Initial Ischemic Stroke Research Articles

The Significance of an Initial Controlling Nutritional Status Score in Predicting the Functional Outcome, Complications, and Mortality in a First-Ever Ischemic Stroke

Background and Purpose: Nutritional status can influence the outcomes and mortality of various diseases. The association between initial nutritional status and ischemic stroke outcomes, however, remains poorly understood. This study investigated whether the Controlling Nutritional Status (CONUT) score at admission could predict functional recovery, complications, and survival following an ischemic stroke. Methods: We enrolled a total of 938 patients experiencing their first acute ischemic stroke and categorized them into three groups based on their CONUT score at admission: CONUT 0–1, CONUT 2–4, and CONUT 5–12. The CONUT score was assessed using the serum albumin, total cholesterol, and lymphocyte count. We evaluated the incidence of complications during their hospital stay. Outcomes, including the Modified Rankin Scale (mRS), Functional Independence Measurement (FIM), Functional Ambulatory Classification (FAC), and mortality, were assessed at baseline, as well as at three and six months post-stroke. Results: CONUT scores were significantly associated with functional outcomes (mRS, FIM, and FAC) and mortality during the six-month follow-up period post-stroke (all p < 0.05). The CONUT 5–12 group exhibited significantly poorer improvements in mRS, FIM, and FAC scores (all p < 0.05) and a lower survival rate (p < 0.01) during the six-month follow-up compared to the CONUT 0–1 and CONUT 2–4 groups. Additionally, the incidence of pneumonia, urinary tract infections, pressure sores, falling injuries, and fractures was significantly higher in the CONUT 5–12 group than in the other groups (all p < 0.01). Conclusions: CONUT scores at admission are associated with functional recovery, mortality, and the incidence of complications following a first-ever ischemic stroke. Consequently, the early identification of patients at risk of malnutrition via CONUT scores can be crucial in enhancing patient assessment after an acute stroke.

Evaluation of Middle Cerebral Artery Culprit Plaque Inflammation in Ischemic Stroke Using CAIPIRINHA-Dixon-TWIST Dynamic Contrast-Enhanced Magnetic Resonance Imaging.

Middle cerebral artery (MCA) plaques are a leading cause of ischemic stroke (IS). Plaque inflammation is crucial for plaque stability and urgently needs quantitative detection. To explore the utility of Controlled Aliasing in Parallel Imaging Results in Higher Acceleration (CAIPIRINHA)-Dixon-Time-resolved angiography With Interleaved Stochastic Trajectories (TWIST) (CDT) dynamic contrast-enhanced MRI (DCE-MRI) for evaluating MCA culprit plaque inflammation changes over stroke time and with diabetes mellitus (DM). Prospective. Ninety-four patients (51.6 ± 12.23 years, 32 females, 23 DM) with acute IS (AIS; N = 43) and non-acute IS (non-AIS; 14 days < stroke time ≤ 3 months; N = 51). 3-T, CDT DCE-MRI and three-dimensional (3D) Sampling Perfection with Application optimized Contrast using different flip angle Evolution (3D-SPACE) T1-weighted imaging (T1WI). Stroke time (from initial IS symptoms to MRI) and DM were registered. For 94 MCA culprit plaques, Ktrans from CDT DCE-MRI and enhancement ratio (ER) from 3D-SPACE T1WI were compared between groups with and without AIS and DM. Shapiro-Wilk test, Bland-Altman analysis, Passing and Bablok test, independent t-test, Mann-Whitney U test, Chi-squared test, Fisher's exact test, receiver operating characteristics (ROC) with the area under the curve (AUC), DeLong's test, and Spearman rank correlation test with the P-value significance level of 0.05. Ktrans and ER of MCA culprit plaques were significantly higher in AIS than non-AIS patients (Ktrans = 0.098 s-1 vs. 0.037 s-1; ER = 0.86 vs. 0.55). Ktrans showed better AUC for distinguishing AIS from non-AIS patients (0.87 vs. 0.75) and stronger negative correlation with stroke time than ER (r = -0.60 vs. -0.34). DM patients had significantly higher Ktrans and ER than non-DM patients in IS and AIS groups. Imaging by CDT DCE-MRI may allow to quantitatively evaluate MCA culprit plaques over stroke time and DM. 2 TECHNICAL EFFICACY: Stage 2.

Necessary to continue imaging spontaneous cervical artery dissecting pseudoaneurysms after one year?

Background and purposeThe value of long-term serial imaging of dissecting pseudoaneurysm (dPSA) is poorly characterized. This study investigated the long-term radiographic evolution of dPSA. MethodsWe performed a query in our institutional craniocervical artery dissection registry to identify cases with spontaneous dPSA who had at least one year of follow-up with serial angiographic imaging. We performed Wilcoxon rank-sum pairwise comparison test to determine if there was a significant change in the aneurysm size over time. ResultsThis observational cohort study included 76 patients (46 females; 64 dPSA in the internal carotid artery [ICA] and 12 in the vertebral artery [VA]) with a median age of 49.5 years (range 24-77). The initial median dPSA size was 8 mm (interquantile range(iqr) = 5.88-11mm), and the final median dPSA size was 7 mm (iqr = 4-11 mm). Most patients had either no change or reduction in dPSA size in the serial follow-up, with no significant change over time. All the patients had favorable outcomes at the last follow-up, and most patients were symptom-free from dPSA (92 %). Two patients (2.6%) experienced recurrent ischemic strokes in the same territory as the initial ischemic stroke without any change in dPSA size. ConclusionFurther serial scans for dPSA after one year may be deferred in the absence of interim clinical symptoms as most dPSA either remains stable or decreases in size. Recurrent stroke, although a rare event, was not associated with an increase in dPSA size.

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.

Resourcefulness Among Initial Ischemic Stroke Patients: A Longitudinal Study of 12 Months.

To explore distinct longitudinal trajectories of resourcefulness among initial ischemic stroke patients from diagnosis to 12 months, and to identify whether sociodemographic factors, disease-related factors, self-efficacy, family function, and social support can predict patterns in the trajectories of resourcefulness. A prospective longitudinal study was conducted. Initial ischemic stroke patients who met inclusion and exclusion criteria were followed up when still in hospital (Preparing for discharge, Baseline, T1), at 1 month (T2), at 3 months (T3), at 6 months (T4), at 9 months (T5) and 12 months (T6) (±1 week) after discharge. General information, National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), General Self-Efficacy Scale (GSES), General Family Functioning Subscale (FAD-GF), and Social Support Rate Scale (SSRS) were used in T1. The Resourcefulness Scale© was evaluated at 6 time points. Growth mixture modeling was used to identify trajectory patterns of resourcefulness. Logistic regression was used to identify predictors of resourcefulness trajectories. Three longitudinal trajectories of resourcefulness were identified and named as the high-stable class (38.9%, n=71), fluctuation class (41.2%, n=75), and low-stable class (19.9%, n=36), respectively. Dwelling areas (x2=6.805, P=0.009), education (x2=44.865, P=0.000), monthly income (x2=13.063, P=0.001), NIHSS scores (x2=44.730, P=0.000), mRS scores (x2=51.788, P=0.000), Hcy (x2=9.345, P=0.002), GSES (x2=56.933, P=0.000), FAD-GF (x2=41.305, P=0.000) and SSRS (x2=52.373, P=0.000) were found to be statistically significant for distinguishing between different resourcefulness trajectory patterns. Lower education (OR=0.404), higher NIHSS(OR=6.672) scores, and higher mRS(OR=21.418) scores were found to be risk factors for lower resourcefulness, whereas higher education(OR=0.404), GSES(OR=0.276), FAD-GF(OR=0.344), and SSRS(OR=0.358) scores were identified as protective factors enhancing resourcefulness. This study obtained three patterns of trajectories and identified their predictive factors in initial ischemic stroke. The findings will assist health care professionals in identifying subgroups of patients and when they may be at risk of low resourcefulness and provide timely targeted intervention to promote resourcefulness.

Sex-specific racial and ethnic variations in short-term outcomes among patients with first or recurrent ischemic stroke: Paul Coverdell National Acute Stroke Program, 2016-2020

Background and purposeTo understand the association of sex-specific race and ethnicity on the short-term outcomes of initial and recurrent ischemic stroke events. MethodsUsing the Paul Coverdell National Acute Stroke Program from 2016-2020, we examined 426,062 ischemic stroke admissions from 629 hospitals limited to non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic patients. We performed multivariate logistic regression analyses to assess the combined effects of sex-specific race and ethnicity on short-term outcomes for acute ischemic stroke patients presenting with initial or recurrent stroke events. Outcomes assessed include rates of in-hospital death, discharge to home, and symptomatic intracranial hemorrhage (sICH) after reperfusion treatment. ResultsAmong studied patients, the likelihood of developing sICH after reperfusion treatment for initial ischemic stroke was not significantly different. The likelihood of experiencing in-hospital death among patients presenting with initial stroke was notably higher among NHW males (AOR 1.59 [95 % CI 1.46, 1.73]), NHW females (AOR 1.34 [95 % CI 1.23, 1.45]), and Hispanic males (AOR 1.57 [95 % CI 1.36, 1.81]) when compared to NHB females. Hispanic females were more likely to be discharged home when compared to NHB females after initial stroke event (AOR 1.32 [95 % CI 1.23, 1.41]). NHB males (AOR 0.90 [95 % CI 0.87, 0.94]) and NHW females (AOR 0.89 [95 % CI 0.86, 0.92]) were less likely to be discharged to home. All groups with recurrent ischemic strokes experienced higher likelihood of in-hospital death when compared to NHB females with the highest likelihood among NHW males (AOR 2.13 [95 % CI 1.87, 2.43]). Hispanic females had a higher likelihood of discharging home when compared to NHB females hospitalized for recurrent ischemic stroke, while NHB males and NHW females with recurrent ischemic stroke hospitalizations were less likely to discharge home. ConclusionsSex-specific race and ethnic disparities remain for short-term outcomes in both initial and recurrent ischemic stroke hospitalizations. Further studies are needed to address disparities among recurrent ischemic stroke hospitalizations.

Estimating a two-year recurrence risk of ischemic stroke based on Essen Stroke Risk Score and retinal characteristics

Objectives: Prediction of recurrence risk after initial ischemic stroke helps improve patient outcomes. We estimated the validity of combining the Essen Stroke Risk Score (ESRS) with retinal characteristics to predict the two-year recurrent risk of ischemic stroke. Methods: A prospective cohort study was conducted at Shenzhen Traditional Chinese Medicine Hospital. Patients with initial ischemic stroke were recruited. ESRS was measured, and fundus photographs were taken by trained physicians. All patients were followed up for 2 years to determine the outcome of recurrent stroke. Logistic models were built using ESRS alone and combined with ESRS and retinal characteristics. The prognostic value of recurrence risk was evaluated by calculating the area under the receiver operating characteristic curve. Results: The total recurrence rate of ischemic events within 2 years was 20%. The risk of recurrence was significantly higher in patients with an ESRS score of &gt;2. Regarding retinal characteristics, patients with recurrent stroke had a lower mean asymmetry index of venules (0.76 vs. 0.77, P=0.00) and bifurcation coefficient of venules (1.29 vs. 1.28, P=0.03) but a higher mean occlusion of arterioles (0.11 vs. 0.13, P=0.01). The area under the curve was 0.5985 based on the logistic regression model with ESRS alone to 0.7294 for the model with both ESRS and retinal characteristics. This study was registered in the Chinese Clinical Trial Registry (registration no. ChiCTR1800019648). Conclusion: A model combining ESRS with retinal characteristics can accurately predict the risk of recurrent stroke.

Predictive value of motor-evoked potentials for motor recovery in patients with hemiparesis secondary to acute ischemic stroke

Background Motor recovery following a stroke is related to the initial stroke severity and corticospinal tract integrity. One of the outcomes representing corticospinal tract integrity is the motor evoked potential (MEP). This study aimed to investigate the predictive value of MEP for motor recovery in patients with acute ischemic stroke. Patients and Methods Patients with hemiparesis secondary to initial acute ischemic stroke were enrolled. MEPs of the upper limb were assessed as preserved (MEP+) or absent (MEP-) response ≤10 days post-stroke. Fugl-Meyer assessment (FMA) was performed at baseline and post-stroke at 30 and 90 days. A modified Rankin scale (mRS) was conducted at 90 days post-stroke. Patients were divided into two groups according to the highest FMA score of MEP- patients. Generalized estimating equations and logistic regression were used for our study analysis. Results Sixty-one participants were included in this study. The highest FMA score of MEP- patients ≤10 days after stroke was 38. Among patients with an initial FMA score ≤38, FMA scores at 30 and 90 days post-stroke were significantly higher in MEP + patients than in MEP- patients. Proportional recovery at 30 and 90 days post-stroke was significantly higher in MEP + patients than in MEP- patients. MEP + patients had a higher percentage of good functional outcomes than MEP- patients, without statistical difference. Among patients with initial FMA score >38, FMA scores were 60.4 ± 4.8 and 63.9 ± 2.9 and proportional recovery was 65.2 ± 27.0% and 83.7 ± 24.6% at 30 and 90 days post-stroke, respectively. Conclusions Among patients with moderate-to-severe ischemic stroke, MEP + patients had better motor recoveries (approximately 70%) than MEP– patients at 90 days post-stroke. MEP + patients had better functional outcomes than MEP- patients.

Abstract TP193: Atrial Fibrillation Burden Is Not Associated With Recurrent Cerebrovascular Events In Anticoagulated Stroke Patients: An Arest Trial Sub-study

Introduction: The burden of Atrial Fibrillation (AF) has previously been associated with a higher stroke risk in non-anticoagulated patients. We aim to find whether there is also an association between AF burden and recurrent cerebrovascular events in anticoagulated AF patients after their initial acute ischemic stroke (AIS) or transient ischemic attacks (TIA). Methods: The AREST study (Apixaban for Early Prevention of Recurrent Embolic Stroke and Hemorrhagic Transformation) was a multi-center, randomized controlled trial of early apixaban versus warfarin at one week post-TIA or two weeks post-AIS, in AF patients from 2015 to 2019. Subjects received either 30-day continuous electrocardiographic monitoring or an implantable device (i.e., pacemaker, loop recorder, or defibrillator). Logistic regression and Kendall's tau-b test were utilized to identify an association between AF burden and the proportion of subjects who developed recurrent cerebrovascular events. Results: Of 91 subjects enrolled into AREST, heart rhythm monitoring was assessed in 49 (54%); over half (59%) clustered at the extreme ends of the distribution, at either low (≤1%) or high (≥99%) AF burden. Higher AF burden was not significantly correlated with an increased risk of recurrent stroke or TIA (Odds Ratio = 0.99 [95% confidence interval (CI), 0.98-1.0]; p=0.518). Moreover, there was no statistically significant association between AF burden and the composite outcomes after adjusting for either apixaban or warfarin. Conclusions: AF Burden was not found to be associated with recurrent cerebrovascular events in patients taking oral anticoagulant after an AIS or TIA. Further research is needed to confirm these findings.

DON'T TAKE MY BREATH AWAY: A CASE OF HIGH-RISK PULMONARY EMBOLISM IN THE SETTING OF PATENT FORAMEN OVALE REQUIRING EXTRACORPOREAL MEMBRANE OXYGENATION

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pulmonary emboli precipitate cardiovascular collapse by mechanical obstruction of the right ventricular outflow tract and pulmonary artery vasoconstriction, leading to right ventricular overload. The presence of a patent foramen ovale (PFO) can subvert this typical physiology by creating a right-to-left shunt, permitting left ventricular filling and near-normal cardiac output. However, this also causes intracardiac mixing of oxygenated and deoxygenated blood, which can further worsen hypoxemia. Here, we present a patient with saddle pulmonary emboli who was incidentally found to have a PFO due to persistent hypoxemia. CASE PRESENTATION: A 67-year-old man with a past medical history of coronary artery disease, alcohol abuse, hypertension, hyperlipidemia, and obstructive sleep apnea presented with word-finding difficulty and behavioral changes. He was found to have acute occlusion of the bilateral middle cerebral arteries, requiring mechanical thrombectomy. He was recovering successfully when he suddenly developed dyspnea and lightheadedness with exertion, which rapidly progressed to mechanical ventilation. He remained hypoxic on optimal ventilator settings and inhaled nitric oxide, prompting suspicion for acute pulmonary embolism. Chest x-ray was unchanged. EKG showed inferior ST-segment elevations, and a trans-thoracic echocardiogram revealed a newly dilated and overloaded right ventricle with an underfilled left ventricle, as well as McConnell's sign. Transesophageal echocardiogram showed a saddle pulmonary embolus and an incidental PFO with right-to-left shunting. Veno-venous extracorporeal membrane oxygenation (ECMO) was initiated as a bridge to mechanical thrombectomy. His course was complicated by cardiogenic shock, septic shock, and progression of his initial ischemic stroke. Encephalopathy remained a barrier to extubation. DISCUSSION: Recent studies have recognized ECMO as a promising adjunctive therapy for pulmonary emboli for those who are too unstable for surgical thrombectomy or who have contraindications to systemic thrombolysis. Our patient was not a candidate for thrombolysis given his recent stroke. His PFO, while beneficial in preventing florid cardiogenic shock by offloading the right ventricle, caused hypoxemia refractory to mechanical ventilation alone. As such, ECMO was a crucial temporizing measure until the patient was stable enough for surgical thrombectomy. CONCLUSIONS: This case highlights, prompt recognition of intracardiac shunts in cases of refractory hypoxemia, and the importance of early identification of patients who need advanced intervention such as ECMO. REFERENCE #1: Al-Bawardy R, Rosenfield K, Borges J, Young MN, Albaghdadi M, Rosovsky R, Kabrhel C. Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a case series and review of the literature. Perfusion. 2019 Jan;34(1):22-28. doi: 10.1177/0267659118786830. Epub 2018 Jul 16. PMID: 30009670. REFERENCE #2: Askari K, Sneij W, Krick S, Alvarez RA. Going with the Flow: Saddle Pulmonary Embolism Complicated by Severe Hypoxemia without Shock. Annals of the American Thoracic Society. 2017;14(9):1479-1484. doi:10.1513/annalsats.201702-145cc REFERENCE #3: Corsi F, Lebreton G, Bréchot N, Hekimian G, Nieszkowska A, Trouillet JL, Luyt CE, Leprince P, Chastre J, Combes A, Schmidt M. Life-threatening massive pulmonary embolism rescued by venoarterial-extracorporeal membrane oxygenation. Crit Care. 2017 Mar 28;21(1):76. doi: 10.1186/s13054-017-1655-8. PMID: 28347320; PMCID: PMC5369216 DISCLOSURES: No relevant relationships by Sonali Bishnoi, source=Web Response No relevant relationships by Scott Blumhof, source=Web Response No relevant relationships by Amy Lam, source=Web Response No relevant relationships by Kaitlyn Musco, source=Web Response No relevant relationships by Jeffrey Wright, source=Web Response

PCV44 Real-World Assessment of the Use of Anti-platelet Therapy for Recurrent Stroke Prevention in US Patients without Atrial Fibrillation with Recent Ischemic Stroke or Transient Ischemic Attack

Antiplatelet (AP) therapies are the recommended treatment for prevention of recurrent stroke. However, bleeding is a significant risk with any AP therapy. Data on the real-world use of AP therapies in the prevention of recurrent stroke is lacking. This study evaluated current AP treatment patterns in a real-world setting following an initial ischemic stroke (IS) or transient ischemic attack (TIA).

Vessel Wall Enhancement on Black-Blood MRI Predicts Acute and Future Stroke in Cerebral Amyloid Angiopathy.

Cerebral amyloid angiopathy (CAA) is a known risk factor for ischemic stroke though angiographic imaging is often negative. Our goal was to determine the relationship between vessel wall enhancement (VWE) in acute and future ischemic stroke in CAA patients. This was a retrospective study of patients with new-onset neurologic symptoms undergoing 3T vessel wall MR imaging from 2015 to 2019. Vessel wall enhancement was detected on pre- and postcontrast flow-suppressed 3D T1WI. Interrater agreement was evaluated in cerebral amyloid angiopathy-positive and age-matched negative participants using a prevalence- and bias-adjusted kappa analysis. In patients with cerebral amyloid angiopathy, multivariable Poisson and Cox regression were used to determine the association of vessel wall enhancement with acute and future ischemic stroke, respectively, using backward elimination of confounders to P < .20. Fifty patients with cerebral amyloid angiopathy underwent vessel wall MR imaging, including 35/50 (70.0%) with ischemic stroke and 29/50 (58.0%) with vessel wall enhancement. Prevalence- and bias-corrected kappa was 0.82 (95% CI, 0.71-0.93). The final regression model for acute ischemic stroke included vessel wall enhancement (prevalence ratio = 1.5; 95% CI, 1.1-2.2; P = .022), age (prevalence ratio = 1.02; 95% CI, 1.0-1.05; P = .036), time between symptoms and MR imaging (prevalence ratio = 0.9; 95% CI, 0.8-0.9; P < .001), and smoking (prevalence ratio = 0.7; 95% CI, 0.5-1.0; P = .042) with c-statistic = 0.92 (95% CI, 0.84-0.99). Future ischemic stroke incidence with cerebral amyloid angiopathy was 49.7% (95% CI, 34.5%-67.2%) per year over a total time at risk of 37.5 person-years. Vessel wall enhancement-positive patients with cerebral amyloid angiopathy demonstrated significantly shorter stroke-free survival with 63.9% (95% CI, 43.2%-84.0%) versus 32.2% (95% CI, 14.4%-62.3%) ischemic strokes per year, chi-square = 4.9, P = .027. The final model for future ischemic stroke had a c-statistic of 0.70 and included initial ischemic stroke (hazard ratio = 3.4; 95% CI, 1.0-12.0; P = .053) and vessel wall enhancement (hazard ratio = 2.5; 95% CI, 0.9-7.0; P = .080). Vessel wall enhancement is associated with both acute and future stroke in patients with cerebral amyloid angiopathy.

Nonlinear relationship between serum total bilirubin levels and initial ischemic stroke in patients with non-valvular atrial fibrillation.

ObjectiveThis study aimed to examine the relationship between total bilirubin levels and initial ischemic stroke in patients with non-valvular atrial fibrillation.MethodsThis was a retrospective study. Atrial fibrillation was diagnosed by 24-hour Holter electrocardiography and serum total bilirubin levels were divided into quintiles. Ischemic stroke was diagnosed by symptoms, signs, and a medical image examination. The multivariate Cox proportional hazards model and survival analysis were used to estimate the association of total bilirubin with initial ischemic stroke.ResultsWe studied 316 patients with non-valvular atrial fibrillation. During follow-up, there were 42 (13.29%) first ischemic strokes. After multivariate adjustment, for each 1 µmol/L increase in total bilirubin, the risk of first ischemic stroke increased by 4% (95% confidence interval [CI]: 1.01, 1.07). When using the first quintile as the reference, from the second to fifth quintiles, the risks of first ischemic stroke were 0.52 (95% CI: 0.17, 1.65), 0.23 (95% CI: 0.06, 0.87), 0.92 (95% CI: 0.32, 2.67), and 1.33 (95% CI: 1.09, 4.41), respectively. The optimal cut-off point of total bilirubin for the lowest risk of ischemic stroke was 17.0 µmol/L.ConclusionsTotal bilirubin levels are nonlinearly associated with initial ischemic stroke in patients with non-valvular atrial fibrillation.

Factors associated with fracture after stroke and TIA: a long-term follow-up.

In the present study, we aimed to assess the long-term incidence of fractures and analyze associated factors after stroke or transient ischemic attack (TIA). The current cohort study included patients who had received an initial ischemic stroke or TIA diagnosis documented anonymously in the Disease Analyzer database (IQVIA) between 2000 and 2016 by physicians in 1262 general practices in Germany. Univariate Cox and multivariate regression models were carried out. Three groups (stroke, TIA, no stroke/TIA), each with 12,265 individuals, were selected (mean age 67.3years, 48.1% female). A fracture was diagnosed in 12.9% of stroke patients and in 11.4% of TIA patients. Among male stroke patients, 11.1% had a fracture (15.4% among female stroke patients). The hazard ratio (HR) for fractures after stroke was 1.26 (CI: 1.15-1.39) and for fractures after TIA, it was 1.14 (CI: 1.03-1.25). In female stroke patients, the HR for fractures was 1.32 (CI: 1.15-1.60), while in males, it was 1.20 (CI: 1.03-1.39). Among TIA patients, females had an elevated HR for fractures (HR: 1.21; CI: 1.06-1.37). In individuals aged ≥ 80years, an increased risk for fractures was only detected among TIA patients (HR: 1.26; CI: 1.05-1.51). Dementia and non-opioid analgesic therapy were positively associated with fracture after both stroke and TIA. Stroke was positively associated with fracture in patients < 80years, while TIA was positively associated with fracture in patients ≥ 80years and females. Dementia and analgesic therapy were also associated with fracture after either stroke or TIA.

Is incident stroke associated with increased risk of major adverse cardiovascular events?

In this issue of Neurology ®, Sposato et al.1 perform a population-based retrospective cohort study of older adults with cardiovascular disease to determine whether initial ischemic stroke is associated with incident heart disease within the first year after stroke. The study defined major adverse cardiovascular events (MACE) as a composite outcome, specifically including myocardial infarction, acute coronary syndrome, percutaneous coronary intervention, coronary artery bypass graft surgery, incident coronary artery disease, congestive heart failure, or cardiovascular death. The primary finding from the study is that first-ever ischemic stroke is associated with incident unadjusted MACE risk (hazard ratio [HR] 4.5, 95% confidence interval [CI] 4.3–4.8), with the adjusted risk highest in the first 30 days (HR 25.0, 95% CI 4.3–4.8); this is still significant but with lower risk in the next 60 days (HR 4.8, 95% CI 4.1–5.7), with lowest risk past 90 days (HR 2.2, 95% CI 2.0–2.4). These effect estimates are quite robust, and the authors are to be commended for their careful attention to detail when handling these data.

Development and validation of a prognostic model predicting symptomatic hemorrhagic transformation in acute ischemic stroke at scale in the OHDSI network.

Background and purposeHemorrhagic transformation (HT) after cerebral infarction is a complex and multifactorial phenomenon in the acute stage of ischemic stroke, and often results in a poor prognosis. Thus, identifying risk factors and making an early prediction of HT in acute cerebral infarction contributes not only to the selections of therapeutic regimen but also, more importantly, to the improvement of prognosis of acute cerebral infarction. The purpose of this study was to develop and validate a model to predict a patient’s risk of HT within 30 days of initial ischemic stroke.MethodsWe utilized a retrospective multicenter observational cohort study design to develop a Lasso Logistic Regression prediction model with a large, US Electronic Health Record dataset which structured to the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). To examine clinical transportability, the model was externally validated across 10 additional real-world healthcare datasets include EHR records for patients from America, Europe and Asia.ResultsIn the database the model was developed, the target population cohort contained 621,178 patients with ischemic stroke, of which 5,624 patients had HT within 30 days following initial ischemic stroke. 612 risk predictors, including the distance a patient travels in an ambulance to get to care for a HT, were identified. An area under the receiver operating characteristic curve (AUC) of 0.75 was achieved in the internal validation of the risk model. External validation was performed across 10 databases totaling 5,515,508 patients with ischemic stroke, of which 86,401 patients had HT within 30 days following initial ischemic stroke. The mean external AUC was 0.71 and ranged between 0.60–0.78.ConclusionsA HT prognostic predict model was developed with Lasso Logistic Regression based on routinely collected EMR data. This model can identify patients who have a higher risk of HT than the population average with an AUC of 0.78. It shows the OMOP CDM is an appropriate data standard for EMR secondary use in clinical multicenter research for prognostic prediction model development and validation. In the future, combining this model with clinical information systems will assist clinicians to make the right therapy decision for patients with acute ischemic stroke.

Late Detection of Atrial Fibrillation after Stroke: Implications for the Secondary Prevention

Background: This study is aimed at investigating the incidence of atrial fibrillation (AF) within 5 years after an acute cerebrovascular event in AF-naive patients and its relevance for secondary prevention. Methods: The current case-control study sample included patients who had received an initial ischemic stroke diagnosis documented in the Disease Analyzer database (IQVIA), which compiles data such as risk factors, drug prescriptions, and diagnoses obtained from 1,262 general practices in Germany. Results: After the selection procedure, the stroke and non-stroke groups each included 22,774 patients. In both groups, the mean age of the population was 68.0 years (SD ±12 years), and the proportion of male participants was 51.1%. Within 5 years of follow-up, we calculated a higher probability for detecting AF in stroke patients than in controls (hazard ratio 4.95; 95% CI 1.93–2.09, p < 0.001). In the stroke group, AF was detected in 2,369 individuals (10.4%), whereas AF was only evident in 1,101 patients (4.8%) in the non-stroke group. In 1,741 (73.5%) patients (out of 2,369), oral anticoagulants had been prescribed after the AF diagnosis. In stroke patients, factors like diabetes mellitus and ischemic heart disease were associated with restraint in prescribing oral anticoagulants; age did not influence the decision for or against oral anticoagulants (mean age 72.9 vs. 72.7 years). Conclusion: A recent stroke is a strong preconditioning factor for detecting AF within 5 years after an acute event. The majority of these patients are treated with oral anticoagulants, regardless of their age.

Increased risk for cancer after stroke at a young age: etiological relevance or incidental finding?

Etiological factors, such as a malignant disease, in young stroke patients are often neglected. Therefore, in this study, we aimed to investigate the risk of developing cancer in young stroke survivors. The current case-control study sample included patients who received an initial ischemic stroke diagnosis documented in the Disease Analyzer database (IQVIA), which compiles data such as risk factors, drug prescriptions, and diagnoses obtained from general practitioners and specialists. The stroke and non-stroke groups included 18,668 patients each; each group had 2836 (15.3%) participants ≤ 55years. The cancer incidence in the stroke group over the age of 55years was higher than in the younger subgroup (29.4% versus 17.3%). The proportions of cancer patients within 10years of follow-up were higher in the stroke group versus the non-stroke group, as well as in the subgroup of patients aged ≤ 55 versus patients > 55years (17.3% versus 9.5% and 29.4% versus 24.9%, respectively). The calculated hazard ratio for developing cancer within 10years of follow-up was higher in the younger stroke population (≤ 55years) than in the older population (hazard ratio: 1.47 (CI 1.18-1.83) versus 1.17 (CI 1.10-1.25). In our cohort, young individuals aged ≤ 55years who suffered a stroke had twice as high risk for developing cancer within 10years after the index event compared to the control group. Stroke might have implication regarding the subsequent development of cancer and vice versa.

Association of residential air pollution, noise, and greenspace with initial ischemic stroke severity.

Background and PurposeA number of environmental risk factors of acute ischemic stroke have been identified, but few studies have evaluated the influence of the outdoor environment on stroke severity. We assessed the association of residential ambient fine particulate matter air pollution (PM2.5), noise, and surrounding greenspace with initial stroke severity. MethodsWe obtained data on patients hospitalized with acute ischemic stroke from a hospital-based prospective stroke register (2005–2014) in Barcelona. We estimated residential PM2.5 based on an established land use regression model, greenspace as the average satellite-based Normalized Difference Vegetation Index (NDVI) within a 300 m buffer of the residence, and daily (Lday), evening (Levening), night (Lnight) and average noise (Lden) level at the street nearest to the residential address using municipal noise models. Stroke severity was assessed at the time of hospital presentation using the National Institute of Health Stroke Scale (NIHSS).We used logistic regression and binomial models to evaluate the associations of PM2.5, greenspace, and noise with initial stroke severity adjusting for potential confounders. ResultsAmong 2761 patients, higher residential surrounding greenspace was associated with lower risk of severe stroke (OR for NIHSS>5, 0.75; 95% CI: 0.60–0.95), while, living in areas with higher Lden was associated with a higher risk of severe stroke (OR, 1.30; 95% CI: 1.02–1.65). PM2.5 was not associated with initial stroke severity. ConclusionsIn an urban setting, surrounding greenspace and traffic noise at home are associated with initial stroke severity, suggesting an important influence of the built environment on the global burden of ischemic stroke.

Abstract 100: In-Hospital Delirium and Long-Term Cognitive Outcomes Among Patients With Ischemic Stroke: A Population-Based Cohort Analysis

Introduction: Evidence of association between delirium during initial hospitalization of ischemic stroke (IS) patients, and development of long-term mild cognitive impairment or dementia (MCID) is lacking. We examined the prospective incident risk of MCID among IS patients who experienced in-hospital delirium in a large multi-state population-based cohort. Methods: We utilized NY, CA, and FL (2005 - 2014) State Inpatient and Emergency Department Databases, and established a cohort by selecting MCID free patients with a primary diagnosis of IS (ICD-9: 433.x1, 434.x1, 436) during a 2yr period. Delirium during the initial IS event was tagged using a validated algorithm with high specificity for the confusion assessment method. The cohort was followed for MCID diagnoses. Patients that died within 90 days of initial IS event were excluded. We conducted time-to-event analyses and report cumulative incidence, 95% Confidence Interval (CI) and hazard ratios (HR) for risk of MCID among IS patients with and without delirium. Results: A total of 133,815 IS patients (age: 70.5, female: 51.7%, white: 65.5%) were followed for up to 8yrs, resulting in 357,500 person-years. Patients who experienced delirium were significantly older and had a higher comorbidity burden. A significantly smaller proportion of delirium patients underwent IV or IA thrombolysis. Cumulative incidence (95% CI) for development of MCID was significantly higher among delirium patients (9.01, 8.32 - 9.74) as compared to non-delirium patients (3.99, 3.93 - 4.06). Likewise, the HR for MCID among delirium patients was statistically significant (1.86, 1.71 - 2.02) in the fully adjusted Cox proportional model (Figure). Conclusion: In-hospital delirium was independently associated with a higher risk of developing MCID in this large population-based cohort. Further investigation is warranted to elucidate the mechanistic basis for the role of delirium in long-term cognitive decline among IS patients.