Risultati per: Stroke

Stroke, Ahead of Print. BACKGROUND:Sex and social determinants of health predict stroke, yet few studies focus exclusively on women at high social risk. Understanding associations between stroke and modifiable risk factors that are disproportionately common in high-risk populations may aid in tailoring primary and secondary prevention services. We sought a better understanding of the association between polysubstance use, with an emphasis on stimulant use, and stroke in women who experience homelessness and unstable housing.METHODS:We recruited women who experience homelessness and unstable housing from San Francisco community–based venues to participate in a cohort study. We identified stroke from electronic health records during the 2.5-year study period and prospectively for up to 2 years after study completion. We then assessed associations with baseline study factors, including social determinants of health, toxicology-confirmed use of multiple substances, and traditional stroke risk factors. We used multiple logistic regression and the Akaike Information Criterion to construct the most parsimonious adjusted model to determine independent relationships between study factors and stroke risk.RESULTS:Of 245 participants, 238 had a complete data set and were included. The median participant age was 53.4 (interquartile range, 45.4–59.4) years. Nine (3.8%) participants had documented strokes. After adjusting for age, hyperlipidemia, and opioid use, cocaethylene—a biomarker signaling alcohol and cocaine concurrent co-use—had a particularly strong association with stroke (odds ratio, 3.22 [95% CI, 1.02–10.20]).CONCLUSIONS:Cocaethylene and opioids were strongly associated with stroke among women who experience homelessness and unstable housing. This suggests 2 possible opportunities for prevention in an environment where opioid use is already closely monitored. First, women reporting cocaine and alcohol co-use should be counseled about the especially harmful effects of this substance combination on their cerebrovascular health. Second, the utility of cocaethylene to assess stroke risk in high-risk populations may be currently underestimated.

Stroke, Ahead of Print. BACKGROUND:The purpose of this study is to examine the association between race and ethnicity and ischemic stroke severity in the United States.METHODS:We performed an analysis of adult hospital discharges in the National Inpatient Sample from 2018 to 2021 with a primary discharge diagnosis of ischemic stroke. We stratified our cohort based on self-reported race and ethnicity and evaluated stroke severity using the National Institutes of Health Stroke Scale. Age- and sex-adjusted estimates of the National Institutes of Health Stroke Scale were derived from linear regression models.RESULTS:We included 231 396 stroke discharges with a mean National Institutes of Health Stroke Scale of 6.5±7.2. The cohort was 68.1% White, 17.4% Black, 8.2% Hispanic, and 6.3% other. The age- and sex-adjusted National Institutes of Health Stroke Scale for White patients was 6.25 (95% CI, 6.22–6.29), for Black patients was 7.12 (95% CI, 7.05–7.19), for Hispanic patients was 6.86 (95% CI, 6.76–6.97), and for patients of other races and ethnicities was 7.29 (95% CI, 7.18–7.41). Further adjustment for the Charlson Comorbidity Index, socioeconomic factors, and poorly controlled hypertension or diabetes did not significantly alter these findings.CONCLUSIONS:In a large, contemporary, and nationally representative sample of patients with acute ischemic stroke, we show an association between non-White race and ethnicity and higher stroke severity. These results are concerning for an underappreciated health disparity in acute ischemic stroke.

Stroke, Ahead of Print. BACKGROUND:Past failures in translating stroke cerebroprotection provoked calls for a more rigorous methodological approach, leading to the stroke preclinical assessment network SPAN (Stroke Preclinical Assessment Network), where uric acid (UA) treatment exceeded a prespecified efficacy boundary for the primary functional outcome. Still, successful translation to humans requires confirmation of the effect of UA across key biological variables relevant to patients with stroke.METHODS:We measured the effects of intravenous UA treatment (16 mg/kg) versus intravenous saline in groups of animals enrolled in the SPAN network with diverse comorbidities, sex, and age. The masked study drug or placebo was administered during reperfusion in rodents undergoing a transient middle cerebral artery filament occlusion. The primary outcome was the modified corner test index at day 30 poststroke, and numerous secondary outcomes were collected. A modified intention-to-treat population was used in the analysis. We tested for any interactions with sex, age, and comorbidities (obesity-induced hyperglycemia and hypertension).RESULTS:In total, 710 animals were randomized to receive either intravenous UA or saline. After accounting for procedural dropouts and exclusions from treatment, a total of 687 animals were qualified and analyzed, including 458 assigned to UA and 229 to intravenous saline control. UA-treated animals exhibited a better primary functional outcome at day 30 (probability, 0.56 [95% CI, 0.52–0.60];P=0.006). UA-treated animals also had a better corner test index at day 7 (probability, 0.55 [95% CI, 0.5–0.59];P=0.035) and a higher survival rate at day 30 (hazard ratio, 1.41 [95% CI, 1.08–1.83];P=0.011). Brain morphometry at day 2 and 30 was comparable between the treatment groups. The improved functional outcome and survival in UA-treated animals were preserved across different species, sexes, ages, and comorbidities.CONCLUSIONS:UA provides ischemic stroke cerebroprotection across key relevant biological variables, making it a promising intervention to be further tested in human clinical trials.

Stroke, Ahead of Print. BACKGROUND:Providing equitable health care to rural stroke patients is challenging and associated with less intervention and poorer outcomes. We assessed how several distinct patient-related geographic classifications influenced stroke care and outcomes in Scotland, United Kingdom.METHODS:We conducted a population-level data-linkage study of ischemic stroke patients admitted to the hospital (2010–2018). Geographic classifications included 2 binary (urban versus rural; accessible versus remote) and 1 six-category classification encompassing both rurality and accessibility (large urban areas, other urban areas, accessible small towns, remote small towns, accessible rural areas, and remote rural areas). Process outcomes included achievement of a stroke care bundle and thrombolysis administration. Clinical outcomes included 30-day discharge from hospital care, 90-day home time, inpatient and 1-year all-cause mortality.RESULTS:We included 42 917 ischemic stroke patients (35 766 urban and 7151 rural). Binary classifications of rurality or accessibility missed important differences in stroke care and outcomes revealed using 6-category classification. Using the latter, compared with large urban areas, patients in accessible rural areas were more likely to receive a complete stroke care bundle (adjusted odds ratio, 1.21 [95% CI, 1.12–1.31]); patients in remote rural areas were less likely (adjusted odds ratio, 0.85 [95% CI, 0.78–0.93]). Compared with large urban areas, 30-day discharge from hospital care was more likely for patients residing elsewhere (eg, remote rural areas adjusted subdistribution hazards ratio, 1.11 [95% CI, 1.05–1.17]); home time within 90 days was higher for other urban areas (adjusted incidence rate ratio, 1.05 [95% CI, 1.03–1.07]) and accessible rural areas (adjusted incidence rate ratio, 1.03 [95% CI, 1.01–1.06]); and 1-year mortality was less likely in other urban areas (adjusted hazard ratio, 0.93 [95% CI, 0.88–0.98]) and remote small towns (adjusted hazard ratio, 0.89 [95% CI, 0.80–0.99]).CONCLUSIONS:When considering geographic disparities in stroke care and outcomes across Scotland, it is important to account for both home location and accessibility of care. Despite patients residing in remote rural areas being less likely to achieve a complete stroke care bundle, this did not translate into poorer outcomes.

Stroke, Ahead of Print. Brain arteriovenous malformations (AVMs), cerebral cavernous malformations (CCMs), and intracranial aneurysms are major causes of hemorrhagic stroke, yet noninvasive therapies to prevent growth or rupture are lacking. Understanding the genetic basis of these malformations is critical for uncovering underlying mechanisms, developing targeted prevention strategies, and identifying novel therapeutic targets. This review highlights the causal genes and signaling pathways in AVMs, CCMs, and intracranial aneurysms, noting both their commonalities and differences. For AVMs, somatic mutations in the Ras/MAPK (mitogen-activated protein kinase) and MAPK/ERK (extracellular signal–regulated kinase) pathway are key, particularly in sporadic cases, whereas hereditary conditions like hereditary hemorrhagic telangiectasia and capillary malformation–AVM involve the TGF-β (transforming growth factor β), Ephrin receptor, and angiopoietin-VEGF (vascular endothelial growth factor) signaling pathways. In CCMs, pathways affecting endothelial junctions and vascular stability, such as the ROCK (RhoA/Rho–associated coiled-coil containing kinases) pathway, play a central role. Although the genetic drivers of intracranial aneurysms are more diverse and less clearly linked to specific pathways, there is some overlap with genes in the TGF-β and endothelial function pathways seen in AVMs and CCMs. Emerging therapies for AVMs and CCMs include MAPK/ERK inhibitors, anti-VEGF treatments, and RhoA/ROCK inhibitors, showing potential in preclinical models. Due to the genetic overlap, these advancements may also offer future therapeutic strategies for intracranial aneurysms. As personalized medicine progresses, the development of reliable biomarkers, such as the candidate biomarker VEGF for AVMs and CCMs, will be crucial for guiding treatment decisions. In conclusion, ongoing research into genetic pathways holds promise for novel therapeutic targets that could transform the management of vascular malformations and reduce the risk of hemorrhagic stroke.

Objectives
This systematic review examines prehospital and in-hospital delays in acute stroke care in Indonesia.

Design
Systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Data sources
We conducted a thorough search across 11 databases, ClinicalTrials.gov registries and three preprint repositories up until October 2024.

Eligibility criteria
Studies that examined risk variables associated with hospital delays in the treatment of acute stroke in Indonesian individuals were included.

Data extraction and synthesis
Two reviewers each carried out the data extraction and risk-of-bias evaluation separately. The quality of the study was evaluated using the Risk of Bias in Non-randomised Studies of Exposures tool. The ‘combining p values’ approach and albatross plots were used to synthesise the findings.

Results
A total of 27 studies with 3610 patients were included. Key factors contributing to prehospital delays included low educational level (p=0.014, 6 studies), low socioeconomic status (p=0.003, 5 studies), cultural beliefs affecting decision-making (p

Stroke, Ahead of Print.

Stroke, Ahead of Print. BACKGROUND:As the impact of stroke remains, primary healthcare will continue to be a critical platform managing the poststroke journey. We aimed to identify stroke survivors assisted by community health worker in Brazil and how they relate to the location of rehabilitation facilities locations.METHODS:We developed a cross-sectional study using deidentified data from a real-world database generated by a free data collection app used by community health workers from May 2015 to January 2021 in Brazil to identify stroke survivors and to assess demographics and clinical characteristics. We used data from a public database, Cadastro Nacional de Estabelecimentos de Saúde, for identifying rehabilitation facilities. Locations were obtained by a geocoding application programming interface (Google Maps Platform), distances were measured in kilometers, and travel time in minutes.RESULTS:Among 2 397 764 individuals assisted by community health workers, 21 785 were stroke survivors, representing a 0.9% prevalence. Among this subgroup, the majority were in the Northeast region (n=10 951; 50.3%) and 16 922 (77.7%) in urban areas. Most individuals (n=11 504; n=142; 52.8%) were women, the mean age was 66.5 (SD, 14.7), and 4313 reported physical disability. In total, 348 rehabilitation facilities were identified, mostly located in the Southeast region (40.8%). The mean distance from stroke survivor to facility was 79.13 km (SD, 97.73; median [1Q, 3Q], 47.64 km [12.19, 107.80 km]), and mean travel time was 81.18 minutes (SD, 85.85). The Southern region recorded the largest mean and median distance (mean 175.58 km; SD, 163.18; median [1Q, 3Q] 88.47 [59.38, 425.38]) to rehabilitation center and the longest mean travel time (144.48 minutes; SD, 112.57; median [1Q, 3Q] 92.34 [60.59, 305.12]).CONCLUSIONS:Despite the availability of rehabilitation centers in Brazil, geographic access as represented by the distances and travel times observed access is still suboptimal. As a means of improving the clinical pathway and resource allocation, the use of large real-world databases and adequate analysis may become a key component for real needs assessments.

Stroke, Ahead of Print. BACKGROUND:It is unclear how poststroke cognitive trajectories differ by stroke type and ischemic stroke subtype. We studied associations between stroke types (ischemic and hemorrhagic), ischemic stroke subtypes (cardioembolic, large artery atherosclerotic, lacunar/small vessel, and cryptogenic/other determined causes), and poststroke cognitive decline.METHODS:We pooled participants from 4 US cohort studies (1971–2019). Outcomes were change in global cognition (primary) and changes in executive function and memory (secondary). Outcomes were standardized as T scores (mean [SD], 50 [10]); a 1-point difference represents a 0.1 SD difference in cognition. The median follow-up for the primary outcome was 6.0 (interquartile range, 3.2–9.2) years. Linear mixed-effects models estimated changes in cognition after stroke.RESULTS:We identified 1143 dementia-free individuals with acute stroke during follow-up: 1061 (92.8%) ischemic, 82 (7.2%) hemorrhagic, 49.9% female, and 30.8% Black. The median age at stroke was 74.1 (interquartile range, 68.6–79.3) years. On average, ischemic stroke survivors showed declines in global cognition (−0.35 [95% CI, −0.43 to −0.27] points/y;P

Stroke, Ahead of Print. The 2024 Guidelines for the Primary Prevention of Stroke, recently updated by the American Heart Association and the American Stroke Association, serve as an essential resource for clinicians aiming to reduce the growing impact of cerebrovascular disease. These guidelines emphasize modifiable risk factors and population-specific considerations, covering a range of cardiovascular conditions, including hypertension, diabetes, atherosclerotic disease, and genetic predispositions to stroke. However, a notable omission in these guidelines is the absence of specific recommendations for patients with thrombotic thrombocytopenic purpura. Indeed, these patients are particularly susceptible to stroke, which can be the sole manifestation of the disease. Given the established association between thrombotic thrombocytopenic purpura and ischemic stroke and the effectiveness of preventive interventions, future guidelines should include specific recommendations for patients with thrombotic thrombocytopenic purpura to avert thrombotic events, including stroke. In that regard, ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13) activity measurement should be considered in the workup of cryptogenic stroke.

Stroke, Ahead of Print.

Stroke, Ahead of Print. BACKGROUND:Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin is recommended for secondary prevention in patients with a minor stroke or transient ischemic attack. However, the effectiveness of DAPT can be significantly influenced by genetic variations. This study aimed to estimate the impact of multiple single-nucleotide polymorphisms across various genes on DAPT efficacy using polygenic risk score (PRS).METHODS:In this post hoc analysis, we included 2905 patients from the CHANCE trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events), which enrolled a total of 5170 patients in China between October 2009 and July 2012. The primary outcome was new stroke within 90 days. Sixteen single-nucleotide polymorphisms across 7 genes involved in clopidogrel metabolism were selected for PRS development. PRS were calculated by summing single-nucleotide polymorphisms from each individual. The Cox proportional-hazards regression model was utilized to estimate the hazard ratio (HR) and 95% CIs of PRS. The predictive value of PRS was estimated by C statistic and compared with a previously validated model.RESULTS:The elevated PRSs were associated with an increased risk of new stroke within 90 days (Ptrend=0.01). The efficacy of DAPT versus aspirin alone in preventing 1-year composite vascular events was significantly different between patients with low (adjusted HR, 0.47 [95% CI, 0.31–0.71]) and high PRSs (adjusted HR, 0.84 [95% CI, 0.60–1.18];Pinteraction=0.03). In patients receiving DAPT, higher PRSs were associated with increased risk of new stroke and composite vascular events at 90 days (adjusted HR per SD increase was 1.51 [95% CI, 1.15–1.99]) and at 1 year (adjusted HR per SD increase was 1.34 [95% CI, 1.08–1.67]). The C statistic for predicting 90-day new stroke using the PRS developed in this study was 0.57 (95% CI, 0.52–0.62), compared with 0.52 (95% CI, 0.48–0.55) for the ABCD-GENE score.CONCLUSIONS:Using PRS integrating multiple genes may enhance the precision of secondary prevention strategies for patients with minor stroke or transient ischemic attack in the short and long term.REGISTRATION:URL:https://www.clinicaltrials.gov; Unique identifier: NCT00979589.

Stroke, Ahead of Print.

Stroke, Ahead of Print. BACKGROUND:More than half of patients with ischemic stroke experience futile reperfusion, increasing the risk of death and disabilities despite a successful recanalization. The reason behind this is debated, and we aim to investigate cerebrovascular changes toward a broader understanding of these conditions. We hypothesize that ischemic stroke reperfusion modifies the expression profile in the microvasculature in a spatial manner toward peri-infarct brain edema and circulatory failure.METHODS:We investigated the early (24-hour) changes in spatial gene expression in the brain parenchymal endothelial cells and mural cells following ischemia stroke reperfusion in 13- to 14-week-old C57BL/6JRj male mice (n=5). Ischemia was induced by occlusion of the middle cerebral artery for 60 minutes, and Nissl staining was used to validate infarct size. Spatial transcriptomics complemented by bulk proteomics was conducted in the peri-infarct cortex region and validated with immunohistochemical semiquantification of proteins of interest. To avoid individual biological variations, changes in the peri-infarct cortex region were expressed relatively to the matching contralateral hemisphere region.RESULTS:Ischemic stroke reperfusion impaired the blood-brain barrier integrity through junctionalCldn5(claudin-5) downregulation, changes of the actin cytoskeleton adhesion, and high expression of the proinflammatoryIl-6(interleukin-6). Molecules important for extracellular Ca2+influx and intracellular Ca2+release,Cacna1e(R-type Ca2+channels),Orai2,Ryr3,Itpr1, andItpka(inositol-trisphosphate 3-kinase A), were markedly reduced. Furthermore, reducedGrm5(glutamate receptor 5) associated with upregulatedNfatc3andStat3implicates suppression of the contractile phenotype, suggesting reduced poststroke vascular resistance due to loss of mural cell tone. The complete spatial transcriptomics map over the ipsilateral and contralateral hemispheres is available online as a Web tool.CONCLUSIONS:Emphasizing the spatial molecular pattern behind blood-brain barrier disruption and loss of the vascular tone in the acute phase following ischemic stroke reperfusion suggests the gene expression contribution for a therapeutic target in ischemia-reperfusion abnormalities.

Stroke, Ahead of Print. BACKGROUND:The benefits and safety of mechanical thrombectomy (MT) in patients with prestroke disability, classified as modified Rankin Scale (mRS) score of 3 to 4, and anterior circulation stroke remain uncertain. This study aims to evaluate these factors using data from the Italian Registry of Endovascular Treatment in Acute Stroke.METHODS:We analyzed data collected between 2015 and 2021, comparing functional outcomes (mRS), symptomatic intracerebral hemorrhage, and recanalization rates (Thrombolysis in Cerebral Infarction) at 90 days post-MT in patients with prestroke mRS score of 3 to 4 versus 0 to 2. A good outcome was defined as no change in the mRS score from baseline. Subgroup analysis was stratified by age.RESULTS:A total of 11.411 (96%) patients with prestroke mRS score of 0 to 2 and 477 (4%) patients with prestroke mRS score of 3 to 4 were included. Compared with patients with a baseline mRS score 0 to 2, those with mRS score 3 to 4 were older (82 versus 75 years;P

Stroke, Ahead of Print. BACKGROUND:Various measures of abnormal left atrial (LA) structure or function (LA myopathy) are associated with a higher risk of ischemic stroke and dementia, independent of atrial fibrillation. However, limited data exist on their prognostic usefulness. Therefore, we aimed to assess the ability of markers of LA myopathy to improve the prediction of ischemic stroke and dementia.METHODS:The ARIC study (Atherosclerosis Risk in Communities) is a prospective community-based cohort study. For this analysis, we included participants who attended visit 5 (2011–2013) without a history of stroke or atrial fibrillation and had a 12-lead ECG and a transthoracic echocardiogram. Markers of LA myopathy included P wave abnormalities from 12-lead ECG, NT-proBNP (N-terminal pro-B-type natriuretic peptide), and LA volume and strain parameters from the echocardiogram. The primary composite outcome comprised ischemic stroke and dementia, which were ascertained through hospital surveillance, cohort follow-up, and death registries. To determine improvement in risk prediction of the composite outcome, each marker was individually added to a model that included CHA2DS2-VASc variables, and Akaike information criterion, C statistic, and its change were computed. Cox proportional hazards models were used to assess the independent association of LA myopathy markers with the outcome.RESULTS:Among 4712 participants (59% female; mean age, 74 years), 193 ischemic strokes and 769 dementia cases were ascertained over a median follow-up of 8.3 years. Of LA myopathy markers, only LA reservoir strain and NT-proBNP significantly improved C statistic when added to the CHA2DS2-VASc model (base C statistic, 0.677) for the prediction of the composite outcome. Adding the LA reservoir yielded the highest increase in C statistic (0.010 [95% CI, 0.003–0.017]), and the model including the LA reservoir showed the lowest Akaike information criterion. In multivariable regression models, LA volume index, NT-proBNP, and LA strain parameters were significantly associated with the composite outcome.CONCLUSIONS:Of various LA myopathy markers, LA reservoir yields the greatest improvement in the prediction of ischemic stroke and dementia, supporting its use to identify people at high risk of cerebrovascular events and dementia.