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Background: Depicting the time trends of ischemic stroke subtypes may inform healthcare resource allocation on etiology-based stroke prevention and treatment. Aim: To reveal the evolving ischemic stroke subtypes from 2004 to 2018. Methods: We determined the stroke etiologies of consecutive first-ever transient ischemic attack or ischemic stroke patients admitted to a regional hospital in Hong Kong from 2004 to 2018. We analyzed the age-standardized incidences and the two-year recurrence rate of major ischemic stroke subtypes. Results: Among 6940 patients admitted from 2004 to 2018, age-standardized incidence of ischemic stroke declined from 187.0 to 127.4 per 100,000 population (p < 0.001), driven by the decrease in large artery disease (43.0–9.67 per 100,000 population (p < 0.001)), and small vessel disease (71.9–45.7 per 100,000 population (p < 0.001)). Age-standardized incidence of cardioembolic stroke did not change significantly (p = 0.2). Proportion of cardioembolic stroke increased from 20.4% in 2004–2006 to 29.3% in 2016–2018 (p < 0.001). Two-year recurrence rate of intracranial atherothrombotic stroke reduced from 19.3% to 5.1% (p < 0.001) with increased prescriptions of statin (p < 0.001) and dual antiplatelet therapy (p < 0.001). In parallel with increased anticoagulation use across the study period (p < 0.001), the two-year recurrence of AF-related stroke reduced from 18.9% to 6% (p < 0.001). Conclusion: Etiology-based risk factor control might have led to the diminishing stroke incidences related to atherosclerosis. To tackle the surge of AF-related strokes, arrhythmia screening, anticoagulation usage, and mechanical thrombectomy service should be reinforced. Comparable preventive strategies might alleviate the enormous stroke burden in mainland China. [ABSTRACT FROM AUTHOR]

Background: Intracranial atherosclerotic stenosis is an important etiology subtype of ischemic stroke. Stenosis severity was thought to be the main reference index for clinical treatment and research. However, stenosis could not reflect the ischemia risk completely, instead the hemodynamic state across the lesion, the extent of collateral circulation, and perfusion impairment downstream the stenosis are more important. Aims: We write this review aimed to summarize novel angiographic methods applied in the evaluation of functional severity of ICAS, and commented on their limitations and prospects in future research. Summary of review: The main methods to estimate cerebral blood flow including fractional flow assessed by signal intensity ratio, computational fluid dynamics analysis or pressure wire, quantitative magnetic resonance angiography. Fractional flow as a series cerebral hemodynamic parameters may reflect the status of collateral circulation and cerebral blood flow. But the accuracy of the methods was not validated. The method to calculate fractional flow reserve in cardiovascular disease cannot duplicate in cerebrovascular disease. Fractional flow measurement by floating a pressure guidewire across the intracranial stenosis was technically feasible and safe. In the future researches, a non-invasive method should be established to identify high-risk intracranial lesions and may help in decision-making. Conclusions: The relationship between stenosis and cerebral blood flow was individualized. Cerebral hemodynamic criteria should be used to screen patients to endovascular treatment, which will optimize the diagnosis and treatment strategies for patients with symptomatic intracranial artery stenosis. [ABSTRACT FROM AUTHOR]

Rationale The risk of recurrent ischemia is high in the acute period after ischemic stroke and transient ischemic attack. Aspirin is recommended by guidelines for this indication, but more intensive antiplatelet therapy may be justified. Aims We aim to evaluate whether ticagrelor, a potent antiplatelet agent that blocks the P2Y12 receptor without requiring metabolic activation, reduces the risk of major vascular events compared with aspirin when randomization occurs within 24 h after symptom onset of a nonsevere ischemic stroke or high-risk transient ischemic attack. Design Acute Stroke or Transient Ischemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes (SOCRATES) is a randomized, double-blind, event-driven trial and will include an estimated 13 600 participants randomized in 33 countries worldwide to collect 844 primary events. Study outcomes The primary endpoint is the composite of stroke (ischemic or hemorrhagic), myocardial infarction, and death. Time to the first primary endpoint will be compared in the treatment groups during 90-day follow-up, with major hemorrhage serving as the primary safety endpoint. Participants will be followed for an additional 30 days after the randomized treatment period. Discussion The SOCRATES trial fulfills an important clinical need by evaluating a potent antiplatelet agent as a superior alternative to current standard of care in patients presenting acutely with ischemic stroke or transient ischemic attack. [ABSTRACT FROM AUTHOR]

This study examined the validity and reliability of the Neuropsychiatric Inventory Questionnaire version (NPI-Q), a proxy-reported format of the interview-based NPI, in assessing neuropsychiatric symptoms in 173 patients with stroke or transient ischemic attack (TIA) having cognitive impairment. The NPI-Q was validated against the NPI as a gold standard. Informants took approximately 7 minutes to complete the NPI-Q. Bland-Altman analysis revealed a bias of 0.7 points, with 95% limits of agreement between −8.6 and 10.0 between the total symptom scores of the NPI and NPI-Q. The NPI-Q correlated significantly with the NPI in individual and total symptom scores and caregiver distress scores. In predicting presence of symptoms on the NPI, the NPI-Q yielded, on average, sensitivity of 74.1% and specificity of 79.5%. On the NPI-Q, informants tended to overreport symptoms in patients with less severe symptoms but underreport with increasing symptom severity. Internal consistency of the NPI-Q was acceptable (Cronbach's α = 0.756). One-week test–retest reliability of the NPI-Q was excellent (intraclass correlation coefficient = .990). The NPI-Q is a valid and reliable instrument for screening neuropsychiatric symptoms in patients with stroke and TIA. [ABSTRACT FROM AUTHOR]

Background Antihypertensive drugs are useful in the prevention of stroke; however, much debate surrounds which class of agent provides the most benefit post-stroke. Aims The aim of this study was to examine the impact of different classes of antihypertensive agent on stroke outcome using data from the ChinaQUEST study, a prospective, hospital-based stroke registry undertaken across 62 hospitals in China. Methods Logistic regression analysis was used to determine the comparative associations of different antihypertensive medications when initiated in-hospital post-stroke on the following poor outcomes in stroke survivors at three- and 12 months post-stroke: (1) death and dependency, based on modified Rankin Scale scores 3–5; (2) death; and (3) dependency. Results Of the 6416 patients with baseline data, 3986 (62%) were on at least one antihypertensive agent. After adjustment for baseline characteristics and concomitant therapies, there were no differences in outcomes between therapies at threeand 12 months, but at 12 months, calcium channel blocker use was associated with reduced risks of death/dependency (odds ratio 0·78, P = 0·001) and death (odds ratio 0·66, P < 0·001). In addition, angiotensin-converting enzyme inhibitor/ angiotensin II receptor antagonist use was associated with reduced risk of death (odds ratio 0·76, P = 0·009), whereas both beta-blockers and diuretics were shown to increase the risk of death/dependency and death but had no effect on the risk of dependency. Conclusion This study suggests that early initiation of calcium channel blockers is associated with improved outcome after stroke. Further randomized studies are warranted to confirm these findings and to delineate differential beneficial effects of antihypertensive therapy in stroke prevention. [ABSTRACT FROM AUTHOR]

Background and Aim Studies in stroke patients suggest that lacunar stroke and intracerebral hemorrhage might be more common in Chinese than Whites. We hypothesized that other manifestations of subclinical cerebral small vessel disease, namely white matter hyperintensities (WMH), lacunes, and microbleeds, are also more common in Chinese than Whites. We compared the community prevalence of these lesions between Han Chinese and White Australians. Methods Magnetic resonance imaging (1·5-Tesla) was performed on participants of the Shanghai Aging Study (n = 321, mean age 69 ± 6 years) and Tasmanian Study of Cognition and Gait (n = 397, mean age 72 ± 7 years). A single-rater recorded measures of WMH, lacunes, and microbleeds. We compared lesion prevalence between age- and gender-matched subgroups from the two cohorts. Among all subjects (n = 718), we performed multivariable logistic regression to examine if race-ethnicity was independently associated with these lesions. Results Among age- and gender-matched subjects, confluent WMH were significantly more prevalent in Chinese (38·5%) than Whites (28·4%; P = 0·01). There was no difference in the prevalence of lacunes (Chinese 29·1% vs. Whites 29·5%, P = 0·93) and microbleeds (Chinese 10·1% vs. 9·0%, P = 0·67) between Chinese and Whites. In multivariable logistic regression, Chinese ethnicity was associated with confluent WMH (odds ratio 1·7, 95% confidence interval 1·1–2·6, P = 0·01), but no differences were seen for lacunes and microbleeds. The association between Chinese ethnicity with confluent WMH became insignificant when subjects with history of stroke were excluded. Conclusions In this population-based cross-national comparison, Han Chinese had a higher prevalence of confluent WMH than White Australians, but had a similar prevalence of lacunes and microbleeds. [ABSTRACT FROM AUTHOR]

Background and purpose Studies mostly use the analysis of heart rate variability to measure cardiovascular autonomic regulation in ischemic stroke. Besides power spectral analysis of heart rate variability, this study sought to determine whether autonomic function was impaired during different phases in ischemic stroke by Ewing's battery of autonomic function tests. Methods Ninety-four patients with ischemic stroke (34 patients in acute phase and 60 patients in chronic phase, average six-months after stroke onset) and thirty-seven elderly controls were recruited. Ewing's battery autonomic function tests and power spectral analysis of heart rate variability were performed in all the subjects. Results From power spectral analysis of heart rate variability, stroke patients of both acute and chronic phases had significantly lower low frequency power spectral density than controls. From Ewing's battery of autonomic function tests, patients in acute phase showed impairment in two parasympathetic tests ( Valsalva ratio: P = 0·002; heart rate response to deep breathing: P < 0·001) and those in chronic phase showed impairment in all parasympathetic tests (all P < 0·05) in comparison with controls. Conclusions The comprehensive assessment indicates that autonomic dysfunction occurs in acute phase of ischemic stroke and may persist up to six-months after stroke. Parasympathetic dysfunction rather than sympathetic dysfunction is predominant after ischemic stroke. [ABSTRACT FROM AUTHOR]

Rationale The clinical effects of neuroprotective and/or neurorestorative therapies may vary according to location and size of the ischemic injury. Imaging techniques can be useful in stratifying patients for trials that may be beneficial against particular ischemic lesion characteristics. Aim To test the hypothesis that the efficacy of NeuroAiD compared with placebo in improving functional outcome and reducing neurological deficit in patients with cerebral infarction of intermediate severity varies between sub-groups of patients randomized in the main Chinese Medicine Neuroaid Efficacy on Stroke study when categorized according to baseline imaging characteristics. Design This is a retrospective cohort sub-group analysis of patients who participated in the main Chinese Medicine Neuroaid Efficacy on Stroke study, a multicenter, double-blind, placebo-controlled trial that recruited 1100 patients within 72 h of ischemic stroke onset with National Institutes of Health Stroke Scale 6-14 and were randomized to either NeuroAiD or placebo taken four capsules three times daily for three months. Review of the baseline images to classify the acute stroke lesions in terms of size, location, and extent of involvement will be performed retrospectively by two readers who will remain blinded as to treatment allocation and outcomes of the subjects. Study outcomes The primary efficacy end-point in the main Chinese Medicine Neuroaid Efficacy on Stroke study is the modified Rankin Scale grades at three-months. Secondary efficacy end-points are the National Institutes of Health Stroke Scale score at three-months; difference of National Institutes of Health Stroke Scale scores between baseline and 10 days and between baseline and three-months; difference of National Institutes of Health Stroke Scale sub-scores between baseline and 10 days and between baseline and three-months; modified Rankin Scale at 10 days, one-month, and three-months; Barthel index at three-months; and Mini Mental State Examination at 10 days and three-months. Analysis of these primary and secondary end-points will be performed for sub-groups defined in this study after review of the baseline brain imaging: nonlacunar and lacunar, cortical and sub-cortical, hemispheric vs. brainstem, Alberta Stroke Program Early CT score <7 and 7-10, and score <8 and 8-10. [ABSTRACT FROM AUTHOR]

Background As a leading cause of severe disability and death, stroke places an enormous burden on the health care system in China. There are limited data on the pattern of current medical practice and quality of care delivery for stroke patients at the national level. Aim The nation-wide prospective registry, China National Stroke Registry, will be considered with regard to its design, progress, geographic coverage, and hospital and patient characteristics. Methods Between September 2007 and August 2008, the China National Stroke Registry recruited consecutive patients with diagnoses of acute cerebrovascular events from 132 hospitals that cover all 27 provinces and four municipalities (including Hong Kong region) in China. Clinical data were collected prospectively using paper-based registry forms. Patients were followed for clinical and functional outcomes through phone interviews at three, six, 12, 18, and 24 months after disease onset. Results These patients (n521 902) were 63.8 years of age on average, and 39% were females. Ischaemic stroke was predominant (66.4%), and the other subtypes were intracerebral haemorrhage (23.4%), subarachnoid haemorrhage (3.4%), and transient ischaemic attack (6.2%). Conclusions The China National Stroke Registry is a largescale nationwide registry in China. Rich data collected from this prospective registry may provide the opportunity to evaluate the quality of care for stroke patients in China. [ABSTRACT FROM AUTHOR]

The article focuses on the development of stroke management guidelines. It says that the World Stroke Organization (WSO) Stroke Guidelines Subcommittee conducted an electronic survey highlighting several issues including guideline development process, involvement of healthcare providers and guideline effectiveness. It mentions that 65 from 85 WSO member countries responded, while guidelines were not standardised in 17 countries and have 35 distinct stroke registries.

Background Stroke is a major health issue in China. Aims We aimed to describe the management of patients admitted to hospitals in China with acute ischaemic stroke, and to determine whether there were any differences by age and gender. Methods Using a multicentre prospective hospital register across all eight major economic (geographic) regions in China, data on the socioeconomic characteristics, medical history, clinical features, and in-hospital investigations, management, and outcomes were collected on consecutive patients with acute stroke due to cerebral ischaemia during a 5-month period in 2006. Results Overall, traditional Chinese medicine and neuroprotectant use were remarkably high, with nearly 80% of patients receiving the former and >70% receiving the latter in hospital. Length of hospital stay was also long (median duration 16-days). Multivariate analyses revealed no clinically important differences in management between the genders. For the age-specific analyses, there were significant trends of decreasing use of thrombolysis ( P=0·04), warfarin ( P=0·01), corticosteroids ( P=0·03), and lipid-lowering therapy ( P=0·001); however, more assisted feeding ( P=0·004) and rising rates of disability and in-hospital complications occurred with increasing age. Conclusions New information is provided regarding the current state of ischaemic stroke management in China. Notably, there is high use of traditional Chinese medicine and neuroprotectants and long lengths of hospital stay. Similar to many other countries, differences in stroke care and management by age and gender also exist to a small extent in China. [ABSTRACT FROM AUTHOR]

Rationale Lacunar infarct associated with small vessel disease is a common stroke subtype in China and has a favorable short-term prognosis. Data on its long-term prognosis among Chinese patients are lacking. Aims We aimed to study its long-term prognosis and predictors for poor outcomes. Design We followed up to 75 consecutive Chinese stroke patients who had a lacunar infarct for a period of 5 years. Clinical outcomes with respect to mortality and recurrent stroke were noted. We evaluated baseline clinical and imaging predictors for such outcomes using the Cox regression analysis. Study Outcomes Sixteen (21·3%) patients died and 12 (16%) patients had recurrent stroke during follow-up. Twenty-one (28%) patients had combined events of either death and/or recurrent stroke. Univariate Cox regression analysis showed that age, literacy, National Institute of Health Stroke Scale, incident stroke/transient ischemic attack, and white matter lesion volume predicted survival, while, age, National Institute of Health Stroke Scale, systolic blood pressure, hyperhomocysteinemia, silent lacunes, microbleeds, and white matter lesion volume predicted recurrent stroke. Multivariate Cox regression analysis showed that National Institute of Health Stroke Scale (HR 1·25, 95% CI 1·05–1·48) and white matter lesion volume (HR 1·46, 95% CI 1·11–1·92) predicted combined events of mortality and/or recurrent stroke after age adjustment. Conclusion Approximately one in four patients either died and/or had recurrent stroke within 5 years after a lacunar infarct. Age, stroke severity, and volume of white matter lesion predict a poor long-term prognosis. [ABSTRACT FROM AUTHOR]

Teachers have a key role in adolescents’ career development. Nevertheless, few studies examined their effect on career outcomes. The present study has two objectives. First, to test the factorial structure of the Italian version of the Career-related Teacher Support Scale (CRTSS) with Italian adolescents. Second, to test how career-related teacher support leads to career decision self-efficacy through career adaptability. In Study I, 469 adolescents were asked to complete the CRTSS. A first-order model, a second-order model (hierarchical), a bi-factor model (hierarchical), and a single-factor model were compared to check the best model solution. Additionally, the measurement invariance was examined across male and female. Results reveal the superiority of the second-order (hierarchical) model and the invariance between males and females. In the Study II took part 228 adolescents. A structural equation modeling approach assessed the relationship between career-related teacher support, career adaptability and career decision self-efficacy. A mediation model showed a significant indirect effect of career-related teacher support on decision self-efficacy through career adaptability. Practical implications for interventions were discussed. [ABSTRACT FROM AUTHOR]

The article deals with intracranial atherosclerosis which is considered the most common vascular lesion in stroke patients worldwide. The disease affects the middle cerebral artery, intracranial portion of the internal carotid artery, vertebrobasilar artery, posterior and anterior cerebral arteries. Patients of Asian, African and Hispanic descent are more at risk in developing the disease.

Presents updates related to stroke as of May 2006. Stroke experienced by Israeli Prime Minister Ariel Sharon; Benefits of repetitive transcranial magnetic stimulation to stroke patients; Features of CoAxia NeuroFlo Perfusion Augmentation technology; Role of fruit and vegetables in reducing the risk of stroke.

A letter to the editor related to a study concerning the hemodynamic role and importance of intracranial arterial stenosis (ICAS) in diagnosing the risk of stroke in patients with symptomatic ICAS is presented.