Recurrent Ischemic Stroke In Patients Research Articles

Factors that Cause Recurrent Stroke amongst Ischemic Stroke Patients: A Literature Review

In patients, recurrent stroke is prevalent and could be avoided, but at the same time, stroke could recur due to various reasons. These comprised the same causes as it caused the initial stroke and with the incorporation of risk factors, like smoking, obesity, and diabetes. The prevalence of recurrent stroke is considered high and could increase as time goes by. As mentioned in research on hemorrhagic stroke, the risk significantly increases overtime, up to 45% within 5 years and if exposed to stroke unit care, the risk will be reduced [1.] However, because of the vagueness in specificity of whether the causes are the same, this research aims to dive into the specific factors that will eventually lead to recurrent stroke. Moreover, this research aims to underscore activities or practices that would reduce the risk of recurrent stroke. Recurrent stroke is seen as a relatively dangerous disease since it could possibly increase the mortality rates in an individual. Therefore, finding the main causes will underscore the significance of preventing recurrent stroke amongst ischemic stroke patients. All data are gathered from different sources of articles and publications to conclude. As a result, factors that cause recurrent ischemic stroke in patients are hypertension, diabetes, smoking, high cholesterol, physical inactivity, alcohol consumption, genetic factors, age, gender, and more.

Difference between Nutrition Status in First and Recurrent Ischemic Stroke Patients: a Retrospective Cross-Sectional Study

Malnutrition in stroke patients can be caused by neurological deficits such as decreased consciousness, dysphagia, cranial nerve paresis, and hemiparesis/hemiplegia. The condition of malnutrition seriously impacts healing and can exacerbate the underlying disease, in this case, stroke, so malnutrition in stroke patients extends the length of stay and increases morbidity and mortality. This study compares nutritional status between first and recurrent ischemic stroke patients based on body mass index (BMI) and subjective global assessment (SGA). This study is a comparative analysis of the medical records of ischemic stroke patients in Dr. Hasan Sadikin General Hospital Bandung from January 2018 until December 2020. The chi-square and Fisher's exact tests were used for statistical analysis. The significance criteria are the p-value if p≤0.05 means statistically significant. A total of 236 subjects in both groups of first and recurrent ischemic stroke patients consisting of 130 men and 106 women with an average age of 56.64 and 61.75 years, and the majority had risk factors for hypertension. The first ischemic stroke group has a good nutrition status compared with the recurrent stroke group (p<0.05). Thirteen patients (11.02%) of first ischemic stroke and 11 patients of recurrent ischemic stroke (9.32%) were underweight, 67 patients (56.78%) of first ischemic stroke and 74 patients of recurrent ischemic stroke (62.71%) had average weight, 31 patients (26.27%) first ischemic stroke and 33 patients (27.97%) recurrent ischemic stroke were overweight, five patients (4.24%) first ischemic stroke and seven patients (5.93%) recurrent ischemic stroke were obese (p<0.05). In conclusion, there was a significant difference in the nutritional status of first and repeated ischemic stroke patients. The nutritional status of recurrent ischemic stroke patients is worse than that of first ischemic stroke patients.

Association of culprit plaque enhancement ratio, hypoperfusion and HbA1c with recurrent ischemic stroke in patients with atherosclerotic stenosis of the middle cerebral artery

PurposeTo investigate the differences in intracranial culprit plaque characteristics of the middle cerebral artery (MCA), collateral circulation and hypoperfusion in patients with and without recurrent ischemic stroke and to identify the association with the recurrent ischemic cerebrovascular events. MethodEighty-six patients with acute/subacute ischemic stroke caused by atherosclerotic plaques of the MCA were retrospectively enrolled and grouped into patients with recurrence (n = 36) and without recurrence (n = 50). All patients underwent high-resolution vessel wall imaging and dynamic susceptibility contrast-enhanced perfusion weighted imaging. The differences in culprit plaque characteristics, collateral circulation and hypoperfusion in the territory of the stenotic MCA were assessed between the two groups. The relationship between plaque characteristics and hypoperfusion was evaluated. The independent factors of recurrent ischemic stroke were identified by logistic regression analyses. ResultsHigher HbA1c, culprit plaque enhancement grade, culprit plaque enhancement ratio, and lower time to peak map based on the Alberta Stroke Program Early CT score (TTP-ASPECTS) were observed in the recurrence group(all p < 0.050). Both plaque enhancement grade and enhancement ratio were significantly associated with TTP-ASPECTS (p = 0.030 and 0.039, respectively). HbA1c, culprit plaque enhancement ratio and TTP-ASPECTS were independent factors of the recurrence of ischemic stroke (all p < 0.050). The area under the curve of the combination including the above factors (AUC = 0.819) was significantly higher than that of any variable alone after adjustment (all p < 0.050). ConclusionsCulprit plaque enhancement ratio, TTP-ASPECTS and HbA1c were independent factors of recurrent ischemic stroke. Their combination improved the accuracy in identifying the risk of recurrent ischemic stroke.

Risk of recurrent ischemic stroke in patients with patent foramen ovale: The role of D-dimer

BackgroundParadoxical embolism under elevated thromboembolic conditions is known to be the primary mechanism of patent foramen ovale (PFO)-related stroke. We hypothesized that higher levels of D-dimer, a marker of thromboembolism, could increase the risk of stroke recurrence in patients with PFO. MethodsWe conducted a retrospective analysis of data from 1226 consecutive patients with acute ischemic cryptogenic stroke (CS) who underwent transesophageal echocardiography (TEE). D-dimer was assessed during admission. We used a multivariate Cox proportional hazards model to evaluate the association of long-term outcomes between the presence of PFO and levels of D-dimer. ResultsOf the 1226 patients, the study included 461 who underwent TEE. Among them, 242 (52.5%) had PFOs. Among PFO patients, those with a D-dimer level >1.0 mg/L had a significantly higher risk of stroke recurrence compared to those with <0.5mg/L (adjusted hazard ratio (aHR) 4.04, 95% confidence interval [CI] 1.63–10.02). A pattern of increased risk of event with increasing D-dimer levels was observed (Ptrend=0.008). However, there was no significant difference in the risk of stroke recurrence at any D-dimer level compared to D-dimer level <0.5 mg/L among patients without PFO. In these patients, there was little evidence of increased risk with increasing D-dimer levels (Ptrend=0.570). ConclusionsThis study demonstrated that the elevated D-dimer level increased the recurrence of stroke in CS patients with PFO, particularly showing a dose-dependent relationship between D-dimer levels and recurrence. However, no such effect was observed in patients without PFO. These findings provide valuable insights into the potential benefits of anticoagulation for strokes related to PFO.

Intracranial Spotty Calcium Predicts Recurrent Stroke in Patients with Symptomatic Intracranial Atherosclerotic Stenosis

PurposeAccumulating evidence highlights the association of calcium characteristics and cardiovascular events, but its role in cerebrovascular stenosis has not been well studied. We aimed to investigate the contribution of calcium patterns and density to recurrent ischemic stroke in patients with symptomatic intracranial atherosclerotic stenosis (ICAS).MethodsIn this prospective study, 155 patients with symptomatic ICAS in the anterior circulation were included, and all subjects underwent computed tomography angiography. The median follow-up for all patients was 22 months and recurrent ischemic stroke were recorded. Cox regression analysis was performed to examine whether calcium patterns and density were associated with recurrent ischemic stroke.ResultsDuring the follow-up, 29 patients who experienced recurrent ischemic stroke were older than those without recurrent ischemic stroke (62.93 ± 8.10 years vs. 57.00 ± 12.07 years, p = 0.027). A significantly higher prevalence of intracranial spotty calcium (86.2% vs. 40.5%, p < 0.001) and very low-density intracranial calcium (72.4% vs. 37.3%, p = 0.001) were observed in patients with recurrent ischemic stroke. Multivariable Cox regression analysis showed that intracranial spotty calcium, rather than very low-density intracranial calcium, remained an independent predictor of recurrent ischemic stroke (adjusted hazard ratio 5.35, 95% confidence interval 1.32–21.69, p = 0.019).ConclusionIn patients with symptomatic ICAS, intracranial spotty calcium is an independent predictor of recurrent ischemic stroke, which will further facilitate risk stratification and suggest that more aggressive treatment should be considered for these patients.

Biliverdin Reductase B Is a Plasma Biomarker for Intraplaque Hemorrhage and a Predictor of Ischemic Stroke in Patients with Symptomatic Carotid Atherosclerosis

Background: Intraplaque hemorrhage (IPH) is a hallmark of atherosclerotic plaque instability. Biliverdin reductase B (BLVRB) is enriched in plasma and plaques from patients with symptomatic carotid atherosclerosis and functionally associated with IPH. Objective: We explored the biomarker potential of plasma BLVRB through (1) its correlation with IPH in carotid plaques assessed by magnetic resonance imaging (MRI), and with recurrent ischemic stroke, and (2) its use for monitoring pharmacotherapy targeting IPH in a preclinical setting. Methods: Plasma BLVRB levels were measured in patients with symptomatic carotid atherosclerosis from the PARISK study (n = 177, 5 year follow-up) with and without IPH as indicated by MRI. Plasma BLVRB levels were also measured in a mouse vein graft model of IPH at baseline and following antiangiogenic therapy targeting vascular endothelial growth factor receptor 2 (VEGFR-2). Results: Plasma BLVRB levels were significantly higher in patients with IPH (737.32 ± 693.21 vs. 520.94 ± 499.43 mean fluorescent intensity (MFI), p = 0.033), but had no association with baseline clinical and biological parameters. Plasma BLVRB levels were also significantly higher in patients who developed recurrent ischemic stroke (1099.34 ± 928.49 vs. 582.07 ± 545.34 MFI, HR = 1.600, CI [1.092–2.344]; p = 0.016). Plasma BLVRB levels were significantly reduced following prevention of IPH by anti-VEGFR-2 therapy in mouse vein grafts (1189 ± 258.73 vs. 1752 ± 366.84 MFI; p = 0.004). Conclusions: Plasma BLVRB was associated with IPH and increased risk of recurrent ischemic stroke in patients with symptomatic low- to moderate-grade carotid stenosis, indicating the capacity to monitor the efficacy of IPH-preventive pharmacotherapy in an animal model. Together, these results suggest the utility of plasma BLVRB as a biomarker for atherosclerotic plaque instability.

Contemporary Antiplatelet and Anticoagulant Therapies for Secondary Stroke Prevention: A Narrative Review of Current Literature and Guidelines.

Stroke is a leading cause of death and disability worldwide. The annual incidence of new or recurrent stroke is approximately 795,000 cases per year in the United States, of which 87% are ischemic in nature. In addition to the management of modifiable high-risk factors to reduce the risk of recurrent stroke, antithrombotic agents (antiplatelets and anticoagulants) play an important role in secondary stroke prevention. This review will discuss the published literature on the use of antiplatelets and anticoagulants in secondary prevention of acute ischemic stroke and transient ischemic attack (TIA), including their pharmacology, efficacy, and adverse effects. We will also highlight the role of dual antiplatelet therapy (DAPT) in secondary stroke prevention, along with supporting literature. Single antiplatelet therapy (SAPT) with aspirin or clopidogrel reduces the risk of recurrent ischemic stroke in patients with non-cardioembolic ischemic stroke or TIA. However, as shown in recent trials, short-term DAPT with aspirin and clopidogrel or ticagrelor for 21-30days is more effective than SAPT in patients with minor acute non-cardioembolic stroke or high-risk TIA. Although short-term DAPT is highly effective in preventing recurrent stroke, a more prolonged course can increase bleeding risks without additional benefit. DAPT for 90days, followed by aspirin monotherapy for patients with large vessel intracranial atherosclerotic disease, is suitable for secondary stroke prevention. However, patients need to be monitored for both minor (e.g., bruising) and major (e.g., intracranial) bleeding complications. Conversely, oral warfarin and newer direct oral anticoagulant (DOACs) such as dabigatran, rivaroxaban, apixaban, and edoxaban are the agents of choice for secondary stroke prevention in patients with non-valvular cardioembolic strokes. DOACs may be preferred over warfarin due to decreased bleeding risks, including ICH, lack of need for international normalized ratio monitoring, no dietary restrictions, and limited drug-drug interactions. The choice between different antiplatelets and anticoagulants for prevention of ischemic stroke depends on the underlying stroke mechanism, cytochrome P450 2C19 polymorphisms, bleeding risk profile, compliance, drug tolerance, and drug resistance. Physicians must carefully weigh each patient's relative benefits and bleeding risks before initiating an antiplatelet/anticoagulant treatment regimen. Further studies are warranted to study the optimal duration of DAPT in symptomatic intracranial atherosclerosis since the benefit is most pronounced in the short term while the bleeding risk remains high during the extended duration of therapy.

Perbandingan Status Nutrisi Pasien Stroke Iskemik Pertama dan Ulang di RSUP Dr. Hasan Sadikin Bandung

Background and Objective: Stroke has various clinical manifestations that can cause low nutritional intake. Stroke patients can also experience recurrent stroke. This study aims to determine the comparison of nutritional status in patients with first and recurrent ischemic stroke based on Body Mass Index (BMI) and Subjective Global Assessment (SGA). Subject and Methods: This study is a comparative analysis of the medical records of patients with first and recurrent ischemic stroke at RSUP Dr. Hasan Sadikin Bandung period 2018−2019. The sample selection method was carried out by consecutive sampling with 118 patients for each group. Data analysis for nominal data was tested by Fisher’s exact test, for ordinal and numerical data tested by Mann Whitney test. Result: A total of 236 subjects in both groups of first and recurrent ischemic stroke patients consisting of 130 men and 106 women with an average age of 56,64±14,60 and 61,75±11,36 years, and the majority had risk factors for hypertension. Based on BMI, the majority of ischemic stroke patients were categorized as normal and obese in the first (33,05%) and obese in recurrent ischemic stroke (37,39%), p&gt;0,05. SGA B rating (64,41% in the first and 66,95% in the recurrent ischemic stroke), p&gt;0,05. Conclusion: There was no statistically significant difference in the nutritional status of first and recurrent ischemic stroke patients based on SGA and BMI, but the proportion of recurrent ischemic stroke patients had worse nutritional status. The majority of ischemic stroke patients are obese, in contrast to the SGA which shows that patients are mildly-moderately malnourished

Precision medicine as a predictive factor for risk of hospitalization of recurrent ischemic stroke patients treated with low dose aspirin. A pilot study

ABSTRACT Recurrent ischemic stroke risk after transient ischemic attack was underestimated by most of epidemiological studies due to the widespread use of very different and sometimes restrictive definitions for recurrent stroke instead of a standard definition, making it difficult to assess the benefit of early prevention of recurrence. Knowing that early intervention by treatment with aspirin reduced fatal recurrent stroke and proved to be cost effective by reducing hospital admission, it was worthwhile studying the pharmacogenetics association as well as biological risk factors of aspirin intolerance for patients with recurrent ischemic stroke. Accordingly, our primary outcome was to investigate the association of CYP2C9*3 (Rs1057910) polymorphism as well as other factors such as diabetes, hypertension and smoking with aspirin intolerance for these patients. The secondary outcome was to study the correlation between TNF-alpha as an inflammatory mediator and the prognosis of ischemic stroke for these patients. Our results showed that although smoking and heterozygous A/C of Rs1057910 still have a higher prevalence however statistically insignificant risk for ischemic stroke recurrence compared with other risk factors; OR1.69 and 1.9, 95%CI (0.471–1.695) and (0.321–11.257) respectively. Also, our results suggest that there is a borderline statistically significant correlation between recurrent stroke prognosis and TNF alpha (p = 0.043). Conclusion: This study failed to detect association of Rs1057910 variant of CYP2C9 gene with preventive aspirin for patients with ischemic stroke. However, a somehow significant association was detected between ischemic stroke prognosis and TNF- α as an inflammatory marker. Further research investigations on larger sample size population are encouraged.

Ophthalmic artery flow direction change predicts recurrence of ischemic stroke after carotid stenting: a longitudinal observational study

Background and purposeThe implantation of carotid artery stents prevents recurrent ischemic stroke in patients with carotid stenosis. This study aimed to investigate associations between change of ophthalmic artery flow (COAF) post carotid stenting and recurrent ischemic stroke, as well as the link toward the anterior and posterior circulations and patients’ prognosis after carotid stenting.MethodsThis retrospective, longitudinal cohort study recruited 87 left side carotid stenosed ischemic stroke patients undergoing left side carotid stenting between year of 2009 and 2013, and patients were followed up to 9 years after carotid procedures. Clinical data were derived from medical records. The primary outcome was stroke recurrence. Predictive factors were stenosis > 50% in one intracranial artery and ROAF. Kaplan–Meier and Cox regression analyses were used to identify risk factors associated with stroke recurrence.ResultsAmong 87 included patients undergone left side carotid stent treatment, 44 had stroke recurrence within 3 years after carotid stenting. The recurrence group had significantly greater proportions of COAF after stenting (p = 0.001), and middle cerebral artery (MCA) and basilar artery or vertebral artery (BA/VA) stenosis > 50% (all p < 0.001) than the no-recurrence group. Survival was significantly shorter in patients with COAF than in those without (p < 0.01). Regression analysis showed that COAF was associated with stroke recurrence (HR: 3.638, 95% CI 1.54–8.62, p = 0.003). The recurrence rate was highest in patients with bilateral MCA stenosis > 50% (100%), followed by left MCA stenosis > 50% plus BA/VA stenosis > 50% (83.33%) or COAF (82.14%). Patients with bilateral MCA stenosis < 50% had no recurrence within 3-year follow-up.ConclusionsPrognosis after carotid stenting is poorer for patients with MCA stenosis > 50%, BA/VA stenosis > 50% and/or COAF. Carotid duplex and magnetic resonance angiography provide definitive information for prognosis prediction.

Outcomes associated with antithrombotic strategies in heart failure with reduced ejection fraction and sinus rhythm following acute ischemic stroke.

Insufficient data exist regarding the benefit of long-term antiplatelet vs. anticoagulant therapy in the prevention of recurrent ischemic stroke in patients with ischemic stroke and heart failure with reduced ejection fraction (HFrEF). Therefore, this study aimed to compare longitudinal outcomes associated with antiplatelet vs. anticoagulant use in a cohort of patients with stroke and with an ejection fraction of ≤40%. We retrospectively analyzed single-center registry data (2015-2021) of patients with ischemic stroke, HFrEF, and sinus rhythm. Time to the primary outcome of recurrent ischemic stroke, major bleeding, or death was assessed using the adjusted Cox proportional hazards model and was compared between patients treated using anticoagulation (±antiplatelet) vs. antiplatelet therapy alone after propensity score matching using an intention-to-treat (ITT) approach, with adjustment for residual measurable confounders. Sensitivity analyses included the multivariable Cox proportional hazards model using ITT and as-treated approaches without propensity score matching. Of 2,974 screened patients, 217 were included in the secondary analyses, with 130 patients matched according to the propensity score for receiving anticoagulation treatment for the primary analysis, spanning 143 patient-years of follow-up. After propensity score matching, there was no significant association between anticoagulation and the primary outcome [hazard ratio (HR) 1.10, 95% confidence interval (CI): 0.56-2.17]. Non-White race (HR 2.26, 95% CI: 1.16-4.41) and the presence of intracranial occlusion (HR 2.86, 95% CI: 1.40-5.83) were independently associated with the primary outcome, while hypertension was inversely associated (HR 0.42, 95% CI: 0.21-0.84). There remained no significant association between anticoagulation and the primary outcome in sensitivity analyses. In HFrEF patients with an acute stroke, there was no difference in outcomes of antithrombotic strategies. While this study was limited by non-randomized treatment allocation, the results support future trials of stroke patients with HFrEF which may randomize patients to anticoagulation or antiplatelet.

Borderzone infarction and recurrent stroke in intracranial atherosclerosis

BackgroundIntracranial stenosis (ICAS) is a common cause of stroke worldwide and patients with symptomatic ICAS exhibit a high rate of recurrence, particularly in the early period after the initial event. In this study, we aimed to study the association between borderzone infarct and recurrent ischemic stroke in patients hospitalized with symptomatic ICAS. MethodsThis is a retrospective single center study that included patients hospitalized with acute ischemic stroke in the setting of intracranial stenosis (50% or more and an acute ischemic stroke in the territory supplied by the stenosed artery) over a 32-month period. We excluded patients who did not receive a brain MRI or did not have an infarct on brain imaging. The primary predictor is infarct pattern (any borderzone vs. no borderzone infarct) and the primary outcome was recurrent cerebrovascular events (RCVE) within 90 days. We used unadjusted, and age and sex adjusted logistic regression models to determine associations between infarct pattern and RCVE at 90-days. ResultsAmong 99 patients who met the inclusion criteria (4 tandem), the mean age was 70.1 ± 11.2 years and 41.4% were women; 43 had borderzone infarcts and 19 had RCVE. In adjusted binary logistic regression analysis, borderzone infarct was associated with increased risk of RCVE (adjusted OR 4.00 95% CI 1.33-11.99, p=0.013). The association between borderzone infarction and RCVE was not different among anterior circulation ICAD (adjusted HR 2.85 95% CI 0.64-12.76, p=0.172) vs. posterior circulation ICAD (adjusted HR 6.69 95% CI 1.06-42.11, p=0.043), p-value for interaction = 0.592. ConclusionIn real world post-SAMMPRIS medically treated patients with ICAD, the borderzone infarct pattern was associated with 90-day RCVE. Borderzone infarcts are likely a surrogate marker of impaired distal blood flow, highlighting the importance of targeting stroke mechanisms and developing alternative treatment strategies for high-risk cohorts.

Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios Are Associated with Recurrent Ischemic Stroke in Patients with Embolic Stroke of Undetermined Source.

Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios Are Associated with Recurrent Ischemic Stroke in Patients with Embolic Stroke of Undetermined Source.

Antithrombotic drugs in secondary stroke prevention: still some way to go

Patients who have ischaemic stroke or a transient ischaemic attack have a high risk of recurrent ischaemic stroke. This risk is highest in the first few days after the primary ischaemic event and then slowly decreases over time. Therefore, it is important to start secondary prevention as soon as possible, ideally oriented to the pathophysiology of cerebral ischaemia in the individual patient. Early antithrombotic therapy is particularly important. Several large randomised trials have found that aspirin significantly reduces the risk of recurrent ischaemic stroke in patients without overt atrial fibrillation, with the greatest benefit in the first few weeks after transient ischaemic attack or stroke.

Oral anticoagulant decreases stroke recurrence in patients with atrial fibrillation detected after stroke.

BackgroundAtrial fibrillation detected after stroke (AFDAS) has a lower risk of ischemic stroke recurrence than known atrial fibrillation (KAF). While the benefit of oral anticoagulants (OAC) for preventing ischemic stroke recurrence in KAF is well established, their role in patients with AFDAS is more controversial. This study aimed to evaluate the association between OAC use and the risk of recurrent ischemic stroke in patients with AFDAS in a real-world setting.MethodsThis nationwide retrospective cohort study was conducted using the Taiwan National Health Insurance Research Database. Patients hospitalized with a first-ever ischemic stroke and AFDAS confirmed within 30 days after hospitalization were assigned to OAC and non-OAC cohorts. Inverse probability of treatment weighting was applied to balance the baseline characteristics of the cohorts. The primary outcome was ischemic stroke recurrence. Secondary outcomes were intracranial hemorrhage (ICH), death, and the composite outcome of “ischemic stroke recurrence, ICH, or death.” Multivariate Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI).ResultsA total of 4,508 hospitalized patients with stroke and AFDAS were identified. Based on OAC use, 2,856 and 1,652 patients were assigned to the OAC and non-OAC groups, respectively. During the follow-up period (median duration, 2.76 years), the OAC cohort exhibited a lower risk of ischemic stroke recurrence (aHR, 0.84; 95% CI, 0.70–0.99), death (aHR, 0.65; 95% CI, 0.58–0.73), and composite outcome (aHR, 0.70; 95% CI, 0.63–0.78) than did the non-OAC cohort. The risk of ICH (aHR, 0.96; 95% CI, 0.62–1.50) was not significantly different between the two cohorts.ConclusionOAC use in patients with AFDAS was associated with reduced risk of ischemic stroke recurrence, without an increased risk of ICH. This supports current guidelines recommending OACs for secondary stroke prevention in patients with AF, regardless of the time of diagnosis.

Cross sectional descriptive study of clinical and radiological profile of patients presenting with recurrent ischemic stroke in a tertiary care centre of South India

Even with recent advances in the management of ischemic stroke, incidence of recurrence is quite frequent. Identification of risk factors is of prime importance especially during the first episode of ischemic stroke. Imaging in stroke has pivotal role to play in understanding the stroke and also the recurrence risk. Hence we present a study about clinical and radiological profile of recurrent ischemic stroke patients. The study was conducted for a period of five consecutive years with a sample size of 100 patients. It is a cross sectional descriptive study where in data was collected and analysed among various variables necessary. Patients with recurrent ischemic stroke were examined and investigated. Continuous variable is expressed as mean +SD or median (Range) if non- normally distributed. Categorical data is expressed in proportions. Recurrence of the ischemic stroke was commonly seen in the patients with uncontrolled blood pressure, hyperglycemia, dyslipidemia, ischemic heart disease and patients with large artery atherosclerosis. Incidence was higher among male patients, patients above 60 years of age and stroke involving MCA and ACA territories. Identification of the risk factors responsible for the recurrence at the first episode of ischemic stroke and appropriate management are of prime importance. Apart from clinical and biochemical parameters, considering the radiological parameters like extent of stenosis and appropriate dosing and choice of medication also is of utmost importance in preventing the recurrence of stroke.

COMPARISON OF COGNITIVE FUNCTION BETWEEN FIRST ISCHEMIC STROKE AND RECURRENT ISCHEMIC STROKE PATIENTS

Background: Cognitive impairment is a common condition that may affect up to 50% of stroke patients. Post stroke cognitive impairment is associated with reduced quality of life, which may increase the number of dependency. Recurrent stroke may happen in approximately 25% patients and they have higher rates of cognitive impairment. Objective: The aim of this study is to examine the comparison of cognitive function between first ischemic stroke and recurrent ischemic stroke patients in Hasan Sadikin Hospital, Bandung. Methods: This study is a retrospective, cross-sectional study using the data recruited between the year 2012 - 2016 at the Department of Neurology at the Hasan Sadikin Hospital Bandung. The data collected in this study were demographic data, including age, level of education, and residence, and the clinical data as well. Cognitive function was assessed using Mini-Mental State Examination (MMSE). The comparison between the cognitive function between both groups were analyzed using the Mann-Whitney U test. Results: There were 428 subjects eligible for this study, with 207 subjects categorized as first ischemic stroke group and 221 subjects categorized as recurrent ischemic stroke group. There was a statistically significant difference in MMSE scores between the first ischemic stroke patients (24.90 ± 4.64) and recurrent ischemic stroke patients (22.85 ± 4.64 ) with a p value of 0.002. Conclusion: Recurrent ischemic stroke patients had lower MMSE scores than the first ischemic stroke patients. Clinicians should be more aware in detecting early cognitive impairment in stroke patients and in preventing the incidence of recurrent stroke.

Clopidogrel Resistance in Patients With Stroke Recurrence Under Single or Dual Antiplatelet Treatment.

Background: The factors associated with clopidogrel resistance in patients with stroke recurrence receiving single or dual antiplatelet treatment (SAPT or DAPT) may differ. This study compared the high on-treatment platelet reactivities (HPRs) and the factors associated with clopidogrel resistance in recurrent ischemic stroke patients receiving clopidogrel or aspirin and clopidogrel.Methods: We enrolled and allocated 275 recurrent ischemic stroke patients to the clopidogrel and DAPT groups and compared their demographics, conventional risk factors, and P2Y12 reaction units (PRUs). Clopidogrel resistance was categorized as PRU higher than 275. We performed a multivariate logistic regression analysis to determine the factors underlying clopidogrel resistance during SAPT and DAPT.Results: In total, 145 (52.7%) and 130 (47.3%) patients received clopidogrel and DAPT, respectively at recurrence. The risk factors of the two groups were not significantly different, except that coronary artery disease was more frequent in the DAPT group. The PRU was higher (255 ± 91 vs. 221 ± 84; p = 0.002) and clopidogrel resistance was more frequent (45.5 vs. 31.5%; p = 0.018) in the SAPT than in the DAPT group. Hyperlipidemia was associated with clopidogrel resistance during SAPT, and smoking (Odds ratio = 0.426, 95% confidence interval 0.210–0.861; p = 0.018) had a protective effect against clopidogrel resistance. For those receiving DAPT, old age, female, low hemoglobin A1c level, and high ARU were associated with clopidogrel resistance.Conclusions: HPR and clopidogrel resistance were more frequent in recurrent ischemic stroke patients receiving clopidogrel than in those receiving DAPT. Smoking was independently associated with less clopidogrel resistance among those receiving clopidogrel SAPT but not in those receiving DAPT.

Cost-Effectiveness Analysis of Percutaneous Patent Foramen Ovale Closure Preventing Secondary Ischemic Stroke in Japan

ObjectivesPatent foramen ovale is a hemodynamically insignificant interatrial communication that may cause ischemic stroke. Percutaneous patent foramen ovale closure reduces the risk for recurrent ischemic stroke in patients with a history of cryptogenic ischemic stroke. This study evaluated the cost-effectiveness of patent foramen ovale closure against medical therapy in patients after their first cryptogenic ischemic stroke in Japan. Materials and methodsThe cost-effectiveness of patent foramen ovale closure compared with medical therapy was evaluated using the Markov model. The target patients started with patent foramen ovale closure or medical therapy for preventing secondary ischemic stroke under a stable state. Quality-adjusted life year was used as the outcome of effectiveness, and the analysis was conducted with a discount rate of 2% applied to both cost and effectiveness. The results of a multicenter open-label randomized controlled trial (RESPECT trial) evaluating patent foramen ovale closure using the Amplatzer™ PFO Occluder were used as clinical evidence. Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio. It was evaluated as cost-effective if it was lower than 5 million JPY/ quality-adjusted life year. ResultsPatent foramen ovale closure was dominant over medical therapy by 2.53 quality-adjusted life years and an estimated cost reduction of 2,353,926 JPY. The probability of patent foramen ovale closure being dominant was 82.9%. ConclusionsPatent foramen ovale closure was dominant over medical therapy for preventing secondary ischemic stroke in patients with cryptogenic ischemic stroke.

Association of Global Cardiac Calcification with Atrial Fibrillation and Recurrent Stroke in Patients with Embolic Stroke of Undetermined Source

Calcium deposits in the heart have been associated with cardiovascular events, mortality, stroke, and atrial fibrillation (AF). However, there is no accepted standard method for scoring cardiac calcifications. Existing methods have also not been validated for the assessment of patients with embolic stroke of undetermined source (ESUS). The aim of this study was to evaluate the association of various cardiac calcification scores with new-onset AF and stroke recurrence in a cohort of patients with ESUS. In this study, 181 consecutive patients with stroke diagnosed with ESUS were identified and evaluated. They were followed for new-onset AF and ischemic stroke recurrence for a median duration of 2.1years. Various echocardiographic cardiac calcification scores were assessed on transthoracic echocardiography performed during the evaluation of ESUS and subsequently assessed for their relation to AF detection and recurrent stroke. The echocardiographic calcium scores assessed were the (1) global cardiac calcium score (GCCS), (2) echocardiographic calcium score (eCS), (3) echocardiographic calcification score, (4) echocardiographic composite cardiac calcium score, and (5) total heart calcification score. Only two of these scoring schemes, GCCS and eCS, quantified the cardiac calcium burden. Higher calcium scores as measured by GCCS and eCS were found to be significantly associated with subsequent AF detection as well as recurrent ischemic stroke in patients with ESUS. The association with recurrent stroke remained significant even after adjustment for comorbidities and AF. Higher cardiac calcification measured using the GCCS and eCS is independently associated with AF detection and recurrent ischemic stroke in patients with ESUS, and these scores can be useful markers for further risk stratification in patients with ESUS.