Miguel Barboza Elizondo

Background: Stroke burden varies across the Americas, yet data on modifiable risk factor contributions remain limited. Methods: Using GBD (Global Burden of Disease) study 2021 data, we analyzed stroke mortality and disability‐adjusted life‐year (DALY) rates attributable to 23 modifiable risk factors across 39 countries and territories in the Americas. Age‐standardized rates were compared by sex, stroke subtype, region, and Socio‐Demographic Index; age‐specific estimates used 5‐year groups (25–95+ years). Trends were assessed using average annual percentage change (AAPC) from Joinpoint regression. Results: In 2021, 78.8% (95% uncertainty interval, 70.1%–85.9%) of stroke deaths and 76.9% (68.2%–83.6%) of DALYs were attributable to the 23 risk factors combined. High systolic blood pressure was the leading contributor, accounting for 20.87 attributable deaths (95% uncertainty interval, 15.17–25.80) and 453.30 DALYs (333.16–556.41) per 100 000, representing 54.8% of deaths and 52.2% of DALYs. From 1990 to 2021, the largest reductions occurred for household air pollution from solid fuels (deaths AAPC, −5.09% [95% CI, −5.17 to −5.02]; DALYs AAPC, −4.92% [−4.98 to −4.86]) and secondhand smoke (deaths AAPC, −3.45% [−3.49 to −3.41]). Reductions were minimal for high body mass index (deaths AAPC, −0.54% [−0.59 to −0.49]; DALYs AAPC, −0.42% [−0.46 to −0.37]), high fasting plasma glucose (deaths AAPC, −1.10% [−1.14 to −1.06]), and dietary risks; high body mass index burden increased in the Caribbean, notably in Haiti and the Dominican Republic. Stroke deaths attributable to high temperature increased >3.5% annually (AAPC) in Panama, Jamaica, and the Dominican Republic. High systolic blood pressure burden remained highly unequal, with age‐standardized death rates of 10.42 per 100 000 in high–Socio‐Demographic Index versus 109.33 in low–Socio‐Demographic Index countries. Conclusions: Stroke burden attributable to modifiable risk factors declined overall, but marked disparities persisted. High systolic blood pressure remained dominant, whereas stalled or increasing burden from obesity, metabolic, and dietary risks highlights the need for equity‐focused prevention across the Americas.

Cerebral edema is a common yet poorly defined neuroimaging feature in cerebral venous thrombosis (CVT), and its influence on downstream clinical outcomes has not been fully elucidated. We aimed to characterize cerebral edema subtypes and evaluate their effect on functional outcomes in patients with CVT. We conducted a retrospective analysis using the CLOT-VENUS (Collaboration on Cerebral Venous Thrombosis) registry, an international cohort of patients with acute CVT treated at 2 major stroke centers in the United States and Mexico between 2004 and 2024. Admission neuroimaging (MRI and/or CT) was independently reviewed to classify cerebral edema into 3 subtypes: global cerebral edema, cytotoxic edema, and vasogenic edema. The primary outcome was the 6-month modified Rankin Scale (mRS) score, which was assessed as an ordinal shift. Secondary outcomes included ordinal mRS score at discharge, poor functional outcome (mRS 3-6 vs 0-2 and mRS 2-6 vs 0-1), in-hospital mortality, 6-month mortality, and length of hospital stay (LOS). Multivariable models adjusted for prespecified baseline confounders were used to estimate the effect of cerebral edema on these outcomes. We included 394 patients with CVT (mean age was 42.7 ± 16.9 years; 65.5% female). Cerebral edema was identified in 220 patients and classified as cytotoxic edema (32.5%), global cerebral edema (25.6%), or vasogenic edema (24.9%). At discharge, global cerebral edema (adjusted odds ratio [aOR]: 2.79; 95% CI 1.83-4.27; p < 0.001) and cytotoxic edema (aOR: 1.89; 95% CI 1.27-2.80; p = 0.002) increased the odds of worse mRS scores. Similarly, at 6-month follow-up, both global cerebral edema (aOR: 1.83; CI 1.19-2.81; p = 0.006) and cytotoxic edema (aOR: 1.92; CI 1.28-2.88; p = 0.002) had a direct effect on higher odds of mRS scores. In addition, cytotoxic edema increased the risk of in-hospital mortality (aOR: 3.17; 95% CI 1.22-8.96; p = 0.021). Global cerebral edema led to a prolonged LOS (+2.00 days at median; p = 0.014). Our results suggest that cytotoxic and global cerebral edema independently worsened 6-month functional outcomes in patients with CVT, with cytotoxic edema also increasing the risk of in-hospital mortality. Prospective studies should evaluate whether early cerebral edema subtypes can serve as critical entities that could potentially stratify patients for adjunctive therapies beyond anticoagulation.

BACKGROUND: Inflammatory serum biomarkers, including neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII), are associated with outcomes in acute cerebrovascular diseases. However, their prognostic role in cerebral venous thrombosis remains uncertain. We aimed to assess the prognostic value of these biomarkers in acute cerebral venous thrombosis by identifying optimal thresholds and internally validating their predictive performance. METHODS: This retrospective observational cohort study included adults diagnosed with acute cerebral venous thrombosis from the international CLOT-VENUS registry (Collaboration on Cerebral Venous Thrombosis Study; 2004–2024), including 2 comprehensive stroke centers in the United States and Mexico. Biomarkers of interest (NLR, MLR, PLR, SII) were calculated from admission complete blood counts. The primary outcome was functional status at 6 months, measured by the modified Rankin Scale dichotomized as 0 to 2 versus 3 to 6. Secondary outcomes included modified Rankin Scale score at discharge and mortality. Associations were tested with multivariable logistic regression adjusted for clinically relevant covariates. Optimal biomarker cutoffs were identified using stratified bootstrap receiver operating characteristic analysis and internally validated with out-of-bag testing. RESULTS: Of 432 patients, 394 met the inclusion criteria, and complete data were available for 339 of those patients. Median age was 40 years [interquartile range, 27–45], and 65.2% were female. Elevated biomarkers at admission were associated with modified Rankin Scale score 3 to 6 at discharge and 6 months. At 6 months, optimal cutoff values for NLR ≥4.88 (adjusted odds ratio [aOR], 2.19; P =0.044), MLR ≥0.54 (aOR, 2.32; P =0.027), PLR ≥161.04 (aOR, 3.33; P =0.003), and SII ≥1388.58 (aOR, 2.03; P =0.049). Similar associations occurred at discharge using the same thresholds. PLR and SII notably predicted mortality at discharge (PLR aOR, 6.33; P =0.008, and SII aOR, 3.93; P =0.031) and at 6 months (PLR aOR, 7.19; P =0.004, and SII aOR, 4.69; P =0.010). CONCLUSIONS: Elevated admission levels of NLR, PLR, MLR, and SII are independently associated with poor discharge and 6-month outcomes in patients with acute cerebral venous thrombosis. These accessible biomarkers may aid early risk stratification. Further studies should validate and explore its usefulness in clinical models for personalized management.

Background: Stroke remains a major public health concern with marked disparities across populations, particularly in the Americas. Despite documented declines in overall burden, limited data exist on how modifiable risk factors contribute to contemporary stroke trends across the continent. Methods: Using data from the Global Burden of Disease 2021 study, we analyzed age- standardized mortality rates and age-standardized disability-adjusted life-years (DALYs) rates from stroke attributable to 23 modifiable risk factors across 39 countries and territories in the Americas. Estimates were stratified by age, sex, stroke subtype, and Socio-Demographic Index (SDI). Temporal trends from 1990 to 2021 were assessed using the average annual percent change (AAPC), which was estimated applying Joinpoint regression analysis. Results: In 2021, 78% of stroke deaths and 77% of stroke DALYs were attributable to modifiable risk factors in the Americas. High systolic blood pressure was the leading risk factor (20.87 deaths [95% uncertainty interval: 15.17–25.8] and 453.30 DALYs [333.16–556.41] per 100,000), contributing over half of stroke burden. From 1990–2021, the largest reductions occurred in household air pollution (deaths AAPC −5.09% [−5.17–−5.02]; DALYs AAPC −4.92% [−4.98–−4.86]) and secondhand smoke (deaths AAPC −3.45% [−3.49–−3.41]; DALYs AAPC −3.37% [−3.41–−3.33]). In contrast, several risk factors showed minimal progress: high body-mass index (deaths AAPC −0.54% [−0.59–−0.49]; DALYs AAPC −0.42% [−0.46–−0.37]) and high fasting glucose (deaths AAPC −1.10% [−1.14–−1.06]; DALYs AAPC −0.99% [−1.05–−0.93]). High temperature demonstrated increases, with AAPCs exceeding +3.5% in select countries. High systolic blood pressure declined moderately (deaths AAPC −1.89% [−1.93–−1.85]; DALYs AAPC −1.84% [−1.89–−1.80]), with stroke burden remaining disproportionately higher in low-SDI countries. Conclusion: Although encouraging declines in stroke burden attributable to risk factors have been observed over three decades, substantial variation persists by geography and SDI. High systolic blood pressure remains the leading modifiable risk factor. Minimal progress in obesity and metabolic factors highlights the need for equity-focused strategies to address persistent and emerging stroke risks across the Americas.

Introduction: Among stroke patients with atrial fibrillation (AF), it is not uncommon to identify carotid atherosclerosis. This study aimed to estimate the prevalence of, and factors associated with, carotid atherosclerosis among patients with AF and acute ischemic stroke. Patients and Methods: Prospectively collected data from consecutive patients with anterior ischemic stroke and AF who underwent carotid imaging from 10 stroke registries were categorized retrospectively according to the degree of stenosis in: no atherosclerosis, stenosis <50%, stenosis ≥50%, and occlusion. Logistic regression analysis was used to identify factors associated with ipsilateral carotid atherosclerosis. Results: Among 2,955 patients with ischemic stroke and AF, carotid atherosclerosis was evident in 1,022 (34.6%) patients, while carotid stenosis ≥50% and occlusion were identified in 204 (6.9%) and 168 (5.7%) patients, respectively. Ipsilateral carotid stenosis ≥50% or occlusion was associated with higher age (OR: 1.15, 95% CI: 1.01–1.32, per decade), previous ischemic stroke or transient ischemic attack (OR: 1.70, 95% CI: 1.29–2.25), peripheral artery disease (OR: 1.85, 95% CI: 1.23–2.78), coronary artery disease (OR: 1.53, 95% CI: 1.16–2.04), and statin treatment on admission (OR: 1.30, 95% CI: 1.01–1.67). Patients with lacunar stroke had a lower likelihood of stenosis ≥50% or occlusion (OR: 0.29, 95% CI: 0.13–0.68). Compared to the absence of atherosclerotic disease, atherosclerosis in one and two arterial beds was associated with the identification of ipsilateral carotid stenosis (OR: 1.49, 95% CI: 1.22–2.98 and OR: 3.18, 95% CI: 1.85–5.49, respectively). Conclusion: Among acute ischemic stroke patients with AF, 1 out of 3 had ipsilateral carotid atherosclerosis, and 1 out of 8 had ipsilateral carotid stenosis ≥50% or occlusion. Atherosclerosis in two arterial beds was the most important predictor for the identification of ipsilateral carotid stenosis. Among ischemic stroke patients with AF, carotid atherosclerosis is common, while carotid imaging should not be overlooked, especially in those with coronary or/and peripheral artery disease.

Objective: Quality of performance after stroke in working-active survivors has been poorly studied. The aim of this study is to analyze work performance after stroke not only by the probability of being active in daily job activities but also by the survivor's ability to recover capability in different cognitive and motor areas. Material and methods: We developed a 15-item survey for stroke who had returned to their work activity. The survey evaluated 11 different domains (language, memory, attention, planning, calculating, writing, motor skills, gait, visual, mood, and self-perception). Internal consistency, test-retest reliability, item-scale correlation, and factor analysis were conducted. Results: A total of 100 ischemic stroke survivors were recruited (51 [51.0%] female patients, median age 42 years [interquartile range = 34.5-54.5 years]); median time to return to work was 4 months. Work performance after stroke was high in 16% of cases, good in 58% of cases, moderate in 24%, and low in 2%. Chronbach's alpha coefficient was 0.75 for the scale. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.72 (p < 0.001). The test-retest reliability, as estimated by the intraclass correlation coefficients, was good. Memory, language, and attention explained 59.7% of the variance of the questionnaire in the extraction analysis. Conclusion: The WPQ-INNN is a reliable and valid tool for the assessment of performance quality in stroke survivors who returned to work.