Epidemiology and prevention of stroke: a worldwide perspective

Interacting and joint effects of triglyceride-glucose index (TyG) and body mass index on stroke risk and the mediating role of TyG in middle-aged and older Chinese adults: a nationwide prospective cohort study

BACKGROUND

Individuals who are overweight or obese often develop insulin resistance, mediation of the association between body mass index (BMI) and stroke risk through the triglyceride-glucose index (TyG) seems plausible but has not been investigated. This study aims to examine whether TyG mediates associations of BMI with stroke risk and the extent of interaction or joint relations of TyG and BMI with stroke outcome.

METHODS

The China Health and Retirement Longitudinal Study, initiated in 2011, is a nationally representative, ongoing prospective cohort study involving 8 231 middle-aged and older Chinese adults without a stroke history at baseline. Exposures examined include BMI and the TyG, the latter being the logarithmized product of fasting triglyceride and glucose concentrations. The primary study outcome is stroke incidence, as determined through self-reports, with a follow-up period extending from June 1, 2011, to June 30, 2018.

RESULTS

Of the 8 231 participants, 3 815 (46.3%) were men; mean (SD) age was 59.23 (9.32) years. During a median follow-up of 7.1 years, 585 (7.1%) participants developed stroke. The TyG was found to mediate the association between BMI and incident stroke, proportions mediated were 16.3% for BMI in the 24.0-27.9 kg/m2 group and 53.8% for BMI ≥ 28.0 kg/m2 group. No significant multiplicative and additive interactions were found between BMI and TyG on incident stroke (Additive: RERI = 1.78, 95% CI - 1.29-4.86; Multiplicative, HR = 1.40, 95% CI 0.86-2.27). HRs for individuals with BMI ≥ 28.0 kg/m2 and quartile 4 of TyG compared with those with BMI < 24.0 kg/m2 and quartile 1 of TyG were 2.05 (95% CI 1.37-3.06) for incident stroke. Combining BMI and TyG enhanced predictive performance for stroke when compared to their individual (AUCBMI+TyG vs AUCBMI vs AUCTyG, 0.602 vs 0.581 vs 0.583).

CONCLUSIONS

TyG appeared to be associated with stroke risk and mediates more than 50% of the total association between BMI and stroke in middle-aged and older Chinese adults. Public health efforts aiming at the reduction of body weight might decrease the stroke risk due to insulin resistance and the burden of stroke.

Risk factors of disturbed sleep phases to posterior circulation cerebral infarctions: A single-center retrospective study

Posterior circulation stroke differs from anterior circulation stroke in terms of etiological, clinical, and prognostic properties. Sleep architecture is impaired in patients with acute stroke, which may correlate with disease severity and outcome, and the correlation between the location of cerebral infarction (CI) and sleep phase disturbance remains unknown. This study aimed to assess the correlation between disturbed sleep phases in CI and posterior circulation cerebral infarction (PCCI). We retrospectively enrolled 192 patients with first-onset acute CI, who were assigned to the anterior circulation cerebral infarction (n = 101) and PCCI (n = 91) groups. The polysomnograms in both groups were analyzed by phase. The proportions of sleep phases were significantly different between the 2 groups (P < .05). The awake (W) and non-rapid eye movement 3 (N3) phases were independently associated with PCCI in multivariate analysis. The W phase may be a risk factor for PCCI (odds ratio = 1.60, 95% CI 1.30-1.97), while the N3 phase may be a protective factor for PCCI (odds ratio = 0.498, 95% CI 0.353-0.703). This study demonstrated that CI causes different degrees of sleep phase disturbances, and the percentages of W and N3 phase disturbances were independent factors associated with PCCI. The former was a risk factor, whereas the latter was a protective factor. This study demonstrated the correlation between cerebral infarction and sleep phase disturbances from a new perspective and suggested that cerebral infarcts may alter the structure of sleep.

Knowledge of stroke risk factors and warning symptoms among adults with type 2 diabetes in Addis Ababa, Ethiopia, 2021: an institution-Based cross-sectional study

BACKGROUND

Stroke is a global public health concern with type 2 diabetes being one of the common risk factors. Knowledge of stroke risk factors and warning symptoms among type 2 diabetes patients is largely unknown in developing countries like Ethiopia. The inability to recognize stroke warning symptoms accurately is an important cause of delay in seeking medical attention. We investigated knowledge of stroke risk factors and warning symptoms among adults with type 2 diabetes and the factors associated with these variables.

METHODS

This was an institution-based cross-sectional study. We enrolled 470 adult type 2 diabetes patients using a systematic random sampling method from four government-managed hospitals in Addis Ababa from 1 to 30 February 2021. The Stroke Recognition Questionnaire was adapted to measure the knowledge of stroke risk factors and warning symptoms. Sociodemographic characteristics, source of information, and reaction to stroke were also measured. Data were analyzed using SPSS version 25 and linear regression analysis was used to determine factors independently associated with knowledge of stroke risk factors and warning symptoms.

RESULT

The mean age of the participants was 50.6 ± 12.9 years. The mean score of knowledge of stroke risk factors and warning symptoms was 67.2% and 63.9%, respectively. Higher educational level (B = 2.007, 95% CI = 1.101, 2.914, P < 0.001), knowing someone diagnosed with stroke (B = 3.328, 95% CI = 2.734, 3.922, P < 0.001), and living with others (B = 2.28, 95% CI = 1.606, 2.954, P < 0.001) were independently associated with knowledge of stroke risk factors. Younger age (B = - 0.021, 95% CI= -0.038, 0.005, P = 0.01), higher educational level (B = 1.873, 95% CI = 1.017, 2.730, P < 0.001), and knowing someone diagnosed with stroke (B = 3.64, 95% CI = 3.079, 4.200, P < 0.001) were independently associated with knowledge of warning symptoms of stroke.

CONCLUSION

The mean score of knowledge of stroke risk factors and warning symptoms was 67.2% and 63.9%, respectively. Younger age, higher educational level, and living with other people are predictors of better knowledge of stroke risk factors and warning symptoms in this study. Future educational interventions should target type 2 diabetes adults with advancing age and the involvement of their family members.

Ischemic Stroke Impacts the Gut Microbiome, Ileal Epithelial and Immune Homeostasis

Ischemic stroke critically impacts neurovascular homeostasis, potentially resulting in neurological disorders. However, the mechanisms through which stroke-induced inflammation modifies the molecular and metabolic circuits, particularly in ileal epithelial cells (iECs), currently remain elusive. Using multiomic approaches, we illustrated that stroke impaired the ileal microbiome and associated metabolites, leading to increased inflammatory signals and altered metabolites, potentially deteriorating the iEC homeostasis. Bulk transcriptomic and metabolomic profiling demonstrated that stroke enhanced fatty acid oxidation while reducing the tricarboxylic acid (TCA) cycle in iECs within the first day after stroke. Intriguingly, single-cell RNA sequencing analysis revealed that stroke dysregulated cell-type-specific gene responses within iECs and reduced frequencies of goblet and tuft cells. Additionally, stroke augmented interleukin-17A+ γδ T cells but decreased CD4+ T cells in the ileum. Collectively, our findings provide a comprehensive overview of stroke-induced intestinal dysbiosis and unveil responsive gene programming within iECs with implications for disease development.

Network pharmacology and molecular docking analysis on molecular targets and mechanisms of Gastrodia elata Blume in the treatment of ischemic stroke

Gastrodia elata Blume (GEB) is widely used to treat cardio-cerebrovascular disease in China and in traditional Chinese medicine it is considered to be a dispelling wind and dredging collateral. However, the mechanism and active components of the plant in treating ischemic stroke (IS) remain unclear. The present study aimed to identify the active components and mechanism of GEB in treating IS using network pharmacology and molecular docking technology. Network analysis predicted 752 potential targets from 14 compounds in GEB, sharing 32 key targets with IS-associated targets. Gene Ontology analysis of key targets showed that 'oxidative stress', 'immune response' and 'regulation of blood circulation' were significantly enriched. Kyoto Encyclopedia of Genes and Genomes pathway analysis indicated that the key targets regulated 11 representative pathways including 'arachidonic acid metabolism', 'lipid and galactose metabolism'. In the protein-protein interaction network, five core targets, including toll-like receptor agonist, STAT3, myeloperoxidase (MPO), prostaglandin-endoperoxide synthase and matrix metalloproteinase (MMP)9, were identified and successfully docked with four active components: Palmitic acid, alexandrin, para-hydroxybenzaldehyde and gastrodin. Alexandrin, para-hydroxybenzaldehyde, and gastrodin are closely related to brain ischemia/reperfusion damage and repair. Therefore, to further verify the mechanism of action of three active components in the second part, we established the HT22 oxygen-glucose deprivation-reperfusion (OGD/R) model. Cell Counting Kit-8 assay and western blot analysis demonstrated that these three active components of GEB regulated core targets of molecular docking, such as STAT3, MPO and MMP9. In vitro experiments showed that OGD/R decreased cell survival, while this effect was reversed by the three active components of GEB. In addition, western blot analysis indicated that alexandrin upregulated expression of phosphorylated-STAT3, para-hydroxybenzaldehyde downregulated MPO and gastrodin downregulated MMP9. Therefore, the present study showed that GEB may prevent and treat IS via interaction between the active components and the main targets, which is key for investigating the efficacy of traditional Chinese medicine.

The construction of neurogenesis-related ceRNA network of ischemic stroke treated by oxymatrine

BACKGROUND

Known as a disease associated with high mortality, disability and a significant financial burden, ischemic stroke ranks as one of the three diseases threatening human health. Recent advances in omics technology created opportunities to uncover the mechanism in ischemic stroke occurrence and treatment. In this study, we aimed to construct the competitive endogenous RNA (ceRNA) networks of ischemic stroke treated by oxymatrine intervention.

METHOD

The middle cerebral artery occlusion (MCAO) mouse model of ischemic stroke was constructed, and oxymatrine was administered. Then RNA-Sequencing was performed and integrated analysis of mRNAs, lncRNAs and circRNAs was conducted to reveal the pharmacology of oxymatrine. Functional enrichment analysis was performed to explore the underlying mechanism of differentially expressed (DE) mRNAs. The protein-protein interaction (PPI) network of neurogenesis-related genes and long noncoding RNAs (lncRNAs)/circular RNAs (circRNAs) based ceRNA networks were constructed.

RESULTS

First, this study revealed the DE-mRNAs, DE-lncRNAs and DE-circRNAs between Oxymatrine treated group and the MCAO group. Then, the common 1231 DE-mRNAs, 32 DE-lncRNAs and 31 DE-circRNAs with opposite trends were identified. The Kyoto Encyclopedia of Genes and Genomes to identify the functional enrichment of 1231 DE-mRNAs were enriched in neurogenesis-related biological processes. Based on neurogenesis-related DE-mRNAs, the PPI network was constructed, and hub genes were identified based on centrality. Finally, both the lncRNA-based and circRNAs-based ceRNA networks were constructed.

CONCLUSION

In summary, this study identified novel coding and noncoding ischemic stroke targets of oxymatrine-treated MCAO. Most importantly, we identified lncRNAs and circRNAs candidates as potential oxymatrine targets and constructed the neurogenesis-related ceRNA networks.

Topography of neurotrophins in the rat neocortex and their role in neuron apoptosis after experimental ischemic stroke

Neuronal loss due to apoptosis after ischemic injury depends on the trophic support of neurons and cytoprotective effects of neurotrophins (NTs). Different NTs may activate both pro- and antiapoptotic factors. Their distribution in the ischemic core (IC) and penumbra (IP) has been poorly studied. The available data on the localization of NTs in the ischemic brain are contradictory and depend to a certain degree on the pathogenetic model used. The distribution of NTs in different layers of the ischemic cortex is also largely unknown hindering our understanding of their exact effects and targets in different zones of the ischemic brain. We examined the immunolocalization of brain-derived neurotrophic factor (BDNF), neurotrophin-3, and glial cell line-derived neurotrophic factor (GDNF) in the parietal cortex using a rat model of ischemic stroke due to permanent occlusion of the middle cerebral artery. The spatial density of immunoreactive (IR) cells varied across the cortical layers and changed with time after ischemic injury. Their distribution in the IC differed considerably from that in the IP. The immunolocalization of neurotrophins in the contralateral hemisphere was similar to that in IP. We also studied the distribution of pro- and anti-apoptotic factors in IC and IP with and without intravenous BDNF administration. In the model without BDNF administration, the proportions of Bcl-2-, p53-, caspase-3-, and Mdm2-IR cells showed different dynamics during the ischemic period. In the model with BDNF administration, Mdm2 immunoreactivity was mainly observed in pyramidal cells of layers V/VI, and Bcl-2, in interneurons of layers II and III. The dynamics of p53 immunoreactivity was opposite to that of caspase-3 throughout the ischemic period. The present results suggest that after ischemic injury, 1) the number of neurotrophin-positive cells increases in the early ischemic period and decreases afterwards; 2) there is a close metabolic relationship between astrocytes and neurons contributing to their adaptation to ischemic conditions; 3) the IP borders undergo constant changes; 4) in the IP, neuronal loss occurs mainly by apoptotic pathway throughout the ischemic period; 5) BDNF may enhance considerably antiapoptotic mechanisms with a predominance of Mdm-2 activity in pyramidal neurons.

Oral health status and its associated factors among post-stroke inpatients: a cross-sectional study in Hungary

Background

Post-stroke inpatients are at risk of poor oral health for a number of reasons. The aim of this study was to assess the oral health status of post-stroke patients and also to explore the factors that may influence it.

Methods

This cross-sectional study was organised at National Institute for Medical Rehabilitation in Hungary. Altogether 410 post-stroke patients were enrolled in the survey. Personal medical history and functional assessment was obtained from the final medical reports of the patients. The clinical examination and data collection were conducted according to the World Health Organization (2013) criteria. Socio-demographic background and behaviours related to oral health were assessed using a questionnaire. The dental status was explained by the number of Decayed, Missing and Filled Teeth (DMFT). The association of socio-demographic factors, stroke and functional assessment with oral health status and behaviour was evaluated. Chi-square test, Fisher’s exact test, Welch test, Mann–Whitney U test, Kruskal–Wallis test, ANOVA model and correlation analysis were used to analyse our data. The level of significance was set at p < 0.05.

Results

Mean age of stroke patients was 59.21(Standard Deviation [SD] 14.74) years. Mean DMFT score was 20.13 (8.08), including 3.28 (4.24) decayed teeth, 15.02 (10.29) missing teeth and 1.83 (2.94) filled teeth score. Factors that influenced the oral health status were gender, age, occupational status, level of education, type and risk factors for stroke. Significant correlation was found between the Functional Independence Measure and oral health-related behaviours with patients brushing their teeth once a month showing the lowest value.

Conclusion

According to the results, low socio-demographic and economic status, low level of education and the Functional Independence Measure score, unemployment, the combination of risk factors for stroke and residual dysfunctions are associated with poor oral health status. The data indicate that a series of changes are needed, for special attention and care in oral health for patients who have had a stroke. Based on the findings of this research, a new model of prevention and care can be developed, with an interdisciplinary collaboration, to promote the quality of life of these individuals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02259-2.

Ozone treatment alleviates brain injury in cerebral ischemic rats by inhibiting the NF-κB signaling pathway and autophagy

Stroke is the most frequent cause of disability in developed countries. A common phenomenon of stroke, cerebral ischemia, is threatening many lives worldwide. In addition, ozone treatment was previously reported to exert functions in relieving brain injury. In the current study, the therapeutic effects of ozone on cerebral ischemia are investigated. A rat model of middle cerebral artery occlusion (MCAO) was established. The brain water content was calculated by weighing brain tissues, and the 2, 3, 5-triphenyltetrazolium chloride staining was performed to measure brain infarction volume in rats. A colorimetric assay was conducted to examine expression levels of malondialdehyde, superoxide dismutase, catalase, and glutathione in the rat hippocampus. Reverse transcription quantitative polymerase-chain reaction and Western blot analyses were employed to evaluate expression levels of Beclin1, LC3B, p62, and critical factors implicated in the NF-κB signaling pathway. We found that ozone significantly improved the survival rate of MCAO model rats, reduced the cerebral water content, and decreased the neurological scores of ischemic rats. Ozone markedly reduced cerebral ischemia-induced infarction in ischemic rats. Ozone decreased MDA levels and increased SOD, catalase, and GSH levels in the hippocampus of rats. Ozone significantly inhibited autophagy by decreasing Beclin1 and LC3B expression and increasing p62 expression. The ozone inactivated the NF-κB signaling pathway by decreasing the protein levels of TLR4, p-IKKβ, p-IKBα, and p-p65. We conclude that ozone treatment alleviates the brain injury in ischemic rats by suppressing autophagy and inactivating the NF-κB signaling pathway.

Key Phytochemicals and Biological Functions of Chuanxiong Rhizoma Against Ischemic Stroke: A Network Pharmacology and Experimental Assessment

Presently, the treatment options for ischemic stroke (IS) are limited due to the complicated pathological process of the disease. Chuanxiong Rhizome (CR), also known as Conioselinum anthriscoides "Chuanxiong" (rhizome), is the most widely used traditional Chinese medicine for treating stroke. This study aimed to uncover the key phytochemicals and biological functions of CR against IS through a network pharmacology approach combining with IS pathophysiology analysis. We employed permanent unilateral common carotid artery ligation to construct a mouse model of global cerebral ischemia and found that cerebral ischemia injuries were improved after 7 days of gavage treatment of CR (1,300 mg/kg/day). CR exerts protective effects on neurons mainly by acting on targets related to synaptic structure, synaptic function, neuronal survival and neuronal growth. A total of 18 phytochemicals from CR based on UHPLC-MS/MS that corresponded to 85 anti-IS targets. Coniferyl ferulate, neocnidilide and ferulic acid were identified as the key phytochemicals of CR against IS. Its brain protective effects involve anti-inflammatory, anti-oxidative stress, and anti-cell death activities and improves blood circulation. Additionally, the two most important synergistic effects of CR phytochemicals in treating IS are prevention of infection and regulation of blood pressure. In brain samples of Sham mice, L-tryptophan and vanillin were detected, while L-tryptophan, gallic acid, vanillin and cryptochlorogenic acid were detected in IS mice by UHPLC-MS/MS. Our findings provide a pathophysiology relevant pharmacological basis for further researches on IS therapeutic drugs.

Clinical Significance of Hyperdense Lesions on Non-enhanced Brain CT Obtained Immediately after Arterial Revascularization in Acute Ischemic Stroke Patients

Purpose

To analyze the characteristics of hyperdense lesions on brain CT conducted immediately after arterial revascularization (AR) in patients with acute ischemic stroke (AIS), track the outcome of those lesions and investigate their clinical significance.

Materials and Methods

97 AIS patients were enrolled in our study. Among them, 52 patients showed hyperdense lesions and were divided into three categories: type I, type II and type III according to the morphologic characteristics of hyperdense lesions. All patients underwent several follow-up CT/MR examinations to visualize the outcomes of the lesions.

Results

Among the 52 patients, 22 showed contrast extravasation, 23 displayed contrast extravasation combined with hemorrhagic transformation (HT) and 7 confirmed symptomatic intracranial hemorrhage (SICH) in follow-up CT/MR. Among the without hyperdense lesions group, only 7 converted to hemorrhage, and no SICH occurred. All type I lesions showed contrast extravasation; 23 type II lesions turned to hemorrhage, 2 revealed SICH and 6 were pure contrast extravasation; all of the type III developed into SICH.

Conclusion

Hyperdense lesions on non-enhanced brain CT obtained immediately after arterial revascularization (AR) exhibited varying features. Type I indicated a pure contrast extravasation. Type II and type III hyperdense lesions suggested higher incidence of HT, the presence of type III lesions indicated an ominous outcome.

Effect of Anti-inflammatory Treatment with AMD3100 and CX3CR1 Deficiency on GABAA Receptor Subunit and Expression of Glutamate Decarboxylase Isoforms After Stroke

Following stroke, attenuation of detrimental inflammatory pathways might be a promising strategy to improve long-term outcome. In particular, cascades driven by pro-inflammatory chemokines interact with neurotransmitter systems such as the GABAergic system. This crosstalk might be of relevance for mechanisms of neuronal plasticity, however, detailed studies are lacking. The purpose of this study was to determine if treatment with 1,1′-[1,4-phenylenebis(methylene)]bis[1,4,8,11-tetraazacyclotetradecane] (AMD3100), an antagonist to the C-X-C chemokine receptor type 4 (CXCR4) and partial allosteric agonist to CXCR7 (AMD3100) alone or in combination with C-X3-C chemokine receptor type 1 (CX3CR1) deficiency, affect the expression of GABA_A subunits and glutamate decarboxylase (GAD) isoforms. Heterozygous, CX3CR1-deficient mice and wild-type littermates were subjected to photothrombosis (PT). Treatment with AMD3100 (0.5 mg/kg twice daily i.p.) was administered starting from day 2 after induction of PT until day 14 after the insult. At this time point, GABA_A receptor subunits (α3, β3, δ), GAD65 and GAD67, and CXCR4 were analyzed from the peri-infarct tissue and homotypic brain regions of the contralateral hemisphere by quantitative real-time PCR and Western Blot. Fourteen days after PT, CX3CR1 deficiency resulted in a significant decrease of the three GABA_A receptor subunits in both the lesioned and the contralateral hemisphere compared to sham-operated mice. Treatment with AMD3100 promoted the down-regulation of GABA_A subunits and GAD67 in the ipsilateral peri-infarct area, while the β3 subunit and the GAD isoforms were up-regulated in homotypic regions of the contralateral cortex. Changes in GABA_A receptor subunits and GABA synthesis suggest that the CXCR4/7 and CX3CR1 signaling pathways are involved in the regulation of GABAergic neurotransmission in the post-ischemic brain.

Development and validation of a model to estimate the risk of acute ischemic stroke in geriatric patients with primary hypertension

Objectives

This study aimed to construct and validate a prediction model of acute ischemic stroke in geriatric patients with primary hypertension.

Methods

This retrospective file review collected information on 1367 geriatric patients diagnosed with primary hypertension and with and without acute ischemic stroke between October 2018 and May 2020. The study cohort was randomly divided into a training set and a testing set at a ratio of 70 to 30%. A total of 15 clinical indicators were assessed using the chi-square test and then multivariable logistic regression analysis to develop the prediction model. We employed the area under the curve (AUC) and calibration curves to assess the performance of the model and a nomogram for visualization. Internal verification by bootstrap resampling (1000 times) and external verification with the independent testing set determined the accuracy of the model. Finally, this model was compared with four machine learning algorithms to identify the most effective method for predicting the risk of stroke.

Results

The prediction model identified six variables (smoking, alcohol abuse, blood pressure management, stroke history, diabetes, and carotid artery stenosis). The AUC was 0.736 in the training set and 0.730 and 0.725 after resampling and in the external verification, respectively. The calibration curve illustrated a close overlap between the predicted and actual diagnosis of stroke in both the training set and testing validation. The multivariable logistic regression analysis and support vector machine with radial basis function kernel were the best models with an AUC of 0.710.

Conclusion

The prediction model using multiple logistic regression analysis has considerable accuracy and can be visualized in a nomogram, which is convenient for its clinical application.

Ligands of the Neuropeptide Y Y2 Receptors as a Potential Multitarget Therapeutic Approach for the Protection of the Neurovascular Unit Against Acute Ischemia/Reperfusion: View from the Perspective of the Laboratory Bench

Ischemic stroke is the third leading cause of death and disability worldwide, with no available satisfactory prevention or treatment approach. The current treatment is limited to the use of “reperfusion methods,” i.e., an intravenous or intra-arterial infusion of a fibrinolytic agent, mechanical removal of the clot by thrombectomy, or a combination of both methods. It should be stressed, however, that only approximately 5% of all acute strokes are eligible for fibrinolytic treatment and fewer than 10% for thrombectomy. Despite the tremendous progress in understanding of the pathomechanisms of cerebral ischemia, the promising results of basic research on neuroprotection are not currently transferable to human stroke. A possible explanation for this failure is that experiments on in vivo animal models involve healthy young animals, and the experimental protocols seldom consider the importance of protecting the whole neurovascular unit (NVU), which ensures intracranial homeostasis and is seriously damaged by ischemia/reperfusion. One of the endogenous protective systems activated during ischemia and in neurodegenerative diseases is represented by neuropeptide Y (NPY). It has been demonstrated that activation of NPY Y2 receptors (Y2R) by a specific ligand decreases the volume of the postischemic infarction and improves performance in functional tests of rats with arterial hypertension subjected to middle cerebral artery occlusion/reperfusion. This functional improvement suggests the protection of the NVU. In this review, we focus on NPY and discuss the potential, multidirectional protective effects of Y2R agonists against acute focal ischemia/reperfusion injury, with special reference to the NVU.

Interventions for reducing sedentary behaviour in people with stroke

BACKGROUND

Stroke survivors are often physically inactive as well as sedentary,and may sit for long periods of time each day. This increases cardiometabolic risk and has impacts on physical and other functions. Interventions to reduce or interrupt periods of sedentary time, as well as to increase physical activity after stroke, could reduce the risk of secondary cardiovascular events and mortality during life after stroke.

OBJECTIVES

To determine whether interventions designed to reduce sedentary behaviour after stroke, or interventions with the potential to do so, can reduce the risk of death or secondary vascular events, modify cardiovascular risk, and reduce sedentary behaviour.

SEARCH METHODS

In December 2019, we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, Conference Proceedings Citation Index, and PEDro. We also searched registers of ongoing trials, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing interventions to reduce sedentary time with usual care, no intervention, or waiting-list control, attention control, sham intervention or adjunct intervention. We also included interventions intended to fragment or interrupt periods of sedentary behaviour.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and performed 'Risk of bias' assessments. We analyzed data using random-effects meta-analyses and assessed the certainty of the evidence with the GRADE approach.

MAIN RESULTS

We included 10 studies with 753 people with stroke. Five studies used physical activity interventions, four studies used a multicomponent lifestyle intervention, and one study used an intervention to reduce and interrupt sedentary behaviour. In all studies, the risk of bias was high or unclear in two or more domains. Nine studies had high risk of bias in at least one domain. The interventions did not increase or reduce deaths (risk difference (RD) 0.00, 95% confidence interval (CI) -0.02 to 0.03; 10 studies, 753 participants; low-certainty evidence), the incidence of recurrent cardiovascular or cerebrovascular events (RD -0.01, 95% CI -0.04 to 0.01; 10 studies, 753 participants; low-certainty evidence), the incidence of falls (and injuries) (RD 0.00, 95% CI -0.02 to 0.02; 10 studies, 753 participants; low-certainty evidence), or incidence of other adverse events (moderate-certainty evidence). Interventions did not increase or reduce the amount of sedentary behaviour time (mean difference (MD) +0.13 hours/day, 95% CI -0.42 to 0.68; 7 studies, 300 participants; very low-certainty evidence). There were too few data to examine effects on patterns of sedentary behaviour. The effect of interventions on cardiometabolic risk factors allowed very limited meta-analysis.

AUTHORS' CONCLUSIONS

Sedentary behaviour research in stroke seems important, yet the evidence is currently incomplete, and we found no evidence for beneficial effects. Current World Health Organization (WHO) guidelines recommend reducing the amount of sedentary time in people with disabilities, in general. The evidence is currently not strong enough to guide practice on how best to reduce sedentariness specifically in people with stroke. More high-quality randomised trials are needed, particularly involving participants with mobility limitations. Trials should include longer-term interventions specifically targeted at reducing time spent sedentary, risk factor outcomes, objective measures of sedentary behaviour (and physical activity), and long-term follow-up.

Salivary Biomarkers of Oxidative Stress and Inflammation in Stroke Patients: From Basic Research to Clinical Practice

Cerebral stroke is a serious worldwide health problem, as can be seen by the global epidemic of the disease. In this disorder, when the blood flow is compromised by ruptures or blocked arteries, sudden death of neurons is observed as a result of a lack of oxygen and nutrients. Numerous severe problems and frequent complications also exist in stroke patients; therefore, there is an urgent need to develop new therapeutic, diagnostic, and prognostic methods for the disease. At present, the diagnosis of stroke is based on a neurological examination, medical history, and neuroimaging, due to the fact that rapid and noninvasive diagnostic tests are unavailable. Nevertheless, oxidative stress and inflammation are considered key factors in stroke pathogenesis. Oxygen free radicals are responsible for oxidation of lipids, proteins, and DNA/RNA, which in turn contributes to oxidative damage of the brain. Toxic products of the oxidation reactions act cytostatically on the cell by damaging cell membranes and leading to neuronal death by apoptosis or necrosis. Thus, it seems that redox/inflammatory biomarkers might be used in the diagnosis of the disease. Nowadays, saliva is of increasing interest in clinical laboratory medicine. Redox biomarkers could be obtained easily, noninvasively, cheaply, and stress-free from saliva. This minireview is aimed at presenting the current knowledge concerning the use of salivary biomarkers of oxidative stress and inflammation in the diagnosis and prognosis of stroke.

The impact of reactive oxygen species in the development of cardiometabolic disorders: a review

Oxidative stress, an alteration in the balance between reactive oxygen species (ROS) generation and antioxidant buffering capacity, has been implicated in the pathogenesis of cardiometabolic disorders (CMD). At physiological levels, ROS functions as signalling mediators, regulates various physiological functions such as the growth, proliferation, and migration endothelial cells (EC) and smooth muscle cells (SMC); formation and development of new blood vessels; EC and SMC regulated death; vascular tone; host defence; and genomic stability. However, at excessive levels, it causes a deviation in the redox state, mediates the development of CMD. Multiple mechanisms account for the rise in the production of free radicals in the heart. These include mitochondrial dysfunction and uncoupling, increased fatty acid oxidation, exaggerated activity of nicotinamide adenine dinucleotide phosphate oxidase (NOX), reduced antioxidant capacity, and cardiac metabolic memory. The purpose of this study is to discuss the link between oxidative stress and the aetiopathogenesis of CMD and highlight associated mechanisms. Oxidative stress plays a vital role in the development of obesity and dyslipidaemia, insulin resistance and diabetes, hypertension via various mechanisms associated with ROS-led inflammatory response and endothelial dysfunction.

Risk of fatal and nonfatal coronary heart disease and stroke events among adult patients with hypertension: basic Markov model inputs for evaluating cost-effectiveness of hypertension treatment: systematic review of cohort studies

Objectives

Hypertension is a risk factor for a number of vascular and cardiac complications. A Markov like simulation based on cardiovascular disease (CVD) policy model is being used for evaluating cost-effectiveness of hypertension treatment. Stroke, angina, myocardial infarction (MI), cardiac arrest and all-cause mortality were only included CVD outcome variables in the model. Therefore this systematic review was conducted to evaluate completeness of CVD policy model for evaluation of cost-effectiveness across different regions.

Key findings

Fourteen cohort studies involving a total of 1 674 773 hypertensive adult population and 499 226 adults with treatment resistant hypertension were included in this systematic review. Hypertension is clearly associated with coronary heart disease (CHD) and stroke mortality, unstable angina, stable angina, MI, heart failure (HF), sudden cardiac death, transient ischemic attack, ischemic stroke, sub-arachnoid hemorrhage, intracranial hemorrhage, peripheral arterial disease (PAD), and abdominal aortic aneurism (AAA). Lifetime risk of developing HF is higher among hypertensives across all ages, with slight variation among regions. Treatment resistant hypertension is associated with higher relative risk of developing major CVD events and mortality when compared with the non-resistant hypertension.

Summary

The CVD policy model can be used in most of the regions for evaluation of cost-effectiveness of hypertension treatment. However, hypertension is highly associated with HF in Latin America, Eastern Europe, and Sub-Saharan Africa. Therefore, it is important to consider HF in CVD policy model for evaluating cost-effectiveness of hypertension treatment in these regions. We do not suggest the inclusion of PAD and AAA in CVD policy model for evaluating cost-effectiveness of hypertension treatment due to lack of sufficient evidence. Researchers should consider the effect of treatment resistant hypertension either through including in the basic model or during setting the model assumptions.

Ferritin reduction is essential for cerebral ischemia-induced hippocampal neuronal death through p53/SLC7A11-mediated ferroptosis

Cerebral ischemia is the most common cause of hippocampal neuronal death and the most prevalent cause of stroke with high mortality rate. Ferroptosis has been suggested to affect the role of hippocampal neurons. This study explores the influence of lentivirus infection-induced ferritin overexpression in hippocampal neuronal injury and death through simulations in August Copenhagen Irish rat models. Twenty-four-hour cerebral ischemia-reperfusion injury was induced in the rats after 90-min middle cerebral artery occlusion (MCAO). Ferritin overexpression was induced through lentivirus infection. The Morris Water Maze (MWM) test and tau hyperphosphorylation test were performed on hippocampal neurons to establish a MCAO model. The effect of ferritin overexpression on hippocampal neuronal death was evaluated using hematoxylin-eosin staining and annexin V/propidium iodide flow cytometry. The MWM test revealed that MCAO modeling decreased the cognitive and locomotor capacity of the rats, whereas ferritin overexpression partially reversed the effect of MCAO. In addition, the hyperphosphorylation of tau caused by MCAO was reduced by ferritin. Pathogenic changes, impaired viability, increased apoptosis, and elevated caspase-9 cleavage in hippocampal neurons were clearly recovered by ferritin. Moreover, robust reactive oxygen species production and glutathione consumption, which was induced by MCAO modeling, were ameliorated by ferritin. Furthermore, two key modulators of ferroptosis, p53 and SLC7A11, were demonstrated to be upregulated by MCAO modeling and downregulated by ferritin. Ferritin reduction is essential for cerebral ischemia-induced hippocampal neuronal ferroptosis mediated via p53 and SLC7A11.

Prevalence of Lower Extremity Arterial Disease as Measured by Low Ankle-Brachial Index in Patients with Acute Cerebral Ischemic Events

BACKGROUND

Low ankle-brachial index (ABI) of ≤0.9 is diagnostic of lower extremity arterial disease (LEAD). It is also a strong marker of generalized atherosclerosis. The objective of this study was to assess the prevalence of low ABI in patients with acute cerebral ischemic events (ACIE): ischemic stroke (IS) or transient ischemic attack (TIA).

METHODS

We compared 150 inpatients with ACIE to 50 inpatient controls and assessed risk factors, ABI measurements, and Duplex ultrasound of the cervical vessels.

RESULTS

Low ABI was seen in 69 patients (46%) in the ACIE group and in 8 (16%) in the control group; p < 0.01. The mean and median ABI values in the ACIE group were 0.88 (SD = 0.22) and 0.91 (0.24-1.33), which were significantly lower than in the control group: 1.04 (SD = 0.16) and 1.0 (0.66-1.36); p < 0.0001, respectively. Coronary artery disease, carotid stenosis of ≥50% and smoking were risk factors, which were associated with significantly lower ABI in the study group; the ABI with risk factors vs. without was 0.85 vs. 0.92 (coronary artery disease); p < 0.05, 0.7 vs. 0.92; (carotid stenosis) p < 0.001 and 0.83 vs. 0.98; (smoking) p < 0.001, respectively.

CONCLUSION

Our study demonstrated that patients with ACIE have significantly higher involvement of another vascular bed as LEAD. Coronary artery disease, carotid stenosis ≥50% and smoking were main risk factors associated with coexistence of LEAD and ACIE.

The Effect of Hedysarum multijugum Maxim.-Chuanxiong rhizoma Compound on Ischemic Stroke: A Research Based on Network and Experimental Pharmacology

Background

Hedysarum multijugum Maxim.-Chuanxiong rhizoma compound (HCC) is a common herbal formula modified from Buyang Huanwu decoction. Clinical trials have demonstrated its therapeutic potential for ischemic stroke (IS). However, the mechanism of HCC remains unclear.

Methods

The HCC's components were collected from the TCMSP database and TCM@Taiwan database. After that, the HCC's compound targets were predicted by PharmMapper. The IS-related genes were obtained from GeneCards, and OMIM and the protein-protein interaction (PPI) data of HCC's targets and IS genes were obtained from the String database. After that, the DAVID platform was applied for Gene Ontology (GO) enrichment analysis and pathway enrichment analysis and the Cytoscape 3.7.2 was utilized to construct and analyze the networks. Finally, a series of animal experiments were carried out to validate the prediction results of network pharmacology. The expressions of GRP78, p-PERK, and CHOP proteins and mRNAs in different time periods after HCC intervention were detected by Western blot, immunohistochemistry, and RT-qPCR.

Results

A total of 440 potential targets and 388 IS genes were obtained. The results of HCC-IS PPI network analysis showed that HCC may regulate IS-related targets (such as ALB, AKT1, MMP9, IGF1, and CASP3), biological processes (such as endoplasmic reticulum stress, inflammation modules, hypoxia modules, regulation of neuronal apoptosis and proliferation, and angiogenesis), and signaling pathways (such as PI3K-Akt, FoxO, TNF, HIF-1, and Rap1 signaling). The animal experiments showed that HCC can improve the neurobehavioral scores and protect the neurons of IS rats (P < 0.05). HCC inhibited the expression of p-PERK in the PERK pathway from 12 h after surgery, significantly promoted the expression of GRP78 protein, and inhibited the expression of CHOP protein after surgery, especially at 24 h after surgery (P < 0.05). The results of RT-qPCR showed that HCC can significantly reduce the expression of CHOP mRNA in the neurons in the CA1 region of the hippocampus 72 h after MCAO (P < 0.05).

Conclusion

HCC may achieve a role in the treatment of IS by intervening in a series of targets, signaling pathways, and biological processes such as inflammation, oxidative stress, endoplasmic reticulum stress, and angiogenesis.

Use of statins for the secondary prevention of stroke: are we respecting the scientific evidences?

BACKGROUND

Stroke accounts for approximately as 5.0% of disability-adjusted years of life and 10.0% of all deaths worldwide. Secondary stroke prevention in surviving individuals, which includes the use of statins, reduces atherothrombotic stroke recurrence, complications and mortality. The present study aimed to characterize the Brazilian population with stroke history and estimate the prevalence of statin use as secondary prevention.

METHODS

This is a population-based cross-sectional study conducted in Brazilian urban areas. A total of 41.433 individuals were interviewed, representing 171 million of Brazilians, based on post-stratification weights. We included only participants aged 20 years or older who answered "yes" to the following question: "Did any doctor ever tell you that you had a stroke?" The main outcome was the prevalence of statin use among individuals who answered affirmatively. To identify the factors associated with stroke occurrence, the participants were categorized according to clinical and sociodemographic characteristics.

RESULTS

Only 24.2% (95% CI 19.9 - 29.1) of those who reported history of stroke regardless of other conditions also reported statin use. However, the results indicated that 52.9% (95% CI 43.6 - 62.0) of individuals who reported a previous diagnosis of dyslipidemia stated the use of statins. Regarding patients who reported stroke and did not report dyslipidemia history, only 9.1% (95% CI 5.9 - 13.8) referred to use statins.

CONCLUSION

This study showed a low prevalence of statin use by individuals with a history of stroke in Brazil. Actions involving the organization of services and training of professionals may positively impact the rates of stroke recurrence.

Cell Therapy for Ischemic Stroke: How to Turn a Promising Preclinical Research into a Successful Clinical Story

Stroke is a major public health issue with limited treatment. The pharmacologically or mechanically removing of the clot is accessible to less than 10% of the patients. Stem cell therapy is a promising alternative strategy since it increases the therapeutic time window but many issues remain unsolved. To avoid a new dramatic failure when translating experimental data on the bedside, this review aims to highlight the indispensable checkpoints to make a successful clinical trial based on the current preclinical literature. The large panel of progenitors/ stem cells at the researcher's disposal is to be used wisely, regarding the type of cells, the source of cells, the route of delivery, the time window, since it will directly affect the outcome. Mechanisms are still incompletely understood, although recent studies have focused on the inflammation modulation of most cells types.

Metabolomics coupled with integrative pharmacology reveals the therapeutic effect of l-borneolum against cerebral ischaemia in rats

Objectives

This study aimed to investigate metabolic biomarker changes and related metabolic pathways before and after treatment with l-borneolum in cerebral ischaemic rats.

Methods

Rats were subjected to pMCAO surgery. The Zea-Longa scoring method was used to evaluate neurological deficits. TTC staining was used to observe cerebral infarction. HE staining was used to observe the pathological changes in brain tissue. The metabolomics method was used to analyse the changes in metabolism.

Results

The pharmacology changes of the H-B group were significantly different from those of the vehicle group. Moreover, according to the metabolomics method, identification of potential biomarkers in cerebral ischaemia treatment showed that the levels of l-valine and l-arginine were increased while the levels of N-succinyl-L,L-2,6-diaminopimelate and LysoPC (18 : 1(9Z)) were reduced, which were related to energy metabolism. Simultaneously, thermogenesis and bile secretion levels were inhibited by l-borneolum. Furthermore, elevated level of methotrexate might be related to an anti-inflammatory effect.

Conclusions

The therapeutic effect of l-borneolum on cerebral ischaemia might be associated with the regulation of energy metabolism, thermogenesis and bile secretion. These metabolic changes and the core target changes, as well as the metabolic-target pathway network, help to elucidate the mechanisms governing the effect of l-borneolum on cerebral ischaemia.

Ischemic postconditioning for stroke treatment: current experimental advances and future directions

Ischemic postconditioning (IPostC) protects against brain injury induced by stroke and is a potential strategy for ischemic stroke treatment. Understanding its underlying mechanisms and potential hurdles is essential for clinical translation. In this review article, we will summarize the current advances in IPostC for stroke treatment and the underlying protective mechanisms. Strong evidence suggests that IPostC reduces brain infarct size, attenuates blood-brain barrier (BBB) damage and brain edema, and improves neurological outcomes. IPostC also promotes neurogenesis and angiogenesis at the recovery phase of ischemic stroke. The protective mechanisms involve its effects on anti-oxidative stress, anti-inflammation, and anti-apoptosis. In addition, it regulates neurotransmitter receptors, ion channels, heat shock proteins (HSP) 40/70, as well as growth factors such as BDNF and VEGF. Furthermore, IPostC modulates several cell signaling pathways, including the PI3K/Akt, MAPK, NF-κB, and the Gluk2/PSD95/MLK3/MKK7/JNK3 pathways. We also discuss the potential hurdles for IPostC's clinical translation, including insufficient IPostC algorithm studies, such as therapeutic time windows and ischemia-reperfusion periods and cycles, as well as its long-term protection. In addition, future studies should address confounding factors such as age, sex, and pre-existing conditions such as hypertension and hyperglycemia before stroke onset. At last, the combination of IPostC with other treatments, such as tissue plasminogen activator (t-PA), merits further exploration.

In-depth transcriptomic and proteomic analyses of the hippocampus and cortex in a rat model after cerebral ischemic injury and repair by Shuxuetong (SXT) injection

BACKGROUND

There is a lack of systematic descriptions and characterization of strokes and their effects in both the cerebral hippocampus and cortex. Shuxuetong (SXT) injection was reported to have good therapeutic effects in the clinic; therefore, it was selected as a drug intervention method for cerebral ischemia repair in rat models. The aim of this study was to understand the features of molecules and pathways and to reveal key processes of SXT repair.

MATERIALS AND METHODS

Evaluation of neurological deficit and infarct volume measurement was used to estimate the pharmacological effects of SXT injection on Ischemia-reperfusion(I/R) model rats. LC-MS/MS and RNA-Seq analysis were used to analyze the proteins and mRNA expression in the cerebral hippocampus and cortex 6 h and 24 h after ischemic injury and repair. A label-free approach (IBAQ) for proteomics analysis and FPKM based on gene read count for transcriptomics analysis were used to quantify the differences among the three experimental groups (Sham, Model and SXT-treated groups). Transcriptomics and proteomics analyses were verified by RT-qPCR and western blotting.

RESULTS

By combining LC-MS/MS and RNA-Seq, eight larger datasets (two time points and two tissues) were confidently identified in more than three biological replicates. An average of 4500 unique proteins and 8200 protein-coding genes were confidently identified. By combining the subcellular localization, hierarchical clustering, pathway enrichment analysis in the injury and repair phase, six core proteins and related genes that were significantly expressed were verified as candidates for cerebral ischemic injury by western blotting and quantitative real-time PCR. Meanwhile, the results indicated that there was better expression in the 6 h group by significant proteomics analysis during the development and progression of cerebral ischemia. Two primary co-enriched pathways, the PI3K-AKT and MAPK signaling pathways, and six related core candidates may play key roles in molecular mechanisms related to cerebral ischemic injury and repair by SXT injection.

CONCLUSION

Our data not only identified six core candidates and two key signaling pathways for cerebral ischemic injury and verification but also provided evidence for the explanation, prevention and treatment of cerebral ischemia by SXT injection. The results of the present study provide evidence for the explanation, prevention and treatment of cerebral ischemia by SXT injection.

Multiple protein and mRNA expression correlations in the rat cerebral cortex after ischemic injury and repair due to buchang naoxintong jiaonang (BNJ) intervention

Stroke is the one of the most common causes of death worldwide. Systematic description and characterization of the types of stroke and the effects induced in the cerebral cortex have not been performed so far. Here, we analyzed the protein and mRNA expression in the cerebral cortex12 h after ischemic injury and repair. Drug intervention using Buchang Naoxintong Jiaonang (BNJ), which has been reported to have good clinical therapeutic effects, was selected for our study of cerebral ischemic repair in rat models. Two powerful techniques can be merged in a single study to examine and yield new perspectives in physiology and pathophysiology. Combining LC-MS/MS and DNA microarray analyses of the rat cerebral cortex confidently identified two large datasets in more than three biological replicates. Quantitative approaches were then used to quantify the differences among the four experimental groups the naive, sham, middle cerebral artery occlusion MCAO and MCAO + BNJ groups by a label-free proteomics approach and a Cy5-labeled microarray approach. In brief, 3217 unique proteins and 24,300 unique gene symbols were confidently identified. Bioinformatics analysis revealed that of these unique proteins and gene symbols, 269 proteins and 632 gene symbols were identified to be differentially expressed. The results of subcellular localization, hierarchical clustering, and pathway enrichment analyses were combined with the results of the injury and repair phase analyses, and twelve proteins and twenty-seven gene symbols were significantly differentially expressed and were identified as potential candidates for cerebral ischemic injury involvement; all the candidates were verified by western blot and quantitative real-time PCR analysis. The primary enriched MAPK signaling pathway may play a key role in the molecular mechanisms related to cerebral ischemic injury. The observations of the present study help to illuminate the regulatory mechanism of cerebral ischemic injury and repair due to BNJ intervention.

Proteomic analysis of protein changes in plasma by balloon test occlusion

Transient ischemia provides the tolerance against prolonged ischemia in the brain. In mouse experimental model, transient ischemia changes the composition ratio of circulating proteins, which associate with neuroprotection; however, the human evidence is lacking. Here we mimicked balloon test occlusion (BTO) of carotid artery as a transient ischemia and investigated the change of composition ratio of the circulating protein in the human plasma. We collected blood samples from nine patients (5 men and 4 women; mean age 64.2 years; range 45 to 77 years) before and 48 h after BTO and investigated the changes of circulating molecules level in the proteome using LC-MS/MS analysis. Leucine-rich alpha-2-glycoprotein and serum amyloid A-1 increased and protein AMBP decreased in the blood samples after BTO. Transient change of blood flow in the brain alters molecular expression in the plasma. Because the alteration of plasma protein composition is involved in ischemic tolerance in animal models, the proteins whose level was changed by BTO may be also involved in neuroprotection against ischemia in human.

Acute ischemic stroke in a third trimester of pregnancy - cesarean section followed by mechanical thrombectomy

Background: Acute ischemic stroke (AIS) in pregnancy, despite being a rare event, poses a serious risk for mother's and child's health. There are no strict treatment guidelines in this group of patients, with safety and efficacy of intravenous recombinant tissue-plasminogen-activator (rtPA) and mechanical thrombectomy (MT) being uncertain.Case Presentation: We present a case of gravid 27-year-old patient with left middle cerebral artery (MCA) proximal occlusion causing AIS that was successfully treated with MT. Being in 35^th gestational week, it was decided to perform caesarean section before endovascular treatment. The outcome of treatment was good, with no mother's neurological deficit and proper child development in the 5-year observation.Conclusions: MT is probably safe and efficient treatment method in selected pregnant women. No harmful effects on further pregnancy course and parturition have been observed to date.

From Tumor Metastasis towards Cerebral Ischemia-Extracellular Vesicles as a General Concept of Intercellular Communication Processes

Extracellular vesicles (EVs) have been tremendous carriers in both experimental and translational science. These vesicles—formerly regarded as artifacts of in vitro research—have a heterogeneous population of vesicles derived from virtually all eukaryotic cells. EVs consist of a bilayer lipid structure with a diameter of about 30 to 1000 nm and have a characteristic protein and non-coding RNA content that make up different forms of EVs such as exosomes, microvesicles, and others. Despite recent progress in the EV field, which is known to serve as potential biomarkers and therapeutic tools under various pathological conditions, fundamental questions are yet to be answered. This short review focuses on recently reported data regarding EVs under pathological conditions with a particular emphasis on the role of EVs under such different conditions like tumor formation and cerebral ischemia. The review strives to point out general concepts of EV intercellular communication processes that might be vital to both diagnostic and therapeutic strategies in the long run.

Can a multicomponent multidisciplinary implementation package change physicians' and nurses' perceptions and practices regarding thrombolysis for acute ischemic stroke? An exploratory analysis of a cluster-randomized trial

BACKGROUND

The Thrombolysis ImPlementation in Stroke (TIPS) trial tested the effect of a multicomponent, multidisciplinary, collaborative intervention designed to increase the rates of intravenous thrombolysis via a cluster randomized controlled trial at 20 Australian hospitals (ten intervention, ten control). This sub-study investigated changes in self-reported perceptions and practices of physicians and nurses working in acute stroke care at the participating hospitals.

METHODS

A survey with 74 statements was administered during the pre- and post-intervention periods to staff at 19 of the 20 hospitals. An exploratory factor analysis identified the structure of the survey items and linear mixed modeling was applied to the final survey domain scores to explore the differences between groups over time.

RESULT

The response rate was 45% for both the pre- (503 out of 1127 eligible staff from 19 hospitals) and post-intervention (414 out of 919 eligible staff from 18 hospitals) period. Four survey domains were identified: (1) hospital performance indicators, feedback, and training; (2) personal perceptions about thrombolysis evidence and implementation; (3) personal stroke skills and hospital stroke care policies; and (4) emergency and ambulance procedures. There was a significant pre- to post-intervention mean increase (0.21 95% CI 0.09; 0.34; p < 0.01) in scores relating to hospital performance indicators, feedback, and training; for the intervention hospitals compared to control hospitals. There was a corresponding increase in mean scores regarding perceptions about the thrombolysis evidence and implementation (0.21, 95% CI 0.06; 0.36; p < 0.05). Sub-group analysis indicated that the improvements were restricted to nurses' responses.

CONCLUSION

TIPS resulted in changes in some aspects of nurses' perceptions relating to the evidence for intravenous thrombolysis and its implementation and hospital performance indicators, feedback, and training. However, there is a need to explore further strategies for influencing the views of physicians given limited statistical power in the physician sample.

TRIAL REGISTRATION

ACTRN12613000939796, UTN: U1111-1145-6762.

In vivo muscle morphology comparison in post-stroke survivors using ultrasonography and diffusion tensor imaging

Skeletal muscle architecture significantly influences the performance capacity of a muscle. A DTI-based method has been recently considered as a new reference standard to validate measurement of muscle structure in vivo. This study sought to quantify muscle architecture parameters such as fascicle length (FL), pennation angle (PA) and muscle thickness (tm) in post-stroke patients using diffusion tensor imaging (DTI) and to quantitatively compare the differences with 2D ultrasonography (US) and DTI. Muscle fascicles were reconstructed to examine the anatomy of the medial gastrocnemius, posterior soleus and tibialis anterior in seven stroke survivors using US- and DTI-based techniques, respectively. By aligning the US and DTI coordinate system, DTI reconstructed muscle fascicles at the same scanning plane of the US data can be identified. The architecture parameters estimated based on two imaging modalities were further compared. Significant differences were observed for PA and tm between two methods. Although mean FL was not significantly different, there were considerable intra-individual differences in FL and PA. On the individual level, parameters measured by US agreed poorly with those from DTI in both deep and superficial muscles. The significant differences in muscle parameters we observed suggested that the DTI-based method seems to be a better method to quantify muscle architecture parameters which can provide important information for treatment planning and to personalize a computational muscle model.

The Factors Associated with the Fatal Outcome of Stroke

The aim of this study is to determine the risk factors associated with the fatal outcome of stroke. The research was designed as observational, non-interventional study, conducted by the type of case series, and it included 290 patients hospitalized with a diagnosis of stroke at Neurology Clinic of the Clinical Center Kragujevac during the observed period from 01/02/2013 to 31/01/2014. The data used for the research were: documentation of Neurology Clinic of the Clinical Center Kragujevac, documentation of the Institute of Public Health Kragujevac and patients’ questionnaires. The results of univariate binary logistic regression pointed out a relevant connection between the fatal outcome of stroke and age (p˂ 0.0001), gender (p˂ 0.0001), the severity of the disease (p = 0.002), smoking (p = 0.021), care for the parents’ health (p = 0.018), the concern about business problems (p = 0.018), while the influence of antidepressants was indicative (p = 0.066), whereas using the multivariate binary logistic regression, it was concluded that age (OR=1.096; 95% CI=1.059-1.134; p<0.001), the severity of the disease (OR=4.324; 95% CI=1.256-14.885; p=0.020) and the use of antidepressants (OR=5.578; 95% CI=1.178-26.423; p=0.030) were factors independently associated with the mortality rate. These findings suggest that it would be useful to carry out additional comprehensive research about all potential risk factors for the occurrence of stroke, and also to establish all the steps that can be taken in order to identify and detect risk factors, their elimination or reduction, and, accordingly, to take aggressive measures of primary and secondary prevention.

PTPN22 Gene Polymorphisms Are Associated with Susceptibility to Large Artery Atherosclerotic Stroke and Microembolic Signals

Large artery atherosclerotic stroke (LAAS) is the most common ischemic stroke (IS) subtype, and microemboli may be clinically important for indicating increased risk of IS. The inflammatory process of atherosclerosis is well known, and lymphoid phosphatase (Lyp), which is encoded by the protein tyrosine phosphatase nonreceptor type 22 (PTPN22) gene, plays an important role in the inflammatory response. Our study was intended to evaluate the relationship between PTPN22 gene and LAAS and microembolic signals (MES). Three loci of the PTPN22 gene (rs2476599, rs1217414, and rs2488457) were analyzed in 364 LAAS patients and 369 control subjects. A genotyping determination was performed using the TaqMan assay. The G allele of rs2488457 might be related to a higher risk for developing LAAS and MES (odds ratio (OR) = 1.456, 95% confidence interval (CI) 1.156-1.833, P = 0.001; OR = 1.652, 95% CI 1.177-2.319, P = 0.004, respectively). In the LAAS group, the prevalence of the GTG haplotype was higher (P < 0.001) and the prevalence of the GCC haplotype was lower (P = 0.001). An interaction analysis of rs2488457 with smoking showed that smokers with the CG/GG genotypes had a higher risk of LAAS, compared to nonsmokers with the rs2488457 CC genotype (OR = 2.492, 95% CI 1.510–4.114, P < 0.001). Our research indicated that the PTPN22 rs2488457 might be related to the occurrence of LAAS and MES in the Han Chinese population. In addition, the rs2488457 polymorphism and the environmental factor of smoking jointly influenced the susceptibility of LAAS.

Cross-Reactivity as a Mechanism Linking Infections to Stroke

The relevance of infections as risk factor for cerebrovascular disease is being increasingly recognized. Nonetheless, the pathogenic link between the two entities remains poorly understood. Consistent with recent advances in medicine, the present work addresses the hypothesis that infection-induced immune responses may affect human proteins associated with stroke. Applying established procedures in bioinformatics, the pathogen antigens and the human proteins were searched for common sequences using pentapeptides as probes. The resulting data demonstrate massive peptide sharing between infectious pathogens-such as Chlamydia pneumoniae, Streptococcus pneumoniae, Tannerella forsythia, Haemophilus influenzae, Influenza A virus, and Cytomegalovirus-and human proteins related to risk of ischemic and hemorrhagic stroke. Moreover, the shared peptides are also evident in a number of epitopes experimentally proven immunopositive in the human host. The present findings suggest cross-reactivity as a potential mechanistic link between infections and stroke.

Urban-rural differences in risk factors for ischemic stroke in northern China

This study aims to investigate urban-rural differences in characteristics and risk factors of ischemic stroke in northern China.The present cross-sectional study was based on the High-risk Population Screening and Intervention Project for Stroke. The cluster sampling method was used to select urban and rural screening sites in northern China. By collecting information and screening the data, patients with ischemic stroke were obtained and a control group with similar gender, age, and regional distribution was selected among the nonischemic stroke patients. Then, the demographic and risk factors of patients with ischemic stroke were described and analyzed.The prevalence of ischemic stroke in northern China was 2.88%, with a greater prevalence in rural areas than in urban areas (3.32% vs 2.43%), and a greater prevalence in males than in females (3.06% vs 2.73%). Furthermore, rural stroke patients were younger than urban stroke patients. Hypertension, family history of stroke, and smoking were the top 3 independent risk factors for ischemic stroke. Overweight/obesity and low education were associated with increased ischemic stroke in urban areas, while low education was associated with less ischemic stroke in rural areas. In addition, the prevalence of alcoholism, dyslipidemia, diabetes, and obvious overweight/obesity was greater in urban areas, while high-salt diet and low education and income were more prevalent in rural regions. Moreover, the smoking index was higher in rural areas than in urban areas.The characteristics and risk factors of ischemic stroke differ between rural and urban areas, which could be used to design specific preventative measures.

A new era for stroke therapy: Integrating neurovascular protection with optimal reperfusion

Recent advances in stroke reperfusion therapies have led to remarkable improvement in clinical outcomes, but many patients remain severely disabled, due in part to the lack of effective neuroprotective strategies. In this review, we show that 95% of published preclinical studies on "neuroprotectants" (1990-2018) reported positive outcomes in animal models of ischemic stroke, while none translated to successful Phase III trials. There are many complex reasons for this failure in translational research, including that the majority of clinical trials did not test early delivery of neuroprotectants in combination with successful reperfusion. In contrast to the clinical trials, >80% of recent preclinical studies examined the neuroprotectant in animal models of transient ischemia with complete reperfusion. Furthermore, only a small fraction of preclinical studies included long-term functional assessments, aged animals of both genders, and models with stroke comorbidities. Recent clinical trials demonstrate that 70%-80% of patients treated with endovascular thrombectomy achieve successful reperfusion. These successes revive the opportunity to retest previously failed approaches, including cocktail drugs that target multiple injury phases and different cell types. It is our hope that neurovascular protectants can be retested in future stroke research studies with specific criteria outlined in this review to increase translational successes.

Understanding the potential for yoga and tai chi interventions to moderate risk factors for stroke – a scoping review

Following an initial stroke, approximately two in five people will experience another stroke within 10 years. Recurrent strokes are often more severe and fatal. Mindfulness-based interventions (MBIs) that use movement to focus attention, such as yoga and tai chi, may offer a lifestyle strategy in addition to standard rehabilitation options, for moderating risk factors for stroke. We conducted a scoping review to explore the potential for yoga or tai chi to moderate modifiable risk factors for stroke. 26 papers between 1985 and 2017 were identified using online and gray literature databases. Overall, yoga or tai chi may reduce hypertension (up to 16/9 mmHg), and to a lesser extent some lipid and blood sugar levels. Study designs were heterogeneous. Further research on mediating pathways of MBIs, such as yoga or tai chi, on modifiable risk factors for stroke is warranted.

The Effect of Unihemispheric Concurrent Dual-Site Transcranial Direct Current Stimulation of Primary Motor and Dorsolateral Prefrontal Cortices on Motor Function in Patients With Sub-Acute Stroke

It is believed that unihemispheric concurrent dual-site transcranial direct current stimulation (tDCS_UHCDS) of the primary motor cortex (M1) and the dorsolateral prefrontal cortex (DLPFC) causes an increase in motor cortex excitability. However, the clinical effect of this type of stimulation on patients with neurological conditions is not yet known. The aim of the present study was to assess the effect of anodal-tDCS_UHCDS (a-tDCS_UHCDS) on upper limb motor function in subacute stroke patients. Fifteen patients participated in this sham-controlled crossover study. The main outcome measures were the reaction time (RT) to visual stimuli, completion time of a nine-pin pegboard (9-PPB), and the scores from the Fugl–Meyer assessment (FMA) for the upper limb of the involved side before and after three brain stimulation conditions. For a-tDCS_UHCDS, the anodal electrodes were placed on the M1 and the DLPFC, while for a-tDCS, the anodal electrode was placed on the M1. For the sham stimulation, the tDCS was turned off after 30 s. For brain stimulation, the selected current was 1 mA for 20 min. After a-tDCS_UHCDS, there was a significant reduction in the RT and completion time of the 9-PPB compared with the times after a-tDCS and the sham stimulation: p = 0.013 and p = 0.022, respectively). However, there was no significant difference in the FMA scores after the three types of stimulations (p = 0.085). Compared with a-tDCS, a-tDCS_UHCDS temporarily improved the RT and dexterity of the involved hand in subacute stroke patients.

Clinical Trial Registration: Iranian Registry of Clinical Trials (IRCT), identifier IRCT2015012520787N1.

Relative Telomere Length and Stroke Risk in a Chinese Han Population

This study aimed to further understand the role of relative telomere length (RTL) in susceptibility to stroke and investigate the association regulator of telomere elongation helicase 1 (RETL1) gene polymorphisms and RTL. RTL was measured using the real-time quantitative polymerase chain reaction (qPCR) from 300 stroke patients and 299 healthy controls. Genotyping was performed using the Sequenom MassARRAY platform. The results indicated that stroke patients had significantly shorter median RTL than controls (P < 0.001). Compared with the longer RTL (≥ 0.766), the shorter RTL (< 0.766) was significantly increased the risk of stroke (odds ratio [OR] = 8.44, 95% confidence interval [CI] 5.42-13.14, P < 0.001). The RTL was categorized into tertiles, we found that the shorter RTL (0.515-1.366) (OR = 16.27, 95% CI 7.72-34.29, P < 0.001) and lowest RTL (< 0.515) (OR = 30.63, 95% CI 14.27-65.75, P < 0.001) were significantly increased stroke risk compared with the highest RTL (> 1.366). Stratified analysis showed that the shorter RTL was also significantly increased the risk of stroke compared with the longer RTL in male, age < 60 years and ≥ 60 years, except the female participants. In addition, individuals with the genotypes AA (rs2297441) and GG (rs6089953) have shorter telomeres than the genotypes GG (P = 0.031) and AA (P = 0.032), respectively. Our results suggested that shorter RTL was associated with an increased risk of stroke. The association was found between the genotypes AA (rs2297441) and GG (rs6089953) and shorter RTL in case group. Further studies in larger sample size and biological functional assays are warranted to validate our findings.

Intra-carotid arterial transfusion of autologous circulatory derived CD34+ cells for old ischemic stroke patients - a phase I clinical trial to evaluate safety and tolerability

This phase I clinical trial tested the hypothesis that circulatory CD34+ cell therapy might be safe for old ischemic stroke (IS) (defined as IS>6 months) patients and also to evaluate the neurological function after the therapy. Nine old IS patients (with mean IS interval: 8.6 ± 6.4 years) were consecutively enrolled and received intra-carotid artery transfusion of circulatory-derived autologous CD34+ cells (3.0×10⁷ cells/patient) into the ipsilateral brain infarct area at catheterization room by Catheter Looping Technique, after subcutaneous G-CSF injection (5 μg/kg twice a day for 4 days). The results showed that procedural safety was 100% with all patients uneventfully discharged. The circulating number of EPCs and angiogenesis (i.e., by Matrigel assay) were significantly higher at post than at prior to G-CSF treatment (all P<0.001). Time courses (0/5/10/30 minutes) of blood samplings from right-internal jugular vein exhibited significantly increased in levels of SDF-1α and EPCs numbers in time points of 5/10/30 minutes than in the baseline (0 minute) (all P<0.05). Barthel index was increased (defined as ≥5 scores) in 44.4% (4/9) and CASI score was notably improved (all P<0.01) at 6-month follow-up after the cell therapy as compared to the baseline. No recurrent IS or any tumorigenesis was found in these patients with a mean follow-up time interval of 16.5 ± 6.2 months. All of these patients remain survive and are followed up at outpatient department. In conclusion, CD34+ cell therapy is safe and might offer some benefit to old IS patients.

Using Extracellular Circulating microRNAs to Classify the Etiological Subtypes of Ischemic Stroke

There is no effective biological method to classify ischemic stroke subtypes. In this study, we first performed a systematical gene array study on serum microRNAs with different ischemic stroke subtypes including 13 normal control subjects (NCs) and 87 ischemic stroke (IS) patients including 23 cardioembolism (CARD), 26 large artery atherosclerosis (LAA), 27 lacunar infarct (LAC), and 11 stroke of undetermined etiology (SUE). Validation was performed by using an independent cohort of 20 NCs and 85 IS patients including 28 CARD, 23 LAA, 18 LAC, and 16 SUE. In the pilot discovery gene array study, we found specific serum microRNA signatures between different ischemic stroke subtypes (CARD, LAA, LAC, and SUE). We further validated 6 microRNAs [miR-125b, miR-125a, let-7b, let-7e, miR-7-2-3p, miR-1908] in a different group of ischemic stroke subtypes by using an independent cohort of 20 NCs, 28 CARD, 23 LAA, 18 LAC, and 16 SUE. Moreover, these circulating miRNAs were further detected to be differentially expressed between pre- vs. post-stroke in different ischemic stroke subtypes. The ROC analysis showed that miR-125b, miR-125a, let-7b, and let-7e could discriminate CARD patients from normal controls and other subtypes. Furthermore, ROC curves shown that miR-7-2-3p and miR-1908 showed significant area-under-the-curve values in both LAA and LAC patients. In conclusion, these results demonstrated that circulating miRNAs in sera could be potentially novel risk factors that involve in the pathogenesis of ischemic stroke subtypes.

Genome-Wide Expression Profiles for Ischemic Stroke: A Meta-Analysis

BACKGROUND

Genome-wide expression studies (GWES), using microarray platforms, have allowed a deeper understanding of the molecular factors involved in the pathophysiology of ischemic stroke (IS), one of the main global causes of mortality and disability.

METHODS

In the current work, we carried out a meta-analysis of available GWES for IS. Bioinformatics and computational biology analyses were applied to identify enriched functional categories and convergence with other genomic datasets for IS.

RESULTS

Three primary datasets were included and in the meta-analyses for GWES and IS, 41 differentially expressed (DE) genes were identified using a random effects model. Thirteen of these genes were downregulated and 28 were upregulated. An analysis of functional categories found a significant enrichment for the Gene Ontology Term "Inflammatory Response" and for binding sites for the PAX2 transcription factor.

CONCLUSIONS

The list of DE genes identified in this meta-analysis of GWES for IS is useful for future genetic and molecular studies, which would allow the identification of novel mechanisms involved in the pathophysiology of IS. Several of the DE genes found in this meta-analysis have known functional roles related to mechanisms involved in the pathophysiology of IS. It is recognized the role of the inflammatory response in the pathophysiology of IS.

Regional differences in the temporal evolution of stroke: a population-based study of Brazil according to sex in individuals aged 15-49 years between 1997 and 2012

Objective

The present study analyzed the temporal trend of stroke mortality according to sex in individuals aged 15–49 years in the different regions of Brazil between 1997 and 2012.

Results

There was progressive reduction in mortality rate due to stroke in Brazil. The reduction trend was the same for both sexes, although mortality remained slightly higher among men. There was a difference in mortality rates according to the administrative region of the country.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3439-x) contains supplementary material, which is available to authorized users.