Risk Of Early Recurrent Stroke Research Articles

Abstract TMP51: A Validation Study of Recurrence Risk Estimator Score in Acute Ischemic Stroke

Background and Objectives: The Recurrence Risk Estimator (RRE) is a web-based prognostic score that integrates clinical and imaging information available in the acute setting to quantify early risk of recurrent stroke. The score has been reported to have adequate calibration and good discrimination in the original derivation cohort (AUC=0.81, 95% confidence interval [CI] 0.76-0.87). In the present study, we sought to investigate the validity of RRE score in internal and external datasets. Methods: Internal validation was performed in a prospectively collected dataset from 899 consecutive patients admitted to the Massachusetts General Hospital. External validation was performed in a retrospective stroke cohort of 711 patients from 2 teaching hospitals in Brazil and South Korea. The RRE-90 score was calculated by summing up the number of independent predictors weighted by their corresponding beta-coefficients. (Available at: http://www.nmr.mgh.harvard.edu/RRE-90). We assessed the score’s predictive performance by computing the area under the receiver operating characteristic curve (AUC). Results: Internal and external validation cohorts differed from each other as well as from the original derivation cohort in age, gender, admission NIH stroke scale score, stroke risk factors, and etiologic stroke subtypes. Stroke recurrence rate during the 90-day follow-up period was 6.5% and 2.7% in the internal and external cohorts respectively. The AUC was 0.76 (95% CI 0.68-0.83) in the internal and 0.75 (95% CI 0.66-0.85) in the external validation cohort. Conclusions: RRE score performs well in independent cohorts with different baseline patient characteristics and stroke features. As a reliable, valid, and easy-to-use web-based tool, RRE may find widespread utility in identifying high- and low-risk patients for targeted stroke prevention.

Abstract WP252: Reduction in Stroke Readmission Rates After Implementing an Emergency Department-based Transient Ischemic Attack Observation Unit

Background and Purpose —Diagnosis and treatment of transient ischemic attacks (TIAs) is often delayed by lack of access to immediate comprehensive evaluation of the underlying etiology. Early initiation of treatment can reduce the risk of early recurrent stroke by up to 80%. Up to 40% of people who have experienced a TIA will go on to have a stroke. The purpose of this review was to determine the efficacy of an Emergency Department (ED)-based TIA observation unit using a standardized TIA protocol designed to provide rapid evaluation and treatment of patients presenting with TIA in reducing the rates of readmission with stroke to a community-based hospital. Methods —We did a retrospective chart review of all patients discharged from Bellin Hospital with a diagnosis of stroke before implementing a standardized TIA protocol in our ED-based TIA observation unit (July to December 2010) and after implementation of the TIA observation unit (November 2011 to April 2012). We identified the patients in these cohorts who had previously been evaluated in the ED with signs or symptoms of stroke in the 6 months prior to admission and compared their stroke readmission rates. Patients who received evaluation through the TIA observation unit from November 2011 to April 2012 were monitored for readmission for stroke in the 6 months after evaluation. Results —Prior to use of the TIA observation unit, 7 of 51 (13.7%) patients discharged with a diagnosis of stroke had been seen in the ED in the previous 6 months with stroke-like symptoms. After implementation of the TIA observation unit, 7 of 119 (5.9%) patients discharged with a diagnosis of stroke had been seen in the ED, a 57.1% reduction in stroke readmission at 6 months. Of these, 4 (57.1%) had not completed the work-up during their previous ED visit. 122 patients underwent evaluation using the TIA observation unit. Of these, only 3 (2.5%) patients were readmitted for stroke in the next 6 months. 16 of these 122 (13.1%) patients were diagnosed with stroke during their TIA work-up. Conclusions —Rapid evaluation and treatment of TIA through an ED-based TIA observation unit substantially reduces the risk of readmission for stroke.

Carotid plaque inflammation on 18F‐fluorodeoxyglucose positron emission tomography predicts early stroke recurrence

Symptomatic carotid stenosis is associated with a 3-fold risk of early stroke recurrence compared to other stroke subtypes. Current carotid imaging techniques rely on estimating plaque-related lumen narrowing but do not evaluate intraplaque inflammation, a key mediator of plaque rupture and thromboembolism. Using combined (18) F-fluorodeoxyglucose positron-emission tomography (FDG-PET)/computed tomography, we investigated the relation between inflammation-related FDG uptake and stroke recurrence. Consecutive patients with a recent (median, 6.5 days; interquartile range, 4-8) stroke, transient ischemic attack (TIA), or retinal embolism and ipsilateral carotid stenosis (≥50%) were included. FDG uptake was quantified as mean standardized uptake values (SUVs, g/ml). Patients were followed prospectively for stroke recurrence. Sixty patients were included (25 stroke, 29 TIA, 6 retinal embolism). Twenty-two percent (13 of 60) had stroke recurrence within 90 days. FDG uptake in ipsilateral carotid plaque was greater in patients with early recurrent stroke (mean SUV, 1.85 g/ml; standard deviation [SD], 0.44 vs 1.58 g/ml; SD, 0.32, p = 0.02). On life-table analysis, 90-day recurrence rates with mean SUV greater than a 2.14 g/ml threshold were 80% (95% confidence interval [CI], 41.8-99.2) versus 22.9% (95% CI, 12.3-40.3) with SUV ≤2.14 g/ml (log-rank, p < 0.0001). In a Cox regression model including age and degree of stenosis (50-69% or ≥70%), mean plaque FDG uptake was the only independent predictor of stroke recurrence (adjusted hazard ratio, 6.1; 95% CI, 1.3-28.8; p = 0.02). In recently symptomatic carotid stenosis, inflammation-related FDG uptake was associated with early stroke recurrence, independent of the degree of stenosis. Plaque FDG-PET may identify patients at highest risk for stroke recurrence, who may be selected for immediate revascularization or intensive medical treatment.

Abstract P333: Post-Stroke Outcomes Vary by Etiologic Stroke Subtype in the Atherosclerosis Risk in Communities Study

Background: Early risk of recurrent stroke and mortality after stroke differ by subtype, but less is known about long-term outcomes and all-cause hospital readmission. Understanding these differences may have implications for secondary prevention and treatment of stroke. We examined rates of recurrent stroke, all-cause hospital readmission, and mortality by index stroke etiologic subtype. Methods: Atherosclerosis Risk in Communities Study cohort participants with a definite/probable first-ever stroke were identified and followed until death or 12/31/2008. The association between index and recurrent stroke subtype and median times to first recurrent stroke and first hospital admission were assessed according to index stroke subtype (infarction: thrombotic, cardioembolic [CE], and lacunar; hemorrhagic: subarachnoid [SAH] and intraparenchymal [IPH]). Incidence rates of recurrent stroke, all-cause hospitalization, and death were calculated by index subtype. Reasons for hospitalization were identified using primary ICD-9 codes. Recurrent stroke outcomes for hemorrhagic subtypes are not reported here due to small numbers of events. Results: A total of 987 persons with first-ever stroke were identified and followed for an average 5.3±5.0 years post-stroke (48.7% thrombotic, 20.0% CE, 18.5% lacunar, 8.6% IPH, and 4.2% SAH). During follow-up, there were 183 recurrent strokes among 147 participants, 3234 hospitalizations among 746 participants, and 529 deaths. Only 139 (14.1%) participants had none of these events during follow up. Roughly 70% of recurrent strokes were of the same subtype as the index stroke; however, only a third were the same when the index stroke was lacunar. Time to first recurrent stroke varied by subtype (median days [range]; thrombotic, 930.5[2-4692]; CE, 271[2-5566]; lacunar, 789[5-4361]) while time to first hospitalization was more similar, ranging from 102.5[4-3634] among CE to 370[6-6506] among IPH. Incidence rates of recurrent stroke (per 100 person-years) were highest after lacunar stroke (4.4) followed by thrombotic (3.7), and CE (2.7). All-cause hospital readmission rates were: thrombotic (58.8), CE (88.9), lacunar (60.1), IPH (59.4), and SAH (35.3); and mortality rates were: thrombotic (9.0), CE (15.1), lacunar (7.4), IPH (22.3), and SAH (7.3). Non-stroke related hospitalizations, including heart failure, ischemic heart disease, and diabetes were not uncommon after stroke, particularly after thrombotic and CE strokes. Conclusion: While the highest mortality was observed for IPH, there was significant burden of recurrent stroke and all-cause hospitalization for other stroke subtypes, especially lacunar and CE. Hospital readmission rates were high for all subtypes, suggesting there may be opportunities to reduce post-stroke readmissions. Prevention efforts tailored according to etiologic stroke subtype may be warranted.

Abstract 2743: Effectiveness of Early Dual Antiplatelets in Patients with TIA and Minor Stroke: Post-hoc Analysis of CLAIR Study

Background Patients with symptomatic intracranial atherosclerosis are at high risk of early recurrent stroke. Dual antiplatelet therapy appears promising for early secondary prevention of stroke or TIA, yet the ideal patients to benefit from this regime have not been identified. Methods We investigated the efficacy and safety of early dual antiplatelets use in TIA and minor stroke patients (NIHSS 0-3) by performing a post-hoc analysis of CLAIR (Clopidogrel plus aspirin versus aspirin alone for reducing embolisation in patients with acute symptomatic cerebral or carotid artery stenosis) study - a randomized, open-label, blinded-endpoint study in patients who had symptomatic large artery atherosclerosis, in whom micro-embolic signals (MES) were present on transcranial doppler monitoring. MES was used as surrogate marker for recurrent stroke risk. Analysis was by modified intention to treat. Results Sixty-five of 100 patients recruited had TIA or minor stroke (NIHSS 0-3); 30 received dual therapy (aspirin 75-60mg daily and clopidogrel 300mg day 1 then 75mg daily) and 35 received aspirin alone (75-160mg daily) for 7 days. 93% patients had intracranial stenosis. Mean onset-to-randomization was 2.3 days in dual therapy group and 3.2 days in monotherapy group (p=0.03). At day 7, 9 of 29 patients in dual therapy group and 18 of 34 patients in monotherapy group for whom data were available had ≥ 1 MES (relative risk reduction 41.4%, 95% CI 29.8-51.1, p&lt;0.001). The median number of MES on day 7 was 0 in dual therapy group and 1.0 in monotherapy group (p=0.02). Two patients in monotherapy group had recurrent stroke. No patients had intracranial or severe systemic hemorrhage, except two patients in dual therapy group had minor bleeding. Conclusion Early dual therapy with clopidogrel and aspirin reduces MES at day 7 among patients with predominant intracranial atherosclerosis who had minor ischemic stroke or TIA, without causing significant bleeding complications.

Abstract 2756: Carotid Plaque Inflammation On 18 F-Fluorodeoxyglucose Positron Emission Tomography Predicts Early Stroke Recurrence- The Dublin Carotid Atherosclerosis Stroke Study

Background Symptomatic carotid stenosis is associated with a 3-fold risk of early stroke recurrence compared to other stroke subtypes. Current carotid imaging techniques rely on estimating plaque-related lumen narrowing but do not evaluate intra-plaque inflammation, a key mediator of plaque rupture and thromboembolism. Using combined 18 F-fluorodeoxyglucose positron emission tomography/CT (FDG-PET/CT) we investigated the relationship between inflammation-related FDG uptake and stroke recurrence. Methods Consecutive patients with a recent (median 6.5 days [IQR 4-8]) stroke, TIA, or retinal embolism and ipsilateral carotid stenosis ( ≥50%) were included. FDG uptake was quantified as mean standardised uptake values (SUV, g/ml). Patients were followed prospectively for stroke recurrence. Results 60 patients were included (25 stroke, 29 TIA, 6 retinal embolism). 22% (13/60) had stroke recurrence within 90 days. FDG uptake in ipsilateral carotid plaque was greater in patients with early recurrent stroke (mean SUV 1.85 [SD 0.44] vs. 1.58 [SD 0.32] g/ml, p=0.02). On life-table analysis, 90-day recurrence rates with mean SUV greater than a 2.14g/ml threshold were 80% (CI 41.8-99.2%) versus 22.9% (CI 12.3-40.3%) with SUV ≤2.14g/ml (log-rank p&lt;0.0001). In a Cox regression model including age and degree of stenosis (50-69% or ≥70%), mean plaque FDG uptake was the only independent predictor of stroke recurrence (adjusted hazard ratio 6.1, CI 1.3-28.8, p=0.02). Conclusion In recently-symptomatic carotid stenosis, inflammation-related FDG uptake was associated with early stroke recurrence, independent of the degree of stenosis. Plaque FDG-PET may identify patients at highest risk for stroke recurrence, who may be selected for immediate revascularisation or intensive medical treatment.

Low Ankle-Brachial Index predicts early risk of recurrent stroke in patients with acute cerebral ischemia

Objective Low Ankle-Brachial Blood Pressure Index (ABI) identifies patients with symptomatic and asymptomatic peripheral arterial disease (PAD). We sought to investigate the association of low ABI with early risk of stroke recurrence in patients with acute cerebral ischemia (ACI) and without history of symptomatic PAD. Methods Consecutive patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) and no previous history of PAD were prospectively evaluated with ABI measurements. Demographic characteristics, vascular risk factors and secondary prevention therapies were documented. An ABI ≤0.90 in either leg was considered as evidence of asymptomatic PAD, and an ABI >0.90 was considered as normal. Patients with elevated ABI (>1.30) were excluded. The outcome of interest was recurrent stroke during 30-day follow-up. Results A total of 176 patients with acute cerebral ischemia (mean age 64 ± 14 years, 59.1% men, 76.7% AIS) were evaluated. Asymptomatic PAD was detected in 14.8% (95%CI: 10.2–20.8%) of the studied population. The following factors were independently associated with low ABI on multivariate logistic regression models, after adjustment for potential confounders: coronary artery disease ( p = 0.008), diabetes mellitus ( p = 0.017) and increasing age ( p = 0.042). The cumulative 30-day recurrence rate was higher in patients with low ABI (19.2%; 95%CI: 4.1–34.3) compared to the rest (3.3%; 95%CI: 0.4–6.2%; p = 0.001). Atherothrombotic stroke (ASCO grade I; p < 0.001), increasing age ( p = 0.002) and low ABI ( p = 0.004) were independent predictors of stroke recurrence on multivariate Cox regression models adjusting for confounders. Conclusions Low ABI appears to be associated with a higher risk of early recurrent stroke in patients with ACI and no history of symptomatic PAD.

Cerebrovascular disorders: carotid-wall intima-media thickness, stroke recurrence, and β-blocker selectivity

It is always amazing to see how many articles are published in the field of cerebrovascular disorders every month, even in very high-ranking journals. This is most certainly justified because daily clinical practice shows how relevant cerebrovascular disorders are. The three articles discussed in this month’s Journal Club primarily focus on primary or secondary prophylaxis. In the first study published in the New England Journal of Medicine, intima-media thickness of the walls of the common carotid artery and internal carotid artery, as well as the presence of plaque, were identified as a predictor for cardiovascular outcomes. The second article deals with stroke recurrence within the time window recommended for carotid endarterectomy, i.e. within 2 weeks after the first stroke due to a carotid stenosis. The article shows that early recurrent stroke risk was indeed high, particularly within the first 72 h, which has a considerable clinical impact. The final article, a systematic review on the effects of b-blocker selectivity on blood pressure variability and stroke also has clinical implications: non-selective b-blockers should be avoided in neurologic practice. In other words, b1-selective blockers can be used with the exception of atenolol, which has been shown not to be effective for stroke prevention. Carotid-wall intima-media thickness and cardiovascular events Known risk factors for cardiovascular events are increased systolic blood pressure, cholesterol, diabetes, cigarettesmoking, age, male sex, and history of cardiovascular disease. On the other hand, patients clearly benefit from hypertension treatment. In the current study, Polak and co-workers from Boston University examined whether intima-media thicknesses of the walls of the common carotid artery and internal carotid artery are independent risk factors and, further, if they may add to the Framingham risk score for predicting cardiovascular events. In 2,965 members of the Framingham Offspring Study cohort, the mean intima-media thickness of the common carotid artery and the maximum intima-media thickness of the internal carotid artery as well as the presence of plaque (defined as intima-media thickness of the internal carotid artery of more than 1.5 mm) were measured. Of these 2,965 participants a total of 296 had a cardiovascular event. The major findings were as follows: First, in the group of patients with no cardiovascular disease at follow-up the mean common carotid artery thickness was 0.59 ± 0.13 versus 0.66 ± 0.15 mm in the group of patients with cardiovascular disease at follow-up. Second, in those with no cardiovascular disease at follow-up the maximum internal carotid artery thickness was 1.30 ± 0.79 versus 1.9 ± 1.00 mm in those with cardiovascular disease at follow-up. Third, 27.4% of patients with no cardiovascular disease at follow-up had evidence of a plaque versus 59.6% of those with cardiovascular disease at follow-up. Fourth, the above-mentioned risk factors predicted the cardiovascular events with a so-called C statistic of 0.748. Fifth, the mean intima-media thickness of the common carotid artery and the maximum intima-media thickness of the internal

Stroke recurrence within the time window recommended for carotid endarterectomy

In the North Dublin Population Stroke Study, we investigated the risk of recurrent stroke within the 14-day time window recommended for endarterectomy. In a population-based prospective cohort study, all ischemic stroke patients were identified over 1 year and categorized into those with (CS-positive) and without (CS-negative) ipsilateral carotid stenosis (CS) (≥50% lumen narrowing). Nonprocedural stroke recurrence was determined at 72 hours and 7 and 14 days. Of 365 ischemic stroke patients with carotid imaging, 51 were excluded due to posterior circulation or nonlateralizing stroke, ipsilateral carotid occlusion, or intracranial stenosis, leaving 314 included for analysis (36 CS-positive and 278 CS-negative). Recurrent stroke occurred in 5.6% (2/36) CS-positive and 0.4% (1/278) CS-negative patients by 72 hours of symptom onset (p =0.003), 5.6% (2/36) CS-positive and 0.7% (2/278) CS-negative patients (p =0.01) by 7 days, and in 8.3% (3/36) CS-positive and 1.8% (5/278) CS-negative patients by 14 days (p =0.02). On multivariable Cox regression analysis, CS was the only independent predictor of recurrence at 72 hours (adjusted hazard ratio [HR] 36.1, 95% confidence interval [CI] 1.6-837.5, p =0.03), and 7 days (HR 9.1, 1.1-79.2, p =0.05), with a trend at 14 days (HR 4.6, 0.9-22.8, p =0.06). Although only a minority of patients with symptomatic CS had a recurrent stroke within 14 days, early recurrent stroke risk was high, particularly within the first 72 hours. Earlier carotid revascularization or improved acute medical treatment may reduce recurrence in this high-risk group.

Safety of early carotid artery stenting after systemic thrombolysis: a single center experience.

Background. Patients with acute ischemic stroke due to internal carotid artery (ICA) disease are at high risk of early stroke recurrence. A combination of IV thrombolysis and early carotid artery stenting (CAS) may result in more effective secondary stroke prevention. Objective. We tested safety and durability of early CAS following IV thrombolysis in stroke patients with residual stenosis in the symptomatic ICA. Methods. Of consecutive patients treated with IV rtPA, those with residual ICA stenosis ≥70% or <70% with an ulcerated plaque underwent early CAS (>24 hours). The protocol included pre-rtPA MRI and MR angiography, and post-rtPA carotid ultrasound and CT angiography. Stroke severity was assessed by the NIH Stroke Scale (NIHSS). Three- and twelve-month stent patency was assessed by ultrasound. Twelve-month functional outcome was assessed by the modified Rankin Scale (mRS). Results. Of 145 consecutive IV rtPA-treated patients, 6 (4%) underwent early CAS. Median age was 76 (range 67–78) years, median NIHSS at stroke onset was 12 (range 9–16) and 7 (range 7-8) before CAS. Median onset-to-CAS time was 48 (range 30–94) hours. A single self-expandable stent was implanted to cover the entire lesion in all patients. The procedure was uneventful in all patients. After 12 months, all patients had stent patency, and the functional outcome was favourable (mRS ≤ 2) in all but 1 patient experiencing a recurrent stroke for new-onset atrial fibrillation. Conclusion. This small case series of a single centre suggests that early CAS may be considered a safe alternative to CEA after IV rtPA administration in selected patients at high risk of stroke recurrence.

Clopidogrel Versus Dipyridamole in Addition to Aspirin in Reducing Embolization Detected with Ambulatory Transcranial Doppler: A Randomized Trial

Background and Purpose—After stroke and transient ischemic attack there is a high early risk of recurrent stroke, particularly in large artery disease. It has been suggested more intensive antiplatelet regimens are required, but trial data are lacking. Treatment efficacy can be evaluated using transcranial Doppler detection of embolic signals. Ambulatory transcranial Doppler has recently been developed; prolonged recording may reduce subject numbers required to determine therapeutic efficacy. In a randomized trial (ISRCTN68019845) with blinded end point evaluation, we determined whether treatment with dipyridamole or clopidogrel, in addition to aspirin, was more effective at reducing embolization. Methods—Consecutive patients with recent symptomatic carotid stenosis were recruited. Ambulatory transcranial Doppler and platelet aggregometry were performed at baseline and 48 hours. Patients, all on aspirin, were randomized to dipyridamole or clopidogrel. Recordings were analyzed offline masked to subject ide...

Atherogenic Dyslipidemia in Patients With Transient Ischemic Attack

There is mounting evidence that atherogenic dyslipidemia (ie, low high-density lipoprotein cholesterol combined with high triglyceride concentrations) is an independent predictor of high cardiovascular risk and possibly of stroke. All patients included in the SOS-TIA cohort underwent an initial standardized evaluation, including medical history, physical examination, routine blood biochemistry, and diagnostic testing, and were followed for 1 year. Lipid profile was evaluated under fasting conditions. Atherogenic dyslipidemia was defined as high-density lipoprotein cholesterol blood concentration ≤ 40 mg/dL and triglycerides ≥ 150 mg/dL. Among 1471 consecutive patients with transient ischemic attack (TIA) or minor stroke, overall prevalence of atherogenic dyslipidemia was 5.8%, but varied from 4.6% to 11.1%, depending on final diagnosis (possible TIA or TIA with a cerebral ischemic lesion, respectively). Prevalence of atherogenic dyslipidemia was independently associated with male sex, diabetes, and body mass index, but not with ABCD2 score. Atherogenic dyslipidemia also strongly associated with symptomatic intracranial stenosis ≥ 50% (adjusted odds ratio, 2.77; 95% CI, 1.38-5.55), but not with symptomatic extracranial stenosis ≥ 50% (adjusted odds ratio, 1.20; 95% CI, 0.64-2.26). Despite appropriate secondary prevention treatment, 90-day stroke risk was greater in patients with versus without atherogenic dyslipidemia (4.8% versus 1.7%; P=0.04). The atherogenic dyslipidemia phenotype in patients with TIA may be associated with intracranial artery stenosis and higher risk of early recurrent stroke. Additional data are needed to confirm these findings and to assess the best way to reduce important residual risk in such patients.

Clopidogrel Versus Dipyridamole in Addition to Aspirin in Reducing Embolization Detected With Ambulatory Transcranial Doppler

After stroke and transient ischemic attack there is a high early risk of recurrent stroke, particularly in large artery disease. It has been suggested more intensive antiplatelet regimens are required, but trial data are lacking. Treatment efficacy can be evaluated using transcranial Doppler detection of embolic signals. Ambulatory transcranial Doppler has recently been developed; prolonged recording may reduce subject numbers required to determine therapeutic efficacy. In a randomized trial (ISRCTN68019845) with blinded end point evaluation, we determined whether treatment with dipyridamole or clopidogrel, in addition to aspirin, was more effective at reducing embolization. Consecutive patients with recent symptomatic carotid stenosis were recruited. Ambulatory transcranial Doppler and platelet aggregometry were performed at baseline and 48 hours. Patients, all on aspirin, were randomized to dipyridamole or clopidogrel. Recordings were analyzed offline masked to subject identity. Sixty patients were recruited, 30 in each arm. The primary end point of change in embolic signal frequency did not differ between groups (P=0.36). In patients with embolic signals at baseline, there was no difference in reduction in embolic signal frequency: dipyridamole (75.5; SD 17.7%) versus clopidogrel (77.5; SD 20.5%; P=0.77). Baseline platelet aggregation was not different between regimens, but at 48 hours, adenosine 5'-diphosphate aggregation rate (but not collagen) was lower with clopidogrel (P<0.001). Both dipyridamole and clopidogrel reduced embolization to a similar extent. Embolic signals are strong predictors of future stroke rate in this patient group. Our results suggest these 2 treatment regimens have similar efficacy in early secondary prevention of stroke, although this now needs testing in large Phase III trials.

Carotid stenting in acute ischemic stroke patients with intraluminal thrombus

Carotid stenosis with intraluminal thrombus is associated with a high risk of early recurrent stroke. We evaluated the feasibility and outcome of carotid stenting in acute ischemic stroke patients with carotid stenosis and intraluminal thrombus. Among 295 consecutive acute ischemic stroke patients who were referred for intra-arterial thrombolytic (IAT) therapy, six patients with carotid stenosis and intraluminal thrombus were treated by stent assisted angioplasty. The clinical characteristics, feasibility, and clinical outcomes were assessed. All patients had severe stenosis of the underlying carotid bulb (mean, 86.8%; range, 71-99%) with adjacent intraluminal thrombus. Stent assisted angioplasty resulted in successful recanalization in all six patients. Thrombus was captured with the filter device in four patients. Three patients with tandem occlusion of the ipsilateral proximal middle cerebral artery were successfully recanalized with intra-arterial urokinase. No patients suffered procedure related complications or symptomatic hemorrhage. Four patients showed good long-term outcome (3 month mRS; 0-2). Stent assisted angioplasty is a feasible treatment option for acute ischemic stroke patients caused by carotid stenosis with intraluminal thrombus and may be effective in preventing early recurrent stroke.

Recurrent stroke after cervical artery dissection

ObjectiveCervical artery dissection (CAD) accounts for 10–20% of all strokes in young adults, but no randomised controlled trial has investigated the best secondary prevention after ischaemic stroke or transient ischaemic...

A score to predict early risk of recurrence after ischemic stroke

There is currently no instrument to stratify patients presenting with ischemic stroke according to early risk of recurrent stroke. We sought to develop a comprehensive prognostic score to predict 90-day risk of recurrent stroke. We analyzed data on 1,458 consecutive ischemic stroke patients using a Cox regression model with time to recurrent stroke as the response and clinical and imaging features typically available to physician at admission as covariates. The 90-day risk of recurrent stroke was calculated by summing up the number of independent predictors weighted by their corresponding beta-coefficients. The resultant score was called recurrence risk estimator at 90 days or RRE-90 score (available at: http://www.nmr.mgh.harvard.edu/RRE-90/). Sixty recurrent strokes (54 had baseline imaging) occurred during the follow-up period. The risk adjusted for time to follow-up was 6.0%. Predictors of recurrence included admission etiologic stroke subtype, prior history of TIA/stroke, and topography, age, and distribution of brain infarcts. The RRE-90 score demonstrated adequate calibration and good discrimination (area under the ROC curve [AUC] = 0.70-0.80), which was maintained when applied to a separate cohort of 433 patients (AUC = 0.70-0.76). The model's performance was also maintained for predicting early (14-day) risk of recurrence (AUC = 0.80). The RRE-90 is a Web-based, easy-to-use prognostic score that integrates clinical and imaging information available in the acute setting to quantify early risk of recurrent stroke. The RRE-90 demonstrates good predictive performance, suggesting that, if validated externally, it has promise for use in creating individualized patient management algorithms and improving clinical practice in acute stroke care.

Vertebrobasilar Stenosis Predicts High Early Recurrent Stroke Risk in Posterior Circulation Stroke and TIA

20% of ischemic stroke is in the posterior circulation, but there is little prospective data on early recurrent stroke risk and whether vertebrobasilar stenosis predicts a high recurrence risk. This natural history data are important as it is technically possible to stent such lesions. Contrast enhanced MRA (CE-MRA) and CT angiography (CTA) now allow noninvasive identification of vertebrobasilar stenosis. 216 consecutive patients presenting with posterior circulation TIA or stroke were recruited and prospectively followed for 90 days. 8 patients with vertebral dissection were excluded. CE-MRA or CTA at presentation and 90-day follow-up was available in 182. Any posterior circulation TIA/stroke in the month before the presenting episode was recorded. Taking the first event (including TIA/stroke in the previous month) as the index case recurrent stroke risk in patients with stenosis was 30.5% versus 8.9% in those without; RR 3.4 (95% CI 1.7 to 7.0), P<0.001). Taking the presenting episode as the index case the risk was 13.8% versus 4.1%; RR 3.4 (95% CI 1.1 to 10.5) P=0.0274. The probability of recurrence was highest soon after the initial event. The presence of vertebro-basilar stenosis identifies a group of patients with posterior circulation stroke who have a high early recurrent stroke risk. Early intervention might reduce recurrent stroke risk. Vertebral stenosis can now be treated by stenting, but determining whether this reduces the early stoke risk requires randomized controlled trials.

Association of neutrophil count with microembolization in patients with symptomatic carotid artery stenosis

Background and purpose Inflammation plays an important role in the initiation and progression of atherosclerosis but the contribution of neutrophils to this process is unclear. Asymptomatic cerebral microembolization can be detected by transcranial Doppler (TCD) and has been associated with increased risk of early stroke recurrence in patients with recently symptomatic carotid stenosis. In the present study, we sought to determine whether spontaneous microembolization was associated with neutrophil count in patients with recently symptomatic carotid stenosis. Methods We continuously monitored Transcranial Doppler (TCD) spectra of middle cerebral artery blood flow ipsilateral to recently symptomatic carotid artery stenosis in 60 consecutive patients. Microembolic signals (MES) were diagnosed by experienced observers blinded to leukocyte count and high-sensitive C-reactive protein (hs-CRP) level measurement. Results We found MES in 20 (33.3%) patients. Microembolization was associated with higher neutrophil counts ( p = 0.003). Differences in monocyte count and lymphocyte count between patients with MES and patients without MES were not statistically significant. Microembolization remained strongly associated with neutrophil count in multivariable analysis ( p = 0.003) whereas the association with hs-CRP was not significant. Conclusions Neutrophil count was associated with microembolization in patients with recently symptomatic carotid artery stenosis. Our findings suggest that neutrophils may play a role in the pathogenesis of stroke related to carotid atherosclerosis.

Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison

Evidence is available on the effectiveness and costs of treatments to reduce stroke risk in long-term secondary prevention. However, there are few data on the costs and outcomes of urgent assessment and treatment after the onset of transient ischaemic attack (TIA) or minor stroke. The Early use of eXisting PREventive Strategies for Stroke (EXPRESS) study showed that urgent assessment and treatment reduced the 90-day risk of recurrent stroke by about 80%. We now report the effect of the EXPRESS intervention on admissions to hospital, costs, and disability. EXPRESS was a prospective population-based before (phase 1: April 1, 2002, to Sept 30, 2004) versus after (phase 2: Oct 1, 2004, to March 31, 2007) study of the effect of early assessment and treatment of TIA or minor stroke on the risk of early recurrent stroke. This report assesses the effect of the introduction of the phase 2 clinic on admissions to hospital within 90 days, hospital bed-days, hospital costs, and 6-month new disability (progression from no disability before event [modified Rankin scale score < or =2 points] to disability at 6 months [modified Rankin scale score >2 points]) or death, compared with the phase 1 clinic. To assess the main predictors of these outcomes, multivariate regression analyses were done. The 90-day risk of fatal or disabling stroke was reduced in phase 2 (1 of 281 vs 16 of 310; p=0.0005). Hospital admissions for recurrent stroke were also lower in phase 2 than in phase 1 (5 vs 25; p=0.001), which reduced the overall number of hospital bed-days compared with phase 1 (672 vs 1957 days; p=0.017). Hospital bed-days for admissions to hospital due to vascular causes were also lower in phase 2 (427 vs 1365 days; p=0.016), which generated savings of 624 pounds per patient referred to the phase 2 clinic (p=0.028). Results from the multivariate analyses showed that assessment in phase 2 was an independent predictor of reduced disability, days in hospital, and costs. Urgent assessment and treatment of patients with TIA or minor stroke who were referred to a specialist outpatient clinic reduced subsequent hospital bed-days, acute costs, and 6-month disability.

The risk of stroke within a week of minor stroke or transient ischemic attack

Background: The risk of stroke is highest in the first week following an index stroke or transient ischemic attack (TIA). Recent evidence indicates that prompt pharmacological treatment and evaluation may help mitigate this risk. Objective: To identify risk factors for recurrent stroke 1 week after index cerebrovascular event and review evidence for early and aggressive evaluation and management. Methods: We searched the National Library of Medicine Pubmed database to identify studies reporting recurrent or secondary stroke in individuals with identified stroke or TIA. Results/conclusion: The risk of recurrent stroke in the week after a TIA or minor stroke is up to 10%. Factors identified with risk of early stroke recurrence include age, elevated blood pressure, clinical symptoms of motor weakness or speech disturbance, and large vessel atherothrombotic mechanism. Studies have shown that timely initiation of stroke preventative therapy may reduce the risk of stroke within this early period.