TOAST Subtypes of Ischemic Stroke and Its Risk Factors: A Hospital-Based Study at Cipto Mangunkusumo Hospital, Indonesia

Stroke in Asia

BACKGROUND

There is a significant burden of stroke in Asia. Asia has the largest population in the world in 2023, estimated at 4.7 billion. Approximately 9.5-10.6 million strokes will be anticipated annually in the backdrop of a diverse group of well-developed and less developed countries with large disparities in stroke care resources. In addition, Asian countries are in varying phases of epidemiological transition.

SUMMARY

In this review, we examined recent epidemiological features of ischaemic stroke and intracerebral haemorrhage in Asia with recent developments in hyperacute stroke reperfusion therapy and technical improvements in intracerebral haemorrhage. The article also discussed the spectrum of cerebrovascular diseases in Asia, which include intracranial atherosclerosis, intracerebral haemorrhage, infective aetiologies of stroke, moyamoya disease, vascular dissection, radiation vasculopathy, and cerebral venous thrombosis.

KEY MESSAGES

The review of selected literature and recent updates calls for attention to the different requirements for resources within Asia and highlights the breadth of cerebrovascular diseases still requiring further research and more effective therapies.

Association between Genetic Polymorphism of The lncRNA MIAT rs1894720 with Ischemic Stroke Risk and lncRNA MIAT Expression Levels in The Blood after An Ischemic Stroke: A Case-Control Study

OBJECTIVE

Genetic aspects can play an essential role in the occurrence and development of ischemic stroke (IS). Rs1894720 polymorphism is one of the eight single nucleotide polymorphisms (SNPs) in the long non-coding RNA (lncRNA) myocardial infarction-associated transcript (MIAT) locus. The aim of study is the lncRNA MIAT rs1894720 polymorphism decreases IS risk by reducing lncRNA MIAT expression.

MATERIALS AND METHODS

In this case-control study, we studied 232 Iranian patients and 232 controls. The blood samples were collected from patients admitted at different times after stroke symptoms. We enrolled 80, 78, and 74 patients who arrived at the hospital between 0-24, 24-48, and 48-72 hours after the first appearance of symptoms, respectively. DNA genotyping was done by the tetra-primer ARMS-PCR method. Circulating MIAT levels were evaluated by real-time polymerase chain reaction (PCR).

RESULTS

The GT genotype of MIAT rs1894720 showed a significant association with the risk of IS (OR=3.53, 95% CI=2.13-5.84, P<0.001). MIAT expression was higher relative to the control within the first hours after IS. The MIAT levels in IS patients with rs1894720 (GT) were significantly lower relative to patients who had the GG and TT genotypes. Linear regression model indicated a significant correlation between MIAT expression with atherosclerotic risk factors and types of stroke in IS patients. Receiver operating characteristic (ROC) curve analysis showed that the level of lncRNA MIAT after IS could be diagnostic with an area under the curve (AUC) of 0.82. The sensitivity and specificity were 80.17 and 67.24%, respectively (P<0.001).

CONCLUSION

Our study demonstrated that the MIAT rs1894720 polymorphism (GT) might increase the risk of IS in the Iranian population. MIAT expression was up-regulated in our IS patients. Hence, it could be a diagnostic biomarker for IS.

Cortical deafness as a sequel of recurrent stroke in patient with prosthetic heart valves and atrial fibrillation: a case report

Background

Cortical deafness is an unusual occurrence caused by injury to the central auditory pathway but not to the hearing organ. This paper reports the first case of cortical deafness as a sequel of recurrent stroke in a patient with prosthetic heart valves and atrial fibrillation in Asia.

Case presentation

A 40-year-old man with a history of atrial fibrillation and valvular heart disease comes with weakness on the right side of the body and slurred speech. Examination showed hemiplegia with increased d-dimer and activated partial thromboplastin time. (APTT). Brain MRI showed multiple subacute infarctions in the temporal lobe. Diffusion Tensor Imaging (DTI) tractography showed no visible auditory tract. Pure tone audiogram and brainstem auditory evoked potential test was normal, but speech reception threshold test was very poor. The patient has been diagnosed with recurrent ischemic stroke with sequel cortical deafness and received anticoagulant therapy and speech therapy. The patient reported minimal subjective impairment 1 month later with no further neurological deterioration.

Conclusions

A multidisciplinary clinical approach is needed in patients with cortical deafness, especially distinguishing it from other central hearing losses.

Characteristic of Acute Ischemic Stroke Patients Based on TOAST Classification During COVID-19 Pandemic Era: A Single Centre Study

Introduction

The categorization system used in the Trial Org 10172 classification in Acute Stroke Treatment (TOAST) provided more insight into the causal process. The aims of this study were to characterize individuals with acute ischemic stroke using the TOAST criteria and to determine risk variables for patients with acute ischemic stroke during the COVID-19 pandemic.

Methods

A cross-sectional study was done on the medical records of acute ischemic stroke patients at Hasan Sadikin Hospital (RSHS) Bandung, Indonesia, who were hospitalized in the Neurology Department of Hasan Sadikin Hospital from January to December 2021. Eligible patients were divided into 2 groups, with and without COVID-19 infection.

Results

There were 136 participants with acute ischemic stroke. Thirty-one percent of strokes were caused by atherosclerosis in the large arteries (LAA), followed by small-vessel occlusion (SVO) (25%), cardioembolism (CE) (22.1%), an undetermined cause (21.3%), and an other etiology (1.5%). CE risk factor was atrial fibrillation (p < 0.001), while hypertension, diabetes, and smoking were significant for LAA (p < 0.05). However, in patients with COVID-19 who had an acute ischemic stroke, most of the subtypes were stroke of undetermined etiology (76%), and hypercoagulation was the main risk factor (p < 0.001).

Conclusion

Patients with and without COVID-19 show varied distributions of stroke subtypes according to the TOAST categorization. Hypercoagulation is a major risk factor for stroke of undetermined etiology in individuals with COVID-19 who suffer from acute ischemic stroke. Increased viral-mediated endothelial inflammation leading to aberrant coagulopathy may explain the correlation between COVID-19 and acute ischemic stroke.

Pediatric vs. adult stroke: comparative study in a tertiary referral hospital, Cairo, Egypt

Background

Even though stroke is rare in children, it is associated with serious or life-threatening consequences. Despite its rarity, the occurrence of stroke in children has age-related differences in risk factors, etiopathogenesis, and clinical presentations. Unlike adults, who have arteriosclerosis as the major cause of stroke, risk factors for pediatric strokes are multiple, including cardiac disorders, infection, prothrombotic disorders, moyamoya disease, moyamoya syndrome, and others. The goal of the current study was to compare the characteristics, clinical features, etiology, subtypes, and workup of pediatric and adult strokes.

Methods

This was a hospital-based observational study conducted on 222 participants. All patients underwent a full clinical and neurological examination, full laboratory study, cardiac evaluation, and neuroimaging; CT scan, MRI, MRA, MRV, carotid duplex, and transcranial Doppler (TCD). Ischemic stroke (IS) etiology was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria, the "proposed classification for subtypes of arterial ischemic stroke in children," and the Oxfordshire Community Stroke Project (OCSP). Stroke severity was determined by the National Institutes of Health Stroke Scale (NIHSS) and PedNIHSS on admission.

Results

The proportion of pediatric ischemic strokes in the current study was 63.4 percent, while hemorrhagic strokes were 36.5%. The majority of the adult patients had ischemic strokes (84.1%), while hemorrhagic strokes were noted in 15.8% of the patients. According to the original TOAST classification, in the current study, the etiology of pediatric IS was other determined causes in 63.6%, undetermined etiology in 27.2%, and cardioembolic in 9.0%. For the adult group, the major stroke subtypes were large artery disease, small vessel disease, cardioembolic, other determined causes, and undetermined etiology at 49.6%, 28.6%, 6.9%, 0.6%, and 12.5%, respectively.

Conclusions

There is a greater etiological role for non-atherosclerotic arteriopathies, coagulopathies, and hematological disorders in pediatric stroke, while adults have more atherothrombotic causes. The co-existence of multiple risk factors in pediatric ischemic stroke is noticed. Thrombophilia evaluation is helpful in every case of childhood stroke. Children who have had a stroke should undergo vascular imaging as soon as possible. Imaging modalities include TCD and Doppler ultrasound, CT, MRI, MRA, and MRV, and cerebral angiography.

Stroke Burden and Stroke Services in Indonesia

Stroke is a major cause of death and disability in Indonesia. Stroke requires high quality, fast and precise management to prevent and avoid disability and death. Stroke can be prevented by adequately controlling for risk factors and encouraging healthy life styles. Efforts are needed to organize health promotion programs at the community level. More and a better distribution of neurologists and neurointerventionalists is needed. All hospitals should have a CT scan machine and stroke units. Telemedicine for stroke patient is very promising endeavor for an integrated acute stroke management system.

Analysis of Prognostic Risk Factors for Ischemic Stroke in China: A Multicentre Retrospective Clinical Study; A National Survey in China

BACKGROUND

Stroke is a serious disease that threatens human health both in China and worldwide. Identifying and establishing its risk factors are prerequisites for intervention and evaluation of prognosis. Over the years, risk factors, such as age, diabetes, and hypertension, have gradually been established. However, at present, there is no consensus on the influence of sex on the prognosis of ischaemic stroke.

AIMS

The aims of our research was to analyse the correlation between sex and poststroke prognosis based on the results of the Third China National Stroke Registry [CNSR-III], as well as the influence of other risk factors that may be confounded by sex on ischaemic stroke and potential interventions.

METHODS

The CNSR-III recruited 14146 acute ischaemic stroke [AIS] patients between 2015 and 2018. Our study included 13,972 patients who had complete follow-up information. This research analysed basic information, socioeconomic status, lifestyle habits, medical history, and poststroke prognosis.

RESULTS

There was a conspicuous relationship between sex and functional prognosis, stroke recurrence and all-cause death due to ischemic stroke in univariate analysis. Male stroke patients had a better prognosis than female patients. In multivariate analysis, we found that age, atrial fibrillation [AF], diabetes, hypertension and the severity of stroke had adverse effects on ischemic stroke prognosis. After adjustment for other risk factors, the functional prognosis of female patients at 3 months was worse than that of male patients [odds ratio [OR] 1.16, 95% confidence interval [CI], 1.025- 1.314]. Sex had a nonsignificant association with stroke recurrence at 3 months [hazard ratio [HR] 1.141, 95% CI, 0.975-1.336]. Furthermore, compared to male patients, female stroke patients had a lower cumulative death rate at 12 months [HR 0.777, 95% CI, 0.628-0.963].

CONCLUSION

Our study identified sex differences in stroke-related disability, recurrence, and death and attempted to explain the causes of these differences. Our study clearly showed that a large proportion of this difference could be attributed to age, socioeconomic factors, lifestyle habits, and medical history, confounded by sex differences rather than sex per se.

Prevalence and Clinical Characteristics of Lacunar Stroke: A Hospital-Based Study

Lacunar stroke (LS) is responsible for one-quarter of the overall number of ischemic strokes with long-term complications and carries health and economic issues for patients and health care systems. Therefore, we aimed to investigate lacunar versus non-lacunar strokes in a tertiary academic center. From February 2016 to July 2019, all patients admitted to the stroke unit were retrospectively reviewed. We included LS patients and compared them to other TOAST subtypes. Hemorrhagic stroke and conditions mimicking stroke were excluded. Regression analysis was done to determine LS predictors and outcomes. A 35.5% rate of LS among 989 ischemic stroke patients was found. Most patients (71.9%) were males. Lower National Institutes of Health Stroke Scale (NIHSS) scores at admission and negative history for cardiac diseases were predictors for LS in our population. At discharge, LS patients had low NIHSS scores and shorter hospitalization periods compared to non-LS patients. In conclusion, LS was prevalent among ischemic stroke patients in our cohort. Future studies are highly needed with long follow-up intervals to identify the stroke recurrence, complications, and outcomes.

Stroke risk factors, subtypes and outcome in elderly Thai patients

Background

Nowadays, the number of elderly has steadily increased annually.

Elderly patients with ischemic stroke often have worse outcomes than younger patients. However, there has not been a study of ischemic stroke in the elderly in Thailand. A better knowledge of the risk factors, subtypes, and outcomes of strokes in the elderly may have significant practical implications for the aged society in the future. The objective of the study was to assess the risk factor, stroke subtypes, and outcome of stroke in the elderly compared to the younger patients.

Method

All patients presented with acute ischemic stroke and transient ischemic attack (TIA) aged over 45 years who were admitted in the Stroke unit between November 1st, 2016 and December 31st, 2017 were retrospectively studied.

Result

Five hundred forty-two patients were included. The average age was 68.78 ± 12.03, 44.8% of them were male. 186 (34.3%) patients were 75 or older. Cardioembolism was found to be the most common cause of ischemic stroke in 156 patients (28.8%) and was associated with poor outcome. Patients who were 75 or older had significantly worse outcomes in all categories including NIHSS at discharge, modified Rankin scale, length of stay and the number of deaths compared to the younger group. Atrial fibrillation was the risk factors associated with older age with OR 3.861 (p value< 0.001). Aged 75 years or older, atrial fibrillation, more NIHSS score on admission and history of the previous stroke were the risk factors associated with a patient’s death.

Conclusion

The elderly who are 75 years or older accounts for more than one-third of ischemic stroke in our study. Stroke in the elderly correlates with higher mortality and poorer outcome. Cardioembolism related to atrial fibrillation is the major cause of stroke in this population.

Characterization of familial hypercholesterolemia in Taiwanese ischemic stroke patients

Familial hypercholesterolemia (FH) is a common genetic disorder characterized by a lifelong elevated low-density lipoprotein cholesterol (LDL-C) level. The relationship between FH and ischemic stroke is still controversial. We enrolled ischemic stroke patients prospectively in our neurological ward, and divided them into two groups according to LDL-C levels with a threshold of 130 mg/dl. Targeted sequencing was performed in all stroke patients for LDLR, APOB, and PCSK9 genes. The fifty-eight high-LDL subjects were older, prevalence of previous myocardial infarction/stroke history was lower, and the first stroke age was older compared with values in the sixty-three low-LDL cases. The prevalence of FH in Han-Chinese stroke patients was 5.0%, and was 10.3% in those with a higher LDL-C level. We identified six carriers, who had higher percentages of large vessel stroke subtype (66.7% vs. 15.4%) and transient ischemic attack (33.3% vs. 3.8%), previous myocardial infarction/stroke history (50.0% vs. 11.5%), statin use (50.0% vs. 11.5%), and increased carotid intima-media thickness (IMT) (0.9-1.2mm vs.0.7-9.0mm) compared with the other hypercholesterolemic patients without pathogenic variants. Ischemic stroke patients carrying FH pathogenic variants seemed to have a higher risk for large artery stroke and transient ischemic attack. The IMT exam could be useful to screen for FH in hypercholesterolemic stroke patients.

Metal-containing taurine compounds protect rat’s brain in reperfusion-induced injury

Introduction: The study aim was to explore a neuroprotective action of magnesium (LKhT-317) and zinc (LKhT-318) taurine salts on experimental models of reperfusion brain damage in rats and cell culture.

Materials and methods: The study was performed on male Sprague Dawley rats, and rat’s hippocampal mixed neuroglial cell culture. Magnesium- (LKhT-317) and zinc-containing (LKhT-318) derivatives of taurine were studied. Reperfusion brain damage was induced 30 min after intraluminal cerebral middle artery occlusion. Severity of the injury was assessed by local blood flowmetry, neurological symptoms scaling and brain tissue staining. Levels of IL-1b, IL-10 and TNF-alpha in tissue were determined by qualitative ELISA. Caspase-3 and Bcl-2 expressions were detected by IHC. Neurons survival was assessed by cytochemistry. Cellular calcium responses were detected by fluorescent microscopy of Fura-2-containig cells.

Results and discussion: Metal-containing taurine derivatives – LKhT-317 and LKhT-318 – demonstrated a sufficient neuroprotective property in rats with a reperfusion-induced brain injury. Both derivatives effectively prevented severity of the animals’ brain damage, motor deficiency, reduction of microvascular perfusion, and proinflammatory cytokines production. Magnesium-containing compound LKhT-317 was comparatively more effective than zinc-containing one. LKhT-317 possessed an anti-apoptotic action in vivo, and protected neurons from OGD-mediated cell death in mixed hippocampal culture. The aforementioned actions may be associated with an LKhT-317 inhibitory effect on NMDA-induced cellular Ca2+ response and, therefore, the anti-excitotoxic property of the compound.

Conclusion: Magnesium- and zinc-containing taurine derivatives may be considered as promising neuroprotectors in the reperfusion-induced brain injury.

QT interval prolongation in patients with acute ischemic stroke: a report in northwest China

Aims

QT interval prolongation is common in patients with stroke and increases the risk of malignant arrhythmia and sudden death. Our aim was to analyze differences in the QT interval and electrocardiogram abnormalities between acute ischemic stroke patients and controls.

Methods

We retrospectively collected data from 273 patients with acute ischemic stroke from the neurological intensive care unit and 495 controls from other departments. A standard 12-lead electrocardiogram was recorded within 24 hours of hospitalization. Clinical information, the QT interval corrected for heart rate (QTc), and the incidence of electrocardiogram abnormalities were compared between groups.

Results

There was no difference in age, sex, or the prevalence of hypertension or diabetes mellitus between the acute ischemic stroke group and controls. Acute ischemic stroke patients showed a significantly longer QTc and a higher incidence of both sinus bradycardia and ST-T changes compared with controls. We also showed that the changes in electrocardiogram results observed in acute ischemic stroke might be transient.

Conclusion

Acute ischemic stroke patients may have a longer QT interval and a higher incidence of electrocardiogram abnormalities. In clinical practice, careful attention should be paid to acute ischemic stroke patients to prevent malignant arrhythmia.