Blood pressure management for secondary stroke prevention

Association Between Monounsaturated Fatty Acid Intake and Risk of Total Stroke and Its Subtypes: A Systematic Review and Dose-Response Meta-analysis of Prospective Cohort Studies

CONTEXT

There are contradictory results regarding the relationship between dietary intakes of monounsaturated fatty acids (MUFAs) and risk of stroke.

OBJECTIVE

The purpose of this study was to review the existing body of research on the relationship between MUFA consumption and stroke risk through a systematic review and meta-analysis.

DATA SOURCE

PubMed, Scopus, and ISI Web of Science were all systematically searched up to January 2023.

DATA EXTRACTION

A total of 11 prospective cohort studies that investigated MUFA consumption in relation to stroke risk were included.

DATA ANALYSIS

Relative risk (RR) and 95% CIs for the highest vs lowest category of dietary MUFA intake were combined using a random-effects model. Linear and nonlinear dose-response relations were assessed through 1-stage weighted mixed-effects meta-analysis. These studies included 475 207 participants and 8438 cases. In highest vs lowest consumption analysis, MUFA intake was inversely associated with total stroke (RR: 0.80; 95% CI: 0.67, 0.96; I2 =65.2%, Q-test P = .001; n = 11) and hemorrhagic stroke (RR: 0.80; 95% CI: 0.68, 0.95; I2 = 0.0%, Q-test P = .77; n = 5) risk. Conversely, this association was not significant for ischemic stroke (RR: 0.86; 95% CI: 0.69, 1.07; I2 =62.3%, Q-test P = .01; n = 8). An inverse association was observed between each 10-g/d MUFA intake and hemorrhagic stroke (RR: 0.79; 95% CI: 0.65, 0.96) but not total and ischemic stroke. We did not find any evidence for a nonlinear association between MUFA intake and total stroke and its subtypes.

CONCLUSION

This meta-analysis shows that higher MUFA intake could lower the risk of total and hemorrhagic, but not ischemic, stroke. This could be important for public health.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42023458555.

A randomized controlled pilot study investigating adherence to blood pressure diaries with personal pictures in stroke follow-up care

INTRODUCTION

Blood pressure (BP) management is essential in secondary stroke prevention. Strategies to ensure continuous home BP monitoring are needed. Few studies investigated factors influencing adherence to home BP management. Therefore, we designed a pilot study to investigate the feasibility of keeping BP diaries (BPDs) with personal images.

METHODS

In this prospective trial, we randomized persons with a diagnosis of stroke or transient ischemic attack into two groups: (i) 10 patients received a personalized BPD with pictures of their choosing and (ii) 10 patients received a BPD without photographs. We instructed participants in both groups to document their BP at home twice daily over 28 days. Adherence was defined as the number of BP measurements performed relative to the maximum number of recommended measurements. We assessed patient reported outcomes as exploratory endpoints.

RESULTS

We found no statistically significant difference in mean adherence between the control group (64%) and the intervention group (69%). The BP was within the recommended range and precision of documentation was high in both groups, without statistically significant differences. Patient reported outcomes such as depression scores did not differ significantly between study groups.

CONCLUSION

Our findings underline the relevance to investigate aspects of adherence to home BP management suggesting the inclusion of patient-provided pictures to be feasible.

From apoplexy in antiquities to cerebrovascular stroke in modernity: a narrative timeline and tale

Background

Stroke is one of the commonest encountered brain and neurological disorders worldwide. Stroke management has had a major shift in the last 50 years and precisely since the discovery and approval of thrombolysis as an acute management followed by multiple trials on mechanical thrombectomy and its approval. Yet, Stroke is as old as the history of mankind. Historically stroke symptoms’ description is older than the descriptions of the Greco-Roman civilization (500 BC – 800 AD). Before Stroke, the term apoplexy was described in ancient civilizations and evidence of suffering and managing it is preserved within the mummies, inscriptions, and papyri of the Egyptian civilization, clay tablets of the Mesopotamian civilization, medical books of the Chinese civilization, and although physicians and scientists consider the Greco-Roman civilization the base for modern medicine, yet the golden age of Islam (800 – 1200 AD) might have shared more in identifying bases of stroke. The European Renaissance beginning from 1400 AD with its famous anatomists and physicians greatly contributed too to stroke localization and vascular supply.

Conclusions

As medicine and science are in a continuous chain from the past to the future through the present, the current comprehensive review highlights the major important and documented shifts in the history of stroke over more than 4500 years starting from ancient civilizations BC up to 2024 AD.

Text mining of hypertension researches in the west Asia region: a 12-year trend analysis

More than half of the world population lives in Asia and hypertension (HTN) is the most prevalent risk factor found in Asia. There are numerous articles published about HTN in Eastern Mediterranean Region (EMRO) and artificial intelligence (AI) methods can analyze articles and extract top trends in each country. Present analysis uses Latent Dirichlet allocation (LDA) as an algorithm of topic modeling (TM) in text mining, to obtain subjective topic-word distribution from the 2790 studies over the EMRO. The period of checked studied is last 12 years and results of LDA analyses show that HTN researches published in EMRO discuss on changes in BP and the factors affecting it. Among the countries in the region, most of these articles are related to I.R Iran and Egypt, which have an increasing trend from 2017 to 2018 and reached the highest level in 2021. Meanwhile, Iraq and Lebanon have been conducting research since 2010. The EMRO word cloud illustrates 'BMI', 'mortality', 'age', and 'meal', which represent important indicators, dangerous outcomes of high BP, and gender of HTN patients in EMRO, respectively.

Small vessel disease burden predicts incident stroke and all-cause death, but not acute coronary event

Total small vessel disease (SVD) score is used to measure the burden of SVD by incorporating four established neuroimaging markers; white matter hyperintensity, lacune, cerebral microbleed, and enlarged perivascular space, ranging from 0 to 4. Whether total SVD scores predict all vascular outcomes remains unclear. This study aimed to clarify the predictive value of the total SVD score for incident stroke, mortality, and acute coronary syndrome in independent outpatients with vascular risk factors. We derived data from The Tokyo Women's Medical University Cerebrovascular Disease registry, a prospective observational registry in which 1011 patients with evidence of cerebral vessel disease on magnetic resonance imaging were enrolled. They were followed up until March 2023. The primary outcomes were stroke, all-cause death, and acute coronary syndrome (ACS). After excluding those with a modified Rankin scale score >1, Mini-mental State Examination score <24, and missing T2* images, 692 patients were included. During a median follow-up period of 4.6 years, stroke, ACS, and all-cause death occurred in 52, 24, and 45 patients, respectively. In multivariate analysis, the total SVD score was independently associated with stroke, and all-cause death but not with acute coronary syndrome. Both cutoff values of the total SVD score for stroke, and all-cause death were 1. In conclusion, the total SVD score could predict stroke and mortality but not acute coronary syndrome. Our results suggest intensive management of patients with a total SVD score ≥1 to prevent stroke and all-cause death. Patients with higher total SVD scores were significantly more likely to have a stroke (A; P = 0.012) than those with lower total SVD scores. However, no association was observed between total SVD scores and acute coronary syndrome (B, P = 0.604). For incident stroke, total SVD scores of 1 and 2 were the cutoff levels.

miR-193b-3p and miR-346 Exert Antihypertensive Effects in the Rostral Ventrolateral Medulla

BACKGROUND

Rostral ventrolateral medulla (RVLM) neuron hyperactivity raises sympathetic outflow, causing hypertension. MicroRNAs (miRNAs) contribute to diverse biological processes, but their influence on RVLM neuronal excitability and blood pressure (BP) remains widely unexplored.

METHODS AND RESULTS

The RVLM miRNA profiles in spontaneously hypertensive rats were unveiled using RNA sequencing. Potential effects of these miRNAs in reducing neuronal excitability and BP and underlying mechanisms were investigated through various experiments. Six hundred thirty-seven miRNAs were identified, and reduced levels of miR-193b-3p and miR-346 were observed in the RVLM of spontaneously hypertensive rats. Increased miR-193b-3p and miR-346 expression in RVLM lowered neuronal excitability, sympathetic outflow, and BP in spontaneously hypertensive rats. In contrast, suppressing miR-193b-3p and miR-346 expression in RVLM increased neuronal excitability, sympathetic outflow, and BP in Wistar Kyoto and Sprague-Dawley rats. Cdc42 guanine nucleotide exchange factor (Arhgef9) was recognized as a target of miR-193b-3p. Overexpressing miR-193b-3p caused an evident decrease in Arhgef9 expression, resulting in the inhibition of neuronal apoptosis. By contrast, its downregulation produced the opposite effects. Importantly, the decrease in neuronal excitability, sympathetic outflow, and BP observed in spontaneously hypertensive rats due to miR-193b-3p overexpression was greatly counteracted by Arhgef9 upregulation.

CONCLUSIONS

miR-193b-3p and miR-346 are newly identified factors in RVLM that hinder hypertension progression, and the miR-193b-3p/Arhgef9/apoptosis pathway presents a potential mechanism, highlighting the potential of targeting miRNAs for hypertension prevention.

Extreme Temperatures and Stroke Mortality: Evidence From a Multi-Country Analysis

BACKGROUND

Extreme temperatures contribute significantly to global mortality. While previous studies on temperature and stroke-specific outcomes presented conflicting results, these studies were predominantly limited to single-city or single-country analyses. Their findings are difficult to synthesize due to variations in methodologies and exposure definitions.

METHODS

Within the Multi-Country Multi-City Network, we built a new mortality database for ischemic and hemorrhagic stroke. Applying a unified analysis protocol, we conducted a multinational case-crossover study on the relationship between extreme temperatures and stroke. In the first stage, we fitted a conditional quasi-Poisson regression for daily mortality counts with distributed lag nonlinear models for temperature exposure separately for each city. In the second stage, the cumulative risk from each city was pooled using mixed-effect meta-analyses, accounting for clustering of cities with similar features. We compared temperature-stroke associations across country-level gross domestic product per capita. We computed excess deaths in each city that are attributable to the 2.5% hottest and coldest of days based on each city's temperature distribution.

RESULTS

We collected data for a total of 3 443 969 ischemic strokes and 2 454 267 hemorrhagic stroke deaths from 522 cities in 25 countries. For every 1000 ischemic stroke deaths, we found that extreme cold and hot days contributed 9.1 (95% empirical CI, 8.6-9.4) and 2.2 (95% empirical CI, 1.9-2.4) excess deaths, respectively. For every 1000 hemorrhagic stroke deaths, extreme cold and hot days contributed 11.2 (95% empirical CI, 10.9-11.4) and 0.7 (95% empirical CI, 0.5-0.8) excess deaths, respectively. We found that countries with low gross domestic product per capita were at higher risk of heat-related hemorrhagic stroke mortality than countries with high gross domestic product per capita (P=0.02).

CONCLUSIONS

Both extreme cold and hot temperatures are associated with an increased risk of dying from ischemic and hemorrhagic strokes. As climate change continues to exacerbate these extreme temperatures, interventional strategies are needed to mitigate impacts on stroke mortality, particularly in low-income countries.

Causal associations of COVID-19 on neurosurgical diseases risk: a Mendelian randomization study

Many researchers have explored the potential association between one neurosurgical disease and coronavirus disease 2019 (COVID-19), but few systematically analyzed the association and causality between COVID-19 and various neurosurgical diseases. A Mendelian randomization analysis was conducted to evaluate the causal association between COVID-19 (including critically ill COVID-19, hospitalized COVID-19, and respiratory syndrome coronavirus 2 (SARS-CoV-2) infection) and 30 neurosurgical diseases within European populations. The consequences of inverse variance weighted models suggest that genetic susceptibility of critically ill COVID-19 may increase the risk of cerebral infarction (odds ratio [OR] = 1.02; p-value = 0.006), genetic susceptibility of SARS-CoV-2 infection may increase the risk of stroke (OR = 1.02; p-value = 0.047), and conversely, genetic susceptibility of hospitalized COVID-19 may reduce the risk of pituitary adenoma and craniopharyngioma (OR = 0.90; p-value = 0.032). In addition, evidences revealed potential associations between genetic susceptibility of COVID-19 and spinal stenosis (OR = 1.03; p-value = 0.028), diffuse brain injury (OR = 1.21; p-value = 0.040) and focal brain injury (OR = 1.12; p-value = 0.040). By testing for heterogeneity and pleiotropy, the above causal conclusions are robust. In summary, our analysis shows that COVID-19 has an independent and powerful causal influence on multiple neurosurgical disorders.

Nocturnal Intermittent Hypoxia and the Risk of Cardiovascular Disease among Japanese Populations: The Circulatory Risk in Communities Study (CIRCS)

AIMS

Information is limited about the influence of obstructive sleep apnea (OSA) on developing cardiovascular disease (CVD) among Asian community-dwelling populations. We examined the association between nocturnal intermittent hypoxia as a surrogate marker of OSA and the risk of CVD in a Japanese community-based cohort study.

METHODS

We used baseline surveys from 2000 to 2008 to study the cohort data of 5,313 residents from three Japanese communities who were between the ages of 40 and 74 years and initially free from ischemic heart disease and stroke. We assessed the number of 3% oxygen desaturation index (ODI) as the indicator of nocturnal intermittent hypoxia. We divided individuals into two groups depending on 3% ODI (3% ODI ≥ 5 or 3% ODI ＜5). Cox proportional hazards regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD according to 3% ODI. Age, sex, body mass index, alcohol, and smoking were adjusted in the multivariable models.

RESULTS

During 12.8 years of the median follow-up with 66,796 person-years, 185 cases with CVD (115 stroke and 70 coronary heart disease [CHD]) were recorded. The multivariable HRs (95% CIs) were 1.49 (1.09-2.03), 2.13 (1.08-4.22), and 1.93 (1.16-3.19) for the 3% ODI ≥ 5 group versus the 3% ODI ＜5 group of developing CVD, lacunar infarction, and CHD, respectively.

CONCLUSIONS

Nocturnal intermittent hypoxia may increase the risk of developing lacunar infarction and CHD among community-dwelling Japanese populations. However, we could not find a significant risk of developing total stroke or stroke subtypes such as intraparenchymal hemorrhage, subarachnoid hemorrhage, and total ischemic stroke.

Leukoaraiosis as a Promising Biomarker of Stroke Recurrence among Stroke Survivors: A Systematic Review

Stroke is the leading cause of functional disability worldwide, with increasing prevalence in adults. Given the considerable negative impact on patients' quality of life and the financial burden on their families and society, it is essential to provide stroke survivors with a timely and reliable prognosis of stroke recurrence. Leukoaraiosis (LA) is a common neuroimaging feature of cerebral small-vessel disease. By researching the literature of two different databases (MEDLINE and Scopus), the present study aims to review all relevant studies from the last decade, dealing with the clinical utility of pre-existing LA as a prognostic factor for stroke recurrence in stroke survivors. Nineteen full-text articles published in English were identified and included in the present review, with data collected from a total of 34,546 stroke patients. A higher rate of extended LA was strongly associated with stroke recurrence in all stroke subtypes, even after adjustment for clinical risk factors. In particular, patients with ischemic stroke or transient ischemic attack with advanced LA had a significantly higher risk of future ischemic stroke, whereas patients with previous intracerebral hemorrhage and severe LA had a more than 2.5-fold increased risk of recurrent ischemic stroke and a more than 30-fold increased risk of hemorrhagic stroke. Finally, in patients receiving anticoagulant treatment for AF, the presence of LA was associated with an increased risk of recurrent ischemic stroke and intracranial hemorrhage. Because of this valuable predictive information, evaluating LA could significantly expand our knowledge of stroke patients and thereby improve overall stroke care.

Survivability of patients admitted for stroke in a primary stroke center, Penang, Malaysia: a retrospective 5-year study

BACKGROUND

Stroke is one of the most common noncommunicable diseases, with significant public health implications both globally and in Malaysia. The aim of this study was to evaluate post-stroke survivability as well as the major drug classes prescribed for hospitalized stroke patients.

METHODS

A 5-year retrospective study was carried out on the survival of stroke patients admitted to Hospital Seberang Jaya, a main stroke center in the state of Penang, Malaysia. Patients admitted for stroke were first identified using the local stroke registry database, and their medical records were then accessed for data collection, which included demographic information, comorbid conditions, and medications prescribed during admission.

RESULTS

The Kaplan-Meier overall survivability analysis performed indicated 50.5% survival for the duration of 10 days (p < 0.001) post-stroke. Ten-day survivability differences (p < 0.05) were observed for the categories of type of stroke (ischemic stroke (60.9%) and hemorrhagic stroke (14.1%)); stroke episodes (first (61.1%) and recurrent (39.6%)); anti-platelets (prescribed (46.2%) and not prescribed (41.5%)); statins (prescribed (68.7%) and not prescribed (28.1%)); anti-hypertensive (prescribed (65.4%) and not prescribed (45.9%)); and anti-infectives (prescribed (42.5%) and not prescribed (59.6%)) respectively. Higher risks of mortality were observed among patients with hemorrhagic stroke (HR: 10.61, p = 0.004); with 3 or more comorbidities (HR:6.60, p = 0.020); and not prescribed with statins and anti-diabetic. Patients prescribed anti-infectives, on the other hand, had a higher risk of mortality when compared to patients who did not receive anti-infectives (HR: 13.10, p = 0.019). The major drug classes prescribed for stroke patients were antiplatelet drugs (86.7%), statins (84.4%), and protein pump inhibitors (75.6%).

CONCLUSION

The findings of the study are intended to encourage more non-stroke hospitals in Malaysia to increase their efforts in treating stroke patients, as early treatment can help reduce the severity of the stroke. With the incorporation of evidence-based data, this study also contributes to local data for comparison and improves the implementation of regularly prescribed stroke medication.

Association between total cerebral small vessel disease score and cognitive function in patients with vascular risk factors

Hypertension is the most important risk factor for cerebral small vessel disease (SVD). In this cross-sectional study, we tested the independent association of cerebral SVD burden with global cognitive function and each cognitive domain in patients with vascular risk factors. The Tokyo Women's Medical University Cerebral Vessel Disease (TWMU CVD) registry is an ongoing prospective, observational registry in which patients with any evidence of CVD in magnetic resonance imaging (MRI) and at least one vascular risk factor were consecutively enrolled. For SVD-related findings, we evaluated white matter hyperintensity, lacunar infarction, cerebral microbleeds, enlarged perivascular space, and medial temporal atrophy. We used the total SVD score as the SVD burden. They underwent the Mini-mental State Examination (MMSE) and Japanese version of the Montreal Cognitive Assessment (MoCA-J) global cognitive tests, and each cognitive domain was evaluated. After excluding patients without MRI T2* images and those with MMSE score <24, we analyzed 648 patients. The total SVD score was significantly associated with MMSE and MoCA-J scores. After adjustment for age, sex, education, risk factors, and medial temporal atrophy, the association between the total SVD score and MoCA-J score remained significant. The total SVD score was independently associated with attention. In conclusion, the total SVD score, cerebral SVD burden, was independently association with global cognitive function and attention. A strategy to reduce SVD burden will have the potential to prevent cognitive decline. A total of 648 patients with any evidence of cerebral small vessel disease (SVD) in MRI and at least one vascular risk factor underwent Mini-mental State Examination (MMSE) and Japanese version of the Montreal Cognitive Assessment (MoCA-J) global cognitive tests. The total SVD scores count the presence of each SVD-related findings (white matter hyperintensity, Lacunar infarction, cerebral microbleeds and enlarged perivascular space), ranging from 0 to 4, as the SVD burden. Total SVD scores were significantly associated with MoCA-J scores (r = -0.203, P < 0.001). After adjustment for age, sex, education, risk factors, and medial temporal atrophy, the association between the total SVD score and global cognitive scores remained significant.

Maximum ambulatory daytime blood pressure and risk of stroke in individuals with higher ambulatory arterial stiffness index: the JAMP study

The aim of this study was to determine whether a high daytime maximum blood pressure (BP) assessed by ambulatory BP monitoring (ABPM) constitutes a risk for atherosclerotic cardiovascular disease (ASCVD) events, especially in those with increased arterial stiffness, because BP variability is linked to arterial stiffness. A total of 6294 participants (mean age, 68.6 ± 11.7 years; 78% treated hypertensive patients), who had at least 1 cardiovascular risk factor, were followed for 4.5 years. Daytime maximum BP was calculated as the highest 1-hour moving average of 2 consecutive systolic BP (SBP) readings during the daytime. The ambulatory arterial stiffness index (AASI) was calculated as 1 minus the slope of the linear regression line between SBP and diastolic BP during 24-hour BP. During the follow-up, there were 217 ASCVD events (119 stroke and 98 coronary artery disease [CAD]). In the higher-AASI group (≥0.5783), subjects in the top quartile of daytime maximum SBP (≥179.4 mmHg) had a greater risk of stroke events compared to those in other quartiles (adjusted hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.13-3.15). In the higher-AASI group, participants with 24-hour SBP of 130 mmHg or more and in the top quartile of daytime maximum SBP had an adjusted HR (95%CI) of 2.55 (1.32-4.95) compared to those without. The analysis did not suggest that daytime maximum SBP posed a risk for CAD events and in the lower-AASI group. Daytime maximum SBP did pose a risk of stroke events, especially for those with higher arterial stiffness represented as AASI.