Angiography-based hemodynamic features predict recurrent ischemic events after angioplasty and stenting of intracranial vertebrobasilar atherosclerotic stenosis.

OBJECTIVES: To assess the predictive value of hemodynamic features for stroke relapse in patients with intracranial vertebrobasilar atherosclerotic stenosis treated with percutaneous transluminal angioplasty and stenting (PTAS) using quantitative digital subtraction angiography (q-DSA). METHODS: In this retrospective longitudinal study, patients with intracranial vertebrobasilar atherosclerotic stenosis and who underwent PTAS treatment between January 2012 and May 2020 were enrolled. The q-DSA assessment was performed before and after PTAS. ROIs 1-4 were placed along the vertebral artery, proximal and distal basilar artery, and posterior cerebral artery; ROIs 5-8 were in 5 mm and 10 mm proximal and distal to the lesion, respectively. Relative time to peak (rTTP) was defined as the difference in TTP between ROIs. Cox regression analyses were performed to determine risk factors for recurrent stroke. RESULTS: A total of 137 patients (mean age, 62 years ± 10 [standard deviation], 83.2% males) were included, and 26 (19.0%) patients had stroke relapse during follow-up (median time of 42.6 months [interquartile range, 19.7-60.7]). Preprocedural rTTP4-1 (adjusted hazard ratio (HR) = 2.270; 95% CI 1.371-3.758; p = 0.001) and preprocedural rTTP8-5 (adjusted HR = 0.240; 95% CI 0.088-0.658; p = 0.006) were independently associated with the recurrent stroke. These hemodynamic parameters provided an incremental prognostic value for stroke relapse (AUC, 0.817 [0.704-0.931]; the net reclassification index, 0.431 [0.057-0.625]; and the integrated discrimination index, 0.140 [0.035-0.292]). CONCLUSIONS: In patients with intracranial vertebrobasilar atherosclerosis treated with PTAS, preprocedural prolonged TTP of the target vessel and shortened trans-stenotic TTP difference were associated with stroke relapse. Q-DSA-defined hemodynamic parameters provided incremental predictive value over conventional parameters for stroke recurrence. CLINICAL RELEVANCE STATEMENT: Quantitative DSA analysis enables intuitive observation and semi-quantitative evaluation of peri-therapeutic cerebral blood flow. More importantly, quantitative DSA-defined hemodynamic parameters have the potential for risk stratification of patients with intracranial atherosclerotic stenosis. KEY POINTS: Semi-quantitative angiography-based parameters can reflect pre- and postprocedural subtle changes in blood flow in patients with intracranial atherosclerotic stenosis. Although angioplasty procedures can significantly improve blood flow status, patients with more restricted baseline blood flow still show a higher risk of stroke recurrence. Angiography-based hemodynamic features possess prognostic value and can serve as clinical markers to assess stroke risk of patients with intracranial atherosclerotic stenosis.

The relationship between occlusion patterns and outcomes after thrombectomy in patients with acute internal carotid artery occlusion.

BACKGROUND AND PURPOSES: Ischemic stroke caused by acute internal carotid artery occlusions (AICO) is usually associated with high disability and mortality. We aimed to investigate whether occlusion patterns significantly influence clinical outcome in patients receiving endovascular thrombectomy (EVT). PATIENTS AND METHODS: We performed a retrospective analysis of databases from two comprehensive stroke centers and consecutively investigated patients who had underwent EVT. AICO was defined as acute internal carotid artery occlusions (cervical segment to terminal segment). The clinical characteristics, intervention parameters, and prognosis data were collected. Leptomeningeal collaterals (LMC) were assessed with the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale (ASITN/SIRs), graded on a 5-point scale. The occlusion patterns based on Willisian collaterals were categorized into I-type, L-type, and T-type by contralateral carotid artery injections at digital subtraction angiography. Multivariate regression models were applied to evaluate the relationship between occlusion patterns and the prognosis of patients at 90 days after stroke. RESULTS: A total of 213 patients were included in the study. Of those,142 (66.7%) achieved successful reperfusion and 64 (30.0%) achieved favorable outcomes at 90 days. Overall, 26 (12.2%), 117 (54.9%), and 70 (32.9%) cases respectively suffered from I-type, L-type, and T-type occlusion. In addition, patients with I-type occlusions had a higher percentage of complete LMC compared with L-type or T-type occlusions (88.5% versus 30.8% versus 27.1%, P< 0.0167). In multivariable logistic regression, we found T-type occlusion was no longer an independent predictor of poor functional outcomes in AICO after adjusting LMC (T versus I, OR, 2.555, 95%CI: 0.717-9.103, P = 0.148; L versus I, OR, 0.815, 95%CI: 0.258-2.574, P = 0.727). CONCLUSIONS: For ACIO, occlusion patterns are still a topic that needs attention. Furthermore, compensatory LMC may affect the association between occlusion patterns and functional prognosis in AICO. Occlusion patterns and LMC status distinguish the nature and impact of AICO on expected EVT and subsequent clinical outcomes.

Non-alcoholic fatty liver disease and stroke: A Mendelian randomization study.

BACKGROUND: The association between non-alcoholic fatty liver disease (NAFLD) and the risk of stroke is heterogeneous. Therefore, we aimed to examine any potential causal relationship between these two traits through Mendelian randomization. METHODS: The genetic instruments associated with NAFLD were selected from a large genome-wide association study in individuals of European ancestry (1483 cases and 17,781 controls, replicated in 559 cases and 945 controls). The genetic associations for stroke (40,585 cases and 406,111 controls) and ischemic stroke (34,217 cases and 406,111 controls) were selected from the MEGASTROKE consortium of European ancestry participants. The causal effects on ischemic stroke subtypes, including large artery atherosclerosis (LAA) (4373 cases and 146,392 controls), small vessel occlusion (SVO) (5386 cases and 192,662 controls), and cardioembolic stroke (7193 cases and 204,570 controls), were also analyzed. The inverse variant weighted method was performed to obtain the casual estimates. Heterogeneity and pleiotropy of individual single nucleotide polymorphisms were also tested for the robustness of the results. RESULTS: NAFLD was not associated with stroke (odds ratio [OR] 1.015; 95% confidence interval [CI] 0.996-1.034; p = 0.121) and ischemic stroke (OR 1.017; 95% CI 0.997-1.037; p = 0.092). Regarding ischemic stroke subtypes, there were positive causal inferences on LAA (OR 1.065; 95% CI 1.004-1.129; p = 0.037) and SVO (OR 1.058; 95% CI 1.003-1.116; p = 0.037), while it was not significant for cardioembolic stroke (OR 1.026; 95% CI 0.983-1.071; p = 0.243). CONCLUSION: This study suggests that the potential causal effect of NAFLD on ischemic stroke may be confined to the LAA and SVO subtypes.

Predictors of mortality for acute vertebrobasilar artery occlusion receiving endovascular treatment.

OBJECTIVES: Acute vertebrobasilar artery occlusion (VBAO) is a devastating type of stroke with a high mortality rate. This study aimed to investigate the predictors of 3-month and 1-year mortality in VBAO patients receiving endovascular treatment (EVT). MATERIALS & METHODS: Consecutive acute VBAO patients undergoing EVT between January 2014 and December 2019 were retrospectively analyzed in a prospectively maintained database. Multivariate logistical regression models were used to explore the potential predictors of mortality at 3 months and 1 year, respectively. The discrimination of the final model was assessed with the area under the receiver operating characteristic curve. RESULTS: A total of 100 patients were enrolled in this study (mean age 62 years; 77.0% male). After excluding patients lost to follow-up, the overall mortality rate was 34.3% (34/99) at 3 months and 45.4% (44/97) at 1 year. The Glasgow Coma Scale (GCS) score at 24 h (Odds ratio [OR], 0.676; 95% confidence interval [CI], 0.540-0.846; p = .001) and mechanical ventilation (MV) (OR, 7.356; 95% CI, 2.200-24.593; p = .001) were predictors of 3-month mortality after adjusting for potential confounders in multivariable analysis. Furthermore, the GCS score at 24 h (OR, 0.714; 95% CI, 0.590-0.864; p = .001), intracranial hemorrhage (OR, 7.330; 95% CI, 1.772-30.318; p = .006), and MV (OR, 5.804; 95% CI, 1.841-18.294; p = .003) were independently associated with mortality at 1 year. Sensitivity analyses showed similar results. CONCLUSION: The 24-h GCS score and MV were common predictors of 3-month and 1-year mortality, and ICH was an additional predictor of 1-year mortality.

Increased intracranial hemorrhage of mechanical thrombectomy in acute ischemic stroke patients with atrial fibrillation.

The impact of atrial fibrillation (AF) on outcomes of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is controversial, and with a paucity of evidence base. This study aimed to investigate the potential association between AF and outcomes after MT in AIS patients. A post-hoc analysis of a multi-center prospective clinical trial was conducted. Before and after propensity score matching (PSM), the clinical features were compared between patients with and without AF. Multivariable logistic regression and mediation analyses were performed to assess the relationship between AF and ICH. Of the total 245 patients, 123 patients were included in the AF group. After PSM, the AF group showed more retrieval attempts (P = 0.004), comparable favorable outcome (P = 0.493), and mortality (P = 0.362) at 90 days. Multivariate analysis revealed that AF was significantly associated with increased risk for ICH (OR 2.198; 95%CI 1.099-4.395; P = 0.026). INR and retrieval attempts were found to act as partial mediations. In the subgroup with lower INR, AF still had a significant association with ICH (OR 2.496; 95%CI 1.331-4.679; P = 0.004). In AIS patients undergoing MT, AF was associated with more retrieval attempts and higher risk of any ICH. Of note, the effect of AF on the increased risk of ICH was partly attributable to the adjusted anticoagulation status and more retrieval attempts. It is crucial to elaborately prevent ICH after thrombectomy for stroke patients with AF.

Bridge mechanical thrombectomy may be a better choice for acute large vessel occlusions.

Direct mechanical thrombectomy (DMT) was confirmed non-inferior to bridge mechanical thrombectomy (BMT, MT preceded by intravenous alteplase within 4.5 h after symptom onset) for acute ischemic stroke with large vessel occlusions (AIS-LVO) in mothership patients. However, the noninferiority of DMT in the general population (including drip and ship mode) is controversial, and the impact of thrombolysis on retrieval attempts remains uncertain. This was a post-hoc analysis of a multi-center, prospective enrolled study. Patients were divided into the BMT group and the DMT group. Baseline characteristics and clinical outcomes were compared by using univariate analysis, multivariable analysis, and propensity score matching analysis, respectively. Of all 245 patients enrolled in this study, 79 (32.2%) patients underwent BMT. In the multivariable analysis, the ratio of excellent prognosis (defined as modified Rankin Scale [mRS] score 0-1 at 90 days) was significantly higher in the BMT group compared with the DMT group (odds ratio, 2.731; 95% confidence interval, 1.238-6.023; P = 0.013). The ratio of good prognosis (mRS score 0-2 at 90 days), successful recanalization rate [modified Thrombolysis In Cerebral Ischemia (mTICI) score 2b-3] and mortality rate were similar between the two groups. The excellent prognosis rate was significantly higher in the BMT group after propensity score matching (P = 0.023). BMT was associated with a higher ratio of excellent prognosis (mRS 0-1) and a similar successful recanalization rate without increasing peri-operation complications compared with DMT in AIS-LVO patients. It is prudent to continue BMT until further data is available.

The effect of noise exposure on insulin sensitivity in mice may be mediated by the JNK/IRS1 pathway.

BACKGROUND: Epidemiological studies have suggested that noise exposure may increase the risk of type 2 diabetes mellitus (T2DM), and experimental studies have demonstrated that noise exposure can induce insulin resistance in rodents. The aim of the present study was to explore noise-induced processes underlying impaired insulin sensitivity in mice. METHODS: Male ICR mice were randomly divided into four groups: a control group without noise exposure and three noise groups exposed to white noise at a 95-dB sound pressure level for 4 h/day for 1, 10, or 20 days (N1D, N10D, and N20D, respectively). Systemic insulin sensitivity was evaluated at 1 day, 1 week, and 1 month post-noise exposure (1DPN, 1WPN, and 1MPN) via insulin tolerance tests (ITTs). Several insulin-related processes, including the phosphorylation of Akt, IRS1, and JNK in the animals' skeletal muscles, were examined using standard immunoblots. Biomarkers of inflammation (circulating levels of TNF-α and IL-6) and oxidative stress (SOD and CAT activities and MDA levels in skeletal muscles) were measured via chemical analyses. RESULTS: The data obtained in this study showed the following: (1) The impairment of systemic insulin sensitivity was transient in the N1D group but prolonged in the N10D and N20D groups. (2) Noise exposure led to enhanced JNK phosphorylation and IRS1 serine phosphorylation as well as reduced Akt phosphorylation in skeletal muscles in response to exogenous insulin stimulation. (3) Plasma levels of TNF-α and IL-6, CAT activity, and MDA concentrations in skeletal muscles were elevated after 20 days of noise exposure. CONCLUSIONS: Impaired insulin sensitivity in noise-exposed mice might be mediated by an enhancement of the JNK/IRS1 pathway. Inflammation and oxidative stress might contribute to insulin resistance after chronic noise exposure.

Theta-burst transcranial magnetic stimulation attenuates chronic ischemic demyelination and vascular cognitive impairment in mice.

Vascular cognitive impairment and dementia (VCID) is mainly caused by chronic cerebral hypoperfusion and subsequent white matter lesions. Noninvasive transcranial magnetic stimulation has been utilized in treating various neurological disorders. However, the function of theta-burst transcranial magnetic stimulation on VCID remains to be defined. We utilized 4-week bilateral carotid artery stenosis model of male mice to mimic VCID. Intermittent theta-burst stimulation (iTBS) or consecutive theta-burst stimulation (cTBS) was administered for 14 consecutive days. Through luxol fast blue staining, electron microscopy and immunofluorescence, we found that iTBS, not cTBS, significantly improved demyelination, axonal damage and ß-amyloid deposition, without affecting cerebral blood flow in VCID mice. At cellular levels, iTBS rescued the loss of mature oligodendrocytes, promoted precursor cell differentiation, and inhibited pro-inflammatory activation of astrocytes and microglia. Notably, iTBS attenuated cognitive deterioration in both short-term retention and long-term spatial memory of VCID mice as indicated by serial neurobehavioral tests. To explore the molecular involvement of iTBS, mRNA sequencing was carried out. By real-time PCR and combined RNA fluorescence in situ hybridization with immunofluorescence, iTBS was confirmed to increase Rxrg expression specifically in mature oligodendrocytes. Collectively, iTBS could ameliorate vascular cognitive dysfunction, probably via mitigating white matter lesions and neuroinflammation in the corpus callosum. Rxrg signaling in mature oligodendrocytes, which was increased by iTBS, might be a potential target for VCID treatment.

Study on the Modification of Silty Soil Sites Using Nanosilica and Methylsilicate.

The special particle grading properties of silt lead to the strong water sensitivity and low soil strength of silt sites, many of which are severely damaged and urgently need to be repaired. This article takes the powder soil from a certain burial site area in Xizhu Village, Luoyang as the research object, which is improved by adding nanosilica and potassium methylsilicate. The modified soil is studied through mechanical and waterproof performance tests, and the mechanism of action of the modified material is analyzed through SEM and XRD. The experimental results show that the mechanical properties and waterproof properties of the composite modified soil were improved when the nanosilica content was 2% and the potassium methylsilicate content was 0.5%; the durability of the composite modified soil is improved, making this the optimum ratio. The mechanical properties and water resistance of the silty soil were significantly improved by adding the appropriate amount of nanosilica and potassium methylsilicate. Nanosilica can be evenly dispersed in the soil matrix, absorb a small amount of water to form a gel state, fill the pores in the silt aggregates, and improve soil compactness. In addition, nanosilica aggregates can attach to the surface of the soil particles and extend from the particle surface to the particle edge. By increasing the contact between soil particles and increasing the particle size, the mechanical properties of the modified soil are improved. When potassium methylsilicate solution is added to the soil, it reacts with water and carbon dioxide, decomposes into methylsilicate, and quickly generates a polymethylsiloxane film to cover the surface of soil particles, forming a waterproof film on the surface and thereby improving the waterproof performance of modified soil. Our research results can provide a reference for the restoration and protection of silty and silt-like sites. The next step is to apply the composite modified soil in engineering restoration through field tests in order to study the repairing ability of composite modified soil and its actual protective effects.

Delayed neurological improvement is predictive to long-term clinical outcome on endovascular thrombectomy patients.

OBJECTIVES: This study aims at exploring the 3-month outcome predicting ability of delayed neurological improvement and the cause of delayed neurological improvement. MATERIALS AND METHODS: Early neurological improvement and delayed neurological improvement were calculated to represent the neurological improvements. Good functional outcome was defined as a 90-day modified Rankin Scale score 0-2. We used multivariant logistic regression to explore the influential factors of good functional outcome as well as delayed neurological improvement. We applied net reclassification improvement and integrated discrimination improvement to assess the quantitative improvement of the predictive model. RESULTS: Early neurological improvement was observed in 50 (23%) patients and delayed neurological improvement exhibited in 67 (30%) patients. Early neurological improvement and delayed neurological improvement were both independent predictive factors to good functional outcome. In the basic model (adjusted for age, admission glucose level, baseline National Institute of Health Stroke Scale, and complications and number of retrieval attempts), early neurological improvement and delayed neurological improvement statistically improved the predictive ability (early neurological improvement: net reclassification improvement = 0.34, 95% confidence interval, 95% confidential interval (0.06, 0.69); integrated discrimination improvement = 0.05, p < 0.001; delayed neurological improvement: net reclassification improvement = 0.79, 95% confidential interval (0.47, 1.12); integrated discrimination improvement = 0.14, p < 0.001) delayed neurological improvement could predict clinical outcomes more accurately than early neurological improvement (early neurological improvement vs. delayed neurological improvement: integrated discrimination improvement = 0.09, p < 0.001). Moreover, delayed neurological improvement was affected by hypertension (odds ratio = 0.40, 95% CI (0.18, 0.88), p = 0.02), early neurological improvement (odds ratio = 20.10, 95% confidential interval (8.24, 19.02), p < 0.001), number of retrieval attempts (odds ratio = 0.39, 95% confidential interval (0.24, 0.66), p < 0.001), and complication (odds ratio = 0.25, 95% confidential interval (0.12, 0.54), p < 0.001). CONCLUSIONS: Delayed neurological improvement could predict clinical outcomes more accurately than early neurological improvement. Hypertension, early neurological improvement, numbers of retrieval attempts, and complications were all predicting factors to delayed neurological improvement.

Off-hour effect on time metrics and clinical outcomes in endovascular treatment for large vessel occlusion: A systematic review and meta-analysis.

BACKGROUND: There is an ongoing debate on the off-hour effect on endovascular treatment (EVT) for acute large vessel occlusion (LVO). AIM: This meta-analysis aimed to compare time metrics and clinical outcomes of acute LVO patients who presented/were treated during off-hour with those during working hours. SUMMARY OF REVIEW: Structured searches on the PubMed, Embase, Web of Science, and Cochrane Library databases were conducted through 23 February 2021. The primary outcomes were onset to door (OTD), door to imaging, door to puncture (DTP), puncture to recanalization, procedural time, successful recanalization, symptomatic intracranial hemorrhage (SICH), mortality in hospital, good prognosis (90-day modified Rankin Scale (mRS) score 0-2), and 90-day mortality. The secondary outcomes were imaging to puncture (ITP), onset to puncture (OTP), onset to recanalization (OTR), door to recanalization (DTR) time, mRS 0-2 at discharge, and consecutive 90-day mRS score. The odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) of the outcomes were calculated using random-effect models. Heterogenicity and publication bias were analyzed. Subgroup and sensitivity analyses were conducted as appropriate. Nineteen studies published between 2014 and 2021 with a total of 14,185 patients were eligible for quantitative synthesis. Patients in the off-hour group were significantly younger than those in the on-hour group and with comparable stroke severity and intravenous thrombolysis rate. The off-hour group had longer OTD (WMD [95% CI], 12.83 [1.84-23.82] min), DTP (WMD [95% CI], 11.45 [5.93-16.97] min), ITP (WMD [95% CI], 10.39 [4.61-16.17] min), OTP (WMD [95% CI], 25.30 [13.11-37.50] min), OTR (WMD [95% CI], 25.16 [10.28-40.04] min), and DTR (WMD [95% CI], 18.02 [10.01-26.03] min) time. Significantly lower successful recanalization rate (OR [95% CI], 0.85 [0.76-0.95]; p = 0.004; I2 = 0%) was detected in the off-hour group. No significant difference was noted regarding SICH and prognosis. But a trend toward lower OR of good prognosis was witnessed in the off-hour group (OR [95% CI], 0.92 [0.84-1.01]; p = 0.084; I2 = 0%). CONCLUSIONS: Patients who presented/were treated during off-hour were associated with excessive delays before the initiation of EVT, lower successful reperfusion rate, and a trend toward worse prognosis when compared with working hours. Optimizing the workflows of EVT during off-hour is needed.

Endothelial caveolin-1 regulates cerebral thrombo-inflammation in acute ischemia/reperfusion injury.

BACKGROUND: Thrombo-inflammation is an important checkpoint that orchestrates infarct development in ischemic stroke. However, the underlying mechanism remains largely unknown. Here, we explored the role of endothelial Caveolin-1 (Cav-1) in cerebral thrombo-inflammation. METHODS: The correlation between serum Cav-1 level and clinical outcome was analyzed in acute ischemic stroke patients with successful recanalization. Genetic manipulations by endothelial-specific adeno-associated virus (AAV) and siRNA were applied to investigate the effects of Cav-1 in thrombo-inflammation in a transient middle cerebral artery occlusion (tMCAO) model. Thrombo-inflammation was analyzed by microthrombosis formation, myeloid cell infiltration, and endothelial expression of adhesion molecules as well as inflammatory factors. FINDINGS: Reduced circulating Cav-1, with the potential to predict microembolic signals, was more frequently detected in recanalized stroke patients without early neurological improvement. At 24 h after tMCAO, serum Cav-1 was consistently reduced in mice. Endothelial Cav-1 was decreased in the peri-infarct region. Cav-1-/- endothelium, with prominent barrier disruption, displayed extensive microthrombosis, accompanied by increased myeloid cell inflammatory infiltration after tMCAO. Specific enhanced expression of endothelial Cav-1 by AAV-Tie1-Cav-1 remarkably reduced infarct volume, attenuated vascular hyper-permeability and alleviated thrombo-inflammation in both wild-type and Cav-1-/- tMCAO mice. Transcriptome analysis after tMCAO further designated Rxrg as the most significantly changed molecule resulting from the knockdown of Cav-1. Supplementation of RXR-γ siRNA reversed AAV-Tie1-Cav-1-induced amelioration of thrombo-inflammation without affecting endothelial tight junction. INTERPRETATION: Endothelial Cav-1/RXR-γ may regulate infarct volume and neurological impairment, possibly through selectively controlling thrombo-inflammation coupling, in cerebral ischemia/reperfusion. FUNDING: This work was supported by National Natural Science Foundation of China.

The global prevalence of essential tremor, with emphasis on age and sex: A meta-analysis.

BACKGROUND: Essential tremor (ET) is one of the most common neurological disorders that impairs quality of life and leads to disability and social handicap. It was estimated that approximate 0.9% of people worldwide were affected by ET. The last decade has seen new investigations on the epidemiology of ET, enabling us to provide an up-to-date estimation of ET prevalence, with emphasis on age and sex. METHODS: We searched PubMed, Medline, Embase and Global Health for studies that reported the prevalence of ET in the general population. Potential sources of heterogeneity were examined by age-adjusted meta-regression. The age- and sex-specific prevalence of ET was constructed with a multilevel mixed-effects meta-regression. RESULTS: A total of 29 articles were included in our systematic review and meta-analysis. The prevalence of ET increased dramatically with advancing age, where the prevalence estimate in people aged under 20 years was 0.04% (95% confidence interval [CI] = 0.00-0.29) and that in elderly aged 80 years and above was 2.87% (95% CI = 1.07-7.49). ET was consistently more common in males than in females. In 2020, the overall prevalence of ET in the general population was 0.32% (95% CI = 0.12-0.91), and the prevalence was higher in males (0.36%, 95% CI = 0.14-1.03) than in females (0.28%, 95% CI = 0.11-0.79). In 2020, the number of people affected by ET was 24.91million (95% CI = 9.51-70.92), among whom 56% were males. CONCLUSIONS: This study provides an up-to-date estimation of ET prevalence in the general population throughout the whole life span, with emphasis on age and sex. The adoption of an internationally acknowledged diagnostic strategy is prompted in future epidemiological investigations. PROTOCOL REGISTRATION: PROSPERO (CRD42020203979).

The prevalence of adult attention-deficit hyperactivity disorder: A global systematic review and meta-analysis.

BACKGROUND: Adult attention-deficit hyperactivity disorder (ADHD) has recently attracted much attention, however, an up-to-date estimation on the prevalence of adult ADHD is lacking. In this study, we aimed to assess the global prevalence of adult ADHD in the general population through a systematic review and meta-analysis. METHODS: PubMed, Medline, Embase and PsycINFO were searched to identify relevant articles published from January 2000 onwards. Population-based studies that were conducted in the general adult population and quantified the prevalence of adult ADHD were included. RESULTS: The prevalence of persistent adult ADHD (with a childhood onset) and symptomatic adult ADHD (regardless of a childhood onset) both decreased with advancing age. By adjusting for the global demographic structure in 2020, the prevalence of persistent adult ADHD was 2.58% and that of symptomatic adult ADHD was 6.76%, translating to 139.84 million and 366.33 million affected adults in 2020 globally. CONCLUSIONS: This study provides an up-to-date estimation of the global prevalence of both persistent and symptomatic adult ADHD. A well-defined strategy for diagnosing adult ADHD and large-scale investigations on the epidemiology of adult ADHD are needed.

Trends in Prevalence of Hypertension and Hypertension Phenotypes Among Chinese Children and Adolescents Over Two Decades (1991-2015).

Background: Hypertension is a leading cause of cardiovascular-related morbidity and mortality. Elevated blood pressure (BP) in children is related to long-term adverse health effects. Until recently, few studies have reported the secular trend and associated factors of hypertension phenotypes in Chinese children and adolescents. Methods: From the China Health and Nutrition Survey (CHNS) 1991-2015, a total of 15,143 records of children aged 7-17 years old were included. Following definitions of hypertension from the Chinese Child Blood Pressure References Collaborative Group, we estimated the prevalence of prehypertension, hypertension, stage 1 hypertension, stage 2 hypertension and its phenotypes (ISH, isolated systolic hypertension; IDH, isolated diastolic hypertension; SDH, combined systolic and diastolic hypertension). General estimation equation was used to analyze the trends in the prevalence of hypertension and hypertension phenotypes, and a multivariable logistic regression was constructed to explore the associated factors. Results: During 1991-2015, increasing trends were revealed in BP and hypertension prevalence (P < 0.001) in Chinese children and adolescents. For ISH, IDH and SDH, the age-standardized prevalence increased dramatically from 0.9 to 2.2%, from 6.2 to 14.1%, and from 1.4 to 2.9%, respectively (all P < 0.001). Adolescents aged 13-17 years (OR = 1.76, 95% CI: 1.56-1.97, P < 0.001), general obesity (OR = 2.69, 95% CI: 2.10-3.44, P < 0.001) and central obesity (OR = 1.49, 95% CI: 1.21-1.83, P < 0.001) were positively associated with hypertension, whereas the South region (OR = 0.65, 95% CI: 0.58-0.73, P < 0.001) was a negative factor. Furthermore, body mass index (BMI) and general obesity were linked to the presence of ISH, IDH and SDH. Age, waist circumference (WC) and central obesity were additionally associated with ISH, and sex, age, urban/rural setting, North/South region, WC and central obesity were additionally associated with IDH. Conclusion: BP levels and prevalence of hypertension and phenotypes increased dramatically in Chinese children and adolescents from 1991 to 2015. Regional discrepancy, demographic features, BMI, WC and overweight/obesity status were associated factors of hypertension among youths.

Off-hour effect is not significant in endovascular treatment for anterior circulation large vessel occlusion in a multicentre registry.

BACKGROUND AND PURPOSE: Whether the off-hour effect has an impact on workflow and outcomes of endovascular treatment (EVT) for anterior circulation large vessel occlusion (AC-LVO) remains uncertain. This study aimed to compare the characteristics and outcomes of patients who presented or were treated during off-hour versus on-hour in a multi-center registry. METHODS: AC-LVO patients from 21 centres were categorised into the off-hour group and the on-hour group. Off-hour (weekends, holidays, and 18:00-7:59 on weekdays) and on-hour (8:00-17:59 on weekdays except for holidays) were defined according to arrival and groin-puncture time points, respectively. Subgroup comparisons between patients both arrived and treated during off-hour (true off-hour) and on-hour (true on-hour) were performed. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Secondary outcomes included favourable outcome (mRS 0-2 at 90 days), EVT-related time metrics, and other clinical outcomes. Ordinary and binary logistic regression and linear regression were taken to adjust for confounding factors. RESULTS: Of all 698 patients enrolled, 435 (62.3%) and 456 (65.3%) patients were categorised into the off-hour arrival and off-hour puncture group, respectively. Shorter onset to door time (adjusted ß coefficient: -21.56; 95% CI -39.96 to -3.16; p=0.022) was noted in the off-hour arrival group. Ordinal and dichotomous mRS scores at 90 days were comparable between the off-hour group and the on-hour group regardless of off-hour definitions. Other time metrics and outcomes were comparable between the two groups. Of 595 patients both presented and were treated during off-hour or on-hour, 394 patients were categorised into the true off-hour group and 201 into the true on-hour group. Time metrics and clinical outcomes were similar between the true off-hour and the true on-hour group. CONCLUSIONS: The off-hour effect was not significant regarding clinical outcomes and in-hospital workflow in AC-LVO patients receiving EVT in this Chinese multicentre registry.

Trends in the prevalence of hypertension according to severity and phenotype in Chinese adults over two decades (1991-2015).

Until recently, few studies have reported the secular trend and associated factors of hypertension severities and phenotypes in China. In this study, the authors aimed to assess the trend in the prevalence of hypertension according to severity and phenotype in Chinese adults from 1991 to 2015 and to explore potential cardiometabolic factors. From the China Health and Nutrition Survey (CHNS), the authors included 164 682 records of adults (≥18 years). The prevalence of hypertension by severity (stage 1 and stage 2 hypertension) and by phenotype (isolated systolic hypertension [ISH], isolated diastolic hypertension [IDH], and systolic-diastolic hypertension [SDH]), during 1991-2015 was explored. The potential effects of demographic, socioeconomic, geographic, and cardiometabolic factors on hypertension severities and phenotypes were assessed by multivariable logistic regression. During 1991-2015, the overall prevalence of hypertension increased dramatically from 15.7% to 23.3%. For stage 1 and stage 2 hypertension, the age-standardized prevalence increased from 10.1% to 15.6% and from 5.5% to 7.4%, respectively. For ISH and SDH, the age-standardized prevalence rates rose from 3.6% to 6.4% and from 6.9% to 10.4%, respectively. Advanced age and medium/high urbanization were positively associated factors, whereas females, higher educational attainments, and residing in Southern China were negatively associated factors. Additionally, general obesity, central obesity, diabetes, and elevated triglyceride levels were linked to ISH, IDH, and SDH. The present study documents an increasing trend in the prevalence of hypertension, including different severities and phenotypes, among Chinese adults over more than two decades. Efforts for the prevention and management of hypertension are in urgent need in China.

Prognostic Value of Abnormal Liver Function Tests After Mechanical Thrombectomy for Acute Ischemic Stroke.

Objective: To determine the clinical significance of post-procedural abnormal liver function test (ALFT) on the functional outcomes at 90 days in acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT). Methods: In this retrospective observational study, patients with AIS undergoing MT were enrolled from the Nanjing Stroke Registry Program and the multicenter Captor trial. A favorable outcome was defined as a modified Rankin Scale score 0-2 at 90 days. Predictive models were established by multivariable logistic regression. Improved predictive value of models was assessed by continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI). In addition, multivariable logistic regression and restricted cubic spline were used to analyze dose-response correlations between the severity of ALFT and prognosis. Results: Among 420 patients enrolled, 234 (55.7%) patients were diagnosed as post-procedural ALFT after MT. Patients with post-procedural ALFT had higher National Institute of Health Stroke Scale score on admission (median, 18 vs. 15, p < 0.001) and more pneumonia (65.4 vs. 38.2%, p < 0.001) than those without post-procedural ALFT. Post-procedural ALFT, rather than preprocedural ALFT, was independently associated with favorable outcome (adjusted odds ratio, 0.48; 95% CI 0.28-0.81; p = 0.006). The improvement of predictive model after adding post-procedural ALFT was significant [continuous NRI (value, 0.401; p < 0.001), IDI (value, 0.013; p < 0.001)]. However, the restricted cubic spline indicated no evidence of a dose-response relationship between the severity of post-procedural ALFT and prognosis. Conclusions: In AIS patients treated by MT, post-procedural ALFT was associated with more severe stroke and served as an independent predictor of worse prognosis at 90 days.

A Score of Low-Grade Inflammation for Predicting Stroke Recurrence in Patients with Ischemic Stroke.

BACKGROUND AND PURPOSE: The impact of low-grade inflammation (LGI) on stroke recurrence has not been well studied yet. We aimed to evaluate the association between LGI and stroke recurrence in patients with ischemic stroke. METHODS: Patients with first-ever ischemic stroke diagnosed within 72 hours of symptoms onset were consecutively recruited from the Nanjing Stroke Registry Program. C-reactive protein (CRP) level, white blood cell (WBC) count, platelet (PLT) count, and neutrophil-to-lymphocyte ratio (NLR) were conceived as low-grade inflammation biomarkers and combined into a standardized LGI score. The association of LGI score with the risk of stroke recurrence was analyzed with multivariate Cox regression models. Analyses accounting for the competing risk of stroke recurrence and death were also performed. RESULTS: Of the 1214 patients studied (median age, 61 years; male, 71.6%), 177 (14.6%) patients experienced a recurrent stroke with a median follow-up of 23.0 (interquartile ranges, 14.5-34.0) months. Patients with stroke recurrence had a higher LGI score (median, 3 versus -2; P < 0.001) than those without recurrence. The univariate analysis indicated that patients with LGI scores in the fourth quartile were more likely to have a stroke recurrence (hazard ratios [HR], 4.312; 95% confidence interval [CI], 2.675-6.952; P < 0.001). After adjusting for potential confounders, the association remained significant in the multivariate Cox regression model (HR, 4.080; 95% CI, 2.420-6.879; P < 0.001). Competing risks model and sensitivity analysis further confirmed this conclusion. CONCLUSION: This study showed that an elevated LGI score was associated with a higher risk of stroke recurrence, independent of other vascular risk factors.

A Pre-Interventional Scale to Predict in situ Atherosclerotic Thrombosis in Acute Vertebrobasilar Artery Occlusion Patients.

Background and Purpose: Determining the occlusion mechanism before endovascular treatment (EVT) is of great significance for acute large vessel occlusion patients. We aimed to develop and validate a simple pre-EVT scale with readily available variables for predicting in situ atherosclerotic thrombosis (ISAT) in acute vertebrobasilar artery occlusion (VBAO) patients. Materials and Methods: Consecutive patients were retrieved from Nanjing Stroke Registry Program between January 2014 and December 2019 as a derivation cohort. Anonymous data of consecutive patients between January 2014 and December 2019 were collected from another comprehensive stroke center as an external validation cohort. Demographics, medical histories, and clinical characteristics were collected. ISAT was defined according to the following criteria: (a) detection of moderate to severe (≥50%) stenosis or stenosis with significant distal flow impairment at the occluded segment when successful reperfusion was achieved; (b) transient visualization of eccentric plaque contour or a recurrent re-occlusion tendency when reperfusion was unsuccessful. Logistic regression was taken to develop a predictive scale. The performance of the scale was assessed by area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow test. Results: ISAT was observed in 41 of 95 (43.2%) patients included in the derivation cohort. The ISAT predictive scale consisted of three pre-interventional predictors, including the history of hypertension, atrial fibrillation rhythm, and baseline serum glucose level ≥7.55 mmol/L. The model depicted acceptable calibration (Hosmer-Lemeshow test, P = 0.554) and good discrimination (AUC, 0.853; 95% confidence interval, 0.775-0.930). The optimal cutoff value of the ISAT scale was 1 point with 95.1% sensitivity, 64.8% specificity, and 77.9% accuracy. In the validation cohort, the discrimination ability was still promising with an AUC value of 0.800 (0.682-0.918). Conclusion: The three-item scale comprised of the history of hypertension, atrial fibrillation rhythm, and dichotomous serum glucose level had a promising predictive value for ISAT before EVT in acute VBAO patients.