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A comprehensive health risk assessment of PM 2.5 is meaningful to understand the current status and directions regarding further improving air quality from the perspective of human health. In this study, we evaluated the health risks of PM 2.5 as well as highly toxic inorganic components, including heavy metals (HMs) and black carbon (BC) based on long-term observations in Beijing from 2019 to 2021. Our results showed that the relative risks of chronic obstructive pulmonary disease, lung cancer, acute lower respiratory tract infection, ischemic heart disease, and stroke decreased by 4.07%-9.30% in 2020 and 2.12%-6.70% in 2021 compared with 2019. However, they were still at high levels ranging from 1.26 to 1.77, in particular, stroke showed the highest value in 2021. Mn had the highest hazard quotient (HQ, from 2.18 to 2.56) for adults from 2019 to 2021, while Ni, Cr, Pb, As, and BC showed high carcinogenic risks (CR > 1.0×10 -6 ) for adults. The HQ values of Mn and As and the CR values of Pb and As showed constant or slight upwards trends during our observations, which is in contrast to the downward trends of other HMs and PM 2.5 . Mn, Cr, and BC are crucial toxicants in PM 2.5 . A significant shrink of southern region sourcesof HMs and BCshrank suggests the increased importance of local sources. Industry, dust, and biomass burning are the major contributors to the non-carcinogenic risks, while traffic emissions and industry are the dominant contributors to the carcinogenic risks in Beijing., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

Background: Extreme ambient temperatures have been linked to increased risks of stroke morbidity and mortality. However, global estimates of the burden of stroke due to extreme low temperatures are not well-defined., Aims: This study aimed to determine the global burden of stroke due to extreme low temperatures and its spatiotemporal trend from 1990 to 2019., Methods: Based on the Global Burden of Disease Study 2019, we obtained global, regional, and national data on deaths, disability-adjusted life years (DALYs), age-standardized mortality rate (ASMR), and age-standardized rate of DALYs (ASDR) of stroke attributed to extreme low temperatures, further stratified by age, sex, and sociodemographic index (SDI)., Results: Globally, in 2019, an estimated 474,000 stroke deaths with the corresponding ASMR (6.2 (95% uncertainty interval (UI): 4.6-7.9)) and ASDR (103.9 (95% UI: 77.0-134.5)) per 100,000 population, were attributable to extreme low temperatures. The most significant burden was observed in Central Asia, followed by Eastern Europe and East Asia. From 1990 to 2019, the global burden of stroke and its subtypes (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) attributable to extreme low temperatures exhibited a decrease in both ASMR and ASDR. Significant decreases in stroke burden occurred in the high-SDI regions, high-income Asia Pacific, and subarachnoid hemorrhage cases. Moreover, the ASMR and ASDR increased with age and were higher in males than females., Conclusion: The global stroke burden due to extreme low temperatures remains high despite a decreasing trend over the past three decades. The stroke burden due to extreme low temperatures was more notable for Central Asia, older people, and the male sex., 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.

Objectives: To investigate the incidence rate, clinical characteristics, and prognosis of neonatal stroke in Shenzhen, China., Methods: Led by Shenzhen Children's Hospital, the Shenzhen Neonatal Data Collaboration Network organized 21 institutions to collect 36 cases of neonatal stroke from January 2020 to December 2022. The incidence, clinical characteristics, treatment, and prognosis of neonatal stroke in Shenzhen were analyzed., Results: The incidence rate of neonatal stroke in 21 hospitals from 2020 to 2022 was 1/15 137, 1/6 060, and 1/7 704, respectively. Ischemic stroke accounted for 75% (27/36); boys accounted for 64% (23/36). Among the 36 neonates, 31 (86%) had disease onset within 3 days after birth, and 19 (53%) had convulsion as the initial presentation. Cerebral MRI showed that 22 neonates (61%) had left cerebral infarction and 13 (36%) had basal ganglia infarction. Magnetic resonance angiography was performed for 12 neonates, among whom 9 (75%) had involvement of the middle cerebral artery. Electroencephalography was performed for 29 neonates, with sharp waves in 21 neonates (72%) and seizures in 10 neonates (34%). Symptomatic/supportive treatment varied across different hospitals. Neonatal Behavioral Neurological Assessment was performed for 12 neonates (33%, 12/36), with a mean score of (32±4) points. The prognosis of 27 neonates was followed up to around 12 months of age, with 44% (12/27) of the neonates having a good prognosis., Conclusions: Ischemic stroke is the main type of neonatal stroke, often with convulsions as the initial presentation, involvement of the middle cerebral artery, sharp waves on electroencephalography, and a relatively low neurodevelopment score. Symptomatic/supportive treatment is the main treatment method, and some neonates tend to have a poor prognosis.

Confronting the rising tide of ischemic stroke and its associated mortality and morbidity with ageing, prevention and acute management of ischemic stroke is of paramount importance. Mounting observational studies have established a non-linear association of vitamin D status with cardiovascular diseases, including ischemic stroke. Paradoxically, current clinical trials fail to demonstrate the cardiovascular benefits of vitamin D supplementation. We aim to update recent clinical and experimental findings on the role of vitamin D in the disease course of ischemic stroke, from its onset, progression, recovery, to recurrence, and the established and alternative possible pathophysiological mechanisms. This review justifies the necessities to address stroke etiological subtypes and focus on vitamin D-deficient subjects for investigating the potential of vitamin D supplementation as a preventive and therapeutic approach for ischemic stroke. Well-powered clinical trials are warranted to determine the efficacy, safety, timing, target individuals, optimal dosages, and target 25OHD concentrations of vitamin D supplementation in the prevention and treatment of ischemic stroke., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Cerebral small vessel disease (CSVD) causes 20%-25% of stroke and contributes to 45% of dementia cases worldwide. However, since its early symptoms are inconclusive in addition to the complexity of the pathological basis, there is a rather limited effective therapies and interventions. Recently, accumulating evidence suggested that various brain-waste-clearance dysfunctions are closely related to the pathogenesis and prognosis of CSVD, and after a comprehensive and systematic review we classified them into two broad categories: trans-barrier transport and lymphatic drainage. The former includes blood brain barrier and blood-cerebrospinal fluid barrier, and the latter, glymphatic-meningeal lymphatic system and intramural periarterial drainage pathway. We summarized the concepts and potential mechanisms of these clearance systems, proposing a relatively complete framework for elucidating their interactions with CSVD. In addition, we also discussed recent advances in therapeutic strategies targeting clearance dysfunction, which may be an important area for future CSVD research., Competing Interests: Declaration of Competing Interest The Authors declare that there is no conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background and Aim: The aim of this study was to investigate the potential value of intracranial carotid artery calcification (ICAC) in therapeutic efficacy and functional outcomes in patients with anterior circulation acute ischemic stroke (AIS) undergoing intravenous thrombolysis., Materials and Methods: A total of 207 patients with anterior circulation AIS who underwent intravenous thrombolysis were enrolled in this retrospective study. We divided them into three groups according to thin-slice head noncontrast computed tomography as follows: no ICAC, medial ICAC, and intimal ICAC. The differences in risk factors of different ICAC subtypes were compared, and the effect of ICAC subtype on hemorrhage transformation (HT) after intravenous thrombolysis was also evaluated. Functional outcomes were assessed at 90 days using the modified Rankin Scale., Results: Compared to the no and intimal ICAC, patients with the medial ICAC were older and more likely to have diabetes mellitus, hyperlipidemia, previous stroke, and atrial fibrillation. Moreover, the medial ICAC group had a high baseline National Institute of Health Stroke Scale (NIHSS) score and a high incidence of HT. Multivariate logistic regression analysis showed that baseline NIHSS score (odds ratio [OR]: 1.121, 95% confidence interval [CI]: 1.027-1.224) was independently associated with HT. Medial ICAC (OR: 7.418, 95% CI: 1.190-46.231) and baseline NIHSS score (OR: 1.141, 95% CI: 1.042-1.250) were independent risk factors of poor functional outcome at 90 days., Conclusions: Medial ICAC could be a new imaging biomarker for predicting functional outcomes in patients with anterior circulation AIS undergoing intravenous thrombolysis. Medial ICAC and baseline NIHSS score were independently associated with poor prognosis at 90 days., Competing Interests: None

Background: Stroke is rarely accompanied with peripheral facial paralysis and supranuclear palsy of the hypoglossal nerve. Both sides of the motor cortex innervate the hypoglossal nucleus; therefore, unilateral lesions of the upper motor neurons rarely result in contralateral lingual paresis. We report a rare case of crossed syndrome with associated hyperacute peripheral hemifacial paralysis and contralateral lingual paresis after a lower pontine tegmentum ischemic stroke., Case Presentation: A 73-year-old man presented with symptoms of hyperacute peripheral hemifacial paralysis. Upon protrusion, the patient's tongue deviated to the contralateral side, without fasciculation or atrophy. Brain imaging showed focal ischemic stroke in the pontine tegmentum. However, lingual hemiparesis and multimodal neuroimaging findings differed., Conclusions: We suggest that cortico-hypoglossal fibers pass through the dorsal pontine. This case of crossed syndrome is a rare report of a lower pontine tegmentum ischemic stroke resembling an upper motor neuron lesion of the contralateral hypoglossal nerve., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Imaging indicators of early neurological deterioration (END) in patients with acute isolated pontine infarctions (AIPI) remained ambiguous. We aimed to find more specific neuroimaging markers for the development of END in patients with AIPI., Methods: Patients with AIPI within 72 h of stroke onset were screened from a stroke database from January 2018 to July 2021 in the First Affiliated Hospital of Zhengzhou University. Clinical characteristics, laboratory tests, and imaging parameters were collected. The layers having the largest infarct area on diffusion-weighted imaging (DWI) and T 2 sequences were chosen. On the transverse plane of DWI and sagittal plane of T 2 -Flair images, the maximum length (a, m) and maximum width (b, n) vertical to the length of the infarcted lesions were measured respectively. On the sagittal plane of T 2 -Flair image, the maximum ventrodorsal length (f) and rostrocaudal thickness (h) were measured. On the sagittal plane, lesions were evenly split into upper, middle, and lower types based on the lesion's location in the pons. The ventral and dorsal types of location were separated based on whether the ventral borders of the pons were involved on transvers plane. END was defined as a ≥2 point increase in the National Institutes of Health Stroke Scale (NIHSS) total score or a ≥1 point increase in the motor items within 72 h after admission. Multivariate logistic regression analyses were used to explore risk factors associated with END. The receiver operating characteristic (ROC) curve analysis and the area under the curve (AUC) was performed to estimate the discriminative power and determine the optimal cut-off points of imaging parameters on the prediction of END., Results: A total of 218 patients with AIPI were included in the final analysis. END occurred in 61 cases (28.0%). Multivariate logistic regression analysis showed that the ventral type of lesion location was associated with END in all models adjusted. In addition, in Model 1, b (odds ratio (OR) 1.145, 95% confidence interval (95% CI), 1.007-1.301) and n (OR 1.163, 95% CI 1.012-1.336); in Model 2, b * n (OR 1.010, 95% CI 1.002-1.018); in Model 3, n (OR 1.179, 95% CI, 1.028-1.353); and in Model 4, b (OR 1.143, 95% CI 1.006-1.298) and n (OR 1.167, 95% CI 1.016-1.341) were found to be associated with END respectively after different adjustments. ROC curve analysis with END showed that the AUC, the optimal cut-off value, and its sensitivity and specificity were 0.743 (0.671-0.815), 9.850 mm, and 68.9% and 79.0% for b; 0.724 (0.648-0.801), 10.800 mm, and 57.4% and 80.9% for n; and 0.772 (0.701-0.842), 108.274 mm 2 , and 62.3% and 85.4% for b*n, respectively (b*n vs b: P =0.213; b*n vs n: P =0.037; b vs n: P =0.645)., Conclusions: Our study revealed that besides the ventral type of lesion location, the maximum width of lesion on the transverse plane of DWI and sagittal plane of T 2 image (b, n) may be imaging markers for the development of END in AIPI patients, and the product of the two (b*n) showed a better prediction value on the risks of END., (© 2023. Fondazione Società Italiana di Neurologia.)

Background: We aimed to assess the prevalence of prior anticoagulation therapy (warfarin or non-vitamin K antagonist oral anticoagulants [NOACs]) among patients with acute ischemic stroke (AIS) and atrial fibrillation (AF) in China and investigate the associations between prior anticoagulation therapy and initial stroke severity and in-hospital outcomes., Methods: We included consecutive patients with AIS and known history of AF admitted to hospitals in the China Stroke Center Alliance (CSCA) program from January 2019 to July 2019. Multivariate logistic regression analyses were performed to determine the associations between prior anticoagulation therapy and initial stroke severity and in-hospital outcomes., Results: Of 7181 patients (median [IQR] age, 75.0 [68.0-81.0] years; 48.7% men), 700 (9.7%), 129 (1.8%), and 255 (3.6%) patients received prior subtherapeutic warfarin (international normalized ratio [INR] <2.0), therapeutic warfarin (INR ≥2.0), and NOACs therapy, respectively. A total of 6499 patients had a preadmission CHA 2 DS 2 -VASc score ≥ 2, among whom 94.6% were not adequately anticoagulated. Compared with no prior anticoagulation therapy, prior NOACs therapy was associated with reduced risk of moderate or severe stroke at admission (odds ratio [95% CI], 0.64 [0.43-0.94], P = 0.023) and in-hospital mortality or discharge against medical advice (DAMA) (0.46 [0.24-0.86], P = 0.015). However, no significant association was observed between prior therapeutic warfarin therapy and stroke severity or in-hospital mortality or DAMA., Conclusions: Among patients with AIS and AF in China, the proportion of patients with inadequate anticoagulation prior to stroke remained substantially high. Prior NOACs therapy was associated with reduced stroke severity and less in-hospital mortality or DAMA., Competing Interests: Conflicts of interest The author(s) declare no potential conflicts of interest., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Locked-in syndrome (LiS) is a rare and devastating condition in patients with acute basilar artery occlusion. However, the benefits of endovascular treatment (EVT) for LiS remain unclear., Objective: To assess the outcomes associated with EVT and identify the factors associated with outcomes of LiS., Methods: We used the data of the Endovascular Treatment for Acute Basilar Artery Occlusion Study Registry (BASILAR) from 47 tertiary stroke centers in China. The included patients had LiS and received EVT or standard medical treatment (SMT) alone. The primary outcome was improvement in the modified Rankin Scale (mRS) score at 90 days., Results: Among the 120 patients with LiS, 92 (76.7%) received EVT and 28 (23.3%) received SMT. Compared with SMT, EVT was associated with improved mRS score (common OR (cOR)=2.68 (95% CI 1.16 to 6.20); p=0.02) and decreased mortality (aOR=0.35 (95% CI 0.13 to 0.90); p=0.03). Moreover, the benefit of EVT for LiS was sustained for at least 1 year (p=0.008). Higher baseline posterior circulation Alberta Stroke Prognosis Early CT Score (pc-ASPECTS, aOR=2.04 (95% CI 1.34 to 3.10); p<0.001) and absence of pneumonia (aOR=0.26 (95% CI 0.08 to 0.90); p=0.03) were significantly associated with favorable functional outcome at 90 days in patients who received EVT, while lower pc-ASPECTS (aOR=0.52 (95% CI 0.36 to 0.76); p<0.001) was associated with increased 90-day mortality., Conclusions: This study found that EVT was associated with favorable functional outcomes and decreased mortality among patients with LiS. Baseline pc-ASPECTS and pneumonia were independent predictors of outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Aim: The goal of this study was to determine whether the stress hyperglycemia ratio (SHR) is associated with early neurological deterioration (END) and poor outcomes in patients with single subcortical infarct (SSI)., Methods: For this study, we prospectively enrolled patients with SSI admitted between 2015 and 2021. SHR was distributed in quartiles according to the size of each subgroup. END was defined as an increase of ≥ 2 total points in the National Institutes of Health Stroke Scale (NIHSS) or ≥ 1 point in the motor items of the NIHSS within 7 days of hospital admission. The modified Rankin Scale (mRS) was used to evaluate patient prognosis. Good and poor outcomes were defined as mRS scores ≤2 and >2, respectively. The relationships between SHR and risk of END as well as outcomes were analyzed using multivariate logistic regression models., Results: A total of 1049 patients with SSI with an average age of 59.49 years met the inclusion criteria for the analysis. The incidence of END markedly increased with increasing SHR. Multivariate logistic regression analysis revealed that the highest SHR quartile was independently associated with an increased risk of both END (OR 4.04, 95% CI, 2.43-6.69, P < 0.001) and 3-month poor outcomes (OR 2.34, 95% CI, 1.44-3.82, P = 0.001), compared to the lowest quartile. A receiver operating characteristic curve analysis of the SHR based on the area under the curve showed a diagnostic accuracy equal or greater than fasting plasma glucose., Conclusion: SHR is a reliable predictor of END and poor outcomes in patients with SSI., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: The effect of imaging selection paradigms on endovascular thrombectomy outcomes in patients with acute ischemic stroke with large vessel occlusion remains uncertain. The study aimed to assess the effect of basic imaging (noncontrast computed tomography with or without computed tomographic angiography) versus advanced imaging (magnetic resonance imaging or computed tomography perfusion) on clinical outcomes following thrombectomy in patients with stroke with large vessel occlusion in the early and extended windows using a pooled analysis of patient-level data from 2 pivotal randomized clinical trials done in China., Methods: This post hoc analysis used data from 1182 patients included in 2 multicenter, randomized controlled trials in China that evaluated adjunct therapies to endovascular treatment for acute ischemic stroke (Direct Endovascular Treatment for Large Artery Anterior Circulation Stroke performed from May 20, 2018, through May 2, 2020, and Intravenous Tirofiban Before Endovascular Treatment in Stroke from October 10, 2018, through October 31, 2021). Patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery (M1/M2 segments) were categorized according to baseline imaging modality (basic versus advanced) as well as treatment time window (early, 0-6 hours versus extended, 6-24 hours from last known well to puncture). The primary outcome was the proportion of patients with functional independence (modified Rankin Scale score of 0-2) at 90 days. Multivariable Poisson regression analysis was performed to determine the association between imaging selection modality and outcomes after endovascular treatment at each time windows., Results: A total of 1182 patients were included in this cohort analysis, with 648 in the early (471 with basic imaging versus 177 advanced imaging) and 534 in the extended (222 basic imaging versus 312 advanced imaging) time window. There were no differences in 90-day functional independence between the advanced and basic imaging groups in either time windows (early window: adjusted relative risk, 0.99 [95% CI, 0.84-1.16]; P =0.91; extended window: adjusted relative risk, 1.00 [95% CI, 0.84-1.20]; P =0.97)., Conclusions: In this post hoc analysis of 2 randomized clinical trial pooled data involving patients with large vessel occlusion stroke, an association between imaging selection modality and clinical or safety outcomes for patients undergoing thrombectomy in either the early or extended windows was not detected. Our study adds to the growing body of literature on simpler imaging paradigms to assess thrombectomy eligibility across both the early and extended time windows., Registration: URL: http://www.chictr.org.cn; Unique identifiers: ChiCTR-IOR-17013568 and ChiCTR-INR-17014167., Competing Interests: Disclosures Dr Nogueira reports consulting fees for advisory roles with Anaconda Biomed, Biogen, Cerenovus, Corindus, Imperative Care, Medtronic, Genentech, NeuroVasc Technologies, Perfuze, Phenox, Prolong Pharmaceuticals, RapidPulse, Stryker, Vesalio, and Viz-AI, and stock options for advisory roles with Brainomix, Ceretrieve, Corindus, Perfuze, Vesalio, and Viz-AI, and receiving grants from Cerenovus, and Stryker. Dr Saver reports consulting fees for advisory roles with Biogen, Boehringer Ingelheim (prevention only), BrainQ, BrainsGate, Johnson & Johnson Health Care Systems Inc, Medtronic USA, Roche, and stock options for advisory roles with MindRhythm, Neuronics Medical, and Rapid Medical, and Data And Safety Monitoring fee from MIVI Neuroscience. Dr Nguyen reports research support from Medtronic/SVIN; advisory board Idorsia (unrelated). The other authors report no conflicts.

Objective: Determining the changes in the prognosis of the cerebral infarction area has an important guiding role in the selection of the treatment plan. The goal of this study is to propose a machine learning-based method that can predict the prognosis of stroke effectively and efficiently., Methods: 97 cases of stroke were analyzed retrospectively. Firstly, we extracted vascular structural features from computed tomography angiography (CTA) images and stroke location features from diffusion-weighted imaging (DWI) images to comprehensively characterize the lesions, respectively. Then, we performed sparse representation-based feature selection and classification to predict the prognosis of stroke based on the extracted features. Finally, we randomly divided the 97 cases into cross-validation set, independent testing set 1 and independent testing set 2 to validate the proposed model., Results: 464 vascular structure features and 116 positional features were extracted. After feature selection, 52 features were finally applied to build the classification model. The proposed model achieved promising prediction performance on the two independent testing sets, with the classification accuracies of 85.19% and 81.25%, respectively., Conclusion: The proposed machine learning approach can effectively mine and accurately quantify the features related to the prognosis, which include the vascular structural features and the stroke location features. In addition, the established prognostic prediction model based on these features has achieved interesting performances, which may provide valuable guidance for the clinical treatment of stroke., Competing Interests: Competing interest The authors declare that they have no competing interests., (Copyright © 2023. Published by Elsevier Inc.)

Background: Only a few clinical research had previously investigated the dehydration status to predict the evolution of the ischemic core. The aim of this study is to clarify the association between blood urea nitrogen (BUN)/creatinine (Cr)ratio-based dehydration and infarct volume measured using DWI (Diffusion-weighted imaging) at admission in patients with AIS (Acute Ischemic Stroke)., Methods: We retrospectively recruited a total of 203 consecutive patients who were hospitalized through emergency or outpatient services within 72 h of acute ischemic stroke onset between October 2015 and September 2019. Stroke severity was measured by assessing the National Institutes of Health Stroke Scale (NIHSS) on admission. Infarct volume was measured using DWI with MATLAB software., Results: In this study, 203 patients who met the study criteria were enrolled. Patients in the dehydration group (Bun/Cr ratio>15) had a higher median NIHSS score (6(IQR:4-10) VS. 5(3-7); P = 0.0015)and larger DWI infarct volume (1.55 ml (IQR:0.51-6.79) VS. (0.37 ml (0.05-1.22); P < 0.001) on admission compared with patients in normal group. Further, a statistically significant correlation was found between DWI infarct volumes and NIHSS score with nonparametric Spearman rank correlation (r = 0.77; P < 0.001). The median NIHSS scores for the DWI infarct volumes quartiles were 3 ml (IQR, 2-4), 5 ml (4-7), 6 ml (5-8), and12 ml (8-17) from lowest to highest. However, the second quartile group did not show any significant correlation with the third quartile group (P = 0.4268). Multivariable linear and logistic regression analyses were used to test dehydration (Bun/Cr ratio>15), representing a predictor of infarct volume and stroke severity., Conclusion: Bun/Cr ratio-based dehydration is associated with larger volumes of ischemic tissue measured using DWI and worse neurological deficit assessed by the NIHSS score in acute ischemic stroke., Competing Interests: Conflict of Interest Statement The authors have no conflicts to disclose., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background and Purpose: Symptomatic intracranial atherosclerotic stenosis (sICAS) is associated with a considerable risk of recurrent stroke despite contemporarily optimal medical treatment. Severity of luminal stenosis in sICAS and its haemodynamic significance quantified with computational fluid dynamics (CFD) models were associated with the risk of stroke recurrence. We aimed to develop and compare stroke risk prediction nomograms in sICAS, based on vascular risk factors and these metrics., Methods: Patients with 50%-99% sICAS confirmed in CT angiography (CTA) were enrolled. Conventional vascular risk factors were collected. Severity of luminal stenosis in sICAS was dichotomised as moderate (50%-69%) and severe (70%-99%). Translesional pressure ratio (PR) and wall shear stress ratio (WSSR) were quantified via CTA-based CFD modelling; the haemodynamic status of sICAS was classified as normal (normal PR&WSSR), intermediate (otherwise) and abnormal (abnormal PR&WSSR). All patients received guideline-recommended medical treatment. We developed and compared performance of nomograms composed of these variables and independent predictors identified in multivariate logistic regression, in predicting the primary outcome, recurrent ischaemic stroke in the same territory (SIT) within 1 year., Results: Among 245 sICAS patients, 20 (8.2%) had SIT. The D 2 H 2 A nomogram, incorporating diabetes, dyslipidaemia, haemodynamic status of sICAS, hypertension and age ≥50 years, showed good calibration (P for Hosmer-Lemeshow test=0.560) and discrimination (C-statistic 0.73, 95% CI 0.60 to 0.85). It also had better performance in risk reclassification and provided larger net benefits in decision curve analysis, compared with nomograms composed of conventional vascular risk factors only, and plus the severity of luminal stenosis in sICAS. Sensitivity analysis in patients with anterior-circulation sICAS showed similar results., Conclusions: The D 2 H 2 A nomogram, incorporating conventional vascular risk factors and the haemodynamic significance of sICAS as assessed in CFD models, could be a useful tool to stratify sICAS patients for the risk of recurrent stroke under contemporarily optimal medical treatment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To investigate whether intravenous thrombolysis (IVT) with alteplase (a recombinant tissue plasminogen activator, rt-PA) before endovascular treatment (EVT) is beneficial for acute ischemic stroke (AIS) patients in different periods., Methods: This study enrolled a total of 140 patients hospitalized between 2019 and 2022 with AIS from large vessel occlusion (LVO) in the anterior circulation. Those patients were divided into the EVT alone group and IVT + EVT group, in which EVT was preceded by intravenous rt-PA. According to the time from onset to femoral artery puncture, the above two groups were divided into the following subgroups: < 4.5 h, between 4.5 and 6 h, between 6 and 8 h, and between 8 and 10 h. There were 78 patients in the EVT alone group and 62 patients in the IVT + EVT group., Results: There was no statistically significant difference in functional independence, recanalization rate, favorable outcome rate, or mortality between the EVT and IVT + EVT groups (P > 0.05). After adjusting for confounding factors, a lower incidence of intracerebral hemorrhage was observed in the EVT group (P < 0.05). A comparison of time-dependent efficacy between the two groups showed that within 6-8 h, there were statistically significant differences between admission and postoperation in the National Institutes of Health Stroke Scale scores at 24 h (P = 0.01) or 7 days (P = 0.02)., Conclusions: Although there was no difference in clinical efficacy and safety between the abovementioned two groups, treatment with IVT + EVT could increase the risk of bleeding compared to EVT. Moreover, in the 6-8 h subgroup, the efficacy of EVT alone was better than that of IVT + EVT., (© 2023. The Author(s).)

Evidence showing the association of perfluoroalkylated substance (PFAS) exposure with CVD risk is scarce. The objective of this study was to explore the relationships of CVD risk with mixed or individual serum PFAS levels among general adults. We analyzed combined data of 7904 adults who participated in the National Health and Nutrition Examination Survey 2003-2012 with a Bayesian kernel machine regression (BKMR) to examine the relationships of individual or mixed PFAS exposure with total CVD risk. A logistic regression model and restricted cubic spline (RCS) regression with multivariate adjustment were conducted to assess the relationships between individual serum PFAS levels and the risk of total CVD or its subtypes. A mediation model was applied to investigate how C-reactive protein (CRP) levels mediate the strength of the association. The BKMR results indicated a positive relationship between mixed PFAS exposure and total CVD risk; among the PFASs, perfluorooctane sulfonic acid (PFOS) had the highest posterior inclusion probability. As determined by logistic regression, a log-unit change in PFOS levels was positively related to a higher risk of heart attack and stroke in males (both P < 0.05). A nonlinear relationship was found between PFOS levels and stroke risk (P for nonlinearity = 0.04), as illustrated in the RCS plot. The mediation analysis showed that CRP levels mediated 8% and 1.2% of the relationship between serum PFOS and PFNA levels, respectively, and the prevalence of stroke. A significant relationship between higher serum PFAS concentrations and an increased risk of CVD was observed, mainly in males., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Arterial stiffness index (ASI) is a potential risk factor for cerebrovascular and cardiometabolic diseases, but the causal links between them are inconclusive. The aim is to evaluate the causal effects of ASI on cerebrovascular and cardiometabolic diseases by Mendelian randomization (MR)., Methods: Two-sample MR analysis was performed to infer causal links. Genetic variants significantly associated with ASI were extracted. The inverse variance weighted method was used for estimating the effects. Sensitivity analysis was performed to test heterogeneity or pleiotropy., Results: MR analysis indicated an effect of genetically predicted ASI on the risk of ischemic stroke (IS) of all causes (OR = 1.894, 95% CI 1.210-2.965, p  = 0.005). No links were identified between genetically predicted ASI and other cerebrovascular or cardiometabolic diseases (all p  > 0.05). Subgroup analysis of IS etiologies found a suggestive association between genetically predicted ASI and large artery atherosclerosis stroke (LAS) (OR = 3.726, 95% CI 1.230-11.286, p  = 0.020). There were no effects of ASI on IS due to cardioembolism or small vessel occlusion., Conclusion: The current MR analysis suggested that genetically predicted ASI was associated with higher risk of IS of all causes. The results and the underlying pathways or mechanisms between ASI and IS needs further investigation.

Background: Post-stroke shoulder pain is a relatively common complication in stroke patients, with an incidence of 16% to 84% and poor outcomes with anti-inflammatory or sedative medications. This study will evaluate the results of a randomized controlled trial to determine the effectiveness and safety of Tuina in the treatment of post-stroke shoulder pain., Methods: The Chinese and English search strategies were used to search China National Knowledge Infrastructure, Chinese Scientific Journal Database, Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, PubMed, Wanfang Database, and Web of Science were used to search seven databases. All eligible studies published on or before September 15, 2022, will be selected. To improve the validity of this study, only clinical randomized controlled trials related to the use of Tuina for post-stroke shoulder pain will be included. The screening will be performed by 2 independent reviewers and data synthesis, bias analysis, subgroup analysis, and meta-analysis will be performed using RevMan (V.5.4) software., Results: The study will provide a high-quality evaluation of the effectiveness and safety of Tuina in the treatment of post-stroke shoulder pain., Conclusion: This systematic review will provide evidence to determine whether Tuina is an effective and safe intervention for treating patients with post-stroke shoulder pain.PROSPERO registration number: CRD42022360401., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Immune and inflammatory responses after stroke are important pathophysiological processes. This study explored the relationship between the systemic immune-inflammation index (SII) and stroke prognosis. Patients from the China National Stroke Registry III were investigated. SII was defined as neutrophils × platelets/lymphocytes, and the patients were divided into four groups according to quartiles based on SII values. The primary outcome was poor functional outcome, assessed by the modified Rankin Scale (mRS), defined as an mRS score of ≥3. The secondary outcome was the incidence of all-cause death and recurrent stroke. Data were analyzed using either the logistic regression or Cox regression models. As the SII quartile increased, the percentage of patients with poor functional outcomes increased: 178 (7.8%), 223 (9.8%), 292 (12.8%), and 417 (18.3%) ( P < 0.0001) at the 90-day follow-up and 172 (7.6%), 203 (8.9%), 266 (11.7%), and 386 (17.0%) ( P < 0.0001) at the 1-year follow-up. Compared to patients in the quartile (Q)1 group, those in the Q4 group had a higher risk for adverse events, especially all-cause death at the 90-day follow-up (adjusted hazard ratio [HR], 2.409; 95% confidence interval [CI], 1.273-4.559, P = 0.0069) and at the 1-year follow-up visits (adjusted HR, 2.209; 95% CI, 1.474-3.311, P = 0.0001). The SII was closely related to the short- and long-term prognosis of patients with acute ischemic stroke, and patients with higher SIIs were more likely to have poor outcomes.

Stroke continues to be the most common cause of death in China. It has great significance for mortality prediction for stroke patients, especially in terms of analyzing the complex interactions between non-negligible factors. In this paper, we present a gated spatio-temporal correlation network (GSTCNet) to predict the one-year post-stroke mortality. Based on the four categories of risk factors: vascular event, chronic disease, medical usage and surgery, we designed a gated correlation graph convolution kernel to capture spatial features and enhance the spatial correlation between feature categories. Bi-LSTM represents the temporal features of five timestamps. The novel gated correlation attention mechanism is then connected to the Bi-LSTM to realize the comprehensive mining of spatio-temporal correlations. Using the data on 2275 patients obtained from the neurology department of a local hospital, we constructed a series of sequential experiments. The experimental results show that the proposed model achieves competitive results on each evaluation metric, reaching an AUC of 89.17%, a precision of 97.75%, a recall of 95.33% and an F1-score of 95.19%. The interpretability analysis of the feature categories and timestamps also verified the potential application value of the model for stroke.

Ischemic stroke is the most common type of stroke, ranked as the second leading cause of death worldwide. The Alberta Stroke Program Early CT Score (ASPECTS) is considered as a systematic method of assessing ischemic change on non-contrast CT scans (NCCT) of acute ischemic stroke (AIS) patients, while still suffering from the requirement of experts' experience and also the inconsistent results between readers. In this study, we proposed an automated ASPECTS method to utilize the powerful learning ability of neural networks for objectively scoring CT scans of AIS patients. First, we proposed to use the CT perfusion (CTP) from one-stop stroke imaging to provide the golden standard of ischemic regions for ASPECTS scoring. Second, we designed an asymmetry network to capture features when comparing the left and right sides for each ASPECTS region to estimate its ischemic status. Third, we performed experiments in a large main dataset of 870 patients, as well as an independent testing dataset consisting of 207 patients with radiologists' scorings. Experimental results show that our network achieved remarkable performance, as sensitivity and accuracy of 93.7 and 92.4% in the main dataset, and 95.5 and 91.3% in the independent testing dataset, respectively. In the latter dataset, our analysis revealed a high positive correlation between the ASPECTS score and the prognosis of patients in 90DmRs. Also, we found ASPECTS score is a good indicator of the size of CTP core volume of an infraction. The proposed method shows its potential for automated ASPECTS scoring on NCCT images., (© 2022 The Authors. Human Brain Mapping published by Wiley Periodicals LLC.)

Background and Purpose: Previous studies have reported the association between frailty and stroke or Alzheimer's disease (AD). However, the causality remains unclear. The aim of the present study was to evaluate whether genetically predicted frailty is associated with the risk of stroke or AD by a Mendelian randomization (MR) study., Methods: Genetic variants associated with the frailty index (FI) were obtained from a large genome-wide association study (GWAS). Summary-level data for stroke and AD were adopted from the corresponding large GWAS of individuals of European ancestry. The inverse variance weighted method was used for estimating causal effects. Multivariable analysis was performed for further adjustment., Results: The present MR study indicated a suggestive association between genetically predicted FI and a higher risk of any stroke (odds ratio 1.360, 95% confidence interval 1.006-1.838, p = 0.046). Regarding the subtypes of stroke, genetically predicted FI was associated with a higher risk of large artery atherosclerosis stroke (LAS) (odds ratio 2.487, 95% confidence interval 1.282-4.826, p = 0.007). No causal links were identified between genetically predicted FI and any ischaemic stroke, intracranial haemorrhage, cardioembolic stroke, small artery stroke, AD or AD-by-proxy. Multivariable MR analysis indicated that the association of genetically predicted FI with LAS was attenuated after adjustment for inflammatory bowel disease (p = 0.114)., Conclusions: The MR study suggested that genetically predicted FI may be associated with an increased risk of any stroke. Subgroup analysis indicated a suggestive association between genetically predicted FI and the risk of LAS. The underlying mechanisms need further investigation., (© 2022 European Academy of Neurology.)

Background: This study aims is to explore whether it is feasible to use magnetic resonance texture analysis (MRTA) in order to distinguish favorable from unfavorable function outcomes and determine the prognostic factors associated with favorable outcomes of stroke., Methods: The retrospective study included 103 consecutive patients who confirmed unilateral anterior circulation subacute ischemic stroke by computed tomography angiography between January 2018 and September 2019. Patients were divided into favorable outcome (modified Rankin scale, mRS ≤ 2) and unfavorable outcome (mRS > 2) groups according to mRS scores at day 90. Two radiologists manually segmented the infarction lesions based on diffusion-weighted imaging and transferred the images to corresponding apparent diffusion coefficient (ADC) maps in order to extract texture features. The prediction models including clinical characteristics and texture features were built using multiple logistic regression. A univariate analysis was conducted to assess the performance of the mean ADC value of the infarction lesion. A Delong's test was used to compare the predictive performance of models through the receiver operating characteristic curve., Results: The mean ADC performance was moderate [AUC = 0.60, 95% confidence interval (CI) 0.49-0.71]. The texture feature model of the ADC map (tADC), contained seven texture features, and presented good prediction performance (AUC = 0.83, 95%CI 0.75-0.91). The energy obtained after wavelet transform, and the kurtosis and skewness obtained after Laplacian of Gaussian transformation were identified as independent prognostic factors for the favorable stroke outcomes. In addition, the combination of the tADC model and clinical characteristics (hypertension, diabetes mellitus, smoking, and atrial fibrillation) exhibited a subtly better performance (AUC = 0.86, 95%CI 0.79-0.93; P > 0.05, Delong's)., Conclusion: The models based on MRTA on ADC maps are useful to evaluate the clinical function outcomes in patients with unilateral anterior circulation ischemic stroke. Energy obtained after wavelet transform, kurtosis obtained after Laplacian of Gaussian transform, and skewness obtained after Laplacian of Gaussian transform were identified as independent prognostic factors for favorable stroke outcomes., (© 2022. The Author(s).)

Background: Trimethylamine N-oxide (TMAO) has been recognized as a risk factor for cardiovascular disease. However, the role of TMAO in ischemic stroke remains unclear. As we know, ischemic stroke is a heterogeneous disease with variable pathogenesis. Hence, we aimed to investigate the association between TMAO and stroke recurrence according to etiology subtypes., Methods: A total of 10 756 ischemic stroke/transient ischemic attack patients from the Third China National Stroke Registry were enrolled, and 1-year follow-up data for stroke recurrence were analyzed. TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria was used to classify the etiology subtypes. Plasma TMAO levels were quantified by liquid chromatography-mass spectrometry. The association between TMAO and stroke outcomes was analyzed using Cox regression models. We also conducted a meta-analysis on the association of TMAO levels and stroke risk., Results: Elevated TMAO level was independently associated with the risk of stroke recurrence (Q4 versus Q1: adjusted hazard ratio, 1.37 [95% CI, 1.15-1.64]) in multivariate Cox regression model. After stratification by TOAST subtypes, there was a significant association between TMAO and stroke recurrence in small artery occlusion subtype (adjusted hazard ratio, 1.43 [95% CI, 1.03-2.00]) but not in the others subtype (large-artery atherosclerosis, 1.19 [0.95-1.48]; cardioembolism, 1.54 [0.95-2.48]; others, 1.19 [0.98-1.44]). The meta-analysis reported on stroke recurrence for the highest versus lowest TMAO levels with a pooled hazard ratio of 1.66 (95% CI, 0.91-3.01) and similarly found an increased risk of stroke recurrence., Conclusions: Elevated TMAO level is associated with increased risk of stroke recurrence in patients with small artery occlusion subtype, but this association seems to be attenuated in large-artery atherosclerosis, cardioembolism, and others subtypes.

Clinically, physicians collect the benchmark medical data to establish archives for a stroke patient and then add the follow up data regularly. It has great significance on prognosis prediction for stroke patients. In this paper, we present an interpretable deep learning model to predict the one-year mortality risk on stroke. We design sub-modules to reconstruct features from original clinical data that highlight the dissimilarity and temporality of different variables. The model consists of Bidirectional Long Short-Term Memory (Bi-LSTM), in which a novel correlation attention module is proposed that takes the correlation of variables into consideration. In experiments, datasets are collected clinically from the department of neurology in a local AAA hospital. It consists of 2,275 stroke patients hospitalized in the department of neurology from 2014 to 2016. Our model achieves a precision of 0.9414, a recall of 0.9502 and an F1-score of 0.9415. In addition, we provide the analysis of the interpretability by visualizations with reference to clinical professional guidelines.

It is essential to identify high risk transient ischemic attack (TIA) patients. The previous study reported that the CSR (comprehensive stroke recurrence) model, a neuroimaging model, had a high predictive ability of recurrent stroke. The aims of this study were to validate the predictive value of CSR model in TIA patients and compare the predictive ability with ABCD 3 -I score. Data were analyzed from the prospective hospital-based database of patients with TIA which defined by the World Health Organization time-based criteria. The predictive outcome was stroke occurrence at 90 days. The receiver-operating characteristic (ROC) curves were plotted and the C statistics were calculated as a measure of predictive ability. Among 1186 eligible patients, the mean age was 57.28 ± 12.17 years, and 474 (40.0%) patients had positive diffusion-weighted imaging (DWI). There were 118 (9.9%) patients who had stroke within 90 days. In 1186 TIA patients, The C statistic of CSR model (0.754; 95% confidence interval [CI] 0.729-0.778) was similar with that of ABCD 3 -I score (0.717; 95% CI 0.691-0.743; Z = 1.400; P = 0.1616). In 474 TIA patients with positive DWI, C statistic of CSR model (0.725; 95% CI 0.683-0.765) was statistically higher than that of ABCD 3 -I score (0.626; 95% CI 0.581-0.670; Z = 2.294; P = 0.0245). The CSR model had good predictive value for assessing stroke risk after TIA, and it had a higher predictive value than ABCD 3 -I score for assessing stroke risk for TIA patients with positive DWI., (© 2022. The Author(s).)

Background: TOAST subtype classification is important for diagnosis and research of ischemic stroke. Limited by experience of neurologist and time-consuming manual adjudication, it is a big challenge to finish TOAST classification effectively. We propose a novel active deep learning architecture to classify TOAST., Methods: To simulate the diagnosis process of neurologists, we drop the valueless features by XGB algorithm and rank the remaining ones. Utilizing active learning framework, we propose a novel causal CNN, in which it combines with a mixed active selection criterion to optimize the uncertainty of samples adaptively. Meanwhile, KL-focal loss derived from the enhancement of Focal loss by KL regularization is introduced to accelerate the iterative fine-tuning of the model., Results: To evaluate the proposed method, we construct a dataset which consists of totally 2310 patients. In a series of sequential experiments, we verify the effectiveness of each contribution by different evaluation metrics. Experimental results show that the proposed method achieves competitive results on each evaluation metric. In this task, the improvement of AUC is the most obvious, reaching 77.4., Conclusions: We construct a backbone causal CNN to simulate the neurologist process of that could enhance the internal interpretability. The research on clinical data also indicates the potential application value of this model in stroke medicine. Future work we would consider various data types and more comprehensive patient types to achieve fully automated subtype classification., (© 2022. The Author(s).)

Background: Early neurological deterioration (END) often occurs during hospitalization in single small subcortical infarct (SSSI). While, symptoms on admission were rarely reported about its performance on predicting the risk of END., Objectives: The objective of this study is to explore the relationship between symptoms on admission and END in SSSI., Methods: Patients with SSSI in the lenticulostriate artery (LSA) territory presenting within 72 hours of stroke onset were screened prospectively. Clinical characteristics, including symptoms on admission, laboratory tests and imaging findings, were collected. Based on the body regions involved including spherical face (SF), upper limb (UL) or lower limb (LL), symptoms on admission were classified into single spherical face (sSF) and any involvement of limbs (AL). END was defined as ≥2 points increase in total National Institutes of Health Stroke Scale (NIHSS) score or ≥ 1 point increase in motor score within 72 hours after admission. Multivariate logistic regression was used to analyze factors associated with END., Results: Out of 5,832 ischemic stroke patients in the database, 394 patients were finally enrolled in analysis. 65 patients (16.5%) developed END. Multivariable logistic regression revealed that symptoms with LL (OR 2.337, 95% CI 1.041-5.246), UL (OR 2.936, 95% CI 1.349-6.390) were both associated with END, while the involvement of SF (OR 0.447, 95% CI 0.249-0.804) showed the opposite result. Further analysis found that symptoms with AL (OR 3.958, 95% CI 1.355-11.565) showed a higher risk of END compared to sSF after adjustment., Conclusion: Our results discovered that symptoms with AL carried a higher risk of END than those involving sSF in SSSI., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: Single Small Subcortical Infarction (SSSI) is an isolated small infarction in the territory of perforating artery with a maximum diameter of 20 mm in axial Diffusion-Weighted Imaging (DWI). About 20 to 30% of SSSI patients were reported to have Early Neurological Deterioration (END) in the acute phase, which brought adverse effects on long-term outcomes. The effect of the alteplase on the outcome of SSSI, especially END and long-term outcomes, was ambiguous., Objective: The study aims to find out the efficacy and safety of intravenous recombinant tissue Plasminogen Activator (rt-PA) on long-term and short- outcomes of patients with SSSI as compared to patients who received standard medical care., Methods: The patients were retrospectively screened from a stroke registry of the neurology department of 1st Affiliated Hospital of Zhengzhou University from January 2013 to December 2020. Based on treatment modality, patients were dichotomized into alteplase and standard medical care groups. To minimize confounding factors in subgroups, a propensity score matching analysis was done. The primary outcome was the favorable functional outcome 3 months after stroke onset, defined by attaining a score of ≤2 points on the modified Rankin scale (mRS), secondary outcome was the prevention of occurrence of END, defined as an increase of ≥2 points in the total score or ≥1point on motor subunit in the National Institutes of Health Stroke Scale (NIHSS) score within 72 hours after admission, safety features were symptomatic intracranial hemorrhage (sICH) or death. Multivariate analysis was employed to find the efficacy and safety of alteplase in the treatment of SSSI., Results: A total of 717 patients with anterior circulation SSSI were selected, and 132 were included in the final analysis. Forty-five patients were treated with alteplase within 4.5 hours and 87 with standard medical care, and 44 pairs were successfully matched by propensity score. Pre-match data showed that the alteplase thrombolysis group showed a higher proportion of favorable outcomes at 3-month follow-up [OR=0.315, 95%CI:0.106, 0.931, P = 0.037] but did not reduce the incidence of END compared with the non-thrombolytic group [OR = 1.033, 95%CI:0.417,2.554, P = 0.943]. Post-match data showed that the alteplase group also showed a higher proportion of favorable outcomes at 3-month follow-up [OR = 0.247, 95%CI: 0.074, 0.830, P = 0.024]; however, it did not reduce the incidence of END compared with the non-thrombolytic group [OR = 1.241, 95%CI: 0.433,3.554, P = 0.688]. There was one case of asymptomatic ICH in alteplase treated patients., Conclusion: Patients with SSSI in the anterior circulation are more likely to achieve 3 months favorable outcomes than those who were treated with standard medical care; however, treatment with alteplase may not prevent the occurrence of END., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: Nonvalvular atrial fibrillation (NVAF) affects almost 6 million Americans and is a major contributor to stroke but is significantly undiagnosed and undertreated despite explicit guidelines for oral anticoagulation., Objective: The aim of this study is to investigate whether the use of semisupervised natural language processing (NLP) of electronic health record's (EHR) free-text information combined with structured EHR data improves NVAF discovery and treatment and perhaps offers a method to prevent thousands of deaths and save billions of dollars., Methods: We abstracted 96,681 participants from the University of Buffalo faculty practice's EHR. NLP was used to index the notes and compare the ability to identify NVAF, congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category (CHA 2 DS 2 -VASc), and Hypertension, Abnormal liver/renal function, Stroke history, Bleeding history or predisposition, Labile INR, Elderly, Drug/alcohol usage (HAS-BLED) scores using unstructured data (International Classification of Diseases codes) versus structured and unstructured data from clinical notes. In addition, we analyzed data from 63,296,120 participants in the Optum and Truven databases to determine the NVAF frequency, rates of CHA 2 DS 2 ‑VASc ≥2, and no contraindications to oral anticoagulants, rates of stroke and death in the untreated population, and first year's costs after stroke., Results: The structured-plus-unstructured method would have identified 3,976,056 additional true NVAF cases (P<.001) and improved sensitivity for CHA 2 DS 2 -VASc and HAS-BLED scores compared with the structured data alone (P=.002 and P<.001, respectively), causing a 32.1% improvement. For the United States, this method would prevent an estimated 176,537 strokes, save 10,575 lives, and save >US $13.5 billion., Conclusions: Artificial intelligence-informed bio-surveillance combining NLP of free-text information with structured EHR data improves data completeness, prevents thousands of strokes, and saves lives and funds. This method is applicable to many disorders with profound public health consequences., (©Peter L Elkin, Sarah Mullin, Jack Mardekian, Christopher Crowner, Sylvester Sakilay, Shyamashree Sinha, Gary Brady, Marcia Wright, Kimberly Nolen, JoAnn Trainer, Ross Koppel, Daniel Schlegel, Sashank Kaushik, Jane Zhao, Buer Song, Edwin Anand. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 09.11.2021.)

Background and Purpose: Stroke is the second leading cause of death worldwide and the leading cause of mortality and long-term disability in China, but its underlying risk genes and pathways are far from being comprehensively understood. We here describe the design and methods of whole genome sequencing (WGS) for 10 914 patients with acute ischaemic stroke or transient ischaemic attack from the Third China National Stroke Registry (CNSR-III)., Methods: Baseline clinical characteristics of the included patients in this study were reported. DNA was extracted from white blood cells of participants. Libraries are constructed using qualified DNA, and WGS is conducted on BGISEQ-500 platform. The average depth is intended to be greater than 30× for each subject. Afterwards, Sentieon software is applied to process the sequencing data under the Genome Analysis Toolkit best practice guidance to call genotypes of single nucleotide variants (SNVs) and insertion-deletions. For each included subject, 21 fingerprint SNVs are genotyped by MassARRAY assays to verify that DNA sample and sequencing data originate from the same individual. The copy number variations and structural variations are also called for each patient. All of the genetic variants are annotated and predicted by bioinformatics software or by reviewing public databases., Results: The average age of the included 10 914 patients was 62.2±11.3 years, and 31.4% patients were women. Most of the baseline clinical characteristics of the 10 914 and the excluded patients were balanced., Conclusions: The WGS data together with abundant clinical and imaging data of CNSR-III could provide opportunity to elucidate the molecular mechanisms and discover novel therapeutic targets for stroke., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aims: The association between low-density lipoprotein cholesterol (LDLc) to high-density lipoprotein cholesterol (HDLc) ratio (LDLc/HDLc) and carotid plaques remains controversial. We conducted a cross-sectional study to evaluate whether LDLc/HDLc is associated with carotid plaques in individuals with a high-stroke-risk., Methods and Results: The study initially enrolled 5529 residents aged 40 years or older from Yangzhou, China in 2013-2014. All participants received a questionnaire interview, physical examination, and laboratory tests. Risk factors for stroke included hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, smoking, less exercise, overweight/obesity, and family stroke history. Subjects with at least three of the risk factors or a history of stroke/transient ischemic attack (TIA) were defined as a high-stroke-risk population. Carotid ultrasonography was only conducted for this high-stroke-risk population. Logistic regression was used to examine the association of LDLc/HDLc with the presence of carotid plaques. Final analysis included 839 high-stroke-risk subjects and 40.6% were identified to have carotid plaques. Subjects with the highest tertiles group of LDLc/HDLc had a higher proportion of carotid plaques than the other two groups (47.1% vs. 34.6% and 40.4%, P < 0.001). With each unit increase of LDLc/HDLc, the chance of having carotid plaques increased by 65% (OR 1.65, 95%CI 1.31-2.08) after adjusted for potential confounders. Among most subgroups, a higher LDLc/HDLc was significantly correlated with the presence of carotid plaques., Conclusion: Higher LDLc/HDLc was significantly associated with the presence of carotid plaques in the Chinese population with a high risk of stroke., (Copyright © 2020 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.)

Background and Objective: Patients with transient ischemic attack（TIA）occasionally showed nonfocal symptoms, such as decreased consciousness, amnesia and non-rotatory dizziness. This study intended to evaluate the effect of nonfocal symptoms on the prognosis of patients with TIA., Methods: Data from the prospective hospital-based TIA database of the First Affiliated Hospital of Zhengzhou University were analyzed. The predictive outcome was stroke occurrence at 1 year. Cumulative risks of stroke in patients with and without nonfocal symptoms were estimated with Kaplan-Meier models., Results: We studied 1384 patients with TIA (842 men; mean age, 56±13 years), including 450 (32.5%) with nonfocal symptoms. In the first year after TIA, stroke occurred in 168（12.1%） patients. There was no difference in the risk of stroke between patients with both focal and nonfocal symptoms and patients with focal symptoms alone (11.8% vs 12.4%, log-rank; P=0.691)., Conclusions: The occurrence of nonfocal symptoms did not increase the risk of stroke at one-year follow-up compared to the occurrence of focal symptoms alone., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background and Purpose: Soluble ST2 (sST2) is a promising biomarker in inflammation, atherosclerosis and cardiovascular diseases. We investigated the association between serum sST2 and poor outcome in patients with transient ischaemic attack (TIA)/ischaemic stroke., Methods: Patients within 24 h after onset and with measured serum sST2 were prospectively enrolled in this study. Poor outcome was a combination of a new stroke event (ischaemic or haemorrhagic) and all-cause death within 90 days and 1 year. The associations of serum sST2 with poor outcome were analysed by Cox proportional hazards., Results: Among the 430 patients included, the median (interquartile range) sST2 was 17.72 (9.31-28.84) ng/mL. A total of 19 (4.4%) and 38 (8.8%) patients experienced poor outcome within 90 days and 1 year, respectively. Compared with the lowest sST2 tertile, hazard ratios (HRs) [95% confidence intervals (CI)] for the highest tertile were 5.14 (1.43-18.51) for poor outcome within 90 days and 3.00 (1.29-6.97) at 1 year after multivariate adjustments. Adding sST2 to a prediction model significantly improved risk stratification of poor outcome in TIA/ischaemic stroke, as observed by the continuous net reclassification improvement of 60.98% (95% CI, 15.37-106.6%, P = 0.009) and integrated discrimination improvement of 2.63% (95% CI, 0.08-5.18%, P = 0.043) at 90 days and the continuous net reclassification improvement of 41.68% (95% CI, 8.74-74.61%, P = 0.013) at 1 year., Conclusions: Increased serum sST2 levels in TIA/ischaemic stroke were associated with increased risks of poor outcome within 90 days and 1 year, suggesting that serum sST2 may be a potential long-term prognostic biomarker for TIA/ischaemic stroke., (© 2020 European Academy of Neurology.)

Objectives: To explore the feasibility of texture analysis based on T2-weighted fluid-attenuated inversion recovery (T2-FLAIR) images and apparent diffusion coefficient (ADC) maps in the assessment of the severity and prognosis of ischaemic stroke using the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) scores, respectively., Methods: Overall, 116 patients diagnosed with subacute ischaemic stroke were included in this retrospective study. Based on T2-FLAIR images and ADC maps, 15 texture features were extracted from the ROIs of each patient using grey-level co-occurrence matrix (GLCM) and local binary pattern histogram Fourier (LBP-HF) methods. The correlations of NIHSS score on admission (NIHSS baseline ), NIHSS score 24 h after stroke onset (NIHSS 24h ) and mRS score with the texture features were evaluated using Spearman's partial correlations. The receiver operating characteristic (ROC) curve was used to compare the performance of the selected texture features in the evaluation of stroke severity and prognosis., Results: Texture features derived from the T2-FLAIR images and ADC maps were correlated with NIHSS score and mRS score. Entropy ADC and 0.75Quantile T2-FLAIR showed the best diagnostic performance for assessing stroke severity. The combination of Entropy ADC and 0.75Quantile T2-FLAIR achieved a better performance in the evaluation of stroke severity (AUC = 0.7, p = 0.01) than either feature alone. Only 0.05Quantile T2-FLAIR was found to be correlated with mRS score, and none of the texture features were predictive of mRS score., Conclusion: Texture features derived from T2-FLAIR images and ADC maps might serve as biomarkers to evaluate stroke severity, but were insufficient to predict stroke prognosis., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: While a nursing intervention program for immobile patients with stroke can improve clinic outcomes, less is known about the cost-effectiveness of these interventions., Objectives: The goal of this study was to evaluate the cost-effectiveness of the intervention program for immobile patients with stroke in China., Design: A cost-effectiveness analysis alongside a pre-test/post-test (before and after) study was undertaken from a health care perspective., Settings: Participants were recruited from 25 hospitals among six provinces or municipal cities in eastern (Guangdong province, Zhejiang province, and Beijing municipal city), western (Sichuan province), and central (Henan province and Hubei province) China., Participants: A total of 7,653 immobile stroke patients were included in our sample. Patients in routine care settings were recruited from November 2015 to June 2016, and the recruitment of the intervention group patients was from November 2016 to July 2017., Methods: To adjust for potential bias from confounding variables, the 1:1 propensity score matching yielded matched pairs of 2,966 patients in the routine care group and 2,966 patients in the intervention group, with no significant differences in sociodemographic or clinical characteristics between two groups. All patients were followed-up 3 months after enrolment in the study. Total healthcare costs were extracted from the hospital information system, with the health outcome effectiveness of the intervention program measured using the EuroQol five-dimensional questionnaire (EQ-5D) instrument and the cost-effectiveness of the intervention measured by the incremental cost-effectiveness ratio with a time horizon of 3 months., Results: Compared to routine care, the intervention program decreased the total costs of stroke patients by CN¥4,600 (95% confidence interval [CI]: [-7050, -2151]), while increasing quality-adjusted life year 0.009 (95% CI: [0.005, 0.013]). The incremental cost-effectiveness ratios over 3 months was CN¥-517,011 per quality-adjusted life year (95% CI: [-1,111,442, -203,912]). Subgroup analysis reveals that both the health-related quality of life and cost effectiveness improved significantly for ischemic patients and tertiary hospitals patients while for hemorrhagic patients and non-tertiary hospital patients only the health-related quality of life improved significantly., Conclusions: Findings from this first cost-effectiveness analysis in immobile stroke patients provide evidence that an intervention program provided significant cost saving, but mainly in ischemic patients and tertiary hospital patients. Wider adoption of such programs may be a sensible approach to reducing the burden of stroke and for immobile patients more generally., Competing Interests: Declaration of Competing Interest We declare no competing interests relevant to this manuscript., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Evidence on the association between the non-high-density lipoprotein cholesterol (non-HDLc)-to-high-density lipoprotein cholesterol (HDLc) ratio (non-HDLc/HDLc) and carotid plaques is still limited. This study aims to assess the relationship between the non-HDLc/HDLc and carotid plaques in a population with a high risk of stroke., Methods: A cross-sectional study based on the community was conducted in Yangzhou, China. Residents (no younger than 40 years old) underwent questionnaire interviews, physical examinations, and laboratory testing during 2013-2014. The subjects with a high risk of stroke were further selected (at least three of eight risk factors including hypertension, atrial fibrillation, type 2 diabetes mellitus, dyslipidaemia, smoking, lack of exercise, overweight, and family history of stroke) or a transient ischaemic attack (TIA) or stroke history. Carotid ultrasonography was then performed on the high stroke risk participants. Carotid plaque was defined as a focal carotid intima-media thickness (cIMT) ≥1.5 cm or a discrete structure protruding into the arterial lumen at least 50% of the surrounding cIMT. Logistic regression was employed to evaluate the relationship between the non-HDLc/HDLc and carotid plaques., Results: Overall, 839 subjects with a high risk of stroke were ultimately included in the analysis, and carotid plaques were identified in 341 (40.6%) of them. Participants in the highest non-HDLc/HDLc tertile group presented a higher proportion of carotid plaques than did those in the other two groups. After adjustment for other confounders, each unit increase in the non-HDLc/HDLc was significantly associated with carotid plaques (OR 1.55, 95%CI 1.28-1.88). In the subgroup analysis, the non-HDLc/HDLc was positively and significantly associated with the presence of carotid plaques in most subgroups. Additionally, the non-HDLc/HDLc interacted significantly with three stratification variables, including sex (OR 1.31 for males vs. OR 2.37 for females, P interaction = 0.016), exercise (OR 1.18 for subjects without lack of exercise vs. OR 1.99 for subjects with lack of exercise, P interaction = 0.004) and heart diseases (OR 1.40 for subjects without heart diseases vs. OR 3.12 for subjects with heart diseases, P interaction = 0.033)., Conclusion: The non-HDLc/HDLc was positively associated with the presence of carotid plaques in a Chinese high stroke risk population. A prospective study or randomized clinical trial of lipid-lowering therapy in the Chinese population is needed to evaluate their causal relationship.

Interleukin-33 (IL-33) is known to activate the regulatory T lymphocytes (Tregs), which are negatively correlated with brain damage after ischemic stroke. In this study, we aimed to investigate the role of Tregs in IL-33-mediated neuroprotection and elucidate the underlying mechanisms. In vivo, male C57BL/6 N mice were subjected to 60 min of transient middle cerebral artery occlusion (tMCAO), followed by daily administration of vehicle or IL-33 immediately after injury. Tregs were depleted by intraperitoneal administration of anti-CD25 antibody (anti-CD25Ab). Behavioral changes, brain edema, neuronal injury, Treg percentages, and cytokine expression levels were investigated in each group. In vitro experiments, primary mouse neuronal cells were subjected to oxygen-glucose deprivation (OGD) for 3 h. Vehicle- or drug-conditioned Tregs were applied to the neurons at the time of induction of hypoxia. Neuronal apoptosis and cytokine expression were measured in each group. The results indicate that intraperitoneal administration of anti-CD25Ab reduced CD4 + CD25 + Foxp3+ Tregs, increased infarct volume, enhanced stroke-induced cell death, and decreased sensorimotor functions. Notably, IL-33 increased CD4 + CD25 + Foxp3+ Tregs in the spleen and brain. However, blockading ST2 attenuated these effects of IL-33. The supernatant of the IL-33-treated Treg culture reduced neuronal apoptosis and elevated the production of the Treg cytokines IL-10, IL-35, and transforming growth factor-β (TGF-β). Anti-CD25Ab abrogated the neuroprotective effect of IL-33. Mechanistically, the neuroprotective effects of IL-33 were associated with reduction in apoptosis-related proteins and production of Tregs related cytokines. Overall, these findings showed that IL-33 afforded neuroprotection against ischemic brain injury by enhancing ST2-dependent regulatory T-cell expansion and activation via a mechanism involving anti-apoptosis proteins and cytokines, representing a promising immune modulatory target for the treatment of stroke., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier Inc.)

Background: Tong Jing Tiao Xing tuina (TJTX) is a Chinese massage method. Excising with scalp acupuncture (ESA) is a treatment combining scalp electroacupuncture with physical therapy (PT), and yinao fujian formula (YNFJ) is a Chinese oral herbal granule medicine. The combination of the 3 methods is called the "Zhishen Tiaoxing" (ZSTX) rehabilitation program, which is used as an alternative of limb spasm after stroke. There is little available evidence demonstrating its safety and efficacy., Methods: This will be a subject-blind, randomized controlled trial conducted in 3 medical centers. It will strictly follow the Standards for Reporting Interventions in Clinical Trials of Acupuncture, 2010. We will recruit 316 patients with limb spasm after stroke, 200 from the Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, China, 80 from the Second Affiliated Hospital of Heilongjiang University of Chinese medicine, Harbin, China, and 36 from Huashan Hospital of Fudan University, Shanghai, China. A block randomization sequence stratified by centers will be generated using SAS Version 9.2 software (SAS Institute, Cary, NC, USA), which was performed at the Guangdong Provincial Hospital of Chinese Medicine's Key Unit of Methodology in Clinical Research. The treatment group is treated with TJTX (once a day), ESA (once a day), and oral YNFJ (twice a day). The control group will be treated with PT. Two groups of patients will be treated 5 sessions a week for 4 weeks, and there will be 6-month follow-up. The outcome evaluators will be blinded to patient grouping. The primary outcome will be modified Ashworth scales. The secondary outcome indexes will be the simplified Fugl-Meyer assessment scale, surface electromyogram root mean square value, modified Barthel index, stroke-specific quality of life scale, health scale of traditional Chinese medicine, visual analogue scale (VAS), and the Hamilton depression scale., Discussion: The Randomized Controlled Trial (RCT) mainly aim to evaluate the effectiveness and safety of traditional Chinese medicine rehabilitation program, by comparing the treatment of ZSTX with the PT for the treatment of limb spasm after stroke., Trial Registration: Chinese Clinical Trial Registry: ChiCTR 1900024255. Registered on July 3, 2019.

Background: Stroke outpatients have a high risk of falling. However, fall prevention measures in the community are insufficient to effectively reduce the fall rate among outpatients with stroke. We aimed to determine the correlation between fall prevention knowledge and behavior among outpatients with stroke and provide new strategies for community fall prevention., Methods: We recruited 124 patients with stroke who were followed up in the outpatient department of a tertiary hospital in Zhuhai, China. Patients were assessed using a general information questionnaire, a fall prevention knowledge questionnaire for patients with stroke, and the Stroke Fall Prevention Behavior Scale. IBM SPSS 22.0 software was used for statistical analysis., Results: The median fall prevention knowledge was 82.76 (68.97, 93.10) points, out of 100. The mean (SD) score for fall prevention behavior was 2.90 (0.52; range, 1-4) points. Fall prevention knowledge scores were positively related to those fall prevention behavior (Spearman r = 0.454, P < .01)., Conclusion: Levels of fall prevention knowledge among outpatients with stroke were adequate, and this population had medium to high levels of fall prevention behavior. Better knowledge was accompanied with better prevention of falls. However, whether enriching the knowledge could lead to improvement of fall prevention is still undetermined.

Background: Immobility complications, including pressure injuries (PIs), deep vein thrombosis (DVT), pneumonia, and urinary tract infections (UTIs), affect the clinical outcomes of stroke patients. A standardized nursing intervention model (SNIM) was constructed and implemented to improve the quality of care and clinical outcomes among immobile patients with stroke., Aims: To assess the benefit of SNIM for immobility complication rates, including PIs, DVT, pneumonia, and UTIs, and mortalities in immobile patients with stroke., Methods: A before and after study design was used. Patients were divided into a pre- and post-SNIM training original cohort and matched for socioeconomic, demographic, and disease characteristics using propensity score. We fitted logistic regression models to examine the effect of SNIM, and whether the benefit differed between tertiary and non-tertiary hospitals., Results: In the original cohort, the rate of pneumonia, UTIs, and mortality was lower after SNIM training. Furthermore, in the matched cohort, the difference in PI rates was significant. Logistic regression analysis revealed that the probability of PIs, pneumonia, UTIs, and mortality were significantly reduced after SNIM training in the original cohort and this estimated value changed little in the matched cohort. Our results show that the decreased rates of pneumonia, UTIs, and mortality were mainly among non-tertiary hospitals., Conclusions: A structured and systematic SNIM benefited immobile stroke patients' clinical outcomes, but mainly in non-tertiary hospitals in China. Standardized nursing training is needed in non-tertiary hospitals.

Background: Early prediction of unfavorable outcome after ischemic stroke is of great significance to the clinical and therapeutic management. A nomogram is a better visual tool than earlier models and prognostic scores to predict clinical outcomes, which incorporates different factors to develop a graphic continuous scoring system and calculates accurately the risk probability of poor outcome entirely based on individual characteristics. However, to date, no nomogram models have been found to predict the probability of 6-month poor outcome after ischemic stroke. We aimed to develop and validate a nomogram for individualized prediction of the probability of 6-month unfavorable outcome in Chinese patients with ischemic stroke., Methods: Based on the retrospective stroke registry, a single-center study which included 499 patients from May, 2013 to May, 2018 was conducted in Nanjing First Hospital (China) for ischemic stroke within 12 h of symptoms onset. The main outcome measure was 6-month unfavorable outcome (mRS > 2). To generate the nomogram, NIHSS score on admission, Age, previous Diabetes mellitus and crEatinine (NADE) were integrated into the model. We assessed the discriminative performance by using the area under the curve (AUC) of receiver-operating characteristic (ROC) and calibration of risk prediction model by using the Hosmer-Lemeshow test., Results: A visual NADE nomogram was constructed that NIHSS score on admission (OR: 1.190, 95%CI: 1.125-1.258), age (OR: 1.068, 95%CI: 1.045-1.090), previous diabetes mellitus (OR: 1.995, 95%CI: 1.236-3.221) and creatinine (OR: 1.010, 95%CI: 1.002-1.018) were found to be significant predictors of 6-month unfavorable outcome after acute ischemic stroke in Chinese patients. The AUC-ROC of nomogram was 0.791. Calibration was good (p = 0.4982 for the Hosmer-Lemeshow test)., Conclusion: The NADE is the first nomogram developed and validated in Chinese ischemic stroke patients to provide an individual, visual and precise prediction of the risk probability of 6-month unfavorable outcome.

Background and Purpose: Previous studies have shown that common variants within CYP3A4 and CYP3A5 are associated with statin pharmacokinetics and the risk of cardiovascular disease. However, the association of variants in CYP3A4 and CYP3A5 with the prognosis of ischemic stroke remains undetermined. Therefore, we investigated this herein., Methods: Four hundred thirty-three consecutive patients with acute ischemic stroke were recruited. The outcome at the 1-year follow-up was assessed using the modified Rankin Scale (mRS). Two variants, CYP3A4*1G and CYP3A5*3, were genotyped by the improved Multiple Ligase Detection Reaction platform., Results: Binary logistic regression analysis showed that the CYP3A4*1G/*1G homozygote was associated with poor outcome at 1 year (mRS score ≥2) after adjustment for conventional factors in the additive model (odds ratio [OR] = 2.92; 95% confidence interval, 1.07-7.98; P = .037) and recessive model (OR = 3.37; 95% confidence interval, 1.26-9.04; P = .016). Subgroup analysis indicated that the CYP3A4*1G/*1G homozygote was associated with poor prognosis at 1 year among patients with stable high-intensity atorvastatin therapy (40-80 mg/d) after adjustment for conventional factors in the additive model (OR = 8.16; 95% confidence interval, 1.50-44.44; P = .015) and recessive model (OR = 9.06; 95% confidence interval, 1.72-47.64; P = .009). No significant association was identified between CYP3A5*3 and the 1-year outcome of patients with ischemic stroke., Conclusions: Our study findings suggest that the CYP3A4*1G/CYP3A4*1G genotype may be associated with poor prognosis at 1 year after acute ischemic stroke in the Han Chinese population., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Recently, the NIHSS STroke Scale score, Age, pre-stroke mRS score, onset-to-treatment Time (START nomogram) predicts 3-month functional outcome after intravenous thrombolysis in ischemic stroke patients. However, this model has not yet been an external validation. We aim to validate the performance of START nomogram., Methods: Data were derived from the stroke center of the Nanjing First Hospital (China). Patients who lacked the necessary data to calculate the nomogram and missed 3-month modified Ranking scale scores were excluded. Modified Rankin Scale score more than 2 at 3-month was assessed as an unfavorable outcome. We used areas under the receiver operator characteristic curves (AUC-ROC) to quantify the prognostic value. Calibration was assessed by calibration plots and Hosmer-Lemeshow (HL) goodness of fit test., Result: The final cohort included 306 eligible patients. For 3-month unfavorable outcome, the AUC-ROC of the START nomogram was .766 (95%CI: .7013-.8304, P < .0001), suggesting good discrimination in the START nomogram. It also showed good calibration (HL goodness of fit test P = .1261) in the external validation sample., Conclusion: The START nomogram with good predictive performance is a reliable and simple clinical instrument to predict unfavorable outcome after acute stroke., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background and Purpose: Several clinical trials have demonstrated that dual antiplatelet therapy (DAPT) benefited patients with transient ischaemic attack (TIA) with an ABCD2 score ≥4. The present study aimed to investigate whether the ABCD3-I score could be a more appropriate tool for selection of patients with TIA to receive DAPT in real-world settings., Methods: We derived data from the TIA database of The First Affiliated Hospital of Zhengzhou University. The predictive outcome was ischaemic stroke at 90 days. The additive interaction effect was presented by the attributable proportion due to interaction. Kaplan-Meier curves were plotted to present cumulative stroke rates in different risk categories with monotherapy and DAPT. Cox proportional hazards regression was used to determine risk factors associated with stroke., Results: Among 785 patients, the mean (SD) age was 56.95 (12.73) years and 77 patients (9.8%) had an ischaemic stroke at 90 days. A total of 55.8% of patients (attributable proportion due to interaction; 95% confidence interval, 20.8%-90.9%) were attributed to additive interaction of ABCD3-I score and antiplatelet therapy. Kaplan-Meier curves showed a significant difference between patients receiving monotherapy and DAPT in high-risk patients with TIA (P = 0.021). DAPT reduced 90-day stroke risk in high-risk patients with TIA as assessed independently by ABCD3-I score (adjusted hazard ratio, 0.43; 95% confidence interval, 0.20-0.92, P = 0.031). The benefit did not exist in low- and medium-risk patients by ABCD3-I score (patients with ABCD2 score ≥ 4 or <4)., Conclusions: High-risk patients with TIA assessed by ABCD3-I score received the most pronounced clinical benefit from early use of DAPT in real-world clinical experience., (© 2018 EAN.)

Background: About 40% of acute ischemic stroke patients are under antiplatelet pretreatment. Previous studies have shown conflicting results on the effect of prior antiplatelet agents on post thrombolytic clinical outcomes., Methods: A systematic search using PubMed and EMBASE databases for eligible studies. Prior antiplatelet safety was measured by symptomatic intracerebral hemorrhage (sICH) and mortality. Efficacy was measured by functional independence and favorable functional outcome., Results: Crude analysis indicated that antiplatelet pretreatment was associated with sICH and mortality. In adjusted analysis, the results confirmed a nonsignificant association between antiplatelet pretreatment and a higher risk of sICH and mortality, but demonstrated that antiplatelet pretreatment tended to improve functional independence and favorable functional outcome. Subgroup analysis detected a racial disparity in prior antiplatelet effect on sICH and the association between antiplatelet pretreatment and sICH was dependent on different antiplatelet regiments., Conclusion: There was no significant difference in sICH and mortality between patients with and without antiplatelet pretreatment. Besides, antiplatelet pretreatment did not adversely affect the efficacy outcomes. The prevalence of sICH among Asians receiving antiplatelet pretreatment was relatively high. Additionally, it needs to be noticed that the effect of preexisting antiplatelet on clinical outcomes may be dependent on post thrombolytic antiplatelet regiments.

To determine whether positive or negative DWI TIA patients could get benefits from HST we conducted a cohort study which data from the prospective, hospital-based, TIA database of the First Affiliated Hospital of Zhengzhou University. The end-point was 7-day and 90-day incidence of stroke. Cox proportional hazard regression models were used to analyze the association between end-points and high-intensity statin treatment in TIA patients with positive and negative DWI. A total of 987 eligible TIA patients were analyzed. The stroke risk of patients with positive DWI was about a four-fold increase compared to that with negative DWI (7 d, 10.9 versus 1.8, p < 0.001 and 90 d, 18.3 versus 4.2, p < 0.001). After adjusting confounding factors, HST significantly improved both 7-day (HR 0.331, 95% CI 0.165-0.663; p = 0.002) and 90-day (HR 0.480, 95% CI 0.288-0.799; p = 0.005) outcomes in positive DWI patients. As a conclusion, high-intensity statin use reduces the 90 days' recurrent stroke risk in DWI-positive TIA patients but not in DWI-negative patients.

Background: Accurate prognostication of unfavorable outcome made at the early onset of stroke is important to both the clinician and the patient management. This study was aimed to develop a nomogram based on the integration of parameters to predict the probability of 3-month unfavorable functional outcome in Chinese acute ischemic stroke patients., Methods: We retrospectively collected patients who underwent acute ischemic stroke at Stroke Center of the Nanjing First Hospital (China) between May 2013 and May 2018. After exclusion, the study population includes 1,025 patients for nomogram development. The main outcome measure was 3-month unfavorable outcome (modified Rankin Scale > 2). Multivariable logistic regression analysis was used to develop the predicting model, and stepwise logistic regression with the Akaike information criterion was utilized to find best-fit nomogram model. We incorporated the creatinine, fast blood glucose, age, previous cerebral hemorrhage, previous valvular heart disease, and NHISS score (COACHS), and these factors were presented with a nomogram. We assessed the discriminative performance by using the area under curve (AUC) of receiver-operating characteristic (ROC) and calibration of risk prediction model by using the Hosmer-Lemeshow test., Results: Multivariate analysis of the 1,025 patients for logistic regression helped identify the independent factors as National Institutes of Health Stroke Scale score on admission, age, previous valvular heart disease, fasting blood glucose, creatinine, and previous cerebral hemorrhage, which were included in the COACHS nomogram. The AUC-ROC of nomogram was 0.799. Calibration was good (p = 0.1376 for the Hosmer-Lemeshow test)., Conclusions: The COACHS nomogram may be used to predict unfavorable outcome at 3 months after acute ischemic stroke in Chinese population. It may be also a reliable tool that is effective in its clinical utilization to risk-stratify acute stroke patients., (© 2019 S. Karger AG, Basel.)