Neurologists and stroke physicians will be familiar with atrial fibrillation as a major cause of ischaemic stroke, and the role of anticoagulation in preventing cardioembolic stroke. However, making ...decisions about anticoagulation for individual patients remains a difficult area of clinical practice, balancing the serious risk of ischaemic stroke against that of major bleeding, particularly intracranial haemorrhage. Atrial fibrillation management requires interdisciplinary collaboration with colleagues in cardiology and haematology. Recent advances, especially the now-widespread availability of direct oral anticoagulants, have brought opportunities to improve stroke care while posing new challenges. This article gives an overview of the contemporary diagnosis and management of atrial fibrillation, and the associated evidence base. Where there is uncertainty, we describe our own approach to these areas, while highlighting ongoing research that will likely guide future practice.
Almost half of ischemic strokes in young individuals are cryptogenic. Thrombophilia testing is routinely sent despite limited evidence linking to arterial cerebrovascular events. A full blood count ...may identify underlying hematological disorder.
We retrospectively reviewed all patients younger than 60 years with stroke and transient ischemic attack (TIA) presenting to a regional hyperacute stroke unit and daily TIA clinic from January 2015 to August 2016. We examined hematocrit level and platelet count, and whether abnormalities were further investigated. We examined if primary hematological disorders associated with stroke were considered, specifically myeloproliferative diseases (MPDs) and thrombotic thrombocytopenic purpura (TTP).
Of 609 patients who presented with stroke or TIA, there were 161 abnormalities in hematocrit level or platelet count in 153 patients (25.1%). One hundred sixteen patients had high hematocrit levels (19%), 19 had thrombocytosis (3.1%), 26 had thrombocytopenia (4.3%), and 8 had abnormalities in both lineages (1.3%). A total of 119 patients had repeat testing (74%). Molecular investigations for MPD were warranted in 19 patients (3.1%), performed in 3 patients (.5%) with 2 patients subsequently diagnosed. ADAMTS13 analysis was indicated in 10 patients with thrombocytopenia, performed in 2 patients with 1 diagnosed with TTP thereafter.
One quarter of our cohort (n = 153) had abnormalities in hematocrit and/or platelets. MPD or TTP was present in 3 of the 5 patients specifically investigated. At least 22 patients (14%) merited further investigation. Although primary hematological disorders are rare in stroke aetiology, the full blood count is important to exclude known causes of arterial cerebrovascular events in young patients.
Introduction: Atrial fibrillation (AF) is a major cause of ischemic stroke and Transient Ischemic Attack (TIA) and investigation for paroxysmal AF is recommended following an embolic brain event. In ...contrast, retinal ischemic monocular blindness is traditionally considered most linked to carotid artery disease (CAS) and investigating for AF is less vigilant. We aimed to determine the prevalence of AF in patients with ischemic monocular blindness. Methods: Consecutive records of all patients presenting to a daily TIA clinic with transient or permanent ischemic monocular blindness were reviewed, January 2014-October 2016. Results: Of 400 patients, 224 (56.0%) were male, mean age 64.5 years (SD 15.1). A total of 263 (66%) presented with transient and 137 (34%) with permanent ischemic monocular blindness. ECG was performed in 364 patients (91%) but only 211 (52%) had further cardiac monitoring. The vast majority (97.3%) had carotid imaging. Thirty-six patients (9%) were found to have AF while 53 (14%) had ipsilateral CAS. Median ABCD2 score was 1 in AF and non-AF groups. Only 55% of known AF patients were anticoagulated at presentation, despite all having CHADVASC2 score greater than or equal to 1. Patients with AF had more hypertension (P = .004), previous TIA (P = .002), previous stroke (P = .044) and ischemic heart disease (P = .022) with no difference in age (P = .791), diabetes (P = .563), smoking (P = .460) nor hypercholesterolaemia (P = .083). Conclusions: A total of 9% of patients with ischemic monocular blindness had AF. This is an underestimate, as only 53% of patients had prolonged cardiac monitoring. Known AF was suboptimally managed with only 55% receiving anticoagulation despite being eligible.
Most guidelines now recommend that patients with minor stroke or high-risk transient ischemic attack (TIA) are assessed within 24 hours of their event, but the feasibility of this depends on ...patients' behavior. We studied behavior immediately after TIA and minor stroke according to clinical characteristics, patients' perception of the nature of the event, and their predicted stroke risk.
In a population-based study in Oxfordshire, UK, with face-to-face interview of 1000 consecutive patients with TIA and minor stroke (National Institutes of Health Stroke Scale < or =5) from 2002 to 2007 (Oxford Vascular Study), we studied delay in seeking medical attention and identified patients who did not seek attention after an initial event and only presented after a recurrent stroke.
Of 1000 patients (459 TIAs, 541 minor strokes), 300 (67%) with TIA and 400 (74%) with minor stroke sought medical attention within 24 hours and 208 (47%) and 234 (46%), respectively, sought attention within 3 hours. Most patients (77%) first sought attention through their primary care physician. In patients with TIA, incorrect recognition of symptoms, absence of motor or speech symptoms, shorter duration of event, lower ABCD(2) score, no history of stroke or atrial fibrillation, and weekend presentation were associated with significantly longer delays. However, age, sex, social class, and educational level were all unrelated to either correct recognition of symptoms or to delay in seeking attention. Of 129 patients with TIA or minor stroke who had a recurrent stroke within 90 days, 41 (31%) did not seek medical attention after their initial event. These patients were more likely to have had a TIA (P=0.003), shorter duration of event (P=0.02), and a history of TIA (P=0.09) and less likely to have had motor (P=0.004) or speech symptoms (P=0.04) compared with those patients who sought medical attention for their initial event.
Approximately 70% of patients do not correctly recognize their TIA or minor stroke, 30% delay seeking medical attention for >24 hours, regardless of age, sex, social class, or educational level, and approximately 30% of early recurrent strokes occur before seeking attention. Without more effective public education of all demographic groups, the full potential of acute prevention will not be realized.
Differentiating between peripheral and central causes of acute vertigo remains a clinical obstacle in the acute setting. Despite the availability of several validated diagnostic algorithms adoption ...and implementation of these tools is low because most emergency physicians are unfamiliar with them. Embedding an acute vertigo service within the emergency setting may help improve the diagnostic workup of patients presenting with this specific symptomatology and may have significant economic benefits, such as the avoidance of hospital admissions, reduction in unnecessary investigations, and decrease in length of hospital stay. In this work, we present four patients who were referred to the acute vertigo service at University College London Hospital (UCLH) for review. We discuss the indications for and limitations of implementing such a service.
Diagnosing atrial fibrillation (AF) in patients following Cryptogenic stroke (CS) has therapeutic implications that can reduce the risk of further strokes. However, it's indolent and paroxysmal ...nature makes this challenging. Prolonged rhythm monitoring using implantable loop recorders (ILRs) can significantly increase the AF detection rate in the clinical trial paradigm. Whether this can be translated to real-world practice is unknown. An evaluation of referral pathways, workload and real-world efficacy may help select patients and inform service development.
Retrospective review of all patients with CS referred to a tertiary electrophysiology referral hospital for ILR implantation between February 2017 and October 2020 for AF detection was conducted. The electronic health record was used to determine demographic and mortality data. Remote monitoring was used to identify AF occurrence.
107 patients were included. The average time from stroke to ILR implantation was 10.5 (5.9–18.6) months. The average monitoring duration was 18.1 ± 11.2 months with 15 (14.0%) patients diagnosed with AF and commenced on anticoagulation. One diagnosis were made in the first 30 days whereas 11 (73%) were made within 12 months. Paroxysmal AF episodes ranged from 6 min to 13 h. Patients with CHA2DS2-VASc >3 were more likely to have AF (20.3% vs 4.7%, p = 0.02). Age was independently associated with AF detection after multi-variate regression. 352 ± 1171 unique events were recorded per patient, 75% of which were for suspected AF. External manufacturer-led triage of transmissions reduced transmission volume by 33%.
ILR-based AF detection rate was high among referred CS patients, despite implantation occurring relatively late. Older patients may be less likely to be referred despite positive correlation between age and AF detection. Although recording algorithms and external triage reduced transmission volume, specialist analysis was required to manage the ILR event burden.
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.
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.
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.
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.
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.
•Diagnosis and antithrombotic treatment of antiphospholipid syndrome–associated acute ischemic stroke are poorly defined.•An international survey to define current practice was performed.•Antiphospholipid antibody testing strategy and antithrombotic treatment lack uniformity.•The survey results could inform a more uniform multidisciplinary consensus approach.
IntroductionApproximately 40% of strokes in young adults are cryptogenic. The diagnostic yield of thrombophilia screening remains controversial. We aimed to determine utility of current thrombophilia ...testing for young patients with stroke and transient ischaemic attack (TIA).MethodsWe present a retrospective review of all patients with stroke and TIA ≤60 years presenting to University College London Hospital stroke unit and daily TIA clinic from 1 January 2015 to 1 August 2016. Consecutive clinical records and thrombophilia tests, including factor V Leiden (FVL), prothrombin G20210A mutation (PGM), antiphospholipid antibody (APA), and protein S, C and antithrombin (AT) levels, were reviewed.ResultsThe mean age of 628 patients with stroke and TIA was 49.1 years (SD 9.2). Thrombophilia testing was performed in 360 (57%) patients, including 171 with stroke and 189 with TIA. Positive tests were found in 50 (14%) patients, of whom 24 patients were <50 years. Positive results were found in 36 (10%) with acute ischaemic stroke, 4 (1%) with haemorrhagic stroke and 10 (3%) with TIA. Thirteen patients (4%) had homozygous/heterozygous FVL or PGM, and 27 (7.5%) had positive APA (anticardiolipin antibody, anti-β2 glycoprotein antibody or lupus anticoagulant). Of 27 (7.5%) patients with protein C, S or AT deficiency, 10 (2.8%) had primary deficiency, presumed hereditary with other secondary causes excluded. 9% of patients with protein C, S or AT and 27% with APA were followed by confirmatory testing.ConclusionThrombophilia testing was positive in only 14% of cases overall. Thrombophilia mutations and protein C, S or AT abnormalities were found rarely and were very uncommon in patients with TIA. Follow-up of abnormal results was generally poor for all groups, which further limited the impact of the thrombophilia testing policy.
Objective To assess the influence of general practice opening hours on healthcare seeking behaviour after transient ischaemic attack (TIA) and minor stroke and feasibility of clinical assessment ...within 24 hours of symptom onset.Design Population based prospective incidence study (Oxford vascular study).Setting Nine general practices in Oxfordshire.Participants 91 000 patients followed from 1 April 2002 to 31 March 2006.Main outcome measures Events that occurred overnight and at weekends (out of hours) and events that occurred during surgery hours.Results Among 359 patients with TIA and 434 with minor stroke, the median (interquartile range) time to call a general practitioner after an event during surgery hours was 4.0 (1.0-45.5) hours, and 68% of patients with events during surgery hours called within 24 hours of onset of symptoms. Median (interquartile range) time to call a general practitioner after events out of hours was 24.8 (9.0-54.5) hours for patients who waited to contact their registered practice compared with 1.0 (0.3-2.6) hour in those who used an emergency general practitioner service (P<0.001). In patients with events out of hours who waited to see their own general practitioner, seeking attention within 24 hours was considerably less likely for events at weekends than weekdays (odds ratio 0.10, 95% confidence interval 0.05 to 0.21): 70% with events Monday to Friday, 33% on Sundays, and none on Saturdays. Thirteen patients who had events out of hours and did not seek emergency care had a recurrent stroke before they sought medical attention. A primary care centre open 8 am-8 pm seven days a week would have offered cover to 73 patients who waited until surgery hours to call their general practitioner, reducing median delay from 50.1 hours to 4.0 hours in that group and increasing those calling within 24 hours from 34% to 68%.Conclusions General practitioners’ opening hours influence patients’ healthcare seeking behaviour after TIA and minor stroke. Current opening hours can increase delay in assessment. Improved access to primary care and public education about the need for emergency care are required if the relevant targets in the national stroke strategy are to be met.
Optimal secondary prevention antithrombotic therapy for patients with antiphospholipid syndrome (APS)-associated ischemic stroke, transient ischemic attack, or other ischemic brain injury is ...undefined. The standard of care, warfarin or other vitamin K antagonists at standard or high intensity (international normalized ratio (INR) target range 2.0-3.0/3.0-4.0, respectively), has well-recognized limitations. Direct oral anticoagulants have several advantages over warfarin, and the potential role of high-dose direct oral anticoagulants vs high-intensity warfarin in this setting merits investigation.
The Rivaroxaban for Stroke patients with APS trial (RISAPS) seeks to determine whether high-dose rivaroxaban could represent a safe and effective alternative to high-intensity warfarin in adult patients with APS and previous ischemic stroke, transient ischemic attack, or other ischemic brain manifestations.
This phase IIb prospective, randomized, controlled, noninferiority, open-label, proof-of-principle trial compares rivaroxaban 15 mg twice daily vs warfarin, target INR range 3.0-4.0. The sample size target is 40 participants. Triple antiphospholipid antibody-positive patients are excluded. The primary efficacy outcome is the rate of change in brain white matter hyperintensity volume on magnetic resonance imaging, a surrogate marker of presumed ischemic damage, between baseline and 24 months follow-up. Secondary outcomes include additional neuroradiological and clinical measures of efficacy and safety. Exploratory outcomes include high-dose rivaroxaban pharmacokinetic modeling.
Should RISAPS demonstrate noninferior efficacy and safety of high-dose rivaroxaban in this APS subgroup, it could justify larger prospective randomized controlled trials.
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