Recurrent Ischemic Attacks Research Articles

Variations in Risk Factors across Different Periods of Stroke and Transient Ischemic Attack Recurrence.

Accurately discerning periods of heightened risk of stroke or transient ischemic attack (TIA) recurrence and managing modifiable risk factors are essential for minimizing overall recurrence risk. This study identified differences in the timing of stroke or TIA recurrence based on risk factors and patient characteristics to develop strategies for reducing recurrence in clinical practice. We retrospectively selected patients with ischemic stroke or TIA at the Korea University Ansan Hospital Stroke Center between March 2014 and December 2021 using the prospective institutional database of the Korea University Stroke Registry. We collected demographic, clinical data, and categorized participants by recurrence timing (early within or late after 3 months). Using multinomial logistic regression analysis, we examined variables associated with early and late recurrent stroke or TIAs. Among 3,646 patients, 255 experienced a recurrent stroke or TIA and 3,391 experienced their first stroke or TIA. Multinomial logistic regression analysis revealed significant associations between early recurrent stroke or TIA and diabetes mellitus (odds ratio [OR]: 1.98, 95% confidence interval [CI]: 1.25-3.15), other determined etiologies in the Trial of Org 10172 in the Acute Stroke Treatment classification (OR: 3.00, 95% CI: 1.37-6.61), and white matter changes (OR: 1.97, 95% CI: 1.17-3.33). Late recurrence showed a significant correlation with TIA (OR: 2.95, 95% CI: 1.52-5.71) and cerebral microbleeds (OR: 2.22, 95% CI: 1.32-3.75). Substantial differences in factors contribute to stroke or TIA recurrence based on timing. Managing the risk of recurrence in clinical practice necessitates accurate identification of heightened risk periods and rigorous control of modifiable risk factors.

OUTCOMES OF WARFARIN THERAPY FOR SECONDARY PREVENTION OF ISCHEMIC STROKE: A RETROSPECTIVE, FOLLOW-UP STUDY

Aim: Anticoagulant prophylaxis is recommended because cardioembolic ischemic stroke is associated with worse functional outcomes, increased recurrence rates, and higher mortality. This study aimed to investigate the rates of recurrent ischemic attacks and bleeding complications in patients receiving warfarin following ischemic stroke. Method: In this retrospective analysis, a total of 181 individuals who were initiated on warfarin therapy following an ischemic stroke were included in the study. These patients were subsequently monitored for a duration spanning from 1 month to as long as 16 years. The acute ischemic stroke diagnosis was established using the Trial of Org 10172 in Acute Stroke Treatment classification criteria. Patient follow-up periods, international normalized ratio (INR) levels, ischemic events, and bleeding were recorded and evaluated. Results: In the patient cohort, 97 (53.6%) were women and 84 (46.4%) were men. The recurrent ischemic stroke rate was 7.2%, major bleeding rate was 3.3%, and minor bleeding rate was 12.7%. While the average INR value during recurrent ischemic stroke was 1.69±0.31, the average INR value during bleeding complications was observed to be 3.15±1.38. The rate of minor bleeding was related to duration of warfarin use and non-valvular atrial fibrillation. Conclusion: Our results show that long-term warfarin use and non-valvular atrial fibrillation are risk factors for bleeding.

Novel Genetic Microvascular Dysplasia Causing Hypoperfusion of Cardiac, Renal, and Cerebral Circulation.

Microvascular disorders represent an uncommon site of tissue hypo-perfusion and damage. Various genetic and acquired causes can be involved. A 65-year-old man was admitted because of refractory angina, which he had had since the age of 30 years, micro-hematuria, and recurrent transitory ischemic attacks from the age of 64. Hematochemical studies, ECG, Holter monitoring, 2D-echo, cardiac magnetic resonance (CMR), CTA of cerebral vessels, endomyocardial coronary angiography, and kidney biopsy processes were undertaken. Gene mutation analysis was conducted using next-generation sequencing, which included more than 5000 genes associated with inherited diseases. Hematochemical findings were unremarkable. The ECG, Holter, 2D-echo, and CTA of brain vessels were normal. Cerebral magnetic resonance showed the presence of multiple small foci of ischemia. Coronary and ventricular angiography showed normal arteries with remarkably slow flow and multiple biventricular micro-aneurysms. At the endomyocardial biopsy, five of seven arterioles presented severe lumen obstruction due to hypertrophy and disarray of the muscular coat. Similarly, obstructed pre-glomerular arteries with glomerular sclerosis were seen at the renal biopsy. Genetics identified mutations in the ABCC6, MMP2, and XYLT1 genes, which play pivotal roles in the extracellular matrix. This study described a new genetic microvascular obstructive disease causing progressive hypo-perfusion of the human brain, heart, and kidney.

Ninety‐Day Stroke or Transient Ischemic Attack Recurrence in Patients Prescribed Anticoagulation in the Emergency Department With Atrial Fibrillation and a New Transient Ischemic Attack or Minor Stroke

Background For patients with atrial fibrillation seen in the emergency department (ED) following a transient ischemic attack (TIA) or minor stroke, the impact of initiating oral anticoagulation immediately rather than deferring the decision to outpatient follow-up is unknown. Methods and Results We conducted a planned secondary data analysis of a prospective cohort of 11 507 adults in 13 Canadian EDs between 2006 and 2018. Patients were eligible if they were aged 18 years or older, with a final diagnosis of TIA or minor stroke with previously documented or newly diagnosed atrial fibrillation. The primary outcome was subsequent stroke, recurrent TIA, or all-cause mortality within 90 days of the index TIA diagnosis. Secondary outcomes included stroke, recurrent TIA, or death and rates of major bleeding. Of 11 507 subjects with TIA/minor stroke, atrial fibrillation was identified in 11.2% (1286, mean age, 77.3 [SD 11.1] years, 52.4% male). Over half (699; 54.4%) were already taking anticoagulation, 89 (6.9%) were newly prescribed anticoagulation in the ED. By 90 days, 4.0% of the atrial fibrillation cohort had experienced a subsequent stroke, 6.5% subsequent TIA, and 2.6% died. Results of a multivariable logistic regression indicate no association between prescribed anticoagulation in the ED and these 90-day outcomes (composite odds ratio, 1.37 [95% CI, 0.74-2.52]). Major bleeding was found in 5 patients, none of whom were in the ED-initiated anticoagulation group. Conclusions Initiating oral anticoagulation in the ED following new TIA was not associated with lower recurrence rates of neurovascular events or all-cause mortality in patients with atrial fibrillation.

Sneddon Syndrome: Livedo Reticularis and Ischemic Stroke

Sneddon syndrome(SS) is a rare, progressive vasculopathy with recurrent ischemic attacks. There is no specified treatment recommendation, various treatment methods such as anticoagulants, antiaggregants, and immunosuppressions are recommended. A 44-years-old woman who applied with a temporary numbness on her right side and speech disorder. In her neurological examination, there was central facial asymmetry on the right and mild dysarthria in his speech. In cranial diffusion MR, there was an acute ischemic change in the left lentiform nucleus and at the head of the caudate nucleus. In cranial MR, there were perivascular ischemic gliotic changes and diffuse cerebral cortical atrophy. The patient underwent a skin biopsy to have livedo reticularis-like lesions on both legs. Skin biopsy was compatible with vasculopathy. Due to the ischemic attack, periventricular ischemic changes, and livedoreticularis, the patient was accepted as SS. Since the antiphospholipid antibodies (APL) were negative, that she was followed up with dual antiplatelet therapy. There was no new attack within a year with dual therapy. Dual antiplatelet therapy may be used in SS patients with recurrent ischemic events and negative APL.

The pericyte: A critical cell in the pathogenesis of CADASIL.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary small vessel disease presenting with migraine, mood and cognitive disorders, focal neurological deficits, recurrent ischemic attacks, lacunar infarcts and brain white matter changes. As they age, CADASIL patients invariably develop cognitive impairment and subcortical dementia. CADASIL is caused by missense mutations in the NOTCH3 gene resulting in a profound cerebral vasculopathy affecting primarily arterial vascular smooth muscle cells, which target the microcirculation and perfusion. Based on a thorough review of morphological lesions in arteries, veins, and capillaries in CADASIL, we surmise that arteriolar and capillary pericyte damage or deficiency appears a key feature in the pathogenesis of the disease. This may affect critical pericyte-endothelial interactions causing stroke injury and vasomotor disturbances. Changes in microvascular permeability due to perhaps localized blood-brain barrier alterations and pericyte secretory dysfunction likely contribute to delayed neuronal as well as glial cell death. Moreover, pericyte-mediated cerebral venous insufficiency may explain white matter lesions and the dilatation of Virchow-Robin perivascular spaces typical of CADASIL. The postulated central role of the pericyte offers some novel approaches to the study and treatment of CADASIL and enable elucidation of other forms of cerebral small vessel diseases and subcortical vascular dementia.

Clinical and Radiological Characteristics of Patients with Symptomatic Internal Carotid Artery Stenosis and Early and Late Outcomes of Carotid Artery Stenting

Background and Aim: Carotid artery stenting (CAS) is an alternative approach to carotid endarterectomy in cerebrovascular diseases. The applicability of this procedure has increased as a result of development of cerebral protection devices. In the trial, the clinical and radiological characteristics and early and late outcomes of patients who received CAS were investigated. Methods: The study had a retrospective design. The clinical and radiological characteristics and early and late outcomes after CAS of 76 patients (54 male, 22 female) who were admitted to a university hospital between 2008 and 2014 due to a diagnosis of internal carotid artery stenosis (ICA) were retrospectively reviewed. Results: All patients were symptomatic during their admissions, and after their workups were completed, ICA stenosis was determined. Unilateral (Right ICA 34.2%, left ICA 47.4%) stenosis in 62 patients and bilateral stenosis (18.4%) in 14 patients were determined. The mean degree of stenosis was 82.1 (SD:11.36, range: 60-99%). All patients were treated with stenting for ICA stenosis (technical success rate: 100%). No complications occurred during these procedures. During the one-year follow-up, no recurrent ischemic attack occurred in any patients. Carotid artery disease is highly associated with hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, a history of cerebrovascular accidents and transient ischemic attack. Conclusions: Carotid artery disease is a critical factor with co-morbidities and history of cerebrovascular incidents. The carotid artery stenting (CAS) procedure is a method that can be used safely because its serious complication rate is low in cases that are well-selected and have had risk analyses performed regarding medical treatments.

(Frequency of CYP2C19 Gene Polymorphisms (SNP) and its Impact on Clinical Outcome in Ischemic Heart Disease Patients Taking Clopidogrel after percutaneous coronary intervention (PCI

كلوبيدوجريل ، أحد مشتقات ثينوبيريدين عن طريق الفم قادر على تثبيط تنشيط الصفائح الدموية. Clopidogrel هو دواء أولي يتم تحويله إلى عقار نشط بواسطة السيتوكروم الكبدي CYP2C19 و CYP2C19 * 2 و CYP2C19 * 3 الأليلات متعددة الأشكال التي تعتبر من الأليلات متعددة الأشكال التي تؤدي إلى فقدان الوظيفة مما يؤدي إلى تقليل الاستجابة للكلوبيدوجريل. هدفت دراستنا إلى الكشف عن تواتر تعدد الجينات CYP2C19 وتأثيرها على النتائج السريرية في مرضى نقص تروية القلب الذين يتناولون عقار كلوبيدوجريل. الأم والطرق: تم جمع عينات الدم من 102 مريض بأمراض القلب الإقفارية وتم تحديد الأليلات التكرارية بواسطة تفاعل البوليميراز المتسلسل وتبع جميع المرضى التقييم السريري والفحوصات القلبية الغازية وغير الغازية. كان تردد CYP2C19 * 1 49٪ ، CYP2C19 * 2 كان 15٪ و CYP2C19 * 3 كان 1٪ ، CYP2C19 * 17 كان 34٪ ، المرضى الذين يعانون من نوبات إقفارية متكررة 37 مريضًا (35.8٪) ، من هؤلاء المرضى ، كان 10 مرضى مستقلب طبيعي (27٪) ، و 27 مريضاً كانوا مستقلبات غير طبيعية (73٪) بقيمة p- 0.047 لاحتشاء عضلة القلب و 0.020 للذبحة الصدرية غير المستقرة. خاتمة:. تم العثور على علاقة لا معنوية بين CYP2C19 تعدد الأشكال والنوبات الإقفارية المتكررة في هذه الدراسة ودراسات متعددة المراكز مطلوبة لتأكيد هذه النتائج.

Direct Oral Anticoagulants in Addition to Antiplatelet Therapy for Secondary Prevention after Acute Coronary Syndromes: a Review.

As the management of acute coronary syndrome (ACS) continues to evolve, many old practices proved to be of a little benefit and other approaches established the new pillars of modern medicine. Treating ACS patients with dual antiplatelet therapy (DAPT) for a year by combining aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) has resulted in better outcomes and is currently the standard of therapy. However, owing to the persistent activation of the coagulation cascade, patients may continue to experience recurrent ischemia and high mortality rates despite compliance with the dual antiplatelet therapy. Research is underway to establish new treatment modalities for secondary prevention post-ACS, including the use of the novel direct oral anticoagulants (DOACs). Multiple trials have been conducted to evaluate the use of DOACs for the secondary prevention after ACS. Recent emerging data showed that the addition of rivaroxaban in a very low dose of 2.5mg twice daily to the regular DAPT regimen after ACS is beneficial in the reduction of major cardiovascular events, including recurrent myocardial infarction (MI) and strokes. On the other hand, other DOACs, including apixaban, did not show similar efficacy and did not improve the cardiovascular outcomes. Patients who experience an ACS continue to suffer long-term consequences and thromboembolic complications. Many studies have shown that after the initial ACS event, patients remain in a hypercoagulable state and are more prone to recurrent ischemic attacks including stroke, recurrent MI, or unstable angina (UA). With the objective of seeking better outcomes, it is imperative to explore more aggressive anticoagulation strategies in ACS patients. In this article, we discuss the progress that was made and the limitations we face regarding the role of different anticoagulants in this setting.

National Institutes of Health Stroke Scale Zero Strokes.

Background and Purpose- We aimed to characterize acute ischemic stroke patients who have an immeasurable deficit on the admission National Institutes of Health Stroke Scale (NIHSS), and to evaluate their long-term outcome. Methods- We retrospectively compared all acute ischemic stroke patients with an admission NIHSS of 0 in the Acute Stroke Registry and Analysis of Lausanne from 2003 to 2013 with all other acute ischemic stroke patients. We compared demographics, clinical, radiological, and laboratory findings. Outcome was considered favorable at 3 months if the modified Rankin Scale score corrected for prestroke disability was ≤1. Stroke recurrences >12 months were also assessed. Results- Comparing 108 NIHSS zero (NIHSS=0) patients with the 2889 other strokes by multivariate analysis, NIHSS=0 had lower prestroke disability, longer onset-to-hospital delays and more lacunar and infratentorial strokes. NIHSS=0 patients were less likely to have early ischemic changes on acute computed tomography, had less arterial pathology and lower creatinine levels. They were more likely to have favorable modified Rankin Scale score after correction for prestroke modified Rankin Scale score (zero versus others: 83.2% versus 44.6%) and less likely to die (3.9% versus 13.3%) at 12 months. Stroke and transient ischemic attack recurrence rates were similar (11% versus 11.4%), however. Conclusions- Patients with NIHSS=0 strokes are characterized by lacunar and infrantentorial strokes, normal acute computed tomography, and less arterial pathology. However, a significant proportion face recurrent ischemic events and persistent handicap at 12 months. Therefore, NIHSS=0 stroke patients require aggressive secondary prevention and adequate follow-up.

Deficiency of adenosine deaminase 2; special focus on central nervous system imaging

PurposeTo increase the knowledge of central nervous system (CNS) imaging features in deficiency of adenosine deaminase 2 (DADA2) by examining magnetic resonance imaging (MRI) studies of a relatively large number of patients. MethodsWe retrospectively examined neuroimages of 12 patients (7 male, 5 female) diagnosed with DADA2. The mean age of the patients at the time of initial brain MRI was 16.7±10.2 years. Seven patients (58.3%) fulfilled the classification criteria of polyarteritis nodosa. Brain MRI studies were assessed with respect to findings of ischemia, intracranial hemorrhages, focal parenchymal signal abnormalities, cerebral/cerebellar volume loss, and abnormal contrast enhancement. Angiographic studies of 7 patients were evaluated for the signs of vasculitis. ResultsThe most frequent finding was acute and/or chronic lacunar ischemic lesions in the brainstem and/or deep gray matter (n=9, 75%). Six patients (50%) revealed MRI findings compatible with recurrent ischemic attacks. Small nodular contrast enhancement (n=2, 16.6%), acute putaminal hemorrhage (n=1, 8.3%) and findings compatible with posterior reversible encephalopathy syndrome (n=1, 8.3%) were also detected. Slight-to-moderate diffuse cerebral and/or cerebellar volume loss (n=7, 58.3%), decreased T1 signal of the bone marrow (n=6, 50%) and optic atrophy (n=1, 8.3%) were the other findings on brain MRI. The only abnormal angiographic finding was reduced caliber of the right distal posterior cerebral artery in MRA of a patient (14.6%). ConclusionDADA2 should be included in the differential diagnosis of young patients presenting with ischemic and/or hemorrhagic lesions located in the brainstem and deep gray matter, especially if they have a family history or additional systemic abnormalities.

THE CHARACTERISTICS OF MORBIDITY OF PATIENTS SURVIVED A TRANSITORY ISCHEMIC ATTACK

The actuality. The transitory ischemic attacks very often are considered as precursors of the stroke. The individual prognosis of risk of development of stroke after transitory ischemic attacks is unequal and is determined by differences in causes and risk factors of patients. The important place in establishing individual approach to treatment of patients with transitory ischemic attacks belongs to analysis of corresponding concomitant pathology. The analysis of morbidity is conditioned by necessity of differentiated analysis of characteristics of morbidity for development of personalized approach to treatment and restoration of health of this category of patients. The purpose of study is to investigate and analyze characteristics of morbidity of patients survived transitory ischemic attacks. Material and methods. The analysis was applied to morbidity of 351 patients survived transitory ischemic attacks, including 227 females (average age 59,6 ± 3,6 years) and 124 males (average age 57,6 ± 2,2 years). Results and discussion. It is demonstrated that level of morbidity increases with age from 233,9 до 605,9 cases of diseases per 100 examined. The analysis of rank distribution of diseases according classes of diseases demonstrated that teh first place belongs to diseases of blood circulation system (32.6%), the second place - to mental disorders (31.5%) and the third place - to diseases of endocrine system (15.5%). The positive correlation is established between availability of teo and more diseases of blood circulation system and development of recurrent transitory ischemic attacks (r = 0,688, p < 0,05). Conclusion. The availability of combined pathology in patients with transitory ischemic attacks dictates necessity of its registration at complex evaluation of health state of the given category of patients and development of multi-disciplinary approach to diagnostic and treatment of patients.

Why does my patient\u2019s basilar artery continue to grow? A four-year case study of a patient with symptoms of vertebrobasilar dolichoectasia

BackgroundVertebrobasilar dolichoectasia (VBD) is a clinical entity associated with ischemic stroke, compression of cranial nerves or brainstem, and hydrocephalus. There have been relatively few studies following the progression of VBD in patients presenting with a variety of diverse clinical features.Case presentationHere, we report a case study of a male with progressive VBD who was followed from November 2012 to December 2016. The patient had diagnosed hypertension for several years and suffered from left peripheral facial paralysis, recurrent ischemic attacks in the brainstem and cerebellum, obstructive hydrocephalus and frequent pneumonia. A series of cranial CT and multi-modal MRI scans were performed to explore the brain imaging features of the patient during follow-up.ConclusionsThe presented case study suggests that aging, uncontrolled hypertension, arterial dissection and infection may contribute to the exacerbation of VBD and recurrent ischemic stroke.

Novel α-Actin Gene Mutation p.(Ala21Val) Causing Familial Hypertrophic Cardiomyopathy, Myocardial Noncompaction, and Transmural Crypts. Clinical-Pathologic Correlation.

BackgroundMutations of α‐actin gene (ACTC1) have been phenotypically related to various cardiac anomalies, including hypertrophic cardiomyopathy and dilated cardiomyopathy and left ventricular (LV) myocardial noncompaction. A novel ACTC mutation is reported as cosegregating for familial hypertrophic cardiomyopathy and LV myocardial noncompaction with transmural crypts.Methods and ResultsIn an Italian family of 7 subjects, 4 aged 10 (II‐1), 14 (II‐2), 43 (I‐4) and 46 years (I‐5), presenting abnormal ECG changes, dyspnea and palpitation (II‐2, I‐4, and I‐5), and recurrent cerebral ischemic attack (I‐5), underwent 2‐dimensional echo, cardiac magnetic resonance, Holter monitoring, and next‐generation sequencing gene analysis. Patients II‐2 and I‐5 with ventricular tachycardia underwent a cardiac invasive study, including coronary with LV angiography and endomyocardial biopsy. In all the affected members, ECG showed right bundle branch block and left anterior hemiblock with age‐related prolongation of QRS duration. Two‐dimensional echo and cardiac magnetic resonance documented LV myocardial noncompaction in all and in I‐4, I‐5, and II‐2 a progressive LV hypertrophy up to 22‐mm maximal wall thickness. Coronary arteries were normal. LV angiography showed transmural crypts progressing to spongeous myocardial transformation with LV dilatation and dysfunction in the oldest subject. At histology and electron microscopy detachment of myocardiocytes were associated with cell and myofibrillar disarray and degradation of intercalated discs causing disanchorage of myofilaments to cell membrane. Next‐generation sequencing showed in affected members an unreported p.(Ala21Val) mutation of ACTC.ConclusionsNovel p.(Ala21Val) mutation of ACTC1 causes myofibrillar and intercalated disc alteration leading to familial hypertrophic cardiomyopathy and LV myocardial noncompaction with transmural crypts.

Fluctuating Position-Related Cognitive Disturbances and Recurrent Cerebral Ischemic Attacks as Presenting Symptoms in a Patient with Platypnea-Orthodeoxia Syndrome

Platypnea-orthodeoxia syndrome is a condition of dyspnea and hypoxia whilst in the upright position, which improves in the recumbent position. We present a case of platypnea-orthodeoxia due to a fenestrated atrial septal aneurysm that induced recurrent strokes and a recent condition of fluctuating confusion and cognitive impairment, modified by position, associated with rapid variations of O2 saturation position related. The suspect of platypnea-orthodeoxia syndrome may be hypothesized in case of patients with recurrent cerebral ischemia and fluctuating cognitive disturbances induced by change of position. In those cases a careful echocardiographic evaluation and O2 saturation determination in up and downright position are required.

Unruptured Vertebral Artery Dissecting Aneurysms: Approach Strategy by Retrospective Analysis

Objectives: The natural course of un-ruptured vertebral artery dissecting aneurysms (VADAs) is not completely clear. We aim to retrospectively develop a strategy for treating un-ruptured VADAs based on long-term follow-up. Methods: We retrospectively studied 35 patients with un-ruptured VADAs. The initial symptom of 20 patients was headache, followed by ischemic symptoms and mass effect in 11 and 4 patients respectively. All of the patients underwent Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) at the time of admission and 2 weeks and 1, 4, 6, 12, and 24 months after initial presentation. Asymptomatic patients with enlarging dissection site defined on MRI and MRA, received further treatment and work up. Results: Two patients received emergency intervention due to symptom exacerbation and unstable status. The other 33 patients underwent conservative management. Lesion enlargement was observed in 2 cases during imaging follow up. In follow up period, additional interventions including dissection trap by surgery and coil embolization were conducted in 1 and 3 patients respectively. Other 31 patients remain symptom free and were managed conservatively. Dissection site remained unchanged in majority of patients (68.57%), improved in 28.57% and disappeared in 2.85% of the patients. Ten patients with recurrent ischemic attacks underwent anti-platelet therapy, without any bleeding complaint or permanent neurological deficits. Conclusion: The nature of an un-ruptured VADA is not highly aggressive. However, enlarged dissection site without new manifestations, occlusion is recommended. Also, anti-platelet therapy is suggested in patients with recurrent ischemic attacks.

PHARMACOGENETIC VARIATIONS RELATED TO CLOPIDOGREL RESISTANCE AND ITS CLINICAL IMPLICATIONS: AN ISSUE WHICH REMAINS LARGELY UNADDRESSED

ABSTRACTObjectives: Antiplatelet therapy with either clopidogrel alone or in combination with aspirin is the mainstay prophylactic drug therapy followingpercutaneous coronary intervention and long-term prevention of cardiovascular and cerebrovascular events. Non-responders/semi-responders toclopidogrel are reported to have increased incidences of adverse outcomes like recurrent ischemic attacks. Variability in response to clopidogrel ismore common among Asians, and it is as high as 70% in some of the Asian communities. Researchers attribute inter-individual variations in responseto clopidogrel to various pharmacogenetic determinants. Polymorphisms of multidrug resistance protein 1, CYP2C19 and its alleles, P2Yadenosine diphosphate (ADP) receptor are concluded to be specific to clopidogrel resistance in Indian population.Methods: A thorough literature search was done use different keywords such as clopidogrel resistance, pharmacogenomics, pharmacogeneticvariability, and ethnic variability from database sources such as Google Scholar, Medline, PubMed Central, and Scopus.Results and Conclusion: Literature revealed a disparity between various pharmacogenetic determinants of clopidogrel resistance, particularly inthe Asian population. Few studies suggest that there is no significant association between clopidogrel response variability and ADP receptor P2Yand P2Y gene polymorphisms. Variation in the cytochrome P450 2C19 (CYP2C19) gene coding for the CYP2C19 enzyme, involved in metabolismand conversion of the clopidogrel to active metabolites is considered one of the major determinants of clopidogrel resistance in some populations.Pooled data from various studies suggest that variability in clopidogrel response cannot be attributed to a single gene polymorphism and is thoughtto be multifactorial. However, disparity in the data related to the specific gene polymorphisms responsible for the encountered clopidogrel resistancenecessitates the further evaluation of genome.12Keywords: Clopidogrel, Clopidogrel resistance, Single gene polymorphisms, Inter-individual variability.1, and P2Y121

Predictors of hospital readmission 1year after ischemic stroke.

Predictors of short-term readmission after ischemic stroke have been previously identified, but few studies analyzed predictors of long-term readmission, namely early imaging findings and treatment with intravenous thrombolysis (IVT). To characterize predictors of hospital readmission during the first year after hospitalization for ischemic stroke. The study consists of a retrospective cohort of consecutive ischemic stroke patients admitted in a Portuguese university hospital during 2013, who survived index hospitalization. We collected clinical and imaging information using the electronical clinical record. Information concerning 1-year unplanned hospital readmissions was assessed using the Portuguese electronic Health Data Platform. Descriptive and univariate analyses, Kaplan-Meier survival curve and multivariate survival analysis with Cox regression model were used. We included 480 patients, 50.6% women, median age 79years (interquartile range=68-85). One-year hospital readmissions occurred in 165 patients [34.4%, 95% confidence interval (95% CI) 30.2-38.7]. The main causes for readmission were infectious diseases (43.8%), ischemic stroke or transient ischemic attack recurrence (13.2%) and cardiac diseases (6.4%). In-hospital mortality associated with readmission was 23.0%. The independent predictors of 1-year hospital readmission after ischemic stroke were admission mini-National Institute of Health Stoke Scale [hazards ratio (HR) 1.05, 95% CI 1.02-1.08, p=0.002], and mild or absent early signs of ischemia on admission computed tomography (CT) (HR 0.54, 95% CI 0.32-0.91, p=0.021) and IVT (HR 0.11, 95% CI 0.01-0.80, p=0.029). Hospital readmission during the first year after ischemic stroke occurs in 1/3 of patients and is associated with high in-hospital mortality. Clinical stroke severity, early signs of ischemia on admission CT, and treatment with IVT are independent predictors of 1-year hospital readmission.

Clinical and pathophysiologic features of cerebral hypertensive crisis

Aim. To specify clinical and pathophysiologic features and prognostic significance of cerebral hypertensive crisis.Methods. The study involved 44 patients with cerebral hypertensive crisis, 53 people with coronary artery disease and 14 healthy volunteers. All patients underwent complete blood count and biochemical blood tests, vegetative status determination using questionnaire survey and recording heart rate variability parameters. In patients with cerebral hypertensive crisis systemic inflammation parameters (concentration of interleukin-6 and -8, C-reactive protein in the blood plasma) were determined. Catamnesis was specified by telephone interview.Results. In cerebral hypertensive crisis, in contrast to coronary artery disease, the parasympathetic autonomic nervous system tone decreases, which is combined with inflammatory changes in the blood (increase in segmented leukocytes number and erythrocyte sedimentation rate), and an increase in the level of systemic inflammation markers: interleukin-6 and C-reactive protein. Vegetative regulation changes closely correlated with the inflammation level and the latter correlated with the clinical symptoms severity and determined poor prognosis in terms of recurrent transient episode. 90-day risk of ischemic stroke after cerebral hypertensive crisis was 2.3%.Conclusion. In patients with cerebral hypertensive crisis the autonomic nervous system parasympathetic tone reduction combined with increased levels of inflammation markers in blood were revealed; adverse prognostic significance for recurrent ischemic attacks occurrence were leukocytes rate increase, band shift in leukocyte blood count, serum total calcium concentration reduction and blood plasma total protein level decrease.

Effects of Surgery and Antiplatelet Therapy in Ten-Year Follow-Up from the Registry Study of Research Committee on Moyamoya Disease in Japan

Despite the common practice of surgery and antiplatelet therapy for the prevention of recurrent stroke in patients with moyamoya disease, the benefit of these treatments is controversial. We analyzed the stroke recurrence rate in the Registry Study of Research Committee on Moyamoya Disease in Japan funded by the Health, Labor and Welfare Ministry of Japan. An annual follow-up study of the registered cases was continued for 10 years. The rate of recurrent stroke, including cerebral infarction and hemorrhage but not transient ischemic attack and seizure, was evaluated with Kaplan-Meier analysis. The proportion of childhood-onset cases decreased in recently registered cases (within 10 years, n = 541) compared to remote cases (> 10 years, n = 735). Among types at disease onset in adult-onset cases, intracerebral hemorrhage decreased recently. In recent cases, the rate of subsequent cerebral hemorrhage was much higher in the hemorrhagic group (10.9 ± 3.3%/5 years) than in the ischemic group (2.0 ± .9%/5 years). The recurrence rate of cerebral infarction was lower in the surgery group (1.8 ± .9%/5 years) than in the nonsurgery group (3.8 ± 2.2%/5 years). In the adult-onset ischemic group, the proportion of surgically treated patients increased and their recurrence rate was lower than that of nonsurgery patients. In the ischemic group, the rate of cerebral infarction was not significantly different between the antiplatelet subgroup and the non-antiplatelet subgroup, whereas the rate of cerebral hemorrhage was higher in the non-antiplatelet subgroup than in the antiplatelet subgroup. Our results suggest revascularization surgery may suppress recurrent ischemic attacks in patients with moyamoya disease.