Effect of recurrent stroke on poor functional outcome in transient ischemic attack or minor stroke

Background and Purpose: It is still unclear whether the residual cholesterol and inflammatory risk in the acute phase is associated with prognosis of stroke. We aimed to investigate the proportion and relative contribution of residual cholesterol and inflammatory risk, determined by baseline low-density lipoprotein cholesterol (LDL-C) and high-sensitivity C-reactive protein (hsCRP) levels, to the risk of recurrent stroke and poor functional outcome at 1 year. Methods: In this prospective multicenter cohort study, 10 499 consecutive acute ischemic stroke and transient ischemic attack patients with levels of LDL-C and hsCRP were enrolled. Patients were divided into 4 groups: residual cholesterol risk only (LDL-C ≥2.6 mmol/L and hsCRP <3 mg/L), residual inflammatory risk (RIR) only (LDL-C <2.6 mmol/L and hsCRP ≥3 mg/L), both risk (LDL-C ≥2.6 mmol/L and hsCRP ≥3 mg/L), and neither risk (LDL-C <2.6 mmol/L and hsCRP <3 mg/L). The primary outcomes consisted of stroke recurrence and a modified Rankin Scale score of 2 to 6 within 1 year. Results: The relative proportions of patients with RIR only, residual cholesterol risk only, both risk, and neither were 21.3%, 23.7%, 14.4%, and 40.6%, respectively. RIR only was independently associated with recurrent stroke (adjusted hazard ratio, 1.18 [95% CI, 1.00–1.40]; P =0.05). The association was slightly attenuated after further adjusting for usage of antiplatelet agent and statin during 1-year follow-up in addition to the traditional risk factors (hazard ratio, 1.31 [95% CI, 0.99–1.76]; P =0.07). When applying the LDL-C cutoff value of 1.8 mmol/L in the sensitivity analyses, such association in large-artery atherosclerosis subtype was more significant (adjusted hazard ratio, 1.69 [95% CI, 1.06–2.67]; P =0.03). Patients with RIR only also had increased risk of poor functional outcome (adjusted odds ratio, 1.43 [95% CI, 1.24–1.64]; P <0.0001). Conclusions: In the patients with acute ischemic stroke or transient ischemic attack, RIR only could be predictive for recurrent stroke, especially for those with large-artery atherosclerosis, and poor functional outcome.

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Serum Phosphate and 1-Year Outcome in Patients With Acute Ischemic Stroke and Transient Ischemic Attack

Frontiers in Neurology ◽

10.3389/fneur.2021.652941 ◽

2021 ◽

Vol 12 ◽

Author(s):

Jun-Fang Zhang ◽

Jing Jing ◽

Xia Meng ◽

Yuesong Pan ◽

Yi-Long Wang ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Transient Ischemic Attack ◽

Recurrent Stroke ◽

Serum Phosphate ◽

Poor Functional Outcome ◽

End Point ◽

All Cause Mortality ◽

Ischemic Attack

Objective: To determine the association between serum phosphate level and 1-year clinical outcomes in patients with acute ischemic stroke and transient ischemic attack.Methods: We included 7,353 patients with acute ischemic stroke and transient ischemic attack from the China National Stroke Registry III for analysis. Participants were divided into 4 groups according to serum phosphate quartiles. Composite end point included recurrent stroke, myocardial infarction, other ischemic vascular events, and all-cause mortality. Poor functional outcome is defined as modified Rankin Scale score of 3 to 6. Multivariable Cox regression or logistic regression was used to evaluate the independent association of serum phosphate with 1-year all-cause mortality, recurrent stroke, composite end point and poor functional outcome.Results: The mean age of the included 7,353 patients was 62.5 years, and 68.6% of them were men. Plotting hazard ratios over phosphate levels suggested a U-shaped association especially for recurrent stroke and composite end point, and therefore the third quartile group was set as reference group. Compared with the third quartile of phosphate (1.06–1.20 mmol/L), the adjusted hazard ratios/odds ratios (95% CI) of the lowest quartile (<0.94 mmol/L) were 0.98 (0.67–1.42) for all-cause mortality, 1.31 (1.05–1.64) for stroke recurrence, 1.26 (1.02–1.57) for composite end point, and 1.27 (1.01–1.61) for poor functional outcome, and the adjusted odds ratio of the highest quartile (≥1.2 mmol/L) was 1.40 (1.11–1.77) for poor functional outcome.Conclusions: Serum phosphate may be an independent predictor of stroke recurrence, composite end point and poor functional outcome after ischemic stroke.

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Association of Level and Increase in D‐Dimer With All‐Cause Death and Poor Functional Outcome After Ischemic Stroke or Transient Ischemic Attack

Journal of the American Heart Association ◽

10.1161/jaha.120.018600 ◽

2021 ◽

Author(s):

Huiqing Hou ◽

Xianglong Xiang ◽

Yuesong Pan ◽

Hao Li ◽

Xia Meng ◽

...

Keyword(s):

Ischemic Stroke ◽

Functional Outcome ◽

Transient Ischemic Attack ◽

Cox Regression ◽

Poor Functional Outcome ◽

Stroke Registry ◽

Poor Outcomes ◽

Ischemic Attack ◽

High Level ◽

D Dimer

Background D‐dimer is involved in poor outcomes of stroke as a coagulation biomarker. We aimed to investigate the associations of the level and increase in D‐dimer between baseline and 90 days with all‐cause death or poor functional outcome in patients after ischemic stroke or transient ischemic attack. Methods and Results We collected data from the CNSRIII (Third China National Stroke Registry) study. The present substudy included 10 518 patients within 7 days (baseline) of ischemic stroke or transient ischemic attack and 6268 patients at 90 days. Poor functional outcome at 1 year was assessed on the basis of the modified Rankin Scale (≥3). Multivariable Cox regression or logistic regression was used to assess the association of D‐dimer levels with all‐cause death or poor functional outcome. D‐dimer levels at 90 days were lower than those at baseline (1.4 µg/mL versus 1.7 µg/mL; P <0.001). Higher baseline D‐dimer level was associated with all‐cause death (adjusted hazard ratio [HR], 1.77; 95% CI, 1.25–2.52; P =0.001) and poor functional outcome (adjusted odds ratio [OR], 1.49; 95% CI, 1.23–1.80; P <0.001) during 1‐year follow‐up. Higher D‐dimer level at 90 days was also associated with poor outcomes independently. Furthermore, an increase in D‐dimer levels between baseline and 90 days was associated with all‐cause death (since 90 days to 1 year after index event) (adjusted HR, 1.99; 95% CI, 1.12–3.53; P =0.019) but not with poor functional outcome (adjusted OR, 1.08; 95% CI, 0.82–1.41). Conclusions Our study shows that high level and an increase in D‐dimer between baseline and 90 days are associated with poor outcomes in patients after ischemic stroke or transient ischemic attack.

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Abstract 41: Prognostic Value of Perfusion MRI in Patients with Transient Ischemic Attack or Minor Stroke

Stroke ◽

10.1161/str.48.suppl_1.41 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Joon Hwa Lee ◽

Hyunjin Jo ◽

Jihoon Cha ◽

Woo-Keun Seo ◽

Oh Young Bang ◽

...

Keyword(s):

Cardiovascular Event ◽

Transient Ischemic Attack ◽

Recurrent Stroke ◽

Perfusion Mri ◽

Minor Stroke ◽

Secondary Outcome ◽

Stroke Recurrence ◽

Composite Outcome ◽

Stroke Patients ◽

Ischemic Attack

Background and purpose: We aimed to investigate the role of perfusion MRI parameters (TTP: time to peak, CBF: cerebral blood flow, CBV: cerebral blood volume) as a prognostic factor for the risk of stroke recurrence or cardiovascular outcome in patients with transient ischemic attack (TIA) or minor stroke. Methods: We retrospectively reviewed TIA or minor stroke patients who underwent our stroke MRI protocol (DWI, perfusion MRI, and MRA) in a consecutively collected stroke registry. Primary outcome was nonfatal stroke recurrence and secondary outcome was cardiovascular composite outcome. Multivariate analysis was used to examine the association of perfusion MRI parameters and angiographic findings with the risk of stroke recurrence and cardiovascular event. Results: Of the 326 patients who met inclusion criteria, we identified 15(4.6%) nonfatal strokes and 25(7.7%) cardiovascular composite events during the first 1 year after the index TIA or minor stroke. The presence of regional delayed perfusion on TTP maps (p=0.002) and regional hyperperfusion on CBV maps (p<0.001) were associated with recurrent stroke. In MRA images, concomitant stenosis of the intracranial arteries and/or extracranial carotid arteries was associated with cardiovascular events (p=0.009). Using multivariate cox proportional hazard analysis, presence of regional hyperperfusion on CBV remained an independent predictor of recurrent stroke (HR 10.82, 95% CI 4.19-38.67, p<0.001) and cardiovascular event (HR 6.30, 95% CI 2.67-18.25, p<0.001). The AUC of the CBV maps was also greater than other parameters for the prediction of stroke recurrence (AUC=0.701, 95% CI 0.54-0.86) and cardiovascular composite outcome (AUC=0.628, 95% CI 0.50-0.76). Conclusions: Increased CBV on perfusion MRI, representing the hemodynamic status of postischemic hyperperfusion, could be more useful than other perfusion parameters in predicting poor prognosis of TIA or minor stroke patients.

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Recurrent Stroke was Associated with Poor Quality of Life in Patients with Transient Ischemic Attack or Minor Stroke: Finding from the CHANCE Trial

CNS Neuroscience & Therapeutics ◽

10.1111/cns.12329 ◽

2014 ◽

Vol 20 (12) ◽

pp. 1029-1035 ◽

Cited By ~ 18

Author(s):

Yi-Long Wang ◽

Yue-Song Pan ◽

Xing-Quan Zhao ◽

David Wang ◽

S Claiborne Johnston ◽

...

Keyword(s):

Quality Of Life ◽

Transient Ischemic Attack ◽

Recurrent Stroke ◽

Poor Quality ◽

Minor Stroke ◽

Ischemic Attack

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Predicting recurrent stroke after minor stroke and transient ischemic attack

Expert Review of Cardiovascular Therapy ◽

10.1586/erc.09.105 ◽

2009 ◽

Vol 7 (10) ◽

pp. 1273-1281 ◽

Cited By ~ 6

Author(s):

Philippe Couillard ◽

Alexandre Y Poppe ◽

Shelagh B Coutts

Keyword(s):

Transient Ischemic Attack ◽

Recurrent Stroke ◽

Minor Stroke ◽

Ischemic Attack

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Abstract WP56: Refinement of imaging predictors of recurrent events following Transient Ischemic Attack and Minor Stroke.

Stroke ◽

10.1161/str.44.suppl_1.awp56 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Myles Horton

Keyword(s):

White Matter ◽

Transient Ischemic Attack ◽

Recurrent Events ◽

Recurrent Stroke ◽

Initial Assessment ◽

Minor Stroke ◽

White Matter Disease ◽

Ischemic Attack ◽

Symptom Progression ◽

Prior Stroke

Background: Transient ischemic attack (TIA) and minor stroke have a high risk of recurrent stroke. We recently showed in the CATCH study that predefined radiographic abnormalities on CT/CTA and MRI predicted recurrent events after TIA and minor stroke. Specifically, the study recognized the predictive value of CT/CTA abnormalities that were defined apriori: acute ischemia on CT, intracranial or extracranial occlusion or stenosis > 50% (the CT/CTA positive metric), and diffusion-weighted imaging positivity on MRI. Aims: To improve upon the CT, CTA, MRI and clinical parameters that predict recurrent events after TIA and minor stroke. Our secondary aim was to explore predictors of stroke progression versus recurrence. Methods: 510 consecutive TIA and minor stroke patients (NIHSS score of <4) had CT/CTA and most had MRI. Primary outcome was recurrent events (combined outcome of stroke progression or distinct recurrent stroke) within 90 days. Imaging parameters not included in the original CATCH imaging (CT/CTA and MRI) metrics were assessed for prediction of recurrent events. We also completed an exploratory analysis comparing predictors of symptom progression versus recurrence. Results: There were 36 recurrent events (36/510, 7.1% (95%CI: 5.0-9.6)) including 19 progression and 17 recurrent strokes. On CT/CTA: white matter disease, prior stroke, aortic arch focal plaque≥4mm, or intraluminal thrombus did not predict recurrent events. On MRI: white matter disease, prior stroke, and microbleeds did not predict recurrent events. The only additional clinical predictor was symptom fluctuation (hazard ratio 2.3; 95% CI: 1.05-5.0). Parameters predicting symptom progression included: ongoing symptoms at initial assessment, symptom fluctuation, intracranial occlusion, intracranial occlusion or stenosis, and the CT/CTA metric. No parameter was strongly predictive of recurrent stroke. Conclusions: There was no imaging parameter that could improve upon our original CT/CTA or MRI metrics to predict recurrent events after TIA and minor stroke. Only the addition of symptom fluctuation to the CT/CTA metric improved the prediction of recurrent events. Imaging was more predictive of symptom progression than distinct recurrent events.

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CT/CT Angiography and MRI Findings Predict Recurrent Stroke after Transient Ischemic Attack and Minor Stroke: Results of the Prospective CATCH Study

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2012.05.023 ◽

2012 ◽

Vol 43 (1) ◽

pp. 207

Author(s):

Peter Emiley

Keyword(s):

Ct Angiography ◽

Transient Ischemic Attack ◽

Recurrent Stroke ◽

Minor Stroke ◽

Mri Findings ◽

Ischemic Attack

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Hemoglobin Concentration and Clinical Outcomes After Acute Ischemic Stroke or Transient Ischemic Attack

Journal of the American Heart Association ◽

10.1161/jaha.121.022547 ◽

2021 ◽

Author(s):

Runhua Zhang ◽

Qin Xu ◽

Anxin Wang ◽

Yong Jiang ◽

Xia Meng ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Clinical Outcomes ◽

Transient Ischemic Attack ◽

Stroke Recurrence ◽

Vascular Events ◽

Poor Functional Outcome ◽

Ischemic Attack ◽

The Relationship

Background Anemia or low hemoglobin can increase the risk of stroke. However, the association between hemoglobin and outcomes after stroke is uncertain. In this study, we aimed to investigate the association between hemoglobin and clinical outcomes, including mortality, poor functional outcome, stroke recurrence, and composite vascular events at 1 year. Methods and Results We included the patients diagnosed with acute ischemic stroke or transient ischemic attack from the Third China National Stroke Registry. We used the Cox model for mortality, stroke recurrence, and composite vascular events and the logistic model for the poor functional outcome to examine the relationship between hemoglobin and clinical outcomes. In addition, we used the restricted cubic spline to evaluate the nonlinear relationship. This study included 14 159 patients with acute ischemic stroke or transient ischemic attack. After adjusted for potential cofounders, both anemia and high hemoglobin were associated with the higher risk of mortality (hazard ratio [HR], 1.73; 95% CI, 1.39–2.15; HR, 2.71; 95% CI, 1.95–3.76) and poor functional outcome (odds ratio [OR], 1.36; 95% CI, 1.18–1.57; OR, 1.42; 95% CI, 1.07–1.87). High hemoglobin, but not anemia, increased the risk of stroke recurrence (HR, 1.37; 95% CI, 1.05–1.79) and composite vascular events (HR, 1.41; 95% CI, 1.08–1.83). There was a U‐shaped relationship between hemoglobin and mortality and poor functional outcome. Conclusions Abnormal hemoglobin was associated with a higher risk of all‐cause mortality, poor functional outcome, stroke recurrence, and composite vascular events. More well‐designed clinical studies are needed to confirm the relationship between hemoglobin and clinical outcomes after stroke.

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Long-Term Impact of Urgent Secondary Prevention After Transient Ischemic Attack and Minor Stroke: Ten-Year Follow-Up of the EXPRESS Study

Stroke ◽

10.1161/strokeaha.121.034279 ◽

2021 ◽

Author(s):

Ramon Luengo-Fernandez ◽

Linxin Li ◽

Louise Silver ◽

Sergei Gutnikov ◽

Nicola C. Beddows ◽

...

Keyword(s):

Transient Ischemic Attack ◽

Stroke Risk ◽

Recurrent Stroke ◽

Hazard Ratio ◽

Minor Stroke ◽

Phase 2 ◽

Short Term ◽

Ischemic Attack

Background and Purpose: Urgent assessment aimed at reducing stroke risk after transient ischemic attack or minor stroke is cost-effective over the short-term. However, it is unclear if the short-term impact is lost on long-term follow-up, with recurrent events being delayed rather than prevented. By 10-year follow-up of the EXPRESS study (Early Use of Existing Preventive Strategies for Stroke), previously showing urgent assessment reduced 90-day stroke risk by 80%, we determined whether that early benefit was still evident long-term for stroke risk, disability, and costs. Methods: EXPRESS was a prospective population-based before (phase 1: April 2002–September 2004; n=310) versus after (phase 2: October 2004–March 2007; n=281) study of the effect of early assessment and treatment of transient ischemic attack/minor stroke on early recurrent stroke risk, with an external control. This report assesses the effect on 10-year recurrent stroke risk, functional outcomes, quality-of-life, and costs. Results: A reduction in stroke risk in phase 2 was still evident at 10 years (55/23.3% versus 82/31.6%; hazard ratio=0.68 [95% CI, 0.48–0.95]; P =0.024), as was the impact on risk of disabling or fatal stroke (17/7.7% versus 32/13.1%; hazard ratio=0.54 [0.30–0.97]; P =0.036). These effects were due to maintenance of the early reduction in stroke risk, with neither additional benefit nor rebound catch-up after 90 days (post-90 days hazard ratio=0.88 [0.65–1.44], P =0.88; and hazard ratio=0.83 [0.42–1.65], P =0.59, respectively). Disability-free life expectancy was 0.59 (0.03–1.15; P =0.043) years higher in patients in phase 2, as was quality-adjusted life expectancy (0.49 [0.03–0.95]; P =0.036). Overall, 10-year costs were nonsignificantly higher in patients attending the phase 2 clinic ($1022 [-3865–5907]; P =0.66). The additional cost per quality-adjusted life year gained in phase 2 versus phase 1 was $2103, well below current cost-effectiveness thresholds. Conclusions: Urgent assessment and treatment of patients with transient ischemic attack or minor stroke resulted in a long-term reduction in recurrent strokes and improved outcomes, with little atrophy of the early benefit over time, representing good value for money even with a 10-year time horizon. Our results suggest that other effective acute treatments in transient ischemic attack/minor stroke in the short-term will also have the potential to have long-term benefit.

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