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Background: Development of acute ischemic stroke in hospitalized patients represents a significant proportion of all cerebral ischemia. Several prehospital stroke scales were developed to screen for acute ischemic stroke in the community. Despite the advent of inpatient stroke alert systems, there is a lack of validated screening tools for the inpatient population. This study aims to assess the validity of BE-FAST (Balance, Eyes, Face, Arm, Speech, Time) as a screening tool for acute ischemic stroke among inpatients., Methods: We retrospectively analyzed all stroke alert activations at a single academic medical center between 2012 and 2016. We classified the triggering symptom as: focal neurologic deficit, aphasia, dysarthria, ataxia/vertigo/dizziness, alteration of consciousness, acute confusion, or headache. BE-FAST was applied retrospectively, and patients were classified as BE-FAST positive or negative. The final diagnosis was classified as acute ischemic stroke, transient ischemic attack , intracranial hemorrhage or noncerebrovascular diagnosis., Results: Of 1965 stroke alerts, 489 were among inpatients. The mean age was 63 ± 16.1 years; 57% of patients were women (n = 1121). Acute ischemic stroke was diagnosed in 29% of all the activations (n = 567), transient ischemic attack in 12% (n = 232), intracranial hemorrhage in 8 % (n = 160) and noncerebrovascular in 51% (n = 1006). When comparing inpatient with community-onset stroke alerts, the sensitivity of BE-FAST for diagnosing acute ischemic stroke was 85% versus 94% (P = .005), with a specificity of 43% versus 23% (P < .001), respectively. However, when evaluating in-patients with an intact level of consciousness separately, BE-FAST sensitivity for diagnosing acute ischemic stroke was 92% compared to 94% in the community (P = .579). Among in-patients with acute ischemic stroke who were (1) candidates for reperfusion therapy and (2) diagnosed with acute large vessel occlusion, the sensitivity of BE-FAST was 83% and 94%, respectively., Conclusions: This is the first study to analyze the performance of BE-FAST among hospitalized patients evaluated through the inpatient stroke alert system. We found BE-FAST to be a very sensitive tool for screening for all in-hospital acute ischemic strokes, including inpatients that were candidates for acute reperfusion therapy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Aim: Patients with in-hospital acute ischemic stroke (AIS) have, in general, worse outcomes compared to those presenting from the community, partly attributed to the numerous contraindications to intravenous thrombolysis. We aimed to identify and analyze a group of patients with in-hospital AIS who remain suitable candidates for acute endovascular therapies., Methods: A retrospective 6-year data analysis was conducted in patients evaluated through the in-hospital stroke alert protocol in a single tertiary care university hospital to identify those with in-hospital AIS due to acute intracranial large vessel occlusion (ILVO). Feasibility and safety of mechanical thrombectomy for in-hospital AIS was assessed in a case-control study comparing inpatients to those presenting from the community., Results: From 1460 in-hospital stroke alert activations, 11% had a final diagnosis of AIS (n = 167). One hundred and two patients with in-hospital AIS had emergent intracranial vessel imaging and were included in our cohort. Acute ILVO was identified in 27 patients within this cohort. Patients were younger in the ILVO group and had more severe neurologic deficit on presentation. Compared to a matched (1:2) control group of patients presenting from the community, inpatients who underwent mechanical thrombectomy achieved equivalent technical success, safety, and clinical outcomes., Conclusions: The incidence of acute ILVO in patients with in-hospital AIS who underwent emergent vessel imaging is similar to the reported incidence of ILVO in patients presenting with community-onset AIS. Among patients with in-hospital AIS secondary to ILVO, mechanical thrombectomy is a feasible and safe therapy associated with favorable outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Despite the assumption that dementia is increasing in rural areas of Latin America, there is no information on the burden and risk factors leading to dementia in these settings., Aims: To assess prevalence and incidence of dementia, and its cerebrovascular correlates in an established cohort of community-dwelling older adults living in rural Ecuador, and to explore the impact of dementia on functional disability and the role of the social determinants of health in the above-mentioned relationships., Design: Population-based, cohort study with cross-sectional and longitudinal components. Baseline clinical interviews will focus on the assessment of cognitive performance and dementia by means of the clinical dementia rating scale (CDRS). Functional disability and social determinants of health will be correlated with CDRS scores. In addition, participants will undergo interviews and procedures to assess cardiovascular risk factors and signatures of brain damage, cerebral small vessel disease, and other stroke subtypes. The CDRS and the Functional Activities Questionnaire will be administered every year to assess the rate of incident dementia and the severity of functional disability. Neuroimaging studies will be repeated at the end of the study (5 years) to assess the impact of newly appeared cerebral and vascular lesions on cognitive decline., Comment: This study will allow determine whether cerebrovascular diseases are in the path of dementia development in these rural settings. This may prove cost-effective for the development of preventive strategies aimed to control modifiable factors and reduce disability in patients with dementia living in underserved populations., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Information on the relationship between the diameters of the abdominal aorta (AA) and the basilar artery (BA) is limited. Using the Atahualpa Project cohort, we aimed to assess this association in Atahualpa residents aged ≥ 60 years., Materials and Methods: Atahualpa residents aged ≥ 60 years underwent abdominal ultrasound and MRA of intracranial vessels. The independent association between both arterial diameters was estimated in a generalized linear model adjusted for demographics, cardiovascular risk factors, the presence of a fetal-type Circle of Willis, and severity of white matter hyperintensities. Fractional polynomials were fitted to model the relationship between AA and BA diameters., Results: The mean age of 277 participants was 69.5 ± 7.7 years (61% women). The mean AA diameter was 19.8 ± 3.3 mm, and the mean BA diameter was 3.1 ± 0.7 mm. The mean diameters of both arteries were significantly higher in men than in women. Locally weighted scatterplot smoothing showed a non-linear relationship between both arterial diameters. Fractional polynomial models showed that AA and BA diameters had a significant non-linear association in men (p = 0.005), but not in women (p = 0.315). When sex was excluded from a generalized linear model, the relationship between both arterial diameters became significant (p = 0.017)., Conclusion: In this population of community-dwelling older adults, the relationship between AA and BA diameters was confined to men. The finding of a large AA diameter in men should prompt the investigation of the intracranial vasculature because of the possibility of BA ectasia.

Background: Little is known on factors influencing cognitive function in rural communities. Using the Atahualpa Project cohort, we aimed to assess whether the carotid intima-media thickness (cIMT) - used as a surrogate of extracranial carotid atherosclerosis - is associated with cognitive performance and further decline in community-dwelling adults living in a rural setting., Methods: The study included Atahualpa residents aged greater than or equal to 40 years who had ultrasound examination of the extracranial carotid arteries and a baseline Montreal Cognitive Assessment (MoCA), as well as the subset of individuals who also had a follow-up MoCA at least 1 year after baseline. Relationship between cIMT and cognitive function was assessed by means of generalized linear and longitudinal models, adjusted for relevant covariates. Mediation analysis was utilized to establish the proportion of the effect between increased cIMT and cognitive performance, which is mediated by age., Results: A total of 561 individuals were included for the cross-sectional study, and 510 of them were assessed for the prospective cohort. Univariate analysis showed a significant association between increased cIMT and worse cognitive performance (P < .001), which vanishes after considering the effect of age and low scholarity. Causal mediation analysis confirms that age captures 82.6% (95% C.I.: 63.9% to 100%) of the effect of this association. There was no relationship between increased cIMT and cognitive decline in the follow-up., Conclusions: In this rural population, the association between increased cIMT and cognitive dysfunction is mostly mediated by increasing age., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Evidence of the relationship between periodic limb movements during sleep (PLMS) and cerebral small vessel disease (cSVD) is limited and inconsistent. Here, we aimed to assess the independent association between PLMS and the different neuroimaging signatures of cSVD., Methods: Atahualpa residents aged more than or equal to 60 years enrolled in the Atahualpa Project undergoing polysomnography and MRI with time intervals less than or equal to 6 months were included. MRI readings focused on white matter hyperintensities (WMH) of presumed vascular origin, deep cerebral microbleeds (CMB), silent lacunar infarcts (LI), and more than 10 enlarged basal ganglia-perivascular spaces (BG-PVS). Data from single-night polysomnograms were interpreted according to recommendations of the American Academy of Sleep Medicine. Associations between the PLMS index and neuroimaging signatures of cSVD (as dependent variables) were assessed by means of logistic regression models, adjusted for relevant confounders., Results: A total of 146 individuals (mean age: 71.4 ± 7.5 years; 64% women) were included. A PLMS index more than or equal to 15 per hour were noted in 48 (33%) participants. Moderate-to-severe WMH were present in 33 individuals (23%), deep CMB in 9 (6%), silent LI in 16 (11%), and more than 10 BG-PVS in 44 (30%). In univariate analyses, silent LI (P = .035) and the presence of more than 10 enlarged BG-PVS (P = .034) were significantly higher among participants with a PLMS index more than or equal to 15 per hour. However, fully-adjusted multivariate models showed no significant association between PLMS index more than or equal to 15 per hour and any of the neuroimaging signatures of cSVD., Conclusions: This study shows no independent association between the PLMS index and neuroimaging signatures of cSVD in stroke-free community-dwelling older adults., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Pineal gland calcification (PGC) has been associated with low melatonin production, a hormone with anti-oxidant, anti-inflammatory, and neuro-protective effects. Therefore, melatonin deficiency may play a role in the development of cerebral small vessel disease (cSVD), a condition that is partly related to upregulation of oxidative and inflammatory mechanisms leading to endothelial dysfunction, breakdown of the blood-brain barrier, and impaired interstitial fluid drainage. In this study, the association between PGC (a surrogate for melatonin deficiency) and white matter hyperintensities (WMHs) of presumed vascular origin (a biomarker of cSVD) was assessed in Atahualpa cohort individuals aged ≥60 years undergoing head CT and brain MRI. PGC was rated as none-to-mild and moderate-to-severe. WMHs were classified according to the modified Fazekas scale. A logistic regression model was fitted to assess the independent association between moderate-to-severe PGC and WMHs. Inverse probability of exposure weighting was used to estimate the effect of PGC on WMH. Of 373 individuals, 96 (26%) had moderate-to-severe PGC and 86 (23%) had moderate-to-severe WMHs. Moderate-to-severe PGC and WMH were independently associated in a fully-adjusted logistic regression model (OR: 2.21; 95% C.I.: 1.19-4.11; p = 0.012). Inverse probability of exposure weighting showed an estimate for the proportion of moderate-to-severe WMH among those with none-to-mild PGC of 20.5%, and the exposure-effect was 13.2% higher among those with moderate-to-severe PGC (β: 0.132; 95% C.I: 0.036-0.229; p = 0.007). The association found in this study provides grounds for further evaluation of the role of melatonin deficiency in cSVD development., 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 © 2019 Elsevier Ltd. All rights reserved.)

Stroke survivors carry a high risk of recurrence. Antithrombotic medications are paramount for secondary prevention and thus crucial to reduce the overall stroke burden. Appropriate antithrombotic agent selection should be based on the best understanding of the physiopathological mechanism that led to the initial ischemic injury. Antiplatelet therapy is preferred for lesions characterized by atherosclerosis and endothelial injury, whereas anticoagulant agents are favored for cardiogenic embolism and highly thrombophilic conditions. Large randomized controlled trials have provided new data to support recommendations for the evidence-based use of antiplatelet agents and anticoagulant agents after stroke. In this review, the authors cover recent trials that have altered clinical practice, cite systematic reviews and meta-analyses, review evidence-based recommendations based on older landmark trials, and indicate where there are still evidence-gaps and new trials being conducted., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Perivascular spaces (PVS) are involved in mechanisms of brain interstitial fluid and metabolic waste clearance. Since most of this clearance occurs during sleep, it is plausible that sleep-related disorders favor PVS dilatation. Knowledge on the association between enlarged basal ganglia (BG) PVS and sleep disorders is limited. Here, we aimed to assess the association between sleep parameters and enlarged BG-PVS in older adults., Patients and Methods: Atahualpa residents aged ≥60 years were interviewed with the Pittsburgh sleep quality index and underwent MRI for identification of enlarged BG-PVS and other neuroimaging signatures of cerebral small vessel disease. Then, a representative random sample of the study population underwent a single-night polysomnography (PSG). Using logistic regression models, we evaluated whether sleep quality, sleep efficiency and the apnea-hypopnea index (AHI) associate with enlarged BG-PVS, after adjusting for demographics, cardiovascular risk factors, neuroimaging signatures of cerebral small vessel disease and other relevant confounders., Results: The association between sleep quality and enlarged BG-PVS, assessed in 338 individuals, was significant in the univariate model, but the significance was taken away by the effect of confounders. The association between PSG parameters and enlarged BG-PVS was assessed in a random sample of 97 individuals. Logistic regression models showed a significant association between poor sleep efficiency and enlarged BG-PVS (p = 0.045). In contrast, there was no association between the AHI and BG-PVS., Conclusion: Poor sleep efficiency is independently associated with enlarged BG-PVS, suggesting that sleep may influence structural changes in these fluid-filled cavities., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background and Purpose: Emergent evaluation of inpatients with suspected acute ischemic stroke faces difficulty of symptoms recognition, false alarms, and high rate of contraindications to reperfusion therapies. We aim to assess the clinical characteristics and therapeutic interventions implemented in patients evaluated though the in-hospital Stroke Alert Protocol., Methods: We analyzed 4 years-worth of Stroke Alert cases at a university hospital. Demographics, clinical presentation, final diagnosis, and acute interventions were compared between inpatients and those presenting to the emergency department., Findings: A total of 1965 Stroke Alert cases were included: 959 (48.8%) were acute cerebrovascular events and 1006 (51.2%) were noncerebrovascular. Hospitalized patients accounted for 489 (24.9%) of Stroke Alerts and patients in the emergency department for 1476 (75.1%). Inpatients were more likely to present with nonfocal neurological deficits (46.2% versus 32.4%, P < .0001) and be diagnosed with noncerebrovascular disorders (62.4% versus 47.5%, P < .0001). Acute interventions other than thrombolysis were delivered in 77.1% of in-hospital cases. Compared to the emergency department, inpatients were more commonly managed with rectification of metabolic abnormalities (21.5% versus 13.7%, P < .001), suspension or pharmacological reversal of drugs (11% versus 3.7%, P < .001), and initiation of respiratory support (13.5% versus 9.3%, P = .01). Inpatients with acute ischemic stroke received intravenous thrombolysis less frequently (4.9% versus 23.9%, P < .001), but the endovascular treatment rate was comparable (9.8% versus 10.3%) to the emergency department., Conclusion: Nonfocal neurological deficits and noncerebrovascular disorders are commonly encountered during in-hospital Stroke Alerts. In the inpatient setting, intravenous thrombolysis is rarely delivered while other time-sensitive therapeutic interventions are frequently implemented., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Basilar artery (BA) dolichoectasia has been associated with cerebral small vessel disease (SVD). However, studies have focused on stroke patients, and results cannot be extrapolated to the population at large. In this study, we aimed to assess prevalence of BA dolichoectasia and its association with SVD in community-dwelling older adults living in rural Ecuador., Methods: Atahualpa residents aged ≥60 years underwent brain magnetic resonance imaging and magnetic resonance angiography of intracranial vessels. Following Smoker's criteria, the mean BA diameter plus 2 standard deviation defined ectasia. In addition, a location lateral to the lateral margin of the clivus of dorsum sellae or a bifurcation at the third ventricle floor or higher defined dolichosis. Associations between BA abnormalities and imaging markers of SVD were assessed by the use of regression models adjusted for demographics and cardiovascular risk factors., Results: Of 346 participants, 11 (3.2%) had ectasia, 40 (11.6%) had dolichosis, and 47 (13.6%) had dolichoectasia (ectasia, dolichosis, or both). BA diameter was only associated with severity of white matter hyperintensities (P = .038). Dolichosis was associated with deep cerebral microbleeds (P = .002) but not with white matter hyperintensities. Dolichoectasia was associated with both white matter hyperintensities (P = .031) and cerebral microbleeds (P = .001). There were no associations with lacunar infarcts or enlarged perivascular spaces in any model., Conclusions: Prevalence of BA dolichoectasia in this rural setting is similar to that reported in other populations. Associations with imaging markers of SVD differ according to whether the subject has ectasia or dolichosis., (Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Studies in industrialized nations suggest that severe edentulism correlates with cognitive impairment, but there is little information on this association in underserved populations. We conducted a community-based study to assess whether edentulism associates with cognitive impairment in elders living in rural Ecuador. Atahualpa residents aged ≥60 years were identified during a door-to-door census and evaluated using the Montreal Cognitive Assessment (MoCA). Persons were classified into two groups according to whether they have severe edentulism (<10 remaining teeth) or not. In addition, a questionnaire allowed self-rating of oral health. A total of 274 persons (mean age 69.6 ± 7.7 years; 59% women) were included. Persons with <10 remaining teeth (n = 116) have significantly lower MoCA scores than those with ≥10 teeth (n =158), after adjusting for demographics, cardiovascular risk factors, depression and dementia (β = -1.06, p = 0.03). Self-rated poor oral health was more prevalent among persons with <10 teeth (p < 0.0001), but did not correlate with MoCA scores (good vs. poor, β = -0.89, p = 0.89). Severe edentulism is associated with poor cognitive performance in elders living in rural Ecuador. Public health campaigns directed to improve oral health may facilitate early recognition of persons with cognitive impairment in underserved populations.