Increased Incidence Of Stroke Research Articles

Short-Term Exposure to Air Pollution and the Incidence and Mortality of Stroke: A Meta-Analysis.

The relationship between short-term exposure to various air pollutants [particulate matter <10 μm (PM 10 ), particulate matter <2.5 μm (PM 2.5 ), nitrogen dioxide (NO 2 ), sulfur dioxide (SO 2 ), carbon monoxide, and ozone (O 3 )] and the incidence and mortality of stroke remain unclear. We conducted a comprehensive search across databases, including PubMed, Web of Science, and others. A random-effects model was employed to estimate the odds ratios (OR) and their 95% CIs. Short-term exposure to PM 10 , PM 2.5 , NO 2 , SO 2 , and O 3 was associated with increased stroke incidence [per 10 μg/m 3 increase in PM 2.5 : OR = 1.005 (95% CI: 1.004-1.007), per 10 μg/m 3 increase in PM 10 : OR = 1.006 (95% CI: 1.004-1.009), per 10 μg/m 3 increase in SO 2 : OR = 1.034 (95% CI: 1.020-1.048), per 10 μg/m 3 increase in NO 2 : OR = 1.029 (95% CI: 1.015-1.043), and O 3 for per 10 μg/m 3 increase: OR: 1.006 (95% CI: 1.004-1.007)]. In addition, short-term exposure to PM 2.5 , PM 10 , SO 2, and NO 2 was correlated with increased mortality from stroke [per 10 μg/m 3 increase in PM 2.5 : OR = 1.010 (95% CI: 1.006-1.013), per 10 μg/m 3 increase in PM 10 : OR = 1.004 (95% CI: 1.003-1.006), per 10 μg/m 3 increase in SO 2 : OR = 1.013 (95% CI: 1.007-1.019) and per 10 μg/m 3 increase in NO 2 : OR = 1.012 (95% CI: 1.008-1.015)]. Reducing outdoor air pollutant levels may yield a favorable outcome in reducing the incidence and mortality associated with strokes.

A systematic review of the incidence and outcomes of ICD-11 defined stroke

The World Health Organisation has expanded the definition of stroke to include people with symptoms less than 24 hours if they have evidence of stroke on neuroimaging. The impact is that people previously diagnosed as having a transient ischaemic attack (TIA) would now be considered to have had a stroke. This change will impact incidence and outcomes of stroke and increase eligibility for secondary prevention. We aimed to evaluate the new ICD-11 criteria retrospectively to previous TIA studies to understand the change in incidence and outcomes of this type of stroke. We conducted a systematic review of observational studies of the incidence and outcomes of clinically defined TIA. We searched PubMed, EMBASE, and Google Scholar from inception to 23rd May 2023. Study quality was assessed using a risk of bias tool for prevalence studies. Our review included 25 studies. The rate of scan positivity for stroke among those with clinically defined TIA was 24%, (95% CI, 16% - 33%) but with high heterogeneity (I2=100%, p = 0). Sensitivity analyses provided evidence that heterogeneity could be explained by methodology and recruitment method. The scan positive rate when examining only studies at low risk of bias was substantially lower, at 13% (95% CI, 11 - 15%, I2=0, p = 0.77). We estimate from population-based incidence studies that ICD-11 would result in an increase stroke incidence between 4.8 and 10.5 per 100,000 persons/year. Of those with DWI-MRI evidence of stroke, 6% (95% CI, 3 - 11%) developed a recurrent stroke in the subsequent 90 days, but with substantial heterogeneity (I2=67%, p = 0.02). The impact of the ICD-11 change in stroke definition on incidence and outcomes may have been overestimated by individual studies. Community-based stroke services with access to DWI MRI are likely to accurately diagnose greater numbers of people with mild ICD-11 stroke, increasing access to effective prevention.

Risk factors for stroke in the African populace: need for action

The burden of stroke cannot be overemphasized especially in low and middle-income countries (LMICs). More than two-thirds of stroke deaths arise from these countries as well as nearly 90% of stroke-related morbidities. Unfortunately, it has been suggested that there might be up to a three-fold increase in stroke incidence and a higher prevalence in Africa in the year 2021. The known risk factors for stroke are similar to those in developed countries: age, hypertension, diabetes mellitus, hypercholesterolaemia, and central obesity. These risk factors have often been overlooked in patients who present with stroke in Africa. Other important risk factors for stroke include high salt intake and red meat consumption, low consumption of green leafy vegetables, air pollution, undernutrition in infancy and genetic factors. Possibly the most efficient way of curbing the impact of stroke in Africa is to address the risk factors. The aim of this article is to shine some light on these risk factors in sub-Saharan Africa and proffer some solutions to address the menace of stroke

Association between HDL levels and stroke outcomes in the Arab population

Low HDL levels are associated with an increased stroke incidence and worsened long-term outcomes. The aim of this study was to assess the relationship between HDL levels and long-term stroke outcomes in the Arab population. Patients admitted to the Qatar Stroke Database between 2014 and 2022 were included in the study and stratified into sex-specific HDL quartiles. Long-term outcomes included 90-Day modified Rankin Score (mRS), stroke recurrence, and post-stroke cardiovascular complications within 1 year of discharge. Multivariate binary logistic regression analyses were performed to identify the independent effect of HDL levels on short- and long-term outcomes. On multivariate binary logistic regression analyses, 1-year stroke recurrence was 2.24 times higher (p = 0.034) and MACE was 1.99 times higher (p = 0.009) in the low-HDL compared to the high-HDL group. Mortality at 1 year was 2.27-fold in the low-normal HDL group compared to the reference group (p = 0.049). Lower sex-specific HDL levels were independently associated with higher adjusted odds of 1-year post-stroke mortality, stroke recurrence, and MACE (p < 0.05). In patients who suffer a stroke, low HDL levels are associated with a higher risk of subsequent vascular complication.

Physical activity can reduce the risk of blood cadmium and blood lead on stroke: Evidence from NHANES

The detrimental impact of heavy metals on cardiovascular well-being is a global concern, and engaging in suitable physical activity has been shown to confer cardiovascular advantage. Nevertheless, the potential of exercise to mitigate the deleterious effects of heavy metals on stroke remains uncertain. We conducted a cross-sectional survey to assess the influence of blood cadmium and blood lead on stroke occurrence, while also examining the role of physical activity. Weighted multivariate regression analysis was employed to examine the potential correlation, while subgroup and interaction analyses were used to investigate the sensitivity and robustness of the results. After controlling risk factors, it revealed a positive correlation between blood cadmium and lead levels and the occurrence of stroke. Specifically, a 50% increase in blood cadmium was associated with a 28% increase in stroke incidence, while a 50% increase in blood lead was associated with a 47% increase in stroke incidence. To estimate the non-linear relationship, we employed restricted cubic models. The results demonstrate a gradual decrease in the slope of the model curve as the intensity of physical activity increases, implying that engaging in physical activity may contribute to a reduction in the occurrence of stroke caused by blood cadmium and lead. Our findings suggest that blood cadmium and lead could be considered an autonomous risk factor for stroke within the general population of the United States. Moreover, engaging in physical activity has the potential to mitigate the potential detrimental consequences associated with exposure to heavy metals.

Global trends and regional differences in disease burden of stroke among children: a trend analysis based on the global burden of disease study 2019

BackgroundStroke is a major cause of acute neurological symptoms in children with significant long-term neurological sequelae. However, data of diseases burden on stroke among children was lack. We aimed to be dedicated to analyze and compare global trends as well as regional and sociodemographic differences in stroke prevalence, incidence, mortality and disability-adjusted life-years (DALYs) among children aged 0 ~ 14 years.MethodWe obtained data on annual number of incident strokes, prevalent strokes, deaths, and DALYs, age-standardized incidence rates (ASIRs), prevalence rates (ASPRs), mortality rates (ASMRs) and DALY rates (ASDRs) of stroke among individuals aged 14 years and younger during 1990–2019 from the 2019 Global Burden of Disease Study. To quantify the temporal trends, we calculated changes (%) in number, and used joinpoint regression analysis to identify the average annual percentage changes (AAPCs) of age standardized rates.ResultGlobally, the incident strokes and prevalent strokes increased by 18.51% and 31.97%, respectively, but DALYs due to stroke and deaths due to stroke decreased by 60.18% and 65.03%, respectively, from 1990 to 2019. During the same period, ASIR increased by 0.21% (95%CI: 0.17, 0.24) from 18.02 to 100,000 population in 1990 to 19.11 per 100,000 in 2019; ASPR increased by 0.66% (95%CI: 0.36, 0.96) from 68.88 to 100,000 population in 1990 to 81.35 per 100,000 in 2019; while ASMR (AAPC= -3.94; 95%CI: -4.07, -3.81) and ASDR (AAPC= -3.50; 95%CI: -3.64, -3.36) both decreased. In 2019, the highest age standardized incidence, prevalence, mortality, and DALY rates all occurred in low sociodemographic index (SDI) regions. The greatest increase of age standardized incidence rate (AAPC = 0.21; 95%CI: 0.18, 0.25) and prevalence rate (AAPC = 1.15; 95%CI: 0.34, 1.96) both were in high SDI regions. Eastern Sub-Saharan Africa had the highest ASIR and ASPR in 2019, and Oceania had the highest ASMR and ASDR in 2019 across 21 GBD regions. High-income North America had the largest increase in ASIR (AAPC = 0.63; 95%CI: 0.59, 0.66) and ASPR (AAPC = 1.58; 95%CI: 0.54, 2.63). Against the overall decreasing trend of ASMR, an increasing trend of ASMR was found in Zimbabwe (AAPC = 0.91; 95%CI: 0.44, 1.37) and Botswana (AAPC = 0.74; 95%CI: 0.02, 1.47).ConclusionThe overall increasing stroke incidence and prevalence indicated that prevention and management of stroke among younger population should be critical in the future. Despite stroke mortality with falling trend worldwide, specific countries or territories present worrying increase in stroke mortality. Without urgent implementation of effective primary prevention strategies, the stroke burden of children will probably continue to grow across the world, particularly in high-SDI countries.

Temporal trends of stroke incidence over 14 years in Iran: Findings of a large-scale multi-centric hospital-based registry

Background: The burden of stroke is high worldwide, especially in low-middle income countries. We aim to explore the temporal trends of the incidence rate (IR) of stroke over 14 years in Iran’s central areas. Methods: Stroke registry as part of cardiovascular disease (CVD) registry in Isfahan that focused on hospitalized patients (≥15 years) with first or recurrent stroke from 2001 to 2015. Factors included date of symptoms, demographics, management, survival at 28 days, date of admission, history of stroke, and other CVD and clinical diagnosis according to Computer Tomography Scan. We calculated age-, sex, and place-of-residence-adjusted IR based on multiple reference populations. Data were analyzed by bootstrap robust zero-truncated negative binomial regression models using R Statistical Software. Results: From 19,174 registered patients with stroke assessed by ICD-10; 18,010 (93.93%) cases were identified based on WHO-MONICA. Approximately 51% of hospitalized stroke patients were women. The average annual increase in stroke incidence based on ICD-10 ranged from 1.56% (95% CI, 0.14, 2.97) to 2.67% (95% CI, 1.25, 4.09) for different reference populations. In addition, a similar trend was also observed for stroke IR based on WHO-MONICA during the study period for the whole reference population, with an average annual change of 2.5% (95% CI, 1.28, 3.72) to 3.64 % (95% CI, 2.47, 4.82). Conclusion: Given that temporal trends of stroke have increased in both sexes, especially in Iran’s urban areas, prevention programs are needed for public awareness and physician motivation in order to identify risk factors as well as primary and secondary prevention.

Mixtures of long-term exposure to ambient air pollution, built environment and temperature and stroke incidence across Europe

IntroductionThe complex interplay of multiple environmental factors and cardiovascular has scarcely been studied. Within the EXPANSE project, we evaluated the association between long-term exposure to multiple environmental indices and stroke incidence across Europe. MethodsParticipants from three traditional adult cohorts (Germany, Netherlands and Sweden) and four administrative cohorts (Catalonia [region Spain], Rome [city-wide], Greece and Sweden [nationwide]) were followed until incident stroke, death, migration, loss of follow-up or study end. We estimated exposures at residential addresses from different exposure domains: air pollution (nitrogen dioxide (NO2), particulate matter < 2.5 μm (PM2.5), black carbon (BC), ozone), built environment (green/blue spaces, impervious surfaces) and meteorology (seasonal mean and standard deviation of temperatures). Associations between environmental exposures and stroke were estimated in single and multiple-exposure Cox proportional hazard models, and Principal Component (PC) Analyses derived prototypes for specific exposures domains. We carried out random effects meta-analyses by cohort type. ResultsIn over 15 million participants, increased levels of NO2 and BC were associated with increased higher stroke incidence in both cohort types. Increased Normalized Difference Vegetation Index (NDVI) was associated with a lower stroke incidence in both cohort types, whereas an increase in impervious surface was associated with an increase in stroke incidence. The first PC of the air pollution domain (PM2.5, NO2 and BC) was associated with an increase in stroke incidence. For the built environment, higher levels of NDVI and lower levels of impervious surfaces were associated with a protective effect [%change in HR per 1 unit = −2.0 (95 %CI, −5.9;2.0) and −1.1(95 %CI, −2.0; −0.3) for traditional adult and administrative cohorts, respectively]. No clear patterns were observed for distance to blue spaces or temperature parameters. ConclusionsWe observed increased HRs for stroke with exposure to PM2.5, NO2 and BC, lower levels of greenness and higher impervious surface in single and combined exposure models.

Reoperative aortic root replacement for prosthetic aortic valve endocarditis: impact of aortic graft.

Existing aortic graft complicates the surgical management of prosthetic valve endocarditis (PVE); yet, its impact has not been well studied. We compared outcomes of patients with prior aortic valve replacement (AVR) versus aortic surgery plus AVR, who underwent reoperative aortic root replacement (ARR) for PVE of the aortic valve. All patients who underwent reoperative ARR for PVE between 2004 and 2021 from 2 aortic centres were included. Two groups were formed based on the presence/absence of aortic graft: prior aortic surgery (AO) and prior AVR (AV) alone. Inverse propensity treatment weighting matched the groups. The Kaplan-Meier method was used to analyse long-term survival, and Fine and Gray model was used to compare the cumulative incidence of reoperation. A total of 130 patients were included (AO n = 59; AV n = 71). After matching, AO patients had increased stroke incidence (12.4% vs 0.9%) and renal failure requiring dialysis (11.5% vs 2.5%). In-hospital mortality was comparable (21.5% AO and 18.6% AV). Survival over 5 years was 68.9% (56.6-83.8%) in AO and 62.7% (48.1-81.7%) in AV (P = 0.70). The cumulative incidence of reoperation was similar [AO 6.3% (0.0-13.2%) vs AV 6.1% (0.0-15.1%), P = 0.69]. Reoperative ARRs for prosthetic valve/graft endocarditis are high-risk procedures. AO patients had higher incidence of postoperative morbidity versus AV patients. For all patients surviving operative intervention, survival and reoperation rates over 5 years were comparable between groups.

Sex differences in the association between stroke risk factors and pre-clinical predictors of stroke in the childhood determinants of Adult Health study

Background and aimsIt is unclear why blood pressure (BP), metabolic markers and smoking increase stroke incidence in women more than men. We examined these associations with carotid artery structure and function in a prospective cohort study. MethodsParticipants in the Australian Childhood Determinants of Adult Health study at ages 26–36 years (2004–06) were followed-up at 39–49 years (2014–19). Baseline risk factors included smoking, fasting glucose, insulin, systolic and diastolic BP. Carotid artery plaques, intima-media thickness [IMT], lumen diameter and carotid distensibility [CD] were assessed at follow up. Log binomial and linear regression with risk factor × sex interactions predicted carotid measures. Sex-stratified models adjusting for confounders were fitted when significant interactions were identified. ResultsAmong 779 participants (50% women), there were significant risk factor × sex interactions with baseline smoking, systolic BP and glucose associated with carotid measures in women only. Current smoking was associated with incidence of plaques (RRunadjusted 1.97 95% CI 1.4, 3.39), which reduced when adjusted for sociodemographics, depression, and diet (RRadjusted 1.82 95% CI 0.90, 3.66). Greater systolic BP was associated with lower CD adjusted for sociodemographics (βadjusted −0.166 95% CI -0.233, −0.098) and hypertension with greater lumen diameter (βunadjusted 0.131 95% CI 0.037, 0.225), which decreased when adjusted for sociodemographics, body composition and insulin (βadjusted 0.063 95% CI -0.052, 0.178). Greater glucose (βunadjusted −0.212 95% CI -0.397, −0.028) was associated with lower CD, which decreased when adjusted for sociodemographics, BP, depression and polycystic ovary syndrome (βadjusted −0.023 95% CI -0.249, 0.201). ConclusionsSmoking, SBP and glucose affect carotid structure and function more in women than men with some of this risk due to co-occurring risk factors.

EFFICACY OF BETA-BLOCKERS ON BLOOD PRESSURE CONTROL, MORBIDITY AND MORTALITY ENDPOINTS IN HYPERTENSIVES OF AFRICAN ANCESTRY: AN INDIVIDUAL PATIENT DATA META-ANALYSIS

Objective: Beta-blockers have been reported to sub-optimally lower central aortic blood pressure and cause an increased stroke incidence. There is a paucity of data regarding beta-blocker efficacy in patients of African origin. We proposed that an individual patient data meta-analysis (IPD-MA) focusing on the efficacy of traditional and second or third-generation beta-blockers (STGBBs) in the whole and African hypertensive population may provide new insights. Design and method: A single-stage IPD-MA analysed the efficacy of STGBBs in the setting of other anti-hypertensives for lowering mean arterial pressure (MAP) and reducing the occurrence of composite outcome (total cardiovascular mortality, stroke and myocardial infarction). Results: A total of 11860 participants were included in the analysis, of which 3864 (32.5%) were on STGBB. STGBBs reduced the MAP by 1.75 mmHg (95% confidence interval (CI): 1.16 - 2.33; p&lt;0.001) in the whole population and by 1.93 mmHg (95% CI: 0.86 - 3.00; p&lt;0.001) in 3880 African hypertensives, outperforming angiotensin-converting enzyme inhibitors (ACE-I) in the whole population studied and ACE-I and calcium channel blockers in the African population. Confounding through beta-blocker use in established cardiovascular disease resulted in STGBBs being associated with an adjusted odds ratio of 1.33 (95 % CI: 1.06 - 1.65; p = 0.015) of the composite outcome while controlling for age, gender, race and smoking history. STGBBs were not associated with an increase in the odds of stroke in African hypertensives nor the whole population. Conclusions: STGBBs reduced the MAP comparably to other anti-hypertensives. No increase in the odds of stroke was found.

Associations Between Long-Term Air Pollutant Exposure and 30-Day All-Cause Hospital Readmissions in US Patients With Stroke.

Long-term exposure to air pollutants is associated with increased stroke incidence, morbidity, and mortality; however, research on the association of pollutant exposure with poststroke hospital readmissions is lacking. We assessed associations between average annual carbon monoxide (CO), nitrogen dioxide (NO2), ozone (O3), particulate matter 2.5, and sulfur dioxide (SO2) exposure and 30-day all-cause hospital readmission in US fee-for-service Medicare beneficiaries age ≥65 years hospitalized for ischemic stroke in 2014 to 2015. We fit Cox models to assess 30-day readmissions as a function of these pollutants, adjusted for patient and hospital characteristics and ambient temperature. Analyses were then stratified by treating hospital performance on the Centers for Medicare and Medicaid Services risk-standardized 30-day poststroke all-cause readmission measure to determine if the results were independent of performance: low (Centers for Medicare and Medicaid Services rate for hospital <25th percentile of national rate), high (>75th percentile), and intermediate (all others). Of 448 148 patients with stroke, 12.5% were readmitted within 30 days. Except for tropospheric NO2 (no national standard), average 2-year CO, O3, particulate matter 2.5, and SO2 values were below national limits. Each one SD increase in average annual CO, NO2, particulate matter 2.5, and SO2 exposure was associated with an adjusted 1.1% (95% CI, 0.4-1.9%), 3.6% (95% CI, 2.9%-4.4%), 1.2% (95% CI, 0.2%-2.3%), and 2.0% (95% CI, 1.1%-3.0%) increased risk of 30-day readmission, respectively, and O3 with a 0.7% (95% CI, 0.0%-1.5%) decrease. Associations between long-term air pollutant exposure and increased readmissions persisted across hospital performance categories. Long-term air pollutant exposure below national limits was associated with increased 30-day readmissions after stroke, regardless of hospital performance category. Whether air quality improvements lead to reductions in poststroke readmissions requires further research.

Abstract 117: Low-to-moderate Risk Transient Ischemic Attack Patients Can Be Safely Discharged From The Emergency Department To A Nurse Practitioner-Led Clinic

Background: Unnecessary admissions fuel rising healthcare costs and take away resources from higher acuity patients without evidence of increased safety. Purpose: The purpose of this quality improvement project was to determine if the care diversion for transient ischemic attack (TIA), from inpatient to a nurse practitioner (NP)-led specialty clinic, resulted in no increase in stroke incidence at 90 days. Methods: The sample included all adults (18 years or older) presenting to the emergency department (ED) with TIA at low-to-moderate risk for stroke. Risks were defined by the ABCD 2 score and non-invasive vessel imaging. Patients who met the criteria were discharged and evaluated by a stroke NP at the TIA clinic within seven days. These patients were compared to those who were admitted to the hospital prior to clinic launch. Chart reviews were conducted to determine stroke incidence at 90 days post TIA. Descriptive statistics were used to evaluate clinical variables, and Fisher’s Exact test was used to assess difference in stroke rates. Patient satisfaction score was collected using the existing institutional survey. Results: Eighty-one participants were included, 40 in the clinic group and 41 in the admission group. The mean ages in the clinic group and the admission group were 72.8 and 75.2 years, respectively ( p =0.37). Females comprised 45% of patients in the clinic group, compared to 51.2% in the admission group ( p =0.58). The mean ABCD 2 scores were 4.08 and 3.95 in the clinic and admission groups, respectively ( p= 0.63). The median clinic follow-up time was six days. There was no stroke incidence in the clinic group and one incidence in the admission group ( p =1.0) within 90 days of index TIA. Patient satisfaction score of the NP was 92.6%. Conclusions: In conclusion, referral to an NP-led clinic in patients with low-to-moderate risk TIA was equally safe as hospital admission.

Abstract 13658: Impact of Risk Factors for Atrial Fibrillation on the Incidence of Stroke in African American Females

Background: It is well-known that African American (AA) patients with Atrial Fibrillation (AF) have a higher incidence of stroke in comparison to the general population. To our knowledge, limited data exist on gender disparities in risk factors contributing to a higher incidence of stroke among AA patients. The objective of this study is to identify gender disparities in risk factors for AF by comparing AA females and males with AF. Methods: AA patients aged 18 years old or above with a diagnosis of AF were included in this study. Patients were selected from the 2019 national inpatient sample. The primary outcome of interest was incidence of stroke. T-test was used to compare differences in continuous variables. For categorical variables, pearson chi-square was used to compare differences. Multivariate logistic regression was used to adjust for potential confounders. A 2-sided P&lt;0.05 was considered significant throughout the analyses. Results: This study included 45,102 AA female patients with AF, and 46,768 AA male patients with AF. In our study, female patients had higher prevalence of Hypertension (HTN) (22.3% vs 19.0, P&lt;0.001), Diabetes Mellitus (DM) (48.1 vs 46.0, P&lt;0.001), Obesity (27.8 vs 20.8), Hyperlipidemia (HLD) (50.9% vs 49.1%, P&lt;0.001), Hyperthyroidism (2.2% vs 1.2%, P&lt;0.001), and Chronic Obstructive Pulmonary Disease (COPD) (24.8% vs 23.2%, P&lt;0.001). AA female patients with AF experienced higher incidence of stroke compared to AA male patients with AF, (4.9% vs 4.1%, p-value &lt;0.001) and the odds of stroke also showed higher in female patients (aOR=1.10, 95% CI: 1.03-1.18, p &lt;0.005) after controlling for comorbidities. Only HTN and HLD showed statistically significant association with stroke in univariate analysis, (OR=2.02, 95% CI: 1.89-2.16 and OR=1.24, 95% CI:1.16-1.31, respectively) Conclusion: In our study, we identified that AA female patients with AF had a higher incidence of stroke compared to AA male patients with AF. Only HTN and HLD were significant risk factors contributing to the increased stroke incidence in the female group. The findings of our study are hypothesis-generating, and well-powered randomized controlled trials are needed to validate these findings.

Low-to-Moderate Risk Transient Ischemic Attack Patients Can Be Safely Discharged From the Emergency Department to a Nurse Practitioner-Led Clinic.

BACKGROUND: Unnecessary admissions fuel rising healthcare costs and take away resources from higher acuity patients without evidence of increased safety. The purpose of this quality improvement project was to determine whether the care diversion for transient ischemic attack (TIA), from inpatient to a nurse practitioner (NP)-led specialty clinic, resulted in no increase in stroke incidence at 90 days. METHODS: The sample included all adults presenting to the emergency department with TIA at a low-to-moderate risk for stroke. Risks were defined by the ABCD 2 score and noninvasive vessel imaging. Patients who met the criteria were discharged and evaluated by a stroke NP at the TIA clinic within 7 days. These patients were compared with those who were admitted before clinic launch. Medical record reviews were conducted to determine stroke incidence at 90 days post TIA. Descriptive statistics were used to evaluate clinical variables, and Fisher exact test was used to assess difference in stroke rates. Patient satisfaction score was collected using the existing institutional survey. RESULTS: Eighty-one participants were included, 40 in the clinic group and 41 in the admission group. The mean ages in the clinic and admission groups were 72.8 and 75.2 years, respectively ( P = .37). Women comprised 45% of patients in the clinic group, compared with 51.2% in the admission group ( P = .58). The mean ABCD 2 scores were 4.08 and 3.95 in the clinic and admission groups, respectively ( P = .63). The median clinic follow-up time was 6 days. There was no stroke incidence in the clinic group and 1 in the admission group within 90 days post TIA. Patient satisfaction score metrics for the NP exceeded the institutional benchmark of 90%. CONCLUSION: Referral to an NP-led clinic in patients with low- to moderate-risk TIA was equally safe as hospital admission.

Urban exposome and stroke incidence across Europe

Background and Aim: Multiple environmental factors of urban environments may influence cardiovascular health, however their complex interplay has scarcely been studied. Within the EXPANSE project, we evaluated the association between multiple urban exposures and stroke incidence across Europe. Methods: We will conduct a meta-analysis including 3 population-based cohorts (from Sweden, Netherlands, Germany) and 6 administrative cohorts (from Greece, Rome, Catalonia, Switzerland, Sweden, Netherlands). Participants were followed-up until incident stroke, death, migration, disappearance or end of study period. We estimated multiple long-term exposures at residential addresses from different domains: ambient air pollution (nitrogen dioxide, particulate matter &amp;#x3c;2.5m, black carbon, ozone), built environment (green and blue spaces, impervious surface) and meteorology (mean and standard deviation temperatures during summer and winter). Associations between environmental exposures and incident stroke were estimated in single and multiple-exposure Cox proportional hazard models, and Principal Component Analyses (PCA) derived prototypes for exposures domain (i.e built environment). Results: Preliminary results from Sweden (N=19,247), from single and multiple exposures, indicate associations between increased levels of NDVI and reduced incident stroke (hazard ratio (HR) per 0.1 units = 0.92, 95%CI 0.85; 0.99). The first component of each domain in the PCA explained more than 60% of the variability. The built environment domain (capturing high levels of green spaces and low levels of impervious surface) showed a borderline association with incident stroke (HR per interquartile range of the component = 0.92, 95%CI 0.83; 1.01). We also found a suggestive association between air pollution and increased stroke incidence. Conclusions: In preliminary results in Sweden, we found a suggestion for independent effects of green space and air pollution on incident stroke. Further analyses on the other cohorts are ongoing. Keywords: stroke, urban exposome, meta-analysis, air pollution, green space, temperature, blue space.

Efficacy of Robots-Assisted Therapy in Patients With Stroke: A Meta-analysis Update.

Robot-assisted therapy (RAT) could address an unmet need to relieve the strain on healthcare providers and intensify treatment in the context of an increasing stroke incidence. A comprehensive meta-analysis could provide firmer data about the topic by considering methodology limitations discovered in previous reviews and providing more rigorous evidence. This meta-analysis study identifies RAT's efficacy for patients with stroke. A systematic search of the 7 databases from January 10 to February 1, 2022, located relevant publications. We used the updated Cochrane risk-of-bias checklist for 52 trials to assess the methodologic quality of the included studies. The efficacy of RAT for patients with stroke was estimated using a pooled random-effects model in the Stata 16 software application. The final analysis included 2774 patients with stroke from 52 trials. In those patients, RAT was proven to improve quality of movement (mean difference, 0.15; 95% confidence interval, 0.03-0.28) and to reduce balance disturbances (mean difference, -1.28; 95% confidence interval, -2.48 to -0.09) and pain (standardized mean difference, -0.34; 95% confidence interval, -0.58 to -0.09). Robot-assisted therapy seems to improve the quality of mobility and reduce balance disturbances and pain for patients with stroke. These findings will help develop advanced rehabilitation robots and could improve health outcomes by facilitating health services for healthcare providers and patients with stroke.

Association of Younger vs Older Ages With Changes in Incidence of Stroke and Other Vascular Events, 2002-2018

Some studies have reported increasing stroke incidence at younger ages (<55 years) but have often relied only on administrative data, and more population-based studies of adjudicated stroke are required. An understanding of the drivers of any increase in incidence of young stroke also requires comparisons with stroke trends at older ages and with trends in incidence of other vascular events at younger ages. To determine temporal changes in incidence of stroke and other major vascular events at younger vs older ages. Prospective population-based incidence study conducted from April 2002 to March 2018 with a mean catchment population of 94 567 in Oxfordshire, England. Calendar time, premorbid vascular risk factors, and occupation. Changes in incidence of stroke, transient ischemic attack (TIA), and other major vascular events (myocardial infarction, sudden cardiac death, and peripheral vascular events) stratified by age, sex, diagnostic workup, etiology, and severity. A total of 2429 incident strokes were ascertained (mean age, 73.6 [SD, 14.4] years; 51.3% female). From 2002-2010 to 2010-2018, stroke incidence increased significantly among participants younger than 55 years (incidence rate ratio [IRR], 1.67; 95% CI, 1.31-2.14) but fell significantly among participants aged 55 years or older (IRR, 0.85; 95% CI, 0.78-0.92; P < .001 for difference). The significant increase in incidence at younger than 55 years was independent of sex, stroke severity, pathological subtype, and changes in investigation and was also seen for TIA (IRR, 1.87; 95% CI, 1.36-2.57) but not for myocardial infarction and other major vascular events (IRR, 0.73; 95% CI, 0.58-0.93). Although TIA and stroke at younger than 55 years were significantly associated with diabetes (risk ratio [RR], 3.47; 95% CI, 2.54-4.74), hypertension (RR, 2.52; 95% CI, 2.04-3.12), current smoking (RR, 2.38; 95% CI, 1.92-2.94), and obesity (RR, 1.36; 95% CI, 1.07-1.72), the significant increase in incidence from 2002-2010 to 2010-2018 was still seen in individuals without these risk factors. The increase was greatest in professional/managerial occupations (IRR, 2.52; 95% CI, 1.75-3.62) and least in partially skilled/unskilled occupations (IRR, 1.17; 95% CI, 0.79-1.74). The proportion of TIAs and strokes among those younger than 55 years without known vascular risk factors increased significantly over time (45 [30.4%] vs 115 [42.4%]; absolute difference, 12.0%; 95% CI, 2.6-21.5), especially in patients with cryptogenic events (10 [18.5%] vs 63 [49.2%]; absolute difference, 30.7%; 95% CI, 17.2-44.2; P < .001; P = .002 for heterogeneity). Comparing persons living in Oxfordshire, England, in 2002-2010 vs 2010-2018, there was a significant increase in stroke incidence in those younger than 55 years, but a decrease in those aged 55 years or older. Given the absence of this divergence for other vascular events, further research is needed to understand the causes of this difference.

Acute Ischemic Stroke in the Context of SARS-CoV-2 Vaccination: A Systematic Review.

BackgroundThere have been reports suggesting an increased incidence of acute ischemic stroke among anti-SARS-CoV-2 vaccinees. We aimed to systematically review the literature to summarize the available evidence on the association between SARS-CoV-2 vaccination and acute ischemic stroke.MethodsA systematic literature search on MEDLINE, LitCovid and LIVIVO databases was performed for eligible randomized controlled trials, observational studies, registries and case reports that reported on imaging-confirmed acute ischemic stroke in the context of any SARS-CoV-2 vaccination with BNT162b2, mRNA-1273, Ad26.COV2.S, ChAdOx1 or Gam-COVID-Vac. Literature search was limited to English and German languages and publication date before October 19, 2021.ResultsWe identified a total of 395,105,670 individuals who underwent vaccination. We found 21 sources, including 2 cohort studies, 4 registry studies, 3 randomized clinical trials, and 12 case reports. Individuals included in these studies were at least 16 years old. Cari et al observed a higher likelihood of acute ischemic stroke in vaccinees aged 18–64 years, compared to Whiteley et al observing vaccinees older than 70 years when vaccinated. In addition, differences in the likelihood of acute ischemic stroke were found among the vaccines studied, although no overall increased stroke incidence was demonstrated with vaccination.ConclusionIn this systematic review of the available literature, we found that the risk of acute ischemic stroke does not appear to be increased in vaccinated individuals who have received any of the currently licensed SARS-CoV-2 vaccines compared with the baseline incidence of stroke.

Bringing rehabilitation home with an e-health platform to treat stroke patients: study protocol of a randomized clinical trial (RGS@home)

BackgroundThere is a pressing need for scalable healthcare solutions and a shift in the rehabilitation paradigm from hospitals to homes to tackle the increase in stroke incidence while reducing the practical and economic burden for patients, hospitals, and society. Digital health technologies can contribute to addressing this challenge; however, little is known about their effectiveness in at-home settings. In response, we have designed the RGS@home study to investigate the effectiveness, acceptance, and cost of a deep tech solution called the Rehabilitation Gaming System (RGS). RGS is a cloud-based system for delivering AI-enhanced rehabilitation using virtual reality, motion capture, and wearables that can be used in the hospital and at home. The core principles of the brain theory-based RGS intervention are to deliver rehabilitation exercises in the form of embodied, goal-oriented, and task-specific action.MethodsThe RGS@home study is a randomized longitudinal clinical trial designed to assess whether the combination of the RGS intervention with standard care is superior to standard care alone for the functional recovery of stroke patients at the hospital and at home. The study is conducted in collaboration with hospitals in Spain, Sweden, and France and includes inpatients and outpatients at subacute and chronic stages post-stroke. The intervention duration is 3 months with assessment at baseline and after 3, 6, and 12 months. The impact of RGS is evaluated in terms of quality of life measurements, usability, and acceptance using standardized clinical scales, together with health economic analysis. So far, one-third of the patients expected to participate in the study have been recruited (N = 90, mean age 60, days after stroke ≥ 30 days). The trial will end in July 2023.DiscussionWe predict an improvement in the patients’ recovery, high acceptance, and reduced costs due to a soft landing from the clinic to home rehabilitation. In addition, the data provided will allow us to assess whether the prescription of therapy at home can counteract deterioration and improve quality of life while also identifying new standards for online and remote assessment, diagnostics, and intervention across European hospitals.Trial registrationClinicalTrials.gov NCT04620707. Registered on November 3, 2020