An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association

Differentially expressed miRNA profiles of serum derived extracellular vesicles from patients with acute ischemic stroke

BACKGROUND

MicroRNAs (miRNAs) participate in diverse cellular changes following acute ischemic stroke (AIS). Circulating miRNAs, stabilized and delivered to target cells via extracellular vesicles (EVs), are potential biomarkers to facilitate diagnosis, prognosis, and therapeutic modulation. We aimed to identify distinctive expression patterns of circulating EV-miRNAs in AIS patients.

METHODS

miRNA profiles from EVs, isolated from plasma samples collected within 24 h following AIS diagnosis, were examined between a dataset of 10 age-, gender- and existing comorbidities-matched subjects (5 AIS and 5 healthy controls, HC). We measured 2578 miRNAs and identified differentially expressed miRNAs between AIS and HC. An enrichment analysis was conducted to delineate the networks and biological pathways implicated by differentially expressed microRNAs. An enrichment analysis was conducted to delineate the networks and biological pathways implicated by differentially expressed microRNAs.

RESULTS

Five miRNAs were differentially expressed between stroke (AIS) versus control (HC). hsa-let-7b-5p, hsa-miR-16-5p, and hsa-miR-320c were upregulated, whereas hsa-miR-548a-3p and hsa-miR-6808-3p, with no previously reported changes in stroke were downregulated. The target genes of these miRNAs affect various cellular pathways including, RNA transport, autophagy, cell cycle progression, cellular senescence, and signaling pathways like mTOR, PI3K-Akt, and p53. Key hub genes within these networks include TP53, BCL2, Akt, CCND1, and NF-κB. These pathways are crucial for cellular function and stress response, and their dysregulation can have significant implications for the disease processes.

CONCLUSION

Our findings reveal distinct circulating EV-miRNA expression patterns in AIS patients from Qatar, highlighting potential biomarkers that could aid in stroke diagnosis and therapeutic strategies. The identified miRNAs are involved in critical cellular pathways, offering novel insights into the molecular mechanisms underlying stroke pathology. Circulating EV-miRNAs differentially expressed in AIS may have a pathophysiological role and may guide further research to elucidate their precise mechanisms.

Prediction of Major Adverse Cardiovascular Events in Patients with Peripheral Artery Disease Using Circulating Immunomodulatory Proteins

Background/Objectives: The leading cause of death for people with peripheral artery disease (PAD) is major adverse cardiovascular events (MACE), including heart attacks and strokes. However, research into biomarkers that could help predict MACE in patients with PAD has been limited. Immunomodulatory proteins are known to significantly influence systemic atherosclerosis, suggesting they could be useful prognostic indicators for MACE in patients with PAD. In this study, we evaluated a broad panel of immunomodulatory proteins to identify those linked to MACE in individuals with PAD. Methods: We conducted a prognostic study involving a prospectively recruited cohort of 406 patients consisting of 254 with PAD and 152 without PAD. At the baseline, we measured the plasma concentrations of 17 circulating immunomodulatory proteins and followed the cohort for two years. The primary outcome was 2-year MACE, a composite of myocardial infarction, stroke, or death. Plasma protein concentrations were compared between patients with PAD with and without 2-year MACE using Mann-Whitney U tests. We further examined the prognostic potential of differentially expressed proteins through a Cox proportional hazards analysis, determining their independent associations with 2-year MACE while controlling for all the baseline demographic and clinical characteristics, including the existing coronary artery and cerebrovascular diseases. Additionally, A Kaplan-Meier analysis was performed to evaluate the 2-year freedom from MACE in patients with low versus high levels of the differentially expressed proteins based on the median plasma concentrations. Results: The mean age of the cohort was 68.8 years (SD 11.1), with 134 patients (33%) being female. During the two-year follow-up, 63 individuals (16%) developed MACE. The following proteins were significantly elevated in patients with PAD who experienced 2-year MACE compared to those who did not: galectin-1 (0.17 [SD 0.06] vs. 0.10 [SD 0.07] pg/mL, p = 0.012), alpha-1-microglobulin (16.68 [SD 7.48] vs. 14.74 [SD 6.71] pg/mL, p = 0.019), and galectin-9 (0.14 [SD 0.09] vs. 0.09 [SD 0.05] pg/mL, p = 0.033). The Cox proportional hazards analysis indicated that these three proteins were independently associated with 2-year MACE after adjusting for all the baseline demographic and clinical factors: galectin-1 (HR 1.45 [95% CI 1.09-1.92], p = 0.019), alpha-1-microglobulin (HR 1.31 [95% CI 1.06-1.63], p = 0.013), and galectin-9 (HR 1.35 [95% CI 1.02-1.78], p = 0.028). Over the two-year follow-up, patients with higher levels of galectin-1, galectin-9, and alpha-1-microglobulin had a lower freedom from MACE. Additional analysis showed that these three proteins were not significantly associated with 2-year MACE in patients without PAD. Conclusions: Among the 17 immunomodulatory proteins evaluated, galectin-1, galectin-9, and alpha-1-microglobulin were found to be independently and specifically associated with 2-year MACE in patients with PAD. Assessing the plasma concentrations of these proteins can aid in risk stratification for MACE in patients with PAD, helping to inform clinical decisions regarding multidisciplinary referrals to cardiologists, neurologists, and vascular medicine specialists. This information can also guide the aggressiveness of medical management, ultimately improving cardiovascular outcomes for patients with PAD.

Changes Over Time in Short-Term Stroke Outcomes by Race-Ethnicity

OBJECTIVES

The objective of this study was to quantify trends (2008-2019) in stroke outcomes by race-ethnicity.

METHODS

Patients with ischemic stroke from a population-based study were interviewed at 90 days to assess outcomes. Linear regression with multiple imputation and inverse probability weighting was used to model trends.

RESULTS

The median age was 66 years (n = 1,449); 61% were Mexican American (MA). QOL remained stable with no race-ethnic difference in trends (p for time*race-ethnicity interaction = 0.81). Neurologic outcomes improved for MA (p < 0.01) but not non-Hispanic White (NHW) persons with stroke (p = 0.23) with no race-ethnic difference in trends (p for interaction = 0.23). For functional outcomes, trends were stable and then improved in MA persons with stroke (p for interaction = 0.01), whereas trends were stable in NHW persons with stroke (p = 0.52). For cognitive outcomes, there was little change in NHW persons with stroke (p = 0.50); in MA persons with stroke, there was improvement followed by decline and then improvement (p = 0.03). No race-ethnic differences in trends in functional (p for interaction = 0.51) or cognitive (p for interaction = 0.21) outcomes were noted.

DISCUSSION

Outcome improvements were noted in MA but not NHW persons with stroke; race-ethnic differences were not present in 2019. Understanding factors contributing to favorable trends in MA persons may be informative for improving outcomes in all persons.

Baseline systolic blood pressure and efficacy of dual antiplatelet in acute ischaemic stroke

OBJECTIVE

Systolic blood pressure (SBP) affects the risk of early neurological deterioration (END). This subgroup analysis of Antiplatelet Therapy in Acute Mild to Moderate Ischemic Stroke (ATAMIS) trial aimed to explore whether SBP at admission affected the efficacy of different antiplatelet therapies in preventing END.

METHODS

Based on the modified intention-to-treat analysis set of the ATAMIS trial, patients were divided into two subgroups according to whether SBP at admission was equal to or higher than 140 mm Hg, which were further subdivided into clopidogrel plus aspirin and aspirin alone treatments according to the randomised assignment. We conducted multivariable regression analyses to detect relationship between SBP at admission and END, as well as efficacy of different antiplatelet therapies in each SBP subgroup. Primary endpoint was END defined as ≥2-point increase in 7-day National Institutes of Health Stroke Scale score. Safety endpoints included intracranial haemorrhage and bleeding events during the trial.

RESULTS

This study included 2915 patients. Risk of END raised by 16% as SBP at admission increased by every 10 mm Hg (p<0.001). Clopidogrel plus aspirin resulted in significantly lower risk of END than aspirin alone in patients with SBP≥140 mm Hg (5.5% vs 7.9%; adjusted risk difference (RD) and 95% CI -2.5% (-4.1% to -1.0%)), but not in those with SBP<140 mm Hg (3.4% vs 4.2%; adjusted RD and 95% CI -0.8% (-3.2% to 1.7%)). Efficacy of different antiplatelet therapies and SBP did not show significant interaction (p=0.50). Safety endpoints were similar between treatments in SBP subgroups.

CONCLUSION

The risk of END increases with elevated SBP at admission among patients with acute mild-to-moderate ischaemic stroke who are not suitable for reperfusion treatments. Fewer END occurred following clopidogrel plus aspirin compared with aspirin alone across different SBP levels. The finding should be interpreted cautiously.

Risk of new tumor, carotid stenosis, and stroke after stereotactic radiosurgery for pituitary tumor: A multicenter study of 2254 patients with imaging follow-up

BACKGROUND

A higher risk of secondary brain tumor, carotid stenosis, and stroke has been reported after conventional sella irradiation for pituitary neuroendocrine tumors (PitNET). Stereotactic radiosurgery (SRS), which is a more focused approach, is now increasingly used instead. The aim was to assess the risk of secondary brain tumor, carotid stenosis/occlusion, and stroke after SRS.

METHODS

In this multicentric retrospective study, 2254 patients with PitNET were studied, 1377 in the exposed group, and 877 in the control group.

RESULTS

There were 9840.1 patient-years at risk for the SRS and 5266.5 for the control group. The 15-year cumulative probability of secondary intracranial tumor was 2.3% (95% CI: 0.5%, 4.1%) for SRS and 3.7% (95% CI: 0%, 8.7%) for the control group (P = .6), with an incidence rate of 1.32 per 1000 and 0.95 per 1000, respectively. SRS was not associated with an increased risk of tumorigenesis when stratified by age (HR: 1.59 [95% CI: 0.57, 4.47], Pp = .38). The 15-year probability of new carotid stenosis/occlusion was 0.9% (95% CI: 0.2, 1.6) in the SRS and 2% (95% CI: 0, 4.4) in the control group (P = .8). The 15-year probability of stroke was 2.6% (95% CI: 0.6%, 4.6%) in the SRS and 11.1% (95% CI: 6%, 15.9%) in the control group (P < .001). In Cox multivariate analysis stratified by age, SRS (HR 1.85 [95% CI:0.64, 5.35], P = .26) was not associated with risk of new stroke.

CONCLUSIONS

No increased risk of long-term secondary brain tumor, new stenosis or occlusion, and stroke was demonstrated in the SRS group compared to the control in this study with imaging surveillance.

Resistant and refractory migraine - two different entities with different comorbidities? Results from the REFINE study

BACKGROUND

Resistant and refractory migraine are commonly encountered in specialized headache centers. Several comorbidities, mostly psychiatric conditions, have been linked to migraine worsening; however, there is little knowledge of the comorbidity profile of individuals with resistant and refractory migraine.

METHODS

REFINE is a prospective observational multicenter international study involving individuals with migraine from 15 headache centers. Participants were categorized into three groups based on the European Headache Federation criteria: non-resistant and non-refractory (NRNRM), resistant (ResM), and refractory (RefM). We explored the prevalence of 20 comorbidities at baseline in the three groups.

RESULTS

Of the 689 included patients (82.8% women), 262 (38.0%) had ResM, 73 (10.4%) had RefM and 354 (51.4%) NRNRM. A higher prevalence of psychiatric comorbidities, trigger points, temporomandibular joint disorders, thyroiditis, and cerebrovascular diseases was observed in the RefM group, followed by ResM and NRNRM. Multiple comorbidities were more common in the RefM group, followed by the ResM group and by the NRNRM group (41.6% vs. 24.5% vs. 14.1% respectively; p < 0.001). At the sensitivity analysis, exploring participants with chronic migraine, significant differences among the NRNRM, ResM, and RefM groups were found in the prevalence of anxiety (p < 0.001), asthma and rhinitis (p = 0.013), bipolar and other psychiatric disorders (p = 0.049), cerebrovascular diseases (p < 0.001), depression (p < 0.001), obesity (p = 0.002), thyroiditis (p < 0.001), and trigger points (p = 0.008).

CONCLUSION

REFINE data indicate that individuals with ResM and RefM have a higher burden of comorbidities than those with NRNRM. It can be postulated that those comorbidities may have an impact on the progression of migraine from a form that is easy to treat to a form that is resistant or refractory to treatments. Longitudinal studies are needed to understand the direction of the association between ResM or RefM and those comorbidities and if proper treatment of comorbidities might help overcome treatment resistance or refractoriness.

Perspectives of Clients and Health Care Professionals on the Opportunities for Digital Health Interventions in Cerebrovascular Disease Care: Qualitative Descriptive Study

BACKGROUND

Cerebrovascular diseases (CVDs) are a major and potentially increasing burden to public health. Digital health interventions (DHIs) could support access to and provision of high-quality health care (eg, outcomes, safety, and satisfaction), but the design and development of digital solutions and technologies lack the assessment of user needs. Research is needed to identify opportunities to address health system challenges and improve CVD care with primary users of services as the key informants of everyday requirements.

OBJECTIVE

This study aims to identify opportunities for DHIs from clients' and health care professionals' perspectives to address health system challenges and improve CVD care.

METHODS

This study used a qualitative, descriptive approach. Semistructured, in-person interviews were conducted with 22 clients and 26 health care professionals in a single tertiary-level hospital in Finland between August 2021 and March 2022. The data were analyzed using a deductive and inductive content analysis.

RESULTS

Identified opportunities for DHIs in CVD care were organized according to clients, health care professionals, and data services and classified into 14 main categories and 27 generic categories, with 126 subcategories of requirements. DHIs for clients could support the long-term management of health and life changes brought on by CVD. They could provide access to personal health data and offer health information, support, and communication possibilities for clients and their caregivers. Health care professionals would benefit from access to relevant patient data, along with systems and tools that support competence and decision-making. Intersectoral and professional collaboration could be promoted with digital platforms and care pathways. DHIs for data services could enhance care planning and coordination with novel predictive data and interoperable systems for data exchange.

CONCLUSIONS

The combined study of client and health care professional perspectives identified several opportunities and requirements for DHIs that related to the information, availability, quality, acceptability, utilization, efficiency, and accountability challenges of health systems. These findings provide valuable social insights into digital transformation and the emerging design, development, and use of user-centered technologies and applications to address challenges and improve CVD care and health care.

Impact of symptom-to-balloon time in patients with non-ST-segment elevation myocardial infarction and complex lesions

AIMS

Considering the limited data regarding clinical outcomes of patients with non-ST-segment on the ECG elevation myocardial infarction (NSTEMI), this study compared the outcomes of patients undergoing percutaneous coronary intervention with newer-generation drug-eluting stents stratified by the presence/absence of complex lesions and symptom-to-balloon time (SBT; <48 h or ≥48 h).

METHODS

We enrolled 4373 patients with NSTEMI from the Korea Acute Myocardial Infarction Registry-National Institute of Health dataset and stratified them into the complex group (2106 patients; SBT < 48 h, n  = 1365; SBT ≥48 h, n  = 741) and the noncomplex group (2267 patients; SBT < 48 h, n  = 1573; SBT ≥48 h, n  = 694). The primary outcome was the 3-year all-cause mortality rate. The secondary outcomes were any major adverse cardiac events (MACE), including cardiac death (CD), recurrent myocardial infarction, and stroke.

RESULTS

The incidence of all-cause mortality (adjusted hazard ratio, 0.656; P  = 0.009), CD ( P  = 0.037), and MACE ( P  = 0.047) in the complex group and of stroke in the noncomplex group ( P  = 0.020) were significantly lower in patients with SBT < 48 h than in those with SBT ≥48 h. Among patients with SBT < 48 h, the stroke incidence ( P  = 0.019) was higher in the complex group than in the noncomplex group, while among patients with SBT ≥48 h, the MACE incidence ( P  = 0.011) was higher in the former than in the latter.

CONCLUSION

SBT reduction effectively decreased the 3-year mortality in patients with NSTEMI in the complex group compared with the noncomplex group.

Identification of 3-methyl-1-(3-methylpyridin-2-yl)-1H-pyrazol-5-ol as promising neuroprotective agent

Pyrazolol derivatives are gaining significant attention for their diverse pharmacological effects, such as analgesic, anti-inflammatory, antioxidant, and anticancer activities. In this study, 20 pyrazolol derivatives were designed and synthesized to develop an anti-ischemic stroke formulation with free radical scavenging activity. Most of these synthesized compounds demonstrated antioxidant capabilities in DPPH, ABTS radical scavenging, and ORACFL assays. The methyl-substituted compound Y12, in particular, showed exceptional antioxidant capacity. Additionally, these compounds showed excellent neurocytoprotective effects in the SH-SY5Y cell injury model subjected to oxygen-glucose deprivation/reoxygenation (OGD/R). Notably, Y12 exhibited significant metal chelating activity with Cu2+. In vivo studies confirmed that compound Y12 has neuroprotective effects and can significantly reduce the infarct area in a mouse model of focal cerebral ischemia induced by transient middle cerebral artery occlusion (tMCAO).

The feasibility of the adapted H-GRASP program for perceived and actual daily-life upper limb activity in the chronic phase post-stroke

PURPOSE

Assessing feasibility and initial impact of the Home-Graded Repetitive Arm Supplementary Program combined with in-home accelerometer-based feedback (AH-GRASP) on perceived and actual daily-life upper limb (UL) activity in stroke survivors during the chronic phase with good UL motor function but low perceived daily-life activity.

MATERIAL AND METHODS

A 4-week intervention program (4 contact hours, 48 h self-practice) encompassing task-oriented training, behavioral techniques, phone-based support, monitoring, and weekly feedback sessions using wrist-worn accelerometery was implemented using a pre-post double baseline repeated measures design. Feasibility, clinical assessments, patient-reported outcomes, and accelerometer data were investigated.

RESULTS

Of the 34 individuals approached, nineteen were included (recruitment rate 56%). Two dropped out, one due to increased UL pain (retention rate 89%). Seven (41%) achieved the prescribed exercise target (120 min/day, six days/week). Positive patient experiences and improvements in UL capacity, self-efficacy, and contribution of the affected UL to overall activity (p < 0.05, small to large effect sizes) were observed. Additionally, seven participants (41%) surpassed the minimal clinically important difference in perceived UL activity.

CONCLUSIONS

A home-based UL exercise program with accelerometer-based feedback holds promise for enhancing perceived and actual daily-life UL activity for our subgroup of chronic stroke survivors.

Resting-state functional abnormalities in ischemic stroke: a meta-analysis of fMRI studies

Ischemic stroke is a leading neurological cause of severe disabilities and death in the world and has a major negative impact on patients' quality of life. However, the neural mechanism of spontaneous fluctuating neuronal activity remains unclear. This meta-analysis explored brain activity during resting state in patients with ischemic stroke including 22 studies of regional homogeneity, amplitude of low-frequency fluctuation, and fractional amplitude of low-frequency fluctuation (692 patients with ischemic stroke, 620 healthy controls, age range 35-80 years, 41% female, 175 foci). Results showed decreased regional activity in the bilateral caudate and thalamus and increased regional activity in the left superior occipital gyrus and left default mode network (precuneus/posterior cingulate cortex). Meta-analysis of the amplitude of low-frequency fluctuation studies showed that increased activity in the left inferior frontal gyrus was reduced across the progression from acute to chronic phases. These findings may indicate that disruption of the subcortical areas and default mode network could be one of the core functional abnormalities in ischemic stroke. Altered brain activity in the inferior frontal gyrus could be the imaging indicator of brain recovery/plasticity after stroke damage, which offers potential insight into developing prediction models and therapeutic strategies for ischemic stroke rehabilitation and recovery.

Spatio-temporal distribution, prediction and relationship of three major acute cardiovascular events: Out-of-hospital cardiac arrest, ST-elevation myocardial infarction and stroke

Background

Predicting the incidence of time-sensitive cardiovascular diseases like out-of-hospital cardiac arrest (OHCA), ST-elevation myocardial infarction (STEMI), and stroke can reduce time to treatment and improve outcomes. This study analysed the spatio-temporal distribution of OHCAs, STEMIs, and strokes, their spatio-temporal correlation, and the performance of different prediction algorithms.

Methods

Adults who experienced an OHCA, STEMI, or stroke in Canton Ticino, Switzerland from 2005 to 2022 were included. Datasets were divided into training and validation samples. To estimate and predict the yearly per-capita population incidences of OHCA, STEMI, and stroke, the integrated nested Laplace approximation (INLA), machine learning meta model (MLMM), the Naïve prediction method, and the exponential moving average were employed and compared. The relationship between OHCA, STEMI, and stroke was assessed by predicting the incidence of one condition, considering the lagged incidence of the other two as explanatory variables.

Results

We included 3,906 OHCAs, 2,162 STEMIs, and 2,536 stroke patients. INLA and MLMM yearly predicted incidence OHCA, STEMI, and stroke at municipality level with very high accuracy, outperforming the Naïve forecasting and the exponential moving average. INLA exhibited errors of zero or one event in 82%, 87%, and 72% of municipalities for OHCA, STEMI, and stroke, respectively, whereas ML had errors in 81%, 89%, and 71% of municipalities for the same conditions. INLA had a prediction error of 0.87, 0.77, and 1.50 events per year per municipality for OHCA, STEMI and stroke, whereas MLMM of 0.70, 0.74, and 1.09 events, respectively. Including in the INLA model the lagged absolute values of the other conditions as covariates improved the prediction of OHCA and stroke but not STEMI. MLMM predictions were consistently the most accurate and did not benefit from the inclusion of the other conditions as covariates. All the three diseases showed a similar spatial pattern.

Conclusions

Prediction of incidence of OHCA, STEMI, and stroke is possible with very high accuracy using INLA and MLMM models. A robust spatio-temporal correlation between the 3 pathologies exists. Widespread implementation in clinical practice of prediction algorithms may allow to improve resource allocation, reduce treatment delays, and improve outcomes.

Baseline characteristics, reperfusion treatment secondary prevention and outcome after acute ischemic stroke in three different socioeconomic environments in Europe

INTRODUCTION

The differences in vascular risk factors' and stroke burden across Europe are notable, however there is limited understanding of the influence of socioeconomic environment on the quality of secondary prevention and outcome after acute ischemic stroke.

PATIENTS AND METHODS

In this observational multicenter cohort study, we analyzed baseline characteristics, reperfusion treatment, outcome and secondary prevention in patients with acute ischemic stroke from three tertiary-care teaching hospitals with similar service population size in different socioeconomic environments: Bern/CH/n = 293 (high-income), Gdansk/PL/n = 140 (high-income), and Lutsk/UA/n = 188 (lower-middle-income).

RESULTS

We analyzed 621 patients (43.2% women, median age = 71.4 years), admitted between 07 and 12/2019. Significant differences were observed in median BMI (CH = 26/PL = 27.7/UA = 27.8), stroke severity [(median NIHSS CH = 4(0-40)/PL = 11(0-33)/UA = 7(1-30)], initial neuroimaging (CT:CH = 21.6%/PL = 50.7%/UA = 71.3%), conservative treatment (CH = 34.1%/PL = 38.6%/UA = 95.2%) (each p < 0.001), in arterial hypertension (CH = 63.8%/PL = 72.6%/UA = 87.2%), atrial fibrillation (CH = 28.3%/PL = 41.4%/UA = 39.4%), hyperlipidemia (CH = 84.9%/PL = 76.4%/UA = 17%) (each p < 0.001) and active smoking (CH = 32.2%/PL = 27.3%/UA = 10.2%) (p < 0.007). Three-months favorable outcome (mRS = 0-2) was seen in CH = 63.1%/PL = 50%/UA = 59% (unadjusted-p = 0.01/adjusted-p CH-PL/CH-UA = 0.601/0.981), excellent outcome (mRS = 0-1) in CH = 48.5%/PL = 32.1%/UA = 27% (unadjusted-p < 0.001/adjusted-p CH-PL/CH-UA = 0.201/0.08 and adjusted-OR CH-UA = 2.09). Three-months mortality was similar between groups (CH = 17.2%/PL = 15.7%/UA = 4.8%) (unadjusted-p = 0.71/adjusted-p CH-PL/CH-UA = 0.087/0.24). Three-months recurrent stroke/TIA occurred in CH = 3.1%/PL = 10.7%/UA = 3.1%, adjusted-p/OR CH-PL = 0.04/0.32). Three-months follow-up medication intake rates were the same for antihypertensives. Statin/OAC intake was lowest in UA = 67.1%/25.5% (CH = 87.3%/39.2%/unadjusted-p < 0.001/adjusted-p CH-UA = 0.02/0.012/adjusted-OR CH-UA = 2.33/2.18). Oral intake of antidiabetics was lowest in CH = 10.8% (PL = 15.7%/UA = 16.1%/unadjusted-p = 0.245/adjusted-p CH-PL/CH-UA = 0.061/0.002/adjusted-OR CH-UA = 0.25). Smoking rates decreased in all groups during follow-up.

DISCUSSION AND CONCLUSION

Substantial differences in presentation, treatment and secondary prevention measures, are linked to a twofold difference in adjusted 3-months excellent outcome between Switzerland and Ukraine. This underscores the importance of socioeconomic factors that influence stroke outcomes, emphasizing the necessity for targeted interventions to address disparities in treatment and secondary prevention strategies.

Clinical Impact of Sarcopenia Screening on Long-Term Mortality in Patients Undergoing Coronary Bypass Grafting

BACKGROUND

Sarcopenia is an aging-related condition characterized by loss of skeletal muscle mass and is an indicator of subclinical atherosclerosis. The relationship between reduced muscle mass and long-term clinical outcomes in patients with advanced coronary artery disease who have undergone coronary artery bypass grafting (CABG) is not fully understood. This study is sought to evaluate the prognostic implications of sarcopenia screening in patients undergoing CABG.

METHODS

A total of 2810 patients who underwent CABG were analysed and classified according to presence of reduced muscle mass. The skeletal muscle index (SMI) was calculated as L3 muscle area (cm2)/height (m)2 on computed tomography. Reduced SMI was defined as SMI ≤ 45 cm2/m2 in male and ≤ 38 cm2/m2 in female. The primary outcome was all-cause mortality, and survival analysis was performed using the Kaplan-Meier method and compared with the log-rank test.

RESULTS

The median follow-up was 8.7 years, and 924 patients (32.9%) had reduced SMI. Patients with reduced SMI were older (67.7 ± 8.8 vs. 62.2 ± 9.8 years; p < 0.001) and less frequently male (69.8% vs. 81.1%; p < 0.001). SMI was significantly associated with risk of death on a restricted cubic spline curve (HR = 1.04 per-1 decrease; 95% CI 1.03-1.05; p < 0.001). Patients with reduced SMI had a higher incidence of long-term mortality than those with preserved SMI (survival rate 41.4% vs. 62.8%; HRadj = 1.18, 95% CI 1.03-1.36, p = 0.020). Subgroup analysis showed that the prognostic implication of reduced SMI on long-term survival was more evident in male (HRadj = 2.01, 95% CI 1.72-2.35) than female (HRadj = 1.28, 95% CI 0.98-1.68) (interaction p = 0.006).

CONCLUSIONS

Reduced muscle mass, defined by SMI on computed tomography, was associated with long-term mortality after CABG. These results provide contemporary data to allow the evaluation of physical frailty in patients with advanced coronary artery disease before surgery.

TRIAL REGISTRATION

Long-Term Outcomes and Prognostic Factors in Patients Undergoing CABG or PCI: NCT03870815.

A Novel Compound Ligusticum Cycloprolactam Alleviates Neuroinflammation After Ischemic Stroke via the FPR1/NLRP3 Signaling Axis

BACKGROUND

Microglia/macrophages, as pivotal immune cells in the central nervous system (CNS), play a critical role in neuroinflammation associated with ischemic brain injury. Targeting their activation through pharmacological interventions represents a promising strategy to alleviate neurological deficits, thereby harboring significant implications for the prevention and treatment of ischemic stroke. Ligusticum cycloprolactam (LIGc), a novel monomeric derivative of traditional Chinese medicine, has shown potential as a therapeutic agent; however, its specific role in cerebral ischemic injury remains unclear.

METHODS

In vitro experiments utilized lipopolysaccharide (LPS)-induced inflammation models of RAW264.7 cells and primary mouse microglia. In vivo studies employed LPS-induced neuroinflammation models in mice and a transient middle cerebral artery occlusion (tMCAO) mouse model to evaluate the impact of LIGc on neuroinflammation and microglia/macrophage phenotypic alterations. Further elucidation of the molecular mechanisms underlying these effects was achieved through RNA-Seq analyses.

RESULTS

LIGc exhibited the capacity to attenuate LPS-induced production of pro-inflammatory markers in macrophages and microglia, facilitating their transition to an anti-inflammatory phenotype. In models of LPS-induced neuroinflammation and tMCAO, LIGc ameliorated pathological behaviors and neurological deficits while mitigating brain inflammation. RNA-seq analyses revealed formyl peptide receptor 1 (FPR1) as a critical mediator of LIGc's effects. Specifically, FPR1 enhances the pro-inflammatory phenotype of microglia/macrophages and inhibits their anti-inflammatory response by upregulating NLR family pyrin domain protein 3 (NLRP3) inflammasomes, thus aggravating inflammatory processes. Conversely, LIGc exerts anti-inflammatory effects by downregulating the FPR1/NLRP3 signaling axis. Furthermore, FPR1 overexpression or NLRP3 agonists reversed the effects of LIGc observed in this study.

CONCLUSION

Our findings suggest that LIGc holds promise in improving ischemic brain injury and neuroinflammation through modulation of microglia/macrophage polarization. Mechanistically, LIGc attenuates the pro-inflammatory phenotype and promotes the anti-inflammatory phenotype by targeting the FPR1/NLRP3 signaling pathway, ultimately reducing inflammatory responses and mitigating neurological damage.

Professional reintegration of stroke survivors and their mental health, quality of life and community integration

PURPOSE

To assess the association between professional reintegration and mental health, quality of life (QoL) and community reintegration of stroke survivors.

METHODS

Using a cross-sectional study design, a structured questionnaire was administered to previously working stroke survivors, 18-24 months post-stroke. Data on sociodemographic characteristics, professional reintegration (prevalence of return to work (RTW), period of RTW, job placement, function at work, reintegration support, association of stroke with work and number of working hours), mental health (Hospital Anxiety and Depression Questionnaire), QoL (Stroke Specific Quality of Life Scale) and community integration (Community Integration Questionnaire) were reported by 553 stroke survivors.

RESULTS

Twenty months after stroke, 313 (56.6%; 95%CI 52.4-60.8) stroke survivors had return to work. RTW was positively associated with both global and sub-domains scores of Community Integration Questionnaire (CIQ) (global CIQ β = 3.50; 95%CI 3.30-3.79) and with depressive symptomatology (β = 0.63; 95%CI 0.20-1.46) measured by the Hospital Anxiety and Depression Scale. No significant differences were found regarding QoL, according to RTW status. For those who RTW, no significant associations were found between any of the professional reintegration determinants assessed and mental health, QoL and community integration scores.

CONCLUSIONS

RTW seems to be associated to better community integration after stroke, but appears to be negatively associated to stroke survivor's mental health, namely considering depression symptoms. Future studies should explore the barriers to stroke survivors' RTW and the challenges and strategies used to overcome them, to allow the development of professional reintegration policies.

Leat S. An international survey of optometric management of stroke survivors

OBJECTIVES

A survey was conducted to describe the current status of optometric awareness and involvement regarding post-stroke management as literature suggests that visual impairment often goes undiagnosed and unmanaged in stroke survivors.

MATERIALS AND METHODS

A questionnaire was developed by the researchers, pilot tested by 5 other optometric researchers and 15 optometrists and modified based on the feedback. Practicing optometrists were invited to complete the anonymous online survey through optometric organizations in Canada, Hong Kong, India, UK, and US.

RESULTS

Results showed that the majority of optometrists (61%) see 1-5 post-stroke patients per month, although 15% report seeing none. In all cases, optometrists referred stroke patients to other health care professionals more often than receiving incoming referrals from them. About 21% of all respondents were already fully involved in post-stroke vision care and 57% were interested in being more involved. Limiting factors to seeing more post-stroke patients included resources (29.8%), funding (25.8%), awareness (25.1%), and interest (9.8%). There was consensus among respondents in all countries that optometrists should be members of post-stroke care teams.

CONCLUSION

Optometrists are well suited to provide post-stroke visual rehabilitation but are often not included in care teams for these patients. As a result, the visual management of post-stroke patients often is unaddressed.

Evaluation of silent brain injury in patients undergoing aorto-ostial coronary stent implantation

BACKGROUND

Aorto-ostial (AO) coronary interventions may be associated with multiple problems, including the potential embolization of atherothrombotic debris into the aorta and systemic circulation. Such embolization could theoretically lead to stroke or silent brain injury (SBI). In this study, we aimed to investigate whether there is an increased risk of SBI in patients undergoing AO stent implantation.

METHODS

Fifty-five consecutive patients undergoing AO stenting and 55 consecutive patients undergoing non-AO stenting were included. Venous blood samples were obtained before and 12 h after the procedure to measure neuron-specific enolase (NSE), which is a sensitive marker of brain injury. Newly developed NSE elevation after the procedure in an asymptomatic patient was defined as SBI.

RESULTS

SBI was detected in 24 (43.6%) patients in the AO stenting group and 17 (30.9%) patients in the non-AO stenting group (p = .167). Although the SBI rates were statistically comparable between the groups, the presence of significant (≥50%) AO stenosis was found to be an independent predictor of SBI in multivariate logistic regression analysis [odds ratio (OR) 2.856; 95% confidence interval (CI) 1.057-7.716; p = .038]. A longer procedure time was another independent predictor for the development of SBI (OR 1.037; 95% CI 1.005-1.069; p = .023).

CONCLUSION

This study suggests that AO stenting may be associated with an increased risk of SBI if the lesion in the ostium is significant.

Transcutaneous electrical acupoint stimulation for upper limb motor recovery after stroke: a systematic review and meta-analysis

Background

Transcutaneous electrical acupoint stimulation (TEAS) is an innovative, non-invasive therapy that stimulates the contraction of paralyzed muscles in the upper limbs, promoting functional recovery. Several studies have demonstrated the efficacy of TEAS in restoring upper limb function. This study aims to evaluate the impact of TEAS on upper limb motor recovery after stroke.

Objectives

This study aims to evaluate the influence of TEAS on upper limb motor recovery after stroke and improve the quality of life in such patients.

Methods

Eight databases were systematically searched from inception to 1st October 2024. Two independent reviewers conducted the screening and data extraction of the study. The primary outcome measure was the Fugl Meyer Assessment of the Upper Extremity (FMA-UE), which evaluates upper extremity motor function in stroke patients. Secondary outcomes included the Modified Ashworth Scale (MAS) for assessing spasticity and the Modified Barthel Index (MBI) to evaluate patients' abilities to perform activities of daily living. Data synthesis was conducted using RevMan 5.4 and Stata 14.0. The GRADE method was employed to assess the quality of evidence.

Results

A total of 16 trials involving 1,218 stroke patients were included in this meta-analysis. Meta-analysis showed that the TEAS significantly improved upper limb function (SMD = 1.70, 95CI% = 1.09 to 2.31, p < 0.00001, I 2 = 93%; low certainty of evidence), reduced spasticity (SMD = -1.18, 95CI% = -1.79 to -0.58, p < 0.00001, I 2 = 90%; very low certainty of evidence), and enhanced the ability to perform daily activities (SMD = 1.53, 95CI% = 0.85 to 2.20, p < 0.00001, I 2 = 95%; low certainty of evidence).

Conclusion

Our results indicated that TEAS improved motor function and functional activities and reduced muscle tone in the upper limbs after stroke. However, these results should be interpreted with caution due to the limited strength of the evidence. High-quality, larger sample, multi-center studies are needed to validate these preliminary findings.

Systematic review registration

This study was registered on PROSPERO with registration number CRD42024592509. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024592509.

Clinical Efficacy and Safety of Reduced-Dose Prasugrel After Percutaneous Coronary Intervention for Taiwanese Patients with Acute Coronary Syndromes

Background/Objectives: The efficacy and safety of reduced-dose prasugrel (loading dose/maintenance dose: 20/3.75 mg) in preventing major adverse cardiovascular events (MACEs) among patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) have been well-estab-lished. However, long-term real-world data for this population remains limited in Taiwan. Methods: This study enrolled 226 Taiwanese ACS patients (with 448 lesions) who received reduced-dose pra-sugrel after PCI and completed one year of follow-up. Results: The primary efficacy outcome was the in-cidence of MACEs. After one year, the MACE rate was 7.1% (16/226). A comparative analysis of MACEs was conducted across subgroups stratified by age (<75 vs. ≥75 years), body mass index (<25 vs. ≥25 kg/m2), body weight (<60 vs. ≥60 kg), and estimated glomerular filtration rate (<60 vs. ≥60 mL/min/1.73 m2). Patients with impaired renal function had a 4.03-fold higher risk (95% con-fidence interval = 1.37-11.90, p = 0.01) of MACEs than those with optimal renal function. The primary safety endpoint was major bleeding events (Bleeding Academic Research Consortium types 3 or 5), which occurred in 0.8% (2/226) of patients, all gastrointestinal. The secondary end-point was net adverse clinical events (NACEs), a composite of MACEs and major bleeding, with an observed rate of 8.0% (18/226). Conclusions: Reduced-dose prasugrel demonstrated both safety and efficacy in Taiwanese ACS patients undergoing PCI.

Time-varying differences in stroke recurrence risk between types of atrial fibrillation based on screening methods and timing of detection

INTRODUCTION

Atrial fibrillation (AF) burden progresses with time. Among ischemic stroke (IS) patients, AF can be detected at different burden progression stages based on the timing and screening method. We hypothesized that AF detected after IS on 12-lead ECGs (ECG-AF) and via 14-day-Holter prolonged cardiac monitoring (AFDAS) are linked to lower IS recurrence risk than AF known before stroke occurrence (KAF) because of being at an earlier progression stage than KAF. Additionally, we posited that IS recurrence risk differences between AF types vary over time due to their differential progression stages.

PATIENTS AND METHODS

Retrospective observational cohort study including IS/TIA patients with KAF, ECG-AF, and AFDAS [2018-2021]. Adjusted hazard ratios (aHR) were estimated using multivariable cause-specific Cox proportional-hazard models to compare IS recurrence between ECG-AF versus KAF and AFDAS versus KAF. Proportional hazards assumptions were tested to assess whether IS recurrence risk differences were time-varying.

RESULTS

Of 758 AF patients (385 KAF, 236 ECG-AF, 137 AFDAS), 603 received anticoagulation and 59 experienced a recurrent IS after 1441 patient-years of follow-up. No IS recurrence risk differences were observed at the end of follow-up between ECG-AF and KAF (aHR 0.67, 95% CI 0.36-1.26), although ECG-AF showed lower risk only within the first year (aHR 0.15; 95% CI 0.04-0.56). AFDAS exhibited a lower IS recurrence risk than KAF (aHR 0.22, 95% CI 0.08-0.63), without time-varying differences.

DISCUSSION

Differences in IS recurrence risk between ECG-AF and KAF varied over time. However, AFDAS showed a consistently lower IS risk than KAF throughout the entire study period.

Effectiveness of abdominal electroacupuncture therapy for poststroke constipation: a meta-analysis

Background

Electroacupuncture (EA) has been employed to address the symptoms of constipation in individuals who have experienced a stroke. However, supporting evidence for its efficacy is lacking. This meta-analysis aims to investigate whether EA was effective in treating poststroke constipation.

Methods

We conducted a comprehensive search of eight databases, including four English-language databases (PubMed, Embase, Web of Science, and the Cochrane Library) and four Chinese-language databases (Chinese Biomedical Literature Database, China National Knowledge Infrastructure, VIP, and Wanfang), for randomized controlled trials (RCTs) published from inception through January 31, 2023. To assess treatment effectiveness, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI).

Results

A total of 9 RCTs involving 601 participants were included. No heterogeneity was found across the included RCTs. The results of this meta-analysis indicated significant improvements in the total effective rate (RR = 1.39, 95% CI 1.27, 1.52), cure rates (RR 1.87, 95% CI 1.38, 2.54), constipation scoring system (MD = -2.51, 95% CI -3.05, -1.97), and quality of life (MD = -10.69, 95% CI -14.2, -7.17) in the EA group compared with the control group.

Conclusion

Current evidence indicates that EA may be recommended for patients experiencing poststroke constipation. The lack of thorough investigations has undermined the quality of the major findings.

Molecular Targeting of Ischemic Stroke: The Promise of Naïve and Engineered Extracellular Vesicles

Ischemic stroke (IS) remains a leading cause of mortality and long-term disability worldwide, with limited therapeutic options available. Despite the success of early interventions, such as tissue-type plasminogen activator administration and mechanical thrombectomy, many patients continue to experience persistent neurological deficits. The pathophysiology of IS is multifaceted, encompassing excitotoxicity, oxidative and nitrosative stress, inflammation, and blood-brain barrier disruption, all of which contribute to neural cell death, further complicating the treatment of IS. Recently, extracellular vesicles (EVs) secreted naturally by various cell types have emerged as promising therapeutic agents because of their ability to facilitate selective cell-to-cell communication, neuroprotection, and tissue regeneration. Furthermore, engineered EVs, designed to enhance targeted delivery and therapeutic cargo, hold the potential to improve their therapeutic benefits by mitigating neuronal damage and promoting neurogenesis and angiogenesis. This review summarizes the characteristics of EVs, the molecular mechanisms underlying IS pathophysiology, and the emerging role of EVs in IS treatment at the molecular level. This review also explores the recent advancements in EV engineering, including the incorporation of specific proteins, RNAs, or pharmacological agents into EVs to enhance their therapeutic efficacy.

Knowledge of stroke risk factors and prevention among hypertensive patients on follow-up at Addis Ababa University Tertiary Hospital, Addis Ababa, Ethiopia: a cross-sectional study

OBJECTIVE

This study was conducted to assess knowledge of stroke risk factors and prevention among hypertensive patients on follow-up at Addis Ababa University Tertiary Hospital, Addis Ababa, Ethiopia.

DESIGN

Cross-sectional study design.

SETTING

This study was conducted at Addis Ababa University Tertiary Hospital in Addis Ababa, Ethiopia.

PARTICIPANTS

The sample size was determined using the single population proportion calculation. A list of all patients with hypertension on follow-up was framed from the appointment book of the cardiovascular clinic. Then, 316 participants were recruited by simple random sampling procedure from 18 April 2022 to 19 May 2022. The study included all patients with hypertension >18 years of age who were on follow-up during the data-collecting period. In contrast, patients with memory loss or cognitive impairment and who are unable to communicate were excluded from the study.

RESULT

With a response rate of 96.8%, 306 respondents in total were questioned. The average age of the participants was 53.6 years (SD±13.4). More than half of participants (52.9%) were female. The average score for understanding stroke risk factors and prevention is 44.1% and 49.7%, respectively. Knowledge of stroke risk factors was substantially correlated with residency and educational level, while knowledge of stroke prevention was significantly associated with sex, income and educational level.

CONCLUSION

This study indicates that patients with hypertension who participated in the study had poor knowledge of stroke risk factors and prevention. The mean score of knowledge on risk factors and prevention strategies of stroke is 44.1% and 49.7%, respectively, and needs improvement.

Association between platelet-to-high-density lipoprotein cholesterol ratio and future stroke risk: a national cohort study based on CHARLS

Background

According to recent research, there is a considerable correlation between the severity of coronary artery disease and the platelet-to-high-density lipoprotein cholesterol ratio (PHR), which suggests that PHR is a potentially valuable inflammatory biomarker. However, the body of current research offers insufficiently strong evidence to clarify the connection between PHR and the incidence of stroke. Therefore, this study aims to elucidate any potential associations between PHR and stroke risk.

Methods

This study employed data from the China Health and Retirement Longitudinal Study (CHARLS) covering the period from 2011 to 2018. It included 5,872 participants who did not have a history of stroke in 2011. These patients were separated into four groups according to their baseline PHR quartiles. The main goal of the study was to focus on stroke outcomes. Stroke was defined as an occurrence of a cerebrovascular accident confirmed by a physician. We employed Cox proportional hazards regression models to investigate the association between PHR and the likelihood of experiencing a stroke. Furthermore, we conducted restricted cubic spline regression analysis and subgroup analysis.

Results

The average follow-up period was 77.5 months, during which 390 participants experienced a stroke. In comparison to the lowest quartile group, participants in the highest quartile of PHR had a 49% increased risk of stroke (HR 1.49, 95% CI 1.13-1.96, p = 0.004). The adjusted multivariable Cox regression analysis maintained the statistical significance of this association (aHR 1.42, 95% CI 1.06-1.90, p = 0.019). After adjustment, a positive linear relationship between stroke risk and PHR was identified through restricted cubic spline regression analysis (nonlinear p > 0.05). Additionally, the impact of stroke was consistent across a variety of subgroups, as evidenced by subgroup analysis.

Conclusion

Our study indicates that higher PHR levels are significantly associated with an increased risk of stroke and that these levels can be used to identify groups that are at high risk of stroke.

Therapeutic Strategies for Retinal Artery Occlusion-A Literature Review

Retinal artery occlusion (RAO) is an emergency condition causing acute retinal ischemia and is considered an equivalent of ischemic stroke. The occurrence of an episode of RAO is associated with significant impairment of visual functions and correlates with an increased risk of future vascular events. Although RAO requires immediate diagnosis and treatment, there are currently no clear guidelines specifying optimal management. This review discusses current and future therapeutic strategies following an episode of RAO, including secondary prevention.

Nose-to-brain delivery of stem cells in stroke: the role of extracellular vesicles

Stem cell transplantation offers a promising therapy that can be administered days, weeks, or months after a stroke. We recognize 2 major mitigating factors that remain unresolved in cell therapy for stroke, notably: (1) well-defined donor stem cells and (2) mechanism of action. To this end, we advance the use of ProtheraCytes, a population of non-adherent CD34+ cells derived from human peripheral blood and umbilical cord blood, which have been processed under good manufacturing practice, with testing completed in a phase 2 clinical trial in post-acute myocardial infarction (NCT02669810). We also reveal a novel mechanism whereby ProtheraCytes secrete growth factors and extracellular vesicles (EVs) that are associated with angiogenesis and vasculogenesis. Our recent data revealed that intranasal transplantation of ProtheraCytes at 3 days after experimentally induced stroke in adult rats reduced stroke-induced behavioral deficits and histological damage up to 28 days post-stroke. Moreover, we detected upregulation of human CD63+ EVs in the ischemic brains of stroke animals that were transplanted with ProtheraCytes, which correlated with increased levels of DCX-labeled neurogenesis and VEGFR1-associated angiogenesis and vasculogenesis, as well as reduced Iba1-marked inflammation. Altogether, these findings overcome key laboratory-to-clinic translational hurdles, namely the identification of well-characterized, clinical grade ProtheraCytes and the elucidation of a potential CD63+ EV-mediated regenerative mechanism of action. We envision that additional translational studies will guide the development of clinical trials for intranasal ProtheraCytes allografts in stroke patients, with CD63 serving as a critical biomarker.

Specific gut microbiome signatures predict the risk of acute ischemic stroke

Introduction

Numerous studies have reported alterations in the composition of gut microbiota in patients with acute ischemic stroke (AIS), with changes becoming more pronounced as the disease progresses. However, the association between the progression of transient ischemic attack (TIA) and AIS remains unclear. This study aims to elucidate the microbial differences among TIA, AIS, and healthy controls (HC) while exploring the associations between disease progression and gut microbiota.

Methods

Fecal samples were collected from acute TIA patients (n = 28), AIS patients (n = 235), and healthy controls (n = 75) and analyzed using 16 s rRNA gene sequencing. We determined characteristic microbiota through linear discriminant analysis effect size and used the receiver operating characteristic (ROC) curve to assess their predictive value as diagnostic biomarkers.

Results

Our results showed significant gut microbial differences among the TIA, AIS, and HC groups. Patients with AIS exhibited higher abundances of Lactobacillus and Streptococcus, along with lower abundances of Butyricicoccaceae and Lachnospiraceae_UCG-004. Further analysis revealed that the abundance of characteristic bacteria, such as Lactobacillus and Streptococcus, was negatively correlated with HDL levels, while Lactobacillus was positively correlated with risk factors such as homocysteine (Hcy). In contrast, the abundance of Lachnospiraceae_UCG-004 was negatively correlated with both Hcy and D-dimer levels. ROC models based on the characteristic bacteria Streptococcus and Lactobacillus effectively distinguished TIA from AIS, yielding areas under the curve of 0.699 and 0.626, respectively.

Conclusion

We identified distinct changes in gut bacteria associated with the progression from TIA to AIS and highlighted specific characteristic bacteria as predictive biomarkers. Overall, our findings may promote the development of microbiome-oriented diagnostic methods for the early detection of AIS.

Qualitative and quantitative analysis of 18F-GP1 positron emission tomography in thrombotic cardiovascular disease

18F-GP1 is a novel highly specific radiotracer that binds to activated platelets and thrombus. We aimed to establish the observer repeatability of coronary, carotid and cerebral 18F-GP1 uptake in patients presenting with acute myocardial infarction or ischaemic stroke. Forty-three patients presenting with acute myocardial infarction or ischaemic stroke underwent hybrid positron emission tomography (PET) and computed tomography (CT) angiography. Qualitative and quantitative assessment of 18F-GP1 uptake was performed on coronary arteries, carotid arteries and brain parenchyma. Qualitative uptake of 18F-GP1 had excellent intraobserver and interobserver agreement, with complete agreement for the presence or absence of visual 18F-GP1 uptake. For quantitative analysis, there were excellent intraclass correlation coefficients for intraobserver repeatability for coronary artery, carotid artery and brain parenchymal SUVmax and TBRmax measurements (all ≥ 0.92). Coronary artery and brain parenchymal analyses showed the strongest agreement in SUVmax values with mean biases of - 0.04 (limits of agreement - 0.21 to 0.20) and 0.02 (limits of agreement - 0.29 to 0.32) respectively. There was good interclass correlation coefficients for interobserver repeatability for coronary artery, carotid artery and brain parenchymal SUVmax and TBRmax measurements (all ≥ 0.89). The strongest interobserver agreement was seen with brain parenchymal SUVmax (mean SUVmax 1.95 ± 0.94) and TBRmax (mean TBRmax 9.55 ± 6.56) with mean biases of - 0.05 (limits of agreement - 0.37 to 0.27) and 0.04 (limits of agreement - 0.59 to 0.52) respectively. Visual qualitative and quantitative 18F-GP1 PET-CT image analyses provide robust and repeatable measurements of activated platelets and thrombi within the coronary arteries, carotid arteries and brain parenchyma.

Mendelian randomization studies of lifestyle-related risk factors for stroke: a systematic review and meta-analysis

Objective

Stroke risk factors often exert long-term effects, and Mendelian randomization (MR) offers significant advantages over traditional observational studies in evaluating the causal impact of these factors on stroke. This study aims to consolidate and evaluate the relationships between potential causal factors and stroke risk, drawing upon existing MR research.

Methods

A comprehensive search for MR studies related to stroke was conducted up to August 2023 using databases such as PubMed, Web of Science, Embase, and Scopus. This meta-analysis examines the relationships between potential causative factors and stroke risk. Both random-effects and fixed-effects models were utilized to compile the dominance ratios of various causative elements linked to stroke. The reliability of the included studies was assessed according to the Strengthening the Reporting of Observational Studies in Epidemiology incorporating Mendelian Randomization (STROBE-MR) guidelines.

Results

The analysis identified several risk factors for stroke, including obesity, hypertension, low-density lipoprotein cholesterol (LDL-C), chronic kidney disease (CKD), and smoking. Protective factors included high-density lipoprotein cholesterol (HDL-C), estimated glomerular filtration rate (eGFR), and educational attainment. Subgroup analysis revealed that type 2 diabetes mellitus (T2DM), diastolic blood pressure (DBP) are risk factors for ischemic stroke (IS).

Conclusion

This study confirms that variables such as obesity, hypertension, elevated LDL-C levels, CKD, and smoking are significantly linked to the development of stroke. Our findings provide new insights into genetic susceptibility and potential biological pathways involved in stroke development.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42024503049.

Combined robot-assisted therapy virtual reality for upper limb rehabilitation in stroke survivors: a systematic review of randomized controlled trials

BACKGROUND

Upper limb impairments are among the most common consequences following a stroke. Recently, robot-assisted therapy (RT) and virtual reality (VR) have been used to improve upper limb function in stroke survivors.

OBJECTIVES

This review aims to investigate the effects of combined RT and VR on upper limb function in stroke survivors and to provide recommendations for researchers and clinicians in the medical field.

METHODS

We searched PubMed, SCOPUS, REHABDATA, PEDro, EMBASE, and Web of Science from inception to March 28, 2024. Randomized controlled trials (RCTs) involving stroke survivors that compared combined RT and VR interventions with either passive (i.e., sham, rest) or active (i.e., traditional therapy, VR, RT) interventions and assessed outcomes related to upper limb function (e.g., strength, muscle tone, or overall function) were included. The Cochrane Collaboration tool was used to evaluate the methodological quality of the included studies.

RESULTS

Six studies were included in this review. In total, 201 patients with stroke (mean age 57.84 years) were involved in this review. Four studies were considered 'high quality', while two were considered as 'moderate quality' on the Cochrane Collaboration tool. The findings showed inconsistent results for the effects of combined RT and VR interventions on upper limb function poststroke.

CONCLUSION

In conclusion, there are potential effects of combined RT and VR interventions on improving upper limb function, but further research is needed to confirm these findings, understand the underlying mechanisms, and assess the consistency and generalizability of the results.

Impact of Newly Diagnosed Cancer on Bleeding Events in Patients with Atrial Fibrillation Treated with Direct Oral Anticoagulants

BACKGROUND

In patients with atrial fibrillation (AF), the association between cancer and cardioembolic or bleeding risk during oral anticoagulant therapy still remains unclear.

PURPOSE

We aimed to assess the impact of cancer present at baseline (CB) or diagnosed during follow-up (CFU) on bleeding events in patients treated with direct oral anticoagulants (DOACs) for non-valvular AF (NVAF) compared with patients without CB or CFU, respectively.

METHODS

All consecutive patients with NVAF treated with DOACs for stroke prevention were enrolled between January 2017 and March 2019. Primary outcomes were bleeding events or cardiovascular death, non-fatal stroke and non-fatal myocardial infarction, and the composite endpoint between patients with and without CB and between patients with and without CB.

RESULTS

The study population comprised 1170 patients who were followed for a mean time of 21.6 ± 9.5 months. Overall, 81 patients (6.9%) were affected by CB, while 81 (6.9%) were diagnosed with CFU. Patients with CFU were associated with a higher risk of bleeding events and major bleeding compared with patients without CFU. Such an association was not observed between the CB and no CB populations. In multivariate analysis adjusted for anemia, age, creatinine, CB and CFU, CFU but not CB remained an independent predictor of overall and major bleeding (hazard ratio [HR] 2.67, 95% confidence interval [CI] 1.8-3.89, p < 0.001; HR 3.02, 95% CI 1.6-3.81, p = 0.001, respectively).

CONCLUSION

During follow-up, newly diagnosed primitive or metastatic cancer in patients with NVAF taking DOACs is a strong predictor of major bleeding regardless of baseline hemorrhagic risk assessment. In contrast, such an association is not observed with malignancy at baseline. Appropriate diagnosis and treatment could therefore reduce the risk of cancer-related bleeding.

Healthcare self-management support of stroke patients after discharge: A conceptual analysis using Rodger's evolutionary approach

AIM(S)

To explore the meaning of healthcare self-management support for post-discharged stroke patients.

METHOD

Rodgers' evolutionary approach was used to identify antecedents, attributes, related terms, surrogate terms and consequences.

DATA SOURCE

Literature from 2012 to 2022 was searched from MEDLINE, CINAHL, PsycINFO and Google Scholar.

RESULTS

Three antecedents preceded healthcare self-management support for post-discharged stroke patients: loss of inpatient support, preparedness for self-management and presence of self-management support. Healthcare self-management support for post-discharged stroke patients was defined by eight attributes: pre-discharge assessment and planning; provision of continuous education and training; collaborative goal-setting; reinforcement and documentation of vital information; coordination of post-discharge care; provision of rehabilitation support and promoting community reintegration; provision of counselling support; and using clear communication, patient empowerment and promoting self-efficacy. The identified consequences of the concept were as follows: improved patient outcomes; improved life quality; decreased healthcare cost; decreased re-admission rate and inpatient care burden; and decreased complication rate.

CONCLUSION

Healthcare self-management support for post-discharged stroke patients is an emerging concept that can help to significantly improve stroke patients' health outcomes and life quality. However, its applicability is uncertain considering the workload, time and resources available to healthcare professionals. There is a need for future studies to focus on the feasibility and applicability of this concept in clinical practice and to identify any challenges healthcare providers may have in supporting stroke patients after discharge.

IMPACT

This concept analysis brings clarity to the concept of healthcare self-management support of post-discharged stroke patients and distinguishes it from other self-management supports. It provides an opportunity for further studies and a pathway for generalized healthcare self-management support for stroke patients after discharge to improve health outcomes and quality of life.

NO PATIENT OR PUBLIC CONTRIBUTION

No patients, service users, caregivers or members of the public were involved in conducting this concept analysis.

Life's Essential 8 Trajectories and Risk of Stroke: A Prospective Cohort Study

BACKGROUND

Evidence is lacking regarding long-term patterns of change in Life's Essential 8 (LE8) and their association with the risk of stroke. We aim to evaluate LE8 trajectories and examine their association with the risk of stroke in China.

METHODS

This study, conducted in a workplace setting, recruited 26 719 participants (average age, 46.02±11.27 years and a male population of 73.73%) who had no history of stroke and consecutively participated in 6 surveys from 2006 to 2016. Repeated LE8 measurements were determined by taking the unweighted average of the 8 component scores ranging from 0 to 100. People with higher scores had better overall cardiovascular health. By examining the medical records of the participants, stroke cases were identified for the period from 2016 to 2020. A latent mixture model was applied to classify the trajectory clusters of LE8 from 2006 to 2016, and Cox proportional hazard models were used to analyze the data.

RESULTS

Five LE8 trajectories were detected between 2006 and 2016. Four hundred ninety-eight incident strokes including 55 (11.04%) hemorrhagic and 458 (91.97%) ischemic strokes were documented. After adjusting for covariates, the hazard ratios and 95% CIs for the association between stable-low, moderate-increasing, moderate-stable, and high-stable trajectories and incident stroke, compared with the moderate-decreasing trajectory, were 1.42 (1.11-1.84), 0.73 (0.56-0.96), 0.49 (0.39-0.62), and 0.19 (0.11-0.32), respectively. Individuals with high LE8 status (LE8≥80) exhibited a significantly reduced risk of stroke compared with those with low one (LE8≤49; P-trend <0.001). A faster annual growth in LE8 was related to a lower risk of stroke.

CONCLUSIONS

Maintaining high LE8 over an extended period and high baseline LE8 status were related to a decreased risk of stroke. Despite the initial low level of LE8, improvement in LE8 attenuates or even reverses the risk of stroke.

Migraine May Represent an Independent Risk Factor for Retinal Stroke: A Population-Based Cohort Study

INTRODUCTION

Migraine is an established risk factor for cerebral ischemic stroke, with an especially robust association in patients with migraine with aura. However, it is not known if migraine is a risk factor for retinal stroke (central or branch retinal artery occlusion; CRAO or BRAO).

METHODS

We performed a retrospective, observational, cohort study using population-based data from the State Inpatient Databases and State Emergency Department Databases from New York (2006-2015), California (2003-2011), and Florida (2006-2015) to determine the association between hospital-documented migraine and retinal stroke. The primary exposure was hospital-documented migraine (ascertained from admission or emergency department diagnosis codes). The primary endpoint was time to hospital-documented CRAO (ICD-9-CM code 362.31 in the primary diagnosis position) and secondary endpoints included time to BRAO and any retinal artery occlusion (RAO). Cause-specific hazard models were used to model the association between migraine and subsequent CRAO.

RESULTS

Of 39,835,024 patients included in the study, 1109,140 had migraine documented during our two year ascertainment window. Patients with migraine were younger (40.2±15.2 vs. 46.9±19.8, standardized difference (SD) 0.38), more likely to be female (81.4 % vs. 54.7 %, SD 0.6), and had a lower burden of atrial fibrillation (4.5 % vs. 6.9 %, SD 0.1), chronic kidney disease (1.9 % vs. 3.6 %, SD 0.2), and congestive cardiac failure (2.7 % vs. 5.1 %, SD 0.12). Migraine was not associated with CRAO in the primary diagnostic position (adjusted hazard rate (aHR) 1.15 (95 % CI: 0.79-1.67). However, it was associated with CRAO in any diagnostic position (aHR 1.39 (95 % CI: 1.08-1.78). As positive controls, we replicated previously established associations of migraine with cerebral ischemic stroke (aHR 1.35 (95 % CI: 1.32-1.38) and embolic ischemic stroke (aHR 1.15 (95 % CI: 1.08-1.22).

CONCLUSIONS

In a large, nationally-representative, claims-based study of patients from 3 regions in the United States (US), we did not find an adjusted association between migraine and a primary discharge diagnosis of CRAO. Our hypothesis-generating finding that migraine was associated with CRAO when using a broader definition sets the stage for future work leveraging both outpatient and pharmacy based claims to further explore this finding.

Rate and predictors of thromboprophylaxis in internal medicine wards: Results from the AURELIO study

BACKGROUND

Randomized controlled trials suggest that prophylactic doses of anticoagulants effectively prevent venous thromboembolism (VTE) in hospitalized medical patients with high thromboembolic risk. However, no prospective studies exist regarding the real-world prevalence of prophylactic anticoagulant use. This prospective study aimed to determine the rate and predictors of thromboprophylaxis in an unselected population of patients hospitalized in medical departments.

METHODS

We conducted a multicenter prospective observational study (AURELIO - rAte of venous thrombosis in acutely iLl patIents hOspitalized) to assess the rate of deep vein thrombosis (DVT) in unselected acutely ill patients hospitalized in medical wards using compression ultrasound (CUS) at admission and discharge. Additionally, we evaluated the rate of pharmacological thromboprophylaxis administration in this population and analyzed the thrombotic risk by assessing RAMs (Risk Assessment Models) such as the IMPROVE-VTE and PADUA scores following the clinician's decision to administer thromboprophylaxis. Patients with IMPROVE-VTE scores ≥3 and/or PADUA scores ≥4 were classified as high thrombotic risk; those with IMPROVE-VTE scores <3 and/or PADUA scores <4 were classified as low risk.

RESULTS

We recruited 2371 patients (1233 males [52 %] and 1138 females [48 %]; mean age 72 ± 16 years). The median length of hospitalization was 13 ± 12 days. Overall, 442/2371 (18.6 %) patients received prophylactic parenteral anticoagulants (subcutaneous low weight molecular heparin or fondaparinux once daily) at admission. Assessing the thrombotic risk of the population recruited 1016 (42.9 %) patients were classified as high risk and 1354 (57.1 %) were low risk. Among high-risk patients, 339/1016 (33.4 %) received anticoagulant prophylaxis compared to 103/1354 (7.6 %) low-risk patients. During hospitalization, 9 patients developed DVT, comprising 7 asymptomatic and 2 symptomatic cases of proximal DVT. Of these, 3 patients were on anticoagulant prophylaxis, while 6 were not. Among the high-risk population, 7 out of 1016 patients (0.7 %) experienced proximal DVT during hospitalization, with 2 out of these 7 (28 %) receiving anticoagulant thromboprophylaxis. In the low-risk population, 2 out of 1354 patients (0.2 %) developed DVT, with 1 out of these 2 (50 %) receiving anticoagulant thromboprophylaxis. Age, heart or respiratory failure, pneumonia, active neoplasia, previous VTE, reduced mobility, and absence of kidney failure were more frequent in patients receiving prophylaxis. Multivariable logistic regression identified age (RR 1.010; CI 95 % 1002-1019; p = 0.015), heart/respiratory failure (RR 1.609; CI 95 % 1248-2075; p < 0.0001), active neoplasia (RR 2.041; CI 95 % 1222-2141; p < 0.0001), pneumonia (RR 1.618; CI 95 % 1557-2676; p < 0.0001), previous VTE (RR 1.954; CI 95 % 1222-3125; p < 0.0001), and reduced mobility (RR 4.674; CI 95 % 3700-5905; p < 0.0001) as independent predictors of thromboprophylaxis.

CONCLUSIONS

This study, conducted without pre-established thromboembolic risk scores, offers a comprehensive view of venous thromboembolism prophylaxis in medical patients with acute conditions hospitalized in internal medicine departments. It reveals that advanced age, heart or respiratory failure, active cancer, pneumonia, previous VTE, and reduced mobility are predictors that may influence the decision to administer thromboprophylaxis in these patients.

A systematic review of the socioeconomic impact of mechanical thrombectomy for acute ischemic stroke

BACKGROUND

Mechanical Thrombectomy (MT) is an efficacious treatment for severe acute ischemic stroke patients. However, access to MT is limited in many parts of the world, partly due to economic barriers. The purpose of this systematic review is to provide an updated frame about the socioeconomic impact of MT.

METHODS

To carry out this systematic review we used the PRISMA guidelines. We included scientific articles analyzing the socioeconomic impact of MT for acute ischemic stroke, in which MT was compared to best medical therapy (BMT). The online databases of Pubmed, Scopus and Web of Science were used as main sources of information. To carry out the comparative analysis, the incremental cost-effectiveness ratio (ICER) was used, relating the cost to quality-adjusted life-year (QALY). Risk of bias was assessed with the Consensus Health Economic Criteria (CHEC) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).

RESULTS

Eight hundred thirty-two studies were identified in this systematic review. As a result, studies that used cost-effectiveness analysis show that MT saves costs in the long term and cost-utility analysis show that the cost per QALY is reasonable with a mean ICER value of $14242.36/QALY.

CONCLUSIONS

MT has a favorable socioeconomic impact, as derived from cost-effectiveness and cost-utility analyses. Therefore, public policies should encourage the implementation of MT for stroke patients around the world.

Translation and validation of the Persian version of the Stroke Self-Efficacy Questionnaire in stroke survivors

BACKGROUND

The Stroke Self-Efficacy Questionnaire (SSEQ) is a self-report scale that measures stroke survivors' self-efficacy and covers specific domains of functioning after stroke.

OBJECTIVES

We aimed to determine the validity and reliability of the Persian version of the SSEQ.

METHODS

This descriptive cross-sectional study included 124 stroke patients in the sub-acute phase (between 2 weeks and 3 months of stroke onset). The original SSEQ was translated to Persian and back-translated to English. Demographic, neurologic examination, 'Persian Stroke Self-Efficacy Questionnaire (SSEQ-P)', and 'General Self-Efficacy Scale' (GSE-10) data were collected. The reliability of the questionnaire was evaluated by test-retest assessment among 30 people with stroke at an interval of two weeks. Factor analysis was used to assess the validity of SSEQ-P. Cronbach's alpha assessed internal consistency in all participants. Statistical analysis was performed by SPSS software version 23 and SmartPLS version 3.

RESULTS

In this study, the mean of SSEQ scores was 87.99 ± 37.09. Content Validity Ratio (CVR) and Content Validity Index (CVI) were favorable. Convergent validity of the questionnaire was reported (r = 0.669) using GSE. Factor loadings of items in SSEQ ranged from 0.41 to 0.92. Validity indices (AVE = 0.75, SRMR = 0.07) showed that the single-factor model of the present study owns a favorable fit. Test-retest reliability and Cronbach's alpha values of SSEQ in the present study were calculated at 0.80 and 0.97, respectively.

CONCLUSIONS

The Persian version of the SSEQ depicted acceptable reliability and validity and can be utilized to evaluate the self-efficacy of patients with stroke.HIGHLIGHTSStroke Self-Efficacy Questionnaire (SSEQ) is a self-report scale that measures stroke survivors' self-efficacy.The Persian version of the SSEQ demonstrated acceptable reliability and validity and can be used in stroke patients.

Challenges in Diagnosis of Non-A Non-B Acute Aortic Dissection

BACKGROUND

Non-A non-B (NANB) aortic dissections are uncommon and frequently unrecognized diseases. However, their proper identification is crucial given the unpredictable behavior of the dissected aorta with potential mortality and increased morbidity. We investigate the accuracy of radiological computed tomography angiography (CTA) reports in the diagnosis of acute NANB and the risk related to delayed recognition or misdiagnosis.

METHODS

The pretreatment contrast CTA of all consecutive patients admitted with acute aortic dissection (AAD) in a University Hospital in London (UK) between January 2017 and May 2023 were reviewed to retrospectively verify the accuracy of CTA reports in the diagnosis of NANB AAD (B1-2D The risk related to the delayed diagnosis (morbidity, mortality, and hospital readmissions) were evaluated as secondary outcomes. The study was conducted according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

RESULTS

Overall, 588 aortic CTAs were reviewed for a total of n = 393 (66.8%) type A AADs, n = 171 (29%) type B AADs and n = 25 (4.3%) NANB AADs (n = 16, 64% men, mean age 60.56, standard deviation ± 14.6 years). While no case of misdiagnosis was identified in Type A or B AAD groups, in NANBs only about a third of cases (n = 9, 36%) were immediately indicated as "NANB" (n = 2, 8%) or "B with retrograde extension into the arch" (n = 7, 28%), n = 8 cases (32%) were described generically as "arch dissections" (n = 6, 24%) or "type A and B" AAD (n = 2, 8%). The remaining 32% of patients received a diagnosis that did not include mention of the arch, as n = 6 (24%) cases were reported to be "type A″ and n = 2 (8%) to be "type B″ AADs. Despite the heterogeneity of terms used to describe NANB AAD, no case of cardiac tamponade, new onset malperfusion nor neurological complications were reported, and no sudden death nor home-discharge and readmission while waiting for the proper diagnosis.

CONCLUSIONS

The heterogeneity of terms used to describe NANB aortic dissection highlights the need for increased awareness, adoption of in guideline based classification systems, and further education to better understand and correctly address this challenging entity, minimizing misdiagnosis in ambiguous or difficult cases.

PCSK9 inhibitor added to high-intensity statin therapy to prevent cardiovascular events in patients with acute coronary syndrome after percutaneous coronary intervention: a randomized, double- blind, placebo-controlled, multicenter SHAWN study

BACKGROUND

It is currently uncertain whether the combination of a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor and high-intensity statin treatment can effectively reduce cardiovascular events in patients with acute coronary syndrome (ACS) who have undergone percutaneous coronary intervention (PCI) for culprit lesions.

METHODS

This study protocol describes a double-blind, randomized, placebo-controlled, multicenter study aiming to investigate the efficacy and safety of combining a PCSK9 inhibitor with high-intensity statin therapy in patients with ACS following PCI. A total of 1,212 patients with ACS and multiple lesions will be enrolled and randomly assigned to receive either PCSK9 inhibitor plus high-intensity statin therapy or high-intensity statin monotherapy. The randomization process will be stratified by sites, diabetes, initial presentation and use of stable (≥4 weeks) statin treatment at presentation. PCSK 9 inhibitor or its placebo is injected within 4 hours after PCI for the culprit lesion. The primary endpoint is the composite of cardiovascular death, myocardial infarction, stroke, re-hospitalization due to ACS or heart failure, or any ischemia-driven coronary revascularization at 1-year follow-up between 2 groups. Safety endpoints mean PCSK 9 inhibitor and statin intolerance.

CONCLUSION

The SHAWN study has been specifically designed to evaluate the effectiveness and safety of adding a PCSK9 inhibitor to high-intensity statin therapy in patients who have experienced ACS following PCI. The primary objective of this study is to generate new evidence regarding the potential benefits of combining a PCSK9 inhibitor with high-intensity statin treatment in reducing cardiovascular events among these patients.

The benefit of optimizing recanalization during mechanical thrombectomy in patients with acute ischemic stroke depends on preprocedural tissue-level collateralization

PURPOSE

Thrombolysis in Cerebral Infarction (TICI) 3 represents the optimal angiographic outcome following mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Although it is known to yield better outcomes than TICI 2b, the influence of preprocedural cerebral hemodynamics on the clinical advantage of TICI 3 over TICI 2b remains unexplored.

METHODS

This single-center retrospective analysis involved patients with anterior circulation AIS who underwent successful recanalization during MT at the Comprehensive Stroke Center, University Hospital, Krakow between January 2019 and July 2023. We assessed the benefit of achieving TICI 2c/3 over TICI 2b on the basis of preprocedural computed perfusion imaging results, primarily focusing on early infarct volume (EIV) and tissue-level collaterals indicated by hypoperfusion intensity ratio (HIR). Good functional outcome (GFO) was defined as a modified Rankin Score < 3 on day 90.

RESULTS

The study comprised 612 patients, of whom 467 (76.3%) achieved TICI 2c/3. GFO was more frequent in the TICI 2c/3 group (54.5% vs 69.4%, p < 0.001). There was interaction between the recanalization status and both HIR (Pi = 0.042) and EIV (Pi = 0.012) in predicting GFO, with disproportionately higher impact of HIR and EIV in TICI 2b group. The benefit from TICI 2c/3 over TICI 2b was insignificant among patients with good collaterals, defined by HIR < 0.3 (odds ratio:1.36 [0.58-3.18], p = 0.483).

CONCLUSION

TICI 2c/3 improves patient functional outcomes compared to TICI 2b regardless of EIV. However, such angiographic improvement may be clinically futile in patients with good tissue-level collateralization. Our findings suggest that preprocedural HIR should be considered when optimization of recanalization is considered during MT.

Remnant cholesterol as a residual risk in atherosclerotic cardiovascular disease patients under statin-based lipid-lowering therapy: A post hoc analysis of the RACING trial

BACKGROUND

Remnant cholesterol (remnant-C) levels during lipid-lowering therapy (LLT) may indicate residual risk.

OBJECTIVE

We aimed to investigate the clinical outcomes based on on-treatment remnant-C distribution in patients with atherosclerotic cardiovascular disease (ASCVD) under statin-based LLT.

METHODS

In this post hoc analysis of the RACING trial, 3,348 patients with ASCVD lipid profiles 1 year after randomization were investigated. Remnant-C was calculated as total cholesterol minus low-density lipoprotein cholesterol (LDL-C) minus high-density lipoprotein cholesterol. The primary endpoint was a 3-year composite of cardiovascular death, major cardiovascular events, or non-fatal stroke.

RESULTS

The study population was grouped into tertiles according to on-treatment remnant-C: high (> 20.5 mg/dL; n = 1,116), intermediate (14‒20.5 mg/dL; n = 1,031), and low (≤14.0 mg/dL; n = 1,201) remnant-C groups. The high remnant-C group showed the highest incidence of the primary endpoint at 3 years (11.0%, 10.3%, and 7.5% in the high, intermediate, and low remnant-C groups, respectively; p = 0.009). The high remnant-C levels at 1 year were independently associated with an increased risk of the primary outcome, whereas achieving LDL-C < 55 or 70 mg/dL was not associated with the incidence of the primary endpoint. The on-treatment remnant-C cut-off of 17 mg/dL (median) demonstrated the ability to discriminate between patients at higher and lower risks for the primary endpoints (hazard ratio: 1.42; 95% confidence interval: 1.14‒1.78; p = 0.002).

CONCLUSIONS

In patients with ASCVD undergoing statin-based LLT, high on-treatment remnant-C values were associated with unfavorable clinical outcomes. On-treatment remnant-C levels may serve as an additional means of assessing residual cardiovascular risk.

CLINICAL TRIAL REGISTRATION

ClinicalTrials. gov ID: NCT03044665.

Diabetes Mellitus and Risk of Future Stroke: Evidence From CHARLS and Mendelian Randomization Analyses

OBJECTIVES

This study leveraged the China Health and Retirement Longitudinal Study (CHARLS) to explore the association between diabetes and stroke in middle-aged and older adults in East Asia and assess the causality of this relationship using Mendelian randomization.

METHODS

Data from the 2011-2020 CHARLS cohort identified individuals with diabetes at baseline. Stroke incidence was self-reported through standardized questionnaires. Logistic regression and restricted cubic spline analysis examined the relationship between diabetes and stroke risk alongside nonlinear correlations between glucose levels and stroke. Mendelian randomization clarified the causal link and analyzed the mediating effect between diabetes and stroke using genetic methods.

RESULTS

In the study population aged 45 and above, stroke incidence was 5.99% in normoglycemic, 6.82% in prediabetic, and 9.93% in diabetic individuals. Over 7 years, 473 strokes occurred. Diabetes was associated with a 1.35-fold increased stroke risk compared to normoglycemia (OR = 1.35; 95% CI: 1.03-1.79). Subgroup analyses highlighted higher stroke risks in middle-aged women, nonsmokers, and nondrinkers. Mendelian randomization supports a genetic causal relationship between diabetes and stroke. Diabetes may indirectly lead to stroke through the mediating effects of hypertension and high cholesterol.

CONCLUSION

The findings confirm a significant association and causal link between diabetes and stroke risk in an East Asian population. In addition, the results indicate that controlling blood glucose in prediabetic individuals reduces stroke risk, with no similar benefits in diabetes.

Stroke patient and stakeholder engagement (SPSE): concepts, definitions, models, implementation strategies, indicators, and frameworks-a systematic scoping review

BACKGROUND

Involving stroke patients in clinical research through patient engagement aims to ensure that studies are patient-centered, and may help ensure they are feasible, ethical, and credible, ultimately leading to enhanced trust and communication between researchers and the patient community. In this study, we have conducted a scoping review to identify existing evidence and gaps in SPSE.

METHODS

The five-step approach outlined by Arksey and O'Malley, in conjunction with the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) guidelines, provided the structure for this review. To find relevant articles, we searched PubMed, Web of Science, and Embase databases up to February 2024. Additionally, the review team conducted a hand search using Google Scholar, key journals, and references of highly relevant articles. Reviewers screened articles, selecting eligible English-language ones with available full texts, and extracted data from them into a pre-designed table tested by the research team.

RESULT

Of the 1002 articles initially identified, 21 proved eligible. Stakeholder engagement primarily occurred during the design phase of studies and within the studies using qualitative methodologies. Although the engagement of stakeholders in the research process is increasing, practice regarding terminology and principles of implementation remains variable. Researchers have recognized the benefits of stakeholder engagement, but have also faced numerous challenges that often arise during the research process.

CONCLUSION

The current study identifies stakeholder groups and the benefits and challenges researchers face in implementing their engagement. Given existing challenges and limited specific models or frameworks, it is suggested to explore applied recommendations for stakeholder engagement in future studies, that may enhance stakeholder engagement, overcome obstacles, and unify researchers' understanding of engagement and implementation.

Left Atrial Appendage Closure in Atrial Fibrillation Patients with Cancer

Background: There are limited data about left atrial appendage closure (LAAC) in patients with cancer. We therefore sought to compare the outcome after LAAC in patients with vs. without cancer in a multicentre registry. Methods: In this sub-analysis of the prospective Austrian LAAC Registry, we analysed consecutive patients undergoing LAAC to assess the relationship between baseline characteristics and outcome in patients with vs. without cancer. Inverse probability weighting was performed to adjust for differences in baseline characteristics. Results: A total of 486 consecutive patients from 9 centres with a median age of 75 years (IQR 70-79 years; 35.8% female) were included. Fifty-seven patients (11.7%) had a history of cancer. The median CHA2DS2-VASc and HAS-BLED scores were similar in both groups (median [IQR], 4 [4-6] vs. 5 [3-5], p = 0.415; 4 [3-4] vs. 3 [3-4], p = 0.428 in cancer vs. other patients). Cancer patients were significantly older, and anaemia and gastrointestinal bleeding were significantly more common. Major procedural complications occurred in 5.3% vs. 7.0% (p = 0.276) of patients. The cumulative five-year survival rates were 80.7% and 84.8% in cancer vs. other patients (adjusted hazard ratio for death 1.29 [95% CI 0.67-2.48], p = 0.443). There were also no differences in one-year survival (96.1% vs. 94.0%, p = 0.582) and five-year event-free survival (64.9% vs. 74.4%, p = 0.124). Conclusions: In daily clinical practice, LAAC has already been accepted as a treatment option in patients with cancer. This retrospective analysis shows that short-term and adjusted long-term complications are similar in patients with vs. without cancer undergoing LAAC.

Impact of Paroxysmal Atrial Tachycardia on Thromboembolic Events and Major Adverse Cardiovascular Events: A Single-Center Retrospective Study

Objective

Atrial fibrillation (AF) is known to increase the risk of thromboembolic events and major adverse cardiovascular events (MACE). The impact of paroxysmal atrial tachycardia (PAT) on these risks remains unclear.

Methods

This retrospective cohort study was conducted involving 889 patients diagnosed with PAT and 1106 control patients without PAT, all of whom underwent their initial 24-hour ECG monitoring between 2015 to 2020. Kaplan-Meier survival analysis and Cox regression analysis were used to evaluate the association between PAT and the study endpoints, including thromboembolic events and MACE.

Results

Over a mean follow-up period of 50.3 months, the incidence of thromboembolic events and MACE was significantly higher in the PAT group compared to the control group (6.5% vs 1.7% and 19.1% vs 9.9%, respectively). After adjusting for common risk factors and baseline imbalances, the PAT group exhibited a significantly elevated risk of thromboembolic events (hazard ratio [HR] 3.782, 95% confidence interval [CI] 2.212-6.467; P <0.001) and MACE (HR 1.795, 95% CI 1.398-2.305; P <0.001). However, the frequency of PAT episodes, heart rate, and maximum heart rate were not significantly associated with these outcomes. Within the PAT group, a history of stroke, transient ischemic attack, and chronic renal failure were identified as independent risk factors for thromboembolic events, while hypertension, coronary heart disease, heart failure, and chronic renal failure were independently associated with MACE.

Conclusion

PAT, as detected by 24-hour dynamic ECG, is associated with an increased risk of thromboembolic events and MACE.

Palmitoylethanolamide, an endogenous fatty acid amide, and its pleiotropic health benefits: A narrative review

The global nutritional transition has led to high frequency and severity of chronic degenerative diseases worldwide, primarily driven by chronic inflammatory stress. At the mealtimes, various pharmaceutical products aim to prevent such an inflammatory stress, they usually cause various systemic side effects. Therefore, supplementation of natural and safe ingredients is a great strategy to reduce the risk and severity of inflammatory stress-related diseases. As a result, palmitoylethanolamide (PEA), an endocannabinoid-like mediator, has been extensively studied for its myriad of actions, including anti-inflammatory, anti-microbial, immunostimulatory, neuroprotective, and pain-reducing effects with high tolerability and safety of PEA in animals and humans. Because of the multiple molecular targets and mechanisms of action, PEA has shown therapeutic benefits in various diseases, including neurological, psychiatric, ophthalmic, metabolic, oncological, renal, hepatic, immunological, rheumatological, and gastrointestinal conditions. The current review highlights the roles and functions of PEA in various physiological and pathological conditions, further supporting the use of PEA as an important dietary agent.

Diagnostic value of routine CT perfusion imaging for radiology residents

To evaluate whether incorporating CT perfusion imaging can significantly enhance diagnostic CT accuracy in stroke detection. Two 3rd-year residents (3rd of 5 years of residency) reviewed CT scans of 200 patients with suspected stroke, consisting of 104 patients with a proven stroke and a control group with 96 patients. They analyzed each patient in a blinded and randomized manner in two runs. In one session, they had only non-contrast CT and CT angiography available for diagnosis; in the other session at a later time point, an additional CT perfusion imaging was available. The performance achieved by the two readers was determined in terms of AUC (area under the curve), accuracy, sensitivity, specificity, positive and negative predictive value and Cohen's Kappa. Reader 1 achieved an AUC of 87.64% with the basic stroke-protocol vs. an AUC of 97.4% with an additional CT-perfusion given. Based on the DeLong test, these values differ significantly (p-value: 0.00017). Reader 2 achieved an AUC of 91.23% in basic stroke-protocol vs. an AUC of 96.42% with an additional CT-perfusion. These values also differ significantly (p-value: 0.02612).. The performance gain achieved with CT-perfusion is most evident in the decrease in the number of false classified cases (Reader 1: 24 to 5; Reader 2: 18 or 14 to 7) and the significant increase in Cohen's kappa. Our study shows that additional CT-perfusion imaging in stroke diagnosis significantly improves the diagnostic reliability of residents. Therefore, it should be further investigated whether perfusion imaging should be a general standard of initial stroke diagnosis no matter of the onset.

Efficacy and safety of very early rehabilitation for acute ischemic stroke: a systematic review and meta-analysis

Background

Early rehabilitation after acute ischemic stroke (AIS) contributes to functional recovery. However, the optimal time for starting rehabilitation remains a topic of ongoing investigation. This article aims to shed light on the safety and efficacy of very early rehabilitation (VER) initiated within 48 h of stroke onset.

Methods

A systematic search in PubMed, Embase, Cochrane Library, and Web of Science databases was conducted from inception to January 20, 2024. Relevant literature on VER in patients with AIS was reviewed and the data related to favorable and adverse clinical outcomes were collected for meta-analysis. Subgroup analysis was conducted at different time points, namely at discharge and at three and 12 months. Statistical analyses were performed with the help of the Meta Package in STATA Version 15.0.

Results

A total of 14 randomized controlled trial (RCT) studies and 3,039 participants were included in the analysis. VER demonstrated a significant association with mortality [risk ratio (RR) = 1.27, 95% confidence interval (CI) (1.00, 1.61)], ability of daily living [weighted mean difference (WMD) = 6.90, 95% CI (0.22, 13.57)], and limb motor function [WMD = 5.02, 95% CI (1.63, 8.40)]. However, no significant difference was observed between the VER group and the control group in adverse events [RR = 0.89, 95% CI (0.79, 1.01)], severity of stroke [WMD = 0.52, 95% CI (-0.04, 1.08)], degree of disability [RR = 1.06, 95% CI (0.93, 1.20)], or recovery of walking [RR = 0.98, 95% CI (0.94, 1.03)] after stroke. Subgroup analysis revealed that VER reduced the risk of adverse events in the late stage (at three and 12 months) [RR = 0.86, 95% CI (0.74, 0.99)] and degree of disability at 12 months [RR = 1.28, 95% CI (1.03, 1.60)], and improved daily living ability at 3 months [WMD = 4.26, 95% CI (0.17, 8.35)], while increasing severity of stroke during hospitalization [WMD = 0.81, 95% CI (0.01, 1.61)].

Conclusion

VER improves activities of daily living (ADLs) and lowers the incidence of long-term complications in stroke survivors. However, premature or overly intense rehabilitation may increase mortality in patients with AIS during the acute phase. PROSPERO registration number: CRD42024508180.

Systematic review registration

This systematic review was registered with PROSPERO (https://www.crd.york.ac.uk/PROSPERO/). PROSPERO registration number: CRD42024508180.