Background and Purpose As a leading cause of disability and death in China, stroke as well as its epidemiologic features have gained increasing attention. Prior studies, however, have overgeneralized the north-to-south gradient in China. Whether the differences exist across urban and rural areas remains unexplored. This study therefore aims to investigate the north-to-south gradient in stroke incidence across urban and rural China.Methods The present prospective cohort study analyzed data from the China Health and Nutrition Survey 1997 to 2015. By including 16,917 individuals from diverse social contexts, we calculated the age-standardized incidence of stroke across regions and the age-adjusted risk ratio (aRR). Cox proportional hazards models with time-varying covariates were employed to analyze variations in incident stroke.Results During the follow-up, age-standardized incidence of stroke ranged from 4.17 per 1,000 person-years (95% confidence interval [CI], 3.38 to 4.96) in the north region to 1.95 (95% CI, 1.60 to 2.30) in the south region (aRR, 2.04; 95% CI, 1.58 to 2.64; <i>P</i>&lt;0.001). The north-to-south gradient of stroke incidence was observed only in rural areas, but not in urban areas. Hierarchical modelling analyses further indicated that the regional differences could be mostly explained by the disparities in the prevalence of hypertension.Conclusions The present study extends the current evidence on the north-to-south gradient by demonstrating that the difference varied across urban and rural China. Our findings highlight the importance of hypertension management as the measure for alleviating regional differences in stroke incidence.

Background and Purpose: Practice guidelines recommend that most patients receive moderate- or high-potency statins after ischemic stroke or transient ischemic attack (TIA) of atherosclerotic origin. We tested the association of different patterns of potency for prescribed statin therapy—assessed before admission and at hospital discharge for ischemic stroke or TIA—on mortality in a large, nationwide sample of US Veterans. Methods: The study population included patients with an ischemic stroke or TIA occurring during 2011 at any of the 134 Veterans Health Administration facilities. We used electronic outpatient pharmacy files to identify statin dose at hospital admission and within 7 days after hospital discharge. We categorized statin dosing as low, moderate, or high potency; moderate or high potency was considered at goal. We created 6 mutually exclusive groups to reflect patterns of statin potency from hospital admission to discharge: goal to goal, low to goal, goal to low or goal to none (deintensification), none to none, none to low, and low to low. We used logistic regression to compare 30-day and 1-year mortality across statin potency groups. Results: The population included 9380 predominately White (71.1%) men (96.3%) who were hospitalized for stroke or TIA. In this sample, 34.1% of patients (n=3194) were discharged off a statin medication. Deintensification occurred in 14.0% of patients (n=1312) and none to none in 20.5% (n=1924). Deintensification and none to none were associated with a higher odds of mortality as compared with goal to goal (adjusted odds ratio 1-year mortality: deintensification versus goal to goal, 1.26 [95% CI, 1.02–1.57]; none to none versus goal to goal, 1.59 [95% CI, 1.30–1.93]). Adjustments for differences in baseline characteristics using propensity weighted scores demonstrated similar results. Conclusions: Underutilization of statins, including no treatment or underdosing after stroke (deintensification), was observed in approximately one-third of veterans with ischemic stroke or TIA and was associated with higher mortality when compared with patients who were at goal for statin prescription dosing.

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To the Editor:We congratulate Geraghty et al 1 and their team for their finding that SII index was an independent predictor of delayed cerebral vasospasm in aneurysmal subarachnoid hemorrhage (aSAH). Delayed cerebral ischemia (DCI) is one of the common complications after aSAH contributing to poor functional outcomes. 2 Until now, cerebral vasospasm is still widely accepted as the primary cause to DCI after aSAH. 3 Therefore, identification of easily accessible and reliable predictors for vasospasm could bring improvement in patient risk stratification and future intervention. However, several issues in this great work still need to be addressed.First, the authors did not set up exclusion criteria during the patient collection. Other conditions, such as thrombocytopenia, lymphoma, infections, or autoimmune disease cancer, might also affect the SII index. These comorbidities should be taken into consideration in the future prospective studies. Second, neutrophil-to-lymphocyte ratio (NLR), another readily available and convenient biomarker, has been reported to independently predict development of DCI (odds ratio [OR] 1.7, 95% CI 1.1-2.5, P = .008) 4 and unfavorable functional outcomes (OR 1.014, 95% CI 1.001-1.027, P = .028). 5 The main difference between SII and NLR is the platelet count when calculating the index. In this study, Geraghty et al reported that NLR also independently predicted vasospasm with an OR of 1.088 (95% CI 1.032-1.147, P = .002) in the multivariable logistic regression analysis. However, in the receiver operating characteristic curves, the authors only compared SII and the multivariable SII model with modified Fisher scale, with the NLR not included. Third, the authors reported the optimal cutoff of SII in the receiver operating characteristic curve for distinguishing between patients with or without vasospasm. It would provide more information if the association between the admission characteristics and SII was analyzed with the aim to detect the predictors of elevated SII.In all, we thank the authors for their original work and their detection of a new promising index for predicting vasospasm in patients with aSAH.

Epidermal or epidermoid cysts are 1 of the most frequent benign masses, they rarely grow to a huge size, and only a few cases have been reported. We report a rare case of a 52-year-old man with giant neoplasm growing invasively in the frontal region, including both intracranial and extracranial extensions, and caused extensive brain deformation and skull lesions. It is worth noting that the patient did not present any significant neurological symptoms and deficits for more than 40 years on admission. A combination of gross total tumor resection and cranioplasty was performed. The patient was satisfied with the results of the surgery, and no evidence of recurrence or complications were found in the 2 years follow-up. The authors reported the case not only to propose the first-stage aesthetic treatment option for this unusual mass on the scalp but also hinted at the vigilance and importance of systematic monitoring of the small skull mass for avoiding the potential risk of tumor progression, malignant transformation, operative trauma, and financial burden.