Secondary Prevention Of Ischemic Stroke Research Articles

Factor XI Inhibitors: perspectives in primary and secondary prevention of ischemic stroke.

Stroke is one of the most common causes of mortality and disability worldwide. Antithrombotic therapy represents the mainstay in primary and secondary prevention, both in cardioembolic and non-cardioembolic stroke. Particularly, direct oral anticoagulants play a crucial role in atrial fibrillation, the most common cause of cardioembolic stroke, whereas single or dual antiplatelet therapy is preferred in non-cardioembolic stroke. However, the limitations related to the residual risk of cardioembolic or cerebrovascular events, and the risk of major bleeding, still represent unmet medical needs. To overcome them, new drugs inhibiting Factor XI (FXI) and Factor XII have been proposed, with a selective inhibition of contact pathway of coagulation, delineating a new anticoagulant approach. This review provides a summary of the currently available evidence and future perspectives on FXI inhibitors, that can represent an additional therapeutic option in the primary and secondary prevention of cardioembolic and non-cardioembolic ischemic stroke, also in challenging therapeutic contexts.

Trends in the Use of Medications for Secondary Ischemic Stroke Prevention in Denmark, 2005-2021.

Understanding trends in the use of medications for secondary stroke prevention is crucial for identifying areas for improvement in stroke care. We examined the use of lipid-lowering, antihypertensive, glucose-lowering, oral anticoagulant, and antiplatelet medications after ischemic stroke hospitalization, from 2005 to 2021. Using nationwide registries in Denmark, we identified a cohort of patients discharged from hospital with a first-time or recurrent ischemic stroke (N = 150,744). Stratified by calendar year, we ascertained the 180-day probability of filling a prescription for the abovementioned medications after discharge. We further assessed factors associated with medication use. From 2005 to 2021, lipid-lowering medication use increased from 58.3% to 82.0%; atorvastatin use rose from 2.1% to 64.8% and simvastatin use decreased from 55.7% to 8.6%. Antihypertensive medication use remained stable, at approximately 89%, and various antihypertensive classes were used comparably. Glucose-lowering medication use increased from 71.5% in 2005 to 84.1% in 2021, driven primarily by an increase in metformin use (from 28.0% to 59.5%). Use of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors continually increased (from 1.7% to 17.5% and from 0.5% to 17.3%, respectively) between 2015 and 2021. Anticoagulant medication use rose from 45.9% in 2005 to 87.0% in 2021, primarily because of increased use of direct oral anticoagulant medications starting around 2010 and a decline in warfarin use. Antiplatelet use remained consistently high, at approximately 95%. Trends were consistent across subgroups of interest; however, overall medication use was lower in older patients (65 years and older), patients with severe stroke, and patients with neurologic and psychiatric comorbidities. Despite increasing trends in the use of 3 of 5 medication classes, the overall use of lipid-lowering, glucose-lowering, and oral anticoagulant medications was somewhat lower than expected according to clinical guidelines, particularly among older patients with more severe stroke and other comorbidities. The relatively low use in these subgroups may signify appropriate clinical decision making in consideration of frequent contraindications and reduced life expectancy or highlight potential areas of improvement for the care of patients with recent ischemic stroke.

Long-term combined antiplatelet therapy for secondary prevention of noncardioembolic stroke

Introduction. The high risk of recurrent ischemic events after non-cardioembolic ischemic stroke(IS), the prevalence of which is 25% of all strokes in the Russian Federation, determines the need to search for effective and safe secondary prevention strategies.Аim. The study was to evaluate the efficacy and safety of a combination of ADP receptor inhibitors (dipyridamole) with acetylsalicylic acid in patients with ischemic stroke (IS) in the secondary prevention of noncardioembolic stroke.Materials and methods. 229 patients in the early recovery period of noncardioembolic IS (139 women, 90 men), with an average age of 59.0 ± 5.7 years were included in the study. The duration of IS was 54.4 ± 6.1 days. All patients received a multimodal medical rehabilitation (MMR) program. Long-term double antiplatelet therapy with acetylsalicylic acid (ASA) 75 mg per day and dipyridamole at a daily dose of 225 mg divided into 3 doses were prescribed to all the patients. The neurological and neuropsychological status of the patient, quality of life and hemorheological parameters were assessed initially (T0), after MMR (T1, 6 weeks) and 12 months after IS(T2).Results. Motor and coordination indicators of patients as well as the cognitive and emotional parameters were significantly (p < 0,05) improved due to MMR technology. These were confirmed by the dynamics of the corresponding scales. The prescribed double antiplatelet therapy did not cause significant adverse events and worsening of the patients’ well-being both during the MMR process and during the observation period. The combination of ASA with dipyridamole was well tolerated. At the end of the study, recurrent IS, myocardial infarctions, and fatal bleeding were not recorded. In 5.2% patients with severe risks of cardiovascular complications there was occurred TIA. The effectiveness of the dual antiplatelet therapy was confirmed by a decrease in the level of platelet aggregation (p < 0,05).Conclusions. The high effectiveness of secondary prevention of IS with a combination of ASA and dipyridamole with good tolerability and safety in patients after IS has been shown.

Artificial intelligence predicts undiagnosed atrial fibrillation in patients with embolic stroke of undetermined source using sinus rhythm electrocardiograms

BackgroundArtificial intelligence (AI)–enabled sinus rhythm (SR) electrocardiogram (ECG) interpretation can aid in identifying undiagnosed paroxysmal atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS). ObjectiveThe purpose of this study was to assess the efficacy of an AI model in identifying AF based on SR ECGs in patients with ESUS. MethodsA transformer-based vision AI model was developed using 737,815 SR ECGs from patients with and without AF to detect current paroxysmal AF or predict the future development of AF within a 2-year period. Probability of AF was calculated from baseline SR ECGs using this algorithm. Its diagnostic performance was further tested in a cohort of 352 ESUS patients from 4 tertiary hospitals, all of whom were monitored using an insertable cardiac monitor (ICM) for AF surveillance. ResultsOver 25.1-month follow-up, AF episodes lasting ≥1 hour were identified in 58 patients (14.4%) using ICMs. In the receiver operating curve (ROC) analysis, the area under the curve for the AI algorithm to identify AF ≥1 hour was 0.806, which improved to 0.880 after integrating the clinical parameters into the model. The AI algorithm exhibited greater accuracy in identifying longer AF episodes (ROC for AF ≥12 hours: 0.837, for AF ≥24 hours: 0.879) and a temporal trend indicating that the AI-based AF risk score increased as the ECG recording approached the AF onset (P for trend <.0001). ConclusionsOur AI model demonstrated excellent diagnostic performance in predicting AF in patients with ESUS, potentially enhancing patient prognosis through timely intervention and secondary prevention of ischemic stroke in ESUS cohorts.

Acute Ischaemic Stroke in Patients Treated with Direct Oral Anticoagulants: Potential Causes, Clinical Characteristics, and Short-Term Outcomes.

Direct oral anticoagulants (DOAC) are the first-line treatment for primary and secondary acute ischaemic stroke (AIS) prevention in patients with nonvalvular atrial fibrillation (NVAF), but a significant percentage of patients develop AIS despite being treated with DOAC. As the number of DOAC-treated patients is growing, so is the number of patients with AIS on DOAC. The aim of the study was to assess the incidence of AIS with prestroke DOAC treatment among patients hospitalised in the University Hospital in Kraków, to analyse the clinical characteristics of AIS occurring in patients on DOAC, and to identify potential causes of treatment ineffectiveness in this group. In the study, we included all patients hospitalised in the Department of Neurology of the University Hospital in Kraków within one year (July 2022 to June 2023) with the diagnosis of AIS. The group was divided into two subgroups of patients with and without prestroke DOAC treatment. Based on medical files, we retrospectively analysed the profile of cardiovascular risk factors, stroke severity (assessed with National Institutes of Health Stroke Scale, NIHSS), use of causative stroke treatment and short-term outcomes (defined as NIHSS score, modified Rankin scale (mRS) score at discharge, in-hospital mortality, and secondary intracerebral haemorrhage among patients treated with mechanical thrombectomy, MT). Within the DOAC-treated subgroup, we looked for potential causes of AIS occurring despite DOAC treatment (valvular AF, poor adherence to treatment, underdosing, other prothrombotic conditions, aetiology of stroke other than thromboembolic, and drug-drug interactions). In the study, we included 768 AIS patients. 109 (14.2%) had a history of prestroke DOAC treatment. A potential cause of DOAC treatment failure was identified in the majority of them (n = 63, 57.8%). Patients with prestroke DOAC treatment had worse functional condition before stroke and higher stroke severity on admission but similar short-term outcomes and similar short-term effects of treatment with MT. DOAC (+) and DOAC (-) patients had different profiles of cardiovascular risk factors and different factors associated with short-term outcome. Conclusions and Clinical Implications. A potential cause of AIS occurring in DOAC-treated patients can be identified in most cases and in many of them prevented.

Abstract 132: Disability and Enrollment in Secondary Stroke Prevention Trials: Evidence for a New Paradigm of Inclusion

Background: Ischemic stroke secondary prevention trials have disproportionately enrolled participants with mild or no disability. The impact of this skew on trial event rates is unclear. Methods: We included participants with ischemic stroke in two secondary stroke prevention trials, PRoFESS and IRIS. The exposure was functional status at entry, defined as modified Rankin Scale (mRS) 0 vs. 1-2 vs. &gt;2. The primary outcome was recurrent stroke (ischemic or hemorrhagic). The secondary outcome was a composite of major adverse cardiovascular events (MACE=stroke, myocardial infarction, heart failure, and vascular death). Results: The cohorts had 20,384 participants from PRoFESS and 3,374 from IRIS. The mean duration of follow-up was 2.4 years in PRoFESS and 3.8 years in IRIS. The rate of recurrent stroke in the mRS categories (0 vs. 1-2 vs. &gt;2) was 7.2%, 8.7%, and 10.6% in PRoFESS and 6.2%, 9.1%, and 11.9% in IRIS (both p≤0.001). The rate of MACE in the mRS categories was 10.1%, 12.2%, and 17.3% in PRoFESS (p&lt;0.001) and 10.6%, 13.3%, and 15.3% in IRIS (p=0.030). In both trials we saw consistent increases in the hazard ratio for recurrent stroke (Table 1) and MACE (Table 2) across mRS categories, after adjusting for potential confounders. There was no evidence that treatment effects differed across mRS categories (mRS by treatment interaction p&gt;0.4). Conclusion: Secondary stroke prevention trial participants with higher levels of baseline disability have increased rates of recurrent stroke and MACE. By enrolling participants across the full range of disability, stroke trials would observe more recurrent stroke events, enhance statistical power, and improve generalizability of results.

Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review.

To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.

Antiplatelet therapy in the prevention of recurrent ischemic stroke

Stroke that includes both ischemic and hemorrhagic events is a major cause of death worldwide. It is currently the most common cause of disability. The risk of recurrence is the highest among cases where a recent stroke or transient ischemic attack was left untreated. In about 30% of these cases, a recurrent stroke leads to the worsening neurological symptoms or even death. Therefore, primary prevention of first stroke and secondary prevention of recurrent stroke are a top priority. Primary prevention of ischemic stroke includes lifestyle modification and diets, treatment of risk factors including hypertension, diabetes mellitus and lipid disorders, antiplatelet therapy for high vascular risk patients, and anticoagulation therapy in atrial fibrillation. Secondary prevention of ischemic stroke includes additional carotid surgery in symptomatic patients. Up to 90% of all strokes are preventable, and attributable to major modifiable risk factors. Optimal stroke prevention requires a harmonious, integrated approach to educating about stroke risk and healthy lifestyle, simple screening and management of patients for a history and presence of modifiable and treatable causal risk factors, and improving social and environmental factors. Intake of antiplatelet agents according to the subtype improves the prognosis of patients after an ischemic stroke or transient ischemic attack. Current data on stroke recurrence and mortality are important to examine trends, risk factors, and treatment effects.

Probucol will become a New Model for Treating Cerebral Infarction with a High Risk of Hemorrhage.

Antiplatelet, antihypertensive, and lipid-lowering agents are the three foundational agents for secondary prevention of ischemic stroke, among which lipid-lowering is one of the most important cornerstones. Probucol is a potent antioxidative lipid-lowering drug used to prevent and treat atherosclerotic cardiovascular diseases and xanthomas. However, it has faded from Western markets by lowering LDL-C and HDL-C levels. Probucol alleviates atherosclerosis improving high-density lipoprotein function, and does not increase the risk of cardiovascular events. Probucol-induced pharmacological changes in HDL-C may not be a reliable prognostic marker for cardiovascular risk. Q-T interval prolongation is a rare adverse reaction as described in the manufacturer's instructions, but prolonged Q-T interval may only be an intermediate pharmacological phenomenon of electrophysiological changes, and as a result, probucol has a strong benefit for secondary prevention of cardiovascular events and can reduce mortality without increasing the risk of cardiovascular and cerebrovascular adverse events. The new mechanism is that probucol penetrates the core of lowdensity lipoprotein particles, enhancing the activity of plasma cholesteryl ester transfer protein and liver scavenger receptor type I activity, thereby reducing LDH; at the same time, increasing the activity of paraoxonase 1, strengthened the antioxidant function of HDL, and reduced the serum HDL-C. If clinical or imaging findings suggest a high risk of recurrence of cerebral ischemia with a high risk of cerebral hemorrhage, probucol may be selected for prevention. This article focuses on basic research and clinical evidence and provides new insights into the low bioavailability.

Effects of preceding antiplatelet agents on severity of ischemic stroke in patients with a history of stroke

IntroductionAntiplatelet agents are effective for secondary prevention of ischemic stroke and can reduce the severity of first-ever ischemic stroke. However, it is uncertain if prophylactic antiplatelet therapy reduces the severity of recurrent ischemic stroke. The aim of this study was to determine the effect of preceding antiplatelet treatment on the severity of thrombotic stroke (TS) in patients with a prior history of stroke. MethodsFrom a prospective hospital registry of 1338 consecutive patients with acute ischemic stroke, we identified patients with a prior history of stroke who were admitted for cardioembolic stroke (CE); TS including large-artery atherosclerosis, small vessel occlusion, and branch atheromatous disease; or other cause or cryptogenic stroke (OCS). Cases in each subtype were categorized based on preceding medication: antiplatelet agents (AP) and none (N). Severity of stroke (National Institutes of Health Stroke Scale: NIHSS) on admission was compared between AP and N cases. ResultsThe total cohort of 252 patients included 83 with CE, 102 with TS, and 67 with OCS. After excluding those with prior anticoagulants, the median NIHSS on admission was lower in AP cases than in N cases (3 vs. 5, p = 0.002). In multivariate analysis, preceding AP treatment was independently associated with minor stroke (NIHSS ≤4) on admission in CE group (OR 8.48, 95% CI 1.71–62.9, p = 0.008) and TS group (OR 4.24, 95% CI 1.44–13.4, p = 0.009). ConclusionPreceding antiplatelet treatment in patients with a prior history of stroke may reduce the severity of subsequent thrombotic and cardiogenic stroke.

Early warning model for stroke recurrence in acute ischemic stroke patients based on traditional Chinese medicine syndrome theory.

This study aimed to establish an early warning model for stroke recurrence in acute ischemic stroke patients based on Traditional Chinese Medicine (TCM) syndrome theory. This retrospective study collected the data of 1741 patients with ischemic stroke from 7 clinical centers between July 2016 and November 2019. Distance correlation coefficient, mutual information entropy, and statistical correlation test were used for univariate analysis. Cox proportional hazards regression model was applied to construct and validate the stroke recurrence warning model at different time. The area under the ROC curve (AUC) was used to evaluate the early warning ability of the model. We successfully constructed the early warning model. The median follow-up time was 1.42 years (95% CI [1.37, 1.47]). Recurrence events occurred in 175 patients, with a cumulative recurrence rate of 10.05% (95% CI [8.64, 11.47]). The AUC of the model was 0.64±0.02 in the training set and 0.70±0.03 in the validation set. The TCM syndrome model can give an early warning for the recurrence of stroke and provide reference for the secondary prevention of ischemic stroke.

The Role of Transcranial Doppler in Patients with Cryptogenic Stroke

Identifying the stroke mechanism is crucial for secondary prevention of ischemic stroke. However, approximately 20% to 30% of patients with ischemic stroke do not display a discernible cause after standard diagnostic evaluation and are classified as having cryptogenic stroke. Most cryptogenic strokes are believed to be of embolic origin, referred to as embolic stroke of undetermined source. Several potential causes, including occult atrial fibrillation, aortic arch atheroma, non-stenotic atherosclerosis, coagulopathy, and patent foramen ovale (PFO), are significant contributors to cryptogenic stroke. Among these, PFO-associated strokes often manifest as small cortical lesions in the posterior circulation and are associated with fewer traditional risk factors. Ischemic stroke is considered a high risk if there is a large PFO with significant shunting or the presence of an atrial septal aneurysm. Although transesophageal echocardiography is regarded as the gold standard for diagnosing PFO, its invasiveness, high cost, and challenges in certain stroke patients necessitate alternative approaches. Recently, transcranial Doppler (TCD) has emerged as a valuable screening tool for detecting high-risk PFOs, as supported by recent research. Accurate determination of the culprit PFO responsible for ischemic stroke remains crucial for guiding appropriate treatment decisions. This article provides a comprehensive review of the different modalities used to diagnose PFO, strategies for assessing the risk of PFO causing paradoxical embolism, and the role of TCD in patients with cryptogenic stroke caused by other etiologies.

An isolated pontine infarct extending to the basal pontine surface has a higher abnormal ankle-brachial index

Patients with ischemic stroke and branch atheromatous disease (BAD) have worse neurological deficits and prognoses than those with small vessel occlusion (SVO). However, both disorders are forms of deep brain infarctions. This study aimed to investigate an MRI-based etiological classification for isolated pontine infarctions and assess differences in vascular risk factors and peripheral arterial disease among etiological subtypes. Consecutive data of patients admitted for acute ischemic stroke or transient ischemic attack between August 2016 and July 2019 were reviewed. Acute isolated pontine infarcts were classified into 3 groups: BAD, SVO, and large-artery atherosclerosis (LAA), according to basilar or vertebral artery steno-occlusion and the extent of the infarct lesion on the basal pontine surface as displayed on magnetic resonance imaging and angiography. Vascular risk factors, ankle-brachial index (ABI), and brachial-ankle pulse wave velocity were analyzed in the 3 groups. Among 64 enrolled patients, BAD was the most common cause of isolated pontine infarct. The BAD group had a higher frequency of abnormal ABI and hypertension than the SVO group. The BAD group had abnormal ABI and hyperlipidemia more frequently than the LAA group. No significant difference was found in diabetes or brachial-ankle pulse wave velocity incidence between the BAD and SVO groups. ABI and vascular risk factors in the BAD group were more similar to those in the LAA group than to those in the SVD group. This finding suggests that pontine lesions extending to the basal pontine surface have an atherosclerotic mechanism in BAD, requiring potent antiplatelet therapy for the secondary prevention of ischemic stroke.

Анализ частоты встречаемости полиморфных аллелей генов, ассоциированных с биотрансформацией и механизмом действия статинов, с учетом их роли во вторичной профилактике инфаркта мозга у пациентов в возрасте от 18 до 45 лет

Цель. Изучить частоту полиморфных аллелей генов SLCO1B1, ABCB1, ABCG2, ассоциированных с биотрансформацией и механизмом действия статинов, у пациентов, перенесших инфаркт головного мозга в возрасте от 18 до 45 лет, во вторичной профилактике. Материалы и методы. Объектом исследования были 137 пациентов с инфарктом головного мозга. Для генотипирования пациентов были использованы методы ПЦР-ПДРФ анализа, а также аллель-специфичной ПЦР с линейными разрушаемыми пробами (TaqMan). Аллель-специфичная ПЦР с помощью линейных разрушаемых проб (TaqMan) проводилась на амплификаторе в режиме реального времени CFX96 (Bio-Rad, США). Результаты. В результате проведенного фармакогенетического тестирования полиморфных аллелей генов SLCO1B1, ABCB1, ABCG2 установлена частота пациентов с низким, умеренным и высоким риском статин-индуцированной миопатии. Установлены варианты генотипов, при которых вероятность неблагоприятных исходов инфаркта головного мозга с развитием статин-индуцированной миопатии возрастает. Выводы. Персонализированный подход с учетом фармакогенетических маркеров позволит заранее прогнозировать фармакологический ответ на лекарственное средство конкретного пациента и определять тактику вторичной медицинской профилактики. Purpose. To study the frequency of polymorphic alleles of the SLCO1B1, ABCB1, ABCG2 genes associated with the biotransformation and mechanism of action of statins in patients who survivors a ischemic stroke aged 18 to 45 years in secondary prevention. Materials and methods. The subjects of the study were 137 patients with ischemic stroke. For genotyping of patients, PCR-RFLP analysis methods were used, as well as allele-specific PCR with linear destructible samples (TaqMan). Allele-specific PCR using destructible sample (TaqMan) was carried out on a real-time cycler CFX96 (Bio-Rad, USA). Results. As a result of pharmacogenetic testing of polymorphic alleles of the SLCO1B1, ABCB1, ABCG2 genes, the frequency of patients with low, moderate and high risk of statin- induced myopathy was established. Variants of genotypes have been identified in which the likelihood of adverse outcomes of ischemic stroke with the development of statin- induced myopathy increases. Conclusions. A personalized approach taking into account pharmacogenetic markers will make it possible to predict in advance the pharmacological response to a drug in a particular patient and determine the tactics of secondary medical prevention.

Stroke in Patients with Atrial Fibrillation: Epidemiology, Screening, and Prognosis.

Atrial fibrillation (AF) is the most common sustained arrythmia and one of the strongest risk factors and causal mechanisms of ischemic stroke (IS). Acute IS due to AF tends to be more severe than with other etiology of IS and patients with treated AF have reported to experience worse outcomes after endovascular treatment compared with patients without AF. As cardioembolism accounts for more than a fifth of ISs and the risk of future stroke can be mitigated with effective anticoagulation, which has been shown to be effective and safe in patients with paroxysmal or sustained AF, the screening of patients with cryptogenic IS (CIS) for AF is paramount. Embolic stroke of undetermined source (ESUS) is a subtype of CIS with a high likelihood of cardioembolism. The European Stroke Organization and European Society of Cardiology guidelines recommend at least 72 h of screening when AF is suspected. The longer the screening and the earlier the time point after acute IS, the more likely the AF paroxysm is found. Several methods are available for short-term screening of AF, including in-hospital monitoring and wearable electrocardiogram recorders for home monitoring. Implantable loop monitors provide an effective long-term method to screen patients with high risk of AF after IS and artificial intelligence and convolutional neural networks may enhance the efficacy of AF screening in the future. Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists in both primary and secondary prevention of IS in AF patients. Recent data from the randomized controlled trials (RCT) also suggest that early initiation of DOAC treatment after acute IS is safe compared to later initiation. Anticoagulation treatment may still predispose for intracranial bleeding, particularly among patients with prior cerebrovascular events. Left atrial appendix closure offers an optional treatment choice for patients with prior intracranial hemorrhage and may offer an alternative to oral anticoagulation even for patients with IS, but these indications await validation in ongoing RCTs. There are still controversies related to the association of found AF paroxysms in CIS patients with prolonged screening, pertaining to the optimal duration of screening and screening strategies with prolonged monitoring techniques in patients with ESUS. In this review, we summarize the current knowledge of epidemiology, screening, and prognosis in AF patients with stroke.

Hospital-Level Variability in Reporting of Ischemic Stroke Subtypes and Supporting Diagnostic Evaluation in GWTG-Stroke Registry.

Secondary prevention of ischemic stroke (IS) requires adequate diagnostic evaluation to identify the likely etiologic subtype. We describe hospital-level variability in diagnostic testing and IS subtyping in a large nationwide registry. We used the GWTG-Stroke (Get With The Guidelines-Stroke) registry to identify patients hospitalized with a diagnosis of acute IS at 1906 hospitals between January 1, 2016, and September 30, 2017. We compared the documentation rates and presence of risk factors, diagnostic testing, achievement/quality measures, and outcomes between patients with and without reported IS subtype. Recording of diagnostic evaluation was optional in all IS subtypes except cryptogenic, where it was required. Of 607 563 patients with IS, etiologic IS subtype was documented in 57.4% and missing in 42.6%. Both the rate of missing stroke pathogenesis and the proportion of cryptogenic strokes were highly variable across hospitals. Patients missing stroke pathogenesis less frequently had documentation of risk factors, evidence-based interventions, or discharge to home. The reported rates of major diagnostic testing, including echocardiography, carotid and intracranial vascular imaging, and short-term cardiac monitoring were <50% in patients with documented IS pathogenesis, although these variables were missing in >40% of patients. Long-term cardiac rhythm monitoring was rarely reported, even in cryptogenic stroke. Reporting of IS etiologic subtype and supporting diagnostic testing was low overall, with high rates of missing optional data. Improvement in the capture of these data elements is needed to identify opportunities for quality improvement in the diagnostic evaluation and secondary prevention of stroke.

Evaluating the role of Ginkgo biloba extract in the secondary prevention of acute ischemic stroke with cerebral microbleeds by quantitative susceptibility mapping (QSM)

Background EGb 761, a standardized dry extract of Ginkgo biloba leaves, has certain anti-inflammatory and thrombotic effects and can be used to treat cerebrovascular diseases. Methods A total of 49 patients were randomly assigned to the Aspirin group (24 cases in Controlled group) and the Aspirin + Ginkgo biloba group (25 cases in Treatment group). The quantitative magnetic sensitivity and venous oxygen saturation of cerebral microbleeds were analyzed at admission, discharge, and after follow-up for 3 and 6 months. Results The demographic details age, gender, and admission to NIHSS were not significantly different between the two groups (p < 0.05). Quantitative susceptibility mapping (QSM) showed that the magnetic sensitivity of patients in both groups remained stable after 3 and 6 months of follow-up, while the venous oxygen saturation of the Treatment group increased. The venous oxygen saturation at 3 and 6 months of follow-up was negatively correlated with the modified mRS grade score. Conclusions QSM can be used as a quantitative follow-up tool in monitoring both oxygen saturation and Magnetic susceptibility of microbleeds noninvasively in ischemic stroke patients with cerebral microbleeds. EGB combined with Aspirin can improve blood oxygen saturation in those patients and this effect is particularly significant in the long-term efficacy of secondary prevention.

Risk factors for stroke recurrence in young patients with first-ever ischemic stroke: A meta-analysis.

At present, the incidence rate of ischemic stroke in young people is increasing yearly, and the age of onset is increasingly young. Therefore, primary and secondary prevention of ischemic stroke in young people, especially secondary prevention, is particularly crucial. We aimed to comprehensively evaluate risk factors for stroke recurrence in first-ever young ischemic stroke (YIS) patients. The meta-analysis was used to quantitatively analyze the research results on risk factors for stroke recurrence in first-ever YIS patients both domestically and internationally. Stata12.0 software was used for heterogeneity testing, publication bias analysis, sensitivity analysis, and the calculation of combined odds ratios and 95% confidence intervals. The odds ratio (OR) values of the relationship between hypertension and hyperlipidemia and recurrence of first-ever YIS were 1.54 (1.05-2.26) and 1.12 (1.00-1.25), respectively. The OR values of male sex, type 2 diabetes, smoking, drinking and YIS recurrence were 1.66 (0.98-2.79), 1.01 (0.64-1.59), 1.21 (0.83-1.76), and 1.28 (0.82-2.53), respectively. The relationship between male sex, type 2 diabetes, smoking, drinking and YIS recurrence was ambiguous. Hypertension and hyperlipidemia are important risk factors for stroke recurrence in first-ever YIS patients, and active intervention should be taken.

A Review of Antithrombotic Agents for the Treatment of Ischemic Stroke

Ischemic stroke caused by a blockage in blood vessels that supplies blood to the brain, can lead to severe neurological disability or even death if not treated in a timely proper manner. Current treatment for ischemic stroke comprises Intravenous Thrombolytic Therapy (IVT) and Endovascular Therapy (EVT). However, the unmet medical needs lie in the high disability, narrow therapeutic window, low patient eligibility for operations, and recurrent ischemic stroke and bleeding complications. The development of antithrombotic agents is key to reducing complications of current treatment and secondary prevention of ischemic stroke. This review paper covers a wide range of most commonly used antithrombotic medications or advancements in antithrombotic agents, including warfarin, heparins (UFH and LMWH), direct oral anticoagulants (dabigatran, rivaroxaban, apixaban), aspirin, dual-antiplatelet therapies (clopidogrel/aspirin and dipyridamole/aspirin), and Glycoprotein (GP) inhibitors (tirofiban and anfibatide). This paper compares the efficacy and safety of antithrombotic agents and discusses the advancement and potential of GP inhibitors in treating ischemic stroke patients. Based on preclinical and clinical results, it was found that GP inhibitors have higher antithrombotic and neuroprotective efficacy and are relatively safe with a lower rate of bleeding complications among all agents. The novel Anfibatide, a snake venom-derived GPIba inhibitor currently in the early clinical development stage, has shown superior efficacy and safety profile compared to other agents. It has great potential to fulfill the current unmet medical needs in ischemic stroke treatment. It is worth exploring the mechanism of GP inhibitors and their applications in ischemic stroke treatment.

Ticagrelor plus aspirin in patients with minor ischemic stroke and transient ischemic attack: a network meta-analysis

BackgroundDual antiplatelet therapy (DAPT) with aspirin and clopidogrel was recommended as the secondary prevention of minor ischemic stroke or transient ischaemic attack (TIA). However, genetic polymorphisms of CYP2C19 had been identified as the major cause of poor responsiveness to clopidogrel. Ticagrelor, unlike clopidogrel, did not depend on metabolic activation, but it remained unclear whether ticagrelor was superior to clopidogrel in ischemic stroke. We performed a network meta-analysis to compare the efficacy and safety of ticagrelor, clopidogrel, and aspirin in the minor ischemic stroke and TIA populations.MethodsDatabases of Cochrane Library, ClinicalTrials.gov, and PubMed were searched up to June 19, 2023. Randomized controlled trials (RCTs) assessing antiplatelet drugs for minor stroke or TIA were included. Statistical processing was conducted by using multivariate meta-analysis routines of STATA.ResultsSeven RCTs were included involving 41,745 participants. There was no significant difference between the two DAPTs in preventing stroke recurrence (OR, 1.16; 95% CI, 0.93-1.44), ischemic stroke recurrence (OR, 1.16; 95% CI, 0.93-1.45), and major hemorrhage (OR, 1.22; 95% CI, 0.62,2.39). Compared with aspirin alone, the two DAPT regimen reduced the risk of stroke recurrence (clopidogrel: OR, 0.69; 95% CI, 0.60-0.80, ticagrelor: OR, 0.66; 95% CI, 0.49-0.87) and ischemic stroke recurrence, but increased the incidence of major hemorrhage (clopidogrel: OR, 2.05; 95% CI, 1.22- 3.77; ticagrelor: OR, 2.55; 95% CI, 1.25-4.99). Despite being associated with a higher risk of any bleeding, ticagrelor did not impact the composite of vascular events or mortality. While ticagrelor and aspirin reduced the risk of ischemic stroke recurrence (OR, 0.77; 95% CI, 0.63- 0.92) without increasing the risk of major bleeding (OR 0.94; 95% CI 0.45–1.95) in the Asian population mainly Chinese.ConclusionsDAPT was superior to aspirin in stroke prevention, but little difference existed between the two DAPT regimens. Asian population mainly Chinese may benefit from DAPT with aspirin and ticagrelor. But further head-to-head RCTs are needed to validate the study results.