High Risk Of Recurrent Stroke Research Articles

Oxidized Low-Density Lipoprotein to High-Density Lipoprotein Ratio Predicts Recurrent Stroke in Minor Stroke or Transient Ischemic Attack.

Background and Purpose- Oxidized low-density lipoprotein (oxLDL) level is thought to be associated with recurrent stroke. We aimed to investigate the association between oxLDL to high-density lipoprotein (HDL) ratio and recurrent stroke in patients with minor stroke or transient ischemic attack. Methods- The study included 3019 patients with minor ischemic stroke or high-risk transient ischemic attack from the CHANCE trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events). Baseline oxLDL and HDL levels were measured. The primary outcome was any stroke within 90 days. The secondary outcomes included any stroke within 1 year and ischemic stroke and combined vascular events within 90 days and 1 year. The association between oxLDL/HDL and recurrent stroke was analyzed by using Cox proportional hazards. Results- Patients in the highest oxLDL/HDL quartile had a higher risk of recurrent stroke within 90 days (hazards ratio, 1.50; 95% CI, 1.08-2.08) compared with the lowest quartile after adjusting relevant confounding factors ( P=0.02). Similar results were found for secondary outcomes ( P<0.05 for all). There were no significant interaction between oxLDL/HDL and use of statins agents. Conclusions- Higher serum oxLDL/HDL level in minor stroke or transient ischemic attack was associated with increased risk of recurrent stroke in 90 days and 1 year. OxLDL/HDL may act as a powerful indicator of recurrent stroke in patients with minor stroke or transient ischemic attack. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT00979589.

Medium-Chain Acylcarnitines Are Associated With Cardioembolic Stroke and Stroke Recurrence.

Objective- Stroke is a heterogeneous disease with diverse causes, which affect the risk of recurrence. This study aimed to identify novel biomarkers that are clinically relevant to the diagnosis of cardioembolic stroke (CE) and the prediction of stroke recurrence using metabolomics. Approach and Results- We obtained blood samples and clinical data from a consecutively registered, hospital-based acute stroke registry and from healthy controls. Mass-spectrometry-based profiling was performed, and several metabolomic signatures were selected for the discrimination of CE and stroke recurrence, coupled with multivariate statistical analysis. Finally, 190 acute ischemic stroke participants (43 CE patients and 147 non-CE patients) and 30 control participants were included. We obtained 29 metabolomics signatures, and of these, 2 medium-chain acylcarnitines (decanoylcarnitine and octanoylcarnitine) were selected as independent discriminants for CE (odds ratio, 2.839; 95% CI, 1.241-6.493 for decanoylcarnitine; odds ratio, 2.839; 95% CI, 1.241-6.493 for octanoylcarnitine). Elevated medium-chain acylcarnitines were also associated with a higher risk of stroke recurrence (hazard ratio, 3.767; 95% CI, 1.276-11.117 for decanoylcarnitine; hazard ratio, 5.519; 95% CI, 1.22-18.781 for octanoylcarnitine). The levels of decanoylcarnitine and octanoylcarnitine were correlated as known surrogate markers of CE. The levels of decanoylcarnitine and octanoylcarnitine were significantly higher in stroke patients with a high-risk potential of cardioembolism than in those with low or intermediate risk. Conclusions- Metabolomics provided an improved understanding of CE pathogenesis and stroke recurrence. We have identified decanoylcarnitine and octanoylcarnitine as novel biomarkers for CE and stroke recurrence.

Oxidized low-density lipoprotein predicts recurrent stroke in patients with minor stroke or TIA.

To investigate the association between oxidized low-density lipoprotein (oxLDL) and recurrent stroke in patients with minor stroke or TIA. In the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial, baseline oxLDL levels were blindly measured in plasma with the 4E6 antibody in the core laboratory. The primary outcome was any stroke within 90 days. The secondary outcomes included any stroke within 1 year and ischemic stroke and combined vascular events within 90 days and 1 year. The associations of oxLDL with recurrent stroke were analyzed by Cox proportional hazards. Among 3,019 patients included in this study, the median (interquartile range) of oxLDL was 13.96 (6.65-28.81) μg/dL. After adjustment for conventional confounding factors, patients in the highest oxLDL quartile (≥28.81 μg/dL) had a higher risk of recurrent stroke within 90 days (hazard ratio 1.43, 95% confidence interval 1.03-1.98) compared to those in the lowest oxLDL quartile (<6.65 μg/dL). Similar results were found for secondary outcomes. We also found a J-shaped association between oxLDL and risk of each outcome. There were no significant interactions between oxLDL and low-density lipoprotein and use of dual antiplatelet, antihypertensive, antidiabetic, and statins agents. Elevated oxLDL levels can independently predict recurrent stroke in patients with minor stroke or TIA. NCT00979589.

Symptomatic intracranial atherosclerotic disease: an ultrasound 2-year follow-up pilot study.

The objective of this single-center pilot study was to assess if symptomatic intracranial atherosclerotic disease (ICAD) ultrasound features change through the 2years after acute ischemic stroke or TIA, being ICAD a relevant cause of acute ischemic stroke or TIA, linked to high rates of recurrent stroke. We consecutively enrolled 48 patients with acute ischemic stroke or TIA with symptomatic ICAD detected by transcranial color-coded duplex sonography (TCCS) and confirmed by MR-angiography and/or CT-angiography. We set a neurosonological and clinical follow-up at 3, 6, 12, and 24months (T0, T1, T2, T3, and T4). We observed that the hemodynamic effect of the stenosis changed during the 2-year follow-up, as revealed by the modifications of Peak Systolic Velocity (PSV) (Friedman-ANOVA test, p < 0.001). The pairwise post-hoc analysis showed a statistically significant difference between PSV at T0 and PSV at T3 (p = 0.005) and between PSV at T0 and PSV at T4 (p < 0.001) being PSV at T3 and T4 lower than PSV at T0. Seven patients had a new event in the first 12months. The high rate of recurrent stroke or death among ICAD patients seems to be independent of progressive arterial narrowing. A wide multicenter follow-up study is needed in order to identify the factors that, alongside the hemodynamic features, contribute to the high risk of recurrent stroke among patient with symptomatic ICAD.

Delayed diagnosis of atrial fibrillation after first-ever stroke increases recurrent stroke risk: a 5-year nationwide follow-up study.

Delayed detection of atrial fibrillation (AF) is common in patients with stroke. However, it is not well known whether delayed identification of AF in patients with stroke affects the prognosis of patients. To evaluate the association between the timing of AF diagnosis after stroke and clinical outcomes. We identified a cohort of all patients admitted with a primary diagnosis of first-ever ischaemic stroke, which was categorised into three groups, namely, non-AF, AF presenting with stroke and delayed AF diagnosis groups. The study patients were individually followed for 5 years to evaluate the occurrence of recurrent stroke and death. In total, 17 399 patients were hospitalised with first-ever ischemic stroke, of whom 16 261 constituted the non-AF group, 907 the AF presenting with stroke group and 231 the delayed AF diagnosis group. During the 5-year follow up, 2773 (17.1%), 175 (19.3%) and 68 (29.4%) patients in the non-AF, AF presenting with stroke and delayed AF diagnosis groups, respectively, were hospitalised for recurrent stroke. The delayed AF diagnosis group exhibited a 1.57-times higher risk of recurrent stroke than the AF presenting with stroke group, after adjustment for the CHA2DS2-VASc scores (adjusted hazard ratio (HR): 1.57; 95% confidence interval (CI) = 1.19-2.08; P = 0.002). In addition, delayed diagnosis of AF significantly increased the risk of recurrent stroke in men, but not in women, after adjustment for the CHA2DS2-VASc scores. Delayed diagnosis of AF after stroke increased the risk of recurrent stroke, particularly in men.

Clinical Significance of the Circle of Willis in Patients with Symptomatic Internal Carotid Artery Occlusion

Despite improvements in medical treatment, many patients experience ischemic stroke owing to internal carotid artery occlusion. We retrospectively evaluated a novel method based on the arterial structure of the circle of Willis (CoW) to identify patients at a high risk of recurrent stroke. The study enrolled 104 patients with symptomatic occlusion of the internal carotid artery. CoW integrity was evaluated by a quantitative scoring system based on conventional angiography. Patients were categorized into a good integrity (n= 45) or poor integrity (n=59) group. Primary endpoint was early neurologic deterioration, recurrent ischemic stroke, or transient ischemic attack. History of ischemic stroke before initial presentation was more prevalent in the poor integrity group (22.2% vs. 47.5%, P= 0.01), and there were no differences between the 2 groups in terms of stroke risk factors. Overall estimated rate of the primary endpoint was 25.6% 2 years after angiography. It was 5.7% in the good integrity group and 39.8% in the poor integrity group (P < 0.001). In a Cox regression analysis, male sex (P= 0.01, hazard ratio=6.60), use of a tissue plasminogen activator (P= 0.00, hazard ratio= 6.10), and poor integrity of CoW (P= 0.00, hazard ratio= 5.42) were risk factors for the primary endpoint. Patients in the poor integrity group with decreased vascular reserve experienced frequent primary endpoint events compared with patients in the good integrity group (P= 0.00). Patients with poor integrity of CoW are vulnerable to recurrent ischemic stroke and appear to require more aggressive treatment.

Dual Antiplatelet Therapy in Transient Ischemic Attack and Minor Stroke With Different Infarction Patterns

Infarction patterns may serve as important imaging markers to assess the probability of stroke recurrence in transient ischemic attack (TIA) and minor stroke. However, it is unclear whether patients with different infarction patterns benefit differently from dual antiplatelet therapy. To investigate whether infarction patterns can stratify the risk of recurrent stroke and whether the efficacy and safety of clopidogrel plus aspirin vs aspirin alone are consistent in different infarction patterns after TIA or minor stroke. In this prespecified imaging substudy of the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) randomized clinical trial, a total of 1342 patients with noncardioembolic TIA or minor stroke at 45 sites of CHANCE from October 1, 2009, to July 30, 2012, were included in this substudy. The final analysis was conducted on July 30, 2016, and included 1089 patients with required magnetic resonance imaging sequences. Infarction patterns were grouped into multiple acute infarctions (MAIs), single acute infarction (SAI), and no acute infarction (NAI) according to diffusion-weighted imaging. Primary and secondary efficacy outcomes were stroke recurrence and new clinical vascular event after 3 months, respectively. The safety outcome was moderate to severe bleeding risk after 3 months. Among 1089 patients, the mean (SD) age was 63.1 (10.7) years and 731 patients (65%) were men. Patients with MAIs (hazard ratio [HR], 5.8; 95% CI, 2.2-15.1; P < .001) and SAI (HR, 3.9; 95% CI, 1.5-10.5; P = .007) had higher risk of recurrent stroke than those with NAI after adjustment for potential confounders at 3-month follow-up. Stroke recurrence occurred in 15 (10.1%) and 25 (18.8%) of patients with MAIs administered clopidogrel plus aspirin and placebo plus aspirin, respectively (HR, 0.5; 95% CI, 0.3-0.96; P = .04), 24 (8.9%) and 24 (8.5%) of patients with SAI administered clopidogrel plus aspirin and placebo plus aspirin, respectively (HR, 1.1; 95% CI, 0.6-2.0; P = .71), and 3 (2.6%) and 2 (1.4%) of patients with NAI administered clopidogrel plus aspirin and placebo plus aspirin, respectively (HR, 1.7; 95% CI, 0.3-11.1; P = .56), with P = .04 for treatment × infarction pattern interaction effect. Clopidogrel plus aspirin did not increase moderate to severe bleeding risk. Infarction patterns can efficiently stratify the risk of recurrent stroke within 3 months of noncardioembolic TIA or minor ischemic stroke. Patients with MAIs received the most pronounced clinical benefit from dual antiplatelet therapy without increasing the risk of moderate to severe bleeding. However, even if after dual antiplatelet treatment, patients with MAIs still had a risk of stroke recurrence as high as those with SAI. clinicaltrials.gov Identifier: NCT00979589.

Implantable Loop Recorders for Cryptogenic Stroke (Plus Real-World Atrial Fibrillation Detection Rate with Implantable Loop Recorders).

Cryptogenic stroke (CS) represents 10%-40% of ischemic strokes and is associated with significant morbidity and mortality and high risk of recurrence. Undetected atrial fibrillation is an important consideration in these patients. Tools for electrocardiographic monitoring range from 12-lead electrocardiogram to implantable loop recorders (ILRs). ILRs have become an important tool for long-term electrocardiogram monitoring in CS patients. Advancements in ILR technology are needed to ensure more robust connectivity and to help triage incoming data. An unresolved issue is what duration of AF indicates that the CS patient is at high risk for recurrent stroke and thus would benefit from initiation of anticoagulation.

A Modified Anatomical-Functional-RoPE (AF-RoPE) Score Improves Patient Selection for Patent Foramen Ovale Closure

Background: RoPE score calculator has been proposed to stratify the patients in whom PFO may be considered not a confounding but presumably a causative factor.Objectives To implement the RoPE score calculator.Methods. We reviewed the medical data of 1040 consecutive patients (mean age 47.3±17.1 years) prospectively enrolled in two centres over a 13 years period for management of PFO in order to select anatomic and functional parameters to be incorporated in a modified RoPE score. A scoring system (AF-RoPE) was build up and applied in a prospective blind fashion to a cohort of 406 consecutive patients (mean age 43.6 ±17. 5 years, 264 females) with cryptogenic stroke and PFO comparing its performance with the standard RoPE.Results. Multiple stepwise logistic regression analysis demonstrated that right-to-left (R-L) shunt at rest (OR 5.9), huge ASA (&gt; 20 mm) (OR 3.9), long tunnelized PFO (&gt; 12 mm) (OR 3.5), and massive R-L shunt (grade 5 by TCD) (OR 1.9) conferred the highest risk of recurrent stroke. The AF-RoPE score resulted in a more precise separation of patients with RoPE score 8-10. Patients with AF-RoPE score &gt; 11 had more stroke recurrences and more diffuse area of stroke on MRI in the medical history than those ranging 10 to 7 or less.Conclusion. The AF-RoPE score discriminates cryptogenic stroke patients who are more likely to develop recurrent stroke compared with a RoPE score between 8-10. These highest risk patients may be more likely to benefit from PFO closure.

Abstract TP119: Feasibility of Automated Analysis of Dual- Venc 4d Flow Mri to Assess Hemodynamics in Patients With Intracranial Atherosclerotic Disease

Purpose: Advanced imaging and automated image processing techniques were used to demonstrate the feasibility of 4D flow MRI as a clinical tool for assessment of intracranial hemodynamics in patients with intracranial atherosclerotic disease (ICAD). Introduction: ICAD patients have a high risk of stroke recurrence, which could be partly due to intracranial hemodynamic failure. Thus, it is critical to assess the impact of ICAD on cerebrovascular flow dynamics. Dual- venc 4D flow MRI allows the assessment of flow in major intracranial arteries and veins by providing a large dynamic range. A new automated post-processing tool was developed to ease the cumbersome processing task that hinders clinical application of 4D flow MRI. Method: Intracranial dual- venc 4D flow MRI (Fig 1a) was acquired in 20 healthy volunteers (12M, 43±18Y) and three ICAD patients: two men, 65Y with near occlusion and 43Y with 65% stenotic right MCAs and a 70Y woman with stenoses in PCAs and ACAs (&gt; 50%). Post-processing included automated segmentation of vessels, extraction of centerlines, positioning multiple analysis cut-planes (1 mm inter-plane distance) along the vessels, and computing peak velocity (PK) and flow rate (FR) for each vessel (Fig. 1b and 1c). Results: Fig. 1d and 1e present cumulative results for the control subjects, which show the PV and FR left/right ratios are close to one. this suggests hemodynamic symmetry between left and right hemispheres for controls. For the 65M patient with RMCA stenosis, the PV ratio/FR ratio in ICA and MCA were 1.37/2.26 and 1.44/7.09. The 43M patient with stenotic RMCA showed asymmetry only in the MCA-FR (1.6). The 70F case had multiple stenoses with the most pronounced asymmetry in PCA-PV and -FR (0.42 and 0.6). Discussion: We demonstrated the feasibility of using dual- venc 4D flow MRI and automated flow analysis tool to quantify hemodynamic markers such as PV, FR and flow asymmetry in ICAD patients with the potential application for ICAD risk stratification.

Abstract TMP114: Oxidized Low Density Lipoprotein Predicts Recurrent Stroke in Patients With Minor Stroke or Transient Ischemic Attack

Introduction: Elevated oxidized low-density lipoprotein (oxLDL) was shown to be related to atherosclerotic cardiovascular diseases, but the role of oxLDL in predicting recurrent stroke in patients with minor stroke or transient ischemic attack remains unclear. We aimed to investigate the association between oxLDL and recurrent stroke. Methods: In the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial, baseline oxLDL levels were measured. The primary outcomes were any stroke within 90 days and 1 year. The association of oxLDL with recurrent stroke was analyzed by using Cox proportional hazards model. Results: Among the 3019 patients included in this study, the median (IQR) of oxLDL was 13.96 (6.65-28.81) ug/dl. After adjusted for conventional confounding factors, patients in the highest oxLDL quartile had a higher risk of recurrent stroke within 90 days (HR, 1.42; 95% CI, 1.02-1.96) and 1 year (HR, 1.41; 95% CI, 1.05-1.90) compared with the lowest oxLDL quartile. There was no significant interaction between oxLDL levels and randomized antiplatelet therapy. Conclusions: Elevated oxLDL levels can independently predict recurrent stroke in patients with minor stroke or transient ischemic attack.

Abstract WMP59: Sleep Apnea is Associated with the Combined Endpoint of Recurrent Stroke and Post-Stroke Mortality

Introduction: No data are available about the relationship between sleep apnea (SA) and recurrent stroke and mortality from population-based studies, large samples, or ethnically diverse populations. Methods: In the Brain Attack Surveillance in Corpus Christi (BASIC) project, we identified patients with ischemic stroke between 2010-2015. Subjects who enrolled were offered screening for SA with the ApneaLink Plus device from which an apnea-hypopnea index (AHI) was derived (≥10 defined SA). Demographics and baseline characteristics were determined from chart review and interview. Recurrent ischemic stroke was identified through active and passive surveillance and confirmed by study neurologists. All-cause mortality was identified through Texas Department of State Health Services records. Cox proportional-hazards models were used to assess the association between AHI (modeled linearly) and combined ischemic stroke recurrence and mortality unadjusted and adjusted for multiple potential confounders. Results: Of the 842 subjects, the median age was 65 (IQR: 57, 76), 47% were female, 58% were Mexican American, and 34% were non-Hispanic white. The median AHI was 14 (IQR: 6, 26); 63% had SA. SA was associated with male sex, Mexican American ethnicity, being insured, nonsmoking status, diabetes, hypertension, lower educational attainment, and higher BMI. In the time period (median time to event 584 days), 90 (10.7%) recurrent strokes and 125 (14.8%) deaths occurred with a cumulative incidence of recurrence or death of 202 (24%). AHI was associated with the combined endpoint in unadjusted (HR=1.09 per one unit increase in AHI (95%CI: 1.08, 1.10)) and fully adjusted models (HR=1.09 (95%CI: 1.08, 1.10)). Mexican American ethnicity was associated with the endpoint (HR=1.71 (95%CI: 1.16, 2.54) in the fully adjusted model. Conclusion: SA is associated with the combined endpoint of recurrent ischemic stroke and mortality in this population-based study. Mexican Americans are also at higher risk of recurrent stroke and death following ischemic stroke than non-Hispanic whites. SA may therefore represent an important modifiable risk factor for poor stroke outcomes and a target to reduce ethnic stroke disparities.

Embolic strokes of undetermined source in young adults: baseline characteristics and long-term outcome.

Embolic strokes of undetermined source (ESUS) are a recent entity, not yet thoroughly investigated in young stroke patients. The clinical characteristics and long-term risks of vascular events and all-cause mortality between young-onset ESUS and other aetiological subgroups were compared. Patients with ESUS were identified amongst the 1008 patients aged 15-49 years with first-ever ischaemic stroke in Helsinki Young Stroke Registry, and primary end-points were defined as recurrent stroke, composite vascular events and all-cause mortality. Cumulative 15-year risks for each end-point were analysed with life tables and adjusted risks were based on Cox proportional hazard analyses. Of the 971 eligible patients, 203 (20.9%) were classified as ESUS. They were younger (median age 40 years, interquartile range 32-46 vs. 45 years, 39-47), more often female (43.3% vs. 35.7%) and had fewer cardiovascular risk factors than other modified TOAST groups. With a median follow-up time of 10.1 years, ESUS patients had the second lowest cumulative risk of recurrent stroke and composite vascular events and lowest mortality compared to other TOAST groups. Large-artery atherosclerosis and small vessel disease carried significantly higher risk for recurrent stroke than did ESUS, whilst no difference appeared between cardioembolism from high-risk sources and ESUS. In our cohort, ESUS patients were younger and had milder cardiovascular risk factor burden and generally better long-term outcome compared to other causes of young-onset stroke. The comparable risk of recurrent stroke between ESUS and high-risk sources of cardioembolism might suggest similarities in their pathophysiology.

Recurrence of embolism post intravenous thrombolysis on an asymptomatic bilateral carotid stenosis

Atherosclerosis is the most common cause of stroke and patients with stroke due to large-vessel atherosclerosis are at the highest risk of recurrent stroke. Carotid endarterectomy (CEA) is a secondary prevention method for reducing the risk of stroke, but endovascular therapy has developed rapidly in recent years. The long-term therapeutic efficacy of endovascular stenting for carotid artery stenosis has been shown not to be inferior to CEA. We present the case of a 61-year-old female, smoker, dyslipidemic, hypertensive, therapeutically neglected, who suddenly developed right hemiplegia accompanied by central facial palsy and motor aphasia. The inclusion criteria allowed the initiation of intravenous thrombolytic therapy. At 2 and 24 hours after thrombolysis the evolution was favorable with the almost complete recovery of motor and speech production deficits. At 48 hours after thrombolysis, the patient experienced rapid decompensation and worsening, with recurrence of hemiplegia on the same side and motor aphasia. Cervical echoDoppler and cerebro-cervical CT angiography (CTA) revealed a complete right internal carotid artery (ICA) and quantified the degree of left ICA stenosis asymptomatic up to that time. The case was a challenge in terms of subsequent secondary prevention. Although most studies dealt with endarterectomy as a treatment for tight carotid stenosis, in the here reported case this was not possible, so we had to resort to angioplasty with placement of a self-expandable stent in the left ICA.

Stroke Risk Is Low after Urgently Treated Transient Ischemic Attack

Over the last decades, the approach to patients with transient ischemic attack (TIA) has shifted from treating only patients considered at high risk of recurrent stroke, to referring all patients with TIA to urgent assessment and immediate initiation of preventive treatment. The data on how this change has influenced the stroke rate after TIA are limited. Thus, the primary aim of this study was to identify the incidence of stroke recurrence after TIA. Second, we wanted to evaluate the ABCD2 score as a predictor of recurrent stroke. Patients discharged with a diagnosis of TIA from the Stroke Unit at Akershus University Hospital between January 1, 2013 and December 31, 2013 were included in the study. Data were obtained from the electronic medical records. Readmission data to capture recurrent strokes were registered until December 31, 2015. In total, 261 patients were included. Mean age was 70.7 years. Stroke incidence at 1 month, 1 year, and the end of follow-up was 1.5% (n = 4), 3.4% (n = 9), and 4.2% (n = 11), respectively. Median time from TIA until recurrent stroke was 90 days. The ability of the ABCD2 score to predict recurrent stroke was low. Urgent admission of patients with TIA is followed by a very low risk of early and late recurrent stroke. The ABCD2 score did not identify patients at high risk of recurrent stroke.

Isolated left ventricular non-compaction (LVNC) and recurrent strokes: to anticoagulate or not to anticoagulate, that is the question

Isolated left ventricular non-compaction (LVNC) is an uncommon primary cardiomyopathy associated with significant risk of thromboembolic stroke. We report a case of a 69-year-old man with a medical history of...

Ischemic Stroke Patients Demonstrate Increased Carotid Plaque Microvasculature Compared to (Ocular) Transient Ischemic Attack Patients

Background: Patients with a recent ischemic stroke have a higher risk of recurrent stroke compared to (ocular) transient ischemic attack (TIA) patients. Plaque microvasculature is considered as a feature of plaque vulnerability and can be quantified with carotid dynamic contrast-enhanced MRI (DCE-MRI). The purpose of this cross-sectional study was to explore the association between plaque microvasculature and the type of recent cerebrovascular events in symptomatic patients with mild-to-moderate carotid stenosis. Methods: A total of 87 symptomatic patients with a recent stroke (n = 35) or (ocular) TIA (n = 52) underwent carotid DCE-MRI examination. Plaque microvasculature was studied in the vessel wall and adventitia using DCE-MRI and the pharmacokinetic modeling parameter K^trans. Statistical analysis was performed with logistic regression, correcting for associated clinical risk factors. Results: The 75th percentile adventitial (OR 1.97, 95% CI 1.18-3.29) K^trans was significantly associated with a recent ischemic stroke compared to (ocular) TIA in multivariate analysis, while clinical risk factors were not significantly associated with the type of event. Conclusions: This study indicates a positive association of leaky plaque microvasculature with a recent ischemic stroke compared to (ocular) TIA. Prospective longitudinal studies are needed to investigate whether K^trans or other plaque characteristics may serve as an imaging marker for predicting (the type of) future cerebrovascular events.

Aspirin resistance are associated with long-term recurrent stroke events after ischaemic stroke.

To investigate the prevalent of aspirin resistance (AR) in stroke and its association with recurrent stroke in 214 patients with ischemic stroke who were receiving aspirin before the stroke onset. Two hundreds and fourteen acute stroke patients who previously received aspirin therapy (100mg/day for ≥7days) were enrolled. Whole blood samples were collected for platelet aggregation testing. The result is expressed in aspirin reaction units (ARU). A cutoff of 550 ARU was used to determine the presence of AR. A follow-up period of 1year was performed to record stroke recurrence events. In this study, the median age was 68 years (IQR, 60-77 years), and 118 (55.1%) were men. A total of 43 of 214 enrolled patients (20.1%) were AR. ARU levels were significantly higher in patients with recurrence than those without (514[IQR: 466-592] vs. 454[IQR: 411-499]; P <0.001). The stroke recurrence distribution across the ARU quartiles ranged between 7.41% (first quartile) to 40.74% (fourth quartile). In multivariate analyses, the 3th and 4th quartile of ARU was significantly associated with stroke recurrence during the observation period compared to the 1st quartile group, and the adjusted risk increased by 215% (OR=3.15 [95% CI 1.96-4.33], P=0.007) and 322% (4.22[2.56-7.16], P<0.001). In multivariate logistic regression analysis, AR was associated with a higher risk of stroke recurrence, and the adjusted risk increased by 365% (OR=4.65; 95% CI=2.99-8.16; P<0.001). In conclusion, AR is not uncommon in Chinese stroke patients who receive anti-platelet medications. Patients with AR may have a greater risk of suffering stroke recurrence events.

Left Atrial Size and Long-Term Risk of Recurrent Stroke After Acute Ischemic Stroke in Patients With Nonvalvular Atrial Fibrillation.

BackgroundAmong patients with ischemic stroke and atrial fibrillation, which ones are at high risk of recurrent stroke is unclear. This study aimed to determine whether left atrial size was associated with long‐term risk of stroke recurrence in patients with nonvalvular atrial fibrillation.Methods and ResultsIn this multicenter prospective cohort study, nonvalvular atrial fibrillation patients hospitalized for acute ischemic stroke were enrolled and followed up after discharge. Indexed‐left atrial diameter was obtained by dividing left atrial diameter by body surface area. Cause‐specific and subdistribution hazard ratios of recurrent stroke were estimated by Cox proportional hazards and Fine–Gray models, respectively. Risk prediction was evaluated by integrated discrimination improvement and net reclassification improvement. In total, 1611 patients (77.8±10.2 [mean±SD] years, 44.5% female) were included. During follow‐up for 2.40±1.63 (mean±SD) years, 251 patients had recurrent stroke and 514 patients died. An increased indexed‐left atrial diameter (per 1 cm/m2) was significantly associated with elevated risk of stroke recurrence (hazard ratio 1.60, 95% CI 1.30–1.98). The association was maintained when death was regarded as the competing risk and in 1464 patients who were treated with anticoagulants (hazard ratio 1.59, 95% CI 1.27–2.00). Risk prediction for recurrent stroke was significantly improved by adding indexed‐left atrial diameter to the baseline model composed of the factors in the CHADS 2 score or those in the CHA 2 DS 2‐VASc score.ConclusionThese findings suggest that left atrial enlargement is associated with an increased risk of recurrent stroke in nonvalvular atrial fibrillation patients with ischemic stroke.

Association of circulating high-sensitivity C-reactive protein with late recurrence after ischemic stroke.

We investigated the association between serum levels of high-sensitivity C-reactive protein (hs-CRP) and stroke recurrence events in a cohort of patients with acute ischemic stroke (IS). We prospectively studied 286 patients with acute IS who were admitted within 24 h after the onset of symptoms. Serum levels of hs-CRP, and National Institutes of Health stroke scale (NIHSS) were measured at admission. The primary endpoint was stroke recurrence 1 year after stroke onset. We used logistic regression models to assess the relationship between hs-CRP levels and the risk of recurrent stroke. In multivariable models, hs-CRP levels were associated with an increased risk of an NIHSS greater than 6 [odds ratio=1.17; 95% confidence interval (CI)=1.05-1.48; P=0.021]. Among the participants, stroke recurrence was found in 48 (16.8%) cases. In multivariate analyses, the third and fourth quartiles of hs-CRP were significantly associated with stroke recurrence during the observation period compared with the first quartile group (P<0.01). In addition, the hs-CRP level in the highest quartile was associated with a higher risk of stroke recurrence (odds ratio=2.75; 95% CI=1.62-3.92; P=0.006). Hs-CRP (area under the curve=0.71; 95% CI=0.64-0.79) improved the ability of the NIHSS score to diagnose stroke recurrence (area under the curve of the combined model 0.78; 95% CI=0.73-0.84; P<0.01). Serum levels of hs-CRP at admission predicted the future stroke recurrence in patients with IS.