Differences in initial stroke severity between Mexican Americans and non-Hispanic whites vary by age: the Brain Attack Surveillance in Corpus Christi (BASIC) project

Decompressive hemicraniectomy for stroke by race/ethnicity in the United States

Objective

Racial and ethnic differences in the performance of indicated neurosurgical procedures have been reported. However, it is not clear whether there are racial or ethnic differences in the performance of decompressive hemicraniectomy (DHC) for acute ischemic stroke. This study evaluated the rate, trends, and independent association of race and ethnicity with DHC among hospitalized ischemic stroke patients in the United States.

Materials and methods

We used the International Classification of Diseases, Clinical Modification (ICD-9-CM) to identify adult patients (18-year-old and older) with a primary discharge diagnosis of ischemic stroke, excluding those with a posterior circulation ischemic stroke in the Nationwide Inpatient Sample between 2006 and 2014. We computed the rate and trends of DHC. We then applied a multivariable logistic regression model to evaluate the independent association of race with DHC.

Results

A total 715,649 patients had anterior ischemic stroke, including 1514 who underwent DHC (2.1 per 1000). The rate of DHC increased overall from 1 per 1000 in 2006 to 3 per 1000 in 2014. Similar upward trends were noted among Non-Hispanic Whites, Non-Hispanic Blacks, and Hispanics. Hispanics with anterior ischemic stroke were 1.28 times more likely than non-Hispanic Whites to have DHC but no difference was observed between Non-Hispanic Blacks and Non-Hispanic Whites.

Conclusions

In this nationally representative sample of patients with anterior ischemic strokes, being of Hispanic ethnicity was independently associated with a higher frequency of receiving DHC compared to being Non-Hispanic White. Future studies should confirm this difference and explore the underlying reasons for it.

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Between 2006 and 2014,

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The rate of decompressive hemicraniectomy (DHC) increased from 1 per 1000 to 3 per 1000.

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The rate of DHC increased across all races/ethnicities.

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DHC was performed less frequently in Whites compared with other races each year.

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Hispanics with anterior ischemic stroke were 1.28 times more likely than non-Hispanic Whites to have DHC.

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No difference in the rate of DHC was observed between Blacks and Non-Hispanic Whites.

Diverging Temporal Trends in Stroke Incidence in Younger vs Older People: A Systematic Review and Meta-analysis

IMPORTANCE

Overall stroke incidence is falling in high-income countries, but data on time trends in incidence of young stroke (ie, stroke in individuals younger than 55 years) are conflicting. An age-specific divergence in incidence, with less favorable trends at younger vs older ages, might be a more consistent underlying finding across studies.

OBJECTIVE

To compare temporal trends in incidence of stroke at younger vs older ages in high-income countries.

DATA SOURCES

PubMed and EMBASE were searched from inception to February 2022. One additional population-based study (Oxford Vascular Study) was also included.

STUDY SELECTION

Studies reporting age-specific stroke incidence in high-income countries at more than 1 time point.

DATA EXTRACTION AND SYNTHESIS

For all retrieved studies, 2 authors independently reviewed the full text against the inclusion criteria to establish their eligibility. Meta-analysis was performed with the inverse variance-weighted random-effects model. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed.

MAIN OUTCOMES AND MEASURES

The main outcome was age-specific divergence (<55 vs ≥55 years) in temporal trends in stroke incidence (relative temporal rate ratio [RTTR]) in studies extending to at least 2000. RTTRs were calculated for each study and pooled by random-effects meta-analysis, with stratification by administrative vs prospective population-based methodology, sex, stroke subtype (ischemic vs intracerebral hemorrhage vs subarachnoid hemorrhage) and geographical region.

RESULTS

Among 50 studies in 20 countries, 26 (13 prospective population-based and 13 administrative studies) reported data allowing calculation of the RTTR for stroke incidence at younger vs older ages across 2 or more periods, the latest extending beyond 2000. Reported trends in absolute incidence of young individuals with stroke were heterogeneous, but all studies showed a less favorable trend in incidence at younger vs older ages (pooled RTTR = 1.57 [95% CI, 1.42-1.74]). The overall RTTR was consistent by stroke subtype (ischemic, 1.62 [95% CI, 1.44-1.83]; intracerebral hemorrhage, 1.32 [95% CI, 0.91-1.92]; subarachnoid hemorrhage, 1.54 [95% CI, 1.00-2.35]); and by sex (men, 1.46 [95% CI, 1.34-1.60]; women, 1.41 [95% CI, 1.28-1.55]) but was greater in studies reporting trends solely after 2000 (1.51 [95% CI, 1.30-1.70]) vs solely before (1.18 [95% CI, 1.12-1.24]) and was highest in population-based studies in which the most recent reported period of ascertainment started after 2010 (1.87 [95% CI, 1.55-2.27]).

CONCLUSIONS AND RELEVANCE

Temporal trends in stroke incidence are diverging by age in high-income countries, with less favorable trends at younger vs older ages, highlighting the urgent need to better understand etiology and prevention of stroke at younger ages.

Multiple Chronic Conditions Explain Ethnic Differences in Functional Outcome Among Patients With Ischemic Stroke

BACKGROUND AND PURPOSE

Mexican Americans (MAs) have worse stroke outcomes and a different profile of multiple chronic conditions (MCC) compared with non-Hispanic White people. MCC has implications for stroke treatment, complications, and poststroke care, which impact poststroke functional outcome (FO). We sought to assess the contribution of MCC to the ethnic difference in FO at 90 days between MAs and non-Hispanic White people.

METHODS

In a prospective cohort of ischemic stroke patients (2008-2016) from Nueces County, Texas, data were collected from patient interviews, medical records, and hospital discharge data. MCC was assessed using a stroke-specific and function-relevant index (range, 0-35; higher scores greater MCC burden). Poststroke FO was measured by an average score of 22 activities of daily living (ADLs) and instrumental ADLs at 90 days (range, 1-4; higher scores worse FO). The contribution of MCC to the ethnic difference in FO was assessed using Tobit regression. Effect modification by ethnicity was examined.

RESULTS

Among the 896 patients, 70% were MA and 51% were women. Mean age was 68±12.2 years; 33% of patients were dependent in ADL/instrumental ADLs (FO score >3, representing a lot of difficulty with ADL/instrumental ADLs) at 90 days. MAs had significantly higher age-adjusted MCC burden compared with non-Hispanic White people. Patients with high MCC score (at the 75th percentile) on average scored 0.70 points higher in the FO score (indicating worse FO) compared with those with low MCC score (at the 25th percentile) after adjusting for age, initial National Institutes of Health Stroke Scale, and sociodemographic factors. MCC explained 19% of the ethnic difference in FO, while effect modification by ethnicity was not statistically significant.

CONCLUSIONS

MAs had a higher age-adjusted MCC burden, which partially explained the ethnic difference in FO. The prevention and treatment of MCC could potentially mitigate poststroke functional impairment and lessen ethnic disparities in stroke outcomes.

Obstructive sleep apnea and stroke severity: Impact of clinical risk factors

BACKGROUND

Specific clinical and demographic risk factors may be associated with improving or worsening neurologic outcomes within a population of acute ischemic stroke (AIS) patients with a history of obstructive sleep apnea (OSA). The objective of this study was to determine the changes in neurologic outcome during a 14-day recovery as it relates to initial stroke severity in AIS patients with OSA.

METHODS

This retrospective study analyzed baseline clinical risk factors and demographic data collected in a regional stroke center from January 2010 to June 2016. Our primary endpoint measure was the National Institutes of Health Stroke Scale (NIHSS) score and our secondary endpoint measures included the clinical factors associated with improving (NIHSS score ≤7) or worsening (NIHSS score >7) neurological outcome. The relative contribution of each variable to stroke severity and related outcome was determined using a logistic regression. The regression models were checked for the overall correct classification percentage using a Hosmer-Lemeshow test, and the sensitivity of our models was determined by the area under the receiver operating characteristic curve.

RESULTS

A total of 5469 AIS patients were identified. Of this, 96.89% did not present with OSA while 3.11% of AIS patients presented with OSA. Adjusted multivariate analysis demonstrated that in the AIS population with OSA, atrial fibrillation (AF) (odds ratio [OR] = 3.36, 95% confidence interval [CI], 1.289-8.762, P = 0.013) and changes in ambulatory status (OR = 2.813, 95% CI, 1.123-7.041, P = 0.027) showed an association with NIHSS score >7 while being Caucasian (OR = 0.214, 95% CI, 0.06-0.767, P = 0.018) was associated with NIHSS score ≤7.

CONCLUSION

In AIS patients with OSA, AF and changes in ambulatory status were associated with worsening neurological outcome while Caucasian patients were associated with improving neurological outcome. Our findings may have significant implications for patient stratification when determining treatment protocols with respect to neurologic outcomes in AIS patients with OSA.

Early Neurological Change After Ischemic Stroke Is Associated With 90-Day Outcome

BACKGROUND AND PURPOSE

Large-scale observational studies of acute ischemic stroke (AIS) promise to reveal mechanisms underlying cerebral ischemia. However, meaningful quantitative phenotypes attainable in large patient populations are needed. We characterize a dynamic metric of AIS instability, defined by change in National Institutes of Health Stroke Scale score (NIHSS) from baseline to 24 hours baseline to 24 hours (NIHSSbaseline - NIHSS24hours = ΔNIHSS6-24h), to examine its relevance to AIS mechanisms and long-term outcomes.

METHODS

Patients with NIHSS prospectively recorded within 6 hours after onset and then 24 hours later were enrolled in the GENISIS study (Genetics of Early Neurological Instability After Ischemic Stroke). Stepwise linear regression determined variables that independently influenced ΔNIHSS6-24h. In a subcohort of tPA (alteplase)-treated patients with large vessel occlusion, the influence of early sustained recanalization and hemorrhagic transformation on ΔNIHSS6-24h was examined. Finally, the association of ΔNIHSS6-24h with 90-day favorable outcomes (modified Rankin Scale score 0-2) was assessed. Independent analysis was performed using data from the 2 NINDS-tPA stroke trials (National Institute of Neurological Disorders and Stroke rt-PA).

RESULTS

For 2555 patients with AIS, median baseline NIHSS was 9 (interquartile range, 4-16), and median ΔNIHSS6-24h was 2 (interquartile range, 0-5). In a multivariable model, baseline NIHSS, tPA-treatment, age, glucose, site, and systolic blood pressure independently predicted ΔNIHSS6-24h (R2=0.15). In the large vessel occlusion subcohort, early sustained recanalization and hemorrhagic transformation increased the explained variance (R2=0.27), but much of the variance remained unexplained. ΔNIHSS6-24h had a significant and independent association with 90-day favorable outcome. For the subjects in the 2 NINDS-tPA trials, ΔNIHSS3-24h was similarly associated with 90-day outcomes.

CONCLUSIONS

The dynamic phenotype, ΔNIHSS6-24h, captures both explained and unexplained mechanisms involved in AIS and is significantly and independently associated with long-term outcomes. Thus, ΔNIHSS6-24h promises to be an easily obtainable and meaningful quantitative phenotype for large-scale genomic studies of AIS.

Design and implementation of observational studies to measure disease burden with a focus on stroke

Observational epidemiological studies have the dual goals of measuring disease burden and assessing the association between exposures and outcomes. This report focuses on the first of these goals and provides an overview of design considerations of commonly used approaches, specifically community surveillance studies, cross-sectional studies, and longitudinal cohort studies. Each of these designs has strengths and weaknesses, with no study design being superior in all cases. Rather, these designs are complementary to achieve a better understanding of the burden of stroke.

Painless Acute Aortic Dissection May Present as a Stroke; Risky Markers that Could be Identified on Hospital Arrival

INTRODUCTION

Acute aortic dissection (AAD) is a life-threatening emergency. A small portion of AAD patients presents as an acute stroke without chest pain. A missed or delayed diagnosis of AAD often brings catastrophic outcome. We aimed to identify clinical markers suggestive of the presence of painless AAD in acute stroke patients.

METHODS

From January 2007 through December 2014, painless AAD patients were retrospectively collected from our stroke registry. We expanded the search by reviewing Medline and the Science Citation Index Expanded from 1981 until March 2015. We enrolled 200 consecutive cases of acute ischemic stroke without AAD as the control. Univariate analyses were performed to compare clinical markers, followed by logistic regression to analyze the markers with signifi cant differences.

RESULTS

The AAD group had more female, younger patients and fewer co-morbidities. They more frequently had consciousness disturbances (p < 0.001), were brought to the hospital sooner (p < 0.001), arrived more frequently with impaired consciousness (p = 0.001), hypotension and bradycardia (p < 0.001) and left-sided weakness (70.2%; p < 0.001). In the risk factor analysis, hypotension (OR 48.86, 95% CI 5.70-420.28), bradycardia (OR 8.11, 95% CI 2.71-24.24), initial loss of consciousness (OR 5.27, 95% CI 1.88-14.76), andleft-sided weakness (OR 3.31, 95% CI 1.17-9.40) were observed more frequently in the AAD group.

CONCLUSIONS

Consider to rule out a painless AAD in stroke patients presenting with hypotension, bradycardia, initial loss of consciousness, or left-sided weakness.

Spanish Version of the National Institutes of Health Stroke Scale: Awareness and Use in United States. A Survey Study

OBJECTIVE

To investigate the awareness and the use of Spanish version of National Institutes of Health Stroke Scale (NIHSS) throughout the United States (US) by regions using a web-based survey.

METHODS

A survey targeting physicians from two specialties that regularly manage acute stroke patients was conducted from February to August of 2015. Academic centers from the Accreditation Council for Graduate Medical Education online directory belonging to emergency medicine (EM) and neurology residency programs were identified. The questionnaire was composed of ten questions separated into three different groups. The responses received from the programs were separated by specialty and grouped into different regions in the US for comparison.

RESULTS

Out of 230 residency-invited programs, we received a total of 73 responses, 35 from EM and 26 responses from neurology residency programs. In addition, 12 respondents were categorized as unknown recipients. The South region had the highest response rate with 30.3%. There was no significant difference in the responses by region if Puerto Rico was not analyzed. Interviewees reported a substantial percentage of Spanish-speaking patients reported across the regions and more than 75% of the programs report lack of knowledge of the Spanish version of the NIHSS and/or the use of it.

CONCLUSION

There may be a need to increase awareness and to promote the use of the Spanish version of the NIHSS. Spanish-speaking population in the US may be inaccurately assessed for acute stroke and could impact the outcomes. Larger population studies should be conducted to confirm our findings.

AUTHOR CONTRIBUTIONS

Dr. Villalobos and Dr. Barnes are involved in formulating the study concept and design; Dr. Rodriguez and Dr. Maud are involved in manuscript writing; Dr. Qureshi is involved in statistical analysis of the data; Dr. Cruz-Flores is involved in critical revision of the manuscript.

DISCLOSURES

Dr. Villalobos reports no disclosure; Dr. Barnes reports no disclosure; Dr. Qureshi reports no disclosure; Dr. Cruz-Flores reports no disclosure; Dr. Maud reports no disclosure; Dr. Rodriguez reports no disclosure.

Determinants and Time Trends for Ischaemic and Haemorrhagic Stroke in a Large Chinese Population

Background

The clinical epidemiology of stroke has been widely investigated in Caucasian populations, but the changes over time in the proportion of ischaemic to haemorrhagic strokes is less clear, especially in the Chinese population.

Aims

Our objective was to study the determinants and time trends for ischaemic and haemorrhagic stroke, in relation to age, in a large Chinese population cohort.

Methods

Using a medical insurance database in the southwest of China from 2001 to 2012, time trends in age-adjusted ischaemic and haemorrhagic stroke incidence and the contributing risk factors associated with age were investigated.

Results

Among 425,901 individuals without prior stroke (52.4% male, median age 54), the rate of ischaemic stroke (per 1000 patient-years) decreased between 2002–2007, then remained broadly similar between 2008–2012. The rate of haemorrhagic stroke showed a similar trend, being approximately 1.3–1.9 from 2008–2012. Compared to patients age<65, ischaemic and haemorrhagic stroke incidences (rate, 95% confidential interval, CI) were higher in the elderly population (age <65 versus age ≥65: ischaemic: 3.64, 3.33–4.00, vs 14.33, 14.01–14.60; haemorrhagic: 1.09, 1.00–1.10 vs 2.52,2.40–2.70, respectively, both p<0.001). There were no significant differences in haemorrhagic stroke rates between the elderly and the very elderly population. Ischaemic and haemorrhagic stroke shared similar risk factors (age, hypertension, coronary artery disease (CAD), vascular disease, and diabetes mellitus) (all p<0.05). In subjects age<75 years, CAD (7.17, 4.14–12.37) and diabetes mellitus (3.27, 2.42–4.42) contributed most to the developing of haemorrhagic stroke (all p<0.001). Amongst the very elderly, vascular disease (2.24, 1.49–3.37) was an additional major risk factor for haemorrhagic stroke, together with CAD and diabetes mellitus (all p<0.001).

Conclusion

In this large Chinese cohort, there was an increased risk of ischaemic stroke compared to haemorrhagic stroke with ageing. CAD, vascular disease, diabetes mellitus, and hypertension were major contributors to the development of hemorrhagic stroke in the very elderly Chinese population.

Aspirin resistance is associated with increased stroke severity and infarct volume

OBJECTIVES

To investigate whether aspirin resistance is associated with initial stroke severity and infarct volume, using diffusion-weighted imaging (DWI) in patients with acute ischemic stroke that occurred while taking aspirin.

METHODS

We studied a total of 310 patients who were admitted within 48 hours of acute ischemic stroke onset. All patients had been taking aspirin for at least 7 days before stroke onset. Aspirin resistance, defined as high residual platelet reactivity (HRPR) on aspirin treatment, was measured using the VerifyNow assay and defined as an aspirin reaction unit ≥550. Initial stroke severity was assessed using the NIH Stroke Scale (NIHSS) score. Infarct volume was measured using DWI.

RESULTS

HRPR occurred in 86 patients (27.7%). The initial NIHSS score (median [interquartile range]) was higher in patients with HRPR than in the non-HRPR group (6 [3-15] vs 3 [1-8], p < 0.001). DWI infarct volumes were also larger in the HRPR group compared to the non-HRPR group (5.4 [0.8-43.2] vs 1.7 [0.4-10.3], p = 0.002). A multivariable median regression analysis showed that HRPR was significantly associated with an increase of 2.1 points on the NIHSS (95% confidence interval 0.8-4.0, p < 0.001) and an increase of 2.3 cm(3) in DWI infarct volume (95% confidence interval 0.4-3.9, p < 0.001).

CONCLUSIONS

Aspirin resistance is associated with an increased risk of severe stroke and large infarct volume in patients taking aspirin before stroke onset.