Ischemic Cerebrovascular Events Research Articles

Elevated plasma protein carbonylation increases the risk of ischemic cerebrovascular events in patients with atrial fibrillation: association with a prothrombotic state.

Plasma protein carbonylation that reflects oxidative stress has been demonstrated to be associated with the prothrombotic fibrin clot phenotype. However, the role of protein carbonyls (PC) in predicting ischemic stroke in atrial fibrillation (AF) is largely unknown. This study aimed to investigate whether PC increase the risk of stroke in anticoagulated AF patients during follow-up. In 243 AF patients on anticoagulation (median age 69years; median CHA2DS2-VASc of 4), we measured plasma PC using the assay by Becatti, along with plasma clot permeability (Ks), clot lysis time (CLT), thrombin generation, and fibrinolytic proteins, including plasminogen activator inhibitor type 1 (PAI-1) and thrombin activatable fibrinolysis inhibitor (TAFI). Ischemic stroke, major bleeding, and mortality were recorded during a median follow-up of 53months. Plasma PC levels (median, 3.16 [2.54-3.99] nM/mg protein) at baseline showed positive associations with age (P < 0.001), CHA2DS2-VASc (P = 0.003), and N-terminal B-type natriuretic peptide (P = 0.001), but not with type of AF or comorbidities except for heart failure (P = 0.007). PC levels were correlated with CLT (r = 0.342, P < 0.001), endogenous thrombin potential (r = 0.217, P = 0.001) and weakly with Ks (r = -0.145, P = 0.024), but not with fibrinogen, PAI-1, or TAFI levels. Stroke was recorded in 20 patients (1.9%/year), who had at baseline 36% higher PC levels (P < 0.001). Elevated PC (P = 0.003) at baseline were independently associated with stroke risk. Our findings suggest that in patients with AF enhanced protein carbonylation is associated with increased "residual" risk of stroke despite anticoagulation, which is at least in part due to unfavorably altered fibrin clot phenotype.

HR-MRI-based nomogram network calculator to predict stroke recurrence in high-risk non-disabling ischemic cerebrovascular events patients.

To investigate the use of high-resolution magnetic resonance imaging (HR-MRI) to identify the characteristics of culprit plaques in intracranial arteries, and to evaluate the predictive value of the characteristics of culprit plaques combined with the modified Essen score for the recurrence risk of high-risk non-disabling ischemic cerebrovascular events (HR-NICE) patients. A retrospective analysis was conducted on 180 patients with HR-NICE at the First Affiliated Hospital of Xinxiang Medical University, including 128 patients with no recurrence (non-recurrence group) and 52 patients with recurrence (recurrence group). A total of 65 patients with HR-NICE were collected from the Sixth Affiliated Hospital of Shanghai Jiaotong University as a validation group, and their modified Essen scores, high-resolution magnetic resonance vessel wall images, and clinical data were collected. The culprit plaques were analyzed using VesselExplorer2 software. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for recurrence, and a nomogram was constructed using R software to evaluate the discrimination of the model. The area under the curve (AUC) of the receiver operating characteristic curve (ROC) was used to evaluate the model performance. Calibration curves and Decision Curve Analysis (DCA) were used to evaluate the model efficacy. Intra-plaque hemorrhage (OR = 3.592, 95% CI = 1.474-9.104, p = 0.006), homocysteine (OR = 1.098, 95% CI = 1.025-1.179, p = 0.007), and normalized wall index (OR = 1.114, 95% CI = 1.027-1.222, p = 0.015) were significantly higher in the recurrent stroke group than in the non-recurrent stroke group, and were independent risk factors for recurrent stroke. The performance of the nomogram model (AUC = 0.830, 95% CI: 0.769-0.891; PR-AUC = 0.628) was better than that of the modified Essen scoring model (AUC = 0.660, 95% CI: 0.583-0.738) and the independent risk factor combination model (AUC = 0.827, 95% CI: 0.765-0.889). The nomogram model still had good model performance in the validation group (AUC = 0.785, 95% CI: 0.671-0.899), with a well-fitting calibration curve and a DCA curve indicating good net benefit efficacy for patients. High-resolution vessel wall imaging combined with a modified Essen score can effectively assess the recurrence risk of HR-NICE patients, and the nomogram model can provide a reference for identifying high-risk populations with good clinical application prospects.

Precise risk-prediction model including arterial stiffness for new-onset atrial fibrillation using machine learning techniques.

Atrial fibrillation (AF) is the most common clinically significant cardiac arrhythmia and is an important risk factor for ischemic cerebrovascular events. This study used machine learning techniques to develop and validate a new risk prediction model for new-onset AF that incorporated the use electrocardiogram to diagnose AF, data from participants with a wide age range, and considered hypertension and measures of atrial stiffness. In Japan, Industrial Safety and Health Law requires employers to provide annual health check-ups to their employees. This study included 13 410 individuals who underwent health check-ups on at least four successive years between 2005 and 2015 (new-onset AF, n=110; non-AF, n=13 300). Data were entered into a risk prediction model using machine learning methods (eXtreme Gradient Boosting and Shapley Additive Explanation values). Data were randomly split into a training set (80%) used for model construction and development, and a test set (20%) used to test performance of the derived model. The area under the receiver operator characteristic curve for the model in the test set was 0.789. The best predictor of new-onset AF was age, followed by the cardio-ankle vascular index, estimated glomerular filtration rate, sex, body mass index, uric acid, γ-glutamyl transpeptidase level, triglycerides, systolic blood pressure at cardio-ankle vascular index measurement, and alanine aminotransferase level. This new model including arterial stiffness measure, developed with data from a general population using machine learning methods, could be used to identify at-risk individuals and potentially facilitation the prevention of future AF development.

Factors impacting D-dimer levels in patients with acute ischemic cerebrovascular events

Background and objectivesA better understanding of the factors influencing D-dimer levels in code stroke patients is needed to guide further investigations of concomitant thrombotic conditions. This study aimed to investigate the impact of time from symptom onset and other factors on D-dimer levels in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). MethodsData on consecutive AIS and TIA patients treated at our tertiary-care stroke center between January 2015 and December 2020 were retrospectively assessed. Patients with available D-dimer levels were evaluated for eligibility. Multivariable non-linear regression analyses were performed. ResultsIn total, 2467 AIS patients and 708 TIA patients were included. The median D-dimer levels differed between the AIS and TIA groups (746 µg/L [interquartile range 381–1468] versus 442 µg/L [interquartile range 244–800], p<0.001). In AIS patients, an early increase in D-dimer levels was demonstrated within the first 6 h (standardized beta coefficient [β] 0.728; 95% confidence interval [CI] 0.324–1.121). This was followed by an immediate decrease (β −13.022; 95% CI −20.401 to −5.643) and then by a second, late increase after 35 h (β 11.750; 95% CI 4.71–18.791). No time-dependent fluctuation in D-dimer levels was observed in TIA patients. ConclusionThe time from symptom onset may affect D-dimer levels in patients with AIS but not those with TIA. Further studies confirming these findings and validating time-specific variations are needed to enable D-dimer levels to be used efficiently as an acute stroke and thrombotic risk biomarker.

Identification of nitrated proteins in human thrombi from ischemic cerebrovascular events

Identification of nitrated proteins in human thrombi from ischemic cerebrovascular events

Angiogenesis inhibitors and cardiovascular outcomes in cancer: Real-world, population-based, matched cohort study.

e24024 Background: Angiogenesis inhibitors (AI) have vascular side effects and are now recognized forcardiovascular adverse events (CVAEs). Clinical trial outcomes can underestimate treatment-related adverse events due to restrictive eligibility criteria, limited sample size, and failure to anticipate specific toxicities. In contrast, observational studies have small sample sizes and insufficient adjustment of confounding covariates. In addition, prospective high-quality evidence in real-world settings is scarce. We evaluated the incidence of CVAEs in real-world populations on AI therapy. Methods: This large retrospective cohort study was conducted using the TriNetX database and included adult patients ( &gt; 18 years) with new cancer diagnoses. We performed 1:1 propensity score matching (PSM) for demographics, BMI, nicotine dependence, comorbidities, cancer type, and medications to similar controls as cancer patients never treated with AIs. The primary outcome was the new incidence of CVAEs-like heart failure (HF), major adverse cardiovascular events (MACE; coronary artery intervention myocardial infarction, or unstable angina), arrhythmia, ischemic heart disease (IHD), venous thromboembolism (VT), and cerebrovascular events (CVE cerebral infarction, carotid intervention, stroke, transient ischemic attack). Sensitivity analysis assessed statistical robustness. Hazard ratios (HR) were calculated to compare the AI therapy association with incident CVAEs. Results: We identified 1,170,667 patients with diagnoses of colorectal, cervical, kidney, liver, nonsmall cell lung, or ovarian cancer between 2010 and 2022. Among these, 59,890 had an AI treatment history, and 110,777 did not, with a median follow-up time of 3.1 years. After PSM, both cohorts (59545 each) were well-matched. In the adjusted analysis, AI therapy was associated with higher risks of MACE (HR, 1.23; 95% CI 1.16 -1.31), HF (HR, 1.16; 95% CI 1.08 - 1.25), and VT (HR 2.07; 95% CI 1.95 - 2.19), IHD (HR 1.23; 95% CI 1.16- 1.31), arrhythmias (HR 1.19; 95% CI 1.12-1.27), CVEs (HR, 1.30; 95% CI 1.21- 1.40) at 1 year of exposure. These outcomes were still significantly higher “increased,” suggesting causation; this is an association at follow-up by increasing the lag exposure. Sensitivity analysis results were consistent, and all statistically significant associations remained unchanged. Conclusions: Angiogenesis inhibitor treatment was associated with a significantly higher risk of CVAEs and various malignancies. The increased risk ranges from approximately 1.16 to 2.07 fold, indicating a substantial elevation in risk. These findings highlight the importance of risk stratification and cardiovascular monitoring during and after AI therapy. There is an unmet need to define strategies for CVAE prevention in this high-risk population.

Signal intensity and volume of carotid intraplaque hemorrhage on magnetic resonance imaging and the risk of ipsilateral cerebrovascular events: The Plaque At RISK (PARISK) study

BackgroundThe Plaque at RISK (PARISK) study demonstrated that patients with a carotid plaque with intraplaque hemorrhage (IPH) have an increased risk of recurrent ipsilateral ischemic cerebrovascular events. It was previously reported that symptomatic carotid plaques with IPH showed higher IPH signal intensity ratios (SIR) and larger IPH volumes than asymptomatic plaques. We explored whether IPH SIR and IPH volume are associated with future ipsilateral ischemic cerebrovascular events beyond the presence of IPH. MethodsTIA and ischemic stroke patients with mild-to-moderate carotid stenosis and an ipsilateral IPH-positive carotid plaque (n=89) from the PARISK study were included. The clinical endpoint was a new ipsilateral ischemic cerebrovascular event during 5 years of follow-up, while the imaging-based endpoint was a new ipsilateral brain infarct on brain MRI after 2 years (n=69). Trained observers delineated IPH, a hyperintense region compared to surrounding muscle tissue on hyper T1-weighted MR images. The IPH SIR was the maximal signal intensity in the IPH region divided by the mean signal intensity of adjacent muscle tissue. The associations between IPH SIR or volume and the clinical and imaging-based endpoint were investigated using Cox-proportional hazard models and logistic regression, respectively. ResultsDuring 5.1 (interquartile range (IQR): 3.1-5.6) years of follow-up, 21 ipsilateral cerebrovascular ischemic events were identified. Twelve new ipsilateral brain infarcts were identified on the 2-year neuro MRI. There was no association for IPH SIR or IPH volume with the clinical endpoint (HR: 0.89 [95% CI: 0.67-1.10] and HR: 0.91 [0.69-1.19] per 100µl increase, respectively) nor with the imaging-based endpoint (OR: 1.04 [0.75-1.45] and OR: 1.21 [0.87-1.68] per 100µl increase, respectively). ConclusionsIPH SIR and IPH volume were not associated with future ipsilateral ischemic cerebrovascular events. Therefore, quantitative assessment of IPH does not seem to provide additional value beyond the presence of IPH for stroke risk assessment.Trial registrationThe PARISK study was registered on ClinicalTrials.gov with ID NCT01208025 on 21 September 2010 (https://clinicaltrials.gov/study/NCT01208025).

Recurrent cerebrovascular events after recent small subcortical infarction.

Recent small subcortical infarcts (RSSI) are the neuroimaging hallmark feature of small vessel disease (SVD)-related acute lacunar stroke. Long-term data on recurrent cerebrovascular events including their aetiology after RSSI are scarce. This retrospective study included all consecutive ischaemic stroke patients with an MRI-confirmed RSSI (in the supply area of a small single brain artery) at University Hospital Graz between 2008 and 2013. We investigated associations between clinical and SVD features on MRI (STRIVE criteria) and recurrent cerebrovascular events, using multivariable Cox regression adjusted for age, sex, vascular risk factors and MRI parameters. We analysed 332 consecutive patients (mean age 68years, 36% women; median follow-up time 12years). A recurrent ischaemic cerebrovascular event occurred in 70 patients (21.1%; 54 ischaemic strokes, 22 transient ischaemic attacks) and was mainly attributed to SVD (68%). 26 patients (7.8%) developed intracranial haemorrhage. In multivariable analysis, diabetes (HR 2.43, 95% CI 1.44-3.88), severe white matter hyperintensities (HR 1.97, 95% CI 1.14-3.41), and cerebral microbleeds (HR 1.89, 95% CI 1.32-3.14) on baseline MRI were related to recurrent ischaemic stroke/TIA, while presence of cerebral microbleeds increased the risk for intracranial haemorrhage (HR 3.25, 95% CI 1.39-7.59). A widely used SVD summary score indicated high risks of recurrent ischaemic (HR 1.22, 95% CI 1.01-1.49) and haemorrhagic cerebrovascular events (HR 1.57, 95% CI 1.11-2.22). Patients with RSSI have a substantial risk for recurrent cerebrovascular events-particularly those with coexisting chronic SVD features. Recurrent events are mainly related to SVD again.

SAFETY AND EFFICACY OF A LIGHT ANTITHROMBOTIC REGIMEN AFTER LEFT ATRIAL APPENDAGE OCCLUSION: INSIGHTS FROM THE LOGIC (LEFT ATRIAL APPENDAGE OCCLUSION IN PATIENTS WITH GASTROINTESTINAL OR INTRACRANIAL BLEEDING) INTERNATIONAL MULTICENTER REGISTRY

Abstract Background Antithrombotic therapy (AT) after left atrial appendage occlusion (LAAO) in patients with non–valvular atrial fibrillation (NVAF) has the purpose of preventing device related thrombosis (DRT), avoiding embolic events; nevertheless, the correct antithrombotic regimen after LAAO is still under debate. Aims Aim of this substudy of the observational LOGIC registry was to describe the efficacy and safety of a light antithrombotic regimen, comprising single antiplatelet therapy or none, compared to a standard antithrombotic regimen, after a successful LAAO. Methods Patients with NVAF that underwent LAAO were previously included in the LOGIC registry. Patients receiving single or no AT were considered as light therapy group, while other regimen were considered as standard regimen group. Outcomes of interest were: death from any causes and cardiovascular death, ischemic stroke, transient ischemic attack and systemic embolization, any bleeding and major bleeding at 12 months. Results. Six hundred and twenty–eight patients were considered in the analysis, 31.4% received a light antithrombotic regimen. There were no differences in overall and cardiovascular mortality (5.1% Vs 6.7%, p=0.426 and 2.0% Vs 1.4%, p=0.553 respectively). Cerebrovascular stroke and transient ischemic attack were similar between the two groups (1.5% Vs 1.4%, p=0.898 and 1.5% Vs 1.3%, p=0.847). Light regimen was not associated with an increased rate of systemic embolism (1.0% Vs 0.7%, p=0.447 and HR 0.88 [95% CI: 0.34 – 2.27; p=0.79]). Conclusions An AT regimen based on single or no antithrombotic therapy after LAAO seems to be safe in patients with high–bleeding risk, without increasing cerebrovascular or peripheral ischemic events.

The Impact of Changing Antithrombotic Management in Patients With Atrial Fibrillation and Ischemic Cerebrovascular Events Despite Anticoagulation

Background Patients with atrial fibrillation (AF) are at increased risk of ischemic cerebrovascular events despite anticoagulants (AC). We aim to evaluate whether changing AC or adding antiplatelet therapy to anticoagulants (AP + AC) in patients with AF presenting with acute ischemic stroke (AIS) or transient ischemic attack (TIA) despite AC, decreases the risk of recurrent AIS/TIA compared to patients continued on same AC regimen. Methods Patients with AF on AC presenting with AIS or TIA at our center between 2011- 2021 were included. Data on Demographics, index event, antithrombotic therapy before and after index event, recurrent AIS/TIA, or major bleeding events (MBE) were extracted. Cox proportional hazards models were used to compare outcomes between AC unchange vs AC change, and AP + AC vs AC only groups. Results One hundred eighty-five patients were included (mean age 78.3 years; 62% males, median follow-up 9 months (IQR 1-34)). Seventeen patients (9%) had AC change, 100 (54%) received AP + AC, 39 (21%) had recurrent AIS/TIA, and 27 (15%) had MBE following index event. No difference was observed between AC unchange vs AC change and AP + AC vs AC only groups regarding recurrent AIS/TIA (HR 1.72 [.65-4.57], P = .27 and HR 1.02 [.53- 1.98], P = .95, respectively) or MBE (HR .85 [.19-3.67], P = .83 and HR 1.49 [.67-3.33)], P = .33, respectively). Fourteen vascular neurologists treated this cohort and 9(64%) implemented AC changes. Conclusion In this single center retrospective study of 185 patients with AF and AIS/TIA despite AC, changing AC or adding AP agents did not decrease the risk of ischemic cerebrovascular events.

Robustness and classification capabilities of MRI radiomic features in identifying carotid plaque vulnerability.

To assess how radiomic features may be combined with plaque morphological and compositional features identified by multi-contrast MRI to improve upon conventional risk assessment models in determining culprit carotid artery lesions. Fifty-five patients (mean age: 62.6; 35 males) with bilateral carotid stenosis who experienced transient ischaemic attack (TIA) or stroke were included from the CARE-II multi-centre carotid imaging trial (ClinicalTrials.gov Identifier: NCT02017756). They underwent MRI within 2 weeks of the event. Classification capability in distinguishing culprit lesions was assessed by machine learning. Repeatability and reproducibility of the results were investigated by assessing the robustness of the radiomic features. Radiomics combined with a relatively conventional plaque morphological and compositional metric-based model provided incremental value over a conventional model alone (area under curve [AUC], 0.819 ± 0.002 vs 0.689 ± 0.019, respectively, P = .014). The radiomic model alone also provided value over the conventional model (AUC, 0.805 ± 0.003 vs 0.689 ± 0.019, respectively, P = .031). T2-weighted imaging-based radiomic features had consistently higher robustness and classification capabilities compared with T1-weighted images. Higher-dimensional radiomic features outperformed first-order features. Grey Level Co-occurrence Matrix, Grey Level Dependence Matrix, and Grey Level Size Zone Matrix sub-types were particularly useful in identifying textures which could detect vulnerable lesions. The combination of MRI-based radiomic features and lesion morphological and compositional parameters provided added value to the reference-standard risk assessment for carotid atherosclerosis. This may improve future risk stratification for individuals at risk of major adverse ischaemic cerebrovascular events. The clinical relevance of this work is that it addresses the need for a more comprehensive method of risk assessment for patients at risk of ischaemic stroke, beyond conventional stenosis measurement. This paper shows that in the case of carotid stroke, high-dimensional radiomics features can improve classification capabilities compared with stenosis measurement alone.

Identification of nitrated proteins in human thrombi from ischemic cerebrovascular events

Identification of nitrated proteins in human thrombi from ischemic cerebrovascular events

Cerebrovascular disease in patients with antiphospholipid antibody syndrome: a transcranial Doppler and magnetic resonance imaging study.

Transcranial Doppler (TCD) and brain MRI may be useful in evaluating patients with APS, helping to stratify the risk of cerebrovascular ischaemic events in this population. This study aimed to assess the frequency of brain MRI abnormalities in patients with primary antiphospholipid syndrome, secondary antiphospholipid syndrome and SLE and correlate to TCD findings. The study, conducted over four years at two autoimmune disease referral centres, included 22 primary antiphospholipid syndrome patients, 24 secondary antiphospholipid syndrome patients, 27 SLE patients without APS and 21 healthy controls. All participants underwent TCD to assess cerebral haemodynamics, detect microembolic signals and evaluate right-to-left shunts, followed by brain MRI and magnetic resonance angiography. MRI scans were reviewed for acute microembolism, localized cortical infarctions, border infarctions, lacunar infarctions, ischaemic lesions, white matter hyperintensity, micro and macro haemorrhages and arterial stenosis ≥50% of the cervical carotid artery, by two neuroradiologists blinded to the clinical data. Brain MRI findings were similar between the groups, except for lacunar infarction, more frequent in patients with secondary antiphospholipid syndrome (P = 0.022). Patients with intracranial stenosis detected by TCD had a higher frequency of territorial infarction (40% vs 7.5%, P = 0.02), lacunar (40% vs 11.3%, P = 0.075) and border zone infarcts (20% vs 1.9%, P = 0.034). Patients with intracranial stenosis presented a higher frequency of territorial, lacunar and border zone infarcts, suggesting that evaluating the intracranial vasculature should not be neglected in patients with APS and stroke.

Should left atrial appendage closure be considered in resistant left atrial appendage thrombus cases? 'Former Foe, New Ally'.

The study explores left atrial appendage closure (LAAC) as a safe and effective alternative to anticoagulation for atrial fibrillation (AF) patients at high bleeding risk. Complications, such as cardioembolic events due to left atrial appendage thrombus (LAAT), highlight the need for alternative stroke prevention strategies. This research assesses LAAC's safety and efficacy in patients with LAAT, aiming to offer valuable insights into its potential as a viable option for stroke prevention in such cases. The study included 205 patients who underwent LAAC using specific devices between September 2015 and February 2023. Among them, 32 patients had persistent LAAT. Baseline characteristics, antithrombotic medications, risk scores, and LAAC indications were documented. Patients were followed to monitor significant clinical events like stroke, cardiovascular mortality, and all-cause mortality. The mean age was 71.9 and mostly female. Indications for LAAC were ischemic cerebrovascular events (CVE) despite anticoagulation (25%), bleeding complications (major/minor, 37.5% each), or both. Successful LAA closure was achieved in all cases, with minimal pericardial effusion in one. One-month follow-up showed no major events or device-related issues. Median follow-up of 16.5 months saw 21.9% non-cardiac deaths. The study underscores LAAC's efficacy for stroke prevention in patients with persistent LAAT. The LAAC in cases of LAAT, whether pursued initially or as a deferred approach, demonstrates feasibility and safety, exhibiting notable procedural success and minimal incidence of periprocedural complications.

The associations between peripheral inflammatory and lipid parameters, white matter hyperintensity, and cognitive function in patients with non-disabling ischemic cerebrovascular events

BackgroundThe global prevalence of VCI has increased steadily in recent years, but diagnostic biomarkers for VCI in patients with non-disabling ischemic cerebrovascular incidents (NICE) remain indefinite. The primary objective of this research was to investigate the relationship between peripheral serological markers, white matter damage, and cognitive function in individuals with NICE.MethodsWe collected clinical data, demographic information, and medical history from 257 patients with NICE. Using the MoCA upon admission, patients were categorized into either normal cognitive function (NCF) or VCI groups. Furthermore, they were classified as having mild white matter hyperintensity (mWMH) or severe WMH based on Fazekas scores. We then compared the levels of serological markers between the cognitive function groups and the WMH groups.ResultsAmong 257 patients with NICE, 165 were male and 92 were female. Lymphocyte count (OR = 0.448, P < 0.001) and LDL-C/HDL-C (OR = 0.725, P = 0.028) were protective factors for cognitive function in patients with NICE. The sWMH group had a higher age and inflammation markers but a lower MoCA score, and lymphocyte count than the mWMH group. In the mWMH group, lymphocyte count (AUC = 0.765, P < 0.001) and LDL-C/HDL-C (AUC = 0.740, P < 0.001) had an acceptable diagnostic value for the diagnosis of VCI. In the sWMH group, no significant differences were found in serological markers between the NCF and VCI groups.ConclusionLymphocyte count, LDL-C/HDL-C were independent protective factors for cognitive function in patients with NICE; they can be used as potential biological markers to distinguish VCI in patients with NICE and are applicable to subgroups of patients with mWMH.

Predictors for Adherence to Recommended Anticoagulation after Stroke Unit Discharge in Patients with Atrial Fibrillation

Introduction: Non-adherence to recommended secondary preventive anticoagulation in stroke patients with atrial fibrillation (AF) is a common phenomenon, although the introduction of direct oral anticoagulants (DOACs) has simplified anticoagulation management for physicians as well as for patients. Methods: We examined the adherence of secondary preventive anticoagulation in AF patients after re-integration in their social environment 6–12 weeks after stroke unit and rehabilitation clinic treatment and analyzed for predictors for adherence and non-adherence. We conducted a telephone survey in consecutive patients treated between January 2013 and December 2021 at our institutional stroke unit with an acute cerebrovascular ischemic event, and we analyzed discharge letters of rehabilitation clinics of those patients not anticoagulated at follow-up. All patients had known or newly diagnosed AF, and in all, we had recommended secondary preventive anticoagulation. Results: Follow-up information about anticoagulant intake could be obtained in 1,348 of 1,685 patients (80.0%) treated within the study period. Anticoagulation rate was 91.5%, with 83.6% of patients receiving DOACs and 7.9% receiving vitamin K antagonists (VKAs). Adherence to recommended anticoagulation was associated with intake of the recommended anticoagulant already at discharge (adjusted odds ratio [OR], 18.357; confidence interval [CI], 9.637–34.969), recommendation of a specific DOAC and dose (in contrast to “DOAC” as drug category) (adjusted OR, 2.971; CI, 1.173–7.255), a lower modified Rankin Scale at discharge (per point; adjusted OR, 0.813; CI, 0.663–0.996), younger age (per year; OR, 0.951; CI, 0.926–0.976), and the absence of peripheral vascular disease (adjusted OR, 0.359; CI, 0.173–0.746). In patients already anticoagulated at discharge, adherence was 98.5%, irrespective of a patient’s age, functional deficit at discharge, and peripheral vascular disease. Avoidable obstacles for non-adherence in patients not on anticoagulants at stroke unit discharge were (1) non-implementation of recommended anticoagulation by rehabilitation physicians predominantly in patients with moderate-severe or severe stroke disability (2.1%), (2) delegation of anticoagulation start from rehabilitation physicians to general practitioners/resident radiologists (1.3%), and (3) rejection of recommended anticoagulation because of patients’ severe stroke disability (0.5%). Non-avoidable obstacles were contraindications to anticoagulation (2.1%) and patients’ refusal (0.7%). Conclusions: Commencing drug administration already during stroke unit hospitalization and providing an explanation for the selection of the recommended anticoagulant in discharge letters ensures high adherence at patients’ re-integration in their social environment after acute stroke treatment. If drug administration cannot be commenced before discharge, education of rehabilitation physicians by stroke physicians and the involvement of stroke physicians into the post-stroke decision process might hinder avoidable obstacles.

Modifying effects of green space on the relationships between air pollution and ischemic cerebrovascular event recurrence in Tianjin, China

ABSTRACT This study aimed to explore how air pollution and green space influence ICE recurrence and whether they might interact with each other. A case-cross design was used in this study, which was carried out in Tianjin, China. A total of 8306 patients with recurrent ICE were collected from 2019 to 2020. The maximum effects of PM2.5, PM10, SO2, NO2, CO were 1.012 (95%CI: 1.004, 1.019), 1.010 (95%CI: 1.004, 1.016), 1.035 (95%CI: 0.982, 1.091), 1.067 (95%CI: 1.043, 1.091) and 1.012 (95%CI: 1.004, 1.021) , respectively, and the risk was higher in males and in the 50–60 age group. In the stratification of greening, it was found that air pollution except O3 had the highest risk of ICE recurrence for those with lower green space. Our study found that air pollution (except O3) can increase the risk of ICE recurrence, and this risk can be reduced by increasing green space.

Abstract WP243: Elevated Lipoprotein(a) as a Predictor for Recurrent Ischemic Cerebrovascular Events: A Meta-Analysis of Cohort Studies

Introduction: Elevated levels of Lipoprotein(a) [Lp(a)] have been associated with an increased risk of incidental acute ischemic stroke (AIS). Our study represents the first meta-analysis investigating the relationship between Lp(a) levels and the recurrence of AIS or transient ischemic attacks (TIA) in both adult and pediatric populations. Methods: We conducted a systematic search of PubMed and Google Scholar databases up to August 2023, utilizing medical subject headings and title/abstract terms. Studies reporting on Lp(a) levels predicting recurrent AIS or TIA were screened. From 85 identified studies, 8 met our inclusion criteria: 5 focusing on adults and 3 on pediatric cohorts. Binary random effects models were used to estimate pooled unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI). Subgroup analysis was performed by country. Sensitivity analysis was done by the leave-one-out method, and the heterogeneity was assessed with I 2 statistics. Results: Our analysis included data from 13,549 patients. The mean age in years was 66 for adults and 7.6 for the pediatric cohort. The majority of the cohorts were male and identified as being of a white racial background. The median follow-up duration was 22.5 months. Elevated Lp(a) indicated an unadjusted OR of 1.60 (95% CI: 1.18-2.16) for recurrent AIS or TIA, with moderate heterogeneity (I 2 =56.17%, p=0.003) and the association validated by sensitivity analysis. When adjusted, the OR increased to 1.84 (95% CI: 1.20-2.84) with high heterogeneity (I 2 =82.36%, p&lt;0.001). Country-specific sub-analysis identified the highest OR in Germany, followed by China and the USA. Conclusion: Elevated Lp(a) levels corresponded to a 60% unadjusted and 84% adjusted increase in the risk of recurrent AIS or TIA. This underscores the significance of Lp(a) as a valuable predictor for recurring cerebrovascular events, offering insight to inform clinical management and decision-making.

Thrombomodulin Serum Levels-A Predictable Biomarker for the Acute Onset of Ischemic Stroke.

The early diagnosis of acute ischemic stroke (AIS) can be challenging in cases presenting with a scarcity of clinical signs, normal cerebral imaging in early stages and a lack of specific serum markers. Thrombomodulin has been shown to be associated with cerebrovascular ischemic events and can be considered an important biomarker for the acute onset of ischemic stroke. In our study, we compared the serum levels of thrombomodulin (sTM) between a relevant patient group of 70 AIS patients and a control group of patients without AIS admitted into the neurology department between June 2022 and May 2023. sTM levels were measured at 24 h and 48 h after patients' admissions into the hospital. There was a significant difference between the two groups (AIS: 23.2 ± 9.17 ng/mL vs. controls: 3.64 ± 1.72 ng/mL; p-value < 0.001). sTM values were correlated with the score of neurological deficits, with gender and dyslipidemia. The association of sTM values with the acute onset of AIS as an end point was significant, which allows rapid therapeutic interventions, even in the absence of a well-defined clinical syndrome (AUC = 0.99). Reanalysis of the patients after propensity score matching increased the power of sTM as a biomarker (AUC = 1). sTM represents a potentially useful biomarker to diagnose the onset of an AIS, even in scarce clinical presentations, which makes thrombomodulin a valuable indicator for early treatment initiation.

Insulin-like growth factor 1 and its prognostic value in the course of acute ischemic cerebrovascular events.

The aim of the study was to evaluate insulin-like growth factor 1 (IGF-1) as a predictor of the course of an acute cerebral ischemic event (AICE). This polypeptide, by activating receptors that are present in most tissues, including the brain, mediates the anabolic activity of growth hormone (GH) and its impact on growth and maturation processes, as well as organisms' survival time. AICE can occur in the form of a transient ischemic attack (TIA) or an ischemic stroke (IS). The study included 86 participants. The correlation between serum IGF-1 concentration and the clinical status of 56 patients on days 1 and 9 of AICE, as well as risk factors and the course of the disease, were prospectively analyzed. The control group consisted of 30 healthy volunteers. Patients with a minor baseline neurological syndrome had higher serum IGF-1 concentrations than patients with severe baseline neurological dysfunctions. Multidimensional analyses showed that high IGF-1 values independently determined the worse course of the disease, especially in patients with a severe neurological deficit present on the first day of AICE. Our results indicate that the high level of circulating IGF-1 on the first day of AICE is an independent factor determining the unfavorable course of the stroke, and this relationship is proportional to the severity of the baseline neurological deficit. The study also revealed a positive correlation between the decreased plasma IGF-1 concentration on the first day of AICE and the severity of neurological symptoms.