Incidence, risk, and case fatality of first ever stroke in the elderly population. The Rotterdam Study

Progression of arterial calcifications: what, where, and in whom?

OBJECTIVES

There is a lack of information on the development of arteriosclerosis over time. This study aims to assess long-term sex-specific changes in arterial calcifications in five arteries, and the influence of cardiovascular risk factors hereon.

METHODS

From a population-based cohort, 807 participants (mean baseline age, 65.8; SD, 4.2) underwent a non-contrast computed tomography (CT) examination between 2003 and 2006, and after a median follow-up of 14 years. We assessed incidences and changes in volumes of coronary artery calcification (CAC), aortic arch calcification (AAC), extracranial (ECAC) and intracranial carotid artery calcification (ICAC), and vertebrobasilar artery calcification (VBAC). We investigated the simultaneous presence of severe progression (upper quartile of percentual change volumes). Associations of cardiovascular risk factors with changes in calcification volumes were assessed using multivariate linear regression models.

RESULTS

The difference in AAC was most substantial; the median volume (mm3) increased from of 129 to 916 in men and from 93 to 839 in women. For VBAC, no change in volumes was observed though more than a quarter of participants without baseline VBAC developed VBAC during follow-up. Severe progression was most often observed in only one artery at the same time. Hypertension was most consistently associated with increase in calcifications. Associations of diabetes, hypercholesterolemia, and smoking with changes in calcifications varied across arteries and sex.

CONCLUSIONS

We found a considerable incidence and increase in volumes of calcifications in different arteries, over a 14-year time interval. Cardiovascular risk factors were associated with increase of calcifications with sex-specific differential effects across arteries.

CLINICAL RELEVANCE STATEMENT

There is a considerable incidence and increase in volumes of calcifications in different arteries, over a 14-year time interval. Cardiovascular risk factors are associated with increase of calcifications with sex-specific differential effects across arteries; thus, assessing changes in only one artery may thus not provide a good reflection of the systemic development of arteriosclerosis.

KEY POINTS

• Assessing change in arterial calcification in only one artery does not reflect the systemic development of arterial calcification. • Cardiovascular risk factors are associated with progression of arterial calcifications. • Progression of arterial calcification is sex and artery-specific.

Sex differences in stroke reperfusion therapy in Aotearoa (New Zealand)

BACKGROUND AND AIMS

Stroke is a leading cause of death in Aotearoa (New Zealand), and stroke reperfusion therapy is a key intervention. Sex differences in stroke care have previously been asserted internationally. This study assessed potential differences in stroke reperfusion rates and quality metrics by sex in Aotearoa (New Zealand).

METHODS

This study used data from three overlapping sources. The National Stroke Reperfusion Register provided 4-year reperfusion data from 2018 to 2021 on all patients treated with reperfusion therapy (intravenous thrombolysis and thrombectomy), including time delays, treatment rates, mortality and complications. Linkage to Ministry of Health administrative and REGIONS Care study data provided an opportunity to control for confounders and explore potential mechanisms. T-test and Wilcoxon rank-sum analyses were used for continuous variables, while the chi-squared test and logistic regression were used for comparing dichotomous variables.

RESULTS

Fewer women presented with ischaemic stroke (12 186 vs 13 120) and were 4.2 years older than men (median (interquartile range (IQR)) 79 (68-86) vs 73 (63-82) years). Women were overall less likely to receive reperfusion therapy (13.9% (1704) vs 15.8% (2084), P < 0.001) with an adjusted odds ratio of 0.83 (0.77-0.90), P < 0.001. The adjusted odds ratio for thrombolysis was lower for women (0.82 (0.76-0.89), P < 0.001), but lower rates of thrombectomy fell just short of statistical significance ((0.89 (0.79-1.00), P = 0.05). There were no significant differences in complications, delays or documented reasons for non-thrombolysis.

CONCLUSIONS

Women were less likely to receive thrombolysis, even after adjusting for age and stroke severity. We found no definitive explanation for this disparity.

Therapeutic potential of berries in age-related neurological disorders

Aging significantly impacts several age-related neurological problems, such as stroke, brain tumors, oxidative stress, neurodegenerative diseases (Alzheimer's, Parkinson's, and dementia), neuroinflammation, and neurotoxicity. Current treatments for these conditions often come with side effects like hallucinations, dyskinesia, nausea, diarrhea, and gastrointestinal distress. Given the widespread availability and cultural acceptance of natural remedies, research is exploring the potential effectiveness of plants in common medicines. The ancient medical system used many botanical drugs and medicinal plants to treat a wide range of diseases, including age-related neurological problems. According to current clinical investigations, berries improve motor and cognitive functions and protect against age-related neurodegenerative diseases. Additionally, berries may influence signaling pathways critical to neurotransmission, cell survival, inflammation regulation, and neuroplasticity. The abundance of phytochemicals in berries is believed to contribute to these potentially neuroprotective effects. This review aimed to explore the potential benefits of berries as a source of natural neuroprotective agents for age-related neurological disorders.

Future Burden of Ischemic Stroke in Australia: Impact on Health Outcomes between 2019 and 2038

BACKGROUND

Projections of the future burden of ischemic stroke (IS) has not been extensively reported for the Australian population; the availability of such data would assist in health policy planning, clinical guideline updates, and public health.

METHODS

First, we estimated the lifetime risk of IS (from age 40 to 100 years) using a multistate life table model. Second, a dynamic multistate model was constructed to project the burden of IS for the whole Australian population aged between 40 and 100 years over a 20-year period (2019-2038). Data for the study were primarily sourced from a large, representative Victorian linked dataset based on the Victorian Admitted Episode Dataset and National Death Index. The model projected prevalent and incident cases of nonfatal IS, fatal IS, and years of life lived (YLL) with and without IS. The YLL outcome was discounted by 5% annually; we varied the discounting rate in scenario analyses.

RESULTS

The lifetime risk of IS from age 40 years was estimated as 15.5% for males and 14.0% for females in 2018. From 2019 to 2038, 644,208 Australians were projected to develop incident IS (564,922 nonfatal and 79,287 fatal). By 2038, the model projected there would be 358,534 people with prevalent IS, 35,554 people with incident nonfatal IS and 5,338 people with fatal IS, a 14.2% (44,535), 72.9% (14,988), and 106.3% (2,751) increase compared to 2019 estimations, respectively. Projected YLL (with a 5% discount rate) accrued by the Australian population were 174,782,672 (84,251,360 in males and 90,531,312 in females), with 4,053,794 YLL among people with IS (2,320,513 in males, 1,733,281 in females).

CONCLUSION

The burden of IS was projected to increase between 2019 and 2038 in Australia. The outcomes of the model provide important information for decision-makers to design strategies to reduce stroke burden.

Clinical outcome and outcome prediction of octogenarians with acute basilar artery occlusion and endovascular stroke treatment compared to younger patients

Background and aims

Octogenarians are underrepresented in recently published studies that showed the benefit of endovascular stroke treatment (EST) for patients with acute basilar artery occlusion (BAO). We aimed to compare the clinical outcome of octogenarians with BAO and EST compared to younger patients (YPs) and identify independent outcome predictors.

Methods

This is a retrospective, single-center analysis of patients treated for BAO with EST from January 2013 until June 2021 in a tertiary stroke center. Octogenarians (80-89 years) were compared to YPs. A study endpoint was a favorable clinical outcome as per the modified Rankin Scale (mRS 0-3), 90 days after stroke onset. The study groups were compared using univariate analysis, and a multivariable logistic regression analysis was performed to define independent predictors for favorable and unfavorable (mRS 5-6) clinical outcomes.

Results

In this study cohort, 74/191 (38.7%) octogenarians had a higher pre-stroke mRS [median, interquartile range (IQR): 2, 1-3 octogenarians vs. 0, 0-1 YP, p < 0.001] and a comparable National Institutes of Health Stroke Scale (NIHSS) before EST (median, IQR: 21, 10-38 vs. 20, 8-35 in YP, p = 0.487). They showed a comparable rate of favorable outcome (mRS 0-3, 90 days, 23.0 vs. 25.6% in YP, p = 0.725), but were less often functionally independent (mRS 0-2: 10.8% in octogenarians vs. 23.0% in YP, p = 0.049). The rate of unfavorable clinical outcome was comparable (mRS 5-6, n = 40, 54.1% in octogenarians vs. n = 64, 54.7% in YP, p = 0.831). A baseline NIHSS was an independent predictor for clinical outcome in YPs [e.g., for unfavorable clinical outcome: odds ratio (OR) 1.061, confidence interval (CI) 1.027-1.098, p = 0.005] and for favorable clinical outcome in octogenarians. Pre-stroke mRS predicted favorable outcomes in octogenarians (OR 0.54, CI 0.30-0.90, p = 0.0291), while age predicted unfavorable outcomes in YPs (OR 1.045, CI 1.011-1.086, p = 0.0137).

Conclusion

Octogenarians with acute BAO eligible for EST are as likely to achieve a favorable outcome as YPs, and the rate of death or severe disability is comparable. The admission NIHSS is an independent predictor for favorable and unfavorable outcomes in YP and for favorable outcomes in octogenarians. In this study cohort, pre-stroke mRS predicted favorable outcomes in octogenarians while age predicted an unfavorable outcome in YPs.

Lipoprotein(a) is associated with a larger systemic burden of arterial calcification

AIMS

Lipoprotein(a) [Lp(a)] is a genetically determined risk factor for cardiovascular disease. However, population-based evidence on the link between Lp(a) and subclinical arteriosclerosis is lacking. We assessed associations of Lp(a) concentrations with arteriosclerosis in multiple arteries.

METHODS AND RESULTS

From the population-based Rotterdam study, 2354 participants (mean age: 69.5 years, 52.3% women) underwent non-contrast computed tomography to assess arterial calcification as a hallmark of arteriosclerosis. We quantified the volume of coronary artery calcification (CAC), aortic arch calcification (AAC), extracranial (ECAC), and intracranial carotid artery calcification (ICAC). All participants underwent blood sampling, from which plasma Lp(a) concentrations were derived. The association of plasma Lp(a) levels was assessed with calcification volumes and with severe calcification (upper quartile of calcification volume) using sex-stratified multivariable linear and logistic regression models. Higher Lp(a) levels were associated with larger ln-transformed volumes of CAC [fully adjusted beta 95% confidence interval (CI) per 1 standard deviation (SD) in women: 0.09, 95% CI 0.04-0.14, men: 0.09, 95% CI 0.03-0.14], AAC (women: 0.06, 95% CI 0.01-0.11, men: 0.09, 95% CI 0.03-0.14), ECAC (women: 0.07, 95% CI 0.02-0.13, men: 0.08, 95% CI 0.03-0.14), and ICAC (women: 0.09, 95% CI 0.03-0.14, men: 0.05, 95% CI -0.02 to 0.11]. In the highest Lp(a) percentile, severe ICAC was most prevalent in women [fully adjusted odds ratio (OR) 2.41, 95% CI 1.25-4.63] and severe AAC in men (fully adjusted OR 3.29, 95% CI 1.67-6.49).

CONCLUSION

Higher Lp(a) was consistently associated with a larger calcification burden in all major arteries. The findings of this study indicate that Lp(a) is a systemic risk factor for arteriosclerosis and thus potentially an effective target for treatment. Lp(a)-reducing therapies may reduce the burden from arteriosclerotic events throughout the arterial system.

TRANSLATIONAL PERSPECTIVE

In 2354 participants from the Rotterdam study, we assessed the link between Lp(a) concentrations and arterial calcifications, as proxy for arteriosclerosis, in major arteries. We found that higher Lp(a) levels were consistently associated with larger volumes of calcification in the coronary arteries, aortic arch, extracranial carotid arteries, and intracranial carotid arteries. The findings of our study indicate that Lp(a) is a systemic risk factor for arteriosclerosis, suggesting that the systemic burden of arteriosclerosis throughout the arterial system could be reduced by targeting Lp(a).

A multiscale computational framework to evaluate flow alterations during mechanical thrombectomy for treatment of ischaemic stroke

The treatment of ischaemic stroke increasingly relies upon endovascular procedures known as mechanical thrombectomy (MT), which consists in capturing and removing the clot with a catheter-guided stent while at the same time applying external aspiration with the aim of reducing haemodynamic loads during retrieval. However, uniform consensus on procedural parameters such as the use of balloon guide catheters (BGC) to provide proximal flow control, or the position of the aspiration catheter is still lacking. Ultimately the decision is left to the clinician performing the operation, and it is difficult to predict how these treatment options might influence clinical outcome. In this study we present a multiscale computational framework to simulate MT procedures. The developed framework can provide quantitative assessment of clinically relevant quantities such as flow in the retrieval path and can be used to find the optimal procedural parameters that are most likely to result in a favorable clinical outcome. The results show the advantage of using BGC during MT and indicate small differences between positioning the aspiration catheter in proximal or distal locations. The framework has significant potential for future expansions and applications to other surgical treatments.

Translation of the Fugl-Meyer assessment into Romanian: Transcultural and semantic-linguistic adaptations and clinical validation

Purpose

The Fugl-Meyer Assessment (FMA) scale, which is widely used and highly recommended, is an appropriate tool for evaluating poststroke sensorimotor and other possible somatic deficits. It is also well-suited for capturing a dynamic rehabilitation process. The aim of this study was to first translate the entire sensorimotor FMA scale into Romanian using the transcultural and semantic-linguistic adaptations of its official afferent protocols and to then validate it using the preliminary clinical evaluation of inter- and intra-rater reliability and relevant concurrent validity.

Methods

Through three main steps, we completed a standardized procedure for translating FMA's official afferent evaluation protocols into Romanian and their transcultural and semantic-linguistic adaptation for both the upper and lower extremities. For relevant clinical validation, we evaluated 10 patients after a stroke two times: on days 1 and 2. All patients were evaluated simultaneously by two kinesi-physiotherapists (generically referred to as KFT1 and KFT2) over the course of 2 consecutive days, taking turns in the roles of an examiner and observer, and vice versa (inter-rater). Two scores were therefore obtained and compared for the same patient, i.e., being afferent to an inter-rater assay by comparing the assessment outcomes obtained by the two kinesi-physiotherapists, in between, and respectively, to the intra-rater assay: based on the evaluations of the same kinesi-physiotherapist, in two consecutive days, using a rank-based method (Svensson) for statistical analysis. We also compared our final Romanian version of FMA's official protocols for concurrent validity (Spearman's rank correlation statistical method) to both of the widely available assessment instruments: the Barthel Index (BI) and the modified Rankin scale (mRS).

Results

Svensson's method confirmed overall good inter- and intra-rater results for the main parts of the final Romanian version of FMA's evaluation protocols, regarding the percentage of agreement (≥80% on average) and for disagreement: relative position [RP; values outside the interval of (-0.1, 0.1) in only two measurements out of the 56 comparisons we did], relative concentration [RC; values outside the interval of (-0.1, 0.1) in only nine measurements out of the same 56 comparisons done], and relative rank variation [RV; all values within an interval of (0, 0.1) in only five measurements out of the 56 comparisons done]. High correlation values were obtained between the final Romanian version of FMA's evaluation protocols and the BI (ρ = 0.9167; p = 0.0002) for FMA-upper extremity (FMA-UE) total A-D (motor function) with ρ = 0.6319 and for FMA-lower extremity (FMA-LE) total E-F (motor function) with p = 0.0499, and close to the limit, with the mRS (ρ = -0.5937; p = 0.0704) for FMA-UE total A-D (motor function) and (ρ = -0.6615; p = 0.0372) for FMA-LE total E-F (motor function).

Conclusions

The final Romanian version of FMA's official evaluation protocols showed good preliminary reliability and validity, which could be thus recommended for use and expected to help improve the standardization of this assessment scale for patients after a stroke in Romania. Furthermore, this endeavor could be added to similar international translation and cross-cultural adaptations, thereby facilitating a more appropriate comparison of the evaluation and outcomes in the management of stroke worldwide.

Red cell distribution width: a novel predictive biomarker for stroke risk after transient ischaemic attack

OBJECTIVE

Predicting the prognosis of transient ischaemic attack (TIA) is difficult for many frontline clinicians. The purpose of this study was to determine whether subsequent stroke in TIA patients can be predicted via red blood cell distribution width (RDW).

MATERIAL AND METHODS

A total of 360 consecutive patients with new-onset TIA in our stroke centre, were enrolled over the period studied. The patients were divided into three groups: 103 TIA patients, 206 ischaemic stroke (IS) patients and 51 patients with haemorrhagic stroke (HS) within 7 days after TIA. Complete blood count, biochemical parameters and brain imaging were performed on all patients.

RESULTS

The mean RDW values of patients with IS and HS after TIA were significantly higher than patients with TIA (13.35 ± 1.59 vs 12.84 ± 1.19, 13.32 ± 1.08 vs 12.84 ± 1.19, respectively, all p ≤ .001). In a multivariate model, RDW was independently associated with stroke after TIA (IS: odds ratio (OR) = 2.52, 95% confidence interval (CI) = 1.46-3.35, p = .002; HS: OR = 1.511, 95% CI = 1.101-2.074, p = .011). Compared to ABCD² scores, the diagnostic power of RDW in the differentiation of patients with IS after TIA was better (area under curve (AUC): 0.731 vs 0.613, p = .015). When an RDW cut-off value of 13.95% was accepted for differentiating patients with IS from TIA, the sensitivity and specificity were 73.7% and 74.3%, respectively. However, the AUC for the ability of the RDW to predict HS was 0.653 (95% CI = 0.589-0.716; p < .001).

CONCLUSIONS

The early determination of RDW is a promising, rapid, easy and inexpensive biomarker to predict the subsequent stroke in TIA patients, especially for IS. KEY MESSAGESThe most important result of our study is to show that (1) the higher RDW, the earlier the stroke onset and (2) RDW ≥13.95% has a 2.52-fold risk of ischaemic stroke in TIA patients, and RDW ≥12.85% has a 1.51-fold risk of haemorrhagic stroke.As an economic and accessible hematological marker, baseline RDW may serve as a useful biomarker for risk stratification in TIA patients.

From kitchen to clinic: Pharmacotherapeutic potential of common spices in Indian cooking in age-related neurological disorders

Aging is described as an advanced time-related collection of changes that may negatively affect with the risk of several diseases or death. Aging is a main factor of several age-related neurological disorders, including neurodegenerative diseases (Alzheimer’s disease, Parkinson’s disease, and dementia), stroke, neuroinflammation, neurotoxicity, brain tumors, oxidative stress, and reactive oxygen species (ROS). Currently available medications for age-related neurological disorders may lead to several side effects, such as headache, diarrhea, nausea, gastrointestinal (GI) diseases, dyskinesia, and hallucinosis. These days, studies on plant efficacy in traditional medicine are being conducted because herbal medicine is affordable, safe, and culturally acceptable and easily accessible. The Indian traditional medicine system called Ayurveda uses several herbs and medicinal plants to treat various disorders including neurological disorders. This review aims to summarize the data on the neuroprotective potential of the following common Indian spices widely used in Ayurveda: cumin (Cuminum cyminum (L.), Apiaceae), black cumin (Nigella sativa (L.), Ranunculaceae), black pepper (Piper nigrum (L.), Piperaceae), curry leaf tree (Murraya koenigii (L.), Spreng Rutaceae), fenugreek (Trigonella foenum-graecum (L.), Fabaceae), fennel (Foeniculum vulgare Mill, Apiaceae), cardamom (Elettaria cardamomum (L.) Maton, Zingiberaceae), cloves (Syzygium aromaticum (L.) Merr. & L.M.Perry, Myrtaceae), and coriander (Coriandrum sativum (L.), Apiaceae) in age-related neurological disorders.

Incidence, early case fatality and determinants of stroke in Iran: Golestan Cohort Study

OBJECTIVES

While few studies investigated the incidence of stroke in Iran, no Iranian cohort has estimated the standardized-incidence rate and early fatality of first-ever-stroke subtypes along with associated factors.

METHODS

Golestan Cohort Study is a prospective study launched in northeastern Iran in 2004, including 50,045 individuals aged 40-75 at baseline. Age-standardized incidence rate of first-ever-stroke was calculated per 100,000 person-years, according to World Standard Population. The 28-day case fatality was calculated by dividing the number of fatal first-ever-stroke during the first 28 days by total events. Cox proportional hazard models were conducted to assess incidence and fatality risk factors. We used Population Attributable Fractions to estimate the incidence and early fatality proportions reduced by ideal risk factor control.

RESULTS

1,135 first-ever-strokes were observed during 8.6 (median) years follow-up. First-ever-stroke standardized incidence rate was estimated 185.2 (95% CI: 173.2-197.2) per 100,000 person-years. The 28-day case fatality was 44.1% (95% CI: 40.4-48.2). Hypertension and pre-stroke physical activity were the strongest risk factors associated with first-ever-stroke incidence (Hazard ratio: 2.83; 2.47-3.23) and 28-day case fatality (Hazard ratio: 0.59; 0.44-0.78), respectively. Remarkably, opium consumption was strongly associated with hemorrhagic stroke incidence (Hazard ratio: 1.52; 1.04-2.23) and ischemic stroke fatality (Hazard ratio: 1.44; 1.01-2.09). Overall, modifiable risk factors contributed to 83% and 61% of first-ever-stroke incidence and early fatality, respectively.

CONCLUSION

Efficient risk factor control can considerably reduce stroke occurrence and fatality in our study. Establishing awareness campaigns and 24-hour stroke units seem necessary for improving the stroke management in this area.

Biological Age Acceleration Is Lower in Women With Ischemic Stroke Compared to Men

BACKGROUND

Stroke onset in women occurs later in life compared with men. The underlying mechanisms of these differences have not been established. Epigenetic clocks, based on DNA methylation (DNAm) profiles, are the most accurate biological age estimate. Epigenetic age acceleration (EAA) measures indicate whether an individual is biologically younger or older than expected. Our aim was to analyze whether sexual dichotomy at age of stroke onset is conditioned by EAA.

METHODS

We used 2 DNAm datasets from whole blood samples of case-control genetic studies of ischemic stroke (IS), a discovery cohort of 374 IS patients (N women=163, N men=211), from GRECOS (Genotyping Recurrence Risk of Stroke) and SEDMAN (Dabigatran Study in the Early Phase of Stroke, New Neuroimaging Markers and Biomarkers) studies and a replication cohort of 981 IS patients (N women=411, N men=570) from BASICMAR register. We compared chronological age, 2 DNAm-based biomarkers of aging and intrinsic and extrinsic epigenetic age acceleration EAA (IEAA and extrinsic EAA, respectively), in IS as well as in individual IS etiologic subtypes. Horvath and Hannum epigenetic clocks were used to assess the aging rate. A proteomic study using the SOMAScan multiplex assay was performed on 26 samples analyzing 1305 proteins.

RESULTS

Women present lower Hannum-extrinsic EAA values, whereas men have higher Hannum-extrinsic EAA values (women=-0.64, men=1.24, P=1.34×10^-2); the same tendency was observed in the second cohort (women=-0.57, men=0.79, P=0.02). These differences seemed to be specific to cardioembolic and undetermined stroke subtypes. Additionally, 42 blood protein levels were associated with Hannum-extrinsic EAA (P<0.05), belonging to the immune effector process (P=1.54×10^-6) and platelet degranulation (P<8.74×10^-6) pathways.

CONCLUSIONS

This study shows that sex-specific underlying biological mechanisms associated with stroke onset could be due to differences in biological age acceleration between men and women.

Stroke in Djibouti

•

Sub-Saharan Africa is experiencing an increasing burden of stroke, with current prevalence as high as 1.46 per 1000 population.

•

Limited cohort studies exist to profile the epidemiological, clinical and paraclinical characteristics of stroke in this setting.

•

Identifying the most at-risk population for ischemic and haemorrhagic stroke can improve approaches for prevention in this setting.

Background

Stroke is a neurological emergency affecting both developed and developing countries. In Djibouti, stroke is the fourth leading cause of death. Our objective was to describe the demographic, clinical, paraclinical profile of stroke in Djibouti and identify the possible underlying risk factors.

Methods

We conducted a cross-sectional multicentre study carried out over a period of 6 months in the medical services of the Soudano-Djibouti military hospital, the General Peltier hospital and the emergency department of the National fund for social security health centre.

Results

A total of seventy patients were included. The mean age was 59.61 years with a male predominance (sex ratio: 2.5) and a statistically significant female-related difference beyond the age of 60 years (p <10⁻³). Cardiovascular risk factors were mainly hypertension (73%), khat chewing (64%) and tobacco use (50%). Khat chewing and tobacco use were associated with a younger age of occurrence of stroke (p=0.020 and p=0.004, respectively). Diabetes mellitus and hypercholesterolemia were found respectively in 30% and 19% of cases, and were more associated with ischemic stroke. Coronary disease (11%), heart failure (3%) and obesity (4%) (significantly associated with the female gender; p= 0,021) were less common. Motor deficits (94%) were the most common clinical manifestations, followed by sensory deficits (51%) and alteration of consciousness (37%). Stroke was ischemic in 61.5% of patients. The most affected territory in ischemic stroke was the territory of the middle cerebral artery, and capsulo-thalamic involvement in haemorrhagic stroke which was significantly associated with the alteration of consciousness(p=0,003).

Discussion

Stroke had primarily modifiable risk factors in Djiboutian patients dominated by high blood pressure, tobacco use and khat chewing especially in the male population under the age of 60 years. These findings could have implications on future preventive measures and a better approach to public health policy.

Diet-Derived Antioxidants Do Not Decrease Risk of Ischemic Stroke: A Mendelian Randomization Study in 1 Million People

Background

Dietary intake and blood concentrations of vitamins E and C, lycopene, and carotenoids have been associated with a lower risk of incident (ischemic) stroke. However, causality cannot be inferred from these associations. Here, we investigated causality by analyzing the associations between genetically influenced antioxidant levels in blood and ischemic stroke using Mendelian randomization.

Methods and Results

For each circulating antioxidant (vitamins E and C, lycopene, β‐carotene, and retinol), which were assessed as either absolute blood levels and/or high‐throughput metabolite levels, independent genetic instrumental variables were selected from earlier genome‐wide association studies (P<5×10⁻⁸). We used summary statistics for single‐nucleotide polymorphisms–stroke associations from 3 European‐ancestry cohorts (cases/controls): MEGASTROKE (60 341/454 450), UK Biobank (2404/368 771), and the FinnGen study (8046/164 286). Mendelian randomization analyses were performed on each exposure per outcome cohort using inverse variance–weighted analyses and subsequently meta‐analyzed. In a combined sample of 1 058 298 individuals (70 791 cases), none of the genetically influenced absolute antioxidants or antioxidant metabolite concentrations were causally associated with a lower risk of ischemic stroke. For absolute antioxidants levels, the odds ratios (ORs) ranged between 0.94 (95% CI, 0.85–1.05) for vitamin C and 1.04 (95% CI, 0.99–1.08) for lycopene. For metabolites, ORs ranged between 1.01 (95% CI, 0.98–1.03) for retinol and 1.12 (95% CI, 0.88–1.42) for vitamin E.

Conclusions

This study did not provide evidence for a causal association between dietary‐derived antioxidant levels and ischemic stroke. Therefore, antioxidant supplements to increase circulating levels are unlikely to be of clinical benefit to prevent ischemic stroke.

Testosterone and estradiol in men with acute ischemic stroke: A North Indian case control

Background: One intriguing aspect of stroke is its higher incidence in men as compared to women. Endogenous sex hormones, testosterone and estradiol, may be responsible for this difference. This research aims to study serum testosterone and estradiol levels in men with acute ischemic stroke (AIS) and to correlate these levels with National Institutes of Health Stroke Scale (NIHSS) score and infarct size in computed tomography (CT). Methods: 100 male patients with AIS and 100 age-matched controls were included in this case-control study. Patients with hemorrhagic stroke, taking hormonal preparations, or suffering from chronic illnesses like tuberculosis (TB), cancer, etc. were excluded. Complete history was obtained including presence of established risk factors and physical examination was done in cases and controls with informed written consent. Severity of stroke in cases was assessed by the NIHSS. CT scan of brain was performed within 72 hours of patient's admission to hospital. The infarct size was measured in centimeters as the largest visible diameter of the infarct on CT scan. Fasting blood samples were obtained for routine investigations and estimating estradiol and testosterone levels. Results: Mean total testosterone level in cases (223.30 ± 143.44 ng/dl) was significantly lower than that of controls (515.34 ± 172.11 ng/dl) (P < 0.001), while estradiol levels had no significant statistical difference (P = 0.260). A significant inverse correlation was found between total testosterone levels and stroke severity (r = -0.581, P < 0.001) and also, total testosterone levels and infarct size (r = -0.557, P < 0.001). Estradiol levels in patients had no significant correlation with stroke severity (P = 0.618) or infarct size (P = 0.463). Conclusion: Low testosterone levels are associated with increased stroke severity and infarct size in men. Further studies are required to establish whether low testosterone is a cause or effect of ischemic stroke and also to explore the potential benefits of testosterone supplementation in men with AIS.

Incidental Unruptured Intracranial Aneurysms Do Not Impact Outcome in Patients With Acute Cerebral Infarction

Background: This study was to examine the patients with acute cerebral infarction (ACI) treated at a single center over 9 years and who underwent Unruptured intracranial aneurysm (UIA) screening by three-dimensional time-of-flight magnetic resonance angiography (3D-TOF-MRA), and to explore the factors associated with outcomes.

Methods: The outcome was the modified Rankin scale (mRS) score at 90 days after stroke onset. The outcome was classified into a good outcome (mRS score of 0–2 points) and poor outcome (mRS score of 3–6 points).

Results: UIAs were found in 260 (6.5%) of 4,033 patients with ACI; 2,543 (63.1%) had a good outcome, and 1,490 (36.9%) had a poor outcome. There was no difference in outcomes between the two groups (P = 0.785). The multivariable analysis showed that age (OR = 1.009, 95%CI: 1.003–1.014, P = 0.003), diabetes (OR = 1.179, 95%CI: 1.035–1.342, P = 0.013), ischemic stroke history (OR = 1.451, 95%CI: 1.256–1.677, P < 0.001), and baseline NIHSS score (OR = 1.034, 95%CI: 1.018–1.050, P < 0.001) were independently associated with the 90-day outcomes in patients with ACI. The presence of incidental UIA was not associated with outcomes after ACI.

Conclusions: Age, diabetes, ischemic stroke history, and baseline NIHSS score were independently associated with the early outcomes of patients with ACI.

Stroke case fatality in sub-Saharan Africa: Systematic review and meta-analysis

Background

The burden of stroke is high in sub-Saharan Africa; however, few data are available on long-term mortality.

Objective

To estimate over one-month stroke case fatality in sub-Saharan Africa.

Methods

A systematic review and meta-analysis were performed according to meta-analysis of observational studies in epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO protocol: CRD42020192439), on five electronic databases (PubMed, Science direct, AJOL, EMBASE, and Web of Sciences). We searched all studies on stroke case fatality over one month in sub-Saharan Africa published between 1st January 2000 and 31st December 2019.

Results

We included 91 studies with a total of 34,362 stroke cases. The one-month pooled stroke case-fatality rate was 24.1% [95% CI: 21.5–27.0] and 33.2% [95% CI: 23.6–44.5] at one year. At three and five years, the case-fatality rates were respectively 40.1% [95% CI: 20.8–63.0] and 39.4% [95% CI: 14.3–71.5] with high heterogeneity. Hemorrhagic stroke was associated with a higher risk of mortality at one month, but ischemic stroke increased the risk of mortality over six months. Diabetes was associated with poor prognosis at 6 and 12 months with odds ratios of 1.64 [95% CI: 1.22–2.20] and 1.85 [1.25–2.75], respectively.

Conclusion

The stroke case fatality over one month was very high, compared to case fatalities reported in Western countries and can be explained by a weak healthcare systems and vascular risk factors.

Cost-Effectiveness of Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients With Severe Aortic Stenosis

BACKGROUND

Recent studies have shown that transcatheter aortic valve implantation (TAVI) is non-inferior to surgical aortic valve replacement (SAVR) for treatment of low-risk patients with severe aortic stenosis (AS). However, the cost-effectiveness of TAVI in this population is unknown. We sought to evaluate the cost-effectiveness of both balloon-expandable and self-expanding TAVI compared to SAVR in patients with severe AS at low operative risk.

METHODS

We developed a Markov model comparing TAVI to SAVR over a lifetime horizon. Key data inputs were drawn from the Placement of AoRTic TraNscathetER Valve (PARTNER) 3 trial for balloon-expandable TAVI and the Evolut Low-Risk trial for self-expanding TAVI. Costs were obtained from Australian sources. The perspective was that of the Australian health care system.

RESULTS

Although procedural costs were higher for TAVI compared to SAVR, these were offset by a shorter length of hospitalisation and lower acute complication costs in the TAVI group. Over a lifetime horizon, balloon-expandable TAVI was associated with increased costs of A$702 compared to SAVR, and increased quality-adjusted survival by 0.20 years, yielding an incremental cost-effectiveness ratio of A$3,521 per quality-adjusted life year (QALY) saved. Self-expanding TAVI was associated with lower lifetime costs compared to SAVR, and increased quality-adjusted survival by 0.08 years, and was therefore economically dominant. In probabilistic sensitivity analyses, balloon-expandable TAVI was cost-effective in 78% of iterations (at a cost-effectiveness threshold of A$50,000 per QALY gained) and self-expanding TAVI was cost-effective in 70% of iterations.

CONCLUSIONS

Among low-risk AS patients, both balloon-expandable and self-expanding TAVI are likely to be cost-effective relative to SAVR.

Aortic Arch Calcification and the Risk of Cancer: A Population-Based Cohort Study

Background: Atherosclerosis and cancer share multiple disease pathways. Yet, it is unclear if atherosclerosis is associated with a subsequent higher cancer risk. We determined the association of atherosclerotic calcification in the aortic arch, as proxy for systemic atherosclerosis, with the risk of cancer.

Methods: Between 2003 and 2006, 2,404 participants (mean age: 69.5 years, 52.5% women) from the prospective population-based Rotterdam Study underwent computed tomography to quantify calcification in the aortic arch. Participants were followed for the onset of cancer, death, loss to follow-up, or January 1st, 2015, whichever came first. We computed sex-specific tertiles of aortic arch calcification volumes. Next, we examined the association between the volume and severity (i.e., tertiles) of aortic arch calcification and the risk of cancer using Cox proportional hazard models.

Results: During a median (interquartile range) follow-up of 9.6 years (8.9–10.5), 348 participants were diagnosed with cancer. Participants with the greatest severity of aortic arch calcification had a higher risk of cancer [hazard ratio for the third tertile compared to the first tertile of aortic arch calcification volume in the total population is 1.39 (95% CI = 1.04–1.86)].

Conclusions: Individuals with the most severe aortic arch calcification had a higher risk of cancer. While this could reflect the impact of long-term exposure to shared risk factors, it might also point toward the co-occurrence of both conditions.

Activation of neuronal Ras-related C3 botulinum toxin substrate 1 (Rac1) improves post-stroke recovery and axonal plasticity in mice

Long-term disability after stroke is common but the mechanisms of post-stroke recovery remain unclear. Cerebral Ras-related C3 botulinum toxin substrate (Rac) 1 contributes to functional recovery after ischemic stroke in mice. As Rac1 plays divergent roles in individual cell types after central neural system injury, we herein examined the specific role of neuronal Rac1 in post-stroke recovery and axonal regeneration. Young male mice were subjected to 60-min of middle cerebral artery occlusion (MCAO). Inducible deletion of neuronal Rac1 by daily intraperitoneal injection of tamoxifen (2 mg/40 g) into Thy1-creER/Rac1-floxed mice day 7-11 after MCAO worsened cognitive (assayed by novel object recognition test) and sensorimotor (assayed by adhesive removal and pellet reaching tests) recovery day 14-28 accompanied with the reduction of neurofilament-L (NFL) and myelin basic protein (MBP) and the elevation of glial fibrillary acidic protein (GFAP) in the peri-infarct zone assessed by immunostaining. Whereas the brain tissue loss was not altered assayed by cresyl violet staining. In another approach, delayed overexpression of neuronal Rac1 by injection of lentivirus encoding Rac1 with neuronal promotor into both the cortex and striatum (total 4 μl at 1 × 10⁹ transducing units/mL) of stroke side in C57BL/6J mice day 7 promoted stroke outcome, NFL and MBP regrowth and alleviated GFAP invasion. Furthermore, neuronal Rac1 over-expression led to the activation of p21 activating kinases (PAK) 1, mitogen-activated protein kinase kinase (MEK) 1/2 and extracellular signal-regulated kinase (ERK) 1/2, and the elevation of brain-derived neurotrophic factor (BDNF) day 14 after stroke. Finally, we observed higher counts of neuronal Rac1 in the peri-infarct zone of subacute/old ischemic stroke subjects. This work identified a neuronal Rac1 signaling in improving functional recovery and axonal regeneration after stroke, suggesting a potential therapeutic target in the recovery stage of stroke.

Arterial calcification at multiple sites: sex-specific cardiovascular risk profiles and mortality risk-the Rotterdam Study

BACKGROUND

Evidence has pointed towards differences in the burden of arteriosclerosis according to its location and sex. Yet there is a scarcity of population-based data on aggregated sex-specific cardiovascular risk profiles, instead of single risk factors, and mortality risk according to the location of arteriosclerosis. We assessed sex-specific cardiovascular risk profiles and mortality risk associated with arteriosclerosis.

METHODS

From the population-based Rotterdam Study, 2357 participants (mean age 69 years, 53% women) underwent non-contrast computed tomography to quantify calcification, as a proxy for arteriosclerosis, in the coronary arteries (CAC), aortic arch (AAC), extracranial (ECAC) and intracranial carotid arteries (ICAC), vertebrobasilar arteries (VBAC), and aortic valve (AVC). Principal component analysis (PCA) of eight distinct cardiovascular risk factors was performed, separately for women and men, to derive risk profiles based on the shared variance between factors. We used sex-stratified multivariable logistic regression to examine the associations between PCA-derived risk profiles and severe calcification at different locations. We investigated the associations of severe calcification with mortality risk using sex-stratified multivariable Cox regression.

RESULTS

PCA identified three cardiovascular risk profiles in both sexes: (1) anthropometry, glucose, and HDL cholesterol; (2) blood pressure; and (3) smoking and total cholesterol. In women, the strongest associations were found for profile 2 with severe ECAC and ICAC (adjusted OR [95% CI] 1.32 [1.14-1.53]) and for profile 3 with severe at all locations, except AVC. In men, the strongest associations were found for profile 2 with VBAC (1.31 [1.12-1.52]) and profile 3 with severe AAC (1.28 [1.09-1.51]). ECAC and AVC in women and CAC in men showed the strongest, independent associations with cardiovascular mortality (HR [95% CI] 2.11 [1.22-3.66], 2.05 [1.21-3.49], 2.24 [1.21-3.78], respectively).

CONCLUSIONS

Our findings further underline the existence of sex- and location-specific differences in the etiology and consequences of arteriosclerosis. Future research should unravel which distinct pathological processes underlie differences in risk profiles for arteriosclerosis.

Demographics and medical disorders associated with smoking: a population-based study

Background

Few studies have investigated factors associated with smoking behaviors. In this population-based study, we investigated demographics and medical comorbid diseases to establish a prediction model for smoking behaviors by using the National Health Interview Survey (NHIS) and National Health Insurance Research Database (NHIRD).

Methods

We enrolled individuals aged ≥40 years who had participated in the NHIS in 2001, 2005, and 2009. We identified the smoking behaviors of the study participants in the NHIS. Smoking behaviors were divided into ever smokers (current smokers and ex-smokers) and nonsmokers (never smokers).We defined medical comorbid disorders of the study participants by using medical claim data from the NHIRD. We used multivariable logistic regression models to calculate the adjusted odds ratio and 95% confidence interval for variables associated with smoking. The significant variables in the multivariable model were included in the receiver operating characteristic curves (ROC) to predict the sensitivity and specificity of the model.

Results

In total, 26,375 participants (12,779 men and 13,596 women) were included in the analysis. The prevalence of smoking was 39.29%. The mean ages of the 16,012 nonsmokers were higher than those of the 10,363 smokers (57.86 ± 12.92 years vs. 53.59 ± 10.82 years). Men outnumbered women among smokers (68.18% vs. 31.82%). Male sex, young age and middle age, being insured categories, residence in suburban areas, and chronic obstructive pulmonary disease (COPD) were independent factors associated with smoking. The area under the ROC curve of these significant factors to predict smoking behaviors was 71.63%.

Conclusion

Sex, age, insured categories, residence in suburban areas, and COPD were associated with smoking in people.

Objectives, design and main findings until 2020 from the Rotterdam Study

The Rotterdam Study is an ongoing prospective cohort study that started in 1990 in the city of Rotterdam, The Netherlands. The study aims to unravel etiology, preclinical course, natural history and potential targets for intervention for chronic diseases in mid-life and late-life. The study focuses on cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, otolaryngological, locomotor, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. Since 2016, the cohort is being expanded by persons aged 40 years and over. The findings of the Rotterdam Study have been presented in over 1700 research articles and reports. This article provides an update on the rationale and design of the study. It also presents a summary of the major findings from the preceding 3 years and outlines developments for the coming period.

Effect of Age on Arterial Recanalization and Clinical Outcome in Thrombolyzed Acute Ischemic Stroke in CLOTBUST Cohort

Background and Aims:

Despite the evidence from randomized clinical trials, the effectiveness of intravenous tissue recombinant plasminogen activator (IV-tPA) for elderly patients (≥80 yrs) with acute ischemic stroke (AIS) is often an important consideration in clinical practice. We evaluated the effect of older age on arterial recanalization, timing of recanalization and outcome in thrombolysed AIS patients.

Methods:

Consecutive AIS patients treated with IV-tPA and transcranial Doppler (TCD) examination within 3 hours of symptom-onset were included. Thrombolysis in Brain Ischemia (TIBI) flow-grading system was used to interpret TCD findings of persistent occlusion, re-occlusion and complete recanalization within 2 hours of IV-tPA bolus. Poor functional outcome was defined by modified Rankin score of 3 or more. Univariate and multiple logistic regression analyses were performed to assess the effect of age on clinical and TCD outcome measures.

Results:

The study included 361 patients (elderly = 85, <80 yrs = 276). Median age was 68 years (range 18-91 years). Compared to the elderly, younger patients (<80 years) were more females (63.5% versus 41.3%), had higher baseline National Institute of Health Stroke Scale score (17.5 versus 16.0 points) and shorter time from symptom-onset to IV-tPA bolus (median 136.6 versus 139.7 minutes). No significant differences were noted between the site of arterial occlusion, TCD outcome measures or time of complete recanalization between the 2 groups. More patients aged < 80 years achieved good functional outcome (51.9% versus 31.8% in the older age group; P = 0.004). IV-tPA induced recanalization and symptomatic intracranial hemorrhage were similar in the 2 groups. Multivariate logistic regression showed elderly age as an independent predictor of poor outcome (adjusted OR 2.5, 95%CI 1.26-4.95; P = 0.008).

Conclusion:

Elderly AIS patients achieve relatively poor functional outcome after IV-tPA despite similar rates of arterial recanalization. However, there is no increase in the hemorrhagic risk. Perhaps, decision for IV thrombolysis in elderly patients should be made cautiously.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Workforce requirements for comprehensive ischaemic stroke care in a developing country: the case of Saudi Arabia

BACKGROUND

Ischaemic stroke care requires a co-ordinated multi-disciplinary approach to optimise patient outcomes. Current care provision in Saudi Arabia is below international recommendations, and with increasing patient numbers, variable access to new therapies, and sub-optimal co-ordination of staff, the Kingdom's Ministry of Health has prioritised strategies to develop stroke care. Our objective was to use local epidemiological data to predict stroke incidence and to combine this with international staffing recommendations to estimate future staff requirements and their costs over a 10-year period.

METHODS

We researched existing stroke services and staff availability within Saudi Arabia to establish current provision, undertook epidemiological modelling to predict stroke incidence, and used international staffing recommendations for acute and rehabilitation services to develop a care pathway to provide state-of-the-art stroke services. This information was used to determine the additional staff requirements, and their costs, across the Kingdom.

RESULTS

Our research concluded that current staff numbers and services are inadequate to cope with the projected increase in the number of stroke cases. In order to provide acute and rehabilitation services which use the latest technologies, re-organisation of existing staff and services would be required, together with significant investment in new staff across several disciplines. An estimated additional 43.8 full-time equivalent stroke neurologists would be required, plus 53.5 full-time equivalent interventional neuroradiologists in addition to expansion of occupational therapy and psychology services. The total cost of additional staff over 10 years was estimated to be 862 390 778 Saudi Riyals ($229 970 874).

CONCLUSIONS

Providing high-quality care for ischaemic stroke patients would involve significant investment in new staff in Saudi Arabia. Further research is required on the applicability of international staffing ratios to countries where there is a significant workforce gap. Nevertheless, this analysis provides a framework to inform stroke care planning and can be adapted to other regions or countries.

Prescription of Pharmacotherapy and the Incidence of Stroke in Patients With Symptoms of Peripheral Artery Disease

Background and Purpose- Current guidelines recommend prescription of a number of medications to prevent cardiovascular events in patients with peripheral artery disease (PAD). The impact that these medications have on the incidence of stroke in PAD patients has not been thoroughly investigated. This study aimed to investigate the association of prescription of antihypertensive drugs, antiplatelet medications, and statins, as well as cardiovascular disease risk factors, with stroke incidence in patients with symptoms of PAD. Methods- A database search was completed to identify studies reporting the incidence of stroke and prescription of antihypertensive drugs, antiplatelet medications, and statins in patients with PAD symptoms. A random-effects model was used to meta-analyze the incidence of stroke in patients with symptoms of PAD and in subgroups with intermittent claudication and critical limb ischemia. Metaregression was performed to explore the association between the incidence of stroke and the prescription of medications and the presence of cardiovascular disease risk factors. Results- Twelve studies including 67 915 patients with symptoms of PAD were included. A meta-analysis of data from 7 studies demonstrated an incidence of stroke of 1.31 per 100 patient-years. Patients with critical limb ischemia experienced stroke 2.3× more frequently than those with intermittent claudication (95% CI, 1.58-3.36; P<0.01). The reported prescription of antihypertensive agents varied between 10% and 71%, antiplatelet drugs between 49% and 90%, and statins between 11% and 79% in different studies. Metaregression suggested an association between a lower incidence of stroke and the prescription of antiplatelet drugs ( R²=0.81, P<0.01), and statins ( R²=0.85, P<0.01), but not antihypertensives medications. A prior history of cerebrovascular events was associated with a higher incidence of stroke ( R²=0.58, P<0.05). Conclusions- This review supports previous research which suggests the need for more effective means of ensuring more widespread prescription of preventative medications in patients with PAD.

Involvement of Epigenetic Mechanisms and Non-coding RNAs in Blood-Brain Barrier and Neurovascular Unit Injury and Recovery After Stroke

Cessation of blood flow leads to a complex cascade of pathophysiological events at the blood-vascular-parenchymal interface which evolves over time and space, and results in damage to neural cells and edema formation. Cerebral ischemic injury evokes a profound and deleterious upregulation in inflammation and triggers multiple cell death pathways, but it also induces a series of the events associated with regenerative responses, including vascular remodeling, angiogenesis, and neurogenesis. Emerging evidence suggests that epigenetic reprograming could play a pivotal role in ongoing post-stroke neurovascular unit (NVU) changes and recovery. This review summarizes current knowledge about post-stroke recovery processes at the NVU, as well as epigenetic mechanisms and modifiers (e.g., DNA methylation, histone modifying enzymes and microRNAs) associated with stroke injury, and NVU repair. It also discusses novel drug targets and therapeutic strategies for enhancing post-stroke recovery.

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.

Gait analysis with the Kinect v2: normative study with healthy individuals and comprehensive study of its sensitivity, validity, and reliability in individuals with stroke

Background

Gait is usually assessed by clinical tests, which may have poor accuracy and be biased, or instrumented systems, which potentially solve these limitations at the cost of being time-consuming and expensive. The different versions of the Microsoft Kinect have enabled human motion tracking without using wearable sensors at a low-cost and with acceptable reliability. This study aims: First, to determine the sensitivity of an open-access Kinect v2-based gait analysis system to motor disability and aging; Second, to determine its concurrent validity with standardized clinical tests in individuals with stroke; Third, to quantify its inter and intra-rater reliability, standard error of measurement, minimal detectable change; And, finally, to investigate its ability to identify fall risk after stroke.

Methods

The most widely used spatiotemporal and kinematic gait parameters of 82 individuals post-stroke and 355 healthy subjects were estimated with the Kinect v2-based system. In addition, participants with stroke were assessed with the Dynamic Gait Index, the 1-min Walking Test, and the 10-m Walking Test.

Results

The system successfully characterized the performance of both groups. Significant concurrent validity with correlations of variable strength was detected between all clinical tests and gait measures. Excellent inter and intra-rater reliability was evidenced for almost all measures. Minimal detectable change was variable, with poorer results for kinematic parameters. Almost all gait parameters proved to identify fall risk.

Conclusions

Results suggest that although its limited sensitivity to kinematic parameters, the Kinect v2-based gait analysis could be used as a low-cost alternative to laboratory-grade systems to complement gait assessment in clinical settings.

Age and sex differences in the pathophysiology of acute CNS injury

Despite the immeasurable burden on patients and families, no effective therapies to protect the CNS after an acute injury are available yet. Furthermore, the underlying mechanisms that promote neuronal death and functional deficits after injury remain to be poorly understood. The prevalence, age of onset, pathophysiology, and symptomatology of many CNS insults differ significantly between males and females. In the case of stroke, younger males tend to show a higher risk than younger females, while this trend reverses with age. Accumulating evidence from preclinical studies have shown that sex hormones play a crucial role in providing neuroprotection following ischemic stroke and other acute CNS injuries. Estrogen, in particular, exerts a neuroprotective effect by modulating the immune responses after injury. In addition, there exists a sexual dimorphism in cell death pathways between males and females that are independent of hormones. Meanwhile, recent studies suggest that microRNAs are critically involved in the sex-specific mechanisms of cell death. This review discusses the current knowledge on the contribution of sex and age to outcome after stroke. Implication of the interplay between these two factors on other CNS injuries (spinal cord injury and traumatic brain injury) from the experimental evidence were also discussed.

Vertebrobasilar artery calcification: Prevalence and risk factors in the general population

BACKGROUND AND AIMS

Arteriosclerosis in the vertebrobasilar arteries may play an important role in the etiology of posterior circulation strokes, but little is known on its prevalence, its correlation with arteriosclerosis in other major arteries, and its risk factors. Hence, we investigated these aspects of vertebrobasilar artery calcification (VBAC) as marker of vertebrobasilar arteriosclerosis.

METHODS

To quantify VBAC, 2483 participants (mean age: 69.2 years, 52% female) from the Rotterdam Study underwent non-enhanced computed tomography. We determined the presence and volume of VBAC. Next, using Spearman's rank correlation, we examined the correlation between the volume of VBAC and the volume of coronary artery calcification (CAC), aortic arch calcification (AAC), and both extracranial- (ECAC), and intracranial carotid artery calcification (ICAC). Finally, we investigated associations of cardiovascular risk factors with the presence and volume of VBAC using logistic and linear regression models.

RESULTS

The overall prevalence of VBAC was 21.0% (median volume: 7.3 mm³ [IQR: 2.0-25.6]). Correlations between VBAC and CAC, AAC, ECAC, and ICAC were weak to moderate (men: 0.33, 0.28, 0.30, 0.36; women: 0.26, 0.24, 0.24, 0.35, respectively). Hypertension, diabetes, and current smoking were associated with the presence of VBAC in both sexes (men: OR 1.67 [95%-CI, 1.14-2.46], 1.60 [95%-CI, 1.10-2.34], 1.48 [95%-CI, 1.02-2.14]; women: OR 1.51 [95%-CI, 1.01-2.26], 1.56 [95%-CI, 1.02-2.39], 1.53 [95%CI, 1.00-2.33], respectively). In men, obesity was also associated with VBAC (1.42 [95%-CI, 1.00-2.02]).

CONCLUSIONS

VBAC occurs in over 20% of elderly community dwelling persons. Cardiovascular risk factors are associated with VBAC with similar patterns for men and women.

Neck dissection does not increases the risk of stroke in thyroid cancer: A national cohort study

Objectives

The purpose of this study is to evaluate the risk of stroke (hemorrhagic or ischemic) after neck dissection in thyroid cancer patients in Korea using national cohort data.

Methods

Using the national cohort study from the Korean Health Insurance Review and Assessment Service, patients with neck dissection for thyroid cancer (1,041) and control participants (4,164) were selected and matched 1:4 (age, gender, income, and region of residence). The Chi-square test, Fischer’s exact test, and the Cox-proportional hazard model were used. The Cox-proportional analysis used a crude model and an adjusted model for age, gender, income, region of residence, hypertension, diabetes, dyslipidemia.

Results

None of the participants had suffered hemorrhagic stroke in the neck dissection group, while 0.3% (13/4,164) of participants had suffered hemorrhagic stroke in the control group (P = 0.085). In total, 0.8% (8/1,041) of participants had suffered an ischemic stroke in the neck dissection group, and 0.7% (31/4,133) of participants had suffered an ischemic stroke in the control group (P = 0.936). The adjusted hazard ratio for ischemic stroke after neck dissection was 1.06 (95% confidence interval [CI] = 0.49–2.31, P = 0.884).

Conclusion

The risk of hemorrhagic or ischemic stroke was not higher in thyroid cancer patients who underwent neck dissection than that in the matched control group.

The Rotterdam Study: 2018 update on objectives, design and main results

The Rotterdam Study is a prospective cohort study ongoing since 1990 in the city of Rotterdam in The Netherlands. The study targets cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, otolaryngological, locomotor, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. Since 2016, the cohort is being expanded by persons aged 40 years and over. The findings of the Rotterdam Study have been presented in over 1500 research articles and reports (see www.erasmus-epidemiology.nl/rotterdamstudy ). This article gives the rationale of the study and its design. It also presents a summary of the major findings and an update of the objectives and methods.

Testosterone Propionate Exacerbates the Deficits of Nigrostriatal Dopaminergic System and Downregulates Nrf2 Expression in Reserpine-Treated Aged Male Rats

There is a controversy over the effects of testosterone supplements on dopaminergic function. Both neuroprotective and toxic effects of testosterone supplements are reported. The status of oxidative stress seems to explain the neuroprotective or toxic properties of testosterone. To determine the efficacy of testosterone supplements in different status of oxidative stress, the present studies analyzed the dopamine (DA)-related behaviors and neurochemical indices, as well as markers of nigrostriatal dopaminergic (NSDA) system in reserpine-treated aged male rats followed by testosterone propionate (TP) supplements. The status of oxidative stress of experimental animals was evaluated by analyzing oxidative stress parameters and nuclear factor erythroid 2-related factor 2 (Nrf2)-antioxidant response element (ARE) signaling pathway in substantia nigra (SN). Consistent with our previous studies, TP supplements to 21-month old aged male rats had the beneficial effects on NSDA system and DA-related behaviors and enhanced the antioxidative capabilities in SN. However, the beneficial effects of TP supplements on NSDA system and DA-related behaviors in aged male rats were reversed by reserpine pretreatment to them. Reserpine treatment induced the severe oxidative stress and reduced the expressions of Nrf2, heme oxygenase-1 (HO-1) and NAD(P)H:quinone oxidoreductase-1 (NQO1) in the SN of aged male rats. The TP supplements to reserpine-pretreated aged male rats exacerbated the defects in NSDA system and DA-related behaviors, aggravated oxidative damages and downregulated the expression of Nrf2, HO-1 and NQO1 in the SN. These results suggested that the efficacy of TP supplements on impaired NSDA system was related to the status of oxidative stress in experimental rats.

Diabetes and lifetime risk of stroke and subtypes in an urban middle-aged population

AIMS

Lifetime risk (LTR) is defined as the cumulative probability of developing a disease in one's remaining lifetime from a given index age. The impact of diabetes on the LTR of stroke events in Asians, where stroke incidence is higher than for Westerners, has not been estimated yet. These estimates can be useful for diabetes knowledge translation activities.

METHODS

All participants who were stroke-free at baseline in the Suita Study, a cohort study of cardiovascular diseases in Japan, were included in the study sample. Age, in years, was used as the time-scale. Age-specific incidence rates were calculated using the person-years method within five-year bands. We estimated the sex- and index-age-specific LTR of first-ever stroke accounting for the competing risk of death.

RESULTS

In this cohort study, we followed 5515 participants from 1989 to 2007 for 71,374.23 person-years. At age 40, the LTRs, adjusted for competing risk of death, for all strokes were 15.98% for men without diabetes and 26.64% for men with diabetes. The LTR for stroke was 10.66% higher for men with diabetes than men without diabetes. For women of same index age, the LTR of stroke was 17.29% and 30.72% with diabetes and without diabetes, respectively. The difference in LTR between persons with diabetes and without diabetes was 13.43%. This increased LTR of strokes for persons with diabetes was observed among both men and women across all index ages. Similar results were observed for cerebral infarction stroke subtype.

CONCLUSIONS

In this urban community-based population we observed that diabetes has a significant effect on the residual LTR of stroke for both men and women of middle age. This knowledge can be used to inform public health education and planning.

Non-vitamin K Oral Anticoagulants Versus Warfarin for Patients with Atrial Fibrillation: Absolute Benefit and Harm Assessments Yield Novel Insights

BACKGROUND AND OBJECTIVES

Benefits and/or harms (including costs) of non-vitamin K oral anticoagulants (NOACs) versus warfarin therapy need appreciation in relative and absolute terms.

METHODS

Accordingly, we derived clinically relevant relative and absolute benefit/harm parameters for NOACs (apixaban, dabigatran, rivaroxaban, edoxaban) compared to warfarin from four clinical trials involving atrial fibrillation (AF) patients. For each trial, we tabulated patient numbers enduring four important outcomes and calculated unadjusted relative risk reduction (RRR) and number needed to treat (NNT)/year values (and 95% confidence intervals) for the NAOC compared to warfarin. These outcomes were as follows: stroke/systemic embolism (primary endpoint), hemorrhagic stroke, major bleeds, and death. We also addressed drug acquisition costs.

RESULTS

Each NOAC was noninferior to warfarin for primary-outcome prevention; RRRs were 12-33% and NNT/year values were 182-481, and all but one indicated statistically significant superiority. All the NOACs yielded statistically significant reductions in hemorrhagic stroke risk; RRRs were 42-74% and NNT/year values were 364-528. Major bleeding risk was comparable in both groups. Apixaban yielded a lower NNT/year for preventing death than for primary-outcome prevention. Compared to warfarin, NOAC acquisition costs were 70- to 140-fold greater.

CONCLUSIONS

For the primary outcome, the absolute benefits of NOACs were modest (NNT/year values being large). Reduced hemorrhagic stroke rates with NOACs could be due to superior embolic infarct prevention and fewer consequential hemorrhagic transformations. Among apixaban recipients, the absolute mortality benefit exceeded that for the primary outcome, indicating prevention of additional unrelated deaths. The substantially greater NOAC acquisition costs need viewing against probable greater safety and the avoidance of monitoring bleeding risks.

Incidence of First Time Stroke: A Saudi Experience

BACKGROUND

Stroke is one of the major causes of morbidity and mortality throughout the world. A number of studies were conducted in Saudi Arabia. However, there were no studies conducted in Al-Madinah Al-Munawarah city.

OBJECTIVE

The aim of this study was to ascertain the incidence rate of first time stroke and the age-specific incidence in both genders in Al-Madinah Al-Munawarah city.

METHODS

A prospective hospital based study was conducted over a 1-year period (2014). The cases were included in the study when they were admitted with a diagnosis of cerebrovascular accident.

RESULTS

A total 164 patients (91 men and 73 women) who had first time stroke were found in this study with no significant difference between them (p = 0.565). The crude incidence rate of stroke was 13.89 per 100,000 persons. The age-specific incidence rate increased with age in the current study, where the peak was in the age group of more than 75 years old for men and women.

CONCLUSIONS

Total crude and the age-specific rates for first time stroke patients revealed in this study were markedly lower than the range reported from the developed countries. However, they were within the range that showed previously in Saudi Arabia and Arabian Peninsula countries.

Long-term restrictions in participation in stroke survivors under and over 70 years of age

PURPOSE

This study aims to (1) assess differences in participation restrictions between stroke survivors aged under and over 70 years and (2) identify predictors associated with favorable and unfavorable long-term participation in both age groups.

METHODS

Prospective cohort study in which 326 patients were assessed at stroke onset, two months and one year after stroke. The Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-Participation) was used to measure participation restrictions one year after stroke. Bivariate and multivariate logistic regression analyses were performed including demographic factors, stroke-related factors, emotional functioning and comorbidity as possible predictors.

RESULTS

Stroke survivors aged over 70 years perceived more participation restrictions in comparison to stroke survivors aged under 70 years one year after stroke. Independently significant predictors for unfavorable participation outcomes were advancing age, more severe stroke and anxiety symptoms in patients aged over 70 years, and female gender, more severe stroke, impaired cognition and depression symptoms in patients aged under 70 years. Lower age was the only independent predictor associated with favorable participation after one year in stroke survivors aged over 70 years.

CONCLUSIONS

This study emphasizes the need to pay more attention to participation restrictions in elderly stroke survivors. Implications for rehabilitation More attention in the rehabilitation process should be paid to restrictions in participation of stroke survivors aged older than 70 years, taking into account the different participation needs and predictors of older stroke survivors. Early screening on the presence of anxiety symptoms could potentially prevent long-term restrictions in participation in stroke survivors aged over 70-year old. Stroke survivors experience considerable restrictions in physical activity and mobility after one year, highlighting the need for the development of community-based exercise programs for stroke survivors.

Personalized absolute benefit of statin treatment for primary or secondary prevention of vascular disease in individual elderly patients

OBJECTIVE

To estimate the absolute treatment effect of statin therapy on major adverse cardiovascular events (MACE; myocardial infarction, stroke and vascular death) for the individual patient aged ≥70 years.

METHODS

Prediction models for MACE were derived in patients aged ≥70 years with (n = 2550) and without (n = 3253) vascular disease from the "PROspective Study of Pravastatin in Elderly at Risk" (PROSPER) trial and validated in the "Secondary Manifestations of ARTerial disease" (SMART) cohort study (n = 1442) and the "Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm" (ASCOT-LLA) trial (n = 1893), respectively, using competing risk analysis. Prespecified predictors were various clinical characteristics including statin treatment. Individual absolute risk reductions (ARRs) for MACE in 5 and 10 years were estimated by subtracting on-treatment from off-treatment risk.

RESULTS

Individual ARRs were higher in elderly patients with vascular disease [5-year ARRs: median 5.1 %, interquartile range (IQR) 4.0-6.2 %, 10-year ARRs: median 7.8 %, IQR 6.8-8.6 %] than in patients without vascular disease (5-year ARRs: median 1.7 %, IQR 1.3-2.1 %, 10-year ARRs: 2.9 %, IQR 2.3-3.6 %). Ninety-eight percent of patients with vascular disease had a 5-year ARR ≥2.0 %, compared to 31 % of patients without vascular disease.

CONCLUSIONS

With a multivariable prediction model the absolute treatment effect of a statin on MACE for individual elderly patients with and without vascular disease can be quantified. Because of high ARRs, treating all patients is more beneficial than prediction-based treatment for secondary prevention of MACE. For primary prevention of MACE, the prediction model can be used to identify those patients who benefit meaningfully from statin therapy.

Assessing the burden of medical impoverishment by cause: a systematic breakdown by disease in Ethiopia

BACKGROUND

Out-of-pocket (OOP) medical expenses often lead to catastrophic expenditure and impoverishment in low- and middle-income countries. Yet, there has been no systematic examination of which specific diseases and conditions (e.g., tuberculosis, cardiovascular disease) drive medical impoverishment, defined as OOP direct medical costs pushing households into poverty.

METHODS

We used a cost and epidemiological model to propose an assessment of the burden of medical impoverishment in Ethiopia, i.e., the number of households crossing a poverty line due to excessive OOP direct medical expenses. We utilized disease-specific mortality estimates from the Global Burden of Disease study, epidemiological and cost inputs from surveys, and secondary data from the literature to produce a count of poverty cases due to OOP direct medical costs per specific condition.

RESULTS

In Ethiopia, in 2013, and among 20 leading causes of mortality, we estimated the burden of impoverishment due to OOP direct medical costs to be of about 350,000 poverty cases. The top three causes of medical impoverishment were diarrhea, lower respiratory infections, and road injury, accounting for 75 % of all poverty cases.

CONCLUSIONS

We present a preliminary attempt for the estimation of the burden of medical impoverishment by cause for high mortality conditions. In Ethiopia, medical impoverishment was notably associated with illness occurrence and health services utilization. Although currently used estimates are sensitive to health services utilization, a systematic breakdown of impoverishment due to OOP direct medical costs by cause can provide important information for the promotion of financial risk protection and equity, and subsequent design of health policies toward universal health coverage, reduction of direct OOP payments, and poverty alleviation.

Validation of international stroke scales for use by nurses in Greek settings

BACKGROUND

Improving stroke outcomes by educating nurses in state-of-the-art stroke nursing skills is essential, but unfortunately, to date, there are limited validated stroke assessment scales for routine clinical and research use in Greece.

OBJECTIVE

The aim of this paper is to validate and culturally adapt three internationally recognised stroke scales for use in Greece.

METHODS

A critical appraisal of the international literature was undertaken to identify suitable scales to assess stroke impact: neurological, functional status and level of dependence. We identified: Scandinavian Stroke Scale (SSS), Barthel Index (BI) and modified Rankin Scale (mRS). They were formally translated and culturally adapted from English to Greek. Their validity was tested using Cronbach's alpha and Median Discrimination Index, while construct validity was checked by Principal Component Analysis (PCA). These were used on 57 consecutively selected patients with stroke from a Greek hospital, mean age 67.7 (±6.7 SD) years, range 54-85 years, length of stay, 8.5 (±2.7 SD) days.

RESULTS

All three scales show high internal consistency. The Cronbach's α on admission/ discharge for the SSS ranged from 0.86 to 0.88. The BI's reliability ranged from 0.95 to 0.93. The Median Discrimination Index was 0.70 (SSS) and 0.83 (BI). PCA showed that although a significant general factor (F1) explains most of the variance (57.0% on admission and 56.4% on discharge) a second factor (F2) of less significance was also highlighted. The convergent validity of the three scales was confirmed.

DISCUSSION

The stroke tools selected showed high reliability and validity, thus making these suitable for use in Greek clinical/academic environments. All three scales used are almost routinely undertaken in stroke studies internationally and form a backdrop for bio-statistical, functional and social outcome post-stroke.

CONCLUSIONS

The Greek version of the stroke tools show that both SSS and BI have high internal consistency and reliability and together with the mRS could be used in any Greek stroke care delivery setting.

Association of dementia with death after ischemic stroke: A two-year prospective study

The association between dementia and the risk of death after ischemic stroke was investigated. Neurological, neuropsychological and functional assessments were evaluated in 619 patients with acute ischemic stroke. Dementia was diagnosed at admission and at three months after stroke onset. The patients were scheduled for a two-year follow-up after the index stroke. The Kaplan-Meier survival and Cox proportional hazards regression analyses were used to estimate the cumulative proportion of survival, and the association between dementia and risk of death after stroke. In total, 146 patients (23.6%) were diagnosed with dementia after stroke. The cumulative proportion of surviving cases was 49.3% in patients with dementia after a median follow-up of 21.2±5.6 months, and 92.5% in patients without dementia. Multivariate analysis revealed that dementia (HR, 7.21; 95% CI, 3.85–13.49) was associated with death, independent of age, atrial fibrillation, previous stroke and NIH stroke scale. In conclusion, the mortality rate is increased in stroke patients with dementia. Dementia is an important risk factor for death after stroke, independent of age, atrial fibrillation, previous stroke, and the severity of the stroke.