Comparison of Recovery Patterns and Prognostic Indicators for Ischemic and Hemorrhagic Stroke in China

Temporal Trends and Racial Disparities in Long-Term Survival After Stroke

BACKGROUND AND OBJECTIVES

Few studies have examined trends and disparities in long-term outcome after stroke in a representative US population. We used a population-based stroke study in the Greater Cincinnati Northern Kentucky region to examine trends and racial disparities in poststroke 5-year mortality.

METHODS

All patients with acute ischemic strokes (AISs) and intracerebral hemorrhages (ICHs) among residents ≥20 years old were ascertained using ICD codes and physician-adjudicated using a consistent case definition during 5 periods: July 1993-June 1994 and calendar years 1999, 2005, 2010, and 2015. Race was obtained from the medical record; only those identified as White or Black were included. Premorbid functional status was assessed using the modified Rankin Scale, with a score of 0-1 being considered "good." Mortality was assessed with the National Death Index. Trends and racial disparities for each subtype were analyzed with logistic regression.

RESULTS

We identified 8,428 AIS cases (19.3% Black, 56.3% female, median age 72) and 1,501 ICH cases (23.5% Black, 54.8% female, median age 72). Among patients with AIS, 5-year mortality improved after adjustment for age, race, and sex (53% in 1993/94 to 48.3% in 2015, overall effect of study year p = 0.009). The absolute decline in 5-year mortality in patients with AIS was larger than what would be expected in the general population (5.1% vs 2.8%). Black individuals were at a higher risk of death after AIS (odds ratio [OR] 1.23, 95% CI 1.08-1.39) even after adjustment for age and sex, and this effect was consistent across study years. When premorbid functional status and comorbidities were included in the model, the primary effect of Black race was attenuated but race interacted with sex and premorbid functional status. Among male patients with a good baseline functional status, Black race remained associated with 5-year mortality (OR 1.4, 95% CI 1.1-1.7, p = 0.002). There were no changes in 5-year mortality after ICH over time (64.4% in 1993/94 to 69.2% in 2015, overall effect of study year p = 0.32).

DISCUSSION

Long-term survival improved after AIS but not after ICH. Black individuals, particularly Black male patients with good premorbid function, have a higher mortality after AIS, and this disparity did not change over time.

Incidence of Altered Level of Consciousness in Hemorrhagic Stroke Survivors: Associated Factors From a Korean Nationwide Study

OBJECTIVE

This study aimed to demonstrate the incidence of altered level of consciousness after hemorrhagic stroke and identify factors associated with altered level of consciousness at 3 mos after stroke.

DESIGN

This study used data from a prospective multicenter cohort study conducted in nine hospitals in Korea and included 1677 patients with first-ever hemorrhagic stroke. Patients were dichotomized into those with and without altered level of consciousness at 3 mos after stroke. Multivariate logistic regression analysis was performed to identify factors associated with subacute to chronic stage altered level of consciousness.

RESULTS

Among patients with hemorrhagic stroke (age: 20-99 yrs, female 50.21%), the prevalence of altered level of consciousness at admission was 38.58% (25.4% [drowsy], 6.38% [stupor], and 6.8% [coma]) and 17.29% 3 mos after stroke. Multivariate logistic regression analysis revealed that independent factors associated with altered level of consciousness at 3 mos after stroke included late seizure (odds ratio [95% confidence interval], 5.93 [1.78-20.00]), stroke progression (3.84 [1.48-9.64]), craniectomy (2.19 [1.19-4.00]), history of complications (1.74 [1.18-2.55]), age at stroke onset (1.08 [1.07-1.10]), and initial Glasgow Coma Scale score category (0.36 [0.30-0.44]).

CONCLUSIONS

The factors associated with altered level of consciousness at 3 mos after stroke should be considered when explaining long-term consciousness status and focused management of modifiable factors in acute care hospitals could help ameliorate altered level of consciousness and promote recovery after stroke.

Prognostic Significance of Plasma VEGFA and VEGFR2 in Acute Ischemic Stroke-a Prospective Cohort Study

Enhancement of vascular remodeling in affected brain tissue is a novel therapy for acute ischemic stroke (AIS). However, conclusions regarding angiogenesis after AIS remain ambiguous. Vascular endothelial growth factor A (VEGFA) and VEGF receptor 2 (VEGFR2) are potent regulators of angiogenesis and vascular permeability. We aimed to investigate the association between VEGFA/VEGFR2 expression in the acute stage of stroke and prognosis of patients with AIS. We enrolled 120 patients with AIS within 24 h of stroke onset and 26 healthy controls. Plasma levels of VEGFA and VEGFR2 were measured by enzyme-linked immunosorbent assay (ELISA). The primary endpoint was an unfavorable outcome defined as a modified Rankin Scale (mRS) score > 2 at 3 months after AIS. Univariate and multivariate logistic regression analyses were used to identify risk factors affecting prognosis. Plasma VEGFA and VEGFR2 were significantly higher in patients with AIS than in health controls, and also significantly higher in patients with unfavorable than those with favorable outcomes. Moreover, both VEGFA and VEGFR2 showed a significantly positive correlation with mRS at 3 months. Univariate and multivariate analyses showed VEGFA and VEGFR2 remained associated with unfavorable outcomes, and adding VEGFA and VEGFR2 to the clinical model significantly improved risk reclassification (continuous net reclassification improvement, 105.71%; integrated discrimination improvement, 23.45%). The new risk model curve exhibited a good fit with an area under the receiver operating characteristic curve (ROC) curve of 0.9166 (0.8658-0.9674). Plasma VEGFA and VEGFR2 are potential markers for predicting prognosis; thus these two plasma biomarkers may improve risk stratification in patients with AIS.

Lesion-specific cortical activation following sensory stimulation in patients with subacute stroke

BACKGROUND

Sensory stimulation can play a fundamental role in the activation of the primary sensorimotor cortex (S1-M1), which can promote motor learning and M1 plasticity in stroke patients. However, studies have focused mainly on investigating the influence of brain lesion profiles on the activation patterns of S1-M1 during motor tasks instead of sensory tasks. Therefore, the objective of this study is to explore the lesion-specific activation patterns due to different brain lesion profiles and types during focal vibration (FV).

METHODS

In total 52 subacute stroke patients were recruited in this clinical experiment, including patients with basal ganglia hemorrhage/ischemia, brainstem ischemia, other subcortical ischemia, cortical ischemia, and mixed cortical-subcortical ischemia. Electroencephalograms (EEG) were recorded following a resting state lasting for 4 min and three sessions of FV. FV was applied over the muscle belly of the affected limb's biceps for 3 min each session. Beta motor-related EEG power desynchronization overlying S1-M1 was used to indicate the activation of S1-M1, while the laterality coefficient (LC) of the activation of S1-M1 was used to assess the interhemispheric asymmetry of brain activation.

RESULTS

(1) Regarding brain lesion profiles, FV could lead to the significant activation of bilateral S1-M1 in patients with basal ganglia ischemia and other subcortical ischemia. The activation of ipsilesional S1-M1 in patients with brainstem ischemia was higher than that in patients with cortical ischemia. No activation of S1-M1 was observed in patients with lesions involving cortical regions. (2) Regarding brain lesion types, FV could induce the activation of bilateral S1-M1 in patients with basal ganglia hemorrhage, which was significantly higher than that in patients with basal ganglia ischemia. Additionally, LC showed no significant correlation with the modified Barthel index (MBI) in all patients, but a positive correlation with MBI in patients with basal ganglia lesions.

CONCLUSIONS

These results reveal that sensory stimulation can induce lesion-specific activation patterns of S1-M1. This indicates FV could be applied in a personalized manner based on the lesion-specific activation of S1-M1 in stroke patients with different lesion profiles and types. Our study may contribute to a better understanding of the underlying mechanisms of cortical reorganization.

Xuesaitong promotes myocardial angiogenesis in myocardial infarction mice by inhibiting MiR-3158-3p targeting Nur77

This study aims to investigate the regulatory effect of Xuesaitong (XST) and miR-3158-3p on angiogenesis. All mice were randomly assigned into Sham group, Model group, XST group, XST + miR-3158-3P-overexpression (miRNA-OE) group. XST was found to increase the left ventricular anterior wall thickness at end diastole and end systole (LVAWd and LVAWs), left ventricular internal dimension at end diastole and end systole (LVIDd and LVIDs), fractional shortening (FS), and ejection fraction (EF) and decrease the proportion of fibrotic areas in mice. In contrast to those in Sham group, the protein expressions of Nur77, p-PI3K, HIF-1α, VEGFs, COX-2 in the heart tissues of mice in Model group were elevated and further increased after XST treatment in comparison with those in Model group. Nur77-/- mice were utilized. It was found that XST enhanced cell viability through a methyl thiazolyl tetrazolium assay and facilitated angiogenesis in each group, as assessed by a catheter formation assay. Specifically, XST was shown to promote the formation of blood vessels. Moreover, the protein expression levels of Associated proteins in the heart tissues of Nur77-/- mice were dramatically reduced in mice in Model and XST group compared with those in WT mice. Additionally, the above-mentioned protein expressions in the heart tissues of Nur77-/- mice did not change significantly in mice in Model + miRNA-OE + XST group compared with those in WT mice, suggesting that miR-3158-3p can specifically inhibit the expression of Nur77. In conclusion, XST inhibits miR-3158-3p targeting Nur77 to facilitate myocardial angiogenesis in mice with myocardial infarction.

Psychometric properties of the 12-item Stroke-Specific Quality of Life Scale among stroke survivors in Hong Kong

The present study examined the psychometric properties of the 12-item Stroke-Specific Quality of Life Scale (SSQOL-12) in 184 stroke survivors in Hong Kong. The participants completed a self-report questionnaire including the SSQOL-12, SF-12 health survey, and validating variables at baseline and 148 stroke survivors completed SSQOL-12 two months later. Confirmatory factor analysis investigated the construct validity, reliability, and measurement invariance of SSQOL-12 across two months. Concurrent, convergent, and divergent validity was examined with respect to SF-12, hope, self-esteem, functional disability, anxiety, and depression. The original 2-factor model did not reveal a superior fit over the 1-factor model and a modified 1-factor model provided an acceptable fit to the data in both waves. The SSQOL-12 factor displayed substantial factor loadings (λ = 0.40-0.87), good internal consistency (Ω = 0.88), temporal stability (r = 0.70), and scalar measurement invariance across time. Stroke-specific quality of life was significantly associated with higher levels of SF-12, hope, and self-esteem and lower levels of functional disability, anxiety, and depression. Most correlations remained significant after controlling for demographic covariates and SF-12. The present findings offered empirical support for the validity and reliability of the unidimensional structure for SSQOL-12 as a measure of stroke-specific quality of life among stroke survivors.

Neuroimaging biomarkers of cognitive recovery after ischemic stroke

Post-stroke cognitive impairment affects more than one-third of patients after an ischemic stroke (IS). Identifying markers of potential cognitive recovery after ischemic stroke can guide patients' selection for treatments, enrollment in clinical trials, and cognitive rehabilitation methods to restore cognitive abilities in post-stroke patients. Despite the burden of post-stroke cognitive impairment, biomarkers of cognitive recovery are an understudied area of research. This narrative review summarizes and critically reviews the current literature on the use and utility of neuroimaging as a predictive biomarker of cognitive recovery after IS. Most studies included in this review utilized structural Magnetic Resonance Imaging (MRI) to predict cognitive recovery after IS; these studies highlighted baseline markers of cerebral small vessel disease and cortical atrophy as predictors of cognitive recovery. Functional Magnetic Resonance Imaging (fMRI) using resting-state functional connectivity and Diffusion Imaging are potential biomarkers of cognitive recovery after IS, although more precise predictive tools are needed. Comparison of these studies is limited by heterogeneity in cognitive assessments. For all modalities, current findings need replication in larger samples. Although no neuroimaging tool is ready for use as a biomarker at this stage, these studies suggest a clinically meaningful role for neuroimaging in predicting post-stroke cognitive recovery.

Multifaceted Assessment of Functional Outcomes in Survivors of First-time Stroke

IMPORTANCE

Because stroke causes diverse functional deficits, understanding the long-term recovery pattern of each functional domain may inform prognosis and therapeutic strategies.

OBJECTIVE

To observe long-term changes in functional status and residual disability in survivors of first-time stroke.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation. Between August 2012 and May 2015, 7858 of 10 636 screened patients with first-time strokes from 9 district hospitals in Korea provided informed consent to participate. Data were analyzed from September 2021 through February 2022.

EXPOSURE

First-time stroke.

MAIN OUTCOMES AND MEASURES

Study data include multifaceted face-to-face functional assessments obtained at 8 to 9 points until 60 months after stroke onset. The Korean Mini-Mental State Examination (K-MMSE), Fugl-Meyer Assessment, Functional Ambulatory Category, American Speech-Language-Hearing Association National Outcome Measurement System Swallowing Scale, and Short Korean version of the Frenchay Aphasia Screening Test were performed from 7 days to 60 months after stroke. The Korean Modified Barthel Index was measured from 3 months to 60 months after stroke.

RESULTS

A total of 4443 patients (2649 men [59.62%]; mean [SD] age 62.13 [12.43] years) who underwent repeated functional assessments for 60 months after stroke (3508 patients with ischemic and 935 patients with hemorrhagic stroke) were included. Overall, functions plateaued between 12 and 18 months after stroke and declined after 30 months; for example, mean (SD) K-MMSE improved from 7 days (22.89 [7.89]) to 12 months (26.03 [5.48]) (P < .001), plateaued until 36 months (26.03 [5.84]), and decreased to 48 months (26.02 [5.82]) (P < .001). Interaction associations were found between time after stroke and age, stroke severity, and stroke type in functional assessment outcomes. For example, mean (SE) FMA for ages 65 years or younger vs older than 65 years was 81.64 (0.63) vs 80.69 (0.68) at 7 days and 91.28 (0.47) vs 88.46 (0.58) at 6 months (P for interaction < .001), and for IS vs HS, it was 84.46 (0.47) vs 69.02 (1.24) at 7 days and 91.20 (0.38) vs 85.51 (0.98) at 6 months (P for interaction < .001). Mean (SE) FMA was 94.39 (0.21) at 7 days and 97.57 (0.14) at 6 months for mild stroke, 44.69 (1.18) at 7 days and 70.43 (1.21) at 6 months for moderate stroke, and 13.22 (0.99) at 7 days and 48.07 (2.62) at 6 months for severe stroke (P for interaction < .001). Factors associated with activities of daily living independence at 60 months included older age (β per 1-year increase = -0.35; standard error [SE], 0.03; P < .001), male sex (β = 2.12; SE, 0.73; P = .004), and hemorrhagic stroke type (β vs ischemic stroke = 2.35; SE, 0.81; P = .004).

CONCLUSIONS AND RELEVANCE

This study found that long-term recovery patterns in multifaceted functional domains differed from one another and varied by patient age, stroke severity, and stroke type. Understanding the diversity of long-term functional recovery patterns and factors associated with these outcomes in survivors of stroke may help clinicians develop strategies for effective stroke care and rehabilitation.

Health State Utility Values in People With Stroke: A Systematic Review and Meta-Analysis

Background Health state utility values are commonly used to provide summary measures of health-related quality of life in studies of stroke. Contemporaneous summaries are needed as a benchmark to contextualize future observational studies and inform the effectiveness of interventions aimed at improving post-stroke quality of life. Methods and Results We conducted a systematic search of the literature using Medline, EMBASE, and Web of Science from January 1995 until October 2020 using search terms for stroke, health-related quality of life, and indirect health utility metrics. We calculated pooled estimates of health utility values for EQ-5D-3L, EQ-5D-5L, AQoL, HUI2, HUI3, 15D, and SF-6D using random effects models. For the EQ-5D-3L we conducted stratified meta-analyses and meta-regression by key subgroups. We screened 14 251 abstracts and 111 studies met our inclusion criteria (sample size range 11 to 12 447). EQ-5D-3L was reported in 78% of studies (study n=87; patient n=56 976). The pooled estimate for EQ-5D-3L at ≥3 months following stroke was 0.65 (95% CI, 0.63-0.67), which was ≈20% below population norms. There was high heterogeneity (I2>90%) between studies, and estimates differed by study size, case definition of stroke, and country of study. Women, older individuals, those with hemorrhagic stroke, and patients prior to discharge had lower pooled EQ-5D-3L estimates. Conclusions Pooled estimates of health utility for stroke survivors were substantially below population averages. We provide reference values for health utility in stroke to support future clinical and economic studies and identify subgroups with lower healthy utility. Registration URL: https://www.crd.york.ac.uk/prospero/. Unique Identifier: CRD42020215942.

Predictors for the prognosis and recurrence of ischaemic stroke among young Chinese patients: a cohort study

OBJECTIVE

To identify predictors of young Chinese patients with ischaemic stroke outcome and recurrence of stroke.

DESIGN

Through considered the risk factors, neuroimaging findings, distribution, vascular stenosis, and the post-stroke treatment of young Chinese patients with ischemic stroke.

SETTING

The First Hospital of Jilin University.

PARTICIPANTS

We enrolled 579 patients (median age 45 years, range 15-49, men 81.0%) treated for the first occurrence of ischaemic stroke between January 2014 and December 2017.

MAIN OUTCOME MEASURES

We assessed stroke outcome based on the modified Rankin Scale (mRS) scores and recurrence of cerebrovascular events at 12 months. Multivariate logistic regression was used to identify the independent predictors of unfavourable outcomes (mRS score ≥2) and recurrence.

RESULTS

We observed stenosis in 295 patients (50.9%)-middle cerebral artery stenosis was the most common (18.1%). Of all 579 included patients, normal or mild, moderate and severe stenoses or occlusions were observed in 51.8%, 6.0% and 42.1% of patients, respectively. Unfavourable outcomes were observed in 91 patients (15.7%), including 10 patients (1.7%) who died. The rate of stroke recurrence was 7.9%. Independent predictors of unfavourable outcomes included a high National Institutes of Health Stroke Scale score (OR 1.151, 95% CI 1.094 to 1.210; p<0.001) and severe vascular stenosis or occlusion (OR 1.867, 95% CI 1.181 to 2.952; p=0.008). Predictors of recurrence included age of ≥45 years (OR 2.072, 95% CI 1.066 to 4.025; p=0.032) and atrial fibrillation (OR 15.207, 95% CI 4.273 to 54.120; p<0.001).

CONCLUSIONS

Our research shows that when developing prevention strategies for young people, measures that focus on mitigating risk factors should be considered. In addition, vascular screening of young populations is also of vital importance for stroke prevention and poor prognosis prediction.

Effect of Diabetes on Post-stroke Recovery: A Systematic Narrative Review

Background: Patients with stroke often have comorbid diabetes. Considering its detrimental effects on brain function, diabetes may increase the risk of poor recovery.

Methods: The aim of this review was to investigate the effect of diabetes on post-stroke recovery by a systematic review. Several specific aspects of post-stroke recovery, including activities of daily living (ADL), motor, cognitive, and quality of life (QOL) recovery, were examined. We searched the PubMed, SCOPUS, Embase, and Cochrane Library databases for relevant studies on the effect of diabetes on post-stroke recovery, published until May 26, 2021. A total of 52,051 potentially relevant articles were identified. After reading the titles and abstracts and assessing their eligibility based on full-text articles, 34 publications were included in this review.

Results: Of 29 studies that assessed ADL recovery after stroke, 22 studies suggested that diabetes had a negative effect on recovery of ADL after stroke. Regarding motor recovery, only one out of four studies showed that diabetes had some effect on motor recovery after stroke. Of the two studies on cognitive recovery, one reported that diabetes was an independent predictor of poor cognitive recovery after stroke. Three studies on QOL reported that a poor QOL after stroke was associated with the presence of diabetes.

Conclusions: The current review suggests that the post-stroke recovery of ADL seems to be poorer in patients with diabetes than patients without diabetes. Further, there are insufficient data to conclude the effect of diabetes on motor and cognitive recovery, but it may have some influence on the quality of life after stroke.

Systematic Review Registration: doi: 10.37766/inplasy2021.11.0032, identifier: INPLASY2021110032.

Study on collateral circulation level and prognosis of acute ischemic stroke by 4D CTA-CTP integrated technology and serum S100B

OBJECTIVE

To evaluate the cerebral collateral circulation in patients with acute ischemic stroke (AIS) by Four-dimensional CT angiography-CT perfusion (4D CTA-CTP)-integrated technology, and to explore the feasibility of predicting the prognosis of patients with AIS by using cerebral collateral circulation and serum S100B protein concentration.

METHODS

Thirty-two patients with anterior circulation AIS who underwent 4D CTA-CTP were retrospectively analysed. The level of cerebral collateral circulation was assessed by multi-phase CT angiography (mCTA) scores and regional leptomeningeal collateral (rLMC) scores. Combined with serum S100B protein concentration, multivariate binary logistic regression was used to explore the indicators that can independently predict the prognosis of AIS neurological function.

RESULTS

Univariate analysis showed that the baseline National Institutes of Health stroke scale score, rLMC score, and mCTA score were correlated with the neurological prognosis of patients with AIS; multivariate analysis showed that mCTA cerebral collateral circulation score was the only indicator that could independently predict the neurological prognosis of AIS patients (OR = 0.065, P = 0.030). The baseline serum S100B protein concentration could not independently predict the neurological prognosis of AIS patients.

CONCLUSION

mCTA cerebral collateral circulation scores can independently predict the neurological prognosis of patients with AIS. For the assessment of neurological prognosis of AIS patients, the cerebral collateral circulation phase score is better than the regional score.

Increased COVID-19 Mortality in People With Previous Cerebrovascular Disease: A Population-Based Cohort Study

BACKGROUND AND PURPOSE

The aim of the study was to determine the association between previous stroke and mortality after coronavirus disease 2019 (COVID-19) according to sex, age groups, and stroke subtypes.

METHODS

Prospective population-based cohort study including all COVID-19 positive cases between February 1 and July 31, 2020. Comorbidities and mortality were extracted using linked health administration databases. Previous stroke included transient ischemic attack, ischemic stroke, hemorrhagic stroke, spontaneous subarachnoid hemorrhage, and combined stroke for cases with more than one category. Other comorbidities were obesity, diabetes, hypertension, ischemic heart disease, atrial fibrillation, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, cirrhosis, dementia, individual socioeconomic index, and deprivation index. Cases were followed up until December 31, 2020. Primary outcome was mortality of any cause after COVID-19 positivity. Cox proportional regression analysis adjusted for comorbidities was used. Stratified analyses were performed for sex and age (<60, 60-79, and ≥80 years).

RESULTS

There were 91 629 COVID-19 cases. Previous strokes were 5752 (6.27%), of which 3887 (67.57%) were ischemic, 1237 (21.50%) transient ischemic attack, 255 (4.43%) combined, 203 (3.53%) hemorrhagic, and 170 (2.96%) subarachnoid hemorrhage. There were 9512 deaths (10.38%). Mortality was associated with previous stroke (hazard ratio [HR]=1.12 [95% CI, 1.06-1.18], P<0.001), in both sexes separately (men=1.13 [1.05-1.22], P=0.001; women=1.09 [1.01-1.18], P=0.023), in people <60 years (HR=2.97 [1.97-4.48], P<0.001) and 60 to 79 years (HR=1.32 [1.19-1.48], P<0.001) but not in people ≥80 years (HR=1.02 [0.96-1.09], P=0.437). Ischemic (HR=1.11 [1.05-1.18], P=0.001), hemorrhagic (HR=1.53 [1.20-1.96], P=0.001) and combined (HR=1.31 [1.05-1.63], P=0.016) strokes were associated but not transient ischemic attack. Subarachnoid hemorrhage was associated only in people <60 years (HR=5.73 [1.82-18.06], P=0.003).

CONCLUSIONS

Previous stroke was associated with a higher mortality in people younger than 80 years. The association occurred for both ischemic and hemorrhagic stroke but not for transient ischemic attack. These data might help healthcare authorities to establish prioritization strategies for COVID-19 vaccination.

Risk of Post-stroke Epilepsy Following Stroke-Associated Acute Symptomatic Seizures

Objective: Post-stroke epilepsy (PSE) is associated with increased morbidity and mortality. Stroke-associated acute symptomatic seizures are an important risk factor: 20.8–34.3% of these patients will go on to develop PSE. Identifying these “high risk” individuals may result in earlier PSE diagnosis, treatment, and avoidance of seizure-related morbidity. This study was to identify predictors of PSE development in patients with stroke-associated acute symptomatic seizures.

Participants and Methods: This was a retrospective cohort study of 167 patients with stroke-associated acute symptomatic seizures admitted to the Neurology Department of a tertiary Hospital of China, from 1 May 2006 to 30 January 2020. Both those with primary ischemic stroke and intracerebral hemorrhage were included in the study. Patient demographics, medical history, stroke-associated, and seizure-related variables were evaluated with univariable analysis and multivariable Cox regression analysis. PSE was defined as unprovoked seizures occurring > 7 days post-stroke. Data points were extracted from medical records and supplemented by tele-interview.

Results: Of the 167 patients with stroke-associated acute symptomatic seizures, 49 (29.3%) developed PSE. NIHSS score > 14 [hazard ratio (HR) 2.98, 95% CI 1.57–5.67], longer interval from stroke to acute symptomatic seizures (days 4–7 post-stroke) (HR 2.51, 95% CI 1.37–4.59) and multiple acute symptomatic seizures (HR 5.08, 95% CI 2.58–9.99) were independently associated with PSE development. This association remained in the sub-analysis within the ischemic stroke cohort. In the sub-analysis of the hemorrhagic stroke cohort, multilobar involvement (HR 4.80, 95% CI 1.49–15.39) was also independently associated with development of PSE. Further, we developed a nomogram to predict individual risk of developing PSE following stroke-associated acute symptomatic seizures. The nomogram showed a C-index of 0.73.

Conclusion: More severe neurofunctional deficits (NIHSS score > 14), longer interval from stroke to acute symptomatic seizures (days 4–7 post-stroke), and multiple acute symptomatic seizures were independently associated with development of PSE in patients with stroke-associated acute symptomatic seizures. This knowledge may increase clinical vigilance for development of PSE, facilitating rapid diagnosis and treatment initiation, and subsequently reduce seizure-related morbidity.

Prevalence of and factors associated with stroke in hypertensive patients in Thailand from 2014 to 2018: A nationwide cross-sectional study

Stroke is a significant cause of death and disability. In Thailand, it imposes a major health burden, and the prevalence of stroke is increasing, particularly in patients with hypertension (HT), diabetes mellitus (DM), and dyslipidemia (DLP). We aimed to determine the trends in the prevalence of stroke and the associated factors among Thai patients with HT. Nationwide cross-sectional studies were conducted annually in 2014, 2015 and 2018 based on data obtained from the Thailand DM/HT study. Nationally, representative patients with HT in Thailand were sampled with stratified one-stage cluster sampling. A total of 104,028 participants were included in this study. The prevalence of stroke remained constant, with prevalence rates of 4.0%, 3.8%, and 3.9% in 2014, 2015 and 2018, respectively (p for trend = 0.221). Our findings suggested that the management of stroke patients who are covered by the universal coverage scheme should be evaluated. Effective interventions, including promoting smoking cessation, attenuating cholesterol levels, and controlling blood pressure should be provided to hypertensive patients to prevent ischemic stroke. Young adults with HT should be more concerned about the possibility of stroke. The use of prophylactic low-dose aspirin should be carefully monitored to prevent hemorrhagic stroke.

The up-regulation of miR-21 by gastrodin to promote the angiogenesis ability of human umbilical vein endothelial cells by activating the signaling pathway of PI3K/Akt

Studies have shown that gastrodin has a protective effect on blood vessels. The purpose of this study was to investigate the influence of gastrodin on the angiogenesis ability of human umbilical vein endothelial cells (HUVECs) and its mechanism. We found that treatment of HUVECs with 10 µM and 25 µM gastrodin, and Vascular endothelial growth factor (VEGF) significantly upregulated the miR-21 expression in the cells. Meanwhile, gastrodin significantly increased the cell proliferation, migration and tube formation ability of HUVECs and increased the expression of MMP-2 and MMP-9 mRNA. In addition, gastrodin promoted the phosphorylation level of PI3K/Akt protein. However, down-regulating the miR-21 expression reduced the promoting effect of gastrodin on the HUVECs angiogenesis. In conclusion, gastrodin activates the PI3K/Akt pathway by up-regulating the miR-21 expression and promotes the HUVECs angiogenesis.

How outcomes are measured after spontaneous intracerebral hemorrhage: A systematic scoping review

Background and purpose

Recovery after intracerebral haemorrhage (ICH) is often slower than ischemic stroke. Despite this, ICH research often quantifies recovery using the same outcome measures obtained at the same timepoints as ischemic stroke. The primary objective of this scoping review is to map the existing literature to determine when and how outcomes are being measured in prospective studies of recovery after ICH.

Methods

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Web of Science from inception to November 2019, for prospective studies that included patients with ICH. Two investigators independently screened the studies and extracted data around timing and type of outcome assessment.

Results

Among the 9761 manuscripts reviewed, 395 met inclusion criteria, of which 276 were observational studies and 129 were interventional studies that enrolled 66274 patients. Mortality was assessed in 93% of studies. Functional outcomes were assessed in 85% of studies. The most frequently used functional assessment tool was the modified Rankin Scale (mRS) (60%), followed by the National Institute of Health Stroke Severity Scale (22%) and Barthel Index (21%). The most frequent timepoint at which mortality was assessed was 90 days (41%), followed by 180 days (18%) and 365 days (12%), with 2% beyond 1 year. The most frequent timepoint used for assessing mRS was 90 days (62%), followed by 180 days (21%) and 365 days (17%).

Conclusion

While most prospective ICH studies report mortality and functional outcomes only at 90 days, a significant proportion do so at 1 year and beyond. Our results support the feasibility of collecting long-term outcome data to optimally assess recovery in ICH.

Comparison between Ischemic and Hemorrhagic Strokes in Functional Outcome at Discharge from an Intensive Rehabilitation Hospital

Comparison studies on recovery outcomes in ischemic (IS) and hemorrhagic strokes (HS) have yielded mixed results. In this retrospective observational study of consecutive IS and HS patients, we aimed at evaluating functional outcomes at discharge from an intensive rehabilitation hospital, comparing IS vs. HS, analyzing possible predictors. Modified Rankin Scale (mRS) at discharge was the main outcome. Out of the 229 patients included (mean age 72.9 ± 13.9 years, 48% males), 81 had HS (35%). Compared with IS (n = 148), HS patients were significantly younger (75 ± 12.5 vs. 68.8 ± 15.4 years, p = 0.002), required longer hospitalizations both in acute (23.9 ± 36.7 vs. 35.2 ± 29.9 days, p = 0.019) and rehabilitation hospitals (41.5 ± 31.8 vs. 77.2 ± 51.6 days, p = 0.001), and had more severe initial clinical deficit (mean number of neurological impairments: 2.0 ± 1.1 vs. 2.6 ± 1.4, p = 0.001) and mRS scores at admission (p = 0.046). At discharge, functional status change, expressed as mRS, was not significantly different between IS and HS (F = 0.01, p = 0.902), nor was the discharge destination (p = 0.428). Age and clinical severity were predictors of functional outcome in both stroke types. On admission in an intensive rehabilitation hospital, HS patients presented a worse functional and clinical status compared to IS. Despite this initial gap, the two stroke types showed an overlapped trajectory of functional recovery, with age and initial stroke severity as the main prognostic factors.

Canadian stroke best practice recommendations: Management of Spontaneous Intracerebral Hemorrhage, 7th Edition Update 2020

Spontaneous intracerebral hemorrhage is a particularly devastating type of stroke with greater morbidity and mortality compared with ischemic stroke and can account for half or more of all deaths from stroke. The seventh update of the Canadian Stroke Best Practice Recommendations includes a new stand-alone module on intracerebral hemorrhage, with a focus on elements of care that are unique or affect persons disproportionately relative to ischemic stroke. Prior to this edition, intracerebral hemorrhage was included in the Acute Stroke Management module and was limited to its management during the first 12 h. With the growing evidence on intracerebral hemorrhage, a separate module focused on this topic across the care continuum was added. In addition to topics related to initial clinical management, neuroimaging, blood pressure management, and surgical management, new sections have been introduced addressing topics surrounding inpatient complications such as venous thromboembolism, seizure management, and increased intracranial pressure, rehabilitation as well as issues related to secondary management including lifestyle management, maintaining a normal blood pressure and antithrombotic therapy, are addressed. The Canadian Stroke Best Practice Recommendations (CSBPR) are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke and to promote optimal recovery and reintegration for people who have experienced stroke, including patients, families, and informal caregivers.

miR-331-3p Inhibits Inflammatory Response after Intracerebral Hemorrhage by Directly Targeting NLRP6

Background

The mechanism of inflammatory reaction after intracerebral hemorrhage remains unclear, which to some extent restrains the therapeutic development of hemorrhagic stroke. The present study attempts to verify whether NLRP6 plays an important role in inflammatory reaction after intracerebral hemorrhage and identify the critical microRNA during the process.

Methods

Suitable simulated cerebral hemorrhage environments were established in vitro and in vivo. BV2 cells were treated with hemin to induce cell damage. Collagenase was used to establish a model of mouse cerebral hemorrhage. The relationship among NLRP6, miR-331-3p, and the corresponding inflammatory expression was closely observed during this process. Techniques, such as western blot, real-time quantitative PCR, immunofluorescence, and immunocytochemistry, were used to detect the expression of relative genes and molecules in the in vitro and in vivo models.

Results

Downregulated miR-331-3p increased the expression of NLRP6 and alleviated the expression of TNF-α and IL-6. The neurological function recovery of mice was promoted after intracerebral hemorrhage.

Conclusion

miR-331-3p regulated the inflammatory response after cerebral hemorrhage by negatively regulating the expression of NLRP6.

Stroke in China: advances and challenges in epidemiology, prevention, and management

With over 2 million new cases annually, stroke is associated with the highest disability-adjusted life-years lost of any disease in China. The burden is expected to increase further as a result of population ageing, an ongoing high prevalence of risk factors (eg, hypertension), and inadequate management. Despite improved access to overall health services, the availability of specialist stroke care is variable across the country, and especially uneven in rural areas. In-hospital outcomes have improved because of a greater availability of reperfusion therapies and supportive care, but adherence to secondary prevention strategies and long-term care are inadequate. Thrombolysis and stroke units are accepted as standards of care across the world, including in China, but bleeding-risk concerns and organisational challenges hamper widespread adoption of this care in China. Despite little supporting evidence, Chinese herbal products and neuroprotective drugs are widely used, and the increased availability of neuroimaging techniques also results in overdiagnosis and overtreatment of so-called silent stroke. Future efforts should focus on providing more balanced availability of specialised stroke services across the country, enhancing evidence-based practice, and encouraging greater translational research to improve outcome of patients with stroke.

Health-related quality of life (HRQoL) after stroke: Positive relationship between lower extremity and balance recovery

Background: Stroke survivors have poor long-term quality of life (QoL), especially in the dimensions of mobility and daily activities. Objectives: We aimed to investigate how clinical variables influence QoL during subacute stroke rehabilitation. Methods: We assessed the evolution of the health-related QoL (HRQoL), the balance skills, the sensory-motor functions, and the ability in the activity of daily living in 25 hospitalized patients (60.6 ± 11.14 years old; 32% female) during a period of 2 months of stroke rehabilitation. We used the Stroke-Specific Quality of Life scale (SSQoL) to assess the HRQoL; the Berg Balance Scale to assess gait and balance functions; the Fugl-Meyer Assessment scale for sensory-motor functions of upper (UE) and lower limb (LE); and the Barthel Index for activity of daily living. All data have been investigated with the repeated-measures analysis of variance before and after normalization. Multiple Regression Analysis (MRA) has been performed on the normalized data and between the normalized data and the demographic characteristics (Gender; Age; Lesion side). Results: A significant improvement was found in all the assessed scales during the time of observation. MRA shows a positive regression between HRQoL and the motor recovery of LE and between HRQoL and the balance skills in 60 days from the stroke (MR = 0.88; respectively: p = 0.004 and p = 0.02). Conclusions: Our result shows that LE motor recovery impacts the QoL more than motor recovery of UE after 60 days of neurorehabilitation. This finding is strengthened by a positive regression between balance skills and QoL.

Trends in Outcomes of Patients With Ischemic Stroke Treated Between 2002 and 2016

Background:

Little is known about long-term trends in outcomes of patients with ischemic stroke in China. We aimed to assess longitudinal trends in these outcomes over the past 15 years in China and explore possible factors behind the trends.

Methods and Results:

Patients with ischemic stroke admitted to the Department of Neurology at West China Hospital were prospectively and consecutively enrolled in a central registry since 2002, and the present study analyzed data from those admitted to hospital within 7 days of stroke during the period 2002 to 2016. Patients were binned into three 5-year intervals for temporal analysis. Death, disability, and death/disability at 3 and 12 months after stroke were compared among the time intervals across the entire sample and in subsets stratified by age (<65 or ≥65 years). To explore the possible factors related to the trends in outcomes, interaction between the factors and time on outcomes was entered separately into the multivariable logistic regression model. Of 6462 patients with ischemic stroke in the final analysis, 3837 (59.4%) were men, and mean age was 64.2 years (SD, 13.7). Mean age at stroke onset and National Institutes of Health Stroke Scale score at admission decreased significantly during the 15-year period ( P <0.001). Between 2002 to 2006 and 2012 to 2016, cumulative incidences declined significantly for death at 3 months (from 9.6% to 6.4%), disability at 3 months (from 36.8% to 28.7%), and death/disability at 3 months (from 42.9% to 33.3%), as well as for death at 12 months (from 15.9% to 10.7%), disability at 12 months (from 23.2% to 17.6%), and death/disability at 12 months (from 35.4% to 26.4%; all P <0.001). The decreases in disability and death/disability at 3 and 12 months between 2002 to 2006 and 2012 to 2016 remained significant after adjusting for confounders, and the results were similar for the entire cohort and for subgroups of patients <65 or ≥65 years. Only interactions of National Institutes of Health Stroke Scale score on admission and time period (2012–2016) were found to significantly correlate with disability and death/disability at 3 and 12 months (all P ≤0.03).

Conclusions:

Our study from a large medical center in southwest China suggests that since 2002, risks of disability and death/disability at 3 and 12 months after ischemic stroke have declined. This appears to be due, at least in part, to a significant decline in National Institutes of Health Stroke Scale score on admission, which may reflect greater public awareness of stroke detection, willingness to seek medical attention, and ease of access to healthcare infrastructure. The factors behind this apparent improvement require further study.

The Prevalence of Dyslipidemia and Hyperglycemia among Stroke Patients: Preliminary Findings

Background/Aim

Stroke or cerebrovascular accident is defined as sudden or sub acute onset of focal neurologic deficit, caused by the interruption of blood flow to parts of the brain. In this study, we aimed to investigate the prevalence of dyslipidemia and hyperglycemia among stroke patients in Palestine.

Materials and Methods

A total of 70 patients with stroke were included in a cross-sectional study between November 2017 and February 2018. Stroke patients were diagnosed based on a CT scan reviewed by a neurologist. Fasting venous blood samples were collected to measure the lipid profile (cholesterol, low-density lipoproteins (LDL), triacylglycerol (TAG), high-density lipoproteins (HDL)), fasting blood glucose (FBG), and glycosylated hemoglobin (Hb_A1c) levels. An interview-based questionnaire, included background data, past medical history, family history, and other risk factors for stroke, was filled for each patient.

Results

Based on our results, 28.57% of patients had high LDL, 17.1% had high cholesterol, 15.7% had high TAG and 61.3% had low HDL. About half of the patients (51.4%) had abnormal Hb_A1c and abnormal FBG (52.8%). The majority (67.1%) of patients were males, whereas, 11% of patients were obese (BMI of more than 30 kg/m²) and 51.4% were smokers. Regarding the family history of diseases, 81% of patients had a family history of hypertension, 50% had a family history of stroke, and 58% had a family history of diabetes mellitus.

Conclusion

Male gender and smoking were most likely to increase the risk of stroke. Risk factors like low HDL, high LDL, high FBG, high Hb_A1c, and hypertension contribute substantially to the incidence of stroke. A family history of stroke, hypertension and diabetes were significant risk factors for stroke.

Temporal Trends and Predictors of Drug Utilization and Outcomes in First-Ever Stroke Patients: A Population-Based Study Using the Singapore Stroke Registry

INTRODUCTION

Drug utilization and outcomes research in multi-ethnic Asian stroke populations is lacking.

OBJECTIVES

Our objective was to examine temporal trends and predictors of drug utilization and outcomes in a multi-ethnic Asian stroke population.

METHODS

This registry-based study included ischemic and hemorrhagic first-ever stroke patients hospitalized between 2009 and 2016. Utilization of medications included in-hospital thrombolytic agents, early antithrombotics (antiplatelets, anticoagulants) within 48 h of admission, and antithrombotics and statins at discharge. Outcomes analyzed were in-hospital all-cause mortality; 28-day, 90-day, and 1-year case fatality (CF); and discharge destination.

RESULTS

Of the 36,615 included patients, 81.6% had ischemic stroke and 18.4% had hemorrhagic stroke (15.5% intracerebral hemorrhage [ICH] and 2.8% subarachnoid hemorrhage [SAH]). For ischemic stroke, the combined use of all three guideline medications (in-hospital thrombolytic therapy, as well as antithrombotics and statins at discharge) increased (P = 0.006). Being on the stroke pathway was associated with prescription of all three guideline medications in ischemic stroke. Decreasing trends for in-hospital mortality, 28-day, 90-day, and 1-year CF and proportion of patients discharged home without rehabilitation appointment were observed in ischemic stroke (P < 0.05) but not in ICH or SAH (apart from 28-day CF). Ischemic stroke patients who received guideline medications were less likely to die or be discharged to nursing homes and chronic sick hospitals. Hemorrhagic stroke patients prescribed statins at discharge were less likely to have 28-day and 1-year CF.

CONCLUSIONS

Prescription of secondary stroke preventive medications (particularly in ischemic stroke) was associated with more favorable outcomes, highlighting the importance of physician adherence to evidence-based pharmacotherapy.

The Third China National Stroke Registry (CNSR-III) for patients with acute ischaemic stroke or transient ischaemic attack: design, rationale and baseline patient characteristics

Background and purpose

Stroke is the leading cause of mortality and disability in China. Precise aetiological classification, imaging and biological markers may predict the prognosis of stroke. The Third China National Stroke Registry (CNSR-III), a nationwide registry of ischaemic stroke or transient ischaemic attack (TIA) in China based on aetiology, imaging and biology markers, will be considered to clarify the pathogenesis and prognostic factors of ischaemic stroke.

Methods

Between August 2015 and March 2018, the CNSR-III recruited consecutive patients with ischaemic stroke or TIA from 201 hospitals that cover 22 provinces and four municipalities in China. Clinical data were collected prospectively using an electronic data capture system by face-to-face interviews. Patients were followed for clinical outcomes at 3 months, 6 months and 1–5 year annually. Brain imaging, including brain MRI and CT, were completed at baseline. Blood samples were collected and biomarkers were tested at baseline.

Results

A total of 15 166 stroke patients were enrolled, among which 31.7% patients were women with the average age of 62.2±11.3 years. Ischaemic stroke was predominant (93.3%, n=14 146) and 1020 (6.7%) TIAs were enrolled.

Conclusions

CNSR-III is a large scale nationwide registry in China. Data from this prospective registry may provide opportunity to evaluate imaging and biomarker prognostic determinants of stroke.

Sex-Specific Differences in Clinical Characteristics and Outcomes Among Patients with Vascular Abnormality-Related Intracerebral Hemorrhage

BACKGROUND

Results are conflicting as to whether sex has an impact on the outcome of intracerebral hemorrhage (ICH), especially when etiologies differ. In this study, we investigated whether sex differences exist in patients with vascular abnormality-related ICH.

METHODS

Patients (age ≥18 years) diagnosed with ICH within 7 days of symptom onset were admitted consecutively between January 2012 and February 2014 from 50 hospitals across mainland China. Vascular abnormality related to ICH included aneurysm, arteriovenous malformation, moyamoya disease, and cavernous malformation. The outcomes were death and death/disability at 3 months. Disability was defined as modified Rankin Scale score >2. Multivariable logistic regression was used to estimate the association between sex and outcome.

RESULTS

Women accounted for 41.9% (170) of the 406 patients, and they tended to be older than the men (women: 43.5 ± 19.3 years; men: 40.0 ± 17.7 years; P = 0.056). The proportions of ICH-related vascular abnormalities were as follows: aneurysm, 32% (130/406); arteriovenous malformation, 50.3% (204/406); moyamoya disease, 11.3% (46/406); and cavernous malformation, 6.4% (26/406). After we adjusted for age, National Institute of Health Stroke Scale, Glasgow Coma Scale score, location of hemorrhage, and surgery, female sex remained an independent predictor of death/disability at 3 months (odd ratio 2.49, 95% confidence interval 1.31-4.75), but not for death alone (odd ratio 1.45, 95% confidence interval 0.58-3.61).

CONCLUSIONS

In our study, female sex was an independent risk factor for poor outcomes in patients with vascular abnormality-related ICH. The factors contributing to this sex difference should be investigated in the future.

MiR-191 inhibit angiogenesis after acute ischemic stroke targeting VEZF1

Acute ischemic stroke (AIS) is a major public health problem in China. Impaired angiogenesis plays crucial roles in the development of ischemic cerebral injury. Recent studies have identified that microRNAs (miRNAs) are important regulators of angiogenesis, but little is known the exact effects of angiogenesis-associated miRNAs in AIS. In the present study, we detected the expression levels of angiogenesis-associated miRNAs in AIS patients, middle cerebral artery occlusion (MCAO) rats, and oxygen-glucose deprivation/reoxygenation (OGD/R) human umbilical vein endothelial cells (HUVECs). MiR-191 was increased in the plasma of AIS patients, OGD/R HUVECs, and the plasma and brain of MCAO rats. Over-expression of miR-191 promoted apoptosis, but reduced the proliferation, migration, tube-forming and spheroid sprouting activity in HUVECs OGD/R model. Mechanically, vascular endothelial zinc finger 1 (VEZF1) was identified as the direct target of miR-191, and could be regulated by miR-191 at post-translational level. In vivo studies applying miR-191 antagomir demonstrated that inhibition of miR-191 reduced infarction volume in MCAO rats. In conclusion, our data reveal a novel role of miR-191 in promoting ischemic brain injury through inhibiting angiogenesis via targeting VEZF1. Therefore, miR-191 may serve as a biomarker or a therapeutic target for AIS.

Microembolic Signals is Associated With Insulin Resistance Among Acute Ischemic Stroke Patients

BACKGROUND

Microembolic signals (MES) and insulin resistance (IR) is common in patients with acute ischemic stroke (AIS). Patients with active MES tend to be more seriously ill and prone to aggravating disease progression. IR is an important risk factor for stroke which has been found to be associated with the severity of stroke. This study aims to investigate the clinical correlation between intracranial MES and IR in AIS patients.

METHODS

A total of 119 patients with AIS were enrolled in this study. The IR index (HOMA-IR) was calculated according to the homeostasis model and divided into 4 levels, where IR was defined by HOMA-IR index in the top quartile (Q4). Transcranial Doppler Sonography was performed in all patients within 72 hours after the stroke onset to monitor arterial MES in the lesion side of the brain for 30 minutes.

RESULTS

It is found that the positive rate of MES increased with the increase of IR level. The positive rate of MES in IR group was 55.2% (16/29), and that in non-IR group was 32.2% (29/90). In addition, HOMA-IR in patients with MES- were significantly lower than those in patients with MES+ (1.6 [Interquartile range: 0.9-2.5] compared with 2.2 [Interquartile range: 1.3-4.1], P < .05).In multiple logistic regression analysis, we calculated the OR of MES as compared with the HOMA-IR. The result of OR value is 1.38 (95% confidence interval: 1.05-1.82, P = .02).

CONCLUSIONS

IR is positively related to MES in patients with AIS. Higher level of IR might contribute to plaque destabilization and the formation of MES, which finally leading to the occurrence of stroke.

Increased center of pressure trajectory of the finger during precision grip task in stroke patients

The aim of this study was to assess the spatial stability of stroke patients while holding a freely movable object. Twenty-two acute stroke patients with mild hand impairment performed a grip and lift task using the thumb and index finger. The displacement of the center of pressure (COP) trajectory, the grip force (GF) and several clinical parameters were monitored. Although the GF was not different between paretic and nonparetic hands, the COP trajectory of the paretic index finger was increased. Moreover, the COP trajectories of the thumb and index finger in hemorrhagic patients were longer than those in ischemic patients. These discrepancies between kinetic parameters suggest that different aspects of grip force control may be considered in patients with mild stroke.

Post-stroke neovascularization and functional outcomes differ in diabetes depending on severity of injury and sex: Potential link to hemorrhagic transformation

Diabetes is associated with increased risk and worsened outcome of stroke. Previous studies showed that male diabetic animals had greater hemorrhagic transformation (HT), profound loss of cerebral vasculature, and poor behavioral outcomes after ischemic stroke induced by suture or embolic middle cerebral artery occlusion (MCAO). Females are protected from stroke until reaching the menopause age, but young females with diabetes have a higher risk of stroke and women account for the majority of stroke mortality. The current study postulated that diabetes is associated with greater vascular injury and exacerbated sensorimotor and cognitive outcome after stroke even in young female animals. Male and female control and diabetic animals were subjected to transient MCAO and followed for 3 or 14 days to assess the neurovascular injury and repair. The vascularization indices after stroke were lower in male diabetic animals with 90-min but not 60-min ischemia/reperfusion injury, while there was no change in female groups. Cognitive deficits were exacerbated in both male and female groups regardless of the injury period, while the sensorimotor dysfunction was worsened in male diabetic animals with longer ischemia time. These results suggest that diabetes negates the protection afforded by sex in young female animals, and post-stroke vascularization pattern is influenced by the degree of injury and correlates with functional outcome in both sexes. Vasculoprotection after acute ischemic stroke may provide a novel therapeutic strategy in diabetes.

Interactions among variants in TXA2R, P2Y12 and GPIIIa are associated with carotid plaque vulnerability in Chinese population

PURPOSE

The associations between variants in platelet activation-relevant genes and carotid plaque vulnerability are not fully understood. The aim of the present study was to investigate the associations of the variants in platelet activation-relevant genes and interactions among these variants with carotid plaque vulnerability.

RESULTS

There were no significant differences in the frequencies of genotypes of the 11 variants between patients and controls. Among 396 patients, 102 patients had not carotid plaque, 106 had VP, and 188 had SP. The 11 variants were not independently associated with risk of carotid plaque vulnerability after adjusting for potential confounding variables. However, the GMDR analysis showed that there were synergistic effects of gene-gene interactions among TXA2Rr s1131882, GPIIIa rs2317676 and P2Y12 rs16863323 on carotid plaque vulnerability. The high-risk interactions among the three variants were associated with high platelet activation, and independently associated with the risk of carotid plaque vulnerability.

METHODS

Eleven variants in platelet activation-relevant genes were examined using mass spectrometry methods in 396 ischemic stroke patients and 291controls. Platelet-leukocyte aggregates and platelet aggregation were also measured. Carotid plaques were assessed by B-mode ultrasound. According to the results of ultrasound, the patients were stratified into three groups: non-plaque group, vulnerable plaque (VP) group and stable plaque (SP) group. Furthermore, gene-gene interactions were analyzed using generalized multifactor dimensionality reduction (GMDR) methods.

CONCLUSIONS

The rs1131882, rs2317676, and rs16863323 three-loci interactions may confer a higher risk of carotid plaque vulnerability, and might be potential markers for plaque instability.

Platelet function-guided modification in antiplatelet therapy after acute ischemic stroke is associated with clinical outcomes in patients with aspirin nonresponse

PURPOSE

To investigate the association of clinical outcomes with platelet function-guided modification in antiplatelet therapy in patients with ischemic stroke.

RESULTS

Among 812 patients, 223 patients had aspirin nonresponse, 204 patients was modified in antiplatelet therapy after platelet function testing. Mean follow-up period was 4.8 ± 1.7 years (ranged from 1 to 6.4 years). The incidence rates of ischemic events, death, or bleeding events were not significantly different between the patients with and without antiplatelet therapy modification. However, in patients with aspirin nonresponse, antiplatelet therapy modification was associated with decreased ischemic events (hazard ratio, 0.67; 95% confidence interval [CI], 0.62-0.97; P = 0.01) and ischemic stroke (hazard ratio, 0.70; 95% CI, 0.63-0.98; P = 0.03) compared with no modification in antiplatelet therapy.

CONCLUSIONS

In patients with aspirin nonresponse, platelet function-guided modification in antiplatelet therapy after an ischemic stroke was associated with significantly lower rate of ischemic events. The platelet function testing may be useful to guide antiplatelet therapy modification.

METHODS

This is a retrospective, multicentre study. From August 2010 to December 2014, 812 patients with ischemic stroke underwent platelet function testing using platelet aggregation. Antiplatelet therapy modification was defined as any change in antiplatelet therapy after testing, including increasing aspirin dosage, adding an additional antiplatelet agent to aspirin, or switching to a more potent antiplatelet agent. The primary outcome was ischemic events. Secondary outcomes included death and bleeding events. Clinical outcomes were compared between patients with and without antiplatelet therapy modification using univariate and propensity score-adjusted analyses.

Characteristics, management and response to alteplase in China versus non-China participants of the ENCHANTED trial

Background

The characteristics of patients with acute ischaemic stroke (AIS) and their management vary across regions, which may influence outcomes. We examined for differential patterns of outcome between China and non-China participants of the ENhanced Control of Hypertension And Thrombolysis strokE stuDy (ENCHANTED), which tested different alteplase doses in AIS.

Methods

ENCHANTED was an international, multicentre, open, blinded-endpoint trial of the effects of low-dose (0.6 mg/kg) versus standard-dose (0.9 mg/kg) intravenous alteplase on 90-day disability outcomes and symptomatic intracerebral haemorrhage (sICH) in 3310 patients with AIS.

Results

Participants (n=1419, 48%) in China were younger, and more often male, hypertensive and with prior stroke and coronary artery disease, but less likely to have atrial fibrillation and use antihypertensive, antithrombotic and lipid-lowering agents, compared with non-China patients with AIS. Although China participants had more AIS due to large artery occlusion, were treated later and had differing ancillary management, there was no significant difference in 90-day modified Rankin scale scores 2–6 (55.6% vs 47.8%; OR, adjusted for baseline and management factors 0.87 (95% CI 0.71 to 1.07; p=0.20)) and risk of sICH (Safe Implementation of Thrombolysis in Stroke-Monitoring Study criteria: 1.4% vs 1.8%; p=0.12) compared with non-China participants. There was no heterogeneity in the treatment effects of low-dose versus standard-dose alteplase between China and non-China participants.

Conclusion

Patients with AIS recruited to the ENCHANTED trial in China had similar outcomes in response to thrombolysis treatment despite significantly differing demographic, clinical and management factors to patients with AIS in other regions.

Risk of dementia in patients with non-haemorrhagic stroke receiving acupuncture treatment: a nationwide matched cohort study from Taiwan's National Health Insurance Research Database

OBJECTIVE

To investigate the risk of dementia in patients with stroke who did and did not receive acupuncture treatment.

DESIGN

Retrospective cohort study.

SETTING

This study was based on Taiwan's National Health Insurance Research Database that included patients with stroke hospitalised between 1 January 2000 and 31 December 2004.

PARTICIPANTS

We identified 11 220 patients aged 50 years and older with newly diagnosed stroke hospitalisation.

PRIMARY AND SECONDARY OUTCOME MEASURES

We compared the incident dementia during the follow-up period until the end of 2009 in patients with stroke who did and did not receive acupuncture. The adjusted HRs and 95% CIs of dementia associated with acupuncture were calculated in multivariate Cox proportional hazard regressions.

RESULTS

Acupuncture treatment was associated with a decreased risk of dementia with multivariate adjustment (HR, 0.73; 95% CI 0.66 to 0.80), and the association was significant in both sexes and every age group, as well as in groups with ischaemic stroke, with fewer medical conditions and those hospitalised after stroke. Patients with stroke received acupuncture treatment, and conventional rehabilitation was associated with a significantly reduced risk of poststroke dementia (HR, 0.64; 95% CI 0.56 to 0.74).

CONCLUSIONS

This study raises the possibility that patients with non-haemorrhagic stroke who received acupuncture had a reduced risk of dementia. The results suggest the need for prospective sham-controlled and randomised trials to establish the efficacy of acupuncture in preventing dementia.

Association of body mass index with mortality and functional outcome after acute ischemic stroke

The relation between obesity and stroke outcome has been disputed. This study was aimed to determine the association of body mass index (BMI) with mortality and functional outcome in patients with acute ischemic stroke. Data were from a national, multi-centre, prospective, hospital-based register: the ChinaQUEST (Quality Evaluation of Stroke Care and Treatment) study. Of 4782 acute ischemic stroke patients, 282 were underweight (BMI < 18.5 kg/m²), 2306 were normal-weight (BMI 18.5 to < 24 kg/m²), 1677 were overweight (BMI 24 to <28 kg/m²) and 517 were obese (BMI ≥ 28 kg/m²). The risks of death at 12 months and death or high dependency at 3 and 12 months in overweight (HR: 0.97, 95% CI: 0.78–1.20; OR: 0.93, 95% CI: 0.80–1.09; OR: 0.95, 95% CI: 0.81–1.12) and obese patients (HR: 1.07, 95% CI: 0.78–1.48; OR: 0.96, 95% CI: 0.75–1.22; OR: 1.06, 95% CI: 0.83–1.35) did not differ from normal-weight patients significantly after adjusting for baseline characteristics. Underweight patients had significantly increased risks of these three outcomes. In ischemic stroke patients, being overweight or obese was not associated with decreased mortality or better functional recovery but being underweight predicted unfavourable outcomes.

Importance and Difficulties of Pursuing rTMS Research in Acute Stroke

Although much research has been done on repetitive transcranial magnetic stimulation (rTMS) in chronic stroke, only sparse research has been done in acute stroke despite the particularly rich potential for neuroplasticity in this stage. We attempted a preliminary clinical trial in one active, high-quality inpatient rehabilitation facility (IRF) in the -United States. But after enrolling only 4 patients in the grant period, the study was stopped because of low enrollment. The purpose of this paper is to offer a perspective describing the important physiologic rationale for including rTMS in the early phase of stroke, the reasons for our poor patient enrollment in our attempted study, and recommendations to help future studies succeed. We conclude that, if scientists and clinicians hope to enhance stroke outcomes, more attention must be directed to leveraging conventional rehabilitation with neuromodulation in the acute phase of stroke when the capacity for neuroplasticity is optimal. Difficulties with patient enrollment must be addressed by reassessing traditional inclusion and exclusion criteria. Factors that shorten patients' length of stay in the IRF must also be reassessed at all policy-making levels to make ethical decisions that promote higher functional outcomes while retaining cost consciousness.

Management of intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a potentially devastating neurologic injury representing 10-15% of stroke cases in the USA each year. Numerous risk factors, including age, hypertension, male gender, coagulopathy, genetic susceptibility, and ethnic descent, have been identified. Timely identification, workup, and management of this condition remain a challenge for clinicians as numerous factors can present obstacles to achieving good functional outcomes. Several large clinical trials have been conducted over the prior decade regarding medical and surgical interventions. However, no specific treatment has shown a major impact on clinical outcome. Current management guidelines do exist based on medical evidence and consensus and these provide a framework for care. While management of hypertension and coagulopathy are generally considered basic tenets of ICH management, a variety of measures for surgical hematoma evacuation, intracranial pressure control, and intraventricular hemorrhage can be further pursued in the emergent setting for selected patients. The complexity of management in parenchymal cerebral hemorrhage remains challenging and offers many areas for further investigation. A systematic approach to the background, pathology, and early management of spontaneous parenchymal hemorrhage is provided.

Illuminating the Effects of Stroke on the Diabetic Brain: Insights From Imaging Neural and Vascular Networks in Experimental Animal Models

Type 1 diabetes is known to cause circulatory problems in the eyes, heart, and limbs, and the brain is no exception. Because of the insidious effects of diabetes on brain circulation, patients with diabetes are two to four times more likely to have an ischemic stroke and are less likely to regain functions that are lost. To provide a more mechanistic understanding of this clinically significant problem, imaging studies have focused on how stroke affects neural and vascular networks in experimental models of type 1 diabetes. The emerging picture is that diabetes leads to maladaptive changes in the cerebrovascular system that ultimately limit neuronal rewiring and recovery of functions after stroke. At the cellular and systems level, diabetes is associated with abnormal cerebral blood flow in surviving brain regions and greater disruption of the blood-brain barrier. The abnormal vascular responses to stroke can be partly attributed to aberrant vascular endothelial growth factor (VEGF) signaling because genetic or pharmacological inhibition of VEGF signaling can mitigate vascular dysfunction and improve stroke recovery in diabetic animals. These experimental studies offer new insights and strategies for optimizing stroke recovery in diabetic populations.

Intracerebral hemorrhage and cognitive impairment

Vascular cognitive impairment and vascular dementia are composed of cognitive deficits resulted from a range of vascular lesions and pathologies, including both ischemic and hemorrhagic. However the contribution of spontaneous intracerebral hemorrhage presumed due to small vessel diseases on cognitive impairment is underestimated, in contrast to the numerous studies about the role of ischemic vascular disorders on cognition. In this review we summarize recent findings from clinical studies and appropriate basic science research to better elucidate the role and possible mechanisms of intracerebral hemorrhage in cognitive impairment and dementia. This article is part of a Special Issue entitled: Vascular Contributions to Cognitive Impairment and Dementia edited by M. Paul Murphy, Roderick A. Corriveau and Donna M. Wilcock.

Delayed inhibition of VEGF signaling after stroke attenuates blood-brain barrier breakdown and improves functional recovery in a comorbidity-dependent manner

Diabetes is a common comorbidity in stroke patients and a strong predictor of poor functional outcome. To provide a more mechanistic understanding of this clinically relevant problem, we focused on how diabetes affects blood-brain barrier (BBB) function after stroke. Because the BBB can be compromised for days after stroke and thus further exacerbate ischemic injury, manipulating its function presents a unique opportunity for enhancing stroke recovery long after the window for thrombolytics has passed. Using a mouse model of Type 1 diabetes, we discovered that ischemic stroke leads to an abnormal and persistent increase in vascular endothelial growth factor receptor 2 (VEGF-R2) expression in peri-infarct vascular networks. Correlating with this, BBB permeability was markedly increased in diabetic mice, which could not be prevented with insulin treatment after stroke. Imaging of capillary ultrastructure revealed that BBB permeability was associated with an increase in endothelial transcytosis rather than a loss of tight junctions. Pharmacological inhibition (initiated 2.5 d after stroke) or vascular-specific knockdown of VEGF-R2 after stroke attenuated BBB permeability, loss of synaptic structure in peri-infarct regions, and improved recovery of forepaw function. However, the beneficial effects of VEGF-R2 inhibition on stroke recovery were restricted to diabetic mice and appeared to worsen BBB permeability in nondiabetic mice. Collectively, these results suggest that aberrant VEGF signaling and BBB dysfunction after stroke plays a crucial role in limiting functional recovery in an experimental model of diabetes. Furthermore, our data highlight the need to develop more personalized stroke treatments for a heterogeneous clinical population.

Poor Utility of Grading Scales in Acute Intracerebral Hemorrhage: Results from the Interact2 Trial

Background

Several simple clinical grading scores have been developed for intracerebral hemorrhage, primarily to predict 30-day mortality.

Aims

We aimed to determine the accuracy of three popular scores (original intracerebral hemorrhage, modified intracerebral hemorrhage, and intracerebral hemorrhage grading scale) on 30-day mortality and 90-day death or major disability, and whether the magnitude of benefit varies according to prognosis graded by the three predictive scores.

Methods

Data from the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial which included 2839 intracerebral hemorrhage patients (<6 hours) and elevated systolic blood pressure (150–220 mmHg), randomized to intensive (target systolic blood pressure <140 mmHg) or guideline-based (<180 mmHg) blood pressure management. Discrimination of scales for predicting death and poor outcome (modified Rankin scale 3–6) was evaluated in area under receiver operator characteristic curves.

Results

Among 2556 (90%) participants with available data, the modified intracerebral hemorrhage had the highest discrimination (receiver operator characteristic 0·75) for 90-day poor outcome compared with the original intracerebral hemorrhage (receiver operator characteristic 0·68) and intracerebral hemorrhage grading scale (receiver operator characteristic 0·69). All scores had good positive predictive value (approximately 80–90%) for poor outcome but poor sensitivity and positive predictive value for death. The scores do not clearly discriminate a patient group most likely to benefit from blood pressure lowering.

Conclusions

Intracerebral hemorrhage prognostic scores are not useful in defining patients at high probability of early death, but they are reliable for predicting poor outcome, defined by death or major disability. Potential benefits of early intensive blood pressure lowering are broadly applicable across grades of severity defined by such scores.

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage.

METHODS

A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee.

RESULTS

Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated.

CONCLUSIONS

Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

Management and Outcomes Among Chinese Hospitalized Patients With Established Cardiovascular Disease or Multiple Risk Factors

We assessed the management and outcomes among hospitalized patients with coronary artery disease (CAD), stroke, peripheral artery disease (PAD), or with multiple (≥2) cardiovascular (CV) risk factors (multiple risk factors [MRFs]). We retrospectively studied 3732 hospitalized patients of either CV disease or ≥2 risk factors for atherothrombosis from October 2004 to January 2005. Outcomes included CV death, myocardial infarction (MI), stroke, and hospitalization for atherothrombotic events. About one-third had disease involving ≥1 vascular bed. Medication was more intense in patients with CAD than in others. The lowest use of statins and antiplatelet treatment was in the PAD-only group. Patients with PAD experienced a higher CV mortality (5.1%) than the patients with CAD (3.73%) or stroke (4.1%), P < .001. Cardiovascular death ranged from 1.2% for patients with MRFs, 2.8% for patients with 1-bed disease, 4.7% for patients with 2-bed disease to 6.4% for patients with 3-bed disease ( P for trend <.001). For hospitalized patients with established atherosclerotic arterial disease, a substantial increase in CV event rates occurs with increasing numbers of affected arterial beds. Patients with PAD were at an especially high risk.

Troublesome heterotopic ossification and stroke: Features and risk factors. A case control study

PRIMARY OBJECTIVE

To determine the features of stroke-related HO in a large sample of patients and to assess if HO risk is increased by haemorrhagic stroke.

RESEARCH DESIGN

A case control study (risk factor of a rare event using retrospective analysis).

METHODS AND PROCEDURES

Sixty-one patients with stroke-81 troublesome HOs-were included, each was matched with four controls, i.e. 244 patients with no HO after stroke. Matching criteria were age (±3.5 years) and sex. Data recorded were time from stroke to surgery, ischaemic or haemorrhagic stroke and presence of HO risk factors.

MAIN OUTCOMES AND RESULTS

Mean age at time of stroke = 46.02 ± 11.4 years (15.9-76.3) for the case sub-group. Time from stroke to surgery = 23.4 ± 27.8 months (3.6-150.0). There was a significant relationship between haemorrhagic stroke and HO development (OR = 3.01; 95% CI = 1.14-7.98; p < 0.05), but not for ischaemic stroke. This became non-significant when all matching and risk factors were included in the model (adjusted OR = 1.98; 95% CI = 0.60-6.54; p = 0.26).

CONCLUSION

Haemorrhagic stroke appears to increase the risk of HO development. Further studies are required to determine if this risk factor is independent from other comorbid factors.

Outcome of Intensive Care Unit-Dependent, Tracheotomized Patients with Cerebrovascular Diseases

BACKGROUND

Outcome studies in intensive care unit -dependent, tracheotomized, and mechanical ventilated patients with cerebrovascular disease (CVD) are scarce.

METHODS

In a retrospective approach, we analyzed the outcome of 143 patients with ischemic stroke (IS), primary intracerebral hemorrhage (PICH), and subarachnoid hemorrhage (SAH). To measure the potential benefit of in-patient rehabilitation, we used the Functional Independence Measure (FIM). In addition, weaning and rehabilitation duration, duration of mechanical ventilation (MV) in the acute care hospital (preweaning), and mortality rates were assessed.

RESULTS

Approximately 50% of all patients were transferred home. These patients were fully independent or under nursing support. We found no differences regarding weaning and rehabilitation durations, or FIM scores in between each entity. Log-regression analyses showed that every day on MV generates a 3.2% reduction of the possibility to achieve a beneficial outcome (FIM ≥ 50 points [only moderate assistance necessary]), whereas every day in-patient rehabilitation without MV increases the chance for favorable outcome by 1.9%. Mortality rates were 5% for IS and 10% for PICH and SAH, respectively.

CONCLUSIONS

This study shows that even severely affected, tracheotomized patients with CVD benefit from early in-patient rehabilitation, irrespective of the etiology of vascular brain injury. Mortality rates of early rehabilitation in CVD are low. Until no validated outcome predictors are available, all efforts should be undertaken to enable in-patient rehabilitation, even in severe cases of CVD to improve outcome and to prevent accommodation in long-time-care facilities.