High Risk Of Recurrent Stroke Research Articles

Peripheral blood mononuclear cell low molecular mass protein 7 in acute ischemic stroke: vertical change from admission to discharge and correlation with disability, stroke recurrence, and death.

Low molecular mass protein 7 (LMP7) aggravates abnormal T cell differentiation and atherosclerosis, but its clinical role in acute ischemic stroke (AIS) is still unclear. This study aimed to investigate the correlation of peripheral blood mononuclear cell (PBMC) LMP7 with T cell subsets, disease severity, and prognosis in AIS patients. A total of 162 AIS patients were enrolled for detecting PBMC LMP7 and T helper (Th) 1, Th2, and Th17 cells via reverse transcriptase-polymerase chain reaction and flow cytometry, respectively. In addition, PBMC LMP7 at discharge was also quantified. Increased LMP7 at admission was associated with decreased Th2 cells (P=0.014), elevated Th17 cells (P<0.001), C-reactive protein (P=0.005), National Institutes of Health Stroke Scale (NIHSS) score (P=0.007), and disease severity (defined by NIHSS score) (P=0.010). LMP7 at admission reflected a high risk of stroke recurrence (area under curve (AUC): 0.748, 95% confidence interval (CI): 0.564-0.932), but not mRS score at month 3 (M3) >2 (AUC: 0.585, 95%CI: 0.479-0.691), or death (AUC: 0.723, 95%CI: 0.338-1.000). LMP7 at discharge was reduced compared to that at admission (P<0.001). LMP7 at discharge was positively correlated with the risk of stroke recurrence (AUC: 0.849, 95%CI: 0.735-0.963) and death (AUC: 0.919, 95%CI: 0.836-1.000), but had a weak capacity to reflect mRS score at M3 >2 (AUC: 0.671, 95%CI: 0.578-0.765). PBMC LMP7 positively correlates with Th17 cells, inflammation, and disease severity in AIS patients, meanwhile, its level at discharge shows a good ability to reflect the risks of stroke recurrence and death.

Abstract TMP66: Ipsilateral Carotid Web is Associated With Higher Risk of Recurrent Stroke in Patients With Large Vessel Occlusion Undergoing Thrombectomy

Introduction: Carotid artery webs are a rare cause of embolic stroke of undetermined source, especially among the young without conventional risk factors. However, despite its detriment, the rate of stroke recurrence is not well studied. We aimed to understand the likelihood of stroke recurrence in patients with a confirmed symptomatic carotid web. Methods: We analyzed data from adult patients admitted with anterior large vessel occlusion at Rhode Island Hospital from July 2015 to March 2023. The assessment of carotid webs was conducted by a group of endovascular neurosurgeons and vascular neurologists by reviewing the vessel imaging. Any identified carotid webs on vascular imaging were reviewed by an independent vascular neurologist for adjudication. Chi square and fisher’s exact tests were used for the comparison of groups. After adjusting for age, admission NIHSS, known atrial fibrillation, and site of occlusion, multivariate logistic regression modeling was performed for in-hospital recurrence ischemic stroke. Results: Of the 1225 patients with anterior circulation large vessel occlusion, 22(1.80%) had ipsilateral carotid artery web. Patients with carotid web were younger than those without carotid web (73% &lt;65 years). Patients with ipsilateral carotid web had a higher risk of recurrent stroke compared to those without ipsilateral carotid web (OR 3.35, 95% CI,1.043373-10.7041, p = 0.042). Conclusion: Carotid webs are an under recognized cause of acute large vessel occlusion and are associated with higher risk of early recurrence. Studies are needed to validate our findings and test early revascularization strategies in patients with symptomatic carotid artery webs.

Future of Endovascular and Surgical Treatments of Atherosclerotic Intracranial Stenosis.

Intracranial atherosclerotic disease and resultant intracranial stenosis is a global leading cause of stroke, and poses an ongoing treatment challenge. Among patients with intracranial stenosis, those with hemodynamic compromise are at high risk for recurrent stroke despite medical therapy and risk factor modification. Revascularization of the hypoperfused territory is the most plausible treatment strategy for these high-risk patients, yet surgical and endovascular therapies have not yet shown to be sufficiently safe and effective in randomized controlled trials. Advances in diagnostic and therapeutic technologies have led to a resurgence of interest in surgical and endovascular treatment strategies, with a growing body of evidence to support their further evaluation in the treatment of select patient populations. This review outlines the current and emerging endovascular and surgical treatments and highlights promising future management strategies.

Optimal Medical Management of Atherosclerotic Intracranial Stenosis.

Reducing the high risk of recurrent stroke in patients with symptomatic intracranial atherosclerotic stenosis (sICAS) has proven to be challenging, but aggressive medical management, with intensive risk factor control and antithrombotic therapy, has been shown to be beneficial. High-intensity statins are recommended for patients with atherosclerotic stroke, including sICAS. Ezetimibe and PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors are beneficial for those who fail to reach low-density lipoprotein targets or those with statin intolerance. The treatment target for sICAS is low-density lipoprotein <70 mg/dL. In neurologically stable patients, blood pressure should be treated to goal <140/90 mm Hg with the use of thiazide diuretics, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers preferentially. For those with diabetes, treat to goal hemoglobin A1C ≤7% for most patients through combination of diet, insulin, and hypoglycemic drugs. Some degree of physical activity (eg, walking, stationary biking with arms or legs, etc) should be encouraged in all patients with sICAS who are not severely disabled. A minimum of 10 minutes of moderate-intensity aerobic activity 4 times a week is recommended for patients who are capable of exercise. For all patients with severe sICAS (70%-99% stenosis), dual antiplatelet therapy for up to 90 days followed by single antiplatelet agent is recommended.

Abstract 39: Slow-Flow in the Left Atrial Appendage on Cardiac CT in Patients With Acute Ischemic Stroke

Background: Slow-flow in the left atrial appendage (LAA) is thought to be associated with an increased risk of thrombus formation and stroke. We studied LAA slow-flow on cardiac CT in patients with acute ischemic stroke (AIS). Method: We used data from Mind the Heart, a prospective cohort study of AIS patients who underwent ECG-gated cardiac CT during the acute imaging protocol. We compared baseline characteristics, functional outcome (modified Rankin scale), stroke recurrence and major adverse cardiovascular events (MACE) after 2-year follow-up between patients with LAA thrombus (filling defect &lt;100 Hounsfield Unit [HU]), slow-flow (filling defect, but with ≥100 HU) and normal filling. We performed a sensitivity analysis restricted to cryptogenic stroke patients. Results: Of 421 patients, 31 (7%) were classified as LAA thrombus, 69 (16%) as LAA slow-flow and 321 (76%) as normal LAA filling. Patients with LAA thrombus or slow-flow more often had atrial fibrillation compared to normal filling (45%, 39%, 9%, p&lt;0.001, respectively). LAA thrombus patients had more severe strokes compared to slow-flow and normal filling (NIHSS 18 [IQR: 9-22], 6 [IQR: 3-17], 5 [IQR: 2-11], p&lt;0.001). There was no significant difference between LAA slow-flow patients and normal LAA filling in functional outcome (acOR: 0.8, 95%CI 0.5-1.4), recurrent ischemic stroke (aHR 0.8, 95%CI: 0.3-1.9) or MACE (aHR 1.2, 95%CI 0.7-2.1). In cryptogenic stroke patients (n=156), LAA slow-flow was associated with a higher risk of recurrent stroke (aHR: 4.1, 95%CI: 1.1-15.7) compared to normal LAA filling (Figure 1). Conclusion: Patients with LAA slow-flow had similar characteristics compared to patients with a thrombus, including high rates of atrial fibrillation, but had less severe strokes. Compared to patients with normal filling, LAA slow-flow was not significantly associated with worse functional outcome or MACE, but was associated with recurrent stroke in patients with cryptogenic stroke.

Association between antithrombotic therapy after stroke in patients with atrial fibrillation and the risk of net clinical outcome: an observational cohort study.

Data on the optimal use of antithrombotic drugs and associated clinical outcomes in patients with atrial fibrillation (AF) and acute ischaemic stroke (IS) are limited. We investigated the prescription patterns of antithrombotics in community practice and long-term clinical prognosis according to early post-stroke antithrombotic therapy in patients with AF and acute IS. Patients with AF who were admitted for acute IS at a single tertiary hospital in 2010-2020 were retrospectively reviewed. Clinical profiles including the aetiology of stroke and prescription patterns of antithrombotics were identified. The net clinical outcome (NCO)-the composite of recurrent stroke, any bleeding, hospitalization or emergency department visits for cardiovascular (CV) events, and death-was compared according to the antithrombotic therapy at the first outpatient clinic visit [oral anticoagulation (OAC) alone vs. antiplatelet (APT) alone vs. OAC/APT(s)] following discharge. A total of 918 patients with AF and acute IS (mean age, 72.6 years; male, 59.3%; mean CHA₂DS₂-VASc score 3.3) were analysed. One-third (33.9%, n = 310) of patients were simultaneously diagnosed with AF and IS. The most common aetiology of IS was cardioembolism (71.2%), followed by undetermined aetiology (19.8%) and large artery atherosclerosis (6.0%). OAC, APT(s), and concomitant OAC and APT(s) were prescribed in 33.4%, 11.1%, and 53.4% of patients during admission that changed to 67.0%, 9.1%, and 21.7% at the first outpatient clinic, and were mostly continued up to one year after IS. Non-prescription of OAC was observed in 11.3% of post-stroke patients with AF. During a median follow-up of 2.1 years, the overall incidence rate of NCO per 100 patient-year (PY) was 20.14. APT(s) monotherapy presented the highest cumulative risk of NCO (adjusted hazard ratio 1.47, 95% confidence interval 1.08-2.00, P = 0.015; with reference to OAC monotherapy) mainly driven by the highest rates of recurrent stroke and any bleeding. OAC/APT(s) combination therapy was associated with a 1.62-fold significantly higher risk of recurrent stroke (P = 0.040) and marginally higher risk of any bleeding than OAC monotherapy. Approximately one-third of acute IS in AF have a distinctive mechanism from cardioembolism. Although APT was frequently prescribed in post-stroke patients with AF, no additive clinical benefit was observed. Adherence to OAC treatment is essential to prevent further CV adverse events in patients with AF and IS.

Edge-Type Hyperintense Intracranial Artery Plaque: A Potential MRI Biomarker of Stroke Recurrence.

Identifying patients at high risk of stroke recurrence is important for stroke prevention and treatment. To explore the characteristics of T1 hyperintense plaques (HIP) and their relationship with stroke recurrence in patients with symptomatic intracranial atherosclerotic stenosis (sICAS). Retrospective. One hundred fifty-seven patients with moderate-to-severe (≥50%) nonocclusive sICAS and MRI studies (42 females and 115 males, mean age 58.69 ± 10.68 years). 3D higher-resolution black-blood T1-weighted fast-spin-echo sequence at 3.0 T. HIP (signal intensity [SI] of plaque-to-adjacent gray matter >1.0 on non-contrast T1-weighted images) and non-HIP plaques were identified. HIP plaques were categorized as edge type (high SI adjacent to lumen) and non-edge type (high SI within plaque). Clinical and imaging features of different plaque types were compared. Stroke recurrence was assessed through telephone or medical records at 3 and 6 months, and then once a year post-MRI. The relationship between edge type and non-edge types HIP with stroke recurrence was analyzed. Student's t test, Mann-Whitney U-test, chi square test and Fisher's exact test to compare features between plaque types. Kaplan-Meier curves (with log-rank tests) and Cox proportional hazards regression to assess relationship between stroke recurrence and different plaque types. A two-tailed P-value of <0.05 was considered statistically significant. Of 157 culprit lesions, 87 (55%) were HIPs (43 edge type, 44 non-edge type) and 70 (45%) were non-HIPs. Plaque thickness, area, and volume were significantly higher for HIPs than for non-HIPs. Among patients with HIPs, edge type was significantly more likely in the posterior circulation (53.5% vs. 27.3%), and had significantly higher plaque thickness, length, area, volume, plaque burden, and remodeling index than non-edge type. Edge-type HIP was significantly more common than non-edge HIP in patients with diabetes mellitus (51.2% vs. 29.5%) and dyslipidemia (79.1% vs. 54.5%). During median follow-up of 27 months, 33 patients experienced stroke recurrence. Recurrence was associated with edge-type HIP (adjusted hazard ratio = 2.83; 95% confidence interval: 1.40-5.69), both in the overall cohort (34.9% vs. 15.8%) and in patients with HIP (34.9% vs. 9.0%). Age ≥60 years and edge-type HIP had a significant interaction. Hyperintense plaque may be categorized as edge type or non-edge type. Edge-type HIP may be a potential MRI biomarker of stroke recurrence. 3 TECHNICAL EFFICACY: Stage 2.

Association of Prediabetes and Recurrent Stroke in Atrial Fibrillation Patients: A Population-Based Analysis of Hospitalizations and Outcomes.

Prediabetes is a risk factor for ischemic stroke in atrial fibrillation (AF) patients, yet, its impact on recurrent stroke in AF patients remains understudied. Using the 2018 National Inpatient Sample, we investigated the link between Prediabetes and recurrent stroke in AF patients with prior stroke or transient ischemic attack (TIA). Among 18,905 non-diabetic AF patients, 480 (2.5%) had prediabetes. The prediabetic group, with a median age of 78, exhibited a two-fold higher risk of recurrent stroke compared to the non-prediabetic cohort (median age 82), as evidenced by both unadjusted (OR 2.14, 95% CI 1.72-2.66) and adjusted (adjusted for socio-demographics/comorbidities, OR 2.09, 95% CI 1.65-2.64, p < 0.001). The prediabetes cohort, comprising more male and Black patients, demonstrated associations with higher Medicaid enrollment, admissions from certain regions, and higher rates of hyperlipidemia, smoking, peripheral vascular disease, obesity, and chronic obstructive pulmonary disease (all p < 0.05). Despite higher rates of home health care and increased hospital costs in the prediabetes group, the adjusted odds of all-cause mortality were not statistically significant (OR 0.55, 95% CI 0.19-1.56, p = 0.260). The findings of this study suggest that clinicians should be vigilant in managing prediabetes in AF patients, and strategies to prevent recurrent stroke in this high-risk population should be considered.

Acute Ischaemic Stroke in the Context of Neurosyphilis: How Does Antibiotic Therapy Help, and When Should It Be Given?

Neurosyphilis (NS) refers to a central nervous system infection caused by Treponema pallidum. In recent years, there has been an increasing incidence of syphilis; however, NS is uncommon compared to the era before the discovery of penicillin. Manifestations are usually non-specific, ranging from asymptomatic cases to syphilitic meningitis, meningovascular syphilis, general paresis and tabes dorsalis. Meningovascular syphilis can cause an inflammatory arteritis of cerebral arteries, leading to vascular occlusion and cerebral infarction. We report a case of an ischaemic stroke in a patient with several vascular risk factors, presenting with right hemiparesis, hemihypesthesia and dysarthria. Initial computed tomography with angiography of the head and neck was normal; however, magnetic resonance imaging of the brain revealed a thalamic and internal capsule infarct. Serum T. pallidum antibodies were positive, as well as a rapid plasma reagin test. Cerebrospinal fluid analysis confirmed the diagnosis of neurosyphilis, and the patient was treated with ceftriaxone for 14 days due to a penicillin allergy. Although there is a high prevalence of stroke in patients with NS, this condition is typically underdiagnosed. Untreated NS carries a higher risk of stroke recurrence compared to other risk factors. Therefore, early diagnosis and treatment are essential. This case highlights the importance of considering NS in stroke victims, even in older patients with several additional vascular risk factors, to prevent recurrence and other complications. Neurosyphilis (NS) can occur at any stage of syphilis infection, and it can be asymptomatic or symptomatic, presenting as syphilitic meningitis, meningovascular syphilis, general paresis or tabes dorsalis.Ischaemic strokes are a frequent complication of NS, occurring in 14% of the cases. However, only 19% of the cases are correctly diagnosed.NS should be considered as a potential cause of stroke, even in older patients with several other vascular risk factors. This is essential to prevent future strokes, as well as dementia and other complications.

Effect of pioglitazone on vascular events in post-stroke cognitive impairment: Post hoc analysis of the IRIS trial.

In stroke patients with insulin resistance (IR), post-stroke cognitive impairment (PSCI) is associated with higher risk of recurrent stroke, but the effect of pioglitazone on that risk has not been explored. The goal of this study was to compare the secondary stroke prevention effect of pioglitazone against placebo in patients with versus without PSCI. We studied patients enrolled in the Insulin Resistance Intervention after Stroke (IRIS) trial with a post-stroke modified Mini-Mental State Examination (3MS) cognitive assessment (mean time of assessment: 79 days post-stroke). We considered a baseline score of ⩽ 88 on the 3MS to indicate global PSCI, and domain-specific summary scores in the lowest quartile to indicate attention, language, memory, orientation, and visuospatial impairments. In n = 3338 patients with IR, the effect of pioglitazone versus placebo on secondary stroke significantly differed by initial post-stroke global (interaction p = 0.0127) and memory impairment status (interaction p = 0.0003). Hazard ratios (HRs) were time-dependent such that, among those with either global or memory impairment, pioglitazone has an increasingly stronger protective effect at later timepoints. There was no statistically significant effect of pioglitazone among those without either global or memory impairment. The effect of pioglitazone versus placebo on myocardial infarction (MI) also significantly differed by global impairment status (interaction p = 0.030). Pioglitazone was protective among those with global impairment (HR = 0.23 [95% CI: 0.08, 0.71]) but not among those without (HR = 0.88 [95% CI: 0.59, 1.31]). These data indicate that pioglitazone treatment may be more effective at reducing risk of recurrent stroke and MI in stroke patients with PSCI. Simple cognitive testing 2-3 months post-stroke may identify patients for whom treatment would be most beneficial.

D-Dimer Trends Predict Recurrent Stroke in Patients with Cancer-Related Hypercoagulability.

In patients with cancer-associated hypercoagulability (CAH)-related stroke, D-dimer trends after anticoagulant therapy may offer a biomarker of treatment efficacy. The purpose of this study was to clarify the association between D-dimer trends and recurrent stroke after anticoagulant therapy in patients with CAH-related stroke. We performed retrospective cohort study of consecutive patients with CAH-related stroke at two stroke centers from 2011 to 2020. The ratio of posttreatment to pretreatment D-dimer levels (post/pre ratio) was used as an indicator of D-dimer trends after anticoagulant therapy. Fine-Gray models were used to evaluate the association between post/pre ratio and recurrent stroke. Among 360 acute ischemic stroke patients with active cancer, 73 patients with CAH-related stroke were included in this study. Recurrent stroke occurred in 13 patients (18%) during a median follow-up time of 28 days (interquartile range, 11-65 days). Multivariate analysis revealed that high post/pre ratio was independently associated with recurrent stroke (per 0.1 increase: hazard ratio 2.20, 95% confidence interval 1.61-3.01, p = 0.012). D-dimer levels after anticoagulant therapy were associated with recurrent stroke in CAH-related stroke patients. Patients with neutral trends in high D-dimer levels after anticoagulant therapy were at high risk of recurrent stroke.

Imaging of Vertebral Artery Dissection in Children: An Underrecognized Condition with High Risk of Recurrent Stroke.

Vertebral artery dissection (VAD) is a common cause of a rare condition, pediatric posterior circulation arterial ischemic stroke (PCAIS). VAD is clinically important due to the risk of multifocal and continuing infarcts from artery-to-artery thromboembolism, with the potential for occlusion of arteries that perfuse the brainstem. Early diagnosis is important, as recurrent stroke is a common effect of VAD in children. Although the relative efficacies of different treatment regimens for VAD in children remain unsettled, early initiation of treatment can mitigate the risk of delayed stroke. Clinical diagnosis of PCAIS may be delayed due to multiple factors, including nonspecific symptoms and the inability of younger patients to express symptoms. In fact, subacute or chronic infarcts are often present at initial imaging. Although the most common cause of isolated PCAIS is VAD, imaging of the cervical arteries has been historically underused in this setting. Cervical vascular imaging (MR angiography, CT angiography, and digital subtraction angiography) for VAD must be optimized to detect the sometimes subtle findings, which may be identified at initial or follow-up imaging. Osseous variants of the craniocervical junction and upper cervical spine and other extrinsic lesions that may directly injure the vertebral arteries or lead to altered biomechanics have been implicated in some cases. The authors review characteristic imaging features and optimized imaging of VAD and associated PCAIS and related clinical considerations. Identification of VAD has important implications for evaluation, treatment, and imaging follow-up, as this condition may result in progressive arteriopathy and recurrent stroke. © RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Prevalence and prognosis of acute ischemic stroke coexisting with unruptured intracranial aneurysms.

The prevalence of unruptured intracranial aneurysms (UIAs) in the acute ischemic stroke (AIS) cohort is probably higher than in the general population. This study investigated the prevalence of UIAs in AIS patients and the management risk and prognosis when treating AIS. From January 2020 to January 2023, we conducted a single-center retrospective study at Tianjin Huanhu Hospital. Each patient underwent both brain MRI and MRA/CTA to diagnose AIS and UIAs. Clinical, radiologic, and therapeutic data during hospitalization and prognosis were analyzed. Propensity-score matching (PSM) was performed to evaluate the risk of in-hospital adverse events, unfavorable outcomes at discharge when receiving post-stroke treatment and stroke recurrence. In all, 2,181 AIS patients were included, of whom 270 had UIAs (12.4%; 95%CI 11.0-13.8%). From the unmatched and matched cohort, the incidence of in-hospital adverse events and unfavorable outcomes at discharge in patients with UIAs were not significantly different; the risk of stroke recurrence was significantly higher in patients with UIAs than in those without (unmatched: aHR, 1.71 [1.08-2.70]; matched: aHR, 2.55 [1.16-5.58]). Multivariable Cox regression models showed that aneurysm size and the presence of homoregional infarction associated with higher risk of recurrence (unmatched: aHR, 1.31 [1.21-1.41] and aHR, 3.50 [1.52-8.10]; matched: aHR, 1.28 [1.18-1.40]; p < 0.001 and aHR, 3.71 [1.12-12.34]). The UIAs may not increase the risk of in-hospital adverse events and unfavorable outcomes at discharge in receiving post-stroke treatment, but it may associated with a high risk of stroke recurrence.

NCMP-20. ASSESSING THE IMPACT OF DRIVER MUTATIONS AND ANTINEOPLASTIC TREATMENTS ON RISK FOR STROKE RECURRENCE IN PATIENTS WITH LUNG ADENOCARCINOMA

Abstract BACKGROUND Hypercoagulability is a well-described paraneoplastic phenomenon associated with strokes in cancer patients, but whether driver mutations or antineoplastic treatments contribute in a significant way to recurrent stroke risk are not well understood. METHODS As part of a larger study focusing on lung cancer and stroke, we retrospectively identified 103 patients with tissue-confirmed adenocarcinoma and prior diagnosis of stroke treated at the Mayo Clinic between 2000-2022. We collected data regarding demographics, performance status, cerebrovascular risk factors, antithrombotic use, chemotherapy, radiation, and genetic testing data, which were assessed for impact on recurrent stroke risk. RESULTS 71.8% of patients had recurrent strokes (74/103). No class of chemotherapeutics was significantly associated with increased risk for recurrent strokes, including immune checkpoint inhibitors and thrombogenic chemotherapeutics (Gemcitabine, Cisplatin, Carboplatin, anti-VEGF therapies). 78 patients had genetic testing data available. Driver mutations in KRAS, EGFR, MET, and BRAF were not associated with increased risk for recurrent stroke. There was a signal towards increased risk for stroke recurrence in patients with ALK mutations (OR 2.647, p=0.4056). There was a trend towards increased risk for stroke recurrence in patients with advanced staging (Stage III/IV) at diagnosis (OR 2.125, p=0.09). Stroke recurrence risk was higher in patients treated with single antiplatelet agents compared to anticoagulation or dual antiplatelet therapy (OR 3.385, p=0.0061) though risk of hemorrhagic complications was similar (OR 1.559, p=0.3376). Patients with recurrent stroke had longer overall survival compared to those without (Median OS 43.2 months vs 26.3 months, Mantel-Haenszel HR 0.5202, p=0.0367). CONCLUSIONS In patients with lung adenocarcinoma who experienced ischemic stroke, prolonged survival and single antiplatelet therapy compared to dual antiplatelet therapy or anticoagulation were associated with increased recurrent stroke risk. ALK mutations and higher stage at initial diagnosis trended towards higher risk for stroke recurrence. Larger retrospective analyses are under way to confirm these findings.

Left atrial strain predicts stroke recurrence and death in patients with cryptogenic stroke

Abstract Background Left atrial strain (LAS) has been widely studied as predictor of atrial fibrillation (AF) after cryptogenic stroke (CS). However, the evidence about its prognostic role in terms of stroke recurrence and death in this setting remains scarce. Methods From April 2019 to April 2022, 92 consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale ≥4 of unknown etiology were prospectively recruited. Echocardiography, including LAS was performed during admission. The primary outcome was the composite of stroke recurrence or death. Results Mean age was 77.5±7.7 and 58% of patient were female. After a median follow up of 28 months, the primary outcome measure occurred in 15 patients (16%). The primary outcome was more frequent in patients with diabetes (53% vs 21%; p=0.02), chronic kidney disease (33% vs 10%; p=0.034) and history of heart failure (13% vs 0%; p=0.025). LAS reservoir (LASr) and LAS conduct (LAScd) were lower in patients developing the primary outcome (21±7 vs 28.8±11%; p=0.017 and 7.7±3.9 vs 13.7±7%; p=0.007, respectively). On multivariate analysis, diabetes (HR 7.4, 95%CI 1.2-47; p=0.034)), LASr (HR 0.2, 95%CI 0.05-0.8; p=0.023), LAScd (HR 0.17, 95%CI 0.04-0.7; p=0.013) and LAS contraction (HR 0.2, 95%CI 0-05-0.8; p=0.025) were independent predictors of stroke recurrence or all-cause death after CS (Table). On long-rank test (using the discriminatory cut-off values of LASr &amp;lt;23% and LAScd &amp;lt;10%), LASr (p=0.009) (Figure 1) and LAScd (p=0.016) were associated with higher risk of the primary outcome. Conclusion Lower values of LAS reservoir, conduct and contraction are independently associated with higher risk of stroke recurrence or death after CS

The effect of educational level on the recurrence rate and number of episodes of stroke in stroke survivors

ObjectivesThis study aimed to assess the influence of educational level on the recurrence rate and number of stroke episodes in stroke survivors. Materials and methodsFor this cross-sectional study, information regarding patient characteristics, medical history, ability to perform activities of daily living, level of disability, number of episodes, and stroke recurrence was collected. Analyses were conducted using the chi-square test, analysis of variance, nonparametric test, Cox regression model, and the Kaplan-Meier method. ResultsOf the 696 stroke survivors enrolled in this study, the average stroke recurrence rate was 20.83 %, and the recurrence rates in patients with primary (or lower), secondary, and university (or higher) education were 26.58, 19.54 and 14.29 %, respectively. Patients with primary (or lower) or secondary education had a higher risk for stroke recurrence than those with a university education or higher. We found that the recurrence rate 10 years after an initial stroke was higher than that after 5 years. Moreover, there was a statistically significant difference in the cumulative recurrence rate among the three groups (χ2 = 9.36, P < 0.05). Lastly, the proportions of the number of stroke episodes differed between the various education level groups (P < 0.05). ConclusionsA lower educational level was shown to be a risk factor for stroke recurrence and education levels have an impact on the number of stroke episodes. Our results suggest that is necessary to strengthen post-stroke management and rehabilitation interventions for patients with low educational levels.

Left Atrial Strain Predicts Stroke Recurrence and Death in Patients With Cryptogenic Stroke

Left atrial strain (LAS) has been widely studied as a predictor of atrial fibrillation (AF) after cryptogenic stroke (CS). However, the evidence about its prognostic role in terms of stroke recurrence and death in this setting remains scarce. A total of 92 consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale ≥4 of unknown etiology were prospectively recruited. Echocardiography, including LAS was performed during admission. The primary outcome measure was the composite of stroke recurrence or death. The mean age was 77.5 ± 7.7, and 58% of patients were female. After a median follow up of 28 months, the primary outcome measure occurred in 15 patients (16%). The primary outcome was more frequent in patients with diabetes (53% vs 21%, p=0.02), chronic kidney disease (33% vs 10%, p=0.034), and a history of heart failure (13% vs 0%, p=0.025). LAS reservoir (LASr) and LAS conduit (LAScd) were lower in patients developing the primary outcome (21% ± 7% vs 28.8% ± 11%, p=0.017 and 7.7% ± 3.9% vs 13.7% ± 7%, p=0.007, respectively). On multivariate analysis, LASr (hazard ratio 0.9, 95% confidence interval 0.85 to 0.99, p=0.048) and diabetes (hazard ratio 3.3, 95% confidence interval 1.03 to 10.4, p=0.045) were associated with stroke recurrence or all-cause death after CS. On the log-rank test (using the discriminatory cut-off value of LASr <23%), LASr (p=0.009) was associated with higher risk of the primary outcome. In conclusion, lower values of the LAS reservoir were associated with a higher risk of stroke recurrence or death after CS. LAS may identify patients at higher risk of thromboembolism and stress conditions.

Low-density Lipoprotein Cholesterol Reduction Therapies for Secondary Prevention in Patients with Stroke: A Network Meta-analysis.

Patients with previous strokes are at a higher risk of stroke recurrence. Current guidelines recommend a range of low-density lipoprotein cholesterol (LDL-C)-lowering treatments to reduce the risk of recurrent stroke. However, the optimal agent for decreasing LDL-C to lower the risk of recurrent stroke remains unclear. This study aimed to assess the relative effects of various LDL-C -lowering agents for secondary stroke prevention. Several databases were searched from inception up to 2022. Only randomized controlled trials that compared different LDL-C-lowering agents in adult patients with previous strokes were included. The primary endpoint was a recurrent stroke. The surface under the cumulative ranking curve (SUCRA) was also applied to estimate the overall ranking probability of the treatment agents for each outcome. Overall, nine trials comprising 17,226 patients were included. Ezetimibe plus statins (RR: 0.56, 95% CrI: 0.35-0.87) and statins alone (RR: 0.90, 95% CrI: 0.81-1.00) reduced the risk of stroke recurrence. Ezetimibe plus statins was superior to statins alone in decreasing the incidence of recurrent stroke (RR: 0.62, 95% CrI: 0.39-0.95). However, treatment with statins was related to an increased risk of hemorrhagic stroke compared to placebo (RR: 1.57, 95% CrI: 1.13-2.21). All agents were related to a decreased incidence of major adverse cardiovascular events. Treatment with ezetimibe plus statins was suggested as the most efficacious in decreasing the incidence of recurrent stroke. The analysis also revealed that statin monotherapy was related to an increased risk of hemorrhagic stroke.

Endovascular Treatment of Symptomatic Basilar Artery Stenosis.

While symptomatic basilar artery (BA) stenosis is associated with a higher risk of recurrent stroke or death, there is no consensus on the management of these patients who are refractory to antiplatelet therapy. This study retrospectively assesses the outcomes of endovascular treatment (EVT) for symptomatic BA stenosis. We conducted a retrospective review of patients with symptomatic BA stenosis who underwent EVT, including angioplasty or stenting, from 2006 to 2018. A total of 15 patients, who experienced transient ischemic attacks or strokes despite dual antiplatelet therapy, were included. EVT was performed under local anesthesia after pretreatment with antiplatelet medications. Angiographic follow-up was performed at 12 and 24 months post-EVT. Clinical outcomes were evaluated using the modified Rankin Scale (mRS). EVT was successfully completed in all patients. Peri/post-procedural complications occurred in 33% of cases, including in-stent thrombosis, intracranial hemorrhage, and pontine infarction. At long-term follow-up (mean 98.5±80.5 months), 73.3% of patients achieved a favorable functional outcome (mRS≤2) without disability or mortality. Patients with unfavorable outcomes had previous infarcts, with 2 experiencing new pontine infarctions after stenting. This study suggests that EVT, including angioplasty and stenting, may offer promise as a treatment option for symptomatic BA stenosis refractory to medical therapy. However, the procedure carries a notable risk of complications, especially in patients with severe stenosis and previous infarcts. Careful patient selection, based on clinical and radiological criteria, is crucial.

Intracranial stenting versus aggressive medical therapy for symptomatic intracranial stenosis: A meta-analysis of multicenter randomized controlled trials and an expert assessment of the current data.

Intracranial atherosclerotic stenosis (ICAS) is associated with high risk of recurrent strokes despite best medical management (MM). We aimed to synthesize the evidence from randomized studies comparing intracranial stenting plus MM versus MM alone. Comprehensive search of MEDLINE database was performed until May 2023. The data were extracted and pooled as risk ratio (RR) with 95% confidence interval (95% CI). We included three multicenter RCTs totaling 919 patients. As compared to MM alone, intracranial stenting was associated with statistically significant higher risks of any stroke or death (RR = 2.93, 95%CI [1.80-4.78], p < 0.0001), stroke in the same territory of qualifying artery (RR = 3.56, 95%CI [1.97-6.44], p < 0.0001), any ischemic stroke (RR = 2.22, 95%CI [1.27-3.87], p = 0.005), hemorrhagic stroke (RR = 13.49, 95%CI [2.59-70.15], p = 0.0002), and death (RR = 5.43, 95%CI [1.21-24.40], p = 0.003) within 30 days of randomization. There was a persistent lack of benefit and signals of harm at the last follow up within 1-3 years: any stroke or death (RR = 1.57, 95%CI [0.92-2.67], p = 0.1), stroke in the same territory of qualifying artery (RR = 1.84, 95%CI [0.97-3.50], p = 0.06), any ischemic stroke (RR = 1.56, 95%CI [1.11-2.20], p = 0.01), death (RR = 1.61, 95%CI [0.77-3.38], p = 0.2). The cumulative rate of stroke in the same territory of qualified artery with MM alone within the 1-3-year follow up was lower than expected, with only 47 out of the 450 (10.4%) MM alone patients suffering such events. The findings from this meta-analysis do not recommend stenting as a routine care option for the broader symptomatic ICAS patient population. The rates of recurrent strokes in ICAS patients managed with aggressive MM do not seem to be as high as anticipated. Additional multicenter RCTs including safer devices, larger sample sizes, and patients at higher risk of recurrent events are warranted.