Modifiable vascular risk factors contribute to stroke in 1080 NOTCH3 R544C carriers in Taiwan Biobank

BACKGROUND AND AIM

Previous studies have suggested cardiovascular risk factors increase the risk of not only common sporadic stroke but also of stroke in patients with monogenic stroke disorders including CADASIL. We investigated the effects of the NOTCH3 Arg544Cys (R544C) variant and associated vascular risk factors on stroke in the Taiwanese population.

METHODS

This study was conducted using data from the Taiwan Biobank, consisting of at least 130,000 Han Chinese participants. The genotype was derived from customized genome-wide arrays for 650,000 to 750,000 single-nucleotide polymorphisms (SNPs). Individuals with NOTCH3 R544C were subsequently matched with noncarriers based on the propensity score at a 1:10 ratio by demographic and cardiovascular risk factors. The odds ratio (OR) for stroke or other phenotypes in NOTCH3 R544C carriers and matched noncarriers was then calculated. Univariate and multivariate regression analyses were performed on cardiovascular risk factors in NOTCH3 R544C carriers with and without stroke. The polygenic risk score (PRS) model, adopted from the UK Biobank, was then applied to evaluate the role of NOTCH3 R544C in stroke.

RESULTS

From the 114,282 participants with both genotype and questionnaire results, 1080 (0.95%) harbored the pathogenic NOTCH3 R544C variant. When compared to the matched controls (n = 10,800), the carriers presented with a history of stroke (OR: 2.52, 95% confidence interval (CI) (1.45, 4.37)), dementia (OR: 30.1, 95% CI (3.13, 289.43)), and sibling history of stroke (OR: 2.48, 95% CI (1.85, 3.34)) phenotypes. The risk of stroke increased with every 10-year increase in age (p = 0.006, Cochran-Mantel-Haenszel test). Among NOTCH3 R544C carriers, 16 (1.3%) of the 1080 carriers with a stroke history were older, male, and more likely to have hypertension, diabetes, dyslipidemia, and a family history of stroke. In the stepwise multivariate analysis, hypertension (OR: 11.28, 95% CI (3.54, 43.3)) and diabetes mellitus (OR: 4.10, 95% CI (1.31, 12.4)) were independently associated with stroke. Harboring the NOTCH3 R544C variant in the Taiwan Biobank is comparable with a 6.74 standard deviations increase in individual's polygenic risk score for stroke.

CONCLUSION

While the NOTCH3 R544C variant alone increased the risk of stroke, modifiable vascular risk factors also played a role in the occurrence of stroke in Taiwanese community-dwelling individuals carrying the NOTCH3 variant.

Lifelong cerebrovascular disease burden among CADASIL patients: analysis from a global health research network

Introduction

Data reporting on patients with Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) within the United States population is limited. We sought to evaluate the overt cerebrovascular disease burden among patients with CADASIL.

Methods

Harmonized electronic medical records were extracted from the TriNetX global health research network. CADASIL patients were identified using diagnostic codes and those with/without history of documented stroke sub-types (ischemic stroke [IS], intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH] and transient ischemic attack [TIA]) were compared. Adjusted odds ratios (OR) and 95% confidence intervals (CI) of stroke incidence and mortality associated with sex were computed.

Results

Between September 2018 and April 2020, 914 CADASIL patients were identified (median [IQR] age: 60 [50-69], 61.3% females); of whom 596 (65.2%) had documented cerebrovascular events (i.e., CADASIL-Stroke patients). Among CADASIL-Stroke patients, 89.4% experienced an IS, co-existing with TIAs in 27.7% and hemorrhagic strokes in 6.2%; initial stroke events occurred ≤65 years of age in 71% of patients. CADASIL-Stroke patients (vs. CADASIL-non-Stroke) had higher cardiovascular and neurological (migraines, cognitive impairment, epilepsy/seizures, mood disorders) burden. In age- and comorbidity-adjusted models, males had higher associated risk of stroke onset (OR: 1.37, CI: 1.01-1.86). Mortality risk was higher for males (OR: 2.72, CI: 1.53-4.84).

Discussion

Early screening and targeted treatment strategies are warranted to help CADASIL patients with symptom management and risk mitigation.

Prevalence & Risk Factors for Perinatal Stroke: A Population-Based Study

Objectives

The study objective was to calculate the birth prevalence of perinatal stroke and examine risk factors in term infants. Some risk factors are present in healthy infants, making it difficult to determine at-risk infants.

Study Design

Prospective population-based perinatal stroke data were compared to the Australian general population data using chi-squared and Fisher's exact tests and multivariable logistic regression analysis.

Results

Sixty perinatal stroke cases were reported between 2017 and 2019. Estimated stroke prevalence was 9.6/100,000 live births/year including 5.8 for neonatal arterial ischemic stroke and 2.9 for neonatal hemorrhagic stroke. Eighty seven percent had multiple risk factors. Significant risk factors were cesarean section (p = 0.04), 5-min Apgar score <7 (p < 0.01), neonatal resuscitation (p < 0.01) and nulliparity (p < 0.01).

Conclusions

Statistically significant independent risk factors do not fully explain the cause of perinatal stroke, because they are not a direct causal pathway to stroke. These data now require validation in a case-control study.

Elevated visceral adiposity index is associated with increased stroke prevalence and earlier age at first stroke onset: Based on a national cross-sectional study

OBJECTIVE

The purpose of this study was to examine the association between the VAI (visceral adiposity index) and stroke prevalence and age at stroke in US adults.

METHODS

We examined the association between VAI and stroke prevalence and age at stroke using logistic regression, subgroup analysis, and dose-response curves using participants from the National Health and Nutrition Examination Survey (NHANES) database from 2007-2018.

RESULTS

This study ultimately included 29,337 participants aged >20 years, of whom 1022 self-reported a history of stroke, and after adjusting for all confounders, each unit increase in corrected VAI was associated with a 12% increase in the prevalence of stroke (OR= 1.12, 95% CI: 1.01, 1.24) along with an earlier age at stroke 1.64 years (β= -1.64, 95% CI: -2.84, -0.45), stratified analysis showed that the prevalence of stroke was 20% higher in the female group (OR= 1.20, 95% CI: 1.04, 1.39), black group (OR= 1.22, 95% CI: 1.01, 1.48), age ≤60 years group (OR= 1.25, 95% CI: 1.05, 1.48), hypertensive group (OR=1.15, 95% CI:1.01, 1.31), and diabetic group (OR=1.23, 95% CI:1.02, 1.48) VAI increase was positively correlated with stroke prevalence increase. The dose-response curves showed a positive linear correlation between increased VAI and stroke prevalence, while a negative linear correlation was observed between increased VAI and age at stroke.

CONCLUSION

Although a causal relationship cannot be proven, higher VAI was positively associated with stroke prevalence and can lead to earlier stroke onset.

A prospective population-based study of stroke in the Central Region of Iran: The Qom Incidence of Stroke Study

OBJECTIVE

Based on the few population-based studies that have been conducted in the Middle East, we determined the incidence of stroke in Qom, one of the central provinces of Iran.

METHODS

The Qom province includes an estimated at-risk population of about 1 million. During a 12-month period (November 2018-November 2019), all first-ever strokes occurring in the target population were registered. Hospitalized cases were ascertained by discharge codes. Out-of-hospital cases were ascertained by a prospective screening of emergency medical services, emergency departments, ambulances records, primary care clinics, rural and urban public health centers, primary care physician offices, and neurologists' offices. Crude and age-adjusted incidence rates (per 100,000 person-years) were calculated.

RESULTS

During the study period, 1462 first-ever strokes occurred with a mean age of 68.1 (17-103) years; of these 45.2% were females (661 cases). The crude annual incidence rate per 100,000 at-risk populations was 145.4 (95% confidence interval, 138.1-153.0) for all types of stroke (156.5 for males and 134.3 for females), 26.4 (95% confidence interval, 23.5-29.8) for hemorrhagic stroke, and 114 (95% confidence interval, 105-121) for ischemic stroke. The incidence rate adjusted to the world population was 201.4 (95% confidence interval, 193-210) per 100,000 at-risk populations (adj incidence, 218.5 for males vs 187.4 for females). The total fatality rate during the first 28 days was 19.6%.

CONCLUSION

This study states that in this region there is a high incidence of stroke, which occurs at a younger age than the global average. There was a high prevalence of underlying stroke risk factors.

Preceding infection and risk of stroke: An old concept revived by the COVID-19 pandemic

Anecdotal reports and clinical observations have recently emerged suggesting a relationship between COVID-19 disease and stroke, highlighting the possibility that infected individuals may be more susceptible to cerebrovascular events. In this review we draw on emerging studies of the current pandemic and data from earlier, viral epidemics, to describe possible mechanisms by which SARS-CoV-2 may influence the prevalence of stroke, with a focus on the thromboinflammatory pathways, which may be perturbed. Some of these potential mechanisms are not novel but are, in fact, long-standing hypotheses linking stroke with preceding infection that are yet to be confirmed. The current pandemic may present a renewed opportunity to better understand the relationship between infection and stroke and possible underlying mechanisms.

Effect of seasonal and temperature variation on hospitalizations for stroke over a 10-year period in Brazil

BACKGROUND

Seasonal variation in stroke incidence remains controversial.

AIMS

We aimed to describe the pattern of seasonality in hospitalizations for stroke in Brazil.

METHODS

We evaluated age-adjusted hospitalization rates for stroke per month using data from the Brazilian Unified Healthcare System and median monthly temperature data obtained from the National Institute of Meteorology. To detect a seasonality pattern in time series, we used seasonal-trend decomposition using LOESS. We calculated a seasonal strength statistic and used Kruskal-Wallis test to evaluate the presence of seasonality in Brazil and its five regions. We also assessed the association of temperature and stroke hospitalization rates using Spearman's rho correlation.

RESULTS

We identified 1,422,496 stroke-related hospitalizations between 2009 and 2018. Mean age was 67 years, 51% were male and 77.5% of stroke diagnoses were not specified as ischemic or hemorrhagic. Median temperature was 23.8℃ (IQR 22.3-24.4). Age-adjusted hospitalizations demonstrated significant seasonal variation during all the years analyzed, with increased rates during the winter. When regional differences were analyzed, seasonal behavior was present in the south, southeast and northeast regions of the country. These were also the regions with lower median temperatures during the winter months and greater amplitude of average temperatures between warmer and colder months.

CONCLUSIONS

In this large national cohort of stroke patients in Brazil, we demonstrated the presence of seasonal variation in the age-adjusted hospitalization rate, with peak rates during the winter months. The regional gradient of incidence of stroke was directly associated with colder winters and greater amplitude of temperature.

Stroke in the Middle-East and North Africa: A 2-year prospective observational study of stroke characteristics in the region-Results from the Safe Implementation of Treatments in Stroke (SITS)-Middle-East and North African (MENA)

BACKGROUND AND METHODS

Stroke incidence and mortality are reported to have increased in the Middle-East and North African (MENA) countries during the last decade. This was a prospective observational study to examine the baseline characteristics of stroke patients in the MENA region and to compare the MENA vs. the non-MENA stroke cohort in the Safe Implementation of Treatments in Stroke (SITS) International Registry.

RESULTS

Of the 13,822 patients with ischemic and hemorrhagic stroke enrolled in the SITS-All Patients Protocol between June 2014 and May 2016, 5897 patients (43%) were recruited in MENA. The median onset-to-door time was 5 h (IQR: 2:20-13:00), National Institutes of Health Stroke Scale (NIHSS) score was 8 (4-13) and age was 65 years (56-76). Hypertension (66%) and diabetes (38%) were the prevailing risk factors; large artery stenosis > 50% (25.3%) and lacunar strokes (24.1%) were the most common ischemic stroke etiologies. In comparison, non-MENA countries displayed an onset-to-door time of 5:50 h (2:00-18:45), a median of NIHSS 6 (3-14), and a median age of 66 (56-76), with other large vessel disease and cardiac embolism as the main ischemic stroke etiologies. Hemorrhagic strokes (10%) were less common compared to non-MENA countries (13.9%). In MENA, only a low proportion of patients (21%) was admitted to stroke units.

CONCLUSIONS

MENA patients are slightly younger, have a higher prevalence of diabetes and slightly more severe ischemic strokes, commonly of atherosclerotic or microvascular etiology. Admission into stroke units and long-term follow-up need to be improved. It is suspected that cardiac embolism and atrial fibrillation are currently underdiagnosed in MENA countries.

Risk of Stroke After Colorectal Surgery for Cancerous Versus Benign Conditions

BACKGROUND

Cancer treatment, specifically surgical intervention, as a possible stroke trigger is understudied.

METHODS

Using the Nationwide Readmissions Database and validated diagnosis and procedure codes, we identified adults with index admissions for colorectal surgery for colorectal adenocarcinoma (Group A) and compared them to admissions for colorectal surgery for benign conditions (Group B) and hepatobiliary or pancreatic surgery for benign conditions (Group C). Within the colorectal cancer cohort, we further identified patients who underwent open versus laparoscopic surgery. The primary outcome was readmission for ischemic or hemorrhagic stroke up to 1 year. Cumulative risk of ischemic stroke was calculated using risk survival statistics, and hazard ratios (HR) were calculated using adjusted Cox regression.

RESULTS

Patients in Group A had higher 3-month readmission rates for ischemic and hemorrhagic strokes than those in Groups B and C. Higher risk of ischemic stroke (HR 1.46, 95% confidence interval [CI] 1.20-1.79) in Group A compared to Group B was eliminated following adjustments for illness severity and vascular risk factors. Comparing types of colorectal surgical intervention for cancer, there was significantly greater risk of ischemic stroke with open versus laparoscopic surgery, despite adjusting for vascular risk factors (HR 1.70, 95% CI 1.15-2.52).

CONCLUSIONS

We found elevated risk of ischemic stroke up to 1 year following open surgery for colorectal adenocarcinoma compared to laparoscopic. More research is necessary to clarify the underlying surgery-related mechanisms that contribute to elevated risk.

Prevalence of stroke, risk factors, disability and care needs in older adults in Singapore: results from the WiSE study

OBJECTIVES

The aims of the present study were to establish the prevalence of stroke, and to explore the association between stroke prevalence and sociodemographic and health factors, disability, cognitive functioning and care needs among older adult residents in Singapore.

SETTING

Data were drawn from the Well-being of the Singapore Elderly study-a cross-sectional epidemiological survey conducted from 2012 to 2013 on older adults living in Singapore.

PARTICIPANTS

Participants were Singapore residents (citizens and permanent residents) 60 years and above who were living in Singapore during the survey period . Older adult residents who were institutionalised were also included in this study. Those who were not living in Singapore or who were not contactable were excluded from the study. The response rate was 65.6 % (2565/3913). A total population sample of 2562 participants completed the survey. Participants comprised 43.6% males and 56.4% females. The sample comprised 39.4% Chinese, 29.1% Malay, 30.1% Indian and 1.4% other ethnicities .

PRIMARY AND SECONDARY OUTCOME MEASURES

History of stroke, along with other health and mental health conditions, disability and cognitive functioning, were determined by self-report.

RESULTS

Weighted stroke prevalence was 7.6% among older adults aged 60 and above. At a multivariate level, Malay ethnicity (OR 0.41, p=0.012, 95% CI 0.20 to 0.82), hypertension (OR 4.58, p=0.001, 95% CI 1.84 to 11.40), heart trouble (OR 2.45, p=0.006, 95% CI 1.30 to 4.63), diabetes (OR 2.60, p=0.001, 95% CI 1.49 to 4.53) and dementia (OR 3.57, p=0.002, 95% CI 1.57 to 8.12) were associated with stroke prevalence.

CONCLUSIONS

Several findings of this study were consistent with previous reports. Given that Singapore's population is ageing rapidly, our findings may indicate the need to review existing support services for stroke survivors and their caregivers. Future research could investigate the association between various sociodemographic and health conditions and stroke prevalence to confirm some of the findings of this study.

Burden of stroke in Puerto Rico

Stroke is the fifth leading cause of death and the first cause of long-term disability in Puerto Rico. Trained staff reviewed and independently validated the medical records of patients who had been hospitalized with possible stroke at any of the 20 largest hospitals located in Puerto Rico during 2007, 2009, and 2011. The mean age of the 5005 newly diagnosed stroke patients (51·2% female) was 70 years. At the time of hospitalization, women were 4½ years older, were less likely to be married (60·2% vs. 39·9%, P < 0·001), smoked less (5·8% vs. 13·4%, P < 0·001), and had significantly higher proportion of diabetes (56·0% vs. 54·8%), hypertension (89·1% vs. 85·0%), and low density lipoprotein-cholesterol (LDL-Chol) > 100 mg/dL (65·7% vs. 57·5%) P < 0·05. Ischemic stroke represented 75% of all types of strokes. Atrial fibrillation was mentioned in 7·9% of the medical records. The risk for dying before discharge was similar for both genders, but was 40% higher for women than for men at one-year follow-up: age-adjusted odds ratio = 1·4 (95% confidence interval = 1·2-1·5).

Estimating the annual number of strokes and the issue of imperfect data: an example from Australia

BACKGROUND

Estimates of strokes in Australia are typically obtained using 1996-1997 age-specific attack rates from the pilot North East Melbourne Stroke Incidence (NEMESIS) Study (eight postcode regions). Declining hospitalizations for stroke indicate the potential to overestimate cases.

AIMS

To illustrate how current methods may potentially overestimate the number of strokes in Australia.

METHODS

Hospital separations data (primary discharge ICD10 codes I60 to I64) and three stroke projection models were compared. Each model had age- and gender-specific attack rates from the NEMESIS study applied to the 2003 population. One model used the 2003 Burden of Disease approach where the ratio of the 1996-1997 NEMESIS study incidence to hospital separation rate in the same year was adjusted by the 2002/2003 hospital separation rate within the same geographic region using relevant ICD-primary diagnosis codes. Hospital separations data were inflated by 12·1% to account for nonhospitalized stroke, while the Burden of Disease model was inflated by 27·6% to account for recurrent stroke events in that year. The third model used 1997-1999 attack rates from the larger 22-postcode NEMESIS study region.

RESULTS

In 2003, Australian hospitalizations for stroke (I60 to I64) were 33,022, and extrapolation to all stroke (hospitalized and nonhospitalized) was 37,568. Applying NEMESIS study attack rates to the 2003 Australian population, 50,731 strokes were projected. Fewer cases for 2003 were estimated with the Burden of Disease model (28,364) and 22-postcode NEMESIS study rates (41,332).

CONCLUSIONS

Estimating the number of strokes in a country can be highly variable depending on the recency of data, the type of data available, and the methods used.

The burden of stroke in México

Regrettably, stroke has been scarcely studied in México, and the available data suffer from great variability in diagnostic testing, risk factor definitions, and poor generalizability. The current cumulative incidence of stroke in Mexico is 232.2 per 100,000, whereas prevalence among people aged 60 years or older is 18.2 per 1000. Hypertension and diabetes are the main risk factors. Ischemic stroke is the most frequent sub-type. Stroke mortality has been increasing during last years, and 30-day case fatality rate doubles at one-year follow-up. A remarkable finding of a hospital-based registry was that most of ischemic stroke cases are of undetermined etiology and even when a quarter of patients arrive on time for thrombolysis, less than 1% received this management.

Stroke in rural coastal Ecuador: a community-based survey

Stroke will be South America's next epidemic. Therefore, information on stroke particularities in the region will help to overcome its impact burden. We evaluated prevalence, pattern of sub-types, and pathogenic mechanisms underlying stroke in Atahualpa, a village representative of rural coastal Ecuador. In a three-phase epidemiologic study, suspected cases were detected by a door-to-door survey (Phase I). Then, neurologists evaluated suspected cases and randomly selected negative persons (Phase II), and confirmed patients underwent complementary exams (Phase III). We found 20 stroke patients (mean age 70 years, 60% men) among 642 persons aged ≥40 years. Stroke prevalence was 31.15‰ that increased with age. Most patients had sub-cortical infarctions associated with leukoaraiosis or microbleeds. Hypertensive arteriolopathy was the most likely mechanism underlying strokes (55% patients). Intracranial arterial lesions were found in 47% cases. Extracranial atherosclerotic lesions or cardiac sources of emboli were not found in any case. Comparison of our findings with a previous survey performed in the same village showed an alarming increase in stroke prevalence (from 14.08‰ in 2003 to 31.15‰ in 2012, P = 0.03).

Door-to-door survey of cardiovascular health, stroke, and ischemic heart disease in rural coastal Ecuador--the Atahualpa Project: methodology and operational definitions

RATIONALE

Stroke and cardiovascular diseases will be the next health epidemics in Latin America due to increased life expectancy and changes in the lifestyle and dietary habits of the population. Knowledge of the cardiovascular health status of the inhabitants will allow the implementation of policies directed to reduce the burden of stroke and cardiovascular diseases in the region.

AIMS

To evaluate the cardiovascular health status of the inhabitants of Atahualpa (a rural village in coastal Ecuador) and to determine the prevalence and incidence of stroke and ischemic heart disease in the region.

DESIGN

Three-phase epidemiologic survey. During phase I, Atahualpa residents aged ≥40 years will be screened with standardized questionnaires to evaluate their cardiovascular health and to identify those with suspected stroke or ischemic heart disease. In phase II, neurologists and cardiologists will examine suspected cases of stroke or ischemic heart disease, as well as a random sample of matched negative individuals, to assess the prevalence and incidence of these conditions. In phase III, patients with a diagnosis of stroke and ischemic heart disease will undergo complementary tests for achieving a more specific diagnosis.

DISCUSSION

Implementation of public health strategies directed to improve the cardiovascular health status of a given population must be based on studies evaluating specific risk factors at regional levels. Epidemiologic surveys such as the Atahualpa Project may prove cost-effective in improving the cardiovascular health status of people living in Latin American rural villages by increasing the knowledge on the particular needs of these populations.