Stroke最新文献

Background: Physical activity is an effective modifiable behavior for preventing recurrent strokes. This study aims to determine the adherence to physical activity recommendations among stroke survivors in the United States. We further compared our findings with the adherence observed among myocardial infarction (MI) survivors and healthy adults, each assessed against distinct physical activity guidelines specific to their respective populations.

Methods: We utilized data from the 2011 to 2019 Behavioral Risk Factor Surveillance System, a nationally representative survey. To establish benchmarks for stroke survivors, we referenced 3 different physical activity recommendations outlined in 2011, 2014, and 2021 American Heart Association stroke prevention guidelines. Similarly, for MI survivors and healthy adults, we used the 2011 guidelines for secondary prevention of coronary vascular diseases and the 2020 World Health Organization physical activity guidelines, respectively. Adherence to recommendations was determined by the respondents' self-reported intensity, duration, and frequency of physical activity. Multivariate logistic regression compared adherence in stroke survivors, MI survivors, and healthy adults.

Results: Among 48 222 stroke survivors in the United States, the overall adherence rates to 2011, 2014, and 2021 physical activity guidelines were 75.4%, 40.2%, and 69.2%. For independently mobile stroke survivors, the adherence rates increased to 78.1%, 42.1%, and 69.9%. Among MI survivors and healthy adults, the adherence rates were 42.7% and 72%. When 2021 recommendations were used as a benchmark, older (aged ≥65 years) stroke survivors were more likely to adhere to recommendations than younger survivors (71.9% versus 62.3%; P<0.0001). After adjusting for sociodemographic factors and comorbidities, non-Hispanic Black survivors were less likely to adhere to recommendations (adjusted odds ratio, 0.81 [95% CI, 0.7-0.94]), whereas older and higher educated stroke survivors were more likely to adhere to recommendations. Geographically, stroke belt and nonrural residents were less likely to adhere to recommendations ([63.5% versus 67.9%; P<0.0001]; [53.8% versus 58.7%; P<0.0001]). Stroke and MI survivors were less likely to adhere to the latest recommendations than healthy adults (adjusted odds ratio, 0.74 [95% CI, 0.69-0.8]; (adjusted odds ratio, 0.24 [95% CI, 0.22-0.26]).

Conclusions: A substantial number of stroke survivors do not meet physical activity recommendations. Tailored interventions should be designed for at-risk populations, for example, non-Hispanic Black survivors and lower educated stroke survivors.

Telemedicine for stroke (Telestroke) has been a key component to efficient, widespread acute stroke care for many years. The expansion of reimbursement through the Furthering Access to Stroke Telemedicine Act and rapid deployment of telemedicine resources during the COVID-19 public health emergency have further expanded remote care, with practitioners of varying educational backgrounds, and experience providing acute stroke care via telemedicine (Telestroke). Some Telestroke practitioners have not had fellowship-level vascular neurology training and many are without training specific to virtual modalities. While many vascular neurology fellowship programs incorporate Telestroke training into the curriculum, components of this curriculum are not consistent, extent of involvement is variable, and not all fellows receive hands-on training in remote care. Furthermore, the extent of training and evaluation of Telestroke in American Board of Psychiatry and Neurology training requirements and Accreditation Council for Graduate Medical Education assessments for vascular neurology fellowship are not standardized. We suggest that Telestroke be formally incorporated into vascular neurology fellowship curricula and provide considerations for key components of this training and metrics for evaluation.

Background: In ischemic cerebral small vessel diseases (cSVD), recurrent ischemic stroke is rare (2%-3% per year). Because acute ischemia may not always lead to stroke in cSVD due to the small size of lesions, acute stroke may not reliably reflect ischemic activity or the risk of further clinical worsening, as both incident lacunes and incidental diffusion-weighted imaging-positive lesions can occur without stroke symptoms. We aimed to evaluate the total ischemic activity by measuring the incidence of magnetic resonance imaging (MRI)-proven incident ischemia, independent of the presence of stroke symptoms in a large cohort of cSVD.

Methods: DHU-LAC is an ongoing French multicenter cohort study of MRI-proven ischemic stroke presumably due to cSVD. We report data on patients recruited between June 2018 and October 2023. In DHU-LAC, patients are enrolled within 15 days of stroke onset and are cared for according to current guidelines. During the first 6 months, patients are systematically reassessed clinically and by brain MRI: (1) at any time if stroke symptoms occur and (2) at the end of the period. We defined MRI-proven incident ischemia as either recurrent ischemic stroke or at least 1 incident lacune or incidental diffusion-weighted imaging-positive lesion on brain MRI at 6 months.

Results: Two hundred forty-nine patients were included, of whom 172 had available data at both inclusion and after 6 months. They were aged 63±6 years, 28% were women, and 65% had hypertension. Six (3%) had a recurrent ischemic stroke, but 25 more (15%) had at least 1 incident lacune or incidental diffusion-weighted imaging-positive lesion on brain MRI. MRI-proven ischemia occurs about 5× more frequently than ischemic stroke in cSVD.

Conclusions: As data confirming the detrimental clinical effect of both incident lacunes and incidental diffusion-weighted imaging-positive lesions accumulate, MRI-proven incident ischemia may become a plausible outcome for future clinical trials in cSVD.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03552926.

Systemic, nonneurological complications are common after ischemic and hemorrhagic strokes, affect different organ systems, and have a major impact on patient outcomes. Despite their obvious implications, this area in stroke management remains inadequately researched, and current literature offers fragmentary guidance for care. The purpose of this scientific statement is to elucidate the major systemic complications of strokes that occur during hospitalization, to synthesize evidence from current literature and existing guidelines, to address gaps in knowledge, and to provide a coherent set of suggestions for clinical care based on interpretation of existing evidence and expert opinion. This document advocates for improved interdisciplinary collaboration, team effort, and effective implementation strategies to reduce the burden of these events in clinical practice. It also calls for further research on strategies for preventing and managing systemic complications after stroke that improve outcomes in stroke survivors.

Background: Mislabeled drug allergy can restrict future prescriptions and medication use, but its prevalence and impact among patients with stroke remain unknown. This study investigated the prevalence of the most commonly labeled drug allergies, their accuracy, and their impact among patients with stroke.

Methods: In this combined longitudinal and cross-sectional study, we compared the prevalence of allergy labels among the general population and patients with ischemic stroke between 2008 and 2014 from electronic health care records in Hong Kong. Outcomes between patients with stroke with or without the most prevalent labels (ie, NSAID) were compared. Rate of mislabeled NSAID allergy was confirmed by provocation testing.

Results: Compared with the general population (n=702 966), patients with stroke had more labels (n=235) to cardiovascular and hematopoietic system (prevalence, 19.5% versus 9.2%; odds ratio [OR], 2.4 [95% CI, 1.74-3.32]; P<0.001) and radiographic and diagnostic agents (prevalence, 4.2% versus 0.9%; OR, 4.82 [95% CI, 2.56-9.08]; P<0.001). The most common labels were to NSAID (prevalence, 1.8%). Patients with NSAID allergy labels were significantly less likely to be prescribed aspirin after acute stroke (OR, 0.24 [95% CI, 0.09-0.60]; P=0.003) and on follow-up (OR, 0.22 [95% CI, 0.08-0.56]; P=0.002). The median duration of follow-up was 6.7 years (6499±2.49 patient-years). Patients with stroke with NSAID allergy labels also experienced significantly higher mortality (OR, 7.44 [95% CI, 2.44-23.18]; P<0.001), peripheral vascular disease (OR, 9.35 [95% CI, 1.95-44.86]; P=0.005), and major adverse cardiovascular events (OR, 6.09 [95% CI, 2.00-18.58]; P=0.001) in the poststroke period. Patients with NSAID allergy labels (who remained alive and could consent) were referred for allergist assessment and offered drug provocation testing. The majority (80%; 4/5) had negative provocation tests and were delabeled.

Conclusions: NSAID allergy labels were significantly more prevalent among patients with stroke, associated with excessive mortality, peripheral vascular disease, and major adverse cardiovascular events. Given the high rate of mislabeled allergies, multidisciplinary neuro-allergy interventions could have the potential to improve patient outcomes.

Antibodies directed at the amyloid-β peptide offer the prospect of disease-modifying therapy for early-stage Alzheimer disease but also carry the risk of brain edema or bleeding events, collectively designated amyloid-related imaging abnormalities. Introduction of the antiamyloid immunotherapies into practice is therefore likely to present a new set of questions for clinicians treating patients with cerebrovascular disease: Which manifestations of cerebrovascular disease should preclude, or permit, antibody treatment? Is it safe to prescribe amyloid immunotherapies to individuals who require antithrombotic treatment, or to administer thrombolysis to antibody-treated individuals with acute stroke? How should severe amyloid-related imaging abnormalities be managed? This science advisory summarizes the data and key considerations to guide these challenging decisions as the medical community collects further data and experience with these groundbreaking agents.

Background: Allostatic load index (ALI) is often utilized to quantify the physiological response to stress. This study assesses the relationship between ALI and its impact on all-cause, cardiovascular, and stroke mortality in individuals with a self-reported history of stroke and within the general National Health and Nutritional Examination Survey sampled population.

Methods: Using data from the National Health and Nutritional Examination Survey (III, 1988-1994) and the 2015 Linked Mortality File, we selected adults aged ≥25 years with self-reported stroke. We computed the weighted prevalence of each ALI category to obtain nationally representative estimates with higher ALI corresponding to a higher stress burden. We evaluated the relationship between ALI category and mortality outcomes using the Cox proportional hazard model, considering the survey design variables and adjusting for age, sex, race/ethnicity, education, marital status, income, drinking, and smoking status.

Results: Of 17 284 people screened in the National Health and Nutritional Examination Survey sample population, 15 567 individuals were included in the study. The ALI distribution was 48.3% ALI ≤1, 21.7% ALI=2, and 30% ALI ≥3. Of 414 individuals with a reported history of stroke, there were 11.8% ALI ≤1, 22.1% ALI=2, and 66.1% ALI ≥3. There was an association between a higher ALI and older age, Black and Mexican American race, and >1 comorbidity in the overall sampled population. In the population with prior stroke, those with ALI ≥3 had 2.7× higher adjusted all-cause mortality (hazard ratio, 2.7 [CI, 1.5-4.9]) and 4.5× higher adjusted cardiovascular mortality (hazard ratio, 4.5 [CI, 1.4-14.3]) compared with those with ALI ≤1. In the general sampled National Health and Nutritional Examination Survey population, the ALI ≥3 group had 1.8× higher adjusted stroke mortality (hazard ratio, 1.8 [CI, 1.1-3.1]).

Conclusions: Baseline higher ALI is associated with greater all-cause and cardiovascular mortality in stroke survivors and greater stroke mortality in the overall sampled National Health and Nutritional Examination Survey population.

Background: Risk profile of recurrence may influence the effect of antiplatelet therapy. This study aimed to evaluate the efficacy and safety of clopidogrel-aspirin initiated within 72 hours after symptom onset for acute mild stroke or high-risk transient ischemic attack stratified by risk profile.

Methods: This is a secondary post hoc analysis of the INSPIRES (Intensive Statin and Antiplatelet Therapy for Acute High-risk Intracranial or Extracranial Atherosclerosis) randomized clinical trial that enrolled patients 35 to 80 years old with acute mild ischemic stroke or high-risk transient ischemic attack between 2018 and 2022. Patients were stratified into different groups based on the Essen Stroke Risk Score (ESRS) and modified ESRS. The primary efficacy outcome was any new stroke within 90 days. The primary safety outcome was moderate-to-severe bleeding within 90 days.

Results: Among 6100 patients (3050 each in the clopidogrel-aspirin group and aspirin group), the median age was 65 years (interquartile range, 57-71 years), and 3915 (64.2%) were male. Clopidogrel-aspirin was associated with a reduced risk of new stroke in patients with an ESRS of <3 (hazard ratio [HR], 0.67 [95% CI, 0.52-0.86]), but not in those with an ESRS of ≥3 (HR, 0.92 [95% CI, 0.72-1.18]), compared with aspirin (P_interaction=0.07). Similar results were found in patients stratified by modified ESRS (modified ESRS <6 in male and <5 in female: HR, 0.68 [95% CI, 0.55-0.83]; modified ESRS ≥6 in male and ≥5 in female: HR, 1.14 [95% CI, 0.82-1.59]; P_interaction=0.01). The association between antiplatelet therapy and the moderate-to-severe bleeding did not differ across risk profile subgroups (ESRS of <3: HR, 1.35 [95% CI, 0.54-3.35]; ESRS of ≥3: HR, 3.21 [95% CI, 1.18-8.78]; P_interaction=0.21; modified ESRS of <6 in male and <5 in female: HR, 1.96 [95% CI, 0.88-4.36]; modified ESRS of ≥6 in male and ≥5 in female: HR, 2.27 [95% CI, 0.70-7.39]; P_interaction=0.85).

Conclusions: This post hoc analysis of the INSPIRES trial showed that patients with a low level of risk profile assessed by ESRS received greater benefit from clopidogrel-aspirin initiated within 72 hours after symptom onset than aspirin alone.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03635749.