Global trends and regional differences in disease burden of stroke among children: a trend analysis based on the global burden of disease study 2019.

BACKGROUND: Stroke is a major cause of acute neurological symptoms in children with significant long-term neurological sequelae. However, data of diseases burden on stroke among children was lack. We aimed to be dedicated to analyze and compare global trends as well as regional and sociodemographic differences in stroke prevalence, incidence, mortality and disability-adjusted life-years (DALYs) among children aged 0 ~ 14 years. METHOD: We obtained data on annual number of incident strokes, prevalent strokes, deaths, and DALYs, age-standardized incidence rates (ASIRs), prevalence rates (ASPRs), mortality rates (ASMRs) and DALY rates (ASDRs) of stroke among individuals aged 14 years and younger during 1990-2019 from the 2019 Global Burden of Disease Study. To quantify the temporal trends, we calculated changes (%) in number, and used joinpoint regression analysis to identify the average annual percentage changes (AAPCs) of age standardized rates. RESULT: Globally, the incident strokes and prevalent strokes increased by 18.51% and 31.97%, respectively, but DALYs due to stroke and deaths due to stroke decreased by 60.18% and 65.03%, respectively, from 1990 to 2019. During the same period, ASIR increased by 0.21% (95%CI: 0.17, 0.24) from 18.02 to 100,000 population in 1990 to 19.11 per 100,000 in 2019; ASPR increased by 0.66% (95%CI: 0.36, 0.96) from 68.88 to 100,000 population in 1990 to 81.35 per 100,000 in 2019; while ASMR (AAPC= -3.94; 95%CI: -4.07, -3.81) and ASDR (AAPC= -3.50; 95%CI: -3.64, -3.36) both decreased. In 2019, the highest age standardized incidence, prevalence, mortality, and DALY rates all occurred in low sociodemographic index (SDI) regions. The greatest increase of age standardized incidence rate (AAPC = 0.21; 95%CI: 0.18, 0.25) and prevalence rate (AAPC = 1.15; 95%CI: 0.34, 1.96) both were in high SDI regions. Eastern Sub-Saharan Africa had the highest ASIR and ASPR in 2019, and Oceania had the highest ASMR and ASDR in 2019 across 21 GBD regions. High-income North America had the largest increase in ASIR (AAPC = 0.63; 95%CI: 0.59, 0.66) and ASPR (AAPC = 1.58; 95%CI: 0.54, 2.63). Against the overall decreasing trend of ASMR, an increasing trend of ASMR was found in Zimbabwe (AAPC = 0.91; 95%CI: 0.44, 1.37) and Botswana (AAPC = 0.74; 95%CI: 0.02, 1.47). CONCLUSION: The overall increasing stroke incidence and prevalence indicated that prevention and management of stroke among younger population should be critical in the future. Despite stroke mortality with falling trend worldwide, specific countries or territories present worrying increase in stroke mortality. Without urgent implementation of effective primary prevention strategies, the stroke burden of children will probably continue to grow across the world, particularly in high-SDI countries.

Automatic cerebral computed tomography venographic imaging based on the prior knowledge of cerebral blood circulation.

BACKGROUND AND PURPOSE: Current clinical computed tomography venographic (cCTV) images present limited cerebral venous profiles. Therefore, this study aimed to develop an automatic cerebral CTV imaging technique using computed tomographic perfusion (CTP) images in a cohort of patients with stroke. MATERIALS AND METHODS: We retrospectively evaluated 10 (intracerebral hemorrhage) and 2 (acute ischemic stroke) patients who underwent institutional CTP imaging. CTV images were processed with the proposed CTV (pCTV) technique, and pCTV and cCTV images were then independently evaluated by two experienced neuroradiologists blinded to all clinical information using a novel scoring method that considered overall image quality, venous visibility, and arterial mis-segmentation. Venous visibility was separately evaluated for the dural sinus, superficial vein, and deep vein. Then, statistical analysis was performed to determine whether the pCTV technique was superior to the cCTV technique. RESULTS: In total, 14 sets of pCTV images were generated and compared with cCTV images. The overall image quality and venous visibility scores of pCTV images were significantly higher than those of cCTV images (all values of p<0.05), especially for the dural sinus (median [25th, 75th percentiles], 14.00 [13.63, 15.50] vs. 7.50 [7.00, 10.88]), and superficial vein (9.00 [8.88, 10.00] vs. 3.25 [1.63, 8.25]), while the difference in arterial mis-segmentation was not statistically significant (p= 0.164). CONCLUSIONS: This study proposed an automatic cerebral CTV imaging technique to eliminate residual bone and soft tissues, minimize the impact of the cerebral arterial system, and present a relatively comprehensive cerebral venous system, which would help physicians assess cerebral venous outflow profiles after stroke and seek imaging markers associated with clinical outcomes.

A case of ischemic stroke with hemorrhagic transformation associated with essential thrombocythemia and JAK-2 V617F mutation.

BACKGROUND: Essential thrombocythemia (ET) is a rare cause of stroke. The V617F mutation in the Janus kinase 2 (JAK2) gene is one of the most typical mutations in ET and has been shown to be a risk factor for stroke, especially in younger people. However, to date, there have been few reports of intracranial thrombotic and hemorrhagic complications in patients with ET. Herein, we present a case of JAK2 gene mutation-associated ET in a patient who developed both ischemic and hemorrhagic stroke, and discuss potential underlying mechanisms. CASE PRESENTATION: A 45-year-old Chinese male presented to our center with gradually developing weakness of the right limbs for 3 months. A computed tomography scan of the brain showed an area of infarction with hemorrhage in the left subcortical and corona radiata regions. High-resolution magnetic resonance imaging revealed a thrombosis on the surface of the atherosclerotic plaque. Digital subtraction angiography revealed an insect bite-like change in the C1 branch of the left internal carotid artery, which caused up to 50% stenosis. Blood tests showed continued elevation of the platelet and white blood cell counts. After consultation with a hematologist, a bone marrow biopsy was performed, which revealed proliferative bone marrow changes with numerous megakaryocytes and proliferative but mature granulocytes. Further genetic testing revealed a positive JAK2-V617F mutation. Therefore, the diagnosis of ET was confirmed according to the World Health Organization (WHO) 2016 diagnostic criteria. Finally, we decided to administer aspirin and hydroxyurea. The patient remained stroke free and the platelet levels were normal throughout the 1-year follow-up period. CONCLUSIONS: JAK2 mutations affect the proliferation and differentiation of blood cells through the JAK, signal transducer and activator of transcription pathway, which leads to changes in platelets and macrophages, and an increase in neutrophil extracellular traps, which may explain the patient's ischemic and hemorrhagic changes. Further investigation of the underlying mechanisms may change the treatment strategy for such patients in the future.

Extracranial carotid plaque hemorrhage predicts ipsilateral stroke recurrence in patients with carotid atherosclerosis - a study based on high-resolution vessel wall imaging MRI.

BACKGROUND: Intraplaque hemorrhage (IPH) is a hallmark of carotid plaque vulnerability. We aim to investigate the association between IPH and recurrent ipsilateral ischemic stroke. METHODS: Patients with a recent stroke or transient ischemic attack (TIA) were prospectively recruited and underwent an ultrasonographic examination and carotid HR VWMRI on the side consistent with symptoms. Carotid plaque was defined as carotid intima-media-thickness (IMT) by ultrasound≥1.5 mm. IPH was determined that the ratio of the plaque signal intensity relative to that of adjacent muscle was > 1.5. All enrolled patients were clinically followed until an ipsilateral ischemic stroke, TIA, carotid endarterectomy (CEA)/carotid artery stenting (CAS), or death within 12 months. Univariate analysis was used to analyze the correlation between clinical characteristics and IPH. Kaplan-Meier survival analysis and a log-rank test were used to compare recurrence-free survival time between the IPH and non-IPH groups. Cox regression models evaluated IPH as the predictor of ipsilateral stroke recurrence. RESULTS: A total of 171 patients (mean age, 60.13 ± 10.04 years; 118 males) were included in the final analysis. Thirty-two patients (18.7%) showed carotid IPH. During the follow-up, patients with carotid IPH suffered 60.9% (14 of 23) of recurrent ipsilateral strokes and 60.0% (3 of 5) TIA. Multivariate Cox regression analysis proved IPH as a strong predictor of ipsilateral stroke; the adjusted hazard ratio (HR) was 6.64 (95% confidence interval [CI], 2.84-15.54, P < 0.001). Meanwhile, Cox regression analysis also proved that IPH could predict recurrent ischemic events; the adjusted HR was 8.08 (95% CI, 3.65-17.91, P < 0.001). CONCLUSIONS: Carotid intraplaque hemorrhage is strongly associated with recurrent ischemic events and could predict recurrent ipsilateral stroke.

Insulin resistance is an independent risk factor for early neurological deterioration in non-diabetic patients with acute ischemic stroke.

BACKGROUND: The role of insulin resistance (IR) in stroke prognosis remains largely unknown. This study aimed to investigate the relationship between IR and the risk of early neurological deterioration (END) in non-diabetic patients with acute ischemic stroke. METHODS: This is a retrospective analysis of non-diabetic patients with acute ischemic stroke enrolled in the prospective multicenter ACROSS-China study. The homeostasis model assessment 2 (HOMA2-IR) was evaluated and the patients were divided into HOMA2-IR quartiles (Q1 0-1.24, Q2 1.25-1.95, Q3 1.96-2.96, Q4 ≥ 2.97). END was defined as an increment in total National Institutes of Health Stroke Scale (NIHSS) of ≥ 2 points or ≥ 4 points on day 14 ± 3 after stroke onset. Logistic regression was performed to explore the relationship between HOMA2-IR and END. RESULTS: Finally, 556 patients were included (63.7 ± 12.9 years, 64.6% male); thirty-three patients developed END. The median HOMA2-IR of all patients was 1.95 (inter-quartile = 1.24-2.96). There were 148, 135, 130, and 143 patients in Q1, Q2, Q3, and Q4, respectively. Compared with Q1, END (NIHSS ≥ 2) risk was increased in Q4: adjusted odds ratio (OR) = 6.051, 95% CI = 1.638-22.354, P = 0.0069. In additon, END (NIHSS ≥ 2) risk was increased in Q4 compared with the Q1-Q3 combined group: adjusted OR = 2.853, 95% CI = 1.308-6.224, P = 0.0084. END (NIHSS ≥ 4) risk was also increased in Q4: adjusted OR = 7.507, 95% CI = 2.357-23.906, P = 0.0006) compared with the Q1-Q3 combined group. CONCLUSION: This study strongly suggests that IR is probably an independent risk factor for END in non-diabetic patients with acute ischemic stroke.

Insulin Resistance and Prognosis of Nondiabetic Patients With Ischemic Stroke: The ACROSS-China Study (Abnormal Glucose Regulation in Patients With Acute Stroke Across China).

BACKGROUND AND PURPOSE: Insulin resistance was common in patients with stroke. This study investigated the association between insulin resistance and outcomes in nondiabetic patients with first-ever acute ischemic stroke. METHODS: Patients with ischemic stroke without history of diabetes mellitus in the ACROSS-China registry (Abnormal Glucose Regulation in Patients With Acute Stroke Across China) were included. Insulin resistance was defined as a homeostatis model assessment-insulin resistance (HOMA-IR) index in the top quartile (Q4). HOMA-IR was calculated as fasting insulin (µU/mL)×fasting glucose (mmol/L)/22.5. Multivariable logistic regression or Cox regression was performed to estimate the association between HOMA-IR and 1-year prognosis (mortality, stroke recurrence, poor functional outcome [modified Rankin scale score 3-6], and dependence [modified Rankin scale score 3-5]). RESULTS: Among the 1245 patients with acute ischemic stroke enrolled in this study, the median HOMA-IR was 1.9 (interquartile range, 1.1-3.1). Patients with insulin resistance were associated with a higher mortality risk than those without (adjusted hazard ratio, 1.68; 95% confidence interval, 1.12-2.53; P=0.01), stroke recurrence (adjusted hazard ratio, 1.57, 95% confidence interval, 1.12-2.19; P=0.008), and poor outcome (adjusted odds ratio, 1.42; 95% confidence interval, 1.03-1.95; P=0.03) but not dependence after adjustment for potential confounders. Higher HOMA-IR quartile categories were associated with a higher risk of 1-year death, stroke recurrence, and poor outcome (P for trend =0.005, 0.005, and 0.001, respectively). CONCLUSIONS: Insulin resistance was associated with an increased risk of death, stroke recurrence, and poor outcome but not dependence in nondiabetic patients with acute ischemic stroke.

Co-existing intracranial and extracranial carotid artery atherosclerotic plaques and recurrent stroke risk: a three-dimensional multicontrast cardiovascular magnetic resonance study.

BACKGROUND: As a systemic disease, atherosclerosis commonly affects intracranial and extracranial carotid arteries simultaneously which is defined as co-existing plaques. Previous studies demonstrated that co-existing atherosclerotic diseases are significantly associated with ischemic cerebrovascular events. The aim of this study was to investigate the characteristics of co-existing intracranial and extracranial carotid atherosclerotic plaques and their relationships with recurrent stroke by using 3D multi-contrast magnetic resonance (MR) vessel wall imaging. METHODS: Patients with recent cerebrovascular symptoms in anterior circulation and at least one carotid plaque were recruited. All patients underwent cardiovascular magnetic resonance (CMR) for brain and intracranial and extracranial arteries. Presence/absence of atherosclerotic plaque at each arterial segment was identified. The maximum wall thickness (Max WT), length, stenosis of each plaque was measured. The presence/absence of calcification, lipid-rich necrotic core (LRNC), and intraplaque hemorrhage (IPH) was assessed. Cerebral old and acute infarcts in anterior circulation were evaluated. RESULTS: Fifty-eight patients (mean age: 58.0 ± 8.5 years old, 34 males) were recruited. Of the 58 patients, co-existing intracranial and extracranial carotid artery plaques were found in 45 patients (77.6%), of which 7 (15.6%) had first time acute stroke and 26 (57.8%) had recurrent stroke. For these 33 patients with stroke, the number of intracranial plaques (OR = 11.26; 95% CI, 1.27-100; p = 0.030) and co-existing intracranial and extracranial carotid artery plaques (OR = 2.42; 95% CI, 1.04-5.64; p = 0.040) was significantly associated with recurrent stroke. After adjusting for traditional risk factors, the number of co-existing plaques was still significantly correlated with recurrent stroke (OR = 3.31; 95% CI, 1.09-10.08; p = 0.035). No correlations were found between recurrent stroke and Max WT, length, stenosis, and compositions of plaques. CONCLUSIONS: Co-existing intracranial and extracranial carotid artery plaques are prevalent in symptomatic patients and the number of co-existing plaques is independently associated with the risk of recurrent stroke.

Safety and efficacy of tight versus loose glycemic control in acute stroke patients: A meta-analysis of randomized controlled trials.

BACKGROUND: Hyperglycemia is associated with worse stroke outcomes, but it is uncertain whether tight glycemic control during the acute stroke period is associated with a better outcome. We conducted a meta-analysis to compare the effect of tight glycemic control versus loose glycemic control in the acute phase of stroke patients. METHODS: A literature search was performed to identify randomized controlled trials comparing the safety and efficacy of tight glycemic control with a relatively loose control of blood glucose of acute stroke (ischemic or hemorrhagic) patients within 24 h after stroke onset. We required that the blood glucose level of the patients should not be lower than 6.11 mmol/L at the time of enrollment, and for the intensive blood glucose control range, we defined the blood glucose level as lower than that of the control group. The primary efficacy outcome measure was deaths from any cause at 90 days. Secondary efficacy outcomes comprised the number of participants with modified Rankin score (mRS). We define mRS scores 0-2 as favorable scores, recurrent stroke, and the National Institute of Health Stroke Scale or the European Stroke Scale scores. We defined the number of participants with hypoglycemia as our primary safety outcome. Subgroup analysis was performed according to age, the variety of interventions, maintained glucose level, and status of hypoglycemia on National Institute of Health Stroke Scale (NIHSS) scores or European Stroke Scale (ESS) scores. RESULTS: Fifteen randomized controlled trials (RCTs) with 2957 participants meeting the including criteria were identified and included in this meta-analysis, although not all included data on every outcome measure. Data on the primary efficacy endpoint, mortality at 90 days, was available in 11 RCTs, a total of 2575 participants. There was no significant difference between the intervention and control groups (odds ratio (OR): 1.00; 95% confidence interval (CI): 0.81-1.23; P = 0.99). For secondary endpoints, there was no difference between intervention and control groups for a mRS from 0 to 2 (OR: 0.96; 95% CI: 0.80-1.15; P = 0.69; data from 9 RCTs available), or recurrent stroke (OR: 1.34; 95% CI: 0.92-1.96; P = 0.13; data from 3 RCTs available). For NIHSS scores or ESS scores, there was a small difference in favor of intensive controls (standardized mean difference: -0.29; 95% CI: -0.54 to -0.04; P = 0.02). There was a marked increase in hypoglycemia with tight control: (OR of 9.46 (95% CI: 4.59-19.50; P < 0.00001; data from 9 RCTs available). CONCLUSION: There was no difference between tight and loose glycemic control on mortality, independence, or recurrent stroke outcome in acute stroke, but an increase in hypoglycemia. There was a small effect improvement on neurological scales, but the relevance of this needs to be confirmed in future adequately powered studies.

A task-driven cerebral angiographic imaging based on CT perfusion.

Introduction: Current clinical computed tomography arteriography (cCTA) and clinical computed tomography venography (cCTV) images often display restricted cerebrovascular profiles, incomplete brain tissue segmentation, and incomplete artery-vein segmentation. Especially for vessels associated with diseases, capturing their complete profiles proves challenging. Methods: In this work, we developed a Task-driven Cerebral Angiographic Imaging (TDCAI) technique using computed tomography perfusion (CTP) images of stroke patients. A evaluation on intracranial hemorrhagic stroke (IHS) and acute ischemic stroke (AIS) cases was performed with CT perfusion imaging. The TDCAI technique processed the CTP images, resulting in supplementary diagnostic images, including CTA, CTV, centerline images of the vessels-of-interest [internal carotid artery (ICA) for AIS patients, Labbé vein for IHS patients], and straightened images of the vessels-of-interest. Results: We conducted a comparison between the obtained CTA/CTV images and the cCTA/cCTV images in terms of overall image quality and visibility of the vessels-of-interest. By constructing a virtual vascular phantom, we extracted its centerline and compared it with the actual centerline to calculate maximum and average deviations. This allowed us to evaluate both the accuracy of the centerline extraction algorithm and its capability to resist the influence of side branches. We assessed whether vascular stenosis and dilatation could be expressed in straightened vessel images, conducting statistical analyses to establish the superiority of TDCAI technique. Discussion: This study proposes a TDCAI technique to eliminate bone and soft tissue interference, effectively segregate the comprehensive cerebral venous and arterial systems, and extract centerlines and straighten the vessels-of-interest, which would aid doctors in assessing the outflow profiles of vessels after a stroke and seeking imaging biomarkers correlated with clinical outcomes.

Prevalence and incidence of stroke among people with HIV.

OBJECTIVE: We aimed to obtain more precise estimates of stroke to address the wide variation of stroke burden among people with HIV (PWH) in different clinical settings. DESIGN: Systematic review and meta-analysis. METHODS: We systematically searched PubMed, EMBASE, and Web of Science for original articles reporting the prevalence and incidence of stroke among PWH up to November 23, 2022. Der Simonian-Laird random effects were used to obtain pooled estimates and 95% confidence intervals (CIs). RESULTS: We included 17 observational studies covering 1 749 003 PWH on estimation of prevalence, and 17 cohort studies covering 249 606 PWH on estimation of incidence. The pooled prevalence of stroke was 1.30% (95% CI: 1.01%, 1.59%) for PWH aged at least 15 years, and 3.98% (95% CI: 2.45%, 5.51%) for PWH aged at least 50 years. The pooled incidence of stroke was 17.86 per 10 000 person-years (95% CI: 15.96, 19.76), meanwhile, the pooled incidence of ischemic stroke (31.50 per 10 000 person-years; 95% CI: 11.11, 51.89) was higher than hemorrhagic stroke (4.43 per 10 000 person-years; 95% CI: 1.95, 6.91) among PWH aged at least 15 years. CONCLUSION: The prevalence of stroke was nearly one per hundred among PWH aged ≥15 years, and reached four per hundred for those aged ≥50 years. The occurrence of stroke is common during HIV progression, particularly ischemic stroke. Therefore, more efforts should be made on implementing policies, strategies, and programs aimed at identifying the risk factors, improving treatment, and facilitating rehabilitation for stroke to reduce the disease burden among PWH.

Stress hyperglycemia is associated with in-hospital mortality in patients with diabetes and acute ischemic stroke.

BACKGROUND AND OBJECTIVE: Stress hyperglycemia may occur in diabetic patients with acute severe cerebrovascular disease, but the results regarding its association with stroke outcomes are conflicting. This study aimed to examine the association between stress-induced hyperglycemia and the occurrence of in-hospital death in patients with diabetes and acute ischemic stroke. RESEARCH DESIGN AND METHODS: All data were from the Chinese Stroke Center Alliance (CSCA) database and were collected between 2016 and 2018 from >300 centers across China. Patients' demographics, clinical presentation, and laboratory data were extracted from the database. The primary endpoint was in-hospital death. The ratio of fasting blood glucose (FBG) to HbA1c was calculated, that is, the stress-induced hyperglycemia ratio (SHR), to determine stress hyperglycemia following acute ischemic stroke. RESULTS: A total of 168,381 patients were included. The mean age was 66.2 ± 10.7, and 77,688 (43.0%) patients were female. The patients were divided into two groups: survivors (n = 167,499) and non-survivors (n = 882), as well as into four groups according to their SHR quartiles (n = 42,090-42,099/quartile). There were 109 (0.26%), 142 (0.34%), 196 (0.47%), and 435 (1.03%) patients who died in the Q1, Q2, Q3, and Q4 quartiles, respectively. Compared with Q1 patients, the death risk was higher in Q4 patients (odds ratio (OR) = 4.02) (adjusted OR = 1.80, 95% confidence interval [CI] = 1.10-2.92, p = 0.018 after adjustment for traditional cardiovascular risk factors). The ROC analyses showed that SHR (AUC = 0.667, 95% CI: 0.647-0.686) had a better predictive value for mortality than that of fasting blood glucose (AUC = 0.633, 95% CI: 0.613-0.652) and HbA1c (AUC = 0.523, 95% CI: 0.504-0.543). CONCLUSIONS: The SHR may serve as an accessory parameter for the prognosis of patients with diabetes after acute ischemic stroke. Hyperglycemia in stroke patients with diabetes mellitus is associated with a higher risk of in-hospital death.

DIRECT-Net: A unified mutual-domain material decomposition network for quantitative dual-energy CT imaging.

PURPOSE: The purpose of this paper is to present an end-to-end deep convolutional neural network to improve the dual-energy CT (DECT) material decomposition performance. METHODS: In this study, we proposes a unified mutual-domain (sinogram domain and CT domain) material decomposition network (DIRECT-Net) for DECT imaging. By design, the DIRECT-Net has immediate access to mutual-domain data, and utilizes stacked convolution neural network layers for noise reduction and material decomposition. The training data are numerically generated following the fundamental DECT imaging physics. Numerical simulation of the XCAT digital phantom, experiments of a biological specimen, a calcium chloride phantom and an iodine solution phantom are carried out to evaluate the performance of DIRECT-Net. Comparisons are performed with different DECT decomposition algorithms. RESULTS: Results demonstrate that the proposed DIRECT-Net can generate water and bone basis images with less artifacts compared to the other decomposition methods. Additionally, the quantification errors of the calcium chloride (75-375 mg/cm3 ) and the iodine (2-20 mg/cm3 ) are less than 4%. CONCLUSIONS: An end-to-end material decomposition network is proposed for quantitative DECT imaging. The qualitative and quantitative results demonstrate that this new DIRECT-Net has promising benefits in improving the DECT image quality.

Feasibility study of three-material decomposition in dual-energy cone-beam CT imaging with deep learning.

Objective.In this work, a dedicated end-to-end deep convolutional neural network, named as Triple-CBCT, is proposed to demonstrate the feasibility of reconstructing three different material distribution volumes from the dual-energy CBCT projection data.Approach.In Triple-CBCT, the features of the sinogram and the CT image are independently extracted and cascaded via a customized domain transform network module. This Triple-CBCT network was trained by numerically synthesized dual-energy CBCT data, and was tested with experimental dual-energy CBCT data of the Iodine-CaCl2solution and pig leg specimen scanned on an in-house benchtop system.Main results.Results show that the information stored in both the sinogram and CT image domains can be used together to improve the decomposition quality of multiple materials (water, iodine, CaCl2or bone) from the dual-energy projections. In addition, both the numerical and experimental results demonstrate that the Triple-CBCT is able to generate high-fidelity dual-energy CBCT basis images.Significance.An innovative end-to-end network that joints the sinogram and CT image domain information is developed to facilitate high quality automatic decomposition from the dual-energy CBCT scans.

Cerebral Hemodynamic Evaluation After Cerebral Recanalization Therapy for Acute Ischemic Stroke.

Cerebral recanalization therapy, either intravenous thrombolysis or mechanical thrombectomy, improves the outcomes in patients with acute ischemic stroke (AIS) by restoring the cerebral perfusion of the ischemic penumbra. Cerebral hemodynamic evaluation after recanalization therapy, can help identify patients with high risks of reperfusion-associated complications. Among the various hemodynamic modalities, magnetic resonance imaging (MRI), computed tomography perfusion, and transcranial Doppler sonography (TCD) are the most commonly used. Poststroke hypoperfusion is associated with infarct expansion, while hyperperfusion, which once was considered the hallmark of successful recanalization, is associated with hemorrhagic transformation. Either the hypo- or the hyperperfusion may result in poor clinical outcomes. Individual blood pressure target based on cerebral hemodynamic evaluation was crucial to improve the prognosis. This review summarizes literature on cerebral hemodynamic evaluation and management after recanalization therapy to guide clinical decision making.

DPP-4 inhibitors promote proliferation and migration of rat brain microvascular endothelial cells under hypoxic/high-glucose conditions, potentially through the SIRT1/HIF-1/VEGF pathway.

BACKGROUND: Vascular disease in diabetes, for example, stroke, presents a significant public health burden. Recently, the dipeptidyl peptidase 4 (DPP-4) inhibitor linagliptin has been found to counteract stroke among diabetic patients, showing great promise in drug repurposing and indication expansion. However, the molecular basis of this protection mechanism remains unknown. METHODS: The expression and localization of DPP-4 in rat brain microvascular endothelial cells (rBMVECs) were assessed with immunofluorescent staining and Western blotting. The effects of DPP-4 inhibitors on cell proliferation and migration of rBMVECs were determined using MTT and transwell assays, separately. The influence of DPP-4 inhibition on the expression of molecular markers (eg, VEGF, eNOS, HIF-1α. SIRT1) was examined at both mRNA and protein levels with qRT-PCR and Western blotting, individually. RESULTS: DPP-4 inhibitors (40 nmol/L linagliptin, 30 µmol/L berberine) offer protection from hypoxia/high glucose induced impairments in the proliferation and migration of rBMVECs. Treatment with DPP-4 inhibitors counteracted the attenuating effects of hypoxic/high-glucose conditions on the expression of VEGF, eNOS, HIF-1α, and SIRT1, which can be completely eliminated by the inhibition of SIRT1 with 1 mmol/L nicotinamide. CONCLUSIONS: The protection of rBMVECs from hypoxia/high-glucose induced impairment by DPP-4 inhibitors may be mediated by the SIRT1/HIF-1α/VEGF pathway.

Correlation of hyperglycemia with mortality after acute ischemic stroke.

BACKGROUND: Hyperglycemia has been considered a predictor of stroke outcomes. In this article we study the correlation between blood glucose levels within the first 24 h after stroke onset and patients' outcomes in mortality and hemorrhagic transformations. METHODS: Ninety-one non-diabetic patients with acute ischemic stroke admitted to a neurological intensive unit were recruited. Their blood glucose was measured twice within 6 h (baseline) and at every hour after stroke onset. Patients were collected into four groups as follows: those in which normoglycemia and no hyperglycemia were observed at either baseline or 24 h; those with baseline hyperglycemia and hyperglycemia only at baseline; those with 24 h hyperglycemia and hyperglycemia only at 24 h after stroke; and those with persistent hyperglycemia and hyperglycemia at both baseline and at 24 h. Endpoints were designated as the patient's death within 30 days and/or hemorrhagic transformation under computerized tomography within the first 7 days after stroke onset. RESULTS: Persistent hyperglycemia was correlated with an increased risk of mortality within 30 days (OR = 24.0; 95% CI = 2.8-199.3) and it was also correlated with hemorrhagic transformation (OR = 13.3; 95% CI = 2.7-66.1). Baseline or delayed hyperglycemia were not correlated with any outcome. CONCLUSIONS: Persistent hyperglycemia was correlated with mortality after acute ischemic stroke.

Intracranial Atherosclerosis Burden and Stroke Recurrence for Symptomatic Intracranial Artery Stenosis (sICAS).

Intracranial atherosclerosis burden is an arising key index for the risk and prognosis for Intracranial Atherosclerosis Stenosis (ICAS). The present study estimated one-year prognosis for patients of symptomatic ICAS with different degrees of intracranial atherosclerosis burden (ICASB) and identified whether the category of multiple and single acute infarction was associated with atherosclerosis burden. A total of 2864 consecutive patients, from 22 hospitals across China, who experienced an acute cerebral ischemia <7 days after onset of symptoms were evaluated. All patients underwent magnetic resonance angiography, and the degree of intracranial stenosis with the ICASB was calculated. The patients were categorized into three groups according to ICASB grading: <4, 4-5 and >5scores. Multivariate Cox proportional hazards regression models were used to estimate the impact of the hazard ratios(HR) of the putative determinants of recurrent stroke in one year. In the groups with ICASB 4-5 and ICASB >5scores recurrent stroke were significantly higher than the other (P<0.0001). On multivariate logistic analysis, ICASB (4-5) indicated more stroke recurrence at 12 months (adjusted hazard ratio, 1.96; 95% confidence interval, 1.08-3.56; P=0.027), compared to the ICASB<4scores and >5 groups (P<0.001). Moreover, proportion of single and multiple infarction lesions differs with different ICASB. Multiple lesions were related with higher of ICASB(P<0.001). Intracranial atherosclerosis burden was associated with recurrent stroke at 12 months. Multiple infarction lesions were associated with higher ICASB score which indicate higher risk of recurrent.

A cohort study of isolated brainstem infarction based on head MR imaging and clinical findings.

OBJECTIVE: The prognosis of patients with isolated brainstem infarction (BSI) differs on an individual patient basis. This study was undertaken to analyze the influences of different imaging and clinical features with the prognosis of patients with BSI. METHODS: The study population was derived from a multicenter study of intracranial atherosclerosis in China. In the present study, 300 patients were selected who had experienced non-cardiogenic brain stem infarction within the prior 7 days. Evaluations included clinical characteristics, location and size of the brainstem infarction, and whether the infarction was located in multiple perforating branches of the brainstem. Poor prognosis was defined as the presence of disability within 1 year from the onset of disease. RESULTS: In total, 281 patients were followed up at 1 year post-infarction. Of these 281 patients, 84 (29.9%) exhibited disability at 1 year; these patients showed a median National Institutes of Health Stroke Scale score of 6 on admission. Multiple logistic regression analysis showed that patients with BSI located in the territory of multiple perforating arteries, who were discharged without administration of statins, showed a poor 1-year prognosis. CONCLUSION: Isolated BSI involving multiple perforating arteries, without statin medication at discharge, indicated poor prognosis for patients with BSI.

Birth weight and type 2 diabetes: A meta-analysis.

The prevalence of T2DM is increasing around the world on a yearly basis. A meta-analysis was conducted to analyze the association between birth weight and incidence of type 2 diabetes mellitus (T2DM). A literature search was performed from January 1990 to June 2016 in PubMed, ScienceDirect, SpringerLink, China National Knowledge Infrastructure and Chinese Biomedical Literature Database. After reviewing characteristics of all the included studies systematically, a meta-analytical method was employed to calculate the pooled odds ratios (ORs) and associated 95% confidence intervals (CI) from random-effects models. Heterogeneity was assessed by Q-statistic test. Funnel plot, Begg's and Egger's linear regression tests were applied to evaluate publication bias. A sensitivity analysis was also performed to assess the robustness of results. According to inclusion and exclusion criteria, 8 studies were selected to be included in the meta-analysis. Compared with normal birth weight (2,500-4,000 g), low birth weight (<2,500 g) was associated with an increased risk of T2DM (OR, 1.55; 95% CI, 1.39-1.73; P<0.001). No significant difference was observed between high birth weight (>4,000 g) and normal birth weight in terms of the risk of T2DM (OR, 0.98; 95% CI, 0.79-1.22). Compared with high birth weight, low birth weight was associated with an increased risk of diabetes mellitus (OR, 1.58; 95% CI, 1.30-1.93; P<0.001). These findings indicated that there may be an inverse linear association between birth weight and T2DM.

Post-Glucose Load Measures of Insulin Resistance and Prognosis of Nondiabetic Patients With Ischemic Stroke.

BACKGROUND: Insulin resistance is associated with an increased risk of cardiovascular events in the general population. This study aimed to estimate the association between post-glucose load measures of insulin resistance and prognosis of nondiabetic patients with ischemic stroke. METHODS AND RESULTS: Data were derived from the ACROSS-China (Abnormal Glucose Regulation in Patients with Acute Stroke across China) registry. Patients with ischemic stroke without a history of diabetes mellitus were included. Two post-glucose load measures of insulin sensitivity, the insulin sensitivity indices ISI(composite) and the ISI0,120, were calculated. Outcomes included stroke recurrence, all-cause death, and poor functional outcome at 12 months. Among 1203 patients, 63.3% were male with an average age of 62.1 years. At 12 months, 168 (14.4%) patients had recurrent stroke, 111 (9.2%) had died, and 288 (24.4%) had poor outcome. After adjustment for potential covariates, the first quartile of the ISI(composite) was associated with increased 12-month stroke recurrence (adjusted hazard ratio 2.02, 95% CI 1.28-3.18, P=0.003), death (adjusted hazard ratio 2.78, 95% CI 1.59-4.86, P<0.001), and poor outcome (adjusted odds ratio 2.67, 95% CI 1.69-4.21, P<0.001) compared with the fourth quartile. Similar results were observed for the ISI0,120 but with a larger magnitude of association. Using a multivariable regression model with restricted cubic spline, we found an L-shaped association between the insulin sensitivity indices and the risk of each end point. CONCLUSIONS: In this large-scale registry, post-glucose load measures of insulin resistance with the ISI(composite) and the ISI0,120 were associated with 12-month poor outcomes of nondiabetic patients with ischemic stroke.