Recurrent Acute Ischemic Stroke Research Articles

ABCD2-I Score Predicts Unplanned Emergency Department Revisits within 72 Hours Due to Recurrent Acute Ischemic Stroke

Background: the ABCD2 score is valuable for predicting early stroke recurrence after a transient ischemic attack (TIA), and Doppler ultrasound can aid in expediting stroke triage. The study aimed to investigate whether combining the ABCD2 score with carotid duplex results can enhance the identification of early acute ischemic stroke after TIA. Methods: we employed a retrospective cohort design for this study, enrolling patients diagnosed with TIA who were discharged from the emergency department (ED). The modified ABCD2-I (c50) score, which incorporates a Doppler ultrasound assessment of internal carotid artery stenosis > 50%, was used to evaluate the risk of acute ischemic stroke within 72 h. Patients were categorized into three risk groups: low risk (with ABCD2 and ABCD2-I scores = 0–4), moderate risk (ABCD2 score = 4–5 and ABCD2-I score = 5–7), and high risk (ABCD2 score = 6–7 and ABCD2-I score = 8–9). Results: between 1 January 2014, and 31 December 2019, 1124 patients with new neurological deficits were screened, with 151 TIA patients discharged from the ED and included in the analysis. Cox proportional hazards analysis showed that patients in the high-risk group, as per the ABCD2-I (c50) score, were significantly associated with revisiting the ED within 72 h due to acute ischemic stroke (HR: 3.12, 95% CI: 1.31–7.41, p = 0.0102), while the ABCD2 alone did not show significant association (HR: 1.12, 95% CI: 0.57–2.22, p = 0.7427). Conclusion: ABCD2-I (c50) scores effectively predict early acute ischemic stroke presentations to the ED within 72 h after TIA.

Ischemic Stroke and Reduced Left Ventricular Ejection Fraction: A Multidisciplinary Approach to Optimize Brain and Cardiac Health.

Reduced left ventricular ejection fraction ≤40%, a known risk factor for adverse cardiac outcomes and recurrent acute ischemic stroke, may be detected during an acute ischemic stroke hospitalization. A multidisciplinary care paradigm informed by neurology and cardiology expertise may facilitate the timely implementation of an array of proven heart failure-specific therapies and procedures in a nuanced manner to optimize brain and cardiac health.

Analyzing prehospital delays in recurrent acute ischemic stroke: Insights from interpretable machine learning

ObjectiveThis study investigates prehospital delays in recurrent Acute Ischemic Stroke (AIS) patients, aiming to identify key factors contributing to these delays to inform effective interventions. MethodsA retrospective cohort analysis of 1419 AIS patients in Shenzhen from December 2021 to August 2023 was performed. The study applied the Extreme Gradient Boosting (XGBoost) algorithm and SHapley Additive exPlanations (SHAP) for identifying determinants of delay. ResultsLiving with others and lack of stroke knowledge emerged as significant risk factors for delayed hospital presentation in recurrent AIS patients. Key features impacting delay times included residential status, awareness of stroke symptoms, presence of conscious disturbance, diabetes mellitus awareness, physical weakness, mode of hospital presentation, type of stroke, and presence of coronary artery disease. ConclusionPrehospital delays are similarly prevalent among both recurrent and first-time AIS patients, highlighting a pronounced knowledge gap in the former group. This discovery underscores the urgent need for enhanced stroke education and management. Practice implicationThe similarity in prehospital delay patterns between recurrent and first-time AIS patients emphasizes the necessity for public health initiatives and tailored educational programs. These strategies aim to improve stroke response times and outcomes for all patients.

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

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

Abstract 13: Prior Bariatric Surgery is Associated With Reduced Risk of Recurrent Stroke Among Elderly Obese Stroke Survivors: A National Inpatient Sample Study (2016-2019)

Introduction: The paucity of large-scale data exploring the effect of prior bariatric surgery on recurrent stroke outcomes in elderly obese stroke survivors led us to address the gap, with an emphasis on the risk of recurrent stroke and its trends. Methods: A retrospective study was conducted using National Inpatient Sample data from 2016-2019. Elderly obese stroke survivors (> 65 years) having a recurrent acute ischemic stroke (AIS), with or without prior bariatric surgery (PBS), were identified using ICD-10 codes. We compared recurrent stroke trends, demographic characteristics, and comorbidities between the cohorts, employing multivariable and other statistical analyses. Results: The study included 643,505 elderly obese stroke survivors, of which 1.8% (11,820) had PBS. Both groups (PBS vs. no PBS) were predominantly female (59.7% vs. 73.7%), identified as white (76.5% vs. 83.8%), and covered by Medicare (91.7% vs. 90.7%). Despite being the most prevalent comorbidity, hypertension (83.6% vs. 83.2%) was not significantly associated with bariatric surgery status, followed by hyperlipidemia (68.2% vs. 61.6%), diabetes mellitus (60% vs. 52.2%), tobacco use (37.5% vs. 36.4%), prior myocardial infarction (12.8% vs. 15.7%), peripheral vascular disease (8.8% vs. 11.9%), valvular disease (3.9% vs. 3.5%), and drug abuse (1.6% vs. 1.1%). Between 2016 and 2019, recurrent AIS decreased in the PBS group (from 4% to 2.9%, p=0.035) whilst remaining stable in the other group (4.4% to 4.2%, p=0.064). The PBS group exhibited a significantly lower adjusted odds ratio for recurrent AIS (aOR: 0.77, 95% CI: 0.60 - 0.98). Conclusion: Prior bariatric surgery in elderly obese stroke survivors was associated with a 23% lower risk of recurrent AIS and a decreasing trend of AIS recurrence over time. These findings could influence clinical practice and contribute to developing secondary prevention strategies for recurrent stroke among these patients.

Abstract WP235: Cannabis Use Disorder in Elderly Stroke Survivors (≥65 Years) Elevates the Risk of Stroke Recurrence: An Analysis From the National Inpatient Sample (2016-2019)

Introduction: Amid the rising prevalence of cannabis use disorder (CUD) in older adults and with surveys reporting ~85% of overlapping use for medicinal and recreational purposes in American cannabis users, the link between CUD and stroke is paramount. This study explores the risk of recurrent acute ischemic stroke (AIS) or hemorrhagic stroke (HS) in CUD while also evaluating the effects of coexisting substance abuse and mental health conditions. Methods: Elderly (age >65 years) stroke survivors were identified using ICD-10 codes from the National Inpatient Sample (2016-2019) and categorized based on the presence or absence of CUD and recurrent AIS or HS. Multivariable statistical methods assessed demographics, comorbidities, and temporal trends. Results: Out of 5,284,119 elderly stroke survivors, 16,820 (0.3%) had CUD and presented younger (median age: 69 vs. 79), predominantly male (68.8% vs. 45.1%), with a larger representation of black individuals (30.8% vs. 12.8%), and higher prevalence in the lowest income quartile (39.7% vs. 28.4%). Comorbidities like diabetes, hyperlipidemia, obesity, and hypothyroidism were less common in CUD patients, but substance abuse and mental health disorders were more prevalent. From 2016 to 2019, CUD among stroke survivors rose from 0.24% to 0.37%. The uptrend was observed across genders, racial groups (except Asians and Native Americans), income quartiles, hospital regions, and in cohorts with and without anxiety, depression, alcohol abuse, and tobacco use. Additionally, the recurrence of AIS decreased from 5.32% to 5.13% in the non-CUD group. After adjustment, the odds of recurrent AIS in the CUD cohort was 1.56 (95% CI:1.35-1.79), and for any stroke type (AIS or HS) 1.44 (95% CI:1.26-1.65). Conclusion: Elderly stroke survivors with concurrent CUD have a 56% increased risk of recurrent AIS and a 44% heightened risk for AIS or HS. The growing prevalence of CUD in this demographic underscores it's escalating clinical significance.

Abstract WMP10: Carotid Floating Thrombus; Medical Management and Outcomes

Background: Carotid free-floating-thrombus(CFT)is a rare cause of stroke describing an intraluminal thrombus that is loosely associated with the arterial wall and manifesting as a filling defect fully surrounded by contrast. Unfortunately, there is no clear consensus among experts on the ideal treatment for CFT. Methods: Retrospective analysis of acute ischemic stroke(AIS)patients diagnosed with internal carotid CFT on CTA between January2015-March2023.We aimed to compare two treatment regimens: antiplatelet(APT) and anticoagulation(ACT) in the treatment of CFT. APT regimens included the use of dual or single APT (aspirin, clopidogrel and ticagrelor) and ACT regimens included the use of direct oral anticoagulants, warfarin, heparin or low molecular weight heparin+/-aspirin. Patients that underwent thrombectomy were excluded. Results: During study time there were 8252 AIS patients, of which 137(1.6%) patients were diagnosed with CFT. Sixty-six patients were included in our analysis. Patients assigned to APT were older (60.4years + 12.8;p<0.01) (Table 1) .Other demographic variables were similar between groups. Complete CFT resolution by repeat imaging was comparable between groups at 30 days (58.8vs31.6%;p=0.1) and at latest follow-up (70.8vs50%;p=0.1) on ACT vs APT, respectively. There were similar rates of any ICH (13.5vs27.6%;p=0.5), PH1/2, independence at discharge and similar hospital length of stay between APT and ACT groups, respectively ( Table 1 ). Patients assigned to APT were more likely to be discharged on their assigned treatment compared to those assigned to ACT (86.5vs55.2%;p<0.001).The rate of recurrent AIS was comparable among APT and ACT at 30 days (0vs3.4%;p=0.1,respectively).Sensitivity analysis comparing DAPT to exclusive ACT lead to similar results. Conclusion: Our study showed comparable efficacy and safety outcomes in CFT patients who were exclusively managed with APT vs ACT. Larger prospective studies are needed.

Repeated mechanical thrombectomy in recurrent ischemic stroke due to large vessel occlusion: A case report and literature review

Introduction: Recurrent acute ischemic stroke due to large vessel occlusion is a rare condition that primarily affects patients with cardioembolic risk factors. This condition is more frequent in patients who lack sufficient anticoagulation therapy. Case presentation: We present a case of a 77-year-old woman with paroxysmal atrial fibrillation experienced an acute ischemic stroke due to occlusion of the M2 segment of the left middle cerebral artery. She underwent successful mechanical thrombectomy, leading to revascularization. However, two hours after the procedure, she developed acute left hemiplegia caused by occlusion of the proximal right middle cerebral artery. Another successful mechanical thrombectomy was performed. After a hospital stay of 7 days, the patient was discharged, exhibiting complete regression of the neurological symptoms. Conclusion: Although literature on this subject is limited, available data indicate that repeated mechanical thrombectomy is an effective and safe procedure.

Direct Oral Anticoagulant Failures in Atrial Fibrillation With Stroke: Retrospective Admission Analysis and Novel Classification System.

Breakthrough acute ischemic stroke (AIS) in patients with known, nonvalvular Atrial Fibrillation (AF), on Direct Oral Anticoagulants (DOAC), is an ongoing clinical conundrum. Switching anticoagulants was shown to be ineffective in preventing recurrent AIS. Systematic, patient-level chart review of so-called "DOAC failures" may offer insight into this phenomenon. We conducted an IRB-approved, 6-year, retrospective study of AIS admissions, already prescribed DOAC for known AF. We sought plausible, alternative reasons for the AIS using a novel classification schema, CLAMP: C for Compliance concerns, L for Lacunes (small-vessel disease), A for Arteriopathy (atherosclerosis, web, or vasculitis), M for Malignancy, and P for Patent Foramen Ovale (PFO). These categories were labeled as DOAC "Pseudo-failures." Conversely, absence of CLAMP variables were labeled as DOAC "Crypto-failures" conceivably from AF itself ("atriopathy") or pharmacokinetic/pharmacogenomic dysfunction (ie, altered DOAC absorption, clearance, metabolism, or genetic polymorphisms). Forward logistic regression analysis was performed on prespecified DOAC subgroups. Of 4890 AIS admissions, 606 had AF, and 87 were previously prescribed DOAC (14.4% overall DOAC failure rate, 2.4% annualized over 6 years). Pseudo-failures comprised 77%: Compliance concerns (48.9%), Lacunes (5.7%), Arteriopathy (17.0%), Malignancy (26.1%), and PFO (2.3%). Crypto-failures comprised 23%, had lower CHADSVASc scores (AOR = .65, P = .013), and occurred more with rivaroxaban (41%) than apixaban (16%) or dabigatran (5.6%). In AIS patients with known AF, DOAC Pseudo-failures, with identified alternate etiologies, are 3 times more likely than DOAC Crypto-failures. The CLAMP schema represents a novel approach to diagnostic classification and therapeutic adjustments in patients already prescribed DOAC for AF.

Clinical analysis of 4 acute ischemic stroke children treated with endovascular thrombectomy

Objective: To assess the feasibility of endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke (AIS) in children. Methods: Clinical data and follow-up information of 4 AIS children who received EVT in the Department of Intervention & Hemangioma at the Children's Hospital of the Capital Institute of Pediatrics from December 2020 to June 2021 were collected retrospectively. The vascular recanalization after EVT was assessed by the modified thrombolysis in cerebral infarction (mTICI) score. Efficacy outcomes were assessed with initial and postprocedural Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score, and the modified Rankin scale (mRS) score at 3 and 6 months after treatment. Safety assessments included perioperative complications and intracranial hemorrhage post-treatment. Results: A total of 5 EVT treatment were performed on 4 children with AIS, of whom 3 were male. The age of onset was 4.6, 13.8, 7.8, 8.0, 8.9 years, respectively. The time from symptom onset to initiation of EVT was 19.0, 25.0, 22.0, 4.0, 16.5 hours, respectively and all patients achieved successful recanalization of the vessel after EVT (mTICI≥2b). The PedNIHSS score was 39, 14, 25, 39, 24 before treatment and decreased to 8, 1, 12, 39, 5 at discharge. All the procedures were performed with no perioperative complications. Only 1 patient with congenital heart disease had a recurrent AIS with malignant brain oedema and brain hernia. Although the occluded vessels were successfully recanalized,the symptoms were not improved and this patient died after treatment abandonment. The other 3 patients achieved good recovery at 6 months postoperatively. The mRS score of 3 patients was 3, 1, 2 at 3 months after EVT and decreased to 2, 1, 1 at 6 months. Conclusion: EVT treatment may be feasible and safe for pediatric AIS due to large vessel occlusion even when the treatment was initiated 6 hours post stroke, but children with heart disease may have a dismal prognosis.

Recurrence and Mortality Risks in Patients with First Incident Acute Stroke or Myocardial Infarction: A Longitudinal Study Using the Korean National Health Insurance Service Database.

We aimed to identify the long-term risk of recurrence and mortality in patients who experienced acute ischemic stroke (AIS), acute myocardial infarction (AMI), or acute hemorrhagic stroke (AHS) using a population-level database. This retrospective cohort study included adults aged ≥55 years diagnosed with AIS, AMI, and AHS in the National Health Insurance Service Database between 2004 and 2007. The target outcomes were secondary AIS, AMI, AHS, and all-cause mortality. Predetermined covariates, such as age, sex, socioeconomic status, hypertension, diabetes, and dyslipidemia, were adjusted. We included 151,181, 49,077, and 41,636 patients in the AIS, AHS, and AMI groups, respectively. The AMI (adjusted hazard ratio [aHR], 0.318; 95% confidence interval [CI], 0.306-0.330; p < 0.001) and AHS (aHR, 0.489; 95% CI, 0.472-0.506; p < 0.001) groups had a significantly lower risk of developing secondary AIS than the AIS group. The risk of developing secondary AMI was significantly lower in the AMI (aHR, 0.388; 95% CI, 0.348-0.433; p < 0.001) and AHS (aHR, 0.711; 95% CI, 0.640-0.790; p < 0.001) groups than in the AIS group. Initial AHS was a decisive risk factor for secondary AHS (aHR, 8.546; 95% CI, 8.218-8.887; p < 0.001). The AMI (aHR, 1.436; 95% CI, 1.412-1.461; p < 0.001) and AHS (aHR, 1.328; 95% CI, 1.309-1.348; p < 0.001) groups were associated with a significantly higher risk of long-term mortality than the AIS group. Our results elucidated that initial AIS was a significant risk factor for recurrent AIS and AMI; initial AHS was a decisive risk factor for developing secondary AHS. Further, AMI and AHS were more closely related to long-term mortality than AIS.

The optimum anticoagulation time after endovascular thrombectomy for atrial fibrillation-related large vessel occlusion stroke: a real-world study

ObjectivesTo investigate the relationship between the initiation time of anticoagulation after endovascular treatment (EVT) and the outcomes in atrial fibrillation (AF)-related acute ischemic stroke (AIS) patients.MethodsIn this prospective registry study, from March 2013 to June 2022, patients with anterior circulation territories AF-related AIS who underwent EVT within 24 h were included. The primary outcome was favorable [modified Rankin Scale (mRS) 0–1) at ninety days and the secondary outcome was hemorrhage events after anticoagulants. Factors affecting the outcomes were pooled into multivariate regression and ROC curve analysis.ResultsOf 234 eligible patients, there were 63 (26.9%) patients achieved a favorable outcome. The symptomatic intracranial hemorrhage (sICH), ICH, and systemic hemorrhage events after anticoagulants occurred in 8 (3.4%), 28 (12.0%), and 39 (16.7%) patients, severally. A longer EVT to anticoagulation time (p = 0.033) was associated with an unfavorable outcome (mRS 3–6). An earlier EVT to anticoagulation time was the independent risk factor of sICH (p = 0.043), ICH (p = 0.005), and systemic hemorrhage (p = 0.005). There was no significant difference in recurrent AIS/ transient ischemic attack (TIA) or mortality among patients who started anticoagulation at ≤ 4 days, ≥ 15 days, or 4 to 15 days. The optimum cut-off for initiating anticoagulants to predict a favorable outcome and hemorrhage events was 4.5 days and 3.5 days after EVT, respectively.ConclusionsIn AF-related AIS, the time of EVT to anticoagulation is an independent factor of the functional outcome and hemorrhage events after anticoagulation. The optimal initiate time of anticoagulant after EVT is 4.5 days.ClinicalTrialRegisterNCT03754738.

Global Cortical Atrophy Is Associated with an Unfavorable Outcome in Stroke Patients on Oral Anticoagulation

Introduction: Measures of cerebral small vessel disease (cSVD), such as white matter hyperintensities (WMH) and cerebral microbleeds (CMB), are associated with an unfavorable clinical course in stroke patients on oral anticoagulation (OAC) for atrial fibrillation (AF). Here, we investigated whether similar findings can be observed for global cortical atrophy (GCA). Methods: Registry-based prospective observational study of 320 patients treated with OAC following AF stroke. Patients underwent magnetic resonance imaging (MRI) allowing assessment of GCA. Using the simplified visual Pasquier scale, the severity of GCA was categorized as follows: 0: no atrophy, 1: mild atrophy; 2: moderate atrophy, and 3: severe atrophy. Using adjusted logistic and Cox regression analysis, we investigated the association of GCA using a composite outcome measure, comprising: (i) recurrent acute ischemic stroke (IS); (ii) intracranial hemorrhage (ICH); and (iii) death. Results: In our time to event analysis after adjusting for potential confounders (i.e., WMH, CMB, age, sex, diabetes, arterial hypertension, coronary heart disease, hyperlipidemia, and antiplatelet use), GCA was associated with an increased risk for the composite outcome in all three degrees of atrophy (grade 1: aHR 3.95, 95% CI 1.34–11.63, p = 0.013; grade 2: aHR 3.89, 95% CI 1.23–12.30, p = 0.021; grade 3: aHR 4.16, 95% CI 1.17–14.84, p = 0.028). Conclusion: GCA was associated with our composite outcome also after adjusting for other cSVD markers (i.e., CMB, WMH) and age, indicating that GCA may potentially serve as a prognostic marker for stroke patients with atrial fibrillation on oral anticoagulation.

Ischemic stroke with cancer: Hematologic and embolic biomarkers and clinical outcomes

BackgroundPatients with cancer and acute ischemic stroke (AIS) face high rates of recurrent thromboembolism or death. ObjectivesTo examine whether hematologic and embolic biomarkers soon after AIS are associated with subsequent adverse clinical outcomes. MethodsWe prospectively enrolled 50 adults with active solid tumor cancer and AIS at two hospitals from 2016 to 2020. Blood was collected 72–120 h after stroke onset. A 30‐min transcranial Doppler (TCD) microemboli detection study was performed. The exposure variables were hematologic markers of coagulation (D‐dimer, thrombin‐antithrombin), platelet (P‐selectin), and endothelial activation (thrombomodulin, soluble intercellular adhesion molecule‐1 [sICAM‐1], soluble vascular cell adhesion molecule‐1 [sVCAM‐1]), and the presence of TCD microemboli. The primary outcome was a composite of recurrent arterial/venous thromboembolism or death. We used Cox regression to evaluate associations between biomarkers and subsequent outcomes. ResultsDuring an estimated median follow‐up time of 48 days (IQR, 18–312), 43 (86%) participants developed recurrent thromboembolism or death, including 28 (56%) with recurrent thromboembolism, of which 13 were recurrent AIS (26%). In unadjusted analysis, D‐dimer (HR 1.6; 95% CI 1.2–2.0), P‐selectin (HR 1.9; 95% CI 1.4–2.7), sICAM‐1 (HR 2.2; 95% CI 1.6–3.1), sVCAM‐1 (HR 1.6; 95% CI 1.2–2.1), and microemboli (HR 2.2; 95% CI 1.1–4.5) were associated with the primary outcome, whereas thrombin‐antithrombin and thrombomodulin were not. D‐dimer was the only marker associated with recurrent AIS (HR 1.2; 95% CI 1.0–1.5). Results were generally consistent in analyses adjusted for important prognostic variables. ConclusionsMarkers of hypercoagulability and embolic disease may be associated with adverse clinical outcomes in cancer‐related stroke.

Effectiveness and Safety of Clopidogrel vs Aspirin in Elderly Patients With Ischemic Stroke

ObjectiveTo evaluate the risks of recurrent stroke and major bleeding events with clopidogrel and aspirin use among patients aged 80 years or older. Patients and MethodsThis retrospective cohort study was conducted using the Full Population Data of the Health and Welfare Database in Taiwan. Patients aged 80 years or older who received monotherapy with clopidogrel or aspirin following hospitalization for primary acute ischemic stroke between January 1, 2009, and December 31, 2018, were included. Inverse probability of treatment weighting was used to balance measured covariates between clopidogrel and aspirin users. Measured outcomes included recurrent acute ischemic stroke, acute myocardial infarction, composite cardiovascular events (recurrent stroke or acute myocardial infarction), intracranial hemorrhage, major gastrointestinal tract bleeding, and composite major bleeding events (intracranial hemorrhage or major gastrointestinal tract bleeding). ResultsA total of 15,045 patients were included in the study, 1979 of whom used clopidogrel and 13,066 who used aspirin following hospitalization for primary acute ischemic stroke. Clopidogrel use was associated with significantly lower risk of recurrent acute ischemic stroke (hazard ratio [HR], 0.89; 95% CI, 0.83 to 0.96; P=.002), composite cardiovascular events (HR, 0.88; 95% CI, 0.82 to 0.95; P<.001), intracranial hemorrhage (HR, 0.71; 95% CI, 0.56 to 0.90; P=.005), and composite major bleeding events (HR, 0.89; 95% CI, 0.80 to 0.99; P=.04) compared with aspirin use. ConclusionIn patients aged 80 years or older with primary acute ischemic stroke, clopidogrel users had lower risks of recurrent stroke and the composite cardiovascular events compared with aspirin users. Clopidogrel users also had lower risks of intracranial hemorrhage and the composite major bleeding events compared with aspirin users.

Reminiscence therapy is a feasible care program for improving cognitive function, anxiety, and depression in recurrent acute ischemic stroke patients: a randomized, controlled study.

Reminiscence therapy provides benefits among first-episode acute ischemic stroke (AIS) patients and their caregivers. This study intended to further compare the effect of reminiscence therapy plus usual care (RTUC) and usual care (UC) on cognitive function, anxiety, and depression among recurrent AIS patients. Totally, 160 recurrent AIS patients were enrolled and randomized in a 1:1 ratio into the RTUC group (N = 81) and UC group (N = 79), then a 12-month corresponding intervention was conducted in each group. Mini-Mental State Examination (MMSE) score and Hospital Anxiety and Depression Scale (HADS) were evaluated on discharge (M0), at month (M) 3, M6, M9, and M12 after discharge. MMSE scores at M6 (27.0 ± 1.6 vs. 26.3 ± 2.3, P = 0.031) and M12 (27.0 ± 1.7 vs. 26.1 ± 2.4, P = 0.009) were elevated, while cognitive impairment rate at M12 (29.2% vs. 45.7%, P = 0.042) and cognitive impairment severity at M12 (P = 0.029) were declined in RTUC group compared to UC group. Meanwhile, the HADS-anxiety scores at M9 (5.7 ± 3.1 vs. 6.9 ± 4.0, P = 0.046) and M12 (5.6 ± 2.7 vs. 7.0 ± 4.3, P = 0.024), anxiety rate at M12 (22.2% vs. 38.2%, P = 0.039) and anxiety severity at M12 (P = 0.018) were declined in RTUC group compared to UC group. Besides, the HADS-depression score at M12 (5.7 ± 3.1 vs. 6.8 ± 3.3, P = 0.043) was decreased in RTUC group compared to UC group, but depression rate and severity were not different between the two groups at each visit point (all P > 0.05). RTUC program elevates cognitive functions and alleviates mental problems in recurrent AIS patients.

β2-Microglobulin is a Novel and Reliable Biomarker for Predicting Ischemic Stroke Recurrence: A Prospective Cohort Study.

Immune and inflammatory mechanisms play key roles in the development and outcome of acute ischemic stroke (AIS). β2-Microglobulin (β2M) is the light chain of major histocompatibility complex-1 (MHC-1), which can directly and quickly reflect the immune and inflammatory state of the body. Previous studies have shown a close relationship between β2M and AIS, but its relationship with the recurrence of AIS has not been reported. This study attempted to explore the relationship between β2M and the recurrence of AIS. A single-center AIS cohort involving 135 patients was followed for approximately 26–46 months. Clinical and laboratory data from the patients were collected when hospitalized. The endpoint was the occurrence of recurrent AIS after patients were discharged. Propensity score matching was used to match cohort groups. Cox regression analysis was used to predict risk factors for recurrent AIS, and receiver operating characteristic curve (ROC) analysis was used to calculate the optimal cutoff value for discriminating recurrence in patients with AIS. The rate of recurrence was 29.6% [95% CI, 21.8%–37.3%] in the follow-up group. Patients with higher levels of serum β2M had a higher risk of AIS recurrence than patients with lower levels of β2M (adjusted hazard ratio, 3.214 [95% CI, 1.557–6.633]; adjusted hazard ratio after matching, 5.831, [95% CI, 2.052–16.572]). A β2M value of 2.31 mg/L was calculated by ROC analysis as the optimal cutoff value for AIS recurrence (area under the curve 0.770, [95% CI, 0.687–0.853]). As a quick responder to the body’s immune and inflammatory states, β2M may be a novel and reliable biomarker in predicting AIS recurrence.

Longitudinal variation of circulating Inc-ITSN1-2: A novel biomarker reflecting disease severity, inflammation, recurrence, and death risk in acute ischemic stroke patients.

BackgroundLong noncoding RNA intersectin 1–2 (lnc‐ITSN1‐2) regulates inflammation and neuronal apoptosis; meanwhile, the latter two factors participate in the pathogenesis of acute ischemic stroke (AIS). Therefore, this study detected lnc‐ITSN1‐2 at multiple time points, aiming to explore its longitudinal variation and clinical value in the management of AIS patients.MethodsThe current study enrolled 102 AIS patients, then detected their lnc‐ITSN1‐2 in peripheral blood mononuclear cell (PBMC) at baseline (D0), day (D)1, D3, D7, month (M)1, M3, M6, and year (Y)1 after admission using RT‐qPCR. Additionally, lnc‐ITSN1‐2 in PBMC of 50 controls was also detected.ResultsLnc‐ITSN1‐2 was up‐regulated in AIS patients than that in controls (p < 0.001). Lnc‐ITSN1‐2 positively associated with NIHSS score, TNF‐α, and IL‐17A (all p < 0.050) but was not linked with IL‐6 (p = 0.093) in AIS patients. Notably, lnc‐ITSN1‐2 was gradually increased from D0 to D3; while it switched to decrease from D3 to Y1 in AIS patients. Lnc‐ITSN1‐2 disclosed similar longitudinal variation during 1 year in non‐recurrent (p < 0.001), recurrent (p = 0.001), and survived patients (p < 0.001), while the variation of lnc‐ITSN1‐2 in died patients was not obvious (p = 0.132). More importantly, lnc‐ITSN1‐2 at D0, D3, D7, M1, M3, M6, and Y1 was higher in recurrent AIS patients than that in non‐recurrent AIS patients (all p < 0.050); moreover, lnc‐ITSN1‐2 at D3, D7, M1, M3, and M6 was up‐regulated in died AIS patients than AIS survivors (all p < 0.050).ConclusionThe dynamic variation of Inc‐ITSN1‐2 could serve as a biomarker reflecting disease severity, inflammatory cytokines, recurrence, and death risk in AIS patients.

In-Hospital Outcomes and Recurrence of Acute Ischemic Stroke in Patients With Solid Organ Malignancy.

The aim of this work was to evaluate the influence of solid organ malignancies on the in-hospital outcomes and recurrent strokes among patients hospitalized with acute ischemic stroke (AIS). Adult hospitalizations with a primary diagnosis of AIS were identified from the Nationwide Readmissions Database from 2016 to 2018. Logistic regression was used to compare the differences in the use of acute stroke interventions and clinical outcomes in patients with and without malignancy. Survival analysis was used to evaluate the risk of readmission due to recurrent stroke after discharge. There were 1,385,840 hospitalizations due to AIS (mean ± SD age 70.4 ± 14.0 years, female 50.2%). Of these, 50,553 (3.7%) had a concurrent diagnosis of solid organ malignancy. The 5 most common malignancies included lung cancer (24.6%), prostate cancer (13.2%), breast cancer (9.3%), pancreatic cancer (6.5%), and colorectal cancer (6.2%). After adjustment for baseline differences, patients with malignancy were more likely to have intraparenchymal hemorrhage (odds ratio [OR] 1.11, 95% CI 1.04-1.19), in-hospital mortality (OR 2.15, 95% CI 2.04-2.28), and discharge disposition other than to home (OR 1.70, 95% CI 1.64-1.75). Patients with malignancy were less likely to receive IV thrombolysis (tissue plasminogen activator [tPA]) and were more likely to undergo mechanical thrombectomy (MT). Among the subgroups of patients treated with tPA or MT, the outcomes were comparable between patients with and without malignancy, except patients with lung cancer remained at a higher risk of mortality and adverse disposition despite these acute stroke interventions. Patients with malignancy were at a higher risk of readmission due to recurrent AIS within 1 year of discharge (hazards ratio 1.18, 95% CI 1.11-1.25), and this risk was driven specifically by the lung and pancreatic cancers. While patients with malignancy generally have worse in-hospital outcomes compared to those without, there is considerable variation in these outcomes according to the different cancer types and the use of acute stroke interventions. The use of tPA and MT is generally safe for eligible patients with an underlying malignancy. Patients with lung and pancreatic cancers have a higher early risk of recurrent stroke and might need more intensive surveillance and careful institution of the optimal secondary prevention measures.

Recurrent Multi-territorial Acute Ischemic Stroke due to Cardiac Angiosarcoma.

A 64-year-old man with hypertension, hyperlipidemia, and diabetes mellitus presented on 2 separate occasions with recurrent acute ischemic strokes in multiple vascular territories (Figure 1). Transthoracic echocardiogram revealed a 4.2 × 2.1 cm left atrial mass with heterogenous contrast enhancement on heart MRI (Figure 2). A PET scan showed corresponding avid uptake in the left atrium with widespread bone, skin, and pulmonary metastases. Left ischial bone biopsy was consistent with angiosarcoma.