Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank

High serum uric acid levels are a protective factor against unfavourable neurological functional outcome in patients with ischaemic stroke

Objective

We aimed to evaluate the association between serum uric acid levels at the onset and prognostic outcome in patients with acute ischaemic stroke.

Methods

We retrospectively analysed the outcomes of 1166 patients with ischaemic stroke who were hospitalized in our centre during August 2008 to November 2012. Correlations of serum uric acid levels and prognostic outcomes were analysed.

Results

Men had higher serum uric acid levels and better neurological functional outcomes compared with women. There was a strong negative correlation between serum uric acid levels and unfavourable neurological functional outcomes. Generalized estimated equation analysis showed that a higher serum uric acid level (>237 µmol/L) was a protective factor for neurological functional outcome in male, but not female, patients. Among five trial of ORG 10172 in acute stroke treatment classification subtypes, only patients with the large-artery atherosclerosis subtype had a significant protective effect of serum uric acid levels on neurological outcome.

Conclusions

Our study shows that high serum uric acid levels are a significant protective factor in men and in the large-artery atherosclerosis subtype in patients with ischaemic stroke. This is helpful for determining the prognostic value of serum uric acid levels for neurological outcome of acute ischaemic stroke.

Diagnostic yield of 90-kVp low-tube-voltage carotid and intracerebral CT-angiography: effects on radiation dose, image quality and diagnostic performance for the detection of carotid stenosis

OBJECTIVE

To investigate the impact of low-tube-voltage 90-kVp acquisition combined with advanced modeled iterative reconstruction algorithm (Admire) on radiation exposure, image quality, artifacts, and assessment of stenosis in carotid and intracranial CT angiography (CTA).

METHODS

Dual-energy CTA studies of 43 patients performed on a third-generation 192-slice dual-source CT were retrospectively evaluated. Intraindividual comparison of 90-kVp and linearly blended 120-kVp equivalent image series (M_0.6, 60% 90-kVp, 40% Sn-150-kVp) was performed. Contrast-to-noise and signal-to-noise ratios of common carotid artery, internal carotid artery, middle cerebral artery, and basilar artery were calculated. Qualitative image analysis included evaluation of artifacts and suitability for angiographical assessment at shoulder level, carotid bifurcation, siphon, and intracranial by three independent radiologists. Detection and quantification of carotid stenosis were performed. Radiation dose was expressed as dose-length product (DLP).

RESULTS

Contrast-to-noise values of all arteries were significantly increased in 90-kVp compared to M_0.6 (p < 0.001). Suitability for angiographical evaluation was rated excellent with low artifacts for all levels in both image series. Both 90-kVp and M_0.6 showed excellent accordance for detection and grading of carotid stenosis with almost perfect interobserver agreement (carotid stenoses in 32 of 129 segments; intraclass correlation coefficient, 0.94). dose-length product was reduced by 40.3% in 90-kVp (110.6 ± 32.1 vs 185.4 ± 47.5 mGy·cm, p < 0.001).

CONCLUSION

90-kVp carotid and intracranial CTA with Admire provides increased quantitative and similarly good qualitative image quality, while reducing radiation exposure substantially compared to M_0.6. Diagnostic performance for arterial stenosis detection and quantification remained excellent. Advances in knowledge: 90-kVp carotid and intracranial CTA with an advanced iterative reconstruction algorithm results in excellent image quality and reduction of radiation exposure without limiting diagnostic performance.

Partners in crime: neutrophils and monocytes/macrophages in inflammation and disease

Neutrophils are becoming recognized as highly versatile and sophisticated cells that display de novo synthetic capacity and potentially prolonged lifespan. Emerging concepts such as neutrophil heterogeneity and plasticity have revealed that, under pathological conditions, neutrophils may differentiate into discrete subsets defined by distinct phenotypic and functional characteristics. Indeed, these newly described neutrophil subsets will undoubtedly add to the already complex interactions between neutrophils and other immune cell types for an effective immune response. The interactions between neutrophils and monocytes/macrophages enable the host to efficiently defend against and eliminate foreign pathogens. However, it is also becoming increasingly clear that these interactions can be detrimental to the host if not tightly regulated. In this review, we will explore the functional cooperation of neutrophil and monocytes/macrophages in homeostasis, during acute inflammation and in various disease settings. We will discuss this in the context of cardiovascular disease in the form of atherosclerosis, an autoimmune disease mainly occurring in the kidneys, as well as the unique intestinal immune response of the gut that does not conform to the norms of the typical immune system.

Clinical outcome of cardioembolic stroke treated by intravenous thrombolysis

INTRODUCTION

Cardioembolic stroke (CS) in patients without thrombolytic treatment is associated with a worse clinical outcome and higher mortality compared to other types of stroke. The aim of this study was to determine the clinical outcome of CS in patients treated by intravenous thrombolysis (IVT).

MATERIAL AND METHODOLOGY

Data of patients from the SITS-EAST register (Safe Implementation of Treatments in Stroke) were analyzed in patients who received IVT treatment from 2000 to April 2014. The effect of the stroke etiology according to ICD-10 classification on outcome was analyzed using a univariate and multivariate analysis. The outcomes were assessed as follows: excellent clinical outcome (modified Rankin scale (mRS) 0-1) at 3 months, the rate of symptomatic intracranial hemorrhage (sICH), mortality, and improvement at 24 hours after IVT.

RESULTS

Data of 13 772 patients were analyzed. CS represented 30% of all strokes. The mean age of patients with CS, atherothrombotic stroke, lacunar stroke, and other stroke was 70.8, 66.7, 66.2, and 63.3 years, respectively (P < .001). Severity of stroke on admission by median NIHSS score was 13 points in patients with CS, 12 points - in atherothrombotic stroke, 7 points - in lacunar stroke, and 10 points-in other stroke types (P < .001). No difference in mortality was detected among atherothrombotic and CS; however, atherothrombotic strokes had higher odds of sICH [OR = 1.63 (95% CI: 1.07-2.47), P = .023], lower odds of early improvement [OR = 0.79 (95% CI: 0.72-0.86), P < .001], and excellent clinical outcome [OR = 0.77 (95% CI: 0.67-0.87), P < .001] compared with CS.

CONCLUSIONS

Cardioembolic strokes are not associated with increased mortality. Patients with CS are less likely to have sICH and have better outcome after IVT.

Efficacy of carotid thrombus penetration with a balloon guiding catheter to fast recanalization of acute extra- and intra-cranial carotid artery tandem occlusion - a preliminary report

Acute ischemic stroke with ipsilateral Internal carotid artery (ICA) stenosis presents a great management dilemma. We present our preliminary report of retrograde retrieval of clot from middle cerebral artery (MCA) followed by delayed carotid artery stenting (CAS) with dual anti platelet therapy (DAPT).

Prediction of Incident Atrial Fibrillation According to Gender in Patients With Ischemic Stroke From a Nationwide Cohort

The CHA₂DS₂-VASc score may identify patients at higher risk of atrial fibrillation (AF) following ischemic stroke (IS) in patients without known AF. We compared gender-related differences in items from CHA₂DS₂-VASc score and their relation with AF occurrence after IS. This French cohort study was based on the database covering hospital care from 2009 to 2012 for the entire population. Of 336,291 patients with IS, 240,459 (71.5%) had no AF at baseline. Women were older, more frequently had hypertension, heart failure, and had a higher CHA₂DS₂-VASc score than men (4.63 vs 4.39, p<2DS₂-VASc score items were independent predictors of incident AF, except diabetes and vascular disease). Results were mostly similar in men and women when one analyzed separately these predictors. Predictive value of the CHA₂DS₂-VASc score for identifying patients at higher risk of incident AF was somewhat higher in men (C statistic 0.720, 95% confidence interval 0.717 to 0.722) than in women (0.702, 95% confidence interval 0.699 to 0.704). Coronary artery disease, valvular disease, and history of pacemaker or defibrillator implantation were also independent predictors of incident AF. In conclusion, there were significant differences in co-morbidities, possible mechanisms, incidence, and predictors of AF between men and women after IS. However, a strategy using CHA₂DS₂-VASc score for identifying a higher risk of incident AF following IS was useful in both genders.

[Estimating disability-adjusted life-years for subtypes of acute ischemic stroke]

Objective To test the hypothesis that DALYs, estimated individually for each patient with acute ischemic stroke upon hospital discharge, without reperfusion therapy, are not different between the different subtypes of ischemic stroke. Patients and Methods In the Hospital Universitario de la Samaritana in Bogotá, the health records of patients diagnosed with their first acute ischemic stroke event from admission and monitoring to discharge were selected. The subtype of acute ischemic stroke was classified according to the criteria established by the Trial of Org 10172 in Acute Stroke Treatment (TOAST). DALYs were estimated for each patient with acute ischemic stroke at hospital discharge. To establish differences of DALYs among the five acute ischemic stroke subtypes (TOAST), the Kruskal Wallis test was used. Results Of the 39 cases of acute ischemic stroke, 17 (43.6 %) were classified as artherosclerosis, 10 (25.6 %) as lacunar events, 6 (15.4 %) as cardioembolic attacks, and another 6 (15.4 %) cases with unclear etiology. At hospital discharge, the estimated total DALYs provided by patients with acute ischemic stroke was 316.9 years, without statistically significant differences between the subtypes of ischemic stroke. At hospital discharge, the average of optimal years free of disability lost by a patient surviving an acute ischemic stroke was 8.12. Conclusion Non conclusive results are attributed to the concurrence of dissimilar acute clinical care processes and to the risk factors distributions, comorbidities and patient complications.

Intravenous administration of xenogenic adipose-derived mesenchymal stem cells (ADMSC) and ADMSC-derived exosomes markedly reduced brain infarct volume and preserved neurological function in rat after acute ischemic stroke

We tested the hypothesis that combined xenogenic (from mini-pig) adipose-derived mesenchymal stem cell (ADMSC) and ADMSC-derived exosome therapy could reduce brain-infarct zone (BIZ) and enhance neurological recovery in rat after acute ischemic stroke (AIS) induced by 50-min left middle cerebral artery occlusion. Adult-male Sprague-Dawley rats (n = 60) were divided equally into group 1 (sham-control), group 2 (AIS), group 3 [AIS-ADMSC (1.2×106 cells)], group 4 [AIS-exosome (100μg)], and group 5 (AIS-exosome-ADMSC). All therapies were provided intravenously at 3h after AIS procedure. BIZ determined by histopathology (by day-60) and brain MRI (by day-28) were highest in group 2, lowest in group 1, higher in groups 3 and 4 than in group 5, but they showed no difference between groups 3 and 4 (all p < 0.0001). By day-28, sensorimotor functional results exhibited an opposite pattern to BIZ among the five groups (p < 0.005). Protein expressions of inflammatory (inducible nitric oxide synthase/tumor necrosis factor-α/nuclear factor-κB/interleukin-1β/matrix metalloproteinase-9/plasminogen activator inhibitor-1/RANTES), oxidative-stress (NOX-1/NOX-2/oxidized protein), apoptotic (caspase-3/ Poly-ADP-ribose polymerase), and fibrotic (Smad3/transforming growth factor-β) biomarkers, and cellular expressions of brain-damaged (γ-H2AX+/ XRCC1-CD90+/p53BP1-CD90+), inflammatory (CD11+/CD68+/glial fibrillary acid protein+) and brain-edema (aquaporin-4+) markers showed a similar pattern of BIZ among the groups (all n < 0.0001). In conclusion, xenogenic ADMSC/ADMSC-derived exosome therapy was safe and offered the additional benefit of reducing BIZ and improving neurological function in rat AIS.

Cervical ICA pseudo-occlusion on single phase CTA in patients with acute terminal ICA occlusion: what is the mechanism and can delayed CTA aid diagnosis?

Background

Single-phase CT angiography (CTA) forms the basis of hyperacute stroke imaging but many patients with terminal internal carotid artery (ICA) occlusion exhibit a pseudo-occlusion of the cervical ICA whereby a column of unopacified blood mimics a tandem cervical ICA lesion. We aimed to investigate the utility of a delayed phase acquisition to aid identification of a pseudo-occlusion and investigated the mechanism for this imaging artefact.

Methods

Thirteen patients with a pseudo-occlusion were compared with 13 patients without. CT, CTA, and digital subtraction angiographic images were reviewed by two interventional neuroradiologists for extension of thrombus into the ophthalmic segment, filling of the posterior communicating artery and ophthalmic artery, and for extension of contrast beyond the cervical segment and outline of the proximal clot surface by contrast on delayed imaging performed at 40 or 80 s.

Results

Those with a pseudo-occlusion demonstrated more frequent thrombus extension into the ophthalmic segment (100% vs 23%, P=0.0001), less frequent filling of the posterior communicating artery (15% vs 85%, P=0.0012), and less frequent filling of the ophthalmic artery (15% vs 92%, P=0.0002) compared with those without a pseudo-occlusion. Delayed CTA imaging showed contrast beyond the cervical segment and meeting the proximal clot face in 2/11 patients. Each of these two patients showed patency of the posterior communicating artery origin.

Conclusion

Thrombus extension into the ophthalmic segment and patency of the posterior communicating artery and ophthalmic artery seem to govern whether a patient with a terminal ICA occlusion exhibits a pseudo-occlusion. Delayed imaging was of limited value in identification of a pseudo-occlusion.

Anti-inflammatory approaches to ischaemic stroke prevention

Stroke is a major cause of neurological morbidity and mortality. Atherosclerosis is a major contributor to first and recurrent stroke. A growing evidence base indicates that inflammation is a key process in the pathogenesis of atherosclerosis, leading to thromboembolic events. In this review, we summarise the evidence linking inflammation to stroke risk and discuss clinical trials addressing the 'inflammation hypothesis' in coronary disease and stroke. Trial registration number CONVINCE trial ClinicalTrials.gov number; NCT 02898610; Pre-results.

Efficacy and safety of rivaroxaban compared with warfarin in patients with carotid artery disease and nonvalvular atrial fibrillation: Insights from the ROCKET AF trial

BACKGROUND

Atrial fibrillation (AF) increases risk of stroke 5-fold. Carotid artery disease (CD) also augments the risk of stroke, yet there are limited data about the interplay of these 2 diseases and clinical outcomes in patients with comorbid AF and CD.

HYPOTHESIS

Among patients with both AF and CD, use of rivaroxaban when compared with warfarin is associated with a lower risk of stroke.

METHODS

This post hoc analysis from ROCKET AF aimed to determine absolute rates of stroke/systemic embolism (SE) and bleeding, and the efficacy and safety of rivaroxaban compared with warfarin in patients with AF and CD (defined as history of carotid occlusive disease or carotid revascularization [endarterectomy and/or stenting]).

RESULTS

A total of 593 (4.2%) patients had CD at enrollment. Patients with and without CD had similar rates of stroke or SE (adjusted hazard ratio [HR]: 0.99, 95% confidence interval [CI]: 0.66-1.48, P = 0.96), and there was no difference in major or nonmajor clinically relevant bleeding (adjusted HR: 1.04, 95% CI: 0.88-1.24, P = 0.62). The efficacy of rivaroxaban compared with warfarin for the prevention of stroke/SE was not statistically significant in patients with vs those without CD (interaction P = 0.25). The safety of rivaroxaban vs warfarin for major or nonmajor clinically relevant bleeding was similar in patients with and without CD (interaction P = 0.64).

CONCLUSIONS

Patients with CD in ROCKET AF had similar risk of stroke/SE compared with patients without CD. Additionally, there was no interaction between CD and the treatment effect of rivaroxaban or warfarin for stroke prevention or safety endpoints.

Left Ventricular Ejection Fraction Predicts Poststroke Cardiovascular Events and Mortality in Patients without Atrial Fibrillation and Coronary Heart Disease

BACKGROUND AND OBJECTIVES

It is controversial that decreased left ventricular function could predict poststroke outcomes. The purpose of this study is to elucidate whether left ventricular ejection fraction (LVEF) can predict cardiovascular events and mortality in acute ischemic stroke (AIS) without atrial fibrillation (AF) and coronary heart disease (CHD).

METHODS

Transthoracic echocardiography was conducted consecutively in patients with AIS or transient ischemic attack at Soonchunhyang University Hospital between January 2008 and July 2016. The clinical data and echocardiographic LVEF of 1,465 patients were reviewed after excluding AF and CHD. Poststroke disability, major adverse cardiac events (MACE; nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death) and all-cause mortality during 1 year after index stroke were prospectively captured. Cox proportional hazards regressions analysis were applied adjusting traditional risk factors and potential determinants.

RESULTS

The mean follow-up time was 259.9±148.8 days with a total of 29 non-fatal strokes, 3 myocardial infarctions, 33 cardiovascular deaths, and 53 all-cause mortality. The cumulative incidence of MACE and all-cause mortality were significantly higher in the lowest LVEF (<55) group compared with the others (p=0.022 and 0.009). In prediction models, LVEF (per 10%) had hazards ratios of 0.54 (95% confidence interval [CI], 0.36-0.80, p=0.002) for MACE and 0.61 (95% CI, 0.39-0.97, p=0.037) for all-cause mortality.

CONCLUSIONS

LVEF could be an independent predictor of cardiovascular events and mortality after AIS in the absence of AF and CHD.

Epidemiology of Stroke in Costa Rica: A 7-Year Hospital-Based Acute Stroke Registry of 1319 Consecutive Patients

BACKGROUND

Limited data on stroke exist for Costa Rica. Therefore, we created a stroke registry out of patients with stroke seen in the Acute Stroke Unit of the Hospital Calderon Guardia.

METHODS

We analyzed 1319 patients enrolled over a 7-year period, which incorporated demographic, clinical, laboratory, and neuroimaging data.

RESULTS

The mean age of patients with stroke was 68.0 ± 15.5 years. Seven hundred twenty-five were men and the age range was 13-104 years. The most prevalent risk factors were hypertension (78.8%), dyslipidemia (36.3%), and diabetes (31.9%). Fifteen percent had atrial fibrillation and 24.7% had a previous stroke or transient ischemic attack. Prevalence of hypertension and atrial fibrillation increased with age; however, younger patients were more associated with thrombophilia. We documented 962 (72.9%) ischemic and 270 (20.5%) hemorrhagic strokes. Of the ischemic strokes, 174 (18.1%) were considered secondary to large-artery atherothrombosis, 175 (18.2%) were due to cardiac embolism, 19 (2.0%) were due to lacunar infarcts, and 25 (2.6%) were due to other determined causes. Five hundred sixty-nine (59.1%) remained undetermined. Atherothrombotic strokes were mostly associated with dyslipidemia, diabetes, metabolic syndrome, and obesity, whereas lacunar infarcts were associated with hypertension, smoking, sedentary lifestyle, and previous stroke or transient ischemic attack. Of our patients, 69.9% scored between 0 and 9 in the initial National Institutes of Health Stroke Scale (NIHSS).

CONCLUSIONS

We found differences in sociodemographic features, risk factors, and stroke severity among stroke subtypes. Risk factor prevalence was similar to other registries involving Hispanic populations.

Atrial fibrillation is not uncommon among patients with ischemic stroke and transient ischemic stroke in China

Background

Atrial fibrillation (AF) is reported to be a less frequent cause of ischemic stroke in China than in Europe and North America, but it is not clear whether this is due to underestimation. Our aim was to define the true frequency of AF-associated stroke, to determine the yield of 6-day Holter ECG to detect AF in Chinese stroke patients, and to elucidate predictors of newly detected AF.

Methods

Patients with acute ischemic stroke or transient ischemic attack (TIA) were enrolled in a prospective, multicenter cohort study of 6-day Holter monitoring within 7 days after stroke onset at 20 sites in China between 2013 and 2015. Independent predictors of newly-detected AF were determined by multivariate analysis.

Results

Among 1511 patients with ischemic stroke and TIA (mean age 63 years, 33.1% women), 305 (20.2%) had either previously known (196, 13.0%) or AF newly-detected by electrocardiography (53, 3.5%) or by 6-day Holter monitoring (56/1262, 4.4%). A history of heart failure (OR = 4.70, 95%CI, 1.64–13.5), advanced age (OR = 1.06, 95%CI, 1.04–1.09), NIHSS at admission (OR = 1.06, 95%CI, 1.02–1.10), blood high density lipoprotein (HDL) (OR = 1.52, 95%CI, 1.09–2.13), together with blood triglycerides (OR = 0.64, 95%CI, 0.45–0.91) were independently associated with newly-detected AF.

Conclusions

Contrary to previous reports, AF-associated stroke is frequent (20%) in China if systemically sought. Prolonged noninvasive cardiac rhythm monitoring importantly increases AF detection in patients with recent ischemic stroke and TIA in China. Advanced age, history of heart failure, and higher admission NIHSS and higher level of HDL were independent indicators of newly-detected AF.

Trial registration

NCT02156765 (June 5, 2014).

[Current indications for left atrial appendage occlusion]

Among patients with atrial fibrillation, the bleeding risk is linked to the stroke risk. Left atrial appendage (LAA) occlusion may reduce bleeding risk in high-risk patients. On the basis of a literature analysis and the Consensus Document of European Heart Rhythm Association (EHRA), the indications for a LAA occluder are clarified and a clear decision strategy for daily clinical practice is presented.

Time is brain: Balancing risk in the treatment of presumed cardioembolic stroke

OBJECTIVE

To assess whether clinical criteria can differentiate between presumed embolic strokes and non-embolic strokes before the full etiologic workup.

METHODS

Between January 1, 2014 to December 30, 2015, patients with a diagnosis of stroke or transient ischemic attack were first classified clinically (without access to a cardiac assessment) as: 1. presumed embolic stroke defined as a combination of definite cardioembolic stroke and likely to be embolic stroke (no evidence of large/small artery atherosclerosis); 2. non-embolic strokes; i.e. small/large artery diseases and stroke due to other causes. Stroke etiology was reassessed after investigations and concordances between the early diagnosis and final classifications were analyzed.

RESULTS

77 patients with early diagnosis of presumed embolic strokes and 45 cases with non-embolic stroke (selected randomly) were enrolled. We were able to differentiate between presumed embolic strokes and non-embolic strokes with a high level of accuracy (sensitivity 81.40%, 95% CI: 71.55%-88.98%; specificity 80.56%, 95% CI: 63.98%-91.81%). A moderate level of agreement between initial and final diagnosis of embolic/non-embolic strokes (kappa 0.58, SE 0.08, p≤0.01) was observed. The results of carotid imaging improved the specificity and positive likelihood ratio of correct differentiation.

CONCLUSIONS

Those at high risk of embolism can be diagnosed clinically even before the completion of tests. This is a practical approach to distinguish patients at risk and help balance early risks of recurrence with those of short-term anticoagulation.

Clinical outcomes of radiofrequency catheter ablation of atrial fibrillation in octogenarians-10-year experience of a one high-volume center

BACKGROUND

Prevalence of atrial fibrillation (AF) increases with age. Radiofrequency catheter ablation (RFCA) is an established treatment option superior to antiarrhythmics (AAs). In this study, we investigated safety and efficacy of RFCA of AF in octogenarians.

METHODS

From our database, we extracted procedural and follow-up data for patients ≥ 80 years with symptomatic AF undergoing RFCA and compared this population to RFCA patients ≤ 50 years. All patients underwent pulmonary vein isolation (PVI) supplemented by linear lesions in PVI-nonresponders. Arrhythmia-free survival was assessed using seven day Holter every three months post procedure. All patients completed their 12 months follow-up.

RESULTS

Fifty patients aged ≥ 80 years (80.5 ± 1.6 years) were compared to 259 patients aged ≤ 50 years (43.5 ± 5.5 years). The RFCA complication rate did not vary between groups. No differences in procedural characteristics were seen after being analyzed by type of AF. Among patients with paroxysmal AF, 71.4% octogenarian vs. 84.7% young patients was free of any arrhythmia, without AAs, after single procedure. For non-paroxysmal AF, arrhythmia-free survival without AAs, was considerably lower (58.6% octogenarians vs. 81.2% younger patients, P = 0.023). If AAs were used, arrhythmia-free survival for paroxysmal AF increased to 90.5% and 92.1% in octogenarians and younger patients, respectively; and in non-paroxysmal AF it increased to 79.3% vs. 88.4%.

CONCLUSIONS

RFCA is a safe and effective strategy to achieve normal sinus rhythm in a highly selected group of octogenarians. Paroxysmal AF ablation in octogenarians has similar clinical effectiveness as that seen in much younger patients. Non-paroxysmal AF ablation has lower, but still reasonable clinical effectiveness.

Sex difference in types and distribution of risk factors in ischemic and hemorrhagic stroke

Background

Stroke is the second leading cause of death worldwide and is associated with several risk factors with variable risk factor distribution by population. We report the types and frequency of the associated factors of stroke in north Iran.

Methods

Consecutive patients with stroke were recruited from 2014 to 2015. The two groups of ischemic and hemorrhagic stroke were compared with respect to age, sex, the prevalence, and distribution of the risk factors.

Results

Among 230 patients (84.3% ischemic stroke) with mean age of 61.2 years, hypertension (73%), diabetes mellitus (53%), cardiovascular disease (51%), and dyslipidemia (47%) were the most frequent risk factors. Hypertension was significantly more prevalent in males compared with females (88% vs. 60%, OR = 4.91, 95% CI: 2.48–9.71). Hypertension, smoking, and opioid consumption were associated with hemorrhagic stroke. Dyslipidemia was significantly higher in ischemic stroke (OR = 2.65, 95% CI: 1.21–5.8). Overall, 84.3% of stroke occurred in patients aged >50 years (92.8% of women vs. 74.5% of the men, OR = 4.43, 95% CI: 1.93–10.16, p = 0.001).

Conclusion

Stroke was more prevalent in females; hypertension was more prevalent in males. In the age group less than 50 years old, stroke is more prevalent in men.

Considerations and treatment options for patients with comorbid atrial fibrillation and diabetes mellitus

INTRODUCTION

Atrial fibrillation (AF) and diabetes mellitus (DM) are common worldwide and their incidence is increasing, representing a significant public health and economic burden as well as an increase in individual increased morbidity and mortality risk profiles. Both conditions are closely related, as patients with DM are at increased risk of incident AF, and AF patients with DM are at higher risk of cardiovascular events compared to non-AF patients. Areas covered: This review article aims to provide an overview of the current evidence linking DM and AF, as well as the impact of obesity, weight loss and stroke on these coexisting conditions. Second, the effects of new oral anti hyperglycaemic medications on cardiovascular risk will be considered. Expert opinion: In conclusion, coexisting AF and DM represent a high risk population of patients requiring aggressive risk factor identification and treatment optimisation. The multifactorial interplay between these conditions requires individual assessment of patient risk profiles with the aim of minimising the impact of each modifiable risk factor.

Cross-level interaction between individual socioeconomic status and regional deprivation on overall survival after onset of ischemic stroke: National health insurance cohort sample data from 2002 to 2013

INTRODUCTION

The literature on stroke mortality and neighborhood effect is characterized by studies that are often Western society-oriented, with a lack of racial and cultural diversity. We estimated the effect of cross-level interaction between individual and regional socioeconomic status on the survival after onset of ischemic stroke.

METHODS

We selected newly diagnosed ischemic stroke patients from 2002 to 2013 using stratified representative sampling data of 1,025,340 subjects. A total of 37,044 patients over the 10 years from 2004 to 2013 had newly diagnosed stroke. We calculated hazard ratios (HR) of 12- and 36-month mortality using the Cox proportional hazard model, with the reference group as stroke patients with high income in advantaged regions.

RESULTS

For the middle income level, the patients in advantaged regions showed low HRs for overall mortality (12-month HR 1.27; 95% confidence interval [CI], 1.13-1.44; 36-month HR 1.25; 95% CI, 1.14-1.37) compared to the others in disadvantaged regions (12-month HR 1.36; 95% CI, 1.19-1.56; 36-month HR 1.30; 95% CI, 1.17-1.44). Interestingly, for the low income level, the patients in advantaged regions showed high HRs for overall mortality (12-month HR 1.27; 95% CI, 1.13-1.44; 36-month HR 1.33; 95% CI, 1.22-1.46) compared to the others in disadvantaged regions (12-month HR 1.25; 95% CI, 1.09-1.43; 36-month HR 1.30; 95% CI, 1.18-1.44).

CONCLUSION

Although we need to perform further investigations to determine the exact mechanisms, regional deprivation, as well as medical factors, might be associated with survival after onset of ischemic stroke in low-income patients.

Risk factors and subtypes of acute ischemic stroke. A study at King Fahd Hospital of the University

Objective:

To identify the different subtypes of acute ischemic stroke, and estimate the frequency of various risk factors among these patients.

Methods:

In this retrospective, cross-sectional study, we reviewed the medical records of patients admitted with the diagnosis of acute ischemic stroke at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia from March 2008 till December 2015. The demographic characteristics, subtypes of stroke, risk factors (hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, atrial fibrillation, valvular heart disease) and other relevant data were documented on pre-defined data sheets.

Results:

The records of 343 patients were included in the study; 64.4% were male and 35.6% were female. The mean age was 59.3+13.6 (mean+SD) years for males, and 66.8+14.9 years for females. Small vessel occlusion was the most common etiologic subtype of ischemic stroke (32.1%), followed by cardio embolic (21.9%), and large artery atherosclerosis (14.6%). The middle cerebral artery was the most commonly affected territory. Hypertension was found in 78.1%, diabetes mellitus in 62.7%, hyperlipidemia in 54.8%, and ischemic heart disease in 24.2% of patients.

Conclusion:

Small vessel occlusion was the most common etiology in our cohort. The onset of stroke at a relatively younger age group in the male population is of great concern and needs to be verified by further epidemiological studies. Adequate control of modifiable risk factors may help in reducing the disease burden caused by stroke.

Neurologic Complications of Cardiac and Aortic Disease

PURPOSE OF REVIEW

This article discusses neurologic complications that can arise from cardiac and aortic disease and dysfunction.

RECENT FINDINGS

Advances in the care of patients with cardiac or aortic disease include the use of prolonged cardiac monitoring in cryptogenic stroke and the approval of the use of left atrial appendage closure devices for stroke prevention in patients with atrial fibrillation who are not candidates for anticoagulation. Continuing controversy surrounds patent foramen ovale closure, and new evidence indicates that cognitive impairment following coronary artery bypass grafting surgery may be less common than previously thought.

SUMMARY

Dysfunction of the cardiovascular system can cause serious neurologic injury. In some cases, both the initial presenting symptom and the most serious damage done by cardiac or aortic dysfunction may be neurologic. Prompt recognition of the symptoms, combined with recent advances in both cardiology and neurology, may permit more accurate diagnoses, more effective treatment, and less injury to patients.

Blood Pressure Management for Stroke Prevention and in Acute Stroke

Elevated blood pressure (BP) is the leading modifiable risk factor for stroke and the benefit of BP lowering therapy on the stroke risk reduction is well established. The optimal BP target for preventing stroke and other vascular events have been controversial, but the evidences from epidemiological studies and randomized controlled trials (RCTs) support intensive BP lowering for greater vascular protection, particularly for stroke prevention. For secondary stroke prevention, the evidence of intensive BP lowering benefit is limited since only a single RCT for patients with lacunar infarctions was conducted and most data were driven by exploratory analyses. In acute intracerebral hemorrhage, immediate BP lowering targeting systolic BP<140 mm Hg is recommended by guidelines based on the results from RCTs. In contrast, in acute ischemic stroke, early BP lowering is not usually recommended because of no benefit on functional outcome and future vascular events and potential harm of stroke progression. This review aims to summarize the updated evidence for optimal BP management for primary and secondary stroke prevention and in patients with acute stroke.

Assessment of the Predictive Validity of Etiologic Stroke Classification

Importance

The ability of present-day etiologic stroke classification systems to generate subtypes with discrete stroke characteristics is not known.

Objective

To test the hypothesis that etiologic stroke subtyping identifies different disease processes that can be recognized through their different clinical courses.

Design, Setting, and Participants

We performed a head-to-head evaluation of the ability of the Causative Classification of Stroke (CCS), Trial of Org 10172 in Acute Stroke Treatment (TOAST), and ASCO (A for atherosclerosis, S for small-vessel disease, C for cardiac source, and O for other cause) classification systems to generate etiologic subtypes with different clinical, imaging, and prognostic characteristics in 1816 patients with ischemic stroke. This study included 2 cohorts recruited at separate periods; the first cohort was recruited between April 2003 and June 2006 and the second between June 2009 and December 2011. Data analysis was performed between June 2014 and May 2016.

Main Outcomes and Measures

Separate teams of stroke-trained neurologists performed CCS, TOAST, and ASCO classifications based on information available at the time of hospital discharge. We assessed the association between etiologic subtypes and stroke characteristics by computing receiver operating characteristic curves for binary variables (90-day stroke recurrence and 90-day mortality) and by calculating the ratio of between-category to within-category variability from the analysis of variance for continuous variables (admission National Institutes of Health Stroke Scale score and acute infarct volume).

Results

Among the 1816 patients included, the median age was 70 years (interquartile range, 58-80 years) (830 women [46%]). The classification systems differed in their ability to assign stroke etiologies into known subtypes; the size of the undetermined category was 33% by CCS, 53% by TOAST, and 42% by ASCO (P < .001 for all binary comparisons). All systems provided significant discrimination for the validation variables tested. For the primary validation variable (90-day recurrence), the area under the receiver operating characteristic curve was 0.71 (95% CI, 0.66-0.75) for CCS, 0.61 (95% CI, 0.56-0.67) for TOAST, and 0.66 (95% CI, 0.60-0.71) for ASCO (P = .01 for CCS vs ASCO; P < .001 for CCS vs TOAST; P = .13 for ASCO vs TOAST). The classification systems exhibited similar discrimination for 90-day mortality. For admission National Institutes of Health Stroke Scale score and acute infarct volume, CCS generated more distinct subtypes with higher between-category to within-category variability than TOAST and ASCO.

Conclusions and Relevance

Our findings suggest that the major etiologic stroke subtypes are distinct categories with different stroke characteristics irrespective of the classification system used to identify them. We further show that CCS generates discrete etiologic categories with more diverse clinical, imaging, and prognostic characteristics than either TOAST or ASCO.

Acute Stroke and Transient Ischemic Attack in the Outpatient Clinic

Ischemic stroke is cause of substantial death and disability in the United States. Transient ischemic attack, a precursor to ischemic stroke, conveys a high risk of recurrent stroke within 90 days from event. These conditions are highly preventable and treatable. The cause is heterogenous and includes atherothrombosis, cardioembolism, lacunar disease, or cryptogenic, and some uncommon causes, such as arterial dissection and prothrombotic states. The emergent evaluation includes establishing time of onset, vital signs, glucose level, and severity of the deficit.

Association between Embolic Stroke Patterns, ESUS Etiology, and New Diagnosis of Atrial Fibrillation: A Secondary Data Analysis of the Find-AF Trial

Background. Atrial fibrillation (AF) is an important cause of embolic stroke of undetermined source (ESUS). Imaging-patterns like multiple infarcts, simultaneous involvement of different circulations, infarcts of different ages, and isolated cortical infarcts are likely to indicate cardioembolic stroke. The aim of our study was to evaluate the association between embolic stroke patterns, ESUS, and the new diagnosis of AF. Methods. Stroke etiology and imaging characteristics from patients included in the Find-AF study were obtained. Embolic stroke patterns in CT- or MR-imaging were correlated with the diagnosis of ESUS as well as the short- (on baseline ECG and during 7-day Holter) and long-term (12-month follow-up) diagnosis of AF. Results. From 281 patients included in the Find-AF study, 127 (45.2%) patients with ischemic lesions detected in CT or MRI were included. 26 (20.5%) of these patients had ESUS. At least one embolic stroke pattern was detected in 67 (52.7%) patients. Embolic stroke patterns were not associated with ESUS (OR 1.57, 0.65–3.79, p = 0.317), the short-term (OR 0.64, 0.26–1.58, p = 0.327) or long-term diagnosis of AF (OR 0.72, 0.31–1.68, p = 0.448). Conclusions. This secondary data analysis of the Find-AF study could not provide evidence for an association between embolic stroke patterns, ESUS, and the new diagnosis of AF.

Usefulness of the MrWALLETS Scoring System to Predict First Diagnosed Atrial Fibrillation in Patients With Ischemic Stroke

Some cryptogenic strokes are caused by undetected paroxysmal atrial fibrillation (AF) and could benefit from oral anticoagulation. In this study, we searched for echocardiographic parameters associated with first diagnosed AF, to form a scoring system for the identification of patients with AF. We examined 571 patients with ischemic stroke (72.7 ± 13.5 years, 50.6% women), subdivided into 4 groups: documented cause without AF, first diagnosed AF, known paroxysmal AF, and permanent AF. All patients underwent transthoracic echocardiography, brain computed tomography scan, carotid/vertebral ultrasound, and continuous electrocardiographic monitoring. Eight factors independently characterized first diagnosed AF and formed the "MrWALLETS" score: mitral regurgitation, mild-to-moderate (+1), white matter lesions (-1), age ≥75 years (+1), left atrium ≥4 cm (+1), cerebral lesion diameter ≥4 cm (+1), left ventricular end-diastolic volume <65 ml (+1), tricuspid regurgitation ≥moderate (+1), carotid stenosis ≥50% (-1). In the patients with ≥3 points, positive predictive value was 80%, specificity 97.5%, and sensitivity 57.1%. In the patients with ≥2 points sensitivity rose to 85.7%, but positive predictive value was 47.1%. The area under the receiver-operating characteristic curve was 0.89 (95% CI 0.83 to 0.95). There were important differences among AF groups, which therefore could not be merged. In conclusion, 4 echocardiographic parameters, 3 additional instrumental parameters, and age allow the identification of stroke patients with first diagnosed AF with high positive predictive value.

Obesity paradox in stroke - Myth or reality? A systematic review

Background and purpose

Both stroke and obesity show an increasing incidence worldwide. While obesity is an established risk factor for stroke, its influence on outcome in ischemic stroke is less clear. Many studies suggest a better prognosis in obese patients after stroke (“obesity paradox”). This review aims at assessing the clinical outcomes of obese patients after stroke by performing a systematic literature search.

Methods

The reviewers searched MEDLINE from inception to December 2015. Studies were eligible if they included outcome comparisons in stroke patients with allocation to body weight.

Results

Twenty-five studies (299’750 patients) were included and none was randomised. Ten of 12 studies (162’921 patients) reported significantly less mortality rates in stroke patients with higher BMI values. Seven of 9 studies (92’718 patients) ascertained a favorable effect of excess body weight on non-fatal outcomes (good clinical outcome, recurrence of vascular events). Six studies (85’042 patients) indicated contradictory results after intravenous thrombolysis (IVT), however. Several methodological limitations were observed in major part of studies (observational study design, inaccuracy of BMI in reflecting obesity, lacking body weight measurement, selection bias, survival bias).

Conclusion

Most observational data indicate a survival benefit of obese patients after stroke, but a number of methodological concerns exist. No obesity paradox was observed in patients after IVT. There is a need for well-designed randomized controlled trials assessing the effects of weight reduction on stroke risk in obese patients.

Silent Atrial Fibrillation and Cryptogenic Strokes

A new suspected cause of cryptic strokes is "silent atrial fibrillation." Pacemakers and other implanted devices allow continuous recording of cardiac rhythm for months or years. They have discovered that short periods of atrial fibrillation lasting minutes or hours are frequent and usually are asymptomatic. A meta-analysis of 50 studies involving more than 10,000 patients with a recent stroke found that 7.7% had new atrial fibrillation on their admitting electrocardiogram. In 3 weeks during and after hospitalization, another 16.9% were diagnosed. A total of 23.7% of these stroke patients had silent atrial fibrillation; that is, atrial fibrillation diagnosed after hospital admission. Silent atrial fibrillation is also frequent in patients with pacemakers who do not have a recent stroke. In a pooled analysis of 3 studies involving more than 10,000 patients monitored for 24 months, 43% had at least 1 day with atrial fibrillation lasting more than 5 minutes. Ten percent had atrial fibrillation lasting at least 12 hours. Despite the frequency of silent atrial fibrillation in these patients with multiple risk factors for stroke, the annual incidence of stroke was only 0.23%. When silent atrial fibrillation is detected in patients with recent cryptogenic stroke, anticoagulation is indicated. In patients without stroke, silent atrial fibrillation should lead to further monitoring for clinical atrial fibrillation rather than immediate anticoagulation, as some have advocated.

Early-onset and delayed-onset poststroke dementia - revisiting the mechanisms

Incident stroke has long been recognized to cause dementia shortly after the event. Patients who survive stroke without early-onset poststroke dementia (PSD) are at a high risk of developing dementia months to years after the initial stroke incident, which has generated enthusiasm for exploring treatments to prevent delayed-onset PSD in survivors of stroke. However, results from clinical trials completed in the past 10-15 years have been disappointing. In light of these results, the present Review revisits the mechanisms of both early-onset and delayed-onset PSD and proposes preventive strategies and directions for future clinical trials. Early-onset PSD results from a complex interplay between stroke lesion features and brain resilience, whereas delayed-onset PSD is associated mainly with the presence of severe sporadic small vessel disease (SVD), and to a lesser extent with Alzheimer disease pathology or recurrent stroke. As well as preventing stroke and delivering acute stroke treatments to reduce initial brain damage, measures to increase brain resilience could also reduce the risk of developing dementia if an incident stroke occurs. Future efforts to prevent delayed-onset PSD should focus on the study of sporadic SVD and on evaluating whether other strategies, in addition to conventional secondary stroke prevention, are effective in dementia prevention in this high-risk group.

Contrast-enhanced ultrasound of the carotid system: a review of the current literature

Carotid disease is a major current health problem accounting for a significant part of stroke patients. Ultrasound with colour Doppler and spectral analysis is the primary imaging technique used for screening and diagnostic evaluation of the extracranial part of carotid arteries offering identification and grading of carotid disease. However, inherent limitations of this technique include flow-related artefacts like Doppler angle dependence and aliasing artefact which may sometimes hinder complete assessment of a stenotic part of the vessel, potentially failing to address clinically significant differential diagnosis issues. The intravenous use of microbubbles as an US contrast agent has been introduced for the supplementation of conventional technique. The value of contrast-enhanced ultrasound (CEUS) has been investigated in the evaluation of carotid disease leading to promising results. CEUS provides improved flow visualization free of artefacts and detailed plaque surface delineation, thus being able to accurately grade stenosis, identify carotid plaque ulcerations, differentiate occlusion from highly stenotic plaques and identify carotid dissection. Furthermore, microbubbles can be used to identify and grade intraplaque neovascularization, carotid wall inflammation in patients with arteritis, follow-up patients after carotid intervention and assist interventional procedures reducing the need for nephrotoxic contrast agents. The purpose of this review is to present and discuss the current literature regarding the various uses of CEUS in carotid arteries.

Incidence of First Time Stroke: A Saudi Experience

BACKGROUND

Stroke is one of the major causes of morbidity and mortality throughout the world. A number of studies were conducted in Saudi Arabia. However, there were no studies conducted in Al-Madinah Al-Munawarah city.

OBJECTIVE

The aim of this study was to ascertain the incidence rate of first time stroke and the age-specific incidence in both genders in Al-Madinah Al-Munawarah city.

METHODS

A prospective hospital based study was conducted over a 1-year period (2014). The cases were included in the study when they were admitted with a diagnosis of cerebrovascular accident.

RESULTS

A total 164 patients (91 men and 73 women) who had first time stroke were found in this study with no significant difference between them (p = 0.565). The crude incidence rate of stroke was 13.89 per 100,000 persons. The age-specific incidence rate increased with age in the current study, where the peak was in the age group of more than 75 years old for men and women.

CONCLUSIONS

Total crude and the age-specific rates for first time stroke patients revealed in this study were markedly lower than the range reported from the developed countries. However, they were within the range that showed previously in Saudi Arabia and Arabian Peninsula countries.

Diagnostic Impact of Transesophageal Echocardiography in Patients with Acute Cerebral Ischemia

OBJECTIVES

Transesophageal echocardiography (TEE) is the diagnostic gold standard for the detection of structural heart diseases as potential sources of cardiac emboli in patients with acute cerebral ischemia. We sought to determine the diagnostic yield of TEE in patients with acute ischemic stroke or transient ischemic attack (TIA).

METHODS

We retrospectively analyzed consecutive patients with acute cerebral ischemia who were admitted to our hospital between October 2008 and December 2011. TEE reports were screened for detection of cardiac source of embolism judged by the recommendation to change medical management. We performed univariate and multivariate analyses to identify predictors of clinically relevant TEE findings among baseline characteristics.

RESULTS

Of 3314 patients with ischemic stroke or TIA, TEE was performed in 791 (24%) patients (mean age 64 ± 13 years, 589 [74%] ischemic stroke, 202 [26%] TIA). A potential cardioembolic source was found in 71 (9%) patients with patent foramen ovale with atrial septal aneurysm being the most common finding (24/71 patients, 34%). In multivariate analysis, peripheral vascular disease (OR 2.57; 95%CI 1.00-6.61), imaging evidence of infarction in multiple locations (OR 4.13; 95%CI 1.36-12.58), and infarction in the posterior circulation (OR 2.11; 95%CI 1.01-4.42) were associated with the identification of a potential cardioembolic source with TEE.

CONCLUSION

TEE identified a potential structural cardioembolic source in nearly 10% of our selected patient population with acute ischemic stroke or TIA, thus underlining its diagnostic value. Our data suggest that patients with hitherto unknown stroke etiology should be considered for additional TEE.

Evaluation of Freehand B-Mode and Power-Mode 3D Ultrasound for Visualisation and Grading of Internal Carotid Artery Stenosis

Background

Currently, colour-coded duplex sonography (2D-CDS) is clinical standard for detection and grading of internal carotid artery stenosis (ICAS). However, unlike angiographic imaging modalities, 2D-CDS assesses ICAS by its hemodynamic effects rather than luminal changes. Aim of this study was to evaluate freehand 3D ultrasound (3DUS) for direct visualisation and quantification of ICAS.

Methods

Thirty-seven patients with 43 ICAS were examined with 2D-CDS as reference standard and with freehand B-mode respectively power-mode 3DUS. Stenotic value of 3D reconstructed ICAS was calculated as distal diameter respectively distal cross-sectional area (CSA) reduction percentage and compared with 2D-CDS.

Results

There was a trend but no significant difference in successful 3D reconstruction of ICAS between B-mode and power mode (examiner 1 {Ex1} 81% versus 93%, examiner 2 {Ex2} 84% versus 88%). Inter-rater agreement was best for power-mode 3DUS and assessment of stenotic value as distal CSA reduction percentage (intraclass correlation coefficient {ICC} 0.90) followed by power-mode 3DUS and distal diameter reduction percentage (ICC 0.81). Inter-rater agreement was poor for B-mode 3DUS (ICC, distal CSA reduction 0.36, distal diameter reduction 0.51). Intra-rater agreement for power-mode 3DUS was good for both measuring methods (ICC, distal CSA reduction 0.88 {Ex1} and 0.78 {Ex2}; ICC, distal diameter reduction 0.83 {Ex1} and 0.76 {Ex2}). In comparison to 2D-CDS inter-method agreement was good and clearly better for power-mode 3DUS (ICC, distal diameter reduction percentage: Ex1 0.85, Ex2 0.78; distal CSA reduction percentage: Ex1 0.63, Ex2 0.57) than for B-mode 3DUS (ICC, distal diameter reduction percentage: Ex1 0.40, Ex2 0.52; distal CSA reduction percentage: Ex1 0.15, Ex2 0.51).

Conclusions

Non-invasive power-mode 3DUS is superior to B-mode 3DUS for imaging and quantification of ICAS. Thereby, further studies are warranted which should now compare power-mode 3DUS with the angiographic gold standard imaging modalities for quantification of ICAS, i.e. with CTA or CE-MRA.

Role of brain natriuretic peptide as a novel prognostic biomarker in acute ischemic stroke

Aim:

We investigated to study the prognostic importance of brain natriuretic peptide (BNP) in ischemic stroke.

Materials and Methods:

We prospectively enrolled 100 patients with acute ischemic stroke and measured plasma BNP levels and compared with age- and sex-matched healthy controls. Risk factors, biochemical parameters, lipid profile, carotid and vertebral Doppler, imaging, and cardiac evaluation were done. Stroke severity was assessed by the National Institutes of Health Stroke Scale (NIHSS) score on admission and functional disability by Barthel Index (BI) at 3 months. Ischemic stroke subtype was classified according to the Oxfordshire Community Stroke Project (OCSP). Data were entered in MS Excel, and appropriate statistical analysis was done using the SPSS software version 21.0. A P = 0.05 was considered as significant.

Results:

Mean age of patients was 55.17 ± 11.37 years with a male:female ratio 3:1. OCSP showed total anterior circulation infarct (TACI) 35, partial anterior circulation infarct 9, lacunar infarct 12, and posterior circulation infarct 44. NIHSS on admission was average 10 ± 7 and BI was 57 ± 30. BNP in patients (435 ng/ml) was very high as compared to controls (<60 ng/ml) (P < 0.001). There was a positive correlation between age and BNP (R² = 0.34; P < 0.00); NIHSS and BNP (R² = 0.255; P < 0.01), negative correlation between BI and BNP (R² = −0.064; P < 0.01). Mean BNP levels across the OCSP showed higher values in TACI (F = 4.609 P = 0.005). Regression analysis showed that BNP can predict BI which was statistically significant.

Conclusion:

Plasma BNP levels was significantly elevated in patients with ischemic stroke. Our study concludes that high BNP levels are seen in large anterior circulation stroke and is a predictor for the poor functional outcome at 3 months. Determination of BNP levels as a biomarker could be helpful in predicting the outcome in stroke patients.

Stenting of the cervical internal carotid artery in acute stroke management: The Karolinska experience

Background Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is a routine procedure. Yet, precise indications and clinical safety in this setting remains controversial. Present data for mechanical thrombectomy include few studies with acute stenting of tandem occlusions. We evaluated the feasibility, safety and clinical outcome of this endovascular treatment in a retrospective analysis of all consecutive cases at a comprehensive stroke centre. Methods This was a retrospective analysis of all consecutive patients with acute extracranial carotid artery occlusion including acute dissection or high-grade stenosis and concomitant intracranial large-vessel occlusion treated with emergency carotid stenting and intracranial mechanical thrombectomy between November 2007 and May 2015. Results A total of 63 patients with a median age of 67 years (range 33-84 years) were treated. Of these, 33 (52%) patients had concomitant intravenous thrombolysis with recombinant tissue-type plasminogen activator initially. Median admission National Institutes of Health Stroke Scale was 14 (range 1-29). Median time from stroke onset to recanalization was 408 minutes (range 165-1846 minutes). Procedure time was significantly shorter after intravenous thrombolysis (110 minutes [range 15-202 minutes] vs. 130 minutes [range 60-280 minutes]; p = 0.02). Three (5%) patients experienced post-procedural symptomatic intracerebral haemorrhage. In 55/63 (87%) patients, a score of ≥2b on the Thrombolysis in Cerebral Infarction scale could be achieved. Eight (13%) patients died, five (8%) during the acute phase. A total of 29/63 (46%) patients showed a favourable outcome (modified Rankin Scale score of 0-2) after three months. Conclusions Our single-centre retrospective analysis of emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy demonstrated high technical success, reasonable clinical outcomes and acceptable rates of symptomatic intracranial haemorrhage in carefully chosen patients which are triaged interdisciplinary based on clinical and computed tomography imaging criteria. This warrants further study in a randomised prospective trial.

Carotid artery stenting versus no stenting assisting thrombectomy for acute ischaemic stroke: protocol for a systematic review of randomised clinical trials with meta-analyses and trial sequential analyses

BACKGROUND

In patients with intracranial large vessel arterial occlusion, ipsilateral extracranial carotid artery occlusions or near-occlusions pose a significant hurdle in endovascular management of acute ischaemic stroke. Stenting of the carotid lesion may be beneficial in this situation to provide a stable access for introducing catheters through the carotid lesion into the intracranial vasculature and the target occlusion. Furthermore, carotid stenting may ensure ample blood flow for wash-out of clot material and reperfusion of the ischaemic penumbral tissue. However, antiplatelet therapy administered to prevent stent thrombosis and sudden increase in blood flow after reopening of the carotid lesion may increase the risk for intracranial haemorrhagic complications. This review aims to assess the benefits and harms of carotid stenting vs. no stenting assisting thrombectomy for acute ischaemic stroke.

METHODS

International and regional electronic databases will be searched to identify eligible randomised clinical trials. To identify further published, unpublished, or on-going and planned trials searches of Google Scholar, Worldwide Food and Drug Administrations, Worldwide Medicines Agencies, company homepages, reference lists, conference proceedings, and the Science Citation Index cited reference search index will be conducted. Manufacturers of relevant interventional equipment, authors, colleagues, and researchers active in the field will be contacted. No language restrictions will be applied to these searches. Randomised clinical trials will be included for assessing benefits and harms and quasi-randomised studies, and observational studies will be included for assessing harms of the intervention. Meta-analyses will be performed according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, and Trial Sequential Analyses will be conducted to control the risk of random errors and prevent premature statements of superiority of the experimental or control intervention or premature statement of futility. The quality of the evidence will be evaluated with the Grading of Recommendations Assessment, Development, and Evaluation.

DISCUSSION

This systematic review of carotid stenting in endovascular management of acute ischaemic stroke in patients with concomitant extracranial carotid lesions and intracranial embolism will assess benefits and harms of this intervention and assesses whether carotid stenting should be encouraged or avoided in acute ischaemic stroke and identify targets for further research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016033346.

Association of hepatitis B virus infection with decreased ischemic stroke

OBJECTIVES

Inflammatory processes (both infections and autoimmune diseases) may cause endothelial dysfunction and arterial atherosclerosis, subsequently increasing the risk of acute ischemic stroke (AIS). In this investigation, we analyzed the association between hepatitis B virus (HBV) infection and AIS risk.

METHODS

A Taiwan national insurance claims data set of 1,000,000 patients was used to extract 22,303 patients with HBV and 89,212 randomly selected sex- and age-matched controls from the beginning of 2000 to the end of 2006. Both groups were followed up until the appearance of AIS or the end of 2011. AIS risk was measured using the Cox proportional regression model.

RESULTS

After adjusting for the relevant covariates, the HBV group exhibited a lower AIS risk (adjusted hazard ratio [aHR] = 0.77, 95% confidence interval [CI]: 0.66-0.89) compared with the controls at the end of follow-up. Under the condition of no comorbidities, patients with HBV had a lower AIS risk compared with the controls (aHR = 0.65, 95% CI: 0.48-0.87). In 3 age-stratified subgroups, HBV was correlated with a significantly diminished risk of AIS (age ≤ 49 years: aHR = 0.57, 95% CI: 0.39-0.82; age 50-64 years: aHR = 0.65, 95% CI: 0.53-0.80; age ≥ 65 years: aHR = 0.96, 95% CI: 0.76-1.23).

CONCLUSION

HBV was correlated with a reduced risk of AIS development. Although a decrease in AIS risk was noted in the patients with HBV, preventing the development of AIS in this population warrants further attention.