Prevalence of depression and anxiety symptoms after stroke in young adults: A systematic review and meta-analysis.

BACKGROUND: Young adults with stroke have distinct professional and social roles making them vulnerable to symptoms of post-stroke depression (PSD) and post-stroke anxiety (PSA). Prior reviews have examined the prevalence of anxiety and depression in stroke populations. However, there are a lack of studies that have focused on these conditions in young adults. OBJECTIVE: We performed a systematic review and meta-analysis of observational studies that reported on symptoms of PSD, PSA and comorbid PSD/PSA in young adults aged 18 to 55 years of age. METHODS: MEDLINE, EMBASE, SCOPUS and PsycINFO were searched for studies reporting the prevalence of symptoms of PSD and/or PSA in young adults with stroke from inception until June 23, 2023. We included studies that evaluated depression and/or anxiety symptoms with screening tools or interviews following ischemic or hemorrhagic stroke. Validated methods were employed to evaluate risk of bias. RESULTS: 4748 patients from twenty eligible studies were included. Among them, 2420 were also evaluated for symptoms of PSA while 847 participants were evaluated for both PSD and PSA symptoms. Sixteen studies were included in the random effects meta-analysis for PSD symptoms, with a pooled prevalence of 31 % (95 % CI 24-38 %). Pooled PSA symptom prevalence was 39 % (95 % CI 30-48 %) and comorbid PSD with PSA symptom prevalence was 25 % (95 % CI 12-39 %). Varying definitions of 'young adult', combinations of stroke subtypes, and methods to assess PSD and PSA contributed to high heterogeneity amongst studies. CONCLUSIONS: We identified high heterogeneity in studies investigating the prevalence of symptoms of PSD and PSA in young adults, emphasizing the importance of standardized approaches in future research to gain insight into the outcomes and prognosis of PSD and PSA symptoms following stroke in young adults. Larger longitudinal epidemiological studies as well as studies on tailored interventions are required to address the mental health needs of this important population. FUNDING: None.

Nonaneurysmal perimesencephalic subarachnoid hemorrhage on noncontrast head CT: An accuracy, inter-rater, and intra-rater reliability study.

BACKGROUND AND PURPOSE: To evaluate the reliability and accuracy of nonaneurysmal perimesencephalic subarachnoid hemorrhage (NAPSAH) on Noncontrast Head CT (NCCT) between numerous raters. MATERIALS AND METHODS: 45 NCCT of adult patients with SAH who also had a catheter angiography (CA) were independently evaluated by 48 diverse raters; 45 raters performed a second assessment one month later. For each case, raters were asked: 1) whether they judged the bleeding pattern to be perimesencephalic; 2) whether there was blood anterior to brainstem; 3) complete filling of the anterior interhemispheric fissure (AIF); 4) extension to the lateral part of the sylvian fissure (LSF); 5) frank intraventricular hemorrhage; 6) whether in the hypothetical presence of a negative CT angiogram they would still recommend CA. An automatic NAPSAH diagnosis was also generated by combining responses to questions 2-5. Reliability was estimated using Gwet's AC1 (κG), and the relationship between the NCCT diagnosis of NAPSAH and the recommendation to perform CA using Cramer's V test. Multi-rater accuracy of NCCT in predicting negative CA was explored. RESULTS: Inter-rater reliability for the presence of NAPSAH was moderate (κG = 0.58; 95%CI: 0.47, 0.69), but improved to substantial when automatically generated (κG = 0.70; 95%CI: 0.59, 0.81). The most reliable criteria were the absence of AIF filling (κG = 0.79) and extension to LSF (κG = 0.79). Mean intra-rater reliability was substantial (κG = 0.65). NAPSAH weakly correlated with CA decision (V = 0.50). Mean sensitivity and specificity were 58% (95%CI: 44%, 71%) and 83 % (95%CI: 72 %, 94%), respectively. CONCLUSION: NAPSAH remains a diagnosis of exclusion. The NCCT diagnosis was moderately reliable and its impact on clinical decisions modest.

Perfusion vs non-perfusion computed tomography imaging in the late window of emergent large vessel ischemic stroke: A systematic review and meta-analysis.

BACKGROUND: Guidelines recommend the treatment of emergent large vessel ischemic stroke (ELVIS) patients presenting beyond 6 hours of last known well time with endovascular thrombectomy (EVT) based on perfusion computed tomography (CT) neuroimaging. We compared the outcomes (long-term good clinical outcomes, symptomatic intracranial hemorrhage (sICH), and mortality) of ELVIS patients according to the type of CT neuroimaging they underwent. METHODS: We searched the following databases: Medline, Embase, CENTRAL, and Scopus from January 1, 2015, to June 14, 2023. We included studies of late-presenting ELVIS patients undergoing EVT that had with data for non-perfusion and perfusion CT neuroimaging. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were pooled using a random effects model. RESULTS: We found 7 observational cohorts. Non-perfusion versus perfusion CT was not statistically significantly different for both long-term clinical (n = 3,224; RR: 0.96; 95% CI 0.86 to 1.06; I2 = 18%) and sICH (n = 3,724; RR: 1.08 95% CI 0.60 to 1.94; I2 = 76%). Perfusion CT had less mortality (n = 3874; RR: 1.22; 95% CI 1.07 to 1.40; I2 = 0%). The certainty of these findings is very low because of limitations in the risk of bias, indirectness, and imprecision domains of the Grading of Recommendations, Assessment, Development and Evaluations. CONCLUSION: The use of either non-perfusion or perfusion CT neuroimaging may have little to no effect on long-term clinical outcomes and sICH for late-presenting EVT patients. Perfusion CT neuroimaging may be associated with a reduced the risk of mortality. Evidence uncertainty warrants randomized trial data.

Successful thrombectomy is beneficial in patients with pre-stroke disability: Results from an international multicenter cohort study.

BACKGROUND: Patients with pre-stroke disability, defined as a modified Rankin Scale (mRS) ≥3, were excluded from most trials of endovascular thrombectomy (EVT) for acute stroke. We sought to evaluate the prognostic factors associated with favorable outcome in stroke patients with known disability undergoing EVT, and the impact of successful reperfusion. METHODS: Consecutive acute stroke patients with pre-stroke disability, undergoing EVT, were retrospectively collected between 2016 to 2019 from a Canadian cohort and a multicenter French cohort (Endovascular Treatment in Ischemic Stroke registry-ETIS). Favorable outcome was defined as an mRS equal to pre-stroke mRS. Patients achieving successful reperfusion (defined as a modified Thrombolysis in Cerebral Infarction score of 2b/3) were compared with patients without successful reperfusion to determine if successful EVT was associated with better functional outcomes. RESULTS: Among 6220 patients treated with EVT, 280 (4.5%) patients with a pre-stroke mRS ≥3 were included. Sixty-one patients (21.8%) had a favorable outcome and 146 (52.1%) died at 3 months. Patients with successful reperfusion had a higher proportion of favorable 90-day mRS (27.6% versus 19.6%, p = 0.025) and a lower mortality (48.3% versus 69.6%, p = 0.008) than patients without successful reperfusion. After adjusting for baseline prognostic factors, successful reperfusion defined by TICI ≥2b was associated with favorable functional outcome (OR 3.16 CI95% [1.11-11.5]; p 0.048). CONCLUSION: In patients with pre-stroke disability, successful reperfusion is associated with a greater proportion of favorable outcome and lower mortality.

Neurosurgical research in Southeast Asia: A bibliometric analysis.

OBJECTIVES: Bibliometric analysis can provide insight into the growth, development and dissemination of research in neurosurgery. Little work has been done to examine the role of country-specific characteristics affecting research productivity. We aimed to characterize andcompare the research productivity among SEA countries in terms of bibliometric indicesand determine associations with country-specific factors. METHODS: We performed a systematic search of all articles by authors affiliated with a neurosurgical department in any of the Southeast Asian countries, indexed in 3 databases from inception to June 10, 2020. Bibliometric indices - number of publications, number of citations, average citations per publication, h-index, and the i-10-index - were computed for each country. Correlations between the indices and country-specific characteristics (population size, GDP per capita, percentage of GDP allocation to research and development (R&D), number of neurosurgeons, number of neurosurgeons per capita, and number of collaborations with non-SEA authors) were determined. RESULTS: The number of publications showed an increasing trend up to 2019. Most studies were cohort studies (37%) or case reports or series (37%). Of the country-specific factors analyzed, only percentage of the GDP allocated to R&D was positively correlated with number of publications (p = 0.0004), total citations (p < 0.0001), H-index (p < 0.0001), and i(10)-index (p < 0.0001). Number of collaborations also positively correlated with the same indices. CONCLUSION: Our bibliometric analysis showed increasing contribution by neurosurgeons in the SEA region. Correlational analysis support the view that increased R&D budget allocation and international collaboration can improve neurosurgical research capacity and productivity.

Physical activity level and stroke risk in US population: A matched case-control study of 102,578 individuals.

BACKGROUND: Stroke has been linked to a lack of physical activity; however, the extent of the association between inactive lifestyles and stroke risk has yet to be characterized across large populations. PURPOSE: This study aimed to explore the association between activity-related behaviors and stroke incidence. METHODS: Data from 1999 to 2018 waves of the concurrent cross-sectional National Health and Nutrition Examination Survey (NHANES) were extracted. We analyzed participants characteristics and outcomes for all participants with data on whether they had a stroke or not and assessed how different forms of physical activity affect the incidence of disease. RESULTS: Of the 102,578 individuals included, 3851 had a history of stroke. A range of activity-related behaviors was protective against stroke, including engaging in moderate-intensity work over the last 30 days (OR = 0.8, 95% CI = 0.7-0.9; P = 0.001) and vigorous-intensity work activities over the last 30 days (OR = 0.6, 95% CI = 0.5-0.8; P < 0.001), and muscle-strengthening exercises (OR = 0.6, 95% CI = 0.5-0.8; P < 0.001). Conversely, more than 4 h of daily TV, video, or computer use was positively associated with the likelihood of stroke (OR = 11.7, 95% CI = 2.1-219.2; P = 0.022). CONCLUSION: Different types, frequencies, and intensities of physical activity were associated with reduced stroke incidence, implying that there is an option for everyone. Daily or every other day activities are more critical in reducing stroke than reducing sedentary behavior duration.

Predictive Value of Hematologic Inflammatory Markers in Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND AND OBJECTIVE: Our study aimed to determine the ability of hematologic markers (neutrophil/lymphocyte ratio [NLR], platelet/lymphocyte ratio, and red cell distribution width [RDW]) in predicting delayed cerebral ischemia (DCI), modified Rankin Scale scores, and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: A retrospective observational 6-year review of medical records was conducted to identify all consecutive patients with aSAH admitted to the largest training hospital in the Philippines. Univariable and multivariable regression analyses were performed to determine the association of the biomarkers with the respective outcomes. Receiver operating characteristic curves were used to detect overall predictive accuracy. RESULTS: A total of 222 patients with aSAH were included, of whom 11.71% developed DCI. Most patients with NLR ≥5.9 subsequently died (77 vs. 52%; P = 0.03). DCI was also associated with poor functional outcomes with higher modified Rankin Scale scores (3-6) on discharge (92% vs. 49%; P < 0.01), and longer duration of hospitalization (median, 20 vs. 13 days; P = 0.01). In receiver operating characteristic analyses, the value of RDW was predictive for DCI (area under the curve, 0.70; 95% confidence interval, 0.62-0.79; P < 0.01). The values of NLR (area under the curve, 0.67; 95% CI, 0.59-0.74) potentially predict functional outcome. RDW, NLR, and their combinations were poor discriminators of mortality. CONCLUSIONS: Our study showed that some hematologic parameters analyzed could be of potential value as prognostic biomarkers in patients with aSAH. Hematologic biomarkers are widely available and practical parameters that may be of considerable clinical value in aSAH management, especially in lower-middle-income countries such as the Philippines.

Stroke in Male-to-Female Transgenders: A Systematic Review and Meta-Analysis.

BACKGROUND: The effect of hormonal therapy has been extensively studied in women. However, similar data on male-to-female (MTF) transgenders, another important population that receives hormonal therapy is lacking. Existing studies in MTF transgenders are skewed toward mental health and health-harming behaviors while few have focused on chronic health conditions. Our study aims to review the existing data on stroke in MTF transgenders and perform a quantitative analysis on the frequency of this condition in this special population. METHODS: PubMed, Cochrane, Scopus, Embase, ClinicalTrials.gov, and Web of Science were systematically searched for studies that reported data on the occurrence of cerebrovascular diseases in MTF transgenders. We reported the hormonal regimens, clinical characteristics, and outcomes of stroke in MTF transgenders. A meta-analysis of proportions was performed by the random-effects model to compute for the frequency of cerebrovascular events in MTF transgenders. RESULTS: Fourteen studies were included in the qualitative analysis while five studies were included in the quantitative analysis. A total of 109 MTF transgenders (Mean 14; range 1-53) suffered a cerebrovascular event. Random-effect modeling analysis showed an overall estimated frequency of 2% for cerebrovascular events in transgenders with a moderate degree of heterogeneity (I2 = 62%). CONCLUSION: Hormonal therapy in MTF transgenders may confer cardiovascular risks in this population. However, more population-based studies that include clinical characteristics and outcomes of chronic health diseases in MTF transgenders are warranted. Such studies may be crucial in directing future guidelines on the health care and management of MTF transgenders.

Depression and Anxiety after Stroke in Young Adult Filipinos.

BACKGROUND AND OBJECTIVES: Young adult patients may suffer from poststroke depression (PSD) and anxiety. Few studies have evaluated these important psychiatric conditions that may lead to adverse outcomes in young adults. We aimed to determine the prevalence of PSD and anxiety as well as to identify their predictors in a population of young Filipino adults (18-49 years old). METHODS: We performed a cross-sectional epidemiologic study in the largest tertiary hospital in the Philippines. The study involved the administration of a structured survey tool and review of medical records. The Hospital Anxiety and Depression Score - Pilipino version (HADS-P) was used to screen for anxiety and depression. Multivariable logistic regression analysis was performed to determine significant socio-economic and clinical risk factors of PSD and anxiety. RESULTS: 114 young adult stroke patients were included. The prevalence of depression was 20.2% while that of anxiety was 34.2%. Significant predictors of PSD were the presence of anxiety (OR 1.84; CI 1.05-3.22), lower mRS scores (mRS 3-5 OR 5.52; 95% CI 1.09-8.03) and diabetes (OR 2.09; 95% CI 1.67-6.26). Meanwhile, significant predictors of poststroke anxiety included depression (OR 7.5; 95% CI 5.02-21.94) and dependency (Barthel Index scores 95-100; OR 0.94; 95% CI 0.89-0.99). Relationship status, educational attainment, stroke subtype and location were not found to be significant predictors of PSD and anxiety. CONCLUSION: A significant proportion of young adults suffered from depression and anxiety after stroke. Clinicians should be aware of these psychiatric conditions that influence outcomes and quality of life of young adults with stroke.

Neuroleptic Malignant Syndrome in a Patient With Anti-N-Methyl-D-Aspartate Receptor Encephalitis: Case Report and Review of Related Literature.

INTRODUCTION: Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is a severe but treatable disease that presents with symptoms similar to neuroleptic malignant syndrome (NMS). CASE REPORT: We describe a 28-year old female who initially presented with headaches, behavioral changes, anxiety, lip tremors, and rigidity of extremities. She was prescribed with olanzapine and later manifested with neuroleptic malignant syndrome symptoms such as decrease in sensorium, muscle rigidity, hyperthermia and tachycardia. Further investigation showed presence of bilateral ovarian teratoma and anti-NMDAR antibodies in her serum and cerebrospinal fluid. Symptoms resolved after intravenous high-dose methylprednisolone, bilateral oophoro-cystectomy, and intravenous immunoglobulin administration. Overlapping pathological mechanisms of anti- NMDAR encephalitis and NMS were discussed. Ten patients with anti- NMDAR encephalitis and NMS were noted in a review of literature. Prognosis was favorable and intervention ranged from supportive to methylprednisolone and intravenous immunoglobulin administration, plasma exchange and teratoma resection. CONCLUSION: Anti- NMDAR encephalitis patients are at risk for NMS due to antipsychotic intolerance and other interrelated pathophysiological mechanisms. The overlap between the signs and symptoms of anti-NMDAR encephalitis and NMS poses a diagnostic dilemma and warrants a careful investigation and management.

Cardiocerebral Infarction: A Single Institutional Series.

OBJECTIVES: Cardiocerebral infarction (CCI) is the rare occurrence of acute ischemic stroke (AIS) and acute myocardial infarction (AMI), either at the same time (simultaneous or synchronous) or one after the other (metachronous). The aim of this study is to describe the clinical profile, management and treatment outcomes of patients with CCI. MATERIALS AND METHODS: This is a 3-year cross-sectional study of patients with CCI describing their clinical presentation, management, and outcomes. The primary outcome measures were all-cause mortality and functional outcome measured with the modified Rankin Scale score (mRS) at discharge and at 30 days post-CCI. We also described the frequency of major and minor hemorrhagic events. RESULTS: Out of 1683 AIS patients and 1983 AMI patients admitted during our time period, 29 patients fulfilled the inclusion criteria (mean age 60 ±12, 79% males, median admission NIHSS 16 [range 1-26]). Of these, 20 (69%) had metachronous CCI while 9 (31%) had synchronous CCI. Most of the patients were given antithrombotics and only 14% were given reperfusion therapies. The all-cause mortality is 45% and 69% of which were cardiovascular deaths. Seventeen and 21% of CCI patients had a good functional outcome on discharge and at 30 days from CCI onset respectively. A total of 8 (28%) patients had hemorrhagic events. CONCLUSIONS: We present the largest single institutional series showing the prevalence rate of cardiocerebral infarction to be 0.79% (0.55% for metachronous, 0.25% for synchronous), with patients presenting as moderate-severe acute ischemic strokes and high-risk acute myocardial infarction. These patients have a high mortality rate with a significant proportion having cardiovascular deaths.

Efficacy of aspirin for sporadic vestibular schwannoma: a meta-analysis.

BACKGROUND: Pharmacologic treatment of vestibular schwannomas (VSs) may increase the success of conservative management for small lesions, and offer an alternative to surgery and stereotactic radiotherapy in symptomatic cases in the high-risk population. Agents that have been studied include aspirin (ASA), but the results of the preliminary studies have been conflicting. In this study, we aimed to systematically review the evidence on the effect of ASA intake on tumor growth in patients with VSs. METHODS: Pubmed, Cochrane, Scopus, Embase, ClinicalTrials.gov , and Web of Science were searched for studies comparing VS tumor growth in patients with aspirin intake and those without. Random-effect meta-analysis was used to evaluate the outcomes in terms of linear and/or volumetric tumor growth. RESULTS: Four retrospective cohort studies were included in the meta-analysis. No significant difference was found in tumor growth between VS patients with aspirin intake and those without. This result held true for the analysis of linear tumor growth (OR 1.23; 95% CI 0.49, 3.10), volumetric tumor growth (OR 1.41; 95% CI 0.36, 5.59), and both combined (OR 1.02; 95% CI 0.56, 1.86). CONCLUSIONS: Our meta-analysis suggests that there is insufficient evidence to recommend ASA therapy in patients with VSs. High-quality randomized controlled trials are warranted to determine the efficacy of this drug in reducing VS tumor growth.

Non-Traumatic Intracerebral Hematoma in the Young: Findings from a Tertiary Hospital in the Philippines.

BACKGROUND: There is geographic variability in the clinical profile and outcomes of non-traumatic intracerebral hematoma (ICH) in the young, and data for the Philippines is lacking. We aimed to describe this in a cohort from the Philippines, and identify predictors of mortality. METHODS: We performed a retrospective study of all patients aged 19-49 years with radiographic evidence of non-traumatic ICH admitted in our institution over five years. Data on demographics, risk factors, imaging, etiologies, surgical management, in-hospital mortality, and discharge functional outcomes were collected. Multivariate logistic regression analysis was done to determine factors predictive of mortality. RESULTS: A total of 185 patients were included, which had a mean age of 40.98 years and a male predilection (71.9%). The most common hematoma location was subcortical, but it was lobar for the subgroup of patients aged 19-29 years. Overall, the most common etiology was hypertension (73.0%), especially in patients aged 40-49. Conversely, the incidence of vascular lesions and thrombocytopenia was higher in patients aged 19-29. Surgery was done in 7.0% of patients. The rates of mortality and favorable functional outcome at discharge were 8.7% and 35.1%, respectively. Younger age (p = 0.004), higher NIHSS score on admission (p=0.01), higher capillary blood glucose on admission (p=0.02), and intraventricular extension of hematoma (p = 0.01) predicted mortality. CONCLUSIONS: In the Philippines, the most common etiology of ICH in young patients was hypertension, while aneurysms and AVM's were the most common etiology in the subgroup aged 19 - 29 years. Independent predictors of mortality were identified.

Safety and Clinical Outcome of Good-Grade Aneurysmal Subarachnoid Hemorrhage in Non-Intensive Care Units.

BACKGROUND: While patients with good grade aneurysmal subarachnoid hemorrhage are routinely admitted in intensive care units, critical care capacity in low-middle income countries (LMICs) is limited. In this study, we report the outcomes of good-grade SAH (Hunt and Hess grades I & II) patients admitted in ICU and non-ICU settings at a center in the Philippines and determine if site of care is predictive of outcome. METHODS: We performed a retrospective study of all adults diagnosed with good-grade SAH in a five-year period. Patients were analyzed according to three groups based on site of care: Group A (>50% of length of stay in ICU), Group B (>50% of LOS in non-ICU), and Group C (100% of LOS in non-ICU). The primary outcome measures were in-hospital mortality and mRS score at discharge. The secondary outcome measures were complication rate and LOS. RESULTS: A total of 242 patients was included in the cohort, which had a mean age of 51.16 years and a female predilection (64%). The rates of in-hospital mortality and favorable functional outcome at discharge were 0.82% and 93.8%, respectively, with no difference across groups. Delayed cerebral ischemia and infection were more frequently diagnosed in ICUs (p < 0.001), while rebleeding occurred more commonly in non-ICUs (p = 0.02). The median LOS was significantly longer in patients who developed complications. CONCLUSIONS: Admission of good-grade aneurysmal SAH patients in non-ICU settings did not adversely affect both in-hospital mortality and functional outcome at discharge. Prospective, randomized studies may lead to changes in pattern of ICU utilization which are critical for LMICs.

Endovascular Thrombectomy for Low ASPECTS Large Vessel Occlusion Ischemic Stroke: A Systematic Review and Meta-Analysis.

BACKGROUND: The current American Heart Association guidelines for acute ischemic stroke reserve Grade 1A recommendation for the use of endovascular thrombectomy (EVT) for patients with an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6. OBJECTIVE: We aim to determine the safety and efficacy of EVT for large vessel occlusion ischemic stroke patients with low ASPECTS (5 or less). METHODS: Medline, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched for studies appraising the outcomes of EVT for low ASPECTS ischemic stroke. A meta-analysis of proportions compared the clinical outcomes of patients undergoing EVT and those receiving best medical therapy only. RESULTS: Nine studies (1,196 patients) were included. There was a trend (p = 0.11) toward a higher rate of symptomatic intracranial hemorrhage (sICH) in the EVT group (9.2%; 95% CI 6.1-13.6; I2 53.37%) compared to the medical group (5.5%; 95% CI 3.7-8.1; I2 0%). There was no difference (p = 0.41) in the pooled 90-day mortality of EVT patients (30.7%; 95% CI 21.7-41.5; I2 84.23%) and medical patients (36.6%; 95% CI 26.4-48.1; I2 76.2%). EVT patients had better (p = 0.001) 90-day outcomes, with 27.7% (95% CI 21.8-34.5; I2 62.08%) of patients attaining a modified Rankin Scale of 0-2 compared to only 3.7% (95% CI 2.3-5.9; I2 87.21%) in the medical group. CONCLUSIONS: This meta-analysis demonstrates a trend in higher sICH among low ASPECTS patients undergoing EVT. Despite this, a significant proportion of this subset of patients still achieved good functional outcomes at 90 days. Randomized trials are necessary to substantiate this result as significant bias is inherent in the observational studies included in this review.