Frontiers in stroke最新文献

Introduction: Nigeria has the highest proportion of children with sickle cell anemia (SCA) globally; without transcranial Doppler screening and ongoing treatment (regular blood transfusions or hydroxyurea therapy), 10% will have a stroke in childhood. In low-resource settings, training to recognize and prevent strokes in children with SCA is vital. A sustainable Sickle Cell Disease Stroke Prevention Teams program was established, as part of clinical trials, to address the need for stroke care in northern Nigeria. We describe our health professional stroke training curriculum and specific application to detect strokes in clinical trials in low-resource settings.

Methods: Children aged 5-12 and 2-16 years with SCA in northern Nigeria were enrolled in the SPRING and SPRINT primary and secondary stroke prevention trials, respectively. The primary outcome measure in both trials was a clinical stroke based on the World Health Organization definition. Non-neurologist physicians were trained in-person and via video lectures regarding stroke recognition, performing neurological examinations using the adapted Pediatric NIH Stroke Scale, and acute stroke care. Central stroke adjudicators, two pediatric neurologists, reviewed the case report forms and recorded videos of the neurological examinations.

Results: Six physicians completed the curriculum at three sites and were certified to detect strokes. Of 20 children with suspected stroke, 8 and 11 children had acute initial or acute recurrent strokes confirmed in the SPRING (N = 220) and SPRINT (N = 101) trials, respectively. The concordance rate between local stroke diagnoses and the central stroke adjudication process was 95% (19 of 20). One child presented with non-specific symptoms and hypertonia and was mislabeled locally as an acute stroke.

Discussion: A curriculum to train healthcare providers in pediatric acute stroke recognition and care in a low-resource setting is feasible and sustainable. We successfully identified strategies for task shifting from a single pediatric neurologist in the region to multiple non-neurologist physicians.

Stroke is a leading cause of death and disability globally, with significant long-term impacts such as post-stroke cognitive impairment (PSCI). PSCI affects up to one-third of stroke survivors, substantially increasing their risk of dementia, especially after recurrent strokes. Despite advances in acute stroke treatments, the mechanisms underlying PSCI remain poorly understood. Emerging evidence highlights that PSCI arises from a complex interplay of vascular damage, neurodegenerative pathologies, and chronic inflammation. This review explores the epidemiology and clinical characteristics of PSCI, emphasizing the role of age, education, vascular integrity, and comorbidities such as diabetes. Additionally, we examine experimental findings that utilize rodent models to elucidate the time course and biological mechanisms of PSCI. Notable contributions include insights from transgenic Alzheimer's disease (AD) mouse models, revealing how vascular and amyloid pathologies accelerate cognitive decline post-stroke. Moreover, studies on neuroinflammation and immune responses, such as those involving TREM2, underscore the significance of inflammatory pathways in PSCI. By integrating clinical and experimental findings, this literature review provides a comprehensive understanding of PSCI mechanisms, offering a foundation for developing targeted diagnostic tools and therapeutic interventions to mitigate the long-term cognitive effects of stroke.

Objective: The stroke burden in Uganda ranks ninth among the ten causes of death, a major cause of chronic illnesses, accounting for the top ten causes of hospitalization. This baseline study examined how mobile phones can improve the prevention, management, and treatment of stroke in rural Uganda.

Methods: It was a cross-sectional study that utilized a mixture of methods. Quantitative data was collected from the districts' health information management system while qualitative data were from healthcare providers and patients/caregivers/survivors using a semi-structured guide. Quantitative data was analyzed descriptively while qualitative data was inductively analyzed through creating themes.

Results: All participants supported the use of mobile phone interventions and suggested three major types of information to be included in this intervention: warning signs and indicators, underlying causes of stroke, and prevention measures. The challenges that might be faced in implementing this intervention are contextual, health system, and economic related.

Conclusion: These baseline findings support the possibility of mobile phone intervention as an important instrument to improve stroke prevention, management, and treatment in rural Uganda. Challenges that might accompany the use of ICT have to be addressed as the intervention is designed.

Background: Cerebral venous thrombosis (CVT) is a rare but serious subtype of stroke. Several studies have reported an increased incidence of CVT after either COVID-19 (CoV19) infection or vaccination; however, data on clinical characteristics, the radiological profiles, and the outcomes of these patients with CVT as the only severe symptom of a CoV19 infection or vaccination compared to patients with non-CoV19-related CVT are still scarce.

Methods: We performed a retrospective monocentric study over 10 years (January 2013-December 2022) that included consecutive patients with a confirmed diagnosis of CVT based on imaging of the cerebral venous system. Patients were categorized as CoV19 CVT (either due to infection or post-vaccination) or non-CoV19 CVT and compared regarding demographics, risk factors, clinical characteristics, and imaging findings as well as outcome (at discharge, at 6 months, and last follow-up). Furthermore, sub-analyses were performed to compare CoV19-infection-related-CVT and CoV19-vaccination-related-CVT patients.

Results: Overall, 122 patients with suspected CVT were identified. After excluding patients with missing data (n = 20) or missing imaging of the cerebral venous system (n = 31), 71 patients with confirmed CVT remained for the final analyses. Of those, 11 patients had CoV19 CVT (infection n = 3, vaccination n = 8), and 60 patients had non-CoV19-CVT. There were no differences regarding median age (CoV19: 40 [IQR: 22-70] vs. non-CoV19: 41 [IQR:27-64]) or percentage of female sex among both groups. A lower rate of CVT risk factors was observed in the CoV19 group but without significant differences. No patient with CoV19 CVT displayed impaired consciousness on presentation, and only 30% had focal neurological deficits compared to 51.7% in the control group. The rate of CVT-related intracranial hemorrhage and venous infarcts were 27.3% and 9.1%, respectively, in the CoV19 group and 30% and 16.7%, respectively, in the non-CoV19 group. The mortality rate at discharge was 9.1% in the CoV19-CVT group vs. 3.3% in the non-CoV19-CVT group, without differences in functional outcomes during the follow-up period. Sub-analyses comparing CoV19-infection-related CVT vs. CoV19-vaccination-related CVT patients revealed no significant differences in clinical, imaging, or treatment characteristics.

Conclusion: In this monocentric study, there was no signal for a worse severity of CoV19 CVT compared to non-CoV19 CVT regarding clinical characteristics, imaging profile, or outcomes in patients with CVT only. Larger observational data with sophisticated workups of CVT patients are needed to confirm our results.

Introduction: Undiagnosed atrial fibrillation (AF) is a potential underlying cause of cryptogenic stroke. Prolonged screening for AF using a photoplethysmography (PPG) smartwatch might offer a solution for detecting AF in patients with cryptogenic stroke. In this study, we aim to investigate this strategy by comparing AF detection rates using a PPG-smartwatch and 48 h Holter monitor.

Methods: From December 2019, patients with cryptogenic stroke were included to undergo 28 days of semi-continuous AF monitoring using a Fitbit smartwatch with a PPG-based FibriCheck algorithm, with simultaneous Holter monitoring during the first 48 h. From April 2021, a detailed screening log was installed to characterize potential study participants.

Results: After logged screening of 1,312 patients, enrollment was prematurely halted due to slower-than-expected inclusion rates. 40.8% of the screened patients had cryptogenic stroke, of which 92.5% were non-eligible for inclusion due to logistical, technological, and study-related challenges. Of the 43 patients enrolled, 37 completed PPG monitoring using a smartwatch. 43% of patients had PPG-detected AF in the 28 days after cryptogenic stroke. During the first 48 h, PPG-based screening detected AF in 2 patients, whereas no AF was detected using concurrent Holter monitoring.

Conclusion: The PPG-smartwatch detected AF in 43% of the participants after cryptogenic stroke. However, discrepancies with concurrent Holter monitoring raise major concerns about the accuracy of the detected PPG-based AF. Moreover, the feasibility of a PPG-based screening strategy is limited due to logistical and technological challenges, partly inherent to cryptogenic stroke patients.

Acute ischemic stroke (AIS) is a known complication of Takayasu arteritis (TAK); however, it is infrequently the first symptom observed. There have been no reports of concomitant AIS and anterior ischemic optic neuropathy (AION) as an initial manifestation of TAK. We present a case of TAK causing stroke and painless vision loss in a young Nigerian woman. A 33-year-old female patient presented with abrupt onset weakness in the right extremities and painless vision loss in her left eye. Her medical history included joint pain, malaise, syncope, and dizziness, along with peripheral vascular collapse, requiring recurrent hospital admissions. She had an absent left radial pulse, reduced left carotid pulse, and unrecordable blood pressure in her left arm. There was a relative afferent pupillary defect (RAPD), with fundoscopy findings indicating optic disc pallor. She had expressive aphasia, right facial paresis, and right flaccid hemiparesis. Brain computed tomography (CT) showed an infarct in the left middle cerebral artery (MCA) territory. The brain CT angiography showed diffuse enhancing aortic arch wall thickening and multiple aortic arch branch obstructive disease. The diagnosis was TAK complicated by left hemispheric infarctive stroke and left AION. She began treatment with prednisolone, azathioprine, and secondary stroke preventive care. Her vision improved to the ability to count fingers, with good functional outcomes and reduced disease activity. This case highlights the challenging diagnostic trajectory of TAK in a Nigerian female patient, featuring a unique multi-vessel affectation. Clinicians should be aware of the protean clinical presentations of TAK to reduce adverse cardiovascular complications.

Background: Mechanical thrombectomy is a highly effective emergency treatment for selected cases of ischemic stroke but can only be provided at hospitals with appropriate facilities and interventionists. Many patients require transfers for treatment, including some who are subsequently considered ineligible. To maintain capacity at thrombectomy centers, displaced patients should soon be returned to their local hospital following assessment and treatment, but return processes vary. We sought the views of stroke and ambulance services, clinicians, and public representatives about the timing, planning and implementation of acceptable processes to inform recommendations about the early return of patients (< 24 h) displaced as a result of thrombectomy pathways.

Methods: Three workstreams were undertaken between 01/05/2023 and 31/10/2023: 1. An online survey of hospital stroke services supplemented by a convenience poll of stroke clinicians. 2. An online survey of ambulance services. 3. Focus groups with stroke patients and carers using a topic guide describing typical early return scenarios. The surveys used multiple choice answers supplemented by free text boxes for additional comments. Data were reported descriptively without statistical comparison. Focus group data were analyzed thematically using emergent coding.

Results: Responses were obtained from 32 stroke services, 44 stroke clinicians, and 11 ambulance services. Stroke service and clinician respondents generally supported early return for most clinical scenarios but advised caution regarding transfers < 4 h after thrombectomy and < 24 h for hemorrhagic stroke due to the higher risk of complications. Ambulance respondents highlighted travel time, immediate service pressures and crew type as influences upon providing early returns, but supported 24/7 provision. Twenty-nine patients and four carers participated in three focus groups. There was general acceptance of early return processes but these participants emphasized the need for clear communication and individualized decisions based upon clinical status, age, journey length, patient preferences and individual contextual factors.

Conclusions: All contributors were generally supportive of early patient returns to maintain thrombectomy center capacity, but the results suggest important organizational, clinical, and patient-focused considerations for successful implementation.

Background: COVID-19 infections have been implicated in cerebral ischemia, but their relationship to cervical arterial dissections remains poorly characterized. Descriptions of cervical arterial dissections in patients with COVID-19 infections with details regarding their presenting symptomatology, imaging findings, and responses to treatment with antithrombotic therapy may be helpful to clinicians.

Methods and observations: We present six adult cases of cervical arterial dissections in the setting of recent COVID-19 infections from 2021 to 2022 at our institution. Four cases presented with dissections involving the internal carotid artery, while two cases had dissections of bilateral vertebral arteries. In one patient, we found imaging evidence for a possible inflammatory process. All patients were treated with either antiplatelet agents or direct oral anticoagulants.

Conclusions and relevance: COVID-19 infections may predispose patients to spontaneous cervical arterial dissections. Such patients can have variable neurologic presentations, though headaches and neck pain were common complaints. Most patients responded well to antithrombotic therapy, with improvement in symptoms and radiologic findings at follow-up. Clinicians should maintain a high degree of suspicion for cervical arterial dissections in patients who present acutely with severe headache/neck pain and/or new neurologic deficits in the setting of COVID-19 infections.

Introduction: Stroke among Americans under age 49 is increasing. While the risk factors for stroke among older adults are well-established, evidence on stroke causes in young adults remains limited. This study used machine learning techniques to explore the predictors of stroke in young men and women.

Methods: The least absolute shrinkage and selection operator algorithm (LASSO) was applied to data from Wave V of the National Longitudinal Survey of Adolescent to Adult Health (N = 12,300)-nationally representative, longitudinal panel containing demographic, lifestyle, and clinical information for individuals aged 33-43-to identify the key factors associated with stroke in men and women. The resulting LASSO model was tested and validated on an independent sample and model performance was assessed using the area under the receiver operating characteristic curve (AUC) and calibration. For robustness, synthetic minority over sampling technique (SMOTE) was applied to address data imbalance and analyses were repeated on the balanced sample.

Results: Approximately 1.1% (N = 59) and 1.3% (N = 90) of the 5,318 and 6,970 men and women in the sample reported having a stroke. LASSO was used to predict stroke using demographic, lifestyle, and clinical predictors on both balanced and imbalanced data sets. LASSO performed slightly better on the balanced data set for women compared to the unbalanced set (Female AUC: 0.835 vs. 0.842), but performance for men was nearly identical (Male AUC: 0.820 vs. 0.822). Predictor identification was similar across both sets. For females, marijuana use, receipt of health services, education, self-rated health status, kidney disease, migraines, diabetes, depression, and PTSD were predictors. Among males, income, kidney disease, heart disease, diabetes, PTSD, and anxiety were risk factors.

Conclusions: This study showed similar clinical risk factors among men and women. However, variations in the behavioral and lifestyle determinants between sexes highlight the need for tailored interventions and public health strategies to address sex-specific stroke risk factors among young adults.