Previous Transient Ischemic Attack Research Articles

Infarction Patterns in Posterior Cerebral Circulation: Etiology and Prognosis

Study Objectives: About a quarter of strokes and transient ischemic attacks occur in the vertebrobasilar distribution. Vertebrobasilar stroke is particularly prone to devastating consequences especially brain stem infarctions due to damage of the regional brain tissues that contain vital centers, and is associated with high rates of death and disability. Study Design: This was across sectional observational prospective hospital-based study conducted on 60 patients with first-ever acute posterior circulation ischemic stroke. The aim of the current study was to determine the relationship between different risk factors and different infarction patterns in posterior circulation; single small lacunar lesion, single large lesion, or multiple scattered lesions. Diagnosis of ischemic stroke and stroke subtypes were defined using the Trial of ORG 10,172 in Acute Stroke Treatment (TOAST) criteria as well as clinical and brain imaging features. Stroke severity using National Institutes of Health Stroke Scale (NIHSS) score was done on admission, after 24 hours from admission, and at 7 days from onset of symptoms. The patients functional status was assessed by modified Rankin scale (mRS) done on admission and on discharge from hospital and at 7-day follow up from onset of symptoms. Patients were classified according to infarction patterns into a single small lacunar lesion (group I), a single large lesion (group II), and multiple scattered lesions (group III) 20 patients in each group. Results: There was no significant difference between the three groups as regard the presence of vascular risk factors and the only significant difference as regard vascular risk factors was atrial fibrillation (AF). There was significant difference between the three groups as regard the occurrence of previous transient ischemic attacks (TIA). There was significant difference between the three groups as regard NIHSS score on admission, after 24 hours, and at 7 days from admission. There were significant differences between the three groups as regard mRS score at discharge and at 7-day follow up from the onset of symptoms and the degree of improvement from admission to discharge. There was significant difference between the three groups as regard volume of infarction in Brain magnetic resonance imaging (MRI). Group II and group III patients had larger volumes of infarction when compared to group I patients. There was no significant difference between the three groups as regard presence of significant intracranial stenosis in magnetic resonance angiography (MRA). There was significant difference between the three groups as regard stroke etiology. It was found that largeartery atherosclerosis (LAA) was the most common stroke etiology in posterior circulation being present in (53.3%) of the patient group and was common in group II and III in contrast to group I patients. Conclusions: Different vascular risk factors such as hypertension, diabetes, dyslipidemia, and smoking are present in all infarction patterns of posterior circulation ischemic stroke either single or multiple infarctions. However, AF and significant vertebrobasilar stenosis were mostly associated with large and multiple infarct lesion patterns. Small vessel disease was the most common stroke etiology for single small lacunar lesion while large artery atherosclerosis was associated with single large lesion and multiple lesions in the posterior circulation. Early MRI and MRA help in define type and prognosis of posterior circulation infarcts. Early diagnosis and control of potentially modifiable risk factors and comorbid conditions are an important aspect in the early management of patients with infarction in the posterior circulation.

Polyvascular disease, type 2 diabetes, and long-term vascular risk: a secondary analysis of the IMPROVE-IT trial

Polyvascular disease and type 2 diabetes are each associated with increased cardiovascular risk, but whether these risks are additive is unknown. In this exploratory analysis of a randomised trial, we explored the long-term cardiovascular risk associated with polyvascular disease, type 2 diabetes, and their combination in patients with acute coronary syndrome, and assessed the effect of ezetimibe given on top of statin therapy in patients with these concomitant conditions. IMPROVE-IT was a multicentre, double-blind, randomised, placebo-controlled trial assessing the effect of ezetimibe added to statin therapy after acute coronary syndrome. Recruitment was from Oct 26, 2005, to July 8, 2010, and the trial was done at 1158 sites in 39 countries. 18 144 patients aged 50 years and older who had been stabilised after an acute coronary syndrome were randomly assigned to 40 mg per day simvastatin plus either 10 mg per day ezetimibe or matched placebo, for a median duration of 6 years. In this post-hoc exploratory analysis, we assessed the prespecified endpoints of the trial, including the primary composite endpoint (cardiovascular death, a major coronary event [non-fatal myocardial infarction, documented unstable angina requiring hospital admission, or coronary revascularisation occurring at least 30 days after randomisation], or stroke [ischaemic or haemorrhagic]) by concomitant polyvascular disease at baseline (peripheral artery disease or previous stroke or transient ischaemic attack) and stratified by concomitant type 2 diabetes. Efficacy analyses were done according to intention to treat and event rates. IMPROVE-IT is registered with ClinicalTrials.gov, number NCT00202878. 1005 patients (6%) had peripheral artery disease and 1071 (6%) had stroke or transient ischaemic attack at baseline. Of these, 388 (39%) and 409 (38%) also had concomitant type 2 diabetes, respectively. At 7 years, patients with either polyvascular disease or type 2 diabetes had similar rates of the primary endpoint (39·8% and 39·9%, respectively), which were higher than patients without polyvascular disease or diabetes (29·6%). Polyvascular disease with concomitant type 2 diabetes was associated with further heightened risk (60·0% 7-year Kaplan-Meier rate, adjusted hazard ratio versus those with polyvascular disease 1·60, 95% CI 1·38-1·85; p<0·0001). Ezetimibe reduced cardiovascular risk consistently across groups with greater numerical absolute risk reductions in the highest-risk subgroups. In patients with coronary artery disease, concomitant polyvascular disease or type 2 diabetes are associated with increased long-term cardiovascular risk. The combination of polyvascular disease and diabetes is additive, resulting in very high risk. The benefit of ezetimibe is consistent in patients with and without polyvascular disease and type 2 diabetes; however, by nature of their higher risk patients with one, or especially both, of these diseases might derive the greatest absolute benefits. Merck.

Endovascular treatment for emergent large vessel occlusion due to severe intracranial atherosclerotic stenosis.

The optimal treatment strategy for patients with emergent large vessel occlusion (ELVO) due to underlying severe intracranial atherosclerotic stenosis (ICAS) is unclear. The purpose of this study was to compare treatment outcomes from intracranial angioplasty with or without stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor in patients with ELVO due to severe ICAS, and to investigate predictors of outcome after endovascular therapy in such patients. A total of 140 consecutive patients with ELVO attributable to severe ICAS underwent endovascular therapy at two stroke centers (A and B). Intracranial angioplasty/stenting was primarily performed at center A and intraarterial infusion of glycoprotein IIb/IIIa inhibitor (tirofiban) at center B. Data from both centers were prospectively collected into a database and retrospectively analyzed. Overall, successful reperfusion was achieved in 95% (133/140) of patients and a good outcome in 60% (84/140). The mortality rate was 7.9%. Symptomatic hemorrhage occurred in 1 patient. There were no significant differences in the rates of successful reperfusion, symptomatic hemorrhage, 3-month modified Rankin scale score 0-2, and mortality between the two centers. Multivariate logistic regression analysis revealed the only independent predictor of good outcome was a history of previous stroke or transient ischemic attack (TIA) (odds ratio 0.254, 95% confidence interval 0.094-0.689, p = 0.007). Both intracranial angioplasty/stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor are effective and safe in the treatment of underlying severe ICAS in acute stroke patients with ELVO. In addition, a lack of a history of stroke/TIA was the only independent predictor of good outcome after endovascular therapy in such patients.

Risk factor profile and anatomic features of previously asymptomatic patients presenting with carotid-related stroke

ObjectiveAlthough carotid atherosclerotic-mediated stroke remains a major cause of morbidity and mortality, some have suggested intervention in carotid stenosis should be limited to symptomatic patients given the advances in medical therapy. The present study was conducted to assess the atherosclerotic risk factor profiles, anatomic features, and clinical outcomes of previously asymptomatic patients admitted with stroke of carotid etiology. MethodsWe reviewed the data from 3382 patients admitted to a tertiary referral center with an ischemic stroke during 2005 to 2015. We focused on patients admitted with a radiographically confirmed infarct ipsilateral to a documented carotid artery stenosis ≥50%, with the admitting neurology team adjudicating the stroke etiology as carotid related. Patients were excluded if they had had a previous transient ischemic attack, previous infarct ipsilateral to any carotid lesion, or previous carotid revascularization, intracranial hemorrhage, or malignancy. Patient demographic data, medical treatments before stroke, stroke admission carotid imaging, and stroke treatments and outcomes were assessed. ResultsA total of 219 carotid stroke patients (7% of all strokes) were identified, of whom 61% were white and 66% were men, with a mean age of 68 ± 12 years. Hypertension (79%) and smoking (33% current; 29% former) were predominant risk factors. On admission, 50% were receiving antiplatelet therapy (aspirin, n = 92 [41%]; clopidogrel, n = 9 [4%]; dual therapy, n = 11 [5%]) and 55% were receiving lipid-lowering agents (statin, n = 115 [53%]; other, n = 6 [2%]); 77 patients (35%) were receiving both antiplatelet and lipid-lowering therapy. Of the 219 patients, 156 (71%) presented with a moderate or severe stroke (National Institutes of Health stroke scale ≥5 at admission), 54 (25%) received lytic therapy, 96 (43%) presented with an occluded ipsilateral internal carotid artery, and 117 (53%) ultimately underwent carotid revascularization at a median of 4 days. Individuals receiving both antiplatelet and lipid-lowering therapy were significantly less likely to experience a moderate or severe stroke (44% vs 78%; P = .006). ConclusionsInternal carotid artery occlusion is the culprit lesion in 43% of carotid-related strokes in those without previous symptoms. Previously asymptomatic patients not receiving combined antiplatelet and lipid-lowering medical therapy presenting with carotid-related stroke are significantly more likely to experience a severe, debilitating stroke. However, those receiving appropriate risk-reduction medical therapy are still at risk of carotid-mediated stroke. These results suggest medical therapy alone is unlikely to be sufficient stroke prevention for patients with significant carotid stenosis.

Predictors of Cardioembolic Stroke in Japanese Patients with Atrial Fibrillation in the Fushimi AF Registry

Background: Large-scale clinical trials have analyzed risk factors for any ischemic stroke in patients with atrial fibrillation (AF). However, the risk factors for cardioembolic stroke (CES), specifically, have not been reported. To clarify the risk factors for CES and clinically significant cardioembolic infarction, we examined the incidence of CES and larger infarct volume (IV) (> 30 mL) CES, employing the Fushimi AF Registry, a community-based prospective cohort of AF patients in the Fushimi ward, Kyoto, Japan. Methods: A total of 4,182 Fushimi AF patients were enrolled from March 2011 to December 2014. The risk factors for CES were evaluated using multivariate analysis. Results: Of 4,182 patients enrolled, 3,749 patients were observed for ≥1 year. During the follow-up period (mean duration, 979 ± 7.7 days), 91/3,749 patients experienced a CES (2.43%). Significant risk factors associated with CES were older age (odds ratio [OR], 1.31; 95% confidence interval [CI], 1.01–1.72; p = 0.046), low body weight (OR, 1.30; 95% CI, 1.03–1.65; p = 0.033), sustained AF (OR, 1.67; 95% CI, 1.05–2.71; p = 0.034), and previous stroke or transient ischemic attack (TIA) (OR, 1.94; 95% CI, 1.22–3.06; p = 0.004). Predictors of a large IV were chronic kidney disease (CKD) (OR, 2.08; 95% CI, 1.09–4.05; p = 0.027) and previous stroke/TIA (OR, 2.27; 95% CI, 1.19–4.24; p = 0.011). Conclusions: In this population-based cohort of Japanese patients with AF, in addition to previous stroke/TIA and older age, sustained AF and low body weight emerged as risk factors for CES, as opposed to any stroke, which may have a different risk profile. Patients with CKD or previous stroke/TIA who developed cardioembolic infarction exhibited more advanced severity. There is a need for direct oral anticoagulants that can be used safely in patients with comorbid AF and CKD.

Risk of stroke and transient ischaemic attack in patients with a diagnosis of resolved atrial fibrillation: retrospective cohort studies

ObjectivesTo determine rates of stroke or transient ischaemic attack (TIA) and all cause mortality in patients with a diagnosis of “resolved” atrial fibrillation compared to patients with unresolved atrial fibrillation...

Efficacy and Tolerability of Fixed-Dose Combination Perindopril/Indapamide in Hypertensive Patients with a History of Stroke or Transient Ischemic Attack: PICASSO Trial

In everyday medical practice, physicians often need to manage patients whose blood pressure is not well controlled. Those with a history of cerebrovascular disease are a high-risk group in need of rapid blood pressure control. The PICASSO study was a real-life, observational trial involving 9257 inadequately treated hypertensive patients who were switched from previous therapy to the fixed-dose combination of perindopril 10mg/indapamide 2.5mg (PI) for 3months. A subanalysis of data of 1117 hypertensive patients who met the clinical criteria of previous stroke or transient ischemic attack was performed. Twenty-four hour ambulatory blood pressure measurements (ABPMs) were also done in a small group of patients (n:38). At baseline, mean systolic/diastolic blood pressure (SBP/DBP) was 161.5 ± 15.2/93.1 ± 9.9mmHg. After 1month with the fixed dose of PI, average office SBP/DBP decreased to 140.0 ± 11.9/83.5 ± 7.7mmHg. After 3months, SBP/DBP had dropped to 132.9 ± 9.8/80.0 ± 6.2mmHg, by 28.6 ± 15.5/13.1 ± 10.0mmHg (p < 0.001). Blood pressure control rate (< 140/90mmHg) was 67.3% after 3months. When data were stratified by baseline blood pressure, decreases in SBP/DBP were statistically significant in patients with all grades (1-3) of hypertension. In patients previously treated with an angiotensin-converting enzyme inhibitor ± hydrochlorothiazide (n = 677), blood pressure decreased by 29.8 ± 15.5/13.3 ± 10.2mmHg (p < 0.001). Decreases in 24-h ABPM values were also significant (n = 38). Treatment was well tolerated; only a few adverse events were recorded. This study suggests that fixed combination perindopril 10mg/indapamide 2.5mg is an effective and well-tolerated treatment for patients with a history of stroke or transient ischemic attack. EGIS Pharmaceuticals Plc.

Risk Factors, Clinical Features and Prognosis for Subtypes of Ischemic Stroke in a Chinese Population.

It is unanimously accepted that stroke is a highly heterogeneous disorder. Different subtypes of ischemic stroke may have different risk factors, clinical features, and prognoses. The aim of this study was to evaluate the risk factors, clinical characteristics, and prognoses of different subtypes of ischemic stroke defined by the Trial of ORG10172 in Acute Stroke Treatment (TOAST) criteria. We prospectively analyzed the data from 530 consecutive patients who were admitted to our hospital with acute ischemic stroke within 7 days of stroke onset during the study period. Standardized data assessment was used and the cause of ischemic stroke was classified according to the TOAST criteria. Patients were followed up till 30 and 90 days after stroke onset. It was found that large-artery atherosclerosis was the most frequent etiology of stroke (37.4%), and showed the highest male preponderance, the highest prevalence of previous transient ischemic attack, and the longest hospital stay among all subtypes. Small artery disease (36.4%) was associated with higher body mass index, higher plasma triglycerides, and lower plasma high-density lipoprotein cholesterol than cardioembolism. Cardioembolism (7.7%), which was particularly common in the elderly (i.e., individuals aged 65 years and older), showed the highest female preponderance, the highest prevalence of atrial fibrillation, the earliest presentation to hospital after stroke onset, the most severe symptoms on admission, the maximum complications associated with an adverse outcome, and the highest rate of stroke recurrence and mortality. Our results suggest that ischemic stroke should be regarded as a highly heterogeneous disorder. Studies involving risk factors, clinical features, and prognoses of ischemic stroke should differentiate between etiologic stroke subtypes.

Atrial fibrillation and prediction of mortality by conventional clinical score systems according to the setting of care

BackgroundAtrial fibrillation (AF) is associated with high morbidity and mortality, also among anticoagulated patients. Our aim was to evaluate the predictive role for long-term mortality of a series of risk stratification scores associated with cardiovascular or thromboembolic outcomes (CHADS2, CHA2DS2-VASc, ATRIA, TIMI-AF), and bleeding complications (HAS-BLED) in an unselected population of patients with AF. MethodsSingle center, observational, prospective registry of consecutive patients with AF, undergoing clinical/echocardiographic evaluation in a University Hospital, as either in-patients or out-patients. We assessed the role of each single score as predictors of long-term survival according to clinical setting. ResultsWe enrolled 1051 patients, mean age 72 ± 12 years, who were followed for 797 ± 298 days. All the tested scores showed a good performance in prediction of mortality, together with several clinical factors (older age, chronic heart failure, diabetes, renal impairment, previous transient ischemic attack, left ventricular ejection fraction). The values at C-statistics ranged between modest (0.608–0.684) of inpatients to good (0.708–0.751) in outpatients without any statistical difference between the scores, excepted a lower performance of HAD-BLED. ConclusionsRisk scores currently adopted for decision making on starting oral anticoagulation provide good prediction of long-term survival in unselected AF patients, especially in the outpatient setting.

Endovascular treatment of acute ischaemic stroke under conscious sedation: Predictors of poor outcomes.

Background and Aims:Though, many practitioners prefer conscious sedation (CS), it is unclear which factors most influence neurological outcome following mechanical thrombectomy under CS. The aim of this retrospective study is to identify these factors.Methods:After institutional review board approval, data were collected for the patients >18 years of age who underwent endovascular treatment of AIS under CS at our comprehensive stroke centre between January 2009 and June 2015. The primary outcome measure was the modified Rankin Scale (mRS) at discharge. A good outcome was defined as mRS 0–3 and poor outcome as mRS 4–6. Univariate and logistic regression analysis were performed to identify the independent predictors of poor outcomes at discharge. A P < 0.05 was considered statistically significant.Results:One hundred two patients, aged 67 ± 16 years were included. The anterior cerebral circulation was affected in 88 patients (86%), and the median National Institute of Health Stroke Scale (NIHSS) score at presentation was 17.5 (range: 1–36). Overall, 21 (21%) patients had good outcome and 81 (79%) had poor outcome. Logistic regression identified the modified treatment in cerebral ischaemia (mTICI) score [odds ratio (OR): 0.443, confidence interval (CI): 0.244–0.805], NIHSS score (OR: 1.290, CI: 1.125–1.481) and previous transient ischaemic attack (TIA) (OR: 6.988, CI: 1.342–36.380) as significant independent predictors of poor outcome at discharge.Conclusion:The outcome of patients who underwent endovascular treatment of AIS under CS depends on the mTICI score, NIHSS score and history of previous TIA.

Epidemiology of Stroke in Costa Rica: A 7-Year Hospital-Based Acute Stroke Registry of 1319 Consecutive Patients

Limited data on stroke exist for Costa Rica. Therefore, we created a stroke registry out of patients with stroke seen in the Acute Stroke Unit of the Hospital Calderon Guardia. We analyzed 1319 patients enrolled over a 7-year period, which incorporated demographic, clinical, laboratory, and neuroimaging data. The mean age of patients with stroke was 68.0 ± 15.5 years. Seven hundred twenty-five were men and the age range was 13-104 years. The most prevalent risk factors were hypertension (78.8%), dyslipidemia (36.3%), and diabetes (31.9%). Fifteen percent had atrial fibrillation and 24.7% had a previous stroke or transient ischemic attack. Prevalence of hypertension and atrial fibrillation increased with age; however, younger patients were more associated with thrombophilia. We documented 962 (72.9%) ischemic and 270 (20.5%) hemorrhagic strokes. Of the ischemic strokes, 174 (18.1%) were considered secondary to large-artery atherothrombosis, 175 (18.2%) were due to cardiac embolism, 19 (2.0%) were due to lacunar infarcts, and 25 (2.6%) were due to other determined causes. Five hundred sixty-nine (59.1%) remained undetermined. Atherothrombotic strokes were mostly associated with dyslipidemia, diabetes, metabolic syndrome, and obesity, whereas lacunar infarcts were associated with hypertension, smoking, sedentary lifestyle, and previous stroke or transient ischemic attack. Of our patients, 69.9% scored between 0 and 9 in the initial National Institutes of Health Stroke Scale (NIHSS). We found differences in sociodemographic features, risk factors, and stroke severity among stroke subtypes. Risk factor prevalence was similar to other registries involving Hispanic populations.

Sodium Valproate, a Histone Deacetylase Inhibitor, Is Associated With Reduced Stroke Risk After Previous Ischemic Stroke or Transient Ischemic Attack.

Background and Purpose—A variant in the histone deacetylase 9 (HDAC9) gene is associated with large artery stroke. Therefore, inhibiting HDAC9 might offer a novel secondary preventative treatment for ischemic stroke. The antiepileptic drug sodium valproate (SVA) is a nonspecific inhibitor of HDAC9. We tested whether SVA therapy given after ischemic stroke was associated with reduced recurrent stroke rate.Methods—Data were pooled from 3 prospective studies recruiting patients with previous stroke or transient ischemic attack and long-term follow-up: the South London Stroke Register, The Vitamins to Prevent Stroke Study, and the Oxford Vascular Study. Patients receiving SVA were compared with patients who received antiepileptic drugs other than SVA using survival analysis and Cox Regression.Results—A total of 11 949 patients with confirmed ischemic event were included. Recurrent stroke rate was lower in patient taking SVA (17 of 168) than other antiepileptic drugs (105 of 530; log-rank survival analysis P=0.002). On Cox regression, controlling for potential cofounders, SVA remained associated with reduced stroke (hazard ratio=0.44; 95% confidence interval: 0.3–0.7; P=0.002). A similar result was obtained when patients taking SVA were compared with all cases not taking SVA (Cox regression, hazard ratio=0.47; 95% confidence interval: 0.29–0.77; P=0.003).Conclusions—These results suggest that exposure to SVA, an inhibitor of HDAC, may be associated with a lower recurrent stroke risk although we cannot exclude residual confounding in this study design. This supports the hypothesis that HDAC9 is important in the ischemic stroke pathogenesis and that its inhibition, by SVA or a more specific HDAC9 inhibitor, is worthy of evaluation as a treatment to prevent recurrent ischemic stroke.

Public and Private Hospital Care Disparities of Ischemic Stroke in Mexico: Results from the Primer Registro Mexicano de Isquemia Cerebral (PREMIER) Study

Mortality and bad outcome by stroke are higher in developing countries than in industrialized countries. Health-care system efficiency could explain these disparities. Our objective was to identify the impact on short- and middle-term outcomes of patients with acute ischemic stroke (AIS) among public and private Mexican medical care. We analyzed data from patients with AIS included in the Primer Registro Mexicano de Isquemia Cerebral (PREMIER) study. Transient ischemic attacks (TIAs) and ambulatory patients were excluded. Mortality and good outcome were assessed by the modified Rankin Scale (mRS) and analyzed at 1, 3, and 12 months of follow-up. From 1246 patients with AIS included in the registry, 1123 were hospitalized, either in public (n = 881) or in private (n = 242) hospitals. There were no significant differences regarding age and gender. In private settings, patients had a higher educational level, a major frequency of dyslipidemia, a previous stroke and TIA, less overweight and obesity, a sedentary lifestyle, and diabetes; stroke severity, the rate of systemic complications, the length of stay, and in-hospital mortality were also lower; a major frequency of thrombolysis was observed when compared with public hospitals. Our study showed a better outcome (mRS score ≤2) in private scenarios and a higher mortality in patients treated in public hospitals at short- and middle-term follow-ups. A polarized medical practice was observed in the AIS care in this large multicenter cohort of Mexico. There is evidence of an advantage for private scenarios, possibly related with an optimal infrastructure or with a strong patient's economic status.

Statins and the Risk of Intracerebral Hemorrhage in Patients With Previous Ischemic Stroke or Transient Ischemic Attack

Although there is no overall association between statin use and intracerebral hemorrhage (ICH), whether there is an increased risk among those with a history of ischemic stroke (IS) or transient ischemic attack (TIA) remains controversial. We evaluated the relationship of preadmission statin use with the risk of ICH in patients with a history of IS or TIA in a population-based cohort. The Health Improvement Network primary care database in the United Kingdom was used to identify new users of low-dose aspirin and a matched comparison. Both cohorts were followed to identify incident cases of ICH, with validation by manual review of patient records and linkage to hospitalization data. In a nested case-control study, we compared the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for ICH based on statin use in the subgroup of individuals with history of IS/TIA. Last statin use within 1 year of ICH (OR, 0.92; 95% CI [confidence interval], 0.60-1.4), last use between 8 days and 1 year (OR, 1.81; 95% CI, 0.99-3.28), and statin use at the time of ICH (OR, 0.77; 95% CI, 0.49-1.21) were not associated with the overall ICH risk among 157 patients with ICH and 884 controls with a history of IS/TIA. There was also no difference in 30-day rates of fatal (OR, 0.82; 95% CI, 0.41-1.64) or nonfatal (OR, 0.90; 95% CI, 0.51-1.57) ICH. Statin use was not associated with an increased risk of ICH among patients with a previous history of IS/TIA.

Risk factors associated with post-stroke dementia: a systematic review and meta-analysis

This study aimed to evaluate the risk factors for prognostic of post-stroke dementia (PSD). A systematic review included case-control and/or cohort studies, we searched both published and unpublished literatures between 2000 to July 31, 2016. Two authors independently screened and selected research articles. If another one disagreed, the third author would be just along with his/her professionally. Moreover, Critical appraisal was measured by the quality (GRADE). Data collection was in the data extraction form. The Rev-Man 5.3 was used to estimate pooled data. The fixed-effect model will be used when the heterogeneity I2&gt;50%. Result eight publications were pooled for measuring an association between risk factors and PSD by meta-analysis. There were 6 strongly PSD risk factors. The pooled relative ratio (RR) of atrial fibrillation was 1.68, previous stroke 1.59, myocardial infarction 1.40, hypertension 1.36, diabetes mellitus 1.25 and previous transient ischemic attack 1.25 respectively. Un-pooled data from 13 publications reported that the risk factors for dementia in stroke patients were i) demographic factors, ii) vascular risk factors, iii) stroke factors, iv) stroke complications, and v) abnormalities on brain imaging. Strongly risk factors associated with increasing PSD risk were atrial fibrillation, previous stroke, myocardial infarction, hypertension, diabetes mellitus, and previous transient ischemic attack. Further studies, strongly risk factors need to investigate and develop the risk score for the prediction of dementia in stroke patients.

Predicting Major Bleeding in Ischemic Stroke Patients With Atrial Fibrillation.

Performance of risk scores for major bleeding in patients with atrial fibrillation and a previous transient ischemic attack or ischemic stroke is not well established. We aimed to validate risk scores for major bleeding in patients with atrial fibrillation treated with oral anticoagulants after cerebral ischemia and explore the net benefit of oral anticoagulants among bleeding risk categories. We analyzed 3623 patients with a history of transient ischemic attack or stroke included in the RE-LY trial (Randomized Evaluation of Long-Term Anticoagulation Therapy). We assessed performance of HEMORR2HAGES (hepatic or renal disease, ethanol abuse, malignancy, older age, reduced platelet count or function, hypertension [uncontrolled], anemia, genetic factors, excessive fall risk, and stroke), Shireman, HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly), ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation), and ORBIT scores (older age, reduced haemoglobin/haematocrit/history of anaemia, bleeding history, insufficient kidney function, and treatment with antiplatelet) with C statistics and calibration plots. Net benefit of oral anticoagulants was explored by comparing risk reduction in ischemic stroke with risk increase in major bleedings on warfarin. During 6922 person-years of follow-up, 266 patients experienced a major bleed (3.8 per 100 person-years). C statistics ranged from 0.62 (Shireman) to 0.67 (ATRIA). Calibration was poor for ATRIA and moderate for other models. The reduction in recurrent ischemic strokes on warfarin was larger than the increase in major bleeding risk, irrespective of bleeding risk category. Performance of prediction models for major bleeding in patients with cerebral ischemia and atrial fibrillation is modest but comparable with performance in patients with only atrial fibrillation. Bleeding risk scores cannot guide treatment decisions for oral anticoagulants but may still be useful to identify modifiable risk factors for bleeding. Clinical usefulness may be best for ORBIT, which is based on a limited number of easily obtainable variables and showed reasonable performance.

Relationship of Preexisting Cardiovascular Comorbidities to Newly Diagnosed Atrial Fibrillation After Ischemic Stroke

There remains uncertainty as whether newly diagnosed atrial fibrillation (AF) after ischemic stroke reflects underlying heart disease and represents an increased risk of cardioembolic stroke, or whether it is triggered by neurogenic mechanisms. We aimed to determine whether cardiovascular comorbidities in patients with new AF after ischemic stroke differ from patients with previous known AF or without AF. This French longitudinal cohort study was based on the database covering hospital care from 2009 to 2012 for the entire population. Of 336 291 patients with ischemic stroke, 240 459 (71.5%) had no AF and 95 832 (28.5%) had previously known AF at baseline. Patients without previous AF had a mean CHA2DS2-VASc score of 4.98±1.63 SD. During a mean follow-up of 7.9±11.5 months, 14 095 (5.9%) of these patients had incident AF, representing an annual incidence of AF after ischemic stroke of 8.9 per 100 person-years (95% confidence interval, 8.8-9.0). New AF patients had higher CHA2DS2-VASc score, more likely comorbidities, and more frequent history of previous transient ischemic attack than patients with previous known AF or without AF. Preexisting cardiovascular comorbidities underlie AF newly diagnosed after stroke. Consequently, these high-risk patients should be closely monitored for incident AF to facilitate an earlier diagnosis of AF and avoid stroke with appropriate thromboprophylaxis.

Risk Factor Profile of Previously Asymptomatic Patients Presenting With Carotid-Related Stroke

Whereas carotid atherosclerosis-mediated stroke remains a major cause of morbidity and mortality, some have suggested that intervention in carotid stenosis should be limited to symptomatic patients, given advances in medical therapy. This study was conducted to assess atherosclerotic risk factor profiles of those previously asymptomatic patients admitted with stroke of carotid etiology. We reviewed 3382 patients admitted to a tertiary care center diagnosed with an ischemic stroke during 2005 to 2015. This study focused on patients admitted with a radiographically confirmed infarct ipsilateral to a documented carotid artery stenosis ≥50%, with the admitting neurology team adjudicating the stroke etiology as carotid related. Patients were excluded if they had previous transient ischemic attack, prior infarct ipsilateral to any carotid lesion, prior carotid revascularization, intracranial hemorrhage, or malignant disease. A total of 219 (7% of all strokes) carotid stroke patients were identified, of whom 61% were white and 66% were male, with a mean age of 68 ± 12 years. Hypertension (79%) and smoking (33% current; 29% former) were predominant risk factors. On admission, 47% were receiving antiplatelet therapy (aspirin, 42% [n = 92]; clopidogrel, 4% [n = 8]; dual therapy, 5% [n = 11]) and 55% were taking lipid-lowering agents (statin, 53% [n = 115]; other, 2% [n = 6]); 35% (n = 77) were receiving both antiplatelet and lipid-lowering therapy. Of these patients, 80% (n = 177) presented with a moderate or severe stroke (National Institutes of Health Stroke Scale ≥5 at admission), 25% (n = 54) received lytic therapy, 44% (n = 96) presented with an occluded ipsilateral internal carotid artery, and 53% (n = 117) ultimately underwent carotid revascularization at a median of 4 days. Individuals receiving both antiplatelet and lipid-lowering therapy were significantly less likely to experience a moderate or severe stroke event (44% vs 78%; P = .006). Previously asymptomatic patients receiving inadequate medical therapy presenting with carotid-related stroke are significantly more likely to experience a severe, debilitating stroke. However, those receiving appropriate medical therapy are still at risk for carotid-mediated stroke. These data refute the contention that medical therapy alone is sufficient stroke prevention therapy for patients with significant carotid bifurcation atherosclerotic stenosis.

Association between gastrointestinal bleeding and 3-year mortality in patients with acute, first-ever ischemic stroke

The influence of gastrointestinal bleeding on clinical presentation and outcomes of patients with acute ischemic stroke remains controversial. We investigate the effect of gastrointestinal bleeding on the outcomes of patients with acute, first-ever ischemic stroke. We enrolled 934 patients with acute, first-ever ischemic stroke and followed up them for 3years. Patients were divided into 2 groups according to the presence or absence of gastrointestinal bleeding during acute stroke stage. Clinical presentation, stroke risk factors, laboratory data, co-morbidities, and outcomes were recorded. Seventy-six (8.1%) patients had gastrointestinal bleeding at admission. The prevalence of old age, atrial fibrillation, and previous transient ischemic attack was higher in patients with gastrointestinal bleeding (P<0.001, P=0.038, and P=0.018, respectively). Total anterior circulation syndrome occurred more frequently among patients with gastrointestinal bleeding (P<0.001). The mean length of acute ward stay, initial impaired consciousness, and stroke in evolution were higher in patients with gastrointestinal bleeding (P<0.001, P<0.001, and P<0.001, respectively). The occurrence of pneumonia and dependent functional outcome were higher in patients with gastrointestinal bleeding (P<0.001 and P<0.001, respectively). A multivariate Cox regression analysis revealed that gastrointestinal bleeding is a significant risk factor for 3-year all-cause mortality (hazard ratio=2.76; 95% confidence interval=1.61–4.72; P<0.001). In conclusion, gastrointestinal bleeding is associated with increased risk of 3-year mortality in patients with acute, first-ever ischemic stroke. Prophylactic therapies for gastrointestinal bleeding might improve ischemic stroke outcome.

ХИРУРГИЧЕСКАЯ КОРРЕКЦИЯ НЕДОСТАТОЧНОСТИ МОЗГОВОГО КРОВООБРАЩЕНИЯ ПРИ АТЕРОСКЛЕРОЗЕ ЭКСТРАЦЕРЕБРАЛЬНЫХ АРТЕРИЙ

There is more than 1 million people who have had a stroke in Russia; the third part of these people are of working age, and only every fourth patient returned to job. This article discusses one of the most effective methods of stroke prevention - the procedure of carotid endarterectomy. We performed 468 reconstructive operations in 448 patients. 65 % (305) of surgeries were open carotid endarterectomies. In other cases, operations of prosthetics or blood flow switching between extracerebral arteries (ECA) (163) were carried out. Short-term results of reconstructive operations showed that 96 % of outcomes were positive. Perioperative mortality at operations made 1.06 %. The general complications made 4.5 %, minor complications were observed in 21 patients (4.4 %). The five years survival rate of patients operated on ECA made 86 %, the main cause of death in recent follow-up period was a cardiac pathology (58 %), brain disorders made 15 %. Among dominating risk factors are coronary heart disease, previous transient ischemic attacks and residual neurologic impairment.