Ischemic Stroke Syndrome Research Articles

American Telemedicine Association: Telestroke Guidelines.

The following telestroke guidelines were developed to assist practitioners in providing assessment, diagnosis, management, and/or remote consultative support to patients exhibiting symptoms and signs consistent with an acute stroke syndrome, using telemedicine communication technologies. Although telestroke practices may include the more broad utilization of telemedicine across the entire continuum of stroke care, with some even consulting on all neurologic emergencies, this document focuses on the acute phase of stroke, including both pre- and in-hospital encounters for cerebrovascular neurological emergencies. These guidelines describe a network of audiovisual communication and computer systems for delivery of telestroke clinical services and include operations, management, administration, and economic recommendations. These interactive encounters link patients with acute ischemic and hemorrhagic stroke syndromes with acute care facilities with remote and on-site healthcare practitioners providing access to expertise, enhancing clinical practice, and improving quality outcomes and metrics. These guidelines apply specifically to telestroke services and they do not prescribe or recommend overall clinical protocols for stroke patient care. Rather, the focus is on the unique aspects of delivering collaborative bedside and remote care through the telestroke model.

Emergent Carotid Thromboendarterectomy for Acute Symptomatic Occlusion of the Extracranial Internal Carotid Artery.

Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with an extremely poor prognosis. The best treatment approach in this setting is still unknown. The aim of our study was to evaluate the efficacy, safety, and outcomes of emergent surgical revascularization of acute extracranial ICA occlusion in patients with minor to severe ischemic stroke. A retrospective analysis was performed using prospectively collected data of consecutive patients who underwent carotid thromboendarterectomy for symptomatic acute ICA occlusion during the period from January 2013 to December 2015. Primary outcomes were disability at 90 days assessed by the modified Rankin Scale (mRS) and neurological deficit at discharge assessed using the National Institute of Health Stroke Scale (NIHSS). Secondary outcomes were the recanalization rate, 30-day overall mortality, and any intracerebral bleeding. During the study period, a total of 6 patients (5 men and 1 woman) with a median age of 64 years (range: 58-84 years) underwent emergent reconstruction for acute symptomatic ICA occlusion within a median of 5.4 hours (range: 2.9-12.0 hours) after symptoms onset. The median presenting NIHSS score was 10.5 points (range: 4-21). Before surgery, 4 patients (66.7%) had been treated by systemic recombinant tissue plasminogen activator lysis. The median time interval between initiation of intravenous thrombolysis and carotid thromboendarterectomy was 117.5 minutes (range: 65-140 minutes). Patency of the ICA was achieved in all patients. On discharge, the median NIHSS score was 2 points (range: 0-11 points). There was no postoperative intracerebral hemorrhage and zero 30-day mortality rate. At 3 months, 5 patients (83.3%) had a good clinical outcome (mRS ≤ 2). Patients presenting with minor to severe ischemic stroke syndromes due to isolated extracranial ICA occlusion may benefit from emergent carotid revascularization. Thorough preoperative neuroimaging is essential to aid in selecting eligible candidates for acute surgical intervention.

Correlation between CH2DS2-VASc Score and Serum Leptin Levels in Cardioembolic Stroke Patients: The Impact of Metabolic Syndrome.

Objective To determine adipokines levels in patients with different etiologic subtypes of acute ischemic stroke (AIS) and metabolic syndrome (MetS) status. Methods Serum adiponectin, leptin, and resistin levels were determined by ELISA in 99 AIS patients and 59 stroke-free control group subjects. Stroke patients were grouped based on MetS, modified TOAST classification, and CHA2DS2-VASc scale in case of cardioembolic stroke following atrial fibrillation. Results No differences were found in all adipokine serum levels between AIS patients and appropriately matched control group. MetS-AIS patients had significantly higher leptin levels (22.71 ± 19.01 ng/ml versus 8.95 ± 9.22 ng/ml, p < 0.001) and lower adiponectin levels (10.71 ± 8.59 ng/ml versus 14.93 ± 10.95 ng/ml, p < 0.05) than non-MetS-AIS patients. In patients with cardioembolic stroke, leptin levels were significantly higher than in remaining stroke cases (19.57 ± 20.53 ng/ml versus 13.17 ± 12.36 ng/ml, p < 0.05) and CHA2DS2-VASc score positively correlated with leptin levels only (p < 0.001). Analysis of individual components of CHA2DS2-VASc score showed that hypertension, female gender, and diabetes had greatest impact on elevated serum leptin level. Conclusion This pilot study revealed that leptin could be a potential biomarker for risk stratification of cardioembolic stroke in MetS patients and that heterogeneity of stroke subtypes should be considered for more refined and precise clinical stroke studies.

DC Electroacupuncture Effects on Scars and Sutures of a Patient with Postconcussion Pain

Introduction: This case study offers a detailed comparative analysis of the effects of direct-current electroacupuncture (DC-EA) on the autonomic nervous system (ANS), when DC-EA was applied to the cranial sutures and scars of a patient with a history of ischemic stroke and postconcussion syndrome (PCS) pain.Case: A 56-year-old female suffering from severe tremors and debilitating headaches requested acupuncture after conventional biomedicines failed to relieve her symptoms. Evaluations were performed to check the status of 27 ANS functions. These detailed evaluations were performed to obtain a baseline status of ANS function on this patient, who had a history of ischemic stroke, PCS, and chronic pain. All evaluations were repeated pre–post her DC-EA treatment.Results: This patient experienced significant relief from her symptoms after DC-EA treatment. An analysis of this patient's risk for ANS complications showed improvements in four key homeostatic markers post treatment.Conclusions: The ANS response of a patient with ischemic stroke, PCS, and chronic pain, who received electrical nerve stimulation using DC-EA reflected a measurable improvement in sympathetic tone, along with reductions in pain levels and PCS symptoms. The positive results in this case study could have applications to other pathologies that can be affected by the sympathetic nervous system activation on the body.

Lambl's excrescences: A case report and review of the literature.

Lambl's excrescences are filamentous extensions of cardiac valves, mostly asymptomatic but rarely associated with catastrophic thromboembolic events such as acute ischemic stroke and acute coronary syndromes. Numerous case reports cited in the literature have addressed various spectrum of presentation of these syndromes and their outcomes based on therapies used. We encountered such a patient from our own experience who presented with an acute ischemic stroke with no other identifiable cause other than the Lambl's excrescences. We subsequently carried out an extensive literature search and based on our interpretation of the outcomes we decided to treat the patient to the best of our understanding. In the proceeding section we describe the case and the discussion and our rationale to treat the patient accordingly.

Chapter 66 - Endovascular treatment of acute ischemic stroke

Endovascular thrombectomy is an effective treatment for major acute ischemic stroke syndromes caused by major anterior circulation artery occlusions (commonly referred to as large vessel occlusion) and is superior to intravenous thrombolysis and medical management. Treatment should occur as quickly as is reasonably possible. All patients with moderate to severe symptoms (National Institutes of Health stroke scale >8) and a treatable occlusion should be considered. The use of neuroimaging is critical to exclude hemorrhage and large ischemic cores. Very shortly after stroke onset (<3 hours) computed tomography (CT) and CT angiography provide sufficient information to proceed; diffusion magnetic resonance imaging (MRI) is less reliable during this early stage. After 3 hours from onset diffusion MRI is the most reliable method to define ischemic core size and should be used in centers that can offer it rapidly. Recanalization is highly effective with a stentriever or using a direct aspiration technique, with the patient awake or under conscious sedation rather than general anesthesia, if it may be performed safely. After thrombectomy the patient should be admitted to an intensive care setting and inpatient rehabilitation undertaken as soon as feasible. Patient outcomes should be assessed at 3 months, preferably using the modified Rankin score.

THE SELECTION PROBLEMS OF ANTITHROMBOTIC THERAPY IN NONVALVULAR ATRIAL FIBRILLATION WITH COMORBIDITIES

As does the clinical practice show, physician often deals with a problem of intolerability of oral anticoagulants, both vitamin K antagonists and new oral anticoagulants, either with a refuse taking these drugs at all. Hence there is an issue raises on the selection of antithrombotic therapy in atrial fibrillation (AF), and primarily, with ischemic heart disease, diabetes, stroke in anamnesis. There is a broad discussion in literature of the purpose for prescription of aspirin monotherapy to such patients with the aim of myocardial infarction and ischemic stroke prevention. In the article we present a case of female patient with nonvalvular AF having ischemic stroke and acute coronary syndrome at the background of serious comorbidities, the errors in the management are shown on the selection of antithrombotic therapy and directions provided for secondary prevention of thromboembolic complications, recurrent ischemic events according to International and Russian Guidelines.

Recent Advances in Cerebellar Ischemic Stroke Syndromes Causing Vertigo and Hearing Loss.

Cerebellar ischemic stroke is one of the common causes of vascular vertigo. It usually accompanies other neurological symptoms or signs, but a small infarct in the cerebellum can present with vertigo without other localizing symptoms. Approximately 11% of the patients with isolated cerebellar infarction simulated acute peripheral vestibulopathy, and most patients had an infarct in the territory of the medial branch of the posterior inferior cerebellar artery (PICA). A head impulse test can differentiate acute isolated vertigo associated with PICA territory cerebellar infarction from more benign disorders involving the inner ear. Acute hearing loss (AHL) of a vascular cause is mostly associated with cerebellar infarction in the territory of the anterior inferior cerebellar artery (AICA), but PICA territory cerebellar infarction rarely causes AHL. To date, at least eight subgroups of AICA territory infarction have been identified according to the pattern of neurotological presentations, among which the most common pattern of audiovestibular dysfunction is the combined loss of auditory and vestibular functions. Sometimes acute isolated audiovestibular loss can be the initial symptom of impending posterior circulation ischemic stroke (particularly within the territory of the AICA). Audiovestibular loss from cerebellar infarction has a good long-term outcome than previously thought. Approximately half of patients with superior cerebellar artery territory (SCA) cerebellar infarction experienced true vertigo, suggesting that the vertigo and nystagmus in the SCA territory cerebellar infarctions are more common than previously thought. In this article, recent findings on clinical features of vertigo and hearing loss from cerebellar ischemic stroke syndrome are summarized.

Safety of percutaneous coronary intervention in patients with acute ischemic stroke/transient ischemic attack and acute coronary syndrome.

Cardiac events in patients with acute stroke are frequent. Urgent PCI in myocardial infarction is crucial to improve outcome. However, the situation is complex as intracranial hemorrhage is a frequent complication of stroke but antithrombotic medication is indispensable during and after PCI. Therefore in this study, we aimed to investigate the safety of percutaneous coronary intervention (PCI) in patients hospitalized with acute ischemic stroke and concomitant acute coronary syndrome (ACS). In a single-center, case-series study we investigated 80 patients hospitalized with acute stroke/transient ischemic attack (TIA) and concomitant ACS undergoing coronary angiography. Patients with subsequent PCI were compared to patients with medical treatment alone. The primary end point was the composite of death, recurrent MI, coronary re-intervention, recurrent stroke or bleeding during 1-year follow-up. The secondary end point consisted of the components of the primary end point. Age, gender and cardiovascular risk factors did not differ between groups. However, severity of initial stroke and coronary artery disease was higher in the PCI group. Accordingly, antiplatelet medication with aspirin and clopidogrel was prescribed more frequently in the PCI group. Nevertheless, during 1-year follow-up, the primary end point did not differ between groups [38 vs. 50 %, odds ratio (OR) 1.7, CI 0.69-4.07, P = 0.23]. Intracranial hemorrhage was even numerically lower in patients undergoing PCI (5 vs. 3 %, OR 0.4, CI 0.04-5.6, P = 0.46). The primary and secondary end points were not enhanced in patients undergoing PCI. Therefore PCI is safe in patients with stroke/TIA and concomitant ACS.

Arterial ischemic stroke and diarrhea-associated hemolytic uremic syndrome in childhood

Arterial ischemic stroke and diarrhea-associated hemolytic uremic syndrome in childhood

Lambl's Excrescence, Migrainous Headaches, and “Tiger Stripes”: Puzzling Findings in One Patient

Lambl's excrescences are mobile, thin, filiform structures that occur at sites of valve closure. Even though many clinicians consider them to be part of the normal aging process, evidence suggests an association between Lambl's excrescences and ischemic stroke, migrainous headaches, and acute coronary syndromes. As a thin filamentous structure, a Lambl's excrescence is better detected and characterized with transesophageal than with transthoracic echocardiography. Intracardiac oscillatory structures can also be seen as "tiger stripes" on spectral pulsed Doppler echocardiographic recordings. Herein, we present the case of a 68-year-old woman who had 3 concurrent enigmatic findings with unclear correlation: migrainous headaches, Lambl's excrescences, and the uncommon finding of "tiger stripes" on spectral Doppler echocardiography. We discuss the possible correlation between these 3 findings and review the available literature on Lambl's excrescences and tiger stripes.

Abstract W P208: Weekend Effect on the Utilization of Intravenous Thrombolysis: Myth or Reality in the Era of Regional Tele-Stroke Networks

Background: There is a significant shortage of neurologists and specialists especially on the weekends in rural hospitals. Regional Tele-stroke networks are developing across the US, and have enabled 24/7 coverage for the management of acute ischemic stroke. The impact of regional Tele-stroke networks on the utilization of intravenous thrombolysis (IV r-tPA) on weekends remains to be understood. Methods: Standardized color-coded algorithms for rapid triage of acute strokes in the emergency room (ER) (Fig: 1) were implemented in 2010 within a regional Tele-stroke network of 122 urban and rural hospitals. All acute stroke consults within the regional Tele-stroke network were prospectively collected in a Tele-stroke registry from January 1, 2012. Demographic factors, days of the week when consultation (Tele-phone or Tele-camera) was performed, time from last known normal (LKN) at time of consultation, and whether IV r-tPA was administered were analyzed. Fisher’s exact p -test was used to calculate 2-tailed p -values ( p ≤0.05 was consider significant). Results: A total of 4,028 consecutive acute stroke consults were performed over a 2 ½ -year period, of which 880 patients had an acute ischemic stroke syndrome within 4.5 hours of LKN. Median age was 65 years (range 16-103 years) and the median NIHSS was 8 (range 0-31). IV r-tPA was given 559 of the 880 patients (63.5%) who met eligibility criteria. Out of the 559 patients, 159 patients were treated with IV r-tpA over the weekend (28.4%, p =0.817). There were no gender differences in the utilization of IV r-tPA. Conclusion: In the era of Tele-stroke, utilization of IV r-tPA over weekends in urban and rural hospitals is a reality. Establishing regional Tele-stroke networks can help avoid the “weekend effect” in treating acute ischemic stroke patients.

The thrombogenicity of C1 esterase inhibitor (human): review of the evidence.

Thromboembolic events associated with human plasma-derived C1 esterase inhibitor (C1-INH) use in patients with hereditary angioedema (HAE) have been reported in the U.S. Food and Drug Administration (FDA) Adverse Event Reporting System database. The purpose of this article is to review and assess the strength of available evidence regarding the thrombogenicity of human plasma-derived C1-INH. A PubMed search was conducted of English language articles from January 1990 to December 2013 reporting the thrombogenicity of C1-INH. Original research articles were selected if the following criteria were met: (1) C1-INH was the focus of the study and (2) the authors addressed the pro- or antithrombotic potential of C1-INH. Additional articles on the clinical use of C1-INH in disease states other than HAE were obtained using reference lists of selected articles. Pivotal studies and prescribing information for C1-INH products were also reviewed. Limited animal and clinical data suggest that C1-INH, particularly at high doses of up to 500 U/kg (compared with the U.S. FDA-approved 20-U/kg dose), may be prothrombotic. In contrast, C1-INH has been used in some patients with myocardial infarction, ischemic stroke, sepsis, and capillary leak syndrome at off-label supratherapeutic doses (up to 100 U/kg) without evidence of a thrombogenic effect. Based on our review, thromboembolic events reported with C1-INH use are rare and patients with HAE who experienced such events often have underlying thromboembolic risk factors.

Cardiac myxoma as a mimic: a diagnostic challenge

ObjectivePatients with occult, undiagnosed cardiac myxomas (CM) often present with acute complications that mimic other, more common, conditions. We describe two recently encountered patients who classically demonstrate this phenomenon and report the results of an integrative review of CM cases to define the characteristics of such patients. MethodsA comprehensive 20-year review of reported cases that described patient-specific data of CM was performed. Using a standardized tool, the following elements were collected: age; gender; presenting symptoms and signs; diagnostic and management approaches; and outcomes. ResultsOne hundred twenty-six cases of CM were identified. The mean patient age was 47.5 years (range, 6-90). Seventy (56%) were women. The most common mimic conditions initially being considered were cardiac complications, including acutely decompensated heart failure, myocardial infarction, dysrhythmia and sudden death (46%); systemic embolization, including cutaneous infarction and pulmonary embolism (23%); central nervous system embolization, including transient ischemic attack and acute stroke syndrome (22%); and constitutional conditions, such as fever, myalgia, arthralgia, fatigue, and myxoma infections (17%). Echocardiography proved to be a readily available and accurate diagnostic test. The majority of reported patients experienced full recoveries after surgical intervention. ConclusionsCM is a rare but potentially life-threatening condition. Symptoms and signs relating to CM mimic other, more common conditions, resulting in diagnostic delay. Echocardiography can quickly and accurately diagnose CM and timely surgical intervention is curative. Clinician awareness of this condition, in a suggestive clinical context, will increase the likelihood of optimal patient outcome.

Imaging of functional and structural alterations of large arteries after acute ischaemic atherothrombotic stroke or acute coronary syndromes

Non-invasive methods allow the evaluation of structural and functional arterial abnormalities. So far, no study has focused on the comparison of vascular parameters by type of cardiovascular event. In this pilot study, cardiovascular risk factors, carotid parameters, carotid-to-femoral pulse wave velocity (PWV), brachial flow-mediated dilation and ambulatory blood pressure were assessed in patients who presented with acute coronary syndromes (ACS) or ischaemic atherothrombotic stroke (IAS). Groups were matched for age and gender. Prevalences of hypertension, diabetes and dyslipidaemia and heredity, smoking and body mass index were similar in the ACS (n=50) and IAS (n=50) groups. Carotid intima-media thickness (IMT) and PWV were significantly higher in the IAS vs. ACS group (769±180 vs. 701±136 μm; P=0.039 and 12.5±3.5 vs. 10.7±2.4 m/s; P=0.006). Carotid distensibility was significantly lower in the IAS vs. ACS group (16.2±3.2 vs. 18.9±7.6 10(-3)/kPa; P=0.02). These differences persisted after adjustment for blood pressure for carotid distensibility but not for PWV. The prevalences of endothelial dysfunction and carotid plaques were not significantly different in the ACS and IAS groups (86% and 74%; 80% and 78%). In a multivariable model, carotid distensibility remained associated with ACS (odds ratio 1.19; 95% confidence interval 1.03-1.38; P=0.016). Stiffness and carotid wall thickness were higher in IAS than in ACS patients. These differences may support the interest in new therapeutic targets for cardiovascular secondary prevention. NCT00926874.

Study on differentially expressed proteins of effect of Kudiezi injection on cerebral cortexin rats with cerebral ischemic stroke and heat toxin syndrome

This study is to investigate the modulation of Kudiezi (KDZ) injection on differential protein expression in cerebral cortex of rats with cerebral ischemic stroke and heat toxin syndrome established by intraperitoneal injection of carrageenan and middle cerebral artery occlusion (MCAO) methods. According to random number table rats were divided into three groups: drug group, model group and sham group. The tripheye tetrazolium chloride (TTC) staining and HE staining were used to observe brain tissue injury of rats. After therapeutic intervention with above drug for seventy-two hours, the level of differential protein expression was analyzed by two-dimensional gel electrophoresis (2-DE). The results show that there are differential protein expressions between cerebral ischemic stroke and heat toxin syndrome rats and sham rats. Furthermore, as a Chinese medicine injection with effect of clearing heat, resolving toxin and dredging collaterals, KDZ injection can decrease alleviate morphological changes of cerebral ischemia, regulate the levels of some differential proteins expression.

Primary Sjögren’s syndrome and risk of ischemic stroke: a nationwide study

Few studies are available on the risk of ischemic stroke after a diagnosis of primary Sjögren's syndrome (PSS). This study investigated whether PSS increased the risk of ischemic stroke in a large, nationwide cohort. Data for 4,276 patients who were newly diagnosed with PSS from 2000 to 2006 and who did not have a stroke prior to diagnosis of PSS were obtained from the Registry of Catastrophic Illness in Taiwan. For each PSS patient, data for ten controls (matched by age, gender, comorbidities, and enrollment date) without systemic autoimmune disease or previous stroke were obtained from the Longitudinal Health Insurance 2000 database. All study subjects were followed up from the date of enrollment until they developed ischemic stroke, died, or until the end of 2006, whichever was earliest. To investigate if PSS was an independent factor in determining the risk of developing ischemic stroke, a Cox regression model was used with adjustment for age, gender, and comorbid disorders. Among 4,276 PSS patients and 42,760 controls, 669 subjects (51 PSS patients and 618 controls) developed ischemic stroke during the mean 3.7-year follow-up period (interquartile range 2.2-5.2years). Patients with PSS and controls had a similar incidence of ischemic stroke occurrence (3.17/1,000 vs. 3.90/1,000 person years). Multivariate analysis adjusted for baseline covariates indicated that PSS did not increase the risk of ischemic stroke (adjusted hazard ratio: 0.84, 95% confidence interval: 0.63-1.12, P = 0.244). PSS is not associated with an increased risk of ischemic stroke subsequent to diagnosis.

Immune-inflammatory markers and arterial stiffness indexes in subjects with acute ischemic stroke with and without metabolic syndrome

ObjectiveThe aim of our study was to evaluate the associations between arterial stiffness indexes and immune-inflammatory markers in subjects with acute ischemic stroke with and without metabolic syndrome.Materials/MethodsWe enrolled 130 patients with acute ischemic stroke and metabolic syndrome, 127 patients with acute ischemic stroke without metabolic syndrome and 120 control subjects without acute stroke. Applanation tonometry was used to record the augmentation index (Aix) and pulse wave velocity (PWV). We also evaluated plasma levels of C-reactive protein (CRP), Interleukin-1beta (IL-1β), tumor necrosis factor-alpha (TNF-α), Interleukin-6 (IL-6) and Interleukin-10 (IL-10), E-selectin, P-selectin, intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), von Willebrand Factor (vWF) plasma levels, tissue plasminogen activator (TPA) and plasminogen activator inhibitor-1 (PAI-1).ResultsIn subjects with acute ischemic stroke and metabolic syndrome we observed higher median plasma values of immuno-inflammatory markers. In acute ischemic stroke patients and metabolic syndrome in relation of each TOAST subtype we observed a more significant positive correlation between PWV and immuno-inflammatory markers.ConclusionsStroke subjects with acute ischemic stroke and metabolic syndrome showed a higher degree of immuno-inflammatory and arterial stiffness indexes possibly due to metabolic background of these types of patients that trigger a more intense immune-inflammatory activation irrespective of stroke subtype, whereas being related to stroke subtype in subjects without metabolic syndrome.

Antiviral treatment for hepatitis C virus infection is associated with improved renal and cardiovascular outcomes in diabetic patients

Hepatitis C virus (HCV) infection is causally associated with insulin resistance and diabetes mellitus. This population-based cohort study aimed to investigate whether antiviral therapy for HCV infection was associated with improved clinical outcomes related to diabetes. From the Taiwan National Health Insurance Research Database, 2,267,270 Taiwanese residents diagnosed with diabetes mellitus were screened for eligibility. HCV infection was defined by a specific diagnosis code and measurement of serum antibody. After excluding patients with serious comorbidity, we enrolled a total of 1,411 eligible patients who received pegylated interferon plus ribavirin (treated cohort), and matched them 1:1 with 1,411 untreated controls by propensity scores (untreated cohort). We also matched the treated cohort 1:4 with 5,644 diabetic patients without HCV infection (uninfected cohort). Participants were followed up for the occurrence of endstage renal disease (ESRD), ischemic stroke, and acute coronary syndrome (ACS) after receiving antiviral treatment or the corresponding calendar date. From 2003 to 2011, the 8-year cumulative incidences of ESRD in the treated, untreated, and uninfected cohorts were 1.1% (95% confidence interval [CI], 0.3-2.0%), 9.3% (95% CI, 5.9-12.7%), and 3.3% (95% CI, 2.3-4.3%), respectively (P < 0.001); those of stroke were 3.1% (95% CI, 1.1-5.0%), 5.3% (95% CI, 3.0-7.5%), and 6.1% (95% CI, 4.8-7.4%), respectively (P = 0.01); and those for ACS were 4.1% (95% CI, 2.1-6.1%), 6.6% (95% CI, 3.7-9.5%), and 7.4% (95% CI, 5.9-9.0%), respectively (P = 0.05). As compared with the untreated cohort, antiviral treatment was associated with multivariate-adjusted hazard ratios of 0.16 (95% CI, 0.07-0.33%) for ESRD, 0.53 (95% CI, 0.30-0.93) for ischemic stroke, and 0.64 (95% CI, 0.39-1.06) for ACS. Antiviral treatment for HCV infection is associated with improved renal and cardiovascular outcomes in diabetic patients.

Primary Sjogren's syndrome and risk of ischemic stroke: a nationwide study

Objective: Few studies are available on the risk of ischemic stroke after a diagnosis of primary Sjogren's syndrome (PSS). This study investigated whether PSS increased the risk of ischemic stroke in a large, nationwide cohort. Methods: Data for 4,276 patients who were newly diagnosed with PSS from 2000 to 2006 and who did not have a stroke prior to diagnosis of PSS were obtained from the Registry of Catastrophic Illness in Taiwan. For each PSS patient, data for 10 controls (matched by age, gender, comorbidities, and enrollment date) without systemic autoimmune disease or previous stroke were obtained from the Longitudinal Health Insurance 2000 database. All study subjects were followed up from the date of enrollment until they developed ischemic stroke, died, or until the end of 2006, whichever was earliest. To investigate if PSS was an independent factor in determining the risk of developing ischemic stroke, a Cox regression model was used with adjustment for age, gender, and comorbid disorders. Results: Among 4,276 PSS patients and 42,760 controls, 669 subjects (51 PSS patients and 618 controls) developed ischemic stroke during the mean 3.7-year follow-up period (interquartile range, 2.2–5.2 years). Patients with PSS and controls had a similar incidence of ischemic stroke occurrence (3.17/1000 vs. 3.90/1000 person-years). Multivariate analysis adjusted for baseline covariates indicated that PSS did not increase the risk of ischemic stroke (adjusted hazard ratio: 0.84, 95% confidence interval: 0.63–1.12, P = 0.244). Conclusions: PSS is not associated with an increased risk of ischemic stroke subsequent to diagnosis.