Association between vertebrobasilar artery geometry and vertebrobasilar stenosis,recurrence, and death in posterior circulation stroke and transient ischemic attack

BackgroundIntracranial atherosclerosis is one of the primary causes of posterior circulation stroke and transient ischemic attack (TIA), particularly in people of South and East Asian heritage. Focal vessel geometry may play a role in atherosclerosis progression. Thus, we investigated the relevance of vertebrobasilar artery (VBA) geometry and vertebrobasilar atherosclerotic stenosis, recurrence, and death in posterior circulation stroke and TIA.MethodsFour hundred and twenty patients with posterior circulation ischemic stroke or TIA were included. The VBA geometric features, comprising the geometric configurations (Tuning fork, Walking, Lambda, and No confluence), vascular bends (multi-bending and oligo-bending), and VBA stenosis degrees, were defined based on computed tomography angiography (CTA) images. Recurrence of stroke or TIA and death were assessed through a 1-year follow-up. Additionally, the relationship between VBA geometric features, VBA stenosis, and prognosis were analyzed.ResultsWalking type and vascular multi-bending showed significant associations with more severe VBA stenosis and distribution, and these were also more frequently observed in patients with large-artery atherosclerosis (LAA) stroke (all P < 0.05). Sixty-four patients exhibited recurrent stroke or TIA, and 31 died during the 1-year follow-up. In the binary logistic regression analysis, Walking type (P = 0.018), Lambda type (P = 0.021), and multi-bending type (P = 0.004) were found to be independently associated with stroke recurrence, while No confluence type was independently associated with death (P = 0.010).ConclusionsThe geometric characteristics of the VBA are associated with vertebrobasilar stenosis, LAA stroke, 1-year recurrence, and death in posterior circulation stroke and TIA. VBA geometry may be used to stratify the risk of stroke and TIA in the posterior circulation.     

How predictors and patterns of stroke recurrence after a TIA differ during the first year of follow-up

The highest risk of subsequent stroke after a TIA occurs within the first week after the index event. However, the risk of stroke recurrence (SR) remains high during the first year of follow-up. We studied the temporal pattern and predictors of SR (at 7 days and from 7 days to 1-year follow-up). Between April 2008 and December 2009, we included 1,255 consecutive TIA patients from 30 Spanish stroke centers (PROMAPA study). We determined the short-term (at 7 days) and long-term (from 8 days to 1 year) risk of SR. Patients who underwent short-term recurrence and long-term recurrence were compared with regard to clinical findings, vascular territories, and etiology. Enough information (clinical variables and extracranial vascular imaging) was assessed in 1,137 (90.6 %) patients. The 7-day stroke risk was 2.6 %. 32 (3.0 %) patients had an SR after 7-day follow-up. Multiple TIA (HR 3.50, 1.67–7.35, p = 0.001) and large artery atherosclerosis (HR 2.51, 1.17–5.37, p = 0.018) were independent predictors of early SR, whereas previous stroke (HR 1.40, 1.03–1.92, p = 0.034) and coronary heart disease (2.65, 1.28–5.50, p = 0.009) were independent predictors of late SR. Notoriously, 80 % of SR happened in the same territory of the index TIA at 7-day follow-up, whereas only 38 % during the long-term follow-up (p < 0.001). Different predictors of SR were identified throughout the follow-up period. Moreover, the ischemic mechanism differed in early and late stroke recurrences.     

Restless legs syndrome in stroke patients

BackgroundRestless legs syndrome (RLS) is associated with cerebrovascular risk factors, but its possible association with cerebrovascular disease has yielded conflicting results.ObjectiveThis was a case–control, in-hospital study to evaluate the association between RLS and acute stroke or transient ischemic attack (TIA).MethodsWe evaluated patients hospitalized with acute stroke/TIA and an age and gender 2:1 frequency-matched control group, for the presence of RLS.ResultsTwenty-two of 149 patients (15%) and 10 of 298 controls (3%) suffered from RLS (p <0.0001). A multivariate logistic regression model employing cerebrovascular risk factors as predictors, that is, hypertension, hyperlipidemia, diabetes, and body mass index (BMI), determined that stroke/TIA was significantly associated with RLS with odds ratio for RLS among patients with stroke/TIA versus controls of 7.60 (95% confidence interval (CI): 2.07–27.87; p = 0.002). Another multivariate logistic regression model adjusting for possible RLS risk factors, that is, hypertension, hyperlipidemia, diabetes, BMI, anemia, and reduced renal function, determined that stroke/TIA was significantly associated with RLS with odds ratio of 6.85 (95% CI: 6.85–1.79; p = 0.005). Stepwise logistic regression with hypertension, hyperlipidemia, diabetes, BMI, anemia, and reduced renal function as potential predictors revealed that only stroke/TIA predicted RLS with similar odds ratio to the RLS-based multivariate model of 6.54 (95% CI: 2.63–16.27; p <0.0001).ConclusionsExamining stroke patients while in hospital allowed us to conclude that RLS and acute stroke/TIA are significantly associated. However, the cross-sectional design did not allow for the determination of a causative relationship between the two.     

Predictive utility of stress tests in the detection of asymptomatic coronary artery disease in atherosclerotic stroke patients

IntroductionWhether and how atherosclerotic ischemic stroke patients should be investigated for asymptomatic coronary artery disease (CAD) is controversial. Our aim was to carry out a prospective observational study to determine the frequency and predictors of functionally significant coronary stenosis in these patients as well as the predictors of major adverse cardiovascular events (MACE) during post-stroke follow-up.Material and methodsFrom January 2014 to June 2018, patients with atherosclerotic ischemic stroke were referred from the stroke unit to our cardiovascular department 3+/- 1 months after the acute event where they benefited from evaluation of cardiovascular risk factors, vascular and myocardial disease. Main outcome was defined as the prevalence of myocardial ischemia defined by perfusion stress echography 3 months after stroke. Secondary outcome (MACE) was defined as the incidence of stroke, transient ischemic attack (TIA), acute coronary syndrome, cardiovascular (CV) death or coronary or peripheral revascularization during a 3 year follow-up.ResultsThree hundred and twenty five patients (92% of strokes and 8% TIA) were included and median follow-up was 1075 days. At 3 months post-stroke, myocardial ischemia was found in 17 patients (5.2%). During the 3 year follow-up, 11 MACE occurred (3.4%, all in the non-ischemic group) of which 6 were recurrent strokes. In multivariate analysis, myocardial ischemia was significantly associated with the number of atheromatous vascular beds (OR 4.3; 95% CI, 1.7 to 10.6) and ECG signs of necrosis (OR 6.5; 95% CI, 1.9 to 21.9). MACE were also associated with ECG signs of necrosis (OR 3.5; 95% CI, 1.3 to 9.1), and unrelated to myocardial ischemia.ConclusionMyocardial ischemia and CV events were infrequent and both strongly associated with ECG signs of necrosis, suggesting a low yield of stress tests and the potential for a more straightforward algorithm in the choice of patients eligible to coronary angiogram or other coronary imaging in post-stroke setting.     

Using measures of sarcopenia to predict recurrent cerebrovascular events in stroke and TIA patients

PurposeSarcopenia is associated with poor outcomes, and evidence suggests an inverse relationship between skeletal muscle mass and cardiovascular risk. Sarcopenia has been studied after stroke, but its value as a risk factor for stroke has not been examined. This prospective cohort study measured sarcopenia in stroke/TIA patients at baseline to explore its role in predicting recurrent events.MethodThe Arterial Stiffness In lacunar Stroke and TIA (ASIST) study included 96 patients with TIA/lacunar stroke, of which 82 patients (mean age 71.2±10.8 years) had bioimpedance analysis to assess body composition. Skeletal Mass Index (SMI) was calculated and parameters of sarcopenia assessed using Davison (1) and Janssen (2) criteria. Recurrent cerebrovascular events were monitored over 5 years.ResultsEighteen patients had recurrent events. On independent samples t test there were significantly more participants with sarcopenia in the recurrent events group (89% vs 56%, p<0.001) using Davison (1) criteria, as well as lower mean SMI, significantly more participants with diabetes and higher arterial stiffness. On binary logistic regression, the only significant predictors of recurrent events were SMI (p=0.036, hazard ratio=0.414, 95% confidence interval 0.195-0.948) and diabetes (p=0.004, hazard ratio=9.06, 95% confidence interval 2.009-40.860) when corrected for age, sex and cardiovascular risk factors. Using Janssen (2) criteria in the regression, severe sarcopenia was a significant predictor of recurrent events (p=0.028). There was a significant association between sarcopenia and recurrent events on Chi square based on Davison (p=0.02) and Janssen (p=0.034) definitions.ConclusionsThe presence of baseline sarcopenia in stroke and TIA patients is an independent predictor of recurrent events.     

Long-Term Outcomes of Stroke or Transient Ischemic Attack after Non-Emergency Percutaneous Coronary Intervention

ObjectivesNon-emergency percutaneous coronary intervention (PCI) has lower risk of stroke than emergency PCI. With increasing elective PCI and increasing risk of stroke after PCI, risk factors for stroke or transient ischaemic attack (TIA) in non-emergency PCI and long-term outcomes needs to be better characterised. We aim to identify risk factors for cerebrovascular accidents in patients undergoing non-emergency PCI and long-term outcomes after stroke or TIA.Materials and MethodsA retrospective cohort study was performed on 1724 consecutive patients who underwent non-emergency PCI for non-ST-segment elevation myocardial infarction (NSTEMI), unstable and stable angina. The primary outcomes measured were stroke or TIA, myocardial infarction (MI) and all-cause death.ResultsUpon mean follow-up of 3.71 (SD 0.97) years, 70 (4.1%) had subsequent ischaemic stroke or TIA, and they were more likely to present with NSTEMI (50 [71.4%] vs 892 [54.0%], OR 2.13 [1.26–3.62], p = 0.004) and not stable angina (19 [27.1%] vs 648 [39.2%], OR 0.58 [0.34–0.99]). Femoral access was associated with subsequent stroke or TIA compared to radial access (OR 2.10 [1.30–3.39], p < 0.002). Previous stroke/TIA was associated with subsequent stroke/TIA (p < 0.001), death (p < 0.001) and MI (p = 0.002). Furthermore, subsequent stroke/TIA was significantly associated with subsequent MI (p = 0.006), congestive cardiac failure (CCF) (p = 0.008) and death (p < 0.001).ConclusionsIn patients undergoing non-emergency PCI, previous stroke/TIA predicted post-PCI ischaemic stroke/TIA, which was associated with death, MI, CCF.     

At-risk drinking in employed men and women

Background: “At-risk”drinking is associated with a variety of negative health and social consequences. However, little is known about the characteristics of at-risk drinkers or of changes in at-risk status over time.Purpose: The objective was to examine the correlates of at-risk drinking and the prospective predictors of maintenance or change in at-risk status.Method: Participants were 4,322 employed individuals assessed at baseline and 4 years later. At-risk drinking was defined as 2 or more drinks per day for men and 1 or more drinks per day for women.Results: The baseline prevalence of at-risk drinking was 11%. Four percent of baseline not-at-risk individuals transitioned to at-risk drinking at follow-up, and 54% of the baseline at-risk individuals remained at-risk at follow-up. Several demographic-, work-, and tobacco-related variables differentiated at-risk groups and were prospective predictors of change in at-risk drinking status among those individuals who were not at risk at baseline. However, none of the constructs predicted change among at-risk drinkers.Conclusion: The data suggest that at-risk drinking is of public health concern. Eleven percent of the participants met criteria for at-risk drinking. Further, at-risk and not-at-risk drinkers differed on numerous characteristics, and their drinking may be influenced by different factors. This article was supported by grants from the National Cancer Institute (P01 CA51671, R01 CA94826, R01 CA89350, R25 CA57730)     

Predictors of CPAP adherence following stroke and transient ischemic attack

ObjectiveContinuous positive airway pressure (CPAP) has been shown to improve functional, motor and cognitive outcomes in post-stroke obstructive sleep apnea (OSA). However, rates of CPAP adherence are often low and factors impacting CPAP adherence remain under-explored. Our objective was to determine predictors of CPAP adherence in patients who had a stroke or transient ischemic attack (TIA).MethodsWe screened 313 stroke/TIA patients for OSA using in-hospital polysomnography or the ApneaLink home sleep apnea test. Potential predictors were recorded at baseline and adherence to CPAP was recorded during a six-month follow-up visit. Selected variables from our univariate analyses were included in multivariate regression models to determine predictors of CPAP adherence. For our logistic regression analyses, CPAP adherence (CPAP use of ≥4 h per night) was the dependent outcome variable. In our linear regression analyses, total CPAP use per week (recorded in hours) was the dependent outcome variable.ResultsEighty-eight patients (mean age 67.81 ± 13.09 years, 69.32% male, mean body mass index 27.93 ± 5.23 kg/m²) were diagnosed with OSA, prescribed CPAP, and assessed for adherence at a six-month follow-up visit. In these 88 patients, 46 (52.27%) were adherent with CPAP therapy. From our regression models, two significant predictors of CPAP adherence were identified: greater functional status (p = 0.04) and not endorsing daytime tiredness (p = 0.047) post-stroke/TIA.ConclusionPatients with greater functional capacity and those with less daytime fatigue demonstrated stronger adherence to CPAP therapy. Our findings may facilitate future treatment strategies for enhancing CPAP adherence in the vulnerable stroke/TIA population.     

Peri-device leakage not CHA2DS2-VASc is associated with post-left atrial appendage closure cardiovascular event

ObjectiveIn patients with non-valvular atrial fibrillation (NVAF), the left atrial appendage occluder (LAAO) is an alternative treatment for stroke prevention. However, thromboembolic event still occur, and the predictors are unknown.MethodsThe first Asian long-term follow-up study consisted of 308 patients with mean age 71.9±9.5 years, mean CHA₂DS₂-VASc 4.1 ± 1.8 since 2013. Primary outcome was defined as any type of ischemic stroke/transient ischemic attack (TIA), systemic embolization and cardiovascular death.ResultsThere was no procedural-related TIA or stroke. After a mean follow-up of 38±16 months, the ischemic stroke/TIA rate was 1.9 and cardiovascular death rate 0.3 per 100 patient-year. The rate of peri-device leak (PDL) was 11.9% and device-related thrombus (DRT) 2.6%. In the multivariable analyses, PDL was the only independent predictor of stroke/TIA (hazard ratio 5.5, p=0.008). CHA₂DS₂-VASc score, prior history of stroke, DRT and post-procedural anti-thrombotic regimen/duration were not associated with outcomes. Implantation of Watchman was associated with PDL (odds ratio 4.35, p=0.001).ConclusionsPDL is the only independent predictor of post-LAAO stroke. The risk of stroke for patients with NVAF may be controllable after LAA is occluded, because PDL is preventable and treatable.     

Effect on anxiety and depression of a multifactorial risk factor intervention program after stroke and TIA: a randomized controlled trial

Objectives: Depression and anxiety related to stroke are caused by vascular lesions and psychological reactions. Treatment of vascular and modifiable behavioral risk factors reduces the risk of stroke and may also reduce the risk of emotional changes after stroke. We aimed to investigate whether a multifactorial risk factor intervention program in patients with first-ever stroke or transient ischemic attack (TIA) can influence post-stroke anxiety and depressive symptoms in patients one year post-stroke.

Method: The study population consisted of first-ever stroke and TIA patients allocated in a randomized, evaluator-blinded, controlled trial to care as usual or a structured and multidisciplinary follow-up including intensive treatment of vascular risk. The primary endpoint (cognition) has previously been reported. The secondary endpoint, reported here, was changes in the Hospital Anxiety and Depression Scale (HADS) from baseline to 12-month follow-up.

Results: One hundred and ninety-five patients were randomized. The estimated difference between treatment groups, in changes in HADS, from baseline to 12 months was ?1.32 (95% confidence interval: ?2.61, ?0.04; P = 0.044) in favor of the intervention group. One year post-stroke, 4/85 (4.7%) patients in the intervention group and 12/89 (13.5%) in the control group suffered from depression (P = 0.045), while 7/85 (8.2%) patients in the intervention group and 13/89 (14.6%) patients in the control group suffered from anxiety (P = 0.19).

Conclusion: A structured, multidisciplinary, multifactorial risk factor program including vascular risk factor management may be associated with reduced HADS scores and a lower prevalence of depressive symptoms one year after stroke.     

Mortality and cause of death after hospital discharge in 10,981 patients with ischemic stroke and transient ischemic attack

BACKGROUND: The aim of this study was to examine the 1-year cumulative mortality rate and cause of death, and to identify the predictive factors for death after hospital discharge following ischemic stroke and transient ischemic attack (TIA) using data from the Japan Multicenter Stroke Investigators' Collaboration study. METHODS: We prospectively registered 16,922 consecutive patients with acute ischemic stroke or TIA from May 1999 to April 2000 in 156 Japanese hospitals. We mailed a questionnaire to the 15,322 patients who were alive at hospital discharge. RESULTS: 10,981 patients (6,945 men, 4,036 women, age 70 +/- 11 years, median 71, range 19-100 years) were enrolled in the follow-up study. The mean follow-up period was 271 +/- 110 days (median 272 days; range 1-487 days). The 1-year cumulative mortality was 6.8% (7.0% for 10,234 stroke patients and 3.5% for 747 TIA patients). The causes of death were: cerebrovascular disease, 24.1%; pneumonia, 22.6%; heart disease, 18.1%; cancer, 11.0%, and miscellaneous causes, 24.1%. Multivariate analysis suggested that male gender, age, diabetes mellitus, atrial fibrillation, history of stroke, nonlacunar stroke, functional disability and transfer to another hospital or nursing home on discharge were significant independent predictors of death during the follow-up period. CONCLUSIONS: The major causes of death after hospital discharge were found to be cerebrovascular diseases, pneumonia and heart diseases. Thus, in order to improve survival after hospital discharge, in addition to appropriate management of vascular risk factors following stroke, it appears to be important to take measures to prevent pneumonia and to discharge patients to their own home, if possible.     

Comparison of primary and secondary stroke prevention in patients with nonvalvular atrial fibrillation: Results from the RAFFINE registry

ObjectivesClinical outcome data of primary and secondary prevention in patients with nonvalvular atrial fibrillation (NVAF) after the introduction of direct oral anticoagulant (DOAC) therapy are limited.Materials and MethodsA subgroup analysis of the RAFFINE registry, an observational, multicenter, prospective registry of Japanese patients with AF, was performed. Incidence rates of stroke or systemic embolism, all-cause death, major bleeding, and intracranial hemorrhage were compared between patients with and without a history of stroke or transient ischemic attack (TIA).ResultsOf 3,706 NVAF patients at baseline, 557 (15.0%) had a history of ischemic stroke or TIA (secondary prevention group), and 3,149 (85.0%) had no history of ischemic stroke or TIA (primary prevention group). The proportion of patients receiving oral anticoagulants was 87.2% (42.5% warfarin, 44.7% DOACs). The secondary prevention group had higher rates of stroke or systemic embolism (2.6% vs 1.0%/year, p<0.001), all-cause death (3.6% vs 2.4%/year, p<0.01), and major bleeding (2.0% vs 1.3%/year, p<0.01), and similar rates of intracranial hemorrhage (0.6% vs 0.5%/year, p=0.66) compared with the primary prevention group. A Cox proportional hazards model showed that a history of ischemic stroke or TIA was independently associated with an increased risk of stroke or systemic embolism (adjusted hazard ratio, 2.22; 95% confidence interval, 1.57 – 3.15; p<0.001).ConclusionsIn a contemporary cohort of NVAF patients, a history of ischemic stroke or TIA was still an independent predictor of stroke or systemic embolism, despite advances in anticoagulation therapy.     

Application of High-Resolution CUBE Sequence in Exploring Stroke Mechanisms of Atherosclerotic Stenosis of Middle Cerebral Artery

Background

This study aimed to analyze the vascular wall and atherosclerotic plaques of the middle cerebral artery (MCA) and compare their differences between patients with cerebral infarction and transient ischemic attack (TIA) using 3-dimensional fast-spin-echo T1-weighted sequence (namely CUBE).

Elevated Neutrophil to Lymphocyte Ratio is Associated with Worse Outcomes after Carotid Endarterectomy in Asymptomatic Patients

ObjectiveManagement of carotid artery stenosis (CAS) remains controversial and proper patient selection critical. Elevated neutrophil to lymphocyte ratio (NLR) has been associated with poor outcomes after vascular procedures. The effect of NLR on outcomes after carotid endarterectomy (CEA) in asymptomatic and symptomatic patients is assessed.Materials and MethodsA retrospective review was conducted of all patients between 2010 and 2018 with carotid stenosis >70% as defined by CREST 2 criteria. A total of 922 patients were identified, of whom 806 were treated with CEA and 116 non-operatively with best medical therapy (BMT). Of patients undergoing CEA, 401 patients (290 asymptomatic [aCEA], 111 symptomatic [sCEA]) also had an available NLR calculated from a complete blood count with differential. All patients treated with BMT were asymptomatic and had a baseline NLR available. Kaplan-Meier analysis assessed composite ipsilateral stroke or death over 3 years.ResultsIn sCEA group, the 3-year composite stroke/death rates did not differ between NLR < 3.0 (22.9%) vs NLR > 3.0 (38.1%) (P=.10). In aCEA group, patients with a baseline NLR >3.0 had an increased risk of 3-year stroke/death (42.6%) compared to both those with NLR <3.0 (9.3%, P<.0001) and those treated with BMT (23.6%, P=.003). In patients with NLR <3.0, aCEA showed a superior benefit over BMT with regard to stroke or death (9.3% vs. 26.2%, P=.02). However, in patients with NLR >3.0, there was no longer a benefit to prophylactic CEA compared to BMT (42.6% vs. 22.2%, P=.05). Multivariable analysis identified NLR >3.0 (HR, 3.23; 95% CI, 1.93-5.42; P<.001) and congestive heart failure (HR, 2.18; 95% CI, 1.33-3.58; P=.002) as independent risk factors for stroke/death in patients with asymptomatic carotid artery stenosis.ConclusionsNLR >3.0 is associated with an increased risk of late stroke/death after prophylactic CEA for asymptomatic carotid artery stenosis, with benefits not superior to BMT. NLR may be used to help with selecting asymptomatic patients for CEA. The effect of NLR and outcomes in symptomatic patients requires further study. Better understanding of the mechanism(s) for NLR elevation and medical intervention strategies are needed to modulate outcome risk in these patients.     

Prevalence of asymptomatic atherosclerosis of extracranial vessels among hypertensive patients in southern Egypt: An extracranial duplex study

Objectives:The prevalence of atherosclerosis in extracranial vessels among hypertensive patients in southern Egypt is still unknown. Carotid ultrasound is an accurate method used to identify and follow patients with cerebrovascular disorders. The aim of our study is to detect the prevalence and pattern of extracranial atherosclerosis among those patients.Methods:Our case-control study was performed from January 2017 to January 2018, including 200 subjects, 100 patients recruited consecutively from the Hypertension Clinic in Assiut University hospitals, Egypt, and 100 healthy controls. Detailed history collection and thorough physical examinations were carried out for each patient. All subjects underwent extracranial ultrasound. We omitted patients with history of ischemic stroke and TIAs.Results:The presence of increased intima media thickness was detected in 37 patients (37%). 22 patients (22%) had internal carotid artery (ICA) stenosis, 17 patients (17%) had non-significant stenosis <50%, while five patients (5%) had stenosis 50-69%. 9% had stenosis < 50% in vertebral artery. In addition, age and uncontrolled hypertension have a greater impact on increasing the CCA intima media thickness, which is considered an early sign of atherosclerosis.Conclusions:Uncontrolled hypertension is an important risk factor for atherosclerosis and hence ischemic stroke (IS). The cost of screening is considered low compared to IS management. Greater emphasis should be directed toward regular screening programs in this risky population.

Ischemic stroke (IS) is a major health problem that leads to increased morbidity and mortality all over the world. Moreover, IS has very serious economic consequences, both for its management or during post-stroke care.1 Reducing the burden of stroke requires identification of the most common modifiable risk factors to control and follow. Hypertension is one of the major modifiable risk factors for IS.2 The approximate prevalence rate of hypertension in Egypt was 26.3%,3 and it is more prevalent in the south than in the north of Egypt.3 Hypertension leads to atherosclerosis through several mechanisms like vascular endothelial dysfunction, early vascular aging, systemic inflammation and thickening of the basal membrane .4 Chronic hypertension accelerates the atherosclerotic process by increasing intraluminal pressure and vessel wall thickness.5 Atherosclerosis can lead to IS through progressive stenosis and hence occlusion of the extra or intracranial vessels and or arterio-arterial embolization from an athermanous plaque.6 The classification of subtypes of acute ischemic stroke (TOAST Trial),7 which established the etiologic classification of IS, found that large-artery atherosclerosis played a significant role in the etiology of IS. The incidence rate of stroke among treated hypertensive patients was 289/100,000 and 363/100,000 among untreated hypertensive patients.8 Stroke is more easily prevented than treated, so follow up and early intervention of hypertensive patients could help to prevent the occurrence of IS. Carotid Ultrasound is a cheap and reliable method that enables the early detection and accurate monitoring of the extent and degree of the atherosclerosis of the extracranial vessels.9 Early identification within risky patients could stop them from developing stroke. Up to our knowledge, no previous studies estimating the prevalence and pattern of atherosclerosis among asymptomatic hypertensive patients were performed in southern Egypt. The aim of our work then is to determine the prevalence of asymptomatic atherosclerosis of extracranial vessels and/or stenosis among hypertensive patients who had no other risk factors, previous history of IS or transient ischemic attack (TIA) within the Assiut Governorate in southern Egypt.     

Risk of stroke in patients with idiopathic Parkinson disease

PurposeLarge population based studies on the association of Parkinson disease (PD) with stroke are scarce. This study aimed to quantify the risk of a first-time diagnosis of idiopathic PD in patients with a history of stroke, and to assess incidence rates for stroke in PD patients.MethodsWe used the UK-based General Practice Research Database to compare the prevalence of stroke/TIA in newly diagnosed PD patients and in a matched comparison group without PD between 1994 and 2005. We conducted a follow-up study with a nested case-control analysis to quantify the risk of incident stroke/TIA in relation to a previous PD diagnosis.ResultsA history of stroke/TIA was associated with a significantly increased relative risk of being diagnosed with PD compared to patients without such a history (adj. odds ratio [OR] 1.65, 95% confidence intervals [CI] 1.47–2.00). In the cohort study, the crude incidence rate ratios (IRRs) for incident hemorrhagic stroke, ischemic stroke or TIA were 0.66 (95% CI 0.26–1.72), 1.46 (95% CI 1.03–2.07) and 1.86 (95% CI 1.40–2.47), respectively.ConclusionsIn this large observational study the risk of a PD diagnosis was significantly increased after a previous stroke event, as was the risk of a first-time ischemic stroke in newly diagnosed PD patients compared to persons free of PD.     

Transient Ischemic Attack: Which Determines Diffusion-Weighted Image Positivity?

Aim of the studyDiffusion-weighted image (DWI) of magnetic resonance imaging (MRI) can reveal high signal lesion in up to 50% of transient ischemic attack (TIA) patients. However, it is not well-known which factors determine developing DWI positivity. In order to answer this question, we analyzed factors relevant to DWI positivity in TIA patients.MethodsWe had 257 stroke patients at a university emergency/neurology wards. They were 140 men, 117 women, mean age 72 (45-88) years. Among them, 24 (9.3%) had TIA (14 men, 10 women, mean age 71 [58-82] years). All patients underwent a 1.5T MRI. In 24 TIA patients, we investigated the following parameters in relation with stroke maturation: ABCD2 score, smoking habits, blood profile, HbA1C, dyslipidemia, coagulation factors, carotid echography, electrocardiography, cardiac echography, chest X-ray, neurological symptom/signs, imaging, and recurrence of neurological symptom on follow-up.ResultsIn 24 TIA patients, 13 (54%) were DWI positive and 11 (46%) were DWI negative. After an extensive analysis, all parameters were not relevant to DWI positivity except for plasma osmolarity, i.e., plasma osmolarity in DWI positive cases (305.3 mOsm/l) is significantly higher than that in DWI negative cases (301.3 mOsm/l) (P = .0064). As for recurrence, 4 of 24 TIA patients recurred. They were 1 (9.0%) of 11 DWI negative cases and 3 (23.1%) of 13 DWI positive cases. Therefore, DWI positive cases recurred more frequently than DWI negative cases did, although it did not reach statistical significance.ConclusionsTIA with DWI positivity in our institute was 54%, closely associated with initial dehydration and might predict stroke recurrence.     

Effect of left ventricular ejection fraction Spectrum on 1-Year mortality in patients with acute ischemic stroke or transient ischemic attack

Aims

We aimed to investigate the association of the left ventricular ejection fraction (LVEF) spectrum with 1-year clinical outcomes in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA).

Methods

In a prospective registry for the Third China National Stroke Registry (CNSR-III), AIS or TIA patients with echocardiography records during hospitalization were recruited. All LVEFs were categorized into intervals of 5% in width. The lowest and highest intervals are ≤40% and >70%, respectively. The primary outcome was all-cause death at 1 year. Cox proportional hazards regression analysis was performed to investigate the association between baseline LVEF and clinical outcomes.

Results

This analysis included a total of 14,053 patients. In total, 418 patients died during 1-year follow-up. Overall, LVEF ≤60% was associated with a higher risk of all-cause death compared to LVEF >60%, independent of demographic and clinical characteristics (aHR 1.29 [95% CI 1.06–1.58]; p = 0.01). The cumulative incidence of all-cause death was significantly different among the eight LVEF groups that survival declined successively with the decrease of LVEF (log-rank p ≤ 0.0001).

Conclusions

Patients with AIS or TIA with decreased LVEF (≤60%) had a lower 1-year survival rate after onset. LVEF 50%–60% even within the normal range, may still contribute to poor outcomes in AIS or TIA. Comprehensive evaluation of cardiac function after acute ischemic cerebrovascular disease should be strengthened.     

Family History is Related to High Risk of Recurrent Events after Ischemic Stroke or Transient Ischemic Attack

ObjectivePrior data suggest paternal or sibling stroke was associated with increased risk of offspring stroke. Whether family history of cardiovascular disease (FHc) predicts risk of stroke recurrence remains unclear, we aim to determine this issue on patients with ischemic stroke (IS) or transient ischemic attack (TIA).Materials and MethodsThis is a post hoc analysis based on the Third China National Stroke Registry III. IS/TIA patients with data of FHc status were included. FHc was defined as family history of coronary heart disease (CHD) or stroke among first-degree relatives (include parents, children, and siblings (same parents)). Cox proportional hazards regression models were performed to assess the association between FHc and recurrent events at 1 year follow-up.ResultsTotally 14,208 patients with verified FHc status were included, 4,454 (31.3%) were female and the median (IQR) age was 62.0 (54.0, 70.0) years. Of these, 294 (2.1%), 726 (5.1%) and 1936 (13.6%) had family history of both CHD and stroke, family history of CHD, and family history of stroke only, respectively. Using multivariable Cox models adjusted for age, sex, and vascular risk factors, we found that patients with FHc experienced higher risk of stroke recurrence (HR=1.151, 95%CI=1.000-1.324) and combined vascular events (HR=1.186, 95%CI=1.036-1.358) at 1 year compared with those without FHc. In sensitivity analysis on patients who received primary secondary prevention treatment of antiplatelet and statins, the association persisted.ConclusionsFHc is associated with increased risk of stroke recurrence even under primary secondary prevention treatment.     

Non-association of stroke risk with intracranial hemodynamic steal in patients with symptomatic internal carotid artery occlusions

ObjectivesParadoxical intracranial hemodynamic steal (IHS) is known in patients having persistent proximal arterial occlusions and is linked with early neurological worsening. However, stroke risk specific to symptomatic internal carotid artery occlusions (SICAO) having paradoxical IHS is unknown. Therefore, we aimed to investigate the association of paradoxical IHS in SICAO patients with stroke recurrence during a one-year follow-up.Materials and methodsWe prospectively enrolled adult patients having SICAO with a recent history of ischemic events. Steal magnitude (SM) to classify patients in IHS and non-IHS categories was evaluated by a breath-holding test using bilateral transcranial doppler (TCD). Patients were prescribed optimal medical therapy and followed up for one year for any ischemic stroke/TIA/cardiovascular death.Results36 SICAO patients, mean age of 56 years, were assessed using TCD at median 22.5 days (Interquartile range, IQR= 9-42), and 11 (30.6%) had paradoxical IHS with median SM 12% (IQR= 6%-18%). On follow-up, 7 (19.4%) patients had event recurrence and its association with IHS was non-significant (IHS vs non-IHS, 18.2% vs 20%; Log-rank statistics=0.006; P=0.940). On Cox regression analysis, event recurrence was independently associated with the presence of significant contralateral stenosis only (regression coefficient= 2.237; P= 0.012; 95% CI= 1.63-53.89).ConclusionsIHS prevalence among SICAO is high. However, paradoxical IHS was not associated with an increased risk of stroke in SICAO. Therefore, the presence of paradoxical IHS in SICAO may be considered a transit state and does not necessarily imply an increased risk of stroke.