Ischemic Stroke Cases Research Articles

Frequency of Hyperuricemia In Patients Presenting with Acute Ischaemic Stroke

Hyperuricemia refers to elevated serum uric acid concentration above the upper limit of normal. Objective: To determine hyperuricemia in patients presenting with acute ischemic stroke to the Neurology ward of Lady Reading Hospital, Peshawar. Methods: A total of 153 patients were observed to the frequency of hyperuricemia in patients presenting with acute ischemic stroke. Study design was cross sectional study which was conducted for the period of 6 months. The total Sample size was calculated by using WHO sample size calculator. It was calculated using the World Health Organization software. Results: A total of 153 patients were observed to the frequency of hyperuricemia in patients presenting with acute ischemic stroke. Mean age of study participants was 52.45±1.14 years. Distribution of hyperuricemia was 114(74.5%). Mean serum uric acid level among cases of acute ischemic stroke was 06.15 ± 01.91 mg/dl while the mean serum uric acid level among control group was 05.1 ± 01.4 mg/dl. The results were highly significant p-value < 0.0001. Conclusions: Serum uric acid levels can be used to predict stroke risk. Moreover, serum uric acid can be utilized to stratify risk following a stroke. Long-term prospective research is needed to determine the involvement of serum uric acid in ischemic stroke. A trial of serum uric acid reducing medications in stroke patients as well as those at high risk of stroke may also be worthwhile.

Plasma β-Alanine is Positively Associated With Risk of Ischemic Stroke: a Nested Case-Control Study

BackgroundPrevious studies suggested that β-alanine as a neurotransmitter could affect the pathogenesis of ischemic damage. However, the association between circulating β-alanine and risk of ischemic stroke (IS) has not been evaluated in populations. ObjectivesWe aimed to examine the association between β-alanine and IS risk in a nested case-control study. MethodsWe performed a case-control study nested within a prospective community-based cohort (n = 16457; median follow-up time: 5.3 y), which included 321 incident IS cases and 321 controls matched by age and sex. Β-alanine and other metabolites were measured in plasma after overnight fasting by LC-MS/MS. The association of β-alanine with risk of IS was evaluated by conditional logistic regression. BMI, current smoking, educational attainment, physical activity, total energy intake, family history of stroke, hypertension, diabetes, hyperlipidemia, and estimated GFR were adjusted in multivariable models. ResultsThere was a significant Spearman partial correlation between β-alanine and 4-pyridoxic acid (ρ = 0.239; P < 0.001). Participants with elevated β-alanine levels were more likely to develop IS with an adjusted OR of 1.26 (95% CI: 1.06–1.51; P = 0.011) (per standard deviation increment). This association remained significant after excluding the first 2 y of follow-up, and after further adjustment for red meat intake, total protein intake, medication use, or vitamin B6 indicators. ConclusionsOur novel findings revealed that plasma β-alanine at baseline were positively associated with risk of IS and may function as an early biomarker of IS risk.

Associations of reproductive factors with incidence of myocardial infarction and ischemic stroke in postmenopausal women: a cohort study

BackgroundTo assess the association between the reproductive factors of age at menarche, age at menopause, and reproductive span and the incidence of myocardial infarction (MI) and ischemic stroke (IS).MethodsWe used a population-based retrospective cohort study from the National Health Insurance Service database of Korea including a total of 1,224,547 postmenopausal women. Associations between age at menarche (≤ 12, 13–14 [reference], 15, 16, and ≥ 17 years), age at menopause (< 40, 40–45, 46–50, 51–54 [reference], and ≥ 55 years), and reproductive span (< 30, 30–33, 34–36, 37–40 [reference], and ≥ 41 years) and the incidence of MI and IS were assessed by Cox proportional hazard models with adjustment for traditional cardiovascular risk factors and various reproductive factors.ResultsDuring a median follow-up of 8.4 years, 25,181 MI and 38,996 IS cases were identified. Late menarche (≥ 16 years), early menopause (≤ 50 years), and short reproductive span (≤ 36 years) were linearly associated with a 6%, 12–40%, and 12–32% higher risk of MI, respectively. Meanwhile, a U-shaped association between age at menarche and risk of IS was found, with a 16% higher risk in early menarche (≤ 12 years) and a 7–9% higher risk in late menarche (≥ 16 years). Short reproductive span was linearly associated with an increased risk of MI, whereas both shorter and longer reproductive spans were associated with an increased risk of IS.ConclusionsThis study demonstrated different patterns of association between age at menarche and incidence of MI and IS: a linear association for MI versus a U-shaped association for IS. Female reproductive factors in addition to traditional cardiovascular risk factors should be considered when assessing overall cardiovascular risk in postmenopausal women.

Whole-Exome Sequencing Analyses Support a Role of Vitamin D Metabolism in Ischemic Stroke.

Ischemic stroke (IS) is a highly heritable trait, and genome-wide association studies have identified several commonly occurring susceptibility risk loci for this condition. However, there are limited data on the contribution of rare genetic variation to IS. We conducted an exome-wide study using whole-exome sequencing data from 152 058 UK Biobank participants, including 1777 IS cases. We performed single-variant analyses for rare variants and gene-based analyses for loss-of-function and deleterious missense rare variants. We validated these results through (1) gene-based testing using summary statistics from MEGASTROKE-a genome-wide association study of IS that included 67 162 IS cases and 454 450 controls, (2) gene-based testing using individual-level data from 1706 IS survivors, including 142 recurrent IS cases, enrolled in the VISP trial (Vitamin Intervention for Stroke Prevention); and (3) gene-based testing against neuroimaging phenotypes related to cerebrovascular disease using summary-level data from 42 310 UK Biobank participants with available magnetic resonance imaging data. In single-variant association analyses, none of the evaluated variants were associated with IS at genome-wide significance levels (P<5×10-8). In the gene-based analysis focused on loss-of-function and deleterious missense variants, rare genetic variation at CYP2R1 was significantly associated with IS risk (P=2.6×10-6), exceeding the Bonferroni-corrected threshold for 16 074 tests (P<3.1×10-6). Validations analyses indicated that CYP2R1 was associated with IS risk in MEGASTROKE (gene-based test, P=0.003), with IS recurrence in the VISP trial (gene-based test, P=0.001) and with neuroimaging traits (white matter hyperintensity, mean diffusivity, and fractional anisotropy) in the UK Biobank neuroimaging study (all gene-based tests, P<0.05). Because CYP2R1 plays an important role in vitamin D metabolism and existing observational evidence suggests an association between vitamin D levels and cerebrovascular disease, our results support a role of this pathway in the occurrence of IS.

Abstract WMP108: Genomic Risk Scores And Oral Contraceptive-associated Ischemic Stroke Risk

Objective: To evaluate whether a genomic risk score for ischemic stroke (IS) modifies oral contraceptive (OC)-associated IS risk. Background: OCs are generally safe but vascular risk factors are known to increase OC-associated IS risk. If a genomic risk score could identify a subset of women with substantially increased risk of OC-associated IS, this could influence prescribing guidelines and reduce stroke events. Methods: In the Genetics of Early-Onset Stroke (GEOS) study, there were 340 premenopausal women (143 IS cases and 197 controls) with data on OC use within 30 days prior to index event for cases or prior to interview for controls. Using a previously validated genomic risk score (metaGRS) for IS based on 19 polygenic risk scores of vascular events and risk factors, we stratified our sample into tertiles of genomic risk and calculated the association between OC use and IS within each tertile. We tested if the association between OC use and IS depended on genomic risk of stroke using logistic regression with an OC use*metaGRS interaction term. Results: Among all women, OC use was significantly associated with IS (odds ratio = 2.4, p = 0.002). The odds ratio for IS associated with OC use decreased from 3.9 in the tertile with highest genomic risk of IS to 1.5 in the tertile with lowest genomic risk (see Table). The formal test of interaction was consistent with our hypothesis (p = 0.07) that the genomic risk score modifies the association of OC use with IS. Conclusions: The results of our exploratory analysis support the need for international collaboration to generate sufficient sample sizes to determine whether a genomic risk score could be clinically useful in reducing OC-associated IS.

Abstract WMP106: Sex-stratified Transethnic GWAS Meta-analysis Identifies Novel Candidates For Early Onset Ischemic Stroke

Background: Early onset ischemic stroke (IS) affects males and females unequally, but the etiologic background of the sex differences remains inadequately understood. We hypothesize that stratifying GWAS by sex provides an opportunity to 1) identify loci that shed light on mechanisms and pathways relevant to sex specific effects in IS and 2) discover novel IS loci. Methods: We performed a sex-stratified transethnic GWAS meta-analysis in 6,879 female IS cases and 11,264 male cases &lt; 60 years-old and &gt; 700,000 sex-matched controls from the Early Onset Stroke Genetics Consortium. We tested for difference (p-diff) between the men- and women-specific beta-estimates with corresponding standard errors using the t statistics. Results: We found genome-wide significant evidence for association (p &lt; 5 х 10 -8 ) at a locus near NYAP2 for females (chr2:225661726:C:CT, p = 2.11 х 10 -8 , OR = 1.38, p-diff = 1.69 х 10 -4 ) and in PIAS4 for males (chr19:4013652:C:CA, p = 6.29 х 10 -9 , OR = 0.85, p-diff = 0.02) in transethnic analysis. NYAP2 has previously shown suggestive evidence for association with early onset menopause. PIAS4 , a candidate gene for migraine, has shown sex-specific expression levels in migraine patients compared to controls. Additional loci with suggestive evidence (p &lt; 1 х 10 -6 ) for association in a sex-dependent manner included MMP1-MMP3 - MMP12 , a previously known stroke locus, for males (chr11:102822455:A:G, p = 3.99 х 10 -7 , OR = 1.17, p-diff = 0.02), and a novel stroke locus near TMX1 , a transmembrane platelet protein, for females (chr14:51193174:G:C, p = 4.15 х 10 -7 , OR = 1.76, p-diff = 4.08 х 10 -3 ). The known early onset IS locus ABO did not show evidence for sex-specific association despite suggestive association in the male stratified analysis (chr9:133274295:A:T, p = 3.15 х 10 -7 , OR = 1.17, p-diff = 0.81). Conclusions: We identified potential novel stroke loci and evidence for sex differences at other biologically relevant loci by stratifying GWAS by sex. To our knowledge, our cohort represents the largest early onset IS GWAS cohort to date. However, our findings require verification in large sample sizes and also evaluation in older onset IS. Sex-specific association analysis is a potentially useful tool for characterizing the genetic basis of early onset IS.

Abstract TMP106: Decline In The Severity Of Hospitalized Ischemic Stroke 2005-2015: The Greater Cincinnati/Northern Kentucky Stroke Study

Background: Monitoring changes in ischemic stroke severity at the population level is important as changes in risk factors and clinical treatments could influence stroke severity. We describe trends in the distribution of NIHSS across 3 time periods in a population-based epidemiologic stroke study. Methods: In 2005, 2010, and 2015 all adult acute ischemic strokes occurring within the Greater Cincinnati area presenting to 15 hospitals were ascertained using discharge codes (ICD-9 433-436; IDC-10 I63-I68, G45-46). Following physician verification, confirmed ischemic stroke cases underwent chart abstraction including estimation of a retrospective (rNIHSS) score at presentation. Descriptive statistics (rNIHSS median, IQR) were generated by survey year, demographics, and medical history. Using a binary definition of stroke severity (median rNIHSS score &amp;gt 4 versus &amp;lt 4), multivariable logistic regression was used to estimate changes in stroke severity over time, adjusting for potential confounders. Random effects were used to account for multiple admissions occurring in the same subject. Results: The number of ischemic stroke admissions in the 2005, 2010, and 2015 surveys was 1778, 1903, and 1933, respectively (Table). The median (IQR) rNIHSS scores were 3 (2-7), 3 (1-6), and 2 (1-6) across the 3 surveys, respectively; the proportion of admissions with rNIHSS &amp;gt 4 was 48%, 39% and 37%, respectively. After adjusting for demographics, medical history and pre-stroke function, compared to 2005, the odds ratio for more severe stroke was 0.69 (95% CI= 0.60-0.79, p=0.001) in 2010 and 0.63 (95% CI= 0.55-0.73, p=0.001) in 2015. Conclusions: In this population- based study there was a statistically significant change in the severity of ischemic stroke hospitalizations with increases in the proportion of milder strokes over time. Potential reasons for this change need to be explored but could include changes in risk factors, clinical treatments or diagnostic approach.

Evaluation of Transient Ischemic Stroke Cases Admitted to a Tertiary Hospital in Mehedinți County, South-West of Romania.

The transient ischemic attack (TIA) is a common cerebrovascular ischemic disease whose symptoms resolve within a maximum of 24 hours. The study carried out by us is a retrospective descriptive one, in which we sought to highlight the main characteristics of TIA in patients admitted to the Emergency Hospital in Turnu-Severin municipality in Mehedinți county, in the period 2016-2020, including a group of 53 patients, mainly from Mehedinți county. The analysis of the study group and the risk factors showed that TIA mainly affects the elderly, over 50 years old, with the highest incidence being recorded in the 60-80-year age groups, with an extremely low incidence under 40 years. Significant differences were found between the sexes and between the social environments, with women and people from the urban environment being more prone to suffer a TIA. Among the most important modifiable risk factors encountered in TIA patients included in the study, the following were highlighted: HTN, obesity and atherosclerosis. Knowing the modifiable factors and combating them can improve the prognosis of AIT.

Abstract WP14: A Patient-level Data Euclidean-matched Analysis Of Reperfusion Therapies In Acute Ischemic Stroke From The Latin American Stroke Registry (lase)

Introduction: As acute stroke therapies expand to less well-resourced regions, it is imperative to study real-world data to assess outcomes and the quality of stroke care. The present study analyzes clinical, and imaging outcomes after acute IV thrombolysis (IV-tPA) compared to mechanical thrombectomy (MT) or combined therapy in the LASE. Methods: A retrospective analysis of consecutive acute ischemic stroke cases in 17 centers from 9 Latin American (LA) countries since 2012 was performed using weighted Euclidean matching of nearest neighbors in 3-D space of baseline NIHSS, age, and glucose. Results: 950 patients receiving only IV-tPA were matched to 127 treated with MT+IV-tPA. Matching resulted in 97 pairs well balanced for age (69.1 vs. 69.3), baseline NIHSS (17 vs. 17), and glucose (124.3 vs. 124.5), all p&gt;0.2. 3-month mRS 0-1 (38.3% vs 29.8%, p=0.23) and mRS 0-2 (46.8% vs 41.5%, p=0.54) were non-significantly higher in the MT+IV-tPA group, with higher hemorrhage (26.6% vs 15.5%, p=0.05) and trends for higher death (15.1% vs 9.5%, p=0.40) and symptomatic hemorrhage (7.4% vs 6.2%, p=1.0). One hundred one patients receiving only MT were matched to 127 patients with MT+IV-tPA, resulting in 61 pairs; MT+IV-tPA showed trends for higher rates of 3-month mRS 0-1 (45.0% vs 35.6%, p=0.31), mRS 0-2 (48.3% vs 42.4%, p=0.54); with trends for lower rates of death (16.9% vs 20.0%, p=1.0) and symptomatic hemorrhage (8.3% vs 11.1%, p=0.75). Conclusions: In this real-world LA sample, trends for better functional outcomes were demonstrated with MT+IV-tPA compared to either treatment alone, as in non-LA populations. A trend for higher adverse events in the combined group requires further investigation.

Abstract WP184: Identifying Optimal Cut Points Of National Institutes Of Health Stroke Scale To Predict Mortality: A Population-based Assessment

Background: Ischemic stroke is the 5 th leading cause of death in the US. As a measure of stroke severity, initial NIHSS has been used to predict clinical outcome. We sought to identify the optimal cut-points of NIHSS at initial presentation that are associated with higher 30-day mortality. Methods: In 2005, 2010, and 2015 all hospitalized, first acute ischemic stroke events occurring within the Greater Cincinnati area were ascertained. Potential ischemic stroke cases underwent chart abstraction and physician adjudication, including retrospective NIHSS score (range 0 - 42) based on clinical findings at initial presentation. Descriptive statistics for NIHSS were estimated by study year, demographics, and medical history. Data regarding mortality was obtained from the National Death Index. The Contal and O’Quigley method based on a modified log-rank test statistic was used to determine cut-points of the NIHSS score associated with 30-day mortality, and hazard ratios were obtained from Cox models with adjustment for sex, race, and age. Results: In 2005, 2010, and 2015 there were 1704, 1818 and 1852 ischemic stroke events with 30-day mortality rates of 10.5%, 9.6% and 9.0%, respectively. Optimal cut-points of NIHSS &lt;9, 9-16 and &gt;16 were identified. Across all 3 periods, 3431 (84.5%) cases had NIHSS 0-8, 352 (8.7%) had NIHSS 9-16 and 274 (6.8%) &gt;16. Kaplan Meier Survival Curves for the 3 NIHSS groups are shown in the Figure. Strokes with NIHSS &gt;16 at initial presentation were associated with a 15-fold (HR with 95% CI: 13, 19) increase in the risk of death at 30-days compared to those with NIHSS &lt;9. Discussion: NIH Stroke Scale scores are a reliable predictor of mortality, with higher NIHSS scores having higher risk of death. The cut points reported identify subgroups of stroke patients with dramatically different prognoses. Future studies should assess if this excess mortality risk among severe strokes persists after the more widespread implementation of thrombectomy beyond 2015.

Abstract 83: Racial Disparities In Gluconic Acid, A Lifestyle-related Biomarker Associated With Stroke In REGARDS

Introduction: In the United States, the risk of stroke is greater among Black compared to White adults. Furthermore, hypertension has a greater impact on stroke risk among Black adults. We hypothesized that race-specific metabolites may account for some of this observed disparity. Methods: This was a case-cohort study nested in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Incident ischemic stroke cases (n=1,075) were compared with a random cohort sample (n=968). Metabolites were measured by liquid chromatography-tandem mass spectrometry. Weighted logistic regression and Cox proportional hazard model were used to identify race-specific metabolites in association with prevalent hypertension and incident stroke respectively. Candidate metabolites were assessed for mediation between hypertension and incident ischemic stroke. Linear regression was used to explore the association of metabolites with lifestyle factors. Results: A total of 162 plasma metabolites were quantified. Of these, gluconic acid was associated with prevalent hypertension in Black adults (OR=1.86, 95% CI=1.39-2.47, P =2.58x10 -5 ) but not in White adults (OR=1.00, 95% CI=0.80-1.24, P =0.97; P for interaction=4.57x10 -4 ). Gluconic acid was also associated with incident ischemic stroke among Black adults (HR=1.53, 95% CI=1.28-1.81, P =1.76x10 -6 ) but not White adults (HR=1.16, 95% CI=1.00-1.34, P =0.057; P for interaction=0.019). Gluconic acid mediated 25.4% (95% CI=4.1%-46.8%, P =0.02) of the association between hypertension and ischemic stroke among Black adults. Specific lifestyle factors were linked to elevated gluconic acid level among Black adults in multivariable analysis, including a Southern diet (β=0.18, 95% CI=0.08-0.28, P &lt;0.001), lower educational attainment (β=0.45, 95% CI=0.19-0.72, P =0.001), and lack of exercise (β=0.26, 95% CI=0.01-0.51, P =0.045). Conclusions: Gluconic acid is a lifestyle-related biomarker that is associated with prevalent hypertension, incident ischemic stroke, and mediates the relationship between hypertension and ischemic stroke in Black adults. Key factors linked to gluconic acid include Southern diet, low educational attainment, and low physical activity.

Neutrophil lymphocyte ratio (NLR) and systemic immune inflammatory index (SII) for the differential diagnosis of CT-negative mild acute ischemic stroke and transient ischemic attack

Background: A number of acute ischemic stroke (AIS) cases may be misdiagnosed as transient ischemic attack (TIA), due to no infarct on initial computed tomography scan and/or mild deficits upon presentation. Several studies have found that the neutrophil–lymphocyte ratio (NLR) is an accurate differential diagnostic biomarker for AIS versus TIA; however, no study has evaluated the use of the NLR in differentiating CT negative AIS from TIA. Furthermore, the systemic immune-inflammation index (SII) is a relatively novel immune biomarker that has been shown to be positively correlated with AIS severity, poor functional outcomes and mortality. The purpose of this study is to determine if NLR or SII can be used as a diagnostic biomarker for the differential diagnosis of mild AIS with a negative CT upon admission and TIA. Methods: We performed a retrospective medical record review of patients diagnosed with either AIS or TIA. We collected peripheral white blood cell counts within 24 h of symptom onset and calculated the NLR and SII. Logistic regression was utilized to determine if NLR or SII are significant predictors of CT negative mild AIS. Results: CT negative mild AIS patients were 2 times as likely to have an NLR ≥ 2.71 compared to TIA patients, and CT negative mild AIS patients were 2.1 times as likely to have an SII ≥ 595 compared to TIA patients. Conclusion: NLR and SII are easily obtained biomarkers that can be used in early clinical decision making in cases of mild AIS with negative CT scan upon admission.

Outcome predictors in anterior and posterior ischemic strokes: a study based on the Iranian SITS registry

Ischemic stroke is the major form of stroke with two separate vascular territories. Many risk factors are related to stroke outcomes in both territories. The present descriptive research was carried out on the basis of data obtained from the Safe Implementation of Treatments in Stroke (SITS) registry on Iranian intravenous thrombolysis ischemic stroke cases. Vascular territory involved in each case and three-month excellent outcome, functional independence, mortality rate, and brain hemorrhage occurrence were determined. Univariable and multivariable logistics regression analyses were utilized in order to investigate association of ischemic stroke outcomes with the vascular territory involved and other related factors. Among 1566 patients 95.4% was anterior circulation stroke patients and 4.6% was posterior circulation stroke cases. There is no significant association between vascular territory with mortality (OR of PCS vs ACS: 0.74, 95% CI 0.37–1.46), excellent functional outcome (OR 0.72, 95% CI 0.44–1.19), functional outcome (OR 0.86, 95% CI 0.52–1.42) and local hemorrhage (OR 0.98, 95% CI 0.30–3.21). Among major risk factors, age, diabetes, NIHSS score and admission duration, increased significantly odds of three-month mortality, excellent outcome, and functional independence in the multivariate analysis. The highest of odds was in NIHSS score with a dose–response association. The vascular territory was not an outcome predictor in ischemic strokes. The most important predictor was baseline NIHSS.

Features of prediction of fatal and non-fatal cases of ischemic stroke in patients with peripheral atherosclerosis in the long-term period

Introduction. According to official statistics, stroke ranks second in the structure of mortality in Russia after coronary heart disease. Mortality and morbidity rates from this pathology among people of working age have recently increased by more than 30%. It should be clarified that the main cause influencing the development of acute cerebrovascular accident is hemodynamically significant atherosclerosis of the carotid vessels. Moreover, the pathological process itself can progress rapidly, or, on the contrary, remain stable for a long time.Aim. To assess the features of the development of fatal and non-fatal cases of ischemic stroke and develop an optimal approach to its assessment in patients with peripheral atherosclerosis in the long-term period.Materials and methods. The study included a group of 519 patients with atherosclerotic lesions of various vascular beds. The average age of the examined patients was 60.0 ± 8.7 years.All persons underwent standard biochemical studies, a set of instrumental studies, in the presence of clinical manifestations that arouse suspicion of atherosclerotic lesions of the vascular pools, coronary angiography, angiography of the renal vessels, brachiocephalic arteries and arteries of the lower extremities were performed. The second stage of the work included a prospective follow-up of patients for three years with an assessment of the endpoints.Results. In the course of the statistical analysis, it was revealed that factors such as a history of amputation of the lower limb (p = 0.048), chronic ischemia of the lower extremities (p = 0.016), atherosclerosis of the abdominal aorta (p = 0.024) influenced the risk of developing non-fatal ischemic stroke in examined patientsConclusions. The complex analysis carried out made it possible to develop an original nomogram for assessing the risk of developing fatal and non-fatal cases of ischemic stroke in the long-term period, which can be used in real clinical practice.

Nationally Certified Stroke Centers Outperform Self-Attested Stroke Centers in the Florida Stroke Registry.

The Florida Stroke Act, signed into law in 2004, set criteria for Comprehensive Stroke Centers (CSC). For a set time period, Florida hospitals were permitted to either receive national certification (NC) or could self-attest (SA) as fulfilling CSC criteria. The aim of this project was to evaluate the quality of ischemic stroke care in NC versus SA stroke centers in Florida, using well-known, guideline-driven ischemic stroke outcome metrics. A total of 37 CSCs (74% of Florida CSCs) in the Florida Stroke Registry from January 2013 through December 2018 were analyzed, including 19 SA CSCs and 18 NC (13 CSCs and 5 Thrombectomy-Capable Stroke Center). Hospital- and patient-level characteristics and stroke metrics were evaluated, adjusting for demographics, medical comorbidities, and stroke severity. A total of 78 424 acute ischemic stroke cases, 36 089 from SA CSCs and 42 335 from NC CSC/Thrombectomy-Capable Stroke Centers were analyzed. NC centers had older patients (73 [61-83] versus 71 [60-81]; P<0.001) with more severe strokes (median National Institutes of Health Stroke Scale score of 5 versus 4; P<0.001). NC had higher intravenous tissue-type plasminogen activator utilization (15% versus 13%; P<0.001), endovascular treatment (10% versus 7%; P<0.001) and faster median door-to-computed tomography (23 minutes [11-73] versus 31 [12-78]; P<0.001), door-to-needle (37 minutes [26-50] versus 45 [34-58]; P<0.001) and door-to-puncture times (77 minutes [50-113] versus 93 [62-140]; P<0.001). In adjusted analysis, patients arriving to NC hospitals by 3 hours were more likely to get intravenous tissue-type plasminogen activator in the 3- to 4.5-hour window (adjusted odds ratio, 1.87 [95% CI, 1.30-2.68]; P=0.001) and more likely to be treated with intravenous tissue-type plasminogen activator within 45 minutes (adjusted odds ratio, 1.61 [95% CI, 1.04-2.50]; P=0.04) compared with SA CSCs. Among Florida-Stroke Registry CSCs, acute ischemic stroke performance and treatment measures at NC centers are superior to SA CSCs. These findings have implications for stroke systems of care in Florida and support legislation updates requiring NC and removal of SA claims.

Association of serum uric acid to lymphocyte ratio, a novel inflammatory biomarker, with risk of stroke: A prospective cohort study.

Inflammation plays an important role in the pathological progress associated with stroke. Serum uric acid (SUA) to lymphocyte ratio (ULR), a novel inflammatory biomarker, has been considered as a better risk stratification tool of adverse outcomes than SUA or lymphocyte alone. This study aimed to investigate whether ULR produced more predictive value for stroke and explore the potential mediators of the associations. This study enrolled 93,023 Chinese participants without stroke and myocardial infarction at baseline. Cox proportional hazard models were used to analyze the associations of ULR with stroke and subtypes. Mediation analyses were conducted to explore potential mediators of the associations. During a median follow-up of 13.00 years, 6081 cases of incident stroke occurred, including 5048 cases of ischemic stroke (IS) and 900 cases of hemorrhagic stroke (HS). After adjustment for confounders, the Q4 group was associated with a higher risk of HS (HR, 1.25; 95% CI, 1.03-1.50), but not with total stroke (HR, 1.07; 95% CI, 1.03-1.13) or IS (HR, 1.04; 95% CI, 0.97-1.12). No significant associations were found between SUA or lymphocyte and any stroke. ULR outperformed SUA or lymphocytes alone in predicting stroke. Additionally, the significant association between ULR and HS was partially mediated by systolic blood pressure (20.32%), diastolic blood pressure (11.18%) and estimated glomerular filtration rate (9.19%). ULR was significantly associated with the risk of HS, but not with IS. Systolic blood pressure, diastolic blood pressure and estimated glomerular filtration rate were potential mediators for the association.

Neutrophil-lymphocyte Ratio may be an Early Predictor of the Prognosis in Ischemic Stroke Cases

Neutrophil-lymphocyte Ratio may be an Early Predictor of the Prognosis in Ischemic Stroke Cases

Efficacy and safety of naotaifang capsules for hypertensive cerebral small vessel disease: Study protocol for a multicenter, randomized, double-blind, placebo-controlled clinical trial.

Background: Hypertensive cerebral small vessel disease (HT-CSVD) is a cerebrovascular clinical, imaging and pathological syndrome caused by hypertension (HT). The condition manifests with lesions in various vessels including intracranial small/arterioles, capillaries, and small/venules. Hypertensive cerebral small vessel disease has complex and diverse clinical manifestations. For instance, it can present as an acute stroke which progresses to cause cognitive decline, affective disorder, unstable gait, dysphagia, or abnormal urination. Moreover, hypertensive cerebral small vessel disease causes 25-30% of all cases of ischemic strokes and more than 50% of all cases of single or mixed dementias. The 1-year recurrence rate of stroke in cerebral small vessel disease patients with hypertension is 14%. In the early stage of development, the symptoms of hypertensive cerebral small vessel disease are concealed and often ignored by patients and even clinicians. Patients with an advanced hypertensive cerebral small vessel disease manifest with severe physical and mental dysfunction. Therefore, this condition has a substantial economic burden on affected families and society. Naotaifang (NTF) is potentially effective in improving microcirculation and neurofunction in patients with ischemic stroke. In this regard, this multicenter randomized controlled trial (RCT) aims to furtherly evaluate the efficacy and safety of naotaifang capsules on hypertensive cerebral small vessel disease. Methods: This study is a multicenter, randomized, double-blind, placebo-controlled clinical trial. A total of 388 eligible subjects were recruited from the First Hospital of Hunan University of Chinese Medicine, Hunan Academy of Chinese Medicine Affiliated Hospital, the First Hospital of Shaoyang University, the First Traditional Chinese Medicine Hospital of Changde, and Jiangmen Wuyi Hospital of Traditional Chinese Medicine from July 2020 to April 2022. After a 4-week run-in period, all participants were divided into the intervention group (represented by Y-T, N-T) and control group (represented by Y-C, N-C); using a stratified block randomized method based on the presence or absence of brain damage symptoms in hypertensive cerebral small vessel disease (represented by Y and N). The Y-T and N-T groups were administered different doses of naotaifang capsules, whereas Y-C and N-C groups received placebo treatment. These four groups received the treatments for 6 months. The primary outcome included Fazekas scores and dilated Virchow-robin spaces (dVRS) grades on magnetic resonance imaging (MRI). The secondary outcomes included the number of lacunar infarctions (LI) and cerebral microbleeds (CMB) on magnetic resonance imaging, clinical blood pressure (BP) level, traditional Chinese medicine (TCM) syndrome scores, mini-mental state examination (MMSE) scale, and safety outcomes. Fazekas scores, dilated Virchow-robin spaces grades, and the number of lacunar infarctions and cerebral microbleeds on magnetic resonance imaging were tested before enrollment and after 6months of treatment. The clinical blood pressure level, traditional Chinese medicine syndrome scores, mini-mental state examination scale and safety outcomes were tested before enrollment, after 3-month, 6-month treatment and 12th-month follow-up respectively. Conclusion: The protocol will comfirm whether naotaifang capsules reduce Fazekas scores, dilated Virchow-robin spaces grades, and the number of lacunar infarctions and cerebral microbleeds, clinical blood pressure, increase mini-mental state examination scores, traditional Chinese medicine syndrome scores of Qi deficiency and blood stasis (QDBS), and improve the quality of life of subjects. The consolidated evidence from this study will shed light on the benefits of Chinese herbs for hypertensive cerebral small vessel disease, such as nourishing qi, promoting blood circulation and removing blood stasis, and dredging collaterals. However, additional clinical trials with large samples and long intervention periods will be required for in-depth research. Clinical Trial registration: www.chictr.org.cn, identifier ChiCTR1900024524.

PICA ischemic stroke

The posterior inferior cerebellar artery (PICA) has a unique anatomical complexity, which is of great clinical importance and is involved in many pathologies, such as aneurysm, ischemic stroke, neurovascular compression syndrome (NVCS), arteriovenous malformation (AVM) and brain tumour (1).&#x0D; PICA has a sinuous and variable trajectory, divided into 5 segments. PICA infarction usually manifests lateral bulbar syndrome and is more likely to cause mass effects. PICA frequently compresses the bulb and cranial nerves, resulting in various neurovascular compression syndromes (NVCS) (2).&#x0D; The ischemic stroke caused by thromboembolism in the PICA segment is accounted for more than 2% of all cases of ischemic stroke (3). Moreover, it tends to be underdiagnosed due to the symptomatology, represented usually by vertigo which mimics a possible peripheral vestibulopathy (4).

The insular cortex: a mystery or a verified, documented history. A comprehensive literature review

The insular cortex had been considered a mysterious structure for years and consists of only 2% of all cortical surface area. It is a separate lobe of the cerebral cortex and lies close to the limbic system, which makes it a paralimbic structure, and forms the floor of the lateral sulcus. Despite the myriad of research regarding the insular cortex over the years, it is still considered an obscure and incompletely known structure. Thus, this study aimed to summarize the previous studies regarding the structure, embryology, location, connections, and functions of the insular cortex. Moreover, this review would tend to reorganize the data in a more comprehensive fashion to facilitate reaching the information regarding the insular cortex. The results of the studies were summarized from three perspectives that is neuroanatomy, physiological function, and pathologies commonly affecting the insular cortex. Overall, many textbooks, reviews, case reports, and clinical trials have demonstrated that the insular cortex has a crucial, active, and integrative role in functions throughout the body, from the brain to feeling pain in dorsal part of the foot. Moreover, ischemic stroke cases have demonstrated clearly, how much important the insular cortex is, in normal physiological functioning. More studies, especially clinical trials, should be performed to evaluate the effects of impeding this important intracranial structure.