Stroke Research Articles

Cardiovascular outcomes in pregnant women with congenital heart disease

Abstract Background Individuals with congenital heart disease (CHD) are at increased risk of cardiovascular complications. There is limited available data on burden of acute cardiovascular complications in pregnant women with CHD. Purpose To study the acute cardiovascular complications in pregnant women with CHD. Methods We conducted a retrospective observational analysis using the Nationwide Inpatient Sample (NIS) database. Using ICD-9 and ICD-10-CM codes, we identified pregnant women aged 18 years or older with and without CHD hospitalized between January 1st, 2010, and December 31st, 2019. The outcomes of the study were peripartum cardiomyopathy, hypertensive disorders of pregnancy (gestational hypertension, pre-eclampsia, and eclampsia), acute myocardial infarction, cardiac arrhythmias, cardiac arrest, stroke or transient ischemia, and in hospital mortality. Results During the study period, there were a total of 41,114,105 hospitalizations for pregnancy. Of these, 43,131 (0.1%) had CHD. The mean age of the population was 28 years in both CHD and non-CHD groups. The majority were white patients, followed by black patients and then Asians in both groups. There was a higher proportion of white patients in the CHD group compared to the non-CHD group. Comorbidities including diabetes mellitus, chronic pulmonary disease, chronic kidney disease, hyperlipidemia, smoking, depression, and drug abuse were higher in the CHD group compared to the non-CHD group (Table 1). Pregnant women with CHD had a significantly higher incidence of peripartum cardiomyopathy (1905 vs 89 per 100,000 pregnancy hospitalizations; p<0.001), hypertensive disorders of pregnancy (9332 vs 7802 per 100,000 pregnancy hospitalizations ; p<0.001), acute coronary syndrome (253 vs 12 per 100,000 pregnancy hospitalizations; p<0.001), cardiac arrhythmias (3480 vs 176 per 100,000 pregnancy hospitalizations; p<0.001), cardiac arrest (127 vs 6 per 100,000 pregnancy hospitalizations; p<0.001), stroke or transient ischemic attack (1648 vs 32 per 100,000 pregnancy hospitalizations; p<0.001), and venous thromboembolism (816 vs 124 per 100,000 pregnancy hospitalizations; p<0.001) (Table 2). Similarly, pregnant women with CHD had significantly higher in hospital mortality compared to pregnant women with no CHD (116 vs 11 per 100,000 pregnancy hospitalizations; p<0.001). Conclusion Pregnant women with CHD are at significantly increased risk of acute cardiovascular complications compared to those without CHD. Our study underscores the importance of close monitoring and specialized care for this high-risk population during pregnancy and delivery. Further research is warranted to better understand the risks associated with these complications and to optimize management strategies for pregnant women with CHD.Baseline CharacteristicsOutcomes

Prediction of incident major adverse cardiac events in patients starting haemodialysis for end stage kidney disease, using clinical laboratory cardiac biomarkers - a real world analysis.

Abstract Background and Aims Despite its many advantages, haemodialysis (HD) is associated with increased cardiovascular mortality and morbidity, with some studies reporting 48% higher mortality within 2 years of starting HD. Cardiac biomarkers provide insight into cardiac structure and function, including myocyte stress, inflammation and fibrosis. We aimed to investigate the prognostic significance of routine cardiac biomarkers (troponin and natriuretic peptides) in the prediction of incident major adverse cardiac events (MACE) within 5 years if commencing HD. Methods A retrospective cohort study was performed using electronic medical records from a global federated research network from the US. The network was searched on 26th February 2023. The cohorts commenced HD post-diagnosis of end-stage kidney disease. Data censoring for MACE was invoked prior to the index event of HD. Cardiac biomarkers were the first reported result within 3 months of starting HD. Cohorts were grouped according to biomarker-specific thresholds and 1:1 propensity-score matched for age, gender and co-morbidities (hypertension, diabetes mellitus and smoking status). Logistical regression produced odds ratios with 95%CI for 5-year incident MACE. MACE was defined, a priori, as a composite of ischaemic heart disease, angina pectoris, acute myocardial infarction, heart failure, AF, stroke and all-cause mortality. All statistical analysis was performed on the online platform. Results The results are shown Tables 1(Troponin I and BNP alone) and 2 (Combined Troponin I and BNP). Results that reached statistical significance (p<0.05) are shown. Conclusion Routinely available cardiac biomarkers can predict MACE and cardiac outcomes in incident HD, although results differ between markers of myocyte injury (troponin) and stress (BNP). A combined approach may prove most beneficial. The results suggest the clinical need for CV mortality and morbidity risk profiling in incident dialysis using a combination of clinical and laboratory variables and the need for prospective validation.Table 1Table 2

The knowledge, attitude and practice of cardiologists versus other specialists about the safety and efficacy of influenza vaccination in patients with cardiovascular diseases

Abstract Background Influenza vaccination has been shown to reduce the occurrence of cardiovascular events, both in the general population and especially in individuals with cardiovascular disease. However, the extent to which cardiologists and other physicians support and prescribe influenza vaccination for patients with cardiovascular diseases is not known. Purpose To explore cardiologists' and other specialists' opinions on the safety and efficacy of influenza vaccination in preventing cardiovascular events. Methods From September 2023 to February 2024, a survey was conducted among physicians of any specialty, following the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). The survey was available in 5 languages. Participants' opinions were assessed using Likert-type scales. Non-probabilistic convenience sampling was employed, and duplicated responses were prevented using the SurveyMonkey® platform that identifies duplicated IP addresses. Results A total of 2550 physicians from 44 countries answered the survey; the mean age was 46.1±13.1 years, 46.4% were women, and 17.1% were in training. Among respondents 43.6% were cardiologists. While 91.8% of participants considered the influenza vaccine to be very safe, and 90.6% believed that adverse effects of this intervention were rare, a significant proportion did not consider Influenza vaccine to be very beneficial in reducing acute myocardial infarction (54.4% for cardiologists vs 59.3% for other specialists, p=0.013) or stroke (62.2% for cardiologists vs 64.9% for other specialists, p=0.167). summarizes the participants’ opinions regarding the benefits and risks of influenza vaccination. Regarding potential barriers to achieving higher vaccination rates among patients with cardiovascular disease, cardiologists' opinions were similar to those of other specialists (Table 2). Patient beliefs and patients’ fear of vaccine-related adverse effects were identified as major barriers by both cardiologists and other specialists. Only 19.0% of participants reported having some type of checklist system to remind them to recommend the vaccine to their patients. While 73.0% of participants found this topic highly relevant to their daily clinical practice, with no differences between groups (p=0.178), a notable proportion, comprising 48.5% of cardiologists and 47.1% of other specialists, expressed the necessity for additional training to address the risk-benefit ratio of influenza vaccination with their patients (p=0.485). Conclusion Our data suggest that cardiologists and other specialists view the influenza vaccine as safe with a low rate of adverse effects, both in the general population and in individuals with cardiovascular disease. However, a significant proportion of them are unaware of the vaccination's benefit in reducing cardiovascular events. Additionally, about half of the surveyed professionals expressed a need for further education to discuss the benefits of vaccination with their patients.

The difference between guideline based lipid optimisation and real-world practice in a very high risk population

Abstract Background Elevated low-density lipoprotein cholesterol (LDL-C) is an important risk factor for the progression of cardiovascular disease and early optimisation of lipid lowering therapy following an acute coronary syndrome (ACS) or stroke is associated with improved outcomes. Recent guidelines have advocated the use of combination lipid-lowering therapy and achieving very low LDL-C concentrations.Purpose To identify if optimal lipid management in high risk patients has occurred. Methods A retrospective analysis of high-risk patients with a prior history of ACS or stroke presenting with a further subsequent ACS/stroke from January 2022 to December 2022 in a UK District General Hospital was performed. Lipid lowering therapy in primary care in the 18 months leading up admission, inpatient admission and subsequent 12 month post admission (delivered through the cardiac rehabilitation service post ACS and via primary care post stroke) was compared to our regional secondary prevention lipid lowering pathway. This patient group, with recurrent events, was selected as represents the "very high risk group" and had been through various clinicians multiple times increasing the opportunity to treat to guidance. Results 102 very high risk patients were admitted within the 12 month period. Only 79/102 patients had lipid profile in preceding 18 months and only 19% were compliant with the standard secondary prevention guidelines (20/102 patients high intensity statins), mainly due to reduced intensity statin doses (60%) and no lipid lowering medications (15%). A significant proportion of patients did not have any lipid blood tests during their index admission (no lipid profile 21% in stroke group vs 77% in ACS group) and whilst there was a significant inpatient escalation in lipid therapy this was mainly confined to high dose statins, and seen more clearly in the ACS group (ACS 65% vs stroke 21%). During the 12 months following admission a significant number of patients had no further lipid profiles (21% ACS vs 57% stroke) and minimal further optimisation of lipid management. Further escalation following high intensity statins were rare with only 5 / 102 patients receiving high intensity statin plus ezetimibe, 1 patient receiving statin/ ezetimibe/ PCSK9 inhibitor. Only 45% of patients achieved the guideline target of LDL < 1.8 mmol/L and only 18% achieved the ESC target of LDL <1.4 during 1 year follow up. Conclusion Although lipid guidelines have changed in recent year’s clinical real-world practice locally has not reflected these important developments, even in a very high-risk group patients are not benefiting from established evidence-based interventions. A majority of our ACS patients did not have a lipid profile blood test during their admission highlighting the fact that whilst guidelines have progressed significantly over the last few years the clinical importance of lipid optimisation in practice has not been appreciated by many of the cliniciansResults

Outcome and life expectancy associated with novel subgroups of atrial fibrillation: a data-driven cluster analysis

Abstract Background/Introduction Atrial fibrillation (AF) presents a significant global health burden, affecting millions and associated with elevated risks of mortality, heart failure, and stroke despite current treatment strategies. The current diagnosis of AF relies on episode characteristics, yet its heterogeneity calls for personalized assessment incorporating clinical features, biomarkers, and substrate determination for improved classification and management. Purpose This study aimed to develop a refined classification of AF according to comprehensive risk factors to identify patients at high-risk for poor prognosis and their life expectancy, aiming to facilitate personalized interventions. Methods A total of 7,391 participants aged 40-69 with AF at baseline, from UK Biobank, were recruited in the main analyses. Firstly, LASSO regression with Cox model and factor analysis were adopted for identification and integration of principal risk factors. Second, Consensus clustering analysis was employed to estimate the optimal cluster number and group all 7,391 participants. Difference in the risk of death and major complications, as well as reductions in life expectancy, among clusters were estimated. Replication was done in 2,399 participants with newly diagnosed AF within two years after baseline. Results Risk factors for AF were categorized into seven aspects (metabolic factors, respiratory factors, cardiovascular factors, renal and immunity diseases, mental health, acute illness, age), based on the correlation between them. Five distinct AF clusters were identified according to these seven characteristics: acute illness-related (Cluster 1), mental health-related (Cluster 2), cardiovascular disease-related (Cluster 3), immune-and-renal disease-related (Cluster 4), and respiratory-and-metabolism disease-related AF (Cluster 5). Patients with respiratory-and-metabolism disease-related AF had the highest risk of death, acute myocardial infarction, heart failure, and cerebral ischemic stroke, while those with acute illness-related AF had the lowest corresponding risk. In addition, compared with individuals with acute illness-related AF, those with respiratory-and-metabolism disease-related and mental health-related AF had the top 2 greatest loss of life expectancy. Furthermore, genetic variants for AF had different effect among the five clusters. Replication analysis confirmed the result stability. Conclusion A novel AF classification was developed, which provided insights into varying life expectancy and risks of death and complications among AF subgroups with distinct characteristics. It offers a practical approach for identifying high-risk patients, which may help to tailor precise interventions for AF management.Graphic abstractCluster features

Mild intracerebral bleeding does not adversely affect survival and neurological outcome of surgical therapy for left-sided infective endocarditis

Abstract Background Intracerebral bleeding (IB) is a serious condition that requires increased attention and has implications for treatment options. For patients with infective endocarditis (IE), current guidelines recommend postponing surgery if IB is present. IB can be classified into four relevant groups (following European Cooperative Acute Stroke Study and Heidelberger Bleeding classification): hemorrhagic transformation (HT) 1 and 2, and parenchymal hemorrhage (PH) 1 and 2. PH2 is the only IB with neurological deterioration. These classifications were originally introduced for stroke patients following thrombolysis but without IE. The hypothesis tested in our study is that IB may influence IE treatment and thus outcome. Method Patients were retrospectively identifyied who were operated for left-sided IE, neuroradiologists re-evaluated and classified preoperative cerebral imaging for any IB. Outcome was quantified using the modified Rankin score (mRS), and mRS were extracted from the patients’ hospital chart at admission and by follow-up telephone call (FU), also including mortality. To ensure that the influence of IB was comparable, patients with IB (IB+) were propensity matched (EuroScore 2, Charlson Comorbidity Index, C-reactive protein; nearest neighbor match) to patients without IB (IB-) who also received surgical IE therapy. All IB+ patients underwent a careful risk-benefit analysis before therapy. Results Of 286 consecutive patients (January 2015 - November 2022) operated for left-sided IE, 36 had IB (65±13 years, 26% female): 11 with HT1, 9 with HT2, 8 with PH1, and 8 with PH2. These patients were matched with 36 operated IB- patients. Survival analysis showed no overall effect of IB+ vs. IB- (p = 0.112, 95% CI of hazard ratio was 0.246-1.243 vs. 0.709-3.572). Although there was no effect of IB on survival in the mild IB subgroup (HT1/2, Figure A), there was a difference in patients with severe IB (PH1/2) with less survival in IB+ (Figure B). Neurological outcome (ΔmRS) showed an effect of IB grade in the two-way ANOVA analysis (p = 0.029). Intergroup comparison showed a significantly better outcome for IB- (vs. IB+) in the PH2 subgroup (p = 0.034), but not in other subgroups. For all groups, the mean ΔmRS for IB+ was 1.1±1.6 vs. 0.70±1.4 for IB- (p = 0.256). The mean FU time was 2.6±2.1 years. Conclusion In patients operated for left-sided IE, mild IB did not affect survival or neurological outcome. In the more severe forms of IB, i.e. PH1 and PH2, survival was less favorable compared to matched controls. Furthermore, we observed a difference in neurological outcome in patients with severe IB. Thus, surgical therapy of left-sided IE should be avoided in patients with severe IB, whereas we can add evidence to the safety of surgical therapy in mild IB. Therefore, we recommend regular assessment of the degree of IB in such patients.Figure

The very long-term risk of stroke after acute coronary syndrome and geographic differences. The ABC-10* study on heart disease

Abstract Background Little is known about the very long-term risk of stroke among acute coronary syndrome (ACS) survivors. Methods In this prospective study, we enrolled 535 ACS patients admitted to hospitals in three Italian provinces, discharged alive and followed for 24 years or death. The patient's residency was classified into three urban and three nearby rural areas. Results All patients completed the follow-up (6142 Perso-years). 85 (16%) patients suffered an acute stroke. Patients median age was 67 years, 70% were male, and 318 patients were residing in rural areas. Patients who had a stroke and those who had not shared most of the demographic and clinical characteristics. The incidence rate of overall stroke was 14/1000 person-year. Cox analyses showed older age (HR 3.13;95%CI 2.31-4.26), male gender (HR 1.88;95%CI 1.20-2.95), baseline diabetes (HR 2.25 95%CI 1.37-3.69), heart failure (HR 2.69;95%CI 1.71-4.24), and higher albumin/creatinine ratio (HR 1.75;95%CI 1.33-2.30) were all associated with an increased risk of stroke. while higher baseline eGFR, reperfusion, statin and beta-blockers treatment during follow-up were associated with a decreased risk; HR (0.55 (95%CI 0.42-0.72), 0.45(95%CI 0.29-0.71), 0.21(95%CI 0.13-0.34), and 0.37(95%CI 0.23-0.57), respectively). In the multivariate analysis, only older age (HR1.55;95%CI 1.08-2.21; p=0.02) was an independent predictor of stroke while statin treatment was independently associated with a lower risk (HR 0.35;95% CI 0.21-0.58; p<0.0001). However, all these variables did not predict the risk of stroke in competing risk regression analysis where death was treated as the competing event. A sub-analysis of the 43 patients who had a fatal stroke (FS) revealed 7/1000 person-year FS IR. The Cox regression and competing risk analyses of predictors of FS showed similar results. Interestingly, we observed an association between geographic areas of residence and the long-term FS risk as the risk increased going from rural to urban (HR 2.08;95%CI 1.14-3.80; p=0.02) areas and from north to middle and south provinces (HR 1.47;95%CI 1.00-2.15; p=0.04) in the univariate Cox regression analysis. Results kept true using multivariate Cox and Competing risk regression models. Conclusion This analysis reveals the significant urban-rural difference in the very long–term risk of fatal stroke among unselected ACS patients which highlights the importance of implementing a preventive policy based on area-specific knowledge.

Time-Sensitive Quality Metrics of Acute Stroke Care: A Comprehensive Stroke Center Experience

Time-Sensitive Quality Metrics of Acute Stroke Care: A Comprehensive Stroke Center Experience

Metabolic profile of acute ischemic stroke patients in a tertiary care hospital

Background: When the blood supply to a portion of the brain is blocked or diminished, brain tissue cannot get oxygen and nutrients, resulting in an ischemic stroke. This study aimed to investigate the prevalence of hyperglycemia and dyslipidemia among patients with acute stroke in a tertiary healthcare setting in Bangladesh. Methods: This cross-sectional study was conducted from January 2022 to December 2022 at a tertiary healthcare facility in Bangladesh, focusing on patients with acute ischemic stroke. Data was collected through a face-to-face interview, and medical records were reviewed. The study included 40 patients with acute stroke, evidenced by clinical findings and a CT scan of the Brain. Written informed consent was obtained after proper explanation, and participants were free to refuse or withdraw at any point. Confidentiality and privacy were maintained. Results: The majority of participants (37.5%) were aged 60-69, with more males (57.5%) than females (42.5%). Most (70%) lived in urban areas. Among the participants, 82.5% had hypertension, and 52.5% had diabetes mellitus. The mean of HbA1c was 7.6% and of triglyceride was 205.0 mg/dl. Of the participants with acute stroke, 47.5% had extracranial carotid stenosis. Conclusions: Nearly half of those who had an acute stroke also had diabetes, and four out of five had a history of hypertension. Among the patient hyperglycemia and dyslipidemia was common. Nearly half of those who suffered an acute stroke also experienced carotid stenosis. Consideration should be given to managing hypertension, DM, dyslipidemia, and carotid stenosis among patients with acute stroke. J Shaheed Suhrawardy Med Coll 2023; 15(1): 50-54

Glial 'omics in ischemia: Acute stroke and chronic cerebral small vessel disease.

Vascular injury and pathologies underlie common diseases including ischemic stroke and cerebral small vessel disease (CSVD). Prior work has identified a key role for glial cells, including microglia, in the multifaceted and temporally evolving neuroimmune response to both stroke and CSVD. Transcriptional profiling has led to important advances including identification of distinct gene expression signatures in ischemia-exposed, flow cytometrically sorted microglia and more recently single cell RNA sequencing-identified microglial subpopulations or clusters. There is a reassuring degree of overlap in the results from these two distinct methodologies with both identifying a proliferative and a separate type I interferon responsive microglial element. Similar patterns were later seen using multimodal and spatial transcriptomal profiling in ischemia-exposed microglia and astrocytes. Methodological advances including enrichment of specific neuroanatomic/functional regions (such as the neurovascular unit) prior to single cell RNA sequencing has led to identification of novel cellular subtypes and generation of new credible hypotheses as to cellular function based on the enhanced cell sub-type specific gene expression patterns. A ribosomal tagging strategy focusing on the cellular translatome analyses carried out in the acute phases post stroke has revealed distinct inflammation-regulating roles for microglia and astrocytes in this setting. Early spatial transcriptomics experiments using cerebral ischemia models have identified regionally distinct microglial cell clusters in ischemic core versus penumbra. There is great potential for combination of these methods for multi-omics approaches to further elucidate glial responses in the context of both acute ischemic stroke and chronic CSVD.

Chronopharmacotherapy and correction of central pressure in the aorta, structural and functional state of the left ventricular in patients with arterial hypertension and ischemic stroke

Objective. To evaluate the dynamics of central aortic pressure and the cardioprotective effect of antihypertensive chronopharmacotherapy in patients with arterial hypertension (AH) and ischemic stroke. Materials and methods. The study included 119 patients with AH who has suffered an ischemic stroke; patients were randomized in 2 groups depending on the chronopharmacotherapy option: group 1 (n = 60) – patients who received indapamide retard 1.5 mg and valsartan 160 mg in the morning; group 2 (n = 59) – indapamide retard 1.5 mg in the morning and valsartan 80 mg each in the morning and before bedtime. After 2 months of pharmacotherapy, the achievement of the target level of blood pressure was assessed. In group 1, blood pressure was recorded in 47 (78.3 %), in group 2 – in 56 (94.9 %) patients (p < 0.05). The rest of the respondents, who did not reach the blood pressure target, underwent correction of antihypertensive therapy and were excluded from further follow-up. Accordingly, further follow-up was carried out in 47 patients of group 1 (group 1a) and 56 patients of group 2 (group 2a). Initially and after 12 months of therapy, echocardiography parameters ("ALOKA SSD 2500", Japan), as well as daily blood pressure monitoring with determination of central aortic pressure (Peter Telegin LLC BPLabVasotens, Russia) were performed. The results of the study were processed using the Statistica 12.0 program (StatSoftInc, USA). Results. At the time of inclusion in the study, the main parameters of the central aortic pressure and echocardiography parameters in both groups of patients were equivalent. After 12 months a statistically more significant decrease in the main parameters of the central aortic pressure (average daily systolic and diastolic pressure in the aorta, pulse pressure in the aorta, augmentation index in the aorta, amplification of pulse pressure, duration of the expulsion period, subendocardial blood flow efficiency index), as well as echocardiography indicators was recorded in group 2a (end-systolic and end-diastolic dimensions, thickness of the interventricular septum, thickness of the posterior wall of the left ventricular myocardium, left ventricular myocardial mass, left ventricular myocardial mass index and ejection fraction) (p < 0.05). The left ventricular myocardial geometry normalized during therapy was recorded significantly more often in group 2a than in group 1a (p < 0.05). Conclusion. Two times a day intake of valsartan with thiazidelike diuretic in the morning facilitated more significant improvement of central aortic pressure, echocardiography parameters and as well as an improvement in the geometry of the left ventricular myocardium comparing to just morning intake.

Comparison of risk factors and mortality in veterans with HIV and those without HIV suffering first major acute cardiovascular events.

Previous studies have demonstrated that people with HIV have an increased atherosclerotic plaque vulnerability, making them more susceptible to severe cardiovascular complications. This study aimed to examine the clinical characteristics of people with HIV in comparison to people without HIV admitted to Veterans Health Administration (VHA) with their first major acute cardiovascular events (MACE) and compare their total mortality. We used national VHA data to extract data of those admitted to VHA hospitals with MACE defined as acute myocardial infarction (AMI), acute cerebrovascular accident (CVA) or cardiac arrest during the fiscal years 2003-2021. The hazard ratio (HR) of mortality for people with HIV versus people without HIV was estimated using Cox proportional hazard regression analysis. Out of 280 311 veterans, 2510 people with HIV and 277 801 people without HIV had their first MACE during the study period. People with HIV were younger, more likely to be African American, had a lower prevalence of diabetes mellitus and hypertension, similar total cholesterol levels and a lower mean 10-year cardiovascular risk score (25.4 in people with HIV vs. 28.7 in people without HIV). Among MACE components, people with HIV had a higher proportion of CVA (27% vs. 21.3%, p < 0.001) and cardiac arrest (13.0% vs. 8.4%, p < 0.001) but a lower incidence of AMI (62.4% vs. 72.5%, p < 0.001) than people without HIV. Additionally, people with HIV had a higher risk of total mortality (adjusted HR: 2.05, 95% confidence interval: 1.90-2.22) compared with people without HIV. People with HIV experience MACE at younger ages despite lower cardiovascular risks and similar baseline cholesterol and blood pressure levels. People with HIV had higher mortality and a higher risk of having ventricular fibrillation arrest and stroke as their first MACE.

Intravenous thrombolysis or antiplatelet therapy for acute nondisabling ischemic stroke: A systematic review and network meta-analysis.

Uncertainties remain on the optimal treatment for acute minor stroke with nondisabling symptoms. The two most common therapeutic approaches are intravenous thrombolysis (IVT) and antiplatelet therapy, notably dual antiplatelet therapy (DAPT). We synthesized data from the literature to compare IVT to DAPT and identify the best treatment for this population. We systematically searched Pubmed, Web of Science and the Cochrane Library for randomized trials and observational studies comparing IVT, aspirin, and/or DAPT, started within 24 h of symptom onset in patients with minor stroke (NIHSS ⩽ 5) and nondisabling symptoms. Random-effects Bayesian network meta-analysis was conducted. The primary outcome was excellent functional outcome at 3 months (mRS 0-1). Secondary outcomes included mRS 0-2, symptomatic intracranial hemorrhage, mortality, and recurrent stroke. Four randomized trials and 2 observational studies (5897 patients for the analysis of the primary outcome) were included. Compared with IVT (alteplase), DAPT (clopidogrel + aspirin) was significantly associated with higher odds of mRS 0-1 (OR = 1.52, 95% CrI, 1.09-2.35), but aspirin alone was not (OR = 1.36, 95% CrI, 0.87-2.30). DAPT was also associated with lower odds of symptomatic intracranial hemorrhage than alteplase (OR = 0.14, 95% CrI, 0.03-0.91). There were no significant differences between treatment groups regarding the other outcomes. For each outcome, the ranking for the best treatment was DAPT, then aspirin, and then IVT. This network meta-analysis suggests that DAPT may be the optimal treatment for acute nondisabling stroke, with higher odds of excellent functional outcome compared with IVT.Registration: PROSPERO ID: CRD42024522038.

Evaluating neuromuscular electrical stimulation for preventing and managing intensive care unit-acquired weakness: Current evidence and future directions.

Intensive care unit-acquired weakness (ICU-AW) is a prevalent issue in critical care, leading to significant muscle atrophy and functional impairment. Aiming to address this, Neuromuscular Electrical Stimulation (NMES) has been explored as a therapy. This systematic review assesses NMES's safety and effectiveness in enhancing functional capacity and mobility in pre- and post-cardiac surgery patients. NMES was generally safe and feasible, with intervention sessions varying in frequency and duration. Improvements in muscle strength and 6-minute walking test distances were observed, particularly in preoperative settings, but postoperative benefits were inconsistent. NMES showed promise in preventing muscle loss and improving strength, although its impact on overall functional capacity remained uncertain. Challenges such as short ICU stays and body composition affecting NMES efficacy were noted. NMES also holds potential for other conditions like cerebral palsy and stroke. Further research is needed to optimize NMES protocols and better understand its full benefits in preventing ICU-AW and improving patient outcomes.

Telemedicine networks for acute stroke: An analysis of global coverage, gaps, and opportunities.

Despite the proven efficacy of telestroke in improving clinical outcomes by providing access to specialized expertise and allowing rapid expert hyperacute stroke management and decision-making, detailed operational evidence is scarce, especially for less developed or lower income regions. We aimed to map the global telestroke landscape and characterize existing networks. We employed a four-tiered approach to comprehensively identify telestroke networks, primarily involving engagement with national stroke experts, stroke societies, and international stroke authorities. A carefully designed questionnaire was then distributed to the leaders of all identified networks to assess these networks' structures, processes, and outcomes. We identified 254 telestroke networks distributed across 67 countries. High-income countries (HICs) concentrated 175 (69%) of the networks. No evidence of telestroke services was found in 58 (30%) countries. From the identified networks, 88 (34%) completed the survey, being 61 (71%) located in HICs. Network setup was highly heterogeneous, ranging from 17 (22%) networks with more than 20 affiliated hospitals, providing thousands of annual consultations using purpose-built highly specialized technology, to 11 (13%) networks with fewer than 120 consultations annually using generic videoconferencing equipment. Real-time video and image transfer was employed in 64 (75%) networks, while 62 (74%) conducting quality monitoring. Most networks established in the past 3 years were located in low- and middle-income countries (LMICs). This comprehensive global survey of telestroke networks found significant variation in network coverage, setup, and technology use. Most services are in HICs, and a few services are in LMICs, although an emerging trend of new networks in these regions marks a pivotal moment in global telestroke care. The wide variation in quality monitoring practices across networks, with many failing to report key performance metrics, underscores the urgent need for standardized, resource-appropriate, quality assurance measures that can be adapted to diverse settings.

Arterial Ischemic Stroke in Pediatric Patients: A Tertiary Hospital Experience

Arterial Ischemic Stroke in Pediatric Patients: A Tertiary Hospital Experience

Automated Extraction of Stroke Severity From Unstructured Electronic Health Records Using Natural Language Processing.

Multicenter electronic health records can support quality improvement and comparative effectiveness research in stroke. However, limitations of electronic health record-based research include challenges in abstracting key clinical variables, including stroke severity, along with missing data. We developed a natural language processing model that reads electronic health record notes to directly extract the National Institutes of Health Stroke Scale score when documented and predict the score from clinical documentation when missing. The study included notes from patients with acute stroke (aged ≥18 years) admitted to Massachusetts General Hospital (2015-2022). The Massachusetts General Hospital data were divided into training/holdout test (70%/30%) sets. We developed a 2-stage model to predict the admission National Institutes of Health Stroke Scale, obtained from the GWTG (Get With The Guidelines) stroke registry. We trained a model with the least absolute shrinkage and selection operator. For test notes with documented National Institutes of Health Stroke Scale, scores were extracted using regular expressions (stage 1); when not documented, least absolute shrinkage and selection operator was used for prediction (stage 2). The 2-stage model was tested on the holdout test set and validated in the Medical Information Mart for Intensive Care (2001-2012) version 1.4, using root mean squared error and Spearman correlation. We included 4163 patients (Massachusetts General Hospital, 3876; Medical Information Mart for Intensive Care, 287); average age, 69 (SD, 15) years; 53% men, and 72% White individuals. The model achieved a root mean squared error of 2.89 (95% CI, 2.62-3.19) and Spearman correlation of 0.92 (95% CI, 0.91-0.93) in the Massachusetts General Hospital test set, and 2.20 (95% CI, 1.69-2.66) and 0.96 (95% CI, 0.94-0.97) in the MIMIC validation set, respectively. The automatic natural language processing-based model can enable large-scale stroke severity phenotyping from the electronic health record and support real-world quality improvement and comparative effectiveness studies in stroke.

Effect of the Covid-19 pandemic on hospitalizations for non-Covid-19-pneumonia and exacerbations of chronic obstructive pulmonary diseases in Switzerland: comparison of national data between 2020/2021 and 2015–2019

BackgroundProtective measures applied during the Covid-19 pandemic had a marked impact on the incidence of pneumonia. However, systematic data are lacking for hospitalizations for pneumonia and acute exacerbations of chronic obstructive lung diseases (AECOPD) not caused by SARS-CoV-2 in Switzerland. We aimed to compare the incidences of hospitalization for these entities between 2020/2021 and prepandemic years.MethodsThis retrospective study examined all nationwide hospitalizations for non-Covid-19-pneumonia and AECOPD listed as primary diagnoses based on ICD-10 codes between 2015 and 2021 in a publicly available hospitalization database of the Swiss Federal Statistical Office. Hospitalizations for acute coronary syndrome (ACS) and stroke were used as controls. Changes of monthly incidences of hospitalizations, length of stay (LOS) and mortality were compared between 2020/2021 and the average of 2015–2019.ResultsThe incidences of hospitalizations for AECOPD and for pneumonia showed seasonal variations from 2015 to 2019 followed by significant and almost identical decreases in 2020/2021 (incidence rate ratio [IRR] 0.59, 95% CI: 0.45–0.77, p < 0.001, and IRR: 0.62, 95% CI: 0.52–0.74, p < 0.001, respectively). Hospital-mortality was slightly higher in 2020/2021 for AECOPD (2015–2019: 3.8%; 2020/2021: 4.2%, odds ratio [OR] 1.24, 95% CI: 1.07–1.44, p = 0.004) and for pneumonia (2015–2019: 4.5%, 2020/2021: 4.6%, odds ratio [OR] 1.17, 95% CI: 1.07–1.28, p < 0.001). Median LOS slightly decreased for AECOPD (2015–2019: 8 [IQR: 5–14] days; 2020/2021: 7 [IQR: 4–13] days, Wilcoxon test: p < 0.001) but slightly increased for pneumonia (2015–2019: 7 [IQR: 4–11] days; 2020/2021: 7 [IQR: 4–13] days, Wilcoxon test: p < 0.001). Throughout 2020/2021, there were no significant fluctuations observed in the incidences of ACS and stroke. (IRR: 0.98, 95% CI: 0.83–1.16, p = 0.810, IRR: 0.96, 95% CI: 0.81–1.14, p = 0.636, respectively).ConclusionThe first two years of the Covid-19 pandemic showed a marked decrease in incidences in AECOPD and non-Covid-19 pneumonia hospitalizations in Switzerland. It is likely that this effect is associated with the society-based, at first vigorous, social distancing measures.

Magnetic resonance imaging quantitative assessment of corticospinal tract damage in basal ganglia infarction.

To retrospectively explore the role of magnetic resonance imaging (MRI) diffusion tensor imaging (DTI) in analyzing the corticospinal tract injury in acute cerebral anterior circulation infarction in the basal ganglia region and the correlation between DTI parameters and neurological function scores, patients with acute cerebral infarction and stroke had undergone plain MRI and DTI sequence scanning were enrolled. Diffusion tensor tractography was used to perform 3-dimensional reconstruction of bilateral corticospinal tracts (CST). The image data were processed to obtain fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values, and the correlation between the DTI parameters and neurological function scores of National Institutes of Health Stroke Scale (NIHSS) was evaluated. A total of thirty-two patients with acute ischemic cerebral infarction were retrospectively enrolled, including 19 males and 13 females with a mean age 63.22 ± 7.78 years. The CST score was 0 in 2 (6.25%) patients, 1 in 9 (28.13%), 2 in 9 (28.13%), 3 in 7 (21.88%), and 4 in 5 (15.63%). The FA value significantly (P = .01) decreased (0.52 ± 0.03 vs 0.62 ± 0.04) on the ischemic side compared with that on the normal side. A significant (P < .05) difference was detected in the number of nerve fibers (223.3 ± 110.0 vs 246.7 ± 104.4) rather than in the ADC values (0.86 ± 0.06 vs 0.84 ± 0.06) between the ischemic and healthy sides. The FA and ADC values were not significantly (P > .05) different according to the CST scores 0, 1, 2, 3, or 4 between the ischemic and healthy sides. There was a significant (P < .05) negative correlation between the FA value on the infarcted side and the NIHSS score. In conclusion, with the DTI technology, varying degrees of damage to the corticospinal tract at the infarcted side can be detected and important clinical information can be provided for the diagnosis and prognosis of acute cerebral infarction by evaluating the degree of corticospinal tract injury.

METTL14 Promotes Ischemic Stroke-induced Brain Injury by Stabilizing HDAC3 Expression in an m6A-IGF2BP3 Mechanism.

N6-methyladenosine (m6A) modification is the most abundant post-transcriptional modification of mRNAs and has been identified to play critical roles in ischemic stroke (IS). Herein, this study aimed to investigate the function and mechanism of Methyltransferase-like 14 (METTL14) methylase in cerebral IS. Murine BV-2 microglial cell OGD/R models and rat middle cerebral artery occlusion (MCAO) models were established to mimic IS-induced neuronal damage in vitro and brain injury in vivo. Levels of METTL14, Histone Deacetylase 3 (HDAC3) and cGAS-STING axis-related proteins were detected using qRT-PCR or western blotting. Cell proliferation and inflammation were assessed by CCK-8 assay, EdU assay and ELISA. Flow cytometry detected microglia polarization. Cell pyroptosis was analyzed by detecting related-protein markers by western blotting. The m6A modification was determined by methylated RNA immunoprecipitation assay. Brain injury was analyzed by evaluating infarct volume and neurologic score. METTL14 levels were higher in OGD/R-induced microglial cells, primary microglia and infarct brain tissues of rat MCAO models. Functionally, METTL14 silencing reversed OGD/R-induced proliferation inhibition, inflammation and pyroptosis in microglial cells and primary microglia in vitro, and ameliorated cerebral ischemic injury in rat MCAO models. Mechanistically, METTL14 induced HDAC3 m6A modification in an IGF2BP3-dependent manner, and could activate cGAS-STING pathway through HDAC3. Moreover, HDAC3 overexpression reversed the neuroprotective effects of METTL14 silencing. METTL14 silencing reversed ischemic stroke-induced brain injury by inducing HDAC3 m6A modification in an IGF2BP3-dependent mechanism, recommending a novel insight for ameliorating cerebral ischemic stroke.