Index Ischemic Stroke Research Articles

Ischemic Stroke in Patients With Congenital Heart Disease and Atrial Fibrillation.

Atrial fibrillation (AF) is a common arrhythmia in patients with congenital heart disease (CHD), but little is known about the risk for ischemic stroke among younger patients with CHD (aged <65 years) with AF. Using data from the National Swedish Patient Register and Cause of Death Register, we identified all patients with both CHD and AF born in Sweden between 1970 and 2017. The Swedish total population register was used to identify age- and sex-matched patients without CHD; those with AF were used as controls. Bottos hierarchical classification was used to define CHD as either complex or noncomplex. Controls were followed from the onset of AF until the index ischemic stroke, death, or end of study (December 31, 2017). We identified 951 patients with CHD with AF and 606 controls with AF. Among patients with both CHD and AF, 2.9% of patients (n=28) developed ischemic stroke, compared with 0.5% (n=3) in controls. When adjusted for age, sex, hypertension, and heart failure, a hazard ratio (HR) of 5.16 (95% CI, 1.52-17.46) was acquired. The HR in noncomplex CHD was 3.84 (95% CI, 1.07-13.84), and the HR in complex CHD was 8.34 (95% CI, 2.27-30.57). For patients born in 1970 to 1989, the HR in ischemic stroke was 7.35 (95% CI, 1.70-31.75). No adjusted HR for patients with CHD born in 1990 to 2017 could be acquired due to few events. The risk for ischemic stroke may be 5 times higher in patients with both CHD and AF compared with patients without CHD with AF. However, larger studies may be needed to confirm/refute these results.

Comparing the outcomes and costs of cardiac monitoring with implantable loop recorders and mobile cardiac outpatient telemetry following stroke using real-world evidence.

Aim: Patients with ischemic stroke (IS) commonly undergo monitoring to identify atrial fibrillation with mobile cardiac outpatient telemetry (MCOT) or implantable loop recorders (ILRs). The authors compared readmission, healthcare cost and survival in patients monitored post-stroke with either MCOT or ILR. Materials & methods: The authors used claims data from Optum's de-identified Clinformatics® Data Mart Database to identify patients with IS hospitalized from January 2017 to December 2020 who were prescribed ambulatory cardiac monitoring via MCOT or ILR. They compared the costs associated with the initial inpatient visit as well as the rate and causes of readmission, survival and healthcare costs over the following 18months. Datasets were balanced using patient baseline and hospitalization characteristics. Multivariable generalized linear gamma regression was used for cost comparisons. Cox proportional hazard regression was used for survival and readmission analysis. Sub-cohorts were analyzed based on the severity of the index IS. Results: In 2244 patients, readmissions were significantly lower in the MCOT monitored group (30.2%) compared with the ILR group (35.4%) (hazard ratio [HR] 1.23; 95% CI: 1.04-1.46). Average cost over 18months starting with the index IS was $27,429 (USD) lower in the MCOT group (95% CI: $22,353-$32,633). Survival difference bordered on statistical significance and trended to lower mortality in MCOT (8.9%) versus ILR (11.3%) (HR 1.30; 95% CI: 1:00-1.69), led by significance in patients with complications or comorbidities with the index event (MCOT 7.5%, ILR 11.5%; HR 1.62; 95% CI: 1.11-2.36). Conclusion: The use of MCOT versus ILR as the primary monitor following IS was associated with significant decreases in readmission, lower costs for the initial IS and total care over the next 18months, significantly lower mortality for patients with complications and comorbidities at the index stroke, and a trend toward improved survival across all patients.

Abstract WP269: Food Desert Residence as a Contributing Risk Factor for Acute Ischemic Stroke Patients

Background: Research suggests that residing in a food desert (FD) area may negatively impact health by increasing cardiovascular risk factors. The USDA defines FD as an area of low income in addition to low access to grocery stores at a 1 (urban) or 10-mile (rural) radius and/or low vehicle access. This study aims to assess sociodemographic profile and stroke risk factors among individuals residing in FDs within the predominantly rural state of South Carolina (SC). Methods: Deidentified administrative discharge data included all individuals admitted to SC hospitals between 2010 and 2019 with ICD-9/10 codes for ischemic stroke. Public USDA census tract data were used to define FDs based on patients’ residential addresses at time of admission, with encrypted linkages provided by SC’s clinical data warehouse. Stroke risk factors were compared between those residing in a FD vs. not via chi-square analyses. Results: Out of the identified 63,330 patients with an index ischemic stroke event, 36.8% were classified as residing within a USDA defined FD. Acute stroke patients residing within a FD were significantly more likely to be younger (age &lt;65), of black race, and without health insurance (all p&lt;.0001). FD residents were significantly more likely to have comorbid hypertension (OR 1.14, 95%CI 1.09, 1.19), type 2 diabetes (OR 1.21, 95%CI 1.17, 1.25), heart failure (OR 1.14, 95%CI 1.09, 1.19), and chronic kidney disease (OR 1.24, 95%CI 1.18, 1.30) associated with acute stroke hospital admission. Also, those residing in FDs were significantly more likely to have a history of obesity (OR 1.17, 95%CI 1.11, 1.23), mental health (OR 1.14, 95%CI 1.10, 1.18), tobacco use (OR 1.28, 95%CI 1.23, 1.33), and substance abuse (OR 1.40, 95%CI 1.35, 1.45). There were no significant differences noted in terms of sex/gender, dyslipidemia, discharge disposition, or case fatality. Conclusion: Stroke patients living within FDs are at heightened risks of comorbidities associated with ischemic stroke. Limitations in access to high quality food and suboptimal nutrition may be a contributing risk factor. Future studies focusing on shopping and eating behaviors among those living within FDs are needed to further reduce health disparities within rural and urban geographic locations nationwide.

Prevalence and Characteristics of Known versus Newly Detected Atrial Fibrillation in Ischemic Stroke: A Population-Based Study

Background: Atrial fibrillation (AF) is frequently diagnosed during the acute stage of ischemic stroke (IS), and it may reflect undiagnosed AF before stroke, thus representing a missed opportunity for stroke prevention. This population-based study aimed to assess the prevalence of known AF (KAF) and AF diagnosed early after IS (AFDAS) and to compare clinical and brain/arterial imaging characteristics between patients. Methods: Among patients with acute IS recorded in the population-based Dijon Stroke Registry, France (2013–2020), we identified those with KAF or AFDAS. AFDAS was considered when AF was diagnosed during the initial work-up based on electrocardiograms, in-hospital continuous electrocardiographic and/or Holter monitoring. Clinical and imaging characteristics on brain CT scan or angio-CT scan when available including old parenchymal lesions, arterial territory of the index IS, and aortic arch, cervical and intracranial arteries atheroma were compared between groups (KAF vs. AFDAS). Regression logistic models were used to assess factors associated with AFDAS (compared to KAF). Results: Among 1,756 IS patients, 550 (31.3%) had AF (mean age: 83.6 ± 10.3 years old, 60.5% women), of whom 367 (66.7%) presented with KAF and 183 (33.3%) had AFDAS. In multivariable model, hypertension (OR = 0.37; 95% CI: 0.21–0.64, p p = 0.002), previous stroke (OR = 0.42; 95% CI: 0.26–0.67, p p p = 0.012). Conclusions: Our findings indicate a more advanced stage of the atrial cardiomyopathy in KAF as compared with AFDAS patients and may thus contribute to the fact that in these latter patients AF had not been diagnosed prior to stroke. This group of patients undeniably represents a missed opportunity for stroke prevention.

A Parametric Time-to-Event Modelling of Recurrent Ischemic Stroke After Index Stroke Among Patients With and Without Diabetes Mellitus: Implementation of Temporal Validation of the Model.

Objectives Compared with the first stroke, neurological impairment caused by stroke recurrence is more serious, more difficult to treat, and has a higher mortality rate, especially among ischemic stroke (IS) patients with diabetes mellitus (DM). Although there are established correlations between factors and IS recurrence, there were some issues regarding the naive hazard of IS recurrence with no risk factor influence, and how does the baseline hazard differ among patients with DM and non-DM? Toanswer all these questions, two time-to-event (TTE) models of recurrent IS after the index IS were developed among IS patients with DM and non-DM. Method A total of 7697 patients with an index IS attack were extracted from the Malaysian Registry of Neurology and stratified according to DM status. Several parametric survival models were evaluated using nonlinear mixed-effect modeling software (NONMEM 7.5). The final model was determined according to the lowest objective function value, graphical evaluation, numerical diagnostics, and clinical plausibility. Additionally, the final model was validated internally and temporally using Kaplan-Meier visual predictive checks (KM-VPCs). Results One hundred ninety-five (5.82%) of 3493 DM patients and 138 (3.28%) of 4204 non-DM patients developed a recurrent IS with a maximum follow-up of 7.37 years. Gompertz's model best fitted the data. With no influence on risk factors, the index IS attack was predicted to contribute to the hazard of recurrent IS by 0.356 and 0.253 within the first six months after the index IS among patients with and without DM, respectively. Even after six months of index IS, the recurrent IS baseline hazard was not equal to zero among both groups (0.0023, 0.0018). Moreover, after incorporating the time and risk factors, the recurrent hazards increased exponentially during the first three years after the index IS followed by an exponential reduction afterward. The recurrent IS predictors among DM patients wereischemic heart disease (IHD) and hyperlipidemia (HPLD). IHD and HPLD increased the hazard of recurrent IS by 2.40 and 1.88 times, respectively, compared to those without IHD and HPLD beforeindex IS (HR, 2.40 (1.79-3.20)), and (HR, 1.88 (1.44-2.45)) respectively. Conclusion The baseline hazard was the highest during the first six months after the index IS. Moreover, receiving medications for secondary prevention failed to demonstrate a significant association with reducing IS recurrence among IS patients with DM, suggesting a need for more intensive patient screening and new strategies for secondary prevention among IS patients with DM.

Comparing Efficacy and Safety Between Patients With Atrial Fibrillation Taking Direct Oral Anticoagulants or Warfarin After Direct Oral Anticoagulant Failure.

An increased risk of recurrent stroke is noted in patients with atrial fibrillation despite direct oral anticoagulant (DOAC) use. We investigated the efficacy and safety of treatment with each of 4 different DOACs or warfarin after DOAC failure. We retrospectively analyzed patients with atrial fibrillation with ischemic stroke despite DOAC treatment between January 2002 and December 2016. The different outcomes of patients with DOAC failure were compared, including recurrent ischemic stroke, major cardiovascular events, intracranial hemorrhage and subarachnoid hemorrhage, mortality, and net composite outcomes according to switching to different DOACs or vitamin K antagonist after index ischemic stroke. We identified 3759 patients with DOAC failure. A total of 84 patients experienced recurrent ischemic stroke after switching to different oral anticoagulants, with a total follow-up time of 14 years. Using the vitamin K antagonist group as a reference, switching to any of the 4 DOACs was associated with a 69% to 77% reduced risk of major cardiovascular events (adjusted hazard ratio [aHR], 0.25 [95% CI, 0.16-0.39] for apixaban, 0.23 [95% CI, 0.14-0.37] for dabigatran, 0.23 [95% CI, 0.09-0.60] for edoxaban, and 0.31 [95% CI, 0.21-0.45] for rivaroxaban), and a 69% to 83% reduced risk of net composite outcomes (aHR, 0.25 [95% CI, 0.18-0.35] for apixaban, 0.17 [95% CI, 0.11-0.25] for dabigatran, 0.31 [95% CI, 0.17-0.56] for edoxaban, and 0.31 [95% CI, 0.23-0.41] for rivaroxaban). In Asian patients with DOAC failure, continuing DOACs after index stroke was associated with fewer undesirable outcomes than switching to a vitamin K antagonist. Alternative pharmacologic and nonpharmacologic strategies warrant investigation.

Atrial Fibrillation In Patients With Stroke Attributed to Large- or Small-Vessel Disease

The STROKE AF study found that in patients with prior ischemic stroke attributed to large-artery atherosclerotic disease (LAD) or small-vessel occlusive disease (SVD), 12% developed AF over 1 year when monitored with an insertable cardiac monitor (ICM). The occurrence over subsequent years is unknown. To compare the rates of AF detection through 3 years of follow-up between an ICM vs site-specific usual care in patients with prior ischemic stroke attributed to LAD or SVD. This multicenter, randomized (1:1) clinical trial took place at 33 sites in the US with enrollment between April 2016 and July 2019 and 3-year follow-up through July 2022. Eligible patients were aged 60 years or older, or aged 50 to 59 years with at least 1 additional stroke risk factor and had an index ischemic stroke attributed to LAD or SVD within 10 days prior to ICM insertion. Of the 496 patients enrolled, 492 were randomized and 4 were excluded. ICM monitoring vs site-specific usual care. The prespecified long-term outcome of the trial was AF detection through study follow-up (up to 3 years). AF was defined as an episode lasting more than 30 seconds, adjudicated by an expert committee. In total, 492 patients were randomized and included in the analyses (median [IQR] age, 66 [60-74] years; 307 men [62.4%] and 185 women [37.6%]), of whom 314 completed 3-year follow-up (63.8%). The incidence rate of AF at 3 years was 21.7% (46 patients) in the ICM group vs 2.4% (5 patients) in the control group (hazard ratio, 10.0; 95% CI, 4.0-25.2; P < .001). Patients with ischemic stroke attributed to LAD or SVD face an increasing risk of AF over time and most of the AF occurrences are not reliably detected by standard medical monitoring methods. One year of negative monitoring should not reassure clinicians that patients who have experienced stroke will not develop AF over the next 2 years. ClinicalTrials.gov Identifier: NCT02700945.

Non-Hypertensives and Those with Normal Cholesterol Are More Likely to Have Concomitant Cancer amongst Patients with Ischemic Stroke: A Retrospective Cross-Sectional Registry-Based Study

Introduction: Patients with cancer are known to have an increased risk of ischemic stroke (IS) around the time of their diagnosis. However, there is a paucity of data in Asian populations, and as such, we aimed to determine cancer incidence rates and patterns in Asian IS patients as well as investigate the differences in vascular risk profile of IS patients with and without concomitant cancer. Methods: We conducted a retrospective cross-sectional study using data from the Singapore Stroke and Cancer registries. We defined cases as patients with IS and a cancer diagnosis 2 years before or after the index IS. Cancer incidence was determined using the same direct age-standardization method performed for the Singapore general population in the 2015 Singapore cancer report. Multivariable logistic regression was used to analyze differences in vascular risk factors. Results: Among 21,068 IS patients (mean age, 67.9 ± 13.3 years), 6.3% (1,330) were found to have concomitant cancer; 4.4% (935) had prior cancer while 1.8% (395) had cancer diagnoses within 2 years following IS. The cancer incidence among IS patients was 3,393 (95% confidence interval [CI], 1,937–4,849) per 100,000 person-years compared to 219–231 per 100,000 person-years in the general population. Older age (odds ratio [OR], 1.02 [95% CI, 1.01–1.02] per year), males (OR, 1.25 [95% CI, 1.11–1.41), Chinese ethnicity (OR, 1.61 [95% CI, 1.37–1.89]) and a lower prevalence of hypertension (OR, 0.84 [95% CI, 0.73–0.97)]), and hyperlipidemia (OR, 0.53 [95% CI, 0.45–0.62]) were independently associated with cancer-related IS. Conclusions: The age-standardized cancer incidence was 15 times higher in IS patients than the general population. IS patients with concomitant cancer were older and had a lower prevalence of vascular risk factors.

The impact of competing stroke etiologies in patients with atrial fibrillation.

Data on the impact of competing stroke etiologies in stroke patients with atrial fibrillation (AF) are scarce. We used prospectively obtained data from an observational registry (Novel-Oral-Anticoagulants-in-Ischemic-Stroke-Patients-(NOACISP)-LONGTERM) of consecutive AF-stroke patients treated with oral anticoagulants. We compared the frequency of (i) the composite outcome of recurrent ischemic stroke (IS), intracerebral hemorrhage (ICH) or all-cause death as well as (ii) recurrent IS alone among AF-stroke patients with versus without competing stroke etiologies according to the TOAST classification. We performed cox proportional hazards regression modeling adjusted for potential confounders. Furthermore, the etiology of recurrent IS was assessed. Among 907 patients (median age 81, 45.6% female), 184 patients (20.3%) had competing etiologies, while 723 (79.7%) had cardioembolism as the only plausible etiology. During 1587 patient-years of follow-up, patients with additional large-artery atherosclerosis had higher rates of the composite outcome (adjusted HR [95% CI] 1.64 [1.11, 2.40], p = 0.017) and recurrent IS (aHR 2.96 [1.65, 5.35 ], p < 0.001), compared to patients with cardioembolism as the only plausible etiology. Overall 71 patients had recurrent IS (7.8%) of whom 26.7% had a different etiology than the index IS with large-artery-atherosclerosis (19.7%) being the most common non-cardioembolic cause. In stroke patients with AF, causes other than cardioembolism as competing etiologies were common in index or recurrent IS. Concomitant presence of large-artery-atherosclerosis seems to indicate an increased risk for recurrences suggesting that stroke preventive means might be more effective if they also address competing stroke etiologies in AF-stroke patients. NCT03826927.

Predictive model of recurrent ischemic stroke: model development from real-world data.

There are established correlations between risk factors and ischemic stroke (IS) recurrence; however, does the hazard of recurrent IS change over time? What is the predicted baseline hazard of recurrent IS if there is no influence of variable predictors? This study aimed to quantify the hazard of recurrent IS when the variable predictors were set to zero and quantify the secondary prevention influence on the hazard of recurrent ischemic stroke. In the population cohort involved in this study, data were extracted from 7,697 patients with a history of first IS attack registered with the National Neurology Registry of Malaysia from 2009 to 2016. A time-to-recurrent IS model was developed using NONMEM version 7.5. Three baseline hazard models were fitted into the data. The best model was selected using maximum likelihood estimation, clinical plausibility, and visual predictive checks. Within the maximum 7.37 years of follow-up, 333 (4.32%) patients had at least one incident of recurrent IS. The data were well described by the Gompertz hazard model. Within the first 6 months after the index IS, the hazard of recurrent IS was predicted to be 0.238, and 6 months after the index attack, it reduced to 0.001. The presence of typical risk factors such as hyperlipidemia [HR, 2.22 (95%CI: 1.81-2.72)], hypertension [HR, 2.03 (95%CI: 1.52-2.71)], and ischemic heart disease [HR, 2.10 (95%CI: 1.64-2.69)] accelerated the hazard of recurrent IS, but receiving antiplatelets (APLTs) upon stroke decreased this hazard [HR, 0.59 (95%CI: 0.79-0.44)]. The hazard of recurrent IS magnitude differs during different time intervals based on the concomitant risk factors and secondary prevention.

Machine Learning Prediction of Seizures after Ischemic Strokes. (S30.007)

<h3>Objective:</h3> To develop an artificial intelligence, machine learning prediction model for estimating the risk of seizures at 1 year and 5 years after ischemic stroke (IS). <h3>Background:</h3> Seizures are frequent complications of stroke and are associated with increased mortality, poor functional outcome, and lower quality of life. There are however no established clinical approaches to identify stroke survivors who are at high risk for seizures. <h3>Design/Methods:</h3> We identified patients with IS without a prior diagnosis of seizures from 2015 until inception (08/09/22) in the TriNetX Diamond Network, using the International Classification of Diseases, Tenth Revision (ICD-10) I63, excluding I63.6. The outcome of interest was any ICD-10 diagnosis of seizures (G40/G41) at 1 year and 5 years following the index IS. We applied a conventional logistic regression and a Light Gradient Boosted Machine (LGBM) algorithm to predict the risk of seizures at 1 year and 5 years. The performance of the model was assessed using the area under the receiver operating characteristics (AUROC), the area under the precision-recall curve (AUPRC), the F1 statistic, model accuracy, balanced-accuracy, precision, and recall, with and without seizure medication use in the models. <h3>Results:</h3> We included 444,130 IS patients without a prior diagnosis of seizures. Seizures were present in 20,085 (4.2%) and 24,479 (5.5%) patients within 1 and 5 years after IS, respectively. At 1-year, the AUROC, AUPRC, F1 statistic, accuracy, balanced-accuracy, precision, and recall were respectively 0.7917 (standard error: 0.0029), 0.2604 (0.003), 0.238 (0.0016), 0.819 (0.0024), 0.7267 (0.0008), 0.147 (0.0014), and 0.6252 (0.0036). Corresponding metrics at 5 years were 0.767 (0.0042), 0.2633 (0.0087), 0.2535 (0.0057), 0.8087 (0.0038), 0.7053 (0.0052), 0.1615 (0.0042) and 0.5892 (0.0074). <h3>Conclusions:</h3> Our findings suggest that ML models show good model performance for predicting seizures after IS. Incorporating imaging variables, including markers of brain health could improve these models. <b>Disclosure:</b> Dr. Lekoubou Looti has nothing to disclose. Dr. Petucci has nothing to disclose. Mr. Katoch has nothing to disclose. The institution of Dr. Honavar has received research support from National Science Foundation. The institution of Dr. Honavar has received research support from National Institutes of Health. The institution of Dr. Honavar has received research support from Volvo. The institution of Dr. Honavar has received research support from Department of Homeland Security. The institution of Dr. Honavar has received research support from Samsung . Dr. Honavar has received personal compensation in the range of $0-$499 for serving as a Review Panelist with National Science Foundation. Dr. Honavar has received personal compensation in the range of $0-$499 for serving as a Study Section Member with National Institutes of Health.

Drivers of Ischemic Stroke Hospital Cost Trends Among Older Adults in the United States.

The increased use of neuroimaging and innovations in ischemic stroke (IS) treatment have improved outcomes, but the impact on median hospital costs is not well understood. A retrospective study was conducted using Medicare 5% claims data for 75,525 consecutive index IS hospitalizations for patients aged ≥65 years from 2012 to 2019 (values in 2019 dollars). IS episode cost was calculated in each year for trend analysis and stratified by cost components, including neuroimaging (CT angiography [CTA], CT perfusion [CTP], MRI, and MR angiography [MRA]), treatment (endovascular thrombectomy [EVT] and/or intravenous thrombolysis), and patient sociodemographic factors. Logistic regression was performed to analyze the drivers of high-cost episodes and median regression to assess drivers of median costs. The median IS episode cost increased by 4.9% from $9,509 in 2012 to $9,973 in 2019 (P= .0021). Treatment with EVT resulted in the greatest odds of having a high-cost (>$20,000) hospitalization (odds ratio [OR], 71.86; 95% confidence interval [CI], 54.62-94.55), as did intravenous thrombolysis treatment (OR, 3.19; 95% CI, 2.90-3.52). Controlling for other factors, neuroimaging with CTA (OR, 1.72; 95% CI, 1.58-1.87), CTP (OR, 1.32; 95% CI, 1.14-1.52), and/or MRA (OR, 1.26; 95% CI, 1.15-1.38) had greater odds of having high-cost episodes than those without CTA, CTP, and MRA. Length of stay > 4 days (OR, 4.34; 95% CI, 3.99-4.72) and in-hospital mortality (OR, 1.85; 95% CI, 1.63-2.10) were also associated with high-cost episodes. From 2012 to 2019, the median IS episode cost increased by 4.9%, with EVT as the main cost driver. However, the increasing treatment cost trends have been partially offset by decreases in median length of stay and in-hospital mortality.

Defining the Age of Young Ischemic Stroke Using Data-Driven Approaches

Introduction: The cut-point for defining the age of young ischemic stroke (IS) is clinically and epidemiologically important, yet it is arbitrary and differs across studies. In this study, we leveraged electronic health records (EHRs) and data science techniques to estimate an optimal cut-point for defining the age of young IS. Methods: Patient-level EHRs were extracted from 13 hospitals in Pennsylvania, and used in two parallel approaches. The first approach included ICD9/10, from IS patients to group comorbidities, and computed similarity scores between every patient pair. We determined the optimal age of young IS by analyzing the trend of patient similarity with respect to their clinical profile for different ages of index IS. The second approach used the IS cohort and control (without IS), and built three sets of machine-learning models-generalized linear regression (GLM), random forest (RF), and XGBoost (XGB)-to classify patients for seventeen age groups. After extracting feature importance from the models, we determined the optimal age of young IS by analyzing the pattern of comorbidity with respect to the age of index IS. Both approaches were completed separately for male and female patients. Results: The stroke cohort contained 7555 ISs, and the control included 31,067 patients. In the first approach, the optimal age of young stroke was 53.7 and 51.0 years in female and male patients, respectively. In the second approach, we created 102 models, based on three algorithms, 17 age brackets, and two sexes. The optimal age was 53 (GLM), 52 (RF), and 54 (XGB) for female, and 52 (GLM and RF) and 53 (RF) for male patients. Different age and sex groups exhibited different comorbidity patterns. Discussion: Using a data-driven approach, we determined the age of young stroke to be 54 years for women and 52 years for men in our mainly rural population, in central Pennsylvania. Future validation studies should include more diverse populations.

The results of systemic thrombolytic therapy for acute ischemic stroke in women and men depending on the stroke risk factors

Background: Systemic thrombolytic therapy (STLT) with alteplase is the method of choice in all patients with acute ischemic stroke (IS) within the first 4.5 hours after the symptom onset. There is a noticeable difference between men and women in the clinical characteristics and results of stroke treatment; however, results of studies have been contradictory.&#x0D; Aim: To evaluate the efficacy of STLT with alteplase in women compared to men, depending on the presence of some risk factors for stroke.&#x0D; Materials and methods: This open-label prospective observational non-interventional cohort study of STLT in IS included 209 patients (102 women, the main group, and 107 men, or the comparison group) aged 32 to 86 years. All patients received STLT with alteplase within 4.5 hours from the onset of IS symptoms. The primary endpoint of the study was 28-day survival, and the secondary endpoint was the achievement of mobility independence (0 to 2 points by the modified Rankin Scale (mRS)).&#x0D; Results: The demographic and clinical patient characteristics of both groups were comparable, but women were on average 5 years older than men (p = 0.003). The index IS was not the first one in 31.4% of women and 23.4% of men (p 0.05). There were no significant differences in the severity of stroke and the timing of STLT. Men had a high mortality rate in the acute period of IS, but the difference was non-significant. PST-STLT hemorrhagic transformation was more common in men, with the difference being non-significant (2 0.743, p = 0.389). Women were more likely to have type 2 diabetes mellitus (DM2) (37.3% and 20.6%, respectively, 2 7.111, p = 0.008). In women, there was a trend towards better symptom regression by about 1 point (p = 0.129). The women with DM2 had a 13% higher survival than men (p = 0.038). The numbers of patients achieving independence (02 points on the mRS scale) by Day 28 was not different (56 women and 52 men). No between-groups differences were found in the numbers of patients with arterial hypertension and atrial fibrillation. Only 13 women (12.75%) and 21 men (20%) had a normal body mass index, while 56.3% of women and 46.7% of men had obesity 2 or 3 grades, with the gender differences being non-significant.&#x0D; Conclusion: In women, who have received STLT in the acute period of IS, the death rates and the functional outcomes were non-inferior to those in men, despite their older age, hyperglycemia in the acute period and past history of DM2. The risk factors for stroke in women, compared to men, could be the potential cause of more frequent IS recurrence (every third case in women and every fourth in men was recurrent). Despite a number of negative factors (age, obesity, metabolic syndrome, hyperglycemia, DM2, atrial fibrillation), there was a trend towards better outcomes of STLT in women.

Abstract WMP38: One Year Medicare Spending On Beneficiaries In Atrial Fibrillation Not Being Treating With Long-term Anticoagulants Experiencing A Hospitalization For Ischemic Stroke

Background: It is well known that individuals in atrial fibrillation (AF) who are not using anticoagulants are at higher risk of Ischemic Stroke (IS). These hospitalizations result in the utilization of significant healthcare resources in addition to reducing patients’ quality of life. The purpose of this study is to estimate how much the Medicare program spends treating a Medicare beneficiary (MB) with AF who are not being anticoagulated with an IS hospitalization and the 12-months following discharge. Method: The study population consisted of all MBs in the fee-for-service program who had a hospitalization for IS and were discharged between January 1, 2018 to December 31, 2018. A total of 50,509 MBs met the study inclusion criteria and were not excluded due to prior history of stroke or on long-term anticoagulants. The study period for accumulating Medicare spending at healthcare facilities is for the index hospitalization and all facility claims that occurred within 12-months of the index hospital discharge date. Results: Average total Medicare spending per MB for the study population was $46,867±$49,212 resulting in total Medicare spending of nearly $2.5 billion during the study period. Highest average spending per MB was for hospital services $25,848 (of which $15,790± $20,984 occurred during the index hospitalization and $10,058±$21,956 during readmission during the follow-up period. The Medicare program also spent over $3,000 per study patient at skilled nursing facilities ($8,131±$14,979), rehabilitation facilities ($5,538±$12,739), and outpatient facilities or emergency departments ($3,056±$7,495). At least, 19% of MB died during the study period. Medicare spent $25,397±$30,259 on those MBs that died during their index hospitalization and $67,276±$65,021 on those MBs that survived their index IS hospitalization but died during the follow-up period. Conclusion: MBs with AF who are not being treated with anticoagulants and suffer an ischemic stroke result in one-year Medicare Part A program spending of approximately $47,000 per person compared to the average Medicare spending for all services of approximately $12,000 per beneficiary in 2018. Identification of MB in AF and treatment with anticoagulants would save CMS significant dollars.

Autonomic dysfunction after mild acute ischemic stroke and six months after: a prospective observational cohort study

IntroductionAutonomic dysfunction is prevalent in ischemic stroke patients and associated with a worse clinical outcome. We aimed to evaluate autonomic dysfunction over time and the tolerability of the head-up tilt table test in an acute stroke setting to optimize patient care.Patients and methodIn a prospective observational cohort study, patients were consecutively recruited from an acute stroke unit. The patients underwent heart rate and blood pressure analysis during the Valsalva maneuver, deep breathing, active standing, and head-up tilt table test if active standing was tolerated. In addition, heart rate variability and catecholamines were measured. All tests were performed within seven days after index ischemic stroke and repeated at six months follow-up.ResultsThe cohort was comprised of 91 acute stroke patients, mean (SD) age 66 (11) years, median (IQR) initial National Institute of Health Stroke Scale 2 (1–4) and modified Ranking Scale 2 (1–3). The head-up tilt table test revealed 7 patients (10%) with orthostatic hypotension. The examination was terminated before it was completed in 15%, but none developed neurological symptoms. In the acute state the prevalence of autonomic dysfunction varied between 10–100% depending on the test. No changes were found in presence and severity of autonomic dysfunction over time.ConclusionIn this cohort study of patients with mild stroke, autonomic dysfunction was highly prevalent and persisted six months after index stroke. Head-up tilt table test may be used in patients who tolerate active standing. Autonomic dysfunction should be recognized and handled in the early phase after stroke.

Intracranial plaque with large lipid core is associated with embolic stroke of undetermined source.

To investigate an association between percentage lipid-rich necrotic core (LRNC) and an index ischemic stroke in an embolic stroke of undetermined source (ESUS) cohort. A total of 167 ESUS patients with 259 non-stenotic intracranial plaques including 155 ipsilateral and 104 contralateral to stroke were finally enrolled in the current analysis. The multi-dimensional parameters involving remodeling index (RI), plaque burden (PB), LRNC, discontinuity of plaque surface (DPS), intraplaque hemorrhage (IPH), and vulnerable plaque defined as presence of complicated plaque were evaluated by high-resolution magnetic resonance imaging. We found that %LRNC was an independent predictor for ESUS in model 1 (OR: 2.574, 95% CI: 1.854-3.573, P < 0.001), and model 2 (OR: 2.550, 95% CI: 1.835-3.545, P < 0.001), but the association was not seen in PB. In receiver operating characteristic curve analysis, the discrimination of LRNC for ESUS was significantly superior to that of PB (absolute difference: 0.121, 95% CI: 0.056-0.205, P < 0.001). Importantly, a significantly positive synergy between the remodeling pattern and LRNC in response to plaque vulnerability was found by Sankey diagram (P for interaction=0.001). This is the first report that LRNC, beyond PB, may be correlated with an index ESUS, and a synergistic effect between positive remodeling and larger LRNC could promote plaque vulnerability. The findings suggest that a potential target subgroup may benefit from stroke prevention with intensive statin, although this must be confirmed in future.

Thromboembolism from Carotid Web.

HomeRadiologyVol. 306, No. 3 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyThromboembolism from Carotid WebNoel F. Fanning , Brian J. ManningNoel F. Fanning , Brian J. ManningAuthor AffiliationsFrom the Departments of Neuroradiology (N.F.F.) and Vascular Surgery (B.J.M.), Cork University Hospital, Wilton, Cork, Ireland.Address correspondence to N.F.F. (email: [email protected]).Noel F. Fanning Brian J. ManningPublished Online:Nov 15 2022https://doi.org/10.1148/radiol.221504MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In A 26-year-old woman presented with 5 hours of acute right neck pain and left arm weakness after exercising. At examination, her National Institutes of Health Stroke Scale score was 3, indicating mild deficits. MRI scans showed a right middle cerebral artery (MCA) infarct (Figure, A), and CT head angiogram showed a right MCA occlusion (not shown in Figure). The patient did not receive thrombolytic therapy due to time from symptom onset. She was transferred to a comprehensive stroke center for further management. Subsequent CT head angiogram showed spontaneous recanalization of the right MCA occlusion (not shown in Figure). CT carotid angiogram revealed shelf-like protrusion from the dorsal aspect of the internal carotid artery just beyond the bifurcation, diagnostic of a carotid web (Figure, B). A carotid endarterectomy (CEA) was performed, showing a firm pale protrusive web from the dorsal internal carotid artery (Figure, C) matching the CT angiogram appearance. Histologic findings showed spindle cells and myxoid degeneration (Figure, D) and no features of atherosclerotic plaque.Images in a 26-year-old woman with acute stroke symptoms. (A) Axial diffusion-weighted MRI scan shows an acute right middle cerebral artery territory infarct. (B) Sagittal CT right carotid angiogram shows a shelf-like protrusion from the dorsal aspect of the internal carotid artery (ICA) just beyond the bifurcation (arrow), diagnostic of a carotid web. (C) Intraoperative photograph shows the opened right ICA with a firm pale protrusive web from the dorsal ICA (arrow) matching the CT angiogram appearance. The asterisks in B and C indicate the external carotid artery for orientation. (D) Hematoxylin and eosin stain of the web show myxoid degeneration (arrow) and no features of atherosclerotic plaque.Download as PowerPointOpen in Image Viewer This patient example illustrates the appearance of carotid webs, an underrecognized cause of stroke. Carotid webs represent an intimal variant of fibromuscular dysplasia. In patients presenting with large vessel occlusions, carotid webs are seen in 1% of cases ipsilateral to the index ischemic stroke. Recurrent stroke occurs in 17% of patients with symptomatic carotid webs within 2 years, despite medical management, compared with 3% recurrence rate without carotid webs (1). Optimal management strategies for carotid webs are yet to be defined. Medical management, carotid endarterectomy, or carotid stenting should be considered as part of a multidisciplinary discussion. The patient has remained well 8 months after CEA, with no residual deficits or recurrent stroke symptoms.Disclosures of conflicts of interest: N.F.F. No relevant relationships. B.J.M. No relevant relationships.

Ischemic stroke in patients with congenital heart disease and atrial fibrillation

Abstract Background Atrial fibrillation (AF) is one of the most common arrhythmias in patients with congenital heart disease (CHD). The risk of developing AF is more than 20 times higher in patients with CHD compared with non-CHD controls. However, while it is known that young non-CHD patients with AF have a low risk for ischemic stroke (IS), little is known about the risk for IS young CHD patients with AF. Purpose To investigate the risk of developing IS in younger patients with CHD and AF compared to non-CHD control patients with AF. Method Using data from the National Swedish Patient Register and Cause of Death register, all CHD and born in Sweden between 1970 and 2017 with history of AF were identified. The Swedish total population register was used to identify age and sex matched controls. Among the matched controls, non-CHD patients AF were identified and used as reference group. CHD and non-CHD patients were followed from onset of AF until index IS, death or end of study (31st December 2017). Cox proportional hazard regression model with hazard ratio (HR) and 95% confidence interval (CI) was used to estimate the risk of IS in CHD patients with AF compared with non-CHD controls with AF. Results A total of 951 CHD with AF and 606 non-CHD controls with AF were identified. With ages ranging from 0 to 47 years, the median age was 25.6 and 30.7 years for CHD and non-CHD respectively. In patients with CHD and AF, 2.9% of patients (n=28) developed IS during follow up (mean follow up 34 years, SD ± 11.2), compared 0.5% (n=3) in non-CHD controls with AF (mean follow up 37 years, SD ± 9.5 years). The unadjusted HR for IS in CHD patients with AF compared with non-CHD controls with AF was 4.61 (95% CI1.39–15.25). When adjusted for age, sex, hypertension and heart failure, the risk of IS was more than five times higher (HR 5.16, 95% CI 1.52–17.46) in CHD patients compared with non-CHD patients. The adjusted HR for developing IS in non-complex CHD with AF compared with matched controls was 4.56 (95% CI 1.00–20.79). For patients born 1970–1989 the HR of IS was 7.35 (95% CI 1.70–31.75). Conclusion In this nationwide, register-based cohort study, the absolute number of IS among younger CHD patients with AF was relatively low. However, the risk for developing IS was more than 5 times higher compared to non-CHD patients with AF; highlighting the need of stroke score models in younger population, particularly to CHD patients. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swedish state under an agreement between the Swedish government and city Councils

Protocol for Home-Based Solution for Remote Atrial Fibrillation Screening to Prevent Recurrence Stroke (HUA-TUO AF Trial): a randomised controlled trial

IntroductionCurrent international guidelines recommend ECG monitoring after an ischaemic stroke to detect atrial fibrillation (AF) in order to prevent stroke recurrence. However, optimal strategies to detect AF and the downstream...