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Objective: Abnormal ankle-brachial index (ABI) determinations may be associated with an increased risk of incident strokes. However, the impact of previous strokes in this relationship is unknown. We estimated the role of previous strokes on the association between abnormal ABI determinations and incident stroke risk in community-dwelling older adults., Methods: Atahualpa residents aged ≥60 years received ABI determinations, cardiovascular risk factors assessment, and brain MRIs. ABIs were classified as abnormal if ≤0.9 or ≥1.4. Incident strokes were diagnosed by a certified neurologist with the aid of a post-event MRI. Poisson regression models were fitted to estimate stroke incidence rate ratio (IRR) according to categories of ABI., Results: Analysis included 389 participants (mean age: 68.2 ± 8.1 years). Eighty-six persons (22%) had abnormal ABI determinations. Incident strokes occurred in 38 (9.8%) individuals after a mean follow-up of 6.1 ± 1.9 years. Abnormal ABIs were associated with incident strokes in unadjusted analyses ( p = 0.002) as well as in a Poisson regression model adjusted for demographics and clinical covariates (IRR: 2.57; 95% C.I.: 1.29-5.13), but not when the model was adjusted for neuroimaging covariates (IRR: 1.46; 95% C.I.: 0.67-3.20). Interaction models showed that having both abnormal ABI and non-lacunar strokes at baseline made the individual 9.7 times more likely to have an incident stroke (95% C.I.: 3.87-24.4). The risk was reduced to 2.2 (95% C.I.: 0.96-5.13) for those who only had an abnormal ABI., Conclusions: An abnormal ABI is associated with a doubling the risk of incident strokes, but its importance is superseded by history of non-lacunar strokes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Information on the association between disability and severity of white matter hyperintensities (WMH) among stroke-free individuals is limited. We aimed to assess this association in apparently healthy older adults., Methods: Following a population-based cross-sectional design, community-dwelling older adults received a brain MRI to grade WMH severity and the Functional Activities Questionnaire to assess the ability to perform activities of daily living. Demographics, clinical risk factors and other markers of cerebral small vessel disease were taken into consideration for analysis., Results: Unadjusted analysis showed a significant association between moderate-to-severe WMH and disability (p = 0.003) that was tempered by the effect of age. Causal mediation analysis showed that age took away 65.9% of the effect of WMH severity on disability. An interaction model showed that disability was higher only among subjects with moderate-to-severe WMH above the median age., Conclusions: Increasing age mediates the probability of WMH-related disability in stroke-free individuals., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background and Purpose: Lacunes of presumed vascular origin are perceived as biomarkers of cerebral small vessel disease (cSVD), although they may also be related to other pathogenetic mechanisms. We aimed to assess whether lacunes are more often associated with intracranial artery stenosis (IAS) than with white matter hyperintensities (WMH) of presumed vascular origin (a biomarker of cSVD) in older adults., Methods: This study included 585 individuals aged ≥60 years living in rural Ecuador. Logistic regression models were fitted to assess the strength of the association between IAS or moderate-to-severe WHM on one side, and lacunes on the other. Mediation analysis was used to estimate the percentage of the effect of IAS on lacunes that was mediated by WMH., Results: Lacunes were noticed in 62 (11%) individuals, IAS in 39 (7%), and moderate-to-severe WMH in 169 (29%). Fourteen of 39 individuals (36%) with IAS had lacunes, which corresponded to the territory of the stenotic artery in 50% of cases. Lacunes have a larger association with IAS than with moderate-to-severe WMH. The estimated prevalence rate of lacunes independently of any confounder was 10.6% (95% C.I.: 8.3-12.9%), which increased to 22.2% in subjects with IAS, but only to 16.4% among those with moderate-to-severe WMH. Only 24.5% of the effect of IAS on lacunes was mediated by WMH., Conclusion: Lacunes are more often associated with IAS than with WMH at the population level. Neuroimaging investigation of the intracranial vasculature in individuals with lacunes will provide informed-based decisions for secondary stroke prevention.

Background: Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions., Summary: The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. Key Messages: Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced., (© 2021 S. Karger AG, Basel.)

Background: Knowledge on the prevalence and correlates of intracranial atherosclerotic disease (ICAD) is limited. We aimed to assess prevalence, clinical and neuroimaging correlates of ICAD in a cohort of older adults of Amerindian ancestry., Methods: The study included 581 community-dwellers aged ≥60 years (mean age 71 ± 8.4 years; 57% women) living in rural Ecuadorian villages. ICAD was identified by means of CT determinations of carotid siphon calcifications (CSC) or MRA findings of significant stenosis of intracranial arteries. Fully-adjusted logistic regression models were fitted with biomarkers of ICAD as the dependent variables., Results: A total of 205 (35%) of 581 participants had ICAD, including 185 with high calcium content in the carotid siphons and 40 with significant stenosis of at least one intracranial artery (20 subjects had both biomarkers). Increasing age, high fasting blood glucose, >10 enlarged basal ganglia-perivascular spaces and non-lacunar strokes were associated with high calcium content in the carotid siphons. In contrast, male gender, moderate-to-severe white matter hyperintensities, lacunar and non-lacunar strokes were associated with significant stenosis of intracranial arteries. Stroke was more common among subjects with any biomarker of ICAD than in those with no biomarkers (29% versus 9%, p < 0.001). Significant stenosis of intracranial arteries was more often associated with stroke than high calcium content in the carotid siphons, suggesting that CSC are more likely an ICAD biomarker than causally related to stroke., Conclusions: ICAD prevalence in Amerindians is high, and is significantly associated with stroke. CSC and significant stenosis of intracranial arteries may represent different phenotypes of ICAD., Competing Interests: Declaration of Competing Interest The authors declared they do not have anything to disclose with regards to this study. Dr. José G. Romano is the Principal Investigator of the NIH/NINDS-funded MyRIAD Study (NS084288)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Purpose: Standardized registries may provide valuable data to further improve stroke care. Our aim was to obtain updated information about characteristics of stroke patients and management of stroke across the Ibero-American countries, using a common in-hospital registry (Safe Implementation of Treatments in Stroke–Sociedad Iberoamericana de Enfermedades Cerebrovasculares) as a basis for further quality improvement., Methods: Data for this study were entered into the Safe Implementation of Treatments in Stroke registry from September 2009 to December 2013 by 58 centers in 14 countries. Data included demographics, risk factors, onset-to-door time, National Institutes of Health Stroke Scale score, stroke subtype, ischemic stroke etiology, treatments, 3-month mortality, and modified Rankin Scale score. Time to treatment was also recorded for patients treated with thrombolysis., Results: Five thousand four hundred one patients were registered; median age, 65 years; 46% women; 3915 (72.5%) ischemic strokes; 686 (13.7%) hemorrhagic strokes; 213 (4.3%) subarachnoid hemorrhages; 414 (8.3%) transient ischemic attacks; and 31 (0.6%) cerebral vein thrombosis. The most prevalent risk factors were hypertension (71.3%), dyslipidemia (35.2%), and diabetes mellitus (23.6%). Atrial fibrillation was present in 15.1%. Three hundred one ischemic strokes were treated with intravenous thrombolysis (IVT; 7.7%). Patients undergoing IVT were more severely affected (median baseline National Institutes of Health Stroke Scale score, 11 versus 6). The rate of symptomatic intracerebral hemorrhages after IVT was 5.7%. At 3 months, 60.3% of IVT-treated patients and 59.1% of untreated patients were independent (modified Rankin Scale score, 0–2). Mortality was 11.4% in treated and 12.8% in untreated patients., Conclusions: Safe Implementation of Treatments in Stroke–Sociedad Iberoamericana de Enfermedades Cerebrovasculares is the largest registry of a general stroke population and the first study to evaluate the level of IVT use in Ibero-America. It provides valuable information that may help to improve the quality of stroke care in the Ibero-American region., (© 2019 American Heart Association, Inc.)

Purpose: By the use of a population-based design, this study aimed to evaluate the presence of similar stroke risk factors in couples living in a remote rural setting (Atahualpa)., Methods: Atahualpa residents aged ≥40 years were identified by means of door-to-door surveys, and those who signed a comprehensive consent form were enrolled in the Atahualpa Project. Baselines interviews and procedures, aimed to assess stroke risk factors, were collected at the time of admission in all participants., Results: We identified 268 couples among 898 individuals aged ≥40 years enrolled in the Atahualpa Project. Traditional risk factors were defined according to the American Heart Association criteria. Generalized estimating equations, adjusted for age, showed that being married to a spouse with poor physical activity (p = 0.027) and a poor diet (p < 0.001) were associated with the presence of these risk factors in the other partner., Conclusions: Intervention strategies directed to couples are needed to improve poor healthy styles leading to stroke in underserved populations., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background/objectives: Evidence of an association between sleep disorders and extracranial atherosclerosis is limited and has not been studied in remote rural settings, where living conditions and cardiovascular risk factors are different than in urban centers. We assessed the relationship between the carotid intima-media thickness (cIMT) and sleep quality in stroke-free individuals aged ≥40 years living in rural Ecuador., Methods: Applying a population-based study design, participants underwent face-to-face interviews using the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality, and sonographic examinations for measurement of the carotid intima-media thickness (cIMT). The association between the cIMT and sleep quality (as the dependent variable) was assessed by means of generalized linear models, adjusted for relevant confounders., Results: The mean age of 561 participants was 60.4 ± 12.6 years (58% women). The mean PSQI was 4.6 ± 2.2 points. Of those, 79 (14%) individuals had an increased cIMT (>1 mm). A model adjusted for demographics showed a significant association between increased cIMT and the PSQI score (β: 0.602; 95% C.I.: 0.027-1.177; p = 0.040). This relationship was reduced when cardiovascular risk factors were added to the model (β: 0.514; 95% C.I.: -0.072 - 1.101; p = 0.086). When the model was adjusted for demographics and psychological distress, the association between increased cIMT and the PSQI score became significant (β: 0.573; 95% C.I.: 0.013-1.133; p = 0.045). In addition, both symptoms of depression (p = 0.032) and anxiety (p < 0.001) remained independently significant., Conclusions: This study shows an association between increased cIMT and the PSQI score, which is, at least, partly mediated by manifestations of psychological distress., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: The Evans Index (EI) is used for recognition of individuals with normal pressure hydrocephalus. However, recent studies suggest that the EI is not a reliable marker of this condition. Rather, the EI may be inversely correlated with cognitive performance, but information on this correlation is lacking. We aimed to assess the relationship between the EI and cognitive performance in community-dwelling older adults., Patients and Methods: The study included 314 non-disabled, stroke-free, individuals aged ≥60 years enrolled in the Atahualpa Project undergoing brain MRI and MoCA testing. Using generalized linear models, adjusted for demographics, cardiovascular risk factors edentulism, depression, global cortical atrophy and white matter hyperintensities of vascular origin, we assessed the relationship between the EI and cognitive performance. Predictive margins of the MoCA score according to percentiles of the EI were also evaluated, after adjusting for variables reaching significance in univariate models., Results: The mean EI was 0.248 ± 0.022 and the mean MoCA score was 19.7 ± 4.8 points. A fully-adjusted generalized linear model showed a significant inverse relationship between the EI and the MoCA score. Predictive models showed a decrease in the MoCA score according to increased levels of the EI (β: -3.28; 95% C.I.: -6.09 to -0.47; p = 0.022)., Conclusion: The independent effect of the EI on the MoCA score provides evidence of the utility of the EI to evaluate cognitive performance., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background There is no information on stroke incidence in rural areas of Latin America, where living conditions and cardiovascular risk factors are different from urban centers. Aim Using a population-based prospective cohort study design, we aimed to assess risk factors influencing stroke incidence in community-dwelling adults living in rural Ecuador. Methods First-ever strokes occurring from 1 June 2012 to 31 May 2016, in Atahualpa residents aged ≥40 years, were identified from yearly door-to-door surveys and other overlapping sources. Poisson regression models adjusted for demographics, cardiovascular risk factors, edentulism and the length of observation time per subject were used to estimate stroke incidence rate ratio as well as factors influencing such incidence. Results Of 807 stroke-free individuals prospectively enrolled in the Atahualpa Project, follow-up was achieved in 718 (89%), contributing 2,499 years of follow-up (average 3.48 ± 0.95 years). Overall stroke incidence rate was 2.97 per 100 person-years of follow-up (95% CI: 1.73-4.2), which increased to 4.77 (95% CI: 1.61-14.1) when only persons aged ≥57 years were considered. Poisson regression models, adjusted for relevant confounders, showed that high blood pressure (IRR: 5.24; 95% CI: 2.55-7.93) and severe edentulism (IRR: 5.06; 95% CI: 2.28-7.85) were the factors independently increasing stroke incidence. Conclusions Stroke incidence in this rural setting is comparable to that reported from the developed world. Besides age and high blood pressure, severe edentulism is a major factor independently predicting incident strokes. Public awareness of the consequences of poor dental care might reduce stroke incidence in rural settings.

Background: Intracranial arterial stenosis (IAS) is more prevalent among Asians, Blacks and Caribbean Hispanics than in Whites. However, there is no information on the importance of this common cause of stroke among Mestizo/Native populations of Latin America. We aimed to assess prevalence and correlates of IAS in an indigenous Ecuadorian population of older adults., Methods: Atahualpa residents aged ≥60 years were identified during door-to-door surveys and invited to undergo brain magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of intracranial vessels for identification of stroke lesions and arterial stenosis. Prevalence of IAS was assessed in patients with strokes as well as in stroke-free individuals. A logistic regression model was constructed with stroke as the outcome, IAS as the exposure, and confounders (demographics and cardiovascular risk factors) as independent variables., Results: Out of 267 participants (mean age 71 ± 8 years, 57% women), 15 (5.6%) had intracranial arterial stenosis, including 10 out of 52 (19.2%) persons with stroke and five out of 215 (2.3%) without. The multivariate logistic regression model showed significant association of IAS with stroke after adjusting for demographics and cardiovascular risk factors (OR: 7.9, 95% C.I.: 2.2-27.8, p=0.001). Mechanisms underlying stroke in patients with IAS included perforator occlusion, artery-to-artery embolism and hypoperfusion., Conclusions: Prevalence of IAS in Ecuadorian Natives/Mestizos is similar to that in Asians. Individuals aged ≥60 years with IAS are almost eight times more likely to have a stroke after adjusting for confounding variables., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Cognitive impairment is common among stroke survivors. However, there is controversy on the role of the stroke itself or the associated subcortical damage in post-stroke cognitive decline., Aim: To assess the independent contribution and the interaction of age, the stroke itself and diffuse subcortical damage in the poor cognitive performance observed in patients with stroke., Methods: Atahualpa residents aged ≥60 years were identified during a door-to-door survey and invited to undergo brain MRI for identification of stroke lesions and white matter hyperintensities (WMH) of presumed vascular origin. Cognitive performance was evaluated by the use of the Montreal Cognitive Assessment (MoCA). Using a generalized linear model, we examined the association between MoCA score, stroke and WMH, after adjusting for demographics, education, vascular risk factors, depression and edentulism., Results: Out of 311 persons aged ≥60 years, 242 (78 %) were enrolled. MRI showed strokes in 39 (16 %) and moderate-to-severe WMH in 52 (22 %) cases. Mean MoCA score was 18.5 ± 4.7 in the entire population. When participants were stratified according to the median age of the population (67 years), the generalized linear model showed that MoCA scores were not different in younger persons irrespective of the presence of stroke or WMH. In contrast, increased age associated with lower MoCA scores in persons with WMH (p = 0.002) or with both stroke and WMH (p = 0.003), but not in those with stroke without WMH (p = 0.087)., Conclusions: Interaction of age and diffuse subcortical damage are major determinants for poor cognitive performance among stroke patients.

Background and Purpose: Prevalence of cerebral microbleeds (CMB) in white and Asian populations range from 4% to 15%. However, there is no information from indigenous Latin American people. We aimed to assess prevalence and cerebrovascular correlates of CMB in stroke-free older adults living in rural Ecuador., Methods: Of 311 Atahualpa residents aged ≥60 years identified during a door-to-door survey, 258 (83%) underwent brain magnetic resonance imaging. Twenty-one were further excluded for a diagnosis of overt stroke. Using multivariate logistic regression models, adjusted for demographics and cardiovascular risk factors, we evaluated whether CMB were independently associated with silent strokes, white matter hyperintensities, and global cortical atrophy., Results: Twenty-six (11%) of 237 participants had CMB, which were single in 54% of cases. CMB were deep in 11 patients, cortical in 9, and located both deep and cortical in 6. In univariate analyses, CMB were associated with age, systolic blood pressure, moderate-to-severe white matter hyperintensities, silent lacunar infarcts, and cortical atrophy. Mean (±SD) values for systolic blood pressure were 155±27 mm Hg in patients who had CMB versus 142±26 mm Hg in those who did not (P=0.017). In the adjusted models, moderate-to-severe white matter hyperintensities (P=0.009), silent lacunar infarcts (P=0.003), and global cortical atrophy (P=0.04) were independently associated with CMB., Conclusions: Prevalence of CMB in stroke-free older adults living in Atahualpa is comparable with those reported from other ethnic groups. There is a strong relationship between CMB and increased age, high systolic blood pressure, silent markers of cerebral small vessel disease, and cortical atrophy., (© 2015 American Heart Association, Inc.)

Objective: It has been suggested that pineal gland calcifications (PGC) represent a risk factor for stroke; however, information comes from a single retrospective hospital-based registry. We aimed to validate this association in a population-based study conducted in rural Ecuador., Methods: Atahualpa residents aged ≥60 years were identified during a door-to-door survey and invited to undergo neuroimaging studies (CT/MRI) for identification and rating PGC and lesions consistent with cerebral infarcts and hemorrhages. Cardiovascular health (CVH) status was assessed according to the American Heart Association criteria, and clinical strokes were identified by the use of a validated field instrument and confirmed by neurologists., Results: Out of 248 participants (mean age 70±8 years, 59% women, 73% with poor CVH), 137 (55%) had PGC and 39 (16%) had strokes (silent in 28 cases). PGC were noted in 61% versus 54% persons with and without stroke, respectively. After adjusting for age, sex and cardiovascular health, logistic and ordinal logistic regression models showed no association between any evidence (p=0.916) or severity (p=0.740) of PGC and stroke., Conclusion: PGC is not associated with stroke in this population of community-dwelling elders, where prevalence of PGC and stroke are similar to those found in other regions., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Stroke will be South America's next epidemic. Therefore, information on stroke particularities in the region will help to overcome its impact burden. We evaluated prevalence, pattern of sub-types, and pathogenic mechanisms underlying stroke in Atahualpa, a village representative of rural coastal Ecuador. In a three-phase epidemiologic study, suspected cases were detected by a door-to-door survey (Phase I). Then, neurologists evaluated suspected cases and randomly selected negative persons (Phase II), and confirmed patients underwent complementary exams (Phase III). We found 20 stroke patients (mean age 70 years, 60% men) among 642 persons aged ≥40 years. Stroke prevalence was 31.15‰ that increased with age. Most patients had sub-cortical infarctions associated with leukoaraiosis or microbleeds. Hypertensive arteriolopathy was the most likely mechanism underlying strokes (55% patients). Intracranial arterial lesions were found in 47% cases. Extracranial atherosclerotic lesions or cardiac sources of emboli were not found in any case. Comparison of our findings with a previous survey performed in the same village showed an alarming increase in stroke prevalence (from 14.08‰ in 2003 to 31.15‰ in 2012, P = 0.03)., (© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.)

Rationale: Stroke and cardiovascular diseases will be the next health epidemics in Latin America due to increased life expectancy and changes in the lifestyle and dietary habits of the population. Knowledge of the cardiovascular health status of the inhabitants will allow the implementation of policies directed to reduce the burden of stroke and cardiovascular diseases in the region., Aims: To evaluate the cardiovascular health status of the inhabitants of Atahualpa (a rural village in coastal Ecuador) and to determine the prevalence and incidence of stroke and ischemic heart disease in the region., Design: Three-phase epidemiologic survey. During phase I, Atahualpa residents aged ≥40 years will be screened with standardized questionnaires to evaluate their cardiovascular health and to identify those with suspected stroke or ischemic heart disease. In phase II, neurologists and cardiologists will examine suspected cases of stroke or ischemic heart disease, as well as a random sample of matched negative individuals, to assess the prevalence and incidence of these conditions. In phase III, patients with a diagnosis of stroke and ischemic heart disease will undergo complementary tests for achieving a more specific diagnosis., Discussion: Implementation of public health strategies directed to improve the cardiovascular health status of a given population must be based on studies evaluating specific risk factors at regional levels. Epidemiologic surveys such as the Atahualpa Project may prove cost-effective in improving the cardiovascular health status of people living in Latin American rural villages by increasing the knowledge on the particular needs of these populations., (© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.)

Background: Knowledge of regional-specific cardiovascular risk factors is mandatory to reduce the growing burden of stroke and ischemic heart disease in Latin American populations. We conducted a population-based case-control study to assess which risk factors are associated with the occurrence of vascular events in natives/mestizos living in rural coastal Ecuador., Methods: We assessed the cardiovascular health (CVH) status and the presence of the metabolic syndrome in all Atahualpa residents aged 40 years or more with stroke and ischemic heart disease and in randomly selected healthy persons to evaluate differences in the prevalence of such risk factors between patients and controls., Results: A total of 120 persons (24 with stroke or ischemic heart disease and 96 matched controls) were included. A poor CVH status (according to the American Heart Association) was found in 87.5% case-patients and 81.3% controls (P = .464). The metabolic syndrome was present in the same proportion (58.3%) of case-patients and controls. Likewise, both sets of risk factors (poor CVH status and the metabolic syndrome) were equally prevalent among both groups (58.3% versus 49%, P = .501)., Conclusions: This case-control study suggests that none of the measured risk factors is associated with the occurrence of vascular events. It is possible that some yet unmeasured risk factors or an unknown genetic predisposition may account for a sizable proportion of stroke and ischemic heart disease occurring in the native/mestizo population of rural coastal Ecuador., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Recent stroke registries suggest that the rate of cerebral hemorrhages is declining among stroke patients in South America. High rates of cerebral hemorrhages (approaching 40% of stroke cases) reported in pioneer registries during the 1990s have not been duplicated in more recent studies. In contrast, almost all studies recruiting patients from 2003 on, reported less than 20% of cerebral hemorrhages among their stroke patients. Intermediate rates of hemorrhagic strokes (from 25% to 27%) were noted among registries recruiting patients by the end of the 20th century and the start of the new Millennium. We also noted a significant declining rate of hemorrhagic stroke over the past 20 years at our Institution. In a series of 651 consecutive first-ever stroke patients included in the Hospital-Clínica Kennedy stroke registry (Guayaquil), cerebral hemorrhages accounted for 26·3% of patients recruited between 1990 and 1994 but for only 16·5% of those seen between 2005 and 2009 (P = 0·03). More longitudinal studies are needed to confirm these findings and to determine whether the reported declining rate of hemorrhagic strokes in South America is related to increase life expectancy of the population, or to changes in lifestyle, dietary habits, or some other specific stroke risk factors not well evaluated so far., (© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.)

This study examined the baseline characteristics, racial/ethnic differences, and geographic differences among participants in the Secondary Prevention of Small Subcortical Strokes (SPS3) study. The SPS3 trial enrolled patients who experienced a symptomatic small subcortical stroke (lacunar stroke) within the previous 6 months and an eligible lesion on detected on magnetic resonance imaging. The patients were randomized, in a factorial design, to antiplatelet therapy (aspirin 325 mg daily plus clopidogrel 75 mg daily vs aspirin 325 mg daily plus placebo) and to one of two levels of systolic blood pressure targets ("intensive" [<130 mmHg] or "usual" [130-149 mmHg]). A total of 3020 participants were recruited from 81 clinical sites in 8 countries. In this cohort, the mean age was 63 years, 63% were men, 75% had a history of hypertension, and 37% had diabetes. The racial distribution was 51% white, 30% Hispanic, and 16% black. Compared with white subjects, black subjects were younger (mean age, 58 years vs 64 years; P <.001) and had a higher prevalence of hypertension (87% vs 70%; P <.001). The prevalence of diabetes was higher in the Hispanic and black subjects compared with the white subjects (42% and 40% vs 32%; both P <.001). Tobacco smoking at the time of qualifying stroke was much more frequent in the Spanish participants than in subjects from North America and from Latin America (32%, 22%, and 9%, respectively; P <.001). Mean systolic blood pressure at study entry was 4 mmHg lower in the Spanish subjects compared with the North American subjects (P <.01). The SPS3 cohort is the largest magnetic resonance imaging-defined series of patients with S3. Among the racially/ethnically diverse SPS3 participants, important differences in patient features and vascular risk factors could influence prognosis for recurrent stroke and response to interventions., (Copyright © 2013 National Stroke Association. All rights reserved.)

There is limited information on the prevalence of neurocysticercosis (NCC) among stroke patients, and no community-based survey has addressed this issue. We performed a 3-Phase, population-based study, to assess the prevalence and pathogenesis of stroke in a rural village of coastal Ecuador, where cysticercosis is highly endemic. Twenty stroke patients were found among 642 individuals ≥ 40 years of age. Eighteen of these patients underwent neuroimaging studies and no patient had evidence of NCC or angiitis of intracranial vessels. The serum immunoblot test for the detection of anticysticercal antibodies, performed in 15 of these 20 patients during a previous survey, were negative in 13 cases and the remaining two had a normal computed tomography of the head. This study suggests that NCC is not responsible for the increasing burden of stroke in rural areas of developing countries.

Background and Purpose: Stroke is a leading cause of mortality and disability in South America because of an increase in life expectancy and changes in the lifestyle of the population. Because epidemiological and clinical characteristics of stroke vary according to regional factors, we need to know the peculiarities of stroke on this continent., Methods: We performed a systematic review of articles on stroke in South America, with emphasis on those providing information on the incidence and prevalence of stroke (community-based studies) and the pattern of stroke subtypes (hospital-based studies)., Results: Seven papers provided information on stroke epidemiology; 11 gave data on the pattern of stroke subtypes. Community-based studies showed crude stroke prevalence rates ranging from 1.74 to 6.51 per 1000 and annual incidence rates from 0.35 to 1.83 per 1000. Hospital-based stroke registries consistently reported a high frequency of intracranial hemorrhages, which accounted for 26% to 46% of all strokes. Among patients with cerebral infarctions, intracranial atherosclerotic lesions and small-vessel disease have been common pathogenic mechanisms underlying the stroke. In most studies, hypertensive arteriolopathy was the most common cause of both infarctions and hemorrhages., Conclusions: Stroke has been poorly studied in South America. Available data suggest that the prevalence and incidence of stroke are lower than in developing countries. The pattern of stroke subtypes seems to be different from that reported in other regions of the world, with a higher frequency of cerebral hemorrhages, small-vessel disease, and intracranial atherosclerotic lesions. Such differences may be related to genetic, environmental, or sociocultural factors and to differences in the control of stroke risk factors.

Objective: To determine the prevalence and subtypes of cerebrovascular complications of Bothrops spp. snakebites., Methods: The authors studied 309 consecutive patients bitten by Bothrops spp. who attended a large general hospital. Special emphasis was placed on the time elapsed between the bite and admission to the hospital, clinical manifestations, laboratory findings, severity of envenomation, CT findings, and outcome., Results: Eight of 309 patients (2.6%) developed a cerebrovascular event. Six presented >8 hours after being bitten, and all had clinical and laboratory evidence of severe envenoming. CT revealed intracranial bleeding in seven patients and multiple brain infarcts in one. Hemorrhages were located in the subcortical white matter of the cerebral hemispheres in five patients, in the cerebellum in one, and in the subarachnoid space in one. All patients with intracranial hemorrhage had a bleeding disorder, and the patient with cerebral infarcts may have had angiitis. Five of the eight patients died despite therapy, and the remaining three had irreversible sequelae., Conclusions: The prevalence of cerebrovascular complications related to Bothrops spp. bites is 2.6%. Intracranial hemorrhages are more frequent than cerebral infarcts. The prognosis of these patients is poor.

Introduction: Hypertensive retinopathy (HTRP) predicts all-cause mortality in Asian and Caucasian populations. However, little is known about HTRP impact in other ethnic groups. Aim: We sought to estimate the mortality risk according to HTRP severity in older adults of Amerindian ancestry living in rural Ecuador. Methods: This prospective study enrolled individuals aged ≥ 60 years with baseline blood pressure ≥ 120/≥ 80 mmHg from the ongoing Atahualpa Project cohort who received retinal photographs (for HTRP grading) and a brain MRI. We ascertained all-cause mortality after a mean of 5.2 ± 1.2 years of follow-up. Cox-proportional hazards models adjusted for demographics, cardiovascular risk factors, neuroimaging signatures of cerebral small vessel disease, blood pressure determinations during follow-up and incident strokes, were obtained to estimate mortality risk according to HTRP severity. Results: Analysis included 236 participants (mean age 69.3 ± 7.3 years). HTRP Grade 2 or higher was determined in 42 (18%) individuals. Fifty participants (21%) died during the follow-up, resulting in an overall unadjusted crude mortality rate of 4.1 per 100 person-years. Mortality rate in subjects with HTRP Grade 2 or higher was 7.2 and in those with no HTRP or Grade 1 only was 3.4 per 100 person-years. An adjusted Cox-proportional hazard model showed that individuals with HTRP Grade 2 or higher maintained a greater than two-fold mortality risk (HR 2.08; 95% C.I. 1.04–4.15; p = 0.038) when compared to those with no HTRP or Grade 1 only. Conclusion: Study results show that HTRP severity predicts mortality in this population of older adults. [ABSTRACT FROM AUTHOR]

Accidental falls are a leading cause of disability and death in older adults living in urban centers. However, little is known about the consequences of falls in rural communities. We aimed to assess characteristics and risk of falls in community-dwellers aged ≥ 60 years living in rural Ecuador. Of 463 older adults enrolled in the Atahualpa Project, 327 (71%) were included. Multivariate logistic regression models were fitted to assess factors associated with history of falls and risk of future falls. Sensitivity analysis was conducted to determine which component of the Downton fall risk index (DFRI) better predicts risk of future falls. A history of falls was reported by 173 (53%) individuals. Most were related to stumbling due to uneven (non-paved) streets. Only three individuals had bone fractures after the fall. Previous falls were not associated with any of the investigated covariables. The DFRI was positive in 87 (27%) participants, and was associated with age (p < 0.001) and history of stroke (p < 0.001). None of the subjects were taking tranquilizers/sedatives. The most reliable component of the DFRI was the presence of sensory/motor deficits. History of falls in our population is similar to that reported elsewhere. However, the risk of future falls is lower. Such discrepancies are probably because the DFRI does not take into account environmental factors resulting in falls. There were almost no severe complications from falls, which could be partly related to the lack of use of tranquilizers/sedatives. [ABSTRACT FROM AUTHOR]

Background: Little is known on the role of sleep disorders in the increased prevalence of cerebrovascular diseases in the developing world. Aims: The aim of this study is to assess the prevalence of major sleep disorders in a rural South American population and to determine whether these conditions are associated with stroke, ischemic heart disease, or with a poor cardiovascular health (CVH). Design: Three-phase, population-based, door-to-door survey in Atahualpa. During phase I, all residents aged 40 years or older will be screened with validated Spanish versions of 5 questionnaires to evaluate major sleep disorders. In phase II, neurologists will examine persons suspected of having a sleep disorder and a random sample of negative individuals to assess the prevalence of these conditions and to validate the accuracy of questionnaires. In phase III, patients with a confirmed sleep disorder will undergo nocturnal polysomnography for achieving a more specific diagnosis. The occurrence of sleep disorders will be correlated with the CVH of the population and with the presence of stroke and ischemic heart disease. Discussion: This epidemiologic study may prove cost-effective in improving sleep conditions of people living in rural areas of developing countries and may be used as a model for the evaluation of sleep disorders and their cerebrovascular correlates in these populations. [Copyright &y& Elsevier]

We carried out a door-to-door survey to assess the prevalence, incidence, risk factors and possible etiology of major neurological diseases in Atahualpa, a rural village located in the coastal region of Ecuador. A total of 2,548 individuals were interviewed with standardized screening questionnaires to detect suspected cases of epilepsy, stroke and dementia, and they underwent a serum immunoblot test for the detection of anticysticercal antibodies (phase I). Positive individuals and a random sample of negative subjects were examined by neurologists (phase II). Then, patients with clinically confirmed disease and a control group of healthy subjects were further evaluated with complementary examinations (phase III). Here, we describe the methodology of this field study that may be used as a model for the evaluation of neurological disorders in rural communities of developing countries. [ABSTRACT FROM AUTHOR]

The article focuses on the Atahualpa Project, a population-based study which aims to evaluate the presence of cardiovascular risk factors and determine their impact on the burden of stroke and ischemic heart disease in rural coastal Ecuador. The study involved all Atahualpa residents aged 40 and above. It also presents a flow chart depicting the procedures, methodology and basal results of the project.

The Iberoamerican Cerebrovascular Diseases Society was founded 15 years ago. Being aware of the increased burden of stroke in Latin America, its members have been working to enhance the knowledge on stroke among physicians in the region, to increase public awareness on stroke warning signs, and to motivate public health authorities to implement programs that speed the access of stroke patients to specialized units. Besides organizing annual meetings that have convened an increasing number of attendees, the Society has been actively involved in the elaboration of guidelines for stroke classification and therapy that will be practical for use at a regional level, as well as in the consolidation of links with other stroke societies to increase the diffusion of local stroke issues to the medical community at large. The Society is also involved in the Safe Implementation of Treatment in Stroke trial as well as in other studies that will increase the knowledge on stroke management and prognosis in the region. [ABSTRACT FROM AUTHOR]