Socioeconomic status and stroke: an updated review

Evaluating the impact of influenza vaccine on preventing stroke hospitalization and death in Chinese elderly hypertensive patients: A retrospective cohort study

BACKGROUND

The effect of influenza vaccination on stroke remains controversial, particularly given the paucity of studies conducted in mainland China.

METHODS

Using a comprehensive database obtained from the Regional Health Information Platform, we conducted a 7-month retrospective cohort analysis of 457,887 elderly individuals residing in an eastern Chinese city. Using multivariate competing risks regression analysis, we derived subdistribution hazard ratios (sHRs) along with the corresponding 95 % confidence intervals (CIs).

RESULTS

There was no significant difference in the proportion of hospitalizations for stroke between those who received the influenza vaccine and those who did not (7.50 per 1000 vs. 8.12 per 1000; adjusted sHR: 0.96, 95 % CI: 0.90-1.02). However, a pronounced reduction in stroke-related mortality was observed among vaccinated individuals, with a rate of 0.18 ‰ compared with 0.54 ‰ among the unvaccinated (adjusted sHR: 0.47, 95 % CI: 0.33-0.69).

CONCLUSION

This study highlights the substantial role of influenza vaccination in reducing the risk of stroke-related mortality in elderly hypertensive patients. Therefore, efforts to increase influenza vaccination rates in this population are strongly encouraged.

Disparities in Access to Reperfusion Therapy for Acute Ischemic Stroke (DARTS): A Comprehensive Meta-Analysis of Ethnicity, Socioeconomic Status, and Geographical Factors

BACKGROUND

Reperfusion therapies, such as intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT), are crucial for improving outcomes in patients with acute ischemic stroke (AIS). However, access to these treatments can vary significantly due to ethnicity, socioeconomic status (SES), and geographical location, impacting patient outcomes.

OBJECTIVES

The Disparities in Access to Reperfusion Therapy for Acute Ischemic Stroke (DARTS) study aims to systematically assess disparities in access to IVT and EVT on the basis of ethnicity, SES, and geographical location.

METHODS

A comprehensive meta-analysis was conducted, incorporating data from 38 studies involving 5,256,531 patients with AIS. The analysis evaluated IVT and EVT utilization rates across ethnic groups, SES levels, and geographical locations.

RESULTS

The findings reveal substantial disparities in access to reperfusion therapies. IVT and EVT utilization rates varied significantly by ethnicity (9% ethnic, 11% non-ethnic for IVT; 7% ethnic, 6% non-ethnic for EVT), SES (13% low SES, 16% high SES for IVT; 7% low SES, 10% high SES for EVT), and geography (9% rural, 12% urban for IVT; 1% rural, 4% urban for EVT). Black patients had significantly lower odds of receiving IVT (OR 0.69, p = 0.001) and EVT (OR 0.87, p = 0.005) compared with white patients. Similarly, patients with low SES and those from rural areas faced reduced odds of receiving IVT (OR 0.74, p < 0.001; OR 0.72, p = 0.002) and EVT (OR 0.74, p < 0.001; OR 0.39, p < 0.001). Rural patients also had significantly lower odds of timely hospital arrival (p < 0.001), posing a barrier to accessing reperfusion therapies.

CONCLUSIONS

The DARTS study (and this meta-analysis) reveals significant access disparities in AIS treatment related to ethnicity, geography, and SES, particularly affecting Black communities, low SES individuals, and rural populations. Despite advances in reperfusion therapies, suboptimal implementation rates persist. To address these issues, we recommend the EQUITY framework: Educate, Ensure Quality, provide Universal Access, Implement Inclusive Policy Reforms, Enhance Timely Data Collection, and Yield Culturally Sensitive Care Practices. Adopting these recommendations will improve access, reduce disparities, and enhance stroke management and outcomes globally. Equitable access is essential for all eligible patients to fully benefit from reperfusion treatments.

Racial and Ethnic Disparities in Ischemic Stroke Severity in the National Inpatient Sample Between 2018 and 2021

BACKGROUND

The purpose of this study is to examine the association between race and ethnicity and ischemic stroke severity in the United States.

METHODS

We performed an analysis of adult hospital discharges in the National Inpatient Sample from 2018 to 2021 with a primary discharge diagnosis of ischemic stroke. We stratified our cohort based on self-reported race and ethnicity and evaluated stroke severity using the National Institutes of Health Stroke Scale. Age- and sex-adjusted estimates of the National Institutes of Health Stroke Scale were derived from linear regression models.

RESULTS

We included 231 396 stroke discharges with a mean National Institutes of Health Stroke Scale of 6.5±7.2. The cohort was 68.1% White, 17.4% Black, 8.2% Hispanic, and 6.3% other. The age- and sex-adjusted National Institutes of Health Stroke Scale for White patients was 6.25 (95% CI, 6.22-6.29), for Black patients was 7.12 (95% CI, 7.05-7.19), for Hispanic patients was 6.86 (95% CI, 6.76-6.97), and for patients of other races and ethnicities was 7.29 (95% CI, 7.18-7.41). Further adjustment for the Charlson Comorbidity Index, socioeconomic factors, and poorly controlled hypertension or diabetes did not significantly alter these findings.

CONCLUSIONS

In a large, contemporary, and nationally representative sample of patients with acute ischemic stroke, we show an association between non-White race and ethnicity and higher stroke severity. These results are concerning for an underappreciated health disparity in acute ischemic stroke.

Association Between Sociodemographic Disparities and Door to Computerized Tomography Time in Patients with Acute Ischemic Stroke Across COVID-19 Periods in the Emergency Department: A Multi-Center Cohort Study

INTRODUCTION

Stroke is the fifth leading cause of death and long-term disability in the United States. The current guideline for stroke management includes a 25 min timeframe from door-to-computed tomography time (DTCT). However, sociodemographic backgrounds may impact the DTCT in acute stroke patients.

METHODS

This was a retrospective, multicenter, cohort study between January 2018 and August 2022 throughout North Texas. The primary endpoint was DTCT ≤ 25 min upon arrival to hospital for all patients suspected of acute ischemic stroke.

RESULTS

During the study period, a total of 23,364 patients were included. Only 4468 patients (19.1%) had DTCT times less than or equal to 25 min, and 16,464 patients (70.5%) had DTCT times more than 25 min. In our cohort, Black (OR 1.35; 95% CI 1.23-1.49) and Asian patients (OR 1.33; 95% CI 1.01-1.74) were more likely to have DTCT > 25 min compared to White patients. Hispanic patients (OR 1.20; 95% CI 1.07-1.34) were more likely to have DTCT > 25 min compared to non-Hispanics. Patients presenting during the COVID (OR 1.45; 95% CI 1.34-1.57) and post-COVID period (OR 1.46; 95% CI 1.30-1.65) were more likely to have DTCT > 25 min compared to the pre-COVID period.

CONCLUSIONS

We demonstrated a discrepancy in DTCT time for acute ischemic stroke patients based on their race and ethnic population and an increase in DTCT time after the start of COVID-19, which has persisted after the pandemic. These diverse factors highlight the complex interplay of logistical, organizational, and healthcare challenges that have influenced DTCT time.

Trends in stroke mortality in Latin America and the Caribbean from 1997 to 2020 and predictions to 2035: An analysis of gender, and geographical disparities

BACKGROUND

Stroke is a leading cause of death and disability globally, with significant public health implications. In Latin America, while mortality rates have declined, the number of stroke cases has increased due to prevalent risk factors like high blood pressure and obesity. Unlike Europe, recent trends in stroke mortality in this region remain underreported.

OBJECTIVE

This study evaluates stroke mortality rates in Latin America Latin American and Caribbean (LAC) countries from 1997 to 2020 and predictions to 2035.

METHODS

This ecological observational study utilized mortality data from the World Health Organization database. Trends were analyzed using Joinpoint regression to evaluate the annual percent change (APC) by sex and country. Predicted mortality rates through 2035 were calculated using the Nordpred package in R. Changes in stroke mortality were assessed by disentangling the effects of population growth, aging, and risk factor modifications, based on age-specific rates and projections. Results were presented as absolute case numbers and relative percentages.

RESULTS

From 1997 to 2020, twelve countries presented significant reductions in stroke mortality rates for men in LAC, the main ones being Chile (-4.2 %), El Salvador (-4.2 %), and Puerto Rico (-4.0 %). Thirteen countries reported a reduction in their mortality for women, mainly in Puerto Rico (-4.3 %), Chile (-3.7 %), Argentina, El Salvador, and Uruguay (-3.5 %). By 2035, an increase in deaths among men and women is expected, mainly due to the increase in population structure and size. However, a decrease in the mortality rate will be reported, mainly due to the reduction of risk factors.

CONCLUSION

Our final findings show a reduction in stroke mortality trends in LAC countries between 1997 and 2020, due to creating public awareness about vascular risk factors by authorities and the implementation of effective health policies. By 2035, an overall increase in mortality is expected, mainly due to population change in each country.

Investigating Multiple Mediators to Mitigate Socioeconomic Differences in Patient-Reported Outcomes After Stroke: A Nationwide Register-Based Study

BACKGROUND

Substantial socioeconomic differences in patient-reported outcome measures (PROMs) 3 months after stroke have recently been shown. We aimed to understand the underlying mechanisms and investigate potential interventional targets to equalize differences.

METHODS

All patients aged 18 to 64 years, independent in activities of daily living, registered with a first-time stroke in Riksstroke (the Swedish Stroke Register) from 2015 to 2017 were included. PROMs 3 months after stroke included activities of daily living status, mood, fatigue, pain, and general health. Socioeconomic status (SES) was measured on the basis of income and education. Using causal mediation analysis, we simulated the effect of interventions on the distributions of smoking, metabolic health (diabetes, antihypertensive treatment, statin treatment), atrial fibrillation, and stroke characteristics (stroke type, severity) on the absolute SES-related risk difference in PROMs.

RESULTS

Of 6910 patients, 8% had become dependent in activities of daily living, 13% reported low mood, 42% fatigue, 23% pain, and 17% poor general health 3 months after stroke. Adjusted for sex and age, low SES was associated with increased absolute risks of poor PROMs with between 6% and 18% compared with higher SES with the largest increase for general health (18.2% [95% CI, 13.5%-22.9%]). Intervening to shift the distribution of all mediators among patients with low SES to those of patients with higher SES potentially reduces SES disparities by a proportion of 14% to 45%. For most PROMs the most important intervention was reducing smoking and improving metabolic health.

CONCLUSIONS

Working-age patients with low SES report more severe outcomes 3 months after stroke than patients with higher SES. Targeted interventions reducing the prevalence of smoking, diabetes, hypertension, and high cholesterol in patients with low SES could mitigate these disparities.

Socioeconomic disparities and risk of recurrent cardiovascular events and cardiovascular disease-free life expectancy in patients with established cardiovascular disease

AIM

This study aimed to evaluate whether lower socioeconomic status (SES) is related to a higher risk of recurrent cardiovascular disease (CVD) events and reduced CVD-free life expectancy in a large cohort of patients with established CVD.

METHODS

9,477 patients with established CVD from the Utrecht Cardiovascular Cohort - Secondary Manifestations of ARTerial disease (1996-2022) study were included. SES scores were determined at the neighbourhood level using scores provided by the Netherlands Institute for Social Research, based on income, education and unemployment. The relationship between SES and recurrent CVD events was analysed using Cox proportional hazard models, adjusted for age, sex, and traditional CVD risk factors. Event-free life expectancy across SES quintiles was assessed using Kaplan-Meier survival estimates, with age as the time scale and accounting for competing risks.

RESULTS

Over a median follow-up of 9.0 years (IQI: 4.8-14.1), 2,090 recurrent CVD events occurred. Unfavourable CVD risk factors were more prevalent among low SES patients, who less frequently used preventive drug treatment. After adjusting for age and sex, patients in the lowest SES quintile had a higher risk of recurrent events compared to the highest SES quintile (HR: 1.35; 95%CI 1.17-1.56). This relationship persisted after adjusting for CVD risk factors potentially mediating the effect. The median event-free life expectancy was 5.5 years (95%CI 2.8-8.0) shorter comparing the lowest to highest SES quintile.

CONCLUSIONS

Among patients with established CVD, lower SES is related to a higher risk of recurrent CVD events independent of CVD risk factors, and to a shorter CVD-free survival. These findings underscore the need for targeted interventions to reduce health disparities.

The association between neighborhood social vulnerability and community-based rehabilitation after stroke

BACKGROUND

Timely rehabilitative care is vital for functional recovery after stroke. Social determinants may influence access to and use of post-stroke care but have been inadequately explored. The study examined the relationship between the Social Vulnerability Index (SVI) and community-based rehabilitation utilization.

METHODS

We included 6,843 adults (51.6% female; 75.1% White; mean age 70.1) discharged home after a stroke enrolled in the COMprehensive Post-Acute Stroke Services study, a pragmatic trial conducted in 40 North Carolina hospitals from 2016-2019. Rehabilitation utilization was sourced from administrative claims. Geocoded addresses were linked to 2018 Census tract SVI. Associations between SVI and 90-day rehabilitation use, adjusted for patient's clinical and socio-economic characteristics, were obtained from generalized estimating equations. We also examined the associations of SVI with therapy setting, types of therapy, intensity of visits, and time to first visit.

RESULTS

Thirty-five percent of patients had at least one physical (PT) or occupational therapy (OT) visit within 90 days, ranging from 32.4%-38.7% across SVI quintiles. In adjusted analysis, there was no dose-reponse relationship between higher summary SVI, nor most of its sub-domains, and 90-day rehabilitation use. Greater vulnerability in household composition and disability was modestly associated with -0.4% (95% CI -4.1% to 3.4%) to -4.3% (95% CI -0.8% to -7.7%) lower rehabilitation use across SVI quartiles. Greater summary and subdomain SVI was associated with higher odds of receiving therapy in the home versus outpatient clinic (OR = 1.88, 1.58 to 2.17 for Q5 vs Q1 summary SVI) and receiving both PT and OT versus a single-type therapy (1.72, 1.48 to 1.97 for Q5 vs. Q1 summary SVI). No differences were observed for therapy intensity or time to therapy.

CONCLUSION

Use of rehabilitation care was low, and largely similar across levels of SVI and most of its subdomains. Individuals residing in areas of high SVI were more likely to receive therapy in the home and to receive dual therapy, possibly reflecting greater need among these individuals. Future studies should evaluate potential mechanisms for these findings and further identify both patient and community factors that may inform strategies to improve rehabilitation use.

CLINICAL TRIAL NUMBER

https://www.

CLINICALTRIALS

gov/ NCT02588664 [registration date: 2015-10-23].

The Impact of Socioeconomic Status on Decision on Withdrawal of Life-sustaining Treatments in Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Socioeconomic status affects outcomes in cerebrovascular disease, although its role in the withdrawal of life-sustaining treatments (WLST) remains uncertain. We aim to examine the impact of socioeconomic factors on outcomes including WLST in aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

We conducted a retrospective study of a cohort of consecutive patients with aSAH who were admitted to an academic center from 2016 to 2023. Publicly available data on median neighborhood income by zip code areas were obtained from the US census. Low economic-insurance status (EIS) was defined as using Medicaid or having no insurance or living in a zip code within the lowest two quintiles of household income. High EIS was defined as not using Medicaid and having any other insurance and living in a zip code within the highest two quintiles of household income. The rest of the cohort who was not categorized in the high or low EIS groups was defined as middle EIS. We used multivariable logistic regression analysis to assess the association between socioeconomic and demographic factors and outcomes including WLST, mortality, and 3-month modified Rankin Scale.

RESULTS

We included 410 patients, with mean age 57.9 years (standard deviation 13.8), who were 65% female, 70% white, 36.8% low EIS, and 35.6% high EIS. Higher EIS was associated with WLST (odds ratio 1.53 per increase in EIS, 95% confidence interval 1.07-2.18; p = 0.02) when adjusted for other predictors. In addition, a higher quintile of neighborhood income, regardless of insurance status, was associated with higher odds of WLST (odds ratio 1.41 per each quintile increase, 95% confidence interval 1.07-1.86; p = 0.014). However, there was no association between EIS and 3-month modified Rankin Scale when adjusted for disease severity factors.

CONCLUSIONS

Higher EIS and residing in areas with higher neighborhood incomes were associated with higher odds of WLST in aSAH. Further multicenter studies are needed to investigate the underlying mechanisms that contribute to these associations.

Socioeconomic Disparities in Rate of Poststroke Dementia: A Nationwide Cohort Study

BACKGROUND

Socioeconomic disparities exist in acute stroke care as well as in long-term stroke outcomes. We aimed to investigate whether socioeconomic status was associated with the rate of poststroke dementia (PSD).

METHODS

This was a nationwide register-based cohort study including all patients with incident ischemic or hemorrhagic stroke in Denmark from 2010 to 2020. Socioeconomic status was defined by prestroke income, education, and employment. PSD was defined as a dementia diagnosis in the National Patient Registry or a dispensed prescription of dementia medication after a stroke. PSD incidence rates were compared between socioeconomic status groups using Poisson regression.

RESULTS

A total of 98 489 patients with incident stroke without a diagnosis of prestroke dementia were identified and followed for a median (IQR) of 4.2 (IQR, 2.1-7.3) years. Median age was 72 (62-80) years, 56% were male, 5.1% were immigrants, and 86% had ischemic stroke. Dementia was diagnosed in 5680 patients at a median of 2.4 (IQR, 0.9-4.8) years after stroke (incidence rate=12.1/1000 person-years). After adjusting for age, sex, and immigrant status, PSD rates were 1.24 (1.15-1.34) times higher for low income compared with high income, 1.11 (1.03-1.20) times higher for low education compared with high education, and 1.57 (1.38-1.77) times higher for patients without employment compared with patients with employment. Further adjustments for stroke severity, cohabitation, and comorbidities showed similar results. Stratified analyses showed that the socioeconomic disparities in PSD rates were more pronounced among women, immigrants, and patients <70 years of age.

CONCLUSIONS

Low socioeconomic status measured by prestroke income, education, and employment status was associated with higher rates of PSD. These socioeconomic disparities extended beyond what could be explained by common PSD risk factors.

Baseline characteristics, reperfusion treatment secondary prevention and outcome after acute ischemic stroke in three different socioeconomic environments in Europe

INTRODUCTION

The differences in vascular risk factors' and stroke burden across Europe are notable, however there is limited understanding of the influence of socioeconomic environment on the quality of secondary prevention and outcome after acute ischemic stroke.

PATIENTS AND METHODS

In this observational multicenter cohort study, we analyzed baseline characteristics, reperfusion treatment, outcome and secondary prevention in patients with acute ischemic stroke from three tertiary-care teaching hospitals with similar service population size in different socioeconomic environments: Bern/CH/n = 293 (high-income), Gdansk/PL/n = 140 (high-income), and Lutsk/UA/n = 188 (lower-middle-income).

RESULTS

We analyzed 621 patients (43.2% women, median age = 71.4 years), admitted between 07 and 12/2019. Significant differences were observed in median BMI (CH = 26/PL = 27.7/UA = 27.8), stroke severity [(median NIHSS CH = 4(0-40)/PL = 11(0-33)/UA = 7(1-30)], initial neuroimaging (CT:CH = 21.6%/PL = 50.7%/UA = 71.3%), conservative treatment (CH = 34.1%/PL = 38.6%/UA = 95.2%) (each p < 0.001), in arterial hypertension (CH = 63.8%/PL = 72.6%/UA = 87.2%), atrial fibrillation (CH = 28.3%/PL = 41.4%/UA = 39.4%), hyperlipidemia (CH = 84.9%/PL = 76.4%/UA = 17%) (each p < 0.001) and active smoking (CH = 32.2%/PL = 27.3%/UA = 10.2%) (p < 0.007). Three-months favorable outcome (mRS = 0-2) was seen in CH = 63.1%/PL = 50%/UA = 59% (unadjusted-p = 0.01/adjusted-p CH-PL/CH-UA = 0.601/0.981), excellent outcome (mRS = 0-1) in CH = 48.5%/PL = 32.1%/UA = 27% (unadjusted-p < 0.001/adjusted-p CH-PL/CH-UA = 0.201/0.08 and adjusted-OR CH-UA = 2.09). Three-months mortality was similar between groups (CH = 17.2%/PL = 15.7%/UA = 4.8%) (unadjusted-p = 0.71/adjusted-p CH-PL/CH-UA = 0.087/0.24). Three-months recurrent stroke/TIA occurred in CH = 3.1%/PL = 10.7%/UA = 3.1%, adjusted-p/OR CH-PL = 0.04/0.32). Three-months follow-up medication intake rates were the same for antihypertensives. Statin/OAC intake was lowest in UA = 67.1%/25.5% (CH = 87.3%/39.2%/unadjusted-p < 0.001/adjusted-p CH-UA = 0.02/0.012/adjusted-OR CH-UA = 2.33/2.18). Oral intake of antidiabetics was lowest in CH = 10.8% (PL = 15.7%/UA = 16.1%/unadjusted-p = 0.245/adjusted-p CH-PL/CH-UA = 0.061/0.002/adjusted-OR CH-UA = 0.25). Smoking rates decreased in all groups during follow-up.

DISCUSSION AND CONCLUSION

Substantial differences in presentation, treatment and secondary prevention measures, are linked to a twofold difference in adjusted 3-months excellent outcome between Switzerland and Ukraine. This underscores the importance of socioeconomic factors that influence stroke outcomes, emphasizing the necessity for targeted interventions to address disparities in treatment and secondary prevention strategies.

Socioeconomic influences on stroke outcomes: A comprehensive zip code-based hospital analysis

BACKGROUND AND OBJECTIVES

Stroke remains a leading cause of morbidity and mortality worldwide. Socioeconomic disparities significantly affect the treatment and outcomes of cardiovascular and cerebrovascular diseases, including acute ischemic stroke. This study examines patients treated at Thomas Jefferson University Hospital, with ZIP code-based socioeconomic data predominantly representing areas in Pennsylvania and New Jersey, as the majority of patients originate from these regions.

METHODS

This study is a retrospective analysis based on a prospectively maintained database of 697 patients who underwent mechanical thrombectomy between 2016 and 2023. ZIP codes were retrospectively added to the database to determine socioeconomic status (SES). SES was assessed by matching patient ZIP codes to median household income data from the Census for the years 2016-2022. Baseline characteristics, stroke characteristics, procedural details, and outcomes were collected. Patients were stratified into income quintiles (Q1: $14,658-$52,635; Q2: $52,905-$64,046; Q3: $64,140-$77,737; Q4: $78,449-$95,128; Q5: $95,231-$217,674). Multivariate regression was conducted to identify predictors of good functional outcomes (mRS 0-2).

RESULTS

The study included 697 patients representing 270 zip codes distributed across income quintiles as follows: Q1 (n = 140), Q2 (n = 142), Q3 (n = 138), Q4 (n = 138), and Q5 (n = 139). Significant racial differences were observed between income quintiles, with a higher proportion of African-American patients in Q1 (40.7 %) compared to Q5 (19.9 %; p < 0.001), and more white patients in Q5 (82.7 %) compared to Q1 (47.1 %; p < 0.001). The Onset to arterial puncture time was longer in Q1 (369 min) compared to Q5 (258 min; p = 0.004). There were no significant differences in stroke outcomes such as successful recanalization (TICI 2b-3), hemorrhagic transformation, median NIHSS score on discharge, 30-day readmission, disposition to home, or length of stay between Q1 and Q5. SES was not a significant predictor of good functional outcomes (mRS 0-2).

CONCLUSION

This study found no significant differences in stroke outcomes between low SES and high SES patients undergoing mechanical thrombectomy for acute ischemic stroke. Patients from higher SES had a shorter duration from stroke onset to arterial puncture, and there was a tendency though not significant for higher SES patients to have a higher rate of 30-day readmission, and higher rate of discharge to home. Further research is needed to confirm.

Relationship between socioeconomic status and stroke: An observational and network Mendelian randomization study

BACKGROUND

The relationship between socioeconomic status (SES) and stroke remains controversial, and the underlying mediator is unclear. This study aimed to assess the causal relationship of SES with stroke and its subtypes and to identify potential modifiable risk factors responsible for this relationship.

METHODS

The study included 372,437 participants from the UK Biobank. Over an average period of 12.13 years, 6,457 individuals (2.7 %) were recorded as having experienced a stroke. Cox proportional hazards model was used to determine the relationship between SES (average annual household income before tax and age at the end of full-time education) and stroke, ischemic stroke, and hemorrhagic stroke. Two-sample Mendelian randomization (MR) was employed to assess the causal relationship between SES and stroke and its subtypes. Furthermore, network MR was utilized to evaluate the potential mediating role of modifiable risk factors for stroke in this causal relationship.

RESULTS

After adjusting for factors such as sociodemographic characteristics, health behaviors, health status, and past medical history, participants in the second highest income group showed the lowest risk of stroke, with a hazard ratio (HR) of 0.780 (95 % confidence interval [CI]: 0.702-0.866), and for ischemic stroke, the HR was 0.701 (95 % CI: 0.618-0.795). Those who completed full-time education at the latest age group(>18 years) had the lowest risk of stroke (HR: 0.906, 95 % CI: 0.830-0.988) and ischemic stroke (HR: 0.897, 95% CI: 0.811-0.992). MR analysis showed that higher income and education were both associated with a lower risk of stroke (income: inverse-variance-weighted odds ratio [ORIVW] =0.796, 95 % CI: 0.675-0.940, education: ORIVW = 0.631, 95 % CI: 0.557-0.716) and ischemic stroke (income: ORIVW = 0.813, 95 % CI: 0.684-0.966, education: ORIVW = 0.641, 95 % CI: 0.559-0.735). Additionally, hypertension had the highest mediating effect on this relationship. It accounted for 57.12 % of the effect of income on stroke, 51.24 % on ischemic stroke, and 27 % and 24 % for education.

CONCLUSION

Higher SES was associated with a lower risk of stroke and ischemic stroke, and hypertension had the highest mediating effect on this causal relationship. The results have significant public health implications, emphasizing the importance of early intervention to reduce the risk of stroke in low SES populations.

Disparities in Access to, Use of, and Quality of Rehabilitation After Stroke in the United States: A Scoping Review

OBJECTIVES

To summarize current reports in the literature on disparities in rehabilitation after stroke; identify gaps in our understanding of rehabilitation disparities; and make recommendations for future research.

DATA SOURCES

A health sciences librarian developed a search string based on an a priori protocol and searched Medline (Ovid) Embase (Elsevier), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL and EBSCO).

STUDY SELECTION

A 2-step screening process of titles and abstracts followed by full-text review was conducted. Primary observational studies conducted in the United States that reported on disparities in rehabilitation (ie, physical, occupational, or speech therapy) among adults after stroke were retained. Eligible disparity populations included racial minorities; ethnic minorities; sex and gender minorities; older populations; socioeconomically disadvantaged populations; and geographic minorities (inner city/rural).

DATA EXTRACTION

Data extracted from retained articles included: aims/objectives; data source; sample characteristics, rehabilitation outcomes examined; types of disparities examined; statistical methods used; and disparity findings.

DATA SYNTHESIS

Seven thousand eight hundred fifty-three titles and abstracts were screened, and 473 articles underwent full-text review. Forty-nine articles were included for data extraction and analysis. Many articles examined more than 1 disparity type with most examining disparities in race and/or ethnicity (n=43, 87.7%), followed by sex (n=25, 53.0%), age (n=23, 46.9%), socioeconomic status (n=22, 44.9%), and urban/rural status (n=8, 16.3%). Articles varied widely by sample characteristics, data sources, rehabilitation outcomes, and methods of examining disparities.

CONCLUSIONS

Although we found some consistent evidence of disparities in rehabilitation for older individuals, non-White races, and individuals of lower socioeconomic status, the variability in methods made the synthesis of findings challenging. Further work, including additional well-designed studies and systematic reviews, and/or meta-analyses of current studies, is needed to better understand the extent of rehabilitation disparities after stroke.

Investigating the reporting of participant characteristics relating to health equity in randomised controlled trials of non-pharmacological interventions for post-stroke anxiety and/or depression: a scoping review

PURPOSE

The review aims to identify what characteristics are reported in randomised controlled trials for the non-pharmacological management of post-stroke anxiety and/or depression and whether research has explored the correlation between participant characteristics and their outcomes.

METHODS

A comprehensive systematic search was completed of five databases: CINAHL, Medline, PsychInfo, Web of Science, and The World Health Organisation. Google Scholar was also accessed. The reporting of participant characteristics was assessed by adapting the PROGRESS-Plus framework, a research framework of protected characteristics known to impact health equity (such as, age).

RESULTS

19 papers (n = 2187) were included. There was generally poor reporting of characteristics associated with an increased likelihood of post-stroke anxiety and/or depression. All studies reported the gender/sex of participants, 18 studies reported the age of participants, and 11 studies reported lesion location. None of the studies reported the sexual orientation or pre-existing disabilities of participants.

CONCLUSION

There was variation in the reporting and analyses of protected characteristics. Future research should follow a health equity framework to ensure reporting of protected characteristics to support clinicians in identifying whether the proposed interventions are relevant to their stroke population and consider undergoing subgroup analyses to compare outcomes across protected characteristics.

Correlations of Socioeconomic and Clinical Determinants with United States County-Level Stroke Prevalence

Socioeconomic status (SES) is a multi-faceted theoretical construct associated with stroke risk and outcomes. Knowing which SES measures best correlate with population stroke metrics would improve its accounting in observational research and inform interventions. Using the Centers for Disease Control and Prevention's (CDC) Population Level Analysis and Community Estimates (PLACES) and other publicly available databases, we conducted an ecological study comparing correlations of different United States county-level SES, health care access and clinical risk factor measures with age-adjusted stroke prevalence. The prevalence of adults living below 150% of the federal poverty level most strongly correlated with stroke prevalence compared to other SES and non-SES measures (correlation coefficient = 0.908, R2 = 0.825; adjusted partial correlation coefficient: 0.589, R2 = 0.347). ANN NEUROL 2024;96:739-744.

Spot sign score is associated with hematoma expansion and longer hospital stay but not functional outcomes in primary intracerebral hemorrhage survivors

PURPOSE

The computed tomography angiography (CTA) spot sign is a validated predictor of 30-day mortality in intracerebral hemorrhage (ICH). However, its role in predicting unfavorable functional outcomes remains unclear. This study explores the frequency of the spot sign and its association with functional outcomes, hematoma expansion, and length of hospital stay among survivors of ICH.

MATERIALS AND METHODS

This was a retrospective analysis of consecutive patients with primary ICH who received CTA within 24 h of admission to two medical centers between January 2007 and August 2022. Patients who died before discharge and those referred from other hospitals were excluded. Spot signs were assessed by an experienced neuroradiologist. Functional outcomes were determined by modified Rankin Scale (mRS) scores and the Barthel Index (BI).

RESULTS

In total, 98 patients were included; 14 (13.64%) had a spot sign. No significant differences were observed in the baseline characteristics between the patients with and without a spot sign. Higher spot sign scores were associated with higher odds of experiencing hematoma expansion (p = 0.013, 95% CI = 1.16-3.55), undergoing surgery (p = 0.012, 95% CI = 0.19-1.55), and having longer hospital stay (p = 0.02, 95% CI = 1.22-13.92). However, higher spot sign scores were not associated with unfavorable functional outcomes (p = 0.918 for BI, and p = 0.782 for mRS).

CONCLUSION

Spot signs are common findings among patients with ICH, and higher spot sign scores were associated with subsequent hematoma expansion and longer hospital stays but not unfavorable functional outcomes.

An experimental system for detection and localization of hemorrhage using ultra-wideband microwaves with deep learning

Stroke is a leading cause of mortality and disability. Emergent diagnosis and intervention are critical, and predicated upon initial brain imaging; however, existing clinical imaging modalities are generally costly, immobile, and demand highly specialized operation and interpretation. Low-energy microwaves have been explored as a low-cost, small form factor, fast, and safe probe for tissue dielectric properties measurements, with both imaging and diagnostic potential. Nevertheless, challenges inherent to microwave reconstruction have impeded progress, hence conduction of microwave imaging remains an elusive scientific aim. Herein, we introduce a dedicated experimental framework comprising a robotic navigation system to translate blood-mimicking phantoms within a human head model. An 8-element ultra-wideband array of modified antipodal Vivaldi antennas was developed and driven by a two-port vector network analyzer spanning 0.6-9.0 GHz at an operating power of 1 mW. Complex scattering parameters were measured, and dielectric signatures of hemorrhage were learned using a dedicated deep neural network for prediction of hemorrhage classes and localization. An overall sensitivity and specificity for detection >0.99 was observed, with Rayleigh mean localization error of 1.65 mm. The study establishes the feasibility of a robust experimental model and deep learning solution for ultra-wideband microwave stroke detection.

Return to work within a year after first stroke: blue and white collar workers comparison, predictors and causal mediation assessed during inpatient rehabilitation

BACKGROUND

Most research focuses around impairments in body function and structure, with relatively only a small number exploring their social impact.

OBJECTIVES

1) compare characteristics for individuals who before stroke were blue collar vs. white collar workers 2) identify clinical, functional, and job-related factors associated with return to work within 1 year after discharge 3) identify specific ADL individual items (assessed at rehabilitation discharge) as return to work predictors and 4) identify return to work causal mediators.

METHODS

Retrospective observational cohort study, analyzing adult patients with stroke admitted to rehabilitation between 2007 and 2021, including baseline Barthel Index (BI) and return to work assessments between 2008 and 2022. Kaplan-Meier survival curves and Cox proportional hazards were applied. Causal mediation analyses using 1000-bootstrapped simulations were performed.

RESULTS

A total of 802 individuals were included (14.6% returned to work), 53.6% blue-collar and 46.4% white-collar. Blue-collar workers showed significantly higher proportion of ischemic stroke, diabetes, dyslipidemia, and hypertension.Individuals not returning to work presented a higher proportion of blue collar, dominant side affected, aphasia, lower BI scores, and larger length of stay (LOS). Multivariable Cox proportional hazards identified age at injury, aphasia, hypertension, and total discharge BI score (C-Index = 0.74). Univariable Cox models identified three independent BI items at all levels of independence: bathing (C-Index = 0.58), grooming (C-Index = 0.56) and feeding (C-Index = 0.59). BI efficiency (gain/LOS) was a causal mediator.

CONCLUSION

Blue collar workers showed higher proportion of risk factors and comorbidities. Novel factors, predictors, and a return to work mediator were identified.

Association Between Frequency of Rehabilitation Therapy and Long-Term Mortality After Stroke: A Nationwide Cohort Study

BACKGROUND

Previous studies have demonstrated conflicting results regarding the effects of rehabilitation therapy on poststroke mortality. We aimed to investigate the association between rehabilitation therapy, including both inpatient and outpatient treatment, within the first 6 months after stroke and long-term all-cause mortality in patients with stroke using the Korean National Health Insurance System data.

METHODS

A total of 10 974 patients newly diagnosed with stroke using the International Classification of Diseases, Tenth Revision, codes (I60-I64) between 2003 and 2019 were enrolled and followed up for all-cause mortality until 2019. Follow-up for mortality began 6 months after the index event. Poststroke patients were categorized into 3 groups according to the frequency of rehabilitation therapy: no rehabilitation therapy, ≤40 sessions and >40 sessions. Cox proportional hazards models were used to assess the mortality risk according to rehabilitation therapy stratified by disability severity measured based on activities of daily living 6 months after stroke onset.

RESULTS

Within 6 months after stroke, 6738 patients (61.4%) did not receive rehabilitation therapy, whereas 2122 (19.3%) received ≤40 sessions and 2114 (19.3%) received >40 sessions of rehabilitation therapy. Higher frequency of rehabilitation therapy was associated with significantly lower poststroke mortality in comparison to no rehabilitation therapy (hazard ratio [HR], 0.88 [95% CI, 0.79-0.99]), especially among individuals with severe disability after stroke (mild to moderate: HR, 1.02 [95% CI, 0.77-1.35]; severe: HR, 0.74 [95% CI, 0.62-0.87]). In the context of stroke type, higher frequency of rehabilitation therapy was associated with reduced mortality rates compared with no rehabilitation therapy only in patients with hemorrhagic stroke (ischemic: HR, 1.04 [95% CI, 0.91-1.18]; hemorrhagic: HR, 0.60 [95% CI, 0.49-0.74]).

CONCLUSIONS

We found a positive association between rehabilitation therapy within 6 months after stroke onset and long-term mortality in patients with stroke. A higher frequency of rehabilitation therapy would be recommended for poststroke patients, especially those with hemorrhagic stroke and severe disability.

Impact of demographic and clinical factors on in-hospital delays in acute ischemic stroke treatment

BACKGROUND

Delays in reperfusion treatment, both intravenous thrombolysis (IVT) and endovascular treatment (EVT), adversely affect outcomes in patients with acute ischemic stroke (AIS). To alleviate these delays, it is essential to comprehend how patients' baseline and stroke characteristics impact in-hospital reperfusion delays. While demographic and socioeconomic factors affect stroke outcomes, their impact on in-hospital delays remains unclear.

METHOD

This is retrospective analysis at a tertiary stroke center, encompassing AIS patients receiving IVT and / or EVT between 2019 and 2022 (re-canalization cohort). Outcomes of interest were time intervals of admission to CT and admission to recanalization. Univariable analyses explored age, gender, baseline functional status, socioeconomic status (SES), ethnicity, vascular risk factors, and stroke characteristics. Subsequently, multivariable logistic regression analyses were performed.

RESULTS

Altogether, 313 patients treated with IVT and 293 with EVT were included in the re-canalization cohort. No demographic variables were found to be associated with stroke treatment time intervals. Following multivariable analysis, stroke severity (low NIHSS, p < 0.01), arrival to the hospital by other means than ambulance (p < 0.01), and atypical stroke symptoms (p < 0.01), were associated with in-hospital delays, both in the EVT and the IVT groups.

CONCLUSION

Our findings indicate that patients with a more severe ischemic stroke, typical stroke symptoms, and arrival by ambulance have shorter stroke treatment time intervals. These results emphasize that, in atypical cases, even a lower suspicion of stroke should promote urgent workup for stroke diagnosis. Our findings do not indicate any influence of demographic or SES on in-hospital reperfusion delays.

Experiences and preferences of people with stroke and caregivers, around supports provided at the transition from hospital to home: a qualitative descriptive study

BACKGROUND

Transitioning home from the structured hospital setting poses challenges for people with stroke (PWS) and their caregivers (CGs), as they navigate through complex uncertainties. There are gaps in our understanding of appropriate support interventions for managing the transition home. In this qualitative study, we explored the perspectives of PWS and their CGs regarding their support experiences and preferences during this period.

METHODS

Between November 2022 and March 2023, and within six months of hospital discharge, audio-recorded, semi-structured interviews were conducted with PWS and CGs. All interviews were transcribed, imported into NVivo software, and analysed using reflexive thematic analysis.

RESULTS

Sixteen interviews were conducted, nine with PWS and seven with CGs. Four themes relevant to their collective experiences and preferences were identified: (i) Need for tailored information-sharing, at the right time, and in the right setting; (ii) The importance of emotional support; (iii) Left in limbo, (iv) Inequity of access. Experiences depict issues such as insufficient information-sharing, communication gaps, and fragmented and inequitable care; while a multi-faceted approach is desired to ease anxiety and uncertainty, minimise delays, and optimise recovery and participation during transition.

CONCLUSIONS

Our findings highlight that regardless of the discharge route, and even with formal support systems in place, PWS and families encounter challenges during the transition period. The experiences of support at this transition and the preferences of PWS and CGs during this important period highlights the need for better care co-ordination, early and ongoing emotional support, and equitable access to tailored services and support. Experiences are likely to be improved by implementing a partnership approach with improved collaboration, including joint goal-setting, between PWS, CGs, healthcare professionals and support organisations.

Structural and functional brain correlates of socioeconomic status across the life span: A systematic review

It is well-established that higher socioeconomic status (SES) is associated with improved brain health. However, the effects of SES across different life stages on brain structure and function is still equivocal. In this systematic review, we aimed to synthesise findings from life course neuroimaging studies that investigated the structural and functional brain correlates of SES across the life span. The results indicated that higher SES across different life stages were independently and cumulatively related to neural outcomes typically reflective of greater brain health (e.g., increased cortical thickness, grey matter volume, fractional anisotropy, and network segregation) in adult individuals. The results also demonstrated that the corticolimbic system was most commonly impacted by socioeconomic disadvantages across the life span. This review highlights the importance of taking into account SES across the life span when studying its effects on brain health. It also provides directions for future research including the need for longitudinal and multimodal research that can inform effective policy interventions tailored to specific life stages.

The Janus face of HIF-1α in ischemic stroke and the possible associated pathways

Stroke is the most devastating disease, causing paralysis and eventually death. Many clinical and experimental trials have been done in search of a new safe and efficient medicine; nevertheless, scientists have yet to discover successful remedies that are also free of adverse effects. This is owing to the variability in intensity, localization, medication routes, and each patient's immune system reaction. HIF-1α represents the modern tool employed to treat stroke diseases due to its functions: downstream genes such as glucose metabolism, angiogenesis, erythropoiesis, and cell survival. Its role can be achieved via two downstream EPO and VEGF strongly related to apoptosis and antioxidant processes. Recently, scientists paid more attention to drugs dealing with the HIF-1 pathway. This review focuses on medicines used for ischemia treatment and their potential HIF-1α pathways. Furthermore, we discussed the interaction between HIF-1α and other biological pathways such as oxidative stress; however, a spotlight has been focused on certain potential signalling contributed to the HIF-1α pathway. HIF-1α is an essential regulator of oxygen balance within cells which affects and controls the expression of thousands of genes related to sustaining homeostasis as oxygen levels fluctuate. HIF-1α's role in ischemic stroke strongly depends on the duration and severity of brain damage after onset. HIF-1α remains difficult to investigate, particularly in ischemic stroke, due to alterations in the acute and chronic phases of the disease, as well as discrepancies between the penumbra and ischemic core. This review emphasizes these contrasts and analyzes the future of this intriguing and demanding field.

Cost-effectiveness of endovascular treatment for acute ischemic stroke in China: evidence from Shandong Peninsula

BACKGROUND

Recently, the endovascular treatment (EVT) of acute ischemic stroke has made significant progress in many aspects. Intravenous thrombolysis (IVT) is usually recommended before endovascular treatment in clinical practice, but the value of the practice is controversial. The latest meta-analysis evaluation was that the effect of EVT versus EVT plus IVT did not differ significantly. The cost-effectiveness analysis of EVT plus IVT needs further analysis. This study assesses the health benefits and economic impact of EVT plus IVT in Shandong Peninsula of China.

METHOD

We followed a cross-section design using the Chinese-Shandong Peninsula public hospital database between 2013 and 2023. The real-world costs and health outcomes were collected through the Hospital Information System (HIS) and published references. We calculated incremental cost-effectiveness ratios (ICERs) from the perspective of Chinese healthcare using the complex decision model to compare the costs and effectiveness between EVT versus EVT + IVT. One-way and Monte Carlo probabilistic sensitivity analyses were performed to assess the robustness of the economic evaluation model.

RESULTS

EVT alone had a lower cost compared with EVT + IVT whether short-term or long-term. Until 99% dead of AIS patients, the ICER per additional QALY was RMB696399.30 over the willingness-to-pay (WTP) threshold of 3× gross domestic product (GDP) per capita in Shandong. The probabilistic sensitivity analysis of 3 months, 1 year and long-term horizons had a 97.90%, 97.43% and 96.89% probability of cost-effective treatment under the WTP threshold (1×GDP). The results of the one-way sensitivity analysis showed that direct treatment costs for EVT alone and EVT + IVT were all sensitive to ICER.

CONCLUSIONS

EVT alone was more cost-effective treatment compared to EVT + IVT in the Northeast Coastal Area of China. The data of this study could be used as a reference in China, and the use of the evaluation in other regions should be carefully considered.

Racial and Ethnic Differences in Mortality and Functional Outcomes Following Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Ischemic and hemorrhagic stroke incidence tends to be higher among minority racial and ethnic groups. The effect of race and ethnicity following an aneurysmal subarachnoid hemorrhage (aSAH) remains poorly understood. Thus, we aimed to explore the association between race and ethnicity and aSAH outcomes.

METHODS

Single-center retrospective review of patients with aSAH from January 2009 to March 2023. Primary outcome was in-hospital mortality. Secondary outcomes included delayed cerebral ischemia, cerebral infarction, radiographic and symptomatic vasospasm, pulmonary complications, epileptic seizures, external ventricular drain placement, and modified Rankin Scale score at discharge and 3-month follow-up. Associations between race and ethnicity and outcomes were assessed using binary and ordinal regression models, with multivariable models adjusted for significant covariates.

RESULTS

A total of 1325 patients with subarachnoid hemorrhage presented to our center. Among them, 443 cases were excluded, and data from 882 patients with radiographically confirmed aSAH were analyzed. Distribution by race and ethnicity was 40.8% (n=360) White, 31.4% (n=277) Hispanic, 22.1% (n=195) Black, and 5.7% (n=50) Asian. Based on Hunt-Hess and modified Fisher grade, aSAH severity was similar among groups (P=0.269 and P=0.469, respectively). In-hospital mortality rates were highest for Asian (14.0%) and Hispanic (11.2%) patients; however, after adjusting for patient sex, age, health insurance, smoking history, alcohol and substance abuse, and aneurysm treatment, the overall likelihood was comparable to White patients. Hispanic patients had higher risks of developing cerebral infarction (adjusted odds ratio, 2.17 [1.20-3.91]) and symptomatic vasospasm (adjusted odds ratio, 1.64 [1.05-2.56]) than White patients and significantly worse discharge modified Rankin Scale scores (adjusted odds ratio, 1.44 [1.05-1.99]). Non-White patients also demonstrated a lower likelihood of 0 to 2 discharge modified Rankin Scale scores (adjusted odds ratio, 0.71 [0.50-0.98]). No significant interactions between race and ethnicity and age or sex were found for in-hospital mortality and functional outcomes.

CONCLUSIONS

Our study identified significant differences in cerebral infarction and symptomatic vasospasm risk between Hispanic and White patients following aSAH. A higher likelihood of worse functional outcomes at discharge was found among non-White patients. These findings emphasize the need to better understand predisposing risk factors that may influence aSAH outcomes. Efforts toward risk stratification and patient-centered management should be pursued.

A literature review of outcome and treatment options after acquired brain injury: Suggestions for adult offenders using knowledge from the general population

BACKGROUND

Acquired brain injury (ABI) is a major health problem, often with negative effects on behaviour and mental health as well as cognition. Prevalence of ABI is exceptionally high among offenders and increases their re-offending risk. Information on risk factors for ABI and its outcomes among offenders that could guide effective treatment for them is, nevertheless, scarce and dispersed. However, there is a more substantial literature about the general population that could inform work with brain-injured offenders, especially when selecting for samples or subgroups with similar relevant characteristics, such as lower socio-economic status (SES), pre-injury lower tested intelligence score (<85) and pre-injury mental health problems.

AIMS

To explore brain injury data from non-offender samples of otherwise similar socio-economic and mental health and ability characteristics to offenders then, first, to describe their untreated outcomes and, secondly, outcomes after frequently used interventions in these circumstances, noting factors associated with their effectiveness.

METHOD

Three databases were systematically searched for the years 2010-2022; first, using terms for brain injury or damage and cognitive (dys)function, mental health or quality of life. Second, in a separate search, we used these terms and terms for interventions and rehabilitation. In the second review, studies were selected for clear, distinguishable data on age, sex, SES and lifestyle factors to facilitate inferences for offenders. A narrative analytical approach was adopted for both reviews.

RESULTS

Samples with characteristics that are typical in offender groups, including lower SES, lower pre-injury intelligence quotient (<85), prior cognitive impairments and prior mental health problems, had poorer cognitive and behavioural outcomes following ABI than those without such additional problems, together with lower treatment adherence. With respect to treatment, adequate motivation and self-awareness were associated with better cognitive and behavioural outcomes than when these were low or absent, regardless of the outcome measured.

CONCLUSIONS

More complex pre-injury mental health problems and social disadvantages typical of offenders are associated with poorer post-brain injury recovery. This paper adds to practical knowledge by bringing together work that follows specific outcome trajectories. Overall, succesful ABI-interventions in the general population that aim at pre-injury difficulties comparable to those seen among offenders, show that personalising injury-specific treatments and taking account of these difficulties, maximised positive outcomes.

Influence of Socioeconomic Status on Functional Outcomes After Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

This review aimed to quantify the impact of socioeconomic status on functional outcomes from stroke and identify the socioeconomic status indicators that exhibit the highest magnitude of association.

METHODS AND RESULTS

We performed a systematic literature search across Medline and Embase from inception to May 2022, to identify observational studies (n≥100, and in English). Risk of bias was assessed using the modified Newcastle Ottawa Scale. Random effects meta-analysis was used to pool data. We included 19 studies (157 715 patients, 47.7% women) reporting functional outcomes measured with modified Rankin Scale or Barthel index, with 10 assessed as low risk of bias. Measures of socioeconomic status reported were education (11 studies), income (8), occupation (4), health insurance status (3), and neighborhood socioeconomic deprivation (3). Pooled data suggested that low socioeconomic status was significantly associated with poor functional outcomes, including incomplete education or below high school level versus high school attainment and above (odds ratio [OR], 1.66 [95% CI, 1.40-1.95]), lowest income versus highest income (OR, 1.36 [95% CI, 1.02-1.83]), a manual job/being unemployed versus a nonmanual job/working (OR, 1.62 [95% CI, 1.29-2.02]), and living in the most disadvantaged socioeconomic neighborhood versus the least disadvantaged (OR, 1.55 [95% CI, 1.25-1.92]). Low health insurance status was also associated with an increased risk of poor functional outcomes (OR, 1.32 [95% CI, 0.95-1.84]), although this was association was not statistically significant.

CONCLUSIONS

Despite great strides in stroke treatment in the past decades, social disadvantage remains a risk factor for poor functional outcome after an acute stroke. Further research is needed to better understand causal mechanisms and disparities.

Trends in Demographic and Geographic Disparities in Stroke Mortality Among Older Adults in the United States

BACKGROUND

Stroke is a leading cause of morbidity and mortality in the United States among older adults. However, the impact of demographic and geographic risk factors remains ambiguous. A clear understanding of these associations and updated trends in stroke mortality can influence health policies and interventions.

METHODS

This study characterizes stroke mortality among older adults (age ≥55) in the US from January 1999 to December 2020, sourcing data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. Segmented regression was used to analyze trends in crude mortality rate and age-adjusted mortality rate (AAMR) per 100,000 individuals stratified by stroke subcategory, sex, ethnicity, urbanization, and state.

RESULTS

A total of 3,691,305 stroke deaths occurred in older adults in the US between 1999 and 2020 (AAMR = 233.3), with an overall decrease in AAMR during these years. The highest mortality rates were seen in nonspecified stroke (AAMR = 173.5), those 85 or older (crude mortality rate1276.7), men (AAMR = 239.2), non-Hispanic African American adults (AAMR = 319.0), and noncore populations (AAMR = 276.1). Stroke mortality decreased in all states from 1999 to 2019 with the greatest and least decreases seen in California (-61.9%) and Mississippi (-35.0%), respectively. The coronavirus pandemic pandemic saw increased stroke deaths in most groups.

CONCLUSIONS

While there's a decline in stroke-related deaths among US older adults, outcome disparities remain across demographic and geographic sectors. The surge in stroke deaths during coronavirus pandemic reaffirms the need for policies that address these disparities.

Cumulative Systolic Blood Pressure and Incident Stroke Type Variation by Race and Ethnicity

Importance

Stroke risk varies by systolic blood pressure (SBP), race, and ethnicity. The association between cumulative mean SBP and incident stroke type is unclear, and whether this association differs by race and ethnicity remains unknown.

Objective

To examine the association between cumulative mean SBP and first incident stroke among 3 major stroke types-ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH)-and explore how these associations vary by race and ethnicity.

Design, Setting, and Participants

Individual participant data from 6 US longitudinal cohorts (January 1, 1971, to December 31, 2019) were pooled. The analysis was performed from January 1, 2022, to January 2, 2024. The median follow-up was 21.6 (IQR, 13.6-31.8) years.

Exposure

Time-dependent cumulative mean SBP.

Main Outcomes and Measures

The primary outcome was time from baseline visit to first incident stroke. Secondary outcomes consisted of time to first incident IS, ICH, and SAH.

Results

Among 40 016 participants, 38 167 who were 18 years or older at baseline with no history of stroke and at least 1 SBP measurement before the first incident stroke were included in the analysis. Of these, 54.0% were women; 25.0% were Black, 8.9% were Hispanic of any race, and 66.2% were White. The mean (SD) age at baseline was 53.4 (17.0) years and the mean (SD) SBP at baseline was 136.9 (20.4) mm Hg. A 10-mm Hg higher cumulative mean SBP was associated with a higher risk of overall stroke (hazard ratio [HR], 1.20 [95% CI, 1.18-1.23]), IS (HR, 1.20 [95% CI, 1.17-1.22]), and ICH (HR, 1.31 [95% CI, 1.25-1.38]) but not SAH (HR, 1.13 [95% CI, 0.99-1.29]; P = .06). Compared with White participants, Black participants had a higher risk of IS (HR, 1.20 [95% CI, 1.09-1.33]) and ICH (HR, 1.67 [95% CI, 1.30-2.13]) and Hispanic participants of any race had a higher risk of SAH (HR, 3.81 [95% CI, 1.29-11.22]). There was no consistent evidence that race and ethnicity modified the association of cumulative mean SBP with first incident stroke and stroke type.

Conclusions and Relevance

The findings of this cohort study suggest that cumulative mean SBP was associated with incident stroke type, but the associations did not differ by race and ethnicity. Culturally informed stroke prevention programs should address modifiable risk factors such as SBP along with social determinants of health and structural inequities in society.

Relative and absolute inequalities in cerebrovascular disease mortality rates: exploring the influence of socioeconomic status and urbanization levels in Taiwan

BACKGROUND/OBJECTIVE

Limited evidence exists regarding the socioeconomic inequalities in cerebrovascular disease (CBD) mortality at different urbanization levels. Therefore, this study was conducted to assess the socioeconomic inequalities and urbanization levels in township-based CBD mortality in Taiwan.

METHODS

Socioeconomic variables, including the percentages of low-income households, individuals with a university education and above, and tax payments, were measured at the township level from 2011 to 2020. Urbanization was also determined by the national survey and divided into seven levels. Age-standardized mortality rate (ASMR) of CBD was calculated using a Geographic Information System (GIS) in 358 townships. The effects of socioeconomic variables and urbanization levels on relative and absolute inequalities in township-based CBD mortality rates were examined.

RESULTS

Significant differences in ASMR of CBD were observed across all socioeconomic status indicators over the years. Higher proportions of low-income households were associated with higher ASMR of CBD. Conversely, there were negative correlations between higher proportions of individuals with a university education and above and tax payments with ASMR of CBD. The regression analysis indicated significant impacts of relative and absolute socioeconomic inequalities on ASMR of CBD. Additionally, a moderation effect of socioeconomic variables and urbanization on CBD mortality rates was observed, with rural areas showing sensitivity to these factors.

CONCLUSION

Although ASMR of CBD showed significant decreases over time, socioeconomic inequalities in CBD mortality rates persist. Interventions targeting socioeconomic inequalities in health outcomes, especially in rural areas, are needed to address this issue.

Biopsychosocial factors associated with the state of disability after hemiparesis in the chronic phase of stroke: exploratory analysis based on the International Classification of Functioning, Disability and Health

OBJECTIVE

To identify the main biopsychosocial factors associated with disability level after stroke using the International Classification of Functioning, Disability and Health (ICF) model.

METHODS

A cross-sectional study was conducted with chronic stroke survivors. Disability was assessed using the World Health Disability Assessment Schedule 2.0. The independent variables were: Body functions: emotional functioning and whether the dominant upper limb was affected. For the Activities & Participation component, satisfaction regarding the execution of activities and participation were assessed using the SATIS-Stroke, as well as the locomotion ability for adults (ABILOCO), manual ability (ABILHAND) and the return to work. For environmental factors, income and facilitators and obstacles were assessed using the Measure of the Quality of the Environment (MQE). Personal factors: age and sex. Multiple Linear Regression was employed.

RESULTS

Limited locomotor ability (β = -0.281; t = -3.231 p = 0.002), dissatisfaction regarding activities and participation (β = -0.273; t = -3.070 p = 0.003), and the non-return to work (β = 0.162; t = 2.085 p = 0.04) were associated with disability.

CONCLUSION

The reduction in locomotor ability, dissatisfaction regarding activities and participation and the non-return to work were associated with disability in the chronic phase following a stroke.

Socioeconomic inequalities in cardiovascular disease: a causal perspective

Socioeconomic inequalities in cardiovascular disease (CVD) persist in high-income countries despite marked overall declines in CVD-related morbidity and mortality. After decades of research, the field has struggled to unequivocally answer a crucial question: is the association between low socioeconomic position (SEP) and the development of CVD causal? We review relevant evidence from various study designs and disciplinary perspectives. Traditional observational, family-based and Mendelian randomization studies support the widely accepted view that low SEP causally influences CVD. However, results from quasi-experimental and experimental studies are both limited and equivocal. While more experimental and quasi-experimental studies are needed to aid causal understanding and inform policy, high-quality descriptive studies are also required to document inequalities, investigate their contextual dependence and consider SEP throughout the lifespan; no simple hierarchy of evidence exists for an exposure as complex as SEP. The COVID-19 pandemic illustrates the context-dependent nature of CVD inequalities, with the generation of potentially new causal pathways linking SEP and CVD. The linked goals of understanding the causal nature of SEP and CVD associations, their contextual dependence, and their remediation by policy interventions necessitate a detailed understanding of society, its change over time and the phenotypes of CVD. Interdisciplinary research is therefore key to advancing both causal understanding and policy translation.

Adult offspring and their socioeconomic resources for development and survival of stroke: A Swedish and Danish nationwide register-based study

AIMS

To explore the relationships between adult offspring's socioeconomic resources and the development of stroke and survival after stroke among older adults in Denmark and Sweden.

METHODS

The study included 1,464,740 Swedes and 835,488 Danes who had turned 65 years old between 2000 and 2015. Multivariable Cox proportional hazard regression models were used to analyse incident stroke and survival after stroke until 2020.

RESULTS

Lower level of offspring's education, occupation and income were associated with higher hazards of stroke among both men and women in Sweden and Denmark. Associations with offspring's education, occupation and income were most consistent for death after the acute phase and for educational level. From one to five years after stroke and compared with a high educational level of offspring, low and medium educational level were associated with 1.34 (95% confidence interval (CI): 1.11; 1.62) and 1.18 (95% CI: 1.10; 1.27) as well as 1.26 (95% CI: 1.06; 1.48) and 1.14 (1.07; 1.21) times higher hazard of death in Swedish women and men, respectively. The corresponding estimates in the Danish population were 1.36 (1.20; 1.53) and 1.10 (1.01; 1.20) for women and 1.23 (95% CI: 1.11; 1.32) and 1.13 (95% CI: 1.05; 1.21) for men.

CONCLUSIONS

Adult offspring socioeconomic resources are, independently of how we measure them and of individual socioeconomic characteristics, associated with development of stroke in old age in both Denmark and Sweden. The relationships between offspring socioeconomic resources and death after stroke are present especially after the acute phase and most pronounced for educational level as a measure of offspring socioeconomic resources.

Maintenance of brain health: The role of social determinants of health and other non-traditional cardiovascular risks

Brain health is the complete functioning of the brain across the life course to support the full physical, mental, social, and spiritual well-being and quality of life of an individual towards attaining and maintaining the epitome of a meaningful, impactful, purposeful, and productive life. The determinants of brain health are complex and include at least in part, non-traditional risks such as interactions among social, economic, physical, and internal factors (e.g., emotions and adaptations to changing life experiences), and external factors such as environment, geography, and climate change. Thus, social determinants of health (e.g., where we work, live, and play) are those non-medical factors that influence health outcomes, and as non-traditional cardiovascular factors, may influence the development of traditional cardiovascular risks. Examples of the non-traditional cardiovascular factors include environmental stressors (e.g., climate change, air pollution), and psychological and physical abuse. In this article, we provide a discussion of social determinants of health and other non-traditional cardiovascular risks as they relate to brain health.

Social Determinants of Health Framework to Identify and Reduce Barriers to Imaging in Marginalized Communities

Social determinants of health (SDOH) are conditions influencing individuals' health based on their environment of birth, living, working, and aging. Addressing SDOH is crucial for promoting health equity and reducing health outcome disparities. For conditions such as stroke and cancer screening where imaging is central to diagnosis and management, access to high-quality medical imaging is necessary. This article applies a previously described structural framework characterizing the impact of SDOH on patients who require imaging for their clinical indications. SDOH factors can be broadly categorized into five sectors: economic stability, education access and quality, neighborhood and built environment, social and community context, and health care access and quality. As patients navigate the health care system, they experience barriers at each step, which are significantly influenced by SDOH factors. Marginalized communities are prone to disparities due to the inability to complete the required diagnostic or screening imaging work-up. This article highlights SDOH that disproportionately affect marginalized communities, using stroke and cancer as examples of disease processes where imaging is needed for care. Potential strategies to mitigate these disparities include dedicating resources for clinical care coordinators, transportation, language assistance, and financial hardship subsidies. Last, various national and international health initiatives are tackling SDOH and fostering health equity.

Gender-Based Disparity in Acute Stroke Imaging Utilization and the Impact on Treatment and Outcomes: 2012 to 2021

INTRODUCTION

Prior studies have revealed significant socio-economic disparities in neuro-imaging and treatment utilization for patients with acute ischemic stroke (AIS). In this study, we sought to evaluate whether a sex-based disparity exists in neuro-imaging and to determine its etiology and association with acute treatment and outcomes.

MATERIALS AND METHODS

This was a retrospective study of consecutive patients with AIS admitted to a comprehensive stroke center between 2012 and 2021. Patient demographic and clinical characteristics, neuro-imaging, acute treatment, and early clinical outcomes were extracted from the electronic medical records. Trend analysis, bivariate analysis of patient characteristics by sex, and multivariable logistic regression analyses were conducted.

RESULTS

Of the 7,540 AIS episodes registered from 2012 to 2021, 47.9% were female patients. After adjusting for demographic, clinical, and temporal factors, significantly higher utilization of CTA was found for male patients (odds ratio = 1.20 [95% confidence interval 1.07-1.34]), particularly from socio-economically advantaged groups, and in years 2015 and 2019, representing the years endovascular thrombectomy recommendations changed. Despite this, male patients had significantly lower intravenous thrombolysis utilization (odds ratio = 0.83 [95% confidence interval 0.71-0.96]) and similar endovascular thrombectomy rates as female patients. There were no significant sex differences in early clinical outcomes, and no relevant clinical or demographic factors explained the CT angiography utilization disparity.

CONCLUSION

Despite higher CT angiography utilization in socio-economically advantaged male patients with AIS, likely overutilization due to implicit biases following guideline updates, the rates of acute treatment, and early clinical outcomes were unaffected.

Mediation Analyses of the Mechanisms by Which Socioeconomic Status, Comorbidity, Stroke Severity, and Acute Care Influence Stroke Outcome

BACKGROUND AND OBJECTIVES

Low socioeconomic status (SES) is associated with increased risk of death and disability after stroke, but interventional targets to minimize disparities remain unclear. We aim to assess the extent to which SES-based disparities in the association between low SES and death and dependency at 3 months after stroke could be eliminated by offsetting differences in comorbidity, stroke severity, and acute care.

METHODS

This nationwide register-based cohort study included all 72 hospitals caring for patients with acute stroke in Sweden. All patients registered with an acute ischemic stroke in the Swedish Stroke Register in 2015-2016 who were independent in activities of daily living (ADL) during stroke were included. Data on survival and SES the year before stroke were retrieved by cross-linkage with other national registers. SES was defined by education and income and categorized into low, mid, and high. Causal mediation analysis was used to study the absolute risk of death and ADL dependency at 3 months depending on SES and to what extent hypothetical interventions on comorbidities, stroke severity, and acute care would equalize outcomes.

RESULTS

Of the 25,846 patients in the study, 6,798 (26.3%) were dead or ADL dependent 3 months after stroke. Adjusted for sex and age, low SES was associated with an increased absolute risk of 5.4% (95% CI 3.9%-6.9%; p < 0.001) compared with mid SES and 10.1% (95% CI 8.1%-12.2%; p < 0.001) compared with high SES. Intervening to shift the distribution of all mediators among patients with low SES to those of the more privileged groups would result in absolute reductions of these effects by 2.2% (95% CI 1.2%-3.2%; p < 0.001) and 4.0% (95% CI 2.6%-5.5%; p < 0.001), respectively, with the largest reduction accomplished by equalizing stroke severity.

DISCUSSION

Low SES patients have substantially increased risks of death and ADL dependency 3 months after stroke compared with more privileged patient groups. This study suggests that if we could intervene to equalize SES-related differences in the distributions of comorbidity, acute care, and stroke severity, up to 40 of every 1,000 patients with low SES could be prevented from dying or becoming ADL dependent.

Monitoring Social Determinants of Health Assessing Patients and Communities

Because of the devastating health effects of social determinants of health (SDoH), it is important for the primary care provider to assess and monitor these types of stressors. This can be done via surveys, geomapping, or various biomarkers. To date, however, each of these methods is fraught with obstacles. There are currently are no validated "best" SDoH screening tools for use in clinical practice. Nor is geomapping, a perfect solution. Although mapping can collect location specific factors, it does not account for the fact that patients may live in one area, work in another and travel frequently to a third.

Correlation Between Oncostatin M and Acute Ischemic Stroke: A Case-Control Study

BACKGROUND

The expression of oncostatin M (OSM) has been studied in various diseases related to inflammatory response, but its implementation in acute ischemic stroke (AIS) remains to be explored.  Objective: The objective of this study is to assess the correlation between serum OSM expression and various aspects of AIS in a clinical setting.

MATERIALS AND METHOD

A single-centered case-control study was performed in the First Affiliate Hospital of Chongqing Medical University from October 2020 to March 2021. A total of 134 patients were enrolled in the AIS group and 34 healthy individuals were enrolled in the control group. Physical examinations were performed and venous blood samples were collected. Enzyme-linked immunosorbent assay (ELISA) was used to measure serum OSM. Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, National Institutes of Health Stroke Scale (NIHSS) score, magnetic resonance imaging (MRI) scan, and modified Rankin scale (mRS) were used to assess the classification, etiology, severity, and prognosis of the AIS group. Assessments were done to analyze serum OSM expression based on sensitivity, etiology, severity, prognosis, and several risk factors of AIS. Regression models, correlation, and sensitivity tests were performed to explore the correlation of OSM expression with various aspects of AIS.

RESULTS

There was a statistically significant elevation of serum OSM expression in the AIS group (P<0.001). All AIS subgroups showed elevation in OSM level and statistically significant results were reflected in three subgroups. The area under the curve to differentiate AIS patients and control by serum OSM level was 0.747 (P<0.001), with the optimal cut-off value showing sensitivity at 58.82% and specificity at 75.37%. The elevation of serum OSM expression was proportional with severity, not proportional to the volume of infarct, and less elevated in the favorable outcome group. Serum OSM correlation with several risk factors of AIS was statistically significant in age, low-density lipoprotein, non-high-density lipoprotein, prothrombin time, and systolic blood pressure.

CONCLUSION

Serum OSM was expressed differently in correlation with various aspects of AIS. Our findings supported the initial hypothesis that OSM is correlated with various aspects of AIS in humans.

Outcomes after ischemic stroke for dual-eligible Medicare-Medicaid beneficiaries in the United States

BACKGROUND

Medicaid serves as a safety net for low-income US Medicare beneficiaries with limited assets. Approximately 7.7 million Americans aged ≥65 years rely on a combination of Medicare and Medicaid to obtain critical medical services, yet little is known about whether these patients have worse outcomes after stroke than patients with Medicare alone. We compared geographic patterns in dual Medicare-Medicaid eligibility and ischemic stroke hospitalizations and examined whether these dual-eligible beneficiaries had worse post-stroke outcomes than those with Medicare alone.

METHODS

We identified fee-for-service Medicare beneficiaries aged ≥65 years who were discharged from US acute-care hospitals with a principal diagnosis of ischemic stroke in 2014. Medicare beneficiaries with ≥1 month of Medicaid coverage were considered dual eligible. We mapped risk-standardized stroke hospitalization rates and percentages of beneficiaries with dual eligibility. Mixed models and Cox regression were used to evaluate relationships between dual-eligible status and outcomes up to 1 year after stroke, adjusting for demographic and clinical factors.

RESULTS

At the national level, 12.5% of beneficiaries were dual eligible. Dual-eligible rates were highest in Maine, Alaska, and the southern half of the United States, whereas stroke hospitalization rates were highest in the South and parts of the Midwest (Pearson's r = 0.469, p<0.001). Among 254,902 patients hospitalized for stroke, 17.4% were dual eligible. In adjusted analyses, dual-eligible patients had greater risk of all-cause readmission within 30 days (hazard ratio 1.06, 95% confidence interval [CI] 1.03-1.09) and 1 year (hazard ratio 1.03, 95% CI 1.02-1.05) and had greater odds of death within 1 year (odds ratio 1.20, 95% CI 1.17-1.23) when compared with Medicare-only patients; there was no difference in in-hospital or 30-day mortality.

CONCLUSION

Dual-eligible stroke patients had higher readmissions and long-term mortality than other patients, even after comorbidity adjustment. A better understanding of the factors contributing to these poorer outcomes is needed.

Associations between socioeconomic status and stroke in American adults: A population-based study

Stroke is an acute cerebrovascular disease that can lead to disability and death. This study aimed to investigate the relationship between socioeconomic status (SES) and stroke. SES was evaluated by two variables: poverty to income ratio (PIR) and education level. In this multi-subject study, we collected data from the National Health and Nutrition Examination Survey (NHANES) database between 2009 and 2018, and finally 22,792 adults (≥20 years old) were included in the study. We proceeded with weighted multivariate logistic regression analysis as well as subgroup analysis. When analyzing the effect of PIR on stroke alone, the results showed that an increase in PIR levels was associated with a decrease in stroke incidence (OR = 0.764 95% CI: (0.711, 0.820), p < 0.001). The multivariate analysis presented a decline in stroke incidence in the highest quartile PIR group compared to the lowest quartile PIR group (OR = 0.296 95% CI: (0.214, 0.409), P＜0.001). Our results indicated that PIR is a protective factor for stroke, but there are exceptions in this relationship among different people. Hence, it is imperative that policymakers, healthcare providers, and clinicians take into account the inequality distribution of SES among adults while developing and executing stroke prevention and treatment strategies.

Trends and patterns in stroke incidence, mortality, DALYs and case-fatality by sociodemographic index worldwide: an age-period-cohort analysis using the Global Burden of Disease 2019 study

OBJECTIVES

Stroke is a significant public health burden worldwide. This study aimed to explore the trends and patterns of stroke incidence, mortality, disability-adjusted life years (DALYs) and case-fatality percent (CFP) worldwide from 1990 to 2019.

STUDY DESIGN

Age-period-cohort analysis.

METHODS

Trends in stroke burden worldwide were evaluated using data from the Global Burden of Disease 2019 study. In addition, the relationship between the burden of stroke and sociodemographic index (SDI) was examined by quantile regression. Age, period and cohort patterns in stroke burden across different SDI groups were estimated using age-period-cohort analysis.

RESULTS

Between 1990 and 2019, the age-standardised rates (ASRs) of stroke incidence, mortality and DALYs declined significantly worldwide, with decreases of -16.89% (95% uncertainty interval [UI]: -18.41 to -15.29), -36.43% (95% UI: -41.65 to -31.20) and -35.23% (95% UI: -40.49 to -30.49), respectively. Regions with ASRs in the 75th percentile and below experienced significant decreases in ASRs with increasing SDI. After 2014, there was a stable or slightly increased period effect for stroke incidence in all groups, while mortality, DALYs and CFP increased only in the high SDI group. The cohort effect of stroke incidence remained constant in the high SDI group from the 1960-1964 cohort onwards.

CONCLUSIONS

Although high SDI regions had a lower stroke burden and a faster overall decline in burden, the recent relative risk data suggest a potential deceleration in the progress of reducing stroke burden in these areas. There is a need for more active measures to reduce the stroke burden in areas with the highest incidence, mortality and DALYs, as increasing SDI alone cannot lower the burden in these regions.

Traumatic Brain Injury Mortality and Correlates in Low- and Middle-Income Countries: A Meta-Epidemiological Study

BACKGROUND

It is estimated that up to 69 million people per year experience traumatic brain injury (TBI) with the highest prevalence found in low- and middle-income countries (LMICs). A paucity of data suggests that the mortality rate after severe TBI is twice as high in LMICs than in high-income countries.

OBJECTIVE

To analyze TBI mortality in LMICs and to evaluate what country-based socioeconomic and demographic parameters influence TBI outcomes.

METHODS

Four databases were searched for the period January 1, 2002, to January 1, 2022, for studies describing TBI outcomes in LMICs. Multivariable analysis was performed using multivariable linear regression, with the outcome as the pooled mortality by country and the covariates as the adjusted parameters.

RESULTS

Our search yielded 14 376 records of which 101 were included in the final analysis, totaling 59 197 patients and representing 31 LMICs. The pooled TBI-related mortality was 16.7% (95% CI: 13.7%-20.3%) without significant differences comparing pediatrics vs adults. Pooled severe TBI-related mortality was significantly higher than mild. Multivariable analysis showed a significant association between TBI-related mortality and median income ( P = .04), population percentage below poverty line ( P = .02), primary school enrollment ( P = .01), and poverty head ratio ( P = .04).

CONCLUSION

TBI-related mortality in LMICs is 3-fold to 4-fold higher than that reported in high-income countries. Within LMICs, parameters associated with poorer outcomes after TBI include factors recognized as social determinants of health. Addressing social determinants of health in LMICs might expedite the quest to close the care delivery gap after TBI.

Racial/Ethnic Disparities in the Alzheimer's Disease Link with Cardio and Cerebrovascular Diseases, Based on Hawaii Medicare Data

Background

There is an expanding body of literature implicating heart disease and stroke as risk factors for Alzheimer's disease (AD). Hawaii is one of the six majority-minority states in the United States and has significant racial health disparities. The Native-Hawaiians/Pacific-Islander (NHPI) population is well-known as a high-risk group for a variety of disease conditions.

Objective

We explored the association of cardiovascular disease with AD development based on the Hawaii Medicare data, focusing on racial disparities.

Methods

We utilized nine years of Hawaii Medicare data to identify subjects who developed heart failure (HF), ischemic heart disease (IHD), atrial fibrillation (AF), acute myocardial infarction (AMI), stroke, and progressed to AD, using multistate models. Propensity score-matched controls without cardiovascular disease were identified to compare the risk of AD after heart disease and stroke. Racial/Ethnic differences in progression to AD were evaluated, accounting for other risk factors.

Results

We found increased risks of AD for AF, HF, IHD, and stroke. Socioeconomic (SE) status was found to be critical to AD risk. Among the low SE group, increased AD risks were found in NHPIs compared to Asians for all conditions selected and compared to whites for HF, IHD, and stroke. Interestingly, these observations were found reversed in the higher SE group, showing reduced AD risks for NHPIs compared to whites for AF, HF, and IHD, and to Asians for HF and IHD.

Conclusions

NHPIs with poor SE status seems to be mostly disadvantaged by the heart/stroke and AD association compared to corresponding whites and Asians.

Ameliorating Racial Disparities in Vascular Risk Factor Management With Aggressive Medical Management in the SAMMPRIS Trial

BACKGROUND

The WASID trial (Warfarin-Aspirin Symptomatic Intracranial Disease) and the SAMMPRIS trial (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis) evaluated optimal management of symptomatic intracranial atherosclerotic stenosis. The aim of this retrospective, observational study was to determine whether aggressive medical management used in the SAMMPRIS trial ameliorated disparities in risk factor control between Black and non-Black patients.

METHODS

The SAMMPRIS trial was a randomized controlled trial that enrolled patients with symptomatic intracranial atherosclerotic stenosis between November 2008 and April 2011. The frequency of risk factors at study entry (baseline) and mean levels of systolic blood pressure, diastolic blood pressure, LDL (low-density lipoprotein), hemoglobin A1c, and exercise level (quantified by physician-based assessment and counseling for exercise score) at baseline and at 1 year of follow-up were compared between Black (n=104) versus non-Black patients (n=347).

RESULTS

Significant differences at baseline in Black patients (listed first) versus non-Black patients were age (57.5 versus 61.0 years; P=0.004), hypertension (95.2% versus 87.5%; P=0.027), diabetes (52.9% versus 39.7%; P=0.017), mean diastolic blood pressure (82.4 versus 79.5 mm Hg; P=0.035), and mean physician-based assessment and counseling for exercise score (2.7 versus 3.3; P=0.002). The mean diastolic blood pressure and mean physician-based assessment and counseling for exercise scores at 1 year in Black versus non-Black patients were 74.7 versus 75.5 mm Hg (P=0.575) and 4.2 versus 4.1 (P=0.593), respectively. No disparities in other modifiable risk factors emerged at 1 year.

CONCLUSIONS

Significant differences in important risk factors (physical activity and diastolic blood pressure) at baseline between Black and non-Black patients resolved at 1 year, suggesting that aggressive medical management may have an important role in ameliorating disparities in risk factor control between Black and non-Black patients.

Socioeconomic Inequalities in Functional Outcome After Reperfusion-Treated Ischemic Stroke

BACKGROUND

We aimed to investigate whether socioeconomic status (SES) was associated with functional outcome in patients with ischemic stroke treated with reperfusion therapy (intravenous thrombolysis and/or thrombectomy).

METHODS

This nationwide cohort study included reperfusion-treated patients with ischemic stroke ≥18 years registered in the Danish Stroke Registry between 2015 and 2018. Functional outcome was determined by the modified Rankin Scale score 90 days after stroke. SES was defined by educational attainment, family income, and employment status before stroke. SES data were available from Statistics Denmark and linked on the individual level with data from the Danish Stroke Registry. Uni- and multivariable ordinal logistic regression was performed for each socioeconomic parameter individually (education, income, and employment) to estimate the common odds ratios (cORs) for lower 90-day modified Rankin Scale scores.

RESULTS

A total of 5666 patients were included. Mean age was 68.7 years (95% CI, 68.3-69.0), and 38.4% were female. Low SES was associated with lower odds for achieving lower 90-day modified Rankin Scale score: Low versus high education, cOR, 0.69 (95% CI, 0.61-0.79), low versus high income, cOR, 0.59 (95% CI, 0.53-0.67), and unemployed versus employed, cOR, 0.70 (95% CI, 0.58-0.83). Inequalities were reduced after adjusting for age, sex, and immigrant status, except for unemployed versus employed patients, adjusted cOR, 0.66 (95% CI, 0.54-0.80). No statistically significant differences remained after adjusting for potentially mediating variables (eg, stroke severity, prestroke modified Rankin Scale, and smoking).

CONCLUSIONS

Socioeconomic inequalities were observed in functional outcome after reperfusion treated ischemic stroke. In particular, prestroke unemployment was negatively associated with good functional outcome. A more adverse prognostic profile among patients with low SES appeared to explain the majority of these inequalities.

Pathophysiology and probable etiology of cerebral small vessel disease in vascular dementia and Alzheimer's disease

Vascular cognitive impairment and dementia (VCID) is commonly caused by vascular injuries in cerebral large and small vessels and is a key driver of age-related cognitive decline. Severe VCID includes post-stroke dementia, subcortical ischemic vascular dementia, multi-infarct dementia, and mixed dementia. While VCID is acknowledged as the second most common form of dementia after Alzheimer's disease (AD) accounting for 20% of dementia cases, VCID and AD frequently coexist. In VCID, cerebral small vessel disease (cSVD) often affects arterioles, capillaries, and venules, where arteriolosclerosis and cerebral amyloid angiopathy (CAA) are major pathologies. White matter hyperintensities, recent small subcortical infarcts, lacunes of presumed vascular origin, enlarged perivascular space, microbleeds, and brain atrophy are neuroimaging hallmarks of cSVD. The current primary approach to cSVD treatment is to control vascular risk factors such as hypertension, dyslipidemia, diabetes, and smoking. However, causal therapeutic strategies have not been established partly due to the heterogeneous pathogenesis of cSVD. In this review, we summarize the pathophysiology of cSVD and discuss the probable etiological pathways by focusing on hypoperfusion/hypoxia, blood-brain barriers (BBB) dysregulation, brain fluid drainage disturbances, and vascular inflammation to define potential diagnostic and therapeutic targets for cSVD.