Questionnaire For Verifying Stroke-Free Status Research Articles

Novel functional insights into ischemic stroke biology provided by the first genome-wide association study of stroke in indigenous Africans

BackgroundAfrican ancestry populations have the highest burden of stroke worldwide, yet the genetic basis of stroke in these populations is obscure. The Stroke Investigative Research and Educational Network (SIREN) is a multicenter study involving 16 sites in West Africa. We conducted the first-ever genome-wide association study (GWAS) of stroke in indigenous Africans.MethodsCases were consecutively recruited consenting adults (aged > 18 years) with neuroimaging-confirmed ischemic stroke. Stroke-free controls were ascertained using a locally validated Questionnaire for Verifying Stroke-Free Status. DNA genotyping with the H3Africa array was performed, and following initial quality control, GWAS datasets were imputed into the NIH Trans-Omics for Precision Medicine (TOPMed) release2 from BioData Catalyst. Furthermore, we performed fine-mapping, trans-ethnic meta-analysis, and in silico functional characterization to identify likely causal variants with a functional interpretation.ResultsWe observed genome-wide significant (P-value < 5.0E−8) SNPs associations near AADACL2 and miRNA (MIR5186) genes in chromosome 3 after adjusting for hypertension, diabetes, dyslipidemia, and cardiac status in the base model as covariates. SNPs near the miRNA (MIR4458) gene in chromosome 5 were also associated with stroke (P-value < 1.0E−6). The putative genes near AADACL2, MIR5186, and MIR4458 genes were protective and novel. SNPs associations with stroke in chromosome 2 were more than 77 kb from the closest gene LINC01854 and SNPs in chromosome 7 were more than 116 kb to the closest gene LINC01446 (P-value < 1.0E−6). In addition, we observed SNPs in genes STXBP5-AS1 (chromosome 6), GALTN9 (chromosome 12), FANCA (chromosome 16), and DLGAP1 (chromosome 18) (P-value < 1.0E−6). Both genomic regions near genes AADACL2 and MIR4458 remained significant following fine mapping.ConclusionsOur findings identify potential roles of regulatory miRNA, intergenic non-coding DNA, and intronic non-coding RNA in the biology of ischemic stroke. These findings reveal new molecular targets that promise to help close the current gaps in accurate African ancestry-based genetic stroke’s risk prediction and development of new targeted interventions to prevent or treat stroke.

Prevalence and risk factors of stroke in Bangladesh: A nationwide population-based survey.

BackgroundA paucity of high-quality epidemiological survey on stroke in Bangladesh emphasizes the need for a drastic effort at the national level to study the burden of stroke in Bangladesh. Therefore, this community survey was conducted with to estimate the prevalence of stroke and its associated common risk factors among Bangladeshi population.MethodsThis was a population-based cross-sectional study, carried out in 8 administrative divisions and 64 districts to estimate the prevalence of stroke throughout the country. The study adopted a two-stage cluster random sampling approach. The calculated sample size was 25,287. A semi-structured questionnaire was used to identify suspected stroke patients who were subsequently confirmed by consultant neurologists.ResultIn the first stage, a total number of 25,287 respondents were interviewed throughout the country. Interviewers identified 561 respondents as suspected stroke through the Questionnaire for Verifying Stroke Free Status (QVSFS) system in 64 districts. Of the 25,287 respondents 13,878 (54.9%) were male and 11,409 (45.1%) were female. Mean age was 39.9 years. In the second stage, all suspected stroke cases (561) were further examined by neurologists and finally 288 patients were confirmed as stroke which provided a prevalence of 11.39 per 1000 population. The highest stroke prevalence (14.71 per thousand) were found in Mymensingh division and lowest (7.62 per thousand) found in Rajshahi division. The stroke prevalence varied in different age groups. It was 30.10 per thousand in the age group of >60 years and 4.60 in the age group below 40 years. The prevalence of stroke among male was twice that of female (13.62 versus 8.68 per thousand). The prevalence was slightly higher in rural areas (11.85 versus 11.07). About 50.4% respondents had some idea about stroke.Out of a total of 288 cases, 79.7% (213) patients had an ischemic stroke, 15.7% (42) had hemorrhagic, and 4.6% (12) were diagnosed as subarachnoid hemorrhage. The majority of the stroke patients had hypertension (79.2%), followed by dyslipidemia (38.9%), tobacco use in any form (37.2%), diabetes (28.8%), ischemic heart disease (20.1%).ConclusionWe have found a stroke prevalence of 11.39 per 1000 population, the highest being in the Mymensingh division. The prevalence was much higher in the elderly and male population. More than three fourth had an ischemic stroke. Hypertension, dyslipidemia, tobacco use, diabetes, ischemic heart disease are the most common risk factors observed among stroke patients.

Standalone totally thoracoscopic left appendage exclusion for stroke prevention and absolute contraindication to anticoagulation: a referral centre experience

Abstract Introduction Left atrial appendage is the source of more than 90% of thrombi in patients with atrial fibrillation (AF). ESC guidelines state as class IIB indication left appendage exclusion in patients with contraindication to oral anticoagulation. Here we give our contribute to the issue of safety and efficacy of standalone totally thoracoscopic left appendage exclusion (TT-LAE) for stroke prevention in patients with contraindication to oral anticoagulant or at risk of life threatening hemorrhage on antiplatelet therapy: a large single Centre experience. Materials and methods 60 patients with non valvular AF and contraindication to oral anticoagulation (25 cerebral hemorrhages,8 GI bleeding, 18 non cerebral/Gi bleeding requiring multiple transfusions, 2 myelodysplastic syndrome, 7 anatomy unsuitable for percutaneous closure, 75%male, patients age ranged 53–87 years,mean CHAD-VASC 6.4,mean HASBLED range 4.7, type of AF permanent 76.6%, 23.4% longstanding persistent), underwent stand alone totally thoracoscopic appendage exclusion. All patinets enrolled after Heart Team evaluation, were screened preoperatively with 3D CT scan, transesophageal echocardiography, spirometry and cerebrovascuar doppler ultrasound. Intraoperative appendage exclusion were guided and confirmed by transesophageal echo. All patients were not on anticoagulation nor antiplatelet therapy at the time of surgery, at discharge and at control visit. Follow up (range 35–1 months) included outpatient visit and CT scan or TEE at 3–6-12 month in all patients to document LAA exclusion. Perioperative mortality and early and late morbidity in addition to freedom from neurological events at follow up were analyzed by chart evaluation and full outpatient neurological examination including including the Questionnaire for Verifying Stroke Free Status (QVSFS) as validated screening tool. Results Mean duration of surgery “skin to skin” was 52.4 minutes; all patients were extubated shortly after the procedure. There were no deaths nor need for blood transfusion or pulmonary procedure related morbidities, only three casea of pericarditis treated with colchicine till complete resolution was documented. On CT or TEE follow up 100% of patients had complete exclusion of the left appendage with minimal residual stumps and no dislodgement of the clip detected. Freedom from neurological events in all patients was documented in absence of anticoagulation or antiplatelet regime from the time of surgery to the time of the follow up visit and questionnaire filling. Conclusion Standalone totally thoracoscopic left appendage clipping is a safe and effective procedure for stroke prevention in patients with permanent and longstanding persistent atrial fibrillation with contraindication to oral anticoagulation. Longer follow up and an European registry are needed to, possibly, confirm this preliminary results. Funding Acknowledgement Type of funding source: None

Clinical outcomes after AF cardioversion in patients presenting left atrial sludge in trans-esophageal echocardiography.

Direct-current cardioversion (DCC) for atrial fibrillation carries a risk of stroke, probably associated with the temporary atrial stunning following cardioversion. The presence of a cardiac thrombus, usually localized in the left atrial appendage (LAA), is recognized as a clear contra-indication to the cardioversion. However, the presence of atrial sludge without LAA thrombus in trans-esophageal echocardiography (TEE) remains, for many cardiologists, a relative contra-indication to the cardioversion. The aim of this study was to evaluate the safety of DCC in patients presenting atrial sludge without LAA thrombus. We prospectively included all consecutive patients demonstrating atrial sludge without LAA thrombus in TEE and undergoing DCC for persistent atrial fibrillation (AF). Safety of DCC was evaluated by the occurrence of clinical events at 1month following cardioversion, i.e., up to the end of the atrial stunning period, as assessed by clinical examination and the standardized and validated Questionnaire for Verifying Stroke-Free Status (QVSFS). Over a period of 2years, 21 patients presenting atrial sludge without LAA thrombus underwent DCC for AF. During the follow-up period of 1month after DCC, no clinical embolic event, cardiac event, or unscheduled consultations/hospitalizations occurred. At 1month, 67% of the patients remained in sinus rhythm. No clinical event occurred in patients demonstrating atrial sludge without thrombus and undergoing DCC for AF. These findings support current guidelines that only keep atrial thrombus as a contraindication to cardioversion, but warrant further investigation in large studies.

Abstract WP570: Associations Between Stroke Symptoms and Cognition in Nepal

Introduction: Low and middle income countries have the largest burden of stroke, accounting for more than 85% of stroke deaths globally. As many low- and middle-income countries, including Nepal, transition from communicable to non-communicable diseases (NCDs), the impact of stroke on cognition becomes increasingly important. Methods: Data on cardiovascular risk factors and cognition were collected as part of the Dhulikhel Heart Study, a longitudinal study to evaluate risk factors for heart disease and stroke in Dhulikhel, a community outside of Kathmandu, Nepal. In Phase 1 of the baseline exam, 252 randomly-selected adults age 50 and older completed the Mini-Mental Exam (MMSE) and Digit Spans ( DST) forward and backward as part of a home interview. Mild stroke symptoms were collected by self-report the Questionnaire for Verifying Stroke-Free Status (QVSFS). Multiple linear regression evaluated associations between stroke symptoms and cognition adjusted for demographics (age, sex, education, religion, and ethnicity) and CVD risk factors (smoking, exercise, BMI, blood pressure, hypertension, and diabetes). Results: Mean age of study participants was 62.4 years (SD 9.2) and 57.5% were women. The mean MMSE score (weighted for illiteracy) was 18.7 (SD 6.4) and 19% reported to have had at least one of five stroke symptoms (sudden one-sided numbness or weakness, sudden vision-loss, inability to express oneself or inability to understand). An increased risk of lower memory score was found with report of a previous episode of numbness (DST backward: B=-1.17, SE=0.34, p=0.001). Borderline associations (.05 &lt; p&lt;.10) were found between any stroke symptoms and Digit Span forward, numbness and MMSE, and numbness and DST forward. When adjusted for demographic and cardiovascular risk factors, significant associations were found between having experienced any stroke symptom and Digit Span backward (B=-1.46, SE=0.66, p=.03) as well as numbness (B=-1.75, SE=0.72, p=0.02). Conclusions: Associations between previous stroke symptoms and reduced cognition emphasize the need to screen and treat persons with undiagnosed stroke or TIAs in low-resource settings. A reduction in modifiable vascular risk factors is also needed to reduce CVD and associated dementia.

APOL1 Nephropathy Risk Variants and Incident Cardiovascular Disease Events in Community-Dwelling Black Adults.

APOL1 renal risk variants are strongly associated with chronic kidney disease in Black adults, but reported associations with cardiovascular disease (CVD) have been conflicting. We examined associations of APOL1 with incident coronary heart disease (n=323), ischemic stroke (n=331), and the composite CVD outcome (n=500) in 10 605 Black participants of the REGARDS study (Reasons for Geographic and Racial Differences in Stroke). Primary analyses compared individuals with APOL1 high-risk genotypes to APOL1 low-risk genotypes in Cox proportional hazards models adjusted for CVD risk factors and African ancestry. APOL1 high-risk participants were younger and more likely to have albuminuria at baseline than APOL1 low-risk participants. The risk of incident stroke, coronary heart disease, or composite CVD end point did not significantly differ by APOL1 genotype status in multivariable models. The association of APOL1 genotype with incident composite CVD differed by diabetes mellitus status (Pinteraction=0.004). In those without diabetes mellitus, APOL1 high-risk genotypes associated with greater risk of incident composite CVD (hazard ratio, 1.67; 95% confidence interval, 1.12-2.47) compared with those with APOL1 low-risk genotypes in multivariable adjusted models. This latter association was driven by ischemic strokes (hazard ratio, 2.32; 95% confidence interval, 1.33-4.07), in particular, those related to small vessel disease (hazard ratio, 5.10; 95% confidence interval, 1.55-16.56). There was no statistically significant association of APOL1 genotypes with incident CVD in subjects with diabetes mellitus. The APOL1 high-risk genotype was associated with higher stroke risk in individuals without but not those with chronic kidney disease in fully adjusted models. APOL1 high-risk status is associated with CVD events in community-dwelling Black adults without diabetes mellitus.

Epidemiology of stroke: findings from a community-based survey in rural Bangladesh

ObjectivesThis study was designed to determine the epidemiology of stroke in a rural population of Bangladesh. Study designIn a cross-sectional study, we surveyed stroke patients. MethodsThe survey was conducted in a rural community of Bangladesh from January 2016 to June 2016. All community members 15 years and older in a surveillance system were included in this study. The Questionnaire for Verifying Stroke-Free Status was used to screen stroke cases at household level which were again examined by the neurologist for confirmatory diagnosis. ResultsThe prevalence of stroke was 1.96 (95% confidence interval [CI] 1.69–2.26) per 1000 population. The highest prevalence was 9.65 (95% CI 7.42–12.33) per 1000 population, identified among patients aged 65–79 years. Males had higher prevalence (2.38 per 1000 population) than females (1.55 per 1000 population). Of the 24% of patients who had radiological examination (magnetic resonance imaging and computed tomography scan) reports, 17.2% of stroke cases were ischemic, 4.8% were intracerebral, and about 1.1% were subarachnoid. The ratio of infarction to hemorrhage was 2.91. Approximately 67% of patients were diagnosed as hypertensive, and 37% of patients had elevated blood glucose level. While 15% of patients were found to be overweight or obese, 45% of patients had raised blood cholesterol level. More than 10% of patients reported that they had heart disease before the occurrence of stroke. About 40% of patients had the history of tobacco consumption. ConclusionsThe prevalence of stroke is higher among elderly and male populations. A significant proportion of patients presented with hypertension and/or diabetes.

APOL1, CDKN2A/CDKN2B, and HDAC9 polymorphisms and small vessel ischemic stroke.

Worldwide, the highest frequencies of APOL1-associated kidney variants are found in indigenous West Africans among whom small vessel disease (SVD) ischemic stroke is the most common stroke phenotype. The objective of this study was to investigate the association and effect sizes of 23 selected SNPs in 14 genes of relevance, including the APOL1G1 variants, with the occurrence of SVD ischemic stroke among indigenous West African participants in the Stroke Investigative Research and Education Network (SIREN) Study. Cases were consecutively recruited consenting adults (aged 18years or older) with neuroimaging-confirmed first clinical stroke. Stroke-free controls were ascertained using a locally validated version of the Questionnaire for Verifying Stroke-Free Status (QVSFS). Logistic regression models adjusting for known vascular risk factors were fitted to assess the associations of the 23 SNPs in rigorously phenotyped cases (N=154) of SVD ischemic stroke and stroke-free (N=483) controls. Apolipoprotein L1 (APOL1) rs73885319 (OR=1.52; CI: 1.09-2.13, P-value=.013), rs2383207 in CDKN2A/CDKN2B (OR=3.08; CI: 1.15-8.26, P -value=.026) and rs2107595 (OR=1.70; CI: 1.12-2.60, P-value=.014) and rs28688791 (OR=1.52; CI: 1.03-2.26, P-value=.036) in HDAC9 gene were associated with SVD stroke at 0.05 significance level. Polymorphisms in other genes did not show significant associations. This is the first report of a specific association of APOL1 with a stroke subtype. Further research is needed to confirm these initial findings and deepen understanding of the genetics of stroke in people of African ancestry with possible implications for other ancestries as all humans originated from Africa.

Administration of a pictorial questionnaire to screen for stroke among patients with hypertension or diabetes in rural Ghana

BackgroundStroke prevention is an important public health goal in low-and-middle income countries (LMIC) due to its high mortality and morbidity in these settings. Epidemiological data from high-income countries have demonstrated a potent predictive association between self-reported stroke symptoms and risks of future strokes, incident cognitive impairment and all-cause mortality. ObjectiveTo utilize a pictographic version of the 8-item Questionnaire for Verifying Stroke Free Status (QVSFS) to screen for stroke symptoms and determine its predictors among hypertensive and diabetic patients in a rural hospital within a LMIC. MethodsBetween July and October 2016, 500 consecutive patients with hypertension and/or diabetes mellitus encountered in clinic at the Agogo Presbyterian Hospital, a district level health institution in Ghana were enrolled. A validated pictographic version of the QVSFS was administered by trained research assistants to all study participants and demographic and clinical information on hypertension and diabetes control were collected. The neurologist/specialist physician examined all patients neurologically using a structured questionnaire and reviewed medical charts for objective documentary evidence of stroke. Predictors of stroke symptoms were assessed using a multivariate logistic regression model. ResultsAmong the cohort, median (IQR) age was 58 (51–66) years, 399 (79.8%) were women, 388 (77.6%) had hypertension, 92 (18.4%) had diabetes and hypertension, and 20 (4.0%) had just diabetes. 30 (6.0%) patients had confirmed stroke/TIA after physician evaluation, 151 (30.6%) had at least one symptom of stroke (SS) without prior diagnosis of stroke/TIA and 319 (63.8%) reported no stroke symptoms. Independent predictors of reporting stroke symptoms were increasing age - aOR: 1.38 (1.16–1.64) for each 10years older and HBA1C–OR: 1.74 (1.16–2.61) for each 2% increase. Subjects with previous stroke/TIA diagnosis had significantly higher mean±SD systolic blood pressure (148.0±21.2mmHg vs. 136.0±17.3mmHg vs. 138.3±19.7mmHg, p=0.009) and median (IQR) HBA1C (8.8% (6.7–10.2) vs. 8.2 (6.4–10.6) vs. 7.2 (6.3–8.0), p=0.05) compared with SS and asymptomatic groups. ConclusionOne in three patients with hypertension and/diabetes in rural Ghana report stroke-like symptoms. Routine use of the pictographic version of the QVSFS could assist in identifying patients with or at high risk for stroke who may benefit from appropriate prevention treatments.

Stroke symptoms and risk for incident coronary heart disease in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study

BackgroundMany adults without cerebrovascular disease report a history of stroke symptoms, which is associated with higher risk for stroke. Because stroke and coronary heart disease (CHD) share many risk factors, we examined the association between a history of stroke symptoms and incident CHD. MethodsWe analyzed data from 8999 black and 12,499 white REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants without a prior myocardial infarction, stroke or transitory ischemic attack enrolled in 2003–2007 (total participants=21,498, all ≥45years of age). A history of stroke symptoms (i.e., unilateral weakness, unilateral numbness, full-field vision loss, half-field vision loss, understanding problems and communication problems) was assessed at baseline using the Questionnaire for Verifying Stroke-Free Status. Participants were followed for incident CHD and CHD death through December 2011. ResultsOverall, 3432 (16.0%) participants reported a history of stroke symptoms (1771 [19.7%] blacks and 1661 [13.3%] whites). There were 701 incident CHD events including 209 CHD deaths over a median follow-up of 5.8years. After adjustment for CHD risk factors, hazard ratios (95% confidence interval [95% CI]) for incident CHD associated with reporting any versus no stroke symptoms were 1.26 (1.04–1.51) in the overall population, 1.28 (0.99–1.65) among blacks and 1.23 (0.94–1.61) among whites. Multivariable-adjusted hazard ratios (95% CI) for CHD death associated with any versus no stroke symptoms were 1.50 (1.10–2.06) overall, 1.58 (1.07–2.32) among blacks and 1.41 (0.82–2.43) among whites. ConclusionA history of stroke symptoms is associated with a higher incidence of CHD among black and white adults.

Validation of the 8-item questionnaire for verifying stroke free status with and without pictograms in three West African languages.

BackgroundThe Questionnaire for Verifying Stroke-free Status (QVSFS) has been validated in Western populations as a method for verifying stroke-free status in participants of clinical, epidemiological and genetic studies. This instrument has not been validated in low-income settings where populations have limited knowledge of stroke symptoms and literacy levels are low.ObjectiveTo simultaneously validate the 8-item QVSFS in 3 languages spoken in West Africa (Yoruba, Hausa and Akan) for ascertainment of stroke-free status of control subjects in SIREN.MethodsUsing a cross-sectional study design, 100 participants each from the 3 linguistic groups will be consecutively recruited from neurology and general medicine clinics of 5 tertiary referral hospitals in Nigeria and Ghana. Ascertainment of stroke status will be determined by neurologists using structured neurological examination, review of case records and neuro-imaging (Gold standard). The relative performance of QVSFS without and with pictures of stroke symptoms (pictograms) will be assessed using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).ConclusionThe proposed study will provide valuable data on the performance of the QVSFS in resource-limited settings.

Stroke Symptoms With Absence of Recognized Stroke Are Associated With Cognitive Impairment and Depressive Symptoms in Older Adults With Diabetes.

Self-reported stroke symptoms may represent unrecognized cerebrovascular events leading to poorer cognitive and mental health. We examined relationships between stroke symptoms, cognitive impairment, and depressive symptoms in a high-risk sample: 247 adults aged ≥65 with diabetes. Stroke symptoms were assessed using the Questionnaire for Verifying Stroke-free Status, cognitive impairment was measured with the modified Telephone Interview for Cognitive Status, and depressive symptoms were measured using the 15-item Geriatric Depression Scale. In 206 participants without history of stroke/transient ischemic attack, 27.7% reported stroke symptoms, with sudden loss of comprehension most frequently reported (11.7%). Having >1 versus 0 stroke symptoms was associated with greater odds of cognitive impairment (odds ratio = 3.04, 95% confidence interval 1.15-8.05) and more depressive symptoms (b= 2.60,P< .001) while controlling for age, race, gender, education, diabetes duration, diabetes severity, and cardiovascular comorbidities. Better recognition and treatment of cerebrovascular problems in older adults with diabetes may lead to improved cognition and mental health.

Multilingual Validation of the Questionnaire for Verifying Stroke-Free Status in West Africa.

The Questionnaire for Verifying Stroke-Free Status (QVSFS), a method for verifying stroke-free status in participants of clinical, epidemiological, and genetic studies, has not been validated in low-income settings where populations have limited knowledge of stroke symptoms. We aimed to validate QVSFS in 3 languages, Yoruba, Hausa and Akan, for ascertainment of stroke-free status of control subjects enrolled in an on-going stroke epidemiological study in West Africa. Data were collected using a cross-sectional study design where 384 participants were consecutively recruited from neurology and general medicine clinics of 5 tertiary referral hospitals in Nigeria and Ghana. Ascertainment of stroke status was by neurologists using structured neurological examination, review of case records, and neuroimaging (gold standard). Relative performance of QVSFS without and with pictures of stroke symptoms (pictograms) was assessed using sensitivity, specificity, positive predictive value, and negative predictive value. The overall median age of the study participants was 54 years and 48.4% were males. Of 165 stroke cases identified by gold standard, 98% were determined to have had stroke, whereas of 219 without stroke 87% were determined to be stroke-free by QVSFS. Negative predictive value of the QVSFS across the 3 languages was 0.97 (range, 0.93-1.00), sensitivity, specificity, and positive predictive value were 0.98, 0.82, and 0.80, respectively. Agreement between the questionnaire with and without the pictogram was excellent/strong with Cohen k=0.92. QVSFS is a valid tool for verifying stroke-free status across culturally diverse populations in West Africa.

Prevalence of stroke symptoms among stroke-free residents: first national data from Lebanon.

Stroke symptoms are common among people without a history of stroke or transient ischemic attack. Reported stroke symptoms may represent stroke episodes that failed to reach the threshold for clinical diagnosis. This study aimed to assess in the Lebanese population the prevalence of self-reported stroke symptoms in a stroke- and transient ischemic attack-free population, and the association of these symptoms with major risk factors for stroke. We carried out a cross-sectional study using a multistage cluster sample across Lebanon. We interviewed residents aged 40 years and more. Stroke symptoms were assessed using the Questionnaire for Verifying Stroke-Free Status. We included 1515 individuals (mean age was 57·2 ± 12·4 years, 783 women, 51·7%). Among 1460 participants stroke- and transient ischemic attack-free, 175 had experienced at least one stroke symptom (12·1%, 95% CI 9·9%-14·3%). Arterial hypertension (adjOR 4·37, 95% CI 2·68-7·12), history of heart disease (adjOR 3·34, 95% CI 2·00-5·56), current waterpipe smoking (adjOR 3·88, 95% CI 2·33-6·48), current and former cigarette smoking (adjOR 1·84, 95% CI 1·18-2·87 and adjOR 2·01, 95% CI 1·13-3·5, respectively), psychological distress (adjOR 1·04, 95% CI 1·02-1·05), the Mediterranean diet score (adjOR 0·87, 95% CI 0·76-0·99), and regular physical activity (adjOR 0·45, 95% CI 0·26-0·77) were independently associated with stroke symptoms. This is the first study conducted in the Middle East, assessing self-reported stroke symptoms among stroke-free residents. Our study showed that almost one in eight residents without a history of stroke or transient ischemic attack has had stroke symptoms. Major vascular risk factors are associated with these symptoms, thus allowing for prevention strategies.

Stroke-free status and depression scores among Saudi dialysis patients

Background: To assess the prevalence of stroke symptoms and depression among Saudi dialysis patients and related factors. Methods: This is a cross-sectional multicentre study of Saudi dialysis patients. Demographics, clinical and laboratory’s data were collected. Freedom from stroke symptoms was assessed using the Questionnaire for Verifying Stroke-Free Status and depression using the Geriatric Depression Scale. Results: Five-hundred and forty-nine patients (77.3% response rate); 94.6% were receiving hemodialysis and 5.4% peritoneal dialysis were included in the study. Freedom from stroke was reported in 76.6% of patients, was higher in females (p = 0.07), and was not affected by the presence of diabetes mellitus coronary artery disease or peripheral vascular disease. However, it was significantly lower in hypertensive patients (p = 0.035) and was not affected by age, dialysis duration, Kt/V, albumin or hemoglobin levels. It was, however, more prevalent in the non-depressed patients compared to depressed patients (p = 0.036). Mild and major depression scores were noted in 45.2% and 6.1%, respectively; the depression score being significantly higher in HD than in PD patients (6.3 ± 3.4 vs. 5.0 ± 3.2 p = 0.049) but was not related to sex, employment, vascular access type, age, dialysis duration, Kt/V or serum albumin or hemoglobin levels. Conclusion: A quarter of the patients were not stroke symptom-free and these were more likely the depressed patients, in females, but significantly less in hypertensive patients. Almost half of the patients were depressed with 6.1% having major depression. The depression score was significantly higher in HD than in PD patients.

Clinical, lifestyle, socioeconomic determinants and rate of asymptomatic intracranial atherosclerosis in stroke free Pakistanis.

BackgroundIntracranial Atherosclerotic Disease (ICAD) is the most frequent etiology of stroke with high prevalence among Asians. Despite this, early determinants of ICAD have not been described from this region.MethodsThe study is an analytical prospective cross-sectional study of 200 adults from Radiology Departments of two diagnostic centers in Karachi. Eligible participants confirmed the absence of stroke symptoms via the Questionnaire for Verifying Stroke Free Status (QVSFS) and underwent an interview covering medical, socio demographic, lifestyle and anthropometric evaluation using locally validated and standardized definitions. Magnetic Resonance Images (MRI) were centrally reviewed to detect ICAD using the criterion used in the Warfarin–Aspirin Symptomatic Intracranial Disease study. The risk factors associated with asymptomatic ICAD are reported along with prevalence ratios.ResultsOf the 200 participants, ICAD was found in 34.5% (n = 69) of the participants. Mean age was 37.1 (S.D 15.1) years with 62% younger than 45 years. Self-reported hypertension was found in 26.5% subjects, diabetes in 9%, dyslipidemia in 5% and depression in 60%. Smokeless tobacco (Adjusted PR 3.27 (1.07-6.05)), Western diet, high socioeconomic status (Adjusted PR 2.26 (1.99-5.62)) and dyslipidemia (Adjusted PR 1.88 (1.25-2.21)) had significant associations with ICAD after multivariable analysis. Age, gender, diabetes, hypertension, depression and physical activity did not have a significant association.ConclusionICAD was found on MRI in one in three asymptomatic Pakistanis and was associated with modifiable risks. Initiatives targeting primary prevention may be able to decrease the burden of disease caused by stroke due to ICAD.Study Registration NumberNCT02072876 2/25/2014

Report of stroke-like symptoms predicts incident cognitive impairment in a stroke-free cohort

The present study characterizes the relationship between report of stroke symptoms (SS) or TIA and incident cognitive impairment in the large biracial cohort of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. The REGARDS Study is a population-based, biracial, longitudinal cohort study that has enrolled 30,239 participants from the United States. Exclusion of those with baseline cognitive impairment, stroke before enrollment, or incomplete data resulted in a sample size of 23,830. Participants reported SS/TIA on the Questionnaire for Verifying Stroke-free Status at baseline and every 6 months during follow-up. Incident cognitive impairment was detected using the Six-item Screener, which was administered annually. Logistic regression found significant association between report of SS/TIA and subsequent incident cognitive impairment. Among white participants, the odds ratio for incident cognitive impairment was 2.08 (95% confidence interval: 1.81, 2.39) for those reporting at least one SS/TIA compared with those reporting no SS/TIA. Among black participants, the odds ratio was 1.66 (95% confidence interval: 1.45, 1.89) using the same modeling. The magnitude of impact was largest among those with fewer traditional stroke risk factors, particularly among white participants. Report of SS/TIA showed a strong association with incident cognitive impairment and supports the use of the Questionnaire for Verifying Stroke-free Status as a quick, low-cost instrument to screen for people at increased risk of cognitive decline.

What Stroke Symptoms Tell Us: Association of Risk Factors and Individual Stroke Symptoms in the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

Stroke symptoms are common among people without a history of stroke or transient ischemic attack; however, it is unknown if particular attention should be focused on specific symptoms for subgroups of patients. Using baseline data from 26,792 REasons for Geographic And Racial Differences in Stroke (REGARDS) participants without a history of transient ischemic attack or stroke, we assessed the association between age, sex, race, current smoking, hypertension, and diabetes and the 6 stroke symptoms in the Questionnaire for Verifying Stroke-Free Status. The mean age of participants was 64.4 ± 9.4 years, 40.7% were black, and 55.2% were women. After multivariable adjustment, older persons more often reported an inability to understand (odds ratio [OR] 1.16 per 10 years older age; 95% confidence interval [CI] 1.07-1.25) and unilateral vision loss (OR 1.09; 95% CI 1.01-1.18) and less often reported numbness (OR 0.83; 95% CI 0.79-0.87) and weakness (OR 0.85; 95% CI 0.80-0.90). Women reported difficulty communicating more often than men (OR 1.36; 95% CI 1.19-1.56). The OR for blacks compared to whites for each of the 6 stroke symptoms was increased, markedly so for unilateral numbness (OR 1.97; 95% CI 1.81-2.16), unilateral weakness (OR 1.96; 95% CI 1.76-2.18), and inability to understand (OR 1.87; 95% CI 1.61-2.18). Current smoking, hypertension, and diabetes were associated with higher ORs for each stroke symptom. The association of risk factors with 6 individual stroke symptoms studied was not uniform, suggesting the need to emphasize individual stroke symptoms in stroke awareness campaigns when targeting populations defined by risk.

Abstract 3027: Report of Stroke Symptoms in the Absence of Stroke Predicts Incident Cognitive Impairment

Introduction: Stroke and vascular risk factors are recognized as important markers of increased risk of cognitive impairment. Experience of stroke-like symptoms and/or transient ischemic attack (SS/TIA) are suspected to represent another independent marker of risk for cognitive impairment. Methods: We assessed these relationships in REGARDS, a national longitudinal cohort study following over 30,000 black and white participants aged 45 and older from the 48 contiguous states. Cognitive function is assessed by several scales, including the Six-Item Screener (SIS), conducted by telephone at baseline and annually during follow-up. After excluding those who were impaired at first assessment, 23,830 participants (mean baseline age 64.2) were stroke free at baseline and had at least two cognitive function assessments (11,096 with two to four, and 12,734 with more than four). Observation time was censored after a suspected stroke during follow-up (censoring 1439 assessments in 515 participants). SS/TIA were assessed using the Questionnaire for Verifying Stroke-Free Status. The association between report of SS/TIA and subsequent impairment was assessed using logistic regression, both univariately and after adjustment for a variety of risk factors. In addition, the role of the Framingham Stroke Risk (FSR) in these relationships was examined. Incident impairment was characterized as a score of 4 or fewer on the most recently assessed SIS. Models were fitted separately for white and black subjects to evaluate race-specific effects. Results: Among blacks, the presence of any incident SS/TIA was associated with 1.66 (95% CI: 1.45, 1.89) times the likelihood of impairment in an unadjusted model, compared to those with no SS/TIA, which was slightly attenuated to 1.41 (95% CI: 1.23, 1.62) in a model incorporating gender, income, region and education. Among whites, the unadjusted OR was 2.08 (95% CI: 1.81, 2.39), with an adjusted OR of 1.85 (95% CI: 1.61, 2.13). The association between SS/TIA differed by FSRF, with a stronger association between SS/TIA and impairment among those with lower FSR, both for blacks and whites. Discussion: In an initially stroke-free cohort and with censoring of incident stroke cases in the follow-up, report of SS/TIA was strongly related to increased risk of cognitive impairment. The stronger association between self-report of SS/TIA and incident cognitive impairment among those with lower FSR score suggests these symptoms may reflect risk factors for cognitive impairment not captured in the FSR. This effect was larger in whites, suggesting differential sensitivity or exposure to this risk.

Increased Plasma Lipoprotein(a) Found in Large-Artery Atherosclerotic, but Not Small-Artery Occlusive, Stroke

We previously reported that plasma lipoprotein(a) [Lp(a)]1 is an independent risk factor for coronary artery disease, abdominal aortic aneurysm, peripheral arterial disease, and ischemic stroke (1). Although the exact pathophysiological role of Lp(a) has not been definitively established, both atherogenic and thrombogenic mechanisms have been proposed. In this study, we measured plasma Lp(a) in ischemic stroke patients who had been subdivided into etiologic subtypes with the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) classification to determine if stroke subtype is a confounder of the Lp(a) association. Ischemic stroke patients (n = 245) and arterial disease–free and stroke-free controls (n = 435) were recruited from the Otago region of New Zealand as previously reported (1). Stroke patients were placed into TOAST classification subtypes by means of a computer algorithm developed by Goldstein and colleagues(2). The TOAST subgroups were large-artery atherosclerosis (LAA), cardioembolism, small-artery occlusion (SAO), undetermined due to 2 or more causes (multiple etiologies) (ME), or undetermined etiology due to negative or incomplete evaluation. Inclusion criteria for controls were an age >52 years and no history of ischemic heart disease or stroke, including transient ischemic attack [Questionnaire for Verifying Stroke-Free Status (QVSFS) score = 0]. Plasma lipoprotein and demographic risk factors were assessed as previously described(1). The study …