Global synergistic actions to improve brain health for human development.

The global burden of neurological disorders is substantial and increasing, especially in low-resource settings. The current increased global interest in brain health and its impact on population wellbeing and economic growth, highlighted in the World Health Organization's new Intersectoral Global Action Plan on Epilepsy and other Neurological Disorders 2022-2031, presents an opportunity to rethink the delivery of neurological services. In this Perspective, we highlight the global burden of neurological disorders and propose pragmatic solutions to enhance neurological health, with an emphasis on building global synergies and fostering a 'neurological revolution' across four key pillars - surveillance, prevention, acute care and rehabilitation - termed the neurological quadrangle. Innovative strategies for achieving this transformation include the recognition and promotion of holistic, spiritual and planetary health. These strategies can be deployed through co-design and co-implementation to create equitable and inclusive access to services for the promotion, protection and recovery of neurological health in all human populations across the life course.

Safety and Outcomes of Intravenous tPA in Acute Ischemic Stroke Patients With Prior Stroke Within 3 Months: Findings From Get With The Guidelines-Stroke.

Background Guidelines recommend against the use of intravenous tPA (tissue-type plasminogen activator; IV tPA) in acute ischemic stroke patients with prior ischemic stroke within 3 months. However, there are limited data on the safety of IV tPA in this population. Methods and Results A retrospective observational study of patients ≥66 years of age linked to Medicare claims and treated with IV tPA at Get With The Guidelines-Stroke hospitals (February 2009 to December 2015). We identified 293 patients treated with IV tPA who had a prior ischemic stroke within 3 months and 30 655 with no history of stroke. Patients with prior stroke had a higher stroke severity (median National Institutes of Health Stroke Scale, 11 [6-19] versus 11 [6-18]; absolute standardized difference, 11.2%) and a higher prevalence of cardiovascular comorbidities. Patients with prior stroke had a higher unadjusted risk for symptomatic intracranial hemorrhage (7.7% versus 4.8%) and in-hospital mortality (12.6% versus 8.9%), but these differences were not statistically significant after adjustment. When stratified by prespecified time epochs, the elevated risk for symptomatic intracranial hemorrhage was seen only within the first 14 days (16.3% versus 4.8%; adjusted odds ratio [aOR], 3.7 [95% CI, 1.62-8.43]) but not in other epochs (2.1% versus 4.8%; aOR, 0.38 [95% CI, 0.05-2.79] for 15-30 days and 7.4% versus 4.8%; aOR, 1.36 [95% CI, 0.77-2.40] for 31-90 days). In addition, patients with prior stroke were significantly more likely to have a combined outcome of in-hospital mortality or discharge to hospice (25.9% versus 17.0%; aOR, 1.70 [95% CI, 1.21-2.38]), less likely to be discharged to home (28.3% versus 32.3%; aOR, 0.72 [95% CI, 0.54-0.98]), or to have good functional outcomes at discharge (modified Rankin Scale, 0-1; 11.3% versus 20.0%; aOR, 0.46 [95% CI, 0.24-0.89]). Conclusions Stroke providers need to continue to be vigilant about the safety of IV tPA in patients with prior stroke, particularly those with an event in the previous 14 days.

Gaps in Guidelines for the Management of Diabetes in Low- and Middle-Income Versus High-Income Countries-A Systematic Review.

OBJECTIVE: The extent to which diabetes (DM) practice guidelines, often based on evidence from high-income countries (HIC), can be implemented to improve outcomes in low- and middle-income countries (LMIC) is a critical challenge. We carried out a systematic review to compare type 2 DM guidelines in individual LMIC versus HIC over the past decade to identify aspects that could be improved to facilitate implementation. RESEARCH DESIGN AND METHODS: Eligible guidelines were sought from online databases and websites of diabetes associations and ministries of health. Type 2 DM guidelines published between 2006 and 2016 with accessible full publications were included. Each of the 54 eligible guidelines was assessed for compliance with the Institute of Medicine (IOM) standards, coverage of the cardiovascular quadrangle (epidemiologic surveillance, prevention, acute care, and rehabilitation), translatability, and its target audiences. RESULTS: Most LMIC guidelines were inadequate in terms of applicability, clarity, and dissemination plan as well as socioeconomic and ethical-legal contextualization. LMIC guidelines targeted mainly health care providers, with only a few including patients (7%), payers (11%), and policy makers (18%) as their target audiences. Compared with HIC guidelines, the spectrum of DM clinical care addressed by LMIC guidelines was narrow. Most guidelines from the LMIC complied with less than half of the IOM standards, with 12% of the LMIC guidelines satisfying at least four IOM criteria as opposed to 60% of the HIC guidelines (P < 0.001). CONCLUSIONS: A new approach to the contextualization, content development, and delivery of LMIC guidelines is needed to improve outcomes.

Racial/Ethnic differences in poststroke rehabilitation outcomes.

Background. Significant racial and ethnic disparities in stroke incidence, severity, and morbidity have been consistently reported; however, less is known about potential differences in poststroke rehabilitation outcomes. Objective. To examine racial and ethnic differences in poststroke rehabilitation outcomes. Methods. We completed an in-depth search of Medline and several major journals dedicated to publishing research articles on stroke, rehabilitation, and racial-ethnic patterns of disease over a 10-year period (2003-2012). We identified studies that reported rehabilitation outcomes and the race or ethnicity of at least two groups. Results. 17 studies involving 429,108 stroke survivors met inclusion criteria for the review. The majority (94%) of studies examined outcomes between Blacks and Whites. Of those studies examining outcomes between Blacks and Whites, 59% showed that Blacks were generally less likely to achieve equivalent functional improvement following rehabilitation. Blacks were more likely to experience lower FIM gain or change scores (range: 1-60%) and more likely to have lower efficiency scores (range: 5-16%) than Whites. Conclusions. Black stroke survivors appear to generally achieve poorer functional outcomes than White stroke survivors. Future studies are warranted to evaluate the precise magnitude of these differences, whether they go beyond chance, and the underlying contributory mechanisms.

Persistent racial disparity in stroke hospitalization and economic impact in young adults in the buckle of stroke belt.

BACKGROUND AND PURPOSE: Mounting evidence points to a decline in stroke incidence. However, little is known about recent patterns of stroke hospitalization within the buckle of the stroke belt. This study aims to investigate the age- and race-specific secular trends in stroke hospitalization rates, inpatient stroke mortality rates, and related hospitalization charges during the past decade in South Carolina. METHODS: Patients from 2001 to 2010 were identified from the State Inpatient Hospital Discharge Database with a primary discharge diagnosis of stroke (International Classification of Diseases, Ninth Revision codes: 430-434, 436, 437.1). Age- and race-stroke-specific hospitalization rates, hospital charges, charges associated with racial disparity, and 30-day stroke mortality rates were compared between blacks and whites. RESULTS: Of the 84,179 stroke hospitalizations, 31,137 (37.0%) were from patients aged<65 years and 29,846 (35.5%) were blacks. Stroke hospitalization rates decreased in the older population (aged≥65 years) for both blacks and whites (P<0.001) but increased among the younger group (aged<65 years; P=0.004); however, this increase was mainly driven by a 17.3% rise among blacks (P=0.001), with no difference seen among whites (P=0.84). Of hospital charges totaling $2.77 billion, $453.2 million (16.4%) are associated with racial disparity (79.6% from patients aged<65 years). Thirty-day stroke mortality rates decreased in all age-race-stroke-specific groups (P<0.001). CONCLUSIONS: The stroke hospitalization rate increased in the young blacks only, which results in a severe and persistent racial disparity. It highlights the urgent need for a racial disparity reduction in the younger population to alleviate the healthcare burden.

Cost-Minimization Analysis of Computed Tomography versus Magnetic Resonance Imaging in the Evaluation of Patients with Transient Ischemic Attacks at a Large Academic Center.

BACKGROUND: The type of neuroimaging for the evaluation of transient ischemic attack (TIA) is debatable. Many patients undergo head computed tomography (CT) with or without CT angiogram (CTA) while being at the emergency department (ED) and later magnetic resonance imaging (MRI) with MR angiogram (MRA) during admission. We hypothesized that evaluation with only one imaging modality (CT/CTA or MRI/MRA) is sufficient to formulate a treatment plan. We looked for the most cost-effective way to evaluate TIA patients. METHODS: We performed a retrospective chart review of 82 patients with TIA. All patients had completely resolved neurological deficit at the time of their evaluation in the ED. We divided the patients into two groups. In group 1, the evaluation included CT with CTA of the head and neck. In group 2, the evaluation included brain MRI with MRA or CTA of the head and neck. We compared these two groups for clinical characteristics and etiological evaluations of stroke/TIA. The outcomes were measured by the number of therapeutic adjustments for the prevention of another ischemic stroke/TIA at the time of discharge from the hospital and revascularization procedures. We counted the following as therapeutic adjustment: (1) antiplatelet therapy was started de novo; (2) anticoagulation was started; (3) arterial revascularization procedure was performed, and (4) one antiplatelet agent was substituted for another. We performed a cost-effectiveness analysis if the outcomes of the two groups were different and a cost-minimization analysis if there was no difference in the outcomes. All cost calculations were made based on Medicare CPT codes. RESULTS: Group 1 included 23 patients and group 2 59 patients. The patients in both groups had similar demographic and clinical characteristics. There was no difference in other etiological evaluations in groups 1 and 2. All patients underwent head CT as the first tool of evaluation whether MRI was done later or not. Therapeutic adjustments and revascularization procedures did not differ between the two groups. All head CTs showed no acute changes. MRI showed small ischemic infarcts in 44% of the patients in group 2. The average per-patient cost of neuroimaging with CT/CTA was USD 1,460.00, with CT and MRI/MRA USD 1,569 and with CT/CTA and brain MRI USD 2,090.00 (p < 0.01). CONCLUSION: Either MRI/MRA or CT/CTA might be sufficient for the evaluation of patients with TIA or small asymptomatic strokes. If head CT at the ED is bypassed, a brain MRI with MRA of the head and neck would be the most informative tool at the lowest cost. Prospective studies with larger numbers of patients are needed for a better understanding of the safety and cost of imaging tools used for patients with TIA.

Stroke assessment with diffusional kurtosis imaging.

BACKGROUND AND PURPOSE: Despite being the gold standard technique for stroke assessment, conventional diffusion MRI provides only partial information about tissue microstructure. Diffusional kurtosis imaging is an advanced diffusion MRI method that yields, in addition to conventional diffusion information, the diffusional kurtosis, which may help improve characterization of tissue microstructure. In particular, this additional information permits the description of white matter (WM) in terms of WM-specific diffusion metrics. The goal of this study is to elucidate possible biophysical mechanisms underlying ischemia using these new WM metrics. METHODS: We performed a retrospective review of clinical and diffusional kurtosis imaging data of 44 patients with acute/subacute ischemic stroke. Patients with a history of brain neoplasm or intracranial hemorrhages were excluded from this study. Region of interest analysis was performed to measure percent change of diffusion metrics in ischemic WM lesions compared with the contralateral hemisphere. RESULTS: Kurtosis maps exhibit distinct ischemic lesion heterogeneity that is not apparent on apparent diffusion coefficient maps. Kurtosis metrics also have significantly higher absolute percent change than complementary conventional diffusion metrics. Our WM metrics reveal an increase in axonal density and a larger decrease in the intra-axonal (Da) compared with extra-axonal diffusion microenvironment of the ischemic WM lesion. CONCLUSIONS: The well-known decrease in the apparent diffusion coefficient of WM after ischemia is found to be mainly driven by a significant drop in the intra-axonal diffusion microenvironment. Our results suggest that ischemia preferentially alters intra-axonal environment, consistent with a proposed mechanism of focal enlargement of axons known as axonal swelling or beading.

Influence of age on racial disparities in stroke admission rates, hospital charges, and outcomes in South Carolina.

BACKGROUND AND PURPOSE: Racial disparities among US stroke patients have been well documented. However, the extent to which disparities in outcomes vary by age is unclear. This study's goals were to examine the degree of racial disparities in South Carolina between African Americans (AAs) and Caucasian Americans (CAs) in stroke admission rates, hospital charges, and outcomes and to determine whether racial differences varied by age. METHODS: From the state hospital discharge database, admissions with a primary diagnosis of stroke discharged from 2002 to 2006 were identified. Age group-specific stroke admission rates, hospital charges, length of stay, intensive care unit utilization, medical complications, and discharge disposition (in-hospital death, discharged home, discharge to rehabilitation facility) were compared between AAs and CAs by multiple-linear or logistic-regression analysis. RESULTS: There were 58 272 stroke admissions during the 5-year period. Stroke admission rates were persistently higher for AAs in all age groups except those > or =85 years old. Hospital charges totaled $1.51 billion; 24.0% ($362.5 million) of this total was attributable to racial disparities, 70.8% ($256.5 million) of which stemmed from the 36.6% of patients <65 years old. Most of the acute outcomes were poorer for AAs compared with CAs across age groups. CONCLUSIONS: Racial disparities in stroke admissions are more pronounced in younger age groups and result in significant economic consequences. Although AA stroke patients experienced generally worse acute outcomes than did CAs, these differences appear to be relatively consistent across age groups.