Advancing stroke diagnosis and management through nuclear medicine: a systematic review of clinical trials.

Introduction: Despite advancements in stroke care, challenges persist in timely triage and treatment initiation to prevent the burden of stroke-related disabilities. Although nuclear medicine has shown promise, no imaging technique has yet provided a sufficiently rapid, precise, and cost-effective approach to routine stroke management. This study aims to review the clinical application of nuclear medicine in stroke diagnosis and treatment. Methods: A systematic search of the Cochrane, EU Clinical Trials Register, ISRCTN, the International Stroke Trial, and the ClinicalTrials.gov database was conducted to find all registered trials reporting nuclear medicine's clinical applications in stroke up to June 07, 2024. Results: Among the 220 screened trials, 51 (36 interventional; 15 observational) met the eligibility criteria. Participants were older than 18 years old, with only six studies including pediatric under 17 years old, with a total of 11,262 stroke (9,232 ischemic; 2,030 haemorrhagic) participants. The bias risk varied across trials but remained mostly low to moderate. Discussion: The review highlighted nuclear medicine's significant contributions to stroke diagnosis and management, notably through mobile stroke units, pre-hospital acute stroke magnetic resonance image (MRI) based biomarkers, and MRI-based stroke mechanisms for 4D flow nuclear imaging. These advancements have generally reduced treatment delays and enhance clinical outcomes post-stroke. Specifically, radiopharmaceutical radiotracers can effectively discriminate between strokes and mimics, particularly in high-risk patients. Integrating novel positron emission tomography (PET) radiotracer 18F glycoprotein 1 and radionuclide angiography may improve sensitivity and specificity in thrombi detection for decisions regarding stenting or carotid endarterectomy, and the single-photon emission computed tomography and PET integration with ferumoxytol radiotracer-enhanced MRI enables functional imaging for evaluating cerebral perfusion, metabolic activity, and neuroinflammatory markers post-stroke. Overall, the integration of nuclear medicine into multimodal imaging equipment like computed-tomography PET and MRI-PET offers a more comprehensive picture of the brain. Nevertheless, further research is needed on novel stroke imaging techniques and standardization across stroke centers for optimal performance. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024541680, identifier PROSPERO CRD(42024541680).

Impact of surface ultraviolet radiation intensity on hospital admissions for ischemic and hemorrhagic stroke: A large-scale database study using distributed lag nonlinear analysis, 2015-2022, in Harbin, China.

OBJECTIVES: Our aim is to evaluate the impact of surface ultraviolet radiation intensity on hospital admissions for stroke and to compare the correlation and differences among different subtypes of strokes. MATERIALS AND METHODS: We collected daily data on surface ultraviolet radiation intensity, temperature, air pollution, and hospital admissions for stroke in Harbin from 2015 to 2022. Using a distributed lag non-linear model, we determined the correlation between daily surface ultraviolet radiation intensity and the stroke admission rate. Relative risks (RR) with 95% confidence intervals (CI) and attributable fractions (AF) with 95% CI were calculated based on stroke subtypes, gender, and age groups. RESULTS: A total of 132,952 hospitalized stroke cases (including hemorrhagic and ischemic strokes) were included in the study. We assessed the non-linear effects of ultraviolet intensity on hospitalized patients with ischemic and hemorrhagic strokes. Compared to the maximum morbidity benchmark ultraviolet intensity (19.2 × 10^5 for ischemic stroke and 20.25 for hemorrhagic stroke), over the 0-10 day lag period, the RR for extreme low radiation (1st percentile) was 0.86 (95% CI: 0.77, 0.96), and the RR for extreme high radiation (99th percentile) was 0.86 (95% CI: 0.77, 0.96). In summary, -4.842% (95% CI: -7.721%, -2.167%) and -1.668% (95% CI: -3.061%, -0.33%) of ischemic strokes were attributed to extreme low radiation intensity with a lag of 0 to 10 days and extreme high radiation intensity with a lag of 0 to 5 days, respectively. The reduction in stroke hospitalization rates due to low or high ultraviolet intensity was more pronounced in females and younger individuals compared to males and older individuals. None of the mentioned ultraviolet intensity intensities and lag days had a statistically significant impact on hemorrhagic stroke. CONCLUSIONS: Our study fundamentally suggests that both lower and higher levels of surface ultraviolet radiation intensity in Harbin, China, contribute to a reduced incidence of ischemic stroke, with this effect lasting approximately 10 days. This finding holds significant potential for public health and clinical relevance.

Age- and Sex-Specific Analysis of Stroke Hospitalization Rates, Risk Factors, and Outcomes From German Nationwide Data.

BACKGROUND: Significant age and sex differences have been reported at each stage of the stroke pathway, from risk factors to outcomes. However, there is some uncertainty in previous studies with regard to the role of potential confounders and selection bias. Therefore, using German nationwide administrative data, we aimed to determine the magnitude and direction of trends in age- or sex-specific differences with respect to admission rates, risk factors, and acute treatments of ischemic and hemorrhagic stroke. METHODS: We obtained and analyzed data from the Research Data Centres of the Federal Statistical Office for the years 2010 to 2020 with regard to all acute stroke hospitalizations, risk factors, treatments, and in-hospital mortality, stratified by sex and stroke subtype. This database provides a complete national-level census of stroke hospitalizations combined with population census counts. All hospitalized patients ≥15 years with an acute stroke (diagnosis code: I60-64) were included in the analysis. RESULTS: Over the 11-year study period, there were 3 375 157 stroke events; 51.2% (n=1 728 954) occurred in men. There were higher rates of stroke admissions in men compared with women for both ischemic (378.1 versus 346.7/100 000 population) and hemorrhagic subtypes (75.6 versus 65.5/100 000 population) across all age groups. The incidence of ischemic stroke admissions peaked in 2016 among women (354.0/100 000 population) and in 2017 among men (395.8/100 000 population), followed by a consistent decline from 2018 onward. There was a recent decline in hemorrhagic stroke admissions observed for both sexes, reaching its nadir in 2020 (68.9/100 000 for men; 59.5/100 000 for women). Female sex was associated with in-hospital mortality for both ischemic (adjusted odds ratio, 1.11 [1.09-1.12]; P<0.001) and hemorrhagic stroke (adjusted odds ratio, 1.18 [95% CI, 1.16-1.20]; P<0.001). CONCLUSIONS: Despite improvements in stroke prevention and treatment pathways in the past decade, sex-specific differences remain with regard to hospitalization rates, risk factors, and mortality. Better understanding the mechanisms for these differences may allow us to develop a sex-stratified approach to stroke care.

Disentangling the Inverse LDL-C-hemorrhagic Stroke Association in Chinese Adults with Hypertension: Findings from the Chinese Multi-Provincial Cohort Study.

Why lower low-density lipoprotein cholesterol (LDL-C) was associated with a decreased atherosclerotic cardiovascular disease (ASCVD) risk but an increased hemorrhagic stroke (HS) risk in hypertensive adults remains unclear. We examined whether the inverse LDL-C-HS association partly arises from its effect on ASCVD. We estimated separable effects of LDL-C on HS outside (i.e., separable direct effect) or only through its effect on ASCVD (i.e., separable indirect effect) in hypertensive adults from the Chinese Multi-provincial Cohort Study. We quantified such effects using numbers needed to treat (NNT) to prevent or cause an extra HS based on the restricted mean event-free time till a 25-year follow-up. LDL-C $<$ 70 mg/dL was not associated with an increased HS risk compared to LDL-C $\ge$ 70 mg/dL regarding total and separable direct effects. However, a small separable indirect effect (i.e., NNT to harm: 9722 participants) was noted and validated via a series of sensitivity analyses. Moreover, modified effects were observed, particularly in the 35-49-year age group, men, and those with SBP $\ge$ 140 mm Hg. These results suggest the inverse LDL-C-HS association in hypertensive adults is partly due to its effect on ASCVD. A better understanding of such associations would provide more enlightening into stroke prevention.

[On the issue of optimizing protein and energy supply for patients with acute cerebrovascular accident]. / K voprosu ob optimizatsii belkovogo i energeticheskogo obespecheniya patsientov s ostrym narusheniem mozgovogo krovoobrashcheniya.

OBJECTIVE: To study the severity of systemic metabolic dysfunction in various types of stroke and determine the parameters of optimal energy and protein supply for this category of patients in the presence of severe neurological deficit (National Institutes of Health Stroke Scale - NIHSS score of 15 points or more) during different periods of the disease. MATERIAL AND METHODS: The retrospective study included 512 patients with acute cerebrovascular accident (ACVA) who received nutritional support (NS) for 10 days or more: 367 (71.7%) people with ischemic stroke (IS) and 145 (28.3%) - with hemorrhagic stroke (HS). The course of stroke in all patients included in the study was accompanied by severe and extremely severe neurological disorders (15 points or more on the NIHSS scale). Energy expenditure and the severity of the catabolic reaction of the body were studied by dynamic assessment of indirect calorimetry indicators and actual nitrogen losses. RESULTS: More than 99% of patients received tube feeding. Using the method of indirect calorimetry, the ranges of energy expenditure during stroke were determined: for IS - 1600-2100 kcal/day (24-26 kcal/kg/day), for HS - 1900-2600 kcal/day (26-30 kcal/kg/day) in depending on the period of the disease. The average nitrogen losses at all stages of the disease in patients with IS and HS were comparable. In IS, these amounts were 19 g/day (0.25 g/kg/day), which corresponds to 119 g/day of protein (1.56 g/kg/day of protein), and in HS patients lost an average of 18.9 g/day of nitrogen (0.24 g/kg/day) or 118 g/day of protein (1.5 g/kg/day of protein). The maximum nitrogen losses were observed in the period from 10 to 20 days of illness and amounted to 24.7 g/day in patients with HS (0.31 g/kg/day or 1.93 g/kg/day protein), and in patients with IS - 24.5 g/day (0.29 g/kg/day or 1.81 g/kg/day protein). CONCLUSION: An identified trend towards a decrease in mortality in patients with acute stroke with energy supply in the amount of 27-28 kcal/kg/day and protein consumption in the amount of 1.3-1.4 g/kg/day compared with patients receiving 20-21 kcal/kg /day and 1-1.2 g/kg/day of protein requires further prospective randomized studies.

Corrigendum: Predicting 90-day prognosis for patients with stroke: a machine learning approach.

[This corrects the article DOI: 10.3389/fneur.2023.1270767.].

Impact of intracerebral hemorrhage and cerebral infarction on ADL and outcome in stroke patients: A retrospective cohort study.

BACKGROUND: The impact of different stroke types on specific activities of daily living (ADL) is unclear. OBJECTIVE: To investigate how differences between intracerebral hemorrhage (ICH) and cerebral infarction (CI) affect improvement of ADL in patients with stroke within a hospital by focusing on the sub-items of the Functional Independence Measure (FIM). METHODS: Patients with first-stroke hemiplegia (n = 212) were divided into two groups: ICH (86 patients) and CI (126 patients). Primary assessments included 13 motor and 5 cognitive sub-items of the FIM assessed at admission and discharge. Between-group comparisons and multiple regression analyses were performed. RESULTS: Upon admission, the ICH group exhibited significantly lower FIM scores than those of the CI group across various activities, including grooming, dressing (upper body and lower body), toileting, bed/chair transfer, toilet transfer, walking/wheelchair, and stairs. Age and FIM motor scores at admission influenced both groups' total FIM motor scores at discharge, whereas the duration from onset affected only the CI group. CONCLUSION: Several individual FIM motor items were more adversely affected by ICH than by CI. Factors related to ADL at discharge may differ depending on stroke type. Recognizing these differences is vital for efficient rehabilitation practices and outcome prediction.

Co-localization of NCCT hypodensity and CTA spot sign predicts substantial intracerebral hematoma expansion: The Black-&-White sign.

BACKGROUND: Existing radiological markers of hematoma expansion (HE) show modest predictive accuracy. We aim to investigate a novel radiological marker that co-localizes findings from non-contrast CT (NCCT) and CT angiography (CTA) to predict HE. METHODS: Consecutive acute intracerebral hemorrhage patients admitted at Foothills Medical Centre in Calgary, Canada, were included. The Black-&-White sign was defined as any visually identified spot sign on CTA co-localized with a hypodensity sign on the corresponding NCCT. The primary outcome was hematoma expansion (⩾6 mL or ⩾33%). Secondary outcomes included absolute (<3, 3-6, 6-12, ⩾12 mL) and relative (0%, <25%, 25%-50%, 50%-75%, or >75%) hematoma growth scales. RESULTS: Two-hundred patients were included, with 50 (25%) experiencing HE. Forty-four (22%) showed the spot sign, 69 (34.5%) the hypodensity sign, and 14 (7%) co-localized both as the Black-&-White sign. Those with the Black-&-White sign had higher proportions of HE (100% vs 19.4%, p < 0.001), greater absolute hematoma growth (23.37 mL (IQR = 15.41-30.27) vs 0 mL (IQR = 0-2.39), p < 0.001) and relative hematoma growth (120% (IQR = 49-192) vs 0% (0-15%), p < 0.001). The Black-&-White sign had a specificity of 100% (95%CI = 97.6%-100%), a positive predictive value of 100% (95%CI = 76.8%-100%), and an overall accuracy of 82% (95%CI = 76%-87.1%). Among the 14 patients with the Black-&-White sign, 13 showed an absolute hematoma growth ⩾12 mL, and 10 experienced a HE exceeding 75% of the initial volume. The inter-rater agreement was excellent (kappa coefficient = 0.84). CONCLUSION: The Black-&-White sign is a robust predictor of hematoma expansion occurrence and severity, yet further validation is needed to confirm these compelling findings.

The plasma lipids with different fatty acid chains are associated with the risk of hemorrhagic stroke: a Mendelian randomization study.

Background and objective: Hemorrhagic stroke, characterized by acute bleeding due to cerebrovascular lesions, is associated with plasma lipids and endothelial damage. The causal relationship between genetic plasma lipid levels and hemorrhagic stroke remains unclear. This study employs a two-sample Mendelian randomization (MR) analysis to explore the causal relationship between plasma lipid profiles with different fatty acid chains and the risk of intracerebral and subarachnoid hemorrhage, the two main subtypes of hemorrhagic stroke. Methods: The datasets for exposure and outcome summary statistics were obtained from publicly available sources such as the GWAS Catalog, IEU OpenGWAS project, and FinnGen. The two-sample MR analysis was employed to initially assess the causal relationship between 179 plasma lipid species and the risk of intracerebral and subarachnoid hemorrhage in the Finnish population, leading to the identification of candidate lipids. The same methods were applied to reanalyze data from European populations and conduct a meta-analysis of the candidate lipids. The Inverse Variance Weighting (IVW) method served as the primary analysis for causal inference, with additional methods used for complementary analyses. Sensitivity analysis was conducted to clarify causal relationships and reduce biases. Results: Two analyses using Mendelian randomization were performed, followed by meta-analyses of the results. A causal relationship was established between 11 specific lipid species and the occurrence of intracerebral hemorrhage within the European population. Additionally, 5 distinct lipid species were associated with subarachnoid hemorrhage. Predominantly, lipids with linoleic acid and arachidonic acid side chains were identified. Notably, lipids containing arachidonic acid chains (C20:4) such as PC 18:1;0_20:4;0 consistently showed a decreased risk of both intracerebral hemorrhage [p < 0.001; OR(95% CI) = 0.892(0.835-0.954)] and subarachnoid hemorrhage [p = 0.002; OR(95% CI) = 0.794(0.689-0.916)]. Conversely, lipids with linoleic acid chains (C18:2) were associated with an increased risk of intracerebral hemorrhage. Conclusion: This study identifies a potential causal relationship between lipids with different fatty acid side chains and the risk of intracerebral and subarachnoid hemorrhagic stroke, improving the understanding of the mechanisms behind the onset and progression of hemorrhagic stroke.

Reviewing migraine-associated pathophysiology and its impact on elevated stroke risk.

Migraine affects up to 20 percent of the global population and ranks as the second leading cause of disability worldwide. In parallel, ischemic stroke stands as the second leading cause of mortality and the third leading cause of disability worldwide. This review aims to elucidate the intricate relationship between migraine and stroke, highlighting the role of genetic, vascular, and hormonal factors. Epidemiological evidence shows a positive association between migraine, particularly with aura, and ischemic stroke (IS), though the link to hemorrhagic stroke (HS) remains inconclusive. The shared pathophysiology between migraine and stroke includes cortical spreading depression, endothelial dysfunction, and genetic predispositions, such as mutations linked to conditions like CADASIL and MELAS. Genetic studies indicate that common loci may predispose individuals to both migraine and stroke, while biomarkers such as endothelial microparticles and inflammatory cytokines offer insights into the underlying mechanisms. Additionally, hormonal influences, particularly fluctuations in estrogen levels, significantly impact migraine pathogenesis and stroke risk, highlighting the need for tailored interventions for women. The presence of a patent foramen ovale (PFO) in migraineurs further complicates their risk profile, with device closure showing promise in reducing stroke occurrence. Furthermore, white matter lesions (WMLs) are frequently observed in migraine patients, suggesting potential cognitive and stroke risks. This review hopes to summarize the links between migraine and its associated conditions and ischemic stroke, recognizing the profound implications for clinical management strategies for both disorders. Understanding the complex relationship between migraine and ischemic stroke holds the key to navigating treatment options and preventive interventions to enhance overall patient outcomes.

Acute Myocardial Injury in Spontaneous Intracerebral Hemorrhage: A Secondary Observational Analysis of the FAST Trial.

BACKGROUND: Acute myocardial injury is associated with poor outcomes in patients with acute ischemic stroke, but its prognostic significance in patients with spontaneous intracerebral hemorrhage remains unclear. We investigated whether acute myocardial injury and the direction of the cardiac troponin I (cTnI) change (rising versus falling) affect post-intracerebral hemorrhage outcomes. METHODS AND RESULTS: We re-analyzed the FAST (Factor-Seven-for-Acute-Hemorrhagic-Stroke) trial. Acute myocardial injury was defined as at least 1 cTnI value above the upper reference limit with a rise/fall of >20%. Logistic regression tested for associations (1) between acute myocardial injury (presence versus absence) and poor outcome (modified Rankin Scale 4-6) and mortality at 15 and 90 days; (2) among 3 groups (rising versus falling versus no acute myocardial injury) and outcomes. Among the 841 FAST participants, 785 patients were included. Acute myocardial injury was detected in 29% (n=227); 170 had rising cTnI. At 15 and 90 days, respectively, those with acute myocardial injury had higher odds of poor outcome (adjusted odds ratio) ([aOR] 2.3 [95% CI, 1.3-3.9]); and adjusted odds ratio 2.5 [95% CI, 1.6-3.9];, and higher odds of mortality (adjusted odds ratio 2.4 [95% CI, 1.4-4.3]; and adjusted odds ratio 2.2 [CI, 1.3-3.6]) than patients without. There was no interaction between FAST group assignment and myocardial injury, and associations between myocardial injury and outcomes were consistent across group assignments. Rising cTnI was associated with the highest risk of poor outcomes and mortality. CONCLUSIONS: In this secondary analysis of the FAST trial, acute myocardial injury was common and associated with poor outcomes. The direction of the cTnI change might provide additional risk stratification after intracerebral hemorrhage.

Cardiac Findings Following Cerebrovascular Disease.

BACKGROUND: Accumulating evidence suggests that cardiac findings after stroke are an important, yet understudied, manifestation of brain-heart interactions. Our aim was to investigate and compare cardiac findings after different cerebrovascular events (acute ischemic stroke, transient ischemic attack, and hemorrhagic stroke). METHODS AND RESULTS: There were 7113 patients screened who were treated between December 2013 and December 2020 at the University Hospital Zurich for ischemic stroke, transient ischemic attack, and hemorrhagic stroke. Seven hundred twenty-one patients without evidence of previous cardiac disease or presumed cardioembolic origin of their cerebrovascular disease and with at least 1 cardiac checkup were included. Clinical reports from the year following disease onset were screened for new cardiac findings, which were categorized as arrhythmia/electrocardiographic changes, myocardial alterations, valvular abnormalities, and coronary perfusion insufficiency. Differences in proportions of findings among groups were analyzed using the Pearson χ2 test or Fisher exact test. ECG changes were observed in 81.7% (n=474) of patients with ischemic stroke, 71.4% (n=70) of patients with transient ischemic attack, and 55.8% (n=24) of patients with hemorrhagic stroke (P<0.001). Myocardial alterations occurred often in all 3 groups (60.9% ischemic stroke [n=353], 59.2% transient ischemic attack [n=58], 44.2% hemorrhagic stroke [n=19]; P=0.396). CONCLUSIONS: Cardiac findings are frequent in patients with cerebrovascular disease, even without prior cardiac problems or suspected cardiac cause. Similarities, especially between patients with ischemic stroke and transient ischemic attack, were observed. Our data suggest that all patients with acute cerebrovascular events should receive thorough workup searching for cardiac manifestations.

Comprehensive Stroke Management: a Guide for Hospitalists.

Stroke is a devastating clinical condition characterized by an acute neurological impairment secondary to cerebrovascular disease. Globally, stroke is the second leading cause of mortality and disability, with prominent risk factors including age, hypertension, hyperlipidemia, atrial fibrillation, diabetes, smoking, preexisting vascular anomalies and obesity. Acute neurological deficits are commonly encountered in the inpatient wards. Heightened clinical suspicion and prompt evaluation involving neurological examination and imaging are crucial for effective management. At many hospitals, hospitalists are tasked with managing stroke patients with consultation from neurologists. The management of stroke is constantly evolving as new and advanced therapies emerge. This review of the literature seeks to summarize current practice in stroke management in hopes it is helpful to those hospitalists who care for this patient population frequently. A search of the literature was performed to summarize current research as well as management and therapeutic strategies.

In vitro evaluation of flow diverter performance using a human fibrinogen-based flow model.

OBJECTIVE: Fibrin deposition represents a key step in aneurysm occlusion, promoting endothelization of implants and connective tissue organization as part of the aneurysm-healing mechanism. In this study, the authors introduce a novel in vitro testing platform for flow diverters based on human fibrinogen. METHODS: A flow diverter was deployed in 4 different glass models. The glass models had the same internal parent artery (4 mm) and aneurysm (8 mm) diameters with varying parent artery angulations (paraophthalmic, sidewall, bifurcation, and slightly curved models). The neck size and area were 4 mm and 25 mm2, respectively. Human fibrinogen (330 mg/dl) was circulated within the glass models at varying flow rates (0, 3, 4, and 5 ml/sec) with or without heparin, calcium chloride, and thrombin for as long as 6 hours or until complete fibrin coverage of the flow diverter's neck was achieved. Aneurysm neck coverage was defined as macroscopic fibrin deposition occluding the flow diverters' pores. Flow characteristics after flow diverter deployment were assessed with computational fluid dynamics analysis. The effects of flow rates, heparin, calcium chloride, and thrombin on fibrin deposition rates were tested using 1-way ANOVA and the Tukey test. RESULTS: A total of 84 replicates were performed. Human fibrin did not accumulate on the flow diverter stents under static conditions. The fibrin deposition rate on the aneurysm neck was significantly greater with the 5 ml/sec flow rate as compared to 3 ml/sec for all models. The paraophthalmic model had the highest inflow velocity of 48.7 cm/sec. The bifurcation model had the highest maximum shear stress (SS) and maximum normalized shear stress values at the device cells at 843.3 dyne/cm2 and 35.1 SS/SSinflow, respectively. The fibrin deposition rates of the paraophthalmic and bifurcation models were significantly higher than those of sidewall and slightly curved models for all additive or flow rate comparisons (p = 0.001 for all comparisons). The incorporation of thrombin significantly increased the fibrin deposition rates across all models (p = 0.001 for all models). CONCLUSIONS: Rates of fibrin deposition varied widely across different configurations and additive conditions in this novel in vitro model system. Fibrin accumulation started at the aneurysm inflow zone where flow velocity and shear stress were the highest. The primary factors influencing fibrin deposition included flow velocities, shear stress, and the addition of thrombin at a physiological concentration. Further research is needed to test the clinical utility of fibrinogen-based models for patient-specific aneurysms.

Risk of stroke development following retinal vein occlusion: A systematic review and meta-analysis.

Retinal vein occlusion (RVO) and cerebrovascular disease share common risk factors and may be independently associated; however, the strength and nature of this association remain unclear. We conducted a systematic review and meta-analysis, informed by studies from PubMed, Scopus, EMBASE, Web of Science, and Google Scholar until January 6, 2024, aimed to clarify this relationship. Eligible studies included cohorts observing stroke incidence in RVO patients for over a year. Pooled effect estimates were calculated using random-effects models, with subgroup analyses evaluating associations between RVO types (central and branch) and stroke subtypes (ischemic and hemorrhagic). Ten cohort studies with a total of 428,650 participants (86,299 RVO patients) were included. Compared to controls, RVO patients exhibited a significantly increased risk of stroke (pooled risk ratio [RR]=1.38, 95 % confidence interval (95 %CI)=1.34-1.41). Subgroup analyses indicated elevated risk for both ischemic (RR=1.37, 95 %CI=1.32-1.42) and hemorrhagic (RR=1.55, 95 %CI=1.08-2.22) strokes in RVO patients. Additionally, both central (RR=1.50, 95 %CI=1.27-1.78) and branch (RR=1.41, 95 %CI=1.32-1.50) RVO were associated with stroke risk. Sensitivity analyses confirmed consistent results across various criteria, and funnel plots indicated no publication bias. RVO significantly increases the risk of both ischemic and hemorrhagic stroke, regardless of RVO type, suggesting a strong independent association between these conditions.

Safety and Outcome of Admission to Step-Down Level of Care in Patients with Low-Risk Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis.

Spontaneous intracerebral hemorrhage (ICH) is the most devastating type of stroke, and it is associated with high morbidity and mortality. Patients with a spontaneous ICH are routinely admitted to an intensive care unit (ICU). However, an ICU is a valuable and limited resource, and not all patients may require this level of care. The authors conducted a systematic review and meta-analysis evaluating the safety and outcome of admission to a step-down level of care or stroke unit (SU) compared to intensive care in adult patients with low-risk spontaneous ICH. PubMed, Embase, and the Cochrane Library were searched for randomized clinical trials and observational cohort studies. The Mantel-Haenszel method or inverse variance, as applicable, was applied to calculate an overall effect estimate for each outcome by combining the specific risk ratio (RR) or standardized mean difference. Risk of bias was analyzed using the Newcastle-Ottawa Scale. The protocol was registered in PROSPERO (CRD42023481915). The primary outcome examined was in-hospital mortality. Secondary outcomes were unfavorable short-term outcome, length of hospital stay, and (re)admission to the ICU. Five retrospective cohort studies involving 1347 patients were included in the qualitative analysis. Two of the studies had severity-matched groups. The definition of low-risk ICH was heterogeneous among the studies. Admission to an SU was associated with a similar rate of mortality compared to admission to an ICU (1.4% vs. 0.6%; RR 1.66; 95% confidence interval [CI] 0.24-11.41; P = 0.61), a similar rate of unfavorable short-term outcome (14.6% vs. 19.2%; RR 0.77; 95% CI 0.43-1.36; P = 0.36), and a significantly shorter mean length of stay (standardized mean difference - 0.87 days; 95% CI - 1.15 to - 0.60; P < 0.01). Risk of bias was low to moderate for each outcome. The available literature suggests that a select subgroup of patients with ICH may be safely admitted to the SU without affecting short-term outcome, potentially saving in-hospital resources and reducing length of stay. Further studies are needed to identify specific and reliable characteristics of this subgroup of patients.

The Spectrum of Cerebral Small Vessel Disease: Emerging Pathophysiologic Constructs and Management Strategies.

Cerebral small vessel disease (CSVD) is a spectrum of disorders that affect small arterioles, venules, cortical and leptomeningeal vessels, perivascular spaces, and the integrity of neurovascular unit, blood brain barrier, and surrounding glia and neurons. CSVD is an important cause of lacunar ischemic stroke and sporadic hemorrhagic stroke, as well as dementia-which will constitute some of the most substantive population and public health challenges over the next century. This article provides an overview of updated pathophysiologic frameworks of CSVD; discusses common and underappreciated clinical and neuroimaging manifestations of CSVD; and reviews emerging genetic risk factors linked to sporadic CSVD.

Advances and Future Trends in the Diagnosis and Management of Intracerebral Hemorrhage.

Spontaneous intracerebral hemorrhage accounts for approximately 10% to 15% of all strokes in the United States and remains one of the deadliest. Of concern is the increasing prevalence, especially in younger populations. This article reviews the following: epidemiology, risk factors, outcomes, imaging findings, medical management, and updates to surgical management.

Sex-Based Differences in Patients With Left Ventricular-Assisted Devices and Strokes.

Background: Sex-based differences in clinical outcomes among patients with stroke related to left ventricular assist devices (LVADs) are not well described. Objectives: In this study, the authors examined differences in clinical characteristics and outcomes in men and women who had a stroke during LVAD hospitalization. Methods: The National Inpatient Sample from 2010 and 2019 was used to identify patients with stroke during LVAD hospitalization. Outcomes of interest include inpatient mortality and clinical complications among men vs women. Weighted logistic regression was used to determine the association of sex and outcomes. Adjustments were made for age and the Elixhauser comorbidity index. Results: In total, 35,820 patients underwent LVAD implantation (77% men), and 6.12% (n = 2,192) of patients experienced stroke. Women who had stroke were younger than men who had stroke (mean age in women was 51 years vs men 59 years, P < 0.001). Men with strokes had a higher burden of comorbidities than women. While there were no differences in the odds of ischemic stroke, women had higher odds of hemorrhagic stroke compared to men (OR: 1.49 [95% CI: 1.02-2.18]). Mortality in patients with LVAD who had stroke was significantly higher than in those without stroke. Between 2010 and 2019, stroke rates significantly increased among men, while the trend remained variable among women. Conclusions: In this national cohort, men had a higher comorbidity burden and had worsening stroke trends over the last decade compared to women. Women had fewer LVAD implants and a higher incidence of hemorrhagic stroke. Understanding the factors that contribute to sex-related outcome disparities among LVAD stroke patients is crucial in addressing these diverging trends.

Early poststroke clinically significant fatigue predicts functional independence: a prospective longitudinal study.

Background: Poststroke fatigue is a prevalent issue among stroke survivors, significantly impeding functional recovery and diminishing their quality of life. Aim: This prospective cohort study aims to investigate the association between poststroke fatigue and the extent of functional recovery in survivors of ischemic and hemorrhagic strokes. Additionally, it seeks to delineate the temporal progression of poststroke fatigue in these two stroke subtypes. Methods: We assessed a cohort of 79 patients recovering from acute ischemic or hemorrhagic strokes. Poststroke fatigue was quantified using the Fatigue Severity Scale (FSS) and the Numeric Rating Scale (NRSfatigue). Patients' condition was evaluated using the National Institute of Health Stroke Scale (NIHSS), and functional independence levels were determined using the Barthel Index for Activities of Daily Living (BIADL) and the Modified Rankin Scale (MRS). Depressive mood and pain were measured using the Beck Depression Inventory (BDI) and the Numeric Rating Scale for pain (NRSpain), respectively. Results: Our primary findings indicate that the early manifestation of clinically significant fatigue (CSF) is predictive of a poorer trajectory in functional independence levels during recovery. Furthermore, we observed differing patterns of fatigue progression between ischemic and hemorrhagic strokes. Fatigue tends to ameliorate over time in hemorrhagic stroke cases, paralleling functional recovery, while it remains stable over time in ischemic stroke cases. Conclusion: Our results underscore the detrimental impact of early poststroke fatigue on long-term outcomes. Furthermore, they highlight the imperative of managing poststroke fatigue, particularly during the subacute phase of stroke recovery.