Chengwei Li

Sleep apnea screening is uncommon after stroke

OBJECTIVE/BACKGROUNDnTo assess (1) pre and post-stroke screening for sleep apnea (SA) within a population-based study without an academic medical center, and (2) ethnic differences in post-stroke sleep apnea screening among Mexican Americans (MAs) and non-Hispanic whites (NHWs).nnnPATIENTS/METHODSnMAs and NHWs with stroke in the Brain Attack Surveillance in Corpus Christi project (2011-2015) were interviewed shortly after stroke about the pre-stroke period, and again at approximately 90 days after stroke in reference to the post-stroke period. Questions included whether any clinical provider directly asked about snoring or daytime sleepiness or had offered polysomnography. Logistic regression tested the association between these outcomes and ethnicity both unadjusted and adjusted for potential confounders.nnnRESULTSnAmong 981 participants, 63% were MA. MAs in comparison to NHWs were younger, had a higher prevalence of hypertension, diabetes, and never smoking, a higher body mass index, and a lower prevalence of atrial fibrillation. Only 17% reported having been offered SA diagnostic testing pre-stroke, without a difference by ethnicity. In the post-stroke period, only 50 (5%) participants reported being directly queried about snoring; 86 (9%) reported being directly queried about sleepiness; and 55 (6%) reported having been offered polysomnography. No ethnic differences were found for these three outcomes, in unadjusted or adjusted analyses.nnnCONCLUSIONSnScreening for classic symptoms of SA, and formal testing for SA, are rare within the first 90 days after stroke, for both MAs and NHWs. Provider education is needed to raise awareness that SA affects most patients after stroke and is associated with poor outcomes.

Intracerebral hemorrhage and sleep-disordered breathing

OBJECTIVE/BACKGROUNDnLimited data are available on sleep-disordered breathing (SDB) following intracerebral hemorrhage (ICH). Our aim was to characterize the objective measures of post-ICH SDB and questionnaire-reported pre-ICH sleep characteristics, overall and by ethnicity.nnnPATIENTS/METHODSnParticipants with ICH who were enrolled in the population-based Brain Attack Surveillance in Corpus Christi project (2010-2016) reported their pre-ICH sleep duration and completed the Berlin Questionnaire to characterize pre-ICH risk of SDB. A subsample was screened for SDB (respiratory event index ≥10) using ApneaLink Plus portable monitoring. Ethnic differences in post-ICH SDB or questionnaire-reported pre-ICH sleep characteristics were assessed using a log binomial model or a linear regression model or a Fishers exact test.nnnRESULTSnICH cases (nxa0=xa0298) were enrolled (median agexa0=xa068 years, 67% Mexican American). Among 62 cases with complete ApneaLink data, median time to post-ICH SDB screening was 11 days (IQR: 6, 19). Post-ICH SDB prevalence was 46.8% (95% CI: 34.4-59.2), and this rate did not differ by ethnicity (pxa0=xa01.0). Berlin Questionnaires for 109 of the 298 ICH cases (36.6% (95% CI: 31.1-42.0)) suggested a high risk for pre-ICH SDB, and the median pre-ICH sleep duration was eight hours (IQR: 6, 8). After adjusting for confounders, there was no difference in ethnicity in high risk for pre-ICH SDB or pre-ICH sleep duration.nnnCONCLUSIONSnNearly half of the patients had objective confirmation of SDB after ICH, and more than one-third had questionnaire evidence of high risk for pre-ICH SDB. Opportunities to address SDB may be common both before and after ICH.

Wake-up stroke is not associated with sleep-disordered breathing in women

Background We sought to investigate the frequency of wake-up stroke (WUS) and its association with sleep-disordered breathing (SDB) in women. Methods Within a population-based study, women with acute ischemic stroke were asked about their stroke symptom onset time. SDB screening was performed with the well-validated ApneaLink Plus device; SDB was defined by a respiratory event index ≥10. Logistic regression was used to test the association between SDB presence and severity and WUS unadjusted and adjusted for potential confounders including prestroke depression and sleep duration. Results Among 466 participants, the median age was 67.0 years (interquartile range [IQR] 58.0, 77.0), 55% were Mexican American, and the median initial NIH Stroke Scale score was 3.0 (IQR 1.0, 6.0). Stroke symptom onset occurred during nocturnal sleep (25.3%), during a nap (3.9%), during wakefulness (65.9%), or unknown (4.9%). In those with SDB screening performed (n = 259), a median of 11 days (IQR 5, 17) poststroke, WUS was not associated with the presence or severity (respiratory event index) of SDB in unadjusted or adjusted analysis. Conclusions In this population-based study, WUS represented about 30% of all generally mild severity ischemic strokes in women and was not associated with SDB.

A Population-Based Study of Intracerebral Hemorrhage Survivors’ Outcomes

BACKGROUNDnWe evaluated 3-month neurologic, functional, cognitive, and quality of life (QOL) outcomes in intracerebral hemorrhage (ICH) overall, and by sex and ethnicity in a population-based study.nnnMETHODSnSpontaneous ICH patients were identified from the Brain Attack Surveillance in Corpus Christi project (November 2008 to December 2013). Outcomes included neurologic (National Institutes of Health Stroke Scale: range 0-42), functional (activities of daily living/instrumental activities of daily living score: range 1-4, higher worse), cognitive (Modified Mini-Mental State Examination [3MSE]: range 0-100), and QOL (short-form stroke-specific QOL scale: range 0-5, higher better). Ethnic and sex differences were assessed with Tobit regression adjusted for age, sex, or ethnicity, and presenting Glasgow coma scale.nnnRESULTSnA total of 245 patients completed baseline interviews, with 103 (42%) dying prior to follow-up, leaving 142 eligible for outcome assessment. Three-month follow-up was completed in 100 (neurologic), 107 (functional), 79 (cognitive), and 83 (QOL) participants. Median age was 66 years (interquartile range 58.0-77.0). Cognitive outcomes were worse in Mexican Americans (MA) compared to non-Hispanic whites (NHW) after multivariable adjustment (MA scoring 13.3 3MSE points lower than NHW [95% confidence interval: 5.8, 20.7; Pu202f=u202f.0005]). There was no difference by sex or ethnicity in neurological, functional, or QOL outcomes, and no sex differences in cognitive outcomes.nnnCONCLUSIONSnIn this population-based study, worse cognitive outcomes were found in MAs compared with NHW. There were no differences between neurologic, functional, and QOL outcomes in ICH survivors based on sex or ethnicity.

Lack of Worsening of Sleep-Disordered Breathing After Recurrent Stroke in the BASIC Project

STUDY OBJECTIVESnTo investigate the difference in sleep-disordered breathing (SDB) prevalence and severity after an index and recurrent stroke.nnnMETHODSnIn a sample of 40 subjects, home sleep apnea tests were performed a median of 10 days after an index ischemic stroke and 14 days after a recurrent ischemic stroke. A respiratory event index (REI) of ≥ 10 events/h (apneas plus hypopneas per hour of recording) was used to define clinically significant SDB. The relative difference in REI or relative SDB prevalence was used to compare the post-recurrent stroke measurement with that made after the index stroke, and was expressed as a rate ratio (RR) or prevalence ratio (PR). Adjusted regression models (negative binomial for REI and log binomial for SDB) included change in body mass index and time between the events.nnnRESULTSnThe median time from index to recurrent stroke was 330.5 days (interquartile range [IQR]: 103.5, 766.5). The median REI was 17.5 (IQR: 9.0, 32.0) after the index stroke and 18.0 (IQR: 11.0, 25.5) after the recurrent stroke. The within-subject median difference was zero (IQR: -9, 7.5). The relative difference in REI was not significant in unadjusted or adjusted (RR: 0.97 [95% confidence interval: 0.76, 1.24]) models. The prevalence of SDB was not different after the recurrent stroke compared with the index stroke, in unadjusted or adjusted (PR: 1.10 [95% confidence interval: 0.91, 1.32]) models.nnnCONCLUSIONSnIn this within-subject, longitudinal study, neither severity nor prevalence of SDB worsened after recurrent stroke.

Temporal trends in age at ischemic stroke onset by ethnicity

PURPOSEnTo explore temporal trends in age at first-ever ischemic stroke onset in a bi-ethnic, population-based study.nnnMETHODSnCases of first-ever ischemic stroke (nxa0= 3252) were identified in the Brain Attack Surveillance in Corpus Christi Project (2000-2012). Demographics and risk factors were abstracted from medical records. Trends in age at stroke onset were assessed overall and by ethnicity (Mexican American [MA] and non-Hispanic white [NHW]) using generalized additive models. Differences by ethnicity were tested by including an interaction term between time and ethnicity. Models were run unadjusted and adjusted for age of the population at risk for stroke.nnnRESULTSnMean age at first-ever ischemic stroke significantly decreased from an average of 71.7xa0years in 2000 to an average of 69.3xa0years in 2012 (pxa0= .0043). Ethnicity significantly modified the temporal trends (pxa0<xa0.001) with declines greater in NHWs than in MAs; mean age was estimated to decrease from 74.8 to 71.3 over the 13xa0years for NHWs, whereas for MAs, mean age was estimated to decrease from 68.9 to 66.9 after adjusting for ethnic-specific average age of the population at risk.nnnCONCLUSIONSnAverage age at first-ever stroke onset declined over time in this community. Efforts should be made to prevent stroke by controlling risk factors before and during midlife.

Impact of Stroke Risk Factors on Ethnic Stroke Disparities Among Midlife Mexican Americans and Non-Hispanic Whites

Background and Purpose— We examined the contribution of stroke risk factors to midlife (age 45–59 years) Mexican American and non-Hispanic White ischemic stroke (IS) rate disparities from 2000 to 2010. Methods— Incident IS cases (n=707) and risk factors were identified from the Brain Attack Surveillance in Corpus Christi Project, Nueces County, TX (2000–2010). US Census data (2000–2010) were used to estimate the population at-risk for IS, and the Behavioral Risk Factor Surveillance System (2000–2010) was used to estimate risk factor prevalence in the stroke-free population. Poisson regression models combined IS counts (numerator) and population at-risk counts (denominator) classified by ethnicity and risk factor status to estimate unadjusted and risk factor–adjusted associations between ethnicity and IS rates. Separate models were run for each risk factor and extended to include an interaction term between ethnicity and risk factor. Results— The crude rate ratio (RR) for ethnicity (Mexican American versus non-Hispanic White) was 2.01 (95% confidence interval [CI], 1.71–2.36) and was attenuated in models that adjusted for diabetes mellitus (RR: 1.50; 95% CI, 1.26–1.78) and hypertension (RR: 1.84; 95% CI, 1.50–2.26). In addition, diabetes mellitus had a stronger association with IS rates among Mexican Americans (RR: 6.42; 95% CI, 5.31–7.76) compared with non-Hispanic Whites (RR: 4.07; 95% CI, 3.68–4.51). Conclusions— The higher prevalence of diabetes mellitus and hypertension and stronger association of diabetes mellitus with IS among midlife Mexican Americans likely contribute to persistent midlife ethnic stroke disparities.

Sex differences in sleep-disordered breathing after stroke: results from the BASIC project

OBJECTIVE/BACKGROUNDnSleep-disordered breathing (SDB), an independent risk factor for stroke, is associated with worse post-stroke outcomes. Differences in the relationship between SDB and stroke may exist for women versus men. In this population-based study, we compared the prevalence of both pre- and post-stroke SDB by sex. We also explored whether menopausal status is related to post-stroke SDB.nnnPATIENTS/METHODSnWe performed a cross-sectional study of subjects enrolled in the Brain Attack Surveillance in Corpus Christi (BASIC) project. Each subject (nxa0=xa01815) underwent a baseline interview including the Berlin Questionnaire to assess pre-stroke SDB risk and, if relevant, questions regarding menopausal status. Subjects were offered overnight SDB screening with a validated portable respiratory device (nxa0=xa0832 with complete data). Log Poisson and linear regression models were used to assess the differences in SDB between men and women with adjustment for demographics, stroke risk factors, stroke severity, and other potential confounders.nnnRESULTSnWomen were less likely than men to be at high risk for pre-stroke SDB (56.6% versus 61.9%) (prevalence ratio [PR] 0.87 for women; 95% confidence interval [CI], 0.81-0.95). A lower proportion of women than men (50.8% versus 70.2%) had post-stroke SDB by respiratory monitoring (PR 0.71; 95% CI, 0.63-0.80). SDB severity was higher for men than for women (mean difference in respiratory event index [REI] 6.5; 95% CI, 4.3-8.7). No significant association existed between post-stroke SDB and either menopausal status or age at menopause.nnnCONCLUSIONSnAfter acute ischemic stroke, SDB was more prevalent and more severe in men than in women.