Higher Stroke Research Articles

Abstract WP96: Historical Redlined Communities Overlap with High Mobile Stroke Call Density-A Geospatial Analysis

Background: We sought to find a relationship between historically redlined communities and mobile stroke unit (MSU) call density using geospatial software. Methods: The Mobile Stroke Treatment Unit of metropolitan Columbus, Ohio, provides emergency stroke care coverage for 325 square miles spanning 47 zip codes. Our MSU is operational from 0700-1900 and is dispatched for all 911 calls designated as probable or definite strokes. We retrospectively reviewed all MSU calls from June 2019 to December 2023. and included all confirmed stroke patients in this analysis. Each call address was geocoded and entered into the ESRI/ArcGIS Online geospatial analysis software. Call addresses were then clustered into hexagonal grids with a distance band of 1 km for hotspot analysis. Statistically significant hotspots were qualitatively defined as clustered grids with high activity and quantitatively defined as having a Gi Bin score > 2, which correlates to statistical confidence > 95%. The hotspots were then overlaid upon an ESRI/ArcGIS pre-loaded historical map of redlined communities in Columbus, Ohio. Results: We received 7442 calls during our study period. Of these calls, 738 were accurately diagnosed as a stroke. Our hotspot analysis identified 9 hexagonal grids as statistical hot spots. Disadvantaged communities in the historical redlined map are depicted as red or yellow (Figure). Seven of the nine hotspots abut or overlap with these communities (Figure). Conclusions: Geographic analysis of MSU data shows that redlined communities persistently remain active areas of stroke prevalence. Geospatial analysis can be used to leverage MSU deployment for these high risk communities.

Factors Relating to Sprint Swimming Performance: A Systematic Review.

Swimming performance depends on a wide variety of factors; however, the interaction between these factors and their importance varies between events. In sprint events, the characterized pacing underlines its specific development, as swimmers must achieve the highest possible speed while sustaining it to the greatest extent possible. The aim of this review was to identify the key factors underlying sprint swimming performance and to provide in-depth and practical evidence-based information to optimize performance. The review protocol was not registered. PubMed, Web of Science and Scopus databases were searched up to October 31, 2023. Studies involving competitive swimmers and investigating sprint swimming performance were included, while studies conducted with young or masters' swimmers, triathletes or waterpolo players or not investigating sprint swimming performance were excluded. The Downs and Black Quality Assessment Checklist was performed on the included articles to assess the methodological quality. After applying the PICOS framework, 39 of the 1330 articles initially identified were included according to the PRISMA guidelines. The included records focused mainly on dry-land strength and in-water forces of both upper and lower limbs. A wide range of kinematic variables were also examined, together with the importance of anthropometric and various physiological parameters. This review highlights the importance of developing muscular strength and effectively transferring it to performance in the water. The evidence suggests that muscular development should prioritize enhancing velocity and effective displacement, rather than merely increasing force and performance in loaded tests. However, further research is needed to confirm this. While in-water forces have been well studied, there is a notable lack of analysis regarding drag. The optimal balance between stroke rate and stroke length should be determined individually, with a primary focus on achieving a high stroke length from a high stroke rate. Although anthropometry may play an important role in performance, the interaction of these traits appears to be complex, suggesting that other factors may be more important in determining performance outcomes. From a physiological perspective, the results indicate that the lactate peak and rate of accumulation should be thoroughly developed. Notwithstanding, this review shows the lack of a solid body of knowledge on the importance of anaerobic and especially aerobic factors. Finally, the absence of a list of potential confounders, together with the lack of high-quality studies involving elite swimmers (level 1 and 2), complicates the interpretation of the results.

Association between controlling nutritional status score and the prognosis of patients with acute myocardial infarction: a systematic review and meta-analysis.

Recent studies have reported growing evidence supporting applying the controlling nutritional status (CONUT) score in acute myocardial infarction (AMI) patients. This investigation intended to ascertain the link between CONUT scores and the prognosis in the AMI population. Multiple electronic databases, encompassing PubMed, Web of Science, Embase, and the Cochrane Library, were retrieved from the inception of the databases until July 20, 2024, to explore the link between CONUT scores and adverse clinical outcomes in individuals with AMI. Primary outcomes consisted of major adverse cardiovascular events (MACE) and mortality, while secondary outcomes encompassed stroke, cardiac death, myocardial reinfarction, revascularization, ventricular arrhythmias, and atrioventricular block. A random-effects meta-analysis was executed, with CONUT scores treated as either categorical or continuous variables. Sensitivity analyses and Egger's test were conducted to appraise the robustness of results and publication bias, respectively. Subgroup analyses were executed to account for various confounding factors. Moreover, the GRADE system was leveraged to appraise the quality of evidence for all outcomes. Fifteen studies were included in our analysis. The statistical analyses on both categorical and continuous variables unraveled that a high CONUT score was markedly linked to an elevated risk of MACE [categorical variable: odds ratio (OR) = 1.75, 95% confidence interval (CI) = 1.42-2.15; continuous variable: standardized mean difference (SMD) = 1.02, 95% CI = 0.78-1.26], mortality (categorical variable: OR = 2.08, 95% CI = 1.70-2.55; continuous variable: SMD = 1.16, 95% CI = 0.57-1.74), cardiac death (categorical variable: OR = 2.81, 95% CI = 1.67-4.73), myocardial reinfarction (categorical variable: OR = 2.21, 95% CI = 1.28-3.83), and atrioventricular block (categorical variable: OR = 5.21, 95% CI = 1.83-14.89) in AMI patients. However, no significant association was found between a high CONUT score and stroke (categorical variable: OR = 1.52, 95% CI = 0.98-2.35), revascularization (categorical variable: OR = 2.92, 95% CI = 0.58-14.79), and ventricular arrhythmias (categorical variable: OR = 2.57, 95% CI = 0.06-107.21). The CONUT score may serve as a promising and cost-effective prognostic biomarker for individuals with AMI. PROSPERO: CRD42024574048.

Development of impact characteristics response model for combined tube expansion axial splitting module

Combined tube-expansion and axial splitting mechanism yields excellent force-displacement characteristic and high stroke efficiency. In this paper, a mathematical model to estimate and optimise impact response of such mechanism was developed, to correlate the impact response to the module dimensional parameters, i.e. diameter-to-thickness ratio, D1/t and expansion ratio, D2/D1 and other design parameters such as material strength, expansion angle, and friction coefficient. Accurate finite element (FE) analysis, validated with experimental results were performed to generate results sufficient to form a response surface model (RSM). The current mathematical model successfully captured the effect of expansion ratio, thickness ratio, and initial diameter of the tube, with R 2 of 0.99 for specific energy absorbed and 0.81 for mean crushing force throughout 80 data points. A case study was also presented which shows the result comparison between numerical and the proposed model, yielding error below 1% difference for mean and peak crushing force, total energy absorbed, specific energy absorbed (SEA), stroke and crushing force efficiencies. The model has also been implemented in an optimisation for railway vehicle case study using the proposed mathematical model. The current research found that the combined module could reach SEA and stroke efficiency values of 29.74 kJ/kg and 0.99, respectively, significantly better than most of the metallic-based impact energy absorbing mechanisms.

Prevalence of discussions around left atrial appendage occlusion as a treatment option in patients on oral anticoagulation experiencing a major bleeding event

BackgroundGuidelines recommend considering percutaneous left atrial appendage occlusion (LAAO) in patients with atrial fibrillation (AF) at moderate to high stroke risk and contraindications to long-term anticoagulation. Discontinuation of anticoagulation in this patient population, without an alternative treatment option, may place patients at unnecessary risk. This study aimed to assess the prevalence of discussions around LAAO as a treatment option following major bleeding adverse events in patients on oral anticoagulation for AF and to identify the proportion of patients stopping anticoagulation without evidence of LAAO discussions. MethodsFrom a single, large medical center in the United States, patients on an oral anticoagulant for AF and having at least one major bleeding adverse event, defined by the International Society on Thrombosis and Haemostasis, between January 2015 and October 2023 were identified within a quality improvement registry. Information about LAAO discussions, subsequent procedures, and permanent discontinuation of anticoagulation was assessed using the Electronic Medical Record Search Engine and manual electronic medical record reviews. ResultsA total of 222 patients experienced major bleeding (54.5 % male, 86.9 % white, median age 77 years, 58.6 % on warfarin). From this group, 283 major bleeds were documented (44.2 % gastrointestinal, 17.7 % intracranial). LAAO discussions were documented in 51 patients (23 %), with LAAO procedures performed in 9 of these patients (17.6 %). After the major bleed, 54 (24.3 %) patients permanently stopped anticoagulation. Of these patients, 18 (33.3 %) had LAAO discussions prior to discontinuation and only 1 (1.9 %) had LAAO implantation. ConclusionsIn patients experiencing a major bleed, less than a quarter had documented discussions about LAAO and over a quarter permanently stopped anticoagulation.

Evaluating the Risk of Comorbidity Onset in Elderly Patients After a Cancer Diagnosis.

Cancer is a critical disease that affects a person physically, mentally, socially, and in many other aspects. During the treatment stage of cancer, patients suffer from various health complexities, especially elderly people, which might result in the onset of other diseases development of a comorbid condition. Several studies have shown comorbidity plays a crucial role in cancer survival. However, there remains a lack of comprehensive statistical techniques at the national level studies to assess the significance of comorbidities development in cancer. Our research aims to address this gap by comparing cancer and non-cancer individuals over four years' time period. The Health Retirement Study (HRS) data was used to extract information from 6651 participants aged more than 50. Within a 4-year time span, cross-sectional observations were created whether comorbidities or not based on the development of diseases such as high blood pressure, diabetes, heart disease, stroke, lung disease, and psychological disease. The multivariable logistic regression model, we observe higher chances of developing comorbidity (OR=1.321, p-value 0.0051) among the cancer group compared to the non-cancer group, adjusting the socio-economic factors. Moreover, the socio-economic factors were found to be significantly associated with cancer leading to applying the propensity score matching with (1:3 matching). Finally, the balanced data also showed significantly higher chances of developing comorbidity (OR=1.294, p-value 0.0207) among cancer patients. The above findings demonstrated the imperative development of enhanced treatment protocols, which prioritize the overall health of cancer patients, thereby reducing their susceptibility to additional illnesses.

Stroke-bleeding risk score pairings within individuals in the outcomes registry for better informed treatment of atrial fibrillation (ORBIT-AF) registry.

Decisions about stroke prevention strategies in atrial fibrillation (AF) typically balance thromboembolism reduction against increased bleeding from oral anticoagulation therapy (OAC). When determining eligibility for OAC, guidelines recommend calculation of thromboembolic event rates using a validated score such as CHA2DS2-VASc. In contrast, routine calculation of bleeding scores is not recommended, in part because many patient factors associated with an increased risk of bleeding are associated with an even larger increased risk of ischemic stroke. We set out to characterize patients by paired stroke and bleeding risk scores to understand the level of concordance. Between 2010 and 2016, we identified 20,451 AF patients in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) I and II Registries. We grouped patients by stroke and bleeding risk pairings: low and high stroke risk (CHA2DS2-VASc < and ≥2), low and high bleeding risk (ORBIT < and ≥ 4) and described treatment rates with OAC and antiplatelet (AP) therapy. Most patients (68.6 %) were at high stroke and low bleeding risk. Patients at high bleeding risk (19.4 %) had high stroke risk (98.5 %). Treatment rates differed with combined OAC + AP therapy highest for patients at high stroke and bleeding risks. Ischemic and bleeding events were also highest in this group. Nearly all AF patients in this cohort with high bleeding risk (ORBIT score ≥ 4) had high stroke risk (CHA2DS2-VASc ≥ 2), supporting that bleeding risk should not obviate the need for stroke prevention. In contrast, most at high stroke risk were at low bleeding risk (ORBIT <4), supporting OAC for the majority. Bleeding scores, in combination with factors that specifically indicate a higher risk of bleeding, may identify patients who might be candidates for alternative stroke prevention such as left atrial appendage occlusion devices or bleeding mitigation strategies such as de-escalation of antiplatelet therapy.

A linkage mechanism with high mechanical advantage for robotic grippers

Abstract In this paper, a compact linkage mechanism with high mechanical advantage and stroke is designed. The mechanism converts a small input force into a large output force using a toggle mechanism. Its feasibility for application in large gripping force manipulators has been verified. In the paper, the kinematic and static analyses of the mechanism are carried out. The effects of the mechanism parameters on its characteristics are investigated. Then, a dynamic mechanism simulation is carried out using ADAMS to obtain its mechanical gain and gripping force during motion. Finally, the processed double toggle mechanism is analyzed experimentally to verify its applicability. The simulation and experimental results show that the linkage mechanism performs better in the case of large gripping force demand. It can provide effective help for the design of mechanical grippers with large gripping force.

The direct effect of type 2 diabetes on neurodegenerative processes in the absence of other cardiovascular risk factors

AbstractBackgroundDiabetes is associated with an increased risk of developing neurodegenerative conditions, including Alzheimer’s disease. Abnormal insulin signalling can lead to impaired phosphorylation of protein kinase B and activation of phosphatidylinositol 3‐kinase, resulting in hyperphosphorylation of tau and activation of inflammatory pathways. However, people living with diabetes commonly exhibit comorbid cardiovascular risk, which are also linked with cognitive decline. Here we sought to establish the influence of diabetes on global brain atrophy in the absence of comorbid cardiovascular disease.MethodParticipants diagnosed with diabetes and a matched sample of non‐diabetic control participants were enrolled from the UK biobank database. To reduce the influence of confounding risk factors, diabetic and control participants with additional cardiovascular risk were excluded. Participants diagnosed with cardiovascular/heart problems including high blood pressure, cardiac arrest, stroke, and angina were excluded. Non‐diabetic controls were matched based on age, sex and APOE genotype to enhance statistical precision. Voxel‐based morphometry was performed on T1‐weighted structural magnetic resonance images to evaluate the macrostructural changes associated with diabetes across the cortex. A voxel‐wise t‐test was performed between diabetic and non‐diabetic controls implemented on FSL.ResultA total of 503 diabetic participants and a matched sample of 503 control participants met the inclusion criteria and were enrolled on the study. Even in the absence of comorbid cardiovascular disease, participants with diabetes exhibited widespread reductions in grey matter volume in comparison to non‐diabetic participants. Volumetric reductions were demonstrated in 97% of grey matter (volume = 191605 mm³), indicating neurodegeneration in all major brain lobes. Reductions of brain volume in diabetic participants remained following family‐wise error correction.ConclusionIn the absence of other comorbid cardiovascular diseases, type 2 diabetes mellitus induces widespread neurodegeneration in cortical regions. Impairment to insulin signalling and the initiation of the inflammation response may initiate neurodegenerative processes resulting in the loss of brain cells. The widespread nature of atrophy indicates the potential risk for future cognitive impairment. Targeting molecular mechanisms involved in diabetes, including insulin resistance and inflammation, are important to prevent the development of neurodegenerative conditions. This exemplifies the potential for antidiabetic agents for the treatment of neurodegenerative diseases.

Refreshable Braille Display System Driven by Accordion‐Fold Liquid Crystal Elastomer Actuators

AbstractRefreshable Braille display systems offer dynamic tactile approaches for the blind to obtain text information. However, existing refreshable Braille display systems using soft‐actuator‐driven Braille dots exhibit limitations of small strokes, complex mechanical structures, and high‐driving voltages, which inevitably lead to serious issues in safety, flexibility, and portability. To handle these issues, a novel refreshable Braille display system leveraging accordion‐fold liquid crystal elastomer actuators (AF‐LCEAs) is designed and created, which feature high stroke (1.47 mm), simple mechanical structure, and low driving voltage (20 V). The accordion‐fold structure with a high folding ratio of 59.7% not only enables significantly amplifying actuation strokes, but also brings a compact mechanical architecture for Braille dots. The structured‐LCE‐based refreshable Braille display system can be assembled modularly by multiple display units, which provides the capability to deliver rich and complex tactile information. In addition, a digital electro‐control matrix is designed to enable addressable, programmable electro‐actuation of the multiple LCE Braille dots to enable complicated refreshable tactile patterns. The Braille display system offers a versatile approach to engineering refreshable, portable, small‐sized Braille books useful for the blind.

Risk of Postoperative Hemorrhage After Glioma Surgery in Patients with Preoperative Acetylsalicylic Acid.

Patients with gliomas show an increased risk of spontaneous hemorrhages throughout the disease. Simultaneously, the number of patients taking acetylsalicylic acid (ASA) for primary and secondary prophylaxis is rising in daily clinical practice, and interrupting ASA intake before elective or emergency intracranial surgery is not always feasible. This study aims to evaluate the risks associated with continuing ASA use perioperatively while focusing on hemorrhage and potential thromboembolic events that may arise from discontinuing ASA, particularly in multimorbid patients undergoing glioma surgery. The clinical parameters and imaging data of 7149 patients who underwent intracranial surgery in our department over a 10-year period were retrospectively analyzed. Patients were categorized into two groups based on their ASA status: Group 1 (no ASA impact) included those with no ASA use or who discontinued ASA use more than seven days prior to surgery (low stroke or cardiovascular risk), and Group 2 (ASA impact) included those who continued ASA use within seven days prior to operation (high stroke or cardiovascular risk). In this retrospective study, data from 650 patients with various types of glial tumors who underwent surgery between 2008 and 2018 were examined. Of these patients, 50 experienced a postoperative hemorrhage (POH), and 10 required reoperations due to clinical neurological deterioration and increased intracranial pressure caused by the space-occupying effect of the hemorrhage. In the ASA impact group, 2.7% developed POH, compared to 1.3% in the no ASA impact group (p = 0.098). Our analysis did not show a significantly increased risk of POH after surgery, although patients in the ASA impact group had a one- to two-fold higher risk of developing POH overall. Additionally, other factors contributing to postoperative hemorrhage following glioma surgery were investigated and evaluated. In this cohort, the perioperative use of ASA was not associated with an increased rate of hemorrhagic complications after intracranial glioma surgery, although a trend was observed. In patients with high stroke and cardiovascular risk, ASA can be continued during elective brain tumor surgery.

Prediction models for ischemic stroke and bleeding in dialysis patients: a systematic review and meta-analysis

ABSTRACT Background Patients with kidney failure on maintenance dialysis have a high stroke and bleeding risk. Multivariable prediction models can be used to estimate the risk of ischemic stroke and bleeding. A systematic review and meta-analysis was performed to determine the performance of the existing models in patients on dialysis. Methods MEDLINE and Embase databases were searched, from inception through 12 January 2024, for studies of prediction models for stroke or bleeding, derived or validated in dialysis cohorts. Discrimination measures for models with c-statistic data from three or more cohorts were pooled by random effects meta-analysis and a 95% prediction interval (PI) was calculated. Risk of bias was assessed using PROBAST. The review was conducted according to the PRISMA statement and the CHARMS checklist. Results Eight studies were included in this systematic review. All the included studies validated pre-existing models that were derived in cohorts from the general population. None of the identified studies reported the development of a new dialysis specific prediction model for stroke, while dialysis specific risk scores for bleeding were proposed by two studies. In meta-analysis of c-statistics, the CHA2DS2-VASc, CHADS2, ATRIA, HEMORR(2)HAGES and HAS-BLED scores showed very poor discriminative ability in the dialysis population. Six of the eight included studies were at low or unclear risk of bias and certainty of evidence was moderate. Conclusions The existing prediction models for stroke and bleeding have very poor performance in the dialysis population. New dialysis-specific risk scores should be developed to guide clinical decision making in these patients.

Development and Validation of a Flow-Dependent Endothelialized 3D Model of Intracranial Atherosclerotic Disease.

Intracranial atherosclerotic disease (ICAD) is a major cause of stroke globally, with mechanisms presumed to be shared with atherosclerosis in other vascular regions. Due to the scarcity of relevant animal models, testing biological hypotheses specific to ICAD is challenging. We developed a workflow to create patient-specific models of the middle cerebral artery (MCA) from neuroimaging studies, such as CT angiography. These models, which can be endothelialized with human endothelial cells and subjected to flow forces, provide a reproducible ICAD model. Using imaging from the SAMMPRIS clinical trial, we validated this novel model. Computational fluid dynamics flow velocities correlated strongly with particle-derived flow, regardless of stenosis degree. Post-stenotic flow disruption varied with stenosis severity. Single-cell RNA-seq identified flow-dependent endothelial gene expression and specific endothelial subclusters in diseased MCA segments, including upregulated genes linked to atherosclerosis. Confocal microscopy revealed flow-dependent changes in endothelial cell proliferation and morphology in vessel segments related to stenosis. This platform, rooted in the specific anatomy of cerebral circulation, enables detailed modeling of ICAD lesions and pathways. Given the high stroke risk associated with ICAD and the lack of effective treatments, these experimental models are crucial for developing new ICAD-related stroke therapies.

Machine learning–based predictive model for post-stroke dementia

BackgroundPost-stroke dementia (PSD), a common complication, diminishes rehabilitation efficacy and affects disease prognosis in stroke patients. Many factors may be related to PSD, including demographic, comorbidities, and examination characteristics. However, most existing methods are qualitative evaluations of independent factors, which ignore the interaction amongst various factors. Therefore, the purpose of this study is to explore the applicability of machine learning (ML) methods for predicting PSD.Methods9 acceptable features were screened out by the Spearman correlation analysis and Boruta algorithm. We developed and evaluated 8 ML models: logistic regression, elastic net, k-nearest neighbors, decision tree, extreme gradient boosting, support vector machine, random forest, and multilayer perceptron.ResultsA total of 539 stroke patients were included in this study. Among the 8 models used to predict PSD, extreme gradient boosting and random forest showed the highest area under the curve (AUC) of the receiver operating characteristic curve (ROC), with values of 0.7287 and 0.7285, respectively. The most important features for predicting PSD included age, high sensitivity C-reactive protein, stroke side and location, and the occurrence of cerebral hemorrhage.ConclusionOur findings suggest that ML models, especially extreme gradient boosting, can best predict the risk of PSD.

Abstract 405: Severe “Crescendo” Recurrent TIAs In Moderate Carotid Artery Stenosis Without High‐risk Features

Introduction Symptomatic internal carotid artery stenosis (ICA) is defined as focal neurologic deficits ipsilateral to carotid artery pathology presenting as a transient ischemic attack (TIA) or stroke, frequently seen with moderate to severe (50‐99%) ICA stenosis. Stroke warning syndrome (SWS) is a rare form of TIA presenting as recurrent, or “crescendo”, TIAs with a high stroke risk typically seen in the absence of cortical signs and related to small vessel disease or hypoperfusion. Our case describes a patient with recurrent stereotypic crescendo TIAs with near complete cortical left middle cerebral artery (MCA) syndrome secondary to moderate (50‐69%) ICA stenosis without high‐risk features (intraplaque hemorrhage, large lipid‐rich necrotic core, thin or ruptured fibrous cap), with complete resolution of symptoms after carotid endarterectomy (CEA). Case We report a 66‐year‐old female smoker without significant medical history presenting with complete left MCA syndrome‐ left gaze, dysarthria, complete expressive aphasia, and right sided hemiplegia, with last known well approximately 12 hours prior to presentation. CT angiography (CTA) of the head and neck demonstrated an estimated 60‐65% stenosis of the left carotid bifurcation with mixed hard and soft plaque without ulceration or unstable thrombi; no intracranial occlusions were noted. The patient had spontaneous resolution of symptoms with NIHSS 0, so thrombolysis was deferred. Within a few hours of presentation, she experienced three additional episodes of varying severity, each lasting approximately five minutes, with complete resolution between episodes. This raised concern for an unstable plaque; therefore, she was started on aspirin and intravenous (IV) heparin drip with plan for urgent carotid revascularization. After heparin was paused pre‐operatively, she had two additional witnessed similar events lasting less than ten minutes each. Following endarterectomy, she had complete resolution of symptoms without recurrence. MRI brain showed no infarction, additional stroke workup was otherwise unrevealing, and she was discharged on daily aspirin. On three‐month post‐operative follow up, the patient reported no further symptom recurrence. Discussion The incidence of TIAs presenting as SWS is as high as 4.5%, yet there are no clear guidelines for SWS management. SWS is typically observed in small vessel pathology and hypoperfusion, and less commonly in carotid artery pathology. Our patient presented with episodes consistent with cortical L MCA symptoms, typically seen with a proximal MCA occlusion. However, the frequency of these episodes exceeded what is expected from moderate carotid artery stenosis, especially in the absence of many known high‐risk plaque markers. While stereotypic symptoms raise concern for alternative diagnosis, such as seizures, the cessation of symptoms with IV heparin and subsequent complete resolution following revascularization confirmed the diagnosis of symptomatic carotid disease. In symptomatic moderate ICA stenosis, the benefit of urgent carotid revascularization over medical treatment of anti‐thrombotic or stroke prevention is modest, with the greatest effect observed in cases with severe stenosis. In patients with crescendo TIA with moderate ICA stenosis, even without high‐risk features, carotid revascularization may be beneficial. While there is no strong evidence supporting anticoagulation over anti‐platelet therapy in symptomatic ICA stenosis, anticoagulation may be considered in patients presenting with SWS.

Pharmacologic treatment of hypertension guided by non-invasive haemodynamics in primary care improves blood pressure control

Abstract Background Current guidelines on hypertension (HTN) provide blood pressure (BP) targets and therapeutic algorithms but ignore the potential to treat individual patients according to their haemodynamic profile. We have shown that use of non-invasive haemodynamic information obtained by impedance cardiography (ICG) can improve BP control in the primary care setting. Purpose To investigate whether improved rates of BP control by matching patients’ non-invasive haemodynamics to specific pharmacologic treatments and increasing patient engagement translates into improved clinical outcome measures. Methods Electronic medical records (EMR) were obtained for 14,698 patients from two US primary care groups between 2014 and 2023. ICG was done when BP exceeded 140/90 mmHg. Haemodynamic measurements included mean arterial pressure (MAP), cardiac index (CI), cardiac power index (CPI), total peripheral resistance index (TPRI), stroke index (SI) and heart rate (HR) (Figure 1). Haemodynamic ICG profiles were classified as: Vasoconstriction, Hyperdynamic, or Mixed pattern. Printed clinical decision support (CDS) tools and later an EMR integrated CDS application were used to communicate recommendations to physicians. Printed reports were shared with patients to increase their engagement. Pharmacological therapy was tailored based on haemodynamic information. Rates of successful BP treatment and the occurrence of myocardial infarction (MI) or stroke were tracked through the EMR. Results Of 14,698 patients, 50% were women, 17% were Black and 17% were aged 18-49 years, 45% aged 50-69 years, and 38% age ≥ 70 years. A total of 21,246 ICGs were performed classifying patients as Vasoconstriction 47%, Hyperdynamic with high heart rate (HR) or high stroke index (SI) 24%, and Mixed Haemodynamic (combination of Vasoconstriction and Hyperdynamic) 29% (Figure 1). Demographic features were not strongly associated with haemodynamic classification. Within 2-3 years of inclusion, &amp;gt;85% of patient achieved BP control (&amp;lt;140/90 mmHg), which was sustained during follow-up. Over a median (IQR) follow-up of 8 (2016-2023) years, there were 14 (5) MI and 34 (16) strokes. These event rates appear to be lower than those reported in other large cohorts of patients with HTN. Conclusions Treating patients with HTN according to their individual haemodynamic profile is associated with high rates of BP control. Further analysis will determine whether the rates of MI, stroke and death are lower than expected based on the patients baseline risk profile.Haemodynamic Status (ICG Test Results)

Navigating stroke care: Geospatial assessment of regional stroke center accessibility: Geospatial Assessment of Stroke Centers

IntroductionReducing time between stroke onset and hospital intervention is crucial for positive outcomes in stroke patients. While EMS utilization decreases time to intervention, many US regions are not within timely proximity to an advanced-care-capable stroke center (ASC), defined as a comprehensive or thrombectomy-capable center. This study aims to utilize geographic methodology to identify regions in Wisconsin with both high stroke mortality and low physical accessibility to certified stroke centers (SCs), particularly ASCs. MethodsGeocoded mortality records for stroke death between 2015 and 2020 were accessed from the Wisconsin Department of Health Services. Indirectly age-standardized mortality ratios (SMRs) were estimated continuously across Wisconsin using adaptive spatial filtering and mortality records at the census block group level; the surface was then averaged by census tract for tract level SMRs. Addresses for SC locations within Wisconsin and bordering states were collected, and drive times from Wisconsin census tract centroids to the nearest SC subtypes were estimated. Drive times and mortality ratios were evaluated at the tract level alongside Rural-Urban Commuting Area (RUCA) codes. Spatial error regression modeling was used to determine RUCA classifications with the highest stroke risk independent of accessibility to stroke centers. ResultsApproximately 50%, 68%, and 78% of Wisconsin residents resided within 30, 45, and 60 minutes of an ASC, respectively. Median drive time from census tract centroids to the nearest ASC were highest for rural tracts (M=90 minutes, IQR=68-115) compared to small-town (M=82 minutes, IQR=49-113), micropolitan (M=53 minutes, IQR=43-77), and metropolitan tracts (M=19 minutes, IQR=11-35; p<0.001). Clusters of high stroke SMRs were found in urban centers as well as rural areas irrespective of county declinations. Spatial regression modeling suggested small-town census tracts had the highest SMR irrespective of physical accessibility to care and spatial correlation. In small-town census tracts >45 minutes from the nearest ASC, the median stroke SMR was 1.12 (IQR=0.94-1.40) with 226,000 residents and 150 stroke deaths per year. ConclusionSmall-town areas are associated with both long drive distance to ASC locations and high stroke mortality. Geographical analyses reveal apparent stroke care deserts and may inform strategic allocation of emergency medicine resources and coverage.

Prediction of Aphasia Outcome Using Low Frequency Transcranial Magnetic Stimulation in Post-Stroke Non-Fluent Aphasia

Background: Stroke, a global health concern, often leads to language impairment (aphasia). In Egypt, with a high stroke prevalence, aphasia affects a significant number of survivors. Noninvasive techniques like repetitive transcranial magnetic stimulation (rTMS) show promise in rehabilitation. Cultural variations in test results emphasize the need for region-specific considerations in standardized assessments for post-stroke care. Aim of the work: To evaluate the role of low frequency rTMS to speed up the recovery of post-stroke aphasia for a better quality of life. Patients and Methods: This randomized clinical trial investigates the effects of (rTMS) on post-stroke aphasia. Patients with post-stroke non-fluent aphasia were divided into two groups, with one receiving inhibitory rTMS and the other sham sessions. Inclusion criteria involve adults with a single left hemisphere stroke, while exclusion criteria include prior strokes. The study includes comprehensive assessments for aphasia, and depression. The stimulation protocol involves 20 minutes of daily rTMS for ten days, targeting the right inferior frontal gyrus. The study aims to evaluate the rTMS impact on language recovery. Results: The study evaluated low-frequency rTMS for post-stroke aphasia recovery in 30 patients, comparing TMS and sham groups. No significant demographic or cerebrovascular risk factor differences were found. While rTMS group showed improvement in depression, there were no significant differences between TMS and sham groups in aphasia improvement. Conclusion: Low-frequency rTMS demonstrated no significant superiority over sham stimulation in post-stroke aphasia recovery. Both groups exhibited improved depression without notable distinctions.

High Risk PFO-Associated Stroke: Proposed Algorithm for Better Risk Stratification.

High Risk PFO-Associated Stroke: Proposed Algorithm for Better Risk Stratification.

Current Therapy for Carotid Webs

IntroductionCarotid webs are a potential cause of ischemic stroke, particularly in younger patients with few traditional risk factors. Despite advances in imaging technology, the management of carotid webs remains poorly defined due to its rarity, absence of evidence-based guidelines, and the unique challenges presented by these lesions. This narrative review evaluates current knowledge on carotid web management, emphasizing diagnostic features, pathophysiological considerations, and treatment strategies. MethodsA literature search was conducted using PubMed and Google Scholar databases with search terms “carotid web management,” “carotid web treatment,” and “carotid web,” focusing on studies published between 2014 and 2024. ResultsCarotid webs are a variant of fibromuscular dysplasia and represent a potential source of embolic strokes. Despite the low overall prevalence, they account for a significant proportion of strokes in younger patients, with a high risk of recurrence when managed medically. Diagnosis often requires advanced imaging, such as CTA or MRA. Treatment options include medical management, carotid endarterectomy, and stenting, though no consensus guidelines exist. Medical management alone has a high recurrent stroke risk. ConclusionCarotid webs should be included in the differential diagnosis of patients with cryptogenic stroke, particularly in younger individuals. Given the high recurrence rates with medical management, both endarterectomy and stenting are recognized as safe and effective treatment options. Future prospective studies are needed to determine the optimal management strategy, including the role of preoperative anticoagulation and comparative outcomes of different treatment modalities.