Transient Ischemic Attack Research Articles

Current Practices in Carotid Surgery.

We outline the indications and contraindications of carotid endarterectomy (CEA) and appraise four key areas still debated to this day; shunting versus non-shunting, patch angioplasty (PA) versus primary closure (PC) and local anaesthesia (LA) versus general anaesthesia (GA). Importantly, we compare CEA with Best Medical Therapy (BMT), which is an area that is still largely debated, principally because many of the studies conducted to date do not reflect the era of modern BMT practices, and these outcomes are eagerly awaited. Literature searches were conducted using Pubmed with the keywords 'carotid', and 'endarterectomy', which provided a wide variety of journals and articles. We further stratified our data by using only randomised control trials (RCTs), meta-analyses, and systematic reviews, and then excluded studies with asymptomatic disease, diabetes, and plaque-imaging studies, including studies that did not fit our four desired topics for discussion. For each of the different domain's, results demonstrated similar peri-operative outcomes when comparing shunting vs. non-shunting and modality of anaesthesia and therefore practice still remains dependent on operator experience and preference. Patch-angioplasty reduces the risk of subsequent stroke, transient ischaemic attack (TIA), and re-stenosis compared to PC. In carotid stenosis >50% BMT offers limited benefits without accompanying surgical intervention and BMT alone tends to be advantageous primarily for patients with <50% carotid stenosis. Where CEA is appraised in terms of superiority of the procedural components; the literature does not support wildly contrasting outcomes to change majority practice. However, the area of considerable interest is superiority of BMT to surgical intervention in terms of both carotid artery stenting (CAS) and CEA and more studies need to be conducted in this area.

Safety and efficacy of apixaban versus warfarin in peritoneal dialysis patients with non-valvular atrial fibrillation: protocol for a prospective, randomised, open-label, blinded endpoint trial (APIDP2)

IntroductionSeveral randomised controlled trials have demonstrated that novel oral anticoagulants are safer compared with vitamin K antagonists for the management of non-valvular atrial fibrillation (NVAF) to prevent thromboembolic events in...

The Aortic Prosthesis and Aortic Valve Bioprosthesis Trombosis as a Late Complication in Patients after the Bentall Procedure Followed by a Valve-in-Valve Transcatheter Aortic Valve Implantation.

Background: Valve-in-Valve (ViV) transcatheter aortic valve implantation (TAVI) has emerged as a viable therapeutic option for structural valve degeneration following surgical aortic valve replacement (SAVR) or prior TAVI. However, the understanding of long-term complications and their management remains limited. Case presentation: We present the case of a 69-year-old male with a history of ViV-TAVI, who presented with symptoms of non-ST elevation myocardial infarction (NSTEMI) and transient ischemic attack (TIA). Computed tomography (CT) revealed thrombosis of the ascending aortic graft and aortic valve prosthesis. Transthoracic echocardiography (TTE) further confirmed new valve dysfunction, indicated by an increase in the aortic valve mean gradient. Treatment with low-molecular-weight heparin (LMWH) resulted in partial thrombus resolution. The multidisciplinary Heart Team opted against coronary angiography and recommended the long-term administration of vitamin K antagonists (VKAs). Follow-up CT showed the complete resolution of the thrombus. Conclusions: Thrombosis of the aortic graft and aortic valve following ViV-TAVI may be attributed to alterations in blood flow or mechanical manipulations during the TAVI procedure, yet it can be effectively managed with VKA therapy. CT is a valuable tool in coronary assessment in patients with NSTEMI and aortic valve and/or aortic graft thrombosis.

Neurological and cardiopulmonary manifestations of pulmonary arteriovenous malformations.

Pulmonary arteriovenous malformations (PAVMs) are direct pulmonary artery-to-vein connections without pulmonary capillaries that result in intrapulmonary right-to-left blood shunts. Although most patients with PAVMs may be entirely asymptomatic, PAVMs can induce a series of complications involving the neurological, cardiovascular, and respiratory systems that can lead to catastrophic and often fatal clinical sequelae. In this study we review the available literature and summarize the reported PAVM-related complications among patients with PAVMs. The reviewed studies included observational studies, case studies, prospective studies, and cohort studies, and we provide an overview of PAVM-related neurological and cardiopulmonary manifestations, including stroke, cerebral abscess, transient ischemic attack, cerebral hemorrhage, migraine, seizure, dizziness, cardiac failure, arrhythmia, myocardial infarction, cough, hypoxemia, dyspnea, respiratory failure, hemoptysis, and hemothorax. Identifying and treating PAVMs before the presentation of major complication is important because this can prevent the occurrence of complications and can result in better outcomes. PAVM patients should thus be better evaluated and managed by a multidisciplinary team because they may be in a treatable phase prior to their condition becoming life-threatening.

Acceleration of brain aging after small-volume infarcts.

Previous studies have shown that stroke patients exhibit greater neuroimaging-derived biological "brain age" than control subjects. This difference, known as the brain age gap (BAG), is calculated by comparing the chronological age with predicted brain age and is used as an indicator of brain health and aging. However, whether stroke accelerates the process of brain aging in patients with small-volume infarcts has not been established. By utilizing longitudinal data, we aimed to investigate whether small-volume infarctions can significantly increase the BAG, indicating accelerated brain aging. A total of 123 stroke patients presenting with small-volume infarcts were included in this retrospective study. The brain age model was trained via established protocols within the field of machine learning and the structural features of the brain from our previous study. We used t-tests and regression analyses to assess longitudinal brain age changes after stroke and the associations between brain age, acute stroke severity, and poststroke outcome factors. Significant brain aging occurred between the initial and 6-month follow-ups, with a mean increase in brain age of 1.04 years (t = 3.066, p < 0.05). Patients under 50 years of age experienced less aging after stroke than those over 50 years of age (p = 0.245). Additionally, patients with a National Institute of Health Stroke Scale score >3 at admission presented more pronounced adverse effects on brain aging, even after adjusting for confounders such as chronological age, sex, and total intracranial volume (F 1,117 = 7.339, p = 0.008, η 2 = 0.059). There were significant differences in the proportional brain age difference at 6 months among the different functional outcome groups defined by the Barthel Index (F 2,118 = 4.637, p = 0.012, η 2 = 0.073). Stroke accelerates the brain aging process, even in patients with relatively small-volume infarcts. This phenomenon is particularly accentuated in elderly patients, and both stroke severity and poststroke functional outcomes are closely associated with accelerated brain aging. Further studies are needed to explore the mechanisms underlying the accelerated brain aging observed in stroke patients, with a particular focus on the structural alterations and plasticity of the brain following minor strokes.

Cerebral Ischemia-Reperfusion Induced Neuronal Damage, Inflammation, miR-374a-5p, MAPK6, NLRP3, and Smad6 Alterations: Rescue Effect of N-acetylcysteine

Background: Ischemic stroke (IS) is still a major cause of neurological disability. This study aimed to ascertain potential markers closely related to IS diagnosis and treatment and then we examined the neuroprotective effect of N-acetylcysteine (NAC) in a transient cerebral ischemia. Methods: Male Wistar rats were randomly divided into three groups (n=6), including sham, IR (ischemia-reperfusion), IR+NAC (150 mg/kg, ip; intraperitoneally, 1 hour prior to ischemia and 5 min before reperfusion). The infarct volume was evaluated by 2,3,5-triphenyl tetrazolium chloride staining. H&amp;E and Nissle staining were performed to evaluate cerebral ischemia-reperfusion injury. miR-374a-5p gene expression, MAPK6, NLRP3, smad6, TNF-α, and IL-1β protein levels were determined by Real-time PCR, Western blot, and Elisa in the cerebral cortex exposed to IR. Results: Herein, we found that IR increased infarct volume and pathological damage to the cerebral cortex after global cerebral artery occlusion/reperfusion. In addition, miR-374a-5p gene expression decreased, while MAPK6, NLRP3, and smad6 protein expressions increased in the IR group. TNF-α and IL-1β protein levels increased in the ischemic cortex. Treatment with NAC significantly attenuated infarct size, inflammation and reversed aforementioned molecule levels. Conclusion: Taken together, these results suggested that ischemic insult can increase infarct size, neuronal damage, and inflammation may in part by modulating miR-374a-5p, MAPK6, NLRP3, and smad6 pathway in the brain cortex after cerebral IR insult and providing new clues to molecular mechanisms and treatment targets in IS. It can be alleviated by NAC as a potential therapy for someone afflicted with ischemia.

Short-Term Risk of Cardiovascular Events in People Newly Diagnosed With Gout.

To investigate the temporal association between the first diagnosis of gout and cardiovascular events in the short term. We performed a self-controlled case series analysis and a cohort study using data from linked primary care, hospitalization, and mortality records from the United Kingdom's Clinical Practice Research Database-GOLD. We included individuals with a new diagnosis of gout either in the primary care or secondary care between January 1, 1997 and December 31, 2020. The first consultation at which gout was diagnosed was the exposure of interest. The main outcome consisted of cardiovascular events (ie, a composite of fatal and nonfatal myocardial infarction, ischemic or hemorrhagic stroke, and transient ischemic attack). The 4,398 patients (66.9% male, mean age 74.6 years) had a cardiovascular event within at least two years of their first recorded diagnosis of gout. The incidence of cardiovascular events was significantly higher in the 30 days after the first diagnosis of gout compared to baseline (adjusted incidence rate ratio 1.55, 95% confidence interval [CI] 1.33-1.83). Among 76,440 patients (72.9% male, mean age 63.2 years) included in the cohort study, the incidence of cardiovascular events in the 30 days after the first gout diagnosis (31.2 events per 1,000 person-years, 95% CI 27.1-35.9) was significantly higher than in days 31 to 730 after gout diagnosis (21.6 events per 1,000 person-years, 95% CI 20.8-22.4) with a rate difference of -9.6 events per 1,000 person-years (95% CI -14.0 to -5.1). Individuals had a short-term increased risk of cardiovascular events in the 30 days following the first consultation at which gout was diagnosed.

Maternal metformin administration during the pre-gestation period improves transient cerebral ischemia injury in male offspring rats

Purpose: It seems that maternal intervention, which may involve epigenetic mechanisms, can affect cerebral ischemia in offspring. Metformin consumption by the mother activates the AMP-activated protein kinase (AMPK) pathway. Metformin has also induced the AMPK and protected neurons in cerebral ischemia. This study investigates the effect of maternal metformin administration, which activates the AMPK pathway, on cerebral ischemia in offspring Methods: Animals were separated into four groups: sham, 2-vessels occlusion (2VO), Met+2VO, Met+compound c (CC)+2VO. Female rats were administrated with metformin at a dose of 200 mg.kg-1 body weight for 2 weeks prior to mating. After the final metformin injection, each female rat was paired with an intact adult male to allow for mating. Sixty-days old offspring underwent cerebral ischemia and then memory-related tests were done. Results: Current data revealed that the neurological deficits score was reduced Met+2VO group (P&lt;0.001), and the memory increased (P&lt;0.001) in comparison to the 2VO. The Bcl-2/Bax ratio declined in the metformin group (P&lt;0.001) while the Brain-Derived Neurotropic Factor (BDNF), c-fos, p-AMPK/AMPK ratio and Histone H3K9 acetylation in the hippocampus augmented significantly compared to the 2VO group (P&lt;0.001). Conclusion: These findings indicated that the metformin intervention via AMPK activation could improve the movement disability, enhance spatial memory, increase neural plasticity, and augment the bioenergetics state and histone acetylation in the hippocampus of the offspring.

Impact of sleep disturbance on longitudinal cognitive performance in patients with transient ischemic attack or mild stroke

IntroductionSleep disturbances including obstructive sleep apnea (OSA) and poor sleep quality are common after stroke, while its association with cognitive changes following transient ischemic attack (TIA) or mild stroke remains unclear. We aim to determine whether sleep duration, OSA parameters, or nocturnal hypoxemia is associated with a greater cognitive decline after stroke. MethodsWe prospectively followed-up patients with acute TIA/mild stroke [National Institute Health Stroke Scale (NIHSS) < 7] who underwent baseline sleep questionnaire [Pittsburgh Sleep Quality Index (PSQI)], and serial cognitive assessments [Montreal Cognitive Assessment (MoCA) 5-min, Stroop Test] at baseline and one-year. We also evaluated apnea-hypopnea index (AHI) and nocturnal hypoxemia by Home Sleep Apnea Test (HSAT) at one-year. Primary outcome was one-year change in MoCA 5-min score. ResultsOne hundred and five patients with TIA/mild stroke (mean age 63 years, 65 % male) were included. Baseline short sleep (< 6 hour/night) and AHI ≥ 20/hour at one-year were independently associated with a decline in the MoCA 5-min total score after covariates adjustment [short sleep: β = −2.36 95 % confidence interval (CI) (−4.13, −0.59), p = 0.009; AHI ≥ 20/hour: β = −1.79 (−3.26, −0.32), p = 0.017; remained significant after multiple comparisons correction]. A lower mean MinSpO2 was associated with a decline in executive function [Stroop interference index: β = 0.29 (0.04, 0.53), p = 0.021], but not with MoCA 5-min score at one-year. Moderation analysis indicated AHI ≥ 20/hour was associated with a pronounced decline in executive function only in men. ConclusionsShort sleep after stroke onset, AHI ≥ 20/hour and nocturnal hypoxemia at one-year contributed to an impaired cognitive trajectory at one-year following stroke in patients with TIA/mild stroke.

Role of interatrial block in modulating cryptogenic stroke risk in patients with patent foramen ovale: a retrospective study

BackgroundThe patent foramen ovale (PFO) and interatrial block (IAB) are associated with cryptogenic stroke (CS). However, the role of the interaction between PFO and IAB in CS remains unclear.MethodsThis case–control study enrolled 256 patients with CS and 156 individuals without a history of stroke or transient ischemic attack. IAB was defined as P wave duration > 120 ms. PFO was evaluated by contrast transesophageal echocardiography, and classified as no-PFO, low-risk PFO and high-risk PFO. Multiplicative and additive interaction analysis were used to assess the interaction between PFO and IAB in CS.ResultsMultiplicative interaction analysis unveiled a significant interaction between IAB and low-risk PFO in CS (OR for interaction = 3.653, 95% CI, 1.115–12.506; P = 0.037). Additive interaction analysis indicated that 68.4% (95% CI, 0.333–1.050; P < 0.001) of the increased risk of CS related to low-risk PFO was attributed to the interaction with IAB. The results were robust in multivariate analysis. However, but no significant multiplicative or additive interaction was observed between IAB and high-risk PFO. When stratified by IAB, high-risk PFO was associated with CS in both patients with IAB (OR, 4.186; 95% CI, 1.617–10.839; P = 0.003) and without IAB (OR, 3.476; 95% CI, 1.790–6.750; P < 0.001). However, low-risk PFO was only associated with CS in patients with IAB (OR, 2.684; 95% CI, 1.007–7.149; P = 0.048) but not in those without IAB (OR, 0.753; 95% CI, 0.343–1.651; P = 0.479).ConclusionThe interaction between IAB and PFO might play an important role in CS, particularly in cases with low-risk PFO.

THE ANTICOAGULATION STRATEGIES FOR MANAGEMENT AND PREVENTION OF STROKE IN NEUROLOGICAL PRACTICE

Strokes are categorized as either ischemic or hemorrhagic and the specific interventions will be based on the type of stroke. About 13% of stroke is hemorrhagic and 87% is ischemic. Transient Ischemic Attacks require emergency intervention to decrease the threat of stroke, which is thought to be maximum within the first few days after TIA. Anticoagulants play a major role in the primary and secondary prevention of ischemic strokes. The optimal timing of anticoagulants initiation or resumption inpreventing and managing ischemic strokes is very important. This article will explore certain controversies surrounding this issue, while also highlighting the benefits of antithrombotic therapy used in prevention of ischemic strokes in antiphospholipid antibody syndrome (APS), atrial fibrillation, prosthetic heart valve, cancer, and vascular disorders. Aggressive local and regional efforts to organize stroke care and greater use of evidence-based recommendations may help improve outcomes. Peer Review History: Received 16 May 2024; Reviewed 11 July 2024; Accepted 24 August; Available online 15 September 2024 Academic Editor: Essam Mohamed Eissa, Beni-Suef University, Egypt, dressamceutics@yahoo.com Average Peer review marks at initial stage: 6.0/10 Average Peer review marks at publication stage: 7.0/10 Reviewers: Taha A.I. El Bassossy, Medicinal and Aromatic Plants Department, Desert Research Center, Cairo, Egypt, tahachemist2008@gmail.com Dr. George Zhu, Tehran University of Medical Sciences, Tehran, Iran, sansan4240732@163.com

Clinical presentations and dispositions of transient ischemic attack and minor stroke patients at the emergency department of a tertiary hospital in southern Thailand: A retrospective study

Clinical presentations and dispositions of transient ischemic attack and minor stroke patients at the emergency department of a tertiary hospital in southern Thailand: A retrospective study

Optimal duration of dual antiplatelet therapy for minor stroke within 72 hours of symptom onset: a prospective cohort study

ObjectivesDespite the potential spillover effect, the optimal duration of dual antiplatelet therapy for minor stroke within 72 hours of symptom onset is still uncertain.MethodsSafety and Efficacy of Aspirin-Clopidogrel in Acute...

Low Incidence of Neurological Adverse Events Among Pediatric Patients With Moyamoya Undergoing General Anesthesia for NonRevascularization Procedures

BackgroundGeneral anesthesia poses a significant risk for patients with MMA, yet its risk in the setting of nonrevascularization procedures remains unclear. Data regarding the risk of general anesthesia for nonrevascularization procedures are scarce. We therefore aimed to assess the incidence of neurological adverse events (NAEs) among pediatric patients with MMA undergoing general anesthesia for nonrevascularization procedures. MethodsWe conducted a retrospective cohort study at a tertiary referral pediatric center of patients with MMA aged ≤18 years, who underwent general anesthesia for nonrevascularization procedures between January 2014 and July 2023. Postanesthesia NAEs were defined as occurrence of transient ischemic attacks, seizures, altered mental status, severe headache, or evidence of arterial ischemic stroke (AIS) in the 30 days postprocedure. ResultsAmong 149 procedures on 38 patients (median age [interquartile range]: 8.3 [5.0, 12.7] years; 57% female), 124 (83.2%) procedures were imaging studies and angiographies and 25 (16.8%) were surgical procedures. Preprocedural hyperhydration treatment was administered before most (111, 74.5%) procedures per our institutional protocol. The incidence of postanesthesia NAEs was 0.67% (one of 149), as a result of acute AIS following a ventriculoperitoneal shunt revision surgery, in a patient with postradiation MMA, panhypopituitarism, and uncontrolled diabetes insipidus, despite preprocedural hyperhydration treatment. There were no NAEs after imaging studies performed under general anesthesia. ConclusionsOur results suggest that general anesthesia for nonrevascularization procedures in pediatric patients with MMA prepared with hyperhydration is safe. As neuroradiological follow-up is central in children with MMA, this information can be valuable for reassuring patients and their families.

Effects of Sildenafil on Cognitive Function Recovery and Neuronal Cell Death Protection after Transient Global Cerebral Ischemia in Gerbils.

Cerebral ischemic stroke is a major cause of death worldwide due to brain cell death resulting from ischemia-reperfusion injury. However, effective treatment approaches for patients with ischemic stroke are still lacking in clinical practice. This study investigated the potential neuroprotective effects of sildenafil, a phosphodiesterase-5 inhibitor, in a gerbil model of global brain ischemia. We investigated the effects of sildenafil on the expression of glial fibrillary acidic protein and aquaporin-4, which are markers related to astrocyte activation and water homeostasis, respectively. Immunofluorescence analysis showed that the number of cells co-expressing these markers, which was elevated in the ischemia-induced group, was significantly reduced in the sildenafil-treated groups. This suggests that sildenafil may have a potential mitigating effect on astrocyte activation induced by ischemia. Additionally, we performed various behavioral tests, including the open-field test, novel object recognition, Barnes maze, Y-maze, and passive avoidance tests, to evaluate sildenafil's effect on cognitive function impaired by ischemia. Overall, the results suggest that sildenafil may serve as a neuroprotective agent, potentially alleviating delayed neuronal cell death and improving cognitive function impaired by ischemia.

The Absence of Typical Stroke Symptoms and Risk Factors Represents the Greatest Risk of an Incorrect Diagnosis in Stroke Patients.

Stroke is one of the most misdiagnosed conditions that causes serious medical disabilities. Its early and accurate diagnosis by the emergency team is crucial for the patient's survival. This study aimed to determine the percentage of brain strokes incorrectly diagnosed by paramedic teams and to analyze the factors influencing incorrect diagnoses. The data of 103 patients, mean age of 68.4 ± 14.96 years, admitted in 2019 to hospital emergency departments of the two hospitals in Olsztyn, Poland, were analyzed retrospectively. All patient data were obtained from their information cards. The parameters of the patients misdiagnosed and accurately diagnosed by paramedics were analyzed with Odds Ratio (OR) calculations using IBM SPSS version 23 software. Stroke and transient ischemic attack were recognized in 77 cases (74.8%). In 26 patients (25.2%), the diagnosis made in the ambulance differed from that made in the hospital ward. The analysis of the Odds Ratio (OR) has shown that typical stroke risk factors, if present in a patient, facilitate the correct diagnosis. The greatest source of misdiagnosis of stroke by the paramedic team was the lack of hemiplegia (OR = 6.0). The absence of typical stroke risk factors and neurological stroke symptoms, such as smoking, hemiplegia, aphasia, hypercholesterolemia, arrhythmia, diabetes or a drooping corner of the mouth, constitutes a high risk of misdiagnosing stroke by the paramedic team.

Moya-Moya Disease in Basal Cortical Areas in a Man with a Family History of Vascular Disorders: A Case Report

Introduction: Moya-Moya disease (MMD) is a rare, chronic, and spontaneous steno-occlusive condition that leads to recurrent strokes due to the occlusion of the terminal internal carotid arteries. This article aims to highlight the significance of familial risk for MMD and other vascular disorders among first-degree relatives in Iran. Case Presentation: We report the case of a 55-year-old male who was admitted to our hospital with complaints of transient ischemic attack, left-sided hemiparesis, and decreased vision that occurred during the night. The initial diagnosis was a brain stem stroke. After undergoing digital subtraction angiography, he was diagnosed with MMD. Moya-Moya disease is a rare cause of cerebral stroke and is seldom reported in Iran. The patient was treated conservatively and had a favorable outcome. His family history was notable, with five of his eight siblings having various cardiovascular diseases. Conclusions: These findings may be useful for guiding future genetic studies and preventive counseling, with a focus on the clinical evaluation of serious adverse events.

Policy-driven multidisciplinary primary care after stroke or Transient Ischaemic Attack (TIA) improves survival – an observational target trial evaluation involving linked registry data

ObjectiveTo determine the effectiveness of government policies supporting coordinated multidisciplinary primary care (MDC) in improving long-term survival following stroke or Transient Ischaemic Attack (TIA). ApproachWe used the target trial framework for observational data to assess the average population effect of primary care MDC policies. The cohort comprised patients from the Australian Stroke Clinical Registry (January 2012-June 2015) linked with (i) Australian Medicare claims to define exposures (MDC claims in the 6-18 months post-stroke); (ii) hospital, pharmaceutical and aged care datasets for additional covariates; (iii) National Death Registry for survival outcomes (19-30 months post-stroke). Level of impairment was classified by latent class analysis using EQ-5D-3L questionnaire data obtained 90-180 days post-stroke. Multilevel survival analysis with inverse probability treatment weights was applied. ResultsAmong 7,255 people with stroke (42% female, median age 71 years, 24% TIA, level of impairment: 39% minimal, 32% moderate, 29% severe), 29% had a Medicare claim for MDC (23% minimal, 31% moderate, 39% severe). Mortality was reduced in those receiving a claim (vs non-receipt) in the minimal (adjusted Hazard Ratio (aHR): 0.50, 95%CI:0.27, 0.91) and severe (aHR: 0.65, 95%CI:0.46, 0.91) impairment groups, but not the moderate impairment group (aHR: 1.31, 95%CI:0.86, 1.99). Group differences in allied health services claimed during MDC were observed: secondary prevention (14% minimal vs 10% severe impairment), rehabilitation (21% minimal vs 25% severe impairment). ImplicationsDrawing causal inferences from linked observational data demonstrated the population effectiveness of primary care MDC policies, in improving survival following stroke/TIA, with variation by impairment class.

Early statin use is associated with improved survival and cardiovascular outcomes in patients with atrial fibrillation and recent ischaemic stroke: A propensity-matched analysis of a global federated health database.

Statins reduce recurrent stroke and cardiovascular events in patients with non-cardioembolic stroke. The benefits of statins in patients with AF and recent IS remain unclear. We aimed to investigate the benefits of statins in patients with AF and recent IS. This retrospective, cohort study was conducted using deidentified electronic medical records within TriNetX platform. Patients with AF and recent IS, who received statins within 28 days of their index stroke were propensity score-matched with those who did not. Patients were followed up for up to 2 years. Primary outcomes were the 2-year risk of recurrent IS, all-cause mortality and the composite outcome of all-cause mortality, recurrent IS, transient ischaemic attack (TIA), and acute myocardial infarction (MI). Secondary outcomes were the 2-year risk of TIA, intracranial haemorrhage (ICH), acute MI, and hospital readmission. Cox regression analyses were used to calculate hazard ratios (HRs) with 95% confidence intervals (95%CI). Of 20,902 patients with AF and recent IS, 7500 (35.9%) received statins within 28 days of their stroke and 13,402 (64.1%) did not. 11,182 patients (mean age 73.7 ± 11.5; 5277 (47.2%) female) remained after propensity score matching. Patients who received early statins had significantly lower risk of recurrent IS (HR: 0.45, 95%CI: 0.41-0.48, p < 0.001), mortality (HR: 0.75, 95%CI: 0.66-0.84, p < 0.001), the composite outcome (HR: 0.48, 95%CI: 0.45-0.52, p < 0.001), TIA (HR: 0.37, 95%CI: 0.30-0.44, p < 0.001), ICH (HR: 0.59, 95%CI: 0.47-0.72, p < 0.001 ), acute MI (HR: 0.35, 95%CI: 0.30-0.42, p < 0.001) and hospital readmission (HR: 0.46, 95%CI: 0.42-0.50, <0.001). Beneficial effects of early statins were evident in the elderly, different ethnic groups, statin dose intensity, and AF subtypes, large vessel occlusion and embolic strokes and within the context of statin lipophilicity, optimal LDL-cholesterol levels, various cardiovascular comorbidities, treatment with intravenous thrombolysis or endovascular thrombectomy, and NIHSS 0-5 and NIHSS > 5 subgroups. Patients with AF and recent IS, who received early statins, had a lower risk of recurrent stroke, death, and other cardiovascular outcomes including ICH, compared to those who did not.

Incident Infarcts in Patients With Stroke and Cerebral Small Vessel Disease: Frequency and Relation to Clinical Outcomes.

Factors associated with cerebral small vessel disease (SVD) progression, including incident infarcts, are unclear. We aimed to determine the frequency of incident infarcts over 1 year after minor stroke and their relation to baseline SVD burden, vascular risks, and recurrent stroke and cognitive outcomes. We recruited patients with lacunar or nondisabling cortical stroke. After diagnostic imaging, we repeated structural MRI at 3-6 monthly intervals for 12 months, visually assessing incident infarcts on diffusion-weighted imaging or FLAIR. We used logistic regression to determine associations of baseline vascular risks, SVD score, and index stroke subtype with subsequent incident infarcts. We assessed cognitive and functional outcomes at 1 year using Montreal Cognitive Assessment (MoCA) and modified Rankin scale (mRS), adjusting for baseline age, mRS, MoCA, premorbid intelligence, and SVD score. We recruited 229 participants, mean age 65.9 (SD 11.1). Over half of all participants, 131 of 229 (57.2%) had had an index lacunar stroke. From baseline to 1-year MRI, we detected 117 incident infarcts in n = 57/229 (24.8%) participants. Incident infarcts were mainly of the small subcortical (86/117 [73.5%] in n = 38/57 [66.7%]) vs cortical infarct subtype (n = 19/57 [33.3%]). N = 39/57 participants had incident infarcts at 1 visit; 18 of 57 at 2 or more visits; and 19 of 57 participants had multiple infarcts at a single visit. Only 7 of 117 incident infarcts corresponded temporally to clinical stroke syndromes. The baseline SVD score was the strongest predictor of incident infarcts (adjusted odds ratio [OR] 1.87, 95% CI 1.39-2.58), while mean arterial pressure was not associated. All participants with incident infarcts were prescribed an antiplatelet or anticoagulant. Lower 1-year MoCA was associated with lower baseline MoCA (β 0.47, 95% CI 0.33-0.61), lower premorbid intelligence, and older age. Higher 1-year mRS was associated with higher baseline mRS only (OR 5.57 [3.52-9.10]). Neither outcome was associated with incident infarcts. In the year after stroke in a population enriched for lacunar stroke, incident infarcts occurred in one-quarter and were associated with worse baseline SVD. Most incident infarcts detected on imaging did not correspond to clinical stroke/transient ischemic attack. Worse 1-year cognition and function were not associated with incident infarcts.