Risk Of Subsequent Stroke Research Articles

Efficacy and safety of a TIA/stroke electronic support tool (FASTEST) trial: study protocol.

BackgroundStrokes are a common cause of adult disability and mortality worldwide. Transient ischaemic attacks (TIA) are associated with a high risk of subsequent stroke, and rapid intervention has the potential to reduce stroke burden. This study will assess a novel electronic decision support (EDS) tool to allow general practitioners (GPs) to implement evidence-based care rapidly without full reliance on specialists.Methods/designThis is a cluster randomized controlled trial comparing TIA/stroke management of GPs with access to the EDS tool versus usual care. The intervention period is 12 months with a 3-month follow-up period for individual patients. Primary outcomes consist of stroke within 90 days of presenting event and adherence to the New Zealand national TIA guideline.DiscussionA positive study will provide strong evidence for widespread implementation of this tool in practice and has the potential to improve key outcomes for patients and reduce the burden of stroke.Trial registrationAustralia New Zealand Clinical Trials Registry ACTRN12611000792921

Cardiovascular Outcomes After Preeclampsia or Eclampsia Complicated by Myocardial Infarction or Stroke

To assess the relationship between preeclampsia or eclampsia and stroke, myocardial infarction (MI), subsequent cardiovascular outcomes, and long-term survival. Using the Myocardial Infarction Data Acquisition System in New Jersey (1994-2009), we analyzed cardiovascular outcomes in women with and without preeclampsia or eclampsia and a first MI or stroke but with a hospitalization for a first MI or stroke (analysis 1: MI case group, n=57; MI control group, n=155; stroke case group, n=132; stroke control group, n=379). We also compared these outcomes in women with preeclampsia or eclampsia and a first MI or stroke during pregnancy with women with preeclampsia or eclampsia without MI or stroke during pregnancy (analysis 2: MI case group, n=23; MI control group, n=67; stroke case group, n=90; stroke control group, n=263). A subsequent occurrence of MI, stroke, and cardiovascular death, as well as a combined cardiovascular outcome, was ascertained. In analysis 1, women with preeclampsia or eclampsia were at significantly lower risk for combined cardiovascular outcome with all deaths (frequency of outcome 16.7%) and with cardiovascular deaths (10.6%) compared with women without preeclampsia or eclampsia after a first stroke (33.8% and 23.5%, respectively). In analysis 2, women with preeclampsia or eclampsia and a first stroke during admission were at significantly higher risk of all death (11.1%) and the combined cardiovascular outcome with all deaths (11.1%) compared with women with preeclampsia or eclampsia without a stroke (1.9% and 2.7%, respectively) during that admission. Our study indicates that preeclampsia or eclampsia not complicated by MI or stroke during pregnancy may not confer a very high risk for subsequent MI and stroke in up to 16 years of follow-up. Our data suggest that other known risk factors put women at greater risk for stroke than preeclampsia or eclampsia complicated by a stroke. II.

Extracranial-Intracranial Bypass Surgery for Stroke Prevention in Hemodynamic Cerebral Ischemia

Context Patients with symptomatic atherosclerotic internal carotid artery occlusion (AICAO) and hemodynamic cerebral ischemia are at high risk for subsequent stroke when treated medically. Objective To test the hypothesis that extracranial-intracranial (EC-IC) bypass surgery, added to best medical therapy, reduces subsequent ipsilateral ischemic stroke in patients with recently symptomatic AICAO and hemodynamic cerebral ischemia. Design Parallel-group, randomized, open-label, blinded-adjudication clinical treatment trial conducted from 2002 to 2010. Setting Forty-nine clinical centers and 18 positron emission tomography (PET) centers in the United States and Canada. The majority were academic medical centers. Participants Patients with arteriographically confirmed AICAO causing hemispheric symptoms within 120 days and hemodynamic cerebral ischemia identified by ipsilateral increased oxygen extraction fraction measured by PET. Of 195 patients who were randomized, 97 were randomized to receive surgery and 98 to no surgery. Follow-up for the primary end point until occurrence, 2 years, or termination of trial was 99% complete. No participant withdrew because of adverse events. Interventions Anastomosis of superficial temporal artery branch to a middle cerebral artery cortical branch for the surgical group. Antithrombotic therapy and risk factor intervention were recommended for all participants. Main Outcome Measure For all participants who were assigned to surgery and received surgery, the combination of (1) all stroke and death from surgery through 30 days after surgery and (2) ipsilateral ischemic stroke within 2 years of randomization. For the nonsurgical group and participants assigned to surgery who did not receive surgery, the combination of (1) all stroke and death from randomization to randomization plus 30 days and (2) ipsilateral ischemic stroke within 2 years of randomization. Results The trial was terminated early for futility. Two-year rates for the primary end point were 21.0% (95% CI, 12.8% to 29.2%; 20 events) for the surgical group and 22.7% (95% CI, 13.9% to 31.6%; 20 events) for the nonsurgical group (P = .78, Z test), a difference of 1.7% (95% CI, −10.4% to 13.8%). Thirty-day rates for ipsilateral ischemic stroke were 14.4% (14/97) in the surgical group and 2.0% (2/98) in the nonsurgical group, a difference of 12.4% (95% CI, 4.9% to 19.9%). Conclusion Among participants with recently symptomatic AICAO and hemodynamic cerebral ischemia, EC-IC bypass surgery plus medical therapy compared with medical therapy alone did not reduce the risk of recurrent ipsilateral ischemic stroke at 2 years. Trial Registration clinicaltrials.gov Identifier: NCT00029146

Ischemic Brain Injury After Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the second most common cause of stroke and accounts for 8% to 15% of strokes in Western societies with an estimated incidence of 10 to 25 per 100 000 persons.1–3 Despite advances in the field of stroke and neurocritical care,4 the 30-day mortality has not changed significantly over the past 20 years.3 Indeed, ICH has the highest rates of dependence or death among stroke types and proven treatments are lacking. Clinical trials aimed at limiting hemorrhage growth, procoagulant agents for hemostasis,5 and surgical evacuation6 have not translated into improved clinical outcomes. Antihypertensive therapy for the purpose of reducing hematoma growth has been a mainstay of acute management. Guidelines recommend maintaining mean arterial pressure <130 mm Hg during the acute phase7; however, controversies exist given the lack of randomized clinical trial data and uncertainties about the rapidity and target level of blood pressure (BP)-lowering. Recent Phase 2 clinical trials evaluating acute BP control have shown promise in reducing hematoma expansion with an adequate safety profile and Phase 3 trials are underway.8,9 Besides hematoma growth, other pathophysiological processes occur in the setting of ICH and may serve as potential therapeutic targets. In the acute period after ICH, a rapid rise in intracranial pressure (ICP) from an expanding hematoma may reduce cerebral perfusion pressure. In this setting, interventions aimed at BP-lowering and hemostasis may theoretically induce thrombosis or exacerbate brain ischemia, particularly in patients with pre-existing cerebrovascular disease. A recent publication suggests that aggressive BP-lowering may actually cause acute brain ischemia and worsen outcomes after ICH.10 In this review, we outline the data on secondary acute ischemic injury after ICH, review the prevalence of remote ischemic lesions and risk factors associated with their occurrence, explore potential …

Retinal Artery Occlusion and the 3-Year Risk of Stroke in Taiwan: A Nationwide Population-Based Study

To verify the association between retinal artery occlusion (RAO) and stroke with a large-scale nationwide study. Retrospective nationwide population-based administrative database study. Data were collected from the Longitudinal Health Insurance Database 2000 (LHID2000), which contains claim data from 1 million randomly selected beneficiaries among Taiwan's 23 million residents. The study cohort consisted of all patients with a diagnosis of RAO from January 1999 through December 2006 (n = 464). The control group consisted of randomly selected patients (n = 2748) matched with the study group by age, sex, date of index medical care, and comorbid hypertension. Patients were tracked from their index date for 3 years. The Kaplan-Meier method was used to compute the stroke-free survival rate. Cox proportional hazard regressions were used to compute the adjusted stroke-free survival rate after adjusting for possible confounding factors. Ninety-one RAO patients (19.61%) and 280 controls (10.05%) had a stroke (P < .0001) during the 3-year follow-up period. Compared with the controls, the incidence rate ratios of stroke in RAO patients were 9.46 at 0-1 month, 5.57 at 1-6 months, and 2.16 at 0-3 years after RAO (P < .0001). After adjusting for age, sex, and selected comorbid disorders, the hazard ratio of having a stroke for RAO patients was still 2.07 times higher than that of controls and 3.34 times higher in the ≤60-year-old subgroup. RAO increases the risk for subsequent stroke. Early neurologic evaluation and secondary prevention for stroke are recommended for RAO patients.

Risk of subsequent ischemic and hemorrhagic stroke in patients hospitalized for immune-mediated diseases: a nationwide follow-up study from Sweden

BackgroundCertain immune-mediated diseases (IMDs) have been associated with increased risk for cardiovascular disorders. The aim of the present study was to examine whether there is an association between 32 different IMDs and first hospitalization for ischemic or hemorrhagic stroke.MethodsAll individuals in Sweden hospitalized with a main diagnosis of IMD (without previous or coexisting stroke), between January 1, 1987 and December 31, 2008 (n = 216,291), were followed for first hospitalization for ischemic or hemorrhagic stroke. The reference population was the total population of Sweden. Adjusted standardized incidence ratios (SIRs) for ischemic and hemorrhagic stroke were calculated.ResultsTotally 20 and 15 of the 32 IMDs studied, respectively, were associated with an increased risk of ischemic and hemorrhagic stroke during the follow-up. The overall risks of ischemic and hemorrhagic stroke during the first year after hospitalization for IMD were 2.02 (95% CI 1.90–2.14) and 2.65 (95% CI 2.27–3.08), respectively. The overall risk of ischemic or hemorrhagic stroke decreased over time, to 1.50 (95% CI 1.46–1.55) and 1.83 (95% CI 1.69–1.98), respectively, after 1–5 years, and 1.29 (95% CI 1.23–1.35) and 1.47 (95% CI 1.31–1.65), respectively, after 10+ years. The risk of hemorrhagic stroke was ≥2 during the first year after hospitalization for seven IMDs: ankylosing spondylitis (SIR = 8.11), immune thrombocytopenic purpura (SIR = 8.60), polymyalgia rheumatica (SIR = 2.06), psoriasis (SIR = 2.88), rheumatoid arthritis (SIR = 3.27), systemic lupus erythematosus (SIR = 8.65), and Wegener´s granulomatosis (SIR = 5.83). The risk of ischemic stroke was ≥2 during the first year after hospitalization for twelve IMDs: Addison’s disease (SIR = 2.71), Crohn´s disease (SIR = 2.15), Grave´s disease (SIR = 2.15), Hashimoto´s thyroiditis (SIR = 2.99), immune thrombocytopenic purpura (SIR = 2.35), multiple sclerosis (SIR = 3.05), polymyositis/dermatomyositis (SIR = 3.46), rheumatic fever (SIR = 3.91), rheumatoid arthritis (SIR = 2.08), Sjögren’s syndrome (SIR = 2.57), systemic lupus erythematosus (SIR = 2.21), and ulcerative colitis (SIR = 2.15).ConclusionsHospitalization for many IMDs is associated with increased risk of ischemic or hemorrhagic stroke. The findings suggest that several IMDs are linked to cerebrovascular disease.

Role of the CHADS2 Score in Acute Coronary Syndromes: Risk of Subsequent Death or Stroke in Patients With and Without Atrial Fibrillation

Atrial fibrillation (AF) is common in patients with acute coronary syndromes (ACS). We aimed to describe the value of the CHADS(2) (congestive heart failure, hypertension, age ≥ 75 years, diabetes, prior stroke or transient ischemic attack) score as a risk assessment tool for mortality and stroke in patients with ACS, irrespective of the presence or absence of AF.Consecutive patients with ACS admitted to the coronary care unit were prospectively included in a risk stratification study. We calculated the CHADS(2) scores from the data collected at admission, and all patients were followed until January 1, 2007, or death.Of 2,335 patients with ACS in this study, 442 (age 71 ± 8 years, 142 women) had AF. Their mean CHADS(2) score was 1.6 ± 1.4 vs 1.0 ± 1.1 in patients without AF (P < .0001). The all-cause mortality at 10 years was strongly associated with the CHADS(2) score in patients with AF (hazard ratio [HR] and 95% CI per unit increase in the six-grade CHADS(2) score, 1.21 [1.07-1.36]; P = .002), but the same association was also present in patients without AF (HR 1.38 [1.28-1.48], P < .0001), after adjustment for potential confounders. The more complicated GRACE (Global Registry of Acute Coronary Events) risk score provided a better prediction for short- and long-term mortality than the simpler CHADS(2) score (P < .0001). Hospitalization for stroke was significantly associated with the CHADS(2) score in patients without AF (but not in those with AF) after adjustment (HR 1.46 [1.27-1.68], P < .0001).In patients with ACS, AF is associated with poor prognosis. The CHADS(2) score developed for AF has even greater prognostic value in patients who do not have AF, and it may help to identify patients with high risk for subsequent stroke or death and a need for optimization of risk-reducing treatment.

Urinary calculi and an increased risk of stroke: a population‐based follow‐up study

Study Type--Prognosis (cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? Although early studies failed to detect an association between urinary calculi (UC) and subsequent cardiovascular risk, there is growing evidence among more recent research supporting this association with some studies more specifically suggesting that stroke is a major concern for UC sufferers. After adjusting for potential confounding factors, UC patients were more likely to have experienced a stroke then those without UC during the five-year follow-up period (hazard ratio = 1.43, 95% Cl = 1.35-1.50, P < 0.001). • To examine in a population-based study the relationship between a history of nephrolithiasis and/or ureterolithiasis and the subsequent risk of stroke, as previous studies have shown that stone disease is associated with several cardiovascular risk factors. However, none of the studies that have investigated the relationship between urinary calculi (UC) and stroke were able to detect an association at a significant level. • We used data sourced from the Taiwan Longitudinal Health Insurance Database 2000. • In all, 25,181 adult patients newly diagnosed with UC were recruited as a study cohort, along with 125,905 matched enrolees with no history of stone disease as a comparison cohort. • All the subjects were tracked for a 5-year period beginning from their index ambulatory care visits, and those who subsequently had a stroke identified. • Cox proportional hazards regressions were used to compare the risk of stroke between the study and comparison cohorts. • During the 5-year follow-up period, the incidence rate of stroke was 1.78 (95% confidence interval [CI] 1.71-1.86) per 100 person-years in patients with UC and 1.25 (95% CI 1.22-1.27) per 100 person-years in patients without UC. • After adjusting for hypertension, diabetes, hyperlipidaemia, cardiovascular disease, urbanization level, gout, and obesity, patients with UC were more likely to have had a stroke than those without UC during the 5-year follow-up period (hazard ratio 1.43, 95% CI 1.35-1.50, P < 0.001). • Our results suggest that there is an increased risk of stroke during the first 5 years after a diagnosis of UC.

Sex Differences in Stroke Risk Among Older Patients With Recently Diagnosed Atrial Fibrillation

Stroke is a serious complication associated with atrial fibrillation (AF). Women with AF are at higher risk of stroke compared with men. Reasons for this higher stroke risk in women remain unclear, although some studies suggest that undertreatment with warfarin may be a cause. To compare utilization patterns of warfarin and the risk of subsequent stroke between older men and women with AF at the population level. Population-based cohort study of patients 65 years or older admitted to the hospital with recently diagnosed AF in the province of Quebec, Canada, 1998-2007, using administrative data with linkage between hospital discharge, physicians, and prescription drug claims databases. Risk of stroke. The cohort comprised 39,398 men (47.2%) and 44,115 women (52.8%). At admission, women were older and had a higher CHADS(2) (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack) score than men (1.99 [SD, 1.10] vs 1.74 [SD, 1.13], P < .001). At 30 days postdischarge, 58.2% of men and 60.6% of women had filled a warfarin prescription. In adjusted analysis, women appeared to fill more warfarin prescriptions compared with men (odds ratio, 1.07 [95% CI, 1.04-1.11]; P < .001). Adherence to warfarin treatment was good in both sexes. Crude stroke incidence was 2.02 per 100 person-years (95% CI, 1.95-2.10) in women vs 1.61 per 100 person-years (95% CI, 1.54-1.69) in men (P < .001). The sex difference was mainly driven by the population of patients 75 years or older. In multivariable Cox regression analysis, women had a higher risk of stroke than men (adjusted hazard ratio, 1.14 [95% CI, 1.07-1.22]; P < .001), even after adjusting for baseline comorbid conditions, individual components of the CHADS(2) score, and warfarin treatment. Among older patients admitted with recently diagnosed AF, the risk of stroke was greater in women than in men, regardless of warfarin use.

Etiological Classifications of Transient Ischemic Attacks: Subtype Classification by TOAST, CCS and ASCO – A Pilot Study

Background: In patients with transient ischemic attacks (TIA), etiological classification systems are not well studied. The Trial of ORG 10172 in Acute Stroke Treatment (TOAST), the Causative Classification System (CCS), and the Atherosclerosis Small Vessel Disease Cardiac Source Other Cause (ASCO) classification may be useful to determine the underlying etiology. We aimed at testing the feasibility of each of the 3 systems. Furthermore, we studied and compared their prognostic usefulness. Methods: In a single-center TIA registry prospectively ascertained over 2 years, we applied 3 etiological classification systems. We compared the distribution of underlying etiologies, the rates of patients with determined versus undetermined etiology, and studied whether etiological subtyping distinguished TIA patients with versus without subsequent stroke or TIA within 3 months. Results: The 3 systems were applicable in all 248 patients. A determined etiology with the highest level of causality was assigned similarly often with TOAST (35.9%), CCS (34.3%), and ASCO (38.7%). However, the frequency of undetermined causes differed significantly between the classification systems and was lowest for ASCO (TOAST: 46.4%; CCS: 37.5%; ASCO: 18.5%; p < 0.001). In TOAST, CCS, and ASCO, cardioembolism (19.4/14.5/18.5%) was the most common etiology, followed by atherosclerosis (11.7/12.9/14.5%). At 3 months, 33 patients (13.3%, 95% confidence interval 9.3–18.2%) had recurrent cerebral ischemic events. These were strokes in 13 patients (5.2%; 95% confidence interval 2.8–8.8%) and TIAs in 20 patients (8.1%, 95% confidence interval 5.0–12.2%). Patients with a determined etiology (high level of causality) had higher rates of subsequent strokes than those without a determined etiology [TOAST: 6.7% (95% confidence interval 2.5–14.1%) vs. 4.4% (95% confidence interval 1.8–8.9%); CSS: 9.3% (95% confidence interval 4.1–17.5%) vs. 3.1% (95% confidence interval 1.0–7.1%); ASCO: 9.4% (95% confidence interval 4.4–17.1%) vs. 2.6% (95% confidence interval 0.7–6.6%)]. However, this difference was only significant in the ASCO classification (p = 0.036). Using ASCO, there was neither an increase in risk of subsequent stroke among patients with incomplete diagnostic workup (at least one subtype scored 9) compared with patients with adequate workup (no subtype scored 9), nor among patients with multiple causes compared with patients with a single cause. Conclusion: In TIA patients, all etiological classification systems provided a similar distribution of underlying etiologies. The increase in stroke risk in TIA patients with determined versus undetermined etiology was most evident using the ASCO classification.

Angiographic Predictors of Stroke after Carotid Artery Stenting - A Qualitative and Quantitative Analysis of 1070 Patients in the Carotid Revascularization Endarterectomy Versus Stenting Trial (IN2-2.001)

Objective: To analyze the 1070 catheter-based angiograms performed on patients undergoing carotid artery stenting (CAS) in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Background CAS may be useful as an alternative to carotid endarterectomy in selected patients with symptomatic and asymptomatic carotid artery disease. The angiographic predictors of stroke following CAS have been incompletely described. Design/Methods: Of the 1070 CAS patients, 43 (4%) experienced periprocedural stroke. Angiograms were reviewed before and after CAS. Reviews were blinded to outcomes. Strokes were adjudicated by a committee blinded to results of angiography. The view showing the most severe stenosis was selected. Extreme tortuosity was defined as 2 severe bends >90 degrees (maximum angulation/20 mm segment) beyond the target lesion, sequential lesions as lesions separated by ≥10 mm, and narrow mouth ulcer as a discrete area of contrast extension beyond the normal arterial lumen with a narrow inlet into the ulceration. Results: The internal carotid artery mean reference diameter was 4.2 ± 0.8 mm, the minimal mean lumen diameter was 1.1 ± 0.6 mm, and the baseline mean % diameter stenosis was 74.1 ± 11.6%. There were no differences in vessel size or severity of the stenosis in patients with and without stroke. Morphologic predictors significantly related to the risk of subsequent stroke were lesion length (p=0.009), sequential lesions (p=0.007), severe distal tortuosity (p=0.025), and narrow mouth ulcer (p=0.05). Calcification, lesion eccentricity, baseline flow, and distance from the bifurcation were not predictive of periprocedural stroke (p > 0.05). Conclusions: In CREST, four angiographic variables were found to increase risk for stroke during and within 30 days after CAS: severe distal tortuosity, sequential lesions, lesion length > 20 mm, and narrow mouth ulcer. Angiographic characteristics beyond percent stenosis may help in patient selection in terms of best revascularization option. Supported by: The National Institute of Neurological Disorders and Stroke (NINDS) and the NIH (R01 NS 038384) and by supplemental funding from Abbott Vascular Solutions (formerly Guidant). Disclosure: Dr.Roubin has received royalty payments from Abbott Vascular and Cook Inc. Dr. Popma has received personal compensation for activities with Boston Scientific as a consultant.Dr. Popma has received research support from Boston Scientific, Cordis, Abbott Vascular, and Medtronic. Dr. Almonacid has nothing to disclose. Dr. Morrish has nothing to disclose. Dr. Katzen has received personal compensation for activities with Boston Scientific, W.L. Gore, and Medtronic as a consultant and particpant on an advisory board. Dr. Chakhtoura has nothing to disclose. Dr. Lal has nothing to disclose. Dr. Voeks has nothing to disclose. Dr. Meschia has nothing to disclose. Dr. Brott has received personal compensation for activities with 3D Communications.

Abstract P072: Most U. S. adults do not meet dietary guidelines for sodium and potassium, National Health and Nutrition Examination Survey, 2003-2008

Introduction: The 2010 Dietary Guidelines recommend Americans reduce sodium intake and choose foods that contain potassium to decrease the risk of hypertension and subsequent heart disease and stroke. Limited data exist on the proportion of U.S. adults who meet the 2010 Dietary Guidelines for Americans for sodium and potassium. Hypothesis: We hypothesized that the majority of U.S. adults do not meet the 2010 Dietary Guidelines for sodium and potassium. Methods: We used 24-hour dietary recalls and other data from 12,581 non-institutionalized adults aged &gt; 20 years who participated in the National Health and Nutrition Examination Survey in 2003–2008. We estimated the distributions of usual daily sodium and potassium intakes by sociodemographic and health characteristics relative to the 2010 Dietary Guidelines. Health characteristics included hypertension (use of anti-hypertensive medications, systolic blood pressure &gt; 140 mm Hg or diastolic blood pressure &gt; 90 mm Hg), diagnosed (self report) or undiagnosed diabetes (fasting plasma glucose &gt; 126 mg/dL or glycohemoglobin &gt; 6.5%), and chronic kidney disease (defined by estimated glomerular filtration rate &lt;60 mL/min/1.73 m 2 or urine albumin-creatinine ratio &gt; 30 mg/g). Estimates of usual sodium and potassium intake were adjusted for within-individual, day-to-day variation using measurement error models (Software for Intake Distribution Estimation) with two-24 hour diet recalls on 89.6% of our sample. Standard errors and ninety-five percent confidence intervals were assessed using jack-knife replicate weights. Results: Overall, 99.4% (95% confidence interval [CI], 99.3%, 99.5%) and 90.7% (89.6%, 91.8%) of U.S. adults consumed &gt;1500 mg and &gt; 2300 mg sodium daily, respectively. Among U.S. adults recommended to reduce sodium to 1500 mg daily (i.e., African-Americans, age &gt;51 years, or persons with hypertension, diabetes, or chronic kidney disease), 98.8% (98.4%, 99.2%) consumed &gt;1500 mg daily and 60.4% consumed more than double the recommendation, &gt;3000 mg daily. Regardless of sex, age, race-ethnicity, income, education, body mass index, hypertension, diabetes, or chronic kidney disease more than 84% of adults consumed sodium in excess of guidelines. Overall, less than 2% of U.S. adults and ∼5% of U.S. men consumed &gt; 4700 mg potassium daily, i.e., meeting 2010 Dietary Guidelines for potassium. Conclusions: Limitations of our analyses include estimation of nutrient intake from 24-hour diet recalls and inability to account for salt added at the table or from supplements, potentially resulting in an underestimation of sodium and potassium intake. In conclusion, most U.S. adults consume too much sodium and too little potassium.

A 3‐year follow‐up study on the risk of stroke among patients with conjunctival haemorrhage

To the best of our knowledge, no large population-based studies on the relationship between conjunctival haemorrhage and stroke have been conducted to date. Using a nationwide population-based data set, this study investigated the relationship between conjunctival haemorrhage and the subsequent risk of stroke within a 3-year period following diagnosis. We analysed data sourced from the Taiwan Longitudinal Health Insurance Database 2000. The study cohort consisted of 17 349 patients with conjunctival haemorrhage and 86 745 comparison subjects. Each patient was individually tracked for a 3-year period from their index date to identify all those who had subsequently received a diagnosis of stroke. The incidence rate of stroke was 2.44 (95% CI = 2.31-2.55) per 100 person-years in patients with conjunctival haemorrhage and 1.63 (95% CI = 1.59-1.68) per 100 person-years in comparison patients. After adjusting for patients' monthly income and geographic location, as well as for hypertension, atrial fibrillation, diabetes, hyperlipidaemia and coronary heart disease, stratified Cox proportional hazards regressions revealed a statistically significant hazard ratio for stroke in patients with conjunctival haemorrhage (HR = 1.33; 95% CI = 1.24-1.42, p < 0.001). In this study, patients with conjunctival haemorrhage were found to be at a significant risk of stroke during a 3-year follow-up period after diagnosis.

Abstract 2572: Dual Imaging with MRI and 18 F-FDG PET Can Highly Predict Lipid and Hematoma in Carotid Plaque

Background and Purpose - Recent studies have disclosed that inflamed and vulnerable plaques in the carotid artery are at high risk for subsequent ischemic stroke, suggesting the importance of non-invasive diagnostic modalities with high sensitivity and specificity to detect them in patients with carotid artery stenosis. Although many investigators have reported that MR imaging is a useful tool to predict the components of carotid plaque, its validity is not established. On the other hand, 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET) may be an alternative modality to directly identify the inflamed plaque in carotid artery stenosis. Therefore, this study was aimed to evaluate the validity of MR imaging and 18 F-FDG PET to predict the components of carotid plaques. Methods - Totally 19 patients were included in this study. Prior to carotid endarterectomy (CEA), 18 F-FDG PET, black-blood fat-suppressed T1-weighted (FS-T1) imaging, and 3-dimensional time-of-flight (TOF) imaging were performed in all of them. During CEA, macroscopic observation of carotid plaque was performed under surgical microscope. The specimens were stained with primary antibodies against CD68 and MMP9. Results - 18 F-FDG PET revealed that 11 of 19 patients had the carotid plaque with significantly high 18 F-FDG uptake (SUVmax &gt;2.0). All of them had lipid-rich soft plaque with strong immunoreactivity against CD68 and MMP9. Its sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to identify lipid-rich soft plaque were all 100%. On the other hands, 6 out of 19 patients had the carotid plaque with high signal intensity on both FS-T1 and TOF imaging. Carotid plaque had a large intraplaque hematoma in these 6 patients. Their sensitivity, specificity, PPV, and NPV to identify intraplaque hematoma were 86%, 100%, 100%, and 92%, respectively. Conclusions - These findings strongly suggest that MRI and 18 F-FDG PET are complementary to predict the components of carotid plaque. The former would be useful to detect vulnerable plaque with subintimal hemorrhage, and the latter would be sensitive to identify vulnerable plaque with lipid-rich component. Therefore, combination of these two modalities may be quite valuable to non-invasively predict the carotid plaque at higher risk for subsequent ischemic stroke.

Abstract 2352: 18F-fluorodeoxyglucose PET Can Identify The Inflamed and Vulnerable Carotid Plaque - A Prospective Study in Japan

Objective - There are few studies that denote the validity of 8F-fluorodeoxyglucose (FDG) PET to detect the inflammation of severe (&gt;70%) carotid artery stenosis in Asian populations. This study was aimed to clarify whether 18F-FDG PET can identify inflamed and vulnerable plaque at higher risk for subsequent ischemic stroke in Japanese patients with severe carotid artery stenosis. Methods - This prospective study included 33 patients with severe carotid artery stenosis between 2006 and 2011. Of these, 12 patients were symptomatic and other 21 were asymptomatic. There were 28 males and 5 females. Their mean age was 71.1 ± 8.2 years, ranging from 48 to 85. Their clinical data were precisely collected. All 33 patients underwent 18F-FDG PET and ultrasound sonography (US) to evaluate the plaque composition prior to carotid endarterectomy (CEA). FDG uptake was quantified by maximum standardized uptake values (SUV). Following surgery, the specimens were stained with the antibodies against CD68 and MMP-9. Results - High FDG uptake (SUV&gt;2.0) was observed in 15 (45%) of 33 operated plaques. High FDG uptake significantly correlated with the other vascular disorders (P=0.048), echolucent plaque (P=0.041), lipid-rich plaque (P&lt;0.001), CD68 expression (P&lt;0.001), and MMP-9 expression (P=0.002). 18F-FDG PET showed significantly higher sensitivity and specificity to identify lipid-rich and CD68-positive plaque than US. However, high FDG uptake was not related to patients’ gender, age, and the degree of stenosis. There was no significant correlation between FDG uptake and symptomatic or asymptomatic patients. Conclusion - These findings strongly suggest that 18F-FDG PET would provide more valuable information to identify the inflamed, vulnerable plaque than conventional ultrasound in Japanese patients with severe carotid artery stenosis.

Abstract 4: Angiographic Predictors of Stroke after Carotid Artery Stenting - A Qualitative and Quantitative Analysis of 1070 Patients in the Carotid Revascularization Endarterectomy versus Stenting Trial

Background Carotid artery stent (CAS) placement may be used as an alternative to carotid endarterectomy in selected patients with symptomatic and asymptomatic carotid artery disease. Perhaps because stroke is an uncommon event after CAS, the angiographic predictors of stroke have been incompletely described. Methods A total of 1070 catheter-based angiograms were centrally reviewed in patients undergoing CAS enrolled in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Of these patients, 43 (4%) experienced periprocedural stroke. Angiograms were reviewed using qualitative and quantitative methodology before and after CAS. Reviews were done blinded to patient outcomes and strokes were adjudicated by a central committee blinded to results of angiography. The view showing the greatest carotid stenosis severity was selected. Extreme tortuosity was defined as 2 severe bends &gt;90 degrees (maximum angulation/20 mm segment) beyond the target lesion, sequential lesions as lesions separated by ≥10 mm, and narrow mouth ulcer as a discrete area of contrast extension beyond the normal arterial lumen with a narrow inlet into the ulceration. Results The internal carotid artery reference diameter was 4.2 ± 0.8 mm, the minimal lumen diameter was 1.1 ± 0.6 mm, and the baseline % diameter stenosis was 74.1 ± 11.6%. There were no differences in vessel size or severity of the stenosis in patients with and without stroke. Morphologic predictors significantly related to the risk of subsequent stroke are listed in the Table . Calcification, lesion eccentricity, baseline flow, and distance from the bifurcation were not predictive of periprocedural stroke (p &gt; 0.05). Conclusion In CREST, four angiographic variables were found to increase risk for stroke during and within 30 days after CAS: severe distal tortuosity, sequential lesions, lesion length &gt; 20 mm, and narrow mouth ulcer. Angiographic characteristics beyond percent stenosis may help in patient selection in terms of best revascularization option.

Abstract 2967: Recurrent TIA and Early Risk of Stroke

Background: Many guidelines recommend urgent intervention for TIA patients with 2 or episodes within 7-days to reduce the early risk of stroke. However, whether all patients with multiple TIAs are at high early risk of stroke is unknown. Methods: Between April 2008 and December 2009, we included 1255 consecutive TIA patients from 30 Spanish stroke centers (PROMAPA study). We prospectively recorded clinical characteristics. We also determined the early short-term risk of stroke (at seven and ninety days). Aetiology of TIA was categorised using the SSS-TOAST classification Results: Enough information was assessed in 1137 patients (90.6%). 7-day and 90-day stroke risk were 2.6% and 3.8% respectively. Atherosclerotic etiology (AE) was confirmed in 190 (16.7%) patients. Recurrent TIA was observed in 274 (24,1%) patients. Duration&lt;1 hour (OR 2.94, 95% CI 2.18-3.96, p&lt;0.001), AE (OR 1.97, 95% CI 1.39-2.78, p&lt;0.001) and motor weakness (OR 1.37, 95% CI 1.03-1.82, p&lt;0.029) were independent predictors of recurrent TIA. The subsequent risks of stroke in these patients at 7, and 90 days were significantly higher than those after a single TIA (5.8% versus 1.5%, p&lt;0.001 and 6.8% versus 3.0%, respectively. HR 2.35, 95% CI 1.28-4.31 p=0.006). In the Cox logistic regression model, among patients with recurrent TIA, no variable remained remained as independent predictors of stroke recurrence at 90-day Conclusion: According to our results, recurrent TIA within 7-days is associated with a greater subsequent stroke risk than after a single TIA. Nevertheless, we were not able to find any independent predictor of stroke recurrence among these patients.

Intermediate-term outcome of carotid endarterectomy with bovine pericardial patch closure compared with Dacron patch and primary closure

Multiple studies have established that patch angioplasty following carotid endarterectomy (CEA) reduces the risk of subsequent stroke and restenosis compared with primary closure. Previous reports have also demonstrated bovine pericardium to be associated with similar rates of postoperative complications and restenosis compared with other patch materials. Due to favorable handling and sonographic properties, bovine pericardium has become increasingly popular as a patch option in recent years. However, the intermediate- and long-term performance of this material remains incompletely defined. Through a retrospective analysis of our carotid endarterectomy experience, we sought to compare the bleeding, infection, and pseudoaneurysm rates with bovine pericardium patch closure to those with Dacron patch and primary closure. In this study, 1331 primary carotid endarterectomies performed in our institution between 1996 and 2008 were grouped according to the method of arteriotomy closure: primary closure (PC) (216, 16.3%), Dacron patch angioplasty (DPA) (642, 48.2%), and bovine pericardial patch angioplasty (BPA) (457, 34.3%). Demographic variable and postoperative outcome measures collected real-time via a designated database manager were assessed by univariate and multivariate analysis. Mean follow-up for the entire cohort was 46.1 months. There were no statistically significant differences in rates of postoperative wound infection, hematoma, pseudoaneurysm formation, or 30-day stroke or 30-day mortality among the three groups. Combined 30-day stroke and death was significantly lower in the PC cohort (0.5% vs 2.3% DPA vs 2.4% BPA; P = .94, BPA vs DPA; P = .001, BPA vs PC; P = .001, DPA vs PC), while 5-year restenosis after both DPA (2.0% ± 0.6%) and BPA (1.1% ± 0.6%) was significantly lower compared with PC (5.2% ± 1.6%) (P = .03, DPA vs PC; P = .008, BPA vs PC; P = .14, BPA vs DPA). Five-year survival following BPA (77.9% ± 3.6%) was significantly improved compared with PC (66.9% ± 3.5%) and DPA (60.8% ± 2.1%) in univariate analysis (P = .24, DPA vs PC; P = .01, BPA vs PC; P = .03, BPA vs DPA), with statin use (P = .004) and male gender (P = .05) being positive predictors of enhanced survival on multivariate analysis. This single-institution, retrospective review represents the largest reported experience with BPA after CEA to date and is the only report comparing outcomes after BPA to PC or to DPA. Our experience further demonstrates that patch angioplasty is protective against restenosis after CEA compared with PC. Equivalent rates of perioperative bleeding, infection, and pseudoaneurysm formation were seen with each closure strategy in this study.

How do we manage emergency department patients diagnosed with transient ischemic attack?

Multiple studies have demonstrated low rates of antithrombotic use, low neuroimaging rates, and high subsequent risk of stroke at 90 days following an emergency department (ED) diagnosis of transient ischemic attack (TIA). This study assessed the use of antithrombotic medications, neuroimaging, and subsequent 90-day stroke rate for patients in a more recent cohort of ED patients discharged home with TIA. We conducted a 1-year historical cohort study of all patients discharged with a TIA at a tertiary care ED (census 60,000 visits/year), which was one of the four sites participating in one of the aforementioned studies. Data were extracted from paper and electronic records onto standardized data extraction forms. Clinical findings, medications, and tests were recorded. A total of 211 patients were enrolled in the study. The patients had the following characteristics: the mean age was 71.2 years (SD 13.8 years), 56.9% were female, 53.1% had a history of hypertension, 26.5% had a history of ischemic heart disease, and 17.1% had a previous stroke. The most frequent neurologic deficit was unilateral weakness (53.6%), and most deficits lasted for more than 60 minutes (71.6%). Antithrombotic medications were used for 96.7% of patients at ED discharge. Neuroimaging was conducted in 94.3% of patients while in the ED. Our cohort had a 90-day stroke rate of 1.9%. This study established that most TIA patients receive neuroimaging in the ED and are started on or maintained on antithrombotic agents. Clinicians are encouraged to ensure that electrocardiography is done routinely and to involve Neurology in follow-up care.

Do Not Throw the Baby Out with the Bathwater …

Do Not Throw the Baby Out with the Bathwater …