Rate Of Transient Ischemic Attack Research Articles

A Real-World Comparison of Apixaban and Rivaroxaban in Obese and Morbidly Obese Patients With Nonvalvular Atrial Fibrillation

Background: Contemporary guidelines for managing nonvalvular atrial fibrillation (NVAF) include apixaban and rivaroxaban as first-line anticoagulation treatment options. Minimal guidance is available regarding selecting anticoagulants for patients with class I-III obesity. Objective: This study aims to evaluate the comparative effectiveness and safety of apixaban and rivaroxaban in both obese and morbidly obese patients with NVAF. Methods: A retrospective cohort study was conducted at an outpatient cardiovascular clinic after Institutional Review Board approval. Patients were eligible if they were ≥18 years of age, had a BMI ≥30 kg/m2, and took apixaban or rivaroxaban for NVAF for ≥3 months. The primary endpoint was the composite rate of stroke, transient ischemic attack (TIA), myocardial infarction (MI), or presence of atrial thrombosis. Bleeding events were evaluated as the primary safety endpoint. Results: Combined, the cohorts consisted of 303 obese or morbidly obese patients. The primary composite endpoint occurred in 3.8% of patients taking apixaban and 1.7% of patients taking rivaroxaban (P = .28). Both clinically relevant, non-major and major bleeding occurred more often in the apixaban arm, but this difference was not statistically significant; however, bleeding risk may have been skewed due to differences in baseline characteristics. Conclusion and Relevance: For obese and morbidly obese patients prescribed either apixaban or rivaroxaban for NVAF, rates of stroke, TIA, MI, and atrial thrombosis did not differ. The preferred DOAC for patients with class I-III obesity remains elusive, but current data points to a patient-centered approach for anticoagulant selection.

Combination therapy for Sneddon syndrome to reduce the incidence of cerebrovascular complications.

Sneddon syndrome is an occlusive vasculopathy that presents clinically with generalized livedo racemosa on the skin and transient ischemic attacks, strokes, and cognitive or motor deficits in the central nervous system. Antiplatelet or anticoagulant therapy is recommended. Due to the limited therapeutic efficacy and the resulting serious complications, we propose combination therapy with additional infusion cycles of alprostadil and captopril and report initial long-term results. We performed a systematic retrospective analysis of all patients with primary Sneddon syndrome who received combination therapy in our clinic between 1995 and 2020. Therapeutic outcomes were evaluated using descriptive statistics compared to historical controls receiving monotherapy. We also analyzed the event rate of complications when combination therapy was discontinued. During the 99.7 patient-years of follow-up, there were no transient ischemic attacks and the stroke rate dropped to 0.02 per patient-year. In comparison, the rates of transient ischemic attacks and strokes in the historical controls ranged from 0.08 to 0.035 per patient-year. After discontinuation of alprostadil therapy, eight events occurred in three patients. Combination therapy reduces the long-term incidence of ischemic events in patients with primary Sneddon syndrome.

Device Closure or Antithrombotic Therapy After Cryptogenic Stroke in Elderly Patients With a High-Risk Patent Foramen Ovale.

In young patients (aged 18-60 years) with patent foramen ovale (PFO)-associated stroke, percutaneous closure has been found to be useful for preventing recurrent ischemic stroke or transient ischemic attack (TIA). However, it remains unknown whether PFO closure is also beneficial in older patients. Patients aged ≥60 years who had a cryptogenic stroke and PFO from ten hospitals in South Korea were included. The effect of PFO closure plus medical therapy over medical therapy alone was assessed by a propensity-score matching method in the overall cohort and in those with a high-risk PFO, characterized by the presence of an atrial septal aneurysm or a large shunt. Out of the 437 patients (mean age, 68.1), 303 (69%) had a high-risk PFO and 161 (37%) patients underwent PFO closure. Over a median follow-up of 3.9 years, recurrent ischemic stroke or TIA developed in 64 (14.6%) patients. In the propensity score-matched cohort of the overall patients (130 pairs), PFO closure was associated with a significantly lower risk of a composite of ischemic stroke or TIA (hazard ratio [HR]: 0.45; 95% confidence interval [CI]: 0.24-0.84; P=0.012), but not for ischemic stroke. In a subgroup analysis of confined to the high-risk PFO patients (116 pairs), PFO closure was associated with significantly lower risks of both the composite of ischemic stroke or TIA (HR: 0.40; 95% CI: 0.21-0.77; P=0.006) and ischemic stroke (HR: 0.47; 95% CI: 0.23-0.95; P=0.035). Elderly patients with cryptogenic stroke and PFO have a high recurrence rate of ischemic stroke or TIA, which may be significantly reduced by device closure.

Abstract WP268: Transcarotid Arterial Revascularization of Symptomatic Internal Carotid Artery Disease: A Systematic Review and Meta-Analysis

Introduction: TCAR is an interventional therapy for symptomatic ICA disease. Currently, the utilization of TCAR is contentious due to limited evidence. We conducted a comprehensive systematic review and meta-analysis utilizing existing studies to evaluate the postoperative outcomes and complications of TCAR as compared to CAS and CEA for patients with symptomatic ICA disease. Methods: A systematic review was conducted, spanning from January 2000 to February 2023, encompassing studies that employed TCAR for the treatment of symptomatic ICA disease. The primary outcomes included 30-day combined stroke and transient ischemic attack (TIA), myocardial infarction (MI), and mortality. This was explained in Figure 1. Results: A total of seven studies involving 24,246 patients were analyzed. Compared to CAS, TCAR was associated with a similar rate of stroke and TIA (OR:0.77,95%CI:0.33-1.82), and MI (OR:1.29,95%CI:0.83-2.01) but lower mortality (OR:0.42,95%CI:0.22-0.81). In patients, ≥80 years, the rate of stroke and TIA was lower with TCAR compared to CAS (OR:0.47,95%CI:0.35-0.65). When compared to CEA, TCAR was associated with a higher rate of stroke and TIA (OR:1.26,95%CI:1.03-1.54) but without differing rates of MI (OR:0.9,95%CI:0.64-1.38), and mortality (OR:1.35,95%CI:0.87-2.10). this was explained in figure 2. Conclusions: Although CEA has traditionally been considered superior to stenting for symptomatic carotid stenosis, TCAR may have some advantages over CAS, particularly in the elderly population (≥80 years). Prospective randomized trials comparing the three modalities are needed.

Abstract TP231: Incidence of Stroke and Transient Ischemic Attack in Adults With Congenital Heart Disease: A Systematic Review and Meta-Analysis

Introduction: Congenital cardiac lesions result in abnormal flow patterns that increase risk of cerebrovascular events. We investigated the incidence of stroke and transient ischemic attack (TIA) in adults with congenital heart disease (ACHD). Methods: A systematic review was performed per PRISMA guidelines to identify all studies reporting the incidence of stroke and TIA in ACHD. Two independent reviewers screened studies, which were included if patients were age 16 and older with congenital heart disease, and if the outcome was stroke or TIA. Random-effects meta-analysis was conducted to estimate the pooled incidence rate of stroke and TIA with 95% confidence intervals. The Newcastle-Ottawa Scale for risk of bias was applied. This systematic review is registered (CRD42022322144). Results: Of 11,028 identified abstracts, 27 studies met inclusion criteria. 22 studies reported mean or median age, which was less than 60 years in 18 studies. 39 estimates of incidence rates from 24 studies were entered in the meta-analysis. The pooled incidence rate estimate of stroke and TIA was 0.58 per 100 person years, with significant heterogeneity between studies (95% CI 0.39-0.86, I2 97.8%, p<0.001). Secondary analyses were performed stratified by CHD and outcome subtype. The pooled incidence rate of ischemic stroke was estimated at 0.59 per 100 person years (95% CI 0.36-0.95, I2 98%, p=0.01). Conclusions: This meta-analysis found that the incidence rate of stroke and TIA is higher in ACHD than age-adjusted global estimates, and similar to the American Heart Association reported global ischemic stroke incidence rate for individuals >60 years (0.52 per 100 person years).

Carotid endarterectomy compared with carotid artery stenting for extracranial carotid artery stenosis: a retrospective single-centre study

Aim: One of the main risk factors for an ischemic stroke is significant carotid artery stenosis, and extracranial severe carotid artery stenosis accounts for 20% of ischemic strokes. Prior to the development of carotid artery stenting (CAS), the only effective and reliable treatment for carotid artery stenosis was carotid endarterectomy (CEA). This study compares the results of CAS and CEA in patients with significant carotid artery stenosis. Methods: Between 2018 and 2022, hospital records of all patients who underwent carotid artery revascularization at the institution were retrospectively analyzed. Patients were divided into two groups depending on whether CEA or CAS was performed for carotid revascularization. Propensity score matching was performed to reduce bias by equating the baseline clinical characteristics of the groups. To compare 30-day, 1-year, and long-term outcomes, rates of transient ischemic attack (TIA), myocardial infarction, stroke, all-cause mortality, and composite endpoints were analyzed. Results: After PSM, 76 patients each in the CEA and CAS groups were compared. The mean age was 69.80 years ± 11.35 years and 121 (80%) were male. The patients were followed up for a mean of 33 months ± 6 months. The incidence of TIA in the perioperative period [9 (12%) vs. 4 (5%); P < 0.05], TIA and composite endpoint at 1-year period [11 (15%) vs. 2 (3%); P < 0.05 and 27 (36%) vs. 16 (21%); P < 0.05, respectively] were significantly higher in the CAS group than in the CEA group. No difference was observed between the groups in the long-term. Conclusions: There was no noticeable difference between the CEA and CAS groups in the examination of cases with severe carotid artery stenosis in terms of 1-month, and 1-year results (apart from TIA and composite endpoints), or long-term outcomes. Extracranial carotid artery stenosis can be treated safely and effectively also by CAS.

5-year stroke rates in nonvalvular atrial fibrillation after watchman compared to direct oral anticoagulants

BackgroundThe WATCHMAN device (Boston Scientific; Marlborough, MA, USA) is noninferior to warfarin in preventing ischemic strokes while reducing bleeding risks associated with long term anticoagulation in nonvalvular atrial fibrillation (AFib). The device's performance compared to direct oral anticoagulants (DOAC) is less well known. ObjectiveTo compare 5-year major bleeding and ischemic stroke rates in patients with nonvalvular AFib who received a WATCHMAN device or DOAC therapy after a major bleeding event. MethodsThis retrospective, multicenter, 1:1 matched cohort study was derived from the PearlDiver Mariner database from 2010 to 2020. Patients with nonvalvular AFib on oral anticoagulation who had a major bleeding event were identified. Those who received either WATCHMAN or DOAC after resolution of the bleeding event were selected. The two groups were exactly matched 1:1 based on various comorbidities. Rates of ischemic stroke, transient ischemic attack (TIA), major bleeding, and hemorrhagic stroke were compared over 5 years. ResultsEach cohort consisted of 2248 patients after 1:1 matching. The mean CHADS2-VASC score was 4.81 ± 1.25. At 5 years, the WATCHMAN cohort had significantly lower rates of major bleeding events [OR 0.24 (0.21, 0.27)], TIAs [OR 0.75 (0.58, 0.95)], and ischemic strokes [OR 0.72 (0.61, 0.86)]. There was no significant difference in hemorrhagic strokes [OR 1.14 (0.83, 1.58)]. ConclusionEven in a high-risk population, the WATCHMAN is comparable to DOAC therapy in the primary prevention of hemorrhagic strokes and may provide benefit in the rates of bleeding events, TIAs, and ischemic strokes.

Dual- vs single-layer stents for endovascular treatment of symptomatic and asymptomatic internal carotid artery stenosis

BackgroundsPlaque protrusion is a common event among carotid artery stenting (CAS) patients and increases ischemic complication risk. Dual-layer stents (DLS) with micromesh technology may offer greater plaque protection compared to single-layer stents (SLS), but few data are available. The aim of the study is to compare clinical outcomes at 12 months for asymptomatic and symptomatic patients treated for primary CAS with DLS or SLS in a high-volume center. MethodsA retrospective analysis of consecutive symptomatic and asymptomatic patients treated with primary CAS for internal carotid artery (ICA) stenosis, with either DLS or SLS between 2015 and 2019, was performed. Primary endpoints included rates of ipsilateral transient ischemic attacks (TIA)/stroke and death within 1-year from CAS. Secondary endpoints included patency rates and survival according to stent type. ResultsOf the 301 patients who met inclusion criteria (74.8 % male; 73.6 mean age ± 8.7 years), most patients were asymptomatic (77.4 %). Among all patients DLS was most frequently deployed (66 %); also, among asymptomatic (62 %) and symptomatic patients (81 %), p < 0.01. Symptomatic patients had less comorbidities and severe disease than asymptomatic patients.Six peri-operative strokes were recorded and, within 1 year, 2 additional strokes were registered among symptomatic patients treated with SLS. No post-operative strokes were encountered in the DLS group (p = 0.04) among symptomatic patients. Higher rates of TIA were observed among asymptomatic patients treated with DLS compared to SLS while rates of TIA were reduced among symptomatic patients treated with DLS.There were no differences in patency rates for DLS and SLS in symptomatic and asymptomatic patients. Primary patency was similar among DLS stent types but differed among SLS stent types (p = 0.01).At a mean follow-up of 27 months ±17.6, survival was comparable between DLS and SLS groups (p = 0.98). ConclusionCAS with DLS seems to reduce the risk of post-procedural stroke for symptomatic patients compared to SLS whilst the choice of stent did not influence ipsilateral TIA, survival or patency rates. These data require confirmation from larger, randomized, prospective studies.

Natural History of Internal Carotid Artery Stenosis Progression

To investigate the natural history of internal carotid artery (ICA) stenosis progression. This single-institution retrospective cohort study analyzed patients diagnosed with internal carotid artery stenosis of 50% or greater on duplex ultrasound (DUS) from 2015 to 2022. Subjects were drawn from our institutional IAC-accredited noninterventional vascular laboratory database. Progression was defined as an increase in stenosis classification category. Imaging, demographic, and clinical data was obtained from our institutional electronic medical record via a database mining query. Cases were analyzed at the patient level, with severity corresponding to the greatest degree of ICA stenosis on the bilateral index and follow-up studies. Of 1954 unique patients imaged during the study period, 555 were followed with DUS for over 1 year. Table I summarizes demographic and historical factors for the entire cohort, stratified by availability of follow-up data. Patients with follow-up were more likely to have a history of stroke or transient ischemic attack were more likely to be taking antihypertensives, aspirin, statins, and P2Y12 inhibitors, and were more likely to undergo CEA or TCAR after diagnosis. They were less likely to have diabetes and chronic kidney disease. There were no differences in subsequent stroke or transient ischemic attack rates between groups. Of 555 followed patients, 55.3% at the index imaging study had moderate (50%-69%) stenosis, 34.6% had severe (70-99%) stenosis, and 10.1% had ICA occlusions. Patients were followed with DUS for a mean of 3.4 ± 1.8 years, with no significant difference in follow-up between stable and progressing patients. Mean time to progression was 2.2 ± 1.4 years. By the end of the follow-up period, 20.5% of followed patients experienced stenosis progression. Table II compares demographics, histories, and outcomes of stable vs progressing patients, grouped by initial stenosis severity. There were no significant differences between groups regarding comorbidities, medications, or procedure history. At diagnosis, 58.5% of stable patients and 64.9% of progressing patients were on best medical treatment (statin + antiplatelet agent) (P = .21). In both moderate and severe groups, stable patients underwent CEA more frequently than progressing patients. These results suggest that carotid disease progression occurs in a clinically significant portion of patients, affecting one-fifth of our cohort in an average of 26 months. No reliable factors emerged to predict progression or stroke in these patients. Less than two-thirds of these patients were found to be managed with best medical treatment, suggesting opportunities for further optimization.Table IPatient characteristicsDemographicsFollow-up (n = 555)No Follow-up (n = 1399)P valueMean age at diagnosis, years (range)72.9 (25-97)72.1 (18-105).12Female sex249 (44.9%)608 (43.5%).57Comorbidities Prior smoking277 (49.9%)663 (47.4%).32 Hypertension231 (41.6%)616 (44.0%).33 Hyperlipidemia217 (39.1%)601 (43.0%).12 Diabetes mellitus79 (14.2%)286 (20.4%).001 Coronary artery disease169 (30.5%)448 (32.0%).50 Myocardial infarction18 (3.2%)68 (4.9%).12 Chronic kidney disease79 (14.2%)286 (20.4%).001 Stroke or transient ischemic attack320 (57.7%)632 (45.2%).001 Vasculitis9 (1.6%)27 (1.9%).65 Head and neck cancer28 (5.0%)51 (3.6%).16Medications at diagnosis Antihypertensives393 (70.8%)882 (63.0%).001 Aspirin345 (62.2%)732 (52.3%)<.001 Statin392 (70.6%)893 (63.8%).004 P2Y12 inhibitor348 (62.7%)793 (56.7%).015 Anticoagulation54 (9.7%)148 (10.6%).58 Cilostazol15 (2.7%)27 (1.9%).29Procedure history Prior carotid endarterectomy10 (1.8%)29 (2.1%).70 Prior Transcarotid artery revascularization2 (0.4%)13 (0.9%).19 Prior transfemoral carotid stenting5 (0.9%)5 (0.4%).13Outcomes Subsequent CEA98 (17.7%)180 (12.9%).006 Subsequent transcarotid artery revascularization35 (6.3%)54 (3.9%).019 Subsequent transfemoral carotid stenting11 (2.0%)13 (0.9%).06 Subsequent cerebrovascular accident10 (1.8%)19 (1.4%).47 Subsequent transient ischemic attack2 (0.4%)5 (0.4%).99 Open table in a new tab Table IIComparison of stable and progressing patients, stratified by severityDemographicsModerate (50%-69%) StenosisSevere (70%-99%) StenosisP valueStable (n = 196)Progression (n = 111)Stable (n = 189)Progression (n = 3)Age at diagnosis.822Female sex92 (46.9%)49 (44.1%)84 (44.4%)2 (66.7%).832History Stroke or TIA108 (55.1%)72 (64.9%)113 (59.8%)2 (66.7%).402 Prior smoking96 (49.0%)62 (55.9%)91 (48.1%)1 (33.3%).533 Hypertension88 (44.9%)43 (38.7%)83 (43.9%)1 (33.3%).732 Hyperlipidemia81 (41.3%)46 (41.4%)77 (40.7%)0 (0.0%).551 Diabetes mellitus36 (18.4%)14 (12.6%)21 (11.1%)0 (0.0%).172 Chronic kidney disease36 (18.4%)14 (12.6%)21 (11.1%)0 (0.0%).172 Coronary artery disease73 (37.2%)35 (31.5%)48 (25.4%)0 (0.0%).054 Myocardial Infarction10 (5.1%)3 (2.7%)2 (1.1%)0 (0.0%).136 Vasculitis4 (2.0%)1 (0.9%)2 (1.1%)1 (33.3%)<.001a Head and neck cancer11 (5.6%)5 (4.5%)9 (4.8%)0 (0.0%).942Medications at diagnosis Antihypertensives144 (73.5%)84 (75.7%)137 (72.5%)2 (66.7%).93 Aspirin129 (65.8%)75 (67.6%)117 (61.9%)2 (66.7%).763 Statins143 (73.0%)85 (76.6%)139 (73.5%)1 (33.3%).383 P2Y12 inhibitors129 (65.8%)77 (69.4%)118 (62.4%)1 (33.3%).41 Anticoagulation19 (9.7%)11 (9.9%)19 (10.1%)0 (0.0%).952 Cilostazol6 (3.1%)4 (3.6%)3 (1.6%)0 (0.0%).694Procedure history CEA prior to diagnosis5 (2.6%)3 (2.7%)2 (1.1%)0 (0.0%).683 Transcarotid artery revascularization prior to diagnosis2 (1.0%)0 (0.0%)0 (0.0%)0 (0.0%).376 Transfemoral carotid stenting prior to diagnosis3 (1.5%)2 (1.8%)0 (0.0%)0 (0.0%).36Outcomes CEA after diagnosis38 (19.4%)11 (9.9%)45 (23.8%)0 (0.0%).023 Transcarotid artery revascularization after diagnosis12 (6.1%)8 (7.2%)13 (6.9%)0 (0.0%).946 Transfemoral carotid stenting after diagnosis1 (0.5%)3 (2.7%)5 (2.6%)1 (33.3%)<.001a Stroke after diagnosis2 (1.0%)1 (0.9%)3 (1.6%)1 (33.3%)<.001a Transient ischemic attack after diagnosis1 (0.5%)0 (0.0%)1 (0.5%)0 (0.0%).897aAnalysis limited by small sample size. Open table in a new tab

Del Nido Cardioplegia in Adult Cardiac Surgery: Meta-Analysis of Randomized Clinical Trials

To compare the outcomes of patients receiving del Nido solution versus any other type of cardioplegia. A systematic review and meta-analysis of randomized trials. Cardiac operating rooms. Adult patients (≥18 years old) undergoing cardiac surgery. The EMBASE, MEDLINE, and CENTRAL databases were searched systematically from their inception until August 2022 for randomized controlled trials comparing del Nido versus other cardioplegias. Ten studies were included, including 1,812 patients (871 in the del Nido group and 941 in the control group), and published after 2017. There were significant reductions in postoperative stroke and/or transient ischemic attack rate in the del Nido group: 9/467 (1.9%) v 25/540 (4.6%); odds ratio (OR), 0.43; 95% CI, 0.20-0.92 (p=0.007). Del Nido cardioplegia was also associated with significantly shorter aortic cross-clamp time (mean difference, -8.99 minutes; 95% CI, -17.24 to -0.73 [p < 0.001]), significantly reduced need for defibrillation (89/582 [15%] v 252/655 [38%]; OR, 0.33; 95% CI, 0.15-0.72 [p < 0.001]), significantly lower risk of postoperative acute kidney injury (21/235 [8.9%] v 34/301 [11%]; OR, 0.50; 95% CI, 0.26-0.97 [p=0.04]), with no effect on mortality (14/607 [2.3%] v 12/681 [1.8%]; p=0.5). According to the authors' meta-analysis of recent randomized clinical trials, del Nido is a safe cardioplegic solution, which might provide better organ protection in adult cardiac surgery without differences in mortality when compared to other cardioplegic solutions.

Carotid stenosis patients with a remote history of cerebrovascular events have increased risk of major adverse events over asymptomatic patients.

Asymptomatic patients with a remote history of transient ischemic attack (TIA) or stroke are not well studied as a separate population from asymptomatic patients with no prior history of TIA or stroke. We compared in-hospital outcomes after transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic patients, patients with a remote history of neurologic symptoms, and asymptomatic patients. Data from patients in the Vascular Quality Initiative database who underwent TCAR (January 2017 to April 2020) or TFCAS (May 2005 to April 2020) were analyzed. Symptomatic status was defined as TIA and/or stroke occurring within 180days before the procedure. Asymptomatic status was divided into patients with no history of TIA/stroke (asymptomatic) and patients with a history of TIA/stroke occurring more than 180days before the procedure (remote history of neurologic symptoms). The Student t-test and Pearson χ2 test were used to compare baseline patient characteristics and outcomes. Multivariate logistic regression was used to adjust for significant between-group differences in baseline characteristics. There were 7158 patients who underwent TCAR (symptomatic: 2574, asymptomatic: 3689, and asymptomatic with a remote history of neurologic symptoms: 895) and 18,023 patients who underwent TFCAS (symptomatic: 6195, asymptomatic: 10,333, and asymptomatic with a remote history of neurologic symptoms: 1495). Regardless of symptom status, the mean patient age was 73years for TCAR and 69years for TFCAS. A total of 64% of patients in the study were male and 36% of patients were female. The mean long-term follow-up data ranged between 208 and 331days within the three patient groups. Carotid stenosis patients with a remote history of neurologic symptoms had higher rates of TIA, stroke, TIA/stroke, stroke/death, and stroke/death/myocardial infarction than asymptomatic patients, and these rates were similar to those of symptomatic patients. Comparing TCAR and TFCAS among patients with a remote history of neurologic symptoms, there were statistically significant reductions in the odds of stroke/death (odds ratio: 0.46, 95% confidence interval: 0.27-0.84, P= .011) and stroke/death/myocardial infarction (odds ratio: 0.51, 95% confidence interval: 0.30-0.87, P= .013) after TCAR. This was likely driven by the increased rate of death after TFCAS in patients with a remote history of neurologic symptoms (0.9%) compared with asymptomatic patients (0.6%). Asymptomatic patients with a remote history of TIA/stroke do not have the same outcomes as asymptomatic patients without a history of TIA/stroke and are at higher risk of adverse in-hospital events. Patients with a remote history of TIA/stroke have increased risk of in-hospital death after TFCAS and may benefit from TCAR.

Embolic protection devices for carotid artery stenting: A network meta-analysis.

Carotid artery stenting (CAS) is an alternative treatment option for patients at high risk for carotid endarterectomy (CEA) but has been correlated with increased risk for distal embolization and periprocedural stroke despite the use of adjunctive embolic protection devices (EPD). This study compared four types of EPDs and their intra and periprocedural related complications. A systematic review of the literature was conducted in PubMed/Medline to identify studies that investigated the outcomes of CAS with adjuvant use of EPDs, including Proximal Balloon (PB), Distal Filter (DF), and Distal Balloon (DB) strategy. Continuous flow reversal performed via transcarotid approach by a commercially available device as an embolic protection strategy was intentionally excluded based on its distinct procedural characteristics and lack of availability outside of the United States. This network meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Overall, 45 studies, consisting of 7600 participants satisfied the predetermined search criteria and were included in this network meta-analysis. Overall, 13 studies provided data regarding the number of patients with new ischemic lesions detected in the DW-MRI. DF (OR: 3.15; 95% CI: 1.54-6.44; p = 0.002) and DB (OR: 2.28; 95% CI: 1.58-3.29; p < 0.001) were associated with higher odds of new ischemic lesions compared to PB on DW-MRI imaging. No statistical difference was identified between DB versus DF groups (OR: 1.48; 95% CI: 0.73-2.59; p = 0.317). 36 and 27 studies reported on periprocedural stroke and transient ischemic attack (TIA) rates, respectively, showing similar odds of neurologic adverse events between all three groups. PB deployment during CAS is superior to DF and DB in preventing distal embolization phenomena. However, no statistically significant difference in TIA and stroke rate was found among any of the analyzed EPD groups. Further research is warranted to investigate the association of embolic phenomena on imaging after CAS with clinically significant neurologic deficits.

High Mini-Skin Incision during Carotid Endarterectomy for Carotid Stenosis.

Carotid endarterectomy (CEA) is used to treat carotid stenosis, which is associated with cerebral infarction and may result in neurologic deficits such as stroke, transient ischemic attack (TIA), and local nerve injury. To decrease surgery-related complications and improve patient satisfaction with esthetic outcomes, efforts have been made to minimize incision size instead of using a standard longitudinal incision. We performed a retrospective analysis of 151 cases of CEA, of which 110 used conventional incisions and 41 used high mini-skin incisions (HMIs), from March 2015 to December 2021 at a single institution. Short-term (30-day) postoperative results were evaluated for rates of mortality, stroke, TIA, and cranial/cervical nerve injuries. Risk factors for nerve injury were also assessed. The HMI group showed significantly (p<0.01) shorter operative and clamp times than the conventional group. The HMI group also had significantly shorter incision lengths (5.3±0.9 cm) than the conventional group (11.5±2.8 cm). The rates of stroke, TIA, and death at 30 days were not significantly different between the 2 groups. There was no significant difference in the rate of cranial and cervical nerve injuries, and all injuries were transient. A high lesion level (odds ratio [OR], 9.56; 95% confidence interval [CI], 3.21-28.42; p<0.01) and the clamp time (OR, 1.07; 95% CI, 1.03-1.12; p<0.01) were found to be risk factors for nerve injuries. Use of the HMI in CEA for carotid stenosis was advantageous for its shorter operative time, shorter internal carotid artery clamp time, reduced neurologic complications, and improved esthetics.

Outcomes following patent foramen ovale percutaneous closure according to the delay from last ischemic event

Abstract Background Randomized controlled trials evaluating patent foramen ovale (PFO) percutaneous closure only included patients with recent embolic event. We aimed to evaluate outcomes following percutaneous PFO closure outcomes according to the delay from the last embolic episode. Methods This international ambispective cohort included consecutive patients from two centers in France and Canada undergoing PFO percutaneous closure for secondary prevention of paradoxical embolic event. The primary endpoint was the composite of stroke or transient ischemic attack (TIA). Logistic regression model was used to evaluate determinants of late PFO closure procedures. Results A total of 1,179 patients (mean age 49±12.7 years; 44.4% female) underwent PFO closure from 2001 to 2021 (Figure 1). The median delay from last embolic event to procedure was 6.0 (3.4–11.2) months. Determinants of late PFO closure procedure were the center (France versus Canada) adjusted Odds Ratio (aOR) 1.65 95% confidence interval (CI) 1.25–2.19, year of procedure (≥2018 versus &amp;lt;2018) aOR 1.43 95% CI 1.08–1.90, female sex aOR 1.63 95% CI 1.28–2.07 and lower RoPE score aOR 1.10 95% CI 1.03–1.19. After a median follow-up of 2.61 (1.13–7.25) years, the incidence rate of first stroke or TIA did not differ between early and late PFO procedures with 0.51 versus 0.29 events per 100 patient-years, respectively, incidence rate ratio 1.74 95% CI 0.66–5.08, p=0.25 (Figure 2). In univariate analysis, late PFO percutaneous closure was not associated with the occurrence of stroke or TIA, with hazard ratio 0.54 95% CI 0.22–1.34 p=0.17. Conclusion This analysis provides indirect evidence that delay from last ischemic event does not impact outcomes following PFO percutaneous closure for secondary prevention. Funding Acknowledgement Type of funding sources: None.

Risk of stroke and transient ischemic attack after elective cardioversion of atrial fibrillation: a nationwide study in Finland

Abstract Background Cardioversion is routinely used to restore sinus rhythm in patients with atrial fibrillation (AF). Elective cardioversion (ECV) is associated with an increased risk of thromboembolic complications even during adequate oral anticoagulation (OAC). Purpose The aim was to analyze the incidence of ischemic stroke and transient ischemic attack (TIA) after first-ever ECV of AF in patients using guideline-recommended OAC. Methods This nationwide register-based study includes all (N=9625) AF patients undergoing their first-ever ECV between 2012 and 2018 in Finland. Data was obtained from the Finnish health care registers, including both primary and special health care. The risk of stroke and TIA within 30 days after ECV were estimated in patients using OAC. Results The mean age of patients was 68 (±9.9) years, 61.2% were men, and the mean CHA2DS2-VASc score was 2.6 (±1.6, range 0–9). Warfarin was used in 6245 (64.9%) and non-vitamin K oral anticoagulants in 3380 (35.1%) cardioversions, of which 1453 (15.1%) was rivaroxaban, 1246 (12.9%) apixaban, 635 (6.6%) dabigatran, and 46 (0.5%) edoxaban. Twenty-nine (0.3%; 95% confidence interval [CI] 0.2–0.4%) ischemic strokes or TIAs occurred within 30 days after ECV (median 3 days, interquartile range 2.0–8.5) (Figure 1 and Table 1). In warfarin-treated patients experiencing stroke or TIA, the mean INR value before ECV and at the time of stroke or TIA were 2.5 (±0.5) and 2.5 (±0.5), respectively. One of the patients had INR-value &amp;lt;2.0 before ECV and at the time of stroke and one patient had INR value &amp;lt;2.0 before ECV. Conclusion In our nationwide study, the rate of stroke and TIA after first-ever ECV was low (0.3%) in all OAC groups. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital District

Comprehensive Assessment of Acute Isolated or Prominent Dysarthria in the Emergency Department: A Neuro-Emergency Expert's Experience beyond Stroke.

We investigated the clinical characteristics, neuroimaging findings, and final diagnosis of patients with acute isolated or prominent dysarthria who visited the emergency department (ED) between 1 January 2020 and 31 December 2021. Of 2028 patients aged ≥ 18 years with neurologic symptoms treated by a neuro-emergency expert, 75 with acute isolated or predominant dysarthria within 1 week were enrolled. Patients were categorized as having isolated dysarthria (n = 28, 37.3%) and prominent dysarthria (n = 47, 62.7%). The causes of stroke were acute ischemic stroke (AIS) (n = 37, 49.3%), transient ischemic attack (TIA) (n = 14, 18.7%), intracerebral hemorrhage (n = 1, 1.3%), and non-stroke causes (n = 23, 30.7%). The most common additional symptoms were gait disturbance or imbalance (n = 8, 15.4%) and dizziness (n = 3, 13.0%) in the stroke and non-stroke groups, respectively. The isolated dysarthria group had a higher rate of TIA (n = 7, 38.9%), single and small lesions (n = 10, 83.3%), and small-vessel occlusion in Trial of Org 101072 in acute stroke treatment (n = 8, 66.7%). Acute isolated or prominent dysarthria in the ED mostly presented as clinical symptoms of AIS, but other non-stroke and medical causes were not uncommon. In acute dysarthria with ischemic stroke, multiple territorial and small and single lesions are considered a cause.

Outcomes Following Patent Foramen Ovale Percutaneous Closure According to the Delay From Last Ischemic Event.

Randomised controlled trials evaluating percutaneous closure of patent foramen ovale (PFO) have included only patients with a recent embolic event. We aimed to evaluate outcomes after percutaneous PFO closure according to the delay from the last embolic episode. This international ambispective cohort included consecutive patients from 2 centres in France and Canada undergoing PFO closure for secondary prevention of a paradoxical embolic event. The primary end point was the composite of stroke or transient ischemic attack (TIA). A logistic regression model was used to evaluate determinants of late PFO closure procedures. A total of 1179 patients (mean age 49 ± 12.7 years; 44.4% female) underwent PFO closure from 2001 to 2021. The median delay from last embolic event to procedure was 6.0 (interquartile range 3.4-11.2) months. The determinants of late PFO closure procedure were the centre (France vs Canada; adjusted odds ratio [aOR] 1.65, 95% confidence interval [CI] 1.25-2.19), year of procedure (since 2018 vs before 2018; aOR 1.43, 95% CI 1.08-1.90), female sex (aOR 1.63, 95% CI 1.28-2.07), and lower risk of paradoxical embolism score (aOR 1.10, 95% CI 1.03-1.19). After a median follow-up of 2.61 (1.13-7.25) years, the incidence rate of first stroke or TIA did not differ between early and late PFO procedures, with 0.51 vs 0.29 events per 100 patient-years, respectively (incidence rate ratio 1.74, 95% CI 0.66-5.08; P= 0.24), and the timing of PFO closure was not associated with the occurrence of stroke or TIA in univariate analysis (hazard ratio 0.54, 95% CI 0.22-1.34) for late vs early closure). This analysis provides indirect evidence that the delay from the last ischemic event does not affect outcomes after PFO closure for secondary prevention.

Prevalence of orthostatic hypertension and its association with cerebrovascular diagnoses in patients with suspected TIA and minor stroke

PurposeWe aimed to compare the rate of stroke, transient ischemic attack, and cerebrovascular disease diagnoses across groups of patients based on their orthostatic blood pressure response in a transients ischemic attack clinic setting.Materials and MethodsWe retrospectively analysed prospectively collected data from 3201 patients referred to a transient ischemic attack (TIA)/minor stroke outpatients clinic. Trained nurses measured supine and standing blood pressure using an automated blood pressure device and the patients were categorized based on their orthostatic blood pressure change into four groups: no orthostatic blood pressure rise, systolic orthostatic hypertension, diastolic orthostatic hypertension, and combined orthostatic hypertension. Then, four stroke physicians, who were unaware of patients' orthostatic BP response, assessed the patients and made diagnoses based on clinical and imaging data. We compared the rate of stroke, TIA, and cerebrovascular disease (either stroke or TIA) diagnoses across the study groups using Pearson's χ2 test. The effect of confounders was adjusted using a multivariate logistic regression analysis.ResultsCerebrovascular disease was significantly less common in patients with combined systolic and diastolic orthostatic hypertension compared to the "no rise" group [OR = 0.56 (95% CI 0.35–0.89]. The odds were even lower among the subgroups of patients with obesity [OR = 0.31 (0.12–0.80)], without history of smoking [OR 0.34 (0.15–0.80)], and without hypertension [OR = 0.42 (95% CI 0.19–0.92)]. We found no significant relationship between orthostatic blood pressure rise with the diagnosis of stroke. However, the odds of TIA were significantly lower in patients with diastolic [OR 0.82 (0.68–0.98)] and combined types of orthostatic hypertension [OR = 0.54 (0.32–0.93)]; especially in patients younger than 65 years [OR = 0.17 (0.04–0.73)] without a history of hypertension [OR = 0.34 (0.13–0.91)], and patients who did not take antihypertensive therapy [OR = 0.35 (0.14–0.86)].ConclusionOur data suggest that orthostatic hypertension may be a protective factor for TIA among younger and normotensive patients.

Severity of stenosis in symptomatic patients undergoing carotid interventions might influence perioperative neurologic events

ObjectiveThe carotid artery plaque burden, indirectly measured by the degree of stenosis, quantifies a patient's future embolic risk. In natural history studies, patients with moderate degrees of stenosis have had a lower stroke risk than those with severe stenosis. However, patients with symptomatic carotid stenosis who have experienced transient ischemic attack (TIA) or stroke were found to have both moderate and severe degrees of stenosis. We examined the association of carotid artery stenosis severity with the outcomes for symptomatic patients who had undergone carotid intervention, including carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcervical carotid artery revascularization (TCAR). MethodsThe Society for Vascular Surgery Vascular Quality Initiative database was queried for all patients who had undergone TFCAS, CEA, or TCAR between 2003 and 2020. The patients were stratified into two groups according to stenosis severity—nonsevere (0%-69%) and severe (≥70%). The primary end point was periprocedural neurologic events (stroke and TIA). The secondary end points were periprocedural death, myocardial infarction (MI), and the composite outcomes of stroke/death and stroke/death/MI in accordance with the reporting standards for carotid intervention. ResultsOf the 29,614 included symptomatic patients, 5296 (17.9%) had undergone TCAR, 7844 (26.5%) TFCAS, and 16,474 (55.6%) CEA for symptomatic carotid artery stenosis. In the CEA cohort, the neurologic event rate was significantly lower for the patients with severe stenosis than for those with nonsevere stenosis (2.6% vs 3.2%; P = .024). In the TCAR cohort, the periprocedural neurologic even rate was lower for those with severe stenosis than for those with nonsevere stenosis (3% vs 4.3%; P = .033). No similar difference was noted for the TFCAS cohort, with a periprocedural neurologic event rate of 3.8% in the severe group vs 3.5% in the nonsevere group (P = .518). On multivariable analysis, severe stenosis was associated with significantly decreased odds of postprocedural neurologic events after CEA (odds ratio, 0.75; 95% confidence interval, 0.6-0.92; P = .007) and TCAR (odds ratio, 0.83; 95% confidence interval, 0.69-0.99; P = .039) but not after TFCAS. ConclusionsSevere carotid stenosis, in contrast to more moderate stenosis degrees, was associated with decreased rates of periprocedural stroke and TIA in symptomatic patients undergoing TCAR and CEA but not TFCAS. The finding of increased rates of periprocedural neurologic events in symptomatic patients with lesser degrees of stenosis undergoing TCAR and CEA warrants further evaluation with a particular focus on plaque morphology and brain physiology and their inherent risks with carotid revascularization procedures.

Asymptomatic Patients With a Remote History of Transient Ischemic Attack or Stroke May Benefit From Reduced Hazard of In-hospital Death After Transcarotid Artery Revascularization

Asymptomatic patients with remote history of transient ischemic attack (TIA) or stroke are not well-studied as a separate population from asymptomatic patients with no prior history of TIA or stroke. We compared in-hospital outcomes following transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic and asymptomatic patients with and without a history of TIA or stroke. Data from patients in the Vascular Quality Initiative database undergoing TCAR (January 2017 to April 2020) or TFCAS (May 2005 to April 2020) were analyzed. Symptomatic status was defined as TIA and/or stroke within 180 days before procedure. Asymptomatic status was divided into patients with no history of TIA/stroke (asymptomatic A) and TIA and/or stroke occurring more than 180 days before the procedure (asymptomatic B). The Student t test and χ2 test were used to compare baseline patient characteristics and outcomes. Multivariate logistic regression was used to adjust for significant between-group differences in baseline characteristics. There were 7158 patients who underwent TCAR (symptomatic: 2574; asymptomatic A: 3689; asymptomatic B: 895) and 18,023 patients who underwent TFCAS (symptomatic: 6195; asymptomatic A: 10,333; asymptomatic B: 1495). TCAR patients were generally older, White, smokers, and had more comorbidities than TFCAS. Asymptomatic B patients had higher rates of TIA, stroke, TIA/stroke, stroke/death, and stroke/death/myocardial infarction than asymptomatic A patients, and these rates were similar to those of symptomatic patients (Table). Comparing TCAR and TFCAS among asymptomatic B patients, there were statistically significant reductions in the odds of stroke/death (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.27-0.84; P = .011) and stroke/death/myocardial infarction (OR, 0.51; 95% CI, 0.30-0.87; P = .013) after TCAR. A greater reduction in the odds of death was observed among asymptomatic B patients (OR, 0.30; 95% CI, 0.084-1.110; P = .069) compared with asymptomatic A patients (OR, 0.41; 95% CI, 0.20-0.85; P = .017), which was likely driven by the increased rate of death for TFCAS asymptomatic B patients (0.9%) compared with asymptomatic A (0.6%) Asymptomatic patients with a remote history of TIA/stroke do not have the same outcomes as asymptomatic patients without a history of TIA/stroke and are at higher risk of adverse in-hospital events. Asymptomatic patients with a remote history of TIA/stroke have increased risk of in-hospital death after TFCAS and may benefit from TCAR.TablePercent incidence and adjusted odds ratio (aORs) for in-hospital outcomesIn-hospital eventsSymptomaticAsymptomatic A: No history of TIA/strokeAsymptomatic B: Remote history of TIA/StrokeTCAR (%)TFCAS (%)Odd ratio (95% CI)P valueTCARTFCASOdd ratio (95% CI)P valueTCARTFCASOdd ratio (95% CI)P valueTIA0.710.66 (0.39-1.13).130.40.60.60 (0.31-1.16).131.11.30.76 (0.34-1.70).50Stroke2.13.10.63 (0.46-0.87).0040.81.40.50 (0.32-0.78).0021.92.50.70 (0.38-1.28).25Death0.62.70.18 (0.10-0.30)<.0010.20.60.41 (0.20-0.85).0170.30.90.30 (.084-1.10).069TIA/stroke2.840.63 (0.48-0.82)<.0011.12.00.52 (0.36-0.76)<.0012.83.70.67 (0.41-1.11).12Stroke/death2.45.10.41 (0.31-0.54)<.0011.01.90.48 (0.33-0.70)<.0011.93.30.46 (0.27-0.84).011Stroke/death/MI3.05.70.45 (0.35-0.58)<.0011.42.30.54 (0.39-0.75)<.0012.33.80.51 (0.30-0.87).013MI0.60.80.73 (0.41-1.30).290.40.60.78 (0.43-1.43).430.40.60.77 (0.22-2.74).68Postoperative complications6.610.20.59 (0.49-0.70)<.0015.86.10.93 (0.77-1.13).476.76.90.95 (0.67-1.34).77CI, Confidence interval; MI, myocardial infarction; TCAR, transcarotid artery revascularization; TFAR, transfemoral artery revascularization; TIA, transient ischemic attack.Postoperative complications include any of the listed complications: reperfusion symptoms, myocardial infarction, dysrhythmia (new), congestive heart failure, access site complication, hematoma/bleeding, stenosis/occlusion, infection, pseudoaneurysm, and arteriovenous fistula.Multivariate logistic regression analysis adjusted for baseline age, ethnicity, congestive heart failure diabetes, hypertension, carotid artery disease, prior carotid endarterectomy/carotid artery stenting, smoking, race, and sex. Open table in a new tab