Acute Transient Ischemic Attack Research Articles

High prevalence of erectile dysfunction in male patients with acute stroke was associated with age but not to modifiable cardiovascular risk factors

BackgroundErectile dysfunction (ED) and stroke share common risk factors, and symptoms of ED often precede the development of clinical cardiovascular disease (CVD). However, little is known about how ED is...

Is thrombolysis beneficial in elderly patients with minor ischemic stroke?

IntroductionA pooled analysis of data from randomized controlled trials showed that thrombolysis is an effective treatment in patients older than 80 years of age with acute ischemic stroke. However, the outcomes in daily clinical practice may differ from those observed in randomized controlled trials. Thus, the present study aimed to compare the short-term outcomes of patients older than 80 years of age with ischemic stroke or transient ischemic attacks (TIA) admitted to Haukeland University Hospital in Norway, examining thrombolysis vs. non-thrombolysis treatment in patients.MethodsAll patients with acute ischemic stroke or TIA who were older than 80 years of age and admitted to Haukeland University Hospital within the 4.5-h window after stroke onset between 2006 and 2020 were prospectively included in this observational study. Patients who received thrombolysis were compared to patients who did not receive thrombolysis. The endpoint was a modified Rankin Scale (mRS) score on day 7 or discharge if earlier. The National Institutes of Health Stroke Scale (NIHSS) scores were recorded repeatedly during their hospital stays.ResultsIn total, 808 patients were included. Thrombolysis was given to 393 (49%) patients. In patients with an NIHSS score of <3 (minor ischemic stroke) at admission, thrombolysis was associated with worse short-term outcomes (β = 0.13, p = 0.03), whereas thrombolysis was associated with better short-term outcomes in patients with an NIHSS score of ≥3 (major ischemic stroke) at admission (β = 0.12, p = 0.003). Thrombolysis appeared to be associated with neurological worsening in patients with an NIHSS score of <3 at admission. Excluding patients who underwent a thrombectomy did not change the results.ConclusionIn elderly patients with major ischemic stroke, thrombolysis was associated with better short-term outcomes. However, in patients with minor ischemic stroke, thrombolysis was associated with worse short-term outcomes. Several reasons for this discrepancy are discussed.

Extended Computed Tomography Angiography for the Successful Diagnosis of Cardioaortic Thrombus in Acute Ischemic Stroke and TIA: Study Protocol for a Randomized Controlled Trial.

Cardiac imaging is one of the main components of the etiological investigation of ischemic strokes. However, basic and advanced cardiac imaging remain underused in most stroke centers globally. Computed tomography angiography (CTA) of the supra-aortic and intracranial arteries is the most frequent imaging modality applied during the evaluation of patients with acute ischemic stroke to identify the presence of a large vessel occlusion. Recent evidence from retrospective observational studies has shown a high detection of cardiac thrombi, ranging from 6.6 to 17.4%, by extending a CTA a few cm below the carina to capture cardiac images. However, this approach has never been prospectively compared against usual care in a randomized controlled trial. The Extended Computed Tomography Angiography for the Successful Screening of Cardioaortic Thrombus in Acute Ischemic Stroke and TIA (DAYLIGHT) prospective, randomized, controlled trial evaluates whether an extended CTA (eCTA) + standard-of-care stroke workup results in higher detection rates of cardiac and aortic source of embolism compared to standard-of-care CTA (sCTA) + standard-of-care stroke workup. DAYLIGHT is a single-center, prospective, randomized, open-blinded endpoint trial, aiming to recruit 830 patients with suspected acute ischemic stroke or transient ischemic attack (TIA) being assessed under acute code stroke at the emergency department or at a dedicated urgent stroke prevention clinic. Patients are randomized 1:1 to eCTA versus sCTA. The eCTA expands image acquisition caudally, 6 cm below the carina. All patients receive standard-of-care cardiac imaging and diagnostic stroke workup. The primary efficacy endpoint is the diagnosis of a cardioaortic thrombus after at least 30 days of follow-up. The primary safety endpoint is door-to-CTA completion time. The diagnosis of a qualifying ischemic stroke or TIA is independently adjudicated by a stroke neurologist, blinded to the study arm allocation. Patients without an adjudicated ischemic stroke or TIA are excluded from the analysis. The primary outcome events are adjudicated by a board-certified radiologist with subspecialty training in cardiothoracic radiology and a cardiologist with formal training in cardiac imaging. The primary analysis is performed according to the modified intention-to-diagnose principle and without adjustment by logistic regression models. Results are presented with odds ratios and 95% confidence intervals. The DAYLIGHT trial will provide evidence on whether extending a CTA to include the heart results in an increased detection of cardioaortic thrombi compared to standard-of-care stroke workup.

Immediate- or Delayed-Intensive Statin in Acute Cerebral Ischemia: The INSPIRES Randomized Clinical Trial.

Comparisons are limited for immediate-intensive and delayed-intensive statin for secondary stroke prevention and neuroprotection in patients with acute mild ischemic stroke or transient ischemic attack (TIA) from atherosclerosis. To estimate whether immediate-intensive statin therapy is safe and can lower the risk of recurrent stroke compared with delayed-intensive statin in patients with acute mild ischemic stroke or high-risk TIA from atherosclerosis. The Intensive Statin and Antiplatelet Therapy for High-Risk Intracranial or Extracranial Atherosclerosis (INSPIRES) trial, a double-blind, placebo-controlled, 2 × 2 factorial, randomized clinical trial enrolled patients from September 2018 to October 2022. The trial was conducted at 222 hospitals in China. Patients aged 35 to 80 years with mild ischemic stroke or high-risk TIA of presumed atherosclerosis within 72 hours of symptom onset were assessed. Patients were randomly assigned to receive immediate-intensive atorvastatin (80 mg daily on days 1-21; 40 mg daily on days 22-90) or 3-day delayed treatment (placebo for days 1-3, followed by placebo and atorvastatin, 40 mg daily on days 4-21, and then atorvastatin, 40 mg daily on days 22-90). The primary efficacy outcome was new stroke within 90 days, and a secondary efficacy outcome was poor functional outcome. Moderate to severe bleeding was the primary safety outcome. A total of 11 431 patients were assessed for eligibility, and 6100 patients (median [IQR] age, 65 [57-71] years; 3915 men [64.2%]) were enrolled, with 3050 assigned to each treatment group. Within 90 days, new stroke occurred in 245 patients (8.1%) in the immediate-intensive statin group and 256 patients (8.4%) in the delayed group (hazard ratio, 0.95; 95% CI, 0.80-1.13). Poor functional outcome occurred in 299 patients (9.8%) and 348 patients (11.4%) in the immediate-intensive and delayed-intensive statin groups, respectively (odds ratio, 0.83; 95% CI, 0.71-0.98). Moderate to severe bleeding occurred in 23 of 3050 patients (0.8%) and 17 of 3050 patients (0.6%), in the immediate-intensive and delayed-intensive statin groups, respectively. Immediate-intensive statin initiated within 72 hours did not reduce the risk of stroke within 90 days and may be associated with improved functional outcomes without significant difference in moderate to severe bleeding, compared with 3-day delayed-intensive statin in Chinese patients with acute mild ischemic stroke or TIA from atherosclerosis. ClinicalTrials.gov Identifier: NCT03635749.

Alcohol consumption may be a risk factor for cerebrovascular stenosis in acute ischemic stroke and transient ischemic attack

BackgroundAtherosclerosis are well established risk factors for ischemic stroke, however the association between alcohol consumption and atherosclerosis is controversial. This study aims to explore the potential correlation between alcohol consumption and cerebral stenosis in patients with acute ischemic stroke and transient ischemic attack (TIA).MethodsNine hundreds and eighty-eight patients with first acute ischemic stroke attack or TIA were recruited retrospectively. Alcohol consumption was classified into five consumption categories (non-drinkers, occasional drinkers, < 140 g per week [mild drinkers], 140–279 g per week [moderate drinkers], ≥ 280 g per week [heavy drinkers]). Computed tomography angiography (CTA) and digital subtraction angiography (DSA) were utilized to assess the carotid and cerebral artery in all patients. Five-step scale for degree of stenosis was applied: normal (0, 0 points), mild (< 50%, 1 point), moderate (50–69%, 2 points), severe (70–99%, 3 points), and occlusion (100%, 4 points).ResultsThe carotid and cerebral artery stenosis scores were positively correlated with moderate alcohol consumption (B = 1.695, P < 0.001). Compared with nondrinkers, moderate alcohol consumption had significant increasing risk of moderate carotid and cerebral artery stenosis (OR = 4.28, 95% CI: 1.47–12.49, P = 0.008) and severe stenosis (OR = 4.24, 95% CI: 1.55–11.64, P = 0.005) and occlusion (OR = 3.87, 95% CI: 1.65–9.06, P = 0.002). Compared with nondrinkers, heavy alcohol consumption patients had significant higher risk of carotid and cerebral artery occlusion (OR = 2.71, 95% CI: 1.36–5.41, P = 0.005).ConclusionsHigher alcohol consumption may associate with higher risk and more severity of carotid and cerebrovascular stenosis.

Ticagrelor versus clopidogrel in dual antiplatelet therapy after minor stroke or transient ischemic attack: an updated network meta-analysis.

Dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin is a well-established practice after a minor stroke or transient ischemic attack (TIA). However, ticagrelor plus aspirin may be an alternative. We systematically searched PubMed, Embase, and Cochrane Central from inception to January 2024. We included randomized controlled trials (RCTs) enrolling adults with acute minor stroke or TIA within 72hours of the onset of the symptoms. A total of 8 RCTs were included in our meta-analysis. Ticagrelor plus aspirin (RR, 0.70; 95% CrI 0.52, 0.91) and clopidogrel plus aspirin (RR, 0.79; 95% CrI 0.64, 0.98) were superior to aspirin in preventing stroke recurrence in overall analysis. Excluding studies with dual antiplatelet up to 90days, ticagrelor plus aspirin was the only strategy that maintained superiority compared with aspirin regarding stroke recurrence (RR, 0.70; 95% CrI 0.51, 0.95) and ischemic stroke (RR, 0.68; 95% CrI 0.47, 0.94). There was no significant difference between treatment groups regarding hemorrhagic stroke, functional disability, and mortality. DAPTs were superior to aspirin in preventing recurrence or ischemic stroke. Although no significant difference was observed between DAPTs, ticagrelor plus aspirin may be related to worse major bleeding results, including intracranial bleeding. Ticagrelor plus aspirin is a considerable option for patients after a minor stroke or TIA.

Efficacy and safety of oral factor Xa inhibitors versus vitamin-K antagonists in the early phase after acute ischemic stroke or TIA in the real-world setting: The PRODAST study.

Factor Xa (FXa) inhibitors are superior to vitamin K antagonists (VKAs) in terms of avoiding hemorrhagic complications. However, no robust data are available to date as to whether this also applies to the early phase after stroke. In this prospective registry study, we aimed to investigate whether anticoagulation with FXa inhibitors in the early phase after acute ischemic stroke or transient ischemic attack (TIA) is associated with a lower risk of major bleeding events compared with VKAs. The Prospective Record of the Use of Dabigatran in Patients with Acute Stroke or TIA (PRODAST) study is a prospective, multicenter, observational, post-authorization safety study at 86 German stroke units between July 2015 and November 2020. Primary outcome was a major bleeding event during hospital stay. Secondary endpoints were recurrent strokes, recurrent ischemic strokes, TIA, systemic/pulmonary embolism, myocardial infarction, death and the composite endpoint of stroke, systemic embolism, life-threatening bleeding and death. In total, 10,039 patients have been recruited. 5,874 patients were treated with FXa inhibitors and 1,050 patients received VKAs and were eligible for this analysis. Overall, event rates were low. We observed 49 major bleeding complications during 33,297 treatment days with FXa-inhibitors (rate of 14.7 cases per 10,000 treatment days) and 16 cases during 7,714 treatment days with VKAs (rate of 20.7 events per 10,000 treatment days), translating into an adjusted hazard ratio (aHR) of 0.70 (95% confidence interval (95% CI): 0.37-1.32) in favor of FXa inhibitors. Hazards for ischemic endpoints (63 vs 17 strokes, aHR: 0.96 (95% CI: 0.53-1.74), mortality (33 vs 6 deaths, aHR: 0.87 (95% CI: 0.33-2.34)) and the combined endpoint (154 vs 39 events, aHR: 0.99 (95% CI: 0.65-1.41) were not substantially different. This large real-world study shows that FXa inhibitors appear to be similarly effective in terms of bleeding events and ischemic endpoints compared to VKAs in the early post-stroke phase of hospitalization. However, the results need to be interpreted with caution due to the low precision of the estimates.

Prevalence of primary aldosteronism in acute stroke or transient ischemic attack: a systematic review and meta-analysis.

Primary aldosteronism (PA) is the most common endocrine cause of secondary hypertension with a prevalence of 14% in patients with newly diagnosed hypertension. Patients with PA experience a higher rate of cardiovascular events including stroke when compared to those with blood pressure matched essential hypertension. This systematic review and meta-analysis summarize current evidence on the prevalence of PA in patients with acute stroke or transient ischemic attack (TIA). Two reviewers independently reviewed the literature for observational studies on the prevalence of PA in patients with acute stroke or TIA. MEDLINE and Embase were searched for studies up to December 13, 2023. Three single center studies conducted in Japan, Singapore and China were found to meet the inclusion criteria. The reported prevalence of PA in two cohort studies of adults with stroke or TIA were 3.1% and 4.0% and a third cross-sectional study in adults under 45 years old revealed a prevalence rate of 12.9%. Following a meta-analysis, the pooled prevalence of PA in adults with stroke or TIA is 5.8% [95% CI 1.6%-12.3%]. A considerable proportion of patients with stroke or TIA may have PA as the underlying cause of their hypertension. Given the increased risk of stroke associated with PA, clinicians should consider screening for PA in hypertensive patients with stroke or TIA. Further research is needed to evaluate the effect of timing and interfering medications on test results, which will inform an evidence-based approach to testing for PA following TIA or stroke. https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022328644.

Abstract TMP40: The Impact of Social Determinants of Health on Stroke Readmissions and Recovery

Introduction: The consequences of increased morbidity and increased socioeconomic strain, for stroke survivors and their families, is well documented in stroke literature worldwide. Variables that determine readmission rates of stroke survivors may be complicated by the intersection of social determinants of health (SDOH). SDOH include race/ethnicity, insecurities, living conditions, social isolation, health literacy, income and education. This single center, prospective, observational study explores SDOH that lead to higher risk of readmission (within 30-days to 30-90 days) after discharge from the hospital once diagnosed with stroke or transient ischemic attack (TIA). Methods: A questionnaire was distributed to 100 patients admitted with acute stroke or TIA per the study inclusion criteria. Additional variables of interest collected included race, ethnicity, income, insurance status, treatment, baseline and discharge National Institutes of Health Stroke Scale score and modified Rankin scale (mRS) score, comorbidities, zip code and discharge disposition. Results: Univariate analysis found prior stroke/TIA and baseline mRS score of 0-2 to be statistically significant at predicting readmission within 30-days, p=0.07 and p=0.01, respectively. Multivariate analysis showed patients who find it difficult to eat healthy and participate in activities to improve their health, have history of prior TIA/stroke, coronary artery disease, diabetes and baseline mRS score were highly predictive for readmission. Discussion: SDOH are thought to contribute to readmission rates for patients who experienced stroke or TIA. In conclusion, our preliminary study found that patients who admitted to difficulties maintaining a healthy lifestyle had a correlation with both 30-day and 30-90 day readmission. Further studies are needed to identify the SDOH variables that most accurately predict readmission after stroke/TIA. This will further the mandate for increased precision medicine, tailoring targeted interventions to improve the quality of life for stroke survivors.

Abstract TP271: A Retrospective Analysis of Demographic and Clinical Variables Within a Single Center Young Stroke Cohort

Introduction: Despite significant efforts to increase public awareness of cerebrovascular disease, the incidence of stroke and transient ischemic attack (TIA) in young adults has remained elevated, representing a major public health concern. We sought to better characterize our young stroke population in order to gain insight as to where targeted interventions could be beneficial in community outreach and support of affected patients. Methods: We conducted a retrospective study evaluating young adults (under 50 years of age) presenting to a single urban academic medical center with acute ischemic stroke or TIA between 2013 and 2022. Demographic information and clinical variables (including past medical history, Trial of Org 10172 in Acute Stroke Treatment [TOAST] classification of stroke etiology, and discharge disposition) were extracted from the electronic medical record and descriptive statistics were calculated. Results: A total of 408 patients were reviewed. Within this study population, the median age was 43 years (IQR 38-47 years) and 235 (57.6%) were men. The median initial National Institutes of Health Stroke Scale upon presentation was 3 (IQR 1-7). The most common stroke risk factors were tobacco use (44.6%), pre-existing cardiovascular disease (26.2%), and other substance use (23.8%). The most common TOAST classification upon discharge was Stroke of Undetermined Etiology (32.9%). Most patients (244, 59.8%) were discharged directly to home from the hospital, although 140 (34.3%) were transitioned to another facility, including acute rehabilitation facilities (95, 23.3%), skilled nursing facilities (22, 5.4%), and long-term acute care hospitals (11, 2.7%). Conclusion: Our study highlights that the continued high incidence of stroke in the young may be at least partially attributable to a high prevalence of traditional cardiovascular risk factors, thus emphasizing the importance of smoking cessation counseling and early treatment of hypertension in the primary care setting. In addition, while most young patients will present with minor stroke symptoms, a significant portion are unable to return directly to home upon discharge from the hospital.

Safety and efficacy of factor XIa inhibition with milvexian for secondary stroke prevention (AXIOMATIC-SSP): a phase 2, international, randomised, double-blind, placebo-controlled, dose-finding trial

People with factor XI deficiency have lower rates of ischaemic stroke than the general population and infrequent spontaneous bleeding, suggesting that factor XI has a more important role in thrombosis than in haemostasis. Milvexian, an oral small-molecule inhibitor of activated factor XI, added to standard antiplatelet therapy, might reduce the risk of non-cardioembolic ischaemic stroke without increasing the risk of bleeding. We aimed to estimate the dose-response of milvexian for recurrent ischaemic cerebral events and major bleeding in patients with recent ischaemic stroke or transient ischaemic attack (TIA). AXIOMATIC-SSP was a phase 2, randomised, double-blind, placebo-controlled, dose-finding trial done at 367 hospitals in 27 countries. Eligible participants aged 40 years or older, with acute (<48 h) ischaemic stroke or high-risk TIA, were randomly assigned by a web-based interactive response system in a 1:1:1:1:1:2 ratio to receive one of five doses of milvexian (25 mg once daily, 25 mg twice daily, 50 mg twice daily, 100 mg twice daily, or 200 mg twice daily) or matching placebo twice daily for 90 days. All participants received clopidogrel 75 mg daily for the first 21 days and aspirin 100 mg daily for the first 90 days. Investigators, site staff, and participants were masked to treatment assignment. The primary efficacy endpoint was the composite of ischaemic stroke or incident covert brain infarct on MRI at 90 days, assessed in all participants allocated to treatment who completed a follow-up MRI brain scan, and the primary analysis assessed the dose-response relationship with Multiple Comparison Procedure-Modelling (MCP-MOD). The main safety outcome was major bleeding at 90 days, assessed in all participants who received at least one dose of the study drug. This trial is registered with ClinicalTrials.gov (NCT03766581) and the EU Clinical Trials Register (2017-005029-19). Between Jan 27, 2019, and Dec 24, 2021, 2366 participants were randomly allocated to placebo (n=691); milvexian 25 mg once daily (n=328); or twice-daily doses of milvexian 25 mg (n=318), 50 mg (n=328), 100 mg (n=310), or 200 mg (n=351). The median age of participants was 71 (IQR 62-77) years and 859 (36%) were female. At 90 days, the estimates of the percentage of participants with either symptomatic ischaemic stroke or covert brain infarcts were 16·8 (90·2% CI 14·5-19·1) for placebo, 16·7 (14·8-18·6) for 25 mg milvexian once daily, 16·6 (14·8-18·3) for 25 mg twice daily, 15·6 (13·9-17·5) for 50 mg twice daily, 15·4 (13·4-17·6) for 100 mg twice daily, and 15·3 (12·8-19·7) for 200 mg twice daily. No significant dose-response was observed among the five milvexian doses for the primary composite efficacy outcome. Model-based estimates of the relative risk with milvexian compared with placebo were 0·99 (90·2% CI 0·91-1·05) for 25 mg once daily, 0·99 (0·87-1·11) for 25 mg twice daily, 0·93 (0·78-1·11) for 50 mg twice daily, 0·92 (0·75-1·13) for 100 mg twice daily, and 0·91 (0·72-1·26) for 200 mg twice daily. No apparent dose-response was observed for major bleeding (four [1%] of 682 participants with placebo, two [1%] of 325 with milvexian 25 mg once daily, two [1%] of 313 with 25 mg twice daily, five [2%] of 325 with 50 mg twice daily, five [2%] of 306 with 100 mg twice daily, and five [1%] of 344 with 200 mg twice daily). Five treatment-emergent deaths occurred, four of which were considered unrelated to the study drug by the investigator. Factor XIa inhibition with milvexian, added to dual antiplatelet therapy, did not substantially reduce the composite outcome of symptomatic ischaemic stroke or covert brain infarction and did not meaningfully increase the risk of major bleeding. Findings from our study have informed the design of a phase 3 trial of milvexian for the prevention of ischaemic stroke in patients with acute ischaemic stroke or TIA. Bristol Myers Squibb and Janssen Research & Development.

Urinary ketone bodies and stroke recurrence in patient with acute ischemic stroke or TIA

BackgroundUrine ketone bodies may appear in different states in the acute stage of stroke. We aimed to examine the association between urine ketone bodies and recurrent stroke in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) in this study. MethodsIn Third China National Stroke Registry (CNSR-III), 14,015 patients with AIS or TIA were screened for urine ketone bodies. The outcomes were any stroke, ischemic stroke and combined vascular events within 1 year. The association of urine ketone bodies with recurrent stroke were analyzed by Cox proportional hazards. ResultsDuring 1 year of follow-up, 1,335 (9.53%) participants experienced recurrent stroke. After adjustment for conventional confounding factors, patients with urine ketone bodies test positive had a higher risk of recurrent stroke (hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.13–1.82), compared to those were negative. The correlation between positive urine ketone bodies and recurrent stroke were consistent in patient with (HR, 1.45; 95% CI, 1.00–2.12) and without (HR, 1.40; 95% CI, 1.02–1.94) diabetes. No significant interaction between urine ketone bodies and diabetes were observed. ConclusionsPositive ketone bodies in urine was independently associated with recurrent stroke in patients with AIS or TIA.

Low value of inherited thrombophilia testing among patients with stroke or transient ischemic attack: A three-year retrospective study

Background/PurposeInherited thrombophilia testing in the acute inpatient setting is controversial and expensive, and rarely changes clinical management. We evaluated ordering patterns and results of inpatient inherited thrombophilia testing for patients who presented with an isolated acute ischemic stroke or transient ischemic attack (TIA) without concurrent venous thromboembolism. MethodsWe retrospectively analyzed patients admitted for acute ischemic stroke or TIA between January 1st, 2019 and December 31st, 2021 at Thomas Jefferson University Hospitals in Philadelphia, PA and who underwent inherited thrombophilia testing during the hospital admission. Charts were reviewed to determine stroke risk factors, test results, and clinical management. ResultsAmong 2108 patients admitted for acute ischemic stroke or TIA (including branch and central retinal artery occlusions) during the study period, the study included 249 patients (median age 49.0 years, 50.2% female) who underwent inpatient testing for factor V Leiden, prothrombin G20210A variant, hyperhomocysteinemia, PAI-1 elevation, and deficiencies of protein C and S and antithrombin. 42.2% of patients had at least one abnormal test, and among the 1035 tests ordered, 14.3% resulted abnormal. However, 28% of abnormal tests were borderline positive antigen or activity assays that likely represented false positives. There was no significant difference in the likelihood of a positive test among patients without stroke risk factors vs those with risk factors (47.1% vs 40.9%, P = .428), nor any significant difference between those under vs over age 50 years (45.7% vs 38.3%, P = .237). No patients with an abnormal result had their clinical management changed as a result. Charges for the tests totaled $468,588 USD. ConclusionsInherited thrombophilia testing in the hospital immediately following isolated acute arterial ischemic stroke or TIA was associated with high rates of likely false positive results and was expensive. Positive results did not change clinical management in a single case.

Early or late initiation of dabigatran versus vitamin-K-antagonists in acute ischemic stroke or TIA: The PRODAST study.

The optimal timing of initiating or resuming anticoagulation after acute ischemic stroke (AIS) or transient ischemic attack (TIA) in patients with atrial fibrillation (AF) is debated. Dabigatran, a non-vitamin K oral anticoagulant (NOAC), has shown superiority against vitamin K antagonists (VKA) regarding hemorrhagic complications. In this registry study, we investigated the initiation of dabigatran in the early phase after AIS or TIA. PRODAST (Prospective Record of the Use of Dabigatran in Patients with Acute Stroke or TIA) is a prospective, multicenter, observational, post-authorization safety study. We recruited 10,039 patients at 86 German stroke units between July 2015 and November 2020. A total of 3,312 patients were treated with dabigatran or VKA and were eligible for the analysis that investigates risks for major hemorrhagic events within 3 months after early (⩽ 7 days) or late (> 7 days) initiation of dabigatran or VKA initiated at any time. Further endpoints were recurrent stroke, ischemic stroke, TIA, systemic embolism, myocardial infarction, death, and a composite endpoint of stroke, systemic embolism, life-threatening bleeding and death. Major bleeding event rates per 10,000 treatment days ranged from 1.9 for late administered dabigatran to 4.9 for VKA. Early or late initiation of dabigatran was associated with a lower hazard for major hemorrhages as compared to VKA use. The difference was pronounced for intracranial hemorrhages with an adjusted hazard ratio (HR) of 0.47 (95% confidence interval (CI): 0.10-2.21) for early dabigatran use versus VKA use and an adjusted HR of 0.09 (95% CI: 0.00-13.11) for late dabigatran use versus VKA use. No differences were found between early initiation of dabigatran versus VKA use regarding ischemic endpoints. The early application of dabigatran appears to be safer than VKA administered at any time point with regards to the risk of hemorrhagic complications and in particular for intracranial hemorrhage. This result, however, must be interpreted with caution in view of the low precision of the estimate.

Elevated hs-CRP and Symptomatic Intracranial/Extracranial Artery Stenosis Predict Stroke Recurrence after Acute Ischemic Stroke or TIA.

This study aimed to investigate the relationship between symptomatic or asymptomatic intracranial/extracranial artery stenosis and high-sensitivity C-reactive protein (hs-CRP) levels in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). This study included 10404 patients from the Third China National Stroke Registry. Patients were divided into four or six groups according to patterns of intracranial or extracranial artery stenosis and hs-CRP levels. The outcomes were recurrence of ischemic stroke, stroke, and combined vascular events (CVE) at 1 year. The associations between different combinations of hsCRP levels and patterns of artery stenosis and recurrent events were analyzed by multivariable Cox regression models. Patients in Group III (hs-CRP ＜3＋symptomatic intracranial or extracranial artery stenosis) had higher risk of recurrent ischemic stroke (adjusted hazard ratio (HR) 1.73, 95% confidence interval (CI) 1.20-2.48,p=0.003). Those in Group VI (hs-CRP ≥ 3＋symptomatic intracranial or extracranial artery stenosis) had the highest risk of recurrent ischemic stroke (HR 2.04, 95% CI 1.42-2.92, p=0.0001) within 1 year compared with Group I (hs-CRP ＜3＋no artery stenosis). Asymptomatic intracranial or extracranial artery stenosis did not increase the risk of ischemic events compared with no artery stenosis regardless of hs-CRP levels. Symptomatic intracranial or extracranial artery stenosis was associated with increased risk of recurrent ischemic stroke, stroke, and CVE at 1 year in patients with AIS or TIA, especially in patients with elevated hs-CRP levels. Asymptomatic intracranial or extracranial artery stenosis did not increase the risk of ischemic events compared with no artery stenosis regardless of hs-CRP levels.

Early ischemic stroke predictors after transient ischemic attacks among Egyptians

Background The frequency of early stroke occurrence after transient ischemic attacks (TIAs) has been poorly studied. Aim This work aimed to determine the possible predictors of early ischemic stroke within 90 days of the first attack of TIA among Egyptians. Patients and methods A total of 80 patients presented with acute ischemic stroke or TIAs were recruited and were divided into group A, which included 40 patients presented with ischemic stroke preceded by TIAs within the last 3 months, and group B, which included 40 patients who had one or more TIAs and were asymptomatic for more than 3 months. All patients were subjected to the following: neurological assessment, laboratory investigations, cardiologic assessment, and brain imaging. Results Older patients were more liable to stroke occurrence after TIAs. Hospital admission during TIAs significantly reduced the risk of early stroke occurrence. Receiving medical treatment during TIAs significantly reduced the risk of early stroke occurrence. Hypertension was the only significant modifiable risk factor for early stroke occurrence. Multiple TIAs were significant predictors of early stroke recurrence. The rate of stroke occurrence was higher during the short-term follow-up, especially during the first week. Magnetic resonance diffusion changes were significant predictors of early stroke occurrence. Conclusions The main prognostic factors for early stroke occurrence after TIAs were age, hypertension, hospital admission, early medical treatment after TIAs, duration and frequency of TIAs symptoms, ABCD2 score, and positive findings in brain imaging.

Disparate statin prescribing following hospital discharge for stroke or transient ischemic attack: Findings from COMPASS.

Published guidelines recommend high-intensity statins following an ischemic stroke or transient ischemic attack (TIA). The authors examined the potential for disparate patterns of statin prescribing in a cluster randomized trial of transitional care following acute stroke or TIA. Medications taken before hospitalization and statins prescribed at discharge among stroke and TIA patients at 27 participating hospitals were examined. Any statin and intensive statin prescribed at discharge were compared by age (<65, 65-75, >75 years), racial category (White vs. Black), sex (male vs. female), and rurality (urban vs. non-urban) using logistic mixed models. Among 3211 patients (mean age 67 years; 47% female; 29% Black), 90% and 55%, respectively, were prescribed any statin or intensive statin therapy at discharge. White (vs. Black) patients (0.71, 0.51-0.98) less commonly received any statin prescription, while stroke (vs. TIA) patients (1.90, 1.38-2.62) and those residing in urban areas (1.66, 1.07-2.55) more commonly received any statin prescription. Among those prescribed a statin, only 42% of White and 51% of Black patients >75 years. were prescribed an intensive statin; the OR for intensive statin prescribing was 0.44 for patients >75 years and was similar in a subgroup not on a statin previously. Following stroke or TIA, statin prescribing remains lower in White patients, in those with TIA, and in those in non-urban areas. Intensive statin prescribing remains limited, particularly in patients >75 years. These data may inform efforts to improve guideline concordant prescribing for post-stroke patients.

EVALUATION OF SERUM ANGIOTENSIN CONVERTING ENZYME, OXIDATIVE STRESS, AND ANTIOXIDANT LEVELS IN CEREBROVASCULAR DISORDERS AND HEALTHY CONTROL – A COMPARATIVE STUDY

Objective: Several studies indicate the existence of an abnormal balance between the oxidative and protective mechanisms in patients can be a causative factor for cerebrovascular disease. High plasma levels of angiotensin-converting enzyme (ACE) contribute to the development of vascular diseases. Serum ACE and antioxidant levels were determined in cerebrovascular disorders (CVD) and compared between CVD and healthy person. Methods: A cross-sectional study was conducted on 50 cases of stroke and 10 cases of transient ischemic attack (TIA) with 60 controls matched for age and sex. Fasting blood samples were estimated for serum angiotensin-converting enzyme, serum lipid profile, MDA, SOD, and serum Vitamin E). ACE was estimated by spectrophotometry. The levels of ACE were correlated with the severity and outcome of the stroke. Results: The level of serum ACE was significantly higher in stroke (27.50±1.14U/L) and TIA (31.60±2.02 U/L) as compared to controls (22.61±0.79 U/L). Fasting blood sugar, total cholesterol, triglycerides, LDL cholesterol, and MDA were significantly increased whereas a significant decrease was observed in serum HDL, erythrocyte SOD, and Vitamin E levels in cerebrovascular disease patients as compared to the control group. Statistical p&lt;0.05 was considered significant. Conclusion: Oxidative stress is a potential contributor to acute ischemic stroke and TIA besides deranged lipid profile. The oxidant-antioxidant imbalance may contribute to the severity of stroke. The levels of serum ACE increase significantly in stroke and TIA patients and are associated with increased severity and worse outcome of cerebrovascular diseases.

PREDICT-juvenile-stroke: PRospective evaluation of a prediction score determining individual clinical outcome three months after ischemic stroke in young adults – a study protocol

BackgroundAlthough of high individual and socioeconomic relevance, a reliable prediction model for the prognosis of juvenile stroke (18–55 years) is missing. Therefore, the study presented in this protocol aims to prospectively validate the discriminatory power of a prediction score for the 3 months functional outcome after juvenile stroke or transient ischemic attack (TIA) that has been derived from an independent retrospective study using standard clinical workup data.MethodsPREDICT-Juvenile-Stroke is a multi-centre (n = 4) prospective observational cohort study collecting standard clinical workup data and data on treatment success at 3 months after acute ischemic stroke or TIA that aims to validate a new prediction score for juvenile stroke. The prediction score has been developed upon single center retrospective analysis of 340 juvenile stroke patients. The score determines the patient’s individual probability for treatment success defined by a modified Rankin Scale (mRS) 0–2 or return to pre-stroke baseline mRS 3 months after stroke or TIA. This probability will be compared to the observed clinical outcome at 3 months using the area under the receiver operating characteristic curve. The primary endpoint is to validate the clinical potential of the new prediction score for a favourable outcome 3 months after juvenile stroke or TIA. Secondary outcomes are to determine to what extent predictive factors in juvenile stroke or TIA patients differ from those in older patients and to determine the predictive accuracy of the juvenile stroke prediction score on other clinical and paraclinical endpoints. A minimum of 430 juvenile patients (< 55 years) with acute ischemic stroke or TIA, and the same number of older patients will be enrolled for the prospective validation study.DiscussionThe juvenile stroke prediction score has the potential to enable personalisation of counselling, provision of appropriate information regarding the prognosis and identification of patients who benefit from specific treatments.Trial registrationThe study has been registered at https://drks.de on March 31, 2022 (DRKS00024407).

Prognostic Value of Stress Hyperglycaemia Ratio in Young Patients with Ischaemic Stroke or Transient Ischaemic Attack

Introduction: Stress hyperglycaemia is common in stroke. Recently, the stress hyperglycaemia ratio (SHR) has been proposed as a novel marker for stress hyperglycaemia and found to be associated with adverse outcomes in many diseases. However, data regarding the impact of the SHR on ischaemic stroke, especially in young adults, are limited. Therefore, the aim of this study was to investigate whether the SHR is associated with stroke severity and adverse outcomes in young adults with ischaemic stroke or transient ischaemic attack (TIA). Methods: We retrospectively recruited patients aged 18–45 years with acute ischaemic stroke or TIA. The SHR was calculated as fasting blood glucose (FBG) divided by glycated haemoglobin. The primary and secondary outcomes were 90-day poor functional outcomes and stroke severity on admission, respectively. Multivariable logistic regression, restricted cubic spline models, and subgroup analysis were performed to validate the relationship between the SHR and ischaemic stroke or TIA in young adults. Results: A total of 687 young adults (mean age 36.9 years) were recruited. Among them, 119 (17.3%) patients had prior diabetes, and 568 (82.7%) did not. The SHR was significantly associated with stroke severity and poor functional outcome. Compared with patients with lower SHR values, patients with higher SHR values were more likely to have moderate-to-severe stroke. The multivariable-adjusted OR (95% CI) was 1.70 (1.21–2.39) after adjusting for all potential confounders excluding FBG and 1.50 (1.03–2.17) after FBG adjustment. The restricted cubic spline showed a J-shaped association between the SHR and moderate-to-severe stroke. Compared with patients with lower SHR values, patients with higher SHR values were more likely to have poor functional outcome at 90-day follow-up. The multivariable-adjusted OR (95% CI) was 1.95 (1.12–3.41) after adjusting for all potential confounders excluding FBG and 1.84 (1.01–3.36) after FBG adjustment. A J-shaped association was found between the SHR and poor functional outcomes at the 90-day follow-up. In the subgroup analysis, SHR was independently associated with more severe stroke (OR, 1.79, 95% CI, 1.18–2.72) and poor functional outcomes (OR, 2.11, 95% CI, 1.32–3.35) in nondiabetic patients but not in diabetic patients in multivariate logistic analysis. Despite this, the interaction effects of prior diabetes on the association between the SHR and stroke severity and poor functional outcomes did not reach statistical significance. Conclusion: The SHR is independently related to more severe stroke and an increased risk of poor functional outcomes among young adults with ischaemic stroke or TIA.