First-ever Acute Ischemic Stroke Research Articles

Acute care, secondary prevention, and outcomes after ischaemic and haemorrhagic stroke in men and women: a data-linkage study.

Introduction There is evidence that sex differences exist in stroke presentation, risk factors, severity, treatment, and outcomes. To further understand this, we explored how sex differences influence acute stroke management, secondary prevention prescribing and mortality outcomes in a well-characterised cohort of first-ever stroke patients in Scotland. Methods This is a retrospective, population-based, data-linkage study of stroke admissions to acute care hospitals in Scotland between 1 January 2011 and 31 December 2018. Data sources included the Scottish Stroke Care Audit (SSCA), the Prescribing Information System (PIS), the Scottish Morbidity Record 01 (SMR01), and the National Records of Scotland (NRS) Death Records. Multivariable logistic regression was used to explore the association between patient sex, acute stroke care and secondary prevention prescribing, while Cox proportional hazards models were used to explore the association between patient sex and all-cause mortality up to one year after index event. Results This study included 5901 patients with a first-ever intracerebral haemorrhage (ICH) and 47 087 patients with a first-ever acute ischaemic stroke (AIS). After an ICH, women had significantly lower odds of receiving all components of the stroke care bundle (adjusted odds ratio (aOR), 0.78; 95% confidence interval (CI), 0.69 - 0.87) and were less likely to be prescribed antihypertensives within ninety days after discharge (aOR, 0.78; 95% CI, 0.63 - 0.97) to usual place of residence. There was no sex difference in stroke care bundle achievement for those admitted with AIS, however, women had significantly lower odds of receiving antihypertensives, lipid-lowering drugs or oral anticoagulants (OAC) after discharge. The risk of all-cause mortality was lower in women at one year after both ICH (adjusted hazard ratio (aHR), 0.90; 95% CI, 0.83 - 0.98) and AIS (aHR, 0.91; 95% CI, 0.87 - 0.95) after adjusting for potential confounders. Conclusion The sex differences in stroke treatment and outcomes may be partly explained by the older age of women at the time of stroke, which influences stroke presentation, severity, and prognosis. However, following adjustment, women had reduced risk of all-cause mortality after both ICH and AIS.

Serum levels of vitamin B12 combined with folate and plasma total homocysteine predict ischemic stroke disease: a retrospective case-control study

PurposeThis study aimed to identify and quantify the association and investigate whether serum vitamin B12 alone or vitamin B12 combined with folate and plasma total homocysteine (tHcy) levels could be used to predict the risk of acute ischemic stroke.Materials and methodsThis retrospective case-control study was conducted in the Department of Neurology, First Affiliated Hospital of Chongqing Medical University. It included 259 inpatients experiencing their first-ever acute ischemic stroke and 259 age-matched, sex-matched healthy controls. Patients were categorized into groups based on the etiology of their stroke: large-artery atherosclerosis (LAAS, n = 126), cardio embolism (CEI, n = 35), small vessel disease (SVD, n = 89), stroke of other determined etiology (ODE, n = 5), and stroke of undetermined etiology (UDE, n = 4). The associations of serum vitamin B12, folate, and plasma tHcy levels with the risk of ischemic stroke were evaluated using multivariable logistic regression analysis. Receiver operator characteristic (ROC) curves were used to assess the diagnostic power of vitamin B12, folate, and tHcy levels for ischemic stroke.ResultsSerum vitamin B12 and folate levels were significantly lower in ischemic stroke patients compared to controls, while plasma tHcy levels were significantly higher. The first quartile of serum vitamin B12 levels was significantly associated with an increased risk of LAAS (aOR = 2.289, 95% CI = 1.098–4.770), SVD (aOR = 4.471, 95% CI = 1.110–4.945) and overall ischemic stroke (aOR = 3.216, 95% CI = 1.733–5.966). Similarly, the first quartile of serum folate levels was associated with an increased risk of LAAS (aOR = 3.480, 95% CI = 1.954–6.449), CEI (aOR = 2.809, 95% CI = 1.073–4.991), SVD (aOR = 5.376, 95% CI = 1.708–6.924), and overall ischemic stroke (aOR = 3.381, 95% CI = 1.535–7.449). The fourth quartile of tHcy levels was also significantly associated with an increased risk of LAAS (aOR = 2.946, 95% CI = 1.008–5.148), CEI (aOR = 2.212, 95% CI = 1.247–5.946), SVD (aOR = 2.957, 95% CI = 1.324–6.054), and overall ischemic stroke (aOR = 2.233, 95% CI = 1.586–4.592). For predicting different types of ischemic stroke, vitamin B12 alone demonstrated the best diagnostic value for SVD, evidenced by a sensitivity of 71.0% and negative predictive value of 90.3%, along with the highest positive likelihood ratio (+ LR) for SVD. Vitamin B12 + tHcy + folate are valuable in predicting different types of ischemic stroke, with the most significant effect observed in SVD, followed by LAAS, and the weakest predictive effect in CEI. Additionally, vitamin B12 alone in combination with other indicators, such as folate alone, tHcy alone, and folate + tHcy could reduce negative likelihood ratio (-LR) and improve + LR.ConclusionsVitamin B12 was an independent risk factor for acute ischemic stroke. The risk calculation model constructed with vitamin B12 + tHcy + folate had the greatest diagnostic value for SVD.

Predicting asymptomatic coronary artery disease in first-ever acute ischemic stroke patients: a cross-sectional study.

It is frequently observed that patients with first-ever acute ischemic stroke (AIS) have a common occurrence of asymptomatic coronary artery disease (CAD). This condition is associated with a poor prognosis. Early detection and recognition of asymptomatic CAD in first-ever AIS patients may optimize the clinical management and ultimately lead to improved outcomes. The aim of this study was to investigate the role of aortic arch plaque (AAP) detected through combined computed tomography angiography (CTA) as an early predictor of asymptomatic CAD in patients with first-ever AIS without prior diagnosis of CAD. A cross-sectional study was conducted at Xuanwu Hospital, Capital Medical University from January 2019 to December 2021, involving patients with first-ever AIS caused by large arterial atherosclerosis. Patients with a history of recognized cardiovascular disease, nonatherosclerotic arterial stenosis, atrial fibrillation related to cardioembolism, and complete carotid occlusions were excluded. The study utilized a combined coronary and cervicocephalic CTA to evaluate atherosclerosis in the cervicocephalic, aortic, and coronary arteries simultaneously. First-ever AIS patients without prior diagnosis of CAD were divided into 2 groups: 1 with asymptomatic CAD detected through CTA and the other without. Multivariate logistic regression was used to identify independent risk factors associated with the presence of asymptomatic CAD, including aortic arch, cervical and intracranial atherosclerotic characteristics (e.g., vascular stenosis, plaque thickness, extent, and complexity). Among 182 AIS patients, 84 (46.2%) had asymptomatic CAD. Increased aortic arch plaque (AAP) thickness per millimeter [adjusted odds ratio (aOR): 1.26; 95% confidence interval (CI): 1.08-1.47], presence of severe AAP (aOR: 4.24; 95% CI: 1.59-12.03), mixed AAP (aOR: 2.65; 95% CI: 1.09-6.62), and ulcerative AAP (aOR: 11.76; 95% CI: 2.05-222.84) raised the risk of asymptomatic CAD in stroke patients, independent of other factors. The combination of ulcerative AAP, diabetes mellitus, and smoking could predict asymptomatic CAD with an area under the receiver operating characteristic curve (AUC) of 0.71 (95% CI: 0.64-0.79; P<0.001). Ulcerative AAP was found to be more valuable than cervicocephalic atherosclerotic characteristics for predicting asymptomatic CAD in first-ever AIS patients. The presence of ulcerative AAP was associated with asymptomatic CAD in first-ever AIS patients. As an early systemic atherosclerosis feature, ulcerative AAP is probably a more valuable indicator than cervicocephalic atherosclerotic characteristics for predicting asymptomatic CAD in AIS patients.

Association between high-resolution magnetic resonance vessel wall imaging characteristics and recurrent stroke in patients with intracranial atherosclerotic steno-occlusive disease: A prospective multicenter study.

High-resolution magnetic resonance vessel wall imaging (HRMR-VWI) is a promising technique for identifying intracranial vulnerable plaques beyond lumen narrowing. However, the association between HRMR-VWI characteristics and recurrent stroke remains uncertain. This study aimed to investigate the association between HRMR-VWI characteristics and recurrent ipsilateral stroke in patients with symptomatic intracranial atherosclerotic steno-occlusive disease (ICAS). This multicenter, observational study recruited first-ever acute ischemic stroke patients attributed to ICAS (>50% stenosis or occlusion) within 7 days after onset. Participants were assessed by multiparametric magnetic resonance imaging (MRI) including diffusion-weighted imaging, three-dimension time-of-flight magnetic resonance angiography, and three-dimensional T1-weighted HRMR-VWI. The patients were recommended to receive best medical therapy and were systematically followed up for 12 months. The association between HRMR-VWI characteristics and the time to recurrent ipsilateral stroke was investigated by univariable and multivariable analysis. Two hundred and fifty-five consecutive patients were enrolled from 15 centers. The cumulative 12 month ipsilateral recurrence incidence was 4.1% (95% confidence interval (CI): 1.6-6.6%). Patients with recurrent ipsilateral stroke exhibited higher rates of intraplaque hemorrhage (IPH) (30.0% vs 6.5%) and eccentric plaque (90.0% vs 48.2%), and lower occurrence of occlusive thrombus (10.0% vs 23.7%). Plaque length (5.69 ± 2.21 mm vs 6.67 ± 4.16 mm), plaque burden (78.40 ± 7.37% vs 78.22 ± 8.32%), degree of stenosis (60.25 ± 18.95% vs 67.50% ± 22.09%) and remodeling index (1.07 ± 0.27 vs 1.03 ± 0.35) on HRMR-VWI did not differ between patients with and without recurrent ipsilateral stroke. In the multivariable Cox regression analysis, IPH (hazard ratio: 6.64, 95% CI: 1.23-35.8, p = 0.028) was significantly associated with recurrent ipsilateral stroke after adjustment.Conclusions:Our results suggest intraplaque hemorrhage (IPH) is significantly associated with recurrent ipsilateral stroke and has potential value in the selection of patients for aggressive treatment strategies. Data from this study are available and can be accessed upon request.

Abstract 36: Association Between High-Resolution Magnetic Resonance Imaging Characteristics and Recurrent Stroke in Patients With Symptomatic Intracranial Atherosclerotic Steno-Occlusive Disease: A Prospective Multicenter Study

Background and Objectives: This study aimed to investigate the association between high-resolution magnetic resonance imaging (HR-MRI) characteristics and recurrent ipsilateral stroke in patients with symptomatic intracranial atherosclerotic steno-occlusive disease (ICAS). Methods: This multicenter, observational study recruited first-ever acute ischemic stroke patients attributed to ICAS (&gt;50% stenosis or occlusion) within 7 days after onset. Participants were assessed by multi-parametric MRI including diffusion-weighted imaging, three-dimension time-of-flight magnetic resonance angiography, and three-dimensional T1-weighted HR-MRI. The patients were recommended to receive best medical therapy and were systematically followed up for 12 months. The association between HR-MRI characteristics and the time to recurrent ipsilateral stroke was investigated by univariable and multivariable analysis. Results: Two hundred and fifty-five consecutive patients were enrolled from 15 centers. The cumulative 12-month ipsilateral recurrence incidence was 4.1% (95% confidence interval [CI]: 1.6-6.6%). The plaque length (5.69±2.21 mm vs. 6.67±4.16 mm), plaque burden (78.40±7.37% vs. 78.22±8.32%), degree of stenosis (60.25±18.95% vs. 67.50±22.09%) and remodeling index (1.07±0.27 vs. 1.03±0.35) on HR-MRI did not exhibit discernible difference between patients with and without recurrent ipsilateral stroke. Patients with recurrent ipsilateral stroke exhibited higher rates of intraplaque hemorrhage (IPH) (30.0% vs. 6.5%) and eccentric plaque (90.0% vs. 48.2%), and lower occurrence of occlusive thrombus (10.0% vs. 23.7%). In the multivariable Cox regression analysis, IPH (hazard ratio: 7.05, 95% CI: 1.53-32.41, p=0.012) was significantly associated with recurrent ipsilateral stroke after adjustment. Discussion: We found IPH is significantly associated with recurrent ipsilateral stroke. Our results suggest IPH has potential value in the selection of patients for aggressive treatment strategies.

First-ever acute ischemic strokes in HIV-infected persons: A case-control study from stroke units.

The stroke risk for persons living with human immunodeficiency virus (PLHIVs) doubled compared to uninfected individuals. Stroke-unit (SU)-access, acute reperfusion therapy-use and outcome data on PLHIVs admitted for acute ischemic stroke (AIS) are scarce. AIS patients admitted (01 January 2017 to 31 January 2021) to 10 representative Paris-area SUs were screened retrospectively from the National Hospitalization Database. PLHIVs were compared to age-, initial NIHSS- and sex-matched HIV-uninfected controls (HUCs). Outcome was the 90-day modified Rankin Scale score. Among 126 PLHIVs with confirmed first-ever AIS, ~80% were admitted outside the thrombolysis-administration window. Despite antiretrovirals, uncontrolled plasma HIV loads exceeded 50 copies/mL (26% of all PLHIVs; 38% of those ≤55 years). PLHIVs' stroke causes by decreasing frequency were large artery atherosclerosis (LAA), undetermined, other cause, cerebral small-vessel disease (CSVD) or cardioembolism. No stroke etiology was associated with HIV duration or detectable HIVemia. MRI revealed previously unknown AIS in one in three PLHIVs, twice the HUC rate (p = 0.006). Neither group had optimally controlled modifiable cardiovascular risk factors (CVRFs): 20%-30% without specific hypertension, diabetes, and/or dyslipidemia treatments. Their stroke outcomes were comparable. Multivariable analyses retained good prognosis associated solely with initial NIHSS or reperfusion therapy. Older age and hypertension were associated with CSVD/LAA for all PLHIVs. Standard neurovascular care and reperfusion therapy were well-tolerated. The high uncontrolled HIV-infection rate and suboptimal CVRF treatment support heightened vigilance to counter suboptimal HIV suppression and antiretroviral adherence, and improve CVRF prevention, mainly for younger PLHIVs. Those preventive, routine measures could lower PLHIVs' AIS risk.

Adherence to an integrated care pathway for stroke is associated with lower risk of major cardiovascular events: A report from the Athens Stroke Registry

BackgroundA recent European Society of Cardiology (ESC) Council on Stroke position paper proposed a holistic integrated care management approach for stroke patients, to improve cardiovascular outcomes. The impact of implementing the ABCstroke pathway ‘concept’ on clinical outcomes has never been estimated before. In order to investigate the potential effect of ABCstroke pathway adherence to cardiovascular outcomes post stroke, we performed a post-hoc analysis from the Athens Stroke Registry. Methods and resultsThis analysis was performed in the Athens Stroke Registry, which includes all consecutive patients with acute first-ever ischemic stroke. The Kaplan–Meier product limit was used to estimate the cumulative hazard of each outcome according to adherence with the ABCstroke pathway.We studied 2513 patients [median (IQR) age 71 (62–78) years; 37.7 % female] with ischemic stroke with median follow-up period of 30 (6–75) months. Full adherence to the ABC pathway was identified in 156 (6.2 %) of the patients, while 192 (7.6 %) did not adhere to any of the therapeutic pillars of ABCstroke. Full adherence to ABC treatment pathway was associated with significant reduction of stroke recurrence, compared to patients with no or partial adherence (aHR: 0.61; 95 %CI: 0.37–0.99), as well as a lower risk of MACE (HR: 0.59; 0.39–0.88) and death (aHR: 0.22; 95 %CI: 0.12–0.41). ConclusionFull adherence to the ABCstroke pathway based on the current guidelines was evident in only 6.2 % of our ischaemic stroke cohort but was independently associated with lower risks of stroke recurrence, major cardiovascular events and mortality. This highlights a potential opportunity to improve clinical outcomes post-stroke with a holistic or integrated care management approach.

Factors associated with the laterality of Cardio-Embolic stroke

ObjectiveUnderstanding the lateralization factors, including the anatomic and hemodynamic mechanisms, is essential for diagnosing cardio-embolic stroke. This study aims to investigate the elements, for the first time together, that could affect the laterality of stroke. MethodsWe performed a monocentric retrospective case-control study based on prospective registries of acute ischemic stroke patients in the comprehensive stroke center of the RWTH University hospital of Aachen for three years (June 2018–June 2021). We enrolled 222 patients with cardioembolic stroke (136 left stroke and 86 right stroke) admitted for first-ever acute ischemic stroke with unilateral large vessel occlusion of the anterior circulation. The peak systolic velocity (PSV) asymmetry of middle cerebral artery (MCA) was assessed by doppler as well as internal carotid artery (ICA) angle, aortic arch (AA) branching pattern and anatomy were assessed by CT-Angiography. ResultsWe found that the increasing left ICA angle (p = 0.047), presence of bovine type AA anatomy (p = 0.041) as well as slow PSV of the right MCA with a value of >15% than left (p = 0.005) were the predictors for left stroke lateralization, while the latter was an independent predictor for the left stroke (OR=3.341 [1.415–7.887]). Inter-Rater Reliability ranged from moderate to perfect agreement. ConclusionThe predictors for left stroke lateralization include the higher values of left ICA angle, presence of the bovine type AA and the slow right MCA PSV.

Hemorrhagic transformation in patients with large-artery atherosclerotic stroke is associated with the gut microbiota and lipopolysaccharide.

Abstract JOURNAL/nrgr/04.03/01300535-202407000-00032/figure1/v/2023-11-20T171125Z/r/image-tiff Hemorrhagic transformation is a major complication of large-artery atherosclerotic stroke (a major ischemic stroke subtype) that worsens outcomes and increases mortality. Disruption of the gut microbiota is an important feature of stroke, and some specific bacteria and bacterial metabolites may contribute to hemorrhagic transformation pathogenesis. We aimed to investigate the relationship between the gut microbiota and hemorrhagic transformation in large-artery atherosclerotic stroke. An observational retrospective study was conducted. From May 2020 to September 2021, blood and fecal samples were obtained upon admission from 32 patients with first-ever acute ischemic stroke and not undergoing intravenous thrombolysis or endovascular thrombectomy, as well as 16 healthy controls. Patients with stroke who developed hemorrhagic transformation (n = 15) were compared to those who did not develop hemorrhagic transformation (n = 17) and with healthy controls. The gut microbiota was assessed through 16S ribosomal ribonucleic acid sequencing. We also examined key components of the lipopolysaccharide pathway: lipopolysaccharide, lipopolysaccharide-binding protein, and soluble CD14. We observed that bacterial diversity was decreased in both the hemorrhagic transformation and non-hemorrhagic transformation group compared with the healthy controls. The patients with ischemic stroke who developed hemorrhagic transformation exhibited altered gut microbiota composition, in particular an increase in the relative abundance and diversity of members belonging to the Enterobacteriaceae family. Plasma lipopolysaccharide and lipopolysaccharide-binding protein levels were higher in the hemorrhagic transformation group compared with the non-hemorrhagic transformation group. lipopolysaccharide, lipopolysaccharide-binding protein, and soluble CD14 concentrations were associated with increased abundance of Enterobacteriaceae. Next, the role of the gut microbiota in hemorrhagic transformation was evaluated using an experimental stroke rat model. In this model, transplantation of the gut microbiota from hemorrhagic transformation rats into the recipient rats triggered higher plasma levels of lipopolysaccharide, lipopolysaccharide-binding protein, and soluble CD14. Taken together, our findings demonstrate a noticeable change in the gut microbiota and lipopolysaccharide-related inflammatory response in stroke patients with hemorrhagic transformation. This suggests that maintaining a balanced gut microbiota may be an important factor in preventing hemorrhagic transformation after stroke.

Altered dynamic functional network connectivity states in patients with acute basal ganglia ischemic stroke

BackgroundDynamic functional network connectivity (dFNC) patterns are successfully able to capture the time-varying features of intrinsic fluctuations throughout a scan. We explored dFNC alterations across the entire brain in patients with acute ischemic stroke (AIS) of the basal ganglia (BG). MethodResting-state functional magnetic resonance imaging data were acquired from 26 patients with first-ever AIS in the BG and 26 healthy controls (HCs). Independent component analysis, the sliding window method, and the K-means clustering method were used to obtain reoccurring dynamic network connectivity patterns. Moreover, temporal features across diverse dFNC states were compared between the two groups, and the local and global efficiencies across states were analyzed to explore the characteristics of the topological networks among states. ResultsFour dFNC states were characterized for comparison of dynamic brain network connectivity patterns. In contrast to the HC group, the AIS group spent a significantly higher fraction of time in State 1, which is characterized by a relatively weaker brain network connectome. Conversely, compared with HC, patients with AIS showed a lower mean dwell time in State 2, which was characterized by a relatively stronger brain network connectome. Additionally, functional networks exhibited variable efficiency of information transfer across 4 states. ConclusionsAIS not only altered the interaction between the different dynamic networks but also promoted characteristic alterations in the temporal and topological features of large-scale dynamic network connectivity.

No evidence of oligoclonal bands, intrathecal immunoglobulin synthesis and B cell recruitment in acute ischemic stroke.

Within the past 10 years, immune mechanisms associated with acute ischemic stroke (AIS) have been brought into focus, but data on B cell activation and intrathecal Ig production is still scarce. In this study, we determined the prevalence of an elevated IgG index, positive oligoclonal bands (OCBs) and chemokine C-X-C motif ligand 13 (CXCL13) levels in the cerebrospinal fluid (CSF) as markers of intrathecal IgG synthesis and B cell activation in patients with AIS. In a retrospective study we analyzed the cerebrospinal fluid (CSF) from 212 patients with AIS from December 2013 to May 2018 assessing intrathecal Ig synthesis, OCBs and CXCL13 concentrations. Overall, 5.7% (12/212) of AIS patients showed an intrathecal IgG synthesis, 0.5% (1/212) with isolated elevated IgG index, 5.2% (7/136) isolated positive OCBs and 2.9% (4/136) both elevated IgG index and positive OCBs. CXCL13 levels were elevated in 3.6% (3/83) of the patients. Approximately one third of these patients had simultaneously chronic inflammatory CNS disease (multiple sclerosis, neuromyelitis optica spectrum disorder, neurosarcoidosis). There was no significant association between CSF findings and stroke characteristics including vascular territory, localization, volume, etiology, acute treatment, or blood-brain barrier dysfunction. Intrathecal IgG synthesis was more common in patients with prior stroke. Longitudinal CSF analysis did not reveal any newly-occurring, but instead mostly persistent or even disappearing intrathecal IgG synthesis after AIS. We found no evidence of a relevant B cell recruitment and intrathecal IgG synthesis in patients with AIS. In fact, the occurrence of intrathecal IgG synthesis was associated with concurrent chronic inflammatory CNS disease or previous stroke. Consequently, in patients with first-ever AIS and intrathecal IgG synthesis, physicians should search for concomitant inflammatory CNS disease.

Impact of prestroke physical activity and citalopram treatment on poststroke depressive symptoms: a secondary analysis of data from the TALOS randomised controlled trial in Denmark

ObjectivesTo investigate the association between prestroke physical activity and depressive symptoms up to 6 months after stroke and examine if citalopram treatment modified the association.DesignA secondary analysis of data from...

Abstract WMP50: Lesion-symptom Mapping For Post-stroke Depression

Background: Post-stroke depression poses an important challenge for patients and delays reintegration to societal roles. Earlier identification of patients at higher risk for depression based on clinical imaging would allow a tailored treatment approach. Methods: We conducted machine-learning based lesion-symptom mapping (LSM) using a retrospective cohort of 477 patients with first-ever acute ischemic stroke (AIS) presenting to a large cerebrovascular center from 2013-2019 with mild motor impairment defined by mRS 0-2. Patient Health Questionnaire (PHQ-9) depression scale was collected within 60 days of index stroke. The location and volume of AIS lesions on brain MRI were analyzed using a machine-learning based algorithm coupled with the FreeSurfer parcellation package. LSM after random field theory-based multiple comparison correction was conducted to examine the association of AIS location and volume with PHQ-9 scale, adjusting for patient age, sex and NIHSS. Results: AIS in the right temporal, parietal, occipital lobes and the right basal ganglia were associated with depressive symptoms (Figure A). Sensitivity analysis excluding those with significant sleep disturbance (n=24) demonstrated that strokes in the right frontal and parietal lobes were associated with severe depression measured by PHQ-9&gt;10 (Figure B). Conclusions: This hypothesis generating study was suggestive of a neuroanatomic basis for the development of post-stroke depression. Further studies in a larger dataset are needed to confirm these associations. The methods will help to predict those patients at higher risk for post-stroke depression, allowing for earlier intervention and recovery.

The Frequency of Ischemic Stroke Associated with Atrial Fibrillation at a Tertiary Care Hospital

Acute ischemic stroke is most commonly associated with atrial fibrillation. However, its prognostic impact on patients with acute cerebrovascular accidents is not fully clarified. Stroke associated with AF is associated with the worst outcome as compared to without atrial fibrillation. Atrial fibrillation is present in 20–30% of patients affected by stroke. Also, in Pakistan the prevalence of atrial fibrillation with ischemic stroke patients is still unknown. Objective: To determine the association of atrial fibrillation with acute ischemic stroke. Material &amp; methods: This cross-sectional analytical study was conducted at Neurology ward of Aga Khan University Hospital, Karachi, over eight months from 19th May 2020 to 18th December 2020. A total of two hundred sixteen patients who were admitted with the diagnosis of ischemic stroke were included in the study. Results: The 216 patients with first-ever acute ischemic stroke for more than 24 hours, age range between 30 and 80 years, both male and female were included in the study. The mean systolic blood pressure SBP and diastolic blood pressure DBP was 132.64±17.68 &amp; 84.45±15.01 &amp; mean duration of diabetes mellitus in new onset ischemic stroke patients was 11.1±6.61years male outnumbered females, with 78(36%) women and 138(64%) men. Conclusion: In summary, it was found that incidence of atrial fibrillation with ischemic stroke is most common among Pakistani population. Bangladesh Journal of Medical Science Vol. 22 No. 01 January’23 Page : 91-96

Cerebellar antibodies in post-stroke sera of acute ischemic stroke patients

<p>Although serum anti-neuronal antibodies are found in acute ischemic stroke (AIS) patients, it is not completely clear whether they are already present before the cerebrovascular event or emerge thereafter.&nbsp;</p>. <p>Sera of 21 consecutive first-ever AIS patients were collected within the first day of AIS (baseline), as well as 1 and 6 months after AIS. Well-characterized and novel anti-neuronal antibodies were investigated by cell-based assays, immunoblotting and indirect immunohistochemistry.</p>. <p>None of the AIS sera collected at different time points showed well-characterized antibodies. In 7 patients, 1- and 6-month sera (but not baseline sera) showed IgG mostly reacting with soma and dendrites of cerebellar Purkinje cells. Antibody-positive patients did not differ in terms of clinical and etiological features.</p>. <p>Our results provide evidence for the antibody-triggering action of AIS. Although anti-cerebellar antibodies are not associated with the severity of stroke, they may potentially contribute to chronic post-stroke complications and disability.</p>.

Evaluation of De Ritis (AST/ALT), ALP/ALT, and AST/ALP ratios as prognostic factors in patients with acute ischemic stroke

BackgroundStroke is one of the leading causes of disability worldwide. Recently, stroke prognosis estimation has received much attention. This study investigates the prognostic role of aspartate transaminase/alanine transaminase (De Ritis, AAR), alkaline phosphatase/alanine transaminase (ALP/ALT), and aspartate transaminase/alkaline phosphatase (AST/ALP) ratios in acute ischemic stroke (AIS).MethodsThis retrospective cohort study involved patients who experienced their first-ever AIS between September 2019 and June 2021. Clinical and laboratory data were collected within the first 24 hours after admission. Functional and mortality outcomes were evaluated 90 days after hospital discharge in clinical follow-up. Functional outcome was assessed by a modified Rankin Scale (mRS). The correlation between the laboratory data and study outcomes was evaluated using univariate analysis. In addition, regression models were developed to evaluate the predictive role of AST/ALP, ALP/ALT, and AAR ratios on the study outcomes.ResultsTwo hundred seventy-seven patients (mean age 69.10 ± 13.55, 53.1% female) were included. According to univariate analysis, there was a weak association between 3-months mRS, and both AST/ALT (r = 0.222, P < 0.001), and AST/ALP (r = 0.164, P = 0.008). Subsequently, higher levels of these ratios and absolute values of AST, ALT, and ALP were reported in deceased patients. Based on regression models adjusted with co-variable (age, gender, underlying disease, and history of smoking) AST/ALT and AST/ALP ratios had a significant independent association with 3-month mRS (CI:1.37-4.52, p = 0.003, and CI: 4.45-11,547.32, p = 0.007, respectively) and mortality (CI: 0.17-1.06, adjusted R2 = 0.21, p = 0.007, and CI: 0.10-2.91, p = 0.035, adjusted R2 = 0.20, respectively).ConclusionsElevated AST/ALP and AAR ratios at admission were correlated with poorer outcomes at 3 months in patients with first-ever AIS. Prospective studies in larger cohorts are required to confirm our findings and to evaluate further whether the AST/ALP and De Ritis ratios may represent a useful tool for determining the prognosis of AIS patients.

Factors Determining Not Returning to Full-Time Work 12 Months After Mild Ischemic Stroke

ObjectiveTo evaluate prevalence and factors determining not returning to full-time work 1 year after first-ever mild ischemic stroke. DesignProspective, observational cohort study with 12-month follow-up. SettingStroke units and outpatient clinics at 2 Norwegian hospitals. ParticipantsWe included 84 (N=84) full-time working, cognitively healthy patients aged 70 years or younger who suffered an acute first-ever mild ischemic stroke, defined as National Institutes of Health Stroke Scale (NIHSS) score ≤3 points. InterventionsNot applicable. Main Outcome MeasuresVascular risk factors, sociodemographic factors, stroke localization, and etiology were recorded at inclusion. Cognitive impairment, anxiety, depression, fatigue, and apathy 12 months after stroke were assessed with validated instruments. Logistic regression analyses were performed to find correlates of not returning to full-time employment. ResultsOf 78 patients assessed 1 year after stroke, 63 (81%) had returned to work, 47 (60%) to full-time employment status. Modified Rankin scale score >1 (adjusted odds ratio, 12.44 [95% confidence interval, 2.37-65.43], P=.003) at follow-up was significantly associated, and diabetes (adjusted odds ratio, 10.56 [95% confidence interval, 0.98-113.47], P=.052) was borderline significantly associated with not returning to full-time work. Female sex, NIHSS at discharge, anxiety per point on the anxiety scale, depression per point on the depression scale, and fatigue per point on the fatigue scale were significantly associated with not returning to full-time work after 1 year, but these associations were only seen in the unadjusted models. ConclusionsLow functional level that persists 12 months after stroke is related to not returning to full-time work. Patients with diabetes mellitus, female patients, and patients with a higher score on fatigue, anxiety, and depression scales may also be at risk of not returning to full-time work post stroke. Working patients should be followed up with a particular focus on factors determining participation in work and social life.

Structural disconnection-based prediction of poststroke depression

Poststroke depression (PSD) is a common complication of stroke. Brain network disruptions caused by stroke are potential biological determinants of PSD but their conclusive roles are unavailable. Our study aimed to identify the strategic structural disconnection (SDC) pattern for PSD at three months poststroke and assess the predictive value of SDC information. Our prospective cohort of 697 first-ever acute ischemic stroke patients were recruited from three hospitals in central China. Sociodemographic, clinical, psychological and neuroimaging data were collected at baseline and depression status was assessed at three months poststroke. Voxel-based disconnection-symptom mapping found that SDCs involving bilateral temporal white matter and posterior corpus callosum, as well as white matter next to bilateral prefrontal cortex and posterior parietal cortex, were associated with PSD. This PSD-specific SDC pattern was used to derive SDC scores for all participants. SDC score was an independent predictor of PSD after adjusting for all imaging and clinical-sociodemographic-psychological covariates (odds ratio, 1.25; 95% confidence interval, 1.07, 1.48; P = 0.006). Split-half replication showed the stability and generalizability of above results. When added to the clinical-sociodemographic-psychological prediction model, SDC score significantly improved the model performance and ranked the highest in terms of predictor importance. In conclusion, a strategic SDC pattern involving multiple lobes bilaterally is identified for PSD at 3 months poststroke. The SDC score is an independent predictor of PSD and may improve the predictive performance of the clinical-sociodemographic-psychological prediction model, providing new evidence for the brain-behavior mechanism and biopsychosocial theory of PSD.

Serum neurofilament light chain levels are correlated with the infarct volume in patients with acute ischemic stroke.

Neurofilament light chains (NfLs) are promising biomarkers of neuroaxonal damage in stroke patients. We investigated the correlations between NfL levels and infarct volume, initial stroke severity, and functional outcomes at discharge in patients with acute ischemic stroke.We prospectively included 15 patients with first-ever acute ischemic stroke and 8 age- and sex-matched healthy controls without other neurological disorders. Serum NfL levels were measured using the single-molecule array (Simoa) technique twice within 24 hours of admission (NfL1D) and on the seventh hospital day (NfL7D) in patients with stroke and once in healthy controls. We assessed the infarct volume on diffusion-weighted magnetic resonance imaging using the free software ITK-SNAP.Serum NfL1D levels in stroke patients were significantly higher (28.4 pg/mL; interquartile range [IQR], 43.0) than in healthy controls (14.5 pg/mL; IQR, 3.2; P = .005). Temporal pattern analyses demonstrated that NfL7D levels were increased (114.0 pg/mL; IQR, 109.6) compared to NfL1D levels in all stroke patients (P = .001). There was a strong correlation between NfL7D levels and infarct volume (R = 0.67, P = .007). The difference between NfL1D and NfL7D (NfLdiff levels) was strongly correlated with the infarct volume (R = 0.63; P = .013). However, there was no statistically significant correlation between NfL levels and the initial stroke severity or functional outcomes at discharge.NfL levels in the subacute stage of stroke and the NfL difference between admission and 7th day of hospital were correlated with infarct volume in patients with acute ischemic stroke.

Cumulative rehospitalizations and implications for subsequent mortality after first-ever ischemic stroke

ABSTRACT Introduction Clinical implications of readmission following initial hospitalization for acute ischemic stroke (AIS) are not known. We examined predictors of readmissions and impact of readmissions on subsequent mortality after first-ever AIS. Materials and methods Adults aged ≥18 years who survived to discharge after hospitalization for first-ever AIS from 2003 to 2019 were included in the study. For each patient, the overall burden of hospitalizations was measured as total number of hospitalizations and aggregate days spent hospitalized during follow-up. We used Poisson regression to estimate incident rate ratios (IRR) for predictors of re-hospitalization and time-dependent Cox regression to estimate hazard ratios (HR) for mortality. Results Of 908 AIS survivors, 537 died, 669 had 2,645 readmissions over 4,535 person-years follow-up. Adjusted independent predictors of cumulative readmission inlcuded being white (IRR 1.21, 95% CI 1.03–1.42), dependency on discharge (IRR 1.27, 95% CI 1.17–1.38), cardio-embolism (IRR 1.35, 95% CI 1.18–1.45), smoking (IRR 1.21, 95% CI 1.08–1.35), anemia (IRR 1.40, 95% CI 1.24–1.57), arthritis (IRR 1.20, 95% CI 1.10–1.31), coronary artery disease (IRR 1.34, 95% CI 1.23–1.47), cancer (IRR 1.96, 95% CI 1.64–2.30), chronic kidney disease (IRR 1.36, 95% CI 1.21–1.57), COPD (IRR 1.18, 95% CI 1.04–1.34), depression (IRR 1.50, 95% CI 1.37–1.66), diabetes mellitus (IRR 1.48, 95% CI 1.36–1.48), and heart failure (IRR 1.17, 95% CI 1.03–1.34). Conversely, hyperlipidemia was associated with a lower risk of readmission (IRR 0.79, 95% CI 0.71–0.88). Mortality was significantly increased with each hospitalization and cumulative days spent in hospital. Conclusions Among survivors of AIS hospitalization, certain sociodemographic indicators, stroke-specific features, and several key comorbid conditions were associated with increased risk of readmissions, which in turn correlated with increased mortality. Therefore, lifestyle modification and optimal treatment of comorbidities are likely to improve the outcome after AIS.