Proportion of different subtypes of stroke in China

Antiphospholipid Antibodies Modify the Prognostic Value of Baseline Platelet Count for Clinical Outcomes After Ischemic Stroke

BACKGROUND

Antiphospholipid antibodies (aPLs) have been reported to be involved in platelet-mediated thrombosis and inflammation, but the impact on the prognosis of ischemic stroke remains unclear. We aimed to examine whether the association between baseline platelet count (PLT) and long-term clinical outcomes within 2 years after ischemic stroke onset is modulated by aPLs.

METHODS AND RESULTS

A total of 2938 patients with ischemic stroke were included in this prospective cohort study. Cox proportional hazards regression models were used to assess the association between the baseline PLT stratified by aPLs status and 2-year clinical outcomes after stroke onset, and an interaction effect between PLT and aPLs on clinical outcomes was tested by likelihood ratio test. There was a significant interaction effect of aPLs and PLT on recurrent stroke (Pinteraction=0.002) and cardiovascular events (Pinteraction=0.001) within 2 years after stroke onset. After multivariate adjustment, high PLT was associated with increased risks of recurrent stroke (hazard ratio [HR], 2.78 [95% CI, 1.03-7.45]; Ptrend=0.039) and cardiovascular events (HR, 2.58 [95% CI, 1.12-5.90]; Ptrend=0.024) when 2 extreme tertiles were compared among patients with aPL positive, but not among those with aPL negative.

CONCLUSIONS

The aPLs had a modifying effect on the association between PLT and clinical outcomes within 2 years after ischemic stroke onset. Increased PLT was associated with recurrent stroke and cardiovascular events after ischemic stroke onset among patients with aPL positive, but not in those with aPL negative.

Case fatality and functional outcome after spontaneous subarachnoid haemorrhage: A systematic review and meta-analysis of time trends and regional variations in population-based studies

INTRODUCTION

A previous systematic review of population-based studies from 1973 to 2002 found a decrease in case fatality for spontaneous subarachnoid haemorrhage, but could not find a sufficient number of studies to assess changes in functional outcome. Since then, treatment has advanced distinctly. We assessed whether case fatality has decreased further and whether functional outcome has improved.

PATIENTS AND METHODS

We searched PubMed and Web of Science for new population-based studies using the same criteria as in our previous systematic review. We assessed changes in case fatality and functional outcome over time using linear regression.

RESULTS

We included 24 new studies with 827 patients and analysed 9542 patients described in 62 study periods between 1973 and 2017. Case fatality decreased by 0.3% (95% CI: -0.7 to 0.1) per year. In a sensitivity analysis excluding studies that did not provide 1-month outcome and outliers, the age and sex-adjusted decrease was 0.1% per year (95% CI: -0.9 to 0.6). The mean case fatality rate decreased from 47% (95% CI: 31-63) in the 1970s to 35% (95% CI: 30-39) in the 1990s, and remained stable in the 2000s (34%; 95% CI: 27-41) and 2010s (38%; 95% CI: 15-60). In 15 studies, the mean proportion of patients living independently increased by 0.2% per year (95%CI: -0.7 to 1.1) and the mean was 45% (95% CI: 39-50) in six studies that reported outcome after 12 months.

DISCUSSION AND CONCLUSION

From 1973 to 2017, the case-fatality rate of spontaneous subarachnoid haemorrhage declined overall by 13.5%, but remained stable over the last two decades. The data on time trends in functional outcome were inconclusive.

Protective effects of human urinary kallidinogenase against corticospinal tract damage in acute ischemic stroke patients

This study aimed to assess the effects of human urinary kallidinogenase (HUK) on motor function outcome and corticospinal tract recovery in patients with acute ischemic stroke (AIS). This study was a randomized, controlled, single-blinded trial. Eighty AIS patients were split into two groups: the HUK and control groups. The HUK group was administered HUK and standard treatment, while the control group received standard treatment only. At admission and discharge, the National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI) and muscle strength were scored. The primary endpoint was the short-term outcomes of AIS patients under different treatments. The secondary endpoint was the degree of corticospinal tract fiber damage under different treatments. There was a significant improvement in the NIHSS Scale, BI and muscle strength scores in the HUK group compared with controls (Mann-Whitney U test; P  < 0.05). Diffusion tensor tractography classification and intracranial arterial stenosis were independent predictors of short-term recovery by linear regression analysis. The changes in fractional anisotropy (FA) and apparent diffusion coefficient (ADC) decline rate were significantly smaller in the HUK group than in the control group ( P <  0.05). Vascular endothelial growth factor (VEGF) increased significantly after HUK treatment ( P  < 0.05), and the VEGF change was negatively correlated with changes in ADC. HUK is beneficial for the outcome in AIS patients especially in motor function recovery. It may have protective effects on the corticospinal tract which is reflected by the reduction in the FA and ADC decline rates and increased VEGF expression. The study was registered on ClinicalTrials.gov (unique identifier: NCT04102956).

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.

Sex Differences in the Epidemiology of Intracerebral Hemorrhage Over 10 Years in a Population-Based Stroke Registry

BACKGROUND

We investigated incidence and outcome of spontaneous intracerebral hemorrhage (ICH) in a population-based stroke registry and provided data to inform on the figures of the disease in women and in men.

METHODS AND RESULTS

Our prospective population-based registry included patients with first-ever ICH occurring from January 2011 to December 2020. Incidence rates were standardized to the 2011 Italian and European population, and incidence rate ratios were calculated. Multivariate hazard ratios for 30-day and 1-year fatality were estimated with Cox regression, including components of the ICH score and sex. We included 748 first-ever ICHs (41.3% women). Women were significantly older than men at ICH onset (78.9±12.6 versus 73.2±13.6 years; P<0.001) and showed higher clinical severity on presentation (median National Institutes of Health Stroke Scale score, 11 [interquartile range, 6-20] versus 9 [interquartile range, 4-15], respectively; P=0.016). The crude annual incidence rate was 20.2 (95% CI, 18.0-22.6) per 100 000 person-years in women and 30.2 (95% CI, 27.4-33.2) per 100 000 person-years in men); incidence was lower in women versus men (incidence rate ratio, 0.67 [95% CI, 0.58-0.78]; P<0.001) and did not change over time in both sexes (P for trend=0.073 and 0.904, respectively). Unadjusted comparison showed higher 1-year case-fatality rates in women versus men (48.5% versus 40.1%; P=0.026). After adjusting for components of the ICH score, female sex lost significance as a predictor of mortality.

CONCLUSIONS

We found lower ICH incidence in women than in men. However, women showed a higher 1-year case-fatality rate versus men, which was likely related to older age at ICH onset and higher clinical severity. Identification of factors explaining the reported differences is important to develop targeted interventions.

Effects of evidence-based nursing in patients with stroke: A systematic review and meta-analysis

AIM

The aim of this study was to evaluate the efficacy of evidence-based nursing (EBN) in patients with confirmed stroke.

BACKGROUND

After acute hospital treatment, stroke patients often return home for rehabilitation. Stroke ward nursing, demonstrates improved disability-free survival rates. EBN as a new nursing paradigm, rooted in authentic scientific evidence, will transform traditional nursing models. The goal is to advance nursing science, enhance practices and optimize patient outcomes.

DESIGN AND METHODS

PubMed, Embase, Cochrane Library and Web of Science were comprehensively searched from the inception to July 2nd, 2023. 13015 patients with confirmed stroke were included, of which 3351 patients were in EBN group, 9664 patients were in the control group. Odd ratio (OR) and standardized mean difference (SMD) and the 95% confidence intervals (CIs) were calculated.

RESULTS

Twelve studies were included in this study. The risk of bias in included studies was assessed as low. The OR for cumulative death was 1.61 (95% CI: 0.68, 3.85; z = 1.08, P = 0.2811). The pooled SMD for SF-36 physical component scores was -0.06 (95% CI: -1.15, 0.04; z = -1.11, P = 0.2688). The SMD for SF-36 mental health scores was -0.01 (95% CI: -0.10, 0.09; z = -0.10, P = 0.9207). The SMD for WHOQOL-BREF mentality scores was -0.06 (95% CI: -0.21, 0.10; z = -0.71, P = 0.4754). The SMD for WHOQOL-BREF physiology scores was 1.13 (95% CI: -1.13, 3.39; z = 0.98, P = 0.3283).

CONCLUSIONS

EBN is effective in improving psychological status, physical functions and quality of life in patients with stroke in individual studies, efficacy of EBN was not observed in pooled analyses, more evidence-based information is needed to comprehensively assess the efficacy of EBN in stroke patients.

Efficacy of Immediate Antihypertensive Treatment in Patients With Acute Ischemic Stroke With Different Blood Pressure Genetic Variants

BACKGROUND

It remains unclear whether blood pressure (BP) genetic variants could modify the efficacy of immediate antihypertensive treatment after acute ischemic stroke. We conducted a secondary analysis of the CATIS (China Antihypertensive Trial in Acute Ischemic Stroke) to investigate the effect of early antihypertensive treatment on clinical outcomes among patients with acute ischemic stroke according to 5 BP-associated genetic variants.

METHODS

The CATIS randomized 4071 patients with acute ischemic stroke with elevated systolic BP to receive antihypertensive treatment or discontinue all antihypertensive agents during hospitalization. Randomization was conducted centrally and was stratified by participating hospitals and use of antihypertensive medications. Five BP-associated single nucleotide polymorphisms (rs16849225, rs17030613, rs1173766, rs6825911, and rs35444 in FIGN-GRB14, ST7L-CAPZA1, NPR3, ENPEP, and near TBX3, respectively) were genotyped among 2590 patients. The primary outcome was a combination of death and major disability at 14 days or hospital discharge. A weighted BP genetic risk score was constructed by the 5 single nucleotide polymorphisms.

RESULTS

At 14 days or hospital discharge, the primary outcome was not significantly different between antihypertensive treatment and control groups based on genotype subgroups for all 5 single nucleotide polymorphisms (all P>0.05 for interaction). In addition, the BP genetic risk score did not modify the effect of antihypertensive treatment. The odds ratios (95% CIs) for the primary outcome were 0.95 (0.71-1.26), 1.08 (0.80-1.44), and 0.91 (0.69-1.22) in patients with low, intermediate, and high BP genetic risk score, respectively (P=0.88 for interaction).

CONCLUSIONS

Early antihypertensive treatment had a neutral effect on clinical outcomes among patients with acute ischemic stroke according to 5 BP-associated genetic variants.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01840072.

Changing Patterns of Stroke and Subtypes Attributable to High Systolic Blood Pressure in China From 1990 to 2019

BACKGROUND

It is unknown whether high systolic blood pressure had a similar effect on the disease burden of stroke subtypes. The aim of our study is to compare the long-term trends of stroke subtypes and sex groups attributable to high systolic blood pressure in China from 1990 to 2019.

METHODS

Data about the age-standardized mortality rate and the age-standardized disability-adjusted life-year rate of stroke subtypes attributable to high systolic blood pressure in China were extracted in GBD (Global Burden of Disease) 2019. The trends in the age-standardized mortality rate and the age-standardized disability-adjusted life-year rate were calculated using the liner regression and age-period-cohort method, adjusted for age, period, and cohort.

RESULTS

The estimated annual percentage change for mortality of stroke attributable to high systolic blood pressure was different from subtypes, with an estimated annual percentage change and 95% CI of 0.56 (0.37-0.74) for ischemic stroke (IS), -1.52 (-1.97 to -1.07) for intracerebral hemorrhage, and -7.02 (-7.86 to -6.17) for subarachnoid hemorrhage (SAH). The curve of the net drifts showed a downward trend for intracerebral hemorrhage and SAH, but that showed a stable trend for IS. The curve of local drifts showed a slow upward trend with age for IS, a slow downward trend for intracerebral hemorrhage, and a sharp downward trend for SAH. The drift curves showed different trends for males and females. The proportion of stroke mortality in young males was gradually increasing. The cohort rate ratio varied by subtypes, with the greatest decline for SAH, a slight decrease for intracerebral hemorrhage, and a slight increase for IS. The period rate ratio had decreased over the past 3 decades, with the greatest decline for SAH and the weakest decrease for IS. Moreover, both the period and cohort rate ratios for IS mortality due to high systolic blood pressure in males have increased significantly over the past 3 decades.

CONCLUSIONS

Our results provided strong evidence that the disease burden of stroke attributable to high systolic blood pressure varied by subtypes and sex in China from 1990 to 2019. The age-standardized mortality rate and the age-standardized disability-adjusted life-year rate decreased for hemorrhagic stroke but increased for IS. Males had a higher mortality and exposure risk but a slighter decreasing trend than females. Our study suggested that greater attention should be given to the prevention of the burden of IS attributable to systolic blood pressure in China, especially for males.

Global distributions of age- and sex-related arterial stiffness: systematic review and meta-analysis of 167 studies with 509,743 participants

BACKGROUND

Arterial stiffening is central to the vascular ageing process and a powerful predictor and cause of diverse vascular pathologies and mortality. We investigated age and sex trajectories, regional differences, and global reference values of arterial stiffness as assessed by pulse wave velocity (PWV).

METHODS

Measurements of brachial-ankle or carotid-femoral PWV (baPWV or cfPWV) in generally healthy participants published in three electronic databases between database inception and August 24th, 2020 were included, either as individual participant-level or summary data received from collaborators (n = 248,196) or by extraction from published reports (n = 274,629). Quality was appraised using the Joanna Briggs Instrument. Variation in PWV was estimated using mixed-effects meta-regression and Generalized Additive Models for Location, Scale, and Shape.

FINDINGS

The search yielded 8920 studies, and 167 studies with 509,743 participants from 34 countries were included. PWV depended on age, sex, and country. Global age-standardised means were 12.5 m/s (95% confidence interval: 12.1-12.8 m/s) for baPWV and 7.45 m/s (95% CI: 7.11-7.79 m/s) for cfPWV. Males had higher global levels than females of 0.77 m/s for baPWV (95% CI: 0.75-0.78 m/s) and 0.35 m/s for cfPWV (95% CI: 0.33-0.37 m/s), but sex differences in baPWV diminished with advancing age. Compared to Europe, baPWV was substantially higher in the Asian region (+1.83 m/s, P = 0.0014), whereas cfPWV was higher in the African region (+0.41 m/s, P < 0.0001) and differed more by country (highest in Poland, Russia, Iceland, France, and China; lowest in Spain, Belgium, Canada, Finland, and Argentina). High vs. other country income was associated with lower baPWV (-0.55 m/s, P = 0.048) and cfPWV (-0.41 m/s, P < 0.0001).

INTERPRETATION

China and other Asian countries featured high PWV, which by known associations with central blood pressure and pulse pressure may partly explain higher Asian risk for intracerebral haemorrhage and small vessel stroke. Reference values provided may facilitate use of PWV as a marker of vascular ageing, for prediction of vascular risk and death, and for designing future therapeutic interventions.

FUNDING

This study was supported by the excellence initiative VASCage funded by the Austrian Research Promotion Agency, by the National Science Foundation of China, and the Science and Technology Planning Project of Hunan Province. Detailed funding information is provided as part of the Acknowledgments after the main text.

Receptor-interacting protein 3-phosphorylated Ca2+ /calmodulin-dependent protein kinase II and mixed lineage kinase domain-like protein mediate intracerebral hemorrhage-induced neuronal necroptosis

Necroptosis-mediated cell death is an important mechanism in intracerebral hemorrhage (ICH)-induced secondary brain injury (SBI). Our previous study has demonstrated that receptor-interacting protein 1 (RIP1) mediated necroptosis in SBI after ICH. However, further mechanisms, such as the roles of receptor-interacting protein 3 (RIP3), mixed lineage kinase domain-like protein (MLKL), and Ca²⁺ /calmodulin-dependent protein kinase II (CaMK II), remain unclear. We hypothesized that RIP3, MLKL, and CaMK II might participate in necroptosis after ICH, including their phosphorylation. The ICH model was induced by autologous blood injection. First, we found the activation of necroptosis after ICH in brain tissues surrounding the hematoma (propidium iodide staining). Meanwhile, the phosphorylation and expression of RIP3, MLKL, and CaMK II were differently up-regulated (western blotting and immunofluorescent staining). The specific inhibitors could suppress RIP3, MLKL, and CaMK II (GSK'872 for RIP3, necrosulfonamide for MLKL, and KN-93 for CaMK II). We found the necroptosis surrounding the hematoma and the concrete interactions in RIP3-MLKL/RIP3-CaMK II also both decreased after the specific intervention (co-immunoprecipitation). Then we conducted the short-/long-term neurobehavioral tests, and the rats with specific inhibition mostly had better performance. We also found less blood-brain barrier (BBB) injury, and less neuron loss (Nissl staining) in intervention groups, which supported the neurobehavioral tests. Besides, oxidative stress and inflammation were also alleviated with intervention, which had significant less reactive oxygen species (ROS), tumor necrosis factor (TNF)-α, lactate dehydrogenase (LDH), Iba1, and GFAP surrounding the hematoma. These results confirmed that RIP3-phosphorylated MLKL and CaMK II participate in ICH-induced necroptosis and could provide potential targets for the treatment of ICH patients.

Biopharmaceutical, preclinical pharmacokinetic and pharmaco-dynamic investigations of an orally administered novel 3-nbutylphthalide prodrug for ischemic stroke treatment

Ischemic stroke (IS) has been contributing in leading causes of disability and death worldwide and the cases are still increasing. In China, naturally sourced compound 3-n-butylphthalide (NBP) is widely applied in clinical practice for IS treatment with established evidences of efficacy and safety. However, NBP is an oily liquid at room temperature and has no active brain targeting ability, quite limiting its broader application in clinical practice. Via intravenous injection (i.v.) a prodrug compound (DB1) we previously developed deriving from NBP had dramatically enhanced the pharmacological effects, where however, this i.v. route still discount future patient compliance. As druggability of DB1 in oral administration has yet to be elaborated, the current study intended to systemically investigate its biopharmaceutical properties, so as to further consider clinical applicability of DB1 oral preparations. Additionally, pharmacokinetics and pharmacodynamics of DB1 via oral administered route were also studied, illustrating broad potential of further DB1 medicine development. After the derivation, aqueous solubility of DB1 improved 3∼400 folds compared with NBP in various pH media, and n-octanol/water partition coefficient kept in the range of 0∼2. In situ single-pass intestinal perfusion on rats showed effective permeability coefficient of DB1 over 10^-2 cm/s. In contrast to NBP, oral administration of DB1 could display significant enhanced bioavailability in rats and achieve increased accumulation in brain tissues. As expected, DB1 effectively alleviated oxidative stress damage and reduced infarct volume on ischemia/reperfusion (I/R) modeled rats, resulting in reduced mortality. Additionally, this new prodrug did not add any safety concerns based on NBP. Therefore, biopharmaceutical results and preclinical pharmacodynamic evidences support the conclusion that an oral administration of DB1 may have a good potential for clinical IS treatment.

The gut-brain axis in ischemic stroke: its relevance in pathology and as a therapeutic target

The gut contains the largest reservoir of microorganisms of the human body, termed as the gut microbiota which emerges as a key pathophysiological factor in health and disease. The gut microbiota has been demonstrated to influence various brain functions along the “gut-brain axis”. Stroke leads to intestinal dysmotility and leakiness of the intestinal barrier which are associated with change of the gut microbiota composition and its interaction with the human host. Growing evidence over the past decade has demonstrated an important role of these post-stroke changes along the gut-brain axis to contribute to stroke pathology and be potentially druggable targets for future therapies. The impact of the gut microbiota on brain health and repair after stroke might be attributed to the diverse functions of gut bacteria in producing neuroactive compounds, modulating the host’s metabolism and immune status. Therefore, a better understanding on the gut-brain axis after stroke and its integration in a broader concept of stroke pathology could open up new avenues for stroke therapy. Here, we discuss current concepts from preclinical models and human studies on the bi-directional communication along the microbiota-gut-brain axis in stroke.

Reducing the 10-year risk of ischemic cardiovascular disease to receive early cardiovascular benefits from bariatric surgery for obesity in China

Background

Cardiovascular risk due to obesity can be improved greatly by bariatric surgery. However, there is no research involving appropriate model for evaluating cardiovascular disease risk reduction in bariatric surgery for obesity in China. We selected the ischemic cardiovascular disease (ICVD) risk score that accurately predict cardiovascular risk in Chinese adults to evaluate the 10-year risk of ICVD and estimated early cardiovascular benefits of bariatric surgery in obese Chinese patients through its reduction.

Methods

From 2017 to 2019 we followed up 107 patients 6 months after surgery and measured the ICVD 10-year risk and other cardiovascular factors before and after surgery.

Results

There were significant reductions in the ICVD total score (p < 0.001) and ICVD 10-year risk (%) (p < 0.001) 6 months post-operation compared with baseline. Furthermore, we found significant reductions in body mass index (BMI), body adiposity index (BAI), low-density lipoprotein (LDL), small dense-low-density lipoprotein (sd-LDL) and triglycerides (TG) 6 months after surgery compared with pre-operation (all p < 0.05). The decrease in ICVD total score was correlated with excess BMI loss (%EBMIL), reduced BAI, reduced LDL, reduced sd-LDL and reduced TG respectively (all p < 0.05) at 6 months post-operation. Moreover, there were significant reductions in the ICVD total score in the male subgroup [3 (3, 5) vs. 2.5 (2, 4), p < 0.001] and female subgroup [3 (2, 4) vs. 2 (1, 3), p < 0.001] 6 months post-operation compared with baseline. At last there were also significant reductions in the ICVD total score in the diabetic subgroup [5 (4, 6) vs. 4 (3, 5), p < 0.001] and non-diabetic subgroup [2 (2,3) vs. 2 (1, 2), p < 0.001] 6 months post-operation compared with baseline.

Conclusions

Bariatric surgery could provide early cardiovascular benefits for patients with obesity in China by reducing the 10-year risk of ICVD. Both men and women with obesity achieved cardiovascular benefits according to bariatric surgery, so did diabetic and non-diabetic patients.

Machine Learning Algorithms for Rupture Risk Assessment of Intracranial Aneurysms: A Diagnostic Meta-Analysis

OBJECTIVE

Several machine learning algorithms have been increasingly applied to predict the rupture risk of intracranial aneurysms. We performed the present diagnostic meta-analysis to comprehensively evaluate the diagnostic value of machine learning algorithms for assessing the rupture risk of intracranial aneurysms.

METHODS

We systematically searched 3 electronic databases, including Medline (via PubMed), the Cochrane Register of Controlled Trials (via Ovid), and Embase (via Elsevier), to retrieve eligible studies from the databases' inception through March 2021. The latest update was performed in June 2021. StataMP, version 14, was used to estimate all pooled diagnostic values.

RESULTS

A total of 4 studies involving 6 reports were considered to meet the inclusion criteria. Our diagnostic meta-analysis generated the following pooled diagnostic values: sensitivity, 0.84 (95% confidence interval [CI], 0.75-0.90); specificity, 0.78 (95% CI, 0.68-0.85); positive likelihood ratio, 3.8 (95% CI, 2.4-5.9); negative likelihood ratio, 0.21 (95% CI, 0.12-0.35), diagnostic odd ratio, 18 (95% CI, 7-46), and area under the summary receiver operating characteristic curve, 0.88 (95% CI, 0.85-0.90).

CONCLUSIONS

Our findings have demonstrated that the diagnostic performance of machine learning algorithms for the rupture risk assessment of AIs is excellent. Considering that the negative effects resulted from the limited number of eligible studies, we suggest developing more well-designed studies with larger sample sizes to validate our findings.

Detection of Subarachnoid Hemorrhage in Computed Tomography Using Association Rules Mining

Subarachnoid hemorrhage (SAH) is one of the serious strokes of cerebrovascular accidents. There is an approx. 15% probability of spontaneous subarachnoid hemorrhage in all acute cerebrovascular accidents (CVAs). Most spontaneous subarachnoid hemorrhages are caused by ruptures of intracranial aneurysms, accounting for about 85% of all occurrences. About 15% of acute cerebrovascular disorders are caused by spontaneous subarachnoid hemorrhage. This illness is mostly caused by brain/spinal arteriovenous malformations, extracranial aneurysms, and hypertension. Computed tomography (CT) scan is the common diagnostic modality to evaluate SAH, but it is very difficult to identify the abnormality. Thus, automatic detection of SAH is required to recognize the early signs and symptoms of SAH and to provide appropriate therapeutic intervention and treatment. In this article, the gray-level cooccurrence matrix (GLCM) is used to extract useful features from CT images. Then, the New Association Classification Frequent Pattern (NCFP-growth) algorithm is applied, which is based on association rules. Then, it is compared with FP-growth methods with association rules and FP-growth methods without association rules. The experimental results indicate that the suggested approach outperforms in terms of classification accuracy. The proposed approach equates to a 95.2% accuracy rate compared to the conventional data mining algorithm.

Pooled incidence and case-fatality of acute stroke in Mainland China, Hong Kong, and Macao: A systematic review and meta-analysis

Background

Stroke incidence and case-fatality in Mainland China, Hong Kong, and Macao vary by geographic region and rates often differ across and within regions. This systematic review and meta-analysis (SR) estimated the pooled incidence and short-term case-fatality of acute first ever stroke in mainland China, Hong Kong, and Macao.

Methods

Longitudinal studies published in English or Chinese after 1990 were searched in PubMed/Medline, EMBASE, CINAHL, Web of Science, SinoMed and CQVIP. The incidence was expressed as Poisson means estimated as the number of events divided by time at risk. Random effect models calculated the pooled incidence and pooled case-fatality. Chi-squared trend tests evaluated change in the estimates over time. When possible, age standardised rates were calculated. Percent of variation across studies that was due to heterogeneity rather than chance was tested using the I2 statistic.The effect of covariates on heterogeneity was investigated using meta-regressions. Publication bias was tested using funnel plots and Egger’s tests.

Results

Overall, 72 studies were included. The pooled incidences of total stroke (TS), ischaemic stroke (IS) and haemorrhagic stroke (HS) were 468.9 (95% confidence interval (CI): 163.33–1346.11), 366.79 (95% CI: 129.66–1037.64) and 106.67 (95% CI: 55.96–203.33) per 100,000 person-years, respectively, varied according to the four economic regions (East Coast, Central China, Northeast and Western China) with the lowest rates detected in the East Coast. Increased trends over time in the incidence of TS and IS were observed (p<0.001 in both). One-month and three-to-twelve-month case-fatalities were 0.11 (95% CI: 0.04–0.18) and 0.15 (95% CI: 0.12–0.17), respectively for IS; and 0.36 (95% CI: 0.26–0.45) and 0.25 (95% CI: 0.18–0.32), respectively for HS. One-month case-fatality of IS and HS decreased over time for both (p<0.001). Three-to-twelve-month fatalities following IS increased over time (p<0.001). Publication bias was not found.

Conclusions

Regional differences in stroke incidence were observed with the highest rates detected in less developed regions. Although 1-month fatality following IS is decreasing, the increased trends in 3-12-month fatality may suggest an inappropriate long-term management following index hospital discharge.

Registration

Registration-URL: https://www.crd.york.ac.uk/prospero/; Reference code: CRD42020170724

Changes in microglia during drug treatment of stroke

Microglia are the main immune cells in the brain and the first defense barrier of the nervous system. Microglia play a complex role in the process of stroke. A growing number of studies focus on the mechanism of action of drugs functions and how to regulate microglia. Therefore, we talk about the pathophysiological mechanisms of stroke and elaborate on the microglia signaling pathways of drug action in stroke models and how these drugs play a role in stroke treatment in this review. Understanding how drugs modulate proinflammatory and anti-inflammatory responses of microglia may be critical to implementing therapeutic strategies using immune interventions in stroke.

Incidence and Long-Term Survival of Spontaneous Intracerebral Hemorrhage Over Time: A Systematic Review and Meta-Analysis

Background and Purpose

Recent epidemiological data indicate that the absolute number of hemorrhagic stroke cases increased by 47% between 1990 and 2010 and continued to cause high rates of death and disability. The last systematic review and meta-analysis of incidence and long-term survival of intracerebral hemorrhage (ICH) were published 11 and 7 years ago, respectively, and lacked comparison between different income groups, therefore, a more up to date analysis is needed. We aim to investigate the ICH incidence and long-term survival data in countries of different income groups.

Materials Methods

We systematically searched Ovid Medline for population-based longitudinal studies of first-ever spontaneous ICH published from January 2000 to December 2020. We performed meta-analyses on the incidence and survival rate in countries of 4 different income groups with random-effects models (severe inconsistency). The I² was used to measure the heterogeneity. Heterogeneity was further investigated by conducting the meta-regression on the study mid-year. Time trends of the survival rate were assessed by weighted linear regression.

Results

We identified 84 eligible papers, including 68 publications reporting incidence and 24 publications on the survival rate. The pooled incidence of ICH per 100,000 per person-years was 26.47 (95% CI: 21.84–32.07) worldwide, 25.9 (95% CI: 22.63–29.63) in high-income countries (HIC), 28.45 (95% CI: 15.90–50.88) in upper-middle-income countries, and 31.73 (95% CI: 18.41–54.7) in lower-middle-income countries. The 1-year pooled survival rate was from 50% (95% CI: 47–54%; n = 4,380) worldwide to 50% (95% CI: 47–54%) in HIC, and 46% (95% CI: 38–55%) in upper-middle income countries. The 5-year pooled survival rate was 41% (95% CI: 35–48%; n = 864) worldwide, 41% (95% CI: 32–50%) in high-income and upper-middle countries. No publications were found reporting the long-term survival in lower-middle-income and low-income countries. No time trends in incidence or survival were found by meta-regression.

Conclusion

The pooled ICH incidence was highest in lower-middle-income countries. About half of ICH patients survived 1 year, and about two-fifths survived 5 years. Reliable population-based studies estimating the ICH incidence and long-term survival in low-income and low-middle-income countries are needed to help prevention of ICH.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=170140, PROSPERO CRD42020170140.

Potential Biomarkers for Post-Stroke Cognitive Impairment: A Systematic Review and Meta-Analysis

Stroke is a primary debilitating disease in adults, occurring in 15 million individuals each year and causing high mortality and disability rates. The latest estimate revealed that stroke is currently the second leading cause of death worldwide. Post-stroke cognitive impairment (PSCI), one of the major complications after stroke, is frequently underdiagnosed. However, stroke has been reported to increase the risk of cognitive impairment by at least five to eight times. In recent decades, peripheral blood molecular biomarkers for stroke have emerged as diagnostic, prognostic, and therapeutic targets. In this study, we aimed to evaluate some blood-derived proteins for stroke, especially related to brain damage and cognitive impairments, by conducting a systematic review and meta-analysis and discussing the possibility of these proteins as biomarkers for PSCI. Articles published before 26 July 2021 were searched in PubMed, Embase, the Web of Science, and the Cochrane Library to identify all relevant studies reporting blood biomarkers in patients with stroke. Among 1820 articles, 40 were finally identified for this study. We meta-analyzed eight peripheral biomarker candidates: homocysteine (Hcy), high-density lipoprotein cholesterol (HDL-C), C-reactive protein (CRP), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglyceride (TG), uric acid, and glycated hemoglobin (HbA1c). The Hcy, CRP, TC, and LDL-C levels were significantly higher in patients with PSCI than in the non-PSCI group; however, the HDL-C, TG, uric acid, and HbA1c levels were not different between the two groups. Based on our findings, we suggest the Hcy, CRP, TC, and LDL-C as possible biomarkers in patients with post-stroke cognitive impairment. Thus, certain blood proteins could be suggested as effective biomarkers for PSCI.

ADAM8 Activates NLRP3 Inflammasome to Promote Cerebral Ischemia-Reperfusion Injury

Stroke is the leading cause of death and disability in humans. Strokes are classified as either ischemic or hemorrhagic. Ischemic stroke accounts for 70–80% of the cases. Inflammation is a key factor in ischemic brain injury. Studies have shown that inflammatory response induced by NLRP3 inflammasome is one of the root causes of brain damage in mice with cerebral ischemia. However, its specific mechanism in cerebral ischemia is still unclear. ADAM8 (a disintegrin and metalloproteases 8) is a transmembrane protein with different functions. It plays an important role in tumors and neuroinflammation-related diseases. However, the role and molecular mechanism of ADAM8 in cerebral ischemia injury are still unclear. This study aims to evaluate the role of ADAM8 in cerebral ischemic injury and explore its signal transduction mechanism. This experiment shows that ADAM8 can significantly cause neurological deficits in MCAO mice and can substantially cause ipsilateral cerebral edema and cerebral infarction in MCAO mice. In addition, ADAM8 can significantly induce cortical cell apoptosis in MCAO mice, leading to the loss of neurons and the expression of proinflammatory factors COX2, iNOS, TNFα, and IL-6. Importantly, we confirmed that ADAM8 mediates the inflammatory response by promoting the activation of NLRP3 inflammasome, microglia, and astrocytes. These results indicate that ADAM8 may be a candidate drug target for the prevention and treatment of the cerebral ischemic injury.

Genetic Variation of Inflammatory Genes to Ischemic Stroke Risk in a Chinese Han Population

Background

Inflammation proteins play an important role in stroke occurrence. IL1A, IL1B, PTGS2, MMP2, and MMP9 were the mediators involved in the immune response, and the association of these genetic variations with ischemic stroke (IS) risk was still unclear.

Methods

To investigate the susceptibility of genetic variations of IL1A, IL1B, PTGS2, MMP2, and MMP9 to IS risk, we performed a case–control study involving 299 patients and 300 controls in a Chinese population. Thirteen genetic variations of investigated genes of all participants were genotyped using an improved multiplex ligase detection–reaction technique.

Results

No SNP in all genes showed an association with overall IS. However, in subgroup analysis, PTGS2 rs689466 (dominant model: CT vs TT – OR_adjusted= 2.51, 95% CI: 1.22–5.16, p = 0.012; co-dominant model: CT/CC vs TT – OR_adjusted= 2.53, 95% CI: 1.26–5.07, p = 0.009; additive model – OR_adjusted= 2.26, 95% CI: 1.19–4.28, p = 0.013) and rs5275 (dominant model: GG vs AA – OR_adjusted= 0.31, 95% CI: 0.12–0.80, p = 0.016; co-dominant model: GA/GG vs AA – OR_adjusted= 0.45, 95% CI: 0.21–0.95, p = 0.036; additive model – OR_adjusted= 0.60, 95% CI: 0.39–0.92, p = 0.020) were associated with IS type of small-vessel occlusion.

Conclusion

Our study suggested that PTGS2 rs689466 C and rs5275 A were potentially associated with IS subtype of small-vessel occlusion. Our result should be confirmed with further large sample sized studies.

The Effect of Applying Robot-Assisted Task-Oriented Training Using Human-Robot Collaborative Interaction Force Control Technology on Upper Limb Function in Stroke Patients: Preliminary Findings

Stroke is one of the leading causes of death and the primary cause of acquired disability worldwide. Many stroke survivors have difficulty using their upper limbs, which have important functional roles in the performance of daily life activities. Consequently, the independence and quality of life of most stroke patients are reduced. Robot-assisted therapy is an effective intervention for improving the upper limb function of individuals with stroke. Human-robot collaborative interaction force control technology is critical for improving the flexibility and followability of the robot's motion, thereby improving rehabilitation training outcomes. However, there are few reports on the effect of robot-assisted rehabilitative training on upper limb function. We applied this technology using a robot to assist patients with task-oriented training. Posttreatment changes in Fugl-Meyer and modified Barthel index (MBI) scores were assessed to determine whether this technology could improve the upper limb function of stroke patients. One healthy adult and five stroke patients, respectively, participated in functional and clinical experiments. The MBI and Fugl-Meyer scores of the five patients in the clinical experiments showed significant improvements after the intervention. The experimental results indicate that human-robot collaborative interaction force control technology is valuable for improving robots' properties and patients' recovery. This trial was registered in the Chinese clinical trial registry (ChiCTR2000038676).

Methodological considerations for investigating oral anticoagulation persistence in atrial fibrillation

AIMS

Reports of long-term oral anticoagulant (OAC) therapy for atrial fibrillation (AF) reveal highly variable, and generally suboptimal estimates of medication persistence. The objective of this review is to summarize current literature and highlight important methodological considerations for interpreting persistence research and designing studies of persistence on OAC treatment.

METHODS AND RESULTS

We summarize differences in study methodology, setting, timing, treatment, and other factors associated with reports of better or worse persistence. For example, prospective compared with retrospective study designs are associated with higher reported persistence. Similarly, patient factors such as permanent AF or high stroke risk, and treatment with non-vitamin K oral antagonists relative to vitamin K antagonists are associated with higher persistence. Persistence has also been reported to be higher in Europe compared with North America and higher when the treating physician is a general practitioner compared with a specialist. We propose a framework for assessing and designing persistence studies. This framework includes aspects of patient selection, reliability and validity of measures, persistence definitions, clinical utility of measurements, follow-up periods, and analytic approaches.

CONCLUSIONS

Differences in study design, patient selection, treatments, and factors such as the countries/regions where studies are conducted or the type of treating physician may help explain the variability in OAC persistence estimates. A framework is proposed to assess persistence studies. This may have utility to compare and interpret published studies as well as for planning of future studies.

Relationship between built environments and risks of ischemic stroke based on meteorological factors: A case study of Wuhan's main urban area

Ischemic stroke is one of the most common causes of death worldwide, and uncomfortable meteorological and built environments may increase its risk. Residents in different built environments are exposed to different risks of ischemic stroke in cold and hot weather. By using the data from 3547 patients hospitalized, a distributed lag non-linear model was established to compare the differences in the risk of ischemic stroke in urban areas with respect to different Building Height, Building Density, Normalized Differential Vegetation Index, and Distance to Water under the meteorological condition. The results showed that lower Building Height is related to the negative cold effects in winter, and higher Building Height is related to increased risks at high temperatures. Built environments with Building Heights of 10-15 m in hot weather and above 15 m in cold weather have low risks. Higher Building Density was found to be associated with reduced negative cold effects; however, the negative hot effects increased in summer. Built environments with a Building Density of more than 0.3 showed low risks, regardless of the weather conditions. Increasing NDVI seemed to mitigate negative effects in uncomfortable weather, and built environments with higher NDVI were found to be associated with lower risks of ischemic stroke. Built environments with shorter Distance to Water seemed to pose higher risks in summer, and longer Distance to Water was correlated with higher risks in winter. Built environments with Distance to Water in the range of 0.65-2.30 km showed low risks. The research results could have some implications for urban planners to form reasonable built environments under certain meteorological factors which can be beneficial for the mitigation of incidence of ischemic stroke.

Multidimensional predicting model of intracranial aneurysm stability with backpropagation neural network: a preliminary study

OBJECTIVES

The stability of intracranial aneurysms (IAs) may involve in multidimensional factors. Backpropagation (BP) neural network could be adopted to support clinical work. This preliminary study aimed to delve into the feasibility of BP neural network in assessing the risk of IA rupture/growth and to prove the advantage of multidimensional model over single/double-dimensional model.

METHODS

Thirty-six IA patients were recruited from a prospective registration study (ChiCTR1900024547). All patients were followed up until aneurysm ruptured/grew or 36 months after being diagnosed with the IAs. The multidimensional data regarding clinical, morphological, and hemodynamic characteristics were acquired. Hemodynamic analyses were conducted with patient-specific models. Based on these characteristics, seven models were built with BP neural network (the ratio of training set to validation set as 8:1). The area under curves (AUC) was calculated for subsequent comparison.

RESULTS

Forty-five characteristics were determined from 36 patients with 37 IAs. In the models based on the single dimension of IA characteristics, only morphological characteristics exhibited high performance in assessing 3-year IA stability (AUC = 0.703, P = 0.035). Among the models integrating two dimensions of IA characteristics, clinical-morphological (AUC = 0.731, P = 0.016), clinical-hemodynamic (AUC = 0.702, P = 0.036), and morphological-hemodynamic (AUC = 0.785, P = 0.003) models were capable of assessing the risk of 3-year IA rupture/growth. Moreover, the models including all three dimensions exhibited the maximum predicting significance (AUC = 0.811, P = 0.001).

CONCLUSION

The present preliminary study reported that BP neural network might support assessing the 3-year stability of IAs. Models based on multidimensional characteristics could improve the assessment accuracy for IA rupture/growth.

Hospitalization Expenditures and Out-Of-Pocket Expenses in Patients With Stroke in Northeast China, 2015-2017: A Pooled Cross-Sectional Study

Background: Stroke is the second most common cause of mortality worldwide and the leading cause of death in China. It imposes a heavy financial burden on patients, especially for some social groups that are vulnerable to economic risks.

Objective: This study aimed to comprehensively assess the magnitude of hospital and out-of-pocket (OOP) costs associated with stroke in Northeast China.

Methods: Patients were selected via a multistage stratified cluster random sampling approach. We reviewed all patients’ records from 39 hospitals across six cities in Liaoning Province between 2015 and 2017. Cost characteristics of four major stroke types were analyzed. Multivariate linear regression analyses were employed to examine the determinants of hospitalization costs and OOP expenses.

Results: A total of 138,757 patients were assessed for the medical costs. The mean hospitalization costs were $1,627, while the mean OOP expenses were $691, accounting for 42.5% of the total expenditures. Medication expenses were the largest contributor to hospitalization costs. The regression analysis suggested that age, length of stay (LOS), social identity, type of stroke, surgery, intensive care unit (ICU) admission, hospital level and hospital type were significantly correlated with hospitalization costs and OOP expenses.

Conclusion: Stroke imposes a heavy financial burden on both patients and society in Liaoning Province, Northeast China. Results showed that there are some differences in the individual and social economic burden among different types of stroke. In addition, stroke patients share a high proportion of costs through OOP expenses, especially for poor social-economic status patients. Targeted intervention measures and specific policies are needed to reduce the individual and social economic burden of stroke as well as improve equity in health care among different social groups.

Tobacco Use: A Major Risk Factor of Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (sICH) is one of the deadliest subtypes of stroke, and no treatment is currently available. One of the major risk factors is tobacco use. In this article, we review literature on how tobacco use affects the risk of sICH and also summarize the known effects of tobacco use on outcomes following sICH. Several studies demonstrate that the risk of sICH is higher in current cigarette smokers compared to non-smokers. The literature also establishes that cigarette smoking not only increases the risk of sICH but also increases hematoma growth, results in worse outcomes, and increases the risk of death from sICH. This review also discusses potential mechanisms activated by tobacco use which result in an increase in risk and severity of sICH. Exploring the underlying mechanisms may help alleviate the risk of sICH in tobacco users as well as may help better manage tobacco user sICH patients.

Prognostic value of plasma fibroblast growth factor 21 among patients with acute ischemic stroke

BACKGROUND AND PURPOSE

To evaluate the association between plasma fibroblast growth factor 21 (FGF-21) and clinical outcomes in patients with acute ischemic stroke.

METHODS

A total of 3412 acute ischemic stroke patients from the China Antihypertensive Trial in Acute Ischemic Stroke with plasma FGF-21 measurements were included in this analysis. The primary outcome was a combination of death or major disability (modified Rankin Scale score ≥3) within 1 year after stroke.

RESULTS

During the 1-year of follow-up, 745 (21.83%) patients experienced the primary outcome; 550 had a major disability and 195 died. After multivariate adjustment, higher plasma FGF-21 was significantly associated with increased risk of the primary outcome (odds ratio = 1.52, 95% confidence interval = 1.11-1.29). Each 1-SD increase of log-transformed FGF-21 (0.67 pg/ml) was associated with 19%, 3%, and 33% increased risk of the primary outcome, major disability, and death, respectively. The addition of FGF-21 to the conventional risk factors significantly improved prediction of the primary outcome in ischemic stroke patients (net reclassification index = 10.8%, p = 0.011; integrated discrimination improvement = 0.3%, p = 0.038).

CONCLUSIONS

Higher plasma FGF-21 was associated with poor prognosis in acute ischemic stroke patients, suggesting that FGF-21 may be a prognostic marker for ischemic stroke.

Prevalence, risk factors and associated ocular diseases of cerebral stroke: the population-based Beijing Eye Study

OBJECTIVE

To assess the prevalence of cerebral stroke in the general population of Beijing and its association with systemic risk factors and ocular diseases.

SETTING

The population-based Beijing Eye Study was conducted in a rural and urban region of Beijing.

PARTICIPANTS

With eligibility criteria of age 50+ years and living in the study regions, 3468 subjects (78.8%) out of 4403 eligible individuals participated.

PRIMARY AND SECONDARY OUTCOME MEASURES

The study participants underwent a detailed systemic and ophthalmological examination and an interview in which the occurrence of a previous stroke was assessed.

RESULTS

A previous stroke was reported by 235 individuals (7.33%; 95% CI 6.43% to 8.24%). The prevalence of previous stroke increased from 2.0% (95% CI 0.9% to 3.1%) in the age group of 50 to <55 years to 21.9% (95% CI 16.4% to 27.4%) in the age group of 80+ years. In multivariable regression analysis, a higher prevalence of previous stroke was correlated (Nagelkerke R²=0.20) with the systemic parameters of older age (p<0.001; OR 1.06; 95% CI 1.04 to 1.08), male gender (p<0.001; OR 0.54; 95% CI 0.40 to 0.74), lower quality of life score (p<0.001; OR 1.39; 95% CI 1.25 to 1.55), higher prevalence of arterial hypertension (p<0.001; OR 2.86; 95% CI 2.05 to 3.98), and cardiovascular disease (p<0.001; OR 1.8554; 95% CI 1.34 to 2.56), and with the ocular parameter of higher prevalence of diabetic retinopathy (p<0.001; OR 4.41; 95% CI 2.38 to 8.18) or alternatively, with higher stage of diabetic retinopathy (p<0.001; OR 1.64; 95% CI 1.26 to 2.14).

CONCLUSIONS

In this North Chinese population aged 50+ years, the prevalence of a previous stroke was 7.33% (95% CI 6.43% to 8.24%). After adjusting for systemic risk factors of older age, male gender and higher prevalence of arterial hypertension and cardiovascular disease, a higher prevalence of a previous stroke was significantly correlated with a higher prevalence and stage of diabetic retinopathy. The prevalence of a previous stroke increased for each step of an increase in the stage of diabetic retinopathy with an OR of 1.64 (95% CI 1.26 to 2.14), and it increased by the presence of diabetic retinopathy with an OR of 4.41 (95% CI 2.38 to 8.18).

Associations of socioeconomic factors with cause-specific Mortality and burden of cardiovascular diseases: findings from the vital registration in urban Shanghai, China, during 1974-2015

Background

Cardiovascular disease (CVD) is the leading cause of mortality worldwide. The effect of socioeconomic factors on cause-specific mortality and burden of CVD is rarely evaluated in low- and middle-income countries, especially in a rapidly changing society.

Methods

Original data were derived from the vital registration system in Yangpu, a representative, population-stable district of urban Shanghai, China, during 1974–2015. Temporal trends for the mortality rates and burden of CVD during 1974–2015 were evaluated using Joinpoint Regression Software. The burden was evaluated using age-standardized person years of life loss per 100,000 persons (SPYLLs). Age-sex-specific CVD mortality rates were predicted by using age-period-cohort Poisson regression model.

Results

A total of 101,822 CVD death occurred during 1974–2015, accounting for 36.95% of total death. Hemorrhagic stroke, ischemic heart disease, and ischemic stroke were the 3 leading causes of CVD death. The age-standardized CVD mortality decreased from 144.5/100,000 to 100.7/100,000 in the residents (average annual percentage change [AAPC] -1.0, 95% confidence interval [CI] -1.7 to − 0.2), which was mainly contributed by women (AAPC -1.3, 95% CI − 2.0 to − 0.7), not by men. Hemorrhagic stroke, the major CVD death in the mid-aged population, decreased dramatically after 1991. The crude mortality of ischemic heart disease kept increasing but its age-adjusted mortality decreased continually after 1997. SPYLLs of CVD death increased from 1974 to 1986 (AAPC 2.1, 95% CI 0.4 to 3.8) and decreased after 1986 (AAPC 1.8, 95% CI − 2.3 to − 1.3). These changes were in concert with the implementation of policies including extended medical insurance coverage, pollution control, active prophylaxis of CVD including lifestyle promotion, and national health programs. The mortality of CVD increased in those born during 1937–1945, a period of the Japanese military occupation, and during 1958–1965, a period including the Chinese Famine. Sequelae of CVD and ischemic heart disease are predicted to be the leading causes of CVD death in 2029.

Conclusions

Exposure to serious malnutrition in early life might increase CVD mortality in later life. Improvements in medical services, pollution control, and lifestyle could decrease CVD death. New strategy is needed to prevent the aging-related CVD death and burden in the future.

A novel model for predicting the outcome of intracerebral hemorrhage: Based on 1186 Patients

OBJECTIVE

To establish a model for predicting the outcome according to the clinical and computed tomography(CT) image data of patients with intracerebral hemorrhage(ICH).

METHODS

The clinical and CT image data of the patients with ICH in Qinghai Provincial People's Hospital and Xuzhou Central Hospital were collected. The risk factors related to the poor outcome of the patients were determined by univariate and multivariate logistic regression analysis. To determine the effect of factors related to poor outcome, the nomogram model was made by software of R 3.5.2 and the support vector machine operation was completed by software of SPSS Modelor.

RESULTS

A total of 8265 patients were collected and 1186 patients met the criteria of the study. Age, hospitalization days, blend sign, intraventricular extension, subarachnoid hemorrhage, midline shift, diabetes and baseline hematoma volume were independent predictors of poor outcome. Among these factors, baseline hematoma volume๥20ml (odds ratio:13.706, 95% confidence interval:9.070-20.709, p < 0.001) was the most significant factor for poor outcome, followed by the volume among 10ml-20ml (odds ratio:11.834, 95% confidence interval:7.909-17.707, p < 0.001). It was concluded that the highest percentage of weight in outcome was baseline hematoma volume (25.0%), followed by intraventricular hemorrhage (23.0%).

CONCLUSION

This predictive model might accurately predict the outcome of patients with ICH. It might have a wide range of application prospects in clinical.

Stroke

Stroke is a major cause of death and disability globally. Diagnosis depends on clinical features and brain imaging to differentiate between ischaemic stroke and intracerebral haemorrhage. Non-contrast CT can exclude haemorrhage, but the addition of CT perfusion imaging and angiography allows a positive diagnosis of ischaemic stroke versus mimics and can identify a large vessel occlusion target for endovascular thrombectomy. Management of ischaemic stroke has greatly advanced, with rapid reperfusion by use of intravenous thrombolysis and endovascular thrombectomy shown to reduce disability. These therapies can now be applied in selected patients who present late to medical care if there is imaging evidence of salvageable brain tissue. Both haemostatic agents and surgical interventions are investigational for intracerebral haemorrhage. Prevention of recurrent stroke requires an understanding of the mechanism of stroke to target interventions, such as carotid endarterectomy, anticoagulation for atrial fibrillation, and patent foramen ovale closure. However, interventions such as lowering blood pressure, smoking cessation, and lifestyle optimisation are common to all stroke subtypes.

Mortality and recurrent vascular events after first incident stroke: a 9-year community-based study of 0·5 million Chinese adults

BACKGROUND

Stroke is a leading cause of death and disability worldwide. Despite considerable improvements in diagnosis and treatment, little is known about the short-term and long-term prognosis after a first stroke in low-income and middle-income countries, including China. We aimed to assess the short-term and long-term risk of recurrent stroke and mortality after a first stroke for each of the major pathological stroke types.

METHODS

This population-based cohort study included adults aged 35-74 years without disability who were recruited to the China Kadoorie Biobank (CKB). A baseline survey was conducted in ten geographical areas (five urban, five rural) in China, and participants had clinical measurements recorded. Participants were followed up by monitoring death registries and by electronic linkage to health registries and health insurance claims databases, with follow-up until Jan 1, 2017. Participants were excluded from analyses if they had a previous history of stroke, transient ischaemic attack, or ischaemic heart disease at baseline. All incidences of fatal and non-fatal stroke during the study period were recorded by type (ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and unspecified type). Primary outcome measures were 28-day mortality, recurrent stroke, major vascular events (recurrent stroke, myocardial infarction, or vascular death), vascular mortality, and all-cause mortality.

FINDINGS

Of 512 715 individuals in the CKB, 489 586 participants without previous ischaemic heart disease and stroke at recruitment were included, of whom 45 732 (42 073 [92%] confirmed by brain imaging) had a stroke during the study period. The mean age was 59·3 years (SD 9·8) for participants who had a stroke (54% women) and 50·8 years (10·3) for participants with no stroke (60% women). 36 588 (80%) of the incident cases of stroke were ischaemic stroke, 7440 (16%) were intracerebral haemorrhage, 702 (2%) were subarachnoid haemorrhage, and 1002 (2%) were an unspecified stroke type. 28-day mortality was 3% (95% CI 3-4) for ischaemic stroke, 47% (46-48)for intracerebral haemorrhage, 19% (17-22; 52% for rural areas and 32% for urban areas) subarachnoid haemorrhage, and 24% (22-27) for unspecified stroke. Among participants who survived stroke at 28 days, 41% (41-42) had recurrent stroke at 5 years (ischaemic stroke 41% [41-42], intracerebral haemorrhage 44% [42-46], subarachnoid haemorrhage 22% [18-27], unspecified stroke type 40% [35-44]) and mortality at 5 years was 17% ([17-18] ischaemic stroke 16% [15-16], intracerebral haemorrhage 28% [26-29], subarachnoid haemorrhage 16% [12-20], unspecified stroke type 15% [12-19]). After a first ischaemic stroke, 91% of recurrent strokes were also ischaemic stroke; after an intracerebral haemorrhage, 56% of recurrent strokes were intracerebral haemorrhage, and 41% of recurrent strokes were ischaemic stroke.

INTERPRETATION

After a first stroke, the risk of recurrence or death within 5 years was high among this population of Chinese adults. Urgent improvements to secondary prevention of stroke in China are needed to reduce these risks.

FUNDING

Wellcome Trust, Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, Chinese Ministry of Science and Technology, National Natural Science Foundation of China.

COPYRIGHT

© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Socioeconomic differences in health-care use and outcomes for stroke and ischaemic heart disease in China during 2009-16: a prospective cohort study of 0·5 million adults

BACKGROUND

China initiated major health-care reforms in 2009 aiming to provide universal health care for all by 2020. However, little is known about trends in health-care use and health outcomes across different socioeconomic groups in the past decade.

METHODS

We used data from the China Kadoorie Biobank (CKB), a nationwide prospective cohort study of adults aged 30-79 years in 2004-08, in ten regions (five urban, five rural) in China. Individuals who were alive in 2009 were included in the present study. Data for all admissions were obtained by linkage to electronic hospital records from the health insurance system, and to region-specific disease and death registers. Generalised linear models were used to estimate trends in annual hospital admission rates, 28-day case fatality rates, and mean length of stay for stroke, ischaemic heart disease, and any cause in all relevant individuals.

FINDINGS

512 715 participants were recruited to the CKB between June 25, 2004, and July 15, 2008, 505 995 of whom were still alive on Jan 1, 2009, and contributed to the present study. Among them, we recorded 794 824 hospital admissions (74 313 for stroke, 69 446 for ischaemic heart disease) between 2009 and 2016. After adjustment for demographic, socioeconomic, lifestyle, and morbidity factors, hospitalisation rates increased annually by 3·6% for stroke, 5·4% for ischaemic heart disease, and 4·2% for any cause, between 2009 and 2016. Higher socioeconomic groups had higher hospitalisation rates, but the annual proportional increases were higher in those with lower education or income levels, those enrolled in the urban or rural resident health insurance scheme, and for those in rural areas. Lower socioeconomic groups had higher case fatality rates for stroke and ischaemic heart disease, but greater reductions in case fatality rates than higher socioeconomic groups. By contrast, mean length of stay decreased by around 2% annually for stroke, ischaemic heart disease, and any cause, but decreased to a greater extent in higher than lower socioeconomic groups for stroke and ischaemic heart disease.

INTERPRETATION

Between 2009 and 2016, lower socioeconomic groups in China had greater increases in hospital admission rates and greater reductions in case fatality rates for stroke and ischaemic heart disease. Additional strategies are needed to further reduce socioeconomic differences in health-care use and disease outcomes.

FUNDING

Wellcome Trust, Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, China Ministry of Science and Technology, and Chinese National Natural Science Foundation.

Stroke prevention in atrial fibrillation changes after dabigatran availability in China: The GLORIA-AF registry

Background

Until the approval of dabigatran etexilate, treatment choices for stroke prevention in patients with atrial fibrillation (AF) were vitamin K antagonists (VKAs) or antiplatelet drugs. This analysis explored whether availability of non-vitamin K antagonist oral anticoagulants post-dabigatran approval was associated with changing treatment patterns in China.

Methods

Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) collected data on antithrombotic therapy choices for patients with newly diagnosed nonvalvular AF at risk for stroke. In China, enrollment in phase 1 (before dabigatran approval) and phase 2 (after dabigatran approval) occurred from 2011 to 2013 and 2013 to 2014, respectively. Analyses were restricted to sites within China that contributed patients to both phases. The weighted average of the site-specific results was estimated for standardization. Sensitivity analyses used multiple regression.

Results

Thirteen sites participated in both phase 1 (419 patients) and phase 2 (276 patients), 76.1% and 16.0% were known to be at high risk for stroke (CHA₂DS₂-VASc ≥2) and bleeding (HAS-BLED ≥3); 55.5% were male. In phase 1, 16.7%, 61.6%, and 21.7% of patients were prescribed oral anticoagulants (OACs), antiplatelet agents, and no treatment, respectively. Respective proportions were 26.4%, 40.6%, and 33.0% in phase 2. The absolute increase in the site-standardized proportion of patients prescribed OACs after dabigatran availability was 9.9% (95% confidence interval [CI]: 3.7%-16.0%). There was a standardized 17.3% (95% CI: -24.3% to -10.4%) absolute decrease in antiplatelet agent use.

Conclusions

There was an increase in OAC and decrease in antiplatelet agent prescription since dabigatran availability in China. However, a large proportion of AF patients at risk for stroke remained untreated.

Central nervous system involvement in patients with antineutrophil cytoplasmic antibody-associated vasculitis: a study of 29 cases in a single Chinese center

BACKGROUND

In antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), central nervous system (CNS) involvement is relatively uncommon. The current study retrospectively investigated the clinical features and outcomes of AAV patients with CNS involvement.

METHODS

A total of 497 AAV patients were retrospectively recruited in our center, twenty-nine of which had CNS involvement. Clinical and radiological manifestations and the outcomes of these patients were analyzed.

RESULTS

The predominant symptom was sensorimotor impairment. According to the MRI findings, twenty-four patients had cerebral ischemic lesions, four patients had hemorrhagic lesions, and one patient had pituitary mass. With a median follow-up of 25 (range 9-45) months, 23 of 24 patients with cerebral ischemic lesions responded to induction therapy, and symptoms were ameliorated. The remaining one died from acute myocardial infarction 2 months after the diagnosis of cerebral ischemic lesions. Compared with patients without CNS involvement, patients with CNS involvement had significantly higher level of Birmingham Vasculitis Activity Score (23.5 ± 5.3 versus 18.8 ± 6.5, P < 0.01) and significantly higher proportion of peripheral nervous system involvement (58.6% versus 14.6%, P < 0.01). However, we did not found significant difference of patients' survival between those with and without CNS involvement.

CONCLUSION

CNS involvement in Chinese patients with AAV was mainly manifested as cerebral ischemic lesions. Compared with patients without CNS involvement, patients with CNS involvement had a significantly more active disease of AAV, and significantly higher proportion of peripheral nervous system involvement.Key Points• CNS involvement in Chinese patients with AAV was mainly manifested as cerebral ischemic lesions.• Patients with CNS involvement had a significantly more active disease of AAV.

Burden of Cardiovascular Diseases in China, 1990-2016: Findings From the 2016 Global Burden of Disease Study

Importance

Cardiovascular disease (CVD) remains the top cause of death in China. To our knowledge, no consistent and comparable assessments of CVD burden have been produced at subnational levels, and little is understood about the spatial patterns and temporal trends of CVD in China.

Objective

To determine the national and province-level burden of CVD from 1990 to 2016 in China.

Design, Setting, and Participants

Following the methodology framework and analytical strategies used in the 2016 Global Burden of Disease study, the mortality, prevalence, and disability-adjusted life-years (DALYs) of CVD in the Chinese population were examined by age, sex, and year and according to 10 subcategories. Estimates were produced for all province-level administrative units of mainland China, Hong Kong, and Macao.

Exposures

Residence in China.

Main Outcomes and Measures

Mortality, prevalence, and DALYs of CVD.

Results

The annual number of deaths owing to CVD increased from 2.51 million to 3.97 million between 1990 and 2016; the age-standardized mortality rate fell by 28.7%, from 431.6 per 100 000 persons in 1990 to 307.9 per 100 000 in 2016. Prevalent cases of CVD doubled since 1990, reaching nearly 94 million in 2016. The age-standardized prevalence rate of CVD overall increased significantly from 1990 to 2016 by 14.7%, as did rates for ischemic heart disease (19.1%), ischemic stroke (36.6%), cardiomyopathy and myocarditis (23.1%), and endocarditis (26.7%). Substantial reduction in the CVD burden, as measured by age-standardized DALY rate, was observed from 1990 to 2016 nationally, with a greater reduction in women (43.7%) than men (24.7%). There were marked differences in the spatial patterns of mortality, prevalence, and DALYs of CVD overall as well as its main subcategories, including ischemic heart disease, hemorrhagic stroke, and ischemic stroke. The CVD burden appeared to be lower in coastal provinces with higher economic development. The between-province gap in relative burden of CVD increased from 1990 to 2016, with faster decline in economically developed provinces.

Conclusions and Relevance

Substantial discrepancies in the total CVD burden and burdens of CVD subcategories have persisted between provinces in China despite a relative decrease in the CVD burden. Geographically targeted considerations are needed to tailor future strategies to enhance CVD health throughout China and in specific provinces.

Advances in stroke medicine

In recent years, reperfusion therapies such as intravenous thrombolysis and endovascular thrombectomy for ischaemic stroke have dramatically reduced disability and revolutionised stroke management. Thrombolysis with alteplase is effective when administered to patients with potentially disabling stroke, who are not at high risk of bleeding, within 4.5 hours of the time the patient was last known to be well. Emerging evidence suggests that other thrombolytics such as tenecteplase may be even more effective. Treatment may be possible beyond 4.5 hours in patients selected using brain imaging. Endovascular thrombectomy (via angiography) effectively reduces risk of death or dependency in patients with large vessel occlusion (internal carotid, proximal middle cerebral and basilar arteries) if applied within 6 hours of the time they were last known to be well. Endovascular thrombectomy is also beneficial 6-24 hours from the last known well time in selected patients with favourable brain imaging. Thus, some patients with wake-up stroke are now treatable, and protocols for stroke need to include computed tomography (CT) perfusion scan and CT angiography as routine, in addition to the non-contrast CT brain scan. Optimised pre-hospital and emergency department systems (eg, code stroke response teams, pre-notification by ambulance, direct transport from triage to CT scanner) are essential to maximise the benefit of these strongly time-dependent therapies. Telemedicine is increasingly providing specialist guidance for these more complex treatment decisions in rural areas. Important developments in secondary stroke prevention include the use of direct oral anticoagulants or left atrial appendage occlusion for atrial fibrillation, and endovascular closure of patent foramen ovale.

Endostatin as a novel prognostic biomarker in acute ischemic stroke

BACKGROUND AND AIMS

Endostatin is implicated in the atherosclerosis process and serves as a promising cardiovascular biomarker, while its clinical significance in ischemic stroke patients remains unclear. We aimed to examine the association between endostatin and mortality and disability after ischemic stroke.

METHODS

A total of 3463 acute ischemic stroke patients with measured plasma endostatin from the China Antihypertensive Trial in Acute Ischemic Stroke were included in this study. The primary outcome was death or severe disability (modified Rankin scale score of 4-6), and secondary outcomes included death and vascular events.

RESULTS

After 3-month follow-up, 402 (11.61%) participants experienced severe disability or died. Compared with the lowest quartile of endostatin, odds ratios or hazard ratios (95% confidence intervals) for the highest quartile were 1.47 (1.04-2.09) for the primary outcome, and 2.36 (1.23-4.54) for death after adjustment for multiple covariates, including age, sex, admission NIH Stroke Scale score and systolic blood pressure. Each 1-SD higher log-transformed endostatin was associated with a 20% (6%-36%) increased risk for primary outcome. Adding plasma endostatin to the basic model constructed with conventional factors significantly improved risk stratification of primary outcome, as observed by the category-free net reclassification index of 20.5% (95% CI 10.1%-30.8%; p < 0.001) and integrated discrimination improvement of 0.3% (95% CI 0.01%-0.6%; p = 0.04).

CONCLUSIONS

Increased baseline plasma endostatin levels in acute ischemic stroke were associated with increased risk of mortality and severe disability at 3 months. Plasma endostatin may serve as an important prognostic marker for risk stratification in patients with ischemic stroke.

Long-Term Exposure to Air Pollution and Survival After Ischemic Stroke

Background and Purpose- China bears a heavy burden of stroke because of its large population of elderly people and the propensity for stroke. Previous studies have examined the association between air pollution and stroke mortality or hospital admission. However, the global evidence for adverse effects of air pollution on survival after stroke is scarce. Methods- We used the first national hospital-based prospective registry cohort of stroke in China, which included 12 291 ischemic stroke patients who visited hospitals during 2007 to 2008. All patients were followed for 1-year poststroke. Deaths during the follow-up period were recorded. Participants' 3-year prestroke exposures to ambient PM₁, PM_2.5, PM₁₀ (particulate matter with aerodynamic diameters ≤1, ≤2.5, and ≤10 μm, respectively) and NO₂ (nitrogen dioxide) were estimated by machine learning algorithms with satellite remote sensing, land use information, and meteorological data. Cox proportional hazards models were used to examine the association between air pollution and survival after ischemic stroke. Results- In total, 1649 deaths were identified during the 1-year follow-up period. After controlling for potential confounders, significant associations were observed between exposure to PM₁ and PM_2.5 and incident fatal ischemic stroke. The corresponding hazard ratios and 95% CIs associated with 10 µg/m³ increase in PM₁ and PM_2.5 were 1.05 (1.02-1.09) and 1.03 (1.00-1.06), respectively. No significant association was observed for PM₁₀ or NO₂ (hazard ratios and 95% CIs, 1.01 [1.00-1.03] and 1.03 [0.99-1.06], respectively). Higher hazard ratios (and 95% CIs) were observed for male, elderly and obese individuals. Conclusions- Prestroke exposure to PM₁ and PM_2.5 was associated with increased incident fatal ischemic stroke in the year following an ischemic stroke in China. Improved air quality may be beneficial for people to recover from stroke.

GeographicalDifference, Rural-urban Transition and Trend in Stroke Prevalence in China: Findings from a National Epidemiological Survey of Stroke in China

Accurate and up-to-date provincial and regional-level stroke prevalence estimates are important for research planning and targeted strategies for stroke prevention and management. However, recent and comprehensive evaluation is lacking over the past 30 years in China. This study aimed to examine the geographical variations in stroke prevalence based on data from the National Epidemiological Survey of Stroke in China (NESS-China) and demonstrate urban-rural transition and trend over three decades. The stroke prevalence (prevalence day, August 31, 2013) was estimated using the world standard population. The stroke prevalence was 873.4 per 100,000 population, and varied from 218.0 in Sichuan to 1768.9 in Heilongjiang. Stroke prevalence exhibited a noticeable north-south gradient (1097.1, 917.7, and 619.4 in the north, middle, and the south, respectively; P < 0.001) and showed a 2.0-fold, 1.5-fold, and 1.2-fold increase in rural areas in the north, the middle, and the south, respectively, from 1985 to 2013. Overall, stroke prevalence was higher in the rural regions than in the urban (945.4 versus 797.5, P < 0.001) regions. However, the converse was depicted in 12 provinces. A noticeable geographical variation in stroke prevalence was observed and was evolving overtime in China. It is imperative that effective public health policies and interventions be implemented, especially in those regions with higher prevalence.

Short-term exposure to air pollution and incidence of stroke in the Women's Health Initiative

BACKGROUND

Evidence of the association between daily variation in air pollution and risk of stroke is inconsistent, potentially due to the heterogeneity in stroke etiology.

OBJECTIVES

To estimate the associations between daily variation in ambient air pollution and risk of stroke and its subtypes among participants of the Women's Health Initiative, a large prospective cohort study in the United States.

METHODS

We used national-scale, log-normal ordinary kriging models to estimate daily concentrations of fine particulate matter (PM2.5), respirable particulate matter (PM10), nitrogen dioxide (NO2), nitrogen oxides (NOx), sulphur dioxide, and ozone at participant addresses. Stroke was adjudicated by trained neurologists and classified as ischemic or hemorrhagic. Ischemic strokes were further classified according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. We used a time-stratified case-crossover approach to estimate the odds ratio (OR) of the risk of stroke associated with an interquartile range (IQR) increase in concentrations of each air pollutant. We performed stratified analysis to examine whether associations varied across subgroups defined by age at stroke onset, US census region, smoking status, body mass index, and prior history of diabetes mellitus, hypertension, heart or circulation problems, or arterial fibrillation at enrollment.

RESULTS

Among 5417 confirmed strokes between 1993 and 2012, 4300 (79.4%) were classified as ischemic and 924 (17.1%) as hemorrhagic. No association was observed between day-to-day variation in any pollutant and risk of total stroke, ischemic stroke, or specific etiologies of ischemic stroke. We observed a positive association between risk of hemorrhagic stroke and NO2 and NOx in the 3 days prior to stroke with OR of 1.24 (95% CI: 1.01, 1.52) and 1.18 (95% CI: 1.03, 1.34) per IQR increase, respectively. The observed associations with hemorrhagic stroke were more pronounced among non-obese participants.

CONCLUSIONS

In this large cohort of post-menopausal US women, daily NO2 and NOx were associated with higher risk of hemorrhagic stroke, but ambient levels of four other air pollutants were not associated with higher risk of total stroke, ischemic stroke, or ischemic stroke subtypes.

Neuroprotective Effects and Mechanisms of Zhenlong Xingnao Capsule in In Vivo and In Vitro Models of Hypoxia

Zhenlong Xingnao Capsule (ZXC) is a Tibetan medicine used to treat ischemic stroke. In this study, we determined the in vitro and in vivo effects of ZXC on reactive oxygen species (ROS) in a mouse BV-2 microglial cell hypoxia-reoxygenation and rat middle cerebral artery occlusion infarction models. We aimed to clarify the role of ZXC in cerebral ischemia protection; reveal amino acid neurotransmitter changes in the frontal cortex after drug intervention; determine mRNA and protein expression changes in Bcl-2, Bax, caspase-3, P38, and nuclear factor (NF)-кB in the frontal cortex and changes in antioxidant indices in the brain; and elucidate the mechanisms underlying ZXC action. After hypoxia-reoxygenation, ROS levels were significantly increased in BV-2 cells, and their levels decreased after treatment with ZXC. ZXC had protective effects on ischemic/anoxic injury in vitro and in vivo by downregulating the expressions of caspase-3 and NF-кB mRNA during ischemia and reperfusion and that of p38 and caspase-3 during acute ischemia and reperfusion as well as the steady-state levels of excitatory amino acids/inhibitory amino acids and by improving the total antioxidant capacity and total superoxide dismutase activities during ischemia. These findings provide new molecular evidence for the mechanisms underlying ZXC action.

Exogenous adenosine facilitates neuroprotection and functional recovery following cerebral ischemia in rats

INTRODUCTION & OBJECTIVE

Cerebral ischemia causes physiological and biochemical cellular changes that ultimately result in structural and functional damage to hippocampal neurons. Ischemia also raises endogenous adenosine release that in turn has neuroprotective effects. The purpose of this study was to evaluate the effect of exogenous adenosine on mitigating neuronal lesions to the CA1 region of hippocampus and A2A protein expression following cerebral I/R in rats.

METHODS

Male Wistar rats were randomly assigned to three experimental groups (sham, ischemia + control, and ischemia + adenosine). A daily dose of adenosine (0.1 mg/ml/kg, i.p.) was administered starting 24 h post-ischemia for 7 days. Ischemia was induced by occlusion of both common carotid arteries for 45 min. Cresyl violet and Hematoxylin Eosin staining were used to assess lesion extent and location. To investigate the expression and protein levels, immunohistochemistry and enzyme-linked immunosorbent assay method was used.

RESULTS

The cerebral ischemia caused neuronal loss in the CA1 region and reduced sensorimotor functions in lesion animals. Injection of adenosine significantly diminished cell death and improved sensorimotor functional recovery. Moreover, the expression and concentration of A2A protein was significantly greater in the adenosine group compared to the ischemia group.

CONCLUSION

This study showed that the administration of exogenous adenosine promotes protection against cell death and supports functional recovery following ischemic injury.

Discovery of a New Biomarker Pattern for Differential Diagnosis of Acute Ischemic Stroke Using Targeted Metabolomics

Stroke is one of the leading causes of disability all over the world. However, biomarkers for fast differential diagnosis of acute ischemic stroke (AIS) from vertigo or headache, remains lacking. Using a direct-infusion mass spectrometry method, it is possible to establish an efficient method for AIS differential diagnosis that requires only a few minutes. Thirty-eight clearly diagnosed AIS patients and 46 patients with a main complaint of vertigo were enrolled in this study. There was a total of 58 metabolites that were measured by our targeted metabolomics method, and the data were analyzed by pattern recognition algorithms. As a result, a clear classification between AIS and vertigo patients was achieved. Acylcarnitines are the major discriminating metabolites between the two groups. Arginine and its ratio, which is related to urea cycle metabolites, including arginine/ornithine and citrulline/arginine, also accounted for the classification. Interestingly, the levels of these metabolites were also found to be restored among recovering AIS patients (n = 11), which indicated that the metabolic alterations are possibly related to AIS development. Based on the characters from the data pattern reorganization, a novel biomarkers pattern was established using a binary logistic model, which contained arginine, arginine/ornithine, vaccenylcarnitine, and hydroxylbutyrylcarnitine. This biomarkers pattern achieved an area under the receiver operating characteristic curve of 0.89 for the differential diagnosis of AIS. Considering the efficiency and the diagnostic performance of the biomarkers pattern, our method has potential future use for the clinical application.

Effects of occupation on intracerebral hemorrhage-related deaths in Inner Mongolia

This study assessed the relationship between occupation and Intracerebral Hemorrhage-related deaths and compared the differences in ICH-related deaths rates between the eastern and midwestern regions of Inner Mongolia. We used the case-control method. Cases included Intracerebral Hemorrhage-related deaths that occurred from 2009 to 2012 in Inner Mongolia while controls included non-circulatory system disease deaths that occurred during the same period. Odds ratios (ORs) for Intracerebral Hemorrhage-related deaths were calculated using logistic regression analysis, estimated according to occupation, and adjusted for marital status and age. The Intracerebral Hemorrhage mortality rate in the eastern regions (125.19/100000) was nearly 3 times higher than that in the midwestern regions (45.31/100000). ORs for agriculture-livestock workers, service professionals and general workers, professional workers and senior officials were in descending order. The age-adjusted OR for Intracerebral Hemorrhage-related deaths was lowest in unmarried men senior officials (OR 0.37, 95% CI 0.14-0.99). The Intracerebral Hemorrhage mortality rate in the eastern regions was much higher than that of the midwestern regions, since about 90% of Intracerebral Hemorrhage-related deaths in the eastern regions were those of agriculture-livestock workers who has the largest labor intensity of any other occupation assessed.

Predictive ability of admission neutrophil to lymphocyte ratio on short-term outcome in patients with spontaneous cerebellar hemorrhage

As one of the prototypical intracranial hemorrhage (ICH), spontaneous cerebellar hemorrhage (SCH) is treated with different strategies by comparing with supratentorial hemorrhage (SH). Additionally, SCH patients usually suffer from worse prognosis than patients with other types of ICH. It is well documented that the unique anatomic structures of posterior cranial fossa lead to a higher risk for brainstem compression and/or brain edema in SCH patients. Recently, neutrophil to lymphocyte ratio (NLR) was reported to possess an excellent predictive ability for the prognosis of patients with ICH, and most of those cases are SH. Thus, the potential association between NLR and the prognosis of SCH patients remains to be elucidated. Here, we aim to assess the predictive role of admission NLR and other available inflammatory parameters for the outcomes of patients with SCH.All patients with acute SCH admitting to West China Hospital from February 2010 to October 2017 were retrospectively enrolled. According to the absolute neutrophil count, absolute lymphocyte count, white blood count and absolute monocyte count extracted from electronic medical records, NLR was calculated. The multivariable logistic regression analysis was applied to analyze the associations between disease outcome and laboratory biomarkers. The comparisons of predictive powers of each biomarker were assessed by receiver operating curves (ROCs). The spearman analyses and multiple linear analyses were also conducted to identify the independent predictors for admission NLR.Admission NLR independently associated with 30-day status (odds ratio [OR] 1.785, 95% confidence interval [CI] 1.463-2.666, P <.01) and exhibited a better predictive value (AUC 0.751, 95% CI 0.659-0.830, P <.001) with the best predictive cutoff point of 7.04 in 62 patients with unfavorable outcomes. Moreover, absolute neutrophil count, absolute lymphocyte count, presence of intraventricular hemorrhage (IVH) and Glasgow coma scale (GCS) score were also correlated with admission NLR, respectively.Admission NLR is a potential marker to independently predict the 30 days functional outcome of SCH patients. Based on our results, systemic inflammation in admission might be considered as an important player in participating the pathological process of patients with SCH.

A Genetic Variant of miR-34a Contributes to Susceptibility of Ischemic Stroke Among Chinese Population

miRNAs are small non-coding RNAs modulating gene expression, and variants in miRNA genes are involved in the pathogenesis of ischemic stroke (IS). However, the effect of miR-34a polymorphisms on IS susceptibility has rarely been reported. In the present study, we investigated the association between rs12128240, rs2666433, and rs6577555 of the miR-34a gene and IS susceptibility. Snapshot assay was used to detect miR-34a polymorphisms in 548 IS patients and 560 controls. Relative expression of miR-34a was measured by quantitative real-time PCR. We found that rs2666433 was associated with a significantly increased risk of IS (AA vs. GG: OR = 1.61, 95% CI = 1.05-2.52, P = 0.031; AA vs. GG+GA: OR = 1.58, 95% CI = 1.05-2.45, P = 0.026). For the IS subtypes, rs2666433 was associated with large artery atherosclerosis (AA vs. GG: OR = 2.09, 95% CI = 1.16-3.51, P = 0.007; AA vs. GG+GA: OR = 2.02, 95% CI = 1.15-3.33, P = 0.007; A vs. G: OR = 1.36, 95% CI = 1.07-1.81, P = 0.021). Additionally, the level of miR-34a was significantly up-regulated in IS patients compared to the controls (P < 0.001), and patients with rs2666433 AA genotype had a higher level of miR-34a than those with GG+GA genotypes (P < 0.001). Furthermore, increased level of homocysteine was observed in IS patients compared to the controls (P < 0.001), especially in patients carrying the rs2666433AA genotype compared to those carrying the rs2666433 GG+GA genotypes (P < 0.001). However, no significant association between rs12128240 or rs6577555 and IS was found. Collectively, our study found the association between miR-34a polymorphisms and the risk of IS among the Chinese population. The results may provide an explanation for etiology of IS and a potential biomarker or therapeutic target for IS. HIGHLIGHTS-MiR-34a rs2666433 polymorphism was associated with an increased risk of ischemic stroke.-The level of miR-34a was significantly up-regulated in ischemic stroke patients compared with controls, and patients with rs2666433 AA genotype had a higher level miR-34a than those with GG+GA genotypes.-Furthermore, increased level of homocysteine was showed in IS patients compared to controls, and in patients carrying the rs2666433AA compared to those carrying the rs2666433 GG+GA.