Stroke in women: When gender matters

Unique Characteristics of Stroke in Women and Rehabilitation Considerations

Stroke is the third leading cause of death of women in the United States, and women have a higher lifetime risk of stroke than men. Studies show that women live longer but with poorer functional outcomes and higher rates of disability compared with men. Sex-specific disparities exist between clinical symptoms, medical evaluation, and management after stroke. Stroke rehabilitation strategies specific to women should take into consideration both physiologic and psychosocial demands more common in women to improve functional outcomes. Additional resources for education, clinical research, and implementation of best practices are needed to eliminate gender-related disparities in poststroke care.

Emerging Roles of Meningeal Lymphatic Vessels in Ischemic Stroke

This review highlights the emerging relevance of meningeal lymphatic vessels (MLVs) in the context of ischemic stroke, challenging the conventional view of a privileged immunological central nervous system. MLVs facilitate immunological surveillance by modulating the entry of peripheral immune cells into the meningeal compartment, a process not impeded by the blood-brain barrier. In ischemic stroke, these vessels play a crucial role in the neuroinflammatory cascade, contributing to immune responses by draining antigens and signals to cervical lymph nodes. Their involvement extends to potential contributions to resolving ischemia-induced cerebral edema, impacting fluid homeostasis. The dynamic interaction among MLVs, neuroinflammation, and fluid dynamics suggests promising therapeutic approaches. Targeting these vessels for immunomodulation, fluid drainage, and preserving blood-brain barrier integrity emerges as an innovative approach to improve ischemic stroke outcomes. However, successful clinical translation awaits further exploration of the therapeutic potential of these vessels. The multifaceted contributions of MLVs provide a compelling rationale for ongoing research, aiming to fully harness their therapeutic impact in ischemic stroke management.

Blood-brain barrier repair: potential and challenges of stem cells and exosomes in stroke treatment

Stroke is characterized with high morbidity, mortality and disability all over the world, and one of its core pathologies is blood-brain barrier (BBB) dysfunction. BBB plays a crucial physiological role in protecting brain tissues and maintaining homeostasis in central nervous system (CNS). BBB dysfunction serves as a key factor in the development of cerebral edema, inflammation, and further neurological damage in stroke patients. Currently, stem cells and their derived exosomes have shown remarkable potential in repairing the damaged BBB and improving neurological function after stroke. Stem cells repair the integrity of BBB through anti-inflammatory, antioxidant, angiogenesis and regulation of intercellular signaling mechanisms, while stem cell-derived exosomes, as natural nanocarriers, further enhance the therapeutic effect by carrying active substances such as proteins, RNAs and miRNAs. This review will present the latest research advances in stem cells and their exosomes in stroke treatment, as well as the challenges of cell source, transplantation timing, dosage, and route of administration in clinical application, aiming to discuss their mechanisms of repairing BBB integrity and potential for clinical application, and proposes future research directions. Stem cells and exosomes are expected to provide new strategies for early diagnosis and precise treatment of stroke, and promote breakthroughs in the field of stroke.

Evaluation of Sex-Related Differences in Cerebrovascular Bypass Patency: Review of 357 Direct Cerebral Bypasses

BACKGROUND

Demographics and comorbid conditions play a role in vascular health, yet their specific impact on cerebrovascular bypass patency remains unclear.

METHODS

An institutional database of 357 patients with intracranial bypass procedures between August 2001 and May 2022 was retrospectively reviewed. Patients with bypass for all causes (eg, aneurysm, atherosclerotic disease, moyamoya disease) were included. Medical history, surgical technique, and flow-related measurements (intraoperatively and on quantitative magnetic resonance angiography at follow-up) were compared across biological sex and in relation to bypass patency. Bonferroni correction was applied to the initial analysis (P≤0.00167). The remaining analyses were considered exploratory. Propensity score-matched analysis matched cardiovascular risk factors and compared women and men in bypass patency.

RESULTS

Of 357 patients, 141 were men (39.5%) and 216 were women (60.5%) with average age of 49.0±16.7 years and an average follow-up of 1.97 years. Bypass patency at last follow-up was 84.4% (n=114) for men versus 69.2% (n=148) for women (P=0.001). Differences were seen in underlying diagnoses, with more aneurysm and moyamoya cases represented in female sex (P<0.001); irrespective of diagnosis, lower patency rates were seen in women when considering bypass for aneurysm (P=0.032), moyamoya disease (P=0.035), and for atherosclerotic disease (P=0.159). Medical comorbidities were seen at higher rates in men, with comorbidity score of 2.7 versus 2.1 (P<0.001). Cut flow was higher in men 59.2 versus 51.1 (P=0.028), with no differences in intraoperative bypass flow, cut flow index, or follow-up quantitative magnetic resonance angiography. After removing cases using interposition grafts, similar differences were redemonstrated. Propensity score-matched analysis found women have a 2.71 higher chance of bypass occlusion after adjusting for cut flow index (P=0.017 [95% CI, 1.19-6.18]).

CONCLUSIONS

Biological sex appears to play a role in bypass patency, across diagnoses. Women were less likely to have patent bypasses at the last follow-up, despite having fewer medical comorbidities than men and despite having similar intraoperative and perioperative flows.

Sex-Specific Association between HO-1 (GT)n Promoter Polymorphism and Large-Artery Atherosclerosis Stroke

AIMS

Oxidative stress is a central factor in the pathogenesis of atherosclerosis and potentially exhibits sexual dimorphism. The induction of heme oxygenase-1 (HO-1) serves as a crucial mechanism against reactive oxygen species toxicity in the vascular wall, and this induction is regulated by the promoter (GT)n repeat length. We aim to investigate whether or not HO-1 gene (GT)n polymorphism is associated with the occurrence of large-artery atherosclerotic (LAA) stroke.

METHODS

We consecutively recruited stroke patients, with a control group comprising age- and sex-matched non-stroke individuals. HO-1 (GT)n genotypes were determined using DNA extracted from the peripheral leukocytes. HO-1 (GT)n polymorphism was classified as short [S, ≤ 24 (GT)n], medium [M, 25 ≤ (GT)n ＜31], or long [L, 31 ≤ (GT)n]. Clinical data were collected, and stroke patients were categorized into LAA and non-LAA groups according to the TOAST classification. A multivariable logistic regression analysis was conducted to evaluate the association between HO-1 (GT)n variants and LAA occurrence stratified by sex.

RESULTS

There was no significant difference in the distribution of HO-1 (GT)n genotypes between the stroke and non-stroke populations. However, the proportion of S/S genotype was significantly lower in the LAA stroke patients than in the non-LAA stroke patients (7.08% vs. 21.78%, p＜0.001). A multivariable logistic regression analysis indicated that non-SS genotypes were associated with a significantly increased risk of LAA compared to the S/S genotype patients (odds ratio [OR] 3.35, 95% confidence interval [CI] 1.98-5.67, p＜0.001). After stratification by sex, the protective effect of the HO-1 (GT)n S/S genotype was highly significant in men (OR 5.50, 95% CI 2.67-11.34, p＜0.001), whereas the association was not significant in women (OR 1.60, 95% CI 0.75-3.34, p = 0.228).

CONCLUSION

Short (GT)n variants in HO-1 may confer significant protection against LAA stroke in men but not in women.

Glial 'omics in ischemia: Acute stroke and chronic cerebral small vessel disease

Vascular injury and pathologies underlie common diseases including ischemic stroke and cerebral small vessel disease (CSVD). Prior work has identified a key role for glial cells, including microglia, in the multifaceted and temporally evolving neuroimmune response to both stroke and CSVD. Transcriptional profiling has led to important advances including identification of distinct gene expression signatures in ischemia-exposed, flow cytometrically sorted microglia and more recently single cell RNA sequencing-identified microglial subpopulations or clusters. There is a reassuring degree of overlap in the results from these two distinct methodologies with both identifying a proliferative and a separate type I interferon responsive microglial element. Similar patterns were later seen using multimodal and spatial transcriptomal profiling in ischemia-exposed microglia and astrocytes. Methodological advances including enrichment of specific neuroanatomic/functional regions (such as the neurovascular unit) prior to single cell RNA sequencing has led to identification of novel cellular subtypes and generation of new credible hypotheses as to cellular function based on the enhanced cell sub-type specific gene expression patterns. A ribosomal tagging strategy focusing on the cellular translatome analyses carried out in the acute phases post stroke has revealed distinct inflammation-regulating roles for microglia and astrocytes in this setting. Early spatial transcriptomics experiments using cerebral ischemia models have identified regionally distinct microglial cell clusters in ischemic core versus penumbra. There is great potential for combination of these methods for multi-omics approaches to further elucidate glial responses in the context of both acute ischemic stroke and chronic CSVD.

A comprehensive analysis of stroke risk factors and development of a predictive model using machine learning approaches

Stroke is a leading cause of death and disability globally, particularly in China. Identifying risk factors for stroke at an early stage is critical to improving patient outcomes and reducing the overall disease burden. However, the complexity of stroke risk factors requires advanced approaches for accurate prediction. The objective of this study is to identify key risk factors for stroke and develop a predictive model using machine learning techniques to enhance early detection and improve clinical decision-making. Data from the China Health and Retirement Longitudinal Study (2011-2020) were analyzed, classifying participants based on baseline characteristics. We evaluated correlations among 12 chronic diseases and applied machine learning algorithms to identify stroke-associated parameters. A dose-response relationship between these parameters and stroke was assessed using restricted cubic splines with Cox proportional hazards models. A refined predictive model, incorporating age, sex, and key risk factors, was developed. Stroke patients were significantly older (average age 69.03 years) and had a higher proportion of women (53%) compared to non-stroke individuals. Additionally, stroke patients were more likely to reside in rural areas, be unmarried, smoke, and suffer from various diseases. While the 12 chronic diseases were correlated (p < 0.05), the correlation coefficients were generally weak (r < 0.5). Machine learning identified nine parameters significantly associated with stroke risk: TyG-WC, WHtR, TyG-BMI, TyG, TMO, CysC, CREA, SBP, and HDL-C. Of these, TyG-WC, WHtR, TyG-BMI, TyG, CysC, CREA, and SBP exhibited a positive dose-response relationship with stroke risk. In contrast, TMO and HDL-C were associated with reduced stroke risk. In the fully adjusted model, elevated CysC (HR = 2.606, 95% CI 1.869-3.635), CREA (HR = 1.819, 95% CI 1.240-2.668), and SBP (HR = 1.008, 95% CI 1.003-1.012) were significantly associated with increased stroke risk, while higher HDL-C (HR = 0.989, 95% CI 0.984-0.995) and TMO (HR = 0.99995, 95% CI 0.99994-0.99997) were protective. A nomogram model incorporating age, sex, and the identified parameters demonstrated superior predictive accuracy, with a significantly higher Harrell's C-index compared to individual predictors. This study identifies several significant stroke risk factors and presents a predictive model that can enhance early detection of high-risk individuals. Among them, CREA, CysC, SBP, TyG-BMI, TyG, TyG-WC, and WHtR were positively associated with stroke risk, whereas TMO and HDL-C were opposite. This serves as a valuable decision-support resource for clinicians, facilitating more effective prevention and treatment strategies, ultimately improving patient outcomes.

Roadmap for Health Equity: Understanding the Importance of Community-Engaged Research

Achieving health equity in stroke prevention, treatment, and recovery has continued to be a significant challenge. This article highlights the significance of health equity and the role of community-engaged research in addressing stroke disparities, including concepts around health equity as the fair and just opportunity for everyone to attain their highest level of health and well-being. Social determinants impact stroke incidence, prevalence, morbidity, and mortality, which emphasizes the importance of intersectionality and social risk-informed care. A comprehensive roadmap for achieving health equity in stroke through the integration of community-engaged research is presented, including the necessity of community involvement in all aspects of research. Community is defined beyond geographic boundaries, highlighting the importance of shared identities and values. The process of developing targeted goals with communities toward social justice reform is reviewed, including an evolved community engagement framework, emphasizing the need for training to inform about issues and collaborative leadership models. Several stroke disparities intervention studies are highlighted, demonstrating the successful incorporation of community engagement into intervention design and intervention platforms. For enhanced engagement, the use of community health workers and better integration of community health worker models are essential. There may be a critical need for community engagement to optimize inclusion in clinical trials. Finally, acknowledging the complexities of research around decreasing stroke disparities in prevention, treatment, and recovery, this article delves into a framework for understanding the mechanisms by which interventions affect inequities and the need for multifaceted solutions with the community as a partner. Highlighting the roadmap to health equity, this research argues that community engagement is an integral component at all steps along the road to achieving optimum brain health through equitable stroke treatment, prevention, and recovery.

Perceptions of Sleep Quality, Fatigue, and Cognition Among Women Shift Workers

OBJECTIVE

To explore the perceptions of sleep quality, levels of fatigue, and cognitive executive function in women shift workers.

DESIGN

Qualitative, descriptive study of a sample of participants who participated in a cross-sectional, mixed-methods study.

SETTING

Online focus groups.

PARTICIPANTS

Women shift workers (N = 14) recruited from the southeastern United States.

METHODS

Four focus groups were conducted using the Zoom online videoconferencing platform. Transcripts were coded inductively, and data were analyzed using a thematic analysis approach.

RESULTS

Five major themes were developed from the data: Lots of Sleep Lost, Day Sleep Difficulties, Negative Consequences, Missing Out, and Not in My Own Thoughts.

CONCLUSION

Shift work is associated with sleep loss, which has a negative impact on women's emotional, mental, and physical health. Further nursing science investigation into strategies to enable women to improve their sleep quality, sleep quantity, and social/domestic environment is warranted. Education to increase sleep knowledge and decrease accidents and errors that can result from insufficient sleep is vital.

Forecasting the Worldwide Impact of Stroke for Individuals Aged 45 and Above

BACKGROUND

We aimed to assess the global impact of stroke in people aged 45 years and older between 1990 and 2030, focusing on morbidity, mortality, and disability-adjusted life years (DALYs).

METHODS

Generalized additive models were used to project disease burden from 2020 to 2030. Additionally, the association between sociodemographic index (SDI) and stroke burden was investigated, and regional differences were assessed by Mann-Whitney U test.

RESULTS

The overall age-standardized stroke incidence rate (ASIR) among adults aged 45 years and older is projected to increase from 2020 to 2030, with an estimated annual percentage change (EAPC) of 1.29. Conversely, the age-standardized death rate (ASDR) in EAPC is expected to decrease by -1.48, and the age-standardized DALY in EAPC is expected to decrease by -1.66. By 2030, men are expected to have higher ASIR (181.81) and ASDR (87.31) than women (ASIR: 151.85, ASDR: 65.20). Regional differences are large. East Asia is expected to have the highest ASIR in 2030 (265.55). Age estimates show that older age groups, particularly those aged 75-79, are at higher risk of stroke. In addition, there is a significant inverse relationship between SDI and stroke severity, with areas with higher SDI tending to have lower morbidity, mortality, and DALYs.

CONCLUSION

From 1990 to 2030, ASIR is expected to upgrade, especially in East Asia and regions with lower SDI. Men will bear a greater burden than women.

Sex Alters the Effect of Perfusion Deficits on Functional Outcome in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy

INTRODUCTION

The discourse surrounding differences in cerebral hemodynamics and clinical outcomes among male and female patients treated with mechanical thrombectomy (MT) for acute ischemic stroke (AIS) remains unresolved. We aimed to elucidate these differences by employing computed tomography perfusion (CTP) imaging before MT and examining the influence of perfusion deficits on the 90-day functional outcome.

METHODS

This single-center retrospective analysis involved patients with anterior circulation AIS treated with MT at the Comprehensive Stroke Center, University Hospital, Krakow, from January 2019 to July 2023. We compared male and female patients in terms of baseline characteristics, CTP deficits, hypoperfusion intensity ratio (HIR, defined as T10max/T6max), and complications. The endpoints included the 90-day excellent functional outcome, defined as modified Rankin Score <2, and the 90-day mortality rate.

RESULTS

We included 794 patients, of whom 408 were female (51.4%). Female patients had a smaller early infarct volume (median [interquartile range]: 7 mL [0-24.8] vs. 10 mL [0-33], p = 0.004), smaller penumbra volume (77.5 mL [46-117] vs. 99.5 mL [59.8-140], p < 0.001), lower HIR (0.34 [0.16-0.5] vs. 0.37 [0.2-9.53], p = 0.043) and were less likely to achieve an excellent functional outcome (55.6% vs. 66.1%, p = 0.003). For every 10 mL increase in early infarct volume, the odds for achieving an excellent outcome were lower in females (odds ratio [OR]: 0.82 [95% confidence interval: 0.73-0.92]) compared to males (OR: 0.96 [0.88-1.04]), whereas the risk of death was higher for females (OR: 1.25 [1.13-1.39] than for males (OR: 1.05 [0.98-1.14]).

DISCUSSION

Despite more favorable cerebral hemodynamic profile, female AIS patients have worse outcomes than their male counterparts. This effect seems to be independently mediated by the more pronounced impact of early infarct volume on the prognosis in female patients. These findings underscore the possible explanatory power arising from sex-specific interpretation of early infarct volume in clinical practice.

Effects of CASZ1, WNT2B and PTPRG SNPs on stroke susceptibility in the Chinese Han population

BACKGROUND

Stroke is an important cause of death and disability worldwide, ranking second in the cause of death, and it is thought to be related to genetic factors. The purpose of our study is to investigate the association between CASZ1, WNT2B and PTPRG single nucleotide polymorphisms (SNPs) and stroke risk in the Chinese population.

METHODS

We recruited 1418 volunteers, comprised of 710 stroke cases and 708 controls in this study. We used MassARRAY iPLEX GOLD method to genotype the three SNPs on CASZ1, WNT2B and PTPRG. Logistic regression was used to analyse the association between these SNPs and stroke, and odds ratios (ORs) and 95% confidence intervals (CIs) were then calculated. What's more, the interactions among SNPs were predicted by multi-factor dimensionality reduction (MDR) analysis.

RESULTS

This research demonstrated that CASZ1 rs880315 and PTPRG rs704341 were associated with reduced stroke susceptibility. More precisely, CASZ1 rs880315 was associated with reduced stroke susceptibility in people aged ≤64 years and women. PTPRG rs704341 was associated with reduced stroke susceptibility in people aged >64 years, women, non-smokers and non-drinkers. Conversely, WNT2B rs12037987 was related to elevated stroke susceptibility in people aged >64 years, women and non-smokers. In addition, CASZ1 rs880315, WNT2B rs12037987 and PTPRG rs704341 had a strong redundancy relationship.

CONCLUSION

Our study concludes that CASZ1 rs880315, WNT2B rs12037987 and PTPRG rs704341 are associated with stroke, and the study provides a basis for assessing genetic variants associated with stroke risk in the Han Chinese population.

Understanding gender inequity in brain health outcomes: missed stroke as a case study for intersectionality

Recent attention into sex and gender-based inequities surrounding outcomes for brain health disorders has generated momentum toward addressing what has been called the "brain health gap." Importantly though, "women" are not uniform demographic group. In this perspective piece, we discuss misdiagnosis in stroke as an aspect of access and quality of care within brain health. Drawing on narrative data from a mixed methods study of young stroke survivors we suggest that while missed stroke isn't only an issue of gender, if we are going to understand gender-based gaps in access and navigation through stroke care, we have to understand how intersections of gender with age, ethnoracial identity, nationality, language, (dis)ability, and other aspects of social identity come together to create affordances as well as biases that contribute to stroke outcomes.

Stroke after Cardiac Surgery: A Risk Factor Analysis of 580,117 Patients from UK National Adult Cardiac Surgical Audit Cohort

Cerebrovascular accident is the most ominous complication observed after cardiac surgery, carrying an increased risk of morbidity and mortality. Analysis of the problem shows its multidimensional nature. In this study, we aimed to identify major determinants among classic variables, either demographic, clinical or type of surgical procedure, based on the analysis of a large dataset of 580,117 patients from the UK National Adult Cardiac Surgical Audit (NACSA). For this purpose, univariate and multivariate logistic regression models were utilized to determine associations between predictors and dependent variable (Stroke after cardiac surgery). Odds ratios (ORs) and 95% confidence intervals (CIs) were constructed for each independent variable. Statistical analysis allows us to confirm with greater certainty the predictive value of some variables such as age, gender, diabetes mellitus (diabetes treated with insulin OR = 1.37, 95%CI = 1.23-1.53), and systemic arterial hypertension (OR = 1.11, 95%CI = 1.05-1.16);, to emphasize the role of preoperative atrial fibrillation (OR = 1.10, 95%CI = 1.03-1.16) extracardiac arteriopathy (OR = 1.70, 95%CI = 1.58-1.82), and previous cerebral vascular accident (OR 1.71, 95%CI = 1.6-1.9), and to reappraise others like smoking status (crude OR = 1.00, 95%CI = 0.93-1.07 for current smokers) or BMI (OR = 0.98, 95%CI = 0.97-0.98). This could allow for better preoperative risk stratification. In addition, identifying those surgical procedures (for example thoracic aortic surgery associated with a crude OR of 3.72 and 95%CI = 3.53-3.93) burdened by a high risk of neurological complications may help broaden the field of preventive and protective techniques.

Sex differences in cardiovascular risk factors and quality of life among individuals with hypertension in Korea from 2013 to 2018: A cross-sectional cohort study

As its prevalence increases and its association with cardiovascular disease and mortality is established, there is a need to improve prevention and management strategies for hypertension. Therefore, we aimed to compare differences in cardiovascular health status between men and women with hypertension defined by systolic blood pressure ≥140 mmHg and diastolic blood pressure ≥90 mmHg, and/or treatment with antihypertensive drugs. The association between cardiovascular health status and health-related quality of life was also evaluated. Additionally, a secondary analysis was performed on the cross-sectional data from 7306 adults with hypertension, ≥40 years of age between 2013 and 2018. Of this sample, 51.2% of patients were women from the Korean National Health and Nutrition Examination Survey. The seven Cardiovascular Health Metrics were used to quantify cardiovascular health status and the 5-dimensional European Quality of Life Questionnaire (EQ-5D) was used to evaluate health-related quality of life. A higher proportion of men than that of women was observed in the poor cardiovascular health score group [total score 0-7], with a higher proportion of women in the intermediate group [total score 8-10] and ideal group [total 11-14] (p<0.0001). The proportion of women in the EQ-5D index was higher than that of men in the poor and intermediate groups (p<0.0001), with no difference in the proportion of men and women in the ideal group (p = 0.1452). Furthermore, specific cardiovascular risk factors were different between men and women: women had lower physical activity level and higher prevalence of high cholesterol (≥200 mg/dl), and men had higher body mass indices and worse diet management. These findings indicate that prevention and management strategies for hypertension and cardiovascular health might need to differ for men and women to improve outcomes.

From diabetic hyperglycemia to cerebrovascular Damage: A narrative review

Diabetes mellitus is a globally significant disease that can lead to systemic complications, particularly vascular damage, including cardiovascular and cerebrovascular diseases of relevance. The physiological changes resulting from the imbalance in blood glucose levels play a crucial role in initiating vascular endothelial damage. Elevated glucose levels can also penetrate the central nervous system, triggering diabetic encephalopathy characterized by oxidative damage to brain components and activation of alternative and neurotoxic pathways. This brain damage increases the risk of ischemic stroke, a leading cause of mortality worldwide and a major cause of disability among surviving patients. The aim of this review is to highlight important pathways related to hyperglycemic damage that extend to the brain and result in vascular dysfunction, ultimately leading to the occurrence of a stroke. Understanding how diabetes mellitus contributes to the development of ischemic stroke and its impact on patient outcomes is crucial for implementing therapeutic strategies that reduce the incidence of diabetes mellitus and its complications, ultimately decreasing morbidity and mortality associated with the disease.

Cerebroprotective Effect of 17β-Estradiol Replacement Therapy in Ovariectomy-Induced Post-Menopausal Rats Subjected to Ischemic Stroke: Role of MAPK/ERK1/2 Pathway and PI3K-Independent Akt Activation

Despite the overwhelming advances in the understanding of the pathogenesis of stroke, a devastating disease affecting millions of people worldwide, currently there are only a limited number of effective treatments available. Preclinical and clinical studies show that stroke is a sexually dimorphic disorder, affecting males and females differently. Strong experimental evidence indicates that estrogen may play a role in this difference and that exogenous 17β-estradiol (E2) is neuroprotective against stroke in both male and female rodents. However, the molecular mechanisms by which E2 intervenes in ischemia-induced cell death, revealing these sex differences, remain unclear. The present study was aimed to determine, in female rats, the molecular mechanisms of two well-known pro-survival signaling pathways, MAPK/ERK1/2 and PI3K/Akt, that mediate E2 neuroprotection in response to acute ischemic stroke. E2 pretreatment reduced brain damage and attenuated apoptotic cell death in ovariectomized female rats after an ischemic insult. Moreover, E2 decreased phosphorylation of ERK1/2 and prevented ischemia/reperfusion-induced dephosphorylation of both Akt and the pro-apoptotic protein, BAD. However, MAPK/ERK1/2 inhibitor PD98059, but not the PI3K inhibitor LY294002, attenuated E2 neuroprotection. Thus, these results suggested that E2 pretreatment in ovariectomized female rats modulates MAPK/ERK1/2 and activates Akt independently of PI3K to promote cerebroprotection in ischemic stroke. A better understanding of the mechanisms and the influence of E2 in the female sex paves the way for the design of future successful hormone replacement therapies.

Time to onset of cardiovascular and cerebrovascular outcomes after hypertensive disorders of pregnancy: a nationwide, population-based retrospective cohort study

BACKGROUND

The increased maternal cardiocerebrovascular risk after a pregnancy complicated by hypertensive disorders of pregnancy, is well documented in the literature. Recent evidence has suggested a shorter timeframe for the development of these postnatal outcomes, which could have major clinical implications.

OBJECTIVE

This study aimed to determine the risk of and time to onset of maternal cardiovascular and cerebrovascular outcomes after a pregnancy complicated by hypertensive disorders of pregnancy.

STUDY DESIGN

This study included 2,227,711 women, without preexisting chronic hypertension, who delivered during the period 2008 to 2010: 37,043 (1.66%) were diagnosed with preeclampsia, 34,220 (1.54%) were diagnosed with gestational hypertension, and 2,156,448 had normotensive pregnancies. Hospitalizations for chronic hypertension, heart failure, coronary heart disease, cerebrovascular disease, and peripheral arterial disease were studied. A classical Cox regression was performed to estimate the average effect of hypertensive disorders of pregnancy over 10 years compared with normotensive pregnancy; moreover, an extended Cox regression was performed with a step function model to estimate the effect of the exposure variable in different time intervals: <1, 1 to 3, 3 to 5, and 5 to 10 years of follow-up.

RESULTS

The risk of chronic hypertension after a pregnancy complicated by preeclampsia was 18 times higher in the first year (adjusted hazard ratio, 18.531; 95% confidence interval, 16.520-20.787) to only 5 times higher at 5 to 10 years after birth (adjusted hazard ratio, 4.921; 95% confidence interval, 4.640-5.218). The corresponding risks of women with gestational hypertension were 12 times higher (adjusted hazard ratio, 11.727; 95% confidence interval, 10.257-13.409]) and 6 times higher (adjusted hazard ratio, 5.854; 95% confidence interval, 5.550-6.176), respectively. For other cardiovascular and cerebrovascular outcomes, there was also a significant effect with preeclampsia (heart failure: adjusted hazard ratio, 6.662 [95% confidence interval, 4.547-9.762]; coronary heart disease: adjusted hazard ratio, 3.083 [95% confidence interval, 1.626-5.844]; cerebrovascular disease: adjusted hazard ratio, 3.567 [95% confidence interval, 2.600-4.893]; peripheral arterial disease: adjusted hazard ratio, 4.802 [95% confidence interval, 2.072-11.132]) compared with gestational hypertension in the first year of follow-up. A dose-response effect was evident for the severity of preeclampsia with the averaged 10-year adjusted hazard ratios for developing chronic hypertension after early, preterm, and late preeclampsia being 10, 7, and 6 times higher, respectively.

CONCLUSION

The risks of cardiovascular and cerebrovascular outcomes were the highest in the first year after a birth complicated by hypertensive disorders of pregnancy. We found a significant relationship with both the severity of hypertensive disorders of pregnancy and the gestational age of onset suggesting a possible dose-response relationship for the development of cardiovascular and cerebrovascular outcomes. These findings call for an urgent focus on research into effective postnatal screening and cardiocerebrovascular risk prevention for women with hypertensive disorders of pregnancy.

Awareness of Stroke Risk Factors, Warning Signs, and Preventive Behaviour Among Diabetic Patients in Al-Ahsa, Saudi Arabia

Objectives This study aims to measure the level of awareness about stroke symptoms, risk factors, and preventive health practices that could be taken to reduce the risk of stroke among diabetic patients in Al-Ahsa, Saudi Arabia. Methods A cross-sectional study was conducted in Al-Ahsa, Saudi Arabia in 2020. The sample included a total of 202 male and female Saudi adults aged 18-65 years, with either type 1 or type 2 diabetes mellitus, and living in Al Ahsa, Saudi Arabia. The information was collected randomly through an online questionnaire distributed among patients after getting their contact information from relevant governmental and private diabetes clinics and after signing the informed consent. For awareness and knowledge items, each correct answer was scored one point and the total summation of the discrete scores of the different items was calculated. A diabetic patient with a score less than 60% of the total score was considered to have poor awareness while a score of 60% or more of the total score was considered a good level of awareness. Results A total of 87 (43.1%) participants had an overall good awareness level, while 115 (56.9%) had poor awareness levels. Around 40.6% of the study patients had heard about stroke, 61.9% knew that stroke affects the brain, and 24.3% reported that stroke is higher among males. As for factors associated with stroke, the most reported was high blood pressure (71.8%), followed by diabetes mellitus (69.3%). Exactly 65.8% of participants knew about the mechanism of ischemic stroke and 42.6% reported hemorrhagic stroke. A high percentage of patients (73.1%) realize that they could reduce their risk of stroke. Conclusion The findings of the current study showed that less than half (43.1%) of the Saudi patients with DM had a good awareness level regarding stroke and its related risk factors and warning signs. Older patients (aged 50-65 years) with high social levels (high education and income) and those with a family history of stroke had significantly higher awareness levels. Hypertension, DM, and smoking are the highest reported known risk factors of stroke, and speech disorders are the highest known stroke presentation to the respondents.

C1QC, VSIG4, and CFD as Potential Peripheral Blood Biomarkers in Atrial Fibrillation-Related Cardioembolic Stroke

Atrial fibrillation (AF) is a major risk factor for ischemic stroke. We aimed to identify novel potential biomarkers with diagnostic value in patients with atrial fibrillation-related cardioembolic stroke (AF-CE).Publicly available gene expression profiles related to AF, cardioembolic stroke (CE), and large artery atherosclerosis (LAA) were downloaded from the Gene Expression Omnibus (GEO). Differentially expressed genes (DEGs) were identified and then functionally annotated. The support vector machine recursive feature elimination (SVM-RFE) and least absolute shrinkage and selection operator (LASSO) regression analysis were conducted to identify potential diagnostic AF-CE biomarkers. Furthermore, the results were validated by using external data sets, and discriminability was measured by the area under the ROC curve (AUC). In order to verify the predictive results, the blood samples of 13 healthy controls, 20 patients with CE, and 20 patients with LAA stroke were acquired for RT-qPCR, and the correlation between biomarkers and clinical features was further explored. Lastly, a nomogram and the companion website were developed to predict the CE-risk rate. Three feature genes (C1QC, VSIG4, and CFD) were selected and validated in the training and the external datasets. The qRT-PCR evaluation showed that the levels of blood biomarkers (C1QC, VSIG4, and CFD) in patients with AF-CE can be used to differentiate patients with AF-CE from normal controls (P < 0.05) and can effectively discriminate AF-CE from LAA stroke (P < 0.05). Immune cell infiltration analysis revealed that three feature genes were correlated with immune system such as neutrophils. Clinical impact curve, calibration curves, ROC, and DCAs of the nomogram indicate that the nomogram had good performance. Our findings showed that C1QC, VSIG4, and CFD can potentially serve as diagnostic blood biomarkers of AF-CE; novel nomogram and the companion website can help clinicians to identify high-risk individuals, thus helping to guide treatment decisions for stroke patients.

Interpersonal violence: Serious sequelae for heart disease in women

Experiencing various forms of violence in either childhood or adulthood has been associated with cardiovascular disease, both shortly after the event and during follow-up, particularly in women. The coronavirus disease 2019 pandemic has heightened the risk of domestic violence with serious sequelae for mental and cardiovascular health in women, possibly due to several contributing factors, ranging from lockdown, stay at home regulations, job losses, anxiety, and stress. Accordingly, it remains paramount to enforce proactive preventive strategies, at both the family and individual level, maintain a high level of attention to recognize all forms of violence or abuse, and guarantee a multidisciplinary team approach for victims of interpersonal or domestic violence in order to address physical, sexual, and emotional domains and offer a personalized care.