TIA Patients Research Articles

Derivation of a clinical prediction score for the diagnosis of clinically significant symptomatic carotid artery disease.

Emergent vascular imaging identifies a subset of patients requiring immediate specialized care (i.e. carotid stenosis > 50%, dissection or free-floating thrombus). However, most TIA patients do not have these findings, so it is inefficient to image all TIA patients in crowded emergency departments (ED). Our objectives were to derive and internally validate a clinical prediction score for clinically significant carotid arterydisease in TIA patients. This was a planned secondary analysis of a prospective cohort study from 14 Canadian EDs. Among 11555 consecutive adult ED patients with TIA/minor stroke symptoms over 12 years, 9882 had vascular imaging and were included in the analysis. Our main outcome was clinically significant carotid artery disease, defined as extracranial internal carotid stenosis ≥ 50%, dissection, or thrombus in the internal carotid artery, with contralateral symptoms. Of 9882 patients, 888 (9.0%) had clinically significant carotid artery disease. Logistic regression was used to derive a 13-variable reduced model. We simplified the model into a score (Symcard [Symptomatic carotid artery disease] Score), with suggested cut-points for high, medium, and low-risk stratification. A substantial portion (38%) of patients were classified as low-risk, 33.8% as medium risk, and 28.2% as high risk. At the low-risk cut-point, sensitivity was 92.9%, specificity 41.1%, and diagnostic yield 1.7%. This simple score can predict carotid artery disease in TIA patients using readily available information. It identifies low-risk patients who can defer vascular imaging to an outpatient or specialty clinic setting. Medium-risk patients may undergo imaging immediately or with slight delay, depending on local resources. High-risk patients should undergo urgent vascular imaging.

Individualized MRI-based stroke PRediction scOre using plaque Vulnerability for symptomatic carotid artEry disease patients (IMPROVE).

In TIA and stroke patients with carotid stenosis, estimations of future ipsilateral ischemic stroke risk and treatment decisions are currently primarily based on the degree of stenosis. Intraplaque hemorrhage (IPH), which can be readily visualized on carotid MRI, is increasingly established as an easy to assess and a very strong and independent predictor for ipsilateral stroke risk, stronger than any clinical risk factor. We developed a clinical prediction model (IMPROVE) incorporating IPH, degree of stenosis, and clinical risk factors to select patients with symptomatic carotid stenosis at high risk for stroke. IMPROVE was developed on pooled clinical and MRI data from five cohort studies of 760 recent TIA or minor stroke patients with carotid plaque who received optimal medical treatment. We used Cox proportional hazards models to determine the coefficients of IMPROVE. IMPROVE was internally validated using bootstrapping and converted to one- and three-year ipsilateral ischemic stroke risk. The development dataset contained 65 ipsilateral incident ischemic strokes that occurred during a median follow-up of 1.2 years (IQR: 0.5-4.1). The IMPROVE model includes five predictors, which are in order of importance: degree of stenosis, presence of IPH on MRI, classification of last event (cerebral vs ocular), sex, and age. Internal validation revealed a good accuracy (C-statistic: 0.82; 95% CI: 0.77-0.87) and no evidence for miscalibration (calibration slope: 0.93). Using presence of IPH on MRI and only four conventional parameters, the IMPROVE model provides accurate individual stroke risk estimates, which may facilitate stratification for revascularization.

A novel prediction score determining individual clinical outcome 3 months after juvenile stroke (PREDICT-score)

BackgroundJuvenile strokes (< 55 years) account for about 15% of all ischemic strokes. Structured data on clinical outcome in those patients are sparse. Here, we aimed to fill this gap by systematically collecting relevant data and modeling a juvenile stroke prediction score for the 3-month functional outcome.MethodsWe retrospectively integrated and analyzed clinical and outcome data of juvenile stroke and TIA patients treated at the LMU University Hospital, LMU Munich, Munich. Good outcome was defined as a modified Rankin Scale of 0–2 or return to baseline of function. We analyzed candidate predictors and developed a predictive model. Predictive abilities were inspected using Area Under the ROC curve (AUROC) and visual representation of the calibration. The model was validated internally.Results346 patients were included in the analysis. We observed a good outcome in n = 293 patients (84.7%). The prediction model for an unfavourable outcome had an AUROC of 89.1% (95% CI 83.3–93.1%). The model includes age NIHSS, ASPECTS, blood glucose and type of vessel occlusion as predictors for the individual patient outcome.ConclusionsHere, we introduce the highly accurate PREDICT-score for the 3-month outcome after juvenile stroke derived from clinical routine data. The PREDICT-score might be helpful in guiding individual patient decisions and designing future studies but needs further prospective validation which is already planned.Trial registration The study has been registered at https://drks.de (DRKS00024407) on March 31, 2022.

Classification and management strategy of spontaneous carotid artery dissection

ObjectiveSpontaneous carotid artery dissections (sCADs) are the common cause of stroke in middle-aged and young people. There is still a lack of clinical classification to guide the management of sCAD. We reviewed our experience with 179 patients with sCAD and proposed a new classification for sCAD with prognostic and therapeutic significance. MethodsThis is a retrospective review of prospectively collected data from June 2018 to June 2023 of patients with sCAD treated at a large tertiary academic institution in an urban city in China. Based on imaging results, we categorize sCAD into four types: type Ⅰ, intramural hematoma or dissection with <70% luminal narrowing; type Ⅱ, intramural hematoma or dissection with ≥70% luminal narrowing; type Ⅲ, dissecting aneurysm; type ⅣA, extracranial carotid artery occlusion; and type ⅣB, tandem occlusion. We compared the clinical data and prognostic outcomes among various types of sCADs. ResultsA total of 179 patients and 197 dissected arteries met the inclusion criteria. The mean age of the 179 patients with sCAD was 49.5 years, 78% were male, and 18 patients (10%) had bilateral sCAD. According to our classification, there were 56 type Ⅰ (28.4%), 50 type Ⅱ (25.4%), 60 type Ⅲ (30.5%), and 31 type Ⅳ (15.7%) dissections. During a mean hospitalization length of 11.4 ± 47.0 days, there were nine recurrent strokes (4.6%) after medical treatment, two type Ⅲ dissections (1.0%), seven type Ⅳ dissections (3.6%), all ipsilateral, and one death. Overall, there were seven (3.6%, 1 type Ⅰ dissection, 3 type Ⅱ dissections, 2 type Ⅲ dissections, and 1 type Ⅳ dissection) recurrent strokes and three (1.5%, all type Ⅲ dissections) recurrent transient ischemic attacks in patients treated with just medical therapy during the follow-up period, all ipsilateral, with a mean follow-up of 26 months (range, 3-59 months). These patients did not undergo further intervention due to the high difficulty associated with endovascular treatment (EVT) or the mild nature of recurrent cerebral ischemic symptoms. Twenty-nine type I dissections (51.8%) were completely recanalized after antithrombotic therapy. A total of 19 type II dissections (38%) and 44 type III dissections (73%) received EVT for persistent flow-limited dissections, enlargement of dissecting aneurysms, or aggravation of neurological symptoms despite antithrombotic therapy. Type Ⅳ dissections are more likely to lead to the occurrence of ischemic stroke and presented with more severe symptoms. Eight type IVB dissections (33%) received acute phase intervention due to distal thromboembolism or aggravation of neurological symptoms after medical treatment. In terms of cerebral ischemic events and mortality, there were no statistically significant differences among the four types of sCAD (all P > .05). Favorable outcome was achieved in 168 patients (93.9%). ConclusionsThis study proposed a novel and more comprehensive classification method and the modern management strategy for sCAD. Antithrombotic therapy is beneficial to reduce the risk of recurrent stroke for stable sCAD. Non-emergent EVT can be an alternative therapeutic approach for patients who meet indications as in type II to IVA dissections. Urgent procedure with neurovascular intervention is necessary for some type IVB dissections. The short-term results of EVT for sCAD are encouraging, and long-term device-related and functional outcomes should undergo further research.

The association of CYP2C19 LoF alleles with adverse clinical outcomes in stroke patients taking clopidogrel: An updated meta-analysis.

The aggregated risk of recurrent stroke in stroke/transient ischemic attack (TIA) patients carrying CYP2C19 LoF alleles who take clopidogrel has not been investigated recently, and the available research is limited. This study aimed to perform an updated meta-analysis to assess the association between CYP2C19 LoF alleles and the risk of recurrent stroke in patients taking clopidogrel. Databases were searched for the literature on eligible studies. The end points were recurrent stroke, composite vascular events, and bleeding events. Odds ratios (ORs) were calculated using RevMan software, where p < 0.05 was considered statistically significant. Patients carrying CYP2C19 LoF alleles who were treated with clopidogrel had a significantly increased risk of recurrent ischemic stroke compared with non-carriers (OR 2.18, 96% CI 1.80-2.63; p < 0.00001). The risk of recurrent stroke was only significantly different in Asian patients (OR 2.29, 96% CI 1.88-2.80; p < 0.00001) but not in patients of other ethnicities; however, there were a limited number of studies in other ethnic groups. Both observational studies (OR 2.83, 96% CI 2.20-3.65; p < 0.00001) and RCTs (OR 1.48, 96% CI 1.10-1.98; p = 0.009) found associations with a significantly increased risk of recurrent ischemic stroke. Asian stroke patients or TIA patients carrying CYP2C19 LoF alleles and taking clopidogrel were at a significantly higher risk of recurrent ischemic stroke than non-carriers. Significantly increased risk of recurrent ischemic stroke was found in both observational studies and RCTs.

Asymmetric and symmetric dimethylarginine as markers of endothelial dysfunction in cerebrovascular disease: A prospective study

Background and aimAsymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) have been proposed as mediators of endothelial dysfunction. In this study, we aimed to investigate the diagnostic and prognostic role of ADMA and SDMA in acute cerebrovascular disease. Methods and resultsA prospective case-control study was performed, enrolling 48 patients affected by ischemic stroke with no cardioembolic origin, 20 patients affected by TIA, 40 subjects at high cardiovascular risk and 68 healthy subjects.ADMA levels were significantly lower in high-risk subjects (18.85 [11.78–22.83] μmol/L) than in patients with brain ischemic event, both transient (25.70 [13.15–40.20] μmol/L; p = 0.032) and permanent (24.50 [18.0–41.33] μmol/L; p = 0.001). SDMA levels were different not only between high-risk subjects and ischemic patients, but also between TIA and stroke patients, reaching higher levels in TIA group and lower levels in stroke group (1.15 [0.90–2.0] vs 0.68 [0.30–1.07] μmol/L; p < 0.001). SDMA was also correlated with short-term prognosis, with lower levels in case of adverse clinical course, evaluated by type of discharge (p = 0.009) and need of prolonged rehabilitation (p = 0.042). ConclusionsThe present study highlights the relationship between l-arginine, ADMA, SDMA and acute cerebrovascular events. Therefore, our results suggested a potential role of SDMA as a specific marker of transient ischemic damage and as a short-term positive prognostic marker.

Abstract WP238: Efficacy of Dual Antiplatelet Therapy After Lacunar versus Non-Lacunar Syndromes in the POINT Trial

Introduction: About 20% of ischemic strokes are lacunar infarcts, the pathophysiology of which differs from that of other stroke etiological subtypes. The POINT trial demonstrated the efficacy of dual antiplatelet therapy (DAPT) for secondary stroke prevention in patients with minor ischemic stroke and high-risk TIA, but it remains unknown whether this benefit differed in lacunar versus non-lacunar strokes. Method: In a secondary analysis of POINT trial data, we compared the efficacy of DAPT in patients with an index lacunar syndrome versus not. A lacunar syndrome was defined based on common classic lacunar syndromes (e.g., pure motor hemiparesis, clumsy-hand dysarthria) and ascertained using subcomponents of the National Institutes of Health Stroke Scale documented at baseline. Our primary efficacy outcome was ischemic stroke and the safety outcome was intracranial hemorrhage. We used survival analysis and tests of interaction to compare the effect of DAPT between the lacunar and non-lacunar subgroups. Result: Among 4,881 patients enrolled in the study, 1,083 (22.1%) were classified as having an index lacunar syndrome. The effect of DAPT on the risk of ischemic stroke did not vary significantly after a lacunar syndrome (HR, 0.76; 95% CI, 0.52-1.09) versus after a non-lacunar syndrome (HR, 0.69; 95% CI, 0.50-0.95) (P value for interaction, 0.70). Similarly, the effect of DAPT on the risk of intracranial hemorrhage did not vary significantly after a lacunar syndrome (HR, 2.82; 95% CI, 0.29-27.1) versus after a non-lacunar syndrome (HR, 2.10; 95% CI, 0.63-6.99) (P for interaction, 0.82). Conclusion: In a post hoc secondary analysis of the POINT trial, we found no evidence of a lesser benefit of DAPT after a minor ischemic stroke or TIA in patients presenting with a lacunar syndrome compared to other stroke subtypes.

Abstract TP182: Vessel Wall MRI in Diagnosis and Prognosis of Intracranial Vasculopathy

Introduction: High resolution vessel wall MRI (VWMRI) has been increasingly used in stroke patients to evaluate the arterial pathologies and underlying cause of stroke. We aimed to explore VWMRI features of intracranial vasculopathies in ischemic stroke patients and assess their associations with stroke mechanism and with clinical outcome. Methods: Ischemic stroke or TIA patients with intracranial vasculopathy as the potential cause of stroke were included if they underwent VWMRI (3D T1-weighted, pre- &amp; post- contrast, resolution isotropic 0.625 mm). The VWMRI features including the number of arterial lesions with thickened wall, presence of T1 hyperintensity, degree of enhancement [absent (0), mild (1), significant (2 =similar to infundibulum)], pattern of enhancement [eccentric, concentric, and mixed (both)] were evaluated by board certified neuroradiologists. Primary outcome was defined as recurrent stroke or other cardiovascular events. The association between clinical characteristic VWMRI features &amp; clinical outcome were examined. Results: A total of 46 patients [29 (63%) males; mean age (SD) 55.7 (15) years] were included. Among 41 patients (89%) had at least one lesion with thickened wall, 21 patients (51.2%) had multiple lesions, 28 (68.3%) had T1 hyperintensity, 39 (95%) had contrast enhancement (eccentric n=24, concentric n=10, mixed n=5 ) and 27 (66%) had significant enhancement. Overall, VWMRI suggested a different pathological mechanism of stroke in 16 patients comparing with the original impression. Higher creatinine and lower HDL levels were significantly (p&lt;0.05) associated with presence of multiple vs single lesion on VWMRI. LDL was significantly (p=0.04) higher in those with eccentric vs concentric enhancement. The median follow-up was 28.4 (IQR 13- 47) months, and primary outcome occurred in 6 (13.3%) patients. VWMRI features were not associated with the primary outcome. Conclusions: Presence of some degree of enhancement is common (95%) in patients with ischemic stroke attributed to intracranial vasculopathies. The VWMRI features were not associated with the primary clinical outcome. VWMRI may help to clarify the etiology of the stroke mechanisms. These findings warrant further evaluation in larger studies.

Abstract TP145: Comparison of the Clinical Characteristics of Patients With Minor Ischemic Stroke or TIA Treated Within the Stroke Code Protocol

Introduction: There is a lack of evidence regarding revascularization treatments in patients with minor ischemic stroke (NIHSS &lt; 6). CT angiography (CTA) and CT perfusion (CTP) might help select patients who would benefit from revascularization treatments. The main objective of this study is to compare the findings of CTA and CTP in a population of patients with minor ischemic stroke and TIA attended within the Stroke Code Protocol. Methods: Consecutive patients from Omic Is Brain cohort attended within the Stroke Code Protocol, diagnosed with minor ischemic stroke or TIA, and undergoing CTA and CTP, were included between May 2021 and April 2023. Clinical profiles were collected and classified into three groups: no large vessel occlusion - LVO - and no abnormalities in CTP (LVO-CTP-); no LVO and the presence of CTP abnormalities (LVO-CTP+); and LVO and CTP abnormalities (LVO+CTP+). Results: A total of 319 patients were included. Of these, 24.5% were CTP+, and 15.5% had LVO. The LVO-CTP- group (75.5%) was the youngest (p=0.022). Sex distribution and vascular risk factors were similar, except for hyperlipidemia, which was more frequent in the LVO+CTP+ group (p=0.003). Additionally, 5.3% of TIA patients had CTP+. Aphasia and defects in campimetry were overrepresented in the CTP+ group (p&lt;0.005). Furthermore, 3.5% of strokes classified as lacunar strokes had LVO+. Lacunar strokes were mainly found in the LVO-CTP- group, while cardioembolic strokes were highlighted in the CTP+ group. The LVO+CTP+ group showed the highest variation in NIHSS scores between admission (4 [2.0-5.0]) and discharge (1 [0.0-2.25]) (p=0.024). Reperfusion therapies were more frequently administered in the LVO+ and CTP+ groups (p&lt;0.001). Conclusions: The findings of CTA and CTP are directly correlated with clinical manifestations, severity, and acute-phase management.

Trajectories of self-reported daytime sleepiness post-ischemic stroke and transient ischemic attack: A propensity score matching study versus non-stroke patients.

Severe sleep apnea (SA) affects one-third of stroke patients. Sleepiness, one of the cardinal symptoms of SA, negatively impacts functional stroke outcomes. The impact of continuous positive airway pressure (CPAP) on post-stroke sleepiness is poorly described. We aimed to compare through a propensity score matching the trajectories of self-reported sleepiness post-stroke with matched individuals including SA patients adherent or not to CPAP. Sixty five (80.2%) ischemic stroke and 16 (19.8%) TIA patients (median [Q1;Q3] age = 67.0 [58.0;74.0] years, 70.4% male, body mass index [BMI] = 26.1 [24.5;29.8] kg·m-2, admission NIHSS = 3.0 [1.0;5.0]), with polysomnography and an Epworth Sleepiness Scale (ESS) performed within 1 year following stroke and with a follow-up ESS (delay = 236 [147;399] days) were included in the analysis. A 2:1 propensity score matching based on age, gender, BMI, and the apnea-hypopnea index was performed to identify 162 matched individuals referred for SA suspicion, free of stroke or TIA. Multivariable negative binomial regression models were performed to identify the determinants of sleepiness trajectories post-stroke. Baseline ESS was comparable between stroke/TIA and matched individuals (median [Q1; Q3] ESS = 7 [4;10] versus 6 [4;10], p = 0.86). The range of improvement in ESS was higher in stroke patients compared to controls (∆ESS = -2 [-4;1] vs -1 [-3;2], p = 0.03). In multivariable analysis, comorbid SA and CPAP treatment did not influence trajectories of sleepiness post-stroke. Sleepiness improvement was unexpectedly higher in stroke patients compared to matched individuals, with no significant influence of comorbid SA and CPAP on its trajectory. Sleepiness may not be primarily indicative of SA in stroke or TIA patients.

Prevalence, incidence, and prognostic indicators of Dementia in patients with TIA and Stroke: the Population‐based Rotterdam Study

AbstractBackgroundRisk of dementia is high after major stroke, but reliable estimates of dementia by stroke severity, accounting for competing risk of mortality, in a population‐based setting are scarce. In this study, we aimed to determine risk and prognostic indicators of dementia before and after TIA and stroke.MethodWe included all individuals with first‐ever TIA or stroke from the population‐based Rotterdam Study, between 2002‐2018, and matched those on age (+/‐3 years) and sex, using an incidence density sampling approach. We determined prevalence of pre‐event dementia by event severity (TIA vs. minor stroke [NIHSS≤3] vs. major stroke [NIHSS&gt;3]). Similarly, we determined risk of dementia at 1‐,5‐ and 10‐year post‐event using the subdistribution hazards (SDH) cumulative incidence function (CIF), and explored prognostic indicators of dementia.ResultAmong 1352 participants with first‐ever TIA or stroke (mean age: 79.4 (9.5) years, 59.7% women), 466 had TIA, 392 minor stroke, 494 major stroke. Prevalence of pre‐event dementia was higher among patients with major stroke (90/494; 18.2%) than among those with minor stroke (29/392; 7.3%), TIA (37/466; 7.9%). During 10‐year follow‐up, dementia occurred in 784 of 4703 participants without pre‐event dementia or reference participants. Compared to TIA patients, dementia risk was higher after major stroke (HR 2.17; 95% CI 1.53–3.07) and minor stroke (HR 1.63; 95% CI 1.17–2.26). Dementia risk was associated with male sex (SDH‐ratio 1.23; 95% CI 1.04–1.45), age (per 1‐year increase: 1.07; 1.06–1.08), higher education (0.61; 0.44–0.86), diabetes mellitus (1.29; 1.06–1.56), atrial fibrillation (1.40; 1.14–.71), and premorbid cognition (MMSE≤24, 2.39; 1.87–3.05). Among 417 patients with available pre‐event brain MRI, white matter hyperintensity burden (per 1‐% increase of proportion of total brain volume: 1.24; 95% CI 1.07–1.45) and presence of microbleeds (2.14; 1.18–3.86) were indicators of post‐stroke dementia.ConclusionDementia incidence after TIA and stroke is increased in patients with major stroke and to a lesser extent minor stroke, but not TIA. Event severity in combination with clinical and imaging indicators may hold potential for the prediction of cognitive decline after stroke.

Appropriate use of antiplatelet medications following transient ischemic attacks and stroke: a 9-year study from the Middle East.

Guidelines recommend that patients with high-risk TIAs and minor strokes presenting within 1-3 days from onset should be offered dual antiplatelet therapy (DAPT). There are little data on real-world adherence to these recommendations. We evaluated the appropriateness of DAPT use in TIA and stroke patients in a prospective database. The Qatar Stroke Database began the enrollment of patients with TIAs and acute stroke in 2014 and currently has ~16,000 patients. For this study, we evaluated the rates of guideline-adherent use of antiplatelet treatment at the time of discharge in patients with TIAs and stroke. TIAs were considered high-risk with an ABCD2 score of 4, and a minor stroke was defined as an NIHSS of 3. Patient demographics, clinical features, risk factors, previous medications, imaging and laboratory investigations, final diagnosis, discharge medications, and discharge and 90-day modified Rankin Scale (mRS) were analyzed. After excluding patients with ICH, mimics, and rare secondary causes, 8,082 patients were available for final analysis (TIAs: 1,357 and stroke: 6,725). In high-risk TIAs, 282 of 666 (42.3%) patients were discharged on DAPT. In patients with minor strokes, 1,207 of 3,572 (33.8%) patients were discharged on DAPT. DAPT was inappropriately offered to 238 of 691 (34.4%) low-risk TIAs and 809 of 3,153 (25.7%) non-minor stroke patients. This large database of prospectively collected patients with TIAs and stroke shows that, unfortunately, despite several guidelines, a large majority of patients with TIAs and stroke are receiving inappropriate antiplatelet treatment at discharge from the hospital. This requires urgent attention and further investigation.

Abstract 16877: Role Of Short Term Atrial Fibrillation in Different Stroke Entities

Introduction: Stroke including ESUS is one of the most common causes of disability and death in the world. Atrial fibrillation (AF) of more than 30 sec is considered as reason for cardioembolic stroke. Hypothesis: Nevertheless, shorter periods of AF might also be a possible risk factor. Methods: We determined periods of AF of 0-14 sec, AF 15-30sec and AF&gt; 30 sec in patients with different stroke entities. We analysed all ischemic strokes and transient ischemic attacks at the Stroke Unit in Siegen over 6 months. All stroke patients were prospectively ECG monitored over a minimum of 24h and characterized for the different AF periods. Results: A number of 714 patients over 6 months were hospitalized suffering a stroke. Among them 163 (30.8%) had a cryptogenic Stroke, including 98 (19%) ESUS patients. Furthermore, 185 (26%) TIA, 209 (39%) cardioembolic, 110 (21%) atherosclerotic, 40 (8%) lacunar and 7 (1%) other specific strokes were registered. Manifest atrial fibrillation (&gt;30s) showed a prevalence within our stroke population of 23%. Whereas 15% had an AF episode of 15-29 s and 16% presented AF episode of 0-14 s. Among cardioembolic infarcts, 45% had manifest atrial fibrillation (&gt;30 s), 20% had an atrial fibrillation episode of 15-29 s, and 22% showed an atrial fibrillation episode of 0-14 s. Taken together, more than 90% of cardioembolic infarcts show an episode of atrial fibrillation of any duration. An AF episode of 15-29 s or 0-14 s is also found in almost 35% of ESUS patients;similar to cryptogenic infarcts. In 22% of TIA patients manifest atrial fibrillation has been detected. 7% of TIA patients showed one or more episodes of AF of 15-29 s and 10% an episode of 0-14 s. Among the atherosclerotic infarcts, the proportion of AF &gt;30 s is significantly lower at 12%, however the percentage of AF for 15-29 s was 14. Conclusions: In our study, AF showed the largest ratio with 48% among cardioembolic infarcts. Since a manifest AF is an exclusion criterion for ESUS, none suffered from manifest AF. However, it is striking that 15% had an AF episode of 15-29 s and 18% had an AF episode of 0-15 s. Possibly, the definition of AF has to be adjusted or at least advanced rhythm monitoring should be provided. This should be investigated in future prospective studies.

THU671 Genes Encoding Adaptive Immune Receptor Repertoire Might Be Associated With The Risk Of Graves’ Disease And Antithyroid Drug-induced Agranulocytosis

Abstract Disclosure: C. Huang: None. S. Yang: None. S. Lai: None. H. Chen: None. P. Chen: None. Graves' disease (GD) is an autoimmune disorder characterized by the immune system attacking the thyroid gland cells, leading to hyperthyroidism. One serious adverse effect that can occur in GD patients receiving antithyroid drugs, such as thionamides, is antithyroid drug-induced agranulocytosis (TiA), which affects 0.1% to 0.4% of patients. While previous research has shown that specific human leukocyte antigen (HLA) genes/alleles are associated with GD or TiA, the role of the genes encoding adaptive immune receptor repertoire (gAIRR), including the B cell receptor and T cell receptor genes, in GD or TiA has not been explored. This study aims to investigate whether gAIRR has a genetic association with GD or TiA. We enrolled 128 GD patients, 19 TiA patients, and 104 controls, and conducted gAIRR genotyping using gAIRR Suite, a probe capture-based targeted sequencing and analysis platform. Our results identified several gAIRR alleles that were more prevalent in GD cases than in controls, including IGLV1-41*02N (a novel allele with the sequence closest to IGLV1-41*02, 20.3% in GD patients vs. 7.7% in controls, p=0.008), IGHV1-69*04N (12.5% vs. 3.8%, p=0.02), TRGV4*01 (46.9% vs. 31.7%, p=0.022), and several other alleles (such as TRBV6-6*03, IGKV1/OR22-5*01N, TRVB12-2*01N, TRAV8-4*01N, IGHV3-71*02, IGHV2-70*04N, etc.) We also found several gAIRR alleles that were less prevalent in GD cases than in controls, including IGLV5-45*03N, IGLV2-14*04, IGLV(V)-66*01, IGLV3-13*01N, TRBV20/OR9-2*02N, TRBD2*01, TRAV6*02, among others. Regarding the TiA cohort (compared to GD patients without TiA), some gAIRR alleles showed frequencies difference, but did not reach statistical significance. Overall, our findings provide supporting evidence that gAIRR genes/alleles might be associated with the development of GD or TiA. Future studies with larger sample sizes are necessary. Furthermore, a joint analysis of HLA and gAIRR genotypes might provide valuable insight into the pathogenesis of GD and TiA. Presentation: Thursday, June 15, 2023

Lipidomic signature of stroke recurrence after transient ischemic attack

While TIA patients have transient symptoms, they should not be underestimated, as they could have an underlying pathology that may lead to a subsequent stroke: stroke recurrence (SR). Previously, it has been described the involvement of lipids in different vascular diseases. The aim of the current study was to perform a lipidomic analysis to identify differences in the lipidomic profile between patients with SR and patients without. Untargeted lipidomic analysis was performed in plasma samples of 460 consecutive TIA patients recruited < 24 h after the onset of symptoms. 37 (8%) patients suffered SR at 90 days. Lipidomic profiling disclosed 7 lipid species differentially expressed between groups: 5 triacylglycerides (TG), 1 diacylglyceride (DG), and 1 alkenyl-PE (plasmalogen) [specifically, TG(56:1), TG(63:0), TG(58:2), TG(50:5), TG(53:7, DG(38:5)) and PE(P-18:0/18:2)]. 6 of these 7 lipid species belonged to the glycerolipid family and a plasmalogen, pointing to bioenergetics pathways, as well as oxidative stress response. In this context, it was proposed the PE(P-18:0/18:2) as potential biomarker of SR condition.The observed changes in lipid patterns suggest pathophysiological mechanisms associated with lipid droplets metabolism and antioxidant protection that is translated to plasma level as consequence of a more intensive or high-risk ischemic condition related to SR.

Stages and Processes of Change for Weight Loss in Acute Stroke or TIA Patients Living with Obesity (P6-5.019)

<h3>Objective:</h3> To evaluate the stages and processes of change for weight loss in patients living with obesity who have had a recent stroke or TIA. <h3>Background:</h3> Weight loss is recommended for patients living with obesity in the secondary prevention of stroke. Few studies, however, have examined the stages and processes of change for weight loss in stroke patients living with obesity. <h3>Design/Methods:</h3> Using a validated questionnaire, we assessed each patient’s stage of behavioral change according to the transtheoretical model (precontemplation, contemplation, preparation, action, and maintenance). We also examined 4 processes of behavioral change, which quantify activities and experiences that patients undergo on the way to behavioral change: emotional reevaluation (EMR), weight management action (WMA), weight consequence evaluation, and supporting relationships. Process scores were compared between patients in the action and maintenance stages and those in the precontemplation, contemplation, and preparation stages. <h3>Results:</h3> 44 patients met inclusion/exclusion criteria: 6 (14%) were in the precontemplation stage of change, 7 (16%) were in contemplation, 2 (5%) were in preparation, 13 (30%) were in action, and 16 (36%) were in maintenance. Those in the action and maintenance stages accounted for the majority of participants (<i>n</i> = 29, 66%). Patients in the action and maintenance stages (<i>N</i> = 29) had higher EMR scores (mean 79, SD 13 vs. mean 68, SD 19, <i>t</i> = 2.0, <i>p</i> = 0.03) and WMA scores (mean 69, SD 13 vs. mean 59, SD 19, <i>t</i> = 2.0, <i>p</i> = 0.03) as compared to those in the precontemplation, contemplation, and preparation stages (<i>N</i> = 15). <h3>Conclusions:</h3> Without counseling or specific intervention, two-thirds of stroke/TIA patients living with obesity are in the action or maintenance stage of behavior change with respect to weight loss. Patients who score higher in EMR and WMA are more likely to be in the action or maintenance stage of change. <b>Disclosure:</b> Dr. Wilson has nothing to disclose. Hailey Orgass has nothing to disclose. An immediate family member of Dr. Dearborn-Tomazos has received personal compensation for serving as an employee of PTC Therapeutics. An immediate family member of Dr. Dearborn-Tomazos has received personal compensation for serving as an employee of Alexion Pharmaceuticals. Dr. Dearborn-Tomazos has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Qmetis. An immediate family member of Dr. Dearborn-Tomazos has stock in Alexion Pharmacueticals. The institution of Dr. Dearborn-Tomazos has received research support from BMS.

High-resolution vessel wall magnetic resonance imaging in intracranial vasculopathies: an experience from eastern India.

To evaluate the role of high-resolution intracranial vessel wall imaging (HR-IVWI) in differentiation of various intracranial vasculopathies in addition to luminal and clinical imaging in the largest cohort of Indian stroke patients. A single-center, cross-sectional study was undertaken recruiting consecutive stroke or TIA patients presenting within a month of onset, with luminal irregularity/narrowing upstream from the stroke territory. The patients were initially classified into TOAST and Chinese ischemic stroke sub-classification (CISS) on the basis of clinical and luminal characteristics and reclassified again following incorporation of HR-IVWI findings. In our cohort of 150 patients, additional use of HR-IVWI led to a 10.7 and 14% change in initial TOAST and CISS classification respectively (p < 0.001). In TOAST classification, 12 "undetermined aetiology" were reclassified into intracranial atherosclerotic disease (ICAD), 1 "undetermined aetiology" into CNS angiitis and 1 "undetermined aetiology" into arterial dissection. Similarly, in CISS 19 "undetermined aetiology" was reclassified into 16 large artery atherosclerosis (LAA) and 3 "other aetiology" consisting of one CNS angiitis, Moyamoya disease (MMD) and arterial dissection each. Two initial classification of MMD by CISS and TOAST were changed into ICAD. The observed change in diagnosis following incorporation of HR-IVWI was proportionately highest in ICAD (LAA) subgroup (TOAST-9.3%, CISS-12%). Adjunctive use of HR-IVWI, to clinical and luminal assessment, can significantly improve diagnostic accuracy during evaluation of intracranial vasculopathies, with its greatest utility in diagnosing in ICAD, CNS angiitis and dissection. HR-IVWI allows clearer etiological distinction of intracranial vasculopathies having therapeutic and prognostic implications.

High-Sensitivity C-Reactive Protein Modifies P-Wave Terminal Force in Lead V1-Associated Prognosis in Acute Ischemic Stroke or TIA Patients

Little is known about the role of high-sensitivity C-reactive protein (hsCRP) in the relationship between P-wave terminal force in lead V1 (PTFV1) and stroke prognosis. We aimed to investigate how hsCRP influences the effect of PTFV1 on ischemic stroke recurrence and mortality. In this study, patients enrolled in the Third China National Stroke Registry, which enrolled consecutive patients who had suffered an ischemic stroke or transient ischemic attack in China, were analyzed. After excluding patients with atrial fibrillation, 8271 patients with PTFV1 and hsCRP measurements were included in this analysis. Cox regression analyses were used to assess the association between PTFV1 and stroke prognosis according to different inflammation statuses stratified by an hsCRP level of 3 mg/L. A total of 216 (2.6%) patients died, and 715 (8.6%) patients experienced ischemic stroke recurrence within 1 year. In patients with hsCRP levels ≥ 3 mg/L, elevated PTFV1 was significantly associated with mortality (HR, 1.75; 95% CI, 1.05-2.92; p = 0.03), while in those with hsCRP levels < 3 mg/L, such an association did not exist. In contrast, in patients with hsCRP levels < 3 mg/L and those with hsCRP levels ≥ 3 mg/L, elevated PTFV1 remained significantly associated with ischemic stroke recurrence. The predictive role of PTFV1 towards mortality but not ischemic stroke recurrence differed in terms of hsCRP levels.

Abstract Number ‐ 278: Transient Ischemic Attack Evaluation Pathways: Inpatient Versus Expedited Outpatient Comparative Analysis

Introduction Transient Ischemic Attack (TIA) evaluation requires urgent etiology identification and targeted stroke prevention, traditionally performed via hospital admission. The literature suggests that outpatient evaluation may be safe and cost‐effective. Hence, we implemented an expedited outpatient pathway (OP) for patients presenting to our institution’s Emergency Department (ED) with TIA. To further guide future practice, we compared clinical features and outcomes between expedited OP and our well‐established inpatient pathway (IP). Methods We implemented an algorithm of direct communication between ED providers and Vascular Neurologists for all TIA patients. Certain screening studies (head CT, CT angiogram, basic laboratories) and acute therapies were implemented in the ED, whereas others (brain MRI, echocardiogram, etc) and Vascular Neurology consultations were expedited outpatient within 48–72 hours.We included all patients that underwent OP evaluation from May 2021‐May 2022. Further, we extracted patients with a final diagnosis of TIA and compared them with IP TIA patients hospitalized (2017‐2021), matched by age, gender, and clinical severity (ABCD2). Descriptive statistics were used to summarize patient demographics, clinical data, treatments, and 3‐month outcomes. Continuous variables were summarized with mean and standard deviations while categorical variables were shown as counts and percentages. Chi‐square test was used for categorical variables and Mann‐Whitney U test was used to compare continuous variables. P‐values &lt; 0.05 were considered statistically significant and all tests were two‐sided. Statistical Analysis was completed in R 4.0.3. Results Of 43 patients who underwent expedited OP TIA workup, TIA or minor stroke was diagnosed in 21/43 (48.9%). 18 TIAs underwent comparative analyses. Mean symptom duration was longer in the IP (2.06 hours) than OP (0.99 hours), p = 0.370%. TIA was more likely to be diagnosed in the OP 14/18 (78%) versus IP 12/18 (67%), (p = 0.423). OP had more transesophageal echocardiograms (17% vs 5%, p = 0.630) and longer duration of ambulatory cardiac monitoring (mean 574.3 vs 381.7 hours, p = 0.100). IP patients were more likely to get started on anticoagulation compared to OP (38% vs 11%, p = 0.258) and high‐intensity statin (38% vs 17%, p = 0.260). All laboratories, echocardiograms and brain MR imaging were performed significantly sooner for the IP (p&lt; 0.05 for all). IP had higher rate of return ED visits (22%) and readmissions at 3 months (11%), whereas OP had none. OP had no deaths or recurrent strokes, whereas 11% and 5.6% respectively were noted in the IP at 3 months (p = 0.310, p = 0.310). Conclusions Our study shows that routine IP evaluation for patients presenting with TIA in the ED may not offer diagnostic superiority nor lead to improvement of short‐term clinical outcomes, as compared to the expedited OP evaluation. Careful evaluation of TIA patients in the ED followed by expedited OP evaluation might be a plausible approach to help lower costs and avoid hospitalization without compromising the safety of these patients.

Abstract TP203: Annual Population Burden Of Major Adverse Event From Statin Overuse In Acute Cerebral Ischemia Patients Without Indications

Background: Statin agents play a major role in secondary prevention after acute cerebral ischemia (ACI) events but are not indicated in all ischemic stroke and TIA patients. National guidelines recommend statins for patients: 1) with ACI of large or small vessel atherosclerotic origin; and 2) without these stroke mechanisms, but co-existing CAD or primary prevention indications. The potential adverse effects of statin overuse in the remaining ACI patients has not been well delineated. Methods: Per PRISMA guidelines, we performed systematic meta-analyses of: 1) statin RCTs to determine absolute risk increases for 6 major adverse events; and 2) large clinical series to determine the proportion of ACI events due to large or small vessel atherosclerotic disease and the proportion of remaining patients with CAD/primary prevention statin indications. Results: For adverse effects, data was available from 63 RCTs enrolling 155,107 patients. Statin therapy increased the risk of occurrence of 6 conditions: diabetes, myalgia, myopathy, liver disease, renal insufficiency, and eye disease. Across 16 large series enrolling 16,161 patients, rate of ACI due to large and small artery atherosclerosis was 45.9% (LAA 19.3%, SVD 17.9%), rate of remaining patients with CAD/primary prevention statin indications 24.0%, and rate of patients without statin indication 30.0%. Data synthesis indicated that, in the US, were all ACI without statin indications treated with statins, a total of 8902 patients would develop needless adverse events each year, most commonly diabetes, myopathy, and eye disease (Table). Conclusion: Nearly one-third of acute cerebral ischemia patients do not have an indication for statins and statin overuse in these patients could annually lead to nearly 9000 needless adverse events, including diabetes, myopathy, and eye disease. These findings emphasize the importance of adhering to guideline indications for the start of statin therapy in acute cerebral ischemia.