Clinical impact of body mass index on outcomes of ischemic and hemorrhagic strokes

BACKGROUND AND AIM

To investigate the prognostic implication of body mass index (BMI) on clinical outcomes after acute ischemic and hemorrhagic stroke.

METHODS

The subjects of the study included adult patients with available baseline body weight and height data who had suffered an acute stroke and were registered in the Japan Stroke Data Bank-a hospital-based, multicenter stroke registration database-between January 2006 and December 2020. The outcome measures included unfavorable outcomes defined as a modified Rankin Scale (mRS) score of 5-6 and favorable outcomes (mRS 0-2) at discharge, and in-hospital mortality. Mixed effects logistic regression analysis was conducted to determine the relationship between BMI categories (underweight, normal weight, overweight, class I obesity, class II obesity; <18.5, 18.5-23.0, 23.0-25.0, 25-30, ⩾30 kg/m2) and the outcomes, after adjustment for covariates.

RESULTS

A total of 56,230 patients were assigned to one of the following groups: ischemic stroke (IS, n = 43,668), intracerebral hemorrhage (ICH, n = 9741), and subarachnoid hemorrhage (SAH, n = 2821). In the IS group, being underweight was associated with an increased likelihood of unfavorable outcomes (odds ratio, 1.47 (95% confidence interval (CI):1.31-1.65)) and in-hospital mortality (1.55 (1.31-1.83)) compared to outcomes in those with normal weight. Being overweight was associated with an increased likelihood of favorable outcomes (1.09 (1.01-1.18)). Similar associations were observed between underweight and these outcomes in specific IS subtypes (cardioembolic stroke, large artery stroke, and small-vessel occlusion). Patients with a BMI ⩾30.0 kg/m2 was associated with an increased likelihood of unfavorable outcomes (1.44 (1.01-2.17)) and in-hospital mortality (2.42 (1.26-4.65)) in large artery stroke. In patients with ICH, but not those with SAH, being underweight was associated with an increased likelihood of unfavorable outcomes (1.41 (1.01-1.99)).

CONCLUSIONS

BMI substantially impacts functional outcomes following IS and ICH. Lower BMI consistently affected post-stroke disability and mortality, while higher BMI values similarly affected these outcomes after large artery stroke.

Lung cancer is associated with acute ongoing cerebral ischemia: A population-based study

BACKGROUND AND OBJECTIVES

Cerebral microinfarcts (CMIs) are the most common type of brain ischemia; however, they are extremely rare in the general population. CMIs can be detected by magnetic resonance diffusion-weighted imaging (MRI-DWI) only for a very short period of approximately 2 weeks after their formation and are associated with an increased stroke risk and cognitive impairment. We aimed to examine CMI detection rate in patients with lung cancer (LC), which is strongly associated with ischemic stroke risk relative to other cancer types.

METHODS

We used the Clalit Health Services record (representing more than 5 million patients) to identify adults with LC and breast, pancreatic, or colon cancer (non-lung cancer, NLC) who underwent brain magnetic resonance diffusion (MRI) scan within 5 years following cancer diagnosis. All brain MRI scans were reviewed, and CMIs were documented, as well as cardiovascular risk factors.

RESULTS

Our cohort contained a total of 2056 MRI scans of LC patients and 1598 of NLC patients. A total of 143 CMI were found in 73/2056 (3.5%) MRI scans of LC group compared to a total of 29 CMI in 22/1598 (1.4%) MRI scans of NLC (p < 0.01). Cancer type (e.g. LC vs NLC) was the only associated factor with CMI incidence on multivariate analysis. After calculating accumulated risk, we found an incidence of 2.5 CMI per year in LC patients and 0.5 in NLC.

DISCUSSION

CMIs are common findings in cancer patients, especially in LC patients and therefore might serve as a marker for occult brain ischemia, cognitive decline, and cancer-related stroke (CRS) risk.

Global, regional, and national burden of stroke attributable to extreme low temperatures, 1990-2019: A global analysis

BACKGROUND

Extreme ambient temperatures have been linked to increased risks of stroke morbidity and mortality. However, global estimates of the burden of stroke due to extreme low temperatures are not well-defined.

AIMS

This study aimed to determine the global burden of stroke due to extreme low temperatures and its spatiotemporal trend from 1990 to 2019.

METHODS

Based on the Global Burden of Disease Study 2019, we obtained global, regional, and national data on deaths, disability-adjusted life years (DALYs), age-standardized mortality rate (ASMR), and age-standardized rate of DALYs (ASDR) of stroke attributed to extreme low temperatures, further stratified by age, sex, and sociodemographic index (SDI).

RESULTS

Globally, in 2019, an estimated 474,000 stroke deaths with the corresponding ASMR (6.2 (95% uncertainty interval (UI): 4.6-7.9)) and ASDR (103.9 (95% UI: 77.0-134.5)) per 100,000 population, were attributable to extreme low temperatures. The most significant burden was observed in Central Asia, followed by Eastern Europe and East Asia. From 1990 to 2019, the global burden of stroke and its subtypes (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) attributable to extreme low temperatures exhibited a decrease in both ASMR and ASDR. Significant decreases in stroke burden occurred in the high-SDI regions, high-income Asia Pacific, and subarachnoid hemorrhage cases. Moreover, the ASMR and ASDR increased with age and were higher in males than females.

CONCLUSION

The global stroke burden due to extreme low temperatures remains high despite a decreasing trend over the past three decades. The stroke burden due to extreme low temperatures was more notable for Central Asia, older people, and the male sex.

The added effects of cold spells on stroke admissions: Differential effects on ischemic and hemorrhagic stroke

BACKGROUND

Epidemiological evidence suggests an association between low ambient temperature and stroke risk, but available data are limited particularly on associations with different stroke subtypes.

AIMS

The aim of this study is to estimate the relationship between cold spells and stroke admissions, including the effect of cold spells on different stroke subtypes (ischemic stroke and intracerebral hemorrhage (ICH)).

METHODS

A total of 144,405 stroke admissions from the Tianjin Centre for Health and Meteorology Multidisciplinary Innovation in China, covering the period from January 2016 to December 2020, were studied, as well as meteorological and air pollutant data. A generalized additive model with a distributed lag nonlinear model was employed to assess the relationship, considering 12 different definitions of a cold spell based on various temperature thresholds and durations. The analysis controlled for lagged and nonlinear effects of temperature. Analyses were performed on all strokes as well as ischemic stroke and ICH.

RESULTS

There was a significant increase in stroke admissions during cold spells. Generally, the increased risk during cold spells increased as the temperature threshold decreased, but was not significantly affected by the duration. The optimal model was obtained using the cold-spell definition based on an average daily temperature below the 10th percentile (0.11°C) for 2 or more consecutive days. According to this model, the effect of cold spells on ischemic stroke admissions had a significant lag effect and was long-lasting, with a single-day effect occurring on lag 7d, peaking on lag 13d (relative risk (RR) = 1.05; 95% confidence interval (CI) = 1.02 to 1.09), and lasting until lag 20d. In contrast, the effect on ICH was immediate and short-lived, with the most significant single-day effect occurring on the current day (RR = 1.17; 95% CI = 1.06 to 1.29) and limited within 3 days. 14.15% of stroke cases could be attributed to cold spells, with ICH exhibiting a higher burden than ischemic stroke except for strict temperature threshold definitions.

CONCLUSION

Cold spells are associated with an increased stroke risk. Different patterns of association were seen for different stroke subtypes. The effect on ischemic stroke had a lag effect and a longer duration, whereas the effect on ICH had an immediate effect and a shorter duration. These findings support the development and improvement of stroke cold-spell early warning systems and highlight the importance of public health interventions to mitigate the adverse health impacts of cold spells.

Outcome of COVID-19-Associated Acute Stroke: A Study from South India

Background and Objective

Coronavirus 2019 (COVID-19) infection is prevalent worldwide. COVID-19 infection can lead to various neurological disorders including acute stroke. We investigated the functional outcome and its determinants among our patients with acute stroke associated with COVID-19 infection in the present setup.

Materials and Methods

This study is a prospective study in which we recruited acute stroke patients with COVID-19 positivity. Data on duration of COVID-19 symptoms and type of acute stroke were recorded. All patients underwent stroke subtype workup and measurement of D-dimer, C-reactive protein (CRP), lactate-dehydrogenase (LDH), procalcitonin, interleukin-6, and ferritin levels. Poor functional outcome was defined by modified Rankin score (mRS) ≥3 at 90 days.

Results

During the study period, 610 patients were admitted for acute stroke, of whom 110 (18%) tested positive for COVID-19 infection. Majority (72.7%) were men with a mean age of 56.5 years and mean duration of COVID-19 symptoms for 6.9 days. Acute ischemic and hemorrhagic strokes were observed in 85.5% and 14.5% patients, respectively. Poor outcome was observed in 52.7%, including in-hospital mortality in 24.5% patients. COVID-19 symptoms ≤5 days (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 1.20-2.99), CRP positivity (OR: 1.97, 95% CI: 1.41-4.87), elevated levels of D-dimer (OR: 2.11, 95% CI: 1.51-5.61), interleukin-6 (OR: 1.92, 95% CI: 1.04-4.74), and serum ferritin (OR: 2.4, 95% CI: 1.02-6.07), and cycle threshold (Ct) value ≤25 (OR: 8.8, 95% CI: 6.52-12.21) were independent predictors of poor outcome.

Conclusion

Poor outcomes were relatively higher among acute stroke patients with concomitant COVID-19 infection. In the present study, we established the independent predictors of poor outcome to be onset of COVID-19 symptoms (<5 days) and elevated levels of CRP, D-dimer, interleukin-6, ferritin, and Ct value ≤25 in acute stroke.

Thrombectomy in basilar artery occlusion

BACKGROUND AND PURPOSE

The benefit of thrombectomy (TE) for acute ischemic stroke (AIS) in patients suffering basilar artery occlusion (BAO) is still unclear. Our aim was to analyze functional outcome after 3 months in BAO compared to anterior circulation large vessel occlusion (ACLVO) in a nationwide registry.

METHODS

Patients enrolled into the Austrian Endostroke Registry from 2013 to 2018 were analyzed. We used propensity score matching to control for imbalances and to compare patients with BAO and ACLVO. The primary outcome was favorable functional outcome after 3 months measured by the modified Rankin Scale (mRS) (0-2). Multivariate models were applied to estimate the effect of localization (BAO vs ACLVO).

RESULTS

In total, 2288 patients underwent TE for AIS with proximal vessel occlusion, of these 267 with BAO. Two hundred and sixty-four patients with BAO were matched to 264 patients with ACLVO. Baseline characteristics were well-balanced. The 90-day mortality did not significantly differ between patients with BAO and ACLVO. In a multivariate logistic regression model, we did not detect a significant difference in functional outcome between BAO and ACLVO (odds ratio for favorable outcome defined as mRS = 0-2: 1.19; 95% confidence interval (CI) = 0.78-1.81; p = 0.42). In patients with an onset-to-door-time ⩾270 min, TE of BAO was associated with poor functional outcome defined as mRS 3-6 (odds ratio (OR) = 3.97; 95% CI = 1.32-11.94; p = 0.01) as compared to ACLVO.

CONCLUSION

In this study, functional outcome did not differ after TE in patients with BAO and ACLVO overall; however, we detected an association of BAO with poor outcome in patients arriving late.

Relationship Between Lipoprotein (a) [Lp(a)] and Cognition in Different Ischemic Stroke Subtypes

Background and Purpose: Although elevated serum lipoprotein (a) [Lp(a)] is considered to be a risk factor of ischemic stroke, the relationship between Lp(a) and cognitive impairment after stroke remains unclear. This study investigated the association between serum Lp(a) and cognitive function after acute ischemic stroke (AIS) or transient ischemic attack (TIA). Methods: The study included 1,017 patients diagnosed with AIS or TIA from the cognition subgroup of the Third China National Stroke Registry (CNSR3). Montreal Cognitive Assessment (MoCA) at 2 weeks or discharge, 3 months, and 1 year was evaluated. The primary outcome was cognitive impairment at 1 year, defined as MoCA ≤ 22. The secondary outcome was cognition improvement at 1 year compared with 2 weeks. The association between Lp(a) levels and cognitive function was analyzed. Results: Among the 1,017 patients included, 326 (32.1%) had cognitive impairment at 1 year. Patients with MoCA ≤ 22 at 1 year were older, received less education, and had higher baseline NIHSS, higher proportion of ischemic stroke history, large artery atherosclerosis (LAA) subtype, and multiple infarctions (P < 0.05 for all). Patients with highest Lp(a) quartile had slightly higher percentage of cognitive impairment at 1 year but without statistical difference. In subgroup analysis of LAA subtype, the patients with highest Lp(a) quartile had higher percentage of cognitive impairment at 1 year (adjusted OR:2.63; 95% CI: 1.05-6.61, P < 0.05). What is more, the patients with highest Lp(a) quartile in LAA subtype had lower percentage of cognition improvement at 1 year. However, similar results were not found in small artery occlusion (SAO) subtype. Conclusion: Higher Lp(a) level was associated with cognitive impairment and less improvement of cognition in patients after AIS or TIA with large-artery atherosclerosis subtype.

Post-stroke fatigue is associated with resting state posterior hypoactivity and prefrontal hyperactivity

BACKGROUND

Fatigue is associated with poor functional outcomes and increased mortality following stroke. Survivors identify fatigue as one of their key unmet needs. Despite the growing body of research into post-stroke fatigue, the specific neural mechanisms remain largely unknown.

AIM

This observational study aimed to identify resting state brain activity markers of post-stroke fatigue.

METHOD

Sixty-three stroke survivors (22 women; age 30-89 years; mean 67.5 ± 13.4 years) from the Cognition And Neocortical Volume After Stroke study, a cohort study examining cognition, mood, and brain volume in stroke survivors following ischemic stroke, underwent brain imaging three months post-stroke, including a 7-minute resting state functional magnetic resonance imaging. We calculated the fractional amplitude of low-frequency fluctuations, which is measured at the whole-brain level and can detect altered spontaneous neural activity of specific regions.

RESULTS

Forty-five participants reported experiencing post-stroke fatigue as measured by an item on the Patient Health Questionnaire-9. Fatigued compared to non-fatigued participants demonstrated significantly lower resting-state activity in the calcarine cortex (p < 0.001, cluster-corrected pFDR = 0.009, k = 63) and lingual gyrus (p < 0.001, cluster-corrected pFDR = 0.025, k = 42) and significantly higher activity in the medial prefrontal cortex (p < 0.001, cluster-corrected pFDR = 0.03, k = 45).

CONCLUSIONS

Post-stroke fatigue is associated with posterior hypoactivity and prefrontal hyperactivity reflecting dysfunction within large-scale brain systems such as fronto-striatal-thalamic and frontal-occipital networks. These systems in turn might reflect a relationship between post-stroke fatigue and abnormalities in executive and visual functioning. This whole-brain resting-state study provides new targets for further investigation of post-stroke fatigue beyond the lesion approach.

Types of Stroke Among People Living With HIV in the United States

BACKGROUND

Most studies of stroke in people living with HIV (PLWH) do not use verified stroke diagnoses, are small, and/or do not differentiate stroke types and subtypes.

SETTING

CNICS, a U.S. multisite clinical cohort of PLWH in care.

METHODS

We implemented a centralized adjudication stroke protocol to identify stroke type, subtype, and precipitating conditions identified as direct causes including infection and illicit drug use in a large diverse HIV cohort.

RESULTS

Among 26,514 PLWH, there were 401 strokes, 75% of which were ischemic. Precipitating factors such as sepsis or same-day cocaine use were identified in 40% of ischemic strokes. Those with precipitating factors were younger, had more severe HIV disease, and fewer traditional stroke risk factors such as diabetes and hypertension. Ischemic stroke subtypes included cardioembolic (20%), large vessel atherosclerosis (13%), and small vessel (24%) ischemic strokes. Individuals with small vessel strokes were older, were more likely to have a higher current CD4 cell count than those with cardioembolic strokes and had the highest mean blood pressure of the ischemic stroke subtypes.

CONCLUSION

Ischemic stroke, particularly small vessel and cardioembolic subtypes, were the most common strokes among PLWH. Traditional and HIV-related risk factors differed by stroke type/subtype. Precipitating factors including infections and drug use were common. These results suggest that there may be different biological phenomena occurring among PLWH and that understanding HIV-related and traditional risk factors and in particular precipitating factors for each type/subtype may be key to understanding, and therefore preventing, strokes among PLWH.

Effect of genetic liability to visceral adiposity on stroke and its subtypes: A Mendelian randomization study

BACKGROUND

Observational studies have found an association between visceral adiposity and stroke.

AIMS

The purpose of this study was to investigate the role and genetic effect of visceral adipose tissue accumulation on stroke and its subtypes.

METHODS

In this two-sample Mendelian randomization study, genetic variants (221 single nucleotide polymorphisms; P < 5 × 10^-8) using as instrumental variables for Mendelian randomization analysis was obtained from a genome-wide association study of visceral adipose tissue. The outcome datasets for stroke and its subtypes were obtained from the MEGASTROKE consortium (up to 67,162 cases and 453,702 controls). Mendelian randomization standard analysis (inverse variance weighted method) was conducted to investigate the effect of genetic liability to visceral adiposity on stroke and its subtypes. Sensitivity analyses (Mendelian randomization-Egger, weighted median, Mendelian randomization-pleiotropy residual sum and outlier) were also utilized to assess horizontal pleiotropy and remove outliers. Multi-variable Mendelian randomization analysis was employed to adjust potential confounders.

RESULTS

In the standard Mendelian randomization analysis, genetically determined visceral adiposity (per 1 SD) was significantly associated with a higher risk of stroke (odds ratio (OR) 1.30; 95% confidence interval (CI) 1.21-1.41, P = 1.48× 10^-11), ischemic stroke (OR 1.30; 95% CI 1.20-1.41, P = 4.01 × 10^-10) and large artery stroke (OR 1.49; 95% CI 1.22-1.83, P = 1.16 × 10^-4). The significant association was also found in sensitivity analysis and multi-variable Mendelian randomization analysis.

CONCLUSIONS

Genetic liability to visceral adiposity was significantly associated with an increased risk of stroke, ischemic stroke, and large artery stroke. The effect of genetic susceptibility to visceral adiposity on the stroke warrants further investigation.

Sex- related differences in the factors associated with outcomes among patients with strokes of undetermined source: a hospital-based follow-up study

Objective: Sex-related differences are well established among stroke patients, including the incidence and prevalence of stroke being higher among men than among women. However, the sex-related factors for differences in the outcomes of strokes of undetermined source (SUSs) have not been well described, especially in the Chinese population. We assessed the sex-related differences in the factors associated with outcomes among patients with SUSs in China.Method: Between January 2011 and December 2018, we recruited 205 patients diagnosed with SUSs from Kailuan General Hospital (China). The clinical features, risk factors, and outcome data were collected for the patients at 3 and 12 months after their strokes.Results: There were higher frequencies of hyperlipidemia (27.8% vs. 26.4%), smoking (41.4% vs. 5.6%), and alcohol consumption (21.8% vs. 0%) for male patients than for female patients. However, women were more likely than men to have hypertension (63.9% vs. 46.6%), diabetes (27.8% vs. 20.3%), and atrial fibrillation (9.7% vs. 5.3%); they were also more likely to be obese (16.7% vs. 12.0%). There were no significant differences in outcome between the sexes. Among men, severe strokes were associated with higher case fatality and disability risks at 12 months after stroke onset; hyperlipidemia was a risk factor for recurrence within 3 months of the initial stroke. Among women, severe strokes also increased the risk of disability; in women, high total cholesterol (TC) and age were associated with poor outcomes.Conclusion: The factors associated with outcomes in SUS differed by sex. For male patients, more severe stroke and hyperlipidemia were associated with poor outcomes in SUS. Risk factors for poor outcomes in female patients were stroke severity, age, and TC level. These findings suggest that taking measures to manage blood lipid levels and severe stroke among patients with SUS is important for both male and female patients and is crucial for reducing the burden of stroke in China.

CIMT as a risk factor for stroke subtype: A systematic review

INTRODUCTION

An increase in the common carotid artery intima-media thickness (CCA-IMT) is generally considered an early marker of atherosclerosis and is a well-established predictor of cardiovascular disease (CVD). An association between changes in CCA-IMT and risk of stroke has been reported but has conflicting findings.

OBJECTIVE

The present meta-analysis was aimed to clarify the association between CCA-IMT with the risk of stroke and its subtype by estimating pooled analysis of published literature.

METHODS

Comprehensive search for all published articles was performed in electronic databases including PubMed, Embase, Cochrane Library, Trip Databases, Worldwide Science, CINAHL and Google Scholar from 01 January 1950 to 30 April 2020.

RESULTS

In our meta-analysis, a total of 19 studies, of which sixteen studies involving 3475 ischaemic stroke (IS) cases and 11 826 controls; six studies with 902 large vessel disease (LVD) and 548 small vessel disease (SVD) of IS subtypes; five studies with 228 intracerebral haemorrhage (ICH) and 1032 IS cases, were included. Our findings suggest a strong association between increased CCA-IMT with risk of IS as compared to control subjects [SMD = 1.46, 95% CI = 0.90-2.02]. However, there is an increased risk of LVD as compared to the SVD subtype of IS [SMD = 0.36, 95% CI = 0.19-0.52] and more chance of occurrence of IS rather than ICH [SMD = 0.71, 95% CI = 0.28-1.41].

CONCLUSIONS

Carotid intima thickness measurements are found to be associated with the risk of stroke along with its subtypes and may be used as a diagnostic marker for predicting the risk of stroke events.

Prestroke statin use enhances collateralization in acute ischemic stroke patients

BACKGROUND

Statin therapy has been shown to be effective in the prevention of ischemic stroke. In addition, recent studies have suggested that prior statin therapy could lower the initial stroke severity and improve stroke functional outcomes in the event of stroke. It was speculated that prestroke statin use may enhance collateral circulation and result in favorable functional outcomes.

OBJECTIVE

The aim of the study was to investigate the association of prestroke statin use with leptomeningeal collaterals and to determine the association of prestroke statin use with stroke severity and functional outcome in acute ischemic stroke patients.

METHODS

We prospectively and consecutively enrolled 239 acute ischemic stroke patients with acute infarction due to occlusion of the middle cerebral artery within 24 h in the neurology department of West China Hospital from May 2011 to April 2017. Computed tomographic angiography (CTA) imaging was performed for all patients to detect middle cerebral artery thrombus; regional leptomeningeal collateral score (rLMCS) was used to assess the degree of collateral circulation; the National Institutes of Health Stroke Scale (NIHSS) was used to measure stroke severity at admission; the modified Rankin scale (mRS) was used to measure outcome at 90 days; and premorbid medications were recorded. Univariate and multivariate analyses were performed.

RESULTS

Overall, 239 patients met the inclusion criteria. Fifty-four patients used statins, and 185 did not use statins before stroke onset. Prestroke statin use was independently associated with good collateral circulation (rLMCS > 10) (odds ratio [OR], 4.786; 95% confidence interval [CI], 1.195-19.171; P = 0.027). Prestroke statin use was not independently associated with lower stroke severity (NIHSS score≤14) (OR, 1.955; 95% CI, 0.657-5.816; p = 0.228), but prestroke statin use was independently associated with favorable outcome (mRS score≤2) (OR, 3.868; 95% CI, 1.325-11.289; P = 0.013).

CONCLUSIONS

Our findings suggest that prestroke statin use was associated with good leptomeningeal collaterals and clinical outcomes in acute ischemic stroke (AIS) patients presenting with occlusion of the middle cerebral artery. However, clinical studies should be conducted to verify this claim.

Differential Distribution of Cerebral Microbleeds in Subtypes of Acute Ischemic Minor Stroke and TIA as well as its Association with Vascular Risk Factors

BACKGROUND

Cerebral microbleed (CMB) is a novel neuroimaging marker of cerebral small vessel disease.

OBJECTIVE

To determine the prevalence of CMB in the subtypes of acute ischemic minor stroke (AIS) and transient ischemic attack (TIA) and to identify the risk factors associated with location and number of CMB.

MATERIALS AND METHODS

Patients with AIS (National Institute of Health Stroke Scale of 5 or less) or TIA were included. CMB was characterized using the Microbleed Anatomical Rating Scale (MARS).

RESULTS

Of the 488 subjects [mean age (standard deviation): 57.5 years (14.4 years), males (77.7%)] recruited, CMB was noted in 140 (28.7%). About 35% with CMB had a lacunar stroke etiology, whereas LAA and CE subtype constituted 33.6 and 10.7%, respectively (P = 0.000). Lacunar subtype was more likely to harbor multiple CMB (four or more) and CMB in all locations (lobar, deep or infratentorial). On multivariate analysis, systemic hypertension [P = 0.025; odds ratio (OR) 0.33 (95% confidence interval (CI) 0.129-0.874)], serum triglyceride (TG) levels below 150 mg/dL [P = 0.001; OR 3.70 (95% CI 1.698-8.072)], and presence of white matter hyperintensities on magnetic resonance imaging brain [P = 0.026; OR 2.18 (95% CI 1.096-4.337)] were associated with the presence of CMB. Those with serum TG levels of less than 150 mg/dL were more likely to harbor lobar (P = 0.002) or infratentorial CMB (P = 0.022), whereas those with serum creatinine levels of more than1.5 mg/dL have lobar CMB (P = 0.033).

CONCLUSION

Our study showed a differential distribution of CMB in ischemic stroke subtypes and association of risk factors with the presence, number and location of CMB.

Apolipoproteins B and A1 in Ischemic Stroke Subtypes

INTRODUCTION

Elevated serum apolipoprotein B and the apolipoprotein B/A1 ratio have been associated with ischemic stroke and intracranial atherosclerotic disease. We sought to assess the relationship between serum levels of apolipoprotein B, apolipoprotein A1, and the apolipoprotein B/A1 ratio with ischemic stroke subtypes and large artery atherosclerosis location.

MATERIALS AND METHODS

We evaluated serum apolipoprotein B and apolipoprotein A1 levels in consecutive, statin-naïve, adult ischemic stroke patients admitted to an academic medical center in southern India. We evaluated for differences in the mean serum levels of apolipoprotein B, apolipoprotein A1, and the apolipoprotein B/A1 ratio between patients with ischemic stroke attributed to intracranial atherosclerotic disease, extracranial atherosclerotic disease, small vessel disease, and cardioembolism. In secondary analysis, we assessed for differences in these serum apolipoproteins between patients with moderate-severe intracranial atherosclerotic disease and extracranial atherosclerotic disease, irrespective of ischemic stroke subtype.

RESULTS

Among the 156 ischemic stroke patients enrolled in this study, there were no significant differences in serum levels of apolipoprotein B, apolipoprotein A1, and the apolipoprotein B/A1 ratio between patients with distinct ischemic stroke subtypes. No significant differences were found in serum levels of apolipoprotein B, A1 and the apolipoprotein B/A1 ratio between patients with moderate-severe intracranial atherosclerotic disease and moderate-severe extracranial atherosclerotic disease.

DISCUSSION

Serum levels of apolipoprotein B and A1 did not differ between ischemic stroke subtypes. Additional studies are needed to validate our findings and to better understand the relationship between serum apolipoproteins and stroke.

Risk factors for ischemic stroke and stroke subtypes in patients with chronic kidney disease

BACKGROUND AND PURPOSE

The aim of this study was to compare ischemic stroke subtypes with the effects of risk factors, the relationship between grades of kidney disease and the severity of stroke subtypes.

METHODS

The current study was designed retrospectively and performed with data of patients who were hospitalised due to ischemic stroke. We included 198 subjects who were diagnosed with ischemic stroke of Grade 3 and above with chronic kidney disease.

RESULTS

In our study were reported advanced age, coronary artery disease, moderate kidney disease as the most frequent risk factors for cardioembolic etiology. Hypertension, hyperlipidemia, smoking and alcohol consumption were the most frequent risk factors for large-artery disease. Female sex and anaemia were the most frequent risk factors for small-vessel disease. Dialysis and severe kidney disease were the most frequent risk factors in unknown etiologies, while male sex, diabetes mellitus, prior stroke and mild kidney disease were the most frequent risk factors for other etiologies. National Institute of Health Stroke Scale (NIHSS) scores were lower for small-vessel disease compared with other etiologies. This relation was statistically significant (p=0.002).

CONCLUSION

In order to improve the prognosis in ischemic stroke with chronic kidney disease, the risk factors have to be recognised and the treatment options must be modified according to those risk factors.

Relevance of Carotid Intima-Media Thickness and Plaque Morphology in the Risk Assessment of Patients with Acute Ischemic Cerebral Infarcts: A Case-Control Study of Large Series from a Single Center

Background:

Carotid atherosclerosis is not only a marker of systemic atherosclerosis but also a predictor of ischemic stroke. The purpose of this study is to correlate the relationship between atherosclerotic risk factors, plaque categories, percentage of stenosis, stroke subtypes, and carotid intima-media thickness (CIMT) in patients with acute ischemic stroke.

Methods:

This case–control study was conducted over 4 years from December 2014 to December 2018. A total of 500 cases diagnosed with acute cerebral infarct using computed tomography or magnetic resonance imaging were included in the study. Two hundred and fifty healthy controls were studied for the presence of atherosclerotic risk factors and carotid artery IMT by B-mode Doppler ultrasonography. The IMT value thus calculated was 0.79 mm and such a value would include >95% of the controls. Carotid plaques were detected from both sides of IMT measurement of the carotid system.

Results:

A total of 500 cases of acute infarct and 250 healthy controls were included in this case–control study. CIMT was abnormal in 348 cases with 192 males and 156 females with a mean value of 0.912 ± 0.124 against 0.794 ± 0.132; P < 0.001 controls. Mean CIMT (averaged right and left) varied directly according to the increasing plaque stenosis ranging from 0.70 mm to 0.96 mm in males and 0.68 mm to 0.94 mm in females ranging from no plaque to cases with ≥50% stenosis (P < 0.001 across stenosis categories). On multivariate analysis, CIMT (>0.79) remained associated as compared to other variables (PR [Probability] 5.33, 95% confidence interval: 1.398–22.784; P = 0.012). Mean right CIMT of patients with lacunar infarction, cardioembolism, and large artery stroke was 0.886 ± 0.230, 0.919 ± 0.171, and 0.938 ± 0.169 mm, respectively (P = 0.032). Mean left CIMT of patients with lacunar infarction, cardioembolism, and large artery stroke was 0.884 ± 0.195, 0.916 ± 0.144, and 0.930 ± 0.137 mm, respectively (P = 0.034).

Conclusion:

CIMT measurements are independent markers of acute ischemic cerebral infarcts. In the current study, CIMT was found to be higher among acute ischemic stroke patients who were the elderly, smoker, hypertensive, diabetic, and hypercholesterolemic than that of nonsmoker, normotensive, nondiabetic, and normocholesterolemic controls.

Total Antioxidant Capacity Predicts Outcome in Acute Ischemic Stroke Subtypes in Egyptian Patients

BACKGROUND

Oxidative stress after ischemic stroke contributes to neuronal cell injury. We tried to demonstrate an association between total antioxidant capacity (TAC) levels and outcomes after acute ischemic stroke (AIS).

METHODS

We enrolled 60 patients (36 females and 24 males) who were admitted to our hospital due to AIS, in addition to 30 age and sex-matched healthy controls. TAC levels were measured on day 1 of stroke onset, the relationships between TAC levels, stroke subtypes, and clinical outcomes based on the National Institutes of Health Stroke Scale and modified Rankin scale upon discharge were evaluated.

RESULTS

TAC levels were significantly lower in AIS patients than control (P < .001) being much lower in patients with large-vessel cerebral infarction than in those with small-vessel infarction. We investigated whether TAC concentrations reflected the severity and outcome of ischemic stroke and we found a significantly lower concentration of TAC in the poor outcome group than in the good outcome group (P < .001).

CONCLUSIONS

Our findings suggested that the biochemical changes related to TAC and oxidative stress may be considered a marker of ischemic brain injury and clinical outcome of ischemic stroke.

Outcome after intravenous thrombolysis in patients with acute lacunar stroke: An observational study based on SITS international registry and a meta-analysis

BACKGROUND

Intravenous thrombolysis (IVT) for lacunar stroke (LS) is debated, as the underlying pathophysiological mechanism may not be thrombogenic.

AIMS

To investigate outcomes after IVT in LS in the SITS International Stroke Thrombolysis Register and perform a meta-analysis.

METHODS

LS was identified by both baseline NIHSS-subscores and discharge ICD-10 codes, and contrasted by IVT to non-IVT treated. IVT patients were predominantly from Europe, non-IVT patients predominantly from South America and Asia. Outcome measurements were functional independence (modified Rankin Scale [mRS] score ≤2), excellent outcome (mRS ≤ 1), and mortality at three months. Matched-control comparisons of symptomatic intracerebral hemorrhage (SICH) between IVT-treated LS and IVT-treated non-LS patients were performed. Additionally, we performed a meta-analysis.

RESULTS

Median age for IVT-treated LS patients (n = 4610) was 66 years vs. 64 years and NIHSS score was 6 vs. 3, compared to non-IVT-treated LS (n = 1221). Univariate outcomes did not differ; however, IVT-treated LS patients had higher adjusted odds ratios (aOR) for functional independence (aOR = 1.65, 95% CI = 1.28-2.13) but similar mortality at three months (aOR = 0.57, 0.29-1.13) than non-IVT-LS. Propensity-score matched analysis showed that IVT-treated LS patients had a 7.1% higher chance of functional independency than non-IVT LS patients (p < 0.001). IVT-treated LS patients had lower odds for SICH (aOR = 0.33, 0.19-0.58 per SITS, aOR = 0.40, 0.27-0.57 per ECASS-2) than matched non-LS controls, which was mirrored in the meta-analysis.

CONCLUSIONS

Our adjusted results show that IVT treatment in LS patients was associated with better functional outcome than non-IVT-treated LS and less SICH than IVT-treated non-LS patients.

Stroke in the Middle-East and North Africa: A 2-year prospective observational study of stroke characteristics in the region-Results from the Safe Implementation of Treatments in Stroke (SITS)-Middle-East and North African (MENA)

BACKGROUND AND METHODS

Stroke incidence and mortality are reported to have increased in the Middle-East and North African (MENA) countries during the last decade. This was a prospective observational study to examine the baseline characteristics of stroke patients in the MENA region and to compare the MENA vs. the non-MENA stroke cohort in the Safe Implementation of Treatments in Stroke (SITS) International Registry.

RESULTS

Of the 13,822 patients with ischemic and hemorrhagic stroke enrolled in the SITS-All Patients Protocol between June 2014 and May 2016, 5897 patients (43%) were recruited in MENA. The median onset-to-door time was 5 h (IQR: 2:20-13:00), National Institutes of Health Stroke Scale (NIHSS) score was 8 (4-13) and age was 65 years (56-76). Hypertension (66%) and diabetes (38%) were the prevailing risk factors; large artery stenosis > 50% (25.3%) and lacunar strokes (24.1%) were the most common ischemic stroke etiologies. In comparison, non-MENA countries displayed an onset-to-door time of 5:50 h (2:00-18:45), a median of NIHSS 6 (3-14), and a median age of 66 (56-76), with other large vessel disease and cardiac embolism as the main ischemic stroke etiologies. Hemorrhagic strokes (10%) were less common compared to non-MENA countries (13.9%). In MENA, only a low proportion of patients (21%) was admitted to stroke units.

CONCLUSIONS

MENA patients are slightly younger, have a higher prevalence of diabetes and slightly more severe ischemic strokes, commonly of atherosclerotic or microvascular etiology. Admission into stroke units and long-term follow-up need to be improved. It is suspected that cardiac embolism and atrial fibrillation are currently underdiagnosed in MENA countries.

Association Between Net Vertebral Artery Flow Volume and Non-AF Stroke: A Retrospective 2-Year Analysis

Objectives: Association between net vertebral artery flow volume (NVAFV) and stroke types remains unclear. We hypothesize NVAFV is low in patients with posterior circulation infarction (PCI) and an ideal cut-off value for discriminating PCI from anterior circulation infarction (ACI) and controls may be present.

Materials and Methods: As study candidates, we retrospectively enrolled hospitalized patients with first-time non-AF stroke within 2-years period. Consecutive non-AF, non-stroke subjects were enrolled as the control group. We compared NVAFV values among the PCI, ACI, and control groups.

Results: Overall, 866 candidates—213, 418, and 235 candidates in the PCI, ACI, and control groups, respectively—were enrolled. NVAFV (mean ± SD) values were 134.8 ± 52.7, 152.3 ± 59.2, and 172.0 ± 54.7 mL/min in the PCI, ACI, and control groups, respectively. Statistics revealed significant difference (p < 0.001) among three groups. To use NVAFV as a diagnostic parameter, the AUC of any two groups should be between 0.58 and 0.69. Most (93.6%) of the controls had NVAFV above 100 mL/min. The odds ratio of any non-AF stroke is 3.48 if the NVAFV is below 100 mL/min.

Conclusions: NVAFV is lowest in non-AF PCI group. Low NVAFV is associated with both non-AF ACI and PCI. No ideal cut-off value is available to discriminate PCI from other two conditions. We agree that an NVAFV of 100 mL/min is the lower limit of a normal value. Any value below 100 mL/min indicates high stroke risk and implies diffuse cerebral atherosclerosis and impaired cerebral perfusion.

Anticoagulation in patients with Embolic Stroke of Unknown Source

When warfarin was the mainstay of anticoagulation for the prevention of cardioembolic stroke, the paradigm was essentially "we mustn't anticoagulate anyone unless we prove that the stroke was cardioembolic." Now that direct-acting oral anticoagulants are available, the paradigm should change. The risk of stroke is highest soon after the initial event, particularly in patients with more than one infarction. Direct-acting oral anticoagulants are not significantly more likely than aspirin to cause severe hemorrhage, and it is now clear that patients with paradoxical embolism are better treated with anticoagulant than aspirin. Percutaneous closure of a patent foramen ovale is better than aspirin, but not better than anticoagulant, and some patients with paradoxical embolism may be better treated with anticoagulant than with percutaneous closure, which cannot prevent pulmonary embolism. Patients in whom cardioembolic stroke is strongly suspected should probably be anticoagulated pending the results of investigations such as echocardiography and prolonged cardiac monitoring for atrial fibrillation, and some of them, in whom the suspicion of a cardioembolic source is very strong, should probably be anticoagulated long term, even if such investigations do not confirm a cardiac source.

Intracranial Atherosclerosis is the Most Common Stroke Subtype: Ten-year Data from Hyderabad Stroke Registry (India)

Aim:

Limited data regarding stroke subtypes exist from South Asian countries. The aim of the study was to determine the pattern of ischemic stroke subtypes and their associated risk factors, in a 10-year long hospital-based registry in the South Indian city of Hyderabad.

Materials and Methods:

The Hyderabad stroke registry systematically collected clinical, radiological, and laboratory data of fully investigated consecutive stroke patients and studied pattern of ischemic stroke subtypes and their risk factor association.

Results:

The cohort comprised of 2642 patients: 2072 (78.4%) were ischemic and 570 (21.6%) were hemorrhagic strokes. In the ischemic stroke cohort, the mean age was 54.1 years and 1622 (78.3%) were men. The most common ischemic stroke subtype was large artery atherosclerosis (LAA) comprising 37.6% (n = 779), followed by small vessel occlusion comprising 19.9% (n = 413) and cardioembolism 11% (n = 228). Stroke of other determined etiologies constituted 4.2% (n = 86) and stroke of undetermined etiology was observed in 27.3%. Among patients with LAA, 610 (78.3%) patients had intracranial and 169 (21.7%) had extracranial disease as the underlying mechanism. Risk factor profile demonstrated that hyperlipidemia was significantly associated with LAA and ischemic heart disease with cardioembolic strokes.

Conclusions:

The study reveals a distinct pattern of ischemic stroke subtypes in the Indian context that has overlapping features of registries from West and East Asian countries. Both large artery and small vessel diseases are substantially represented with a predominance of intracranial atherosclerosis. The study results have significant implications for developing preventive and management strategies for stroke care and research in India.

Risk of Stroke After Colorectal Surgery for Cancerous Versus Benign Conditions

BACKGROUND

Cancer treatment, specifically surgical intervention, as a possible stroke trigger is understudied.

METHODS

Using the Nationwide Readmissions Database and validated diagnosis and procedure codes, we identified adults with index admissions for colorectal surgery for colorectal adenocarcinoma (Group A) and compared them to admissions for colorectal surgery for benign conditions (Group B) and hepatobiliary or pancreatic surgery for benign conditions (Group C). Within the colorectal cancer cohort, we further identified patients who underwent open versus laparoscopic surgery. The primary outcome was readmission for ischemic or hemorrhagic stroke up to 1 year. Cumulative risk of ischemic stroke was calculated using risk survival statistics, and hazard ratios (HR) were calculated using adjusted Cox regression.

RESULTS

Patients in Group A had higher 3-month readmission rates for ischemic and hemorrhagic strokes than those in Groups B and C. Higher risk of ischemic stroke (HR 1.46, 95% confidence interval [CI] 1.20-1.79) in Group A compared to Group B was eliminated following adjustments for illness severity and vascular risk factors. Comparing types of colorectal surgical intervention for cancer, there was significantly greater risk of ischemic stroke with open versus laparoscopic surgery, despite adjusting for vascular risk factors (HR 1.70, 95% CI 1.15-2.52).

CONCLUSIONS

We found elevated risk of ischemic stroke up to 1 year following open surgery for colorectal adenocarcinoma compared to laparoscopic. More research is necessary to clarify the underlying surgery-related mechanisms that contribute to elevated risk.

Risk Factors, Clinical Features and Prognosis for Subtypes of Ischemic Stroke in a Chinese Population

It is unanimously accepted that stroke is a highly heterogeneous disorder. Different subtypes of ischemic stroke may have different risk factors, clinical features, and prognoses. The aim of this study was to evaluate the risk factors, clinical characteristics, and prognoses of different subtypes of ischemic stroke defined by the Trial of ORG10172 in Acute Stroke Treatment (TOAST) criteria. We prospectively analyzed the data from 530 consecutive patients who were admitted to our hospital with acute ischemic stroke within 7 days of stroke onset during the study period. Standardized data assessment was used and the cause of ischemic stroke was classified according to the TOAST criteria. Patients were followed up till 30 and 90 days after stroke onset. It was found that large-artery atherosclerosis was the most frequent etiology of stroke (37.4%), and showed the highest male preponderance, the highest prevalence of previous transient ischemic attack, and the longest hospital stay among all subtypes. Small artery disease (36.4%) was associated with higher body mass index, higher plasma triglycerides, and lower plasma high-density lipoprotein cholesterol than cardioembolism. Cardioembolism (7.7%), which was particularly common in the elderly (i.e., individuals aged 65 years and older), showed the highest female preponderance, the highest prevalence of atrial fibrillation, the earliest presentation to hospital after stroke onset, the most severe symptoms on admission, the maximum complications associated with an adverse outcome, and the highest rate of stroke recurrence and mortality. Our results suggest that ischemic stroke should be regarded as a highly heterogeneous disorder. Studies involving risk factors, clinical features, and prognoses of ischemic stroke should differentiate between etiologic stroke subtypes.

Severe Blood-Brain Barrier Disruption in Cardioembolic Stroke

Background

Previous studies demonstrated that cardioembolism (CE) was prone to develop hemorrhagic transformation (HT), whereas hyper-permeability of blood–brain barrier (BBB) might be one reason for the development of HT. We, thus, aimed to investigate whether the BBB permeability (BBBP) was higher in CE stroke than other stroke subtypes in acute ischemic stroke (AIS) patients.

Methods

This study was a retrospective review of prospectively collected clinical and imaging database of AIS patients who underwent CT perfusion. Hypoperfusion was defined as Tmax >6 s. The average relative permeability-surface area product (rPS), reflecting the BBBP, was calculated within the hypoperfusion region (rPS_hypo). CE was diagnosed according to the international Trial of Org 10172 in Acute Stroke Treatment criteria. Receiver operating characteristics (ROC) curve analysis was used to determine predictive value of rPS_hypo for CE. Logistic regression was used to identify independent predictors for CE.

Results

A total of 187 patients were included in the final analysis [median age, 73 (61–80) years; 75 (40.1%) females; median baseline National Institutes of Health Stroke Scale score, 12 (7–16)]. Median rPS_hypo was 65.5 (35.8–110.1)%. Ninety-seven (51.9%) patients were diagnosed as CE. ROC analysis revealed that the optimal rPS_hypo threshold for CE was 86.71%. The value of rPS_hypo and the rate of rPS_hypo>86.71% were significantly higher in patients with CE than other stroke subtypes (p < 0.05), after adjusting for the potential confounds.

Conclusion

The extent of BBB disruption is more severe in CE stroke than other stroke subtypes during the hyperacute stage.

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

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

Sex differences in cerebral venous thrombosis: A systematic analysis of a shift over time

BACKGROUND

In contemporary studies, cerebral venous thrombosis is three times more common in adult women than in men.

AIM

To study the change in sex ratio over time in cerebral venous thrombosis.

SUMMARY OF REVIEW

We systematically reviewed the literature. Any type of study with at least 40 patients with cerebral venous thrombosis that reported sex ratio was eligible. We ranked studies according to the year halfway the period of patient recruitment. Pediatric studies were analyzed separately. Out of 6068 publications identified by our search, 112 studies (23,638 patients), published between 1966 and 2014, were included. The proportion of women among patients with cerebral venous thrombosis significantly increased over time from a median of 54.8% in studies prior to 1981 to 69.8% after 2001 (p = 0.002). There was a significant correlation between time of the study and proportion of women (Pearson's correlation coefficient 0.25, p = 0.01). Oral contraceptive use among women with cerebral venous thrombosis also increased over time (Pearson's correlation coefficient 0.29, p = 0.01). In contrast, the percentage of pregnancy-related cases remained stable (Pearson's correlation coefficient 0.04, p = 0.77). Among 1702 patients from pediatric studies, 39% were female and there was no correlation between sex ratio and time of the study (Pearson's correlation coefficient -0.42, p = 0.14).

CONCLUSIONS

In adult patients with cerebral venous thrombosis, there is a shift in sex ratio over time with an increase in the proportion of women, whereas this is not observed in pediatric populations. A possible explanation for this phenomenon is an increase over time in the use of oral contraceptives by adult women.

IRMA study: Prevalence of subdiaphragmatic visceral infarction in ischemic stroke and atrial fibrillation

Background Occult atrial fibrillation (AF) may, in part, explain cryptogenic stroke. A 22% prevalence of subdiaphragmatic visceral infarction (SDVI) among patients with ischemic stroke (IS) due to AF has been reported, using abdominal MRI. We sought to assess the reproducibility of this method and to confirm that SDVI is more prevalent in cases of AF-caused IS than in IS of other etiologies. Methods In consecutive patients admitted to our hospital, we compared SDVI prevalence in three groups: patients with IS due to AF (IS+/AF+ group), patients with stroke of another determined cause (IS+/AF- group) and patients with AF without stroke (IS-/AF+ group). Results A total of 111 patients were included. The median time between inclusion and abdominal MRI was six days. SDVI was more frequent in the IS+/AF+ group ( n = 10; 21.3%), than in IS+/AF- ( n = 1; 3.3%) and IS-/AF+ ( n = 0) groups, p = 0.002. The most frequent localization was the kidney. Conclusions The prevalence of SDVI was higher among patients with AF-caused IS. In cases of cryptogenic stroke, a positive abdominal MRI may suggest occult AF as the cause and identify a high risk of AF in this subgroup of patients.

Liver Function Indicators Performed Better to Eliminate Cardioembolic Stroke than to Identify It from Stroke Subtypes

BACKGROUND

Identifying the etiology of ischemic stroke is essential to acute management and secondary prevention. The value of liver function indicators in differentiating stroke subtypes remains to be evaluated.

METHODS

A total of 1333 acute ischemic stroke patients were included. Liver function indicators collected within 24 hours from stroke onset, including alanine aminotransferase, aspartate aminotransferase (AST), alkaline phosphatase, gamma-glutamyl transpeptidase (GGT), and bilirubin (BILI), were collapsed into quartiles (Q) and also dichotomized by Q1. Multivariate regression analysis was conducted to identify the independent association between liver function indicators and cardioembolic stroke (SCE). Area under the curve (AUC) of receiver operating characteristic analysis was conducted, and sensitivity (Sen), specificity (Spe), positive prospective value (PPV), and negative prospective value (NPV) were determined to evaluate the predictive value of liver function indicators for SCE.

RESULTS

AST, GGT, and BILI were associated with SCE. After adjustment, only AST was related to SCE independently. The incidence of SCE in the Q1 of AST, GGT, and BILI, particularly in the Q1 of AST, was quite low. The ability of AST, GGT, and BILI to identify SCE was poor, with low AUC, Sen, and PPV. The value of AST, GGT, and BILI in eliminating SCE from stroke subtypes was good, with high Spe and moderate NPV, and was enhanced after combining each liver function indicator.

CONCLUSIONS

Results of present study demonstrated that AST, GGT, and BILI, particularly AST, had a potential to eliminate SCE from stroke subtypes, and the ability of eliminating SCE would be strengthened after combining each liver function indicator together.

Age dependency of ischaemic stroke subtypes and vascular risk factors in western Norway: the Bergen Norwegian Stroke Cooperation Study

OBJECTIVES

Age dependency of acute ischaemic stroke aetiology and vascular risk factors have not been adequately evaluated in stroke patients in Norway. Aims of this study were to evaluate how stroke subtypes and vascular risk factors vary with age in a western Norway stroke population.

MATERIALS AND METHODS

Patients aged 15-100 years consecutively admitted to our neurovascular centre with acute ischaemic stroke between 2006 and 2012 were included. The study population was categorized as young (15-49 years), middle-aged (50-74 years) or elderly (≥ 75 years). Stroke aetiology was defined by TOAST criteria. Risk factors and history of cardiovascular disease were recorded.

RESULTS

In total, 2484 patients with acute cerebral infarction were included: 1418 were males (57.3%). Mean age was 70.8 years (SD ± 14.9), 228 patients were young, 1126 middle-aged, and 1130 were elderly. The proportion of large-artery atherosclerosis and of small-vessel occlusion was highest among middle-aged patients. The proportion of cardioembolism was high at all ages, especially among the elderly. The proportion of stroke of other determined cause was highest among young patients. Some risk factors (diabetes mellitus, active smoking, angina pectoris, prior stroke and peripheral artery disease) decreased among the elderly. The proportions of several potential causes increased with age.

CONCLUSION

The proportion of stroke subtypes and vascular risk factors are age dependent. Age 50-74 years constitutes the period in life where cardiovascular risk factors become manifest and stroke subtypes change.

Brain Natriuretic Peptide and Particular Left Ventricle Segment Asynergy Associated with Cardioembolic Stroke from Old Myocardial Infarction

BACKGROUND

It is important to determine the usage of anticoagulants by defining the actual risk of cardioembolic stroke in patients with old myocardial infarction. In the present study, we aimed to more precisely evaluate the risks of each segment associated with cardioembolic stroke using a 16-segment model. The usage of the plasma brain natriuretic peptide (BNP) associated with cardioembolic stroke was also evaluated in comparison with a left ventricle ejection fraction less than 40%.

METHODS

There were a total of 190 ischemic stroke patients who had premorbid myocardial infarction. The study included a total of 143 ischemic stroke patients with old myocardial infarction who were available for evaluation and excluded patients with atrial fibrillation or acute myocardial infarction. Their left ventricle wall motion abnormality and the level of plasma BNP at their admission were analyzed.

RESULTS

Hypertension and a plasma BNP level of 206.9 pg/mL or higher, determined from the receiver operating characteristic curve, were independently associated with cardioembolic stroke (χ(2) = 35.6, R(2) = .30, P < .001). Adjusting for these factors, statistically independent high risk was observed at the basal-inferior, basal-inferolateral, mid-anterior, mid-anteroseptal, apical-anterior, and apical-septal left ventricles.

CONCLUSION

High plasma BNP levels and left ventricular wall motion abnormalities in the segments perfused with left anterior descending coronary artery or right coronary artery show a high risk for cardioembolic stroke in patients with old myocardial infarction. Considering these factors, it could be possible to more precisely define the risk of cardioembolic stroke and to perform appropriate antithrombotic treatments in old myocardial infarction patients.

Unbalanced Metalloproteinase-9 and Tissue Inhibitors of Metalloproteinases Ratios Predict Hemorrhagic Transformation of Lesion in Ischemic Stroke Patients Treated with Thrombolysis: Results from the MAGIC Study

Background

Experimentally, metalloproteinases (MMPs) play a detrimental role related to the severity of ischemic brain lesions. Both MMPs activity and function in tissues reflect the balance between MMPs and tissue inhibitors of metalloproteinases (TIMPs). We aimed to evaluate the role of MMPs/TIMPs balance in the setting of rtPA-treated stroke patients.

Methods

Blood was taken before and 24-h after rtPA from 327 patients (mean age 68 years, median NIHSS 11) with acute ischemic stroke. Delta median values of each MMP/TIMP ratio [(post rtPA MMP/TIMP-baseline MMP/TIMP)/(baseline MMP/TIMP)] were analyzed related to symptomatic intracranial hemorrhage (sICH) according to NINDS criteria, relevant hemorrhagic transformation (HT) defined as confluent petechiae within the infarcted area or any parenchymal hemorrhage, stroke subtypes (according to Oxfordshire Community Stroke Project) and 3-month death. The net effect of each MMP/TIMP ratio was estimated by a logistic regression model including major clinical determinants of outcomes

Results

Adjusting for major clinical determinants, only increase in MMP9/TIMP1 and MMP9/TIMP2 ratios remained significantly associated with sICH (odds ratio [95% confidence interval], 1.67 [1.17–2.38], p = 0.005; 1.74 [1.21–2.49], p = 0.003, respectively). Only relative increase in MMP9/TIMP1 ratio proved significantly associated with relevant HT (odds ratio [95% confidence interval], 1.74 [1.17–2.57], p = 0.006) with a trend toward significance for MMP9/TIMP2 ratio (p = 0.007).

Discussion

Our data add substantial clinical evidence about the role of MMPs/TIMPs balance in rtPA-treated stroke patients. These results may serve to generate hypotheses on MMPs inhibitors to be administered together with rtPA in order to counteract its deleterious effect.

Stroke incidence and case-fatality among Indigenous and non-Indigenous populations in the Northern Territory of Australia, 1999-2011

BACKGROUND

Stroke is a leading cause of death and disability in Australia. The impact of stroke on the Australia Indigenous people is, however, unclear.

AIM

This study describes hospital-based stroke incidence and case fatality in the Northern Territory population in Australia.

METHODS

Retrospective study of Northern Territory residents with a first-ever stroke episode and case fatality among Northern Territory residents in 1999-2011.

RESULTS

The rate ratio of age-adjusted stroke incidence between Indigenous and non-Indigenous populations was 2·8 for men and 2·7 for women, similar to those reported elsewhere in Australia. The rate ratio increased to 3·8 (95% confidence interval: 3·4-4·3) after adjusting for multiple risk factors. There was no change in annual incidence between 1999 and 2011 for either non-Indigenous (incidence rate ratio per year 1·01, 95% confidence interval: 1·00-1·03) or Indigenous people (incidence rate ratio: 1·00, 95% confidence interval: 0·98-1·02), although incidence did increase for non-Indigenous people in the 15-39 year age group (incidence rate ratio: 1·09, 95% confidence interval: 1·02-1·17) and for Indigenous people in the 40-64 year age group (incidence rate ratio: 1·03, 95% confidence interva1·00-1·06). The case fatality rate decreased from 22% in 1999 to 12% in 2011. In-hospital deaths were more common among; older and Indigenous people, for those with other chronic diseases, and from haemorrhagic stroke compared with ischemic stroke.

CONCLUSIONS

In the Northern Territory, as elsewhere in Australia, Indigenous Australians are more likely than other Australians to suffer a stroke. Lack of falling in incidence in the Northern Territory population highlights the importance for ongoing comprehensive primary and acute care in reducing risk factors and managing stroke patients.

Acute stroke symptoms: do differences exist between sexes?

BACKGROUND

Previous studies have reported that women with stroke often present different stroke symptoms than men. The aim of our study was to assess for the relevance of these differences from a large case series.

METHODS

Consecutive patients admitted to the Stroke Unit at the University of Perugia, with acute stroke or transient ischemic attack between 1 June, 2005, and May 2012, and recorded in Perugia Stroke Registry were prospectively included. Associations between the recorded symptoms and sex were assessed by preliminary cross-tabulations with the Chi-square test or Fisher exact test with Yate correction when appropriate. Multivariable regression analysis was used to identify independent predictors of a single symptom including sex as an independent variable.

RESULTS

Overall, 1072 men and 811 women were included in this study. Women had a higher average age at onset (75.40 ± 12.90 years in women and 70.14 ± 12.61 years in men) and presented more severe strokes with higher National Institute of Health Stroke Scale scores than men, whereas men were more likely to have a posterior stroke.Regarding symptoms, multivariate analysis revealed correlations between postural instability and male sex and between dysphagia and female sex.

CONCLUSIONS

We found no differences in the clinical presentation of stroke between the sexes, except that men were more likely to have postural instability and females were more likely to have dysphagia. These findings suggest that stroke locations and stroke severity were associated with sex.

Burden of stroke in Puerto Rico

Stroke is the fifth leading cause of death and the first cause of long-term disability in Puerto Rico. Trained staff reviewed and independently validated the medical records of patients who had been hospitalized with possible stroke at any of the 20 largest hospitals located in Puerto Rico during 2007, 2009, and 2011. The mean age of the 5005 newly diagnosed stroke patients (51·2% female) was 70 years. At the time of hospitalization, women were 4½ years older, were less likely to be married (60·2% vs. 39·9%, P < 0·001), smoked less (5·8% vs. 13·4%, P < 0·001), and had significantly higher proportion of diabetes (56·0% vs. 54·8%), hypertension (89·1% vs. 85·0%), and low density lipoprotein-cholesterol (LDL-Chol) > 100 mg/dL (65·7% vs. 57·5%) P < 0·05. Ischemic stroke represented 75% of all types of strokes. Atrial fibrillation was mentioned in 7·9% of the medical records. The risk for dying before discharge was similar for both genders, but was 40% higher for women than for men at one-year follow-up: age-adjusted odds ratio = 1·4 (95% confidence interval = 1·2-1·5).

Cost of stroke in low and middle income countries: a systematic review

BACKGROUND

There is limited information available from low and middle-income countries regarding the cost of stroke treatment. Hence, we aimed to review the costs of stroke in low and middle-income countries.

SUMMARY OF REVIEW

The literature search was done using databases: PubMed/Medline, Ovid, EconLit and Google Scholar from 1966 until January 2014 using key words 'economic impact of stroke', 'cost of illness in low and middle income countries' and 'cost of stroke'. With these key words, 10/184 articles were retained for this review. The cost data were converted to 2013 currency values using a web-based tool (CCEMG-EPPI-centre cost converter). Most of the included studies were conducted in Asia. The design of these studies was retrospective and conducted predominantly in multicenter private hospitals. The highest mean direct medical cost of stroke was US$ 8424 in Nigeria. The lowest mean cost of stroke was in Senegal (US$ 416). The average length of hospital stay was longest (20 days) in China. The main predictors of higher costs appeared to be due to differences in length of stay and stroke severity.

CONCLUSION

Costs of stroke are variable because of heterogeneous healthcare systems prevailing in low and middle-income countries. Length of hospital stay and stroke severity appear to be the main predictors of cost. Understanding the costs of stroke in low and middle-income countries is important. However, the evidence remains limited because there is a lack of standardized research. Future research should focus on using a uniform method across low and middle-income countries for estimating the costs of stroke.

Depression: cognition relations after stroke

BACKGROUND

Poststroke depression and cognitive dysfunction are common and are independent predictors of poor recovery.

AIMS

We assessed whether and how depression and cognition were correlated in the subacute period after stroke.

METHOD

We prospectively recruited 207 nondemented patients (Mini Mental State Examination ≥ 23) presenting with a first-ever ischemic stroke (127 males), mean age of 48·5 years (16·4 standard deviation), median 12 days after infarction, as assessed on magnetic resonance imaging. We administered a comprehensive neuropsychological battery involving cognitive domains including instrumental functions, memory, executive functions, and working memory. Depression was quantified with the Beck Depression Inventory.

RESULTS

Depression (Beck Depression Inventory > 9) was identified in 30·4% of the patients (95% confidence interval 24·2-37·2%). Median Beck Depression Inventory was 6. Median Mini Mental State Examination was 30. Cognitive dysfunctioning in at least one neuropsychological test was present in 89% (95% confidence interval 84-93%). Each point increase of Beck Depression Inventory was associated with an odd of 1·1 (95% confidence interval 1·04-1·19) of changing to a worse category of cognition. Stroke location was not correlated with depression. All cognitive domains were significantly correlated with depression. In multivariate analysis, the executive functions (P = 0·001) and the working memory (P = 0·009) were the best predictors of depression when adjusted for demographic and stroke characteristics.

CONCLUSIONS

The rates of depression and cognitive impairment were in the range of previous stroke studies. Our study suggested a strong relation between depression and cognition characterized by executive functions and working memory dysfunctioning.

Enlarged perivascular spaces and cerebral small vessel disease

Background and aims

Enlarged perivascular spaces (also known as Virchow–Robin spaces) on T2-weighted brain magnetic resonance imaging are common, but their etiology, and specificity to small vessel as opposed to general cerebrovascular disease or ageing, is unclear. We tested the association between enlarged perivascular spaces and ischemic stroke subtype, other markers of small vessel disease, and common vascular risk factors.

Methods

We prospectively recruited patients with acute stroke, diagnosed and subtyped by a stroke physician using clinical features and brain magnetic resonance imaging. A neuroradiologist rated basal ganglia and centrum semiovale enlarged perivascular spaces on a five-point scale, white matter lesions, recent and old infarcts, and cerebral atrophy. We assessed associations between basal ganglia-, centrum semiovale- and total (combined basal ganglia and centrum semiovale) enlarged perivascular spaces, stroke subtype, white matter lesions, atrophy, and vascular risk factors.

Results

Among 298 patients (mean age 68 years), after adjusting for vascular risk factors and white matter lesions, basal ganglia–enlarged perivascular spaces were associated with increasing age (P = 0·001), centrum semiovale–enlarged perivascular spaces (P < 0·001), cerebral atrophy (P = 0·03), and lacunar stroke subtype (P = 0·04). Centrum semiovale–enlarged perivascular spaces were associated mainly with basal ganglia–enlarged perivascular spaces. Total enlarged perivascular spaces were associated with increasing age (P = 0·01), deep white matter lesions (P = 0·005), and previous stroke (P = 0·006).

Conclusions

Enlarged perivascular spaces are associated with age, lacunar stroke subtype and white matter lesions and should be considered as another magnetic resonance imaging marker of cerebral small vessel disease. Further evaluation of enlarged perivascular spaces in studies of ageing, stroke, and dementia is needed to determine their pathophysiological importance.

Posterior circulation stroke is associated with prolonged door-to-needle time

BACKGROUND

Lack of recognition of early symptoms of acute posterior circulation ischaemic stroke might delay timely diagnosis and treatment with tissue plasminogen activator.

AIMS AND HYPOTHESIS

We hypothesized that patients with posterior circulation stroke receive delayed thrombolytic treatment in comparison to anterior circulation stroke. We investigated the differences in times to evaluation or treatment between patients with anterior circulation ischaemic stroke and posterior circulation stroke in our aim to understand the barriers that might have caused these delays.

METHODS

A cross-sectional study was conducted using consecutive patients presenting to our tertiary academic centre with acute ischaemic stroke who were treated with intravenous tissue plasminogen activator within 4·5 h from symptom onset. We compared demographics, stroke severity, symptoms and signs, and time intervals among onset, emergency department arrival, emergency department physician evaluation, neurologist evaluation, brain imaging, and tissue plasminogen activator treatment in patients with anterior circulation stroke and posterior circulation stroke.

RESULTS

Among 252 patients treated with intravenous tissue plasminogen activator, 12% had posterior circulation stroke. Patients with posterior circulation stroke had significantly lower median baseline the National Institutes of Health and Stroke Scale (NIHSS) score (P = 0·01), higher frequency of nausea (P < 0·01), vomiting (P < 0·01), dizziness (P < 0·01), and lower frequency of aphasia (P = 0·002) or neglect (P = 0·048). The emergency department physician evaluation-to-neurologist evaluation and door-to-needle intervals were significantly longer for posterior circulation stroke patients compared with anterior circulation stroke patients. The neurologist-to-needle time, however, was similar in the two groups. The presence of nausea and vomiting was associated with a longer time from emergency department evaluation to neurology evaluation and had a significant association with delayed treatment.

CONCLUSIONS

Posterior circulation stroke patients had a delay in neurology evaluation after initial emergency department evaluation and a delay in intravenous tissue plasminogen activator administration compared with anterior circulation stroke patients. There may be difficulties in rapidly recognizing the symptoms of posterior circulation stroke, in contrast to anterior circulation stroke, in the emergency department.

Disparities in stroke type and vascular risk factors between 2 Hispanic populations in Miami and Mexico city

BACKGROUND

The heterogeneous nature and determinants of stroke among different Hispanic groups was examined by comparing hospitalized Hispanic stroke patients in Miami, where the Hispanic population is largely of Caribbean origin, to a Mestizo population in Mexico City.

METHODS

Consecutive Hispanic patients who were admitted with stroke or transient ischemic attack (TIA) and included in the prospective stroke registries of 2 tertiary care teaching hospitals were studied. Demographic factors, stroke subtypes, vascular risk factors, stroke severity, and outcomes were compared. Vascular risk factor definitions were standardized.

RESULTS

A total of 928 patients (520 Mexicans and 408 Miami Hispanics) were analyzed. Mexicans were younger, with a greater proportion of women. More cerebral venous thromboses (CVTs) were admitted in Mexico, while TIA and stroke mimics were more commonly admitted in Miami; cardioembolic strokes were more commonly ascertained in Miami, and more cryptogenic strokes in Mexico. Stroke severity was similar for intracerebral hemorrhages, but more severe ischemic strokes and CVTs were included in the Mexican registry. Outcome at 1 and 3 months was similar in both registries after adjusting for age and baseline stroke severity. After adjusting for age and sex, hypertension, dyslipidemia, and atrial fibrillation were more frequent, and diabetes mellitus was less frequent, among Miami Hispanics compared to Mexicans.

CONCLUSIONS

We found significant differences in the frequency of hypertension, diabetes, dyslipidemia, and atrial fibrillation in Miami Hispanics and Mexican stroke patients, highlighting the heterogeneity of the Hispanic ethnic group. Future studies are needed to clarify the relative contribution of genetic and environmental disparities amongst Mexican and Caribbean Hispanic stroke patients.

Stroke subtyping for genetic association studies? A comparison of the CCS and TOAST classifications

BACKGROUND

A reliable and reproducible classification system of stroke subtype is essential for epidemiological and genetic studies. The Causative Classification of Stroke system is an evidence-based computerized algorithm with excellent inter-rater reliability. It has been suggested that, compared to the Trial of ORG 10172 in Acute Stroke Treatment classification, it increases the proportion of cases with defined subtype that may increase power in genetic association studies. We compared Trial of ORG 10172 in Acute Stroke Treatment and Causative Classification of Stroke system classifications in a large cohort of well-phenotyped stroke patients.

METHODS

Six hundred ninety consecutively recruited patients with first-ever ischemic stroke were classified, using review of clinical data and original imaging, according to the Trial of ORG 10172 in Acute Stroke Treatment and Causative Classification of Stroke system classifications.

RESULTS

There was excellent agreement subtype assigned by between Trial of ORG 10172 in Acute Stroke Treatment and Causative Classification of Stroke system (kappa = 0·85). The agreement was excellent for the major individual subtypes: large artery atherosclerosis kappa = 0·888, small-artery occlusion kappa = 0·869, cardiac embolism kappa = 0·89, and undetermined category kappa = 0·884. There was only moderate agreement (kappa = 0·41) for the subjects with at least two competing underlying mechanism. Thirty-five (5·8%) patients classified as undetermined by Trial of ORG 10172 in Acute Stroke Treatment were assigned to a definite subtype by Causative Classification of Stroke system. Thirty-two subjects assigned to a definite subtype by Trial of ORG 10172 in Acute Stroke Treatment were classified as undetermined by Causative Classification of Stroke system.

CONCLUSIONS

There is excellent agreement between classification using Trial of ORG 10172 in Acute Stroke Treatment and Causative Classification of Stroke systems but no evidence that Causative Classification of Stroke system reduced the proportion of patients classified to undetermined subtypes. The excellent inter-rater reproducibility and web-based semiautomated nature make Causative Classification of Stroke system suitable for multicenter studies, but the benefit of reclassifying cases already classified using the Trial of ORG 10172 in Acute Stroke Treatment system on existing databases is likely to be small.

Posterior circulation ischemic stroke-clinical characteristics, risk factors, and subtypes in a north Indian population: a prospective study

BACKGROUND AND PURPOSE

Posterior circulation stroke accounts for approximately 20% of all strokes with varied clinical presentation, which differ from strokes in anterior circulation, with reference to etiology, clinical features, and prognosis. Short penetrating and circumferential branches in the posterior circulation supply the brain stem, thalamus, cerebellum, occipital, and medial temporal lobes.

MATERIALS AND METHODS

We prospectively analyzed 80 participants of posterior circulation ischemic stroke from a registry of 944 participants attending a tertiary care referral university hospital. Patients were analyzed for demographics, stroke risk factors, clinical characteristics, neuroimaging, and stroke subtypes.

RESULTS

Posterior circulation ischemic stroke accounted for 80 (8.5%) of 944 of all strokes and 80 (10.45%) of 765 of ischemic stroke. Sixty-three were males with mean age 51.7 ± 14.4 years. Twenty-one participants were young (defined as age less than 45 years). Hypertension was found to be the most common risk factor (63.75%). Vertigo was the most common clinical symptom reported in 45 (56.25%) cases. Sixty-eight (85%) patients had large artery disease, 8 (10%) had documented cardioembolic source, 3 (3.75%) small artery disease, and 2 (2.5%) vasculitis. Posterior cerebral artery was most commonly involved. Topographically distal intracranial involvement was most frequent (66.25%) followed by proximal (30%) and middle intracranial territory (3.75%).

CONCLUSIONS

Our study demonatrated the occurrence of posterior circulation stroke in relatively younger age group compared to the Western world. We also found higher percentage of large artery disease, while cardioembolism as a less frequent cause of posterior circulation ischemic stroke in North Indian population. Distal territory involvement was most common in our study.