Early Recurrent Stroke Research Articles

Rivaroxaban vs Warfarin Sodium in the Ultra-Early Period After Atrial Fibrillation–Related Mild Ischemic Stroke

ImportanceIn atrial fibrillation (AF)–related acute ischemic stroke, the optimal oral anticoagulation strategy remains unclear.ObjectiveTo test whether rivaroxaban or warfarin sodium is safer and more effective for preventing early recurrent stroke in patients with AF-related acute ischemic stroke.Design, Setting, and ParticipantsA randomized, multicenter, open-label, blinded end point evaluation, comparative phase 2 trial was conducted from April 28, 2014, to December 7, 2015, at 14 academic medical centers in South Korea among patients with mild AF-related stroke within the previous 5 days who were deemed suitable for early anticoagulation. Analysis was performed on a modified intent-to-treat basis.InterventionsParticipants were randomized 1:1 to receive rivaroxaban, 10 mg/d for 5 days followed by 15 or 20 mg/d, or warfarin with a target international normalized ratio of 2.0-3.0, for 4 weeks.Main Outcomes and MeasuresThe primary end point was the composite of new ischemic lesion or new intracranial hemorrhage seen on results of magnetic resonance imaging at 4 weeks. Primary analysis was performed in patients who received at least 1 dose of study medications and completed follow-up magnetic resonance imaging. Key secondary end points were individual components of the primary end point and hospitalization length.ResultsOf 195 patients randomized, 183 individuals (76 women and 107 men; mean [SD] age, 70.4 [10.4] years) completed magnetic resonance imaging follow-up and were included in the primary end point analysis. The rivaroxaban group (n = 95) and warfarin group (n = 88) showed no differences in the primary end point (47 [49.5%] vs 48 [54.5%]; relative risk, 0.91; 95% CI, 0.69-1.20; P = .49) or its individual components (new ischemic lesion: 28 [29.5%] vs 31 of 87 [35.6%]; relative risk, 0.83; 95% CI, 0.54-1.26; P = .38; new intracranial hemorrhage: 30 [31.6%] vs 25 of 87 [28.7%]; relative risk, 1.10; 95% CI, 0.70-1.71; P = .68). Each group had 1 clinical ischemic stroke, and all new intracranial hemorrhages were asymptomatic hemorrhagic transformations. Hospitalization length was reduced with rivaroxaban compared with warfarin (median, 4.0 days [interquartile range, 2.0-6.0 days] vs 6.0 days [interquartile range, 4.0-8.0]; P < .001).Conclusions and RelevanceIn mild AF-related acute ischemic stroke, rivaroxaban and warfarin had comparable safety and efficacy.Trial Registrationclinicaltrials.gov Identifier: NCT02042534

Early risk of recurrent stroke in patients with symptomatic carotid near-occlusion: Results from CAOS, a multicenter registry study.

Background The risk of recurrent stroke among patients with symptomatic carotid near-occlusion is not well established, and management of the condition remains controversial. Symptomatic carotid near-occlusion with full collapse has been identified as a strong predictor of early recurrence. We aimed to analyze the 90-day risk of recurrent ipsilateral ischemic stroke in medically treated patients with symptomatic carotid near-occlusion. Methods We performed a multicenter, nationwide, prospective study from January 2010 to May 2016. Patients with angiography-confirmed symptomatic carotid near-occlusion were included. The primary endpoint was ipsilateral ischemic stroke or transient ischemic attack (TIA) within 90 days after the presenting event. For this analysis, patients who underwent revascularization within 90 days after stroke were excluded. Results The study population comprised 141 patients from 17 Spanish centers; 83 patients were treated medically. Primary endpoint occurred in eight patients, resulting in a cumulative rate of 10.6% (95% CI, 3.7-17.5). Previous history of stroke or transient ischemic attack was identified as an independent predictor for recurrence in the multivariate Cox regression analysis (HR, 4.37 [95% CI, 1.05-18.18]; p = 0.043), while the presence of full collapse was not associated with an increased risk (HR, 0.81 [95% CI, 0.17-3.92]; p = 0.793). The risk of recurrence was also not affected by the presence of significant stenosis or occlusion of the contralateral carotid artery, or by the collateral circulation. Conclusions Patients with symptomatic carotid near-occlusion seem to have an increased risk of early ipsilateral recurrent stroke. Our results contrast with the low risk of symptomatic carotid near-occlusion reported to date. Full collapse did not increase the risk of recurrent stroke in our study.

Duration of paroxysmal atrial fibrillation in cryptogenic stroke is not associated with stroke severity and early outcomes

The current definition of paroxysmal atrial fibrillation (PAF) requires an arbitrary cut-off of >30s, but in clinical practice cryptogenic stroke (CS) patients with PAF duration of ≤30s are not usually excluded from anticoagulation therapy. We sought to evaluate the clinical relevance of short-duration (≤30s) PAF in CS. Consecutive CS patients with no prior AF history and sinus-rhythm on baseline electrocardiography (ECG) were prospectively evaluated over a three-year period. Baseline stroke severity was assessed by NIHSS-scores. All patients underwent 24-hour Holter-ECG during hospitalization. ECG recordings were analyzed by two blinded investigators using dedicated analysis software. Total time in AF was calculated as the sum of each individual AF episode for patients with multiple episodes during monitoring. Patients were dichotomized in two groups using PAF total duration (≤30s & >30s). Early recurrent stroke and favorable functional outcome (FFO, defined as mRS-grades of 0–1) were evaluated during a three-month follow-up period. A total of 184 patients (66% men, mean age 57±11years) with CS (median NIHSS-score 4, IQR: 2–7) were evaluated. PAF of any duration was detected in 23 individuals (13%; 95%CI: 8%–18%). Among these patients the prevalence of brief PAF was 57% (n=13). The two groups did not differ (p>0.2) in terms of demographics, vascular risk factors and NIHSS-scores. Early recurrent stroke and FFO rates were similar (p>0.4) in the two groups. Duration of PAF is not associated with baseline stroke severity and early outcomes in patients with CS and should not influence anticoagulation decision in these patients.

Abstract WP124: Signal Intensity Ratio Does Not Predict Recurrent Stroke in Patients with Symptomatic Intracranial Atherosclerotic Disease

Background: Symptomatic intracranial atherosclerotic disease (ICAD) is associated with high risk for recurrent stroke. Identification of patients remains a challenge using clinical and radiographic markers. Recent research has identified signal intensity ratio (SIR) across stenotic lesions on time-of-flight magnetic resonance angiography (TOF-MRA) as a novel noninvasive marker of recurrent stroke risk. We sought to externally validate this approach in a single center analysis. Methods: From a prospective observational stroke registry since August 2012, we identified patients with ischemic stroke due to ICAD causing moderate-severe stenosis of the basilar, intracranial vertebral, intracranial internal carotid, or middle cerebral arteries. Using the method described previously, we calculated SIR values across the stenotic lesions corrected for background signal intensity from TOF-MRA performed within 7 days of index stroke admission. Outcomes were prospectively captured by phone interview at 1 and 3 months after stroke. Recurrent stroke was defined by new infarct in the territory of the stenotic artery or absent imaging confirmation, territory-specific clinical symptoms lasting &gt; 24 hours. We evaluated whether baseline SIR values were different between patients with and without recurrent stroke overall and in subgroups by ICAD location. P-value &lt; 0.05 was considered significant. Results: Among 99 consecutive patients with ICAD, 79 (80%) had interpretable MRAs at baseline (mean age 68.4 +11.2 years, 53.2% male, 53.2% black, median NIHSS score 3; 27.7% posterior circulation stenosis). Recurrent stroke occurred in 21.5% and 25.3% of patients at 1 and 3 months, respectively. Median SIR at baseline was 0.86 (interquartile range 0.56-1.04) and was not different those with vs. without recurrent stroke (1-month: 0.79 vs. 0.86, p=0.93; 3-month: 0.79 vs. 0.86, p=0.68). Results were not different by ICAD location. Discussion: In this single center prospective registry, we were unable to validate SIR on time-of-flight MRA as a marker of early recurrent stroke risk in patients with symptomatic ICAD. Further research is needed to identify novel predictors of recurrence in this high-risk cohort.

Abstract TP443: Early Cognitive Decline in Patients with Symptomatic Carotid Stenosis is Related to Plaque Inflammation and Concomitant Intracranial Stenosis

Background and aims: Symptomatic carotid stenosis is associated with an increased risk of early stroke recurrence. Post-stroke vascular cognitive impairment is highly prevalent with significant functional consequences. However, reliable biomarkers for early prediction of cognitive decline are not well established. We postulated that regional hypoperfusion due to carotid stenosis would impair cognitive performance. Hence, we evaluated the cognitive parameters at baseline and their natural course during 90-days of follow up. Methods: This ongoing prospective study included consecutive patients within 30-days of recent stroke and ipsilateral carotid stenosis (≥50%). Data regarding demographics and vascular risk factors were recorded. Cognitive parameters were assessed with the 30-point mini-mental scale (MMSE) and Montreal Cognitive Assessment (MoCA). All patients underwent carotid duplex sonography and 18-fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) of carotid arteries. Embolic potential of the carotid plaque is estimated by presence of spontaneous microembolic signals (MES) on extended transcranial Doppler monitoring of the middle cerebral arteries. Patients are followed prospectively for change in cognitive parameters. Results: Of the 33 patients included in this study, 7 (21%) demonstrated deterioration of their cognitive parameters (MMSE in 4, MOCA in 5 and both in 6) during 90-day follow up. Only high Standard Uptake Value (SUV) on PET (3.62g/ml in cognitive-deterioration group versus 1.72g/ml in the unaffected group; p=0.01) and presence of concomitant intracranial stenosis (p=0.01) were associated with cognitive deterioration. Of the 7 cases who underwent carotid revascularization, 5 (71%) demonstrated improved cognitive performance at day-90. Conclusions: Early cognitive decline is common among patients with symptomatic stenosis of the extracranial carotid artery, especially when associated with concomitant intracranial stenosis and plaque inflammation.

Abstract WMP19: Identifying in vivo Luminal Thrombus Within 72 Hours After Stroke Onset: Interim Results of the Stroke Imaging Package Study

Background: The presence of luminal thrombus is associated with a high risk of stroke recurrence. Using high-resolution magnetic resonance imaging(HRMRI) and susceptibility-weighted imaging(SWI), luminal thrombus can be identified in vivo. We aimed to investigate the occurrence of luminal thrombus in patients with acute ischemic stroke. Methods: Patients with first ever stroke within 72 hours from onset, confirmed by diffusion weighted imaging, were recruited from 16 medical centers. Conventional MRI, magnetic resonance angiography, HRMRI (including 3-dimentional T1 images and 2-dimentional T2 images), and SWI were performed. Luminal thrombus was identified if isointense/hyperintense signals on 3-dimentional T1 images of HRMRI or susceptibility vessel sign on SWI were observed within the course of intracranial arteries. Results: Six hundred and one patients (70% male, mean age 61±16 years old, mean NIHSS 6± 5) were enrolled. Among them, 112 patients underwent recanalization therapies. Median time from symptom onset to MRI was 44 ± 20 hours. Luminal thrombus was identified in 138 (23%)patients. The occurrence rate of luminal thrombus was non-significantly different between the patients treated with and without recanalization therapies(16% vs.25%, p=0.054). Symptomatic luminal thrombus was more likely observed in large artery atherosclerosis stroke(121/240,50%) and cardicac stroke(11/36,31%) than other stroke subtypes (0/288 in lacunar stroke, 0/6 in stroke of undetermined etiology and 1/31 in cryptogenic stroke, P&lt;0.001). There were five patients with asymptomatic luminal thrombus irrelevant to ischemic lesions. Conclusions: Luminal thrombus is common in patients with acute ischemic stroke within 72 hours from onset. Further studies are required to clarify whether in vivo thrombus imaging can predict early stroke recurrence.

Abstract TMP119: Early Cerebral Ischemic Events in Symptomatic Carotid Stenosis are Related to Plaque Inflammation

Background and aims: Symptomatic carotid stenosis is associated with an increased risk of early stroke recurrence. Severity of the stenosis, current basis of revascularization, explains only the cerebral ischemic mechanism of regional hypoperfusion. Plaque inflammation, the initiating event for plaque rupture and thromboembolism (artery-to-artery embolism), is not evaluated routinely. Using 18F-fluorodeoxyglucose positron-emission tomography (FDG-PET)/computed tomography (CT) and high resolution magnetic resonance imaging (HR-MRI), we investigated the role of plaque imaging and stroke recurrence in our cohort of stroke patients with recently symptomatic carotid stenosis. Methods: This ongoing prospective study included consecutive patients within 30-days of recent stroke and ipsilateral carotid stenosis (≥50%). FDG uptake was quantified as mean standardized uptake values (SUV, g/ml). The ratio of T1 hyperintensity of carotid plaque to the ipsilateral sternocleidomastoid muscle (SCM) was recorded on T1-weighted fat suppressed images. Patients were followed prospectively for stroke recurrence within 90-days. Embolic potential of carotid plaque is estimated by presence of spontaneous microembolic signals (MES) on extended transcranial Doppler monitoring of ipsilateral middle cerebral artery. Results: Of the 33 patients included in the study, 6 (18%) suffered from recurrent cerebral ischemic event in the same vascular territory within 90-days. Compared to patients without subsequent cerebral ischemic events, patients with recurrent cerebral ischemia showed higher mean T1 carotid-SCM ratio (2.49 versus 1.53; p&lt;0.0001) and higher mean SUV value in the carotid plaque (3.52g/ml versus 1.51g/ml; p&lt;0.0001). Higher T1 carotid-SCM ratio on HR-MRI (OR 4.249, 95%CI 1.818-5.18; p&lt;0.0001), higher mean SUV on FDG-PET (OR 3.050, 95%CI 5.586-28.571; p=0.005) and MES on TCD (OR 2.186, 95%CI 1.652-47.619;p=0.037) were independent predictors of recurrent cerebral ischemia. Conclusions: FDG-PET/CT and HR-MRI imaging of carotid stenosis helps in identification of patients at higher risk of subsequent cerebral ischemic events and may aid in better therapeutic decision-making.

Interaction among COX-2, P2Y1 and GPIIIa gene variants is associated with aspirin resistance and early neurological deterioration in Chinese stroke patients

BackgroundThe effect of genetic variants on aspirin resistance (AR) remains controversial. We sought to assess the association of genetic variants with AR and early clinical outcomes in patients with acute ischemic stroke (IS).MethodsA total of 850 acute IS patients were consecutively enrolled. Platelet aggregation was measured before and after a 7–10 day aspirin treatment. The sequences of 14 variants of COX-1, COX-2, GPIb, GPIIIa, P2Y1 and P2Y12 were determined using matrix-assisted laser desorption/ionization time of flight mass spectrometry. Gene-gene interactions were analyzed using generalized multifactor dimensionality reduction (GMDR). The primary outcome was early neurological deterioration (END) within 10 days of admission. The secondary outcome was a composite of early recurrent ischemic stroke (ERIS), myocardial infarction (MI) and death within 10 days of admission.Results175 (20.6%) patients were AR, 45 (5.3%) were aspirin semi-resistant, 121 (14.2%) developed END, 17 (0.2%) had ERIS, 2 (0.2%) died, and 6 (0.7%) had MI. Single locus analysis indicated that only rs1371097 was associated with AR. However, GMDR analysis indicated that the following three sets of gene-gene interactions were significantly associated with AR: rs20417CC/rs1371097TT/rs2317676GG; rs20417CC/rs1371097TT/rs2317676GG; rs20417CC/rs1371097CT/rs2317676AG. END occurred significantly more frequently in patients with AR or high-risk interactive genotypes. Moreover, AR and high-risk interactive genotypes were independently associated with END.ConclusionSensitivity of IS patients to aspirin and END may be multifactorial and is not significantly associated with a single gene polymorphism. Combinational analysis may useful for further insight into the genetic risks for AR.

Lipoprotein (a) as a Predictor of Early Stroke Recurrence in Acute Ischemic Stroke.

Inflammation plays a crucial role in the pathogenesis of stroke. This study aims to determine lipoprotein (a) [Lp(a)] levels in serum and to investigate their associations with stroke recurrence events in a 3-month follow-up study in patients with acute ischemic stroke (AIS). Serum Lp(a) levels were determined in 203 ischemic stroke patients and 120 normal controls at admission. The severity and clinical outcome of ischemic stroke patients were evaluated by the National Institutes of Health Stroke Scale (NIHSS). We followed the participants for a median of 3months using a standard questionnaire to determine the stroke recurrence events. The correlation analysis and multiple linear regression analysis were performed. Compared with controls, serum Lp(a) levels were significantly increased in ischemic stroke patients than in controls. NIHSS scores and infarct volume were positively correlated with Lp(a) (P<0.001). Finally, 34 patients (16.7%; 95% CI, 11.6-21.9%) had a stroke recurrence. Serum Lp(a) levels in patients with recurrent stroke were significantly higher as compared with those in patients without recurrent stroke (P<0.001). In multivariate analysis, there was an increased risk of stroke recurrence associated with Lp(a) levels ≥300mg/l (OR, 2.87; 95% CI, 1.98-4.32; P=0.009) after adjusting for possible confounders. With an AUC of 0.872 (95% CI, 0.816-0.927), Lp(a) showed a significantly greater discriminatory ability to predict stroke recurrence as compared with NIHSS score (AUC, 0.782; 95% CI, 0.704-0.859; P<0.01). Our findings suggest that elevated serum Lp(a) levels can predict the risk of early stroke recurrence in patients with first-ever ischemic stroke. Further research is needed to replicate these findings.

A Current Estimation of the Early Risk of Stroke after Transient Ischemic Attack: A Systematic Review and Meta-Analysis of Recent Intervention Studies

Objective: Recent studies have demonstrated that there is a decrease in the risk of subsequent stroke after transient ischemic attack (TIA) when urgent care (UC) is administered. However, no meta-analysis has been developed with contemporaneous TIA studies. We perform a systematic review and a meta-analysis to establish the risk of early stroke recurrence (SR) considering data from studies that offered UC to TIA patients. Methods: We searched for studies, without language restriction, from January 2007 to January 2015 according to PRISMA guidelines. We included studies with TIA patients who underwent UC and reported the proportion of SR at 90 days. We excluded studies that were centered on less than 100 patients and cohorts including both stroke and TIA, if stroke risk after TIA was not described. For its relevance, we included the TIAregistry.org study published in 2016. We performed both fixed and random effects meta-analyses to determine SR and assess sources of heterogeneity. Results: From 4,103 identified citations, we selected 15 papers that included 14,889 patients. There was great variation in terms of the number of patients included in each study, ranging from 115 to 4,160. Seven studies were TIA clinic based. The mean age and the percentage of men were similar among studies, ranging from 62.4 to 73.1 years and 45.1-62%, respectively. The reported risk of stroke ranged from 0 to 1.46% 2 days after TIA (9 studies included), 0-2.55% 7 days after TIA (11 studies included), 1.91-2.85% 30 days after TIA (4 studies included), and 0.62-4.76% 90 days after TIA (all studies included). The pooled stroke risk was 3.42% (95% CI 3.14-3.74) at 90 days, 2.78% (95% CI 2.47-3.12) at 30 days, 2.06% (95% CI 1.83-2.33) at 7 days and 1.36% (95% CI 1.15-1.59) at 2 days. Although we did not find statistically significant heterogeneity in SR among studies, those with a higher proportion of patients with motor weakness had a significantly higher risk of SR. No statistically significant association was observed between TIA clinic management and SR. Conclusion: The pooled early SR is lower than in previous meta-analyses and homogeneous for all studies with an urgent assessment and management strategy regardless of vascular risk factors and clinical characteristics. Therefore, the best setting for TIA management can be individualized for each center.

Effects of Aspirin on Risk and Severity of Early Recurrent Stroke After Transient Ischemic Attack and Ischemic Stroke: Time-Course Analysis of Randomized Trials

Effects of Aspirin on Risk and Severity of Early Recurrent Stroke After Transient Ischemic Attack and Ischemic Stroke: Time-Course Analysis of Randomized Trials

Antiplatelet therapy following ischaemic stroke - Continue or change pre-existing therapy?

Antiplatelet therapy is routinely prescribed early after ischaemic stroke. Many patients will already be taking antiplatelet therapy and it is unknown whether these patients should continue the same antiplatelet treatment or switch to a different regimen. We selected patients with ischaemic stroke from the Virtual International Stroke Trials Archive database who were prescribed antiplatelets both before and after their stroke and who had detailed records of adverse events after stroke. We compared patients who changed to a new antiplatelet regimen after their stroke to those who continued the same regimen. The primary outcome was recurrent ischaemic stroke within 90 days after their index stroke and the secondary outcome was intracranial haemorrhage (ICH) or extracranial haemorrhage (ECH). We used logistic regression analysis and adjusted for age and baseline NIHSS. A total of 1129 participants were included. Of these, 538 subjects changed antiplatelet regimen post stroke and 591 continued the same regimen. A recurrent ischaemic event occurred in 4.1% of subjects who changed regimen and 4.3% who continued unchanged (adjusted OR = 0.93; 95% CI 0.54-1.75, p = 0.929). The incidence of ICH and ECH within the first 90 days was similar in both groups (2.4% vs. 2.6% (adjusted OR = 1.02; 95% CI 0.48-2.18, p = 0.955) and 4.7% vs. 2.9% (adjusted OR = 1.82; 95% CI 0.96-3.43, p = 0.065), respectively). The analysis was performed using a non-randomised registry data. In patients who suffer ischaemic stroke whilst taking antiplatelets, a change in antiplatelet regimen was not associated with an altered risk of early recurrent ischaemic stroke rate or bleeding. However, the results must be interpreted in view of the low event rates.

Aspirin is Key to Reducing Risk of Early Stroke Recurrence.

Aspirin is Key to Reducing Risk of Early Stroke Recurrence.

Pooled RCTs: After ischemic stroke or TIA, aspirin for secondary prevention reduced early recurrence and severity.

Source Citation Rothwell PM, Algra A, Chen Z, et al. Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of...

Instrument for Predicting Early Stroke Recurrence: Ambiguity and Biases

Instrument for Predicting Early Stroke Recurrence: Ambiguity and Biases

Predictive value of ABCD2 and ABCD3-I scores in TIA and minor stroke in the stroke unit setting.

It is not clear whether risk scores for early stroke recurrence after TIA that have been mainly established in outpatient and emergency department settings are valid on the background of highly specialized stroke unit care. ABCD2 and ABCD3-I scores have been prospectively documented in a cohort of patients admitted to Austrian stroke units within 24 hours of symptom onset with TIA or minor stroke (NIH Stroke Scale score <4). A total of 5,237 TIA and minor stroke patients met inclusion criteria, with 3-month follow-up data available on 2,457. Early and 3-month stroke were observed in 2.4% and 4.2% of the study population. The probability of early stroke during the stroke unit stay (median 2 [interquartile range 1-3] days) steadily increased from 0% to 4.8% and 0% to 16.7% with increasing ABCD2 and ABCD3-I score points, respectively. On 3-month follow-up, stroke risk increased from 0% to 8.0% and 0% to 23.8% with increasing ABCD2 and ABCD3-I score points, respectively. Of the individual score components, age, blood pressure, and diabetes were not related to early or 3-month stroke, whereas clinical presentation (C), symptom duration (D), and cerebral as well as carotid imaging (I) were and accounted for the information provided by the full scores. Standard ABCD2 and ABCD3-I scores are useful instruments to estimate the probability of early and 3-month stroke in TIA and minor stroke patients treated at specialized stroke units, with C, D, and I being the most important score components in this setting.

Stroke: How good is aspirin for patients with acute brain ischaemia?

A new meta-analysis, which evaluated individual patient data from randomized trials of aspirin in patients with non-disabling acute brain ischaemia, found this drug to be much more efficacious at reducing early stroke recurrence than was previously estimated.

Repeated Intravenous Thrombolysis for Early Recurrent Stroke

Intravenous thrombolysis (IVT) within 4.5 hours from symptom onset improves functional outcome in patients with acute ischemic stroke. Its use in patients with previous stroke within the preceding 3 months is contraindicated because of the assumed higher risk of intracranial hemorrhage. In addition, tissue-type plasminogen activator may itself promote neurotoxicity and blood-brain barrier disruption. However, safety and effectiveness of repeated IVT is essentially unknown in patients with early (<3 months) recurrent stroke (ERS), because they were excluded from thrombolysis trials. This article reports the largest case series of repeated IVT in ERS. We reviewed databases of prospectively collected patient data of 8 European stroke centers for the presence of patients with ERS, who received IVT for both the index stroke and ERS. Demographics, clinical and radiological data, bleeding complications, and functional outcome were analyzed. We identified 19 subjects with repeated IVT in ERS. Mean age was 68±12 years, and 37% of them were female. Median interthrombolysis interval was 30 days (interquartile range, 13-50). Functional independence (modified Rankin scale score ≤2) was achieved in 79% of patients after the first and in 47.4% after repeated IV tissue-type plasminogen activator, respectively. There was no symptomatic intracranial hemorrhage. Median final infarct volume after the first IVT was 1.5 cm(3) (interquartile range, 0.5-3.1). Patients with small infarct volumes and robust clinical improvement might be considered for repeated IVT within 3 months. Studies following strict protocols and larger registries incorporating these patients might serve to identify selection criteria for the safe use of repeated IVT in ERS.

Serum 25-hydroxyvitamin D predicts early recurrent stroke in ischemic stroke patients

Background and aimThis study was conducted to determine 25-hydroxyvitamin D [25(OH) D] levels in serum, and to investigate their associations with stroke recurrence events in a 3-month follow-up study in Chinese patients with first-ever ischemic stroke. Methods and resultsFrom February 2014 to September 2015, consecutive first-ever ischemic stroke patients admitted to the Department of Emergency of our hospital were identified. Serum 25(OH) D levels were measured at admission. We followed the participants for a median of 3 months (range, 2.5–3.5 months) using a standard questionnaire. We used logistic regression models to assess the relationship between 25(OH) levels and risk of recurrent stroke. In this study, 349 ischemic stroke patients were included and completed follow-up. Thirty-seven patients (10.6%) had a stroke recurrence. Serum 25(OH) D levels in patients with recurrent stroke were significantly lower as compared with those in patients without recurrent stroke [9.9 (IQR, 7.9–14.8) ng/mL vs. 17.9 (IQR, 13.4–23.4) ng/mL; P < 0.001). After adjusting for traditional risk factors, serum 25(OH) D levels were negatively associated with the stroke recurrence (OR, 0.897; 95% CI, 0.848–0.950; P < 0.001). Compared with the first quartile of serum 25(OH) D levels, the second quartile OR for recurrent stroke was 0.466 (95% CI, 0.308–707; P = 0.006). For the third and fourth quartiles, it was 0.248 (95% CI, 0.100–0.618; P = 0.001) and 0.173 (95% CI, 0.062–0.482; P < 0.001), respectively. ConclusionsOur findings suggest that reduced serum levels of 25(OH) D can predict the risk of early stroke recurrence in patients with first-ever ischemic stroke.

Antiplatelet drug resistance is associated with early neurological deterioration in acute minor ischemic stroke in the Chinese population.

To evaluate the prevalence and risk factors of antiplatelet drug resistance and its association with early neurological deterioration (END) and recurrent ischemic stroke (RIS) in patients with acute minor stroke. Antiplatelet drug resistance was assessed by platelet aggregation assay in 426 patients with minor stroke who were receiving combined treatment of aspirin and clopidogrel. All patients were followed up for 90days. The primary endpoint of the study was END within 10days after admission. The secondary endpoints included RIS, myocardial infarction and death during 90days of treatment. The safety endpoints were intracerebral or extracranial hemorrhagic events. Cox proportional hazard regression analysis was performed to determine the risk factors for the primary endpoint and secondary endpoints. Among the 426 patients, 24.4% exhibited aspirin resistance, 35.9% exhibited clopidogrel resistance, and 19.2% displayed concomitant aspirin and clopidogrel resistance. In multivariate analysis, diabetes mellitus and high level of low density lipoprotein-cholesterol were independent risk factors for aspirin resistance, while diabetes mellitus was the only independent risk factor for clopidogrel resistance. END was observed in 93 (21.8%) patients. Diabetes mellitus, high fasting blood glucose level, and concomitant aspirin and clopidogrel resistance were independent risk factors for END. RIS was observed in 40 (9.4%) patients. Diabetes mellitus, hypertension, and concomitant aspirin and clopidogrel resistance were independent risk factors for RIS. Antiplatelet drug resistance is common in acute minor ischemic stroke patients and is associated with END and RIS after acute minor ischemic stroke in the Chinese population. http://www.chictr.org/ . Unique Identifier: ChiCTR-OCH-14004724.