Functional Outcomes Associated With Blood Pressure Decrease After Endovascular Thrombectomy

Importance

The associations between blood pressure (BP) decreases induced by medication and functional outcomes in patients with successful endovascular thrombectomy remain uncertain.

Objective

To evaluate whether BP reductions induced by intravenous BP medications are associated with poor functional outcomes at 3 months.

Design, Setting, and Participants

This cohort study was a post hoc analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control trial, a comparison of intensive and conventional BP management during the 24 hours after successful recanalization from June 18, 2020, to November 28, 2022. This study included 302 patients who underwent endovascular thrombectomy, achieved successful recanalization, and exhibited elevated BP within 2 hours of successful recanalization at 19 stroke centers in South Korea.

Exposure

A BP decrease was defined as at least 1 event of systolic BP less than 100 mm Hg. Patients were divided into medication-induced BP decrease (MIBD), spontaneous BP decrease (SpBD), and no BP decrease (NoBD) groups.

Main Outcomes and Measures

The primary outcome was a modified Rankin scale score of 0 to 2 at 3 months, indicating functional independence. Primary safety outcomes were symptomatic intracerebral hemorrhage within 36 hours and mortality due to index stroke within 3 months.

Results

Of the 302 patients (median [IQR] age, 75 [66-82] years; 180 [59.6%] men), 47 (15.6%)were in the MIBD group, 39 (12.9%) were in the SpBD group, and 216 (71.5%) were in the NoBD group. After adjustment for confounders, the MIBD group exhibited a significantly smaller proportion of patients with functional independence at 3 months compared with the NoBD group (adjusted odds ratio [AOR], 0.45; 95% CI, 0.20-0.98). There was no significant difference in functional independence between the SpBD and NoBD groups (AOR, 1.41; 95% CI, 0.58-3.49). Compared with the NoBD group, the MIBD group demonstrated higher odds of mortality within 3 months (AOR, 5.15; 95% CI, 1.42-19.4). The incidence of symptomatic intracerebral hemorrhage was not significantly different among the groups (MIBD vs NoBD: AOR, 1.89; 95% CI, 0.54-5.88; SpBD vs NoBD: AOR, 2.75; 95% CI, 0.76-9.46).

Conclusions and Relevance

In this cohort study of patients with successful endovascular thrombectomy after stroke, MIBD within 24 hours after successful recanalization was associated with poor outcomes at 3 months. These findings suggested lowering systolic BP to below 100 mm Hg using BP medication might be harmful.

Developing a national surveillance system for stroke and acute myocardial infarction using claims data in the Republic of Korea: a retrospective study

BACKGROUND

Limited information is available concerning the epidemiology of stroke and acute myocardial infarction (AMI) in the Republic of Korea. This study aimed to develop a national surveillance system to monitor the incidence of stroke and AMI using national claims data.

METHODS

We developed and validated identification algorithms for stroke and AMI using claims data. This validation involved a 2-stage stratified sampling method with a review of medical records for sampled cases. The weighted positive predictive value (PPV) and negative predictive value (NPV) were calculated based on the sampling structure and the corresponding sampling rates. Incident cases and the incidence rates of stroke and AMI in the Republic of Korea were estimated by applying the algorithms and weighted PPV and NPV to the 2018 National Health Insurance Service claims data.

RESULTS

In total, 2,200 cases (1,086 stroke cases and 1,114 AMI cases) were sampled from the 2018 claims database. The sensitivity and specificity of the algorithms were 94.3% and 88.6% for stroke and 97.9% and 90.1% for AMI, respectively. The estimated number of cases, including recurrent events, was 150,837 for stroke and 40,529 for AMI in 2018. The age- and sex-standardized incidence rate for stroke and AMI was 180.2 and 46.1 cases per 100,000 person-years, respectively, in 2018.

CONCLUSION

This study demonstrates the feasibility of developing a national surveillance system based on claims data and identification algorithms for stroke and AMI to monitor their incidence rates.

Time Window for Induced Hypertension in Acute Small Vessel Occlusive Stroke With Early Neurological Deterioration

BACKGROUND

Therapeutic-induced hypertension treatment (iHTN) is helpful for alleviating early neurological deterioration (END) in acute small vessel occlusive stroke. We examined the time parameters related to iHTN effectiveness in these patients.

METHODS

We retrospectively reviewed patients with acute small vessel occlusive stroke who underwent iHTN for END, defined as an increase of ≥2 points in total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 point in motor items of NIHSS. The primary outcome was an early neurological improvement (ENI; a decrease of ≥2 points in total NIHSS score or ≥1 point in motor items of NIHSS), and the secondary outcome was any neurological improvement (a decrease of ≥1 point in the total NIHSS score). We conducted a multivariable logistic regression analysis, adjusting for demographics, risk factors, baseline clinical status, and intervention-related variables. We also generated a restricted cubic spline curve for the END-to-iHTN time cutoff.

RESULTS

Among the 1062 patients with small vessel occlusive stroke screened between 2017 and 2021, 136 patients who received iHTN within 24 hours from END were included. The mean age was 65.1 (±12.0) years, and 61.0% were male. Sixty-five (47.8%) patients showed ENI and 77 (56.6%) patients showed any neurological improvement. END-to-iHTN time was significantly shorter in patients with ENI (150 [49-322] versus 290 [97-545] minutes; P=0.018) or any neurological improvement (150 [50-315] versus 300 [130-573] minutes; P=0.002). A 10-minute increase in the time between END and iHTN decreased the odds of achieving ENI (odds ratio, 0.984 [95% CI, 0.970-0.997]; P=0.019) or any neurological improvement (odds ratio, 0.978 [95% CI, 0.964-0.992]; P=0.002). The restricted cubic spline curve showed that the odds ratio of ENI reached its minimum at ≈3 hours.

CONCLUSIONS

Among patients with small vessel occlusive stroke with END, a shorter interval between END and the initiation of iHTN was associated with increased odds of achieving neurological improvement. The efficacy of iHTN may be limited to induction within the first 3 hours of END.

Effect of Intravenous Thrombolysis Prior to Mechanical Thrombectomy According to the Location of M1 Occlusion

BACKGROUND AND PURPOSE

The additive effects of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) remain unclear. We aimed to investigate the efficacy and safety of IVT prior to MT depending on the location of M1 occlusion.

METHODS

We reviewed the cases of patients who underwent MT for emergent large-vessel occlusion of the M1 segment. Baseline characteristics as well as clinical and periprocedural variables were compared according to the location of M1 occlusion (i.e., proximal and distal M1 occlusion). The main outcome was the achievement of functional independence (modified Rankin Scale score, 0-2) at 3 months after stroke. The main outcomes were compared between the proximal and distal groups based on the use of IVT before MT.

RESULTS

Among 271 patients (proximal occlusion, 44.6%; distal occlusion, 55.4%), 33.9% (41/121) with proximal occlusion and 24.7% (37/150) with distal occlusion underwent IVT prior to MT. Largeartery atherosclerosis was more common in patients with proximal M1 occlusion; cardioembolism was more common in those with distal M1 occlusion. In patients with proximal M1 occlusion, there was no association between IVT before MT and functional independence. In contrast, there was a significant association between the use of IVT prior to MT (odds ratio=5.30, 95% confidence interval=1.56-18.05, P=0.007) and functional independence in patients with distal M1 occlusion.

CONCLUSION

IVT before MT was associated with improved functional outcomes in patients with M1 occlusion, especially in those with distal M1 occlusion but not in those with proximal M1 occlusion.

Hypercoagulability on Thromboelastography Can Predict the Functional Outcomes in Patients with Acute Ischemic Stroke

BACKGROUND

 We investigated the association between the reaction time (R), a thromboelastography (TEG) parameter for hypercoagulability, and functional outcomes based on the occurrence of hemorrhagic transformation (HT) and early neurological deterioration (END).

METHODS

 We enrolled ischemic stroke patients and performed TEG immediately after the patients' arrival. The baseline characteristics, occurrence of HT and END, stroke severity, and etiology were compared according to the R. END was defined as an increase of ≥1 point in motor or ≥2 points in the total National Institute of Health Stroke Scale within 3 days after admission. The outcome was the achievement of functional independence (modified Rankin scale [mRS]: 0-2) at 3 months after stroke. Logistic regression analyses were performed to verify the association between R and outcome.

RESULTS

 HT and END were frequently observed in patients with an R of <5 minutes compared with the group with an R of ≥5 minutes (15 [8.1%] vs. 56 [21.0%], p < 0.001; 16 [8.6%] vs. 65 [24.3%], p = 0.001, respectively). In multivariable analysis, an R of <5 minutes was associated with decreased odds of achieving functional independence (0.58 [0.34-0.97], p = 0.038). This association was maintained when the outcome was changed to disability free (mRS 0-1) and when mRS was analyzed as an ordinal variable.

CONCLUSION

 Hypercoagulability on TEG (R <5 minutes) may be a negative predictor for functional outcome of stroke after 3 months, with more frequent HT, END, and different stroke etiologies. This study highlights the potential of TEG parameters as biomarkers for predicting functional outcomes in ischemic stroke patients.

Association between arterial tortuosity and early neurological deterioration in lenticulostriate artery infarction

Early neurological deterioration (END) in lenticulostriate artery (LSA) infarction is associated with perforating artery hypoperfusion. As middle cerebral artery (MCA) tortuosity may alter hemodynamics, we investigated the association between MCA tortuosity and END in LSA infarction. We reviewed patients with acute LSA infarction without significant MCA stenosis. END was defined as an increase of ≥ 2 or ≥ 1 in the National Institutes of Health Stroke Scale (NIHSS) total or motor score, respectively, within first 72 h. The MCA tortuosity index (actual /straight length) was measured. Stroke mechanisms were categorized as branch atheromatous disease (BAD; lesions > 10 mm and 4 axial slices) and lipohyalinotic degeneration (LD; lesion smaller than BAD). Factors associated with END in LD and BAD were investigated. END occurred in 104/390 (26.7%) patients. A high MCA tortuosity index (adjusted odds ratio, aOR 10.63, 95% confidence interval [2.57-44.08], p = 0.001) was independently associated with END. In patients with BAD, high initial NIHSS score (aOR 1.40 [1.03-1.89], p = 0.031) and presence of parental artery disease (stenosis < 50%; aOR 10.38 [1.85-58.08], p = 0.008) were associated with END. In patients with LD, high MCA tortuosity (aOR 41.78 [7.37-237.04], p < 0.001) was associated with END. The mechanism causing END in patients with LD and BAD may differ.

Spatiotemporal association between air pollution and stroke mortality in South Korea

BACKGROUND

Air pollutant concentrations in South Korea vary greatly by region and time. To assess temporal and spatial associations of stroke subtypes with long-term air pollution effects on stroke mortality, we studied ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH).

METHODS

This was an observational study conducted in South Korea from 2001-2018. Concentrations of carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), and particulate matter ≤10 µm in diameter (PM10) were determined from 332 stations. Average air pollutant concentrations in each district were determined by distance-weighted linear interpolation. The nationwide stroke mortality rates in 249 districts were obtained from the Korean Statistical Information Service. Time intervals were divided into three consecutive 6-year periods: 2001-2006, 2007-2012, and 2013-2018.

RESULTS

The concentrations of air pollutants gradually decreased from 2001-2018, along with decreases in IS and ICH mortality rates. However, mortality rates associated with SAH remained constant. From 2001-2006, NO2 (adjusted odds ratio [aOR]:1.13, 95% confidence interval: 1.08-1.19), SO2 (aOR: 1.10, 1.07-1.13), and PM10 (aOR: 1.12, 1.06-1.18) concentrations were associated with IS mortality, and SO2 (aOR: 1.07, 1.02-1.13) and PM10 (aOR:1.11,1.06-1.22) concentrations were associated with SAH-associated mortality. Air pollution was no longer associated with stroke mortality from 2007 onward, as the air pollution concentration continued to decline. Throughout the entire 18-year period, ICH-associated mortality was not associated with air pollution.

CONCLUSIONS

Considering temporal and spatial trends, high concentrations of air pollutants were most likely to be associated with IS mortality. Our results strengthen the existing evidence of the deleterious effects of air pollution on IS mortality.

Corrected QTc interval combined with troponin value and mortality in acute ischemic stroke

Background and Purpose

Cardiac biomarkers including, elevated troponin (ET) and prolonged heart rate-corrected QT (PQTc) interval on electrocardiography are known to frequent and have a prognostic significance in patients with acute ischemic stroke (AIS). However, it is still challenging to practically apply the results for appropriate risk stratification. This study evaluate whether combining ET and PQTc interval can better assess the long-term prognosis in AIS patients.

Methods

In this prospectively registered observational study between May 2007 and December 2011, ET was defined as serum troponin-I ≥ 0.04 ng/ml and PQTc interval was defined as the highest tertile of sex-specific QTc interval (men ≥ 469 ms or women ≥ 487 ms).

Results

Among the 1,668 patients [1018 (61.0%) men; mean age 66.0 ± 12.4 years], patients were stratified into four groups according to the combination of ET and PQTc intervals. During a median follow-up of 33 months, ET (hazard ratio [HR]: 4.38, 95% confidence interval [CI]: 2.94-6.53) or PQTc interval (HR: 1.53, 95% CI: 1.16-2.01) alone or both (HR: 1.77, 95% CI: 1.16-2.71) was associated with increased all-cause mortality. Furthermore, ET, PQTc interval alone or both was associated with vascular death, whereas only ET alone was associated with non-vascular death. Comorbidity burden, especially atrial fibrillation and congestive heart failure, and stroke severity gradually increased both with troponin value and QTc-interval.

Conclusions

In patients with AIS, combining ET and PQTc interval on ECG enhances risk stratification for long-term mortality while facilitating the discerning ability for the burden of comorbidities and stroke severity.

Prospective analysis of video head impulse tests in patients with acute posterior circulation stroke

Background

Video head impulse tests (vHITs), assessing the vestibulo-ocular reflex (VOR), may be helpful in the differential diagnosis of acute dizziness. We aimed to investigate vHITs in patients with acute posterior circulation stroke (PCS) to examine whether these findings could exhibit significant abnormalities based on lesion locations, and to evaluate diagnostic value of vHIT in differentiating dizziness between PCS and vestibular neuritis (VN).

Methods

We prospectively recruited consecutive 80 patients with acute PCS and analyzed vHIT findings according to the presence of dorsal brainstem stroke (DBS). We also compared vHIT findings between PCS patients with dizziness and a previously studied VN group (n = 29). Receiver operating characteristic (ROC) analysis was performed to assess the performance of VOR gain and its asymmetry in distinguishing dizziness between PCS and VN.

Results

Patients with PCS underwent vHIT within a median of 2 days from stroke onset. Mean horizontal VOR gain was 0.97, and there was no significant difference between PCS patients with DBS (n = 15) and without (n = 65). None exhibited pathologic overt corrective saccades. When comparing the PCS group with dizziness (n = 40) to the VN group (n = 29), patients with VN demonstrated significantly lower mean VOR gains in the ipsilesional horizontal canals (1.00 vs. 0.57, p < 0.001). VOR gain and their asymmetry effectively differentiated dizziness in the PCS from VN groups, with an area under the ROC curve of 0.86 (95% CI 0.74-0.98) and 0.91 (95% CI 0.83-0.99, p < 0.001), respectively.

Conclusion

Significantly abnormal vHIT results were rare in patients with acute PCS, even in the presence of DBS. Moreover, vHIT effectively differentiated dizziness between PCS and VN, highlighting its potential for aiding differential diagnosis of acute dizziness.

Intensive vs Conventional Blood Pressure Lowering After Endovascular Thrombectomy in Acute Ischemic Stroke: The OPTIMAL-BP Randomized Clinical Trial

Importance

Optimal blood pressure (BP) control after successful reperfusion with endovascular thrombectomy (EVT) for patients with acute ischemic stroke is unclear.

Objective

To determine whether intensive BP management during the first 24 hours after successful reperfusion leads to better clinical outcomes than conventional BP management in patients who underwent EVT.

Design, Setting, and Participants

Multicenter, randomized, open-label trial with a blinded end-point evaluation, conducted across 19 stroke centers in South Korea from June 2020 to November 2022 (final follow-up, March 8, 2023). It included 306 patients with large vessel occlusion acute ischemic stroke treated with EVT and with a modified Thrombolysis in Cerebral Infarction score of 2b or greater (partial or complete reperfusion).

Interventions

Participants were randomly assigned to receive intensive BP management (systolic BP target <140 mm Hg; n = 155) or conventional management (systolic BP target 140-180 mm Hg; n = 150) for 24 hours after enrollment.

Main Outcomes and Measures

The primary outcome was functional independence at 3 months (modified Rankin Scale score of 0-2). The primary safety outcomes were symptomatic intracerebral hemorrhage within 36 hours and death related to the index stroke within 3 months.

Results

The trial was terminated early based on the recommendation of the data and safety monitoring board, which noted safety concerns. Among 306 randomized patients, 305 were confirmed eligible and 302 (99.0%) completed the trial (mean age, 73.0 years; 122 women [40.4%]). The intensive management group had a lower proportion achieving functional independence (39.4%) than the conventional management group (54.4%), with a significant risk difference (-15.1% [95% CI, -26.2% to -3.9%]) and adjusted odds ratio (0.56 [95% CI, 0.33-0.96]; P = .03). Rates of symptomatic intracerebral hemorrhage were 9.0% in the intensive group and 8.1% in the conventional group (risk difference, 1.0% [95% CI, -5.3% to 7.3%]; adjusted odds ratio, 1.10 [95% CI, 0.48-2.53]; P = .82). Death related to the index stroke within 3 months occurred in 7.7% of the intensive group and 5.4% of the conventional group (risk difference, 2.3% [95% CI, -3.3% to 7.9%]; adjusted odds ratio, 1.73 [95% CI, 0.61-4.92]; P = .31).

Conclusions and Relevance

Among patients who achieved successful reperfusion with EVT for acute ischemic stroke with large vessel occlusion, intensive BP management for 24 hours led to a lower likelihood of functional independence at 3 months compared with conventional BP management. These results suggest that intensive BP management should be avoided after successful EVT in acute ischemic stroke.

Trial Registration

ClinicalTrials.gov Identifier: NCT04205305.

Risk of recurrent ischemic stroke in patients with patent foramen ovale: The role of D-dimer

BACKGROUND

Paradoxical embolism under elevated thromboembolic conditions is known to be the primary mechanism of patent foramen ovale (PFO)-related stroke. We hypothesized that higher levels of D-dimer, a marker of thromboembolism, could increase the risk of stroke recurrence in patients with PFO.

METHODS

We conducted a retrospective analysis of data from 1226 consecutive patients with acute ischemic cryptogenic stroke (CS) who underwent transesophageal echocardiography (TEE). D-dimer was assessed during admission. We used a multivariate Cox proportional hazards model to evaluate the association of long-term outcomes between the presence of PFO and levels of D-dimer.

RESULTS

Of the 1226 patients, the study included 461 who underwent TEE. Among them, 242 (52.5%) had PFOs. Among PFO patients, those with a D-dimer level >1.0 mg/L had a significantly higher risk of stroke recurrence compared to those with <0.5mg/L (adjusted hazard ratio (aHR) 4.04, 95% confidence interval [CI] 1.63-10.02). A pattern of increased risk of event with increasing D-dimer levels was observed (Ptrend=0.008). However, there was no significant difference in the risk of stroke recurrence at any D-dimer level compared to D-dimer level <0.5 mg/L among patients without PFO. In these patients, there was little evidence of increased risk with increasing D-dimer levels (Ptrend=0.570).

CONCLUSIONS

This study demonstrated that the elevated D-dimer level increased the recurrence of stroke in CS patients with PFO, particularly showing a dose-dependent relationship between D-dimer levels and recurrence. However, no such effect was observed in patients without PFO. These findings provide valuable insights into the potential benefits of anticoagulation for strokes related to PFO.

Association between Rapid Ventricular Response and Stroke Outcomes in Atrial Fibrillation-Related Cardiac Embolic Stroke

INTRODUCTION

Patients with atrial fibrillation-related stroke (AF-stroke) are prone to developing rapid ventricular response (RVR). We investigated whether RVR is associated with initial stroke severity, early neurological deterioration (END) and poor outcome at 3 months.

METHODS

We reviewed patients who had AF-stroke between January 2017 and March 2022. RVR was defined as having heart rate >100 beats per minute on initial electrocardiogram. Neurological deficit was evaluated with National Institutes of Health Stroke Scale (NIHSS) score at admission. END was defined as increase of ≥2 in total NIHSS score or ≥1 in motor NIHSS score within first 72 h. Functional outcome was score on modified Rankin Scale at 3 months. Mediation analysis was performed to examine potential causal chain in which initial stroke severity may mediate relationship between RVR and functional outcome.

RESULTS

We studied 568 AF-stroke patients, among whom 86 (15.1%) had RVR. Patients with RVR had higher initial NIHSS score (p < 0.001) and poor outcome at 3 months (p = 0.004) than those without RVR. The presence of RVR [adjusted odds ratio (aOR) = 2.13; p = 0.013] was associated with initial stroke severity, but not with END and functional outcome. Otherwise, initial stroke severity [aOR = 1.27; p = <0.001] was significantly associated with functional outcome. Initial stroke severity as a mediator explained 58% of relationship between RVR and poor outcome at 3 months.

CONCLUSION

In patients with AF-stroke, RVR was independently associated with initial stroke severity but not with END and functional outcome. Initial stroke severity mediated considerable proportion of association between RVR and functional outcome.

Delayed low cerebellar perfusion status is associated with poor outcomes in top-of-basilar occlusion treated with thrombectomy

Background and purpose

Top-of-basilar artery occlusion (TOB) is one of the most devastating strokes despite successful mechanical thrombectomy (MT). We aimed to investigate the impact of initial low cerebellum perfusion delay on the outcomes of TOB treated with MT.

Methods

We included patients who underwent MT for TOB. Clinical and peri-procedural variables were obtained. Perfusion delay in the low cerebellum was defined as (1) time-to-maximum (Tmax) >10 s lesions or (2) relative time-to-peak (rTTP) map >9.5 s with a diameter of ≥6 mm in the low cerebellum. The good functional outcome was defined as the achievement of a modified Rankin Scale score of 0-3 at 3 months after stroke.

Results

Among the 42 included patients, 24 (57.1%) patients showed perfusion delay in the low cerebellum. The admission National Institutes of Health Stroke Scale (NIHSS) score was significantly higher in those with perfusion delay [17 (12-24) vs. 8 (6-15), P = 0.002]. Accordingly, the proportion of good functional outcomes was lower in those with perfusion delay than in those without [5 (20.8%) vs. 13 (72.2%), P = 0.003]. From the multivariable analysis, the admission NIHSS score [odds ratio (OR) = 0.86, 95% confidence intervals (CIs) = 0.75-0.98, P = 0.021] and low cerebellum perfusion delay (OR = 0.18, 95% Cis = 0.04-0.86, P = 0.031) were independently associated with the 3-month functional outcomes.

Conclusion

We found that initial perfusion delay proximal to TOB in the low cerebellum might be a predictor for poor functional outcomes in TOB treated with MT.

Silent brain infarcts after carotid or vertebrobasilar artery stenting

BACKGROUND AND PURPOSE

Stenting is an important treatment for preventing stroke. However, the effect of vertebrobasilar stenting (VBS) might be limited because of relatively high periprocedural risks. Silent brain infarcts (SBIs) are known as a predictor for future stroke. Because of anatomical differences, factors for SBIs might be different between carotid artery stenting (CAS) and VBS. We compared the characteristics of SBIs between VBS and CAS.

METHODS

We included patients who underwent elective VBS or CAS. Diffusion-weighted imaging was performed pre- and post-procedure to detect new SBIs. Clinical variables, occurrence of SBIs, and procedure-related factors were compared between CAS and VBS. Moreover, we investigated predictors of SBIs in each group separately.

RESULTS

Ninety-two (34.2%) out of 269 patients had SBIs. SBIs were more frequently observed in VBS (29 [56.6%] vs. 63 [28.9%], p<.001). The risk of SBIs outside the stent-inserted vascular territory was higher in VBS compared to CAS (14 [48.3%] vs. 8 [12.7%], p<.001). Larger-diameter stents (odds ratio: 1.28, 95% confidence interval: 1.06-1.54, p = .012) and prolonged procedure time (1.01, [1.00-1.03], p = .026) increased the risk of SBIs in CAS, whereas only age increased the risk of SBIs in VBS (1.08 [1.01-1.16], p = .036).

CONCLUSIONS

Compared to CAS, VBS was associated with longer procedure time, more residual stenosis, and more SBIs, especially outside the stent-inserted vascular territory. The risk of SBIs after CAS was associated with stent size and procedural difficulty. Only age was associated with SBIs in VBS. The pathomechanism of SBIs after VBS and CAS may be different.

Thromboelastography as a predictor of functional outcome in acute ischemic stroke patients undergoing endovascular treatment

BACKGROUND

Thromboelastography (TEG) is a useful for predicting hemorrhagic transformation, early neurological deterioration, and functional outcome after stroke. We aimed to investigate whether TEG value could also be useful in predicting functional outcome via various intraprocedural and postprocedural factors in patients with acute large vessel occlusive stroke who underwent intraarterial thrombectomy (IAT).

METHODS

Patients with ischemic stroke who underwent IAT between March 2018 and March 2020 at two tertiary hospitals were included. The association between reaction time (R) and functional outcome was evaluated. The primary outcome was the achievement of functional independence defined as the achievement of a modified Rankin Scale (mRS) score of 0-2 at 3 months after the index stroke.

RESULTS

Among a total of 160 patients (mean age, 70.6 ± 12.3 years; 103 [64.4 %] men), 79 (49.3 %) achieved functional independence at 3 months. R, both as a continuous (odds ratio [OR]: 1.45, 95 % confidence interval [95 % CI]: 1.09-1.92, P = 0.011) and dichotomized parameters (R < 5 min [OR: 0.37, 95 % CI: 0.16-0.82, P = 0.014]), were inversely associated with increased odds of achieving functional independence (mRS score 0-2) after multivariable analysis. The association was still consistent when the outcome was the achievement of disability free (mRS score 0-1) or mRS score analyzed as an ordinal variable.

CONCLUSIONS

Decreased R, especially R < 5 min, was inversely associated with functional outcome pf stroke after EVT.

In-stent restenosis and stented-territory infarction after carotid and vertebrobasilar artery stenting

BACKGROUND

Prognosis after vertebrobasilar stenting (VBS) may differ from that after carotid artery stenting (CAS). Here, we directly compared the incidence and predictors of in-stent restenosis and stented-territory infarction after VBS and compared them with those of CAS.

METHODS

We enrolled patients who underwent VBS or CAS. Clinical variables and procedure-related factors were obtained. During the 3 years of follow-up, in-stent restenosis and infarction were investigated in each group. In-stent restenosis was defined as reduction in the lumen diameter > 50% compared with that after stenting. Factors associated with the occurrence of in-stent restenosis and stented-territory infarction in VBS and CAS were compared.

RESULTS

Among 417 stent insertions (93 VBS and 324 CAS), there was no statistical difference in in-stent restenosis between VBS and CAS (12.9% vs. 6.8%, P = 0.092). However, stented-territory infarction was more frequently observed in VBS than in CAS (22.6% vs. 10.8%; P = 0.006), especially a month after stent insertion. HbA1c level, clopidogrel resistance, and multiple stents in VBS and young age in CAS increased the risk of in-stent restenosis. Diabetes (3.82 [1.24-11.7]) and multiple stents (22.4 [2.4-206.4]) were associated with stented-territory infarction in VBS. However, in-stent restenosis (odds ratio: 15.1, 95% confidence interval: 3.17-72.2) was associated with stented-territory infarction in CAS.

CONCLUSIONS

Stented-territory infarction occurred more frequently in VBS, especially after the periprocedural period. In-stent restenosis was associated with stented-territory infarction after CAS, but not in VBS. The mechanism of stented-territory infarction after VBS may be different from that after CAS.

Abstract WP40: Development Of The System For National Statistics Of Stroke And Acute Myocardial Infarction Using Claims-based Algorithms In Korea

Background: The epidemiology of stroke and acute myocardial infarction (AMI) in Korea is limited by inaccurate methods for estimating incidence. Therefore, this study aimed to build the system for national statistics of stroke and AMI in Korea using claims-based identification algorithms.

Methods: We identified stroke and AMI using the claims-based algorithms based on the 2018 National Health Insurance Service (NHIS) data. The identification algorithms were validated using investigation of medical records of the sampled cases including the patient groups and the control groups based on a 2-stage stratified sampling method. The sampled cases were divided into 6 strata according to regions (capital and non-capital) and types of centers (tertiary hospitals, general hospitals, and hospitals). Based on the medical records results, we calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), and weighted PPV and weighted NPV were calculated by applying strata-specific sampling rates. The incidence rate of stroke and AMI is the number of new cases of stroke and AMI, including recurrent events, which was calculated by applying the algorithms using weighted PPV and NPV to the claims data.

Results: In total, 2,200 cases (1,086 cases in stroke [578 patients and 508 controls] and 1,114 cases in AMI [520 patients and 594 controls]) were sampled after applying algorithms for review of hospital records. In hospital record reviews, the stroke algorithm had 95.2% sensitivity, 99.6% specificity, 89.3% PPV, and 99.8% NPV, and AMI algorithms showed 97.7% sensitivity, 99.9% specificity, 90.0% PPV, and 99.9% NPV. We identified 94,994 stroke and 33,834 AMI cases including recurrent events using validated identification algorithms in 2018. The age- and sex-standardized incidence rate of stroke was 175.7 cases per 100,000 person-years and the incidence rate of AMI was 49.3 cases per 100,000 person-years in 2018.

Conclusion: We developed the national statistical system to estimate the incidence of stroke and AMI using validated claims-based algorithms in Korea. By using this system, we expect that it will be possible to conduct nationwide epidemiological research and improve acute cardiovascular care in Korea.

Abstract TP15: Rationale And Ongoing Status In A Phase 3 Trial Of Nelonemdaz, A Novel Neuroprotection Drug, For Patients With Acute Ischemic Stroke And Reperfusion

Background: A phase III Rescue On reperfusion Damage in cerebral Infarction by Nelonemdaz (RODIN) trial has been launched since December, 2021 and patients are being enrolled.

Rationale: Nelonemdaz (previously, neu2000) targets (1) selectively the 2B subunit of the N-methyl-D-aspartate glutamate receptor, the activation of which causes Na+ and Ca++ influx into neuronal cells and then induces downstream death-signaling pathways, and (2) free radical species, which are released both from the downstream pathways of glutamate receptors and from following reperfusion injury. Phase I and II trials showed its safety and a tendency of clinical outcome improvements.

Methods: RODIN is a multicenter, double-blinded clinical trial. A total of 496 patients will be randomly assigned into nelonemdaz and placebo groups. Patients will be included if they have an acute ischemic stroke (National Institutes of Health Stroke Scale score ≥8 scores) caused by intracranial large vessel occlusion in the anterior circulation (Alberta Stroke Program Early CT Score ≥4), and they are expected to undergo endovascular thrombectomy within 12 hours after stroke onset. The primary endpoint is a favorable shift in the modified Rankin Scale (mRS) score at 90 days after the first dose of drug, analyzed by the Cochran-Mantel-Haenszel shift test.

Ongoing status: By August 23, 2022, 210 patients have been enrolled. It is expected that enrollment could be finalized until spring season of 2023.

Conclusions: This trial will clarify the efficacy and safety of nelonemdaz in patients with acute ischemic stroke and endovascular thrombectomy. This study was registered in ClinicalTrials.gov, number NCT05041010.

Early Response to Endovascular Thrombectomy after Stroke: Early, Late, and Very Late Time Windows

BACKGROUND AND PURPOSE

Endovascular thrombectomy (EVT) has benefits in selected patients 6-24 h after stroke onset. However, the response to EVT >24 h after stroke onset is still unclear. We compared the early response to EVT in patients with different time windows.

METHODS

Patients who underwent EVT in an emergency setting were enrolled and categorized according to when EVT was performed: within 6 (early), 6-24 (late), and >24 h (very late) after stroke onset. Early neurological improvement (ENI) and deterioration (END) were defined as improvement and worsening, respectively, of National Institutes of Health Stroke Scale (NIHSS) score by ≥4 points after EVT. The three groups' clinical characteristics and response to EVT were compared. We also investigated factors associated with ENI and END.

RESULTS

During study period, 274 patients underwent EVT (109 early, 104 late, and 61 very late). Patients who underwent EVT very late were younger (p = 0.007), had smaller ischemic cores, and had lower initial NIHSS scores (8 ± 5) than those who underwent EVT early (14 ± 6) and late (13 ± 7; p < 0.001). Stroke mechanisms also differed according to the time window (p < 0.001): cardioembolism was more common after early EVT, whereas large-artery atherosclerosis was more prevalent among patients who underwent EVT very late. ENI was significantly more common after early (60.6%) and late EVT (51.0%) than after very late EVT (29.5%; p = 0.001); however, rates of END did not differ (11.0%, 13.5%, and 4.9%, respectively). ENI was independently associated with male, higher NIHSS score, and early and late EVT. END was associated with failure of recanalization.

CONCLUSIONS

ENI was more observed and associated with early and late EVT. Highly selected patients receiving very late EVT may not benefit from ENI but may still have a chance to prevent END. The occurrence of END was associated not with time window but with failure of recanalization.

The Rescue on Reperfusion Damage in Cerebral Infarction by Nelonemdaz (RODIN) Trial: Protocol for a Double-Blinded Clinical Trial of Nelonemdaz in Patients with Hyperacute Ischemic Stroke and Endovascular Thrombectomy

BACKGROUND AND PURPOSE

Nelonemdaz (Neu2000) has both selective antagonism against 2B subunit of N-methyl-D-aspartate receptor and antioxidant activity. This drug provides sufficient evidence of neuroprotection in acute cerebral ischemia/reperfusion models. This phase III trial aims to determine this effect in patients.

DESIGN

The Rescue on Reperfusion Damage in Cerebral Infarction by Nelonemdaz is a multicenter, double-blinded clinical trial. A total of 496 patients will be randomly assigned into the nelonemdaz (a total of 5,250 mg divided by 10 times for 5 days) and placebo groups. Patients will be included if they have an acute ischemic stroke (National Institutes of Health Stroke Scale score ≥8) caused by intracranial large vessel occlusion in the anterior circulation (Alberta Stroke Program Early CT Score ≥4), and if they are expected to undergo endovascular thrombectomy within 12 hours after stroke onset.

ENDPOINTS

The primary endpoint is a favorable shift in the modified Rankin Scale (mRS) score at 90 days after the first dose of drug. The data will be analyzed by the Cochran-Mantel-Haenszel shift test. The secondary endpoints include functional independence (mRS 0-2) at 35 and 90 days, the favorable shift of mRS at 35 days, the proportion of mRS 0 at 35 and 90 days, and the occurrence rates of symptomatic intracranial hemorrhage within 7 days.

CONCLUSION

This trial will clarify the efficacy and safety of nelonemdaz in patients with acute ischemic stroke and endovascular thrombectomy. This study has been registered at ClinicalTrials. gov (NCT05041010).

Explanatory Power and Prognostic Implications of Factors Associated with Troponin Elevation in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

We investigated the impact of comorbidity burden on troponin elevation, with separate consideration of neurological conditions, in patients with acute ischemic stroke (AIS).

METHODS

This prospective, observational cohort study consecutively enrolled patients with AIS for 2 years. Serum cardiac troponin I was repeatedly measured, and disease-related biomarkers were collected for diagnosis of preassigned comorbidities, including atrial fibrillation (AF), ischemic heart disease (IHD), myocardial hypertrophy (MH), heart failure (HF), renal insufficiency (RI), and active cancer. The severity of neurological deficits and insular cortical ischemic lesions were assessed as neurological conditions. Adjusted associations between these factors and troponin elevation were determined using a multivariate ordinal logistic regression model and area under the receiver operating characteristic curve (AUC). Cox proportional hazards model was used to determine the prognostic significance of comorbidity beyond neurological conditions.

RESULTS

Among 1,092 patients (66.5±12.4 years, 63.3% male), 145 (13.3%) and 335 (30.7%) had elevated (≥0.040 ng/mL) and minimally-elevated (0.040-0.010 ng/mL) troponin, respectively. In the adjusted analysis, AF, MH, HF, RI, active cancer, and neurological deficits were associated with troponin elevation. The multivariate model with six comorbidities and two neurological conditions exhibited an AUC of 0.729 (95% confidence interval [CI], 0.698-0.759). In Cox regression, AF, IHD, and HF were associated with adverse cardio-cerebrovascular events, whereas HF and active cancer were associated with mortality.

CONCLUSION

Troponin elevation in patients with AIS can be explained by the burden of comorbidities in combination with neurological status, which explains the prognostic significance of troponin assay.

Characteristics of stroke after liver and kidney transplantation

Background

The mechanism and characteristics of a post-transplantation stroke may differ between liver (LT) and kidney transplantation (KT), as the associated comorbidities and peri-surgical conditions are different. Herein, we investigated the characteristics and etiologies of stroke occurring after LT and KT.

Methods

Consecutive patients who received LT or KT between January 2005 to December 2020 who were diagnosed with ischemic or hemorrhagic stroke after transplantation were enrolled. Ischemic strokes were further classified according to the etiologies. The characteristics of stroke, including in-hospital stroke, perioperative stroke, stroke etiology, and timing of stroke, were compared between the LT and KT groups.

Results

There were 105 (1.8%) and 58 (1.3%) post-transplantation stroke patients in 5,950 LT and 4,475 KT recipients, respectively. Diabetes, hypertension, and coronary arterial disease were less frequent in the LT than the KT group. In-hospital and perioperative strokes were more common in LT than in the KT group (LT, 57.9%; KT, 39.7%; p = 0.03, and LT, 43.9%; KT, 27.6%; p = 0.04, respectively). Hemorrhagic strokes were also more common in the LT group (LT, 25.2%; KT, 8.6%; p = 0.01). Analysis of ischemic stroke etiology did not reveal significant difference between the two groups; undetermined etiology was the most common, followed by small vessel occlusion and cardioembolism. The 3-month mortality was similar between the two groups (both LT and KT, 10.3%) and was independently associated with in-hospital stroke and elevated C-reactive protein.

Conclusions

In-hospital, perioperative, and hemorrhagic strokes were more common in the LT group than in the KT group. Ischemic stroke subtypes did not differ significantly between the two groups and undetermined etiology was the most common cause of ischemic stroke in both groups. High mortality after stroke was noted in transplantation patients and was associated with in-hospital stroke.

Association of Left Vertebral Artery Hypoplasia with Posterior Circulation Stroke and the Functional Outcome of Patients with Atrial Fibrillation-Related Cardioembolic Stroke

BACKGROUND AND PURPOSE

A cardiogenic embolus could reach the posterior circulation through the right vertebral artery because of a relatively larger diameter in cases of left vertebral artery hypoplasia. Hence, we investigated whether left vertebral artery hypoplasia is associated with cardiac embolisms with atrial fibrillation in the posterior circulation and its functional outcomes.

MATERIALS AND METHODS

In this monocentric retrospective study, patients with acute cardioembolic stroke with atrial fibrillation were enrolled and underwent CT or neck MRA, which visualized the aortic arch and subclavian arteries. The laterality and size of vertebral artery hypoplasia were recorded. Posterior circulation stroke, basilar artery occlusion, and the functional outcomes after 3 months were investigated.

RESULTS

This study included 407 patients; the patients with left vertebral artery hypoplasia experienced a higher rate of posterior circulation stroke (19 versus 73; 42.2% versus 20.2%; P = .001) and basilar artery occlusion (5 versus 10; 11.1% versus 2.8%; P = .005) than the patients without left vertebral artery hypoplasia. Multivariate analysis revealed that left vertebral artery hypoplasia showed an association with lower odds of achieving a good functional outcome 3 months after the stroke (OR = 0.4; 95% CI, 0.2-0.9; P = .027).

CONCLUSIONS

Patients with cardioembolic stroke and left vertebral artery hypoplasia had posterior circulation stroke, basilar artery occlusion, and poor functional outcomes after 3 months.

Association between lipid profile changes and risk of in-stent restenosis in ischemic stroke patients with intracranial stenosis: A retrospective cohort study

OBJECTIVE

The risk of ischemic stroke with intracranial stenosis is associated with various serum lipid levels. However, the effects of changes in the lipid profile on the risk of in-stent restenosis have not been verified. Therefore, we investigated the association between the occurrence of in-stent restenosis at 12-month follow-up and changes in various lipid profiles.

METHODS

In this retrospective cohort study, we included ischemic stroke patients who had undergone intracranial stenting for symptomatic intracranial stenosis between February 2010 and May 2020. We collected data about serum low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC), and triglyceride (TG) levels, and calculated the TC/HDL-C and LDL-C/HDL-C ratios at baseline and after 12 months. We conducted multivariable logistic regression analyses to verify the association between various lipid profile changes and in-stent restenosis at 12 months.

RESULTS

Among the 100 patients included in the study (mean age, 60.8 ± 10.0 years; male: 80 [80.0%]), in-stent restenosis was found in 13 (13.0%) patients. The risk of in-stent restenosis of more than 50% was significantly decreased when TC/HDL-C ratio (odds ratio [OR] 0.22, [95% confidence interval (CI) 0.05-0.87]) and LDL-C/HDL-C ratio (OR 0.23, [95% CI 0.06-0.93]) decreased or when HDL-C levels (OR 0.10, [95% CI 0.02-0.63]) were increased at 12 months compared with baseline measurements.

CONCLUSIONS

Improvement of HDL-C levels, TC/HDL-C ratio, and LDL-C/HDL-C ratio were associated with decreased risk of in-stent restenosis at 12-month follow-up. Management and careful monitoring of various lipid profiles including HDL-C levels, TC/HDL-C ratio, and LDL-C/HDL-C ratio may be important to prevent in-stent restenosis in patients with intracranial stenting.

Prognostic impact of plasma glucose on cardiogenic shock patients with or without diabetes ellitus: smart rescue trial

Background

Even though the presence of hyperglycemia has shown to affect the clinical outcome of cardiogenic shock patients, the extent of hyperglycemia and its association with prognosis have not been fully addressed in large population

Purpose

Investigate the clinical relationship between hyperglycemic status and in-hospital mortality in cardiogenic shock patients

Method

A total of 1,177 consecutive cardiogenic shock patients were enrolled from January 2014 to December of 2018 at 12 hospitals in South Korea. The primary outcome was in-hospital mortality. Patients were divided into four groups according to their initial plasma glucose level in each of diabetes patients (n=752) and non-diabetes patients (n=425); group 1 (≤8 mmol/L), group 2 (8–12 mmol/L), group 3 (12–16 mmol/L) and group 4 (≥16 mmol/L).

Results

The groups with higher admission plasma glucose were associated with lower systolic blood pressure and higher lactic acid level in both diabetic and non-diabetic patients. In-hospital mortality increased in groups with higher admission plasma glucose level in non-diabetic patients (group-1:24.2%, group-2: 28.6%, group-3: 38.1%, group-4: 49.0%, p&lt;0.01) whereas in diabetic patients, mortality and admission plasma glucose level showed no significant association (group-1: 45%, group-2: 35.4%, group-3: 33.3%, group-4: 43.1%, p=0.26). Even after Multivariate analysis, high plasma glucose was an independent predictor of in-hospital mortality in non-diabetic patients

Conclusion

In cardiogenic shock patients, plasma glucose obtained at admission was associated with in-hospital mortality in non-diabetic patients

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Inha University hospital

Impact of obesity paradox between genders on in-hospital mortality in cardiogenic shock: a retrospective cohort study

Background

In a few studies, obesity was associated with better outcomes in patients with cardiogenic shock (CS). Although this phenomenon, the “obesity paradox”, reportedly manifests differently based on sex in other disease entities, it has not yet been investigated in CS patients.

Methods and results

1,227 patients with CS from The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock (RESCUE) registry in Korea were analyzed. The study population was classified into obese and non-obese groups according to Asian-Pacific criteria (BMI &gt;25.0 kg/m2 for obese). Clinical impact of obesity on in-hospital mortality according to sex was analyzed using logistic regression analysis and restricted cubic spline curves. In-hospital mortality rate was significantly lower in obese men than non-obese men (34.2% vs. 24.1%, p=0.004) while the difference was not significant in women (37.3% vs. 35.8%, p=0.884). As a continuous variable, higher BMI showed a protective effect in men conversely, BMI was not associated with clinical outcomes in women. Comparing to normal-weight patients, obesity was associated with a decreased risk of in-hospital death in men (multivariable-adjusted OR 0.63, CI 0.43–0.92, p=0.016), not in women (multivariable-adjusted OR 0.94, 95% CI 0.55–1.61, p=0.828). Interaction P value for the association between BMI and sex was 0.023.

Conclusions

Obesity paradox exists and apparently occurs in men among CS patients. The differential effect of BMI on in-hospital mortality was observed according to sex.

Funding Acknowledgement

Type of funding sources: None.

Blood pressure variability and early neurological deterioration according to the chronic kidney disease risk categories in minor ischemic stroke patients

Objective

Chronic kidney disease (CKD) increases blood pressure variability (BPV) and affects stroke outcomes. However, the effect of BPV on early neurological deterioration (END) may be different according to the renal function.

Methods

We enrolled ischemic stroke patients with a National Institutes of Health Stroke Scale of ≤5. END was defined as worsening of ≥1 point in motor power or ≥2 points in total score. BPV was calculated with BP measured during the first 5 days and presented as standard deviation (SD) and coefficient of variation (CoV). Renal function was classified using the Kidney Disease Improving Global Outcomes (KDIGO) classification of CKD. Variables were compared between those with (KDIGO classification: moderate- to very-high-risk) and without renal impairment (KDIGO classification: low-risk) and factors associated with END were investigated.

Results

Among the 290 patients (136 [46.9%] renal impairment), END was observed in 59 (20.3%) patients. BPV parameters and the risk of END increased as renal function was impaired. Renal function and systolic BP (SBP) mean, SD, CoV, and diastolic BP (DBP) mean, SD were independently associated with END. We found no association between BPV parameters and END in normal renal function patients; however, among impaired renal function patients, SBP SD (odds ratio [OR]: 1.20, 95% confidence interval [CI]: 1.09–1.32, P<0.001) and CoV (1.30 [1.12–1.50], P<0.001) were associated with END.

Conclusions

The association between END and BPV parameters differs according to renal function in minor ischemic stroke; BPV was associated with END in patients with renal impairment, but less in those with normal renal function.

Nelonemdaz for Patients With Acute Ischemic Stroke Undergoing Endovascular Reperfusion Therapy: A Randomized Phase II Trial

BACKGROUND

Nelonemdaz is a multitarget neuroprotectant that selectively blocks N-methyl-D-aspartate receptors and scavenges free radicals, as proven in preclinical ischemia-reperfusion studies. We aimed to evaluate the safety and efficacy of nelonemdaz in patients with acute ischemic stroke receiving endovascular reperfusion therapy.

METHODS

This phase II randomized trial involved participants with large-artery occlusion in the anterior circulation at baseline who received endovascular reperfusion therapy <8 hours from symptom onset at 7 referral stroke centers in South Korea between October 29, 2016, and June 1, 2020. Two hundred thirteen patients were screened and 209 patients were randomly assigned at a 1:1:1 ratio using a computer-generated randomization system. Patients were divided into 3 groups based on the medication received-placebo, low-dose (2750 mg) nelonemdaz, and high-dose (5250 mg) nelonemdaz. The primary outcome was the proportion of patients with modified Rankin Scale scores of 0-2 at 12 weeks.

RESULTS

Two hundred eight patients were assigned to the placebo (n=70), low-dose (n=71), and high-dose (n=67) groups. The groups had similar baseline characteristics. The primary outcome was achieved in 183 patients, and it did not differ among the groups (33/61 [54.1%], 40/65 [61.5%], and 36/57 [63.2%] patients; P=0.5578). The common odds ratio (90% CI) indicating a favorable shift in the modified Rankin Scale scores at 12 weeks was 1.55 (0.92-2.60) between the placebo and low-dose groups and 1.61 (0.94-2.76) between the placebo and high-dose groups. No serious adverse events were reported.

CONCLUSIONS

The study arms showed no significant difference in the proportion of patients achieving modified Rankin Scale scores of 0-2 at 12 weeks. Nevertheless, nelonemdaz-treated patients showed a favorable tendency toward achieving these scores at 12 weeks, without serious adverse effects. Thus, a large-scale phase III trial is warranted.

REGISTRATION

URL: https://clinicaltrials.gov; Unique identifier: NCT02831088.

Blood Pressure Variability Can Predict Carotid Sinus Reaction After Carotid Stenting

BACKGROUND

Carotid stenting has become an important treatment for carotid disease. Carotid sinus reaction (CSR), a complication which is not uncommon and affects the outcome of carotid stenting. We investigated the predictors of CSR, including blood pressure variability and heart rate variability (BPV and HRV, respectively).

METHODS

We enrolled patients who underwent carotid stenting. CSR was defined as any episode of systolic blood pressure (SBP) <90 mm Hg or heart rate (HR) <60 beats/min after stent deployment or balloon inflation. BPV and HRV were measured before stent insertion and were represented by coefficient of variation (CoV) and SD. Multivariable logistic regression was performed to predict CSR.

RESULTS

Among the 176 patients, 61 (34.7%) patients showed CSR. Blood pressure and HR were measured 14 times before carotid stenting on average. The risk of CSR was independently associated with the use of longer stent (odds ratio: 1.08, 95% confidence interval: 1.00-1.16, P = 0.042) and increased SBP SD (1.07 [1.00-1.14], P = 0.048). Moreover, when the SBP parameter changed to SBP CoV, total stent length (1.08 [1.00-1.16], P = 0.042) and SBP CoV (1.12 [1.02-1.23], P = 0.023) were associated with the occurrence of CSR.

CONCLUSIONS

The use of a longer stent and increased SBP variability before carotid stent insertion were associated with the risk of CSR after carotid stenting. Underlying autonomic dysregulation may increase the risk of CSR during carotid stenting. SBP variability before carotid stenting might be considered a predictor of CSR.

Etiology-Related Outcome of Endovascular Therapy in Posterior Circulation Stroke Compared to Anterior Circulation Stroke

Background and Purpose

We investigated the impact of stroke etiology on the endovascular treatment (EVT) procedure and clinical outcome of posterior circulation stroke (PCS) patients with EVT compared to anterior circulation stroke (ACS) patients.

Methods

We retrospectively analyzed ischemic stroke patients who underwent EVT between January 2012 and December 2020. Enrolled ACS and PCS patients were compared according to etiologies (intracranial arterial steno-occlusion [ICAS-O], artery-to-artery embolic occlusion [AT-O], and cardioembolic occlusion [CA-O]). EVT procedure and favorable clinical outcomes at 3 months (modified Rankin Scale 0–2) were compared between the ACS and PCS groups for each etiology.

Results

We included 419 patients (ACS, 346; PCS, 73) including 88 ICAS-O (ACS, 67; PCS, 21), 66 AT-O (ACS, 50; PCS, 16), and 265 CA-O (ACS, 229; PCS, 36) patients in the study. The onset-to-recanalization time was longer in the PCS group than in the ACS group (median 628.0 minutes vs. 421.0 minutes, P=0.01). In CA-O patients, the door-to-puncture time was longer, whereas the puncture-to-recanalization time was shorter in the PCS group than in the ACS group. The proportions of successful recanalization and favorable clinical outcomes were similar between the ACS and PCS groups for all three etiologies. Low baseline National Institutes of Health Stroke Scale (NIHSS) scores and absence of intracerebral hemorrhage at follow-up imaging were associated with favorable clinical outcomes in both groups, whereas successful recanalization (odds ratio, 11.74; 95% confidence interval, 2.60 to 52.94; P=0.001) was only associated in the ACS group.

Conclusions

The proportions of successful recanalization and favorable clinical outcomes were similar among all three etiologies between PCS and ACS patients who underwent EVT. Initial baseline NIHSS score and absence of hemorrhagic transformation were related to favorable outcomes in the PCS and ACS groups, whereas successful recanalization was related to favorable outcomes only in the ACS group.

Management strategy for extracranial carotid artery aneurysms: A single-center experience

ABSTRACT

This single-center, retrospective study aimed to describe the anatomic and clinical characteristics of extracranial carotid artery aneurysms (ECAAs) and to compare various ECAA management strategies in terms of outcomes.A total of 41 consecutive patients, who underwent treatment for ECAAs between November 1996 and May 2020, were included in this study. The ECAAs were anatomically categorized using the Attigah and Peking Union Medical College Hospital (PUMCH) classifications. The possible study outcomes were restenosis or occlusion of the ipsilateral carotid artery after treatment and treatment-associated morbidity or mortality.The 41 patients were stratified into three groups according to the management strategies employed: surgical (n = 25, 61.0%), endovascular (n = 10, 24.4%), and conservative treatment (n = 6, 14.6%). A palpable, pulsatile mass was the most common clinical manifestation (n = 16, 39.0%), and degenerative aneurysms (n = 29, 65.9%) represented the most common pathogenetic or etiological mechanism. According to the Attigah classification, type I ECAAs (n = 24, 58.5%) were the most common. Using the PUMCH classification, type I ECAAs (n = 26, 63.4%) were the most common. There was a higher prevalence of Attigah type I ECAAs among patients who underwent surgical treatment compared with those who underwent endovascular treatment (64.0% vs 40.0%, P = .09), whereas patients with PUMCH type IIa aneurysms were more likely to receive endovascular treatment (12.0% vs 30.0%). False aneurysms were more likely to be treated using endovascular techniques (20% vs 70%, P = 0.02). Except for two early internal carotid artery occlusions (one each among patients who underwent surgical and endovascular treatments, respectively), there were no early or late restenoses or occlusions during follow-up. Cranial nerve injuries were noted in three patients after surgical treatment, and late ipsilateral strokes occurred in two patients (one each among patients who underwent endovascular and conservative treatment, respectively). There were no other treatment-associated complications or deaths during the study period.

CONCLUSIONS

Both surgical and endovascular treatments could be performed safely for ECAAs with good long-term results according to anatomic location and morphology.

Deep Learning Approach Using Diffusion-Weighted Imaging to Estimate the Severity of Aphasia in Stroke Patients

Background and Purpose

This study aimed to investigate the applicability of deep learning (DL) model using diffusion-weighted imaging (DWI) data to predict the severity of aphasia at an early stage in acute stroke patients.

Methods

We retrospectively analyzed consecutive patients with aphasia caused by acute ischemic stroke in the left middle cerebral artery territory, who visited Asan Medical Center between 2011 and 2013. To implement the DL model to predict the severity of post-stroke aphasia, we designed a deep feed-forward network and utilized the lesion occupying ratio from DWI data and established clinical variables to estimate the aphasia quotient (AQ) score (range, 0 to 100) of the Korean version of the Western Aphasia Battery. To evaluate the performance of the DL model, we analyzed Cohen’s weighted kappa with linear weights for the categorized AQ score (0–25, very severe; 26–50, severe; 51–75, moderate; ≥76, mild) and Pearson’s correlation coefficient for continuous values.

Results

We identified 225 post-stroke aphasia patients, of whom 176 were included and analyzed. For the categorized AQ score, Cohen’s weighted kappa coefficient was 0.59 (95% confidence interval [CI], 0.42 to 0.76; P<0.001). For continuous AQ score, the correlation coefficient between true AQ scores and model-estimated values was 0.72 (95% CI, 0.55 to 0.83; P<0.001).

Conclusions

DL approaches using DWI data may be feasible and useful for estimating the severity of aphasia in the early stage of stroke.

2022 Update of the Korean Clinical Practice Guidelines for Stroke: Antithrombotic Therapy for Patients with Acute Ischemic Stroke or Transient Ischemic Attack

Antithrombotic therapy is a cornerstone of acute ischemic stroke (AIS) management and secondary stroke prevention. Since the first version of the Korean Clinical Practice Guideline (CPG) for stroke was issued in 2009, significant progress has been made in antithrombotic therapy for patients with AIS, including dual antiplatelet therapy in acute minor ischemic stroke or high-risk transient ischemic stroke and early oral anticoagulation in AIS with atrial fibrillation. The evidence is widely accepted by stroke experts and has changed clinical practice. Accordingly, the CPG Committee of the Korean Stroke Society (KSS) decided to update the Korean Stroke CPG for antithrombotic therapy for AIS. The writing members of the CPG committee of the KSS reviewed recent evidence, including clinical trials and relevant literature, and revised recommendations. A total of 35 experts were invited from the KSS to reach a consensus on the revised recommendations. The current guideline update aims to assist healthcare providers in making well-informed decisions and improving the quality of acute stroke care. However, the ultimate treatment decision should be made using a holistic approach, considering the specific medical conditions of individual patients.

Structural Changes of Intra and Extracranial Artery Dissection: a Study of High-Resolution Magnetic Resonance Imaging

OBJECTIVES

The prognosis of a cerebral artery dissection is known to be benign, but the structural changes of vessel wall at follow-up are not well known. The natural course of an intracranial and extracranial artery dissection may differ due to structural differences. We aimed to figure out how stenosis and other wall features change, according to the dissection location.

MATERIALS AND METHODS

We retrospectively enrolled patients who suffered an ischemic stroke or transient ischemic attack due to a dissection and who had undergone both initial and follow-up high-resolution magnetic resonance imaging (HRMRI). Patients were dichotomized to intracranial or extracranial dissection group. The clinical and HRMRI characteristics of two groups were compared. Factors associated with stenosis changes were also investigated.

RESULTS

A total of 57 patients (intracranial, n = 43; and extracranial, n = 14) were enrolled. The mean age (45.6 vs. 32.2, p < 0.001) was higher and hypertension (37.2% vs. 7.1%, p = 0.04) was more frequent in the intracranial dissection group. In HRMRI analysis, stenosis improvement (27.9% vs. 85.7%, p < 0.001) were more frequent whereas residual wall enhancement (86.0% vs. 46.2%, p = 0.006) and intramural hematoma (62.8% vs. 21.4%, p = 0.007) were less frequent in the extracranial dissection group. Multivariate analysis indicated that extracranial location was the only independent factor (odds ratio 8.98, 95 % confidence interval 1.45-55.65; p = 0.02) associated with stenosis improvement.

CONCLUSIONS

Younger age, stenosis improvement, disappearance of wall enhancement and intramural hematoma were more frequent in an extracranial dissection compared with an intracranial dissection. An extracranial location is independently associated with stenosis improvement in dissection patients.

Prognostic Significance of Prolonged Corrected QT Interval in Acute Ischemic Stroke

Background and Purpose: The aim of this study was to determine the relationship between the heart rate-corrected QT (QTc) interval and the risk of incident long-term mortality in patients with acute ischemic stroke (AIS), considering the impact of sex differences on clinical characteristics, outcomes, and QTc intervals.

Methods: We analyzed prospectively registered data included patients with AIS who visited the emergency room within 24 h of stroke onset and underwent routine cardiac testing, such as measurements of cardiac enzymes and 12-lead ECG. QTc interval was corrected for heart rate using Fridericia's formula and was stratified by sex-specific quartiles. Cox proportional hazards models were used to examine the association between baseline QTc interval and incident all-cause death.

Results: A total of 1,668 patients with 1,018 (61.0%) men and mean age 66.0 ± 12.4 years were deemed eligible. Based on the categorized quartiles of the QTc interval, cardiovascular risk profile, and stroke severity increased with prolonged QTc interval, and the risk of long-term mortality increased over a median follow-up of 33 months. Cox proportional hazard model analysis showed that the highest quartile of QTc interval (≥479 msec in men and ≥498 msec in women; hazard ratio [HR]: 1.49, 95% confidence interval [CI]: 1.07–2.08) was associated with all-cause death. Furthermore, dichotomized QTc interval prolongation, defined by the highest septile of the QTc interval (≥501 ms in men and ≥517 m in women: HR: 1.33, 95% CI: 1.00–1.80) was significantly associated with all-cause mortality after adjusting for all clinically relevant variables, such as stroke severity.

Conclusions: Prolonged QTc interval was associated with increased risk of long-term mortality, in parallel with the increasing trend of prevalence of cardiovascular risk profiles and stroke severity, across sex differences in AIS patients.

Carotid Plaque Composition Assessed by CT Predicts Subsequent Cardiovascular Events among Subjects with Carotid Stenosis

BACKGROUND AND PURPOSE

Currently, the characteristics of carotid plaques are considered important factors for identifying subjects at high risk of stroke. This study aimed to test the hypothesis that carotid plaque composition assessed by CTA is associated with an increased risk of future major adverse cardiovascular events among asymptomatic subjects with moderate-to-severe carotid artery stenosis.

MATERIALS AND METHODS

This single-center, retrospective cohort study included 194 carotid plaques from 176 asymptomatic subjects with moderate-to-severe carotid artery stenosis. The association of CTA-determined plaque composition with the risk of subsequent adverse cardiovascular events was analyzed.

RESULTS

During a median follow-up of 41 months, the adverse cardiovascular event incidence among 194 carotid plaques was 19.6%. There were significant differences in plaque Hounsfield units (P < .001) and spotty calcium presence (P < .001) between carotid plaques from subjects with and without subsequent adverse cardiovascular events. Multivariable analysis revealed carotid plaque Hounsfield unit density (P < .001) and spotty calcium (P < .001) as independent predictors of subsequent adverse cardiovascular events. In association with moderate carotid artery stenosis, the plaque Hounsfield unit values were significantly lower among carotid plaques from subjects who experienced subsequent adverse cardiovascular events (P = .002), strokes (P = .01), and cardiovascular deaths (P = .04); the presence of spotty calcium was significantly associated with the occurrence of adverse cardiovascular events (P = .001), acute coronary syndrome (P = .01), and cardiovascular death (P = .04).

CONCLUSIONS

Carotid plaque Hounsfield unit density and spotty calcium were independent predictors of a greater risk of adverse cardiovascular event occurrence.

Elevated Pulse Pressure and Recurrent Hemorrhagic Stroke Risk in Stroke With Cerebral Microbleeds or Intracerebral Hemorrhage

Background Which type of recurrent stroke is associated with pulse pressure (PP) remains uncertain in ischemic stroke with cerebral microbleeds or intracerebral hemorrhage. Methods and Results The (PICASSO) Prevention of Cardiovascular Events in Ischemic Stroke Patients With High Risk of Cerebral Hemorrhage database involving 1454 subjects was analyzed. Subjects were stratified into quartiles according to the distribution of mean PP (mm Hg) during follow-up (mean, 1.9 years): <47 (first quartile), 48 to 53 (second quartile), 54 to 59 (third quartile), and ≥60 mm Hg (fourth quartile). The primary end point was hemorrhagic stroke, and the secondary end points were ischemic stroke, stroke of any type, and major adverse cardiovascular events. Adjusted time-dependent area under the receiver operating characteristic curve analysis was performed to assess the prediction accuracy of mean PP. The mean frequency of visit for blood pressure checkup was 9.4±5.5 times. The stroke incidence rate per 100 person-years was 3.14, 2.24, 5.52, and 6.22, respectively in increasing quartile of mean PP, and the rate of major adverse cardiovascular events was 3.82, 2.84, 6.37, and 7.14, respectively. In the presence of mean arterial pressure, hemorrhagic stroke risk was higher in the highest quartile (adjusted hazard ratio, 6.03; 95% CI, 1.04-34.99) versus the lowest quartile, which was evident at higher mean systolic blood pressure. Higher mean PP as a continuous variable was also a predictor of hemorrhagic stroke (1.09, 1.03-1.15). The time-dependent area under the receiver operating characteristic curve for hemorrhagic stroke was 0.79. Conclusions Long-term elevated PP with higher systolic blood pressure confers a greater risk of subsequent hemorrhagic stroke among stroke patients with cerebral microbleeds or intracerebral hemorrhage. Registration URL: https://www.clinicaltrials.gov; Unique identifier, NCT01013532.

Clinical-Diffusion Mismatch Is Associated with Early Neurological Improvement after Late-Window Endovascular Treatment

BACKGROUND

Clinical-diffusion mismatch (CDM) and perfusion-diffusion mismatch (PDM) are used to select patients for endovascular thrombectomy (EVT) in the late-window period. As CDM well reflects true penumbra, we hypothesized that patients with CDM and PDM would respond better to EVT than those with PDM only at the late-window period.

METHODS

Acute ischemic stroke patients who received EVT 6-24 h after stroke onset were included. PDM (perfusion-/diffusion-weighted image (DWI) lesion volume >1.8) was used to select candidates for EVT in this time-period in our center. CDM was defined according to the DAWN trial criteria. Response to EVT was compared between patients with and without CDM. Early neurological improvement (ENI) was defined as improvement >4 points on National Institutes of Health Stroke Scale (NIHSS) score 1 day after EVT. Multivariable analysis was performed to investigate independent factors associated with ENI. The correlation between DWI lesion volume and NIHSS score was investigated in those with and without CDM.

RESULTS

Among 94 patients enrolled, all patients had PDM and 44 (46.3%) had CDM. Forty-eight patients (51.1%) showed ENI. The prevalence of hypertension, initial NIHSS score, improvement in NIHSS score after EVT, and prevalence of ENI were greater in patients with CDM than those without. ENI was independently associated with onset-to-door time (odds ratio [95% confidence interval]: 0.998 [0.997-1.000]; p = 0.042), complete recanalization (23.912 [2.238-255.489]; p = 0.009), initial NIHSS score (1.180 [1.012-1.377]; p = 0.034), and the presence of CDM (5.160 [1.448-18.386]; p = 0.011). The correlation between DWI lesion volume and initial NIHSS score was strong in patients without CDM (r = 0.731) but only moderate in patients with CDM (r = 0.355).

CONCLUSION

Patients with both CDM and PDM had a better response to late-window EVT than those with PDM only.

Changes in Stroke Patients' Health-Seeking Behavior by COVID-19 Epidemic Regions: Data from the Korean Stroke Registry

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has led to changes in stroke patients' healthcare use. This study evaluated changes in Korean stroke patients' health-seeking behaviors and stroke care services using data from the Korean Stroke Registry (KSR).

Methods

We reviewed data from patients with acute stroke and transient ischemic attack (TIA) during 2019 (before COVID-19 period) and 2020 (COVID-19 period). Outcomes included patient characteristics, time from stroke onset to hospital arrival, and in-hospital stroke pathways. Subgroup analyses were performed for an epidemic region (Daegu city and Gyeongsangbuk-do region, the D-G region).

Results

The study included 1,792 patients from the pre-COVID-19 period and 1,555 patients from the COVID-19 period who visited hospitals that contribute to the KSR. During the COVID-19 period, the D-G region had two-thirds the number of cases (vs. the pre-CO­VID-19 period) and a significant decrease in the proportion of patients with TIA (9.97%–2.91%). Unlike other regions, the median onset-to-door time increased significantly in the D-G region (361 min vs. 526.5 min, p = 0.016), and longer onset-to-door times were common for patients with mild symptoms and who were in their 60s or 70s. The number of patients who underwent intravenous thrombolysis also decreased during the COVID-19 period, although the treatment times were not significantly different between the 2 periods.

Discussion/Conclusion

Korean stroke patients in a CO­VID-19 epidemic region exhibited distinct changes in health-seeking behaviors. Appropriate triage system and public education regarding the importance of early treatment are needed during the COVID-19 pandemic.

Prior intracerebral hemorrhage and white matter hyperintensity burden on recurrent stroke risk

Prior intracerebral hemorrhage (ICH) is associated with increased risk of ischemic stroke. Since white matter hyperintensity (WMH) is associated with ischemic stroke and ICH, this study aimed to evaluate the relationship between ICH and the risk of recurrent stroke by WMH severity. From a prospective multicenter database comprising 1454 noncardioembolic stroke patients with cerebral small-vessel disease, patients were categorized by presence or absence of prior ICH and WMH severity: mild-moderate WMH (reference); advanced WMH; ICH with mild-moderate WMH; and ICH with advanced WMH. Among patients with ICH, the association with stroke outcomes by WMH burden was further assessed. The primary endpoint was ischemic stroke and hemorrhagic stroke. The secondary endpoint was major adverse cardiovascular events (MACE): stroke/coronary heart disease/vascular death. During the mean 1.9-year follow-up period, the ischemic stroke incidence rate per 100 person-years was 2.7, 4.0, 2.5, and 8.1 in increasing severity, and the rate of hemorrhagic stroke was 0.7, 1.3, 0.6, and 2.1, respectively. The risk of ischemic stroke was higher in ICH with advanced WMH (adjusted HR 2.62; 95% CI 1.22−5.60) than the reference group, while the risk of hemorrhagic stroke trended higher (3.75, 0.85–16.53). The risk of MACE showed a similar pattern in ICH with advanced WMH. Among ICH patients, compared with mild WMH, the risk of ischemic stroke trended to be higher in advanced WMH (HR 3.37; 95% CI 0.90‒12.61). Advanced WMH was independently associated with an increased risk of hemorrhagic stroke (HR 33.96; 95% CI 1.52−760.95). Given the fewer rate of hemorrhagic stroke, the risk of hemorrhagic stroke might not outweigh the benefits of antiplatelet therapy for secondary prevention.

Outcome in Patients Treated with Intra-arterial thrombectomy: The optiMAL Blood Pressure control (OPTIMAL-BP) Trial

RATIONALE

Very early stage blood pressure (BP) levels may affect outcome in stroke patients who have successfully undergone recanalization following intra-arterial treatment, but the optimal target of BP management remains uncertain.

AIM

We hypothesized that the clinical outcome after intensive BP-lowering is superior to conventional BP control after successful recanalization by intra-arterial treatment.

SAMPLE-SIZE ESTIMATES

We aim to randomize 668 patients (334 per arm), 1:1.

METHODS AND DESIGN

We initiated a multicenter, prospective, randomized, open-label trial with a blinded end-point assessment (PROBE) design. After successful recanalization (thrombolysis in cerebral infarction score ≥ 2 b), patients with elevated systolic BP level, defined as the mean of two readings ≥ 140 mmHg, will be randomly assigned to the intensive BP-lowering (systolic BP < 140 mm Hg) group or the conventional BP-lowering (systolic BP, 140-180 mm Hg) group.

STUDY OUTCOMES

The primary efficacy outcomes are from dichotomized analysis of modified Rankin Scale (mRS) scores at three months (mRS scores: 0-2 vs. 3-6). The primary safety outcomes are symptomatic intracerebral hemorrhage and death within three months.

DISCUSSION

The OPTIMAL-BP trial will provide evidence for the effectiveness of active BP control to achieve systolic BP < 140 mmHg during 24 h in patients with successful recanalization after intra-arterial treatment.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04205305.

Diagnosis of Acute Central Dizziness With Simple Clinical Information Using Machine Learning

Background: Acute dizziness is a common symptom among patients visiting emergency medical centers. Extensive neurological examinations aimed at delineating the cause of dizziness often require experience and specialized training. We tried to diagnose central dizziness by machine learning using only basic clinical information.

Methods: Patients were enrolled who had visited an emergency medical center with acute dizziness and underwent diffusion-weighted imaging. The enrolled patients were dichotomized as either having central (with a corresponding central lesion) or non-central dizziness. We obtained patient demographics, risk factors, vital signs, and presentation (non-whirling type dizziness or vertigo). Various machine learning algorithms were used to predict central dizziness. The area under the receiver operating characteristic curve (AUROC) was measured to evaluate diagnostic accuracy. The SHapley Additive exPlanations (SHAP) value was used to explain the importance of each factor.

Results: Of the 4,481 visits, 414 (9.2%) were determined as central dizziness. Central dizziness patients were more often older and male and had more risk factors and higher systolic blood pressure. They also presented more frequently with non-whirling type dizziness (79 vs. 54.4%) than non-central dizziness. Catboost model showed the highest AUROC (0.738) with a 94.4% sensitivity and 31.9% specificity in the test set (n = 1,317). The SHAP value was highest for previous stroke presence (mean; 0.74), followed by male (0.33), presentation as non-whirling type dizziness (0.30), and age (0.25).

Conclusions: Machine learning is feasible for classifying central dizziness using demographics, risk factors, vital signs, and clinical dizziness presentation, which are obtainable at the triage.

A prospective, observational study of rivaroxaban for stroke prevention in atrial fibrillation: the XANAP Korea

BACKGROUND/AIMS

Atrial fibrillation (AF)-related stroke accounts for 20% of ischemic strokes. Rivaroxaban use in AF patients for preventing stroke and systemic embolism was approved in 2013 in Korea. This study was to investigate the safety and effectiveness of rivaroxaban use in Korean patients with non-valvular AF in a real-world setting.

METHODS

This was an analysis of the Korean patients in Xarelto for Prevention of Stroke in Patients with Atrial Fibrillation in Asia-Pacific (XANAP), which was a prospective, observational cohort study including patients with non-valvular AF starting rivaroxaban treatment to prevent stroke or non-central nervous system systemic embolism (non-CNS SE), conducted in 10 Asian countries.

RESULTS

A total of 844 patients were enrolled in the Korean portion of the XANAP study. In XANAP Korea, the mean age was 70.1 years and 62.6% were males. The mean CHADS2 score was 2.5 and the mean CHA2DS2-VASc score was 3.8. 47% of the patients had experienced prior stroke or non-CNS SE or transient ischemic attack. 73.6% of the patients had CHADS2 score ≥ 2. Incidence proportions of 0.8% of the patients (1.1 per 100 patient-years) developed adjudicated treatment-emergent major bleeding. Death was observed in 1.2% of the patients. The incidence of non-major bleeding as well as thromboembolic event were 8.4% (11.6 per 100 patient-years) and 1.5% (2.0 per 100 patient-years), respectively.

CONCLUSION

This study reaffirmed the consistent safety profile of rivaroxaban. We found consistent results with overall XANAP population for rivaroxaban in terms of safety in non-valvular AF patients for the prevention of stroke and non-CNS SE.

Newly diagnosed diabetes has high risk for cardiovascular outcome in ischemic stroke patients

We investigated cardiovascular outcomes in ischemic stroke patients with newly diagnosed diabetes mellitus (DM) compared with those of patients with previously known DM and no DM using the glycosylated hemoglobin (HbA1c) criteria. The relationship between new DM diagnosis and cardiovascular risk remains unclear to date. We performed post hoc analysis using the data of participants from the Prevention of Cardiovascular events in iSchemic Stroke patients with high risk of cerebral hemOrrhage (PICASSO) trial. Newly diagnosed DM was defined as HbA1c of ≥ 6.5% without known DM history. The outcome was the incidence of composite cardiovascular events, including stroke (ischemic and hemorrhagic), myocardial infarction, and cardiovascular death. In total, 1306 patients were included; 38 patients (2.9%) had newly diagnosed DM; 438 patients (33.5%), known DM; and 830 patients (63.6%), no DM. In patients with newly diagnosed DM, known DM, and no DM, the incidence of ischemic stroke was 8.93, 3.79, and 2.64 per 100 person-years (log-rank test; p = 0.0092), while that of composite cardiovascular events was 8.93, 5.92, and 3.87 per 100 person-years (p = 0.025), respectively. Newly diagnosed DM was an important risk factor for ischemic stroke and composite cardiovascular events after ischemic stroke.

Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01013532.