Risk Of Stroke In Adults Research Articles

Lifestyle Factors and Gender-Specific Risk of Stroke in Adults with Diabetes Mellitus: A Case-Control Study

The lifestyle interventions are effective preventive measures for stroke in general population, and the stroke risk with lifestyle factors may be modified by gender, health conditions, etc. Therefore, we conducted a case-control study to investigate the gender-specific association between stroke risk and lifestyle factors in adults with diabetes based on the China National Stroke Screening Survey. Structured questionnaires were used to collect demographic data and information regarding lifestyle factors, history of chronic medical conditions, and family history of stroke and the status of treatment. The case group comprised individuals diagnosed with first-ever stroke in 2013-2014 screening period. Their corresponding controls (frequency-matched for age group and urban/rural ratio) were randomly selected from individuals with diabetes without stroke. There were 170 total stroke cases (500 controls) and 152 ischemic stroke cases (456 controls) among men with diabetes, and 183 total stroke cases (549 controls) and 168 ischemic stroke cases (504 controls) among women with diabetes. We found that physical inactivity was significantly associated with increased risk of total stroke (odds ratio [OR] = 1.50, 95% confidence interval [CI] 1.02-2.21) and of ischemic stroke (OR = 1.57, 95% CI 1.04-2.36) in women with diabetes. We found no significant association of smoking, overweight/obesity, or physical inactivity with risk of total or ischemic stroke in men with diabetes. Among the lifestyle factors of smoking, overweight/obesity, and physical inactivity, physical inactivity might increase the risk of total and ischemic stroke in women with diabetes.

Neighborhood socioeconomic status at the age of 40 years and ischemic stroke before the age of 50 years: A nationwide cohort study from Sweden.

Objective We aimed to study the association between neighborhood socioeconomic status at the age of 40 years and risk of ischemic stroke before the age of 50 years. Methods All individuals in Sweden were included if their 40th birthday occurred between 1998 and 2010. National registers were used to categorize neighborhood socioeconomic status into high, middle, and low and to retrieve information on incident ischemic strokes. Hazard ratios and their 95% confidence intervals were estimated. Results A total of 1,153,451 adults (women 48.9%) were followed for a mean of 5.5 years (SD 3.5 years), during which 1777 (0.30%) strokes among men and 1374 (0.24%) strokes among women were recorded. After adjustment for sex, marital status, education level, immigrant status, region of residence, and neighborhood services, there was a lower risk of stroke in residents from high-socioeconomic status neighborhoods (hazard ratio 0.87, 95% confidence interval 0.78-0.96), and an increased risk of stroke in adults from low-socioeconomic status neighborhoods (hazard ratio 1.16, 95% confidence interval 1.06-1.27), compared to their counterparts living in middle-socioeconomic status neighborhoods. After further adjustment for hospital diagnoses of hypertension, diabetes, heart failure, and atrial fibrillation prior to the age of 40, the higher risk in neighborhoods with low socioeconomic status was attenuated, but remained significant (hazard ratio 1.12, 95% confidence interval 1.02-1.23). Conclusions In a nationwide study of individuals between 40 and 50 years, we found that the risk of ischemic stroke differed depending on neighborhood socioeconomic status, which calls for increased efforts to prevent cardiovascular diseases in low socioeconomic status neighborhoods.

A new approach to stroke prevention in Russia

Considerable burden of stroke along with continuously increasing cost of medical help to stroke patients in Russia prompt to search for new and more efficient strategies for stroke prevention. These strategies should encompass improvement of people’s awareness of stroke symptoms and risk factors, as well as accessible information on how to modify the risk factors. Here we present the Stroke Riskometer™ app for smartphones which fulfills the abovementioned criteria. This tool has been developed based on research data and is acknowledged by the international medical community. Russian version is also available. The app allows to determine personal risk of stroke in adults within the next 5 to 10 years; it also helps to reveal personal risk factors for stroke and appropriate ways to mitigate these factors. We believe that wide use of this app in Russia will help to significantly reduce incidence of stroke.

Abstract TMP93: Elevated Oxygen Extraction Fraction Measured With Noninvasive MRI may be Discriminatory for Stroke Risk in Adults With Sickle Cell Anemia

Introduction: No screening procedures exist for evaluating stroke risk in adults with sickle cell anemia (SCA). Reduced oxygen carrying capacity is present in SCA, which may initially be compensated for by an increase in cerebral blood flow (CBF) and then by increased oxygen extraction fraction (OEF). Hypothesis: OEF and CBF can be measured noninvasively and reproducibly with MRI using clinically-available equipment in adults with SCA; elevated OEF provides added discriminatory capacity for clinical impairment relative to vasculopathy extent and CBF alone. Methods: Structural, CBF-weighted, and MRA imaging, together with a noninvasive OEF-weighted T 2 -relaxation-under-spin-tagging (TRUST)-MRI method was applied in SCA adults (n=26) and race and age-matched controls (n=11). A Kruskal-Wallis test was applied to evaluate mean differences between SCA and control parameters. Linear regression assessed how elevated OEF correlated with increasing clinical impairment defined by presence of infarct, vasculopathy, or use of regular blood transfusions for SCA. Results: OEF had high reproducibility within the same scan session, n=37 (ICC = 0.989). Whole-brain OEF and CBF were increased in SCA adults (OEF=0.46±0.08; CBF=52.4±8.3 ml/100g/min) versus controls (OEF=0.35±0.06; CBF=43.6±5.1 ml/100g/min). Hematocrit and OEF were inversely correlated (R 2 =0.72; p<0.01). Linear regression revealed a stronger relationship of OEF than CBF with clinical impairment. In SCA adults without impairment (n=12) CBF and OEF have an inverse relationship (R 2 =0.41; p=0.01, Fig. 1A) but with clinical impairment (infarct, vasculopathy or severe pain requiring regular transfusions, n=14) CBF and OEF become uncoupled (R 2 =0.08; p=0.16; Fig. 1B) as CBF may not be able to increase further and may plateau or decline. Conclusion: TRUST-MRI OEF is a rapid, reproducible measure. OEF shows promise as screening tool for hemodynamic impairment and stroke risk in adults with SCA.

Non-invasive imaging of oxygen extraction fraction in adults with sickle cell anaemia.

Sickle cell anaemia is a monogenetic disorder with a high incidence of stroke. While stroke screening procedures exist for children with sickle cell anaemia, no accepted screening procedures exist for assessing stroke risk in adults. The purpose of this study is to use novel magnetic resonance imaging methods to evaluate physiological relationships between oxygen extraction fraction, cerebral blood flow, and clinical markers of cerebrovascular impairment in adults with sickle cell anaemia. The specific goal is to determine to what extent elevated oxygen extraction fraction may be uniquely present in patients with higher levels of clinical impairment and therefore may represent a candidate biomarker of stroke risk. Neurological evaluation, structural imaging, and the non-invasive T2-relaxation-under-spin-tagging magnetic resonance imaging method were applied in sickle cell anaemia (n = 34) and healthy race-matched control (n = 11) volunteers without sickle cell trait to assess whole-brain oxygen extraction fraction, cerebral blood flow, degree of vasculopathy, severity of anaemia, and presence of prior infarct; findings were interpreted in the context of physiological models. Cerebral blood flow and oxygen extraction fraction were elevated (P < 0.05) in participants with sickle cell anaemia (n = 27) not receiving monthly blood transfusions (interquartile range cerebral blood flow = 46.2-56.8 ml/100 g/min; oxygen extraction fraction = 0.39-0.50) relative to controls (interquartile range cerebral blood flow = 40.8-46.3 ml/100 g/min; oxygen extraction fraction = 0.33-0.38). Oxygen extraction fraction (P < 0.0001) but not cerebral blood flow was increased in participants with higher levels of clinical impairment. These data provide support for T2-relaxation-under-spin-tagging being able to quickly and non-invasively detect elevated oxygen extraction fraction in individuals with sickle cell anaemia with higher levels of clinical impairment. Our results support the premise that magnetic resonance imaging-based assessment of elevated oxygen extraction fraction might be a viable screening tool for evaluating stroke risk in adults with sickle cell anaemia.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Adult stroke risk after growth hormone treatment in childhood

Childhood precursors of adult diseases are increasingly identified by studies that span the period from birth to senescence. This is particularly relevant for cerebrovascular disease, for which links have been discovered with childhood obesity and adolescent-onset hypertension.1 In this issue of Neurology ®, Poidvin et al.2 report an increased risk of stroke in adults treated with growth hormone (GH) during childhood. This report has been much anticipated by the endocrinology community because it extends and clarifies findings in a 2012 study showing increased mortality in adults treated in childhood with GH from the prospective European cohort study—the Safety and Appropriateness of Growth Hormone Treatments in Europe (SAGhE).3

Prothrombin G20210A Mutation Is Associated With Young-Onset Stroke

Although the prothrombin G20210A mutation has been implicated as a risk factor for venous thrombosis, its role in arterial ischemic stroke is unclear, particularly among young adults. To address this issue, we examined the association between prothrombin G20210A and ischemic stroke in a white case-control population and additionally performed a meta-analysis. From the population-based Genetics of Early Onset Stroke (GEOS) study, we identified 397 individuals of European ancestry aged 15 to 49 years with first-ever ischemic stroke and 426 matched controls. Logistic regression was used to calculate odds ratios (ORs) in the entire population and for subgroups stratified by sex, age, oral contraceptive use, migraine, and smoking status. A meta-analysis of 17 case-control studies (n=2305 cases <55 years) was also performed with and without GEOS data. Within GEOS, the association of the prothrombin G20210A mutation with ischemic stroke did not achieve statistical significance (OR=2.5; 95% confidence interval [CI]=0.9-6.5; P=0.07). However, among adults aged 15 to 42 years (younger than median age), cases were significantly more likely than controls to have the mutation (OR=5.9; 95% CI=1.2-28.1; P=0.03), whereas adults aged 42 to 49 years were not (OR=1.4; 95% CI=0.4-5.1; P=0.94). In our meta-analysis, the mutation was associated with significantly increased stroke risk in adults ≤55 years (OR=1.4; 95% CI=1.1-1.9; P=0.02), with significance increasing with addition of the GEOS results (OR=1.5; 95% CI=1.1-2.0; P=0.005). The prothrombin G20210A mutation is associated with ischemic stroke in young adults and may have an even stronger association among those with earlier onset strokes. Our finding of a stronger association in the younger young adult population requires replication.

The Use Of Transcranial Doppler Ultrasonography In Adult Patients With Sickle Cell Disease: A Retrospective Analysis

Background Unlike in children, Transcranial Doppler Ultrasound (TCD) can not currently be used to predict stroke risk in adults with Sickle Cell Disease, and this is confounded by an age related decline in TCD and lack of an established normal TCD velocity range for adults. In addition abnormalities in the extracranial circulation have been associated with increased incidence of stroke in children with SCD, but this has not been shown in adults. Aims To retrospectively review TCD and carotid duplex ultrasound results from adults with SCD and to correlate with neurological outcome. Methods TCD and carotid duplex data were collected from 112 patients from January 2003 to December 2012 and analysed retrospectively. Imaging and non-imaging TCD and carotid duplex were performed as a routine out-patient investigation as part of an annual review in the comprehensive adult sickle cell clinic in our unit. STOP velocity criteria were used for stroke risk stratification. Carotid disease was defined as non-significant (&lt;50%), moderate stenosis (50-69%) and severe disease (≥70%). Results The mean age of patients was 35.4 (range 17-79) years; 65% were female and 78% had HbSS. There were 5 patient exclusions based on the TCD findings; two were non-diagnostic and three had abnormal scans as part of childhood screening. The remaining 107 patients were divided into two groups; Group I patients had a normal neurological examination (n = 95) and Group II had an abnormal neurological examination with a clinical diagnosis of stroke that preceded TCD/carotid duplex examination (n = 12). In Group I there were 4 abnormal TCD scans according to STOP criteria; two showed significant asymmetry (&gt;25%) and two showed abnormally low velocities (&lt;50cm/s), one of whom subsequently developed a silent stroke. Although the remaining 91 patients had normal TCD findings; a limited TCD examination was noted in 6 patients and asymmetrical velocities that fell below the 25% threshold were observed in 7 patients, one of whom subsequently developed a symptomatic lacunar infarct. A further eight patients showed extracranial (ICA) disease and one of these also had evidence of a silent stroke on MRI. In Group II, 5 patients showed abnormal TCD findings; four had low velocities (&lt;50cm/sec) and one had low velocities and significant asymmetry. Six patients had severe extracranial ICA stenosis or occlusion on carotid duplex. There was a significant increase in the incidence of abnormal TCD (C2=19.4, p&lt;0.001) and duplex findings (C2=16.2, p&lt;0.001) in patients in Group II compared to Group I. Conclusions Routine screening of adults with SCD using TCD did not show any asymptomatic patients with elevated TCD flow-velocities (&gt;170cm/s), confirming previous studies. However, other abnormal ultrasound findings were observed including; abnormally low or asymmetric TCD velocities and extracranial ICA disease. These abnormalities were associated with stroke in three cases; TCD asymmetry preceded a lacunar infarct by five years, abnormally low velocities preceded a silent infarct by two years and severe extracranial ICA stenosis was associated with a silent infarct. There was a significantly increased incidence of abnormal ultrasound findings in patients who had neurological symptoms (91.6% versus 12.6%). Further investigation of the incidence and implications of abnormal TCD and extracranial carotid duplex findings in adults with sickle cell disease is required. Longitudinal follow-up of patients with low or asymmetric velocities and ICA disease will clarify if these abnormalities are associated with increased neurological morbidity; if so, intervention may be justified. The traditional STOP criteria of raised TCD velocities are inadequate in the adult sickle population, new velocity criteria are required to stratify the risk of stroke in this population. Disclosures: Howard: Sangart: Membership on an entity’s Board of Directors or advisory committees.

Preterm birth and carotid diameter and stiffness in childhood

Low birthweight, either as a result of poor foetal growth or preterm birth, is a risk factor for stroke in adult life. Carotid stiffening, an early marker of atheromatous disease, has been found in low-birthweight children born at term. We hypothesized that carotid artery growth and dynamic properties are permanently affected by preterm birth. Carotid artery stiffness and dimensions in 56 school children, 39 born very preterm (mean gestational age [GA] 29 weeks) and 17 controls born at term, were studied by ultrasonic measurements of the pulsatile movements of the vessel wall. The carotid artery diameter was 6.4 mm both in children born preterm and at term (p=0.99). No difference in carotid stiffness was found. Within the preterm group, no differences could be seen between those born small for gestational age (SGA) or appropriate for gestational age (AGA). Carotid artery elasticity and structure are not altered after preterm birth. The mechanisms behind the increased stroke risk in adults born preterm remain unresolved.

Transcranial Doppler ultrasonography in adults with sickle cell disease

Transcranial Doppler (TCD) is used to select children with sickle cell disease (SCD) for primary stroke prevention using regular blood transfusion. Whether it can also identify high stroke risk in adults with SCD is not known. The authors examined 112 adult patients from two convenience population samples with SCD and 53 healthy control subjects to compare velocities in adults to those reported in children with SCD and to evaluate the influence of age and hematocrit on TCD. Adults with SCD had a higher mean time-averaged maximum mean velocity (110.9 +/- 25.7 cm/s) compared with healthy controls (71.1 +/- 12.0 cm/s), and the difference is approximately proportional to their anemia. No cases with velocities >/=200 cm/s (the threshold used in children for prophylactic treatment) were found in this sample. Transcranial Doppler velocities in adults with sickle cell disease (SCD) are lower than those in children with SCD. Velocity criteria used in children cannot be used to stratify risk of stroke in adults.

Transcranial Doppler in Adult Patients with Sickle Cell Disease

Background: Transcranial Doppler (TCD) is the key test in determining the need for prophylactic blood transfusion to prevent stroke in children with sickle cell disease (SCD). The role of TCD in assessing stroke risk in adults with SCD as well as the pattern of TCD velocities in these patients are still undetermined. Methods: The authors compared TCD velocities in SCD adults (n = 56) with those of healthy controls (n = 56). Results: Velocities in SCD adults were lower than those found in children and higher than in controls and negatively correlated to hematocrit in both groups. Conclusion: The pattern of TCD velocities in adults with SCD is different from that described in children. Age-specific TCD criteria may assist the detection of stroke risk in these patients.

Risk of stroke in adults with cyanotic congenital heart disease.

Risk of stroke in adults with cyanotic congenital heart disease.

Risk of stroke in adults with cyanotic congenital heart disease.

Adults with cyanotic congenital heart disease and elevated hematocrit levels are often phlebotomized because of an assumed risk of cerebral arterial thrombotic stroke. Whether a relation exists between hematocrit level, symptomatic erythrocytosis (hyperviscosity), and stroke remains to be established in this patient population. Accordingly, 112 cyanotic patients 19-74 years old (mean, 36 +/- 11.7 years) in the UCLA Adult Congenital Heart Disease Center Registry were selected for study by virtue of continuous observation for 1-12 years (total, 748 patient-years). Patients with independent risk factors for embolic or vasospastic stroke were excluded. The study patients were then divided into two groups: 1) compensated erythrocytosis (stable hematocrit levels of 46.0-72.7% [mean, 57.5 +/- 7.2%], iron replete, absent or mild hyperviscosity symptoms), and 2) decompensated erythrocytosis (unstable rising hematocrit levels of 61.5-75.0% [mean, 69.5 +/- 10.6%], iron deficiency, marked-to-severe hyperviscosity symptoms). No patient with either compensated or decompensated erythrocytosis, irrespective of hematocrit level, iron stores, or the presence, degree, or recurrence of cerebral hyperviscosity symptoms, progressed to clinical evidence of a complete stroke (cerebral arterial thrombosis with brain infarction). Because a risk of stroke caused by cerebral arterial thrombosis was not demonstrated, because the circulatory effects of phlebotomy are transient, and because of the untoward sequelae of phlebotomy-induced iron deficiency, we recommend phlebotomy for the temporary relief of significant, intrusive hyperviscosity symptoms but not for the hematocrit level per se. According to our data, phlebotomy is not warranted to reduce an assumed risk of stroke because that risk did not materialize.