Effect of untreated hypertension on hemorrhagic stroke

The transition of metabolic phenotypes and cardiovascular events: Panasonic cohort study 16

OBJECTIVE

The study objective was to investigate whether changes in metabolic phenotype affect the risk of cardiovascular events.

METHODS

All 117,589 participants were included in this retrospective cohort study. The metabolic phenotypes of the participants were assessed at two points (the second evaluation was set 2 years after the first evaluation), and the incidence rate of cardiovascular events was observed for 11 years. The main outcome was 3-point major adverse cardiac events (MACE), which comprises cardiovascular death, nonfatal coronary artery disease, and nonfatal stroke incidence.

RESULTS

Of the participants, 2748 (2.3%) cases of 3-point MACE were identified during follow-up. The stable metabolically healthy obesity group had a higher risk of 3-point MACE than those with stable metabolically healthy nonobesity (MHNO). Additionally, the change from metabolically healthy obesity to MHNO for 2 years decreased the risk of 3-point MACE (hazard ratio [HR], 1.12: 95% CI: 0.84-1.47) to the same level as stable MHNO. However, the change from metabolically abnormal nonobesity and metabolically abnormal obesity to MHNO for 2 years maintained a higher risk of 3-point MACE (HR, 1.66 [95% CI: 1.36-2.01]; HR, 1.91 [95% CI: 1.22-2.81]) than those with stable MHNO.

CONCLUSIONS

Change in metabolic phenotype is associated with incident 3-point MACE.

Obstructive Sleep Apnea and Stroke: Determining the Mechanisms Behind their Association and Treatment Options

Sleep-disordered breathing (SDB) can be a sequela of stroke caused by vascular injury to vital respiratory centers, cerebral edema, and increased intracranial pressure of space-occupying lesions. Likewise, obstructive sleep apnea (OSA) contributes to increased stroke risk through local mechanisms such as impaired ischemic cerebrovascular response and systemic effects such as promoting atherosclerosis, hypercoagulability, cardiac arrhythmias, vascular-endothelial dysfunction, and metabolic syndrome. The impact of OSA on stroke outcomes has been established, yet it receives less attention in national guidelines on stroke management than hyperglycemia and blood pressure dysregulation. Furthermore, whether untreated OSA worsens stroke outcomes is not well-described in the literature. This scoping review provides an updated investigation of the correlation between OSA and stroke, including inter-relational pathophysiology. This review also highlights the importance of OSA treatment and its role in stroke outcomes. Knowledge of pathophysiology, the inter-relationship between these common disorders, and the impact of OSA therapy on outcomes affect the clinical management of patients with acute ischemic stroke. In addition, understanding the relationship between stroke outcomes and pre-existing OSA will allow clinicians to predict outcomes while treating acute stroke.

Perceptions of ACT Team Members on the Implementation of Physical Health Services: A Qualitative Study

BACKGROUND

Adults with severe mental illnesses have mortality rates 2.5 to 3 times higher than the general population, largely due to medical illnesses. Those with the most profound mental illnesses are served by assertive community treatment (ACT) teams that provide intensive mental health care; however, there are no clearly established models to integrate physical health treatment into ACT and this is a critical gap in the literature.

AIMS

To describe perceptions of ACT team members regarding services provided for their clients to treat physical health, how those services can be improved, and what implementation strategies would likely be needed to promote uptake and sustainability of those services on ACT teams.

METHOD

Qualitative interviews were conducted via Zoom using a semistructured interview guide with 19 employees from three ACT teams in a southeastern state. Interview transcripts were analyzed, using manifest content analysis, a form of qualitative analysis, to identify key themes in the interview transcripts.

RESULTS

ACT team members described limited physical health services for their clients. They reported (1) system-level barriers to improving physical health care, such as inadequate tools and training; and (2) patient-level barriers, such as limited awareness of physical care needs. ACT team members reported the need for additional medical staff and strengthened relationships with primary care providers. They also recommended changes in policy, education, and quality monitoring to implement new physical health care services.

CONCLUSIONS

Findings suggest intervention components and implementation strategies for improving physical health care of ACT consumers.

Association of serum uric acid to lymphocyte ratio, a novel inflammatory biomarker, with risk of stroke: A prospective cohort study

MAIN PROBLEM

Inflammation plays an important role in the pathological progress associated with stroke. Serum uric acid (SUA) to lymphocyte ratio (ULR), a novel inflammatory biomarker, has been considered as a better risk stratification tool of adverse outcomes than SUA or lymphocyte alone. This study aimed to investigate whether ULR produced more predictive value for stroke and explore the potential mediators of the associations.

METHODS

This study enrolled 93,023 Chinese participants without stroke and myocardial infarction at baseline. Cox proportional hazard models were used to analyze the associations of ULR with stroke and subtypes. Mediation analyses were conducted to explore potential mediators of the associations.

RESULTS

During a median follow-up of 13.00 years, 6081 cases of incident stroke occurred, including 5048 cases of ischemic stroke (IS) and 900 cases of hemorrhagic stroke (HS). After adjustment for confounders, the Q4 group was associated with a higher risk of HS (HR, 1.25; 95% CI, 1.03-1.50), but not with total stroke (HR, 1.07; 95% CI, 1.03-1.13) or IS (HR, 1.04; 95% CI, 0.97-1.12). No significant associations were found between SUA or lymphocyte and any stroke. ULR outperformed SUA or lymphocytes alone in predicting stroke. Additionally, the significant association between ULR and HS was partially mediated by systolic blood pressure (20.32%), diastolic blood pressure (11.18%) and estimated glomerular filtration rate (9.19%).

CONCLUSIONS

ULR was significantly associated with the risk of HS, but not with IS. Systolic blood pressure, diastolic blood pressure and estimated glomerular filtration rate were potential mediators for the association.

Effects of blood pressure unawareness and poor adherence to antihypertensive drugs on outcomes of cerebrovascular accidents among patients with their first-ever stroke

AIMS

Our main target was to investigate the relationship of blood pressure (BP) unawareness and poor antihypertensive drug adherence with the clinical outcomes of the stroke including hospitalization time, degree of disability, and mortality rate.

METHODS AND RESULTS

In this cross-sectional study, we evaluated 530 eligible patients (male = 313; female = 217), aged 18 years and older who had a proven diagnosis of nontraumatic first-ever stroke and were referred to the Shahid Beheshti Hospital of Hamadan, Iran, during the period from March 2019 to September 2021. The prevalence of BP unawareness was 19.6%, and 31.8% of antihypertensive drug users (14.3% of all studied population) had poor drug adherence, in which, older age, male gender, marriage, rural residence, and smoking were associated with the lack of appropriate drug adherence. There was no significant difference between patients with diverse stroke types (ischemic or hemorrhagic) from the points of BP awareness and adherence to antihypertensive drugs; nevertheless, patients with a positive history of cardiac diseases had a significantly higher awareness of their BP status ( P  = 0.037). BP unawareness was associated with poor clinical prognosis, and could significantly increase stroke mortality ( P  = 0.001) and disability ( P < 0.001) rates as well as the duration of hospitalization ( P  < 0.001). Moreover, those who survived the stroke (modified Rankin Scale < 6) had the highest odds to be aware of their BP status (adjusted odds ratio [AOR] = 2.380 [95% confidence interval [CI] = 1.39-4.07]). Additionally, nonsmokers (AOR = 7.740), urban residents (AOR = 3.314), and literate patients (AOR = 2.092) had the highest odds of having appropriate drug adherence.

CONCLUSION

Stroke mortality and morbidity rates can be significantly modified by persuading people to monitor their BP regularly and maximize antihypertensive medication adherence. In the meantime, increasing the literacy level in society and reducing the smoking rate can play important roles in achieving these goals.

Identifying applications of virtual reality to benefit the stroke translational pipeline

As a leading cause of mortality and morbidity, stroke and its management have been studied extensively. Despite numerous pre-clinical studies identifying therapeutic targets, development of effective, specific pharmacotherapeutics remain limited. One significant limitation is a break in the translational pipeline - promising pre-clinical results have not always proven replicable in the clinic. Recent developments in virtual reality technology might help generate a better understanding of injury and recovery across the whole research pipeline in search of optimal stroke management. Here, we review the technologies that can be applied both clinically and pre-clinically to stroke research. We discuss how virtual reality technology is used to quantify clinical outcomes in other neurological conditions that have potential to be applied in stroke research. We also review current uses in stroke rehabilitation and suggest how immersive programmes would better facilitate the quantification of stroke injury severity and patient recovery comparable to pre-clinical study design. By generating continuous, standardised and quantifiable data from injury onset to rehabilitation, we propose that by paralleling pre-clinical outcomes, we can apply a better reverse-translational strategy and apply this understanding to animal studies. We hypothesise this combination of translational research strategies may improve the reliability of pre-clinical research outcomes and culminate in real-life translation of stroke management regimens and medications.

Glial Cells Response in Stroke

As the second-leading cause of death, stroke faces several challenges in terms of treatment because of the limited therapeutic interventions available. Previous studies primarily focused on metabolic and blood flow properties as a target for treating stroke, including recombinant tissue plasminogen activator and mechanical thrombectomy, which are the only USFDA approved therapies. These interventions have the limitation of a narrow therapeutic time window, the possibility of hemorrhagic complications, and the expertise required for performing these interventions. Thus, it is important to identify the contributing factors that exacerbate the ischemic outcome and to develop therapies targeting them for regulating cellular homeostasis, mainly neuronal survival and regeneration. Glial cells, primarily microglia, astrocytes, and oligodendrocytes, have been shown to have a crucial role in the prognosis of ischemic brain injury, contributing to inflammatory responses. They play a dual role in both the onset as well as resolution of the inflammatory responses. Understanding the different mechanisms driving these effects can aid in the development of therapeutic targets and further mitigate the damage caused. In this review, we summarize the functions of various glial cells and their contribution to stroke pathology. The review highlights the therapeutic options currently being explored and developed that primarily target glial cells and can be used as neuroprotective agents for the treatment of ischemic stroke.

Complications of Vascular Disease

Vascular diseases and their sequelae increase perioperative risk for noncardiac surgical patients. In this review, the authors discuss vascular diseases, their epidemiology and pathophysiology, risk stratification, and management strategies to reduce adverse perioperative outcomes.

Heart Failure Burden by Autopsy, Guideline-Directed Medical Therapy, and ICD Utilization Among Sudden Deaths

BACKGROUND

Studies of heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF) report high sudden cardiac death (SCD) rates but presume cardiac cause. Underlying causes, guideline-directed medical therapy (GDMT), and implantable cardioverter-defibrillator (ICD) use in community sudden deaths with heart failure (HF) are unknown.

OBJECTIVES

This study aims to assess the burden of HF, GDMT, and ICD use among autopsied sudden deaths in the POST SCD (Postmortem Systematic Investigation of Sudden Cardiac Death) study, a countywide postmortem study of all presumed SCDs.

METHODS

Incident WHO-defined (presumed) SCDs for individuals of ages 18 to 90 years were autopsied via prospective surveillance of consecutive out-of-hospital deaths in San Francisco County from February 1, 2011, to March 1, 2014. Sudden arrhythmic deaths (SADs) had no identifiable nonarrhythmic cause (eg, pulmonary embolism), and are thus considered potentially rescuable with ICD.

RESULTS

Of 525 presumed SCDs, 100 (19%) had HF. There were 85 patients with known HF (31 HFpEF, 54 HFrEF) and 15 with subclinical HF (postmortem evidence of cardiomyopathy and pulmonary edema without HF diagnosis). SADs comprised 56% (293 of 525) of all presumed SCDs, and 69% (69 of 100) of HF SCDs. The rates were similar in HFrEF (40 of 54 [74%]) and HFpEF (19 of 31 [61%], P = 0.45). Four SAD patients (4%) had ICDs, 3 of which experienced device failure. Twenty-eight SCDs had ejection fraction ≤35%: 22 (79%) with arrhythmic and 6 (21%) with noncardiac causes. Of the 22 SAD patients, 8 (36%) had no identifiable barrier to ICD referral. Complete use of GDMT in HFrEF was 6%.

CONCLUSIONS

One in 5 community sudden deaths had HF; two-thirds had autopsy-confirmed arrhythmic causes. ICD prevention criteria captured only 8% (22 of 293) of all SAD cases countywide; GDMT and ICD use remain important targets for HF sudden death prevention.

Blood Pressure Variability and Outcome in Traumatic Brain Injury: A Propensity Score Matching Study

Introduction

Patients with tIPH (used here to refer to traumatic intraparenchymal hemorrhagic contusion) or intraparenchymal hemorrhage face high rates of mortality and persistent functional deficits. Prior studies have found an association between blood pressure variability (BPV) and neurologic outcomes in patients with spontaneous IPH. Our study investigated the association between BPV and discharge destination (a proxy for functional outcome) in patients with tIPH.

Methods

We retrospectively reviewed the charts of patients admitted to a Level I trauma center for ≥ 24 hours with tIPH. We examined variability in hourly BP measurements over the first 24 hours of hospitalization. Our outcome of interest was discharge destination (home vs facility). We performed 1:1 propensity score matching and multivariate regressions to identify demographic and clinical factors predictive of discharge home.

Results

We included 354 patients; 91 were discharged home and 263 to a location other than home. The mean age was 56 (SD 21), 260 (73%) were male, 22 (6%) were on anticoagulation, and 54 (15%) on antiplatelet therapy. Our propensity-matched cohorts included 76 patients who were discharged home and 76 who were discharged to a location other than home. One measure of BPV (successive variation in systolic BP) was identified as an independent predictor of discharge location in our propensity-matched cohorts (odds ratio 0.89, 95% confidence interval 0.8–0.98; P = 0.02). Our model demonstrated good goodness of fit (P-value for Hosmer-Lemeshow test = 0.88) and very good discriminatory capability (AUROC = 0.81). High Glasgow Coma Scale score at 24 hours and treatment with fresh frozen plasma were also associated with discharge home.

Conclusion

Our study suggests that increased BPV is associated with lower rates of discharge home after initial hospitalization among patients with tIPH. Additional research is needed to evaluate the impact of BP control on patient outcomes.

Surgical Management among Patients with Spontaneous Supratentorial Intracerebral Haemorrhage Admitted in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

Spontaneous intracerebral haemorrhage is the second most common form of stroke and the most deadly one. An understanding of changing trends in the epidemiology of intracerebral haemorrhage prevalence, its risk factors, current practice in management, case fatality, and long-term outcome is essential to measure the effectiveness of stroke prevention and various treatment efforts. The objective of this study was to find out the prevalence of surgical management among patients with spontaneous supratentorial intracerebral haemorrhage in a tertiary centre.

Methods

A descriptive cross-sectional study was conducted in the Department of Neurosurgery from January 2017 to December 2019. Ethical approval was obtained from the Institutional Review Committee (Reference number: 06/2020/IRC-ANIAS). A convenience sampling method was used. Data of the patients were retrieved from online medical records. Point estimate and 95% Confidence Interval were calculated.

Results

Among 221 patients with spontaneous supratentorial intracerebral haemorrhage, 115 (52.04%) (45.45-58.63, 95% Confidence Interval) underwent surgical management. In-hospital mortality was seen in 23 (20%) and survivors at 3 months were 78 (67.82%) patients.

Conclusions

The prevalence of surgical management among spontaneous supratentorial intracerebral haemorrhages was higher than in other studies done in a similar setting.

Keywords

intracerebral haemorrhage; mortality; surgical procedure.

Effect Western Medicines Combined With Nao-Xue-Shu in Patients With Hypertensive Intracerebral Hemorrhage: A Network Meta-Analysis

Purpose: To explore the efficacy of nimodipine, nifedipine, and edaravone (EDA) combined with Nao-Xue-Shu in patients with hypertensive intracerebral hemorrhage (HICH) and to determine the best western medicine combined with Nao-Xue-Shu for treating HICH patients using a ranking method.

Methods: After a comprehensive search of the China National Knowledge Infrastructure (CNKI), Wanfang Database, VIP information database, Chinese Biomedical Database (CBM), PubMed, Embase, and Cochrane Library database from the database establishment 31 December 2021, data extraction and quality assessment were conducted for the included articles. The primary outcome measure was the effectiveness after treatment. Secondary outcome measures were after-treatment the National Institutes of Health Stroke Scale (NIHSS) scores, hematoma volume, perihematoma edema volume, and inflammatory factor expression levels. Statistical analyses were performed using Stata 16.0 and RevMan 5.3.0 software.

Results: We included 19 randomized controlled trials (RCTs) and six non-RCTs. The effective rate after treatment was ranked from the best to the worst as follows: routine cure measure (RCM) + nifedipine + Nao-Xue-Shu, RCM + EDA + Nao-Xue-Shu, RCM + Nao-Xue-Shu, RCM + nimodipine + Nao-Xue-Shu, RCM + EDA, and RCM. The post-treatment NHISS scores from lowest to highest were as follows: RCM + EDA + Nao-Xue-Shu, RCM + nifedipine + Nao-Xue-Shu, RCM + EDA, RCM + nimodipine + Nao-Xue-Shu, RCM + Nao-Xue-Shu, RCM + Nao-Xue-Kang, and RCM. The post-treatment hematoma volume from minimum to maximum was as follows: RCM + EDA + Nao-Xue-Shu, RCM + nimodipine + Nao-Xue-Shu, RCM + nifedipine + Nao-Xue-Shu, RCM + Nao-Xue-Shu, RCM + Nao-Xue-Kang, and RCM. The post-treatment perihematoma edema volume from minimum to maximum was as follows: RCM + EDA + Nao-Xue-Shu, RCM + nifedipine + Nao-Xue-Shu, RCM + nimodipine + Nao-Xue-Shu, RCM + Nao-Xue-Shu, and RCM. For inflammatory factor expression levels after treatment, IL-6 concentration levels after treatment from lowest to highest wasas follows: RCM + Nao-Xue-Shu, RCM + nifedipine + Nao-Xue-Shu, RCM + nimodipine + Nao-Xue-Shu, RCM + EDA + Nao-Xue-Shu, and RCM. TNF-α concentration levels after treatment from lowest to highest was as follow: RCM + nimodipine + Nao-Xue-Shu, RCM + nifedipine + Nao-Xue-Shu, RCM + Nao-Xue-Shu, and RCM.

Conclusion: Nao-Xue-Shu combined with nifedipine showed better effectiveness after treatment in HICH patients compared with the other combinations. Nao-Xue-Shu combined with EDA was more effective for improving neurological function and reducing both hematoma and edema volumes around the hematoma compared with the other combinations. However, Nao-Xue-Shu alone or Nao-Xue-Shu combined with nimodipine may be more effective for reducing proinflammatory factor expression.

Genetics and Epigenetics of Spontaneous Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is a complex and heterogeneous disease, and there is no effective treatment. Spontaneous ICH represents the final manifestation of different types of cerebral small vessel disease, usually categorized as: lobar (mostly related to cerebral amyloid angiopathy) and nonlobar (hypertension-related vasculopathy) ICH. Accurate phenotyping aims to reflect these biological differences in the underlying mechanisms and has been demonstrated to be crucial to the success of genetic studies in this field. This review summarizes how current knowledge on genetics and epigenetics of this devastating stroke subtype are contributing to improve the understanding of ICH pathophysiology and their potential role in developing therapeutic strategies.

Biological and Social Determinants of Hypertension Severity Before vs After Intracerebral Hemorrhage

BACKGROUND AND OBJECTIVES

Although blood pressure (BP) control is considered the most effective measure to prevent functional decline after intracerebral hemorrhage (ICH), less than half of survivors achieve treatment goals. We hypothesized that long-term (i.e., pre-hemorrhage) hypertension severity may be a crucial factor in explaining poor BP control after ICH. We investigated changes in hypertension severity after vs before ICH using Latent Class Analysis (LCA), and identified patient characteristics predictive of individuals' BP trajectories.

METHODS

We analyzed data for ICH survivors enrolled in a study conducted at Massachusetts General Hospital (MGH) from 2002 to 2019 in Boston MA, a high-resource setting with near-universal medical insurance coverage. We captured BP measurements in the 12 months preceding and following the acute ICH hospitalization. Using LCA we identified patient groups (classes) based on changes in hypertension severity over time in an unbiased manner. We then created multinomial logistic regression models to identify patient factors associated with these classes.

RESULTS

Among 336 participants the average age was 74.4 years, 166 (49%) were male, and 288 (86%) self-reported White race/ethnicity. LCA identified 3 patient classes, corresponding to minimal (n = 114, 34%), intermediate (n = 128, 38%) and substantial (n = 94, 28%) improvement in hypertension severity after vs before ICH. Survivors with undertreated (Relative Risk Ratio [RRR] 0.05, 95% Confidence Interval [CI] 0.01-0.23) or resistant (RRR 0.03, 95% CI 0.01-0.06) hypertension before ICH were less likely to experience substantial improvement afterwards. Residents of high-income neighborhoods were more likely to experience substantial improvement (RRR 1.14 per $10,000, 95% CI 1.02-1.28). Black, Hispanic and Asian participants with uncontrolled hypertension before ICH were more likely to experience minimal improvement after hemorrhagic stroke (interaction p < 0.001).

DISCUSSION

Most ICH survivors do not display consistent improvement in hypertension severity after hemorrhagic stroke compared to prior. BP control after ICH is profoundly influenced by patient characteristics predating the hemorrhage, chiefly pre-stroke hypertension severity and socio-economic status. Of note, neighborhood income was associated with hypertension severity after ICH in a high-resource setting with near-universal healthcare coverage. Furthermore, these findings likely contribute to previously documented racial/ethnic disparities in BP control and clinical outcomes following ICH.

Effect of changes in serum uric acid on the risk of stroke and its subtypes

BACKGROUND AND AIMS

The role of serum uric acid (SUA) in stroke remains controversial and analyses of changes in SUA and stroke are limited. The objective of the study was to investigate the associations of changes in SUA with stroke and its subtypes (ischemic and hemorrhagic stroke).

METHODS AND RESULTS

A total of 51 441 participants (mean age 52.69 ± 11.71 years) without history of myocardial infarction or stroke were enrolled. Participants were divided into four groups based on SUA level changes during 2006 and 2010: stable low, increasing, decreasing, and stable high. SUA score was quantified on a 3-point scale with 1 point awarded for hyperuricemia at either year 2006, 2008 or 2010. Multivariate Cox proportion models were used to calculated hazard ratios (HRs) and their 95% confidence intervals (CIs). During 7.03-year follow up, 1611 stroke (1410 ischemic stroke, 199 hemorrhagic stroke, and 47 subarachnoid hemorrhage) were identified. Participants with stable high SUA had higher risk of hemorrhagic stroke, the HR was 1.93 (95% CI: 1.06-3.51), compared to those with stable low SUA. Furthermore, cumulative high SUA exposure also increased the risk of hemorrhagic stroke, the HR (95%CI) was 2.99 (1.55-5.74), compared with cumulative low SUA exposure. However, no significant evidence indicated changes in SUA was associated with the risk of total and ischemic stroke, the HRs (95% CIs) were 0.98 (0.74-1.29) and 0.88 (0.65-1.19), respectively.

CONCLUSIONS

Stable high SUA was positively associated with the risk of hemorrhagic stroke, but not with total and ischemic stroke risk.

Rare Missense Functional Variants at COL4A1 and COL4A2 in Sporadic Intracerebral Hemorrhage

OBJECTIVE

To test the genetic contribution of rare missense variants in COL4A1 and COL4A2 in which common variants are genetically associated with sporadic intracerebral hemorrhage (ICH), we performed rare variant analysis in multiple sequencing data for the risk for sporadic ICH.

METHODS

We performed sequencing across 559 Kbp at 13q34 including COL4A1 and COL4A2 among 2,133 individuals (1,055 ICH cases; 1,078 controls) in United States-based and 1,381 individuals (192 ICH cases; 1,189 controls) from Scotland-based cohorts, followed by sequence annotation, functional impact prediction, genetic association testing, and in silico thermodynamic modeling.

RESULTS

We identified 107 rare nonsynonymous variants in sporadic ICH, of which 2 missense variants, rs138269346 (COL4A1I110T) and rs201716258 (COL4A2H203L), were predicted to be highly functional and occurred in multiple ICH cases but not in controls from the United States-based cohort. The minor allele of rs201716258 was also present in Scottish patients with ICH, and rs138269346 was observed in 2 ICH-free controls with a history of hypertension and myocardial infarction. Rs138269346 was nominally associated with nonlobar ICH risk (p = 0.05), but not with lobar ICH (p = 0.08), while associations between rs201716258 and ICH subtypes were nonsignificant (p > 0.12). Both variants were considered pathogenic based on minor allele frequency (<0.00035 in European populations), predicted functional impact (deleterious or probably damaging), and in silico modeling studies (substantially altered physical length and thermal stability of collagen).

CONCLUSIONS

We identified rare missense variants in COL4A1/A2 in association with sporadic ICH. Our annotation and simulation studies suggest that these variants are highly functional and may represent targets for translational follow-up.

Risk factors and outcomes of hospitalized stroke patients in Lusaka, Zambia

BACKGROUND

Limited data exists about stroke risk factors and outcomes in sub-Saharan African countries, including Zambia. We aim to fill this gap by describing features of hospitalized stroke patients at University Teaching Hospital (UTH), the national referral hospital in Lusaka, Zambia.

METHODS

We conducted a retrospective study of consecutive adults with stroke admitted to UTH's inpatient neurology service from October 2018 to March 2019. Strokes were classified as ischemic or hemorrhagic based on CT scan results and unknown if CT scan was not obtained. Chi-square analyses and t-tests were used to compare characteristics between cohorts with differing stroke subtypes.

RESULTS

Adults with stroke constituted 43% (n = 324) of all neurological admissions, had an average age of 60 ± 18 years, and 62% of the cohort was female. Stroke subtypes were 58% ischemic, 28% hemorrhagic, and 14% unknown. Hypertension was present in 80% of all strokes and was significantly associated with hemorrhagic stroke (p = 0.03). HIV was present in 18% of all strokes and did not significantly differ by stroke subtype. Diabetes (16%), heart disease (34%), atrial fibrillation (9%), and past medical history of stroke (22%) were all significantly more common in patients with ischemic stroke (p < 0.05). In-hospital mortality was 24% overall and highest among individuals with hemorrhagic strokes (33%, p = 0.005).

CONCLUSIONS

This Zambian stroke cohort is notable for its young age, significant HIV burden, high in-hospital mortality, and high rates of uncontrolled hypertension. Our results demonstrate Zambia's substantial stroke burden, significant contribution of HIV to stroke, and the need to improve primary stroke prevention.

Comparison of Clinical Characteristics of Acute Myocardial Infarction Between Young (< 55 Years) and Older (55 to < 70 Years) Patients

Although the incidence of acute myocardial infarction (AMI) has been decreasing in the elderly, it has been increasing in the young, especially in Japan. A social impact of AMI would be greater in the young, because loss of the young directly influences social activities such as business, child-raising, and tax payment. The aim of this study was to identify the specific characteristics of young AMI patients. We retrospectively included 408 consecutive AMI patients < 70 years of age, divided into a young group (< 55 years: n = 136) and an older group (55 to < 70 years: n = 272). The prevalence of overweight was greater in the young group (58.5%) than in the older group (40.7%) (P = 0.001). The frequency of current smokers was higher in the young group (67.6%) than in the older group (44.9%) (P < 0.001). Although the prevalence of hypertension was lower in the young group (66.7%) than in the older group (77.2%) (P = 0.017), that of untreated hypertension was greater in the young group (40.4%) than in the older group (27.2%) (P = 0.007). Furthermore, the prevalence of untreated dyslipidemia was greater in the young group (45.0%) than in the older group (26.6%) (P < 0.001). In conclusion, the young AMI patients had more modifiable risk factors such as obesity, smoking, untreated hypertension, and untreated dyslipidemia than the older patients. There is an unmet medical need for the prevention of AMI in the young generation.

From Preclinical Stroke Models to Humans: Polyphenols in the Prevention and Treatment of Stroke

Polyphenols are an important family of molecules of vegetal origin present in many medicinal and edible plants, which represent important alimentary sources in the human diet. Polyphenols are known for their beneficial health effects and have been investigated for their potential protective role against various pathologies, including cancer, brain dysfunctions, cardiovascular diseases and stroke. The prevention of stroke promoted by polyphenols relies mainly on their effect on cardio- and cerebrovascular systems. However, a growing body of evidence from preclinical models of stroke points out a neuroprotective role of these molecules. Notably, in many preclinical studies, the polyphenolic compounds were effective also when administered after the stroke onset, suggesting their possible use in promoting recovery of patients suffering from stroke. Here, we review the effects of the major polyphenols in cellular and in vivo models of both ischemic and hemorrhagic stroke in immature and adult brains. The results from human studies are also reported.

Association of prestroke medicine use and health outcomes after ischaemic stroke in Sweden: a registry-based cohort study

OBJECTIVE

The objective was to investigate if there is a relationship between preischaemic stroke medicine use and health outcomes after stroke.

SETTING

This registry-based study covered Swedish stroke care, both primary and secondary care, including approximately 60% of the Swedish stroke cases from seven Swedish regions.

PARTICIPANTS

The Sveus research database was used, including 35 913 patients (33 943 with full information on confounding factors) with an ischaemic stroke (International Classification of Diseases, 10th Revision (ICD-10) I63*) between 2009 and 2011 registered both in the regions' patient administrative systems and in the Swedish Stroke Register. Patients with haemorrhagic stroke (ICD-10 I61*) were excluded.

PRIMARY OUTCOME

The primary outcome was the association, expressed in ORs, of prestroke medicine use (oral anticoagulants, statins, antihypertensives, antidepressants, non-steroidal anti-inflammatory drugs (NSAIDs) and antidiabetic drugs) and health outcomes 1 and 2 years poststroke (survival, activities of daily living dependency and modified Rankin Scale (mRS) 0-2), adjusted for patient characteristics and stroke severity at stroke onset.

RESULTS

The multivariate analysis indicated that patients on drugs for hypertension, diabetes, oral anticoagulants and antidepressants prestroke had worse odds for health outcomes in both survival (OR 0.65, 95% CI 0.60 to 0.69; OR 0.77, 95% CI 0.71 to 0.83; OR 0.72, 95% CI 0.66 to 0.80; OR 0.91, 95% CI 0.84 to 0.98, respectively, for survival at 2 years) and functional outcome (OR 0.82, 95% CI 0.75 to 0.89; OR 0.61, 95% CI 0.55 to 0.68; OR 0.83, 95% CI 0.72 to 0.95; OR 0.58, 95% CI 0.52 to 0.65, respectively, for mRS 0-2 at 1 year), whereas patients on statins and NSAIDS had significantly better odds for survival (OR 1.16, 95% CI 1.08 to 1.25 and OR 1.12, 95% CI 1.00 to 1.25 for 1-year survival, respectively), compared with patients without these treatments prior to stroke.

CONCLUSIONS

The results indicated that there are differences in health outcomes between patients who had different common prestroke treatments, patients on drugs for hypertension, diabetes, oral anticoagulants and antidepressants had worse health outcomes, whereas patients on statins and NSAIDS had significantly better survival, compared with patients without these treatments prior to stroke.

Age as a prognostic factor of 30-day mortality in hemorrhagic stroke patients: A Thai large tertiary care referral center

OBJECTIVE

The aim of the present study was to identify incidences and prognostic factors for 30-day mortality of hemorrhagic strokes (HS) and divide them into intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH).

METHODS

This retrospective cohort study was conducted using medical records of patients who underwent surgery due to HS, between January 2013 and April 2017, at Chiang Mai University Hospital, a large tertiary referral center, in Northern Thailand. 30-day mortality was followed after surgery. Prognostic factors included patients' characteristics, and clinical date related to early death, were determined. Data analysis was performed using Cox's proportional hazards model.

RESULTS

460 patients were enrolled. The 30-day mortality rate was 8.8% and 12.3%, in ICH and SAH patients, respectively. Multivariable analyses demonstrated that the prognostic factors of early mortality in ICH patients were age 65-70 years (Adjusted HR 3.10 (95%CI 1.14-8.41)), >70 years (Adj.HR 2.64 (95%CI 1.09-6.36)) and hypertension (HT) (Adj.HR 2.98 (95%CI 1.25-7.12)). In SAH patients, prognostic factors were HT (Adj.HR 7.32 (95%CI 2.12-25.29)), and atrial fibrillation (AF) (Adj.HR 5.48 (95% CI 1.57-19.09)).

CONCLUSIONS

Ages over 65 years and HT were an important predictor of 30-day mortality in a subgroup of ICH patients, whereas HT and AF were significant prognostic factors in SAH. To reduce early death, management for stroke cases needed to take into account the specifics for older age patients with HT, and AF.

Exercise Training Enhances Platelet Mitochondrial Bioenergetics in Stroke Patients: A Randomized Controlled Trial

Exercise training (ET) may impact physical fitness by affecting mitochondrial functions. This study aimed to elucidate the effect of ET on aerobic capacity and platelet mitochondrial bioenergetics (MTB) in stroke patients. Among the 30 stroke patients who underwent the traditional rehabilitation program (TRP), 15 were randomly assigned to have ET (50-60% VO_2peak for 30 min/day, 5 days/week for 4 weeks), and those remaining received only the TRP (control group). The peak exercise capacity (VO_2peak) and platelet MTB, including oxidative phosphorylation (OXPHOS) and the electron transport chain (ETC), were measured through automatic gas analysis and high-resolution respirometry, respectively. The results demonstrated that ET significantly increased the VO_2peak (17.7%) and O₂ uptake efficiency slope (31.9%) but decreased the ventilation versus CO₂ production slope (-7.65%). Patients who underwent ET also had significantly enhanced platelet mitochondrial OXPHOS and ETC by activating the FADH2 (Complex II)-dependent pathway, but depressed plasma myeloperoxidase (-28.4%) and interleukin-6 levels (-29.9%). Moreover, changes in VO_2peak levels were positively correlated with changes in platelet OXPHOS and ETC capacities. In conclusion, ET increases the platelet MTB by enhancing Complex II activity in stroke patients. The exercise regimen also enhances aerobic fitness and depresses oxidative stress/pro-inflammatory status in stroke patients.

Anton's syndrome: a rare and unusual form of blindness

Anton syndrome is characterised by visual anosognosia. It results from damage to both occipital lobes, while the anterior visual pathways remain intact. We describe four cases of Anton's syndrome. First case is that of a 73-year-old woman, who presented with two separate events of intraparenchymal brain haemorrhage, 4 years apart. Her first stroke affected the left and second affected the right occipital lobe. Bilateral occipital lobe damage resulted in cortical blindness. Second case is an 88-year-old man, who suffered from two ischaemic strokes, 2 days apart. Each stroke involved one posterior cerebral artery. This resulted in bilateral occipital and temporal lobe infarcts. Third case is a 64-year-old woman with chronic renal failure, who suffered bilateral occipital lobe infarction after haemodialysis, due to posterior reversible encephalopathy syndrome. Last case is that of an 80-year-old woman who suffered a basilar artery stroke, resulting in bilateral thalamic, temporal and occipital lobe infarction.

An investigation into the design of a device to treat haemorrhagic stroke

In this study, we present the design considerations of a device to assist in the potential treatment of hemorrhagic stroke with the aim of stopping blood from flowing out into brain tissue. We present and model three designs for the clinical scenarios when saccular aneurysms rupture in the middle cerebral artery in the brain. We evaluate and model these three designs using computer aided design software, SolidWorks, which allows the devices to be tested using finite element analysis and also enables us to justify that the materials chosen were suitable for potential use. Computational fluid dynamics modelling were used to demonstrate and analyse the flow of blood through the artery under conditions of normal and ruptured states. We conclude that our device could potentially be useful in the treatment of hemorrhagic stroke, and the modelling process is useful in assisting in determining the performance of our devices.

Rapid neuroinflammatory changes in human acute intracerebral hemorrhage

Objective

Spontaneous intracerebral hemorrhage (ICH) is the commonest form of hemorrhagic stroke and is associated with a poor prognosis. Neurosurgical removal of intracerebral hematoma has limited benefit and no pharmacotherapies are available. In acute ICH, primary tissue damage is followed by secondary pathology, where the cellular and neuroinflammatory changes are poorly understood.

Methods

We studied histological changes in postmortem tissue from a cohort of spontaneous supra‐tentorial primary ICH cases (n = 27) with survival of 1–12 days, compared to a matched control group (n = 16) examined in corresponding regions. Hematoxylin–eosin and microglial (Iba1) immunolabelled sections were assessed at 0–2, 3–5, and 7–12 days post‐ICH.

Results

Peri‐hematoma, the observed ICH‐related changes include edema, tissue neutrophils and macrophages from day 1. Ischemic neurons and swollen endothelial cells were common at day 1 and universal after day 5, as were intramural erythrocytes within small vessel walls. Activated microglia were evident at day 1 post‐ICH. There was a significant increase in Iba1 positive area fraction at 0–2 (threefold), 3–5 (fourfold), and 7–12 days post ICH (ninefold) relative to controls. Giant microglia were detected peri‐hematoma from day 5 and consistently 7–12 days post‐ICH.

Interpretation

Our data indicate that neuroinflammatory processes commence from day 1 post‐ICH with changing microglial size and morphology following ICH and up to day 12. From day 5 some microglia exhibit a novel multiply nucleated morphology, which may be related to changing phagocytic function. Understanding the time course of neuroinflammatory changes, post‐ICH may reveal novel targets for therapy and brain restoration.

Nosocomial Infections among Patients with Intracranial Hemorrhage: A Retrospective Data Analysis of Predictors and Outcomes

OBJECTIVE

Intracranial hemorrhage is a critical medical emergency. Nosocomial infections may promote worse outcomes in these vulnerable patients. This study investigated microbial features, predictors, and clinical outcomes of nosocomial infections among patients with multiple subtypes of intracranial hemorrhage.

PATIENTS AND METHODS

We conducted a retrospective cohort study of patients that were hospitalized with intracranial hemorrhage between January 2015 and October 2018, and divided them into two groups based on the development of nosocomial infection. Within the cohort of patients with nosocomial infections, microbiology and resistance patterns were established across multiple sites of infection. Moreover, consequences of nosocomial infection such as mortality and length of hospital stay were determined.

RESULTS

A total of 233 cases were identified that met our inclusion and exclusion criteria out of which were 94 cases of nosocomial infection (40.3%) versus 139 cases with no nosocomial infection (59.7%). The most common infections were pneumonia, urinary tract infections, and bacteremia. Resistance accounted for 70.2% of cultures. Multivariable analysis revealed significant association of nosocomial infections with hypertension (OR: 2.62, 95% CI: 1.11-6.16, p = 0.027), hospital LOS (OR: 1.08, 95% CI: 1.05-1.12, p < 0.001), levetiracetam (OR: 3.6, 95% CI: 1.41-0.922, p = 0.007), and GCS category (OR: 5.42, 95% CI: 1.67-17.55, p = 0.005 and OR: 7.63, 95% CI: 2.44-23.87, p < 0.001 for moderate and severe, respectively). Patients with nosocomial infections witnessed a significant increase in the length of hospital stay (23 versus 8 hospital days, p < 0.001). This finding was significant across most types of brain hemorrhage. Mortality was significantly associated with GCS category (OR: 10.1, 95% CI: 4-25.7, p < 0.001) and percutaneous endoscopic gastrostomy tube insertion (OR: 19.6, 95% CI: 4.1-91, p < 0.001).

CONCLUSIONS

Collectively, these findings suggest that nosocomial infections are common among patients with intracranial hemorrhage and can be predictable by considering certain risk factors. Future studies are warranted to evaluate the efficacy of implementing infection control strategies or protocols on these patients to achieve better therapeutic outcomes.

Racial/ethnic variation of APOE alleles for lobar intracerebral hemorrhage

OBJECTIVE

APOE ε2 and ε4 alleles have been associated with lobar intracerebral hemorrhage (ICH) in predominately white populations; we sought to evaluate whether this held true among black and Hispanic populations.

METHODS

The Ethnic/Racial Variations of Intracerebral Hemorrhage study is a prospective, multicenter case-control study of ICH among white, black, and Hispanic participants. Controls were recruited to match cases based on age, ethnicity/race, sex, and geographic location. APOE genotyping and ICH location was determined blinded to clinical data.

RESULTS

There were 907 cases of lobar ICH and 2,660 controls with APOE results. Both APOE ε2 (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1-2.0, p = 0.01) and APOE ε4 (OR 2.0, 95% CI 1.5-2.6, p < 1 × 10^-4) were associated with lobar ICH among white participants. Among black participants, neither APOE ε2 (OR 1.0, 95% CI 0.7-1.5, p = 0.97) nor APOE ε4 (OR 1.0, 95% CI 0.7-1.4, p = 0.90) were independent risk factors for lobar ICH. Similarly, among Hispanic participants, neither APOE ε2 (OR 1.0, 95% CI 0.6-1.8, p = 0.89) nor APOE ε4 (OR 1.2, 95% CI 0.8-1.7, p = 0.36) were associated with lobar ICH. Hypertension was a significant risk factor for lobar ICH in all 3 racial/ethnic groups.

CONCLUSION

In contrast to Caucasian patients, in which amyloid risk factors predominate in lobar ICH, we found that hypertension was the predominant risk factor for lobar ICH. While APOE alleles are a risk factor for lobar ICH in white patients, they appear to have a much lower effect in lobar ICH in African American and Hispanic American populations. This suggests APOE ε2 and APOE ε4 do not affect lobar ICH risk homogeneously across ethnic populations. In addition, hypertension has a prominent role in lobar ICH risk, particularly among minorities.

Statin use associated with lower risk of epilepsy after intracranial haemorrhage: A population-based cohort study

AIMS

To examine the association between statin use before and after intracranial haemorrhage (ICH) and the risk of poststroke epilepsy (PSE).

METHODS

Patients with new-onset ICH between 2004 and 2012 were identified from the Taiwan National Health Insurance Research Database. The main outcome was the occurrence of epilepsy after stroke. Multivariable Cox regression modelling was used to estimate the association between statin use and the risk of PSE, with poststroke medication exposures being treated as time-dependent variables.

RESULTS

A total of 7435 patients with ICH were enrolled with a median follow-up of 17.6 months. Within the study cohort, 709 patients developed PSE. Poststroke, but not prestroke, stain use was associated with a reduced risk of PSE (adjusted hazard ratio 0.62, 95% confidence interval 0.42-0.90, P = 0.01). In subanalyses, a trend of a dose-response relationship was observed. A significant PSE risk reduction was correlated with a higher cumulative statin dose. Moreover, the risk of PSE was lower in patients receiving moderate-to-high-intensity statin therapy (adjusted hazard ratio 0.37, 95% confidence interval 0.18-0.75, P = 0.01). Lipophilic and hydrophilic statins were similar with regard to their associations with the reduced risk of PSE.

CONCLUSIONS

Statin therapy may reduce the risk of PSE after ICH, especially with moderate-to-high therapy intensity. Further research is needed to understand the mechanisms underlying the potential protective effects of statins against PSE in this patient population.

Pathological examination of cerebral amyloid angiopathy in patients who underwent removal of lobar hemorrhages

Cerebral amyloid angiopathy (CAA) is a degenerative disorder characterized by amyloid-β (Aβ) deposition in the brain microvessels. CAA is also known to contribute not only to cortical microbleeds but also lobar hemorrhages. This retrospective study examined CAA pathologically in patients who underwent direct surgeries for lobar hemorrhage. Thirty-three patients with lobar hemorrhage underwent open surgery with biopsy from 2007 to 2016 in our hospital. Cortical tissues over hematomas obtained surgically were pathologically examined using hematoxylin, eosin stain, and anti-Aβ antibody to diagnose CAA. We also investigated the advanced degree of CAA and clinical features of each patient with lobar hemorrhage. In the 33 patients, 4 yielded specimens that were insufficient to evaluate CAA pathologically. Twenty-four of the remaining 29 patients (82.8%) were pathologically diagnosed with CAA. The majority of CAA-positive patients had moderate or severe CAA based on a grading scale to estimate the advanced degree of CAA. About half of the CAA-positive patients had hypertension, and four took anticoagulant or antiplatelet agents. In five patients who were not pathologically diagnosed with CAA, one had severe liver function disorder, three had uncontrollable hypertension, and one had no obvious risk factor. Our pathological findings suggest that severe CAA with vasculopathic change markedly contributes to lobar hemorrhage. The coexistence of severe CAA and risk factors such as hypertension, anticoagulants or antiplatelets may readily induce lobar hemorrhage.

Spontaneous Intracerebral Hemorrhage

Although commonly arising from poorly controlled hypertension, spontaneous intracerebral hemorrhage may occur secondary to several other etiologies. Clinical presentation to the emergency department ranges from headache with vomiting to coma. In addition to managing the ABCs, the crux of emergency management lies in stopping hematoma expansion and other complications to prevent clinical deterioration. This may be achieved primarily through anticoagulation reversal, blood pressure, empiric management of intracranial pressure, and early neurosurgical consultation for posterior fossa hemorrhage. Patients must be admitted to intensive care. The effects of intracerebral hemorrhage are potentially devastating with very poor prognoses for functional outcome and mortality.

Untreated hypertension as predictor of in-hospital mortality in intracerebral hemorrhage: A multi-center study

PURPOSE

Hypertension is a significant risk factor for intracerebral hemorrhage (ICH). The importance of managing blood pressure to reduce the risk of ICH has been recognized. However, few studies have focused on ICH outcomes due to untreated hypertension.

MATERIALS AND METHODS

We conducted a 5-year, retrospective, multicenter study of 490 consecutive ICH patients with histories of untreated-hypertension (n=56), treated-hypertension (n=314), and normotension (n=120). Demographics, symptom onset, vital signs, laboratory tests, and CT imaging were documented alongside in-hospital treatments, complications, and length of stay.

RESULTS

Untreated-hypertension subjects were found to be significantly younger than treated-hypertension. They were found to have lower rates of anticoagulant use (p<0.01), antiplatelet use (p<0.01), and hyperlipidemia (p<0.01) than subjects with treated-hypertension. In a multivariate model, untreated-hypertension, age ≥65years, ≥3 outpatient antihypertensive medications, and hematoma volumes ≥30ml were all associated with significantly increased in-hospital mortality. In contrast, mortality was lower in patients receiving ≥3 antihypertensive medications while in-hospital.

CONCLUSIONS

Subjects with untreated-hypertension were younger and had fewer comorbidities when compared with treated-hypertension and were similar when compared to normotensive individuals. Once demographic and in-hospital factors were accounted for, untreated-hypertension subjects demonstrated significantly increased in-hospital mortality following ICH when compared with normotensive individuals.

Influenza vaccination reduces hemorrhagic stroke risk in patients with atrial fibrillation: A population-based cohort study

PURPOSE

The risk of hemorrhagic stroke in patients with atrial fibrillation (AF) is low but the consequences of its occurrence are extremely severe. In this study, we investigated the association of influenza vaccination with the risk of hemorrhagic stroke to develop an efficient strategy for reducing this risk in patients with AF.

METHODS

In this study, data were retrieved from the Taiwan National Health Insurance Research Database. The study cohort comprised all patients who received a diagnosis of AF (n=14,454) before January 1, 2005 (index date) and were followed until December 31, 2012. Propensity scores were calculated using a logistic regression model to determine the effects of vaccination by accounting for covariates that predict receiving the intervention (vaccine). A time-dependent Cox proportional hazard model was used to calculate the hazard ratios (HRs) for hemorrhagic stroke in vaccinated and unvaccinated patients with AF.

RESULTS

The study population comprised 6570 patients who did (2547 [38.77%]) and did not receive (4023 [61.23%]) influenza vaccination. The adjusted HRs (aHRs) for hemorrhagic stroke were lower in the vaccinated patients than in the unvaccinated patients (influenza season, noninfluenza season, and all seasons: aHRs=0.97 [0.59-1.60], 0.51 [0.30-0.87], and 0.72 [0.50-1.03], respectively).

CONCLUSIONS

Influenza vaccination exerts dose-response and synergistic protective effects against hemorrhagic stroke in patients with AF who have a high risk of hemorrhagic stroke (i.e., male sex, age≥75years, Charlson comorbidity index ≥3, and hypertension) and reduces the incidence of hemorrhagic stroke.

Untreated Hypertension: A Powerful Risk Factor for Lobar and Nonlobar Intracerebral Hemorrhage in Whites, Blacks, and Hispanics

BACKGROUND

Hypertension is a significant risk factor for intracerebral hemorrhage (ICH). Although ethnic/racial disparities related to hypertension and ICH have been reported, these previous studies were limited by a lack of Hispanics and inadequate power to analyze by ICH location. In the current study, while overcoming these prior limitations, we investigated whether there was variation by ethnicity/race of treated and untreated hypertension as risk factors for ICH.

METHODS

The ERICH study (Ethnic/Racial Variations of Intracerebral Hemorrhage) is a prospective, multicenter, case-control study of ICH among whites, blacks, and Hispanics. Cases were enrolled from 42 recruitment sites. Controls matched to cases 1:1 by age (±5 years), sex, ethnicity/race, and metropolitan area were identified by random-digit dialing. Subjects were interviewed to determine history of hypertension and use of antihypertensive medications. Cases and controls within ethnic groups were compared by using conditional logistic regression. Multivariable conditional logistic regression models were computed for ICH as an overall group and separately for the location subcategories deep, lobar, and infratentorial (brainstem/cerebellar).

RESULTS

Nine hundred fifty-eight white, 880 black, and 766 Hispanic ICH patients were enrolled. For ICH cases, untreated hypertension was higher in blacks (43.6%, P<0.0001) and Hispanics (46.9%, P<0.0001) versus whites (32.7%). In multivariable analyses adjusted for alcohol use, anticoagulation, hypercholesterolemia, education, and medical insurance status, treated hypertension was a significant risk factor across all locations of ICH in whites (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.24-1.98; P<0.0001), blacks (OR, 3.02; 95% CI, 2.16-4.22; P<0.0001), and Hispanics (OR, 2.50; 95% CI, 1.73-3.62; P<0.0001). Untreated hypertension was a substantially greater risk factor for all 3 racial/ethnic groups across all locations of ICH: whites (OR, 8.79; 95% CI, 5.66-13.66; P<0.0001), blacks (OR, 12.46; 95% CI, 8.08-19.20; P<0.0001), and Hispanics (OR, 10.95; 95% CI, 6.58-18.23; P<0.0001). There was an interaction between race/ethnicity and ICH risk (P<0.0001).

CONCLUSIONS

Untreated hypertension confers a greater ICH risk in blacks and Hispanics relative to whites across all anatomic locations of ICH. Accelerated research efforts are needed to improve overall hypertension treatment rates and to monitor the impact of such efforts on racial/ethnic disparities in stroke.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01202864.

Risk of Intracerebral Hemorrhage after Emergency Department Discharges for Hypertension

BACKGROUND

Recent literature suggests that acute rises in blood pressure may precede intracerebral hemorrhage. We therefore hypothesized that patients discharged from the emergency department with hypertension face an increased risk of intracerebral hemorrhage in subsequent weeks.

METHODS

Using administrative claims data from California, New York, and Florida, we identified all patients discharged from the emergency department from 2005 to 2011 with a primary diagnosis of hypertension (ICD-9-CM codes 401-405). We excluded patients if they were hospitalized from the emergency department or had prior histories of cerebrovascular disease at the index visit with hypertension. We used the Mantel-Haenszel estimator for matched data to compare each patient's odds of intracerebral hemorrhage during days 8-38 after emergency department discharge to the same patient's odds during days 373-403 after discharge. This cohort-crossover design with a 1-week washout period enabled individual patients to serve as their own controls, thereby minimizing confounding bias.

RESULTS

Among the 552,569 patients discharged from the emergency department with a primary diagnosis of hypertension, 93 (.017%) were diagnosed with intracerebral hemorrhage during days 8-38 after discharge compared to 70 (.013%) during days 373-403 (odds ratio 1.33, 95% confidence interval .96-1.84). The odds of intracerebral hemorrhage were increased in certain subgroups of patients (≥60 years of age and those with secondary discharge diagnoses besides hypertension), but absolute risks were low in all subgroups.

CONCLUSIONS

Patients with emergency department discharges for hypertension do not face a substantially increased short-term risk of intracerebral hemorrhage after discharge.

Sex-Specific Effects of Progesterone on Early Outcome of Intracerebral Hemorrhage

BACKGROUND

Preclinical evidence suggests that progesterone improves recovery after intracerebral hemorrhage (ICH); however, gonadal hormones have sex-specific effects. Therefore, an experimental model of ICH was used to assess recovery after progesterone administration in male and female rats.

METHODS

ICH was induced in male and female Wistar rats via stereotactic intrastriatal injection of clostridial collagenase (0.5 U). Animals were randomized to receive vehicle or 8 mg/kg progesterone intraperitoneally at 2 h, then subcutaneously at 5, 24, 48, and 72 h after injury. Outcomes included relevant physiology during the first 3 h, hemorrhage and edema evolution over the first 24 h, proinflammatory transcription factor and cytokine regulation at 24 h, rotarod latency and neuroseverity score over the first 7 days, and microglial activation/macrophage recruitment at 7 days after injury.

RESULTS

Rotarod latency (p = 0.001) and neuroseverity score (p = 0.01) were improved in progesterone-treated males, but worsened in progesterone-treated females (p = 0.028 and p = 0.008, respectively). Progesterone decreased cerebral edema (p = 0.04), microglial activation/macrophage recruitment (p < 0.001), and proinflammatory transcription factor phosphorylated nuclear factor-x03BA;B p65 expression (p = 0.0038) in males but not females, independent of tumor necrosis factor-α, interleukin-6, and toll-like receptor-4 expression. Cerebral perfusion was increased in progesterone-treated males at 4 h (p = 0.043) but not 24 h after injury. Hemorrhage volume, arterial blood gases, glucose, and systolic blood pressure were not affected.

CONCLUSIONS

Progesterone administration improved early neurobehavioral recovery and decreased secondary neuroinflammation after ICH in male rats. Paradoxically, progesterone worsened neurobehavioral recovery and did not modify neuroinflammation in female rats. Future work should isolate mechanisms of sex-specific progesterone effects after ICH.

Spontaneous Meckel's cave hematoma: A rare cause of trigeminal neuralgia

Background:

The most common etiology of classic trigeminal neuralgia (TN) is vascular compression. However, other causes must be considered. Among these, spontaneous hematoma of the Meckel's cave (MC) causing symptomatic TN is very rare.

Case Description:

We present the case of a 60-year-old woman with a 2-month history of left TN and diplopia. Neuroradiological examinations revealed a well-defined hematoma in the left MC. The patient underwent surgical decompression with a progressive neurological improvement.

Conclusion:

Despite the number of lesions potentially affecting the MC, spontaneous hemorrhage is rare but should be taken into account in the differential diagnosis.

Relationship between intracerebral hemorrhage and diabetes mellitus: a case-control study

INTRODUCTION

The role of diabetes mellitus in the pathogenesis of intracerebral hemorrhage (ICH) is controversial. Underlying comorbidities such as diabetes mellitus may increase the risk of intracerebral hemorrhage. In this study, we sought to assess the role of diabetes mellitus in the occurrence of intracerebral hemorrhage.

MATERIALS AND METHODS

In this case-control study, the prevalence of diabetes mellitus was evaluated in 120 patients presenting with intracerebral hemorrhage and in a control group of 135 patients with low back pain. All patients were treated at the Departments of Neurology and Neurosurgery, Shohadaye Tajrish University Hospital, Tehran, Iran between 2008 and 2012. T-test was applied for analysing the quantitative variables and chi-square and Fisher's exact tests were used to analyse qualitative variables.

RESULTS

The mean age was 67.5±12.7 y in patients with intracerebral hemorrhage and 70.5±12.6 y in the control group (p=0.201). Diabetes mellitus was found in 39 patients with intracerebral hemorrhage (33.1%) and 30 (22.2%) control subjects (p=0.054). The prevalence of diabetes mellitus in patients younger than 60 y was 7.4% in the control group and 27.8% in the case group (p=0.042).

CONCLUSION

In our study, no significant relationship was found between diabetes mellitus and intracerebral hemorrhage (except in patients younger than 60 years) and diabetes mellitus did not cause bleeding in certain brain areas. However, more studies are required on the correlation of diabetes mellitus and intracerebral hemorrhage in the same population to reach a definite conclusion.

The use of ADSCs as a treatment for chronic stroke

Stroke is one of the disorders for which clinically effective therapeutic modalities are most needed, and numerous ways have been explored to attempt to investigate their feasibilities. However, ischemic- or hemorrhagic-induced inflammatory neuron death causes irreversible injuries and infarction regions, and there are currently no truly effective drugs available as therapy. It is therefore urgent to be able to provide a fundamental treatment method to regenerate neuronal brain cells, and therefore, the use of stem cells for curing chronic stroke could be a major breakthrough development. In this review, we describe the features and classification of stroke and focus on the benefits of adipose tissue-derived stem cells and their applications in stroke animal models. The results show that cell-based therapies have resulted in significant improvements in neuronal behaviors and functions through different molecular mechanisms, and no safety problems have so far arisen after transplantation. Further, we propose a clinical possibility to create a homing niche by reducing the degree of invasive intracerebroventricular transplantation and combining it with continuous intravenous administration to achieve a complete cure.

Impact of metabolic syndrome components on incident stroke subtypes: a Chinese cohort study

Limited evidence is available on the risk differences in the development of stroke subtypes in relation to particular clustering patterns of the metabolic syndrome (MetS) components. A follow-up study of a Chinese cohort involving 10,292 individuals was performed to assess the roles of cluster patterns of the MetS components in the prediction of incident stroke subtypes. During follow-up, there were 161 incident cases of ischemic strokes and 41 incident cases of hemorrhagic strokes. Among MetS components, only the hypertensive trait was associated with significantly elevated risks of both ischemic and hemorrhagic strokes. Furthermore, MetS with hypertension as components was associated with increased risk of ischemic and hemorrhagic strokes (adjusted hazards ratio (95% confidence interval) was 2.96 (1.94-4.50) and 2.93 (1.25-6.90), respectively) as compared with those who had neither hypertension nor MetS. Notably, as the number of the MetS components increased, the risk of ischemic stroke significantly and dose-dependently increased. This implies a cumulative effect of MetS components in elevating the risk of ischemic stroke. These findings suggest that MetS comprises heterogenous clusters with respect to the risk of developing the subtype of stroke.

Neuropathologic analysis of hematomas evacuated from patients with spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) is a devastating cause of morbidity and mortality. Intraparenchymal hematomas are often surgically evacuated. This generates fragments of perihematoma brain tissue that may elucidate their etiology. The goal of this study is to analyze the value of these specimens in providing a possible etiology for spontaneous ICH as well as the utility of using immunohistochemical markers to identify amyloid angiopathy. Surgically resected hematomas from 20 individuals with spontaneous ICH were examined with light microscopy. Hemorrhage locations included 11 lobar and nine basal ganglia hemorrhages. Aβ immunohistochemistry and Congo red stains were used to confirm the presence of amyloid angiopathy, when this was suspected. Evidence of cerebral amyloid angiopathy (CAA) was observed in eight of the 20 specimens, each of which came from lobar locations. Immunohistochemistry confirmed CAA in the brain fragments from these eight individuals. Patients with immunohistochemically confirmed CAA were older than patients without CAA, and more likely to have lobar hemorrhages (OR 3.0 and 3.7, respectively). Evidence of CAA was not found in any of the basal ganglia specimens. One specimen showed evidence of CAA-associated angiitis, with formation of a microaneurysm in an inflamed segment of a CAA-affected arteriole, surrounded by acute hemorrhage. In another specimen, Aβ immunohistochemistry showed the presence of senile plaques suggesting concomitant Alzheimer's disease (AD) changes. Surgically evacuated hematomas from patients with spontaneous ICH should be carefully examined, paying special attention to any fragments of included brain parenchyma. These fragments can provide evidence of the etiology of the hemorrhage. Markers such as Aβ 1-40 can help to identify underlying CAA, and should be utilized when microangiopathy is suspected. Given the association of (Aβ) CAA with AD, careful examination of entrapped brain fragments may also provide evidence of AD in a given patient.

Risk factors for intracerebral hemorrhage: the REasons for geographic and racial differences in stroke (REGARDS) study

BACKGROUND AND PURPOSE

Risk factors for intracerebral hemorrhage (ICH) have been largely identified in case-control studies, with few longitudinal studies available.

METHODS

Predictors of incident ICH among 27 760 black and white participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort study were assessed.

RESULTS

There were 62 incident ICH events during an average follow-up of 5.7 years. The increase in risk with age differed substantially between blacks and whites (P=0.006), with a 2.25-fold (95% confidence interval, 1.63-3.12) increase per decade in whites, but no age association with ICH risk in blacks (hazard ratio=1.09; 95% confidence interval, 0.70-1.68). We observed increased risk among men, those with higher systolic blood pressure, and warfarin users.

CONCLUSIONS

The racial differences in the impact of age contributed to a risk of ICH that was >5 times higher for blacks than whites at age 45, but only about one third as great by age 85. Confirming findings from other studies, men participants with elevated systolic blood pressure and warfarin users were also at greater risk. The contributors to the racial differences in ICH risk require additional investigation.