Identification of risk factors and construction of a nomogram predictive model for post-stroke infection in patients with acute ischemic stroke

BACKGROUND Post-stroke infection is the most common complication of stroke and poses a huge threat to patients.In addition to prolonging the hospitalization time and increasing the medical burden,post-stroke infection also significantly increases the risk of disease and death.Clarifying the risk factors for post-stroke infection in patients with acute ischemic stroke(AIS)is of great significance.It can guide clinical practice to perform corresponding prevention and control work early,minimizing the risk of stroke-related infections and ensuring favorable disease outcomes.AIM To explore the risk factors for post-stroke infection in patients with AIS and to construct a nomogram predictive model.METHODS The clinical data of 206 patients with AIS admitted to our hospital between April 2020 and April 2023 were retrospectively collected.Baseline data and post-stroke infection status of all study subjects were assessed,and the risk factors for poststroke infection in patients with AIS were analyzed.RESULTS Totally,48 patients with AIS developed stroke,with an infection rate of 23.3%.Age,diabetes,disturbance of consciousness,high National Institutes of Health Stroke Scale(NIHSS)score at admission,invasive operation,and chronic obstructive pulmonary disease(COPD)were risk factors for post-stroke infection in patients with AIS(P<0.05).A nomogram prediction model was constructed with a C-index of 0.891,reflecting the good potential clinical efficacy of the nomogram prediction model.The calibration curve also showed good consistency between the actual observations and nomogram predictions.The area under the receiver operating characteristic curve was 0.891(95%confidence interval:0.839–0.942),showing predictive value for post-stroke infection.When the optimal cutoff value was selected,the sensitivity and specificity were 87.5%and 79.7%,respectively.CONCLUSION Age,diabetes,disturbance of consciousness,NIHSS score at admission,invasive surgery,and COPD are risk factors for post-stroke infection following AIS.The nomogram prediction model established based on these factors exhibits high discrimination and accuracy.

The potential mechanism and clinical application value of remote ischemic conditioning in stroke

Some studies have confirmed the neuroprotective effect of remote ischemic conditioning against stroke. Although numerous animal researches have shown that the neuroprotective effect of remote ischemic conditioning may be related to neuroinflammation, cellular immunity, apoptosis, and autophagy, the exact underlying molecular mechanisms are unclear. This review summarizes the current status of different types of remote ischemic conditioning methods in animal and clinical studies and analyzes their commonalities and differences in neuroprotective mechanisms and signaling pathways. Remote ischemic conditioning has emerged as a potential therapeutic approach for improving stroke-induced brain injury owing to its simplicity, non-invasiveness, safety, and patient tolerability. Different forms of remote ischemic conditioning exhibit distinct intervention patterns, timing, and application range. Mechanistically, remote ischemic conditioning can exert neuroprotective effects by activating the Notch1/phosphatidylinositol 3-kinase/Akt signaling pathway, improving cerebral perfusion, suppressing neuroinflammation, inhibiting cell apoptosis, activating autophagy, and promoting neural regeneration. While remote ischemic conditioning has shown potential in improving stroke outcomes, its full clinical translation has not yet been achieved.

Prevalence and Risk Factors of Stroke in Inpatients with Type 2 Diabetes Mellitus in China

Objective The prevalence and the cluster characteristics of risk factors of stroke were assessed in a Chinese diabetic population.Methods Clinical data of 30693 inpatients who were diagnosed with type 2 diabetes mellitus(T2DM)and admitted between 2013 and 2018 were retrospectively analyzed.The age-standardized prevalence of stroke was estimated using the 2010 Chinese population census data,and risk factors were analyzed by multiple imputation and regression.Results The crude and standardized prevalence rates of stroke in patients with T2DM were 34.4%and 21.5%,respectively,and 85.2%of the stroke patients had ischemic stroke.Nearly half of the patients who experienced stroke had clusters of more than 4 risk factors.Compared with no-risk-factor clustering,the risk of stroke significantly increased 3-4 times in the presence of more than 4 risk-factor clusters(P<0.001).Hypertension was the most common major risk factor for ischemic stroke[odds ratio(OR),2.34;95%confidence interval(CI),2.18-2.50]and hemorrhagic stroke(OR,3.68;95%CI 2.95-4.59;P<0.001).Moreover,a 1-standard-deviation increase in fasting blood glucose(FBG)was significantly negatively correlated with ischemic stroke risk,and the same change in FBG was significantly associated with an 8%increased risk of hemorrhagic stroke.Conclusion The prevalence of stroke in patients with T2DM is rather high,and the clustering of risk factors is associated with the development of stroke in T2DM patients.Risk factors differ in different stroke subtypes.Identifying risk factors for a specific high-risk group is necessary.

Platelet-to-neutrophil ratio predicts hemorrhagic transformation and unfavorable outcomes in acute ischemic stroke with intravenous thrombolysis

BACKGROUND Acute ischemic stroke(AIS)retains a notable stance in global disease burden,with thrombolysis via recombinant tissue plasminogen activator(rtPA)serving as a viable management approach,albeit with variable outcomes and the potential for complications like hemorrhagic transformation(HT).The platelet-to-neutrophil ratio(P/NR)has been considered for its potential prognostic value in AIS,yet its capacity to predict outcomes following rtPA administration demands further exploration.AIM To elucidate the prognostic utility of P/NR in predicting HT and clinical outcomes following intravenous rtPA administration in AIS patients.METHODS Data from 418 AIS patients treated with intravenous rtPA at Thammasat University Hospital from January 2018 to June 2021 were retrospectively analyzed.The relationship between P/NR and clinical outcomes[early neurological deterioration(E-ND),HT,delayed ND(D-ND),and 3-mo outcomes]was scrutinized.RESULTS Notable variables,such as age,diabetes,and stroke history,exhibited statistical disparities when comparing patients with and without E-ND,HT,D-ND,and 3-mo outcomes.P/NR prognostication revealed an optimal cutoff of 43.4 with a 60.3%sensitivity and a 52.5%specificity for 90-d outcomes.P/NR prognostic accuracy was statistically significant for 90-d outcomes[area under the curve(AUC)=0.562],D-ND(AUC=0.584),and HT(AUC=0.607).CONCLUSION P/NR demonstrated an association with adverse 3-mo clinical outcomes,HT,and D-ND in AIS patients post-rtPA administration,indicating its potential as a predictive tool for complications and prognoses.This infers that a diminished P/NR may serve as a novel prognostic indicator,assisting clinicians in identifying AIS patients at elevated risk for unfavorable outcomes following rtPA therapy.

Advances in the Mechanisms of Hemorrhagic Transformation and Therapeutic Agents after Intravenous Thrombolysis in Ischemic Stroke

Ischemic stroke is an important disease leading to death and disability for all human beings, and the key to its treatment lies in the early opening of obstructed vessels and restoration of perfusion to the local infarcted area. Intravenous thrombolysis with tissue plasminogen activator (tPA) is one of the effective therapies to achieve revascularization, but it faces strict indications with a narrow therapeutic time window, and significantly increases the incidence of hemorrhagic transformation, HT, after reperfusion of the infarcted foci, which greatly reduces the incidence of patients with ischemic stroke. which significantly increases the incidence of hemorrhagic transformation (HT) after reperfusion of the infarcted focus, greatly reducing patient utilization and clinical benefit. Since the mechanism of HT has not been fully elucidated, and the related molecular mechanisms are complex and interactive, there is no specific and effective therapy to avoid the occurrence of HT. In this article, we focus on the research progress on the mechanism of HT after tPA intravenous thrombolysis in ischemic stroke patients from the aspects of vascular integrity disruption, oxidative stress, and neuroinflammatory response and the corresponding therapeutic strategies, in order to improve the safety and prognosis of tPA intravenous thrombolysis in the clinic.

The effect of Huanglian Jiedu Decoction on inflammatory factors and oxidative stress in patients with acute ischemic stroke

Objective:To study the clinical efficacy of Huanglian Jiedu decoction in treating acute ischemic stroke(AIS)and its effects on inflammatory factors and oxidative stress.Method:A total of 53 patients with AIS were recruited as the study subjects and randomly divided into a control group and a treatment group using a random number table method.The control group consisted of 26 patients and the treatment group consisted of 27 patients.The control group received conventional Western medicine treatment.The control group received routine Western medicine treatment,while the treatment group received Huanglian Jiedu decoction based on the control group,with 14 days as a course of treatment.The effects of Huanglian Jiedu decoction on neurological function and activities of daily living were evaluated using the National Institute of Health stroke scale(NIHSS)and activities of daily living(ADL)scores.The effects of Huanglian Jiedu decoction on inflammatory reactions and oxidative stress were evaluated by detecting interleukin-4(IL-4),interleukin-6(IL-6),tumor necrosis factor-α(TNF-α),transforming growth factorβ(TGF-β),total antioxidative capacity(T-AOC),malondialdehyde(MDA),superoxide dismutase(SOD),and catalase(CAT)levels.Results:After treatment with Huanglian Jiedu Decoction,the ALD scores of AIS patients in both groups increased,while the NISHH scores decreased,suggesting that Huanglian Jiedu Decoction has therapeutic effects on AIS patients.It also reduces the levels of serum IL-6,TNF-α,MDA in AIS patients and increases the levels of IL-4,TGF-β,CAT,SOD,T-AOC,suggesting that Huanglian Jiedu decoction can improve the anti-inflammatory and antioxidant abilities of AIS patients.Conclusion:Huanglian Jiedu decoction can help AIS patients recover their neurological function,increase their capacity for self-care in daily life,and strengthen the body’s anti-inflammatory and antioxidant defenses.

Risk Factors, Clinical Features and Prognosis for Subtypes of Ischemic Stroke in a Chinese Population

It is unanimously accepted that stroke is a highly heterogeneous disorder. Different subtypes of ischemic stroke may have different risk factors, clinical features, and prognoses. The aim of this study was to evaluate the risk factors, clinical characteristics, and prognoses of different subtypes of ischemic stroke defined by the Trial of ORG10172 in Acute Stroke Treatment （TOAST） criteria. We prospectively analyzed the data from 530 consecutive patients who were admitted to our hospital with acute ischemic stroke within 7 days of stroke onset during the study period. Standardized data assessment was used and the cause of ischemic stroke was classified according to the TOAST criteria. Patients were followed up till 30 and 90 days after stroke onset. It was found that large-artery atherosclerosis was the most frequent etiology of stroke （37.4%）, and showed the highest male preponderance, the highest prevalence of previous transient ischemic attack, and the longest hospital stay among all subtypes. Small artery disease （36.4%） was associated with higher body mass index, higher plasma triglycerides, and lower plasma high-density lipoprotein cholesterol than cardioembolism. Cardioembolism （7.7%）, which was particularly common in the elderly （i.e., individuals aged 65 years and older）, showed the highest female preponderance, the highest prevalence of atrial fibrillation, the earliest presentation to hospital after stroke onset, the most severe symptoms on admission, the maximum complications associated with an adverse outcome, and the highest rate of stroke recurrence and mortality. Our results suggest that ischemic stroke should be regarded as a highly heterogeneous disorder. Studies involving risk factors, clinical features, and prognoses of ischemic stroke should differentiate between etiologic stroke subtypes.

Cardiovascular risk factors for acute stroke: Risk profiles in the different subtypes of ischemic stroke

Timely diagnosis and control of cardiovascular risk factors is a priority objective for adequate primary and secondary prevention of acute stroke. Hypertension, atrial fibrillation and diabetes mellitus are the most common risk factors for acute cerebrovascular events, although novel risk factors, such as sleep-disordered breathing, inflammatory markers or carotid intima-media thickness have been identified. However, the cardiovascular risk factors profile differs according to the different subtypes of ischemic stroke. Atrial fibrillation and ischemic heart disease are more frequent in patients with cardioembolic infarction, hypertension and diabetes in patients with lacunar stroke, and vascular peripheral disease, hypertension, diabetes, previous transient ischemic attack and chronic obstructive pulmonary disease in patients with atherothrombotic infarction. This review aims to present updated data on risk factors for acute ischemic stroke as well as to describe the usefulness of new and emerging vascular risk factors in stroke patients.

Systematic review of risk factors for progressive ischemic stroke

OBJECTIVE： To determine the risk factors for progressive ischemic stroke, and to prevent onset and make a prognosis of disease, the present study systemically evaluated 19 cohort studies and 10 case-controlled studies of progressive ischemic stroke. SEARCH STRATEGY： A computer-based, online, literature search of PubMed （1966/2007）, China Biological Medicine Database （CBM-disc, 1979/2007） and CNKI （www.cnki.net, 1979/2007） was performed to screen for related studies. DATA SELECTION： Cohort or case-controlled studies that focused on risk factors of progressive ischemic stroke were selected for review. Two reviewers independently extracted data and assessed study quality according to Cochrane Collaboration guidelines. Statistical analysis was performed using RevMan software. MAIN OUTCOME MEASUREMENT： Risk factors for progressive ischemic stroke. RESULTS： Using the inclusion criteria, 29/781 studies published in English and Chinese were initially reviewed, including 19 cohort studies and 10 case-control studies. Despite variations in determination of progressive ischemic stroke and the intervals between 2 evaluations, all studies described the diagnostic criteria for progressive ischemic stroke. Logistic analysis was employed in 20 of the studies. Meta-analysis of primary data in the related studies determined that the following factors that significantly correlated with progressive ischemic stroke： fever [risk ratio （RR） = 2.26, 95% confidence interval （CO： 1.20-4.26, P = 0.01; odds ratio （OR） = 2.85, 95% CI： 1.64-4.98, P 〈 0.01 ）]; diabetes （RR = 1.38, 95% CI： 1.18-1.61, P 〈 0.01 ; OR = 2.48, 95% Ch 1.93-3.19, P 〈 0.01 ）; coronary heart disease （RR = 1.22, 95% CI： 1.08-1.38, P 〈 0.01）; neuroimaging transformation （RR= 1.55, 95%CI： 1.34-1.80, P〈 0.01; OR= 2.29, 95% CI： 1.47-3.58, P〈 0.01）; and hyperglycemia （RR = 2.62, 95% CI： 1.86-3.68, P 〈 0.01 ; OR = 3.49, 95% CI： 1.92-6.35, P 〈 0.01）. CONCLUSION： Fever, diabetes, coronary heart disease, neuroimaging transformation, and hyperglycemia are important risk factors for progressive ischemic stroke. Interventions for these risk factors could effectively prevent occurrence of progressive ischemic stroke.

Risk factors for relapse and nomogram for relapse probability prediction in patients with minor ischemic stroke

BACKGROUND The identification of risk factors for recurrence in patients with minor ischemic stroke(MIS)is a critical medical need.AIM To develop a nomogram for individualized prediction of in-hospital recurrence in MIS patients.METHODS Based on retrospective collection,a single-center study was conducted at the First Affiliated Hospital of Anhui Medical University from January 2014 to December 2019.Univariate and multivariate logistic regression analyses were used to determine the risk factors associated with MIS recurrence.The least absolute shrinkage and selection operator regression was performed for preliminary identification of potential risk factors.Uric acid,systolic blood pressure,serum total bilirubin(STBL),and ferritin were integrated for nomogram construction.The predictive accuracy and calibration of the nomogram model were assessed by the area under the receiver operating characteristic curve(AUC-ROC)and Hosmer-Lemeshow test,respectively.RESULTS A total of 2216 MIS patients were screened.Among them,155 were excluded for intravascular therapy,146 for unknown National Institutes of Health Stroke Scale score,195 for intracranial hemorrhage,and 247 for progressive stroke.Finally,1244 patients were subjected to further analysis and divided into a training set(n=796)and a validation set(n=448).Multivariate logistic regression analysis revealed that uric acid[odds ratio(OR):0.997,95%confidence interval(CI):0.993-0.999],ferritin(OR:1.004,95%CI:1.002-1.006),and STBL(OR:0.973,95%CI:0.956-0.990)were independently associated with in-hospital recurrence in MIS patients.Our model showed good discrimination;the AUC-ROC value was 0.725(95%CI:0.646-0.804)in the training set and 0.717(95%CI:0.580-0.785)in the validation set.Moreover,the calibration between nomogram prediction and the actual observation showed good consistency.Hosmer-Lemeshow test results confirmed that the nomogram was well-calibrated(P=0.850).CONCLUSION Our present findings suggest that the nomogram may provide individualized prediction of recurrence in MIS patients.

Risk factors for progressive ischemic stroke: A retrospective analysis

BACKGROUND： Progressive ischemic stroke has higher fatality rate and disability rate than common cerebral infarction, thus it is very significant to investigate the early predicting factors related to the occurrence of progressive ischemic stroke, the potential pathological mechanism and the risk factors of early intervention for preventing the occurrence of progressive ischemic stroke and ameliorating its outcome. OBJECTIVE： To analyze the possible related risk factors in patients with progressive ishcemic stroke, so as to provide reference for the prevention and treatment of progressive ishcemic stroke. DESIGN： A retrospective analysis. SETTING： Department of Neurology, General Hospital of Beijing Coal Mining Group. PARTICIPANTS： Totally 280 patients with progressive ischemic stroke were selected from the Department of Neurology, General Hospital of Beijing Coal Mining Group from March 2002 to June 2006, including 192 males and 88 females, with a mean age of （62±7） years old. They were all accorded with the diagnostic standards for cerebral infarction set by the Fourth National Academic Meeting for Cerebrovascular Disease in 1995, and confired by CT or MRI, admitted within 24 hours after attack, and the neurological defect progressed gradually or aggravated in gradients within 72 hours after attack, and the aggravation of neurological defect was defined as the neurological deficit score decreased by more than 2 points. Meanwhile, 200 inpatients with non-progressive ischemic stroke （135 males and 65 females） were selected as the control group. METHODS： After admission, a univariate analysis of variance was conducted using the factors of blood pressure, history of diabetes mellitus, fever, leukocytosis, levels of blood lipids, fibrinogen, blood glucose and plasma homocysteine, cerebral arterial stenosis, and CT symptoms of early infarction, and the significant factors were involved in the multivariate non-conditional Logistic regression analysis. MAIN OUTCOME MEASURES： Results of the univariate analysis of variance of the factors related to progressive ischemic stroke; Results of the multivariate regression analysis. RESULTS： All the 480 patients were involved in the analysis of results. ① Results of the univariate analysis variance： There were significantly more patients with fever, leukocytosis, history of diabetes mellitus, cerebral arterial stenosis and CT symptoms of early infarction in the progressive ischemic stroke group than in the control group （P 〈 0.01）; The levels of blood glucose and fibrinogen in the progressive ischemic stroke group were significantly higher than those in the control group, while the level of blood pressure was significantly lower than that in the control group （P 〈 0.05 - 0.01）. ② Results of the multivariate Logistic regression analysis： The independent predicting factors for progressive ischemic stroke were history of diabetes mellitus, fever, leukocytosis, cerebral arterial stenosis, CT symptoms of early infarction, blood glucose and blood pressure （OR =2.61,2.96, 3.79, 1.03, 3.57, 2.68, 95% CI 0.92 - 3.59, P 〈 0.05 - 0.01）. CONCLUSION： History of diabetes mellitus, fever, leukocytosis, levels of blood pressure, blood glucose, cerebral arterial stenosis and CT symptoms of early infarction are the risk factors for progress ischemic stroke

Clinical factors in patients with ischemic versus hemorrhagic stroke in East China

BACKGROUND：Stroke is one of the leading causes of mortality and morbidity of vascular diseases, and its incidence maintains at a high level around the world. In China, stroke has been a major public health problem. Because the pathogenesis of ischemic stroke is different from that of hemorrhagic stroke, their clinical factors would not be the same. Therefore to investigate the different effects of various effect factors on ischemic versus hemorrhagic stroke and then to enhance the prevention are crucial to decrease the incidence.METHODS：A total of 692 patients, consisting of 540 ischemic stroke patients and 152 hemorrhagic stroke patients from East China, were included in this study. The related factors of stroke subtypes were collected and analyzed.RESULTS：The factors significantly associated with ischemic stroke as opposed to hemorrhagic stroke were family history of stroke, obesity, atherosclerotic plaque of the common carotid artery, atrial fibrillation, hyperfibrinogenemia, transient ischemic attack （TIA）, atherosclerotic plaque of the internal carotid artery, coronary heart, lower high-density lipoproteins （lower HDL）, increasing age, diabetes mellitus, and gender （male） （P〈0.05）. Leukocytosis, hypertension and family history of hypertension were the significant factors associated with hemorrhagic stroke versus ischemic stroke. Smoking, drinking, kidney diseases and lower HDL-C were the significant factors contributing to ischemic stroke in man. Obesity, family history of hypertension, family history of stroke, hypercholesteremia and myocardial ischemia were the significant factors for females with ischemic stroke.CONCLUSIONS：The most prominent factors for overall stroke in East China were hypertension, followed by higher pulse pressure and hypercholesteremia. The factors for ischemic and hemorrhagic stroke are not the same. Different effects of risk factors on stroke are found in male and female patients.

Risk factors for stroke recurrence in young patients with first-ever ischemic stroke:A meta-analysis

BACKGROUND At present,the incidence rate of ischemic stroke in young people is increasing yearly,and the age of onset is increasingly young.Therefore,primary and secondary prevention of ischemic stroke in young people,especially secondary prevention,is particularly crucial.AIM We aimed to comprehensively evaluate risk factors for stroke recurrence in firstever young ischemic stroke(YIS)patients.METHODS The meta-analysis was used to quantitatively analyze the research results on risk factors for stroke recurrence in first-ever YIS patients both domestically and internationally.Stata12.0 software was used for heterogeneity testing,publication bias analysis,sensitivity analysis,and the calculation of combined odds ratios and 95%confidence intervals.RESULTS The odds ratio(OR)values of the relationship between hypertension and hyperlipidemia and recurrence of first-ever YIS were 1.54(1.05-2.26)and 1.12(1.00-1.25),respectively.The OR values of male sex,type 2 diabetes,smoking,drinking and YIS recurrence were 1.66(0.98-2.79),1.01(0.64-1.59),1.21(0.83-1.76),and 1.28(0.82-2.53),respectively.The relationship between male sex,type 2 diabetes,smoking,drinking and YIS recurrence was ambiguous.CONCLUSION Hypertension and hyperlipidemia are important risk factors for stroke recurrence in first-ever YIS patients,and active intervention should be taken.

Risk Factors Associated with Various Subtypes of Ischemic Stroke: A Prospective Study in BSMMU, Dhaka, Bangladesh

Introduction: Stroke is the main cause of adult disability and the second most leading cause of death worldwide. The number of deaths due to stroke is 5.54 million worldwide. Globally, 70% of strokes and 87% of both stroke-related deaths and disability-adjusted life years occur in low and middle-income countries. Method: This was a prospective observational cross-sectional study conducted at Indoor, Outdoor, Stroke and Neuro-Intervention clinic of the Department of Neurology, Bangabandhu Sheikh Mujib Medical University Hospital (BSMMU), Dhaka, Bangladesh, from June-2019 to May-2020. A total of 220 ischemic stroke patients aged above 30 years confirmed by CT scan/MRI of brain. Data were collected with a pre-structured questionnaire from the patients, investigations reports and face-to-face interviews and analyzed using IBM SPSS software version 23.0. Proper consent was taken from the participants. The collected data were ANNOVA tests and association within the risk factors and the patterns of subtypes of ischemic stroke where P < 0.05 considered significant. Results: Among the 220 stroke patients, large-artery atherosclerosis (LAA), cardio-embolism (CE), small-vessel occlusion (SVO, stroke of other determined etiology (SODE) and stroke of undetermined etiology (SUDE) were being observed 84 (38.18%), 14 (6.36%), 63 (28.64%), 12 (5.45%) and 47 (18.18%). Eighty-Six (39.09%) prevalence of subtypes was found in rural areas whereas 134 (60.91%) were in urban areas. The significant risk factors are associated with the prevalence of various subtypes (p < 0.05). Conclusion: This study prevails the people of Bangladesh are vulnerable to various subtypes of ischemic stroke. The higher prevalence of large-artery atherosclerosis (LAA) in our patients suggests the presence of uncontrolled hypertension, diabetes mellitus, smoking habit and dyslipidemia.

Epigenetic regulation of the inflammatory response in stroke

Stroke is classified as ischemic or hemorrhagic,and there are few effective treatments for either type.Immunologic mechanisms play a critical role in secondary brain injury following a stroke,which manifests as cytokine release,blood–brain barrier disruption,neuronal cell death,and ultimately behavioral impairment.Suppressing the inflammatory response has been shown to mitigate this cascade of events in experimental stroke models.However,in clinical trials of anti-inflammatory agents,longterm immunosuppression has not demonstrated significant clinical benefits for patients.This may be attributable to the dichotomous roles of inflammation in both tissue injury and repair,as well as the complex pathophysiologic inflammatory processes in stroke.Inhibiting acute harmful inflammatory responses or inducing a phenotypic shift from a pro-inflammatory to an anti-inflammatory state at specific time points after a stroke are alternative and promising therapeutic strategies.Identifying agents that can modulate inflammation requires a detailed understanding of the inflammatory processes of stroke.Furthermore,epigenetic reprogramming plays a crucial role in modulating post-stroke inflammation and can potentially be exploited for stroke management.In this review,we summarize current findings on the epigenetic regulation of the inflammatory response in stroke,focusing on key signaling pathways including nuclear factor-kappa B,Janus kinase/signal transducer and activator of transcription,and mitogen-activated protein kinase as well as inflammasome activation.We also discuss promising molecular targets for stroke treatment.The evidence to date indicates that therapeutic targeting of the epigenetic regulation of inflammation can shift the balance from inflammation-induced tissue injury to repair following stroke,leading to improved post-stroke outcomes.

Early antiplatelet therapy used for acute ischemic stroke and intracranial hemorrhage

In this editorial we comment on the article published by Zhang et al in the recent issue of World Journal of Clinical Cases.We evaluate their claims on the benefit of use of Aspirin in the early management of patients with ischemic stroke.We also comment on their contention of using aspirin in the early management of patients with intracranial hemorrhage,a practice not seen in modern medicine.Large clinical trials such as the International Stroke Trial and the Chinese Acute Stroke Trial have shown the benefit of Aspirin use within 48 h of patients with Acute Ischemic Stroke.The findings were corroborated in the open-label trial performed by Zhang et al in a smaller sample group of 25 patients where they showed improvement in functional scores at 90 days without an increase in adverse events.As such,this intervention is also recommended by the American Heart Association stroke guidelines from 2021.With regard to Intracranial hemorrhage,traditional practice has been to discontinue or avoid antiplatelet therapy in these patient groups.However,no studies have been done to evaluate this management strategy that is more borne out of the mechanism behind Aspirin’s effect on the coagulation pathway.Zhang et al evaluate the benefits of Aspirin on patients with low-volume intracranial hemorrhage,i.e.,less than 30 mL on computed tomo-graphy imaging,and show no increase in mortality.The caveat of this finding is that all outcomes were pooled into one group for results,and the number of patients was low.While more studies with larger patient groups are required,the data from Zhang et al suggests that patients with small-volume intracranial hemorrhages may benefit from Aspirin administration in the acute phase of management.

Variants of the arachidonate 5-lipoxygenase-activating protein (ALOX5AP) gene and risk of ischemic stroke in Han Chinese of eastern China

Variants of the arachidonate 5-1ipoxygenase-activating protein （ALOX5AP） gene have been suggested to play an important role in the pathogenesis of atherosclerosis and ischemic stroke. This study was aimed to explore the association of ALOX5AP variants with ischemic stroke risk in Han Chinese of eastern China. A total of 690 ischemic stroke cases and 767 controls were recruited. The subjects were further subtyped according to the Trial of Org 10172 in Acute Stroke Treatment （TOAST） criteria. On the basis of that, two polymorphisms of the ALOX5AP gene （rs10507391 and rs12429692） were determined by TaqMan genotyping assay. In addition, plasma leukotriene B4 （LTB4） levels were analyzed in these subjects. There was no evidence of association between the two variants of ALOX5AP and the risk of ischemic stroke or its TOAST-subtypes. Haplotype analysis and stratification analysis according to sex, age, body mass index, hypertension, and diabetes also showed negative association. Analysis of LTB4 levels in a subset of cases and controls revealed that LTB4 levels were significantly higher in ischemic stroke cases than in the controls （70.06± 14.75 ng/L vs 57.34±10.93 ng/L; P = 0.000） and carriers of the T allele of the rs10507391 variant were associated with higher plasma LTB4 levels （P = 0.000）. The present study suggests there is no association of the two polymorphisms in the ALOX5AP gene with ischemic stroke risk in Han Chinese of eastern China.

Correlation between muscular strength and basal nuclei ischemic/hemorrhagic stroke-induced corticospinal tract injury,as detected by diffusion tensor imaging and tractography

BACKGROUND： Conventional neuroimaging diagnosis does not assist with the monitoring or evaluation of basal nuclei ischemic and hemorrhagic stroke, or motor functional recovery. Magnetic resonance, diffusion tensor imaging, and diffusion tensor tractography have all been used to observe features of cerebral white matter fibrous structures. In addition, diffusion tensor tractography is the only non-invasive imaging method to display the corticospinal tract in vivo. OBJECTIVE： To evaluate the impairment degree of corticospinal tract induced by basal nuclei ischemic and hemorrhagic stroke through the use of magnetic resonance, diffusion tensor imaging, and diffusion tensor tractography, and to analyze the correlation to muscular strength. DESIGN, TIME AND SETTING： A retrospective case analysis was performed at the Department of Medical Imaging, Neurology and Neurosurgery, Fuzhou General Hospital of Nanjing Military Area Command of Chinese PLA between November 2002 and June 2008. PARTICIPANTS： A total of 15 patients with acute or subacute cerebral ischemic stroke and nine with hemorrhagic stroke in the basal nuclei were selected. METHODS： Magnetic resonance, diffusion tensor imaging, and diffusion tensor tractography results and data were analyzed. Fractional anisotropy and directionally encoded color maps were obtained. Three-dimensional tractography of bilateral corticospinal tract was created, and corticospinal tract integrity was graded. Fractional anisotropy of infarct region and corresponding contralateral normal regions were measured, and hematoma volume in hemorrhagic stroke patients was determined. Hand motor function ability was evaluated using Brunstorm criteria. MAIN OUTCOME MEASURES： Fractional anisotropy of infarct region and corresponding contralateral normal regions; hematoma volume in hemorrhagic stroke patients; correlation between muscular strength and corticospinal tract impairment degree in ischemic stroke and hemorrhagic stroke patients before and after treatment. RESULTS： In ischemic stroke patients, the fractional anisotropy value was significantly lower in the infarct area of white matter than in the normal hemisphere （P 〈 0.01）. The impairment degree of corticospinal tract negatively correlated with muscular strength of the corresponding hand （r = -0.97 P 〈 0.01）. The hematoma volume of hemorrhagic stroke patients significantly negatively correlated with Spearman test results for muscular strength of the corresponding hand （r = -0.88, P 〈 0.01）. CONCLUSION： Corticospinal tract impairment severity negatively correlated with muscular strength and motor functional recovery, which suggested that diffusion tensor imaging and diffusion tensor tractography could be used to evaluate corticospinal tract motor function.

Risk assessment of ischemic stroke associated pneumonia

BACKGROUND:Cerebral stroke is a disease with a high disability rate and a high fatality rate.This study was undertaken to assess the risk of stroke associated pneumonia(SAP) in patients with ischemic stroke using A2DS2 score.METHODS:Altogether 1 279 patients with ischemic stroke who were treated in our department from 2009 to 2011 were retrospectively analyzed with A2DS2 score. A2DS2 score was calculated as follows:age ≥75 years=1,atrial fi brillation=1,dysphagia=2,male sex=1; stroke severity:NIHSS score 0–4=0,5–15=3,≥16=5. The patients were divided into three groups according to A2DS2 score:620 in score 0 group,383 in score 1–9 group,and 276 in score ≥10 group. The three groups were comparatively analyzed. The diagnostic criteria for SAP were as follows:newly emerging lesions or progressively infiltrating lesions on post-stroke chest images combined with more than two of the following clinical symptoms of infection:(1) fever ≥38 °C;(2) newly occurred cough,productive cough or exacerbation of preexisting respiratory tract symptoms with or without chest pain;(3) signs of pulmonary consolidation and/or wet rales;(4) peripheral white blood cell count ≥10×109/L or ≤4×109/L with or without nuclear shift to left,while excluding some diseases with clinical manifestations similar to pneumonia,such as tuberculosis,pulmonary tumors,non-infectious interstitial lung disease,pulmonary edema,pulmonary embolism and atelectasis. The incidence and mortality of SAP as well as the correlation with ischemic stroke site were analyzed in the three groups respectively. Mean± standard deviation was used to represent measurement data with normal distribution and Student's t test was used. The chi-square test was used to calculate the percentage for enumeration data.RESULTS:The incidence of SAP was significantly higher in the A2DS2 score≥10 group than that in the score 1–9 and score 0 groups(71.7% vs. 22.7%,71.7% vs. 3.7%,respectively),whereas the mortality in the score≥10 group was significantly higher than that in the score 1–9 and score 0 groups(16.7% vs. 4.96%,16.7% vs. 0.3%,respectively). The incidences of cerebral infarction in posterior circulation and cross-MCA,ACA distribution areas were signif icantly higher than those in the SAP group and in the non-SAP group(35.1% vs.10.1%,11.4% vs. 7.5%,respectively). The incidence of non-fermentative bacteria infection was signifi cantly increased in the score≥10 group.CONCLUSIONS:A2DS2 score provides a basis for risk stratifi cation of SAP. The prevention of SAP needs to be strengthened in acute ischemic stroke patients with a A2DS2 score≥10.

ANALYSIS OF RISK FACTORS IN 3901 PATIENTS WITH STROKE

Objective To estimate the frequency of various risk factors for overall stroke and to identify risk factors for cerebral infarction (CI) versus intracerebral hemorrhage (ICH) in a large hospital-based stroke registry. Methods Data from a total of 3901 patients, consisting of 3525 patients with CI and 376 patients with ICH were pros-pectively coded and entered into a computerized data bank. Results Hypertension and smoking were the most prominent factors affecting overall stroke followed by mild internal carotid artery stenosis (< 50%), hypercholesterolemia, transient ischemic attacks (TIAs), diabetes mellitus, and cardiac ischemia. Univariate analysis showed that factors in male significantly associated with CI versus ICH were old age, a family history of stroke, and intermittent claudication; whereas in female the factors were oral contraception and migraine. By multivariate analysis, in all patients, the factors significantly associated with CI as opposed to ICH were smoking, hyperch-olesterolemia, migraine, TIAs, atrial fibrillation, structural heart disease, and arterial disease. Hypertension was the only significant factor related with ICH versus CI.Conclusions The factors for ischemic and hemorrhagic stroke are not exactly the same. Cardiac and arterial disease are the most powerful factors associated with CI rather than ICH.