Total Stroke Research Articles

Routine Extubation in the Operating Room After Isolated Coronary Artery Bypass

BackgroundThe benefits of fast-track extubation in the intensive care unit (ICU) after cardiac surgery are well established. Although extubation in the operating room (OR) is safe in carefully selected patients, widespread use of this strategy in cardiac surgery remains unproven. This study was designed to evaluate perioperative outcomes with OR vs ICU extubation in patients undergoing nonemergency, isolated coronary artery bypass grafting (CABG). MethodsThe Society of Thoracic Surgeons (STS) data for all single-center patients who underwent nonemergency isolated CABG over a 6-year interval were analyzed. Perioperative morbidity and mortality with ICU vs OR extubation were compared. ResultsBetween January 1, 2017 and December 31, 2022, 1397 patients underwent nonemergency, isolated CABG; 891 (63.8%) of these patients were extubated in the ICU, and 506 (36.2%) were extubated in the OR. Propensity matching resulted in 414 pairs. In the propensity-matched cohort, there were no differences between the 2 groups in incidence of reintubation, reoperation for bleeding, total operative time, stroke or transient ischemic attack, renal failure, or 30-day mortality. OR-extubated patients had shorter ICU hours (14 hours vs 20 hours; P < .0001), shorter postoperative hospital length of stay (3 days vs 5 days; P < .0001), a greater likelihood of being discharged directly to home (97.3% vs 89.9%; P < .0001), and a lower 30-day readmission rate (1.7% vs 4.1%; P = .04). ConclusionsRoutine extubation in the OR is a feasible and safe strategy for a broad spectrum of patients after nonemergency CABG, with no increase in perioperative morbidity or mortality. Wider adoption of routine OR extubation for nonemergency CABG is indicated.

Mitral Regurgitation Severity Assessment after Transcutaneous Edge-to-Edge Mitral Valve Repair: Recommended Integration versus Volumetric Assessment Guidelines.

Objectives: This article aims to evaluate the accuracy of the color-Doppler-based technique to evaluate residual mitral regurgitation post TEER. Background: The evaluation of residual mitral regurgitation (MR) post-mitral transcutaneous edge-to-edge repair (mitral TEER) is a critical determinant in patients' outcomes. The common methods used today, based on the integration of color flow Doppler parameters, may be misleading because of the multiple jets and high velocities created by the TEER devices. Methods: Patients undergoing TEER at Hadassah hospital were recruited between 2015 and 2019. Post-procedural MR was evaluated using the integrated qualitative approach as recommended by the guidelines. In addition, the MR volume for each patient was calculated by subtracting the forward stroke volume (calculated by multiplying the LVOT area with the velocity time integral of the LVOT systolic flow) from the total stroke volume (calculated by the biplane Simpson method of discs). We compared the two methods for concordance. Results: Overall, 112 cases were enrolled. In 55.4% of cases, the volumetric residual MR was milder than the MR severity assessed by the guidelines' recommended method. In 25.1%, the MR severity was similar in both methods. In 16.2%, the MR severity was worse when calculated using the volumetric method (pValue < 0.001, Kappameasure of agreement = 0.053). The lower residual MR degree using the volumetric approach was mostly observed in patients classified as "moderate" by the integrated approach. Conclusions: MR severity after TEER is often overestimated by the guideline-recommended integrative method when compared with a volumetric method. Alternative methods should be considered to assess the MR severity after mitral TEER.

Association Between Calcium Supplementation and the Risk of Cardiovascular Disease and Stroke: ASystematic Review and Meta-Analysis.

Some observational studies and randomised controlled trials (RCTs) have reported an association between calcium supplementation and increased risk of cardiovascular disease. Previous meta-analyses on the topic, based on data from RCTs and observational studies, have contradictory findings. This meta-analysis was conducted to determine the difference in associated risks of calcium supplementation with cardiovascular disease and stroke in RCTs. Relevant studies published from database inception to 6 August 2021 were sourced from PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials. Any RCTs focusing on the relationship between calcium supplementation and incidence of cardiovascular disease or stroke were included. Articles were screened independently by two authors, according to the PICO criteria, with disagreements resolved by a third author. Twelve RCTs were included in the meta-analysis. Calcium supplementation was not associated with myocardial infarction, total stroke, heart failure admission, and all-cause/cardiovascular mortality. Subgroup analysis focusing on calcium monotherapy/calcium co-therapy with vitamin D, female sex, follow-up duration, and geographical region did not affect the findings. Calcium supplementation was not associated with myocardial infarction, total stroke, heart failure admission, and cardiovascular/all-cause mortality. Further studies are required to examine and understand these associations.

Insurance-Based Disparities in Stroke Center Access in California: A Network Science Approach.

Our objectives were to determine whether there is an association between ischemic stroke patient insurance and likelihood of transfer overall and to a stroke center and whether hospital cluster modified the association between insurance and likelihood of stroke center transfer. This retrospective network analysis of California data included every nonfederal hospital ischemic stroke admission from 2010 to 2017. Transfers from an emergency department to another hospital were categorized based on whether the patient was discharged from a stroke center (primary or comprehensive). We used logistic regression models to examine the relationship between insurance (private, Medicare, Medicaid, uninsured) and odds of (1) any transfer among patients initially presenting to nonstroke center hospital emergency departments and (2) transfer to a stroke center among transferred patients. We used a network clustering method to identify clusters of hospitals closely connected through transfers. Within each cluster, we quantified the difference between insurance groups with the highest and lowest proportion of transfers discharged from a stroke center. Of 332 995 total ischemic stroke encounters, 51% were female, 70% were ≥65 years, and 3.5% were transferred from the initial emergency department. Of 52 316 presenting to a nonstroke center, 3466 (7.1%) were transferred. Relative to privately insured patients, there were lower odds of transfer and of transfer to a stroke center among all groups (Medicare odds ratio, 0.24 [95% CI, 0.22-0.26] and 0.59 [95% CI, 0.50-0.71], Medicaid odds ratio, 0.26 [95% CI, 0.23-0.29] and odds ratio, 0.49 [95% CI, 0.38-0.62], uninsured odds ratio, 0.75 [95% CI, 0.63-0.89], and 0.72 [95% CI, 0.6-0.8], respectively). Among the 14 identified hospital clusters, insurance-based disparities in transfer varied and the lowest performing cluster (also the largest; n=2364 transfers) fully explained the insurance-based disparity in odds of stroke center transfer. Uninsured patients had less stroke center access through transfer than patients with insurance. This difference was largely explained by patterns in 1 particular hospital cluster.

Triglyceride–glucose index and the risk of stroke in American adults: findings from the atherosclerosis risk in communities study

ObjectivesThe associations between the triglyceride–glucose (TyG) index with subsequent stroke in American adults are unknown. The aim of this study was to determine the associations between baseline and trajectories of TyG index with subsequent stroke in American adults.MethodsA total of 10,132 participants free of a history of stroke at baseline were included. We quantified the association of baseline and trajectories of TyG index with incident total stroke, ischemic stroke and intracerebral hemorrhage using Cox regression, restricted cubic splines and logistic regression analysis.ResultsThere were 909 incident stroke cases over a median follow-up of 26.6 years. After adjustment for potential confounders, each unit increase in the TyG index was associated with a 32.1% higher risk of incident stroke. Compared with participants in the lowest quartile of the baseline TyG index, those in the highest quartile had a greater risk of incident stroke [HR (95% CI) 1.254 (1.014–1.552)]. Restricted cubic splines showed that the risk of stroke increased in participants with a higher TyG index, especially when the TyG index was > 8.6. Results were similar for incident ischemic stroke. Compared with participants in the lowest quartile of the baseline TyG index, those in the second quartile had a lower risk of intracerebral hemorrhage [HR (95% CI) 0.494 (0.262–0.931)]. Five discrete trajectories with stable TyG indexes at various levels at follow-up visits were identified, and parallel results were observed for the associations of trajectories of TyG index with outcomes.ConclusionsThe TyG index independently predict stroke progression.

A new instrument to assess physical function in stroke patients: the Dubousset function test and its validity, reliability, responsiveness

ABSTRACT Aim The Dubousset Functional Test (DFT) ia a practical four-component assessment test to assess the physical function and balance capacities. The study aimed to examine the reliability, validity, responsiveness of the DFT in stroke survivors. Methods This study included a total of 57 post-stroke patients (age 60.16 ± 15.08 years). The participants were divided into two groups according to the duration of stroke (6–12 months, 12 months and more). Reliability of DFT test was evaluated with Intraclass Correlation Coefficient (ICC). The correlation between the DFT and The Timed Up and Go test (TUG), dual-task TUG, Functional Reach Test (FRT), 3-meter backward walk test (3MBWT), Tinetti Performance Oriented Mobility Assessment (POMA) was used for the validity. Results For total post-stroke patients, ICC values were between 0.899 and 0.984 (excellent agreement). For stroke patients have 6–12 months stroke duration ICC values were between 0.831 and 0.988 (excellent agreement). For post-stroke patients have 6–12 months stroke duration ICC values were between 0.858 and 0.992 (excellent agreement). For total stroke post-patients the correlation with four component of DFT and TUG, dual-task TUG, FRT, 3MBWT and POMA was found to be statistically significant (p < 0.001). Conclusion The DFT has excellent reliability and validity in post-stroke patients. Therefore, it may be a clinically suitable test for detecting balance and physical function.

Posterior cerebral artery stroke with visual manifestation during COVID pandemic

The posterior cerebral artery (PCA) stroke represents 5% to 10% of total strokes. The number of stroke cases has increased during the Global pandemic of Covid 19. It can be challenging to diagnose PCA stroke presenting as a visual manifestation, as symptoms are nonspecific and variable over due course of time. This is more complex in patients who are not aware of their symptoms, and therefore difficult to establish a timeline of events. Mostly PCA stroke with only visual symptoms visits an ophthalmologist rather than an emergency attendee. Knowledge of the neurovascular anatomy of the brain is required to understand PCA stroke and identify the stroke’s mechanism to select appropriate therapies. In this article, we provide an overview of PCA stroke and focused on visual manifestations, diagnosis, and management of PCA stroke.

Sleep duration and risk of stroke and coronary heart disease: a 9-year community-based prospective study of 0.5 million Chinese adults

BackgroundThere is uncertainty about the optimum sleep duration for risk of different subtypes of stroke and ischaemic heart disease.MethodsThe present analyses involved 409,156 adults in the China Kadoorie Biobank study without a prior history of coronary heart disease or stroke or insomnia symptoms. The mean age of study participants was 52 years and 59% were women. Self-reported sleep duration including daytime napping was recorded using a questionnaire. The adjusted hazard ratios (HRs) for disease outcomes associated with sleep duration were estimated by Cox proportional hazards after adjustment for confounding factors.ResultsThe overall mean (SD) sleep duration was 7.4 (1.4) hours. The associations of sleep duration with CVD types were U-shaped, with individuals reporting 7–8 h of sleep having the lowest risks. Compared with those who typically slept 7–8 h, individuals with very short sleep duration (≤ 5 h) had adjusted HRs of 1.10 (95% CI 1.04–1.16), 1.07 (1.01–1.13), 1.19 (1.06–1.33) and 1.23 (1.10–1.37) for total stroke, ischaemic stroke (IS), Intracerebral haemorrhage (ICH) and major coronary events (MCE), respectively. Likewise, individuals with very long sleep duration (≥ 10 h) had HRs of 1.12 (1.07–1.17), 1.08 (1.03–1.14), 1.23 (1.12–1.35) and 1.22 (1.10–1.34) for the same diseases, respectively, with little differences by sex and age. The patterns were similar for all-cause mortality.ConclusionsWhile abnormal sleep duration (≤ 6 h or ≥ 9 h) was associated with higher risks of CVD, the risks were more extreme for those reporting ≤ 5 or ≥ 10 h, respectively and such individuals should be prioritised for more intensive treatment for CVD prevention.

Instantaneous stroke risk assessment of adults in Enugu, South East Nigeria: results from a random point survey

Stroke remains a major cause of morbidity, death, and disability around the world, most especially in black Africans. Understanding the magnitude and appreciation of stroke risk in susceptible populations remains a key strategy in reducing stroke burden. This study examined and compared 5-year stroke risk in an adult population in Enugu, Southeast Nigeria. A point cross-sectional survey assessing stroke risk in adults was done in October 2019 in the city of Enugu as part of the World Stroke Day commemoration using the Stroke Riskometer app, and the data was analyzed. Ethical approval was obtained. The total number of participants in this survey was 117 traders in a market in the Enugu metropolis, Enugu State, Nigeria. More males, 63%, than females, 37%, participated in this study. The total mean age was 47.50 years, with a total mean 5-year stroke risk of 3.93. Stroke risk was noted to be higher in females 4.56 than in males 3.56. Elevated blood pressure was present in 35% of the participants, and elevated blood glucose was seen in 5% of the total population. The World Stroke Organization’s Stroke Riskometer app is a valuable tool in assessing stroke risks especially in resource poor settings. This app also serves as a cost-effective method of conducting epidemiological research in stroke and other non-communicable diseases internationally. Hypertension remains the most common risk factor for stroke globally. Higher stroke risk in females likely associated with higher mean age.

Direct Versus Indirect Revascularization for Moyamoya: a Large Multicenter Study

BackgroundMoyamoya is a chronic occlusive cerebrovascular disease of unknown etiology causing neovascularization of the lenticulostriate collaterals at the base of the brain. Although revascularization surgery is the most effective treatment...

Nocturnal Intermittent Hypoxia and the Risk of Cardiovascular Disease among Japanese Populations: The Circulatory Risk in Communities Study (CIRCS).

Information is limited about the influence of obstructive sleep apnea (OSA) on developing cardiovascular disease (CVD) among Asian community-dwelling populations. We examined the association between nocturnal intermittent hypoxia as a surrogate marker of OSA and the risk of CVD in a Japanese community-based cohort study. We used baseline surveys from 2000 to 2008 to study the cohort data of 5,313 residents from three Japanese communities who were between the ages of 40 and 74 years and initially free from ischemic heart disease and stroke. We assessed the number of 3% oxygen desaturation index (ODI) as the indicator of nocturnal intermittent hypoxia. We divided individuals into two groups depending on 3% ODI (3% ODI ≥ 5 or 3% ODI ＜5). Cox proportional hazards regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD according to 3% ODI. Age, sex, body mass index, alcohol, and smoking were adjusted in the multivariable models. During 12.8 years of the median follow-up with 66,796 person-years, 185 cases with CVD (115 stroke and 70 coronary heart disease [CHD]) were recorded. The multivariable HRs (95% CIs) were 1.49 (1.09-2.03), 2.13 (1.08-4.22), and 1.93 (1.16-3.19) for the 3% ODI ≥ 5 group versus the 3% ODI ＜5 group of developing CVD, lacunar infarction, and CHD, respectively. Nocturnal intermittent hypoxia may increase the risk of developing lacunar infarction and CHD among community-dwelling Japanese populations. However, we could not find a significant risk of developing total stroke or stroke subtypes such as intraparenchymal hemorrhage, subarachnoid hemorrhage, and total ischemic stroke.

Breakfast Type and Cardiovascular Mortality: The Japan Collaborative Cohort Study.

Little is known regarding the association between breakfast type and cardiovascular mortality. We examined the associations between breakfast type and risks of mortality from stroke, coronary heart disease (CHD), and total cardiovascular disease (CVD). A total of 85,319 males and females aged 40 to 79 years who were free from CVD and cancers at baseline were involved in this study. The participants were divided into five groups according to their self-reported breakfast types: Japanese breakfast, Western breakfast, mixed Japanese-Western breakfast, other breakfast, and skipping breakfast groups. All hazard ratios (HRs) were estimated using Cox proportional hazards regression models after adjusting for the potential confounding factors. During the median 19-year follow-up, we identified CVD deaths of 5,870 subjects. Compared to the Japanese breakfast, the multivariable HRs (95% CIs) of total CVD were 0.64 (0.52-0.79) for mixed Japanese-Western breakfast, 0.90 (0.77-1.04) for Western breakfast, 1.24 (0.95-1.61) for other breakfast, and 1.31 (1.00-1.71) for skipping breakfast. The corresponding HRs (95% CIs) of total stroke were 0.67 (0.49-0.91), 0.83 (0.66-1.05), 1.15 (0.76-1.74), and 1.25 (0.82-1.92), and those of CHD were 0.73 (0.48-1.12), 1.08 (0.81-1.44), 1.09 (0.60-1.98), and 1.77 (1.11-2.83). Compared to Japanese breakfast, mixed Japanese-Western breakfast may have a protective role in cardiovascular mortality whereas skipping breakfast may harm cardiovascular health.

Long-term exposure to ambient ozone and cardiovascular diseases: Evidence from two national cohort studies in China

IntroductionThe health effects of ambient ozone have been investigated in many previous studies. However, the effects of long-term exposure to ambient ozone on the incidence of cardiovascular disease (CVD) remain inconclusive. ObjectivesTo estimate the associations of long-term exposure to maximum daily 8-hours average ozone (MDA8 O3) with the incidence of total CVD, heart disease, hypertension, and stroke. MethodsThis was a prospective cohort study, and the data was obtained from the China Health and Retirement Longitudinal Survey (CHARLS) implemented during 2011–2018 and the China Family Panel Studies (CFPS) implemented during 2010–2018. We applied a Cox proportional hazards regression model to evaluate the associations of MDA8 O3 with total CVD, heart disease, hypertension, and stroke risks, and the corresponding population-attributable fractions (PAF) attributable to MDA8 O3 were also calculated. All analyses were conducted by R software. ResultsThe mean MDA8 O3 concertation of all included participants in the CHARLS and CFPS were 51.03 part per billion (ppb) and 51.15 ppb, respectively. In the CHARLS including 18,177 participants, each 10 ppb increment in MDA8 O3 concentration was associated with a 31% increase [hazard ratio (HR) = 1.31, 95% confidence interval (CI): 1.22–1.42] in the risk of incident heart disease, and the corresponding population-attributable fractions (PAF) was 13.79% [10.12%-17.32%]. In the CFPS including 30,226 participants, each 10 ppb increment in MDA8 O3 concentration was associated with an increase in the risk of incident total CVD (1.07 [1.02–1.13]), and hypertension (1.10 [1.03–1.18]). The PAFs of total CVD, and hypertension attributable to MDA8 O3 were 3.53% [0.82%-6.16%], and 5.11% [1.73%-8.38%], respectively. Stratified analyses showed greater associations in males, urban areas, and Southern China. ConclusionsLong-term exposure to MDA8 O3 may increase the incidence of CVD. Therefore, the policies that control O3 and related precursors are persistently needed.

Association between alcohol consumption and risk of stroke among adults: results from a prospective cohort study in Chongqing, China

BackgroundThe incidence of stroke in China is increasing, along with a clear trend in the prevalence of risk factors. Alcohol consumption is also a risk factor for stroke. Many cohort studies have explored the relationship between alcohol consumption and stroke risk. However, findings have been inconsistent.MethodsWe used cluster sampling to select 13 districts and counties (at the same level) in Chongqing, China. Then, we used stratified random sampling to distribute the number of people in each district and county. 23,308 adults aged 30–79 were recruited between October 2018 and February 2019. Follow-up was conducted through a monitoring system and questionnaires until September 2022. Information on alcohol consumption and other covariates was collected using a standardized questionnaire. Participants were asked to report their weekly frequency of drinking over the past year and weekly intake of various alcoholic beverages in general. The frequency of drinking was divided into three categories: 1–2 d/week, 3–5 d/week, and 6–7 d/week. The average daily alcohol consumption is calculated based on the amount of alcohol contained in different alcoholic beverages. It is classified as nondrinker (0 g/day), light (0 to 12 g/day), moderate (13 to 36 g/day), and high (> 36 g/day). Cox proportional hazard regression models were used to estimate the association between alcohol consumption and stroke risk. Results are shown as multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs).ResultsWith an average follow-up of 3.80 years, there were 310 new stroke events. The incidence of total stroke was 368.69 per 100,000 person-years. Overall, after adjusting for covariates, moderate alcohol consumption (average daily alcohol consumption 13–36 g/d) was associated with a lower risk of total stroke (HR: 0.48; 95% CI: 0.25–0.92) compared with nondrinkers. The adjusted HR and 95% CI for total stroke and ischemic stroke for those who drank alcohol 6–7 days per week were 0.60(0.37, 0.96) and 0.53(0.30, 0.94), respectively. The risk of total stroke (HR: 0.39; 95% CI: 0.17–0.89) was reduced in a pattern of drinking 6–7 days per week but with a mean alcohol consumption of less than 36 g/d. There was no significant association between alcohol consumption and hemorrhagic stroke.ConclusionThis study suggests moderate alcohol consumption is associated with a lower risk of total stroke. And healthy drinking patterns should be of more significant concern.

Correlates and prognostic implications of LVEF reduction after transcatheter edge-to-edge repair for primary mitral regurgitation.

To explore the characteristics and outcomes of patients undergoing transcatheter edge-to-edge repair (TEER) for primary mitral regurgitation (MR) according to the presence of left ventricular ejection fraction (LVEF) reduction post-procedure. We retrospectively analysed 317 individuals [median age 83 (interquartile range, 75-88) years, 197 (62.1%) males] treated with an isolated, first-time TEER that was concluded by a successful clip deployment. Stratified by LVEF change at 1-month compared with baseline, the cohort was evaluated for residual MR and heart failure (HF) indices up to 1-year, as well as all-cause mortality and HF hospitalizations at 2-years. Overall, 212 (66.9%) patients displayed LVEF reduction, which was mainly driven by lowered total stroke volume and diffuse hypocontractility. While post-procedural MR, transmitral mean pressure gradient, and functional status were comparable in the two study groups, patients with LVEF reduction exhibited a greater decline in filling pressures intra-procedurally; left ventricular mass index, pulmonary arterial systolic pressure, and serum natriuretic peptide level at 1-month; and walking limitation at 1-year. Also, by 2 years, they were less likely to die (13.3% vs. 5.7%, P = 0.019), be readmitted for HF (17.1% vs. 9.0%, P = 0.033), and experience either of the two (23.8% vs. 12.7%, P = 0.012). Lastly, LVEF reduction was the only 1-month echocardiographic parameter to independently confer an attenuated risk for the composite of deaths or HF hospitalizations (HR 0.28, 95% CI 0.10-0.78, P = 0.016). LVEF reduction at 1-month post-TEER for primary MR is associated with better clinical outcomes, possibly reflecting a more pronounced unloading effect of the procedure.

Cystatin C-based estimated glomerular filtration rate and risk of stroke in the general population: a prospective cohort study.

Previous results on the association between the estimated glomerular filtration rate (eGFR) and stroke are mixed. Most studies derived the eGFR from serum creatinine, which is affected by non-kidney determinants and thus has possibly biased the association with stroke risk. In this cohort study, we included 429566 UK Biobank participants (94.5% white, 54% women, age 56±8years) free of stroke at enrollment. The eGFRcys and eGFRcr were calculated with serum cystatin C and creatinine, respectively. Outcomes of interest were risk of total stroke and subtypes. We investigated the linear and nonlinear associations using Cox proportional hazards models and restricted cubic splines, corrected for regression dilution bias. During an average follow-up of 10.11years, 4427 incident strokes occurred, among which 3447 were ischemic and 1163 were hemorrhagic. After adjustment for confounders, the regression dilution-corrected hazard ratios (95% confidence intervals) for every 10mL/min/1.73 m2 decrement in eGFRcys were 1.10 (1.05-1.14) for total stroke and 1.11 (1.08-1.15) for ischemic stroke. A similar pattern was observed with eGFRcr, although the association was weaker. When either type of eGFR was below 75mL/min/1.73 m2, the risks of total and ischemic stroke increased exponentially as eGFR decreased. A U-shaped relationship was witnessed if eGFRcr was used instead. There was a null association between eGFR and hemorrhagic stroke. The risks of total stroke and ischemic stroke increased exponentially when the eGFRcys fell below 75mL/min/1.73 m2.

An In-Depth Analysis of Medullary Strokes at a Tertiary Care Stroke Center: Incidence, Clinical and Radiological Characteristics, Etiology, Treatment, and Prognosis.

Introduction Medullary infarctions (MI) are a rare medical entity that is classified mainly as the more commonly lateral medullary infarcts (LMI) and the less common medial medullary infarcts (MMI). Lateral medullary syndrome, also known as Wallenberg syndrome, results when the medulla oblongata is affected and predominantly occurs secondary to atherosclerotic occlusion of the vertebrobasilar arteries. Previous studies have focused more on the anatomical, clinical, and topographical aspects of medullary infarcts. We describe the incidence of their presentation, radiological findings, etiology, treatment, and outcome at our comprehensive stroke center. Material and method This is a retrospective cohort study of 108 medullary stroke patients with confirmed clinical and radiological diagnoses of MI at Hamad General Hospital, Doha, between January 1, 2018 and December 31, 2020. We evaluated the electronic medical records of all stroke patients. Result During the selected period, a total of 2,912 ischemic strokes were reported. Of these, 843 (28.8%) were posterior circulation strokes. Only 108 (3.7%) patients had medullary strokes. Commonly encountered neurological features were dizziness (94.4%), limb ataxia (84.3%), dysarthria (44.4%), ipsilateral facial sensory loss (32.4%), headache (32.4%), contralateral limb sensory loss (25%), ipsilateral hemiparesis (24%), dysphagia (19.4%), and hiccups (13%). Most strokes reported were either minor (73% with National Institutes of Health Stroke Scale [NIHSS] 1-4) or moderate (26% with NIHSS 5-15). LMIs (87.9%) were the most common, followed by medial paramedian MI (10%). Twenty-five percent had extramedullary involvement, predominantly of the cerebellum (17.6%). Out of the total number of patients, 44 (40.7%) had large vessel atherosclerotic disease, followed by 41 (37.6%) whose stroke was due to small vessel disease, 15 (13.8 %) due to undetermined etiology, and 6 (5.5%) due to arterial dissection. Twenty-eight patients (25.4%) underwent 48-hour Holter monitoring, which detected atrial fibrillation in two patients (1.85%). The majority of patients (98.2%, or 106 patients) received antiplatelet therapy, while 68.5% (74 patients) received single antiplatelet therapy (SAPT), and 29.6% (32 patients) received dual antiplatelet therapy (DAPT). Noteworthy is that only 2.7% (three patients) received thrombolysis as an acute reperfusion therapy. Forty-seven percent (51 patients) were discharged home (mRS 0-2), and 51.9% (56 patients) were transferred to rehabilitation facilities. Follow-up assessments were performed at the stroke clinic for 57.4% (62) of the patients. The assessments found that 46 of the follow-up patients were functionally independent at that time (mRS 0-2). Conclusion This is the first large local study of medullary strokes to determine their frequency, presentation, etiology, treatment, and clinical outcome. Medullary strokes represent 3.7% of total ischemic strokes at our comprehensive stroke center. MI is rare and could present with a variety of neurological and non-specific symptoms that mimic common benign conditions. Prompt and early recognition with a high index of suspicion, the use of posterior NIHSS (POST-NIHSS), and urgent MRI-diffusion-weighted imaging (DWI) of the brain in acute settings can improve early diagnosis and the rate of reperfusion therapy. Further studies are needed to enable the early recognition and treatment of medullary infarcts.

External validations of the ABCD2 score in prediction of stroke risk after transient ischemic attack. A Tunisian hospital-based cohort study

Background and purpose Identification of patients with high risk of stroke after transient ischemic attack (TIA) could be helpful to optimize stroke prevention. We aimed to externally validate the ABCD2 score for the prediction of stroke after TIA in a Tunisian population. Methods We conducted a retrospective observational study of consecutive patients admitted for TIA in four university hospitals in Tunisia. Patients were screened for onset of stroke. Sensitivity, specificity, positive and negative predictive values with areas under the receiver operating characteristic (ROC) curves were calculated for risk of stroke at 2, 7, 30 and 90 days after the index event. Results Of 415 patients screened in this study, the total cumulative subsequent stroke rates after TIA at 2, 7, 30 and 90 days were respectively, 4.8%, 10.6%, 13.5% and 20.2%. Using a cut-off value of 4, the ABCD2 showed an overall good sensitivity (95%, 97.7%, 96.4% and 97.6% respectively at 2, 7, 30 and 90 days). Areas under ROC cure of the ABCD2 score in patients with TIA for stroke onset at 2, 7, 30 and 90 days were respectively 0.67 (95% CI, 0.55-0.79), 0.79 (95% CI, 0.71-0.85), 0.79 (95% CI, 0.72-0.85), and 0.76 (95% CI, 0.70-0.81). Conclusion Our findings suggest that the ABCD2 score could be used in our population to discriminate patient with TIA at low and high risk of developing recurrent stroke.

Incidence of Stroke in People With Diabetes Compared to Those Without Diabetes: A Systematic Review.

One of the goals of the St. Vincent Declaration was to reduce serious complications of diabetes, including strokes. However, it remains uncertain whether this goal has been achieved. To evaluate the incidence of stroke in the diabetic population and its differences regarding sex, ethnicity, age, and region, to compare the incidence rate in people with and without diabetes, and to investigate time trends. A systematic review was conducted according to the guidelines for meta-analysis of observational studies in epidemiology (the MOOSE group) and the PRISMA group guidelines. Nineteen of the 6.470 studies retrieved were included in the analysis. The incidence of stroke in the population with diabetes ranged from 238 per 100,000 person-years in Germany in 2014 to 1191 during the 1990s in the United Kingdom. The relative risk comparing people with diabetes to those without diabetes varied between 1.0 and 2.84 for total stroke, 1.0 and 3.7 for ischemic stroke, and 0.68 and 1.6 for hemorrhagic stroke. Differences between fatal and non-fatal stroke were significant, depending on the time period and the population. We found decreasing time trends in people with diabetes and stable incidence rates of stroke over time in people without diabetes. The considerable differences between results can partly be explained by differences in study designs, statistical methods, definitions of stroke, and methods used to identify patients with diabetes. The lack of evidence arising from these differences ought to be rectified by new studies.

Epidemiology of Stroke in a General Japanese Population: The Hisayama Study.

The Hisayama Study is an ongoing epidemiological study of stroke, coronary artery disease (CAD), and other noncommunicable diseases in a general Japanese population established in 1961. According to the longitudinal data from the Hisayama Study, average levels of systolic blood pressure among hypertensive individuals have decreased with time since 1961. In contrast, the prevalence of metabolic risk factors such as obesity, hypercholesterolemia, and glucose intolerance has increased with time. The incidence rates of ischemic stroke in this population have declined significantly as a result of improvement in hypertension management, but the proportion of atherothrombotic brain infarction (ATBI) and embolic stroke among the total ischemic stroke cases have increased probably due to the increased prevalence of metabolic risk factors and the increased number of patients with atrial fibrillation (AF) with super-aging population. Therefore, a strategy to reduce the risks of ATBI and embolic stroke by comprehensive management of their risk factors is necessary.In this review, we first show the secular trends in the incidence of stroke and the prevalence of its risk factors using the data from the Hisayama Study. Then, the studies for the association of traditional risk factors with stroke development in the Hisayama Study are introduced. Finally, we developed risk prediction models to estimate the absolute risk of atherosclerotic cardiovascular disease (ASCVD; including ATBI and CAD) and AF, that may be used for the stratification of future risk of ATBI and AF-related stroke in clinical practice or health examination.