Primary prevention of ischemic stroke: A statement for healthcare professionals from the Stroke Council of the American Heart Association

Left Atrial Appendage Occlusion During Cardiac Surgery to Prevent Stroke: A Systematic Review and Meta-Analysis

Atrial fibrillation accounts for 1/6 of all strokes, potentially leading to significant disability and death. The left atrial appendage (LAA) is the primary location for thrombus formation. Excluding the LAA has been hypothesized to decrease the risk of ischemic stroke. This study examines LAA occlusion (LAAO) with otherwise indicated cardiac surgery and its effect on surgical outcomes. We followed the standards recommended by the Cochrane Collaborative Group and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist to prepare this systematic review and meta-analysis. Studies were retrieved through an online bibliographic search, studies were screened, and data were extracted. We compared the 2 study arms (LAAO and cardiac surgery without LAAO). A total of 10 studies have been included in this study, and 6 randomized controlled trials were included in the meta-analysis, with data pooled from over 10,000 patients. LAAO is associated with no significant difference in the overall mortality (p = 0.98) and systemic embolism (p = 0.31). Strokes, particularly, ischemic strokes, have significantly lower risk in patients who underwent LAAO (p <0.0001 and p = 0.0007), respectively. In conclusion, LAAO can be done safely as a concomitant surgery with other cardiac surgeries, with a minimal incremental cost when performed concurrently. LAAO is associated with a lower risk of all stroke and ischemic strokes. Further studies are needed to shape guidance on the continuation versus discontinuation of anticoagulation after LAAO, especially in patient populations with a higher risk of bleeding.

Risk Factors and a Prediction Model for Hemorrhagic Transformation in Acute Ischemic Stroke With Atrial Fibrillation

OBJECTIVES

To identify the risk factors of hemorrhagic transformation (HT) and to establish a prediction model for HT in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF).

METHODS

From January 2015 to December 2018, patients with AIS and AF were enrolled. Demographics, lesion features, and blood test results were collected. Univariate and multivariate logistic regression analyses were used to identify the independent risk factors of HT. The receiver operating curve (ROC) curve was utilized to determine the cutoff values and the efficiency of the variables. A predictive model was subsequently developed based on the identified independent risk factors.

RESULTS

A total of 259 patients were included. Age [odds ratio (OR): 1.094; 95% CI: 1.048-1.142; P <0.001], LDL-C (OR: 0.633; 95% CI: 0.407-0.983; P =0.042), uric acid (OR: 0.996; 95% CI: 0.991-0.999; P =0.031), Alberta Stroke Program Early CT Score (ASPECTS) (OR: 0.700; 95% CI: 0.563-0.870; P <0.001), cerebral cortex infarction (OR: 0.294; 95% CI: 0.168-0.515; P <0.001), and massive cerebral infarction (OR: 3.683; 95% CI: 3.025-5.378; P <0.001) were independently associated with HT. We have developed a model incorporating these variables. The area under the curve of the predictive model was 0.87 (95% CI: 0.83-0.92), demonstrating satisfactory predictive ability with a sensitivity of 83.5% and a specificity of 76.4%.

CONCLUSIONS

Our predictive model, which integrates age, LDL-C, uric acid, ASPECTS, cerebral cortex infarction, and massive cerebral infarction, can be used to predict HT after AIS in patients with AF, thereby facilitating the mitigation of adverse outcomes.

The link between Alzheimer's disease and stroke: A detrimental synergism

Being age-related disorders, both Alzheimer's disease (AD) and stroke share multiple risk factors, such as hypertension, smoking, diabetes, and apolipoprotein E (APOE) Ɛ4 genotype, and coexist in patients. Accumulation of amyloid-β plaques and neurofibrillary tangled impair cognitive potential, leading to AD. Blocked blood flow in the neuronal tissues, causes neurodegeneration and cell death in stroke. AD is commonly characterized by cerebral amyloid angiopathy, which significantly elevates the risk of hemorrhagic stroke. Patients with AD and stroke have been both reported to exhibit greater cognitive impairment, followed by multiple pathophysiological mechanisms shared between the two. The manuscript aims to elucidate the relationship between AD and stroke, as well as the common pathways and risk factors while understanding the preventive therapies that might limit the negative impacts of this correlation, with diagnostic modalities and current AD treatments. The authors provide a comprehensive review of the link and aid the healthcare professionals to identify suitable targets and risk factors, that may retard cognitive decline and neurodegeneration in patients. However, more intricate research is required in this regard and an interdisciplinary approach that would target both the vascular and neurodegenerative factors would improve the quality of life in AD patients.

Influence of matrix metalloproteinase 9 variant rs17576 on ischemic stroke risk and severity in acute coronary syndrome

BACKGROUND

Ischemic injury is a common mechanism in both ischemic stroke (IS) and acute coronary syndrome (ACS). Matrix metalloproteinase 9 (MMP-9), an endopeptidase that degrades extracellular matrix, is important in the pathogenesis of IS. The purpose of this study is to evaluate the association between the SNP rs17576 in MMP-9 gene with (1) the risk and severity of acute ischemic stroke in Saudi Arab individuals with recent acute coronary syndrome, and (2) the risk of acute coronary syndrome in Saudi Arab individuals without ischemic stroke.

METHODS

A case control study of 200 IS patients, 520 ACS patients (without IS), and 500 aged-matched healthy controls were genotyped to detect the MMP-9 polymorphism rs17156.

RESULTS

Our study demonstrated a non-significant difference in the genotype and allele frequencies of the MMP9 rs17576 polymorphism between the patients with IS and patients with ACS without IS (P = 0.31 for the GA genotype, 0.25 for the AA genotype and P = 0.20 for the A allele). AA genotype was found to be statistically significant between IS and control groups; [OR=1.84, 95 % CI (1.08-3.14), p =0.015]. A allele showed a significant difference between the two groups [OR=1.28, 95 % CI (1.00-1.64), p =0.028]. By comparing ACS without IS and controls, AA genotype was significant [OR=1.46, 95 % CI (1.01-2.12), p =0.029]. Stratification by NIHSS score revealed higher mortality and early neurologic deterioration in IS patients with NIHSS score ≥ 16 (p < 0.001, 0.044 respectively).

CONCLUSION

We deduced the lack of association either with allele or genotype frequencies (p>0.05) between the IS cases and the cases of ACS without IS. In contrast there was a significant association of mutant genotype AA between either the IS group or ACS (without IS) group, and the control group. In addition, different rs17576 genotypes were not associated with raised mortality or a tendency to develop early neurologic deterioration.

Perceptions and self-management of a healthy diet among middle-aged adults with risk of stroke in North China: a qualitative exploration

OBJECTIVE

Although stroke is prevalent among older people, there is a rising incidence among the younger subpopulations, particularly middle-aged adults. A healthy diet is one of the key modifiable factors to primary prevention of stroke among these subpopulations, yet there is limited understanding of the dietary habits among middle agers who have the risk factor(s) but no occurrence of stroke. This study aims to explore the views on perceptions and the self-management of middle-aged adults at risk of stroke on a healthy diet and to identify the enablers and barriers that could inform the future development of dietary interventions.

DESIGN

This study used an interpretive descriptive qualitative design, employing semistructured purposive sampling for focus group discussions. Thematic analysis was conducted on the transcribed interviews and field notes, facilitated by NVivo 12.0 Plus software.

SETTING

Community settings in Zhengzhou City, Henan Province.

PARTICIPANTS

Middle-aged adults (aged 45-59) were identified as at risk of stroke due to the presence of one or more modifiable risk factors.

RESULT

A total of seven focus group discussions were audio recorded. Four main themes emerged, which were: (1) cognitive understanding of a healthy diet; (2) dietary practices; (3) knowledge acquisition and (4) barriers to dietary adherence.

CONCLUSIONS

The middle-aged adults at risk of stroke were generally aware of the risk and attempted to practise healthy eating. The existing educational programmes on following a healthy diet in the prevention of disease need to be made more comprehensible, accessible and equitable, especially for those from socioeconomically disadvantaged communities.

The paradigm change from reactive medical services to 3PM in ischemic stroke: a holistic approach utilising tear fluid multi-omics, mitochondria as a vital biosensor and AI-based multi-professional data interpretation

Worldwide stroke is the second leading cause of death and the third leading cause of death and disability combined. The estimated global economic burden by stroke is over US$891 billion per year. Within three decades (1990-2019), the incidence increased by 70%, deaths by 43%, prevalence by 102%, and DALYs by 143%. Of over 100 million people affected by stroke, about 76% are ischemic stroke (IS) patients recorded worldwide. Contextually, ischemic stroke moves into particular focus of multi-professional groups including researchers, healthcare industry, economists, and policy-makers. Risk factors of ischemic stroke demonstrate sufficient space for cost-effective prevention interventions in primary (suboptimal health) and secondary (clinically manifested collateral disorders contributing to stroke risks) care. These risks are interrelated. For example, sedentary lifestyle and toxic environment both cause mitochondrial stress, systemic low-grade inflammation and accelerated ageing; inflammageing is a low-grade inflammation associated with accelerated ageing and poor stroke outcomes. Stress overload, decreased mitochondrial bioenergetics and hypomagnesaemia are associated with systemic vasospasm and ischemic lesions in heart and brain of all age groups including teenagers. Imbalanced dietary patterns poor in folate but rich in red and processed meat, refined grains, and sugary beverages are associated with hyperhomocysteinaemia, systemic inflammation, small vessel disease, and increased IS risks. Ongoing 3PM research towards vulnerable groups in the population promoted by the European Association for Predictive, Preventive and Personalised Medicine (EPMA) demonstrates promising results for the holistic patient-friendly non-invasive approach utilising tear fluid-based health risk assessment, mitochondria as a vital biosensor and AI-based multi-professional data interpretation as reported here by the EPMA expert group. Collected data demonstrate that IS-relevant risks and corresponding molecular pathways are interrelated. For examples, there is an evident overlap between molecular patterns involved in IS and diabetic retinopathy as an early indicator of IS risk in diabetic patients. Just to exemplify some of them such as the 5-aminolevulinic acid/pathway, which are also characteristic for an altered mitophagy patterns, insomnia, stress regulation and modulation of microbiota-gut-brain crosstalk. Further, ceramides are considered mediators of oxidative stress and inflammation in cardiometabolic disease, negatively affecting mitochondrial respiratory chain function and fission/fusion activity, altered sleep-wake behaviour, vascular stiffness and remodelling. Xanthine/pathway regulation is involved in mitochondrial homeostasis and stress-driven anxiety-like behaviour as well as molecular mechanisms of arterial stiffness. In order to assess individual health risks, an application of machine learning (AI tool) is essential for an accurate data interpretation performed by the multiparametric analysis. Aspects presented in the paper include the needs of young populations and elderly, personalised risk assessment in primary and secondary care, cost-efficacy, application of innovative technologies and screening programmes, advanced education measures for professionals and general population-all are essential pillars for the paradigm change from reactive medical services to 3PM in the overall IS management promoted by the EPMA.

Inverse relationship between platelet Akt activity and hippocampal atrophy: A pilot case-control study in patients with diabetes mellitus

BACKGROUND

Akt plays diverse roles in humans. It is involved in the pathogenesis of type 2 diabetes mellitus (T2DM), which is caused by insulin resistance. Akt also plays a vital role in human platelet activation. Furthermore, the hippocampus is closely associated with memory and learning, and a decrease in hippocampal volume is reportedly associated with an insulin-resistant phenotype in T2DM patients without dementia.

AIM

To investigate the relationship between Akt phosphorylation in unstimulated platelets and the hippocampal volume in T2DM patients.

METHODS

Platelet-rich plasma (PRP) was prepared from the venous blood of patients with T2DM or age-matched controls. The pellet lysate of the centrifuged PRP was subjected to western blotting to analyse the phosphorylation of Akt, p38 mitogen-activated protein (MAP) kinase and glyceraldehyde 3-phosphate dehydrogenase (GAPDH). Phosphorylation levels were quantified by densitometric analysis. Hippocampal volume was analysed using a voxel-based specific regional analysis system for Alzheimer's disease on magnetic resonance imaging, which proposes the Z-score as a parameter that reflects hippocampal volume.

RESULTS

The levels of phosphorylated Akt corrected with phosphorylated p38 MAP kinase were inversely correlated with the Z-scores in the T2DM subjects, whereas the levels of phosphorylated Akt corrected with GAPDH were not. However, this relationship was not observed in the control patients.

CONCLUSION

These results suggest that an inverse relationship may exist between platelet Akt activation and hippocampal atrophy in T2DM patients. Our findings provide insight into the molecular mechanisms underlying T2DM hippocampal atrophy.

A retrospective analysis of the social determinants of health affecting stroke outcomes in a small hospital situated in a health professional shortage area (HPSA)

Where someone lives is a major determinant of population health. In the United States, people who live in Health Professional Shortage Areas are considered medically underserved and have a higher propensity for conditions such as stroke, hypertension, and diabetes. Our goal was to better understand the diverse needs of patients presenting to the Crouse Hospital emergency department with stroke symptoms. Crouse Hospital is a small community hospital located in a shortage area serving both urban and rural populations in and around Syracuse, New York. Despite its small size, Crouse Hospital quickly became a major comprehensive stroke center in Central New York. With this study we assessed the social factors affecting the stroke patient population in the community and compared these characteristics between those living in served and underserved areas. Informed by the social determinants of health framework, we analyzed 1731 incidents of stroke that occurred between January 2019 and January 2021, and observed that the circumstances associated with stroke varied by service category and race, with White patients and those from served areas having better stroke outcomes compared to those residing in underserved areas and those that were not White. Our analyses help us to understand the underlying factors influencing the observed disparities and allow us to move forward by implementing informed community-based interventions to decrease stroke incidence and improve post-stroke care. Using our example other small hospitals can enact similar strategies to address the social determinants affecting their patients to improve stroke outcomes in their region.

Associations of grip strength and walking pace with mortality in stroke survivors: A prospective study from UK Biobank

INTRODUCTION

Although stroke is an emerging cause of disability and mortality globally, associations between physical capability markers and mortality in stroke survivors are elusive. This study investigated the individual and combined associations of walking pace and grip strength with all-cause and stroke mortality in stroke survivors.

METHODS

Individual and combined associations of walking pace and grip strength with stroke deaths and all-cause mortality were investigated using Cox proportional-hazard models adjusted for sociodemographic, lifestyle, and health-related variables.

RESULTS

Seven thousand four hundred eighty-six stroke survivors from the UK Biobank study (aged 40-70 years; 42.4% women) were included in this prospective study. Over a median follow-up of 12.6 (IQR: 11.9-13.3) years, 1490 (19.9%) participants died, of whom 222 (3.0%) died from stroke. After adjusting for confounding factors, and compared to individuals in the average/brisk walking pace category, those who reported a slow walking pace had 2.00 (95% CI: 1.50-2.68) and 1.99 (95% CI: 1.78-2.23) times higher risk of stroke mortality and all-cause mortality, respectively. Similar associations were identified for participants with low grip strength compared with those with normal levels. For combined associations, those with both slow walking pace and low grip strength showed the highest risk of stroke mortality (hazard ratio: 2.86 [95% CI: 1.93-4.22]). Similar results were found for all-cause mortality.

CONCLUSIONS

Low grip strength and slow walking pace were associated with a higher risk of stroke and all-cause mortality in stroke survivors. If these associations are causal, improving physical capability among stroke survivors might potentially prolong survival.

Estimating the Effect of Aerobic Exercise Training on Novel Lipid Biomarkers: A Systematic Review and Multivariate Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Aerobic exercise training (AET) prescribed as lipid management treatment positively affects the standard lipid profile and reduces cardiovascular disease (CVD) risk. Apolipoproteins, lipid and apolipoprotein ratios, and lipoprotein sub-fractions may more effectively predict CVD risk than the standard lipid profile but an AET response in these biomarkers has not been established.

OBJECTIVES

We conducted a quantitative systematic review of randomised controlled trials (RCTs) to (1) determine the effects of AET on lipoprotein sub-fractions, apolipoproteins and relevant ratios; and (2) identify study or intervention covariates associated with change in these biomarkers.

METHODS

We searched PubMed, EMBASE, all Web of Science and EBSCO health and medical online databases from inception to 31 December 2021. We included published RCTs of adult humans with ≥ 10 per group of participants; an AET intervention duration ≥ 12 weeks of at least moderate intensity (> 40% maximum oxygen consumption); and reporting pre/post measurements. Non-sedentary subjects, or those with chronic disease other than Metabolic Syndrome factors, or pregnant/lactating, as well as trials testing diet/medications, or resistance/isometric/unconventional training interventions, were excluded.

RESULTS

Fifty-seven RCTs totalling 3194 participants were analysed. Multivariate meta-analysis showed AET significantly raised antiatherogenic apolipoproteins and lipoprotein sub-fractions (mmol/L mean difference (MD) 0.047 (95% confidence interval (CI) 0.011, 0.082), P = .01); lowered atherogenic apoliproteins and lipoprotein sub-fractions (mmol/L MD - 0.08 (95% CI - 0.161, 0.0003), P = .05); and improved atherogenic lipid ratios (MD - 0.201 (95% CI - 0.291, - 0.111), P < .0001). Multivariate meta-regression showed intervention variables contributed to change in lipid, sub-fraction, and apoliprotein ratios.

CONCLUSION

Aerobic exercise training positively impacts atherogenic lipid and apolipoprotein ratios, alipoproteins, and lipoprotein sub-fractions; and antiatherogenic apolipoproteins and lipoprotein sub-fractions. Cardiovascular disease risk predicted by these biomarkers may be lowered when AET is prescribed as treatment or prevention.

PROSPERO ID

CRD42020151925.

Selenium, Stroke, and Infection: A Threefold Relationship; Where Do We Stand and Where Do We Go?

Stroke is currently the second most common cause of death worldwide and a major cause of serious long-term morbidity. Selenium is a trace element with pleotropic effects on human health. Selenium deficiency has been associated with a prothrombotic state and poor immune response, particularly during infection. Our aim was to synthesize current evidence on the tripartite interrelationship between selenium levels, stroke, and infection. Although evidence is contradictory, most studies support the association between lower serum selenium levels and stroke risk and outcomes. Conversely, limited evidence on the role of selenium supplementation in stroke indicates a potentially beneficial effect of selenium. Notably, the relationship between stroke risk and selenium levels is bimodal rather than linear, with higher levels of serum selenium linked to disturbances of glucose metabolism and high blood pressure, morbidities which are, in turn, substrates for stroke. Another such substrate is an infection, albeit forming a bidirectional relationship with both stroke and the consequences of impaired selenium metabolism. Perturbed selenium homeostasis leads to impaired immune fitness and antioxidant capacity, which both favor infection and inflammation; specific pathogens may also contend with the host for transcriptional control of the selenoproteome, adding a feed-forward loop to this described process. Broader consequences of infection such as endothelial dysfunction, hypercoagulation, and emergent cardiac dysfunction both provide stroke substrates and further feed-forward feedback to the consequences of deficient selenium metabolism. In this review, we provide a synthesis and interpretation of these outlined complex interrelationships that link selenium, stroke, and infection and attempt to decipher their potential impact on human health and disease. Selenium and the unique properties of its proteome could provide both biomarkers and treatment options in patients with stroke, infection, or both.

Clinical and Imaging Phenotypes and Outcomes in a Costa Rican Cohort of Acute Ischemic Stroke Survivors: A Retrospective Study

BACKGROUND

We characterized clinical and imaging phenotypes and their association with clinical outcomes in acute ischemic stroke (AIS) survivors in the understudied region of Costa Rica.

METHODS

We conducted a retrospective cohort study in AIS patients treated at a tertiary stroke center in Costa Rica from 2011-2015. Participants underwent detailed phenotyping for cardiovascular risk factors and stroke etiology. We assessed the association of ischemic brain lesion features and clinical outcomes using the Oxfordshire Community Stroke Project (OCSP) classification.

RESULTS

We included 684 AIS survivors (60.2% males, aged 68.1 ± 13.6 years, mean ± SD). While the cardiovascular risk profiles and mortality rates of our patients were similar to populations in European and North American countries, only 20.2% of patients with atrial fibrillation (AF) received anticoagulation. On multivariable analysis, patients with total anterior circulation infarct (TACI) displayed an increased risk of complications (OR: 4.2; 95% CI: 2.2-7.8; p < 0.001), higher mortality (OR: 6.9; 95% CI: 2.9-16.1; p < 0.001) and lower chance of functional independence at discharge (OR: 8.9; 95% CI: 4.1-19; p < 0.001) compared to non-TACI. The comorbidity of bronchopneumonia increased the probability of death by 14.5 times.

CONCLUSIONS

Our observations in a Costa Rican cohort of AIS survivors might help improve local measures for preventing and managing AIS.

Ischemic stroke of unclear aetiology: a case-by-case analysis and call for a multi-professional predictive, preventive and personalised approach

Due to the reactive medical approach applied to disease management, stroke has reached an epidemic scale worldwide. In 2019, the global stroke prevalence was 101.5 million people, wherefrom 77.2 million (about 76%) suffered from ischemic stroke; 20.7 and 8.4 million suffered from intracerebral and subarachnoid haemorrhage, respectively. Globally in the year 2019 — 3.3, 2.9 and 0.4 million individuals died of ischemic stroke, intracerebral and subarachnoid haemorrhage, respectively. During the last three decades, the absolute number of cases increased substantially. The current prevalence of stroke is 110 million patients worldwide with more than 60% below the age of 70 years. Prognoses by the World Stroke Organisation are pessimistic: globally, it is predicted that 1 in 4 adults over the age of 25 will suffer stroke in their lifetime. Although age is the best known contributing factor, over 16% of all strokes occur in teenagers and young adults aged 15–49 years and the incidence trend in this population is increasing. The corresponding socio-economic burden of stroke, which is the leading cause of disability, is enormous. Global costs of stroke are estimated at 721 billion US dollars, which is 0.66% of the global GDP.

Clinically manifested strokes are only the “tip of the iceberg”: it is estimated that the total number of stroke patients is about 14 times greater than the currently applied reactive medical approach is capable to identify and manage. Specifically, lacunar stroke (LS), which is characteristic for silent brain infarction, represents up to 30% of all ischemic strokes. Silent LS, which is diagnosed mainly by routine health check-up and autopsy in individuals without stroke history, has a reported prevalence of silent brain infarction up to 55% in the investigated populations. To this end, silent brain infarction is an independent predictor of ischemic stroke. Further, small vessel disease and silent lacunar brain infarction are considered strong contributors to cognitive impairments, dementia, depression and suicide, amongst others in the general population. In sub-populations such as diabetes mellitus type 2, proliferative diabetic retinopathy is an independent predictor of ischemic stroke.

According to various statistical sources, cryptogenic strokes account for 15 to 40% of the entire stroke incidence. The question to consider here is, whether a cryptogenic stroke is fully referable to unidentifiable aetiology or rather to underestimated risks. Considering the latter, translational research might be of great clinical utility to realise innovative predictive and preventive approaches, potentially benefiting high risk individuals and society at large.

In this position paper, the consortium has combined multi-professional expertise to provide clear statements towards the paradigm change from reactive to predictive, preventive and personalised medicine in stroke management, the crucial elements of which are:

Consolidation of multi-disciplinary expertise including family medicine, predictive and in-depth diagnostics followed by the targeted primary and secondary (e.g. treated cancer) prevention of silent brain infarction

Application of the health risk assessment focused on sub-optimal health conditions to effectively prevent health-to-disease transition

Application of AI in medicine, machine learning and treatment algorithms tailored to robust biomarker patterns

Application of innovative screening programmes which adequately consider the needs of young populations

Stroke is a severe brain disease which has reached an epidemic scale worldwide: in 2019, the global stroke prevalence was 101.5 million people. The World Stroke Organisation predicted that globally, 1 in 4 adults over the age of 25 will get a stroke in their lifetime. Not only old people but also teenagers and young adults are affected. Current global costs of stroke are estimated at 721 billion US dollars. Due to undiagnosed so-called “silent” brain infarction, the number of affected individuals is about 14 times greater in the population than clinically recorded. If it remains untreated, silent brain infarction may cause many severe and fatal disorders such as dementia, depression and even suicide. In this position paper, the consortium describes how the rudimental approach to treating severely diseased people could be replaced by an innovative predictive and preventive one to protect people against the health-to-disease transition.

Association of modifiable risk factors with ischaemic stroke subtypes in Asian versus Caucasian populations: A systematic review and meta-analysis

BACKGROUND

Ischaemic stroke (IS) is associated with various modifiable risk factors but the association of these risk factors based on TOAST classification, which characterises IS into five subtypes: large artery atherosclerosis (LAA), small vessel occlusion (SVO), cardioembolic disease (CE), other determined aetiology (ODE) and undetermined aetiology (UDE), is unknown. We aimed to summarise the published evidence for the association of modifiable risk factors with IS subtypes based on TOAST classification, specifically focussing on the Asian versus Caucasian population.

METHOD

A comprehensive search for all the published articles was performed in electronic databases including PubMed, EMBASE, Cochrane Library, and Google Scholar from 01st January 1950 to 10th April 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Odds ratio (OR) with 95% confidence interval (CIs) along with random-effect models was used to calculate summary estimates.

RESULTS

In our meta-analysis, 32 studies with a total of 23,404 IS (14,364 in Asian vs. 9040 in Caucasian population), 7121 LAA (5219 in Asian vs. 1902 in Caucasian), 5532 SVO (3604 in Asian vs. 1928 in Caucasian), 3498 CE (1634 in Asian vs. 1864 in Caucasian), 1131 ODE (546 in Asian vs. 585 in Caucasian) and 4519 UDE (2076 in Asian vs. 2443 in Caucasian) were included. Our findings suggest a significant association between LAA and hypertension (OR = 1.07, 95% CI = 1.02-1.12), smoking (OR = 1.11, 95% CI = 1.04-1.17), dyslipidemia (OR = 1.13, 95% CI = 1.06-1.21), diabetes mellitus (OR = 1.18, 95% CI = 1.11-1.25) and atrial fibrillation (OR = 0.55, 95% CI = 0.40-0.75). Significantly strong association of hypertension, smoking, dyslipidemia, diabetes mellitus and atrial fibrillation was observed with SVO and CE stroke subtypes. Subgroup analysis based on ethnicity revealed a significant association for dyslipidemia, diabetes mellitus and atrial fibrillation in LAA for both Asians and Caucasians. Hypertension was significantly associated with SVO and ODE subtypes in both Asians and Caucasians; however, only Asian population showed significant association of hypertension in LAA and CE subtypes. The other risk factors did not show any statistical difference between the ethnic groups for the different stroke subtypes. The majority of the risk factors depicted positive association with LAA and SVO, negative with CE and neutral with ODE and UDE.

CONCLUSION

Our findings suggest strong association of smoking, dyslipidemia and diabetes mellitus with LAA and SVO subtypes in the Caucasian population. However, only diabetes mellitus showed significant association with both LAA and SVO subtypes in Asian population as well. Thus, a majority of the traditional modifiable risk factors had a positive association in LAA and SVO, while a negative protective association was observed in CE subtype, among both the Asian and the Caucasian subgroups.

Dengzhan Shengmai capsule versus Aspirin in the treatment of carotid atherosclerotic plaque: A single-centre, non-inferiority, prospective, randomised controlled trial

BACKGROUND

Aspirin is an effective antiplatelet agent for the treatment of carotid atherosclerosis. However, the high risk of bleeding events associated with the drug makes it necessary to seek a safer alternative, with similar or more efficacy than aspirin. Dengzhan Shengmai (DZSM) capsules have been widely used to treat carotid atherosclerosis, and if proven to be non-inferior to aspirin, it may be preferable over the latter for carotid atherosclerosis treatment due to its numerous advantages. We conducted a randomised trial to test the non-inferiority of DZSM to aspirin for the treatment of carotid atherosclerotic plaques.

METHODS

We performed a single-centre, prospective, open-label, randomised non-inferiority trial. Patients with carotid atherosclerotic plaques were enrolled and randomly assigned (1:1) to receive either DZSM capsules or aspirin. The follow-up period was 12 months. The primary outcome was the mean change in carotid intima-media thickness (IMT). Secondary outcomes included ischaemic events, rate of lumen stenosis, lipid levels, and plaque scores, length, counts, and vulnerability. Adverse events and laboratory test results were recorded as safety outcomes. The non-inferiority of DZSM was demonstrated when the lower limit of the one-sided 97.5% confidence interval (CI) of the difference in IMT between groups was more than -0.06 mm (margin of non-inferiority). This trial has been registered at ClinicalTrials.gov (CHiCTR1900021365).

RESULTS

From 1 April 2019 to 30 September 2019, 150 patients were enrolled, and there was no statistical difference in demographics between the groups. Intention-to-treat analysis showed that the decrease in IMT(_∆IMT) was 0.216 ± 0.160 and 0.225 ± 0.149 mm in the DZSM and aspirin groups, respectively. The one-sided 97.5% CI for the difference between _∆IMTs was (-0.0593, +∞). The non-inferiority of DZSM was demonstrated (P_{non-inferiority} = 0.0234). There was no significant difference in the incidence of ischaemic events between the groups (P = 1.0). The DZSM group had significantly reduced plaque scores (P < 0.0001), length (P < 0.0001), and counts (P < 0.0001), and improved plaque vulnerability (P < 0.0001). The DZSM group also had reduced levels of low-density lipoprotein cholesterol (LDL-C) (P < 0.0001). Finally, the DZSM group had a lower incidence of total adverse events (14.7% vs. 28%, P = 0.046), especially gastrointestinal discomfort (5.3% vs. 16%, P = 0.034). Although there was no significant difference in bleeding events (0 vs. 5.3%, P = 0.120), the DZSM group tended to have a lower incidence.

CONCLUSION

This trial demonstrated that DZSM was not inferior, in efficacy, to aspirin in treating carotid atherosclerotic plaques, and was found to be superior to aspirin in terms of safety. This study provides a new approach for treating carotid plaques, especially in aspirin-intolerant patients.

Dicarbonyl Stress in Diabetic Vascular Disease

Late vascular complications play a prominent role in the diabetes-induced increase in morbidity and mortality. Diabetes mellitus is recognised as a risk factor driving atherosclerosis and cardiovascular mortality; even after the normalisation of blood glucose concentration, the event risk is amplified-an effect called "glycolytic memory". The hallmark of this glycolytic memory and diabetic pathology are advanced glycation end products (AGEs) and reactive glucose metabolites such as methylglyoxal (MGO), a highly reactive dicarbonyl compound derived mainly from glycolysis. MGO and AGEs have an impact on vascular and organ structure and function, contributing to organ damage. As MGO is not only associated with hyperglycaemia in diabetes but also with other risk factors for diabetic vascular complications such as obesity, dyslipidaemia and hypertension, MGO is identified as a major player in the development of vascular complications in diabetes both on micro- as well as macrovascular level. In diabetes mellitus, the detoxifying system for MGO, the glyoxalase system, is diminished, accounting for the increased MGO concentration and glycotoxic load. This overview will summarise current knowledge on the effect of MGO and AGEs on vascular function.

Identifying Key Biomarkers and Immune Infiltration in Female Patients with Ischemic Stroke Based on Weighted Gene Co-Expression Network Analysis

Stroke is one of the leading causes of death and disability worldwide. Evidence shows that ischemic stroke (IS) accounts for nearly 80 percent of all strokes and that the etiology, risk factors, and prognosis of this disease differ by gender. Female patients may bear a greater burden than male patients. The immune system may play an important role in the pathophysiology of females with IS. Therefore, it is critical to investigate the key biomarkers and immune infiltration of female IS patients to develop effective treatment methods. Herein, we used weighted gene co-expression network analysis (WGCNA) to determine the key modules and core genes in female IS patients using the GSE22255, GSE37587, and GSE16561 datasets from the GEO database. Subsequently, we performed functional enrichment analysis and built a protein-protein interaction (PPI) network. Ten genes were selected as the true central genes for further investigation. After that, we explored the specific molecular and biological functions of these hub genes to gain a better understanding of the underlying pathogenesis of female IS patients. Moreover, the “Cell type Identification by Estimating Relative Subsets of RNA Transcripts (CIBERSORT)” was used to examine the distribution pattern of immune subtypes in female patients with IS and normal controls, revealing a new potential target for clinical treatment of the disease.

MiR-494-3p Upregulation Exacerbates Cerebral Ischemia Injury by Targeting Bhlhe40

PURPOSE

Cerebral ischemia is related to insufficient blood supply and is characterized by abnormal reactive oxygen species (ROS) production and cell apoptosis. Previous studies have revealed a key role for basic helix-loop-helix family member e40 (Bhlhe40) in oxidative stress and cell apoptosis. This study aimed to investigate the roles of miR-494-3p in cerebral ischemia/reperfusion (I/R) injury.

MATERIALS AND METHODS

A mouse middle cerebral artery occlusion (MCAO/R) model was established to mimic cerebral ischemia in vivo. Brain infarct area was assessed using triphenyl tetrazolium chloride staining. Oxygen-glucose deprivation/reoxygenation (OGD/R) operation was adopted to mimic neuronal injury in vitro. Cell apoptosis was analyzed by flow cytometry. The relationship between miR-494-3p and Bhlhe40 was validated by luciferase reporter and RNA immunoprecipitation assays.

RESULTS

Bhlhe40 expression was downregulated both in MCAO/R animal models and OGD/R-induced SH-SY5Y cells. Bhlhe40 overexpression inhibited cell apoptosis and reduced ROS production in SH-SY5Y cells after OGD/R treatment. MiR-494-3p was verified to bind to Bhlhe40 and negatively regulate Bhlhe40 expression. Additionally, cell apoptosis and ROS production in OGD/R-treated SH-SY5Y cells were accelerated by miR-494-3p overexpression. Rescue experiments suggested that Bhlhe40 could reverse the effects of miR-494-3p overexpression on ROS production and cell apoptosis.

CONCLUSION

MiR-494-3p exacerbates brain injury and neuronal injury by regulating Bhlhe40 after I/R.

Optimal management of asymptomatic carotid stenosis in 2021: the jury is still out. An International, multispecialty, expert review and position statement

OBJECTIVES

The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic.

MATERIALS AND METHODS

A literature review was performed with a focus on data from recent studies.

RESULTS

Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses.

CONCLUSIONS

Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.

Optimal Management of Asymptomatic Carotid Stenosis in 2021: The Jury is Still Out. An International, Multispecialty, Expert Review and Position Statement

OBJECTIVES

The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic.

MATERIALS AND METHODS

A literature review was performed with a focus on data from recent studies.

RESULTS

Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses.

CONCLUSIONS

Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.

Lipoprotein (a) level as a risk factor for stroke and its subtype: A systematic review and meta-analysis

The role of lipoprotein-A [Lp (a)] as a risk factor for stroke is less well documented than for coronary heart disease. Hence, we conducted a systematic review and meta-analysis for the published observational studies in order to investigate the association of Lp (a) levels with the risk of stroke and its subtypes. In our meta-analysis, 41 studies involving 7874 ischemic stroke (IS) patients and 32,138 controls; 13 studies for the IS subtypes based on TOAST classification and 7 studies with 871 Intracerebral hemorrhage (ICH) cases and 2865 control subjects were included. A significant association between increased levels of Lp (a) and risk of IS as compared to control subjects was observed (standardized mean difference (SMD) 0.76; 95% confidence interval (CIs) 0.53-0.99). Lp (a) levels were also found to be significantly associated with the risk of large artery atherosclerosis (LAA) subtype of IS (SMD 0.68; 95% CI 0.01-1.34) as well as significantly associated with the risk of ICH (SMD 0.65; 95% CI 0.13-1.17) as compared to controls. Increased Lp (a) levels could be considered as a predictive marker for identifying individuals who are at risk of developing IS, LAA and ICH.

Determining the effect size of aerobic exercise training on the standard lipid profile in sedentary adults with three or more metabolic syndrome factors: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

To estimate the change in the standard lipid profile (SLP) of adults diagnosed with ≥3 metabolic syndrome (MetS) factors following aerobic exercise training (AET); and to investigate whether study/intervention covariates are associated with this change.

DESIGN

Systematic review with univariate meta-analysis and meta-regression.

DATA SOURCES

English language searches of online databases from inception until July 2020. ELIGIBILITY CRITERIA: (1) Published randomised controlled human trials with study population ≥10 per group; (2) sedentary adults with ≥3 MetS factors but otherwise free of chronic disease, not pregnant/lactating; (3) AET-only intervention with duration ≥12 weeks; and (4) reporting pre-post intervention SLP outcomes.

RESULTS

Various univariate meta-analyses pooled 48 data sets of 2990 participants. Aerobic exercise training significantly (P<.001) improved all lipids (mmol/L mean difference ranges, 95% CIs): total cholesterol, -0.19 (-0.26 to -0.12) to -0.29 (-0.36 to -0.21); triglycerides, -0.17 (-0.19 to -0.14) to -0.18 (-0.24 to -0.13); high-density lipoprotein-cholesterol (HDL-C), 0.05 (0.03 to 0.07) to 0.10 (0.05 to 0.15); and low-density lipoprotein-cholesterol (LDL-C), -0.12 (-0.16 to -0.9) to -0.20 (-0.25 to -0.14). Meta-regression showed that intensity may explain change in triglycerides and volume may explain change in HDL-C and LDL-C.

CONCLUSION

Aerobic exercise training positively changes the SLP of sedentary and otherwise healthy adults with ≥3 MetS factors. Adjusting AET intervention training variables may increase the effects of AET on triglycerides and HDL-C.

PROSPERO REGISTRATION NUMBER

CRD42020151925.

Blood-brain barrier dysfunction in ischemic stroke and diabetes: the underlying link, mechanisms and future possible therapeutic targets

Ischemic stroke caused by occlusion of cerebral artery is responsible for the majority of stroke that increases the morbidity and mortality worldwide. Diabetes mellitus (DM) is a crucial risk factor for ischemic stroke. Prolonged DM causes various microvascular and macrovascular changes, and blood-brain barrier (BBB) permeability that facilitates inflammatory response following stroke. In the acute phase following stroke, BBB disruption has been considered the initial step that induces neurological deficit and functional disabilities. Stroke outcomes are significantly worse among DM. In this article, we review stroke with diabetes-induce BBB damage, as well as underlying mechanism and possible therapeutic targets for stroke with diabetes.

Non-Coding RNAs Based Molecular Links in Type 2 Diabetes, Ischemic Stroke, and Vascular Dementia

This article reviews recent advances in the study of microRNAs (miRNAs), long non-coding RNAs (lncRNAs), and their functions in type 2 diabetes mellitus (T2DM), ischemic stroke (IS), and vascular dementia (VaD). miRNAs and lncRNAs are gene regulation markers that both regulate translational aspects of a wide range of proteins and biological processes in healthy and disease states. Recent studies from our laboratory and others have revealed that miRNAs and lncRNAs expressed differently are potential therapeutic targets for neurological diseases, especially T2DM, IS, VaD, and Alzheimer's disease (AD). Currently, the effect of aging in T2DM, IS, and VaD and the cellular and molecular pathways are largely unknown. In this article, we highlight results from the works on the molecular connections between T2DM and IS, and IS and VaD. In each disease, we also summarize the pathophysiology and the differential expressions of miRNAs and lncRNAs. Based on current research findings, we hypothesize that 1) T2DM bi-directionally and age-dependently induces IS and VaD, and 2) these changes are precursors to the onset of dementia in elderly people. Research into these hypotheses is required to examine further whether research efforts on reducing T2DM, IS, and VaD may affect dementia and/or delay the AD disease process in the aged population.

A Feasibility Study of Expanded Home-Based Telerehabilitation After Stroke

Introduction: High doses of activity-based rehabilitation therapy improve outcomes after stroke, but many patients do not receive this for various reasons such as poor access, transportation difficulties, and low compliance. Home-based telerehabilitation (TR) can address these issues. The current study evaluated the feasibility of an expanded TR program. Methods: Under the supervision of a licensed therapist, adults with stroke and limb weakness received home-based TR (1 h/day, 6 days/week) delivered using games and exercises. New features examined include extending therapy to 12 weeks duration, treating both arm and leg motor deficits, patient assessments performed with no therapist supervision, adding sensors to real objects, ingesting a daily experimental (placebo) pill, and generating automated actionable reports. Results: Enrollees (n = 13) were median age 61 (IQR 52-65.5), and 129 (52-486) days post-stroke. Patients initiated therapy on 79.9% of assigned days and completed therapy on 65.7% of days; median therapy dose was 50.4 (33.3-56.7) h. Non-compliance doubled during weeks 7-12. Modified Rankin scores improved in 6/13 patients, 3 of whom were >3 months post-stroke. Fugl-Meyer motor scores increased by 6 (2.5-12.5) points in the arm and 1 (-0.5 to 5) point in the leg. Assessments spanning numerous dimensions of stroke outcomes were successfully implemented; some, including a weekly measure that documented a decline in fatigue (p = 0.004), were successfully scored without therapist supervision. Using data from an attached sensor, real objects could be used to drive game play. The experimental pill was taken on 90.9% of therapy days. Automatic actionable reports reliably notified study personnel when critical values were reached. Conclusions: Several new features performed well, and useful insights were obtained for those that did not. A home-based telehealth system supports a holistic approach to rehabilitation care, including intensive rehabilitation therapy, secondary stroke prevention, screening for complications of stroke, and daily ingestion of a pill. This feasibility study informs future efforts to expand stroke TR. Clinical Trial Registration: Clinicaltrials.gov, # NCT03460587.

CIMT as a risk factor for stroke subtype: A systematic review

INTRODUCTION

An increase in the common carotid artery intima-media thickness (CCA-IMT) is generally considered an early marker of atherosclerosis and is a well-established predictor of cardiovascular disease (CVD). An association between changes in CCA-IMT and risk of stroke has been reported but has conflicting findings.

OBJECTIVE

The present meta-analysis was aimed to clarify the association between CCA-IMT with the risk of stroke and its subtype by estimating pooled analysis of published literature.

METHODS

Comprehensive search for all published articles was performed in electronic databases including PubMed, Embase, Cochrane Library, Trip Databases, Worldwide Science, CINAHL and Google Scholar from 01 January 1950 to 30 April 2020.

RESULTS

In our meta-analysis, a total of 19 studies, of which sixteen studies involving 3475 ischaemic stroke (IS) cases and 11 826 controls; six studies with 902 large vessel disease (LVD) and 548 small vessel disease (SVD) of IS subtypes; five studies with 228 intracerebral haemorrhage (ICH) and 1032 IS cases, were included. Our findings suggest a strong association between increased CCA-IMT with risk of IS as compared to control subjects [SMD = 1.46, 95% CI = 0.90-2.02]. However, there is an increased risk of LVD as compared to the SVD subtype of IS [SMD = 0.36, 95% CI = 0.19-0.52] and more chance of occurrence of IS rather than ICH [SMD = 0.71, 95% CI = 0.28-1.41].

CONCLUSIONS

Carotid intima thickness measurements are found to be associated with the risk of stroke along with its subtypes and may be used as a diagnostic marker for predicting the risk of stroke events.

Relationship between methylenetetrahydrofolate reductase (MTHFR) gene (A1298C) polymorphism with the risk of stroke: A systematic review and meta-analysis

Studies on relationship between methylenetetrahydrofolate reductase gene (MTHFR) gene A1298C polymorphism with the risk of ischemic as well as hemorrhagic stroke have shown discordant results. Present meta-analysis was aimed to clarify the relationship between MTHFR gene A1298C polymorphism with risk of stroke. A comprehensive literature search for all published articles was performed in electronic database including PubMed, EMbase, Cochrane Library, Trip Databases, Worldwide Science, CINAHL, and Google Scholar up to 31st  December 2019. Pooled odds ratio (ORs) with 95% confidence interval (CIs) under dominant, recessive, and allelic models was calculated. Sensitivity analysis was also performed to detect the heterogeneity. In our meta-analysis, a total of 20 studies with 19 case control studies involving 2871 ischemic stroke (IS) cases and 3984 controls and 3 studies with 201 hemorrhagic stroke cases and 1349 controls were included. Our findings suggest that there was a significant relationship between MTHFR gene A1298C gene polymorphism with risk of ischemic stroke (dominant model: OR = 1.32, 95% CI = 1.06-1.66, recessive model: OR = 1.45, 95% CI = 1.06-1.99 and allelic model: OR = 1.35, 95% CI = 1.00-1.84, respectively). However, no significant relationship between MTHFR gene A1298C gene polymorphism with the risk of hemorrhagic stroke. Findings of this meta-analysis concludes that MTHFR gene A1298 C polymorphism could be capable of increasing stroke susceptibility in Asian, but not in Caucasian population. Genotyping of MTHFR gene A1298C polymorphism may be used as a predictor for the occurrence of ischemic stroke.

Medical Management for Secondary Stroke Prevention

PURPOSE OF REVIEW

This article reviews the evidence base and recommendations for medical management for secondary stroke prevention.

RECENT FINDINGS

Recent developments for secondary stroke prevention include evidence to support the use of short-term dual antiplatelet therapy after minor stroke and transient ischemic attack, direct oral anticoagulants for nonvalvular atrial fibrillation, reversal agents for direct oral anticoagulant-associated hemorrhage, and aspirin rather than presumptive anticoagulation with a direct oral anticoagulant for embolic stroke of undetermined source.

SUMMARY

Most strokes are preventable. The mainstays of medical management for secondary stroke prevention include antihypertensive therapy; antithrombotic therapy, with antiplatelet agents for most stroke subtypes or anticoagulants such as warfarin or a direct oral anticoagulant for cardioembolic stroke specifically; cholesterol-lowering therapy, principally with statins, but with potential roles for ezetimibe or proprotein convertase subtilisin/kexin type 9 inhibitors in selected patients; and glycemic control to prevent microvascular complications from diabetes mellitus or pioglitazone in selected patients with insulin resistance but not diabetes mellitus.

Carotid, Vertebral, and Brachiocephalic Interventions

Carotid atherosclerosis most frequently manifests in the proximal internal carotid artery and the common carotid artery bifurcations. Subclavian artery atherosclerosis affects the proximal segments with a relatively higher incidence on the left and becomes clinically important in the presence of vertebrobasilar insufficiency or coronary steal. Atherosclerosis of the vertebral artery can lead to posterior circulation stroke. The authors review the major trials on carotid carotid, brachiocephalic and vertebral artery stenosis along with the various available diagnostic and interventional techniques.

Blockade of Nogo-A/Nogo-66 receptor 1 (NgR1) Inhibits Autophagic Activation and Prevents Secondary Neuronal Damage in the Thalamus after Focal Cerebral Infarction in Hypertensive Rats

Focal cerebral infarction leads to autophagic activation, which contributes to secondary neuronal damage in the ipsilateral thalamus. Although Nogo-A deactivation enhances neuronal plasticity, its role in autophagic activation in the thalamus after ischemic stroke remains unclear. This study aimed to investigate the potential roles of Nogo-A/Nogo-66 receptor 1 (NgR1) in autophagic activation in the ipsilateral thalamus after cerebral infarction. Focal neocortical infarction was established using the middle cerebral artery occlusion (MCAO) method. Secondary damage in the ipsilateral thalamus was assessed by Nissl staining and immunostaining. The expression of Nogo-A, NgR1, Rho-A and Rho-associated coiled-coil containing protein kinase 1 (ROCK1) as well as autophagic flux were evaluated by immunofluorescence and immunoblotting. The roles of Nogo-A-NgR1 signaling in autophagic activation were determined by intraventricular delivery of an NgR1 antagonist peptide, NEP1-40, at 24 h after MCAO. The results showed that Nogo-A and NgR1 overexpression temporally coincided with marked increases in the levels of Beclin1, LC3-II and sequestosome 1 (SQSTM1)/p62 in the ipsilateral thalamus at seven and fourteen days after MCAO. In contrast, NEP1-40 treatment significantly reduced the expression of Rho-A and ROCK1 which was accompanied by marked reductions of LC3-II conversion as well as the levels of Beclin1 and SQSTM1/p62. Furthermore, NEP1-40 treatment significantly reduced neuronal loss and gliosis in the ipsilateral thalamus, and accelerated somatosensory recovery at the observed time-points after MCAO. These results suggest that blockade of Nogo-A-NgR1 signaling inhibits autophagic activation, attenuates secondary neuronal damage in the ipsilateral thalamus, and promotes functional recovery after focal cerebral cortical infarction.

HIIT is not superior to MICT in altering blood lipids: a systematic review and meta-analysis

Objective

To compare the effects of moderate intensity continuous training (MICT) and high intensity interval training (HIIT) on adult lipid profiles; to identify training or participant characteristics that may determine exercise-induced change in total cholesterol (TC), triglycerides (TRG), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C).

Design

Systematic review and meta-analysis.

Data sources

English language searches of several databases were conducted from inception until September 2019.

Eligibility criteria for excluding studies

Inclusion: (1) published randomised controlled human trials with group population n≥5; (2) intervention duration ≥4 weeks; (3) comparing HIIT with MICT; and (4) reporting pre–post intervention lipid measurements. Exclusion: subjects with chronic disease, <18 years, pregnant/lactating, in elite athletic training; and studies with a dietary or pharmaceutical intervention component.

Results

Twenty-nine data sets (mmol/L) of 823 participants were pooled and analysed. Neither HIIT nor MICT was better in decreasing TC (0.10 (−0.06 to 0.19), p=0.12, I²=0%), TRG (−0.05 (−0.11 to 0.01), p=0.10, I²=0%), LDL-C (0.05 (−0.06 to 0.17), p=0.37, I²=0%), or TC/HDL-C (−0.03 (−0.36 to 0.29), p=0.85, I²=0%). HIIT significantly raised HDL-C (0.07 (0.04 to 0.11), p<0.0001, I²=0%) compared with MICT.

Conclusion

Neither HIIT nor MICT is superior for altering TC, TRG, or LDL-C, or TC-HDL-C ratio. Compared with MICT, HIIT appeared to significantly improve HDL-C. Clinicians may prescribe either protocol to encourage participation in exercise and reduce cardiovascular risk. To raise HDL-C, HIIT may result in a larger effect size compared with MICT.

PROSPERO registration number

CRD42019136722.

Long-Term Evolutionary Change in the Lumen of Intracranial Atherosclerotic Stenosis Following Angioplasty and Stenting

BACKGROUND

Angioplasty and stenting is a recognized treatment option for patients with intracranial atherosclerosis.

OBJECTIVE

To evaluate the long-term evolutionary luminal changes of intracranial atherosclerosis after angioplasty and stenting.

METHODS

This was a retrospective study with patient consent. Eighty-two patients presenting with acute and minor cerebral ischemia due to stenosis ≥70%, who had received medical therapy with or without stenting (Wingspan), were invited. Luminal imaging was provided using 3-dimensional rotational angiography (3-DRA) at baseline and 12 mo, and cone-beam computed tomography angiography with intravenous contrast (CBCT) was provided at follow-up (median 82.4 mo [interquartile range 61.9-96.9 mo]).

RESULTS

Thirty-six patients in the stenting group and 26 patients in the medical group were recruited and completed the study. There was no statistically significant difference in demographics between the 2 patient groups. The luminal gain at 12 or 80 mo as compared to baseline in the stenting group was significantly greater than that in the medical group (12 mo: median gain 30% vs 7.2%, P < .001; 80 mo: median gain 42.9% vs 7.2%, P < .0001). Luminal loss or unchanged lumen was correlated with recurrent ischemic event. The differences in the stenosis degree assessment between CBCT and 3-DRA in the same 10 patients with or without stenting were 1.2 ± 0.6% or 0.2 ± 0.06%, respectively. There was a correlation between recurrent ischemic events and luminal loss.

CONCLUSION

Arterial lumen after angioplasty and stenting can probably be well maintained and delayed luminal gain does occur, long-term luminal loss is associated with recurrent ischemic events, CBCT might be useful as a less-invasive means for long-term assessment.

The Effects of the Korean Medicine Health Care Program on Stroke-Related Factors and Self-Care Enhancement

Objectives

This study was performed to examine the effects of the Korean medicine healthcare program on stroke-related factors and self-care enhancement.

Methods

This study was a quasi-experimental, pretest-posttest nonequivalent control group design study (N = 58 participants), with 28 in the treatment group (Korean medicine health care program) and 30 in the control group (no intervention). The program was conducted twice a week for 2 hours, for a total of 12 weeks.

Results

There were statistically significant differences in systolic (p = 0.005) and diastolic blood pressure (p = 0.006), cholesterol (p < 0.001), blood glucose (p < 0.001), self-esteem (p = 0.001), self-efficacy (p < 0.001), health perception (p < 0.001), and the health behavior (p < 0.001) between the experimental group and the control group.

Conclusion

Thus, the Korean medicine healthcare program was effective in managing stroke-related factors and enhancing self-care, and should be actively used to develop community health promotion strategies to prevent strokes and prepare long-term measures.

Genetic variants of ADAMTS7 confer risk for ischaemic stroke in the Chinese population

Large-scale genome-wide association analyses show an association between ADAMTS7 variations and coronary risk. However, the link between ADAMTS7 variability and ischaemic stroke (IS) has yet to be determined. This study evaluated ADAMTS7 variants with respect to the risk of IS. Genetic association analyses were performed in two independent case-control cohorts with 1279 patients with IS and 1268 age-matched healthy controls. Four variant genotypes of the ADAMTS7 gene were identified using the Multiplex SNaPshot assay. The rs3825807, rs11634042, and rs7173743 variants of ADAMTS7 were related to lower IS risk in both initial and replication cohort. The G-T-T-C and G-T-C-C haplotypes are significantly less prevalent in the IS group than in the control group. Further stratification according to IS subtypes indicated that carriers with the variant alleles of the rs3825807, rs11634042 and rs7173743 variants of ADAMTS7conferred a lower risk of developing large-artery atherosclerosis stroke subtype. Also, the mutated rs3825807 G allele, as well as the mutated rs11634042 T allele of ADAMTS7, are linked to a significant reduction of ADAMTS7 in patients with IS. Our findings confirm the role of ADAMTS7 in the pathophysiology of IS, with potentially significant implications for the prevention, treatment, and development of novel therapies for IS.

Inhibition of T cell immunoglobulin and mucin-1 (TIM-1) protects against cerebral ischemia-reperfusion injury

Background

The T cell Ig domain and mucin domain (TIM)-1 protein expressed on the surface of Th2 cells regulates the immune response by modulating cytokine production. The present study aimed to investigate the role and possible mechanism of TIM-1 in cerebral ischemia-reperfusion injury.

Methods

Western blot was used to detect TIM-1 and apoptosis-related protein expression, whereas TIM-1 mRNA was examined using quantitative real-time reverse transcription PCR. Flow cytometry and a TdT-mediated biotin-16-dUTP nick-end labeling (TUNEL) assay were used to detect the percentage of apoptotic cells and a pathological examination was performed. The migration of neutrophils and macrophages was analyzed by immunohistochemistry.

Results

Our results suggest that TIM-1 expression was transiently increased 24 h or 48 h following middle cerebral artery occlusion (MCAO)/reperfusion. The infarct size was markedly increased in MCAO, whereas treatment with a TIM-1-blocking mAb could reduce the infarct size. TIM-1 blocking mAb effectively reduced the number of neutrophils, macrophage functionality, cytokine (i.e., IL-6, IL-1β, and TNF-α) and chemokine (i.e., CXCL-1 and CXCL-2) production in the brain tissue. The effect of in vitro T cell damage on neurons was significantly reduced following treatment with a TIM-1 blocking mAb or the knockdown of TIM-1 in co-cultured T cells and neurons.

Conclusion

Take together, these results indicated that TIM-1 blockade ameliorated cerebral ischemia-reperfusion injury. Thus, TIM-1 disruption may serve as a novel target for therapy following MCAO.

Body Fat Mass and Risk of Cerebrovascular Lesions: The PRESENT (Prevention of Stroke and Dementia) Project

Obesity is known to increase the risk of stroke. It is unclear whether high absolute fat mass (FM) increases the risk of stroke independently. We studied the correlation between FM and silent brain infarction/white matter change (SI/WMC) using brain computed tomography. We selected subjects from the local government health promotion project. We randomly selected a target population that had never been diagnosed with stroke or dementia. FM was measured by bioelectrical impedance analysis (BIA). We divided the subjects into three groups according to the FM (gender-specific tertiles [GTx]). Seven hundred and twenty-two subjects (321 men) between 50 and 75 years of age were recruited. The overall odds ratio (OR) of SI/WMC was 2.23 (95% confidence interval (CI), 1.34-3.71; p = 0.002) times higher in the 37th to 100th percentiles (GT3) than in the first to 32nd percentiles (GT1). When men and women were separated, the OR of GT3 was 1.35 (CI, 0.62-2.94; p = 0.45) in men and 3.2 (CI, 1.60-6.40; p = 0.001) in women. The findings were not found to be statistically significant after adjusting for the well-known stroke risk factors. When the subjects were divided into a high FM (HFMG, GT3) and low FM group (LFMG, GT1 + GT2), the HFMG showed an increased OR of SI/WMC in women. Similar results were seen after adjusted (overall: OR, 1.38; CI, 0.85-2.25, p = 0.198; men: OR, 0.93; CI, 0.422-2.051; p = 0.86; women: OR, 2.02; CI, 1.06-3.86; p = 0.03). The findings suggest that high FM may be an independent risk factor for ischemic stroke among adults free from stroke and dementia, especially in women.

Noninvasive optical assessment of resting-state cerebral blood flow in children with sickle cell disease

Sickle cell disease (SCD) is a genetic blood disorder that has profound effects on the brain. Chronic anemia combined with both macro- and microvascular perfusion abnormalities that arise from stenosis or occlusion of blood vessels increased blood viscosity, adherence of red blood cells to the vascular endothelium, and impaired autoregulatory mechanisms in SCD patients all culminate in susceptibility to cerebral infarction. Indeed, the risk of stroke is 250 times higher in children with SCD than in the general population. Unfortunately, while transcranial Doppler ultrasound (TCD) has been widely clinically adopted to longitudinally monitor macrovascular perfusion in these patients, routine clinical screening of microvascular perfusion abnormalities is challenging with current modalities (e.g., positron emission tomography and magnetic resonance imaging) given their high-cost, requirement for sedation in children < 6 year, and need for trained personnel. We assess the feasibility of a low-cost, noninvasive optical technique known as diffuse correlation spectroscopy (DCS) to quantify an index of resting-state cortical cerebral blood flow (BFI) in 11 children with SCD along with 11 sex- and age-matched healthy controls. As expected, BFI was significantly higher in SCD subjects compared to healthy controls ( p < 0.001 ). Within SCD subjects, BFI was inversely proportional to resting-state arterial hemoglobin levels ( p = 0.012 ), consistent with expected anemia-induced compensatory vasodilation that aims to maintain adequate oxygen delivery to the tissue. Further, in a subset of patients measured with TCD ( n = 7 ), DCS-measured blood flow was correlated with TCD-measured blood flow velocity in middle cerebral artery ( R s = 0.68 ), although the trend was not statistically significant ( p = 0.11 ). These results are consistent with those of several previous studies using traditional neuroimaging techniques, suggesting that DCS may be a promising low-cost tool for assessment of tissue-level CBF in pediatric SCD.

Potential Neuroprotective Effect of miR-451 Against Cerebral Ischemia/Reperfusion Injury in Stroke Patients and a Mouse Model

OBJECTIVE

Recently, microRNAs (miRs) have been reported to be novel regulators in ischemic stroke. In this study, we investigated the pattern of miR-451 expression along with its clinical application in human ischemic stroke and in an in vivo mouse model.

METHODS

The level of miR-451 was evaluated in patients and mice after ischemic stroke. National Institute of Health Stroke Scale scores and brain infarct volume were analyzed to the correlation of miR-451 expression and clinical information. In addition, blood samples and brain tissues were collected from an established middle cerebral artery occlusion model consisting of 12 adult male mice at 24 hours after the middle cerebral artery occlusion.

RESULTS

The results showed that miR-451 levels in the circulating blood of ischemic stroke patients were greatly decreased compared with the control. Further correlation analysis revealed a negative association between miR-451 and National Institute of Health Stroke Scale scores (r = -0.6104, P < 0.001) and infarct volume (r = -0.5442, P < 0.001). Moreover, miR-451 was down-regulated in response to middle cerebral artery occlusion in vivo, along with a negative correlation between miR-451 in brain and blood (r = 0.9240, P < 0.01). In addition, forced expression of miR-451 weakened ischemic brain infarction and apoptosis levels in focal ischemia-stroked mice, while downregulation of miR-451 significantly augmented ischemic injury.

CONCLUSIONS

In conclusion, miR-451 displays the neuroprotective effect in ischemic stroke and might serve as a novel therapeutic target of ischemic stroke.

MicroRNA target gene prediction of ischemic stroke by using variational Bayesian inference for Gauss mixture model

MicroRNAs (miRNAs) as biomarkers of numerous diseases, are a novel group of single-stranded, non-coding small RNA molecules, which can regulate the gene expression and transcription or translation of target genes. Therefore, accurately identifying miRNAs and predicting their potential target genes correlated with ischemic stroke contribute to quick understanding and diagnosis of the pathogenesis of ischemic stroke. In order to identify the targets of miRNAs, the differential expression and expression profiling of mRNAs in genome are integrated by using the Gene Expression Omnibus (GEO) database and limma package. Furthermore, the probabilistic scoring approach called TargetScore, is proposed as a promising new technique combined with the expression and sequence information of the known genes. In this study, the priori and posterior probabilities of target genes were obtained by Variational Bayesian-Gaussian Mixture Model (VB-GMM). Consequently, the target genes of miR-124, miR-221 and miR-223, correlated with ischemic stroke, were predicted using the new target prediction algorithm. Ultimately, the comparable downregulation target genes were obtained by integrating the transcendental and posterior values.

Associations of multiple plasma metals with the risk of ischemic stroke: A case-control study

BACKGROUND

Ischemic stroke (IS) is a major cause of morbidity and mortality globally. Environmental exposure to metals may be linked to the risk of IS, but the association remains uncertain in Chinese populations.

OBJECTIVES

The present study aimed to examine the associations between the concentrations of 11 metals (aluminum, arsenic, cadmium, cobalt, copper, iron, manganese, molybdenum, selenium, thallium, and zinc) in plasma and the risk of IS in a Chinese population.

METHODS

A total of 1277 pairs of newly diagnosed IS patients and controls matched on age (±3 years) and sex were recruited in our study. Plasma metal concentrations were measured using inductively coupled plasma mass spectrometry. Multivariable conditional logistic regression models were conducted to investigate the impacts of single and multiple metals, respectively.

RESULTS

In the single-metal model, exposure to seven metals (aluminum, arsenic, cadmium, cobalt, iron, manganese and selenium) was individually associated with the risk of IS based on the trend test. Further stepwise regression analyses with the multiple-metal model revealed increasing trends in the risk of IS associated with aluminum, arsenic, and cadmium quartiles and decreasing trends with iron and selenium quartiles (p-trend < 0.01). Compared to the lowest quartiles, the odds ratios (95% confidence intervals) for the highest quartiles of these five metals were 4.23 (2.63, 6.79), 1.88 (1.25, 2.81), 5.02 (3.30, 7.63), 0.59 (0.40, 0.89), and 0.10 (0.06, 0.17), respectively.

CONCLUSIONS

Our study suggested that higher plasma concentrations of aluminum, arsenic, and cadmium, and lower concentrations of iron and selenium may increase the risk of IS. Further prospective studies in larger populations are warranted to confirm our findings.

Bone marrow-derived mesenchymal stem cells-derived exosomes prevent oligodendrocyte apoptosis through exosomal miR-134 by targeting caspase-8

Ischemic stroke causes severe brain damage and remains one of the leading causes of morbidity and mortality worldwide. The microRNA-134 (miR-134) is involved in regulating the process of ischemia injury in neural cells and brain with ischemia stroke. The role of miR-134 in ischemic stroke remains poorly understood. The purpose of the current study was to investigate the effect of bone marrow-derived mesenchymal stem cells (BMSCs)-derived exosomal miR-134 on rat oligodendrocytes (OLs) apoptosis and its underlying mechanism of action. The results demonstrated that levels of miR-134 in BMSCs-exosome decreased but increased incaspase-8 after oxygen-glucose deprivation (OGD) treatment. Exosomal miR-134 significantly inhibited apoptosis by decreasing caspase-8 expression and activity in OGD-treated group cultured with BMSCs-exosome and OLs. In addition, the miR-134 mimics decreased caspase-8 expression in OGD-treated OLs, whereas miR-134 inhibitors exacerbated the changes in the expression of the procaspase-8 and caspase-8 cleaved product proteins caused by OGD. The caspase-8 knockdown using caspase-8 small interfering RNA decreased OLs apoptosis, reversing the improvements that the miR-134 inhibited cells apoptosis by targeting caspase-8. Taken together, these results demonstrated that BMSCs-derived exosomes suppressed OLs apoptosis through exosomal miR-134 by negatively regulating the caspase-8-dependent apoptosis pathway and may, therefore, be a novel potential therapeutic target for ischemic stroke treatment.

Dissecting the role of miR-21 in different types of stroke

Stroke is an important neurological disease in which blood flow to the brain is interrupted and it is becoming an increasing non-communicable disease in developing countries. Current treatment options for stroke is modifying lifestyle practice, diabetes treatment, drugs, and other factors management, but yet no cure is available in sight for the disease, despite it requires new insight into the molecular and therapeutic targets. In general, MicroRNAs (miRNAs) are small noncoding RNAs considered as of greater biological importance and controls molecular signaling pathways in diabetic pathogenesis. Among the reported MiRNAs, MIR-21 is considered to be an important MiRNA, which is frequently elevated in many types of types of strokes, suggesting that it plays an important role in cell proliferation, and apoptosis. Until now, there is no research paper that signifying the role of miR-21 in all types of strokes and the number of studies on the different category of strokes is limited, so in this paper, we are highlighting the recent investigations related to the significance of miR-21 in different types of strokes based on the up-to-date reports. It was found that MiR-21 was found to be normally up and down regulated in all types of strokes, however; we summarize the important research findings related to the role of miR-21 in different types of strokes.

Stroke Longitudinal Volumetric Measures Correlate with the Behavioral Score in Non-Human Primates

Stroke is the second leading cause of death worldwide. Brain imaging data from experimental rodent stroke models suggest that size and location of the ischemic lesion relate to behavioral outcome. However, such a relationship between these two variables has not been established in Non-Human Primate (NHP) models. Thus, we aimed to evaluate whether size, location, and severity of stroke following controlled Middle Cerebral Artery Occlusion (MCAO) in NHP model correlated to neurological outcome. Forty cynomolgus macaques underwent MCAO, after four mortalities, thirty-six subjects were followed up during the longitudinal study. Structural T2 scans were obtained by magnetic resonance imaging (MRI) prior to, 48 h, and 30 days post-MCAO. Neurological function was assessed with the Non-human Primate Stroke Scale (NHPSS). T2 whole lesion volume was calculated per subject. At chronic stages, remaining brain volume was computed, and the affected hemisphere parceled into 50 regions of interest (ROIs). Whole and parceled volumetric measures were analyzed in relation to the NHPSS score. The longitudinal lesion volume evaluation showed a positive correlation with the NHPSS score, whereas the remaining brain volume negatively correlated with the NHPSS. Following ROI parcellation, NHPSS outcome correlated with frontal, temporal, occipital, and middle white matter, as well as the internal capsule, and the superior temporal and middle temporal gyri, and the caudate nucleus. These results represent an important step in stroke translational research by demonstrating close similarities between the NHP stroke model and the clinical characteristics following a human stroke and illustrating significant areas that could represent targets for novel neuroprotective strategies.

Current advances in ischemic stroke research and therapies

With more than 795,000 cases occurring every year, stroke has become a major problem in the United States across all demographics. Stroke is the leading cause of long-term disability and is the fifth leading cause of death in the US. Ischemic stroke represents 87% of total strokes in the US, and is currently the main focus of stroke research. This literature review examines the risk factors associated with ischemic stroke, changes in cell morphology and signaling in the brain after stroke, and the advantages and disadvantages of in vivo and in vitro ischemic stroke models. Classification systems for stroke etiology are also discussed briefly, as well as current ischemic stroke therapies and new therapeutic strategies that focus on the potential of stem cells to promote stroke recovery.

Trajectories of imaging markers in brain aging: the Rotterdam Study

With aging, the brain undergoes several structural changes. These changes reflect the normal aging process and are therefore not necessarily pathologic. In fact, better understanding of these normal changes is an important cornerstone to also disentangle pathologic changes. Several studies have investigated normal brain aging, both cross-sectional and longitudinal, and focused on a broad range of magnetic resonance imaging (MRI) markers. This study aims to comprise the different aspects in brain aging, by performing a comprehensive longitudinal assessment of brain aging, providing trajectories of volumetric (global and lobar; subcortical and cortical), microstructural, and focal (presence of microbleeds, lacunar or cortical infarcts) brain imaging markers in aging and the sequence in which these markers change in aging. Trajectories were calculated on 10,755 MRI scans that were acquired between 2005 and 2016 among 5286 persons aged 45 years and older from the population-based Rotterdam Study. The average number of MRI scans per participant was 2 scans (ranging from 1 to 4 scans), with a mean interval between MRI scans of 3.3 years (ranging from 0.2 to 9.5 years) and an average follow-up time of 5.2 years (ranging from 0.3 to 9.8 years). We found that trajectories of the different volumetric, microstructural, and focal markers show nonlinear curves, with accelerating change with advancing age. We found earlier acceleration of change in global and lobar volumetric and microstructural markers in men compared with women. For subcortical and cortical volumes, results show a mix of more linear and nonlinear trajectories, either increasing, decreasing, or stable over age for the subcortical and cortical volume and thickness. Differences between men and women are visible in several parcellations; however, the direction of these differences is mixed. The presence of focal markers show a nonlinear increase with age, with men having a higher probability for cortical or lacunar infarcts. The data presented in this study provide insight into the normal aging process in the brain, and its variability.