Reduction In Stroke Recurrence Research Articles

Abstract TP136: STRACK: A Continuum of Stroke Care, Improving Post-Stroke and Cardiometabolic Patient Outcomes

Background: The STRACK project aims to improve post-stroke patient management and the transition from acute to primary care thanks to improvements in patient pathways and monitoring cardiovascular risk factors: heart failure, diabetes, atrial fibrillation, dyslipidemia and hypertension. Collaboration between primary care centers and hospital staff was essential for the project’s success by delivering personalized care and home monitoring devices to patients through access to a digital platform. STRACK was launched with a european value-based contracting process and Roche Diag. as partner. Methods: The three-year project was launched in May 2021, during first year all specialties and professionals participated in the development and planning of the project and were trained in the use of the devices and own digital platform. First STRACK patient was enrolled in May 2022. Once these post-stroke patients have been identified, they are given a personalized monitoring plan depending on the individuals’ risk factors, the personalized care and rehabilitation plans are tracked and followed. For a year post-discharge, a nursing and administrative team follows the data that the patient enters remotely or is automatically available on their mobile application. Results: STRACK has evolved the continuum of care by 421patient in July 2024 and ongoing, by integrating comprehensive monitoring of cardiometabolic risk factors (heart failure, diabetes, atrial fibrillation, dyslipidemia, hypertension) into a patient discharge plan, identified as key to avoiding stroke recurrence and improving control of vascular risk factors are monitored. Preliminary results of 231 patients (May 2022-2023) with full one year follow-up comparing with historical cohort (May 2018-2019) showed: Reduction in unnecessary visits (weighted): -26,3%. Reduction in admissions for stroke recurrence or related to stroke, (heart attack, angina, peripheral embolism, etc.): Stroke, 30days: -100%; Related to stroke, (365d: -47,7%; 30d: -57,0%). Reduction in cardiovascular admissions ( 30d: -100%; 365d: -31,4%). Best treatment adherence: 81,2% (72% previously) Conclusion: The great value of STRACK is knowing the evolution of stroke patients post-discharge through strict self-monitoring of clinical parameters, following prior health education. STRACK has managed to achieve reduction in stroke recurrence and adverse events and readmissions for cardiovascular risk factors, reducing emergency visits for vascular events.

Embolic Stroke of Undetermined Source: New Data and New Controversies on Cardiac Monitoring and Anticoagulation.

Embolic strokes of undetermined source (ESUS) represent 9%-25% of all ischemic strokes. Based on the suspicion that a large proportion of cardioembolic sources remain undetected among embolic stroke of undetermined source patients, it has been hypothesized that a universal approach of anticoagulation would be better than aspirin for preventing recurrent strokes. However, 4 randomized controlled trials (RCTs), with different degrees of patient selection, failed to confirm this hypothesis. In parallel, several RCTs consistently demonstrated that prolonged cardiac monitoring increased atrial fibrillation detection and anticoagulation initiation compared with usual care in patients with ESUS, and later in individuals with ischemic stroke of known cause (e.g., large or small vessel disease). However, none of these trials or subsequent meta-analyses of all available RCTs have shown a reduction in stroke recurrence associated with the use of prolonged cardiac monitoring. In this article, we review the clinical and research implications of recent RCTs of antithrombotic therapy in patients with ESUS and in high-risk populations with and without stroke, with device-detected asymptomatic atrial fibrillation.

Secondary Prevention via Case Managers in Stroke Patients: A Cost-Effectiveness Analysis of Claims Data from German Statutory Health Insurance Providers.

Strokes remain a leading cause of death and disability worldwide. The STROKE OWL study evaluated a novel case management approach for patients with stroke (modified Rankin Scale 0-4) or transient ischemic attack (TIA) who received support across healthcare settings and secondary prevention training from case managers for one year. The primary aim of this quasi-experimental study was a reduction in stroke recurrence. Here, we report the results of a health economic analysis of the STROKE OWL study, conducted in accordance with CHEERS guidelines. The calculations were based on claims data of cooperating statutory health insurance companies. In addition to a regression analysis for cost comparison, the incremental cost-effectiveness ratio was determined, and a probabilistic sensitivity analysis was carried out. In total, 1167 patients per group were included in the analysis. The intervention group incurred 32.3% higher direct costs (p < 0.001) than the control group. With a difference of EUR 1384.78 (95% CI: [1.2384-1.4143], p < 0.0001) and a 5.32% increase in hazards for the intervention group (HR = 1.0532, 95% CI: [0.7869-1.4096], p = 0.7274) resulting in an ICER of EUR 260.30, we found that the case management intervention dominated in the total stroke population, even for an arbitrarily high willingness to pay. In the TIA subgroup, however, the intervention was cost-effective even for a low willingness to pay. Our results are limited by small samples for both TIA and severe stroke patients and by claims data heterogeneity for some cost components, which had to be excluded from the analysis. Future research should investigate the cost-effectiveness of case management interventions for both severe stroke and TIA populations using appropriate data.

Abstract 136: Antiplatelet Regimens for Secondary Prevention in Minor Ischemic Stroke or TIA: A Network Meta‐Analysis

Introduction There is increased risk of major cardiovascular events among patients with minor ischemic stroke or transient ischemic attack (TIA) [1]. Antiplatelet drugs have been proven to reduce the risk of major cardiovascular events and highly recommended for secondary stroke prevention in this population [2]. However, using antiplatelets has shown an increase in the risk of bleeding events. Hence there are multiple antiplatelet regimens, we aim to investigate the efficacy and safety of these different regimens in minor ischemic stroke defined as National Institutes of Health Stroke Scale (NIHSS) score of 5 or less and high‐ risk TIA). Methods A comprehensive literature search of (PubMed, Cochrane, Scopus, and WOS) was conducted to identify randomized controlled trials comparing different antiplatelet regimens in patients with minor ischemic stroke or TIA. Frequentist NMA was conducted to estimate relative risks (RR) and 95% confidence intervals (CI) for the outcomes of interest using R statistical programming language [3]. The primary outcome measure was recurrent stroke while secondary outcomes included, any bleeding events, serious adverse events (SAEs), hemorrhagic stroke, myocardial infarction (MI), cardiovascular mortality, and all‐cause mortality. Results Five RCTs with 34,941 participants were included. Compared to SAPT (aspirin alone), both DAPT regimens (aspirin + clopidogrel and aspirin + ticagrelor) demonstrated a significant reduction in stroke recurrence (RR: 0.72 with 95% CI [0.63, 0.82], P &lt; 0.01) and (RR: 0.75 with 95% CI [0.64, 0.87], P &lt; 0.01), respectively. However, both DAPT regimens were associated with a higher risk of bleeding events (RR: 1.95 with 95% CI [1.09, 3.50], P = 0.02), (RR: 3.07 with 95% CI [1.16, 8.15], P = 0.02), respectively. In contrast, no significant differences were observed among various antiplatelet modalities regarding all‐cause mortality, cardiovascular mortality, hemorrhagic stroke, myocardial infarction, and serious adverse events. In contrast, no significant differences were observed among various antiplatelet modalities regarding all‐cause mortality, cardiovascular mortality, hemorrhagic stroke, myocardial infarction, and serious adverse events. Conclusion Our findings indicate that DAPT regimens were effective in reducing stroke recurrence compared to SAPT. However, caution is warranted as both DAPT regimens were associated with a higher risk of bleeding events. Clinicians should weigh the potential benefits of reduced stroke recurrence with DAPT against the increased risk of bleeding events. Further research and clinical trials assessing both safety and efficacy are warranted to better understand the optimal prevention approach for this specific patient population.

The 'dreaded PFO': anatomical and functional features of high risk for stroke.

Patent foramen ovale (PFO) has a high prevalence in general population and can be implicated in cryptogenic stroke among young people. Recent trials have shown that transcatheter PFO closure is superior to medical treatment in the secondary prevention of ischaemic stroke. The benefit in the reduction of stroke recurrence is particularly evident in patients who have documentation of a PFO with high-risk characteristics. Therefore, after the assessment of a clear causal relationship with the event, a thoughtful documentation of anatomic (height, length, presence of an aneurysmatic or a floppy atrial septum, a prominent Eustachian valve or Chiari’s network, an acute angle with the inferior vena cava) and functional high-risk characteristics is mandatory.

Cilostazol for Secondary Stroke Prevention: History, Evidence, Limitations, and Possibilities.

Cilostazol is a PDE3 (phosphodiesterase III) inhibitor with a long track record of safety that is Food and Drug Administration and European Medicines Agency approved for the treatment of claudication in patients with peripheral arterial disease. In addition, cilostazol has been approved for secondary stroke prevention in several Asian countries based on trials that have demonstrated a reduction in stroke recurrence among patients with noncardioembolic stroke. The onset of benefit appears after 60 to 90 days of treatment, which is consistent with cilostazol's pleiotropic effects on platelet aggregation, vascular remodeling, blood flow, and plasma lipids. Cilostazol appears safe and does not increase the risk of major bleeding when given alone or in combination with aspirin or clopidogrel. Adverse effects such as headache, gastrointestinal symptoms, and palpitations, however, contributed to a 6% increase in drug discontinuation among patients randomized to cilostazol in a large secondary stroke prevention trial (CSPS.com [Cilostazol Stroke Prevention Study for Antiplatelet Combination]). Due to limitations of prior trials, such as open-label design, premature trial termination, large loss to follow-up, lack of functional or cognitive outcome data, and exclusive enrollment in Asia, the existing trials have not led to a change in clinical practice or guidelines in Western countries. These limitations could be addressed by a double-blind placebo-controlled randomized trial conducted in a broader population. If positive, it would increase the evidence in support of long-term treatment with cilostazol for secondary prevention in the millions of patients worldwide who have experienced a noncardioembolic ischemic stroke.

PFO, push-ups and heavy lifting; valsalva provocation before cryptogenic stroke

Background: Patent Foramen Ovale (PFO) can serve as a conduit for paradoxical embolus or as a nidus itself for thrombus formation in Cryptogenic Stroke (CS). Debate for PFO closure is ongoing but favors closure in well-selected patients. Four randomized-control trials demonstrated a reduction in stroke recurrence with PFO closure. Patients were selected with high-risk PFO features in DEFENSE-PFO and CLOSE trials. Cases: This case series describes four patients with CS immediately following or during exercise- induced-Valsalva: Push-ups, bench pressing, and lifting heavy boxes. PFOs with severe shunting during Valsalva were demonstrated with bubble echocardiograms in all cases. Conclusion: Recent clinical trials have shown benefit of percutaneous PFO closure, especially in younger patients with high-risk PFO features. Valsalva-like straining may provide the hemodynamic terminal-step for embolism to occur in CS patients with PFO. Future PFO-closure screening tools should consider Valsalva-like straining as a criterion towards closure.

Multiple versus fewer antiplatelet agents for preventing early recurrence after ischaemic stroke or transient ischaemic attack.

Stroke is a leading cause of morbidity and mortality worldwide. Antiplatelet agents are considered to be the cornerstone for secondary prevention of stroke, but the role of using multiple antiplatelet agents early after stroke or transient ischaemic attack (TIA) to improve outcomes has not been established. To determine the effectiveness and safety of initiating, within 72 hours after an ischaemic stroke or TIA, multiple antiplatelet agents versus fewer antiplatelet agents to prevent stroke recurrence. The analysis explores the evidence for different drug combinations. We searched the Cochrane Stroke Group Trials Register (last searched 6 July 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 7 of 12, 2020) (last searched 6 July 2020), MEDLINE Ovid (from 1946 to 6 July 2020), Embase (1980 to 6 July 2020), ClinicalTrials.gov, and the WHO ICTRP. We also searched the reference lists of identified studies and reviews and used the Science Citation Index Cited Reference search for forward tracking of included studies. We selected all randomised controlled trials (RCTs) that compared the use of multiple versus fewer antiplatelet agents initiated within 72 hours after stroke or TIA. We extracted data from eligible studies for the primary outcomes of stroke recurrence and vascular death, and secondary outcomes of myocardial infarction; composite outcome of stroke, myocardial infarction, and vascular death; intracranial haemorrhage; extracranial haemorrhage; ischaemic stroke; death from all causes; and haemorrhagic stroke. We computed an estimate of treatment effect and performed a test for heterogeneity between trials. We analysed data on an intention-to-treat basis and assessed bias for all studies. We rated the certainty of the evidence using the GRADE approach. We included 15 RCTs with a total of 17,091 participants. Compared with fewer antiplatelet agents, multiple antiplatelet agents were associated with a significantly lower risk of stroke recurrence (5.78% versus 7.84%, risk ratio (RR) 0.73, 95% confidence interval (CI) 0.66 to 0.82; P < 0.001; moderate-certainty evidence) with no significant difference in vascular death (0.60% versus 0.66%, RR 0.98, 95% CI 0.66 to 1.45; P = 0.94; moderate-certainty evidence). There was a higher risk of intracranial haemorrhage (0.42% versus 0.21%, RR 1.92, 95% CI 1.05 to 3.50; P = 0.03; low-certainty evidence) and extracranial haemorrhage (6.38% versus 2.81%, RR 2.25, 95% CI 1.88 to 2.70; P < 0.001; high-certainty evidence) with multiple antiplatelet agents. On secondary analysis of dual versus single antiplatelet agent therapy, benefit for stroke recurrence (5.73% versus 8.06%, RR 0.71, 95% CI 0.62 to 0.80; P < 0.001; moderate-certainty evidence) was maintained as well as risk of extracranial haemorrhage (1.24% versus 0.40%, RR 3.08, 95% CI 1.74 to 5.46; P < 0.001; high-certainty evidence). The composite outcome of stroke, myocardial infarction, and vascular death (6.37% versus 8.77%, RR 0.72, 95% CI 0.64 to 0.82; P < 0.001; moderate-certainty evidence) and ischaemic stroke (6.30% versus 8.94%, RR 0.70, 95% CI 0.61 to 0.81; P < 0.001; high-certainty evidence) were significantly in favour of dual antiplatelet therapy, whilst the risk of intracranial haemorrhage became less significant (0.34% versus 0.21%, RR 1.53, 95% CI 0.76 to 3.06; P = 0.23; low-certainty evidence). Multiple antiplatelet agents are more effective in reducing stroke recurrence but increase the risk of haemorrhage compared to one antiplatelet agent. The benefit in reduction of stroke recurrence seems to outweigh the harm for dual antiplatelet agents initiated in the acute setting and continued for one month. There is lack of evidence regarding multiple versus multiple antiplatelet agents. Further studies are required in different populations to establish comprehensive safety profiles and long-term outcomes to establish duration of therapy.

Abstract TP428: Missed Opportunities for Secondary Stroke Prevention in Embolic Stroke of Undetermined Source Patients in a Community Stroke Unit Setting

Recent post-hoc analyses of the NAVIGATE ESUS trial suggested a reduction in stroke recurrence with anticoagulation in a subset of embolic stroke of unknown source (ESUS) patients with left atrial enlargement (LAE&gt;4.6 cm). In addition, the recent COMPASS trial demonstrated that anticoagulation using low-dose factor Xa inhibition reduces ischemic stroke in patients with clinically-apparent coronary artery (CAD) and peripheral artery disease (PAD). Currently, the rates of LAE, CAD and PAD among patients sent for prolonged cardiac monitoring and the impact of earlier screening in a community setting is unknown. We examined the prevalence of LAE and COMPASS eligibility in a prior stroke cohort who underwent prolonged cardiac monitoring (PROCAM) and identified gaps in antithrombotic therapy at the time of discharge. Patients admitted to the stroke unit with a suspected cardioembolic stroke/TIA and completed both 30-day cardiac monitoring and a transthoracic echocardiogram were offered participation in PROCAM within 30 days of stroke onset. A Spiderflash-T ECG or Northeast DR 200 monitoring device programmed for detecting AF was used. The primary outcomes were number of patients with ESUS, AF, LAE and COMPASS eligibility. Antithrombotic therapy at the time of discharge was also assessed. Among 296 patients referred for prolonged cardiac monitoring with a mean (SEM) age of 69 (0.8) and left atrial diameter of 3.6 cm (0.04), 131 patients (44%) were considered to have ESUS at the time of discharge. Among those ESUS patients, 10 patients (7.6%) had moderate to severe LAE (&gt;4.6 cm), comparable rates to those observed in NAVIGATE ESUS. Additionally, 13 ESUS patients (9.9%) met COMPASS eligibility criteria and 16 (12.2%) were found to have AF following 30-day cardiac monitoring. 33 patients with ESUS (25.2%) were found to have either LAE, COMPASS criteria or AF following 30-day cardiac monitoring and were discharged on antiplatelet therapy. In conclusion, this research provides insight into the necessity of comprehensive stroke work-up for heterogeneous ESUS patients, with particular consideration to 30-day cardiac monitoring, LAE and COMPASS criteria, given that 25% of ESUS patients in our community-based cohort may benefit from anticoagulation therapy.

Triple versus guideline antiplatelet therapy to prevent recurrence after acute ischaemic stroke or transient ischaemic attack: the TARDIS RCT.

Two antiplatelet agents are better than one for preventing recurrent stroke after acute ischaemic stroke or transient ischaemic attack (TIA). Therefore, intensive treatment with three agents might be better still, providing it does not cause undue bleeding. To compare the safety and efficacy of intensive therapy with guideline antiplatelet therapy for acute ischaemic stroke and TIA. International prospective randomised open-label blinded end-point parallel-group superiority clinical trial. Acute hospitals at 106 sites in four countries. Patients > 50 years of age with acute non-cardioembolic ischaemic stroke or TIA within 48 hours of ictus (stroke). Participants were allocated at random by computer to 1 month of intensive (combined aspirin, clopidogrel and dipyridamole) or guideline (combined aspirin and dipyridamole, or clopidogrel alone) antiplatelet agents, and followed for 90 days. The primary outcome was the incidence and severity of any recurrent stroke (ischaemic, haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days by blinded telephone follow-up. Analysis using ordinal logistic regression was by intention to treat. Other outcomes included bleeding and its severity, death, myocardial infarction (MI), disability, mood, cognition and quality of life. The trial was stopped early on the recommendation of the Data Monitoring Committee after recruitment of 3096 participants (intensive, n = 1556; guideline, n = 1540) from 106 hospitals in four countries between April 2009 and March 2016. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy in 3070 (99.2%) participants with data [93 vs. 105 stroke/TIA events; adjusted common odds ratio 0.90, 95% confidence interval (CI) 0.67 to 1.20; p = 0.47]. Major (encompassing fatal) bleeding was increased with intensive as compared with guideline therapy [39 vs. 17 participants; adjusted hazard ratio (aHR) 2.23, 95% CI 1.25 to 3.96; p = 0.006]. There were no differences between the treatment groups in all-cause mortality, or the composite of death, stroke, MI and major bleeding (aHR 1.02, 95% CI 0.77 to 1.35; p = 0.88). Patients and investigators were not blinded to treatment. The comparator group comprised two guideline strategies because of changes in national guidelines during the trial. The trial was stopped early, thereby reducing its statistical power. The use of three antiplatelet agents is associated with increased bleeding without any significant reduction in recurrence of stroke or TIA. The safety and efficacy of dual antiplatelet therapy (combined aspirin and clopidogrel) versus aspirin remains to be defined. Further research is required on identifying individual patient response to antiplatelets, and the relationship between response and the subsequent risks of vascular recurrent events and bleeding complications. Current Controlled Trials ISRCTN47823388. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 48. See the NIHR Journal Library website for further project information. The Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) vanguard phase was funded by the British Heart Foundation (grant PG/08/083/25779, from 1 April 2009 to 30 September 2012) and indirect funding was provided by the Stroke Association through its funding of the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK. There was no commercial support for the trial and antiplatelet drugs were sourced locally at each site. The trial was sponsored by the University of Nottingham.

Abstract 90: Cost-Benefit Comparison of Inpatient versus Clinical Decision Unit Management of TIA

Introduction: Because TIA increases the risk of subsequent stroke, rapid TIA management is key to stroke prevention. Controversy remains regarding the appropriate site of care for TIA patients. Recent literature shows high variability in care processes, admission rates, timeliness of interventions, cost of care, and outcomes, regardless of site of care. We developed a rapid TIA management process in our Clinical Decision Unit (CDU) to reduce cost and adverse outcomes. TIA patients that present to our ED are admitted to the CDU, but transfer patients with TIA are admitted to the inpatient unit (IPU). Methods: Retrospectively, we identified TIA cases by ICD coding, and reviewed records from 4/1/2012 to 3/31/2016 for patients in the CDU and in the IPU. We compared length of stay (LOS), cost of care, readmission rates, and TIA/stroke recurrence between the two groups. Statistical analysis included Chi-square and Wilcoxon two-sample test for recurrence and readmission rates, and generalized linear modeling and Poisson analysis for LOS and cost analysis. Results: A total of 731 patients presented for TIA management in the study period; 393 in CDU, and 338 in IPU. There was no statistical difference in age or sex between the two groups. Mean LOS (hours) in CDU vs IPU was 15 vs 108 (p&lt;0.001), respectively. Total cost of care in CDU vs IPU was $3,835 vs $11,904 (p&lt;0.001), respectively. Univariate analysis showed no appreciable difference in recurrent TIA or stroke rates; multivariate analysis of stroke recurrence for CDU (1.0%) vs IPU (3.6%) did show a small difference (p=0.024). When factoring in reduction of stroke recurrence, the final cost savings of the CDU program equaled $8,258 per patient. There was no difference in readmission rates between the two groups. Conclusion: Using a rapid TIA management protocol yielded a significantly lower LOS and cost per patient. This may justify an avoidance of inpatient admission for TIA patients.

Improvement in cerebral hemodynamic parameters and outcomes after superficial temporal artery-middle cerebral artery bypass in patients with severe stenoocclusive disease of the intracranial internal carotid or middle cerebral arteries.

Both the older and the recent extracranial-intracranial (EC-IC) bypass trials for symptomatic carotid occlusion failed to demonstrate a reduction in stroke recurrence. However, the role of superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in patients with symptomatic intracranial stenoocclusive disease has been rarely evaluated. The authors evaluated serial changes in various cerebral hemodynamic parameters in patients with severe stenoocclusive disease of the intracranial internal carotid artery (ICA) or middle cerebral artery (MCA) and impaired cerebral vasodilatory reserve (CVR), treated by STA-MCA bypass surgery or medical treatment. Patients with severe stenoocclusive disease of the intracranial ICA or MCA underwent transcranial Doppler (TCD) ultrasonography and CVR assessment using the breath-holding index (BHI). Patients with impaired BHI (< 0.69) were further evaluated with acetazolamide-challenge technitium-99m hexamethylpropyleneamine oxime ((99m)Tc HMPAO) SPECT. STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. All patients underwent TCD and SPECT at 4 ± 1 months and were followed up for cerebral ischemic events. A total of 112 patients were included. This total included 73 men, and the mean age of the entire study population was 56 years (range 23-78 years). (99m)Tc HMPAO SPECT demonstrated impaired CVR in 77 patients (69%). Of these 77 patients, 46 underwent STA-MCA bypass while 31 received best medical treatment. TCD and acetazolamide-challenge (99m)Tc HMPAO SPECT repeated at 4 ± 1 months showed significant improvement in the STA-MCA bypass group. During a mean follow-up of 34 months (range 18-39 months), only 6 (13%) of 46 patients in the bypass group developed cerebral ischemic events, as compared with 14 (45%) of 31 patients receiving medical therapy (absolute risk reduction 32%, p = 0.008). STA-MCA bypass surgery in carefully selected patients with symptomatic severe intracranial stenoocclusive disease of the intracranial ICA or MCA results in significant improvement in hemodynamic parameters and reduction in stroke recurrence.

Efficacy of antiplatelet therapy in secondary prevention following lacunar stroke: pooled analysis of randomized trials.

Lacunar stroke accounts for ≈25% of ischemic stroke, but optimal antiplatelet regimen to prevent stroke recurrence remains unclear. We aimed to evaluate the efficacy of antiplatelet agents in secondary stroke prevention after a lacunar stroke. We searched MEDLINE, Embase, and the Cochrane library for randomized controlled trials that reported risk of recurrent stroke or death with antiplatelet therapy in patients with lacunar stroke. We used random effects meta-analysis and evaluated heterogeneity with I(2). We included 17 trials with 42,234 participants (mean age 64.4 years, 65% male) and follow up ranging from 4 weeks to 3.5 years. Compared with placebo, any single antiplatelet agent was associated with a significant reduction in recurrence of any stroke (risk ratio [RR] 0.77, 0.62-0.97, 2 studies) and ischemic stroke (RR 0.48, 0.30-0.78, 2 studies), but not for the composite outcome of any stroke, myocardial infarction, or death (RR 0.89, 0.75-1.05, 2 studies). When other antiplatelet agents (ticlodipine, cilostazol, and dipyridamole) were compared with aspirin, there was no consistent reduction in stroke recurrence (RR 0.91, 0.75-1.10, 3 studies). Dual antiplatelet therapy did not confer clear benefit over monotherapy (any stroke RR 0.83, 0.68-1.00, 3 studies; ischemic stroke RR 0.80, 0.62-1.02, 3 studies; composite outcome RR 0.90, 0.80-1.02, 3 studies). Our results suggest that any of the single antiplatelet agents compared with placebo in the included trials is adequate for secondary stroke prevention after lacunar stroke. Dual antiplatelet therapy should not be used for long-term stroke prevention in this stroke subtype.

Abstract 74: Improvement in Cerebral Hemodynamic Parameters and Outcome after Superficial Temporal Artery- Middle Cerebral Artery Bypass in Patients with Severe Steno-occlusive Disease of Intracranial Carotid and Middle Cerebral Artery

Background and Objective: Older and the recent extracranial-intracranial (EC/IC) bypass trials for symptomatic carotid occlusion failed to demonstrate reduction in stroke recurrence. However, role of superficial temporal artery-middle cerebral artery (STA-MCA) bypass in patients with symptomatic intracranial steno-occlusive disease has been evaluated scarcely. We evaluated serial changes in various cerebral hemodynamic parameters in patients with severe steno-occlusive disease of intracranial internal carotid (ICA) or middle cerebral artery (MCA) and impaired cerebral vasodilatory reserve (CVR), treated with STA-MCA bypass surgery or medical treatment. Methods: Patients with severe steno-occlusive disease of intracranial ICA or MCA underwent transcranial Doppler (TCD) ultrasonography and CVR assessment using breath-holding index (BHI). Patients with impaired BHI (&lt;0.69) were further evaluated with acetazolamide-challenged hexamethylpropyleneamine-oxime single-photon emission computed tomography (HMPAO-SPECT). STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. All patients underwent TCD and SPECT at 4±1 months and followed-up for cerebral ischemic events. Results: A total of 112patients (73males, mean age 56yrs; range 23-78yrs) were included. HMPAO-SPECT demonstrated impaired CVR in 77 (69%) patients. Of them, 46 underwent STA-MCA bypass while 31 received best medical treatment. TCD and acetazolamide-challenged HMPAO-SPECT repeated 4±1months showed significant improvement in STA-MCA bypass group. During follow-up (mean 34months; range 18-39months), only 6/46 (13%) patients in bypass group developed cerebral ischemic events as compared to 14/31 (45%) cases on medical therapy (absolute risk-reduction 32%, p=0.008). Conclusion: STA-MCA bypass surgery in carefully selected patients with symptomatic severe intracranial steno-occlusive disease results in significant improvement in hemodynamic parameters and reduction in stroke recurrence.

Meta-analysis reveals protective effects of vitamin B on stroke patients.

Stroke is the loss of brain function due to a disturbance in the blood supply to the brain resulting from either ischemia or hemorrhage. Previous studies have evaluated the clinical importance of nutritional interventions such as vitamin B supplementation in the management of acute strokes. However, it is still inconclusive whether or not vitamin B supplementation will benefit patients with acute strokes. Therefore, a meta-analysis was performed to assess the efficacy of vitamin B supplementation in the treatment of stroke patients. Medline, Embase, Scopus, and Cochrane Library databases were searched (from 1960 to June 2015) and forest plots were generated to illustrate the treatment effects. A systemic review of the electronic databases yielded 12 eligible studies consisting of 7474 patients. Forest plots from the meta-analyses of the included studies illustrated that vitamin B supplementation significantly lowered the plasma concentration of total homocysteine (SMD = −0.82; 95% CI: −0.77; Z = −29.06, p < 0.0001) and resulted in significant reduction in stroke recurrence (OR = 0.86%; 95% CI: 0.76, 0.97; Z = −2.41; p = 0.016) as well as a combined incidence of vascular events, including recurrent strokes, myocardial infarctions and vascular deaths (OR = 0.87%; 95% CI: 0.79, 0.96; Z= −2.73; p = 0.0063).Additionally, the nearly-symmetrical funnel plot (Egger’s test, t = −1.705, p = 0.1224) indicated the absence of publication bias regarding the meta-analysis that examined the effect of vitamin B supplementation on the plasma levels of homocysteine in acute stroke patients. These findings suggested that vitamin B supplementation presents a potential addition to the armamentarium for the management of acute stroke patients.

Abstract T MP26: Role of 99tc-hmpao Spect in the Assessment of Cerebral Hemodynamic Parameters After Superficial Temporal Artery- Middle Cerebral Artery Bypass in Patients With Severe Steno-Occlusive Disease of Intracranial Carotid and Middle Cerebral Artery

Background and Objective: Although superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery in patients with symptomatic carotid occlusion failed to demonstrate any benefit, its role in symptomatic intracranial steno-occlusive disease has been evaluated scarcely. We evaluated changes in hemodynamic parameters in patients with severe steno-occlusive disease of intracranial internal carotid (ICA) or middle cerebral artery (MCA) who underwent STA-MCA bypass for impaired cerebral vasodilatory reserve (CVR). Methods: Patients with severe steno-occlusive disease of intracranial ICA or MCA underwent transcranial Doppler (TCD) evaluation and CVR assessment using breath-holding index (BHI). Patients with impaired BHI (&lt;0.69) were further evaluated with acetazolamide-challenged 99Tc-HMPAO-SPECT. STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. TCD and SPECT were repeated in all patients at 4±1 months and they were followed-up for cerebral ischemic events. Results: Of the 126 patients (80 male, mean age 56yrs; range 23-78yrs) that fulfilled our inclusion criteria, 84 (67%) showed impaired CVR HMPAO-SPECT. Fifty (60%) of them underwent STA-MCA bypass while 34(40%) received best medical treatment. TCD and acetazolamide-challenged HMPAO-SPECT repeated 4±1 months after surgery showed significant improvement in STA-MCA bypass group. TCD BHI improved from a median (IQR) of -0.05 to 1.1 (p&lt;0.001). Compared to 98% patients with impaired CVR on pre-operative SPECT, only 20% showed abnormal results on post-operative imaging (p&lt;0.001). During follow-up (mean 35 months; range 8 to 49months), only 6/50 (12%) patients in bypass group developed cerebral ischemic events as compared to15/34 (44%) cases on medical therapy (absolute risk reduction 32%, p=0.006). Conclusion: 99Tc-HMPAO SPECT with acetazolamide challenge is a reliable tool for the assessment of cerebral vasodilatory reserve in patients with severe steno-occlusive disease of intracranial ICA or MCA. STA-MCA bypass surgery in carefully selected patients results in significant improvement in hemodynamic parameters and reduction in stroke recurrence.

Medium- and long-term efficacy of ligustrazine plus conventional medication on ischemic stroke: a systematic review and meta-analysis

ObjectiveTo evaluate the medium- to long-term efficacy of ligustrazine plus conventional medicine treating ischemic stroke. MethodsRandomized controlled trials (RCTs) testing ligustrazine in the treatment of acute ischemic stroke were retrieved from Cochrane Library, PubMed, Excerpta Medica Database, Chinese Medical Journal Database, Chinese Biomedical Database, China National Knowledge Infrastructure Database, and Chinese Clinical Trial Register, and then identified by the inclusive and exclusive criteria. The quality of trials was assessed with the Cochrane Handbook 5.1, a risk of bias assessment tool. RevMan 5.1 was used for meta-analysis. ResultsThree RCTs involving 643 patients were included. Compared to conventional medicine treatment alone, ligustrazine plus conventional medicine treatment showed significant difference in reduction of stroke recurrence either at the end of 1-year follow-up [RR=0.42, 95% CI (0.18, 0.94), P< 0.05] or 3-years observation [RR=0.48, 95% CI (0.27, 0.83), P<0.05]. The ligustrazine group also showed higher survival rate [RR=1.67, 95% CI (1.02, 0.2.71), P<0.05] and significantly better effective rate [RR=1.28, 95% CI (1.10, 1.50), P<0.05] than that of the control group at the end of 1 year visit. Only one trial conducted safety assessment and no adverse events were reported. The methodological quality of all the trials included was generally poor. ConclusionThe findings provided evidence that the combination of ligustrazine and conventional medication was medium- and long-term beneficial to the patients suffering ischemic stroke. But more RCTs of high quality are needed to further prove the efficacy and safety of using ligustrazine for ischemic stroke.

Impact of nutritional status and dietary quality on stroke: do we need specific recommendations?

Stroke, one of the most prevalent geriatric diseases, is a leading cause of death worldwide that often results in permanent physical disability and decreased quality of life, and can have a negative impact on families both financially and emotionally. Although many previous studies have shown relationships between the risk of stroke and nutritional factors, clear dietary recommendations for the prevention and reduction of stroke recurrence have not been established. Several factors should be considered to control and manage stroke. For example, a considerable number of patients with stroke are poorly nourished, have several comorbidities and undesirable health-related behaviors may be present. Stroke patients are less likely to consume beneficial foods, have poorer eating habits and have impoverished dietary quality. In addition, psychological factors such as depression must also be considered in stroke management. Given these factors, dietary recommendations for stroke patients should be established. In this article, we summarized the nutritional status and dietary quality of stroke patients. We also suggested some nutritional guidelines for stroke patients and for those who are at risk for stroke.

Abstract WP161: Improvement in Cerebral Hemodynamic Parameters and outcomes after Superficial Temporal Artery- Middle Cerebral Artery Bypass in Patients with Severe Steno-occlusive Disease of Intracranial Carotid and Middle Cerebral Artery

Background and Objective —Older as well as the recent extracranial-intracranial (EC/IC) bypass trial in patients with symptomatic carotid occlusion failed to demonstrate reduction in stroke recurrence. However, the role of superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery in patients with symptomatic intracranial steno-occlusive disease has been evaluated scarcely. We evaluated the changes in various hemodynamic parameters in patients with severe steno-occlusive disease of intracranial internal carotid (ICA) or middle cerebral artery (MCA) who underwent STA-MCA bypass surgery for impaired cerebral vasodilatory reserve (CVR). Methods —Patients with severe steno-occlusive disease of intracranial ICA or MCA underwent transcranial Doppler (TCD) ultrasonography and CVR assessment using breath-holding index (BHI). Patients with impaired BHI (&lt;0.69) were further evaluated with acetazolamide-challenged hexamethylpropyleneamine oxime single-photon emission computed tomography (HMPAO-SPECT). STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. TCD and SPECT were repeated in all patients at 4±1 months and they were followed-up for cerebral ischemic events. Results —112 patients (73males, mean age 56yrs; range 23-78yrs) fulfilled our inclusion criteria. HMPAO-SPECT demonstrated impaired CVR in 77 (69%) patients. Forty-six of them underwent STA-MCA bypass while 31 received best medical treatment. TCD and acetazolamide-challenged HMPAO-SPECT repeated 4±1 months after surgery showed significant improvement in STA-MCA bypass group. During follow-up (mean 24 months; range 4 to 33months), only 6/46 (13%) patients in bypass group developed cerebral ischemic events as compared to14/31 (45%) cases on medical therapy (absolute risk reduction 32%, p=0.008). Conclusion —STA-MCA bypass surgery in carefully selected patients with symptomatic severe intracranial steno-occlusive disease results in significant improvement in hemodynamic parameters and reduction in stroke recurrence

Prevention of dementia by ACE inhibitors and angiotensin receptor blockers - potential but not proven

Dementia currently exacts a substantial economic burden on societies, health and social care systems and carers in addition to the devastating personal and emotional cost to patients and families (1,2). This burden is predicted to increase substantially in the coming decades and is the major public health issue of this century (1). Currently available therapies are symptomatic only (3), with little or no prospect of disease-modifying treatments entering routine clinical use in the short to medium term. Strategies to prevent or delay the onset of dementia or retard its' progression are, therefore, urgently required and will be of extreme importance to individuals and societies. Currently available medications that could achieve these goals would have many advantages ― potential for immediate use; established safety profile; familiarity to clinicians; relatively low cost giving favourable cost-effectiveness breakdown.