Stroke, cerebrovascular diseases and vascular cognitive impairment in Africa

Scientific status analysis of exercise benefits for vascular cognitive impairment: Evidence of neuroinflammation

Vascular cognitive impairment (VCI) is a syndrome characterized by cognitive decline resulting from insufficient perfusion to the entire brain or specific brain regions. The lack of a clear understanding of the mechanisms linking cerebrovascular disease to cognitive impairment has impeded the development of targeted treatments for VCI. Increasing evidence indicates that exercise may offer significant benefits for patients with VCI. This study explores how neuroinflammatory mechanisms mediate the effects of exercise on VCI, focusing on the broader biological processes involved. Exercise plays a crucial role in mitigating vascular risk factors, reducing oxidative stress, and promoting neurogenesis. Furthermore, exercise influences neuroinflammatory mediators and central immune cells via various signaling pathways. Different types and intensities of exercise, including resistance and endurance training, have been shown to differentially modulate neuroinflammation during the progression of VCI. This paper summarizes the current mechanisms of action and proposes exercise interventions targeting neuroinflammatory pathways, along with biomarker studies, to enhance our understanding of VCI pathogenesis and inform clinical practice. A more in-depth understanding of the inflammatory mechanisms underlying VCI may facilitate the development of targeted therapeutic interventions.

Understanding healthcare providers' perspectives on barriers to accessing stroke care at a resource-limited hospital in East Africa: A qualitative study from Mnazi Mmoja Referral Hospital in Zanzibar

Timely and appropriate care reduces the risk of mortality and disability after stroke. Despite high stroke incidence, little is known about the specific barriers to accessing stroke care in Zanzibar, East Africa. The aim of this study was to investigate healthcare providers' perspectives regarding the barriers to stroke care at the main referral hospital in Zanzibar. We used a phenomenological approach and conducted 14 individual semi-structured interviews with healthcare providers at Mnazi Mmoja Referral Hospital in Zanzibar. The interviews took place from April through September 2022. Thematic network analysis was applied to analyse and interpret the data. Three broad themes and eleven sub-themes were identified, relevant at specific stages in the patient's care pathway from deciding to seek care over receiving acute stroke care in hospital to accessing post-stroke care. These themes include health system barriers (medical supplies and equipment; staff shortages; attitudes and teamwork; organization of services; health education); patient-level factors (health literacy; relational factors; worries and feeling hopeless; financial constraints); and cultural context (stroke as a spiritual malady; trust, mistrust and power). Some of the sub-themes of barriers were similar to findings from other studies in both high and low-resource settings, such as shortages of medical supplies, equipment and staff, and sub-optimal organization of care. Other sub-themes were unique findings to low-resource settings, such as Zanzibar, and included relational factors and patients' perception of stroke as a spiritual malady. Interventions to improve stroke care should be informed by all these findings. Otherwise, focus only on removing barriers related to availability of stroke treatment in hospital may divert attention from significant cultural factors that affect health care seeking behaviour.

Towards improving stroke services in Africa: Results from the Africa-UK Stroke Partnership [AUKSP] surveys

BACKGROUND

The African Stroke Organization (ASO) in partnership with the University of Central Lancashire's Stroke Research Team launched the Africa-UK Stroke Partnership (AUKSP). AUKSP undertook two (stroke expert and hospital Stroke Unit (SU)) on-line surveys mapping existing capacity and capability to deliver African stroke care.

METHODS

An on-line expert survey tool was sent to 139 stroke experts in 54 African countries October 2021-March 2022 and the hospital SU survey to 120 hospital SUs (identified from the expert survey) June-October 2022. Both survey tools were prepared according to the World Stroke Organisation's Roadmap for Delivering Quality Stroke Care. Completed responses were exported from Qualtrics into Microsoft excel and were analysed descriptively.

RESULTS

Forty-five expert responses and 62 hospital SU responses were analysed, representing 54(87%) public hospitals, 7(11%) private and 1(2%) charitable organization. In both surveys, three main priorities for improvement of stroke services were: a rapid and prompt stroke diagnosis; effective primary and secondary stroke prevention, and acute stroke management. Survey findings suggest that there is a low presence of national stroke surveillance systems and registries, and heterogeneity in availability of diagnostic services, SUs, endovascular treatments, and rehabilitation.

CONCLUSION

Significant gaps exist in Africa's capacity and capability to deliver essential elements of effective and quality stroke care. Tackling these challenges requires urgent and sustained multi-stakeholder action including: government, administrators, policy makers and other partners. Our survey findings highlight key priority areas for multi-stakeholder engagement and crafting of a pragmatic, prioritized and context-sensitive African Stroke Action Plan.

Development and Validation of a Nomogram for Predicting Lacunar Infarction in Patients with Hypertension

Background

A considerable proportion of hypertensive patients may experience lacunar infarction. Therefore, early identification of the risk for lacunar infarction in hypertensive patients is particularly important. This study aimed to develop and validate a concise nomogram for predicting lacunar infarction in hypertensive patients.

Methods

Retrospectively analyzed the clinical data of 314 patients with accurate history of hypertension in the Second Affiliated Hospital of Wannan Medical College from January 2021 to December 2022. All the patients were randomly assigned to the training set (n=220) and the validation set (n=94) with 7:3. The diagnosis of lacunar infarction in patients was confirmed using cranial CT or MRI. The independent risk factors of lacunar infarction were determined by Least absolute shrinkage and selection operator (LASSO) regression and multivariable logistic regression analysis. The nomogram was built based on the independent risk factors. The nomogram's discrimination, calibration, and clinical usefulness were evaluated by receiver operating characteristics (ROC) curve, calibration curve, and decision curve analysis (DCA) analysis, respectively.

Results

The incidence of lacunar infarction was 34.50% and 33.00% in the training and validation sets, respectively. Five independent predictors were made up of the nomogram, including age (OR=1.142, 95% CI: 1.089-1.198, P<0.001), diabetes mellitus (OR=3.058, 95% CI: 1.396-6.697, P=0.005), atrial fibrillation (OR=3.103, 95% CI: 1.328-7.250, P=0.009), duration of hypertension (OR=1.130, 95% CI: 1.045-1.222, P=0.002), and low-density lipoprotein (OR=2.147, 95% CI: 1.250-3.688, P=0.006). The discrimination with area under the curve (AUC) was 0.847 (95% CI: 0.789-0.905) in the training set and was a slight increase to 0.907 (95% CI: 0.838-0.976) in the validation set. The calibration curve showed high coherence between the predicted and actual probability of lacunar infarction. Moreover, the DCA analysis indicated that the nomogram had a higher overall net benefit of the threshold probability range in both two sets.

Conclusion

Age, diabetes mellitus, atrial fibrillation, duration of hypertension, and low-density lipoprotein were significant predictors of lacunar infarction in hypertensive patients. The nomogram based on the clinical data was constructed, which was a useful visualized tool for clinicians to assess the risk of the lacunar infarction in hypertensive patients.

The guardian of intracranial vessels: Why the pericyte?

Intracranial atherosclerotic stenosis (ICAS) is a pathological condition characterized by progressive narrowing or complete blockage of intracranial blood vessels caused by plaque formation. This condition leads to reduced blood flow to the brain, resulting in cerebral ischemia and hypoxia. Ischemic stroke (IS) resulting from ICAS poses a significant global public health challenge, especially among East Asian populations. However, the underlying causes of the notable variations in prevalence among diverse populations, as well as the most effective strategies for preventing and treating the rupture and blockage of intracranial plaques, remain incompletely comprehended. Rupture of plaques, bleeding, and thrombosis serve as precipitating factors in the pathogenesis of luminal obstruction in intracranial arteries. Pericytes play a crucial role in the structure and function of blood vessels and face significant challenges in regulating the Vasa Vasorum (VV)and preventing intraplaque hemorrhage (IPH). This review aims to explore innovative therapeutic strategies that target the pathophysiological mechanisms of vulnerable plaques by modulating pericyte biological function. It also discusses the potential applications of pericytes in central nervous system (CNS) diseases and their prospects as a therapeutic intervention in the field of biological tissue engineering regeneration.

The 2022 symposium on dementia and brain aging in low- and middle-income countries: Highlights on research, diagnosis, care, and impact

Two of every three persons living with dementia reside in low- and middle-income countries (LMICs). The projected increase in global dementia rates is expected to affect LMICs disproportionately. However, the majority of global dementia care costs occur in high-income countries (HICs), with dementia research predominantly focusing on HICs. This imbalance necessitates LMIC-focused research to ensure that characterization of dementia accurately reflects the involvement and specificities of diverse populations. Development of effective preventive, diagnostic, and therapeutic approaches for dementia in LMICs requires targeted, personalized, and harmonized efforts. Our article represents timely discussions at the 2022 Symposium on Dementia and Brain Aging in LMICs that identified the foremost opportunities to advance dementia research, differential diagnosis, use of neuropsychometric tools, awareness, and treatment options. We highlight key topics discussed at the meeting and provide future recommendations to foster a more equitable landscape for dementia prevention, diagnosis, care, policy, and management in LMICs. HIGHLIGHTS: Two-thirds of persons with dementia live in LMICs, yet research and costs are skewed toward HICs. LMICs expect dementia prevalence to more than double, accompanied by socioeconomic disparities. The 2022 Symposium on Dementia in LMICs addressed advances in research, diagnosis, prevention, and policy. The Nairobi Declaration urges global action to enhance dementia outcomes in LMICs.

VasCog 2023: 20 years of research on vascular behavioural and cognitive disorders

This Commentary describes the 20th Anniversary of VasCog 2023, held in Gothenburg, Sweden.

The Epidemiological Burden of Neurovascular Pathology in Nigeria: A Systematic Review and Pooled Patient-Level Analysis

OBJECTIVE

Vascular neurosurgery has developed significantly in Nigeria, but its burden and challenges remain unclear. This study systematically reviewed vascular neurosurgical literature from Nigeria.

METHODS

Four research databases and gray literature sources were searched from 1962-2021. ROBINS-I tool was used to assess risk of bias. Descriptive, narrative, and statistical analyses were conducted on all variables. Where appropriate, paired t-tests and Chi-squared independence tests were used (α = 0.05).

RESULTS

56 articles were included and 3203 patients pooled for analysis. Risk of bias was moderate-high. Most articles were published over the last 20 years with retrospective cohort studies and case reports being the most common study designs. The cohort had a relatively even gender split and an average age of 49 years (±22). Cerebrovascular accidents accounted for over 85% of diagnoses, with most etiologies being traumatic. Headache and motor deficit were the most prevalent clinical features. X-ray and carotid angiography were the most commonly reported imaging modalities, closely followed by computed tomography (CT) and CT angiography. The top two radiological diagnoses were ischemic cerebrovascular disease and intracerebral hematoma. Aneurysmal clipping and hematoma evacuation were the most commonly reported treatment modalities. Outcome at last follow-up was favorable in 48%. The mortality rate was 6%. Post-treatment complications included chest infection and rebleeding.

CONCLUSIONS

This study illustrates the epidemiological burden of neurovascular pathology (based on the available data in published literature) in Nigeria, and raises awareness amongst service providers and researchers of the attendant challenges and epochal trends seen within vascular neurosurgery in Nigeria.

Stroke Recurrence Rate and Risk Factors Among Stroke Survivors in Sub-Saharan Africa: A Systematic Review

Purpose

Evidence supporting secondary stroke in sub-Saharan Africa is scarce. This study describes the incidence of stroke recurrence and associated risk factors in sub-Saharan Africa.

Methods and Materials

Scientific databases were systematically searched from January 2000 to December 2022 for population-based observational studies, case-control or cohort studies of recurrent stroke involving adults aged 18 years and above in sub-Saharan Africa (SSA). We assessed the quality of the eligible studies using the Critical Appraisal Skills Program (CASP) checklist for observational studies.

Results

Six studies met the inclusion criteria and were included in this study. Stroke recurrence rates in SSA ranged from 9.4% to 25%. Majority of the studies were conducted from Western Africa and showed that stroke recurrence rates are high within sub-Saharan Africa ranging from 2% to 25%. The known stroke risk factors such as hypertension, chronic alcohol consumption, etc., remained the leading causes of stroke recurrence. The studies reported a higher mortality rate ranging from 20.5 -23% among those with recurrent strokes compared to primary strokes.

Conclusion

This systematic review is an update and summary of the available literature on stroke recurrence within sub-Saharan Africa. Further studies are warranted to assess the outcomes and burden of stroke recurrence in SSA.

Novel functional insights into ischemic stroke biology provided by the first genome-wide association study of stroke in indigenous Africans

BACKGROUND

African ancestry populations have the highest burden of stroke worldwide, yet the genetic basis of stroke in these populations is obscure. The Stroke Investigative Research and Educational Network (SIREN) is a multicenter study involving 16 sites in West Africa. We conducted the first-ever genome-wide association study (GWAS) of stroke in indigenous Africans.

METHODS

Cases were consecutively recruited consenting adults (aged > 18 years) with neuroimaging-confirmed ischemic stroke. Stroke-free controls were ascertained using a locally validated Questionnaire for Verifying Stroke-Free Status. DNA genotyping with the H3Africa array was performed, and following initial quality control, GWAS datasets were imputed into the NIH Trans-Omics for Precision Medicine (TOPMed) release2 from BioData Catalyst. Furthermore, we performed fine-mapping, trans-ethnic meta-analysis, and in silico functional characterization to identify likely causal variants with a functional interpretation.

RESULTS

We observed genome-wide significant (P-value < 5.0E-8) SNPs associations near AADACL2 and miRNA (MIR5186) genes in chromosome 3 after adjusting for hypertension, diabetes, dyslipidemia, and cardiac status in the base model as covariates. SNPs near the miRNA (MIR4458) gene in chromosome 5 were also associated with stroke (P-value < 1.0E-6). The putative genes near AADACL2, MIR5186, and MIR4458 genes were protective and novel. SNPs associations with stroke in chromosome 2 were more than 77 kb from the closest gene LINC01854 and SNPs in chromosome 7 were more than 116 kb to the closest gene LINC01446 (P-value < 1.0E-6). In addition, we observed SNPs in genes STXBP5-AS1 (chromosome 6), GALTN9 (chromosome 12), FANCA (chromosome 16), and DLGAP1 (chromosome 18) (P-value < 1.0E-6). Both genomic regions near genes AADACL2 and MIR4458 remained significant following fine mapping.

CONCLUSIONS

Our findings identify potential roles of regulatory miRNA, intergenic non-coding DNA, and intronic non-coding RNA in the biology of ischemic stroke. These findings reveal new molecular targets that promise to help close the current gaps in accurate African ancestry-based genetic stroke's risk prediction and development of new targeted interventions to prevent or treat stroke.

Stroke prevention strategies in Africa: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to map the existing strategies on methods and interventions for primary and secondary stroke prevention in Africa.

INTRODUCTION

Stroke is among the leading causes of disability globally. African nations have higher stroke mortality and case fatality rates than the industrialized world, leading to significant social and financial costs, which necessitates efficient preventative methods. Despite the high prevalence of stroke in Africa, the scope of stroke-prevention strategies in Africa is unknown. Consequently, mapping diverse approaches to preventing stroke in Africa could provide direction for future research into stroke prevention in Africa.

INCLUSION CRITERIA

This review will incorporate studies that report methods or strategies used for stroke prevention in Africa. All primary and gray literature will be considered for inclusion. No language or date restrictions will be applied.

METHODS

The JBI methodological framework for scoping reviews will be adopted for this scoping review. A 3-step search strategy consisting of an initial limited search, a full search, and a screening of the reference lists of all included articles will be undertaken. Databases such as CINAHL, Scopus, PubMed, PEDRo, DORIS, Global Health, Web of Science, and Open Access Thesis and Dissertations will be searched. All search results will be screened, and relevant data extracted by 2 independent reviewers. The findings will be presented in the final scoping review and illustrated in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

REVIEW REGISTRATION

Figshare https://doi.org/10.6084/m9.figshare.21679904.v1.

Current perspectives on prevention of vascular cognitive impairment and promotion of vascular brain health

INTRODUCTION

The true global burden of vascular cognitive impairment (VCI) is unknown. Reducing risk factors for stroke and cardiovascular disease would inevitably curtail VCI.

AREAS COVERED

The authors review current diagnosis, epidemiology, and risk factors for VCI. VCI increases in older age and by inheritance of known genetic traits. They emphasize modifiable risk factors identified by the 2020 Lancet Dementia Commission. The most profound risks for VCI also include lower education, cardiometabolic factors, and compromised cognitive reserve. Finally, they discuss pharmacological and non-pharmacological interventions.

EXPERT OPINION

By virtue of the high frequencies of stroke and cardiovascular disease the global prevalence of VCI is expectedly higher than prevalent neurodegenerative disorders causing dementia. Since ~ 90% of the global burden of stroke can be attributed to modifiable risk factors, a formidable opportunity arises to reduce the burden of not only stroke but VCI outcomes including progression from mild to the major in form of vascular dementia. Strict control of vascular risk factors and secondary prevention of cerebrovascular disease via pharmacological interventions will impact on burden of VCI. Non-pharmacological measures by adopting healthy diets and encouraging physical and cognitive activities and urging multidomain approaches are important for prevention of VCI and preservation of vascular brain health.

Management of Inherited CNS Small Vessel Diseases: The CADASIL Example: A Scientific Statement From the American Heart Association

Lacunar infarcts and vascular dementia are important phenotypic characteristics of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, the most common inherited cerebral small vessel disease. Individuals with the disease show variability in the nature and onset of symptoms and rates of progression, which are only partially explained by differences in pathogenic mutations in the NOTCH3 gene. Recognizing the disease early in its course and securing a molecular diagnosis are important clinical goals, despite the lack of proven disease-modifying treatments. The purposes of this scientific statement are to review the clinical, genetic, and imaging aspects of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, contrasting it with other inherited small vessel diseases, and to provide key prevention, management, and therapeutic considerations with the intent of reducing practice variability and encouraging production of high-quality evidence to support future treatment recommendations.

The essential role of neuroimaging in diagnosing and managing cerebrovascular disease in Africa: a review

BACKGROUND

Cerebrovascular disease is a significant cause of morbidity and mortality in Africa, and using neuroimaging techniques has improved the diagnosis and management of this disease. However, there is a lack of comprehensive reviews of the role and effectiveness of neuroimaging techniques in the African context.

METHODS

We reviewed the literature to evaluate the role of neuroimaging in diagnosing and managing cerebrovascular disease in Africa. Our search included electronic databases such as PubMed, Scopus, and Google Scholar from 2000 to April 2023. We included peer-reviewed studies written in English that reported on the use of neuroimaging in diagnosing and managing cerebrovascular disease in African populations. We excluded non-peer-reviewed articles, letters, editorials, and studies unrelated to cerebrovascular disease, neuroimaging, or Africa. A total of 102 potential articles were identified; after applying our exclusion criteria and removing duplicated articles, 51 articles were reviewed.

RESULTS

Our findings suggest that neuroimaging techniques such as CT, MRI, and Skull x-ray play a crucial role in diagnosing and managing cerebrovascular disease in Africa. CT and MRI were the most commonly used techniques, with CT being more widely available and less expensive than MRI. However, challenges to using neuroimaging in Africa include the high cost of equipment and maintenance, lack of trained personnel, and inadequate infrastructure. These challenges limit the widespread use of neuroimaging in diagnosing and managing cerebrovascular disease in Africa.

CONCLUSION

Neuroimaging techniques are essential for diagnosing and managing cerebrovascular disease in Africa, but challenges to their use must be addressed to improve healthcare outcomes. Our policy recommendations can help improve the availability and accessibility of neuroimaging services in Africa.

Association between altered cognition and Loa loa microfilaremia: First evidence from a cross-sectional study in a rural area of the Republic of Congo

BACKGROUND

Individuals with high Loa loa microfilarial densities are at risk of developing severe encephalopathy after administration of antiparasitic drugs. Apart from this finding, loiasis is considered benign with no effect on brain function. However, recent epidemiological data suggest an increased mortality and morbidity in L. loa infected individuals, underscoring the importance of studies on the possible neurological morbidity associated with loiasis.

METHODOLOGY

Using MoCA tests and neurological ultrasounds, we conducted a cross-sectional study to assess cognitive alteration in a population living in a rural area endemic for loiasis in the Republic of Congo. Fifty individuals with high microfilarial densities (MFD) were matched on sex, age and residency with 50 individuals with low MFD and 50 amicrofilaremic subjects. Analyses focused on individuals with MoCA scores indicating an altered cognition (i.e. < 23/30) and on the total MoCA score according to Loa loa MFD, sociodemographic characteristics and neurological ultrasound results.

PRINCIPAL FINDINGS

MoCA scores were very low in the studied population (mean of 15.6/30). Individuals with more than 15,000 microfilariae per milliliter of blood (mean predicted score:14.0/30) are more than twenty times more likely to have an altered cognition, compared to individuals with no microfilaremia (mean predicted score: 16.3/30). Years of schooling were strongly associated with better MoCA results. Extracranial and intracranial atheroma were not associated with L. loa MFD.

CONCLUSION/SIGNIFICANCE

Loaisis microfilaremia is probably involved in cognitive impairment, especially when the MFD are high. These results highlight the urgent need to better understand loaisis-induced morbidity. Further studies investigating neurological morbidity of loiasis are needed.

Prevalence and predictors of post-stroke cognitive impairment among stroke survivors in Uganda

BACKGROUND

Little is known about the characteristics and determinants of post-stroke cognitive impairment in residents of low- and middle-income countries. The objective of this study was to determine the frequencies, patterns, and risk factors for cognitive impairment in a cross-sectional study of consecutive stroke patients cared for at Uganda's Mulago Hospital, located in sub-Saharan Africa.

METHODS

131 patients were enrolled a minimum of 3-months after hospital admission for stroke. A questionnaire, clinical examination findings, and laboratory test results were used to collect demographic information and data on vascular risk factors and clinical characteristics. Independent predictor variables associated with cognitive impairment were ascertained. Stroke impairments, disability, and handicap were assessed using the National Institute of Health Stroke Scale (NIHSS), Barthel Index (BI), and modified Rankin scale (mRS), respectively. The Montreal Cognitive Assessment (MoCA) was used to assess participants' cognitive function. Stepwise multiple logistic regression was used to identify variables independently associated with cognitive impairment.

RESULTS

The overall mean MoCA score was 11.7-points (range 0.0-28.0-points) for 128 patients with available data of whom 66.4% were categorized as cognitively impaired (MoCA < 19-points). Increasing age (OR 1.04, 95% CI 1.00-1.07; p = 0.026), low level of education (OR 3.23, 95% CI 1.25-8.33; p = 0.016), functional handicap (mRS 3-5; OR 1.84, 95% CI 1.28-2.63; p < 0.001) and high LDL cholesterol (OR 2.74, 95% CI 1.14-6.56; p = 0.024) were independently associated with cognitive impairment.

CONCLUSIONS

Our findings highlight the high burden and need for awareness of cognitive impairment in post stroke populations in the sub-Saharan region and serve to emphasize the importance of detailed cognitive assessment as part of routine clinical evaluation of patients who have had a stroke.

Machine-learning-based analysis of the sensitivity and specificity on lipid-lowering effect of one-month-administered statins

Few predictive studies have been reported on the efficacy of atorvastatin in reducing lipoprotein cholesterol to be qualified after 1-month course of treatment in different individuals. A total of 14,180 community-based residents aged ≥ 65 received health checkup, 1013 of whom had low-density lipoprotein (LDL) higher than 2.6mmol/L so that they were put on 1-month course of treatment with atorvastatin. At its completion, lipoprotein cholesterol was measured again. With < 2.6 mmol/L considered as the treatment standard, 411 individuals were judged as the qualified group, and 602, and as the unqualified group. The basic sociodemographic features covered 57 items. The data were randomly divided into train sets and test ones. The recursive random-forest algorithm was applied to predicting the patients response to atorvastatin, the recursive feature elimination method, to screening all the physical indicators. The overall accuracy, sensitivity and specificity were calculated, respectively, and so were the receiver operator characteristic curve and the area under the curve of the test set. In the prediction model on the efficacy of 1-month treatment of statins for LDL, the sensitivity, 86.86%; and the specificity, 94.83%. In the prediction model on the efficacy of the same treatment for triglyceride, the sensitivity, 71.21%; and the specificity, 73.46%. As to the prediction of total cholesterol, the sensitivity, 94.38%; and the specificity, 96.55%. And in the case of high-density lipoprotein (HDL), the sensitivity, 84.86%; and the specificity, 100%. recursive feature elimination analysis showed that total cholesterol was the most important feature of atorvastatin efficacy of reducing LDL; that HDL was the most important one of its efficacies of reducing triglycerides; that LDL was the most important one of its efficacies of reducing total cholesterol; and that triglyceride was the most important one of its efficacies of reducing HDL. Random-forest can help predict whether atorvastatin efficacy of reducing lipoprotein cholesterol to be qualified after 1-month course of treatment in different individuals.

Prevalence and Predictors of Post-stroke Cognitive Impairment among Stroke Survivors in Uganda

Background Little is known about the characteristics and determinants of post-stroke cognitive impairments in low- and middle-income countries. The objective of this study was to determine the frequencies, patterns, and risk factors for cognitive impairment in a cross-sectional study of consecutive stroke patients cared for at Uganda's Mulago Hospital, located in sub-Saharan Africa. Methods From August 2019 to July 2020, patients were enrolled a minimum of 3-months post-stroke hospital admission. We collected data on their demographics, vascular risk factors and clinical factors using a questionnaire, clinical examination findings, and test results. Independent predictor variables associated with cognitive impairment were ascertained. Stroke impairments, disability, and handicap were assessed using the National Institute of Health Stroke Scale (NIHSS), Barthel Index (BI), and modified Rankin scale (mRS), respectively. The Montreal Cognitive Assessment (MoCA) was used to assess participants' cognitive function. Stepwise multiple logistic regression was used to identify variables independently associated with cognitive impairment. Results The overall mean MoCA score was 11.7-points (range 0.0-28.0-points) for 128 patients with available data of whom 66.4% were categorized as cognitively impaired (MoCA < 19-points). Increasing age (OR 1.04, 95% CI 1.00-1.07; p = 0.026), low level of education (OR 3.23, 95% CI 1.25-8.33; p = 0.016), functional handicap (mRS 3-5; OR 1.84, 95% CI 1.28-2.63; p < 0.001) and high LDL cholesterol (OR 2.74, 95% CI 1.14-6.56; p = 0.024) were independently associated with cognitive impairment. Discussion Further longitudinal, prospective studies are required to confirm these findings and identify strategies for reducing the risk of post-stroke cognitive impairment in this population.

The global burden of cerebral small vessel disease in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Cerebral small vessel disease (cSVD) is a major cause of stroke and dementia. Previous studies on the prevalence of cSVD are mostly based on single geographically defined cohorts in high-income countries. Studies investigating the prevalence of cSVD in low- and middle-income countries (LMICs) are expanding but have not been systematically assessed.

AIM

This study aims to systematically review the prevalence of cSVD in LMICs.

RESULTS

Articles were searched from the Ovid MEDLINE and EMBASE databases from 1 January 2000 to 31 March 2022, without language restrictions. Title/abstract screening, full-text review, and data extraction were performed by two to seven independent reviewers. The prevalence of cSVD and study sample size were extracted by pre-defined world regions and health status. The Risk of Bias for Non-randomized Studies tool was used. The protocol was registered on PROSPERO (CRD42022311133). A meta-analysis of proportion was performed to assess the prevalence of different magnetic resonance imaging markers of cSVD, and a meta-regression was performed to investigate associations between cSVD prevalence and type of study, age, and male: female ratio. Of 2743 studies identified, 42 studies spanning 12 global regions were included in the systematic review. Most of the identified studies were from China (n = 23). The median prevalence of moderate-to-severe white matter hyperintensities (WMHs) was 20.5%, 40.5%, and 58.4% in the community, stroke, and dementia groups, respectively. The median prevalence of lacunes was 0.8% and 33.5% in the community and stroke groups. The median prevalence of cerebral microbleeds (CMBs) was 10.7% and 22.4% in the community and stroke groups. The median prevalence of moderate-to-severe perivascular spaces was 25.0% in the community. Meta-regression analyses showed that the weighted median age (51.4 ± 0.0 years old; range: 36.3-80.2) was a significant predictor of the prevalence of moderate-to-severe WMH and lacunes, while the type of study was a significant predictor of the prevalence of CMB. The heterogeneity of studies was high (>95%). Male participants were overrepresented.

CONCLUSIONS

This systematic review and meta-analysis provide data on cSVD prevalence in LMICs and demonstrated the high prevalence of the condition. cSVD research in LMICs is being published at an increasing rate, especially between 2010 and 2022. More data are particularly needed from Sub-Saharan Africa and Central Europe, Eastern Europe, and Central Asia.

Self-reported prevalence and potential factors influencing cardio-cerebral vascular disease among the Chinese elderly: A national cross-sectional study

BACKGROUND

Aging is an essential national condition throughout China in the 21st century. Cardio-cerebral vascular disease (CCVD) is a common chronic vascular disease in the elderly. Despite aging becoming an increasingly pressing issue, there has been no comprehensive national investigation into the risk factors, prevalence, and management of CCVD among the elderly population in China.

MATERIALS AND METHODS

Through the 4th Survey of the Aged Population in Urban and Rural China (SSAPUR), a nationally representative sample of 224,142 adults aged more than 60 years was surveyed using a multistage, stratified sampling method. The 4th SSAPUR was used to investigate CCVD in the elderly. Univariate and multivariate logistic proportional regression analyses explored the risk factors. These risk factors were then entered into a multivariate linear regression model to identify independent predictive factors for CCVD. Disease management was assessed from the self-reported history of physician diagnosis, treatments, and hospital visits among individuals with CCVD.

RESULTS

After excluding samples with missing information, 215,041 individuals were included in the analysis. The overall prevalence of CCVD was 26%. Living in a rural area, being older, being female, having low literacy, smoking, getting little sleep, losing a spouse, being single, not getting enough exercise, having a bad financial situation, and not taking part in public welfare programs were the main risk factors for CCVD among the elderly in China (P < 0.05). In the multivariate linear regression model, holding all other variables at any fixed value, CCVD remained associated with "urban and rural" (β = 0.012, P < 0.001), "age" (β = -0.003, P < 0.001), "sex" (β = -0.022, P < 0.001), "education level" (β = -0.017, P < 0.001), "marriage" (β = 0.004, P = 0.047), "smoking" (β = 0.012, P = 0.003), "drinking" (β = -0.015, P = 0.001), and "sleep" (β = 0.008, P = 0.005). There were no collinearity problems among these factors.

CONCLUSION

Major risk factors for prevalent CCVD among the elderly in China include the following: rural residence, female, low literacy level, poor sleep quality, bereavement, non-marriage, living alone, lack of exercise, poor financial situation, and non-participation in public welfare activities. Chinese national policies for preventing, controlling, and managing risk factors for CCVD in the elderly must be urgently developed.

Determinants of metabolic syndrome and its prognostic implications among stroke patients in Africa: Findings from the Stroke Investigative Research and Educational Network (SIREN) study

BACKGROUND

The prognostic implications of metabolic syndrome (METS) among African stroke patients are poorly understood. This study aimed to investigate the determinants of METS and its prognostic implications among Africans with newly diagnosed stroke in the SIREN study.

METHODS

We included stroke cases (adults aged >18 years with CT/MRI confirmed stroke). The validated tools comprehensively evaluated vascular, lifestyle, and psychosocial factors. We used logistic regression to estimate adjusted odds ratios (OR) with 95% CIs for the association between METS and risk factors. We also computed the prediction power of the domain of covariates in a sequential manner using the area under the receiver operating curve (ROC) curve.

RESULTS

Among 3998 stroke subjects enrolled in the study, 76.8% had METS by at least one of the clinical definitions. Factors associated with METS were age > 50 years (OR- 1.46, CI-1.19-1.80), male gender (OR 4.06, CI- 3.28-5.03), income >100USD (OR1.42, CI-1.17-1.71), stress (OR1.46, CI-1.14-1.87), family history of diabetes mellitus (OR1.38, CI-1.06-1.78), and cardiac disease (OR1.42, CI-1.18-1.65). Stroke severity was higher among those with METS (SLS = 5.8 ± 4.3) compared with those without METS (6.2 ± 4.5) at p = 0.037. METS was associated with higher odds (aOR 1.31, CI-1.08-1.58) of one-month fatality after adjusting for stroke severity, age > 50 years, and average monthly income >100USD.

CONCLUSION

METS is very common among African stroke patients and is associated with stroke severity and worse one-month fatality. Lifestyle interventions may prevent METS and attenuate its impact on stroke occurrence and outcomes.

Aldehyde Dehydrogenase Isoform 1 Predicts a Poor Prognosis of Acute Cerebral Infarction

To investigate the prognostic potential of serum aldehyde dehydrogenase isoform 1 (ALDH1) level in acute cerebral infarction, and the molecular mechanism in mediating neurological deficits, a total of 120 acute cerebral infarction cases within 72 h of onset were retrospectively analyzed. Serum ALDH1 level in them was detected by qRT-PCR. Receiver operating characteristic (ROC) and Kaplan–Meier curves were depicted for assessing the diagnostic and prognostic potentials of ALDH1 in acute cerebral infarction, respectively. An in vivo acute cerebral infarction model in rats was established by performing MCAO, followed by evaluation of neurological deficits using mNSS and detection of relative levels of ALDH1, Smad2, Smad4, and p21 in rat brain tissues. Pearson's correlation test was carried out to verify the correlation between ALDH1 and mNSS and relative levels of Smad2, Smad4, and p21. Serum ALDH1 level increased in acute cerebral infarction patients. A high level of ALDH1 predicted a poor prognosis of acute cerebral infarction patients. In addition, ALDH1 was sensitive and specific in distinguishing acute cerebral infarction cases, presenting a certain diagnostic potential. mNSS was remarkably higher in acute cerebral infarction rats than that of controls. Compared with sham operation group, relative levels of ALDH1, Smad2, and Smad4 were higher in brain tissues of modeling rats, whilst p21 level was lower. ALDH1 level in brain tissues of modeling rats was positively correlated to mNSS, and mRNA levels of Smad2 and Smad4, but negatively correlated to p21 level. Serum ALDH1 level is a promising prognostic and diagnostic factor of acute cerebral infarction, which is correlated to 90-day mortality. Increased level of ALDH1 in the brain of cerebral infarction rats is closely linked to neurological function, which is associated with the small mothers against decapentaplegic (Smad) signaling and p21.

Nanoparticles in the diagnosis and treatment of vascular aging and related diseases

Aging-induced alternations of vasculature structures, phenotypes, and functions are key in the occurrence and development of vascular aging-related diseases. Multiple molecular and cellular events, such as oxidative stress, mitochondrial dysfunction, vascular inflammation, cellular senescence, and epigenetic alterations are highly associated with vascular aging physiopathology. Advances in nanoparticles and nanotechnology, which can realize sensitive diagnostic modalities, efficient medical treatment, and better prognosis as well as less adverse effects on non-target tissues, provide an amazing window in the field of vascular aging and related diseases. Throughout this review, we presented current knowledge on classification of nanoparticles and the relationship between vascular aging and related diseases. Importantly, we comprehensively summarized the potential of nanoparticles-based diagnostic and therapeutic techniques in vascular aging and related diseases, including cardiovascular diseases, cerebrovascular diseases, as well as chronic kidney diseases, and discussed the advantages and limitations of their clinical applications.

A WeChat-based caregiver education program improves satisfaction of stroke patients and caregivers, also alleviates poststroke cognitive impairment and depression: A randomized, controlled study

Caregiver education program has been applied to stroke patients, while its effect on mental health in stroke patients is still obscure. This study aimed to assess the impact of the WeChat-based caregiver education (WBCE) program on cognition, anxiety, and depression in stroke patients. Totally, 170 patients with ischemic stroke were included. They were randomized at a 1:1 ratio to the WBCE group (N = 86) and control care (CC) group (N = 84), and their caregivers received WBCE or CC for 12 months, respectively. Mini-mental state examination (MMSE) score was increased in the WBCE group compared with that in the CC group at the 9th month (M9) (27.2 ± 1.9 vs 26.6 ± 1.6, P = 0.017) and M12 (27.1 ± 1.8 vs 26.5 ± 1.5, P = 0.015), while cognitive impairment rate was decreased in WBCE group compared with that in CC group at 12th month (M12) (30.2% vs 45.2%, P=0.043). In the meantime, the Hospital Anxiety and Depression Scale (HADS) for Anxiety score (6.5 ± 3.1 vs 7.5 ± 2.8, P = 0.020), HADS for depression score (6.7 ± 3.1 vs 7.7 ± 3.3, P = 0.040) and depression rate (33.7% vs 48.8%, P = 0.046) in WBCE group were reduced compared with those in CC group at M12. Besides, an elevation in the satisfaction score of patients at M12 (8.0 ± 1.2 vs 7.4 ± 1.2, P = 0.002) and that of caregivers at 6th months (M6) (6.6 ± 1.1 vs 6.2 ± 1.3, P = 0.038) and M12 (7.2 ± 1.1 vs 6.8 ± 1.4, P=0.042) were found in WBCE group compared with CC group. WBCE program not only improves the satisfaction of stroke patients and caregivers but also attenuates cognitive impairment and depression in stroke patients.

Effect of Yisui Multipurpose Soup's Amelioration on D-Galactose-Induced Neuronal Cells

This study clarified the regulatory effect of Yisui multipurpose Soup towards D-galactose-induced cognitive impairment cell model on the molecular level. We first constructed and cultured the cell model of cognitive impairment induced by D-galactose in neurons in vitro and then cultured the cells in the medium supplemented with different doses of drug-containing serum of Yisui multipurpose soup. Expressions of inflammatory cytokine tumor necrosis factor-α (TNF-α), inducible nitric oxide synthase (iNOS), nitric oxide (NO), and interleukin-1β (IL-1β) were assessed by the ELISA and western blot, and cell apoptosis was determined by flow cytometry and TUNEL. The expression changes of apoptosis-related proteins Bcl-2 and Bax were estimated by immunofluorescence, qPCR, and western blot. Finally, we analyzed and made the network interaction diagram of Yisui multipurpose soup-components-targets through the network pharmacology method, from which we could learn that there were 1104 gene targets related to vascular cognitive impairment (VCI) and 1071 component targets of Yisui multipurpose soup. And there were 251 overlapping genes, mainly gathering in protein binding, protein modification, MAPK signaling pathway, and calcium signaling pathway. The expressions of TNF-α, iNOS, NO, and IL-1β were significantly decreased after the culture medium was replaced by medium containing drug serum. We also found that the effect of high-dose drug-containing serum on the expression of inflammatory factors was better than that of low dose. The Yisui multipurpose soup drug serum in the medium not only significantly increased Bcl-2 expression and effectively reduced Bax expression, but also inhibited the apoptosis of neurons induced by D-galactose. In conclusion, Yisui multipurpose soup could effectively protect D-galactose-induced neuronal cell cognitive impairment by orchestrating expressions of the inflammatory factors TNF-α, iNOS, NO, and IL-1β and the apoptosis-related proteins Bcl-2 and Bax.

Legal Implications of Stroke Biobanking and Genomics Research in Sub-Saharan Africa

Stroke is a major cause of death in Sub-Saharan Africa (SSA) and genetic factors appear to play a part. This has led to stroke biobanking and genomics research in SSA. Existing stroke studies have focused on causes, incidence rates, fatalities and effects. However, scant attention has been paid to the legal issues in stroke biobanking and genomics research in the sub-region. Therefore, this article examines the legal implications of stroke biobanking and genomics research in SSA. The article adopts a textual analysis of primary and secondary sources in law. It reports that there are laws from the perspectives of human right, the common law, and intellectual property. However, there are gaps to be filled. The article therefore argues for legislative intervention. It concludes that pending the time the statute will be enacted, genomics researchers in Africa should adopt the ethical guidelines prepared by Human Heredity and Health in Africa (H3 Africa).

Electrocardiographic Changes and Serum Troponin Levels in Patients with Acute Stroke: A Prospective Cross-Sectional Study

BACKGROUND

Electrocardiographic changes and elevated serum troponin are frequent findings in acute stroke. They may reflect what is known as the neurogenic myocardial injury. The aim of this study is to determine the electrocardiographic changes and serum troponin level in acute stroke patients and to correlate these changes to the anatomical location and pathological type of the stroke.

METHODS

A prospective cross-sectional study was conducted at the National Center of Neurological Science, from January to December 2019. Non-probability sampling with total coverage was considered. 50 patients with acute stroke were included in the study. Data were analyzed by using (SPSS) version 25. Standardized ECG was performed in the first hours of admission. 2 samples from each patient were obtained for serum troponin with at least 8 hours apart.

RESULTS

All patients had wide variants of ECG changes. But tachycardia was the most frequent one identified in 54% of patients (n=50). Half of them were found to have an anterior circulation stroke. 14% of patients (n=50) have positive troponin; ECG changes are identified in all patients who represent positive troponin 100% (7 patients). Moreover, anterior circulation stroke was recognized in all patients with a positive troponin I marker.

CONCLUSION

This study suggests that ECG abnormalities in patients with acute stroke are very common, especially tachycardia. The site of the lesion appears to play a major factor as a cause of the genesis of arrhythmia. Serum troponin elevation may play a role in diagnosing neurocardiogenic injury; nevertheless, ECG appears to be more sensitive and familial.

Exploring the Effect of Enbrel Softgels on PWI Indicators in VCIND Patients

Objective

To investigate the effect of Enbrel softgels on the head nuclear magnetic (PWI) indices in patients with vascular cognitive impairment-no dementia (vascular cognitive impairment-no dementia, VCIND).

Methods

Patients with confirmed VCIND hospitalized in the Department of Neurology of the Affiliated Hospital of Hebei University from April 2017 to April 2019 were included in the study, and they were divided into experimental and control groups (30 patients in each group) according to the difference of interventions. The PWI examination and neuropsychological assessment were performed at the beginning of the experiment, 12 w after treatment, and 48 w after treatment in the two groups. Score differences between the two groups and the preliminary demonstration of the clinical value of the MMSE and ADAS-Cog in the diagnosis of VCIND.

Results

(1) The difference in PWI positivity rate between the two groups at the beginning of the experiment was not statistically significant (P > 0.05); the PWI positivity rate in the experimental group at 12 W was significantly lower than that in the control group (P < 0.05); the difference in PWI positivity rate between the two groups at 48 W was not statistically significant (P < 0.05); (2) the MMSE scores of patients in the experimental group at 12 W and 48 W were higher than those in the control group, and the ADAS-Cog scores were lower than those in the control group (P < 0.05). (3) The diagnostic AUCs of MMSE and ADAS-Cog for VCIND were 0.7960 (95% CI = 0.6411-0.9508, P=0.0037) and 0.9291 (95% CI = 0.8390), respectively (95% CI = 0.8390-1.000, P < 0.0001).

Conclusion

The addition of Enbrel softgels to concomitant therapy in VCIND patients can lead to changes in their PWI imaging indicators, which in turn can have a significant impact on their neuropsychological indicators, and quantitative analysis scales such as the MMSE and ADAS-Cog can be considered for the diagnostic treatment of VCIND.

Osuntokun Award Lecture 2021: Challenges of Measuring the Burden of Stroke in Africa

BACKGROUND

Over recent years non-communicable diseases have dramatically increased in low- and middle-income countries, including those of sub-Saharan Africa. With continuing high levels of infectious disease, these countries now face the double burden of disease. Stroke has emerged as a major cause of hospital admission, disability, and mortality for which the major modifiable risk factor is hypertension, which is often not diagnosed and, even if diagnosed, not treated and, even if treated, not controlled.

METHODS

In this award lecture paper I outline my personal experience of measuring the burden of, and risk factors for, stroke in sub-Saharan Africa, along with the challenges faced. I will specifically describe the measurement of mortality and case fatality, prevalence and incidence as well as commenting on aetiology and risk factors and reflect on future initiatives and directions.

RESULTS

Over the past 5 decades there has been a dramatic increase in numbers of stroke patients admitted to hospital throughout sub-Saharan Africa, with high in hospital mortality rates, also reflected in high case fatality rates in those cohorts followed up following discharge from hospital. Community-based surveys assessing mortality from stroke using verbal autopsy have demonstrated very high age-adjusted rates. Age adjusted prevalence rates assessed by door-to-door surveys have generally shown lower prevalence than high income countries. The Tanzanian stroke incidence study, which incorporated verbal autopsy for those patients dying before reaching hospital, demonstrated some of the highest age-adjusted stroke incidence rates in the world. There were high rates of stroke in younger ages and high rates of intracranial haemorrhage though not as high as previously shown in hospital-based studies. Hypertension is the main modifiable risk factor but other risk factors such as HIV are important while, certainly in rural populations, raised cholesterol remains rare as does carotid artery stenosis and history of transient ischemic attack. Other vascular disease such as ischemic heart disease and peripheral vascular disease is also less common.

CONCLUSIONS

There is already a large burden relating to stroke in sub-Saharan Africa and this will only escalate further as the population ages. Hypertension is the biggest risk factor for mortality worldwide and in sub-Saharan Africa prevalence rates are very high with the majority of people suffering with stroke not being diagnosed with their hypertension prior to their stroke. The most important challenge is to improve primary prevention for which improving diagnosis and control rates for hypertension is the number one priority. For those who do have stroke there is a need to increase the number of suitably staffed stroke units as these have been shown to have a very large impact on improving both mortality and morbidity in high income countries. There are still many unanswered questions and a need for more research throughout sub-Saharan Africa on risk factors, and treatment, for stroke.

The Effect of Sex and Wealth on Population Attributable Risk Factors for Dementia in South Africa

Background and Aims: South Africa is a middle-income country with high levels of income inequality and a rapidly aging population and increasing dementia prevalence. Little is known about which risk factors for dementia are important and how they differ by social determinants of health as well as key demographic characteristics such as sex and wealth. We sought to calculate the population attributable risks (PARs) for established potentially modifiable risk factors for dementia among these different groups.

Methods: We obtained risk factor prevalence from population-based surveys for established dementia risk factors (diabetes, midlife hypertension, midlife obesity, physical inactivity, depression, smoking, low educational attainment, social isolation). We used relative risk estimates reported in previous meta-analyses and estimated PARs using Levin's formula and accounting for communality. We tested for one-way and two-way interactions by sex and wealth using Pearson's χ2. In stratified analyses, we performed tests for trend using logistic regression.

Results: The prevalence of established risk factors for dementia ranged from 5% for depression to 64% for low education. After accounting for communality, the risk factors contributing the greatest PAR were low education (weighted PAR 12%, 95% CI 7% to 18%), physical inactivity (9, 5–14%), and midlife hypertension (6, 5–14%). Together, 45% of dementia cases may be attributable to modifiable risk factors (95% CI 25–59%). We found significant interactions (p < 0.005) between sex, wealth, or both (sex ^* wealth) and each risk factor except social isolation and physical activity. Low education was inversely associated with wealth in both male and female. The PAR for midlife hypertension, obesity, and diabetes was associated with increasing wealth, and was higher in female. In contrast, the PAR for smoking was higher in male (8% vs. 2%) and was associated with increasing wealth among female only. We found that either a strategy of large reductions in selected risk factors with the highest PAR (midlife hypertension, smoking, physical inactivity) or small reductions across all risk factors could potentially reduce dementia cases by as many as 250,000 by 2050.

Discussions: The potential impact on dementia risk by decreasing exposure to established dementia risk factors is large and differs by sex and social determinants of health like wealth. Risk factor PAR should inform national and local health policy dementia initiatives in South Africa including which risk factors to target in the whole population and which to target in high-risk groups for maximum public health benefit.

The correlation of blood pressure variability and cognitive function in hypertension patients: A meta-analysis

BACKGROUND

Cognitive impairment (CI) is very common in patients with hypertension. It is necessary to conduct a meta-analysis to evaluate the association between cognitive function and blood pressure variability in patients with hypertension, to provide insights into the clinical management of hypertension and cognitive impairment.

METHODS

We searched PubMed and other databases for case-control studies on the association between blood pressure variability and cognitive function up to 15 July 2021. Two researchers independently screened the literature and retrieved the data. RevMan 5.3 was used for meta-analysis.

RESULTS

A total of 13 studies involving 2754 patients were included. Meta-analysis indicated that 24-hours systolic (MD = 3.54, 95% CI [2.48, 4.60]) and diastolic (MD = 2.43, 95% CI [1.55, 3.31]) blood pressure variation coefficients in the CI group were significantly higher than that of non-CI group (all P < .05). Standard deviations of systolic (MD = 2.20, 95% CI [0.27, 4.13]) and diastolic (MD = 1.79, 95% CI [0.80, 2.79]) blood pressure variation in the CI group were significantly higher than that of the non-CI group (all P < .05). Mean systolic (MD = 3.73, 95% CI [0.92, 6.53]) and diastolic (MD = 5.41, 95% CI [0.42, 10.40]) blood pressure variation in the CI group were significantly higher than that of non-CI group (all P < .05). There were no statistically significant differences in the morning peak systolic (MD = 7.85, 95% CI [-1.30, 17.01]) and diastolic (MD = 4.44, 95% CI [-6.00, 14.89]) blood pressure drop between the CI group and non-CI group (all P > .05).

CONCLUSION

CI in hypertensive patients is closely associated with increased blood pressure variability. Clinical healthcare providers should pay attention to the management of blood pressure variability in hypertensive patients to reduce the occurrence of CI.

A Nationwide Multi-Center Questionnaire Survey on the Real-World State and Clinical Management of Poststroke Dementia in Japan

Background:

Poststroke dementia (PSD) is a serious problem for stroke survivors. However, there is still limited data on the real-world state and clinical management of PSD worldwide, and several countries already have a super-aged society.

Objective:

We conducted a nationwide questionnaire survey to examine the real-world state and management of PSD in Japan.

Methods:

A survey was conducted in the top 500 Japanese hospitals regarding the number of stroke patients treated between July 2018 and August 2019. Thirteen questions regarding PSD were mailed to doctors responsible for stroke management.

Results:

Responses were obtained from 251 hospitals (50.2%). The chief doctors responsible for stroke management answered the questionnaires. The median numbers of patients admitted annually with stroke in the departments of neurology and neurosurgery in the hospitals were 281.0 (interquartile range [IQR], 231.8–385.3) and 253.5 (IQR, 210.0–335.3), respectively, and most hospitals were acute care hospitals. Executive dysfunction was the most common cognitive dysfunction (10.9%), followed by amnesia (9.5%) and apathy (4.1%). Surprisingly, many stroke survivors lived alone at home (23.7%). Montreal Cognitive Assessment was significantly uncommon compared to Mini-Mental State Examination (p < 0.01). Furthermore, objective evaluation tests for behavioral and psychological symptoms of dementia were not often performed. Cognitive rehabilitation treatments were performed more often and earlier than drug treatments. The first drug of choice for PSD was predominantly donepezil (79.1%), followed by galantamine (6.1%), cilostazol (4.9%), memantine (2.5%), and rivastigmine (1.8%).

Conclusion:

Our study provides real-world evidence for the state of clinical practice related to PSD in Japan.

Task-shifting to optimize outpatient neurological care in Zambia

OBJECTIVE

To investigate opportunities for task shifting to decongest an outpatient neurology clinic in Zambia by describing current patient flow through the clinic and potential nodes for intervention using process mapping.

BACKGROUND

Zambia has a population of approximately 18 million people with 4 full-time adult neurologists, as of 2018, who all practice at the University Teaching Hospital (UTH), the main tertiary care center in the country. As a result of this provider-to-patient ratio, the outpatient neurology clinic is overcrowded and overbooked. Task-shifting programs have shown to improve efficiency, access and quality of care through the use of less specialized healthcare workers in low- and middle-income countries (LMIC).

METHODS

We evaluated patient flow in the UTH neurology outpatient clinic through the development and analysis of a process map. The characteristics of the clinic population between 2014 and 2018 were retrospectively reviewed from the clinic register. Between July and August 2018, we prospectively collected appointment lag times and time each patient spent waiting at various points in the clinic process. We conducted interviews with clinic staff and neurologists to generate a detailed process map of current pathways to care within the clinic. We then devised task-shifting strategies to help reduce patient wait times based on the overview of clinic process mapping and patient demographics.

RESULTS

From 2014 to 2018, there were 4701 outpatients seen in the neurology clinic. The most common neurological diagnoses were epilepsy (39.2%), headache (21.5%) and cerebrovascular disease (16.7%). During prospective data collection, patients waited an average of 57.8 (SD 73.4) days to be seen by a neurologist. The average wait time from arrival in the clinic to departure was 4.0 (SD 2.5) h. The process map and interviews with clinic staff revealed long waiting times due to a paucity of providers. Nurses and clerks represent an influential stakeholder group, but are not actively involved in any activity to reduce wait times. A large proportion of follow-up patients were stable and seen solely to obtain medication refills.

CONCLUSIONS

Epilepsy, headache, and stroke make up the largest percentage of outpatient neurological illness in Zambia. Targeting stable patients in these diagnostic categories for a task-shifting intervention may lead to substantially decreased patient wait times. Potential interventions include shifting clinical follow-ups and medication refills to less specialized healthcare workers.

The Survival Status and Predictors of Mortality Among Stroke Patients at North West Ethiopia

INTRODUCTION

Stroke is one of the commonest non-communicable disease types that has a great public health impact both in developed and developing countries. However, in Ethiopia, the long-term survival status of stroke patients is not very understood. This study aimed at assessing survival status and predictors of mortality among stroke patients at Felege Hiwot comprehensive specialized hospital from September 1, 2014, to August 31, 2019, Bahirdar, North West Ethiopia.

METHODS

An institutional-based retrospective cohort study was conducted using 368 registered stroke patients between September 1, 2014, and August 31, 2019. We used Kaplan-Meier together with a Log-rank test to compare the survival rate of the study participants using categorical variables and to compare covariate and both bi-variable and multivariable Cox proportional hazards regression analysis model was conducted to identify predictors of mortality among stroke patients. The association between outcome and independent variables was expressed using an adjusted hazard ratio (AHR) with a 95% confidence interval and statistical significances were declared at P-value of <0.05.

RESULTS

Fifty-six (15.2%) of the 368 stroke patients included in the study died, and 312 (84.8%) were correctly censored. The overall survival rate was 72.2% at 51 months of follow-up with a median survival time of 0.26 months. Age greater than 65 (AHR 6.31, 95% CI 1.75-22.74), body temperature >7.1 degree centigrade (AHR = 7.14, 95% CI: 2.76-18.5), potassium level below <2 mmol/l (AHR = 2, 95% CI: 1.9-23.53) and creatinine level >1.2 mg/dl (AHR = 7.85, 95% CI: 2.7-22.6) were predictive predictors of mortality.

CONCLUSIONS

In the follow-up of 51 months, significant mortality occurred. Important predictive predictors of survival status were identified. Interventions should be focused on health education and awareness creation of the community for the early management of stroke.

Infectious disease-associated encephalopathies

Infectious diseases may affect brain function and cause encephalopathy even when the pathogen does not directly infect the central nervous system, known as infectious disease-associated encephalopathy. The systemic inflammatory process may result in neuroinflammation, with glial cell activation and increased levels of cytokines, reduced neurotrophic factors, blood-brain barrier dysfunction, neurotransmitter metabolism imbalances, and neurotoxicity, and behavioral and cognitive impairments often occur in the late course. Even though infectious disease-associated encephalopathies may cause devastating neurologic and cognitive deficits, the concept of infectious disease-associated encephalopathies is still under-investigated; knowledge of the underlying mechanisms, which may be distinct from those of encephalopathies of non-infectious cause, is still limited. In this review, we focus on the pathophysiology of encephalopathies associated with peripheral (sepsis, malaria, influenza, and COVID-19), emerging therapeutic strategies, and the role of neuroinflammation.

17β-oestradiol alleviates endoplasmic reticulum stress injury induced by chronic cerebral hypoperfusion through the Haemoglobin/HIF 1α signalling pathway in ovariectomized rats

Endoplasmic reticulum stress (ERS) is known to be an essential target in protecting against ischaemic brain injury. In this study, using a vascular dementia (VaD) animal model induced by bilateral common carotid artery occlusion (BCCAO), we evaluated the effect and mechanism of 17β-oestradiol (E2) against VaD by inhibiting ERS at the early stage (14 d, 21 d, 28 d) and late stage (3 m) after BCCAO in the hippocampal CA1 region of ovariectomized rats. The results showed that the activation of the PERK-eIF2α-ATF4-CHOP axis, a typical ERS pathway, was significantly increased at the early and late stages after BCCAO. JNK (c-Jun N-terminal kinase)-cJun, a pro-death pathway, also displayed the same pattern as the ERS axis. E2 treatment profoundly suppressed the impairments caused by BCCAO. Further mechanistic studies revealed that cerebral blood flow (CBF) was sharply decreased at 14 d and returned to the normal level at 21 d after BCCAO. E2 could not change CBF, while it unexpectedly enhanced the ability to carry oxygen. This is evidenced by the fact that the protein expression of haemoglobin α/β (Hα/β), an oxygen carrier, robustly increased at BCCAO 21 d and 3 m after E2 treatment. The oxygen carrier increased strongly after 21 d and 3 m of BCCAO treated with E2. Moreover, E2 correspondingly enhanced the protein expression of hypoxia-inducible factor 1α (HIF 1α) in both the early and late stage after BCCAO in the hippocampal CA1 region. Finally, E2 administration markedly decreased the activities of caspase-8, caspase-3, and caspase-12 and increased the number of NeuN-positive cells. These findings suggest that E2 serves as a neuroprotectant to alleviate VaD by suppressing ERS injury involving the haemoglobin/HIF 1α signalling pathway.

Prevalence estimates of dementia in older adults in rural Kilimanjaro 2009-2010 and 2018-2019: is there evidence of changing prevalence?

INTRODUCTION

Although limited, existing epidemiological data on dementia in sub-Saharan Africa indicate that prevalence may be increasing; contrasting with recent decreases observed in high-income countries. We have previously reported the age-adjusted prevalence of dementia in rural Tanzania in 2009-2010 as 6.4% (95% confidence interval [CI] 4.9-7.9) in individuals aged ≥70 years. We aimed to repeat a community-based dementia prevalence study in the same setting to assess whether prevalence has changed.

METHODS

This was a two-phase door-to-door community-based cross-sectional survey in Kilimanjaro, Tanzania. In Phase I, trained primary health workers screened all consenting individuals aged ≥60 years from 12 villages using previously validated, locally developed, tools (IDEA cognitive screen and IDEA-Instrumental Activities of Daily Living questionnaire). Screening was conducted using a mobile digital application (app) on a hand-held tablet. In Phase II, a stratified sample of those identified in Phase I were clinically assessed using the DSM-5 criteria and diagnoses subsequently confirmed by consensus panel.

RESULTS

Of 3011 people who consented, 424 screened positive for probable dementia and 227 for possible dementia. During clinical assessment in Phase II, 105 individuals met DSM-5 dementia criteria. The age-adjusted prevalence of dementia was 4.6% (95% CI 2.9-6.4) in those aged ≥60 years and 8.9% (95% CI 6.1-11.8) in those aged ≥70 years. Prevalence rates increased significantly with age.

CONCLUSIONS

The prevalence of dementia in this rural Tanzanian population appears to have increased since 2010, although not significantly. Dementia is likely to become a significant health burden in this population as demographic transition continues.

Outcomes of Ischemic Stroke and Associated Factors Among Elderly Patients With Large-Artery Atherosclerosis: A Hospital-Based Follow-Up Study in China

Large-artery atherosclerotic (LAA) stroke is the most common subtype of ischemic stroke. However, risk factors for long-term outcomes of LAA stroke in the elderly Chinese population have not been well-described. Therefore, we aimed to assess outcomes and risk factors at 3, 12, and 36 months after LAA stroke onset among stroke patients aged 60 years and older. All consecutive LAA patients aged ≥ 60 years were prospectively recruited from Dongying People's Hospital between January 2016 and December 2018. The clinical features and outcome data at 3, 12, and 36 months after stroke were collected. Differences in outcomes and relationship between outcomes and risk factors were assessed. A total of 1,772 patients were included in our study (61.7% male, 38.3% female). The rates of mortality, recurrence, and dependency were 6.6, 12.6, and 12.6%, respectively, at 3 months after stroke onset. The corresponding rate rose rapidly at 36 months (23.2, 78.7, and 79.7%, respectively). We found the positive predictors associated outcomes at 3, 12, and 36 months after stroke onset. The relative risk (RR) with 95% confidential interval (CI) is 1.06 (1.02–1.10, P = 0.006) at 3 months, 1.06 (1.02–1.10, P = 0.003) at12 months, and 1.10 (1.05–1.15, P < 0.001) at 36 months after stroke onset for age; 1.09 (1.01–1.19, P = 0.029) at 12 months for fasting plasma glucose (FPG) level; 4.25 (2.14–8.43, P < 0.001) at 3 months, 4.95 (2.70–9.10, P < 0.001) at 12 months, and 4.82 (2.25–10.32, P < 0.001) at 36 months for moderate stroke; 7.56 (3.42–16.72, P < 0.001) at 3 months, 11.08 (5.26–23.34, P < 0.001) at 12 months, and 14.30 (4.85–42.11, P < 0.001) at 36 months for severe stroke, compared to mild stroke. Hypersensitive C-reactive protein (hs-CRP) level was an independent risk factor for mortality at different follow-up times, with the RR (95%) of 1.02 (1.01–1.02, P < 0.001) at 3 months, 1.01 (1.00–1.02, P = 0.002) at 12 months. White blood cell count (WBC) level was associated with both stroke recurrence (RR = 1.09, 95%CI: 1.01–1.18, P = 0.023) and dependency (RR = 1.10, 95%CI: 1.02–1.19, P = 0.018) at 3 months. In contrast, a higher level of low-density lipoprotein cholesterol (LDL-C) within the normal range was a protective factor for recurrence and dependency at shorter follow-up times, with the RR (95%) of 0.67 (0.51–0.89, P = 0.005) and 0.67 (0.50–0.88, P = 0.005), respectively. These findings suggest that it is necessary to control the risk factors of LAA to reduce the burden of LAA stroke. Especially, this study provides a new challenge to explore the possibility of lowering LDL-C level for improved stroke prognosis.

Incidence of Cognitive Impairment during Aging in Rural South Africa: Evidence from HAALSI, 2014 to 2019

INTRODUCTION

Despite rapid population aging, there are currently limited data on the incidence of aging-related cognitive impairment in sub-Saharan Africa. We aimed to determine the incidence of cognitive impairment and its distribution across key demographic, social, and health-related factors among older adults in rural South Africa.

METHODS

Data were from in-person interviews with 3,856 adults aged ≥40 who were free from cognitive impairment at baseline in the population-representative cohort, "Health and Aging in Africa: a Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI), in Agincourt sub-district, Mpumalanga province, South Africa (2014-19). Cognitive impairment was defined as scoring <1.5 standard deviations below the mean of the baseline distribution of orientation and episodic memory scores. Incidence rates and rate ratios for cognitive impairment were estimated according to key demographic, social, and health-related factors, adjusted for age, sex/gender, and country of birth.

RESULTS

The incidence of cognitive impairment was 25.7/1,000 person-years (PY; 95% confidence interval [CI]: 23.0-28.8), weighted for mortality (12%) and attrition (6%) over the 3.5-year mean follow-up (range: 1.5-4.8 years). Incidence increased with age, from 8.9/1,000 PY (95% CI: 5.2-16.8) among those aged 40-44 to 93.5/1,000 PY (95% CI: 75.9-116.3) among those aged 80+, and age-specific risks were similar by sex/gender. Incidence was strongly associated with formal education and literacy, as well as marital status, household assets, employment, and alcohol consumption but not with history of smoking, hypertension, stroke, angina, heart attack, diabetes, or prevalent HIV.

CONCLUSIONS

This study presents some of the first incidence rate estimates for aging-related cognitive impairment in rural South Africa. Social disparities in incident cognitive impairment rates were apparent in patterns similar to those observed in many high-income countries.

Stroke in Africa: profile, progress, prospects and priorities

Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.

Conceptual framework for establishing the African Stroke Organization

Africa is the world's most genetically diverse, second largest, and second most populous continent, with over one billion people distributed across 54 countries. With a 23% lifetime risk of stroke, Africa has some of the highest rates of stroke worldwide and many occur in the prime of life with huge economic losses and grave implications for the individual, family, and the society in terms of mental capital, productivity, and socioeconomic progress. Tackling the escalating burden of stroke in Africa requires prioritized, multipronged, and inter-sectoral strategies tailored to the unique African epidemiological, cultural, socioeconomic, and lifestyle landscape. The African Stroke Organization (ASO) is a new pan-African coalition that brings together stroke researchers, clinicians, and other health-care professionals with participation of national and regional stroke societies and stroke support organizations. With a vision to reduce the rapidly increasing burden of stroke in Africa, the ASO has a four-pronged focus on (1) research, (2) capacity building, (3) development of stroke services, and (4) collaboration with all stakeholders. This will be delivered through advocacy, awareness, and empowerment initiatives to bring about people-focused changes in policy, clinical practice, and public education. In the spirit of the African philosophy of Ubuntu "I am because we are," the ASO will harness the power of diversity, inclusiveness, togetherness, and team work to build a strong, enduring, and impactful platform for tackling stroke in Africa.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

Vascular-brain Injury Progression after Stroke (VIPS) study: concept for understanding racial and geographic determinants of cognitive decline after stroke

Cognitive impairment and dementia (CID) are major public health problems with substantial personal, social, and financial burdens. African Americans are at a heightened risk for Vascular Cognitive Impairment (VCI) compared to European Americans. Recent lines of evidence also suggest a high burden of Post-stroke VCI among indigenous Africans. A better understanding of the cause(s) of the racial disparity in CID, specifically VCI, is needed in order to develop strategies to reduce it. We propose and discuss the conceptual framework for a unique tri-population, trans-continental study titled The Vascular brain Injury Progression after Stroke (VIPS) study. The overarching objective of the VIPS Study will be to explore the interplay of multiple factors (racial, geographical, vascular, lifestyle, nutritional, psychosocial and inflammatory) influencing the level and trajectory of post-stroke cognitive outcomes and examine whether differences between indigenous Africans, African Americans and European Americans exist. We hypothesize that differences which might be due to racial factors will be observed in African Americans versus European Americans as well as Indigenous Africans versus European Americans but not in African Americans versus Indigenous Americans; differences due to geographical factors will be observed in Indigenous Americans versus African Americans and Indigenous Africans versus European Americans but not in African Americans versus European Americans. This overarching objective could be accomplished by building upon existing National Institutes of Health investments in the REasons for Geographical And Racial Differences in Stroke (REGARDS) study (based in the United States of America) and the Stroke Investigative Research and educational Network (SIREN) study (based in Sub-Saharan Africa).

Recombinant Human Growth Hormone Ameliorates Cognitive Impairment in Stroke Patients

OBJECTIVE

We aimed to determine the effects of recombinant human growth hormone (rhGH) replacement on cognitive function in subjects with poststroke cognitive impairment using resting-state functional magnetic resonance imaging.

METHODS

We included 60 patients with a first-ever stroke for 3 months and a diagnosis of cognitive impairment who were randomized 1:1 to receive either rhGH subcutaneously or placebo injection for 6 months. All subjects were required to receive the same rehabilitative therapy program. Both groups were subjected to pretreatment and posttreatment neuropsychological assessment using the Montreal Cognitive Assessment, serum neurotrophic factors, biomarkers of glucose and lipid metabolism, and functional magnetic resonance imaging during 6 months of the study period. The pattern of brain activity was determined by examining the functional connectivity and amplitude of low-frequency fluctuations (ALFF) of blood oxygen level dependent signal.

RESULTS

Forty-three (82.7%) completed the study. Treatment with rhGH reduced levels of triglycerides and low-density lipoprotein cholesterol but did not significantly altered plasma concentrations of glucose and glycated hemoglobin. We found a significant increase in serum insulin-like growth factor 1 levels (32.6%; P < 0.001) in the rhGH-treated group compared with that in the controls. After 6 months of rhGH treatment, mean Montreal Cognitive Assessment score improved from 16.31 (5.32) to 21.19 (6.54) (P < 0.001). The rhGH group showed significant increased area of activation with increased ALFF values in the regions of the frontal lobe, putamen, temporal lobe, and thalamus (P < 0.05), relative to the baseline conditions. The correlation analysis revealed that the ALFF and functional connectivity of default mode network was positively correlated with the ΔMoCA score and ΔIGF-1 levels; that is, the more the scale score increased, the higher the functional connection strength. No undesirable adverse effects were observed.

CONCLUSIONS

The rhGH replacement has a significant impact on global and domain cognitive functions in poststroke cognitive impairment.

Hypertension in older adults in Africa: A systematic review and meta-analysis

BACKGROUND

Hypertension is the leading driver of cardiovascular disease deaths in Africa. Its prevalence is highest in older populations. Yet, this group has received little attention in many African countries. We conducted a systematic review and meta-analysis (PROSPERO registration: CRD42017056474) to estimate the prevalence of hypertension in older adults living in Africa.

METHODS

We searched grey literature and major electronic databases including PubMed and Embase for population-based studies and published between 1 January 1980 to 28 May 2018 reporting the prevalence of hypertension for adults aged ≥50 years living in Africa. We employed a random effects model to estimate the pooled prevalence across included studies.

FINDINGS

We screened 10,719 articles and retrieved 103 full-text articles to evaluate for inclusion in the review. Thirty-four unique studies providing 37 data points on 43,025 individuals in 15 African countries were analyzed. The prevalence of hypertension ranged from 22.3% to 90.0% from the individual studies while the overall pooled prevalence was 57.0% (95% CI 52%-61%). The prevalence was not statistically significantly different by sex, residence, or African sub-region. In individual studies, older age and overweight/obesity were independently associated with hypertension. Twenty-nine (78%) data points were deemed to be of low- or moderate-risk of bias. Eliminating high-risk bias studies made little difference to the pooled estimate of hypertension. Sensitivity analyses, omitting one study at a time, identified three studies with significant but relatively small impact on the pooled estimate. We observed substantial heterogeneity (I2 = 98.9%) across the studies which was further explored by meta-regression analyses. Overall, the GRADE assessment suggested moderate quality evidence in the results.

CONCLUSION

The persistent high prevalence of hypertension among older adults in Africa, even in rural populations warrants more attention to the cardiovascular health of this group by public health authorities.