The stroke prognosis instrument II (SPI-II) : A clinical prediction instrument for patients with transient ischemia and nondisabling ischemic stroke

Validating and comparing stroke prognosis scales

Objective:

To compare the prognostic accuracy of various acute stroke prognostic scales using a large, independent, clinical trials dataset.

Methods:

We directly compared 8 stroke prognostic scales, chosen based on focused literature review (Acute Stroke Registry and Analysis of Lausanne [ASTRAL]; iSCORE; iSCORE-revised; preadmission comorbidities, level of consciousness, age, and neurologic deficit [PLAN]; stroke subtype, Oxfordshire Community Stroke Project, age, and prestroke modified Rankin Scale [mRS] [SOAR]; modified SOAR; Stroke Prognosis Instrument 2 [SPI2]; and Totaled Health Risks in Vascular Events [THRIVE]) using individual patient-level data from a clinical trials archive (Virtual International Stroke Trials Archive [VISTA]). We calculated area under receiver operating characteristic curves (AUROC) for each scale against 90-day outcomes of mRS (dichotomized at mRS >2), Barthel Index (>85), and mortality. We performed 2 complementary analyses: the first limited to patients with complete data for all components of all scales (simultaneous) and the second using as many patients as possible for each individual scale (separate). We compared AUROCs and performed sensitivity analyses substituting extreme outcome values for missing data.

Results:

In total, 10,777 patients contributed to the analyses. Our simultaneous analyses suggested that ASTRAL had greatest prognostic accuracy for mRS, AUROC 0.78 (95% confidence interval [CI] 0.75–0.82), and SPI2 had poorest AUROC, 0.61 (95% CI 0.57–0.66). Our separate analyses confirmed these results: ASTRAL AUROC 0.79 (95% CI 0.78–0.80 and SPI2 AUROC 0.60 (95% CI 0.59–0.61). On formal comparative testing, there was a significant difference in modified Rankin Scale AUROC between ASTRAL and all other scales. Sensitivity analysis identified no evidence of systematic bias from missing data.

Conclusions:

Our comparative analyses confirm differences in the prognostic accuracy of stroke scales. However, even the best performing scale had prognostic accuracy that may not be sufficient as a basis for clinical decision-making.

Early risk of recurrent stroke in patients with symptomatic carotid near-occlusion: Results from CAOS, a multicenter registry study

Background

The risk of recurrent stroke among patients with symptomatic carotid near-occlusion is not well established, and management of the condition remains controversial. Symptomatic carotid near-occlusion with full collapse has been identified as a strong predictor of early recurrence. We aimed to analyze the 90-day risk of recurrent ipsilateral ischemic stroke in medically treated patients with symptomatic carotid near-occlusion.

Methods

We performed a multicenter, nationwide, prospective study from January 2010 to May 2016. Patients with angiography-confirmed symptomatic carotid near-occlusion were included. The primary endpoint was ipsilateral ischemic stroke or transient ischemic attack (TIA) within 90 days after the presenting event. For this analysis, patients who underwent revascularization within 90 days after stroke were excluded.

Results

The study population comprised 141 patients from 17 Spanish centers; 83 patients were treated medically. Primary endpoint occurred in eight patients, resulting in a cumulative rate of 10.6% (95% CI, 3.7–17.5). Previous history of stroke or transient ischemic attack was identified as an independent predictor for recurrence in the multivariate Cox regression analysis (HR, 4.37 [95% CI, 1.05–18.18]; p = 0.043), while the presence of full collapse was not associated with an increased risk (HR, 0.81 [95% CI, 0.17–3.92]; p = 0.793). The risk of recurrence was also not affected by the presence of significant stenosis or occlusion of the contralateral carotid artery, or by the collateral circulation.

Conclusions

Patients with symptomatic carotid near-occlusion seem to have an increased risk of early ipsilateral recurrent stroke. Our results contrast with the low risk of symptomatic carotid near-occlusion reported to date. Full collapse did not increase the risk of recurrent stroke in our study.

GRECOS Project (Genotyping Recurrence Risk of Stroke): The Use of Genetics to Predict the Vascular Recurrence After Stroke

BACKGROUND AND PURPOSE

Vascular recurrence occurs in 11% of patients during the first year after ischemic stroke (IS) or transient ischemic attack. Clinical scores do not predict the whole vascular recurrence risk; therefore, we aimed to find genetic variants associated with recurrence that might improve the clinical predictive models in IS.

METHODS

We analyzed 256 polymorphisms from 115 candidate genes in 3 patient cohorts comprising 4482 IS or transient ischemic attack patients. The discovery cohort was prospectively recruited and included 1494 patients, 6.2% of them developed a new IS during the first year of follow-up. Replication analysis was performed in 2988 patients using SNPlex or HumanOmni1-Quad technology. We generated a predictive model using Cox regression (GRECOS score [Genotyping Reurrence Risk of Stroke]) and generated risk groups using a classification tree method.

RESULTS

The analyses revealed that rs1800801 in the MGP gene (hazard ratio, 1.33; P=9×10^-03), a gene related to artery calcification, was associated with new IS during the first year of follow-up. This polymorphism was replicated in a Spanish cohort (n=1.305); however, it was not significantly associated in a North American cohort (n=1.683). The GRECOS score predicted new IS (P=3.2×10^-09) and could classify patients, from low risk of stroke recurrence (1.9%) to high risk (12.6%). Moreover, the addition of genetic risk factors to the GRECOS score improves the prediction compared with previous Stroke Prognosis Instrument-II score (P=0.03).

CONCLUSIONS

The use of genetics could be useful to estimate vascular recurrence risk after IS. Genetic variability in the MGP gene was associated with vascular recurrence in the Spanish population.

Stroke minimization through additive anti-atherosclerotic agents in routine treatment (SMAART): A pilot trial concept for improving stroke outcomes in sub-Saharan Africa

There has been an unprecedented rise in the prevalence of stroke in sub-Saharan Africa (SSA), which when compared to stroke profiles in high-income countries (HIC) is characterized by a younger age of onset, higher case fatality rates, and more severe disability among survivors. Stroke survivors in SSA (vs. HIC) are especially at high risk for recurrent vascular events or death due to undiagnosed or under-controlled vascular risk factors, logistical challenges, low health literacy, and lack of care affordability. While international expert consensus secondary prevention guidelines recommend that antihypertensive, statin and anti-platelet therapy, be initiated promptly after ischemic stroke and adhered to in a persistent fashion to achieve optimal vascular risk reduction, these goals are seldom realized in routine clinical care settings in SSA. A relatively simple, low-cost, evidence-based strategy that could be largely applied in a uniform manner to stroke survivors in low-to-middle income countries (LMICs), including the nations of SSA, is sorely needed. Fixed-dose combination pills, also known "polypills", containing generic drugs, i.e. Aspirin, a statin, and blood pressure (BP) lowering medication(s) may be a viable avenue to improve medication adherence and consequently reduce risk of further disability or death on a large scale among stroke survivors encountered in resource-constrained regions. In this conceptual article, we review the data supporting the rationale for a polypill to improve stroke outcomes in SSA and propose the conduct of a Stroke Minimization through Additive Anti-atherosclerotic Agent in Routine Treatment (SMAART) pilot study to determine the impact of a polypill such as the Polycap DS® in reducing future vascular risk compared to usual care in recent stroke in SSA. A preliminarily feasible and efficacy-suggesting SMAART trial could inform the future design of a multi-center, double-blinded, placebo-controlled, randomized trial comparing the clinical efficacy of the polypill strategy for vascular risk moderation among stroke survivors in LMICs.

Short-term pilot feasibility study of a nurse-led intervention to improve blood pressure control after stroke in Nigeria

BACKGROUND

Given the paucity of neurologists in Sub-Saharan Africa (SSA), task-shifting post-stroke care to nurses could be a viable avenue for enhancing post-stroke outcomes. This pilot study assessed the feasibility and short-term impact of a nurse-led intervention to manage blood pressure (BP) control in recent stroke survivors in Nigeria.

METHODS

A randomized pilot trial allocated patients within one month of an index stroke from two participating hospitals in Nigeria to either nurse-led group clinic or standard care for 14days. Key study endpoints were successful execution of the protocol, subject retention, and short-term BP effects.

RESULTS

There were no significant differences between the intervention (n=17) and control (n=18) groups at baseline. At the post-intervention clinic, patient retention rate was 100%. In the intervention group, both the systolic and diastolic BPs measured at home were lower than the clinic BPs post-intervention (127±12.88/78.13±19.26mmHg versus 137.50±23.05/84.06±9.67mmHg; p=0.05). However, there was no significant change in clinic blood pressure (BP) recordings in both the intervention and control groups.

CONCLUSION

It is possible to initiate a nurse-led group clinic intervention to address BP management among stroke survivors in SSA with good early retention of participants. A larger and longer-term trial is being planned.

Prognosis and Management in the First Few Days after a Transient Ischemic Attack or Minor Ischaemic Stroke

The risk of recurrent stroke during the first few days after a transient ischaemic attack (TIA) or minor stroke is very much higher than previously estimated. However, there is considerable international variation in how patients with suspected TIA or minor stroke are managed in the acute phase, some healthcare systems providing immediate emergency inpatient care and others providing non-emergency outpatient clinic assessment. This review considers what is known about the early prognosis after TIA and minor ischaemic stroke, what factors identify individuals at particularly high early risk of stroke, and what evidence there is that urgent preventive treatment is likely to be effective in reducing the early risk of stroke.

Treatment Effect of Clopidogrel Plus Aspirin Within 12 Hours of Acute Minor Stroke or Transient Ischemic Attack

Background

The aim of this study was to analyze the benefits and safety associated with the combination therapy of clopidogrel and aspirin among minor stroke or transient ischemic attack patients treated within 12 hours.

Methods and Results

This was a subanalysis of the CHANCE (Clopidogrel in High‐Risk Patients with Acute Nondisabling Cerebrovascular Events) trial, mainly limited to the prespecified group of patients randomized within 12 hours to either the combination of clopidogrel plus aspirin or aspirin alone. The primary outcome was ischemic stroke during 90‐day follow‐up. Recurrent ischemic stroke and progressive ischemic stroke were analyzed. Multivariable Cox modeling showed that randomization within 12 hours was an independent predictor of ischemic stroke events (hazard ratio [95% CI] 1.25 [1.04–1.49], P=0.02). Among 2573 patients randomized within 12 hours, 282 (10.96%) patients had ischemic stroke events. Among them, 158 (12.34%) of 1280 patients taking aspirin experienced ischemic stroke compared with 124 (9.59%) of 1293 patients taking clopidogrel–aspirin (P=0.02). The dual antiplatelet was more effective than aspirin alone in reducing the risk of recurrent ischemic stroke (6.57% versus 8.91%, P=0.03) but not progressive ischemic stroke (3.02% versus 3.43%, P=0.28). There was no significant difference in hemorrhagic events (P=0.39).

Conclusions

Among patients treated within 12 hours, the combination of clopidogrel and aspirin was more effective than aspirin alone in reducing the risk of recurrent ischemic stroke during the 90‐day follow‐up and did not increase the hemorrhagic risk.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00979589.

Exercise Induces Peripheral Muscle But Not Cardiac Adaptations After Stroke: A Randomized Controlled Pilot Trial

Objective

To explore the physiological factors affecting exercise-induced changes in peak oxygen consumption and function poststroke.

Design

Single-center, single-blind, randomized controlled pilot trial.

Setting

Community stroke services.

Participants

Adults (N=40; age>50y; independent with/without stick) with stroke (diagnosed >6mo previously) were recruited from 117 eligible participants. Twenty participants were randomized to the intervention group and 20 to the control group. No dropouts or adverse events were reported.

Interventions

Intervention group: 19-week (3times/wk) progressive mixed (aerobic/strength/balance/flexibility) community group exercise program. Control group: Matched duration home stretching program.

Main Outcome Measures

(1) Pre- and postintervention: maximal cardiopulmonary exercise testing with noninvasive (bioreactance) cardiac output measurements; and (2) functional outcome measures: 6-minute walk test; timed Up and Go test, and Berg Balance Scale.

Results

Exercise improved peak oxygen consumption (18±5 to 21±5mL/(kg⋅min); P<.01) and peak arterial-venous oxygen difference (9.2±2.7 to 11.4±2.9mL of O₂/100mL of blood; P<.01), but did not alter cardiac output (17.2±4 to 17.7±4.2L/min; P=.44) or cardiac power output (4.8±1.3 to 5.0±1.35W; P=.45). A significant relation existed between change in peak oxygen consumption and change in peak arterial-venous oxygen difference (r=.507; P<.05), but not with cardiac output. Change in peak oxygen consumption did not strongly correlate with change in function.

Conclusions

Exercise induced peripheral muscle, but not cardiac output, adaptations after stroke. Implications for stroke clinical care should be explored further in a broader cohort.

Prediction of myocardial infarction in patients with transient ischaemic attack

BACKGROUND

Determinants of risk of myocardial infarction (MI) after transient ischaemic attack (TIA) are not well defined. The aim of our study was to determine the risk and risk factors for MI after TIA.

METHODS

We prospectively recruited patients within 24 h of transient ischaemic cerebrovascular events between October 2006 and January 2013. A total of 628 TIA patients were followed for six months or more. MI and stroke recurrence (SR) were recorded. The duration and typology of clinical symptoms, vascular risk factors and aetiological work-ups were prospectively recorded and established prognostic scores (ABCD2, ABCD2I, ABCD3I, Essen Stroke Risk Score, California Risk Score and Stroke Prognosis Instrument) were calculated.

RESULTS

Twenty-eight (4.5%) MI and 68 (11.0%) recurrent strokes occurred during a median follow-up period of 31.2 months (16.1-44.9). In Cox proportional hazards multivariate analyses, we identify previous coronary heart disease (CHD) (hazard ratio [HR] 5.65, 95% confidence interval [CI] 2.45-13.04, P < 0.001) and sex male (HR 2.72, 95% CI 1.02-7.30, P = 0.046) as independent predictors of MI. Discrimination for the prognostic scores only ranged from 0.60 to 0.71. The incidence of MI did not vary among the different aetiological subtypes. Positive diffusion weighted imaging (DWI) (7.5% vs 2.5%, P = 0.007), and ECG abnormalities (Q wave or ST-T wave changes) (13.6% vs 3.6%, P = 0.001) were associated to MI.

CONCLUSION

According to our results, discrimination was poor for all previous risk prediction models evaluated. Variables such as previous CHD, male sex, DWI and ECG abnormalities should be considered in new prediction models.

Tackling the growing diabetes burden in Sub-Saharan Africa: a framework for enhancing outcomes in stroke patients

According to the World Health Organization (WHO), more than 80% of worldwide diabetes (DM)-related deaths presently occur in low- and middle-income countries (LMIC), and left unchecked these DM-related deaths will likely double over the next 20 years. Cardiovascular disease (CVD) is the most prevalent and detrimental complication of DM: doubling the risk of CVD events (including stroke) and accounting for up to 80% of DM-related deaths. Given the aforementioned, interventions targeted at reducing CVD risk among people with DM are integral to limiting DM-related morbidity and mortality in LMIC, a majority of which are located in Sub-Saharan Africa (SSA). However, SSA is contextually unique: socioeconomic obstacles, cultural barriers, under-diagnosis, uncoordinated care, and shortage of physicians currently limit the capacity of SSA countries to implement CVD prevention among people with DM in a timely and sustainable manner. This article proposes a theory-based framework for conceptualizing integrated protocol-driven risk factor patient self-management interventions that could be adopted or adapted in future studies among hospitalized stroke patients with DM encountered in SSA. These interventions include systematic health education at hospital discharge, use of post-discharge trained community lay navigators, implementation of nurse-led group clinics and administration of health technology (personalized phone text messaging and home tele-monitoring), all aimed at increasing patient self-efficacy and intrinsic motivation for sustained adherence to therapies proven to reduce CVD event risk.

Phone-based intervention under nurse guidance after stroke: concept for lowering blood pressure after stroke in Sub-Saharan Africa

Over the last 4 decades, rates of stroke occurrence in low- and middle-income countries (LMIC) have roughly doubled, whereas they have substantively decreased in high-income countries. Most of these LMIC are in Sub-Saharan Africa (SSA) where the burden of stroke will probably continue to rise over the next few decades because of an ongoing epidemiologic transition. Moreover, SSA is circumstantially distinct: socioeconomic obstacles, cultural barriers, underdiagnosis, uncoordinated care, and shortage of physicians impede the ability of SSA countries to implement cardiovascular disease prevention among people with diabetes mellitus in a timely and sustainable manner. Reducing the burden of stroke in SSA may necessitate an initial emphasis on high-risk individuals motivated to improve their health, multidisciplinary care coordination initiatives with clinical decision support, evidence-based interventions tailored for cultural relevance, task shifting from physicians to nurses and other health providers, use of novel patient-accessible tools, and a multilevel approach that incorporates individual- and system-level components. This article proposes a theory-based integrated blood pressure (BP) self-management intervention called Phone-based Intervention under Nurse Guidance after Stroke (PINGS) that could be tested among hospitalized stroke patients with poorly controlled hypertension encountered in SSA. PINGS would comprise the implementation of nurse-run BP control clinics and administration of health technology (personalized phone text messaging and home telemonitoring), aimed at boosting patient self-efficacy and intrinsic motivation for sustained adherence to antihypertensive medications.

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

BACKGROUND

Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment.

OBJECTIVES

Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention?

DATA SOURCES

Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion.

REVIEW METHODS

Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios.

RESULTS

The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective.

LIMITATIONS

Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity.

CONCLUSIONS

Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Formal and informal prediction of recurrent stroke and myocardial infarction after stroke: a systematic review and evaluation of clinical prediction models in a new cohort

BACKGROUND

The objective of this study was to: (1) systematically review the reporting and methods used in the development of clinical prediction models for recurrent stroke or myocardial infarction (MI) after ischemic stroke; (2) to meta-analyze their external performance; and (3) to compare clinical prediction models to informal clinicians' prediction in the Edinburgh Stroke Study (ESS).

METHODS

We searched Medline, EMBASE, reference lists and forward citations of relevant articles from 1980 to 19 April 2013. We included articles which developed multivariable clinical prediction models for the prediction of recurrent stroke and/or MI following ischemic stroke. We extracted information to assess aspects of model development as well as metrics of performance to determine predictive ability. Model quality was assessed against a pre-defined set of criteria. We used random-effects meta-analysis to pool performance metrics.

RESULTS

We identified twelve model development studies and eleven evaluation studies. Investigators often did not report effective sample size, regression coefficients, handling of missing data; typically categorized continuous predictors; and used data dependent methods to build models. A meta-analysis of the area under the receiver operating characteristic curve (AUROCC) was possible for the Essen Stroke Risk Score (ESRS) and for the Stroke Prognosis Instrument II (SPI-II); the pooled AUROCCs were 0.60 (95% CI 0.59 to 0.62) and 0.62 (95% CI 0.60 to 0.64), respectively. An evaluation among minor stroke patients in the ESS demonstrated that clinicians discriminated poorly between those with and those without recurrent events and that this was similar to clinical prediction models.

CONCLUSIONS

The available models for recurrent stroke discriminate poorly between patients with and without a recurrent stroke or MI after stroke. Models had a similar discrimination to informal clinicians' predictions. Formal prediction may be improved by addressing commonly encountered methodological problems.

The need for emergency treatment of transient ischemic attack and minor stroke

The risk of recurrent stroke following transient ischemic attack or minor stroke has recently been shown to be 5-10% at 1 week and 10-20% at 3 months, depending on study population and methods. This is considerably higher than previously estimated and current clinical guidelines reflect the need for rapid assessment although a wide variation in practice exists. Effective management of patients with transient ischemic attack or minor stroke, therefore, requires identification of individuals at the highest (and lowest) risk and initiation of appropriate secondary prevention. Risk can be stratified at initial presentation by the presence or absence of simple clinical features and following subsequent investigation. For transient ischemic attack patients, older age, diabetes, longer duration of symptoms and weakness or speech disturbance identify patients at highest risk, as does the presence of large artery atherosclerosis (mainly internal carotid artery stenosis) and lesions on diffusion-weighted magnetic resonance imaging. Strong evidence exists for the benefit of some early interventions (carotid endarterectomy and antiplatelet agents), but is circumstantial or awaited for others (statins and antihypertensives). In order for the public health challenge posed by transient ischemic attack and minor stroke to be met, considerable change is required in both public education (to ensure correct recognition of symptoms and swift presentation to medical attention) and the provision of clinical services to ensure the timely initiation of effective treatment.

Prediction and prevention of stroke after transient ischemic attack in the short and long term

Over the last 5 years, a number of studies have shown the early risk of stroke following transient ischemic attack (TIA) to be of the order of 5-10% at 1 week and 10-20% at 3 months, considerably higher than previously estimated. Because these studies have been carried out in a variety of different clinical settings, their findings are likely to be generalizable. Various independent prognostic factors for this early risk of stroke have been identified and models, based on clinical features at presentation, have been derived and validated to predict risk of stroke within 7 and 90 days after TIA. At the same time, diffusion-weighted magnetic resonance imaging and carotid imaging provide prognostic information and are likely to refine risk prediction further, although no unified model combining clinical and imaging data currently exists. Uncertainty continues surrounding the most effective secondary prevention in the hyperacute phase after TIA, especially in the choice of antiplatelet agents, although clinical trials to address this question are ongoing. However, the need for carotid endarterectomy in patients with symptomatic carotid stenosis is well established. The risk of vascular disease in the medium term (1-5 years) following TIA has been more widely studied, and predictive models for this are available. Recent data on the long-term (10 years and beyond) vascular risk after TIA demonstrate ongoing mortality from both cerebrovascular and cardiovascular causes, highlighting the need for continued secondary prevention.

What’s new in stroke prevention and treatment

This review summarizes the latest results and developments in stroke prevention and acute treatment studies published in 2004 and 2005. In contrast to primary prevention in men, aspirin did not significantly reduce the risk of myocardial infarction or death from cardiovascular causes in women over 45 years of age. Patients with symptomatic intracranial stenosis do not benefit from secondary prevention with oral anticoagulation. Magnetic resonance-based acute stroke studies with recombinant tissue plasminogen activator (rtPA) or with desmoteplase, a new thrombolytic agent, showed similar safety and potential benefit beyond the 3-h time window, as with the established inclusion criteria of rtPA. The surgical trial in intracerebral hemorrhage (STICH) failed to demonstrate any benefit for early operative evacuation of hematoma. The authors aim to provide a wide overview of stroke prevention and acute treatment studies published in 2004 and 2005. Relevant journals were hand-searched to compile a broad, but not comprehensive, summary of innovative and clinically relevant findings. A short critical evaluation at the end of selected reviews should encourage the reader to further reading of studies of interest.

Predictors of depressive symptoms among community-dwelling stroke survivors

BACKGROUND

Depression is a common yet often unrecognized consequence of stroke, affecting between 25% and 70% of all survivors. Untreated depression post-stroke leads to a poorer prognosis and increased mortality. However, the pattern and profile of post-stroke depression in chronic stroke are poorly understood.

OBJECTIVE

The aim of this study was to examine the independent predictors of depressive symptoms in chronic stroke.

METHODS

Community-dwelling stroke survivors (n = 100) completed the Center for Epidemiological Studies-Depression (CES-D) scale, Multidimensional Scale of Perceived Social Support, Medical Outcomes Study Short Form-36, and the Pittsburgh Sleep Quality Index. Functional disability and cognitive impairment were assessed using standardized procedures. Multiple linear regression was conducted to explore potential independent predictors of depressive symptoms.

RESULTS

Subjects were, on average, 70 ± 10 years old and 39 ± 49 months post-stroke. The majority were white/European-American (78%), college educated (79%), and retirees (77%). Annual income was $50 000 or greater for 32%. Hemiparesis was common (right side, 39%; left side, 42%); 35% had a Center for Epidemiological Studies-Depression scale score of 16 or higher, and 21% had a history of major depression. Approximately 64% of the variance in depressive symptoms could be explained by the independent variables in the model: quality of life, sleep quality, social support, cognitive impairment, functional disability, months post-stroke, age, gender, history of major depression, and lesion location (R = 0.64, F12,87 = 12.97, P < .01). Only poor quality of life (t1,87 = -6.99, P < .01) and low social support (t1,87 = -2.14, P = .04) contributed uniquely and significantly to the severity of depressive symptoms among these stroke survivors.

CONCLUSION

Depressive symptoms are prevalent in chronic stroke survivors, even among an educated and economically advantaged population. Our findings are similar to reports by others that poor quality of life and low social support are major contributors to depressive symptoms in chronic stroke and should be routinely assessed and monitored to improve long-term rehabilitation efforts and promote wellness and community reintegration.

The Addition of MRI to CT Based Stroke and TIA Evaluation Does Not Impact One year Outcomes

Background:

The 2010 American Academy of Neurology guideline for the diagnosis of acute ischemic stroke recommends MRI with diffusion weighted imaging (DWI) over noncontrast head CT. No studies have evaluated the influence of imaging choice on patient outcome. We sought to evaluate the variables that influenced one-year outcomes of stroke and TIA patients, including the type of imaging utilized.

Methods:

Patients were identified from a prospectively collected stroke and TIA database at a single primary stroke center during a one-year period. Data were abstracted from patient electronic medical records. The primary outcome measure was death, myocardial infarction, or recurrent stroke within the following year. Secondary outcome measures included predictors of getting an MRI study.

Results:

727 consecutive patients with a discharge diagnosis of stroke or TIA were identified (616 and 111 respectively); 536 had CT and MRI, 161 had CT alone, 29 had MRI alone, and one had no neuroimaging. On multiple logistic regression analysis, there were no differences in primary or secondary outcome measures among different imaging strategies. Predictors of the primary outcome measure included age and NIHSS, while performance of a CT angiogram (CTA) predicted a decreased odds of death, stroke, or MI. The strongest predictor of having an MRI was admission to a stroke unit.

Conclusions:

These results suggest that long-term (one-year) patient outcomes may not be influenced by imaging strategy. Performance of a CTA was protective in this cohort. A randomized trial of different imaging modalities should be considered.

Risk modeling to identify patients with symptomatic carotid stenosis most at risk of stroke

We have reliable data on the degree of stenosis above which endarterectomy for symptomatic carotid stenosis is beneficial, but benefit is also influenced by other factors, particularly age, sex, the timing of surgery, plaque surface morphology and the nature of the presenting symptomatic event(s). This review will consider the selection of patients for carotid surgery based on the factors that influence the likely risk of stroke on medical treatment. In order to take into account all of the relevant factors, a risk prediction model is considered.

High-sensitivity troponin assay improves prediction of cardiovascular risk in patients with cerebral ischaemia

BACKGROUND AND PURPOSE

Clinical scores are recommended for predicting cardiovascular risk in patients with cerebral ischaemia to inform secondary prevention. Blood biomarkers may improve prediction beyond clinical scores.

METHODS

Within the observational Find-AF trial (ISRCTN46104198), 197 patients >18 years of age with cerebral ischaemia and without atrial fibrillation had blood sampled at baseline. The predictive value of five biomarkers for a combined vascular endpoint (acute coronary syndrome, stroke, cardiovascular death) and all-cause mortality was determined, alone and in addition to the Essen Stroke Risk Score (ESRS), Stroke Prognostic Instrument 2 (SPI-2) and National Institutes of Health Stroke Scale (NIH-SS).

RESULTS

There were 23 vascular events (11.7%) and 13 deaths (6.6%) to 1 year follow-up. In multivariate analyses of all markers, only high-sensitivity troponin T (hsTropT) remained independently predictive for vascular events (p=0.045) and all-cause mortality (p=0.004). hsTropT was higher in patients with a vascular event (median 12.7 ng/ml vs 5.1 ng/ml), and patients with hsTropT above the median of 6.15 ng/ml had vascular events more frequently (HR 3.86, p=0.008). For prediction of vascular events as well as all-cause mortality, hsTropT significantly improved multivariate Cox regression models with ESRS, SPI-2 or NIH-SS. The c-statistic increased non-significantly from 0.695 (ESRS) or 0.710 (hsTropT) to 0.747 (ESRS+hsTropT) and from 0.699 (SPI-2) to 0.763 (SPI-2+hsTropT). No patient with a low-risk ESRS and an hsTropT below the median had a vascular event or died.

CONCLUSIONS

hsTropT predicts vascular events and all-cause mortality in patients with acute cerebral ischaemia and improves prediction beyond established clinical scores.

Transcranial Doppler ultrasound to assess cerebrovascular reactivity: reliability, reproducibility and effect of posture

Transcranial Doppler ultrasound (TCD) allows measurement of blood flow velocities in the intracranial vessels, and can be used to assess cerebral vasodilator responses to a hypercapnic stimulus. The reliability of this technique has not been established, nor is there agreement about whether the technique should be performed in sitting or lying postures. We tested the intra- and inter-rater reliability of measures of cerebrovascular reactivity (CVR) in 10 healthy adults, in sitting and lying postures. Participants underwent triplicate bilateral ultrasound assessment of flow velocities in the middle cerebral arteries whilst sitting and lying supine prior to and during inhalation of Carbogen (5% CO2, 95% O2) for 2 min. This procedure was performed twice by each of two raters for a total of four sessions. CVR was calculated as the difference between baseline and the peak blood flow velocity attained during CO2 inhalation. Intraclass correlation coefficients (ICCs) for intra-rater reliability were greater sitting than lying for both raters (e.g. Rater 1 ICC sitting = 0.822, lying = 0.734), and inter-rater reliability was also greater in sitting (e.g. sitting ICC = 0.504, lying = 0.081). These results suggest that assessment of CVR using TCD should be performed with participants sitting in order to maximise CVR measurement reliability.

Evaluation of the ESRS and SPI-II scales for short-term prognosis of minor stroke and transient ischemic attack

BACKGROUND AND PURPOSE

Rapid evaluation of stroke risk following an initial stroke may improve patient outcome, especially in cases of minor stroke. We investigated the validity of the Essen stroke risk score (ESRS) and stroke prognosis instrument II (SPI-II) scales for predicting the short-term risk of minor stroke and transient ischemic attack (TIA) in the clinic.

METHODS

One hundred and sixty-seven patients with minor stroke or TIA were enrolled in this study. The recurrent ischemic events were recorded within 90 days after the initial onset and the curve of cumulative survival rate was calculated to observe the recurrence risk. The prognostic value of the ESRS and SPI-II scales for recurrence risk were evaluated by calculating the area under receiver operating characteristic (ROC) curve.

RESULTS

The total recurrence rate of ischemic events within 90 days was 12.57% while the recurrence rate was 7.78% in the first week after onset. Remarkable change was observed on the curve of cumulative survival rate during the acute phase of stroke. The area under the ROC curve of the ESRS scale was 0.677 (95% CI: 0.557-0.797) compared to 0.553 (95% CI: 0.413-0.694) of the SPI-II scale.

CONCLUSION

The ESRS and SPI-II scales can be used as screening tools to evaluate the short-term risk for recurrent events of minor stroke and TIA. Importantly, the ESRS was more suitable for predicting the short-term risk of stroke in the clinic.

The role of MRI as a prognostic tool in ischemic stroke

Magnetic resonance imaging (MRI) is an invaluable tool used in the diagnosis of ischemic stroke. Ongoing technological advances in MRI technology and advent of new imaging sequences has now made it possible to use MRI as a prognostic tool both in the acute and chronic stages of cerebral ischemia. This review summarizes the role of MRI in estimating final tissue outcome, specifically by providing information on severity and location of ischemic insult, cerebral blood flow dynamics, vascular status, and cerebral reserve. All of these predictions can then be used to make projections regarding clinical outcome, and can be refined by other prognostic models to estimate recovery and risk of further ischemic events. These algorithms, in the end, can ultimately help the clinician in tailoring therapies on an individual basis and optimize the risk-benefit ratio of therapeutic approaches used in the acute and chronic stages of ischemic stroke. The implementation of such prognostic algorithms to clinical imaging workstations and calculation of all the possible projections within minutes after completion of imaging are likely to become an integral part of clinical practice in the near future.

Analysis of multiple risk factors for the recurrence of nondisabling stroke

BACKGROUND

Recurrent stroke is one of severe outcomes of transient ischemic attack (TIA) and minor ischemic stroke (MIS), which are collectively termed as nondisabling stroke. However, the association between multiple risk factors and nondisabling stroke has not been fully studied. Here, we aimed to identify predicative risk factors in TIA and MIS in order to prevent recurrent nondisabling stroke.

METHODS

We used logistic regression methods to analysis risk factors in 620 patients with TIA or MIS between August 2006 and january 2009 and followed up to 90 days. We selected 20 factors, including age, gender, body mass index (BMI), smoking and alcohol history, blood pressure, limb weakness, speech impairment, diabetes, ischemic brain lesions, previous history of stroke (> 24 hours), coronary atherosclerotic heart disease, cardiac function insufficiency, duration of symptoms of at least 1 hour, blood lipids, lysophosphatidic acid, C-reactive protein, atrial fibrillation, and carotid artery plaque in ultrasound examination.

RESULTS

We found that limb weakness, history of cerebrovascular events, and carotid artery plaque in ultrasound examination were risk factors of recurrent stroke within 14 days, whereas the factors for the recurrence within 90 days were duration of symptoms of at least 1 hour, speech impairment, limb weakness, BMI of at least 25 kg/m2, history of cerebrovascular events, and carotid artery plaque in ultrasound examination.

CONCLUSION

Six risk factors are associated with recurrent nondisabling stroke, including symptom duration of at least 1 hour, speech impairment, limb weakness, BMI of at least 25 kg/m2, history of cerebrovascular events, and carotid artery plaque in ultrasound examination. Thus, identification and prevention of these risk factors may reduce recurrent stroke.

Assessment of ABCD² scale in patients with transient ischaemic attack or stroke

BACKGROUND AND PURPOSE

Stroke risk prediction scores have been designed to stratify risk of recurrent cerebrovascular events in patients with transient ischaemic attack (TIA) or minor ischaemic stroke (MIS).

MATERIAL AND METHODS

Consecutive patients with TIA or MIS referring to Ghaem Hospital, Mashhad presenting within 24 hours from the onset of symptoms were recruited to the prospective cohort study between 2010 and 2011. MIS was defined as an ischaemic stroke with National Institutes of Health Stroke Scale (NIHSS) score < 4. The end-point of the study was a new ischaemic cerebrovascular event or vascular death at 90 days and, additionally, at 3 days after the index TIA or MIS. The decision to admit and of method of treatment in each case was left to the discretion of the stroke neurologist. The predictive accuracy of the ABCD2 scoring system for recurrent stroke or TIA was quantified by the area under the curve (AUC), using the c-statistics.

RESULTS

The study included 393 patients with TIA (238 males, 155 females) and 118 patients with MIS (77 males, 41 females). Among 511 patients with minor ischaemic events, 117 strokes (23.2%), 99 TIAs (19.6%), and 11 vascular deaths (2.2%) occurred within 3 months after the index event. The ABCD2 score had a weak predictive value for 3-month and 3-day recurrent stroke in patients with TIA (AUC = 0.599 and 0.591, respectively), but a high predictive value for 3-month and 3-day recurrent stroke in patients with MIS (AUC = 0.727 and 0.728, respectively).

CONCLUSION

The ABCD2 score is highly predictive for short-term recurrent stroke in patients with MIS but not in patients with TIA, although it was originally designed for patients with TIA.

Prediction of vascular risk after stroke - protocol and pilot data of the Prospective Cohort with Incident Stroke (PROSCIS)

RATIONALE

Long-term risk of vascular disease is substantially increased after stroke with several models proposed to predict subsequent stroke and other vascular events after an index event. However, recent validation studies demonstrate limited predictive properties of available prognostic models.

AIMS

We aim to determine prediction models of different complexity for the combined vascular end-point of stroke, myocardial infarction, and vascular death at three-years after first-ever stroke. An independent external validation of the developed models will be performed.

DESIGN

Prospective observational hospital-based cohort study of patients after first-ever stroke.

METHODS

The new predictive models will be developed using the following steps: (1) Development of a basic score based on clinical history data (e.g. hypertension, myocardial infarction, and atrial fibrillation); (2) Development of an advanced score including additional factors such as blood-based biomarkers and results of vascular imaging; (3) Comparing the models fit using different methods (discrimination, calibration); (4) Assessment of clinical utility of an advanced score using methods based on reclassification tables (e.g. net reclassification improvement, integrated discrimination improvement, decision curve analysis); and (5) Investigation of external validity.

OUTCOMES

Primary outcome is a combined vascular end-point composed of stroke, myocardial infarction, and vascular death at three-years after stroke. Furthermore, each component of the composite end-point will be investigated individually and the patterns and time points of risk transitions between vascular end-points and stroke sub-types will be determined.

A Modified Essen Stroke Risk Score for Predicting Recurrent Cardiovascular Events: Development and Validation

Background

The Essen stroke risk score is widely applied to predict the risk of recurrent ischemic stroke. We developed a modified Essen stroke risk score and validated it using a large prospective Effective Vascular Event REduction after STroke (EVEREST) registry including 3588 patients with ischemic stroke in Japan. Patients with cardioembolic stroke were excluded, and follow-up was one-year.

Methods

The modified Essen stroke risk score was calculated from scores for waist circumference, stroke subtype by etiology, and gender in addition to age, hypertension, diabetes mellitus, previous myocardial infarction, other cardiovascular diseases except myocardial infarction and atrial fibrillation, peripheral artery disease, smoking, and previous stroke or transient ischemic attack. A multiple logistic regression model identified the predictors (each assigned one or two points) and provided c-statistics for the modified Essen stroke risk score. We considered two outcomes, recurrent ischemic stroke and cardiovascular events (defined as the combined outcomes of fatal or nonfatal stroke, myocardial infarction, nonfatal unstable angina, and cardiac death).

Results

Recurrent ischemic stroke occurred in 121 patients (3·7%) and cardiovascular events occurred in 133 (4·0%) within a year. The c-statistic (used for discrimination) was 0·632 for recurrent stroke and 0·640 for cardiovascular events. Patients scoring 6 or greater were classified as high risk, otherwise were classified as low risk. Kaplan–Meier analysis revealed that the modified risk score was more predictive than the Essen stroke risk score in both men and women.

Conclusions

The modified Essen stroke risk score increased the ability of the Essen stroke risk score to predict recurrent cardiovascular events. Patients with a high modified Essen stroke risk score should be candidates for intensified secondary prevention strategies.

The ABCD(2) Score is Highly Predictive of Stroke in Minor Ischemic Stroke Patients

Stroke risk prediction scores have been designed to stratify risk of recurrent cerebrovascular events in transient ischemic attack (TIA) and minor ischemic stroke (MIS) patients. Consecutive TIA or MIS patients referred to Ghaem Hospital, Mashhad were enrolled in a prospective cohort study during 2010-2011. Only TIA or MIS patients presenting within 24 h from the onset of symptoms were recruited. MIS was considered as ischemic stroke with NIHSS <4. The end point of the study was a new ischemic cerebrovascular event or vascular death at 90 days and additionally at 3 days. The decision to admit and treatment in each case was left to the discretion of the stroke neurologist. The predictive accuracy of the ABCD(2) scoring system for recurrent stroke or TIA was quantified by the area under the cure (AUC) using the c statistics. Three hundred ninety-three TIA patients (238 males, 155 females) and 118 MIS patients (77 males, 41 females) were enrolled in the study. One hundred seventeen strokes (23.2%), 99 TIA (19.6%), and 11 vascular death (2.2%) occurred within 3 months postevent in the whole of our 511 patients with minor ischemic events. The ABCD(2) score had a weak predictive value for 3 months and 3 days recurrent stroke in our TIA patients (AUC = 0.599, AUC = 0.591), but a high predictive value for 3 months and 3 days recurrent stroke in our MIS patients (AUC = 0.727, AUC = 0.728), respectively. The ABCD(2) score is highly predictive of short-term recurrent stroke in MIS patients but not TIA cases, despite its creation for TIA cohorts.

Predictors of gait velocity among community-dwelling stroke survivors

INTRODUCTION

Gait velocity is an objective, fundamental indicator of post-stroke walking ability. Most stroke survivors have diminished aerobic endurance or paretic leg strength affecting their walking ability. Other reported underlying factors affecting gait velocity include functional disability, balance, cognitive impairment, or the distance they are required to walk.

OBJECTIVE

To examine the relationship between gait velocity and measures of physical and cognitive functioning in chronic stroke.

METHODS

Cross-sectional design using baseline data from community-dwelling stroke survivors enrolled in an exercise intervention study. Functional disability (modified Rankin Scale), aerobic endurance (2-min step-test), leg strength (timed 5-chair stand test), balance (single-leg stance) and cognitive impairment (Mini-Mental Status Exam) were assessed. Gait velocity was assessed using a timed 4-m walk test. Multiple linear regression was used to explore potential independent predictors of gait velocity.

RESULTS

Subjects had an average gait velocity of 0.75±0.23m/s, categorized as limited community walkers. Approximately 37% of the variance in gait velocity, could be explained by the 5 independent variables, functional disability, aerobic endurance, leg strength, balance, and cognitive impairment (R(2)=0.37, F(5,74)=8.64, p<0.01). Aerobic endurance (t(1,74)=3.41, p<0.01) and leg strength (t(1,74)=-2.23, p=0.03) contributed significantly to gait velocity.

CONCLUSION

Diminished aerobic endurance and leg strength are major contributors to slow gait velocity in chronic stroke. Long term rehabilitation efforts are needed to improve gait velocity in chronic stroke, and may need to incorporate multifaceted strategies concurrently, focusing on aerobic endurance and leg strength, to maximize community ambulation and reintegration.

Atherothrombotic burden and medium-term prognosis in patients with acute ischemic stroke: findings of the SIRIO study

BACKGROUND

Short- and medium-term mortality after acute stroke is related to the severity of the index event and the patient's age. However, recent studies have reassessed the prognostic value of the systemic atherothrombotic burden in these patients, not only in the long term. This post hoc analysis of the findings of the SIRIO trial (Stroke in Italy and Related Impact on Outcome) examined the prognostic impact of systemic atherothrombosis.

METHODS

SIRIO was a multicenter observational study enrolling patients during the acute phase of stroke of both ischemic and hemorrhagic origin. The present analysis, however, only covered patients with ischemic stroke. At baseline, the main personal and clinical details were recorded and patients were classified as having either polyvascular disease or single arterial disease on the basis of whether they had symptomatic atherothrombotic disease in other sites besides the cerebrovascular location. For all patients we calculated the Essen Stroke Risk Score (ESRS), dividing them into groups with scores of less than 3 or 3 and more. We recorded total mortality and nonfatal vascular events 12 months after enrolment. Multivariate logistic regression analysis was used to select predictors of medium-term mortality and nonfatal cardiovascular events. There were 2,561 patients with ischemic stroke, 823 of them classified as having polyvascular disease; 940 (out of 2,485) had an ESRS of less than 3 and 1,545 had a score of 3 or more.

RESULTS

The combined endpoint 'death (all causes) and nonfatal cardiovascular events within 12 months of hospital discharge' was significantly dependent on the following factors: ESRS, Rankin scale and National Institutes of Health Stroke Scale scores, and polyvascular disease. Polyvascular disease status significantly affected mortality and nonfatal cardio- and cerebrovascular events after discharge (OR = 1.44, 95% CI = 1.10-1.88). Age was also confirmed as a significant predictor of the combined endpoint.

CONCLUSIONS

Besides age and the clinical severity of the index event, symptomatic involvement of several vascular districts was also an important predictor of mortality and nonfatal cardiovascular events in the medium term in patients with ischemic stroke.

Vascular risk prediction in ischemic stroke patients undergoing in-patient rehabilitation - insights from the investigation of patients with ischemic stroke in neurologic rehabilitation (INSIGHT) registry

BACKGROUND

In-patient rehabilitation following ischemic stroke offers a unique opportunity for risk factor and lifestyle modification. Quantification of risk in this setting may help to tailor therapy, increase physician awareness and patient compliance and thus to reduce recurrent vascular events.

AIMS

To validate the predictive value of established secondary stroke risk scores.

METHODS

One thousand one hundred sixty-three patients undergoing in-patient rehabilitation following recent ischemic stroke in 15 German neurologic rehabilitation centers were included 0·9 ± 0·5 months after the index event. Outcome information was available for 846 participants (72·7%) after a mean follow-up of 13 ± 2·3 months.

RESULTS

Patients' mean age was 66·3 ± 12·3 years and 42·5% were women. The National Institutes of Health Stroke Scale (mean 4·0 ± 3·9), modified Rankin scale (median 2, range 0-5), and Barthel Index (median 90, range 0-100) indicated good functional status. A recurrent fatal or nonfatal stroke during follow-up occurred in 6·7% and combined vascular events (stroke, myocardial infarction, vascular death) in 10·9%. The predictive accuracy for recurrent stroke was slightly higher on the Essen Stroke Risk Score than on the Stroke Prognostis Instrument II (area under the curve 0·62 vs. 0·56), while both scores had a similar predictive accuracy for combined vascular events.

CONCLUSIONS

Risk stratification on the Essen Stroke Risk Score and Stroke Prognostis Instrument II provides a moderate accuracy for the prediction of recurrent stroke and vascular events in patients undergoing neurologic in-patient rehabilitation. Although individual risk prediction may remain imprecise, the use of these scores should be encouraged.

A Multidimensional Prognostic Index (MPI) based on a comprehensive geriatric assessment predicts short- and long-term all-cause mortality in older hospitalized patients with transient ischemic attack

A multidimensional impairment may influence the clinical outcome of acute diseases in older patients. The aim of the current study was to evaluate whether a Multidimensional Prognostic Index (MPI) based on a comprehensive geriatric assessment (CGA) predicts short- and long-term all-cause mortality in older patients hospitalized for transient ischemic attack (TIA). In this prospective study with 1-year follow-up, 654 patients aged 65 and older with a diagnosis of TIA according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM 435.x) were enrolled. A standardized CGA that included information on functional (activities of daily living, ADL, and Instrumental ADL), cognitive status (Short Portable Mental Status Questionnaire), nutrition (Mini Nutritional Assessment), risk of pressure sores (Exton-Smith Scale), comorbidities (Cumulative Illness Rating Scale), medications and co-habitation status was used to calculate the MPI for mortality using a previously validated algorithm. Higher MPI values were significantly associated with higher 1-month all-cause mortality (incidence rates: MPI-1 low risk = 0.32%, MPI-2 moderate risk = 5.36%, MPI-3 high risk = 10.42%; p < 0.001), 6-month all-cause mortality (MPI-1 = 1.95%, MPI-2 = 9.77%, MPI-3 = 27.22%; p < 0.001) and 12-month all-cause mortality (MPI-1 = 5.19%, MPI-2 = 16.47%, MPI-3 = 44.32%; p < 0.001). Age- and gender-adjusted Cox regression analyses demonstrated that MPI was a significant predictor of all-cause mortality. MPI showed a significant high discriminatory power with an area under the receiver operating characteristics (ROC) curve of 0.819, 95% CI = 0.749-0.888 for 1-month mortality, 0.799, 95% CI = 0.738-0.861 for 6-month mortality and 0.770, 95% CI = 0.716-0.824 for 12-month mortality. The MPI, calculated from information collected in a standardized CGA, appeared to be effective in estimating short- and long-term all-cause mortality in older patients hospitalized for TIA.

Community-based Yang-style Tai Chi is safe and feasible in chronic stroke: a pilot study

Objective: Examine the safety and feasibility of a 12-week Tai Chi intervention among stroke survivors.

Design: Two-group, prospective pilot study with random allocation.

Setting: Outpatient rehabilitation facility.

Subjects: Stroke survivors ≥50 years and at ≥three months post-stroke.

Interventions: Tai Chi subjects attended group-based Yang Style classes three times/week for 12-weeks, while Usual Care subjects received weekly phone calls along with written materials/resources for participating in community-based physical activity.

Main outcome measures: Indicators of study safety and feasibility included recruitment rates, intervention adherence, falls or adverse events, study satisfaction, drop-outs, and adequacy of the outcomes measures.

Results: Interested persons pre-screened by phone ( n = 69) were on average 68 years old, (SD = 13) years old, 48% ( n = 33) women, 94% ( n = 65) were at least three months post-stroke. A total of 28 subjects aged 69 (SD = 11) years enrolled in this pilot study. Intervention adherence rates were very high (≥92%). There were no falls or other adverse events. The dose of Tai Chi exercise (≥150 minutes/week) was well tolerated. Overall study satisfaction was high (8.3 (SD = 1.9); 1 = not satisfied, 10 = most satisfied), while drop-outs ( n = 3, 11%) were unrelated to study intervention. Score distributions for the outcome measures were approximately normal, sensitive to change, and seemed to favor the Tai Chi intervention.

Conclusions: Tai Chi is a safe, community-based exercise program for stroke survivors. Our data suggest that recruitment and retention of an adequate sample is feasible, and that in a full-scale study 52 subjects/group are needed to detect statistically significant between group differences (alpha = 0.05, power = 0.80).

Two-year vascular event rates in patients with symptomatic cerebrovascular disease: the REACH registry

BACKGROUND AND PURPOSE

Few practice-based studies have reported vascular outcome events among patients with cerebrovascular disease (CeVD). We describe 2-year vascular outcomes among symptomatic CeVD patients from the REduction of Atherothrombosis for Continued Health (REACH) Registry.

METHODS

Vascular events (stroke; myocardial infarction, MI; cardiovascular death, CV death; hospitalization) were studied among symptomatic CeVD patients from a prospective cohort of stable outpatients with established atherothrombosis or ≥3 atherothrombotic risk factors.

RESULTS

Of the 69,055 patients in REACH, 18,992 (28%) had symptomatic CeVD, of which outcome data were available for 18,189 patients. At 2 years, the frequency of non-fatal stroke was 5.93% (95% CI 5.22-6.64), non-fatal MI 2.21% (95% CI 1.65-2.76), CV death 4.45% (95% CI 3.66-5.22), combined vascular endpoint 11.48% (95% CI 10.46-12.49), and all deaths 7.39% (95% CI 6.34-8.42). The frequency of stroke, MI, CV death, or hospitalization for atherothrombotic events was 21.05% (95% CI 20.05-22.03). Event rates were lowest among patients with CeVD alone and highest among patients with CeVD, coronary artery disease, and peripheral artery disease. Other predictors of the primary outcome were increasing age, history of diabetes, current smoking, asymptomatic carotid stenosis, and carotid plaque. Outcomes were similar across geographical regions.

CONCLUSIONS

Symptomatic CeVD patients encounter high vascular event rates despite treatment. Recurrent nonfatal stroke is more common than nonfatal MI.

Statin use prior to ischemic stroke onset is associated with decreased in-hospital mortality

Statins can reduce the risk of stroke in at-risk populations and improve survival after acute ischemic stroke (AIS) among patients with previous statin use. This study aimed to investigate the impact of statin use before AIS onset on in-hospital mortality and identify the factors related to in-hospital mortality among patients with and without previous statin use. A retrospective cohort study of all patients with AIS attending hospital from June 1, 2008 to December 31, 2008. Data were collected from medical records including demographic information, diagnostic information, risk factors, previous statin use, and vital discharge status. Chi-square, Fisher's exact tests, student's t-test, and Mann-Whitney U test, whatever appropriate, were used to test the significance between the variables, and multiple logistic regression was used to identify factors associated with in-hospital mortality. Altogether, 386 patients with AIS were studied, of which 113 (29.3%) had a documented previous statin use. A total of 62 (16.1%) patients with AIS died in hospital. In-hospital mortality was significantly lower among previous statin users (P = 0.013). The presence of atrial fibrillation (AF) increased in-hospital mortality among patients with or without previous statin use. The independent predictors for in-hospital mortality among AIS patients without previous statin use were the presence of diabetes mellitus (P = 0.047), AF (P = 0.045), and renal impairment (P < 0.001). The prophylactic administration of statins significantly reduces post-AIS in-hospital mortality. Furthermore, the identification of predictors of in-hospital mortality might reduce death rates and enhance the application of specific therapeutic and management strategies to patients at a high risk of dying.

Using administrative databases to calculate Framingham scores within a large health care organization

BACKGROUND AND PURPOSE

Framingham calculators are typically implemented in 1-on-1 settings to determine if a patient is at high risk for development of cardiovascular disease in the next 10 years. Because health care administrative datasets are including more clinical information, we explored how well administrative data-derived Framingham scores could identify persons who would have stroke develop in the next year.

METHODS

Using a nested case-control design, we compared all 313 persons who had a first-time stroke at 5 Veterans Administration Medical Centers with a random sample of 25,361 persons who did not have a first-time stroke in 2008. We compared Framingham scores and risk using administrative data available at the end of 2007.

RESULTS

Stroke patients had higher risk profile than controls: older age, higher systolic blood pressure and total cholesterol, more likely to have diabetes, cardiovascular disease, left ventricular hypertrophy, and more likely to use treatment for blood pressure (P<0.05). The mean Framingham generalized cardiovascular disease score (18.0 versus 14.5) as well as the mean Framingham stroke-specific score (13.2 versus 10.2) was higher for stroke cases than controls (both P<0.0001). The c-statistic for the generalized cardiovascular disease score was 0.68 (95% CI, 0.65-0.70) and for the stroke score was 0.64 (95% CI, 0.62-0.67).

CONCLUSIONS

Persons who had a stroke develop in the next year had a worse Framingham risk profile, as determined by administrative data. Future studies should examine how to improve the stroke predictive tools and to identify the appropriate populations and uses for applying stroke risk predictive tools.

Final 2 year results of the vascular imaging of acute stroke for identifying predictors of clinical outcome and recurrent ischemic eveNts (VISION) study

Among patients with ischemic stroke, little attention has been paid to differentiation between stroke progression and recurrence. We assessed the role of MR imaging in predicting stroke progression, recurrent stroke, and death within 2 years of symptom onset.

METHODS

Ischemic stroke or TIA patients were prospectively enrolled. They were examined within 12 hours and had a stroke MR completed within 24 hours of symptom onset. Patients were closely followed neurologically and examined if there was any deterioration in neurological status. Relationships between baseline clinical and imaging factors and outcomes were assessed. We also examined whether baseline stroke/TIA severity (NIHSS 0-5 versus NIHSS > 5) modified these relationships.

RESULTS

A total of 334 patients were enrolled. The overall rates of progression, 2-year recurrence, and 2-year death were 8.7%, 8.0%, and 6.6%, respectively. Event rates were similar among patients with mild compared to more severe strokes: 8.3% versus 9.5% (p = 0.73) for progression, and 7.3% versus 9.9% (p = 0.59) for recurrence. The effect of baseline glucose > 8 mmol/l was consistent in predicting stroke progression, recurrent stroke and death, regardless of baseline stroke severity. In multivariable analyses, DWI lesion and intracranial occlusion predicted stroke progression only in the minor stroke/TIA group; symptomatic Internal Carotid Artery (ICA) stenosis predicted stroke recurrence only in the minor stroke/TIA group.

CONCLUSIONS

In a prospective study with early assessment and imaging we have found that stroke progression is different than stroke recurrence. Different imaging factors predict stroke progression versus stroke recurrence. Baseline hyperglycemia, a potentially modifiable factor, consistently predicted all three outcomes (stroke progression, recurrent stroke or death) regardless of baseline stroke severity.

Program of rehabilitative exercise and education to avert vascular events after non-disabling stroke or transient ischemic attack (PREVENT Trial): a multi-centred, randomised controlled trial

BACKGROUND

Despite lack of outward signs, most individuals after non-disabling stroke (NDS) and transient ischemic attack (TIA) have significant cardiovascular and cerebrovascular disease and are at high risk of a major stroke, hospitalization for other vascular events, or death. Most have multiple modifiable risk factors (e.g., hypertension, physical inactivity, hyperlipidaemia, diabetes, tobacco consumption, psychological stress). In addition, accelerated rates of depression, cognitive decline, and poor quality of sleep have been reported following TIA, which correlate with poor functional outcomes and reduced quality of life. Thus, NSD and TIA are important warning signs that should not be overlooked. The challenge is not unlike that facing other 'silent' conditions - to identify a model of care that is effective in changing people's current behaviors in order to avert further morbidity.

METHODS/DESIGN

A single blind, randomized controlled trial will be conducted at two sites to compare the effectiveness of a program of rehabilitative exercise and education versus usual care in modifying vascular risk factors in adults after NDS/TIA. 250 adults within 90 days of being diagnosed with NDS/TIA will be randomly allocated to a 12-week program of exercise and education (PREVENT) or to an outpatient clinic assessment and discussion of secondary prevention recommendations with return clinic visits as indicated (USUAL CARE). Primary outcome measures will include blood pressure, waist circumference, 12-hour fasting lipid profile, and 12-hour fasting glucose/hemoglobin A1c. Secondary measures will include exercise capacity, walking endurance, physical activity, cognitive function, depression, goal attainment and health-related quality of life. Outcome assessment will be conducted at baseline, post-intervention, and 6- and 12-month follow-ups. Direct health care costs incurred over one year by PREVENT versus USUAL CARE participants will also be compared. Ethical approval for the trial has been obtained from the relevant Human Research Ethics Boards.

DISCUSSION

Whether timely delivery of an adapted cardiac rehabilitation model is effective in attaining and maintaining vascular risk reduction targets in adults after NDS/TIA is not yet known. We anticipate that the findings of this trial will make a meaningful contribution to the knowledge base regarding secondary stroke prevention.

Impact of angiotensin-converting enzyme inhibitors administration prior to acute ischemic stroke onset on in-hospital mortality

INTRODUCTION

Angiotensin-converting enzyme inhibitors (ACEIs) have shown promising results in decreasing the incidence and the severity of ischemic stroke in populations at risk and in improving ischemic stroke outcomes.

OBJECTIVES

The objectives of this study were to investigate the impact of ACEI use before ischemic stroke onset on in-hospital mortality and to identify the independent predictors of in-hospital mortality among patients with ischemic stroke.

METHODS AND MATERIALS

A retrospective cohort study of all patients with acute ischemic stroke attending the hospital from June 1, 2008 to November 30, 2008 was performed. Data were collected from medical records and included demographic information, diagnostic information, risk factors, previous ACEI use, and vital discharge status. Statistical Package for Social Sciences (SPSS) version 15 was used for data analysis.

RESULTS

A total of 327 patients with acute ischemic stroke were studied, of which 119 (36.4%) had documented previous ACEI use. During the study period, 52 (15.9%) of the patients with acute ischemic stroke died in hospital. In-hospital mortality was significantly lower among patients who were on ACEI before the attack (P = 0.002). The independent predictors for in-hospital mortality among patients with ischemic stroke were age >or=65 years (P < .001), the presence of diabetes mellitus (P = .012), renal impairment (P = .002), and heart failure (P = .001). Moreover, prior use of ACEI was an independent predictor for survival after ischemic stroke attack (P < .001).

CONCLUSION

This study provides evidence that the prophylactic administration of ACEI before ischemic stroke may be a potential life-saving strategy. Furthermore, knowledge of in-hospital mortality predictors is necessary to improve survival rate after acute stroke.

A score to predict early risk of recurrence after ischemic stroke

BACKGROUND

There is currently no instrument to stratify patients presenting with ischemic stroke according to early risk of recurrent stroke. We sought to develop a comprehensive prognostic score to predict 90-day risk of recurrent stroke.

METHODS

We analyzed data on 1,458 consecutive ischemic stroke patients using a Cox regression model with time to recurrent stroke as the response and clinical and imaging features typically available to physician at admission as covariates. The 90-day risk of recurrent stroke was calculated by summing up the number of independent predictors weighted by their corresponding beta-coefficients. The resultant score was called recurrence risk estimator at 90 days or RRE-90 score (available at: http://www.nmr.mgh.harvard.edu/RRE-90/).

RESULTS

Sixty recurrent strokes (54 had baseline imaging) occurred during the follow-up period. The risk adjusted for time to follow-up was 6.0%. Predictors of recurrence included admission etiologic stroke subtype, prior history of TIA/stroke, and topography, age, and distribution of brain infarcts. The RRE-90 score demonstrated adequate calibration and good discrimination (area under the ROC curve [AUC] = 0.70-0.80), which was maintained when applied to a separate cohort of 433 patients (AUC = 0.70-0.76). The model's performance was also maintained for predicting early (14-day) risk of recurrence (AUC = 0.80).

CONCLUSIONS

The RRE-90 is a Web-based, easy-to-use prognostic score that integrates clinical and imaging information available in the acute setting to quantify early risk of recurrent stroke. The RRE-90 demonstrates good predictive performance, suggesting that, if validated externally, it has promise for use in creating individualized patient management algorithms and improving clinical practice in acute stroke care.

Predicting and preventing stroke after transient ischemic attack

The prognosis of transient ischemic attacks (TIAs) is not as favorable as previously thought. Given a risk of stroke of approximately 10% in the first week following a TIA, urgent evaluation and initiation of treatment are required. Recently developed scores to predict the early risk of subsequent stroke in individual patients may guide treatment decisions in the acute phase. Lately it has become clear that transient attacks with nonfocal symptoms are not benign either, as these were found to be associated with an increased risk of vascular disease. The significance of this finding and its implications for treatment are not yet clear. There is substantial evidence from a number of clinical trials that adequate secondary prevention therapies can reduce the risk of stroke after TIA. In addition to the conventional vascular risk factors, interest has grown in less strong but more prevalent lifestyle factors, but trials evaluating the effect of modifying these factors are as yet lacking.

Screening for kidney disease in vascular patients: SCreening for Occult REnal Disease (SCORED) experience

BACKGROUND

SCreening for Occult REnal Disease (SCORED) is a novel screening guideline recently developed to identify individuals with a high likelihood of having prevalent chronic kidney disease (CKD). This simple scoring system, developed from general US representative samples and independently validated, was shown to outperform current clinical practice guidelines. Recently, CKD screening in individuals with cardiovascular disease (CVD) has been emphasized. We therefore evaluated the SCORED model in CVD patients in order to better understand the implications of CKD screening in this population.

METHODS

Two clinical trials that enrolled patients with heart attack (N = 2481) or stroke (N = 3680) were combined to create our sample. The performance of the SCORED guideline was evaluated by standard diagnostic measures. Correlations among various risk scores and their predictive abilities for recurrent CVD were ascertained.

RESULTS

For heart attack and stroke patients, respectively, the SCORED guideline yielded sensitivity of 94 and 97%, specificity of 27 and 11%, positive predictive value of 32 and 30%, negative predictive value of 93 and 89%, with AUC of 0.75 and 0.68. SCORED was strongly correlated with other risk scores and exhibited a similar performance in the prediction of recurrent CVD.

CONCLUSIONS

The higher risk of CKD in CVD patients with high SCORED values is demonstrated. This simple education and screening tool may help promote awareness of CKD in CVD patients, in addition to general populations, and assess the CKD risk and its relationship with recurrent CVD.