One in six ischaemic stroke patients has an embolic stroke of undetermined source (ESUS), defined as a stroke with unclear aetiology despite recommended diagnostic evaluation. The overall ...cardiovascular risk of ESUS is high and it is important to optimize strategies to prevent recurrent stroke and other cardiovascular events. The aim of clinicians when confronted with a patient not only with ESUS but also with any other medical condition of unclear aetiology is to identify the actual cause amongst a list of potential differential diagnoses, in order to optimize secondary prevention. However, specifically in ESUS, this may be challenging as multiple potential thromboembolic sources frequently coexist. Also, it can be delusively reassuring because despite the implementation of specific treatments for the individual pathology presumed to be the actual thromboembolic source, patients can still be vulnerable to stroke and other cardiovascular events caused by other pathologies already identified during the index diagnostic evaluation but whose thromboembolic potential was underestimated. Therefore, rather than trying to presume which particular mechanism is the actual embolic source in an ESUS patient, it is important to assess the overall thromboembolic risk of the patient through synthesis of the individual risks linked to all pathologies present, regardless if presumed causally associated or not. In this paper, a multi-disciplinary panel of clinicians/researchers from various backgrounds of expertise and specialties (cardiology, internal medicine, neurology, radiology and vascular surgery) proposes a comprehensive multi-dimensional assessment of the overall thromboembolic risk in ESUS patients through the composition of individual risks associated with all prevalent pathologies.
Stroke of undetermined aetiology or 'cryptogenic' stroke accounts for 30-40% of ischaemic strokes despite extensive diagnostic evaluation. The role and yield of cardiac imaging is controversial. ...Cardiac MRI (CMR) has been used for cardiac disorders, but its use in cryptogenic stroke is not well established. We reviewed the literature (randomised trials, exploratory comparative studies and case series) on the use of CMR in the diagnostic evaluation of patients with ischaemic stroke. The literature on the use of CMR in the diagnostic evaluation of ischaemic stroke is sparse. However, studies have demonstrated a potential role for CMR in the diagnostic evaluation of patients with cryptogenic stroke to identify potential aetiologies such as cardiac thrombi, cardiac tumours, aortic arch disease and other rare cardiac anomalies. CMR can also provide data on certain functional and structural parameters of the left atrium and the left atrial appendage which have been shown to be associated with ischaemic stroke risk. CMR is a non-invasive modality that can help identify potential mechanisms in cryptogenic stroke and patients who may be targeted for enrolment into clinical trials comparing anticoagulation to antiplatelet therapy in secondary stroke prevention. Prospective studies are needed to compare the value of CMR as compared to transthoracic and transesophageal echocardiography in the diagnostic evaluation of cryptogenic stroke.
Abstract only Background: A 2004 report from two trials of carotid endarterectomy (CEA) indicated that its benefit was greatest when performed within 2 weeks of stroke onset. In 2006, the AHA ...recommended that carotid revascularization generally occur within 2 weeks of stroke. Hypothesis: Since 2005, the time between stroke and CEA or carotid artery stenting (CAS) has decreased and the proportion of patients undergoing CEA or CAS within 2 weeks has increased. Methods: Using administrative claims data from all nonfederal hospitals in CA, FL, and NY, we identified patients hospitalized with ischemic stroke between 2005 and 2012. We excluded those who did not undergo CEA or CAS within 90 days of admission for the index stroke. When stroke and CEA/CAS were documented in the same hospitalization, we included only strokes coded as present on admission so as to exclude periprocedural strokes in previously asymptomatic patients. All diagnoses and procedures were identified using previously validated ICD-9-CM codes. Our outcomes were the number of days between stroke and CEA/CAS and the proportion of patients who underwent CEA/CAS within the recommended 2-week period. Temporal trends were assessed using nonparametric correlation, chi-square test for trend, and logistic regression. Results: We identified 14,414 patients with ischemic stroke who underwent CEA or CAS within 90 days. The median (interquartile range IQR) number of days from stroke to CEA/CAS decreased from 25 (5-48) in 2005 to 6 (3-24) in 2012 (P <0.001; Figure 1A). The proportion of patients who underwent CEA/CAS within 2 weeks of stroke increased from 40.1% in 2005 to 69.9% in 2012 (P <0.001; Figure 1B). The temporal trends in both outcomes were significant even after adjustment for patient demographics, state of residence, and comorbidities. Conclusions: Since 2005, revascularization for symptomatic carotid disease has been progressively occurring sooner after presentation with stroke.
Abstract only Introduction: Flares of inflammatory bowel disease (IBD) have been associated with venous thromboembolism, and recent studies suggest an association between IBD and myocardial ...infarction. The association between IBD flares and cerebral thrombotic disease is less clear. We therefore sought to evaluate the risk of cerebral venous and arterial stroke during IBD flares. Hypothesis: IBD flares are associated with an increased risk of a cerebral thrombotic event. Methods: We used data on all admissions at nonfederal acute care hospitals in California, Florida, and New York to identify patients with a primary ICD-9-CM diagnosis code for ulcerative colitis or Crohn’s disease between 2005 and 2012. Patients with a documented abdominal surgery during the index hospitalization were excluded. An IBD flare was defined as a period of 120 days from the start of the index IBD-related hospitalization. Our outcomes were ischemic stroke and cerebral venous sinus thrombosis. We used a self-controlled case series design in which we compared the risk of a thrombotic event in the 120 days after hospitalization versus the risk during the 120 days prior to hospitalization. Results: We identified 31,993 patients with IBD, of whom 98 (0.31%) developed ischemic stroke. As compared with the control period preceding the index hospitalization, the risk of stroke was significantly elevated during the 120 days after IBD-related hospitalization (incidence rate ratio IRR 2.0; 95% confidence interval CI 1.3-3.0). In subgroup analyses, this elevated risk was apparent only in the 16,280 patients older than the median age of 44 years (IRR 1.9; 95% CI, 1.27-2.95), and not in the 15,713 patients younger than 44 years of age, among whom we identified only one stroke. We found only one patient with a documented venous sinus thrombosis and thus could not estimate the risk associated with an IBD flare. Conclusion: We found an association between IBD-related hospitalization and the risk of ischemic stroke in older patients. These results build on recent studies suggesting an association between IBD and the risk of arterial thrombotic events. Further research is needed to better define the association between IBD and cerebrovascular events, especially rare events such as cerebral sinus thrombosis.
Abstract only Background: Recent studies suggest that traumatic brain injury (TBI) is a risk factor for subsequent ischemic stroke, even years after the initial insult. The mechanisms of the ...association remain unclear. Hypothesis: The presence of traumatic subarachnoid hemorrhage (tSAH) may mediate the effect of TBI on long-term stroke risk, as it has previously been linked to short-term vasospasm and delayed cerebral ischemia. Methods: Using administrative claims data, we conducted a retrospective cohort study of acute care hospitalizations. Patients discharged with a first-recorded diagnosis of tSAH were followed for a primary diagnosis of stroke. They were matched to patients with TBI but no tSAH, based on age, sex, race, insurance status, income, admission year, coronary heart disease, hypertension, diabetes, congestive heart failure, peripheral vascular disease, chronic kidney disease, chronic obstructive pulmonary disease, atrial fibrillation, alcohol abuse, and tobacco use. Cox proportional hazards modeling was used to assess the association between tSAH and stroke while adjusting for covariates. Results: We identified 34,302 patients with TBI (17,151 patients with tSAH matched to 17,151 patients with non-tSAH TBI) who were followed for a mean of 3.2 ± 1.8 years. Overall, 481 of 34,302 patients with TBI (1.40%; 95% confidence interval CI, 1.28-1.53%) experienced an ischemic stroke after discharge. There was no significant difference in stroke risk between those with tSAH (1.92%; 95% CI, 1.61-2.27%) as compared to no tSAH (2.08%; 95% CI, 1.78-2.44%). The same pattern was found in adjusted analyzes (hazard ratio HR, 0.86; 95% CI 0.70-1.06). This held true even when the group was stratified by age group or by proxies of TBI severity such as mechanical ventilation or discharge disposition during the index hospitalization for TBI. Conclusion: Recent data shows a protracted risk of ischemic stroke following TBI. Our findings do not support a role of vasospasm from tSAH in mediating this association. Further study is required to elucidate the mechanisms of long-term increased stroke risk after TBI
OBJECTIVETo estimate the risk of intracerebral hemorrhage (ICH) recurrence in a large, diverse, US-based population and to identify racial/ethnic and socioeconomic subgroups at higher risk.
METHODSWe ...performed a longitudinal analysis of prospectively collected claims data from all hospitalizations in nonfederal California hospitals between 2005 and 2011. We used validated diagnosis codes to identify nontraumatic ICH and our primary outcome of recurrent ICH. California residents who survived to discharge were included. We used log-rank tests for unadjusted analyses of survival across racial/ethnic groups and multivariable Cox proportional hazards regression to determine factors associated with risk of recurrence after adjusting for potential confounders.
RESULTSWe identified 31,355 California residents with first-recorded ICH who survived to discharge, of whom 15,548 (50%) were white, 6,174 (20%) were Hispanic, 4,205 (14%) were Asian, and 2,772 (9%) were black. There were 1,330 recurrences (4.1%) over a median follow-up of 2.9 years (interquartile range 3.8). The 1-year recurrence rate was 3.0% (95% confidence interval CI 2.8%–3.2%). In multivariable analysis, black participants (hazard ratio HR 1.22; 95% CI 1.01–1.48; p = 0.04) and Asian participants (HR 1.29; 95% CI 1.10–1.50; p = 0.001) had a higher risk of recurrence than white participants. Private insurance was associated with a significant reduction in risk compared to patients with Medicare (HR 0.60; 95% CI 0.50–0.73; p < 0.001), with consistent estimates across racial/ethnic groups.
CONCLUSIONSBlack and Asian patients had a higher risk of ICH recurrence than white patients, whereas private insurance was associated with reduced risk compared to those with Medicare. Further research is needed to determine the drivers of these disparities.
Background and purpose
There is growing recognition that chronic liver conditions influence brain health. The impact of liver fibrosis on dementia risk was unclear. We evaluated the association ...between liver fibrosis and incident dementia in a cohort study.
Methods
We performed a cohort analysis using data from the UK Biobank study, which prospectively enrolled adults starting in 2007, and continues to follow them. People with a Fibrosis‐4 (FIB‐4) liver fibrosis score >2.67 were categorized as at high risk of advanced fibrosis. The primary outcome was incident dementia, ascertained using a validated approach. We excluded participants with prevalent dementia at baseline. We used Cox proportional hazards models to evaluate the association between liver fibrosis and dementia while adjusting for potential confounders.
Results
Among 455,226 participants included in this analysis, the mean age was 56.5 years and 54% were women. Approximately 2.17% (95% confidence interval CI 2.13%–2.22%) had liver fibrosis. The rate of dementia per 1000 person‐years was 1.76 (95% CI 1.50–2.07) in participants with liver fibrosis and 0.52 (95% CI 0.50–0.54) in those without. After adjusting for demographics, socioeconomic deprivation, educational attainment, metabolic syndrome, hypertension, diabetes, dyslipidemia, and tobacco and alcohol use, liver fibrosis was associated with an increased risk of dementia (hazard ratio 1.52, 95% CI 1.22–1.90). Results were robust to sensitivity analyses. Effect modification by sex, metabolic syndrome, and apolipoprotein E4 carrier status was not observed.
Conclusion
Liver fibrosis in middle age was associated with an increased risk of incident dementia, independent of shared risk factors. Liver fibrosis may be an underrecognized risk factor for dementia.
In a retrospective cohort analysis of approximately 450,000 participants in the UK Biobank study, individuals with high probability of advanced liver fibrosis had a 1.5‐fold higher risk of incident dementia. Results were consistent after accounting for potential confounders and were robust to multiple sensitivity analyses and approaches. These findings suggest that liver fibrosis may detrimentally impact future cognitive health.
Factors associated with external ventricular catheter tract hemorrhage (CTH) are well studied; whether CTH adversely influence outcomes after intracerebral hemorrhage (sICH), however, is poorly ...understood. We therefore sought to evaluate the association between CTH and sICH outcomes.
We performed a post hoc analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage trial. The exposure was CTH and evaluated on serial computed tomography scans between admission and randomization (approximately 72 hours). The primary outcomes were a composite of death or major disability (modified Rankin Score >3) and mortality alone, both assessed at 6 months. Secondary outcomes were functional outcomes at 30 days, permanent cerebrospinal fluid (CSF) shunt placement, any infection, and ventriculitis. We performed logistic regression adjusted for demographics, comorbidities, sICH characteristics, and treatment assignment, for all analyses.
Of the 500 patients included, the mean age was 59 (SD, ±11) years and 222 (44%) were female. CTH occurred in 112 (22.4%) patients and was more common in minority patients, those on prior antiplatelet therapy, and patients who had more than 1 external ventricular drain placed. The end of treatment intraventricular hemorrhage volume was higher among patients with CTH (11.7 vs 7.9 mL, P = .01), but there were no differences in other sICH characteristics or the total duration of external ventricular drain. In multivariable regression models, CTH was not associated with death or major disability (odds ratio, 0.7; 95% CI: 0.4-1.2) or death alone (odds ratio, 0.8; 95% CI, 0.5-1.4). There were no relationships between CTH and secondary outcomes including 30-day functional outcomes, permanent CSF shunt placement, any infection, or ventriculitis.
Among patients with sICH and large intraventricular hemorrhage, CTH was not associated with poor sICH outcomes, permanent CSF shunt placement, or infections. A more detailed cognitive evaluation is needed to inform about the role of CTH in sICH prognosis.
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