Background and Aims:

Stroke is one of the leading causes of burden of disease worldwide. We aim to analyze the changes in the burden of stroke in Latin America (LA) between 1990 and 2019 and evaluate them by type and their risk factors.

Methods:

We systematically evaluated the Global Burden of Diseases Database 2019. The measure of burden used was Disability-adjusted life years (DALYs), which were adjusted for comorbidity and were estimated with 95% uncertainty intervals. Data were selected for Latin America (36 countries) in 1990 and 2019, per year, stroke type, and risk factors.

Results:

In 2019, the burden of stroke in LA was 6’957,676.91 DALYs (6’064,946.96 – 7’973,092.68; CI 95%) which corresponded to an increase of 15.5% from 1990. The increase is mainly due to disability (an increase of 68.18%). Hemorrhagic type generated the highest-burden across time, but the ischemic type has increased by more than 30%. High systolic blood pressure and high body mass index are the most important risk factors (26.31% increase from 1990). Regionally in 1990, Guyana was the country with the highest burden per 100,000 inhabitants, while Haiti in 2019.

Conclusions:

The burden of Stroke in LA has increased between 1990 and 2019, mainly due to ischemic type and associated disability. Regional demography and attribution of modifiable risk factors of stroke burden have changed across time in LA. Priority actions should be taken to adapt prevention policies and offer timely rehabilitation to reduce the burden of stroke in LA.

Background and Aims:

Symptomatic intraparenchymal hemorrhage (sICH) and major bleeding can be fatal complications of intravenous thrombolysis (IVT) for acute ischemic stroke. We investigated the impact of early fibrinogen depletion after IVT on major bleeding events.

Methods:

This multicenter observational study enrolled consecutive patients receiving IVT for acute ischemic stroke at 6 Italian centers, undergoing fibrinogen concentration assessment at baseline, 2 hours and 6 hours after IVT. Fibrinogen depletion was defined as a reduction below 200 mg/dl after 2 hours from IVT, or as a reduction below 50% of baseline fibrinogen levels after 2 hours from IVT. Main outcomes were (i) sICH according to National Institute of Neurological Disorders and Stroke criteria, and (ii) major bleeding.

Results:

Overall, 1678 patients were included. sICH (n=116) and major bleeding (n=297) were associated with lower prevalence of good functional recovery (p<0.001). Despite similar fibrinogen levels at admission, fibrinogen depletion after 2 hours from IVT was more common in people with sICH and major bleeding. In the backward stepwise multivariable logistic regression model, fibrinogen depletion remained a significant predictor of sICH (OR 1.55, 95%CI 1.04-2.32) and major bleeding (OR 1.36, 95%CI 1.03-1.8)

Conclusions:

Fibrinogen depletion significantly increases the risk of sICH and major bleeding after IVT for acute ischemic stroke. Routine assessment of fibrinogen might be considered to stratify the risk of ICH.

Background and Aims:

There are no previous controlled studies of sentinel headache in ischemic stroke. The purpose of the present study was to evaluate the presence of such headache, its characteristics and possible risk factors.

Methods:

Eligible patients (n = 550) had first-ever ischemic stroke with presence of new infarction on MRI with DWI (n = 469) or on CT (n = 81). As a control group we studied in parallel patients (n = 192) who were admitted to the emergency room without acute neurological deficits or serious neurological or somatic disorders. Consecutive patients with stroke and a control group were interviewed soon after admission using validated neurologist conducted semi-structured interview forms. Based on our previous study of sentinel headache in TIA we defined sentinel headache as a new type of headache or a previous kind of headache with altered characteristics (severe intensity, increased frequency, absence of effect of drugs) within seven days before stroke.

Results:

Among 550 patients with stroke 94 patients (17.1%) had headache during seven days before stroke and 12 (6.2%) controls (p < 0.001; OR 3.9; 95% CI 1.7–5.8). Totally 81 patients (14.7%) had sentinel headache within the last week before stroke and one control. Attacks of arrythmia during seven days before stroke were significantly associated with sentinel headache (p = 0.04, OR 2.3; 95% CI 1.1–4.8).

Conclusions:

A new type of headache and a previous kind of headache with altered characteristics during one week before stroke are significantly more prevalent than in controls. These headaches represent sentinel headaches.

Background and Aims:

We aimed to clarify the long-term outcome of warfarin, direct oral anticoagulants (DOACs), or antiplatelet drugs for patent foramen ovale (PFO)-associated stroke.

Methods:

Consecutive PFO-associated stroke patients within six months were included from our single-center prospective database from November 2010 to April 2020. Patients with PFO closure were excluded. Subjects were divided into three subgroups by antithrombotic drugs (warfarin, DOAC, antiplatelet drug ). Each incidence rate for the composite event of recurrence ischemic stroke (IS) / cardiovascular death / major bleeding between groups using the Kaplan-Meier method. The hazard ratio (HR) adjusted for age and gender was analyzed from the Cox proportional hazard model.

Results:

The subjects were 231 patients (38% female, mean age ± standard deviation 74 ± 15 years), and the median observation period (IQR) was 2.3 (1.0–4.2) years. Annual incidence of complex events is warfarin 13 cases / 274 person-years (4.7%), DOAC 4 cases / 112 person-years (3.6%; adjusted hazard ratio [aHR] [95% confidence interval (CI)], 0.78 [0.28–2.33]), antiplatelet drugs 28 cases / 276 man-years (10.1%; aHR [95% CI], 2.11 [1.05–4.22]). In PFO-associated stroke high-risk cases (n=92), the annual incidence of compound events was warfarin 7 cases / 92 person-years (7.6%), DOAC 1 case / 42 person-years (2.4%; 0.34 [0.07–6.31]), 16 antiplatelet drugs / 86 man-years (18.6%; 2.11 [1.05–4.22]).

Conclusions:

The annual incidence of compound events in the patients with PFO-associated stroke and the high-risk PFO-associated stroke was significantly higher in antiplatelet drug cases than in warfarin cases.

Background and Aims:

Obstructive Sleep Apnea (OSA) has previously been shown to portend increased morbidity and mortality following acute ischemic stroke (AIS). Evaluation of OSA in the setting of AIS treated with endovascular mechanical thrombectomy (MT) has not yet been evaluated in the literature.

Methods:

The National Inpatient Sample was queried from 2010-2018 to identify adult AIS patients treated with MT. Those with and without OSA were compared on the basis of clinical characteristics, complications, and discharge disposition. Multivariable logistic regression analysis was employed to evaluate independent associations between OSA and clinical outcome.

Results:

Among 101,093 AIS patients treated with MT identified in our analysis, 6,412 (6.3%) had OSA. The OSA group had significantly higher rates of obesity (41.4% vs. 10.5%, p < 0.001), atrial fibrillation (47.1% vs. 42.2%, p = 0.001), hypertension (87.4% vs. 78.5%, p < 0.001), and diabetes mellitus (41.2% vs. 26.9%, p < 0.001). OSA patients treated with MT demonstrated lower rates of intracranial hemorrhage (19.1% vs. 21.8%, p = 0.017), treatment of hydrocephalus (0.3% vs. 1.1%, p = 0.009), and in-hospital mortality compared to non-OSA patients (9.7% vs. 13.5%, p < 0.001). In a multivariable logistic regression model controlling for age, acute illness and stroke severity, and comorbid conditions, OSA status was independently associated with in-hospital mortality (OR = 0.78, 95% CI = 0.63-0.96, p = 0.020).

Conclusions:

OSA was found to be independently associated with in-hospital mortality after treatment of AIS with MT. Our findings suggest MT is a viable and safe treatment option for AIS patients with OSA.

Background and Aims:

The present international prospective longitudinal study, promoted by the Special Interest Group on DoC of the International Brain Injury Association (IBIA), was aimed at identifying clinical and neurophysiologic predictors for 24-month clinical outcome and mortality in patients with prolonged disorders of consciousness (pDoC).

Methods:

Twelve specialized centres enrolled patients in Vegetative State (VS) or in Minimally Conscious State (MCS) within 3 months from acquired brain injury. Patients were followed up to 24 months post-injury for data collection on mortality and clinical improvement (i.e. from VS to MCS, and from VS or MCS to full consciousness).

Results:

24-month outcome data was available for 55 traumatic and 88 non-traumatic patients (VS=68, 19 females; MCS=75, 22 females). At 24 months post-onset, 41/143 patients (28.7%) had died, with higher mortality in VS (42.6%) than in MCS (16%; p<.001). Baseline significant predictors of mortality at multivariate Cox regression were older age and lower Coma Recovery Scale-Revised total score in VS, and female sex and absence of alpha rhythm on EEG in MCS. At the 24-month evaluation, 77 patients (54%; 26 VS) had improved their state of consciousness and 66 (46%; 42 VS) did not. Multivariate logistic regression showed that shorter time post-injury and presence of alpha rhythm on EEG in VS (24/66 improved), and male sex in MCS (47/68 improved) significantly predicted clinical improvement.

Conclusions:

A bedside multimodal assessment could provide valuable information for prognostication in patients with pDoC. These findings can help clinicians and families navigate complex caring and decision-making.

Background and Aims:

Altered corpus callosum integrity has been associated to motor impairment in multiple sclerosis (MS), but its contribution has not been evaluated with multiparametric-MRI approaches on large populations. We investigated structural and functional inter-hemispherical substrates of global disability at different milestones and upper-limb motor impairment in a large cohort of MS patients.

Methods:

In this cross-sectional study, 340 MS patients and 130 age- and sex-matched healthy controls underwent a clinical assessment including Expanded disability status scale (EDSS) rating, 9-Hole-Peg-Test (9HPT) and electronic-finger-tapping-rate (EFTR). Structural and resting-state functional-MRI scans were used to perform: probabilistic-tractography of hand-corticospinal tracts (CSTs) and transcallosal-fibers between hand-motor cortices (hand-M1), supplementary-motor areas (SMAs) and premotor cortices (PMCs); voxel-mirror homotopic connectivity (VMHC) analysis between the same cortical regions. Random forest analyses identified MRI-predictors of clinical disability at different EDSS-milestones (3.0, 4.0, 6.0), and upper-limb motor impairment (defined as z9HPT and zEFRT scores below the 5th percentile).

Results:

Predictors of EDSS-3.0 were global atrophy and lesion measures together with damage of CSTs and PMCs and SMAs transcallosal-fibers (out-of-bag-accuracy [OOB]=0.86, p-range=<0.001-0.03). For EDSS-4.0 similar predictors were found, in addition to hand-M1 transcallosal-fibers damage (OOB-accuracy=0.90, p-range=<0.001-0.045). No MRI-predictors were identified for EDSS-6.0 milestone. Impaired upper-limb motor impairment was predicted by SMAs and PMCs transcallosal-fibers damage (OOB-accuracy-range=0.71-0.76; p-range=<0.001-0.05). No VMHC abnormalities contribute to explain clinical outcomes.

Conclusions:

In MS, transcallosal pre-motor and motor white matter-fibers abnormalities predict global disability and upper-limb motor impairment severity. A plateau-effect for higher levels of disability is present.

Funding: This study was partially supported by Fondazione Italiana Sclerosi Multipla (FISM2018/R/5).