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Seminars in Neurology Oct 2022Ischemic stroke is by far the most common type of cerebrovascular event and remains a major cause of death and disability globally. Despite advancements in acute stroke...
Ischemic stroke is by far the most common type of cerebrovascular event and remains a major cause of death and disability globally. Despite advancements in acute stroke care, primary prevention is still the most cost-effective approach in reducing the burden of ischemic stroke. The two main strategies for primary stroke prevention include population-wide versus high-risk group interventions. Interventions such as increasing access to primary care, regulation of salt and sugar contents in processed foods, public education, and campaigns to control cerebrovascular risk factors are examples of population-wide interventions. High-risk group interventions, on the other hand, focus on recognition of individuals at risk and aim to modify risk factors in a timely and multifaceted manner. This article provides an overview on conventional modifiable risk factors for ischemic stroke and highlights the emerging risk factors and approaches for high-risk group identification and treatment.
Topics: Humans; Ischemic Stroke; Stroke; Risk Factors; Primary Prevention
PubMed: 36395819
DOI: 10.1055/s-0042-1758703 -
Stroke Oct 2023Intravenous thrombolysis via tPA (tissue-type plasminogen activator) is the only approved pharmacological treatment for acute ischemic stroke, but its benefits are... (Review)
Review
Intravenous thrombolysis via tPA (tissue-type plasminogen activator) is the only approved pharmacological treatment for acute ischemic stroke, but its benefits are limited by hemorrhagic transformation. Emerging evidence reveals that tPA swiftly mobilizes immune cells which extravasate into the brain parenchyma via the cerebral vasculature, augmenting neurovascular inflammation, and tissue injury. In this review, we summarize the pronounced alterations of immune cells induced by tPA in patients with stroke and experimental stroke models. We argue that neuroinflammation, triggered by ischemia-induced cell death and exacerbated by tPA, compromises neurovascular integrity and the microcirculation, leading to hemorrhagic transformation. Finally, we discuss current and future approaches to attenuate thrombolysis-associated hemorrhagic transformation via uncoupling immune cells from the neurovascular unit.
Topics: Humans; Ischemic Stroke; Stroke; Thrombolytic Therapy; Inflammation; Brain
PubMed: 37675612
DOI: 10.1161/STROKEAHA.123.044123 -
Journal of the American Heart... Sep 2023Background Observational studies have shown that women with an early menopause are at higher risk of stroke compared with women with a later menopause. However,...
Background Observational studies have shown that women with an early menopause are at higher risk of stroke compared with women with a later menopause. However, associations with stroke subtypes are inconsistent, and the causality is unclear. Methods and Results We analyzed data of the UK Biobank and EPIC-CVD (European Prospective Investigation Into Cancer and Nutrition-Cardiovascular Diseases) study. A total of 204 244 postmenopausal women without a history of stroke at baseline were included (7883 from EPIC-CVD [5292 from the subcohort], 196 361 from the UK Biobank). Pooled mean baseline age was 58.9 years (SD, 5.8), and pooled mean age at menopause was 47.8 years (SD, 6.2). Over a median follow-up of 12.6 years (interquartile range, 11.8-13.3), 6770 women experienced a stroke (5155 ischemic strokes, 1615 hemorrhagic strokes, 976 intracerebral hemorrhages, and 639 subarachnoid hemorrhages). In multivariable adjusted observational Cox regression analyses, the pooled hazard ratios per 5 years younger age at menopause were 1.09 (95% CI, 1.07-1.12) for stroke, 1.09 (95% CI, 1.06-1.13) for ischemic stroke, 1.10 (95% CI, 1.04-1.16) for hemorrhagic stroke, 1.14 (95% CI, 1.08-1.20) for intracerebral hemorrhage, and 1.00 (95% CI, 0.84-1.20) for subarachnoid hemorrhage. When using 2-sample Mendelian randomization analysis, we found no statistically significant association between genetically proxied age at menopause and risk of any type of stroke. Conclusions In our study, earlier age at menopause was related to a higher risk of stroke. We found no statistically significant association between genetically proxied age at menopause and risk of stroke, suggesting no causal relationship.
Topics: Female; Humans; Middle Aged; Cerebral Hemorrhage; Hemorrhagic Stroke; Ischemic Stroke; Mendelian Randomization Analysis; Menopause; Postmenopause; Prospective Studies; Stroke; Observational Studies as Topic
PubMed: 37681566
DOI: 10.1161/JAHA.123.030280 -
Critical Reviews in Oncology/hematology Jan 2021Approximately 5-10 % of the patients with cryptogenic stroke have an underlying malignancy. Stroke as a complication of cancer increases the morbidity and mortality... (Review)
Review
INTRODUCTION
Approximately 5-10 % of the patients with cryptogenic stroke have an underlying malignancy. Stroke as a complication of cancer increases the morbidity and mortality among cancer patients, leading to increased disability and healthcare costs.
OBJECTIVE
To provide elements to guide physicians for when to suspect and evaluate for cancer in stroke patients.
DEVELOPMENT
We performed a narrative review, portrayed in a question-answer format, to report relevant aspects of cancer stroke patients in the clinical practice and provide a guide based on the state-of-the-art literature. Conventional stroke mechanisms are only found in a fraction of patients with cancer. Although cardiovascular risk factors play an important role in both cancer and stroke pathogenesis, the recognition of more specific cancer-associated risk factors raises clinical suspicion for occult malignancy. We also expose the main type location and histology of tumors that are most commonly associated with stroke as well as potential blood biomarkers and current treatment considerations in the scenario of cancer associated stroke.
CONCLUSION
Subjects with active cancer are a patient population at increased risk for developing an ischemic stroke. Cryptogenic stroke patients have a higher risk of cancer diagnosis in the following 6-12 months. We recommend a multidisciplinary approach considering the high probability of a hidden malignancy and running a comprehensive evaluation including neurologic imaging, serological biomarkers and tight follow up.
Topics: Brain Ischemia; Humans; Ischemic Stroke; Neoplasms; Risk Factors; Stroke
PubMed: 33264715
DOI: 10.1016/j.critrevonc.2020.103181 -
International Journal of Epidemiology Jun 2023Whether changes in stroke mortality are affected by age distribution and birth cohorts, and if the decline in stroke mortality exhibits heterogeneity by stroke type,...
BACKGROUND
Whether changes in stroke mortality are affected by age distribution and birth cohorts, and if the decline in stroke mortality exhibits heterogeneity by stroke type, remains uncertain.
METHODS
We undertook a sequential time series analysis to examine stroke mortality trends in the USA among people aged 18-84 years between 1975 and 2019 (n = 4 332 220). Trends were examined for overall stroke and by ischaemic and haemorrhagic subtypes. Mortality data were extracted from the US death files, and age-sex population data were extracted from US census. Age-standardized stroke mortality rates and incidence rate ratio (IRR) with 95% confidence interval [CI] were derived from Poisson regression models.
RESULTS
Age-standardized stroke mortality declined for females from 87.5 in 1975 to 30.9 per 100 000 in 2019 (IRR 0.27, 95% CI 0.26, 0.27; average annual decline -2.78%, 95% CI -2.79, -2.78). Among males, age-standardized mortality rate declined from 112.1 in 1975 to 38.7 per 100 000 in 2019 (RR 0.26, 95% CI 0.26, 0.27; average annual decline -2.80%, 95% CI -2.81, -2.79). Stroke mortality increased sharply with advancing age. Decline in stroke mortality was steeper for ischaemic than haemorrhagic strokes.
CONCLUSIONS
Stroke mortality rates have substantially declined, more so for ischaemic than haemorrhagic strokes.
Topics: Male; Female; Humans; Hemorrhagic Stroke; Stroke; Censuses; Age Distribution; Incidence; Mortality
PubMed: 36343092
DOI: 10.1093/ije/dyac210 -
Journal of Cardiac Surgery Feb 2022Strokes are a longstanding complication of acute type A aortic dissection (ATAAD) repair. Understanding the neuroanatomy, mechanism, and severity of stroke will...
BACKGROUND
Strokes are a longstanding complication of acute type A aortic dissection (ATAAD) repair. Understanding the neuroanatomy, mechanism, and severity of stroke will facilitate efforts to improve prediction, prevention, and treatment strategies.
METHODS
Retrospective review of patients who sustained stroke from a consecutive series of patients undergoing ATAAD repair. Neuroimaging was interpreted by two stroke neurologists blinded to clinical results. Severity of stroke was assessed by the National Institutes of Health Stroke Scale (NIHSS). Residual disability at 30 days was assessed using the modified Rankin Scale (mRS).
RESULTS
Twenty percent (38/189) of patients undergoing repair for ATAAD had stroke (unilateral 58%, bi-hemispheric 42% [p = .33]). All strokes were ischemic. No significant lateralization (right vs. left) was noted with unilateral strokes (26% vs. 32%, p = .67). Etiology of stroke was embolic (58%), hypoperfusion (26%), mixed (11%), and unknown (5%). There were no intraoperative variables that correlated with the neuroanatomy or mechanism of stroke. Preoperative carotid dissection was seen in 40% (n = 15), while postoperatively 10% (n = 4) sustained intracranial large vessel occlusion (LVO). Strokes were moderate or severe (NIHSS ≥ 9) in 97% of cases, with 66% incidence of moderate residual disability (mRS ≥ 3) at 1 month postoperatively.
CONCLUSIONS
Strokes associated with ATAAD are severe at presentation resulting in significant disability. One in 10 strokes is due to LVO and potentially amenable to endovascular treatment. Heterogeneity in both location and etiology of stroke makes prevention challenging. Future trials may evaluate the role of early neuroimaging and simultaneous treatment of stroke given advancements in endovascular therapy.
Topics: Aortic Dissection; Brain Ischemia; Endovascular Procedures; Humans; Neuroanatomy; Neuroimaging; Retrospective Studies; Stroke; Treatment Outcome
PubMed: 34783113
DOI: 10.1111/jocs.16136 -
American Family Physician Jul 2023Ischemic stroke is a major cause of morbidity and mortality worldwide. Ischemic stroke and transient ischemic attack exist on a continuum of the same disease process....
Ischemic stroke is a major cause of morbidity and mortality worldwide. Ischemic stroke and transient ischemic attack exist on a continuum of the same disease process. Ischemic stroke is common, and more than 85% of stroke risk is attributed to modifiable risk factors. The initial management of acute stroke is usually performed in the emergency department and hospital settings. Family physicians have a key role in follow-up, ensuring that a complete diagnostic evaluation has been performed, addressing modifiable risk factors, facilitating rehabilitation, and managing chronic sequelae. Secondary prevention of ischemic stroke includes optimization of chronic disease management (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia), nonpharmacologic lifestyle interventions (e.g., diet changes, exercise, substance use counseling), and pharmacologic interventions. Dual antiplatelet therapy with aspirin and clopidogrel is generally indicated for minor noncardioembolic ischemic strokes and high-risk transient ischemic attacks and should be converted to single antiplatelet therapy after 21 to 90 days. Secondary prevention of cardioembolic stroke requires long-term anticoagulation. Direct oral anticoagulants are preferred over warfarin for patients with nonvalvular atrial fibrillation. Poststroke problems with mobility, balance, cognition, dysphagia, and depression are common. Rehabilitation involves a multidisciplinary, multimodal approach that includes physical therapy, speech therapy, and treatment of chronic pain and poststroke depression.
Topics: Humans; Platelet Aggregation Inhibitors; Ischemic Stroke; Diabetes Mellitus, Type 2; Patient Transfer; Stroke; Ischemic Attack, Transient; Anticoagulants; Atrial Fibrillation
PubMed: 37440741
DOI: No ID Found -
Prevalence and risk factors of stroke in high-altitude areas: a systematic review and meta-analysis.BMJ Open Sep 2023The primary objective of this study is to investigate the prevalence and risk factors of stroke in high-altitude areas through a comprehensive systematic review and... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The primary objective of this study is to investigate the prevalence and risk factors of stroke in high-altitude areas through a comprehensive systematic review and meta-analysis.
DESIGN
This study adopts a systematic review and meta-analysis design.
DATA SOURCES
A thorough search was conducted on databases including PubMed, Web of Science, Embase, Cochrane Library, MEDLINE and SCOPUS, covering the period up to June 2023.
ELIGIBILITY CRITERIA
Studies reporting the prevalence of stroke in high-altitude areas and exploring related risk factors were included, regardless of whether they involved clinical samples or the general population. Studies with incomplete, outdated or duplicate data were excluded.
DATA EXTRACTION AND SYNTHESIS
We performed eligibility screening, data extraction and quality evaluation of the retrieved articles. Meta-analysis was employed to estimate the prevalence and risk factors of stroke in high-altitude areas. The Newcastle-Ottawa Scale was used to assess the risk of bias.
RESULTS
A total of 17 studies encompassing 8 566 042 participants from four continents were included, with altitudes ranging from 1500 m to nearly 5000 m. The pooled prevalence of stroke in high-altitude areas was found to be 0.5% (95% CI 0.3%-7%). Notably, the prevalence was higher in clinical samples (1.2%; 0.4%-2.5%) compared with the general population (0.3%; 95% CI 0.1%-0.6%). When considering geographic regions, the aggregated data indicated that stroke prevalence in the Eurasia plate was 0.3% (0.2%-0.4%), while in the American region, it was 0.8% (0.4%-1.3%). Age (OR, 14.891), gender (OR, 1.289), hypertension (OR, 3.158) and obesity (OR, 1.502) were identified as significant risk factors for stroke in high-altitude areas.
CONCLUSIONS
The findings of this study provide insights into the pooled prevalence of stroke in high-altitude areas, highlighting variations based on geographic regions and sampling type. Moreover, age, gender, hypertension and obesity were found to be associated with the occurrence of stroke.
PROSPERO REGISTRATION NUMBER
CRD42022381541.
Topics: Humans; Altitude; Prevalence; Risk Factors; Obesity; Hypertension; Stroke
PubMed: 37734891
DOI: 10.1136/bmjopen-2022-071433 -
Stroke Aug 2022A polypill-type strategy for primary prevention was first published at the turn of the century and advised that a multi-ingredient pill applied to an adult population... (Review)
Review
A polypill-type strategy for primary prevention was first published at the turn of the century and advised that a multi-ingredient pill applied to an adult population would prevent up to 80% of cardiovascular and stroke events. Such a pill should contain small doses of antihypertensives, lipid-lowering drugs, and some nutrients. The startling increase of the global stroke burden has led to a revival of this concept and the propagation of a population-based prevention strategy. Recent cardiovascular fixed-dose combination trials have shown a significant effect in reducing not only blood pressure and cholesterol levels but also in reducing cardiovascular and stroke events. In most of the studies, the study population was for secondary prevention and the total number of strokes was small. Nevertheless, it is now clear that a large proportion of primary prevention must take this path. It is especially promising when combined with community health workers interventions for modifying risk behavior. While a polypill-type approach seems most efficacious in underserved regions of high-income countries as well as in low- and middle-income countries, it seems to have a large overall effect in spite of some problems with nonadherence or potential side effects. It should be available and affordable for large target populations. Larger phase 4 studies are under way.
Topics: Adult; Antihypertensive Agents; Cardiovascular Diseases; Drug Combinations; Humans; Secondary Prevention; Stroke
PubMed: 35726621
DOI: 10.1161/STROKEAHA.122.037313 -
The Journal of Clinical Endocrinology... Oct 2023
Topics: Humans; Diabetes Mellitus, Type 2; Sodium-Glucose Transporter 2 Inhibitors; Hypoglycemic Agents; Myocardial Infarction; Stroke
PubMed: 37061813
DOI: 10.1210/clinem/dgad216