Undertreatment of Vascular Risk Factors in Patients with Monocular Ischaemic Visual Loss

Background and Purpose: Ischaemic visual loss is often considered a lower risk factor than other transient ischaemic attacks (TIA). We aimed to determine the recurrence risk, prevalence and management of vascular risk factors in these patients. Methods: The study took place in the University College Hospital London daily TIA clinic, main referral centre for North-Central London and Moorfields Eye Hospital. Consecutive records for patients with transient (< 24 h) or permanent (> 24 h) ischaemic visual loss were reviewed during the period January 2014–October 2016. Patients diagnosed with temporal arteritis were excluded. Results: Of 400 patients, 224 (56%) were male with mean age 64.5 years (SD 15.1); 263 patients (65.8%) presented with transient and 137 patients (34.2%) with permanent ischaemic visual loss; 51.3% had hypertension (HTN), 35.3% hypercholesterolaemia, 14.5% diabetes, 11.8% ischaemic ocular events, 10.0% ischaemic heart disease, 7.3% atrial fibrillation (AF), 6.3% TIA, 5.3% stroke, and 12.3% were smokers. Median vascular risk factors were 2 (range 1–6), but 122 (30.5%) had ≥3. Those with diabetes (p < 0.001), HTN (p = 0.008), previous myocardial infarction (p = 0.005), or ≥3 vascular risk factors (p = 0.012) were more likely to present with permanent visual loss, while patients with history of transient events, TIA (p = 0.002), or ocular (p = 0.002) presented with transient visual loss. Ninety-day recurrence was 10.5%; this was higher in patients with ≥3 risk factors (hazard ratio 1.42, 95% CI 0.95–2.11, p = 0.111). Patients with past TIA were more likely to be on secondary prevention than those with ocular ischaemia; 60.0 vs. 34.1% received antiplatelets and 76.0 vs. 43.9% statins. At presentation, only 55.2% (16 patients) with known AF were anticoagulated, despite all of them having CHADSVASC ≥1. Conclusions: Approximately one-third of patients with ocular ischaemia had ≥3 vascular risk factors with recurrences higher in these patients. Yet only half of those with previous ischaemic ocular events were on antiplatelets or statins. These patients should be investigated and treated as aggressively as other forms of TIA or stroke.

Download Full-text

Abstract WP244: Applicability of the Compass Trial Criteria Among Stable Outpatients With Established Atherothrombotic Disease or Major Risk Factors

Stroke ◽

10.1161/str.51.suppl_1.wp244 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Carlos Cantu-Brito ◽

Erwin Chiquete ◽

Jose L Ruiz-Sandoval ◽

Fernando Flores-Silva

Keyword(s):

Risk Factors ◽

Cerebrovascular Disease ◽

Selection Criteria ◽

Vascular Risk Factors ◽

Cox Proportional Hazards Model ◽

Vascular Risk ◽

Similar Frequency ◽

History Of ◽

Atherothrombotic Disease

Background and Purpose: The objective of this study were to describe the proportion of patients eligible for the COMPASS trial among stable outpatients with either established atherothrombotic disease or major vascular risk factors, and to analyze 6-month incident stroke risk according vascular risk factors at baseline. Methods: We prospectively recruited 5,101 stable outpatients in 172 sites, within the Mexican INDAGA cohort study. Inclusion criteria were age >18 years and established atherothrombotic disease [history of either acute coronary syndromes (ACS), acute ischemic stroke (AIS)/transient ischemic attack (TIA) or peripheral artery disease (PAD)] or major vascular risk factors (age <55 years plus ≥2 major vascular risk factors, or age ≥55 years plus ≥1 vascular risk factors). Among these patients, we applied the selection criteria of the COMPASS trial for analysis, dividing the population in no COMPASS criteria met and COMPASS criteria met, and this last group subdivided among patients with previous AIS/TIA and without this antecedent, in order to stratify the risk for stroke during 6-month follow-up (incident AIS/TIA). Results: Among 5,101 stable outpatients with either established atherothrombotic disease (n=2,827) or major vascular risk factors (n=2,274), a total of 1,927 (37.8%) met COMPASS trial criteria: 1,054 (54.7%) with established cerebrovascular disease (past history of AIS/TIA) and 873 (45.3%) without. During 6-month follow-up, there were 89 incident AIS/TIA (39 AIS and 54 TIA): 1.7% among the whole population and 2.2% among the COMPASS subgroup. AIS/TIA occurred in a similar frequency among the COMPASS subgroup with established cerebrovascular disease (1.6%) and COMPASS without cerebrovascular disease (0.9%) (P=0.18). After a Cox-proportional hazards model, independent predictors of incident AIS/TIA were age ≥65 years (HR: 1.99, 95% CI: 1.29-3.07) and established cerebrovascular disease at baseline (HR: 1.61, 95% CI: 1.02-2.53). Conclusions: The majority of stable outpatients at vascular risk met COMPASS selection criteria and could be good candidates for low-dose rivaroxaban in addition to aspirin. Short-term predictors of AIS/TIA were old age and history of cerebrovascular disease

Download Full-text

Abstract P676: Rates of Preventable Thrombectomy in Acute Ischemic Stroke

Stroke ◽

10.1161/str.52.suppl_1.p676 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Rakhee Lalla ◽

Ryan Dunlow ◽

Karen L Yarbrough ◽

Prachi Mehndiratta ◽

Michael S Phipps ◽

...

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Vascular Disease ◽

Antiplatelet Agent ◽

Left Ventricular ◽

Vascular Risk Factors ◽

Large Vessel ◽

Favorable Outcome ◽

Vascular Risk ◽

History Of

Introduction: The AHA notes that more than 76% of strokes are the first occurrence. There are class 1 recommendations for the management of common risk factors such as atrial fibrillation (AF), hyperlipidemia (HLD), hypertension (HTN), diabetes (DM), and vascular disease. The purpose of this study is to investigate the percentage of large vessel strokes that are potentially preventable with adequate management of vascular risk factors. Methods: A retrospective chart review was conducted on all patients undergoing endovascular therapy (EVT) from 2012-2019. Data was collected on vascular risk factors present prior to admission including HTN, DM, HLD, AF, and smoking. Preventable stroke was defined as having at least one of the following: untreated AF, untreated HLD, poorly controlled HTN (presence of left ventricular hypertrophy on transthoracic echo), history of vascular disease not on an antiplatelet agent, poorly controlled DM (A1c>10), current smoking. Groups were compared based on age, sex and 90 day functional outcomes, with favorable outcome defined as mRS ≤ 2. Results: Our sample included 396 patients who underwent EVT (mean age 65, 50% female). 42% of patients with Afib were not on anticoagulation, 31% of patients with HLD were untreated, 39% of patients with HTN were poorly controlled, 27% of patients with a history of vascular disease were not on an antiplatelet, 14% of patients with DM were poorly controlled, and 46% of all patients were smokers. In total, 78% of patients had at least 1 poorly controlled risk factor and 37% had at least 2. There was no difference in rates of preventable stroke between males and females (48% vs 52%, p=0.30) and between age groups above and below 70 (40% vs 60%, p=0.68). 64% of patients with well controlled risk factors had a favorable outcome compared to 51% with at least one poorly controlled risk factor (p=0.03). Conclusions: Our data suggests that despite guidelines on management of vascular risk factors, a large number of these are poorly controlled prior to admission for large vessel stroke, leading to a potentially preventable procedure. Not only could improved primary prevention save the wide array of resources utilized in EVT, but it could also influence long term outcomes in this cohort of patients.

Download Full-text

Abstract 3358: Sex Differences in Vascular Risk Factors in a Multi-ethnic, Medically Underserved Stroke Population

Stroke ◽

10.1161/str.43.suppl_1.a3358 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Daphne Antillon ◽

Natalie Valle ◽

Kaiwen Lin ◽

Waimei Tai ◽

Mary Ann Gallup ◽

...

Keyword(s):

Risk Factors ◽

Blood Pressure ◽

Sex Differences ◽

Alcohol Abuse ◽

Vascular Risk Factors ◽

Medically Underserved ◽

Vascular Risk ◽

Stroke Patients ◽

Low Hdl ◽

History Of

Background: Recent nationally representative studies of stroke patients have revealed that vascular risk factors are not as aggressively controlled in women compared to men. Medically underserved minority populations are at particularly high risk for poor control of vascular risk factors; however, little is known about sex differences in this population. Methods: Sex-specific vascular risk factors and admission medications were assessed for 440 consecutive ischemic stroke patients (39% female) admitted to a safety-net public hospital in Los Angeles County. Multivariate logistic regression was used to determine sex differences in vascular risk factors, adjusting for age and race. Results: The mean age was 58.9 (SE 10.6) years, 58% were Hispanic, 7% were white, 13% were black, 20% were Asian, and 1% were Native American. Stroke classification (using modified TOAST) revealed the following distribution: 35% small vessel, 20% large vessel, 7% cardioembolic, 23% cryptogenic, 13% >1 possible etiology, and 3% other mechanisms (e.g. drug use). Women had higher mean glycosylated hemoglobin levels than men (8.0% vs 7.4%, p<0.01) and were more likely than men to have a history of type 2 diabetes (49% vs. 40% male, p=0.04), systolic blood pressure > 140 mm Hg (72% vs. 62%, p=0.03), total cholesterol > 200 mg/dL (46% vs. 36%, p=0.04), and low HDL levels (<40 mg/dL for men and <50 mg/dL for women)(83% vs. 79%, p <0.01). Men were more likely than women to have a previous history of stroke (19% vs. 13%, p = 0.05), smoking (49% vs 19%, p<0.01), and alcohol abuse (28% vs. 7%, p<0.01). After adjustment for race and age, women were more likely than men to have total cholesterol > 200 mg/dL (OR 1.56, 95% CI 1.05-2.31), BMI ≥ 30 kg/m 2 (OR 1.55, 95% CI 1.03-2.34), systolic blood pressure >140 mm Hg (OR 1.46, 95% CI 0.96-2.22), low HDL (1.26, 95% CI 0.76-2.08), and triglyceride level > 150 mg/dL (OR 1.09, 95% CI 0.74-1.63); however, the latter 3 were not significant. After adjustment for race and age, men were more likely than women to have a history of smoking (OR 4.54, 95% CI 2.78-7.14) and alcohol abuse (OR 5.56, 95% CI 2.86-11.11). Conclusions: In this multi-ethnic population with inadequate access to care, women are more likely than men to have obesity, hypertension, and dyslipidemia while men are more likely than women to smoke or abuse alcohol. Larger studies are necessary to validate these findings. In the meantime, interventions aimed at reducing the incidence of metabolic syndrome components among women and smoking and alcohol abuse among men in underserved communities are likely warranted.

Download Full-text

A case of recurring Amaurosis Fugax

NATIONAL JOURNAL OF NEUROLOGY ◽

10.28942/nnj.v1i3.188 ◽

2019 ◽

pp. 85-87

Author(s):

Y. Suthahar ◽

J. Blackwell ◽

G. Zachariah ◽

V. Umachandran

Keyword(s):

Risk Factors ◽

Visual Loss ◽

Sudden Onset ◽

Vascular Risk ◽

Amaurosis Fugax ◽

Anti Platelet Therapy ◽

History Of ◽

Ct Head ◽

The Right ◽

Hospital Manager

WW a 43 year old Caucasian Hospital Manager, first presented in July 08 complaining of transient mono-ocular visual loss in the right eye. She described sudden onset loss of vision – ‘like a curtain coming across the vision’. She then proceeded to have similar symptoms in the left eye. There was no history of a subsequent headache. The episode would between 30 seconds and 10 minutes and could occur up to 10 times a day. At times, the attack was also associated with some left arm numbness. She was initially reviewed by Dr Vu [ Stroke Consultant] who diagnosed Amaurosis Fugax and started her on standard anti-platelet therapy [combination of Aspirin and Dypyridamole]. She had very little in terms of vascular risk factors [nil hypertensive, minimal alcohol and a life-long non-smoker with a fasting cholesterol 3.12]. Her PMH history consisted of Gilberts’ Syndrome and endometriosis. She also suffered a DVT following a hysterectomy. Her initial investigations of a CT head and carotid duplex were normal.

Download Full-text

Vascular White Matter Lesions in Young Adults: A Neurology Outpatient Clinic Registry

European Neurology ◽

10.1159/000504409 ◽

2019 ◽

Vol 82 (1-3) ◽

pp. 23-31

Author(s):

Miguel Viana-Baptista ◽

Vera Cruz-e-Silva ◽

André Caetano ◽

João Pedro Marto ◽

Elsa Azevedo ◽

...

Keyword(s):

Risk Factors ◽

Young Adults ◽

White Matter ◽

Genetic Disorder ◽

Previous History ◽

White Matter Lesions ◽

Vascular Risk Factors ◽

Outpatient Clinics ◽

Vascular Risk ◽

History Of

Introduction: Although frequently assumed to be age-related changes, vascular white matter lesions (WML) are sometimes found in young adults. Etiology is usually attributed to sporadic small vessel disease; nevertheless, genetic disorders may also be implicated. We aimed to characterize the population of young adults with vascular WML in Neurology outpatient clinics. Methods: Neurologists from 12 Portuguese hospitals were invited to include patients aged 18–55 years evaluated in consultation, with vascular WML on MRI, scoring II or III in the Fazekas scale. Central imaging validation was performed by 2 independent, blinded, Neuroradiologists. Demographic and clinical data were collected as well as results of investigations performed. Results: During 2 years, 77 patients were included (mean age 47.7 years). Vascular risk factors were present in 88.3% patients (hypertension in 53.2%) and previous history of stroke in 36.4%. Patients without history of stroke were younger (46.6 ± 7.2 vs. 49.6 ± 3.9 years, p = 0.045) and had fewer vascular risk factors (p < 0.001). They were more frequently females (87.8 vs. 46.4%, p < 0.001), and headache (30.6 vs. 3.6%, p = 0.007), contrary to focal symptoms (16.3 vs. 53.6%, p = 0.001), was the most frequent reason of referral. Etiological investigations performed differed between Neurologists. A genetic disorder was identified in 6 out of 58 patients (CADASIL n = 5; COL4A1 n = 1). Conclusion: Young adults with vascular WML evaluated in Neurology outpatient clinics concentrate in the oldest age groups. Vascular risk factors should be screened carefully in this population. Among patients without history of stroke, females largely outweigh males. Diagnostic investigations performed do not follow a standardized protocol.

Download Full-text

Abstract 63: Basilar Artery Occlusion due to Vertebral or Basilar Dissection in the Basilar Artery International Cooperation Study (BASICS)

Stroke ◽

10.1161/str.43.suppl_1.a63 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Gabriel R de Freitas ◽

Stefan T Engelter ◽

Volker Puetz ◽

Wouter J Schonewille

Keyword(s):

Risk Factors ◽

International Cooperation ◽

Basilar Artery ◽

Artery Occlusion ◽

Vascular Risk Factors ◽

Basilar Artery Occlusion ◽

Vascular Risk ◽

Prodromal Symptoms ◽

Poor Outcome ◽

History Of

Introduction: Since there are few reports of patients with stroke secondary to basilar artery occlusion (BAO) due to dissection, there are scarce data on its risk factors, clinical presentation, prognosis and best treatment options. Methods: The Basilar Artery International Cooperation Study (BASICS) was a large prospective, observational registry of consecutive patients who presented with an acute symptomatic BAO. We assessed clinical, radiological and therapeutical data of patients with BAO secondary to radiologically confirmed vertebral or basilar artery dissection. Stroke severity at time of treatment was dichotomized as severe (coma, locked-in state, or tetraplegia) or mild to moderate (any deficit that was less than severe). Outcome was assessed at 1 month. Poor outcome was defined as a modified Rankin scale score of 4 or 5, or death. Patients were divided into three groups according to the treatment they received: antithrombotic treatment only (AT), which comprised antiplatelet drugs or systemic anticoagulation; primary intravenous thrombolysis (IVT), including subsequent intra-arterial thrombolysis; or intra-arterial therapy (IAT), which comprised thrombolysis, mechanical thrombectomy, stenting, or a combination of these approaches. Results: In 32 (5.4%) of 592 patients with BAO, the stroke etiology was dissection. Twenty patients were men, mean age was 45.2 (± 12.7 SD) years. Fourteen patients had no vascular risk factors. Seven patients were current smokers; history of hypertension was present in 4, of dyslipidemia in 4 and other risk factors in 6 patients. Prodromal symptoms (e.g. headache, neck pain, vomiting) were present in 24 patients. History of TIA prior to BAO was recorded in 5 patients and minor stroke in 9. Twenty one patients had a progressive stroke, in 6 symptoms fluctuated and 4 presented with a maximum deficit from onset. Deficits at time of treatment were severe in 22 patients and mild to moderate in 10. Initial CT scan was normal in 9 patients, 13 had a dense basilar sign and 13 presented with early ischemic changes. In most (20) patients the BAO was in the proximal third, in 8 it was located in the distal third and in 4 in the middle third. Eleven patients were treated with only AT (3 antiplatelets, 8 anticoagulation), 9 with IVT and 12 with IA. Three patients- all treated with IA - had symptomatic hemorrhage. Overall, 18 (56%) patients had a poor outcome (AT 9 of 11, IVT 2 of 9, IA 7 of 12, p=0.03, Fisher’s exact test). Conclusions: Dissection is a rare cause of BAO that affects mainly younger patients, with few or no vascular risk factors. Patients often present with prodromal symptoms, and a progressive stroke. Initial CT changes are common and the proximal third of the basilar artery is the main localization of occlusion. As in other causes of BAO, prognosis is poor and in this registry patients treated with IVT had a lower rate of poor outcome.

Download Full-text

Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) – Still to be Considered in the Presence of Vascular Risk Factors

Case Reports in Neurology ◽

10.1159/000507542 ◽

2020 ◽

Vol 12 (Suppl. 1) ◽

pp. 196-201

Author(s):

Dinesh Naidu Ganesan ◽

Thibault Coste ◽

Narayanaswamy Venketasubramanian

Keyword(s):

Risk Factors ◽

White Matter ◽

Autosomal Dominant ◽

Vascular Risk Factors ◽

Smoking History ◽

White Matter Disease ◽

Vascular Risk ◽

Limb Weakness ◽

History Of ◽

The Brain

Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is a rare hereditary vasculopathy that primarily affects the brain, caused mostly by missense mutations of the <i>NOTCH3</i> gene which is located on chromosome 19. Clinically, it manifests as transient ischemic attacks and strokes in individuals under the age of 60 years without vascular risk factors. We report a 46-year-old male with a 9 and 3-month history of progressive unilateral lower limb weakness and dysarthria, respectively. He had a history of diabetes mellitus but no hypertension, hyperlipidemia, or smoking history. Both parents had a stroke at the age of 65 years. Neurological examination was significant for moderate dysarthria and reduced right upper limb dexterity. Magnetic resonance imaging (MRI) of the brain revealed extensive white matter disease, lacunar infarcts, and a few microhemorrhages. Electron microscopy of his skin biopsy showed electron-dense deposits of extracellular osmiophilic granular material adjacent to smooth muscle cells. <i>NOTCH3</i> gene analysis revealed a heterozygous typical mutation in exon 6. He was commenced on aspirin and atorvastatin. Over time, he became more dysarthric and demented. MRI revealed the progression of the white matter disease and a new right subcortical infarct. His aspirin was switched to clopidogrel, and donepezil was added. CADASIL should be considered among younger stroke patients with vascular risk factors, especially in the presence of widespread white matter disease. Genetic counselling may be needed after the diagnosis is made.

Download Full-text

Cognitive impairment and intracranial atherosclerotic stenosis in general population

Neurology ◽

10.1212/wnl.0000000000005250 ◽

2018 ◽

Vol 90 (14) ◽

pp. e1240-e1247 ◽

Cited By ~ 11

Author(s):

M. Fareed K. Suri ◽

Jincheng Zhou ◽

Ye Qiao ◽

Haitao Chu ◽

Adnan I. Qureshi ◽

...

Keyword(s):

Risk Factors ◽

Cognitive Impairment ◽

Expert Panel ◽

Vascular Risk Factors ◽

Vascular Risk ◽

Atherosclerosis Risk In Communities ◽

Intracranial Atherosclerotic Stenosis ◽

Atherosclerotic Stenosis ◽

Atherosclerosis Risk ◽

History Of

ObjectiveTo investigate the association between asymptomatic intracranial atherosclerosis and cognitive impairment in the Atherosclerosis Risk in Communities (ARIC) cohort.MethodsARIC participants underwent high-resolution 3T magnetic resonance angiography and a neuropsychology battery and neurologic examination adjudicated by an expert panel to detect mild cognitive impairment (MCI) and dementia. We adjusted for demographic and vascular risk factors in weighted logistic regression analysis, accounting for stratified sampling design and attrition, to determine the association of intracranial atherosclerotic stenosis (ICAS) with cognitive impairment.ResultsIn 1,701 participants (mean age 76 ± 5.3, 41% men, 71% whites, 29% blacks) with adequate imaging quality and no history of stroke, MCI was identified in 578 (34%) and dementia in 79 (4.6%). In white participants, after adjustment for demographic and vascular risk factors, ICAS ≥50% (vs no ICAS) was strongly associated with dementia (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.7–10.0) and with any cognitive impairment (OR 1.7, 95% CI 1.1–2.8). In contrast, no association was found between ICAS ≥50% and MCI or dementia in blacks, although the sample size was limited and estimates were imprecise.ConclusionOur results suggest that asymptomatic ICAS is independently associated with cognitive impairment and dementia in whites.

Download Full-text

Acute Cerebrovascular Events in Hospitalized COVID-19 Patients

Stroke ◽

10.1161/strokeaha.120.030995 ◽

2020 ◽

Vol 51 (9) ◽

Cited By ~ 19

Author(s):

Aaron Rothstein ◽

Olivia Oldridge ◽

Hannah Schwennesen ◽

David Do ◽

Brett L. Cucchiara

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Significant Risk ◽

The United States ◽

Vascular Risk Factors ◽

Vascular Risk ◽

Stroke Incidence ◽

Cerebrovascular Events ◽

History Of

Background and Purpose: Initial reports suggest a significant risk of thrombotic events, including stroke, in patients hospitalized with coronavirus disease 2019 (COVID-19). However, there is little systematic data on stroke incidence and mechanisms, particularly in racially diverse populations in the United States. Methods: We performed a retrospective, observational study of stroke incidence and mechanisms in all patients with COVID-19 hospitalized from March 15 to May 3, 2020, at 3 Philadelphia hospitals. Results: We identified 844 hospitalized patients with COVID-19 (mean age 59 years, 52% female, 68% Black); 20 (2.4%) had confirmed ischemic stroke; and 8 (0.9%) had intracranial hemorrhage. Of the ischemic stroke patients, mean age was 64 years, with only one patient (5%) under age 50, and 80% were Black. Conventional vascular risk factors were common, with 95% of patients having a history of hypertension and 60% a history of diabetes mellitus. Median time from onset of COVID symptoms to stroke diagnosis was 21 days. Stroke mechanism was cardioembolism in 40%, small vessel disease in 5%, other determined mechanism in 20%, and cryptogenic in 35%. Of the 11 patients with complete vascular imaging, 3 (27%) had large vessel occlusion. Newly positive antiphospholipid antibodies were present in >75% of tested patients. Of the patients with intracranial hemorrhage, 5/8 (63%) were lobar intraparenchymal hemorrhages, and 3/8 (38%) were subarachnoid hemorrhage; 4/8 (50%) were on extracorporeal membrane oxygenation. Conclusions: We found a low risk of acute cerebrovascular events in patients hospitalized with COVID-19. Most patients with ischemic stroke had conventional vascular risk factors, and traditional stroke mechanisms were common.

Download Full-text