bluuebunny/crossref_metadata_2025_split huggingface dataset:
Cholesterol Mass Efflux Capacity, Incident Cardiovascular Disease, and Progression of Carotid Plaque
Authors: Shea Steven , Stein James H. , Jorgensen Neal W. , McClelland Robyn L. , Tascau Liana , Shrager Sandi , Heinecke Jay W. , Yvan-Charvet Laurent , Tall Alan R. 
Published: December 2018

Objective—
To assess the role of HDL (high-density lipoprotein)-mediated cholesterol mass efflux capacity (CMEC) in incident cardiovascular disease and carotid plaque progression.

Approach and Results—

We measured CMEC in 2 cohorts aged 45 to 84 years at baseline derived from the MESA (Multi-Ethnic Study of Atherosclerosis). Cohort 1 comprised 465 cases with incident cardiovascular disease events during 10 years of follow-up and 465 age- and sex-matched controls; cohort 2 comprised 407 cases with progression of carotid plaque measured by ultrasonography at 2 exams >10 years and 407 similarly matched controls. Covariates and outcome events were ascertained according to the MESA protocol. CMEC level was modestly correlated with HDL cholesterol (
R
=0.13;
P
<0.001) but was not associated with age, sex, race/ethnicity, body mass index, diabetes mellitus, alcohol use, smoking status, or statin use. Higher CMEC level was significantly associated with lower odds of cardiovascular disease (odds ratio, 0.82 per SD of CMEC [95% CI, 0.69–0.98;
P
=0.031] in the fully adjusted model) in cohort 1 but higher odds of carotid plaque progression (odds ratio, 1.24 per SD of CMEC [95% CI, 1.04–1.48;
P
=0.018] in the fully adjusted model) in cohort 2 but without dose-response effect. In subgroup analysis within cohort 1, higher CMEC was associated with lower risk of incident coronary heart disease events (odds ratio, 0.72 per SD of CMEC (95% CI, 0.5–0.91;
P
=0.007) while no association was found with stroke events.

Conclusions—
These findings support a role for HDL-mediated cholesterol efflux in an atheroprotective mechanism for coronary heart disease but not stroke.
A Systematic Literature Review of Patients With Carotid Web and Acute Ischemic Stroke
Authors: Zhang Andrew J. , Dhruv Parth , Choi Philip , Bakker Caitlin , Koffel Jonathan , Anderson David , Kim Jae , Jagadeesan Bharathi , Menon Bijoy K. , Streib Christopher 
Published: December 2018

Background and Purpose—
Carotid web (CW) is a rare form of focal fibromuscular dysplasia defined as an abnormal shelf-like projection of intimal fibrous tissue into the carotid bulb. It is theorized that CW leads to ischemic stroke secondary to blood flow stasis and subsequent embolization. The natural history and optimal management of CW are unclear. To address this knowledge gap, we performed a systematic literature review (SLR) of CW.

Methods—
Our librarians performed a SLR for CW and related terminology. Patient-level demographics, stroke risk factors, neuroimaging findings, stroke recurrence or stroke free-duration, and treatment modality were extracted. We used descriptive statistics to characterize our results. When specific patient-level metrics were not reported, the denominators for reporting percentage calculations were adjusted accordingly.

Results—
Our literature search produced 1150 articles. Thirty-seven articles including 158 patients (median age 46 years [range 16–85], 68% women, 76% symptomatic) met entry criteria and were included in our SLR. Of the symptomatic CW patients: 57% did not have stroke risk factors, 56% who received medical therapy had recurrent stroke (median 12 months, range 0–97), and 72% were ultimately treated with carotid revascularization (50% carotid stenting, 50% carotid endarterectomy). There were no periprocedural complications or recurrent strokes in carotid revascularization patients.

Conclusions—
CW leads to ischemic stroke in younger patients without conventional stroke risk factors. We found a high stroke recurrence rate in medically managed symptomatic CW patients, whereas carotid revascularization effectively prevented recurrent stroke. Our findings should be interpreted with caution because of risk of publication and reporting bias.
Early Prediction of Malignant Brain Edema After Ischemic Stroke
Authors: Wu Simiao , Yuan Ruozhen , Wang Yanan , Wei Chenchen , Zhang Shihong , Yang Xiaoyan , Wu Bo , Liu Ming 
Published: December 2018

Background and Purpose—
Malignant brain edema after ischemic stroke has high mortality but limited treatment. Therefore, early prediction is important, and we systematically reviewed predictors and predictive models to identify reliable markers for the development of malignant edema.

Methods—
We searched Medline and Embase from inception to March 2018 and included studies assessing predictors or predictive models for malignant brain edema after ischemic stroke. Study quality was assessed by a 17-item tool. Odds ratios, mean differences, or standardized mean differences were pooled in random-effects modeling. Predictive models were descriptively analyzed.

Results—
We included 38 studies (3278 patients) with 24 clinical factors, 7 domains of imaging markers, 13 serum biomarkers, and 4 models. Generally, the included studies were small and showed potential publication bias. Malignant edema was associated with younger age (n=2075; mean difference, −4.42; 95% CI, −6.63 to −2.22), higher admission National Institutes of Health Stroke Scale scores (n=807, median 17–20 versus 5.5–15), and parenchymal hypoattenuation >50% of the middle cerebral artery territory on initial computed tomography (n=420; odds ratio, 5.33; 95% CI, 2.93–9.68). Revascularization (n=1600, odds ratio, 0.37; 95% CI, 0.24–0.57) were associated with a lower risk for malignant edema. Four predictive models all showed an overall C statistic >0.70, with a risk of overfitting.

Conclusions—
Younger age, higher National Institutes of Health Stroke Scale, and larger parenchymal hypoattenuation on computed tomography are reliable early predictors for malignant edema. Revascularization reduces the risk of malignant edema. Future studies with robust design are needed to explore optimal cutoff age and National Institutes of Health Stroke Scale scores and to validate and improve existing models.
Validation of the Intracerebral Hemorrhage Score in Uganda
Authors: Abdallah Amir , Chang Jonathan L. , O’Carroll Cumara B. , Okello Samson , Olum Sam , Acan Moses , Aden Abdirahim Abdi , Chow Felicia C. , Siedner Mark J. 
Published: December 2018

Background and Purpose—
Rates of intracerebral hemorrhage (ICH) are estimated to be highest globally in sub-Saharan Africa. However, outcomes of ICH are poorly described and standard prognostic markers for ICH have not been validated in the region.

Methods—
We enrolled consecutive patients with computed tomography-confirmed ICH at a referral hospital in southwestern Uganda. We recorded demographic, clinical, and radiographic features of ICH, and calculated ICH scores. We fit Poisson regression models with robust variance estimation to determine predictors of case fatality at 30 days.

Results—
We enrolled 73 individuals presenting with computed tomography-confirmed ICH (mean age 60 years, 45% [33/73] female, and 14% [10/73] HIV-positive). The median ICH score was 2 (interquartile range, 1–3; range, 0–5). Case fatality at 30 days was 44% (32/73; 95% CI, 33%–57%). The 30-day case fatality increased with increasing ICH score of 0, 1, and 5 from 17%, 23%, to 100%, respectively. In multivariable-adjusted models, ICH score was associated with case fatality (adjusted relative risk, 1.48; 95% CI, 1.23–1.78), as were HIV infection (adjusted relative risk, 1.92; 95% CI, 1.07–3.43) and female sex (adjusted relative risk, 2.17; 95% CI, 1.32–3.59). The ICH score moderately improved with the addition of a point each for female sex and HIV serostatus (0.81 versus 0.73).

Conclusions—
ICH score at admission is a strong prognostic indicator of 30-day case fatality in Uganda. Our results support its role in guiding the care of patients presenting with ICH in the region.
APOE
and the Association of Fatty Acids With the Risk of Stroke, Coronary Heart Disease, and Mortality
Authors: Satizabal Claudia L. , Samieri Cécilia , Davis-Plourde Kendra L. , Voetsch Barbara , Aparicio Hugo J. , Pase Matthew P. , Romero José Rafael , Helmer Catherine , Vasan Ramachandran S. , Kase Carlos S. , Debette Stéphanie , Beiser Alexa S. , Seshadri Sudha 
Published: December 2018

Background and Purpose—

The role of dietary fat on cardiovascular health and mortality remains under debate. Because the APOE is central to the transport and metabolism of lipids, we examined associations between plasma fatty acids and the risk of stroke, coronary heart disease, and mortality by
APOE-ε4
genotype.

Methods—
We included 943 FHS (Framingham Heart Study) and 1406 3C (Three-City) Bordeaux Study participants. Plasma docosahexaenoic, linoleic, arachidonic, and palmitic fatty acids were measured at baseline by gas chromatography. All-cause stroke, ischemic stroke, coronary heart disease, and all-cause mortality events were identified prospectively using standardized protocols. Each cohort used Cox models to separately relate fatty acid levels to the risk of developing each event during ≤10 years of follow-up adjusting for potential confounders and stratifying by APOE genotype (ε4 carriers versus noncarriers). We then meta-analyzed summary statistics using random-effects models.

Results—

On average, participants had a mean age of 74 years, 61% were women, and 21% (n=483) were
APOE-ε4
carriers. Meta-analysis results showed that, only among
APOE-ε4
carriers, every SD unit increase in linoleic acid was associated with a reduced risk of all-cause stroke (hazard ratio [HR], 0.54 [95% CI, 0.38–0.78]), ischemic stroke (HR, 0.48 [95% CI, 0.33–0.71]), and all-cause mortality (HR, 0.70 [95% CI, 0.57–0.85]). In contrast, every SD unit increase in palmitic acid was related to an increased risk of all-cause stroke (HR, 1.58 [95% CI, 1.16–2.17]), ischemic stroke (HR, 1.76 [95% CI, 1.26–2.45]), and coronary heart disease (HR, 1.48 [95% CI, 1.09–2.01]), also in
APOE-ε4
carriers only. Results for docosahexaenoic acid and arachidonic acid were heterogeneous between cohorts.

Conclusions—

These exploratory results suggest that
APOE-ε4
carriers may be more susceptible to the beneficial or adverse impact of fatty acids on cardiovascular disease and mortality. In this subgroup, higher linoleic acid was protective for stroke and mortality, whereas palmitic acid was a risk factor for stroke and coronary heart disease. The mechanisms underlying these novel findings warrant further investigation.
Weekend Effect in Carotid Endarterectomy
Authors: O’Donnell Thomas F.X. , Schermerhorn Marc L. , Liang Patric , Li Chun , Swerdlow Nicholas J. , Wang Grace J. , Giles Kristina A. , Wyers Mark C. 
Published: December 2018

Background and Purpose—
Patients undergoing surgery on the weekend may experience worse outcomes, but this weekend effect has not been studied in carotid endarterectomy (CEA).

Methods—
We identified patients undergoing isolated CEA in the Vascular Quality Initiative between 2003 and 2018. Our primary outcome was in-hospital stroke or perioperative death (stroke/death), stratified by symptom status. For asymptomatic patients, we also compared rates of the Centers for Medicare and Medicaid Services quality metric prolonged length of stay (>2 days or failed discharge home). We calculated propensity scores and used multilevel, inverse probability weighted logistic regression clustering at the hospital level.

Results—

There were 86 123 repairs during the study period, 53% asymptomatic lesions and 47% symptomatic. Only 0.7% of asymptomatic patients underwent CEA on the weekend, compared with 3.1% of symptomatic patients. Patients undergoing weekend repairs were more often white, with lower rates of most comorbidities. In asymptomatic patients, weekend operations were associated significantly higher odds of stroke/death (odds ratio [OR], 2.3 [1.1–4.8];
P
=0.02), and prolonged length of stay (OR, 3.6 [2.7–4.7];
P
<0.001). In symptomatic patients, weekend operations were associated with significantly higher adjusted odds of stroke/death (OR, 1.7 [1.2–2.4];
P
=0.007) and longer postoperative length of stay (3.3 days versus 2.0 days,
P
=0.002). However, the difference in stroke/death was driven by patients presenting with stroke (OR, 2.2 [1.5–2.3];
P
<0.001), rather than those presenting with transient ischemic attack (OR, 1.2 [0.6–2.1];
P
=0.56).

Conclusions—
We found evidence of a significant weekend effect in CEA, as weekend operations in asymptomatic patients and patients who presented with stroke were associated with higher rates of stroke/death and prolonged length of stay. However, there was no evidence of such an effect in patients with transient ischemic attack. These data suggest that weekend CEA should be avoided except in the case of expedited revascularization after transient ischemic attack.
A Novel Staging System to Evaluate Cerebral Hypoperfusion in Patients With Moyamoya Disease
Authors: Yin Hu , Liu Xingju , Zhang Dong , Zhang Yan , Wang Rong , Zhao Meng , Zhao Jizong 
Published: December 2018

Background and Purpose—
The study goal was to evaluate cerebral perfusion in moyamoya patients with a novel staging system and investigate the association between differences of perfusion status and clinical outcomes in patients treated with revascularization.

Methods—
About 506 consecutive patients from 2009 to 2015 were enrolled. The perfusion status was evaluated by a staging system-the stage of preinfarction period based on the result of computed tomography perfusion. Hemisphere in different perfusion stage was compared between hemorrhagic patients (n=155) and ischemic patients (n=351). The modified Rankin Scale was applied to evaluate the prognosis of patients.

Results—

In the enrolled 506 patients: 229 hemispheres (22.6%) with normal perfusion, 72 hemispheres (7.1%) in stage I, 205 hemispheres (20.3%) in stage II, 308 hemispheres (30.4%) in stage III, and 198 hemispheres (19.6%) in stage IV. Significant difference was observed in stage distribution between hemorrhagic patients and ischemic patients (
P
<0.01). The ratio of hemispheres with normal perfusion in hemorrhagic group is more than the ischemic group (
P
<0.05; odds ratio, 1.440; 95% CI, 1.144–1.811). The ratio of hemispheres in stage III in ischemic group is more than the hemorrhagic group (
P
<0.01; odds ratio, 0.618, 95% CI, 0.487–0.783). In the prognosis-related analysis, the stage I group has the highest improved ratio (73.9%) and the normal perfusion group has the lowest improved ratio (33.3%). The improved ratio has a decreasing tendency from stage I to stage IV.

Conclusions—
The novel preinfarction staging system is a valuable assessment tool to evaluate cerebral perfusion status in moyamoya patients and predict the efficacy of revascularization. Ischemic patients suffer more from hypoperfusion. Patients in stage I and stage II are more likely to obtain improvement after revascularization. This is a retrospective study.
Increased Risk of Traffic Injury After a Cerebrovascular Event
Authors: Yu Amy Y.X. , Kapral Moira K. , Fang Jiming , Redelmeier Donald A. 
Published: December 2018

Background and Purpose—
We aimed to determine the long-term risks of a motor vehicle collision after a cerebrovascular event and whether the risks were similar after left- or right-hemispheric events.

Methods—
We used a population-based registry to identify patients diagnosed with a transient ischemic attack or stroke (hemorrhagic or ischemic) between 2003 and 2013 in Ontario, Canada. Hemispheric laterality was determined using radiological and clinical findings. We identified subsequent serious injuries involving the patient as a driver using linked administrative data. Secondary outcomes included serious injuries involving the patient as a pedestrian, as a passenger, or other traumatic events (fall, fracture, ankle sprain). We used proportional hazard models accounting for death as a competing risk to test the association of hemispheric laterality and outcomes with and without adjustment for age, sex, discharge modified Rankin Scale score, home location, and prior driving record. Patients were followed through to 2017.

Results—
Among 26 144 patients with hemispheric cerebrovascular events, 377 subsequent serious traffic injuries as a driver (2.2 per 1000 person-year) were identified over a median follow-up of 6.4 person-years. The rate did not differ by laterality (adjusted hazard ratio, 1.00; 95% CI, 0.82–1.23). The risk of a serious traffic injury as a pedestrian was significantly higher after a right-sided than left-sided event (adjusted hazard ratio, 1.27; 95% CI, 1.02–1.58). Subsequent risks for other traumatic injuries did not differ by laterality of cerebrovascular event.

Conclusions—
The risk of a serious traffic injury as a pedestrian is substantially higher after a right-hemispheric cerebrovascular event compared with a left-sided event. Walking should be promoted for exercise in survivors of a stroke or transient ischemic attack, but these vulnerable road users may benefit from additional poststroke rehabilitation to optimize safety.
Iron Status and Risk of Stroke
Authors: Gill Dipender , Monori Grace , Tzoulaki Ioanna , Dehghan Abbas 
Published: December 2018

Background and Purpose—
Both iron deficiency and excess have been associated with stroke risk in observational studies. However, such associations may be attributable to confounding from environmental factors. This study uses the Mendelian randomization technique to overcome these limitations by investigating the association between genetic variants related to iron status and stroke risk.

Methods—
A study of 48 972 subjects performed by the Genetics of Iron Status consortium identified genetic variants with concordant relations to 4 biomarkers of iron status (serum iron, transferrin saturation, ferritin, and transferrin) that supported their use as instruments for overall iron status. Genetic estimates from the MEGASTROKE consortium were used to investigate the association between the same genetic variants and stroke risk. The 2-sample ratio method Mendelian randomization approach was used for the main analysis, with the MR-Egger and weighted median techniques used in sensitivity analyses.

Results—
The main results, reported as odds ratio (OR) of stroke per SD unit increase in genetically determined iron status biomarker, showed a detrimental effect of increased iron status on stroke risk (serum iron OR, 1.07; 95% CI, 1.01–1.14; [log-transformed] ferritin OR, 1.18; 95% CI, 1.02–1.36; and transferrin saturation OR, 1.06; 95% CI, 1.01–1.11). A higher transferrin, indicative of lower iron status, was also associated with decreased stroke risk (OR, 0.92; 95% CI, 0.86–0.99). Examining ischemic stroke subtypes, we found the detrimental effect of iron status to be driven by cardioembolic stroke. These results were supported in statistical sensitivity analyses more robust to the inclusion of pleiotropic variants.

Conclusions—
This study provides Mendelian randomization evidence that higher iron status is associated with increased stroke risk and, in particular, cardioembolic stroke. Further work is required to investigate the underlying mechanism and whether this can be targeted in preventative strategies.
Determinants of Stroke in a General Male Population
Authors: Persson Carina U. , Svärdsudd Kurt , Rusek Linnéa , Blomstrand Christian , Blomstrand Ann , Welin Lennart , Wilhelmsen Lars , Hansson Per-Olof 
Published: December 2018

Background and Purpose—
To further improve preventive strategies against stroke, there is a need for epidemiological long-term studies. The study aimed at a prospective investigation of stroke determinants in the general male population.

Methods—
During a period of 48 years, from 50 to 98 years of age, a population-based sample of 854 men was followed using repeated medical examinations, lifestyle questionnaires, data from hospital records and the National Cause of Death Register.

Results—
Determinants of ischemic stroke were atrial fibrillation (hazard ratio [HR], 6.61; 95% CI, 4.47–9.77); mother dead from cardiovascular disease (HR, 1.53; 1.09–2.17); high education (HR, 0.81; 0.69–0.96); and high physical activity level during leisure time (HR, 0.68; 0.50–0.93). For hemorrhagic stroke heart rate (HR, 1.04; 1.01–1.06) and mother dead from stroke (HR, 3.56; 1.43–8.87) constituted an increased risk. Statistically significant determinants for all stroke were atrial fibrillation (HR, 5.34; 3.68–7.75); high diastolic blood pressure (HR, 1.02; 1.01–1.03); high body weight (HR, 0.96; 0.94–0.99); high educational level (HR, 0.79; 0.68–0.92); wide waist circumference (HR, 1.04; 1.01–1.07); smoking (HR, 1.25; 1.06–1.48); mother dead from cerebrovascular disease (HR, 1.43; 1.05–1.94); and diabetes mellitus (HR, 1.65; 1.02–2.68). Of all men diagnosed with atrial fibrillation, 88% had a stroke during follow-up.

Conclusions—
Atrial fibrillation was by far the strongest determinant of stroke during 48 years of follow-up in a male population sample followed until the age of 98 years. The results warrant improved prophylaxis through intense treatment of modifiable determinants.
Has Outcome of Subarachnoid Hemorrhage Changed With Improvements in Neurosurgical Services?
Authors: Dhandapani Sivashanmugam , Singh Apinderpreet , Singla Navneet , Praneeth Kokkula , Aggarwal Ashish , Sodhi Harsimrat B. , Pal Sudhir S. , Goudihalli Sachin , Salunke Pravin , Mohindra Sandeep , Kumar Ajay , Gupta Vivek , Chhabra Rajesh , Mukherjee Kanchan K. , Tewari Manoj K. , Khandelwal Niranjan , Mathuriya Suresh N. , Khosla Virender K. , Gupta Sunil K. 
Published: December 2018

Background and Purpose—
Though reports suggest decreasing fatality rates of subarachnoid hemorrhage with time, trends in outcome are not reported much especially from developing countries. This study was to analyze changes in outcome across 2 decades and elucidate probable factors.

Methods—
Prospective databases during 1996 to 2015 were reviewed for neurological outcome at 3 months in relation to demographics, Hunt and Hess grade, Fisher grade, and definitive treatment; and compared between 2 decades, contrasted by establishment of intensive care unit with continuous monitoring and other advancements. Univariate and multivariate analyses were performed.

Results—

Of the total 2039 patients, 1035 were managed in the former and 1004 in the recent decades. Compared with the former decade, there is delayed age at presentation (46 versus 49 years,
P
<0.001), poorer Fisher grades (81% versus 87%,
P
<0.001), and more patients with Hunt and Hess grade 2 (24% versus 39%,
P
<0.001) in the recent decade. While all patients in databases of the former decade had undergone clipping, 6% in the recent decade underwent coiling. 11% in the recent decade could not undergo definitive treatment. Despite this, there was significantly higher overall favorable outcome (50% versus 60%; odds ratio, 1.5;
P
<0.001) in recent decade. Favorable outcome of surgical clipping per se improved significantly from 50% to 67% (odds ratio 2.0;
P
<0.001). Though the improvement was across subgroups, it was more marked among Hunt and Hess grade 3 and Fisher grades 3 and 4. In multivariate analyses, both overall outcome (adjusted odds ratio, 1.7; 95% CI, 1.4–2.1;
P
<0.001) and surgical outcome (adjusted odds ratio, 1.8; 95% CI, 1.5–2.2;
P
<0.001) were significantly better in recent decade, independent of known prognostic factors.

Conclusions—
This is probably the first report to show independent improvement in outcome of subarachnoid hemorrhage with betterment in neurosurgical services from developing country. Dedicated intensive care unit care and focused management protocols could be the likely causes for improvement. Resource-constrained institutions may target patients in Hunt and Hess grade 3 and Fisher grades 3 and 4 for optimal intensive care unit utilization.