Recurrent Ischemic Stroke - A Systematic Review and Meta-Analysis

Effects of hyperbaric oxygen combined with Danhong injection on 90-day functional independence and the 1-year recurrence rate in patients with ischemic stroke: A matched cohort study

BACKGROUND

Both hyperbaric oxygen therapy and Danshen (Salvia miltiorrhiza) injection have shown potential therapeutic effects on ischemic stroke, but the impact of their combination on long-term functional outcomes and recurrence risk has not been systematically evaluated. This study aimed to assess the effects of hyperbaric oxygen combined with Danhong injection on 90-day functional independence and the 1-year recurrence rate in patients with ischaemic stroke.

METHODS

This study employed a retrospective matched cohort design and collected data from patients with ischemic stroke treated at our hospital between January 2018 and December 2022. After 1:1 propensity score matching, 80 patients were included in each group. The intervention group received hyperbaric oxygen therapy (2.0-2.5 ATA, once daily for 10 sessions) combined with Danhong injection (20 ml/day for 14 consecutive days) in addition to standard treatment; the control group received standard treatment only. The primary outcome was 90-day functional independence (mRS ≤2); secondary outcomes included the 1-year stroke recurrence rate, NIHSS score improvement, and others.

RESULTS

The percentage of 90-day functional independence in the intervention group (72.5 %) was significantly greater than that in the control group (53.8 %) (P = 0.014), with a relative risk ratio of 1.35 (95 % CI: 1.06-1.71). Multivariate analysis revealed that combined therapy was independently associated with 90-day functional independence (adjusted OR = 2.28, 95 % CI: 1.19-4.37; P = 0.013). The 1-year stroke recurrence rate in the intervention group (7.6 %) was significantly lower than that in the control group (16.5 %) (P = 0.042), with an adjusted hazard ratio of 0.46 (95 % CI: 0.22-0.94, P = 0.033). Subgroup analysis revealed that patients aged <65 years, those with NIHSS scores ranging from 4-15, those with small-artery occlusion or large-artery atherosclerosis stroke, and those who began treatment within 24 hours benefited more significantly. The combined therapy was well tolerated, with no serious adverse events.

CONCLUSION

Hyperbaric oxygen combined with Danhong injection significantly improved 90-day functional independence and reduced the 1-year recurrence risk in patients with ischaemic stroke, particularly in specific patient subgroups. This combined treatment strategy provides a new therapeutic option for comprehensive stroke management.

The performance of machine learning for predicting the recurrent stroke: a systematic review and meta-analysis on 24,350 patients

BACKGROUND

Stroke is a leading cause of death and disability worldwide. Approximately one-third of patients with stroke experienced a second stroke. This study investigates the predictive value of machine learning (ML) algorithms for recurrent stroke.

METHOD

This study was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. PubMed, Scopus, Embase, and Web of Science (WOS) were searched until January 1, 2024. The quality assessment of studies was conducted using the QUADAS-2 tool. The diagnostic meta-analysis was conducted to calculate the pooled sensitivity, specificity, diagnostic accuracy, positive and negative diagnostic likelihood ratio (DLR), diagnostic accuracy, diagnostic odds ratio (DOR), and area under of the curve (AUC) by the MIDAS package in STATA V.17.

RESULTS

Twelve studies, comprising 24,350 individuals, were included. The meta-analysis revealed a sensitivity of 71% (95% CI 0.64-0.78) and a specificity of 88% (95% confidence interval (CI) 0.76-0.95). Positive and negative DLR were 5.93 (95% CI 3.05-11.55) and 0.33 (95% CI 0.28-0.39), respectively. The diagnostic accuracy and DOR was 2.89 (95% CI 2.32-3.46) and 18.04 (95% CI 10.21-31.87), respectively. The summary ROC curve indicated an AUC of 0.82 (95% CI 0.78-0.85).

CONCLUSION

ML demonstrates promise in predicting recurrent strokes, with moderate to high sensitivity and specificity. However, the high heterogeneity observed underscores the need for standardized approaches and further research to enhance the reliability and generalizability of these models. ML-based recurrent stroke prediction can potentially augment clinical decision-making and improve patient outcomes by identifying high-risk patients.

The Relationship Between Body Mass Index and Recurrence Risk of Stroke: A Systematic Review and Dose-Response Meta‑Analysis

OBJECTIVE

To explore the relationship between body mass index (BMI) and the recurrence risk of stroke.

METHODS

We searched databases, including the Web of Science, Cochrane Library, Embase, PubMed, Chinese Biomedical Literature (CBM), CQVIP, WanFang Database, and China National Knowledge Infrastructure (CNKI), from inception to February 2025, to collect literature on BMI and the recurrence risk of stroke. After two researchers independently screened the literature, extracted the literature data, and assessed the quality of the literature included in the study, a meta-analysis was conducted using Stata 16.0 software, and the dose-response relationship between BMI and the recurrence risk of stroke was analyzed using generalized least squares trend estimation method (GLST) and restricted cubic spline function.

RESULTS

A total of 18 studies were included, involving 165,366 patients. In terms of stroke recurrence risk, compared with normal-weight patients, underweight patients [relative risk (RR) = 1.59, 95% confidence interval (CI) 1.33-1.90, I2 = 0%, p = 0.444] had a higher recurrence risk of stroke, whereas overweight (RR = 0.91, 95% CI 0.86-0.96, I2 = 0%, p = 0.454) and obese patients (RR = 0.89, 95% CI 0.84-0.94, I2 = 13.1%, p = 0.330) had a lower recurrence risk of stroke. The results of the linear trend show that for every unit increase in BMI, the recurrence risk of stroke decreases by 2% (RR = 0.98, 95% CI 0.96-0.99, p < 0.001).

CONCLUSION

Increased BMI is associated with a decreased recurrence risk of stroke. Underweight is a risk factor for stroke recurrence, whereas overweight and obesity are protective factors for stroke recurrence. Overweight and obesity may be beneficial for secondary prevention in stroke patients.

CLINICAL TRIAL REGISTRATION

Not applicable.

Global trends, disparities, and future projections of ischemic stroke burden attributed to low-fiber diets: An analysis based on GBD 2021

OBJECTIVE

This study aims to analyze the disease burden attributed to ischemic stroke related to low-fiber diets (IFD-IS) from 1990 to 2021, utilizing data from the Global Burden of Disease (GBD) database to identify trends and influencing factors of the disease burden.

METHODS

We conducted a comprehensive analysis of the number of deaths, Disability-Adjusted Life Years (DALYs), Years of Life Lost (YLLs), and Years Lost due to Disability (YLDs) associated with IFD-IS, covering various regions and populations. Statistical methods, including breakpoint regression, decomposition analysis, health inequality analysis, and forecasting analysis, were employed to assess trends and their correlation with the Sociodemographic Index (SDI).

RESULTS

The findings indicate that deaths, DALYs, YLLs, and YLDs related to IFD-IS have gradually increased globally, with a significantly higher burden in males compared to females. Notable regional disparities were observed, particularly with heavier burdens in China and sub-Saharan Africa. Higher SDI regions demonstrated better control over disease burdens, while aging and population growth were the primary factors contributing to the increase. Additionally, the trend of health inequality related to IFD-IS has slightly diminished, although it is projected that the disease burden will continue to rise by 2040.

CONCLUSION

This study underscores the necessity of implementing targeted public health interventions for IFD-IS, particularly in low SDI regions. Enhancing dietary education and resource allocation can significantly mitigate the rising trend of IFD-IS. Ongoing monitoring and research are crucial for formulating effective health policies to address this public health challenge.

National Trends of Vascular Risk Factor Control Among Stroke Survivors in Korea: From the National Health and Nutrition Examination Survey 2010 to 2021

BACKGROUND

To prevent stroke recurrence in stroke survivors, effective management of vascular risk factors (VRFs), including hypertension, diabetes, hyperlipidemia, and smoking, is essential. This study aimed to assess the VRF control status and trends among stroke survivors in Korea.

METHODS

This cross-sectional study analyzed data from 1,261 stroke survivors aged ≥ 19 years (mean age: 65.2 years; 43.1% female) who were part of the Korea National Health and Nutrition Examination Survey from 2010 to 2021. The control status of VRFs was evaluated using standardized criteria: hypertension (blood pressure < 140/90 mmHg), diabetes (hemoglobin A1c < 7%), hyperlipidemia (low-density lipoprotein cholesterol [LDL-C] < 70 mg/dL), and smoking status. Multivariate logistic regression analysis was conducted to identify factors associated with uncontrolled VRFs.

RESULTS

The rates of age-adjusted hypertension, diabetes, and smoking control remained consistent throughout the observation period. However, overall LDL-C control improved from 30.1% in 2010-2012 to 40.4% in 2019-2021 (P = 0.015), particularly in those aged ≥ 65 years. However, in the 19-49 age group, the control rate decreased from 47.0% to 15.8% (P = 0.048). Smoking rates showed no significant improvement (70.2% in 2019-2021 compared to 69.6% in 2010-2012), particularly among men. Living alone (adjusted odds ratio [aOR], 1.85; 95% confidence interval [CI], 1.03-3.32) was significantly associated with uncontrolled hypertension, whereas living in urban areas was linked to uncontrolled diabetes (aOR, 2.75; 95% CI, 1.06-7.17). Non-health screening was significantly associated with uncontrolled hyperlipidemia (aOR, 2.28; 95% CI, 1.25-4.14), and men were more likely to continue smoking (aOR, 4.47; 95% CI, 3.12-6.72).

CONCLUSION

These findings highlight the need for targeted health strategies to enhance risk-factor management and reduce stroke recurrence.

Exposure to greenness modifies the association between extreme temperature events and ischemic stroke recurrence in Tianjin, China

Few studies have found an association between extreme temperature events and an increased risk of recurrent ischemic stroke (IS). We examined associations between extreme temperature events (heat waves, cold spells) and recurrent IS risk in Tianjin, China (2019-2020), using a time-stratified case-crossover design, while evaluating greenness's moderating role. Significant heat wave effects peaked at lag 8, with severe intensity events increasing IS recurrence risk by 39.8% (OR = 1.398, 95% CI:1.032-1.894). Cold spell impacts peaked at lag 3, with moderate intensity cold spells elevating risk by 20.3% (OR = 1.203, 95% CI: 1.052-1.377) and severe intensity cold spells elevating risk by 98.2% (OR = 1.982, 95% CI: 1.407-2.791). Greenness modified these associations: low-greenness areas strengthened heat wave effects(lag9:OR = 2.309,95%CI:1.024-5.209) but weakened cold spell impacts(OR = 1.557,95%CI:1.037-2.340), whereas high-greenness areas attenuated heat wave links(lag8:OR = 1.402,95%CI:1.022-1.924) and nullified cold spell associations. Age and sex disparities emerged - younger individuals and males showed higher susceptibility to heat waves, while older individuals and males were more vulnerable to cold spells. The findings highlight greenness as a potential modifier of extreme temperature events-related IS recurrence risks and underscore demographic-specific vulnerabilities.

The Relationship Between Knowledge, Psychological Flexibility, Anxiety and Healthy Behaviour in Stroke Patients: A Chain Mediation Model

AIMS

To explore the mediating effects of psychological flexibility and anxiety between knowledge and health behaviour in stroke patients, and to provide a reference for improving the health behaviour of stroke patients.

DESIGN

A cross-sectional study.

METHODS

A convenience sampling method was used to recruit 219 stroke patients from a tertiary hospital in China from July to November 2024. Patients were surveyed using an electronic questionnaire containing demographic questions and validated scales for stroke knowledge, psychological flexibility, anxiety and health behaviour. IBM SPSS v26.0 software and PROCESS Process macro were used for data analysis.

RESULTS

The health behaviour score of stroke patients was 54.2 ± 3.8, and health behaviour was positively correlated with stroke knowledge and negatively correlated with psychological flexibility and anxiety. There was a significant chain-mediated effect of psychological flexibility and anxiety in the relationship between stroke knowledge and health behaviour.

CONCLUSION

Stroke knowledge not only directly predicts health behaviour in stroke patients, but also indirectly influences the health behaviour of patients through the chain mediation of psychological flexibility and anxiety.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the importance of caregivers focusing on the interactions between patient knowledge, psychological flexibility, anxiety and health behaviour when caring for stroke patients. Comprehensive interventions aimed at enhancing stroke patients' knowledge, improving patients' psychological flexibility and reducing anxiety have the potential to improve patient health behaviour.

PATIENT OR PUBLIC CONTRIBUTION

Patients completed questionnaires.

REPORTING METHOD

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies was applied to report the results.

The impact of cerebral vessels morphological alteration and white matter hyperintensities burden on the one-year risk of ischemic stroke recurrence

PURPOSE

To assess the associations between cerebral vessels morphological features, white matter hyperintensities (WMHs), and the one-year risk of ischemic stroke recurrence.

METHODS

A total of 677 patients diagnosed with acute ischemic stroke from January 2018 to April 2021 were consecutively enrolled. Head computed tomography angiography (CTA) and magnetic resonance imaging including fluid-attenuated inversion recovery (FLAIR), were obtained on admission. Cerebral vessels morphological features such as volume, length, radius, density, tortuosity, branch complexity, and degree of stenosis were extracted and calculated using CTA data. Additionally, automated segmentation was employed for delineating WMHs lesions based on FLAIR images. By incorporating clinical characteristics, six predictive models were developed using Cox proportional hazards analysis to estimate the one-year risk of stroke recurrence. The performance of these models was evaluated by comparing the concordance index (C-index).

RESULTS

The study found significant associations between the lack of antiplatelet therapy at discharge, reduced length and branching of cerebral vessels, and increased burden of WMHs, with a higher one-year risk of recurrent ischemic stroke (all P < 0.05). The integrated model demonstrated superior prognostic capability (C-index: 0.750; 95% CI: 0.684-0.817), outperforming models based solely on clinical characteristics (C-index: 0.636; 95% CI: 0.555-0.717), cerebral vessels morphology (C-index: 0.601; 95% CI: 0.526-0.676), and WMHs burden (C-index: 0.680; 95% CI: 0.603-0.757).

CONCLUSION

The quantitative assessment of cerebral vessels morphological features and WMHs provides a promising neuroimaging tool for estimating the one-year risk of ischemic stroke recurrence. The incorporation of cerebral vessels morphological features enhances the predictive accuracy.

Exploring the Causal Link Between Systemic Lupus Erythematosus and Stroke Risk Through Mendelian Randomization Study

INTRODUCTION

Observational studies have indicated an association between systemic lupus erythematosus (SLE) and stroke. However, the genetic causality of this association remains incompletely understood. This study utilizes Mendelian randomization (MR) to investigate the potential causal relationship between SLE and the risk of stroke.

METHODS

We utilized summary-level statistics data from the largest genome-wide association studies (GWASs) on SLE and stroke. The primary MR analysis was conducted using the inverse variance weighted (IVW) method, with supplementary analyses performed using the MR-Egger and weighted median (WM) methods. Sensitivity and heterogeneity analyses were additionally performed to ensure the robustness of the results.

RESULTS

The IVW analysis indicated a potential causal relationship between SLE and an increased risk of any ischemic stroke (odds ratio [OR] = 1.039, 95% confidence interval [CI]: 1.014-1.066, p = 0.002). However, no significant genetic association was observed between SLE and large artery stroke (OR: 1.024, 95% CI: 0.975-1.076, p = 0.326), cardioembolic stroke (OR: 1.014, 95% CI: 0.948-1.085, p = 0.667), small vessel stroke (OR: 0.983, 95% CI: 0.942-1.026, p = 0.458), or intracerebral hemorrhage (OR: 0.992, 95% CI: 0.934-1.054, p = 0.804).

CONCLUSION

This MR study provides genetic evidence supporting a causal association between SLE and an increased risk of ischemic stroke. These findings underscore the significance of active monitoring and prevention of ischemic stroke to mitigate cerebrovascular comorbidities in SLE patients. Given the existence of ethnic-specific genomic heterogeneity, caution is warranted in interpreting these results.

Lipoprotein(a) as a Stroke Biomarker: Pathophysiological Pathways and Therapeutic Implications

Lipoprotein(a) [Lp(a)] has attracted widespread interest as a potential biomarker for cerebrovascular diseases due to its genetically determined and stable plasma concentration throughout life. Lp(a) exhibits pro-atherogenic and pro-thrombotic properties that contribute to vascular pathology in both extracranial and intracranial vessels. Elevated Lp(a) levels are strongly associated with large-artery atherosclerotic stroke, while data on its role in other ischemic subtypes and hemorrhagic stroke remains limited and inconsistent. Recent advances in Lp(a)-lowering therapies, such as antisense oligonucleotides and RNA-based agents, have demonstrated significant efficacy in reducing plasma Lp(a) levels. These advances have prompted increasing research into their potential application in the prevention and treatment of cerebrovascular diseases, aiming to determine whether Lp(a) reduction may translate into a reduced risk of stroke and large-artery atherosclerosis. This narrative review summarizes the current evidence on the association between Lp(a) and stroke, focusing on its utility in patient risk stratification. It also highlights existing knowledge gaps and outlines directions for future research, particularly in understanding subtype-specific effects and evaluating the clinical benefits of Lp(a)-targeted therapies.

Proteomic and Demographic Comparisons of Recurrent Ischemic Stroke Patients

Rates of recurrent strokes have remained relatively unchanged over the past couple decades, highlighting a need for advancements in secondary prevention of stroke recurrence. This study utilizes the Blood And Clot Thrombectomy Registry And Collaboration (BACTRAC) tissue bank to identify proteomic and demographic differences in recurrent ischemic stroke patients. Blood samples were collected during mechanical thrombectomy of large-vessel occlusion ischemic strokes. Plasma levels for 184 inflammatory and cardiometabolic proteins were measured in systemic blood and intracranial blood from the infarction area. Differences between recurrent and first-stroke patients were analyzed using Fisher's Exact Test for categorical variables and Student's independent samples t tests or Welch's t tests for continuous variables. Proteins were divided into systemic and intracranial proteins, and independent samples t tests were performed with a False Discovery Rate of 5.0%. Significant variables were used in multiple logistic regression. There were 20 patients in the prior stroke group and 121 in the first stroke group. The prior stroke group had a significantly higher percentage of females (80.0% vs 50.4%, p = 0.016) and lower rate of hyperlipidemia comorbidity (10.5% vs 35.5%, p = 0.034). Two systemic proteins were significantly higher in those with a prior stroke: CCL14 and FGF-19. Multiple logistic regression found higher levels of CCL14 and FGF-19 to be predictive of a stroke being recurrent. Along with other demographics, these proteins could provide a predictive model to identify patients with risk of recurrent ischemic strokes. Serum CCL14 and FGF-19 levels are easily accessible biomarkers, making them possible therapeutic targets for recurrent stroke prevention.

Secondary stroke prevention beyond antiplatelets: The role of colchicine and GLP-1RA - an ounce of prevention is worth a pound of cure

Stroke remains a major global health concern, ranking as the second most common cause of death and the third leading cause of disability worldwide. Despite advances in therapy and management, ischemic stroke patients continue to face high risks of recurrence, cardiovascular events, and mortality. Effective secondary stroke prevention is critical, encompassing antithrombotic therapy, management of vascular risk factors such as hypertension, dyslipidemia, and diabetes mellitus, and conducting healthy lifestyle. Approximately 80% of strokes are ischemic, with a significant proportion attributable to large-artery atherosclerosis of the extra- and intracranial arteries, particularly in the internal carotid artery. Atherothrombotic strokes, linked to plaque rupture and thrombus formation, present a notably high risk of recurrence. Inflammatory and immune mechanisms play pivotal roles in both the initiation and progression of atherosclerosis and stroke. Colchicine, an anti-inflammatory agent, has shown potential in managing cardiovascular disease, though its effects on stroke reduction and prevention have been inconsistent across studies. Its possible protective role against stroke is attributed to its anti-inflammatory actions, which include disrupting microtubule dynamics, inhibiting immune cell movement, and lowering inflammatory markers like L-Selectin and E-Selectin, while also suppressing interleukin release. Glucagon-like peptide-1 receptor agonists (GLP-1RA) agents have emerged as effective therapies for type 2 diabetes with notable cardiovascular benefits. These agents enhance glucose control while also providing protective effects against atherosclerosis and stroke. GLP-1RA drugs work by mimicking the effects of GLP-1, a peptide that regulates insulin release and glucose metabolism. They also exhibit anti-inflammatory properties, potentially reducing stroke risk through mechanisms such as improved endothelial function and reduced plaque formation. Clinical trials have indicated that GLP-1RA agents can significantly lower the incidence of nonfatal strokes and major adverse events. This narrative review underscores the importance of targeting inflammation to reduce the risk of recurrent stroke, emphasizing recent studies on colchicine and GLP-1RA. It consolidates evidence regarding the efficacy of these agents in secondary stroke prevention; however, future studies are needed to further explore their mechanisms and roles in comprehensive stroke management strategies.

Clinical applications of artificial intelligence and machine learning in neurocardiology: a comprehensive review

Neurocardiology is an evolving field focusing on the interplay between the nervous system and cardiovascular system that can be used to describe and understand many pathologies. Acute ischemic stroke can be understood through this framework of an interconnected, reciprocal relationship such that ischemic stroke occurs secondary to cardiac pathology (the Heart-Brain axis), and cardiac injury secondary to various neurological disease processes (the Brain-Heart axis). The timely assessment, diagnosis, and subsequent management of cerebrovascular and cardiac diseases is an essential part of bettering patient outcomes and the progression of medicine. Artificial intelligence (AI) and machine learning (ML) are robust areas of research that can aid diagnostic accuracy and clinical decision making to better understand and manage the disease of neurocardiology. In this review, we identify some of the widely utilized and upcoming AI/ML algorithms for some of the most common cardiac sources of stroke, strokes of undetermined etiology, and cardiac disease secondary to stroke. We found numerous highly accurate and efficient AI/ML products that, when integrated, provided improved efficacy for disease prediction, identification, prognosis, and management within the sphere of stroke and neurocardiology. In the focus of cryptogenic strokes, there is promising research elucidating likely underlying cardiac causes and thus, improved treatment options and secondary stroke prevention. While many algorithms still require a larger knowledge base or manual algorithmic training, AI/ML in neurocardiology has the potential to provide more comprehensive healthcare treatment, increase access to equitable healthcare, and improve patient outcomes. Our review shows an evident interest and exciting new frontier for neurocardiology with artificial intelligence and machine learning.

ECG-based machine learning model for AF identification in patients with first ischemic stroke

BACKGROUND

The recurrence rate of strokes associated with atrial fibrillation (AF) can be substantially reduced through the administration of oral anticoagulants. However, previous studies have not demonstrated a clear benefit from the universal application of oral anticoagulants in patients with embolic stroke of undetermined source. Timely detection of AF remains a challenge in patients with stroke.

AIM

This study aims to develop a convolutional neural network (CNN) model to accurately identify patients with AF using a 12-lead sinus-rhythm electrocardiogram (ECG) recorded around the time of the first ischemic stroke. In addition, this study also evaluates the model's ability to predict future occurrence of AF.

METHODS

A CNN model was trained with ECG data from patients at Taipei Veterans General Hospital. External validation was performed on ischemic stroke patients from National Taiwan University Hospital. The model's performance was assessed for detecting AF at the stroke event and predicting future AF occurrences.

RESULTS

The model demonstrated an area under curve (AUC) of 0.91 for internal validation and 0.69 for external validation in identifying AF at the stroke event, with sensitivity and negative predictive value both achieving 97%. Kaplan-Meier survival analysis of patients without a prior diagnosis of AF revealed a significant increase in future AF incidence among the high-risk group identified by the model (adjusted hazard ratio: 4.06; 95% confidence interval: 2.74-6.00).

CONCLUSIONS

The CNN model effectively identifies AF in stroke patients using 12-lead ECGs and predicts future AF events, facilitating early anticoagulation therapy and potentially reducing recurrent stroke risk. Further prospective studies are warranted to confirm these findings.

Identifying risk factors for recurrent mild ischemic stroke and high-risk population characteristics: A 1-year follow-up study

ObjectiveThis observational study examined the risk factors associated with recurrence in patients with mild ischemic stroke and determined the characteristics of high-risk groups.MethodsA total of 656 patients hospitalized for mild ischemic stroke were monitored for 1 year. Statistical analyses, including odds ratio calculations and K-means clustering, were conducted to examine risk factors for recurrence and the characteristics of high-risk groups.ResultsAfter 1 year of follow-up, 99 patients experienced recurrent mild ischemic stroke, resulting in a recurrence rate of 15.09%. The analysis revealed several significant risk factors, including type 2 diabetes mellitus, atrial fibrillation, smoking and alcohol consumption, carotid artery stenosis, cerebral vascular stenosis, and multiple lesions. Propensity score matching confirmed these associations, and K-means clustering revealed that older males with type 2 diabetes mellitus and hypertension were likely to be in the high-risk group.ConclusionsHealthcare professionals should focus on tailored treatment and prevention strategies for high-risk patients, prioritizing the management of the abovementioned risk factors to reduce recurrence and improve outcomes.

Early statin use is associated with improved survival and cardiovascular outcomes in patients with atrial fibrillation and recent ischaemic stroke: A propensity-matched analysis of a global federated health database

INTRODUCTION

Statins reduce recurrent stroke and cardiovascular events in patients with non-cardioembolic stroke. The benefits of statins in patients with AF and recent IS remain unclear. We aimed to investigate the benefits of statins in patients with AF and recent IS.

PATIENTS AND METHODS

This retrospective, cohort study was conducted using deidentified electronic medical records within TriNetX platform. Patients with AF and recent IS, who received statins within 28 days of their index stroke were propensity score-matched with those who did not. Patients were followed up for up to 2 years. Primary outcomes were the 2-year risk of recurrent IS, all-cause mortality and the composite outcome of all-cause mortality, recurrent IS, transient ischaemic attack (TIA), and acute myocardial infarction (MI). Secondary outcomes were the 2-year risk of TIA, intracranial haemorrhage (ICH), acute MI, and hospital readmission. Cox regression analyses were used to calculate hazard ratios (HRs) with 95% confidence intervals (95%CI).

RESULTS

Of 20,902 patients with AF and recent IS, 7500 (35.9%) received statins within 28 days of their stroke and 13,402 (64.1%) did not. 11,182 patients (mean age 73.7 ± 11.5; 5277 (47.2%) female) remained after propensity score matching. Patients who received early statins had significantly lower risk of recurrent IS (HR: 0.45, 95%CI: 0.41-0.48, p < 0.001), mortality (HR: 0.75, 95%CI: 0.66-0.84, p < 0.001), the composite outcome (HR: 0.48, 95%CI: 0.45-0.52, p < 0.001), TIA (HR: 0.37, 95%CI: 0.30-0.44, p < 0.001), ICH (HR: 0.59, 95%CI: 0.47-0.72, p < 0.001 ), acute MI (HR: 0.35, 95%CI: 0.30-0.42, p < 0.001) and hospital readmission (HR: 0.46, 95%CI: 0.42-0.50, <0.001). Beneficial effects of early statins were evident in the elderly, different ethnic groups, statin dose intensity, and AF subtypes, large vessel occlusion and embolic strokes and within the context of statin lipophilicity, optimal LDL-cholesterol levels, various cardiovascular comorbidities, treatment with intravenous thrombolysis or endovascular thrombectomy, and NIHSS 0-5 and NIHSS > 5 subgroups.

DISCUSSION AND CONCLUSION

Patients with AF and recent IS, who received early statins, had a lower risk of recurrent stroke, death, and other cardiovascular outcomes including ICH, compared to those who did not.

High-dose statins for the prevention of recurrent ischemic stroke: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Ischemic stroke (IS) is a leading cause of disability and mortality, with fatal outcomes increased with recurrent strokes. This systematic review and meta-analysis of randomized controlled trials (RCTs) evaluated the safety and efficacy of high-dose statins for secondary IS prevention.

METHODS

This review was regestered on PROSPERO (registration number: CRD42024574088). Cochrane methodology was followed in this review and comprehensively searched PubMed, Embase, Cochrane Library and clinicaltrial.gov, to include all RCTs conducted from 2004 to 2024, comparing high-dose statins (simvastatin ≥40 mg, atorvastatin ≥40 mg, and rosuvastatin ≥20 mg) with low-dose statins, placebo, or standard care. Outcomes of this review were recurrent IS reduction and adverse events reported in RCTs.

RESULTS

Nine RCTs involving 5,503 patients, with male patients ranging from 25.8% to 81.6% were included. Compared to controls, high-dose statins did not significantly reduce risks for secondary IS (OR 0.78, 95% CI [0.61, 1.00], P=.05) and hemorrhagic stroke (OR 0.85, 95% CI [0.56, 1.29], P=.45). Furthermore, no differences were observed in mortality rates and adverse events between groups.

CONCLUSION

Treatment with high dose statins didn't reduce the risk of stroke recurrence or improve mortality, though further research is needed.

Trends in stroke incidence, death, and disability outcomes in a multi-ethnic population: Auckland regional community stroke studies (1981-2022)

Background

Reliable data on trends of stroke incidence and outcomes over time are necessary for assessing the effectiveness of public health and clinical strategies, and for allocating healthcare resources. We assessed the levels and trends in incidence, mortality, early case fatality and disability for stroke in a defined, ethnically mixed population over 40 years.

Methods

To analyse data from five population-based stroke incidence studies in adult residents (age ≥15 years) of the Greater Auckland Region of New Zealand (NZ) (1.35 million) over 12-month calendar periods for 1981-1982, 1991-1992, 2002-2003, 2011-2012, and 2021-2022. Fatal and non-fatal, hospitalised and non-hospitalised stroke events (first-ever and recurrent) were identified through multiple overlapping sources using clinical World Health Organization (WHO) diagnostic criteria and neuroimaging to define three major pathological types of stroke: ischaemic stroke (IS), primary intracerebral haemorrhage (PICH), subarachnoid haemorrhage (SAH), and stroke of undetermined type (SUT). Crude and age-standardised annual incidence, mortality, 28-day case fatality and disability level, and 40-year trends were calculated by age, sex, and ethnicity assuming a Poisson distribution. For comparison of our findings, we carried out a pooled analysis of methodologically comparable population-based stroke epidemiology estimates in high-income countries over the last two decades.

Findings

Overall, there were 7462 first-ever strokes (9917 events) over the 40-year period (4,682,012 person-years). From 1981-1982 to 2021-2022, age-standardised stroke incidence rates decreased from 156/100,000 (95% confidence interval [CI] 143; 170) to 124/100,000 (119; 130) and mortality rates from 98/100,000 (88; 110) to 28/100,000 (26; 31) in nearly all age, sex, and ethnic groups. Moreover, from 2002-2003 to 2021-2022, there was an increase in stroke incidence of 1.28% per year (95% CI 0.38-2.17) in people aged 15-54 years, with the mean age of people with stroke decreasing from 73.0 (SD ± 13.8) in 2002-2003 to 71.6 (SD ± 14.9) in 2011-2012 and 70.7 (SD ± 15.2) years in 2021-2022 (p for trend <0.0001). The risk of stroke in Māori and Pacific people in 2021-2022 was almost 1.5 and 2.0 times greater than that in NZ Europeans. Ethnic disparities in the risk of stroke and age of stroke onset remained stable over the study period. From 1981-1982 to 2021-2022, 28-day stroke case fatality declined from 33.1% to 12.1% (p < 0.0001). There was a trend towards reducing 28-day case-fatality (from 31.6% [95% CI 27.6; 35.7] in 1981-1982 to 11.4% [10.0; 12.7] in 2021-2022) and an increasing proportion of stroke survivors with good functional outcome at discharge/28-days post-stroke (increased from 45.7% (95% CI 41.3; 50.0) in 1981-1982 to 60.2% (58.1; 62.3) in 2021-2022).

Interpretation

Stroke incidence, 1-year mortality and 28-day case-fatality and disability have decreased in Auckland, NZ over the last 4 decades. However, over the last decade (2011-2022) there was a stagnation in the decline in the age-standardised stroke incidence rates. The absolute numbers of people with strokes, and those who have died or remained disabled from stroke, have significantly increased from 1981 to 2022. Ethnic disparities in the risk and burden of stroke persist. Effective prevention strategies for stroke must remain a high priority.

Funding

Health Research Council of New Zealand.

Efficacy of Intravenous Tenecteplase Bridge Thrombectomy for Recurrent Ischemic Stroke Within 3 Months: A Case Report

In the previous guideline recommendations, patients who have had a stroke within 3 months are excluded from intravenous thrombolysis (IVT) regimens. Some studies have suggested that IVT with alteplase (rt-PA) may be effective and safe in such patients, but evidence supporting the use of tenecteplase (TNK) is not sufficient. This paper includes an 80-year-old male patient readmitted for recurrence of ischaemic stroke (IS) after 48 days, who received TNK IVT as a bridging therapy prior to thrombectomy, with favourable results at 8-week follow-up. This case highlights that TNK alone or IVT as a bridging therapy prior to thrombectomy can also benefit patients with recurrent stroke within 3 months.

Sex Differences in Prescription Patterns and Medication Adherence to Guideline-Directed Medical Therapy Among Patients With Ischemic Stroke

BACKGROUND

Ischemic stroke is a leading cause of death and disability. Society guidelines recommend pharmacotherapies for secondary stroke prevention. However, the role of sex differences in prescription and adherence to guideline-directed medical therapies (GDMT) after ischemic stroke remains understudied. The aim of this study was to examine sex differences in prescription patterns and adherence to GDMT at 1 year after ischemic stroke in a cohort of commercially insured patients.

METHODS

Using the Truven Health MarketScan database from 2016 to 2020, we identified patients admitted with ischemic stroke. GDMT was defined as any statin, antihypertensive agents, or oral anticoagulant prescription within 30 days after discharge. Medication adherence was estimated using the proportion of days covered at 1 year. The proportion of days covered <0.80 was used to define nonadherence. A multivariable model adjusting for covariates was performed to identify the factors associated with nonadherence at 1 year. This analysis was restricted to new users of GDMT.

RESULTS

Among 155 220 patients admitted with acute ischemic stroke during the study period, 15 919 met the inclusion criteria. The mean age was 55.7 years, and 8218 (51.7%) were women. Women were less likely to be prescribed statins (58.0% versus 71.8%) and antihypertensive agents (27.7% versus 41.8%). In this subset of patients with atrial flutter/fibrillation, women were also less likely to be prescribed oral anticoagulants (41.2% versus 45.0%). Women were more likely to be nonadherent (ie, proportion of days covered <0.80) to statins (47.3% versus 41.6%; P<0.0001), antihypertensives (33.3% versus 32.2%; P=0.005), and the combination of both (49.6% versus 45.0%; P=0.003). On multivariable analysis, women were likely to be nonadherent to statins and antihypertensive agents at 1 year (odds ratio, 1.23 [95% CI, 1.08-1.41]).

CONCLUSIONS

In this real-world analysis of commercially insured patients with ischemic stroke, women were less likely initiated on GDMT within 30 days after discharge. Women were more likely to be nonadherent to statins and antihypertensive agents at 1 year. Future efforts and novel interventions are needed to understand the reasons and minimize these disparities.

Use of optical coherence tomography in selected patients with recurrent cryptogenic stroke: A case series and technical discussion

BACKGROUND

Despite advances in secondary stroke prevention during the last several years, cryptogenic stroke remains associated with a high risk of recurrence. Studies have shown that the recurrence risk is higher in patients with large artery disease in which complex carotid plaques and carotid WEBs are identified.

METHODS

This is a case series of six patients with cryptogenic recurrent stroke in which conventional imaging and extensive workup did not identify an etiology. Intravascular optic coherence tomography (OCT) was performed using a ballon-guided flow-arrest technique to identify possible covert carotid lesions.

RESULTS

We present six cases in which, with the help of OCT, we identified three carotid WEBs with associated thrombosis and two ulcerated carotid artery plaques. Four patients were subsequently treated with endovascular stent placement without complications. OCT permitted the distinction between complicated carotid artery plaque and carotid WEB.

CONCLUSION

Intravascular OCT is a feasible and safe approach to identifying patients with covert carotid wall abnormalities, like carotid WEBs and ulcerated plaques, that are amenable to carotid stenting to reduce recurrent stroke risk.

Prediction of ischemic stroke in patients with H-type hypertension based on biomarker

Hypertension combined with hyperhomocysteinemia significantly raises the risk of ischemic stroke. Our study aimed to develop and validate a biomarker-based prediction model for ischemic stroke in Hyperhomocysteinemia-type (H-type) hypertension patients. We retrospectively included 3,305 patients in the development cohort, and externally validated in 103 patients from another cohort. Logistic regression, least absolute shrinkage and selection operator regression, and best subset selection analysis were used to assess the contribution of variables to ischemic stroke, and models were derived using four machine learning algorithms. Area Under Curve (AUC), calibration plot and decision-curve analysis respectively evaluated the discrimination and calibration of four models, then external validation and visualization of the best-performing model. There were 1,415 and 42 patients with ischemic stroke in the development and validation cohorts. The final model included 8 predictors: age, antihypertensive therapy, biomarkers (serum magnesium, serum potassium, proteinuria and hypersensitive C-reactive protein), and comorbidities (atrial fibrillation and hyperlipidemia). The optimal model, named A2BC ischemic stroke model, showed good discrimination and calibration ability for ischemic stroke with AUC of 0.91 and 0.87 in the internal and external validation cohorts. The A2BC ischemic stroke model had satisfactory predictive performances to assist clinicians in accurately identifying the risk of ischemic stroke for patients with H-type hypertension.

A NIRS-Based Technique for Monitoring Brain Tissue Oxygenation in Stroke Patients

Stroke is a global health issue caused by reduced blood flow to the brain, which leads to severe motor disabilities. Measuring oxygen levels in the brain tissue is crucial for understanding the severity and evolution of stroke. While CT or fMRI scans are preferred for confirming a stroke due to their high sensitivity, Near-Infrared Spectroscopy (NIRS)-based systems could be an alternative for monitoring stroke evolution. This study explores the potential of fNIRS signals to assess brain tissue in chronic stroke patients along with rehabilitation therapy. To study the feasibility of this proposal, ten healthy subjects and three stroke patients participated. For signal acquisition, two NIRS sensors were placed on the forehead of the subjects, who were asked to remain in a resting state for 5 min, followed by a 30 s motor task for each hand, which consists of opening and closing the hand at a steady pace, with a 1 min rest period in between. Acomplete protocol for placing sensors and a signal processing algorithm are proposed. In healthy subjects, a measurable change in oxygen saturation was found, with statistically significant differences (females p = 0.016, males p = 0.005) between the resting-state and the hand movement conditions. This work showed the feasibility of the complete proposal, including the NIRS sensor, the placement, the tasks protocol, and signal processing, for monitoring the state of the brain tissue cerebral oxygenation in stroke patients undergoing rehabilitation therapy. Thus this is a non-invasive barin assessment test based on fNIRS with the potential to be implemented in non-controlled clinical environments.

Direct-Acting Oral Anticoagulant Dabigatran as a Bridging Therapy while Optimizing Warfarin Dosage for Cardioembolic Stroke

INTRODUCTION

Parenteral heparin is widely used as bridging therapy while optimizing oral anticoagulation (OAC). Newer direct-acting OACs (DOACs) attain therapeutic effect very quickly. We report the use of dabigatran as bridging therapy during warfarin optimization for cardioembolic stroke in two patients who opted to receive warfarin for long-term anticoagulation for secondary stroke prevention.

CASE PRESENTATIONS

Patient A was a 60-year-old man with hypertension, hyperlipidaemia, and gout who was admitted with a sudden onset of left-sided weakness. Clinically, he was alert but had right gaze preference and left-sided hemiplegia. The clinical diagnosis was of a right cortical stroke. He underwent intravenous tPA augmented with sonothrombolysis - the National Institute of Health Stroke Scale (NIHSS) score fell from 7 to 0. Repeat brain scan showed infarcts in the right frontal and parietal lobes. He was found to have atrial fibrillation (AF) and advised anticoagulation. He opted for warfarin with dabigatran bridging which was started on day 2 of his hospital admission. His International Normalized Ratio (INR) exceeded 2 by day 6 of anticoagulation, at which time the bridging dabigatran was stopped, fixed-dose warfarin was continued, and he was discharged well. On subsequent reviews in the clinic, his INR was in the therapeutic range of 2.0-3.0. He had no bleeding or recurrent ischaemic events during follow-up. Patient B was a 78-year-old man with a hypertension, hyperlipidaemia, and diabetes mellitus. He was admitted after he developed difficulty talking and mild right-sided weakness. Clinically, he was alert but had expressive aphasia and mild right-sided upper limb weakness (NIHSS 6). The clinical diagnosis was of a left cortical stroke. The brain scan showed a left posterior frontal and parietal infarct. He was out of the time window for recanalization therapy and was treated conservatively. He was found to have AF and advised anticoagulation. He opted for warfarin with dabigatran bridging which was started on day 1 of his hospital admission. His INR was almost 2 by day 5 of anticoagulation, at which time the bridging dabigatran was stopped and fixed-dose warfarin continued. He declined daily blood taking - his INR 4 days later was in the therapeutic range of 2.0-3.0. He had no bleeding or recurrent ischaemic events. He underwent rehabilitation uneventfully and was discharged well.

CONCLUSIONS

The use of DOACs such as dabigatran as bridging therapy during optimization of OAC is feasible. Compared to heparin as bridging therapy, DOAC has the advantage of oral administration, lower cost, and possibly lower bleeding risks. This novel practice may be applicable in thrombosis in arterial and venous circulations, e.g., ischaemic stroke, deep venous thrombosis, pulmonary embolism.

Proteomic Composition of Acute Ischemic Stroke Thrombi Retrieved via Endovascular Thrombectomy Is Associated with Stroke Etiology

The objective of this study is to investigate the protein components of acute ischemic stroke (AIS) thrombi using four-dimensional independent data acquisition (4D-DIA) proteomics and reveal the correlations between thrombotic protein components and AIS etiology. From April to September 2023, we enrolled a total of 30 patients who underwent endovascular thrombectomy at our institute and were diagnosed in accordance with large artery atherosclerosis (LAA; n = 15) or cardioembolism (CE; n = 15). Thromboembolic material was collected for 4D-DIA proteomic detection. We then analyzed it for differentially expressed proteins (DEPs; fold change [FC] ≥ 1.5 or ≤ 0.67), performed Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses, and mapped protein-protein interactions (PPIs). In the 30 retrieved clots, 5115 proteins were expressed. Of these, we screened 246 DEPs between the LAA and CE groups, such as histone H4, collagen α1, and differentially expressed in neoplastic versus normal cells domain-containing protein 6A. GO analysis revealed that the DEPs' most important biological process was cellular process, the most important Cell Component was cell part, the molecular function was binding, and the most significantly enriched pathway was thiamine metabolism. PPI results revealed complicated interactions among these DEPs, of which superoxide dismutase, catalase, and γ-enolase might play important roles. This study outlines a promising molecular approach to differentiating the etiology of AIS between CE and LAA through the proteomics of retrieved thrombi, which might also inform future research into thrombotic biology.

Associations of NETs with inflammatory risk and clinical predictive value in large artery atherosclerosis stroke: a prospective cohort study

Background and objective

Neutrophil extracellular traps (NETs) with inflammatory risk are important contributors to cardiovascular disease, but no definitive information is available in large artery atherosclerotic (LAA) stroke. This study aims to investigate the association between NETs with related inflammatory biomarkers and prognosis of LAA stroke in the Chinese population.

Methods

A prospective study involving 145 LAA stroke cases and 121 healthy controls was conducted. Serum levels of MPO-DNA, PAD4, HMGB1, C1q, AIM2, ASC, Caspase-1, IL-1β, IL-6, and IL-8 were determined in all participants. The biomarkers were detected at three time points after stroke onset (24 hours: T1, 48 hours: T2, 7 days: T3) for LAA stroke patients and once for controls. Patients were followed up for 2 years after the ischemic event.

Results

The serum MPO-DNA, PAD4, C1q, IL-1β, IL-6 and IL-8 reach their peak at 24 hours after stroke onset and show a decreasing trend during acute phase. MPO-DNA, AIM2 and IL-1β at baseline were associated with poor outcome at 3 months, further GMDR analysis revealed that the combination of MPO-DNA, AIM2 and IL-1β exert a synergistic effect on the prognosis of LAA stroke (OR: 8.75 95%CI (2.10-32.42)). For time-to-event analysis, MPO-DNA, Caspase-1 and IL-1β at baseline were predictors of MVEs after stroke (HR:4.04 (95%CI 1.28-12.70), 2.33 (95%CI 1.06-5.12) and 4.09 (95%CI 1.39-11.99), respectively).

Conclusions

NETs and related inflammatory biomarkers at baseline predicted outcome at 3 months and late major vascular events following LAA stroke, supporting a rationale of randomized trials for targeted therapy directed at high-risk patients with elevated baseline NETs and related inflammatory biomarkers.

Risk factors and prediction models for recurrent acute ischemic stroke: a retrospective analysis

Background

Ischemic stroke is one of the leading causes of disability and death worldwide, with a high risk of recurrence that severely impacts the quality of life of patients. Therefore, identifying and analyzing the risk factors for recurrent ischemic stroke is crucial for the prevention and management of this disease.

Methods

A total of 114 cases of recurrent acute ischemic stroke patients admitted from July 2017 to March 2021 were selected as the observation group, and another 409 cases of initial ischemic stroke patients from the same period as the control group. The clinical data of the observation group and the control group were compared to analyze the risk factors associated with the readmission of ischemic stroke. A single-factor analysis (Model 1), Least Absolute Shrinkage and Selection Operator (LASSO) regression, and machine learning methods (Model 2) were used to screen important variables, and a multi-factor COX Proportional Hazards Model regression stroke recurrence risk prediction model was constructed. The predictive performance of the model was evaluated by the consistency index (C-index).

Results

Multivariate COX regression analysis revealed that history of hypertension (Hazard Ratio [HR] = 2.549; 95% Confidence Interval (CI) [1.503-4.321]; P = 0.001), history of cerebral infarction (HR = 1.709; 95% CI [1.066-2.738]; P = 0.026), cerebral artery stenosis (HR = 0.534; 95% CI [0.306-0.931]; P = 0.027), carotid arteriosclerosis (HR = 1.823; 95% CI [1.137-2.924]; P = 0.013), systolic blood pressure (HR = 0.981; 95% CI [0.971-0.991]; P < 0.0001), red cell distribution width-coefficient of variation (RDW-CV) (HR = 1.251; 95% CI [1.019-1.536]; P = 0.033), mean platelet volume (MPV) (HR = 1.506; 95% CI [1.148-1.976]; P = 0.003), uric acid (UA) (HR = 0.995; 95% CI [0.991-1.000]; P = 0.049) were found significantly associated with acute ischemic stroke. The C-index of the full COX model was 0.777 (0.732~0.821), showing a good discrimination between Model 1 and Model 2.

Conclusions

History of hypertension, history of cerebral infarction, cerebral artery stenosis, carotid atherosclerosis, systolic blood pressure, UA, RDW-CV, and MPV were identified as risk factors for acute ischemic stroke recurrence. The model can be used to predict the recurrence of acute ischemic stroke.

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.

Paving the Path to Wellness for Stroke Survivors: A Lifestyle Medicine Group Intervention

BACKGROUND

Stroke is the leading cause of disability and the second-most leading cause of mortality. Stroke has both physical and psychological impact on the lives of stroke survivors. Lifestyle modifications have a pivotal role in post-stroke management care. The Paving the Path to Wellness Program (PPWP) is a 12-week program offered to stroke survivors at Spaulding Rehabilitation Center following discharge. The program encompasses the following domains: physical activity, nutrition, stress management, time-outs, energy, sleep, purpose, and social connections.

OBJECTIVE

The purpose of this pilot study was to evaluate the effectiveness of the PPWP on the recovery of stroke survivors.

METHODS

Three stroke survivors who participated in the program were interviewed following completion of the program.

RESULTS

The results showed the PPWP had a positive impact on physical health (e.g., increased physical activity, weight loss, nutrition awareness, and better stress management); helped to create a new purpose (e.g., happiness, satisfaction, and well-being); and improved the social life of the participants (better awareness and importance of friends and family).

CONCLUSIONS

Next steps are to study this program in a larger stroke population and examine long-term effects.

Major vascular events after first incident stroke: a population-based study

Background

Recent advances in stroke care have led to improvements in survival and rates of stroke recurrence. However, there is a lack of data on trends of major vascular events, and risk factors associated with non-fatal and fatal outcomes. We aim to identify demographical and clinical factors leading to incidence of subsequent major vascular events after the first-ever stroke.

Methods

6051 patients' records with first-ever stroke between 1995 and 2018 in South London, UK were analysed. Semicompeting risks models were constructed to estimate factors affecting time to incidence of recurrent stroke, myocardial infarction (MI), mortality and transitions from poststroke recurrence/MI to mortality (indirect mortality). Cumulative incidence functions were plotted for each major vascular event, stratified by stroke subtypes. All models were adjusted for age, sex, socioeconomic status, comorbidities, stroke severity and stroke subtype.

Results

Five years of cumulative incidences were 9.2% (95% CI (8.4% to 10.0%)) for recurrent stroke, 4.4% (95% CI 3.9% to 5.0%) for MI, and 45% (95% CI 44% to 47%) for mortality. Prior atrial fibrillation was associated with 47% increased risk of mortality (HR=1.47 (95% CI 1.23 to 1.75)) and a previous diagnosis of MI was the strongest risk factor for poststroke MI (HR=9.17 (95% CI 6.28 to 13.39)). Stroke unit was associated with a 40% lower hazard of mortality without having a recurrent stroke/MI (HR=0.60 (95% CI 0.50 to 0.72)) and a 39% lower hazard of indirect mortality (HR=0.57 (95% CI 0.37 to 0.87)).

Conclusion

Major vascular events are prevalent after stroke, particularly among those with concurrent vascular conditions. The rate of stroke recurrence plateaued in the last decade, yet MI incidence increased. Targeted strategies to control risk factors are required to reduce the incidence of a second vascular event and prevent progression to mortality in these high-risk groups.

Perioperative care of patients with recent stroke undergoing nonemergent, nonneurological, noncardiac, nonvascular surgery: a systematic review and meta-analysis

PURPOSE OF REVIEW

To systematically review and perform a meta-analysis of published literature regarding postoperative stroke and mortality in patients with a history of stroke and to provide a framework for preoperative, intraoperative, and postoperative care in an elective setting.

RECENT FINDINGS

Patients with nonneurological, noncardiac, and nonvascular surgery within three months after stroke have a 153-fold risk, those within 6 months have a 50-fold risk, and those within 12 months have a 20-fold risk of postoperative stroke. There is a 12-fold risk of in-hospital mortality within three months and a three-to-four-fold risk of mortality for more than 12 months after stroke. The risk of stroke and mortality continues to persist years after stroke. Recurrent stroke is common in patients in whom anticoagulation/antiplatelet therapy is discontinued. Stroke and time elapsed after stroke should be included in the preoperative assessment questionnaire, and a stroke-specific risk assessment should be performed before surgical planning is pursued.

SUMMARY

In patients with a history of a recent stroke, anesthesiology, surgery, and neurology experts should create a shared mental model in which the patient/surrogate decision-maker is informed about the risks and benefits of the proposed surgical procedure; secondary-stroke-prevention medications are reviewed; plans are made for interruptions and resumption; and intraoperative care is individualized to reduce the likelihood of postoperative stroke or death.

Acetylglutamine Differentially Associated with First-Time Versus Recurrent Stroke

Approximately one-quarter of strokes occur in individuals with prior stroke. Despite the advancement in secondary stroke prevention, the long-term risk of recurrent stroke has remained unchanged. The objective of this study was to identify metabolite risk markers that are associated with recurrent stroke. We performed targeted metabolomic profiling of 162 metabolites by liquid chromatography-tandem mass spectrometry in baseline plasma in a stroke case-cohort study nested within the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an observational cohort study of 30,239 individuals aged 45 and older enrolled in 2003-2007. Weighted Cox proportional hazard models were used to identify metabolites that had a differential effect on first-time versus recurrent stroke using an interaction term between metabolite and prior stroke at baseline (yes or no). The study included 1391 incident stroke cases identified during 7.1 ± 4.5 years of follow-up and 1050 participants in the random cohort sample. Among 162 metabolites, 13 candidates had a metabolite-by-prior stroke interaction at a p-value <0.05, with one metabolite, acetylglutamine, surpassing the Bonferroni adjusted p-value threshold (p for interaction = 5.78 × 10-5). In an adjusted model that included traditional stroke risk factors, acetylglutamine was associated with recurrent stroke (HR = 2.27 per SD increment, 95% CI = 1.60-3.20, p = 3.52 × 10-6) but not with first-time stroke (HR = 0.96 per SD increment, 95% CI = 0.87-1.06, p = 0.44). Acetylglutamine was associated with recurrent stroke but not first-time stroke, independent of traditional stroke risk factors. Future studies are warranted to elucidate the pathogenesis of acetylglutamine and recurrent stroke risk.

Intravenous thrombolysis versus dual antiplatelet therapy in minor ischemic stroke within the thrombolytic window (TAMIS): a multicenter cohort study

Intravenous thrombolysis (IVT) and dual antiplatelet therapy (DAPT) have been widely used in minor ischemic stroke (MIS) treatment. However, the clinical outcomes and safety of these two treatments have not been compared within the early thrombolytic time window. Here, we conducted a multicenter, ambispective cohort study involving patients with MIS presenting within 4.5 h of symptom onset at 3 affiliated hospitals of Jinan University from 2018-2022. The patients were divided into the IVT group and DAPT group. The primary outcome was a 90-day excellent outcome (mRS ≤ 1). A total of 1,026 patients were enrolled, of whom 492 were assigned to the IVT group and 534 were assigned to the DAPT group. The IVT group had better 90-day excellent outcomes (mRS ≤ 1) than the DAPT group (OR 1.69, 95% CI 1.14-2.52, P = 0.010). Among the 623 patients with nondisabling stroke, the proportion of mRS ≤ 1 in the IVT group was higher than the DAPT group (P = 0.009). In the subtypes of MIS with large vessel occlusion/stenosis and with isolated symptoms, the 90-day outcomes of the IVT group and DAPT group were not different (P > 0.05). In conclusion, compared with DAPT, IVT was associated with better 90-day clinical outcomes in patients with MIS (in particular, for those with mRS > 1), including earlier clinical improvement.IVT also benefited the early neurological improvement of patients with severe stenosis/occlusion of intracranial large vessels, nondisabling mild stroke, nondisabling mild stroke with isolated symptoms.

Recurrent Ischemic Stroke and Transient Ischemic Attack: Risk of Single and Multiple Recurrence

Background/Objectives: Efforts have been made toward primary or secondary stroke or transient ischemic attack (TIA) prevention. However, little attention has been paid to recurrent stroke or TIA. This study investigated risk factors for multiple or single recurrent stroke or TIA. Methods: Data from 3646 patients with ischemic stroke or TIA were obtained from the Korea University Ansan Hospital Stroke Center between March 2014 and December 2021, using the prospective institutional database of the Korea University Stroke Registry. The associations between clinical features and recurrent stroke or TIA were assessed using bivariable and multivariable Cox models. Results: Recurrent stroke or TIA was associated with male sex (adjusted hazard ratio (HR) 1.95, 95% confidence interval (CI) 1.42-2.80), hypertension (HR 1.49, 95% CI 1.00-2.23), diabetes mellitus (HR 1.54, 95% CI 1.13-2.13), an etiologic subtype of transient ischemic attack (HR 1.88, 95% CI 1.09-3.16), white matter changes (HR 1.62, 95% CI 1.05-2.38), and cerebral microbleeds (HR 1.79, 95% CI 1.26-2.59). Multiple recurrent stroke or TIA was associated with male sex (HR 3.86, 95% CI 1.94-11.55), diabetes mellitus (HR 2.40, 95% CI 1.31-4.53), and anemia (HR 4,58, 95% CI 2.31-10.44). Conclusions: Given the risk factor profiles for recurrent stroke or TIA, risks differed among patient subgroups and were based on multiple or single recurrences. It may exert an effect as a prognostic indicator in the high risk of recurrences.

Impact of Mobile Health Literacy, Stroke-Related Health Knowledge, Health Beliefs, and Self-Efficacy on the Self-Care Behavior of Patients with Stroke

Background: The recent substantial increase in the incidence of stroke cases has resulted in high medical expenses. Stroke necessitates ongoing care, emphasizing the importance of consistent self-management. The occurrence of stroke impacts healthcare costs and has far-reaching effects on social services, encompassing disability, unemployment, and other related concerns beyond individuals and families. This study aimed to assess the impact of mobile health literacy, stroke-related health knowledge, health beliefs, and self-efficacy on self-care behaviors of patients with stroke to plan tailored self-care interventions for this patient population. Methods: This descriptive survey included 99 stroke patients from three hospitals, which provided treatment equivalent to or better than general hospitals, in City C and was conducted between 7 July 2023 and 30 May 2024. The data collected from hospitalized stroke patients were analyzed using descriptive statistics, independent t-tests, one-way ANOVA, and multiple linear regression. Results: The self-care behavior of patients with stroke who participated in the study was 73.01 ± 12.24 points. Stroke self-efficacy was identified as a significant factor influencing stroke self-care behaviors and eating habits. Mobile health literacy and stroke self-efficacy also influenced medication and self-care behavior, whereas hypertension and stroke self-efficacy affected lifestyle self-care behaviors. Conclusions: Strengthening stroke self-efficacy, improving mobile health literacy, and addressing comorbidities such as hypertension are important for promoting self-care behavior in stroke patients.

Prädiktoren für die Folgen eines Schlaganfalls: eine systematische Literaturübersicht für GKV-Routinedatenanalysen

Zielsetzung Ermittlung unabhängiger Variablen (UVs) des Schlaganfallrezidivs, der Mortalität und der Kosten nach Schlaganfall oder transitorisch-ischämischer Attacke, abbildbar in Routinedaten der Gesetzlichen Krankenversicherung.

Methodik Durchführung einer systematischen Literaturrecherche in PubMed und Embase unter Anwendung festgelegter Auswahlkriterien.

Ergebnisse Von 1 982 Treffern wurden 23 eingeschlossen. Robuste UVs für Rezidiv und Mortalität waren Alter, Schlaganfalltyp, Diabetes mellitus und Vorhofflimmern. Bei Mortalität waren zudem Geschlecht, stationärer Aufnahmezeitpunkt und Stroke Unit-Behandlung relevant. Für Kosten war die Evidenzlage zu gering.

Schlussfolgerung Eine Übersicht zu UVs des Rezidivs und der Mortalität wurde gegeben. Folgestudien sollten einheitliche Ansätze hinsichtlich Schlaganfall- und Outcomedefinitionen sowie Evaluationszeiträumen wählen.

An Integrated Multi-omics prediction model for stroke recurrence based on Lnet transformer layer and dynamic weighting mechanism

BACKGROUND AND OBJECTIVE

Stroke is a disease with high mortality and disability. Importantly, the fatality rate demonstrates a significant increase among patients afflicted by recurrent strokes compared to those experiencing their initial stroke episode. Currently, the existing research encounters three primary challenges. The first is the lack of a reliable, multi-omics image dataset related to stroke recurrence. The second is how to establish a high-performance feature extraction model and eliminate noise from continuous magnetic resonance imaging (MRI) data. The third is how to integration multi-omics data and dynamically weighted for different omics data.

METHODS

We systematically compiled MRI and conventional detection data from a cohort comprising 737 stroke patients and established PSTSZC, a multi-omics dataset for predicting stroke recurrence. We introduced the first-ever Integrated Multi-omics Prediction Model for Stroke Recurrence, MPSR, which is based on ResNet, Lnet-transformer, LSTM and dynamically weighted DNN. The MPSR model comprises two principal modules, the Feature Extraction Module, and the Integrated Multi-Omics Prediction Module. In the Feature Extraction module, we proposed a novel Lnet regularization layer, which effectively addresses noise issues in MRI data. In the Integrated Multi-omics Prediction Module, we propose a dynamic weighted mechanism based on evaluators, which mitigates the noise impact brought about by low-performance omics.

RESULTS

We compared seven single-omics models and six state-of-the-art multi-omics stroke recurrence models. The experimental results demonstrate that the MPSR model exhibited superior performance. The accuracy, AUROC, specificity, and sensitivity of the MPSR model can reach 0.96, 0.97, 1, and 0.94, respectively, which is higher than the results of contrast model.

CONCLUSION

MPSR is the first available high-performance multi-omics prediction model for stroke recurrence. We assert that the MPSR model holds the potential to function as a valuable tool in assisting clinicians in accurately diagnosing individuals with a predisposition to stroke recurrence.

Antiphospholipid antibodies as potential prognostic indicators of recurrent ischemic stroke

BACKGROUND

Immunity play a pivotal role in the risk of ischemic stroke, and studies have also shown a relationship between ischemic stroke and autoimmune diseases. In light of this we conducted a prospective cohort study to elucidate the impact of antiphospholipid antibodies (aPLs), antinuclear antibodies (ANA), and anti-extractable nuclear antigen autoantibodies (anti-ENA) on the prognosis of ischemic stroke.

METHODS

245 stroke patients were recruited in this single-center study and followed up with for 3 years. Autoantibodies, including aPLs (ACA, anti-β2GPI, LA), ANA and anti-ENA were evaluated in recurrent ischemic stroke (RIS) and nonrecurrent ischemic stroke (nonRIS). Stroke severity was judged using the National Institutes of Health Stroke Scale (NIHSS). For preventive treatment, 42 IS patients with positive aPLs + ANA/anti-ENA were randomized 1:1 into a hydroxychloroquine (HCQ) treatment group and a control group, and the prognoses were compared.

RESULTS

The positive rate of ACA IgG (p = 0.018), anti-β2GPI IgG (p = 0.047), LA (p = 0.023), and aPLs + ANA/anti-ENA (p = 0.000) were significantly higher in patients with RIS compared to patients with nonRIS, and aPLs + ANA/anti-ENA (HR2.31, 95 % CI1.02-5.25, p = 0.046) and hypertension (HR2.50, 95 % CI1.17-5.35, p = 0.018) were the independent risk factors of recurrence. There were differences in NIHSS at month 36 between those positive and negative for aPLs + ANA/anti-ENA (p = 0.001, Eta2 = 0.052), anti-ENA (p = 0.016, Eta2 = 0.030), ANA (p = 0.035, Eta2 = 0.022), and LA (p = 0.016, Eta2 = 0.028). Furthermore, the recurrence rate of the HCQ treatment group was lower than that of the control group (p = 0.024).

CONCLUSIONS

Co-positivity of aPLs and ANA/anti-ENA is an independent risk factor for RIS. However, HCQ therapy may reduce the recurrence rate of IS for these patients.

Predictors of recurrent stroke and subsequent mortality among patients experiencing housing instability

BACKGROUND

The experience of homelessness has been linked with developing poor health outcomes. Little is known about the risk of recurrent stroke among these individuals. This study investigated the correlates of developing recurrent stroke and subsequent mortality among Veterans with housing instability.

METHODS

Using a national sample of Veterans from the U.S. Department of Veterans Affairs who had an indicator of housing instability between 2014-2018 (n=659,987), we identified 15,566 Veterans who experienced incident stroke. We compared characteristics of Veterans who experienced incident stroke and did and did not experience recurrent stroke and conducted logistic regressions using a discrete-time survival framework to assess two outcomes: recurrent stroke and all-cause mortality.

RESULTS

Among our cohort, 91.3% did not experience recurrent stroke while 8.7% did during the observation period. The receipt of any level of primary care outpatient visits was associated with a reduction in the odds of recurrent stroke. Several medical diagnoses were also associated with increased odds of recurrent stroke, including hypertension (aOR 1.35, 95% CI 1.15-1.59), diabetes (aOR 1.21, 95% CI 1.07-1.36), and renal disease (aOR 1.17, 95% CI 1.02, 1.35). Veterans who used any level of VA Homeless Programs had reduced odds of all-cause mortality (high level: aOR 0.65, 95% CI 0.60-0.71; low level: aOR 0.66, 95% CI 0.60-0.73).

CONCLUSION

Our study found several predictors of developing recurrent stroke and subsequent death in a population of Veterans experiencing housing instability. Implications include the need to monitor closely high-risk patients who have experienced incident stroke and have other co-occurring needs.

High relative cerebral blood volume is associated with good long term clinical outcomes in acute ischemic stroke: a retrospective cohort study

BACKGROUND

Endovascular therapy for acute ischemic stroke has been shown to be highly effective in selected patients. However, the ideal criteria for patient selection are still debated. It is well known that collateral flow is an important factor, but the assessment is often subjective and time-consuming. Relative cerebral blood volume (rCBV) is a putative indicator of collateral capacity and can be quickly and easily determined by automated quantitative analysis. We investigated the relationship between rCBV of the affected region and clinical outcome in patients with acute ischemic stroke after endovascular therapy.

METHODS

We conducted a retrospective study on consecutive patients between January 2017 and May 2019. Patients with acute ischemic stroke of the anterior circulation who underwent imaging including computed tomography perfusion and were treated with mechanical thrombectomy (MT) were eligible for inclusion. rCBV was calculated automatically with RAPID software by dividing the average cerebral blood volume (CBV) of the affected region (time-to-maximum (Tmax) > 6 s) by the CBV of the unaffected contralateral side. The primary outcome was determined by the modified Rankin Scale (mRS) after 90 days. Good clinical outcome was defined as mRS ≤ 2. We compared means, performed mono- and multivariate logistical regression and calculated a receiver operating characteristic (ROC)-analysis to determine the ideal cutoff value to predict clinical outcomes.

RESULTS

155 patients were enrolled in this study. 66 patients (42.58%) had good clinical outcomes. Higher rCBV was associated with good clinical outcome (p < 0.001), even after adjustment for the patients' status according to mRS and National Institute of Health Stroke Scale (NIHSS) age and Alberta stroke program early computed tomography score (ASPECTS) at baseline (p = 0.006). ROC-analysis revealed 0.650 (confidence interval: 0.616-0.778) as the optimal cutoff value.

CONCLUSION

Higher rCBV at baseline is associated with good clinical long-term outcomes in patients with acute ischemic stroke treated by MT. In this study we provide the biggest collective so far that gives evidence that rCBV can be a valuable tool to identify patients who might benefit from MT and are able give a threshold to help to offer patients MT in borderline cases.

Early vs Late Anticoagulation in Minor, Moderate, and Major Ischemic Stroke With Atrial Fibrillation: Post Hoc Analysis of the ELAN Randomized Clinical Trial

Importance

Whether infarct size modifies the treatment effect of early vs late direct oral anticoagulant (DOAC) initiation in people with ischemic stroke and atrial fibrillation is unknown.

Objective

To assess whether infarct size modifies the safety and efficacy of early vs late DOAC initiation.

Design, Setting, and Participants

Post hoc analysis of participants from the multinational (>100 sites in 15 countries) randomized clinical Early Versus Later Anticoagulation for Stroke With Atrial Fibrillation (ELAN) trial who had (1) acute ischemic stroke, (2) atrial fibrillation, and (3) brain imaging available before randomization. The ELAN trial was conducted between October 2017 and December 2022. Data were analyzed from October to December 2023 for this post hoc analysis.

Intervention

Early vs late DOAC initiation after ischemic stroke. Early DOAC initiation was within 48 hours for minor or moderate stroke or on days 6 to 7 for major stroke; late DOAC initiation was on days 3 to 4 for minor stroke, days 6 to 7 for moderate stroke, and days 12 to 14 for major stroke.

Main Outcomes and Measures

The primary outcome was a composite of recurrent ischemic stroke, symptomatic intracranial hemorrhage, extracranial bleeding, systemic embolism, or vascular death within 30 days. The outcome was assessed according to infarct size (minor, moderate, or major) using odds ratios and risk differences between treatment arms. Interrater reliability for infarct size between the core laboratory and local raters was assessed, and whether this modified the estimated treatment effects was also examined.

Results

A total of 1962 of the original 2013 participants (909 [46.3%] female; median [IQR] age, 77 [70-84] years) were included. The primary outcome occurred in 10 of 371 participants (2.7%) with early DOAC initiation vs 11 of 364 (3.0%) with late DOAC initiation among those with minor stroke (odds ratio [OR], 0.89; 95% CI, 0.38-2.10); in 11 of 388 (2.8%) with early DOAC initiation vs 14 of 392 (3.6%) with late DOAC initiation among those with moderate stroke (OR, 0.80; 95% CI, 0.35-1.74); and in 8 of 219 (3.7%) with early DOAC initiation vs 16 of 228 (7.0%) with late DOAC initiation among those with major stroke (OR, 0.52; 95% CI, 0.21-1.18). The 95% CI for the estimated risk difference of the primary outcome in early anticoagulation was -2.78% to 2.12% for minor stroke, -3.23% to 1.76% for moderate stroke, and -7.49% to 0.81% for major stroke. There was no significant treatment interaction for the primary outcome. For infarct size, interrater reliability was moderate (κ = 0.675; 95% CI, 0.647-0.702) for local vs core laboratory raters and strong (κ = 0.875; 95% CI, 0.855-0.894) between core laboratory raters.

Conclusions and Relevance

The treatment effect of early DOAC initiation did not differ in people with minor, moderate, or major stroke assessed by brain imaging. Early treatment was not associated with a higher rate of adverse events, especially symptomatic intracranial hemorrhage, for any infarct size, including major stroke.

Trial Registration

ClinicalTrials.gov Identifier: NCT03148457.

Post-discharge sedentary behavior and light-intensity physical activity-associated stroke recurrence in patients with minor ischemic stroke: A preliminary retrospective observational study

BACKGROUND AND PURPOSE

Evidence regarding whether reducing sedentary behavior and increasing physical activity levels to prevent stroke recurrence is insufficient. Therefore, this study preliminarily investigated whether post-discharge sedentary behavior and physical activity levels in patients with minor ischemic stroke were associated with stroke recurrence.

METHODS

This retrospective observational study included 73 patients (aged 72.0 years) with minor ischemic stroke from a previous study. The outcome was recurrent stroke 2 years after stroke onset, assessed using medical records. Exposure factors including sedentary behavior and physical activity levels 6 months post-discharge were measured using accelerometers; patients were classified into the recurrence or non-recurrence groups. Logistic regression analyses were then conducted to determine whether sedentary behavior and physical activity 6 months after discharge were associated with stroke recurrence.

RESULTS

Six patients experienced stroke recurrence (recurrence rate, 8.2%). The recurrence group showed greater sedentary behavior (recurrence group 68.0%, non-recurrence group 52.0%, p = 0.007) and less light-intensity physical activity (LPA) (recurrence group 21.0%, non-recurrence group 37.0%, p = 0.002) than in the non-recurrence group. Logistic regression analysis showed that sedentary behavior (odds ratio = 1.083, 95% confidence interval = 1.007-1.165, p = 0.032) and LPA (odds ratio = 0.874, 95% confidence interval = 0.785-0.975, p = 0.015) were independent factors for recurrence of stroke.

DISCUSSION

Post-discharge sedentary behavior and LPA in patients with minor ischemic stroke were associated with stroke recurrence. Results suggest that reducing post-discharge sedentary behavior and increasing LPA may be crucial for reducing the risk of stroke recurrence in patients with minor ischemic stroke.

A randomized controlled trial of medication adherence and management of risk factors for secondary prevention of stroke (MaMoRS) using a smartphone-based application

BACKGROUND

There are little data on the use of smartphone-based applications for medication adherence and risk-factor control for the secondary prevention of stroke in low-and-middle-income countries (LMICs).

AIMS

The aim was to determine whether a smartphone-based app improved medication adherence, risk-factor control, and provided health education to stroke survivors for lifestyle and behavioral modifications.

METHODS

An unblinded, single-center randomized controlled double arm trial with 1:1 allocation among stroke survivors was performed in South India. The primary outcome was medication adherence, with co-primary outcomes of lifestyle and behavioral factors and control of vascular risk factors, at 3 and 6 months.

RESULTS

Among 351 stroke survivors screened, 209 were recruited. The mean (standard deviation (SD)) age of the intervention (n = 105) group was 60 (12) years and that of the control (n = 104) group was 60 (10) years. In the primary outcome, mean medication adherence significantly improved in the intervention group with a between group difference of 0.735 (95% confidence interval (CI) = 0.419 to 1.050), p < 0.001. Being in intervention group (OR = 4.5; 95% CI = 2.3 to 8.9), stroke recurrence (OR = 3.3 (95% CI = 1.9 to 7.8)), and regular physician visits (OR = 2.1; 95% CI = 1.0 to 4.4) were significant predictors of good medication adherence. Considering the co-primary outcomes, compared to the control group, participants in the intervention group had a greater improvement in self-reported healthy diet intake (p = 0.003), intake of fruits (p = 0.005), and were physically more active (p = 0.001). At 6 months, mean fasting blood sugar (p = 0.005) and high-density lipoprotein cholesterol higher (p = 0.024) in the intervention group.

CONCLUSIONS

The use of a mobile app is an effective method to improve medication adherence and risk-factor control in stroke survivors and is feasible in LMICs like India.

DATA ACCESS STATEMENT

Data used during the study are available from the corresponding author on request.

TRIAL REGISTRATION

The study is registered in Clinical Trial Registry of India (CTRI/2022/06/042980).

Long-term outcomes among ischemic stroke TOAST subtypes: A 12-year Cohort study in China

BACKGROUND

Disparities in short-term ischemic stroke (IS) prognosis among Trial of Org 10172 in Acute Stroke Treatment (TOAST) subtypes were observed. Notably, little is known about the long-term prognosis of different subtypes in China. We aim to investigate the long-term outcome in IS patients and try to explore the potential interactive effects between IS subtypes and antithrombotic therapy.

METHODS

This is a prospective cohort of stroke survivors. Patients diagnosed with first-ever IS at the Department of Neurology, West China Hospital, Sichuan University from January 2010 to December 2019 were recruited. They were followed until September 2022 to assess recurrence, mortality, and functional recovery. The multivariate Fine-Gray model assessed stroke recurrence, while Cox regression estimated hazard ratios. Modified Rankin Scale scores(mRS) were analyzed using the generalized linear mixed effects model.

RESULTS

At baseline, 589 of 950 participants (62.00 %) were male. The longest follow-up was 150 months, the shortest was 1.5 months, and the median follow-up was 81.0 months. Cardio-embolism (CE) bore the highest mortality risk compared to large artery atherosclerosis (LAA) (HR=4.43,95 %CI 1.61-12.23). Among survivors on anticoagulant therapy, CE exhibited a reduced risk of mortality (HR = 0.18, 95 % CI 0.04-0.80). In function recovery, small artery occlusion (SAO) demonstrated more favorable prognostic outcomes (β=-2.08, P<0.01, OR=0.13,95 %CI 0.03-0.47). Among survivors taking antiplatelet drugs, SAO demonstrated a slower pace of functional recovery compared to LAA (β=1.39, P=0.05, OR=3.99,95 %CI 1.01-15.74).

CONCLUSIONS

Long-term outcomes post-first IS vary among TOAST subtypes. Anticoagulant therapy offers long-term benefits among patients of the CE. However, prolonged administration of antiplatelet drugs among SAO patients may be limited in improving function recovery. Physicians should carefully consider treatment options for different IS subtypes to optimize patient outcomes and stroke care effectiveness.

The impact of frailty on short-term prognosis in discharged adult stroke patients: A multicenter prospective cohort study

BACKGROUND

Frailty is commonly observed in stroke patients and it is associated with adverse outcomes. However, there remains a gap in longitudinal studies investigating the causal relationship between baseline frailty and short-term prognosis in discharged adult stroke patients.

OBJECTIVE

To examine the causal impact of frailty on non-elective readmission and major adverse cardiac and cerebral events, and investigate its associations with cognitive impairment and post-stroke disability.

DESIGN

A multicenter prospective cohort study.

SETTING

Two tertiary hospitals in Central and Northwest China.

PARTICIPANTS

667 adult stroke patients in stroke units were included from January 2022 to June 2022.

METHODS

Baseline frailty was assessed by the Frailty Scale. Custom-designed questions were utilized to assess non-elective readmission and major adverse cardiac and cerebral events as primary outcomes. Cognitive impairment, assessed using the Mini-Mental State Examination Scale (MMSE), and post-stroke disability, measured with the Modified Rankin Scale (mRS), were considered secondary outcomes at a 3-month follow-up. The impact of baseline frailty on non-elective readmission and major adverse cardiac and cerebral events was examined using bivariate and multiple Cox regression analyses. Furthermore, associations between baseline frailty and cognitive impairment, or post-stroke disability, were investigated through generalized linear models.

RESULTS

A total of 5 participants died, 12 had major adverse cardiac and cerebral events, and 57 had non-selective readmission among 667 adult stroke patients. Frailty was an independent risk factor for non-selective readmission (hazard ratio [HR]: 2.71, 95 % confidence interval [CI]: 1.59, 4.62) and major adverse cardiac and cerebral events (HR: 3.77, 95 % CI: 1.07, 13.22) for stroke patients. Baseline frailty was correlated with cognitive impairment (regression coefficient [β]: -2.68, 95 % CI: -3.78, -1.58) adjusting for socio-demographic and clinical factors and follow-up interval. However, the relationship between frailty and cognitive impairment did not reach statistical significance when further adjusting for baseline MMSE (β: -0.39, 95 % CI: -1.43, 0.64). Moreover, baseline frailty was associated with post-stroke disability (β: 0.36, 95 % CI: 0.08, 0.65) adjusting for socio-demographic and clinical variables, follow-up interval, and baseline mRS.

CONCLUSIONS

The finding highlights the importance of assessing baseline frailty in discharged adult stroke patients, as it is significantly associated with non-elective readmission, major adverse cardiac and cerebral events, and post-stroke disability at 3 months. These results highlight the crucial role of screening and evaluating frailty status in improving short-term prognosis for adult stroke patients. Interventions should be developed to address baseline frailty and mitigate the short-term prognosis of stroke.

TWEETABLE ABSTRACT

Baseline frailty predicts non-elective readmission, major adverse cardiac and cerebral events, and post-stroke disability in adult stroke patients. @haiyanhexyyy.

A case management intervention in stroke care: Evaluation of a quasi-experimental study

BACKGROUND

Patients with initial stroke or transient ischemic attack (TIA) are at high risk for further strokes, death or cardiovascular events. Even the first-ever stroke is associated with a high chance of disability and need for assistance. The risk of long-term health care demands increases with each subsequent event. Although the inpatient sector already provides a high standard of care in Germany, it can be difficult to obtain cross-sectoral aftercare. Thus, the study investigated whether a structured case management program can avoid stroke recurrences.

METHODS

The study was conducted with a quasi-experimental study design in three regions in North Rhine-Westphalia. Patients with first-ever stroke or TIA were eligible to participate. The intervention group was prospectively recruited and supported by a case manager during a one-year follow-up. Optimal Full Matching was used to generate a control group based on statutory claims data. The primary outcome was the stroke recurrence. Recurrence and mortality were analysed by using Cox regression; other secondary outcomes were examined with test-based procedures and with logistic regressions. Additionally, subgroup analyses were performed.

RESULTS

From June 2018 to March 2020, 1,512 patients were enrolled in the intervention group. Claims data from 19,104 patients have been transmitted for establishing the control group. After the matching process, 1,167 patients of each group were included in the analysis. 70 recurrences (6.0%) occurred in the intervention group and 67 recurrences (5.7%) in the control group. With a hazard ratio of 1.06 (95% CI: [1.42-0.69]; p=0.69), no significant effect was found for the primary outcome. With regard to the secondary outcome mortality, 36 patients in the intervention group and 46 in the control group died (3.1% vs. 3.9%). Again, there was no significant effect (HR: 0.86; 95% CI: [0.58-1.28], p=0.46).

DISCUSSION

Based on the present findings, the case management approach for stroke patients evaluated here was unable to demonstrate an improvement in health care. Potential effects of case management might not be adequately depicted in short observation periods. Thus, future studies should consider longer observation periods.

CONCLUSION

A panel of experts should discuss whether the core approach of case management to support cost-intensive individual cases is contrary to a broad implementation with a one-size-fits-all intervention for stroke patients. In this case, further research should focus on more specific study populations.

Combined noninvasive brain stimulation virtual reality for upper limb rehabilitation poststroke: A systematic review of randomized controlled trials

Upper limb impairments are common consequences of stroke. Noninvasive brain stimulation (NIBS) and virtual reality (VR) play crucial roles in improving upper limb function poststroke. This review aims to evaluate the effects of combined NIBS and VR interventions on upper limb function post-stroke and to provide recommendations for future studies in the rehabilitation field. PubMed, MEDLINE, PEDro, SCOPUS, REHABDATA, EMBASE, and Web of Science were searched from inception to November 2023. Randomized controlled trials (RCTs) encompassed patients with a confirmed stroke diagnosis, administrated combined NIBS and VR compared with passive (i.e., rest) or active (conventional therapy), and included at least one outcome assessing upper limb function (i.e., strength, spasticity, function) were selected. The quality of the included studies was assessed using the Cochrane Collaboration tool. Seven studies met the eligibility criteria. In total, 303 stroke survivors (Mean age: 61.74 years) were included in this review. According to the Cochrane Collaboration tool, five studies were classified as "high quality," while two were categorized as "moderate quality". There are mixed findings for the effects of combined NIBS and VR on upper limb function in stroke survivors. The evidence for the effects of combined transcranial direct current stimulation and VR on upper limb function post-stroke is promising. However, the evidence regarding the effects of combined repetitive transcranial magnetic stimulation and VR on upper limb function is limited. Further randomized controlled trials with long-term follow-up are strongly warranted.

Pretreatment CTP Collateral Parameters Predict Good Outcomes in Successfully Recanalized Middle Cerebral Artery Distal Medium Vessel Occlusions

BACKGROUND/PURPOSE

Distal medium vessel occlusions (DMVOs) account for a large percentage of vessel occlusions resulting in acute ischemic stroke (AIS) with disabling symptoms. We aim to assess whether pretreatment quantitative CTP collateral status (CS) parameters can serve as imaging biomarkers for good clinical outcomes prediction in successfully recanalized middle cerebral artery (MCA) DMVOs.

METHODS

We performed a retrospective analysis of consecutive patients with AIS secondary to primary MCA-DMVOs who were successfully recanalized by mechanical thrombectomy (MT) defined as modified thrombolysis in cerebral infarction (mTICI) 2b, 2c, or 3. We evaluated the association between the CBV index and HIR independently with good clinical outcomes (modified Rankin score 0-2) using Spearman rank correlation, logistic regression, and ROC analyses.

RESULTS

From 22 August 2018 to 18 October 2022 8/22/2018 to 10/18/2022, 60 consecutive patients met our inclusion criteria (mean age 71.2 ± 13.9 years old [mean ± SD], 35 female). The CBV index (r = -0.693, p < 0.001) and HIR (0.687, p < 0.001) strongly correlated with 90-day mRS. A CBV index ≥ 0.7 (odds ratio, OR, 2.27, range 6.94-21.23 [OR] 2.27 [6.94-21.23], p = 0.001)) and lower likelihood of prior stroke (0.13 [0.33-0.86]), p = 0.024)) were independently associated with good outcomes. The ROC analysis demonstrated good performance of the CBV index in predicting good 90-day mRS (AUC 0.73, p = 0.003) with a threshold of 0.7 for optimal sensitivity (71% [52.0-85.8%]) and specificity (76% [54.9-90.6%]). The HIR also demonstrated adequate performance in predicting good 90-day mRS (AUC 0.77, p = 0.001) with a threshold of 0.3 for optimal sensitivity (64.5% [45.4-80.8%]) and specificity (76.0% [54.9-90.6%]).

CONCLUSION

A CBV index ≥ 0.7 may be independently associated with good clinical outcomes in our cohort of AIS caused by MCA-DMVOs that were successfully treated with MT. Furthermore, a HIR < 0.3 is also associated with good clinical outcomes. This is the first study of which we are aware to identify a CBV index threshold for MCA-DMVOs.