First-ever Stroke Research Articles

Independent Predictive Value of Elevated YKL-40 in Ischemic Stroke Prognosis: Findings from a Nationwide Stroke Registry

Introduction: Elevated circulatory concentrations of YKL-40 have been reported in patients with ischemic stroke. This study further investigated the association of plasma YKL-40 concentrations at admission and short, long-term prognosis after ischemic stroke. Methods: Based on a prospective, nationwide multicenter registry focusing consecutive patients of ischemic stroke and transient ischemic attack, plasma YKL-40 levels were detected by enzyme-linked immunosorbent assay at admission, and patients were stratified into percentile according to the plasma YKL-40 concentrations. The multivariate Cox or logistic regression model was used to investigate the association of YKL-40 concentration with death and functional outcomes at 3 months, 6 months, and 12 months after ischemic stroke, with potential confounders adjusted. Results: A total of 8,006 first-ever ischemic stroke patients, with the age of 61.7 ± 11.5, were included in this study. The mortality of 0–33%, 34–66%, 67–90%, and 91–100% groups at 12 months follow-up was 0.9%, 2.2%, 4.4%, and 9.4%, respectively (p < 0.0001), and the modified Rankin Scale 3–6 ratio was 6.8%, 10.5%, 15.7%, and 24.0%, respectively (p < 0.0001). In the multivariate regression, after adjusting for potential confounders, 91–100% group had higher risk of death (hazard ratio 2.99, 95% confidence interval 1.75–5.11)and modified Rankin Scale 3–6 (odds ratio 1.42, 95% confidence interval 1.08–1.88) at 12 months since onset of ischemic stroke compared to the 0–33% group. Conclusions: The elevated YKL-40 at admission can potentially help predict death, functional prognosis after ischemic stroke, which may help further studies to explore the potential physiological and pathological mechanism including the effects of vulnerable plaque and collateral circulation.

Assessment of Changes in Serum C-Reactive Protein Levels in Patients after Ischemic Stroke Undergoing Rehabilitation-A Retrospective Observational Study.

Inflammation plays a key role in the pathogenesis and prognosis of ischemic stroke. C-reactive protein (CRP) is an inflammatory biomarker of inflammation and may reflect the progression of vascular disease. Using a biomarker such as CRP to predict recovery rather than mortality may present clinical value in providing rehabilitation. The primary aim of the study was to analyze changes in serum CRP levels in patients after ischemic stroke during the regenerative-compensatory period and to assess the usefulness of CRP as a potential biomarker during the rehabilitation period. The project was carried out as a retrospective analysis of prospectively collected data from post-stroke patients from the Department of Neurological Rehabilitation of the Regional Specialist Hospital in Wrocław. A group of 52 patients, after their first-ever ischemic stroke with subsequent hemiplegia, was finally qualified to participate in the study. Serum CRP levels were determined during blood laboratory tests. The Modified Rankin Scale (mRS) and Barthel Index (BI) were used to assess functional outcomes. Rehabilitation using neurophysiological methods was applied five days a week (each session lasted 60 min, and the entire period was 42 days). At the first test, serum CRP levels were found to be above 5 mg/L in 19 patients, the second test in 12 patients, the third test in five patients, and the fourth test in 9 patients. Only three patients had values higher than 5 mg/L in all consecutive assessments (p > 0.05). There was a statistically significant increase in BI scores after therapy (p < 0.001) as well as a decrease in the mRS score by 2.2 points (p < 0.001), in CRP values by 5.02 mg/L (p = 0.019), and in cortisol levels by 2.5 nmol/L (p = 0.002). Statistically significant relationships were observed between the CRP levels after rehabilitation and the corresponding mRS scores (rs = 0.29, p = 0.038). Furthermore, the effect of BMI on CRP levels was demonstrated (B = 0.20, p = 0.038). In conclusion, despite demonstrating a significant relationship between CRP levels and corresponding mRS scores, CRP levels alone may not serve as an independent predictor of long-term functional outcomes in ischemic stroke patients undergoing rehabilitation.

Sex differences and risk factors in recurrent ischemic stroke.

Recurrent ischemic stroke (RIS) is associated with increased mortality and poor outcomes. Therefore, secondary prevention is critical for reducing the risk of recurrent stroke. Previous studies have found sex differences in risk factors in patients with first-ever stroke; however, the results have been inconsistent for recurrent stroke. Therefore, this study aimed to investigate whether there are significant sex differences in the clinical characteristics and risk factors for recurrent ischemic stroke. We retrospectively studied 787 patients with recurrent ischemic stroke after first-ever stroke confirmation using magnetic resonance imaging (MRI) after visiting a regional tertiary hospital between 2014 and 2020. Demographic characteristics, laboratory findings, and risk factors were compared between the male and female patients. In addition, multivariate logistic regression was performed to identify the independent factors associated with stroke recurrence in male patients. Among the 787 patients, 466 (59.2%) were males. Males were younger than females (67.6 vs. 71.9 years). Females had higher rates of hypertension, diabetes mellitus, dyslipidemia, and overweight than those of males. However, the alcohol drinking and smoking rate were significantly higher in males than that in females. There were no statistically significant sex-based differences in the laboratory findings. Among males, hypertension, alcohol drinking, smoking and dyslipidemia was a significant risk factor for ischemic stroke recurrence. Hypertension and dyslipidemia were significant risk factors of recurrent ischemic stroke in both genders. Smoking and alcohol drinking were significant risk factors associated with ischemic stroke recurrence in males. Therefore, smoking cessation and alcohol abstinence are recommended after the first stroke to prevent recurrent ischemic stroke especially for males. Diabetes was a significant risk factor of ischemic stroke recurrence in females. More extensive studies are needed to understand the causal relationship of each factors with ischemic stroke recurrence according to sex differences and specification of preventive management is needed.

Effect of cyborg-type robot Hybrid Assistive Limb on patients with severe walking disability in acute stroke: A randomized controlled study

ObjectivesTo investigate whether early gait training using Hybrid Assistive Limb (HAL) is feasible and improves walking and independency compared with conventional physical therapy (CPT) in patients with severe walking disability after stroke. MethodsWe conducted a single-center, randomized controlled study. Patients with first-ever stroke who had severe walking disability were included. All patients started gait training within 10 days post-stroke onset. Twenty-four patients were randomly assigned into HAL or CPT groups. Outcome measures were collected at three time points, at baseline, completion of 20 sessions of gait training (second assessment), and 3 months after the initiation of gait training. The primary outcomes were changes in motor sub-scores of the Functional Independence Measure or Functional Ambulation Category at the completion of the second assessment from baseline. ResultsTwenty-two patients (median age, 68 years; 12 patients in the HAL group and 10 patients in the CPT group) completed the study. There were no significant differences in primary outcomes. Apathy scale, one of the secondary outcomes, showed a decreasing trend in the HAL group (mean change of -3.8, 95% CI -8.14 to 0.475), and a slight increasing trend in the CPT group (mean change of 1.2, 95% CI -2.66 to 5.06) at the second assessment. Patients in the HAL group experienced no adverse events. ConclusionsEarly gait training in patients with severe walking disability after stroke using HAL was feasible. Walking ability and independency were not improved at the completion of 20 sessions of gait training.

Benefit of linking hospital resource information and patient-level Stroke Registry data.

Variation in delivery of evidence-based care affects outcomes for patients with stroke. A range of hospital (organizational), patient and clinical factors can affect care delivery. Clinical registries are widely used to monitor stroke care and guide quality improvement efforts within hospitals. However, hospital features are rarely collected. We aimed to explore the influence of hospital resources for stroke, in metropolitan and regional/rural hospitals, on the provision of evidence-based patient care and outcomes. 2017 National Audit organizational survey (Australia) linked with patient-level data from the Australian Stroke Clinical Registry (AuSCR) (2016-2017 admissions). Regression models were used to assess the associations between hospital resources (based on the 2015 Australian National Acute Stroke Services Framework) and patient care (reflective of national guideline recommendations), as well as 90 to 180 day readmissions and health-related quality of life (HRQoL). Models were adjusted for patient factors, including severity of stroke. 52/127 hospitals with organizational survey data were merged with 22,832 AuSCR patients with first-ever stroke/transient ischemic attack (median age 75years; 55% male; 66% ischemic). In metropolitan hospitals (N=42, 20,977 patients; 1,701 thrombolyzed; 2,395 readmitted between 90 and 180 days post stroke), a faster median door-to-needle time for thrombolysis was associated with 500+ annual stroke admissions (-15.9min, 95%CI -27.2,-4.7), annual thrombolysis >20 patients (-20.2min, 95%CI -32.0,-8.3), and having specialist stroke staff (dedicated medical lead and stroke coordinator;-12.7min, 95%CI -25.0,-0.4). A reduced likelihood of all cause readmissions between 90 and 180 days was evident in metropolitan hospitals using care pathways for stroke management (OR 0.82, 95%CI 0.67, 0.99). In regional/rural hospitals (N=10, 1,855 patients), being discharged with a care plan was also associated with use of stroke clinical pathways (OR 3.58, 95%CI 1.45, 8.82). No specific hospital resources influenced 90 to 180-day HRQoL. Relevant to all international registries, integrating information about hospital resources with clinical registry data provides greater insights into factors that influence evidence-based care.

Metabolic Profile as a Predictor of Ischaemic Stroke: The Experience of a Rural Hospital in Nigeria

BACKGROUNDThe metabolic profile which includes glycated haemoglobin, insulin resistance, pancreatic beta cell function and lipid profile is frequently deranged in acute ischaemic stroke. Stroke is a leading cause of death worldwide and an emerging cause of long-term disability and mortality in Africa. Our study aimed to determine the correlation between the metabolic profile and acute ischaemic stroke in a rural Hospital in Southern Nigeria.METHODOLOGYThis was a prospective cross-sectional study. Fifty consecutive first-ever ischaemic stroke patients presenting within 72 hours of stroke were matched for age and sex with 3 control groups (49 persons with type 2 diabetes and hypertension, 49 persons with hypertension only and 57 apparently healthy individuals). Blood samples were obtained from all participants to determine glycated haemoglobin, fasting lipid profile, fasting plasma glucose, fasting insulin and C-peptide and random plasma glucose (in stroke cases at presentation). Insulin resistance and pancreatic beta-cell function were determined using the Homeostatic Model Assessment (HOMA). Data were analysed by multivariate and univariate statistics.RESULTSOne hundred and two (49.8%) males and 103 (50.2%) females participated in the study. The overall mean age of the study participants was 61.6 ± 10.1 years. Compared with the control groups, predictors of acute ischaemic stroke were Fasting insulin (hyperinsulinaemia) [OR (95%CI) = 1.108 (1.043-1.178), p= 0.001], HOMA-β% [OR (95%CI) = 0.994 (0.990-1.001) p=0.006] and total cholesterol [OR (95%CI)= 0.009 (0.001-0.012) p=0.022].CONCLUSIONIn this study, hyperinsulinaemia, impaired beta-cell secretory function (HOMA-β) and elevated total cholesterol were found to be significant risk factors of ischaemic stroke. Hence, the need for regular screening to detect abnormal metabolic profiles and prompt treatment.

Acute right insular ischaemic lesions and poststroke left ventricular dysfunction

IntroductionMyocardial injury related to acute ischaemic stroke is common even without primary cardiac disease. We intended to determine associations between values of left ventricular ejection fraction (LVEF) and ischaemic stroke...

Incidence of post-stroke cognitive impairment in patients with first-ever ischemic stroke: a multicenter cross-sectional study in China

Post-stroke cognitive impairment (PSCI) is a common sequela after stroke. China has a large population of stroke survivors, but a large-scale survey on the incidence and risk factors for PSCI has not been undertaken. We aimed to calculate the incidence and risk factors for vascular cognitive symptoms among first-ever stroke survivors in China through a multicenter cross-sectional study. From May 1, 2019 to November 30, 2019, patients with a clinical diagnosis of first-ever ischemic stroke were recruited from 563 hospitalized-based stroke center networks in 30 provinces of China. Cognitive impairment was measured by 5-min National Institute of Neurological Disease and Stroke-Canadian Stroke Network (NINDS-CSN) at 3-6 months after the indexed stroke. Stepwise multivariate regression and stratified analysis were performed to assess the association between PSCI and demographic variables. A total of 24,055 first-ever ischemic stroke patients were enrolled, with an average age of 70.25±9.88 years. The incidence of PSCI as per the 5-min NINDS-CSN was 78.7%. Age ≥75 years old (OR: 1.887, 95%CI: 1.391-2.559), western regional residence (OR: 1.620, 95%CI: 1.411-1.860) and lower education level were associated with increased PSCI risk. Hypertension might be related to non-PSCI (OR: 0.832, 95%CI: 0.779-0.888). For patients under 45 years old, unemployment was an independent risk factor for PSCI (OR: 6.097, 95%CI: 1.385-26.830). For patients who were residents of the southern region (OR: 1.490, 95%CI: 1.185-1.873) and non-manual workers (OR: 2.122, 95%CI: 1.188-3.792), diabetes was related to PSCI. PSCI is common in Chinese patients with first-ever stroke, and many risk factors are related to the occurrence of PSCI. The Beijing Hospitals Authority Youth Program (No. QMS20200801); Youth Program of the National Natural Science Foundation of China (No. 81801142); the Key Project of Science and Technology Development of China Railway Corporation (No. K2019Z005); The Capital Health Research and Development of Special (No. 2020-2-2014); Science and Technology Innovation 2030-Major Project (No. 2021ZD0201806).

Clinical pharmacist’s contribution to treatment adherence and quality of life in patients with stroke

ABSTRACT Primary objective The optimal treatment adherence rate among patients with stroke is low. This study aims to determine the effect of clinical pharmacists’ intervention on treatment adherence and quality of life (QOL) in patients with first-ever stroke. Research design This open, controlled, prospective and interventional study was conducted sequentially at two different university hospitals for 3 months. Patients in the intervention group (IG) were provided with clinical pharmacist-led education whereas the control group (CG) only received routine care. Methods and procedures Treatment adherence and QOL were assessed on discharge day, and in months 1 and 3 after discharge. Morisky Green Levine Adherence Scale and Stroke Specific Quality of Life Scale were employed to evaluate treatment adherence and QOL, respectively. Main outcomes and results Changes in treatment adherence score were higher between discharge day, 1st and 3rd months after discharge in IG than CG (p < 0.001). Regarding ‘energy’ and ‘work/productivity’ domains, patients’ scores in IG were higher than those from CG at months 1 and 3 after discharge (p < 0.05). Conclusion Clinical pharmacist-led education improves treatment adherence in patients with first-ever stroke. The clinical pharmacist might be integrated into the multidisciplinary team to improve QOL and treatment adherence.

Is the female sex associated with an increased risk for long-term cognitive decline after the first-ever lacunar stroke? Prospective study on small vessel disease cohort.

Sex is a significant determinant of survival and functional outcome after stroke. Long-term cognitive outcome after acute lacunar stroke in the context of sex differences has been rarely reported. A cohort of small vessel disease (SVD) patients presenting with first-ever acute lacunar stroke and normal cognitive status has been evaluated 4 years after the qualifying event for the presence of cognitive impairment (CI) with a comprehensive neuropsychological battery. Differences in baseline clinical and neuroimaging characteristics were compared between sexes in relation to cognitive status. A total of 124 female and 150 male patients were analyzed. No difference was detected between the groups regarding age (p = 0.932) or frequency of common vascular risk factors (p > 0.1 for all). At the baseline assessment, women had more disabilities compared to men with a mean modified Rankin scale (mRS) score of 2.5 (1.5 in men, p < 0.0001). Scores of white matter hyperintensities (WMH) of presumed vascular origin and a total number of lacunes of presumed vascular origin on brain MRI were higher in women compared to men (p < 0.0001 for all). As many as 64.6% of patients had CI of any severity on follow-up, women more frequently (77.4%) than men (54.0%; p < 0.0001). Univariate logistic regression analysis showed that female sex, higher NIHSS and mRS scores, presence of depression, and increasing WMH severity were associated with an increased risk for CI. Multivariate regression analysis indicated that only depression (OR 1.74, 95%CI 1.25-2.44; p = 0.001) and WMH severity (OR 1.10, 95%CI 1.03-1.17; p = 0.004) were independently associated with the CI. At the long-term follow-up, women lacunar stroke survivors, compared to men, more frequently had CI in the presence of more severe vascular brain lesions, but this association was dependent on the occurrence of depression and severity of WMH, and could not be explained by differences in common vascular risk factors.

Effects of blood pressure unawareness and poor adherence to antihypertensive drugs on outcomes of cerebrovascular accidents among patients with their first-ever stroke.

Our main target was to investigate the relationship of blood pressure (BP) unawareness and poor antihypertensive drug adherence with the clinical outcomes of the stroke including hospitalization time, degree of disability, and mortality rate. In this cross-sectional study, we evaluated 530 eligible patients (male = 313; female = 217), aged 18 years and older who had a proven diagnosis of nontraumatic first-ever stroke and were referred to the Shahid Beheshti Hospital of Hamadan, Iran, during the period from March 2019 to September 2021. The prevalence of BP unawareness was 19.6%, and 31.8% of antihypertensive drug users (14.3% of all studied population) had poor drug adherence, in which, older age, male gender, marriage, rural residence, and smoking were associated with the lack of appropriate drug adherence. There was no significant difference between patients with diverse stroke types (ischemic or hemorrhagic) from the points of BP awareness and adherence to antihypertensive drugs; nevertheless, patients with a positive history of cardiac diseases had a significantly higher awareness of their BP status ( P = 0.037). BP unawareness was associated with poor clinical prognosis, and could significantly increase stroke mortality ( P = 0.001) and disability ( P < 0.001) rates as well as the duration of hospitalization ( P < 0.001). Moreover, those who survived the stroke (modified Rankin Scale < 6) had the highest odds to be aware of their BP status (adjusted odds ratio [AOR] = 2.380 [95% confidence interval [CI] = 1.39-4.07]). Additionally, nonsmokers (AOR = 7.740), urban residents (AOR = 3.314), and literate patients (AOR = 2.092) had the highest odds of having appropriate drug adherence. Stroke mortality and morbidity rates can be significantly modified by persuading people to monitor their BP regularly and maximize antihypertensive medication adherence. In the meantime, increasing the literacy level in society and reducing the smoking rate can play important roles in achieving these goals.

Family resilience and its predictors among patients with a first-ever stroke one month after stroke: a cross-sectional study

ABSTRACT Background Understanding post-stroke family resilience would be helpful for healthcare professionals in planning interventions to facilitate family adaptation following stroke onset. Objective To investigate the level of family resilience and its predictors among patients with the first stroke. Design An explorative cross-sectional study. Methods The study was conducted on 288 first stroke patients recruited from 7 tertiary hospitals in China between July 2020 and October 2020, and they were followed up one month after stroke. Data were collected using the Medical Coping Modes Questionnaire, Self-efficacy for Managing Chronic Disease 6-item Scale, shortened Chinese version of Family Resilience Assessment Scale, and the Social Support Rating Scale. The predictive variables of family resilience were investigated using hierarchical regression analyses. Results A total of 255 patients finished the survey with a response rate of 88.5%. The mean score of family resilience was 96.19 (SD = 9.87), highest in the dimension of maintaining a positive outlook and lowest in utilizing social resources. Patient subjective support (β = 0.22, P = 0.004), social support utilization (β = 0.13, P = 0.027), self-efficacy for managing disease (β = 0.27, P < 0.001), marriage status (divorced vs married)(β=-0.18, P = 0.002), and caregivers’ relationship with patients (siblings vs spouse)(β=-0.18, P = 0.002) were predictors of family resilience. Conclusion Family resilience was low among stroke patients one month after the onset. Special attention should be paid to families of patients who were divorced, cared for by siblings, or have low social support or self-efficacy in managing stroke. Further research on family-based interventions may focus on increasing patient social support and promoting their self-efficacy in managing stroke.

Clinical characteristics of persistent headaches after the first-ever ischemic stroke (follow-up of 529 patients)

Background. Although persistent headaches are a common post-stroke pain syndrome, the epidemiology and clinical features of persistent headache after first-ever ischemic stroke have not been considered previously. There is no exact data on how often headache attributed to stroke persists for more than 3 months, i.e. meets the criteria for persistent headache after stroke and what are their distinctive clinical features. The tasks of our study were: to analyze the occurrence/incidence of persistent headaches after the first-ever ischemic stroke; to determine clinical characteristics and types of persistent headaches in comparison with headaches at the onset of stroke.&#x0D; Materials and methods. The study included 550 patients (mean age 63.1 years, 54% men) with first-ever ischemic stroke, of which 529 patients were followed up for at least three months after the stroke. Standardized semi-structured interview forms were used to assess these headaches during professional face-to-face interviews at the onset of stroke and 3 months after the stroke using telephone interview by neurologist.&#x0D; Results. Among 529 follow up patients 55 (10.4%) had persistent headaches after first-ever ischemic stroke. Among these 55 patients 34 patients had persistent new-type headaches which arose for the first time during the onset of stroke, they included predominated migraine-like headaches (n=20), tension-type-like headaches (n=9) and thunderclap-like headaches (n=5). 21 patients had persistent headaches with altered characteristics: predominated tension-type-like headaches (n=16), and less common migraine-like headaches (n=5). Persistent headaches after stroke had the following characteristics compared to headaches at onset of stroke: severe headache intensity, a gradual decrease of occurrence of accompanying symptoms (photo- and phonophobia; p=0.03), the transition of unilateral headaches in bilateral (p=0.004), the presence of headaches 15 days per month in 30.9% of the patients.&#x0D; Conclusion. Persistent post-stroke headaches represent a persistent pain syndrome with severe intensity and frequency of attacks, which requires their further study and creation of guidelines for their management.

Risk factors for multiple recurrent ischemic strokes.

Cardiovascular diseases, hypertension, diabetes mellitus, dyslipidemia, and atrial fibrillation are the most common modifiable risk factors for recurrent ischemic stroke. In this study, we aimed to find the risk factors associated with more than two recurrent ischemic strokes after the first-ever stroke. We collected the ischemic stroke patients in our stroke registry data bank, and the eligible patients were followed for recurrent ischemic stroke after 2008. Our study consisted of 927 patients who were followed up for 9 years after the first-ever stroke. We found that 185 (20%) patients had a recurrent ischemic stroke, and another 32 (3.5%) patients had more than one recurrence after the first-ever ischemic stroke. The mean time for the first stroke recurrence was 1 year, and the mean time for the multiple stroke recurrences was 3 years. Significant risk factors for multiple recurrences were congestive heart disease (P < 0.015) and diabetes mellitus (P < 0.006). We concluded that even with the appropriate treatments, patients with congestive heart disease and diabetes mellitus have a higher rate of multiple recurrences for ischemic stroke after the first-ever ischemic stroke, indicating that more attention should be paid to this issue.

Thyroid stimulating hormone correlates with triglyceride levels but is not associated with the severity of acute ischemic stroke in patients with euthyroidism: a cross-sectional study.

Growing evidence suggests an association between thyroid stimulating hormone (TSH) and severity of acute ischemic stroke (AIS). However, few studies have ruled out the potential influences of abnormal thyroid hormones when assessing this association. This study aimed to investigate the association between TSH levels and the severity of AIS patients with euthyroidism, and to explore the potential mechanism of TSH on this disease by analyzing the correlation of TSH with lipid profiles. This retrospective study consisted of 345 patients with normal T3 and T4 levels admitted for first-ever cerebral ischemic stroke. Baseline data of participant were collecte. Laboratory data, including serum levels of TSH and lipid profiles were measured in our hospital's clinical laboratory on admission. Stroke severity was recorded using the National Institutes of Health Stroke Scale (NIHSS). Associations between TSH levels and disease severity were analyzed with logistic regression analysis. Correlations between TSH and lipid profiles were analyzed with Spearman's rank correlation analysis. Among the 345 patients with AIS, the median age was 63 years (63±12 years), 106 patients (30.7%) were female, 237 (68.7%) patients were mild-severity and 108 (31.3%) patients were severity. Data analysis showed that higher serum TSH levels were associated with the mild severity of patients with AIS (P=0.042 in Kruskal-Wallis test, P=0.025 in logistic regression analysis, and P=0.044 in multiple logistic regression), but not in AIS patients with euthyroidism (P=0.078, P=0.337, respectively). Furthermore, TSH levels were correlated with triglycerides (TG) levels not only in total patients (r=0.135, P=0.012) but also in the patients with euthyroidism (r=0.133, P=0.018). TSH levels are associated with the severity of AIS patients, but not in patients with euthyroidism, predicting that stratified management of TSH may be beneficial in patients with AIS. Moreover, TSH levels are correlated with TG levels in patients with AIS.

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

Stroke lesion size – Still a useful biomarker for stroke severity and outcome in times of high-dimensional models

BackgroundThe volumetric size of a brain lesion is a frequently used stroke biomarker. It stands out among most imaging biomarkers for being a one-dimensional variable that is applicable in simple statistical models. In times of machine learning algorithms, the question arises of whether such a simple variable is still useful, or whether high-dimensional models on spatial lesion information are superior. MethodsWe included 753 first-ever anterior circulation ischemic stroke patients (age 68.4±15.2 years; NIHSS at 24 h 4.4±5.1; modified Rankin Scale (mRS) at 3-months median[IQR] 1[0.75;3]) and traced lesions on diffusion-weighted MRI. In an out-of-sample model validation scheme, we predicted stroke severity as measured by NIHSS 24 h and functional stroke outcome as measured by mRS at 3 months either from spatial lesion features or lesion size. ResultsFor stroke severity, the best regression model based on lesion size performed significantly above chance (p < 0.0001) with R2 = 0.322, but models with spatial lesion features performed significantly better with R2 = 0.363 (t(752) = 2.889; p = 0.004). For stroke outcome, the best classification model based on lesion size again performed significantly above chance (p < 0.0001) with an accuracy of 62.8%, which was not different from the best model with spatial lesion features (62.6%, p = 0.80). With smaller training data sets of only 150 or 50 patients, the performance of high-dimensional models with spatial lesion features decreased up to the point of being equivalent or even inferior to models trained on lesion size. The combination of lesion size and spatial lesion features in one model did not improve predictions. ConclusionsLesion size is a decent biomarker for stroke outcome and severity that is slightly inferior to spatial lesion features but is particularly suited in studies with small samples. When low-dimensional models are desired, lesion size provides a viable proxy biomarker for spatial lesion features, whereas high-precision prediction models in personalised prognostic medicine should operate with high-dimensional spatial imaging features in large samples.

Investigating the Impact of Voice Impairment on Quality of Life in Stroke Patients: The Voice Handicap Index (VHI) Questionnaire Study.

The Voice Handicap Index (VHI) is a patient-centered evaluation tool specifically designed for assessing voice-related quality of life. Although the VHI has been extensively used in patients with voice disorders, its applicability in stroke patients has not been fully established. This prospective cross-sectional study aimed to investigate the feasibility of using the VHI questionnaire in identifying stroke patients with voice problems. The study included a cohort of acute to subacute first-ever stroke patients (n = 48), with or without voice problems, as well as other non-stroke patients (n = 31) who agreed to complete the VHI questionnaire. Stroke patients with self-reported voice problems demonstrated significantly higher VHI scores and poorer life quality scores compared to the control groups. These patients also had lower Mini-Mental State Examination (MMSE), Modified Barthel Index (MBI), and Euro-QoL-5D-5L (EQ-5D-5L) scores. Spearman correlation analysis revealed an inverse association between VHI scores and EQ-5D-5L (rho = -0.77, p < 0.001), Korean Mann Assessment of Swallowing Ability (rho = -0.51, p < 0.001), and other functional parameters, including the National Institutes of Health Stroke Scale, MMSE, and MBI scores. Multiple regression analysis indicated that the VHI score was the biggest contributing factor to EQ scores. This is the first study to demonstrate that stroke patients with voice problems may experience reduced quality of life, even after controlling for other confounding factors such as dysphagia or neurological deficits. Future studies are needed whether addressing these issues by implementing the VHI may facilitate the improvement of patients' quality of life.

PS-C08-7: TIME IN THERAPEUTIC RANGE IS NOT A RISK FACTOR FOR CARDIOVASCULAR DISEASE WHEN ADJUSTED FOR MEAN SYSTOLIC BLOOD PRESSURE

Background: Time in therapeutic range (TTR) has been suggested as a novel metric to assess blood pressure (BP) control, the quality of antihypertensive therapy, and the risk of cardiovascular events in people with hypertension. Methods: We used a validated electronic health record dataset, including all BP recordings in primary care in two Swedish counties from 1993 to 2011. People were eligible if they were 18 years or older, had a diagnosis of hypertension, no previous cardiovascular events, and at least five BP recordings during the first five years from the date of hypertension diagnosis. TTR was defined as the percentage of BP readings with a systolic value less than 140 mmHg. Participants were followed until death, migration or the 31st of December 2019. The risk of myocardial infarction and stroke was assessed using Cox proportional hazards model with TTR as independent variable, with and without mean systolic BP as a covariate. All analyses were adjusted for age, sex, diabetes, county, income and educational level. Results: 72 724 participants (56% female, mean age 62 years) were included in the analyses. The mean BP level during the first five years after diagnosis was 151/85 mmHg, with a median TTR of 17.7% (interquartile range 0–40%). During an average 7.7 years of follow-up, 6551 participants experienced a first-ever stroke and 5513 a first-ever myocardial infarction. In the unadjusted analyses, the risk of stroke decreased by 7% (HR 0.93, 95%CI 0.92–0.94) and the risk of myocardial infarction decreased by 6% (0.94, 0.93–0.95) for each 10 percentage points increase in TTR. When including mean systolic BP as a covariate, however, TTR was not associated with either stroke (0.99, 0.97–1.01) or myocardial infarction (1.00, 0.99–1.02). Conclusion: TTR for systolic BP is not an independent risk factor for stroke and myocardial infarction in clinical practice and does not add importantly to mean systolic BP as a measure of BP control.

Reliability and validity of DTI-based indirect disconnection measures

White matter connections enable the interaction within and between brain networks. Brain lesions can cause structural disconnections that disrupt networks and thereby cognitive functions supported by them. In recent years, novel methods have been developed to quantify the extent of structural disconnection after focal lesions, using tractography data from healthy controls. These methods, however, are indirect and their reliability and validity have yet to be fully established. In this study, we present our implementation of this approach, in a tool supplemented by uncertainty metrics for the predictions overall and at voxel-level. These metrics give an indication of the reliability and are used to compare predictions with direct measures from patients’ diffusion tensor imaging (DTI) data in a sample of 95 first-ever stroke patients. Results show that, except for small lesions, the tool can predict fiber loss with high reliability and compares well to direct patient DTI estimates. Clinical utility of the method was demonstrated using lesion data from a subset of patients suffering from hemianopia. Both tract-based measures outperformed lesion localization in mapping visual field defects and showed a network consistent with the known anatomy of the visual system. This study offers an important contribution to the validation of structural disconnection mapping. We show that indirect measures of structural disconnection can be a reliable and valid substitute for direct estimations of fiber loss after focal lesions. Moreover, based on these results, we argue that indirect structural disconnection measures may even be preferable to lower-quality single subject diffusion MRI when based on high-quality healthy control datasets.