Risk Of Early Recurrent Stroke Research Articles

Abstract TMP64: Time-Trends and Determinants of Dual Antiplatelet Therapy Prescription After Acute Moderate-to-Severe Non-Cardioembolic Ischemic Stroke

Introduction: Short-term dual antiplatelet therapy (DAPT) lowers the risk of early stroke recurrence after mild non-cardioembolic ischemic stroke (NCIS) and high-risk transient ischemic attack. However, DAPT benefit in moderate-to-severe NCIS is unknown. We sought to investigate time-trends and determinants of DAPT prescription after moderate-to-severe NCIS in the Florida Stroke Registry (FSR). Methods: Within 168 FSR-participating hospitals, between January 2010 and September 2022, we analyzed NCIS patients with NIHSS score >3, without other indication(s) for DAPT (e.g., carotid stenting) or systemic anticoagulation, hemorrhagic complications, and whom received at least one antiplatelet agent upon discharge. Using single antiplatelet therapy (SAPT) as comparison, we assessed DAPT determinants through logistic regression models adjusted for demographics, hospital characteristics, clinical presentation, vascular risk factors and stroke subtype. Results: Out of 283,264 ischemic stroke patients during the study period, 53,282 had moderate-to-severe NCIS (mean age 68 +/-14 years, 50% women, median presenting NIHSS score 7 [interquartile range 6]). DAPT was prescribed in 15,107 (28.4%) and SAPT in 38,175 (71.6%). DAPT prescription increased from 24.2% in 2010 to 44.8% in 2022 (Figure 1). Independent determinants of DAPT prescription are shown in Table 1. Conclusion: DAPT prescription after moderate-to-severe NCIS is common now, and has nearly doubled over the past decade. Major DAPT determinants were premorbid SAPT and large-artery atherosclerosis. Further research may determine DAPT efficacy and safety in this population.

Abstract WP106: Patient Reported Outcomes as Ischemic Stroke and Transient Ischemic Attack Predictors

Introduction: The risk of early stroke recurrence is higher in patients who have experienced a previous event. Multimodal strategies involving the active participation of patients and family members are likely the most effective therapeutic option, the perspective of which can be standardized and validated through Patient-Reported Outcome Measures (PROMs). We aimed to explore the impact of PROMs as predictors of recurrent ischemic stroke and TIA. Methods: A multicenter study based on a prospective cohort of consecutive patients with TIA and ischemic stroke between January 2022 and March 2023. Demographic and clinical data, as well as outcomes from the PROMS program, were collected through the NORA application, including the PROMIS Global Health survey, Hospital Anxiety and Depression Scale (HADS), Fatigue Assessment Scale (FAS), and the Morisky-Green Scale (MG) at 30 days. Results: A total of 2589 patients were included, with a mean age of 72 +/- 13.8 years (42% females). Forty-five recurrences were observed with a mean time to recurrence of 257 days. Recurrent patients had a higher history of smoking (33.3% vs 14.8%; p<0.001) and anticoagulant use (33.3% vs 20.8%; p<0.041). Regarding the PROMs, these patients experienced greater fatigue (FAS 24.4 vs 19.69; p<0.031), a lower tendency for therapeutic adherence (MG 14.2% vs 12.5%; p=0.77), and less return to their work (12.5% vs 32.4%; p<0.02). After the second episode, recurrent patients engaged more in surveys (2.46x10 16 vs 2.46x10 16 ) and self-education on stroke (2.44x10 16 vs 1.92x10 16 ) (p<0.01). Hypertension, previous smoking, and lower MG scores independently predicted recurrence (OR=2.72, 95% CI 1.20-6.14; OR 2.65, 95% CI 1.40-4.99; OR 0.33, 95% CI 0.11-1.01). Conclusions: In our series of TIA and minor strokes, assessing PROMs seems to be a potentially effective strategy for identifying key factors to reduce the risk of stroke recurrence and optimize secondary stroke prevention.

High risk of early recurrent stroke in patients with near-occlusion with full collapse of the internal carotid artery.

We aimed to validate the prognostic ability and assess interrater reliability of a recently suggested measurement-based definition of near-occlusion with full collapse (distal ICA diameter ≤ 2.0mm and/or ICA ratio ≤ 0.42). 118 consecutive patients with symptomatic near-occlusion were prospectively included and assessed on computed tomography angiography by 2 blinded observers, 26 (22%) had full collapse. At 2days after presenting event, the risk of preoperative stroke was 3% for without full collapse and 16% for with full collapse (p = 0.01). At 28days, this risk was 16% for without full collapse and 22% for with full collapse (p = 0.22). Interrater reliability was perfect (kappa 1.0). Thus, near-occlusion with full collapse should be defined as distal ICA ≤ 2.0mm and/or ICA ratio ≤ 0.42 in order to detect cases with very high risk of early stroke recurrence.

Abstract 074: Early Versus Late Anticoagulation In AF‐related Ischemic Stroke: A Systematic Review and Meta‐analysis of RCTs

Introduction In AF‐associated ischemic stroke, there is increased risk of early stroke recurrence, making anticoagulation treatment is highly recommended for secondary stroke prevention [1‐2]. On the other hand, high rates of ICH were also reported in this population, making it very challenging for physicians to decide when to start anticoagulation treatment [3]. We aim to investigate safety and efficacy of early versus late anticoagulation in AF patients with AIS. Methods This meta‐analysis followed the Preferred Reporting Items for Systematic reviews and Meta‐Analysis (PRISMA) guidelines. We searched PubMed, Cochrane Library, WOS, and Scopus up to June 30, 2023, to collect randomized controlled trials comparing early versus late anticoagulation for acute ischemic stroke in AF patients. The primary outcome assessed in this study was the composite efficacy outcome (as defined by individual studies). Secondary outcomes included recurrent ischemic stroke, all‐cause mortality, ICH, and mRS 0‐2 at 90 days. Using the R statistical programming language, risk ratios (RRs) with 95% confidence intervals (95% CIs) were calculated using a common‐effect model for each outcome [4]. Results Four RCTs were included, involving 3050 patients (with 1527 patients in the early group). In the pooled analysis, early treatment group showed a significantly lower risk of composite efficacy outcome (RR: 0.71, 95% CI: 0.53‐0.96, p‐value: 0.02) compared to late treatment group. Early treatment group demonstrated a lower risk in terms of recurrent ischemic stroke (RR: 0.75, 95% CI: 0.52‐1.08), intracranial hemorrhage (RR: 0.93, 95% CI: 0.59‐1.46), and all‐cause mortality (RR: 0.88, 95% CI: 0.64‐1.22), however these results were not statistically significant. Moreover, the pooled analysis of two studies that reported mRS 0‐2 outcome at 3 months, both treatment groups were found to have similar rates but statistically insignificant. Conclusion This meta‐analysis, which pooled data from 3050 ischemic stroke patients with AF, early initiation of anticoagulation treatment was associated with lower risk of composite efficacy outcome. However, no statistically significant differences were found between the two groups regarding ischemic stroke, all‐cause mortality, ICH, and mRS 0‐2 at 90 days. Early anticoagulation treatment in AF patients with AIS may be as safe and effective as late anticoagulation treatment and might provide more benefit. However, more RCTs need to be conducted.

Abstract 91: Early Stroke Recurrence Is Not Reduced By Early Statin Initiation In The Point Trial Population

Objective: To discern effects of early statin treatment on early stroke recurrence in the POINT trial. Background: Benefits of statin therapy in reducing risk of ischemic stroke over the long-term are well-established, but the immediate effects of statin therapy on early stroke recurrence after an initial ischemic event are less clear. Design/Methods: In secondary analysis of the data of the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial, we evaluated the effects of statins on early stroke recurrence within 7 days of randomization using Cox proportional hazard regression analysis. We separately compared the effects in subgroups of subjects on and not on statins prior to the index event. Results: In the POINT trial, most recurrences of ischemic stroke were early, with 175 occurring within 7 days of trial entry, and only 105 occurring over the remainder of the 90 day trial. Overall, 39% were on statin treatment at time of enrollment which increased to 79% by 7 days post-index event. In Cox proportional hazard analysis for stroke recurrence over the 7 day period after index stroke or TIA, statin administration showed no significant effect in subjects not on statin at baseline (Adjusted p=0.34). In contrast, statin use prior to enrollment was associated with decreased hazard of early stroke recurrence (Adjusted H.R. 0.31, p=0.001). Conclusion: In the POINT trial population of patients with minor ischemic stroke or TIA, prior treatment with statins was associated with decreased risk of early stroke recurrence within 7 days following index stroke or TIA. There was no effect of initiating statin treatment in reducing risk of early stroke recurrence.

Aetiology of extracranial carotid free-floating thrombus in a prospective multicentre cohort

BackgroundCarotid free-floating thrombi (FFT) in patients with acute transient ischaemic attack (TIA)/stroke have a high risk of early recurrent stroke. Management depends on aetiology, which can include local plaque rupture,...

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

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

Long-Term Impact of Urgent Secondary Prevention After Transient Ischemic Attack and Minor Stroke: Ten-Year Follow-Up of the EXPRESS Study.

Urgent assessment aimed at reducing stroke risk after transient ischemic attack or minor stroke is cost-effective over the short-term. However, it is unclear if the short-term impact is lost on long-term follow-up, with recurrent events being delayed rather than prevented. By 10-year follow-up of the EXPRESS study (Early Use of Existing Preventive Strategies for Stroke), previously showing urgent assessment reduced 90-day stroke risk by 80%, we determined whether that early benefit was still evident long-term for stroke risk, disability, and costs. EXPRESS was a prospective population-based before (phase 1: April 2002-September 2004; n=310) versus after (phase 2: October 2004-March 2007; n=281) study of the effect of early assessment and treatment of transient ischemic attack/minor stroke on early recurrent stroke risk, with an external control. This report assesses the effect on 10-year recurrent stroke risk, functional outcomes, quality-of-life, and costs. A reduction in stroke risk in phase 2 was still evident at 10 years (55/23.3% versus 82/31.6%; hazard ratio=0.68 [95% CI, 0.48-0.95]; P=0.024), as was the impact on risk of disabling or fatal stroke (17/7.7% versus 32/13.1%; hazard ratio=0.54 [0.30-0.97]; P=0.036). These effects were due to maintenance of the early reduction in stroke risk, with neither additional benefit nor rebound catch-up after 90 days (post-90 days hazard ratio=0.88 [0.65-1.44], P=0.88; and hazard ratio=0.83 [0.42-1.65], P=0.59, respectively). Disability-free life expectancy was 0.59 (0.03-1.15; P=0.043) years higher in patients in phase 2, as was quality-adjusted life expectancy (0.49 [0.03-0.95]; P=0.036). Overall, 10-year costs were nonsignificantly higher in patients attending the phase 2 clinic ($1022 [-3865-5907]; P=0.66). The additional cost per quality-adjusted life year gained in phase 2 versus phase 1 was $2103, well below current cost-effectiveness thresholds. Urgent assessment and treatment of patients with transient ischemic attack or minor stroke resulted in a long-term reduction in recurrent strokes and improved outcomes, with little atrophy of the early benefit over time, representing good value for money even with a 10-year time horizon. Our results suggest that other effective acute treatments in transient ischemic attack/minor stroke in the short-term will also have the potential to have long-term benefit.

Pediatric Stroke: Overview and Recent Updates.

Stroke can occur at any age or stage in life. Although it is commonly thought of as a disease amongst the elderly, it is important to highlight the fact that it also affects infants and children. In both populations, strokes have a high rate of morbidity and mortality. Arguably, it is more detrimental in the pediatric population given the occurrence at a younger age and therefore, a longer duration of disability, potentially over the entire lifespan. The high rate of morbidity and mortality in pediatrics is attributed to significant delays in diagnosis, as well as misdiagnosis. Acute stroke management is time dependent. Patients who receive acute treatment with either intravenous (IV) tissue plasminogen activator (tPA) or mechanical thrombectomy, have improved mortality and functional outcomes. Additionally, the earlier treatment is initiated, the higher the likelihood of preserving penumbra, restoring cerebral blood flow and potentially reversing symptoms, thereby limiting disability. Prompt identification is essential as it leads to improved patient care in such a narrow therapeutic window. It enhances the care received during hospitalization and reduces the risk of early stroke recurrence. Despite limited data and lack of large randomized clinical trials in pediatrics, both IV tPA and mechanical thrombectomy have been successfully used. Bridging the gap of acute stroke management in the pediatric population is an essential part of minimizing adverse outcomes. In this review, we discuss the epidemiology of pediatric stroke, the diverse etiologies, presentation as well as both acute and preventative management.

Ipsilateral Nonstenotic Carotid Disease in Minor Ischemic Stroke: an Exploratory Analysis of The POINT Randomized Clinical Trial

Background and aimIpsilateral nonstenotic carotid disease is increasingly recognized as an etiology of ischemic stroke, however tailored treatment strategies are lacking. We aimed to examine clinical characteristics and treatment effects in patients with minor ischemic stroke associated with ipsilateral nonstenotic carotid disease in the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial. MethodsWe performed an exploratory analysis of the interaction of the treatment effects of aspirin plus clopidogrel versus aspirin monotherapy, stratified by presence of ipsilateral nonstenotic carotid disease in patients with minor ischemic stroke in the POINT trial. ResultsFor this exploratory analysis, 167 patients presenting with ischemic stroke and ipsilateral nonstenotic carotid disease, defined as 1%-49% carotid stenosis ipsilateral to the corresponding territory of ischemic stroke, and 833 patients no carotid disease were included. Compared to patients with no carotid disease, patients with ipsilateral nonstenotic carotid disease were older (68.5 ± 11.3 years versus 61.3 ± 12.8 years; P < 0.001), and had a higher prevalence of hypertension (76.6% versus 59.2%, P < 0.001), ischemic heart disease (13.8% versus 5.4%, P < 0.001), and tobacco use (past: 34.1% versus 25.2%, P = 0.005; present: 27.5% versus 22.8%, P = 0.005). 5.4% of patients with ipsilateral nonstenotic carotid disease had recurrent ischemic stroke within 14 days. Patients receiving dual antiplatelet therapy had a numerical reduction in recurrent ischemic stroke compared to patients receiving aspirin monotherapy, however the exploratory analysis was underpowered to detect a statistically significant difference in treatment effect (HR 0.50, 95% CI 0.18-1.40, P = 0.19). ConclusionPatients with minor ischemic stroke and ipsilateral nonstenotic carotid disease had a high risk of early stroke recurrence in the POINT trial. Dual antiplatelet therapy provided a non-statistically significant reduction in recurrent ischemic stroke with no difference in safety outcomes compared to aspirin monotherapy. Further study is needed to determine if early and short duration dual antiplatelet therapy is beneficial for all patients with ipsilateral nonstenotic carotid disease.

Impact of Infection on the Risk of Recurrent Stroke Among Patients With Acute Ischemic Stroke.

Infection occurs commonly in patients with acute ischemic stroke. We aimed to investigate the association of infection with short- and long-term risk of recurrent stroke in patients with ischemic stroke. Data were derived from ischemic stroke patients in 2 stroke registries: the CSCA (Chinese Stroke Center Alliance) program recorded medical data during hospitalization, and the CNSR-III (Third China National Stroke Registry) recorded the medical data during hospitalization and finished 1-year follow-up. Associations of infection (pneumonia or urinary tract infection) during hospitalization with recurrent stroke in short (during hospitalization) and long term (since 30 days to 1 year after stroke onset) were analyzed. Short-term outcomes were analyzed with logistic models and long-term outcomes with Cox models. In the CSCA (n=789 596), the incidence of infection during hospitalization reached 9.6%. Patients with infection had a higher risk of stroke recurrence during hospitalization compared with patients without infection (10.4% versus 5.2%; adjusted odds ratio, 1.70 [95% CI, 1.65-1.75]; P<0.0001). In the CNSR-III (n=13 549), the incidence of infection during hospitalization was 6.5%. Infection during hospitalization was significantly associated with short-term risk of recurrent stroke (7.4% versus 3.9%; adjusted odds ratio, 1.40 [95% CI, 1.05-1.86]; P=0.02) but not with long-term risk of recurrent stroke (7.2% versus 5.2%; adjusted hazard ratio, 1.16 [95% CI, 0.88-1.52]; P=0.30). Infection was an independent risk factor for high risk of early stroke recurrence during hospitalization, but we have not found its sustained effect on long-term recurrent risk in patients with acute ischemic stroke.

Vertebral Artery Stenoses Contribute to the Development of Diffuse Plaques in the Basilar Artery.

Vertebral artery (VA) stenosis is relevant to a high early risk of recurrent stroke and basilar artery (BA) is the most common intracranial site of atherosclerotic lesions. It is important to show predictive risk factors for transient ischemic attack (TIA) or posterior infarctions. The aim of the study is to investigate morphometry and hemodynamics in intracranial vertebral and basilar arteries of health and diseased patients to enhance the risk assessment. Based on the geometrical model reconstructed from CTA images in 343 patients, a transient three-dimensional computational model was used to determine the hemodynamics. Patients were classified in symmetric, asymmetric, hypoplastic, and stenotic groups while patients in the stenotic group were divided into unilateral, bilateral, bifurcation, and tandem stenotic sub-groups. Patients in bilateral, bifurcation, and tandem stenotic sub-groups had significantly lower basilar artery diameters than other groups. Patients in the stenotic group had significantly higher surface area ratio (SAR) of high time-averaged wall shear stress gradient (TAWSSG) and higher incidence of TIAs or posterior infarctions than other groups while patients in the tandem stenotic sub-group had the highest values (SAR-TAWSSG of 57 ± 22% and TIAs or posterior infarction incidence of 54%). The high SAR-TAWSSG is predisposed to induce TIAs or posterior infarction.

Higher early recurrence risk and potential benefit of dual antiplatelet therapy for minor stroke with watershed infarction: subgroup analysis of CHANCE.

The aim was to explore the risk of early stroke recurrence within 3months after watershed infarction and to investigate whether early dual antiplatelet therapy is more effective in decreasing such risk. Patients enrolled in the Clopidogrel in High-risk Patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial and who had acute infarction on diffusion-weighted imaging were included in this subgroup analysis. All magnetic resonance images were read centrally by two neurologists who were blinded to the patients' baseline and outcome information. The primary outcome was any stroke recurrence within 3months. The hazard ratios were adjusted by known predictors of stroke recurrence. Of the 1089 patients with magnetic resonance imaging data enrolled in CHANCE, 834 (76.58%) patients had acute infarcts on diffusion-weighted imaging. The median and range of duration from randomization to stroke recurrence was 1.5 (1-6) days. Patients with watershed infarction had higher risk of stroke recurrence than those without (17.20% vs. 6.34%) within the first week after initial stroke; the hazard ratio (95% confidence interval) was 2.799 (1.536-5.101) adjusted by age, sex, smoking, body mass index, medical history, time to randomization, open-label aspirin dose at first day, single or dual antiplatelet therapy, National Institutes of Health Stroke Scale score at randomization, in-hospital treatment and white matter lesions, P<0.001. There was no interaction between antiplatelet therapy and the presence of watershed infarction (P=0.544). Minor stroke with watershed infarction has high recurrent risk in the first week. Dual antiplatelet therapy may be safely implemented, yet watershed infarction mechanisms of hypoperfusion and emboli may not be addressed.

Abstract P605: Border-Zone Infarcts Predict Early Recurrence in Patients With Large Artery Atherosclerotic Subtype Despite Medical Treatment

Objective: We aim to investigate infarct patterns and 90-day recurrence in patients with symptomatic intracranial atherosclerotic disease. Background: Large artery atherosclerosis subtype carries a high risk of early recurrent stroke despite medical management. Predictors of recurrence remain poorly understood. We hypothesized that border-zone infarcts are associated with a higher risk of recurrence. Design/Methods: We included consecutive patients admitted to NYU Langone Health (Manhattan and Brooklyn campuses) over 32-months with a diagnosis of acute ischemic stroke secondary to symptomatic intracranial or tandem atherosclerosis. Patients with purely extracranial stenosis were excluded. The primary predictor was infarct pattern (border-zone vs. non-border-zone infarction), defined in accordance to previous studies. We used univariate and multivariable cox-regression models to determine associations between infarct pattern and recurrent cerebrovascular events (RCVE) at 90-days. Results: Ninety-nine patients met the inclusion criteria; 95 were intracranial and 4 were tandem lesions. The mean age was 70 years, 58.6% were men, 15.1% Black and 16.1% Asian. The median symptom onset to arrival time was 1 day, nearly 74.7% of patients were treated with dual antiplatelet therapy and 99% were treated with high intensity statin. Within 90 days of follow up, 19.2% (19/99) had RCVE. In univariate analyses, the only factor associated with RCVE was border-zone infarct pattern when compared to non-border-zone infarct pattern (30.2% vs. 10.7%, p=0.02). In cox regression models, after adjusting for age and sex, border-zone infarct pattern was associated with increased risk of RCVE (adjusted HR 3.21 95% CI 1.21-8.51, p=0.019). Sensitivity analyses excluding patients with tandem lesions (n = 4) did not meaningfully change our findings (adjusted HR 3.04 95% CI 1.11-8.31, p=0.031). Conclusions: In real world post-SAMMPRIS medically treated patients with ICAD, infarct pattern was predictive of 90-day RCVE. Border-zone infarcts are likely a surrogate marker of impaired distal blood flow, highlighting the importance of targeting stroke mechanisms and developing alternative treatment strategies for this high-risk cohort.

Association of Black Race With Early Recurrence After Minor Ischemic Stroke or Transient Ischemic Attack

Stroke incidence is higher among black than white individuals in the United States. It is unclear whether black individuals have a higher risk of stroke recurrence after a minor ischemic stroke or transient ischemic attack (TIA), a high-risk setting in which focused preventive efforts can be effective. To examine the association between black race and early ischemic stroke recurrence. This cohort study analyzed data from the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial conducted at 269 sites from May 28, 2010, to December 19, 2017. The trial enrolled 4881 adults within 12 hours of onset of a minor ischemic stroke (National Institutes of Health Stroke Scale score, 0-3) or high-risk TIA (ABCD2 score, ≥4). For this analysis, we excluded 598 patients enrolled outside the United States and 239 US patients with missing race/ethnicity data. The primary outcome for this analysis was ischemic stroke within 90 days after randomization. Covariates included age, sex, Hispanic ethnicity, study assignment to take clopidogrel vs placebo, index stroke vs TIA, vascular risk factors, statin use, study drug adherence, and index event etiological subtype. Among 4044 patients included in the analysis, 918 (22.7%) were black. In an adjusted Cox model, black race was associated with a higher risk of recurrence compared with white race (hazard ratio, 1.6; 95% CI, 1.1-2.3). Findings were similar in subgroup analyses and in analyses limited to sites that enrolled black patients. Among US participants in the POINT trial, black individuals faced a higher risk of early stroke recurrence after a minor ischemic stroke or TIA. Our findings support research into black-white racial differences in the underlying mechanisms of recurrent stroke. In the meantime, extra effort should be made to ensure that black patients have access to proven secondary prevention measures. clinicaltrials.gov Identifier: NCT00991029.

Abstract WP183: Borderzone Infarcts Predict Early Recurrence in Patients With Large Artery Atherosclerotic Subtype Despite Medical Treatment

Introduction: Large artery atherosclerosis subtype carries a high risk of early recurrent stroke despite medical management. Predictors of recurrence remain poorly understood. We hypothesized that borderzone infarcts are associated with a higher risk of recurrence. Objectives: We aim to investigate infarct patterns and 90-day recurrence in patients with symptomatic intracranial and/or extracranial atherosclerotic disease. Methods: We included consecutive patients admitted to NYU Langone Health (Manhattan and Brooklyn campuses) over 32-months with a diagnosis of acute ischemic stroke secondary to symptomatic intracranial or extracranial atherosclerosis. The primary predictor was infarct pattern (borderzone vs. non-borderzone infarction), defined in accordance to previous studies. Borderzone infarcts were divided into internal borderzone and cortical borderzone. We used univariate and multivariable cox-regression models to determine associations between infarct pattern and recurrent cerebrovascular events (RCVE) at 90-days. Results: Fifty-five patients met the inclusion criteria; 38 were intracranial, 3 tandem, 14 extracranial. Nearly 71% of patients were treated with dual antiplatelet therapy and 96% were treated with high intensity statin. The RCVE rate was 23.6%. In multivariable models, borderzone infarcts were associated with increased risk of RCVE (adjusted HR 9.8 95% CI 2.1-44.8, p=0.003). The risk of RCVE was highest among internal borderzone infarcts (47.3%) as opposed to cortical borderzone infarcts (33.3%) or non borderzone infarcts (18.8%). Conclusions: Borderzone (and particularly internal borderzone) infarcts are a surrogate marker of impaired distal blood flow and are associated with RCVE despite medical treatment. This highlights the need to develop alternate treatment strategies for this high-risk cohort.

Abstract TP135: Urgent Treatment for Symptomatic Carotid Stenosis: The Pittsburgh Revascularization and Treatment Emergently After Stroke Protocol

Background: Patients with symptomatic carotid stenosis remain at high risk of early recurrent stroke without revascularization. The aim of this report is to analyze prospectively-recorded data from an institutional protocol that standardized the urgent (&lt;48 hours) treatment of patients presenting with symptomatic carotid stenosis and underwent either carotid stenting (CAS) or carotid endarterectomy (CEA). Methods: All patients presenting over 28 months to a comprehensive stroke center with symptomatic carotid stenosis within 48 hours of index event were screened for inclusion. All patients were given dual antiplatelet therapy. If there was clinical equipoise between CEA and CAS, patients underwent angiography and subsequently revascularization if DSA demonstrated ≥50% stenosis. The primary outcome was a composite of stroke or death within 30 days. Results: 178 patients with a diagnosis of recently symptomatic carotid stenosis were included; 120 patients (67%) met criteria. 59 patients underwent CEA and 61 patients underwent CAS. There were not significant differences in the primary outcome; 3 patients (5.1%) in the CEA arm and 3 patients (4.9%) in the CAS arm met the primary outcome. Conclusion: In this prospective analysis, urgent revascularization for symptomatic carotid stenosis can be done with equivalently low rates of stroke or death, regardless of revascularization strategy.

272 Clinical Audit on Transient Ischaemic Attack Investigations in Acute Medical Unit

Abstract Background TIA (Transient Ischaemic Attack) is a transient episode of neurologic dysfunction. Patients with a TIA have a high early risk of recurrent stroke. These patients need urgent initial evaluation with brain imaging, neurovascular imaging and cardiac evaluation. We conducted retrospective audit in our Acute Medical Unit (AMU) to assess waiting time and type of investigations completed as per TIA guidelines Methods All consecutive admissions with suspected TIAs were evaluated on length of stay, type of imaging tests obtained and how long they awaited for these tests. This was assessed by reviewing discharge summaries, and times and dates of scans on hospital imaging system. Results There was a total of 28 patients admitted to AMU with suspected TIA’s. Of these, 16 were female and 12 were male. Mean age was 70. All patients had CT brain done on admission, two out of 28 had to wait more than 12 hours. 25 out of 28 (89%) patients got US Carotid Dopplers, and two had CT intracranial angiograms. Average waiting time for US Carotid Dopplers was 33 hours, shortest wait was 6 hours and longest was 72 hours. 14 out of 24 (58%) had inpatient heart monitoring (24h telemetry or 24h Holter) two were excluded with known atrial fibrillation, one had PPM in situ and one refused monitoring. Average length of stay in AMU was 3 days. Conclusion Patients admitted to AMU with suspected TIAs had relevant imaging and tests completed as per guidelines. 89 % had US Carotid Dopplers which were on average done 33h from admission. 58% of patients had inpatient heart monitoring. The average length of stay was 3 days but three patients stayed in AMU for up to 5 days. Protected imaging slots for AMU would expedite investigations and reduce inpatient stay.

Vertebral artery stenting to prevent recurrent stroke in symptomatic vertebral artery stenosis: the VIST RCT.

Symptomatic vertebral artery (VA) stenosis has been associated with a markedly increased early risk of recurrent stroke. VA stenosis can be treated with stenting; however, there are few data from randomised controlled trials evaluating the efficacy of this treatment, and recent studies in intracranial stenosis have suggested that stenting may be associated with increased risk. The Vertebral artery Ischaemia Stenting Trial (VIST) was established to compare the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for recently symptomatic VA stenosis. VIST was a prospective, randomised, open, parallel, blinded end-point clinical trial. The trial was performed in 14 hospitals in the UK. Recruitment began on 23 October 2008 and follow-up ended on 1 March 2016, by which time every patient had been followed up for at least 1 year. Participants had to have symptomatic vertebral stenosis of at least 50% resulting from presumed atheromatous disease. Both patients and clinicians were aware of treatment allocation; however, an independent adjudication committee, masked to treatment allocation, assessed all primary and secondary end points. Participants were randomly assigned (1 : 1) to either vertebral angioplasty/stenting plus BMT (n = 91) or BMT alone (n = 88). A total of 182 patients were initially enrolled; however, three patients (two who withdrew after randomisation and one who did not attend after the initial randomisation visit) did not contribute any follow-up data and were excluded. None of these three patients had outcome events. The primary end point was the occurrence of fatal or non-fatal stroke in any arterial territory during follow-up. The median follow-up was 3.5 (interquartile range 2.1-4.7) years. Of the 61 patients who were stented, 48 (78.7%) had extracranial stenosis and 13 (21.3%) had intracranial stenosis. No perioperative complications occurred with extracranial stenting; two strokes occurred during intracranial stenting. The primary end point occurred in five patients (including one fatal stroke) in the stent group and in 12 patients (including two fatal strokes) in the medical group (giving a hazard ratio of 0.40, 95% confidence interval 0.14 to 1.13; p = 0.08), with an absolute risk reduction of 25 strokes per 1000 person-years. The study was underpowered because it failed to reach target recruitment. The high rate of non-confirmation of stenosis in the stented group of the trial was a second limitation. The trial found no difference in risk of the primary end point between the two groups. Post hoc analysis suggested that stenting could be associated with a reduced recurrent stroke risk in symptomatic VA and further studies are now required to confirm these findings, particularly in extracranial VA stenosis where complication rates with stenting were confirmed to be very low. Current Controlled Trials ISRCTN95212240. 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. 23, No. 41. See the NIHR Journals Library website for further project information. In addition, funding for the pilot phase was provided by the Stroke Association.

Anticoagulation in the early phase of non-valvular atrial fibrillation-related acute ischemic stroke: where do we stand?

The balance between the risk of early stroke recurrence and hemorrhagic transformation represents the cornerstone of practical management of non-valvular atrial fibrillation (NVAF)-related acute ischemic stroke (AIS). Patients who receive antithrombotic therapy as secondary prevention in the early phase of NVAF-related AIS have a better prognosis compared with patients who do not receive antithrombotic treatment. Recently, the RAF study showed that the best efficacy/safety profile was associated with anticoagulation started between 4 and 14 days from stroke onset. Based on the RAF study, the 2018 American Heart Association/American Stroke Association (AHA/ASA) guidelines suggest starting anticoagulants between 4 and 14 days from stroke onset with a class of recommendation IIa. Strong evidence for the use of direct oral anticoagulants (DOACs) in the early phase of NVAF-related AIS is lacking, because this kind of patients were excluded from phase III randomized clinical trials (RCT) and ad hoc RCTs are ongoing. However, the real life evidence suggests that early starting time of DOACs in patients with NVAF-related AIS is safe and associated with low recurrence risk and all-cause mortality. In the present review the Authors provide an update on anticoagulation in the early phase of NVAF-related AIS with focus on DOACs.