Risk Factor For Stroke Research Articles

Spinal Cord Injuries & Disorders Are a Risk Factor for Ischemic Stroke in US Veterans (S16.002)

Spinal Cord Injuries & Disorders Are a Risk Factor for Ischemic Stroke in US Veterans (S16.002)

Phenotypic and genetic effect of carotid intima-media thickness on the risk of stroke.

While carotid intima-media thickness (cIMT) as a noninvasive surrogate measure of atherosclerosis is widely considered a risk factor for stroke, the intrinsic link underlying cIMT and stroke has not been fully understood. We aimed to evaluate the clinical value of cIMT in stroke through the investigation of phenotypic and genetic relationships between cIMT and stroke. We evaluated phenotypic associations using observational data from UK Biobank (N = 21,526). We then investigated genetic relationships leveraging genomic data conducted in predominantly European ancestry for cIMT (N = 45,185) and any stroke (AS, Ncase/Ncontrol=40,585/406,111). Observational analyses suggested an increased hazard of stroke per one standard deviation increase in cIMT (cIMTmax-AS: hazard ratio (HR) = 1.39, 95%CI = 1.09-1.79; cIMTmean-AS: HR = 1.39, 95%CI = 1.09-1.78; cIMTmin-AS: HR = 1.32, 95%CI = 1.04-1.68). A positive global genetic correlation was observed (cIMTmax-AS: [Formula: see text]=0.23, P=9.44 × 10-5; cIMTmean-AS: [Formula: see text]=0.21, P=3.00 × 10-4; cIMTmin-AS: [Formula: see text]=0.16, P=6.30 × 10-3). This was further substantiated by five shared independent loci and 15 shared expression-trait associations. Mendelian randomization analyses suggested no causal effect of cIMT on stroke (cIMTmax-AS: odds ratio (OR)=1.12, 95%CI=0.97-1.28; cIMTmean-AS: OR=1.09, 95%CI=0.93-1.26; cIMTmin-AS: OR=1.03, 95%CI = 0.90-1.17). A putative association was observed for genetically predicted stroke on cIMT (AS-cIMTmax: beta=0.07, 95%CI = 0.01-0.13; AS-cIMTmean: beta=0.08, 95%CI = 0.01-0.15; AS-cIMTmin: beta = 0.08, 95%CI = 0.01-0.16) in the reverse direction MR, which attenuated to non-significant in sensitivity analysis. Our work does not find evidence supporting causal associations between cIMT and stroke. The pronounced cIMT-stroke association is intrinsic, and mostly attributed to shared genetic components. The clinical value of cIMT as a surrogate marker for stroke risk in the general population is likely limited.

The Impact of Periodontal Inflammation on the Severity of Coronary Atherosclerosis.

Introduction Through plausible biological mechanisms, periodontitis causes systemic inflammatory burden and response, thus resulting in damage far beyond the oral cavity. Studies have demonstrated periodontitis to be a significant risk factor for coronary heart disease (CHD) and stroke. The larger the quantum of periodontal inflamed tissue, the greater the chances of periodontitis eliciting bacteremiaand systemic inflammatory responses. Studies have reported that periodontitis and other common oral infections play an important role in the development of atherosclerosis. Therefore, the quantity of inflamed periodontal tissue assumes significance in determining the severity of atherosclerosis. Hence, this study investigates the impact of periodontal inflamed surface area (PISA) on the severity of coronary atherosclerosis. Materials and methods In this cross-sectional study, a total of 160 patients who presented at the department of periodontics of The British University in Egypt (BUE) from 1 January 2023 to 30 September 2023 were enrolled. Patients were only enrolled if they had undergone coronary angiography within the last six months, were less than 60 years of age, shared their previous medical history and coronary angiographic report, and gave informed written consent. Data on classic coronary risk factors and periodontal inflammatory status and angiographic findings were recorded and subjected to appropriate statistical analysis. Results The results revealed that the periodontal inflamed surface area (p = 0.002) apart from age (p < 0.047) and low-density lipoprotein cholesterol(LDL-C) (p < 0.001) is a significant independent predictor of the severity of coronary atherosclerosis. Conclusions The periodontal inflamed surface area is an independent predictor of the severity of coronary atherosclerosis.

Demography and Etiology of Ischemic Stroke in 18–45 Years

Introduction: The objective of our study was to examine the clinical characteristics and underlying risk factors of acute ischemic stroke in patients aged 18–45. Materials and Methods: We prospectively studied etiology of patients aged 18–45 with acute ischemic stroke presenting to our hospital from September to December of the following year. We aimed for 80% statistical power at a 5% significance level with a precision of 0.15, which led us to a calculated sample size of 39. Results: Fifty patients were observed. The main risk factors identified were alcohol use (36%), smoking (30%), and hypertension (22%). Prothrombotic states were found to be a significant risk factor in cases where the stroke’s origin was undetermined. The most common stroke subtype was large-artery atherosclerosis, which was followed by strokes with other underlying causes. There was a statistically significant association between hypertension and ischemic stroke subtypes ( P = 0.01). Hypertension was associated with small-vessel disease (92.3%) and strokes with undetermined causes (56.5%), with P = 0.023 and P &lt;0.001, respectively. Conclusions: Hypertension was associated with multiple stroke subtypes in young individuals. Therefore, it is essential to strictly control hypertension through antihypertensive therapy and lifestyle changes. As alcohol use and smoking are becoming more prevalent among young individuals, early implementation of awareness programs targeting primary stroke prevention is highly desirable.

Case report: Three characteristics of tyrosine kinase inhibitor-associated cerebrovascular stenosis. High threshold for infarction, atypical infarct area, and vascular recoverability under the use of ponatinib

While tyrosine kinase inhibitors (TKI)-associated cerebral vascular stenosis (CVS) exhibit distinct mechanisms compared to conventional stroke in basic research, the clinical strategy remains nearly the same other than TKI-switching. We present the case of a 22-year-old female with chronic myeloid leukemia without stroke risk factors, who developed ponatinib-associated CVS. Three potential characteristics of TKI-associated CVS were identified: a heightened threshold for infarction, an atypical infarct area, and vascular recoverability. Specifically, brain computed tomography remained normal despite 20 h of severe hemiplegia. The ischemic distribution was confined in gray matter and the anterior cerebral artery territory on magnetic resonance imaging, despite severe stenosis of the internal carotid artery. Ischemic changes resolved within 10 days and arterial stenosis improved after ponatinib withdrawal. These unique features, distinct from typical stroke, could lead to misdiagnosis as non-organic neurological disorders or other conditions in ponatinib-treated patients.

Dual effects of serum urate on stroke risk and prognosis: insights from Mendelian randomization.

To investigate the causal associations of serum urate (SUA) with stroke risk and prognosis using Mendelian randomization (MR) and the potential mediating role of stroke risk factors in the causal pathways. We used the random-effects inverse variance weighting (IVW) as our primary method. We initially performed two-sample univariable MR (UVMR) to identify the causal associations of SUA (n = 437,354) with any stroke (AS, FinnGen: n = 311,635; MEGASTROKE: n = 446,696), ischemic stroke (IS, FinnGen: n = 212,774; MEGASTROKE: n = 440,328), intracranial hemorrhage (ICH, FinnGen: n = 343,663; ISGC: n = 3,026), functional outcome after ischemic stroke at 90d (n = 4,363), and motor recovery within 24 months after stroke (n = 488), and then multivariable MR (MVMR) to estimate the direct causal effects of SUA on these outcomes, adjusting for potential confounders. Finally, we further conducted a two-step MR to investigate the potential mediating role of body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), and estimated glomerular filtration rate (eGFR) in the identified causal pathways. Genetically predicted elevated SUA levels were significantly associated with increased risk of AS (meta-analysis: OR = 1.09, 95% CI [1.04-1.13], p = 3.69e-05) and IS (meta-analysis: OR = 1.10, 95% CI [1.01-1.19], p = 0.021) and with improved poor functional outcome after ischemic stroke at 90d (OR = 0.81, 95% CI [0.72-0.90], p = 1.79e-04) and motor recovery within 24 months after stroke (OR = 1.42, 95% CI [1.23-1.64], p = 2.15e-06). In MVMR, SBP and DBP significantly attenuated the causal effects of SUA on AS, IS, and functional outcome after ischemic stroke at 90d and motor recovery within 24 months after stroke. Further mediation analyses showed that SBP mediated 52.4 and 34.5% of the effects of SUA on AS and IS, while DBP mediated 28.5 and 23.4% of the causal effects, respectively. This study supports the dual role of genetically predicted SUA in increasing stroke risk, especially ischemic stroke risk, and in improving functional outcome and motor recovery. SBP and DBP are key mediators lying on the causal pathways of SUA with AS and IS.

Stroke Recurrence Rate and Risk Factors Among Stroke Survivors in Sub-Saharan Africa: A Systematic Review.

Evidence supporting secondary stroke in sub-Saharan Africa is scarce. This study describes the incidence of stroke recurrence and associated risk factors in sub-Saharan Africa. Scientific databases were systematically searched from January 2000 to December 2022 for population-based observational studies, case-control or cohort studies of recurrent stroke involving adults aged 18 years and above in sub-Saharan Africa (SSA). We assessed the quality of the eligible studies using the Critical Appraisal Skills Program (CASP) checklist for observational studies. Six studies met the inclusion criteria and were included in this study.Stroke recurrence rates in SSA ranged from 9.4% to 25%. Majority of the studies were conducted from Western Africa and showed that stroke recurrence rates are high within sub-Saharan Africa ranging from 2% to 25%. The known stroke risk factors such as hypertension, chronic alcohol consumption, etc., remained the leading causes of stroke recurrence. The studies reported a higher mortality rate ranging from 20.5 -23% among those with recurrent strokes compared to primary strokes. This systematic review is an update and summary of the available literature on stroke recurrence within sub-Saharan Africa. Further studies are warranted to assess the outcomes and burden of stroke recurrence in SSA.

Survival within 12 months after stroke in Madagascar

The data on the long-term prognosis of stroke are scarce in Madagascar. Our objective was to determine survival within 12months after a stroke event. A longitudinal study was carried out on a hospital cohort of subjects with stroke in Mahajanga in western Madagascar. We included in the study all subjects admitted to adult emergencies at Mahajanga University Hospitals during the year 2019 and diagnosed with stroke. A follow-up by telephone call or by descent at the home of the patients was carried out after at least 12months from the onset of the disease. We analyzed in-hospital mortality and survival within 12months after the stroke. At the end of the study period, 144 stroke cases were retained. Strokes accounted for 5.07% of emergency admission causes. Male gender accounted for 51.4% of the population. The average age of the subjects was 60.7years. In-hospital mortality was 32.6%. Survival at 1month was 50%, at 3months 48.4%, and at 12months 43%. High blood pressure was found as a risk factor for stroke in 79.9% of patients, 76.5% of whom were undertreated. Stroke mortality was high in our population. Most of the deaths occurred during the first month. Improved prevention and care are needed in Madagascar.

A Systematic Review of the Epidemiology and The Public Health Implications of Stroke in Sub-Saharan Africa

BackgroundWith approximately 11 million strokes occurring annually worldwide, and over 6.5 million deaths annually, stroke has made its place as one of the major killers in the world. Although developing countries make up more than 4/5 of the global stroke burden, well-grounded information on stroke epidemiology remains lacking there. AimsThis systematic review study aimed to provide a synthesis of studies on the incidence and prevalence of stroke among adults in sub-Saharan Africa (SSA), subsequently deduce the associated risk factors and public health implications (mortality rates and economic costs) of the disease on the population of this region. MethodsA systematic review of studies carried out in the region and published on PUBMED. Eligibility criteria were established using the PEO (Population/Patient, Exposure, Outcome) format. Research articles investigating either (or all) of the following: ischemic or haemorrhagic stroke, incidence, prevalence, and risk factors of stroke in adults (≥ 18 years old), in at least one region of SSA were included. Exclusion criteria comprised studies involving populations younger than 18 years old, research conducted outside the designated research region, and articles inaccessible in full text. The PRISMA guidelines were used for the search strategy. ResultsFifty-two studies were included review. Among them, over 11 studies investigated the prevalence of the disease. Some older studies within the continent (Nigeria, 2011) showed a prevalence of 1.3 per 100 while more recent studies (Zambia, 2021) showed a prevalence of 4.3 per 1000. The highest prevalence noted in this region was in Madagascar (2017) with 48.17 per 100, while the lowest was recorded in (Zimbabwe, 2017) with 0.61 per 100. The study in Tanzania showed a crude incidence of 94·5 per 100 000 (76·0–115·0) while the study in Ghana in 2018 showed an incidence of 14.19 events per 1000 person-years [10.77–18.38]. The identified risk factors included hypertension, diabetes, smoking, alcohol consumption, physical inactivity, poor diets (more salt, less vegetables), dyslipidaemia, HIV/AIDS co-infection, heart disease (cardiomyopathies, cardiac arrhythmias), obesity, previous stroke and/or family history of stroke. Over 21 studies investigated the mortality rates due to stroke in SSA, with most of the studies being in West Africa. These studies revealed mortality rates as high as 43.3% in Ghana, and as low as 10.9% in Cameroon. Few studies reported on the economic costs of stroke in the region; two in Benin, two in Nigeria and one in Tanzania. ConclusionThe increasing incidence/prevalence, lifestyle factors and interactions with other diseases, including major communicable diseases, stroke is becoming a pressing public health problem for SSA. Reducing the incidence of stroke in Africa will surely lower mortality, morbidity, disability, and the neurological as well as cognitive aftereffects of stroke, as is clear from the experience of higher-income nations. We recommend a collective intervention involving the governments of nations, international organizations, civil society, and the private sector for greater impact and sustainable outcomes reducing the epidemiology and implications of stroke in SSA.

Piezo1 Knockout Improves Post-Stroke Cognitive Dysfunction by Inhibiting the Interleukin-6 (IL-6)/Glutathione Peroxidase 4 (GPX4) Pathway.

Cerebral infarction often results in post-stroke cognitive impairment, which impairs the quality of life and causes long-term disability. Astrocytes, the most abundant glial cells in the central nervous system, have a crucial role in cerebral ischemia and neuroinflammation. We explored the possible advantages of interleukin-6 (IL-6), a powerful pro-inflammatory cytokine produced by astrocytes, for post-stroke cognitive function. Mendelian randomization was applied to analyze the GWAS database of stroke patients, obtaining a causal relationship between IL-6 and stroke. Further validation of this relationship and its mechanisms was conducted. Using a mouse model of cerebral infarction, we demonstrated a significant increase in IL-6 expression in astrocytes surrounding the ischemic lesion. This protective effect of Piezo1 knockout was attributed to the downregulation of matrix metalloproteinases and upregulation of tight junction proteins, such as occludin and zonula occludens-1 (ZO-1). Two-step Mendelian randomization revealed that IL-6 exposure is a risk factor for stroke. Moreover, we conducted behavioral assessments and observed that Piezo1 knockout mice that received intranasal administration of astrocyte-derived IL-6 showed notable improvement in cognitive function compared to control mice. This enhancement was associated with reduced neuronal cell death and suppressed astrocyte activation, preserving ZO-1. Our study shows that astrocyte-derived IL-6 causes cognitive decline after stroke by protecting the blood-brain barrier. This suggests that piezo1 knockout may reduce cognitive impairment after brain ischemia. Further research on the mechanisms and IL-6 delivery methods may lead to new therapies for post-stroke cognition.

Baseline lifestyle and biomedical stroke risk factors among New Zealand participants in the PERsonalised Knowledge to reduce the risk of Stroke (PERKS-International) randomised controlled trial –preliminary results

Stroke ranks as the world’s second leading cause of death and third in causing disabilities, a preventable disease affecting people of all demographics. Primary prevention is crucial to mitigate its impact by addressing modifiable risk factors such as poor diet, low physical activity (PA), obesity, smoking, high blood pressure (BP), elevated cholesterol, and blood glucose levels. This study evaluated quality of diet and other stroke modifiable risk factors among New Zealand (NZ) participants recruited at the baseline phase of the PERKS-International trial. PERKS is a Phase III, multicentre, prospective, pragmatic, open-label, single-blinded endpoint, two-arm randomised controlled trial conducted across Australia and NZ(1). Participants aged &gt;35 and ≤75 years with ≥2 modifiable risk factors for stroke were assessed using the Life’s Simple 7 (LS7) score. LS7 includes seven components (BMI, BP, total cholesterol, blood glucose, dietary pattern, smoking, and PA) categorising into ideal,intermediate, and poor level. Height, weight, and BP were measured. Total cholesterol and blood glucose were measured via CardioChek PA Analyser. An online FFQ and Physical Activity Questionnaire were administered. Descriptive analyses and correlation coefficients were used to examine the characteristics of participants at the baseline. In NZ, out of 395 targeted participants, 375 (Female = 230, mean age = 57yrs) from diverse ethnic groups (NZ European = 204, Māori = 35, Pacific = 17) were recruited and assessed. Among LS7 metrics, smoking had the highest proportion of those in the ideal category (88%), followed by blood glucose (62%), total cholesterol (49%), dietary pattern (34%), BP (22%) and BMI (13%). Nearly 64% consumed &lt;5 portions of fruits and vegetables per day. Almost half of the participants consumed beans and pulses less than once a week. About 43% and 31% consumed fibre-rich breakfast cereal and wholemeal bread less than once a week. Almost 10% drank fizzy drinks ≥4 times/week. Nearly 40% consumed sweets such as biscuits, cakes, and chocolate at least twice a week. Over half of the participants consumed red meat and chicken 2-3 times/week. In terms of other risk factors, over half of the participants were obese (BMI≥ 30 kg/m2). Only 12% were current smokers. About 10% drank alcohol 5-7 days/week. Physical activity expenditure (MET minutes/week) showed no significant sex difference. The LS7 factors correlated significantly were BMI and blood glucose (r = 0.157, p&lt;0.01), total cholesterol and smoking (r=-0.129, p&lt;0.01), BP and BMI (with a moderate correlation of r = 0.308, &lt;0.001). The NZ participants in the PERKS-International trial, had poor diets, along with suboptimal lifestyle and biomedical stroke risk factors, reflecting the inclusion criteria for the study. Urgent action is required for the primary stroke prevention at population-level. The results of the trial, expected in 2024, will show the benefit of a mobile phone app on reducing these stroke risk factors.

(109) - Incidence and Risk Factors for Early Stroke Following Durable Left Ventricular Assist Device (LVAD) Implantation: An STS Intermacs Analysis

(109) - Incidence and Risk Factors for Early Stroke Following Durable Left Ventricular Assist Device (LVAD) Implantation: An STS Intermacs Analysis

Treatment Results of Carotid Artery Stenting with an Open-Cell Stent: Analysis of 734 Consecutive Cases at a Single Center

In carotid artery stenting (CAS) for internal carotid artery stenosis (ICS), the stent is often selected according to the plaque properties and arterial tortuosity. In our institute, an open-cell stent is used as the first-line stent regardless of the characteristics of the lesion. This study was performed to examine the outcome of CAS with an open-cell stent as the real-world results. In total, 811 CAS procedures using open-cell stents were performed for ICS from April 2002 to December 2019. Of these patients, we excluded those with hyperacute conditions for which CAS was performed within 3 days of onset, those in whom acute mechanical thrombectomy was performed simultaneously with CAS, and those with stenosis due to arterial dissection. Thus, 734 patients were retrospectively analyzed. Perioperative and long-term outcomes and risk factors for perioperative infarction were investigated. The periprocedural stroke rate and mortality rate were 3.7% (27/734) and 0.4% (3/734), respectively. Low-echoic plaque was a significant risk factor for periprocedural stroke in both univariate (P < 0.03) and multivariate (odds ratio, 2.69; 95% confidence interval, 1.14-6.66; P = 0.02) analyses. Cerebral infarction and high-grade restenosis were observed in 15 (2.0%) and 17 (2.3%) patients during a median 50-month follow-up. CAS with open-cell stents showed good results in terms of both the postoperative stroke incidence and long-term severe restenosis rate. However, low-echoic plaque was a risk factor for perioperative stroke incidence, which should be considered when deciding on the indication for CAS with an open-cell stent.

Risk of Long-Term Ischemic Stroke in Patients With Traumatic Brain Injury and Incident Hypertension.

Traumatic brain injury (TBI) is independently associated with hypertension and ischemic stroke. The goal of this study was to determine the interplay between TBI and incident hypertension in the occurrence of post-TBI stroke. This prospective study used a hospital-based registry to identify patients without pre-existing comorbidities. TBI patients (n = 3664) were frequency matched on age, sex, and race to non-TBI patients (n = 1848). Follow-up started 6 months post-TBI or study entry and extended up to 10 years. To examine hypertension's role in post-TBI stroke, we used logistic regression models to calculate the effect estimates for stroke in four exposure categories that included TBI or hypertension in isolation and in combination. Second, we calculated the conditional direct effect (CDE) of TBI in models that considered hypertension as intermediary. Third, we examined whether TBI effect was modified by antihypertensive medication use. The 10-year cumulative incidence of stroke was higher in the TBI group (4.7%) than the non-TBI group (1.3%; p < 0.001). TBI patients who developed hypertension had the highest risk of stroke (odds ratio [OR] = 4.83, 95% confidence interval [CI] = 2.53-9.23, p < 0.001). The combined effect estimates were less than additive, suggesting an overlapping biological pathway. The total effect of TBI (OR = 3.16, 95% CI = 1.94-5.16, p < 0.001) was higher than the CDE that accounted for hypertension (OR = 2.45, 95% CI = 0.93-6.47, p = 0.06). Antihypertensives attenuated the TBI effect, suggesting that the TBI effect on stroke is partially mediated through hypertension. TBI is an independent risk factor for long-term stroke, and the underlying biological pathway may partly operate through TBI-precipitated hypertension. These findings suggest that screening for hypertension may mitigate stroke risk in TBI.

Age at natural menopause and development of chronic diseases in the female population of Kharameh, Iran: A historical cohort study.

Declines in estradiol levels after menopause have been reported to be associated with several health outcomes. This study aimed to determine the effect of age at natural menopause (ANM) on some of the most common chronic diseases. This historical cohort study was performed on 2636 postmenopausal women aged 40-70 years participating in phase one of the PERSIAN cohort study in Kharameh, Iran, during 2015-2017. The effect of early (<45 years), intermediate (45-53 years), and late menopause (>53 years) on chronic diseases such as hypertension, diabetes, ischemic heart diseases, stroke, thyroid diseases, and depression was assessed using classic logistic regression for diseases with an incidence rate of more than 10% and Firth's logistic regression for diseases with an incidence of less than this amount. The mean age of women was 53.48 ± 8.59. Respectively, early and intermediate menopause was associated with ischemic heart disease (odds ratio [OR = 1.61, 95% confidence interval [CI]: 1.08-2.42; p = 0.020), (OR = 1.57, 95% CI: 1.13-2.21; p = 0.008) and thyroid diseases (OR = 3.10, 95% CI: 1.64-6.24; p < 0.001), (OR = 1.83, 95% CI: 1.02-3.57; p = 0.042). furthermore, early menopause was a risk factor for diabetes (OR = 1.46, 95% CI: 1.07-2.00; p = 0.018), depression (OR = 4.79, 95% CI: 2.20-11.79; p = <0.001) and stroke (OR = 3.00, 95% CI: 1.08-9.32; p = 0.034). In this study, women with diabetes, ischemic heart diseases, stroke, thyroid disorders, and depression had a younger ANM compared to their healthy counterparts. Therefore, applying appropriate strategies to postpone the age of menopause, can reduce the incidence of these types of chronic diseases.

The Potential Role of Preoperative Posterior Cerebral Artery Involvement in Predicting Postoperative Transient Neurological Deficits and Ischemic Stroke After Indirect Revascularization in Patients With Moyamoya Disease

ObjectiveTransient neurological deficits (TNDs) are known to develop after direct bypass for moyamoya disease (MMD) and may be risk factors for subsequent stroke. However, the factors involved in the development of TNDs and stroke after indirect revascularization alone, including their association with subsequent stroke, remain unclear. The purpose of this study was to investigate this issue. MethodsThe subjects of the study were 30 patients with MMD who underwent a total of 40 indirect revascularization procedures at our institution. Clinical and radiological data were collected retrospectively. To examine factors associated with the development of postoperative TND/stroke/asymptomatic disease, the clinical characteristics of each group were statistically compared. ResultsThe mean age at surgery was 7 years (range 1-63). TNDs developed after surgery in 9 out of 40 patients (22.5%). Stroke in the acute postoperative period occurred in 3 patients (7.5%), all of whom experienced cerebral infarctions. Demographic data and preoperative clinical information were not different between the groups. However, posterior cerebral artery (PCA) involvement on preoperative imaging was significantly associated with the development of TNDs and stroke (p=0.006). Furthermore, postoperative stroke was associated with unfavorable outcomes (p=0.025). ConclusionsPCA involvement is significantly associated with the occurrence of TNDs. In contrast, TNDs after indirect revascularization have little relationship with the subsequent development of stroke. TNDs usually resolve without new strokes, and a better understanding of this particular pathology could help establish an optimal treatment regimen.

Stroke Events and Risk Factors in Older Patients with Moyamoya Disease

We aimed to comprehensively analyze the epidemiology, natural history, stroke events and their risk factors, and the RNF213 p.Arg4810Lys variant in older patients with moyamoya disease (MMD). We enrolled patients with MMD followed-up at our hospital between 2000 and 2023. Those who developed MMD at age ≥ 60 years or were diagnosed at a younger age and followed-up after age 60 years were included. Baseline characteristics, onset type, radiological features, and RNF213 p.Arg4810Lys variant status were investigated. Among 56 patients with 100 affected hemispheres, 62 were asymptomatic, 26 experienced ischemic onset, and 12 had hemorrhagic onset. A higher incidence of anterior choroidal artery (AchA) dilatation and lower proportion of favorable modified Rankin scale scores were detected in hemorrhagic onset, whereas greater prevalence of bypass surgery in ischemic onset. Of 76 asymptomatic hemispheres at the age of 60 years, subsequent stroke events occurred in 10 hemispheres, comprising eight hemorrhages and two ischemias. Risk factors for de novo hemorrhage in asymptomatic hemispheres included AchA dilatation and choroidal anastomosis. Comparison of the RNF213 p.Arg4810Lys variant status showed no significant differences in baseline characteristics, onset types, or imaging findings, except for a higher percentage of patients in the GA group with a family history of MMD. Hemorrhagic events were the most prevalent and prognostically deteriorating factors in older patients with MMD aged ≥60 years. AchA dilatation and choroidal anastomosis were predictors of de novo hemorrhage in asymptomatic nonsurgical hemispheres in older patients with MMD.

Food and Cardiovascular Disease: What to Eat and What Not to Eat

In 2019, the Global Burden of Disease study revealed alarming statistics regarding cardiovascular disease (CVD) in Pakistan. The estimated age-standardized incidence and death rates were 918.18 and 357.88 per 100,000 respectively, surpassing global averages.1 Notably, Pakistan faces unique challenges with a high prevalence of Rheumatic heart disease and early onset coronary artery disease.1&#x0D; The World Health Organization's 2021 factsheet underscores four pivotal modifiable behavioral risk factors for CVD and stroke: unhealthy diet, physical inactivity, tobacco use, and harmful alcohol consumption. These behaviors manifest in individuals as elevated blood pressure, glucose, lipids, and adverse body mass index, exacerbating cardiovascular risk.2 In Pakistan, the consumption of unhealthy foods and excessive calories significantly contributes to adverse cardiometabolic profiles, including obesity and dyslipidemia.2&#x0D; Recent research, such as that by Daruish Mozaffain et al. in "Food is Medicine," advocates for food-based interventions tailored to individual health conditions, ranging from medically tailored meals to nutritional and culinary education.3 However, Pakistani patients with CVD face challenges due to the lack of localized guidelines, educational resources, and accessible nutritionists. Shah et al.'s review underscores the importance of providing clear and culturally relevant dietary guidance for the local population.4&#x0D; Addressing these challenges requires the development of high-quality, culturally sensitive educational materials. These resources should be readily understandable, pictorial, and integrated into both inpatient and outpatient care. Local experts, including dietitians and researchers, can play a crucial role in creating tailored educational content. Figures 1 exemplify the efforts of these experts to provide practical guidance to the Pakistani population.4&#x0D; In conclusion, there is an urgent need for comprehensive, easy-to-understand patient education resources catering to the unique nutritional needs of Pakistani individuals with cardiovascular disease. By addressing these gaps, we can empower patients to make informed dietary choices and improve cardiovascular outcomes.&#x0D; References&#x0D; &#x0D; Samad Z, Hanif B. Cardiovascular Diseases in Pakistan: Imagining a Postpandemic, Postconflict Future. Circulation. 2023;147(17):1261-3.&#x0D; Liaquat A, Javed Q. Current trends of cardiovascular risk determinants in Pakistan. Cureus. 2018;10(10):e3409.&#x0D; Mozaffarian D, Aspry KE, Garfield K, Kris-Etherton P, Seligman H, Velarde GP, et al. “Food Is Medicine” Strategies for Nutrition Security and Cardiometabolic Health Equity: JACC State-of-the-Art Review. J Am Coll Cardiol. 2024;83(8):843-64.&#x0D; Shah SU, Waseem T, Afridi T, Shah MI. Nutritional Needs for Cardiovascular Health in Pakistani Population. Pak Heart J. 2022;55(2):101-13.&#x0D; American Heart Association. Lifestyle Changes for Heart Failure. Accessed on March 30, 2024. Available at: https://www.heart.org/en/health-topics/heart-failure/treatment-options-for-heart-failure/lifestyle-changes-for-heart-failure&#x0D; American Diabetes Association. What superstar foods are good for diabetes? Accessed on March 30, 2024. Available at: https://diabetes.org/food-nutrition/food-and-blood-sugar/diabetes-superstar-foods&#x0D; American Heart Association. The American Heart Association Diet and Lifestyle Recommendations. Accessed on March 30, 2024. Available at: https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/aha-diet-and-lifestyle-recommendations&#x0D; American Heart Association. Managing Blood Pressure with a Heart-Healthy Diet. Accessed on March 30, 2024. Available at: https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/managing-blood-pressure-with-a-heart-healthy-diet&#x0D;

Sleep Apnea and Incident Stroke in a National Cohort of Black and White Adults.

Racial/ethnic differences have been documented in the relationship between obstructive sleep apnea (OSA) and stroke incidence, yet racial differences in OSA symptoms or treatment and their relationship with stroke incidence are underexplored and may contribute to stroke disparities. We comprehensively examined OSA symptoms and their relationships to stroke incidence by race/ethnicity. Data were collected from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a population-based cohort of Black and White individuals in the United States. Participants free from a stroke diagnosis at baseline were included. Participants self-reported the following: (1) snoring; (2) daytime sleepiness; (3) provider-diagnosed sleep apnea (PDSA); and (4) treatment for PDSA using positive airway pressure (PAP). OSA risk was categorized as high or low based on the Berlin Sleep Questionnaire. Incident stroke was defined as first occurrence of stroke over an average of 12 (SD 3.9) years of follow-up. We report the relationships between snoring, OSA risk, PDSA, PAP therapy use, and incident stroke by race/ethnicity using Cox proportional hazards models after adjusting for demographic and socioeconomic factors and stroke risk factors. Among the 22,192 participants (mean age [SD] 64.2[9.1] years), 38.1% identified as Black. Overall, snoring was not associated with incident stroke (hazard ratio [HR] 0.98, 95% CI 0.85-1.13). However, among White individuals but not Black individuals, high OSA risk and PDSA were associated with incident stroke (HR 1.22, 95% CI 1.01-1.47; HR 1.33, 95% CI 1.04-1.70, respectively). PAP therapy use among those with PDSA (compared with non-PDSA) was associated with incident stroke in White individuals (HR 1.38, 95% CI 1.05-1.80). PAP therapy use among those with PDSA (compared with those with PDSA without PAP therapy use) was associated with reduced risk of incident stroke in Black (HR 0.39, 95% CI 0.17-0.91) but not White (HR 0.63, 95% CI 0.37-1.10) individuals. White individuals with high OSA risk and those with PDSA with or without PAP therapy use were at increased incident stroke risk, whereas Black individuals reporting PDSA and PAP had reduced incident stroke risk relative to those not using PAP. Future research is needed to understand the mechanisms underlying racial differences in OSA and stroke such as differences in assessment modes and treatment.

Atrial Fibrillation Burden: Impact on Stroke Risk and Beyond.

Atrial fibrillation (AF) is an important independent risk factor for stroke. Current guidelines handle AF as a binary entity with risk driven by the presence of clinical risk factors, which guides the decision to treat with an oral anticoagulant. Recent studies in the literature suggest a dose-response relationship between AF burden and stroke risk, in both clinical AF and subclinical atrial fibrillation (SCAF), which differs from current guidance to disregard burden and utilize clinical risk scores alone. Within clinical classification and at the same risk levels in various scores, the risk of stroke increases with AF burden. This opens the possibility of incorporating burden into risk profiles, which has already shown promise. Long-term rhythm monitoring is needed to elucidate SCAF in patients with stroke. Recent data from randomized trials are controversial regarding whether there is an independent risk from AF episodes with a duration of less than 24 h, including the duration of SCAF greater than six minutes but less than 24 h.