Comparison of acute ischemic stroke evaluation and the etiologic subtypes between university and nonuniversity hospitals in Isfahan, Iran

A Simple Score for Predicting Paroxysmal Atrial Fibrillation in Patients with Embolic Stroke of Undetermined Source in a Tunisian Cohort Study

BACKGROUND

The annualized recurrent stroke rate in patients with Embolic Stroke of Undetermined Source (ESUS) under antiplatelet therapy is around 4.5%. Only a fraction of these patients will develop atrial fibrillation (FA), to which a stroke can be attributed retrospectively. The challenge is to identify patients at risk of occult AF during follow-up.

OBJECTIVE

This work aims to determine clinical factors and electrocardiographic and ultrasound parameters that can predict occult AF in patients with ESUS and build a simple predictive score applicable worldwide.

METHODS

This is a single-center, registry-based retrospective study conducted at the stroke unit of Sahloul University Hospital, Sousse, Tunisia, between January 2016 and December 2020. Consecutive patients meeting ESUS criteria were monitored for a minimum of one year, with a standardized follow-up consisting of outpatient visits, including ECG every three months and a new 24-hour Holter monitoring in case of palpitations. We performed multivariate stepwise regression to identify predictors of new paroxysmal AF among initial clinical, electrocardiographic (ECG and 24-hour Holter monitoring) and echocardiographic parameters. The coefficient of each independent covariate of the fitted multivariable model was used to generate an integerbased point-scoring system.

RESULTS

Three hundred patients met the criteria for ESUS. Among them, 42 (14%) patients showed at least one episode of paroxysmal AF during a median follow-up of two years. In univariate analysis, age, gender, coronary artery disease, history of ischemic stroke, higher NIHSS at admission and lower NIHSS at discharge, abnormal P-wave axis, prolonged P-wave duration, premature atrial contractions (PAC) frequency of more than 500/24 hours, and left atrial (LA) mean area of more than 20 cm2 were associated with the risk of occurrence of paroxysmal AF. We proposed an AF predictive score based on (1.771 x NIHSS score at admission) + (10.015 x P-wave dispersion; coded 1 if yes and 0 if no) + (9.841x PAC class; coded 1 if ≥500 and 0 if no) + (9.828x LA class surface; coded 1 if ≥20 and 0 if no) + (0.548xNIHSS score at discharge) + 0.004. A score of ≥33 had a sensitivity of 76% and a specificity of 93%.

CONCLUSION

In this cohort of patients with ESUS, NIHSS at both admission and discharge, Pwave dispersion, PAC≥500/24h on a 24-hour Holter monitoring, and LA surface area≥20 cm2 provide a simple AF predictive score with very reasonable sensitivity and specificity and is applicable almost worldwide. An external validation of this score is ongoing.

"Incidence, characteristics and prognosis of cervical artery dissection-induced ischemic stroke in central Iran"

OBJECTIVES

Ischemic stroke is the most common presentation of cervical artery dissection (CAD). Information regarding CAD-induced stroke is scarce, especially in the Middle East. Here we investigated the incidence of CAD-induced stroke, its characteristics, and the clinical course in central Iran.

METHODS

This is an observational study conducted in the city of Isfahan, Iran. We recruited patients with ischemic stroke during 2017-2019. We analyzed characteristics of the CAD-induced stroke patients with regards to the involved vessel (internal carotid artery dissection (ICAD) or vertebral artery dissection (VAD)). We assessed functional outcome (modified Rankin Scale [mRS]) and recanalization status after 1 year of follow-up.

RESULTS

Among 3630 ischemic stroke patients, 51(1.4%) had CAD-induced stroke (mean age: 41.8 ± 12.6; 40.4% female; 28 and 19 ICAD and VAD cases, respectively). The crude incidence rate of CAD-induced stroke was 1.20/100,000/year (0.66/100,000/year and 0.45/100,000/year for strokes due to ICAD and VAD, respectively). mRS ≤ 2 was present in 63.8% of the patients after 1 year of follow-up. History of exercise during the last days before stroke occurrence was associated with a better follow-up mRS (β = -3.1, p-value: 0.037). Administration of anticoagulant or double-antiplatelets was related neither to mRS nor recanalization results. Trauma (27.7%), smoking (21.3%), and headache disorders/migraine (21.3%) were the most common reported factors.

CONCLUSION

We found a crude incidence rate of 1.20/100,000/year for CAD-induced stroke. Trauma, smoking, and headache disorders were the most common reported factors among our patients. CAD-induced stroke had a favorable long-term prognosis regardless of the type of the involved vessel or the used medication.

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

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Background and Purpose:

Stroke is reported as a consequence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in several reports. However, data are sparse regarding the details of these patients in a multinational and large scale.

Methods:

We conducted a multinational observational study on features of consecutive acute ischemic stroke, intracranial hemorrhage, and cerebral venous or sinus thrombosis among SARS-CoV-2–infected patients. We further investigated the risk of large vessel occlusion, stroke severity as measured by the National Institutes of Health Stroke Scale, and stroke subtype as measured by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria among patients with acute ischemic stroke. In addition, we explored the neuroimaging findings, features of patients who were asymptomatic for SARS-CoV-2 infection at stroke onset, and the impact of geographic regions and countries’ health expenditure on outcomes.

Results:

Among the 136 tertiary centers of 32 countries who participated in this study, 71 centers from 17 countries had at least 1 eligible stroke patient. Of 432 patients included, 323 (74.8%) had acute ischemic stroke, 91 (21.1%) intracranial hemorrhage, and 18 (4.2%) cerebral venous or sinus thrombosis. A total of 183 (42.4%) patients were women, 104 (24.1%) patients were <55 years of age, and 105 (24.4%) patients had no identifiable vascular risk factors. Among acute ischemic stroke patients, 44.5% (126 of 283 patients) had large vessel occlusion; 10% had small artery occlusion according to the TOAST criteria. We observed a lower median National Institutes of Health Stroke Scale (8 [3–17] versus 11 [5–17]; P=0.02) and higher rate of mechanical thrombectomy (12.4% versus 2%; P<0.001) in countries with middle-to-high health expenditure when compared with countries with lower health expenditure. Among 380 patients who had known interval onset of the SARS-CoV-2 and stroke, 144 (37.8%) were asymptomatic at the time of admission for SARS-CoV-2 infection.

Conclusions:

We observed a considerably higher rate of large vessel occlusions, a much lower rate of small vessel occlusion and lacunar infarction, and a considerable number of young stroke when compared with the population studies before the pandemic. The rate of mechanical thrombectomy was significantly lower in countries with lower health expenditures.

Public Stroke Knowledge, Awareness, and Response to Acute Stroke in Isfahan Iran: What is Less or Misinterpreted in Developing Countries

BACKGROUND

Considering the high burden of stroke in developing countries, it is important for the community to have adequate information and awareness of this disease. In this study, the baseline knowledge of an Iranian population towards stroke has been evaluated.

METHOD

This study was conducted in a governmental hospital in Isfahan, Iran. The participants were selected from the companions of non-cardio-vascular hospitalized patients. A self-administered questionnaire was designed for gathering information RESULTS: A total of 630 questionnaires were analysed. Hypertension and stress were the most frequently identified risk factors (recognised by 83.7% and 75.8% respectively), while pregnancy, oral contraceptives, and anti-coagulants were the least (recognised by 3.5%, 14.2% and 15.8% respectively). Knowledge of other important risk factors such as cardiac diseases was also relatively low (39.4%). Sudden visual difficulties and irrelevant speech were the least identified warning signs of stroke (45.3% and 34.6% respectively), however, knowledge towards all other warning signs was moderately good (each identified by 60-70%). Importantly only 44.2% of respondents were aware that stroke treatment should be started within the first 3 hours. Participants tended to have moderately good insight of most stroke complications and rehabilitation (60-70%). Urban residence, high level of education and knowing someone with a history of stroke were significant predictors of a higher level of stroke awareness.

CONCLUSION

The findings of this study indicate that there is a need to improve general knowledge of cardiac and hypercoagulable related risk factors. Furthermore, understanding of the importance of time critical stroke management and the ineffectiveness of traditional medicine needs to be raised in the general community.

Vascular imaging in the initial evaluation of embolic stroke source

PURPOSE

During acute ischemic stroke evaluations, neurovascular imaging is commonly performed to localize the source of a thromboembolus and to identify vascular stenoses. In this study, we aimed to analyze 1) the usefulness of intracranial and/or cervical CTA and MRA and carotid doppler ultrasound (DUS) for identifying the stroke source and 2) the incidence of vascular stenoses across stroke etiologies.

METHODS

We retrospectively reviewed intracranial and/or cervical CTA, DUS and MRA studies to identify the source of the acute stroke by Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria for 200 consecutive patients admitted with a stroke to our tertiary hospital. Stroke etiologies were ascertained and the rates of intracranial and cervical vascular stenoses were stratified by stroke type.

RESULTS

Of 200 patients, the most probable sources of stroke were small vessel disease (29%), cardioembolic (26.0%) and atheroembolic (23.5%). Across all groups, 27.5% of patients had ≥70% stenosis on neurovascular imaging. The rate of ≥70% vascular stenosis in the neck was 6.9% and 5.8% in the small vessel and cardioembolic categories, respectively.

CONCLUSIONS

The TOAST etiologies of strokes were nearly equally distributed. Neurovascular imaging was of high utility for identifying large vessel intracranial stenoses in patients presenting with acute stroke across all etiologies, although neck CTA/MRA had a lower rate of positive studies with cardiogenic and small vessel strokes. These findings have implications on the use of CTA/MRA in acute stroke work-up.