Sex Differences in Case Fatality of Aneurysmal Subarachnoid Hemorrhage: A Systematic Review

INTRODUCTION

Aneurysmal subarachnoid hemorrhage (SAH) is more common in women than in men, contrary to most cardiovascular diseases. However, it is unclear whether the case fatality rate (CFR) of SAH also differs by sex. Thus, we performed a systematic review to address the relationship between sex and SAH CFRs.

METHODS

We conducted a systematic literature search in PubMed, Scopus, and Cochrane library databases. We focused on population-based studies that included both nonhospitalized and hospitalized SAHs and had either reported 1-month (28-31 day) SAH CFRs separately for men and women or calculated risk estimates for SAH CFR by sex. For quality classification, we used the Cochrane Collaboration Handbook and Critical Appraisal Skills Program guidelines. We pooled the study cohorts and calculated relative risk ratios (RRs) with 95% confidence intervals (CIs) for SAH death between women and men using a random-effects meta-analysis model.

RESULTS

The literature search yielded 5,592 initial publications, of which 33 study cohorts were included in the final review. Of the 33 study cohorts, only three reported significant sex differences, although the findings were contradictory. In the pooled analysis of all 53,141 SAH cases (60.3% women) from 26 countries, the 1-month CFR did not differ (RR = 0.99 [95% CI: 0.93-1.05]) between women (35.5%) and men (35.0%). According to our risk-of-bias evaluation, all 33 study cohorts were categorized as low quality. The most important sources of bias risks were related to the absence of proper confounding control (all 33 study cohorts), insufficient sample size (27 of 33 study cohorts), and poor/unclear diagnostic accuracy (27 of 33 study cohorts).

CONCLUSION

Contrary to SAH incidence rates, the SAH CFRs do not seem to differ between men and women. However, since none of the studies were specifically designed to examine the sex differences in SAH CFRs, future studies on the topic are warranted.

Stroke incidence, mortality, subtypes in rural and urban populations in five geographic areas of India (2018-2019): results from the National Stroke Registry Programme

Background

Increasing stroke burden in India demands a long-term stroke surveillance framework. Earlier studies in India were urban-based, short term and provided limited data on stroke incidence and its outcomes. This gap is addressed by the establishment of five population-based stroke registries (PBSRs) of the National Stroke Registry Programme, India. This paper describes stroke incidence, mortality and age, sex, and subtypes distribution in the five PBSRs with urban and rural populations.

Methods

First-ever incident stroke patients in age group ≥18 years, resident for at least one year in the defined geographic area, identified from health facilities were registered. Death records with stroke as the cause of death from the Civil Registration System (CRS) were included. Transient ischemic attack (TIA) was excluded. Three PBSRs (Cuttack, Tirunelveli, Cachar) included urban and rural populations. PBSRs in Kota and Varanasi were urban areas. The crude and age-standardized incidence rate (ASR) by age, sex, and residence (urban and rural), rate ratios of ASR, case fatality proportions and rates at day 28 after onset of stroke were calculated for years 2018-2019.

Findings

A total of 13,820 registered first-ever stroke cases that included 985 death certificate-only cases (DCOs) were analysed. The pooled crude incidence rate was 138.1 per 100,000 population with an age-standardized incidence rate (ASR) of 103.4 (both sexes), 125.7 (males) and 80.8 (females). The risk of stroke among rural residents was one in seven (Cuttack), one in nine (Tirunelveli), and one in 15 (Cachar). Ischemic stroke was the most common type in all PBSRs. Age-standardized case fatality rates (ASCFR) per 100,000 population for pooled PBSRs was 30.0 (males) and 18.8 (females), and the rate ratio (M/F) ranged from 1.2 (Cuttack) to 2.0 (Cachar).

Interpretation

Population-based registries have provided a comprehensive stroke surveillance platform to measure stroke burden and outcomes by age, sex, residence and subtype across India. The rural-urban pattern of stroke incidence and mortality shall guide health policy and programme planning to strengthen stroke prevention and treatment measures in India.

Funding

The National Stroke Registry Programme is funded through the intramural funding of the Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, India.

Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation

Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.

The downward referral experiences of stroke caregivers in the regional medical alliance in China: A phenomenological study

The downward referral platform in the regional medical alliance has provided more possibilities to follow-up rehabilitation and transitional care for increasing stroke survivors, which also has the most contributions in the rational use of resources and health promotion of stroke survivors. However the downward referral rate is low compared to upward referral. At present, no scholars have explored the downward referral experiences of medical demanders from the perspective of qualitative study, and these experiences may also most truly reflect the influencing factors of their unwillingness to downward referral. Therefore, this study explored the subjective experiences of stroke caregivers who had experienced the downward referral, because stroke attacks often lead to lack of autonomy of patients themselves, making it difficult to complete interviews with them. A descriptive phenomenological study was adopted. A purposive sampling strategy was used to recruit 13 stroke caregivers. Interviews were guided by a semi-structured interview-guide encouraging interviewees to reflect on their experiences with downward referral. Coliazzi's data analysis process was applied. The analysis of the data revealed 4 themes: coping challenges; disrupted information; gaps in medical and nursing transition, and potential enabling factors. The results of this study showed that the lack of knowledge of medical alliance, non-sharing of medical information and non-homogeneousness of medical quality were identified to be impeding positive attitude towards downward referral and be factors of bad experiences. Of course, the interviewees had positive experiences such as smooth referral and comfortable environment. These may be potential enabling factors to their attitude towards downward referral. The challenges and needs of medical demanders after downward referral are worthy of attention, and these should be solved by corresponding measures to improve the downward referral rate and referral experiences.

Has stroke mortality stopped declining in Spain?

OBJECTIVES

To analyse the changes in stroke mortality trends in Spain by autonomous community and by sex during the period 1980-2016, using joinpoint regression models.

METHODS

Mortality data were obtained from the Spanish National Statistics Institute. Crude and standardised rates were calculated for each Spanish autonomous community, and for each sex. Joinpoint analysis was used to identify the best-fitting points showing a statistically significant change in the trend.

RESULTS

Joinpoint analysis enabled us to differentiate between communities in which mortality rates showed a continuous decline throughout the study period in both sexes (Asturias, Cantabria, Castile and Leon, Ceuta, and Melilla) or in men only (Extremadura). In men, in all those communities in which changes in the trend were observed (all but Aragon, the Balearic Islands, and Murcia, where rates remained stable), we observed an initial period of decline (ranging from -3.4% in Catalonia and Extremadura, to -6.0% in Madrid) and a final period where the trends diverged: mortality rates continued to fall in Andalusia, Aragon, the Balearic Islands, and Madrid, but began to stabilise in Castile-La Mancha and Murcia and to increase in the Canary Islands. In women, in those communities where changes were observed (all but Aragon, Murcia, and the Basque Country, where rates remained stable), we observed an initial period of decline (ranging from -3.1% in Catalonia to -6.4% in Navarre) and a final period where divergent trends were observed: rates continued to decline in Andalusia, Aragon, Catalonia, Galicia, Madrid, and the Basque Country, but began to stabilise in Extremadura and Murcia and to increase in the Canary Islands.

CONCLUSIONS

Current data show that stroke mortality rates have decreased (in women in Andalusia), stabilised (in both sexes in Murcia, in men in Castile-La Mancha, and in women in Extremadura), and have even reversed (in both sexes in the Canary Islands). Further study is needed to identify the causes of these trends.

Influence Factors and Predictive Models for the Outcome of Patients with Ischemic Stroke after Intravenous Thrombolysis: A Multicenter Retrospective Cohort Study

Objective

Intravenous thrombolysis (IVT) is currently the main effective treatment for patients with ischemic stroke. This study aimed to analyze the factors affecting the early neurological recovery and prognosis of thrombolytic therapy after surgery and to construct predictive models.

Materials and Methods

A total of 849 patients with ischemic stroke who received IVT treatment at six centers from June 2017 to March 2021 were included. Patients were divided into the training cohort and the validation cohort. Based on the independent factors that influence the early recovery of neurological function and the prognosis, the respective predictive nomograms were established. The predictive accuracy and discrimination ability of the nomograms were evaluated by ROC and calibration curve, while the decision curve and clinical impact curve were adopted to evaluate the clinical applicability of the nomograms.

Results

The nomogram constructed based on the factors affecting the prognosis in 3 months had ideal accuracy as the AUC (95% CI) was 0.901 (0.874~0.927) in the training cohort and 0.877 (0.826~0.929) in the validation cohort. The accuracy of the nomogram is required to be improved, since the AUC (95% CI) of the training cohort and the validation cohort was 0.641 (0.597~0.685) and 0.627 (0.559~0.696), respectively.

Conclusions

Based on this ideal and practical prediction model, we can early identify and actively intervene in patients with ischemic stroke after IVT to improve their prognosis. Nevertheless, the accuracy of predicting nomograms for the recovery of early neurological function after IVT still needs improvement.

Quality of Life in the First Year after Ischemic Stroke Treated with Acute Revascularization Therapy

(1) Background: we aimed to describe the disease-specific quality of life (QoL) of ischemic stroke patients treated with acute revascularization therapy, its evolution from 6 months to 12 months, and associated factors. (2) Methods: QoL was assessed with the SS-QoL in consecutive patients treated with either intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT). Variables associated with QoL scores and its evolution were studied using multivariate mixed models, and interaction with time. Analyses were performed in four domains of SS-QoL: self-care, mobility, mood, and social roles. (3) Results: Among the 501 included patients (mean (sd) age 68.9 (14.5), 49% women), lower post-stroke QoL was independently related to lower level of school education, prestroke mRS > 2, and 24 h NIHSS score > 4. Independent predictors of unfavorable evolution of QoL over time were age <75 years (Mobility p = 0.0194 and Mood p = 0.0015), NIHSS score ≤ 4, (Self-care p = 0.0053 and Mood p = 0.0048), and modified Rankin Scale score ≤ 2 (Social roles, p = 0.0006). Revascularization therapy had no significant effect on the QoL scores, but patients treated with MT (alone or as bridging therapy) had significantly greater improvement in mobility score between 6 and 12 months than patients treated with IVT alone (p = 0.0072). (4) Conclusion: QoL evolution over one year had only slight variation and was associated with the modalities of acute treatment, age, and stroke severity.

Patients Hospitalized for Ischemic Stroke and Intracerebral Hemorrhage in France: Time Trends (2008-2019), In-Hospital Outcomes, Age and Sex Differences

BACKGROUND

Rates of patients hospitalized for stroke increased among people aged under 65 years in France, as has been found in other countries.

METHODS

To analyze time trends in the rates of patients hospitalized for ischemic stroke (IS) and intracerebral hemorrhage (ICH) in France between 2008 and 2019 and determine related short-term outcomes mainly, we selected all patients hospitalized for stroke using the French national hospital database.

RESULTS

The average annual percentage change in the rates of patients hospitalized for IS increased significantly in men and women aged 50-64 years (+2.0%) and in men aged 18-34 years (+1.5%) and 35-44 years (+2.2%). A decrease in the average annual percentage change was observed for IS among people aged over 75 years and among those over 50 years for ICH. After adjustment on confounding factors, women were less likely to die in hospital. Case fatality rates decreased overtime in all age groups for both sexes, with a more pronounced decrease for IS than ICH.

CONCLUSIONS

The increasing trend of IS among adults under 65 years is ongoing, highlighting the urgent need for stroke prevention programs in that age. For the first time, we recorded a decrease in the rates of patients hospitalized for ICH among the population over 50 years.

Twenty-Year Change in Severity and Outcome of Ischemic and Hemorrhagic Strokes

Question

Did the initial neurological severity and functional outcomes of patients with stroke change throughout a 20-year period?

Findings

In this hospital-based, multicenter, prospective registry involving 183 080 patients with acute stroke, initial neurological severity showed a decrease over time in all stroke types. Functional outcome at hospital discharge improved in patients with ischemic stroke but no longer showed improvement after adjustment by reperfusion therapy and others; it did not clearly improve in patients with hemorrhagic stroke.

Meaning

Twenty-year changes in functional outcomes after ischemic and hemorrhagic strokes showed different trends presumably partly owing to differences in the development of acute therapeutic strategies.

Importance

Whether recent changes in demographic characteristics and therapeutic technologies have altered stroke outcomes remains unknown.

Objective

To determine secular changes in initial neurological severity and short-term functional outcomes of patients with acute stroke by sex using a large population.

Design, Setting, and Participants

This nationwide, hospital-based, multicenter, prospective registry cohort study used the Japan Stroke Data Bank and included patients who developed acute stroke from January 2000 through December 2019. Patients with stroke, including ischemic and hemorrhagic strokes, who registered within 7 days after symptom onset were studied. Modified Rankin Scale scores were assessed at hospital discharge for all patients.

Exposure

Time.

Main Outcomes and Measures

Initial severity was assessed by the National Institutes of Health Stroke Scale for ischemic stroke and intracerebral hemorrhage and by the World Federation of Neurological Surgeons grading for subarachnoid hemorrhage. Outcomes were judged as favorable if the modified Rankin Scale score was 0 to 2 and unfavorable if 5 to 6.

Results

Of 183 080 patients, 135 266 (53 800 women [39.8%]; median [IQR] age, 74 [66-82] years) developed ischemic stroke, 36 014 (15 365 women [42.7%]; median [IQR] age, 70 [59-79] years) developed intracerebral hemorrhage, and 11 800 (7924 women [67.2%]; median [IQR] age, 64 [53-75] years) developed subarachnoid hemorrhage. In all 3 stroke types, median ages at onset increased, and the National Institutes of Health Stroke Scale and World Federation of Neurological Surgeons scores decreased throughout the 20-year period on multivariable analysis. In ischemic stroke, the proportion of favorable outcomes showed an increase over time after age adjustment (odds ratio [OR], 1.020; 95% CI, 1.015-1.024 for women vs OR, 1.015; 95% CI, 1.011-1.018 for men) but then stagnated, or even decreased in men, on multivariate adjustment including reperfusion therapy (OR, 0.997; 95% CI, 0.991-1.003 for women vs OR, 0.990; 95% CI, 0.985-0.994 for men). Unfavorable outcomes and in-hospital deaths decreased in both sexes. In intracerebral hemorrhage, favorable outcomes decreased in both sexes, and unfavorable outcomes and deaths decreased only in women. In subarachnoid hemorrhage, the proportion of favorable outcomes was unchanged, and that of unfavorable outcomes and deaths decreased in both sexes.

Conclusions and Relevance

In this study, functional outcomes improved in patients with ischemic stroke during the past 20 years in both sexes presumably partly owing to the development of acute reperfusion therapy. The outcomes of patients with hemorrhagic stroke did not clearly improve in the same period.

Has stroke mortality stopped declining in Spain?

OBJECTIVES

To analyse the changes in stroke mortality trends in Spain by autonomous community and by sex during the period 1980-2016, using joinpoint regression models.

METHODS

Mortality data were obtained from the Spanish National Statistics Institute. Crude and standardised rates were calculated for each Spanish autonomous community, and for each sex. Joinpoint analysis was used to identify the best-fitting points showing a statistically significant change in the trend.

RESULTS

Joinpoint analysis enabled us to differentiate between communities in which mortality rates showed a continuous decline throughout the study period in both sexes (Asturias, Cantabria, Castile and Leon, Ceuta, and Melilla) or in men only (Extremadura). In men, in all those communities in which changes in the trend were observed (all but Aragon, the Balearic Islands, and Murcia, where rates remained stable), we observed an initial period of decline (ranging from -3.4% in Catalonia and Extremadura, to -6.0% in Madrid) and a final period where the trends diverged: mortality rates continued to fall in Andalusia, Aragon, the Balearic Islands, and Madrid, but began to stabilise in Castile-La Mancha and Murcia and to increase in the Canary Islands. In women, in those communities where changes were observed (all but Aragon, Murcia, and the Basque Country, where rates remained stable), we observed an initial period of decline (ranging from -3.1% in Catalonia to -6.4% in Navarre) and a final period where divergent trends were observed: rates continued to decline in Andalusia, Aragon, Catalonia, Galicia, Madrid, and the Basque Country, but began to stabilise in Extremadura and Murcia and to increase in the Canary Islands.

CONCLUSIONS

Current data show that stroke mortality rates have decreased (in women in Andalusia), stabilised (in both sexes in Murcia, in men in Castile-La Mancha, and in women in Extremadura), and have even reversed (in both sexes in the Canary Islands). Further study is needed to identify the causes of these trends.

Stroke in women: When gender matters

Stroke in women may be considered as a distinct entity due to numerous differences compared with men, including specific epidemiological, etiological, and outcome features along with unique pathophysiological mechanisms. Stroke is the second cause of death in women worldwide with sex-specific causes of stroke in youger women such as pregnancy, post-partum period, oral contraception and migraine. Substitutive hormone treatment in older women is no more recommended in regard of the increased thromboembolic risk it generates. Venous thrombolysis with rtPA and mechanical thrombectomy are now proven to be as efficacious in women as in men. After a stroke, women present poorer quality of life than men attributable to age, more severe stroke, pre-stroke dependency and depression. Recent data concerning the latest epidemiological surveys reveal a shift in trends with the rise of incidence of strokes in young women (≤55 years and 64 years) contrasting with the stability of incidence rates in older women. As science is unvealing sex-related differences in cardiovascular disorders, health policies need to be adapted accordingly to improve stroke prevention and pre-stroke health in women. In the meantime, therapeutical trials should include more women in order to be able to formulate adequate management.

Temporal Trends in the Incidence of Ischemic Stroke in Young Adults: Dijon Stroke Registry

INTRODUCTION

Stroke is associated with major consequences in terms of socioeconomic impact and lost disability-adjusted life in young victims, thus justifying a careful surveillance of epidemiological trends. This study aimed to assess changes in the incidence of ischemic stroke in young adults over a long period.

METHODS

All cases of first-ever ischemic stroke that occurred among adults aged 18-55 years were prospectively recorded using the population-based Dijon Stroke Registry, from 1985 to 2017. Sex-specific annual incidence rates were calculated and were presented according to 6 time periods. Incidence rate ratios (IRRs) were determined to assess sex differences in stroke incidence.

RESULTS

Over the whole study period, 4,451 patients suffered a first-ever ischemic stroke. Among these patients, 469 (10.5%) were young adults (median age: 46 years, IQR: 39-50; 53.9% men). Incidence rates rose from the study period 2003 to 2007 compared with previous periods and remained stable thereafter, both in men and women. Hence, incidence per 100,000 per year was globally 11.0 (95% CI: 9.4-12.7) before 2003 and 22.9 (20.3-25.6) thereafter. In individuals aged 18-45 years, incidence rates were 5.4 (4.3-6.9) overall, 4.1 (2.7-6.0) in men, and 6.7 (4.9-9.0) in women, before 2003. After 2003, incidence rates rose to 12.8 (10.7-15.1) overall, 12.0 (9.2-15.4) in men, and 13.6 (10.6-17.0) in women. In this age group, the men/women IRR was 0.78 (95% CI: 0.62-1.26, p = 0.08), although sex differences decreased over time (IRR = 0.62; 95% CI: 0.36-1.02, p = 0.046 before 2003, vs. IRR = 0.88; 95% CI: 0.62-1.26, p = 0.48 after 2003). In individuals aged 45-55 years, incidence rates before 2003 were 47 (37-61) in men and 25 (17-35) in women (IRR = 1.90; 95% CI: 1.24-2.97, p < 0.001), and they increased to 82 (67-100) in men and 46 (35-59) in women (IRR = 1.79; 95% CI: 1.29-2.49, p < 0.001) after 2003.

CONCLUSIONS

The incidence of ischemic stroke in young adults increased during the early 2000s and remained stable thereafter. These results highlight the priority need for dedicated prevention strategies for the young to reduce the burden of stroke.

Evaluation of efficacy and safety of endovascular coiling for patients with aneurysmal subarachnoid hemorrhage: A protocol for systematic review and meta-analysis

BACKGROUND

There is an elevated risk of rebleeding when the aneurysm is left untreated in patients diagnosed with aneurysmal subarachnoid hemorrhage (SAH). Occlusion of the lumen of the aneurysm using endovascular coiling is a common method to prevent rebleeding by occluding the aneurysm. This study aims to evaluate the efficacy and safety of endovascular coiling in patients with aneurysmal SAH.

METHODS

A systematic search for relevant articles will be performed in 4 English electronic databases, including MEDLINE (from 1966 to October 2020), EMBASE (from 1980 to October 2020), the Cochrane Library (from 2020, issue 10), Scopus (from 1823 to October 2020), and 3 Chinese electronic databases, including Chinese Biomedical Literature Database (from 1995 to October 2020), WanFang (last searched October 2020), and China National Knowledge Infrastructure (last searched October 2020). This study will comprise randomized controlled trials (RCTs) that evaluate the effectiveness and safety of using endovascular coiling in the treatment of aneurysmal SAH. The articles in the databases will be independently screened by 2 authors to select potential studies, extract data, and evaluate the bias risk in the selected studies. This study will use suitable statistical methods to merge result data.

RESULTS

The results of this study will be useful in determining the efficacy and safety of endovascular coiling for treating patients with aneurysmal SAH.

CONCLUSION

The findings of this study will summarize the most recent evidence on the effectiveness and safety of using endovascular coiling to treat aneurysmal SAH.

ETHICS AND DISSEMINATION

The present work does not involve any humans or animals; therefore, ethical approval is not needed.

SYSTEMATIC REVIEW REGISTRATION

December 2, 2020.osf.io/yj4gq (https://osf.io/yj4gq/).

Temporal Trends in Case Fatality, Discharge Destination, and Admission to Long-term Care After Acute Stroke

OBJECTIVE

To determine contemporary trends in case fatality, discharge destination, and admission to long-term care after acute ischemic stroke and intracerebral hemorrhage (ICH) using a large, population-based cohort.

METHODS

We used linked administrative data to identify all emergency department visits and hospital admissions for first-ever ischemic stroke or ICH in Ontario, Canada, from 2003 to 2017. We calculated crude and age-/sex-standardized risk of death at 30 days and 1 year from stroke onset. We stratified crude trends by stroke type, age, and sex and used the Kendall τ-b correlation coefficient to evaluate the significance of trends. We determined trends in discharge home and to rehabilitation and admission to long-term care at 1 year. We used Cox proportional hazard and logistic regression models to assess whether trends in outcomes persisted after adjustment for baseline factors, estimated stroke severity, and use of life-sustaining care.

RESULTS

There were 163,574 people with acute ischemic stroke or ICH across the study period. Between 2003 and 2017, age-/sex-standardized 30-day stroke case fatality decreased from 20.5% to 13.2% (7.3% absolute and 36% relative reduction) while that at 1 year decreased from 32.2% to 22.8% (9.3% absolute and 29% relative reduction). Findings were consistent across age, sex, and stroke type, and after adjustment for comorbid conditions, stroke severity, and use of life-sustaining care. There was a reduction in long-term care admission after ischemic stroke and an increase in discharge home or to rehabilitation for both stroke types.

CONCLUSION

We observed substantial reductions in acute stroke case fatality from 2003 to 2017 with a concurrent increase in discharge to home or rehabilitation and a decrease in long-term care admissions, suggesting continuous improvements in stroke systems of care.

Stroke Rehabilitation for Falls and Risk of Falls in Southeast Asia: A Scoping Review With Stakeholders' Consultation

Background: Research on rehabilitation for falls after stroke is warranted. However, published evidence on fall interventions with stroke survivors is limited and these are mainly international studies that may be less relevant for Southeast Asia. Objective: This review aims to systematically identify literature related to stroke rehabilitation for falls and risk of falls in Southeast Asia. Methods: A scoping review with stakeholders' consultation was implemented. An electronic search was conducted up to December 2020 on 4 databases (Medline, CINAHL, Scopus, ASEAN Citation Index). Only original studies conducted in Southeast Asia were selected. Results: The initial search yielded 3,112 articles, however, only 26 were selected in the final analysis. Most of the articles focused on physical rehabilitation and implemented conventional therapies. While the literature may reflect practice in Southeast Asia, stakeholders perceived that the literature was inadequate to show true practice, was not informative and missed several aspects such as functional, cognitive, and psychological interventions in managing falls. Individual-centric interventions dominated the review while community-based and environmental-focused studies were limited. Majority of the articles were written by physiotherapists while others were from physicians, occupational therapists, and an engineer but few from other healthcare practitioners (i.e., speech therapists, psychologists) or disciplines interested in falls. Conclusions: Falls prevention among stroke survivors has received a lack of attention and is perceived as an indirect goal in stroke rehabilitation in Southeast Asia. More innovative research adopted from falls research with older people is needed to advance falls prevention and intervention practice with stroke survivors.

Temporal trends in stroke incidence and case-fatality rates in Arcadia, Greece: A sequential, prospective, population-based study

BACKGROUND

Stroke incidence and case-fatality are reported to decline in high-income countries during the last decades. Epidemiological studies are important for health services to organize prevention and treatment strategies.

AIMS

The aim of this population-based study was to determine temporal trends of stroke incidence and case-fatality rates of first-ever stroke in Arcadia, a prefecture in southern Greece.

METHODS

All first-ever stroke cases in the Arcadia prefecture were ascertained using the same standard criteria and multiple overlapping sources in three study periods: from November 1993 to October 1995; 2004; and 2015-2016. Crude and age-adjusted to European population incidence rates were compared using Poisson regression. Twenty-eight days case fatality rates were estimated and compared using the same method.

RESULTS

In total, 1315 patients with first-ever stroke were identified. The age-standardized incidence to the European population was 252 per 100,000 person-years (95% CI 231-239) in 1993/1995, 252 (95% CI 223-286) in 2004, and 211 (192-232) in 2015/2016. The overall age- and sex-adjusted incidence rates fell by 16% (incidence rates ratio 0.84, 95% CI: 0.72-0.97). Similarly, 28-day case-fatality rate decreased by 28% (case fatality rate ratio = 0.72, 95% CI: 0.58-0.90).

CONCLUSIONS

This population-based study reports a significant decline in stroke incidence and mortality rates in southern Greece between 1993 and 2016.

Predictive Factors of Hemorrhage After Thrombolysis in Patients With Acute Ischemic Stroke

Background: Ischemic stroke has a poor prognosis and brings a ponderous burden on families and society. Hemorrhagic transformation (HT) after intravenous thrombolysis can increase the mortality of patients with ischemic stroke. Thus, finding new HT biomarkers to be applicable in clinical practice is of great importance.

Methods: The related risk factors were recruited for analysis, including smoking, drinking, hyperlipidemia, diabetes, anamnesis, and pathological indicators. Moreover, the relationship between serum levels of caveolin-1, caveolin-2, and HT after rt-PA treatment were also studied.

Results: We studied 306 patients with acute ischemic stroke treated with recombinant tissue type plasminogen activator (rt-PA) within 4.5 h of symptom onset. The results showed that Age ≥68 years, smoking, Atrial fibrillation, NIHSS score before thrombolysis ≥17, and systolic pressure 2 h after thrombolysis (mmHg) ≥149 increased the risks of HT after rt-PA administration. Remarkably, the concentration of caveolin-1 (ng/mL) ≤ 0.12 and caveolin-2 (ng/mL) ≤ 0.43 in serum increased the risks of HT after rt-PA administration.

Conclusion: Knowledge on the risk factors associated with HT after rt-PA treatment may help develop treatment strategies and reduce the risk of HT. Caveolin-1 and caveolin-2 can be predictors of HT after rt-PA administration. These findings provide evidence for future further investigations aimed to validate these biomarkers.

Temporal trends in intracerebral hemorrhage: Evidence from the Austrian Stroke Unit Registry

Background

To assess changes in frequency, severity, complications, therapy and outcome of intracerebral hemorrhage in patients treated in stroke units in Austria, we evaluated data from the Austrian Stroke Unit Registry between 2008 and 2016.

Methods and findings

Data of 6707 cases of ICH covering a time span of 9 years and including information on age, risk factors, pre-stroke modified Rankin Score (mRS), baseline stroke severity (NIHSS), complications, therapy, functional outcome, and mortality were extracted from the Austrian Stroke Unit Registry. A multivariate regularized logistic regression model and linear models for temporal dependence were computed for analyzing statistical inference and time trends. Bonferroni correction was applied to correct for multiple testing.

Between 2008 and 2016, the proportion of ICH admissions to stroke units in Austria declined, with a shift among patients towards older age (>70 years, p = 0.04) and lower admission NIHSS scores. While no significant time trends in risk factors, pre-stroke mRS and medical complications were observed, therapeutic interventions declined significantly (p<0.001). Three-month mortality increased over the years independently (p = 0.003).

Conclusions

Despite declining incidence and clinical severity of ICH we observed a clear increase in three-month mortality. This effect seems to be independent of predictors including age, admission NIHSS, pre-morbid MRS, or medical complications. The observations from this large retrospective database cohort study underline an urgent call for action in the therapy of ICH.

Renin-angiotensin system activation and imbalance of matrix metalloproteinase-9/tissue inhibitor of matrix metalloproteinase-1 in cold-induced stroke

AIMS

In the present study, we investigated the roles of renin-angiotensin system (RAS) activation and imbalance of matrix metalloproteinase-9 (MMP-9)/tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) in cold-induced stroke during chronic hypertension, as well as the protective effects of captopril and recombinant human TIMP-1 (rhTIMP-1).

MAIN METHODS

Rats were randomly assigned to sham; 2-kidney, 2-clip (2K-2C); 2K-2C + captopril, and 2K-2C + rhTIMP-1 groups. After blood pressure values had stabilized, each group was randomly divided into an acute cold exposure (ACE) group (12-h light at 22 °C/12-h dark at 4 °C) and a non-acute cold exposure (NACE) group (12-h light/12-h dark at 22 °C), each of which underwent three cycles of exposure. Captopril treatment was administered via gavage (50 mg/kg/d), while rhTIMP-1 treatment was administered via the tail vein (60 μg/kg/36 h).

KEY FINDINGS

In the 2K-2C group, angiotensin II (AngII) and MMP-9 levels increased in both the plasma and cortex, while no such changes in TIMP-1 expression were observed. Cold exposure further upregulated AngII and MMP-9 levels and increased stroke incidence. Captopril and rhTIMP-1 treatment inhibited MMP-9 expression and activation and decreased stroke incidence in response to cold exposure.

SIGNIFICANCE

The present study is the first to demonstrate that cold exposure exacerbates imbalance between MMP-9 and TIMP-1 by activating the RAS, which may be critical in the initiation of stroke during chronic hypertension. In addition, our results suggest that captopril and rhTIMP-1 exert protective effects against cold-induced stroke by ameliorating MMP-9/TIMP-1 imbalance.

A review of psychosocial factors and stroke: A new public health problem

The role of psychosocial factors (PSF) in increased risk of stroke is a novel public health challenge, but unclear definitions for PSF and the multiple stroke subtypes have led to inconsistent reports. A review of this issue is therefore warranted.

METHODS

Several databases were used for this narrative systematic review (Medline, Embase and Cochrane Library). Two independent reviewers evaluated articles from between 2001 and 2018 on the themes of PSF and stroke/transient ischemic attack (TIA). PSF criteria were job strain, psychological interpersonal and behavioral stress, and social deprivation. Ischemic and hemorrhagic stroke and TIA subtypes were also identified.

RESULTS

Forty-five cohorts, five case-control studies and two meta-analyses were included. Despite mixed results, PSF were associated with an increased risk of ischemic and hemorrhagic stroke in populations of all ages, and more predominantly in women.

CONCLUSION

This broad review shows that the presence of PSF is associated with an increased risk stroke and TIA. As such, PSF must figure in both public health policy and stroke prevention programs, similar to other established metabolic and environmental factors.

Relationship between short telomere length and stroke: A meta-analysis

BACKGROUND

Several epidemiological studies had been carried out in different population cohorts to estimate the relationship between the shortened telomere length and stroke. However, the results still remained dispute. Consequently, we conducted this meta-analysis to estimate the relationship between them.

METHODS

PubMed, EMBASE, and Web of Science were systematically searched for related articles to evaluate the association between "stroke" and "telomere length. STATA 12.0 software was used to perform the meta-analysis. The Cochran Q test and inconsistency index (I) were used to assess the heterogeneity. Begg funnel plot and Egger test were used to assess publication bias.

RESULTS

The meta-analysis was composed of 11 studies, consisting of 25,340 participants. We found a significant relationship between shortened telomere length and stroke (OR: 1.50, 95% CI: 1.13-2.0; P = .005); however, in the prospective and retrospective study subgroup, we did not find a statistical significant relationship between shortened telomere length and stroke (the prospective subgroup: OR: 1.41, 95% CI: 1-1.98; P = .051) (the retrospective subgroup: OR: 1.89, 95% CI: 0.96-3.72; P = .067).

Mexican-National Institute of Neurology and Neurosurgery-Stroke Registry: Results of a 25-Year Hospital-Based Study

Background and purpose

Stroke has been scarcely studied in Latin America (LA). The Mexican Institute of Neurology Stroke Registry was established in 1990 as a prospective computer-based database to register data obtained from patients admitted with stroke. Using this data, we attempted to define the profile of risk factors and outcomes.

Methods

The demographic data, stroke description, ancillary tests, vascular risk factors, and modified Rankin scale (mRs) were registered. Ischemic stroke subtyping was based on the Trial of Org 10,172 of the Acute Stroke Treatment classification. We followed-up patients using multiple overlapping methods. Primary outcomes included mRs, recurrence, and death at 30 days and at the end of follow-up.

Results

We included 4,481 patients with a median follow-up of 27 months, (17,281 person-years follow-up). The mean age was 52.8 ± 18 years. There were 2,229 males (50%) included in the study. CI was present in 64.9%, intracerebral hemorrhage (ICH) in 25.6%, and cerebral venous thrombosis (CVT) in 6.3%. Hypertension was the major risk factor (46.5%). The most common cause of CI was atherosclerosis (27%). ICH was mainly hypertensive (58%), and 60% of CVT were puerperal. Overall, the mortality rate was 24.5%. The recurrence rate was 16.9%. Poor outcome (mRs ≥ 3) was found in 56.2% of patients. The best outcomes were observed in CVT patients (74.5% mRs ≤ 2), whereas 72.1% ICH patients had mRs ≥3.

Conclusion

This is one of the largest hospital-based registries in LA and shows significant differences with other previously published registries, including a younger age, relatively less hypertension, and larger proportion of CVT. Poor functional outcome was common. This study adds to the understanding of geographic differences in stroke characteristics and outcomes.