models (p < 0.005) on day 7. Twenty-six gait parameters exhibited strong correlations with four ischemia-associated genes.Conclusion: This examination of gait variability and the strong correlation to the gene expression profiles associated with transient focal brain ischemia on day 7 provides a quantitative and reliable assessment of the MCAO model's motor performance. This research provides valuable insights into the study of disease progression and offers novel therapeutic interventions in the murine modeling of ischemic stroke.

Genetic variants in CYP4F2 were significantly correlated with susceptibility to ischemic stroke

Background

Ischemic stroke (IS) is a serious cardiovascular disease and is associated with several single nucleotide polymorphisms (SNPs). However, the role of Cytochrome P450 family 4 subfamily F member 2 (CYP4F2) gene in IS remains unknown. Our study aimed to explore whether CYP4F2 polymorphisms influenced IS risk in the Han Chinese population.

Methods

We selected 477 patients and 495 controls to do a case-control study, and five SNPs in CYP4F2 gene were successfully genotyped. And we evaluated the associations using the Chi-squared test, independent sample t test, and genetic models analyses. Logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

Results

In this study, rs12459936 and rs3093144 were associated with IS risk in the overall. After stratified analysis by age (> 61 years), rs3093193 and rs3093144 were related to an increased risk of IS, whereas rs12459936 was related to a decreased risk of IS. In addition, we found that three SNPs (rs3093193, rs3093144 and rs12459936) were associated with the susceptibility to IS in males. We also found five SNPs in the CYP4F2 gene had strong linkage.

Conclusions

Three SNPs (rs3093193, rs3093144 and rs12459936) in the CYP4F2 were associated with IS risk in a Chinese Han population. And, CYP4F2 gene may be involved in the development of IS.

Supplementary information

Supplementary information accompanies this paper at (10.1186/s12881-019-0888-6).

Bridging the Gap Between Diabetes and Stroke in Search of High Clinical Relevance Therapeutic Targets

Diabetes affects more than 425 million people worldwide, a scale approaching pandemic proportion. Diabetes represents a major risk factor for stroke, and therefore is actively addressed for stroke prevention. However, how diabetes affects stroke severity has not yet been extensively considered, which is surprising given the evident but understudied common mechanistic features of both pathologies. The increase in number of diabetic people, incidence of stroke in the presence of this specific risk factor, and the exacerbation of ischemic brain damage in diabetic conditions (at least in animal models) warrants the need to integrate this comorbidity in preclinical studies of brain ischemia to develop novel therapeutic approaches. Therefore, a better understanding of the commonalties involved in the course of both diseases would offer the promise of discovering novel neuroprotective pathways that would be more appropriated to clinical scenarios. In this article, we will review the relevant mechanisms that have been identified as common traits of both pathologies and that could be, to our knowledge, potential targets in both pathologies.

Hyperglycemia is associated with poor in-hospital outcome in elderly patients with acute ischemic stroke

Fasting hyperglycemia is associated with poor neurologic outcome in acute ischemic stroke (AIS), but its relationship with in-hospital outcome in elderly patients remains largely unknown. To assess the association of in-hospital outcome with fasting plasma glucose (FPG) levels at admission in individuals with AIS.This retrospective propensity score-matched case-control study included patients aged over 60 years suffering from AIS and who were admitted to the emergency department from November 2013 to October 2016. Subjects were grouped into the poor-outcome and good-outcome groups based on mortality and intensive care unit (ICU) admission.The poor- and good-outcome groups comprised 74 and 1927 cases, respectively, before propensity score matching (PSM), and 74 and 296 cases, respectively, after PSM. Univariable logistic regression analysis showed that initial FPG after admission was associated with poor in-hospital outcome. Multivariable logistic regression analysis showed that initial FPG after admission was an independent predictor of poor in-hospital outcome (odds ratio = 1.11, 95% confidence interval: 1.037-1.188, P = .003).This study used PSM and strongly suggests that FPG is an independent predictive factor of poor in-hospital outcome in elderly patients with AIS. High initial FPG levels after admission may predict poor in-hospital outcome. Prospective studies are needed to confirm these findings.

Multiple sclerosis and stroke: a systematic review and meta-analysis

BACKGROUND

Multiple sclerosis (MS) and stroke are two common causes of death and disability worldwide. The relationship between these two diseases remains unclear. Effective early preventative measures and treatments are available to reduce the morbidity and mortality of acute stroke. The objectives of our systematic review are to estimate the risk of stroke in patients with MS and to collate related studies to draw preliminary conclusions that may improve clinical practice.

METHOD

Relevant studies were systematically searched in MEDLINE, Embase, the Chinese Biomedical Literature Database (CBM), the China National Knowledge Infrastructure and the VIP database of Chinese periodicals from January 1983 to May 2017, with no restrictions on language. Patients included in this review were adults who suffered from MS. Review Manager 5.3 software program was used to pool data and calculate the risk ratio (RR) and its 95% confidence interval (CI). We also performed heterogeneity and sensitivity analyses and evaluated bias in the meta-analysis.

RESULTS

Nine studies including more than 380,000 participants that met our inclusion criteria were incorporated into the meta-analysis. During different follow-up periods, patients with MS had an increased risk of any type of stroke [RR = 3.48, 95% CI (1.59, 7.64), P = 0.002 for 1 year; RR = 2.45, 95% CI (1.90, 3.16), P < 0.00001 for 10-13 years]. The total prevalence of stroke (any type) in patients with MS exceeded expectations compared to different groups [Comparing with general veteran: RR = 2, 95% CI (1.19, 3.38), P = 0.009. Comparing with general population: RR = 2.93, 95% CI (1.13, 7.62), P = 0.03]. Furthermore, ischemic stroke was particularly more common in the MS population than in people without MS [RR = 6.09, 95% CI (3.44, 10.77), P < 0.00001].

CONCLUSION

Compared with the general population, people with MS have an increased risk of developing any type of stroke and ischemic stroke in particular. Consistent results were obtained from patients of different sexes and age groups. Preventative measures and treatments should be administered at earlier time points to improve patient outcomes.

Clinical application value of brain CT perfusion imaging in the treatment of acute ischemic stroke thrombolytic therapy

Clinical application value of CT perfusion (CTP) imaging in the treatment of acute ischemic stroke (AIS) thrombolytic therapy was investigated. Retrospective analysis of 185 suspected AIS patients in Liaocheng Brain Hospital from April 2012 to December 2017 were involved. We observed the non-contrast CT (NCCT) and CTP in the diagnosis of AIS patients, and recorded as well as compared CTP parameters of AIS patients. The National Institute of Health Stroke Scale (NIHSS) rating was conducted, and the correlation between the prognosis of NIHSS scores and CTP parameters was investigated. A total of 177 patients were diagnosed with AIS. The sensitivity levels of CTP examination for diagnosis of AIS patients was significantly higher than that of the NCCT examination (P<0.050). The diagnostic compliance rates of CTP examination was significantly higher than that of the NCCT examination (P<0.050). The cerebral blood volume (CBV) in the abnormal perfusion area was significantly lower than that in the mirror side zone (t=21.160, P<0.001). The prognostic NIHSS score was negatively correlated with CBV in patients with thrombolytic therapy (r=−0.912, P<0.001). The cerebral blood flow (CBF) in the abnormal perfusion zone was significantly lower than that in the mirror side zone (t=19.170, P<0.001). The prognosis of patients with thrombolytic therapy was negatively correlated with CBF (r=−0.915, P<0.001). The mean transit time (MTT) in the abnormal perfusion zone was higher than that in the mirror side zone (t=13.480, P<0.001). NIHSS scores were obtained 3 months after thrombolytic therapy and found that the prognostic NIHSS scores were positively correlated with MTT (r=0.887, P<0.001). The results indicated that brain CTP has a high diagnostic value for intravenous thrombolytic therapy in AIS and there was a significant correlation between the prognosis scores of patients. Thus, it is worthy of being promoted in the clinical diagnosis and treatment of AIS patients.

Baduanjin exercise intervention for community adults at risk of ischamic stroke: A randomized controlled trial

The aim of current study was to assess the effects of Baduanjin exercise on cerebrovascular function, cardiac structure and cardiac function, static pulmonary function, traditional risk factors of CVD and the related psychological outcomes in older community adults at risk for ischaemic stroke. A randomized controlled trial was conducted in three community between November 2013 and October 2015. Older community-dwelling adults (N = 170) were randomly allocated into either a Baduanjin training (5 × 60 min/weekly) or control group who kept their unaltered lifestyle during a 12-week intervention period. Primary (cerebral haemodynamic parameters) and secondary outcomes (cardiac structure, cardiac function, static pulmonary function, traditional risk factors and the related psychological outcomes) were measured at baseline, after a 12-week intervention period and after an additional 12-week follow-up period. After the 12-week intervention period and additional 12-week follow-up period, the Baduanjin exercise group displayed significant changes in most cerebral haemodynamic parameters compared to the control group: lower systolic blood pressure, diastolic blood pressure, plasma total cholesterol levels, waist circumference, hip circumference and waist/hip ratio; and improved mood, self-confidence, self-esteem, quality of life and sleep quality. A supervised 12-week Baduanjin exercise intervention was effective and safe in modulating cerebral haemodynamics, reducing blood pressure and improving anthropometric parameters and related psychological outcomes in older community adults at risk for ischaemic stroke.