Association of ischemic stroke onset time with presenting severity, acute progression, and long-term outcome: A cohort study

Construction of a machine learning-based prediction model for unfavorable discharge outcomes in patients with ischemic stroke

Background

Ischemic stroke is a common and serious disease with economic and healthcare burdens. Predicting the unfavorable discharge outcome of patients is essential for formulating appropriate treatment strategies and providing personalized care. Therefore, this study aims to establish and validate a prediction model based on machine learning methods to accurately predict the discharge outcome of ischemic stroke patients, providing valuable information for clinical decision making.

Methods

The derivation data consisted of 964 patients from Guangdong Provincial People's Hospital and was used for training and internal validation. A favourable discharge outcome was defined as a National Institutes of Health Stroke Scale score of ≤1 or a decrease of ≥8 points compared to the admission score. A predictive model was created based on 88 medical characteristics gathered during the patient's initial admission, using nine machine learning algorithms. The model's predictive performance was compared using various evaluation metrics. The final model's feature importance was ranked and explained using the Shapley additive explanation method.

Findings

The random forest model demonstrated the greatest discriminative ability among the nine machine learning models. We created an interpretable random forest model by ranking and reducing the features based on their importance, which included eight features. In internal validations, the final model accurately predicted the discharge outcomes of ischemic stroke with AUC values of 0.903 and has been translated into a convenient tool to facilitate its utility in clinical settings.

Conclusions

Our explainable ML model was not only successfully developed to accurately predict discharge outcomes in patients with ischemic stroke and it mitigated the concern of the "black-box" issue with an undirect interpretation of the ML technique.

Ticking Brain: Circadian Rhythm as a New Target for Cerebroprotection

Circadian rhythm is a master process observed in nearly every type of cell throughout the body, and it macroscopically regulates daily physiology. Recent clinical trials have revealed the effects of circadian variation on the incidence, pathophysiological processes, and prognosis of acute ischemic stroke. Furthermore, core clock genes, the cell-autonomous pacemakers of the circadian rhythm, affect the neurovascular unit-composing cells in a nonparallel manner after the same pathophysiological processes of ischemia/reperfusion. In this review, we discuss the influence of circadian rhythms and clock genes on each type of neurovascular unit cell in the pathophysiological processes of acute ischemic stroke.

Exploring the shared biomarkers between cardioembolic stroke and atrial fibrillation by WGCNA and machine learning

Background

Cardioembolic Stroke (CS) and Atrial Fibrillation (AF) are prevalent diseases that significantly impact the quality of life and impose considerable financial burdens on society. Despite increasing evidence of a significant association between the two diseases, their complex interactions remain inadequately understood. We conducted bioinformatics analysis and employed machine learning techniques to investigate potential shared biomarkers between CS and AF.

Methods

We retrieved the CS and AF datasets from the Gene Expression Omnibus (GEO) database and applied Weighted Gene Co-Expression Network Analysis (WGCNA) to develop co-expression networks aimed at identifying pivotal modules. Next, we performed Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis on the shared genes within the modules related to CS and AF. The STRING database was used to build a protein-protein interaction (PPI) network, facilitating the discovery of hub genes within the network. Finally, several common used machine learning approaches were applied to construct the clinical predictive model of CS and AF. ROC curve analysis to evaluate the diagnostic value of the identified biomarkers for AF and CS.

Results

Functional enrichment analysis indicated that pathways intrinsic to the immune response may be significantly involved in CS and AF. PPI network analysis identified a potential association of 4 key genes with both CS and AF, specifically PIK3R1, ITGAM, FOS, and TLR4.

Conclusion

In our study, we utilized WGCNA, PPI network analysis, and machine learning to identify four hub genes significantly associated with CS and AF. Functional annotation outcomes revealed that inherent pathways related to the immune response connected to the recognized genes might could pave the way for further research on the etiological mechanisms and therapeutic targets for CS and AF.

The Role of Circadian Rhythm in Neurological Diseases: A Translational Perspective

Intrinsic biological clocks drive the circadian rhythm, which coordinates the physiological and pathophysiological processes in the body. Recently, a bidirectional relationship between circadian rhythms and several neurological diseases has been reported. Neurological diseases can lead to the disruption of circadian homeostasis, thereby increasing disease severity. Therefore, optimizing the current treatments through circadian-based approaches, including adjusted dosing, changing lifestyle, and targeted interventions, offer a promising opportunity for better clinical outcomes and precision medicine. In this review, we provide detailed implications of the circadian rhythm in neurological diseases through bench-to-bedside approaches. Furthermore, based on the unsatisfactory clinical outcomes, we critically discuss the potential of circadian-based interventions, which may encourage more studies in this discipline, with the hope of improving treatment efficacy in neurological diseases.

Detection of early neurological deterioration using a quantitative electroencephalography system in patients with large vessel occlusion stroke after endovascular treatment

BACKGROUND

Early neurological deterioration (END) is a serious complication in patients with large vessel occlusion (LVO) stroke. However, modalities to monitor neurological function after endovascular treatment (EVT) are lacking. This study aimed to evaluate the diagnostic accuracy of a quantitative electroencephalography (qEEG) system for detecting END.

METHODS

In this prospective, nested case-control study, we included 47 patients with anterior circulation LVO stroke and 34 healthy adults from different clinical centers in Tianjin, China, from May 2023 to January 2024. Patients with stroke underwent EEG at admission and after EVT. The diagnostic accuracy of qEEG features for END was evaluated by receiver operating characteristic curve analysis, and the feasibility was evaluated by the percentage of artifact-free data and device-related adverse events.

RESULTS

14 patients with stroke had END (29.8%, 95% CI 16.2% to 43.4%), with most developed within 12 hours of recanalization (n=11). qEEG features showed significant correlations with National Institutes of Health Stroke Scale score and infarct volume. After matching, 13 patients with END and 26 controls were included in the diagnostic analysis. Relative alpha power demonstrated the highest diagnostic accuracy for the affected and unaffected hemispheres. The optimal electrode positions were FC3/4 in the unaffected hemisphere, and F7/8 and C3/4 in the affected hemisphere. No device-related adverse events were reported.

CONCLUSION

The qEEG system exhibits a high diagnostic accuracy for END and may be a promising tool for monitoring neurological function. The identification of optimal electrode positions may enhance device convenience.

CLINICAL TRIAL REGISTRATION

ChiCTR 2300070829.

FOXP3 gene is associated with susceptibility to ischemic stroke in the Chinese population

AIM

Immunoinflammatory response plays an important role in the pathophysiological process of ischemic stroke (IS). Forkhead box P3 (FOXP3) is a master regulator for immune cells. Polymorphisms of FOXP3 gene might contribute to the susceptibility of IS. This study aimed to explore the association between FOXP3 gene polymorphisms (rs3761548 and rs2232365) and IS susceptibility in the Chinese Han population.

METHODS

Polymerase chain reaction and Sanger sequencing were used to detect the genotype of FOXP3 gene rs3761548 and rs2232365 polymorphisms.

RESULTS

Smoking, diabetes mellitus (DM), and HBP histories, higher TG and HDL-C levels were more frequently observed in IS patients than in controls. In comparison with rs3761548 GG genotype, GT genotype (OR = 1.573, 95 %CI = 1.030-2.402; adjusted: OR = 1.736, 95 %CI = 1.070-2.817) and GT + TT vs. GG model (OR = 1.581, 95 %CI = 1.0449-2.382; adjusted: OR = 1.720, 95 %CI = 1.074-2.755) of rs3761548 polymorphism was significantly correlated with elevated ischemic stroke susceptibility both at prior and after adjusted by smoking, HBP, DM, TG and HDL-C. Recessive model of rs2232365 polymorphism could elevate the susceptibility of ischemic stroke (OR = 11.962, 95 %CI = 1.144-3.3363; adjusted: OR = 1.876, 95 %CI = 1.016-3.463). Besides, rs3761548 dominant model (OR = 2.757, 95 %CI = 1.379-5.552; adjusted: OR = 2.601, 95 %CI = 1.268-5.336) and rs2232365 recessive model (OR = 3.103, 95 %CI = 1.463-6.583; adjusted: OR = 3.545, 95 %CI = 1.600-7.855) were related to the severity of ischemic stroke.

CONCLUSION

FOXP3 gene rs3761548 and rs2232365 polymorphisms were risk factors for susceptibility and severity of IS.

A minimally invasive thrombotic stroke model to study circadian rhythm in awake mice

Experimental stroke models in rodents are essential for mechanistic studies and therapeutic development. However, these models have several limitations negatively impacting their translational relevance. Here we aimed to develop a minimally invasive thrombotic stroke model through magnetic particle delivery that does not require craniotomy, is amenable to reperfusion therapy, can be combined with in vivo imaging modalities, and can be performed in awake mice. We found that the model results in reproducible cortical infarcts within the middle cerebral artery (MCA) with cytologic and immune changes similar to that observed with more invasive distal MCA occlusion models. Importantly, the injury produced by the model was ameliorated by tissue plasminogen activator (tPA) administration. We also show that MCA occlusion in awake animals results in bigger ischemic lesions independent of day/night cycle. Magnetic particle delivery had no overt effects on physiologic parameters and systemic immune biomarkers. In conclusion, we developed a novel stroke model in mice that fulfills many requirements for modeling human stroke.

Impact of Off-Hour Admission on In-Hospital Outcomes for Patients With Stroke Receiving Reperfusion Therapy in China

BACKGROUND

The structure and staffing of hospitals greatly impact patient outcomes, with frequent changes occurring during nights and weekends. This retrospective cohort study assessed the impact of admission timing on in-hospital management and outcomes for patients with stroke receiving reperfusion therapy in China using data from a nationwide registry.

METHODS

Data from patients receiving reperfusion therapy were extracted from the Chinese Stroke Center Alliance. Hospital admission time was categorized according to day/evening versus night and weekday versus weekend. Primary outcomes were in-hospital death or discharge against medical advice, hemorrhage transformation, early neurological deterioration, and major adverse cardiovascular events. Logistic regression was performed to compare in-hospital management performance and outcomes based on admission time categories.

RESULTS

Overall, 42 381 patients received recombinant tissue-type plasminogen activator (r-tPA) therapy, and 5224 underwent endovascular treatment (EVT). Patients admitted during nighttime had a higher probability of receiving r-tPA therapy within 4.5 hours from onset or undergoing EVT within 6 hours from onset compared with those admitted during day/evening hours (adjusted odds ratio, 1.04 [95% CI, 1.01-1.08]; P=0.021; adjusted odds ratio, 1.72 [95% CI, 1.59-1.86]; P<0.001, respectively). However, no significant difference was observed between weekend and weekday admissions for either treatment. No notable differences were noted between weekends and weekdays or nighttime and daytime periods in door-to-needle time for r-tPA or door-to-puncture time for EVT initiation. Furthermore, weekend or nighttime admission did not have a significant effect on the primary outcomes of r-tPA therapy or EVT. Nevertheless, in patients undergoing EVT, a higher incidence of pneumonia was observed among those admitted at night compared with those admitted during day/evening hours (adjusted odds ratio, 1.22 [95% CI, 1.05-1.42]; P=0.011).

CONCLUSIONS

Patients admitted at nighttime were more likely to receive r-tPA therapy or EVT within the time window recommended in the guidelines. However, patients receiving EVT admitted at night had an increased risk of pneumonia.

Stroke signs knowledge and factors associated with a delayed hospital arrival of patients with acute stroke in Kinshasa

Background

Rapid recognition and early medical intervention are essential to reduce stroke-related mortality and long-term disability. This study aimed to evaluate awareness of stroke symptoms/signs and determine factors delaying the hospital arrival of patients with acute stroke in Kinshasa.

Methods

Patients with stroke and/or accompanying family members were interviewed using a standard questionnaire, and their medical records were reviewed. Factors independently associated with a late arrival (≥4.5 h) to the hospital were identified using the logistic regression test in forward multivariate analysis.

Results

Overall, 202 patients with an average age of 57.9 ± 13.1 years were included. Only 27 (13.4%) patients immediately associated the initial symptoms with a stroke episode. Delayed hospital arrival was observed in 180 (89.1%) patients. Unmarried status (adjusted odds ratio [aOR], 2.29; 95% confidence interval [CI], 1.17-4.88; p = 0.007), low education level (aOR, 2.29; 95% CI, (1.12-5.10; p = 0,014), absence of impaired consciousness (aOR, 3.12; 95% CI, 1.52-4.43; p = 0.005), absence of a history of hypertention (aOR, 1.85; 95% CI, 1.18-3.78; p = 0.041), absence of a history of diabetes (aOR, 1.93; 95% CI, 1.15-4.58; p = 0.013), heavy alcohol consumption (aOR, 1.83; 95% CI, 1.12-2.83; p = 0.045), absence of a severe to very severe stroke (aOR, 4.93; 95% CI, 0.82-1.01; p = 0.002), and presence of ischemic stroke (aOR, 2.93; 95% CI, 1.54-4.59; p = 0.001) were identified as independent determinants of delayed hospital arrival.

Conclusions

This study depicted a low stroke awareness rate and a much longer prehospital delay than evidence-based guidelines recommend and identified eight factors that public health actions could target to promote the earliest management of stroke.

Multicenter exploration of tenecteplase transition factors: A quantitative analysis

BACKGROUND

Tenecteplase (TNK) is gaining recognition as a novel therapy for acute ischemic stroke (AIS). Despite TNK offering a longer half-life, time and cost saving benefits and comparable treatment and safety profiles to Alteplase (ALT), the adoption of TNK as a treatment for AIS presents challenges for hospital systems.

OBJECTIVE

Identify barriers and facilitators of TNK implementation at acute care hospitals in Texas.

METHODS

This prospective survey used open-ended questions and Likert statements generated from content experts and informed by qualitative research. Stroke clinicians and nurses working at 40 different hospitals in Texas were surveyed using a virtual platform.

RESULTS

The 40 hospitals had a median of 34 (IQR 24.5-49) emergency department beds and 42.5 (IQR 23.5-64.5) inpatient stroke beds with 506.5 (IQR 350-797.5) annual stroke admissions. Fifty percent of the hospitals were Comprehensive Stroke Centers, and 18 (45 %) were solely using ALT for treatment of eligible AIS patients. Primary facilitators to TNK transition were team buy-in and a willingness of stroke physicians, nurses, and pharmacists to adopt TNK. Leading barriers were lack of clinical evidence supporting TNK safety profile inadequate evidence supporting TNK use and a lack of American Heart Association guidelines support for TNK administration in all AIS cases.

CONCLUSION

Understanding common barriers and facilitators to TNK adoption can assist acute care hospitals deciding to implement TNK as a treatment for AIS. These findings will be used to design a TNK adoption Toolkit, utilizing implementation science techniques, to address identified obstacles and to leverage facilitators.

Stroke in the Time of Circadian Medicine

Time-of-day significantly influences the severity and incidence of stroke. Evidence has emerged not only for circadian governance over stroke risk factors, but also for important determinants of clinical outcome. In this review, we provide a comprehensive overview of the interplay between chronobiology and cerebrovascular disease. We discuss circadian regulation of pathophysiological mechanisms underlying stroke onset or tolerance as well as in vascular dementia. This includes cell death mechanisms, metabolism, mitochondrial function, and inflammation/immunity. Furthermore, we present clinical evidence supporting the link between disrupted circadian rhythms and increased susceptibility to stroke and dementia. We propose that circadian regulation of biochemical and physiological pathways in the brain increase susceptibility to damage after stroke in sleep and attenuate treatment effectiveness during the active phase. This review underscores the importance of considering circadian biology for understanding the pathology and treatment choice for stroke and vascular dementia and speculates that considering a patient's chronotype may be an important factor in developing precision treatment following stroke.

Circadian and Diurnal Regulation of Cerebral Blood Flow

Circadian and diurnal variation in cerebral blood flow directly contributes to the diurnal variation in the risk of stroke, either through factors that trigger stroke or due to impaired compensatory mechanisms. Cerebral blood flow results from the integration of systemic hemodynamics, including heart rate, cardiac output, and blood pressure, with cerebrovascular regulatory mechanisms, including cerebrovascular reactivity, autoregulation, and neurovascular coupling. We review the evidence for the circadian and diurnal variation in each of these mechanisms and their integration, from the detailed evidence for mechanisms underlying the nocturnal nadir and morning surge in blood pressure to identifying limited available evidence for circadian and diurnal variation in cerebrovascular compensatory mechanisms. We, thus, identify key systemic hemodynamic factors related to the diurnal variation in the risk of stroke but particularly identify the need for further research focused on cerebrovascular regulatory mechanisms.

Circadian Effects on Vascular Immunopathologies

Circadian rhythms exert a profound impact on most aspects of mammalian physiology, including the immune and cardiovascular systems. Leukocytes engage in time-of-day-dependent interactions with the vasculature, facilitating the emigration to and the immune surveillance of tissues. This review provides an overview of circadian control of immune-vascular interactions in both the steady state and cardiovascular diseases such as atherosclerosis and infarction. Circadian rhythms impact both the immune and vascular facets of these interactions, primarily through the regulation of chemoattractant and adhesion molecules on immune and endothelial cells. Misaligned light conditions disrupt this rhythm, generally exacerbating atherosclerosis and infarction. In cardiovascular diseases, distinct circadian clock genes, while functioning as part of an integrated circadian system, can have proinflammatory or anti-inflammatory effects on these immune-vascular interactions. Here, we discuss the mechanisms and relevance of circadian rhythms in vascular immunopathologies.

Clinical and imaging markers for the prognosis of acute ischemic stroke

Background and purpose

Significant differences in the outcomes observed in patients with acute ischemic stroke (AIS) have led to research investigations for identifying the predictors. In this retrospective study, we aimed to investigate the relationship of different clinical and imaging factors with the prognosis of AIS.

Materials and methods

All clinical and imaging metrics were compared between the good and poor prognosis groups according to the modified Rankin Scale (mRS) score at 90 days after discharge. Clinical factors included gender, age, NIHSS scores at admission, and other medical history risk factors. Imaging markers included the lesion's size and location, diffusion, and perfusion metrics of infarction core and peripheral regions, and the state of collateral circulation. Spearman's correlations were analyzed for age and imaging markers between the different groups. The Chi-square test and Cramer's V coefficient analysis were performed for gender, collateral circulation status, NIHSS score, and other stroke risk factors.

Results

A total of 89 patients with AIS were divided into the good (mRS score ≤ 2) and poor prognosis groups (mRS score ≥ 3). There were differences in NIHSS score at the admission; relative MK (rMK), relative MD (rMD), relative CBF (rCBF) of the infarction core; relative mean transit time (rMTT), relative time to peak (rTTP), and relative CBF (rCBF) of peripheral regions; and collateral circulation status between the two groups (p < 0.05). Among them, the rMK of infarction lesions had the strongest correlation with the mRS score at 90 days after discharge (r = 0.545, p < 0.001).

Conclusion

Perfusion and diffusion metrics could reflect the microstructure and blood flow characteristics of the lesion, which were the key factors for the salvage ability and prognosis of the infarction tissue. The characteristics of the infarction core and peripheral regions have different effects on the outcomes. Diffusion of infarction core has strong relations with the prognosis, whereas the time metrics (MTT, TTP) were more important for peripheral regions. MK had a more significant association with prognosis than MD. These factors were the primary markers influencing the prognosis of cerebral infarction patients.

The Role of Circadian Rhythms in Stroke: A Narrative Review

Stroke, a debilitating condition often leading to long-term disability, poses a substantial global concern and formidable challenge. The increasing incidence of stroke has drawn the attention of medical researchers and neurologists worldwide. Circadian rhythms have emerged as pivotal factors influencing stroke's onset, pathogenesis, treatment, and outcomes. To gain deeper insights into stroke, it is imperative to explore the intricate connection between circadian rhythms and stroke, spanning from molecular mechanisms to pathophysiological processes. Despite existing studies linking circadian rhythm to stroke onset, there remains a paucity of comprehensive reviews exploring its role in pathogenesis, treatment, and prognosis. This review undertakes a narrative analysis of studies investigating the relationship between circadian variation and stroke onset. It delves into the roles of various physiological factors, including blood pressure, coagulation profiles, blood cells, catecholamines, cortisol, and the timing of antihypertensive medication, which contribute to variations in circadian-related stroke risk. At a molecular level, the review elucidates the involvement of melatonin, circadian genes, and glial cells in the pathophysiology. Furthermore, it provides insights into the diverse factors influencing stroke treatment and outcomes within the context of circadian variation. The review underscores the importance of considering circadian rhythms when determining the timing of stroke interventions, emphasizing the necessity for personalized stroke management strategies that incorporate circadian rhythms. It offers valuable insights into potential molecular targets and highlights areas that require further exploration to enhance our understanding of the underlying pathophysiology. In comparison to the published literature, this manuscript distinguishes itself through its coverage of circadian rhythms' impact on stroke across the entire clinical spectrum. It presents a unique synthesis of epidemiological, clinical, molecular, and cellular evidence, underscoring their collective significance.

CNS Drug Delivery in Stroke: Improving Therapeutic Translation From the Bench to the Bedside

Drug development for ischemic stroke is challenging as evidenced by the paucity of therapeutics that have advanced beyond a phase III trial. There are many reasons for this lack of clinical translation including factors related to the experimental design of preclinical studies. Often overlooked in therapeutic development for ischemic stroke is the requirement of effective drug delivery to the brain, which is critical for neuroprotective efficacy of several small and large molecule drugs. Advancing central nervous system drug delivery technologies implies a need for detailed comprehension of the blood-brain barrier (BBB) and neurovascular unit. Such knowledge will permit the innate biology of the BBB/neurovascular unit to be leveraged for improved bench-to-bedside translation of novel stroke therapeutics. In this review, we will highlight key aspects of BBB/neurovascular unit pathophysiology and describe state-of-the-art approaches for optimization of central nervous system drug delivery (ie, passive diffusion, mechanical opening of the BBB, liposomes/nanoparticles, transcytosis, intranasal drug administration). Additionally, we will discuss how endogenous BBB transporters represent the next frontier of drug delivery strategies for stroke. Overall, this review will provide cutting edge perspective on how central nervous system drug delivery must be considered for the advancement of new stroke drugs toward human trials.

Value of the stroke 1-2-0 prehospital stroke education system: the experience of a general practitioner team

BACKGROUND

Stroke is one of the leading causes of death worldwide, especially in developing countries. In China, there is an urgent need to educate people about stroke awareness and the importance of using emergency medical services (EMS) quickly after a stroke has occurred.

OBJECTIVE

We sought to explore the effects of the Stroke 1-2-0 Prehospital Stroke Education System based on the experience of a general practitioner team.

METHOD

We prospectively enrolled 119 community general practitioners to be trained in the procedures advocated by the Stroke 1-2-0 Prehospital Stroke Education System. The training content included early detection of ischemic stroke, first aid for stroke, and intravenous thrombolysis; The effects of the training were later evaluated via a before-and-after comparison. The 119 enrolled physicians formed a Stroke 1-2-0 lecturer group and taught stroke knowledge to community residents. The group remained active for 6 months, during which the medical treatment data of stroke patients (i.e., stroke onset time, prehospital delay, whether an ambulance was called, and whether thrombolytic therapy was performed) in each of 5 jurisdictions were recorded for the month before (January 2021) and that after (August 2021) the 6-month community education program. Finally, the effects of the community education program were evaluated.

RESULTS

The participants' understanding of intravenous thrombolysis in the treatment of acute ischemic stroke improved significantly after the training as compared with their earlier understanding (96% vs. 78.99%; P < .001), and their understanding of the time window for intravenous thrombolysis increased from 26.05% before to 72% (P < .001) after the training. Most of the participants (90% vs. 67.23%; P < .001) said that they would immediately call the 120 emergency number of China's emergency phone system if they encountered individuals who appeared to be victims of acute stroke. A total of 82 stroke patients were seen before and 67 after the community education program. As for the use of the emergency call system, more patients with stroke activated that system after the program versus before (21.95% vs. 37.31%; P = .04). The 3-hour arrival rate after the program was nearly three times higher than that before the program (62.69% vs. 19.51%; P < .001). Also, regarding receiving thrombolysis after the occurrence of a stroke, the program triggered a substantial increase compared with the total earlier (19.4% vs. 6.1%; P = .013).

CONCLUSION

We found that the Stroke 1-2-0 Prehospital Stroke Education System significantly improved community residents' knowledge regarding stroke.

The Cardiac Circadian Clock: Implications for Cardiovascular Disease and its Treatment

Virtually all aspects of physiology fluctuate with respect to the time of day. This is beautifully exemplified by cardiovascular physiology, for which blood pressure and electrophysiology exhibit robust diurnal oscillations. At molecular/biochemical levels (eg, transcription, translation, signaling, metabolism), cardiovascular-relevant tissues (such as the heart) are profoundly different during the day vs the night. Unfortunately, this in turn contributes toward 24-hour rhythms in both risk of adverse event onset (eg, arrhythmias, myocardial infarction) and pathogenesis severity (eg, extent of ischemic damage). Accumulating evidence indicates that cell-autonomous timekeeping mechanisms, termed circadian clocks, temporally govern biological processes known to play critical roles in cardiovascular function/dysfunction. In this paper, a comprehensive review of our current understanding of the cardiomyocyte circadian clock during both health and disease is detailed. Unprecedented basic, translational, and epidemiologic studies support a need to implement chronobiological considerations in strategies designed for both prevention and treatment of cardiovascular disease.

Association Analysis of Gut Microbiota and Prognosis of Patients with Acute Ischemic Stroke in Basal Ganglia Region

Previous studies have implied the potential impact of gut microbiota on acute ischemic stroke (AIS), but the relationships of gut microbiota with basal ganglia region infarction (BGRI) and the predictive power of gut microbiota in BGRI prognosis is unclear. The aim of this study was to ascertain characteristic taxa of BGRI patients with different functional outcomes and identify their predictive value. Fecal samples of 65 BGRI patients were collected at admission and analyzed with 16s rRNA gene sequencing. Three-month functional outcomes of BGRI were evaluated using modified Rankin Scale (mRS), and patients with mRS score of 0-1 were assigned to good-BGRI group while others were assigned to poor-BGRI group. We further identified characteristic microbiota using linear discriminant analysis effect size, and receiver operating characteristic (ROC) curve was used to determine the predictive value of differential bacteria. According to the mRS score assessed after 3 months of stroke onset, 22 patients were assigned to poor-BGRI group, while 43 patients were assigned to good-BGRI group. Short chain fatty acids-producing bacteria, Romboutsia and Fusicatenibacter, were characteristic microbiota of the good-BGRI group, while pro-inflammatory taxa, Acetanaerobacterium, were characteristic microbiota of the poor-BGRI group. Furthermore, the differential bacteria showed extensive associations with clinical indices. ROC curves, separately plotted based on Romboutsia and Fusicatenibacter, achieved area under the curve values of 0.7193 and 0.6839, respectively. This study identified the efficient discriminative power of characteristic microbiota in BGRI patients with different outcomes and provided novel insights into the associations of gut microbiota with related risk factors.

Association of the time of day of EVT with clinical outcomes and benefit from successful recanalization after stroke

Experimental and neuroimaging studies suggest an influence of the time of day on acute infarct growth, but whether this could inform patient selection for acute treatments is uncertain. In a multicenter cohort of 9357 stroke patients undergoing endovascular treatment, morning treatment (05:00-10:59) was associated with lowest 90-day mRS scores (adjusted odds ratio, 1.27 [95% CI, 1.08-1.47]; p = 0.004). The association between successful recanalization and outcome was stronger in morning compared to evening-treated patients (pia  = 0.046) with treatment benefit persisting until 24 h for morning-treated compared to 11.5 h for evening-treated patients suggesting that the time of day might inform patient selection for EVT.

Consensus Recommendations for Standardized Data Elements, Scales, and Time Segmentations in Studies of Human Circadian/Diurnal Biology and Stroke

Increasing evidence indicates that circadian and diurnal rhythms robustly influence stroke onset, mechanism, progression, recovery, and response to therapy in human patients. Pioneering initial investigations yielded important insights but were often single-center series, used basic imaging approaches, and used conflicting definitions of key data elements, including what constitutes daytime versus nighttime. Contemporary methodologic advances in human neurovascular investigation have the potential to substantially increase understanding, including the use of large multicenter and national data registries, detailed clinical trial data sets, analysis guided by individual patient chronotype, and multimodal computed tomographic and magnetic resonance imaging. To fully harness the power of these approaches to enhance pathophysiologic knowledge, an important foundational step is to develop standardized definitions and coding guides for data collection, permitting rapid aggregation of data acquired in different studies, and ensuring a common framework for analysis. To meet this need, the Leducq Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA) convened a Consensus Statement Working Group of leading international researchers in cerebrovascular and circadian/diurnal biology. Using an iterative, mixed-methods process, the working group developed 79 data standards, including 48 common data elements (23 new and 25 modified/unmodified from existing common data elements), 14 intervals for time-anchored analyses of different granularity, and 7 formal, validated scales. This portfolio of standardized data structures is now available to assist researchers in the design, implementation, aggregation, and interpretation of clinical, imaging, and population research related to the influence of human circadian/diurnal biology upon ischemic and hemorrhagic stroke.

Teleneurocritical Care for Patients with Large Vessel Occlusive Ischemic Stroke Treated by Thrombectomy

BACKGROUND

Teleneurocritical care (TNCC) provides 24/7 virtual treatment of patients with neurological disease in the emergency department or intensive care unit. However, it is not known if TNCC is safe, effective, or associated with similar outcomes compared with in-person neurocritical care. We aim to determine the effect of daily inpatient consults from TNCC on the outcomes of patients with large vessel occlusive acute ischemic stroke treated by thrombectomy.

METHODS

A multicenter, retrospective cohort of consecutive patients ≥ 18 years old with acute ischemic stroke from a large vessel occlusion treated by thrombectomy were identified from 2018 to 2021 within a telehealth network of an integrated not-for-profit health care system in the United States. The primary end point was good functional outcome, i.e., modified Rankin Scale 0-3, at the time of hospital discharge in patients receiving in-person neurocritical care versus TNCC.

RESULTS

A total of 437 patients met inclusion criteria, 226 at the in-person hospital (median age 67, 53% women) and 211 at the two TNCC hospitals (median age 74, 49% women). The rate of successful endovascular therapy (modified Thrombolysis in Cerebral Infarction score 2b-3) was not different among hospitals. Good functional outcome at discharge was similar between in-person neurocritical care and TNCC (in-person 31.4% vs. TNCC 33.5%, odds ratio 0.88, 95% confidence interval 0.6-1.3; p = 0.64). Only National Institutes of Health stroke scale and age were multivariable predictors of outcome. There were no differences in mortality (9.3% vs. 13.2%, p = 0.19), intensive care unit length of stay (2.1 vs. 1.9 days, p = 0.39), or rate of symptomatic intracerebral hemorrhage (6.8% vs. 6.6%, p = 0.47) between in-person neurocritical care and TNCC.

CONCLUSIONS

Teleneurocritical care allows for equivalent favorable functional outcomes compared with in-person neurocritical care for patients with acute large vessel ischemic stroke receiving thrombectomy. The standardized protocols used by TNCC in this study, specifically the comprehensive 24/7 treatment of patients in the intensive care unit for the length of their stay, may be relevant for other health systems with limited in-person resources; however, additional study is required.

Circadian Factors in Stroke: A Clinician's Perspective

Stroke remains one of the leading causes of mortality and long-term and permanent disability worldwide despite technological innovations and developments in pharmacotherapy. In the last few decades, the growing data have evidenced the role of the circadian system in brain vulnerability to damage, the development and evolution of stroke, and short-term and long-term recovery. On the other hand, the stroke itself can affect the circadian system via direct injury of specific brain structures involved in circadian regulation (i.e., hypothalamus, retinohypothalamic tracts, etc.) and impairment of endogenous regulatory mechanisms, metabolic derangement, and a neurogenic inflammatory response in acute stroke. Moreover, the disruption of circadian rhythms can occur or exacerbate as a result of exogenous factors related to hospitalization itself, the conditions in the intensive care unit and the ward (light, noise, etc.), medication (sedatives and hypnotics), and loss of external factors entraining the circadian rhythms. In the acute phase of stroke, patients demonstrate abnormal circadian variations in circadian biomarkers (melatonin, cortisol), core body temperature, and rest-activity patterns. The approaches aimed at the restoration of disrupted circadian patterns include pharmacological (melatonin supplementation) and non-medication (bright light therapy, shifting feeding schedules, etc.) interventions; however, their effects on short- and long-term recovery after stroke are not well understood.

Circadian variation in stroke onset: Differences between ischemic and hemorrhagic stroke and weekdays versus weekends

OBJECTIVES

To delineate diurnal variation onset distinguishing ischemic from hemorrhagic stroke, wake from sleep onset, and weekdays from weekends/holidays.

MATERIALS AND METHODS

We analyzed patients enrolled in the FAST-MAG trial of field-initiated neuroprotective agent in patients with hyperacute stroke within 2h of symptoms onset. Stroke onset times were analyzed in 1h, 4h, and 12h time blocks throughout the 24h day-night cycle. Patient demographic, clinical features, stroke severity, and prehospital workflow were evaluated for association with onset times.

RESULTS

Among 1615 acute cerebrovascular disease patients, final diagnoses were acute cerebral ischemia in 76.5% and Intracerebral hemorrhage in 23.5%. Considering all acute cerebrovascular disease patients, frequency of wake onset times showed a bimodal pattern, with peaks on onsets at 09:00-13:59 and 17:00-18:59 and early morning (00:00-05:59) onset in only 3.8%. Circadian rhythmicity differed among stroke subtypes: in acute cerebral ischemia, a single broad plateau of elevated incidences was seen from 10:00-21:59; in Intracerebral hemorrhage, bimodal peaks occurred at 09:00 and 19:00. The ratio of Intracerebral hemorrhage to acute cerebral ischemia occurrence was highest in early morning, 02:00-06:59. Marked weekday vs weekends pattern variation was noted for acute cerebral ischemia, with a broad plateau between 09:00 and 21:59 on weekdays but a unimodal peak at 14:00-15:59 on weekends.

CONCLUSIONS

Wake onset of acute cerebrovascular disease showed a marked circadian variation, with distinctive patterns of a broad elevated plateau among acute cerebral ischemia patients; a bimodal peak among intracerebral hemorrhage patients; and a weekend change in acute cerebral ischemia pattern to a unimodal peak.

Long-term exposure to ambient air pollution, circadian syndrome and cardiovascular disease: A nationwide study in China

OBJECTIVES

Epidemiological evidence suggests associations between ambient air pollution and cardiovascular disease (CVD), while circadian rhythm dysregulation, presented by circadian syndrome (CircS), is emerging as a new proxy to cardiovascular disorder that could provide a bridge between them. The present study aims to clarify the effect of high levels ambient air pollution exposure on CircS and CVD in China.

METHODS

From the China Health and Retirement Longitudinal Study, we recruited 9116 Chinese participants in 2011 and followed them to 2015. A spatiotemporal model was applied to estimate exposure to particles with diameters ≤2.5 μm (PM_2.5). The variable CircS was defined based on 7 components, including the 5 components used to define metabolic syndrome as well as other two components, lack of sleep and depression. The associations between PM_2.5 exposure and prevalent CircS as well as incident CVD were modeled via logistic regression analysis displaying odds ratios (ORs) and 95 % CIs (confidence intervals). A mediation analysis was undertaken to identify the potential mediating role of CircS between PM_2.5 exposure and CVD.

RESULTS

The mean age (standard deviation) was 59 (9) and 48.22 % were male. The OR (95 % CI) between the highest (Q4) and the lowest (Q1) quartile of PM_2.5 exposure for CircS was 1.13 (1.01-1.28) in 2011 and 1.44 (1.22-1.72) in 2015. The cumulative effect of the components of CircS became more obvious with the increase of the PM_2.5 quartile exposure. For the Q4 versus Q1 of PM_2.5 increment, the multivariate-adjusted OR (95 % CI) was 1.66 (1.20-2.29) for CVD incidence. CircS partially mediated the association between PM_2.5 exposure and CVD.

CONCLUSIONS

Exposure to PM_2.5 is a risk factor for CircS and CVD, and the effect of PM_2.5 on CVD may be explained by CircS. Improving air quality would have high value in preventing CircS as well as CVD in public health.

Age and geographic disparities in acute ischaemic stroke prehospital delays in China: a cross-sectional study using national stroke registry data

Background

Stroke has been the leading cause of death in China for decades. The extremely low intravenous thrombolysis rate is largely due to the prehospital delays that make patients ineligible for the time-sensitive therapy. Limited studies evaluated prehospital delays across China. We investigated prehospital delays in the stroke population across China and the associated age, rurality, and geographic disparities.

Methods

A cross-sectional study design was employed using the Bigdata Observatory platform for Stroke of China in 2020, the nationwide, prospective, multicentre registry of patients with acute ischaemic stroke (AIS). Mixed-effect regression models were used to account for the clustered data.

Findings

The sample contained 78,389 AIS patients. The median onset-to-door (OTD) time was 24 h, with only 11.79% (95% confidence interval [CI]: 11.56-12.02%) patients arriving at hospitals within 3 h. About 12.43% (95% CI: 12.11-12.74%) of patients 65 years or older arrived at hospitals within 3 h, which was significantly higher than the young and middle-aged patients (11.03%; 95% CI: 10.71-11.36%). After controlling for potential confounders, young and middle-aged patients were less likely to present to hospitals within 3 h (adjusted odds ratio: 0.95; 95% CI: 0.90-0.99) compared to patients 65 years or older. The 3-h hospital arrival rate was the highest in Beijing (18.40%, 95% CI: 16.01-20.79%), which was almost 5 times higher than that in Gansu (3.45%, 95% CI: 2.69-4.20%). The arrival rate in urban areas was almost 2 times higher than that in rural areas (13.35% versus. 7.66%).

Interpretation

We found that the low rates of timely arrival at hospitals after a stroke is more salient in the younger population, rural settings, or those residing in less developed geographic regions. This study calls for more tailored interventions focusing on younger people, rural areas, and less developed geographic regions.

Funding

The National Natural Science Foundation of China; CIHR, Grant/Award Number: 81973157, PI: JZ. Natural Science Foundation of Shanghai; CIHR, Grant/Award Number: 17dz2308400, PI: JZ. Funding from the University of Pennsylvania; Grant/Award Number: CREF-030, PI: RL.

Influence of Temperature Chronobiology on Stroke Outcome

The circadian system regulates numerous physiological variables, including body temperature. Additionally, a circadian patter has been described in stroke onset. Considering this, we hypothesised that the chronobiology of temperature may have an impact on stroke onset and functional outcomes. We also studied the variation of blood biomarkers according to stroke onset time. This is a retrospective observational study. Of the patients included, 2763 had a stroke between midnight and 8:00 h; 1571 between 8:00-14:00 h; and 655 between 14:00 h and midnight. Axillary temperature was measured at admission. At this time, blood samples were collected for biomarker analysis (TNF-α, IL-1β, IL-6, IL-10, and glutamate). Temperature was higher in patients admitted from 8:00 h to midnight (p < 0.0001). However, the percentage of poor outcome at 3 months was highest in patients from midnight to 8:00 h (57.7%, p < 0.001). The association between temperature and mortality was highest during night time (OR: 2.79; CI 95%: 2.36-3.28; p < 0.001). These patients exhibited high glutamate (220.2 ± 140.2 µM), IL-6 (32.8 ± 14.3 pg/mL) and low IL-10 (9.7 ± 14.3 pg/mL) levels. Therefore, temperature chronobiology could have a significant impact on stroke onset and functional outcome. Superficial body hyperthermia during sleep seems to be more dangerous than during wakefulness. Further studies will be necessary to confirm our data.

Early neurological deterioration in patients with acute ischemic stroke: a prospective multicenter cohort study

Background

There is still no precise knowledge of the causes of progression in patients with acute ischemic stroke (AIS), and we are unable to predict patients at risk.

Objective

To explore the frequency, predictive factors, and the prognosis of early neurological deterioration (END) in patients with AIS.

Methods

In this prospective multicenter observational study, we assessed patients with AIS admitted to 18 hospitals in Henan, China. We defined END as an increase of ⩾2 points in total National Institutes of Health Stroke Scale (NIHSS) score or ⩾1 point in the motor items of the NIHSS within 7 days after admission. Risk factors were analyzed using multivariate logistic regression models. Prognosis was evaluated using the modified Rankin Scale (mRS), with poor prognosis defined as mRS 3-6.

Results

A total of 9114 patients with AIS within 24 h of symptom onset were enrolled in the study. END occurred in 1286 (14.1%) patients. The highest incidence (62.5%) of END occurred within 24 h after admission. After adjusting potential confounders, age, body mass index, waist-hip ratio, systolic blood pressure, baseline NIHSS, disabled at baseline, history of atrial fibrillation, diabetes mellitus, intracranial arterial stenosis, infarct location in the lenticulostriate artery area and cerebral watershed, neutrophils, lymphocytes, uric acid, and triglycerides were identified as independent predictors for END. END was significantly associated with poor prognosis at 90 days, and the adjusted OR was 1.74 (95% CI: 1.53-1.97).

Conclusion

One in seven hospitalized patients with AIS may experience END within 24 h of onset. The highest incidence of END occurred within 24 h of admission and decreased steeply with time. Easily identifiable risk factors predict END and could help understand the causal mechanisms and thereby prevent END.

The time dimension to stroke: Circadian effects on stroke outcomes and mechanisms

The circadian system is widely involved in the various pathological outcomes affected by time dimension changes. In the brain, the master circadian clock, also known as the "pacemaker," is present in the hypothalamus's suprachiasmatic nucleus (SCN). The SCN consists of molecular circadian clocks that operate in each neuron and other brain cells. These circadian mechanisms are controlled by the transcription and translation of specific genes such as the clock circadian regulator (Clock) and brain and muscle ARNT-Like 1 (Bmal1). Period (Per1-3) and cryptochrome (Cry1 and 2) negatively feedback and regulate the clock genes. Variations in the circadian cycle and these clock genes can affect stroke outcomes. Studies suggest that the peak stroke occurs in the morning after patients awaken from sleep, while stroke severity and poor outcomes worsen at midnight. The main risk factor associated with stroke is high blood pressure (hypertension). Blood pressure usually dips by 15-20% during sleep, but many hypertensives do not display this normal dipping pattern and are non-dippers. A sleep blood pressure is the primary determinant of stroke risk. This article discusses the possible mechanism associated with circadian rhythm and stroke outcomes.

Association between the time of day at stroke onset and functional outcome of acute ischemic stroke patients treated with endovascular therapy

To investigate the association between time-of-day of stroke onset and functional outcome in patients with acute ischemic stroke(AIS) treated with endovascular thrombectomy(EVT). AIS patients treated with EVT between January 2013 and December 2018 were recruited and divided them into four 6-h interval groups according to the time-of-day of stroke onset. A total of 438 patients were enrolled, 3-month favorable outcome were achieved in 58.6%, 43.7%, 36.6%, and 30.5% of patients in the 00:00-06:00, 06:00-12:00, 12:00-18:00, and 18:00-24:00 groups, respectively (adjusted OR 0.61, 95% CI 0.40-0.93; p = 0.020). Compared with the 18:00-24:00 interval, patients in the 00:00-06:00 interval (adjusted OR 4.01, 95%CI 1.02-15.80, p = 0.047) and the 06:00-12:00 interval (adjusted OR 3.24, 95% CI 1.09-9.64, p = 0.034) were more likely to achieve favorable outcome. The time-of-day of stroke onset was not associated with 3-month mortality (adjusted p = 0.829), symptomatic intracerebral hemorrhage (sICH, adjusted p = 0.296), or early successful recanalization (adjusted p = 0.074). In conclusion, in AIS patients treated with EVT, those onsets either between 00:00 and 06:00 or between 06:00 and 12:00 appeared to be associated with a higher proportion of favorable outcomes at 3 months, but the time-of-day at stroke onset was not associated with the incidence of sICH, rate of early successful recanalization, or 3-month mortality.

The neurovascular unit and systemic biology in stroke - implications for translation and treatment

Ischaemic stroke is a leading cause of disability and death for which no acute treatments exist beyond recanalization. The development of novel therapies has been repeatedly hindered by translational failures that have changed the way we think about tissue damage after stroke. What was initially a neuron-centric view has been replaced with the concept of the neurovascular unit (NVU), which encompasses neuronal, glial and vascular compartments, and the biphasic nature of neural-glial-vascular signalling. However, it is now clear that the brain is not the private niche it was traditionally thought to be and that the NVU interacts bidirectionally with systemic biology, such as systemic metabolism, the peripheral immune system and the gut microbiota. Furthermore, these interactions are profoundly modified by internal and external factors, such as ageing, temperature and day-night cycles. In this Review, we propose an extension of the concept of the NVU to include its dynamic interactions with systemic biology. We anticipate that this integrated view will lead to the identification of novel mechanisms of stroke pathophysiology, potentially explain previous translational failures, and improve stroke care by identifying new biomarkers of and treatment targets in stroke.

Risk Prediction Models for Early ICU Admission in Patients With Autoimmune Encephalitis: Integrating Scale-Based Assessments of the Disease Severity

Background

In patients with autoimmune encephalitis (AE), the prediction of progression to a critically ill status is challenging but essential. However, there is currently no standard prediction model that comprehensively integrates the disease severity and other clinical features. The clinical assessment scale in autoimmune encephalitis (CASE) and the modified Rankin Scale (mRS) have both been applied for evaluating the severity of AE. Here, by combining the two scales and other clinical characteristics, we aimed to investigate risk factors and construct prediction models for early critical care needs of AE patients.

Methods

Definite and probable AE patients who were admitted to the neurology department of Tongji Hospital between 2013 and 2021 were consecutively enrolled. The CASE and mRS scores were used to evaluate the overall symptom severity at the time of hospital admission. Using logistic regression analysis, we analyzed the association between the total scores of the two scales and critical illness individually and then we evaluated this association in combination with other clinical features to predict early intensive care unit (ICU) admission. Finally, we constructed four prediction models and compared their performances.

Results

Of 234 patients enrolled, forty developed critical illness and were early admitted to the ICU (within 14 days of hospitalization). Four prediction models were generated; the models were named CASE, CASE-plus (CASE + prodromal symptoms + elevated fasting blood glucose + elevated cerebrospinal fluid (CSF) white blood cell (WBC) count), mRS and mRS-plus (mRS + prodromal symptoms + abnormal EEG results + elevated fasting blood glucose + elevated CSF WBC count) and had areas under the ROC curve of 0.850, 0.897, 0.695 and 0.833, respectively. All four models had good calibrations. In general, the models containing “CASE” performed better than those including “mRS”, and the CASE-plus model demonstrated the best performance.

Conclusion

Overall, the symptom severity at hospital admission, as defined by CASE or mRS, could predict early ICU admission, especially when assessed by CASE. Adding other clinical findings, such as prodromal symptoms, an increased fasting blood glucose level and an increased CSF WBC count, could improve the predictive efficacy.

The impact of heart rate circadian rhythm on in-hospital mortality in stroke and critically ill patients: insights from the eICU Collaborative Research Database

BACKGROUND

Data showing the impact of dysregulated heart rate circadian rhythm in stroke and critically ill patients are scarce.

OBJECTIVE

The purpose of this study was to investigate whether the circadian rhythm of heart rate was an independent risk factor for in-hospital mortality in stroke and critically ill patients.

METHODS

Study patients from the recorded eICU Database were included in the current analyses. Three variables, Mesor, Amplitude, and Peak time were used to evaluate the heart rate circadian rhythm. The incremental value of circadian rhythm variables in addition to Acute Physiology and Chronic Health Evaluation (APACHE) IV score to predict in-hospital mortality was also explored.

RESULTS

A total of 6,201 Patients whose heart rate have cosinor rhythmicity. After adjustments, Mesor per 10 beats per min (bpm) increase was associated with a 1.18-fold (95%CI: 1.12, 1.25, P<0.001) and Amplitude per 5 bpm was associated with a 1.17-fold (95%CI: 1.07, 1.27, P<0.001) increase in the risk of in-hospital mortality, respectively. The risk of in-hospital mortality was highest in patients who had Peak time reached between 12:00-18:00 (OR: 1.35, 95%CI: 1.06, 1.72, P=0.015). Compared with APACHE IV score only (c-index=0.757), combining APACHE IV score and circadian rhythm variables of heart rate (c-index=0.766) was associated with increased discriminative ability (P=0.003).

CONCLUSION

Circadian rhythm of heart rate is an independent risk factor of the in-hospital mortality in stroke and critically ill patients. Including circadian rhythm variables regarding heart rate might increase the discriminative ability of the risk score to predict the prognosis of patients.

Sleep and Stroke: Opening Our Eyes to Current Knowledge of a Key Relationship

PURPOSE OF REVIEW

To elucidate the interconnection between sleep and stroke.

RECENT FINDINGS

Growing data support a bidirectional relationship between stroke and sleep. In particular, there is strong evidence that sleep-disordered breathing plays a pivotal role as risk factor and concur to worsening functional outcome. Conversely, for others sleep disorders (e.g., insomnia, restless legs syndrome, periodic limb movements of sleep, REM sleep behavior disorder), the evidence is weak. Moreover, sleep disturbances are highly prevalent also in chronic stroke and concur to worsening quality of life of patients. Promising novel technologies will probably allow, in a near future, to guarantee a screening of commonest sleep disturbances in a larger proportion of patients with stroke. Sleep assessment and management should enter in the routinary evaluation of stroke patients, of both acute and chronic phase. Future research should focus on the efficacy of specific sleep intervention as a therapeutic option for stroke patients.