Prevention of stroke: a strategic global imperative

Closed-loop rehabilitation of upper-limb dyskinesia after stroke: from natural motion to neuronal microfluidics

This review proposes an innovative closed-loop rehabilitation strategy that integrates multiple subdomains of stroke science to address the global challenge of upper-limb dyskinesia post-stroke. Despite advancements in neural remodeling and rehabilitation research, the compartmentalization of subdomains has limited the effectiveness of current rehabilitation strategies. Our approach unites key areas-including the post-stroke brain, upper-limb rehabilitation robotics, motion sensing, metrics, neural microfluidics, and neuroelectronics-into a cohesive framework designed to enhance upper-limb motion rehabilitation outcomes. By leveraging cutting-edge technologies such as lightweight rehabilitation robotics, advanced motion sensing, and neural microfluidic models, this strategy enables real-time monitoring, adaptive interventions, and personalized rehabilitation plans. Furthermore, we explore the potential of closed-loop systems to drive neural plasticity and functional recovery, offering a transformative perspective on stroke rehabilitation. Finally, we discuss future directions, emphasizing the integration of emerging technologies and interdisciplinary collaboration to advance the field. This review highlights the promise of closed-loop strategies in achieving unprecedented integration of subdomains and improving post-stroke upper-limb rehabilitation outcomes.

Treg Upregulation by Treadmill Training Accelerates Myelin Repair Post-Ischemia

Regulatory T (Treg) cells contribute to white matter repair following ischemic stroke, but their limited availability in circulation restricts their therapeutic potential. Exercise, as a non-invasive and effective rehabilitation method, has been shown to restore Treg balance in diseases. This study explores the effects of treadmill training on Treg upregulation and its influence on myelin repair and functional recovery in rats with middle cerebral artery occlusion (MCAO). After four weeks of treadmill training, we analyzed the proportion of Treg cells (Tregs), FOXP3 expression, and oligodendrocyte-related protein levels using flow cytometry, immunofluorescence, and Western blotting. Myelin structure was examined with transmission electron microscopy (TEM), while motor coordination and balance were assessed using the fatigue rotarod and CatWalk analysis systems. To further explore the role of Tregs, the FOXP3 inhibitor P60 was used to inhibit Treg activity. The findings of our study indicate that training on a treadmill supports the maturation of oligodendrocytes, leads to an increase in myelin-associated proteins and the thickness of myelin, and promotes the recovery of motor function. Inhibition of Treg activity diminished these benefits, highlighting Tregs' key role in exercise-induced remyelination. These findings suggest that treadmill training facilitates myelin regeneration and functional recovery by upregulating Tregs, offering potential new strategies for stroke treatment.

Breaking Barriers in Stroke Therapy: Recent Advances and Ongoing Challenges

Acute ischemic stroke remains a significant global health challenge, prompting notable advancements in its management. Diagnostic innovations, including advanced imaging techniques and biomarker discovery, have greatly improved early detection and treatment precision. Mobile stroke units have expedited pre-hospital care, emphasizing the urgency of intervention under the principle "time is brain." These developments underscore the importance of timely and accurate diagnosis in improving outcomes. Therapeutic breakthroughs in thrombolytic therapy and mechanical thrombectomy have transformed acute stroke treatment. Refined thrombolytic protocols, new agents, and extended treatment windows have expanded therapeutic possibilities. Mechanical thrombectomy, bolstered by improved devices and techniques, has achieved higher recanalization rates and broader applicability, solidifying its role in endovascular interventions. Meanwhile, post-stroke care has embraced personalized, multidisciplinary rehabilitation approaches, with telemedicine breaking geographical barriers and enhancing recovery through patient-centered models. Despite these advancements, challenges persist, including disparities in access to advanced care and the underexplored management of minor strokes. Emerging technologies, such as artificial intelligence and machine learning, offer opportunities for better risk prediction and earlier interventions, though their long-term impacts require further study. This review highlights the transformative progress in stroke care while emphasizing the need for continued innovation, research, and equitable access to ensure better outcomes for all patients.

Global and Regional Burden of Ischemic Stroke Disease from 1990 to 2021: An Age-Period-Cohort Analysis

Ischemic stroke is a significant global public health issue that impacts health burdens across various regions. This study analyzed data from the Global Burden of Disease Study 2021 to assess the incidence, mortality, and disability-adjusted life years (DALYs) associated with ischemic stroke worldwide and across different Socio-demographic Index (SDI) regions. Using joinpoint regression and age-period-cohort (APC) models, we examined trends in disease burden and made projections for 2022 to 2035. As of 2021, approximately 7,804,449 (95% UI, 6,719,760-8,943,692) individuals were affected by ischemic stroke, resulting in 3,591,499 (95% UI, 3,213,281-3,888,327) deaths and 70,357,912 (95% UI, 64,329,576-76,007,063) DALYs. These numbers represent increases of 88.0%, 55.0%, and 52.4% since 1990. Despite these increases, age-standardized incidence, mortality, and DALYs rates are declining, with annual percentage change rates (AAPC) of - 0.578%, - 0.927%, and - 14.372%, consistent across all SDI regions. The global rates of IS are influenced by age, period, and cohort, showing increased rates with age but declining over time, particularly in high SDI regions. Major risk factors include hypertension, environmental pollution, and low-density lipoprotein cholesterol (LDL-C). Projections indicate that by 2035, incidence, mortality, and DALYs will rise among those aged 45 and above, while decreasing for those under 35. This highlights the urgent need for preventive and therapeutic strategies targeting ischemic stroke, particularly for individuals over 45, while addressing the impact of major risk factors in high-burden regions.

Nasal administration of Xingnaojing biomimetic nanoparticles for the treatment of ischemic stroke

Xingnaojing injection (XNJ), is the first-line Chinese medicine injection approved for treating ischemic stroke (IS). XNJ can attenuate the inflammatory responses and oxidative stress, thus reversing neuronal damage of IS. This study aims to prepare the biomimetic nanoparticles (Bo-GEVs/XNJM) of nasal administration for IS treatment. The grapefruit extracellular vesicles (GEVs) loaded with microemulsions sourced from Xingnaojing injection (XNJM) are modified with borneol (Bo) to bypass the blood-brain barrier (BBB). Bo-GEVs/XNJM has the property of brain-targeting, and in vivo and in vitro experiments have validated that it has positive effects in reducing apoptosis, inhibiting oxidative stress, anti-inflammation, protecting mitochondrial function, and protecting the BBB. In summary, Bo-GEVs/XNJM has good neuroprotective effects, and provides an interventional method for the treatment of ischemic stroke.

Exploring the Genetic Relationship Between Type 2 Diabetes and Cardiovascular Disease: A Large-Scale Genetic Association and Polygenic Risk Score Study

Type 2 diabetes (T2D) is often comorbid with cardiovascular diseases (CVDs). The direction of causation between T2D and CVD is difficult to determine; however, there may be a common underlying pathway attributable to shared genetic factors. We aimed to determine whether there is a shared genetic susceptibility to T2D and CVD. This study utilizes large-scale datasets from the UK Biobank (UKB) and DIAGRAM consortium to investigate the genetic association between T2D and CVD through phenotypic association analyses, linkage disequilibrium score (LDSC) analysis, and polygenic risk score (PRS) analysis. LDSC analysis demonstrates significant genetic associations between T2D and various CVD subtypes, including angina, heart failure (HF), myocardial infarction (MI), peripheral vascular disease (PVD), and stroke. Although the genetic association between T2D and atrial fibrillation (AF) was not significant, individuals in the high-T2D PRS group had a significantly increased risk of CVD. These findings suggest a common genetic basis and suggest that genetic susceptibility to T2D may be a potential predictor of CVD risk.

Multidisciplinary lifestyle interventions for neurological disorders during the Silent phase (MINDS) study: a multi-omics randomized controlled trial protocol

INTRODUCTION

Given the prevalence and staggering cost of neurological disorders, there is dire need for effective early detection and intervention tools. Emerging evidence suggests that multidisciplinary lifestyle interventions (MLI) may mitigate the risk and progression of neurological disorders. The objectives of this protocol are (1) to test the impact of MLI on the progression of neurological disorders and (2) to identify multi-omic biomarkers for early stages of neurological disease and the impact of MLIs on these biomarkers.

METHODS AND ANALYSIS

We present the Multidisciplinary lifestyle Interventions for Neurological Disorders during the Silent phase (MINDS) protocol, a randomized controlled trial of MLI in neurologically healthy older adults (≥ 50 years old) exhibiting elevated risk for common neurological disorders: stroke, epilepsy, Parkinson's Disease, or Alzheimer's disease and related dementias. Participants will be randomly assigned to intervention (n = 100) or control (n = 100) groups. The intervention group will receive 3 months of weekly 2-hour sessions on diet education, yoga, music therapy, and cognitive skills training. The participants' neurological health and engagement in relevant lifestyle practices will be assessed at regular intervals for 12 months. Neuroimaging and samples for multi-omic analyses will be collected at baseline, and at 3 months and 12 months after enrollment. Primary outcomes will be signs of progression of the neurological disorder risk that qualified them for study enrollment or a clinical diagnosis of the disorder. Secondary and exploratory outcomes will be based on self-reported health and multi-omic data. Data analysis will include between-group and longitudinal within-group analyses.

PERSPECTIVES

The MINDS protocol and trial aims to clarify the impact of MLI on the progression of neurological disorder risk or diagnosis in older adults and to identify biomarkers that can be used to confirm MLI efficacy. The ability to validate the impact of MLI on neurological disorder progression based on biomarker data allows the identification of individuals most likely to benefit from such therapies in the early stages of neurological disease.

TRIAL REGISTRATION

The trial is registered on the National Institutes of Health (NIH) ClinicalTrials.gov (NCT05984056) site. It was registered on August 2nd, 2023. The trial has full approval of the Cleveland Clinic Internal Review Board.

Global, regional, and national burden of stroke from 1990 to 2019: A temporal trend analysis based on the Global Burden of Disease Study 2019

BACKGROUND

Stroke is the second leading cause of death and the leading cause of disability worldwide. However, how the prevalence of stroke varies across the world is uncertain.

AIMS

The aim of this study was to analyze temporal trends of prevalence for stroke, including ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) at the global, regional, and national levels.

METHODS

The age-standardized prevalence rates (ASPR) of stroke, IS, ICH, and SAH, along with their corresponding 95% uncertainty intervals (UI), were derived from data in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. This provides estimates for the burden of 369 diseases and injuries globally in 2019, as well as their temporal trends over the past 30 years. Joinpoint regression analysis was used to analyze the 1990-2019 temporal trends by calculating the annual percentage change (APC) and average annual percentage change (AAPC), as well as their 95% confidence interval (CI).

RESULTS

In 2019, the global ASPR of stroke was 1240.263 per 100,000 population (95% UI: 1139.711 to 1352.987), with ASPRs generally lower in Europe compared to other regions. Over the period from 1990 to 2019, a significant global decrease in ASPR was observed for stroke (AAPC -0.200, 95% CI: -0.215 to -0.183), IS (AAPC -0.059%, 95% CI: -0.077 to -0.043), SAH (AAPC -0.476, 95% CI: -0.483 to -0.469), and ICH (AAPC -0.626, 95% CI: -0.642 to -0.611). The trends of ASPR of stroke, IS, SAH, and ICH varied significantly across 204 countries and territories.

CONCLUSION

Our findings highlight significant global disparities in stroke prevalence, emphasizing the need for ongoing monitoring and intensified efforts in developing regions to reduce the global burden of stroke.

Determinants influencing health-promoting behaviors in individuals at high risks of stroke: a cross-sectional study

Background

Quit smoking, moderate drinking, exercise, and healthy eating habits are all known to decrease the risk of stroke. As a result, understanding the health behaviors of high risk groups for stroke is crucial. Health behavior is influenced by knowledge, social environment, and health beliefs. However, little research has been done on these relationships. For a better grasp of the relationships mentioned above, consider using the COM-B model (capability, opportunity, motivation, and behavior). The purpose of this study was to investigate the variables related to health behavior and to test the mediating effect of health beliefs.

Methods

The cross-sectional study was carried out at a physical examination center of a tertiary hospital in Shanghai, China. 986 high-risk populations of stroke have been tested using the Health Behavior Scale (HBS-SP), Stroke Knowledge Questionnaire (SKQ), Health Beliefs Questionnaire (HBS), and Multidimensional Scale of Perceived Social Support (MSPSS). The structural equation modeling was used in this study.

Results

The scores for MSPSS, SKQ, HBS, and HBS-SP were 60.64 ± 13.72, 26.60 ± 9.77, 157.71 ± 34.34, and 2.46 ± 0.41, respectively. The revised model fits well (approximate root mean square error = 0.042; comparative fit index = 0.946). The health behavior was obviously and positively correlated to social Support, stroke knowledge, and health beliefs. Moreover, health belief has a mediating effect on the relation of social support, stroke knowledge, and health behavior.

Conclusion

Chinese high risk groups for stroke have a mediate level of health behaviors. Factors associated with health behaviors are knowledge of stroke, health beliefs, and social support. The COM-B-based model can be used to explain the health behavior of individuals at risk of stroke and to guide the formulation of effective health management programs.

Investigating the Pharmacological Mechanisms of Total Flavonoids from Eucommia ulmoides Oliver Leaves for Ischemic Stroke Protection

The aim of this study was to explore how the total flavonoids from Eucommia ulmoides leaves (EULs) regulate ischemia-induced nerve damage, as well as the protective effects mediated by oxidative stress. The cell survival rate was significantly improved compared to the ischemic group (p < 0.05) after treatment with the total flavonoids of EULs. The levels of reactive oxygen species (ROS), lactate dehydrogenase (LDH), and malondialdehyde (MDA) decreased, while catalase (CAT) and glutathione (GSH) increased, indicating that the total flavonoids of EULs can significantly alleviate neurological damage caused by ischemic stroke by inhibiting oxidative stress (p < 0.01). The mRNA expression level of VEGF increased (p < 0.01), which was consistent with the protein expression results. Meanwhile, the protein expression of ERK and CCND1 increased (p < 0.01), suggesting that the total flavonoids of EULs could protect PC12 cells from ischemic injury via VEGF-related pathways. MCAO rat models indicated that the total flavonoids of EULs could reduce brain ischemia-reperfusion injury. In conclusion, this study demonstrates the potential mechanisms of the total flavonoids of EULs in treating ischemic stroke and their potential therapeutic effects in reducing ischemic injury, which provides useful information for ischemic stroke drug discovery.

Determinants Influencing Health-Promoting Behaviors in Individuals at High Risk of Stroke: A Cross-Sectional Study

BACKGROUND

Health-promoting behaviors and positive lifestyle changes are crucial for effective stroke prevention. However, individuals at high risk of stroke exhibit poor health behavior due to a deficiency of individual motivation. Moreover, there are only a few studies on health-promoting behaviors that have applied behavior change theories in individuals at high risk of stroke.

OBJECTIVE

This study aimed to use the theory of the planned behavior (TPB) model to investigate determinants of health-promoting behaviors for stroke prevention and control.

METHOD

In this cross-sectional study, 263 participants were recruited from five community health centers in Qingdao. Confirmatory factor analysis was performed to assess the reliability and validity of the constructs, and structural equation modeling was used to analyze the proposed relationships between the TPB-related variables.

RESULTS

The attitudes, subjective norms, and perceptions of behavioral control positively influenced behavioral intention. The behavioral intention had a positive effect on health-promoting behaviors. Attitudes, subjective norms, and perceived behavioral control were influenced primarily by the mediating variable behavioral intention to affect health-promoting behaviors. Stroke knowledge was an influential facilitator of behavioral attitudes, subjective norms, and perceived behavior control.

CONCLUSION

The TPB-based model is suitable for explaining health-promoting behaviors in individuals at risk of stroke and for guiding the development of effective health management programs. A comprehensive person-centered motivation behavior strategy that is based on health education and complemented by social support and health resource optimization is critical in promoting health behavior motivation and health promotion behaviors in stroke high-risk groups.

Stroke risk prediction models: A systematic review and meta-analysis

BACKGROUND

Prediction algorithms/models are viable methods for identifying individuals at high risk of stroke across diverse populations for timely intervention. However, evidence summarizing the performance of these models is limited. This study examined the performance and weaknesses of existing stroke risk-score-prediction models (SRSMs) and whether performance varied by population and region.

METHODS

PubMed, EMBASE, and Web of Science were searched for articles on SRSMs from the earliest records until February 2022. The Prediction Model Risk of Bias Assessment Tool was used to assess the quality of eligible articles. The performance of the SRSMs was assessed by meta-analyzing C-statistics (0 and 1) estimates from identified studies to determine the overall pooled C-statistics by fitting a linear restricted maximum likelihood in a random effect model.

RESULTS

Overall, 17 articles (cohort study = 15, nested case-control study = 2) comprising 739,134 stroke cases from 6,396,594 participants from diverse populations/regions (Asia; n = 8, United States; n = 3, and Europe and the United Kingdom; n = 6) were eligible for inclusion. The overall pooled c-statistics of SRSMs was 0.78 (95%CI: 0.75, 0.80; I2 = 99.9%), with most SRSMs developed using cohort studies; 0.78 (95%CI: 0.75, 0.80; I2 = 99.9%). The subgroup analyses by geographical region: Asia [0.81 (95%CI: 0.79, 0.83; I2 = 99.8%)], Europe and the United Kingdom [0.76 (95%CI: 0.69, 0.83; I2 = 99.9%)] and the United States only [0.75 (95%CI: 0.72, 0.78; I2 = 73.5%)] revealed relatively indifferent performances of SRSMs.

CONCLUSION

SRSM performance varied widely, and the pooled c-statistics of SRSMs suggested a fair predictive performance, with very few SRSMs validated in independent population group(s) from diverse world regions.

Effects of a nurse-led eHealth programme on functional outcomes and quality of life of patients with stroke: a pooled analysis of randomized controlled trials

BACKGROUND

Stroke remains a leading cause of disability worldwide. Nurse-led eHealth programs have emerged as a potentially effective strategy to improve functional outcomes and quality of life in stroke survivors. However, the variability of study designs and outcomes measured across trials necessitates a pooled analysis to comprehensively assess the efficacy of these interventions. This protocol outlines the methodology for a pooled analysis that aims to synthesize evidence from randomized controlled trials (RCTs) evaluating nurse-led eHealth interventions for stroke patients.

METHODS AND ANALYSIS

This pooled analysis will be conducted according to the PRISMA guidelines. We will include RCTs that evaluate nurse-led eHealth programs and report on functional outcomes or quality of life in stroke patients. Comprehensive searches of electronic databases including Pubmed, EMBASE, the Cochrane Library, CINAHL, and PsycINFO will be conducted with a predefined search strategy. Study selection will involve screening titles and abstracts, followed by full-text review using explicit inclusion and exclusion criteria. Data extraction will be undertaken independently by two reviewers. The risk of bias will be assessed through the Cochrane Risk of Bias tool. Additionally, the quality of evidence for each outcome will be evaluated using the GRADE approach. Meta-analyses will be performed using random-effects models, and heterogeneity will be quantified using the I2 statistic. Subgroup and sensitivity analyses will explore potential sources of heterogeneity.

DISCUSSION AND CONCLUSIONS

This pooled analysis is poised to provide a nuanced understanding of the effectiveness of nurse-led eHealth programs in stroke rehabilitation, leveraging a thorough methodological framework and GRADE tool to ensure robustness and reliability of evidence. The investigation anticipates diverse improvements in patient outcomes, underscoring the potential of personalized, accessible eHealth interventions to enhance patient engagement and treatment adherence. Despite the challenges posed by the heterogeneity of interventions and rapid technological advancements, the findings stand to influence clinical pathways by integrating eHealth into standard care, if substantiated by the evidence. Our study's depth and methodological rigor possess the potential to initiate changes in healthcare policy, advocating for the adoption of eHealth and subsequent investigations into its cost-efficiency. Ultimately, we aim to contribute rich, evidence-based insights into the burgeoning field of digital health, offering a foundational assessment of its applications in stroke care. Our data is expected to have a lasting impact, not only guiding immediate clinical decisions but also shaping the trajectory of future healthcare strategies in stroke recovery.

SYSTEMATIC REVIEW REGISTRATION

Identifier (CRD42024520100: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=520100).

Prolonged myelin deficits contribute to neuron loss and functional impairments after ischaemic stroke

Ischaemic stroke causes neuron loss and long-term functional deficits. Unfortunately, effective approaches to preserving neurons and promoting functional recovery remain unavailable. Oligodendrocytes, the myelinating cells in the CNS, are susceptible to oxygen and nutrition deprivation and undergo degeneration after ischaemic stroke. Technically, new oligodendrocytes and myelin can be generated by the differentiation of oligodendrocyte precursor cells (OPCs). However, myelin dynamics and their functional significance after ischaemic stroke remain poorly understood. Here, we report numerous denuded axons accompanied by decreased neuron density in sections from ischaemic stroke lesions in human brain, suggesting that neuron loss correlates with myelin deficits in these lesions. To investigate the longitudinal changes in myelin dynamics after stroke, we labelled and traced pre-existing and newly-formed myelin, respectively, using cell-specific genetic approaches. Our results indicated massive oligodendrocyte death and myelin loss 2 weeks after stroke in the transient middle cerebral artery occlusion (tMCAO) mouse model. In contrast, myelin regeneration remained insufficient 4 and 8 weeks post-stroke. Notably, neuronal loss and functional impairments worsened in aged brains, and new myelin generation was diminished. To analyse the causal relationship between remyelination and neuron survival, we manipulated myelinogenesis by conditional deletion of Olig2 (a positive regulator) or muscarinic receptor 1 (M1R, a negative regulator) in OPCs. Deleting Olig2 inhibited remyelination, reducing neuron survival and functional recovery after tMCAO. Conversely, enhancing remyelination by M1R conditional knockout or treatment with the pro-myelination drug clemastine after tMCAO preserved white matter integrity and neuronal survival, accelerating functional recovery. Together, our findings demonstrate that enhancing myelinogenesis is a promising strategy to preserve neurons and promote functional recovery after ischaemic stroke.

Risk Factors for the Development of Pneumonia in Stroke Patients: A Systematic Review and Meta-Analysis

Pneumonia is one of the most prevalent medical complications post-stroke. It can have negative impacts on the prognosis of stroke patients. This study aimed to determine the predictors of pneumonia in stroke patients. The authors devised, reviewed, and enhanced the search strategy in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were gathered from various electronic databases, including Medline, CINAHL, Cochrane, Embase, and Web of Science, from January 1st, 2011, to February 25th, 2024. The review encompassed studies involving patients aged 18 years and older who were hospitalized for acute stroke care. Inclusion criteria required patients to have received a clinical diagnosis of stroke, confirmed via medical imaging (CT or MRI), hospital primary diagnosis International Classification of Diseases 10th Revision discharge codes, or pathology reporting. A total of 35 studies met the criteria and were included in our pooled analysis. Among them, 23 adopted a retrospective design, while the remaining 12 were prospective. The pooled incidence of pneumonia among patients with stroke was found to be 14% (95% confidence interval = 13%-15%). The pooled analysis reported that advancing age, male gender, a history of chronic obstructive pulmonary disease (COPD), the presence of a nasogastric tube, atrial fibrillation, mechanical ventilation, stroke severity, dysphagia, and a history of diabetes were identified as significant risk factors for pneumonia development among stroke patients. Our results underscore the importance of proactive identification and management of these factors to mitigate the risk of pneumonia in stroke patients.

Comparison of performances of SIREN or MFSRS in stroke risk prediction in an African environment

BACKGROUND

The Modified Framingham Stroke Risk Score (MFSRS) is a widely utilized stroke risk assessment algorithm usually applied in international comparison. The Stroke Investigative Research and Educational Network (SIREN) is the only known African-specific stroke risk assessment algorithm.

AIMS AND OBJECTIVES

To compare stroke risk estimates from the SIREN and the MFSRS in an African community.

METHODS

This was a population-based cross-sectional survey involving consecutively recruited 310 consenting adult residents (mean age = 37.21 ± 15.84 years) of a Nigerian community. Risk factors of stroke were assessed among the participants and were utilized in calculating stroke risk estimates on the MFSRS and the SIREN. The obtained data were analyzed using descriptive statistics and the Spearman-rank order correlation test at an alpha level of 0.05.

RESULTS

The percentage stroke risk scores estimated by the SIREN and the MFSRS were 34.5% and 6.79% respectively. The most prevalent risk factors among the participants were hypertriglyceridemia (100.0%), raised waist-hip ratio (50.6%), hypercholesterolemia (45.5), physical inactivity (43.2%), psychological stress (41.3%), and hypertension (37.7%). Only two (hypertriglyceridemia and high blood pressure) out of the six factors considered in the MFSRS were rated among the first 10 most impactful risks by the SIREN. There was a weak correlation between the total scores on the MFSRS and the SIREN (rho = 0.39; p < 0.01) suggesting that the two ratings were discordant.

CONCLUSION

There were disagreements between the risk estimates on the SIREN and MFSRS with SIREN having a higher estimate that corresponded with the literature; this may be suggesting a poorer estimation of stroke risks by the MFSRS in an African environment. There is a need for large African-based quality control studies to determine and address these lapses.

Development and usability evaluation of a culturally adapted stroke prevention educational programme on WeChat apps

Background

The persistently high incidence of stroke in many nations is suggestive of an area for further improvement on existing strategies of primary stroke prevention. Although the era of digitalisation has led to the increasing use of mobile applications (apps) in healthcare, more studies are needed to determine the efficacy of apps in producing the desired health outcomes across different nations and cultures.

Objective

To describe the development and evaluate the usability of a mobile app in delivering a culturally adapted stroke prevention educational programme for middle-aged adults in the Republic of China.

Methods

The educational programme was developed in three phases. In Phase 1, the process involved analysing requirements and designing structured modules. Phase 2 concentrated on expert consultation and technical development to deliver the educational programme. Phase 3 included a usability trial and refinement of the educational program based on trial results.

Results

Educational content was derived from the Chinese Guidelines for the Prevention and Treatment of Stroke and the Dietary Guidelines for Residents. The WeChat platform was used to deliver the educational programme. Participants expressed satisfaction with the content, interface, and functions of the apps, indicating that the apps have good usability.

Conclusions

The development process of the Educational Programme was designed to maximise the culturally appropriate, and impact of lifestyle changes and stroke prevention. An app-based educational programme that has demonstrated good usability is a vital factor prior to deploying it in an intervention to evaluate its effects on health outcomes.

Primordial and Primary Prevention of Ischemic Stroke in Saudi Arabia: A Combination Approach and Evolving Concepts

Ischemic stroke is a considerable public health hazard and a significant cause of disability and mortality in Saudi Arabia. Primary prevention strategies in the country are currently limited. With the health sector transformation program that depends on the principles of value-based care and applying the new model of care in disease prevention, aggressive and serious steps for primary stroke prevention are expected to be implemented. This article reviews primordial and primary prevention of ischemic stroke in Saudi Arabia and suggests a combination approach and framework for implementation. We provide a pragmatic solution to implement primordial and primary stroke prevention in Saudi Arabia and specify the roles of the government, health professionals, policymakers, and the entire population. Currently, there are several key priorities for primordial and primary stroke prevention in Saudi Arabia that should target people at different levels of risk. These include an emphasis on a comprehensive approach that includes both individual and population-based strategies and establishing partnerships across health-care providers to share responsibility for developing and implementing both strategies. This is an urgent call for action to initiate different strategies suggested by experts for primary stroke prevention in Saudi Arabia.

Nomogram model for predicting frailty of patients with hematologic malignancies - A cross-sectional survey

Objective

This study aimed to develop and validate an assessment tool for predicting and mitigating the risk of frailty in patients diagnosed with hematologic malignancies.

Methods

A total of 342 patients with hematologic malignancies participated in this study, providing data on various demographics, disease-related information, daily activities, nutritional status, psychological well-being, frailty assessments, and laboratory indicators. The participants were randomly divided into training and validation groups at a 7:3 ratio. We employed Lasso regression analysis and cross-validation techniques to identify predictive factors. Subsequently, a nomogram prediction model was developed using multivariable logistic regression analysis. Discrimination ability, accuracy, and clinical utility were assessed through receiver operating characteristic (ROC) curves, C-index, calibration curves, and decision curve analysis (DCA).

Results

Seven predictors, namely disease duration of 6-12 months, disease duration exceeding 12 months, Charlson Comorbidity Index (CCI), prealbumin levels, hemoglobin levels, Generalized Anxiety Disorder-7 (GAD-7) scores, and Patient Health Questionnaire-9 (PHQ-9) scores, were identified as influential factors for frailty through Lasso regression analysis. The area under the ROC curve was 0.893 for the training set and 0.891 for the validation set. The Hosmer-Lemeshow goodness-of-fit test confirmed a good model fit. The C-index values for the training and validation sets were 0.889 and 0.811, respectively. The DCA curve illustrated a higher net benefit when using the nomogram prediction model within patients threshold probabilities ranging from 10% to 98%.

Conclusions

This study has successfully developed and validated an effective nomogram model for predicting frailty in patients diagnosed with hematologic malignancies. The model incorporates disease duration (6-12 months and>12 months), CCI, prealbumin and hemoglobin levels, GAD-7, and PHQ-9 scores as predictive variables.

Quantitative Assessment of Retinal and Choroidal Microvasculature in Asymptomatic Patients with Carotid Artery Stenosis

SIGNIFICANCE

Carotid disease contributes to 15 to 20% of all ischemic strokes, one of the leading causes of permanent disabilities and mortality globally. With its growing prevalence and the inflicted disability rates, screening for anomalies that precede the onset of its serious complications is of crucial global significance.

PURPOSE

This study aimed to assess the relationship between retinal and choroidal perfusion changes with the degree of stenosis using quantitative swept-source optical coherence tomography angiography in patients with internal carotid artery stenosis.

METHODS

A retrospective cohort study was conducted in 72 eyes with carotid stenosis. According to the degree of stenosis, the participants were divided into a healthy group (group 1: 34 eyes), a mild-moderate stenosis group (group 2: 22 eyes), and a severe stenosis group (group 3: 16 eyes). Swept-source optical coherence tomography angiography was performed to scan macular fovea. Capillary density values in the different retinal and choroidal layers were the major measurements for our study.

RESULTS

Mean vessel density in the midchoroid layer was significantly higher in groups 2 and 3 compared with group 1. Deep choroid disclosed significantly superior vascular density values in group 3 compared with groups 2 and 1. Superficial and deep capillary plexus showed decreased vascular density values when comparing group 3 with groups 1 and 2, although they were not significant.

CONCLUSIONS

Our report provides the first evidence that choroidal microvascular changes were correlated with severity of carotid artery stenosis. Optical coherence tomography angiography can sensitively detect subtle, early changes in the ocular blood in carotid disease representing a useful, noninvasive, and objective approach to the retinal microvasculature.

Trends in all-cause mortality and leading causes of death from 2009 to 2019 among older adults in China

BACKGROUND

This study aimed to determine long-term variations in mortality trends and identify the leading causes of death among older adults in China from 2009 to 2019 so as to propose interventions to further stabilise the mortality rate among older adults and facilitate healthy ageing.

METHODS

We extracted data from the China Death Surveillance database from 2009 to 2019 for all-cause mortality and cause-specific death among individuals aged ≥ 65 years. A joinpoint regression model was used to estimate mortality trends by calculating the annual percentage change (APC). A trend chi-square test was used to estimate sex differences in mortality, and descriptive analysis was used to estimate the leading causes of death. Semi-structured expert interviews were conducted to examine health interventions for older adults.

RESULTS

We observed an overall declining trend in age-adjusted mortality rates among older adults aged ≥ 65 years in China from 2009 to 2019 (APC, -2.44; P < 0.05). In this population, the male mortality rate was higher than the female mortality rate during this period (P < 0.05). However, the mortality rate among older adults aged ≥ 85 years increased since 2014, particularly among females. Cardiovascular disease (CVD) was the leading cause of death among older adults aged 65-84 years, whereas ischaemic heart disease was the leading cause of death among individuals aged ≥ 85 years, especially among females. The majority of injuries resulting in death were caused by falls, showing an increasing trend.

CONCLUSIONS

CVD is a major cause of death among older adults aged ≥ 65 years in China, and relevant health intervention strategies should be implemented from the perspectives of physiology, psychology, and living environment. The change in the mortality trend and the distribution of cause of death among older adults aged ≥ 85 years is noteworthy; a diagnostic and management model centred around females aged ≥ 85 years should be implemented. Additionally, a multidimensional fall prevention strategy involving primary medical institutions and care services needs to be implemented to reduce the risk of falls among older adults.

Surveillance of stroke: a South-East Asia Region (SEAR) perspective

Surveillance of stroke is critical to track its burden and assess progress in prevention and treatment. We reviewed the literature to evaluate stroke surveillance efforts in the South-East Asia Region (SEAR) countries, identify progress and assess gaps. Epidemiological data on all the major parameters such as the incidence, prevalence and mortality of stroke were available for India and Thailand but for none of the other SEAR countries. Most of the epidemiological data came from investigator-initiated studies. National stroke surveillance was present only in India in the form of a National Stroke Registry Programme and Thailand has a national database that was used to obtain epidemiological data for stroke. Research on novel methods for stroke registration, such as using information technology, was absent. This review identified serious gaps in the monitoring and surveillance of stroke in SEAR countries. Systematic efforts are needed to fill those gaps.

The Feasibility of Make My Day-A Randomized Controlled Pilot Trial of a Stroke Prevention Program in Primary Healthcare

Incorporating and sustaining engaging everyday activities (EEAs) in everyday life holds potential for improving health and wellbeing; thus, there is reason to explore EEAs as a behavioral change technique in stroke prevention. The aim of this study was to evaluate the feasibility of the stroke prevention program Make My Day (MMD) for people with moderate-to-high risk for stroke in a primary healthcare setting, where EEAs are utilized to promote healthy activity patterns. A randomized controlled pilot trial was designed to evaluate the feasibility of MMD. Twenty-nine persons at risk for stroke were recruited and randomized into either an intervention group (n = 14) receiving MMD or a control group (n = 15) receiving brief health advice and support with goal setting. The results suggest that MMD is feasible, with timely recruitment, overall high response rates and study completion, and sensitivity to change in key outcome measures. Moreover, the results demonstrate that the application of EEAs can be useful for promoting behavioral change in stroke prevention. Recommendations for improvements for a full-scale trial include recruiting a relevant sample, using reliability- and validity-tested outcome measures, and implementing strategies to limit missing data.

Challenges of neural interfaces for stroke motor rehabilitation

More than 85% of stroke survivors suffer from different degrees of disability for the rest of their lives. They will require support that can vary from occasional to full time assistance. These conditions are also associated to an enormous economic impact for their families and health care systems. Current rehabilitation treatments have limited efficacy and their long-term effect is controversial. Here we review different challenges related to the design and development of neural interfaces for rehabilitative purposes. We analyze current bibliographic evidence of the effect of neuro-feedback in functional motor rehabilitation of stroke patients. We highlight the potential of these systems to reconnect brain and muscles. We also describe all aspects that should be taken into account to restore motor control. Our aim with this work is to help researchers designing interfaces that demonstrate and validate neuromodulation strategies to enforce a contingent and functional neural linkage between the central and the peripheral nervous system. We thus give clues to design systems that can improve or/and re-activate neuroplastic mechanisms and open a new recovery window for stroke patients.

Mediator complex in neurological disease

Neurological diseases, including traumatic brain injuries, stroke (haemorrhagic and ischemic), and inherent neurodegenerative diseases cause acquired disability in humans, representing a leading cause of death worldwide. The Mediator complex (MED) is a large, evolutionarily conserved multiprotein that facilities the interaction between transcription factors and RNA Polymerase II in eukaryotes. Some MED subunits have been found altered in the brain, although their specific functions in neurodegenerative diseases are not fully understood. Mutations in MED subunits were associated with a wide range of genetic diseases for MED12, MED13, MED13L, MED20, MED23, MED25, and CDK8 genes. In addition, MED12 and MED23 were deregulated in the Alzheimer's Disease. Interestingly, most of the genomic mutations have been found in the subunits of the kinase module. To date, there is only one evidence on MED1 involvement in post-stroke cognitive deficits. Although the underlying neurodegenerative disorders may be different, we are confident that the signal cascades of the biological-cognitive mechanisms of brain adaptation, which begin after brain deterioration, may also differ. Here, we analysed relevant studies in English published up to June 2023. They were identified through a search of electronic databases including PubMed, Medline, EMBASE and Scopus, including search terms such as "Mediator complex", "neurological disease", "brains". Thematic content analysis was conducted to collect and summarize all studies demonstrating MED alteration to understand the role of this central transcriptional regulatory complex in the brain. Improved and deeper knowledge of the regulatory mechanisms in neurological diseases can increase the ability of physicians to predict onset and progression, thereby improving diagnostic care and providing appropriate treatment decisions.

Frequency, Risk Factors, and Outcomes of Intracranial Atherosclerotic Stenosis in Stroke Patients From the Southern Region of Saudi Arabia

Background Intracranial Atherosclerotic Stenosis (ICAS) represents a noteworthy cerebrovascular pathology linked to ischemic stroke, contributing to a considerable burden of morbidity and mortality on a global scale. The present study was undertaken with the primary objective of investigating the frequency, risk factors, and outcomes of ICAS in stroke patients within the Southern Region of Saudi Arabia. Methods This was a descriptive cross-sectional study conducted at a tertiary care hospital located in the southern region of Saudi Arabia, from June 2022 to December 2022. The study population consisted of patients aged 18 years and above who were diagnosed with acute ischemic stroke during the designated research period. Patients with hemorrhagic stroke, transient ischemic attack (TIA), or incomplete medical records were excluded from the analysis. Data pertaining to the patients were retrieved from their respective medical records. Results Out of 201 patients admitted with stroke, 92 (45.77%) were found to have intracranial stenosis. The majority of patients were female (52.2%) and aged over 55 years (60.9%). The presence of hypertension exhibited a statistically significant correlation with varying degrees of stenosis (p=0.02), as did ischemic heart disease and obesity (p=0.04) and active smoking (p=0.01). Hypertension displayed a marginal association with intracranial stenosis, with an odds ratio of 1.01 (95% CI: 0.25, 4.11) and a p-value of 0.02. Similarly, dyslipidemia showed a potential correlation, with an odds ratio of 1.16 (95% CI: 0.44, 3.03) and a p-value of 0.014. On the other hand, obesity showed a stronger association, with an odds ratio of 4.53 (95% CI: 1.05, 19.51) and a p-value of 0.04. Among the patients, 25 (27.17%) underwent revascularization procedures, while 44 (47.83%) were not eligible for such intervention. During the three-month follow-up, 4 (16%) experienced an ipsilateral stroke, and 3 (12%) suffered from a contralateral transient ischemic attack (TIA). Encouragingly, 18 (72%) of the treated patients showed no recurrence during the follow-up period. Conclusion This study concludes that approximately half (45.77%) of stroke patients had intracranial stenosis, and significant associations were found between varying degrees of stenosis and hypertension, ischemic heart disease, obesity, and active smoking. Hypertension demonstrated a marginal correlation, while obesity exhibited a stronger association with intracranial stenosis.

Improving multidisciplinary hospital care for acute cerebral circulation disorders in Kazakhstan

Background

According to the World Stroke Organization, there was a significant increase in stroke cases, stroke deaths, and the DALY rate in low- and middle-income countries in 2022. The number of stroke cases rose by 70.0%, stroke deaths reached 86.0%, and the DALY rate reached 89.0%. Among cerebrovascular diseases, ischemic stroke accounts for 62.0% of all strokes, with more than 7.6 million cases reported annually.Kazakhstan, with a population of 19,832,737, is the largest country in Central Asia in terms of territory. In Kazakhstan, the incidence of cerebrovascular disease has risen from 258.4 cases per 100,000 population in 2015 to 433.7 cases per 100,000 population in 2020. Official statistics indicate that the average inpatient mortality rate from stroke in the country is 16.2%, and the average time for patients to be delivered to the hospital after an ambulance call is 40 min (83.2%).Our study findings reveal that in the regions of Kazakhstan, the main contributors to the high morbidity and mortality rates in stroke are a shortage of doctors, inadequate primary healthcare, insufficient follow-up and treatment, and delayed hospitalization. Consequently, this study has helped fill knowledge gaps regarding the epidemiological situation in these regions and underscores the need for training doctors in managing high-risk patients, establishing multidisciplinary home visit teams, and establishing "Stroke Schools" to enhance public awareness of early stroke signs and the fundamentals of a healthy lifestyle. Future research endeavors should consider these study results as valuable contributions towards addressing the existing problems.

Aim

To study the prevalence and mortality of acute cerebral circulation impairment in the population within multidisciplinary hospitals in the cities of Nur-Sultan and Almaty, Republic of Kazakhstan, for the period of 2018-2020.This retrospective study was conducted in two stages. In the first stage, an analysis of morbidity, prevalence, and mortality was conducted for the population of Nur-Sultan and Almaty cities, as well as for the overall population of Kazakhstan. This analysis was based on data from the "Electronic Register of Discharged Patients" (IS ERDB) and the annual collection "Health of the Population of the Republic of Kazakhstan and the Activities of Health Organizations in 2015-2020". In the second stage, we examined the care provided to patients with acute impaired cerebral circulation in a multidisciplinary hospital in these two cities. The analysis was based on data regarding the sex and age composition of treated patients in hospitals across the Republic of Kazakhstan, categorized according to the ICD-10 code "Acute Impaired Cerebral Circulation" (I60-I64). We investigated the methods of patients' delivery to medical organizations, types of hospitalization, and outcomes of treated patients. The sample of patients was selected using data from the "Electronic Register of Dispensary Patients" of the Ministry of Health of the Republic of Kazakhstan, along with the statistical collection "Health of the Population of the Republic of Kazakhstan and the Activities of Healthcare Organizations". Between January 1, 2018, and December 31, 2020, a total of 5965 patients were diagnosed with a cerebrovascular event and admitted to a general hospital in Nur-Sultan city, while 13,498 patients were diagnosed and admitted in Almaty city.

Histopathological lesions induced by stroke in the encephalon

Strokes are conditions with a high degree of morbidity and mortality worldwide. These conditions profoundly affect the quality of life of patients; in addition to physical disabilities, patients present various mental disorders, such as mood disorders, anxiety, depression, behavioral disorders, fatigue, etc. Microscopic lesions of the brain parenchyma explain the clinical symptoms and correlate with the severity of the stroke. Our study consisted of the histopathological (HP) and immunohistochemical analysis of brain fragments, collected from 23 patients, with a clinical and imagistic diagnosis of stroke, who died during hospital admission. The microscopic analysis showed that both neurons and glial cells are affected in the ischemic focus. Neuronal death in the ischemic focus was mostly caused by cell necrosis and only about 10% by apoptosis. Regarding vascular lesions, it was observed that the most frequent HP lesion of intracerebral arterioles was arteriosclerosis. The lumen of the arterioles was reduced, and the vascular endothelium had a discontinuous aspect, which indicates a change in the blood-brain barrier. Sometimes the arteriole lumen was completely obstructed, with fibrinoid necrosis in the internal and middle tunic, or with the proliferation of fibroblasts and the formation of young intraluminal connective tissue. Intraparenchymal blood capillaries in the ischemic area showed endothelium discontinuities, lumen collapse, and sometimes massive perivascular edema. As for neuroinflammation, the presence of numerous neutrophils, lymphocytes, plasma cells and macrophages was found in the ischemic focus, forming a complex and inhomogeneous cellular mixture. Of the inflammatory cells present in the ischemic focus and in the ischemic penumbra area, the most numerous were the macrophages. The HP analysis showed that neuroinflammation is very complex and different in intensity from one patient to another, most likely due to associated comorbidities, age, treatment administered until death, etc.

Assessment of Stroke Patients Admitted to a Tertiary Emergency County Hospital of Mehedinți - Romania

Cerebrovascular accidents (CVA)-strokes represent a major public health problem worldwide, due to the large number of people affected. Also, there is a large number of people who die from stroke, especially in developing countries. Our study included a group of 119 patients, diagnosed with stroke and admitted to the Emergency Hospital of Drobeta Turnul-Severin, Mehedinți county, between 2016-2020. The analysis of risk factors and associated comorbidities showed that stroke can affect both the elderly and young people, under 20 years old. However, approximately 4/5 of CVA patients (79.83%) were aged over 50 years old. If non-ischemic strokes predominated in patients under the age of 50, after this age there is a tendency to balance the incidence between the eight main forms of stroke. No significant differences were observed regarding the social environment of the patients, which shows that the risk factors are almost identical in both social environments. Among the modifiable risk factors, we highlighted: high blood pressure in 55.46% of cases, obesity in 19.33% of cases, atherosclerosis in 10.92% of cases, diabetes mellitus in 10.92%, kidney failure in 6.72% of cases. The data we obtained show that there are possibilities to reduce the incidence of stroke by controlling and reducing the modifiable risk factors.

Stroke Strikes in Bangladesh: Current Insights and Future Directions

Stroke is a neurological condition attributable to vascular injury (e.g., infarction, hemorrhage) of the central nervous system. Globally, it ranks high among the leading causes of death. The poor stroke management system in Bangladesh is contributing to the country's rapid rise in stroke incidence. Stroke-related mortality and disability can be decreased by being aware of and taking steps to address potential risk factors. The population in this area has a generally poor understanding of strokes. Important avenues for preventing stroke in this population may include an effective public awareness campaign which includes spreading knowledge regarding early signs of stroke (facial drooping, arm weakness, speech difficulties, and time), the golden hour of stroke, cardiopulmonary resuscitation, the development of structured emergency medical care, appropriate rehabilitation, control of blood pressure and blood glucose, and cessation of smoking.

Personalized knowledge to reduce the risk of stroke (PERKS-International): Protocol for a randomized controlled trial

RATIONALE

Theoretically, most strokes could be prevented through the management of modifiable risk factors. The Stroke Riskometer™ mobile phone application (hereon "The App") uses an individual's data to provide personalized information and advice to reduce their risk of stroke.

AIMS

To determine the effect of The App on a combined cardiovascular risk score (Life's Simple 7^®, LS7) of modifiable risk factors at 6 months post-randomization.

METHODS AND DESIGN

PERKS-International is a Phase III, multicentre, prospective, pragmatic, open-label, single-blinded endpoint, two-arm randomized controlled trial (RCT). Inclusion criteria are as follows: age ⩾ 35 and ⩽75 years; ⩾2 LS7 risk factors; smartphone ownership; no history of stroke/myocardial infarction/cognitive impairment/terminal illness. The intervention group (IG) will be provided with The App, and the usual care group (UCG) is provided with generic online information about risk factors, but not be informed about The App. Face-to-face assessments will be conducted at baseline and 6 months, and online at 3 and 12 months. The RCT includes a process and economic evaluation.

STUDY OUTCOMES AND SAMPLE SIZE

The primary outcome is a difference in the mean change in LS7 (seven individual items: blood pressure, cholesterol, glucose, body mass index (BMI), smoking, physical activity, and diet) from baseline to 6 months post-randomization with intention-to-treat analysis. Secondary outcomes include: change in individual LS7 items, quality of life; stroke awareness, adverse events; health service use; and costs. Based on pilot data, 790 participants (395 IG, 395 UCG) will be required to provide 80% power (two-sided α = 0.05) to detect a mean difference in the LS7 of ⩾0.40 (SD 1.61) in IG compared to 0.01 (SD 1.44) in the UCG at 6 months post-randomization.

DISCUSSION

Stroke is largely preventable. This study will provide evidence of the effectiveness of a mobile app to reduce stroke risk.

TRIAL REGISTRATION

ACTRN12621000211864.

Usage of RePlay as a Take-Home System to Support High-Repetition Motor Rehabilitation After Neurological Injury

Stroke is a leading cause of chronic motor disability. While physical rehabilitation can promote functional recovery, several barriers prevent patients from receiving optimal rehabilitative care. Easy access to at-home rehabilitative tools could increase patients' ability to participate in rehabilitative exercises, which may lead to improved outcomes. Toward achieving this goal, we developed RePlay: a novel system that facilitates unsupervised rehabilitative exercises at home. RePlay leverages available consumer technology to provide a simple tool that allows users to perform common rehabilitative exercises in a gameplay environment. RePlay collects quantitative time series force and movement data from handheld devices, which provide therapists the ability to quantify gains and individualize rehabilitative regimens. RePlay was developed in C# using Visual Studio. In this feasibility study, we assessed whether participants with neurological injury are capable of using the RePlay system in both a supervised in-office setting and an unsupervised at-home setting, and we assessed their adherence to the unsupervised at-home rehabilitation assignment. All participants were assigned a set of 18 games and exercises to play each day. Participants produced on average 698 ± 36 discrete movements during the initial 1 hour in-office visit. A subset of participants who used the system at home produced 1593 ± 197 discrete movements per day. Participants demonstrated a high degree of engagement while using the system at home, typically completing nearly double the number of assigned exercises per day. These findings indicate that the open-source RePlay system may be a feasible tool to facilitate access to rehabilitative exercises and potentially improve overall patient outcomes.

Dissecting the Spectrum of Stroke Risk Factors in an Apparently Healthy Population: Paving the Roadmap to Primary Stroke Prevention

We aimed to investigate, for the first time, the spectrum of stroke risk factors specific to the population of the Republic of Moldova. The subjects were examined according to a pre-established protocol of risk factor estimation. The study involved 300 subjects, including 60% women and 40% men, with a mean age of 49.9 ± 14.5 years. The most common risk factor was abdominal obesity, identified in 75% of subjects; general obesity was detected in 48%, while 32% of subjects were overweight and 20% were normally weighted. Hypertension was observed in 44%; 8% of those examined had atrial fibrillation, and 9% had diabetes mellitus. Left myocardial hypertrophy on ECG was present in 53% of subjects, and acute ischemic changes in 2%. Laboratory observations detected that glycosylated hemoglobin increased by 7%, and >50% had dyslipidemia. Total cholesterol was significantly elevated by 58%, LDL-cholesterol was increased by 32%, and HDL-cholesterol was decreased by 9%. Homocysteine was increased in 55% and high-sensitivity C-reactive protein in 28% of subjects. These results indicate the presence of modifiable risk factors and the necessity to elaborate on the primary prevention strategies aimed at minimizing the burden of stroke in the population of the Republic of Moldova.

Non-coding RNAs in stroke pathology, diagnostics, and therapeutics

Ischemic stroke is a leading cause of death and disability worldwide. Methods to alleviate functional deficits after ischemic stroke focus on restoration of cerebral blood flow to the affected area. However, pharmacological or surgical methods such as thrombolysis and thrombectomy have a narrow effective window. Harnessing and manipulating neurochemical processes of recovery may provide an alternative to these methods. Recently, non-coding RNA (ncRNA) have been increasingly investigated for their contributions to the pathology of diseases and potential for diagnostic and therapeutic applications. Here we will review several ncRNA - H19, MALAT1, ANRIL, NEAT1, pseudogenes, small nucleolar RNA, piwi-interacting RNA and circular RNA - and their involvement in stroke pathology. We also examine these ncRNA as potential diagnostic biomarkers, particularly in circulating blood, and as targets for therapeutic interventions. An important aspect of this is a discussion of potential methods of treatment delivery to allow for targeting of interventions past the blood-brain barrier, including lipid nanoparticles, polymer nanoparticles, and viral and non-viral vectors. Overall, several long non-coding RNA (lncRNA) discussed here have strong implications for the development of pathology and functional recovery after ischemic stroke. LncRNAs H19 and ANRIL show potential as diagnostic biomarkers, while H19 and MALAT1 may prove to be effective therapeutics for both minimising damage as well as promoting recovery. Other ncRNA have also been implicated in ischemic stroke but are currently too poorly understood to make inferences for diagnosis or treatment. Whilst the field of ncRNAs is relatively new, significant work has already highlighted that ncRNAs represent a promising novel investigative tool for understanding stroke pathology, could be used as diagnostic biomarkers, and as targets for therapeutic interventions.

Association between Use of Spironolactone and Risk of Stroke in Hypertensive Patients: A Cohort Study

Objective: to investigate the relationship between the use of spironolactone and the risk of stroke in hypertensive patients. Methods: a total of 2464 spironolactone users and 12,928 non-users were identified (unmatched original cohort), and 1:1 matched pairs of 2461 spironolactone users and 2461 non-users based on propensity scores were created (propensity-score-matched cohort). Results: In the unmatched original cohort, the unadjusted analysis showed that the use of spironolactone was associated with a lower risk of total stroke (HR, 0.71; 95% CI, 0.61−0.84; p < 0.001), which was sustained in the adjusted analysis. According to stroke type, the association was with ischemic strokes (propensity-score-adjusted HR, 0.71; 95% CI, 0.59−0.85; p < 0.001) and hemorrhagic ones (propensity-score-adjusted HR, 0.63; 95% CI, 0.45−0.88; p = 0.008). Similar results were shown in the propensity-score-matched cohort. The results of the subgroup and sensitivity analyses were consistent with those of the primary analysis. The dose−response analysis demonstrated a dose-dependent association of spironolactone with a lower risk of stroke in hypertensive patients. Conclusions: The use of spironolactone was associated with a significantly lower risk of stroke events in hypertensive patients. Further research, including prospective randomized clinical trials, is needed to validate our findings.

Educational level differences in the primary and secondary prevention of stroke

The aim of this study is to estimate the educational level differences in the primary and secondary prevention of stroke among the Chinese population. Data were obtained from the China Kadoorie Biobank (CKB) survey of 512,891 people aged 30-79 years in 10 geographic regions of China, which was conducted from 2002 to 2008. The Prediction for Atherosclerotic Cardiovascular Disease Risk in China model was used to identify individuals with a high estimated 10-year stroke risk. A total of 8884 participants (1.7%) had established stroke and 218,972 (42.7%) had a high stroke risk. In both primary and secondary prevention, the participants' educational level was positively associated with the control of smoking, blood pressure, consuming a healthy diet, and the use of antiplatelet, BP-lowering medications but negatively associated with higher physical activity levels (all P_trend < 0.001). In addition, the positive associations were observed with the control of drinking and use of anti-hyperglycaemia medication for primary prevention (all P_trend < 0.001) and with the use of lipid-lowering medication for secondary prevention (P_trend = 0.019). The results of the interaction between education level and prevention level showed that, compared with participants in primary prevention, educational level disparities in those with secondary prevention had significantly higher use of antiplatelets and lipid-lowering drugs, achieving the physical activity goal and non-current drinker (all P_{for interaction} < 0.05). A higher education level was associated with an increased acceptance of primary and secondary prevention strategies (not smoking or drinking, consuming a healthier diet) except for engaging in a suitable level of physical activity.

The dynamics of cardiovascular and respiratory deaths attributed to long-term PM2.5 exposures in global megacities

Exposure to ambient fine particulate matter (PM_2.5) air pollution is a significant driver of premature deaths. We estimate the number of cardiovascular and respiratory (CR) premature deaths attributed to long-term exposure to PM_2.5 in 33 global megacities based on long-term remotely sensed observations from 2000 to 2019. Our analysis uses high-resolution (0.01 degree) PM_2.5 concentration data and cause-specific integrated exposure-response (IER) functions developed for the Global Burden of Disease Project. From 2000 to 2019, PM_2.5-related CR death rates per 1000 people increased in 6 of 33 megacities, decreased in 9, and remained constant in 18 megacities. The increase in PM_2.5-related CR mortality in 11 megacities located in South and East Asia during the period 2000-2019 can be attributed to the increases in PM_2.5 concentrations. All 33 megacities could avoid 30,248 (9 %), 62,989 (20 %), 128,457 (40 %), 198,462 (62 %) and all of the estimated 322,515 CR deaths attributed to PM_2.5 pollution in 2019 if they were to attain the World Health Organization's four interim PM_2.5 targets (IT-1, IT-2, IT-3, and IT-4) and the new air quality guideline (AQG), respectively. Major improvements in air quality are needed to reduce the number of CR deaths attributed to PM_2.5 in South and East Asia, in addition to ny reductions that would likely follow shifts in the population structures of these megacities moving forward.

Primary Prevention of Ischemic Stroke

Ischemic stroke is by far the most common type of cerebrovascular event and remains a major cause of death and disability globally. Despite advancements in acute stroke care, primary prevention is still the most cost-effective approach in reducing the burden of ischemic stroke. The two main strategies for primary stroke prevention include population-wide versus high-risk group interventions. Interventions such as increasing access to primary care, regulation of salt and sugar contents in processed foods, public education, and campaigns to control cerebrovascular risk factors are examples of population-wide interventions. High-risk group interventions, on the other hand, focus on recognition of individuals at risk and aim to modify risk factors in a timely and multifaceted manner. This article provides an overview on conventional modifiable risk factors for ischemic stroke and highlights the emerging risk factors and approaches for high-risk group identification and treatment.

Personalized Spiking Neural Network Models of Clinical and Environmental Factors to Predict Stroke

The high incidence of stroke occurrence necessitates the understanding of its causes and possible ways for early prediction and prevention. In this respect, statistical methods offer the “big picture,” but they have a weak predictive ability at an individual level. This research proposes a new personalized modeling method based on computational spiking neural networks (SNN) for the identification of causal associations between clinical and environmental time series data that can be used to predict individual stroke events. The method is tested on 804 stroke patients. Given a clinical data set of patients who experienced a stroke in the past and the corresponding environmental time-series data for a selected time-window before the stroke event, the method identifies the clusters of individuals with a high risk for stroke under similar conditions. The methodology involves a pipeline of processes when creating a personalized model for an individual $$x$$ x : (1) selecting a group of individuals $$Gx$$ Gx with similar personal records to $$x$$ x ; (2) training a personalized SNN $$x$$ x model of several days of environmental data related to the $$Gx$$ Gx group to predict the risk of stroke for $$x$$ x at least one day earlier; (3) model interpretability through 3D visualization; (4) discovery of personalized predictive markers. The results are twofold, first proposing a new computational methodology and second presenting new findings. It is found that certain environmental factors, such as SO2, PM10, CO, and PM2.5, increase the risk of stroke if an individual $$x$$ x belongs to a certain cluster of people, characterized by a combination of family history of stroke and diabetes, overweight, vascular/heart disease, age, and other. For the used population data, the proposed method can predict accurately individual risk of stroke before the day of the stroke. The paper presents a new methodology for personalized machine learning methods to define subgroups of the population with a high risk of stroke and to predict early individual risk of the stroke event. This makes the proposed cognitive computation method useful to reduce morbidity and mortality in society. The method is broadly applicable for predicting individual risk of other diseases and mental health conditions.

LncRNA PEG11as silencing sponges miR-874-3p to alleviate cerebral ischemia stroke via regulating autophagy in vivo and in vitro

Long non-coding RNAs (lncRNAs) are reportedly involved in the regulation of physiological and pathophysiological processes. However, the potential role of lncRNAs in stroke remains largely undefined. Here, RNA-Seq analysis of lncRNAs found that the lncRNA PEG11as (PEG11as) levels were significantly increased in ischemic brain tissue in a transient middle cerebral artery occlusion/reperfusion (tMCAO/R) mouse model of stroke. To explore the role of PEG11as in stroke, the lentivirus containing PEG11as silencing construct(siRNA-PEG11as) was microinjected intracerebroventricularly into male or transfected to N2a cells and then exposed to tMCAO/R or oxygen-glucose deprivation/reoxygenation (OGD/R). Knockdown of PEG11as expression significantly reduced infarct volume, alleviated neuronal deficits and inhibited neuronal apoptosis in tMCAO/R mice. Mechanistically, as an endogenous microRNA-874-3p (miR-874-3p) sponge, PEG11as silencing inhibited miR-874-3p activity, resulting in downregulation of ATG16L1 expression and subsequent inhibition of neuronal apoptosis by regulating autophagy. Overall, the results of this current study indicate that PEG11as is involved in the pathophysiology of cerebral ischemia, thus providing translational evidence that PEG11as can be envisioned as a novel biomarker or/and therapeutic target for stroke.

Stroke Risk Prediction with Machine Learning Techniques

A stroke is caused when blood flow to a part of the brain is stopped abruptly. Without the blood supply, the brain cells gradually die, and disability occurs depending on the area of the brain affected. Early recognition of symptoms can significantly carry valuable information for the prediction of stroke and promoting a healthy life. In this research work, with the aid of machine learning (ML), several models are developed and evaluated to design a robust framework for the long-term risk prediction of stroke occurrence. The main contribution of this study is a stacking method that achieves a high performance that is validated by various metrics, such as AUC, precision, recall, F-measure and accuracy. The experiment results showed that the stacking classification outperforms the other methods, with an AUC of 98.9%, F-measure, precision and recall of 97.4% and an accuracy of 98%.

Association Between Retinal Microvascular Metrics Using Optical Coherence Tomography Angiography and Carotid Artery Stenosis in a Chinese Cohort

Objectives: The main aim was to investigate the association between retinal microvascular metrics using optical coherence tomography angiography (OCTA) and carotid artery stenosis (CAS) in an aging Chinese cohort.

Methods: In this cross-sectional and observational study, 138 eyes of 138 participants were examined. Indices of the microcirculation measured by OCTA included mean vessel density (VD), skeleton density (SD), vessel diameter index (VDI), fractal dimension (FD) and foveal avascular zone (FAZ) of the superficial retinal layer (SRL) and deep retinal layer (DRL), and peripapillary vessel caliber. The correlation of these indices with the carotid atherosclerotic lesions including carotid intima media thickness (CIMT) and common carotid artery (CCA) plaque was assessed.

Results: A total of 72 of 138 eyes demonstrated an increased (≥1 mm) CIMT, and 32 of the eyes presented common carotid plaques. Macular VD, SD, and FD were decreased with the increasing CCA caliber diameter (p &lt; 0.05, respectively). Superficial and deep macular FDs were negatively associated with CIMT as well as the existence of CCA plaques (p &lt; 0.05, respectively).

Conclusion: Changes in retinal microvasculature accessed by OCTA may be used as one of the non-invasive early indicators to monitor asymptomatic CAS.

Digital Health in Primordial and Primary Stroke Prevention: A Systematic Review

The stroke burden continues to grow across the globe, disproportionally affecting developing countries. This burden cannot be effectively halted and reversed without effective and widely implemented primordial and primary stroke prevention measures, including those on the individual level. The unprecedented growth of smartphone and other digital technologies with digital solutions are now being used in almost every area of health, offering a unique opportunity to improve primordial and primary stroke prevention on the individual level. However, there are several issues that need to be considered to advance development and use this important digital strategy for primordial and primary stroke prevention. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines we provide a systematic review of the current knowledge, challenges, and opportunities of digital health in primordial and primary stroke prevention.

Identification of Hub Genes Associated with Immune Infiltration in Cardioembolic Stroke by Whole Blood Transcriptome Analysis

Cardioembolic stroke (CS) is the most common type of ischemic stroke in the clinic, leading to high morbidity and mortality worldwide. Although many studies have been conducted, the molecular mechanism underlying CS has not been fully grasped. This study was aimed at exploring the molecular mechanism of CS using comprehensive bioinformatics analysis and providing new insights into the pathophysiology of CS. We downloaded the public datasets GSE58294 and GSE16561. Differentially expressed genes (DEGs) were screened via the limma package using R software. CIBERSORT was used to estimate the proportions of 22 immune cells based on the gene expression profiling of CS patients. Using weighted gene correlation network analysis (WGCNA) to cluster the genes into different modules and detect relationships between modules and immune cell types, hub genes were identified based on the intersection of the protein-protein interaction (PPI) network analysis and WGCNA, and their clinical significance was then verified using another independent dataset GSE16561. Totally, 319 genes were identified as DEGs and 5413 genes were clustered into nine modules using WGCNA. The blue module, with the highest correlation coefficient, was identified as the key module associated with stroke, neutrophils, and B cells naïve. Based on the PPI analysis and WGCNA, five genes (MCEMP1, CLEC4D, GPR97, TSPAN14, and FPR2) were identified as hub genes. Correlation analysis indicated that hub genes had general association with infiltration-related immune cells. ROC analysis also showed they had potential clinical significance. The results were verified using another dataset, which were consistent with our analysis. Five crucial genes determined using integrative bioinformatics analysis might play significant roles in the pathophysiological mechanism in CS and be potential targets for pharmaceutic therapies.

Do baseline characteristics and treatments account for geographical disparities in the outcomes of patients with newly diagnosed atrial fibrillation? The prospective GARFIELD-AF registry

OBJECTIVE

In patients with newly diagnosed atrial fibrillation (AF), do baseline risk factors and stroke prevention strategies account for the geographically diverse outcomes.

DESIGN

Global Anticoagulant Registry in the FIELD-Atrial Fibrillation is a prospective multinational non-interventional registry of patients with newly diagnosed AF (n=52 018 patients).

SETTING

Investigator sites (n=1317) were representative of the care settings/locations in each of the 35 participating countries. Treatment decisions were all determined by the local responsible clinicians.

PARTICIPANTS

The patients (18 years and over) with newly diagnosed AF had at least 1 investigator-determined stroke risk factor and patients were not required to meet specific thresholds of risk score for anticoagulant treatment.

MAIN OUTCOMES AND MEASURES

Observed 1-year event rates and risk-standardised rates were derived.

RESULTS

Rates of death, non-haemorrhagic stroke/systemic embolism and major bleeding varied more than three-to-four fold across countries even after adjustment for baseline factors and antithrombotic treatments. Rates of anticoagulation and antithrombotic treatment varied widely. Patients from countries with the highest rates of cardiovascular mortality and stroke were among the least likely to receive oral anticoagulants. Beyond anticoagulant treatment, variations in the treatment of comorbidities and lifestyle factors may have contributed to the variations in outcomes. Countries with the lowest healthcare Access and Quality indices (India, Ukraine, Argentina, Brazil) had the highest risk-standardised mortality.

CONCLUSION

The variability in outcomes across countries for patients with newly diagnosed AF is not accounted for by baseline characteristics and antithrombotic treatments. Residual mortality rates were correlated with Healthcare Access and Quality indices. The findings suggest the management of patients with AF needs to not only address guideline indicated and sustained anticoagulation, but also the treatment of comorbidities and lifestyle factors.

TRIAL REGISTRATION NUMBER

NCT01090362.

Primary stroke prevention worldwide: translating evidence into action

Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.

Temporal trend and attributable risk factors of stroke burden in China, 1990–2019: an analysis for the Global Burden of Disease Study 2019

Background

Understanding the temporal trend of the disease burden of stroke and its attributable risk factors in China, especially at provincial levels, is important for effective prevention strategies and improvement. The aim of this analysis from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is to investigate the disease burden of stroke and its risk factors at national and provincial levels in China from 1990 to 2019.

Methods

Following the methodology in the GBD 2019, the incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) of stroke cases in the Chinese population were estimated by sex, age, year, stroke subtypes (ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage), and across 33 provincial administrative units in China from 1990 to 2019. Attributable mortality and DALYs of underlying risk factors were calculated by a comparative risk assessment.

Findings

In 2019, there were 3·94 million (95% uncertainty interval 3·43–4·58) new stroke cases in China. The incidence rate of stroke increased by 86·0% (73·2–99·0) from 1990, reaching 276·7 (241·3–322·0) per 100 000 population in 2019. The age-standardised incidence rate declined by 9·3% (3·3–15·5) from 1990 to 2019. Among 28·76 million (25·60–32·21) prevalent cases of stroke in 2019, 24·18 million (20·80–27·87) were ischaemic stroke, 4·36 million (3·69–5·05) were intracerebral haemorrhage, and 1·58 million (1·32–1·91) were subarachnoid haemorrhage. The prevalence rate increased by 106·0% (93·7–118·8) and age-standardised prevalence rate increased by 13·2% (7·7–19·1) from 1990 to 2019. In 2019, there were 2·19 million (1·89–2·51) deaths and 45·9 million (39·8–52·3) DALYs due to stroke. The mortality rate increased by 32·3% (8·6–59·0) from 1990 to 2019. Over the same period, the age-standardised mortality rate decreased by 39·8% (28·6–50·7) and the DALY rate decreased by 41·6% (30·7–50·9). High systolic blood pressure, ambient particulate matter pollution exposure, smoking, and diet high in sodium were four major risk factors for stroke burden in 2019. Moreover, we found marked differences of stroke burden and attributable risk factors across provinces in China from 1990 to 2019.

Interpretation

The disease burden of stroke is still severe in China, although the age-standardised incidence and mortality rates have decreased since 1990. The stroke burden in China might be reduced through blood pressure management, lifestyle interventions, and air pollution control. Moreover, because substantial heterogeneity of stroke burden existed in different provinces, improved health care is needed in provinces with heavy stroke burden.

Funding

National Key Research and Development Program of China and Taikang Yicai Public Health and Epidemic Control Fund.

Caregiver Engagement in Stroke Care: Opportunities and Challenges in Australia and Denmark

Globally, there is a rise in incident cases of stroke, particularly in low- and middle-income countries, due to obesity-related and lifestyle risk factors, including health issues such as high cholesterol, diabetes and hypertension. Since the early 20th century, stroke mortality has declined due to proper management of the risk factors and improved treatment practices. However, despite the decline in mortality, there is an increase in the levels of disability that requires long-term support. In countries such as Australia and Denmark, where most care is provided within the community; family members, generally spouses, assume the role of caregiver, with little to no preparation that affects the quality of care provided to the person living with stroke. While past research has highlighted aspects to improve caregiver preparedness of stroke and its impact on care; health planning, recovery, and public health policies rarely consider these factors, reducing engagement and increasing uncertainty. Hence, there is a need to focus on improving strategies during recovery to promote caregiver engagement. In this study, we, therefore, try to understand the needs of the caregiver in stroke that limit engagement, and processes employed in countries such as Australia and Denmark to provide care for the person with stroke. Based on our understanding of these factors, we highlight the potential opportunities and challenges to promote caregiving engagement in these countries.