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Schmidt K, Power MC, Ciarleglio A, Nadareishvili Z. Effect of pioglitazone on vascular events in post-stroke cognitive impairment: Post hoc analysis of the IRIS trial. Int J Stroke 2024; 19:414-421. [PMID: 38148372 DOI: 10.1177/17474930231225568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND In stroke patients with insulin resistance (IR), post-stroke cognitive impairment (PSCI) is associated with higher risk of recurrent stroke, but the effect of pioglitazone on that risk has not been explored. The goal of this study was to compare the secondary stroke prevention effect of pioglitazone against placebo in patients with versus without PSCI. METHODS We studied patients enrolled in the Insulin Resistance Intervention after Stroke (IRIS) trial with a post-stroke modified Mini-Mental State Examination (3MS) cognitive assessment (mean time of assessment: 79 days post-stroke). We considered a baseline score of ⩽ 88 on the 3MS to indicate global PSCI, and domain-specific summary scores in the lowest quartile to indicate attention, language, memory, orientation, and visuospatial impairments. RESULTS In n = 3338 patients with IR, the effect of pioglitazone versus placebo on secondary stroke significantly differed by initial post-stroke global (interaction p = 0.0127) and memory impairment status (interaction p = 0.0003). Hazard ratios (HRs) were time-dependent such that, among those with either global or memory impairment, pioglitazone has an increasingly stronger protective effect at later timepoints. There was no statistically significant effect of pioglitazone among those without either global or memory impairment. The effect of pioglitazone versus placebo on myocardial infarction (MI) also significantly differed by global impairment status (interaction p = 0.030). Pioglitazone was protective among those with global impairment (HR = 0.23 [95% CI: 0.08, 0.71]) but not among those without (HR = 0.88 [95% CI: 0.59, 1.31]). CONCLUSION These data indicate that pioglitazone treatment may be more effective at reducing risk of recurrent stroke and MI in stroke patients with PSCI. Simple cognitive testing 2-3 months post-stroke may identify patients for whom treatment would be most beneficial.
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Affiliation(s)
- Kat Schmidt
- Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Melinda C Power
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Adam Ciarleglio
- Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Zurab Nadareishvili
- Department of Neurology, School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
- Stroke Center, Virginia Hospital Center, Arlington, VA, USA
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Pan X, Hu W, Wang Z, Fang Q, Xu L, Shen Y. Effect of self-regulating fatigue on health-related quality of life of middle-aged and elderly patients with recurrent stroke: a moderated sequential mediation model. PSYCHOL HEALTH MED 2024; 29:778-790. [PMID: 37455376 DOI: 10.1080/13548506.2023.2235739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
Although the association between self-regulation of fatigue and health-related quality of life (HRQoL) has been confirmed, the potential mechanism remains unclear. This study aimed to explore the role of health literacy, health behavior, and exercise frequency in the relationship among middle-aged and elderly patients with recurrent stroke. A cross-sectional survey was conducted. A total of 176 patients completed the survey, in which self-regulation of fatigue, HRQoL, health literacy and health behavior were measured by questionnaires. Based on Bootstrap analyses, a moderating sequential mediation model using PROCESS software was constructed with health literacy and health behavior as mediators and exercise frequency as the moderator. Of the participants, the mean age was 65.44 ± 12.43 years. Self-regulation of fatigue was found to affect HRQoL indirectly through two significant mediation pathways: (1) health literacy (β=-0.11, 95%CI = -0.20, -0.03), which accounted for 28.79% of the total effect, and (2) health literacy and health behavior (β=-0.02, 95%CI = -0.05, -0.00), which accounted for 4.80% of the total effect. Exercise frequency moderated the relationship between self-regulating fatigue and HRQoL. Specifically, the interaction term between self-regulating fatigue and exercise frequency significantly predicted HRQoL (β = 0. 25, t = 2.55, p < 0.05). These findings highlight the role of health literacy and health behavior as sequential mediators of the relationship between self-regulating fatigue and HRQoL. Moreover, exercise frequency moderated the relationship between self-regulating fatigue and HRQoL. Encouraging patients with recurrent stroke to increase exercise frequency appropriately might improve HRQoL for patients with poor health literacy and health behavior.
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Affiliation(s)
- Xi Pan
- Departments of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Wei Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, P. R. China
| | - Zhi Wang
- Departments of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Qi Fang
- Departments of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Lan Xu
- Nursing Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yueping Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, P. R. China
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Aarnio K, Martinez-Majander N, Haapaniemi E, Kokkola E, Broman J, Tulkki L, Kaste M, Tatlisumak T, Putaala J. Etiologic subtypes of first and recurrent ischemic stroke in young patients using A-S-C-O and TOAST classification criteria: A retrospective follow-up study. Eur Stroke J 2024:23969873241238508. [PMID: 38528455 DOI: 10.1177/23969873241238508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Scarce data exist on the etiology of recurrent ischemic strokes (ISs) among young adults. We analyzed the etiology of first-ever and recurrent events and the differences between them. PATIENTS AND METHODS Patients aged 15-49 years with a first-ever IS in 1994-2007 were included in the Helsinki Young Stroke Registry. In this retrospective cohort study, data on recurrent ISs were identified from Care Register for Health Care until the end of 2017 and Causes of Death Register and from patient records until the end of 2020. All first-ever and recurrent ISs were classified using Atherosclerosis-Small vessel disease-Cardioembolism-Other Cause (A-S-C-O) and Trial of Org 10172 in Acute Stroke Treatment (TOAST) classifications. RESULTS A total of 970 patients were included (median age at index IS 46 years, interquartile range 43-48, 33% women), of which 155 (16.0%) patients had recurrent IS, with 8 (5.2%) fatal cases and 5 (3.2%) unverifiable cases. The median follow-up was 17.4 (IQR 13.9-21.7) years. Median time from the index event to the first recurrent event was 4.5 (interquartile range [IQR] 1.6-10.2) years. Recurrence was more often due to definite cardioembolism (10.7% vs 18.0%, p = 0.013), while the proportion of other definite A-S-C-O subgroups remained the same. With TOAST classification, the proportion of true cryptogenic ISs decreased (16.7% vs 6.7%, p = 0.003), while those with incomplete evaluation increased (9.3% vs 19.3%, p = 0.015). Other TOAST phenotypes remained the same. CONCLUSION The proportion of definite cardioembolism increased at recurrence using the A-S-C-O classification and the number of cryptogenic ISs decreased using the TOAST classification, while cases with incomplete evaluation increased. Most etiologies remained the same.
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Affiliation(s)
- Karoliina Aarnio
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Elena Haapaniemi
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eeva Kokkola
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jenna Broman
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lauri Tulkki
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Kaste
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Sahlgrenska Academy, University of Gothenburg & Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jukka Putaala
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Zhao B, Yuan Y, Li Z, Chen Y, Gao Y, Yang B, Wu J, Jia W. Risk of intracranial hemorrhage in patients using anticoagulant therapy for atrial fibrillation after cerebral microbleeds combined with acute ischemic stroke: a meta-analysis. Front Neurol 2024; 15:1372231. [PMID: 38560733 PMCID: PMC10978779 DOI: 10.3389/fneur.2024.1372231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Objective To evaluate intracerebral hemorrhage (ICH) risk in patients with ischemic stroke (IS) and cerebral microbleeds (CMBs) undergoing anticoagulation therapy for non-valvular atrial fibrillation (AF). Methods We conducted a comprehensive search across multiple databases, including Embase, PubMed, Cochrane, UpToDate, Scopus, WOS, and SinoMed. The search covered observational literature published from each database inception until February 1, 2023. We analyzed the prevalence of CMBs during the follow-up period, compared future ICH risk between patients with and without baseline CMBs (CMBs presence/absence, ≧5 CMBs), and examined factors influencing ICH occurrence in patients with CMBs. Also studied recurrent stroke during anticoagulation therapy, the risk of future ICH when white matter hyperintensity (WMH) and CMBs coexist, and the effects of anticoagulants vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) on future ICH. Results We included 7 articles involving 5,134 participants. The incidence of CMBs was 24%; baseline CMBs were associated with an increased ICH risk compared to patients without CMBs. ICH-risk was more significant in patients with baseline ≥5 CMBs. After anticoagulant therapy, ICH risk was higher than that of recurrent IS. The risk of future ICH was significantly increased with anticoagulant VKAs compared with NOAC. Conclusion Anticoagulant therapy for ischemic stroke patients with non-valvular AF and CMBs increases future ICH risk. Discontinuing anticoagulation due to ICH risk should be avoided. NOACs are safe and effective for patients with CMBs and IS.
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Affiliation(s)
- Bingqing Zhao
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Ye Yuan
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Zheng Li
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Ying Chen
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Yali Gao
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Baoling Yang
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
| | - Jingyi Wu
- University of Glasgow, Glasgow, United Kingdom
| | - Weihua Jia
- Department of Neurology, Beijing Shijingshan Hospital, Shijingshan Teaching Hospital of Capital Medical University, Beijing, China
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Desai R, Vasavada A, Patel BA, Raval M, Mondal A, Mahajan K, Katukuri N, Varma Y, Jain A, Krishnamoorthy G. Association of Prediabetes and Recurrent Stroke in Atrial Fibrillation Patients: A Population-Based Analysis of Hospitalizations and Outcomes. J Clin Med 2024; 13:573. [PMID: 38276079 PMCID: PMC10816177 DOI: 10.3390/jcm13020573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/17/2023] [Accepted: 12/25/2023] [Indexed: 01/27/2024] Open
Abstract
Prediabetes is a risk factor for ischemic stroke in atrial fibrillation (AF) patients, yet, its impact on recurrent stroke in AF patients remains understudied. Using the 2018 National Inpatient Sample, we investigated the link between Prediabetes and recurrent stroke in AF patients with prior stroke or transient ischemic attack (TIA). Among 18,905 non-diabetic AF patients, 480 (2.5%) had prediabetes. The prediabetic group, with a median age of 78, exhibited a two-fold higher risk of recurrent stroke compared to the non-prediabetic cohort (median age 82), as evidenced by both unadjusted (OR 2.14, 95% CI 1.72-2.66) and adjusted (adjusted for socio-demographics/comorbidities, OR 2.09, 95% CI 1.65-2.64, p < 0.001). The prediabetes cohort, comprising more male and Black patients, demonstrated associations with higher Medicaid enrollment, admissions from certain regions, and higher rates of hyperlipidemia, smoking, peripheral vascular disease, obesity, and chronic obstructive pulmonary disease (all p < 0.05). Despite higher rates of home health care and increased hospital costs in the prediabetes group, the adjusted odds of all-cause mortality were not statistically significant (OR 0.55, 95% CI 0.19-1.56, p = 0.260). The findings of this study suggest that clinicians should be vigilant in managing prediabetes in AF patients, and strategies to prevent recurrent stroke in this high-risk population should be considered.
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Affiliation(s)
- Rupak Desai
- Independent Researcher, Atlanta, GA 30033, USA;
| | - Advait Vasavada
- Department of Family Medicine, University of Nebraska Medicine, Omaha, NE 68198, USA;
| | - Bhavin A. Patel
- Department of Internal Medicine, Graduate Medical Education, Trinity Health Oakland Hospital, Pontiac, MI 48341, USA; (B.A.P.); (K.M.); (G.K.)
| | - Maharshi Raval
- Department of Internal Medicine, Landmark Medical Center, Woonsocket, RI 02895, USA
| | - Avilash Mondal
- Department of Internal Medicine, Nazareth Hospital, Philadelphia, PA 19152, USA;
| | - Kshitij Mahajan
- Department of Internal Medicine, Graduate Medical Education, Trinity Health Oakland Hospital, Pontiac, MI 48341, USA; (B.A.P.); (K.M.); (G.K.)
| | - Nishanth Katukuri
- Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Yash Varma
- Division of Cardiovascular Medicine, Graduate Medical Education, Trinity Health Oakland Hospital, Wayne State University, Detroit, MI 48202, USA;
| | - Akhil Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Geetha Krishnamoorthy
- Department of Internal Medicine, Graduate Medical Education, Trinity Health Oakland Hospital, Pontiac, MI 48341, USA; (B.A.P.); (K.M.); (G.K.)
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Yang D, Sun P, Chen Y, Jin H, Xu B, Ma Q, Xue L, Wang Y. Systemic Characterization of the Gut Microbiota Profile after Single Mild Ischemic Stroke and Recurrent Stroke in Mice. Biomedicines 2024; 12:195. [PMID: 38255299 PMCID: PMC10813150 DOI: 10.3390/biomedicines12010195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/28/2023] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
It has been estimated that one in four stroke patients may have recurrent stroke within five years after they experienced the first stroke. Furthermore, clinical studies have shown that recurrent stroke negatively affects patient outcomes; the risk of disability and the death rate increase with each recurrent stroke. Therefore, it is urgent to find effective methods to prevent recurrent stroke. The gut microbiota has been proven to play an essential role after ischemic stroke, while sudden ischemia disrupts microbial dysbiosis, and the metabolites secreted by the microbiota also reshape the gut microenvironment. In the present study, we established a recurrent ischemic mouse model. Using this experimental model, we compared the survival rate and ischemic infarction between single MCAO and recurrent MCAO, showing that, when two surgeries were performed, the mouse survival rate dramatically decreased, while the infarction size increased. Fecal samples were collected on day 1, day 3 and day 7 after the first MCAO and day 9 (2 days after the second MCAO) for 16S sequencing, which provided a relatively comprehensive picture of the microbiota changes. By further analyzing the potential metabolic pathways, our data also highlighted several important pathways that were significantly altered after the first and recurrent stroke. In the present study, using an experimental mouse model, we showed that acute ischemic stroke, especially recurrent ischemia, significantly decreased the diversity of the gut microbiota.
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Affiliation(s)
- Decao Yang
- Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing 100191, China (L.X.)
- Medical Research Centre, Peking University Third Hospital, Beijing 100191, China
| | - Panxi Sun
- Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing 100191, China (L.X.)
- Ministry-of-Education Key Laboratory of Xinjiang Endemic and Ethnic Diseases, School of Medicine, Shihezi University, Shihezi 832099, China
| | - Yong Chen
- Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing 100191, China (L.X.)
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
| | - Haojie Jin
- The Key Laboratory for Silviculture and Conservation of Ministry of Education, The College of Forestry, Beijing Forestry University, Beijing 100107, China
| | - Baohui Xu
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Qingbian Ma
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Lixiang Xue
- Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing 100191, China (L.X.)
- Medical Research Centre, Peking University Third Hospital, Beijing 100191, China
- BioBank, Peking University Third Hospital, Beijing 100191, China
| | - Yan Wang
- Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing 100191, China (L.X.)
- Medical Research Centre, Peking University Third Hospital, Beijing 100191, China
- Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China
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7
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Clancy B, Bonevski B, English C, Callister R, Baker AL, Collins C, Pollack M, Magin P, Turner A, Faulkner J, Guillaumier A. Health risk factors in Australian Stroke Survivors: A latent class analysis. Health Promot J Austr 2024; 35:37-44. [PMID: 36799087 PMCID: PMC10952979 DOI: 10.1002/hpja.706] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 02/14/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023] Open
Abstract
ISSUES ADDRESSED To (i) determine the prevalence of health risk factors (physical activity, diet, alcohol, smoking, blood pressure medication use and mental health) in community-dwelling stroke survivors; and (ii) examine how these health risk factors cluster, and identify associations with physical functioning, independent living, or sociodemographic factors. METHODS A secondary analysis of data obtained during a national randomised controlled trial. Participants had experienced stroke and completed a baseline telephone survey on demographic and stroke characteristics, health risk factors, physical functioning and independence in activities of daily living. A latent class analysis was performed to determine health risk profiles. Univariate logistic regressions were performed to identify if participant characteristics were associated with resulting classes. RESULTS Data analysed from 399 participants. Two classes of health risk factors were identified: Low Mood, Food & Moves Risk (16% of participants) and Alcohol Use Risk (84% of participants). The Low Mood, Food & Moves Risk group had poorer diet quality, lower physical activity levels and higher levels of depression and anxiety. Lower levels of independence and physical functioning were predictor variables for this group. In contrast, the Alcohol Use Risk group had better physical activity and diet scores, significantly lower probability of depression and anxiety, but a higher probability of risky drinking. CONCLUSIONS We identified two distinct health risk factor groups in our population. SO WHAT?: Future interventions may benefit from targeting the specific needs and requirements of people who have experienced stroke based on their distinct risk group. Alcohol consumption in poststroke populations requires further attention.
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Affiliation(s)
- Brigid Clancy
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of NewcastleCallaghanNSWAustralia
- Hunter Medical Research Institute, John Hunter HospitalNew Lambton HeightsNSWAustralia
| | - Billie Bonevski
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders UniversityBedford ParkSAAustralia
| | - Coralie English
- Hunter Medical Research Institute, John Hunter HospitalNew Lambton HeightsNSWAustralia
- School of Health Sciences, College of Health Medicine and Wellbeing, The University of NewcastleCallaghanNSWAustralia
| | - Robin Callister
- Hunter Medical Research Institute, John Hunter HospitalNew Lambton HeightsNSWAustralia
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, The University of NewcastleCallaghanNSWAustralia
| | - Amanda L. Baker
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of NewcastleCallaghanNSWAustralia
- Hunter Medical Research Institute, John Hunter HospitalNew Lambton HeightsNSWAustralia
| | - Clare Collins
- Hunter Medical Research Institute, John Hunter HospitalNew Lambton HeightsNSWAustralia
- School of Health Sciences, College of Health Medicine and Wellbeing, The University of NewcastleCallaghanNSWAustralia
- Hunter New England Local Health District, John Hunter HospitalNew Lambton HeightsNSWAustralia
| | - Michael Pollack
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of NewcastleCallaghanNSWAustralia
- Hunter New England Local Health District, John Hunter HospitalNew Lambton HeightsNSWAustralia
| | - Parker Magin
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of NewcastleCallaghanNSWAustralia
| | - Alyna Turner
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of NewcastleCallaghanNSWAustralia
- IMPACT Strategic Research Centre, School of Medicine, Deakin UniversityGeelongVic.Australia
| | - Jack Faulkner
- Hunter Medical Research Institute, John Hunter HospitalNew Lambton HeightsNSWAustralia
| | - Ashleigh Guillaumier
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of NewcastleCallaghanNSWAustralia
- Hunter Medical Research Institute, John Hunter HospitalNew Lambton HeightsNSWAustralia
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8
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Gorey S, McCabe JJ, Camps-Renom P, Giannotti N, McNulty JP, Barry M, Cassidy T, Cronin S, Dolan E, Fernández-León A, Foley S, Harbison J, O’Connell M, Williams DJ, Marnane M, Martí-Fabregas J, Kelly PJ. Symptomatic Carotid Atheroma Inflammation Lumen-stenosis score compared with Oxford and Essen risk scores to predict recurrent stroke in symptomatic carotid stenosis. Eur Stroke J 2023; 8:1064-1070. [PMID: 37480278 PMCID: PMC10683720 DOI: 10.1177/23969873231186911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/22/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND The Oxford Carotid Stenosis tool (OCST) and Essen Stroke Risk Score (ESRS) are validated to predict recurrent stroke in patients with and without carotid stenosis. The Symptomatic Carotid Atheroma Inflammation Lumen stenosis (SCAIL) score combines stenosis and plaque inflammation on fluorodeoxyglucose positron-emission tomography (18FDG-PET). We compared SCAIL with OCST and ESRS to predict ipsilateral stroke recurrence in symptomatic carotid stenosis. PATIENTS AND METHODS We pooled three prospective cohort studies of patients with recent (<30 days) non-severe ischaemic stroke/TIA and internal carotid artery stenosis (>50%). All patients had carotid 18FDG-PET/CT angiography and late follow-up, with censoring at carotid revascularisation. RESULTS Of 212 included patients, 16 post-PET ipsilateral recurrent strokes occurred in 343 patient-years follow-up (median 42 days (IQR 13-815)).Baseline SCAIL predicted recurrent stroke (unadjusted hazard ratio [HR] 1.96, CI 1.20-3.22, p = 0.007, adjusted HR 2.37, CI 1.31-4.29, p = 0.004). The HR for OCST was 0.996 (CI 0.987-1.006, p = 0.49) and for ESRS was 1.26 (CI 0.87-1.82, p = 0.23) (all per 1-point score increase). C-statistics were: SCAIL 0.66 (CI 0.51-0.80), OCST 0.52 (CI 0.40-0.64), ESRS 0.61 (CI 0.48-0.74). Compared with ESRS, addition of plaque inflammation (SUVmax) to ESRS improved risk prediction when analysed continuously (HR 1.51, CI 1.05-2.16, p = 0.03) and categorically (ptrend = 0.005 for risk increase across groups; HR 3.31, CI 1.42-7.72, p = 0.006; net reclassification improvement 10%). Findings were unchanged by further addition of carotid stenosis. CONCLUSIONS SCAIL predicted recurrent stroke, had discrimination better than chance, and improved the prognostic utility of ESRS, suggesting that measuring plaque inflammation may improve risk stratification in carotid stenosis.
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Affiliation(s)
- Sarah Gorey
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - John J McCabe
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Stroke Service, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Pol Camps-Renom
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona (Department of Medicine), Barcelona, Spain
| | - Nicola Giannotti
- School of Medicine, University College Dublin, Dublin, Ireland
- Discipline of Medical Imaging Science, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | | | - Mary Barry
- Department of Vascular Surgery, St Vincent’s University Hospital, Dublin, Ireland
| | - Tim Cassidy
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Geriatric Medicine, St Vincent’s University Hospital, Dublin, Ireland
| | - Simon Cronin
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- Department of Neurology, Cork University Hospital, Cork, Ireland
- Department of Clinical Neuroscience, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Eamon Dolan
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- Department of Geriatric Medicine, James Connolly Memorial Hospital, Dublin, Ireland
| | | | - Shane Foley
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Joseph Harbison
- Stroke Service, Department of Geriatric Medicine, St James’ Hospital, Dublin, Ireland
| | - Martin O’Connell
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - David J Williams
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland (RCSI), University of Medicine and Health Sciences, Dublin, Ireland
| | - Michael Marnane
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Stroke Service, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Joan Martí-Fabregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona (Department of Medicine), Barcelona, Spain
| | - Peter J Kelly
- Health Research Board (HRB), Stroke Clinical Trials Network Ireland (SCTNI), Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Stroke Service, Mater Misericordiae University Hospital, Dublin, Ireland
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Shirley AM, Morrisette KL, Choi SK, Reynolds K, Zhou H, Zhou MM, Wei R, Zhang Y, Cheng P, Wong E, Sangha N, An J. Validation of ICD-10 hospital discharge diagnosis codes to identify incident and recurrent ischemic stroke from a US integrated healthcare system. Pharmacoepidemiol Drug Saf 2023; 32:1439-1445. [PMID: 37528669 PMCID: PMC10830879 DOI: 10.1002/pds.5675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE This study validated incident and recurrent ischemic stroke identified by International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) hospital discharge diagnosis codes. METHODS Using electronic health records (EHR) of adults (≥18 years) receiving care from Kaiser Permanente Southern California with ICD-10 hospital discharge diagnosis codes of ischemic stroke (I63.x, G46.3, and G46.4) between October 2015 and September 2020, we identified 75 patients with both incident and recurrent stroke events (total 150 cases). Two neurologists independently evaluated validity of ICD-10 codes through chart reviews. RESULTS The positive predictive value (PPV, 95% CI) for incident stroke was 93% (95% CI: 88%, 99%) and the PPV for recurrent stroke was 72% (95% CI: 62%, 82%). The PPV for recurrent stroke improved after applying a gap of 20 days (PPV of 75%; 95% CI: 63%, 87%) or removing hospital admissions related to stroke-related procedures (PPV of 78%; 95% CI: 68%, 88%). CONCLUSION The ICD-10 hospital discharge diagnosis codes for ischemic stroke showed a high PPV for incident cases, while the PPV for recurrent cases were less optimal. Algorithms to improve the accuracy of ICD-10 codes for recurrent ischemic stroke may be necessary.
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Affiliation(s)
- Abraelle M Shirley
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Kerresa L Morrisette
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Soon Kyu Choi
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
| | - Hui Zhou
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
| | - Mengnan M Zhou
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Rong Wei
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Yiyi Zhang
- Department of Medicine, Columbia University, New York, NY, United States
| | - Pamela Cheng
- Department of Neurology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA, United States
| | - Eric Wong
- Department of Neurology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA, United States
| | - Navdeep Sangha
- Department of Neurology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA, United States
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
| | - Jaejin An
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
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10
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Mimori M, Sakuta K, Miyagawa S, Yaguchi H. Recurrent Watershed Infarction Without Evident Intracranial Arterial Stenosis Due to Antiphospholipid Syndrome: A Case Report. Cureus 2023; 15:e50201. [PMID: 38192909 PMCID: PMC10771988 DOI: 10.7759/cureus.50201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/10/2024] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by arterial, venous, or small vessel thromboembolic events. We present here a rare case of APS with repeated multiple cerebral infarctions in the same watershed area without visible arterial stenosis. A 53-year-old woman without a past medical history presented with a headache and numbness of the right fingers. Magnetic resonance imaging (MRI) showed acute ischemic lesions in the left middle cerebral artery (MCA) watershed area. Blood tests revealed positive anticardiolipin (aCL) and aCL beta-2-glycoprotein I antibodies (aCL-β2GPI). Three months later, aCL and aCL-β2GPi antibodies were still positive, and APS was confirmed. After four months from the index stroke, she was suddenly affected by right arm and leg weakness under a warfarin prescription. Brain MRI showed a recurrence of acute ischemic stroke in the same left MCA watershed area and the right cerebellar hemisphere without visible intracranial artery stenosis in magnetic resonance angiography. The examination of carotid ultrasonography, electrocardiogram monitoring, as well as transthoracic and transesophageal echocardiography revealed no abnormalities, indicating that the recurrent ischemic stroke was due to APS. Single-photon emission-computed tomography captured wide hypoperfusion beyond the infarction area. Thus, the stroke may have been caused by a repeated thromboembolic mechanism. In conclusion, APS should be considered a differential diagnosis in repeated watershed strokes without obvious intracranial arterial stenosis.
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Affiliation(s)
| | - Kenichi Sakuta
- Neurology, Kashiwa Hospital, Jikei University School of Medicine, Kashiwa-shi, JPN
| | - Shinji Miyagawa
- Neurology, Kashiwa Hospital, Jikei University School of Medicine, Kashiwa-shi, JPN
| | - Hiroshi Yaguchi
- Neurology, Jikei University Kashiwa Hospital, Kashiwa-shi, JPN
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11
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Zhao J, Wang D, Liu X, Wang Y, Zhao X. The Predictive Value of Essen and SPI-II on the Risk of 5-Year Recurrence in Chinese Patients with Acute Ischemic Stroke. Neuropsychiatr Dis Treat 2023; 19:2251-2260. [PMID: 37900671 PMCID: PMC10612507 DOI: 10.2147/ndt.s433383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/18/2023] [Indexed: 10/31/2023] Open
Abstract
Background The risk prediction score for stroke recurrence is an important tool for stratifying patients based on the risk of cerebrovascular events and selecting potential preventive treatments. Objective The study aimed to validate the Essen Stroke Risk Score (ESRS) and Stroke Prognosis Instrument II (SPI-II) for predicting long-term risk of stroke recurrence and combined vascular events in Chinese patients with acute ischemic stroke (AIS). Methods A total of 876 consecutive patients with non-atrial fibrillation AIS were recruited. The Kaplan-Meier (KM) method was used to estimate the cumulative incidence of stroke recurrence and combined vascular events in different subgroups stratified by the ESRS and SPI-II scores. The area under the receiver operating characteristic curve (AUC) was calculated to evaluate the predictive value of the two scores for stroke recurrence and combined vascular events. Results The KM estimate for 5-year cumulative incidence of stroke recurrence and combined vascular events was 28.7% (95% confidence interval [CI], 25.4-32.0) and 35.6% (95% CI, 32.3-38.9), respectively, in Chinese AIS patients. The risk of stroke recurrence and combined vascular events were increased significantly with increasing ESRS and SPI-II scores. The ESRS and SPI-II scores had similar predictive accuracy for stroke recurrence (AUC 0.57 [95% CI 0.52-0.64] vs 0.59 [95% CI 0.55-0.64]) and combined vascular events (AUC 0.59 [95% CI 0.55-0.63] vs 0.62 [95% CI 0.58-0.66]) at 5 years. Conclusion In Chinese patients with AIS, both ESRS and SPI-II scores were able to stratify the risk of 5-year recurrent stroke and combined vascular events. The predictive power of the two scores were modest and a prediction model suitable for Chinese IS populations is needed.
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Affiliation(s)
- Jing Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Dandan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xinmin Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yu Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Department of Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, People’s Republic of China
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12
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Prabakar D, Sabesan V, Emenogu OP, Mai C. Recurrent Multifocal Embolic Strokes in a 50-Year-Old Male: Unmasking Occult Squamous Cell Carcinoma. Cureus 2023; 15:e45091. [PMID: 37842450 PMCID: PMC10568952 DOI: 10.7759/cureus.45091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
Recurrent cryptogenic embolic strokes pose a diagnostic challenge, often necessitating an extensive evaluation to determine the underlying cause. Cancer-related stroke is a frequently overlooked etiology, accounting for a substantial proportion of cryptogenic strokes. This case study underscores the importance of considering occult malignancies in patients with recurrent strokes of unknown origin and emphasizes the need for a comprehensive diagnostic workup to detect hidden malignancies. A 50-year-old male with a complex medical history presented with expressive aphasia and blurred vision resembling previous stroke episodes. Neurological examinations revealed right hemianopsia, paraphasia, and abnormal coordination. Neuroimaging studies showed multiple chronic infarctions, a large hemorrhagic infarction in the left posterior cerebral artery territory, and a small acute-to-subacute left parietal infarction. Due to the time of presentation and the presence of hemorrhagic transformation, the patient did not meet the criteria for intravenous tissue plasminogen activator administration. Given the recurrent nature of the strokes, an extensive evaluation was initiated to determine the underlying cause. Vascular imaging, including magnetic resonance angiography (MRA) of the head and neck and a CT angiogram, showed no significant stenosis. Vasculitis workup and cardiac evaluation yielded negative results. The blood workup was notable for elevated D-dimer levels. The involvement of multiple vascular territories and recurrent stroke despite adequate treatment and the absence of traditional risk factors for stroke raised a high clinical suspicion of occult malignancy. Further investigations led to the diagnosis of locally advanced squamous cell carcinoma (P16+), metastatic to the right neck lymph nodes (cTxN3M0). Although the primary source of cancer could not be identified, the P16+ status suggests the right tonsil or base of the tongue as the probable origin. Anticoagulation therapy was initiated, and the patient was scheduled for chemoradiation therapy. Although routine cancer investigation is not justified in ischemic strokes, the possibility of an occult malignancy should be considered in the presence of multifocal infarctions across different vascular territories with elevated D-dimer levels, particularly when traditional risk factors have been ruled out. A detailed physical exam can help localize the malignancy and early identification of occult malignancies can guide appropriate management strategies and help prevent future strokes. Further clinical trials are needed to establish optimal therapeutic approaches for preventing stroke recurrence in cancer-related strokes.
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Affiliation(s)
- Deipthan Prabakar
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Vaishnavi Sabesan
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Oluwasegun P Emenogu
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Cuc Mai
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
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13
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Silimon N, Drop B, Clénin L, Nedeltchev K, Kahles T, Tarnutzer AA, Katan M, Bonati L, Salmen S, Albert S, Salerno A, Carrera E, Berger C, Peters N, Medlin F, Cereda C, Bolognese M, Kägi G, Renaud S, Niederhauser J, Bonvin C, Schärer M, Mono ML, Luft A, Rodic-Tatic B, Fischer U, Jung S, Arnold M, Meinel T, Seiffge D. Ischaemic stroke despite antiplatelet therapy: Causes and outcomes. Eur Stroke J 2023; 8:692-702. [PMID: 37622482 PMCID: PMC10472957 DOI: 10.1177/23969873231174942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/24/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Ischaemic stroke may occur despite antiplatelet therapy (APT). We aimed to investigate frequency, potential causes and outcomes in patients with ischaemic stroke despite APT. METHODS In this cohort study, we enrolled patients with imaging-confirmed ischaemic stroke from the Swiss Stroke Registry (01/2014-07/2022). We determined the frequency of prior APT, assessed stroke aetiology (modified TOAST classification) and determined the association of prior APT with unfavourable functional outcome (modified Rankin Scale score 3-6) and recurrent ischaemic stroke at 3 months using regression models. RESULTS Among 53,352 patients, 27,484 (51.5%) had no prior antithrombotic treatment, 17,760 (33.3%) were on APT, 7039 (13.2%) on anticoagulation and 1069 (2.0%) were on APT + anticoagulation. In patients with a history of ischaemic stroke/TIA (n = 11,948; 22.4%), 2401 (20.1%) had no prior antithrombotic therapy, 6594 (55.2%) were on APT, 2489 (20.8%) on anticoagulation and 464 (3.9%) on APT + anticoagulation. Amongst patients with ischaemic stroke despite APT, aetiology was large artery atherosclerosis in 19.8% (n = 3416), cardiac embolism in 23.6% (n = 4059), small vessel disease in 11.7% (n = 2011), other causes in 7.4% (n = 1267), more than one cause in 6.3% (n = 1078) and unknown cause in 31.3% (n = 5388). Prior APT was not independently associated with unfavourable outcome (aOR = 1.06; 95% CI: 0.98-1.14; p = 0.135) or death (aOR = 1.10; 95% CI: 0.99-1.21; p = 0.059) at 3-months but with increased odds of recurrent stroke (6.0% vs 4.3%; aOR 1.26; 95% CI: 1.11-1.44; p < 0.001). CONCLUSIONS One-third of ischaemic strokes occurred despite APT and 20% of patients with a history of ischaemic stroke had no antithrombotic therapy when having stroke recurrence. Aetiology of breakthrough strokes despite APT is heterogeneous and these patients are at increased risk of recurrent stroke.
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Affiliation(s)
- Norbert Silimon
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Boudewijn Drop
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Leander Clénin
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Neurology, Cantonal Hospital of Aarau, Aarau, Switzerland
| | - Timo Kahles
- Department of Neurology, Cantonal Hospital of Aarau, Aarau, Switzerland
| | | | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Reha Rheinfelden, Rheinfelden, Switzerland
| | | | - Sylvan Albert
- Stroke Unit, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Nils Peters
- Stroke Center, Klinik Hirslanden, Zürich, Switzerland
| | | | - Carlo Cereda
- Stroke Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | | | - Georg Kägi
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Neurology, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Susanne Renaud
- Neurology and Stroke Unit, Neuchâtel Hospital Network, Neuchâtel, Switzerland
| | | | | | | | | | - Andreas Luft
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | | | - Urs Fischer
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Simon Jung
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
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Jud S, Klövekorn R, van Niftrik CHB, Herzog L, Sebök M, Schweizer J, Luft AR, Fierstra J, Wegener S. High posterior cerebral artery flow predicts ischemia recurrence in patients with internal carotid artery occlusion. Front Neurol 2023; 14:1193640. [PMID: 37545725 PMCID: PMC10397388 DOI: 10.3389/fneur.2023.1193640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 06/28/2023] [Indexed: 08/08/2023] Open
Abstract
Recurrent stroke is a dreaded complication of symptomatic internal carotid artery occlusion (ICAO). Transcranial Duplex (TCD)-derived increased flow velocity in the ipsilateral posterior cerebral artery (PCA)-P2 segment indicates activated leptomeningeal collateral recruitment and hemodynamic impairment. Leptomeningeal collaterals are pial vascular connections between the anterior and posterior vascular territories. These secondary collateral routes are activated when primary collaterals via the Circle of Willis are insufficient. Our goal was to test the TCD parameter PCA-P2 flow for prediction of ipsilateral ischemia recurrence. We retrospectively analyzed clinical and ultrasound parameters in patients with ICAO. Together with clinical variables, we tested systolic PCA-P2 flow velocity as predictor of a recurrent ischemic event using logistic regression models. Of 111 patients, 13 showed a recurrent ischemic event within the same vascular territory. Increased flow in the ipsilateral PCA-P2 on transcranial ultrasound (median and interquartile range [IQR]: 60 cm/s [IQR 26] vs. 86 cm/s [IQR 41], p = <0.001), as well as previous transient ischemic attack (TIA) and low NIHSS were associated with ischemia recurrence. Combined into one model, accuracy of these parameters to predict recurrent ischemia was 89.2%. Our data suggest that in patients with symptomatic ICAO, flow increases in the ipsilateral PCA-P2 suggest intensified compensatory efforts when other collaterals are insufficient. Together with the clinical variables, this non-invasive and easily assessable duplex parameter detects ICAO patients at particular risk of recurrent ischemia.
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Affiliation(s)
- Simon Jud
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Robert Klövekorn
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Christiaan Hendrik Bas van Niftrik
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Lisa Herzog
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Institute of Epidemiology, Biostatistics and Prevention, University of Zurich, Zurich, Switzerland
| | - Martina Sebök
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Juliane Schweizer
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- Stadtspital Waid and Triemli, Zurich, Switzerland
| | - Andreas R. Luft
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Jorn Fierstra
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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15
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Kim BK, Eah KY, Park JM. Essential Thrombocythemia and Ischemic Stroke: A Case Series of Five JAK2-Positive Patients. Medicina (Kaunas) 2023; 59:1300. [PMID: 37512112 PMCID: PMC10384755 DOI: 10.3390/medicina59071300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm characterized by elevated platelet counts and an increased risk of thrombotic events, including ischemic strokes. Materials and Methods: We conducted a retrospective analysis of data from consecutive ischemic stroke patients with ET between March 2014 and February 2023. Results: This case series describes the clinical presentation, radiological features, and management of five patients with ET-associated ischemic strokes, all harboring the JAK2 mutation. The diverse radiological findings suggest that both large and small vessel diseases may be influenced by the prothrombotic state induced by ET. A significant elevation in platelet count was observed to correlate with the emergence of new acute infarctions in some cases. Conclusions: The study highlights combined use of antiplatelet and cytoreductive therapy in preventing secondary stroke events in patients with ET and JAK2 mutations. The heterogeneity of stroke patterns in this population necessitates a comprehensive understanding of the underlying pathophysiological mechanisms and tailored therapeutic approaches.
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Affiliation(s)
- Byong-Kyu Kim
- Division of Cardiology, Department of Internal Medicine, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju 38067, Republic of Korea
| | - Kyung Yoon Eah
- Department of Neurology, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju 38067, Republic of Korea
| | - Jin-Mo Park
- Department of Neurology, Dongguk University Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju 38067, Republic of Korea
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16
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Li X, Qin X, Liu C, Zhu L, Wang M, Jiang T, Liu Y, Li S, Shi H, Sun H, Deng Q, Zhou J. Percutaneous angioplasty and/or stenting versus aggressive medical therapy in patients with symptomatic intracranial atherosclerotic stenosis: a 1-year follow-up study. Front Aging Neurosci 2023; 15:1192681. [PMID: 37396661 PMCID: PMC10313453 DOI: 10.3389/fnagi.2023.1192681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Background Symptomatic intracranial atherosclerotic stenosis (sICAS) is one of the common causes of ischemic stroke. However, the treatment of sICAS remains a challenge in the past with unfavorable findings. The purpose of this study was to explore the effect of stenting versus aggressive medical management on preventing recurrent stroke in patients with sICAS. Methods We prospectively collected the clinical information of patients with sICAS who underwent percutaneous angioplasty and/or stenting (PTAS) or aggressive medical therapy from March 2020 to February 2022. Propensity score matching (PSM) was employed to ensure well-balanced characteristics of two groups. The primary outcome endpoint was defined as recurrent stroke or transient ischemic attack (TIA) within 1 year. Results We enrolled 207 patients (51 in the PTAS and 156 in the aggressive medical groups) with sICAS. No significant difference was found between PTAS group and aggressive medical group for the risk of stroke or TIA in the same territory beyond 30 days through 6 months (P = 0.570) and beyond 30 days through 1 year (P = 0.739) except for within 30 days (P = 0.003). Furthermore, none showed a significant difference for disabling stroke, death and intracranial hemorrhage within 1 year. These results remain stable after adjustment. After PSM, all the outcomes have no significant difference between these two groups. Conclusion The PTAS has similar treatment outcomes compared with aggressive medical therapy in patients with sICAS across 1-year follow-up.
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Affiliation(s)
- Xiaohui Li
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaodan Qin
- General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chengfang Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Lin Zhu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Meng Wang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Teng Jiang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yukai Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shuo Li
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Hongchao Shi
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Huiling Sun
- General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Qiwen Deng
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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17
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Wu G, Shen Y, Zhu F, Tao W, Zhou Y, Ke S, Jiang H. Comprehensive Diagnostic Criteria for MELAS Syndrome; a Case Study Involving an Elderly Patient With MT-TWm.5541C>T Mutation. Neurologist 2023; 28:190-194. [PMID: 36125978 PMCID: PMC10158598 DOI: 10.1097/nrl.0000000000000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome is a matrilineal hereditary multisystem disease caused by mutations in the mitochondrial DNA. Although the initial diagnostic criteria correlate with a range of clinical phenotypes, including clinical onset after the age of 40, there is still lack of a unified single diagnostic standard for MELAS. CASE REPORT A 71-year-old female patient with recurrent stroke was reported. Magnetic resonance imaging showed a cerebral gyrus-like diffusion weighted imaging high signal lesion in the parietal-occipital lobe and the area of this lesion expanded with disease progression. The MRS result showed significantly inverted Lac/Lip peaks. The nucleic acid sequencing result displayed a MT-TWm.5541C>T mutation, and a 12.86% mutation rate in the blood sample. The patient had a 6-year history of type 2 diabetes. CONCLUSION Patients with the MELAS syndrome may present with a variety of clinical manifestations. Our data demonstrated that, for patients with atypical cerebral infarction and suspected MELAS syndrome, gene sequencing and muscle biopsy should be performed in time. This case provides a reference for the diagnostic criteria of MELAS syndrome.
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Affiliation(s)
- Gang Wu
- Department of Neurology
- Department of Pharmacy, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
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18
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Frol S, Hudnik LK, Sernec LP, Šabovič M, Šurlan Popovič K, Pretnar Oblak J. Recurrent Strokes in Patients With Atrial Fibrillation Treated With Direct Oral Anticoagulant Agents. Angiology 2023; 74:344-350. [PMID: 35694739 DOI: 10.1177/00033197221108394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recurrent ischemic strokes (IS) in patients treated with direct oral anticoagulant agents (DOACs) are rare. Knowledge regarding the type of recurrent IS and predisposing factors is insufficient. We analyzed a cohort of 1001 patients (77.6 ± 9.2 years; females: 57.1%) with non-valvular atrial fibrillation (AF) treated with DOACs as part of secondary prevention after initial IS or transient ischemic attack. Cardiovascular risk factors, stroke etiology, and Fazekas score based on computed tomography images at the time of the initial IS were assessed. Low Fazekas scores were defined as 0 or 1 and high scores were 2 or 3. Recurrent IS occurred in 46 patients (4.6%, annual rate 1.6%) during the observation period (2.8 ± 1.8 years). Stroke was cardioembolic in 20 patients (43.5%), lacunar in 19 patients (37.5%) and large artery stroke in 6 patients (19.2%). Non-cardioembolic stroke was more common (75.0 vs 26.7%; P = .002) in patients with high Fazekas scores. Arterial hypertension was more frequent (P = .027) in patients with high (93.3%) vs low (68.8%) Fazekas scores. Recurrent IS was predominantly non-cardioembolic with higher Fazekas score and arterial hypertension as predisposing factors. The reported hypothesis-generating results regarding the clinical relevance of the Fazekas score should be further evaluated.
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Affiliation(s)
- Senta Frol
- Department of Vascular Neurology, University Clinical Centre Ljubljana, Slovenia.,Neurology Department, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Liam K Hudnik
- Neurology Department, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Lana P Sernec
- Neurology Department, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Mišo Šabovič
- Department of Vascular Disorders, University Clinical Centre Ljubljana, Slovenia
| | - Katarina Šurlan Popovič
- Clinical Institute of Radiology, University Medical Centre Ljubljana, Slovenia.,Radiology Department, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Janja Pretnar Oblak
- Department of Vascular Neurology, University Clinical Centre Ljubljana, Slovenia.,Neurology Department, Faculty of Medicine, University of Ljubljana, Slovenia
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19
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Yan L, Hou Z, Fu W, Yu Y, Cui R, Miao Z, Lou X, Ma N. Association of periprocedural perfusion non-improvement with recurrent stroke after endovascular treatment for Intracranial Atherosclerotic Stenosis. Ther Adv Neurol Disord 2022; 15:17562864221143178. [PMID: 36601085 PMCID: PMC9806435 DOI: 10.1177/17562864221143178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/17/2022] [Indexed: 12/28/2022] Open
Abstract
Background Predictors of recurrent stroke after endovascular treatment for symptomatic intracranial atherosclerotic stenosis (ICAS) remain uncertain. Objectives Among baseline characteristics, lesion features, and cerebral perfusion changes, we try to explore which factors are associated with the risk of recurrent stroke in symptomatic ICAS after endovascular treatment. Design Consecutive patients with symptomatic ICAS of 70-99% receiving endovascular treatment were enrolled. All patients underwent whole-brain computer tomography perfusion (CTP) within 3 days before and 3 days after the endovascular treatment. Baseline characteristics, lesion features, and cerebral perfusion changes were collected. Methods Cerebral perfusion changes were evaluated with RAPID software and calculated as preprocedural cerebral blood flow (CBF) < 30%, time to maximum of the residue function (Tmax) > 6 s, and Tmax > 4 s volumes minus postprocedural. Cerebral perfusion changes were divided into periprocedural perfusion improvement (>0 ml) and non-improvement (⩽ 0 ml). Recurrent stroke within 180 days was collected. The Cox proportional hazards analysis analyses were performed to evaluate factors associated with recurrent stroke. Results From March 2021 to December 2021, 107 patients with symptomatic ICAS were enrolled. Of the 107 enrolled patients, 30 (28.0%) patients underwent balloon angioplasty alone and 77 patients (72.0%) underwent stenting. The perioperative complications occurred in three patients. Among CBF < 30%, Tmax > 6 s, and Tmax > 4 s volumes, Tmax > 4 s volume was available to evaluate cerebral perfusion changes. Periprocedural perfusion improvement was found in 77 patients (72.0%) and non-improvement in 30 patients (28.0%). Nine patients (8.4%) suffered from recurrent stroke in 180-day follow-up. In Cox proportional hazards analysis adjusted for age and sex, perfusion non-improvement was associated with recurrent stroke [hazards ratio (HR): 4.472; 95% CI: 1.069-18.718; p = 0.040]. Conclusion In patients with symptomatic ICAS treated with endovascular treatment, recurrent stroke may be related to periprocedural cerebral perfusion non-improvement. Registration http://www.chictr.org.cn. Unique identifier: ChiCTR2100052925.
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Affiliation(s)
- Long Yan
- Department of Interventional Neuroradiology,
Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for
Neurological Diseases, Beijing, China
| | - Zhikai Hou
- Department of Interventional Neuroradiology,
Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for
Neurological Diseases, Beijing, China
| | - Weilun Fu
- Department of Interventional Neuroradiology,
Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for
Neurological Diseases, Beijing, China
| | - Ying Yu
- Department of Interventional Neuroradiology,
Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for
Neurological Diseases, Beijing, China
| | - Rongrong Cui
- Department of Interventional Neuroradiology,
Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for
Neurological Diseases, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology,
Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for
Neurological Diseases, Beijing, China
| | - Xin Lou
- Department of Radiology, Chinese PLA General
Hospital, Beijing, China
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20
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Fu X, Zhong K. Clinical value of microemboli combined with cerebrospinal fluid inflammatory factor level monitoring in predicting recurrent stroke of middle cerebral artery stenosis. Am J Transl Res 2022; 14:8741-8750. [PMID: 36628196 PMCID: PMC9827294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/24/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate the clinical value of microemboli combined with cerebrospinal fluid inflammatory factor level monitoring in the prediction of recurrent stroke in middle cerebral artery stenosis. METHODS This is a retrospective study. Patients (n=170) who were hospitalized in the Department of Neurology of the First People's Hospital of Jiangxia District from June 2019 to January 2021 with cerebral infarction or transient ischemic attack were included in the study. Among them, 85 patients with ischemic attack were divided into the non-recurrent stroke group (primary onset, n=40) and the recurrent stroke group (history of cerebral infarction or transient ischemic attack within 5 years prior to the onset, n=45). Routine blood biochemical tests were performed using the Olympus 5800 automated chemical analyzer. Cerebrospinal fluid levels of inflammatory factors (TNF-α, IL-6) were detected by ELISA kits. Special Doppler hyperintensities for microemboli in cerebral blood flow were tested by transcranial Doppler ultrasound. RESULTS The mean age, statins and LDL-C were higher in the recurrent stroke group than the non-recurrent stroke group (P<0.05). The levels of cerebrospinal fluid TNF-α, PCT, CRP and IL-6 in the recurrent stroke group were higher than the non-recurrent stroke group (P<0.05). The proportion of grade 0 microemboli in the recurrent stroke group was lower than the non-recurrent stroke group (P<0.05), and the proportion of grade 1, 2, 3, 4 and 5 microemboli was higher than the non-recurrent stroke group (P<0.05). The positive rate of microemboli in the recurrent stroke group was higher than the non-recurrent stroke group (P<0.05). The accuracy rate of microemboli combined with cerebrospinal fluid inflammatory factor level monitoring in the recurrent stroke group for the prediction of recurrent stroke due to middle cerebral artery stenosis was higher than that in the non-recurrent stroke group (P<0.05). Increased age, statin use, microembolization, and increased LDL-C, TNF-α, PCT, CRP and IL-6 levels were independent risk factors. CONCLUSION Microemboli combined with cerebrospinal fluid inflammatory factor level monitoring can increase the detection rate of recurrent stroke in middle cerebral artery stenosis and prevent vascular events to a great extent.
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21
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Krishnan K, Law ZK, Minhas JS, Bath PM, Robinson TG, Sprigg N, Mavilakandy A, England TJ, Eveson D, Mistri A, Dawson J, Appleton JP. Antiplatelet treatment for acute secondary prevention of non-cardioembolic minor stroke / transient ischaemic attack: an update for the acute physician. Clin Med (Lond) 2022; 22:449-454. [PMID: 38589066 PMCID: PMC9595021 DOI: 10.7861/clinmed.2021-0597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute stroke is the leading cause of disability in the UK and a leading cause of mortality worldwide. The majority of patients with ischaemic stroke present with minor deficits or transient ischaemic attack (TIA), and are often first seen by patient-facing clinicians. Urgent evaluation and treatment are important as many patients are at high risk of major vascular events and death within hours to days after the index event. This narrative review summarises the evidence on four antiplatelet treatments for non-cardioembolic stroke prevention: aspirin, clopidogrel, dipyridamole and ticagrelor. Each of these drugs has a unique mechanism and has been tested as a single agent or in combination. Aspirin, when given early is beneficial and short-term treatment with aspirin and clopidogrel has been shown to be more effective in high-risk TIA / minor stroke. This review concludes by highlighting gaps in evidence, including scope for future trials that could potentially change clinical practice.
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Affiliation(s)
| | - Zhe Kang Law
- National University of Malaysia, Kuala Lumpur, Malaysia
| | - Jatinder S Minhas
- University of Leicester, Leicester, UK and Leicester Royal Infirmary, Leicester, UK
| | | | - Thompson G Robinson
- University of Leicester, Leicester, UK and Leicester Royal Infirmary, Leicester, UK
| | | | | | - Timothy J England
- Queen's Medical Centre, Nottingham, UK and Royal Derby Hospital, Derby, UK
| | | | | | - Jesse Dawson
- University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK and Queen Elizabeth University Hospital, Glasgow, UK
| | - Jason P Appleton
- Queen Elizabeth Hospital, Birmingham, UK and University of Birmingham College of Dental and Medical Sciences, Birmingham, UK
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22
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Wang A, Tian X, Xu J, Li H, Xu Q, Chen P, Meng X, Wang Y. Soluble lectin-like oxidized low-density Lipoproteinreceptor-1 and recurrent stroke: A nested case-control study. CNS Neurosci Ther 2022; 28:2001-2010. [PMID: 35909324 PMCID: PMC9627350 DOI: 10.1111/cns.13932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/06/2022] [Accepted: 07/17/2022] [Indexed: 02/06/2023] Open
Abstract
MAIN PROBLEM The prognostic value of soluble lectin-like oxidized low-density lipoproteinreceptor-1 (sLOX-1) for stroke was unclearly. This study aimed to investigate the association between sLOX-1 and recurrent stroke in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA). METHODS Data were obtained from the Third China National Stroke Registry. Eligible cases consisted of 400 patients who developed recurrent stroke within 1-year follow-up, 800 controls were selected using age- and sex-matched with a 1:2 case-control ratio. Conditional logistic regressions were used to evaluate the association between sLOX-1 and recurrent stroke. RESULTS Among 1200 patients included in this study, the median (interquartile range) of sLOX-1 was 247.12 (132.81-413.58) ng/L. After adjustment for conventional confounding factors, the odds ratio with 95% confidence interval in the highest tertile versus the lowest tertile was 2.23 (1.61-3.08) for recurrent stroke, 2.31 (1.64-3.24) for ischemic stroke, 2.30 (1.66-3.19) for combined vascular events within 1-year follow-up. Furthermore, the addition of sLOX-1 to a conventional risk model had an incremental effect on predictive value for recurrent stroke (C-statistics 0.76, p < 0.0001; integrated discrimination improvement 13.38%, p < 0.0001; net reclassification improvement 55.39%, p < 0.0001). Similar results were observed when the timepoint was set up as 3 months. Subgroup analysis showed the association between higher sLOX-1 and recurrent stroke was more pronounced in patients with a history of stroke (p for interaction = 0.0062). CONCLUSIONS sLOX-1 was positively associated with the risk of recurrent stroke, which may be a candidate biomarker to improve risk stratification of recurrent stroke.
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Affiliation(s)
- Anxin Wang
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xue Tian
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina,Department of Epidemiology and Health StatisticsSchool of Public Health, Capital Medical UniversityBeijingChina
| | - Jie Xu
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Hao Li
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Qin Xu
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Pan Chen
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xia Meng
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Yongjun Wang
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
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23
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He M, Wang H, Tang Y, Cui B, Xu B, Niu X, Sun Y, Zhang G, He X, Wang B, Xu B, Li Z, Zhang Y, Wang Y. Red blood cell distribution width in different time-points of peripheral thrombolysis period in acute ischemic stroke is associated with prognosis. Aging (Albany NY) 2022; 14:5749-5767. [PMID: 35832033 PMCID: PMC9365566 DOI: 10.18632/aging.204174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/05/2022] [Indexed: 12/30/2022]
Abstract
The relationship between red blood cell distribution width (RDW) in peripheral thrombolysis period and prognosis is not fully clarified in those who underwent intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). Our study aimed to clarify this issue. A retrospective analysis of about 510 consecutive thrombolysis cases for AIS from January 2015 to March 2019 in a single-center database was done and followed-up for 3 months. We used univariate and multivariable models to evaluate the relationship between RDW levels at various time-points after IVT and the occurrence risk of hemorrhagic transformation (HT) and recurrent stroke, and used COX regression to assess the hazard ratios of outcomes with RDW levels. Elevated risk of HT was found in higher tertiles of RDW (OR = 10.282, 95% confidence interval (CI) 2.841–39.209, P < 0.001 in Tp tertile G3; OR = 5.650, 95% CI 1.992–16.025, P = 0.001 in T24 tertile G3; OR = 4.308, 95% CI 1.480–12.542, P = 0.007 in T48 tertile G3 and OR = 6.384, 95% CI 2.201–18.515, P = 0.001 in T72 tertile G3, respectively). Occurrence of recurrent stroke was highest in the RDW tertile G3 (HR = 4.580, 95% CI 2.123–9.883, P < 0.001 in Tp tertile G3; HR = 5.731, 95% CI 2.498–13.151, P = 0.001 in T24 tertile G3; HR = 3.019, 95% CI 1.969–4.059, P = 0.031 in T48 tertile G3; HR = 3.318, 95% CI 1.598–6.890, P = 0.001 in T72 tertile G3, respectively). Mean RDW levels ≥13.60 among AIS patients undergoing thrombolysis was associated with higher risk of HT and recurrent stroke.
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Affiliation(s)
- Mingli He
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Jiangsu, China
| | - Hongrui Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Tang
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Jiangsu, China
| | - Bing Cui
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bingchao Xu
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Jiangsu, China
| | - Xiaoqin Niu
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Jiangsu, China
| | - Yongan Sun
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Jiangsu, China
| | - Guanghui Zhang
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Jiangsu, China
| | - Xiaobing He
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Jiangsu, China
| | - Bei Wang
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Jiangsu, China
| | - Bei Xu
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Jiangsu, China
| | - Zaipo Li
- Department of Neurology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Jiangsu, China
| | - Yu Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yibo Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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24
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Noh KC, Choi HY, Woo HG, Chang JY, Heo SH, Chang DI, Kim BJ. High-on-Aspirin Platelet Reactivity Differs Between Recurrent Ischemic Stroke Associated With Extracranial and Intracranial Atherosclerosis. J Clin Neurol 2022; 18:421-427. [PMID: 35796267 PMCID: PMC9262451 DOI: 10.3988/jcn.2022.18.4.421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 12/10/2021] [Accepted: 12/10/2021] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose Ischemic stroke recurs despite the use of antiplatelet agents. Various mechanisms are involved in recurrence due to intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS). High-on-aspirin platelet reactivity (HAPR) may differ between recurrent stroke due to ICAS and ECAS. Methods Patients with recurrent ischemic stroke as a result of large-artery atherosclerosis despite taking aspirin were enrolled consecutively. Ischemic stroke was classified as stroke due to ICAS or ECAS according to the location of the culprit stenosis. An aspirin reaction units (ARU) value of >550 IU was defined as HAPR. HAPR and its associated factors were compared between the two groups and also considering the mechanism of stroke. Results Among the 190 patients with recurrent stroke (111 with ICAS and 79 with ECAS), 36 (18.3%) showed HAPR. The ARU value was higher in the ECAS than the ICAS group (492±83 vs. 465±78, mean±standard deviation; p=0.028), as was the proportion of patients with HAPR (27.8% vs. 12.6%, p=0.008). Being male and having stroke due to ECAS (reference=stroke due to ICAS: odds ratio=5.760; 95% confidence interval=2.154–15.403; p<0.001) was independently associated with HAPR. The ARU value differed according to the stroke mechanism, and was highest in those with artery-to-artery embolism. Artery-to-artery embolism was independently associated with HAPR in both the ICAS and ECAS groups. Conclusions Recurrent stroke due to ECAS was more strongly associated with HAPR and insufficient antiplatelet inhibition than was that due to ICAS. Artery-to-artery embolism was associated with HAPR in recurrent ischemic stroke as a result of ICAS or ECAS.
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Affiliation(s)
- Kyung Chul Noh
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea.,Department of Medicine, Graduate School, Kyung Hee University, Seoul, Korea
| | - Hye-Yeon Choi
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Ho Geol Woo
- Department of Neurology, Kyung Hee University Hospital, Seoul, Korea
| | - Jun Young Chang
- Department of Neurology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Sung Hyuk Heo
- Department of Neurology, Kyung Hee University Hospital, Seoul, Korea
| | - Dae-Il Chang
- Department of Neurology, Kyung Hee University Hospital, Seoul, Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea.
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25
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Muggeridge D, Callum K, Macpherson L, Howard N, Graune C, Megson I, Giangreco A, Gallacher S, Campbell L, Williams G, Macaden A, Leslie SJ. Clinical and health economic evaluation of a post-stroke arrhythmia monitoring service. Br J Cardiol 2022; 29:15. [PMID: 36212791 PMCID: PMC9534108 DOI: 10.5837/bjc.2022.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Atrial fibrillation (AF) is a major cause of recurrent stroke and transient ischaemic attack (TIA) in the UK. As many patients can have asymptomatic paroxysmal AF, prolonged arrhythmia monitoring is advised in selected patients following a stroke or TIA. This service evaluation assessed the clinical and potential health economic impact of prolonged arrhythmia monitoring post-stroke using R-TEST monitoring devices. This was a prospective, case-controlled, service evaluation in a single health board in the North of Scotland. Patients were included if they had a recent stroke or TIA, were in sinus rhythm, and did not have another indication for, or contraindication to, oral anticoagulation. A health economic model was developed to estimate the clinical and economic value delivered by the R-TEST monitoring. Approval to use anonymised patient data in this service evaluation was obtained. During the evaluation period, 100 consecutive patients were included. The average age was 70 ± 11 years, 46% were female. Stroke was the presenting complaint in 83% of patients with the other 17% having had a TIA. AF was detected in seven of 83 (8.4%) patients who had had a stroke and one of 17 (5.9%) patients with a TIA. Health economic modelling predicted that adoption of R-TEST monitoring has a high probability of demonstrating both clinical and economic benefits. In conclusion, developing a post-stroke arrhythmia monitoring service using R-TEST devices is feasible, effective at detecting AF, and represents a probable clinical and economic benefit.
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Affiliation(s)
- David Muggeridge
- Lecturer in Exercise Physiology Institute of Health Research and Innovation, University of the Highlands and Islands, Centre for Health Science, Old Perth Road, Inverness, IV2 3JH
| | - Kara Callum
- Cardiac Physiologist Institute of Health Research and Innovation, University of the Highlands and Islands, Centre for Health Science, Old Perth Road, Inverness, IV2 3JH
| | - Lynsey Macpherson
- Cardiac Physiologist NHS Highland, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ
| | - Nick Howard
- Cardiac Physiologist NHS Highland, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ
| | - Claudia Graune
- Cardiac Physiologist NHS Highland, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ
| | - Ian Megson
- Head of Health Research and Innovation Institute of Health Research and Innovation, University of the Highlands and Islands, Centre for Health Science, Old Perth Road, Inverness, IV2 3JH
| | - Adam Giangreco
- Director of Health and Life Sciences Innovation Institute of Health Research and Innovation, University of the Highlands and Islands, Centre for Health Science, Old Perth Road, Inverness, IV2 3JH
| | - Susan Gallacher
- Stroke Audit Facilitator NHS Highland, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ
| | - Linda Campbell
- Stroke Co-ordinator NHS Highland, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ
| | - Gethin Williams
- Stroke Physician NHS Highland, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ
| | - Ashish Macaden
- Rehabilitation Medicine and Stroke Physician NHS Highland, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ
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26
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Cai X, Geng Y, Zhang S. The Relationship Between Aortic Arch Calcification and Recurrent Stroke in Patients With Embolic Stroke of Undetermined Source-A Case-Control Study. Front Neurol 2022; 13:863450. [PMID: 35547364 PMCID: PMC9084855 DOI: 10.3389/fneur.2022.863450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/16/2022] [Indexed: 11/29/2022] Open
Abstract
Background Aortic arch calcification (AoAC) is associated with plaque development and cardiovascular events. We aimed to estimate the predictive value of AoAC for stroke recurrence in patients with embolic stroke of undetermined source (ESUS). Methods Consecutive patients with ESUS who were admitted to our center between October 2019 and October 2020 and who had a 1-year follow-up of stroke recurrence were retrospectively reviewed. According to our AoAC grading scale (AGS), AoAC was classified into four grades based on chest computed tomography (CT) findings: no visible calcification (grade 0), spotty calcification (grade 1), lamellar calcification (grade 2), and circular calcification (grade 3). Results Of the 158 patients with ESUS (age, 62.1 ± 14.5 years; 120 men) enrolled, 24 (15.2%) had recurrent stroke within a 1-year follow-up. The Cox regression analysis showed that stroke history [hazard ratio (HR), 4.625; 95% confidence interval (CI), 1.828–11.700, p = 0.001] and AoAC (HR, 2.672; 95% CI, 1.129–6.319; p = 0.025) predicted recurrent stroke. AGS grade 1 was associated with a significantly higher risk of stroke recurrence than AGS grade 0 (HR, 5.033; 95% CI, 1.858–13.635, p = 0.001) and AGS grade 2 plus 3 (HR, 3.388; 95% CI, 1.124–10.206, p = 0.030). In patients with AoAC, receiver operating characteristic (ROC) analysis showed that AGS had a good value in predicting stroke recurrence in patients with ESUS, with an area under curve (AUC) of 0.735 (95% CI = 0.601–0.869, p = 0.005). Conclusions Aortic arch calcification, especially spotty calcification, had a good predictive value for stroke recurrence in patients with ESUS.
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Affiliation(s)
- Xiaofeng Cai
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Sheng Zhang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
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Li G, Li L, Adachi JD, Wang R, Ye Z, Liu X, Thabane L, Lip GYH. Relationship between Serum 25-Hydroxyvitamin D Level and Risk of Recurrent Stroke. Nutrients 2022; 14:1908. [PMID: 35565874 PMCID: PMC9099592 DOI: 10.3390/nu14091908] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 04/29/2022] [Accepted: 04/30/2022] [Indexed: 12/04/2022] Open
Abstract
Evidence for the association between vitamin D and risk of recurrent stroke remains sparse and limited. We aimed to assess the relationship between serum circulating 25-hydroxyvitamin D (25(OH)D) level and risk of recurrent stroke in patients with a stroke history, and to identify the optimal 25(OH)D level in relation to lowest recurrent stroke risk. Data from the nationwide prospective United Kingdom Biobank were used for analyses. Primary outcome was time to first stroke recurrence requiring a hospital visit during follow-up. We used Cox proportional hazards regression model with restricted cubic splines to explore 25(OH)D level in relation to recurrent stroke. The dose-response relationship between 25(OH)D and recurrent stroke risk was also estimated, taking the level of 10 nmol/L as reference. A total of 6824 participants (mean age: 60.6 years, 40.8% females) with a baseline stroke were included for analyses. There were 388 (5.7%) recurrent stroke events documented during a mean follow-up of 7.6 years. Using Cox proportional hazards regression model with restricted cubic splines, a quasi J-shaped relationship between 25(OH)D and risk of recurrent stroke was found, where the lowest recurrent stroke risk lay at the 25(OH)D level of approximate 60 nmol/L. When compared with 10 nmol/L, a 25(OH)D level of 60 nmol/L was related with a 48% reduction in the recurrent stroke risk (hazard ratio = 0.52, 95% confidence interval: 0.33-0.83). Based on data from a large-scale prospective cohort, we found a quasi J-shaped relationship between 25(OH)D and risk of recurrent stroke in patients with a stroke history. Given a lack of exploring the cause-effect relationship in this observational study, more high-quality evidence is needed to further clarify the vitamin D status in relation to recurrent stroke risk.
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Affiliation(s)
- Guowei Li
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou 510317, China; (L.L.); (R.W.)
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Likang Li
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou 510317, China; (L.L.); (R.W.)
| | - Jonathan D. Adachi
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Ruoting Wang
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou 510317, China; (L.L.); (R.W.)
| | - Zebing Ye
- Department of Cardiology, Guangdong Second Provincial General Hospital, Guangzhou 510317, China;
| | - Xintong Liu
- Department of Neurology, Guangdong Second Provincial General Hospital, Guangzhou 510317, China;
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON L8S 4L8, Canada;
- Centre for Evaluation of Medicines, St. Joseph’s Healthcare, Hamilton, ON L8N 4A6, Canada
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool L69 3BX, UK;
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
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Lin SY, Law KM, Yeh YC, Wu KC, Lai JH, Lin CH, Hsu WH, Lin CC, Kao CH. Applying Machine Learning to Carotid Sonographic Features for Recurrent Stroke in Patients With Acute Stroke. Front Cardiovasc Med 2022; 9:804410. [PMID: 35155629 PMCID: PMC8833232 DOI: 10.3389/fcvm.2022.804410] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/04/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Although carotid sonographic features have been used as predictors of recurrent stroke, few large-scale studies have explored the use of machine learning analysis of carotid sonographic features for the prediction of recurrent stroke. METHODS We retrospectively collected electronic medical records of enrolled patients from the data warehouse of China Medical University Hospital, a tertiary medical center in central Taiwan, from January 2012 to November 2018. We included patients who underwent a documented carotid ultrasound within 30 days of experiencing an acute first stroke during the study period. We classified these participants into two groups: those with non-recurrent stroke (those who has not been diagnosed with acute stroke again during the study period) and those with recurrent stoke (those who has been diagnosed with acute stroke during the study period). A total of 1,235 carotid sonographic parameters were analyzed. Data on the patients' demographic characteristics and comorbidities were also collected. Python 3.7 was used as the programming language, and the scikit-learn toolkit was used to complete the derivation and verification of the machine learning methods. RESULTS In total, 2,411 patients were enrolled in this study, of whom 1,896 and 515 had non-recurrent and recurrent stroke, respectively. After extraction, 43 features of carotid sonography (36 carotid sonographic parameters and seven transcranial color Doppler sonographic parameter) were analyzed. For predicting recurrent stroke, CatBoost achieved the highest area under the curve (0.844, CIs 95% 0.824-0.868), followed by the Light Gradient Boosting Machine (0.832, CIs 95% 0.813-0.851), random forest (0.819, CIs 95% 0.802-0.846), support-vector machine (0.759, CIs 95% 0.739-0.781), logistic regression (0.781, CIs 95% 0.764-0.800), and decision tree (0.735, CIs 95% 0.717-0.755) models. CONCLUSION When using the CatBoost model, the top three features for predicting recurrent stroke were determined to be the use of anticoagulation medications, the use of NSAID medications, and the resistive index of the left subclavian artery. The CatBoost model demonstrated efficiency and achieved optimal performance in the predictive classification of non-recurrent and recurrent stroke.
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Affiliation(s)
- Shih-Yi Lin
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
| | - Kin-Man Law
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
- Department of Computer Science and Engineering, National Chung Hsing University, Taichung, Taiwan
| | - Yi-Chun Yeh
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
| | - Kuo-Chen Wu
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Jhih-Han Lai
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Hsueh Lin
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Wu-Huei Hsu
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Division of Pulmonary and Critical Care Medicine, China Medical University Hospital and China Medical University, Taichung, Taiwan
| | - Cheng-Chieh Lin
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
- Department of Nuclear Medicine and Positron Emission Tomography Center, China Medical University Hospital, Taichung, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
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Hu G, Pan Y, Wang M, Meng X, Jiang Y, Li Z, Li H, Wang Y, Wang Y. Inverse Association between High-Density Lipoprotein Cholesterol and Adverse Outcomes among Acute Ischemic Stroke Patients with Diabetes Mellitus. Biomedicines 2021; 9:biomedicines9121947. [PMID: 34944763 PMCID: PMC8698640 DOI: 10.3390/biomedicines9121947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 11/16/2022] Open
Abstract
A low high-density lipoprotein cholesterol (HDL-C) level is an identified risk factor for cardiovascular diseases. However, results on the association between HDL-C levels and adverse outcomes in diabetic status still remain limited and controversial. Herein, we evaluated the association between HDL-C levels and adverse outcomes among acute ischemic stroke (AIS) patients with diabetes mellitus. The cohort comprised 3824 AIS patients with diabetes mellitus (62.7 ± 10.5 years; 34.2% women) from the Third China National Stroke Registry (n = 15,166). Patients were classified into five groups by quintiles of HDL-C. The outcomes included recurrent stroke and major adverse cardiovascular events (MACEs) within 1 year. The relationship between HDL-C levels and the risk of adverse outcomes was analyzed by Cox proportional hazards models. Patients in the lowest quintile of HDL-C had a higher risk of recurrent stroke (hazard ratio (HR) 1.59, 95% confidence interval (CI), 1.12-2.25) and MACEs (HR 1.53, 95% CI, 1.09-2.15) during 1-year follow-up compared with those in the highest quintile of HDL-C. There were linear associations between HDL-C levels and the risks of both recurrent stroke and MACEs. Low HDL-C levels were associated with higher risks of recurrent stroke and MACEs within 1 year in AIS patients with diabetes mellitus.
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Affiliation(s)
- Guoliang Hu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China; (G.H.); (Z.L.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China; (Y.P.); (M.W.); (X.M.); (Y.J.); (H.L.)
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100070, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China; (Y.P.); (M.W.); (X.M.); (Y.J.); (H.L.)
| | - Mengxing Wang
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China; (Y.P.); (M.W.); (X.M.); (Y.J.); (H.L.)
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China; (Y.P.); (M.W.); (X.M.); (Y.J.); (H.L.)
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China; (Y.P.); (M.W.); (X.M.); (Y.J.); (H.L.)
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China; (G.H.); (Z.L.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China; (Y.P.); (M.W.); (X.M.); (Y.J.); (H.L.)
- Chinese Institute for Brain Research, Beijing 102206, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China; (Y.P.); (M.W.); (X.M.); (Y.J.); (H.L.)
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China; (G.H.); (Z.L.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China; (Y.P.); (M.W.); (X.M.); (Y.J.); (H.L.)
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100070, China
- Correspondence: (Y.W.); (Y.W.)
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China; (G.H.); (Z.L.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China; (Y.P.); (M.W.); (X.M.); (Y.J.); (H.L.)
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100070, China
- Chinese Institute for Brain Research, Beijing 102206, China
- Correspondence: (Y.W.); (Y.W.)
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Li J, Zhao X, Zhang Y, Wan H, He Y, Li X, Yu L, Jin W. Comparison of Traditional Chinese Medicine in the Long-Term Secondary Prevention for Patients with Ischemic Stroke: A Systematical Analysis. Front Pharmacol 2021; 12:722975. [PMID: 34867326 PMCID: PMC8637749 DOI: 10.3389/fphar.2021.722975] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/05/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Keeping in view the high recurrence rate and risk of ischemic stroke, combinatorial therapy involving traditional Chinese medicine (TCM) with conventional Western medicine (WM) is receiving wider scientific attention. Thus, a systematical analysis was made to explore the efficacy of TCM+WM in the long-term secondary prevention for patients with ischemic stroke. Methods: Qualified inclusion and exclusion criteria were set up beforehand, and two researchers independently read the articles, extracted data, and evaluated the quality of included articles according to Cochrane Reviewer's Handbook 5.1 method. For the sake of comprehensive data acquisition, seven databases from the time of their establishment to May 5, 2021, have been searched completely. Additionally, pairwise meta-analysis was made to compare TCM+WM vs. WM, and network meta-analysis was conducted by frequentist random effects models for the comparison of different kinds of TCM+WM via indirect evidence. The primary outcomes defined were recurrent stroke and NIHSS. Secondary outcomes were fibrinogen (Fib) fasting blood glucose (FBG), triglycerides (TG), and total cholesterol (TC). Safety outcomes were outlined as all-cause mortality and adverse events (AEs). Furthermore, Stata16.0 software was used to accomplish the systematical analysis and cluster analysis. Results: In total, 47 qualified randomized controlled trials (RCTs) including 10,732 patients were taken into consideration. Seven traditional Chinese medicines included in the study are Naoxintong capsule (NXT), Tongxinluo capsule (TXL), Buyang Huanwu decoction (BYHW), Naomaitai capsule (NMT), Dengzhan Shengmai capsule (DZSM), Naoshuantong capsule (NST), and Maixuekang capsule (MXK). With respect to their primary outcomes, all kinds of TCM+WM were significantly more effective than WM (e.g., NXT in recurrent stroke (OR=0.54, P<0.01), TXL in NIHSS (WM=-1.4, P<0.01)). Additionally, the outcomes of cluster analysis indicated that MXK+WM and NST+WM had relatively good preventive effects for recurrent stroke, NIHSS, and all-cause mortality. There was no significant difference in the comparisons of AEs; however, this may arise from the lack of sufficient data. Conclusion: According to our systematical analysis, MXK+WM and NST+WM had relatively good secondary prevention effects for patients with ischemic stroke regarding recurrent stroke, NIHSS, and all-cause mortality. Nevertheless, better, high-quality, large-sample randomized clinical trials (RCTs) are required to verify our conclusions in the future. Systematic Review Registration: [https://inplasy.com/inplasy-2021-5-0036/], identifier [INPLASY202150036].
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Affiliation(s)
- Jiali Li
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xixi Zhao
- School of Life Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yangyang Zhang
- School of Life Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Haitong Wan
- School of Life Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yu He
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaohong Li
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Li Yu
- School of Life Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Weifeng Jin
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
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Yoshida K, Tanaka K, Suto Y, Fukuda H. Repeated Cardioembolic Stroke after COVID-19 mRNA Vaccination: A Case Report. J Stroke Cerebrovasc Dis 2021; 31:106233. [PMID: 34883321 PMCID: PMC8606267 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106233] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/04/2021] [Accepted: 11/16/2021] [Indexed: 12/31/2022] Open
Abstract
Objective There have been no reports suggesting a relationship between the COVID-19 mRNA vaccines that encodes the spike glycoprotein of SARS-CoV-2 and cerebrovascular disease. A case of repeated cardioembolic stroke after vaccination with the BNT162b2 (Pfizer) COVID-19 mRNA vaccine is presented. Methods Imaging and laboratory findings, treatment decisions, and the outcome of this case are presented. Results An 83-year-old Japanese woman developed right hemiplegia and motor aphasia three days after receiving her first dose of the BNT162b2 (Pfizer) COVID-19 mRNA vaccine. She had been taking rivaroxaban for persistent atrial fibrillation for 10 years, but had no symptomatic ischemic strokes. On magnetic resonance imaging (MRI) the left middle cerebral artery (MCA) was occluded. Intravenous recombinant tissue-plasminogen activator (rt-PA) therapy and mechanical thrombectomy were performed, and she recovered almost fully. However, three days after the second dose, she developed left hemiplegia and left hemispatial neglect. MRI showed occlusion of the right MCA. Only mechanical thrombectomy was performed again, but it could not be resumed due to the hard thrombus. Discussion In this case, it is difficult to exclude a causal relationship between the COVID-19 mRNA vaccine and ischemic stroke. This association needs to be carefully monitored.
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Affiliation(s)
| | | | - Yutaka Suto
- Department of Neurology, Matsue Red Cross Hospital
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Jensen MM, Hald SM, Kristensen LMB, Boe NJ, Harbo FSG, Gaist D. Validity of Simple Algorithms to Identify Recurrence of Intracerebral Hemorrhage in Two Danish Nationwide Registries. Clin Epidemiol 2021; 13:949-958. [PMID: 34675683 PMCID: PMC8517414 DOI: 10.2147/clep.s333624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/20/2021] [Indexed: 02/03/2023] Open
Abstract
Purpose Danish registries could be an attractive resource for studies of recurrent intracerebral hemorrhage (re-ICH). We developed and validated algorithms to identify re-ICH in the Danish Stroke Registry (DSR) and the Danish National Patient Registry (DNPR). Patients and Methods Using multiple sources, we followed-up an inception cohort with verified first-ever spontaneous ICH (n = 2528) for their first re-ICH in 2009-2018 (study period). We used verified cases of re-ICH (n = 124) as the gold standard to assess the performance of register-based algorithms for identifying re-ICH. For each cohort member, we traced events of re-ICH (ICD-10-code I61) in the study period according to DSR and DNPR, respectively. For each registry, we tested algorithms with a blanking period (BP) - ie, a period immediately following the index ICH during which outcome events were ignored - of varying length (7 days-360 days). The algorithm with the shortest BP that returned a positive predictive value (PPV) of ≥80% was considered optimal. We also calculated negative predictive value (NPV), sensitivity, and specificity of each algorithm and [95% confidence intervals] for all proportions. Results The optimal algorithm for DSR (BP 30 days) had a PPV of 89.5% [82.2-94.0], NPV 98.8% [98.2-99.1], sensitivity 75.8% [67.6-82.5], and specificity 99.5% [99.2-99.7]. The optimal algorithm for DNPR (BP 120 days) had a PPV of 80.6% [71.7-87.2], NPV 98.1% [97.5-98.6], sensitivity 63.7% [55.0-71.6], and specificity 99.2% [98.8-99.5]. Conclusion Simple algorithms accurately identified re-ICH in DSR and DNPR. Compared with DNPR, DSR achieved higher PPV and sensitivity with a shorter BP. The proposed algorithms could facilitate valid use of DSR and DNPR for studies of re-ICH.
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Affiliation(s)
| | - Stine Munk Hald
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Neurology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Nils Jensen Boe
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Neurology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - David Gaist
- Department of Neurology, Odense University Hospital, Odense, Denmark.,Neurology Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Open Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
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Leber SL, Fandler-Höfler S, Kneihsl M, Augustin M, Deutschmann H, Gattringer T. Case Report: Four Early Recurrent Basilar Artery Occlusions Successfully Treated With Mechanical Thrombectomy and Subsequent Vertebral Artery Coil Occlusion. Front Neurol 2021; 12:698488. [PMID: 34616351 PMCID: PMC8488096 DOI: 10.3389/fneur.2021.698488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/23/2021] [Indexed: 11/25/2022] Open
Abstract
We present the case of a middle-aged patient who had four recurrent acute basilar artery occlusions over a period of 3 months, each time successfully treated with mechanical thrombectomy. Extensive stroke work-up showed no obvious stroke etiology aside from a dysplastic right vertebral artery with multifocal stenoses. Treatment with different antiplatelet and anticoagulant regimes did not prevent basilar artery occlusion recurrence. Therefore, transarterial coil occlusion of the V4-segment of the right vertebral artery was performed as ultima ratio without complications. At final discharge, the patient had no persistent neurological deficits. No further cerebrovascular events occurred over a 12-month follow-up period.
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Affiliation(s)
- Stefan L Leber
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | | | - Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Michael Augustin
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | | | - Thomas Gattringer
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria.,Department of Neurology, Medical University of Graz, Graz, Austria
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Zhong C, Miao M, Che B, Du J, Wang A, Peng H, Bu X, Zhang J, Ju Z, Xu T, He J, Zhang Y. Plasma choline and betaine and risks of cardiovascular events and recurrent stroke after ischemic stroke. Am J Clin Nutr 2021; 114:1351-1359. [PMID: 34159355 DOI: 10.1093/ajcn/nqab199] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/25/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Choline and betaine have been suggested to play a pivotal role in neurotransmitter synthesis, cell membrane integrity, and methyl-group metabolism, exerting neuroprotective effects in patients with various neurological disorders. However, population-based evidence on choline and betaine with subsequent cardiovascular events after stroke is rare. OBJECTIVES We aimed to prospectively investigate the relationships of circulating choline and betaine with cardiovascular events and recurrent stroke in patients with ischemic stroke. METHODS We performed a nested case-control study within the China Antihypertensive Trial in Acute Ischemic Stroke. A total of 323 cardiovascular events (including 264 recurrent strokes) and 323 controls (free of recurrent cardiovascular events) matched for age (±1 y), sex, and treatment group were included. The primary endpoint was a composite of cardiovascular events after ischemic stroke. Plasma choline and betaine were measured at baseline by ultra-high-performance LC-MS/MS. Conditional logistic regression models were applied, and discrimination, reclassification, and calibration of models with choline pathway metabolites were evaluated. RESULTS Plasma choline and betaine were inversely associated with cardiovascular events and recurrent stroke after ischemic stroke. Specifically, in fully adjusted models, each additional SD of choline and betaine was associated with 35% (95% CI: 20%-48%) and 30% (95% CI: 14%-43%) decreased risks of subsequent cardiovascular events, respectively, and 34% (95% CI: 16%-48%) and 29% (95% CI: 12%-43%) decreased risks of recurrent stroke, respectively. In addition, both choline and betaine offered substantial risk discrimination and reclassification improvement for cardiovascular events and recurrent stroke beyond traditional risk factors, as evidenced by an increase in C statistics, the net reclassification index, and integrated discrimination improvement. CONCLUSIONS Plasma choline pathway metabolites, including choline and betaine, were associated with decreased risks of cardiovascular events and recurrent stroke and provided incremental value in risk discrimination and stratification in patients with ischemic stroke. This nested case-control study was based on the China Antihypertensive Trial in Acute Ischemic Stroke, which is registered at clinicaltrials.gov as NCT01840072.
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Affiliation(s)
- Chongke Zhong
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China
| | - Mengyuan Miao
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China
| | - Bizhong Che
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China
| | - Jigang Du
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China
| | - Aili Wang
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China
| | - Hao Peng
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China
| | - Xiaoqing Bu
- Department of Epidemiology, School of Public Health, Chongqing Medical University, Chongqing, China
| | - Jintao Zhang
- Department of Neurology, The 88th Hospital of PLA, Shandong, China
| | - Zhong Ju
- Department of Neurology, Kerqin District First People's Hospital of Tongliao City, Tongliao, China
| | - Tan Xu
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Yonghong Zhang
- Department of Epidemiology, School of Public Health and Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Medical College of Soochow University, Suzhou, China
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Yu S, Alper HE, Nguyen A, Maqsood J, Brackbill RM. Stroke hospitalizations, posttraumatic stress disorder, and 9/11-related dust exposure: Results from the World Trade Center Health Registry. Am J Ind Med 2021; 64:827-836. [PMID: 34558721 DOI: 10.1002/ajim.23271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few studies have examined the association between disaster-related factors and stroke by subtype or number. We investigated the association between 9/11-related posttraumatic stress disorder (PTSD), dust exposure, and stroke subtype as well as recurrent strokes. METHODS The study included 29,012 individuals enrolled in the World Trade Center Health Registry. Stroke cases were obtained by matching Registry enrollees to the New York State Department of Health's discharge records for inpatient visits between 2000 and 2016. Cox proportional hazards regression models were performed to examine the association between 9/11-related risk factors and stroke by subtype. Multinomial logistic regression models were conducted to assess the associations between the same risk factors and the number of stroke hospitalizations. RESULTS Having PTSD significantly increased the risk of developing ischemic and hemorrhagic stroke, with adjusted hazards ratios (AHRs) of 1.64 (95% confidence interval [CI]: 1.28-2.10) and 1.73 (95% CI: 1.10-2.71), respectively. The point estimate for dust cloud exposure, although not significant statistically, suggested an increased risk of ischemic stroke (AHR = 1.20, 95% CI: 0.96-1.50). PTSD was significantly associated with recurrent strokes with an adjusted odds ratio of 1.79 (95% CI: 1.09-2.95). CONCLUSIONS PTSD is a risk factor for both ischemic and hemorrhagic stroke and is associated with recurrent strokes. Dust exposure on 9/11 is a possible risk factor for ischemic stroke but not for hemorrhagic stroke, and was not associated with recurrent strokes. Our findings warrant additional research on stroke-morbidity and mortality associated with 9/11-related PTSD and dust exposure.
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Affiliation(s)
- Shengchao Yu
- New York City Department of Health and Mental Hygiene Long Island City New York USA
| | - Howard E. Alper
- New York City Department of Health and Mental Hygiene Long Island City New York USA
| | - Angela‐Maithy Nguyen
- Interdisciplinary Division, School of Public Health University of California‐Berkeley Berkeley California USA
| | - Junaid Maqsood
- New York City Department of Health and Mental Hygiene Long Island City New York USA
| | - Robert M. Brackbill
- New York City Department of Health and Mental Hygiene Long Island City New York USA
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Liu G, Wang Y, Chu C, Ren Y, Hua Y, Ji X, Song H. Hyoid Elongation May Be a Rare Cause of Recurrent Ischemic Stroke in Youth-A Case Report and Literature Review. Front Neurol 2021; 12:653471. [PMID: 34539537 PMCID: PMC8440883 DOI: 10.3389/fneur.2021.653471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 08/06/2021] [Indexed: 11/25/2022] Open
Abstract
The investigation for etiology of ischemic stroke in young adults remains a diagnostic challenge. Hyoid bone–related carotid injury is a rare and under-recognized cause of ischemic stroke, without established guidelines. We describe a case of recurrent ischemic stroke in a young patient presumably attributed to an impingement of the carotid artery by an elongated hyoid bone, and present other cases reported in the literature. Based on the imaging study as well as the lack of other findings, we attributed recurrent neurovascular events to the repetitive mechanical stimulation by the elongated hyoid bone that caused a vessel wall injury with subsequent thrombus and embolus. Given repeated recurrence under antiplatelet treatment, anticoagulation was added. The following 2-year follow-up showed no new neurologic events or any other complaints. Among the young, a broad spectrum of possibilities should be considered and we call attention to this infrequent etiology of ischemic stroke.
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Affiliation(s)
- Gang Liu
- Department of Neurology, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Yuan Wang
- Department of Neurology, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Changbiao Chu
- Department of Neurology, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Yi Ren
- Department of Neurology, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasound, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medicine University, Beijing, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital, Capital Medicine University, Beijing, China
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Lambert CM, Olulana O, Bailey-Davis L, Abedi V, Zand R. "Lessons Learned" Preventing Recurrent Ischemic Strokes through Secondary Prevention Programs: A Systematic Review. J Clin Med 2021; 10:4209. [PMID: 34575320 DOI: 10.3390/jcm10184209] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022] Open
Abstract
Recurrent ischemic strokes are a cause of significant healthcare burdens globally. Patients with uncontrolled vascular risk factors are more likely to develop recurrent ischemic strokes. This study aims to compile information gained from current secondary prevention programs. A pre-defined literature search strategy was applied to PubMed, SCOPUS, CINAHL, and Google Scholar databases, and studies from 1997 to 2020 were evaluated for quality, study aims, and outcomes. The search produced 1175 articles (1092 after duplicates were removed) and titles were screened; 55 titles were retained for the full-text analysis. Of the remaining studies, 31 were retained for assessment, five demonstrated long-term effectiveness, eight demonstrated short-term effectiveness, and 18 demonstrated no effectiveness. The successful studies utilized a variety of different techniques in the categories of physical fitness, education, and adherence to care plans to reduce the risk of recurrent strokes. The lessons we learned from the current prevention programs included (1) offer tailored care for underserved groups, (2) control blood pressure, (3) provide opportunities for medication dosage titration, (4) establish the care plan prior to discharge, (5) invest in supervised exercise programs, (6) remove barriers to accessing care in low resource settings, and (7) improve the transition of care.
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Aked J, Delavaran H, Lindgren AG. Survival, causes of death and recurrence up to 3 years after stroke: A population-based study. Eur J Neurol 2021; 28:4060-4068. [PMID: 34327786 DOI: 10.1111/ene.15041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/24/2021] [Accepted: 07/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Up-to-date population-based information about long-term survival, causes of death and recurrence after stroke is needed. METHODS Four hundred consecutive individuals in a population-based cohort of first-ever stroke between 2015 and 2016 in Lund, Sweden, were followed up to 3 years regarding (i) survival (Swedish Population Register); (ii) causes of death (Swedish Causes of Death Register); and (iii) stroke recurrence (interview and medical chart review). Index and recurrent ischaemic stroke cases were classified using the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) and Oxfordshire Community Stroke Project; and comorbidities were classified using the Charlson Comorbidity Index. Cox regression was used to determine predictors for 3-year mortality. Survival rates were compared with three local studies over a 30-year timespan. RESULTS Amongst 400 first-ever stroke patients, 265 (66%) survived 3 years post-stroke. Age (hazard ratio [HR] 1.09; 95% confidence interval [CI] 1.06-1.11), stroke severity (HR 1.11; 95% CI 1.08-1.13) and comorbidities (HR 1.36; 95% CI 1.22-1.53) were independently related to 3-year mortality. Amongst index ischaemic stroke patients, survival was lowest amongst those with cardio-aortic embolism (51/91; 56%). Cerebrovascular disease (54/135; 40%) and ischaemic heart disease (25/135; 19%) were the most common causes of death. Within 3 years, 30 (8%) had recurrent stroke. Amongst patients with index ischaemic stroke, 16/29 (55%) had a different TOAST pathogenetic mechanism or hemorrhagic stroke upon recurrence. Stroke survival improved between 1983-1985 and 2015-2016 (p = 0.002), but no significant change was observed between 2001-2002 and 2015-2016 (p = 0.48). CONCLUSIONS Stroke survival rates are relatively high, but their improvement over recent decades may be slowing down, possibly due to the composition of the first-ever stroke population. The common occurrence of changed pathogenetic mechanisms between first-ever and recurrent stroke highlights the value of reassessment in recurrent stroke.
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Affiliation(s)
- Joseph Aked
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden.,Department of Medicine, Blekinge Hospital, Karlskrona, Sweden
| | - Hossein Delavaran
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden.,Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Arne G Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden.,Department of Neurology, Skåne University Hospital, Lund, Sweden
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Panda PK, Sharawat IK, Singh A, Sherwani P. A Young Child with Recurrent Episodes of Headaches and Vision Loss: Diagnostic Clues? J Pediatr Neurosci 2021; 16:82-84. [PMID: 34316317 PMCID: PMC8276967 DOI: 10.4103/jpn.jpn_91_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/07/2020] [Accepted: 07/21/2020] [Indexed: 11/14/2022] Open
Abstract
MELAS is a mitochondrial cytopathy, with maternal inheritance and variable phenotype expression and severity depending on the degree of heteroplasmy. It presents with waxing and waning symptoms, in form of recurrent migrainous headache, transient loss of sight, hemianopsia, transient ischemic attack, or stroke-like episodes, focal seizures and even periods of altered sensorium. Here we present an 8-year-old boy presented with recurrent episodes of migrainous headache associated with vomiting sometimes and recurrent episodes of loss of vision for the past one year. As many of these episodes were precipitated by some febrile illness, so the child was suspected to have neurotuberculosis outside, because of Mantoux positivity. His mother also had similar episodes of recurrent headache and ultimately succumbed to cerebrovascular accident. Mitochondrial genome sequencing revealed heteroplasmic missense variation in the MT-TL1 gene (chrM:3243A>G).
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Affiliation(s)
- Prateek Kumar Panda
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India
| | - Indar Kumar Sharawat
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India
| | - Avinish Singh
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India
| | - Poonam Sherwani
- Department of Radiology, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India
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Schrick D, Ezer E, Tokes-Fuzesi M, Szapary L, Molnar T. Novel Predictors of Future Vascular Events in Post-stroke Patients-A Pilot Study. Front Neurol 2021; 12:666994. [PMID: 34220675 PMCID: PMC8250147 DOI: 10.3389/fneur.2021.666994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/20/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction: A modified platelet function test (mPFT) was recently found to be superior compared to impedance aggregometry for selection of post-stroke patients with high on-treatment platelet reactivity (HTPR). We aimed to explore some peripheral blood cell characteristics as predictors of recurrent ischemic episodes. The predictive value of mPFT was also assessed in a cohort followed up to 36 months regarding recurrent ischemic vascular events. Methods: As a novelty, not only whole blood (WB), but after 1-h gravity sedimentation the separated upper (UB) and lower half blood (LB) samples were analyzed including neutrophil antisedimentation rate (NAR) in 52 post-stroke patients taking clopidogrel. Area under the curve (AUC, AUCupper and AUClower, respectively) was separately measured by Multiplate in the WB, UB and LB samples to characterize ex vivo platelet aggregation in the presence of ADP. Next, the occurrence of vascular events (stroke, acute coronary syndrome, ACS) were evaluated during 36-month follow-up. Results: A total of 11 vascular events (stroke n = 5, ACS n = 6) occurred during the follow-up period. The AUCupper was significantly higher in patients with recurrent stroke compared to those with uneventful follow-up (p = 0.03). The AUCupper with a cut-off value ≥70 based on the mPFT, was able to predict all stroke events (p = 0.01), while the total vascular events were independently predicted by NAR with a sensitivity of 82% and specificity of 88%. Conclusions: A combination of NAR reflecting the inflammatory state and AUCupper indicating HTPR may provide a better prediction of recurrent ischemic events suggesting a better selection of patients at risk, thus providing an individually tailored vascular therapy.
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Affiliation(s)
- Diana Schrick
- Department of Anesthesiology and Intensive Care, Medical School, University of Pécs, Pécs, Hungary
| | - Erzsebet Ezer
- Department of Anesthesiology and Intensive Care, Medical School, University of Pécs, Pécs, Hungary
| | - Margit Tokes-Fuzesi
- Department of Laboratory Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Laszlo Szapary
- Department of Neurology, Medical School, University of Pécs, Pécs, Hungary
| | - Tihamer Molnar
- Department of Anesthesiology and Intensive Care, Medical School, University of Pécs, Pécs, Hungary
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Abstract
Background Patients with congenital heart disease (CHD) are at increased risk of developing ischemic stroke (IS) compared with controls without CHD. However, the long‐term outcomes after IS, including IS recurrence and mortality risk, remain unclear. Methods and Results We identified all patients with CHD in Sweden who were born between 1930 and 2017 using the Swedish National Patient Register and the Cause of Death Register. Ten controls without CHD were randomly selected from the general population and matched for birth year and sex for each patient with CHD. The follow‐up of the study population was performed between January 1970 and December 2017. In total, 88 700 patients with CHD (50.6% men) and 890 450 matched controls (51.0%) were included in this study. During a mean follow‐up of 25.1±22.0 years, patients with CHD had a 5‐fold higher risk of developing an index IS (hazard ratio [HR], 5.01; 95% CI, 4.81–5.22) compared with controls. However, the risk of developing a recurrent IS was lower in patients with CHD compared with controls (HR, 0.66; 95% CI, 0.56–0.78), an observation that persisted after adjustment for cardiovascular risk factors and comorbidities. Patients with CHD were also at a significantly lower risk of all‐cause mortality after index IS than controls (HR, 0.53; 95% CI, 0.49–0.58). Conclusions Patients with CHD had a 5‐fold higher risk of developing index IS compared with matched controls. However, the risk of recurrent IS stroke and all‐cause mortality were 34% and 47% lower, respectively, in patients with CHD compared with controls.
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Affiliation(s)
- Kok Wai Giang
- Institute of Medicine Department of Molecular and Clinical Medicine Sahlgrenska AcademyUniversity of Gothenburg Sweden
| | - Maria Fedchenko
- Institute of Medicine Department of Molecular and Clinical Medicine Sahlgrenska AcademyUniversity of Gothenburg Sweden
| | - Mikael Dellborg
- Institute of Medicine Department of Molecular and Clinical Medicine Sahlgrenska AcademyUniversity of Gothenburg Sweden.,ACHD (Adult Congenital Heart Disease) UnitSahlgrenska University Hospital/Östra Gothenburg Sweden
| | - Peter Eriksson
- Institute of Medicine Department of Molecular and Clinical Medicine Sahlgrenska AcademyUniversity of Gothenburg Sweden.,ACHD (Adult Congenital Heart Disease) UnitSahlgrenska University Hospital/Östra Gothenburg Sweden
| | - Zacharias Mandalenakis
- Institute of Medicine Department of Molecular and Clinical Medicine Sahlgrenska AcademyUniversity of Gothenburg Sweden.,ACHD (Adult Congenital Heart Disease) UnitSahlgrenska University Hospital/Östra Gothenburg Sweden
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Ishikawa T, Yamazaki T, Sato M, Kato N, Ishikawa E, Matsumaru Y, Matsumura A. Endovascular Stent Grafting for Recurrent Strokes Due to Fragile Innominate Artery Plaque: A Case Report. NMC Case Rep J 2021; 8:21-25. [PMID: 34012744 PMCID: PMC8116917 DOI: 10.2176/nmccrj.cr.2020-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/13/2020] [Indexed: 11/30/2022] Open
Abstract
Here we describe a case of recurrent ischemic strokes due to fragile innominate artery plaque successfully treated using endovascular stent grafting. An 80-year-old man presented with a history of recurrent strokes that were refractory to medical treatment. Computed tomography and magnetic resonance images of the thorax revealed a gross intramural plaque in the innominate artery. He was successfully treated using endovascular stent grafting. An AFX stent graft device was used to prevent further embolic strokes. The AFX stent graft has a unique endoskeleton design with a thin-walled expanded polytetrafluoroethylene fabric—known as active sealing structure—attached to the implant. Postoperatively, the patient has experienced no recurrent strokes in over 2 years of follow-up. The stent grafting procedure could be an optimal treatment option for treating fragile innominate artery plaques.
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Affiliation(s)
- Takaaki Ishikawa
- Department of Neurosurgery, National Hospital Organization, Mito Medical Center, Ibaraki, Ibaraki, Japan
| | - Tomosato Yamazaki
- Department of Neurosurgery, National Hospital Organization, Mito Medical Center, Ibaraki, Ibaraki, Japan
| | - Masataka Sato
- Department of Cardiovascular Surgery, National Hospital Organization, Mito Medical Center, Ibaraki, Ibaraki, Japan
| | - Noriyuki Kato
- Department of Neurosurgery, National Hospital Organization, Mito Medical Center, Ibaraki, Ibaraki, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Akira Matsumura
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Ouyang N, Shi C, Guo X, Chen Y, Sun Y. Risk factor control after ischemic stroke or transient ischemic attack. Acta Neurol Scand 2021; 143:367-374. [PMID: 33528038 DOI: 10.1111/ane.13398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/05/2021] [Accepted: 01/18/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We aimed to estimate the status of risk factor control after ischemic stroke or transient ischemic attack (IS/TIA), and the influence on recurrent stroke in rural communities of northeastern China. METHODS This population-based, prospective cohort study enrolled adults aged ≥35 years residing in rural northeastern China. We conducted cardiovascular health examinations in 2012-2015 and followed up in 2018 to record any cardiovascular event. Control of risk factors after IS/TIA was determined through a baseline survey. The Cox proportional hazard model was used to evaluate the relationship between uncontrolled risk factors and stroke recurrence. RESULTS Of the 10,700 participants, 575 were diagnosed with IS/TIA and were included in the analysis. At baseline, the rates of control of risk factors were as follows: fasting plasma glucose (FPG), 81.6%; not currently smoking, 65.7%; and achieving physical activity targets, 61%. Blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), and body mass index (BMI) were poorly controlled (28.3%, 26.3%, and 37.4%, respectively). The rate of stroke recurrence was 12% during a median follow-up of 4.43 years. After adjusting for age, sex, ethnicity, family history of stroke, and current drinking, uncontrolled BP and not achieving physical exercise targets were associated with an increased risk of recurrence (hazard ratios: 2.081, 1.685, respectively; p < .05). Uncontrolled FPG, BMI, or LDL-C and current smoking did not significantly influence recurrent risk (p > .05). CONCLUSIONS Control of risk factors after IS/TIA needs to be improved in rural communities of northeastern China to prevent recurrence and thus alleviate the public health and economic burden of stroke.
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Affiliation(s)
- Nanxiang Ouyang
- Department of Cardiology The First Hospital of China Medical University Shenyang China
| | - Chuning Shi
- Department of Cardiology The First Hospital of China Medical University Shenyang China
| | - Xiaofan Guo
- Department of Cardiology The First Hospital of China Medical University Shenyang China
| | - Yihan Chen
- Department of Cardiology The First Hospital of China Medical University Shenyang China
| | - Yingxian Sun
- Department of Cardiology The First Hospital of China Medical University Shenyang China
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Abedi V, Avula V, Chaudhary D, Shahjouei S, Khan A, Griessenauer CJ, Li J, Zand R. Prediction of Long-Term Stroke Recurrence Using Machine Learning Models. J Clin Med 2021; 10:1286. [PMID: 33804724 DOI: 10.3390/jcm10061286] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 01/01/2023] Open
Abstract
Background: The long-term risk of recurrent ischemic stroke, estimated to be between 17% and 30%, cannot be reliably assessed at an individual level. Our goal was to study whether machine-learning can be trained to predict stroke recurrence and identify key clinical variables and assess whether performance metrics can be optimized. Methods: We used patient-level data from electronic health records, six interpretable algorithms (Logistic Regression, Extreme Gradient Boosting, Gradient Boosting Machine, Random Forest, Support Vector Machine, Decision Tree), four feature selection strategies, five prediction windows, and two sampling strategies to develop 288 models for up to 5-year stroke recurrence prediction. We further identified important clinical features and different optimization strategies. Results: We included 2091 ischemic stroke patients. Model area under the receiver operating characteristic (AUROC) curve was stable for prediction windows of 1, 2, 3, 4, and 5 years, with the highest score for the 1-year (0.79) and the lowest score for the 5-year prediction window (0.69). A total of 21 (7%) models reached an AUROC above 0.73 while 110 (38%) models reached an AUROC greater than 0.7. Among the 53 features analyzed, age, body mass index, and laboratory-based features (such as high-density lipoprotein, hemoglobin A1c, and creatinine) had the highest overall importance scores. The balance between specificity and sensitivity improved through sampling strategies. Conclusion: All of the selected six algorithms could be trained to predict the long-term stroke recurrence and laboratory-based variables were highly associated with stroke recurrence. The latter could be targeted for personalized interventions. Model performance metrics could be optimized, and models can be implemented in the same healthcare system as intelligent decision support for targeted intervention.
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Kauw F, van Ommen F, Bennink E, Cramer MJ, Kappelle LJ, Takx RA, Velthuis BK, Viergever MA, Wouter van Es H, Schonewille WJ, Coutinho JM, Majoie CB, Marquering HA, de Jong HW, Dankbaar JW. Early detection of small volume stroke and thromboembolic sources with computed tomography: Rationale and design of the ENCLOSE study. Eur Stroke J 2021; 5:432-440. [PMID: 33598562 PMCID: PMC7856586 DOI: 10.1177/2396987320966420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/21/2020] [Indexed: 01/01/2023] Open
Abstract
Background Computed tomography is the most frequently used imaging modality in acute stroke imaging protocols. Detection of small volume infarcts in the brain and cardioembolic sources of stroke is difficult with current computed tomography protocols. Furthermore, the role of computed tomography findings to predict recurrent ischemic stroke is unclear. With ENCLOSE, we aim to improve (1) the detection of small volume infarcts with thin slice computed tomography perfusion (CTP) images and thromboembolic source with cardiac computed tomography techniques in the acute stage of ischemic stroke and (2) prediction of recurrent ischemic stroke with computed tomography-derived predictors. Methods/design: ENCLOSE is a prospective multicenter observational cohort study, which will be conducted in three Dutch stroke centers (ClinicalTrials.gov Identifier: NCT04019483). Patients (≥18 years) with suspected acute ischemic stroke who undergo computed tomography imaging within 9 h after symptom onset are eligible. Computed tomography imaging includes non-contrast CT, CTP, and computed tomography angiography (CTA) from base of the heart to the top of the brain. Dual-energy CT data will be acquired when possible, and thin-slice CTP reconstructions will be obtained in addition to standard 5 mm CTP data. CTP data will be processed with commercially available software and locally developed model-based methods. The post-processed thin-slice CTP images will be compared to the standard CTP images and to magnetic resonance diffusion-weighted imaging performed within 48 h after admission. Detection of cardioembolic sources of stroke will be evaluated on the CTA images. Recurrence will be evaluated 90 days and two years after the index event. The added value of imaging findings to prognostic models for recurrent ischemic stroke will be evaluated. Conclusion The aim of ENCLOSE is to improve early detection of small volume stroke and thromboembolic sources and to improve prediction of recurrence in patients with acute ischemic stroke.
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Affiliation(s)
- Frans Kauw
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Fasco van Ommen
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Edwin Bennink
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Maarten J Cramer
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Utrecht University, The Netherlands
| | - L Jaap Kappelle
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Richard Ap Takx
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Max A Viergever
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - H Wouter van Es
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | | | | | - Henk A Marquering
- Department of Neurology, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Hugo Wam de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan W Dankbaar
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Nagalapuram V, Tharumia Jagadeesan C, Ramasamy B. Carotid Stump Syndrome: An Uncommon Cause of Recurrent Ipsilateral Strokes. Cureus 2021; 13:e12688. [PMID: 33604220 PMCID: PMC7880803 DOI: 10.7759/cureus.12688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Carotid stump syndrome is a rare cause of recurrent cerebrovascular accidents. Carotid stump is the patent proximal remnant below the completely occluded internal carotid artery (ICA). Cerebral and retinal ischemic symptoms seen after complete occlusion of ipsilateral ICA is known as carotid stump syndrome. Known for causing recurrent ipsilateral cerebrovascular accidents, it is a potentially treatable entity. The therapeutic goal is medical management with a statin, dual anti-platelet therapy along with surgical intervention either with an endovascular repair or carotid endarterectomy. Herein, we present a case of carotid stump syndrome managed medically.
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Affiliation(s)
- Vishnu Nagalapuram
- Internal Medicine, The University of Alabama at Birmingham (UAB) School of Medicine, Montgomery, USA
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Lambert C, Chaudhary D, Olulana O, Shahjouei S, Avula V, Li J, Abedi V, Zand R. Sex disparity in long-term stroke recurrence and mortality in a rural population in the United States. Ther Adv Neurol Disord 2020; 13:1756286420971895. [PMID: 33414844 PMCID: PMC7750897 DOI: 10.1177/1756286420971895] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/12/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Several studies suggest women may be disproportionately affected by poorer stroke outcomes than men. This study aims to investigate whether women have a higher risk of all-cause mortality and recurrence after an ischemic stroke than men in a rural population in central Pennsylvania, United States. Methods: We analyzed consecutive ischemic stroke patients captured in the Geisinger NeuroScience Ischemic Stroke research database from 2004 to 2019. Kaplan–Meier (KM) estimator curves stratified by gender and age were used to plot survival probabilities and Cox Proportional Hazards Ratios were used to analyze outcomes of all-cause mortality and the composite outcome of ischemic stroke recurrence or death. Fine–Gray Competing Risk models were used for the outcome of recurrent ischemic stroke, with death as the competing risk. Two models were generated; Model 1 was adjusted by data-driven associated health factors, and Model 2 was adjusted by traditional vascular risk factors. Results: Among 8900 adult ischemic stroke patients [median age of 71.6 (interquartile range: 61.1–81.2) years and 48% women], women had a higher crude all-cause mortality. The KM curves demonstrated a 63.3% survival in women compared with a 65.7% survival in men (p = 0.003) at 5 years; however, the survival difference was not present after controlling for covariates, including age, atrial fibrillation or flutter, myocardial infarction, diabetes mellitus, dyslipidemia, heart failure, chronic lung diseases, rheumatic disease, chronic kidney disease, neoplasm, peripheral vascular disease, past ischemic stroke, past hemorrhagic stroke, and depression. There was no adjusted or unadjusted sex difference in terms of recurrent ischemic stroke or composite outcome. Conclusion: Sex was not an independent risk factor for all-cause mortality and ischemic stroke recurrence in the rural population in central Pennsylvania.
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Affiliation(s)
- Clare Lambert
- Geisinger NeuroScience Institute, Geisinger Health System, Danville, PA, USA
| | - Durgesh Chaudhary
- Geisinger NeuroScience Institute, Geisinger Health System, Danville, PA, USA
| | - Oluwaseyi Olulana
- Geisinger NeuroScience Institute, Geisinger Health System, Danville, PA, USA
| | - Shima Shahjouei
- Geisinger NeuroScience Institute, Geisinger Health System, Danville, PA, USA
| | - Venkatesh Avula
- Geisinger NeuroScience Institute, Geisinger Health System, Danville, PA, USA
| | - Jiang Li
- Department of Molecular and Functional Genomics, Weis Center for Research, Geisinger Health System, Danville, PA, USA
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Weis Center for Research, Geisinger Health System, Danville, PA, USA
| | - Ramin Zand
- Geisinger NeuroScience Institute, Geisinger Health System, 100 North Academy Ave., Danville, PA 17822, USA
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Cha JJ, Lee KY, Chung H, Kim IS, Choi EY, Min PK, Yoon YW, Lee BK, Hong BK, Rim SJ, Kwon HM, Kim JY. Frequent Premature Atrial Contractions as a Poor Prognostic Factor in Cryptogenic Stroke Patients with Concomitant Non-Sustained Atrial Tachycardia. Yonsei Med J 2020; 61:965-969. [PMID: 33107240 PMCID: PMC7593104 DOI: 10.3349/ymj.2020.61.11.965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 11/27/2022] Open
Abstract
In cryptogenic stroke patients, early detection of new-onset atrial fibrillation (AF) and recurrent stroke is required to prevent poor clinical outcomes. Therefore, we investigated the predictors of new-onset AF and recurrent stroke in cryptogenic stroke patients without previously diagnosed AF. In total, 390 patients who were diagnosed with stroke and non-sustained atrial tachycardia (NSAT) on 24-hour Holter monitoring were followed up to assess new-onset AF and recurrent stroke. The 5-year event-free survival as well as the predictors of recurrent stroke or new-onset AF were investigated. Based on receiver operating characteristic analysis, frequent premature atrial contractions (PACs) were defined as PACs >44 beats/day. The median follow-up period was 35 months. The composite event rate was 11.5%. In Kaplan-Meier analysis, the 5-year cumulative incidence of composite events was higher in cryptogenic stroke patients with frequent PACs than in those without frequent PACs. Multivariate analysis revealed that current smoking, increased left atrial volume index, and frequent PACs were poor prognostic predictors of composite event, and frequent PACs were an independent poor prognostic factor of new-onset AF in cryptogenic stroke patients. Therefore, frequent PACs might be associated with poor clinical outcomes (new-onset AF and recurrent stroke) in cryptogenic stroke patients with concomitant NSAT.
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Affiliation(s)
- Jung Joon Cha
- Division of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Kyung Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyemoon Chung
- Department of Cardiology, Department of Internal Medicine, Kyung Hee University, Seoul, Korea
| | - In Soo Kim
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eui Young Choi
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Pil Ki Min
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Won Yoon
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byoung Kwon Lee
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Bum Kee Hong
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Se Joong Rim
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuck Moon Kwon
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Youn Kim
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Kate MP, Verma SJ, Arora D, Sylaja PN, Padma MV, Bhatia R, Khurana D, Sharma A, Ojha PK, Renjith V, Kulkarni GB, Sadiq M, Jabeen S, Borah NC, Ray BK, Sharma M, Pandian JD. Systematic Development of Structured Semi-interactive Stroke Prevention Package for Secondary Stroke Prevention. Ann Indian Acad Neurol 2020; 23:681-686. [PMID: 33623271 PMCID: PMC7887475 DOI: 10.4103/aian.aian_639_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/10/2020] [Accepted: 01/26/2020] [Indexed: 11/05/2022] Open
Abstract
Background: Lack of compliance to medication and uncontrolled risk factors are associated with increased risk of recurrent stroke and acute coronary syndrome in patients with recent stroke. Multimodal patient education may be a strategy to improve the compliance to medication and early adoption of nonpharmacological measures to reduce the vascular risk factor burden in patients with stroke. We thus aim to develop multilingual short messaging services (SMS), print, and audio-visual secondary stroke prevention patient education package. The efficacy of the package will be tested in a randomized control trial to prevent major cardiovascular and cerebrovascular events. Methods: In the formative stage, intervention materials (SMS, video, and workbook) were developed. In the acceptability stage, the package was independently assessed and modified by the stakeholders involved in the stroke patient care and local language experts. The modified stroke prevention package was tested for implementation issues (implementation stage). Results: Sixty-nine SMS, six videos, and workbook with 11 chapters with 15 activities were developed in English language with a mean ± SD SMOG index of 9.1 ± 0.4. A total of 355 stakeholders including patients (24.8%), caregivers (24.8%), doctors (10.4%), nurses (14.1%), local language experts (2.8%), physiotherapists (13.2%), and research coordinators (9.8%) participated in 10 acceptability stage meetings. The mean Patient Education Material Assessment Tool understandability score in all languages for SMS, video scripts, and workbook was 95.2 ± 2.6%, 95.2 ± 4.4%, and 95.3 ± 3.6%, respectively. The patients [n = 20, mean age of 70.3 ± 10.6 years and median interquartile range (IQR) baseline NIHSS 1 (0–3)] or the research coordinators (n = 2) noted no implementation issues at the end of 1 month. Conclusion: An implementable complex multilingual patient education material could be developed in a stepwise manner. The efficacy of the package to prevent major adverse cardiovascular events is being tested in the SPRINT INDIA study.
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Affiliation(s)
- Mahesh Pundlik Kate
- Department of Clinical Neurosciences, Alberta Health Services, Edmonton, Canada
| | - Shweta Jain Verma
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Deepti Arora
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - P N Sylaja
- Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - M V Padma
- Department of Neuroscience, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neuroscience, All India Institute of Medical Sciences, New Delhi, India
| | - Dheeraj Khurana
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arvind Sharma
- Department of Neurology, Zydus Hospital, Ahmedabad, Gujarat, India
| | - Pawan Kumar Ojha
- Department of Neurology, Grant Government Medical College, Mumbai, Maharashtra, India
| | - Vishnu Renjith
- Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Girish Baburao Kulkarni
- Department of Neurology, National Institute of Mental Health and Neuro-Sciences, Bangalore, Karnataka, India
| | - Mohammad Sadiq
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
| | - S Jabeen
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - N C Borah
- Department of Neurology, Guwahati Neurological Research Centre, Dispur, Assam, India
| | - Biman Kanti Ray
- Department of Neurology, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Meenakshi Sharma
- Division of Non-Communicable Diseases, Indian Council of Medical Research, New Delhi, India
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Iseki T, Yamashita Y, Ueno Y, Hira K, Miyamoto N, Yamashiro K, Tsunemi T, Teranishi K, Yatomi K, Nakajima S, Kijima C, Oishi H, Hattori N. Cerebral artery dissection secondary to antiphospholipid syndrome: A report of two cases and a literature review. Lupus 2020; 30:118-124. [PMID: 33016197 DOI: 10.1177/0961203320960821] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by thromboembolic events, including ischemic stroke or complications in pregnancy, and the presence of antiphospholipid antibodies. Cervical artery dissection (CAD) is not an uncommon cause of stroke in young adults. The concomitant presence of APS and CAD is extremely rare. METHODS Two cases with APS who developed acute ischemic strokes related to CAD are reported. A comprehensive systematic literature search using the PubMed database was also conducted. RESULTS In Case 1, a 36-year-old woman who had been diagnosed with systemic lupus erythematosus and had been repeatedly positive for lupus anticoagulant tests developed an ischemic stroke caused by a vertebral artery dissection (VAD). After admission, she had a recurrent ischemic stroke, followed by considerable changes in steno-occlusive lesions of the vertebrobasilar artery system. In Case 2, a 36-year-old man developed multiple brain infarcts due to bilateral VAD with aneurysmal formations and associated with pulmonary embolism. The anticardiolipin antibody titer was repeatedly elevated after stroke. The literature review identified 8 patients with CAD associated with APS, involving the internal carotid artery in 6 patients and the middle cerebral artery and vertebral artery in 1 patient each. The patients were predominantly young and female, infrequently had atherosclerotic vascular risk factors, and were positive for various antiphospholipid antibodies. CONCLUSIONS The current report described two rare cases of ischemic stroke caused by CAD secondary to APS, along with a review of the literature; the patients displayed characteristic clinical manifestations, implying specific mechanisms for cerebral artery disorders secondary to APS.
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Affiliation(s)
- Tatou Iseki
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Yuri Yamashita
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Yuji Ueno
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kenichiro Hira
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Nobukazu Miyamoto
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuo Yamashiro
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Taiji Tsunemi
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kosuke Teranishi
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Kenji Yatomi
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Sho Nakajima
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Chikage Kijima
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Hidenori Oishi
- Department of Neurosurgery, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Nobutaka Hattori
- Department of Neurology, Faculty of Medicine, Juntendo University, Tokyo, Japan
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