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Journal of Medicine and Life Jun 2023Watershed strokes have been described previously as ischemic strokes located in vulnerable border zones between brain tissue supplied by the anterior, posterior, and... (Review)
Review
Watershed strokes have been described previously as ischemic strokes located in vulnerable border zones between brain tissue supplied by the anterior, posterior, and middle cerebral arteries in the distal junction between two non-anastomotic arterial territories. Ischemic strokes in border zones are well-recognized entities and well-described in terms of imaging features, but the pathophysiological mechanism of brain injury production is not fully defined. Border zone ischemia is caused by cerebral hypoperfusion through decreased cerebral blood flow and arterial embolism in unstable atheroma plaque. It is often difficult to say which mechanisms are fully responsible for producing cerebral ischemic lesions. This review aimed to highlight the imaging aspect of watershed strokes and to correlate the clinical characteristics of this type of stroke with the diagnostic algorithm for optimal therapeutic management. Neurologists should promptly recognize this type of stroke and investigate its etiology in the shortest possible time.
Topics: Humans; Stroke; Ischemic Stroke; Middle Cerebral Artery
PubMed: 37675172
DOI: 10.25122/jml-2023-0127 -
NeoReviews Mar 2021Perinatal stroke is a focal vascular brain injury that occurs from the fetal period to 28 days of postnatal age. With an overall incidence of up to 1 in 1,000 live... (Review)
Review
Perinatal stroke is a focal vascular brain injury that occurs from the fetal period to 28 days of postnatal age. With an overall incidence of up to 1 in 1,000 live births, the most focused lifetime risk for stroke occurs near birth. Perinatal stroke can be classified by the timing of diagnosis, vessel involvement, and type of injury. Timing of diagnosis may be in the acute neonatal period or retrospectively after a period of normal development, followed by abnormal neurologic findings, with the injury presumed to have occurred around the time of birth. Strokes may be arterial or venous, ischemic, and/or hemorrhagic. Within these classifications, 6 perinatal stroke diseases are recognizable, based on clinical and radiographic features. Morbidity is high in perinatal stroke, because it accounts for most cases of hemiparetic cerebral palsy, with disability lasting a lifetime. Additional complications include disorders of sensation and vision, language delays, cognitive and learning deficits, epilepsy, and mental health consequences that affect the entire family. Advances in neonatal neurocritical care may afford opportunity to minimize brain injury and improve outcomes. In the chronic timeframe, progress made in neuroimaging and brain mapping is revealing the developmental plasticity that occurs, informing new avenues for neurorehabilitation. This review will summarize the diagnosis and management of each perinatal stroke disease, highlighting their similarities and distinctions and emphasizing a patient- and family-centered approach to management.
Topics: Female; Humans; Incidence; Infant, Newborn; Infant, Newborn, Diseases; Pregnancy; Retrospective Studies; Stroke
PubMed: 33649089
DOI: 10.1542/neo.22-3-e163 -
Stroke Sep 2022GLP-1 RA (glucagon-like peptide-1 receptor agonists), including semaglutide, may reduce stroke risk in people with type 2 diabetes. This post hoc analysis examined the... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
GLP-1 RA (glucagon-like peptide-1 receptor agonists), including semaglutide, may reduce stroke risk in people with type 2 diabetes. This post hoc analysis examined the subcutaneous and oral semaglutide effects, versus placebo, on stroke and its subtypes in people with type 2 diabetes at high cardiovascular risk.
METHODS
SUSTAIN 6 (Trial to Evaluate Cardiovascular and Other Long-Term Outcomes With Semaglutide in Subjects With Type 2 Diabetes) and PIONEER 6 (Peptide Innovation for Early Diabetes Treatment) were randomized cardiovascular outcome trials of subcutaneous and oral semaglutide in people with type 2 diabetes at high cardiovascular risk, respectively. Time to first stroke and stroke subtypes were analyzed using a Cox proportional hazards model stratified by trial with pooled treatment as a factor. The impact of prior stroke, prior myocardial infarction or stroke, age, sex, systolic blood pressure, estimated glomerular filtration rate, and prior atrial fibrillation on treatment effects was assessed using interaction values. Risk of major adverse cardiovascular event was analyzed according to prior stroke.
RESULTS
A total of 106/6480 participants had a stroke (1.0 event/100 patient-years of observation [PYO]). Semaglutide reduced incidence of any stroke versus placebo (0.8 versus 1.1 events/100 PYO; hazard ratio, 0.68 [95% CI, 0.46-1.00]; =0.048), driven by significant reductions in risk of small-vessel occlusion (0.3 versus 0.7 events/100 PYO; hazard ratio, 0.51 [95% CI, 0.29-0.89]; =0.017). Hazard ratios for risk of any stroke with semaglutide versus placebo were 0.60 (95% CI, 0.37-0.99; 0.5 versus 0.9 events/100 PYO) and 0.89 (95% CI, 0.47-1.69; 2.7 versus 3.0 events/100 PYO) in those without and with prior stroke, respectively. Except for prior atrial fibrillation (=0.025), no significant interactions were observed between treatment effects on risk of any stroke and subgroups investigated, or between treatment effects on risk of major adverse cardiovascular event and prior stroke ( >0.05 for all).
CONCLUSIONS
Semaglutide reduced incidence of any first stroke during the trials versus placebo in people with type 2 diabetes at high cardiovascular risk, primarily driven by small-vessel occlusion prevention. Semaglutide treatment, versus placebo, lowered the risk of stroke irrespective of prior stroke at baseline.
REGISTRATION
URL: https://www.
CLINICALTRIALS
gov; Unique identifier: NCT01720446 and NCT02692716.
Topics: Atrial Fibrillation; Diabetes Mellitus, Type 2; Glucagon-Like Peptides; Humans; Hypoglycemic Agents; Stroke
PubMed: 35582947
DOI: 10.1161/STROKEAHA.121.037775 -
Brain Research Nov 2019Stroke remains a prevalent disease with limited treatment options. Available treatments offer little in the way of enhancing neurogenesis and recovery. Because of the... (Review)
Review
Stroke remains a prevalent disease with limited treatment options. Available treatments offer little in the way of enhancing neurogenesis and recovery. Because of the limitations of available treatments, new therapies for stroke are needed. Stem cell-based therapies for stroke offer promise because of their potential to provide neurorestorative benefits. Stem cell-based therapies aim to promote neurogenesis and replacement of lost neurons or protect surviving neurons in order to improve neurological recovery. The mechanism through which stem cell treatments mediate their therapeutic effect is largely dependent on the type of stem cell and route of administration. Neural stem cells have been shown in pre-clinical and clinical trials to promote functional recovery when used in intracerebral transplantations. The therapeutic effects of neural stem cells have been attributed to their formation of new neurons and promotion of neuroregeneration. Bone marrow stem cells (BMSC) and mesenchymal stem cells (MSC) have been shown to enhance neurogenesis in pre-clinical models in intracerebral transplantations, but lack clinical evidence to support this therapeutic approach in patients and appear to be less effective than neural stem cells. Intravenous and intra-arterial administration of BMSC and MSC have shown more promise, where their effects are largely mediated through neuroprotective mechanisms. The immune system has been implicated in exacerbating initial damage caused by stroke, and BMSC and MSC have demonstrated immunomodulatory properties capable of dampening post-stroke inflammation and potentially improving recovery. While still in development, stem cell therapies may yield new treatments for stroke which can improve neurological recovery.
Topics: Animals; Brain; Cord Blood Stem Cell Transplantation; Encephalitis; Humans; Mesenchymal Stem Cell Transplantation; Mesenchymal Stem Cells; Neural Stem Cells; Neurogenesis; Stem Cell Transplantation; Stroke; Treatment Outcome
PubMed: 31381876
DOI: 10.1016/j.brainres.2019.146362 -
Current Neurology and Neuroscience... Apr 2020This review overviews perioperative stroke as it pertains to specific surgical procedures. (Review)
Review
PURPOSE OF REVIEW
This review overviews perioperative stroke as it pertains to specific surgical procedures.
RECENT FINDINGS
As awareness of perioperative stroke increases, so does the opportunity to potentially improve outcomes for these patients by early stroke recognition and intervention. Perioperative stroke is defined to be any stroke that occurs within 30 days of the initial surgical procedure. The incidence of perioperative stroke varies and is dependent on the specific type of surgery performed. This chapter overviews the risks, mechanisms, and acute evaluation and management of perioperative stroke in four surgical populations: cardiac surgery, carotid endarterectomy, neurosurgery, and non-cardiac/non-carotid/non-neurological surgeries.
Topics: Carotid Stenosis; Endarterectomy, Carotid; Humans; Postoperative Complications; Risk Factors; Stroke
PubMed: 32342230
DOI: 10.1007/s11910-020-01033-7 -
The Journal of Clinical Investigation May 2023Despite advances in acute care, ischemic stroke remains a major cause of long-term disability. Approaches targeting both neuronal and glial responses are needed to...
Despite advances in acute care, ischemic stroke remains a major cause of long-term disability. Approaches targeting both neuronal and glial responses are needed to enhance recovery and improve long-term outcome. The complement C3a receptor (C3aR) is a regulator of inflammation with roles in neurodevelopment, neural plasticity, and neurodegeneration. Using mice lacking C3aR (C3aR-/-) and mice overexpressing C3a in the brain, we uncovered 2 opposing effects of C3aR signaling on functional recovery after ischemic stroke: inhibition in the acute phase and facilitation in the later phase. Peri-infarct astrocyte reactivity was increased and density of microglia reduced in C3aR-/- mice; C3a overexpression led to the opposite effects. Pharmacological treatment of wild-type mice with intranasal C3a starting 7 days after stroke accelerated recovery of motor function and attenuated astrocyte reactivity without enhancing microgliosis. C3a treatment stimulated global white matter reorganization, increased peri-infarct structural connectivity, and upregulated Igf1 and Thbs4 in the peri-infarct cortex. Thus, C3a treatment from day 7 after stroke exerts positive effects on astrocytes and neuronal connectivity while avoiding the deleterious consequences of C3aR signaling during the acute phase. Intranasal administration of C3aR agonists within a convenient time window holds translational promise to improve outcome after ischemic stroke.
Topics: Mice; Animals; Complement C3a; Astrocytes; Stroke; Ischemic Stroke; Infarction
PubMed: 36995772
DOI: 10.1172/JCI162253 -
Current Pain and Headache Reports Nov 2023Stroke is a major health concern and a leading cause of long-term disability. Persistent post-stroke headache (PPSH) is a common complication of stroke yet little is... (Review)
Review
PURPOSE OF REVIEW
Stroke is a major health concern and a leading cause of long-term disability. Persistent post-stroke headache (PPSH) is a common complication of stroke yet little is known about its specific characteristics or optimal management. The purpose of this review is to discuss the epidemiology, presentation, and hypothesized pathophysiology of PPSH. Acute and preventive treatment options, as well as specific concerns regarding triptans and the newer CGRP antagonists, will be discussed in detail as well.
RECENT FINDINGS
The 2018 International Classification of Headache Disorders, 3rd edition (ICHD-3) was the first headache diagnostic manual to include criteria for PPSH and defines this disorder as an acute headache that develops in close temporal relation to stroke and persists beyond 3 months. Recent literature estimates the prevalence of PPSH to be somewhere between 1 and 23% of patients post-stroke. Presentation is variable, but most often mimics tension-type headache. There are no evidence-based guidelines on the optimal treatment of PPSH. PPSH is a common but poorly understood complication of stroke. Given the significant disability burden that PPSH carries, the epidemiology and pathophysiology of PPSH, as well as the efficacy and safety of potential treatment options, warrant further investigation.
Topics: Humans; Headache; Headache Disorders; Tension-Type Headache; Stroke; Prevalence
PubMed: 37676411
DOI: 10.1007/s11916-023-01169-4 -
Stroke Apr 2024Small, randomized trials of patients with cervical artery dissection showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare... (Observational Study)
Observational Study
BACKGROUND
Small, randomized trials of patients with cervical artery dissection showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with cervical artery dissection treated with antiplatelets versus anticoagulation.
METHODS
This is a multicenter observational retrospective international study (16 countries, 63 sites) that included patients with cervical artery dissection without major trauma. The exposure was antithrombotic treatment type (anticoagulation versus antiplatelets), and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with inverse probability of treatment weighting to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an as-treated crossover approach and only included outcomes occurring with the above treatments.
RESULTS
The study included 3636 patients (402 [11.1%] received exclusively anticoagulation and 2453 [67.5%] received exclusively antiplatelets). By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with inverse probability of treatment weighting, compared with antiplatelet therapy, anticoagulation was associated with a nonsignificantly lower risk of subsequent ischemic stroke by day 30 (adjusted hazard ratio [HR], 0.71 [95% CI, 0.45-1.12]; =0.145) and by day 180 (adjusted HR, 0.80 [95% CI, 0.28-2.24]; =0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR, 1.39 [95% CI, 0.35-5.45]; =0.637) but was by day 180 (adjusted HR, 5.56 [95% CI, 1.53-20.13]; =0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR, 0.40 [95% CI, 0.18-0.88]; =0.009).
CONCLUSIONS
Our study does not rule out the benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings.
Topics: Humans; Platelet Aggregation Inhibitors; Anticoagulants; Fibrinolytic Agents; Retrospective Studies; Carotid Artery, Internal, Dissection; Stroke; Hemorrhage; Ischemic Stroke; Aortic Dissection; Arteries; Atrial Fibrillation; Treatment Outcome
PubMed: 38335240
DOI: 10.1161/STROKEAHA.123.045731 -
Journal of Cardiovascular Pharmacology Feb 2022Sodium-glucose cotransporter 2 (SGLT2) inhibitors have well-documented effects on reducing hospitalization for heart failure and cardiovascular mortality, although the... (Meta-Analysis)
Meta-Analysis
Association of SGLT2 Inhibitors With Risk of Atrial Fibrillation and Stroke in Patients With and Without Type 2 Diabetes: A Systemic Review and Meta-Analysis of Randomized Controlled Trials.
Sodium-glucose cotransporter 2 (SGLT2) inhibitors have well-documented effects on reducing hospitalization for heart failure and cardiovascular mortality, although the effect on atrial fibrillation (AF) has not been comprehensively investigated. Therefore, we performed a meta-analysis to assess the association between SGLT2 inhibitors and AF risk by systematically searching PubMed, Embase, and ClinicalTrials.gov. Two investigators independently identified randomized controlled trials, which compared SGLT2 inhibitors with control in patients with type 2 diabetes, heart failure, or chronic kidney disease. Primary outcomes were incident AF and stroke. We included 20 randomized trials involving 63,604 patients. The SGLT2 inhibitors used were dapagliflozin (7 studies, 28,834 patients), canagliflozin (7 studies, 17,440 patients), empagliflozin (5 studies, 9082 patients), and ertugliflozin (1 study, 8246 patients). Follow-up ranged from 24 weeks to 202 weeks. SGLT2 inhibitors treatment was associated with a significant attenuation in the risk of incident AF (odds ratio = 0.82; 95% confidence interval, 0.72-0.93; P = 0.002) compared with control. No significant difference in stroke between SGLT2 inhibitors and control groups was found (odds ratio = 0.99; 95% confidence interval, 0.85-1.15; P = 0.908). This present meta-analysis indicates that SGLT2 inhibitors are associated with a lower risk of incident AF and do not significantly affect stroke risk for patients with and without type 2 diabetes.
Topics: Atrial Fibrillation; Diabetes Mellitus, Type 2; Heart Failure; Humans; Randomized Controlled Trials as Topic; Sodium-Glucose Transporter 2 Inhibitors; Stroke
PubMed: 34813574
DOI: 10.1097/FJC.0000000000001183 -
Restorative Neurology and Neuroscience 2020Previous studies have shown that hyperbaric oxygen therapy (HBOT) can improve the motor functions and memory of post-stroke patients in the chronic stage.
BACKGROUND
Previous studies have shown that hyperbaric oxygen therapy (HBOT) can improve the motor functions and memory of post-stroke patients in the chronic stage.
OBJECTIVE
The aim of this study is to evaluate the effects of HBOT on overall cognitive functions of post-stroke patients in the chronic stage. The nature, type and location of the stroke were investigated as possible modifiers.
METHODS
A retrospective analysis was conducted on patients who were treated with HBOT for chronic stroke (>3 months) between 2008-2018. Participants were treated in a multi-place hyperbaric chamber with the following protocols: 40 to 60 daily sessions, 5 days per week, each session included 90 min of 100% oxygen at 2 ATA with 5 min air brakes every 20 minutes. Clinically significant improvements (CSI) were defined as > 0.5 standard deviation (SD).
RESULTS
The study included 162 patients (75.3% males) with a mean age of 60.75±12.91. Of them, 77(47.53%) had cortical strokes, 87(53.7%) strokes were located in the left hemisphere and 121 suffered ischemic strokes (74.6%).HBOT induced a significant increase in all the cognitive function domains (p < 0.05), with 86% of the stroke victims achieving CSI. There were no significant differences post-HBOT of cortical strokes compared to sub-cortical strokes (p > 0.05). Hemorrhagic strokes had a significantly higher improvement in information processing speed post-HBOT (p < 0.05). Left hemisphere strokes had a higher increase in the motor domain (p < 0.05). In all cognitive domains, the baseline cognitive function was a significant predictor of CSI (p < 0.05), while stroke type, location and side were not significant predictors.
CONCLUSIONS
HBOT induces significant improvements in all cognitive domains even in the late chronic stage. The selection of post-stroke patients for HBOT should be based on functional analysis and baseline cognitive scores rather than the stroke type, location or side of lesion.
Topics: Aged; Aged, 80 and over; Brain; Cognition; Female; Humans; Hyperbaric Oxygenation; Male; Memory; Middle Aged; Oxygen; Retrospective Studies; Stroke
PubMed: 31985478
DOI: 10.3233/RNN-190959