Cerebrovascular risk factors and stroke subtypes: differences between ethnic groups

Incidence and risk of stroke in Korean patients with congenital heart disease

OBJECTIVES

The incidence and risk of ischemic stroke (IS) and hemorrhagic stroke (HS) in Korean patients with CHD have not been reported, therefore, we aimed to investigate this.

MATERIALS AND METHODS

Participants were selected from the Korean National Health Insurance Service benefit records from 2006-2017. Cases were extracted using diagnosis codes related to CHD. Controls without CHD were selected through age- and sex-matched random sampling at a 1:10 ratio.

RESULTS

The case and control groups included 232,203 and 3,024,633 participants, respectively. The median (interquartile range) follow-up period was 7.28 (3.59-8.73) years. The incidence rates of IS and HS per 100,000 person-years were much higher in cases than in controls (IS: 135 vs. 47; HS: 41.7 vs. 24.9). After adjusting for confounders, CHD was a risk factor for IS and HS (subdistribution HR; 1.96 and 1.71, respectively). In patients with CHD, the following risk factors were identified: diabetes, heart failure, and atrial fibrillation for any stroke; hypertension, atrial septal defects, and use of antiplatelet agents for IS only; and coronary artery bypass graft surgery for HS only.

CONCLUSIONS

Korean patients with CHD have a high risk of stroke. A personalized preventive approach is needed to reduce the incidence of stroke in this population.

Hypertensive disorders of pregnancy and long-term risk of maternal stroke-a systematic review and meta-analysis

OBJECTIVE

Hypertensive disorders of pregnancy are associated with a long-term risk for cardiovascular disease among parous patients later in life. However, relatively little is known about whether hypertensive disorders of pregnancy are associated with an increased risk for ischemic stroke or hemorrhagic stroke in later life. This systematic review aimed to synthesize the available literature on the association between hypertensive disorders of pregnancy and the long-term risk for maternal stroke.

DATA SOURCES

PubMed, Web of Science, and CINAHL were searched from inception to December 19, 2022.

STUDY ELIGIBILITY CRITERIA

Studies were only included if the following criteria were met: case-control or cohort studies that were conducted with human participants, were available in English, and that measured the exposure of a history of hypertensive disorders of pregnancy (preeclampsia, gestational hypertension, chronic hypertension, or superimposed preeclampsia) and the outcome of maternal ischemic stroke or hemorrhagic stroke.

METHODS

Three reviewers extracted the data and appraised the study quality following the Meta-analyses of Observational Studies in Epidemiology guidelines and using the Newcastle-Ottawa scale for risk of bias assessment.

RESULTS

The primary outcome was any stroke (undifferentiated) and secondary outcomes included ischemic stroke and hemorrhagic stroke. The protocol for this systematic review was registered in the International Prospective Register of Systematic Reviews under identifier CRD42021254660. Of 24 studies included (10,632,808 study participants), 8 studies examined more than 1 outcome of interest. Hypertensive disorders of pregnancy were significantly associated with any stroke (adjusted risk ratio, 1.74; 95% confidence interval, 1.45-2.10). Preeclampsia was significantly associated with any stroke (adjusted risk ratio, 1.75; 95% confidence interval, 1.56-1.97), ischemic stroke (adjusted risk ratio, 1.74; 95% confidence interval, 1.46-2.06), and hemorrhagic stroke (adjusted risk ratio, 2.77; 95% confidence interval, 2.04-3.75). Gestational hypertension was significantly associated with any stroke (adjusted risk ratio, 1.23; 95% confidence interval, 1.20-1.26), ischemic stroke (adjusted risk ratio, 1.35; 95% confidence interval, 1.19-1.53), and hemorrhagic stroke (adjusted risk ratio, 2.66; 95% confidence interval, 1.02-6.98). Chronic hypertension was associated with ischemic stroke (adjusted risk ratio, 1.49; 95% confidence interval, 1.01-2.19).

CONCLUSION

In this meta-analysis, exposure to hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension, seems to be associated with an increased risk for any stroke and ischemic stroke among parous patients in later life. Preventive interventions may be warranted for patients who experience hypertensive disorders of pregnancy to reduce their long-term risk for stroke.

Integration of Mendelian randomisation and systems biology models to identify novel blood-based biomarkers for stroke

Stroke is the second largest cause of mortality in the world. Genome-wide association studies (GWAS) have identified some genetic variants associated with stroke risk, but their putative functional causal genes are unknown. Hence, we aimed to identify putative functional causal gene biomarkers of stroke risk. We used a summary-based Mendelian randomisation (SMR) approach to identify the pleiotropic associations of genetically regulated traits (i.e., gene expression and DNA methylation) with stroke risk. Using SMR approach, we integrated cis-expression quantitative loci (cis-eQTLs) and cis-methylation quantitative loci (cis-mQTLs) data with GWAS summary statistics of stroke. We also utilised heterogeneity in dependent instruments (HEIDI) test to distinguish pleiotropy from linkage from the observed associations identified through SMR analysis. Our integrative SMR analyses and HEIDI test revealed 45 candidate biomarker genes (FDR < 0.05; P_HEIDI>0.01) that were pleiotropically or potentially causally associated with stroke risk. Of those candidate biomarker genes, 10 genes (HTRA1, PMF1, FBN2, C9orf84, COL4A1, BAG4, NEK6, SH2B3, SH3PXD2A, ACAD10) were differentially expressed in genome-wide blood transcriptomics data from stroke and healthy individuals (FDR<0.05). Functional enrichment analysis of the identified candidate biomarker genes revealed gene ontologies and pathways involved in stroke, including "cell aging", "metal ion binding" and "oxidative damage". Based on the evidence of genetically regulated expression of genes through SMR and directly measured expression of genes in blood, our integrative analysis suggests ten genes as blood biomarkers of stroke risk. Furthermore, our study provides a better understanding of the influence of DNA methylation on the expression of genes linked to stroke risk.

Assessment of Atherosclerosis in Ischemic Stroke by means of Ultrasound of Extracranial/Intracranial Circulation and Serum, Urine, and Tissue Biomarkers

It is a common practice to take into consideration age, diabetes, smoking, treated and untreated systolic blood pressure, total cholesterol, and high-density lipoprotein cholesterol for the prediction of atherosclerosis and stroke. There are, however, ultrasound markers in use for the assessment of atherosclerosis and the evaluation of stroke risk. Two areas of investigation are of interest: the carotid artery and the intracranial arterial circulation. Again, within the domain of the carotid artery, two ultrasonic markers have attracted our attention: intima media thickness of the carotid artery and the presence of carotid plaque with its various focal characteristics. In the domain of intracranial circulation, the presence of arterial stenosis and the recruitment of collaterals are considered significant ultrasonic markers for the above-mentioned purpose. On the other hand, a series of serum, urine, and tissue biomarkers are found to be related to atherosclerotic disease. Future studies might address the issue of whether the addition of proven ultrasonic carotid indices to the aforementioned serum, urine, and tissue biomarkers could provide the vascular specialist with a better assessment of the atherosclerotic load and solidify their position as surrogate markers for the evaluation of atherosclerosis and stroke risk.

Diabetes is not protective against the formation of unruptured cerebral aneurysm

OBJECTIVES

Diabetes appears to decrease the risk of subarachnoid hemorrhage. However, it is not clear whether diabetes decreases the risk of aneurysm formation. The aim of our study to evaluate the risk of unruptured cerebral aneurysm in patients with diabetes mellitus.

METHODS

We used data from participants who underwent brain magnetic resonance angiography (MRA) and laboratory tests at the Healthcare System Gangnam Center of Seoul National University Hospital between January 2010 and December 2013. From the 17,368 participants who underwent brain MRA, we analyzed 16,337 subjects whose diabetes status could be identified.

RESULTS

The number of participants with diabetes was 2299 (14.1%). The proportion of participants with cerebral aneurysms was 2.3% in the diabetic group and 2.7% in the non-diabetic group, which was not significantly different (P = 0.225). There were no significant differences in the size, location, and multiplicity of aneurysms between the diabetes and control groups. In multivariate logistic regression, older age showed significant risk effects on cerebral aneurysms, but female sex, hypertension, diabetes, obesity, and smoking did not show significant risk effects.

CONCLUSION

In this study, diabetes did not affect the risk of cerebral aneurysm formation. In addition, neither smoking, nor hypertension was a significant risk factor for unruptured cerebral aneurysms. The lack of association between cerebral aneurysm and the traditional risk factors for subarachnoid hemorrhage requires further study. Risk factors for cerebral aneurysm development and those for cerebral aneurysm rupture may be different.

Characteristics and Risk Factors Associated with Stroke Subtypes among Adult Patients Admitted to the Stroke Unit of Jimma University Medical Center: A Retrospective Cross-sectional Study

BACKGROUND

Almost 80% of deaths due to non-communicable diseases occur in lowand middle-income countries. Stroke is a great public health problem in Ethiopia. Stroke mortality was estimated to be 14.7% in Ethiopia. Despite this, researches done in Ethiopia on factors associated with stroke sub-types were inadequate.

OBJECTIVE

To assess the characteristics and risk factors associated with stroke subtypes among patients admitted to Jimma University Medical Center.

MATERIALS AND METHODS

A retrospective cross-sectional study was conducted from May 2017 to May 2018 in the stroke unit of the Jimma University Medical Center. A total of 106 medical charts of patients diagnosed with stroke were reviewed. A checklist comprising relevant variables was used to collect data. SPSS version 21 was employed for data entry and analysis. Pearson chi-square test was used to check the association of different parameters with stroke subtypes. A P-value <0.05 was used as a cutoff point to declare statistical significance. Data were presented using text, tables, and figures.

RESULTS

From a total of 106 patients, 67 (63.2%) were men. The mean ± SD of age was 52.67±12.46 Year's, and the difference was not significant among stroke subtypes. Among all patients, 59 (55.6%) had ischemic strokes and 47 (44.4%) had hemorrhagic strokes. The most prevalent risk factors significantly associated with stroke subtypes were being male 67 (63.2%) followed by dyslipidemia 43 (40.5%) and cigarette smoking 38 (35.8%).

CONCLUSION

The ischemic stroke was reported to be higher than hemorrhagic in this study. The overall mean (±SD) age of the patient was 52.67±(12.46) years. The mean age of hemorrhagic stroke patients was 55.98 (±13.77) years; while in ischemic stroke was 50.03 (±10.70) years. Being male, a history of cigarette smoking, and dyslipidemia were significantly associated with stroke subtypes.

Heterogeneity among women with stroke: health, demographic and healthcare utilization differentials

BACKGROUND

Although age specific stroke rates are higher in men, women have a higher lifetime risk and are more likely to die from a stroke. Despite this increased severity, most studies focus on male/female differences in stroke onset, patterns of care and stroke-related outcomes. Given that stroke presents differently in men and women, mixed sex studies fail to fully capture heterogeneity among women with stroke and the subsequent impact on their outcomes. This study examined the sociodemographic characteristics, factors related to stroke incidence and post-stroke functional status between young (< 60) and old (≥ 60) women with stroke.

METHODS

Using 5 years of data from the National Health Interview Survey (NHIS), a nationally representative sample of US adults, cohorts of young and old women with stroke were identified. A set of demographic/lifestyle, health services utilization and health status characteristics were used evaluate within gender heterogeneity in three ways. First, disparities in population characteristics were assessed using Chi-Square and t tests. Second, young and old women with stroke were matched with women without stroke in their respective cohorts to determine differences in factors related to stroke incidence. Finally, the determinants of post-stroke functional limitation for the two cohorts were determined.

RESULTS

Young women with stroke were more likely to be Black, smoke regularly and frequently consume alcohol than older women. Young women were also less likely to engage with their health provider regularly or receive preventative health screenings. Diabetes, high blood pressure, high cholesterol and high BMI were correlated with an increased relative likelihood of stroke among older women. In contrast, family size, smoking frequency, alcohol consumption and sleep were correlated with an increased prevalence of stroke among young women. Although factors correlated with stroke varied between young and old women, health status and receipt of healthcare were the most significant determinants of post-stroke functional status for both cohorts.

CONCLUSIONS

Health related characteristics were the primary correlates of stroke in older women, whereas post-stroke lifestyle and behaviors are the most significant correlates for younger stroke survivors. These findings suggest that while receipt of health services is essential for preventing stroke in both young and old women, providers should stress the importance of post-stoke lifestyle and behaviors to younger women at risk of stroke using approaches that may be different from older stroke women.

Diffuse optical assessment of cerebral-autoregulation in older adults stratified by cerebrovascular risk

Diagnosis of cerebrovascular disease (CVD) at early stages is essential for preventing sequential complications. CVD is often associated with abnormal cerebral microvasculature, which may impact cerebral-autoregulation (CA). A novel hybrid near-infrared diffuse optical instrument and a finger plethysmograph were used to simultaneously detect low-frequency oscillations (LFOs) of cerebral blood flow (CBF), oxy-hemoglobin concentration ([HbO₂ ]), deoxy-hemoglobin concentration ([Hb]) and mean arterial pressure (MAP) in older adults before, during and after 70° head-up-tilting (HUT). The participants with valid data were divided based on Framingham risk score (FRS, 1-30 points) into low-risk (FRS ≤15, n = 13) and high-risk (FRS >15, n = 11) groups for developing CVD. The LFO gains were determined by transfer function analyses with MAP as the input, and CBF, [HbO₂ ] and [Hb] as the outputs (CA ∝ 1/Gain). At resting-baseline, LFO gains in the high-risk group were relatively lower compared to the low-risk group. The lower baseline gains in the high-risk group may attribute to compensatory mechanisms to maintain stronger steady-state CAs. However, HUT resulted in smaller gain reductions in the high-risk group compared to the low-risk group, suggesting weaker dynamic CAs. LFO gains are potentially valuable biomarkers for early detection of CVD based on associations with CAs.

Genome-Wide Association Study Meta-Analysis of Stroke in 22 000 Individuals of African Descent Identifies Novel Associations With Stroke

BACKGROUND AND PURPOSE

Stroke is a complex disease with multiple genetic and environmental risk factors. Blacks endure a nearly 2-fold greater risk of stroke and are 2× to 3× more likely to die from stroke than European Americans.

METHODS

The COMPASS (Consortium of Minority Population Genome-Wide Association Studies of Stroke) has conducted a genome-wide association meta-analysis of stroke in >22 000 individuals of African ancestry (3734 cases, 18 317 controls) from 13 cohorts.

RESULTS

In meta-analyses, we identified one single nucleotide polymorphism (rs55931441) near the HNF1A gene that reached genome-wide significance (P=4.62×10-8) and an additional 29 variants with suggestive evidence of association (P<1×10-6), representing 24 unique loci. For validation, a look-up analysis for a 100 kb region flanking the COMPASS single nucleotide polymorphism was performed in SiGN (Stroke Genetics Network) Europeans, SiGN Hispanics, and METASTROKE (Europeans). Using a stringent Bonferroni correction P value of 2.08×10-3 (0.05/24 unique loci), we were able to validate associations at the HNF1A locus in both SiGN (P=8.18×10-4) and METASTROKE (P=1.72×10-3) European populations. Overall, 16 of 24 loci showed evidence for validation across multiple populations. Previous studies have reported associations between variants in the HNF1A gene and lipids, C-reactive protein, and risk of coronary artery disease and stroke. Suggestive associations with variants in the SFXN4 and TMEM108 genes represent potential novel ischemic stroke loci.

CONCLUSIONS

These findings represent the most thorough investigation of genetic determinants of stroke in individuals of African descent, to date.

Effectiveness of behaviour change techniques on lifestyle interventions of patients with a high risk of developing cardiovascular disease. Using a qualitative approach

This study aimed to identify key active ingredients on the maintenance of behaviour change for lifestyle interventions of patients with a high risk of developing cardiovascular disease (CVD) who participated in a MOtiVational intErviewing InTervention (MOVE IT) randomised control trial (RCT). A process evaluation was carried out using focus groups. Twenty-six participants of the MOVE IT RCT were purposively recruited and split into six focus groups. Four groups had attended six or more sessions of the intensive phase (completers) and two groups had withdrawn before the end of the intensive phase or had not attended any sessions (non-completers). Focus groups were audio recorded, transcribed verbatim and analysed inductively using thematic analysis. Three overall themes were generated from the six focus groups: (a) long-term benefits from diet and physical activity education, (b) group versus individual structure and adherence and (c) impact on health beliefs and risk of CVD. A fourth theme was generated from the two groups of non-completers only: (d) need for professional rapport building and feedback. We found that the key active ingredients for effective behavioural change in lifestyle interventions are having well-developed rapport between facilitators and patients; and providing alternative forms of feedback to encourage maintenance of behaviour change. Furthermore, such programmes also need to have established and strong relationships with associated health professionals (i.e. the General Practitioner) to increase participation and maintenance of engagement.

Temporal trend analysis of stroke and salt intake: a 15-year population-based study

Objectives: The aim of this study was to evaluate temporal trends of salt intake with stroke incidence, stroke subtypes, and blood pressure in an adult population.Methods: Data were extracted from Isfahan Salt Study. The stroke incidence rate, average salt intake, systolic and diastolic blood pressure in adults, aged over 18 years were considered from 2000 to 2014. The Average Annual Percent Changes (AAPC), parallelism, and the coincidence of trends were estimated, using a permutation test.Results: The trend of salt intake was increased from 2010 to 2014 (AAPC = +1.59, P-value = 0.004). The trend of the stroke incidence rate was nonlinear with two change points in 2003 and 2009. The overall stroke incidence rate increased by 6.65% per year (95% CI: 1.66, 11.8, P-value = 0.015). The temporal trend changes of stroke incidence rate were steeper in patients who aged 40-45 and over 50 years (+6 to +11.5%) than in patients who aged 19-40 and 45-50 (range: -3.3% to 0). The parallelism hypothesis of longitudinal changes between salt intake and ischemic stroke was accepted in patients, aged <50 years (P-value = 0.871).Conclusions: The average salt intake and its cone-shaped variance over 15 years of the study, indicated that salt intake reduction programs and policies were effective to stop associating intake increase until 2007, however, associated intake was increased since that time, which necessitates performing preventive programs. More importantly, the trend of salt intake and ischemic stroke was similar in patients who aged <50 years, regardless of considering their blood pressure.

Extended Risk Factors for Stroke Prevention

Stroke causes disability and high mortality, while it can be prevented by increasing public awareness of risk factors. The common known risk factors are hypertension, atrial fibrillation, heart failure, smoking, alcohol consumption, low physical activity, overweight and hypercholesterolemia. However, the deep understanding of risk factors is limited. Moreover, more risk factor emerges in recent years. To further increase the awareness of risk factors for stroke prevention, this review indicates the reasonable application of antihypertensive agents according to the age-dependent changes of hypertension, and some new risk factors including chronic kidney disease, obstructive sleep apnea, migraine with aura, working environment, genetic factors and air pollution. Therefore, internal risk factors (e.g. heredity, hypertension, hyperglycemia) and external risk factors (e.g. working environment, air pollution) are both important for stroke prevention. All of these are reviewed to provide more information for the pre-hospital prevention and management, and the future clinical studies.

Genetic Polymorphisms Associated with Spontaneous Intracerebral Hemorrhage

Differences in the incidence of spontaneous intracerebral hemorrhage (ICH) between ethnicities exist, with an estimated 42% of the variance explained by ethnicity itself. Caucasians have a higher proportion of lobar ICH (LICH, 15.4% of all ICH) than do Asians (3.4%). Alterations in the causal factor exposure between countries justify part of the ethnic variance in ICH incidence. One third of ICH risk can be explained by genetic variation; therefore, genetic differences between populations can partly explain the difference in ICH incidence. In this paper, we review the current knowledge of genetic variants associated with ICH in multiple ethnicities. Candidate gene variants reportedly associated with ICH were involved in the potential pathways of hypertension, vessel wall integrity, lipid metabolism, endothelial dysfunction, inflammation, platelet function, and coagulopathy. Furthermore, variations in APOE (in multiple ethnicities), PMF1/SLC25A44 (in European), ACE (in Asian), MTHFR (in multiple ethnicities), TRHDE (in European), and COL4A2 (in European) were the most convincingly associated with ICH. The majority of the associated genes provide small contributions to ICH risk, with few of them being replicated in multiple ethnicities.

Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life

Stroke is ranked as the second leading cause of death worldwide with an annual mortality rate of about 5.5 million. Not only does the burden of stroke lie in the high mortality but the high morbidity also results in up to 50% of survivors being chronically disabled. Thus stroke is a disease of immense public health importance with serious economic and social consequences. The public health burden of stroke is set to rise over future decades because of demographic transitions of populations, particularly in developing countries. This paper provides an overview of stroke in the 21^st century from a public health perspective.

Associations of Oxidative Phosphorylation-Related Genes With Deep Intracerebral Hemorrhage in Taiwan

Background

Pathway analysis demonstrated associations between deep intracerebral hemorrhage (DICH) and the genetic risk score of complex IV of the oxidative phosphorylation (OXPHOS) pathway in whites. This study investigated the related genetic variations in the DICH population in Taiwan. Candidate variants were selected from the prior report by the following criteria: (1) nuclear genes encoding mitochondria complex IV, (2) genetic effect >1.08, (3) global minor allele frequency >0.01. Six single-nucleotide polymorphisms fitted in the selection criteria, which were mainly involved in Cox assembly, including Cox10, Cox15, and Cox18, and one structural gene, Cox7C. Associations were tested with adjustment of multiple covariables. Permutation testing of 1000 replicates was performed for empirical estimates.

Results

This study enrolled 336 patients and 379 controls. Compared with whites, the Taiwan population has higher minor allele frequency (MAF) of rs4308511, rs767844, and rs221592 and lower MAF of rs8079640. There was no variation of rs16949067 in the Taiwan population. When adjusting for the traditional risk factors, rs221592 G allele was associated with DICH risk in women under additive (odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.02-2.3, P = .04) and recessive models (OR = 2.9, 95% CI = 1.2-6.9, P = .013). In an additive fashion, a poor 30-day outcome was associated with rs4308511 T allele (OR = 1.6, 95% CI = 1.1-2.3, P = .014) and rs9891372 C allele (OR = 1.7, 95% CI = 1.05-2.8, P = .024) in all subjects and in men (rs4308511, OR = 1.8, 95% CI = 1.2-2.7, P = .008; rs9891372, OR = 2.1, 95% CI = 1.1-3.8, P = .02).

Conclusions

The results showed ethnic disparities in the complex IV-related genes. COX18-rs221592 G allele was associated with female DICH risks. COX7C-rs4308511 T allele was an independent risk of poor outcome in men.

Sex Differences in Stroke Incidence in a Portuguese Community-Based Study

BACKGROUND AND AIM

Stroke is a major health problem. Several studies reported sex differences regarding stroke. We aim to study this issue in an incidence stroke study.

METHODS

Data were retrieved from a community-based prospective register of patients that had a first ever stroke in a life time between October 2009 and September 2011. We studied sex differences regarding demographic data, vascular risk factors, stroke type, stroke severity (NIHSS), disability at 28days (modified Rankin scale (mRS)), and case fatality at 30 and 90days.

RESULTS

From 720 stroke patients, 45.3% were men. Women were older (75.0 ± 13.6 versus 67.2 ± 14.9 years), had a worse premorbid mRS (39.3% versus 25.5%, P < .001), and a higher prevalence of hypertension (P = .004) and atrial fibrillation (P < .001). Previous myocardial infarction was more frequent in men (P = .001), as well as smoking habits (P < .001). Ischemic stroke was more common in women than men (87.6% versus 81.3%, P = .038). The 28 days' outcome was worse in women (mRS ≥ 2, 77.2% versus 70.6%, P = .044). No differences were found in initial stroke severity (median NIHSS = 4) and case fatality at 30 and 90days, after adjusting for age and premorbid mRS.

CONCLUSION

No differences were found in stroke initial severity and mortality at 30 and 90days between men and women, despite the sex differences pertaining to the stroke profile-age, vascular risk factors, stroke type, and outcome. Our results are somewhat discrepant from those described in the literature; more research is needed to understand if this may be due to changes in stroke standard of care.

Association Between the Subtypes of Stroke and the Various Risk Factors of Cerebrovascular Accidents: A Cross-Sectional Study

Objective

Stroke is a common heterogeneous disease classified into two subtypes: ischemic and hemorrhagic. Many risk factors have been associated with stroke, and the most well-known is hypertension. Although the relation between stroke and these risk factors has been emphasized before, there is inconclusive evidence about the relation between the different risk factors and the subtypes of stroke. The present study aims to fill this gap.

Materials and Methods

In the present retrospective, cross-sectional study, 827 patients with diagnosed stroke were included. Demographic data and the acquired risk factors were determined using pre-designed questionnaires. Statistical analysis was conducted using chi-square test, Student t-test, and Pearson correlation coefficient.

Results

Among the included 827 patients, 432 (52.2%) were men and 395 (47.8%) were women. The mean±standard deviation of age was 68.41±12.46 y in men and 67.89±11.85 y in women, respectively, and the difference was not significant. Of all the patients, 672 had ischemic strokes and 155 had hemorrhagic strokes. The most common risk factor in the patients was hypertension with a prevalence of 66.7%. Of all the risk factors, only hypertension, atrial fibrillation (AF), age, and a positive family history were significantly related to a subtype of stroke.

Conclusion

Knowing that the prevalence of hypertension, AF, age, and positive family history are significantly different between the two subtypes, the patients having these risk factors can be entered into more specified public health measures, which puts more emphasis on the subtype that they are more prone to.

A retrospective analysis of 254 acute stroke cases admitted to two university hospitals in Beirut: classification and associated factors

Lebanon is a developing country where the prevalence of stroke subtypes and their correlation with risk factors have not been studied, even though stroke management is an ongoing major national healthcare challenge. In a retrospective study conducted in two university hospitals, data were collected on all stroke cases admitted in 2012 and 2013. Ischemic strokes were then classified according to a modified TOAST classification. A total of 254 inpatients (mean age 68.41 years ±13.34, 55.1% males) was included in the study; of these, 15% had had a hemorrhagic stroke and was therefore excluded. Conversely to findings from studies in other Arab and Asian countries, where small vessel disease is the most frequent subtype, our study showed a predominance of large artery atherosclerosis (53.5%) which, in comparison with other subtypes, was found to be associated with dyslipidemia (OR= 3.82, 95% CI= [1.76-8.28]; p=0.001). Cardioembolic stroke and small vessel disease were found to be positively associated with aging and living in Beirut, respectively. Larger studies are needed to explain these findings.

Stroke in Indigenous Africans, African Americans, and European Americans: Interplay of Racial and Geographic Factors

BACKGROUND AND PURPOSE

The relative contributions of racial and geographic factors to higher risk of stroke in people of African ancestry have not been unraveled. We compared stroke type and contributions of vascular risk factors among indigenous Africans (IA), African Americans (AA), and European Americans (EA).

METHODS

SIREN (Stroke Investigative Research and Educational Network) is a large multinational case-control study in West Africa-the ancestral home of 71% AA-whereas REGARDS (Reasons for Geographic and Racial Differences in Stroke) is a cohort study including AA and EA in the United States. Using harmonized assessments and standard definitions, we compared data on stroke type and established risk factors for stroke in acute stroke cases aged ≥55 years in both studies.

RESULTS

There were 811 IA, 452 AA, and 665 EA stroke subjects, with mean age of 68.0±9.3, 73.0±8.3, and 76.0±8.3 years, respectively (P<0.0001). Hemorrhagic stroke was more frequent among IA (27%) compared with AA (8%) and EA (5.4%; P<0.001). Lacunar strokes were more prevalent in IA (47.1%), followed by AA (35.1%) and then EA (21.0%; P<0.0001). The frequency of hypertension in decreasing order was IA (92.8%), followed by AA (82.5%) and then EA (64.2%; P<0.0001) and similarly for diabetes mellitus IA (38.3%), AA (36.8%), and EA (21.0%; P<0.0001). Premorbid sedentary lifestyle was similar in AA (37.7%) and EA (34.0%) but lower frequency in IA (8.0%).

CONCLUSIONS

Environmental risk factors such as sedentary lifestyle may contribute to the higher proportion of ischemic stroke in AA compared with IA, whereas racial factors may contribute to the higher proportion of hypertension and diabetes mellitus among stroke subjects of African ancestry.

Health Inequalities Associated with Post-Stroke Visual Impairment in the United Kingdom and Ireland: A Systematic Review

The aim of this study was to report on the health inequalities facing stroke survivors with visual impairments as described in the current literature. A systemic review of the literature was conducted to investigate the potential health inequalities facing stroke survivors with subsequent visual impairments. A quality-of-evidence and risk-of-bias assessment was conducted for each of the included articles using the appropriate tool dependent on the type of article. Only four articles discussed health inequalities affecting stroke survivors with visual impairment specifically. A further 23 articles identified health inequalities after stroke, and 38 reported on health inequalities within the visually impaired UK or Irish population. Stroke survivors with visual impairment face inconsistency in eye care provision nationally, along with variability in the assessment and management of visual disorders. The subgroups identified as most at risk were females; black ethnicity; lower socioeconomic status; older age; and those with lower education attainment. The issue of inconsistent service provision for this population must be addressed in future research. Further research must be conducted in order to firmly establish whether or not stroke survivors are at risk of the aforementioned sociodemographic and economic inequalities.

Risk Factors for Stroke in the Chinese Population: A Systematic Review and Meta-Analysis

BACKGROUND

Stroke is the leading cause of death in China. According to the Chinese Stroke Screening and Prevention Project, 8 main risk factors were assessed and individuals with 3 or more risk factors were identified as high-risk population of stroke. To explore the potential impropriety of counting the risk factors but ignoring the different strength of association of each risk factor, we performed this study.

METHODS

Relevant databases were searched for case-control and cohort studies focusing on the risk factors of stroke. We systematically identified studies conducted between 1990 and 2015 that included data on the frequency of risk factors in Chinese Han populations. Pooled relative risks and odds ratios, with their 95% confidence intervals, were calculated for the cohort and case-control studies, respectively.

RESULTS

Fifteen cohort studies and 178 case-control studies were identified. Hypertension was the strongest independent risk factor for stroke (pooled odds ratio, 3.50; pooled relative risk, 2.68). Diabetes mellitus, heart disease, family history of stroke, hyperlipidemia, overweight, and smoking were also mildly predictive (pooled odd ratios, 1.82-2.68; pooled relative risks, 1.27-2.47). By contrast, physical exercise was a protective factor against stroke (pooled odd ratio, .49).

CONCLUSIONS

There was a measurable difference in the strength of association of the 8 risk factors with stroke; hypertension and diabetes were associated with the highest risks, indicating a need to focus resources on patients with these conditions. Giving risk factors equal weighting may not be an appropriate screening methodology.

[Liposomal form of lipoic acid: preparation and determination of antiplatelet and antioxidant activity]

Optimal conditions for obtaining phosphatidylholine (PC) liposomes with lipoic acid (LA) are chosen that lead to the formation of nanoparticles with a size of 175¸284 nm with efficiency (extent) of inclusion of LA in liposomes equal 85% and characterized by a slow release of substance from the nanoparticles. The effect of "empty" liposomes and liposomal form of LA on platelet aggregation induced by arachidonic acid (AA) is established. It is found that liposomes with LА inhibit platelet aggregation, caused by AА, to 80%. In addition, it is shown that "empty" liposomes slightly (to 30%) suppress platelet aggregation, caused by AА. The amount of TBA-sensitive products in samples of platelet-rich plasma (PRP) incubated with liposomal LA is determined. It is shown that LA in the composition of liposomes retains its antioxidant properties, and the amount of products of lipid peroxidation in platelet-rich plasma decreases in a dose-dependent manner when arachidonic acid is used as an inductor of platelet aggregation. It is assumed that the antiplatelet action of the liposomal form of LА is induced by inhibition of the initiation of lipid peroxidation products caused by exogenous inducer AА. It is supposed that, after additional research, the liposomal form of LA can be considered as a new drug in complex treatment of cerebral ischemia.

The prevalence of lacunar infarct decreases with aging in the elderly: a case-controlled analysis

Background and purpose

Lacunar infarct (LI) is well known as a heterogeneous primary disorder of cerebral small vessel. Compelling results have demonstrated that age is a risk factor to the prevalence of LI. However, the relationship between age and the prevalence of LI remains obscure. It is essential to note the relationship between age and the prevalence of LI through more clinical data.

Methods

A total of 3,500 patients were included in the case-controlled study. All data were collected from the Examination Center of Magnetic Resonance Imaging, Lu’an People’s Hospital from January 2014 to December 2015. A primary discharge diagnosis of LI was done, and all subjects were evaluated as retrospective data. The relationship between the risk factors and the prevalence of diabetes and the relationship between age and the prevalence of diabetes was analyzed. A chi-square test was used to analyze the associations between different variables. A one-way analysis of variance was used to test the equality of three or more means at one time by using variances. Statistical significance was defined as a P-value of <0.05.

Results

The one-way analysis of variance demonstrated that the prevalence of LI increased with age before 60 years and decreased with age after 69 years. The same results were found in both the male and the female subjects. These results showed that the age-related risk factors (hypertension, diabetes, cerebral infarct, cardiovascular diseases, smoking, and drinking) have no relationship with the prevalence of LI on the basis of age. There is a significant difference among the different age ranges (P=0.0006). Two-tailed P-value (unpaired t-test) showed the mean significant difference between 30–39 years and 40–49 years (P=0.009) and between 70–79 years and 80–100 years (P=0.0196). F-test (to compare variances) demonstrated that the variances of the different age ranges are significantly different between 30–39 years and 40–49 years (P=0.0002), between 40–49 years and 50–59 years (P=0.0424), and between 70–79 years and 80–100 years (P=0.0003).

Conclusion

The age-related risk factors (hypertension, diabetes, cerebral infarct, cardiovascular diseases, smoking, and drinking) have no relationship with the prevalence of LI on the basis of age. A decreasing prevalence of LI with aging occurs in the elderly, while the prevalence of LI increases with aging in the young and in adults. This investigation implicates that age is not a risk factor for LI in the elderly.

Post-stroke bacteriuria among stroke patients attending a physiotherapy clinic in Ghana: a cross-sectional study

BACKGROUND

Infections are known to be a major complication of stroke patients. In this study, we evaluated the risk of community-acquired bacteriuria among stroke patients, the associated factors, and the causative organisms.

METHODS

This was a cross-sectional study involving 70 stroke patients and 83 age- and sex-matched, apparently healthy controls. Urine specimens were collected from all the study subjects and were analyzed by standard microbiological methods. Demographic and clinical information was also collected from the study subjects. For stroke patients, the information collected also included stroke parameters, such as stroke duration, frequency, and subtype.

RESULTS

Bacteriuria was significantly higher among stroke patients (24.3%, n=17) than among the control group (7.2%, n=6), with a relative risk of 3.36 (confidence interval [CI], 1.40-8.01, P=0.006). Among the control group, all six bacteriuria cases were asymptomatic, whereas the 17 stroke bacteriuria cases comprised 15 cases of asymptomatic bacteriuria and two cases of symptomatic bacteriuria. Female sex (OR, 3.40; CI, 1.12-10.30; P=0.03) and presence of stroke (OR, 0.24; CI, 0.08-0.70; P=0.009) were significantly associated with bacteriuria. The etiology of bacteriuria was similar in both study groups, and coagulase-negative Staphylococcus spp. were the most predominant organisms isolated from both stroke patients (12.9%) and the control group (2.4%).

CONCLUSION

Stroke patients in the study region have a significantly higher risk of community-acquired bacteriuria, which in most cases is asymptomatic. Community-acquired bacteriuria in stroke patients appears to have little or no relationship with clinical parameters of stroke such as stroke subtype, duration and frequency.

[Epidemiological aspects of stroke at emergencies services of Abidjan Heart Institute]

Introduction

L'objectif de notre étude était de décrire les caractéristiques sociodémographiques et les Facteurs de Risque cardio-Vasculaires (FRV) des patients admis pour accidents vasculaires cérébraux (AVC) dans un service autre que celui de la neurologie.

Méthodes

Étude transversale rétrospective sur une période de 2 ans (janv. 2010 et déc. 2011), réalisée aux urgences de l'institut de cardiologie d'Abidjan.

Résultats

Il s'agissait de 176 adultes avec un âge moyen de 60 ans, une prédominance féminine. Les facteurs de risque majeurs retrouvés étaient l'hypertension artérielle dans 86,4% des cas, le diabète dans 11,4% des cas, le tabagisme dans 2,2% des cas. Les motifs de consultation étaient la perte de connaissance dans 36,4% des cas, l'hémiplégie dans 31,8% des cas, les céphalées dans 17,4% des cas, les vertiges dans 10,9% et les palpitations dans 2,2% des cas. La tension artérielle systolique moyenne était à 174 mmHg, la tension artérielle diastolique moyenne était à 105 mmHg et la pression pulsée moyenne était à 70 mmHg. Les AVC étaient associés à une arythmie complète par fibrillation auriculaire dans 11,4% des cas. Les AVC ischémiques représentaient 84,1%. L’évolution aux urgences a été marquée par un décès dans 17% (30) des cas.

Conclusion

Les AVC constituent un problème majeur de santé publique. Malgré sa prédominance féminine, ils (AVC) touchaient 44% des hommes dans notre étude lorsqu'on sait qu'en Afrique l'activité sociale repose sur les hommes. Ils restent une pathologie grave par la forte létalité.

30-Year Trends in Stroke Rates and Outcome in Auckland, New Zealand (1981-2012): A Multi-Ethnic Population-Based Series of Studies

Background

Insufficient data exist on population-based trends in morbidity and mortality to determine the success of prevention strategies and improvements in health care delivery in stroke. The aim of this study was to determine trends in incidence and outcome (1-year mortality, 28-day case-fatality) in relation to management and risk factors for stroke in the multi-ethnic population of Auckland, New Zealand (NZ) over 30-years.

Methods

Four stroke incidence population-based register studies were undertaken in adult residents (aged ≥15 years) of Auckland NZ in 1981–1982, 1991–1992, 2002–2003 and 2011–2012. All used standard World Health Organization (WHO) diagnostic criteria and multiple overlapping sources of case-ascertainment for hospitalised and non-hospitalised, fatal and non-fatal, new stroke events. Ethnicity was consistently self-identified into four major groups. Crude and age-adjusted (WHO world population standard) annual incidence and mortality with corresponding 95% confidence intervals (CI) were calculated per 100,000 people, assuming a Poisson distribution.

Results

5400 new stroke patients were registered in four 12 month recruitment phases over the 30-year study period; 79% were NZ/European, 6% Māori, 8% Pacific people, and 7% were of Asian or other origin. Overall stroke incidence and 1-year mortality decreased by 23% (95% CI 5%-31%) and 62% (95% CI 36%-86%), respectively, from 1981 to 2012. Whilst stroke incidence and mortality declined across all groups in NZ from 1991, Māori and Pacific groups had the slowest rate of decline and continue to experience stroke at a significantly younger age (mean ages 60 and 62 years, respectively) compared with NZ/Europeans (mean age 75 years). There was also a decline in 28-day stroke case fatality (overall by 14%, 95% CI 11%-17%) across all ethnic groups from 1981 to 2012. However, there were significant increases in the frequencies of pre-morbid hypertension, myocardial infarction, and diabetes mellitus, but a reduction in frequency of current smoking among stroke patients.

Conclusions

In this unique temporal series of studies spanning 30 years, stroke incidence, early case-fatality and 1-year mortality have declined, but ethnic disparities in risk and outcome for stroke persisted suggesting that primary stroke prevention remains crucial to reducing the burden of this disease.

Meta-Analysis of Genome-Wide Association Studies Identifies Genetic Risk Factors for Stroke in African Americans

BACKGROUND AND PURPOSE

The majority of genome-wide association studies (GWAS) of stroke have focused on European-ancestry populations; however, none has been conducted in African Americans, despite the disproportionately high burden of stroke in this population. The Consortium of Minority Population Genome-Wide Association Studies of Stroke (COMPASS) was established to identify stroke susceptibility loci in minority populations.

METHODS

Using METAL, we conducted meta-analyses of GWAS in 14 746 African Americans (1365 ischemic and 1592 total stroke cases) from COMPASS, and tested genetic variants with P<10(-6) for validation in METASTROKE, a consortium of ischemic stroke genetic studies in European-ancestry populations. We also evaluated stroke loci previously identified in European-ancestry populations.

RESULTS

The 15q21.3 locus linked with lipid levels and hypertension was associated with total stroke (rs4471613; P=3.9×10(-8)) in African Americans. Nominal associations (P<10(-6)) for total or ischemic stroke were observed for 18 variants in or near genes implicated in cell cycle/mRNA presplicing (PTPRG, CDC5L), platelet function (HPS4), blood-brain barrier permeability (CLDN17), immune response (ELTD1, WDFY4, and IL1F10-IL1RN), and histone modification (HDAC9). Two of these loci achieved nominal significance in METASTROKE: 5q35.2 (P=0.03), and 1p31.1 (P=0.018). Four of 7 previously reported ischemic stroke loci (PITX2, HDAC9, CDKN2A/CDKN2B, and ZFHX3) were nominally associated (P<0.05) with stroke in COMPASS.

CONCLUSIONS

We identified a novel genetic variant associated with total stroke in African Americans and found that ischemic stroke loci identified in European-ancestry populations may also be relevant for African Americans. Our findings support investigation of diverse populations to identify and characterize genetic risk factors, and the importance of shared genetic risk across populations.

Positive correlation between care given by specialists and registered nurses and improved outcomes for stroke patients

BACKGROUND

Cerebrovascular diseases are the second-highest cause of death in South Korea (9.6% of all causes of mortality in 2013). South Korea has a shortage of trained medical personnel compared with other countries and the demands for health care are continuously increasing. Our study sought to determine the relationship between hospital human resources and the outcomes of stroke patients.

METHODS

We used data from NHI claims (n=99,464) at 120 hospitals to analyze readmission or death within 30 days after discharge or hospitalization for stroke patients during 2010-2013. We used multilevel models that included both patient-level and hospital-level variables to examine factors associated with readmission or death within 30 days.

RESULTS

A total of 1782 (1.8%) patients were readmitted within 30 days, and death occurred within 30 days for 6926 (7.0%) patients. Patients cared for by a higher percentages of specialists or registered nurses had a lower risk of readmission or death within 30 days (readmission per 10% increase in registered nurses, OR=0.89 and SD=0.85-0.94; death per 10% increase in specialists, OR=0.93 and SD=0.89-0.98).

CONCLUSIONS

The percentages of specialist and registered nurses caring for stroke patients were positively correlated with better patient outcomes, particularly for patients with cerebral infarction.

Risk Factors for Ischemic Stroke and its Subtypes in Chinese vs. Caucasians: Systematic Review and Meta-Analysis

Background

Chinese populations are reported to have a different distribution of ischemic stroke subtypes compared with Caucasians.

Aims

To understand this better, we aimed to evaluate the differences in prevalence of risk factors in ischemic stroke and their distributions among ischemic stroke subtypes in Chinese vs. Caucasians.

Summary or review

We systematically sought studies conducted since 1990 with data on frequency of risk factors among ischemic stroke subtypes in Chinese or Caucasians. For each risk factor, we calculated study-specific and random effects pooled estimates in Chinese and Caucasians separately for: prevalence among ischemic stroke; odds ratios, comparing prevalence for each ischemic stroke subtype vs. all others. We included seven studies among 16 199 Chinese, and eleven among 16 189 Caucasian ischemic stroke patients. Risk factors studied were hypertension, diabetes, atrial fibrillation, ischemic heart disease, hypercholesterolemia, smoking and alcohol. Chinese ischemic stroke patients had younger onset of stroke than Caucasians, similar prevalence of hypertension, diabetes, smoking and alcohol, and significantly lower prevalence of atrial fibrillation, ischemic heart disease and hypercholesterolemia. Risk factor associations with ischemic stroke subtypes were mostly similar among Chinese and Caucasian ischemic stroke patients. Compared with all other ischemic subtypes, diabetes was more common in large artery stroke, atrial fibrillation and ischemic heart disease in cardioembolic stroke, and hypertension and diabetes in lacunar stroke.

Conclusion

Our study showed a lower prevalence of atrial fibrillation, ischemic heart disease and hypercholesterolemia in Chinese, and mostly similar risk factor associations in Chinese and Caucasian ischemic stroke patients. Further analyses of individual patient data to allow adjustment for confounders are needed to confirm and extend these findings.

Triggering of stroke by ambient temperature variation: a case-crossover study in Maputo, Mozambique

OBJECTIVES

The effect of ambient temperature as a stroke trigger is likely to differ by type of stroke and to depend on non-transient exposures that influence the risk of this outcome. We aimed to quantify the association between ambient temperature variation and stroke, according to clinical characteristics of the events, and other risk factors for stroke.

METHODS

We conducted a case-crossover study based on a 1-year registry of the hospital admissions due to newly occurring ischemic and hemorrhagic stroke events in Maputo, Mozambique's capital city (N=593). The case-period was defined as the 7 days before the stroke event, which was compared to two control periods (14-21 days and 21-28 days before the event). We computed humidity- and precipitation-adjusted odds ratios (OR) and 95% confidence intervals (95%CI) using conditional logistic regression.

RESULTS

An association between minimum temperature declines higher than 2.4 °C in any two consecutive days in the previous week and the occurrence of stroke was observed only for first events (OR=1.43, 95%CI: 1.15-1.76). Stronger and statistically significant associations were observed for hemorrhagic stroke (OR=1.50, 95%CI: 1.07-2.09) and among subjects not exposed to risk factors, including smoking, high serum cholesterol or atrial fibrillation. No differences in the effect of temperature were found according to the patients' vital status 28 days after the event.

CONCLUSIONS

First stroke events, especially of the hemorrhagic type, were triggered by declines in the minimum temperature between consecutive days of the preceding week.

Blood Pressure and Early Clinical Outcome Among Acute Ischemic Stroke Patients

Objectives:

The association between blood pressure (BP) and short-term clinical outcome of acute ischemic stroke is inconclusive. We investigated the association between BP in the first 72 hours following admission and death in-hospital and neurologic deficiency at discharge among patients with acute ischemic stroke.

Methods:

A total of 2675 acute ischemic stroke patients confirmed by a computed tomography scan or magnetic resonance imaging were included in the present study. Blood pressure in the first 72 hours after admission and other study variables were collected for all ischemic stroke patients. Neurological functions National Institute of Health Stroke Scale (NIHSS) were evaluated by trained neurologists at discharge. The study outcome was defined as death in-hospital and neurologic deficiency (NIHSS≥10) at discharge.

Results:

Systolic and diastolic BP were significantly and positively associated with odds of study outcome in acute ischemic stroke. For example, compared to those with a systolic BP<140 mmHg, multiple-adjusted odds ratio (95% confidence interval) of study outcome was 3.29(1.22, 8.90) among participants with systolic BP of 180-219 mmHg,P<0.05; compared to those with a diastolic BP<90 mmHg, multiple-adjusted odds ratio of study outcome was 7.05(1.32, 37.57) among participants with diastolic BP ≥ 120 mmHg,P<0.05.

Conclusion:

Systolic BP≥180 and diastolic BP≥120 were significantly and positively associated with death in-hospital or neurologic deficiency at discharge among patients with acute ischemic stroke.

Profile and health-related quality of life of Ghanaian stroke survivors

BACKGROUND

Stroke is a leading cause of mortality with a major effect on health-related quality of life (HRQoL). There are no previous studies exploring HRQoL among stroke survivors in Ghana, despite the increasing public health significance of the disease in this country. Here we describe the profile of and factors associated with HRQoL among stroke survivors in Ghana.

METHODS

This was a cross-sectional study involving 156 stroke survivors and 156 age- and sex-matched, apparently healthy controls. A robust HRQoL questionnaire involving seven domains was used to collect data from the study participants. Clinical epidemiology data were also collected from stroke survivors on parameters such as stroke severity and risk factors. Statistical analyses were performed on the interrelationships among the study variables.

RESULTS

The mean ages of the stroke survivors and healthy controls were 58.0 (standard deviation, 11.4) and 57.6 (standard deviation, 12.0) years, respectively. Fifty-three percent (86) of the stroke survivors had mild stroke and 35.3% (55) had moderate stroke, whereas 12.2% (19) had severe stroke. Ischemic infarction was the prevalent stroke subtype (78.1%). Hypertension was the most common risk factor (89%) among the stroke survivors, followed by diabetes (29%). HRQoL scores ranged from 57.7% (cognitive domain) to 80.0% (spirit domain) for stroke survivors, whereas HRQoL scores of the control group ranged from 65.6% (cognitive domain) to 85.2% (soul domain). For each HRQoL domain, significantly higher scores were observed for the control group compared with the stroke survivors, at P<0.05. Determinants of HRQoL of stroke survivors in multivariate analysis included age, stroke severity, poststroke duration, stroke recurrence, frequency of laughter, and negative emotions.

CONCLUSION

The most affected HRQoL domains are of the physical, psychoemotional, and cognitive domains. Rehabilitation of stroke patients in this region should include interventions targeted at these domains and modifying the statistical determinants of HRQoL where possible.

The frequency of alcohol consumption is associated with the stroke mortality

OBJECTIVES

The purpose of this study was to examine the association between the frequency of alcohol consumption and stroke mortality among eastern Finnish men.

MATERIAL AND METHODS

This study is a population-based sample of men with an average follow-up of 20.2 years. A total of 2609 men with no history of stroke at baseline participated in the study. During the follow-up, 66 deaths from stroke occurred.

RESULTS

After adjustment for systolic blood pressure, smoking, BMI, diabetes, and socioeconomic status, the relative risk (RR) among men who consumed alcohol <0.5 times per week was 0.70 (95% CI, 0.30-1.66; P = 0.419) compared with nondrinkers. Respective RR was 1.08 (95% CI, 0.51-2.27; P = 0.846) for men with alcohol consumption of 0.5-2.5 times per week and 2.44 (95% CI, 1.11-5.40; P = 0.027) for men who consumed alcohol >2.5 times per week after adjustment for risk factors. When the total amount of alcohol consumption (g/week) was taken into account with other covariates, RR was 0.71 (95% CI, 0.30-1.68; P = 0.437) for men with alcohol consumption <0.5 times per week and 1.16 (95% CI, 0.54-2.50; P = 0.704) among men who consumed alcohol 0.5-2.5 times per week. Among men who consumed alcohol >2.5 times per week compared with nondrinkers, RR was 3.03 (95% CI, 1.19-7.72; P = 0.020).

CONCLUSIONS

This study shows a strong association between the frequency of alcohol consumption and stroke mortality, independent of total amount of alcohol consumption. The risk of stroke death was the highest among men who consumed alcohol >2.5 times per week.

Modelling, evaluating and implementing cost-effective services to reduce the impact of stroke

Background

Stroke is a leading cause of death and disability but there is little information on the longer-term needs of patients and those of different ethnic groups.

Objectives

To estimate risk of stroke, longer-term needs and outcomes, risk of recurrence, trends and predictors of effective care, to model cost-effective configurations of care, to understand stakeholders’ perspectives of services and to develop proposals to underpin policy.

Design

Population-based stroke register, univariate and multivariate analyses, Markov and discrete event simulation, and qualitative methods for stakeholder perspectives of care and outcome.

Setting

South London, UK, with modelling for estimates of cost-effectiveness.

Participants

Inner-city population of 271,817 with first stroke in lifetime between 1995 and 2012.

Outcome measures

Stroke incidence rates and trends, recurrence, survival, activities of daily living, anxiety, depression, quality of life, appropriateness and cost-effectiveness of care, and qualitative narratives of perspectives.

Data sources

South London Stroke Register (SLSR), qualitative data, group discussions.

Results

Stroke incidence has decreased since 1995, particularly in the white population, but with a higher stroke risk in black groups. There are variations in risk factors and types of stroke between ethnic groups and a large number of strokes occurred in people with untreated risk factors with no improvement in detection observed over time. A total of 30% of survivors have a poor range of outcomes up to 10 years after stroke with differences in outcomes by sociodemographic group. Depression affects over half of all stroke patients and the prevalence of cognitive impairment remains 22%. Survival has improved significantly, particularly in the older black groups, and the cumulative risk of recurrence at 10 years is 24.5%. The proportion of patients receiving effective acute stroke care has significantly improved, yet inequalities of provision remain. Using register data, the National Audit Office (NAO) compared the levels of stroke care in the UK in 2010 with previous provision levels and demonstrated that improvements have been cost-effective. The treatment of, and productivity loss arising from, stroke results in total societal costs of £8.9B a year and 5% of UK NHS costs. Stroke unit care followed by early supported discharge is a cost-effective strategy, with the main gain being years of life saved. Half of stroke survivors report unmet long-term needs. Needs change over time, but may not be stroke specific. Analysis of patient journeys suggests that provision of care is also influenced by structural, social and personal characteristics.

Conclusions/recommendations

The SLSR has been a platform for a range of health services research activities of international relevance. The programme has produced data to inform policy and practice with estimates of need for stroke prevention and care services, identification of persistent sociodemographic inequalities in risk and care despite a reduction in stroke risk, quantification of the effectiveness and cost-effectiveness of care and development of models to simulate configurations of care. Stroke is a long-term condition with significant social impact and the data on need and economic modelling have been utilised by the Department of Health, the NAO and Healthcare for London to assess need and model cost-effective options for stroke care. Novel approaches are now required to ensure that such information is used effectively to improve population and patient outcomes.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme and the Department of Health via the National Institute for Health Research Biomedical Research Centre award to Guy’s and St Thomas’ NHS Foundation Trust in partnership with King’s College London.

Clinical-MRI correlations in a multiethnic cohort with recent lacunar stroke: the SPS3 trial

BACKGROUND

Neuroimaging manifestations of small vessel disease are heterogeneous, and correlation with patient features has not been adequately characterized.

AIM

Our goal was to correlate magnetic resonance imaging findings with clinical features in a large multiethnic cohort with recent lacunar stroke.

METHODS

Patient characteristics were correlated with neuroimaging results in the Secondary Prevention of Small Subcortical Stroke study participants.

RESULTS

Among 3005 patients, mean age was 63 years; 62% were men; and 51%, 30%, and 16% were non-Hispanic White, Hispanic, and Black, respectively. Recent lacunar infarcts were distributed between the subcortical hemisphere (31%), thalamus (26%), brainstem/cerebellum (26%), and basal ganglia/internal capsule (16%). Multiple lacunar infarcts (i.e., acute and remote) were present in 40% and associated with increased age (OR 1·3 per 20 years, 95% CI 1·1, 1·5), male gender (OR 1·5, CI 1·3, 1·7), hypertension (OR 1·5, CI 1·2, 1·8), increased systolic blood pressure (OR 1·2 per 20 mmHg, CI 1·1, 1·3), and prior stroke (OR 3·8, CI 2·9, 5·0). Moderate-severe white matter hyperintensities were present in 50% and associated with increased age (OR 4·3 per 20 years, CI 3·4, 5·4), hypertension (OR 1·8, CI 1·4, 2·3), increased systolic blood pressure (OR 1·3 per 20 mmHg, CI 1·1, 1·5), increased diastolic blood pressure (OR 1·2 per 10 mm, CI 1·0, 1·3), and prior stroke (OR 3·3, CI 2·3, 4·5). Infarct location varied significantly by race-ethnicity (P < 0·001), with Blacks and Hispanics having more infarcts in the brainstem/cerebellum than non-Hispanic Whites, and by gender with women more often having thalamic lacunes than men (P ≤ 0·001).

CONCLUSIONS

In patients with recent lacunar stroke, infarct location and number have distinctie associations with gender, vascular risk factors, and race-ethnicity, demonstrating the complex pathogenesis of lacunar stroke and cerebral small artery disease.

Stroke types in rural and urban northern portugal: incidence and 7-year survival in a community-based study

BACKGROUND/AIM

Differences in stroke incidence and mortality between regions could stem from differences in the incidence of particular stroke types and long-term prognosis. The aim of this study was to investigate whether different risk profiles and stroke types underlie the difference in stroke incidence and patient long-term survival in rural and urban populations.

METHODS

All suspected first-ever-in-a-lifetime strokes occurring between October 1998 and September 2000 in 37,290 residents of rural municipalities and in 86,023 individuals living in the city of Porto were entered into a population-based registry. Standard definitions of stroke types and overlapping comprehensive sources of information were used for patient identification. Patients were examined by neurologists at 3 months, 1 year and 7 years after the index event.

RESULTS

From a total of 688 patients included (226 in rural and 462 in urban areas), 76.2% had an ischaemic stroke (IS; 75.3 vs. 77.9%), 16.1% a primary intracerebral haemorrhage (PICH; 16.3 vs. 14.6%) and 3.3% a subarachnoid haemorrhage (SAH; 2.7 vs. 3.7%); in 4.4% (4.9 vs. 4.1%), the stroke type could not be determined. The annual incidence rate per 1,000 was 2.13 (95% CI, 1.95-2.31), 0.45 (95% CI, 0.37-0.53), 0.09 (95% CI, 0.06-0.14) and 0.12 (95% CI, 0.08-0.17), respectively. The age-specific rural/urban incidence rate ratios for IS in the youngest group (<55 years) was 0.27 (95% CI, 0.11-0.69), increasing to 1.47 (95% CI, 1.07-2.01) for those aged 65-74 years and to 1.87 (95% CI, 1.39-2.52) for those between 75 and 84 years. Rural compared to urban patients with an IS were predominantly men, had a prevalence ratio (PR) of 1.28 (95% CI, 1.05-1.56), were 65 years or older (PR = 1.18; 95% CI, 1.08-1.30) and had in general a lower prevalence of risk factors. There was no evidence of rural/urban differences in 28-day case fatality for the stroke types, although IS tended to be less fatal among urban patients (10.3 vs. 13.1%), whereas PICH (33.3 vs. 24.2%) and SAH (35.3 vs. 16.7%) were less fatal among rural patients. Independently of rural/urban residence, predictors of poor survival after the acute phase (28 days) were age >65 years (HR = 3.57; 95% CI, 2.6-4.9), diabetes (HR = 1.5; 95% CI, 1.2-1.9), ischaemic heart disease (HR = 1.8; 95% CI, 1.3-2.6), atrial fibrillation (HR = 1.5; 95% CI, 1.1-2.0) and smoking habits (HR = 1.6; 95% CI, 1.1-2.3).

CONCLUSIONS

The age pattern of IS incidence marks the difference between rural and urban populations; the youngest urban and the oldest rural residents were at a higher risk. Although patients from rural areas were older, the relatively lower prevalence of simultaneously occurring risk and prognostic factors among them as well as the similar management of rural and urban patients may justify why rurality is not associated with long-term survival.

Racial and ethnic disparities in stroke subtypes: a multiethnic sample of patients with stroke

Stroke subtypes have been reported to differ by race and ethnic subgroups and have not been adequately explained. We aim to evaluate if the prevalence of vascular risk factors accounts for differences observed in stroke subtypes by race/ethnicity. Patients with acute stroke were prospectively enrolled in the Miami Stroke Registry. Patients' demographic, clinical and radiological characteristics were systematically collected. Stroke subtypes were ascertained using TOAST criteria. The sample was divided into Non-Hispanic Whites (NHW), Hispanics, African Americans (AA), and Non-Hispanic Black Caribbean (NHBC). Univariable and multivariable logistic regression analyses were performed to assess differences among groups. Among 473 stroke patients (mean age 64 ± 14 years; 63.7% were men) of which 52.9% were Hispanic, 22.6% were AA, 13.5% NHBC and 11.0% were NHW. Large artery atherosclerosis was more prevalent in NHBC (OR 1.74, 95% CI 1.02-2.97) than in the other groups. Adjusting for covariates rendered the association not significant (OR 1.71, 95% CI 0.93-3.16). Cardioembolism was more frequent in Hispanics (OR 1.94, 95% CI 1.28-2.96) and NHW (OR 2.66, 95% CI 1.42-4.96) as compared to NHBC and AA combined. Adjusting for covariates, the association was no longer significant for Hispanics but was further strengthened for NHW (OR 3.02, 95% CI 1.42-6.42). Our results suggest that the vascular risk factors prevalence among different racial and ethnic groups partially explains disparities found in the prevalence of some stroke subtypes. Addressing health disparities remains an important public health aspect of stroke prevention.

Which risk factors are more associated with ischemic rather than hemorrhagic stroke in black Africans?

OBJECTIVE

To comprehensively examine the relationship of vascular risk factors to stroke type in native black Africans.

METHODS

We explored 34 candidate demographic, clinical, and laboratory variables in 282 consecutive adult stroke patients with brain imaging.

RESULTS

Ischemic stroke (IS) was found in 61.7% (174). Gender, alcohol, cigarette, homocysteine, C-reactive peptide, anthropometry, and carotid parameters were not significantly associated with stroke type (p>0.05). Patients with IS had relatively lower BP, were significantly older, and more frequently had diabetes mellitus, cardiac disease, or previous transient ischemic attack than patients with hemorrhagic stroke (HS). However, in multivariate regression model predicting 69% of stroke type correctly, age≥62 years (OR: 4.0, 95% CI: 2.0-7.9), previous TIA (OR: 4.3, 95% CI: 1.2-15.7) and systolic BP≥140 mmHg (OR: 0.4, 95% CI: 0.2-0.9) were the only independent significant predictors of IS.

CONCLUSIONS

With increasing proportion of the population over 61 years and better BP control, the proportion of IS is expected to rise in black African countries currently undergoing epidemiological transition (changing lifestyle/disease pattern). Therefore, relevant components of the stroke intervention quadrangle (stroke surveillance, acute care, preventive and rehabilitation services) should be tailored toward this need.

Disparities among Asians and native Hawaiians and Pacific Islanders with ischemic stroke

OBJECTIVES

To evaluate disparities in cardiovascular risk factors among Asians and Native Hawaiians and other Pacific Islanders (NHPI) in Hawaii who are hospitalized with ischemic stroke.

METHODS

We performed a retrospective study on consecutive patients hospitalized for ischemic stroke at a single tertiary center in Honolulu between 2004 and 2010. The prevalence of cardiovascular risk factors was compared for NHPI, Asians, and whites who were hospitalized for ischemic stroke.

RESULTS

A total of 1,921 patients hospitalized for ischemic stroke were studied. NHPI were less likely to be older (odds ratio [OR] 0.95, 95% confidence interval [CI] 0.94-0.96), more likely to be female (OR 1.55, 95% CI 1.07-2.24), and more likely to have diabetes (OR 2.74, 95% CI 1.87-4.00), hypertension (OR 1.98, 95% CI 1.27-3.10), and obesity (OR 1.82, 95% CI 1.25-2.65) than whites. NHPI had higher low-density lipoprotein levels (114 ± 50 mg/dL vs 103 ± 45 mg/dL, p = 0.001) and lower high-density lipoprotein levels (38 ± 11 mg/dL vs 45 ± 15 mg/dL, p < 0.0001) than whites. Compared with Asians, NHPI were less likely to be older (OR 0.95, 95% CI 0.94-0.97) and more likely to have diabetes (OR 1.88, 95% CI 1.35-2.61), previous stroke or TIA (OR 1.57, 95% CI 1.09-2.25), and obesity (OR 6.05, 95% CI 4.31-8.48).

CONCLUSIONS

Asians, NHPI, and whites with ischemic stroke have substantially different cardiovascular risk factors. Targeted secondary prevention will be important in reducing disparities among these racial groups.

Airborne pollutants and lacunar stroke: a case cross-over analysis on stroke unit admissions

Particulate air pollution is known to be associated with cardiovascular disease. The relation of particulate air pollution with cerebrovascular disease (CVD) has not been extensively studied, particularly in relation to different subtypes of stroke. A time-series study was conducted to evaluate the association between daily air pollution and acute stroke unit hospitalizations in Mantua, Italy. We analyzed 781 CVD consecutive patients living in Mantua county admitted between 2006-08. Data on stroke types, demographic variables, risk factors were available from the Lombardia Stroke Registry. Daily mean value of particulate matter with a diameter <10 µm (PM(10)), carbon monoxide, nitric oxide, nitrogen dioxide, sulphur dioxide, benzene and ozone were used in the analysis. The association between CVD, ischemic strokes subtypes and pollutants was investigated with a case-crossover design, using conditional logistic regression analysis, adjusting for temperature, humidity, barometric pressure and holidays. Among the 781 subjects admitted 75.7% had ischemic stroke, 11.7% haemorrhagic stroke 12.6% transient ischemic attack. In men admission for stroke was associated with PM(10) [odds ratio (OR) 1.01, 95%; confidence interval (CI) 1.00-1.02; P<0.05]. According to the clinical classification, lacunar anterior circulation syndrome stroke type was related to PM(10) level registered on the day of admission for both genders (OR: 1.01, 95%; CI: 1.00-1.02; P<0.05) while for total anterior circulation syndrome stroke only in men (OR: 1.04, 95%; CI 1.01-1.07; P<0.05).In conclusion, our study confirms that air pollution peaks may contribute to increase the risk of hospitalization for stroke and particulate matter seems to be a significant risk factor, especially for lacunar stroke.

Types, Outcome and Risk Factors of Stroke in Tribal Patients

Introduction

Studies suggest that ethnicity and racial factors has an important role in the variation in epidemiology of stroke. The present study was conducted to assess the subtypes, risk factors, and outcome of stroke in the tribal community of Jharkhand state and to compare it with that in the non-tribals from the same geographical location.

Methods

We carried out a hospital-based prospective observational study at Rajendra Institute of Medical Sciences-Ranchi. Patients of acute stroke, reporting to the medical outpatient department and emergency department from January 1, 2006 to December 31, 2010 were studied. Computed tomography scan was done immediately and again after 24 h to confirm the diagnosis of stroke. To compare the findings between tribal and non-tribal patients, we used chi-square test/Fisher exact test as appropriate.

Results

Of the total 1156 patients included in the study, 536 were tribals, while 620 were non-tribals. Significant differences were found in tribal stroke patients as compared with non-tribals: mean age of tribal subjects was 53·8 years (60·8 years in non-tribals); stroke in young individual was present in 25% of tribal subjects (17% in non-tribals, P = 0·01); primary intracerebral hemorrhage variety was present in 31% of tribals (18% in non-tribals, P-value < 0·001); the 28th day case fatality rate was 43% among tribal subjects (35% among non-tribals, P = 0·02). Hypertension and alcohol abuse was found to be associated with intracerebral hemorrhage in tribal subjects, although no such association was found in non-tribals.

Conclusion

Tribals have early onset, poor outcomes and higher proportion of ICH compared to non-tribals. [Correction added after online publication 7 Aug 2012: The sentence ‘Tribals have early with non-tribals.’ in the Conclusion section of the abstract was deleted.]