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Stroke: Risk Factors, Mechanisms, Outcomes and Ethnicity

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A special issue of Journal of Cardiovascular Development and Disease (ISSN 2308-3425). This special issue belongs to the section "Stroke and Cerebrovascular Disease".

Deadline for manuscript submissions: 30 August 2024 | Viewed by 11891

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Dr. Narayanaswamy Venketasubramanian

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Guest Editor

Raffles Neuroscience Centre, Raffles Hospital, Singapore 188770, Singapore
Interests: stroke; neurosonology; neuroepidemiology; clinical trials
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Stroke is a major cause of death and disability globally. Well-known risk factors include hypertension, diabetes mellitus, hyperlipidemia, and cigarette smoking, in addition to aging, gender, and lifestyle factors. It is more often a complex interplay of these known factors as well as unknown ones, or one mechanistic cause rather than another, that places one person at a higher risk for stroke compared to another. New mechanisms including genetic causes are being uncovered with more detailed investigation and research. Stroke outcomes also vary greatly, ranging from no or minimal disability to severe disability or even death, which may be due not just to premorbid status, stroke severity, acute treatment, and environment (e.g., organized stroke care), but also due to the interplay between risk factors, mechanisms, and other post-stroke interventions. An emerging issue has been the differences observed in different ethnicities who appear to be living in a similar environment.

This Special Issue focuses on sharing new insights into stroke risk factors, mechanisms, and outcomes that offer new knowledge and challenge existing paradigms, with the ultimate aims of reducing occurrence, improving care, and reducing the burden of stroke for the patient, family, society, and healthcare systems globally. Papers that investigate inter-ethnic differences are especially welcome.

Dr. Narayanaswamy Venketasubramanian
Guest Editor

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Keywords

stroke
ethnicity
risk factors
mechanisms
outcome
prognosis

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Published Papers (9 papers)

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Research

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13 pages, 889 KiB

Open AccessArticle

The Modified Risk of Paradoxical Embolism Score Is Associated with Patent Foramen Ovale in Patients with Ischemic Stroke: A Nationwide US Analysis

by Chun Shing Kwok, Zaheer Alisiddiq, Maximilian Will, Konstantin Schwarz, Chee Khoo, Adrian Large, Robert Butler, Gregory Y. H. Lip, Adnan I. Qureshi and Josip Andelo Borovac

J. Cardiovasc. Dev. Dis. 2024, 11(7), 213; https://doi.org/10.3390/jcdd11070213 - 5 Jul 2024

Viewed by 561

Abstract

Background: The Risk of Paradoxical Embolism (RoPE) score was developed to identify stroke-related patent foramen ovale (PFO) in patients with cryptogenic stroke. Methods: We conducted a retrospective analysis of the 2016 to 2020 National Inpatient Sample to determine the performance of the modified RoPE score in identifying the presence of a PFO in patients with acute ischemic stroke (AIS). Results: A total of 3,338,805 hospital admissions for AIS were analysed and 3.0% had PFO. Patients with PFO were younger compared to those without a PFO (median 63 years vs. 71 years, p < 0.001) and fewer were female (46.1% vs. 49.7%, p < 0.001). The patients with PFO had greater mean modified RoPE scores (4.0 vs. 3.3, p < 0.001). The area under the curve for the RoPE score in predicting PFOs was 0.625 (95%CI 0.620–0.629). The best diagnostic power of the RoPE score was achieved with a cut-off point of ≥4 where the sensitivity was 55% and the specificity was 64.2%. A cut-off point of ≥5 increased the specificity (83.1%) at the expense of sensitivity (35.8%). The strongest predictor of PFOs was deep vein thrombosis (OR 3.97, 95%CI 3.76–4.20). Conclusions: The modified RoPE score had modest predictive value in identifying patients with PFO among patients admitted with AIS. Full article

(This article belongs to the Special Issue Stroke: Risk Factors, Mechanisms, Outcomes and Ethnicity)

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15 pages, 477 KiB

Open AccessArticle

Stroke Demographics, Risk Factors, Subtypes, Syndromes, Mechanisms and Inter-Ethnic Differences between Chinese, Malays and Indians in Singapore—A Hospital-Based Study

by Narayanaswamy Venketasubramanian

J. Cardiovasc. Dev. Dis. 2024, 11(6), 180; https://doi.org/10.3390/jcdd11060180 - 12 Jun 2024

Viewed by 736

Abstract

Disparities in stroke may be due to socioeconomics, demographics, risk factors (RF) and ethnicity. Asian data are scant. This retrospective hospital-based study aimed to explore demographics, RF, stroke subtypes and mechanisms among the Chinese, Malays and Indians in Singapore. Stroke was subtyped into haemorrhagic stroke (HS) and ischaemic stroke (IS). For IS, the clinical syndrome was classified using the Oxfordshire Community Stroke Project (OCSP) classification while the stroke mechanism was categorised using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. During the study period 1 June 2015 to 31 December 2023, data were collected on 1165 patients, with a mean age of 65.6 ± 12.9 yr; 47.4% were female, 83% were Chinese and hypertension (63.5%) and hyperlipidaemia (60.3%) were the most common RF. HS comprised 23.5% (95%CI 21.1–26.1%) (intracerebral 21.7%, subarachnoid 1.3%) of the patients, while IS comprised 76.5% (95%CI 73.9–78.9%) (small artery occlusion 29.0%, cardioembolism 13.3%, large artery atherosclerosis 9.4%, stroke of other determined aetiology 6.2%, stroke of undetermined aetiology 18.6%); 55% of patients had lacunar syndrome. A multivariable analysis showed that HS was associated with ethnicity (p = 0.044), diabetes mellitus (OR 0.27, 95%CI 0.18–0.41, p < 0.001) and smoking (OR 0.47, 95%CI 0.34–0.64, p < 0.001). There were no significant inter-ethnic differences by the OCSP (p = 0.31) or TOAST (p = 0.103) classification. While differences in stroke subtype in Asia may be due to RF, ethnicity has a role. More studies are needed to further explore this. Full article

(This article belongs to the Special Issue Stroke: Risk Factors, Mechanisms, Outcomes and Ethnicity)

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10 pages, 239 KiB

Open AccessArticle

Comparative Prevalence of Cerebrovascular Disease in Vietnamese Communities in South-Western Sydney

by Deena Alysha, Christopher Blair, Peter Thomas, Timmy Pham, Tram Nguyen, Theodore Ross Cordato, Helen Badge, Nicola Chappelow, Longting Lin, Leon Edwards, James Thomas, Suzanne Hodgkinson, Cecilia Cappelen-Smith, Alan McDougall, Dennis John Cordato and Mark Parsons

J. Cardiovasc. Dev. Dis. 2024, 11(6), 164; https://doi.org/10.3390/jcdd11060164 - 24 May 2024

Viewed by 769

Abstract

Culturally and linguistically diverse (CALD) communities are growing globally. Understanding patterns of cerebrovascular disease in these communities may improve health outcomes. We aimed to compare the rates of transient ischaemic attack (TIA), ischaemic stroke (IS), intracerebral haemorrhage (ICH), intracranial atherosclerosis (ICAD), and stroke risk factors in Vietnamese-born residents of South-Western Sydney (SWS) with those of an Australian-born cohort. A 10-year retrospective analysis (2011–2020) was performed using data extracted from the Health Information Exchange database characterising stroke presentations and risk factor profiles. The rates of hypertension (83.7% vs. 70.3%, p < 0.001) and dyslipidaemia (81.0% vs. 68.2%, p < 0.001) were significantly higher in Vietnamese patients, while the rates of ischaemic heart disease (10.4% vs. 20.3%, p < 0.001), smoking (24.4% vs. 40.8%, p < 0.001), and alcohol abuse (>1 drink/day) (9.6% vs. 15.9%, p < 0.001) were lower. The rates of ICAD and ICH were higher in Vietnamese patients (30.9% vs. 6.9%, p < 0.001 and 24.7% vs. 14.4%, p = 0.002). Regression analysis revealed that diabetes (OR: 1.86; 95% CI: 1.14–3.04, p = 0.014) and glycosylated haemoglobin (OR: 1.51; 95% CI: 1.15–1.98, p = 0.003) were predictors of ICAD in Vietnamese patients. Vietnamese patients had higher rates of symptomatic ICAD and ICH, with unique risk factor profiles. Culturally specific interventions arising from these findings may more effectively reduce the community burden of disease. Full article

(This article belongs to the Special Issue Stroke: Risk Factors, Mechanisms, Outcomes and Ethnicity)

13 pages, 873 KiB

Open AccessArticle

Comparative Assessment of Percutaneous Left-Atrial Appendage Occlusion (LAAO) Devices—A Single Center Cohort Study

by Elham Kayvanpour, Max Kothe, Ziya Kaya, Sven Pleger, Norbert Frey, Benjamin Meder and Farbod Sedaghat-Hamedani

J. Cardiovasc. Dev. Dis. 2024, 11(6), 158; https://doi.org/10.3390/jcdd11060158 - 21 May 2024

Viewed by 911

Abstract

Background: Percutaneous left-atrial appendage closure (LAAC) is an established method for preventing strokes in patients with atrial fibrillation, offering an alternative to oral anticoagulation. Various occluder devices have been developed to cater to individual anatomical needs and ensure a safe and effective procedure. In this retrospective, monocentric cohort study, we compare different LAAO devices with respect to clinical outcomes, LAA sealing properties, and device-related complications. Methods: We conducted a retrospective analysis of 270 patients who underwent percutaneous LAA closure in our center between 2009 and 2023. Patient data were extracted from medical records, including gender, age at implantation, indication, device type and size, laboratory values, LAA anatomy, periprocedural complications, ECG parameters, transthoracic and transesophageal echocardiography parameters (TTE and TEE), as well as medication at discharge. Moreover, fluoroscopy time and implantation duration, as well as post-implantation clinical events up to 1 year, were collected. Endpoints were bleeding events, recurrent stroke, thrombi on devices, and death. Results: The implanted devices were the Watchman 2.5, Watchman FLX, Amplatzer Cardiac Plug (ACP), and Amulet. The procedural success rate was 95.7% (n = 265), with cactus anatomy posing the most challenges across all devices. The mean patient age was 75.5 ± 7.7 years, with 64.5% being male. The median CHA2DS2-VASc score was 4.8 ± 1.5 and the median HAS-BLED score was 3.8 ± 1.0. Indications for LAA closure included past bleeding events and elevated bleeding risk. Periprocedural complications were most commonly bleeding at the puncture site, particularly after ACP implantation (p = 0.014). Significant peridevice leaks (PDL) were observed in 21.4% of simple sealing mechanism devices versus 0% in double sealing mechanism devices (p = 0.004). Thrombi were detected on devices in six patients, with no subsequent ischemic stroke or thromboembolic event. Comparative analysis revealed no significant differences in the occurrence of stroke, transient ischemic attack (TIA), thromboembolic events, device-related thrombi, or mortality among different device types. A 62.3% relative risk reduction in thromboembolic events and 38.6% in major bleedings could be observed over 568.2 patient years. Conclusions: In summary, our study highlights the efficacy and safety of LAA closure using various occluder devices despite anatomical challenges. Our long-term follow-up findings support LAA closure as a promising option for stroke prevention in selected patient cohorts. Further research is needed to refine patient selection criteria and optimize outcomes in LAA closure procedures. Full article

(This article belongs to the Special Issue Stroke: Risk Factors, Mechanisms, Outcomes and Ethnicity)

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10 pages, 620 KiB

Open AccessArticle

Left Ventricular Diastolic Dysfunction Is Associated with Poor Functional Outcomes after Endovascular Thrombectomy

by Tony Y. W. Li, Emma M. S. Toh, Ying Ying Koh, Aloysius S. T. Leow, Bernard P. L. Chan, Hock-Luen Teoh, Raymond C. S. Seet, Anil Gopinathan, Cunli Yang, Vijay K. Sharma, Leonard L. L. Yeo, Mark Y. Chan, William K. F. Kong, Kian-Keong Poh, Benjamin Y. Q. Tan and Ching-Hui Sia

J. Cardiovasc. Dev. Dis. 2024, 11(3), 87; https://doi.org/10.3390/jcdd11030087 - 5 Mar 2024

Viewed by 1433

Abstract

Introduction: With the advent of endovascular thrombectomy (ET), patients with acute ischaemic strokes (AIS) with large vessel occlusion (LVO) have seen vast improvements in treatment outcomes. Left ventricular diastolic dysfunction (LVDD) has been shown to herald poorer prognosis in conditions such as myocardial infarction. However, whether LVDD is related to functional recovery and outcomes in ischaemic stroke remains unclear. We studied LVDD for possible relation with clinical outcomes in patients with LVO AIS who underwent ET. Methods: We studied a retrospective cohort of 261 LVO AIS patients who had undergone ET at a single comprehensive stroke centre and correlated LVDD to short-term mortality (in-hospital death) as well as good functional recovery defined as modified Rankin Scale of 0–2 at 3 months. Results: The study population had a mean age of 65-years-old and were predominantly male (54.8%). All of the patients underwent ET with 206 (78.9%) achieving successful reperfusion. Despite this, 25 (9.6%) patients demised during the hospital admission and 149 (57.1%) did not have good function recovery at 3 months. LVDD was present in 82 (31.4%) patients and this finding indicated poorer outcomes in terms of functional recovery at 3 months (OR 2.18, 95% CI 1.04–4.54, p = 0.038) but was not associated with increased in-hospital mortality (OR 2.18, 95% CI 0.60–7.99, p = 0.240) after adjusting for various confounders. Conclusion: In addition to conventional echocardiographic indices such as left ventricular ejection fraction, LVDD may portend poorer outcomes after ET, and this relationship should be investigated further. Full article

(This article belongs to the Special Issue Stroke: Risk Factors, Mechanisms, Outcomes and Ethnicity)

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10 pages, 257 KiB

Open AccessArticle

Pre-Stroke Loop Diuretics and Anemia in Elderly Patients Are Associated Factors of Severe Renal Dysfunction at the Time of Acute Stroke Onset

by Takahisa Mori, Tetsundo Yano, Kazuhiro Yoshioka and Yuichi Miyazaki

J. Cardiovasc. Dev. Dis. 2023, 10(9), 405; https://doi.org/10.3390/jcdd10090405 - 19 Sep 2023

Cited by 1 | Viewed by 1404

Abstract

Background: Severe renal dysfunction (SRD), an advanced stage of chronic kidney disease (CKD), can limit the treatment options for acute stroke (AS) patients. Therefore, it is important to investigate the associated factors of SRD in AS patients to inhibit CKD progression to SRD before AS. Sex differences exist in the renal function. Therefore, we investigated the frequency of SRD and its associated factors among AS patients by sex. Methods: Our cross-sectional study included patients admitted within 24 h of AS onset between 2013 and 2019 with available pre-stroke medication information. We used the Cockcroft–Gault equation for calculating the creatinine clearance (Ccr) and defined SRD as a Ccr < 30 mL/min. We performed multivariable logistic regression analysis to identify the independent factors associated with SRD. Results: Out of 4294 patients, 3472 matched our criteria. Of these, 1905 (54.9%) were male, with median ages of 75 and 81 years for males and females, respectively. The frequency of SRD was 9.7% in males and 18.7% in females. Loop diuretics and anemia were associated factors of SRD. Conclusions: Pre-stroke loop diuretics and anemia in elderly patients were associated factors of SRD in both sexes. Individualized drug therapy and anemia management are essential to prevent SRD. Full article

(This article belongs to the Special Issue Stroke: Risk Factors, Mechanisms, Outcomes and Ethnicity)

16 pages, 1509 KiB

Open AccessArticle

Textural Analysis of the Hyperdense Artery Sign in Patients with Acute Ischemic Stroke Predicts the Outcome of Thrombectomy

by Lucian Mărginean, Rares Cristian Filep, Bogdan Andrei Suciu, Tudor G. Jovin, Paul-Andrei Ștefan, Roxana-Adelina Lupean, Eliza Mihaela Arbănași, Emil Marian Arbănași, Diana Roxana Opriș, Alexander Niklas Timm, Rareș Vodă and Vlad Vunvulea

J. Cardiovasc. Dev. Dis. 2023, 10(9), 359; https://doi.org/10.3390/jcdd10090359 - 24 Aug 2023

Viewed by 1243

Abstract

Textural analysis is pivotal in augmenting the diagnosis and outcomes of endovascular procedures for stroke patients. Due to the detection of changes imperceptible to the human eye, this type of analysis can potentially aid in deciding the optimal type of endovascular treatment. We included 40 patients who suffered from acute ischemic stroke caused by large vessel occlusion, and calculated 130 different textural features based on the non-enhanced CT scan using an open-source software (3D Slicer). Using chi-squared and Mann–Whitney tests and receiver operating characteristics analysis, we identified a total of 21 different textural parameters capable of predicting the outcome of thrombectomy (quantified as the mTICI score), with variable sensitivity (50–97.9%) and specificity (64.6–99.4%) rates. In conclusion, CT-based radiomics features are potential factors that can predict the outcome of thrombectomy in patients suffering from acute ischemic stroke, aiding in the decision between aspiration, mechanical, or combined thrombectomy procedure. Full article

(This article belongs to the Special Issue Stroke: Risk Factors, Mechanisms, Outcomes and Ethnicity)

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Review

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24 pages, 1855 KiB

Open AccessReview

Diagnosis and Management of Atrial Fibrillation in Acute Ischemic Stroke in the Setting of Reperfusion Therapy: Insights and Strategies for Optimized Care

by Jay Patel and Sonu M. M. Bhaskar

J. Cardiovasc. Dev. Dis. 2023, 10(11), 458; https://doi.org/10.3390/jcdd10110458 - 12 Nov 2023

Cited by 1 | Viewed by 3609

Abstract

Reperfusion therapy in the form of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) has revolutionised the field of stroke medicine. Atrial fibrillation (AF) patients constitute a major portion of the overall stroke population; however, the prevalence of AF amongst acute ischemic stroke (AIS) patients receiving reperfusion therapy remains unclear. Limitations in our understanding of prevalence in this group of patients are exacerbated by difficulties in appropriately diagnosing AF. Additionally, the benefits of reperfusion therapy are not consistent across all subgroups of AIS patients. More specifically, AIS patients with AF often tend to have poor prognoses despite treatment relative to those without AF. This article aims to present an overview of the diagnostic and therapeutic management of AF and how it mediates outcomes following stroke, most specifically in AIS patients treated with reperfusion therapy. We provide unique insights into AF prevalence and outcomes that could allow healthcare professionals to optimise the treatment and prognosis for AIS patients with AF. Specific indications on acute neurovascular management and secondary stroke prevention in AIS patients with AF are also discussed. Full article

(This article belongs to the Special Issue Stroke: Risk Factors, Mechanisms, Outcomes and Ethnicity)

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8 pages, 627 KiB

Open AccessBrief Report

Causal Relationship between Chronic Hepatitis B and Stroke in East Asians: A Mendelian Randomization Study

by Qi Zhang, Cancong Shen, Lei Zhang and Maiqiu Wang

J. Cardiovasc. Dev. Dis. 2024, 11(8), 247; https://doi.org/10.3390/jcdd11080247 - 10 Aug 2024

Viewed by 395

Abstract

Both chronic hepatitis B (CHB) and stroke contribute to a high burden of disease in the majority of low- and middle-income countries. Epidemiological studies yield conflicting results on the association between CHB and stroke, and the causal relationship remains inconclusive. This study aimed to assess the causal effects of CHB on stroke and its subtypes in East Asians by Mendelian randomization (MR) analysis. Variants associated with CHB were obtained from a genome-wide association study (GWAS) of Chinese samples as instrumental variables. The summary statistics for stroke in East Asians were derived from the largest published GWAS to date. Two-sample MR analyses were implemented to evaluate the causal effects of CHB on stroke and its subtypes by using the canonical inverse variance weighting method and other supplementary approaches. We observed an association between genetic predisposition to CHB and a decreased risk of large-artery atherosclerotic stroke (odds ratio = 0.872, 95% confidence interval = 0.786–0.967, p = 0.010). The causal effects of CHB on other stroke outcomes were not statistically significant. Evidence for heterogeneity and horizontal pleiotropy were not found in our analyses. This study provides genetic evidence for a negative association between CHB and stroke in East Asians, which helps improve our understanding of the etiology of stroke. Full article

(This article belongs to the Special Issue Stroke: Risk Factors, Mechanisms, Outcomes and Ethnicity)

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