Clinical recurrent events after incident stroke or transient ischemic attack

Ischemic stroke survivors are at high risk of experiencing new or re-expressed focal neurological symptoms. This may be due to a recurrent stroke or due to other medical conditions, known as stroke mimics. Long-term outcomes after ischemic stroke are scarcely studied. In addition, distinguishing recurrent stroke from stroke mimics is challenging. Admissions with stroke mimics are resource-consuming and may be troublesome for the patients. Knowledge on recurrence, its associated factors, mortality and stroke mimics after ischemic stroke is of value in clinical decision-making. The present study investigated incidence, predictors and impact of recurrent stroke in a hospital-based ischemic stroke population. In addition, we investigated the burden of stroke mimics after ischemic stroke. This thesis is based on a hospital-based cohort of patients registered in the Norwegian Stroke Research Registry (NORSTROKE) at the stroke unit at the Department of Neurology, Haukeland University Hospital. A total of 1874 surviving patients who were admitted with ischemic stroke or transient ischemic attack (TIA) between July 1, 2007, and December 31, 2013 were followed for new hospital admissions with recurrent ischemic stroke/TIA or stroke mimics. The 30-day recurrence rate was 1.8%. Patients with large artery atherosclerosis and stroke of other etiology had increased risk of 30-day recurrence. The long-term recurrence rates were modest, being 5.4% and 11.3% at 1 and 5 years respectively. Hypertension, prior symptomatic stroke, chronic infarcts on MRI and increasing age were independently associated with long-term recurrence. Recurrence more than doubled the all-cause mortality. Stroke mimics were more common than recurrence after ischemic stroke or TIA. Stroke mimics were multi-etiological and unspecific diagnoses were most frequent directly after index stroke

Secondary stroke prevention: patent foramen ovale, aortic plaque, and carotid stenosis

Stroke is the most debilitating cardiovascular event. It has a variety of causes that may be present simultaneously. In young or otherwise healthy people, the search for a patent foramen ovale (PFO) has become standard. In stroke of the elderly, atherosclerosis and atrial fibrillation are in the foreground but the PFO should not be ignored. The risk of a PFO-related stroke over time is controversial and so is its prevention by device closure. The association of proximal aortic plaques in arteries subtending the brain and stroke is considered strong, ignoring that it is as putative as that of the PFO. Statins can prevent progression of such plaques. Antiplatelet agents in asymptomatic and surgical endarterectomy in symptomatic patients or highly ulcerated lesions are the treatment of choice. Stenting with protection devices was shown competitive in selected patient

Secondary stroke prevention: patent foramen ovale, aortic plaque, and carotid stenosis

Stroke is the most debilitating cardiovascular event. It has a variety of causes that may be present simultaneously. In young or otherwise healthy people, the search for a patent foramen ovale (PFO) has become standard. In stroke of the elderly, atherosclerosis and atrial fibrillation are in the foreground but the PFO should not be ignored. The risk of a PFO-related stroke over time is controversial and so is its prevention by device closure. The association of proximal aortic plaques in arteries subtending the brain and stroke is considered strong, ignoring that it is as putative as that of the PFO. Statins can prevent progression of such plaques. Antiplatelet agents in asymptomatic and surgical endarterectomy in symptomatic patients or highly ulcerated lesions are the treatment of choice. Stenting with protection devices was shown competitive in selected patients

Translational Stroke Research Using a Rabbit Embolic Stroke Model: A Correlative Analysis Hypothesis for Novel Therapy Development

Alteplase (tissue plasminogen activator, tPA) is currently the only FDA-approved treatment that can be given to acute ischemic stroke (AIS) patients if patients present within 3 h of an ischemic stroke. After 14 years of alteplase clinical research, evidence now suggests that the therapeutic treatment window can be expanded 4.5 h, but this is not formally approved by the FDA. Even though there remains a significant risk of intracerebral hemorrhage associated with alteplase administration, there is an increased chance of favorable outcome with tPA treatment. Over the last 30 years, the use of preclinical models has assisted with the search for new effective treatments for stroke, but there has been difficulty with the translation of efficacy from animals to humans. Current research focuses on the development of new and potentially useful thrombolytics, neuroprotective agents, and devices which are also being tested for efficacy in preclinical and clinical trials. One model in particular, the rabbit small clot embolic stroke model (RSCEM) which was developed to test tPA for efficacy, remains the only preclinical model used to gain FDA approval of a therapeutic for stroke. Correlative analyses from existing preclinical translational studies and clinical trials indicate that there is a therapeutic window ratio (ARR) of 2.43-3 between the RSCEM and AIS patients. In conclusion, the RSCEM can be used as an effective translational tool to gauge the clinical potential of new treatments

Paroxysmal atrial fibrillation in cryptogenic stroke

Neha S Dangayach1, Kevin Kane2, Majaz Moonis31Saint Vincent Hospital, 2University of Massachusetts Medical School, 3University of Massachusetts Memorial Health Center, Worcester, MA, USAIntroduction: Paroxysmal atrial fibrillation (PAF) is perhaps the most underdiagnosed mechanism of apparent cryptogenic stroke (CS). Various studies have shown that increasing the duration of monitoring can increase the diagnosis of PAF in CS.Methods: We compared demographic and risk factors for ischemic stroke across different TOAST (Trial of ORG 10172 in Acute Stroke Treatment) stroke subtypes to look for clinical differences between other subtypes and CS and subsequently performed periodic Holter monitoring and imaging studies in apparent CS patients.Results: Of the 298 patients with ischemic stroke, 17% had CS. Periodic holter monitoring enabled diagnosis of PAF in 29% of patients. Five of 51 patients with CS had recurrent ischemic stroke and all 5 were demonstrated as PAF on repeated Holter monitoring.Conclusions: Long-term periodic rhythm monitoring in patients with apparent CS showed PAF in a significant percentage of CS patients, which altered subsequent treatment.Keywords: cryptogenic stroke, atrial fibrillation, stroke of undetermined etiolog

Infections in post stroke setting: a study from The neurology section of Aga Khan University Hospital, Karachi

Stroke is one of the commonest neurological disorders, contributing to the major burden of inpatient and outpatient neurology services. Infections after the stroke are the major factor, contributingto prolonged hospital stay and poor outcome in term of increasing morbidity and mortality. The aim of this study is to define the different types of infections in post stroke patients and their impact on the outcome of patients with stroke. METHOD: This is a descriptive, cross sectional study, that was carried out in the section of Neurology, Department of Medicine at Aga Khan University Hospital, Karachi over the span of one year. The strokes were classified as either ischemic or hemorrhagic. Different types of infections i.e. chest infections, urinary tract infections,, phlebitis, cellulitis and others were noted and the risk factors associated with their occurrence were identified. Data was entered and analyzed on SPSS 23. RESULTS: 104 patients with the diagnosis of acute stroke, who developed infections at least 48 hours after their presentation, were identified. There were sixty (58%) male and forty-four (42 %) females. Sixty-four (61.5%) of patients had a diagnosis of ischemic stroke, while thirty-six (34.6%) had hemorrhagic strokes, while data was missing in 4(3.8%)cases about the type of stroke. The commonest infection was Aspiration pneumonia, accounting for seventy-two (69%) of patients, followed by Urinary tract infections, that was found in fifty-six (54%) of the patients. Significant association of aspiration pneumonia with the level of consciousness was found. CONCLUSION: Stroke is one of the commonest neurological disorders. Ischemic strokes accounts for almost 2/3rd. of the stroke.The commonest infection was Aspiration pneumonia, accounting for seventy-two(69%) of patients, followed by Urinary tract infections, that was found in fifty-six (54%) of the patients. Significant association of aspiration pneumonia with the level of consciousness was found

Efficacy of antiplatelet therapy in secondary prevention following lacunar stroke:Pooled analysis of randomized trials

Background and Purpose: Lacunar stroke accounts for ≈25% of ischemic stroke, but optimal antiplatelet regimen to prevent stroke recurrence remains unclear. We aimed to evaluate the efficacy of antiplatelet agents in secondary stroke prevention after a lacunar stroke. Methods: We searched MEDLINE, Embase, and the Cochrane library for randomized controlled trials that reported risk of recurrent stroke or death with antiplatelet therapy in patients with lacunar stroke. We used random effects meta-analysis and evaluated heterogeneity with I2. Results: We included 17 trials with 42 234 participants (mean age 64.4 years, 65% male) and follow up ranging from 4 weeks to 3.5 years. Compared with placebo, any single antiplatelet agent was associated with a significant reduction in recurrence of any stroke (risk ratio [RR] 0.77, 0.62–0.97, 2 studies) and ischemic stroke (RR 0.48, 0.30–0.78, 2 studies), but not for the composite outcome of any stroke, myocardial infarction, or death (RR 0.89, 0.75–1.05, 2 studies). When other antiplatelet agents (ticlodipine, cilostazol, and dipyridamole) were compared with aspirin, there was no consistent reduction in stroke recurrence (RR 0.91, 0.75–1.10, 3 studies). Dual antiplatelet therapy did not confer clear benefit over monotherapy (any stroke RR 0.83, 0.68–1.00, 3 studies; ischemic stroke RR 0.80, 0.62–1.02, 3 studies; composite outcome RR 0.90, 0.80–1.02, 3 studies). Conclusions: Our results suggest that any of the single antiplatelet agents compared with placebo in the included trials is adequate for secondary stroke prevention after lacunar stroke. Dual antiplatelet therapy should not be used for long-term stroke prevention in this stroke subtype

Frequency of recurrent stroke in Burkina Faso: an observational hospital based study of 6 months

Introduction: studies on stroke recurrence are rare in sub Sahara Africa. The aim to this study is to determine the prevalence and risk factors for recurrent stroke in two University Teaching Hospital in Burkina Faso. Methods: this prospective cross-sectional study was carried on 266 stroke patients admitted in two hospitals in the city of Ouagadougou from September 1, 2017 to February 28, 2018. Patients with stroke recurrence (ischemic or hemorrhagic) were included. Results: of 266 acute stroke patients included, 44(16.4%) had recurrent stroke. The mean age of patients was 66.5 ± 11.49 years with male predominance. Hypertension was the most vascular risk factors (81.8%). Previous stroke was ischemic in 61.4%, hemorrhagic in 22.7% and unknown in 15.9% of cases. Poor compliance (< 60%) was determined in patients taking antiagregant agents (43.6%) and statins (50%). At admission, the most neurological disorders was motor deficit (100%), aphasia (84.1%), and deglutition disorders (15.9%). CT scan showed ischemic in 82% and hemorrhagic stroke in 18% of cases. With the analysis of second stroke, recurrent stroke after intracerebral hemorrhage was hemorrhagic in 77.8% and ischemic in 22.2%. Recurrent stroke after ischemic stroke was ischemic in 100%. Conclusion: stroke recurrence is common in our context. Hypertension was the most common vascular risk factor in recurrent stroke. Poor compliance was determined in patients taking antiagregant agents and statins in previous stroke