Air pollution and surrounding greenness in relation to ischemic stroke: A population-based cohort study.

BACKGROUND: Evidence for the association between environmental exposures and ischemic stroke (IS) is limited and inconsistent. We aimed to assess the relationship between exposure to air pollutants, residential surrounding greenness, and incident IS, and to identify population subgroups particularly sensitive to these exposures. METHODS: We used data from administrative health registries of the public healthcare system in Catalonia, Spain to construct a cohort of individuals aged 18 years and older without a previous stroke diagnosis at 1st January 2016 (n = 3 521 274). We collected data on sociodemographic characteristics and cerebrovascular risk factors, and derived exposure at the participant's residence to ambient levels of fine particulate matter (PM2.5), black carbon (BC), nitrogen dioxide (NO2), and Normalized Difference Vegetation Index (NDVI) in a 300 m buffer as an indicator of greenness. The primary outcome was IS diagnosis at any point during the follow-up. We used Cox proportional hazards models to estimate associations between environmental exposures and incident IS and stratified analyses to investigate effect modification. RESULTS: Between 1st January 2016 and 31st December 2017, 10 865 individuals were admitted to public hospitals with an IS diagnosis. Median exposure levels were: 17 µg/m3 PM2.5, 35 µg/m3 NO2, 2.28 µg/m3 BC and 0.27 NDVI. Individuals with higher residential exposure to air pollution were at greater risk of IS: HR 1·04 (95% CI:0·99-1·10) per 5 µg/m3 of PM2.5; HR 1.05 (95% CI:1·00-1·10) per 1 µg/m3 of BC; HR 1·04 (95% CI:1·03-1·06) per 10 µg/m3 of NO2. Conversely, individuals with higher residential surrounding green space, had lower risk of IS (HR 0·84; CI 95%:0·7-1.0). There was no evidence of effect modification by individual characteristics. CONCLUSIONS: Higher incidence of IS was observed in relation to long-term exposures to air pollution, particularly NO2, in a region that meets European health-based air quality standards. Residential surrounding greenness was associated with lower incidence of IS.

Alcohol overuse and intracerebral hemorrhage: characteristics and long-term outcome.

BACKGROUND AND PURPOSE: Alcohol overuse (AOu) is considered an important risk factor for spontaneous intracerebral hemorrhage (ICH). The clinical and outcome characteristics of these patients (AOu-ICH) are not well known. METHODS: All patients with ICH admitted to a single university tertiary stroke center were prospectively studied from May 2005 to May 2015. Demographic profiles, radiologic characteristics and clinical outcomes of patients with acute ICH and previous AOu (>40 g/day or >300 g/week) were analyzed. RESULTS: During the study period, 555 patients with spontaneous primary ICH met the inclusion criteria. A total of 81 patients (14.6%) reported AOu (24.3% of men vs. 3.1% of women; P < 0.0001; mean age, 63 years old for AOu vs. 74 years old for non-AOu; P < 0.0001). Of the classic cardiovascular risk factors, only smoking was associated with AOu (63% vs. 12.2% of non-AOu; P < 0.0001). Initial severity and hematoma volume were similar in both groups, with no observed differences in stroke care or in-hospital medical complications. Patients with AOu had worse outcome (modified Rankin Scale score, 3-6 points) than patients without AOu at 3 months [odds ratio (OR), 2.50; 95% confidence interval (CI), 1.32-4.75; P = 0.005] and 12 months (OR, 2.47; 95% CI, 1.23-5.00; P = 0.011). A similar trend was observed at 5 years (OR, 2.48; 95% CI, 0.96-6.39; P = 0.059). CONCLUSIONS: Alcohol overuse was present in 14.6% of patients with ICH, who were predominantly male, smokers and a mean of 11 years younger than the non-AOu group. Despite a lack of differences in initial clinical severity, stroke care and early medical complications, patients with AOu had worse short- and long-term outcomes.

Ultra-early hematoma growth in antithrombotic pretreated patients with intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Patients with acute intracerebral hemorrhage (ICH) pretreated with antithrombotic drugs may have increased early hematoma growth, which would increase mortality risk. The effect of antiplatelet (AP) and vitamin K antagonist (VKA) pretreatment on ultra-early hematoma growth (uHG) and its relationship with mortality in patients with acute supratentorial ICH was analyzed. METHODS: This is an observational retrospective study of a prospective register of 197 ICH patients with first computed tomography (CT) scan taken <6 h from ICH symptom onset. ICH volume was calculated by the ABC/2 formula and uHG by the baseline ICH volume/onset-to-CT time (ml/h) formula. The uHG analysis took into account the patient's pretreatment (none, AP or VKA) and the relationship between uHG and very-early (first 24 h) and 3-month mortality. RESULTS: In the pretreatment group, 50 (25.4%) patients were treated with AP and 37 (18.8%) with VKA. The median (interquartile range 25-75) uHG was 19.7 ml/h (2.9-44.8) for AP pretreated patients, 16.2 ml/h (5.1-42.5) for VKA pretreated patients and 8.4 ml/h (2.4-21.8) for non-pretreated patients, P = 0.019. The uHG was higher in patients with very-early [42.1 ml/h (20.1-79.6)] and total 3-month mortality [28.0 ml/h (15.8-52.5)] compared with survivors [3.9 ml/h (1.5-10.4)], P < 0.0001. Adjusted by ICH severity and previous functional status, uHG was an independent factor related to very-early (P = 0.028) and total 3-month mortality (P = 0.014). CONCLUSIONS: Patients pretreated with antithrombotics have much higher uHG, which would explain the increased mortality in these patients compared to untreated patients.

People with epilepsy receive more statins than the general population but have no higher cardiovascular risk: results from a cross-sectional study.

BACKGROUND AND PURPOSE: Epilepsy has been associated with cardiovascular comorbidity. Risk prediction equations are the standard tools in primary prevention of cardiovascular disease. Our aim was to compare the prevalence of cardiovascular risk factors (CVRFs), cardiovascular risk and statin use in people with epilepsy (PWE) and the general population. METHODS: The CVRFs and cardiovascular risk score were compared between 815 PWE from an outpatient register and 5336 participants from a general population cohort. RESULTS: People with epilepsy had less hypertension (43.3% vs. 50.4%), less diabetes (15.8% vs. 19.2%), more dyslipidemia (40.2% vs. 34.6%) and lower cardiovascular risk than the general population (P < 0.01). No etiology was associated with a worse CVRF profile or higher cardiovascular risk. Patients taking enzyme-inducing antiepileptic drugs (EIAEDs) had more dyslipidemia than the general population (41.6% vs. 34.6%) but similar cardiovascular risk. Independently of risk or CVRFs, PWE had 60% more probability of receiving statins than the general population. CONCLUSIONS: People with epilepsy had more dyslipidemia, related to EIAEDs, and lower cardiovascular risk but still took more statins than the general population. Physicians should use clinical judgement to decide on further treatment of CVRFs in PWE who are below the recommended risk threshold for treatment and should consider lipid abnormalities a potential side-effect of EIAEDs. Other therapy options may need to be evaluated before starting lipid-lowering treatment.

Ammonia encephalopathy and awake craniotomy for brain language mapping: cause of failed awake craniotomy.

We report the case of an aborted awake craniotomy for a left frontotemporoinsular glioma due to ammonia encephalopathy on a patient taking Levetiracetam, valproic acid and clobazam. This awake mapping surgery was scheduled as a second-stage procedure following partial resection eight days earlier under general anesthesia. We planned to perform the surgery with local anesthesia and sedation with remifentanil and propofol. After removal of the bone flap all sedation was stopped and we noticed slow mentation and excessive drowsiness prompting us to stop and control the airway and proceed with general anesthesia. There were no post-operative complications but the patient continued to exhibit bradypsychia and hand tremor. His ammonia level was found to be elevated and was treated with an infusion of l-carnitine after discontinuation of the valproic acid with vast improvement. Ammonia encephalopathy should be considered in patients treated with valproic acid and mental status changes who require an awake craniotomy with patient collaboration.

Acute brain MRI-DWI patterns and stroke recurrence after mild-moderate stroke.

Brain ischemic lesions identified by diffusion-weighted imaging (DWI) have been shown to predict high risk of early future ischemic events in patients with transient ischemic attacks and minor stroke. The aim of this study is to analyze different brain MRI-DWI patterns in patients with mild-moderate stroke to define acute patterns related with a higher risk of stroke recurrence in long-term follow-up (from 6 to 36 months). Retrospective review of case series from a prospective stroke record including 253 patients with mild-moderate stroke (NIHSS from 1 to 7) and acute MRI-DWI lesions. MRI-DWI lesions were analyzed to determine clinically relevant lesions, based on the number, location, age and affected arterial territories. We defined three patterns: (1) multiple versus single lesions; (2) single deep versus single cortical lesions; and (3) single lesions versus multiple lesions affecting different arterial territories and/or of different age. The impact of these patterns on recurrence was analyzed by Cox regression analysis. 38 patients (15.0%) suffered a recurrence. Univariate analysis showed the risk of recurrence for each pattern. Pattern 1: patients with multiple lesions had greater risk of recurrence than those with single lesions (28.2 vs. 9.9%; OR: 3.75 (95% CI: 1.76-7.27), p < 0.0001). Pattern 2: patients with single cortical lesions had higher risk than those with deep lesions (14.3 vs. 6.7% OR: 2.33 (95% CI: 0.86-6.33), p < 0.089). Pattern 3: patients with multiple DWI in different territories or different age had the highest recurrence rate (30.6%), OR: 4.01 (95% CI: 1.70-9.47), p < 0.001, compared to patients with single lesions. Cox regression analysis adjusted by possible confounders, showed that for pattern 1 the OR for recurrence was 2.49 (95% CI: 1.27-4.89), p = 0.008; for pattern 2, OR:1.99 (95% CI: 0.74-5.37), p = 0.17; for pattern 3, OR: 2.85 (95% CI: 1.31-6.15), p = 0.008. Brain MRI-DWI patterns assessed in the acute phase of mild-moderate stroke are useful to identify those patients at high risk of recurrence.