Background
Stroke not only substantially increases the risk of incident dementia early after stroke but also the risk remains elevated years after.
Aim
We aimed to determine the risk factors of ...dementia onset more than three to six months after stroke or transient ischemic attack.
Methods
This is a single-center prospective cohort study. We recruited consecutive subjects with stroke/transient ischemic attack without early-onset dementia. We conducted an annual neuropsychological assessment for five years. We investigated the association between baseline demographic, clinical, genetic (APOEɛ4 allele), and radiological factors as well as incident recurrent stroke with delayed-onset dementia using Cox proportional hazards models.
Results
In total, 1007 patients were recruited, of which 88 with early-onset dementia and 162 who lost to follow-ups were excluded. Forty-nine (6.5%) out of 757 patients have incident delayed-onset dementia. The presence of ≥3 lacunes, history of ischemic heart disease, history of ischemic stroke, and a lower baseline Hong Kong version of the Montreal Cognitive Assessment (MoCA) score were significantly associated with delayed-onset dementia. APOEɛ4 allele, medial temporal lobe atrophy, and recurrent stroke were not predictive.
Conclusion
The presence of ≥3 lacunes, history of ischemic heart disease, history of ischemic stroke, and a lower baseline MoCA score are associated with delayed-onset dementia after stroke/transient ischemic attack.
There is increasing information available about the effects of the SARS-CoV-2 virus on the systemic and ocular health of patients, as well as the effects of delayed health care. This mini-review ...summarizes the potential complications and treatments of COVID-19. Systemic findings include respiratory illness, risk of thromboembolic events, and neurologic findings. Some patients may develop persistent symptoms even after the infection resolves. Effective treatment options include glucocorticoids, antivirals, interleukin-6 antagonists, monoclonal antibodies, Janus kinase inhibitors and vaccines. Potential ocular findings of COVID-19 include conjunctivitis, cranial nerve palsies, and microvascular changes in the retina; most symptoms resolved over time. During the lockdown periods, teleophthalmology was utilized to triage non-urgent issues; patients who did present to emergency departments tended to have more severe disease with worse visual prognoses. While transient delays in outpatient ophthalmic care may be tolerated in some patients, others experienced significant vision loss with interruptions in treatments. Resumption of ophthalmic care as soon as possible may help mitigate the effects of delayed care due to the pandemic.
Computational fluid dynamics (CFD) allows noninvasive fractional flow (FF) computation in intracranial arterial stenosis. Removal of small artery branches is necessary in CFD simulation. The ...consequent effects on FF value needs to be judged.
An idealized vascular model was built with 70% focal luminal stenosis. A branch with one third or one half of the radius of the parent vessel was added at a distance of 5, 10, 15 and 20 mm to the lesion. With pressure and flow rate applied as inlet and outlet boundary conditions, CFD simulations were performed. Flow distribution at bifurcations followed Murray’s law. By including or removing side branches, five patient-specific intracranial artery models were simulated. Transient simulation was performed on a patient-specific model, with a larger branch for validation. Branching effect was considered trivial if the FF difference between paired models (branches included or removed) was within 5%.
Compared with the control model without a branch, in all idealized models the relative differences of FF was within 2%. In five pairs of cerebral arteries (branches included/removed), FFs were 0.876 and 0.877, 0.853 and 0.858, 0.874 and 0.869, 0.865 and 0.858, 0.952 and 0.948. The relative difference in each pair was less than 1%. In transient model, the relative difference of FF was 3.5%.
The impact of removing side branches with radius less than 50% of the parent vessel on FF measurement accuracy is negligible in static CFD simulations, and minor in transient CFD simulation.
Background and Purpose. Inflammation exists in inception, progression, and reperfusion of acute ischemic stroke. Insightful understanding of correlation in inflammatory mediators and stroke severity ...with intracranial artery stenosis may improve rational stroke therapy. Methods. We prospectively recruited 977 patients with acute noncardioembolic ischemic stroke with MCA stenosis by MRA as none to mild (<50%), moderate (50–69%), severe (70–99%), or occlusive (100%). The peripheral levels of WBC, homocysteine (HCY), and high sensitivity C-reactive protein (hs-CRP) were recorded. All patients were assessed of 1-year outcome by mRS as favorable (0–2) or poor (3–6). Results. The levels of WBC, HCY, and hs-CRP had no significant differences in patients with categorized MCA stenosis (all P>0.05). Higher levels of WBC, HCY, and hs-CRP were found in patients with 1-year poor outcome (all P<0.05), but only hs-CRP is an independent predictor (OR 1.06, 95% CI 1.027–1.093, P=0.0003). The combination of any two of increased hs-CRP (>3 mg/L), WBC (>6.91 × 109/L), and HCY (>15 μmol/L) had higher power in predicting 1-year poor outcome than the single elevated mediator. Conclusions. Elevated hs-CRP independently predicts 1-year poor outcome in acute stroke. The combination of increased hs-CRP, WBC, or HCY had a stronger predictive value in poor outcome than individual elevated mediator.
An intergenerational “mismatch,” a transition from limited to plentiful living conditions over generations, may increase cardiovascular disease risks. In a migrant population within a homogenous ...culture, we tested the hypothesis that an intergenerational mismatch in childhood living condition is associated with higher body mass index (BMI) and blood pressure in childhood and adolescence.
We used data from 6,965 native born Chinese in Hong Kong (participated in “Children of 1997” birth cohort) and migrant Chinese born elsewhere in China in 1997 (N = 9,845). We classified children into those with intergenerational mismatch (child migrants or first-generation migrants) or those without (second+-generation migrants). Generalized estimating equations were used to examine the associations of migration status (child migrants, first-generation migrants or second+-generation migrants) with age- and sex-specific BMI z-score at 8–15 years and age-, sex-, and height-specific blood pressure z-score at 11–13 years, adjusted for sex, month of birth, and age.
Compared with second+-generation migrants, first-generation migrants had higher diastolic blood pressure z-score (.04, 95% confidence interval (CI) .02, .06) and BMI z-score (.12, 95% CI .06, .18), whereas child migrants had higher diastolic blood pressure z-score (.03, 95% CI .01, .05) regardless of age at migration and higher BMI z-score if they had migrated in infancy (.17, 95% CI .11, .23).
Different relations for blood pressure and BMI suggest that intergenerational mismatch and proximal exposures may have different impacts on adiposity and blood pressure.
An ethnic extraintracranial difference in atherosclerosis has been well reported, whereas the potential mechanism remains unclear. We aimed to investigate neurovascular coupling in healthy whites and ...Asians.
Twenty volunteers of each ethnicity were recruited to perform a functional transcranial Doppler examination with standardized checkerboard patterns as visual stimulation (3 x 4, 6 x 8, and 12 x 16 checks subtending a visual field section of 18 degrees x 24 degrees , flicker rate 1 Hz). Hemodynamic responses in both posterior cerebral arteries were evaluated with a control system approach.
The rate time, that is, the initial speed of flow velocity adaptation, was significantly lower in Asians leading to an approximately 2-second delayed hemodynamic adaptation. The other hemodynamic parameters and the dependency of hemodynamic responses in regard to the complexity degree of the stimulus were similar between groups.
The constellation suggests a greater initial mismatch between functionally increased metabolic demand of neurons and adjusted cerebral blood flow in Asians.
To examine the impact of the 21-gene Oncotype DX Breast Cancer Assay on the adjuvant treatment decision-making process for early-stage breast cancer in Hong Kong.
Retrospective study.
Private ...hospital, Hong Kong.
Study included cases of early-stage breast cancer (T1-2N0-1M0, oestrogen receptor-positive, human epidermal growth factor receptor 2-negative) that were presented at a multidisciplinary breast meeting at a single site. Cases were selected for Oncotype DX testing with the assistance of Adjuvant! Online. The recommendations for adjuvant therapy before and after obtaining the Oncotype DX Recurrence Score results were analysed.
A total of 154 cases that met the inclusion criteria were discussed at our multidisciplinary breast meeting. Of these, 64 cases with no clear recommendation by the Meeting Panel were selected for this study and reviewed. The distribution of Recurrence Score results was similar to that reported by others, with a somewhat higher proportion of low Recurrence Scores. Treatment recommendation was changed for 20 (31%) patients after the Oncotype DX result was received. Of the changes in treatment decisions, 16 (80%) were changes to lower-intensity regimens (either equipoise or hormonal therapy). The number of cases receiving an equipoise recommendation decreased by nine (82%), based on the additional information provided by the Oncotype DX test.
The Oncotype DX Recurrence Score information impacts the decision-making process for adjuvant therapy for early-stage breast cancer in the multidisciplinary care setting in Hong Kong. A larger-scale study is required to gain more experience, evaluate its impact more thoroughly, and assess its cost-effectiveness.
Abstract Thalamic infarcts may lead to diverse neurological disturbances, which easily results in misdiagnosis. Diffusion-weighed magnetic resonance imaging (DWI) is sensitive for the early diagnosis ...of the infarct and identification of the territory involved. The aim of this study was to analyze the clinical features, topographic appearance on DWI and etiology of thalamic infarcts. We reviewed clinical data, vascular risk factors, topographic patterns and etiology of thalamic infarcts. The patients were divided into 2 groups according to DWI patterns: isolated thalamic infarcts (ISO-TH) and combined thalamic infarcts (COM-TH). The former were further subdivided into 2 subgroups: inferolateral isolated thalamic infarcts (INF-TH) and non-inferolateral isolated thalamic infarcts (NON-INF) according to the vascular territories. The Patients were also divided according to etiology based on TOAST classification. The association of clinical features, DWI patterns and etiology was analyzed. Twenty nine patients were included, among which, 23 (79.3%) were ISO-TH and 6 (20.7%) were COM-TH. The most common territory involved in the ISO-TH was inferolateral territory n = 17 (73.9%), followed by tuberothalamic artery territory n = 3 (13.0%), and posterior choroidal artery territory n = 2 (8.7%). In COM-TH, the most common territory also was the inferolateral territory ( n = 3), followed by posterior choroidal artery territory ( n = 1). In 2 patients, the lesions involved more than one vascular thalamic territory. Significant association between small-vessel occlusion (SVO) and ISO-TH (INF-TH + NON-IFN) infarcts were found. Our study suggested that SVO was more prevalent in ISO-TH, and COM-TH needed more etiological examination. DWI might provide meaningful clues about etiology of thalamic infarcts.
Intravenous tissue plasminogen activator (TPA) is the only proven medical treatment for acute ischaemic stroke.1 Early recanalisation of occluded vessels can be achieved in 30% to 46% of ...cases.1Prognosis for patients who fail recanalisation is mostly dismal unless endovascular thrombectomy can be performed in a timely manner.2 Over the last few years, neurologists around the world have witnessed a paradigm shift in treating stroke patients with moderate-to-severe neurological disability (ie, an National Institute of Health Stroke Scale score of 10-25, or even higher).3 Five randomised studies that recruited patients refractory to TPA (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA) showed that endovascular thrombectomy improved clinical outcomes in terms of reducing functional disability at 90 days (ie, a modified Rankin Scale mRS of 0-2).3 In a meta-analysis of these five studies by HERMES collaboration, the investigators directly accessed and extracted patient data at an individual level. There was no heterogeneity of treatment effect across all subgroups, including patients older than 80 years (cOR 3.68, 95% CI=1.95-6.92) and randomisation more than 300 minutes (1.76, 1.05-2.97).3 Among the five trials, only MR CLEAN had complete recruitment4; the other four studies were prematurely terminated due to the high probability of improvement according to interim analyses.3 Although endovascular thrombectomy studies have reset the treatment paradigm for large cerebral vessel occlusion stroke, the recently published DAWN (DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo) study went one step further in this revolution.5 6 The DAWN trial extended the therapeutic time window for endovascular thrombectomy to up to 24 hours in carefully selected patients based on a clinical-radiological mismatch.5 The study enrolled patients with acute large intracranial vessel occlusion, namely the terminal internal carotid artery or M1 middle cerebral artery (on computed tomography CT or magnetic resonance angiography), who presented after 6 to 24 hours, with a mismatch between the severity of clinical deficit and infarct volume (measured by magnetic resonance diffusion-weighted imaging or perfusion CT) and defined according to age (lesser than80 years or greater than or equal to80 years). Replacing clock time by salvageable tissue provided treatment opportunities for 60% of patients in this trial who awake with a stroke, and 14.3% of all ischaemic stroke patients who presented to the emergency department.8 The benefit of early intravenous TPA has been proven for decades.1 In the real world, due to various limitations, its availability varies widely among countries.9 10 According to the Management Information Portal (an intranet for the Hospital Authority staff), in 2015-2016 there were about 11 000 patients with acute ischaemic stroke and unspecified stroke in Hong Kong. With around 70 neurologists in the public sector serving a population of more than 7 million, the narrow therapeutic window for reperfusion therapy poses a great challenge to an acute stroke service. Since 2012, the introduction of telestroke with iPad has expedited the development of 24-hour thrombolytic therapy in Hong Kong.
To assess the outcome of acute ischaemic stroke patients who received intra-arterial therapy in our unit.
Case series.
A tertiary hospital in Hong Kong.
Patients with ischaemic stroke due to large ...artery occlusion treated within 6 hours from symptom onset between January 2007 and May 2011.
Acute intra-arterial revascularisation therapy.
Primary outcome was functional independence (modified Rankin Scale score of ≤ 2) at 3 months. Secondary outcome was rate of recanalisation. Safety outcomes were symptomatic intracranial haemorrhage and 3-month mortality.
Twenty-one patients with a mean age of 67 years fulfilled the inclusion criteria. Their mean National Institutes of Health Stroke Scale score was 18. The mean onset-to-puncture time was 212 minutes. Nine received intra-arterial tissue plasminogen activator alone, 11 had an adjunctive mechanical thrombectomy, and one received balloon angioplasty without tissue plasminogen activator. At the end of the procedure, thrombolysis grade 2a or better was attained in 18 (86%) of the patients, and 8 (38%) achieved functional independence at 3 months. Rates of symptomatic intracranial haemorrhage and 3-month mortality were 10% and 24%, respectively.
In this setting, intra-arterial revascularisation therapy appeared safe and efficacious for this selected group of ischaemic stroke patients with large artery occlusions. Experience gained from this pilot study may help improve clinical outcomes of such patients.
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