Small vessel occlusion is a high-risk etiology for early recurrent stroke after transient ischemic attack

Background Recent prospective registration studies of transient ischemic attack in Western countries demonstrated that large artery atherosclerosis is the highest risk etiology for early stroke recurrence under urgent evaluation and treatment. On the other hand, some limited transient ischemic attack studies from East Asian countries showed transient ischemic attack patients due to small vessel occlusion were at a higher early stroke risk. Aims We aimed to assess the risk for early stroke in small vessel occlusion-transient ischemic attack patients in a Japanese large transient ischemic attack registry. Methods We analyzed the data of a prospective Japanese transient ischemic attack registry including 1320 transient ischemic attack patients within seven days after onset. Small vessel occlusion-transient ischemic attack was defined as the presence of lacunar transient ischemic attack syndrome, without other etiologies. The outcome measure was recurrent stroke within 30 days after transient ischemic attack. The predictors of 30-day recurrent stroke were estimated using the Cox proportional hazards model. Results The study population had a mean age of 69 ± 12 years and 470 were women. Recurrent stroke was observed in 61 patients (4.6%), and the highest rate was observed with small vessel occlusion-transient ischemic attack (7.8%), followed by large artery atherosclerosis (5.4%). In multivariate analysis, recurrent stroke was independently associated with small vessel occlusion-transient ischemic attack (hazard ratio (HR): 2.01, 95% confidence interval (CI): 1.19–3.35), higher systolic blood pressure (HR: 1.18, 95% CI: 1.08–1.28), and presentation within 3 h after onset (HR: 2.21, 95% CI: 1.27–4.04). Furthermore, small vessel occlusion-transient ischemic attack with acute small deep infarct on diffusion-weighted imaging was a stronger predictor of recurrent stroke (HR: 4.87, 95% CI: 2.09–10.0). Conclusion Small vessel occlusion-transient ischemic attack, especially with acute small deep infarct, had a higher early stroke risk compared with other etiologies in Japanese transient ischemic attack patients who received early management.

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Abstract TMP20: Small Vessel Occlusion is a High Risk Etiology of Early Recurrent Stroke After Transient Ischemic Attack

Stroke ◽

10.1161/str.49.suppl_1.tmp20 ◽

2018 ◽

Vol 49 (Suppl_1) ◽

Author(s):

Tomoyuki Ohara ◽

Toshiyuki Uehara ◽

Rieko Suzuki ◽

Shoichiro Sato ◽

Mikito Hayakawa ◽

...

Keyword(s):

High Risk ◽

Transient Ischemic Attack ◽

Recurrent Stroke ◽

Small Vessel ◽

Vessel Occlusion ◽

Ischemic Attack

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Why do transient ischemic attack patients have higher early stroke recurrence risk than those with ischemic stroke? Influence of patient behavior and other risk factors in the North Dublin Population Stroke Study

International Journal of Stroke ◽

10.1177/1747493016669851 ◽

2016 ◽

Vol 12 (1) ◽

pp. 96-104 ◽

Cited By ~ 3

Author(s):

Layan Akijian ◽

Danielle Ní Chróinín ◽

Elizabeth Callaly ◽

Niamh Hannon ◽

Michael Marnane ◽

...

Keyword(s):

Risk Factors ◽

Transient Ischemic Attack ◽

Recurrent Stroke ◽

Recurrence Risk ◽

Medical Attention ◽

Stroke Recurrence ◽

The North ◽

Stroke Study ◽

Ischemic Attack ◽

Early Stroke

Background Few studies have directly compared stroke recurrence rates after stroke and transient ischemic attack, and the risk factors underlying early recurrence are poorly understood. We aimed to investigate risk factors for recurrent stroke after first stroke and transient ischemic attack in a population-based study. Methods The North Dublin Population Stroke Study applied multiple overlapping hot and cold pursuit methods, to ascertain hospital- and community-treated stroke and transient ischemic attack patients over a 12-month period. Inclusion criteria were: (1) Stroke-physician confirmed transient ischemic attack/ischemic stroke; (2) first-stroke/transient ischemic attack event within the ascertainment period. Patients were prospectively followed at 72 h, 7, 28 and 90 days. Results A total of 584 patients met eligibility criteria (172 transient ischemic attack, 412 stroke). More transient ischemic attack than stroke patients presented to medical attention with recurrent stroke (8.24% vs. 0.24%, p = 0.0002). Recurrent stroke was more common after transient ischemic attack than index stroke at each time-interval (at 72 h, 4.07% vs. 1.23%, p = 0.03; at 90 days, 13.45% vs. 5.72%, p = 0.002). Stroke recurrence at 90 days was also associated with delay seeking medical attention after the index event (OR 3.2, p = 0.001), delayed anti-platelet (OR 2.8, p = 0.001) and statin (OR 2.4, p = 0.009) treatment, carotid stenosis/occlusion (OR 2.4, p = 0.008). On multivariable analysis, transient ischemic attack as index event (adjusted OR 2.3, p = 0.02), delayed statin treatment (OR 2.5, p = 0.02), and carotid stenosis/occlusion (OR 2.4, p = 0.02) were independent predictors of 90-day recurrent stroke. Conclusion A combination of pathophysiological and behavioral factors was associated with early stroke recurrence risk. Improved public awareness to reduce delays to self-referral for transient ischemic attack symptoms is needed.

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Early Stroke Risk after Transient Ischemic Attack in Patients without Large-Artery Disease or Atrial Fibrillation

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2015.03.039 ◽

2015 ◽

Vol 24 (7) ◽

pp. 1656-1661 ◽

Cited By ~ 4

Author(s):

Tomoyuki Ohara ◽

Toshiyuki Uehara ◽

Kazunori Toyoda ◽

Rieko Suzuki ◽

Shoichiro Sato ◽

...

Keyword(s):

Atrial Fibrillation ◽

Transient Ischemic Attack ◽

Stroke Risk ◽

Large Artery ◽

Artery Disease ◽

Ischemic Attack ◽

Early Stroke

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Validation of CSR model to predict stroke risk after transient ischemic attack

Scientific Reports ◽

10.1038/s41598-021-04405-2 ◽

2022 ◽

Vol 12 (1) ◽

Author(s):

Lu Zhao ◽

Shuang Cao ◽

Lulu Pei ◽

Hui Fang ◽

Hao Liu ◽

...

Keyword(s):

Transient Ischemic Attack ◽

Predictive Value ◽

Stroke Risk ◽

Recurrent Stroke ◽

Predictive Ability ◽

Roc Curves ◽

World Health ◽

Stroke Recurrence ◽

C Statistic ◽

Ischemic Attack

AbstractIt is essential to identify high risk transient ischemic attack (TIA) patients. The previous study reported that the CSR (comprehensive stroke recurrence) model, a neuroimaging model, had a high predictive ability of recurrent stroke. The aims of this study were to validate the predictive value of CSR model in TIA patients and compare the predictive ability with ABCD3-I score. Data were analyzed from the prospective hospital-based database of patients with TIA which defined by the World Health Organization time-based criteria. The predictive outcome was stroke occurrence at 90 days. The receiver-operating characteristic (ROC) curves were plotted and the C statistics were calculated as a measure of predictive ability. Among 1186 eligible patients, the mean age was 57.28 ± 12.17 years, and 474 (40.0%) patients had positive diffusion-weighted imaging (DWI). There were 118 (9.9%) patients who had stroke within 90 days. In 1186 TIA patients, The C statistic of CSR model (0.754; 95% confidence interval [CI] 0.729–0.778) was similar with that of ABCD3-I score (0.717; 95% CI 0.691–0.743; Z = 1.400; P = 0.1616). In 474 TIA patients with positive DWI, C statistic of CSR model (0.725; 95% CI 0.683–0.765) was statistically higher than that of ABCD3-I score (0.626; 95% CI 0.581–0.670; Z = 2.294; P = 0.0245). The CSR model had good predictive value for assessing stroke risk after TIA, and it had a higher predictive value than ABCD3-I score for assessing stroke risk for TIA patients with positive DWI.

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2014 Chinese guidelines for secondary prevention of ischemic stroke and transient ischemic attack

International Journal of Stroke ◽

10.1177/1747493017694391 ◽

2017 ◽

Vol 12 (3) ◽

pp. 302-320 ◽

Cited By ~ 24

Author(s):

Yongjun Wang ◽

Ming Liu ◽

Chuanqiang Pu

Keyword(s):

Ischemic Stroke ◽

Secondary Prevention ◽

Transient Ischemic Attack ◽

Recurrent Stroke ◽

Stroke Recurrence ◽

Evidence Based ◽

Cerebrovascular Disorder ◽

Level Of Evidence ◽

Vascular Stenosis ◽

Ischemic Attack

Ischemic stroke and transient ischemic attack (TIA) are the most common cerebrovascular disorder and leading cause of death in China. The Effective secondary prevention is the vital strategy for reducing stroke recurrence. The aim of this guideline is to provide the most updated evidence-based recommendation to clinical physicians from the prior version. Control of risk factors, intervention for vascular stenosis/occlusion, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke are all recommended, and the prevention of recurrent stroke in a variety of uncommon causes and subtype provided as well. We modified the level of evidence and recommendation according to part of results from domestic RCT in order to facility the clinical practice.

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Abstract TP438: Japanese versus Non-Japanese Patients With Transient Ischemic Attack or Minor Stroke: Five-Year Risk of Stroke and Vascular Events

Stroke ◽

10.1161/str.51.suppl_1.tp438 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Shinichiro Uchiyama ◽

Takao Hoshino ◽

Hugo Charles ◽

Kenji Kamiyama ◽

Taizen Nakase ◽

...

Keyword(s):

Intracranial Hemorrhage ◽

Transient Ischemic Attack ◽

Japanese Patients ◽

Minor Stroke ◽

Stroke Recurrence ◽

Large Artery ◽

Vascular Events ◽

Minor Ischemic Stroke ◽

Ischemic Attack

Background: We have reported 5-year risk of stroke and vascular events after a transient ischemic attack (TIA) or minor ischemic stroke in patients enrolled into the TIAregistry.org, which was an international multicenter-cooperative, prospective registry (N Engl J Med 2018;378:2182-90). We conducted subanalysis on the 5-year follow-up data of Japanese patients in comparison with non-Japanese patients. Methods: The patients were classified into two groups on ethnicity, Japanese (n=345) and non-Japanese (n=3502), and their 5-year event rates were compared. We also determined predictors of five-year stroke in both groups. Results: Death from vascular cause (0.9% vs 2.7%, HR 0.28, 95% CI 0.09-0.89, p=0.031) and death from any cause (7.8% vs 9.9%, HR 0.67, 95% CI 0.45-0.99, p=0.045) were fewer in Japanese patients than in non-Japanese patients, while stroke (13.9% vs 7.2%, HR 1.78, 95% CI 1.31-2.43, p<0.001) and intracranial hemorrhage (3.2% vs 0.8%, HR 3.61. 95% CI 1.78-7.30, p<0.001) were more common in Japanese than non-Japanese patients during five-year follow-up period. Caplan-Meyer curves at five-years showed that the rates of stroke was also significantly higher in Japanese than non-Japanese patients (log-rank test, p=0.001). Predictors for stroke recurrence at five years were large artery atherosclerosis (HR 1.81, 95% CI 1.31-2.52, p<0.001), cardioembolism (HR 1.71, 95% CI 1.18-2.47, p=0.004), multiple acute infarction (HR 1.77, 95% CI 1.27-2.45, p<0.001) and ABCD 2 score 6 or 7 (HR 1.96, 95% CI 1.38-2.78, p<0.001) in non-Japanese patients, although only large artery atherosclerosis (HR 3.28, 95% CI 1.13-9.54, p=0.029) was a predictor for stroke recurrence in Japanese patients. Conclusions: Recurrence of stroke and intracranial hemorrhage were more prevalent in Japanese than non-Japanese patients. Large artery atherosclerosis was a predictor for stroke recurrence not only in non-Japanese patients but also in Japanese patients.

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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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Abstract WP49: Distal Hyperintense Vessels Were not a Predictor of Large Vessel Occlusion in Patients With Transient Ischemic Attack

Stroke ◽

10.1161/str.47.suppl_1.wp49 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Marcelo M de Figueiredo ◽

Marcela R Vazzoller ◽

Edson Amaro Jr ◽

Renata A Miranda ◽

Gisele S Silva

Keyword(s):

Transient Ischemic Attack ◽

Surrogate Marker ◽

Multivariate Logistic Regression Analysis ◽

Clinical Information ◽

Large Vessel ◽

Arterial Stenosis ◽

Large Artery ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Ischemic Attack

Introduction: Distal hyperintense vessels (DHV) detected by FLAIR imaging are not uncommon in patients with acute ischemic stroke. The presence of DHV and its predictors has been scarcely evaluated in patients with transient ischemic attack (TIA), being associated to the presence of large vessel occlusion in such patients. We assessed the hypothesis that DHV are frequent in patients with TIA and do correlate with relevant clinical and neuroimaging characteristics. Methods: We evaluated a database of consecutive patients admitted with TIA from February 2009 to June 2012 who had undergone magnetic resonance imaging within 30 h of symptoms onset and intracranial and extracranial vascular imaging. We analyzed the relationship between DHV, clinical presentation, risk factors, neuroimaging characteristics and large artery stenosis or occlusion. DHV signals were defined on FLAIR images as focal, linear or serpentine, hyperintense signals relative to gray matter. Two neuroradiologists blinded to clinical information reached consensus regarding the presence of DHV. Results: Seventy-two TIA patients were enrolled. The median time from symptoms onset to MRI was 8:39 h [4:21, 14:13]. DHV signals on FLAIR images were present in 12 (16.7 %) patients. The overall agreement between examiners was good (k 0.67). Patients with DHV had more atrial fibrillation (AF) than those without (41.7% versus 21.7%, p=0.05) and a trend towards more congestive heart failure (CHF) (8.3% versus 1.7%, p=0.2) and diabetes (41.7% versus 21.7%, p=0.1). There were no differences in the frequency of intracranial or cervical arterial stenosis, cerebral microbleeds and white matter abnormalities in patients with and without DHV. In a multivariate logistic regression analysis, only AF had a trend to be a predictor of DHV (OR=4.24, p=0.1). The statistical model to predict DHV including AF, diabetes, and CHF had a moderate fit in terms of discrimination (c statistic=0.62) Conclusion: DHV signals on FLAIR images occur in patients with TIA and might correlate with clinical variables like AF and not only with large vessel occlusion as previously described. The presence of DVH in patients with TIA and AF might be a surrogate marker for a previous large vessel occlusion spontaneously recanalized.

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Validation of the Essen Stroke Risk Score and the Stroke Prognosis Instrument II in Chinese Patients

Stroke ◽

10.1161/strokeaha.111.624148 ◽

2011 ◽

Vol 42 (12) ◽

pp. 3619-3620 ◽

Cited By ~ 11

Author(s):

Xia Meng ◽

Yilong Wang ◽

Xingquan Zhao ◽

Chunxue Wang ◽

Hao Li ◽

...

Keyword(s):

Risk Score ◽

Transient Ischemic Attack ◽

Stroke Risk ◽

Predictive Accuracy ◽

Recurrent Stroke ◽

Chinese Patients ◽

Vascular Events ◽

Ischemic Attack ◽

Event Rates ◽

Prognostic Instrument

Background and Purpose— Little was known about the predictive accuracy of the Essen Stroke Risk Score and the Stroke Prognostic Instrument II in Chinese patients with stroke. Methods— We evaluated the predictive accuracy of both Essen Stroke Risk Score and Stroke Prognostic Instrument II scores for both recurrent stroke and combined vascular events using data from a prospective cohort of 11 384 patients with acute ischemic stroke and transient ischemic attack admitted to 132 urban hospitals throughout China. Results— The cumulative 1-year event rates were 16% (95% CI, 15%–16%) for recurrent stroke and 18% (95% CI, 18%–19%) for combined vascular events. Both event rates were significantly higher in patients with transient ischemic attack and increased significantly from lower to higher Essen Stroke Risk Score and Stroke Prognostic Instrument II categories. Essen Stroke Risk Score and Stroke Prognostic Instrument II had similar predictive accuracies for each study outcome. Conclusions— In Chinese patients with ischemic stroke or transient ischemic attack, both Essen Stroke Risk Score and Stroke Prognostic Instrument II scores are equally able to stratify the risk of recurrent stroke and combined vascular events.

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