First-ever Stroke Patients Research Articles

Acute Care, Secondary Prevention, and Outcomes after Ischaemic and Haemorrhagic Stroke in Men and Women: A Data-Linkage Study.

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. This is a retrospective, population-based, data-linkage study of stroke admissions to acute care hospitals in Scotland between January 1, 2011, and December 31, 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 1 year after index event. This study included 5,901 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 90 days after discharge to the usual place of residence (aOR, 0.78; 95% CI, 0.63-0.97). 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 after discharge. The risk of all-cause mortality was lower in women at 1 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. 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 a reduced risk of all-cause mortality after both ICH and AIS.

Investigating the link between antipsychotic use and post-stroke infections in older people: multi-centre propensity score analysis.

The risk of stroke increases with age, and although previous reports have suggested that infection risk may increase with antipsychotic use, relevant studies after stroke are scarce. We aimed to investigate whether antipsychotics increase post-stroke infection risk in the acute stroke period. This propensity score matching study included adults diagnosed with first-ever stroke between 2011 and 2020 at five university hospitals. In-hospital antipsychotic exposure was defined as any administration during hospitalisation for stroke. The primary outcome was post-stroke infection after the first 2 days of hospitalisation, and the secondary outcome was the presence of pneumonia, bacteraemia and/or bacteriuria. Among 23,885 first-ever stroke patients, 2,773 antipsychotic users (age 71.6 ± 12.4, male 54.6%) and 2,773 non-users (age 71.2 ± 13.2, male 54.6%) were selected as matched cohorts. After adjusting for propensity score, antipsychotics were not associated with an increased risk of post-stroke infection (odds ratio 0.99, 95% confidence interval 0.87-1.14). While our study did not find conclusive evidence linking antipsychotic medication to an increased risk of post-stroke infection, prescribing these medications should still be approached with prudence. Until further research can provide more definitive insights, clinicians should carefully weigh the potential infection risks when considering antipsychotic treatment during the acute stroke care period.

Sex Differences in Trends in Stroke Recurrence and Postrecurrence Mortality 2000-2020: Population-Based Brain Attack Surveillance in Corpus Christi Project.

This study was undertaken to delineate 21-year sex-specific trends in recurrence and postrecurrence mortality. Between 2000 and 2020, first-ever ischemic stroke (IS) patients, ascertained from the population-based BASIC (Brain Attack Surveillance in Corpus Christi) project in South Texas, were followed for recurrent stroke and all-cause mortality until December 31, 2020. Multivariable regression models with an interaction between calendar year and sex were used to estimate sex-specific trends and sex differences in recurrence and postrecurrence mortality. Of the 6,057 IS patients (median age = 69 years, 49.8% women), 654 (10.8%) had a recurrence and 399 (47.7%) had postrecurrence mortality during 5 years of follow-up. In 2000, women had 2.5% higher albeit non-statistically significant 5-year risk of recurrence than men in absolute scale. With the trend declining in women by 7.6% (95% confidence interval [CI] = -10.8 to -4.5%) and in men by 3.6% (95% CI = -6.5% to -0.7%), the risk at the end of the study period was 1.5% (95% CI = -0.3% to 3.6%) lower among women than men. For postrecurrence mortality, the risk was 10.2% lower among women in 2000, but the sex difference was 3.3% by the end of the period, which was due to a larger overall increase in the risk among women than men over the entire time period. The declines in recurrent stroke suggest successful secondary stroke prevention, especially in women. However, the continued high postrecurrence mortality among both sexes at the end of study period emphasizes the need for ongoing interventions to improve prognosis in those who have had recurrent cerebrovascular events. ANN NEUROL 2024;96:332-342.

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.

Toe Grip Strength Is Associated with Improving Gait Function in Patients with Subacute Stroke.

Toe grip strength has recently been suggested to play an essential role in maintaining balance and postural stability for ambulatory function in older populations. This study aimed to investigate its association with improving gait function three months after onset in patients with subacute stroke. This longitudinal cohort study included 98 first-ever stroke patients (67 ± 9 years, 56% female) within one month from the onset who could not ambulate independently. Functional outcome indicators, including toe grip strength, hand grip strength, knee extensor strength, Fugl-Meyer Assessment of Lower Extremity (FMA_LE), and the Postural Assessment Scale for Stroke (PASS), were assessed before and three months after the intervention. We analyzed the correlation between participants' gait function using a 10-meter walk test time and various functional indicators. Then, multiple linear regression analysis was used to investigate whether toe grip strength was related to the improvement of gait function. Correlation analysis revealed a significant positive correlation between the 10MWT time and toe grip strength ratio (affected/unaffected side), with a moderate effect size (r = -0.61, p <0.001). Multiple regression analysis with covariates showed a significant relationship between 10MWT time and toe grip strength ratio (β = -0.113, p < 0.001), FMA_LE (β = -1.315, p = 0.004), PASS (β = -3.275, p <0.001), and age (β = -0.159, p = 0.004). In conclusion, toe grip strength was an essential factor associated with ambulatory function improvement in subacute stroke patients three months after onset. Additional toe grip muscle strengthening rehabilitation treatment can be expected to help improve the ambulatory function of subacute stroke patients in the future.

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.

Association of covert brain infarct phenotype with stroke recurrence in first-ever manifest ischemic stroke according to etiology.

Covert brain infarcts (CBI) are frequent incidental findings on MRI and associated with future stroke risk in patients without a history of clinically evident cerebrovascular events. However, the prognostic value of CBI in first-ever ischemic stroke patients is unclear and previous studies did not report on different etiological stroke subtypes. We aimed to test CBI phenotypes and their association with stroke recurrence in first-ever ischemic stroke patients according to stroke etiology. This study is a pooled data analysis of two prospectively collected cohorts of consecutive first-ever ischemic stroke patients admitted to the comprehensive stroke centers of Bern (Switzerland) and Graz (Austria). CBI phenotypes were identified on brain MRI within 72 h after admission. All patients underwent a routine follow-up (median: 12 months) to identify stroke recurrence. Of 1577 consecutive ischemic stroke patients (median age: 71 years), 691 patients showed CBI on brain MRI (44%) and 88 patients had a recurrent ischemic stroke (6%). Baseline CBI were associated with stroke recurrence in multivariable analysis (HR 1.9, 95% CI 1.1-3.3). CBI phenotypes with the highest risk for stroke recurrence were cavitatory CBI in small vessel disease (SVD)-related stroke (HR 7.1, 95% CI 1.6-12.6) and cortical CBI in patients with atrial fibrillation (HR 3.0, 95% CI 1.1-8.1). This study reports a ≈ 2-fold increased risk for stroke recurrence in first-ever ischemic stroke patients with CBI. The risk of recurrent stroke was highest in patients with cavitatory CBI in SVD-related stroke and cortical CBI in patients with atrial fibrillation.Subject terms: Covert brain infarcts, stroke.

Disconnection-Based Prediction of Poststroke Dysphagia.

Dysphagia is a common deficit after a stroke and is associated with serious complications. It is not yet fully clear which brain regions are directly related to swallowing. Previous lesion symptom mapping studies may have overlooked structural disconnections that could be responsible for poststroke dysphagia. Here, we aimed to predict and explain the relationship between poststroke dysphagia and the topologic distribution of structural disconnection via a multivariate predictive framework. We enrolled first-ever ischemic stroke patients classified as full per-oral nutrition (71 patients) and nonoral nutrition necessary (43 patients). After propensity score matching, 43 patients for each group were enrolled (full per-oral nutrition group with 17 women, 68 ± 15 years; nonoral nutrition necessary group with 13 women, 75 ± 11 years). The structural disconnectome was estimated by using the lesion segmented from acute phase diffusion-weighted images. The prediction of poststroke dysphagia by using the structural disconnectome and demographics was performed in a leave-one-out manner. Using both direct and indirect disconnection matrices of the motor network, the disconnectome-based prediction model could predict poststroke dysphagia above the level of chance (accuracy = 68.6%, permutation P = .001). When combined with demographic data, the classification accuracy reached 72.1%. The edges connecting the right insula and left motor strip were the most informative in prediction. Poststroke dysphagia could be predicted by using the structural disconnectome derived from acute phase diffusion-weighted images. Specifically, the direct and indirect disconnection within the motor network was the most informative in predicting poststroke dysphagia.

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

ObjectiveTo investigate the occurrence of post-stroke cognitive impairment (PSCI) and its influencing factors in convalescent young patients with first-ever stroke. MethodsA total of 300 first-ever young stroke patients (age ≤45 years) were collected. The Mini-Mental State Examination (MMSE) was used to assess the cognitive status. The sociodemographic data, clinical symptoms, social environment, and behavior-related information were collected and analyzed. ResultsThe incidence of PSCI in young stroke patients was 62.33 %. Through univariate analysis, there were statistical differences in different levels of education, smoking status and hypertension (P < 0.05). With subsequently multivariate logistic regression analysis, it was found that junior high school (OR=8.58,95 %CI:2.25∼32.70) and high school (OR=10.50,95 %CI:2.69∼41.00) education levels, lesion volume >3.00 cm3 (OR=8.03,95 %CI:2.28∼28.36), stroke in the frontal-parietal-temporal region (OR=7.26,95 %CI:1.58∼33.40) and the basal ganglia area (OR=6.13,95 %CI:1.24∼30.43), high NIHSS score (OR=1.17,95 %CI: 1.06∼1.29), and high diastolic blood pressure variability coefficient (OR=1.43,95 %CI: 1.02∼2.01) were risk factors for PSCI. Meanwhile, 24≤BMI<28 (OR=0.06,95 %CI:0.02∼0.23) and BMI<24 (OR=0.18,95 %CI:0.06∼0.53), hospitalization cost >20,000/month (OR=0.22,95 %CI:0.09∼0.56), and stroke onset in spring and summer (OR=0.37,95 %CI:0.14∼0.96) were protective factors. ConclusionThe incidence of PSCI is relatively high in young stroke patients. Junior high and high school education, stroke lesions >3.00cm3, strokes in the frontal-parietal-temporal and basal ganglia regions, high NIHSS scores, and high DBPV are risk factors for PSCI in young stroke patients. Meanwhile, BMI<28, treatment cost >20,000/month, and stroke onset in spring and summer are protective factors for PSCI in young stroke patients.

Prognostic factors of first-ever stroke patients in suburban Malaysia by comparing regression models

&lt;b&gt;Introduction:&lt;/b&gt; The aim of this study was to compare regression models based on the parameter estimates of prognostic factors of mortality in first-ever stroke patients.&lt;br /&gt; &lt;b&gt;Methods:&lt;/b&gt; A retrospective study among 432 first-ever stroke patients admitted to Hospital Universiti Sains Malaysia, Kelantan, Malaysia, was carried out. Patient’s medical records were extracted using a standardized data collection sheet. The statistical analyses used for modelling the prognostic factors of mortality were Cox proportional hazards regression, multinomial logistic regression, and multiple logistic regression.&lt;br /&gt; &lt;b&gt;Results:&lt;/b&gt; A total of 101 (23.4%) events of death were identified and 331 patients (76.6%) were alive. Despite using three different statistical analyses, the results were very similar in terms of five major aspects of parameter estimates, namely direction, estimation, precision, significance, and magnitude of risk assessment. It was reported slightly better in Cox proportional hazards regression model, especially in terms of the precision of the results.&lt;br /&gt; &lt;b&gt;Conclusions:&lt;/b&gt; Given that this study had compared the findings from three different types of advanced statistical methods, this research has clearly yielded that with data of high quality, the selection of appropriate statistical method should not be a worrisome problem for researchers who may not be of expertise in the field of medical statistics.

Associations of C-reactive protein with depressive symptoms over time after mild to moderate ischemic stroke in the PROSCIS-B cohort

Background and purposeC-reactive protein serves as a marker of inflammation and is linked to depression in the general population. We aimed to assess whether elevated baseline levels of high-sensitivity C-reactive protein (hs-CRP) are associated with depressive symptoms over time in a prospective cohort of mild-to-moderate first-ever ischemic stroke patients.MethodsData were obtained from the Prospective Cohort with Incident Stroke Berlin (NCT01363856). Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale (CES-D) at three annual follow-up points. We assessed the association of elevated levels of hs-CRP with CES-D scores over time via linear mixed models. In a subgroup analysis, we explored an interaction effect with sex.ResultsWe included 585 ischemic stroke patients with baseline data on CRP levels. The mean age was 67 (13 SD), 39% (n = 226) were female, and the median National Institutes of Health Stroke Scale (NIHSS) was 3 (IQR 1–4). Twenty percent of survivors showed evidence for depressive symptoms one year after stroke with CES-D ≥ 16, 21% at year two, and 17% at year three. Higher log-transformed baseline hs-CRP levels were associated with higher CES-D Scores over time in the adjusted linear mixed model (β = 1.28; (95% CI 0.22–2.34)). The subgroup analysis revealed an interaction effect of hs-CRP on depressive symptoms in women (β = 2.33; (95% CI 0.71–3.95)).ConclusionIn our cohort with mild-to-moderate first-ever ischemic stroke patients, hs-CRP levels were associated with more depressive symptoms over time, with an interaction effect for the female sex.Study registrationhttps://clinicaltrials.gov; Unique identifier: NCT01363856.

Increased brain activation and functional connectivity after working memory training in patients with ischemic stroke: an fMRI study

ObjectiveWorking memory (WM) impairment is common in patients after a stroke. WM training (WMT) has been suggested as a way to improve cognitive function. However, the neural effects following WMT in stroke patients remain largely unclear. This study aimed to explore the behavioral changes and neural effects of WMT on patients with chronic ischemic stroke.MethodsFifty first-ever ischemic stroke patients with WM deficits in the chronic stage were randomly assigned to either a 4-week WMT group or a control group. Verbal n-back, digital and spatial memory-span, Raven's standard progressive matrices, and the Stroop color-word test, as well as task-state and resting-state fMRI were assessed for all patients at baseline and after the intervention.ResultsThe WMT group showed improvements in WM, fluid intelligence, and attention after training. Additionally, the WMT group exhibited increased activation in the left middle frontal gyrus (MFG) and middle occipital gyrus after training. At baseline, all patients were impaired in their abilities to elevate activation in their WM network as a response to increasing WM load. However, in the WMT group, increased activation was observed in the left cerebellum anterior lobe, right cerebellum posterior lobe (CPL), and MFG in the 2-back vs. 1-back contrast after WMT. We also found increased functional connectivity between the left MFG and the left inferior parietal lobule (IPL), and between the bilateral IPL and the right CPL after training in the WMT group.ConclusionOur study supported that WMT potentially improved WM capacity in ischemic stroke patients during the chronic stage, and that the training effects might transfer to fluid intelligence and attention ability. Our results also demonstrated that repeated WMT potentially increased brain activation and resting-state functional connectivity within the WM network in patients with ischemic stroke. These findings provided robust evidence to support WMT as an effective intervention to enhance cognitive rehabilitation and shed light on the functional neuroplasticity mechanism of WMT on cognitive recovery after ischemic stroke.

Risk factors for stroke recurrence in young patients with first-ever ischemic stroke: A meta-analysis.

At present, the incidence rate of ischemic stroke in young people is increasing yearly, and the age of onset is increasingly young. Therefore, primary and secondary prevention of ischemic stroke in young people, especially secondary prevention, is particularly crucial. We aimed to comprehensively evaluate risk factors for stroke recurrence in first-ever young ischemic stroke (YIS) patients. The meta-analysis was used to quantitatively analyze the research results on risk factors for stroke recurrence in first-ever YIS patients both domestically and internationally. Stata12.0 software was used for heterogeneity testing, publication bias analysis, sensitivity analysis, and the calculation of combined odds ratios and 95% confidence intervals. The odds ratio (OR) values of the relationship between hypertension and hyperlipidemia and recurrence of first-ever YIS were 1.54 (1.05-2.26) and 1.12 (1.00-1.25), respectively. The OR values of male sex, type 2 diabetes, smoking, drinking and YIS recurrence were 1.66 (0.98-2.79), 1.01 (0.64-1.59), 1.21 (0.83-1.76), and 1.28 (0.82-2.53), respectively. The relationship between male sex, type 2 diabetes, smoking, drinking and YIS recurrence was ambiguous. Hypertension and hyperlipidemia are important risk factors for stroke recurrence in first-ever YIS patients, and active intervention should be taken.

Stroke Patients' Management During COVID-19 Pandemic: Results from the Sun4Patients Web-Based Registry.

Covid-19 pandemic has influenced stroke care in different ways. Recent reports demonstrated a sharp decline in acute stroke admissions worldwide. Even for patients presented to dedicated healthcare services, management at the acute phase may be sub-optimal. On the other hand, Greece has been praised for the early initiation of restriction measures which were associated with a 'milder' surge of SARS-CoV-2 infection. Methods Data derived from a prospective cohort multicenter registry. The study population consisted of first-ever acute stroke patients, hemorrhagic or ischemic, admitted within 48 hours of symptom onset in seven national healthcare system (NHS) and University hospitals in Greece. Two different time periods have been considered, defined as "before Covid-19" (15/12/2019-15/02/2020) and "during Covid-19" (16/02/2020-15/04-2020) era. Statistical comparisons on acute stroke admission characteristics between the two different time periods have been performed. Results This exploratory analysis of 112 consecutive patients showed a reduction of acute stroke admissions by 40during Covid-19 period. No significant differences were observed regarding stroke severity, risk factor profile and baseline characteristics for patients admitted before and during Covid-19 pandemic period. There is a significant delay between symptom onset to CT scan during Covid-19 era compared to the period before pandemic reached Greece (p=0.03). Conclusions The rate of acute stroke admissions has been reduced by 40% during Covid-19 pandemic. Further research is needed to clarify whether the reduction in stroke volume is actual or not and identifying the reasons underlying the paradox.

A typology of cerebral small vessel disease based on imaging markers

BackgroundLacunes, microbleeds, enlarged perivascular spaces (EPVS), and white matter hyperintensities (WMH) are brain imaging features of cerebral small vessel disease (SVD). Based on these imaging markers, we aimed to identify subtypes of SVD and to evaluate the validity of these markers as part of clinical ratings and as biomarkers for stroke outcome.MethodsIn a cross-sectional study, we examined 1207 first-ever anterior circulation ischemic stroke patients (mean age 69.1 ± 15.4 years; mean NIHSS 5.3 ± 6.8). On acute stroke MRI, we assessed the numbers of lacunes and microbleeds and rated EPVS and deep and periventricular WMH. We used unsupervised learning to cluster patients based on these variables.ResultsWe identified five clusters, of which the last three appeared to represent distinct late stages of SVD. The two largest clusters had no to only mild or moderate WMH and EPVS, respectively, and favorable stroke outcome. The third cluster was characterized by the largest number of lacunes and a likewise favorable outcome. The fourth cluster had the highest age, most pronounced WMH, and poor outcome. Showing the worst outcome, the fifth cluster presented pronounced microbleeds and the most severe SVD burden.ConclusionThe study confirmed the existence of different SVD types with different relationships to stroke outcome. EPVS and WMH were identified as imaging features of presumably early progression. The number of microbleeds and WMH severity appear to be promising biomarkers for distinguishing clinical subgroups. Further understanding of SVD progression might require consideration of refined SVD features, e.g., for EPVS and type of lacunes.

ASSOCIATION BETWEEN A HISTORY OF CHRONIC DISEASES AND AMBULANCE USE AT THE ONSET AMONG FIRST-EVER STROKE PATIENTS. THE SHIGA STROKE AND HEART ATTACK REGISTRY STUDY

Objective: It is essential to immediately call an ambulance and visit the medical institution specializing stroke. This study aimed to examine the differences in ambulance utilization at the onset of stroke, depending on the pre-stroke history of hypertension, diabetes, dyslipidemia, and atrial fibrillation. Design and method: First-ever stroke patients over 20 years old enrolled in part of the Shiga Stroke and Heart Attack Registry, the Shiga Stroke Registry from January 1 to December 31, 2011, were analyzed. A logistic regression analysis was performed using the presence or absence of a history of each disease (hypertension, diabetes, dyslipidemia, atrial fibrillation), the independent variable (with the no history group as the reference group), and ambulance use at the onset of stroke as the dependent variable, and odds ratios (ORs) and 95% confidence intervals (95%Cis) for ambulance use in the no history group as the reference group was calculated. Results: Of the 2054 first-ever stroke patients analyzed, 1212 (59.0%) used an ambulance. The prevalence of each disease (percentage of patients who used an ambulance according to whether they had the disease or not, %) was 45.5% for hypertension (56.3%, 61.3%), diabetes 14.0% (46.7%, 61.0%), dyslipidemia 12.5% (51.0%, 60.2%), and atrial fibrillation 7.3% (68.5%, 58.3%). The multivariate-adjusted odds ratios and 95% confidence intervals for ambulance use at the onset of stroke for each disease were hypertension (ORs and 95% CI: 0.91, 0.73-1.12), diabetes (0.61, 0.45-0.81), and dyslipidemia. (0.90, 0.66-1.21) and atrial fibrillation (1.35, 0.89-2.04). Conclusions: From this regional stroke registry survey, it was not observed that patients with a history of hypertension, diabetes, dyslipidemia, and atrial fibrillation tend to use an ambulance at the onset of a stroke compared with those without it. Our study indicated that patient education regarding appropriate reaction/ response at the stroke onset might not be efficient among patients with chronic diseases, including hypertension. In addition to the information for primary disease control, information on the importance of requesting an ambulance at the onset of a stroke should be provided.

Attempt to Make the Upper-Limb Item of Objective Fugl-Meyer Assessment Using 9-Axis Motion Sensors.

The Fugl-Meyer Assessment (FMA) has been used as a functional assessment of upper-limb function in stroke patients. This study aimed to create a more objective and standardized evaluation based on an FMA of the upper-limb items. A total of 30 first-ever stroke patients (65.3 ± 10.3 years old) and 15 healthy participants (35.4 ± 13.4 years old) admitted to Itami Kousei Neurosurgical Hospital were included. A nine-axis motion sensor was attached to the participants, and the joint angles of 17 upper-limb items (excluding fingers) and 23 FMA upper-limb items (excluding reflexes and fingers) were measured. From the measurement results, we analyzed the time-series data of each movement and obtained the correlation between the joint angles of each part. Discriminant analysis showed that 17 and 6 items had a concordance rate of ≥80% (80.0~95.6%) and <80% (64.4~75.6%), respectively. In the multiple regression analysis of continuous variables of FMA, a good regression model was obtained to predict the FMA with three to five joint angles. The discriminant analysis for 17 evaluation items suggests the possibility of roughly calculating FMA scores from joint angles.

Association between clinician reported outcome and patient reported outcome measures one year after stroke

ObjectivesPatient reported outcome measures (PROM) are increasingly important in the evaluation of care. In this study we evaluate patient PROM in stroke patients and the association with clinical reported outcomes. Materials and methodsOf 3706 first-ever stroke patients, 1861 were discharged home and invited to fill out PROM at discharge, 90 days and one-year after stroke. PROM include mental and physical health and patients’ self-reported functionals status, all available via International Consortium for Health Outcomes Measurement. Clinician reported measures as NIHSS, Barthel index were collected during hospital admission and modified Rankin Scale (mRS) 90 days after stroke. PROM compliance was evaluated. Clinician reported measures were related to PROM. Results844 (45%) of the invited stroke patients filled out PROM. In general, those patients were younger and less severely affected (higher Barthel index and lower mRS). Compliance after enrolment is about 75%. Barthel index and mRS correlated with all PROM at 90 days and one-year. In age and gender adjusted multiple regression analysis, mRS was a consistent predictor for all PROM subsets, and Barthel index holds predictive value for physical health and patients’ self-reported functional status. ConclusionsParticipation rate to fill out PROM is only 45% among stroke patients who were discharged home, and compliance rate is around 75% up one-year follow-up. PROM associated with the clinician reported functional outcome measures Barthel index, and mRS score. Low mRS score is a consistent predictor of better PROM at one year. We propose to use mRS in stroke care evaluation, until PROM participation improves.

Association Between Serum Vitamin D Levels and Physical Outcomes of Patients Who Underwent Rehabilitation Following Ischemic Stroke.

BACKGROUND Ischemic stroke is the most common cause of disability in adults. Deficiency of vitamin D in patients with cardiovascular diseases is increasing. Only a few studies have assessed the relationship between serum vitamin D levels and functional capacity and degree of disability. This study aimed to evaluate the association between serum vitamin D levels and physical outcomes of 94 patients who underwent physical rehabilitation following ischemic stroke. MATERIAL AND METHODS A group of 94 patients was enrolled; however, 80 patients (61.8±6.9 years) were included. They underwent a 6-week rehabilitation using proprioceptive neuromuscular facilitation (PNF, 60 min daily), mirror therapy (MT, 30 min daily), and occupational therapy (OT, 45 min daily). The Barthel Index (BI) and modified Rankin scale (mRS) were used for functional assessments. Laboratory blood tests for serum vitamin D and insulin-like growth factor 1 (IGF-1) levels were conducted. RESULTS There was a significant increase in BI scores (median difference=2.0 points [pts]; P<0.001) and IGF levels (median difference=124.6 ng/ml; P<0.001) after rehabilitation. There was a significant decrease in mRS scores (median difference=7.0 pts; P<0.001), but there was no significant difference in vitamin D levels (P=0.40). The effect of age (B=-0.01, P=0.04) and serum vitamin D level (B=-0.02, P=0.01) on the BI score was demonstrated. The effect of body mass index (BMI) results (B=-0.07, P=0.02) on the mRS score was observed. CONCLUSIONS Lower serum vitamin D levels and more advanced age may be associated with worse functional outcomes in first-ever ischemic stroke patients.