May 2023 Stroke Highlights

Abstract

Interhospital transfer (IHT) is frequently required to receive optimal acute stroke care, including timely endovascular thrombectomy. Oh and colleagues studied IHT using a large national inpatient sample over a 7-year period to assess whether historically marginalized groups had lower odds of IHT for acute ischemic stroke care. In over 3.7 million hospital admissions , 48% were women, 65% were White people, and 57% were on Medicare insurance. Endovascular thrombectomy was 1.5× higher among transferred patients. In multivariable analysis adjusted for sociodemo-graphic variables and comorbidities, women, Black patients, and Hispanic patients were less likely to receive IHT, but these differences were no longer significant after accounting for hospital-level variables. In fully adjusted models, uninsured patients and those with lower income were less likely to undergo IHT. Higher severity of illness was related to higher IHT as expected. There were regional differences in IHT, occurring less frequently in the Midwest and South of the United States. Although detailed information about factors influencing IHT decisions was not available, this study highlights inequities in care, some of which could be targets for intervention at a public health level to reduce inequities in care. See p 1320. PROJECTED GLOBAL TRENDS IN ISCHEMIC STROKE INCIDENCE, DEATHS AND DISABILITY-ADJUSTED LIFE YEARS FROM 2020 TO 2030 Pu and colleagues studied trends in ischemic stroke incidence between 1990 and 2019 using the global burden of disease data, in analyses stratified by sex, age, and location. The outcomes included incidence, deaths, and disability-adjusted life-years due to ischemic stroke. The increases in global numbers (millions) between 1990 and 2020 were as follows: for ischemic stroke incidence, from 4.07 to 7.86; deaths, from 2.05 to 3.15; and disability-adjusted life-years, from 40.50 to 62.53 million. Global projections for 2030 noted further increase to 9.62 million for ischemic stroke incidence, decrease to 2.45 million for deaths, and decrease to 57.89 million for disability-adjusted life-years. Age-standardized rates for the 3 outcomes decreased from 1990 to 2020 but were projected to increase for ischemic stroke incidence by 2030. Sex-stratified, age-standardized projections of ischemic stroke incidence by 2030 noted increases for men and women but higher for women. In addition, deaths and disability-adjusted life-years were projected to increase except for individuals ≥60 years of age. The projected increase in ischemic stroke incidence was independent of country and region's sociodemographic index, but deaths were only projected to increase in countries with low sociodemographic index. This study calls for enhancement of preventive efforts to halt a possible rise in stroke incidence around the world. See p 1330. CHANGES IN CARDIOVASCULAR HEALTH ACROSS MIDLIFE AND LATE-LIFE AND MAGNETIC RESONANCE IMAGING MARKERS OF CEREBRAL VASCULAR DISEASE IN LATE-LIFE Sedaghat and colleagues evaluated the relation of cardiovascular health in mid and late life, and change from mid to late life, to prevalence of brain magnetic resonance imaging markers of cerebral small vessel disease in late life. The authors included 1638 participants from the ARIC study ([Atherosclerosis Risk in Communities]; 60% women, 25% Black people). The brain magnetic resonance imaging markers included white matter hyperintensity volume, cerebral microbleeds, and lacunar, sub-cortical, and cortical infarcts. Cardiovascular health was assessed with 6 of the 7 American Heart Association Life's Simple 7 metrics, including nonsmoking, ideal levels of body mass index, physical activity, untreated blood pressure, fasting blood glucose, and total cholesterol. Cardiovas-cular health improved in 17.1%, stayed the same in 16.9%, and worsened in 65.9% of participants. The prevalence of magnetic resonance imaging markers was 11.6 cm 3 median white matter hyperintensity volume (interquartile range, 6.5-21.7), 23.8% cerebral microbleeds, and 17.6% lacunar infarcts (18.7% subcortical and 10.5% cortical). Higher cardiovascular health at midlife was associated with smaller white matter hyperintensity volume and lower odds of cerebral microbleeds, lacu-nar infarcts, and subcortical infarcts. Similar findings were observed at late life, in addition to lower odds of cortical infarcts. Change in car-diovascular health (improvement) from mid to late life was associated with the same beneficial effects. In subgroup analyses, participants with favorable increase in cardiovascular health had lower burden of cerebral small vessel disease on magnetic resonance imaging compared with those who stayed the same, and the opposite was also true (eg, participants with lower cardiovascular health in midlife had higher burden). No single factor was noted to be driving the findings. While this study does not represent a randomized clinical trial, it supports paying stronger attention to cardiovascular health in midlife as better health in midlife, or a change to improve cardiovascular health from mid to late life, is related to lower burden of cerebral small vessel disease, which in turn is strongly associated with higher risk of stroke and dementia. See p 1280.