Risk Of Early Stroke Research Articles

Commonly asked questions in transient ischemic attack

With the advent of modern neuroimaging techniques, transient ischemic attack (TIA) has been redefined as, “a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia, without acute infarction.” If infarct is evident on neuroimaging, the event is a stroke. It is important to recognize and correctly diagnose TIA and minor stroke because of the substantial early risk of stroke. Much of the early stroke risk is attributable to large artery atherosclerosis. Stroke-risk stratification in TIA patients can be done based on clinical grounds using an ABCD2 score. There is, however, abundant data to support inclusion of neuroimaging in stroke-risk determination, which can also be combined with a clinical risk assessment. The hybrid ABCDE⊕ score further refines early stroke risk. Rapid assessment and treatment in the emergency department or in specially designed ‘TIA clinics’ appear to reduce stroke rate.

Abstract TMP51: A Validation Study of Recurrence Risk Estimator Score in Acute Ischemic Stroke

Background and Objectives: The Recurrence Risk Estimator (RRE) is a web-based prognostic score that integrates clinical and imaging information available in the acute setting to quantify early risk of recurrent stroke. The score has been reported to have adequate calibration and good discrimination in the original derivation cohort (AUC=0.81, 95% confidence interval [CI] 0.76-0.87). In the present study, we sought to investigate the validity of RRE score in internal and external datasets. Methods: Internal validation was performed in a prospectively collected dataset from 899 consecutive patients admitted to the Massachusetts General Hospital. External validation was performed in a retrospective stroke cohort of 711 patients from 2 teaching hospitals in Brazil and South Korea. The RRE-90 score was calculated by summing up the number of independent predictors weighted by their corresponding beta-coefficients. (Available at: http://www.nmr.mgh.harvard.edu/RRE-90). We assessed the score’s predictive performance by computing the area under the receiver operating characteristic curve (AUC). Results: Internal and external validation cohorts differed from each other as well as from the original derivation cohort in age, gender, admission NIH stroke scale score, stroke risk factors, and etiologic stroke subtypes. Stroke recurrence rate during the 90-day follow-up period was 6.5% and 2.7% in the internal and external cohorts respectively. The AUC was 0.76 (95% CI 0.68-0.83) in the internal and 0.75 (95% CI 0.66-0.85) in the external validation cohort. Conclusions: RRE score performs well in independent cohorts with different baseline patient characteristics and stroke features. As a reliable, valid, and easy-to-use web-based tool, RRE may find widespread utility in identifying high- and low-risk patients for targeted stroke prevention.

Abstract WP252: Reduction in Stroke Readmission Rates After Implementing an Emergency Department-based Transient Ischemic Attack Observation Unit

Background and Purpose —Diagnosis and treatment of transient ischemic attacks (TIAs) is often delayed by lack of access to immediate comprehensive evaluation of the underlying etiology. Early initiation of treatment can reduce the risk of early recurrent stroke by up to 80%. Up to 40% of people who have experienced a TIA will go on to have a stroke. The purpose of this review was to determine the efficacy of an Emergency Department (ED)-based TIA observation unit using a standardized TIA protocol designed to provide rapid evaluation and treatment of patients presenting with TIA in reducing the rates of readmission with stroke to a community-based hospital. Methods —We did a retrospective chart review of all patients discharged from Bellin Hospital with a diagnosis of stroke before implementing a standardized TIA protocol in our ED-based TIA observation unit (July to December 2010) and after implementation of the TIA observation unit (November 2011 to April 2012). We identified the patients in these cohorts who had previously been evaluated in the ED with signs or symptoms of stroke in the 6 months prior to admission and compared their stroke readmission rates. Patients who received evaluation through the TIA observation unit from November 2011 to April 2012 were monitored for readmission for stroke in the 6 months after evaluation. Results —Prior to use of the TIA observation unit, 7 of 51 (13.7%) patients discharged with a diagnosis of stroke had been seen in the ED in the previous 6 months with stroke-like symptoms. After implementation of the TIA observation unit, 7 of 119 (5.9%) patients discharged with a diagnosis of stroke had been seen in the ED, a 57.1% reduction in stroke readmission at 6 months. Of these, 4 (57.1%) had not completed the work-up during their previous ED visit. 122 patients underwent evaluation using the TIA observation unit. Of these, only 3 (2.5%) patients were readmitted for stroke in the next 6 months. 16 of these 122 (13.1%) patients were diagnosed with stroke during their TIA work-up. Conclusions —Rapid evaluation and treatment of TIA through an ED-based TIA observation unit substantially reduces the risk of readmission for stroke.

Abstract TP387: Abcd 2 Score Predicts The Long-term Risk Of Stroke After Transient Ischemic Attack: Fukuoka Stroke Registry

Background and Purpose— ABCD 2 score has been developed to predict the early risk of stroke after transient ischemic attack (TIA). The aim of this study was to clarify whether ABCD 2 score predicts the occurrence of stroke in the long term after TIA. Methods— Fukuoka Stroke Registry (FSR) is a multicenter epidemiological study database on acute stoke. From June 2007 to June 2011, 496 (305 males, 70 ± 13 years of age) patients who had suffered from TIA and were hospitalized in the 7 stroke centers within 7 days after the onset of TIA were enrolled in this study. The patients were divided into three groups according to the risk: low-risk (ABCD 2 score 0-3; n=72), moderate-risk (4-5; n=229) and high-risk group (6-7; n=195). They were followed up prospectively for up to 3 years. Cox proportional hazard regression model was used to elucidate whether ABCD 2 score was a predictor for stroke after TIA after adjusting for confounding factors. Results— Among three groups, there were significant differences in age, hypertension, diabetes mellitus and the decrease in estimated glomerular filtration rate (P<0.01, significantly). During a mean follow-up of 1.3 years, Kaplan-Meier analysis demonstrated that the stroke rate in TIA patients was significantly lower in low-risk group than in moderate-risk or high-risk group (log rank test, p<0.001). The adjusted hazard ratios for stroke in patients with TIA increased with moderate-risk group (Hazard ratio [HR]: 3.47, 95% CI: 1.03-21.66, P<0.05) and high-risk group (HR: 4.46, 95% CI: 1.31-27.85, P<0.05), compared to low-risk group. Conclusions— The ABCD 2 score is able to predict the long-term risk of stroke after TIA.

Abstract WP164: Role of Risk Factors in the Paradoxical Effect of Smoking on Peri-procedural Stroke in SAMMPRIS

Background: A previous SAMMPRIS analysis of patients randomized to stenting showed that peri-procedural ischemic infarcts were significantly associated with diabetes, basilar stenosis, age, and smoking status with never smokers having a higher risk (odds ratio = 8.8, p< 0.001). We sought to determine if this finding could be due to a higher burden of other risk factors in never smokers. Method: Baseline features in 213 patients undergoing stenting in SAMMPRIS were compared between never smokers vs. former and current smokers in univariate and multivariate analyses. Logistic regression was used to determine the effect of smoking on peri-procedural ischemic infarcts after adjusting for factors related to smoking. Data: Univariate results are shown in Table 1. Never smokers were significantly (P<0.05) more likely to be female, diabetic, hypertensive, and have another intracranial stenosis, but in multivariate analyses only hypertension and another intracranial stenosis remained significantly (P<0.05) associated with smoking status. In a multivariate model that incorporated hypertension and another intracranial stenosis along with smoking status, diabetes, basilar stenosis, and age, smoking status remained significant with an increased risk among patients who never smoked (odds ratio = 5.3, p = 0.005). Conclusion: While never smokers had significantly higher rates of some risk factors compared to active or previous smokers, these risk factors do not explain all the increased risk of early stroke in never smokers after stenting in SAMMPRIS. Another contributory factor may be that smoking accelerates the conversion of clopidogrel to its active form.

Abstract TP231: Clinical Characteristics of TIA with Atrial Fibrillation

Objectives: Patients with transient ischemic attack (TIA) are at high risk of early stroke, indicating a need for urgent diagnostic workup and treatment. Atrial fibrillation (AF) is one of important causes for TIA. The purpose of this study was to investigate characteristics of TIA patients with AF, using data of a multicenter retrospective study. Methods: The subjects of this study were TIA patients admitted to 13 stroke centers within 7 days after onset between 2008 and 2009. The definition of TIA used in this study was that of clinical symptoms lasting less than 24 hours, regardless of imaging findings. We compared baseline characteristics and diffusion weighted-MRI (DWI) findings between patients with AF and those without AF. Results: A total of 464 patients (69 ± 13 years in age, 172 women) were enrolled. We diagnosed 79 patients (17%) as having AF. TIA patients with AF were older (74 ± 9 vs. 67 ± 14 years old, P = 0.0001) and more likely to have a longer length of hospital stay (15 ± 9 vs. 14 ± 20 days, P = 0.046) than those without AF. Of 464 TIA patients, 458 patients (99%) underwent head MRI. DWI lesion was detected in 96 (21%) patients. There was no difference of DWI positivity rate between patients with or without AF (28% vs. 20%, P = 0.10). Compared to patients without AF, patients with AF were more likely to have a single lesion on DWI (86% vs. 51%, P = 0.005). DWI lesion of ≥15 mm was found more frequently in TIA patients with AF than in those without AF (45% vs. 22%, P = 0.04). Conclusions: This study demonstrated that TIA patients with AF were older and had a longer length of hospital stay than those without AF. In addition, characteristics of DWI findings differed between TIA patient with AF and those without AF; TIA patients with AF were more likely to have a single lesion with a size of ≥15 mm.

Recurrent transient ischaemic attack and early risk of stroke: data from the PROMAPA study

BackgroundMany guidelines recommend urgent intervention for patients with two or more transient ischaemic attacks (TIAs) within 7 days (multiple TIAs) to reduce the early risk of stroke.ObjectiveTo determine whether all...

Population-Based Study of Capsular Warning Syndrome and Prognosis After Early Recurrent TIA

Conclusions: Capsular warning syndrome comprises 1.5% of transient ischemic attack (TIA) presentations but has a poor prognosis, with a 7-day stroke risk of 60%. With the exception of capsular warning syndrome, recurrent TIAs ≤7 days are not associated with a greater stroke risk than a single TIA. Summary: Stroke risk after TIA is highest within the first 7 days (Hill MD et al, Neurology 2004;62:2015-20). In addition, many guidelines recommend urgent evaluation for carotid stenosis for patients with more than two TIAs ≤7 days (Johnston SC et al, Ann Neurology 2006;60:301-13). Capsular warning syndrome, manifested by multiple stereotype motor TIAs, is thought to place patients at particular risk and precedes capsular infarction (Donnan GA et al, Neurology 1993;43:957-62). However, it is unclear whether patients with multiple TIAs have relatively untreatable or treatable underlying pathologic conditions such as carotid stenosis or atrial fibrillation. The authors used data from the Oxford Vascular Study (OXVASC) to delineate whether patients with multiple TIAs are at high early stroke risk and whether a treatable underlying condition is more common in patients with multiple TIAs. They studied clinical characteristics, acute STROKE treatment (TOAST) classification, and risk of stroke in 1000 consecutive patients with incident and recurrent TIAs as part of the prospective, population-based Oxford Vascular Study. Of the 1000 patients with TIAs, 170 had a further TIA ≤7 days (105 ≤24 hours). Multiple TIAs were not associated with carotid stenosis or atrial fibrillation. Much of the 10.6% (95% confidence interval [CI], 6.5%-15.9%) risk of stroke in the first 7 days after the an initial TIA was due to patients with small-vessel disease (SVD) etiology (10 of 24 vs 8 of 146; odds ratio, 12.3; 95% confidence interval, 3.7-41.9; P = .0001), particularly in those with motor weakness (ie, capsular warning syndrome) compared with hemisensory events (9 of 15 [60%], 95% CI, 35.3-84.7 vs 1 of 9 [11.1%], 95% CI, 0-31.7; P = .03). The 7-day risk of stroke after recurrent TIA was similar to the risk after a single TIA in patients with non-SVD TIA (8 of 146 [5.5%] vs 76 of 830 [9.2%]; odds ratio, 0.58; 95% CI, 0.25-1.3; P = .20). All of the nine patients with stroke after a capsular warning syndrome had recurrent TIA ≤24 hours after the first TIA, and the subsequent stroke occurred ≤72 hours of the second TIA in eight patients. The ABCDE2 scores of all preceding TIAs were ≤4 in all nine patients with capsular warning syndrome before their stroke. Comment: The data point out that not all TIAs have the same prognosis for stroke. In particular, multiple TIAs without association with large-vessel disease may have the worst prognosis of all. The implication is that the emphasis on recurrent TIAs in many societal guidelines scores may not be justified. At least in this study, multiple TIAs were not associated with medically (atrial fibulation) or surgical (cervical carotid stenosis) correctable conditions. Patients with capsular warning syndrome should have treatment emphasis on hydration, antiplatelet, and anticoagulation therapies and, perhaps, thrombolysis rather than a search for an underlying surgically correctable large-vessel problem.

WHY DO MOTOR SYMPTOMS PREDICT A HIGH EARLY RISK OF STROKE AFTER TIA?

BackgroundThe ABCD2 score predicts early risk of stroke in unselected TIA referrals, those with clinically diagnosed TIA and even in those with ‘positive’ DWI. The age, blood pressure (BP) and...

C0167 Pregnancy and labor in patients with history of ischemic stroke

Background: Arterial thrombosis is uncommon in pregnancy but may have devastating consequences. The incidence of ischemic stroke associated with pregnancy is estimated to be about 4.2 to 210 per 100 000 deliveries. Mortality level is very high and is 8-26%. Events occur most frequently in the III trimester of pregnancy or postpartum. Pregnancy is a kind of an essential spontaneous screening test for the risk of early stroke in women and augments the risk of stroke in 3-13%. Methods: We observed 59 patients with history of arterial thrombotic complications and 60 healthy pregnant women. Among 59 women 4 of them had stroke and VTE, 3 had myocardial infarction, 2 patients – acute arterial cerebral thromboembolism and thrombosis of prosthetic heart valves. Some women had history of stroke and ileo-femoral thrombosis and splenic infarction and thrombosis occurred in different other localizations (n=16, 27.1%) including combination of ischemic stroke and retinal thrombosis, deep vein thrombosis, Takayasu syndrome and renal thrombosis, subclavian artery thrombosis, avascular necrosis of the femoral head and reoccurred cerebral thromboembolism in patients with catastrophic antiphospholipid syndrome. I subgroup consists of 20 patients with history of arterial thrombosis. All these women were enrolled into the study from the fertile cycle or from the beginning of pregnancy andd therapy was started early. II subgroup accepted 17 patients from II or III trimesters of pregnancy and therapy was started after their admission. Thrombosis was associated with pregnancy in 17 women (28.8%). The remaining 22 patients with arterial thrombosis had thromboembolic complications during current pregnancy. All included patients had been examined for the hemostasis system abnormalities. Results: Risk factors included SLE, vasculitis, metabolic syndrome, hypertonic diseases, cardiac arrhythmia, the presence of prosthetic heart valves, inadequate anticoagulant therapy, open foramen ovale, intake of OC, surgery interventions, septic complications, vertebrobasilar abnormalities. The examination demonstrated the high frequency of genetic and acquired froms of thrombophilia and high level of resistance to protein C in patients with arterial thrombotic events. Different forms of thrombophilia were present in 88.2% of patients. Multigenic thrombophilia was recorded in 84,3% of patients, fibrinolytic defects in 76.5% patients, APA in 41.2%, and hyperhomocysteinemia in 19.6%. Comment: The revelation of the multigenic thrombophilia, fibrinolytic defects and APA circulation indicates an essential role of thrombophilia in the genesis of thrombotic complications. Early pathogenic anticoagulant therapy with LMWH, antiaggregant drugs, antioxidants, vitamins group B from the fertile cycle when a women start to plan a pregnancy allows prevent reoccurred thrombotic events, severe obstetric complications and improve perinatal outcomes.

C0284 Does a tight fibrin clot in premenopausal women with type 1 diabetes explain the lack of gender difference in cardiovascular disease?

Background: Arterial thrombosis is uncommon in pregnancy but may have devastating consequences. The incidence of ischemic stroke associated with pregnancy is estimated to be about 4.2 to 210 per 100 000 deliveries. Mortality level is very high and is 8-26%. Events occur most frequently in the III trimester of pregnancy or postpartum. Pregnancy is a kind of an essential spontaneous screening test for the risk of early stroke in women and augments the risk of stroke in 3-13%. Methods: We observed 59 patients with history of arterial thrombotic complications and 60 healthy pregnant women. Among 59 women 4 of them had stroke and VTE, 3 had myocardial infarction, 2 patients – acute arterial cerebral thromboembolism and thrombosis of prosthetic heart valves. Some women had history of stroke and ileo-femoral thrombosis and splenic infarction and thrombosis occurred in different other localizations (n=16, 27.1%) including combination of ischemic stroke and retinal thrombosis, deep vein thrombosis, Takayasu syndrome and renal thrombosis, subclavian artery thrombosis, avascular necrosis of the femoral head and reoccurred cerebral thromboembolism in patients with catastrophic antiphospholipid syndrome. I subgroup consists of 20 patients with history of arterial thrombosis. All these women were enrolled into the study from the fertile cycle or from the beginning of pregnancy andd therapy was started early. II subgroup accepted 17 patients from II or III trimesters of pregnancy and therapy was started after their admission. Thrombosis was associated with pregnancy in 17 women (28.8%). The remaining 22 patients with arterial thrombosis had thromboembolic complications during current pregnancy. All included patients had been examined for the hemostasis system abnormalities. Results: Risk factors included SLE, vasculitis, metabolic syndrome, hypertonic diseases, cardiac arrhythmia, the presence of prosthetic heart valves, inadequate anticoagulant therapy, open foramen ovale, intake of OC, surgery interventions, septic complications, vertebrobasilar abnormalities. The examination demonstrated the high frequency of genetic and acquired froms of thrombophilia and high level of resistance to protein C in patients with arterial thrombotic events. Different forms of thrombophilia were present in 88.2% of patients. Multigenic thrombophilia was recorded in 84,3% of patients, fibrinolytic defects in 76.5% patients, APA in 41.2%, and hyperhomocysteinemia in 19.6%. Comment: The revelation of the multigenic thrombophilia, fibrinolytic defects and APA circulation indicates an essential role of thrombophilia in the genesis of thrombotic complications. Early pathogenic anticoagulant therapy with LMWH, antiaggregant drugs, antioxidants, vitamins group B from the fertile cycle when a women start to plan a pregnancy allows prevent reoccurred thrombotic events, severe obstetric complications and improve perinatal outcomes.

Low positive predictive value of the ABCD2 score in emergency department transient ischaemic attack diagnoses: the South Western Sydney Transient Ischaemic Attack Study

The ABCD(2) stroke risk score is recommended in national guidelines for stratifying care in transient ischaemic attack (TIA) patients, based on its prediction of early stroke risk. We had become concerned about the score accuracy and its clinical value in modern TIA cohorts. We identified emergency department-diagnosed TIA at two hospitals over 3 years (2004-2006). Cases were followed for stroke occurrence and ABCD(2) scores were determined from expert record review. Sensitivity, specificity and positive predictive values (PPV) of moderate-high ABCD(2) scores were determined. There were 827 indexed TIA diagnoses and record review was possible in 95.4%. Admitted patients had lower 30-day stroke risk (n = 0) than discharged patients (n = 7; 3.1%) (P < 0.0001). There was no significant difference in proportion of strokes between those with a low or moderate-high ABCD(2) score at 30 (1.2 vs 0.8%), 90 (2.0 vs 1.9%) and 365 days (2.4 vs 2.4%) respectively. At 30 days the sensitivity, specificity and PPV of a moderate-high score were 57% (95% confidence interval (CI) 25.0-84.2), 32.2% (95% CI 29.1-35.6) and 0.75% (95% CI 0.29-1.91) respectively. Early stroke risk was low after an emergency diagnosis of TIA and significantly lower in admitted patients. Moderate-high ABCD(2) scores did not predict early stroke risk. We suggest local validation of ABCD(2) before its clinical use and a review of its place in national guidelines.

Performance of the ABCD2 score for stroke risk post TIA

To study the accuracy of the ABCD2 score in predicting early stroke risk following TIA and to model post-test probability of stroke for varying cutoff scores and baseline stroke risk. Medline, PubMed, Embase, conference proceedings, and manuscript references up to October 2010 were searched for studies reporting ABCD2 score and stroke outcome after TIA. Additional data were requested from authors. Meta-analysis, meta-regression, and post-test probability modeling were undertaken to assess prediction of stroke at 2, 7, and 90 days. Of 44 eligible studies, data were available for 33 (16,070 patients): 26/33 reported stroke at 2 days (533 strokes), 32/33 at 7 days (781 strokes), and 28/33 at 90 days (1,028 strokes) after TIA. Using scores 0-3 ("low risk") and 4-7 ("high risk") for stroke at 7 days, pooled measures were sensitivity 0.89 (0.87-0.91), specificity 0.34 (0.33-0.35), positive predictive value 0.08 (0.07-0.09), negative predictive value 0.98 (0.98-0.98), positive likelihood ratio (PLR) 1.43 (1.33-1.54), negative likelihood ratio (NLR) 0.40 (0.33-0.50), and area under the curve (AUC) 0.70 (0.62-0.78). Results were similar at days 2 and 90. There was moderate heterogeneity while pooling PLR (p < 0.01, I(2) >50%), with stroke specialist TIA diagnosis associated with slightly higher PLR. At 5% baseline stroke risk, ABCD2 >3 indicated an absolute increase in 7-day stroke risk of only 2.0% while a score ≤3 indicated a 2.9% decrease in risk. Changes in risk were very small when baseline stroke risk was lower. The ABCD2 score leads to only small revisions of baseline stroke risk particularly in settings of very low baseline risk and when used by nonspecialists.

Transient Ischaemic Attack (TIA) Knowledge in General Practice: a cross-sectional study of Western Adelaide general practitioners

BackgroundWith evidence to support early assessment and management of TIAs, the role of the general practitioner (GP) needs to be considered in developing a TIA service in Western Adelaide. We thus aimed to determine GP knowledge of TIA assessment and management and identify perceived barriers, in order to tailor subsequent GP education and engage primary care in the co-ordinated care of TIA patients.FindingsA self-administered questionnaire was mailed to all GPs (n = 202) in the Adelaide Western General Practice Network. Response frequencies were calculated for all variables, and associations examined by univariate analysis.32 GPs responded. All respondents correctly identified early risk of stroke following a TIA. Difficulty accessing neurological expertise was identified as a barrier (40.6 %), as was a lack of GP knowledge (18.8 %). Areas for improvement included access to neurologists (36.7 %), relevant guidelines and education (43.3 %).ConclusionsDiagnosis of TIA is difficult and this study highlights the need for further education and practical guidelines for GPs. With this training, GPs could be better equipped to assess and manage TIAs effectively in the community in consultation with stroke physicians.

Use of cranial CT to identify a new infarct in patients with a transient ischemic attack

Research on infarct detection by noncontrast cranial computed tomography (CCT) in patients with transient ischemic attack (TIA) is sparse. However, the aims of this study are to determine the frequency of new infarcts in patients with TIA, to evaluate the independent predictors of infarct detection, and to investigate the association between a new infarct and early short-term risk of stroke during hospitalization. We prospectively evaluated 1533 consecutive patients (mean age, 75.3 ± 11 years; 54% female; mean National Institutes of Health Stroke Scale [NIHSS] score, 1.7 ± 2.9) with TIA who were admitted to hospital within 48 h of symptom onset. A new infarct was detected by CCT in 47 (3.1%) of the 1533 patients. During hospitalization, 17 patients suffered a stroke. Multivariate logistic regression analysis revealed the following independent predictors for infarct detection: NIHSS score ≥10 (odds ratio [OR], 4.8), time to CCT assessment >6 h (OR 2.2), and diabetes (OR 2.3). The evidence of a new infarct was not associated with the risk of stroke after TIA. The frequency of a new infarct in patients with TIA using CCT is low. The use of the CCT tool to predict the stroke risk during hospitalization in patients with TIA is found to be inappropriate. The estimated clinical predictors are easy to use and may help clinicians in the TIA work up.

Carotid Artery Surgery: High-Risk Patients or High-Risk Centers?

Carotid angioplasty and stenting has been proposed as an alternative to carotid endarterectomy (CEA) in patients deemed as at high risk for this surgical procedure. To date, definitely accepted criteria to identify "high-risk" patients for CEA do not exist. Our objective was to assess the relevance of numerous supposed high-risk factors in our experience, as well as their possible effect on our early postoperative results. A retrospective review of 1,033 consecutive CEAs performed during a 5.6-year period at a single institution was conducted (Vascular Surgery Department, St. Etienne University Hospital, France). Early results in terms of mortality and neurologic events were recorded. Univariate and multivariate analyses for early risk of stroke, myocardial infarction, and death were performed, considering the influence of age, sex, comorbidities, clinical symptoms, and anatomic features. The cumulative 30-day stroke and death rate was 1.2%. A total of 10 strokes occurred and resulted in three deaths. The postoperative stroke risk was significantly higher in the subgroup of patients treated for symptomatic carotid artery disease: 2,6% (P = 0,004). Univariate analysis and logistic regression did not show statistical significance for 30-day results in any of the considered variables. Patients with significant medical comorbidities, contralateral carotid occlusion, and high carotid lesions can undergo surgery without increased complications. Those parameters should not be used as exclusion criteria for CEA.

Hospital Admission After Transient Ischemic Attack

Patients with TIA are at high risk of short-term stroke, myocardial infarction, and vascular death. Because stroke risk is reduced by immediate medical or surgical intervention, emergent evaluation and treatment is warranted. The Effect of urgent treatment of transient ischemic attack and minor stroke on early recurrent stroke (EXPRESS) and effectiveness of round-the-clock access (SOS-TIA) studies1 showed that urgent evaluation and initiation of preventive treatments such as antiplatelets, statins, anticoagulation, and carotid revascularization markedly reduce the risk of early stroke after a TIA or minor stroke. The ABCD2 score, based on clinical features and demographic data, has been shown to predict the short-term stroke risk after TIA and is being increasingly used to triage patients with TIA. However, its low interrater reliability, poor correlation with imaging findings, and its inability to identify patients who require in-hospital intervention preclude the use of the ABCD2 scores as a sole decision-making tool. In other words, the ABCD2 score represents field glasses that help shepherds to visualize a flock at a long distance in an attempt …

Familial Effects on Ischemic Stroke

Background— Previous studies on familial risk of ischemic stroke have supported genetic influence on the disease incidence. This study aimed to characterize these familial effects in a nationwide population-based study by taking into account sibling relations, sex of siblings, and age of onset, with respect to ischemic stroke incidence. Methods and Results— Incident ischemic stroke cases identified from the Swedish Hospital Discharge and Cause of Death Registers between 1987 and 2007 were linked to their stroke-free siblings (study participants), forming an exposed sib-pair. Each exposed sib-pair was matched up to 5 unexposed sib-pairs from the Multi-Generation Registry by birth and calendar years. Incident ischemic stroke risk was assessed using hazard estimates obtained from stratified Cox regression analyses. A total of 30 735 exposed and 152 391 unexposed study participants were included in the analyses. The overall risk of incident ischemic stroke when exposed was significantly increased (relative risk, 1.61; 95% confidence interval, 1.48–1.75; P &lt;0.001). Familial risk was higher in full (relative risk, 1.64; 95% confidence interval, 1.50–1.81; P &lt;0.001) than in half (relative risk, 1.41; 95% confidence interval, 1.10–1.82; P =0.007) siblings. Familial risk of early ischemic stroke almost doubled when exposed to early ischemic stroke (relative risk, 1.94; 95% confidence interval, 1.41–2.67; P &lt;0.001). Conclusions— There was a 60% increased risk for ischemic stroke in individuals having a sibling with prior stroke. The familial effect was even higher for full-sibling relations. Familial effects were observed in both male and female individuals, and no differential effects depending on the sex of either of the siblings were found.

Journal Club: Early stroke risk and ABCD2 score performance in tissue vs time-defined TIA

In this journal club article, we evaluate a study by Giles and colleagues1 that reports stroke risk in patients with classically defined TIA subcategorized by presence or absence of radiologic brain infarction. The concept of a TIA is evolving in parallel with better understanding of brain ischemia and insights gained from neuroimaging studies. TIAs were classically defined as a sudden focal neurologic deficit resulting from brain or retinal ischemia lasting less than 24 hours.2,3 The time threshold of 24 hours was arbitrarily chosen, and given that there is no evidence to support any single time criterion associated with infarction, this has appropriately been questioned. A newer and well-received definition of TIA is “a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.”4 This definition communicates the important concept that transient symptoms can nonetheless be associated with permanent brain injury, encourages the use of neuroimaging studies, and may promote rapid interventions for acute brain ischemia. The ABCD2 score, a risk-stratifying score for patients with TIA, is derived from the patient's age, blood pressure, clinical features, TIA duration, and history of diabetes. This simple, validated score identifies patients at highest risk of early stroke after TIA.5 Scores are commonly divided into low risk (0–3), intermediate risk (4–5), and high risk.6,7 The clinical ABCD2 scale is integrated in this study with results from acute brain imaging to assess how the new tissue-based definition of TIA further assists with risk stratification of patients with transient neurologic symptoms. In this analysis of data pooled from 12 medical centers which included 4,574 patients, Giles and colleagues subcategorized TIA as “tissue positive” or “tissue negative,” depending on the presence or absence of radiographic brain infarction seen on MRI or CT …

Abstract P333: Post-Stroke Outcomes Vary by Etiologic Stroke Subtype in the Atherosclerosis Risk in Communities Study

Background: Early risk of recurrent stroke and mortality after stroke differ by subtype, but less is known about long-term outcomes and all-cause hospital readmission. Understanding these differences may have implications for secondary prevention and treatment of stroke. We examined rates of recurrent stroke, all-cause hospital readmission, and mortality by index stroke etiologic subtype. Methods: Atherosclerosis Risk in Communities Study cohort participants with a definite/probable first-ever stroke were identified and followed until death or 12/31/2008. The association between index and recurrent stroke subtype and median times to first recurrent stroke and first hospital admission were assessed according to index stroke subtype (infarction: thrombotic, cardioembolic [CE], and lacunar; hemorrhagic: subarachnoid [SAH] and intraparenchymal [IPH]). Incidence rates of recurrent stroke, all-cause hospitalization, and death were calculated by index subtype. Reasons for hospitalization were identified using primary ICD-9 codes. Recurrent stroke outcomes for hemorrhagic subtypes are not reported here due to small numbers of events. Results: A total of 987 persons with first-ever stroke were identified and followed for an average 5.3±5.0 years post-stroke (48.7% thrombotic, 20.0% CE, 18.5% lacunar, 8.6% IPH, and 4.2% SAH). During follow-up, there were 183 recurrent strokes among 147 participants, 3234 hospitalizations among 746 participants, and 529 deaths. Only 139 (14.1%) participants had none of these events during follow up. Roughly 70% of recurrent strokes were of the same subtype as the index stroke; however, only a third were the same when the index stroke was lacunar. Time to first recurrent stroke varied by subtype (median days [range]; thrombotic, 930.5[2-4692]; CE, 271[2-5566]; lacunar, 789[5-4361]) while time to first hospitalization was more similar, ranging from 102.5[4-3634] among CE to 370[6-6506] among IPH. Incidence rates of recurrent stroke (per 100 person-years) were highest after lacunar stroke (4.4) followed by thrombotic (3.7), and CE (2.7). All-cause hospital readmission rates were: thrombotic (58.8), CE (88.9), lacunar (60.1), IPH (59.4), and SAH (35.3); and mortality rates were: thrombotic (9.0), CE (15.1), lacunar (7.4), IPH (22.3), and SAH (7.3). Non-stroke related hospitalizations, including heart failure, ischemic heart disease, and diabetes were not uncommon after stroke, particularly after thrombotic and CE strokes. Conclusion: While the highest mortality was observed for IPH, there was significant burden of recurrent stroke and all-cause hospitalization for other stroke subtypes, especially lacunar and CE. Hospital readmission rates were high for all subtypes, suggesting there may be opportunities to reduce post-stroke readmissions. Prevention efforts tailored according to etiologic stroke subtype may be warranted.