Trial Of Org 10172 In Acute Stroke Treatment Criteria Research Articles

Risk Factors and Etiological Classification of Ischemic Stroke Subtypes in Southwest Iran

Precise categorization of the causes of ischemic stroke (IS) is crucial for optimizing stroke treatment and assessing the prognosis of patients. This cross-sectional study aimed to determine the risk factors and various subcategories of IS in Iranian patients. The study included all patients with IS referred to Golestan Hospital (Ahvaz, Iran) for one year. Their demographics and clinical data were collected. The etiology of IS was classified based on the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria. A total of 1100 patients with IS were evaluated, 658 were male and 442 were female. They had an average age of 66 years (ranging between 20 and 99 years). The majority of them were in the 61-80 age group. The prevalence of risk factors for IS included hypertension (HTN) (71.4%), diabetes (50.4%), smoking (42.4%), history of previous stroke (28%), dyslipidemia (15.4%), and cardiovascular disease (22.5%). Three months after admission, the mortality rate was 10.7% and the majority of patients exhibited a lower level of disability based on the modified Rankin Score (mRS) compared to the time of admission. The frequency of all risk factors, except for HTN, differed significantly between genders (P<0.05). Furthermore, the prevalence of risk factors varied significantly among different stroke etiologic subgroups (P<0.05). The most common etiological factors identified by TOAST classification were associated with large artery atherosclerosis (LAA) and small artery occlusion (SAO). Significant variations were observed in the prevalence of different etiologic subtypes of stroke among genders and across different age groups.

Functional outcomes of COVID-19 patients with acute ischemic stroke: A prospective, observational, single-center study in North Jordan.

We assessed whether stroke severity, functional outcome, and mortality in patients with ischemic stroke differed between patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and those without.We conducted a prospective, single-center cohort study in Irbid, North Jordan. All patients diagnosed with ischemic stroke and SARS-CoV-2 infection were consecutively recruited from October 15, 2020, to October 16, 2021. We recorded demographic data, vascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score, stroke subtype according to the Trial of ORG 10172 in Acute Stroke Treatment Criteria (TOAST), treatments at admission, and laboratory variables for all patients. The primary endpoint was the functional outcome at 3 months assessed using the modified Rankin Score. Secondary outcomes involved in-hospital mortality and mortality at 3 months.We included 178 patients with a mean (standard deviation) age of 67.3 (12), and more than half of the cases were males (96/178; 53.9%). Thirty-six cases were coronavirus disease 2019 (COVID-19) related and had a mean (standard deviation) age of 70 (11.5). When compared with COVID-19-negative patients, COVID-19-positive patients were more likely to have a higher median NIHSS score at baseline (6 vs 11; P = .043), after 72 hours (6 vs 12; P = .006), and at discharge (4 vs 16; P < .001). They were also more likely to have a higher median modified Rankin Score after 3 months of follow-up (P < .001). NIHSS score at admission (odds ratio = 1.387, 95% confidence interval = 1.238–1.553]; P < .001) predicted having an unfavorable outcome after 3 months. On the other hand, having a concomitant SARS-CoV-2 infection did not significantly impact the likelihood of unfavorable outcomes (odds ratio = 1.098, 95% confidence interval = 0.270–4.473; P = .896).The finding conclude that SARS-CoV-2 infection led to an increase in both stroke severity and in-hospital mortality but had no significant impact on the likelihood of developing unfavorable outcomes.

Abstract TP152: A Comparison Of Thrombus Characteristics In Patients With Anterior Circulation Stroke And Posterior Circulation Stroke In The Mr Clean Registry

Introduction: In posterior circulation stroke (PCS), large artery atherosclerosis at the occlusion site or dissection is most often reported as underlying stroke etiology, while cardio embolism is less common than in anterior circulation stroke (ACS). As thrombus characteristics are related to the underlying stroke etiology, we hypothesized that differences in radiological thrombus characteristics between PCS and ACS are fully explained by differences in underlying etiology. We compared radiological thrombus characteristics between PCS and ACS to gain insight in the differences in order to optimize treatment options for PCS. Methods: In patients treated with endovascular treatment (EVT) for acute ischemic stroke in the MR CLEAN Registry, radiological thrombus characteristics (perviousness, density, and length) were assessed on thin-slice (&lt;2.5mm) non-contrast computed tomography and computed tomography angiography imaging acquired within 30 minutes from each other. Radiological thrombus characteristics between PCS and ACS patients were compared with univariable and multivariable linear regression with adjustments for baseline differences which could influence thrombus characteristics (age, gender, TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria and intravenous alteplase treatment. Results: We analyzed 1052 patients: 118 PCS and 934 ACS patients. PCS thrombi were significantly longer and denser than ACS thrombi: median 23 mm vs 18 mm (p&lt;0.001) and median 53 HU vs 50 HU respectively (p=0.04) (Table 1). After adjustments, thrombus length was significantly different: PCS thrombi were 15 mm longer compared with ACS thrombi (aβ 15, 95% CI 12-18), while thrombus density and perviousness did not significantly differ between ACS and PCS (Table 1). Conclusion: PCS thrombi are significantly longer and denser than ACS thrombi. After adjustment for stroke etiology, only thrombus length was significantly different between PCS and ACS patients.

Abstract WP27: Sars-cov-2 And Stroke Characteristics: A Report From A Regional Medical Center Serving Three Counties In South Carolina

Introduction: Recent studies have shown patients with coronavirus disease 2019 (COVID-19) develop significant coagulopathy with thromboembolic complications including ischemic stroke. However, data are sparse regarding the clinical characteristics, stroke mechanism, and patient outcomes. Methods: We conducted a retrospective cohort study of consecutive patients with ischemic stroke who were hospitalized between March 2020 and June 2021, within at a Regional Medical Center serving three large counties in South Carolina. We further investigated clinical and demographic characteristics, stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS), and stroke subtype as measured by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria among patients with COVID-19 who also suffered from an acute ischemic stroke. Results: During the study period, out of 1087 hospitalized patients with a diagnosis of COVID-19 infection, 18 patients (1.6%) had an imaging-proven ischemic stroke. Of these 18 patients, 10 (56%) were men, 16 were African-Americans (89%), 2 (11.1%) patients were &lt;55 years of age. All patients had at least one known vascular risk factor. Cryptogenic stroke was more common in patients with COVID-19 (83%). The median time (days) from COVID-19 symptom onset to stroke symptom onset was 11 (IQR 10-28), while the median time from being tested positive for COVID-19 to stroke diagnosis was 10 (IQR 2-24). Our study sample had a median admission NIHSS score of 5 (IQR 3-11) and a median peak D-dimer level of 2101 (IQR 1349 - 3213). Interestingly, 38% of these patients were already on therapeutic anticoagulation before the diagnosis of stroke. Patients with COVID-19 and stroke had an inpatient mortality rate of 11%. None of these patients met the criteria for IV-tPA treatment or thrombectomy. Conclusion: We observed a modest rate of ischemic stroke in hospitalized patients with COVID-19. Most strokes were cryptogenic, possibly secondary to coagulopathy associated with COVID-19 infection. Further studies are needed to guide management for stroke prevention in patients with COVID-19.

Trimethylamine N-Oxide and Stroke Recurrence Depends on Ischemic Stroke Subtypes.

Trimethylamine N-oxide (TMAO) has been recognized as a risk factor for cardiovascular disease. However, the role of TMAO in ischemic stroke remains unclear. As we know, ischemic stroke is a heterogeneous disease with variable pathogenesis. Hence, we aimed to investigate the association between TMAO and stroke recurrence according to etiology subtypes. A total of 10 756 ischemic stroke/transient ischemic attack patients from the Third China National Stroke Registry were enrolled, and 1-year follow-up data for stroke recurrence were analyzed. TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria was used to classify the etiology subtypes. Plasma TMAO levels were quantified by liquid chromatography-mass spectrometry. The association between TMAO and stroke outcomes was analyzed using Cox regression models. We also conducted a meta-analysis on the association of TMAO levels and stroke risk. Elevated TMAO level was independently associated with the risk of stroke recurrence (Q4 versus Q1: adjusted hazard ratio, 1.37 [95% CI, 1.15-1.64]) in multivariate Cox regression model. After stratification by TOAST subtypes, there was a significant association between TMAO and stroke recurrence in small artery occlusion subtype (adjusted hazard ratio, 1.43 [95% CI, 1.03-2.00]) but not in the others subtype (large-artery atherosclerosis, 1.19 [0.95-1.48]; cardioembolism, 1.54 [0.95-2.48]; others, 1.19 [0.98-1.44]). The meta-analysis reported on stroke recurrence for the highest versus lowest TMAO levels with a pooled hazard ratio of 1.66 (95% CI, 0.91-3.01) and similarly found an increased risk of stroke recurrence. Elevated TMAO level is associated with increased risk of stroke recurrence in patients with small artery occlusion subtype, but this association seems to be attenuated in large-artery atherosclerosis, cardioembolism, and others subtypes.

SARS-CoV-2 and Stroke Characteristics: A Report From the Multinational COVID-19 Stroke Study Group.

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Inconsistent centralised versus non-centralised ischaemic stroke aetiology

Background and purposeThe Trial of Org 10 172 in Acute Stroke Treatment (TOAST) system is the most widely used aetiological categorisation system in clinical practice and research. Limited studies have...

Etiological Subtypes of Transient Ischemic Attack and Ischemic Stroke in Chronic Kidney Disease: Population-Based Study.

Chronic kidney disease (CKD) is strongly associated with stroke risk, but the mechanisms underlying this association are unclear and might be informed by subtype-specific analyses. However, few studies have reported stroke subtypes in CKD according to established classification systems, such as the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria. We, therefore, aimed to determine which transient ischemic attack and ischemic stroke subtypes using the TOAST classification occur most frequently in patients with CKD. In a population-based study of all transient ischemic attack and stroke (OXVASC [Oxford Vascular Study]; 2002-2017), all ischemic events were classified by TOAST subtypes (cardioembolism, large artery disease, small vessel disease, undetermined, multiple, other etiology, or incompletely investigated). Logistic regression was used to determine the relationship between CKD (defined as an estimated glomerular filtration rate <60 mL/min per 1.73 m2) and transient ischemic attack/stroke subtypes adjusted for age, sex, and hypertension and then stratified by age and estimated glomerular filtration rate category. Among 3178 patients with transient ischemic attack (n=1167), ischemic stroke (n=1802), and intracerebral hemorrhage (n=209), 1267 (40%) had CKD. Although there was a greater prevalence of cardioembolic events (31.8% versus 21.2%; P<0.001) in patients with CKD, this association was lost after adjustment for age, sex, and hypertension (adjusted odds ratio=1.20 [95% CI, 0.99-1.45]; P=0.07). Similarly, although patients with CKD had a lower prevalence of small vessel disease (8.8% versus 13.6%; P<0.001), undetermined (26.1% versus 39.4%; P<0.001), and other etiology (1.0% versus 3.6%; P<0.001) subtypes, these associations were also lost after adjustment (adjusted odds ratio=0.86 [0.65-1.13]; P=0.27 and 0.73 [0.36-1.43]; P=0.37 for small vessel disease and other defined etiology, respectively) for all but undetermined (adjusted odds ratio=0.81 [0.67-0.98]; P=0.03). There were no independent positive associations between CKD and specific TOAST subtypes, which suggest that renal-specific risk factors are unlikely to play an important role in the etiology of particular subtypes. Future studies of stroke and CKD should report subtype-specific analyses to gain further insights into potential mechanisms.

Demographic and clinical profile of cardioembolic stroke patients in Western Sydney.

Cardioembolism (CE) contributes to a large proportion of ischaemic stroke. To evaluate the demographic and clinical profile of CE stroke in Western Sydney. A retrospective analysis of ischaemic stroke patients presenting to Westmead Hospital (January-October 2016) was performed. Strokes were classified by TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria into different categories. Clinical and demographic data were collected on all stroke patients, and differences between CE and other stroke causes were identified. Two hundred and twenty-eight consecutive patients (70.9 years; 53% male) were identified. By TOAST criteria, 21 (9%) had large-artery atherosclerosis, 94 (41%) CE, 10 (5%) small-vessel disease, 2 (1%) other aetiology and 101 (44%) undetermined aetiology. A significant proportion of CE stroke patients had cardiovascular risk factors including hypertension (66%), hypercholesterolaemia (50%), diabetes (26%) and ischaemic heart disease (28%). The majority (81%) of patients with CE had atrial flutter/flutter. CE stroke, compared with other types of stroke, was more common in females (56 vs 41%, P = 0.022) and patients with CE stroke were more likely to have previous cerebral ischaemia (34 vs 21%, P = 0.026), suggesting increased recurrence in this group. Of the patients with atrial flutter/flutter (n = 56), the majority (87%) had a high CHA2 DS2 -VASC score (≥2); however, a significant proportion (55.4%) were not on anticoagulation. Cardioembolic stroke remains a significant burden in Western Sydney, and it is likely that a significant proportion may be preventable, as evidenced by the substantial presence of modifiable cardiovascular risk factors, and inadequate anticoagulation of patients with atrial arrhythmias.

Intravenous Thrombolysis Benefits Mild Stroke Patients With Large-Artery Atherosclerosis but No Tandem Steno-Occlusion.

At present, there is controversy regarding whether thrombolysis is beneficial for patients suffering from a mild stroke. In this study, we therefore sought to determine whether the therapeutic benefit of thrombolysis is dependent upon stroke subtype for those with mild stroke. We conducted a retrospective analysis of data from consecutive mild stroke patients (National Institutes of Health Stroke Scale ≤5) with and without recombinant tissue plasminogen activator (rt-PA) therapy. The TOAST (Trial of Org 10172 in acute stroke treatment) criteria was used to determine stroke subtypes. Patients suffering from large-artery atherosclerosis (LAA) were subdivided based upon whether or not they exhibited tandem steno-occlusion, as defined by the association of a proximal intracranial occlusion and a cervical internal carotid artery lesion (complete occlusion or severe stenosis ≥ 90%). For this study, favorable outcomes at 90 days of onset (modified Rankin Scale Score [mRS] of 0–1) were the primary measured outcome. Three hundred thirty-nine patients were included in the study. For patients with non-LAA, there were not statistically significant improvements in favorable outcomes for rt-PA treatment (p = 0.889, 0.929, 0.708; respectively). For patients with LAA, compared with non-treated group, rt-PA-treated patients had a significant in the rate of favorable outcomes at 90 days (82.8 vs. 64.9%; OR 2.59; 95%CI, 1.13–5.92; P = 0.024). Among LAA patients exhibiting tandem lesions, favorable outcomes were observed in 66.7% of rt-PA-treated patients, with no significant differences to those observed in untreated patients (OR 1.00; 95%CI, 0.23–4.28; p = 1.000). Among LAA patients without tandem lesions, compared with non-treated group, we found that rt-PA treatment was associated with a significant beneficial impact on favorable outcomes after 90 days (64.4 vs. 88.4%; OR 4.20; 95%CI, 1.43–12.30; p = 0.009). Our findings suggest that intravenous rt-PA is only beneficial in mild stroke patients with LAA-type strokes that do not exhibit tandem steno-occlusion.

Factors Associated with Failure of Reperfusion in Endovascular Therapy for Acute Ischemic Stroke

AimIn acute large vessel occlusions, endovascular therapy (EVT) achieves flow restoration in the majority of cases; however, EVT fails to achieve sufficient reperfusion in a substantial minority of patients. This study aimed to identify predictors of failed reperfusion.MethodsIn this study 2211 patients from the German Stroke Registry who received EVT for anterior circulation stroke were retrospectively analyzed. Failure of reperfusion was defined as thrombolysis in cerebral infarction (TICI) grades 0/1/2a, and sufficient reperfusion as TICI 2b/3. In 1629 patients with complete datasets, associations between failure of reperfusion and baseline clinical data, comorbidities, location of occlusion, and procedural data were assessed with multiple logistic regression.ResultsFailure of reperfusion occurred in 371 patients (16.8%) and was associated with the following locations of occlusion: cervical internal carotid artery (ICA, adjusted odds ratio, OR 2.01, 95% confidence interval, CI 1.08–3.69), intracranial ICA without carotid T occlusion (adjusted OR 1.79, 95% CI 1.05–2.98), and M2 segment (adjusted OR 1.86, 95% CI 1.21–2.84). Failed reperfusion was also associated with cervical ICA stenosis (>70% stenosis, adjusted OR 2.90, 95% CI 1.69–4.97), stroke of other determined etiology by TOAST (Trial of ORG 10172 in acute stroke treatment) criteria (e.g. nonatherosclerotic vasculopathies, adjusted OR 2.73, 95% CI 1.36–5.39), and treatment given outside the usual working hours (adjusted OR 1.41, 95% CI 1.07–1.86). Successful reperfusion was associated with higher Alberta stroke program early CT score (ASPECTS) on initial imaging (adjusted OR 0.85, 95% CI 0.79–0.92), treatment with the patient under general anesthesia (adjusted OR 0.72, 95% CI 0.54–0.96), and concomitant ICA stenting in patients with ICA stenosis (adjusted OR 0.20, 95% CI 0.11–0.38).ConclusionSeveral factors are associated with failure of reperfusion, most notably occlusions of the proximal ICA and low ASPECTS on admission. Conversely, stent placement in the proximal ICA was associated with reperfusion success.

Abstract TP80: Imaging Characteristics of Methamphetamine-Associated Ischemic Strokes

Objective: To examine the clinical and neuroimaging characteristics in patients with acute ischemic stroke and concurrent methamphetamine (meth) use. Introduction: Meth is a highly addictive stimulant with harmful effects that lead to cardiovascular disease and stroke. Despite a strong association between meth use and increased cerebrovascular risk, detailed descriptions of clinical and neuroradiologic characteristics in larger cohorts are lacking. Methods: Single-center retrospective analysis of consecutive adults admitted for acute ischemic stroke and meth-positive toxicology between 2016 and 2019. Stroke imaging characteristics, including suspected etiologic mechanism as defined by Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria, were documented. Results: Ninety patients were admitted with radiologically confirmed acute ischemic stroke and meth exposure. The average age was 55 years (range, 36-77 years) and 69% were male. Although 47% were Caucasian, nearly half were from an underrepresented minority ethnic/racial group (24% Black, 8% Hispanic/Latino, 9% Asian/Pacific Islander). A multiplicity of strokes was seen in the majority of cases (57%), and 31% affected the bilateral hemispheres. Although 91% of all cases had subcortical involvement, only 34% were purely subcortical of which one-half had brainstem infarctions. The middle cerebral artery distribution was affected most commonly (71%) while multiple vascular territories were involved in 30% of cases. The most frequently encountered stroke subtypes were small vessel occlusion (27%) and a cardioembolic source (26%) as defined by the TOAST criteria. A substantial proportion of patients (31%) were discharged to a rehabilitation or nursing facility, dispositions with high predictive value for unfavorable post-stroke outcomes. Moreover, 15% of patients died during their hospitalization. Conclusion: Meth-associated acute ischemic stroke is a multicultural problem with variable widespread effects throughout the cerebrum. Although small vessel vasculopathy is suspected in most, a significant proportion is due to proximal embolic sources. Long-term care is often required in survivors, and nearly 1 in 6 died during their hospitalization.

Abstract TP375: Using Characteristics of Secondary Ischemic Stroke Events to Improve Stroke Education Initiatives

Purpose: While it is common practice for nursing to perform the duty of stroke education,it is not common to use secondary stroke event data to determine what aspect of stroke education should be emphasized for the greatest impact on secondary stroke prevention. The purpose of this descriptive study is to exam the characteristics of secondary stroke events using the TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria so future educational initiatives can be customized to the needs of the local high risk population. Methods: The team collected data characteristics on all ischemic stroke admissions with previous admitting diagnosis of acute ischemic stroke. The strokes were further characterized using the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification to determine any emerging patterns of both risk factors and etiological types. Conclusions: A total of n=51 admissions were previous adult stroke survivors, (M=30, F=21). Pre-morbid risk factors were as follows: hypertension=78%, type 2 diabetes=39%, hyperlipidemia =54%, smoking=8%, atrial fibrillation=24%. TOAST classification results: Large Vessel Atherosclerosis=14%, Cardioembolic =17%, Small Vessel Disease=3%, Other Known Cause=2%, Cryptogenic=15%. Summary: The results reveal a striking pattern of the presence of premorbid hypertension. While the TOAST classification did not have a single dominant type, but nearly equal distribution of large vessel atherosclerosis, cardioembolic, and small vessel disease etiologies. Not surprising, the decline in stroke mortality is felt to be due to improved blood pressure control, but in discharge stroke education, hypertension is not necessarily emphasized over other perhaps less impactful risk factors. Yet, the most recent acute ischemic stroke clinical guidelines gave providers a first-time recommendation to start or restart antihypertensive therapy in stable patients with BP &gt; 140/90. Nursing has enough encouragement to take the lead on hypertension prevention education in appropriate stable patients ready for discharge. The next goal will be to develop a multimedia educational effort in patient stroke education on hypertension as a risk factor for secondary stroke prevention in this Comprehensive Stroke Center.

Abstract WP261: The Left Atrial Septal Pouch: A New Stroke Risk Factor?

Background: The left atrial septal pouch (LASP) is a common anatomic variant produced by the incomplete fusion of septa primum and secondum at the inter-atrial septum, thus creating a potential embolic source from an open flap or blind pouch in the left atrium. Our prior work demonstrated increased prevalence of LASP in cryptogenic strokes (Frontiers Neurology 3-24-15). The aim of the current study was to examine the prevalence of LASP in a separate, more recent group of stroke patients and control subjects who underwent transesophageal echocardiography (TEE). Methods: We examined consecutive TEE studies performed between July, 2011 and December, 2018 at UC Irvine Medical Center. Prevalence of LASP was determined in TEE studies referred for ischemic stroke or TIA (“stroke subjects”), and compared to LASP prevalence in patients undergoing TEE for other reasons (“control subjects”). Stroke subtyping was performed using TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Results: TEE studies were performed on 221 cerebrovascular cases and 164 control subjects. Age and sex were 57±1 years (mean±SE) and 53% male for stroke subjects, and 56±1 years and 62% male for control subjects. Prevalence of LASP was 24% (40/164) in control subjects, 17% (24/138) in non-cryptogenic stroke subjects, and 36% (30/83) in cryptogenic stroke subjects. LASP prevalence was significantly higher for cryptogenics compared to the other groups (p=0.007). There was no significant difference between LASP prevalence in controls vs non-cryptogenic stroke. Elimination from analysis of subjects with other inter-atrial septal abnormalities (ie, patent foramen ovale or atrial septal defect) did not significantly change results. Conclusions: These findings demonstrate an increased prevalence of LASP in cryptogenic stroke, confirming our prior published findings. Given the plausibility of LASP acting as a thromboembolic nidus, additional studies are needed to determine the generalizability of these findings and their therapeutic implications.

Association Between Low-Dose Rivaroxaban With or Without Aspirin and Ischemic Stroke Subtypes

The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) randomized clinical trial was stopped early owing to the efficacy of low-dose rivaroxaban plus aspirin in preventing major cardiovascular events. The main reason for early trial termination was the effect of combination therapy on reducing ischemic strokes. To analyze the association between low-dose rivaroxaban with or without aspirin and different ischemic stroke subtypes. This is a secondary analysis of a multicenter, double-blind, randomized, placebo-controlled study that was performed in 33 countries from March 12, 2013, to May 10, 2016. Patients with stable atherosclerotic vascular disease were eligible, and a total of 27 395 participants were randomized and followed up to February 6, 2017. All first ischemic strokes and uncertain strokes that occurred by this date were adjudicated using TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. The analysis of ischemic stroke subtypes was evaluated using an intention-to-treat principle. Statistical analysis was performed from March 12, 2013, to February 6, 2017. Participants received rivaroxaban (2.5 mg twice a day) plus aspirin (100 mg once a day), rivaroxaban (5 mg twice a day), or aspirin (100 mg once a day). Risk of ischemic stroke subtypes during follow-up. A total of 291 patients (66 women; mean [SD] age, 69.4 [8.5] years; 43 [14.8%] had a previous nonlacunar stroke) experienced an ischemic stroke. During the study, 49 patients (16.8%) received a diagnosis of atrial fibrillation. Applying TOAST criteria, 59 strokes (20.3%) were cardioembolic, 54 strokes (18.6%) were secondary to greater than 50% stenosis of the ipsilateral internal carotid artery, 42 strokes (14.4%) had a negative evaluation that met criteria for embolic stroke of undetermined source, and 21 strokes (7.2%) were secondary to small vessel disease. There were significantly fewer cardioembolic strokes (hazard ratio [HR], 0.40 [95% CI, 0.20-0.78]; P = .005) and embolic strokes of undetermined source (HR, 0.30 [95% CI, 0.12-0.74]; P = .006) in the combination therapy group compared with the aspirin-only group. A trend for reduction in strokes secondary to small vessel disease (HR, 0.36 [95% CI, 0.12-1.14]; P = .07) was not statistically significant. No significant difference was observed between the 2 groups in strokes secondary to greater than 50% carotid artery stenosis (HR, 0.85 [95% CI, 0.45-1.60]; P = .61). Rivaroxaban, 5 mg, twice daily showed a trend for reducing cardioembolic strokes compared with aspirin (HR, 0.57 [95% CI, 0.31-1.03]; P = .06) but was not associated with reducing other stroke subtypes. For patients with systemic atherosclerosis, low-dose rivaroxaban plus aspirin was associated with large, significant reductions in cardioembolic strokes and embolic strokes of undetermined source. However, these results of exploratory analysis need to be independently confirmed before influencing clinical practice. ClinicalTrials.gov identifier: NCT01776424.

Clinical evaluation of young adult patients with ischemic stroke applying to emergency department

Objective: Ischemic stroke in young adults constitutes about 10-15% of all strokes. It is also a serious socioeconomic burden since it leaves these young adults disabled at their most productive years. For this reason, it is necessary to investigate underlying causes in order to identify and prevent the disease. The purpose of our study was to compare causes and outcomes of ischemic stroke at young age with the results available in the literature. Methods: The study retrospectively covers patients aged 18 to 50 diagnosed with ischemic stroke between 2014 and 2017 years. Age, gender, emergency department complaints, neurological findings detected on physical examination, and comorbid diseases which were risk factors for stroke were recorded for all patients. Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification was used for identification of stroke subtypes. Hospital outcomes were assessed by the modified Rankin Scale (mRS). Pearson Chi-square test was used to compare the groups. p &amp;lt;0.05 was assumed for statistical significance.Results: A total of 87 patients who satisfied inclusion criteria, 34 female (39.1%) and 53 male (60.9%), were included in the study. Mean age of the patients was 44.41 ± 6.96 (range 18-50). The highest risk factors were hypertension (55.2%) and dyslipidemia (52.9). When assessed according to TOAST criteria, the most frequently detected subtype was cardioembolic (28.7%). When we looked at the mRS scores, 54% of the patients were completely cured. Conclusion: Since it threatens youngs and productive population, identification of etiologies and taking precautions before stroke development is the most effective way to fight the disease. Racial differences require every nation to conduct a detailed research.

Clinical and echocardiographic characteristics of cardioembolic stroke.

Ischaemic stroke frequently has a cardioembolic (CE) source. Clinical and echocardiographic parameters associated with CE stroke were evaluated. In all, 93 consecutive ischaemic stroke patients who underwent a transthoracic echocardiogram were retrospectively analysed; strokes were classified by TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Echocardiographic parameters related to CE stroke, including left atrial volumes and function, were compared to 73 healthy controls. Of 93 patients (mean age 66.1years, 56% male), nine (10%) had large artery atherosclerosis, 38 (41%) CE stroke, two (2%) small vessel disease, two (2%) other and 42 (45%) undetermined aetiology. Left atrial (LA) maximum volumes (LAVImax ) and minimum volumes (LAVImin ) were larger in the CE group than the non-CE group (45 vs. 32ml/m2 , 32 vs. 13ml/m2 , respectively, P<0.001), whilst LA function indices including LA emptying fraction and LA function index (LAFI) were lower in the CE group (34% vs. 55%, and 0.12 vs. 0.35, respectively, P<0.001). Adjusting for clinical characteristics, LAFI ≤0.3 was an independent predictor of CE stroke (adjusted odds ratio 5.3, P=0.001). Additionally, LAVImax and LAVImin were larger (61 vs. 44 and 32 vs. 24ml/m2 respectively, P<0.01) and LAFI significantly lower (0.34 vs. 0.52, P<0.001) in the undetermined aetiology group versus healthy controls. Left atrial enlargement with reduced LA function was associated with CE stroke and LAFI was the best independent predictor. LA parameters were also altered in the undetermined aetiology group, suggesting an underlying LA myopathy in this subset.

Frequency of Ischemic Stroke Subtypes Based on Toast Classification at a Tertiary Care Center in Pakistan.

Background:The purpose of this study was to determine the frequency of ischemic stroke subtypes based on Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification at a tertiary care center in Pakistan.Materials and Methods:A cross-sectional study was conducted in Stroke Unit of Shifa International Hospital, Islamabad. We included 145 patients who presented to us from November 2015 to February 2016 with radiological confirmed neurological deficits consistent with ischemic stroke. The causes of ischemic stroke were classified according to TOAST criteria. Regression analysis and Chi-square test were used to compute P value.Results:Among the 145 patients diagnosed with ischemic stroke, there were 54.1% males and 45.9% females with a mean age of 65 ± 14 years. Nearly 62.7% patients had hypertension (HTN) as the most common risk factor, followed by 38.6% diabetes mellitus (DM), 27.5% heart failure, 19.3% valvular disease, 18.6% previous stroke, 16.4% smoking, 15.1% dyslipidemia, 13.7% ischemic heart disease, and 13.1% atrial fibrillation. HTN was significantly associated with large vessel disease (P = 0.028). DM was significantly associated with small vessel disease (P = 0.001). Smoking and atrial fibrillation both were associated with unknown etiology of stroke (P = 0.001 and P = 0.039, respectively). Most common etiology of stroke was cardioembolism (40%), and atrial fibrillation is found to be the most common cause of cardioembolic stroke with 30.6% incidence.Conclusion:Our study concludes that cardioembolic stroke is the most common cause of acute ischemic stroke in our stroke unit. Atrial fibrillation is found to be the most common cause of cardioembolic stroke.

The level of interleukin-6 in acute ischemic stroke: effect on the rate of recovery in patients and on the severity of neurological defect

Interleukin 6 (IL-6) plays an important role in the pathogenesis of ischemic stroke (IS), exerting a modulating effect on a number of processes that determine the outcome of this disease. Objective: to investigate the peripheral blood levels of IL-6 in patients in the acute period of different IS pathogenetic subtypes and its effect on recovery rates. Patients and methods. The study enrolled 155 patients (74 men and 81 women; mean age, 63.8 years). A control group consisted of 28 people without IS. Pathogenetic subtype II was established in accordance with the TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria on the basis of their clinical picture and the data of computed tomography or magnetic resonance imaging and ultrasonography of the main arteries of the head. The severity of a patient's condition and a focal neurological defect and the time course of clinical changes after stroke were determined using the National Institutes of Health Stroke Scale (NIHSS). An enzyme immunoassay (EIA) was used to measure IL-6 levels on days 1, 7, and 21 after onset of IS. An enzyme immunoassay (EIA) was used to measure IL-6 levels on days 1, 7, and 21 after onset of IS. Results. In the acute period of IS, there were significantly elevated levels of IL-6. The latter reached its highest values on day 7 in patients with the atherothrombotic pathogenetic subtype of IS. On day 7 of the study, the peak concentration of IL6 was typical for patients with all subtypes of IS, except for lacunar stroke. After its increase on day 1 of the study, the IL6 level in patients with lacunar stroke did not change significantly in all other periods. In acute IS, the concentration of IL-6 was significantly influenced by the following cardiovascular risk factors: hypercholesterolemia of days 1, 7 (p&lt;0.01) and 21 (p&lt;0.05), hypertension in day 1 (p&lt;0.05), diabetes mellitus on days 1 and 7 (p&lt;0.05), and coronary heart disease in all the study periods (p&lt;0.01). The IL-6 concentration significantly correlated with the severity of neurological defect, but did not significantly affect the rate of recovery in the patient with acute IS. Conclusion. IL-6 was established to be of prognostic value for the outcome of acute IS on day 7. The rate of recovery can be used to identify targets for therapeutic intervention.

Retrospective analysis of prognosis and risk factors of patients with stroke by TOAST.

To determine differences in 90-day mortality and identify risk factors among different etiological classifications of ischemic stroke using the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification.Our retrospective analysis included 538 ischemic stroke patients. The cause of stroke was categorized according to the TOAST criteria, and 90-day mortality rates were obtained through the patient follow-up. Age, sex, previous medical history, and clinical features were used in the analysis of potential risk factors.There were 38 deaths during the 90-day follow-up period. Patients in the undetermined cause subgroups experienced significantly higher mortality rate than those in subgroups with small artery occlusion and large artery atherosclerosis. Factors independently associated with 90-day mortality for patients with the large artery atherosclerosis stroke subtype were age (95% confidence interval [CI], 1.010–1.192, P = .028), history of hypertension (95% CI, 3.030–99.136, P = .001), high blood glucose (95% CI, 1.273–2.354, P < .001), high cholesterol (95% CI, 0.017–0.462, P = .004), high uric acid (95% CI, 2.360–64.389, P = .003), and National Institute of Health Stroke Scale(95% CI, 1.076–1.312, P = .001). Age (95% CI, 1.012–1.358, P = .034) and high cholesterol (95% CI, 0.011–0.496, P = .007) were independently associated with 90-day mortality for patients with the small artery occlusion subtype of stroke.Our analysis identified that certain risk factors and 90-day mortality differ significantly among different stroke subtypes, as classified by the TOAST criteria. These risk factors must be considered carefully to provide the best clinical management of these patients and thus reduce mortality.