Preterm Preeclampsia as an Independent Risk Factor for Thromboembolism in a Large National Cohort

BACKGROUND

Preterm preeclampsia, a product of vascular dysfunction, is associated with prolonged hospital admission and proteinuria, significant risk factors for thromboembolism in pregnancy. The risk of thromboembolism in preterm preeclampsia warrants further investigation.

OBJECTIVES

To determine the relationship between preterm preeclampsia and thromboembolic risk. We hypothesize that preterm preeclampsia is an independent risk factor for thromboembolism in pregnancy.

STUDY DESIGN

This is a retrospective cohort study using the National Inpatient Sample database via HCUP-AHRQ from 2017-2019. All subjects with an ICD-10 code for pregnancy or peripartum encounter were included. Subjects were excluded if gestational age at delivery was less than 20 weeks or if they had a history of thromboembolism, inherited thrombophilia, or antiphospholipid syndrome. Patients with preterm (delivered less than 37 weeks) preeclampsia and term (delivered 37 weeks or greater) preeclampsia were compared to those without preeclampsia. The primary outcome was a composite of any thromboembolic event, including pulmonary embolism, deep vein thrombosis, cerebral thrombosis/transient ischemic attack (TIA), or other thromboses. The secondary outcomes were rates of each individual type of thromboembolic event. The groups were compared via analysis of variance, chi-squared, and logistic regression analyses. The logistic regression included those variables that differed between groups with p<0.05.

RESULTS

Of individuals in the database more than 2.2 million met inclusion criteria. A total of 56,446 (2.7%) had preterm preeclampsia and 86,152 (6.7%) had term preeclampsia. Those with preterm preeclampsia were more likely to be older, identify as non-Hispanic black, be obese, have chronic hypertension among other chronic diseases, and be in the lowest quartile of income (p<0.001). Among patients with preterm preeclampsia, 0.32% experienced thromboembolism while those with term preeclampsia and without preeclampsia experienced thromboembolism 0.10% and 0.09%, respectively. After controlling for confounders that differed between groups with p<0.05, preterm preeclampsia remained independently associated with any thromboembolic event (aOR 2.21 95%CI 1.84-2.65) as well as each individual type of thromboembolism. Term preeclampsia was not associated with an increased risk of thromboembolism (aOR 1.18, 95%CI 0.94-1.48).

CONCLUSION

Preterm preeclampsia is independently associated with an increased risk of thromboembolic events.

Effectiveness of motivational interviewing on medication adherence for the prevention of recurrent stroke or transient ischemic attack: Systematic review of randomized controlled trials

BACKGROUND AND PURPOSE

This systematic review examines the effectiveness of motivational interviewing (MI) on medication adherence for preventing recurrent stroke and transient ischemic attack (TIA).

METHODS

MEDLINE (via PubMed), CINAHL, PsycINFO, CENTRAL, and ClinicalTrials.gov were searched from inception to 12 June 2023. Randomized controlled trials comparing MI with usual care or interventions without MI in participants with any stroke type were identified and summarized descriptively. Primary outcome was medication adherence. Secondary outcomes were quality of life (QoL) and different clinical outcomes. We assessed risk of bias with RoB 2 (revised Cochrane risk-of-bias tool) and intervention complexity with the iCAT_SR (intervention Complexity Assessment Tool for Systematic Reviews).

RESULTS

We screened 691 records for eligibility and included four studies published in five articles. The studies included a total of 2751 participants, and three were multicentric. Three studies had a high risk of bias, and interventions varied in complexity. Two studies found significantly improved medication adherence, one at 9 (96.9% vs. 88.2%, risk ratio = 1.098, 95% confidence interval = 1.03-1.17) and one at 12 months (97.0% vs. 95.0%, p = 0.026), but not at other time points, whereas two other studies reported no significant changes. No significant differences were found in QoL or clinical outcomes.

CONCLUSIONS

Evidence on MI appears inconclusive for improving medication adherence for recurrent stroke and TIA prevention, with no benefits on QoL and clinical outcomes. There is a need for robustly designed studies and process evaluations of MI as a complex intervention for people with stroke.

REGISTRATION

PROSPERO (CRD42023433284).

Carotid Artery Calcification Detected on Panoramic Radiography Is Significantly Related to Cerebrovascular Accident, Coronary Artery Disease, and Poor Oral Health: A Retrospective Cross-Sectional Study

Panoramic radiography imaging modality is widely used by dentists for diagnosing dental and jaw conditions. It can also detect carotid artery calcification (CAC), indicative of calcified atherosclerotic plaques in the carotid arteries. This cross-sectional retrospective study at the University of Tennessee Health Science Center investigated the link between CAC identified on panoramic radiograph (PR) and cerebrovascular accident (CVA), coronary artery disease (CAD), and poor oral health. Data from 314 CAC patients collected from 2014 to 2023 included age at diagnosis, gender, and clinical histories of hypertension, hyperlipidemia, diabetes mellitus, CVA, CAD, and the decay, missing, and filled permanent teeth (DMFT) index. These patients were age- and gender-matched with non-CAC patients for analysis. The findings revealed high prevalences of hypertension (86.2%), hyperlipidemia (57.6%), diabetes mellitus (30.7%), CVA (15.5%), and CAD (28.7%) amongst CAC patients and the average DMFT index was 26.6. A comparative analysis of 276 matched controls demonstrated significant differences in hypertension (85.9% vs. 57.6%), hyperlipidemia (58.3% vs. 33.7%), diabetes (32.6% vs. 22.1%), CVA history (14.9% vs. 5.1%), CAD (26.1% vs. 9.8%), and DMFT scores (26.3 vs. 23.7), all indicating strong associations between CAC and these health conditions. The adjusted analysis showed that hypertension (aOR: 3.20 [95% CI: 2.06-5.07]), hyperlipidemia (aOR: 1.70 [95% CI: 1.14-2.50]), CVA (aOR: 2.20 [95% CI: 1.13-4.30]), and CAD (aOR: 2.10 [95% CI: 1.28-3.60]) were significantly associated with CAC. Notably, only 41.7% of the patients received a medical consultation after CAC detection on PR. It is crucial for dentists to refer patients for further evaluation.

Atrial septum anatomy as a predictor of ischemic neurological episodes in patients with a patent foramen ovale

BACKGROUND

The correlation between atrial septum anatomy and the risk of ischemic neurological events remains underexplored.

AIMS

This study aimed to examine both the functional and anatomical attributes of the atrial septum and identify predictors of stroke and/or transient ischemic attack (TIA) in patients diagnosed with patent foramen ovale (PFO).

METHODS

A total of 155 patients diagnosed with PFO, with a cardiological cause of neurological events, were enrolled. Transesophageal echocardiography was utilized to assess the anatomy of the PFO canal, size of the right-to-left shunt, thickness of the primary and secondary atrial septum, presence of atrial septum aneurysm, and anatomical structures of the right atrium.

RESULTS

Regression analysis showed that factors such as female sex, hypercholesterolemia, PFO canal width, and a large right-to-left shunt were significantly associated with stroke and/or TIA. Receiver operating characteristic analysis indicated that the width of the PFO canal holds a relatively weak, although significant predictive, value for ischemic neurological episodes (area under the curve = 0.7; P = 0.002). A PFO canal width of 4 mm was associated with 70% sensitivity and 55% specificity for predicting stroke and/or TIA.

CONCLUSIONS

The atrial septum's anatomy, especially the dimensions of the PFO canal and the magnitude of the right-to-left shunt, combined with specific demographic and clinical factors, are linked to ischemic neurological incidents in PFO patients.

Posttraumatic Stress Disorder Is Associated With Elevated Risk of Incident Stroke and Transient Ischemic Attack in Women Veterans

BACKGROUND

Posttraumatic stress disorder (PTSD) has been associated with ischemic heart disease in women veterans, but evidence for associations with other cardiovascular disorders remains limited in this population. This retrospective longitudinal cohort study evaluated the association of PTSD with incident stroke/transient ischemic attack (TIA) in women veterans.

METHODS AND RESULTS

Veterans Health Administration electronic health records were used to identify women veterans aged ≥18 years engaged with Veterans Health Administration health care from January 1, 2000 to December 31, 2019. We identified women veterans with and without PTSD without a history of stroke or TIA at start of follow-up. Propensity score matching was used to match groups on age, race or ethnicity, traditional cardiovascular risk factors, female-specific risk factors, a range of mental and physical health conditions, and number of prior health care visits. PTSD, stroke, TIA, and risk factors used in propensity score matching were based on diagnostic codes. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs for associations of PTSD with an incident stroke/TIA composite. Subanalyses considered stroke and TIA separately, plus age- and race- or ethnicity-stratified analyses were carried out. The analytic sample included 208 092 women veterans (104 046 with and 104 046 without PTSD). PTSD was associated with a greater rate of developing stroke/TIA (HR, 1.33 [95% CI, 1.25-1.42], P<0.001). This elevated risk was especially pronounced in women <50 years old and in Hispanic/Latina women.

CONCLUSIONS

Findings indicate a strong association of PTSD with incident stroke/TIA in women veterans. Research is needed to determine whether addressing PTSD and its downstream consequences can offset this risk.

In patients who had a stroke or TIA, enlarged perivascular spaces in basal ganglia may cause future haemorrhagic strokes

INTRODUCTION

It remains unclear whether enlarged perivascular spaces (EPVS) predict poor clinical outcomes in patients with acute ischaemic stroke (AIS) or transient ischaemic attack (TIA).

METHOD

Data were obtained from the Third China National Stroke Registry study. We estimated EPVS in basal ganglia (BG) and centrum semiovale (CSO) using a semiquantified scale (Grade from 0 to 4). Using Cox and logistic regression analyses, the associations of EPVS with 3-month and 1-year adverse outcomes (including recurrent stroke, ischaemic stroke, haemorrhagic stroke, combined vascular event, disability and mortality) were explored. Sensitivity analyses of any association of cerebral small vessel disease at baseline and development of a small arterial occlusion (SAO) were conducted.

RESULT

Among 12 603 patients with AIS/TIA, median age was 61.7±11.6 years, and 68.2% were men. After adjusting for all potential confounders, frequent-to-severe BG-EPVS was associated with a decreased risk of recurrent ischaemic stroke (HR 0.71, 95% CI 0.55 to 0.92, p=0.01) but an increased risk of haemorrhagic stroke (HR 1.99, 95% CI 1.11 to 3.58, p=0.02) at 1 year after AIS/TIA, compared with none-to-mild BG-EPVS. Patients with frequent-to-severe CSO-EPVS had a decreased risk of disability (OR 0.76, 95% CI 0.62 to 0.92, p=0.004) and all-cause death (HR 0.55, 95% CI 0.31 to 0.98, p=0.04) within 3-month but not 1-year follow-ups, compared with those with none-to-mild BG-EPVS. Sensitivity analyses showed that both BG-EPVS (HR 0.43, 95% CI 0.21 to 0.87, p=0.02) and CSO-EPVS (HR 0.58, 95% CI 0.35 to 0.95, p=0.03) were associated with a decreased risk of subsequent ischaemic stroke in patients with SAO during 1-year follow-up.

CONCLUSION

BG-EPVS increased the risk of haemorrhagic stroke in patients already with AIS/TIA within 1 year. Therefore, caution is recommended when selecting antithrombotic agents for secondary stroke prevention in patients with AIS/TIA and more severe BG-EPVS.

Measurement of optic nerve sheath diameter on computed tomography for the differentiation of transient ischemic attacks

OBJECTIVE

The objective of this study was to investigate whether the measurement of mean optic nerve sheath diameter in patients with transient ischemic attack could be used to distinguish between control groups, the acute ischemic stroke group, and subgroups within the acute ischemic stroke category.

METHODS

Retrospectively, the mean optic nerve sheath diameters of patients aged 18 years and older belonging to control, transient ischemic attack, acute ischemic stroke, and subgroups within the acute ischemic stroke category were measured with initial computed tomography conducted in the emergency department.

RESULTS

Out of the 773 patients included in the study, 318 (41.1%) were in the control group, 77 (10%) had transient ischemic attack, and 378 (49%) were categorized as stroke patients. The average mean optic nerve sheath diameter was significantly higher in both the stroke and transient ischemic attack groups compared with the control group (p<0.001 for both comparisons). Furthermore, the mean optic nerve sheath diameter in the stroke subgroups was significantly higher than in both the transient ischemic attack and control groups (p<0.001 for all comparisons). In transient ischemic attack patients, the mean optic nerve sheath diameter showed a significant ability to predict transient ischemic attack (AUC=0.913, p<0.001), with a calculated optimal cutoff value of 4.72, sensitivity of 94.8%, and specificity of 73.9%.

CONCLUSION

The mean optic nerve sheath diameter of patients in the transient ischemic attack group was lower compared with those in the stroke subgroups but higher compared with the control group.

Initial experience with radiomics of carotid perivascular adipose tissue in identifying symptomatic plaque

Background

Carotid atherosclerotic ischemic stroke threatens human health and life. The aim of this study is to establish a radiomics model of perivascular adipose tissue (PVAT) around carotid plaque for evaluation of the association between Peri-carotid Adipose Tissue structural changes with stroke and transient ischemic attack.

Methods

A total of 203 patients underwent head and neck computed tomography angiography examination in our hospital. All patients were divided into a symptomatic group (71 cases) and an asymptomatic group (132 cases) according to whether they had acute/subacute stroke or transient ischemic attack. The radiomic signature (RS) of carotid plaque PVAT was extracted, and the minimum redundancy maximum correlation, recursive feature elimination, and linear discriminant analysis algorithms were used for feature screening and dimensionality reduction.

Results

It was found that the RS model achieved the best diagnostic performance in the Bagging Decision Tree algorithm, and the training set (AUC, 0.837; 95%CI: 0.775, 0.899), testing set (AUC, 0.834; 95%CI: 0.685, 0.982). Compared with the traditional feature model, the RS model significantly improved the diagnostic efficacy for identifying symptomatic plaques in the testing set (AUC: 0.834 vs. 0.593; Z = 2.114, p = 0.0345).

Conclusion

The RS model of PVAT of carotid plaque can be used as an objective indicator to evaluate the risk of plaque and provide a basis for risk stratification of carotid atherosclerotic disease.

Transient Hemichorea-hemiballism Induced by a Combination of Postprandial Hypotension and Severe Stenosis of the Innominate Artery Concomitant with Left Carotid Occlusion

Hemichorea-hemiballism (HCHB) due to transient ischemic attacks (TIAs) is rare. An 83-year-old woman had repeated episodes of right-sided HCHB for 3 months. Magnetic resonance (MR) angiography demonstrated occlusion of the left carotid and middle cerebral arteries and severe stenosis of the innominate artery, and 24-hour ambulatory blood pressure monitoring showed a blood pressure decrease of >20 mmHg after each meal. We speculated that HCHB developed as TIAs due to hemodynamic failure in the left cerebral hemisphere, caused by a combination of severe stenosis of the innominate artery concomitant with occlusion of the left carotid and middle cerebral arteries as well as postprandial hypotension.

Transient ischemic attack and pregnancy, delivery and neonatal outcomes-An evaluation of a population database

OBJECTIVE

Transient ischemic attack (TIA) is rare in women of reproductive age. We aimed to compare perinatal outcomes between women who suffered from a TIA to those who did not.

METHODS

A retrospective population-based cohort study utilizing the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS). All women who delivered or had a maternal death in the US (2004-2014) were included in the study. Pregnancy, delivery, and neonatal outcomes were compared between women with an ICD-9 diagnosis of a TIA to those without.

RESULTS

Overall, 9 096 788 women met the inclusion criteria. Of these, 203 women (2.2/100000) had a TIA (either before or during pregnancy). Women with TIA, compared to those without, were more likely to be older than 35 years of age, white, in the highest income quartile, be insured by private insurance and suffer from obesity and chronic hypertension. Patients in the TIA group, compared to those without, had a higher rate of pregnancy-induced hypertension (aOR 2.5, 95% CI: 1.55-4.05, P < 0.001), pre-eclampsia (aOR 3.77, 95% CI: 2.15-6.62, P < 0.001), eclampsia (aOR 28.05, 95% CI: 6.91-113.95, P < 0.001), preterm delivery (aOR 1.78, 95% CI: 1.03-3.07, P = 0.039), and maternal complications such as deep vein thrombosis (aOR 33.3, 95% CI: 8.07-137.42, P < 0.001). Regarding neonatal outcomes, patients with a TIA, compared to those without, had a higher rate of congenital anomalies (aOR 7.04, 95% CI: 2.86-17.32, P < 0.001).

CONCLUSION

Women with a TIA diagnosis before or during pregnancy had a higher rate of maternal complications, including hypertensive disorders of pregnancy and venous thromboembolism, as well as an increased risk of congenital anomalies.

Clinical, imaging, and management features of symptomatic carotid web: Insight from CAROWEB registry

BACKGROUND

Although carotid web (CaW) is increasingly diagnosed as a cause of cryptogenic stroke, data are still limited to monocentric small sample cohort. To broaden knowledge on symptomatic CaW, CAROWEB registry has been recently implemented.

AIMS

In a large cohort of symptomatic CaW patients, we described epidemiologic characteristics, admission clinical and imaging features, and the current management including the secondary preventive strategy choice made in comprehensive French Stroke Units.

METHODS

CAROWEB is an ongoing French observational multicenter registry enrolling consecutive CaW patients diagnosed after an ipsilateral ischemic stroke (IS) or transient ischemic attack (TIA). Submitted cases were validated by two experienced neurologist and neuroradiologist. Clinical, imaging, and management features were collected for this study.

RESULTS

Between June 2019 and December 2021, 244 cases were submitted by 14 centers, 42 rejected, and 202 included (IS, 91.6%; TIA, 7.9%; retinal infarction, 0.5%; mean age, 50.8 ± 12.2 years; female, 62.9%; Caucasian, 47.5%; Afro-Caribbean, 20.3%). IS patients showed median (interquartile range (IQR)) admission National Institutes of Health Stroke Scale (NIHSS) score, 8 (2-15); intracranial artery occlusion, 71.8%; ipsilateral chronic cerebral infarction (CCI), 16.3%; and reperfusion treatment, 57.3%. CaW was not identified during the mechanical thrombectomy procedure in 30 of 85 (35.3%) patients. Secondary prevention was invasive in 55.6% (stenting, n = 80; surgery, n = 30). In multivariable analysis, the invasive therapeutic option was associated with ipsilateral CCI (odds ratio (OR): 4.24 (1.27-14.2), p = 0.019) and inversely associated with risk factors (OR: 0.47 (0.24-0.91), p = 0.025) and admission NIHSS score (OR: 0.93 (0.89-0.97), p = 0.001).

CONCLUSION

CaW must be considered in all ethnic groups including Caucasians. Secondary prevention is heterogeneous in large French Stroke Centers. The absence of risk factors, milder severity strokes, and ipsilateral CCI were predictive variables of secondary invasive treatment. The high rate of invasive treatment suggests that medical treatment alone is deemed ineffective to avoid recurrence and emphasize the need of randomized trials.

Association Between Cardiovascular Event Type and Smoking Cessation Rates Among Outpatients With Atherosclerotic Cardiovascular Disease: Insights From the NCDR PINNACLE Registry

BACKGROUND

It is unclear how the type of an atherosclerotic cardiovascular disease (ASCVD) event potentially influences patients' likelihood of smoking cessation.

METHODS

Using 2013 to 2018 data from the US based National Cardiovascular Data Registry Practice Innovation and Clinical Excellence outpatient cardiac registry, we identified patients who were current smokers at a clinic visit and followed them over time for a subsequent ASCVD event. Self-reported smoking status was assessed at each consecutive visit and used to determine smoking cessation after each interim ASCVD event (myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, stroke/transient ischemic attack, peripheral artery disease). We constructed separate multivariable Cox models with nonproportional hazards to examine the association of each interim ASCVD event with smoking cessation, compared with not having an interim ASCVD event. We estimated the relative association of ASCVD event type with smoking cessation using contrast tests. Analyses were stratified by presence versus absence of ASCVD at baseline.

RESULTS

Across 530 cardiology practices, we identified 1 933 283 current smokers (mean age 62±15, male 54%, ASCVD at baseline 50%). Among the 322 743 patients who had an interim ASCVD event and were still smoking, 41 336 (12.8%) quit smoking by their first subsequent clinic visit, which was higher among those with baseline ASCVD (13.4%) as compared with those without baseline ASCVD (11.5%). Each type of ASCVD event was associated with an increased likelihood of smoking. Patients who had an myocardial infarction, underwent coronary artery bypass graft (hazard ratio, 1.60 [95% CI, 1.55-1.65]), or had a stroke or transient ischemic attack were more likely to quit smoking as compared with those who underwent elective percutaneous coronary intervention or had a new diagnosis of peripheral artery disease (hazard ratio, 1.20 [95% CI, 1.17-1.22]).

CONCLUSIONS

Only 13% of patients reported smoking cessation after an ASCVD event, with the type of event being associated with the likelihood of smoking cessation, prompting the need for patient-centered interventions.

Empiric treatment with aspirin and ticagrelor is the most cost-effective strategy in patients with minor stroke or transient ischemic attack

BACKGROUND

Patients with minor ischemic stroke or transient ischemic attacks (TIAs) are often treated with dual antiplatelet therapy regimens as part of secondary stroke prevention. Clopidogrel, an antiplatelet used in these regimens, is metabolized into its active form by the CYP2C19 enzyme. Patients with loss of function (LOF) mutations in CYP2C19 are at risk for poorer secondary outcomes when prescribed clopidogrel.

AIMS

We aimed to determine the cost-effectiveness of three different treatment antiplatelet regimens in ischemic stroke populations with minor strokes or TIAs and how these treatment regimens are influenced by the LOF prevalence in the population.

METHODS

Markov models were developed to look at the cost-effectiveness of empiric treatment with aspirin and clopidogrel versus empiric treatment with aspirin and ticagrelor, versus genotype-guided therapy for either 21 or 30 days. Effect ratios were obtained from the literature, and incidence rates and costs were obtained from the national data published by the Singapore Ministry of Health. The primary endpoints were the incremental cost-effectiveness ratios (ICERs).

RESULTS

Empiric treatment with aspirin and ticagrelor was the most cost-effective treatment. Genotype-guided therapy was more cost-effective than empiric aspirin and clopidogrel if the LOF was above 48%. Empiric ticagrelor and aspirin was cost saving when compared to genotype-guided therapy. Results in models of dual antiplatelet therapy for 30 days were similar.

CONCLUSION

This study suggests that in patients with minor stroke and TIA planned for dual antiplatelet regimens, empiric ticagrelor and aspirin is the most cost-effective treatment regimen. If ticagrelor is not available, genotype-guided therapy is the most cost-effective treatment regimen if the LOF prevalence in the population is more than 48%.

An overview of the utility of prasugrel hydrochloride as a treatment option for ischemic stroke

INTRODUCTION

Prasugrel, a potent P2Y12 receptor inhibitor, is not currently recommended in patients with stroke due to a higher rate of recurrent stroke. Prasugrel was associated with comparable efficacy to clopidogrel in reducing the risk of ischemic stroke in a recent phase III study.

AREAS COVERED

The authors provide an overview of the potential role of prasugrel in the management of ischemic stroke. The authors searched PUBMED, MEDLINE, and clinicaltrials.org and recently presented trials at the conferences for clinical trials of prasugrel therapy in patients with stroke and TIA, and important original investigations are reviewed.

EXPERT OPINION

The recent PRASTRO-trials demonstrated comparable outcomes of lower maintenance dose (3.5 mg daily dose) with clopidogrel in East Asian stroke patients, thus can be a credible option as a P2Y12 receptor inhibitor. It can also be considered as a credible option in other races and ethnicities and in other clinical situations that may require DAPT, such as intracranial or carotid stenting. Since prasugrel is associated with a superior antiplatelet effect and is not influenced by genetic polymorphisms, there is no need for platelet function or genetic testing. More work is needed to establish the safety and efficacy of low-dose prasugrel plus aspirin in comparison with currently used clopidogrel plus aspirin in non-East Asian populations.

Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review

To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.

Outcomes after Perioperative Transient Ischemic Attack Following Cardiac Surgery

Perioperative transient ischemic attacks (PTIAs) are associated with significantly increased rates of postoperative complications such as low cardiac output, atrial fibrillation, and significantly higher mortality in cardiac procedures. The current literature on PTIAs is sparse and understudied. Therefore, we aim to understand the effects of PTIA on hospital utilization, readmission, and morbidity. Using data on all the cardiac procedures at the University of Pittsburgh Medical Center from 2011 to 2019, fine and gray analysis was performed to identify whether PTIAs and covariables correlate with increased hospital utilization, stroke, all-cause readmission, Major Adverse Cardiac and Cerebrovascular Events (MACCE), MI, and all-cause mortality. Logistic regression for longer hospitalization showed that PTIA (HR: 2.199 [95% CI: 1.416-3.416] increased utilization rates. Fine and gray modeling indicated that PTIA (HR: 1.444 [95% CI: 1.096-1.902], p < 0.01) increased the rates of follow-up all-cause readmission. However, PTIA (HR: 1.643 [95% CI: 0.913-2.956] was not statistically significant for stroke readmission modeling. Multivariate modeling for MACCE events within 30 days of surgery (HR: 0.524 [95% CI: 0.171-1.605], p > 0.25) and anytime during the follow-up period (HR: 1.116 [95% CI: 0.825-1.509], p > 0.45) showed no significant correlation with PTIA. As a result of PTIA's significant burden on the healthcare system due to increased utilization, it is critical to better define and recognize PTIA for timely management to improve perioperative outcomes.

Neurological abnormalities among pediatric patients with sickle cell disease in Saudi Arabia: a single-center retrospective study

Introduction

Sickle cell disease (SCD) is a common inherited blood disorder characterized by the production of abnormal sickle-shaped red blood cells. SCD can lead to various complications including neurological issues. Early detection and treatment are crucial for preventing these complications. This study aimed to describe the neurological manifestations, radiological findings, and neurological diagnosis related to SCD in Saudi children with the aim of contributing to the formulation of population-based guidelines for screening and treating SCD-related neurological complications.

Methods

This descriptive retrospective study included pediatric patients aged < 14 years diagnosed with SCD who were regularly followed up at the hematology clinic in KAMC, Jeddah, Saudi Arabia, from January 2008 to January 2022. Demographic and clinical data were collected from the clinical charts of 101 participants.

Results

This study included 101 patients with SCD with a mean age of 23 months at diagnosis. Among these, 59% had SCD and high fetal hemoglobin (HbF) levels. Neurological sequelae, including seizures, stroke, and other abnormalities, were observed in 26.7% of patients. There were no significant differences in the onset of neurological issues between the patients with SCD-high HbF and those with other SCD phenotypes.

Discussion

This study highlights the increased risk of brain injury and neurocognitive deficits in children with SCD. The occurrence of neurological sequelae in many patients emphasizes the need for early detection and intervention. Some patients experience neurological complications despite having high HbF levels, suggesting that further interventions are needed. This study has some limitations, including its small sample size and retrospective nature.

Conclusion

Early detection and intervention are crucial for neurological complications in patients with SCD. This study emphasizes the need for further research and effective treatment strategies considering the presence of neurological complications despite the presence of high HbF levels. Large-scale studies and population-specific guidelines are warranted for better understanding and management of SCD-related neurological complications in the Saudi population.

Effect of atorvastatin calcium plus clopidogrel in the treatment of patients with transient ischemic attacks and its effect on blood lipids and platelets

OBJECTIVE

To explore the clinical effect of atorvastatin calcium combined with clopidogrel in the treatment of patients with transient ischemic attacks (TIAs) and its effect on blood lipids and platelets.

METHODS

Low-density lipoprotein cholesterol (LDL-C)], platelet-related parameters [prothrombin time (PT), activated partial thromboplastin time (APTT), platelet count (PLT)], incidence of cerebral infarction, and adverse reactions.

RESULTS

The clinical outcomes of the experimental group patients were significantly better than those of the control group patients (p < 0.05). The experimental group exhibited notably lower levels of TG, TC, and LDL-C compared to the control group (p < 0.05). Platelet-related indices-PT, APTT, and PLT-showed no significant differences between groups before and after treatment (p > 0.05). The incidence of cerebral infarction was notably lower in the experimental group (p < 0.005), while the occurrence of adverse reactions showed no significant difference between groups (p > 0.05).

CONCLUSION

Atorvastatin calcium combined with clopidogrel demonstrates a positive impact on individuals with TIAs by significantly lowering levels of LDL, total cholesterol, and triglycerides. However, it is noteworthy that platelet-related indices did not exhibit significant differences between the experimental and control groups. While the observed improvements in blood lipids are attributed to the effects of atorvastatin, the combination with clopidogrel did not show a substantial influence on platelet-related parameters. Thus, the overall therapeutic impact, particularly on platelet-related indices, may require further investigation and clarification. Despite these nuances, our findings suggest potential benefits in reducing the risk of adverse reactions and cerebral infarction, supporting the consideration of this approach for wider clinical use.

Age-dependent seasonality in the incidence of stroke: A 21-year population-based study

INTRODUCTION

Seasonality in the incidence of stroke has been examined in numerous studies, yet data on whether it differs with age are limited. To fill this gap, we utilized a largescale dataset from Israel.

PATIENTS AND METHODS

We retrieved data of all hospitalizations for ischemic stroke (IS), transient ischemic attack (TIA) and intra cerebral hemorrhage (ICH) from 2000 to 2020. We maintained separate datasets for IS/TIA and ICH, divided into five age groups: 18-49, 50-59, 60-69, 70-79, and 80+. We modeled the monthly incidence using a generalized additive model. The seasonal effect was defined by the rate ratio (RR) of each month compared to the annual mean.

RESULTS

The analysis included 317,586 and 23,789 events of IS/TIA and ICH respectively. We found an interaction between age and seasonality, accounting for a phase shift with age in the seasonal pattern of IS/TIA incidence. For cases under 70 years, the peak was during summertime and the RRs increased with decreasing age, reaching 1.11 (95% CI 1.09-1.13) at the youngest age group. In contrast, among the elderly, a winter peak was observed and the RRs increased with age to 1.07 (95% CI 1.06-1.08) at the oldest age group. For ICH, a winter/autumn peak was identified and the RRs increased with age to 1.20 (95% CI 1.16-1.24).

CONCLUSIONS

Our finding of age-dependent seasonal patterns in the occurrence of stroke, suggests closer monitoring of cardiovascular risk factors during wintertime among elderly individuals. The mechanism governing the seasonal phase shift with age in IS/TIA incidence, requires further investigation.

Improving Stroke Risk Factor Management Focusing on Health Disparities and Knowledge Gaps

Stroke is a leading cause of death and disability in the United States and worldwide, necessitating comprehensive efforts to optimize stroke risk factor management. Health disparities in stroke incidence, prevalence, and risk factor management persist among various race/ethnic, geographic, and socioeconomic populations and negatively impact stroke outcomes. This review highlights existing literature and guidelines for stroke risk factor management, emphasizing health disparities among certain populations. Moreover, stroke risk factors for special groups, including the young, the very elderly, and pregnant/peripartum women are outlined. Strategies for stroke risk factor improvement at every level of the health care system are discussed, from the individual patient to providers, health care systems, and policymakers. Improving stroke risk factor management in the context of the social determinants of health, and with the goal of eliminating inequities and disparities in stroke prevention strategies, are critical steps to reducing the burden of stroke and equitably improving public health.

Referral to Community-Based Rehabilitation Following Acute Stroke: Findings From the COMPASS Pragmatic Trial

BACKGROUND

Few studies on care transitions following acute stroke have evaluated whether referral to community-based rehabilitation occurred as part of discharge planning. Our objectives were to describe the extent to which patients discharged home were referred to community-based rehabilitation and identify the patient, hospital, and community-level predictors of referral.

METHODS

We examined data from 40 North Carolina hospitals that participated in the COMPASS (Comprehensive Post-Acute Stroke Services) cluster-randomized trial. Participants included adults discharged home following stroke or transient ischemic attack (N=10  702). In this observational analysis, COMPASS data were supplemented with hospital-level and county-level data from various sources. The primary outcome was referral to community-based rehabilitation (physical, occupational, or speech therapy) at discharge. Predictor variables included patient (demographic, stroke-related, medical history), hospital (structure, process), and community (therapist supply) measures. We used generalized linear mixed models with a hospital random effect and hierarchical backward model selection procedures to identify predictors of therapy referral.

RESULTS

Approximately, one-third (36%) of stroke survivors (mean age, 66.8 [SD, 14.0] years; 49% female, 72% White race) were referred to community-based rehabilitation. Rates of referral to physical, occupational, and speech therapists were 31%, 18%, and 10%, respectively. Referral rates by hospital ranged from 3% to 78% with a median of 35%. Patient-level predictors included higher stroke severity, presence of medical comorbidities, and older age. Female sex (odds ratio, 1.24 [95% CI, 1.12-1.38]), non-White race (2.20 [2.01-2.44]), and having Medicare insurance (1.12 [1.02-1.23]) were also predictors of referral. Referral was higher for patients living in counties with greater physical therapist supply. Much of the variation in referral across hospitals remained unexplained.

CONCLUSIONS

One-third of stroke survivors were referred to community-based rehabilitation. Patient-level factors predominated as predictors. Variation across hospitals was notable and presents an opportunity for further evaluation and possible targets for improved poststroke rehabilitative care.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.

A Novel Nomogram for Predicting Warfarin-Related Bleeding: A Retrospective Cohort Study

Warfarin is a widely used anticoagulant, and bleeding complications are the main reason why patients discontinue the drug. Currently, there is no nomogram model for warfarin-associated bleeding risk. The aim of this study was to develop a risk-prediction nomogram model for warfarin-related major and clinically relevant non-major (CRNM) bleeding. A total of 280 heart disease outpatients taking warfarin were enrolled, 42 of whom experienced major or CRNM bleeding at the one-year follow-up. The Least Absolute Shrinkage and Selection Operator regression model was employed to identify potential predictors. Backward stepwise selection with the Akaike information criterion was used to establish the optimal predictive nomogram model. The receiver operating characteristic (ROC) curve, calibration plot, Hosmer-Lemeshow goodness-of-fit test, and decision curve analysis (DCA) were used to evaluate the performance of the nomogram. The nomogram consisted of four predictors: female (OR = 1.85; 95% CI: 0.91-3.94), TIA (OR = 6.47; 95% CI: 1.85-22.7), TTR (OR = 0.99; 95% CI: 0.97-1.00), and anemia (OR = 2.30; 95% CI: 1.06-4.84). The model had acceptable discrimination (area under the ROC curve = 0.68, 95% CI: 0.59-0.78), and was significantly better than the existing nine warfarin-related bleeding prediction scoring systems. The calibration plot and Hosmer-Lemeshow test (χ² = 7.557; P = .478) indicated well-calibrated data in the model. The DCA demonstrated good clinical utility. In this study, we developed a nomogram to predict the risk of warfarin-related major or CRNM bleeding. The model has good performance, allows rapid risk stratification of warfarin users, and provides a basis for personalized treatment.

Neurological event rates and associated risk factors in acute type B aortic dissections treated by thoracic aortic endovascular repair

OBJECTIVES

Thoracic endovascular aortic repair is the method of choice in patients with complicated type B acute aortic dissection. However, thoracic endovascular aortic repair carries a risk of periprocedural neurological events including stroke and spinal cord ischemia. We aimed to look at procedure-related neurological complications within a large cohort of patients with type B acute aortic dissection treated by thoracic endovascular aortic repair.

METHODS

Between 1996 and 2021, the International Registry of Acute Aortic Dissection collected data on 3783 patients with type B acute aortic dissection. For this analysis, 648 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair were included (69.4% male, mean age 62.7 ± 13.4 years). Patients were excluded who presented with a preexisting neurologic deficit or received adjunctive procedures. Demographics, clinical symptoms, and outcomes were analyzed. The primary end point was the periprocedural incidence of neurological events (defined as stroke, spinal cord ischemia, transient neurological deficit, or coma). Predictors for perioperative neurological events and follow-up outcomes were considered as secondary end points.

RESULTS

Periprocedure neurological events were noted in 72 patients (11.1%) and included strokes (n = 29, 4.6%), spinal cord ischemias (n = 21, 3.3%), transient neurological deficits (n = 16, 2.6%), or coma (n = 6, 1.0%). The group with neurological events had a significantly higher in-hospital mortality (20.8% vs 4.3%, P < .001). Patients with neurological events were more likely to be female (40.3% vs 29.3%, P = .077), and aortic rupture was more often cited as an indication for thoracic endovascular aortic repair (38.8% vs 16.5%, P < .001). In patients with neurological events, more stent grafts were used (2 vs 1 stent graft, P = .002). Multivariable logistic regression analysis showed that aortic rupture (odds ratio, 3.12, 95% confidence interval, 1.44-6.78, P = .004) and female sex (odds ratio, 1.984, 95% confidence interval, 1.031-3.817, P = .040) were significantly associated with perioperative neurological events.

CONCLUSIONS

In this highly selected group from dedicated aortic centers, more than 1 in 10 patients with type B acute aortic dissection treated by thoracic endovascular aortic repair had neurological events, in particular women. Further research is needed to identify the causes and presentation of these events after thoracic endovascular aortic repair, especially among women.

[Advisability of carotid endarterectomy in asymptomatic patients]

OBJECTIVE

To determine the optimal treatment strategy for patients with asymptomatic carotid stenosis.

MATERIAL AND METHODS

The authors reviewed clinical guidelines for the management of patients with asymptomatic carotid stenosis 60-99%, as well as medical studies and meta-analyses comparing carotid endarterectomy and optimal drug therapy in asymptomatic patients between 1993 and 2023.

RESULTS

The choice of treatment strategy for patients with asymptomatic carotid artery stenosis is still a controversial issue. There were several large randomized clinical trials comparing carotid endarterectomy with optimal medical therapy in asymptomatic patients at the end of the 20th century. However, drug therapy has undergone significant changes calling into question the relevance of previous results. This review highlights the evolution of management of patients with asymptomatic carotid stenosis and also presents modern approaches to the treatment of these patients.

CONCLUSION

Patients younger 75 years old gain an advantage from carotid endarterectomy with small perioperative risk compared to optimal drug therapy and yearly risk of cerebral embolism. Patients with asymptomatic carotid stenosis 80-99% are candidates for carotid endarterectomy due to higher risk of acute cerebrovascular accident at least until more data are available. The choice of the best tactics for a particular patient should be made individually depending on own experience and patient's adherence to therapy and lifestyle correction. The results of the ACTRIS (2025) and CREST-2 (2026) studies are expected to clarify this issue.

A Rare Case of Spontaneous Pneumothorax Leading to Cerebral Air Embolism

Cerebral arterial air embolism (CAE), a rare subtype of air embolism, carries a 21% mortality rate. We present a unique case involving a 69-year-old female with a history of usual interstitial pneumonia (UIP) who suffered a transient ischemic attack (TIA) due to CAE. Unlike typical cases, CAE in this instance resulted from spontaneous pneumothorax, not the more common iatrogenic causes. Adding complexity, an unexpected discovery emerged during evaluation: a patent foramen ovale, contributing to paradoxical embolism. This underscores the vital need to consider CAE as a differential diagnosis in UIP patients with neurological symptoms, highlighting its rarity and diagnostic challenges.

Insulin-like growth factor 1 and its prognostic value in the course of acute ischemic cerebrovascular events

Introduction

The aim of the study was to evaluate insulin-like growth factor 1 (IGF-1) as a predictor of the course of an acute cerebral ischemic event (AICE). This polypeptide, by activating receptors that are present in most tissues, including the brain, mediates the anabolic activity of growth hormone (GH) and its impact on growth and maturation processes, as well as organisms' survival time. AICE can occur in the form of a transient ischemic attack (TIA) or an ischemic stroke (IS).

Material and methods

The study included 86 participants. The correlation between serum IGF-1 concentration and the clinical status of 56 patients on days 1 and 9 of AICE, as well as risk factors and the course of the disease, were prospectively analyzed. The control group consisted of 30 healthy volunteers.

Results

Patients with a minor baseline neurological syndrome had higher serum IGF-1 concentrations than patients with severe baseline neurological dysfunctions. Multidimensional analyses showed that high IGF-1 values independently determined the worse course of the disease, especially in patients with a severe neurological deficit present on the first day of AICE.

Conclusions

Our results indicate that the high level of circulating IGF-1 on the first day of AICE is an independent factor determining the unfavorable course of the stroke, and this relationship is proportional to the severity of the baseline neurological deficit. The study also revealed a positive correlation between the decreased plasma IGF-1 concentration on the first day of AICE and the severity of neurological symptoms.

Transient Ischemic Attack (TIA) presenting with isolated anomic aphasia due to ischemia in the posterior cingulate gyrus in a 11-year-old girl

INTRODUCTION

Anomic aphasia, characterized by difficulty in word finding, is a subtype without impairments in fluent speech, comprehension, reading, writing, and repetition. Recognizing pure anomic aphasia in this group is crucial for a comprehensive understanding of localization and brain functions.

CASE REPORT

We present the case of an 11-year-old girl with transient ischemic attack and anomic aphasia. Neuroimaging identified abnormalities in the cingulate gyrus and temporo-occipital regions. No focal neurological findings were observed without aphasia. In terms of etiology, an MTHFR mutation was detected, and aside from this, no hematological or systemic cause could be identified.

CONCLUSION

This case marks the first demonstration of posterior cingulate gyrus involvement in pure anomic aphasia.

Osteovascular Conflicts in the Neck Region and Cerebrovascular Events: Illustrative Cases and Literature Review

STUDY DESIGN

Literature Review.

OBJECTIVE

Abnormal bone structures in the neck can cause headache, neck pain, and difficulty swallowing, but also cerebrovascular events. We introduce the term "osteovascular conflicts" to describe this phenomenon. The objective of this study was to conduct a literature review of such conflicts involving the anterior and posterior cerebral circulation. Furthermore, we aimed at presenting additional illustrative cases from our institution both for increasing awareness for unusual osteovascular conflicts, and for assessing the practice and care of such patients.

METHODS

We focused on osteovascular conflicts in the neck leading to cerebrovascular events related to an abnormal bone structure causing arterial or venous compression, dissection, and/or occlusion. We excluded pure vascular forms without cerebrovascular repercussions. Our PubMed/MEDLINE search for articles published in any language and for which an English abstract was available (from 1966 to 2022) included Eagle's neurovascular, bow hunter's syndrome, and golfer's stroke, excluding trauma-induced artery dissections or compressions and those concerning systemic bone disorders. We also provided illustrative cases collected by the authors.

RESULTS

All studies were either case reports or small case series. We found 82 cases of Eagle's neurovascular, 258 of bow hunter's syndrome, and 17 golfer's stroke cases. Mean ages were 52, 48, and 47 years, respectively. Male predominance was evident: 81% for Eagle's, 74% for bow hunter's, and 93% for golfer's.

CONCLUSION

Osteovascular conflicts are rare but important causes of cerebrovascular events and often go unrecognised. A greater awareness of cerebrovascular symptoms related to these conflicts can facilitate early diagnosis and treatment.

Indications and Outcome of Carotid Endarterectomy (CEA): A Single Centre Experience

Background Stroke is a prevalent ailment that impacts a substantial number of individuals globally, resulting in both physical impairment and mortality. One of its major causes is carotid artery stenosis. The symptoms and degree of stenosis are key indications for carotid endarterectomy (CEA). In this study, we highlight the indications and outcomes of carotid endarterectomy in our center. Methods This is a descriptive, retrospective, observational study. Data of patients who underwent CEA at Glan Clwyd Hospital from January 2018 to January 2023 was retrieved. The study sample consisted of patients diagnosed with symptomatic carotid artery stenosis who had CEA at Glan Clwyd Hospital. The data was analyzed using statistical software SPSS (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp). Results A total of 150 patients were enrolled in the study. A majority of the patients were male, accounting for 69.3% (n = 104), and had a mean age of 71.1 ± 9.9 standard deviation. A majority of the patients were smokers (48.7%) and had additional medical conditions, including hypertension (34%), ischemic heart disease (17.3%), chronic obstructive pulmonary disease (73.3%), and diabetes (46.7%). Nevertheless, the remaining comorbidities were less common. The outcome of the CEA among the patients was cardiac event 3.3% (n = 5); transient ischemic attack (TIA) 3.3% (n = 5); stroke 0.6% (n = 1); hemorrhage 2.6% (n = 4); surgical site infection 2% (n = 3); perioperative mortality 1.3% (n = 2); and cranial nerve injury 1.3% (n = 2). However, no complications were reported in most of the patients, 85.6% (n = 128). Conclusion An endarterectomy is quite advantageous for treating symptomatic stenosis. The findings can be applied to patients who are physically suitable for surgery. The efficacy of endarterectomy is contingent upon not only the severity of carotid stenosis but also various other parameters, such as the time elapsed between the presenting event and the surgical intervention, as well as the patient's overall medical condition. However, the CEA is the gold standard in surgical management for symptomatic carotid disease.

Early or late initiation of dabigatran versus vitamin-K-antagonists in acute ischemic stroke or TIA: The PRODAST study

BACKGROUND

The optimal timing of initiating or resuming anticoagulation after acute ischemic stroke (AIS) or transient ischemic attack (TIA) in patients with atrial fibrillation (AF) is debated. Dabigatran, a non-vitamin K oral anticoagulant (NOAC), has shown superiority against vitamin K antagonists (VKA) regarding hemorrhagic complications.

AIMS

In this registry study, we investigated the initiation of dabigatran in the early phase after AIS or TIA.

METHODS

PRODAST (Prospective Record of the Use of Dabigatran in Patients with Acute Stroke or TIA) is a prospective, multicenter, observational, post-authorization safety study. We recruited 10,039 patients at 86 German stroke units between July 2015 and November 2020. A total of 3,312 patients were treated with dabigatran or VKA and were eligible for the analysis that investigates risks for major hemorrhagic events within 3 months after early (⩽ 7 days) or late (> 7 days) initiation of dabigatran or VKA initiated at any time. Further endpoints were recurrent stroke, ischemic stroke, TIA, systemic embolism, myocardial infarction, death, and a composite endpoint of stroke, systemic embolism, life-threatening bleeding and death.

RESULTS

Major bleeding event rates per 10,000 treatment days ranged from 1.9 for late administered dabigatran to 4.9 for VKA. Early or late initiation of dabigatran was associated with a lower hazard for major hemorrhages as compared to VKA use. The difference was pronounced for intracranial hemorrhages with an adjusted hazard ratio (HR) of 0.47 (95% confidence interval (CI): 0.10-2.21) for early dabigatran use versus VKA use and an adjusted HR of 0.09 (95% CI: 0.00-13.11) for late dabigatran use versus VKA use. No differences were found between early initiation of dabigatran versus VKA use regarding ischemic endpoints.

CONCLUSIONS

The early application of dabigatran appears to be safer than VKA administered at any time point with regards to the risk of hemorrhagic complications and in particular for intracranial hemorrhage. This result, however, must be interpreted with caution in view of the low precision of the estimate.

Mild Stroke, Serious Problems: Limitations in Balance and Gait Capacity and the Impact on Fall Rate, and Physical Activity

BACKGROUND

After mild stroke persistent balance limitations may occur, creating a risk factor for fear of falling, falls, and reduced activity levels. Objective. To investigate whether individuals in the chronic phase after mild stroke show balance and gait limitations, elevated fall risk, reduced balance confidence, and physical activity levels compared to healthy controls.

METHODS

An observational case-control study was performed. Main outcomes included the Mini-Balance Evaluation Systems Test (mini-BEST), Timed Up and Go (TUG), 10-m Walking Test (10-MWT), and 6-item version Activity-specific Balance Confidence (6-ABC) scale which were measured in 1 session. Objectively measured daily physical activity was measured for 7 consecutive days. Fall rate in daily life was recorded for 12 months. Individuals after a mild stroke were considered eligible when they: (1) sustained a transient ischemic attack or stroke longer than 6 months ago, resulting in motor and/or sensory loss in the contralesional leg at the time of stroke, (2) showed (near-) complete motor function, that is, ≥24 points on the Fugl-Meyer Assessment-Lower Extremity (range: 0-28).

RESULTS

Forty-seven healthy controls and 70 participants after mild stroke were included. Participants with stroke fell more than twice as often as healthy controls, had a 2 point lower median score on the mini-BEST, were 1.7 second slower on TUG, 0.6 km/h slower on the 10-MWT, and had a 12% lower 6-ABC score. Intensity for both total activity (8%) as well as walking activity (6%) was lower in the participants with stroke, while no differences were found in terms of duration.

CONCLUSIONS

Individuals in the chronic phase after a mild stroke demonstrate persistent balance limitations and have an increased fall risk. Our results point at an unmet clinical need in this population.

Symptoms of Patients With Vertebral Artery Dissection Presenting to Chiropractors: A Systematic Review and Meta-Analysis

Early symptoms of vertebral artery dissection (VAD) may be nonspecific, including neck pain and headache. Neck pain and headache are also common reasons for patients to seek chiropractic care. We hypothesized that neck pain and/or headache would be the most prevalent symptoms among patients with undiagnosed VAD presenting to chiropractors compared to dizziness or other symptoms. We searched PubMed, Ovid, the Index to Chiropractic Literature, Google Scholar, and gray literature through September 2023 for observational studies describing patients aged ≥10 with previously undiagnosed VAD presenting to a chiropractor. Article selection, data extraction, and quality assessment were performed in duplicate. We synthesized the point prevalence of symptoms and other clinical features. We included 10 case reports describing 10 patients (mean age = 37, SD = 7, 60% female). All patients had either neck pain or headache (100%; 95% confidence interval (CI) = 100%-100%). The most prevalent individual symptoms were neck pain (90%; 95% CI = 71%-100%), headache (80%; 95% CI = 55%-100%), visual disturbance (50%; 95% CI = 19%-81%), and dizziness (40%; 95% CI = 10%-70%). The certainty of results was very low due to publication bias. While our findings suggest that neck pain and/or headache are the most prevalent symptoms among patients with undiagnosed VAD visiting a chiropractor, the small sample size and reliance on case reports preclude any definitive conclusions. Further research with larger sample sizes, control groups, and better control of confounders is required to corroborate these results. Chiropractors should be aware of VAD features and refer suspected patients for emergency care.

Association of Incomplete Neurovascular Imaging After Emergency Department Encounters for Transient Ischemic Attack and Odds of Subsequent Stroke: A National Medicare Analysis

BACKGROUND. Multisociety guidelines recommend urgent brain and neurovascular imaging for patients with transient ischemic attack (TIA), to identify and treat modifiable stroke risk factors. Prior research suggests that most patients with TIA who present to the emergency department (ED) do not receive prompt neurovascular imaging. OBJECTIVE. The purpose of this study was to evaluate the association between incomplete neurovascular imaging workup during ED encounters for TIA and the odds of subsequent stroke. METHODS. This retrospective study obtained data from the Medicare Standard Analytical Files for calendar years 2016 and 2017; these files contain 100% samples of claims for Medicare beneficiaries. Information was extracted using ICD 10th revision (ICD-10) and CPT codes. Those patients who were discharged from an ED encounter with a TIA diagnosis and who underwent brain CT or brain MRI during or within 2 days of the encounter were identified. Patients were considered to have complete neurovascular imaging if they underwent cross-sectional vascular imaging of both the brain (brain CTA or brain MRA) and neck (neck CTA, neck MRA, or carotid ultrasound) during or within 2 days of the encounter. The association between incomplete neurovascular imaging and a new stroke diagnosis within the subsequent 90 days was tested by multivariable logistic regression analysis. RESULTS. The sample included 111,417 patients (47,370 men, 64,047 women; 26.0% older than 84 years) who had TIA ED encounters. A total of 37.3% of patients (41,592) had an incomplete neurovascular imaging workup. A new stroke diagnosis within 90 days of the TIA ED encounter occurred in 4.4% (3040/69,825) of patients with complete neurovascular imaging versus 7.0% (2898/41,592) of patients with incomplete neurovascular imaging. Incomplete neurovascular imaging was associated with increased likelihood of stroke within 90 days (OR, 1.30 [95% CI, 1.23-1.38]) after adjustment for patient characteristics (age, sex, race and ethnicity, high-risk comorbidities, median county household income) and hospital characteristics (region, rurality, number of beds, major teaching hospital designation). CONCLUSION. TIA ED encounters with incomplete neurovascular imaging were associated with higher odds of subsequent stroke occurring within 90 days. CLINICAL IMPACT. Increased access to urgent neurovascular imaging for patients with TIA may represent a target that could facilitate detection and treatment of modifiable stroke risk factors.

Long-term clinical outcomes for patients with uncrossable patent foramen ovale

Introduction

Patent foramen ovale (PFO) closure is performed in selected patients with cryptogenic stroke to prevent recurrence. The prognosis of patients with uncrossable PFO after failed guidewire or catheter passage during the procedure remains unknown. We compared the long-term prognosis between uncrossable PFO and successful PFO closure in patients with high-grade PFO shunts.

Methods

We analyzed patients who underwent PFO closure for stroke or transient ischemic attack (TIA) prevention at Gachon University Gil Medical Center between April 2010 and March 2022. The primary outcome was a composite of recurrent stroke or TIA. Secondary outcomes included stroke, TIA, all-cause death, and a composite of stroke, TIA, and all-cause death.

Results

Of 286 patients, 245 were included in the analysis after excluding those with transseptal puncture technique usage or concurrent atrial septal defect. Among them, 82 had uncrossable PFO, and 163 underwent successful PFO closure. Large shunts were more prevalent in the PFO closure group compared to the uncrossable PFO group (62.0% vs. 34.1%, P < 0.001), and resting shunts were also more common in the PFO closure group (17.8% vs. 2.4%, P < 0.001). Stroke or TIA occurred in 2 patients (2.4%) in the uncrossable PFO group and 8 patients (4.9%) in the PFO closure group (hazard ratio, 1.44; 95% confidence interval, 0.30-6.81; P = 0.647). Additionally, no disparities in the occurrence of stroke or TIA were found in subgroups divided by baseline characteristics, RoPE score, or shunt grade.

Conclusion

Clinical outcomes for patients with uncrossable PFO seem similar to those with successful PFO closure.

Breaking Stereotypes: A Unique Presentation of New-Onset Multiple Sclerosis

Multiple sclerosis (MS) is a chronic demyelinating disorder resulting in demyelination, neuroaxonal degeneration, and sclerosis. This often-debilitating disease affects young females mainly. Literature describing the pathology and phenotypic features is vast. Although there are extensive descriptions of new-onset MS presentations, few document the initial presentation as a transient ischemic attack or ischemic stroke. The case we present highlights the rarity of such presentation. In the literature, we found scarce reports about MS as presenting as a stroke mimicker with some studies quoting from 2.2% to 4.4% of the cases having MS. Our case serves as a reminder that MS can mimic acute ischemic strokes and the importance of maintaining MS apart of the differential in a young female with no significant history present with acute neurological deficits to reduce the complications of MS and the healthcare-associated costs.

Transient aphonia following spinal anesthesia during emergency cesarean section: Case report and review of literature

Subarachnoid block with local anesthetic agents is a well-established anesthesia technique among pregnant females for labor analgesia and cesarian delivery. Although it is considered a reliable and safe technique for both mothers and fetuses, unexpected high or low levels of block may occur due to accidental injection of these agents into different meningeal spaces other than intended. Hypotension, bradycardia, headache, and failed anesthesia are common complications of spinal anesthesia. Though rare, neurological complications like aphonia, dysphagia, and tingling sensation have also been reported. The article reports a case of a 22-year-old primigravida who sustained transient aphonia following intrathecal administration of bupivacaine for an emergency cesarian section for meconium-stained liquor with fetal distress. There were no other neurological manifestations or features suggestive of high spinal block. The sensory level of the block was fixed to T6 with hemodynamic stability throughout aphasia with an episode of hypotension preceding aphonia. Aphonia commenced 9 min after the spinal anesthesia continued for a total duration of 15 min. Neurological examination, relevant investigations, and consultations were done to make a diagnosis. Thus, it is important to be aware of the possible neurological complications associated with spinal anesthesia.

Survey on antiphospholipid syndrome diagnosis and antithrombotic treatment in patients with ischemic stroke, other brain ischemic injury, or arterial thromboembolism in other sites: communication from ISTH SSC Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies

BACKGROUND

The optimal strategy for diagnosis and antithrombotic treatment of patients with antiphospholipid syndrome (APS)-associated acute ischemic stroke (AIS), transient ischemic attack (TIA), or other brain ischemic injury is poorly defined.

OBJECTIVES

The survey goal was to capture variations in diagnosis and antithrombotic treatment of APS-associated ischemic stroke and related disorders to inform guidance and clinical trials to define optimal management.

METHODS

Professional colleagues, including key opinion leaders, were invited to complete a REDCap survey questionnaire initiated by the International Society on Thrombosis and Haemostasis Scientific and Standardisation Committee Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. The survey data were tallied using simple descriptive statistics.

RESULTS

There was generally good agreement on several aspects, including which patients to test for antiphospholipid antibodies (aPL), use of a lifelong vitamin K antagonist for AIS or recurrent TIA, and formal cognitive assessment for suspected cognitive impairment. There was less agreement on other aspects, including aPL testing for brain ischemic injury other than AIS/TIA or if an alternative cause for AIS or TIA exists; choice of aPL tests, their timing, and age cutoff; the aPL phenotype to trigger antithrombotic treatment; management for patent foramen ovale; antithrombotic treatment for first TIA or white matter hyperintensities; head magnetic resonance imaging specifications; and low-molecular-weight heparin dosing/anti-Xa monitoring in pregnancy. The survey highlighted that approximately 25% practice at dedicated APS clinics and <50% have a multidisciplinary team structure for patients with APS.

CONCLUSION

Much of the variation in practice reflects the lack of evidence-based recommendations. The survey results should inform the development of a more uniform multidisciplinary consensus approach to diagnosis and antithrombotic treatment.

Using the PEAR1 Polymorphisms Rs12041331 and Rs2768759 as Potential Predictive Markers of 90-Day Bleeding Events in the Context of Minor Strokes and Transient Ischemic Attack

In this study, we explored the relationship between the platelet endothelial aggregation receptor 1 (PEAR1) polymorphisms, platelet reactivity, and clinical outcomes in patients with minor stroke or transient ischemic attack (TIA). Randomized controlled trial subgroups were assessed, wherein patients received dual antiplatelet therapy for at least 21 days. Platelet reactivity was measured at different time intervals. Genotypes were categorized as wild-type, mutant heterozygous, and mutant homozygous. Clinical outcomes were evaluated after 90 days. The rs12041331 polymorphism predominantly influenced adenosine diphosphate channel platelet activity, with the AA genotype displaying significantly lower residual platelet activity to the P2Y12 response unit (p < 0.01). This effect was more evident after 7 days of dual antiplatelet treatment (p = 0.016). Mutant A allele carriers had decreased rates of recurrent stroke and complex endpoint events but were more prone to bleeding (p = 0.015). The rs2768759 polymorphism majorly impacted arachidonic acid (AA) channel platelet activity, which was particularly noticeable in the C allele carriers. Our regression analysis demonstrated that rs12041331 AA + GA and rs2768759 CA predicted 90-day post-stroke bleeding. In conclusion, the PEAR1 polymorphisms rs12041331 and rs2768759 interfere with platelet aggregation and the performance of antiplatelet drugs. These genetic variations may contribute to bleeding events associated with minor stroke and TIA.

Transient ischemic attacks in patients with active and occult cancer

Background and aim

Paraneoplastic coagulopathy can present as stroke and is associated with specific biomarker changes. Identifying paraneoplastic coagulopathy can help guide secondary prevention in stroke patients, and early cancer detection might improve outcomes. However, unlike ischemic stroke, it remains unclear whether paraneoplastic coagulopathy is associated with transient ischemic attacks (TIA). This study assessed the presence of cancer-related biomarkers in TIA patients and evaluated long-term mortality rates in patients with and without active cancer.

Methods

Active cancer was retrospectively identified in consecutive TIA patients treated at a comprehensive stroke center between 2015 and 2019. An association between the presence of cancer and cancer-related biomarkers was assessed using multivariable logistic regression. Long-term mortality after TIA was analyzed using multivariable Cox regression.

Results

Among 1436 TIA patients, 72 had active cancer (5%), of which 17 were occult (1.2%). Cancer-related TIA was associated with male gender (adjusted odds ratio [aOR] 2.29, 95% CI 1.12-4.68), history of smoking (aOR 2.77, 95% CI 1.34-5.7), elevated D-dimer (aOR 1.77, 95% CI 1.26-2.49), lactate dehydrogenase (aOR 1.003, 95% CI 1.00-1.005), lower leukocyte count (aOR 1.20, 95% CI 1.04-1.38), and lower hemoglobin (aOR 1.02, 95% CI 1.00-1.04). Long-term mortality was associated with both active cancer (adjusted hazard ratios [aHR] 2.47, 95% CI 1.58-3.88) and occult cancer (aHR 3.08, 95% CI 1.30-7.32).

Conclusion

Cancer-related TIA is not uncommon. Biomarkers known to be associated with cancer-related stroke also seem to be present in TIA patients. Early identification would enable targeted treatment strategies and could improve outcomes in this patient population.

Cerebral venous sinus thrombosis presenting as transient ischemic attacks: A case report

Cerebral sinus venous thrombosis (CSVT) is a rare form of venous thromboembolism. Recurrent transient ischemic attacks were extremely rare clinical manifestation of CSVT. We reported a case of transient ischemic attack as an exceptionally rare form of CSVT. A 29-year-old woman presented with a headache and four episodes of a transient right limb weakness, numbness, and dysphasia lasting approximately 15 mins over the course of 2 weeks. Magnetic resonance venography revealed a superior sagittal sinus thrombosis with numerous prominent enlarged and dilated venous. Magnetic resonance imaging revealed venous infarction of the left frontal lobe. Transient ischemic attack-like episodes stopped with anticoagulation. We suggested that the patients with transient ischemic attack and symptoms of increased intracranial pressure should be carefully investigated in terms of CSVT.

Long-Term Incidence of Ischemic Stroke After Transient Ischemic Attack: A Nationwide Study From 2014 to 2020

BACKGROUND

The short-term incidence of ischemic stroke after a transient ischemic attack (TIA) is high. However, data on the long-term incidence are not well known but are needed to guide preventive strategies.

METHODS

Patients with first-time TIA (index date) in the Danish Stroke Registry (January 2014-December 2020) were included and matched 1:4 with individuals from the background population and 1:1 with patients with a first-time ischemic stroke on the basis of age, sex, and calendar year. The incidences of ischemic stroke and mortality from index date were estimated by Aalen-Johansen and Kaplan-Meier estimators, respectively, and compared between groups using multivariable Cox regression.

RESULTS

We included 21 500 patients with TIA, 86 000 patients from the background population, and 21 500 patients with ischemic stroke (median age, 70.8 years [25th-75th percentile, 60.8-78.7]; 53.1% males). Patients with TIA had more comorbidities than the background population, yet less than the control stroke population. The 5-year incidence of ischemic stroke after TIA (6.1% [95% CI, 5.7-6.5]) was higher than the background population (1.5% [95% CI, 1.4-1.6], P<0.01; hazard ratio, 5.14 [95% CI, 4.65-5.69]) but lower than the control stroke population (8.9% [95% CI, 8.4-9.4], P<0.01; hazard ratio, 0.58 [95% CI, 0.53-0.64]). The 5-year mortality for patients with TIA (18.6% [95% CI, 17.9-19.3]) was higher than the background population (14.8% [95% CI, 14.5-15.1], P<0.01; hazard ratio, 1.26 [95% CI, 1.20-1.32]) but lower than the control stroke population (30.1% [95% CI, 29.3-30.9], P<0.01; hazard ratio, 0.41 [95% CI, 0.39-0.44]).

CONCLUSIONS

Patients with first-time TIA had an ischemic stroke incidence of 6.1% during the 5-year follow-up period. After adjustment for relevant comorbidities, this incidence was approximately 5-fold higher than what was found for controls in the background population and 40% lower than for patients with recurrent ischemic stroke.

Idiopathic hypereosinophilic syndrome presenting as capsular warning syndrome: A case report and literature review

RATIONALE

Few reports of idiopathic hypereosinophilic syndrome exist presenting as ischemic cerebrovascular disease, and the majority are watershed infarction. We report the first case of idiopathic hypereosinophilic syndrome that has clinical features of capsular warning syndrome lasting 6 weeks.

PATIENT CONCERNS

A 26-year-old man complained of recurrent right limb weakness, accompanying slurred speech, and right facial paresthesia.

DIAGNOSES

The patient was diagnosed with idiopathic hypereosinophilic syndrome (IHES).

INTERVENTIONS

Adequate glucocorticoid and anticoagulant treatments were given.

OUTCOMES

The patient's motor ability improved, and he was discharged 2 weeks later. Muscle strength in the right-side extremities had fully recovered at a 3-month follow-up after discharge.

LESSONS

This case suggests that idiopathic hypereosinophilic syndrome should be considered as a cause of capsular warning syndrome, and the dose of glucocorticoid and the efficacy evaluation index needs to be reevaluated for the treatment of ischemic cerebrovascular disease associated with idiopathic hypereosinophilic syndrome.

Predictive value of whole-brain CT perfusion combined with ABCD3 score for short-term secondary cerebral infarction after TIA

Objective

To investigate the predictive value of Whole Brain CT Perfusion (WB-CTP) combined with the ABCD3 score in patients with transient ischemic attack (TIA).

Methods

A total of 336 TIA patients with TIA underwent WB-CTP and ABCD3 score assessment within 48 h of admission. Spearman correlation test was performed to analyze the relationship between the degree of vascular stenosis, relative perfusion values, and ABCD3 score. Logistic regression analysis was used to identify independent risk factors for secondary cerebral infarction. Receiver operating characteristic (ROC) curves were generated to evaluate the predictive value of relative cerebral blood flow (rCBF), degree of vascular stenosis, ABCD3 score, and the WB-CTP-ABCD3 combined model for secondary cerebral infarction after TIA. Calibration curves and H-L tests were used to evaluate the predictive efficacy of the model.

Results

Among the 336 TIA patients, 143 showed abnormal perfusion areas and 146 had responsible vessel stenosis. The degree of vascular stenosis, relative time-to-maximum (rTmax), and relative mean transit time (rMTT) were positively correlated with the ABCD3 score, while rCBF and relative cerebral blood volume (rCBV) were negatively correlated with the ABCD3 score. ROC curve analysis identified a cutoff value of 0.8205 for rCBF, with a sensitivity of 84.10% and specificity of 58.10% for distinguishing the cerebral infarction group from the non-cerebral infarction group. Furthermore, rCBF ≤ 0.8205, degree of vascular stenosis, and ABCD3 score > 6 were identified as independent risk factors for secondary cerebral infarction in TIA patients within 90 days in TIA patients. The AUC of the WB-CTP-ABCD3 combined model for predicting secondary cerebral infarction within 90 days was 0.836. The model risk was assessed by plotting calibration curves. The value of p for the H-L goodness of fit test was 0.366 (p > 0.05), which indicated that the difference between the obtained model and the perfect model were statistically insignificant.

Conclusion

The combined model of WB-CTP-ABCD3 shows promise as a valuable method for predicting secondary cerebral infarction within 90 days following TIA.

Association of immune checkpoint inhibitors therapy with arterial thromboembolic events in cancer patients: A retrospective cohort study

BACKGROUND

Immune checkpoint inhibitors (ICIs) have emerged as a standard treatment for various malignancies. However, research indicates blocking the immune checkpoint pathway may exacerbate atherosclerotic lesions.

OBJECTIVES

We aimed to investigate whether ICI therapy increases the risk of arterial thromboembolic events (ATEs).

METHODS

A retrospective cohort study was conducted on patients with histologically confirmed cancer at our institution between 2018 and 2021, using the propensity score matching method. The primary endpoint was ATEs occurrence, comprising acute coronary syndrome, stroke/transient ischemic attack, and peripheral arterial thromboembolism. Subgroup analyses assessed whether the ICI treatment effect on ATEs varied over time by limiting the maximum follow-up duration. Logistic regression analysis identified ATE risk factors in ICI-treated patients.

RESULTS

Overall, the ICI group (n = 2877) demonstrated an ATEs risk 2.01 times higher than the non-ICI group (RR, 2.01 [95% CI (1.61-2.51)]; p < 0.001). Subgroup analysis revealed no significant increase in ATEs risk for ICI-treated patients within 1 year (Limited to a max 9-month follow-up, p = 0.075). However, ATEs risk in the ICI group rose by 41% at 1 year (p = 0.010) and 97% at 4 years (p ≤ 0.001). Age, diabetes, hypertension, peripheral atherosclerosis, atrial fibrillation, chronic ischemic heart disease, distant cancer metastasis, and ICI treatment cycles contributed to ATEs risk elevation in ICI-treated patients.

CONCLUSION

ICI-treated patients may exhibit a higher risk of ATEs, especially after 1 year of treatment.

Comparison of Prehospital Assessment by Paramedics and In-Hospital Assessment by Physicians in Suspected Stroke Patients: Results From 2 Prospective Cohort Studies

BACKGROUND

It is unknown if ambulance paramedics adequately assess neurological deficits used for prehospital stroke scales to detect anterior large-vessel occlusions. We aimed to compare prehospital assessment of these stroke-related deficits by paramedics with in-hospital assessment by physicians.

METHODS

We used data from 2 prospective cohort studies: the LPSS (Leiden Prehospital Stroke Study) and PRESTO study (Prehospital Triage of Patients With Suspected Stroke). In both studies, paramedics scored 9 neurological deficits in stroke code patients in the field. Trained physicians scored the National Institutes of Health Stroke Scale (NIHSS) at hospital presentation. Patients with transient ischemic attack were excluded because of the transient nature of symptoms. Spearman rank correlation coefficient (rs) was used to assess correlation between the total prehospital assessment score, defined as the sum of all prehospital items, and the total NIHSS score. Correlation, sensitivity and specificity were calculated for each prehospital item with the corresponding NIHSS item as reference.

RESULTS

We included 2850 stroke code patients. Of these, 1528 had ischemic stroke, 243 intracranial hemorrhage, and 1079 stroke mimics. Correlation between the total prehospital assessment score and NIHSS score was strong (rs=0.70 [95% CI, 0.68-0.72]). Concerning individual items, prehospital assessment of arm (rs=0.68) and leg (rs=0.64) motor function correlated strongest with corresponding NIHSS items, and had highest sensitivity (arm 95%, leg 93%) and moderate specificity (arm 71%, leg 70%). Neglect (rs=0.31), abnormal speech (rs=0.50), and gaze deviation (rs=0.51) had weakest correlations. Neglect and gaze deviation had lowest sensitivity (52% and 66%) but high specificity (84% and 89%), while abnormal speech had high sensitivity (85%) but lowest specificity (65%).

CONCLUSIONS

The overall prehospital assessment of stroke code patients correlates strongly with in-hospital assessment. Prehospital assessment of neglect, abnormal speech, and gaze deviation differed most from in-hospital assessment. Focused training on these deficits may improve prehospital triage.

Dual Antiplatelet Therapies and Causes in Minor Stroke or Transient Ischemic Attack: A Prespecified Analysis in the CHANCE-2 Trial

BACKGROUND

It is unclear whether patients with different stroke/transient ischemic attack etiologies benefit differently from gene-directed dual antiplatelet therapy. This study explored the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in transient ischemic attack or minor stroke with different causes in the CHANCE-2 trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events-II).

METHODS

This was a prespecified analysis of the CHANCE-2 trial, which enrolled 6412 patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles. Patients with centralized evaluation of TOAST (Trial of ORG 10172 in Acute Stroke Treatment) classification of large-artery atherosclerosis, small-vessel occlusion, and stroke of undetermined cause were included. The primary efficacy outcome was new stroke, and the primary safety outcome was severe or moderate bleeding, both within 90 days. Cox proportional hazards models were used to assess the interaction of TOAST classification with the effects of dual antiplatelet therapy with ticagrelor-aspirin versus clopidogrel-aspirin.

RESULTS

A total of 6336 patients were included in this study. In patients administered ticagrelor-aspirin and clopidogrel-aspirin, respectively, stroke recurred in 85 (9.8%) and 88 (10.7%) patients with large-artery atherosclerosis (hazard ratio, 0.86 [95% CI, 0.63-1.18]; P=0.34); 32 (3.6%) and 61 (7.0%) patients with small-vessel occlusion (hazard ratio, 0.51 [95% CI, 0.33-0.79]; P=0.002); and 68 (4.8%) and 87 (5.9%) patients with stroke of undetermined cause (hazard ratio, 0.80 [95% CI, 0.58-1.10]; P=0.17), with P=0.08 for the treatment×cause subtype interaction effect. There were no significant differences in severe or moderate bleeding events in patients with different cause and different treatment.

CONCLUSIONS

In this prespecified analysis of the CHANCE-2 trial, the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in preventing new stroke were consistent in patients with different causes. The influence of stroke cause on benefit of gene-guided antiplatelet therapy should be explored by further trials.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04078737.

Prevalence and Factors Associated with Atrial Fibrillation in Patients with Transient Ischemic Attack or Ischemic Stroke in Northern Vietnam

BACKGROUND

The prevalence and risk factors of atrial fibrillation (AF) in patients with transient ischemic attack (TIA) or ischemic stroke in Northern Vietnam are not well understood. This study aimed to estimate the prevalence and identify factors associated with AF in this population.

METHODS

A cross-sectional study was conducted on 2038 consecutive patients with TIA or ischemic stroke admitted to Bach Mai Hospital. AF was diagnosed using an electrocardiogram or Holter monitor. Logistic regression analyses were performed to determine the association between AF and risk factors.

RESULTS

Among the patients, 18.1% (95% CI: 16.46 to 19.85) had AF. Older age, renal dysfunction, valvular heart disease (VHD), and low ejection fraction were significantly associated with AF. Advanced age (per 10 years) (adjusted OR, aOR 1.39; 95% CI, 1.23 to 1.57), estimated glomerular filtration ratio decrease (per 10 mL/min/1.73 m2) (aOR 1.12; 95% CI, 1.06 to 1.17), VHD (aOR 9.59; 95% CI, 7.10 to 12.95), and low ejection fraction (<50%) (aOR 2.61; 95% CI, 1.62 to 4.21) had notable odds ratios for AF.

CONCLUSIONS

Atrial fibrillation is prevalent among patients with TIA or ischemic stroke in Northern Vietnam, surpassing rates in other Southeast Asian countries. Age, renal dysfunction, VHD, and low ejection fraction were significant risk factors for AF in this population.

Transient ischemic attack and coronary artery disease: a two-sample Mendelian randomization analysis

Background

Although observational studies have shown that patients who experienced transient ischemic attacks (TIAs) had a higher risk of coronary artery disease (CAD), the causal relationship is ambiguous.

Methods

We conducted a two-sample Mendelian randomization (MR) study to analyze the causal relationship between TIA and CAD using data from the FinnGen genome-wide association study. Analysis was performed using the inverse-variance weighted (IVW) method. The robustness of the results was evaluated using MR-Egger regression, the weighted median, MR pleiotropy residual sum, and outlier (MR-PRESSO) and multivariable MR analysis.

Results

Results from IVW random-effect model showed that TIA was associated with an increased risk of coronary artery atherosclerosis (OR 1.17, 95% CI 1.06-1.28, P = 0.002), ischemic heart disease (OR 1.15, 95% CI 1.04-1.27, P = 0.007), and myocardial infarction (OR1.15, 95% CI 1.02-1.29, P = 0.025). In addition, heterogeneity and horizontal pleiotropy were observed in the ischemic heart disease results, while the sensitivity analysis revealed no evidence of horizontal pleiotropy in other outcomes.

Conclusions

This MR study demonstrated a potential causal relationship between TIA and CAD. Further research should be conducted to investigate the mechanism underlying the association.