Worse stroke outcome in atrial fibrillation is explained by more severe hypoperfusion, infarct growth, and hemorrhagic transformation

Hemostasis functions are associated with hemorrhagic transformation in non-atrial fibrillation patients: a case-control study

Background

Hemorrhagic transformation (HT) is a serious neurological complication of acute ischemic stroke (AIS) after revascularization. The majority of AIS patients do not have atrial fibrillation (AF) which could also develop into HT. In this study, we aimed to explore whether hemostasis parameters are risk factors of HT in non-AF patients.

Methods

We consecutively enrolled 285 AIS patients with HT. Meanwhile, age- and sex-matched 285 AIS patients without HT were included. The diagnosis of HT was determined by brain CT or MRI during hospitalization. All patients were divided into two subgroups based on the presence of AF and explore the differences between the two subgroups. Blood samples were obtained within 24 h of admission, and all patients were evenly classified into three tertiles according to platelet counts (PLT) levels.

Results

In this study, we found the first PLT tertile (OR = 3.509, 95%CI = 1.268–9.711, P = 0.016) was independently associated with HT in non-AF patients, taking the third tertile as a reference. Meanwhile, we also found mean platelet volume (MPV) (OR = 0.605, 95%CI = 0.455–0.805, P = 0.001) and fibrinogen (FIB) (OR = 1.928, 95%CI = 1.346–2.760, P < 0.001) were significantly associated with HT in non-AF patients. But in AF patients, hemostasis parameters showed no significant difference. Meanwhile, we found the MPV (OR = 1.314, 95%CI = 1.032–1.675, P = 0.027) and FIB (OR = 1.298, 95%CI = 1.047–1.610, P = 0.018) were significantly associated with long-term outcomes in non-AF HT patients.

Conclusions

Low PLT, low MPV, and high FIB levels were independently associated with HT in non-AF patients. Additionally, MPV and FIB levels were significantly associated with unfavorable long-term outcomes in non-AF HT patients. Our study showed that hemostasis functions at admission may be beneficial for clinicians to recognize patients with a high risk of HT at an early stage and improve unfavorable long-term outcomes in non-AF patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02065-3.

A Nomogram to Predict Symptomatic Intracranial Hemorrhage After Intravenous Thrombolysis in Chinese Patients

BACKGROUND AND AIMS

A reliable predictive score system to identify the risk of symptomatic intracranial hemorrhage (sICH) after intravenous thrombolysis (IVT) in acute ischemic stroke patients is of great essence. We aimed to develop a nomogram for predicting the risk of sICH after IVT in Chinese patients.

METHODS

We recruited acute ischemic stroke patients who were treated with IVT from five advanced stroke centers in China from April 2014 to November 2020. sICH was diagnosed according to the European Cooperative Acute Stroke Study II (ECASS-II) definition. Multivariable logistic regression was performed to construct the best-fit nomogram. The discrimination and calibration of the nomogram were evaluated by the area under the receiver operating characteristic curve (AUC-ROC) and calibration plot.

RESULTS

A total of 1200 patients were enrolled, of whom 66 (5.5%) developed sICH. In the multivariate logistic regression model, atrial fibrillation (odds ratio [OR] 3.25; 95% confidence interval [CI], 1.89-5.60; P < 0.001), baseline glucose level (OR, 1.13; 95% CI, 1.07-1.20; P < 0.001), neutrophil to lymphocyte ratio (OR, 1.05; 95% CI, 1.01-1.09; P = 0.024) and baseline National Institute of Health Stroke Scale (NIHSS) (OR, 1.07; 95% CI, 1.04-1.10; P < 0.001) were independent predictors for sICH and were used to generate the nomogram. The nomogram demonstrated good discrimination as the AUC-ROC value was 0.788 (95% CI, 0.737-0.840). The calibration plot revealed good calibration.

CONCLUSION

The nomogram consisted of atrial fibrillation, baseline glucose level, neutrophil to lymphocyte ratio, and NIHSS score may predict the risk of sICH in Chinese acute ischemic stroke patients treated with IVT.

Clinical and budget impacts of changes in oral anticoagulation prescribing for atrial fibrillation

OBJECTIVE

To assess temporal clinical and budget impacts of changes in atrial fibrillation (AF)-related prescribing in England.

METHODS

Data on AF prevalence, AF-related stroke incidence and prescribing for all National Health Service general practices, hospitals and registered patients with hospitalised AF-related stroke in England were obtained from national databases. Stroke care costs were based on published data. We compared changes in oral anticoagulation prescribing (warfarin or direct oral anticoagulants (DOACs)), incidence of hospitalised AF-related stroke, and associated overall and per-patient costs in the periods January 2011-June 2014 and July 2014-December 2017.

RESULTS

Between 2011-2014 and 2014-2017, recipients of oral anticoagulation for AF increased by 86.5% from 1 381 170 to 2 575 669. The number of patients prescribed warfarin grew by 16.1% from 1 313 544 to 1 525 674 and those taking DOACs by 1452.7% from 67 626 to 1 049 995. Prescribed items increased by 5.9% for warfarin (95% CI 2.9% to 8.9%) but by 2004.8% for DOACs (95% CI 1848.8% to 2160.7%). Oral anticoagulation prescription cost rose overall by 781.2%, from £87 313 310 to £769 444 028, (£733,466,204 with warfarin monitoring) and per patient by 50.7%, from £293 to £442, giving an incremental cost of £149. Nevertheless, as AF-related stroke incidence fell by 11.3% (95% CI -11.5% to -11.1%) from 86 467 in 2011-2014 to 76 730 in 2014-2017 with adjustment for AF prevalence, the overall per-patient cost reduced from £1129 to £840, giving an incremental per-patient saving of £289.

CONCLUSIONS

Despite nearly one million additional DOAC prescriptions and substantial associated spending in the latter part of this study, the decline in AF-related stroke led to incremental savings at the national level.

Patterns of Infarction on MRI in Patients With Acute Ischemic Stroke and Cardio-Embolism: A Systematic Review and Meta-Analysis

Background: Cardioembolic strokes are common however atrial fibrillation, the most common cause, is often asymptomatic and difficult to detect. There is evidence that infarct topography and volume on magnetic resonance imaging may be associated with specific stroke etiologies.

Aim: A systematic review and meta-analysis were undertaken to summarize the available evidence on the association between stroke etiology, infarct topography, and volume.

Methods: A systematic review was conducted using Medline (OVID), Embase (OVID), and PubMed databases. Hand searches of the gray literature and of reference lists in relevant articles were also performed. A quality assessment was undertaken, based on the STROBE checklist. For each study, the number of patients with and without a CE source of stroke and infarct topography was collected and outcomes presented as odds ratios (OR) with 95% CI and p-values.

Results: Four thousand eight hundred and seventy-three patients with ischemic stroke were included, of whom 1,559 were determined to have a CE source. Bilateral infarcts (OR 3.41; 95% CI 2.20–5.29; p < 0.0001) and multiple territory infarcts (OR 1.57; 95% CI 1.12–2.21; p = 0.009) were more common in patients with a CE source of stroke, than patients without a CE source. Lacunar infarcts (OR 0.49; 95% CI 0.31–0.80; p = 0.004) were more likely to occur in patients without a CE source. No significant difference between the frequency of multiple infarcts (OR 0.96; 95% CI 0.57–1.61; p = 0.87) anterior circulation (OR 1.45; 95% CI 0.83–2.53; p = 0.19) or posterior circulation infarcts (OR 1.06; 95% CI 0.72–1.57; p = 0.75), between the two groups were identified. Three out of four studies examining volume, found a significant association between increased infarct volume and CE source of stroke. A sensitivity analysis with cryptogenic and undetermined stroke sources assumed to be cardioembolic, did not alter the associations observed.

Conclusion: The findings of this systematic review and meta-analysis are broadly consistent with previous literature and provide more robust evidence on the association between infarct topography, volume and stroke etiology. Our findings may assist with refining cardiac investigations for patients with cryptogenic stroke, based on infarct topography.

Mono antiplatelet therapy for cardioembolic and undetermined etiological stroke after receiving successful mechanical thrombectomy

BACKGROUND

Recent studies indicated that majority of stroke with undetermined etiology (SUE) showed strong overlap with cardioembolic stroke (CE). We intended to determine the efficacy of the mono antiplatelet (MA) therapy in both stroke types after receiving successful mechanical thrombectomy (MT) recanalization in the acute stage.

METHODS

178 consecutive stroke patients who received MT treatment were retrospectively analyzed. For CE and SUE type stroke patients, aspirin 100 mg or clopidogrel 75 mg was added immediate for those didn`t received IV-rtPA and after 24 h for those received IV-rtPA if symptomatic intracranial hemorrhage (sICH) was not found. MA treatment outcomes included recanalized artery patency, subsequent sICH and functional independence (mRS score 0-2) were compared between two stroke types.

RESULTS

75 CE and 50 SUE patients were included into final analysis. Target artery was confirmed 100 % patency in the CE group and 97.5 % in the SUE group at 7 days after recanalization. Hemorrhagic transformation after 24 h was found in 10 % patients in the SUE group and in 12 % patients in the CE group (P > 0.05). sICH was confirmed in 1 patient in the SUE group and in 2 patients in the CE group. At 90 days, 45.8 % in the SUE group and 46.5 % in the CE group of patients had achieved good outcomes (P = 1.00). However, accumulative death was higher in the CE group than in the SUE group (21 % vs. 15 %; P = 0.47).

CONCLUSION

For patients considered CE or SUE stroke types, mono antiplatelet therapy after good flow restoration by thrombectomy is safe and effective.

Health related quality of life and satisfaction with care of stroke patients in Budapest: A substudy of the EuroHOPE project

BACKGROUND

Disadvantaged socioeconomic status is associated with higher stroke incidence and mortality, and higher readmission rate. We aimed to assess the effect of socioeconomic factors on case fatality, health related quality of life (HRQoL), and satisfaction with care of stroke survivors in the framework of the European Health Care Outcomes, Performance and Efficiency (EuroHOPE) study in Hungary, one of the leading countries regarding stroke mortality.

METHODS

We evaluated 200 consecutive patients admitted for first-ever ischemic stroke in a single center and performed a follow-up at 3 months after stroke. We recorded pre- and post-stroke socioeconomic factors, and assessed case fatality, HRQoL and patient satisfaction with the care received. Stroke severity at onset was scored by the National Institutes of Health Stroke scale (NIHSS), disability at discharge from acute care was evaluated by the modified Rankin Score (mRS). To evaluate HRQoL and patient satisfaction with care we used the EQ-5D-5L, 15D and EORTC IN PATSAT 32 questionnaires.

RESULTS

At 3 months after stroke the odds of death was significantly increased by stroke severity (NIHSS, OR = 1.209, 95%CI: 1.125-1.299, p<0.001) and age (OR = 1.045, 95%CI: 1.003-1.089, p = 0.038). In a multiple linear regression model, independent predictors of HRQoL were age, disability at discharge, satisfaction with care, type of social dwelling after stroke, length of acute hospital stay and rehospitalization. Satisfaction with care was influenced negatively by stroke severity (Coef. = -1.111, 95%C.I.: -2.159- -0.062, p = 0.040), and positively by having had thrombolysis (Coef. = 25.635, 95%C.I.: 5.212-46.058, p = 0.016) and better HRQoL (Coef. = 22.858, 95%C.I.: 6.007-39.708, p = 0.009).

CONCLUSION

In addition to age, disability, and satisfaction with care, length of hospital stay and type of social dwelling after stroke also predicted HRQoL. Long-term outcome after stroke could be improved by reducing time spent in hospital, i.e. by developing home care rehabilitation facilities thus reducing the need for readmission to inpatient care.

A web based dynamic MANA Nomogram for predicting the malignant cerebral edema in patients with large hemispheric infarction

Background

For large hemispheric infarction (LHI), malignant cerebral edema (MCE) is a life-threatening complication with a mortality rate approaching 80%. Establishing a convenient prediction model of MCE after LHI is vital for the rapid identification of high-risk patients as well as for a better understanding of the potential mechanism underlying MCE.

Methods

One hundred forty-two consecutive patients with LHI within 24 h of onset between January 1, 2016 and August 31, 2019 were retrospectively reviewed. MCE was defined as patient death or received decompressive hemicraniectomy (DHC) with obvious mass effect (≥ 5 mm midline shift or Basal cistern effacement). Binary logistic regression was performed to identify independent predictors of MCE. Independent prognostic factors were incorporated to build a dynamic nomogram for MCE prediction.

Results

After adjusting for confounders, four independent factors were identified, including previously known atrial fibrillation (KAF), midline shift (MLS), National Institutes of Health Stroke Scale (NIHSS) and anterior cerebral artery (ACA) territory involvement. To facilitate the nomogram use for clinicians, we used the “Dynnom” package to build a dynamic MANA (acronym for MLS, ACA territory involvement, NIHSS and KAF) nomogram on web (http://www.MANA-nom.com) to calculate the exact probability of developing MCE. The MANA nomogram’s C-statistic was up to 0.887 ± 0.041 and the AUC-ROC value in this cohort was 0.887 (95%CI, 0.828 ~ 0.934).

Conclusions

Independent MCE predictors included KAF, MLS, NIHSS, and ACA territory involvement. The dynamic MANA nomogram is a convenient, practical and effective clinical decision-making tool for predicting MCE after LHI in Chinese patients.

Increased intracranial hemorrhage of mechanical thrombectomy in acute ischemic stroke patients with atrial fibrillation

The impact of atrial fibrillation (AF) on outcomes of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is controversial, and with a paucity of evidence base. This study aimed to investigate the potential association between AF and outcomes after MT in AIS patients. A post-hoc analysis of a multi-center prospective clinical trial was conducted. Before and after propensity score matching (PSM), the clinical features were compared between patients with and without AF. Multivariable logistic regression and mediation analyses were performed to assess the relationship between AF and ICH. Of the total 245 patients, 123 patients were included in the AF group. After PSM, the AF group showed more retrieval attempts (P = 0.004), comparable favorable outcome (P = 0.493), and mortality (P = 0.362) at 90 days. Multivariate analysis revealed that AF was significantly associated with increased risk for ICH (OR 2.198; 95%CI 1.099-4.395; P = 0.026). INR and retrieval attempts were found to act as partial mediations. In the subgroup with lower INR, AF still had a significant association with ICH (OR 2.496; 95%CI 1.331-4.679; P = 0.004). In AIS patients undergoing MT, AF was associated with more retrieval attempts and higher risk of any ICH. Of note, the effect of AF on the increased risk of ICH was partly attributable to the adjusted anticoagulation status and more retrieval attempts. It is crucial to elaborately prevent ICH after thrombectomy for stroke patients with AF.

Clinical Characteristics and Outcome of Patients With Hemorrhagic Transformation After Intravenous Thrombolysis in the WAKE-UP Trial

Background: Hemorrhagic transformation (HT) is an important complication of intravenous thrombolysis with alteplase. HT can show a wide range from petechiae to parenchymal hematoma with mass effect with varying clinical impact. We studied clinical and imaging characteristics of patients with HT and evaluated whether different types of HT are associated with functional outcome.

Methods: We performed a post-hoc analysis of WAKE-UP, a multicenter, randomized, placebo-controlled trial of MRI-guided intravenous alteplase in unknown onset stroke. HT was assessed on follow-up MRI or CT and diagnosed as hemorrhagic infarction type 1 and type 2 (HI1 and HI2, combined as HI), and parenchymal hemorrhage type 1 and type 2 (PH1 and PH2, combined as PH). Severity of stroke symptoms was assessed using the National Institutes of Health Stroke Scale (NIHSS) at baseline. Stroke lesion volume was measured on baseline diffusion weighted imaging (DWI). Primary endpoint was a favorable outcome defined as a modified Rankin Scale score 0–1 at 90 days.

Results: Of 483 patients included in the analysis, 95 (19.7%) showed HI and 21 (4.4%) had PH. Multiple logistic regression analysis identified treatment with alteplase (OR, 2.08 [95% CI, 1.28–3.40]), baseline NIHSS score (OR, 1.11 [95% CI, 1.05–1.17]), DWI lesion volume (OR, 1.03 [95% CI, 1.01–1.05]), baseline glucose levels (OR, 1.01 [95% CI, 1.00–1.01]) and atrial fibrillation (OR, 3.02 [95% CI, 1.57–5.80]) as predictors of any HT. The same parameters predicted HI. Predictors of PH were baseline NIHSS score (OR, 1.11 [95% CI, 1.01–1.22]) and as a trend treatment with alteplase (OR, 2.40 [95% CI, 0.93–6.96]). PH was associated with lower odds of favorable outcome (OR 0.25, 95% [CI 0.05–0.86]), while HI was not.

Conclusion: Our results indicate that HI is associated with stroke severity, cardiovascular risk factors and thrombolysis. PH is a rare complication, more frequent in severe stroke and with thrombolysis. In contrast to HI, PH is associated with worse functional outcome. The impact of HT after MRI-guided intravenous alteplase for unknown onset stroke on clinical outcome is similar as in the trials of stroke thrombolysis within a known early time-window.

Differentiation of hemorrhagic infarction from primary intracerebral hemorrhage in the chronic period

Regarding incidentally found old hemorrhagic foci on gradient-echo magnetic resonance imaging (GRE), it is difficult to distinguish whether the foci are the consequence of hemorrhagic infarction (HI) or primary intracerebral hemorrhage (PICH). We analyzed the radiological characteristics of patients with a definite history of HI or PICH by reviewing long-term follow-up GRE. We retrospectively enrolled patients with HI or PICH, verified by clinical history and radiological findings, who had undergone follow-up GRE at least 3 months after the first imaging. The shape of the hemorrhagic lesion was classified as "cavitation" or "no cavitation." The shape of the hemosiderin rim was classified as total dark rim and partial dark rim. Hyperintense perilesional signal was determined when an obvious hyperintensity on T2-weighted image was present. Further, we compared the radiological characteristics between HI and PICH. In total, 69 patients (38 with HI and 31 with PICH) were enrolled, of whom 45 (65%) were men. The mean patient age was 65.5 ± 12.7 years. The mean time interval from the initial stroke onset to the follow-up image was 56.2 months. Hyperintense perilesional signal was observed in 38 patients; it was associated with HI (33/38 vs. 5/31, p < 0.001). Furthermore, partial dark rim was associated with HI (34/40 vs. 4/29, p < 0.001). Cavitation was more frequently observed in patients with HI than in those with PICH (36/60 vs. 2/9, p = 0.068). Presence of hyperintense perilesional signal and partially encasing dark hemosiderin rim suggest that chronic hemorrhagic foci are the sequelae of HI, not PICH.

Implication of MicroRNA503 in Brain Endothelial Cell Function and Ischemic Stroke

The role of miR-503 in brain endothelium and ischemic stroke (IS) remains unclear. We aimed to study the relationship between plasma miR-503 and the onset time, severity, subtypes, and von Willebrand Factor (vWF) level in IS patients and to investigate the roles and underlying mechanisms of miR-503 in middle cerebral artery occlusion (MCAO) mice and cultured cerebral vascular endothelial cells (ECs). In MCAO mice, the effects of plasma from acute severe IS patients (ASS) with or without miR-503 antagomir on brain and ECs damage were determined. In cultured human ECs, the effects of miR-503 overexpression or knockdown on the monolayer permeability, apoptosis, ROS, and NO generation were investigated. For mechanism study, the PI3K/Akt/eNOS pathway, cleaved caspase-3, and bcl-2 were analyzed. Results showed that plasma miR-503 was significantly increased in IS patients, especially in acute period and severe cases and subtypes of LAA and TACI, and was positively correlated with vWF. Logistic analysis indicated that miR-503 was an independent risk factor for IS, with the area under curve of 0.796 in ROC analysis. In MCAO mice, ASS pretreatment aggravated neurological injury, BBB damage, brain edema, CBF reduction, and decreased NO production while increased apoptosis and ROS generation in brain ECs, which were partly abolished by miR-503 antagomir. In cultured ECs, miR-503 overexpression and knockdown confirmed its effects on regulating monolayer permeability, cell apoptosis, NO, and ROS generation via PI3K/Akt/eNOS pathway or bcl-2 and cleaved caspase-3 proteins. These together indicate that miR-503 is a promising biomarker and novel therapeutic target for IS.

Assessment of the manifestations of atrial fibrillation in patients with acute cerebral stroke - a single-center study based on 998 patients

Aim of the Study: Cardioembolic stroke accounts for approximately 15-25% of ischemic strokes and is characterized by a poor prognosis. Atrial fibrillation (AF) is more commonly diagnosed in the elderly.The aim of the study was the assessment of the manifestations of AF in patients hospitalized due to cerebral stroke, with particular attention paid to newly diagnosed AF.Methods: A retrospective analysis was performed on 998 cerebral stroke patients. The data were analyzed for sex, age, cerebral stroke risk factors, drugs, NIHSS, RANKIN scores and ECG recordings on admission and at discharge.Results: The mean age of disease onset was 73 ± 16 years. Women accounted for 50.8% of patients. AF prior to hospital admission was diagnosed in 20.1% of patients, while de novo AF in 26.3% of patients during hospitalization. Hypercholesterolemia, hypertriglyceridemia and smoking were more commonly reported in ischemic stroke patients without AF compared to patients with ischemic stroke and AF. Ischemic heart disease, more frequent deaths, and a worse prognosis were more frequently observed in patients with ischemic stroke and AF compared to patients without AF. The first manifestation of AF in 25% of stroke patients was related to the period of the first 10 days of hospitalization.Discussion: The above data should prompt neurologists, cardiologists and family doctors to try to detect AF as a risk factor for ischemic stroke which worsens patient prognosis, prolongs hospital stay and contributes to increase in mortality, especially when more effective drug treatment is currently possible.

Haemorrhagic transformation following ischaemic stroke: A retrospective study

The aim of this study was to identify the prevalence of haemorrhagic transformation (HT) in patients with ischaemic stroke, and evaluate its association with medical comorbidities, stroke subtypes, premorbid medication, and long-term survival. To achieve this, we performed a retrospective analysis of 527 consecutive stroke rehabilitation patients. Of these, 102 (19.4%) developed HT. Older patients, and those with large artery strokes, had a higher risk of HT. Forty-one patients received alteplase (rtPA), of which 15 (36.6%) developed HT. A total of 129 (24.5%) patients were taking aspirin prior to their stroke and, of these, 39 (30.2%) developed HT. Twenty-three (4.36%) patients were taking vitamin k antagonists, prior to stroke, of which 14 (60.9%) developed HT. There were 102 patients (19.35%) with underlying atrial fibrillation, of whom 55 (53.9%) developed HT. Patients with known ischaemic heart disease had an increased risk of HT, and patients with HT had significantly lower total cholesterol levels (4.96 vs. 5.34) and lower LDL cholesterol levels (3.20 vs. 3.5). In conclusion, older age, atrial fibrillation, treatment with oral anticoagulants and antiplatelet medications prior to stroke, low total and LDL cholesterol, and rtPA use, are all associated with HT. Survival was not affected by the presence of HT.

Nonatrial Fibrillation was Associated With Early Neurological Improvement After Intravenous Thrombolysis With rt-PA in Patients With Acute Ischemic Stroke

BACKGROUND

Intravenous thrombolysis is the only approved pharmacological treatment for acute ischemic stroke (AIS) patients, but the immediate response to thrombolysis varies by patient.

OBJECTIVE

To investigate the factors associated with early neurological improvement (ENI) after the administration of intravenous recombinant tissue plasminogen activator (rt-PA) treatment to AIS patients within 4.5 hours of onset.

METHODS

Demographics, onset to treatment time, risk factors, and clinical and laboratory data of 209 AIS patients undergoing intravenous rt-PA therapy at a Chinese hospital between January 2013 and August 2016 were retrospectively analyzed. The National Institutes of Health Stroke Scale (NIHSS) score was recorded before thrombolytic therapy, 24 hours after the treatment, and 7 days after the treatment to evaluate the recovery of neurological function. ENI was defined as a ≥4-point decrease in NIHSS score compared with baseline or a score of 0 or 1 at 24 hours and 7 days. A multivariate logistic regression analysis was performed to assess the outcomes.

RESULTS

Of the 209 AIS patients treated by intravenous thrombolysis with rt-PA, low-density lipoprotein (LDL) levels were significantly lower (P<0.05) in patients with ENI. The multivariable analysis showed that non-atrial fibrillation (AF) was independently associated with ENI at 24 hours and 7 days after thrombolysis. An overall 40.3% non-AF patients had ENI 24 hours after thrombolysis (odds ratio=2.501, 95% confidence interval: 1.204-5.198; P=0.014), and 65.9% non-AF patients had ENI 7 days after thrombolysis (odds ratio=2.953, 95% confidence interval: 1.434-6.081; P=0.003). Onset to treatment time was an independent predictor (P<0.05) for ENI at 7 days after thrombolysis. The NIHSS score and diastolic blood pressure on admission were associated with symptomatic intracerebral hemorrhagic transformation.

CONCLUSIONS

Non-AF was independently associated with ENI after intravenous thrombolysis in AIS patients, but non-AF was not associated with the occurrence of symptomatic intracerebral hemorrhage. Onset to treatment time was an independent predictor of ENI at 7 days after thrombolysis in AIS patients.

Multiphase MR Angiography Collateral Map: Functional Outcome after Acute Anterior Circulation Ischemic Stroke

Background Collateral circulation determines tissue fate and affects treatment result in acute ischemic stroke. A precise method for collateral estimation in an optimal imaging protocol is necessary to make an appropriate treatment decision for acute ischemic stroke. Purpose To verify the value of multiphase collateral imaging data sets (MR angiography collateral map) derived from dynamic contrast material-enhanced MR angiography for predicting functional outcomes after acute ischemic stroke. Materials and Methods This secondary analysis of an ongoing prospective observational study included data from participants with acute ischemic stroke due to occlusion or stenosis of the unilateral internal carotid artery and/or M1 segment of the middle cerebral artery who were evaluated within 8 hours of symptom onset. Data were obtained from March 2016 through August 2018. The collateral grading based on the MR angiography collateral map was estimated by using six-scale MR acute ischemic stroke collateral (MAC) scores. To identify independent predictors of favorable functional outcomes, age, sex, risk factors, baseline National Institutes of Health Stroke Scale (NIHSS) score, baseline diffusion-weighted imaging (DWI) lesion volume, site of steno-occlusion, collateral grade, mode of treatment, and early reperfusion were evaluated with multiple logistic regression analyses. Results One hundred fifty-four participants (mean age ± standard deviation, 69 years ± 13; 99 men) were evaluated. Younger age (odds ratio [OR], 0.45; 95% confidence interval [CI]: 0.29, 0.70; P < .001), lower baseline NIHSS score (OR, 0.85; 95% CI: 0.78, 0.94; P < .001), MAC score of 3 (OR, 27; 95% CI: 4.0, 179; P < .001), MAC score of 4 (OR, 17; 95% CI: 2.1, 134; P = .007), MAC score of 5 (OR, 27; 95% CI: 2.5, 306; P = .007), and successful early reperfusion (OR, 7.5; 95% CI: 2.6, 22; P < .001) were independently associated with favorable functional outcomes in multivariable analysis. There was a linear negative association between collateral perfusion grades and functional outcomes (P < .001). Conclusion An MR angiography collateral map was clinically reliable for collateral estimation in patients with acute ischemic stroke. This map provided patient-specific pacing information for ischemic progression. © RSNA, 2020.

Chronic Kidney Disease and Outcome Following Endovascular Thrombectomy for Acute Ischemic Stroke

BACKGROUND AND OBJECTIVES

Chronic kidney disease (CKD) is present in 20% to 35% of acute ischemic stroke patients and may increase the risk of poor functional outcome or death. We aimed to determine whether CKD was associated with worse outcome in stroke patients treated with endovascular thrombectomy (EVT).

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

Consecutive EVT patients were identified from a prospective registry and dichotomized into patients with and without CKD, defined as an eGFR of less than 60 mL/min/1.73m². The primary outcome was 3-month mortality following EVT. Secondary outcomes included symptomatic intracerebral hemorrhage (defined by the Safe Implementation of Thrombolysis in Stroke-Monitoring Study), early neurological recovery (defined as change in National Institutes of Health Stroke Scale [NIHSS] score of ≥8 at 24 hours or an NIHSS of 0-1 at 24 hours) and functional independence (defined as a modified Rankin Scale [mRS] score of 0, 1 or 2) at 3 months.

RESULTS

378 EVT patients (223 men; mean ± SD age 65 ± 15 years) were included. The median (IQR) admission eGFR was 71 (58-89) mL/min/1.73 m² and 117 (31%) patients had CKD. Multiple logistic regression adjusted for potential confounders demonstrated that CKD was a significant predictor of lower rates of functional independence (OR = .54, 95% CI, .31 to .90, P = .02), higher mRS scores (common OR = 1.78, 95% CI, 1.14 to 2.81, P = .01), and increased mortality (OR = 2.19, 95% CI, 1.16 to 4.12, P = .01). There was no association between CKD and early neurological recovery (OR = .92, 95% CI, .55 to 1.49, P = .71) or symptomatic intracerebral hemorrhage (OR = 1.18, 95% CI, .38 to 3.69, P = .77).

CONCLUSIONS

CKD was a significant predictor of worse functional outcome and mortality in stroke patients treated with EVT. The presence of CKD should not preclude patients from proceeding to EVT, but may help with prognostication and improve shared decision-making between patients, families and physicians.

Timing of Initiation of Oral Anticoagulation after Acute Ischemic Stroke in Patients with Atrial Fibrillation

Patients with atrial fibrillation (AF) who suffer an acute ischemic stroke are at risk for both hemorrhagic transformation and recurrent ischemic stroke in the acute post-stroke period. Oral anticoagulants are recommended for secondary stroke prevention in patients with AF. The optimal time to initiate anticoagulant therapy after acute ischemic stroke in patients with AF is uncertain. There is concern that early initiation increases the risk of hemorrhagic transformation, whereas delayed initiation leaves the patient at risk for recurrent ischemic stroke. In this article, we provide a review of the risk of hemorrhagic transformation of acute ischemic stroke as well as review the literature and major guidelines addressing the timing of anticoagulation initiation after an acute ischemic stroke in patients with AF. Relevant articles published from 1990 to the present were identified using the PubMed and Embase databases. The majority of available literature is observational data. Large ischemic lesions, cerebral microbleeds, thrombolytic therapy, and other clinical factors may increase the risk of hemorrhagic transformation of an acute ischemic stroke. Parenteral anticoagulation within 48 hours is associated with an increased risk of hemorrhagic transformation and is not recommended. Insufficient data exist to support the safety of routine oral anticoagulant (direct oral anticoagulants or warfarin) initiation within 48 hours of an acute ischemic stroke. Direct oral anticoagulant initiation within 2 days of an acute ischemic stroke is associated with a 5% rate of hemorrhagic transformation. Infarct size and presence of hemorrhage are important factors in identifying the optimal time to initiation and should guide decisions when available. A recommended framework for patient decision making is provided. Randomized controlled trials in this area are needed to identify the optimal timing of anticoagulation initiation, and such trials are under way.

Collateral Circulation and Outcome in Atherosclerotic Versus Cardioembolic Cerebral Large Vessel Occlusion

Supplemental Digital Content is available in the text.

Due to chronic hypoperfusion, cervical atherosclerosis may promote cerebral collateral circulation. We hypothesized that patients with ischemic stroke due to cervical carotid atherosclerosis have a more extensive collateral circulation and better outcomes than patients with cardioembolism. We tested this hypothesis in a population of patients who underwent endovascular treatment for large vessel occlusion.

Interaction of atrial fibrillation and antithrombotics on outcome in intracerebral hemorrhage

OBJECTIVE

To analyze the clinical differences between patients with primary intracerebral hemorrhage (ICH) with and without atrial fibrillation (AF) and assess whether the effect of the antithrombotic pretreatment on outcome is modified by the presence of AF.

METHODS

In this prospective observational study, researchers from 2 university hospitals included 1,106 consecutive patients with ICH. Clinical characteristics were described and stratified by presence of AF. In-hospital and 3-month mortality and 3-month disability were analyzed, considering antithrombotic pretreatment (none, antiplatelets, or oral anticoagulants) and AF (yes/no).

RESULTS

AF was present in 21.9% of primary ICH cases. Patients with AF-ICH were older, with more vascular risk factors, more antithrombotic pretreatment, higher clinical severity, higher hematoma volume, and higher in-hospital and 3-month mortality. Do-not-resuscitate orders were applied more frequently in AF-ICH cases. After 2 different adjustment models, mortality remained significantly higher in patients with AF-ICH. However, after introducing previous antithrombotic treatment in the model, the adjusted odds ratio for 3-month mortality was 1.45 (95% confidence interval 0.74-2.85, p = 0.284) for patients with AF-ICH compared with non-AF cases. AF modified the effect of antithrombotic pretreatment on in-hospital (p _int = 0.077) and 3-month mortality (p _int = 0.008). Among patients without AF, antithrombotic pretreatment increased mortality; no effect was observed in patients with AF-ICH.

CONCLUSIONS

Patients with AF and ICH had increased mortality; however, AF had no independent effect on mortality after adjustment for antithrombotic pretreatment. Conversely, antithrombotic pretreatment had a deleterious effect on outcome in patients with ICH without AF, but no detectable effect in patients with AF with ICH.

Time-dependent infarct volume affects the benefit of recanalization

Objectives

The benefit threshold of infarct volume from recanalization remains unclear. We assumed that the threshold decreased over time, and then investigated the benefit curve of infarct volume during different time periods.

Methods

We reviewed prospectively collected clinical and imaging data from acute ischemic stroke patients with internal carotid artery and M1 occlusion who underwent angiography before and 24 h after reperfusion therapy. Ordinal analyses of modified Rankin Scale scores were performed and curves were fitted.

Results

Of the included 445 patients, the median age was 71 years and 157 (35.3%) were women. The mean time from onset to treatment (OTT) was 248 ± 142 min. The median baseline infarct core volume was 49 (IQR 22–85) ml. Follow-up angiography revealed recanalization in 265 (59.6%) patients. The fitting curves showed that patients with an OTT ≤3 h would benefit from recanalization no matter how large the infarct volume was, whereas patients with an OTT between 3 and 4.5 h and with an infarct volume ≥ 125 ml, and those with an OTT ≥ 4.5 h and with an infarct volume ≥ 80 ml did not benefit from recanalization.

Conclusions

We established a time-dependent benefit threshold of infarct volume from recanalization, and thus suggested to estimate infarct core volume to select patients for reperfusion therapy in those with an OTT beyond 3 h.

•

The benefit of recanalization within 3 h is independent of infarct volume.

•

The benefit threshold of infarct volume decreases over time if beyond 3 h.

•

Infarct volume is recommended to aid in patient selection for reperfusion therapy.

MMP-9-Related microRNAs as Prognostic Markers for Hemorrhagic Transformation in Cardioembolic Stroke Patients

Studies suggest that microRNAs that regulate expression of matrix metalloproteinase (MMP)-9 may be involved in hemorrhagic transformation (HT) after cardioembolic stroke, so we examined whether such microRNAs could predict HT in acute cardioembolic stroke patients. Blood samples were prospectively collected from patients who later experienced HT (n = 29) or did not (n = 29), and the samples were assayed for eight microRNAs identified as related to MMP-9 based on three microRNA databases. Expression levels of these microRNAs were analyzed by quantitative real-time polymerase chain reaction (qRT-PCR) in 28 of the 58 patients, 14 of whom suffered HT and 14 of whom did not. Four differentially expressed miRNAs were identified: hsa-miR-21-5p, hsa-miR-206, hsa-miR-491-5p, and hsa-miR-3123. Subsequent qRT-PCR analysis of these four miRNAs across all 58 patients showed that levels of miR-21-5p, miR-206, and miR-3123 were significantly higher in patients with HT than in those without HT, while expression of miR-491-5p was similar between the two groups. The area under the receiver operating characteristic curve for predicting HT was 0.677 (95% CI 0.535–0.818) for miR-21-5p, 0.687 (95% CI 0.543–0.830) for miR-206, and 0.661 (95% CI 0.512–0.810) for miR-3123. Our results suggest that these three microRNAs may be prognostic markers for HT after cardioembolic stroke, which should be verified by future studies with large samples.

Low-dose statin pretreatment reduces stroke severity and improves functional outcomes

OBJECTIVES

Pre-stroke statin use reduces stroke severity and improves functional outcomes; however, whether low-dose statins as a primary preventive measure have similar effects on the Chinese population remains unclear.

METHODS

Consecutive cases of ischaemic stroke between May 2011 and January 2017 were retrospectively analysed. The primary endpoints were stroke severity on admission and functional outcomes at 90 days. The secondary endpoints were factors related to lower stroke severity on admission. Propensity score matching and logistic regression analyses were performed.

RESULTS

Of the 1878 patients, 6.4% and 23.8% were pre-stroke statin users before and after propensity matching, respectively, reducing the National Institutes of Health Stroke Scale (NIHSS) score on admission from 5 (2-9) to 3 (2-4) (P < 0.001). Patients receiving pretreatment with low-dose statins tended to have a better mRS distribution (median mRS score 2 [1-3] vs. 3 [2-4], P = 0.007) and a higher likelihood of favourable functional outcomes (FFOs) at 90 days (61 [65.6%] vs. 151 [50.8%], P = 0.005). The logistic regression analysis showed that low-dose statins taken before stroke (odds ratio [OR] = 0.15, 95% confidence interval [CI] = 0.08-0.27, P < 0.001) and being male (OR = 0.81, 95% CI = 0.66-0.99, P = 0.035) were related to a lower stroke severity on admission but not among patients with atrial fibrillation (OR = 1.65, 95% CI = 1.12-2.44, P = 0.012) or elevated white blood cell (WBC) counts (OR = 1.12, 95% CI = 1.08-1.17, P < 0.001).

CONCLUSIONS

Pretreatment with low-dose statins reduced initial stroke severity, improved functional outcomes at 90 days and was independently associated with a lower stroke severity on admission among Chinese patients.

Validation of a clinical-genetics score to predict hemorrhagic transformations after rtPA

OBJECTIVE

To validate the Genot-PA score, a clinical-genetic logistic regression score that stratifies the thrombolytic therapy safety, in a new cohort of patients with stroke.

METHODS

We enrolled 1,482 recombinant tissue plasminogen activator (rtPA)-treated patients with stroke in Spain and Finland from 2003 to 2016. Cohorts were analyzed on the basis of ethnicity and therapy: Spanish patients treated with IV rtPA within 4.5 hours of onset (cohort A and B) or rtPA in combination with mechanical thrombectomy within 6 hours of onset (cohort C) and Finnish participants treated with IV rtPA within 4.5 hours of onset (cohort D). The Genot-PA score was calculated, and hemorrhagic transformation (HT) and parenchymal hematoma (PH) risks were determined for each score stratum.

RESULTS

Genot-PA score was tested in 1,324 (cohort A, n = 726; B, n = 334; C, n = 54; and D, n = 210) patients who had enough information to complete the score. Of these, 213 (16.1%) participants developed HT and 85 (6.4%) developed PH. In cohorts A, B, and D, HT occurrence was predicted by the score (p = 2.02 × 10^-6, p = 0.023, p = 0.033); PH prediction was associated in cohorts A through C (p = 0.012, p = 0.034, p = 5.32 × 10^-4). Increased frequency of PH events from the lowest to the highest risk group was found (cohort A 4%-15.7%, cohort B 1.5%-18.2%, cohort C 0%-100%). The best odds ratio for PH prediction in the highest-risk group was obtained in cohort A (odds ratio 5.16, 95% confidence interval 1.46-18.08, p = 0.009).

CONCLUSION

The Genot-PA score predicts HT in patients with stroke treated with IV rtPA. Moreover, in an exploratory study, the score was associated with PH risk in mechanical thrombectomy-treated patients.

Disparities and Temporal Trends in Stroke Care Outcomes in Patients with Atrial Fibrillation: The FLiPER-AF Stroke Study

Background and Purpose

Atrial Fibrillation (AF) is the most common cardiac cause of ischemic stroke. However, the relation between AF and stroke care outcomes in diverse populations is understudied. We aimed to evaluate sex and race-ethnic disparities associated with AF in hospital stroke outcomes utilizing data from the FLorida PuErto Rico Atrial Fibrillation (FLiPER-AF) Stroke Study.

Methods

The study included 104,308 ischemic stroke cases with available information on AF status enrolled in a state-wide stroke registry from 2010 to 2016. Multivariable logistic regression models were performed to evaluate the association between AF and stroke outcomes and the modification effects on the associations by sex and by race-ethnicity, adjusted for socio-demographic status, vascular risk factors and stroke severity.

Results

AF was present in 23% of ischemic stroke cases. AF was associated with worse disability at discharge (OR=1.11, 95% CI, 1.04-1.18), less discharge to home (OR=0.89, 0.85-0.92), and longer length of hospital stay (LOS>6 days, OR=1.53, 1.46-1.60). Interaction analyses showed that the association between AF and less discharge to home was stronger in women than men (p for interaction <0.001), as well as in FL-whites than in FL-blacks, FL-Hispanics or PR-Hispanics (p for interaction=0.002). The association between AF and prolonged LOS was more prominent in PR-Hispanics than in FL-blacks, FL-Hispanics, or FL-whites (p for interaction <0.001). From 2010 to 2016, the effects of AF on hospital length of stay attenuated (p for interaction<0.001).

Conclusions

AF was associated with poor disability at discharge, less discharge to home, and prolonged hospital length of stay for acute stroke care. The effect of AF on length of stay attenuated over time. Sex and race-ethnic disparities were observed in the effect of AF on being less discharge to home and prolonged hospital stay. Further research is needed to identify and modify the biologic and systems of care contributors to these disparities.

Cerebrovascular accidents differ between patients with atrial flutter and patients with atrial fibrillation

INTRODUCTION

Few studies have explored the potential impact of atrial flutter (AFl) on ischaemic stroke (IS) outcome. The aim of the present study was to compare the clinical course of IS in patients with AFl and patients with atrial fibrillation (AF).

MATERIAL AND METHODS

A retrospective analysis of patients consecutively admitted to a tertiary care centre between 2013 and 2015 due to IS or transient ischaemic attack with permanent AFl or permanent or persistent AF was performed.

RESULTS

The study groups consisted of 528 patients, including 490 (92.8%) patients with AF and 38 (7.2%) patients with AFl. The mean age and prestroke CHA2DS2-VASc scores were similar between the patients with AFl and those with AF. Most IS cases in the AF group were classified as cardioembolic strokes (74.9% vs. 39.5% in AFl, p < 0.01), and lacunar strokes were the most common in the AFl group (47.4% vs. 14.3% in AF, p < 0.01). The multivariable analysis revealed that the presence of AF (OR = 8.6, 95% CI: 1.2-57, p = 0.02), lacunar stroke (OR = 0.1, 95% CI: 0.03-0.31, p < 0.001), baseline Rankin scale score (OR = 16.6, 95% CI: 9.8-28), lack of prestroke therapeutic anticoagulation (OR = 6.1, 95% CI: 1.1-33), diabetes (OR = 2.9, 95% CI: 1.3-6.5, p < 0.01), chronic heart failure (OR = 14.2, 95% CI: 5.8-34, p < 0.001), and current smoking (OR = 0.92, 95% CI: 0.39-0.99, p < 0.01) were significantly associated with the stroke outcome.

CONCLUSIONS

Disabling or fatal IS was observed less often in patients with AFl than in patients with AF. This finding can possibly be explained by the more frequent occurrence of lacunar strokes in the AFl group compared with that in the AF group.

[Association of atrial fibrillation with hemorrhagic transformation after intravenous thrombolysis in patients with ischemic stroke]

OBJECTIVE

To investigate the association of atrial fibrillation (AF) with hemorrhagic transformation (HT) in patients with ischemic stroke treated by intravenous thrombolysis.

METHODS

Clinical data of 3272 patients treated by intravenous thrombolysis from 71 hospitals in Zhejiang Province during June 2017 and December 2018 were retrospectively reviewed. Intracranial HT was defined as intracranial hemorrhage suggested by imaging examination 24 hours after intravenous thrombolysis. Patients were dichotomized into HT group (n=533) and non-HT group (n=2739). The association of AF and HT was analyzed by univariate analysis and binary logistic regression.

RESULTS

Compared with the non-HT group, the HT group were older, had longer onset to needle time (ONT), higher baseline National Institute of Health Stroke Scale (NIHSS) score, higher baseline glucose level, and higher AF rate (P<0.05 or P<0.01). Binary logistic regression analysis revealed that AF was independently associated with HT (OR=2.527, 95%CI:2.030-3.146, P<0.01).

CONCLUSIONS

AF is independently associated with the occurrence of HT in ischemic stroke patients treated with intravenous thrombolysis.

Influencing factors of hemorrhagic transformation in non-thrombolysis patients with cerebral infarction

OBJECTIVES

Hemorrhagic transformation (HT) is a serious complication of acute cerebral infarction. The aim of study is to investigate the influencing factors of HT in non-thrombolysis patients with acute cerebral infarction, and to explore its clinical significance.

PATIENTS AND METHODS

From June 2016 to March 2017, a total of 346 non-thrombolysis patients with acute cerebral infarction hospitalized in the Department of Neurology of Guangdong Second Provincial General Hospital, were chosen and randomly devided into the non-HT group (control) and HT group. A record of 17 indices including the patients'age, gender, hypertension, diabetes, dyslipidemia, hyperhomocystinemia, atrial fibrillation, drinking or smoking, anticoagulation, antithrombosis, international normalized ratio (INR) and platelet count were measured. Then regression analysis was made to find the independent factors for HT.

RESULTS

It was found that 38 of non-thrombolysis patients with acute cerebral infarction involved in this study were with HT. The indices including dyslipidemia, drinking, atrial fibrillation, antiplatelet aggregation, anticoagulation, INR > 1.7, cholesterin, triglyceride and platelet count showed statistical differences between the HT group and the non-HT group (P < 0.05). According to the binary logistic regression analysis, there was a negative correlation between dyslipidemia and HT (odds ratio (OR)=0.371, 95% confidence interval (CI) 0.186-0.740, P = 0.005), while there was a positive correlation between atrial fibrillation (OR=2.476, 95% CI 1.140-5.377, P=0.022), platelet count (OR=1.006, 95% CI 0.682-1.611, P = 0.007), INR>1.7 (OR=10.889, 95% CI 4.760-24.910, P = 0.000) and HT.

CONCLUSION

There is independent correlation between dyslipidemia, atrial fibrillation, platelet count, INR > 1.7 and HT. Dyslipidemia is the protective factor for HT, and atrial fibrillation, platelet count, INR > 1.7 are the risk factors for HT.

Glomerular Filtration Rate is Associated with Hemorrhagic Transformation in Acute Ischemic Stroke Patients without Thrombolytic Therapy

Background:

Whether there is a relationship between glomerular filtration rate (GFR) and hemorrhagic transformation (HT) after acute ischemic stroke (AIS) is still under debate. The aim of our study was to determine whether the GFR level is a predictor of HT in AIS patients without thrombolytic therapy (TT).

Methods:

Consecutive AIS patients without TT were included in this prospective study from January 2014 to December 2016 in the First Affiliated Hospital of Chongqing Medical University. We divided them into two groups (HT and non-HT group) and meticulously collected baseline characteristics and laboratory and imaging data of interested individuals. Multivariate regression analysis was performed to assess the correlation between GFR and HT in stroke patients without TT.

Results:

Among 426 consecutive patients, 74 (17.3%) presented HT (mean age: 65 ± 12 years, number of male patients: 47) on the follow-up scans. In multivariate regression analysis, HT was significantly associated with low GFR (odds ratio [OR] = 3.708, confidence interval [CI] = 1.326–10.693, P = 0.013), atrial fibrillation (AF; OR = 2.444, CI = 1.087–5.356, P = 0.027), large cerebral infarction (OR = 2.583, CI = 1.236–5.262, P = 0.010), and hypoalbuminemia (HA; OR = 4.814, CI = 1.054–22.153, P = 0.037) for AIS patients without TT.

Conclusions:

The present study strongly showed that lower GFR is an independently predictor of HT; in addition, large infarct volume, AF, and HA are also important risks of HT for AIS patients without TT, which offered a practical information that risk factors should be paid attention or eliminated to prevent HT for stroke patients though the level of evidence seems to be unstable.

Management of acute ischemic stroke, thrombolysis rate, and predictors of clinical outcome

BACKGROUND AND AIMS

Monitoring the quality of acute ischemic stroke (AIS) management is increasingly important since patient outcome could be improved with better access to evidence-based treatments. In this scenario, the aim of our study was to identify thrombolysis rate, reasons for undertreatment, and factors associated with better outcome.

METHODS

From January to December 2016, individuals diagnosed with AIS at the Policlinic San Martino Hospital in Genoa, Italy, were prospectively included. Severity of stroke, site of occlusion, rate and time related in-hospital management of systemic thrombolysis, and mechanical thrombectomy were recorded. Safety and clinical outcomes were compared between different subgroups.

RESULTS

Of 459 AIS patients (57.3% females, mean age 78.1), 111 received i.v. thrombolysis (24.4%) and 50 received mechanical thrombectomy (10.9%). Apart from arrival behind the therapeutic window, which was the first limitation to thrombolysis, the main reason of undertreatment was minor stroke or stroke in rapid improvement. Baseline NIHSS ≥ 8 was associated with unfavorable clinical outcome (mRS > 2) (OR 20.1; 95% CI, 1.1-387.4, p = 0.047). Age older than 80 years (OR 5.0; 95% CI, 1.4-64.1, p = 0.01), baseline NIHSS ≥ 7 (OR 20.1; 95% CI, 1.1-387.4, p = 0.047), and symptomatic intracranial hemorrhage (OR 22.9; 95% CI, 2.0-254.2, p = 0.01) proved independently associated with mortality.

CONCLUSIONS

i.v. thrombolysis and mechanical thrombectomy rate was higher than that of previous reports. Minor stroke or stroke in rapid improvement was a major reason for exclusion from thrombolysis of eligible patients. Higher NIHSS proved an independent predictor of unfavorable clinical outcome and death. Strategies to avoid in-hospital delays need to be enforced.

Sex Differences in Stroke Incidence in a Portuguese Community-Based Study

BACKGROUND AND AIM

Stroke is a major health problem. Several studies reported sex differences regarding stroke. We aim to study this issue in an incidence stroke study.

METHODS

Data were retrieved from a community-based prospective register of patients that had a first ever stroke in a life time between October 2009 and September 2011. We studied sex differences regarding demographic data, vascular risk factors, stroke type, stroke severity (NIHSS), disability at 28days (modified Rankin scale (mRS)), and case fatality at 30 and 90days.

RESULTS

From 720 stroke patients, 45.3% were men. Women were older (75.0 ± 13.6 versus 67.2 ± 14.9 years), had a worse premorbid mRS (39.3% versus 25.5%, P < .001), and a higher prevalence of hypertension (P = .004) and atrial fibrillation (P < .001). Previous myocardial infarction was more frequent in men (P = .001), as well as smoking habits (P < .001). Ischemic stroke was more common in women than men (87.6% versus 81.3%, P = .038). The 28 days' outcome was worse in women (mRS ≥ 2, 77.2% versus 70.6%, P = .044). No differences were found in initial stroke severity (median NIHSS = 4) and case fatality at 30 and 90days, after adjusting for age and premorbid mRS.

CONCLUSION

No differences were found in stroke initial severity and mortality at 30 and 90days between men and women, despite the sex differences pertaining to the stroke profile-age, vascular risk factors, stroke type, and outcome. Our results are somewhat discrepant from those described in the literature; more research is needed to understand if this may be due to changes in stroke standard of care.

Safety of Recanalization Therapy in Patients with Acute Ischemic Stroke Under Anticoagulation: A Systematic Review and Meta-Analysis

BACKGROUND

Intravenous thrombolysis treatment (IVT) and endovascular therapy (EVT) have been proved as fist-line beneficial option for eligible patients who have acute ischemic stroke (AIS) with major safety concern of symptomatic intracranial hemorrhage (sICH). Unfortunately, the emergency management of patients with AIS taking vitamin K antagonists and with international normalized ratio higher than 1.7 or taking new oral anticoagulants (NOACs) represents a great challenge. We aim to comprehensively determine the safety of EVT in patients under prior-stroke anticoagulants and IVT in patients under NOAC use.

METHODS

Clinical researches published in the Embase, PubMed, and Cochrane Library electronic databases up to December 2017 were identified for analysis. Subgroup and sensitivity analyses were also conducted to evaluate the robustness of the conclusions.

RESULTS

Overall, 9 studies involving 3885 patients met the inclusion criteria. The rate of sICH (risk ratio [RR] = .94, 95% CI = .61-1.47, P = .799), mortality (P = .495), and recanalization (P = .655) after EVT did not differ between patients under and those who were not under anticoagulants, although patients under anticoagulants were less likely to achieve good functional outcome (P < .001) than those who were not. Moreover, prior NOAC therapy was not significantly associated with increasing sICH in patients with AIS after IVT (RR = .79, 95% CI = .41-1.53, P = .492).

CONCLUSIONS

Patients under anticoagulation appear to be safe after EVT with relatively lower rate of good outcome; furthermore, prior NOAC therapy was not associated with an increasing sICH rate after IVT. This offered a practical information to select appropriate therapeutic strategies for patients under anticoagulation, although the level of evidence seems to be quite shaky.

The JAGUAR Score Predicts 1-Month Disability/Death in Ischemic Stroke Patient Ineligible for Recanalization Therapy

BACKGROUND AND PURPOSE

Most available scoring system to predict outcome after acute ischemic stroke (AIS) were established in Western countries. We aimed to develop a simple prediction score of 1-month severe disability/death after onset in AIS patients ineligible for recanalization therapy based on readily and widely obtainable on-admission clinical, laboratory and radiological examinations in Asian developing countries.

METHODS

Using the Shiga Stroke Registry, a large population-based registry in Japan, multivariable logistic regression analysis was conducted in 1617 AIS patients ineligible for recanalization therapy to yield ß-coefficients of significant predictors of 1-month modified Rankin Scale score of 5-6, which were then multiplied by a specific constant and rounded to nearest integer to develop 0-10 points system. Model discrimination and calibration were evaluated in the original and bootstrapped population.

RESULTS

Japan Coma Scale score (J), age (A), random glucose (G), untimely onset-to-arrival time (U), atrial fibrillation (A), and preadmission dependency status according to the modified Rankin Scale score (R), were recognized as independent predictors of outcome. Each of their β-coefficients was multiplied by 1.3 creating the JAGUAR score. Its area under the curve (95% confidence interval) was .901 (.880- .922) and .901 (.900- .901) in the original and bootstrapped population, respectively. It was found to have good calibration in both study population (P = .27).

CONCLUSIONS

The JAGUAR score can be an important prediction tool of severe disability/death in AIS patients ineligible for recanalization therapy that can be applied on admission with no complicated calculation and multimodal neuroimaging necessary, thus suitable for Asian developing countries.

Presence of multi-segment clot sign on dynamic CT angiography: a predictive imaging marker of recanalisation and good outcome in acute ischaemic stroke patients

OBJECTIVE

To investigate the value of multi-segment clot (MSC) sign on dynamic CT angiography (CTA) in predicting recanalisation and outcome after reperfusion therapy in acute ischaemic stroke (AIS) with large artery occlusion (LAO).

METHODS

We retrospectively reviewed data of anterior circulation LAO patients from a prospectively collected database for consecutive AIS patients who underwent perfusion CT (CTP) before treatment. MSC sign was defined as the presence of multiple segments on dynamic CTA derived from CTP data. Good outcome was defined as modified Rankin score 0-3 at 90 days.

RESULTS

A total of 181 LAO patients were enrolled. MSC sign was present in 73 (40.3%) patients. When compared with patients without MSC sign, patients with MSC sign had a significantly higher rate of recanalisation (76.7% versus 56.5%, p = 0.005) and good outcome (67.1% versus 51.0%, p = 0.035). Multivariable logistic regression analyses showed that MSC sign was an independent predictor for both recanalisation (OR [95% CI] = 2.237 [1.069-4.681]; p = 0.033) and good outcome (OR [95% CI] = 2.715 [1.154-6.388]; p = 0.022) after adjustment.

CONCLUSIONS

The MSC sign is a good indicator for recanalisation and good outcome after reperfusion therapy in anterior circulation LAO patients.

KEY POINTS

• MSC sign was present in about 40% acute anterior circulation LAO patients. • MSC sign is a predictor for recanalisation after reperfusion treatment. • Patients with MSC sign have a better outcome.

The complexity of atrial fibrillation newly diagnosed after ischemic stroke and transient ischemic attack: advances and uncertainties

Purpose of review

Atrial fibrillation is being increasingly diagnosed after ischemic stroke and transient ischemic attack (TIA). Patient characteristics, frequency and duration of paroxysms, and the risk of recurrent ischemic stroke associated with atrial fibrillation detected after stroke and TIA (AFDAS) may differ from atrial fibrillation already known before stroke occurrence. We aim to summarize major recent advances in the field, in the context of prior evidence, and to identify areas of uncertainty to be addressed in future research.

Recent findings

Half of all atrial fibrillations in ischemic stroke and TIA patients are AFDAS, and most of them are asymptomatic. Over 50% of AFDAS paroxysms last less than 30 s. The rapid initiation of cardiac monitoring and its duration are crucial for its timely and effective detection. AFDAS comprises a heterogeneous mix of atrial fibrillation, possibly including cardiogenic and neurogenic types, and a mix of both. Over 25 single markers and at least 10 scores have been proposed as predictors of AFDAS. However, there are considerable inconsistencies across studies. The role of AFDAS burden and its associated risk of stroke recurrence have not yet been investigated.

Summary

AFDAS may differ from atrial fibrillation known before stroke in several clinical dimensions, which are important for optimal patient care strategies. Many questions remain unanswered. Neurogenic and cardiogenic AFDAS need to be characterized, as it may be possible to avoid some neurogenic cases by initiating timely preventive treatments. AFDAS burden may differ in ischemic stroke and TIA patients, with distinctive diagnostic and treatment implications. The prognosis of AFDAS and its risk of recurrent stroke are still unknown; therefore, it is uncertain whether AFDAS patients should be treated with oral anticoagulants.

Treatment of atrial fibrillation in nursing homes: A place for direct acting oral anticoagulants?

Atrial fibrillation affects ~1 in 6 long-term nursing home residents. After an ischemic stroke hospitalization, ~2/3 of nursing home residents receive skilled nursing care and functional independence continues to decline, a process often complicated by rehospitalization and stroke recurrence. Due to advanced age and multimorbidity, anticoagulation is indicated for essentially all nursing home residents with atrial fibrillation. Yet as the severity of cognitive and/or functional deficits increases, the net clinical benefit of anticoagulation becomes less certain. Therefore, nursing home residents are most likely to be in need of supportive clinical evidence regarding anticoagulation, but least likely to have risk/benefit information from trials. Approximately half of US nursing home residents with atrial fibrillation have been treated with warfarin historically. Trial evidence in ambulatory older adults supports a large relative risk reduction (~50%) for stroke with warfarin versus aspirin and generally comparable bleeding risk. However, nursing home residents have a complex confluence of multimorbidity and polypharmacy that distinguishes them from healthier, non-institutionalized trial populations. Exemplifying this distinction, maintaining nursing home residents treated with warfarin within the therapeutic range has been a challenge historically, increasing the risk of adverse events. The direct acting oral anticoagulants may be a preferred therapeutic option for an indeterminate fraction of nursing home residents with atrial fibrillation. A review of the literature on anticoagulant use in nursing homes underscores the need for evidence on the effectiveness and safety of the direct acting oral anticoagulants specific to clinically complex older adults.

Frequency and determinants for hemorrhagic transformation of posterior cerebral stroke : Posterior ischemic stroke and hemorrhagic transformation

BACKGROUND

hemorrhagic transformation is a threatening ischemic stroke complication. Frequency of hemorrhagic transformation differs greatly among studies, and its risk factors have been usually studied in patients with anterior ischemic stroke who received thrombolytic therapy. We evaluated, in a hospital-based series of patients with posterior ischemic stroke not treated with thrombolysis, frequency and risk factors of hemorrhagic transformation. Patients with posterior circulation stroke were seen in our Department during the period January 2004 to December 2009. Demographic and clinical information were collected. We estimated risk for spontaneous hemorrhagic transformation by means of uni- and multivariate logistic regression analyses.

RESULTS

119 consecutive patients were included (73 males, 61.3%). Hemorrhagic transformation was observed in 7 patients (5.9%). Only clinical worsening was significantly associated with hemorrhagic transformation (OR 6.8, 95% CI 1.3-34.5).

CONCLUSIONS

Our findings indicate that patients with posterior have a low risk of spontaneous hemorrhagic transformation, suggesting that these patients might have greater advantage from intravenous thrombolysis.

Comparing the economic burden of ischemic stroke patients with and without atrial fibrillation: a retrospective study in Beijing, China

BACKGROUND

Little is known about the economic burden for ischemic stroke (IS) patients with atrial fibrillation (AF) in China.

AIM

We aimed to compare the economic burden of treatment-related costs in IS patients with AF vs. without AF in China.

METHODS

This retrospective analysis used economic burden data from the Beijing urban health insurance database. Using a random sampling method, 10% of the patients diagnosed with IS from 1 January through 31 December 2012 were enrolled. First hospitalization was considered as the index event and hospital utilization after the index event was followed up until September 2013. Overall healthcare cost during the study period was analyzed.

RESULTS

In 4061 patients with IS (mean ± SD age, 68.45 ± 13.95 years; AF: 992; without AF: 3069), the AF group had a higher percentage of patients with co-morbidities at baseline. Compared with the non-AF group, the AF group had significantly greater hospitalization at the index event (p < .001). Overall inpatient cost per patient during the observational period (Renminbi (RMB) 141,875.9 ± 121,071.8 vs. RMB 53,834.03 ± 63,535.72, in 2012 terms), total healthcare cost per patient (RMB 163,550.4 ± 131,103.5 vs. RMB 64,735.41 ± 67,584.95), total healthcare cost covered by health insurance, and annualized total healthcare cost per patient were higher in the AF group than in the non-AF group (p < .001). Treatment costs were significantly associated with old age, male gender, AF, and frequency of outpatient visits and hospitalization.

CONCLUSIONS

AF increased the use of healthcare resources, treatment cost, and economic burden in patients with IS. Therefore, prevention of cardio-embolic events in patients with AF by anticoagulants may decrease the economic burden in patients with IS.

Shared decision making for stroke prevention in atrial fibrillation: study protocol for a randomized controlled trial

Background

Nonvalvular atrial fibrillation (AF) is a common ongoing health problem that places patients at risk of stroke. Whether and how a patient addresses this risk depends on each patient’s goals, context, and values. Consequently, leading cardiovascular societies recommend using shared decision making (SDM) to individualize antithrombotic treatment in patients with AF. The aim of this study is to assess the extent to which the Anticoagulation Choice conversation tool promotes high-quality SDM and influences anticoagulation uptake and adherence in patients with AF at risk of strokes.

Methods

This study protocol describes a multicenter, encounter-level, randomized trial to assess the effect of using the Anticoagulation Choice conversation tool in the clinical encounter, compared to usual care. The participating centers include an academic hospital system, a suburban community group practice, and an urban safety net hospital, all in Minnesota, USA. Patients with ongoing nonvalvular AF at risk of strokes (CHA₂DS₂-VASc score ≥ 1 in men, or ≥ 2 in women) will be eligible for participation. We aim to include 999 patients and their clinicians. The primary outcome is the quality of SDM as perceived by participants, and as assessed by a post-encounter survey that ascertains (a) knowledge transfer, (b) concordance of the decision made, (c) quality of communication, and (d) satisfaction with the decision-making process. Recordings of encounters will be reviewed to assess the extent of patient involvement and how participants use the tool (fidelity). Anticoagulant use, choice of agent, and adherence will be drawn from patients’ medical and pharmacy records. Strokes and bleeding events will be drawn from patient records.

Discussion

This study will provide a valid and precise measure of the effect of the Anticoagulation Choice conversation tool on SDM quality and processes, and on the treatment choices and adherence to therapy among AF patients at risk of stroke.

Trial registration

ClinicalTrials.gov, NCT02905032. Registered on 9 September 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2178-y) contains supplementary material, which is available to authorized users.

Recanalisation therapy in patients with acute ischaemic stroke caused by large artery occlusion: choice of therapeutic strategy according to underlying aetiological mechanism?

Various mechanisms underlie causative large artery occlusion (LAO) in patients with acute ischaemic stroke. Cardioembolic and atherosclerotic occlusions are the two most common types. The pathophysiological changes and responses to mechanical thrombectomy (MT) and antithrombotic treatments including thrombolysis, antiplatelet and anticoagulation therapy may vary among patients with different aetiological mechanisms of occlusion. Atherosclerotic occlusion is inclined to have relatively abundant collaterals and larger area of penumbra, hence a relatively wider time window for reperfusion therapy, while poor response to medical thrombolysis and MT. Severe residual stenosis and reocclusion occurred frequently after MT in atherosclerotic LAO. Angioplasty and stenting as rescue or the first-line therapy and more intensified antiplatelet therapy beyond related recommendations in the current guidelines are sometimes used in managing acute causative LAO because of poor recanalisation after recommended standard thrombolysis or MT therapy, which are usually based on individual experience. Standard protocol to establish emergent aetiological diagnosis of causative LAO and individualised aetiology-specific treatment strategy is needed.

Sex Differences in Outcomes among Stroke Survivors with Non-Valvular Atrial Fibrillation in China

Atrial fibrillation (AF) significantly increases the risk of stroke and disease burden and is an established predictor of poor outcomes after stroke. However, data regarding sex differences in long-term outcomes following stroke in patients with AF are scarce. We thus aimed to assess these differences. We recruited 951 consecutive patients with acute ischemic stroke and non-valvular atrial fibrillation (NVAF) treated at three hospitals in Tianjin, China, from January 2006 to September 2014. Information regarding stroke subtype, severity, risk factors, and outcomes (mortality, dependency, and recurrence) at 3, 12, and 36 months after stroke was recorded. The prevalence of NVAF was 8.4% overall, with a higher frequency in women than in men (11.3 vs. 6.9%, P < 0.001). Among patients with NVAF, women were older than men. Women were more likely than men to have severe stroke (38.8 vs. 29.5%, P < 0.001), high levels of total cholesterol and high- and low-density lipoprotein cholesterol (all P < 0.001), hypertension (69.1 vs. 61.2%, P = 0.012), dyslipidemia (29.8 vs. 20.7%, P = 0.001), and obesity (18.5 vs. 11.6%, P = 0.003); they were less likely than men to be current smokers (12.2 vs. 33.6%, P < 0.001) and to consume alcohol (0.9 vs. 13.9%, P < 0.001). There were greater risks of dependency and recurrence at 36 months after stroke in women than in men [odds ratios (95% confidence intervals), 1.64 (1.02–2.64) for dependency, P = 0.043; and 2.03 (1.28–3.20) for recurrence, P = 0.002] after adjustment for stroke subtype, severity, and risk factors. These findings suggest that it is crucial to emphasize the need for individualized stroke prevention education and promotion of healthy lifestyles in order to improve NVAF-related stroke outcomes and reduce disease burden in women.

Tachycardia as a Negative Prognostic Factor for Stroke Outcome

INTRODUCTION

The outcome of stroke, especially lethal one is significant, as in the hemorrhagic as well as in ischemic stroke.

GOAL

was to show the impact on the stroke outcome of tachycardia correlated with lesion localization.

MATERIAL AND METHODS

Material for our work was patients who were treated due to the stroke at the Neurology Clinic Sarajevo in the period from 31 March 2015 until 01 January 2016. A total of 544 stoke patients were treated in the reporting period, 221 (44.6%) died. There were 70.9% patients with ischemic and 29.1% with hemorrhagic stroke. Each patient underwent ECG, which registered tachycardia during admission and on third day of hospitalization.

RESULTS

In relation to the presence of tachycardia on admission there were statistically significant differences in the group of patients with hemorrhage and ischemia in relation to presence of tachycardia (p <0.01). In the group of patients with hemorrhage coma was more present (78.9%), while tachycardia was statistically more often in those with loss of consciousness than in the group with coma. Group of patients with ischemia has 52.75% of the patients with tachycardia without statistical correlation between the presence and absence of disorders of consciousness. Midline lesions were statistically more often associated with paroxysmal tachycardia in relation to the lateral lesions (p <0.01). Statistical analysis shows that there are statistically significant differences between observed groups χ2=35.576, p=0.0001. Lethal outcome of hemorrhagic stroke was 55.45%, 32.6% for ischemia. A significant statistical significance of ischemic and hemorrhagic stroke compared to the lethal outcome correlated with the registered tachycardia and medial lesion localization.

CONCLUSION

Tachycardia on admission in patients with stroke is a relevant negative predictor for stroke outcome. Medial localization of changes significantly affects the occurrence of tachycardia and lethal outcome of stroke which is statistically significantly more associated with hemorrhagic stroke.

Decision-making interventions to stop the global atrial fibrillation-related stroke tsunami

Atrial fibrillation affects 33.5 million people worldwide and its prevalence is expected to double by 2050 because of the aging population. Atrial fibrillation confers a 5-fold higher risk of ischemic stroke compared to sinus rhythm. We present our view of the role of shared medical decision-making to combat global underutilization of oral anticoagulation for stroke prevention in atrial fibrillation patients. Oral anticoagulation underuse is widespread as it is present within atrial fibrillation patients of all risk strata and in countries across all income levels. Reasons for oral anticoagulation underuse include but are probably not limited to poor risk stratification, over-interpretation of contraindications, and discordance between physician prescription preferences and actual administration. By comparing a catastrophic event to the consequences of atrial fibrillation related strokes, it may help physicians and patients understand the negative outcomes associated with oral anticoagulation under-utilization and the magnitude to which oral anticoagulations neutralize atrial fibrillation burden.

Holter-electrocardiogram-monitoring in patients with acute ischaemic stroke (Find-AFRANDOMISED): an open-label randomised controlled trial

BACKGROUND

Atrial fibrillation is a major risk factor for recurrent ischaemic stroke, but often remains undiagnosed in patients who have had an acute ischaemic stroke. Enhanced and prolonged Holter-electrocardiogram-monitoring might increase detection of atrial fibrillation. We therefore investigated whether enhanced and prolonged rhythm monitoring was better for detection of atrial fibrillation than standard care procedures in patients with acute ischaemic stroke.

METHODS

Find-AF_randomised is an open-label randomised study done at four centres in Germany. We recruited patients with acute ischaemic stroke (symptoms for 7 days or less) aged 60 years or older presenting with sinus rhythm and without history of atrial fibrillation. Patients were included irrespective of the suspected cause of stroke, unless they had a severe ipsilateral carotid or intracranial artery stenosis, which were the exclusion criteria. We used a computer-generated allocation sequence to randomly assign patients in a 1:1 ratio with permuted block sizes of 2, 4, 6, and 8, stratified by centre, to enhanced and prolonged monitoring (ie, 10-day Holter-electrocardiogram [ECG]-monitoring at baseline, and at 3 months and 6 months of follow-up) or standard care procedures (ie, at least 24 h of rhythm monitoring). Participants and study physicians were not masked to group assignment, but the expert committees that adjudicated endpoints were. The primary endpoint was the occurrence of atrial fibrillation or atrial flutter (30 sec or longer) within 6 months after randomisation and before stroke recurrence. Because Holter ECG is a widely used procedure and not known to harm patients, we chose not to assess safety in detail. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01855035.

FINDINGS

Between May 8, 2013, and Aug 31, 2014, we recruited 398 patients. 200 patients were randomly assigned to the enhanced and prolonged monitoring group and 198 to the standard care group. After 6 months, we detected atrial fibrillation in 14% of 200 patients in the enhanced and prolonged monitoring group (27 patients) versus 5% in the control group (nine of 198 patients, absolute difference 9·0%; 95% CI 3·4-14·5, p=0·002; number needed to screen 11).

INTERPRETATION

Enhanced and prolonged monitoring initiated early in patients with acute ischaemic stroke aged 60 years or older was better than standard care for the detection of atrial fibrillation. These findings support the consideration of all patients aged 60 years or older with stroke for prolonged monitoring if the detection of atrial fibrillation would result in a change in medical management (eg, initiation of anticoagulation).

FUNDING

Boehringer Ingelheim.

Outcomes and costs of left atrial appendage closure from randomized controlled trial and real-world experience relative to oral anticoagulation

AIMS

The aim of this study was to analyse randomized controlled study and real-world outcomes of patients with non-valvular atrial fibrillation (NVAF) undergoing left atrial appendage closure (LAAC) with the Watchman device and to compare costs with available antithrombotic therapies.

METHODS AND RESULTS

Registry data of LAAC from two centres were prospectively collected from 110 patients with NVAF at risk of stroke, suitable and unsuitable for long-term anticoagulation (age 71.3 ± 9.2 years, CHADS2 2.8 ± 1.2, CHA2DS2-VASc 4.5 ± 1.6, and HAS-BLED 3.8 ± 1.1). Outcomes from PROTECT AF and registry study LAAC were compared with warfarin, dabigatran, rivaroxaban, apixaban, aspirin, and no treatment using a network meta-analysis. Costs were estimated over a 10-year horizon. Uncertainty was assessed using sensitivity analyses. The procedural success rate was 92% (103/112). Follow-up was 24.1 ± 4.6 months, during which annual rates of stroke, major bleeding, and all-cause mortality were 0.9% (2/223 patient-years), 0.9% (2/223 patient-years), and 1.8% (4/223 patient-years), respectively. Anticoagulant therapy was successfully stopped in 91.2% (93/102) of implanted patients by 12 months. Registry study LAAC stroke and major bleeding rates were significantly lower than PROTECT AF results: mean absolute difference of stroke, 0.89% (P = 0.02) and major bleeding, 5.48% (P < 0.001). Left atrial appendage closure achieved cost parity between 4.9 years vs. dabigatran 110 mg and 8.4 years vs. warfarin. At 10 years, LAAC was cost-saving against all therapies (range £1162-£7194).

CONCLUSION

Left atrial appendage closure in NVAF in a real-world setting may result in lower stroke and major bleeding rates than reported in LAAC clinical trials. Left atrial appendage closure in both settings achieves cost parity in a relatively short period of time and may offer substantial savings compared with current therapies. Savings are most pronounced among higher risk patients and those unsuitable for anticoagulation.

Atrial Fibrillation Is Associated With a Worse 90-Day Outcome Than Other Cardioembolic Stroke Subtypes

BACKGROUND AND PURPOSE

Patients with a cardioembolic stroke (CES) have worse outcomes than stroke patients with other causes of stroke. Among patients with CES, atrial fibrillation (AF) is a common comorbidity. Mounting data indicate that AF may be related to stroke pathogenesis beyond acute cerebral thromboembolism. We sought to determine whether AF represents an independent risk factor for stroke severity and outcome among patients with CES.

METHODS

We retrospectively analyzed patients with acute hemispheric CES included in an academic medical center's stroke registry. CES was determined using the Causative Classification System of ischemic stroke. Multivariable logistic regression was used to determine whether AF was associated with 90-day outcome functional status.

RESULTS

Our cohort included 140 patients. Of these, 52 had prevalent AF and 28 had incident AF diagnosed during their index hospitalization or within 90 days of hospital discharge. After adjustment for potential confounders or mediators, any AF (odds ratio, 2.51; 95% confidence interval, 1.03-6.33; P=0.049), infarct volume (odds ratio, 1.03; 95% confidence interval, 1.01-1.06; P=0.005), preadmission modified Rankin Scale score (odds ratio, 2.58; 95% confidence interval, 1.66-4.01; P<0.001), and admission National Institutes of Health Stroke Scale score (odds ratio, 1.17; 95% confidence interval, 1.08-1.28; P<0.001) remained associated with an unfavorable 90-day outcome (modified Rankin Scale score, 2-6).

CONCLUSIONS

AF is associated with an unfavorable 90-day outcome among patients with a CES independent of established risk factors and initial stroke severity. This suggests that AF-specific mechanisms affect CES severity and functional status after CES. If confirmed in future studies, further investigation into the underlying pathophysiological mechanisms may provide novel avenues to AF detection and treatment.

Atrial Fibrillation is Associated With Poor Outcomes in Thrombolyzed Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

The influence of atrial fibrillation (AF) on the clinical outcomes of patients with ischemic stroke (IS) has not been completely determined. We aimed to perform a systematic review and meta-analysis to assess the relationship between AF and adverse events in patients with acute IS treated with thrombolysis.PubMed, EMBASE, and the Cochrane Library were searched for relevant studies regarding the association between AF and the outcomes of patients with IS treated with thrombolysis. Random and fixed effect models were used for pooling data.Twelve cohort studies involving 14,801 patients with acute IS were included. Meta-analysis revealed that patients with AF were more likely to die within 90 days after thrombolysis (odds ratio [OR], 2.13; 95% confidence interval [CI]: 1.68-2.70, P < 0.001), whereas this association was not observed in hospitalized patients (OR, 1.50; 95% CI, 0.86-2.60; P = 0.150). AF was associated with a reduced incidence of favorable outcomes (modified Rankin Scale ≤ 2) (OR, 1.95; 95% CI: 1.33-2.85, P = 0.001) and an increased risk of symptomatic intracerebral hemorrhage (OR, 1.28; 95% CI: 1.08-1.52, P = 0.006). No evident publication bias was found by Begg's test or Egger's test.Comorbidity of AF may increase the risk of adverse outcomes for patients with IS undergoing thrombolysis. Further well-designed trials are warranted to confirm this association.

Thrombolytic-Related Asymptomatic Hemorrhagic Transformation Does Not Deteriorate Clinical Outcome: Data from TIMS in China

OBJECTIVE

It has been unclear whether thrombolytic-related asymptomatic hemorrhagic transformation (AHT) affects the clinical outcome. To answer this question, we examined whether thrombolytic-related AHT affect short-term and long-term clinical outcome.

METHODS

All data were collected from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) registry. The patients were diagnosed as having AHT group and non- hemorrhagic transformation (HT) group based on clinical and imaging data. The patients with symptomatic hemorrhagic transformation were excluded from this study. Thrombolytic-related AHT was defined according to European-Australasian Acute Stroke Study (ECASS) II criteria. 90-day functional outcome, 7-day National Institutes of Health Stroke Scale (NIHSS) score, 7-day and 90-day mortalities were compared between two groups. Logistic regression analysis was used to evaluate the effects of AHT on a short-term and long-term clinical outcome.

RESULTS

904 of all 1440 patients in TIMS-China registry were enrolled. 89 (9.6%) patients presented with AHT after thrombolysis within 24-36 h. These patients with AHT were more likely to be elder age, cardioembolic subtype, and to have higher National Institutes of Health Stroke Scale score before thrombolysis than patients without AHT. No significant difference was found on the odds of 7-day (95% CI:0.692 (0.218-2.195), (P = 0.532) or 90-day mortalities (95% CI:0.548 (0.237-1.268), P = 0.160) and modified Rankin Score(0-1) at 90-day (95% CI:0.798 (0.460-1.386), P = 0.423) or modified Rankin Score(0-2) at 90-day (95% CI:0.732 (0.429-1.253), P = 0.116) or modified Rankin Score(5-6) at 90-day (95% CI:0.375 (0.169-1.830), P = 0.116) between two groups.

CONCLUSIONS

Thrombolytic-related AHT does not deteriorate short-term and long-term clinical outcome.

Hemorrhagic transformation after cerebral infarction: current concepts and challenges

Hemorrhagic transformation (HT) is a frequent complication of acute ischemic stroke that is especially common after thrombolytic therapy. The risk of HT limits the applicability of tissue plasminogen activator (tPA). Here, we sought to review the rate, classification, predictors, possible mechanism, and clinical outcomes of HT, as well as existing therapeutic approaches, in order to call attention to the current challenges in the treatment of this complication.