Risk Factors for Ischemic Stroke in Younger Adults: A Focused Update

Dysregulation of proBDNF/p75NTR and BDNF/TrkB Signaling in Acute Ischemic Stroke: Different Sides of the Same Coins

Acute ischemic stroke (AIS) is a focal neurological deficit due to sudden occlusion of cerebral vessels in the brain. AIS-induced neuronal injury and associated excite-toxicity and neurodegeneration affect the synthesis and the release of different neurotrophic factors such as brain-derived neurotropic factor (BDNF) and its precursor proBDNF. Both BDNF and proBDNF act on the specific receptors with different neurological effects. BDNF activates tropomyosin receptor kinase B (TrkB) receptor results in promoting neuronal survival, synaptic plasticity, and neuronal growth. However, the proBDNF activates p75 neurotrophin receptor (p75NTR) and sortilin which attenuates synaptic plasticity and promotes neuronal apoptosis. Dysregulation of central and peripheral expression of proBDNF/BDNF is linked with the severity and clinical outcomes of AIS. Therefore, this review aims to discuss the alterations of proBDNF/BDNF signaling in AIS. Findings from the present review illustrated that proBDNF/p75NTR/sortilin signaling pathway is exaggerated whereas; BDNF-TrkB signaling is reduced in AIS leading to neuronal apoptosis. Therefore, activation of BDNF-TrkB signaling, and inhibition of proBDNF/p75NTR/sortilin signaling pathway could be a promising therapeutic strategy in the management of AIS.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sphingosine-1-Phosphate Modulation in Neurological Disorders: Insights from MS and Stroke

Multiple sclerosis is a chronic autoimmune disease in which the immune system attacks the protective sheath or myelin that covers nerve fibers, impacting the brain's ability to communicate with other areas of the body. This abnormal immune response recruits inflammatory substances, which appear as lesions on the brain and spinal cord. A stroke is characterized by a sudden impairment of neurological function resulting from the loss or restriction of blood flow due to acute damage to a localized area of the central nervous system, including the brain, retina, or spinal cord. While strokes, both ischemic and hemorrhagic, are different in terms of their pathogenesis to MS, mechanisms such as neuroinflammation and neurodegeneration are common denominators among these conditions. Recent studies highlight the involvement of the sphingosine-1-phosphate receptor in the treatment of strokes and how fingolimod, an S1P receptor modulator employed in MS treatment, may play a role in the treatment of stroke-like symptoms. This review aims to explore the potential link between stroke and MS, providing a comprehensive analysis of the existing evidence. It will also shed light on the role of S1P receptors in the pathophysiology of stroke, offering insights into their mechanistic contributions. Furthermore, the review will examine recent studies investigating the therapeutic potential of the S1P modulator, fingolimod, in acute stroke patients, highlighting its efficacy and potential clinical applications. Through this multifaceted approach, we hope to contribute to the development of a deeper understanding of these interconnected neurological conditions and their treatment strategies.

Young stroke in Bangladesh: addressing rare cases with diagnostic challenges and much-needed solutions

Stroke is a leading cause of mortality and morbidity in Bangladesh, and young adults are increasingly affected. Common risk factors include hypertension, diabetes, dyslipidaemia, obesity and smoking, whereas rare causes include haematologic disorders, premature atherosclerosis, vasculopathy and arteritis. Treatment barriers include inadequate infrastructure, a lack of trained staff and high intervention costs. Bangladesh faces a scarcity of neurologists and well-equipped hospitals, necessitating strategies to mitigate the burden of stroke among young people. This editorial summarises the current knowledge regarding the aetiology, pathophysiology and challenges in diagnosing and treating stroke in young people in Bangladesh, while addressing rare vasculopathy. Initiatives to support young stroke survivors and their families were also discussed. Prospective cohort studies, such as the Norwegian Stroke in the Young Study, provide insights into optimising prevention and early intervention by assessing family history and subclinical vascular diseases, which have also been highlighted. Recommendations include advanced neuroimaging for risk assessment, incorporating patient care and rehabilitation into medical education, conducting relevant research and promoting healthy lifestyles through campaigns and training of the healthcare staff.

Oral microbiome dysbiosis in cryptogenic ischemic stroke patients with high-risk patent foramen ovale

Patent foramen ovale (PFO) is the most common congenital heart abnormality of foetal origin and has been associated with cryptogenic ischemic stroke (CIS) through several mechanisms, with most theories supporting paradoxical embolism. Other possible but unknown contributing factors, such as the role of the microbiome in PFO-associated strokes, remain unclear. We analysed saliva metagenomes to study the differences in the oral microbiome between young-onset CIS patients with clinically relevant high-risk PFO (n = 52) and those without PFO (n = 52). Age- and sex-matched stroke-free controls (n = 16) with high-risk PFO were included for the comparison. Beta diversity was significantly different between patients and controls with high-risk PFO, but not between patients with and without high-risk PFO. The phylum Ascomycota and class Saccharomycetes were significantly more abundant in patients with high-risk PFO than in those without high-risk PFO. Additionally, the abundance of Lactococcus, including Lactococcus raffinolactis and L. cremoris, was higher in controls with high-risk PFO than in patients with high-risk PFO. These findings highlight that oral dysbiosis and high-risk PFO may form a critical but under-recognized combination in the aetiology of CIS. Future research should focus on elucidating the precise mechanisms of these interactions and developing targeted interventions.

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

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

Ischemic Stroke May Increase the Risk of Crohn's Disease and Ulcerative Colitis: Evidence from a Bidirectional Mendelian Randomization Study

BACKGROUND

The bidirectional causal relationship between ischemic stroke (IS) and inflammatory bowel disease (IBD) remains unclear, prompting us to propose a bidirectional Mendelian randomization (MR) study to investigate this relationship further.

METHODS

We obtained IS data from the MEGASTROKE consortium and IBD data, including its subtypes ulcerative colitis (UC) and Crohn's disease (CD), from the International Inflammatory Bowel Disease Genetics Consortium. In this study, we utilized IBD and its subtypes as exposure variables and IS as the outcome variable, and vice versa, to explore the bidirectional relationship between them. We used the IBD genetic data from the FinnGen database as replication data to further explore the causality. In this study, we employed the inverse variance weighting method as our primary approach. For sensitivity analyses, we utilized additional methods including MR-Egger regression, weighted median estimation, MR pleiotropy residual sum and outlier (MR-PRESSO), and MR-Robust adjusted profile score. Furthermore, we conducted a random effects meta-analysis to combine the causal relationships derived from both the International Inflammatory Bowel Disease Genetics Consortium and FinnGen datasets, aiming to ascertain more robust causal associations.

RESULTS

The initial phase of the bidirectional MR study revealed a causal relationship between IS and the risk of CD (odds ratio [OR] = 1.56, 95% confidence interval [CI]: 1.20-2.02, P = 0.0008) and UC (OR = 1.33, 95% CI: 1.05-1.69, P = 0.0179), but did not find a causal relationship between IBD as a whole and the risk of IS, nor between IBD subtypes and the risk of IS. During the replication phase, the FinnGen database did not reveal any significant correlation between IS and the risk of IBD, including its subtypes CD and UC. However, additional meta-analysis of the combined data from both databases indicated that IS is significantly associated with an increased risk of CD (OR inverse-variance weighted (IVW) = 1.38, 95% CI: 1.07-1.69, P < 0.05) and UC (ORIVW = 1.27, 95% CI: 1.04-1.50, P < 0.05), but not with the overall risk of IBD (ORIVW = 1.05, 95% CI: 0.87-1.16, P > 0.05). No significant effects were observed between IBD and IS risk, nor were there significant effects between IS and the risks of IBD, CD, or UC. To ensure the robustness of these findings, heterogeneity and pleiotropy tests were conducted.

CONCLUSIONS

IBD and its subtypes were not found to be causally associated with the risk of IS, whereas IS was found to be causally associated with the risk of CD and UC. This suggests that the risks of CD and UC should be closely monitored in patients with IS.

Burden and risk factors of stroke in Vietnam from 1990 to 2021 - a systematic analysis from global burden disease 2021

BACKGROUND

Stroke is a leading cause of death in Vietnam. However, a comprehensive analysis of stroke burden remains limited. This study aims to investigate the burden of stroke and various risk factors in Vietnam from 1990 to 2021.

STUDY DESIGN AND METHODS

We utilized data from the Global Burden of Disease 2021 estimates. For the burden of stroke, we included the following variables as age-standardized rates (ASR) per 100,000 people per year: incidence, prevalence, disability-adjusted life years (DALYs), and mortality. Stroke-related mortality and DALYs associated with 23 risk factors were also analyzed. Trends were analyzed using joinpoint regression analysis.

RESULTS

In 2021, stroke was responsible for 166,954 deaths (Males:96,764; Females:70,190). The ASR for stroke incidence was 203·36 (95%CI: 190·51-271·81) per 100,000 people, exceeding 187·98 in Southeast Asia and 141·55 globally. From 1990 to 2021, stroke incidence, death, and DALYs decreased steadily, with average annual percentage changes (AAPCs) of -0·34%, -0·49%, and -0·61%. The prevalence of stroke decreased among women (AAPC:-0·19%) and increased among men (AAPC:0·26%). Metabolic risks were the largest contributors to stroke-related mortality (144·89 per 100,000) and DALYs (2,872·37 per 100,000). The analysis revealed that behavioral risks were more prevalent in males, and metabolic risks in females.

CONCLUSION

Stroke is the leading cause of death and disability in Vietnam. Although its overall burden has declined, the persistent and significant burden among males, coupled with specific risk factors, remains a major concern. Further researches are warranted to develop targeted interventions addressing the distinct risk factors.

The possible therapeutic role of advanced glycation end-product inhibitors in ischemic stroke

The advanced glycation end-products (AGEs) are toxic molecules result from non-enzymatic interactions of sugar with lipids or proteins. AGEs promote the generation of reactive oxygen species that induce the release of pro-inflammatory cytokines, and alter the intracellular signaling leading to progressive biochemical and metabolic derangements. AGEs-induced cellular aging is implicated in the development and progression of different neurological disorders such as dementia, neuropsychiatric disorders, and cerebrovascular diseases. Particularly, AGEs-induced microangiopathy and macroangiopathy trigger the induction of prothrombotic/thrombotic cascades with subsequent increase risk of acute ischemic stroke (AIS). Many studies highlighted that AGEs serum levels are correlated with the incidence, pathogenicity, and severity of AIS. However, the relationship between AGEs and AIS is not elucidated completely. Therefore, this review aims to discuss how AGEs promote the development and progression of AIS, and how AGEs inhibitors could be effective in the management of AIS.

Migraine-like headache in subjects with isolated Lambl's excrescences: a case series and literature review

AIM

Lambl's excrescences are mobile, thin, fibrinous connective tissue strands typically found on left-sided cardiac values. Migraine is positively associated with structural cardiac anomalies. However, it remains unclear whether Lambl's excrescences are associated with migraine.

METHODS

Retrospective review of 182 inpatients with Lambl's excrescences confirmed by transesophageal echocardiogram in Chinese PLA General Hospital since January 2010. Among them, those with isolated Lambl's excrescences presented with migraine-like headache were included. We collected information on the demographics and clinical profiles of all participants, and performed follow-up visits.

RESULTS

A total of 8 patients presented with migraine-like headache among 15 patients with isolated Lambl's excrescences. They included 2 men and 6 women, with an average age of 44.63 ± 12.24 years. Among these patients, 3 had visual aura, and 6 manifested infarct-like lesions on magnetic resonance imaging, of which 2 developed lesions after first visit. During follow-up, 4 patients suffering from intervention for Lambl's excrescences dramatically reduced headache recurrence compared to the other 4 patients only receiving migraine preventive medications.

CONCLUSIONS

This study supports the hypothesis that microemboli from isolated Lambl's excrescences could cause migraine-like headache. And intervention for Lambl's excrescences may be crucial for preventing headache recurrence.

Potential effects of induced focal ischemia in the motor cortex of rats undergoing experimental periodontitis

Stroke is a severe medical condition resulting from an interruption in the blood supply to the brain, ultimately compromising tissue homeostasis. Currently, stroke stands as the second leading cause of death worldwide and the third leading cause when considering both mortality and disability together. Periodontitis is characterized by persistent inflammation in hard and soft tissues which support the teeth, primarily caused by bacterial biofilms, and is one of the most common causes of tooth loss in adults and can contribute to a systemic inflammatory burden. In the light of this, the present study investigated the effects of inducing focal ischemia in the motor cortex in rats undergoing experimental periodontitis. Adult Wistar rats were divided into four groups (control, ischemia, periodontitis, and periodontitis + ischemia) and were evaluated for motor performance, basic histology, and the volume and microarchitecture of alveolar bone. The results showed that the comorbidity between ischemia and periodontitis aggravates the spontaneous locomotion of rats, although the motor performance of adult rats had not been altered. Nonetheless, they revealed significant tissue impairment in the motor cortex. Additionally, there was a meaningful alteration in both the volume and microarchitecture of alveolar bone in this group. Our results indicate that the model of comorbidity between ligature-induced experimental periodontitis and focal ischemia was capable of inducing greater neurological impairment and alveolar bone loss in rats, attributable to diminished bone quality, when compared to each condition individually.

Ischemic Stroke in a Young Individual as an Atypical Presentation of Polycythemia Vera

Polycythemia vera represents a neoplastic proliferative disorder characterized by an abnormal overproduction of cells of myeloid lineage, especially erythrocytes. It can infrequently present as an acute ischemic stroke as the initial manifestation. This presentation is rarer in young patients; hence, it signifies the essence of a complete evaluation to elicit an accurate diagnosis to help prevent morbidity and mortality. In this report, we present a young male with acute onset hemiparesis who, on imaging, was found to have an ischemic infarct in the posterior limb of the internal capsule. On further investigation, the patient had a markedly elevated hematocrit and hemoglobin, and a mutation in JAK2 on genetic analysis. After confirming the diagnosis, phlebotomy was performed, which brought hemoglobin levels closer to the reference range and provided symptomatic relief.

Neurological function is restored post-ischemic stroke in zebrafish, with aging exerting a deleterious effect on its pathology

Ischemic stroke (IS) is a pathological condition characterized by the cessation of blood flow due to factors such as thrombosis, inflicting severe damage to the cranial nervous system and resulting in numerous disabilities including memory impairments and hemiplegia. Despite the critical nature of this condition, therapeutic options remain limited, with a pressing challenge being the development of treatments aimed at restoring neurological function. In this study, we leveraged zebrafish, renowned for their exceptional regenerative capabilities, to analyze the pathology of IS and the subsequent recovery process. We induced photothrombosis in the telencephalon utilizing rose bengal and conducted a temporal investigation of changes in cerebral vascular function and learning ability. Our findings revealed that blood flow in young zebrafish was restored approximately 7 days post-IS induction (dpi), with brain function recuperating by 14 dpi. Furthermore, we observed an escalation in the expression of the neural stem marker gene at 3dpi, followed by an upregulation of the differentiated neuron marker at 7 and 14dpi. In the aged IS model, symptoms were exacerbated. While cerebral blood flow was restored in 7 days, similar to young zebrafish, the recovery of learning ability was protracted in aged fish. Moreover, an upregulation of the differentiated neuron marker seen in young fish was not observed in the aged model. Collectively, our analysis of the zebrafish IS model and its comparison with existing rodent models may lay the groundwork for novel IS treatment strategies. Furthermore, the zebrafish IS model may prove beneficial for analyzing the impact of aging on the pathology of IS and the recovery process.

Effects of stem cell therapy on preclinical stroke

Stroke, particularly ischemic stroke, is a leading cause of global mortality and disability. It is caused by blood flow obstruction and reduced oxygen delivery to brain tissue. Conventional treatments, such as tissue plasminogen activator (tPA) and mechanical thrombectomy (MT), have limited efficacy in repairing neural damage and carry risks of adverse effects. As a result, stem cell therapies, including mesenchymal stem cells (MSCs), have emerged as promising approaches for enhancing neural recovery and offering neuroprotection in ischemic stroke management. MSCs offer multifaceted benefits, such as reducing inflammation, protecting neurons, and promoting angiogenesis and neurogenesis. Recent evidence highlights the importance of MSC secretomes-extracellular vesicles (EVs) and exosomes rich in neuroprotective factors, such as microRNAs, proteins, and cytokines. These bioactive molecules demonstrated considerable efficacy in preclinical models by reducing neuroinflammation, preserving neurovascular integrity, and promoting cellular repair in ischemic environments. Preclinical in vitro and in vivo studies demonstrate the potential of the MSC secretomes to restore brain function after ischemic stroke. This is achieved by enhancing neuronal survival through mechanisms such as angiogenesis or vascular recovery, neuroprotection including modulation of immune or inflammatory responses, apoptosis, and autophagy, and promoting post-stroke neurogenesis. This review explores the translational challenges and future potential of integrating conventional ischemic stroke therapies with stem cell-based or cell-free approaches. The present study synthesizes current insights into the role of MSC-derived secretomes from both in vitro and in vivo studies.

Cerebrovascular accident and essential and toxic metals: cluster analysis and principal component analysis

BACKGROUND

Cerebrovascular accidents are known as a great cause of morbidity and mortality worldwide. Although there are known risk factors for ischemic stroke, the cases that cannot be justified with these risk factors are increasing. Toxic metals as a potential risk factor for other diseases in humans are assessed in this study in the CVA group and compared to controls.

METHOD

70 participants (35 each group) have been selected for this study. The group with recent medical history of documented CVA and a control non-CVA group. The serum level of several metals has been assessed using Inductively coupled plasma mass spectrometry (ICP-MS) method. principal components and cluster analyses were employed to compare toxic metal toxicity between the groups.

RESULTS

Cu (p < 0.001) and Pb (p = 0.002) levels were significantly higher in the CVA group whereas Ni (0.003) were significantly lower. There was no significant difference between the smoking (p = 0.56) and opium (p = 0.46) use between these groups. Most of the essential metals were positively correlated with each other in both groups (Ni with Fe, Zn; Fe with Zn with r over 0.6). there was also PCA and CA are crucial in and cluster analysis in which Ni, Fe, and Zn were most similarly correlated in both groups.

CONCLUSION

we found a complex interaction between toxic metals in the healthy and CVA human body. Due to the lack of data on in vivo interaction of these metals even in healthy individuals, further investigation is needed to evaluate the exact mechanism of such relations.

Suspected Transient Ischemic Attack Related to Dysfunctional Quadricuspid Aortic Valve

We describe a 30-year-old Caribbean-Black woman with a clinical presentation suggestive of a transient ischemic attack (TIA) with no conventional cerebrovascular risk factors, albeit with a newly diagnosed quadricuspid aortic valve (QAV) with moderate aortic regurgitation (AR). Although QAV is a recognized congenital cardiac defect, its association with TIA remains elusive. This case highlights the importance of considering potential atypical etiologies, such as QAV, in the evaluation and management of young patients presenting with cerebrovascular events.

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

Background

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

Conclusions

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

Effect of stroke etiology on treatment-related outcomes in young adults with large vessel occlusion: Results from a retrospective cohort study

INTRODUCTION

Large vessel occlusion-acute ischemic stroke (LVO-AIS) is infrequent in young adults and exhibits distinct stroke mechanisms compared to older adults. This study sought to evaluate the impact of varying stroke etiologies on treatment-related outcomes in young adults with LVO-AIS, an aspect that remains unclear.

METHODS

This retrospective cohort study included patients aged 18-50 presenting with AIS from January 2017 to December 2021 within our multi-center stroke network. Patients with LVO on CTA/MRA at presentation were included. We assessed demographics, stroke etiology (TOAST classification), and treatment-related outcomes. Based on intervention received, patients were divided into 5 groups [IV-thrombolysis (IVT) only, Mechanical Thrombectomy (MT) only, IVT+MT, no treatment, unsuccessful MT].

RESULTS

Among 1210 AIS patients, 220 with LVO were included. The median age was 42 (36, 46). 75 (34.1 %) patients underwent successful MT (46.7 % received IVT+MT). 26 (11.8 %) received IVT only, 110 (50 %) received neither intervention, and 9 (4.1 %) underwent unsuccessful MT. Per TOAST, 17.4 % had large artery atherosclerosis (LAA), 19.2 % cardio-embolism, 28.6 % stroke of other etiology, and 34.7 % had undetermined etiology. Favorable thrombectomy outcomes (TICI 2b/2c/3) were observed in 87.2 %. Discharge NIH Stroke Scale (NIHSS) scores improved for patients with IVT+MT in all TOAST categories except LAA.

CONCLUSIONS

Young adults with LVO-AIS had good outcomes irrespective of stroke etiology, except LAA, which was associated with a higher discharge NIHSS. Moreover, 50 % of young adults in our study received no intervention, a quarter of those owing to delayed presentation. Further studies are needed to identify barriers in seeking acute treatment in young adults with LVO-AIS.

Adolescent Blood Pressure and Early Age Stroke

BACKGROUND

Underdiagnosis of relevant risk factors has contributed to the increasing stroke incidence in young adults. Blood pressure cut-off values for adolescents are neither sex specific nor based on cardiovascular outcomes.

METHODS

This nationwide, population-based, retrospective cohort study included all Israeli adolescents 16-19 years of age who were medically evaluated before compulsory military service from 1985 to 2013, including routine blood pressure measurements. The primary outcome was the first occurrence of a stroke (ischemic or hemorrhagic) at a young age (≤52 years), as documented in the Israeli National Stroke Registry. Cox proportional hazard models were stratified by sex and adjusted for birth year, sociodemographic variables, and adolescent body mass index.

RESULTS

The cohort comprised 1,897,048 adolescents (42.4% women). During 11,355,476 person-years of follow-up, there were 1470 first stroke events at a young age. In men, an adolescent diastolic blood pressure value of ≥80 mmHg, compared with the reference group (diastolic blood pressure value of <70 mmHg), was associated with an increased risk of stroke (adjusted hazard ratio 1.28; 95% confidence interval [CI], 1.04 to 1.58), while a diastolic blood pressure value of 70-79 mmHg was not associated with an increased risk of stroke (adjusted hazard ratio 1.11; 95% CI 0.90 to 1.34). Among women, an adolescent diastolic blood pressure value of ≥80 mmHg, compared with the reference group (diastolic blood pressure value of <70 mmHg) was associated with an increased risk of stroke at a young age (adjusted hazard ratio 1.38; 95% CI 1.03 to 1.88), as was a diastolic blood pressure value of 70-79 mmHg (adjusted hazard ratio 1.41; 95% CI 1.09 to 1.81). Elevated adolescent systolic blood pressure values (≥120 mmHg) were not associated with an increased risk of stroke.

CONCLUSIONS

Diastolic blood pressure values of ≥80 mmHg in adolescence were associated with an increased risk of stroke at a young age in both men and women. No similar association was observed for elevated systolic blood pressure.

A Narrative Review of the Best Anesthesia Care for Endovascular Thrombectomy: Early Diagnosis of the Ischemic Stroke and Evaluation of Risk Factors in Female Population

Background: The increasing incidence of cerebrovascular accidents represents an emerging problem. The rise in risk factors such as lifestyle choices—smoking, poor nutrition, and metabolic diseases—poses a significant challenge for the global healthcare system. The female population, due to physiological conditions and iatrogenic risks, may be at a greater risk of developing ischemic accidents. In addition to these acquired conditions, life phases such as pregnancy or puerperium, and medical conditions like surgical treatments and hormone therapy, may elevate this risk. Methods: This narrative aims to assess the various risk factors specific to the female population and evaluate the appropriate management strategies, including anesthetic support. Anesthesia plays a crucial role in enabling pharmacological procedures, such as thrombolysis, or surgical procedures like thrombectomy, in the management of ischemic cerebrovascular events. Results: The review emphasizes the importance of early recognition of risk factors to ensure prompt diagnosis and the most appropriate treatment options for ischemic events. Anesthesia support has become essential for carrying out necessary medical interventions effectively. Choosing the right anesthesia technique for endovascular thrombectomy is particularly significant, requiring consideration of the patient’s characteristics, the timing of diagnosis, and the preferences of the interventional neuroradiologists. Conclusions: It is vital to identify risk factors in the female population early to facilitate timely diagnosis and optimize treatment outcomes. Anesthetic support plays a key role in ensuring that critical procedures, such as thrombolysis and thrombectomy, are carried out effectively. Tailoring anesthesia choices to the patient’s individual needs is critical for a successful intervention.

Current understanding of stroke and stroke mimics in adolescents and young adults: a narrative review

BACKGROUND

Stroke in adolescents and young adults are uncommon, and unlike in older adults, the etiology can be a challenging puzzle to solve. Patients often lack traditional risk factors such as hypertension or may be too young for suspected atherosclerotic disease. Additionally, among this group, various stroke mimics exist that can cloud physician judgment, leading to under- or overtreatment.

AIM

There is a significant gap in the current literature and clinical evidence regarding stroke in this population. This review of the literature aims to extract important information surrounding the etiology, risk factors, diagnosis, management, and complications of stroke in younger people and address stroke mimics and how they can appear similar and different from ischemic or hemorrhagic stroke. Additionally, we discuss the importance of furthering research in this specific population in all areas due to a concerning rise in stroke frequency and unique associated disabilities.

CONCLUSION

The acute treatment of stroke in young patients is similar to older adults. While stroke mimics may complicate suspicion and cause hesitance, delays in stroke care should be avoided. There remains a need for research in the areas of diagnosis, management, and assessment of long-term care and challenges in this population of patients.

Impact of smoke-free legislation on stroke risk: A systematic review and meta-analysis

PURPOSE

Secondhand smoke significantly increases the risk of cerebrovascular diseases, prompting recent public smoking bans. We aimed to ascertain the effects of smoke-free legislation on stroke incidence and mortality.

METHODS

We systematically searched Medline, Embase, Cochrane Library, and Scopus up to August 13, 2023, for studies reporting changes in stroke incidence following partial or comprehensive smoking bans. A random-effects meta-analysis was conducted on hospital admissions and mortality for stroke, stratified based on comprehensiveness of the ban ((i) workplaces-only, (ii) workplaces and restaurants, (iii) workplaces, restaurants and bars). The effect of post-ban follow-up duration was assessed visually by a forest plot, while meta-regression was employed to evaluate for any dose-response relationship between ban comprehensiveness and stroke risk.

FINDINGS

Of 3987 records identified, 15 studies analysing bans across a median follow-up time of 24 months (range: 3-67) were included. WRB bans were associated with reductions in the rates of hospital admissions for stroke (nine studies; RR, 0.918; 95% CI, 0.872-0.967) and stroke mortality (three studies; RR, 0.987; 95% CI, 0.952-1.022), although the latter did not reach statistical significance. There was no significant difference in the risk of stroke admissions for studies with increased ban comprehensiveness and no minimum duration for significant post-ban effects to be observed.

DISCUSSION AND CONCLUSION

Legislative smoking bans were associated with significant reductions in stroke-related hospital admissions, providing evidence for its utility as a public health intervention.

Predicting 3-month poor functional outcomes of acute ischemic stroke in young patients using machine learning

BACKGROUND

Prediction of short-term outcomes in young patients with acute ischemic stroke (AIS) may assist in making therapy decisions. Machine learning (ML) is increasingly used in healthcare due to its high accuracy. This study aims to use a ML-based predictive model for poor 3-month functional outcomes in young AIS patients and to compare the predictive performance of ML models with the logistic regression model.

METHODS

We enrolled AIS patients aged between 18 and 50 years from the Third Chinese National Stroke Registry (CNSR-III), collected between 2015 and 2018. A modified Rankin Scale (mRS) ≥ 3 was a poor functional outcome at 3 months. Four ML tree models were developed: The extreme Gradient Boosting (XGBoost), Light Gradient Boosted Machine (lightGBM), Random Forest (RF), and The Gradient Boosting Decision Trees (GBDT), compared with logistic regression. We assess the model performance based on both discrimination and calibration.

RESULTS

A total of 2268 young patients with a mean age of 44.3 ± 5.5 years were included. Among them, (9%) had poor functional outcomes. The mRS at admission, living alone conditions, and high National Institutes of Health Stroke Scale (NIHSS) at discharge remained independent predictors of poor 3-month outcomes. The best AUC in the test group was XGBoost (AUC = 0.801), followed by GBDT, RF, and lightGBM (AUCs of 0.795, 0, 794, and 0.792, respectively). The XGBoost, RF, and lightGBM models were significantly better than logistic regression (P < 0.05).

CONCLUSIONS

ML outperformed logistic regression, where XGBoost the boost was the best model for predicting poor functional outcomes in young AIS patients. It is important to consider living alone conditions with high severity scores to improve stroke prognosis.

Assistive technology on upper extremity function for stroke patients: A systematic review with meta-analysis

BACKGROUND

In stroke rehabilitation, the selection of appropriate assistive devices is of paramount importance for patients. Specifically, the choice of device can significantly influence the functional recovery of the upper limb, impacting their overall activities or functional tasks.

OBJECTIVES

This review aimed to comprehensively analyze and summarize the clinical evidence from randomized controlled trials (RCTs) regarding the therapeutic effects of commonly used assistive devices on upper extremity function in patients with stroke.

METHODS

To evaluate assistive devices for patients with stroke, we summarized qualitatively throughout synthesis of results, such as therapeutic intervention, intensity, outcome, and summary of results, and examined risk of bias, heterogeneity, mean difference, 95% confidence interval, and I-squared value. To analyze, we used RoB 2 and RevMan 5.4.

RESULTS

The qualitative synthesis included 31 RCTs. The randomization process and the reporting of results showed minimal bias, but there were issues with bias from intended interventions, and missing outcome data presented some concerns. The quantitative synthesis included 16 RCTs. There was a significant difference in the Fugl-Meyer assessment-upper extremity functioning (FMA-UE) scores between the groups, with a total mean difference (95% confidence interval) of 2.40 (0.21, 4.60), heterogeneity values were Tau2 = 0.32, chi-square = 8.22, degrees of freedom = 8 (p = 0.41), and I2 = 3% for FMA-UE and the test for the overall effect produced Z = 2.14 (p = 0.03) in patients with chronic stroke. However, there was no significant difference in all other outcome measures.

CONCLUSIONS

Upper-limb robots did not demonstrate significant superiority over conventional treatments in improving function of upper limbs, with the exception of FMA-UE scores for patients with chronic stroke. The mean difference of FMA-UE was also lower than minimally important difference. Nonetheless, the usage of upper-limb robots may contribute to enhanced function for patients with stroke, as those devices support clinicians and enable a greater number of movement repetitions within specific time frames.

OX26-cojugated gangliosilated liposomes to improve the post-ischemic therapeutic effect of CDP-choline

Cerebrovascular impairment represents one of the main causes of death worldwide with a mortality rate of 5.5 million per year. The disability of 50% of surviving patients has high social impacts and costs in long period treatment for national healthcare systems. For these reasons, the efficacious clinical treatment of patients, with brain ischemic stroke, remains a medical need. To this aim, a liposome nanomedicine, with monosialic ganglioside type 1 (GM1), OX26 (an anti-transferrin receptor antibody), and CDP-choline (a neurotrophic drug) (CDP-choline/OX26Lip) was prepared. CDP-choline/OX26Lip were prepared by a freeze and thaw method and then extruded through polycarbonate filters, to have narrow size distributed liposomes of ~80 nm. CDP-choline/OX26Lip were stable in human serum, they had suitable pharmacokinetic properties, and 30.0 ± 4.2% of the injected drug was still present in the blood stream 12 h after its systemic injection. The post-ischemic therapeutic effect of CDP-choline/OX26Lip is higher than CDP-choline/Lip, thus showing a significantly high survival rate of the re-perfused post-ischemic rats, i.e. 96% and 78% after 8 days. The treatment with CDP-choline/OX26Lip significantly decreased the peroxidation rate of ~5-times compared to CDP-choline/Lip; and the resulting conjugated dienes, that was 13.9 ± 1.1 mmol/mg proteins for CDP-choline/Lip and 3.1 ± 0.8 for CDP-choline/OX26Lip. OX26 increased the accumulation of GM1-liposomes in the brain tissues and thus the efficacious of CDP-choline. Therefore, this nanomedicine may represent a strategy for the reassessment of CDP-choline to treat post-ischemic events caused by brain stroke, and respond to a significant clinical need.

High Resting Heart Rate Is Associated with Cardiovascular Death in Patients with Stroke, Independent of Sex

INTRODUCTION

High resting heart rate (HRHR) is a surrogate marker of increased sympathetic outflow. In acute stroke patients, HRHR is more commonly observed in women than in men. We analyzed whether HRHR (>86 bpm) adds incremental prognostic value for stroke outcomes in women.

METHODS

We analyzed data of 6,024 patients (2,568 women, mean age 68.98 years) with acute ischemic stroke from the Virtual International Stroke Trials Archive (VISTA).

RESULTS

Patients with HRHR were more often female (45.3 vs. 41.8%, p = 0.017), younger (66.0 ± 13.2 vs. 67.8 ± 12.6 years, p < 0.001), had higher baseline systolic blood pressure and more often diabetes. The primary composite endpoint of recurrent ischemic stroke, transient ischemic attack, myocardial infarction, or cardiovascular death within 90 days occurred more often in patients with HRHR (19.3 vs. 14.6%, p < 0.001). HRHR was associated with worse functional outcome at 90 days as assessed by modified Rankin Scale (mRS90: 3.03 ± 1.98 vs. 2.82 ± 1.94, p = 0.001). As exclusion of deceased patients (mRS90 of 6) resulted in a loss of association of HRHR with mRS90, it can be assumed that HRHR is mainly associated with poststroke vascular mortality, but not disability. Female sex was not associated with the primary endpoint but with adverse functional outcome measured by mRS90.

CONCLUSION

HRHR was associated with adverse events and mortality after stroke. Despite a higher prevalence of HRHR in women, they did not reach the primary endpoint more often. However, women had a worse functional outcome (mRS) 3 months after stroke, independent of HRHR.

Incidence and Predictors of Stroke in Australian Adults With Congenital Heart Disease (2000-2017)

BACKGROUND

Adults with congenital heart disease (CHD) are at increased risk of stroke but high-quality population level data on stroke incidence in these patients are scant.

METHODS AND RESULTS

A retrospective whole-population Western Australian cohort of adult patients with CHD aged 18 to 64 years was created and followed from January 2000 to December 2017 using linked hospital data. Stroke incidence rates within the adult cohort with CHD were calculated and compared with the general population via direct standardization. A nested case-control design assessed predictors of ischemic and hemorrhagic stroke within the cohort. Among 7916 adults with CHD, 249 (3.1%) incident strokes occurred at a median age of 47 years; 186 (2.3%) ischemic, 33 (0.4%) hemorrhagic and 30 (0.4%) unspecified strokes. Ischemic and hemorrhagic stroke incidence was, respectively, 9 and 3 times higher in adults with CHD than the general population. Absolute risk was low with annual rates of 0.26% (ischemic) and 0.05% (hemorrhagic). Highest rates were observed in adults with shunt and left-sided lesions. Predictors of ischemic stroke in adults with CHD included recent cardiac surgery, left-sided valve repair/replacements, shunt lesions, and traditional risk factors (hypertension, infective endocarditis, peripheral vascular disease, and tobacco use). Mental health disorders and increasing Charlson's comorbidity scores were strongly associated with higher risk of ischemic and hemorrhagic stroke. The CHA2DS2VASc score was associated with ischemic stroke incidence.

CONCLUSIONS

This study provides the first population-based stroke incidence estimates for adults with CHD in Australia, showing elevated stroke risk across different CHD lesions. It highlights the potential clinical importance of managing comorbidities, especially mental health.

Testosterone supplementation and stroke in young adults: a review of the literature

Testosterone supplementation has increased in recent years for both treatment of hypogonadism and recreational use. Strokes in young adults have similarly increased with a larger proportion of patients in this age group having a stroke due to early onset of cardiovascular risk factors or unrelated to conventional risks. Hormonal treatments are associated with increased stroke risk amongst women, with some studies indicating an increase in stroke risk as high as 40% when compared to non-users. However, less is known about male sex hormones and risks associated with increased stroke. Limited data evaluates the relationship between testosterone supplementation and stroke in young adults. In this review, we analyze the literature and plausible underlying pathophysiological mechanisms associated with increased risks in patients using exogenous testosterone. Furthermore, we highlight the gaps in research about safety and long-term effects on young patients.

The Impact of miR-34a on Endothelial Cell Viability and Apoptosis in Ischemic Stroke: Unraveling the MTHFR-Homocysteine Pathway

INTRODUCTION

Ischemic stroke (IS) is a global health concern, often tied to dyslipidemia and vascular endothelial dysfunction. MicroRNA-34a (miR-34a) was reported to be up-regulated in the blood samples of patients with IS, but the specific role of miR-34a and methylenetetrahydrofolate reductase (MTHFR) in IS remains to be elucidated.

METHODS

We studied 143 subjects: 71 IS patients, and 72 healthy controls. Human umbilical vein endothelial cells (HUVECs) were cultured and transfected with a miR-34a mimic, inhibitor, or negative control. The miR-34a expression in serum and HUVECs was quantified via quantitative reverse transcription polymerase chain reaction (qRT-PCR). Viability and apoptosis of HUVECs were assessed using CCK-8 assay and flow cytometry. The expression levels of bcl-2, bax, cyt-c, cleaved caspase 3, MTHFR, and homocysteine were measured by Western blot or enzyme-linked immunosorbent assay (ELISA). The relationship between miR-34a and MTHFR was verified by luciferase reporter assay. The levels of MTHFR and homocysteine in serum were examined by ELISA.

RESULTS

MiR-34a expression was increased in IS patients and inhibited viability of HUVECs while promoting their apoptosis. Overexpression of miR-34a up-regulated pro-apoptotic proteins (bax, cyt-c and cleaved caspase 3) and down-regulated anti-apoptotic protein bcl-2 in HUVECs. MTHFR was identified as the downstream target of miR-34a and its expression was reduced by miR-34a overexpression, while homocysteine levels increased. Consistently, MTHFR levels were lower and homocysteine levels were higher in IS patients compared with controls.

DISCUSSION

Our results suggest that up-regulated miR-34a plays a role in the pathogenesis of IS, potentially through inhibiting MTHFR expression and increasing homocysteine in endothelial cells. Therefore, miR-34a might be a therapeutic target for IS.

Sex Differences in the Risk of Stroke Associated With Traditional and Non-Traditional Factors in a US Cohort of People With HIV Infection

BACKGROUND AND OBJECTIVES

Although stroke risk associated with HIV may be greater for women than men, little is known about whether the impact of different factors on cerebrovascular risk varies by sex in people with HIV (PWH) and contributes to stroke risk disparities in this population. The primary objective of this study was to examine whether sex modifies the effect of demographics, cardiometabolic factors, health-related behaviors, and HIV-specific variables on stroke risk in PWH from the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort.

METHODS

In this observational cohort study, we analyzed data from clinical encounters for PWH followed at 5 CNICS sites from approximately 2005 to 2020. All potential stroke events were adjudicated by neurologists. Patient-reported outcomes collected at clinic visits, including substance use and depression, were also available. We used Cox proportional hazards models to determine whether sex modified the association of predictors of interest with incident stroke.

RESULTS

Among 13,573 PWH (19% female sex at birth, mean age 44 years, mean follow-up 5.6 years), female sex was associated with a higher risk of stroke only among individuals aged 50 years or younger (hazard ratio [HR] 2.01 at age 40 [1.25-3.21] vs HR 0.60 at age 60 [0.34-1.06]; p = 0.001 for the interaction). Younger female participants who developed a stroke were more likely to have treated hypertension, a higher cardiovascular risk score, and detectable HIV than younger male participants whereas these factors were comparable by sex among older participants who developed a stroke. Sex modified the effect of detectable HIV (HR 4.66 for female participants [2.48-8.74] vs HR 1.30 for male participants [0.83-2.03]; p = 0.001 for the interaction), methamphetamine use (HR 4.78 for female participants [1.47-15.56] vs HR 1.19 for male participants [0.62-2.29]; p = 0.04 for the interaction), and treated hypertension (HR 3.44 for female participants [1.74-6.81] vs HR 1.66 for male participants [1.14-2.41]; p = 0.06 for the interaction) on stroke risk.

DISCUSSION

Younger female participants with HIV were at elevated cerebrovascular risk compared with younger male participants. Several risk factors had a greater adverse effect on stroke risk in female participants than in male participants, including HIV viremia, methamphetamine use, and treated hypertension. These findings underscore the importance of a personalized approach to predict and prevent cerebrovascular risk among PWH.

Drug-coated balloon angioplasty for the treatment of intracranial arterial stenosis in a young stroke patient: A case report

BACKGROUND

Intracranial arterial narrowing is a significant factor leading to brief episodes of reduced blood flow to the brain, known as transient ischemic attacks, or full-blown strokes. While atherosclerosis is commonly associated with intracranial arterial narrowing, it is frequently of a non-atherosclerotic nature in younger patients.

CASE SUMMARY

Here, we present the case of a young stroke patient with narrowing of the middle cerebral artery (MCA), characterized as non-atherosclerotic lesions, who experienced an ischemic stroke despite receiving standard drug therapy. The patient underwent digital subtraction angiography (DSA) to assess the entire network of blood vessels in the brain, revealing significant narrowing (approximately 80%) in the M1 segment of the right MCA. Subsequently, the patient underwent Drug-Coated Balloon Angioplasty to treat the stenosis in the right MCA's M1 segment. Follow-up DSA confirmed the resolution of stenosis in this segment. Although the remaining branches showed satisfactory blood flow, the vessel wall exhibited irregularities. A review of DSA conducted six months later showed no evident stenosis in the right MCA, with a smooth vessel wall.

CONCLUSION

The use of drug-coated balloon angioplasty demonstrated favorable outcomes in repairing and reshaping the blood vessel wall in young patients. Therefore, it may be considered a promising treatment option for similar cases.

Atrial fibrillation: age at diagnosis, incident cardiovascular events, and mortality

BACKGROUND AND AIMS

Patients with atrial fibrillation (AF) are at increased risks of cardiovascular diseases and mortality, but risks according to age at diagnosis have not been reported. This study investigated age-specific risks of outcomes among patients with AF and the background population.

METHODS

This nationwide population-based cohort study included patients with AF and controls without outcomes by the application of exposure density matching on the basis of sex, year of birth, and index date. The absolute risks and hazard rates were stratified by age groups and assessed using competing risk survival analyses and Cox regression models, respectively. The expected differences in residual life years among participants were estimated.

RESULTS

The study included 216 579 AF patients from year 2000 to 2020 and 866 316 controls. The mean follow-up time was 7.9 years. Comparing AF patients with matched controls, the hazard ratios among individuals ≤50 years was 8.90 [95% confidence interval (CI), 7.17-11.0] for cardiomyopathy, 8.64 (95% CI, 7.74-9.64) for heart failure, 2.18 (95% CI, 1.89-2.52) for ischaemic stroke, and 2.74 (95% CI, 2.53-2.96) for mortality. The expected average loss of life years among individuals ≤50 years was 9.2 years (95% CI, 9.0-9.3) years. The estimates decreased with older age.

CONCLUSIONS

The findings show that earlier diagnosis of AF is associated with a higher hazard ratio of subsequent myocardial disease and shorter life expectancy. Further studies are needed to determine causality and whether AF could be used as a risk marker among particularly younger patients.

Paradoxical Embolism in Juveniles and Young Adults With Severe-to-Profound Sudden Sensorineural Hearing Loss

Objective: Paradoxical embolism from right-to-left shunting is a common cause of cryptogenic stroke in the young. Circulatory ischemia of the cochlea is closely connected with severe-to-profound sudden sensorineural hearing loss. This study aimed to explore the role of paradoxical embolism in severe-to-profound sudden sensorineural hearing loss in juveniles and young adults. Methods: From August 2021 to September 2022, consecutive outpatients under 35 years of age with severe-to-profound sudden hearing loss were included in the study. Routine auditory electrophysiological testing and contrast transcranial Doppler ultrasonography (c-TCD) were conducted, and the results were retrospectively analyzed. Results: Seven patients (age: 19.4 ± 6.5 years) were enrolled, including 5 juveniles and 2 young adults. Three patients had severe deafness, and 4 patients had profound deafness. Right-to-left shunting was detected in all patients through c-TCD. Patent foramen ovale was found in 2 patients while pulmonary arteriovenous fistula was found in 1 patient through contrast transthoracic echocardiography or cardiac catheterization. No patients had precipitating factors for sudden sensorineural hearing loss, and none had abnormalities on head magnetic resonance imaging. Six patients underwent whole-exome sequencing, and no known deafness gene variant was detected. After standard treatment for 1 month, 2, 3, and 2 patients had complete, slight, and no hearing recovery, respectively. Conclusions: Paradoxical embolism is a possible cause of severe-to-profound sudden sensorineural hearing loss in juveniles and young adults. In young patients, c-TCD is an effective screening tool to detect right-to-left shunting, while contrast transthoracic echocardiography is a complementary examination to c-TCD.

Utilising interactive technology for stroke patient education: a systematic review

PURPOSE

As a leading cause of death and disability worldwide, how to effectively manage and prevent stroke is a key consideration for health care systems. Throughout the world stroke management recommendations include education; however, not all patients receive this intervention. Advances in technology have provided health professionals with a range of innovative, effective, and modern tools that may be useful in delivering stroke education. This study aimed to systematically review the current evidence for the use of interactive technology in stroke patient education, and whether this was effective for increasing patients' stroke knowledge and behaviours that lower stroke risk.

METHODS AND MATERIALS

The protocol was registered with PROSPERO (#225223) and a literature search undertaken in Embase (including MEDLINE and PubMed), PsycInfo and CINAHL from inception until August 2022. The Mixed Methods Appraisal Tool was used to assess the methodological quality of the included articles.

RESULTS

From an initial yield of 760 articles, 10 articles met the study inclusion criteria. The articles explored a range of interactive technologies, with none of them includes articles using the same technology. All of the articles reported at least one positive effect from the technology. Two articles reported on stroke incidence post-intervention. The methodological quality of the articles varied, but was largely medium to high.

CONCLUSION

The paucity of evidence highlights a need for future studies to provide insights into the benefits of quality interactive technology-based stroke education and to identify options for optimal delivery modes in stroke education.

Ischemic Stroke in Young Tunisian Adults

INTRODUCTION

Ischemic Stroke in young adults is a real public health problem; it's a major cause of disability, alters quality of life and has a great socio-economic impact.

AIM

determine risk factors and specify the etiology of arterial ischemic stroke in young Tunisian adults.

METHODS

In this 5 years retrospective study (2015-2020), we included all young adults (18-50 years) admitted for arterial ischemic stroke (AIS). Risk factors were registered and analyzed. All patients were investigated using a standard protocol: biological tests, brain imaging, carotid ultrasound and cardiac assessment. Additional investigations were carried out at the discretion of the treating physician. The cause of ischemic stroke was classified according to the TOAST criteria.

RESULTS

We collected 200 patients with AIS. The mean age was 41.37 years ± 6.99. Traditional vascular risk factors were observed in more than 1⁄4 patients. A definite cause of stroke was identified in 120 patients. Cardio-embolic causes were the most common among our patients (19%) followed by atherosclerosis of the large arteries (11.5%). Other determined etiologies were found in 27.5% of patients. The etiology remained unclear in 40% of cases: undetermined despite complete investigation in 17.5%, undetermined and incompletely investigated 14.5 % and more than one potential pathomechanisms in 8%.

CONCLUSION

Through this study, we demonstrated the diversity of etiology of stroke in young Tunisian adults. Changes of lifestyle are responsible for the occurrence of the traditional risk factors at an early age. Rheumatic heart diseases remain a frequent cause of AIS in our area.

Primary antiphospholipid syndrome in the elderly: Four strokes and mechanical thrombectomies until the diagnosis - A case report

Antiphospholipid syndrome (APS) is known as a rare etiology of embolic ischemic stroke. In individuals below 50 years, up to 20% of strokes are associated with APS, whereas in patients >50 years, it is considered a very seldom cause of stroke. We describe the course of a 66-year-old white woman, who experienced four embolic strokes with large vessel occlusion over a period of 2 years, which were repeatedly and successfully treated by mechanical thrombectomy. Initially attributed to atrial fibrillation and treated with direct oral anticoagulants, the patient was finally diagnosed with primary APS due to isolated anti-beta 2-glycoprotein antibodies and successfully treated after several stroke recurrences. After initiation of Vitamin K antagonist therapy, no further strokes occurred. For recurrent embolic stroke despite oral anticoagulation, late-onset APS might be considered a rare etiology also in the elderly.

Sex and Racial/Ethnic Patterns of Tobacco Product Use Among Students at a U.S. University in 2021-2023

Background: Although the prevalence of conventional tobacco product use among U.S. college students has declined, an increasing number of students use various novel tobacco products. Objectives: This study aims to examine up-to-date sex and racial/ethnic patterns of tobacco use among students at a U.S. university in 2021-2023. Methods: Data of 2,732 students at an urban university in the Southeast of the U.S. were collected in 2021-2023 as part of the National College Health Assessment of the American College Health Association. Self-reported past 3-month use of five tobacco products (cigarette, electronic vapor products, water pipe/hookah, smokeless tobacco, and cigars) was dichotomized. We conducted multinomial logistic regression analysis to examine sex (male or female) and racial/ethnic (non-Hispanic White, non-Hispanic Black, Hispanic, or non-Hispanic Other) differences in single and dual/poly (con-current use of two or more tobacco products) tobacco use compared to nonuse, adjusting for age, student status, parent education level, obese status, psychological distress level, and survey year. Results: Male students had higher odds of being dual/poly tobacco user than female students, adjusting for covariates (adjusted odds ratio [AOR] = 2.00, 95% confidence interval [CI] = 1.42, 2.82). Non-Hispanic Black students had lower odds of being single (AOR = 0.43, 95% CI = 0.26, 0.69) and dual/poly (AOR = 0.09, 95% CI = 0.02, 0.37) tobacco user compared to non-Hispanic White students, adjusting for covariates. Conclusions: Considering higher health risk of con-current use of multiple tobacco products, dual/poly tobacco use prevention strategies targeting male and non-Hispanic White students may be considered.

Atrial Septal Abnormalities and Cryptogenic Stroke: A Cross-Sectional Study

BACKGROUND

Cryptogenic stroke, whose underlying pathology is unknown, accounts for 30-40% of all ischemic strokes. Studies have mentioned the association between atrial septal abnormalities and cryptogenic stroke, but there are still disparities in the results among different studies.

OBJECTIVE

We aimed to clarify the prevalence of atrial septal abnormalities in patients with cryptogenic stroke.

METHODS

We conducted a cross-sectional study on 91 patients with cryptogenic stroke/transient ischemic attack from March 2021 to March 2022. We evaluated the demographic data of the patients and also the existence of neurologic attacks. Furthermore, echocardiography was performed to determine the type of atrial septal abnormality.

RESULTS

Out of 91 patients with cryptogenic stroke/transient ischemic attack, 16 patients (17.5%) had patent foramen ovale, 1 man (1.1%) had atrial septal aneurysm, and 1 woman (1.1%) had an atrial septal defect. Patients with patent foramen ovale were significantly younger than those without. The size of patent foramen ovale in patients with cryptogenic stroke was larger than those with transient ischemic attack, but this difference was not significant. Also, the size of the patent foramen ovale (length and width) was not significantly related to any of the demographic variables (p-value = 0.544, 0.604).

CONCLUSION

Based on our results, the prevalence of atrial septal abnormalities was relatively high. Considering these issues and the importance of preventing neurological accidents in patients, especially young people, it is recommended to always consider atrial septal disorders and, if diagnosed, to carry out the necessary treatment in this field.

Design, synthesis, and evaluation of n-butylphthalide and ligustrazine hybrids as potent neuroprotective agents for the treatment of ischemic stroke in vitro and in vivo

A series of novel NBP-TMP hybrids with neuroprotective effects were designed and synthesized for the treatment of ischemic stroke. The anti-cerebral ischemic activity of these compounds was screened by evaluating their neuroprotective effects on the oxygen glucose deprivation/reperfusion (OGD/R)-induced SH-SY5Y cell injury model in vitro. Nine compounds 7e, 7h-7i, 7k, 7m-7p and 7r showed better activities on cell viability and LDH levels compared to NBP at the concentration of 6.25 μM. Among them, compound 7m showed the best potency with a percentage of protection 90.2 % compared to NBP (69.2 %) and other compounds. Preliminary structure-activity analysis revealed that the introduction of iodine and N-methylpiperazine groups could significantly improve the neuroprotective effect. Further mechanism research showed that compound 7m could reduce the damage to neuronal mitochondria caused by OGD/R by reducing ROS and increasing mitochondrial membrane potential (MMP), and reduce the apoptosis and necrosis of neurons to play a neuroprotective role. In addition, 7m could regulate the levels of mitochondrial apoptosis pathway-related proteins Bcl-2, Bax, and caspase 3. Finally, in vivo experiments showed that the compound 7m significantly inhibited ischemia-reperfusion injury and cerebral blood flow in rats, and showed a more significant neuroprotective effect than the positive drug NBP at a dose concentration of 20 mg/kg. In conclusion, our results suggest that 7m may be used as a novel lead compound for the future development of anti-cerebral ischemic agents.

[Ischemic stroke in men 18-50 years of age]

OBJECTIVE

To evaluate the main modifiable risk factors for ischemic stroke (IS) and features of the course in atherothrombotic, cardioembolic, and lacunar subtypes of IS in men aged 18-50 years.

MATERIAL AND METHODS

The study included 125 men (the mean age was 42.6±5.3 years) who were admitted to the Vascular department before the COVID-19 pandemic and survived for the first 30 days after IS. Information on patients' baseline characteristics, traditional vascular risk factors, and lifestyle risk factors was systematically collected. Neuroimaging, ultrasound and laboratory tests were performed.

RESULTS

Atherothrombotic subtype was identified in 60 patients, lacunar subtype in 46 patients and cardioembolic subtype in 19 patients. In the group as a whole, major risk factors included arterial hypertension (83.2%), dyslipidemia (50.4%), smoking (67.2%), alcohol consumption (29.6%), obesity (16.8%), heart rhythm disorders (12%), and diabetes mellitus (8%).

CONCLUSION

The study revealed the main risk factors, the frequency of which differed depending on the stroke subtype and the age of the patients.

Incidence and influencing factors of post-stroke cognitive impairment in convalescent young patients with first-ever stroke

OBJECTIVE

To investigate the occurrence of post-stroke cognitive impairment (PSCI) and its influencing factors in convalescent young patients with first-ever stroke.

METHODS

A total of 300 first-ever young stroke patients (age ≤45 years) were collected. The Mini-Mental State Examination (MMSE) was used to assess the cognitive status. The sociodemographic data, clinical symptoms, social environment, and behavior-related information were collected and analyzed.

RESULTS

The incidence of PSCI in young stroke patients was 62.33 %. Through univariate analysis, there were statistical differences in different levels of education, smoking status and hypertension (P < 0.05). With subsequently multivariate logistic regression analysis, it was found that junior high school (OR=8.58,95 %CI:2.25∼32.70) and high school (OR=10.50,95 %CI:2.69∼41.00) education levels, lesion volume >3.00 cm3 (OR=8.03,95 %CI:2.28∼28.36), stroke in the frontal-parietal-temporal region (OR=7.26,95 %CI:1.58∼33.40) and the basal ganglia area (OR=6.13,95 %CI:1.24∼30.43), high NIHSS score (OR=1.17,95 %CI: 1.06∼1.29), and high diastolic blood pressure variability coefficient (OR=1.43,95 %CI: 1.02∼2.01) were risk factors for PSCI. Meanwhile, 24≤BMI<28 (OR=0.06,95 %CI:0.02∼0.23) and BMI<24 (OR=0.18,95 %CI:0.06∼0.53), hospitalization cost >20,000/month (OR=0.22,95 %CI:0.09∼0.56), and stroke onset in spring and summer (OR=0.37,95 %CI:0.14∼0.96) were protective factors.

CONCLUSION

The incidence of PSCI is relatively high in young stroke patients. Junior high and high school education, stroke lesions >3.00cm3, strokes in the frontal-parietal-temporal and basal ganglia regions, high NIHSS scores, and high DBPV are risk factors for PSCI in young stroke patients. Meanwhile, BMI<28, treatment cost >20,000/month, and stroke onset in spring and summer are protective factors for PSCI in young stroke patients.

[Post-stroke cognitive impairment in young patients]

OBJECTIVE

To evaluate the effect of Cortexin treatment on cognitive function and quality of life for young patients after ischemic stroke.

MATERIAL AND METHODS

The open prospective observational study included 30 patients from 18 to 45 years old with confirmed ischemic stroke in the carotid blood supply who received a course of treatment with Cortexin. Before and after therapy, all patients in the study group underwent examination to assess their neuropsychological status (MoCA test), The Short Form-36 (SF-36) questionnaire was used to assess quality of life. The study results were processed using statistical analysis.

RESULTS

Based on the results of neurocognitive tests, changes in indicators of neurodynamic, visual-spatial and mnestic functions were determined. Thus, in the beginning of the study the MoCA test scores were 25.1±1.4 points. Over time, there was an improvement mainly in the areas of attention, short-term memory, and multiple aspects of executive functions. However, statistical significance for MoCA was achieved by the end of the second course of treatment with Cortexin (visit 4) - 28.4±1.3 points. Delayed neuropsychological testing showed encouraging results - the achieved level of cognitive functioning was maintained (28.0±1.1). According to SF-36 questionnaire at the stage of inclusion in the observation, low results were noted, which indicated the negative impact of the underlying disease on the daily life of the patient who had suffered a stroke. Low quality of life scores persisted until the third visit; a significant improvement in SF-36 results was recorded at visit 4 and persisted with a positive trend at the fifth visit.

CONCLUSION

Cortexin therapy has been shown to be effective, safe and well tolerated in young people with cognitive deficits in the poststroke period.

Hyperhomocysteinemia Presenting as Stroke in a Young Individual: A Case Report

This case report details the sudden onset of an ischemic stroke in a man in his late 20s, attributed to elevated homocysteine levels. Despite his young age, the patient exhibited increased homocysteine levels, a recognized stroke risk factor. This report underscores the critical importance of recognizing hyperhomocysteinemia as a potential underlying cause of strokes, even in younger age groups. Following ischemic stroke-directed treatment along with the addition of folic acid, vitamin B6, vitamin B12, and methylcobalamin, the patient's condition improved, leading to discharge with normalized homocysteine levels. Highlighting the significance of identifying this risk factor is particularly essential in regions like Pakistan, where a notably high prevalence of hyperhomocysteinemia has been reported. This case serves as a poignant reminder of the need for comprehensive stroke evaluations, urging medical practitioners to consider homocysteine as a potential contributing factor, even when dealing with young and healthy patients.

Diagnostic Yield of High-Resolution Vessel Wall Magnetic Resonance Imaging in the Evaluation of Young Stroke Patients

(1) Background: The mechanism responsible for stroke in patients younger than 50 often remains unknown. This study was designed to assess whether high-resolution intracranial vessel wall MR imaging (icVWI) may be instrumental in determining stroke cause. (2) Methods: Young stroke patients with and without an identified cause of stroke despite an exhaustive investigation were prospectively included. Patients who underwent icVWI were compared to those who did not. We next compared patients with and without intracranial vulnerable plaques on icVWI. (3) Results: Overall, 47 young stroke patients were identified over the span of 2 years and included in this study. Of those, 20 (42%) underwent intracranial icVWI. Cancer prevalence was higher among patients who did not have an icVWI study (19% vs. 0% p = 0.042) but there were no other significant differences between patients who had an icVWI study and those who did not have an icVWI. Among patients who had an icVWI, 11 (55%) had vulnerable plaques and the remaining nine studies were negative. Patients with positive icVWI scans had significantly higher stroke severity at admission (mean ± SD NIHSS score 5.5 ± 3.5 vs. 1.7 ± 2.3, p = 0.012). Patients with positive icVWI scans were more often treated with antiplatelets upon discharge (100% vs. 67%, p = 0.038). (4) Conclusions: icVWI can add significant information relevant to stroke pathogenesis and secondary prevention among young stroke patients with a negative exhaustive diagnostic workup.

Cumulative Blood Pressure in Early Adulthood and Coronary Artery Calcium and Carotid Intima-Media Thickness in Middle Age Among Adults With Maintained Blood Pressure of <130/80 mm Hg: A Post Hoc Analysis

BACKGROUND

To examine the association of blood pressure (BP) levels with coronary artery calcium and carotid intima-media thickness (CIMT) in people with maintained BP below the hypertension range based on current definitions.

METHODS AND RESULTS

In this post hoc analysis of the CARDIA (Coronary Artery Risk Development in Young Adults) prospective observational cohort study conducted in 4 US cities, we examined 1233 study participants (mean [SD] age at year 20 examination was 45.3 [3.5] years; 65.4% women). Participants with BP assessments across 20 years and untreated BP of <130/80 mm Hg were included. Multivariable logistic or linear regression models, adjusted for age, sex, race, education, diabetes, body mass index, serum creatinine, smoking, alcohol intake, physical activity, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides, were used to examine the associations between cumulative BP measures with coronary artery calcium and CIMT. Higher long-term cumulative systolic BP and pulse pressure across early adulthood were associated with higher CIMT (both P<0.001) but not coronary artery calcium in the multivariable-adjusted model. The associations remained significant even after adjustment for a single BP measurement at year 0 or year 20. The odds ratio (OR) of a maximal CIMT >1.01 mm was ≈50% higher per 1-SD increase in systolic BP (OR, 1.50 [95% CI, 1.19-1.88]) and pulse pressure (OR, 1.46 [95% CI, 1.19-1.79]). Similar findings for CIMT were observed among individuals with a coronary artery calcium score of 0 as well as those with maintained BP of <120/80 mm Hg throughout young adulthood.

CONCLUSIONS

Long-term cumulative systolic BP and pulse pressure across early adulthood within the nonhypertensive range were associated with adverse midlife alterations in CIMT.

A Young Female Newly Diagnosed With Takayasu's Arteritis Masquerading As Cerebrovascular Stroke

The condition known as Takayasu's disease or Takayasu's arteritis is a type of vascular inflammation that affects the large and medium arteries. It can lead to a reduction in blood flow to various parts of the body, and it can cause severe complications. Patients with this disease may not have specific symptoms, which can lead to their diagnosis not being confirmed. Takayasu's disease is believed to be a probable cause of stroke in young patients. Although stroke is a common cause of morbidity, it is usually not an initial presentation in Takayasu's disease. In this study, a young female with left-sided hemiparesis was diagnosed with Takayasu's disease after a clinical and angiographic examination.

Cognitive impairment after a stroke in young adults: A systematic review and meta-analysis

BACKGROUND

Information about cognitive functioning is vital in the management of stroke, but the literature is mostly based on data from individuals older than 50 years of age who make up the majority of the stroke population. As cognitive functioning is subject to change due to aging, it is unclear whether such cognitive impairment patterns from the general stroke literature apply to the growing population of younger people with a stroke.

AIM

The aim of the study was to conduct a systematic review and meta-analysis of the proportion and severity of cognitive impairment in young-stroke patients.

SUMMARY OF REVIEW

MEDLINE, Embase, PsycINFO, and Web of Science were systematically searched up to 11 October 2022. Studies were included if they reported on a population of young-stroke patients, evaluated cognitive functioning as an outcome measure, and reported original data. We estimated the pooled prevalence rates for cognitive impairment and for aphasia. In addition, we calculated the pooled estimates for the severity of impairment per cognitive domain in the chronic phase (defined as >6 months post-stroke). Six hundred thirty-five articles were identified, of which 29 were eligible for inclusion. The pooled prevalence of cognitive impairment was 44% (k = 10; 95% confidence interval (CI): 34-54%) and of aphasia 22% (k = 13; 95% CI: 12-39%). Young-stroke patients in the chronic phase performed worse than stroke-free healthy age-appropriate controls across all cognitive domains examined, with Hedges' g effect sizes ranging from -0.49 to -1.64.

CONCLUSION

Around half of all young-stroke patients present with cognitive impairment and around a quarter with aphasia. Our data suggest that patterns of impairment in young-stroke patients follow those in the general stroke literature.

Preclinical examination of early-onset thalamic-cortical seizures after hemispheric stroke

OBJECTIVE

Ischemic stroke is one of the main causes of death and disability worldwide and currently has limited treatment options. Electroencephalography (EEG) signals are significantly affected in stroke patients during the acute stage. In this study, we preclinically characterized the brain electrical rhythms and seizure activity during the hyperacute and late acute phases in a hemispheric stroke model with no reperfusion.

METHODS

EEG signals and seizures were studied in a model of hemispheric infarction induced by permanent occlusion of the middle cerebral artery (pMCAO), which mimics the clinical condition of stroke patients with permanent ischemia. Electrical brain activity was also examined using a photothrombotic (PT) stroke model. In the PT model, we induced a similar (PT group-1) or smaller (PT group-2) cortical lesion than in the pMCAO model. For all models, we used a nonconsanguineous mouse strain that mimics human diversity and genetic variation.

RESULTS

The pMCAO hemispheric stroke model exhibited thalamic-origin nonconvulsive seizures during the hyperacute stage that propagated to the thalamus and cortex. The seizures were also accompanied by progressive slowing of the EEG signal during the acute phase, with elevated delta/theta, delta/alpha, and delta/beta ratios. Cortical seizures were also confirmed in the PT stroke model of similar lesions as in the pMCAO model, but not in the PT model of smaller injuries.

SIGNIFICANCE

In the clinically relevant pMCAO model, poststroke seizures and EEG abnormalities were inferred from recordings of the contralateral hemisphere (noninfarcted hemisphere), emphasizing the reciprocity of interhemispheric connections and that injuries affecting one hemisphere had consequences for the other. Our results recapitulate many of the EEG signal hallmarks seen in stroke patients, thereby validating this specific mouse model for the examination of the mechanistic aspects of brain function and for the exploration of the reversion or suppression of EEG abnormalities in response to neuroprotective and anti-epileptic therapies.