Long-term Risk Of Stroke Research Articles

Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials

SummaryBackgroundAspirin is recommended for secondary prevention after transient ischaemic attack (TIA) or ischaemic stroke on the basis of trials showing a 13% reduction in long-term risk of recurrent stroke. However, the risk of major stroke is very high for only the first few days after TIA and minor ischaemic stroke, and observational studies show substantially greater benefits of early medical treatment in the acute phase than do longer-term trials. We hypothesised that the short-term benefits of early aspirin have been underestimated.MethodsPooling the individual patient data from all randomised trials of aspirin versus control in secondary prevention after TIA or ischaemic stroke, we studied the effects of aspirin on the risk and severity of recurrent stroke, stratified by the following time periods: less than 6 weeks, 6–12 weeks, and more than 12 weeks after randomisation. We compared the severity of early recurrent strokes between treatment groups with shift analysis of modified Rankin Scale (mRS) score. To understand possible mechanisms of action, we also studied the time course of the interaction between effects of aspirin and dipyridamole in secondary prevention of stroke. In a further analysis we pooled data from trials of aspirin versus control in which patients were randomised less than 48 h after major acute stroke, stratified by severity of baseline neurological deficit, to establish the very early time course of the effect of aspirin on risk of recurrent ischaemic stroke and how this differs by severity at baseline.FindingsWe pooled data for 15 778 participants from 12 trials of aspirin versus control in secondary prevention. Aspirin reduced the 6 week risk of recurrent ischaemic stroke by about 60% (84 of 8452 participants in the aspirin group had an ischaemic stroke vs 175 of 7326; hazard ratio [HR] 0·42, 95% CI 0·32–0·55, p<0·0001) and disabling or fatal ischaemic stroke by about 70% (36 of 8452 vs 110 of 7326; 0·29, 0·20–0·42, p<0·0001), with greatest benefit noted in patients presenting with TIA or minor stroke (at 0–2 weeks, two of 6691 participants in the aspirin group with TIA or minor stroke had a disabling or fatal ischaemic stroke vs 23 of 5726 in the control group, HR 0·07, 95% CI 0·02–0·31, p=0·0004; at 0–6 weeks, 14 vs 60 participants, 0·19, 0·11–0·34, p<0·0001). The effect of aspirin on early recurrent ischaemic stroke was due partly to a substantial reduction in severity (mRS shift analysis odds ratio [OR] 0·42, 0·26–0·70, p=0·0007). These effects were independent of dose, patient characteristics, or aetiology of TIA or stroke. Some further reduction in risk of ischaemic stroke accrued for aspirin only versus control from 6–12 weeks, but there was no benefit after 12 weeks (stroke risk OR 0·97, 0·84–1·12, p=0·67; severity mRS shift OR 1·00, 0·77–1·29, p=0·97). By contrast, dipyridamole plus aspirin versus aspirin alone had no effect on risk or severity of recurrent ischaemic stroke within 12 weeks (OR 0·90, 95% CI 0·65–1·25, p=0·53; mRS shift OR 0·90, 0·37–1·72, p=0·99), but dipyridamole did reduce risk thereafter (0·76, 0·63–0·92, p=0·005), particularly of disabling or fatal ischaemic stroke (0·64, 0·49–0·84, p=0·0010). We pooled data for 40 531 participants from three trials of aspirin versus control in major acute stroke. The reduction in risk of recurrent ischaemic stroke at 14 days was most evident in patients with less severe baseline deficits, and was substantial by the second day after starting treatment (2–3 day HR 0·37, 95% CI 0·25–0·57, p<0·0001).InterpretationOur findings confirm that medical treatment substantially reduces the risk of early recurrent stroke after TIA and minor stroke and identify aspirin as the key intervention. The considerable early benefit from aspirin warrants public education about self-administration after possible TIA. The previously unrecognised effect of aspirin on severity of early recurrent stroke, the diminishing benefit with longer-term use, and the contrasting time course of effects of dipyridamole have implications for understanding mechanisms of action.FundingWellcome Trust, the National Institute of Health Research (NIHR) Biomedical Research Centre, Oxford.

Endarterectomy vs. stenting vs. medical therapy

In recent trials, after deducting the risks in the 30-day periprocedural period, the long-term risk of stroke or death was similar with carotid stenting (CAS) and endarterectomy (CEA) for asymptomatic carotid stenosis (ACS) - approximately 0.5% per year. These findings may exacerbate the problem of inappropriate routine intervention in ACS, being justified on the basis of an invalid comparison of the risks in the medical arms of clinical trials conducted decades ago (˜ 2% per year) to the risks in modern trials of CAS vs. CEA with no medical arm. Intervention is regarded as justified if it can be carried out with a risk below 3%. The annual risk of ipsilateral stroke or death in ACS with intensive medical therapy is now ˜ 0.5% - similar to the long-term risk after the periprocedural period in recent trials of intervention. However, periprocedural risk was ˜ 3% for CAS and 1.7% for CEA. Thus with modern CAS and CEA, the risk remains much higher than with modern medical therapy, even with careful vetting of the surgeons and interventionalists. In real world practice, documented in registries, the risks are much higher. National differences - 90% of carotid intervention for ACS in the US vs. 0% in Denmark - bring into question the advisability and ethics of routine intervention. A moratorium on routine intervention for ACS should be respected except in ongoing randomized trials comparing CAS, CEA and modern intensive medical therapy. Patients with high-risk ACS can be identified for appropriate intervention.

Long-Term Risk of Stroke, Seizures and Cognitive Impairment After Transient Global Amnesia: A Case-Control, Population-Based Study with Long Term Follow Up (P1.114)

Long-Term Risk of Stroke, Seizures and Cognitive Impairment After Transient Global Amnesia: A Case-Control, Population-Based Study with Long Term Follow Up (P1.114)

Abstract WP203: Subarachnoid Hemorrhage and Long-Term Stroke Risk After Traumatic Brain Injury

Background: Recent studies suggest that traumatic brain injury (TBI) is a risk factor for subsequent ischemic stroke, even years after the initial insult. The mechanisms of the association remain unclear. Hypothesis: The presence of traumatic subarachnoid hemorrhage (tSAH) may mediate the effect of TBI on long-term stroke risk, as it has previously been linked to short-term vasospasm and delayed cerebral ischemia. Methods: Using administrative claims data, we conducted a retrospective cohort study of acute care hospitalizations. Patients discharged with a first-recorded diagnosis of tSAH were followed for a primary diagnosis of stroke. They were matched to patients with TBI but no tSAH, based on age, sex, race, insurance status, income, admission year, coronary heart disease, hypertension, diabetes, congestive heart failure, peripheral vascular disease, chronic kidney disease, chronic obstructive pulmonary disease, atrial fibrillation, alcohol abuse, and tobacco use. Cox proportional hazards modeling was used to assess the association between tSAH and stroke while adjusting for covariates. Results: We identified 34,302 patients with TBI (17,151 patients with tSAH matched to 17,151 patients with non-tSAH TBI) who were followed for a mean of 3.2 ± 1.8 years. Overall, 481 of 34,302 patients with TBI (1.40%; 95% confidence interval [CI], 1.28-1.53%) experienced an ischemic stroke after discharge. There was no significant difference in stroke risk between those with tSAH (1.92%; 95% CI, 1.61-2.27%) as compared to no tSAH (2.08%; 95% CI, 1.78-2.44%). The same pattern was found in adjusted analyzes (hazard ratio [HR[, 0.86; 95% CI 0.70-1.06). This held true even when the group was stratified by age group or by proxies of TBI severity such as mechanical ventilation or discharge disposition during the index hospitalization for TBI. Conclusion: Recent data shows a protracted risk of ischemic stroke following TBI. Our findings do not support a role of vasospasm from tSAH in mediating this association. Further study is required to elucidate the mechanisms of long-term increased stroke risk after TBI

Incongruence Between Perceived Long-Term Risk and Actual Risk of Stroke in Rural African Americans.

Stroke has increased among young adults. In addition, the accuracy by which African Americans perceive their risk of stroke is unclear. The purpose of the study was to examine the accuracy of perceived stroke risk of African Americans aged 19-54 years. A descriptive-correlational design was used. Accuracy of perceived stroke risk was determined by comparing perceived risk with actual risk. Participants (N = 66) had a mean age of 43.3 (SD = 9.4) years and were mostly female, high school graduates, and unemployed. Most (66%) perceived themselves as having no/low risk of future stroke. However, actual risk factors averaged 2.98 + 1.63 of 8, placing 59% of the sample in the moderate-high category of actual stroke risk. Comparisons of perceived and actual risk showed that 44% underestimated their risk, 47% were accurate, and 9% overestimated their risk. Strategies to address risk misperceptions should be explored to improve accuracy of perceived stroke risk and culturally relevant interventions to reduce stroke among African Americans.

Abstract 134: Postoperative Atrial Fibrillation and the Short-term Risk of Ischemic Stroke

Introduction: We have recently shown an association between new-onset postoperative atrial fibrillation (AF) and the long-term risk of ischemic stroke after noncardiac surgery. However, the degree of stroke risk with AF in the postoperative setting remains unclear. Hypothesis: New-onset postoperative AF is associated with an increased risk of ischemic stroke in the 30 days after surgery. Methods: Administrative claims data from all discharges at nonfederal acute care hospitals in California, New York, and Florida were used to identify patients who underwent inpatient surgery in 2007-2012. Our predictor variable was new-onset AF, defined using validated ICD-9-CM diagnosis and present-on-admission codes. Patients with prior stroke or AF were excluded. The outcome was postoperative stroke, defined as ischemic stroke occurring within 30 days of surgery. Cox proportional hazards analysis was used to examine the association between postoperative AF and stroke while adjusting for demographics and vascular risk factors. In sensitivity analyses, we limited the outcome to stroke occurring after discharge but within 30 days of surgery. Cardiac and noncardiac surgeries were analyzed separately. Results: Among 7,139,472 patients with inpatient surgery, 102,831 (1.44%) developed postoperative AF and 17,117 (0.24%) developed a postoperative stroke. After noncardiac surgery, the 30-day cumulative risk of stroke was significantly higher in those with postoperative AF (2.07%) than those without AF (0.18%). This difference was significant after adjustment for demographics and potential confounders (hazard ratio [HR], 4.3; 95% CI, 4.1-4.6). After cardiac surgery, postoperative AF was also associated with an increased cumulative risk of stroke (2.27%) compared to those without AF (1.17%), but the strength of association (HR, 1.8; 95% CI, 1.6-1.9) was less marked than in the setting of noncardiac surgery ( P value for interaction &lt;0.001). Postoperative AF was associated with stroke occurring after discharge and within 30 days of noncardiac surgery (HR, 1.9; 95% CI, 1.6-2.3), but not cardiac surgery (HR, 1.1; 95% CI, 0.9-1.3). Conclusions: Postoperative AF is associated with an increased short-term risk of stroke after noncardiac surgery.

Long-term risk of myocardial infarction and stroke in bipolar I disorder: A population-based Cohort Study

ObjectivesTo estimate the risk of fatal and non-fatal myocardial infarction (MI) and stroke in patients with bipolar I disorder compared to people without bipolar I disorder. MethodUtilizing a records-linkage system spanning 30 years (1966–1996), a population-based cohort of 334 subjects with bipolar I disorder and 334 age and sex-matched referents from Olmsted County, Minnesota, U.S. was identified. Longitudinal follow-up continued until incident MI or stroke (confirmed by board-certified cardiologist/neurologist), death, or study end date (December 31, 2013). Cox proportional hazards models assessed the hazard ratio (HR) for MI or stroke, adjusting for potential confounders. ResultsThere was an increased risk of fatal or non-fatal MI or stroke (as a composite outcome) in patients with bipolar I disorder [HR 1.54, 95% confidence interval (CI) 1.02, 2.33; p=0.04]. However, after adjusting for baseline cardiovascular risk factors (alcoholism, hypertension, diabetes, and smoking), the risk was no longer significantly increased (HR 1.19, 95% CI 0.76, 1.86; p=0.46). LimitationsSmall sample size for the study design. Findings were not retained after adjustment for cardiovascular disease risk factors. Psychotropic medication use during the follow-up was not ascertained and was not included in the analyses. ConclusionThis study in a geographically defined region in the U.S. demonstrated a significant increased risk of MI or stroke in bipolar I disorder, which was no longer significant after adjustment for cardiovascular risk factors.

Long-Term Stroke Risk Due to Partial White-Coat or Masked Hypertension Based on Home and Ambulatory Blood Pressure Measurements: The Ohasama Study.

The prognostic significance of white-coat hypertension (WCHT) is controversial, and different findings on self-measured home measurements and 24-h ambulatory monitoring make identifying WCHT difficult. We examined whether individuals with partially or completely defined WCHT, as well as masked hypertension, as determined by different out-of-office blood pressure measurements, have a distinct long-term stroke risk. We followed 1464 participants (31.8% men; mean age, 60.6±10.8 years) in the general population of Ohasama, Japan, for a median of 17.1 years. A first stroke occurred in 212 subjects. Using sustained normal blood pressure (events/n=61/776) as a reference, adjusted hazard ratios for stroke (95% confidence intervals; events/n) were 1.38 (0.82-2.32; 19/137) for complete WCHT (isolated office hypertension), 2.16 (1.36-3.43; 29/117) for partial WCHT (either home or ambulatory normotension with office hypertension), 2.05 (1.24-3.41; 23/100) for complete masked hypertension (both home and ambulatory hypertension with office normotension), 2.08 (1.37-3.16; 38/180) for partial masked hypertension (either home or ambulatory hypertension with office normotension), and 2.46 (1.61-3.77; 42/154) for sustained hypertension. When partial WCHT and partial masked hypertension groups were further divided into participants only with home hypertension and those only with ambulatory hypertension, all subgroups had a significantly higher stroke risk (adjusted hazard ratio ≥1.84, P≤0.04). In conclusion, impacts of partial WCHT as well as partial masked hypertension for long-term stroke risk were comparable to those of complete masked hypertension or sustained hypertension. We need both home and 24-h ambulatory blood pressure measurements to evaluate stroke risk accurately.

Pathophysiological effects of particulate matter air pollution on the central nervous system

Particulate matter (PM) air pollution is a leading public health concern across most of the populated world. Elevated PM levels cause both acute increases in cardiovascular mortality and the development of long-term neurological pathology. Upon inhalation, PM reaches the brain through entry into pulmonary capillaries and directly through the olfactory mucosa. Population-based and animal studies reveal decreases in brain size and increases in inflammatory markers following long-term exposure to elevated PM concentrations. In vitro, cell culture studies indicate that components of PM air pollution are neurotoxic. In addition to direct effects on the central nervous system (CNS), PM induces aberrant local and systemic inflammatory responses that can induce and exacerbate cerebral injury. Hypertension and decreased cerebral blood flow velocity are observed within days of increased PM exposure and may contribute to short-term rises in mortality rate. Substantial epidemiological evidence links PM concentration with both short-term and long-term risk of stroke. It has been suggested that the increased stroke risk is due to potentiation of cerebrovascular inflammation, endothelial cell dysfunction, reactive oxygen species production, and atherosclerosis. This review examines the pathophysiological mechanisms by which PM damages the CNS and the cerebrovasculature.

Antiplatelet therapy as an element of primary and secondary prevention of ischemic stroke

Antiplatelet medications are essential in the primary and secondary prevention of stroke. All currently available antiplatelet drugs are platelet aggregation inhibitors acting at various points of application, but they differ in their mechanism of action. Successful treatment and prevention of cerebrovascular diseases with antiplatelet drugs largely depend on the sensitivity and susceptibility of platelets to the impact produced by these medications. Study of changes in platelet functional activity during treatment with antiplatelet drugs allows to monitor the effectiveness of therapy, identify resistance and detect lower reactivity to the drug, as well as to select the proper drug and its dosage. In practice, the approach helps to assess the individual patient response to antiplatelet therapy, choose the effective antiplatelet medication, reduce the risk of long-term complications and recurrent stroke, and, therefore, improve the quality of life and prognosis of the disease.

Cognitive improvement in patients with carotid stenosis is independent of treatment type.

Treatment of carotid artery stenosis decreases the long-term risk of stroke and may enhance cerebral blood flow. It is therefore expected to have the potential to prevent cognitive decline or even improve cognition over the long-term. However, intervention itself can cause peri-interventional cerebral infarcts, possibly resulting in a decline of cognitive performance, at least for a short time. We investigated the long-term effects of three treatment methods on cognition and the emotional state one year after intervention. In this prospective observational cohort study, 58 patients with extracranial carotid artery stenosis (≥ 70%) underwent magnetic resonance imaging and assessment of cognition, mood and motor speed before carotid endarterectomy (n = 20), carotid stenting (n = 10) or best medical treatment (n = 28) (i.e., time-point 1 [TP1]), and at one-year follow-up (TP2). Gain scores, reflecting cognitive change after treatment, were built according to performance as (TP2 -TP1)/TP1. Independent of the treatment type, significant improvement in frontal lobe functions, visual memory and motor speed was found. Performance level, motor speed and mood at TP1 were negatively correlated with gain scores, with greater improvement in patients with low performance before treatment. Active therapy, whether conservative or interventional, produces significant improvement of frontal lobe functions and memory in patients with carotid artery disease, independent of treatment type. This effect was particularly pronounced in patients with low cognitive performance prior to treatment.

Association of CYP2C19 gene polymorphisms with long-term recurrent risk of ischemic stroke among ethnic Han Chinese from Fujian

To assess the association of genetic polymorphisms of CYP2C19*2,*3,*17 with the recurrence risk of ischemic stroke during clopidogrel prevention in ethnic Han Chinese from Fujian Province. Clinical data of 985 patients with acute ischemic stroke was collected. After 1 year postdischarge follow-up evaluations, only 114 patients with persistence of clopidogrel were enrolled. CYP2C19 genetic polymorphisms were detected by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP)and direct sequencing ,then we analysis the correlation between polymorphisms and the recurrence of stroke. Among the 114 patients, 23 had a second onset whilst receiving clopidogrel treatment. During the antiplatelet therapy with clopidogrel, carriers of CYP2C19 poor metabolizer (CYP2C19*2/*2 or *2/*3) had a higher rate of recurrent stroke compared with extensive metabolizers (CYP2C19*1/*1) (OR=4.71, 95%CI: 1.18-18.80, P<0.05). Carriers of CYP2C19 *2 mutant allele had increased recurrence compared with those carrying none loss-of-function allele (OR=2.31, 95%CI: 1.20-4.46, P<0.05). The rate of recurrent stroke in those carrying homozygous mutant *2 allele (CYP2C19*2/*2) was 6.14 times greater than the rate of wild-type homozygotes (CYP2C19*1/*1) (95%CI: 1.54-24.54, P<0.05). Patients with previous stroke history had increased risk of recurrence (OR= 4.146, 95%CI: 1.259-13.655, P<0.05). However, CYP2C19*17 was not detected in the group. For ethnic Han Chinese patients receiving clopidogrel treatment, carriers of poor metabolizer or homozygous mutant *2 allele (CYP2C19*2/*2) have a higher risk of recurrent stroke. The CYP2C19 *2 allele is an independent risk factor for recurrent stroke. Those with previous history of stroke are more prone to the recurrence.

Abstract 17564: Long-term Risk of Stroke in Patients With Type 1 and Type 2 Diabetes Following Coronary Artery Bypass Grafting

Background: We performed a nationwide population-based cohort study to investigate the long-term risk of stroke after coronary artery bypass grafting (CABG) in patients with type 1 and type 2 diabetes. Hypothesis: Type 1 and type 2 diabetes is associated with an increased longterm risk of stroke after CABG. Methods and Results: All patients who underwent primary CABG in Sweden from 2000 through 2011 were included from the SWEDEHEART register. We excluded patients with prior stroke, and patients who had a stroke or died within 30 days of surgery. The National Diabetes Register was used to identify patients with type 1 and type 2 diabetes. Incident stroke (ischemic and hemorrhagic), and all-cause mortality was obtained by record linkage with the National Patient Register and the Cause of Death register. A total of 53 820 patients (type 1 diabetes (n=714), type 2 diabetes (n=10 054), no diabetes (n=43 052)) were included. During a mean follow-up of 7.4 years (398 337 person-years), in total, 8.0% (n=4 296) of the patients had a stroke: 7.3% (n=52) in patients with type 1 diabetes, 9.1% (n=915) in patients with type 2 diabetes, and 7.7% (n=3 329) in patients with no diabetes. The multivariable adjusted hazard ratio (95% confidence interval) for all stroke was 1.59 (1.20-2.11) in type 1 diabetes, and 1.32 (1.23-1.43) in type 2 diabetes compared to patients without diabetes. Figure 1 shows the age-adjusted cumulative incidence of stroke in relation to type 1 diabetes, type 2 diabetes and no diabetes. Conclusions: The long-term risk for stroke after CABG was higher in both patients with type 1 diabetes, and type 2 diabetes, compared to patients without diabetes.

Long-Term Risk of Stroke in Patients With Type 1 and Type 2 Diabetes Following Coronary Artery Bypass Grafting.

BackgroundWe performed a nationwide population‐based cohort study to investigate the long‐term risk of stroke after coronary artery bypass grafting in patients with type 1 and type 2 diabetes.Methods and ResultsAll patients who underwent primary coronary artery bypass grafting in Sweden from 2000 through 2011 were included from the SWEDEHEART register. We excluded patients with prior stroke, and patients who had a stroke or died within 30 days of surgery. The National Diabetes Register was used to identify patients with type 1 and type 2 diabetes. Incident stroke (ischemic and hemorrhagic), and all‐cause mortality was obtained by record linkage with the National Patient Register and the Cause of Death register. We used multivariable Cox regression to estimate the risk of stroke in relation to type of diabetes. A total of 53 820 patients (type 1 diabetes [n=714], type 2 diabetes [n=10 054], no diabetes [n=43 052]) were included. During a mean follow‐up of 7.4 years (398 337 person‐years), in total, 8.0% (n=4296) of the patients had a stroke: 7.3% (n=52) in patients with type 1 diabetes, 9.1% (n=915) in patients with type 2 diabetes, and 7.7% (n=3329) in patients with no diabetes. The multivariable adjusted hazard ratio (95% CI) for all stroke was 1.59 (1.20–2.11) in type 1 diabetes, and 1.32 (1.23–1.43) in type 2 diabetes.ConclusionsThe long‐term risk for stroke after coronary artery bypass grafting was increased in patients with type 1 and type 2 diabetes, compared to patients with no diabetes.

Lower Risk of Stroke after Deformity Surgery: Long Term Benefit Demonstrated by a National Cohort Study.

Objectives: This study aimed to investigate the long-term risk of stroke in adult patients with spinal deformity. Specifically, the study addressed the possible protective effect of surgery for spinal deformity against stroke. Methods: Using the National Health Insurance Research Database (NHIRD), a monopolistic national database in Taiwan, this retrospective cohort study analyzed the incidence of stroke in patients with adult spinal deformity (ASD) in a 11-year period. A total of 13,503 patients, between 55 and 75 years old, were identified for the diagnosis of ASD. The patients were grouped into two: the surgical group (n = 10,439) who received spinal fusion surgery, and the control group (n = 2124) who received other medical treatment. The incidence rates of all subsequent cerebrovascular accidents, including ischemic and hemorrhagic strokes, were calculated. Hazard ratios for stroke were calculated use a full cohort and a propensity score matched cohort. Adjustments for co-morbidities that may predispose to stroke, including hypertension, diabetes mellitus, arrhythmia and coronary heart disease were conducted. Kaplan-Meier and Cox regression analyses were performed to compare the risk of stroke between the two groups. Results: During the total observation period of 50,450 person-years, the incidence rate of stroke in the surgical group (15.55 per 1000 person-years) was significantly lower than that of the control group (20.89 per 1000 person-years, p < 0.001). Stroke was more likely to occur in the control group than in the surgical group (crude hazard ratio 1.34, p < 0.001; adjusted HR 1.28, p < 0.001, by a propensity score matched model). Conclusions: In this national cohort of more than 13,000 ASD patients covering 10 years, stroke was approximately 25% less likely to happen in patients who underwent spinal fusion surgery than those who received medical management. Therefore, spinal fusion surgery may provide a protective effect against stroke in adult patients with spinal deformity.

Predictors of intracranial cerebral artery stenosis in patients before cardiac surgery and its impact on perioperative and long-term stroke risk

BackgroundThe aim of this prospective study was to determine the prevalence of stenosis within intracranial and extracranial arteries in patients before coronary artery bypass surgery (CABG), to evaluate the influence of intracranial artery stenosis on neurological outcome and to identify preoperative risk factors for these patients. MethodsOne hundred and seventy-five patients (71% males, mean age=66.1) scheduled for CABG were enrolled for extracranial Doppler duplex sonography, transcranial color-coded duplex sonography (TCCS) and transcranial Doppler (TCD) examination. ResultsTwenty-six patients (14.7%) had extracranial stenosis or occlusion and 13 patients (7.3%) intracranial vascular disease. Six patients (3.5%) had both extra- and intracranial artery disease. The presence of peripheral artery disease and diabetes mellitus was a strong risk factor for extracranial artery stenosis but not for intracranial artery stenosis, which occurred independently also of typical atherosclerotic risk factors like age >70, male sex, hypertension, hyperlipidemia, hyperhomocysteinemia, smoking habit, obesity (BMI>30) and waist to hip ratio >1. Functional neurological outcome of the patients with intracranial arterial disease evaluated 7 days after CABG was the same as the patients without extra- and intracranial stenosis. However, 12-months neurological follow-up revealed significantly more ischemic strokes in patients with intracranial artery stenosis compared to patients without intracranial stenosis (p=0.015). ConclusionThe occurrence of intracranial artery stenosis in CABG patients cannot be predicted by well-known atherosclerotic risk factors and seems not to be associated with perioperative stroke.

Frequency of cancer in patients operated on for acute peripheral arterial thrombosis and the impact on prognosis

Little is known about acute peripheral arterial thrombosis in patients with concomitant cancer. Small studies suggest that revascularization in this patient group is associated with thrombosis and increased risk of amputation and death. We investigated the frequency of cancer in patients operated on for acute peripheral arterial thrombosis and the long-term risk of amputation, mortality, myocardial infarction, and stroke in a national cohort. This was a prospective case/noncase study comprising all Danish citizens undergoing vascular surgery for acute arterial thrombosis from 1986 to 2012 with up to 26 years of follow-up. A total of 7840 patients were treated surgically for acute arterial thrombosis; 2384 (30.4%) were previously diagnosed with cancer or developed cancer during the observation period. Risk of amputation was not significantly different in patients with or without cancer, except in patients with cancer diagnosed <24 months before acute limb ischemia (hazard ratio, 2.0). Mortality was significantly greater in all patients having or developing cancer within 24 months after surgery (hazard ratio, 1.2-2.2). The frequencies of myocardial infarction and stroke were similar to those among patients without cancer. One of five patients operated on for acute limb ischemia has a diagnosis of cancer, and a further 3.4% will develop cancer within 24 months. The data further show that patients with acute limb ischemia and concomitant cancer can be successfully revascularized and that the majority of these patients preserve their limb. Cancer should therefore not contravene interventional treatment.

Long-term stroke rates after catheter ablation or antiarrhythmic drug therapy for atrial fibrillation: a meta-analysis of randomized trials.

BackgroundAtrial fibrillation (AF) is an independent risk factor for ischemic stroke and is associated with increased risk of death. Randomized studies suggest improved quality of life for patients with AF after successful catheter ablation compared to antiarrhythmic drug therapy. The value of ablation in long-term risk of ischemic stroke, however, has not been assessed. We conducted a meta-analysis to determine whether AF ablation reduces the long-term risk of stroke compared to antiarrhythmic drug therapy in randomized controlled trials.Methods & ResultsPubMed and the Cochrane Central Register were searched for randomized trials from January 1990 to December 2014 comparing AF catheter ablation to drug therapy. The results are reported as risk differences (RDs) and 95% CI. Thirteen trials were analyzed with 1097 patients treated by catheter ablation and 855 patients received antiarrhythmic drug therapy. Overall, seven patients (0.64%) in the catheter ablation group had ischemic stroke or transient ischemic attacks vs. two patients (0.23%) in the drug therapy group. No difference was shown in the rate of stroke or transient ischemic attack between ablation and drug therapy (RD: 0.003, 95% CI: −0.006 to 0.012, P = 0.470), and no evidence of heterogeneity was observed (I2 = 0, P = 0.981). No potential publication bias was found. There was also no difference in mortality between the two groups (RD: −0.004, 95% CI: −0.014 to 0.006, P = 0.472).ConclusionsThis meta-analysis of randomized controlled trials showed similar rates of ischemic stroke or transient ischemic attack and death in AF patients undergoing catheter ablation compared to drug therapy. A larger prospective randomized trial to confirm this finding is warranted.

Further Innovation in Carotid Revascularization Requires Greater Insight into Minor Stroke Prevention and Quality of Life Outcomes

Carotid stenting and endarterectomy are complementary techniques to treat carotid stenosis. A number of studies have examined their merits. In symptomatic patients, carotid endarterectomy has been associated with lower long-term risk of stroke (1). Carotid artery stenting is known to be associated with higher risk of procedure-associated stroke, particularly in the elderly population, but with lower risk of myocardial infarction, cranial nerve palsy, and access-site hematoma than carotid endarterectomy (2-5). In 2010, the International Carotid Stenting Study (ICSS) reported the short-term results of patients with symptomatic carotid artery stenosis who were randomized to receive carotid endarterectomy or endovascular carotid stenting (4). The authors now report on the long-term outcomes of the ICSS study, in which Bonati et al. followed up on the patients of the ICSS trial for up to 10 years and reported their results in Lancet. The authors randomized patients older than 40 years with symptomatic carotid stenosis with at least 50% stenosis of the carotid artery lumen to receive endarterectomy or stenting in 50 global centers with an intention-to-treat (ITT) analysis. Exclusion criteria included major stroke, previous treatment with stenting or endarterectomy, contraindications to stenting or endarterectomy, nonatherosclerotic disease stenosis, life expectancy less than 2 years, or patients who were scheduled for major surgery in less than a 1-month period. Follow-up visits were scheduled 30 days after the procedure, 6 months after randomization, and yearly thereafter. Initial follow-up was extended from 5 years to 10 years for patients willing to continue. All patients received standard medical care including antiplatelet medication or anticoagulation when indicated. The authors reported the fatal or disabling stroke after randomization to the end of follow-up as the primary end point of the study. The secondary end points were the all-cause mortality, any stroke, combined procedural stroke in any territory, procedural death, and ipsilateral stroke during follow-up. A total of 1713 patients participated in the study. Stenting was assigned to 855 patients, while endarterectomy was performed on

Transient Ischemic Attack Fast-track and Long-Term Stroke Risk: Role of Diffusion-Weighted Magnetic Resonance Imaging

Acute ischemic lesions on diffusion-weighted magnetic resonance imaging (DWI-MRI) are reliable predictors of recurrent stroke at 90 days. However, to date, limited information on transient ischemic attack (TIA) patients with positive DWI lesions for stroke risk from 1 to 5 years is available. In this study, we evaluated the role of positive DWI lesions and vascular risk factors on stroke, cardiovascular death, and mortality at 90 days (T0), 1 year (T1), and 5 years (T2). Moreover, we also evaluated the association between stroke risk and the presence of DWI lesions. We performed an observational study on consecutive patients admitted to the emergency department of San Camillo-Forlanini Hospital, Rome, Italy, from January 2007 to November 2012. Over the study period, 4300 patients with TIA or ischemic stroke were examined by stroke specialists in an emergency room setting within 1 hour from admittance. In 510 of 4300 patients (11.86%), a TIA was diagnosed, and 445 patients satisfy the study inclusion criteria. For all 445 patients, the mean ABCD2 score was 4.35 ± 1.30. Using DWI-MRI, we identified acute ischemic lesions in 185 patients (41.57%). We did not observe any correlation between duration of symptoms, ABCD2 score, and positive or negative DWI lesions. Positivity for DWI was not associated with the presence of diabetes mellitus, hypertension, smoking habit, or age; however, an association with weakness was observed. We documented a time-dependent increase in the absolute risk of stroke: T0: 1.35% (95% confidence interval [CI], .81-2.8); T1: 4.78% (95% CI, 2.88-7.47); T2: 9.02% (95% CI, 4.66-5.70). We did not record any difference in stroke risk in patients with positive DWI lesions: T0: hazard ratio [HR], 1.43; 95% CI, .35-5.88; log-rank P = .60; T1: HR, 1.04; 95%CI, .42-2.61; log-rank P = .91; T2: HR, .83; 95% CI, .25-2.67; log-rank P = .86. This long-term follow-up study in TIA patients documents that both positive and negative DWI patients treated with fast-track had similar long-term risks of stroke.