Predictors Of Stroke Recurrence Research Articles

Arterial Wall Imaging in Pediatric Stroke.

Arteriopathy is common in childhood arterial ischemic stroke (AIS) and predicts stroke recurrence. Currently available vascular imaging techniques mainly image the arterial lumen rather than the vessel wall and have a limited ability to differentiate among common arteriopathies. We aimed to investigate the value of a magnetic resonance imaging-based technique, namely noninvasive arterial wall imaging (AWI), for distinguishing among arteriopathy subtypes in a consecutive cohort of children presenting with AIS. Children with confirmed AIS and magnetic resonance angiography underwent 3-Tesla AWI including T1-weighted 2-dimensional fluid-attenuated inversion recovery fast spin echo sequences pre- and post-gadolinium contrast. AWI characteristics, including wall enhancement, wall thickening, and luminal stenosis, were documented for all. Twenty-six children with AIS had AWI. Of these, 9 (35%) had AWI enhancement. AWI enhancement was associated with anterior circulation magnetic resonance angiography abnormality and cortical infarction in 8 of 9 (89%) children and normal magnetic resonance angiography with posterior circulation subcortical infarction in 1 (1 of 9; 11%) child. AWI enhancement was not seen in 17 (65%), 10 (59%) of whom had an abnormal magnetic resonance angiography. Distinct patterns of pre- and postcontrast signal abnormality were demonstrated in the vessel wall in the region of interest in children with transient cerebral arteriopathy, arterial dissection, primary central nervous system angiitis, dissecting aneurysm, and cardioembolic stroke. AWI is a noninvasive, high-resolution magnetic resonance AWI technique, which can be successfully used in children presenting with AIS. Patterns of AWI enhancement are recognizable and associated with specific AIS pathogeneses. Further studies are required to assess the additional diagnostic utility of AWI over routine vascular imaging techniques, in childhood AIS.

Abstract TMP20: Small Vessel Occlusion is a High Risk Etiology of Early Recurrent Stroke After Transient Ischemic Attack

Introduction: Early stroke risk in patients with transient ischemic attack (TIA) due to small vessel occlusion (SVO) is underestimated. We assessed whether TIA patients due to SVO are at a higher early stroke risk, using the data of a prospective, multicenter, observational registration study in Japan (PROMISE-TIA registry). Methods: The study subjects were 1,320 TIA patients (470 women, 69±12 years, median ABCD2 score 5) within 7 days of onset. The primary outcome was recurrent stroke within 30 days after TIA. SVO-TIA was defined as having lacunar TIA syndrome without cardiac source of embolism or large artery stenosis, as the exact determination of TIA due to SVO is difficult. Lacunar TIA syndrome was defined as unilateral weakness or sensory disturbance of at least two of three body parts (face, arm, and leg) in the absence of cortical dysfunction. Predictors for 30-day recurrent stroke were estimated using a Cox proportional hazards model. Results: Recurrent stroke within 30 days after TIA was observed in 61 patients (4.6%). In multivariable analysis, SVO-TIA (hazard ratio, 1.87; 95%CI, 1.11-3.11), higher systolic blood pressure at presentation (hazard ratio, 1.18 (per 10mmHg increase); 95%CI, 1.08-1.28) and presentation within 3 hours after onset (hazard ratio, 2.25; 95%CI, 1.30-4.10) were independently associated with recurrent stroke. Furthermore, SVO-TIA with an evidence of subcortical or brainstem infarcts on diffusion weighted imaging (definite TIA due to SVO) was a stronger predictor for recurrent stroke (hazard ratio, 3.63; 95%CI, 1.59-7.23). The presence of cardiac source of embolism and symptomatic large artery steno-occlusion were not significant predictors. Conclusions: The data from a Japanese large TIA registry suggested that patients with TIA due to SVO were at a higher risk of early recurrent stroke.

Abstract WP395: Verifynow P2Y12 Assay With Regard to Cytochrome P450 2C19 Polymorphisms and Stroke Recurrence

Background and Purpose: No evidence as yet that clopidogrel resistance (CR) on VerifyNow assay in relation to cytochrome P450 2C19 (CYP2C19) polymorphisms are more clinically informative at predicting recurrent vascular events during follow-up after ischemic stroke (IS). The aim of this study was to perform a subgroup analysis of MESTRO study to explore the relationship between VerifyNow P2Y12 assay with regard to CYP2C19 polymorphisms and stroke recurrence in patients with non-cardiogenic IS and clopidogrel treatment. Methods: The methods of the MAESTRO study have been published previously. For the study, CR was tested by the VerifyNow P2Y12 assay (Accumetrics, San Diego, CA, USA). CYP2C19 genotype was classified as an ultrarapid metabolizer (UM; *1/*17, *17/*17), extensive metabolizer (EM; *1/*1), intermediate/unknown metabolizer (*1/*2, *1/*3 and *2/*17, *3/*17), or poor metabolizer (PM; *2/*2, *2/*3, *3/*3) based on CYP2C19 genotype status. UM or EM status patients were allocated into the good genotype group for clopidogrel metabolism, and intermediate/unknown metabolizer or PM status patients were allocated into the poor genotype group. Results: Of the 256 patients with clopidogrel treatment, 20 (7.8%) had a recurrent stroke: 15 (75%) experienced an IS and 5 (25%) experienced an ICH. Of the patients with percent inhibition (% INH) ≥40, the risk of recurrent stroke in the good genotype group was 2.2% and was not significantly different from that in the poor genotype group (6.7%) (P=0.400). There was also no significant reduction in the risk of a major vascular event between the groups (2.2% vs 6.7%, P=0.400). Of the patients with % INH <40, there was a trend towards reduction in risk for the recurrent stroke (2.1% vs 8.3%, p=0.142) and a major vascular event (2.1% vs 9.8%, p=0.081) in the good genotype group. Conclusions: Impaired responsiveness to the platelet P2Y12 receptor antagonist clopidogrel alone may not predict stroke recurrence.

Abstract WP198: Intracranial Arterial Calcification Predicts Stroke Recurrence: an 11-year Follow-up Study

Introduction: Intracranial arterial calcification (IAC) is frequently observed on brain computed tomography (CT) in stroke patients. However, the association between IAC and stroke recurrence after hospital discharge has received little attention. In this study, we aim to explore the effect of IAC on the long-term stroke recurrence. Subjects and methods: We prospectively recruited consecutive patients with ischemic stroke or transient ischemic attack during December 2004 and March 2005 from a population-based stroke registry at Prince of Wales Hospital. Demographic characteristics, stroke risk factors, and stroke etiology were recorded at baseline. IAC volume and IAC Agatston score were both measured on 16-slice CT with a semi-automatic system. All patients were regularly followed up for stroke recurrence till July 2016. Results: Total 694 patients (age 71.6±12.4; male sex 50.3%; median follow-up period 8.8 years) were followed up. Stroke recurred in 156 patients (22.5%). Multivariate Cox proportional hazard model found higher IAC Agatston score was predictive factor for both recurrent stroke (HR per 1-SD increment 1.301; 95% CI, 1.084-1.561, p =0.005) and stroke death (HR per 1-SD increment, 1.441; 95% CI, 1.061-1.956, p =0.019). In addition, among different stroke etiological subtypes, IAC Agatston score was independent risk factor of stroke recurrence for index small-vessel occlusive stroke patients (HR per 1-SD increment, 1.674; 95% CI, 1.061-2.639, p =0.027). Conclusions: Quantitative-evaluated IAC scores can predict long-term stroke recurrence and stroke death.

The establishment of ischemic stroke recurrence prediction model and its application value

Objective To establish a prediction model for 3-years recurrence after initial ischemic stroke by Cox proportional hazards regression and individual prognostic Index(PI)equation, and to evaluate its application value and external reality. Methods The inpatients with cerebral ischemic stroke hospitalized in Neurology Department in North China University of Science and Technology Affiliated Hospital were finally internalized between January 2013 and December 2013.Follow-up study on recurrence was carried out between January 2016 and December 2016.The recurrence prediction model was constructed by the Cox proportional hazards regression model.During January 2016 and December 2016, data of patients with ischemic stroke were prospectively continuously collected.And PI equation was used to verify its external reality in ischemic stroke patients. Results A total of 184 cases had stroke recurrence during the follow-up period.The Cox proportional hazards regression model analysis showed that age(RR=1.303, 95%CI: 1.019-1.666), history of heart disease(RR=1.788, 95%CI: 1.127-2.836), hypertension(RR=1.897, 95%CI: 1.097-3.280), diabetes(RR=1.674, 95%CI: 1.015-2.760)and total cholesterol (RR=2.136, 95%CI: 1.396-3.266) were the independent risk factors for stroke recurrence.The established recurrence model was correlated with individual PI equation, which was PI=0.265X1+ 0.581X2+ 0.640X3+ 0.515X4+ 0.759X5.By the validation study of PI equation to predict stroke recurrence among patients admitted later, the sensitivity was 0.719, specificity was 0.769, and accuracy was 0.800. Conclusions Age, history of heart disease, hypertension, diabetes, and total cholesterol are independent risk factors for recurrence of ischemic stroke.And the PI for predicting stroke recurrence within 3 years after initial stroke is successfully established, which is good and helpful for predicting ischemic stroke recurrence. Key words: Stroke; Risk factors; Cox's regression model; Prognosis index

Visual field impairment predicts recurrent stroke after acute posterior circulation stroke and transient ischemic attack.

To evaluate whether visual field impairment (VFI) can predict stroke recurrence in patients with vertebral-basilar (VB) stroke. A total of 326 patients were eligible for a VFI evaluation within 1week of stroke onset. One-year follow-up data were obtained after VB stroke and other vascular events. All predictors were determined using Cox regression models. The overall incidence of recurrent VB stroke and transient ischemic attack (TIA) was 29% (n=92). After multivariate adjustment, severe and moderate VFI were predictors of recurrent VB stroke and TIA. VFI is an independent predictor of recurrent VB stroke and TIA.

Predictors of Stroke Recurrence in Malaysian Diabetic Population with Different Body Mass Index Classification: The observation from Malaysian National Stroke Registry

Predictors of Stroke Recurrence in Malaysian Diabetic Population with Different Body Mass Index Classification: The observation from Malaysian National Stroke Registry

Stroke Risk Is Low after Urgently Treated Transient Ischemic Attack

Over the last decades, the approach to patients with transient ischemic attack (TIA) has shifted from treating only patients considered at high risk of recurrent stroke, to referring all patients with TIA to urgent assessment and immediate initiation of preventive treatment. The data on how this change has influenced the stroke rate after TIA are limited. Thus, the primary aim of this study was to identify the incidence of stroke recurrence after TIA. Second, we wanted to evaluate the ABCD2 score as a predictor of recurrent stroke. Patients discharged with a diagnosis of TIA from the Stroke Unit at Akershus University Hospital between January 1, 2013 and December 31, 2013 were included in the study. Data were obtained from the electronic medical records. Readmission data to capture recurrent strokes were registered until December 31, 2015. In total, 261 patients were included. Mean age was 70.7 years. Stroke incidence at 1 month, 1 year, and the end of follow-up was 1.5% (n = 4), 3.4% (n = 9), and 4.2% (n = 11), respectively. Median time from TIA until recurrent stroke was 90 days. The ability of the ABCD2 score to predict recurrent stroke was low. Urgent admission of patients with TIA is followed by a very low risk of early and late recurrent stroke. The ABCD2 score did not identify patients at high risk of recurrent stroke.

The association of vertebrobasilar calcification with etiological subtypes, stroke recurrence and outcome in acute brainstem ischemic stroke

Arterial calcification (AC), a frequent finding on imaging studies, has been reported as a risk factor for ischemic stroke. However few studies have explored the association of AC with etiological subtypes and prognostic implications. The purpose of this study was to investigate the association of AC with demograhics, risk factors and etiological subtypes and to determine whether it predicts stroke recurrence and functional outcome in patients with acute brainstem ischemic stroke. We analyzed our database consisting of patients who were diagnosed as acute brainstem ischemic stroke admitted within 24hours of onset. Etiological classification of stroke was made based on The Trial of ORG in Acute Stroke Treatment (TOAST) Classification. AC in vertebral and basilar arteries were assessed from baseline brain CT. AC degree was categorized according to calcification along the circumference in the densest calcified segment of each vessel (0 point if no calcification in any of the CT slices, 1 point if calcification <50% of circumference and 2 points if calcification ≥50% of circumference). Three AC categories were defined according to the total AC score as follows: no AC (0 point), mild AC (1–2 points), severe AC (≥3 points). Recurrent stroke within the first 3 months of follow up and modified Rankin Score (mRS) at 3-month were reviewed. 42% of 188 patients had AC in at least of the vertebrobasilar arteries. Severe AC was related to age and the presence of diabetes mellitus and coronary artery disease. The prevalence of AC was significantly higher in large artery atherosclerosis subtype. The presence of AC was marginally associated with recurrent stroke but did not find to be related with functional outcome. Further studies with larger sample size are warranted to explore this topic.

External Validation of Pooled Cohort Risk Equations to Predict 1-Year Clinical Outcome in Ischemic Stroke Patients.

BackgroundThe present study aimed to validate the pooled cohort risk (PCR) equations in a Chinese ischemic stroke population and to explore its prognostic value in predicting stroke recurrence, coronary heart disease, and vascular death.Material/MethodPatients were selected from the China National Stroke Registry. The C statistic was used to examine the clinical prediction of the scores. To analyze the relevant risk factors, univariate and multivariate logistic regressions were performed.ResultsOut of a total of 22 216 patients, 8287 patients (including 7652 acute ischemic stroke [AIS] and 635 transient ischemic attack [TIA] patients) were selected and enrolled in the study. At 1-year follow-up, for stroke recurrence rate, the C statistic value was 0.584 in AIS patients and 0.573 in all patients. For non-fatal myocardial infarction, the C statistic value was 0.533 in AIS patients and 0.493 in all patients. For vascular death, the C statistic value was 0.592 in AIS patients and 0.592 in all patients. For all events, the C statistic value was 0.582 in AIS patients and 0.575 in all patients. For AIS patients, the 12-month cumulative rates for recurrent stroke, vascular death, and combined vascular events were higher in the high-PCR group (PCR ≥20%).ConclusionsPooled cohort risk equations may serve as potential tools to predict and stratify the 1-year risk of recurrent stroke and combined vascular events in AIS/TIA patients in China.

Abstract 73: Risk of Paradoxical Embolism (RoPE) Score Stratification of Pooled Pfo Closure Clinical Trial Data: Lack of Evidence for Improvement in Patient Selection for Closure

Introduction: The Risk of Paradoxical Embolism (RoPE) Score can disaggregate patients with cryptogenic stroke (CS) and patent foramen ovale (PFO) into those who are more likely to have a pathogenic PFO (high RoPE score) than an incidental PFO (low RoPE score). Those with higher RoPE scores have a lower risk of recurrent stroke and different recurrence predictors compared to those with low RoPE scores. Hypotheses: Patients with high RoPE scores benefit more from PFO closure than patients with low RoPE scores. Patients with high RoPE scores and risk factors for recurrence should benefit even more. Methods: The RoPE score was created from a database of CS patients with known PFO status to estimate stratum-specific PFO-attributable fraction and recurrence rates. Variables that predict stroke recurrence in high RoPE score groups (atrial septal aneurysm, history of stroke/TIA prior to index event) were added – the “RoPE Recurrence Score.” Using pooled individual patient data from all 3 RCTs of PFO closure vs. medical therapy (ITT populations; stroke outcome) we tested the ability of the scores to predict the heterogeneity of response to assigned treatment. Results: The mean RoPE score was significantly higher (6.8 vs. 6.3) with smaller variance (Stdev 1.5 vs. 1.9) in the pooled RCT population than in the original RoPE cohort (p&lt;0.0001). Hazard ratios favoring closure were 0.82 (0.42-1.59, p=0.56) in the low RoPE score (&lt;7) group and 0.31 (0.11-0.85, p=0.02) in the high RoPE score (≥7) group but the interaction p-value was not significant (p=0.12). The RoPE Recurrence score did not improve the prediction of treatment response (low score HR=0.65 (0.31-1.37), p=0.26; high score HR=0.58 (0.26-1.26), p=0.17; interaction p=0.82). Conclusion: As expected, the HR favoring closure trended lower in the high RoPE score group in the RCTs but missed statistical significance. The RoPE Recurrence score did not improve the prediction. This may be due to the narrow distribution of relatively high RoPE scores amongst RCT patients and so a low power to detect heterogeneity of treatment effect. Given that PFO closure can only prevent PFO-related recurrences, the treatment effect may also have been obscured by including recurrent strokes with non-PFO-related mechanisms.

Abstract 41: Prognostic Value of Perfusion MRI in Patients with Transient Ischemic Attack or Minor Stroke

Background and purpose: We aimed to investigate the role of perfusion MRI parameters (TTP: time to peak, CBF: cerebral blood flow, CBV: cerebral blood volume) as a prognostic factor for the risk of stroke recurrence or cardiovascular outcome in patients with transient ischemic attack (TIA) or minor stroke. Methods: We retrospectively reviewed TIA or minor stroke patients who underwent our stroke MRI protocol (DWI, perfusion MRI, and MRA) in a consecutively collected stroke registry. Primary outcome was nonfatal stroke recurrence and secondary outcome was cardiovascular composite outcome. Multivariate analysis was used to examine the association of perfusion MRI parameters and angiographic findings with the risk of stroke recurrence and cardiovascular event. Results: Of the 326 patients who met inclusion criteria, we identified 15(4.6%) nonfatal strokes and 25(7.7%) cardiovascular composite events during the first 1 year after the index TIA or minor stroke. The presence of regional delayed perfusion on TTP maps (p=0.002) and regional hyperperfusion on CBV maps (p&lt;0.001) were associated with recurrent stroke. In MRA images, concomitant stenosis of the intracranial arteries and/or extracranial carotid arteries was associated with cardiovascular events (p=0.009). Using multivariate cox proportional hazard analysis, presence of regional hyperperfusion on CBV remained an independent predictor of recurrent stroke (HR 10.82, 95% CI 4.19-38.67, p&lt;0.001) and cardiovascular event (HR 6.30, 95% CI 2.67-18.25, p&lt;0.001). The AUC of the CBV maps was also greater than other parameters for the prediction of stroke recurrence (AUC=0.701, 95% CI 0.54-0.86) and cardiovascular composite outcome (AUC=0.628, 95% CI 0.50-0.76). Conclusions: Increased CBV on perfusion MRI, representing the hemodynamic status of postischemic hyperperfusion, could be more useful than other perfusion parameters in predicting poor prognosis of TIA or minor stroke patients.

Lipoprotein (a) as a Predictor of Early Stroke Recurrence in Acute Ischemic Stroke.

Inflammation plays a crucial role in the pathogenesis of stroke. This study aims to determine lipoprotein (a) [Lp(a)] levels in serum and to investigate their associations with stroke recurrence events in a 3-month follow-up study in patients with acute ischemic stroke (AIS). Serum Lp(a) levels were determined in 203 ischemic stroke patients and 120 normal controls at admission. The severity and clinical outcome of ischemic stroke patients were evaluated by the National Institutes of Health Stroke Scale (NIHSS). We followed the participants for a median of 3months using a standard questionnaire to determine the stroke recurrence events. The correlation analysis and multiple linear regression analysis were performed. Compared with controls, serum Lp(a) levels were significantly increased in ischemic stroke patients than in controls. NIHSS scores and infarct volume were positively correlated with Lp(a) (P<0.001). Finally, 34 patients (16.7%; 95% CI, 11.6-21.9%) had a stroke recurrence. Serum Lp(a) levels in patients with recurrent stroke were significantly higher as compared with those in patients without recurrent stroke (P<0.001). In multivariate analysis, there was an increased risk of stroke recurrence associated with Lp(a) levels ≥300mg/l (OR, 2.87; 95% CI, 1.98-4.32; P=0.009) after adjusting for possible confounders. With an AUC of 0.872 (95% CI, 0.816-0.927), Lp(a) showed a significantly greater discriminatory ability to predict stroke recurrence as compared with NIHSS score (AUC, 0.782; 95% CI, 0.704-0.859; P<0.01). Our findings suggest that elevated serum Lp(a) levels can predict the risk of early stroke recurrence in patients with first-ever ischemic stroke. Further research is needed to replicate these findings.

Intracranial Collateral Flow Estimated by Color Velocity Imaging Quantification Ultrasound: A Protector of Recurrent Stroke in Patient with Carotid Stenosis?

Stroke patients with carotid disease have a high risk of recurrence of disease. By measuring cerebral blood flow volume (BFV) using extracranial duplex technique for clinical estimation of intracranial collaterals, we aimed to investigate the relationship between the presence of intracranial collaterals and stroke recurrence in stroke patients with carotid disease. Consecutive stroke patients indicated for carotid duplex ultrasound investigations in our hospital were recruited during three years' period. Carotid stenosis was diagnosed as ≥50% stenosis and extracranial arterial BFV was measured by using color velocity imaging quantification ultrasound (CVIQ) software. Presence of intracranial collateral flow was defined as a blood flow volume of either ≥370 mL/min in common carotid artery or ≥120 mL/min in vertebral artery. Univariate and multivariate analyses were performed to determine the independent predictors of recurrent stroke. One hundred and twelve stroke patients (19.1%) with ≤50% carotid stenosis were recruited from consecutive ischemic stroke patients. During a mean follow-up of 28.6±13.1 months, recurrent stroke was recorded in 32 (28.6%) out of the total recruited patients. Estimated by blood flow volume measured by CVIQ, the patients with intracranial collateral flow had a lower rate of recurrent stroke than those without (9.5% vs. 33%, P=0.032). After adjusting for potential confounders, the presence of CVIQ-estimated intracranial collateral flow was an independent protector of recurrent stroke (OR, 0.169; 95% CI, 0.034- 0.842; P=0.03). It could be concluded that blood supply through intracranial collateral flow estimated by CVIQ technique may protect stroke patients with carotid stenosis from suffering recurrent stroke.

Minor Stroke and Transient Ischemic Attack: Research and Practice.

A majority of patients with ischemic stroke present with mild deficits for which aggressive management is not often pursued. Comprehensive work-up and appropriate intervention for minor strokes and transient ischemic attacks (TIAs) point toward better patient outcomes, lower costs, and fewer cases of disability. Imaging is a key modality to guide treatment and predict stroke recurrence. Patients with large vessel occlusions have been found to suffer worse outcomes and could benefit from intervention. Whether intravenous thrombolytic therapy decreases disability in minor stroke patients and whether acute endovascular intervention improves functional outcomes in patients with minor stroke and known large vessel occlusion remain controversial. Studies are ongoing to determine ideal antiplatelet therapy for stroke and TIA, while ongoing statin therapy, surgical management for patients with carotid stenosis, and anticoagulation for patients with atrial fibrillation have all been proven to decrease the rate of stroke recurrence and improve outcomes. This review summarizes the current evidence and discusses the standard of care for patients with minor stroke and TIA.

Abstract 103: Infarct Patterns in the Anterior Circulation as Predictors of Recurrent Stroke in the Medical Arm of SAMMPRIS

Introduction: A previous SAMMPRIS analysis showed that stroke as the qualifying event and old infarct in the territory of the stenosis were independently associated with recurrent stroke in the medical arm. We sought to refine these findings by characterizing the relationships between the patterns of infarcts on baseline brain imaging, collateral flow, and risk of stroke. Methods: In the medical arm of SAMMPRIS, 101 patients had acute infarcts in the territory of a stenotic MCA or ICA stenosis on baseline imaging. Blinded to patient outcome, infarcts were characterized as involving primarily the core MCA, internal or cortical borderzone (BZN), or perforator territories. Among these 3 subgroups, the time to primary endpoint (logrank test) and collateral blood flow on baseline angiography (Chi-square tests) were compared. Old infarcts in the same territory were also characterized according to infarct patterns and correlated with acute infarct patterns and outcome. Results: The table shows rates of stroke in the territory during follow-up in the 3 groups of patients (n = 101) with different acute infarct patterns. Data on collaterals were available in 82/101 patients. Among those, no or partial collaterals were seen in 30/43 patients (70%) with acute BDZ, 7/19 (37%) with core MCA, and 11/20 (55%) with perforator patterns (p = 0.049). Old infarcts in the territory on baseline imaging were also seen in 30/101 patients. Among those, recurrent stroke in the territory occurred in 12/30 (40%), all of whom had either an acute or old BDZ infarct on baseline imaging. Of 14 patients with both acute and old BDZ infarcts on baseline imaging, 50% had a recurrent stroke in the territory during follow-up. Conclusion: Infarct patterns in patients with intracranial stenosis presenting with stroke help refine risk stratification. BDZ infarcts are usually associated with impaired collateral flow and are predictive of a particularly high risk of recurrent stroke during follow-up.

Abstract TP422: High Pulse Pressure and Risk of Stroke Recurrence in Patients With Tia

Introduction: stroke recurrence in patients with TIA is one of the most frustrating medical situations and it is very important to identify strong predictors of stroke recurrence to enable practitioners to take clinical decisions Hypothesis: to evaluate the relationship between pulse pressure (PP), a marker of vascular disease, and the risk of stroke recurrence in patients with TIA. Methods: TIA patients were prospectively included in a multidisciplinary secondary stroke prevention program. Pre-stroke vascular risk factor profile and control were obtained from electronic medical records. Stroke recurrence was analyzed after five years of follow up. For the purpose of the analysis, three groups were defined according to pre-stroke PP: &lt; 60, 60-69 and &gt; 70 mmHg. Results: 357 patients (mean age 75±10 years, 55% females) were included. Vascular risk factors profile: hypertension 83%, dislipidemia 74%, obesity 54%, smoking 41%, diabetes 12%, AF 12%, CKD 28%, CHD 18%. Mean SBP was 130 mmHg and DBP 80 mmHg; 78% was receiving antihypertensives, 47% statins, 43% antiplatelets and 9% anticoagulants before the event. There was a direct relationship between pre-stroke PP and stroke recurrence during follow-up (figure). Conclusion: PP is related to higher burden of vascular disease, mainly an increase in arterial stiffness, which might be a key element in clinical decision making in the setting of stroke recurrence prevention.

Intracranial plaque enhancement from high resolution vessel wall magnetic resonance imaging predicts stroke recurrence.

Intracranial atherosclerosis is associated with frequent stroke recurrence. High resolution vessel wall magnetic resonance imaging (HRMRI) can provide atheroma information related to its vulnerability. We performed HRMRI in stroke patients with intracranial atherosclerosis to determine whether plaque characteristics from vessel wall imaging can predict future stroke recurrence. Between July 2011 and June 2013, acute stroke patients with symptomatic intracranial atherosclerosis were prospectively enrolled and 3-tesla HRMRI was performed on the relevant artery. The plaque enhancement was visually determined from T1 post-gadolinium enhancement image. Stroke recurrence was monitored after index event and multivariate Cox proportional hazards model was constructed to identify factors related to future stroke recurrence. A total of 138 patients were included with a median follow-up of 18 months. There were 39 stroke recurrences. Plaque enhancement was detected in 108 patients (78.3%), and 37 of them experienced stroke recurrence. Among 30 stroke patients without plaque enhancement, two patients experienced stroke recurrence. Kaplan-Meier curves demonstrated a significant difference in event free survival between the patients with plaque enhancement and those patients without plaque enhancement (event rates at year 1: 30.3% vs. 6.8%, log-rank test, p = 0.004). Multivariate Cox-regression analysis showed that the plaque enhancement from HRMRI was independently associated with stroke recurrence (hazard ratio: 7.42, 95% confidence interval: 1.74-31.75, p = 0.007). Intracranial plaque enhancement from HRMRI is associated with stroke recurrence among the patients with symptomatic intracranial atherosclerosis.

Ankle-Brachial Index and Recurrent Stroke Risk: Meta-Analysis.

The ankle-brachial index (ABI) is a fast, cheap, noninvasive indicator of atherosclerotic burden that may also be a predictor of stroke recurrence. In this systematic review and meta-analysis, we sought to explore ABI's merit as a marker for stroke recurrence and vascular risk by synthesizing the data currently available in stroke literature. We searched Embase, MEDLINE, and Pubmed databases for prospective cohort studies that included consecutive patients with stroke and transient ischemic attack, measured ABI at baseline, and performed a follow-up assessment at least 12 months after initial stroke or transient ischemic attack. The following end points were chosen for our analysis: recurrent stroke and combined vascular end point (recurrent vascular event or vascular death). Crude risk ratios and adjusted Cox proportional hazard ratios were combined separately using the random-effects model. Study-level characteristics (eg, percent of cohort with a history of hypertension, average cohort age, level of adjustment, and mean follow-up duration) were included as covariates in a metaregression analysis. We identified 11 studies (5374 patients) that were not significantly heterogeneous. Pooling adjusted hazard ratios showed that low ABI was associated with both an increased hazard of recurrent stroke (hazard ratio, 1.70; 95% confidence interval, 1.10-2.64) and an increased risk of vascular events or vascular death (hazard ratio, 2.22; 95% confidence interval, 1.67-2.97). Our results confirm the positive association between ABI and stroke recurrence. Further studies are needed to see whether inclusion of ABI will help improve the accuracy of prediction models and management of stroke patients.

Risk of Recurrent Arterial Ischemic Stroke in Childhood: A Prospective International Study.

Published cohorts of children with arterial ischemic stroke (AIS) in the 1990s to early 2000s reported 5-year cumulative recurrence rates approaching 20%. Since then, utilization of antithrombotic agents for secondary stroke prevention in children has increased. We sought to determine rates and predictors of recurrent stroke in the current era. The Vascular Effects of Infection in Pediatric Stroke (VIPS) study enrolled 355 children with AIS at 37 international centers from 2009 to 2014 and followed them prospectively for recurrent stroke. Index and recurrent strokes underwent central review and confirmation, as well as central classification of causes of stroke, including arteriopathies. Other predictors were measured via parental interview or chart review. Of the 355 children, 354 survived their acute index stroke, and 308 (87%) were treated with an antithrombotic medication. During a median follow-up of 2.0 years (interquartile range, 1.0-3.0), 40 children had a recurrent AIS, and none had a hemorrhagic stroke. The cumulative stroke recurrence rate was 6.8% (95% confidence interval, 4.6%-10%) at 1 month and 12% (8.5%-15%) at 1 year. The sole predictor of recurrence was the presence of an arteriopathy, which increased the risk of recurrence 5-fold when compared with an idiopathic AIS (hazard ratio, 5.0; 95% confidence interval, 1.8-14). The 1-year recurrence rate was 32% (95% confidence interval, 18%-51%) for moyamoya, 25% (12%-48%) for transient cerebral arteriopathy, and 19% (8.5%-40%) for arterial dissection. Children with AIS, particularly those with arteriopathy, remain at high risk for recurrent AIS despite increased utilization of antithrombotic agents. Therapies directed at the arteriopathies themselves are needed.