Age at stroke: temporal trends in stroke incidence in a large, biracial population

National and Subnational Trends of Mortality and Years of Life Lost Due to Stroke and Its Subtypes in Young Adults in China, 2005-2020

BACKGROUND AND OBJECTIVES

The incidence of stroke among young adults was rising globally, but the death burden of stroke in young adults in China is lacking. We aimed to examine the temporal trends in mortality and years of life lost (YLLs) caused by stroke among young adults from 2005 to 2020 across China.

METHODS

Based on the data from the National Mortality Surveillance System in China, we estimated the number and age-standardized rate of mortality and YLLs due to stroke and its subtypes among young adults aged 15-49 years during 2005-2020, for both China and its 31 mainland provinces.

RESULTS

During 2005-2020, the age-standardized mortality rate of stroke among young adults aged 15-49 years in China decreased by 21.0%, from 5.9/100,000 to 4.7/100,000, and the YLL rate decreased from 286.9/100,000 to 229.5/100,000. The age-standardized mortality rate among young adults due to intracerebral hemorrhage (ICH) showed a significant downward trend with a decrease of 26.3% while that of ischemic stroke (IS) and subarachnoid hemorrhage (SAH) decreased by 4.5% and 0.6%, respectively. In 2020, the mortality rate of ICH was 3.5 times higher than that of IS (3.3/100,000 vs 0.9/100,000) among young adults in China. The male/female ratio of age-standardized mortality rate of stroke in young adults increased from 2.0 in 2005 to 3.1 in 2020. The age-standardized mortality rate of IS and SAH in young men increased by 11.0% and 2.5%, respectively. In 2020, Tibet (18.4/100,000), Jilin (10.4/100,000), and Qinghai (8.3/100,000) were the top 3 provinces holding the highest age-standardized mortality rate due to stroke among young adults. Tibet was found to have the highest mortality rate due to ICH and SAH while that of IS was higher in northeast China.

DISCUSSION

In China, the death burden caused by ICH among young adults was substantially higher than that of IS. The increasing death burden of IS and SAH among young men requires special attention. Evidence-based intervention strategies are needed to improve the outcomes of stroke and alleviate the death burden due to stroke among young adults in Chinese population.

Assessing the Severity of ODT and Factors Determinants of Late Arrival in Young Patients with Acute Ischemic Stroke

Background

Acute ischemic stroke (AIS) is increasingly affecting younger populations, necessitating prompt thrombolytic therapy within a narrow therapeutic window. Pre-hospital delays are prevalent, particularly in China, yet targeted research on the youth population remains scarce.

Methods

In this retrospective cohort study, data from AIS patients aged 18-50 admitted to Longhua District People's Hospital, Shenzhen from December 2021 to December 2023 were analyzed using XGBoost and Random Forest machine learning algorithms, coupled with SHAP visualization, to identify factors contributing to pre-hospital delays.

Results

Among 1954 AIS patients, 528 young patients were analyzed. The median time to hospital arrival was 8.34 hours, with 82.0% experiencing delays. Analysis of different age subgroups showed that young patients aged 36-50 years old had a higher delay rate than patients under 36 years old. Machine learning algorithms identified stroke awareness, age, TOAST classification, ambulance arrival, dysarthria, mRS on admission, dizziness, wake-up stroke, etc. as important determinants of delay.

Conclusion

This study highlights the necessity of machine learning in identifying delay risk factors in young stroke patients. Enhanced public education, particularly regarding stroke symptoms and the use of emergency services, is crucial for reducing pre-hospital delays and improving patient outcomes.

Bimanual Arm Trainer Versus Traditional Occupational Therapy Services in Upper Extremity Function

IMPORTANCE

Upper extremity (UE) dysfunction resulting from stroke significantly affects a person's ability to complete self-care activities, consequently diminishing functional independence. Effective interventions that improve UE function in persons with stroke are needed.

OBJECTIVE

To explore the effectiveness of the Bimanual Arm Trainer (BAT) compared with traditional occupational therapy treatment sessions (i.e., a control group) on improving UE function after acute ischemic stroke.

DESIGN

Clinical trial, two-group, nonrandomized repeated-measures design.

SETTING

Inpatient rehabilitation facility.

PARTICIPANTS

Twenty-seven persons with ischemic stroke and an Action Research Arm Test (ARAT) score ≤17.

INTERVENTION

Minimum of three 10-min sessions on the BAT.

OUTCOMES AND MEASURES

ARAT, Upper Extremity Fugl-Meyer Assessment of Motor Recovery after Stroke (FMA-UE).

RESULTS

Both the intervention and control groups showed significant improvement on the ARAT from evaluation to discharge (main effect of time: p = .02). There was no statistically significant main effect of group and no significant Time × Group interaction (p = .63). FMA-UE scores also improved significantly in the intervention group from evaluation to discharge (p < .001). FMA-UE scores were not available for the control group.

CONCLUSIONS AND RELEVANCE

Both the intervention and control groups demonstrated significant improvements in UE function from evaluation to discharge. There were no statistically significant differences between groups, indicating that the BAT results in similar improvements in UE function, as would be expected in traditional occupational therapy. Further research is warranted to examine additional BAT programs, use different outcome measures, and assess participants over a longer time span. Plain-Language Summary: The Bimanual Arm Trainer (BAT) is a novel device that can be used in occupational therapy to improve arm function among stroke patients. There is limited research on BAT's effectiveness in improving arm function among stroke patients. In an acute inpatient rehabilitation setting, we compared outcome scores of patients who received traditional occupational therapy services with those who also used the BAT. Both groups achieved significant improvements in arm function from evaluation to discharge. We found that the addition of the BAT interventions did not significantly affect the outcome measure scores for either group. We conclude that more research is needed to examine additional BAT programs, use different outcome measures, and assess participants over a longer period of time.

Hematological causes of acute ischemic stroke in younger individuals

Ischemic stroke is a common cause of morbidity and mortality worldwide. The majority of affected individuals are older, with clear cardiovascular or embolic risk factors; however, up to a fifth of cases may occur in patients under the age of 50 years. In this review, we discuss some common hematological causes of ischemic stroke in this age range, with a focus on antiphospholipid syndrome, myeloproliferative neoplasms, immune thrombocytopenic purpura, and sickle cell disease. We review the etiology of stroke associated with these conditions and explore important management considerations that may be unique to these settings. These include the choice of antithrombotic agents, cytoreduction in myeloproliferative neoplasms, management of thrombocytopenia in immune thrombocytopenic purpura, and treatment of sickle cell disease.

What do employers need when supporting stroke survivors to return to work?: a mixed-methods study

BACKGROUND

Employers are key in supporting stroke survivors to return to work (RTW) but do not always have knowledge/skills or guidance to do so.

OBJECTIVES

To explore employers' needs for provision of post-stroke RTW support.

METHODS

Mixed-methods study. Participants recruited through voluntary response/purposive sampling. Survey of employers investigated stroke knowledge (maximum score: 7), RTW process knowledge (maximum score: 8), and perceived competency for actions supporting RTW (maximum score: 100%). Regression analyses explored relationships between employers' demographic/contextual characteristics and knowledge and perceived competency scores. Interviews with employers explored factors influencing their post-stroke RTW support. Interview data were analyzed using a framework analysis. Survey/interview findings were synthesized with those from a qualitative systematic review.

RESULTS

Across the survey (n = 50), interviews (n = 7), and review (25 studies), employers' support was influenced by stroke survivors' decisions to disclose stroke-related limitations, employers' knowledge regarding roles/responsibilities, employers' communication skills, and information provided by healthcare. Regression analyses: Human resources/occupational health support was positively associated with stroke knowledge (ß = 2.30, 95% CI 0.36-4.41, p = 0.013) and RTW process knowledge (ß = 5.12, 95% CI 1.80-6.87, p = 0.001). Post-stroke RTW experience was positively associated with stroke knowledge (ß = 1.36, 95% CI 0.46-2.26, p = 0.004) and perceived competency (ß = 31.13, 95% CI 18.40-44.76, p = 0.001). Organization size (i.e. working in a larger organization) was positively associated with RTW process knowledge (ß = 2.96, 95% CI 1.52-4.36, p = <.001).

CONCLUSIONS

Employers' RTW support was influenced by personal and environmental factors; they may benefit from education and guidance on stroke and their roles/responsibilities during the RTW process.

Holo-Stroke: Assessing for Immersive Stroke Care Through Stroke Hologram Teleportation

Background: Augmented reality enables the wearer to see both their physical environment and virtual objects. Holograms could allow 3D video of providers to be transmitted to distant sites, allowing patients to interact with virtual providers as if they are in the same physical space. Our aim was to determine if Tele-Stroke augmented with Holo-Stroke, compared with Tele-Stroke alone, could improve satisfaction and perception of immersion for the patient. Methods: Kinect cameras positioned at 90-degree intervals around the hub practitioner were used. Cameras streamed real-time optical video to a unity point-cloud program where the data were stitched together in a 360-degree view. The resultant hologram was positioned in 3D space and was visible through the head-mounted display by the patient. Radiology images were shared in Tele-Stroke and via hologram. Likert satisfaction questions were administered. Wilcoxon signed-rank testing was used. Results: Each of the 30 neurology clinic participants scored both Tele-Stroke and Holo-Stroke. Out of these, 29 patients completed the assessments (1 failure owing to computer reboot). Average age was 52 years, with 53.3% of the patients being female, 70.0% being White, and 13.3% being Hispanic. Likert scale score median "Overall" was 32 Tele-Stroke versus 48 Holo-Stroke (p < 0.00001), "Immersion" was 5 versus 10 (p < 0.00001), "Beneficial Technique" was 6 versus 10 (p < 0.00001), and "Ability to See Images" was 5 versus 10 (p < 0.00001). Discussion: Holo-Stroke 3D holographic Tele-Stroke exams resulted in feasibility, satisfaction, and high perception of immersion for the patient. Patients were enthusiastic for the more immersive, personal discussion with their provider and a robust way to experience radiology images. Though further assessments are needed, Holo-Stroke can help the provider "be there, not just see there!"

Associated demographic factors for the recurrence and prognosis of stroke patients within a multiethnic Asian population

OBJECTIVE

There is a paucity of studies investigating the outcomes among Asian stroke patients. Identifying subgroups of stroke patients at risk of poorer outcomes could identify patients who would benefit from targeted interventions. Therefore, the aim of this study was to identify which ischemic stroke patients at high risk of recurrent events and mortality.

METHODS

This cohort study adhered to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines. We obtained data from the Singapore Stroke Registry (SSR) from 2005 to 2016 and cross referenced to the Death Registry and the Myocardial Infarction Registry. Outcome measures included recurrent stroke, acute myocardial infarction (AMI), and all-cause and stroke-related deaths. Multivariable Cox proportional hazards regression models were performed to determine risk factors for recurrent stroke, AMI, and all-cause and stroke-related deaths.

RESULTS

A total of 64,915 patients (6705 young, and 58,210 older) were included in our analysis. Older stroke patients were found to have an increased risk of recurrent stroke (hazard ratio (HR) = 1.21, 95% confidence interval (CI) = 1.12-1.30), AMI (HR = 1.73, 95% CI = 1.54-1.95), all-cause death (HR = 2.49, 95% CI = 2.34-2.64), and stroke-related death (HR = 176, 95% CI = 1.61-1.92). Among young stroke patients, males were at increased risk for recurrent stroke (HR = 1.18, 95% CI = 1.01-1.39) and AMI (HR = 1.41, 95% CI = 1.08-1.83), but at reduced risk for all-cause (HR = 0.78, 95% CI = 0.69-0.89) and stroke-related deaths (HR = 0.79, 95% CI = 0.67-0.94). Ethnicity appeared to influence outcomes, with Malay patients at increased risk of recurrent stroke (HR = 1.37, 95% CI = 1.14-1.65), AMI (HR = 2.45, 95% CI = 1.87-3.22), and all-cause (HR = 1.43, 95% CI = 1.24-1.66) and stroke-related deaths (HR = 1.34, 95% CI = 1.09-1.64). Indian patients were also at increased risk of AMI (HR = 1.96, 95% CI = 1.41-2.72). Similar findings were seen among the older stroke patients.

CONCLUSION

This study found that older stroke patients are at risk of poorer outcomes. Within the young stroke population specifically, males were predisposed to recurrent stroke and AMI but were protected against all-cause and stroke-related deaths. Males were also at reduced risk of all-cause and stroke-related deaths in the older stroke population. In addition, Malay and Indian patients experience poorer outcomes after first stroke. Further optimization of risk factors targeting these high-priority populations are needed to achieve high-quality care.

Investigating secondary hypertension in cerebrovascular disease

Hypertension is the leading cause of stroke in the UK and worldwide. In recent years, stroke incidence has increased by 30%-41.5% in people aged under 64 years, with the prevalence of hypertension increasing by 4%-11%. Given that 5%-10% of people with hypertension in the general population have an underlying cause for their elevated blood pressure, it is important that all clinicians should maintain a high clinical suspicion for secondary hypertension. This review provides a clinical perspective of when to consider the underlying causes of secondary hypertension, with investigation algorithms for patients presenting with stroke and hypertension. Early involvement of hypertension specialist services is important to identify secondary causes of hypertension, as its effective control reduces cardiovascular-associated morbidity.

Plasminogen Activation Inhibitor-1 Promotes Resilience to Acute Oxidative Stress in Cerebral Arteries from Females

Plasminogen activation inhibitor-1 (PAI-1) plays a central role in thrombus formation leading to stroke; however, the contributions of PAI-1 to cellular damage in response to reactive oxygen species which are elevated during reperfusion are unknown. Given that PAI-1 can limit apoptosis, we hypothesized that PAI increases the resilience of cerebral arteries to H2O2 (200 µM). Cell death, mitochondrial membrane potential, and mitochondrial ROS production were evaluated in pressurized mouse posterior cerebral arteries from males and females. The effects of pharmacological and genetic inhibition of PAI-1 signaling were evaluated with the inhibitor PAI-039 (10 µM) and PAI-1 knockout mice, respectively. During exposure to H2O2, PCAs from male mice lacking PAI-1 had reduced mitochondrial depolarization and smooth muscle cell death, and PAI-039 increased EC death. In contrast, mitochondrial depolarization and cell death were augmented in female PCAs. With no effect of PAI-1 inhibition on resting mitochondrial ROS production, vessels from female PAI-1 knockout mice had increased mitochondrial ROS generation during H2O2 exposure. During acute exposure to oxidative stress, protein ablation of PAI-1 enhances cell death in posterior cerebral arteries from females while limiting cell death in males. These findings provide important considerations for blood flow restoration during stroke treatment.

Strength of association of classical vascular risk factors in young patients with ischaemic stroke: a case-control study

INTRODUCTION

Recent studies have reported an increasing incidence of ischaemic stroke among young adults. However, the strength of the association between traditional vascular risk factors has not been fully established.

METHODS

We compared 120 patients with a first ischaemic stroke before the age of 55 years admitted to the stroke unit of our centre with 600 healthy non-stroke controls from a population-based cohort study (HERMEX), matched for sex. Risk factors assessed included: hypertension, obesity, auricular fibrillation, current smoking, estimated glomerular filtration rate (eGFR), total cholesterol, low-density lipoprotein cholesterol (LDL-C), triglycerides, high-density lipoprotein cholesterol (HDL-C) and diabetes mellitus. We used logistic regression analysis and calculated population attributable risk. We performed an overall analysis, by sex and aetiological subgroup.

RESULTS

Using logistic regression analysis, we found that overall, the significant risk factors were: hypertension (OR: 1.58; 95%CI: 1.01-2.50), atrial fibrillation (OR: 4.77; 95%CI: 1.20-19.00), low eGFR (OR: 4.74; 95%CI: 1.3-21.94) and low HDL-C (OR: 5.20; 95%CI: 3.29-8.21), as well as smoking for males (OR: 1.86; 95%CI: 1.14-3.03). LDL-C showed an inverse association with stroke. The population attributable risk for HDL-C was 37.8% and for hypertension 21.1%. In terms of aetiological subgroups, only low HDL-C was associated with stroke of undetermined aetiology.

CONCLUSIONS

Hypertension, auricular fibrillation, low eGFR, and low HDL-C, plus tobacco use in men, are the main risk factors among patients under 55 years of age with a first ischaemic stroke. We believe that it would be of particular interest to further explore the management of low HDL-C levels as part of preventive strategies in young stroke patients.

A systematic review of Intensive Comprehensive Aphasia Programmes - who takes part, what is measured, what are the outcomes?

PURPOSE

This study synthesizes participant and outcome data from peer-reviewed Intensive Comprehensive Aphasia Programme (ICAP) studies.

METHODS

A systematic review was conducted following PRISMA guidelines. Study eligibility criteria were specified in relation to population, intervention, comparison, outcome, and design considerations. Data were extracted according to six research questions. Narrative synthesis was used.

RESULTS

Twenty-one studies were included covering 13 ICAPs (N = 485, aged 18-86 years, between 11 and 335 months post-stroke). Twenty-seven participant selection criteria were identified. Fifty-six outcome measures spanning the WHO-ICF were used, with the majority assessing the body function domain. Only eight studies employed an experimental design with data appropriate for analysis and synthesis. Risk of bias was noted across this sub-group. Participants improved in word-finding, communication, activity/participation, and communication-related quality of life, and maintained their gains; however, except for word finding, evidence of effect came from isolated studies. Factors influencing outcomes were rarely considered. Some drop-outs, missed sessions, and fatigue were noted. Some studies reported IPD alongside group analyses.

CONCLUSIONS

ICAP selection criteria need justification and should contribute to the understanding of candidacy for this treatment model. Rationalisation of ICAP treatment content and outcome measurement is required, spanning all WHO-ICF domains. Employment of the core outcome set for aphasia would enable data synthesis and facilitate comparisons between the ICAP and other therapy models.

A case report about anorexia nervosa and ischemic stroke: what can we learn?

INTRODUCTION

Anorexia Nervosa (AN) is a complex psychiatric illness, characterized by a high risk of developing cardiovascular complications. Given the high risk of vascular diseases in patients with AN, we can assume that patients with severe AN have a high risk of developing ischemic stroke. However, to the best of our knowledge, no reports of patients with AN presenting with ischemic stroke have been published, other than a report of the development of IS during refeeding therapy in patients with severe AN.

CASE PRESENTATION

The present case report is aimed at describing the characteristics of an ischemic stroke occurring in a 19-year-old university student who had a 6-month history of AN. She was a non-smoker, had no relevant medical history and no family history of stroke. Upon hospital admission due to symptoms of stroke (aphasia and facial droop), she exhibited severe malnutrition with a BMI of 12.8 kg/m2. Computerized tomography imaging revealed occlusion of the left M2 branch and a congruous extensive area of hypoperfusion. Further investigations ruled out all common causes of stroke: she had no vascular stenosis, no heart diseases or arrhythmias, and no shunts, and gave negative results in autoimmune, toxicological and thrombophilia screenings.

CONCLUSION

Clinicians should suspect development of severe complications, including ischemic stroke, in patients with severe AN. Further extensive group studies or group-based studies are needed to elucidate the etiology of ischemic stroke in patients with severe AN. This will enable us to develop more precise and effective interventions.

Exploring Factors Influencing Stroke Risk: Insights From a Predictive Analysis

Introduction Stroke is a serious medical condition characterized by the sudden interruption of blood flow to the brain, resulting in the death of brain cells. It is a leading cause of long-term disability and mortality worldwide. Stroke has some associated risk factors, both modifiable and non-modifiable ones. As for non-modifiable risk factors, these are age, gender (men are more vulnerable), and family history of stroke. The controllable or adjustable risk factors include hypertension (high blood pressure), diabetes, smoking, high cholesterol levels, obesity, and insulin resistance. Methods In our study, we collected data from 229 patients which were originally collected for clinical purposes and were retrospectively analyzed. These data contain features such as sex and age, the presence of ischemic heart disease (IHD) or stroke history, and different blood sugar readings. These measurements include fasting blood sugar (FBS), postprandial blood sugar (PPBS), HbA1c%, and insulin levels (fasting and postprandial). Furthermore, cholesterol was also tested, such as total cholesterol, triglycerides (TGL), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and very low-density lipoprotein (VLDL). Surprisingly, stroke was observed in 24 of the 205 patients. This contrast permits us to be concerned with the chance of the association between stroke and insulin levels. Given the imbalanced nature of our outcome variable (stroke occurrence), the primary analytical method will be logistic regression. Results In this cross-sectional study, we investigated the association between high insulin levels (both fasting and postprandial) and the occurrence of stroke within a dataset of 229 patients. Out of the 229 included cases, 102 individuals were female (44.5%) and 127 individuals were male (55.5%). Twenty-four cases have ischemic heart disease (10.5%). Among the analyzed cases, 24 individuals have a history of stroke. The average age of the sample is approximately 57 years ± 14.87. There was no significant difference between the males and females in most of the descriptive statistics. However, females experienced significantly higher levels of postprandial glucose level and significantly lower levels of postprandial insulin. According to our predictive model, we found that an increase in fasting insulin levels was linked to a lower risk of stroke occurrence. On the other hand, increasing insulin postprandial levels and age were associated with an increased risk of stroke. Conclusion Our study identified age, fasting insulin, and postprandial insulin as key factors influencing stroke risk. Higher fasting insulin levels were associated with reduced risk, while increased postprandial insulin and age were linked to higher risk. Blood glucose, cholesterol, and triglycerides had minor effects. Notably, higher total cholesterol and triglyceride levels were slightly associated with lower stroke occurrence. Further research with larger samples is needed for validation.

Hemodynamic activity is not parsimoniously tuned to index-of-difficulty in movement with dual requirements on speed-accuracy

Background

Reaching movements are crucial for daily living and rehabilitation, for which Fitts' Law describes a speed-accuracy trade-off that movement time increases with task difficulty. This study aims to investigate whether cortical activation in motor-related areas is directly linked to task difficulty as defined by Fitts' Law. Understanding this relationship provides a physiological basis for parameter selection in therapeutic exercises.

Methods

Sixteen healthy subjects performed 2D reaching movements using a rehabilitation robot, with their cortical responses detected using functional near-infrared spectroscopy (fNIRS). Task difficulty was manipulated by varying target size and distance, resulting in 3 levels of index-of-difficulty (ID). Kinematic signals were recorded alongside cortical activity to assess the relationship among movement time, task difficulty, and cortical activation.

Results

Our results showed that movement time increased with ID by 0.2974s/bit across all subjects (conditional r2 = 0.6434, p < 0.0001), and all subjects showed individual trends conforming Fitts' Law (all p < 0.001). Neither activation in BA4 nor in BA6 showed a significant correlation with ID (p > 0.05), while both the target size and distance, as well as the interaction between them, showed a significant relationship with BA4 or BA6 activation (all p < 0.05).

Conclusion

This study found that although kinematic measures supported Fitts' Law, cortical activity in motor-related areas during reaching movements did not correlate directly with task difficulty as defined by Fitts' Law. Additional factors such as muscle activation may call for different cortical control even when difficulty was identical.

Associations between Physical Activity and the Incidence of Cerebrovascular Disease or All-Cause Mortality among 146,742 Older Adults: A 13-Year Prospective Cohort Study

OBJECTIVES

Although studies have indicated that physical activity (PA) is related to cardiovascular disease, the specific association between PA and incident cerebrovascular disease (CBVD) remains uncertain. The current study aimed to investigate the associations between PA levels and the CBVD incidence or all-cause mortality.

DESIGN

Prospective cohort study.

SETTINGS AND PARTICIPANTS

Older participants (aged >60 years) from the UK Biobank.

METHODS

The baseline PA was classified as total, light, moderate, and vigorous PA based on the metabolic equivalent-minutes per week (MET-min/wk) and considered as exposures, whereas CBVD incidence and all-cause mortality were considered as the outcomes. Cox proportional hazards were used to calculate the hazard ratios (HRs) and 95% CIs for the influence of the association between PA and CBVD incidence and all-cause mortality.

RESULTS

A total of 146,742 participants aged 60 years and older were included. During a median follow-up period of 13.5 years (interquartile range of 12.8-14.2), 9338 older individuals developed CBVD and 3033 death were recorded (including 767 CBVD-related deaths). High volumes of PA were consistently associated with lower risks of CBVD and all-cause mortality. The lowest risk of CBVD incidence was observed at 2001-2500 MET-min/wk of total PA (HR 0.61, 95% CI 0.53-0.70), and the lowest risk of all-cause mortality was observed at 2501-5000 MET-min/wk (HR 0.52, 95% CI 0.43-0.63) in older adults. Total PA at 2001-2500 MET-min/wk significantly reduced the CBVD incidence in older women (HR 0.57, 95% CI 0.46-0.71), which was more pronounced than that in older men (HR for 2001-2500 MET-min/wk: 0.64, 95% CI 0.50-0.77).

CONCLUSIONS AND IMPLICATIONS

Total PA at 2001-2500 MET-min/wk significantly reduced the risk of incident CBVD and all-cause mortality in adults aged >60 years, although the extents of risk reduction vary in men and women.

Risk Factors and Stroke Subtyping in Young Adults: A Study From a Tertiary Care Hospital in South India

OBJECTIVES

This study aimed to determine the risk factors and stroke subtypes for young ischemic stroke patients and their outcomes at the time of discharge.

METHODS

This is a retrospective cross-sectional study of ischemic stroke patients (n = 264) between the age groups of 18 and 45. The study population was divided into two broad age groups: 18 to 35 years and 36 to 45 years; and compared based on demographics, risk factors, the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, and outcomes. The outcomes were compared based on the National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (MRS) systems at the time of admission and discharge.

RESULTS

The mean age of patients was 37.84±6.19 years. The male-to-female ratio was 2.5:1. The most common vascular risk factors identified were diabetes (29.16%), hypertension (49.62%), dyslipidaemia (DLP, 44.4%), and smoking (10.9%). The most common TOAST subtype was large vessel disease (38.63%), followed by the undetermined category (35.6%). The elderly group showed a high proportion of strokes secondary to small vessel disease (14.13%; p = 0.03), while cardioembolic strokes were common in the female subgroup (p = 0.05). The majority of strokes were in the anterior circulation (66.6%) as compared to the posterior (25.75%), and nearly 50% of the patients had intracranial disease. Overall, there was a favourable MRS outcome at discharge.

CONCLUSION

Conventional vascular risk factors are equally prevalent, even among young stroke patients. The benchmark for young stroke age is showing a downward shift as more stroke patients above the age of 35 are showing similar risk factor trends as those of their older counterparts. The majority of stroke burden still falls under the undermined category, which requires aggressive risk factor identification and management.

Clinical Characteristics, Functional Outcome, and Socioeconomic Impact of Ischemic Stroke among Young Egyptian Adults

BACKGROUND

Stroke in young patients results in disproportionately high societal cost given the productive life-years lost. Little is known about stroke in young Egyptian patients. We aimed to analyze clinicodemographic characteristics, functional outcome, and socioeconomic impact of ischemic stroke among young Egyptian adults.

METHODS

This is a prospective, observational cohort study of consecutively recruited patients with acute ischemic stroke (AIS), 18-50 years, between September 2022 and September 2023 at a tertiary stroke center in the south of Egypt. We recorded baseline demographic and cardiovascular risk factors, stroke severity, stroke subtype according to the TOAST classification, intravenous thrombolysis, employment, and ambulation status pre- and post-stroke, post-stroke complications, and 90-day functional outcome measured by the modified Rankin Scale (mRS).

RESULTS

Our cohort comprised 210 patients, 38.0 (±7.8) years, 89 (42%) females. Mean NIHSS score was 11.2 (±4.8); in-hospital case fatality was 9% (19 patients). Dyslipidemia (n = 105, 50%), smoking (n = 105, 50%), and hypertension (n = 67, 32%) were the most prevalent cardiovascular risk factors. At 90 days, 58 (29%) patients had a 90-day mRS 0-1 and 53 (26%) met criteria for depression diagnosis. Sixty-nine of the 116 employed individuals (59%) remained out of work after 90 days of stroke, 61 of whom were single earners in their household. 36/60 (60%) thrombolysis-eligible patients received it; an additional 98 otherwise thrombolysis-eligible patients presented >4.5 h from symptom onset. Patients receiving IV thrombolysis were significantly more likely to have resumed full-time work at 90 days (32% vs. 11%, p = 0.006) but with no significant difference in 90-day mRS.

CONCLUSIONS

Young adult AIS patients in Egypt experience high rates of post-stroke depression and face challenges in their ability to work and provide for their families. Since most patients have treatable cardiovascular risk factors and only about two-thirds of eligible patients receive thrombolysis, reinforcing primary prevention, education about early stroke signs, and benefits of acute can improve outcomes and have significant potential societal benefit.

Association of the High-Sensitivity C-Reactive Protein-to-Albumin Ratio with Carotid Atherosclerotic Plaque: A Community-Based Cohort Study

Background

The inflammatory response is a pivotal factor in accelerating the progression of atherosclerosis. The high-sensitivity C-reactive protein-to-albumin ratio (CAR) has emerged as a novel marker of systemic inflammation. However, few studies have shown the CAR to be a promising prognostic marker for carotid atherosclerotic disease. This study aimed to analyse the predictive role of the CAR in carotid atherosclerotic disease.

Methods

This community-based cohort study recruited 2003 participants from the Rose asymptomatic IntraCranial Artery Stenosis (RICAS) study who were free of stroke or transient ischemic attack. Carotid atherosclerotic plaques and their stability were identified via carotid ultrasound. Logistic regression models were utilized to investigate the association between CAR and the presence of carotid atherosclerotic plaques.

Results

The prevalence of carotid atherosclerotic plaques was 38.79% in this study. After adjusting for clinical risk factors, including sex, age, dyslipidemia, hypertension, diabetes mellitus (DM), and smoking and drinking habits, a high CAR-level was independently associated with carotid plaque (odds ratio [OR] of upper: 1.46, 95% confidence interval [CI]: 1.13-1.90, P = 0.004; P for trend = 0.011). The highest CAR tertile was still significantly associated with carotid plaques among middle-aged (40-64 years) or female participants. Notably, an elevated CAR may be an independent risk factor for vulnerable carotid plaques (OR of upper: 2.06, 95% CI: 1.42-2.98, P < 0.001; P for trend <0.001).

Conclusion

A high CAR may be correlated with a high risk of carotid plaques, particularly among mildly aged adults (40-64 years) or females. Importantly, the CAR may be associated with vulnerable carotid plaques, suggesting that the CAR may be a new indicator for stroke prevention.

Effects of modified-constraint induced movement therapy based telerehabilitation on upper extremity motor functions in stroke patients

INTRODUCTION

The aim of this study is to investigate the effects of Modified-Constraint Induced Movement Therapy (m-CIMT) based telerehabilitation on upper extremity motor functions in stroke patients.

METHODS

Eighteen stroke patients were included and randomly allocated into two groups. The Tele-CIMT (modified-constraint induced movement therapy-based telerehabilitation) (n = 10) group received m-CIMT based telerehabilitation for 90 min a day, 5 weekdays for 3 weeks at home. Additionally, both the Tele-CIMT group and the control group (CG) (n = 8) underwent the home exercise program aimed at improving range of motion, active movement, balance, and walking every weekday for 3 weeks at home. The outcome measures were the Stroke Rehabilitation Assessment of Movement Scale (STREAM), Fugl-Meyer Upper Extremity Motor Evaluation Scale (FM-UE), Wolf Motor Function Test (WMFT), 9-Hole Peg Test (9-HPT), grip strengths, pinch strengths, Motor Activity Log-28 (MAL-28), and Functional Independence Measure (FIM).

RESULTS

Significant group-by-time interactions on STREAM, FM-UE, WMFT, grip strength, pinch strengths, MAL-28, and FIM were found to be in favor of the Tele-CIMT group. Additionally, post hoc analyses revealed that the Tele-CIMT group significantly improved in terms of these parameters (p > .05).

CONCLUSION

This is the first randomized controlled trial showing that Tele-CIMT improved upper extremity motor functions and activities of daily living in stroke patients. Tele-CIMT can help improve the upper extremities in stroke survivors who have difficulties reaching rehabilitation clinics.

Ischemic Brain Injury: Involvement of Lipids in the Pathophysiology of Stroke and Therapeutic Strategies

Stroke is a devastating neurological disorder that is characterized by the sudden disruption of blood flow to the brain. Lipids are essential components of brain structure and function and play pivotal roles in stroke pathophysiology. Dysregulation of lipid signaling pathways modulates key cellular processes such as apoptosis, inflammation, and oxidative stress, exacerbating ischemic brain injury. In the present review, we summarize the roles of lipids in stroke pathology in different models (cell cultures, animal, and human studies). Additionally, the potential of lipids, especially polyunsaturated fatty acids, to promote neuroprotection and their use as biomarkers in stroke are discussed.

Risk of cardiovascular diseases among young adults: a cross-sectional study in Malaysia

BACKGROUND

Cardiovascular disease (CVD) is the major cause of mortality worldwide. Recent studies showed that there is increasing CVD incidence at younger ages. Therefore, this study aimed to estimate the risk of CVD and its associated factors among young adults.

METHODS

A cross-sectional study was conducted among university students in Selangor, Malaysia, using a self-administered questionnaire along with anthropometric measurements. The sample size was calculated using a single proportion formula. The CVD risk was calculated using the non-laboratory-based Inter-Heart Modifiable Risk Score (IHMRS). Participants aged 18 years and above, with no CVD history, were recruited using a convenience sampling method between February and May 2022. CVD risk was classified as low (scores between 0 and 9 points), moderate (scores between 10 and 15 points) and high (scores between 16 and 48 points). The factors associated with the CVD risk were identified using χ2 analysis.

RESULTS

A total of 241 participants were included in this study. The median age was 28 years and the majority were females (75.1%). The IHMRS revealed that 46.5%, 44.4% and 9% of the respondents have low, moderate and high CVD risk, respectively. The CVD risk associated factors were education, the history of heart attacks among parents, feeling sad or depressed for 2 weeks or more in a row, having several episodes/permanent stress, expose to secondhand smoke and consuming meat and poultry more than two times daily.

CONCLUSIONS

This study found that more than 50% of study participants had moderate to high risk of CVD. Family history and lifestyle factors are the most likely determinants of CVD risk among the young age group. These findings support the development and implementation of targeted prevention programmes as well as provide useful information for action planning and policymaking to curb the disease in the future.

Addressing disparities in the global epidemiology of stroke

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.

Association of Traditional and Nontraditional Risk Factors in the Development of Strokes Among Young Adults by Sex and Age Group: A Retrospective Case-Control Study

BACKGROUND

Despite women having fewer traditional risk factors (eg, hypertension, diabetes), strokes are more common in women than men aged ≤45 years. This study examined the contributions of traditional and nontraditional risk factors (eg, migraine, thrombophilia) in the development of strokes among young adults.

METHODS

This retrospective case-control study used Colorado's All Payer Claims Database (2012-2019). We identified index stroke events in young adults (aged 18-55 years), matched 1:3 to stroke-free controls, by (1) sex, (2) age±2 years, (3) insurance type, and (4) prestroke period. All traditional and nontraditional risk factors were identified from enrollment until a stroke or proxy-stroke date (defined as the prestroke period). Conditional logistic regression models stratified by sex and age group first assessed the association of stroke with counts of risk factors by type and then computed their individual and aggregated population attributable risks.

RESULTS

We included 2618 cases (52% women; 73.3% ischemic strokes) and 7827 controls. Each additional traditional and nontraditional risk factors were associated with an increased risk of stroke in all sex and age groups. In adults aged 18 to 34 years, more strokes were associated with nontraditional (population attributable risk: 31.4% men and 42.7% women) than traditional risk factors (25.3% men and 33.3% women). The contribution of nontraditional risk factors declined with age (19.4% men and 27.9% women aged 45-55 years). The contribution of traditional risk factors peaked among patients aged 35 to 44 years (32.8% men and 39.7% women). Hypertension was the most important traditional risk factor and increased in contribution with age (population attributable risk: 27.8% men and 26.7% women aged 45 to 55 years). Migraine was the most important nontraditional risk factor and decreased in contribution with age (population attributable risk: 20.1% men and 34.5% women aged 18-35 years).

CONCLUSIONS

Nontraditional risk factors were as important as traditional risk factors in the development of strokes for both young men and women and have a stronger association with the development of strokes in adults younger than 35 years of age.

Age-Specific Association of Co-Morbidity With Home-Time After Acute Stroke

OBJECTIVE

To examine the association of co-morbidity with home-time after acute stroke and whether the association is influenced by age.

METHODS

We conducted a province-wide study using linked administrative databases to identify all admissions for first acute ischemic stroke or intracerebral hemorrhage between 2007 and 2018 in Alberta, Canada. We used ischemic stroke-weighted Charlson Co-morbidity Index of 3 or more to identify those with severe co-morbidity. We used zero-inflated negative binomial models to determine the association of severe co-morbidity with 90-day and 1-year home-time, and logistic models for achieving ≥ 80 out of 90 days of home-time, assessing for effect modification by age and adjusting for sex, stroke type, comprehensive stroke center care, hypertension, atrial fibrillation, year of study, and separately adjusting for estimated stroke severity. We also evaluated individual co-morbidities.

RESULTS

Among 28,672 patients in our final cohort, severe co-morbidity was present in 27.7% and was associated with lower home-time, with a greater number of days lost at younger age (-13 days at age < 60 compared to -7 days at age 80+ years for 90-day home-time; -69 days at age < 60 compared to -51 days at age 80+ years for 1-year home-time). The reduction in probability of achieving ≥ 80 days of home-time was also greater at younger age (-22.7% at age < 60 years compared to -9.0% at age 80+ years). Results were attenuated but remained significant after adjusting for estimated stroke severity and excluding those who died. Myocardial infarction, diabetes, and cancer/metastases had a greater association with lower home-time at younger age, and those with dementia had the greatest reduction in home time.

CONCLUSION

Severe co-morbidity in acute stroke is associated with lower home-time, more strongly at younger age.

Burden of Ischemic and Hemorrhagic Stroke Across the US From 1990 to 2019

Importance

Stroke is a leading cause of death and disability in the US. Accurate and updated measures of stroke burden are needed to guide public health policies.

Objective

To present burden estimates of ischemic and hemorrhagic stroke in the US in 2019 and describe trends from 1990 to 2019 by age, sex, and geographic location.

Design, Setting, and Participants

An in-depth cross-sectional analysis of the 2019 Global Burden of Disease study was conducted. The setting included the time period of 1990 to 2019 in the US. The study encompassed estimates for various types of strokes, including all strokes, ischemic strokes, intracerebral hemorrhages (ICHs), and subarachnoid hemorrhages (SAHs). The 2019 Global Burden of Disease results were released on October 20, 2020.

Exposures

In this study, no particular exposure was specifically targeted.

Main Outcomes and Measures

The primary focus of this analysis centered on both overall and age-standardized estimates, stroke incidence, prevalence, mortality, and DALYs per 100 000 individuals.

Results

In 2019, the US recorded 7.09 million prevalent strokes (4.07 million women [57.4%]; 3.02 million men [42.6%]), with 5.87 million being ischemic strokes (82.7%). Prevalence also included 0.66 million ICHs and 0.85 million SAHs. Although the absolute numbers of stroke cases, mortality, and DALYs surged from 1990 to 2019, the age-standardized rates either declined or remained steady. Notably, hemorrhagic strokes manifested a substantial increase, especially in mortality, compared with ischemic strokes (incidence of ischemic stroke increased by 13% [95% uncertainty interval (UI), 14.2%-11.9%]; incidence of ICH increased by 39.8% [95% UI, 38.9%-39.7%]; incidence of SAH increased by 50.9% [95% UI, 49.2%-52.6%]). The downturn in stroke mortality plateaued in the recent decade. There was a discernible heterogeneity in stroke burden trends, with older adults (50-74 years) experiencing a decrease in incidence in coastal areas (decreases up to 3.9% in Vermont), in contrast to an uptick observed in younger demographics (15-49 years) in the South and Midwest US (with increases up to 8.4% in Minnesota).

Conclusions and Relevance

In this cross-sectional study, the declining age-standardized stroke rates over the past 3 decades suggest progress in managing stroke-related outcomes. However, the increasing absolute burden of stroke, coupled with a notable rise in hemorrhagic stroke, suggests an evolving and substantial public health challenge in the US. Moreover, the significant disparities in stroke burden trends across different age groups and geographic locations underscore the necessity for region- and demography-specific interventions and policies to effectively mitigate the multifaceted and escalating burden of stroke in the country.

Strategies for Recruiting Young African American Men for Primary Stroke Prevention Research

BACKGROUND

African American (AA) men bear a disproportionate burden of cardiovascular disease and stroke but are often underrepresented in research.

OBJECTIVE

This article describes the development and evaluation of a recruitment plan to reach young AA men for the Stroke Counseling for Risk Reduction in Men project.

METHODS

The plan was developed from researchers' previous experiences and a literature review, and used to recruit AA men, ages 20 to 35 years, for focus groups about stroke and Stroke Counseling for Risk Reduction.

RESULTS

Screening survey respondents (N = 81) were reached mostly by word of mouth (42%) and social media (28%). Focus group participants (N = 32) recommended appropriate incentives and social media to recruit young AA men for research. They also suggested learning about the study from a friend, colleague, or study participant could motivate participation.

CONCLUSION

The plan was successful in reaching and enrolling an adequate sample. Findings and recommendations highlight the importance of social networks and trusted sources.

The contribution of raised blood pressure to all-cause and cardiovascular deaths and disability-adjusted life-years (DALYs) in Australia: Analysis of global burden of disease study from 1990 to 2019

AIMS

In a high-income country, Australia, it is unclear how raised systolic blood pressure (SBP) ranks among other risk factors regarding the overall and cardiovascular disease (CVD) burden, and whether the situation has changed over time.

METHODS

We analysed the 2019 Global Burden of Disease (GBD) data, with focus on Australia. We assessed ten leading risk factors for all-cause and CVD deaths and disability-adjusted life-years (DALYs) and compared findings with the Australian Burden of Diseases Study.

RESULTS

From 1990 to 2019, raised SBP remained the leading risk factor for attributable all-cause deaths (followed by dietary risks and tobacco use), accounting for 29,056/75,235 (95% Uncertainty Interval (UI) [24,863 to 32,915]) deaths in 1990; 21,845/76,893 [17,678 to 26,044] in 2010; and 25,498/90,393 [20,152 to 30,851] in 2019. Contributions of raised SBP to cardiovascular deaths for both sexes were 54.0% [45.8 to 61.5] in 1990, 44.0% [36.7 to 51.3] in 2010 and 43.7% [36.2 to 51.6] in 2019, respectively. The contribution of raised SBP to cardiovascular deaths declined between 1990 and 2010 but exhibited an increase in males from 2010 onwards, with figures of 52.6% [44.7 to 60.0] in 1990, 43.1% [36.0 to 50.5] in 2010 and 43.5% [35.7 to 51.4] in 2019. The contribution of raised SBP to stroke deaths and DALYs in males aged 25-49 years were higher than other age groups, in excess of 60% and increasing steeply between 2010 and 2019.

CONCLUSION

Raised SBP continues to be the leading risk factor for all-cause and cardiovascular deaths in Australia. We urge cross-disciplinary stakeholder engagement to implement effective strategies to detect, treat and control raised blood pressure as a central priority to mitigate the CVD burden.

The effect of the interaction of sleep onset latency and age on ischemic stroke severity via inflammatory chemokines

Objective

Prolonged sleep onset latency (PSOL) and age have been linked to ischemic stroke (IS) severity and the production of chemokines and inflammation, both of which contribute to IS development. This study aimed to explore the relationship between chemokines, inflammation, and the interplay between sleep onset latency (SOL) and age in influencing stroke severity.

Methods

A cohort of 281 participants with mild to moderate IS was enrolled. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and SOL was recorded. Serum levels of macrophage inflammatory protein-1alpha (MIP-1α), macrophage inflammatory protein-1beta (MIP-1β), monocyte chemoattractant protein-1 (MCP-1), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) were measured.

Results

NIHSS scores of middle-aged participants with PSOL were significantly higher than those with normal sleep onset latency (NSOL) (p = 0.046). This difference was also observed when compared to both the elderly with NSOL (p = 0.022), and PSOL (p < 0.001). Among middle-aged adults with PSOL, MIP-1β exhibited a protective effect on NIHSS scores (β = -0.01, t = -2.11, p = 0.039, R2 = 0.13). MIP-1α demonstrated a protective effect on NIHSS scores in the elderly with NSOL (β = -0.03, t = -2.27, p = 0.027, R2 = 0.12).

Conclusion

This study reveals a hitherto undocumented association between PSOL and IS severity, along with the potential protective effects of MIP-1β in mitigating stroke severity, especially among middle-aged patients.

Trends Over Time in Stroke Incidence by Race in the Greater Cincinnati Northern Kentucky Stroke Study

BACKGROUND AND OBJECTIVES

Understanding the current status of and temporal trends of stroke epidemiology by age, race, and stroke subtype is critical to evaluate past prevention efforts and to plan future interventions to eliminate existing inequities. We investigated trends in stroke incidence and case fatality over a 22-year time period.

METHODS

In this population-based stroke surveillance study, all cases of stroke in acute care hospitals within a 5-county population of southern Ohio/northern Kentucky in adults aged ≥20 years were ascertained during a full year every 5 years from 1993 to 2015. Temporal trends in stroke epidemiology were evaluated by age, race (Black or White), and subtype (ischemic stroke [IS], intracranial hemorrhage [ICH], or subarachnoid hemorrhage [SAH]). Stroke incidence rates per 100,000 individuals from 1993 to 2015 were calculated using US Census data and age-standardized, race-standardized, and sex-standardized as appropriate. Thirty-day case fatality rates were also reported.

RESULTS

Incidence rates for stroke of any type and IS decreased in the combined population and among White individuals (any type, per 100,000, 215 [95% CI 204-226] in 1993/4 to 170 [95% CI 161-179] in 2015, p = 0.015). Among Black individuals, incidence rates for stroke of any type decreased over the study period (per 100,000, 349 [95% CI 311-386] in 1993/4 to 311 [95% CI 282-340] in 2015, p = 0.015). Incidence of ICH was stable over time in the combined population and in race-specific subgroups, and SAH decreased in the combined groups and in White adults. Incidence rates among Black adults were higher than those of White adults in all time periods, and Black:White risk ratios were highest in adults in young and middle age groups. Case fatality rates were similar by race and by time period with the exception of SAH in which 30-day case fatality rates decreased in the combined population and White adults over time.

DISCUSSION

Stroke incidence is decreasing over time in both Black and White adults, an encouraging trend in the burden of cerebrovascular disease in the US population. Unfortunately, however, Black:White disparities have not decreased over a 22-year period, especially among younger and middle-aged adults, suggesting the need for more effective interventions to eliminate inequities by race.

Activation of testosterone-androgen receptor mediates cerebrovascular protection by photobiomodulation treatment in photothrombosis-induced stroke rats

RATIONALE

Numerous epidemiological studies have reported a link between low testosterone levels and an increased risk of cerebrovascular disease in men. However, there is ongoing controversy surrounding testosterone replacement therapy due to potential side effects. PBMT has been demonstrated to improve cerebrovascular function and promote testosterone synthesis in peripheral tissues. Despite this, the molecular mechanisms that could connect PBMT with testosterone and vascular function in the brain of photothrombosis (PT)-induced stroke rats remain largely unknown.

METHODS

We measured behavioral performance, cerebral blood flow (CBF), vascular permeability, and the expression of vascular-associated and apoptotic proteins in PT-induced stroke rats treated with flutamide and seven consecutive days of PBM treatment (350 mW, 808 nM, 2 min/day). To gain further insights into the mechanism of PBM on testosterone synthesis, we used testosterone synthesis inhibitors to study their effects on bEND.3 cells.

RESULTS

We showed that PT stroke caused a decrease in cerebrovascular testosterone concentration, which was significantly increased by 7-day PBMT (808 nm, 350 mW/cm2 , 42 J/cm2 ). Furthermore, PBMT significantly increased cerebral blood flow (CBF) and the expression of vascular-associated proteins, while inhibiting vascular permeability and reducing endothelial cell apoptosis. This ultimately mitigated behavioral deficits in PT stroke rats. Notably, treatment with the androgen receptor antagonist flutamide reversed the beneficial effects of PBMT. Cellular experiments confirmed that PBMT inhibited cell apoptosis and increased vascular-associated protein expression in brain endothelial cell line (bEnd.3) subjected to oxygen-glucose deprivation (OGD). However, these effects were inhibited by flutamide. Moreover, mechanistic studies revealed that PBMT-induced testosterone synthesis in bEnd.3 cells was partly mediated by 17β-hydroxysteroid dehydrogenase 5 (17β-HSD5).

CONCLUSIONS

Our study provides evidence that PBMT attenuates cerebrovascular injury and behavioral deficits associated with testosterone/AR following ischemic stroke. Our findings suggest that PBMT may be a promising alternative approach for managing cerebrovascular diseases.

A task-driven cerebral angiographic imaging based on CT perfusion

Introduction

Current clinical computed tomography arteriography (cCTA) and clinical computed tomography venography (cCTV) images often display restricted cerebrovascular profiles, incomplete brain tissue segmentation, and incomplete artery-vein segmentation. Especially for vessels associated with diseases, capturing their complete profiles proves challenging.

Methods

In this work, we developed a Task-driven Cerebral Angiographic Imaging (TDCAI) technique using computed tomography perfusion (CTP) images of stroke patients. A evaluation on intracranial hemorrhagic stroke (IHS) and acute ischemic stroke (AIS) cases was performed with CT perfusion imaging. The TDCAI technique processed the CTP images, resulting in supplementary diagnostic images, including CTA, CTV, centerline images of the vessels-of-interest [internal carotid artery (ICA) for AIS patients, Labbé vein for IHS patients], and straightened images of the vessels-of-interest.

Results

We conducted a comparison between the obtained CTA/CTV images and the cCTA/cCTV images in terms of overall image quality and visibility of the vessels-of-interest. By constructing a virtual vascular phantom, we extracted its centerline and compared it with the actual centerline to calculate maximum and average deviations. This allowed us to evaluate both the accuracy of the centerline extraction algorithm and its capability to resist the influence of side branches. We assessed whether vascular stenosis and dilatation could be expressed in straightened vessel images, conducting statistical analyses to establish the superiority of TDCAI technique.

Discussion

This study proposes a TDCAI technique to eliminate bone and soft tissue interference, effectively segregate the comprehensive cerebral venous and arterial systems, and extract centerlines and straighten the vessels-of-interest, which would aid doctors in assessing the outflow profiles of vessels after a stroke and seeking imaging biomarkers correlated with clinical outcomes.

Outreach for Young Adult African Americans with Risk Factors for Stroke

BACKGROUND

Research suggests that younger adult African American people (age 18-35 years) have more than double the risk of having a stroke than White people. Stroke risk education is lacking for this cohort; there is a dearth of materials that are targeted and focused for young adult African Americans. There is also little research on developing and testing age and culturally appropriate health literate materials that may help this population better understand personal risk factors for stroke.

OBJECTIVE

The aim of this study was to understand factors to guide creating and disseminating plain language health messages about stroke risk awareness among young adult African Americans.

METHODS

African American participants age 18 years and older completed an online survey (N = 413). Descriptive statistics, one-way analysis of variance, and two-step cluster analyses were used to evaluate stroke risk awareness, perceived risk of stroke, message creation factors, and online health information seeking behavior. Open-ended survey items described modifiable and non-modifiable reasons for perceived risk of stroke.

KEY RESULTS

Participants reported differences on overall stroke risk factor awareness by perceived risk of stroke was significant (F[2, 409] = 4.91, p = .008) with the very low/low group (M = 1.66, p < .01), showing significantly lower overall stroke risk factor awareness compared to the moderate and high/very high groups. Both respondents who thought their stroke risk was very low/low and moderate/high/very high commented about family history (54.1% and 45.9%, respectively) as the reason and 88.2% of very low/low commented that they did not have risk factors for stroke because they were young. Cluster analysis indicated the Mostly Clear Preferences cluster was more likely to select mostly/very on positive, informational, and long-term messages and medical authority sources. The largest of three clusters reported medical sources as the highest rated source for both finding and trusting health information (47.2%, n = 195).

CONCLUSION

Young adult African Americans have a scarce understanding of modifiable stroke risk factors; health education materials should focus on positive information messaging that shows a long-term result and is presented by a medical authority. We did not observe any age or sex differences among the data, which suggests different message modalities may not be needed. [HLRP: Health Literacy Research and Practice. 2024;8(1):e38-e46.].

Predicting motor gains with home-based telerehabilitation after stroke

INTRODUCTION

Telerehabilitation (TR) may be useful for rehabilitation therapy after stroke. However, stroke is a heterogeneous condition, and not all patients can be expected to derive the same benefit from TR, underscoring the need to identify predictors of response to TR.

METHODS

A prior trial provided patients with 6 weeks of intensive rehabilitation therapy targeting arm movement, randomly assigned to be provided in the home via TR (current focus) or in clinic. Eligible patients had moderate arm motor deficits and were in the subacute-chronic stage post stroke. Behavioral gains were measured as change in the arm motor Fugl-Meyer score from baseline to 30 days post therapy. To delineate predictors of TR response, multivariable linear regression was performed, advancing the most significant predictor from each of eight categories: patient demographics, stroke characteristics, medical history, rehabilitation therapy outside of study procedures, motivation, sensorimotor impairment, cognitive/affective deficits, and functional status.

RESULTS

The primary focus was on patients starting TR >90 days post stroke onset (n = 44), among whom female sex, less spasticity, and less visual field defects predicted greater motor gains. This model explained 39.3% of the variance in treatment-related gains. In secondary analysis that also included TR patients enrolled ≤90 days post stroke (total n = 59), only female sex was a predictor of treatment gains. A separate secondary analysis examined patients >90 days post stroke (n = 34) randomized to in-clinic therapy, among whom starting therapy earlier post stroke and less ataxia predicted greater motor gains.

DISCUSSION

Response to TR varies across patients, emphasizing the need to identify characteristics that predict treatment-related behavioral gain. The current study highlights factors that might be important to patient selection for home-based TR after stroke.

The Functional Balance Ability Measure: A Measure of Balance Across the Spectrum of Functional Mobility in Persons Post-Stroke

Objective

To determine whether the measurement properties of an instrument that combines items from the Berg Balance Scale (BBS) and the Functional Gait Assessment (FGA) called the Functional Balance Ability Measure (FBAM) supports measuring balance across the functional mobility spectrum.

Design

Retrospective cohort.

Setting

Item-level data were from an archival research database.

Participants

Ambulatory individuals (N=93, BBS=50 [29-56], FGA=16 [0-30], Fugl-Meyer Assessment of Lower Extremities=27 [14-34], self-selected walking speed=0.4±0.2 m/s, mean age ± SD, 61.7±11.3y; 30.1% female) with chronic stroke (≥6 months).

Interventions

Not applicable.

Main Outcome Measures

Unidimensionality was evaluated with a principal components analysis (PCA) of residuals. FBAM rating-scale characteristics, item hierarchy, item and person fit, and person separation were investigated using the Andrich Rating Scale Model.

Results

PCA findings indicate the FBAM is sufficiently unidimensional. Rating scale structure was appropriate without modifying the original BBS and FGA scoring systems. Item hierarchy aligned with clinical and theoretical predictions (hardest item: FGA-gait with narrow base of support, easiest item: BBS-sitting unsupported). One item (BBS-standing on 1 foot) misfit, however, removal marginally affected person measures and model statistics. The FBAM demonstrated high person reliability (0.9) and 6 people (∼6%) misfit the expected response pattern. The FBAM separated participants into 4 statistically distinct strata, without a floor or ceiling effect.

Conclusions

The FBAM is a unidimensional measure for balance ability across a continuum of functional tasks. Rating-scale characteristics, item hierarchy, item and person fit, and person separation support the FBAM's measurement properties in persons with chronic stroke. Future work should investigate measurement with fewer items and whether the FBAM addresses barriers to adoption of standardized balance measures in clinical practice.

Increasing of Cortisol Level and Neutrophil-Lymphocyte-Ratio are Associated with Severity Level and Sleep Disturbances in Acute Ischemic Stroke

Background

Acute ischemic stroke can cause sleep disturbances. These complaints involve various factors, such as disturbances of the hormone cortisol and Neutrophil-Lymphocyte-Ratio (NLR) that can cause increasing severity levels in acute ischemic stroke patients. This study aimed to determine the relationship between cortisol levels and NLR with severity levels and sleep disturbances in acute ischemic stroke patients.

Methods

A cross-sectional analytic observational study was conducted on acute ischemic stroke patients during Agustus - December 2022. Examine cortisol levels using the ELISA method, NLR from blood test, asses severity levels using the National Institute of Health Stroke Scale (NIHSS), and The Pittsburgh Sleep Questionnaire Index (PSQI) is used as a measure for the initial screening of sleep disturbances-statistical analysis using Spearman correlation.

Results

Total study subjects were 48 patients, with the majority 62.5% women; the mean age of study subjects was above 60 years (56.3%), and the most common type of stroke was large artery atherosclerotic stroke (77.1%), the highest NIHSS score was in the moderate category (85.4%), the most common risk factor is hypertension (64.4%), and basal ganglia area is the most common ischemic stroke location (52.1%). There was a positive correlation between cortisol levels with NIHSS (r=0.874; p-value <0.001), NLR with sleep disturbances (r=0.829; p-value<0.001), NLR with NIHSS (r=0.893; p-value<0.001), and NIHSS with PSQI (r=0.836; p-value<0.001).

Conclusion

There were a positive correlation between cortisol level, NLR level, and NIHSS score with sleep quality disturbances based on PSQI in acute ischemic stroke patients.

Association between inflammatory bowel disease and risk of stroke: a systematic review and meta-analysis of cohort studies

Background/objectives

Recently, four meta-analyses have explored the association between inflammatory bowel disease (IBD) and the risk of stroke. These studies have demonstrated that people with IBD may be at an increased risk of stroke. However, some limitations such as high heterogeneity and the lack of uniformity in the types of research, especially the reuse of some sample sizes, cannot be neglected. These factors reduce the credibility of their research conclusions. Therefore, we conducted a meta-analysis to explore this possible association.

Methods

PubMed, Embase, and Web of Science were searched from inception to 30 June 2023. A random effects model with the generic inverse variance method was used in this meta-analysis. The Review Manager software was used to obtain all relative risks (RRs) and their 95% confidence intervals (CIs). Publication bias was tested, and sensitivity and subgroup analyses were conducted to explore possible heterogeneities.

Results

This meta-analysis included 12 cohort studies (involving 4,495,055 individuals). Meta-analysis of these data has shown that IBD was associated with an increased risk of stroke (RR = 1.19, 95%CI:1.14-1.24, p < 0.00001). Our results were stable and robust in subgroup and sensitivity analyses.

Conclusions

Our results suggest that IBD is associated with an increased risk of stroke. To reduce the incidence of stroke, patients with IBD are encouraged to undergo stroke risk assessments, especially for young female patients; assessing the risk of ischemic stroke is of particular importance. Prospective studies considering stroke subtypes, IBD severity and treatments, regions, and other confounding factors are needed to further explore the nature of each association.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022373656.

Thirty-day mortality rates among young adult stroke patients and their characteristics at Kiruddu and Mulago hospitals in Uganda: A prospective observational cohort study

Stroke outcomes among young adults in Uganda are unclear. This study therefore determined the clinical characteristics and 30-day outcome among young adults with an acute stroke. In a prospective observational cohort study, 61 young adults with confirmed stroke were followed up for 30 days. Socio-demographic and clinical characteristics were collected using a study questionnaire. Kaplan-Meier curves, and modified Poisson regression were performed for factors associated with the 30-day mortality outcome. A third of the screened stroke survivors, (61/195) were young adults aged between 18 and 50 years. About two-thirds were male. More than half were diagnosed with ischaemic strokes while 42.6% had a haemorrhagic stroke. Nearly half (29/61) were known hypertensives, 43% (26/61) had a history of alcohol consumption with 95% classified as dependent on CAGE assessment. Ten percent had a prior smoking history while 29% of the female gender had a prior history of oral contraception use. Twenty-three percent (14/61) of the young stroke patients died within 30 days of stroke onset (95% CI: 0.01, 0. 901). A history of smoking (adjusted prevalence ratio: aPR;5. 094, 95% CI: 3.712, 6. 990) and stroke severity National Institutes of Health Stroke score (NIHSS) >16; Prevalence ratio (PR) -3. 301, 95%CI: 1. 395, 7. 808) and not drinking alcohol (aPR (adjusted prevalence ratio) -7. 247, 95% CI: 4. 491, 11.696) were associated with 30- day mortality. A third of all stroke survivors were young adults. About 23. 3% died within 30 days of stroke onset. Stroke severity and a history of smoking were associated with mortality. Identifying high risk patients and early outpatient follow up may help reduce the 30-day mortality in our settings.

Endovascular treatment for young patients with acute large vessel occlusion stroke in China: analysis of the ANGEL-ACT registry

Background

The incidence of acute ischemic stroke caused by large vessel occlusion is relatively infrequent in the young adult population. We sought to evaluate their clinical outcomes after endovascular treatment (EVT) and stroke etiology compared with older patients.

Methods

We examined data from the ANGEL-ACT registry, a nationwide study in China focusing on EVT for acute ischemic stroke. We compared two age groups: <50 years old and ≥50 years old. Our analysis focused on outcome measures such as the 90-day modified Rankin Scale (mRS) score, mortality, and symptomatic intracranial hemorrhage (sICH). We adjusted for confounding variables.

Results

We included 1,691 patients, and 216 patients (13%) were <50 years old. Young patients had lower median National Institutes of Health Stroke Scale (NIHSS) scores (14 vs. 17, P < 0.001) and fewer cardiovascular comorbidities than older patients. Underlying intracranial atherosclerosis disease (ICAD) was higher in young patients (39.4 vs. 28.7%, P = 0.001). Clinical outcome was less favorable in older compared to younger patients (mRS shift: 0.76 [95% confidence interval (CI), 0.58-0.99]); functional independence [mRS score 0-2] 61% vs. 39% (adjusted odds ratio (OR), 0.7 [95% CI, 0.51-0.97]). Mortality and sICH did not differ between groups. Onset to puncture time (OTP) was longer in young patients (357 min vs. 294 min, P = 0.001).

Conclusion

An estimated 13% of patients who underwent endovascular thrombectomy for acute ischemic stroke were <50 years old. Symptomatic underlying ICAD was more prevalent in the younger patient population. Despite a prehospital delay, younger patients exhibited more favorable outcomes than their older counterparts.

Subventricular zone cytogenesis provides trophic support for neural repair in a mouse model of stroke

Stroke enhances proliferation of neural precursor cells within the subventricular zone (SVZ) and induces ectopic migration of newborn cells towards the site of injury. Here, we characterize the identity of cells arising from the SVZ after stroke and uncover a mechanism through which they facilitate neural repair and functional recovery. With genetic lineage tracing, we show that SVZ-derived cells that migrate towards cortical photothrombotic stroke in mice are predominantly undifferentiated precursors. We find that ablation of neural precursor cells or conditional knockout of VEGF impairs neuronal and vascular reparative responses and worsens recovery. Replacement of VEGF is sufficient to induce neural repair and recovery. We also provide evidence that CXCL12 from peri-infarct vasculature signals to CXCR4-expressing cells arising from the SVZ to direct their ectopic migration. These results support a model in which vasculature surrounding the site of injury attracts cells from the SVZ, and these cells subsequently provide trophic support that drives neural repair and recovery.

Trends and patterns in stroke incidence, mortality, DALYs and case-fatality by sociodemographic index worldwide: an age-period-cohort analysis using the Global Burden of Disease 2019 study

OBJECTIVES

Stroke is a significant public health burden worldwide. This study aimed to explore the trends and patterns of stroke incidence, mortality, disability-adjusted life years (DALYs) and case-fatality percent (CFP) worldwide from 1990 to 2019.

STUDY DESIGN

Age-period-cohort analysis.

METHODS

Trends in stroke burden worldwide were evaluated using data from the Global Burden of Disease 2019 study. In addition, the relationship between the burden of stroke and sociodemographic index (SDI) was examined by quantile regression. Age, period and cohort patterns in stroke burden across different SDI groups were estimated using age-period-cohort analysis.

RESULTS

Between 1990 and 2019, the age-standardised rates (ASRs) of stroke incidence, mortality and DALYs declined significantly worldwide, with decreases of -16.89% (95% uncertainty interval [UI]: -18.41 to -15.29), -36.43% (95% UI: -41.65 to -31.20) and -35.23% (95% UI: -40.49 to -30.49), respectively. Regions with ASRs in the 75th percentile and below experienced significant decreases in ASRs with increasing SDI. After 2014, there was a stable or slightly increased period effect for stroke incidence in all groups, while mortality, DALYs and CFP increased only in the high SDI group. The cohort effect of stroke incidence remained constant in the high SDI group from the 1960-1964 cohort onwards.

CONCLUSIONS

Although high SDI regions had a lower stroke burden and a faster overall decline in burden, the recent relative risk data suggest a potential deceleration in the progress of reducing stroke burden in these areas. There is a need for more active measures to reduce the stroke burden in areas with the highest incidence, mortality and DALYs, as increasing SDI alone cannot lower the burden in these regions.

Cognitive impairment after a stroke in young adults: A systematic review and meta-analysis

BACKGROUND

Information about cognitive functioning is vital in the management of stroke, but the literature is mostly based on data from individuals older than 50 years of age who make up the majority of the stroke population. As cognitive functioning is subject to change due to aging, it is unclear whether such cognitive impairment patterns from the general stroke literature apply to the growing population of younger people with a stroke.

AIM

The aim of the study was to conduct a systematic review and meta-analysis of the proportion and severity of cognitive impairment in young-stroke patients.

SUMMARY OF REVIEW

MEDLINE, Embase, PsycINFO, and Web of Science were systematically searched up to 11 October 2022. Studies were included if they reported on a population of young-stroke patients, evaluated cognitive functioning as an outcome measure, and reported original data. We estimated the pooled prevalence rates for cognitive impairment and for aphasia. In addition, we calculated the pooled estimates for the severity of impairment per cognitive domain in the chronic phase (defined as >6 months post-stroke). Six hundred thirty-five articles were identified, of which 29 were eligible for inclusion. The pooled prevalence of cognitive impairment was 44% (k = 10; 95% confidence interval (CI): 34-54%) and of aphasia 22% (k = 13; 95% CI: 12-39%). Young-stroke patients in the chronic phase performed worse than stroke-free healthy age-appropriate controls across all cognitive domains examined, with Hedges' g effect sizes ranging from -0.49 to -1.64.

CONCLUSION

Around half of all young-stroke patients present with cognitive impairment and around a quarter with aphasia. Our data suggest that patterns of impairment in young-stroke patients follow those in the general stroke literature.

A systematic review and meta-analysis on the efficacy of glibenclamide in animal models of intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a devastating stroke with many mechanisms of injury. Edema worsens outcome and can lead to mortality after ICH. Glibenclamide (GLC), a sulfonylurea 1- transient receptor potential melastatin 4 (Sur1-Trpm4) channel blocker, has been shown to attenuate edema in ischemic stroke models, raising the possibility of benefit in ICH. This meta-analysis synthesizes current pre-clinical (rodent) literature regarding the efficacy of post-ICH GLC administration (vs. vehicle controls) on behaviour (i.e., neurological deficit, motor, and memory outcomes), edema, hematoma volume, and injury volume. Six studies (5 in rats and 1 in mice) were included in our meta-analysis (PROSPERO registration = CRD42021283614). GLC significantly improved behaviour (standardized mean difference (SMD) = -0.63, [-1.16, -0.09], n = 70-74) and reduced edema (SMD = -0.91, [-1.64, -0.18], n = 70), but did not affect hematoma volume (SMD = 0.0788, [-0.5631, 0.7207], n = 18-20), or injury volume (SMD = 0.2892, [-0.4950, 1.0734], n = 24). However, these results should be interpreted cautiously. Findings were conflicted with 2 negative and 4 positive reports, and Egger regressions indicated missing negative edema data (p = 0.0001), and possible missing negative behavioural data (p = 0.0766). Experimental quality assessed via the SYRCLE and CAMARADES checklists was concerning, as most studies demonstrated high risks of bias. Studies were generally low-powered (e.g., average n = 14.4 for behaviour), and future studies should employ sample sizes of 41 to detect our observed effect size in behaviour and 33 to detect our observed effect in edema. Overall, missing negative studies, low study quality, high risk of bias, and incomplete attention to key recommendations (e.g., investigating female, aged, and co-morbid animals) suggest that further high-powered confirmatory studies are needed before conclusive statements about GLC's efficacy in ICH can be made, and before further clinical trials are performed.

Effect of an educational intervention to increase stroke awareness among Italian high school students: A prospective study in Tuscany

INTRODUCTION

Stroke in young people shares traditional modifiable risk factors with older groups, and greatly affects quality of life. However, evidence on the effectiveness of educational interventions in young populations, aiming at spreading stroke knowledge and enhancing prevention, is still scarce. We evaluated baseline knowledge of stroke and possible improvements after an educational intervention among Italian high school students, also considering differences related to sex and type of school.

SUBJECTS AND METHODS

Using a mixed educational strategy, a prospective evaluation of stroke knowledge was performed in five humanities and sciences (lyceums) and five vocational high schools of Tuscany (students of the 12th and 13th grade). A baseline assessment with a structured questionnaire (21 questions) was followed by a standardized oral presentation, using audiovisual materials. After 3 months, the same questionnaire was re-administered to evaluate the long-term impact of the educational intervention.

RESULTS

Overall, 573 students (50.8% males; age range, 17-19 years) were enrolled; 288 (50.3%) were from lyceums and 285 (49.7%) from vocational schools. Follow-up participation was 97.2%. Baseline performances were comparable between groups for most variables examined. At 3 months, all groups showed a significant improvement from baseline regarding reaction to a stroke event, identification of stroke risk factors, such as smoking (from 62.9% to 83.7%; p < 0.001) and alcohol abuse (from 49.6% to 67.2%; p < 0.001), and symptoms. Knowledge of the existence of stroke units and thrombolysis increased from 25.4% to 60.7% (p < 0.001) and from 35.8% to 84.0% (p < 0.001), respectively.

CONCLUSIONS

Our educational intervention improved stroke awareness in high school students. The effects persisted after 3 months. Improved knowledge in young populations may reduce stroke burden in adult life, increase timely access to therapies, and spread knowledge across families.

An analysis of racial inequities in emergency department triage among patients with stroke-like symptoms in the United States

BACKGROUND

Racial inequities exist in treatment and outcomes in patients with acute stroke.

OBJECTIVES

Our objective was to determine if racial inequities exist in the time-lapse between patient presentation and provider assessment in patients with stroke-like symptoms in Emergency Departments (ED) across the U.S.

METHODS

This study is a retrospective, observational study of the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2014-2018. We identified visits with stroke-like symptoms and stratified the proportion of door-to-provider (DTP) times by racial groups. We used broad and narrow definitions of stroke-like symptoms. We performed bivariate and multivariate analyses using race and clinical and demographic characteristics as covariates.

RESULTS

Between 2014-2018, there were an average of 138.58 million annual ED visits. Of the total ED visits, 0.36% to 7.39% of the ED visits presented with stroke-like symptoms, and the average DTP time ranged from 39 to 49 min. The proportion of the visits with a triage level of 1 (immediate) or 2 (emergent) ranged from 16.03% to 23.27% for stroke-like symptoms. We did not find statistically significant racial inequities in DTP or ED triage level. We found significantly longer DTP times in non-Hispanic blacks (15.88 min, 95% CI: 4.29-27.48) and Hispanics (by 14.77 min, 95% CI: 3.37-26.16) than non-Hispanic whites that presented with atypical stroke-like symptoms. We observed that non-Hispanic whites were significantly more diagnosed with a stroke/TIA than other racial minority groups (p = 0.045) for atypical stroke-like symptoms.

CONCLUSION

In our population-based analysis, we did not identify systemic racial inequities in the DTP times or ED triage level at ED triage for stroke-like symptoms.

Qualitative feasibility study of the mobile app Destroke for clinical stroke monitoring based on the NIH stroke scale

BACKGROUND

Stroke is a leading cause of severe disability in the United States, but there is no effective method for patients to accurately detect the signs of stroke at home. We developed a mobile app, Destroke, that allows remote performance of a modified NIH stroke scale (NIHSS) by patients.

AIMS

To assess the feasibility of a mobile app for stroke monitoring and education by patients with a history of stroke.

MATERIALS AND METHODS

We enrolled 25 patients with a history of stroke in a prospective open-label study to evaluate the feasibility of the Destroke app in patients with stroke. Nineteen patients completed all study assessments, with a median time from stroke onset to enrollment of 5.6 years (range 0.1-12 years). We designed a modified NIHSS that assessed 12 out of 16 tasks on the NIHSS. Patients completed this test eight times over a 28-day period. We conducted pre-study surveys that assessed demographic information, stroke and cardiovascular history, baseline NIHSS, and experience using mobile technologies, and mid- and post-study surveys that assessed patient satisfaction on app usage and confidence in stroke detection.

RESULTS

Ten men and nine women participated in this study (median age of 64 (33-76)), representing ten US states and Washington D.C. Median baseline NIHSS was 0 (0-4). 15 patients reported using health apps. On a 5-point Likert scale, patients rated the app as 4.2 on being able to understand and use the app and 4.3 on using the app when instructed by their doctor. For eight patients with poor confidence in detecting the signs of a stroke before the study, six showed higher confidence after the study.

CONCLUSIONS

The use of an at-home stroke monitoring app is feasible by patients with a history of stroke and improves confidence in detecting the signs of stroke.

Association of co-morbidity with acute stroke mortality by age and time since stroke: A population-based study

OBJECTIVE

To examine whether the association of co-morbidity with mortality after acute stroke is influenced by stroke type, age, sex, or time since stroke.

MATERIALS AND METHODS

We conducted a province-wide population-based study using linked administrative databases to identify all admissions for acute stroke between 2007-2018 in Alberta, Canada. We used Cox proportional hazard models to determine the association of severe co-morbidity based on the Charlson Co-morbidity Index with 1-year mortality after stroke, assessing for effect modification by stroke type, age, and sex, and with adjustment for estimated stroke severity, comprehensive stroke centre care, hypertension, atrial fibrillation, and year of study. We used a piecewise model to analyze the impact of co-morbidity across four time periods.

RESULTS

We had 28,672 patients in our final cohort (87.8% ischemic stroke). The hazard of mortality with severe co-morbidity was higher for individuals with ischemic stroke (adjusted hazard ratio [aHR] 2.20, 95% CI 2.07-2.32) compared to those with intracerebral hemorrhage (aHR 1.70, 95% CI 1.51-1.92; pint<0.001), and higher in individuals under age 75 (aHR 3.20, 95% CI 2.90-3.53) compared to age ≥75 (aHR 1.93, 95% CI 1.82-2.05, pint<0.001). There was no interaction by sex. The hazard ratio increased in a graded fashion at younger ages and was higher after the first 30 days of acute stroke.

CONCLUSION

There was a stronger association between co-morbidity and mortality at younger age and in the subacute phase of stroke. Further research is needed to determine the reason for these findings and identify ways to improve outcomes among those with stroke and co-morbid conditions at young age.

Twenty-Year Disparity Trends in United States Stroke Death Rate by Age, Race/Ethnicity, Geography, and Socioeconomic Status

BACKGROUND AND OBJECTIVES

In 2017, the Centers for Disease Control and Prevention (CDC) issued an alert that, after decades of consistent decline, the stroke death rate levelled off in 2013, particularly in younger individuals and without clear origin. The objective of this analysis was to understand whether social determinants of health have influenced trends in stroke mortality.

METHODS

We performed a longitudinal analysis of county-level ischemic and hemorrhagic stroke death rate per 100,000 adults from 1999 to 2018 using a Bayesian spatiotemporally smoothed CDC dataset stratified by age (35-64 years [younger] and 65 years or older [older]) and then by county-level social determinants of health. We reported stroke death rate by county and the percentage change in stroke death rate during 2014-2018 compared with that during 2009-2013.

RESULTS

We included data from 3,082 counties for younger individuals and 3,019 counties for older individuals. The stroke death rate began to increase for younger individuals in 2013 (p < 0.001), and the slope of the decrease in stroke death rate tapered for older individuals (p < 0.001). During the 20-year period of our study, counties with a high social deprivation index and ≥10% Black residents consistently had the highest rates of stroke death in both age groups. Comparing stroke death rate during 2014-2018 with that during 2009-2013, larger increases in younger individuals' stroke death rate were seen in counties with ≥90% (vs <90%) non-Hispanic White individuals (3.2% mean death rate change vs 1.7%, p < 0.001), rural (vs urban) populations (2.6% vs 2.0%, p = 0.019), low (vs high) proportion of medical insurance coverage (2.9% vs 1.9%, p = 0.002), and high (vs low) substance abuse and suicide mortality (2.8 vs 1.9%, p = 0.008; 3.3% vs 1.5%, p < 0.001). In contrast to the younger individuals, in older individuals, the associations with increased death rates were with more traditional social determinants of health such as the social deprivation index, urban location, unemployment rate, and proportion of Black race and Hispanic ethnicity residents.

DISCUSSION

Improvements in the stroke death rate in the United States are slowing and even reversing in younger individuals and many US counties. County-level increases in stroke death rate were associated with distinct social determinants of health for younger vs older individuals. These findings may inform targeted public health strategies.

Pregnancy-Associated Stroke and Outcomes Related to Timing and Hypertensive Disorders

OBJECTIVE

To estimate temporal trends of stroke in the peripartum period and to assess the relationship between stroke and maternal adverse outcomes vis-à-vis timing and hypertension.

METHODS

We conducted a retrospective, cross-sectional study using the National Inpatient Sample to identify hospitalizations with pregnancy-associated stroke in the United States (2016-2019). Temporal trends in pregnancy-associated stroke were examined according to timing of stroke (antepartum vs postpartum) and both prepregnancy and pregnancy hypertensive disorders (yes vs no). Multivariable Poisson regression models with robust error variance were used to examine the association among maternal adverse outcomes, timing of stroke, and hypertensive disorders.

RESULTS

Among 15,977,644 pregnancy hospitalizations, 6,100 hospitalizations (38.2/100,000 hospitalizations) were with pregnancy-associated stroke. Of these, 3,635 (59.6%) had antepartum pregnancy-associated stroke and 2,465 (40.4%) had postpartum pregnancy-associated stroke; alternatively, 2,640 (43.3%) had hypertensive disorders, and 3,460 (56.7%) were without hypertensive disorders. From 2016 to 2019, the overall rate of pregnancy-associated stroke (37.5 to 40.8/100,000 pregnancy hospitalizations, P=.028), rate of postpartum pregnancy-associated stroke (14.6 to 17.6/100,000 pregnancy hospitalizations, P=.005), and rate of pregnancy-associated stroke with hypertensive disorders (14.9 to 17.2/100,000 pregnancy hospitalizations, P=.013) increased. Antepartum pregnancy-associated stroke and pregnancy-associated stroke without hypertensive disorders, however, remained stable. Despite higher risk of maternal morbidity in postpartum stroke hospitalizations, including mechanical ventilation and pneumonia, there was no significant difference in in-hospital mortality between antepartum and postpartum stroke. Similarly, between pregnancy-associated stroke with hypertensive disorders and stroke without hypertensive disorders, an increased risk of mechanical ventilation, seizure, and prolonged hospital stay was seen for stroke with hypertensive disorders without an increase in mortality.

CONCLUSION

A nationally representative sample of hospitalizations in the United States indicates an increasing trend in the rate of postpartum stroke. Almost half of hospitalizations with pregnancy-associated stroke have concomitant hypertensive disorders. Risk of adverse outcomes, but not mortality, is elevated in patients with stroke occurring in the postpartum period and stroke associated with hypertensive disorders.

Polymorphisms of TRIB1 Genes for Coronary Artery Disease and Stroke Risk: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

In recent years, the results of the association between Tribbles Pseudokinase 1 (TRIB1) gene polymorphism and the risk of coronary artery disease (CAD) and stroke are inconsistent. This study aimed to systematically review the literature on TRIB1 gene polymorphisms and susceptibility to coronary atherosclerotic heart disease (CAD) and stroke.

METHODS

This study collected studies published until May 2022 through a systematic search of PubMed, Web of Science, and Google Scholar databases. After a systematic literature search, pooled odds ratio (OR) and their corresponding 95% confidence interval (CI) were used to assess the strength of the association.

RESULTS

We identified 6 studies on rs17321515, including 12892 controls and 4583 patients, and 3 on rs2954029, including 1732 controls and 1305 patients. In different genetic models, the rs2954029 genetic polymorphism significantly increased the risk of CAD and stroke. In the codominant model, the AA genotype increased the risk of CAD and stroke (OR=1.74, 95% CI=1.39-2.17, P<0.001); the TA genotype also increased the prevalence of CAD and stroke risk (OR=1.39, 95% CI=1.18-1.64, P<0.001). Compared with the control group, the TT+TA genotype increased the risk of CAD and stroke in the dominant genetic model (OR=1.46, 95%CI=1.25-1.71, P<0.001), and in the recessive model, the TA+AA genotype increased the risk of CAD and stroke (OR=1.41, 95% CI=1.15-1.72, P<0.001). In addition, the TRIB1 rs17321515 polymorphism was not found to be associated with the risk of CAD and stroke, which may be related to other factors such as race.

CONCLUSIONS

The rs2954029 A allele was significantly associated with an increased risk of CAD and stroke, according to the present meta-analysis. However, the association of rs17321515 polymorphism with susceptibility to CAD and stroke has not been found in this study.