Obesity-stroke paradox and initial neurological severity

Mechanistic correlation of molecular pathways in obesity-mediated stroke pathogenesis

Obesity, a prominent risk factor for the development of heart attacks and several cardiovascular ailments. Obesity ranks as the second most significant avoidable contributor to mortality, whereas stroke stands as the second leading cause of death on a global scale. While changes in lifestyle have been demonstrated to have significant impacts on weight management, the long-term weight loss remains challenging, and the global prevalence of obesity continues to rise. The pathophysiology of obesity has been extensively studied during the last few decades, and an increasing number of signal transduction pathways have been linked to obesity preclinically. This review is focused on signaling pathways, and their respective functions in regulating the consumption of fatty food as well as accumulation of adipose tissue, and the resulting morphological and cognitive changes in the brain of individuals with obesity. We have also emphasized the recent progress in the mechanisms behind the emergence of obesity, as elucidated by both experimental and clinical investigations. The mounting understanding of signaling transduction may shed light on the future course of obesity research as we move into a new era of precision medicine.

Predictors for Failed Removal of Nasogastric Tube in Patients With Brain Insult

OBJECTIVE

To construct a prognostic model for unsuccessful removal of nasogastric tube (NGT) was the aim of our study.

METHODS

This study examined patients with swallowing disorders receiving NGT feeding due to stroke or traumatic brain injury in a regional hospital. Clinical data was collected, such as age, sex, body mass index (BMI), level of activities of daily living (ADLs) dependence. Additionally, gather information regarding the enhancement in Functional Oral Intake Scale (FOIS) levels and the increase in food types according to the International Dysphagia Diet Standardization Initiative (IDDSI) after one month of swallowing training. A stepwise logistic regression analysis model was employed to predict NGT removal failure using these parameters.

RESULTS

Out of 203 patients, 53 patients (26.1%) had experienced a failed removal of NGT after six months of follow-up. The strongest predictors for failed removal were age over 60 years, underweight BMI, total dependence in ADLs, and ischemic stroke. The admission prediction model categorized patients into high, moderate, and low-risk groups for removal failure. The failure rate of NGT removal was high not only in the high-risk group but also in the moderate-risk groups when there was no improvement in FOIS levels and IDDSI food types.

CONCLUSION

Our predictive model categorizes patients with brain insults into risk groups for swallowing disorders, enabling advanced interventions such as percutaneous endoscopic gastrostomy for high-risk patients struggling with NGT removal, while follow-up assessments using FOIS and IDDSI aid in guiding rehabilitation decisions for those at moderate risk.

Correlation of TyG-BMI and TyG-WC with severity and short-term outcome in new-onset acute ischemic stroke

Objectives

To research the connection between the indexes of the indexes of triglyceride-glucose (TyG) combined with obesity indices and the initial neurological severity and short-term outcome of new-onset acute ischemic stroke.

Methods

Data of patients with acute ischemic stroke admitted to the Stroke Ward of the Affiliated Hospital of Beihua University from November 2021 to October 2023, were collected. The two indexes were calculated by combining TyG and obesity indices: TyG-body mass index (TyG-BMI) and TyG-waist circumference (TyG-WC). The National Institute of Health Stroke Scale (NIHSS) was used to assess and group patients with neurological deficits within 24 hours of admission: mild stroke (NIHSS ≤5) and moderate-severe stroke (NIHSS >5). Short-term prognosis was evaluated using the modified Rankin Scale (mRS) at discharge or 14 days after onset of the disease and grouped: good outcome (mRS ≤2) and poor outcome (mRS >2). According to the quartiles of TyG-BMI and TyG-WC, the patients were placed into four groups: Q1, Q2, Q3 and Q4. Multi-factor logistic regression analysis was utilized to evaluate the correlation of TyG-BMI and TyG-WC with the severity and short-term outcome.

Results

The study included 456 patients. After adjusting for multiple variables, the results showed that compared with the quartile 1, patients in quartile 4 of TyG-BMI had a reduced risk of moderate-severe stroke [Q4: OR: 0.407, 95%CI (0.185-0.894), P = 0.025]; Patients in quartiles 2, 3 and 4 of TyG-BMI had sequentially lower risk of short-term adverse outcomes [Q2: OR: 0.394, 95%CI (0.215-0.722), P = 0.003; Q3: OR: 0.324, 95%CI (0.163-0.642), P = 0.001; Q4: OR: 0.158, 95%CI (0.027-0.349), P <0.001]; Patients in quartiles 3 and 4 of TyG-WC had sequentially lower risk of moderate-severe stroke [Q3: OR: 0.355, 95%CI (0.173-0.728), P = 0.005; Q4: OR: 0.140, 95%CI (0.056-0.351), P <0.001]; Patients in quartiles 3 and 4 of TyG-WC had sequentially lower risk of short-term adverse outcomes [Q3: OR: 0.350, 95%CI (0.175-0.700), P = 0.003; Q4: OR: 0.178, 95%CI (0.071-0.451), P <0.001].

Conclusions

TyG-WC and TyG-BMI were correlated with the severity and short-term outcome of new-onset acute ischemic stroke. As TyG-WC and TyG-BMI increased, stroke severity decreased and short-term outcome was better.

U-shaped associations between glycated albumin and obesity and role of IL-10 in hyperacute ischemic stroke

OBJECTIVE

There is growing interest in the use of new biomarkers such as glycated albumin (GA). In contrast to glycated hemoglobin (HbA1c), GA showed an inverse correlation with prestroke obesity status, but data are limited for ischemic stroke (IS).

MATERIALS AND METHODS

We explored the association between GA and body mass index (BMI) and investigated inflammatory cytokines to support the academic background. In total, 155 patients with hyperacute IS (HIS) between 2011 and 2019 were included. To identify the association between GA and BMI, patients were divided into four groups according to BMI quartiles. Levels of inflammatory cytokines, including IL-1β, IL-10, IL-6, TNF-α, and TNF-R1, were determined by ELISA using a ProcartaPlex multiplex immunoassay.

RESULTS

The mean age of the 155 patients was 68 ± 12 years, and 67.1% were men. The lowest BMI group had higher GA levels (GA 2 T and 3 T = 80%) (p-value=0.017), and these U-shaped associations were maintained only for small vessel occlusion etiology (p-value= 0.004). Plasma IL-10 levels were positively correlated with BMI and showed a U-shaped pattern (p-value= 0.001).

CONCLUSION

GA levels and BMI had U-shaped associations with HIS. IL-10, which acts as a protective cytokine for cardiovascular disease, may play a novel role in this association. Although GA is an emerging favorable clinical marker of cardiovascular outcomes, obesity status should be considered when interpreting these associations.

Role of age and sex in the association between BMI and functional limitations in stroke patients: Cross-sectional analysis in three European and US cohorts

BACKGROUND

A U- or J-shaped association between BMI and different post-stroke outcomes is suggested. Thus, the aim is to evaluate the association between BMI with ADL, IADL and mobility limitations in the ageing post-stroke population at different ages, as well as the differences in this association by sex.

METHODS

A total of 5,468 participants with stroke and 21,872 without stroke over 50 years of age were assessed for the number of limitations in basic or instrumental activities of daily living (ADL/IADL) as well as mobility tasks. The association between BMI at the interview (continuous time-dependent variable) and the level of limitations was assessed using a linear mixed model stratified by sex and stroke status.

RESULTS

The association between BMI and ADL/IADL and mobility limitations were found to be significant in both men and women regardless of stroke status (p<0.001 for all). The association differs between those who have suffered a stroke and those who have not (p<0.001 for all). In ADL/IADL limitations, men with stroke showed a transition from an inverted J-shape to a U-shape association with age. In women, the BMI showed a less pronounced association between BMI and ADL/IADL limitations compared to men but with similar trends. A effect of sex was observed in the association between BMI and mobility, with women with and without stroke showing a linear association that differed from the inverted J-shaped or U-shaped association of men.

CONCLUSION

Our results suggest that BMI is associated with limitations in ADL, IADL and mobility in stroke patients. In addition, this association differs between men and women and is also influenced by age.

Targeting Neutrophil α9 Improves Functional Outcomes After Stroke in Mice With Obesity-Induced Hyperglycemia

BACKGROUND

Obesity-induced hyperglycemia is a significant risk factor for stroke. Integrin α9β1 is expressed on neutrophils and stabilizes adhesion to the endothelium via ligands, including Fn-EDA (fibronectin containing extra domain A) and tenascin C. Although myeloid deletion of α9 reduces susceptibility to ischemic stroke, it is unclear whether this is mediated by neutrophil-derived α9. We determined the role of neutrophil-specific α9 in stroke outcomes in a mice model with obesity-induced hyperglycemia.

METHODS

α9Neu-KO (α9fl/flMRP8Cre+) and littermate control α9WT (α9fl/flMRP8Cre-) mice were fed on a 60% high-fat diet for 20 weeks to induce obesity-induced hyperglycemia. Functional outcomes were evaluated up to 28 days after stroke onset in mice of both sexes using a transient (30 minutes) middle cerebral artery ischemia. Infarct volume (magnetic resonance imaging) and postreperfusion thrombo-inflammation (thrombi, fibrin, neutrophil, phospho-nuclear factor kappa B [p-NFκB], TNF [tumor necrosis factor]-α, and IL [interleukin]-1β levels, markers of neutrophil extracellular traps) were measured post 6 or 48 hours of reperfusion. In addition, functional outcomes (modified Neurological Severity Score, rota-rod, corner, and wire-hanging test) were measured for up to 4 weeks.

RESULTS

Stroke upregulated neutrophil α9 expression more in obese mice (P<0.05 versus lean mice). Irrespective of sex, deletion of neutrophil α9 improved functional outcomes up to 4 weeks, concomitant with reduced infarct, improved cerebral blood flow, decreased postreperfusion thrombo-inflammation, and neutrophil extracellular traps formation (NETosis) (P<0.05 versus α9WT obese mice). Obese α9Neu-KO mice were less susceptible to thrombosis in FeCl3 injury-induced carotid thrombosis model. Mechanistically, we found that α9/cellular fibronectin axis contributes to NETosis via ERK (extracellular signal-regulated kinase) and PAD4 (peptidyl arginine deiminase 4), and neutrophil α9 worsens stroke outcomes via cellular fibronectin-EDA but not tenascin C. Obese wild-type mice infused with anti-integrin α9 exhibited improved functional outcomes up to 4 weeks (P<0.05 versus vehicle).

CONCLUSIONS

Genetic ablation of neutrophil-specific α9 or pharmacological inhibition improves long-term functional outcomes after stroke in mice with obesity-induced hyperglycemia, most likely by limiting thrombo-inflammation.

Effects of body mass index on the immune response within the first days after major stroke in humans

INTRODUCTION

Immunological alterations associated with increased susceptibility to infection are an essential aspect of stroke pathophysiology. Several immunological functions of adipose tissue are altered by obesity and are accompanied by chronic immune activation. The purpose of this study was to examine immune function (monocytes, granulocytes, cytokines) as a function of body mass index (BMI: 1st group: 25; 2nd group: 25 BMI 30; 3rd group: 30) and changes in body weight post stroke.

METHOD

Fat status was assessed using standardized weight measurements on days 1, 2, 3, 4, 5, and 7 after ischemic stroke in a cohort of 40 stroke patients and 16 control patients. Liver fat and visceral fat were assessed by MRI on day 1 or 2 [I] and on day 5 or 7 [II]. Leukocyte subpopulations in peripheral blood, cytokines, chemokines, and adipokine concentrations in sera were quantified. In a second cohort (stroke and control group, n = 17), multiple regression analysis was used to identify correlations between BMI and monocyte and granulocyte subpopulations.

RESULTS

Weight and fat loss occurred from the day of admission to day 1 after stroke without further reduction in the postischemic course. No significant changes in liver or visceral fat were observed between MRI I and MRI II. BMI was inversely associated with IL-6 levels, while proinflammatory cytokines such as eotaxin, IFN-β, IFN -γ and TNF-α were upregulated when BMI increased. The numbers of anti-inflammatory CD14+CD16+ monocytes and CD16+CD62L- granulocytes were reduced in patients with higher BMI values, while that of proinflammatory CD16dimCD62L+ granulocytes was increased.

CONCLUSION

A small weight loss in stroke patients was detectable. The data demonstrate a positive correlation between BMI and a proinflammatory poststroke immune response. This provides a potential link to how obesity may affect the clinical outcome of stroke patients.

Obesity and risk of hearing loss in the middle-aged and elderly: a national cohort of Chinese adults

BACKGROUND

The relationship between obesity and hearing loss among the middle-aged and older population remained unclear. Moreover, few studies have focused on the impact of gender on this association.

METHODS

This cohort study extracted the data from the China Health and Retirement Longitudinal Study, a national survey of adults aged 45 years or over. Waist circumference was categorized into three groups: normal, pre-central obesity, and central obesity. We classified BMI into four categories: underweight, normal weight, overweight, and obese. The primary endpoint was the incidence of self-reported hearing loss.

RESULTS

Of the 14,237 participants, 1972 incidents of hearing loss were identified during a median 6.9 years of follow-up. The cumulative incidence of hearing loss was 13.9% (95% CI 13.3% -14.4%). Our study showed that central obesity was significantly associated with hearing loss (HR 0.84, 95%CI 0.75-0.94), and this relationship was more prominent in males (HR 0.76, 95%CI 0.63-0.91). Among male participants, the underweight group was at the highest risk of hearing loss (HR 1.39, 95%CI 1.08-1.79). Compared with the normal weight group, the adjusted HR for hearing loss in the obese groups was 0.69 (95%CI 0.51-0.94) among men. Among female participants, only the overweight group had a lower risk of hearing loss than the normal weight group (HR 0.83, 95%CI 0.71-0.96).

CONCLUSIONS

Being overweight and obese were significantly associated with a decreased risk of hearing loss, whereas being underweight was associated with an increased risk of hearing loss.

Obesity paradox and stroke outcomes according to stroke subtype: a propensity score-matched analysis

OBJECTIVE

Obesity has traditionally been considered a risk factor for ischemic stroke. However, some clinical observations have reported a complex relationship between patients who are overweight or obese with paradoxically better stroke outcomes. Stroke subtypes have differing distributions of risk factors, so this study aimed to explain the relationship between body mass index (BMI) and functional prognosis according to stroke subtype.

METHODS

A prospective institutional database on stroke was accessed between March 2014 and December 2021, and consecutive patients with ischemic stroke were retrospectively selected. BMI was categorized into five groups (underweight, normal weight, overweight, obese, and morbid obesity). The outcome of interest in this study was the modified Rankin Scale (mRS) at 90 d, which was divided into favorable (mRS = 0-2) and unfavorable (mRS ≥ 3) groups. The relationship between functional outcome and BMI was analyzed according to stroke subtype.

RESULTS

Among 2779 patients with stroke, 913 (32.9%) had unfavorable outcomes. After a propensity score-matched analysis, obesity was inversely associated with unfavorable outcomes (adjusted odds ratio [aOR] = 0.61, 95% confidence interval [95% CI]: 0.46-0.80) in all patients with stroke. Among the stroke subtypes, overweight (aOR = 0.38, 95% CI: 0.20-0.74) and obese (aOR = 0.40, 95% CI: 0.21-0.76) groups were inversely associated with unfavorable outcomes in the cardioembolism subtype. Obesity (aOR = 0.55, 95% CI: 0.32-0.95) was inversely associated with unfavorable outcomes in the small vessel disease subtype. There was no significant relationship between stroke outcome and BMI classification in the large artery disease subtype.

CONCLUSIONS

These findings suggest that the obesity paradox in ischemic stroke outcomes might differ according to the stroke subtype.

Association of body mass index and waist-to-height ratio with outcomes in ischemic stroke: results from the Third China National Stroke Registry

BACKGROUND AND PURPOSE

Conflicting reports of obesity paradox have led to confusion about weight management strategies for post-stroke patients. The main purpose of this study is to determine whether the obesity paradox measured by body mass index (BMI) or by waist-to-height ratio (WHtR) is real.

METHODS

We evaluated the association of general obesity measured by BMI, and abdominal obesity measured by WHtR with 1-year all-cause mortality, recurrence of stroke and combined vascular events of acute ischemic stroke (AIS) patients in a cohort -- the Third China National Stroke Registry (CNSR-III). Cox proportional hazards models and restricted cubic splines were performed to investigate the association between obesity and clinical outcomes.

RESULTS

A total of 14,146 patients with ischemic stroke were included. When BMI was used as a measure of obesity, compared to the normal weight patients, mortality decreased in overweight patients (hazard ratio [HR] 0.74 [95% confidence interval (CI) 0.61-0.91], P = 0.0035) and obese patients (HR 0.54 [0.40-0.73], P < 0.0001); and increased in underweight patients (HR 2.55 [1.75-3.73], P < 0.0001). After adjustment for confounding factors, the protective effect of obesity and overweight disappeared. BMI had no association with recurrence of stroke or combined vascular events. When WHtR was used as a measure of obesity, obese patients had lower 1-year all-cause mortality (HR 0.64 [0.43-0.97], P = 0.0357). After adjustment for confounding factors, this difference disappeared; overweight patients still had lower all-cause mortality (adjusted hazard ratio [aHR] 0.42 [0.26-0.67], P = 0.0003), recurrence of stroke (aHR 0.77 [0.60-0.99], P = 0.0440) and combined vascular events (aHR 0.75 [0.58-0.95], P = 0.0198).

CONCLUSIONS

Among Chinese patients with AIS, our study does not support the BMI paradox; overweight patients measured by WHtR had a more favorable prognosis. TOAST subtypes did not modify the association.

Factors Contributing to Complete Oral Intake in Dysphagic Stroke Patients with Enteral Feeding Tubes in Convalescent Rehabilitation Wards

Objectives:

This study investigated the factors contributing to complete oral intake (COI) in dysphagic stroke patients with enteral feeding tubes in the local clinical setting.

Methods:

Data of patients with percutaneous endoscopic gastrostomy (PEG) or nasogastric tube (NGT) feeding on admission to convalescent rehabilitation wards (CRWs) were extracted from the Kaga Regional Cooperation Clinical Pathway for Stroke database for multiple centers including 19 acute care hospitals and 11 hospitals with CRWs. Patients were divided into two groups based on their status regarding COI or incomplete oral intake (ICOI) at discharge. Logistic regression analysis with forced-entry variables was used to identify factors contributing to COI.

Results:

On discharge from CRWs, COI and ICOI were observed in 140 and 207 cases, respectively. The COI group was younger, had a higher rate of initial stroke, higher Functional Oral Intake Scale (FOIS) scores, higher Functional Independence Measure (FIM) motor and cognitive scores, higher Body Mass Index (BMI), lower rate of patients with PEG, and shorter stays in acute care wards. Logistic regression analysis with forced entry revealed that younger age; initial stroke; higher FOIS score, FIM cognitive score, and BMI; and shorter stay in the acute care ward contributed to COI.

Conclusions:

The primary factors contributing to COI in dysphagic stroke patients with enteral feeding tubes were younger age, initial stroke, higher swallowing and cognitive function, good nutritional status, and shorter stay in the acute care ward.

Association of the body mass index with poor outcome at discharge in patients with aneurysmal subarachnoid hemorrhage: a registry study

Although several studies have reported on the impact of the body mass index (BMI) on functional outcome of aneurysmal subarachnoid hemorrhage (aSAH), the relationship remains unclear. This study aimed to investigate the risk factors of poor outcome of aSAH, with particular attention to BMI. A total of 860 patients with aSAH were enrolled in our registry at Shimane Prefectural Central Hospital between 2000 and 2017, of whom 393 were included in the analysis. Basic patient characteristics, including BMI, and data related to aSAH were recorded. We conducted a univariable analysis, followed by a multivariable analysis to identify the risk factors of poor outcome, defined as a modified Rankin Scale score > 2 at discharge. We also compared our study with previous studies that reported a relationship between BMI and aSAH. Multivariable analysis revealed that age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.07-1.12), underweight (OR, 2.36; 95% CI, 1.13-4.90), overweight (OR, 2.22; 95% CI, 1.06-4.64), World Federation of Neurosurgical Societies grade (III vs I: OR, 3.10; 95% CI, 1.03-9.35; IV vs I: OR, 8.02; 95% CI, 3.54-18.19; V vs I: OR, 13.37; 95% CI, 5.33-33.54), and symptomatic vasospasm (OR, 3.40; 95% CI, 1.73-6.70) were risk factors for poor outcome at discharge. This study showed the association of underweight (BMI < 18.5 kg/m²) and overweight (≥ 25 kg/m²) with poor outcome; therefore, both high and low BMI are associated with a poor outcome at discharge for patients with aSAH. Clinical trial registry: University Hospital Medical Information Network (UMIN000035160; date of registration: December 6, 2018).

Early neurological deterioration in patients with acute ischemic stroke: a prospective multicenter cohort study

Background

There is still no precise knowledge of the causes of progression in patients with acute ischemic stroke (AIS), and we are unable to predict patients at risk.

Objective

To explore the frequency, predictive factors, and the prognosis of early neurological deterioration (END) in patients with AIS.

Methods

In this prospective multicenter observational study, we assessed patients with AIS admitted to 18 hospitals in Henan, China. We defined END as an increase of ⩾2 points in total National Institutes of Health Stroke Scale (NIHSS) score or ⩾1 point in the motor items of the NIHSS within 7 days after admission. Risk factors were analyzed using multivariate logistic regression models. Prognosis was evaluated using the modified Rankin Scale (mRS), with poor prognosis defined as mRS 3-6.

Results

A total of 9114 patients with AIS within 24 h of symptom onset were enrolled in the study. END occurred in 1286 (14.1%) patients. The highest incidence (62.5%) of END occurred within 24 h after admission. After adjusting potential confounders, age, body mass index, waist-hip ratio, systolic blood pressure, baseline NIHSS, disabled at baseline, history of atrial fibrillation, diabetes mellitus, intracranial arterial stenosis, infarct location in the lenticulostriate artery area and cerebral watershed, neutrophils, lymphocytes, uric acid, and triglycerides were identified as independent predictors for END. END was significantly associated with poor prognosis at 90 days, and the adjusted OR was 1.74 (95% CI: 1.53-1.97).

Conclusion

One in seven hospitalized patients with AIS may experience END within 24 h of onset. The highest incidence of END occurred within 24 h of admission and decreased steeply with time. Easily identifiable risk factors predict END and could help understand the causal mechanisms and thereby prevent END.

The Impact of Body Mass Index Classification on Outcomes After Stroke Rehabilitation: A Retrospective Study

ABSTRACT

With improving stroke mortality rates, more individuals are living with the consequences of stroke. Obesity is a known risk factor for stroke, but its effect on functional outcomes poststroke is less clear. The aim of this study was to determine the association between body mass index classification (underweight, normal weight, overweight, and obese) and functional outcomes, as measured by Functional Independence Measure change, Functional Independence Measure efficiency, and rehabilitation length of stay after inpatient stroke rehabilitation. A retrospective cohort study of individuals with a diagnosis of stroke admitted to a high-intensity inpatient rehabilitation program was performed. Patients were divided into 4 groups based on body mass index category using normal body mass index as the reference. Overall, 34 individuals (4.5%) were classified as underweight, 303 (40.1%) had body mass indices within the normal range, 269 (35.6%) were overweight, and 149 (19.7%) were obese. Ischemic stroke was the most common stroke type across all body mass index categories. Patients in the overweight and obese groups tended to be younger. There were no statistically significant differences in rehabilitation length of stay, Functional Independence Measure change, or Functional Independence Measure efficiency with all groups demonstrating significant functional improvements. Based on these findings, patients admitted for inpatient rehabilitation after stroke can be expected to make similar functional improvements regardless of BMI class.

Body Mass Index and the Risk of Poor Outcome in Surgically Treated Patients With Good-Grade Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Heterogeneity among study populations and treatment procedures has led to conflicting results on outcome predictors for patients with aneurysmal subarachnoid hemorrhage (aSAH). One such conflicting predictor is body mass index (BMI).

OBJECTIVE

To clarify whether high BMI values protect patients from poor outcome after aSAH, as previously suggested.

METHODS

We surveyed 6 prospective studies conducted in 14 different countries (93 healthcare units) between 1985 and 2016 and pooled the data on surgically treated patients with good-grade (Glasgow Coma Scale 13-15 on admission) aSAH. We calculated BMI for each patient and created 4 balanced categories based on the BMI quartiles of each cohort. We calculated adjusted odds ratios (ORs) with 95% CIs for the 3-month poor outcome (Glasgow Outcome Scale 1-3) by BMI.

RESULTS

The pooled study cohort included 1692 patients with good-grade aSAH (mean age 51 years; 64% female). At 3 months, 288 (17%) had poor outcomes. The risk for poor outcomes increased with increasing BMI values (OR = 1.15 [1.02-1.31] per each standard deviation increase of BMI). The risk for poor outcome was over 1.6 times higher (OR = 1.66 [1.13-2.43]) in the highest BMI category (range 27.1-69.2) compared with the lowest BMI category (range 14.4-23.8). These associations were found in each of the 6 study cohorts in both men and women, regardless of age.

CONCLUSION

Because higher BMI values seem to associate with poor outcomes in surgically treated patients with good-grade aSAH, it seems unlikely that obesity protects patients with aSAH from poor outcomes.

Hypertriglyceridemic waist phenotype: Association with initial neurological severity and etiologic subtypes in patients with acute ischemic stroke

OBJECTIVE

To explore the relationship of hypertriglyceridemic waist phenotype (HTWP) with initial neurological severity and etiologic subtypes in patients with acute ischemic stroke.

METHODS

The data for this study were collected from hospitalized patients within 72 h of acute ischemic stroke onset at the Department of Neurology of the Affiliated Hospital of Beihua University from 1 July 2020 to 30 June 2022. The initial neurological severity was assessed by the National Institute of Health Stroke Scale (NIHSS) on the day of admission: NIHSS <6 was defined as mild stroke, and NIHSS ≥6 as moderate to severe stroke. HTWP was defined by fasting serum triglycerides ≥1.7 mmol/L and waist circumference ≥90 cm in men and ≥80 cm in women. Differentiation of etiologic subtypes was based on the method reported in the Trial of Org 10 172 in Acute Stroke Treatment. Multivariate logistic regression analysis was used to analyze the association of HTWP with initial neurological severity and etiologic subtypes.

RESULTS

The study included 431 patients. Compared with the normal waist-normal blood triglyceride group, patients with HTWP had reduced risks of moderate to severe stroke [odds ratio (OR): 0.384, 95% confidence interval (CI): 0.170-0.869; P = 0.022]. In addition, the risk of small-artery occlusion stroke was 2.318 times higher in the HTWP group than in the normal triglyceride-normal waist (NWNT) group (OR: 2.318, 95% CI: 1.244-4.319; P = 0.008).

CONCLUSION

Initial neurological severity was less severe in patients with HTWP, and HTWP was associated with an increased risk of small-artery occlusion stroke.

Another Look at Obesity Paradox in Acute Ischemic Stroke: Association Rule Mining

Though obesity is generally associated with the development of cardiovascular disease (CVD) risk factors, previous reports have also reported that obesity has a beneficial effect on CVD outcomes. We aimed to verify the existing obesity paradox through binary logistic regression (BLR) and clarify the paradox via association rule mining (ARM). Patients with acute ischemic stroke (AIS) were assessed for their 3-month functional outcome using the modified Rankin Scale (mRS) score. Predictors for poor outcome (mRS 3–6) were analyzed through BLR, and ARM was performed to find out which combination of risk factors was concurrently associated with good outcomes using maximal support, confidence, and lift values. Among 2580 patients with AIS, being obese (OR [odds ratio], 0.78; 95% CI, 0.62–0.99) had beneficial effects on the outcome at 3 months in BLR analysis. In addition, the ARM algorithm showed obese patients with good outcomes were also associated with an age less than 55 years and mild stroke severity. While BLR analysis showed a beneficial effect of obesity on stroke outcome, in ARM analysis, obese patients had a relatively good combination of risk factor profiles compared to normal BMI patients. These results may partially explain the obesity paradox phenomenon in AIS patients.

Diabetes, Vascular Aging and Stroke: Old Dogs, New Tricks?

BACKGROUND

Stroke remains a leading cause of death and disability throughout the world. It is well established that Diabetes Mellitus (DM) is a risk factor for stroke, while other risk factors include dyslipidaemia and hypertension. Given that the global prevalence of diabetes steadily increases, the need for adequate glycaemic control and prevention of DM-related cardiovascular events remains a challenge for the medical community. Therefore, a re-examination of the latest data related to this issue is of particular importance.

OBJECTIVE

This review aims to summarise the latest data on the relationship between DM and stroke, including epidemiology, risk factors, pathogenesis, prevention and biomarkers.

METHODS

For this purpose, comprehensive research was performed on the platforms PubMed, Google Scholar and EMBASE with a combination of the following keywords: diabetes mellitus, stroke, macrovascular complications, diabetic stroke, cardiovascular disease.

CONCLUSIONS

Much progress has been made in stroke in people with DM in terms of prevention and early diagnosis. In the field of prevention, the adaptation of the daily habits and the regulation of co-morbidity of individuals play a particularly important role. Simultaneously, the most significant revolution has been brought by the relatively new treatment options that offer protection to the cardiovascular system. Moreover, many prognostic and diagnostic biomarkers have been identified, paving the way for early and accurate diagnoses. However, to date, there are crucial points that remain controversial and need further clarification.

Association Between Weight Loss and Activities of Daily Living in Obese and Overweight Patients after Stroke: A Cross-Sectional Study

OBJECTIVE

Whether weight loss during hospitalization is associated with improvement in activities of daily living (ADL) in overweight and obese stroke patients remains unclear. This study investigated the association between decreases in body mass index (BMI), fat-free mass (FFM), and fat mass (FM) and ADL improvement.

MATERIALS AND METHODS

In this cross-sectional study, we analyzed data of patients admitted to acute care hospitals with stroke. Patients were classified into two groups based on their change in BMI during their hospital stay (i.e. decreased or nondecreased group). To control and adjust for patient characteristics and confounders, we created an inverse probability-weighted (IPW) model using propensity scoring, which was used to compare the Functional Independence Measure Motor (FIM-M) efficacy between the two groups. We also compared FFM and FM between admission and discharge in each group.

RESULTS

A total of 556 patients were analyzed, among whom 391 (70.3%) had a decrease in BMI and 165 (29.7%) had a nondecrease. After IPW adjustment, efficiency of FIM-M was significantly higher in the nondecreased group as compared to that in the decreased group (median: 0.44 vs. 0.29, P < 0.001). FFM and FM were significantly decreased from admission to discharge in the decreased group, but there was no significanct difference observed in the nondecreased group. Preserving BMI during hospitalization was associated with a positive improvement in ADL in overweight and obese stroke patients undergoing rehabilitation.

CONCLUSIONS

Risks and benefits of weight loss should be balanced in nutritional care and rehabilitation for overweight and obese stroke patients.

Differential effects of body mass index on domain-specific cognitive outcomes after stroke

Although the obesity paradox is an important modifiable factor in cardiovascular diseases, little research has been conducted to determine how it affects post-stroke cognitive function. We aimed to investigate the association between body mass index (BMI) and domain-specific cognitive outcomes, focusing on the subdivision of each frontal domain function in post-ischemic stroke survivors. A total of 335 ischemic stroke patients were included in the study after completion of the Korean-Mini Mental Status Examination (K-MMSE) and the vascular cognitive impairment harmonization standards neuropsychological protocol at 3 months after stroke. Frontal lobe functions were analyzed using semantic/phonemic fluency, processing speed, and mental set shifting. Our study participants were categorized into four groups according to BMI quartiles. The z-scores of K-MMSE at 3 months differed significantly between the groups after adjustment for initial stroke severity (p = 0.014). Global cognitive function in stroke survivors in the Q1 (the lowest quartile) BMI group was significantly lower than those in Q2 and Q4 (the highest quartile) BMI groups (K-MMSE z-scores, Q1: − 2.10 ± 3.40 vs. Q2: 0.71 ± 1.95 and Q4: − 1.21 ± 1.65). Controlled oral word association test findings indicated that phonemic and semantic word fluency was lower in Q4 BMI group participants than in Q2 BMI group participants (p = 0.016 and p = 0.023 respectively). BMI might differentially affect cognitive domains after ischemic stroke. Although being underweight may negatively affect global cognition post-stroke, obesity could induce frontal lobe dysfunctions, specifically phonemic and semantic word fluency.

Post-traumatic stress disorder and its association with stroke and stroke risk factors: A literature review

Stroke is a major cause of mortality and disability globally that has multiple risk factors. A risk factor that has recently gained more attention is post-traumatic stress disorder (PTSD). Literature searches were carried out for updated PTSD information and for the relationship between PTSD and stroke. The review was divided into two sections, one exploring PTSD as an independent risk factor for stroke, with a second concentrating on PTSD's influence on stroke risk factors. The study presents accumulating evidence that shows traumatic stress predicts stroke and is also linked to many major stroke risk factors. The review contributes knowledge to stroke aetiology and acts as a reference for understanding the relationship between PTSD and stroke. The information presented indicates that screening and identification of traumatic experience would be beneficial for directing stroke patients to appropriate psychological and lifestyle interventions. In doing so, the burden of stroke may be reduced worldwide.

Body mass index and leptin levels in serum and cerebrospinal fluid in relation to delayed cerebral ischemia and outcome after aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is associated with a high mortality rate and may leave surviving patients severely disabled. After the initial hemorrhage, clinical outcome is further compromised by the occurrence of delayed cerebral ischemia (DCI). Overweight and obesity have previously been associated with protective effects in the post-bleeding phase. The aim of this study was to assess the effects of a patient’s body mass index (BMI) and leptin levels on the occurrence of DCI, DCI-related cerebral infarction, and clinical outcome. In total, 263 SAH patients were included of which leptin levels were assessed in 24 cases. BMI was recorded along disease severity documented by the Hunt and Hess and modified Fisher scales. The occurrence of clinical or functional DCI (neuromonitoring, CT Perfusion) was assessed. Long-term clinical outcome was documented after 12 months (extended Glasgow outcome scale). A total of 136 (51.7%) patients developed DCI of which 72 (27.4%) developed DCI-related cerebral infarctions. No association between BMI and DCI occurrence (P = .410) or better clinical outcome (P = .643) was identified. Early leptin concentration in serum (P = .258) and CSF (P = .159) showed no predictive value in identifying patients at risk of unfavorable outcomes. However, a significant increase of leptin levels in CSF occurred from 326.0 pg/ml IQR 171.9 prior to DCI development to 579.2 pg/ml IQR 211.9 during ongoing DCI (P = .049). In our data, no association between obesity and clinical outcome was detected. After DCI development, leptin levels in CSF increased either by an upsurge of active transport or disruption of the blood-CSF barrier. This trial has been registered at ClinicalTrials.gov (NCT02142166) as part of a larger-scale prospective data collection. BioSAB: https://clinicaltrials.gov/ct2/show/NCT02142166

Higher BMI Confers a Long-Term Functional Status Advantage in Elderly New Zealand European Stroke Patients

OBJECTIVE

Obesity is a risk factor for ischaemic stroke but provides a survival advantage. The relationship between body mass index (BMI) and long-term function is less clear. The presence of an obesity paradox can inform clinical care and identify vulnerable patients who need additional support post-stroke.

MATERIALS AND METHODS

This study used linked health administrative data of a population based cohort of adult patients who experienced an ischaemic stroke between 2012 and 2017 in New Zealand. Patient demographics were obtained from the National Minimum Dataset (NMDS). BMI and Activities of Daily Living scores (ADLs) for the same patients were obtained from the International Resident Assessment Instrument (InterRAI™).

RESULTS

Linked data was obtained for 3731 patients. Ninety-five percent of the cohort were aged 65 or older and the average age of stroke was 84.5 years. The majority of patients (55%) identified as New Zealand European. Beta regression indicated BMI and European ethnicity were negatively associated with ADL score. Univariate analysis confirmed patients with underweight stroke had significantly higher ADL scores than other BMI categories (p<0.001), however functional status for patients with overweight and obesity were comparable. Further, Asian and Pacific Peoples had higher ADL scores than Europeans (p<0.05). A higher BMI was advantageous to all ADL subscores.

CONCLUSION

An abridged obesity paradox was evident in our cohort of stroke patients where a BMI in the overweight, but not obese range conferred a long-term functional status advantage. Collectively these results suggest underweight and non-European patients may require additional supportive clinical care post-stroke.

Obesity and Stroke: Does the Paradox Apply for Stroke?

Historically, obesity has been identified as one of the most important risk factors for developing cardiovascular diseases including stroke; however, a theory called "The Obesity Paradox" has been recently considered. The paradoxical theory is that obese or overweight patients (according to body mass index score) can have better outcomes compared to leaner or malnourished patients. The paradox was initially discovered in patients with heart failure. The purpose of this manuscript was to investigate whether this paradox also applies to stroke patients, according to information available in the current literature.

Obesity paradox and stroke: a narrative review

BACKGROUND

Despite obesity is an established risk factor for stroke, several studies reported a better outcome after stroke in obese and overweight patients. This counterintuitive finding, which was described in the whole spectrum of cardiovascular diseases, is known as obesity paradox.

OBJECTIVE

This is a narrative overview on the obesity paradox and stroke.

METHODS

We used as sources MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library from inception to 2019, and selected papers that discussed the association of obesity with outcome and mortality after stroke.

RESULTS

The majority of studies reported lower mortality rates and better functional outcome after stroke in obese and overweight patients compared with normal weight and underweight patients, suggesting the existence of an obesity paradox in stroke. However, available studies are limited by several major methodological concerns including absence of randomized trials, retrospective nature of most studies, assessment of obesity with body mass index (BMI), non-linear relationship between BMI and outcome, short follow-up period, and differences in co-morbid conditions and stroke characteristics.

CONCLUSIONS

The existence of an obesity paradox in stroke is still controversial and further higher quality evidence is needed to clarify the relationship between obesity and stroke outcome.

LEVEL OF EVIDENCE

Level V, narrative review.

New Insights into Stroke Prevention and Treatment: Gut Microbiome

Stroke, a lethal neurological disease, accounts for a grave economic burden on society. Despite extensive basic and clinical studies on stroke prevention, a precise effective treatment approach for stroke at this stage remains unavailable. The majority of our body's gut microbiota plays a vital role in food digestion, immune regulation, and nervous system development, which is highly associated with the development of some diseases. Multiple clinical studies have documented variation in the composition of gut microbiota between stroke patients and healthy counterparts. Moreover, the intervention of intestinal symbiotic microorganisms via several mechanisms plays an active role in stroke prognosis. In the prevention and treatment of stroke, the gut microbiota gives off a seductive glow, this is a promising therapeutic target. This paper summarizes the current knowledge of stroke and gut microbiota, and systematically describes the possible mechanisms of interaction between stroke and gut microbiota, the relationship between stroke-related risk factors and gut microbiota, and the treatment of gut flora using microorganisms. Thus, it could valuably elucidate the correlation of gut microbiota with stroke incidence, providing stroke researchers with a new strategy for stroke prevention and treatment by regulating gut microbiota.

Association of obesity with recurrent stroke and cardiovascular events

BACKGROUND AND PURPOSE

The relation between obesity and stroke recurrence is still under debate. In this study, we investigated whether initial obesity was associated with recurrent stroke and major cardiovascular events over a long period of time.

MATERIALS AND METHODS

Five-years follow-up data of the Ege Stroke Registry for stroke recurrence and cardiovascular events related to obesity were analyzed. Data include age, gender, stroke severity, neuroimaging studies, cardiovascular risk factors. Within the inclusion period, all of the included patients were followed until censoring (10th of December 2011) or readmission because of recurrent stroke, cardiovascular event or death, whichever came first. The Kaplan-Meier method was used for survival analysis. Cox proportional hazard model was applied to identify predictors of stroke and all major vascular events.

RESULTS

Of 9285 eligible patients for evaluation, 5158 (56%) were male and 3068 (33%) with a prior stroke were obese at baseline. Among 2198 patients with recurrent stroke, 843 (38%) had obesity while 2229 (62%) had no obesity (HR, 1.36; 95% CI, 1.23-1.50; P<0.001). Overall major vascular events (recurrent stroke, cardiovascular events, and death) occurred in 1464 obese patients (48%) and in 2182 non-obese patients (35%) (HR, 1.69; 95%CI, 1.55-1.84). Cox hazard model showed that being obese was associated with increased recurrent stroke risk compared with those without obesity (HR, 0.85; 95%CI, 0.76-0.94; P<0.001), being obese was not associated with cardiovascular events (HR, 1.09; 95%CI, 0.95-1.26; P=0.22).

CONCLUSIONS

Our results showed that obesity is a significant risk factor for recurrent stroke, although obesity was not associated significantly with myocardial infarction and death after 5-years of first stroke. Further clinical goal-directed weight reduction outcome trials in this area will be critical to validate the most effective approaches and, ultimately, to guide policy is certainly needed.

Association between body mass index and stroke severity in acute ischaemic stroke with non-valvular atrial fibrillation

BACKGROUND AND PURPOSE

The objective of this study was to investigate the association between body mass index (BMI) and both initial stroke severity at presentation and functional outcomes after acute ischaemic stroke (AIS) in patients with non-valvular atrial fibrillation (NVAF).

METHODS

Patients were categorized on the basis of their BMI into underweight (BMI <18.5, n = 111), normal (18.5 ≤ BMI <25, n = 1036) and overweight to obese (BMI ≥25, n = 472) groups. Initial stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) score and functional outcomes were assessed using the modified Rankin Scale score at discharge. The differences in stroke severity and functional outcomes were compared between groups using robust log-linear regression with a Poisson distribution and binary logistic regression analysis.

RESULTS

A total of 1619 AIS patients with NVAF from six hospitals were included. Compared with the NIHSS scores [median 5, interquartile range (IQR) 2-14] of normal-weight patients, the NIHSS scores (median 9, IQR 4-19) of underweight patients were more likely to be higher, whereas those of overweight to obese patients were lower (median 4, IQR 1-12) (P < 0.001). In terms of functional outcomes after stroke, underweight patients had a higher risk of poor functional outcomes (odds ratio 1.78, 95% confidence interval 1.09-2.56, P = 0.01) but overweight to obese patients had no significant difference in functional outcomes compared with normal-weight patients.

CONCLUSION

An inverse association was found between BMI and stroke severity in AIS patients with NVAF. This suggests the presence of an obesity paradox for short-term outcomes in patients with NVAF.

The Effect of Body Mass Index on Outcome after Endovascular Treatment in Acute Ischemic Stroke Patients: A Post Hoc Analysis of the MR CLEAN Trial

BACKGROUND

Though obesity is a well-known risk factor for vascular disease, the impact of obesity on stroke outcome has been disputed. Several studies have shown that obesity is associated with better functional outcome after stroke. Whether obesity influences the benefit of endovascular treatment (EVT) in stroke patients is unknown. We evaluated the association between body mass index (BMI) and outcome in acute ischemic stroke patients with large vessel -occlusion (LVO), and assessed whether BMI affects the -benefit of EVT.

METHODS

This is a post hoc analysis of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands trial (-ISRCTN10888758). BMI was used as a continuous and categorical variable, distinguishing underweight and normal weight (BMI <25), overweight (BMI 25-30), and obesity (BMI ≥30). We used multivariable ordinal logistic regression analysis to estimate the association of BMI with functional outcome (shift analysis), assessed with modified Rankin Scale (mRs) at 90 days. The impact of BMI on EVT effect was tested by the use of a multiplicative interaction term.

RESULTS

Of 366 patients, 160 (44%) were underweight or normal weight, 145 (40%) overweight, and 61 (17%) were obese. In multivariable analysis with BMI as a continuous variable, we found a shift toward better functional outcome with higher BMI (mRS adjusted common OR 1.04; 95% CI 1.0-1.09), and mortality was inversely related to BMI (aOR 0.92; 95% CI 0.85-0.99). Safety analysis showed that higher BMI was associated with lower risk of stroke progression (aOR 0.92, 95% CI 0.87-0.99). Additional analysis showed no interaction between BMI and EVT effect on functional outcome, mortality, and other safety outcomes.

CONCLUSION

Our study confirms the effect of obesity on outcome in acute ischemic stroke patients with LVO, meaning better functional outcome, lower mortality, and lower risk of stroke progression for patients with higher BMI. As we found no interaction between BMI and EVT effect, all BMI classes may expect the same benefit from EVT.

Uric Acid Contributes to Obesity-Paradox of the Outcome of Ischemic Stroke

Background: The mechanism of obesity paradox in stroke is not clear. This study aimed to investigate whether uric acid (UA) contributes to obesity-stroke outcome paradox.

Material and Methods: The study cohort consisted of 1,984 IS patients recruited in the ACROSS-China study. Serum UA and BMI were measured at admission. Low and high BMI groups were defined by the threshold of 24, and low and high UA by the age- and sex-specific median. Poor outcomes were defined as modified Rankin scale score ≥3 in 1 year after onset.

Results: UA was significantly and positively correlated with BMI. Lower levels of UA and BMI were significantly associated with higher risk of poor outcomes. Incidence of the poor outcome was 34.5, 29.4, 27.7, and 23.5% in the BMI/UA groups of low/low, high/low, low/high and high/high, respectively, with p = 0.001 for trend. The association between low UA and poor outcome was significant in lower BMI groups (odds ratio = 1.36, p = 0.006 in quartile 1 and 1.28, p = 0.021 in quartile 2), but the odds ratios were not significant in the BMI quartile 3 and 4 groups, with p = 0.038 for trend. The adverse effect of lower UA was significant in males, but not in females, with p = 0.006 for sex difference.

Conclusions: These findings suggest that low UA and low BMI have a joint effect on poor outcomes in IS patients. Across BMI categories, uric acid is differentially associated with functional outcome after stroke. This effect of low UA in the low BMI groups may be one of the mechanisms underlying the obesity-stroke paradox of the outcome in IS patients.

Obesity paradox in subarachnoid hemorrhage: a systematic review

As the number of obese people is globally increasing, reports about the putative protective effect of obesity in life-threatening diseases, such as subarachnoid hemorrhage (SAH), are gaining more interest. This theory-the obesity paradox-is challenging to study, and the impact of obesity has remained unclear in survival of several critical illnesses, including SAH. Thus, we performed a systematic review to clarify the relation of obesity and SAH mortality. Our study protocol included systematic literature search in PubMed, Scopus, and Cochrane library databases, whereas risk-of-bias estimation and quality of each selected study were evaluated by the Critical Appraisal Skills Program and Cochrane Collaboration guidelines. A directional power analysis was performed to estimate sufficient sample size for significant results. From 176 reviewed studies, six fulfilled our eligibility criteria for qualitative analysis. One study found paradoxical effect (odds ratio, OR = 0.83 (0.74-0.92)) between morbid obesity (body mass index (BMI) > 40) and in-hospital SAH mortality, and another study found the effect between continuously increasing BMI and both short-term (OR = 0.90 (0.82-0.99)) and long-term SAH mortalities (OR = 0.92 (0.85-0.98)). However, according to our quality assessment, methodological shortcomings expose all reviewed studies to a high-risk-of-bias. Even though two studies suggest that obesity may protect SAH patients from death in the acute phase, all reviewed studies suffered from methodological shortcomings that have been typical in the research field of obesity paradox. Therefore, no definite conclusions could be drawn.

Body mass index and clinical outcomes in patients after ischaemic stroke in South Korea: a retrospective cohort study

OBJECTIVES

Although obesity is a risk factor for stroke, its impact on mortality in patients with stroke remains unclear. In this study, we aimed to evaluate the relationship between body mass index (BMI) and mortality due to ischaemic stroke among adults aged 20 years and above in Korea.

DESIGN

Retrospective cohort study.

SETTING

A tertiary-hospital-based stroke registry linked to the death records.

PARTICIPANTS

3599 patients admitted for ischaemic stroke from January 2007 to June 2013.

OUTCOME MEASURES

The HRs for all-cause and stroke-related mortality were calculated using Cox proportional hazards models. Progression from stroke-related mortality was assessed using the Fine-Grey competing risk model, treating other-cause mortality as a competing risk. Adjustments were made for age, gender, smoking status, Charlson comorbidity index, cardiovascular or non-cardiovascular comorbidities, stroke severity, severity related to other medical conditions, complications and enrolment year. We repeated the analysis with stratification based on age groups (less than 65 vs 65 years and above).

RESULTS

For stroke-related mortality, there was no significant difference among the four BMI groups. The risk of all-cause mortality was 36% higher in the underweight group than in the normal weight group (long-term HR=1.36, 95% CI: 1.04 to 1.79), whereas the mortality risk of the obese group was significantly lower (HR=0.66, 95% CI: 0.54 to 0.81). Although this relationship was not estimated in the younger group, it was found that obesity had a protective effect on the all-cause mortality in the elderly (long-term HR=0.66, 95% CI: 0.52 to 0.83).

CONCLUSIONS

Obesity is more likely to reduce mortality risk than normal weight, especially in elderly patients.

Obesity-Stroke Paradox Exists in Insulin-Resistant Patients But Not Insulin Sensitive Patients

Background and Purpose- The underlying mechanisms of stroke-obesity paradox are still not fully understood. This study aims to investigate the contribution of insulin resistance to the association between body mass index and stroke outcomes. Methods- Patients with ischemic stroke without history of diabetes mellitus in the Abnormal Glucose Regulation in Patients With Acute Stroke Across-China registry were included. Overweight or obese was defined as body mass index ≥23, and the median of homeostasis model assessment-insulin resistance index was chosen as cutoff to define insulin resistance. Cox or logistic regression model was used to assess the interaction between body mass index and homeostasis model assessment-insulin resistance on 1-year prognosis (all-cause mortality and poor functional outcome defined as modified Rankin Scale score 3-6). Results- Of 1227 study participants, the median homeostasis model assessment-insulin resistance was 1.9 (interquartile range, 1.1-3.1) and 863 (70.3%) patients were classified as overweight or obese. Among insulin-resistant patients, overweight/obese patients experienced one-half of the risk of death after stroke than their low/normal weight counterparts (9.42% versus 17.69%, unadjusted hazard ratio, 0.50; 95% CI, 0.31-0.82), while among insulin-sensitive ones, no significant difference of mortality risk was found (7.58% versus 6.91%, 1.07; 0.57-1.99). Similar trends were observed for poor functional outcome. Results were similar after adjustments for confounders. There were significant interactions between body mass index and homeostasis model assessment-insulin resistance on the risks of mortality (P=0.045) and poor functional outcome (P=0.049). Conclusions- We observed the obesity paradox for mortality and functional outcome in insulin-resistant patients but did not find the obesity paradox in insulin-sensitive patients. Insulin resistance may be one of the mechanisms underlying the obesity paradox of the outcome in patients with ischemic stroke.

Obesity Paradox in Ischemic Stroke: Clinical and Molecular Insights

It has recently emerged the concept of "obesity paradox," a term used to describe the unexpected improved prognosis and lower mortality rates found in several diseases in patients with higher body weight. Concerning stroke, few clinical studies have assessed this obesity paradox showing contradictory results. Therefore, our aim was to compare clinical evolution and inflammatory balance of obese and non-obese patients after ischemic stroke. We designed a prospective case-control study in patients with acute ischemic stroke categorized into obese (body mass index, BMI ≥ 30 kg/m²) and non-obese (BMI < 30 kg/m²). We compared clinical, anthropometric, radiological, and laboratory variables. The main outcome variable was the functional outcome at 3 months. We included 98 patients (48 non-obese and 50 obese). No differences in functional outcome at 3 months were found (p = 0.882) although a tendency of a greater recovery on neurological impairments was seen in obese subjects. Importantly, obese patients (p = 0.007) and patients who experienced poor outcome (p = 0.006) exhibited a higher reduction in body weight at 3 months after stroke. Moreover, pro-inflammatory IL-6 levels (p = 0.002) were higher in the obese group. However, IL-6 levels decreased over the first week in obese while increased in non-obese. On the contrary, levels of the anti-inflammatory IL-10 rose over the first week in obese patients, whereas remained stable in non-obese. In summary, despite exhibiting several factors associated with poor outcome, obese patients do not evolve worse than non-obese after ischemic stroke. Obesity may counterbalance the inflammatory reaction through an anti-inflammatory stream enhanced in the first moments of stroke.

The association between obesity and outcomes in acute pancreatitis: an individual patient data meta-analysis

OBJECTIVES

There are data to suggest that obesity is associated with local and systemic complications as well as mortality in acute pancreatitis (AP). Cohort studies to date, however, have shown conflicting results from mostly unadjusted analyses. Therefore, we performed an individual patient data meta-analysis with the primary aim to investigate the association between obesity and mortality in AP. Our secondary aim was to investigate the association between obesity and necrosis, organ failure, multiple organ failure, and invasive intervention.

PATIENTS AND METHODS

We systematically searched four electronic databases for prospective studies on obesity and outcomes in AP. Researchers of eligible studies were invited to share individual patient data using a standardized data collection form. All end points were investigated with a one-stage mixed effects Poisson model with random intercepts and forced entry of relevant confounders.

RESULTS

We included five databases with 1302 patients, of whom 418 (32%) were obese. In total, 466 (36%) patients had necrosis, 328 (25%) had organ failure, 188 (14%) had multiple organ failure, 210 (16%) had an intervention, and 84 (7%) patients died. We found no significant association between obesity and mortality [relative risk (RR) 1.40, 95% confidence interval (CI): 0.89-2.20], necrosis (RR: 1.08, 95% CI: 0.90-1.31) or invasive intervention (RR: 1.10, 95% CI: 0.83-1.47) after adjustment for confounders. However, obesity was independently associated with the development of organ failure (RR: 1.38, 95% CI: 1.11-1.73) and multiple organ failure (RR: 1.81, 95% CI: 1.35-2.42).

CONCLUSION

Obesity is independently associated with the development of organ failure and multiple organ failure in AP. However, there is no association between obesity and mortality, necrosis, and an intervention.

The impact of malnutrition on efficacy of resistance training in community-dwelling older adults

OBJECTIVE

Few studies have focused on the effect of resistance training under conditions of malnutrition in older adults requiring long-term care. The purpose of this study was to investigate the influence of nutritional status in older adults on resistance training-induced changes in physical performance.

METHODS

A total of 91 community-dwelling older adults participated in 24 weeks of resistance training. Participants used the 60% of one repetition maximum for three sets of 10 repetitions for resistance training. Short Physical Performance Battery (SPPB), Mini Nutritional Assessment Short Form (MNA-SF), Barthel Index, and grip strength were measured before and after the resistance training. The participants were classified into three groups according to the MNA-SF score at baseline (0 to 7 as malnutrition group, 8 to 11 as at risk group, and 12 to 14 as well-nourished group).

RESULTS

In comparing the preintervention and postintervention changes in functional fitness of the groups, there was a significant Group × Time interaction for SPPB scores (F = 11.59, p < 0.01), 4-m walk speed (F = 5.87, p < 0.01), and grip strength (F = 3.27, p < 0.05). Multivariate logistic regression analysis showed that well-nourished group was significantly more likely to improvement of physical function (odds ratio 3.08, 95% confidence interval [1.54, 6.15], p < 0.01).

CONCLUSIONS

The results of study revealed that malnutrition was an independent negative factor of effects of resistance training in older adults. These results suggested that effects of resistance training may be affected by the nutritional state.

Functional Outcome Measures of Recombinant Tissue Plasminogen Activator-Treated Stroke Patients in the Telestroke Technology

The efficiency of telestroke programs in improving the rates of recombinant tissue plasminogen activator (rtPA) in stroke patients has been reported. Previous studies have reported favorable treatment outcomes with the use of telestroke programs to improve the use of rtPA, but functional outcomes are not fully understood. This study investigated the effect of telestroke technology in the administration of rtPA and related functional outcomes associated with baseline clinical variables. Retrospective data of a telestroke registry were analyzed. Univariate analysis was used to compare demographic and clinical variables in the rtPA group and the no rtPA group and between the improved functional ambulation group and the no improvement group. A stepwise binary logistic regression identified factors associated with improved functional outcome in the total telestroke population and in the subset of the telestroke population who received rtPA. In adjusted analysis and elimination of any multicollinearity for patients who received rtPA in the telestroke setting, obesity (odds ratio [OR] = 2.138, 95% confidence interval [CI], 1.164-3.928, P < .05), higher systolic blood pressure at the time of presentation (OR = 1.015, 95% CI, 1.003-1.027, P < .05), and baseline high-density lipoprotein at the time of admission (OR = 1.032, 95% CI, 1.005-1.059, P < .05) were associated with improved functional outcomes. Increasing age (OR = 0.940, 95% CI, 0.916-0.965, P < .0001) and higher calculated National Institutes of Health Stroke Scale (OR = 0.903, 95% CI, 0.869-0.937) were associated with a poorer outcome in rtPA-treated patients. Telestroke technology improves functional outcomes at spoke stations where neurological expertise is unavailable. Further studies are necessary to determine how telestroke technology can be optimized, especially to improve contraindications and increase eligibility for thrombolysis therapy.

Association of higher waist circumference with milder stroke severity in acute ischaemic stroke

OBJECTIVES

Although higher body mass index (BMI) was reported to be associated with increased stroke incidence, having a higher BMI is known to be associated with better clinical outcomes after stroke. However, BMI has shown conflicting associations with baseline stroke severity. The aim of our study was to assess the relationship between waist circumference (WC) at admission and baseline stroke severity among patients with ischaemic stroke.

METHODS

The WC of acute stroke patients was divided into sex-specific quartiles. Baseline stroke severity was categorised as mild [National Institutes of Health Stroke Scale (NIHSS) score 0-4], moderate (NIHSS score 5-10), and severe (NIHSS score ≥11). Multinomial logistic regression was used and reference categories were men or women in the lowest sex-specific WC quartiles who had experienced a mild stroke.

RESULTS

A total of 637 female and 766 male patients were included. The adjusted OR of severe stroke were 1.3 (95% CI, 0.7-2.4) for male patients in the third WC quartile, 0.7 (95% CI, 0.3-1.5) for male patients in the second WC quartile, and 0.4 (95% CI, 0.2-0.8) for male patients in the top WC quartile. The adjusted OR of severe stroke for female patients in the third WC quartile, the second WC quartile, and the top WC quartile were 0.8 (95% CI, 0.4-1.5), 0.4 (95% CI, 0.2-0.9), and 0.7 (95% CI, 0.3-1.3), respectively.

DISCUSSION

Higher WC at admission is associated with milder baseline stroke severity among patients with acute ischaemic stroke.

ABBREVIATIONS

BMI: body mass index; CE: cardioembolism; CI: confidence interval; LAA: large-artery atherosclerosis; NIHSS: National Institutes of Health Stroke Scale; OR: odds ratio; SAO: small-artery occlusion; WC: waist circumference.

Effect of body mass index on outcome after aneurysmal subarachnoid hemorrhage treated with clipping versus coiling

OBJECTIVE It has been suggested that increased body mass index (BMI) may confer a protective effect on patients who suffer from aneurysmal subarachnoid hemorrhage (aSAH). Whether the modality of aneurysm occlusion influences the effect of BMI on patient outcomes is not well understood. The authors aimed to compare the effect of BMI on outcomes for patients with aSAH treated with surgical clipping versus endovascular coiling. METHODS The authors retrospectively reviewed the outcomes for patients admitted to their institution for the management of aSAH treated with either clipping or coiling. BMI at the time of admission was recorded and used to assign patients to a group according to low or high BMI. Cutoff values for BMI were determined by classification and regression tree analysis. Predictors of poor functional outcome (defined as modified Rankin Scale score > 2 measured ≥ 90 days after the ictus) and posttreatment cerebral hypodensities detected during admission were then determined separately for patients treated with clipping or coiling using stepwise multivariate logistic regression analysis. RESULTS Of the 469 patients admitted to the authors' institution with aSAH who met the study's inclusion criteria, 144 were treated with clipping and 325 were treated with coiling. In the clipping group, the frequency of poor functional outcome was higher in patients with BMI ≥ 32.3 kg/m² (47.6% vs 19.0%; p = 0.007). In contrast, in the coiling group, patients with BMI ≥ 32.3 kg/m² had a lower frequency of poor functional outcome at ≥ 90 days (5.8% vs 30.9%; p < 0.001). On multivariate analysis, high BMI was independently associated with an increased (OR 3.92, 95% CI 1.20-13.41; p = 0.024) and decreased (OR 0.13, 95% CI 0.03-0.40; p < 0.001) likelihood of poor functional outcome for patients treated with clipping and coiling, respectively. For patients in the surgical group, BMI ≥ 28.4 kg/m² was independently associated with incidence of cerebral hypodensities during admission (OR 2.44, 95% CI 1.16-5.25; p = 0.018) on multivariate analysis. For patients treated with coiling, BMI ≥ 33.2 kg/m² was independently associated with reduced odds of hypodensities (OR 0.45, 95% CI 0.21-0.89; p = 0.021). CONCLUSIONS The results of this study suggest that BMI may differentially affect functional outcomes after aSAH, depending on treatment modality. These findings may aid in treatment selection for patients with aSAH.

Plasminogen activator inhibitor links obesity and thrombotic cerebrovascular diseases: The roles of PAI-1 and obesity on stroke

One of the global socioeconomic phenomena occurred during the last decades is the increased prevalence of obesity, with direct consequence on the risk of developing thrombotic disorders. As the physiological inhibitor of tissue plasminogen activator (tPA) and urokinase plasminogen activator (uPA), plasminogen activator inhibitor-1 (PAI-1) is well known for its role in fibrinolysis. More and more evidences have shown that PAI-1 involves in physiopathologic mechanisms of many diseases and metabolic disorder. Increased serum level of PAI-1 has been observed in obesity and it also contributes to the development of adipose tissue and then has effects on obesity. Meantime, obesity affects also the PAI-1 levels. These evidences indicate the complicated interaction between PAI-1 and obesity. Many clinic studies have confirmed that obesity relates to the stroke outcome although there are many contradictory results. Simultaneously, correlation is found between plasma PAI-1 and thrombotic cerebrovascular diseases. This article reviews contemporary knowledge regarding the complex interplay of obesity, PAI-1 and stroke.

Association of body mass index with mortality and functional outcome after acute ischemic stroke

The relation between obesity and stroke outcome has been disputed. This study was aimed to determine the association of body mass index (BMI) with mortality and functional outcome in patients with acute ischemic stroke. Data were from a national, multi-centre, prospective, hospital-based register: the ChinaQUEST (Quality Evaluation of Stroke Care and Treatment) study. Of 4782 acute ischemic stroke patients, 282 were underweight (BMI < 18.5 kg/m²), 2306 were normal-weight (BMI 18.5 to < 24 kg/m²), 1677 were overweight (BMI 24 to <28 kg/m²) and 517 were obese (BMI ≥ 28 kg/m²). The risks of death at 12 months and death or high dependency at 3 and 12 months in overweight (HR: 0.97, 95% CI: 0.78–1.20; OR: 0.93, 95% CI: 0.80–1.09; OR: 0.95, 95% CI: 0.81–1.12) and obese patients (HR: 1.07, 95% CI: 0.78–1.48; OR: 0.96, 95% CI: 0.75–1.22; OR: 1.06, 95% CI: 0.83–1.35) did not differ from normal-weight patients significantly after adjusting for baseline characteristics. Underweight patients had significantly increased risks of these three outcomes. In ischemic stroke patients, being overweight or obese was not associated with decreased mortality or better functional recovery but being underweight predicted unfavourable outcomes.

Physical activity, but not body mass index, predicts less disability before and after stroke

OBJECTIVE

To determine whether physical activity and body mass index (BMI) predict instrumental or basic activities of daily living (I/ADL) trajectories before or after stroke compared to individuals who remained stroke-free.

METHODS

Using a prospective cohort, the Health and Retirement Study, we followed adults without a history of stroke in 1998 (n = 18,117) for up to 14 years. We estimated linear regression models of I/ADL trajectories comparing individuals who remained stroke-free throughout follow-up (n = 16,264), those who survived stroke (n = 1,374), and those who died after stroke and before the next interview wave (n = 479). We evaluated whether I/ADL trajectories differed by physical activity or BMI at baseline (before stroke), adjusting for demographic and socioeconomic covariates.

RESULTS

Compared to those who were physically active, stroke survivors who were physically inactive at baseline had a lower probability of independence in ADLs and IADLs 3 years after stroke (risk difference = -0.18 and -0.16 for ADLs and IADLs, respectively). However, a similar difference in the probability of independence was also present 3 years before stroke, and we observed no evidence that physical activity slowed the rate of decline in independence before or after stroke. Unlike the results for physical activity, we did not observe a consistent pattern for the probability of independence in ADLs or IADLs comparing obese stroke survivors to normal-weight or to overweight stroke survivors 3 years before stroke or 3 years after stroke.

CONCLUSIONS

Physical inactivity predicts a higher risk of being dependent both before and after stroke.

Obesity paradox in stroke - Myth or reality? A systematic review

Background and purpose

Both stroke and obesity show an increasing incidence worldwide. While obesity is an established risk factor for stroke, its influence on outcome in ischemic stroke is less clear. Many studies suggest a better prognosis in obese patients after stroke (“obesity paradox”). This review aims at assessing the clinical outcomes of obese patients after stroke by performing a systematic literature search.

Methods

The reviewers searched MEDLINE from inception to December 2015. Studies were eligible if they included outcome comparisons in stroke patients with allocation to body weight.

Results

Twenty-five studies (299’750 patients) were included and none was randomised. Ten of 12 studies (162’921 patients) reported significantly less mortality rates in stroke patients with higher BMI values. Seven of 9 studies (92’718 patients) ascertained a favorable effect of excess body weight on non-fatal outcomes (good clinical outcome, recurrence of vascular events). Six studies (85’042 patients) indicated contradictory results after intravenous thrombolysis (IVT), however. Several methodological limitations were observed in major part of studies (observational study design, inaccuracy of BMI in reflecting obesity, lacking body weight measurement, selection bias, survival bias).

Conclusion

Most observational data indicate a survival benefit of obese patients after stroke, but a number of methodological concerns exist. No obesity paradox was observed in patients after IVT. There is a need for well-designed randomized controlled trials assessing the effects of weight reduction on stroke risk in obese patients.

Factors Predicting Recovery of Oral Intake in Stroke Survivors with Dysphagia in a Convalescent Rehabilitation Ward

BACKGROUND

Percutaneous endoscopic gastrostomy may be performed in dysphagic stroke patients. However, some patients regain complete oral intake without gastrostomy. This study aimed to investigate the predictive factors of intake, thereby determining gastrostomy indications.

METHOD

Stroke survivors admitted to our convalescent rehabilitation ward who underwent gastrostomy or nasogastric tube placement from 2009 to 2015 were divided into 2 groups based on intake status at discharge. Demographic data and Functional Independence Measure (FIM), Dysphagia Severity Scale (DSS), National Institutes of Health Stroke Scale, and Glasgow Coma Scale (GCS) scores on admission were compared between groups. We evaluated the factors predicting intake using a stepwise logistic regression analysis.

RESULTS

Thirty-four patients recovered intake, whereas 38 achieved incomplete intake. Mean age was lower, mean body mass index (BMI) was higher, and mean time from stroke onset to admission was shorter in the complete intake group. The complete intake group had less impairment in terms of GCS, FIM, and DSS scores. In the stepwise logistic regression analysis, BMI, FIM-cognitive score, and DSS score were significant independent factors predicting intake. The formula of BMI × .26 + FIM cognitive score × .19 + DSS score × 1.60 predicted recovery of complete intake with a sensitivity of 88.2% and a specificity of 84.2%.

CONCLUSIONS

Stroke survivors with dysphagia with a high BMI and FIM-cognitive and DSS scores tended to recover oral intake.

Obesity and stroke: Can we translate from rodents to patients?

Obesity is a risk factor for stroke and is consequently one of the most common co-morbidities found in patients. There is therefore an identified need to model co-morbidities preclinically to allow better translation from bench to bedside. In preclinical studies, both diet-induced and genetically obese rodents have worse stroke outcome, characterised by increased ischaemic damage and an altered inflammatory response. However, clinical studies have reported an 'obesity paradox' in stroke, characterised by reduced mortality and morbidity in obese patients. We discuss the potential reasons why the preclinical and clinical studies may not agree, and review the mechanisms identified in preclinical studies through which obesity may affects stroke outcome. We suggest inflammation plays a central role in this relationship, as obesity features increases in inflammatory mediators such as C-reactive protein and interleukin-6, and chronic inflammation has been linked to worse stroke risk and outcome.