Lipidomic signature of stroke recurrence after transient ischemic attack.

While TIA patients have transient symptoms, they should not be underestimated, as they could have an underlying pathology that may lead to a subsequent stroke: stroke recurrence (SR). Previously, it has been described the involvement of lipids in different vascular diseases. The aim of the current study was to perform a lipidomic analysis to identify differences in the lipidomic profile between patients with SR and patients without. Untargeted lipidomic analysis was performed in plasma samples of 460 consecutive TIA patients recruited < 24 h after the onset of symptoms. 37 (8%) patients suffered SR at 90 days. Lipidomic profiling disclosed 7 lipid species differentially expressed between groups: 5 triacylglycerides (TG), 1 diacylglyceride (DG), and 1 alkenyl-PE (plasmalogen) [specifically, TG(56:1), TG(63:0), TG(58:2), TG(50:5), TG(53:7, DG(38:5)) and PE(P-18:0/18:2)]. 6 of these 7 lipid species belonged to the glycerolipid family and a plasmalogen, pointing to bioenergetics pathways, as well as oxidative stress response. In this context, it was proposed the PE(P-18:0/18:2) as potential biomarker of SR condition.The observed changes in lipid patterns suggest pathophysiological mechanisms associated with lipid droplets metabolism and antioxidant protection that is translated to plasma level as consequence of a more intensive or high-risk ischemic condition related to SR.

Tratamiento de reperfusión en el ictus isquémico agudo por disección arterial cervicocerebral: descripción de los resultados de un estudio nacional multicéntrico / Reperfusion treatment in acute ischaemic stroke due to cervical and cerebral artery dissection: results of a Spanish national multicentre study

Introducción: El ictus isquémico (II) por disección arterial cervicocerebral (DAC) es una entidadinfrecuente y existen pocos datos sobre el uso de terapias de reperfusión como la fibrinólisis intravenosa y la trombectomía mecánica. Se analizó el uso de dichas terapias en pacientes conII por DAC y se comparó con aquellos pacientes reperfundidos con II por otras causas.Método: Estudio observacional retrospectivo multicéntrico de pacientes con II por DAC basadoen el Registro Nacional de Ictus de la Sociedad Espa˜nola de Neurología durante el periodo 2011-2019. Se realizaron análisis comparativos entre: a) pacientes con DAC tratados y no tratados conterapias de reperfusión y b) pacientes reperfundidos con II por DAC y pacientes reperfundidoscon II por otras causas. Se incluyeron variables epidemiológicas, del ictus y resultados al alta ya los 3 meses.Resultados: Un total de 21.037 pacientes con II fueron incluidos; 223 (1%) fueron por DAC y 68(30%) recibieron tratamiento de reperfusión. El uso de tratamientos de reperfusión fue menor enlos casos de DAC de arteria vertebral y mayor en los casos de oclusión carotídea. Los pacientescon II por DAC reperfundidos respecto a aquellos con II reperfundidos por otras causas fueronmás jóvenes, la trombectomía mecánica se utilizó más y la fibrinólisis intravenosa menos. Lascomplicaciones hemorrágicas, la mortalidad y la autonomía a los 3 meses fueron similares.Conclusiones: Las terapias de reperfusión se usan con frecuencia en los pacientes con II porDAC. Los resultados demuestran eficacia y seguridad y son equiparables a los pacientes tratadoscon terapias de reperfusión por II de otras causas.(AU)

Introduction: Ischaemic stroke (IS) due to cervical and cerebral artery dissection (CAD) is arare entity, and few data are available on the use of such reperfusion therapies as intravenousfibrinolysis and mechanical thrombectomy in these patients. We analysed the use of these treat-ments in patients with IS due to CAD and compared them against patients receiving reperfusiontreatment for IS of other aetiologies.Method: We conducted an observational, retrospective, multicentre study of patients with ISdue to CAD recorded in the National Stroke Registry of the Spanish Society of Neurology duringthe period 2011-2019. Comparative analyses were performed between: a) patients with CADtreated and not treated with reperfusion therapies and b) patients treated with reperfusion forIS due to CAD and patients treated with reperfusion for IS due to other causes. Epidemiologicaldata, stroke variables, and outcomes at discharge and at 3 months were included in the analysis.Results: The study included 21,037 patients with IS: 223 (1%) had IS due to CAD, of whom68 (30%) received reperfusion treatment. Reperfusion treatments were used less frequently incases of vertebral artery dissection and more frequently in patients with carotid artery occlu-sion. Compared to patients with IS due to other causes, patients with CAD were younger, morefrequently underwent mechanical thrombectomy, and less frequently received intravenous fibri-nolysis. Rates of haemorrhagic complications, mortality, and independence at 3 months weresimilar in both groups.Conclusions: Reperfusion therapy is frequently used in patients with IS due to CAD. The outco-mes of these patients demonstrate the efficacy and safety of reperfusion treatments, and arecomparable to the outcomes of patients with IS due to other aetiologies.(AU)

La influencia de la gestión organizativa en el tiempo puerta-aguja del tratamiento fibrinolítico / The influence of organisational management on door-to-needle times for fibrinolytic treatment

Introducción: El tiempo puerta-aguja (TPA) es el principal indicador del proceso del código ictus (CI). Según la guía de 2018 de la American Heart Association/American Stroke Associa-tion, el objetivo TPA debe ser inferior a 45 minutos. Para conseguirlo son necesarios protocolos eficaces y revisados de actuación extrahospitalaria e intrahospitalaria. Método: Analizamos la influencia de cambios organizativos entre 2011 y 2019 en el TPA y en la evolución clínica de los pacientes tratados con fibrinólisis. Utilizamos los datos de nuestro centro monitorizados y custodiados por el Pla Director en l’àmbit de la Malaltia Vascular Cerebral dela Generalitat de Catalunya. Entre otras medidas se han analizado las diferencias entre los a ̃nos y las derivadas de la implantación del modelo Helsinki. Resultados: Se estudiaron 447 pacientes, existiendo diferencias estadísticamente significativas en el TPA entre los diferentes a ̃nos. La activación del CI de forma extrahospitalaria en 315(70,5%) pacientes redujo el TPA una mediana de 14 minutos. Sin embargo, el modelo de regresión lineal sólo evidenció una relación inversamente proporcional entre la adopción del modelo deCI Helsinki (MH) y el TPA (coeficiente beta −0,42; p < 0,001). La eliminación de la figura delneurólogo vascular tras la adopción del MH empeoró el TPA y la mortalidad a los 90 días.Conclusión: El modelo organizativo influye en el TPA, siendo en nuestra muestra la aplicacióndel MH, la existencia de la figura del neurólogo vascular referente y la prenotificación del CIfactores claves para la reducción del TPA y la mejora clínica del paciente.(AU)

Introduction: Door-to-needle time (DNT) has been established as the main indicator in codestroke protocols. According to the 2018 guidelines of the American Heart Association/AmericanStroke Association, DNT should be less than 45 minutes; therefore, effective and revised pre-admission and in-hospital protocols are required. Method: We analysed organisational changes made between 2011 and 2019 and their influenceon DNT and the clinical progression of patients treated with fibrinolysis. We collected datafrom our centre, stored and monitored under the Master Plan for Cerebrovascular Disease ofthe regional government of Catalonia. Among other measures, we analysed the differencesbetween years and differences derived from the implementation of the Helsinki model.Results: The study included 447 patients, and we observed significant differences in DNTbetween different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%),reduced DNT by a median of 14 minutes. However, the linear regression model only showed aninversely proportional relationship between the adoption of the Helsinki code stroke model andDNT (beta coefficient, —0.42; P < .001). The removal of vascular neurologists after the adoptionof the Helsinki model increased DNT and the 90-day mortality rate. Conclusion: DNT is influenced by the organisational model. In our sample, the application ofthe Helsinki model, the role of the lead vascular neurologist, and notification of code strokeby pre-hospital emergency services are key factors for the reduction of DNT and the clinicalimprovement of the patient.(AU)

The influence of organisational management on door-to-needle times for fibrinolytic treatment.

INTRODUCTION: Door-to-needle time (DNT) has been established as the main indicator in code stroke protocols. According to the 2018 guidelines of the American Heart Association/American Stroke Association, DNT should be less than 45minuts; therefore, effective and revised pre-admission and in-hospital protocols are required. METHOD: We analysed organisational changes made between 2011 and 2019 and their influence on DNT and the clinical progression of patients treated with fibrinolysis. We collected data from our centre, stored and monitored under the Master Plan for Cerebrovascular Disease of the regional government of Catalonia. Among other measures, we analysed the differences between years and differences derived from the implementation of the Helsinki model. RESULTS: The study included 447 patients, and we observed significant differences in DNT between different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%), reduced DNT by a median of 14minutes. However, the linear regression model only showed an inversely proportional relationship between the adoption of the Helsinki code stroke model and DNT (beta coefficient, -0.42; P<.001). The removal of vascular neurologists after the adoption of the Helsinki model increased DNT and the 90-day mortality rate. CONCLUSION: DNT is influenced by the organisational model. In our sample, the application of the Helsinki model, the role of the lead vascular neurologist, and notification of code stroke by pre-hospital emergency services are key factors for the reduction of DNT and the clinical improvement of the patient.

Reperfusion therapy in acute ischaemic stroke due to cervical and cerebral artery dissection: Results from a Spanish multicentre study.

INTRODUCTION: Ischaemic stroke (IS) due to cervical and cerebral artery dissection (CAD) is a rare entity, and few data are available on the use of such reperfusion therapies as intravenous fibrinolysis and mechanical thrombectomy in these patients. We analysed the use of these treatments in patients with IS due to CAD and compared them against patients receiving reperfusion treatment for IS of other aetiologies. METHODS: We conducted an observational, retrospective, multicentre study of patients with IS due to CAD recorded in the National Stroke Registry of the Spanish Society of Neurology during the period 2011-2019. Comparative analyses were performed between: a) patients with CAD treated and not treated with reperfusion therapies and b) patients treated with reperfusion for IS due to CAD and patients treated with reperfusion for IS due to other causes. Epidemiological data, stroke variables, and outcomes at discharge and at 3 months were included in the analysis. RESULTS: The study included 21,037 patients with IS: 223 (1%) had IS due to CAD, of whom 68 (30%) received reperfusion treatment. Reperfusion treatments were used less frequently in cases of vertebral artery dissection and more frequently in patients with carotid artery occlusion. Compared to patients with IS due to other causes, patients with CAD were younger, more frequently underwent mechanical thrombectomy, and less frequently received intravenous fibrinolysis. Rates of haemorrhagic complications, mortality, and independence at 3 months were similar in both groups. CONCLUSIONS: Reperfusion therapy is frequently used in patients with IS due to CAD. The outcomes of these patients demonstrate the efficacy and safety of reperfusion treatments, and are comparable to the outcomes of patients with IS due to other aetiologies.

Evaluación de la incidencia y tendencia de la enfermedad cerebrovascular en la región sanitaria de Lleida (España) en el periodo 2010-2014 / Assessment of incidence and trends in cerebrovascular disease in the healthcare district of Lleida (Spain) in the period 2010-2014

ObjetivoDeterminar la incidencia de la enfermedad cerebrovascular (ECV) y su tendencia en el área sanitaria de Lleida.Material y métodosEstudio de cohortes de base poblacional que incluyó a toda la población del área sanitaria de Lleida (440.000 personas). Se utilizaron los listados del Conjunto Mínimo Básico de Datos (CMBD) de urgencias y de las altas hospitalarias en el periodo comprendido entre enero de 2010 y diciembre de 2014. Se seleccionaron todos los episodios de ictus. Se evaluaron las tasas brutas y las tasas estandarizadas por edad utilizando la población mundial como referencia. Se excluyeron aquellos casos sin confirmación diagnóstica por neuroimagen.ResultadosSe incluyeron 4.397 casos, de los cuales 1.617 (36,8%) fueron ≥ 80 años; 3.969 (90,3%) sujetos sufrieron un ictus isquémico, mientras que 1.741 (39,6%) casos correspondieron a mujeres. La tasa de incidencia cruda osciló entre los 192 (intervalo de confianza [IC] del 95%: 179-205) en 2012 y los 211 (IC 95%: 197-224) en 2013 casos cada 100.000 habitantes. Las tasas estandarizadas por edad oscilaron entre los 93 (IC 95%: 86-100) en 2012 y los 104 (IC 95%: 96-111) en 2013 casos por cada 100.000 habitantes. En todos los años, las tasas de incidencia fueron significativamente mayores entre los varones en comparación con las mujeres; y se incrementaron con la edad.ConclusionesEl impacto de la ECV en Lleida es equiparable a otras regiones europeas, pero que el envejecimiento de la población se traduce en una incidencia bruta elevada que se mantiene estable en los 5 años analizados. (AU)

ObjectivesThis study aimed to determine the incidence and trends of cerebrovascular disease (CVD) in the healthcare district of Lleida.Material and methodsWe performed a population-based prospective cohort study including the entire population of the healthcare district of Lleida (440 000 people). Information was gathered from the minimum basic data set from the emergency department and hospital discharges for the period from January 2010 to December 2014. All types of stroke were included. We evaluated crude and age-standardised rates using the world population as a reference. Patients without neuroimaging confirmation of the diagnosis were excluded.ResultsWe identified 4397 patients: 1617 (36.8%) were aged 80 years or over; 3969 (90.3%) presented ischaemic stroke, and 1741 (39.6%) were women. The crude incidence rate ranged from 192 (95% confidence interval [CI], 179-205) to 211 (95% CI, 197-224) cases per 100 000 population, in 2012 and 2013, respectively. Age-standardised rates ranged from 93 (95% CI, 86-100) to 104 (95% CI, 96-111) cases per 100 000 population, in 2012 and 2013, respectively. For all years, incidence rates increased with age, and were significantly higher among men than among women.ConclusionThe impact of CVD in Lleida is comparable to that observed in other European regions. However, population ageing induces a high crude incidence rate, which remained stable over the five-year study period. (AU)

Inhibidores de la proproteína convertasa subtilisina/kexina tipo 9 (iPCSK9) en la prevención secundaria de episodios vasculares en pacientes con ictus isquémico: Documento de consenso y aplicaciones prácticas / Proprotein convertase subtilisin/kexin type 9 inhibitors in secondary prevention of vascular events in patients with stroke: Consensus document and practice guidance

Introducción: Los pacientes, tras un ictus o un ataque isquémico transitorio, presentan un riesgo muy elevado de sufrir nuevos episodios vasculares. La reducción del nivel de colesterol unido a lipoproteínas de baja densidad (cLDL) reduce la incidencia de nuevos episodios, si bien una proporción importante de pacientes no alcanza los objetivos terapéuticos recomendados con los tratamientos hipolipemiantes actuales. El objetivo de este documento de consenso es actualizar el papel de los inhibidores de la proproteína convertasa subtilisina/kexina tipo 9 (iPCSK9; alirocumab y evolocumab) en la prevención secundaria de episodios vasculares en pacientes con ictus isquémico previo. Métodos: Se realizó una revisión bibliográfica para identificar las principales evidencias sobre el uso de iPCSK9 en estos pacientes y los objetivos terapéuticos recomendados de cLDL. Los resultados se discutieron en 2 reuniones de consenso, que constituyeron la base para la elaboración del documento. Conclusiones: Los iPSCSK9 son eficaces en la reducción del riesgo vascular en prevención secundaria y, específicamente, evolocumab ha demostrado esta reducción en pacientes con ictus isquémico previo. Ambos fármacos han demostrado un buen perfil de seguridad, incluso en pacientes que alcanzaron un nivel de cLDL < 20 mg/dL. En este sentido, en el subestudio de episodios neurocognitivos con evolocumab no se observó ninguna señal de empeoramiento de la función cognitiva en pacientes con nivel muy bajo de cLDL. Con base en estas evidencias, en el documento se presentan recomendaciones prácticas sobre el uso de iPCSK9 para la prevención secundaria y seguimiento de episodios vasculares en pacientes con ictus isquémico previo. (AU)

Introduction: Patients with history of stroke or transient ischaemic attack present considerable risk of future vascular events. Reducing levels of low-density lipoprotein (LDL) cholesterol decreases the incidence of new vascular events, although in a substantial number of patients, the currently available lipid-lowering therapies fail to achieve the therapeutic goals recommended in clinical guidelines. The aim of this consensus statement is to provide updated information on the role of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors alirocumab and evolocumab in the secondary prevention of vascular events in patients with history of ischaemic stroke. Methods: A literature review was performed to identify the main evidence on the use of PCSK9 inhibitors in these patients and the recommended therapeutic targets of LDL cholesterol. The results were discussed in 2 consensus meetings that constituted the basis for the drafting of the document. Conclusions: PCSK9 inhibitors are effective in reducing vascular risk in secondary prevention; evolocumab specifically has achieved this reduction in patients with history of ischaemic stroke. Moreover, both alirocumab and evolocumab present good safety profiles, even in patients achieving LDL cholesterol levels < 20 mg/dL, and no signs of cognitive impairment have been observed in patients treated with evolocumab who achieved very low levels of LDL cholesterol. In the light of this evidence, we provide practical recommendations about the use of PCSK9 inhibitors in secondary prevention of vascular events in patients with history of ischaemic stroke and follow-up of these patients. (AU)

Assessment of incidence and trends in cerebrovascular disease in the healthcare district of Lleida (Spain) in the period 2010-2014. / Evaluación de la incidencia y tendencia de la enfermedad cerebrovascular en la región sanitaria de Lleida (España) en el periodo 2010-2014.

OBJECTIVES: This study aimed to determine the incidence and trends of cerebrovascular disease (CVD) in the healthcare district of Lleida. MATERIAL AND METHODS: We performed a population-based prospective cohort study including the entire population of the healthcare district of Lleida (440 000 people). Information was gathered from the minimum basic data set from the emergency department and hospital discharges for the period from January 2010 to December 2014. All types of stroke were included. We evaluated crude and age-standardised rates using the world population as a reference. Patients without neuroimaging confirmation of the diagnosis were excluded. RESULTS: We identified 4397 patients: 1617 (36.8%) were aged 80 years or over; 3969 (90.3%) presented ischaemic stroke, and 1741 (39.6%) were women. The crude incidence rate ranged from 192 (95% confidence interval [CI], 179-205) to 211 (95% CI, 197-224) cases per 100 000 population, in 2012 and 2013, respectively. Age-standardised rates ranged from 93 (95% CI, 86-100) to 104 (95% CI, 96-111) cases per 100 000 population, in 2012 and 2013, respectively. For all years, incidence rates increased with age, and were significantly higher among men than among women. CONCLUSION: The impact of CVD in Lleida is comparable to that observed in other European regions. However, population ageing induces a high crude incidence rate, which remained stable over the five-year study period.

Proprotein convertase subtilisin/kexin type 9 inhibitors in secondary prevention of vascular events in patients with stroke: Consensus document and practice guidance.

INTRODUCTION: Patients with history of stroke or transient ischaemic attack present considerable risk of future vascular events. Reducing levels of low-density lipoprotein (LDL) cholesterol decreases the incidence of new vascular events, although in a substantial number of patients, the currently available lipid-lowering therapies fail to achieve the therapeutic goals recommended in clinical guidelines. The aim of this consensus statement is to provide updated information on the role of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors alirocumab and evolocumab in the secondary prevention of vascular events in patients with history of ischaemic stroke. METHODS: A literature review was performed to identify the main evidence on the use of PCSK9 inhibitors in these patients and the recommended therapeutic targets of LDL cholesterol. The results were discussed in 2 consensus meetings that constituted the basis for the drafting of the document. CONCLUSIONS: PCSK9 inhibitors are effective in reducing vascular risk in secondary prevention; evolocumab specifically has achieved this reduction in patients with history of ischaemic stroke. Moreover, both alirocumab and evolocumab present good safety profiles, even in patients achieving LDL cholesterol levels < 20 mg/dL, and no signs of cognitive impairment have been observed in patients treated with evolocumab who achieved very low levels of LDL cholesterol. In the light of this evidence, we provide practical recommendations about the use of PCSK9 inhibitors in secondary prevention of vascular events in patients with history of ischaemic stroke and follow-up of these patients.

Assessment of incidence and trends in cerebrovascular disease in the healthcare district of Lleida (Spain) in the period 2010-2014.

OBJECTIVES: This study aimed to determine the incidence and trends of cerebrovascular disease (CVD) in the healthcare district of Lleida. MATERIAL AND METHODS: We performed a population-based prospective cohort study including the entire population of the healthcare district of Lleida (440 000 people). Information was gathered from the minimum basic data set from the emergency department and hospital discharges for the period from January 2010 to December 2014. All types of stroke were included. We evaluated crude and age-standardised rates using the world population as a reference. Patients without neuroimaging confirmation of the diagnosis were excluded. RESULTS: We identified 4397 patients: 1617 (36.8%) were aged 80 years or over; 3969 (90.3%) presented ischaemic stroke, and 1741 (39.6%) were women. The crude incidence rate ranged from 192 (95% confidence interval [CI], 179-205) to 211 (95% CI, 197-224) cases per 100 000 population, in 2012 and 2013, respectively. Age-standardised rates ranged from 93 (95% CI, 86-100) to 104 (95% CI, 96-111) cases per 100 000 population, in 2012 and 2013, respectively. For all years, incidence rates increased with age, and were significantly higher among men than among women. CONCLUSION: The impact of CVD in Lleida is comparable to that observed in other European regions. However, population ageing induces a high crude incidence rate, which remained stable over the five-year study period.

Epidemiología del ictus en la última década: revisión sistemática / Epidemiology of stroke in the last decade: a systematic review

Introduction: Cerebrovascular disease (CVD) is responsible for the majority of disability-adjusted life years and is a leading cause of mortality. This impact justifies having up-to-date data on its incidence. Patients and methods: We conducted a systematic review of the studies published since 2010 that provided information on the crude incidence rate (CIR) and adjusted incidence rate of CVD during the second decade of the 21st century. Results: Thirty-five articles were identified. Twenty-eight provided information on the overall incidence of CVD, 19 on the incidence of ischaemic stroke (IS), 19 on the incidence of haemorrhagic stroke (HS) and 10 on the incidence of subarachnoid haemorrhage (SAH). The incidence was heterogeneous across countries. Thus, the median CIR was 149.5 – confidence interval 95% (CI 95%): 122-256 – cases per 100,000 inhabitants for CVD; 155 (CI 95%: 95.6-246.12) for SI; 29 (CI 95%: 19-43) for HS; and 6.5 (CI 95%: 4.8-13.5) for SAH. The incidence for both CVD and IS and HS was higher in men than in women in most studies, with the exception of some Asian, European and North American studies. The majority of studies showed a decreasing or stabilising trend in incidence, with the exception of studies conducted in China, Singapore, France and Australia. Conclusion: There are few studies that analyse the incidence of CVD and even fewer that analyse its evolution. The overall median remains high, although the figures are heterogeneous across studies. Worldwide the trend is towards its decrease, and there are geographical areas, especially in Asia, with an alarming upward trend.(AU)

Introducción: La enfermedad cerebrovascular (ECV) es la responsable de la mayoría de los años de vida ajustados por discapacidad y una de las principales causas de mortalidad. Dicho impacto justifica disponer de datos actualizados sobre su incidencia. Pacientes y métodos: Se realizó una revisión sistemática de los estudios publicados desde 2010 hasta la actualidad que aportaran información sobre la tasa de incidencia cruda (TIC) y la tasa de incidencia ajustada de la ECV durante la segunda década del siglo xxi. Resultados: Se identificaron 35 artículos. Veintiocho ofrecieron información sobre la incidencia global de ECV, 19 sobre la incidencia de ictus isquémico (IcI), 19 sobre la de ictus hemorrágico (IH) y 10 sobre la de hemorragia subaracnoidea (HSA). La incidencia fue heterogénea entre países. Así, la mediana de la TIC fue de 149,5 –intervalo de confianza al 95% (IC 95%): 122-256– casos por cada 100.000 habitantes para la ECV; 155 (IC 95%: 95,6-246,12) para el IcI; 29 (IC 95%: 19-43) para el IH; y 6,5 (IC 95%: 4,8-13,5) para la HSA. La incidencia tanto para la ECV como para el IcI y el IH fue mayor en los hombres que en las mujeres en la mayoría de los estudios, a excepción de algunos estudios asiáticos, europeos y norteamericanos. En la mayoría de los estudios se registró una tendencia al descenso o la estabilización en la incidencia, a excepción de estudios realizados en China, Singapur, Francia y Australia. Conclusión: Existen pocos estudios que analicen la incidencia y aún menos la evolución de la ECV. La mediana global continúa siendo elevada, aunque las cifras son heterogéneas entre los estudios. Existe una tendencia mundial a su decremento, y hay áreas geográficas, sobre todo en el continente asiático, con una preocupante tendencia al incremento.(AU)

[Epidemiology of stroke in the last decade: a systematic review]. / Epidemiología del ictus en la última década: revisión sistemática.

INTRODUCTION: Cerebrovascular disease (CVD) is responsible for the majority of disability-adjusted life years and is a leading cause of mortality. This impact justifies having up-to-date data on its incidence. PATIENTS AND METHODS: We conducted a systematic review of the studies published since 2010 that provided information on the crude incidence rate (CIR) and adjusted incidence rate of CVD during the second decade of the 21st century. RESULTS: Thirty-five articles were identified. Twenty-eight provided information on the overall incidence of CVD, 19 on the incidence of ischaemic stroke (IS), 19 on the incidence of haemorrhagic stroke (HS) and 10 on the incidence of subarachnoid haemorrhage (SAH). The incidence was heterogeneous across countries. Thus, the median CIR was 149.5 - confidence interval 95% (CI 95%): 122-256 - cases per 100,000 inhabitants for CVD; 155 (CI 95%: 95.6-246.12) for SI; 29 (CI 95%: 19-43) for HS; and 6.5 (CI 95%: 4.8-13.5) for SAH. The incidence for both CVD and IS and HS was higher in men than in women in most studies, with the exception of some Asian, European and North American studies. The majority of studies showed a decreasing or stabilising trend in incidence, with the exception of studies conducted in China, Singapore, France and Australia. CONCLUSION: There are few studies that analyse the incidence of CVD and even fewer that analyse its evolution. The overall median remains high, although the figures are heterogeneous across studies. Worldwide the trend is towards its decrease, and there are geographical areas, especially in Asia, with an alarming upward trend.

TITLE: Epidemiología del ictus en la última década: revisión sistemática.Introducción. La enfermedad cerebrovascular (ECV) es la responsable de la mayoría de los años de vida ajustados por discapacidad y una de las principales causas de mortalidad. Dicho impacto justifica disponer de datos actualizados sobre su incidencia. Pacientes y métodos. Se realizó una revisión sistemática de los estudios publicados desde 2010 hasta la actualidad que aportaran información sobre la tasa de incidencia cruda (TIC) y la tasa de incidencia ajustada de la ECV durante la segunda década del siglo xxi. Resultados. Se identificaron 35 artículos. Veintiocho ofrecieron información sobre la incidencia global de ECV, 19 sobre la incidencia de ictus isquémico (IcI), 19 sobre la de ictus hemorrágico (IH) y 10 sobre la de hemorragia subaracnoidea (HSA). La incidencia fue heterogénea entre países. Así, la mediana de la TIC fue de 149,5 ­intervalo de confianza al 95% (IC 95%): 122-256­ casos por cada 100.000 habitantes para la ECV; 155 (IC 95%: 95,6-246,12) para el IcI; 29 (IC 95%: 19-43) para el IH; y 6,5 (IC 95%: 4,8-13,5) para la HSA. La incidencia tanto para la ECV como para el IcI y el IH fue mayor en los hombres que en las mujeres en la mayoría de los estudios, a excepción de algunos estudios asiáticos, europeos y norteamericanos. En la mayoría de los estudios se registró una tendencia al descenso o la estabilización en la incidencia, a excepción de estudios realizados en China, Singapur, Francia y Australia. Conclusión. Existen pocos estudios que analicen la incidencia y aún menos la evolución de la ECV. La mediana global continúa siendo elevada, aunque las cifras son heterogéneas entre los estudios. Existe una tendencia mundial a su decremento, y hay áreas geográficas, sobre todo en el continente asiático, con una preocupante tendencia al incremento.

Nivel de conocimiento de la enfermedad de Alzheimer en cuidadores y población general / Level of understanding of Alzheimer disease among caregivers and the general population

Introducción: El conocimiento de la enfermedad de Alzheimer es fundamental para el diagnóstico precoz y para reducir la sobrecarga del cuidador. El objetivo fue evaluar el grado de conocimiento de la enfermedad de Alzheimer mediante la Alzheimer's Disease Knowledge Scale en cuidadores informales y diferentes segmentos de población.Sujetos y métodosSe evaluó el conocimiento a cuidadores en diferente periodo de seguimiento (menor de un año, entre 1-5 y más de 5 años desde el diagnóstico) y sujetos de la población general. La puntuación Alzheimer's Disease Knowledge Scale se agrupó en distintos ítems: impacto vital, factores de riesgo, síntomas, diagnóstico, tratamiento, progresión de la enfermedad y cuidadores.ResultadosTotal de 419 personas; 215 cuidadores, 204 población general. Respecto a la puntuación global de la escala no se encontraron diferencias entre ambos grupos (19,1 vs. 18,8; p=0,9). Destaca un escaso conocimiento de los factores de riesgo de la enfermedad (49,3%) y de los cuidados necesarios (51,2%) mientras que los síntomas (78,6%) y el curso de la enfermedad (77,2%) fueron los aspectos mejor reconocidos. Entre las variables, la edad del cuidador se correlacionó con peor puntuación total de la escala Alzheimer's Disease Knowledge Scale, peor conocimiento sobre el impacto vital, síntomas, cuidados y de la progresión de la enfermedad (p<0,05). La duración de los cuidadores mejoró el conocimiento de los síntomas (p=0,00) y el diagnóstico de la enfermedad (p=0,05).ConclusiónEvaluar el grado de conocimiento de la enfermedad es fundamental para poder elaborar estrategias de educación sanitaria tanto a nivel poblacional como en los cuidadores. (AU)

Introduction: Understanding of Alzheimer disease is fundamental for early diagnosis and to reduce caregiver burden. The objective of this study is to evaluate the degree of understanding of Alzheimer disease among informal caregivers and different segments of the general population through the Alzheimer's Disease Knowledge Scale.Patients and methodsWe assessed the knowledge of caregivers in different follow-up periods (less than one year, between 1 and 5 years, and over 5 years since diagnosis) and individuals from the general population. Alzheimer's Disease Knowledge Scale scores were grouped into different items: life impact, risk factors, symptoms, diagnosis, treatment, disease progression, and caregiving.ResultsA total of 419 people (215 caregivers and 204 individuals from the general population) were included in the study. No significant differences were found between groups for overall Alzheimer's Disease Knowledge Scale score (19.1 vs. 18.8, P = .9). There is a scarce knowledge of disease risk factors (49.3%) or the care needed (51.2%), while symptoms (78.6%) and course of the disease (77.2%) were the best understood aspects. Older caregiver age was correlated with worse Alzheimer's Disease Knowledge Scale scores overall and for life impact, symptoms, treatment, and disease progression (P < .05). Time since diagnosis improved caregivers’ knowledge of Alzheimer disease symptoms (P = .00) and diagnosis (P = .05).ConclusionAssessing the degree of understanding of Alzheimer disease is essential to the development of health education strategies both in the general population and among caregivers. (AU)

Level of understanding of Alzheimer disease among caregivers and the general population.

INTRODUCTION: Understanding of Alzheimer disease (AD) is fundamental for early diagnosis and to reduce caregiver burden. The objective of this study is to evaluate the degree of understanding of AD among informal caregivers and different segments of the general population through the Alzheimer's Disease Knowledge Scale (ADKS). PATIENTS AND METHODS: We assessed the knowledge of caregivers in different follow-up periods (less than one year, between 1 and 5 years, and over 5 years since diagnosis) and individuals from the general population. ADKS scores were grouped into different items: life impact, risk factors, symptoms, diagnosis, treatment, disease progression, and caregiving. RESULTS: A total of 419 people (215 caregivers and 204 individuals from the general population) were included in the study. No significant differences were found between groups for overall ADKS score (19.1 vs 18.8, P = .9). There is a scarce knowledge of disease risk factors (49.3%) or the care needed (51.2%), while symptoms (78.6%) and course of the disease (77.2%) were the best understood aspects. Older caregiver age was correlated with worse ADKS scores overall and for life impact, symptoms, treatment, and disease progression (P < .05). Time since diagnosis improved caregivers' knowledge of AD symptoms (P = .00) and diagnosis (P = .05). CONCLUSION: Assessing the degree of understanding of AD is essential to the development of health education strategies both in the general population and among caregivers.

[Evolution of the degree of disease knowledge in subjects who have suffered an ischaemic stroke]. / Evolución del grado de conocimiento de la enfermedad en pacientes que han sufrido un ictus isquémico.

INTRODUCTION: The delay in seeking medical care in patients who suffer a cerebrovascular disease (CVD) event depends, largely, on knowledge of the disease. Our aim is to study the evolution of the knowledge of patients admitted to hospital due to an ischaemic stroke. PATIENTS AND METHODS: A structured interview was used to determine the level of knowledge of CVD (terminology, risk factors, symptoms and attitude) of patients admitted due to an ischaemic stroke without language impairment or cognitive impairment in two distinct time periods: January 2011 and December 2013 (n = 295), and October 2015 and December 2016 (n = 325). RESULTS: Better knowledge of the disease was observed over time, both in the number of terms recognised - 4.1 (standard deviation: 2) vs. 4.8 (standard deviation: 1.7); p < 0.001 - and in a good knowledge of symptoms (more than three factors and less than two distractors) (56.6 vs. 69.8%; p < 0.001). The proportion of patients who called the emergency services directly was significantly higher (17.3 vs. 24.6%; p = 0.003), as was the recognition of the term 'stroke' (51.9 vs. 74.5%; p < 0.001). There was no difference in the degree of knowledge of risk factors. Improvement in knowledge did not translate into a decrease in the delay between symptom onset and arrival at the hospital. CONCLUSION: Despite improved knowledge of CVD, further efforts still need to be made to improve attitudes towards CVD and reduce the delay prior to hospital arrival.

TITLE: Evolución del grado de conocimiento de la enfermedad en pacientes que han sufrido un ictus isquémico.Introducción. La demora hasta la demanda de la atención médica en pacientes que sufren un episodio de enfermedad cerebrovascular (ECV) depende, en gran parte, del conocimiento que existe de la enfermedad. Pretendemos estudiar la evolución del conocimiento de los pacientes que ingresaron por un ictus isquémico. Pacientes y métodos. Se utilizó una entrevista estructurada para conocer el grado de conocimiento de la ECV (terminología, factores de riesgo, síntomas y actitud) de los pacientes ingresados por ictus isquémico sin trastorno del lenguaje ni alteración cognitiva en dos períodos de tiempo diferenciados: enero de 2011 y diciembre de 2013 (n = 295), y octubre de 2015 y diciembre de 2016 (n = 325). Resultados. Se observó un mejor conocimiento de la enfermedad a lo largo del tiempo, tanto en el número de términos reconocidos ­­4,1 (desviación estándar: 2) frente a 4,8 (desviación estándar: 1,7); p menor de 0,001­ como en el buen conocimiento de los síntomas (más de tres factores y menos de dos distractores) (56,6 frente a 69,8%; p menor de 0,001). La proporción de pacientes que llamaron directamente al 112 fue significativamente mayor (17,3 frente a 24,6%; p = 0,003), así como el reconocimiento del término 'ictus' (51,9 frente a 74,5%; p menor de 0,001). No hubo diferencias en el grado de conocimiento de los factores de riesgo. La mejoría en el grado de conocimiento no se tradujo en una disminución en la demora entre el inicio de los síntomas y la llegada al hospital. Conclusión. Pese a la mejoría en el conocimiento de la ECV, todavía se deben hacer esfuerzos para mejorar la actitud frente a la ECV y disminuir la demora hasta la llegada al hospital.

Uso de la polipíldora cardiovascular en la prevención secundaria de la enfermedad cerebrovascular / Use of cardiovascular polypills for the secondary prevention of cerebrovascular disease

INTRODUCCIÓN: El control de los factores de riesgo cardiovascular (CV) en la prevención secundaria tras un ictus isquémico es bajo, en parte debido a la falta de adherencia terapéutica. La polipíldora CV puede contribuir a la buena cumplimentación del adecuado tratamiento para la prevención cerebrovascular. El objetivo fue establecer cómo y en qué casos se debería administrar. MÉTODOS: Un grupo de neurólogos redactaron recomendaciones consensuadas mediante una técnica de brainstorming estructurado, basándose en su experiencia y en una revisión bibliográfica. RESULTADOS: Los resultados atienden a la opinión de los expertos. El uso de la polipíldora CV tiene ventajas para pacientes, profesionales sanitarios y para el sistema de salud. Las situaciones clínicas más adecuadas para su uso son el ictus aterotrombótico, el lacunar, el asociado a deterioro cognitivo, el criptogénico con factores de riesgo CV y la enfermedad cerebrovascular silente. Su uso preferente incluye la sospecha de mal cumplimiento, a los pacientes polimedicados, ancianos, polivasculares o con alta carga aterotrombótica, jóvenes activos laboralmente y pacientes con preferencias por la polipíldora CV. Las opciones de administración incluyen el paso de fármacos individuales a la polipíldora CV, el inicio directo desde la fase aguda en casos particulares, a los pacientes con otra estatina o con un antagonista del receptor de la angiotensina ii, o de novo si hubiera sospecha de mala adherencia. No obstante, su uso implica realizar seguimiento del cumplimiento de los objetivos terapéuticos para ajustar la dosis. CONCLUSIONES: Este documento es el primero en establecer recomendaciones de uso de la polipíldora CV en enfermedad cerebrovascular, aparte de sus ventajas sobre la adherencia

INTRODUCTION: There is little control of cardiovascular (CV) risk factors in secondary prevention after an ischaemic stroke, in part due to a lack of adherence to treatment. The CV polypill may contribute to proper treatment adherence, which is necessary for CV disease prevention. This study aimed to establish how and in what cases the CV polypill should be administered. METHODS: A group of 8 neurologists drafted consensus recommendations using structured brainstorming and based on their experience and a literature review. RESULTS: These recommendations are based on the opinion of the participating experts. The use of the CV polypill is beneficial for patients, healthcare professionals, and the health system. Its use is most appropriate for atherothrombotic stroke, lacunar stroke, stroke associated with cognitive impairment, cryptogenic stroke with CV risk factors, and silent cerebrovascular disease. It is the preferred treatment in cases of suspected poor adherence, polymedicated patients, elderly people, patients with polyvascular disease or severe atherothrombosis, young patients in active work, and patients who express a preference for the CV polypill. Administration options include switching from individual drugs to the CV polypill, starting treatment with the CV polypill in the acute phase in particular cases, use in patients receiving another statin or an angiotensin II receptor antagonist, or de novo use if there is suspicion of poor adherence. Nevertheless, use of the CV polypill requires follow-up on the achievement of the therapeutic objectives to make dose adjustments. CONCLUSIONS: This document is the first to establish recommendations for the use of the CV polypill in cerebrovascular disease, beyond its advantages in terms of treatment adherence

Use of cardiovascular polypills for the secondary prevention of cerebrovascular disease. / Uso de la polipíldora cardiovascular en la prevención secundaria de la enfermedad cerebrovascular.

INTRODUCTION: There is little control of cardiovascular (CV) risk factors in secondary prevention after an ischaemic stroke, in part due to a lack of adherence to treatment. The CV polypill may contribute to proper treatment adherence, which is necessary for CV disease prevention. This study aimed to establish how and in what cases the CV polypill should be administered. METHODS: A group of 8 neurologists drafted consensus recommendations using structured brainstorming and based on their experience and a literature review. RESULTS: These recommendations are based on the opinion of the participating experts. The use of the CV polypill is beneficial for patients, healthcare professionals, and the health system. Its use is most appropriate for atherothrombotic stroke, lacunar stroke, stroke associated with cognitive impairment, cryptogenic stroke with CV risk factors, and silent cerebrovascular disease. It is the preferred treatment in cases of suspected poor adherence, polymedicated patients, elderly people, patients with polyvascular disease or severe atherothrombosis, young patients in active work, and patients who express a preference for the CV polypill. Administration options include switching from individual drugs to the CV polypill, starting treatment with the CV polypill in the acute phase in particular cases, use in patients receiving another statin or an angiotensin ii receptor antagonist, or de novo use if there is suspicion of poor adherence. Nevertheless, use of the CV polypill requires follow-up on the achievement of the therapeutic objectives to make dose adjustments. CONCLUSIONS: This document is the first to establish recommendations for the use of the CV polypill in cerebrovascular disease, beyond its advantages in terms of treatment adherence.

Reperfusion treatment in acute ischaemic stroke due to cervical and cerebral artery dissection: results of a Spanish national multicentre study. / Tratamiento de reperfusión en el ictus isquémico agudo por disección arterial cervicocerebral: descripción de los resultados de un estudio nacional multicéntrico.

INTRODUCTION: Ischaemic stroke (IS) due to cervical and cerebral artery dissection (CAD) is a rare entity, and few data are available on the use of such reperfusion therapies as intravenous fibrinolysis and mechanical thrombectomy in these patients. We analysed the use of these treatments in patients with IS due to CAD and compared them against patients receiving reperfusion treatment for IS of other aetiologies. METHOD: We conducted an observational, retrospective, multicentre study of patients with IS due to CAD recorded in the National Stroke Registry of the Spanish Society of Neurology during the period 2011-2019. Comparative analyses were performed between: a) patients with CAD treated and not treated with reperfusion therapies and b) patients treated with reperfusion for IS due to CAD and patients treated with reperfusion for IS due to other causes. Epidemiological data, stroke variables, and outcomes at discharge and at 3 months were included in the analysis. RESULTS: The study included 21,037 patients with IS: 223 (1%) had IS due to CAD, of whom 68 (30%) received reperfusion treatment. Reperfusion treatments were used less frequently in cases of vertebral artery dissection and more frequently in patients with carotid artery occlusion. Compared to patients with IS due to other causes, patients with CAD were younger, more frequently underwent mechanical thrombectomy, and less frequently received intravenous fibrinolysis. Rates of haemorrhagic complications, mortality, and independence at 3 months were similar in both groups. CONCLUSIONS: Reperfusion therapy is frequently used in patients with IS due to CAD. The outcomes of these patients demonstrate the efficacy and safety of reperfusion treatments, and are comparable to the outcomes of patients with IS due to other aetiologies.

The influence of organisational management on door-to-needle times for fibrinolytic treatment. / La influencia de la gestión organizativa en el tiempo puerta-aguja del tratamiento fibrinolítico.

INTRODUCTION: Door-to-needle time (DNT) has been established as the main indicator in code stroke protocols. According to the 2018 guidelines of the American Heart Association/American Stroke Association, DNT should be less than 45minutes; therefore, effective and revised pre-admission and in-hospital protocols are required. METHOD: We analysed organisational changes made between 2011 and 2019 and their influence on DNT and the clinical progression of patients treated with fibrinolysis. We collected data from our centre, stored and monitored under the Master Plan for Cerebrovascular Disease of the regional government of Catalonia. Among other measures, we analysed the differences between years and differences derived from the implementation of the Helsinki model. RESULTS: The study included 447 patients, and we observed significant differences in DNT between different years. Pre-hospital code stroke activation, recorded in 315 cases (70.5%), reduced DNT by a median of 14minutes. However, the linear regression model only showed an inversely proportional relationship between the adoption of the Helsinki code stroke model and DNT (beta coefficient, -0.42; P<.001). The removal of vascular neurologists after the adoption of the Helsinki model increased DNT and the 90-day mortality rate. CONCLUSION: DNT is influenced by the organisational model. In our sample, the application of the Helsinki model, the role of the lead vascular neurologist, and notification of code stroke by pre-hospital emergency services are key factors for the reduction of DNT and the clinical improvement of the patient.

Proprotein convertase subtilisin/kexin type 9 inhibitors in secondary prevention of vascular events in patients with stroke: Consensus document and practice guidance. / Inhibidores de la proproteína convertasa subtilisina/kexina tipo 9 (iPCSK9) en la prevención secundaria de episodios vasculares en pacientes con ictus isquémico: Documento de consenso y aplicaciones prácticas.

INTRODUCTION: Patients with history of stroke or transient ischaemic attack present considerable risk of future vascular events. Reducing levels of low-density lipoprotein (LDL) cholesterol decreases the incidence of new vascular events, although in a substantial number of patients, the currently available lipid-lowering therapies fail to achieve the therapeutic goals recommended in clinical guidelines. The aim of this consensus statement is to provide updated information on the role of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors alirocumab and evolocumab in the secondary prevention of vascular events in patients with history of ischaemic stroke. METHODS: A literature review was performed to identify the main evidence on the use of PCSK9 inhibitors in these patients and the recommended therapeutic targets of LDL cholesterol. The results were discussed in 2 consensus meetings that constituted the basis for the drafting of the document. CONCLUSIONS: PCSK9 inhibitors are effective in reducing vascular risk in secondary prevention; evolocumab specifically has achieved this reduction in patients with history of ischaemic stroke. Moreover, both alirocumab and evolocumab present good safety profiles, even in patients achieving LDL cholesterol levels <20 mg/dL, and no signs of cognitive impairment have been observed in patients treated with evolocumab who achieved very low levels of LDL cholesterol. In the light of this evidence, we provide practical recommendations about the use of PCSK9 inhibitors in secondary prevention of vascular events in patients with history of ischaemic stroke and follow-up of these patients.