An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association

Troponin I biomarker sensing from clinical patient samples using molecularly imprinted polymer nanoparticles for advancing healthcare approaches in cardiovascular disease

Cardiac troponin I (cTnI) is a critical protein biomarker for heart attack diagnosis. This study presents a thorough analysis of a novel biosensing device utilizing molecularly imprinted polymer nanoparticles (nanoMIPs) for detecting cTnI in clinical patient serum samples post myocardial infarction. The methodology, based on the heat-transfer method approach, offers faster measurements times than the current gold standard and sample volumes equivalent to a single blood drop. Biomarker binding shows performance comparable to a high-sensitivity ELISA, accurately identifying patients with elevated cTnI levels (R2 = 0.893). The cTnI peak concentration time variations are attributed to heterogeneous serum complexes, with different troponin complex sizes potentially generating differing thermal insulation levels. Comparison with an established patient database demonstrates robust correlations between our cTnI concentrations and clinical parameters (R2 = 0.855). This underscores the potential of nanoMIP sensors for sensitive cTnI detection, providing insights into post-heart attack biomarker levels. Furthermore, our methodology presents the additional benefits of being low cost and portable enabling measurements at time and place of patients. Consequently, it holds the potential to become a vital part of the diagnostic pathway for heart attack treatment, ultimately reducing healthcare costs and improving patient outcomes.

Use of the Brain Care Score to Estimate the Risk of Incident Cerebrovascular Events in Middle-Aged Women

BACKGROUND AND OBJECTIVES

In the United States, stroke is the third leading cause of death among women, with 1 in 5 women aged 55 to 75 years expected to experience a stroke. The Brain Care Score (BCS) is an evidence-based tool designed to motivate lifestyle changes, with higher scores associated with reduced risk of stroke, dementia, and depression. We aim to measure the association of the BCS and incident cerebrovascular events (CVEs), including stroke and transient ischemic attack (TIA), in the Women's Health Study (WHS).

METHODS

The WHS comprises women health professionals aged 45 and older in the United States. Participants without history of CVE and complete data available to calculate a BCS and covariates 5 years after enrollment were included. Higher BCS reflects better risk factor control, with the minimum score being 0 and the maximum score being 20. Cox proportional hazard models examined the association between BCS and incident CVE adjusted for potential confounders.

RESULTS

A total of 21,271 women were eligible with a median age of 57.9 years (interquartile range: 53.9-63.8) and median BCS of 15 (interquartile range [IQR]:13-16). There were 1,294 incident CVE cases (6.1%) during a median follow-up of 22.4 (IQR: 15.9-23.5) years. A five-point higher baseline BCS was associated with a 37% decrease in the risk of incident CVE after adjusting for age, menopausal status, use of hormonal replacement therapy, and other known cardiovascular disease risk factors (hazard ratio [HR] 0.63, 95% CI 0.56-0.71). This association remained significant after adjusting for race, educational attainment, and income (HR 0.64, 95% CI 0.57-0.72). There was a 28% decreased risk of incident CVE among those with a BCS equal to or above the median compared with those with a BCS below the median, in a fully adjusted model (HR 0.72, 95% CI 0.64-0.80).

DISCUSSION

Higher baseline BCS was associated with a decreased risk of incident CVE in the WHS. Future studies are needed to study the BCS in more diverse populations and to investigate how changes in BCS across the lifespan affect risk of CVE.

Exploring medical gas therapy in hemorrhagic stroke treatment: A narrative review

Hemorrhagic stroke (HS) is a neurological disorder caused by the rupture of cerebral blood vessels, resulting in blood seeping into the brain parenchyma and causing varying degrees of neurological impairment, including intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Current treatment methods mainly include hematoma evacuation surgery and conservative treatment. However, these methods have limited efficacy in enhancing neurological function and prognosis. The current challenge in treating HS lies in inhibiting the occurrence and progression of secondary brain damage after bleeding, which is a key factor affecting the prognosis of HS patients. Studies have shown that medical gas therapy is gaining more attention and has demonstrated various levels of neuroprotective effects on central nervous system disorders, such as hyperbaric oxygen, hydrogen sulfide, nitric oxide, carbon monoxide, and other inhalable gas molecules. These medical gas molecules primarily improve brain tissue damage and neurological dysfunction by regulating inflammation, oxidative stress, apoptosis, and other processes. However, many of these medical gasses also possess neurotoxic properties. Therefore, the use of medical gases in HS deserves further exploration and research. In this review, we will elucidate the therapeutic effects and study the advances in medical gas molecules in HS.

Design and early progress of the Comparison of Anticoagulation and anti-Platelet Therapies for Intracranial Vascular Atherostenosis (CAPTIVA) trial

BACKGROUND

The usual antithrombotic treatment for symptomatic intracranial atherosclerotic stenosis (ICAS) consists of dual treatment with clopidogrel and aspirin for 90 days followed by aspirin alone but the risk of recurrent stroke remains high up to 12 months. The Comparison of Anticoagulation and anti-Platelet Therapies for Intracranial Vascular Atherostenosis (CAPTIVA) trial was designed to determine whether other combinations of dual antithrombotic therapy are superior to clopidogrel and aspirin.

METHODS

CAPTIVA is an ongoing, prospective, double-blinded, three-arm clinical trial at over 100 sites in the United States and Canada that will randomize 1683 high-risk subjects with a symptomatic infarct attributed to 70-99% stenosis of a major intracranial artery to 12 months of treatment with (1) ticagrelor (180 mg loading dose, then 90 mg twice daily), (2) low-dose rivaroxaban (2.5 mg twice daily), or (3) clopidogrel (600 mg loading dose, then 75 mg daily). All subjects receive aspirin (81 mg daily), intensive risk factor management, and will undergo blinded CYP2C19 genotype analysis. The primary goal of the trial is to determine whether rivaroxaban or ticagrelor or both are superior to clopidogrel for lowering the primary endpoint (ischemic stroke, intracerebral hemorrhage (ICH), or vascular death) within 12 months. A prespecified interim safety analysis will be conducted when the first 450 randomized subjects have been followed for 12 months to evaluate the risk of major hemorrhage in the rivaroxaban and ticagrelor arms.

RESULTS

Enrollment began in August 2022 and, as of 26 June 2024, the 450th subject was randomized into the study.

CONCLUSION

CAPTIVA is evaluating two alternative dual antithrombotic therapies to clopidogrel and aspirin to maximize the chance of establishing more effective antithrombotic therapy for symptomatic ICAS, one of the most common and high-risk cerebrovascular diseases worldwide.

The frequency of carotid web in cryptogenic stroke and its association with stroke risk factors

BACKGROUND

The carotid web (CaW) is considered a rare source of cerebral embolism. The aim of this study is to determine the prevalence of CaW, clinical data of CaW cases, risk factors, morphological features of CaW and its relationship with cerebrovascular disease and to contribute to the classification of CaW and the most appropriate treatment approaches in the future.

METHODS

Angiographic images of 1,520 patients who were evaluated with a preliminary diagnosis of cerebrovascular disease and underwent carotid computed tomographic angiography (CTA) and/or digital subtraction angiography (DSA) at Süleyman Demirel University Medical Faculty Hospital and Isparta City Hospital between 2016 and 2022 were examined. 31 CaW patients were included in the study. Radiological imaging, laboratory findings and clinical information of the patients were evaluated retrospectively.

RESULTS

The prevalence of CaW was found to be 2.03 %. 35.5 % of CaW cases were symptomatic and the most common risk factor in these patients were hypertension. The optimum threshold value for CaW length in symptomatic patients was ≥ 2.86 mm. There was a moderate positive linear relationship between CaW length and the degree of CaW stenosis. The optimum threshold value for the degree of web stenosis in symptomatic patients was determined as ≥ 31.33 %.

CONCLUSION

This study showed that some morphological features of CaW increase the risk of stroke. These findings suggest that the evaluation and classification of the morphological features of CaW and the development of risk scoring systems based on these features may be effective in estimating the risk of stroke and planning treatment.

Extended CT angiography versus standard CT angiography for the detection of cardioaortic thrombus in patients with ischaemic stroke and transient ischaemic attack (DAYLIGHT): a prospective, randomised, open-label, blinded end-point trial

BACKGROUND

Cardioembolic sources often remain undetected after standard diagnostic stroke workup, contributing to high rates of recurrence. We aimed to assess whether a head-to-neck CT angiography extended at least 6 cm below the carina (extended CT angiography) can increase the detection of cardioaortic thrombi compared with standard-of-care CT angiography (standard CT angiography) in patients with ischaemic stroke or transient ischaemic attack.

METHODS

This single-centre, prospective, randomised, open-label, blinded end-point trial was done at London Health Sciences Centre, Western University, Canada. Eligible patients were adults aged 18 years or older with ischaemic stroke or transient ischaemic attack assessed during acute code strokes. Exclusion criteria were known allergy or concerns about the safety of iodinated contrast agents (eg, severe renal failure) and no intravenous access. Participants were randomly assigned in a 1:1 ratio to receive standard CT angiography or extended CT angiography. Patients, neurologists adjudicating qualifying events, cardiothoracic radiologists, and cardiologists adjudicating study outcomes were masked to randomisation. Adjudicators were considered masked to randomisation as they did not know which patients were crossovers, which patients in the standard of care arm had partial imaging of the left atrial appendage due to normal variations in size and shape, and which patients in the extended CT angiography group also had partial imaging of the left atrial appendage instead of full imaging. The primary efficacy outcome was the detection of a cardioaortic thrombus (modified intention-to-treat population). The primary safety outcome was time to CT angiography completion (as-treated population). The trial was registered at ClinicalTrials.gov, NCT05522244, and is closed.

FINDINGS

Between July 17, 2023, and May 6, 2024, 963 patients were assessed for inclusion. 133 were excluded because they already had a CT angiography at their local hospital, intracranial haemorrhage was identified on the initial non-contrast CT, a diagnosis of stroke was considered highly unlikely by the treating stroke neurologist, or randomisation was not possible. 830 patients were enrolled and randomly assigned to extended CT angiography (n=415) or standard CT angiography (n=415). One patient withdrew consent and was excluded from the analyses. 364 participants who were later adjudicated as having experienced stroke mimics were excluded. 465 patients with ischaemic stroke or transient ischaemic attack were included in the modified intention-to-treat population (226 in the extended CT angiography group and 239 in the standard CT angiography group). 239 (51%) of 465 patients were female and 226 (49%) were male. Median age of the analysis group at enrolment was 78·0 years (IQR 69·0-84·0). The primary outcome (cardioaortic thrombus) was detected in 20 (8·8%) of 226 patients in the extended CT angiography group and four (1·7%) of 239 in the standard CT angiography group (odds ratio 5·70, 95% CI 1·92-16·96; p=0·002). There were no statistically significant differences in the median time from code stroke activation to CT angiography completion between the extended CT angiography group (21·0 min; IQR 15·8-27·0 min) and the standard CT angiography group (20·0 min, 17·0-26·0 min). The median difference between extended CT angiography and standard CT angiography groups was 1·0 min (-1·0 to 2·5), p=0·67).

INTERPRETATION

Performing extended CT angiography during acute code strokes is feasible and results in increased cardioaortic thrombi detection without causing delays in CT angiography completion. Future studies should assess whether extended CT angiography can reduce recurrent stroke risk by prompting early anticoagulation after thrombus detection.

FUNDING

Western University, and the Kathleen and Dr Henry Barnett Chair in Stroke Research.

Time-dependency of test-retest reliability and measurement error of center-of-pressure synchronization and symmetry during quiet standing within specific frequencies in early sub-acute stroke

BACKGROUND

People with unilateral sensorimotor impairments after a stroke exhibit poor between-limb synchronization and asymmetries in balance control by relying on their less-affected side to maintain stability during standing. Therefore, there is a growing consensus to include center-of-pressure metrics as between-limb synchronization and dynamic control asymmetry when investigating balance improvements poststroke. However, the test-retest reliability of these metrics remains under-investigated, hindering uptake of these assessments in future stroke rehabilitation and recovery studies.

RESEARCH QUESTION

First, are three immediate test-repetitions necessary for obtaining reliable synchronization and asymmetry scores in individuals with sub-acute stroke, or can fewer repetitions suffice? Second, does timing of assessments at 3-, 5-, 8-, and 12-weeks poststroke affect these estimates' test-retest reliability and measurement error?

METHODS

Thirty stroke survivors with moderate-to-severe motor impairments were tested at 3-, 5-, 8-, and 12-weeks poststroke. At each timepoint, they completed three 40-second quiet standing trials on a dual force plate which measured center-of-pressure signals separately on each side. We calculated between-limb synchronization (i.e., cross-correlation) and dynamic control asymmetry (i.e., symmetry index) using the original center-of-pressure signal, and after decomposition into high and low (cut-off 0.4 Hz) frequency bands. Intraclass correlation coefficients (ICC) and Bland-Altman plots were used to assess test-retest reliability and measurement error. A cut-off was used to determine acceptable reliability (ICC>0.75).

RESULTS

Between-limb synchronization and dynamic control asymmetry showed good-to-excellent reliability (ICCs=0.80-0.97) across three repetitions at all timepoints. Reducing to two repetitions yielded acceptable reliability (ICC=0.77-0.95) for dynamic control asymmetry and high-frequency measures, yet insufficient reliability for between-limb synchronization. At the 3-weeks timepoint, ICCs were generally lower, with more error, compared to later timepoints.

CONCLUSION

Novel performance metrics quantifying synchronization and asymmetry of balance control can be reliably obtained during the early sub-acute phase if three test-repetitions are administered per assessment.

The diagnosis and treatment of asymptomatic and symptomatic patients with carotid artery stenosis

Carotid artery atherosclerotic stenosis is an important annual cause of stroke in the United States. Moreover, the incidence of carotid artery stenosis is significantly increasing due to the widespread popularity of high fat and high salt diets, sedentary lifestyles, and the increasing age of the population. Of major importance to cardiovascular specialists is the fact that individuals with atherosclerotic carotid artery stenosis can have a prevalence of atherosclerotic coronary artery disease as high as 50 to 75%. Vascular screening for carotid artery stenosis with Doppler ultrasound should be considered for all symptomatic patients with possible carotid stenosis and also considered for asymptomatic patients with (1) symptomatic peripheral arterial disease, coronary artery disease, or atherosclerotic aortic aneurysm or, (2) multiple atherosclerotic risk factors. Carotid artery atherosclerotic plaques that are at high risk for rupture and thrombosis or cerebral embolization are characterized by large lipid cores, intraplaque hemorrhage, thin fibrous caps less than 165 μms that are infiltrated by macrophages and T cells or have surface ulcer(s) or fissures. Carotid artery plaque rupture with cerebral embolism can cause a stroke, transient ischemic attacks (TIA), or ipsilateral blindness (amaurosis fugax). Medical treatment based on the recommendations of the American and European Societies for Vascular Surgery and the American Heart Association for symptomatic patients with carotid stenosis and also asymptomatic patients with high risk carotid stenosis plaques include antiplatelet drugs, antihypertensive drugs for hypertension control and lipid lowering drugs. Management strategies and decisions about carotid revascularization in asymptomatic patients with high risk carotid stenosis should involve a multidisciplinary team and shared decision-making is recommended. The 30 day and five to 10 year outcomes in asymptomatic carotid stenosis patients who have undergone carotid endarterectomy, carotid stenting and/or optimal medical therapy are summarized from the Veterans Administration Cooperative Study, the Asymptomatic Carotid Atherosclerosis Study and the Asymptomatic Carotid Surgery Trials. The current Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) should help to resolve the debate regarding carotid artery revascularization versus primary medical treatment in asymptomatic patients with >70% carotid artery stenosis. Symptomatic patients who present within 4.5 hours of stroke onset require evaluation for acute intravenous pharmacologic thrombolysis and patients who present with large vessel occlusion within 24 hours of symptom onset should be considered for mechanical thrombectomy to reduce the neurologic deficit. Patients with carotid artery stenosis who present with a history of cerebral infarct in the preceding six months due to cerebral embolism require medical treatment and evaluation by a multidisciplinary team for carotid revascularization in order to prevent future strokes or TIAs. The outcomes of the North American Symptomatic Carotid Endarterectomy Trial, Carotid Revascularization Endarterectomy Versus Stent Trial, Stent-Supported Percutaneous Angioplasty of the Carotid Artery vs. Endarterectomy Trial, and the Safety and Efficacy Study for Reverse Flow Used during Carotid Artery Stenting Procedure trials for symptomatic patients with carotid stenosis are reviewed. A synopsis of treatment guidelines for symptomatic and asymptomatic carotid stenosis patients from the American and European Societies of Vascular Surgery and the American Heart Association/American Stroke Association are presented. Each patient with carotid artery stenosis must be carefully evaluated to determine the best treatment based on the clinical presentation, the imaging and laboratory diagnostic information, the treatment guidelines, and the patient needs and preferences as well as the patient's social and cultural factors.

Effect of subclinical esketamine on NLRP3 and cognitive dysfunction in elderly ischemic stroke patients

Objective

This study investigates the effects of subclinical doses of esketamine on serum NLRP3 levels and early cognitive dysfunction in elderly ischemic stroke patients after neurointerventional procedures under general anesthesia.

Methods

A prospective cohort study included 120 elderly ischemic stroke patients undergoing general anesthesia from January 2022 to September 2023. The esketamine group received 0.25 mg/kg of esketamine. Serum levels of NLRP3, C-reactive protein, interleukin-6 (IL-6), IL-1β, and IL-17 were measured before surgery and 24 h postoperatively. Cognitive dysfunction was assessed using the Mini-Mental State Examination (MMSE).

Results

At 24 h postoperatively, the esketamine group had significantly higher MMSE scores (p < 0.05) and lower serum levels of NLRP3, IL-17, and IL-6. Pearson's correlation showed a link between NLRP3 levels and cognitive outcomes. Logistic regression identified heart rate, mean arterial pressure, preoperative NLRP3, IL-6, IL-17, and esketamine treatment as risk factors for cognitive dysfunction.

Conclusion

Subclinical doses of esketamine might reduce postoperative cognitive dysfunction risk and offer neuroprotection, presenting potential therapeutic options for elderly ischemic stroke patients.

Relationship Between Objective Performance and Patient-Reported Outcomes Measurement Information System Physical Function in Patients With Stroke

BACKGROUND

The relationship between self-reported physical function (PF) and objective performance in patients with stroke remains unclear. This study explored how various self-reported health domains influence the correlation between Patient-Reported Outcomes Measurement Information System (PROMIS) PF and the Timed Up and Go (TUG) test.

METHODS

A retrospective cohort study examined patients with stroke who completed the TUG and PROMIS PF within 90 days post stroke. Correlations between these measures were analyzed, both overall and stratified by performance on other patient-reported outcomes (Quality of Life in Neurological Disorders cognitive function, depression, and the following PROMIS scales: global health, social satisfaction, pain, sleep, and fatigue). Structural equation modeling assessed how these patient-reported outcomes influenced the PROMIS PF-TUG relationship.

RESULTS

There were 432 patients with average age 63.7 (SD 13.5) years. Average TUG and PROMIS PF scores were 16.6 (SD 10.4) seconds and 36.8 (SD 8.5), respectively. TUG and PROMIS PF showed moderate correlation (r=-0.47 [95% CI, -0.54 to -0.40]). Fatigue (r=-0.53 [95% CI, -0.59 to -0.45]) and satisfaction with social roles (r=0.53 [95% CI, 0.45 to 0.60]) had the strongest correlations with PROMIS PF. Both social roles (estimate=0.08, SE=0.02, P=0.001) and fatigue (0.06, SE=0.02, P=0.001) demonstrated indirect effects on the TUG-PROMIS PF relationship. Although not significant, correlations between PROMIS PF and TUG scores were consistently weaker in patients with poor scores in any patient-reported outcome.

CONCLUSIONS

There is only moderate correlation between self-reported PF and the performance measure TUG, which is mediated by fatigue and satisfaction with social roles. These findings highlight the importance of considering these broader dimensions of health in addition to physical capacity when interpreting patient-reported PF scores.

Early neurological deterioration in patients with minor stroke: A single-center study conducted in Vietnam

A minor ischemic stroke is associated with a higher likelihood of poor clinical outcomes at 90 days when there is early neurological deterioration (END). The objective of this case-control study conducted in a comprehensive stroke facility in Vietnam is to examine the frequency, forecast, and outcomes of patients with END in minor strokes. The study employs a descriptive observational design, longitudinally tracking patients with minor strokes admitted to Bach Mai Hospital's Stroke Center between December 1, 2023, and August 31, 2024. Hospitalized within 24 hours of symptom onset, minor stroke patients with National Institutes of Health Stroke Scale (NIHSS) scores ≤ 5 and items 1a, 1b, and 1c on the NIHSS scale, each equal to 0, were included in the study. The primary measure of interest is the END rate, defined as a rise of 2 or more points in the NIHSS score during the first 72 hours after admission. We conduct a logistic regression analysis to identify forecasting factors for END. Out of 839 patients, 88 (10.5%) had END. In the END group, we found that most patients had complications within the first 24 hours of stroke, accounting for 43.2%; the 24 - 48-hour window accounted for 35.2%, and the 48 - 72-hour window accounted for 21.6%. END was associated with a higher likelihood of poor outcomes (mRS 2 - 6) at discharge (OR = 22.76; 95% CI 11.22 - 46.20; p < 0.01), 30 days post-stroke(OR = 24.38; 95% CI 14.40 - 41.29; p < 0.01), and 90 days post-stroke (OR = 21.74; 95% CI 12.63 - 37.43; p < 0.01). Some of the prognostic factors for END were admission NIHSS score (OR = 1.24; 95% CI 1.03 - 1.49; p = 0.02), admission systolic blood pressure greater than 150mmHg (OR = 1.70; 95% CI 1.03 - 2.81; p = 0.04), admission blood glucose (OR = 1.07; 95% CI 1.01 - 1.14; p = 0.02), reperfusion therapy (OR = 3.35; 95% CI 1.50 - 7.49; p < 0.01), use of antiplatelet monotherapy (OR = 3.69; 95% CI 2.24 - 6.08; p < 0.01), internal capsule infarction (OR = 2.54; 95% CI 1.37 - 4.71; p < 0.01), hemorrhagic transformation (OR = 5.72; 95% CI 1.07 - 30.45; p = 0.04), corresponding extracranial carotid artery occlusion (OR = 4.84; 95% CI 1.26 - 18.65; p = 0.02), and middle cerebral artery occlusion OR = 3.06; 95% CI 1.29 - 7.30; p = 0.01). END in minor stroke patients accounts for 10.5% and is a risk factor for poor neurological outcomes. Admission NIHSS score, higher systolic blood pressure, admission blood glucose, reperfusion therapy, use of antiplatelet monotherapy, internal capsule infarction, hemorrhagic transformation, corresponding extracranial carotid artery occlusion, and middle cerebral artery occlusion were some of the prognostic factors for END in our observational study.

SORLA Orchestrates microglial dynamics for enhanced neuroprotection and recovery following ischemic stroke

This study identifies a novel function of Sortilin-related receptor with A-type repeats (SORLA), traditionally linked to Alzheimer's Disease (AD) as a high-risk gene and associated with neuronal function, in modulating microglial responses to ischemic stroke. We discovered that SORLA expression is significantly reduced in microglia following stroke, a change linked to increased brain injury and diminished neurological recovery. Utilizing SORLA knockout and overexpression models, we demonstrated its essential role in adjusting microglial inflammatory responses. Notably, microglial-specific overexpression of SORLA not only promoted anti-inflammatory actions and effective phagocytosis but also surpassed traditional concepts of microglial polarization. This overexpression mitigated brain damage and enhanced neurofunctional recovery post-stroke, highlighting the neuroprotective potential of SORLA. This breakthrough challenges the prevailing understanding the role of SORLA and opens new therapeutic possibilities for stroke recovery, indicating its wider relevance for neurodegenerative disease management.

Long-term risk and characteristics of cerebrovascular events after upper body radiotherapy among childhood cancer survivors in the DCCSS-LATER cohort

Cerebrovascular events (CVEs) are serious late adverse events among childhood cancer survivors. We estimated the incidence and risk factors of symptomatic CVEs and described the clinical characteristics among childhood cancer survivors after upper body radiotherapy. The Dutch Childhood Cancer Survivor Study LATER cohort study includes 5-year childhood cancer survivors diagnosed 50 Gy was associated with 6-fold increased risk, compared to upper body radiotherapy not involving the cranium (hazard ratio = 6.3, 95%CI: 3.3-12.1). In a subgroup with available data on lifestyle and comorbidities, hypertension (odds ratio[OR] = 6.2, 95%CI: 1.6-23.8) and obesity (BMI≥30 vs. <30 = 2.95, 95%CI: 1.1-8.0) significantly increased CVE risk. During CVE episode, 17 (16%) had a life-threatening situation, and two (2%) others died. In 28%, a second CVE developed during follow-up. At end of follow-up, 29% were deceased, and 40% of those alive were unable to carry out normal activities/active work. Childhood cancer survivors treated with higher doses of cranial radiotherapy are at highest risk for developing CVEs. CVEs occur at a young age and cause a high morbidity. Studies to investigate risk-reducing secondary preventive interventions are warranted.

The role of myeloperoxidase in the pathogenesis of stroke

Stroke is the leading cause of mortality and morbidity worldwide, significantly impacting human welfare and overall health. Myeloperoxidase (MPO), a heme peroxidase secreted by neutrophils, plays a crucial role in the body's defense mechanisms, exhibiting pro-inflammatory and pro-oxidative properties. Additionally, MPO compromises the structural integrity and functional capacity of blood vessels, potentially leading to the formation and dislodgement of atherosclerotic plaques, vascular stenosis, thrombosis, and ultimately contributing to stroke occurrence. Following a stroke, a significant influx of neutrophils infiltrates the cerebral tissue, leading to an excessive release of MPO-derived oxidants and the subsequent promotion of various inflammatory mediators, thereby exacerbating cerebral tissue damage. Numerous studies have consistently demonstrated the pivotal role of MPO in the pathogenesis and progression of stroke, establishing it as a reliable prognostic indicator. Exploring the association between MPO and stroke enhances our understanding of the pathological mechanisms underlying stroke and aids in the development of therapeutic interventions. This review provides a comprehensive analysis of the molecular structure and cellular localization of MPO, elucidating its critical role in mediating vascular injury, the formation of Neutrophil Extracellular Traps (NETs), oxidative stress, neuroinflammation, disruption of the blood-brain barrier (BBB), and neuronal apoptosis during stroke pathogenesis. Additionally, we discuss recent advancements in MPO-targeted drugs and Traditional Chinese Medicine compounds as potential therapeutic strategies for stroke treatment.

Left atrial low voltage areas predicts clinical stroke after radiofrequency ablation in patients with atrial fibrillation

BACKGROUND

Current anticoagulation strategies of atrial fibrillation (AF) after radiofrequency ablation (RFCA) are still based on the CHA₂DS₂-VASc scoring system. The predictive value of the CHA2DS2-VASc score is limited and shows only moderate ability to assess risk.[1] Previous studies have shown that the left atrial substrate is associated with thrombosis.[2] Low-voltage areas(LVA) obtained in the left atrium (LA) are an accurate indicator to identify and measure atrial fibrosis. There are limited studies analyzing the association between low-voltage areas and clinical stroke post-RFCA.

METHODS

This retrospective cohort study included 528 patients with non-valvular atrial fibrillation (NVAF) who underwent first-time AF ablation. Intraoperative left atrial voltage mapping was completed using ablation catheter in sinus rhythm after circumferential pulmonary vein isolation (CPVI). Patients were followed up postoperatively and divided into stroke-positive (n = 31) and stroke-negative groups(n = 497) based on clinical stroke occurrence. The association between LA-LVA% and other clinical factors with postoperative clinical stroke was analyzed.

RESULTS

In the stroke-positive group, LVA was more prevalent than in the stroke-negative group [18/31 (58.0 %) vs. 82/497 (16.4 %), p < 0.001]. Multivariate logistic analysis showed a higher prevalence of CHA₂DS₂-VASc scores [OR: 1.34 95 % CI: (1.08-1.66), p = 0.008], LVA% [OR: 1.11 95 % CI: (1.02-1.20), p = 0.019] and LAD [OR: 1.05 95 % CI: (1.01-1.09), p = 0.010] were correlated with the occurrence of clinical stroke in patients after RFCA. In the patients who discontinued anticoagulation therapy (non-anticoagulation subgroup, n = 378), stratified analyses showed that the stroke rate in the low-risk group (0.00 %) was significantly lower than in the intermediate-risk group (4.5 %) and the high-risk group (27.3 %), with significant differences (p < 0.001).

CONCLUSIONS

The LA-LVA% was significantly associated with postoperative clinical stroke. The combination of CHA₂DS₂-VASc score and LA-LVA% can identify low-risk patients.

Efficacy of a Rehabilitation Treatment Using Action Observation Therapy Enhanced by Muscle Synergy-Derived Electrical Stimulation (OTHELLO) in Post-Stroke Patients: A RCT Study Protocol

Background: Action Observation Therapy (AOT) and Neuromuscular Electrical Stimulation (NMES) are widely adopted techniques for upper-limb rehabilitation in post-stroke patients. Although AOT and NMES are individually effective, studies investigating a potential synergistic effect on enhancing rehabilitative outcomes are lacking. Objectives: This study aims at comparing the effect of AOT and NMES applied together (AOT-NMES) on muscle synergies with respect to either AOT alone or a Motor Neutral Observation treatment alone (MNO, involving neither AOT nor NMES) on motor function recovery of upper limb. Design: Randomized Controlled Trial (RCT) with n = 60 post-stroke patients with resulting upper limb disability, randomly allocated (1:1:1 ratio) in three interventional arms: AOT-NMES (n = 20), AOT (n = 20) and MNO (n = 20). Methods and Analyses: All rehabilitation treatments will consist of n°15 60 min-long rehabilitative sessions. Primary outcome measure will be upper limb motor function, assessed using the Fugl-Meyer Assessment scale for upper limb (FM-UL), collected at the baseline (T0), post-intervention (T1) and at follow-up (T2, 6-months after T1). Other outcome measures will be collected through a multidimensional evaluation including assessing stroke-associated quality of life, neurophysiological data, biomechanical and MRI measures. The innovative protocol will also be evaluated for usability and safety. Discussion: We expect to determine the efficacy, usability and safety of the AOT-NMES rehabilitation approach for the recovery of upper limb motor function in post-stroke patients. The obtained results will also help reveal the neural underpinnings of motor recovery, as assessed by neurophysiological data, biomechanical and MRI measures.

Elucidating stroke etiology through lipidomics of thrombi and plasma in acute ischemic stroke patients undergoing endovascular thrombectomy

Acute ischemic stroke (AIS) requires detailed etiology information to guide optimal management. Given the pivotal role of lipids in AIS, we conducted a comprehensive lipidomics analysis of paired thrombi and plasma from AIS patients, correlating the findings with stroke etiology. Patients were recruited across four etiologies: cardioembolism (CE), large artery atherosclerosis (LAA), active cancer (Cancer), and undetermined. Plasma and thrombi were collected before and during endovascular thrombectomy and analyzed using in-house targeted lipidomics. Among 51 patients (37 CE, 7 LAA, 4 Cancer, and 3 undetermined), we identified 37 and 70 lipid species significantly different between thrombi in CE and LAA, and CE and Cancer, respectively (FDR-corrected P < 0.05). No significant differences were observed in plasma. Notably, 21 diacylglycerols and 11 polyunsaturated triacylglycerols were depleted (2.5 to 12 folds) in LAA compared to CE, while 10 ceramides and 57 glycerophospholipids were elevated in Cancer. With 80% validation accuracy, 29 and 59 lipids distinguished LAA and Cancer from CE, respectively. A neural network model using these lipids effectively classified undetermined patients. This study emphasizes the significance of thrombus lipids in distinguishing between LAA, CE, and Cancer etiologies in AIS, enhancing our understanding of stroke pathophysiology and informing future clinical managements.

National cohort study on cardiometabolic index and incident stroke in middle-aged and older adults in China

Background The Cardiometabolic Index (CMI), a novel marker integrating central obesity and lipid metabolism, serves as a comprehensive indicator of metabolic health. While CMI has been linked to metabolic disorders like diabetes and cardiovascular diseases, its role in predicting stroke risk remains unclear. This study examines the association between CMI and stroke risk in Chinese adults aged 45 and older, highlighting its potential as a predictive tool for public health.

METHODS

Data from the China Health and Retirement Longitudinal Study (CHARLS) were analyzed. Participants were divided into CMI quartiles. Stroke incidence was the primary endpoint. Cox proportional hazards models evaluated the CMI-stroke risk association. Kaplan-Meier curves compared stroke incidence across quartiles, while restricted cubic splines (RCS) assessed non-linear trends. Subgroup analyses verified robustness.

RESULTS

Among 7,821 participants (47 % male), 418 strokes (5.3 %) occurred over a mean follow-up of 7 years. Higher CMI was significantly associated with increased stroke risk [HR, 1.153 (95 % CI: 1.048-1.269), P = 0.004]. RCS revealed a non-linear rise in stroke risk with increasing CMI (P for nonlinearity = 0.005). No significant interactions were observed between CMI and subgroups (all P > 0.05).

CONCLUSION

Elevated CMI correlates with higher stroke risk in middle-aged and older Chinese adults. Incorporating CMI into routine assessments could improve early stroke prevention strategies, addressing the increasing burden of cerebrovascular disease in aging populations.

Automatic prediction of stroke treatment outcomes: latest advances and perspectives

Stroke is a major global health problem that causes mortality and morbidity. Predicting the outcomes of stroke intervention can facilitate clinical decision-making and improve patient care. Engaging and developing deep learning techniques can help to analyse large and diverse medical data, including brain scans, medical reports, and other sensor information, such as EEG, ECG, EMG, and so on. Despite the common data standardisation challenge within the medical image analysis domain, the future of deep learning in stroke outcome prediction lies in using multimodal information, including final infarct data, to achieve better prediction of long-term functional outcomes. This article provides a broad review of recent advances and applications of deep learning in the prediction of stroke outcomes, including (i) the data and models used, (ii) the prediction tasks and measures of success, (iii) the current challenges and limitations, and (iv) future directions and potential benefits. This comprehensive review aims to provide researchers, clinicians, and policy makers with an up-to-date understanding of this rapidly evolving and promising field.

Renal arteriosclerosis in kidney biopsies associated with higher 10-year atherosclerotic cardiovascular disease in lupus nephritis

OBJECTIVE

Patients with lupus nephritis (LN), including those below age 50, face significantly higher risk of atherosclerotic cardiovascular disease (ASCVD) vs peers. This highlights the need for identifying specific ASCVD risk factors in LN. Renal arteriosclerosis in kidney biopsies (subclinical arteriosclerosis) may be able to predict future clinical ASCVD events. However, renal arteriosclerosis is under-reported in LN biopsies and is not taken into consideration when ASCVD risk is calculated. Therefore, we aimed to systematically grade renal arteriosclerosis in kidney biopsies at LN diagnosis and examined associations with 10-year and 20-year ASCVD occurrence.

METHODS

Adults with biopsy-proven LN were included. Clinical ASCVD, including fatal and non-fatal events, were adjudicated. Utilizing standard Banff grading criteria, all biopsies at LN diagnosis were re-read to grade renal arteriosclerosis. Covariables (e.g. socio-demographics, comorbidities, med exposure) were abstracted. Using Cox models, factors (including renal arteriosclerosis) associated with 10-year and 20-year clinical ASCVD were examined.

RESULTS

Among 209 patients, 36 and 49 clinical ASCVD occurred within 10 and 20 years. Renal arteriosclerosis (>25%) was associated with 3× higher 10-year ASCVD. High area deprivation index (>80) and longer angiotensin converting enzyme inhibitor (ACEi) exposure were associated with 4× higher and 0.65× lower ASCVD occurrence. Adding renal arteriosclerosis >25% improved model performance for 10-year ASCVD risk estimation from 65% to 80%. Similar associations were seen with 20-year ASCVD.

CONCLUSION

Renal arteriosclerosis >25%, area deprivation and ACEi exposure could inform ASCVD risk stratification in LN. Prospective studies should validate findings and inform clinical use.

Taking Food to Mouth: Correlation Between Repetitive Movement and Upper Limb Flexion Synergy After Stroke

BackgroundPathological upper-limb synergistic movement is a prevalent symptom of post-stroke motor dysfunction and pose a significant challenge in the rehabilitation of hemiplegia. However, the underlying mechanisms remain elusive, hindering the development of effective therapeutic strategies.ObjectiveThis study aims to explore the mechanisms underlying pathological synergic movements post-stroke by examining the interrelationship between motor modules associated with upper limb flexion synergy and the repetitive action of "taking food to the mouth."MethodsSurface electromyography (sEMG) was employed to capture the EMG signals of normal elbow flexion, the act of "taking food to the mouth," and post-stroke upper limb flexion synergy. Non-negative matrix factorization (NMF) was employed to compare and analyze the corresponding modular and coefficient matrices derived from these three motor tasks.ResultsThe modular matrix associated with flexion synergy exhibited the most significant correlation with the "taking food to the mouth" task, whereas the coefficient matrix shared the lowest correlation.ConclusionUpper limb flexion synergy after stroke may be related to the activation of the highly excitatory motor module formed by previously repeated movement of "taking food to mouth".

Transcranial Doppler Monitoring of the Wolf Procedure Versus Conventional Ablation to Treat Atrial Fibrillation

BACKGROUND AND PURPOSE

Transfemoral radiofrequency ablation (tfRFA) is the most performed procedure to address atrial fibrillation (AF); however, tfRFA produces thousands of microemboli that can reach major cerebral arteries and cause silent ischemic lesions. We measured the microembolization rate during an alternative procedure, the Wolf Procedure (formerly Mini-Maze), to address AF and compared our findings with the literature.

METHODS

We used transcranial Doppler monitoring on 10 patients with AF (seven permanent, three paroxysmal) who underwent the Wolf Procedure at Houston Methodist Hospital. Intraoperative emboli, mean flow velocity, and pulsatility index in the middle cerebral artery were monitored and recorded. Standard of care follow-up visits were done at Houston Methodist Hospital. During these visits, the patients' loop recorder and current heart rhythm were analyzed.

RESULTS

Overall, we saw an average of 4.7 high-intensity transient signals (HITS) in our 10 patients with a median of 3 HITS (interquartile range = 1-5.25), which is markedly less than the thousands of HITS typically reported in the literature for cases that use tfRFA. In two of the 10 Wolf Procedure cases, zero microembolus was detected. At their last follow-up appointments, nine out of 10 patients were in sinus rhythm.

CONCLUSION

The Wolf Procedure is a safe surgical option for AF treatment with a high success rate even after one procedure. The number of emboli during The Wolf Procedure appears to be markedly lower than that during tfRFA, which reduces patient risk for transient ischemic attack, stroke, and silent ischemic brain lesions.

Differences in door-to-device times in a retrospective cohort of patients with ischemic stroke who received CTA only or CTA and CTP imaging

BACKGROUND

In the treatment of acute ischemic stroke, there are differing views about the utility of computerized tomography perfusion (CTP). Two approaches are employed depending on hospital preference. The first approach is to perform non-contrast computed tomography (CT) scans followed by vascular imaging with computed tomography angiography (CTA) for patients arriving within 6 h of last known well. In the first approach, CTP is reserved for patients who arrive 6-24 h after last known well. The second approach is to utilize both CTA and CTP regardless of the time window in which the patient presents. In this study, we sought to answer whether patients triaged with CTP and CTA had increased door-to-device times compared to those only triaged with CTA.

METHODS

We investigated a retrospective cohort of 1,357 patients with ischemic stroke who received endovascular therapy (EVT) and were triaged with CTA only or CTA and CTP. Patients were stratified by when they arrived at the hospital (<6 h and 6-24 h from last known well). Linear mixed-effects models (LMM) were used to investigate the association between door-to-device times and CTA/CTP usage.

RESULTS

Our results showed that using CTP and CTA was not associated with increased time to treat compared to CTA alone. There was no increase in time from door to device in patients presenting within 6 h. Furthermore, for patients who arrived 6-24 h of last known well, the use of CTP and CTA was associated with an accelerated time to treatment with EVT.

CONCLUSIONS

CTA and CTP usage was not associated with added time costs with respect to door-to-device in this patient cohort. Our results are consistent with other data showing that radiologists have faster read times when given both CTP and CTA. It is noteworthy that the majority of EVT patients in our dataset (70.6 %) presented in the <6-hour time window.

Acute Ischemic and Hemorrhagic Cerebrovascular Strokes After Cardiac Surgery: Incidence, Predictors, and Outcomes

Background: Many studies have attempted to determine the incidence, predictors, and outcomes of cerebrovascular stroke after cardiac surgery, with different, sometimes contradictory, results because of differences in population risk profiles, study design, and surgical details. Methods: We retrospectively reviewed the records of all adult patients who underwent cardiac surgery between January 2018 and January 2023. Univariate, multivariable, and survival analyses were performed to identify the outcomes and predictors of ischemic and hemorrhagic strokes. Results: Of the 1334 patients studied, 70 (5.2%) patients had ischemic stroke, 23 (1.7%) had intracranial hemorrhage (ICH), and 9 (0.7%) had combined ischemic and hemorrhagic strokes. The patients who developed strokes had longer cardiopulmonary bypass (CPB) time (165.5 [126, 234] versus 136 [104, 171] min, p < 0.001) and aortic cross-clamping time (112 [79, 163] versus 89 [75, 121.5] min, p < 0.001), with higher rates of intra-aortic balloon pump (IABP) use (13.3% vs. 4.4%, p < 0.001), veno-arterial extracorporeal membrane oxygenation use (24.8% vs. 12.37%, p < 0.001), and mediastinal exploration for bleeding (22.9% vs. 8.9%, p < 0.0011). The patients who developed strokes showed increased hospital mortality (37.1% vs. 5.6%, p < 0.001), new need for dialysis (29.5% vs. 10.7%, p < 0.001), higher rate of tracheostomy (13.3% vs. 1.2%, p < 0.001), and longer intensive care unit (ICU) stay (12 [7, 28] versus 3 [2, 8] days, p < 0.001) and post-ICU stay (16 [7, 39] versus 5 [3, 10] days, p < 0.001). Follow-up for 36.4 (21.67, 50.7) months revealed an insignificant mortality difference, but there was an increased risk of recurrent cerebrovascular strokes. Cox-proportional hazards regression showed an increased risk of hospital mortality after cardiac surgery in patients who developed acute ischemic stroke (HR: 5.075, 95% CI: 3.28-7.851, p < 0.001) and ICH (HR: 12.288, 95% CI: 7.576-19.93, p < 0.001). Logistic multivariable regression showed that increased age, hyperlactatemia, redo cardiotomy, history of old stroke, CPB time, and perioperative IABP use were the predictors of ischemic stroke. Young age, old ICH, hyperlactatemia, and hypoalbuminemia were the predictors of postoperative ICH. Postoperative ICH, ischemic stroke, atrial fibrillation, chronic kidney disease, blood lactate level 24 h after surgery, and increased age were the independent predictors of mortality. Conclusions: Ischemic and hemorrhagic cerebrovascular strokes are serious complications that increase postoperative mortality and prolong hospitalization after cardiac surgery. Atrial fibrillation was not a significant predictor of postoperative stroke but was a predictor of hospital mortality. Careful attention should be given to maintaining hemodynamic stability and minimizing CPB time, especially in patients with a history of cerebrovascular strokes and redo cardiotomy.

Recurrent ischemic stroke in young adults: A multicenter cohort study, systematic review, and meta-analysis

BACKGROUND

Recurrent ischemic stroke (IS) disproportionately affects individuals in their most productive years, contributing to significant morbidity and mortality. Despite its growing importance, data on this critical population remain limited.

AIM

The aim of the study is to characterize rates and factors associated with recurrent IS in young adults.

METHODS

We performed a retrospective multicentre cohort study of consecutive acute IS patients aged 18-50 years from three tertiary hospitals in Singapore and Christchurch, New Zealand. We characterized rates and prognostic factors associated with recurrent IS over 1-year follow-up using univariate and multivariable Cox Proportional Hazards models. We then performed a systematic review and meta-analysis of PubMed, Embase, Scopus and Cochrane databases for all studies from January 2000 to July 2024 evaluating recurrent stroke or transient ischemic attack (TIA) following an index IS or TIA. We meta-analyzed rates and factors associated with recurrent cerebrovascular events based on aggregate count, aggregate survival, and individual patient-level survival data reconstructed from Kaplan-Meier curves.

RESULTS

The cohort study of 845 patients showed a 3.41% (95% confidence interval (CI) = 2.16-4.64) recurrence rate over 1-year follow-up. Patients with diabetes mellitus and prior stroke/TIA had significantly higher rates of recurrent IS. The systematic review and meta-analysis of 18,955 patients across 31 studies yielded a recurrence rate of 4.5-7.3% at 1 year, 10.5-12.8% at 5 years, and 14.0-20.3% at >10 years. Large artery atherosclerosis (LAA) etiology, hypertension, diabetes mellitus, and prior stroke/TIA were significantly associated with recurrent stroke or TIA.

CONCLUSIONS

Young adults with IS face a long-term risk of recurrent cerebrovascular events. More prospective studies are warranted to better characterize long-term prognosis for these patients.

Microaxial pump-supported coronary surgery without CPB to optimize outcome in severely impaired left ventricles

AIMS

Cardiopulmonary bypass (CPB) is the standard approach for coronary artery bypass grafting (CABG) in advanced ischaemic cardiomyopathy. Microaxial pump support has been envisioned to allow for beating-heart CABG without CPB (MPCAB), thereby avoiding CPB-inherent complications. This study aims to compare the in-hospital and follow-up outcome of MPCAB versus CPB-CABG in patients with severely impaired left ventricular function.

METHODS AND RESULTS

Eleven patients suffering from three-vessel coronary artery disease with median ejection fraction of 27% and deemed appropriate for CABG according to a heart team decision underwent MPCAB (support up to 5.5 L/min). Propensity score matching generated a CPB-CABG control group (n = 33). The primary endpoint was defined as death from any cause by the end of the follow-up (up to 4 years). MPCAB enabled continuous intraoperative and postoperative haemodynamic stabilization and complete myocardial revascularization. After CPB-CABG, additional mechanical circulatory support was required in 45.5% (vs. 9.1% in MPCAB; P = 0.0363). The follow-up all-cause mortality after MPCAB amounted to 0% (vs. 33.3% after CPB-CABG; P = 0.0414; NNT = 3). MPCAB patients showed a significantly decreased occurrence of major adverse cardiovascular events (MACE: 0% vs. 39.4%; P = 0.0189).

CONCLUSIONS

MPCAB allows for complete surgical revascularization without the necessity of extracorporeal circulation in spite of severely impaired left ventricular function. This first comparative study on the outcome after MPCAB versus CPB-CABG demonstrates a significantly decreased risk of death as well as MACE in MPCAB patients. The MPCAB concept expands the spectrum of patients eligible for CABG without CPB towards patients with severely impaired left ventricular function.

Late neurological improvement during hospitalization is a predicative factor for acute ischemic stroke

PURPOSE

This study aimed to investigate whether late neurological improvement (LNI) during hospitalization serves as a favorable prognostic indicator in patients with acute ischemic stroke (AIS) and to identify the predictors of LNI.

METHODS

We retrospectively analyzed data from the Safe Implementation of Treatments in Stroke (SITS) registry at two stroke centers in Egypt. LNI was defined as the lack of early neurological improvement (ENI) within 24 h after admission, accompanied by neurological improvement within 7 days of hospitalization. Multivariate logistic regression was employed to analyze the factors influencing favorable prognosis (modified Rankin Scale score 0-2) and LNI.

RESULTS

A total of 834 patients with AIS were included in this study, of which 130 (15.6%) exhibited LNI. Among these, 99 (76.2%) achieved favorable outcomes. Both ENI (OR = 6.756, 95% CI 3.355-13.603, P < 0.001) and LNI (OR = 5.760, 95% CI 3.146-10.545, P < 0.001) were independently associated with favorable prognosis after adjustment. Predictors of LNI in multivariable-adjusted logistic regression included younger age (OR = 0.973, 95% CI 0.957-0.990, P = 0.001), higher baseline National Institutes of Health Scale (NIHSS) score (OR = 1.196, 95% CI 1.146-1.248, P < 0.001), and rt-PA treatment (OR = 1.953, 95% CI 1.206-3.163, P = 0.006).

CONCLUSIONS

Approximately three-quarters of patients with LNI are expected to achieve good outcome. LNI was a favorable prognostic indicator in patients with AIS and younger age, higher baseline NIHSS score and rt-PA treatment predicted LNI.

Advancing Ischemic Stroke Prognosis: Key Role of MiR-155 Non-Coding RNA

Ischemic stroke (IS) is the leading cause of long-term disability and the second leading cause of death worldwide. It remains a significant clinical problem because only supportive therapies exist, such as thrombolytic agents and surgical thrombectomy, which do not restore function. Understanding the molecular pathogenesis of IS, including dysfunction in oxidative homeostasis, apoptosis, neuroinflammation and neuroprotection, is crucial to developing therapies. Non-coding RNAs (ncRNAs) are master regulators, and one ncRNA that stands out is miR-155, a pro-inflammatory micro-RNA elevated in stroke. This review addresses the biological mechanisms reported in the literature that support using miR-155 as a biomarker and therapeutic agent to treat IS in patients.

High-sensitivity C-reactive protein and risk of retinal artery occlusion and ischaemic stroke: a cross-cohort study

AIMS

Previous studies have suggested an association between retinal artery occlusion (RAO) and ischaemic stroke (IS), both associated with elevated inflammatory factors. However, the role of high-sensitivity C-reactive protein (hs-CRP) in the sequential onset of these two diseases is still unclear. Based on this evidence, we evaluated the association of hs-CRP with RAO and IS.

METHODS

We examined hs-CRP from both the large multicentre cohort study UK Biobank and Chinese Retinal Artery Occlusion study. Cox proportional hazard models were used to study the association of hs-CRP with incident RAO and IS during the long-term follow-up in the UK Biobank. Logistic regression analysis was employed to assess the cross-sectional relationship between hs-CRP with RAO and IS in the Chinese cohort. A restricted cubic spline (RCS) approach was employed to evaluate potential non-linear associations of hs-CRP with IS.

RESULTS

After exclusions, the analysis included 459 188 participants from the UK and 338 participants from China. Over a median follow-up of 12.2 years, 136 cases of incident RAO and 3206 cases of incident IS events were recorded in the UK Biobank. After multivariable adjustment, higher hs-CRP (per 10 mg/L) level was associated with increased risks of RAO (HR: 1.34, 95% CI: 1.01 to 1.76) and IS (HR: 1.24, 95% CI: 1.17 to 1.33). RCS analysis revealed a significant non-linear relationship between hs-CRP levels and incident IS (Pnon-linear<0.001). Furthermore, RAO patients with higher hs-CRP levels were more likely to be combined with IS (2.81 mg/L vs 10.14 mg/L, p<0.001). In the Chinese cohort, the association between hs-CRP with RAO and IS was further confirmed. Higher hs-CRP (per 1 mg/L) level was associated with increased risks of RAO (OR: 1.43, 95% CI: 1.15 to 1.78) and IS (OR: 1.13, 95% CI: 1.03 to 1.24).

CONCLUSIONS

Our findings underscore hs-CRP as a robust risk factor for both RAO and IS. Controlling hs-CRP levels might reduce the incidence of RAO and secondary stroke.

Prognostic value of a combination of cardiac biomarkers and risk indices for major adverse cardiovascular events following non-cardiac surgery in geriatric patients: a prospective cohort study

Major adverse cardiovascular events (MACEs) in geriatric patients are an important cause of increased mortality and morbidity. The results of current studies regarding the predictive value of the NT-proBNP, H-FABP, and AUB-HAS2 scales for cardiovascular complications are inconsistent, and there is no relevant large sample study. Therefore, this study aimed to investigate whether preoperative NT-proBNP, H-FABP, and AUB-HAS2 alone or in combination can effectively predict postoperative cardiovascular complications in geriatric patients. A total of 1736 geriatric patients (aged ≥ 65 years) who were scheduled for elective non-cardiac surgery under general anesthesia were enrolled. AUB-HAS2 risk assessment is required for each patient, and blood was collected 1 h before surgery for the measurement of NT-proBNP and H-FABP. The primary outcomes were MACEs within 30 days after surgery. The secondary outcomes were other complications. Its predictive value was analyzed by receiver operating characteristic (ROC) curves. Of the 1736 patients, 71 (4.1%) had MACEs. NT-proBNP was a predictor of MACEs (AUC = 0.763; 95% CI 0.695-0.832; P < 0.001). When H-FABP was combined with AUB-HAS2, AUB-HAS2 increased the predictive value of H-FABP (AUC = 0.736; 95% CI 0.673-0.799; P < 0.001). Multiple logistic regression analysis revealed increased predictive value of the modified AUB-HAS2 scale for MACEs (AUC = 0.794, 95% CI = 0.737-0.851, P < 0.001). Our study revealed the predictive efficacy and prognostic value of NT-proBNP, H-FABP and the AUB-HAS2 score alone or in combination for postoperative MACE risk assessment in geriatric patients undergoing non-cardiac surgery.This trial was registered at the Chinese Clinical Trial Registry (2019/09/27 ChiCTR1900026223, https://www.chictr.org.cn ).

Predictors of pre-hospital delay among stroke patients in Yekatit-12 hospital Addis Ababa, Ethiopia: unmatched case-control study

BACKGROUND

Timely detection and early medical interventions are critical in reducing complications and mortality related to stroke. The duration from onset to hospital presentation is an essential factor in determining the outcome of stroke treatment. The sooner a stroke patient receives medical attention, the better the chances of preventing long-term complications. Pre-hospitalization delays can significantly decrease the chances of successful therapy and recovery from stroke.

OBJECTIVE

The study aims to assess predictors of delayed hospital presentation after a stroke attack.

METHOD

An unmatched case-control study was conducted from September 2021 to November 2023 at Yekatit 12 Hospital Medical College. Descriptive statistics were used to describe study variables. Bivariable and multivariable logistic regression were used to identify the predictors of delay hospital presentation after stroke attack. All statistical tests were run with a significance threshold of 5%.

RESULT

A total of 83 cases (presenting after four hours) and 166 controls (presenting within four or fewer hours) of an acute stroke patients were included in this study. The median duration of symptoms from the onset of stroke to hospital arrival were 24 h (IQR, 12 h) and 2 h(IQR,1 h) for cases and controls respectively. The study found that age 60 or less (AOR 1.75, 95% CI 1-3.09, p < 0.05), living outside of Addis Ababa (AOR 3.55, 95% CI 1.33-9.46, p < 0.011), onset of stroke happening at night (AOR 1.75, 95% CI 1.2-3.1, p < 0.05) and not having health insurance (AOR 0.43, 95% CI 0.23-0.8,p < 0.007) were identified as predicting factors of late presentation to hospital in stroke patients.

CONCLUSION

This study highlights key predictors of delayed hospital presentation in stroke patients. Specifically, age, place of residence, health insurance, and stroke onset time were significantly influence the timeliness of seeking medical care. Recognizing and addressing the predicting factors can improve the health care treatment outcome and help to design targeted health policies that reduce barriers to timely presentation of stroke patients.

Return to Work After Ischemic Stroke in Young Adults: A Multicenter Cohort Study, Systematic Review, and Meta-Analysis

BACKGROUND

Ischemic stroke incidence in young adults is increasing globally, with return to work (RTW) a key rehabilitation goal. We aimed to assess the overall proportions of and factors associated with RTW following young adult ischemic stroke.

METHODS AND RESULTS

We performed a retrospective cohort study of all patients with ischemic stroke aged 18 to 50 years at 2 tertiary hospitals in Singapore from 2020 to 2022. We evaluated associations between patient characteristics and 3-month RTW status, augmenting these findings with a systematic review and meta-analysis of PubMed, Embase, Scopus, and Cochrane databases from January 2000 to November 2023. We pooled proportions for RTW and functional recovery (defined as a 90-day modified Rankin Scale score of 0-2) and meta-analyzed associations between patient characteristics and RTW using random-effects models. In this multicenter cohort, 68.8% (249/362) of young patients with ischemic stroke returned to work, while 87.8% (318/362) achieved functional recovery. Multivariable logistic regression showed that patients with large-artery atherosclerosis pathogenesis, diabetes, higher admission National Institutes of Health Stroke Scale scores, and higher 90-day modified Rankin Scale had significantly lower odds of RTW. The systematic review and meta-analyses of 1914 patients across 6 cohort studies identified significantly lower odds of RTW in patients with large-artery atherosclerosis, diabetes, and admission National Institutes of Health Stroke Scale SCORE >15. The pooled proportion of RTW was 63.2% (984/1574 [95% CI, 56.0-69.9]) and functional recovery 84.7% (719/846 [95% CI, 81.1-87.8]).

CONCLUSIONS

Patients with large-artery atherosclerosis, diabetes, and higher admission National Institutes of Health Stroke Scale score at baseline are less likely to RTW. While lower 90-day modified Rankin Scale is significantly associated with RTW, many patients achieving functional recovery do not RTW. Well-designed cohort studies are warranted to explore this disparity.

Stroke risk management in carotid atherosclerotic disease: a clinical consensus statement of the ESC Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Diseases

Carotid atherosclerotic disease continues to be an important cause of stroke, often disabling or fatal. Such strokes could be largely prevented through optimal medical therapy and carotid revascularization. Advancements in discovery research and imaging along with evidence from recent pharmacology and interventional clinical trials and registries and the progress in acute stroke management have markedly expanded the knowledge base for clinical decisions in carotid stenosis. Nevertheless, there is variability in carotid-related stroke prevention and management strategies across medical specialities. Optimal patient care can be achieved by (i) establishing a unified knowledge foundation and (ii) fostering multi-specialty collaborative guidelines. The emergent Neuro-Vascular Team concept, mirroring the multi-disciplinary Heart Team, embraces diverse specializations, tailors personalized, stratified medicine approaches to individual patient needs, and integrates innovative imaging and risk-assessment biomarkers. Proposed approach integrates collaboration of multiple specialists central to carotid artery stenosis management such as neurology, stroke medicine, cardiology, angiology, ophthalmology, vascular surgery, endovascular interventions, neuroradiology, and neurosurgery. Moreover, patient education regarding current treatment options, their risks and advantages, is pivotal, promoting patient's active role in clinical care decisions. This enables optimization of interventions ranging from lifestyle modification, carotid revascularization by stenting or endarterectomy, as well as pharmacological management including statins, novel lipid-lowering and antithrombotic strategies, and targeting inflammation and vascular dysfunction. This consensus document provides a harmonized multi-specialty approach to multi-morbidity prevention in carotid stenosis patients, based on comprehensive knowledge review, pinpointing research gaps in an evidence-based medicine approach. It aims to be a foundational tool for inter-disciplinary collaboration and prioritized patient-centric decision-making.

Ischemic stroke as a presenting feature of neurosyphilis in an immunocompetent adult and attained complete recovery following treatment: a case report and review of the literature

BACKGROUND

Neurosyphilis typically presents with nonspecific symptoms such as behavioral changes or cognitive impairment, rather than an initial stroke.

CASE PRESENTATION

This case report describes a Black African man in his thirties who experienced sudden weakness on the left side of his body. Computed tomography suggested a nucleo-capsular ischemic lesion. However, given his young age and lack of traditional stroke risk factors, further investigations were pursued. Laboratory tests revealed positive results for syphilis in both blood and cerebrospinal fluid. Additional imaging (head and neck angiography) indicated intracranial vasculitis with widespread and acute ischemia in the right hemisphere. Treatment with ceftriaxone and aspirin was initiated. Through ongoing monitoring and care, the patient's neurological condition improved.

CONCLUSION

The case underscores the critical need for prompt diagnosis and comprehensive assessment in patients experiencing stroke-like symptoms, especially in younger individuals. By recognizing neurosyphilis as a potential cause, healthcare providers can initiate timely treatment and improve patient outcomes.

Efficacy and safety of intra-arterial thrombolysis following successful endovascular thrombectomy in patients with large vessel occlusion stroke: A meta-analysis

INTRODUCTION

The impact of intra-arterial thrombolysis (IAT) following successful endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) remains uncertain. This study aims to assess the efficacy and safety of IAT as an adjunct to EVT in patients with AIS-LVO.

PATIENTS AND METHODS

We searched PubMed, Embase, and Cochrane databases to identify randomized controlled trials (RCTs) that compared EVT + IAT with EVT-only for AIS-LVO. The primary outcome was an excellent functional outcome, defined as a modified Rankin Scale (mRS) score of 0-1 at 90 days. Secondary outcomes included functional independence (mRS 0-2), symptomatic intracranial hemorrhage (sICH), and mortality. The pooled data were analyzed using random-effects models.

DISCUSSION AND CONCLUSION

A total of four RCTs, involving 1395 patients, were included in the analysis. The results showed that patients who received EVT + IAT had a significantly higher likelihood of achieving an excellent functional outcome at 90 days compared to those who received EVT-only (risk ratio [RR], 1.16; 95% confidence interval [CI], 1.03-1.31). No statistically significant differences were observed between the EVT + IAT and EVT-only groups in terms of 90-day functional independence (RR, 1.03; 95% CI, 0.94-1.13), sICH (RR, 1.30; 95% CI, 0.80-2.13), or 90-day mortality (RR, 0.94; 95% CI, 0.76-1.17).

CONCLUSIONS

Among patients with AIS-LVO who have undergone successful EVT, the use of adjunct IAT, compared to no additional treatment, was associated with a greater likelihood of achieving an excellent functional outcome at 90 days.

SYSTEMATIC REVIEW REGISTRATION

CRD42024602099.

Bilirubin as a predictor of severity and adverse clinical outcomes of acute ischemic stroke: a systematic review and meta-analysis

BACKGROUND

This review aims to comprehensively examine the role of bilirubin in predicting severity and adverse clinical outcomes in patients with acute ischemic stroke (AIS).

METHODS

We searched the electronic PubMed, Embase, Scopus, and Web of Science repositories for articles published in English available before the 15th of June 2024. The outcomes assessed were stroke severity, haemorrhagic transformation, symptomatic intracranial haemorrhage (sICH), mortality, and poor functional results.

RESULTS

We analysed data from 13 studies. Our meta-analysis showed that both total bilirubin (RR, 1.10; 95% CI, 1.01-1.19) and direct bilirubin (RR, 1.79; 95% CI, 1.33-2.42) were independently associated with the severity of AIS. Higher quartiles of total bilirubin were associated with an increased risk of haemorrhagic transformation, but without statistical significance (RR, 2.34; 95% CI, 0.90-6.07). In addition, each unit increase in direct (RR, 1.25; 95% CI, 1.09-1.43) and indirect (RR, 1.09; 95% CI, 1.02-1.17) bilirubin levels was significantly associated with a higher risk of haemorrhagic transformation. Moreover, each unit increases in total (RR, 1.08; 95% CI, 1.04-1.12), direct (RR, 1.28; 95% CI, 1.13-1.44), and indirect (RR, 1.10; 95% CI, 1.03-1.18) bilirubin levels was significantly associated with a higher risk of sICH. Data on mortality and poor functional outcomes were insufficient.

CONCLUSION

Serum bilirubin levels were positively associated with the severity of AIS. The evidence suggests that bilirubin may be a potential indicator for haemorrhagic transformation and sICH after AIS.

Prediction of Recurrent Venous Thromboembolism and Arterial Cardiovascular Events after Discontinuation of Anticoagulation: The R-VTE-predict and MACE-predict Risk Scores

Patients who had venous thromboembolism (VTE) are not only at increased risk of recurrent VTE but also of major adverse cardiovascular events (MACEs) than the general population. Therefore, the prediction of the risk of these events is important for a tailored prevention and mitigation strategy. We aimed to develop simple scores to estimate recurrent VTE and MACE risks after the discontinuation of anticoagulation in a large cohort of individuals who suffered VTE (EDITH cohort). The primary endpoints were recurrent symptomatic VTE and MACE (composite of non-fatal acute coronary syndrome, stroke and cardiovascular death). Arterial thrombotic event (ATE) exclusively was also considered. Independent predictors of main outcomes were derived from multivariable Cox regression models. Weighted integer points based on the effect estimate of identified predictors were used to derive the final risk scores. A total of 1,999 participants (mean age: 54.78 years, 46.4% male, 43.6% unprovoked VTE) were included in the derivation cohort and 10,000 in the validation cohort (built using bootstrapping). During a median post-anticoagulation follow-up of 6.9 years, recurrent VTE occurred in 29.5% of participants and MACE in 14.8%. Independent predictors of recurrent VTE were male sex, age >65 years, cancer-associated VTE, and unprovoked VTE (vs. transient risk factor-associated VTE). Independent predictors of MACE were age >65 years, cancer-associated VTE, hypertension, renal insufficiency, and atrial fibrillation. The risk of recurrent VTE (moderate vs. low: hazard ratio [HR]: 2.62, 95% confidence interval [CI]: 2.06-3.34; high vs. low: HR: 3.78, 95% CI: 2.91-4.89), MACE (moderate vs. low: HR: 6.37, 95% CI: 3.19-12.69; high vs. low: HR: 12.32, 95% CI: 6.09-24.89), and ATE (based on MACE-predict risk score) increased gradually from the lowest to highest of the respective prediction risk score groups. These results were confirmed in the validation cohort with overall reasonable models' discrimination performance (recurrent VTE C-statistic: 0.62-0.63, MACE and ATE C-statistic: 0.72-0.77). Contemporary simple risk scores based on readily available clinical characteristics can reasonably predict the risk of recurrent VTE and MACE after the discontinuation of anticoagulation. These findings may influence the choice of anticoagulation strategy after the acute phase of VTE and, therefore, need confirmation by further studies.

The clinical value of triglyceride to high-density lipoprotein cholesterol ratio for predicting stroke-associated pneumonia after spontaneous intracerebral hemorrhage

OBJECTIVE

Stroke-associated pneumonia (SAP) is relevant to the poor functional outcomes of patients with spontaneous intracerebral hemorrhage (SICH). It is unclear if the triglyceride (TG) to high-density lipoprotein cholesterol (HDL-C) ratio (TG/HDL-C) is related to the risk of SAP in SICH patients. This study aimed to investigate the association between TG/HDL-C and SAP in SICH patients.

METHODS

Consecutive patients with SICH were enrolled in this retrospective study. Relevant clinical variables were extracted from electronic medical records. All enrolled participants were divided into SAP (n = 71) and non-SAP (n = 187) groups. Multivariate binary logistic regression analysis was used to explore the association between TG/HDL-C and SAP. The optimal cutoff value of TG/HDL-C was defined by the receiver operating characteristic (ROC).

RESULTS

Among 258 patients, 71 (27.5%) had SAP. Patients with SAP were older (72.75 ± 11.10 vs. 64.81 ± 12.70 years), with a lower TG, higher HDL-C, and lower TG/HDL-C than participants in the non-SAP group. TG/HDL-C was an independent protective factor for SAP (adjusted OR 0.516, 95% CI 0.339-0.784) after adjusting for relevant risk factors. According to ROC analysis, the optimal cutoff value was a TG/HDL-C > 1.09 for decreased SAP [area under the ROC curve (AUC) 0.705; sensitivity 76.1% and specificity 59.4%]. Patients with a TG/HDL-C of > 1.09 were independently associated with decreased SAP (adjusted OR 0.285, 95% CI 0.138-0.591 ) after adjustment.

CONCLUSION

This study suggests that a lower TG/HDL-C is independently associated with increased SAP after SICH.

Early Outcomes in Severely Obese Patients Undergoing Sternum-Sparing Minimally Invasive Multivessel Artery Bypass Grafting Using Total Coronary Revascularization via Left Anterior Mini-Thoracotomy

Background/Objectives: Severe obesity significantly increases the risk of complications following full sternotomy in coronary artery bypass grafting (CABG). However, these patients are frequently excluded from less invasive, sternum-sparing surgical alternatives. This study aimed to assess the safety and practicality of a newly developed technique-Total Coronary Revascularization via left Anterior miniThoracotomy (TCRAT)-that avoids sternotomy in patients with severe obesity requiring multivessel CABG. Methods: From November 2019 to May 2024, a total of 502 non-emergency patients with multivessel coronary artery disease underwent CABG through a left anterior minithoracotomy using cardiopulmonary bypass (CPB) and cardioplegic arrest. Of these, 43 patients with a body mass index (BMI) exceeding 35.0 kg/m2 were classified as severely obese and included for subgroup analysis. Their outcomes were compared to those of the remaining 459 patients with BMI below 35.0 kg/m2. Key intraoperative variables-such as total operative time, CPB duration, aortic cross-clamp time, and graft strategy-were evaluated. Postoperative outcomes, such as the incidence of major adverse cardiac and cerebrovascular events, minor complications, and length of stay in ICU and hospital, were also analyzed. Results: Severely obese patients exhibited a longer total operation time (353.5 ± 83.6 min vs. 320.4 ± 73.4 min, p < 0.05). In contrast, no statistical differences were observed in aortic cross-clamp time (97.9 ± 27.6 min vs. 95.6 ± 33.0 min; p = 0.307) or CPB time (163.3 ± 35.0 min vs. 155.0 ± 42.9 min; p = 0.078). Both groups received a similar number of distal anastomoses (3.1 ± 0.7 vs. 3.0 ± 0.8; p = 0.194), and the frequency of total arterial revascularization was comparable (34.9% vs. 40.0%; p = 0.268). There were no differences between the groups in major complications, including hospital mortality (2.3% vs. 1.1%, p = 0.227), stroke (0.0% vs. 0.6% p = 0.300), or need for re-revascularization (0.0% vs. 1.1%, p = 0.248). Similarly, minor complications, such as wound healing issues (2.3% vs. 1.1%, p = 0.233) and revisions for bleeding (4.6% vs. 7.2%, p = 0.276), were comparable between groups. ICU stay (2.7 ± 4.5 days vs. 2.2 ± 4.0 days; p = 0.225) and total hospital stay (12.3 ± 9.6 days vs. 10.8 ± 8.6 days; p = 0.142) showed no meaningful differences. Conclusions: TCRAT can be performed safely and effectively in severely obese patients, providing a feasible minimally invasive option for complete coronary revascularization in cases of multivessel disease. This approach eliminates the complications associated with sternotomy, making it a valuable surgical alternative for this high-risk patient group.

Relevance of cervical internal carotid artery patency after thrombectomy in tandem occlusion. Are we missing an opportunity to revascularize?

BACKGROUND

Treatment options for cervical internal carotid artery (c-ICA) occlusion in tandem occlusions (TOs) include emergent carotid artery stenting (eCAS) and angioplasty. We attempted to determine the impact of c-ICA reocclusion on the risk of recurrent ischemic stroke (IS) and stroke-related death, as well as functional independence.

METHODS

Patients with TOs undergoing endovascular thrombectomy (EVT) from April 2016 to October 2024 were included. The primary outcome was the 90-day composite of recurrent IS and stroke-related death. Secondary outcomes included the rate of 90-day functional independence (modified Rankin Scale (mRS) 0-2) and mortality. We used binary logistic regression to explore the association between c-ICA reocclusion and the outcomes and to identify predictors of c-ICA reocclusion or future revascularization.

RESULTS

We included 163 patients, 85.9% with successful recanalization. Angioplasty and eCAS were performed in 70% and 19%, respectively. c-ICA reocclusion occurred in 22% at a median of 3.5 (0-41.7) days. c-ICA reocclusion increased the odds of recurrent IS or stroke-related death (adjusted OR (aOR) 2.90, 95% CI 1.07 to 8.30, P=0.036) and was associated with lower rates of independence (aOR 0.18, 95% CI 0.05 to 0.58, P=0.004). Among patients who did not undergo eCAS, c-ICA angioplasty (aHR 0.28, 95% CI 0.09 to 0.86, P=0.026) and residual stenosis (aHR 1.04, 95% CI 1.02 to 1.07, P<0.001) were independent predictors of reocclusion or future revascularization.

CONCLUSION

Maintaining c-ICA patency after EVT might be essential due to the association of reocclusion with recurrent IS, stroke-related death, and worse functional outcomes. Residual c-ICA stenosis and angioplasty are valuable predictors of c-ICA patency that can guide management during EVT.

Comparative analysis of stroke burden between ages 20-54 and over 55 years: based on the global burden of disease study 2019

BACKGROUND

Stroke remains one of the major diseases threatening human health and life worldwide. Therefore, it is urgent to investigate the stroke burden in different age groups.

METHODS

We described the disease burden of three subtypes of stroke, namely intracranial haemorrhage (ICH), subarachnoid haemorrhage (SAH), and ischaemic stroke (IS), among people aged 20 ~ 54 years and > 55 years from 1990 to 2019, based on data from Global Burden of Disease Study 2019 and calculated the estimated annual percentage changes (EAPC) for age-specific incidence, disability-adjusted life-years (DALYs), mortality and prevalence rates. Joinpoint regression analyzes showed the critical years of trend inflexion points. Decomposition and health inequality analyses determined the impact of different epidemiological factors on stroke burden. Population-attributable fractions were calculated for deaths and DALYs due to risk factors.

RESULTS

From 1990 to 2019, the incidence of ICH and SAH decreased by 11.32% and 10.45%, respectively, in the 20-54 age group globally, while the incidence of IS increased by 14.95%. Meanwhile, the incidence of stroke in the > 55 years group showed an overall decreasing trend. The burden of adverse outcomes, including death and DALYs, varied by stroke subtype, with the rates of mortality and DALYs decreasing significantly less in IS than in ICH and SAH. In addition, the decline in mortality and DALYs rates was consistently greater in the over 55 years age group than in the 20-54 years age group. Notably, the prevalence of ICH, SAH, and IS increased by 20.55%, 11.50%, and 7.38% in the 20-54 years age grouper group, respectively, whereas in the elderly group, there was only a mild increase of IS in the over 55 years group. What is more, stroke burden showed a negative correlation with regional development. Furthermore, high systolic blood pressure was a common contributor to stroke burden in both age groups. The difference is that a high body mass index affects people aged 20-54 years more, while abnormal fasting blood glucose affects older people more.

CONCLUSION

The stroke burden in people 20-54 years of age is increasingly becoming a global health problem, particularly the incidence of IS in lower economic development areas.

CLINICAL TRIAL NUMBER

Not applicable.

Hyperhomocysteinemia in Takayasu arteritis-genetically defined or burden of the proinflammatory state?

Takayasu arteritis (TAK) is associated with high plasma homocysteine (Hcy) and elevated Hcy predicts ischemic events. Thus, this study aims to compare the frequency of single-nucleotide polymorphisms (SNPs) of genes involved in Hcy metabolism between TAK and controls and analyze associations with Hcy levels, TAK features, and acute ischemic arterial events (AIAEs). A cross-sectional study was performed with 73 TAK patients and 71 controls. SNPs of genes involved in the Hcy metabolism, plasma Hcy, and risk factors were analyzed for hyperhomocysteinemia (HHcy), cardiovascular disease (CVD), and AIAEs. Patients presented a higher frequency of risk factors for CVD and HHcy. At least one AIAE was observed in 27 (37.0%) patients and one control. The frequency of the SNPs was similar between both groups, and there was no association between SNP carriage and AIAEs. TAK patients presented higher Hcy levels than controls (13.9 ± 5.6 µmol/L vs. 8.6 ± 4.0 µmol/L; p < 0.001), and patients carrying MTHFR677TT presented higher Hcy levels than those carrying MTHFR677CT (20.4 ± 7.8 µmol/L vs. 13.7 ± 5.2 µmol/L; p = 0.02) or MTHFR677CC (20.4 ± 7.8 µmol/L vs. 13.1 ± 4.7 µmol/L; p = 0.009). TAK was an independent risk factor for HHcy [odds ratio (OR) = 10.20; 95% confidence interval (95% CI): 4.16-25.00; p < 0.001], and in TAK, thiazide diuretic use was a risk factor for HHcy (OR = 11.61; 95% CI: 1.63-82.63; p < 0.01). In conclusion, TAK was a risk factor for HHcy but not related to SNPs in genes encoding Hcy metabolism enzymes. The burden of chronic inflammation and thiazide diuretics contribute to HHcy in TAK.

Motivational interviewing for improving functional and psychosocial outcomes among stroke survivors

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the benefits and harms of motivational interviewing for functional and psychosocial outcomes in stroke survivors, compared to no intervention, waiting list, or attention controls.

Causal effects of Annexin A1 and Annexin A2 on ischemic stroke and its subtypes: A two-sample Mendelian randomization study

BACKGROUND

Preclinical studies have suggested that Annexin A1 and Annexin A2 act as anti-inflammatory agents, slowing the progression of atherosclerosis and further potentially reducing the risk of ischemic stroke. Since the causality of Annexins and ischemic stroke remains uncertain, this study aimed to investigate the causal effects of both using a two-sample Mendelian randomization (MR) method.

METHODS

The genetic instruments associated with Annexin A1 and Annexin A2 originated from a European-descent genome-wide association study (GWAS) of 50,000 participants from the INTERVAL study. Summary statistics for ischemic stroke and ischemic stroke subtypes were derived from the MEGASTROKE consortium's GWAS dataset, involving 40,585 cases and 406,111 controls of European ancestry. The inverse-variance weighted method was utilized in the main analysis, followed by a series of sensitivity analyses for robustness validation.

RESULTS

In the primary analysis, genetically predicted high Annexin A1 levels were associated with decreased risks of ischemic stroke (OR = 0.96; 95 % CI = 0.93-0.99; p = 0.023) and large artery stroke (OR = 0.88; 95 % CI = 0.81-0.96; p = 0.004). Similarly, genetically predicted high Annexin A2 levels also had significant associations with decreased risks of ischemic stroke (OR = 0.97; 95 % CI = 0.95-1.00; p = 0.019) and large artery stroke (OR = 0.90; 95 % CI = 0.85-0.96; p = 0.001).

CONCLUSION

In this two-sample MR study, we found that Annexins had causal protective effects against ischemic stroke, especially large artery stroke. Further basic mechanistic studies should be conducted to investigate the biological roles of these genes.

Stroke in Young Adults: An Overview and Non-Pharmacological Preventive Strategies

Stroke is one of the most common causes of death and disability worldwide, with significant impact on both physical and cognitive health. Although strokes are less common in young adults, they still occur in this population, particularly in those with certain comorbidities, such as Autosomal Dominant Polycystic Kidney Disease (ADPKD). Despite the lack of specific guidelines for stroke prevention in young adults, certain preventive measures can be implemented. Smoking cigarettes is the most significant stroke risk factor in this group. Additionally, psychosocial stress, often exacerbated by academic, career, and financial pressures, is emerging as a modifiable risk factor for stroke in young adults. Key preventive measures include dietary changes, management of underlying health conditions, incorporating regular physical activity into daily routines, smoking cessation, and effective stress management techniques such as mindfulness-based stress reduction (MBSR) and cognitive-behavioral therapy (CBT). Promoting mental health awareness, directing public health campaigns toward young adults, educating them on recognizing stroke symptoms and administering first aid, and improving the quality of healthcare for this population all play a vital role in preventing stroke in young adults.

Elevated risk of perioperative ischemic stroke in noncardiac surgery patients with atrial fibrillation: a retrospective cohort study

BACKGROUND

Stroke is still a significant and growing challenge of global health, however, the impact of Atrial Fibrillation (AF) on the risk of perioperative stroke remains unclear.

AIM

This study aims to evaluate the clinical prognostic value of AF in patients undergoing noncardiac surgery, with perioperative ischemic stroke as the primary prognostic indicator.

METHODS

A retrospective cohort study was conducted on patients who underwent noncardiac surgery between January 2008 and August 2019 at The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital. The study included patients with a procedure duration exceeding one hour. Participants were categorized into two groups: an AF group and a non-AF group, based on the presence or absence of AF. The primary outcome was the occurrence of perioperative ischemic stroke. To determine whether AF is an independent prognostic indicator, primary and subgroup analyses were performed. Logistic regression models were used to identify risk factors. Besides, sensitivity analysis, propensity score matching (PSM) analysis were applied to mitigate potential residual confounding effects and assess the robustness of the findings.

RESULTS

The primary analysis demonstrated that patients in the AF group had a significantly higher risk of perioperative ischemic stroke (OR: 6.843; 95% CI: 3.73-11.413; P < 0.001). Further modeling analyses confirmed a significant correlation between AF and perioperative ischemic stroke across various models: model 2 (OR: 1.789; 95% CI: 0.958-3.053; P < 0.05), model 3 (OR: 5.121; 95% CI: 2.749-8.716; P < 0.001), and model 4 (OR: 2.122; 95% CI: 1.123-3.677; P < 0.05). Sensitivity analysis excluding neurosurgeries were conducted. The adjusted OR of perioperative ischemic stroke in neurosurgery patients with the AF was 1.623(95% CI: 0.359-5.165; P = 0.463). While, the association between AF and perioperative ischemic stroke remained stable in those non-neurosurgical patients (OR: 2.154;95% CI: 1.044-3.964; P = 0.023). After PSM adjustments, the association between AF and perioperative ischemic stroke remained significant (OR: 2.106; 95% CI: 1.003-4.159; P < 0.05). Subgroup analyses revealed that AF significantly increased the risk of perioperative ischemic stroke, particularly in males, patients aged ≥ 60.5 years, those with an ASA score ≥ 3, those with hypertension, and those not on antiplatelet medication.

CONCLUSION

Atrial fibrillation is an independent prognostic risk factor for perioperative ischemic stroke in patients undergoing noncardiac surgery, especially pronounced in specific subgroups, including males, elderly patients, those with high ASA scores, with hypertension, and not receiving antiplatelet therapy. These findings emphasize the need for heightened awareness and prompt clinical intervention in these high-risk patients.

Distinctive cerebral small vessel disease patterns are associated with ischemic stroke in systemic lupus erythematosus

BackgroundSystemic lupus erythematosus (SLE) increases the risk of ischemic stroke (IS) and cerebral small vessel disease (CSVD) through a unique interplay of cardiovascular and immune-mediated mechanisms. There is an unmet need of predictors of IS risk and of characterization of the distinctive features of CSVD in patients with SLE.ObjectivesTo assess if CSVD is more extensive in patients with SLE and ischemic stroke (IS+) than in those without (IS-); to identify distinctive neuroimaging features of CSVD in patients with SLE.MethodsThis observational study, conducted at an academic referral center in São Paulo, Brazil, included SLE patients who underwent brain MRI between 2010 and 2021. Two neuroradiologists, blinded to clinical data, reached a consensus on the summary CSVD score, that consists of microbleeds, lacunes of presumed vascular origin, enlarged perivascular spaces, and white matter hyperintensities of presumed vascular origin. Logistic regression was performed with IS as the dependent variable.ResultsWe included 106 patients, 53 IS+ and 53 IS- (median age: 41; interquartile range, 34;51 years; 92% women). The summary CSVD score was independently associated with the IS + group (OR 3.83, 95% CI 1.73 - 9.87, p = 0.002), even after adjusting for age, hypertension, secondary antiphospholipid syndrome, and use of antimalarial drugs. Microbleeds predominated in cortical regions (23/24, 92%), lacunes in the basal ganglia (10/16, 63%) and white matter hyperintensities in the deep white matter (47/59, 80%).ConclusionCSVD was more frequent in IS+ than in IS-, highlighting the need for prospective studies in SLE to test CSVD as a biomarker of IS risk. Microbleeds predominated in the cortical region, different from reports of age-related and hypertension-associated CSVD.

Predicting Atrial Fibrillation After Stroke by Combining Polygenic Risk Scores and Clinical Features

BACKGROUND

Because treatment with anticoagulants can prevent recurrent strokes, identification of patients at risk for incident atrial fibrillation (AF) after stroke is crucial. We aimed to investigate whether the addition of AF polygenic risk scores (PRSs) to existing clinical risk predictors could improve prediction of AF after stroke.

METHODS

Patients diagnosed with ischemic stroke at the Massachusetts General Hospital between 2003 and 2017 were included. Clinical AF risk was estimated using the Recalibrated Cohorts for Heart and Aging Research in Genomic Epidemiology Atrial Fibrillation model, and genetic risk was estimated using a contemporary AF PRS from 1 093 050 variants. Patients were divided into clinical and genetic risk tertiles. Cox proportional hazards models at different follow-up windows were fit, and C indices and percentile-based net reclassification index were used to determine the improvement of clinical risk models with the addition of AF PRS.

RESULTS

Of 1004 stroke survivors, 900 (90%) were non-Hispanic White, 413 (41%) were female, and the mean age was 67 (SD, 14) years. Of 1004 survivors, 239 (23.8%) had prevalent AF and 87 of 765 (11.4%) remaining patients developed incident AF during 5 years of follow-up. AF PRS was associated with greater risk of incident AF after stroke (hazard ratio, 1.21 [95% CI, 0.97-1.50] per 1-SD increase), although the association was not statistically significant. PRS improved discrimination in the first month (area under the curve, 0.78 [95% CI, 0.70-0.82] versus 0.71 [95% CI, 0.60-0.82]; P=0.05), with more modest estimates across longer time windows.

CONCLUSIONS

Addition of an AF PRS to clinical risk models may improve identification of individuals at risk of AF after stroke, particularly within the first month.

Long-term cardiovascular outcomes of immune checkpoint inhibitor-related myocarditis: A large single-centre analysis

AIMS

Immune checkpoint inhibitors (ICI) are the cornerstone of modern oncology; however, side effects such as ICI-related myocarditis (irM) can be fatal. Recently, Bonaca proposed criteria for irM; however, it is unknown if they correlate well with cardiovascular (CV) ICI-related adverse events. Additionally, whether incident irM portends worse long-term CV outcomes remains unclear. We aimed to determine the incidence of long-term CV comorbidities and CV mortality among irM patients.

PATIENTS AND METHODS

The ICI-related adverse event (irAE) registry was queried to identify irM patients by using Bonaca criteria. Random controls were selected after excluding patients with other concomitant irAEs. Patients' demographics, comorbidities and myocarditis presenting features were gathered. Outcomes included 2-year freedom from CV comorbidities (composite of atrial fibrillation, stroke, myocardial infarction and heart failure) and freedom from CV death. IrM was treated as a time-varying covariate.

RESULTS

Seventy-six patients developed irM at a median of 167 days (mean age 69, 63.2% male, 47% lung cancer). Majority of patients had new wall motion abnormalities or EKG changes on presentation. Mean LVEF was 43%, median peak TnT was 0.81, and median NTproBNP was 2057 at irM onset. Two-year freedom from CV comorbidities (67% vs 86.8%, P < 0.001) and death (93.4% vs 99.3%, P = 0.003) was lower among irM patients. Incident irM was an independent predictor of CV death (HR 8.28, P = 0.048), but not CV comorbidities (HR 2.21, P = 0.080).

CONCLUSIONS

This is the largest case-control study on irM highlighting worse long-term CV outcomes. Future studies are needed to establish appropriate therapeutic strategies and efficient screening strategies for irM survivors.