Risks of Stroke Recurrence and Mortality After First and Recurrent Strokes in Denmark: A Nationwide Registry Study

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000013118
Author(s):  
Nils Skajaa ◽  
Kasper Adelborg ◽  
Erzsébet Horváth-Puhó ◽  
Kenneth J Rothman ◽  
Victor W. Henderson ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Risk Score ◽  
Recurrent Stroke ◽  
Recurrent Event ◽  
Risk Scores ◽  
Stroke Recurrence ◽  
Stroke Severity ◽  
Risk Of Death ◽  
First Time

Background and Objectives:To examine risks of stroke recurrence and mortality after first and recurrent stroke.Methods:Using Danish nationwide health registries, we included patients (age ≥18 years) with first-time ischemic stroke (N = 105,397) or intracerebral hemorrhage (N = 13,350) during 2004–2018. Accounting for the competing risk of death, absolute risks of stroke recurrence were computed separately for each stroke subtype and within strata of age groups, sex, stroke severity, body mass index, smoking, alcohol, the Essen stroke risk score, and atrial fibrillation. Mortality risks were computed after first and recurrent stroke.Results:After adjusting for competing risks, the overall 1-year and 10-year risks of recurrence were 4% and 13% following first-time ischemic stroke and 3% and 12% following first-time intracerebral hemorrhage. For ischemic stroke, the risk of recurrence increased with age, was higher for men and following mild than more severe stroke. The most marked differences were across Essen risk scores, for which recurrence risks increased with increasing scores. For intracerebral hemorrhage, risks were similar for both sexes and did not increase with Essen risk score. For ischemic stroke, the 1-year and 10-year risks of all-cause mortality were 17% and 56% after a first-time stroke and 25% and 70% after a recurrent stroke; corresponding estimates for intracerebral hemorrhage were 37% and 70% after a first-time event and 31% and 75% after a recurrent event.Conclusion:The risk of stroke recurrence was substantial following both subtypes, but risks differed markedly among patient subgroups. The risk of mortality was higher after a recurrent than first-time stroke.

scholarly journals A Nomogram for Predicting Stroke Recurrence Among Young Adults

Stroke ◽  
2020 ◽  
Vol 51 (6) ◽  
pp. 1865-1867
Author(s):  
Kang Yuan ◽  
Jingjing Chen ◽  
Pengfei Xu ◽  
Xiaohao Zhang ◽  
Xiuqun Gong ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Young Adults ◽  
Ischemic Stroke ◽  
High Risk ◽  
Smoking Status ◽  
Recurrent Stroke ◽  
Risk Groups ◽  
Risk Scores ◽  
Stroke Recurrence ◽  
Large Artery

Background and Purpose— This study aimed to develop and validate a nomogram for predicting the risk of stroke recurrence among young adults after ischemic stroke. Methods— Patients aged between 18 and 49 years with first-ever ischemic stroke were selected from the Nanjing Stroke Registry Program. A stepwise Cox proportional hazards regression model was employed to develop the best-fit nomogram. The discrimination and calibration in the training and validation cohorts were used to evaluate the nomogram. All patients were classified into low-, intermediate-, and high-risk groups based on the risk scores generated from the nomogram. Results— A total of 604 patients were enrolled in this study. Hypertension (hazard ratio [HR], 2.038 [95% CI, 1.504–3.942]; P =0.034), diabetes mellitus (HR, 3.224 [95% CI, 1.848–5.624]; P <0.001), smoking status (current smokers versus nonsmokers; HR, 2.491 [95% CI, 1.304–4.759]; P =0.006), and stroke cause (small-vessel occlusion versus large-artery atherosclerosis; HR, 0.325 [95% CI, 0.109–0.976]; P =0.045) were associated with recurrent stroke. Educational years (>12 versus 0–6; HR, 0.070 [95% CI, 0.015–0.319]; P =0.001) were inversely correlated with recurrent stroke. The nomogram was composed of these factors, and successfully stratified patients into low-, intermediate-, and high-risk groups ( P <0.001). Conclusions— The nomogram composed of hypertension, diabetes mellitus, smoking status, stroke cause, and education years may predict the risk of stroke recurrence among young adults after ischemic stroke.

Abstract TP176: Stroke Recurrence Among South Asians With diabetes in Ontario, Canada

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Mandip S Dhamoon ◽  
Limei Zhou ◽  
Melissa Stamplecoski ◽  
Moira K Kapral ◽  
Baiju R Shah
Keyword(s):  
Ischemic Stroke ◽  
South Asian ◽  
Recurrent Stroke ◽  
South Asians ◽  
Population Based ◽  
Competing Risk ◽  
Stroke Recurrence ◽  
Risk Of Death ◽  
Patients With Diabetes ◽  
Competing Risk Models

Introduction: South Asians have earlier cardiovascular disease onset and higher stroke mortality than non-South Asians, but disparities in long-term outcomes after stroke in patients with diabetes are not well described. We compared risk of cardiovascular outcomes after first ischemic stroke between South Asian and non-South Asian patients with diabetes. Hypothesis: We hypothesized that South Asian stroke patients with diabetes were younger and had higher stroke recurrence, even accounting for competing risk of death. Methods: Using population-based health care databases in Ontario, Canada, we selected all patients with diabetes hospitalized with first ischemic stroke between April 1, 2002 and March 31, 2012, and assigned South Asian vs. non-South Asian ethnicity using a validated surname algorithm. Kaplan-Meier survival analysis and competing risk models estimated risk of death, stroke, and myocardial infarction. The primary predictor was ethnicity; models were adjusted for demographics and vascular risk factors. Sensitivity analysis including adjustment for medication use was performed in those aged >=65 years. Results: There were 25495 diabetics with first ischemic stroke; 840 were South Asian and were younger, more often male, had lower income, and had shorter Ontario residency compared to non-South Asians. South Asians had higher incidence and cumulative risk of recurrent stroke (Figure). In adjusted competing risk models, recurrent stroke risk was increased among South Asians compared to non-South Asians (HR 1.17 [95% CI 1.00-1.38]) in the whole cohort and in those aged >=65 years, both with adjustment for medication use (HR 1.23 [1.01-1.50]) and without (1.27 [1.04-1.54]). Conclusions: In this large population-based study, South Asian stroke patients with diabetes had higher recurrent stroke risk compared to non-South Asians, despite younger age. Further research and targeted interventions are needed to reduce stroke burden in South Asians.

scholarly journals WMH and long-term outcomes in ischemic stroke

Neurology ◽  
2019 ◽  
Vol 92 (12) ◽  
pp. e1298-e1308 ◽  
Author(s):  
Marios K. Georgakis ◽  
Marco Duering ◽  
Joanna M. Wardlaw ◽  
Martin Dichgans
Keyword(s):  
Ischemic Stroke ◽  
Functional Impairment ◽  
Recurrent Stroke ◽  
Meta Analysis ◽  
Sensitivity Analyses ◽  
Stroke Recurrence ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Increased Risk

ObjectiveTo investigate the relationship between baseline white matter hyperintensities (WMH) in patients with ischemic stroke and long-term risk of dementia, functional impairment, recurrent stroke, and mortality.MethodsFollowing the Meta-analysis of Observational Studies in Epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO protocol: CRD42018092857), we systematically searched Medline and Scopus for cohort studies of ischemic stroke patients examining whether MRI- or CT-assessed WMH at baseline are associated with dementia, functional impairment, recurrent stroke, and mortality at 3 months or later poststroke. We extracted data and evaluated study quality with the Newcastle–Ottawa scale. We pooled relative risks (RR) for the presence and severity of WMH using random-effects models.ResultsWe included 104 studies with 71,298 ischemic stroke patients. Moderate/severe WMH at baseline were associated with increased risk of dementia (RR 2.17, 95% confidence interval [CI] 1.72–2.73), cognitive impairment (RR 2.29, 95% CI 1.48–3.54), functional impairment (RR 2.21, 95% CI 1.83–2.67), any recurrent stroke (RR 1.65, 95% CI 1.36–2.01), recurrent ischemic stroke (RR 1.90, 95% CI 1.26–2.88), all-cause mortality (RR 1.72, 95% CI 1.47–2.01), and cardiovascular mortality (RR 2.02, 95% CI 1.44–2.83). The associations followed dose-response patterns for WMH severity and were consistent for both MRI- and CT-defined WMH. The results remained stable in sensitivity analyses adjusting for age, stroke severity, and cardiovascular risk factors, in analyses of studies scoring high in quality, and in analyses adjusted for publication bias.ConclusionsPresence and severity of WMH are associated with substantially increased risk of dementia, functional impairment, stroke recurrence, and mortality after ischemic stroke. WMH may aid clinical prognostication and the planning of future clinical trials.

White Matter Hyperintensities Improve Ischemic Stroke Recurrence Prediction

2016 ◽  
Vol 43 (1-2) ◽  
pp. 17-24 ◽  
Author(s):  
Søren Due Andersen ◽  
Torben Bjerregaard Larsen ◽  
Anders Gorst-Rasmussen ◽  
Yousef Yavarian ◽  
Gregory Y.H. Lip ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Risk Score ◽  
White Matter Hyperintensities ◽  
Stroke Risk ◽  
Risk Scores ◽  
Stroke Recurrence ◽  
Cerebral White Matter ◽  
Clinical Scores ◽  
Recurrence Prediction

Background: Nearly one in 5 patients with ischemic stroke will invariably experience a second stroke within 5 years. Stroke risk stratification schemes based solely on clinical variables perform only modestly in non-atrial fibrillation (AF) patients and improvement of these schemes will enhance their clinical utility. Cerebral white matter hyperintensities are associated with an increased risk of incident ischemic stroke in the general population, whereas their association with the risk of ischemic stroke recurrence is more ambiguous. In a non-AF stroke cohort, we investigated the association between cerebral white matter hyperintensities and the risk of recurrent ischemic stroke, and we evaluated the predictive performance of the CHA2DS2VASc score and the Essen Stroke Risk Score (clinical scores) when augmented with information on white matter hyperintensities. Methods: In a registry-based, observational cohort study, we included 832 patients (mean age 59.6 (SD 13.9); 42.0% females) with incident ischemic stroke and no AF. We assessed the severity of white matter hyperintensities using MRI. Hazard ratios stratified by the white matter hyperintensities score and adjusted for the components of the CHA2DS2VASc score were calculated based on the Cox proportional hazards analysis. Recalibrated clinical scores were calculated by adding one point to the score for the presence of moderate to severe white matter hyperintensities. The discriminatory performance of the scores was assessed with the C-statistic. Results: White matter hyperintensities were significantly associated with the risk of recurrent ischemic stroke after adjusting for clinical risk factors. The hazard ratios ranged from 1.65 (95% CI 0.70-3.86) for mild changes to 5.28 (95% CI 1.98-14.07) for the most severe changes. C-statistics for the prediction of recurrent ischemic stroke were 0.59 (95% CI 0.51-0.65) for the CHA2DS2VASc score and 0.60 (95% CI 0.53-0.68) for the Essen Stroke Risk Score. The recalibrated clinical scores showed improved C-statistics: the recalibrated CHA2DS2VASc score 0.62 (95% CI 0.54-0.70; p = 0.024) and the recalibrated Essen Stroke Risk Score 0.63 (95% CI 0.56-0.71; p = 0.031). C-statistics of the white matter hyperintensities score were 0.62 (95% CI 0.52-0.68) to 0.65 (95% CI 0.58-0.73). Conclusions: An increasing burden of white matter hyperintensities was independently associated with recurrent ischemic stroke in a cohort of non-AF ischemic stroke patients. Recalibration of the CHA2DS2VASc score and the Essen Stroke Risk Score with one point for the presence of moderate to severe white matter hyperintensities led to improved discriminatory performance in ischemic stroke recurrence prediction. Risk scores based on white matter hyperintensities alone were at least as accurate as the established clinical risk scores in the prediction of ischemic stroke recurrence.

Abstract WMP58: Blacks Have Higher Risk of 1-Year Recurrent Ischemic Stroke: An Analysis of White and Black Medicare Beneficiaries 1999-2013

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Karen C Albright ◽  
Lei Huang ◽  
Justin Blackburn ◽  
George Howard ◽  
Michael Mullen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Racial Differences ◽  
Stroke Risk ◽  
Recurrent Stroke ◽  
The United States ◽  
Stroke Recurrence ◽  
Fee For Service ◽  
Age Group ◽  
Medicare Beneficiaries ◽  
Risk Of Death

Introduction: Blacks have a higher incidence of stroke compared with whites. Most stroke survivors in the United States are 65 years and older but few data are available on racial differences in recurrent stroke risk in this age group. Methods: We conducted a retrospective cohort of Medicare beneficiaries in the 5% sample from 1999-2013 to compare 1-year recurrent stroke risk in older black and white Americans following hospitalization for ischemic stroke. We studied beneficiaries with Medicare fee-for-service coverage for 182 days before the index stroke hospitalization with no claims for stroke-related events. Patients were divided into two age groups (66-74, 75 years and above) and stratified into 3 calendar periods (1999-2001, 2002-2006, 2007-2013) allowing for implementation of secondary stroke prevention trial findings (PROGRESS, 2001; SPARCL, 2006). Hazard ratios for recurrent ischemic stroke comparing blacks to whites were calculated with adjustment for demographics, risk factors, and the competing risk of death. Results: Of 128,789 ischemic stroke patients (mean age 80 years [SD 8], 11.1% black, 60.4% male), 7.8% of whites and 11.0% of blacks had a recurrent ischemic stroke overall (Table 1). For each time period, blacks had a higher risk of recurrent stroke compared with whites (Figure 1). This disparity increased over time among patients age 66-74 years (p=0.038) but no trend was present for those 75 years and above (p=0.301). Conclusion: The risk of stroke recurrence among older Americans hospitalized for ischemic stroke is higher for blacks than whites, regardless of age group.

scholarly journals Recurrent stroke in midlife is associated with not having a primary care physician

Neurology ◽  
2019 ◽  
Vol 92 (6) ◽  
pp. e560-e566 ◽  
Author(s):  
Rebecca J. Lank ◽  
Lynda D. Lisabeth ◽  
Brisa N. Sánchez ◽  
Darin B. Zahuranec ◽  
Kevin A. Kerber ◽  
...  
Keyword(s):  
Primary Care ◽  
Ischemic Stroke ◽  
Primary Care Physician ◽  
Recurrent Stroke ◽  
Recurrence Risk ◽  
Care Physician ◽  
Recurrent Event ◽  
Sensitivity Analyses ◽  
Stroke Recurrence ◽  
Stroke Patients

ObjectiveTo determine using a population-based study whether midlife stroke patients having a primary care physician (PCP) at the time of first stroke have a lower risk of stroke recurrence and mortality than those who do not have a PCP.MethodsFirst-ever ischemic stroke patients 45 to 64 years of age at stroke onset were ascertained through the Brain Attack Surveillance in Corpus Christi (BASIC) project from 2000 to 2013 in Texas. Cox proportional hazards models were used to examine the association between not having a PCP and stroke recurrence or all-cause mortality in separate models. Cases were followed up for up to 5 years or until December 31, 2013, whichever came first. Cases were censored for recurrence if they died before experiencing a recurrent event. We adjusted for clinical risk factors that could be associated with having a PCP and recurrence or mortality.ResultsThere were 663 first-occurrence ischemic stroke cases. Of these, 77% had a PCP, 43% were female, and average age was 55.6 years. Five-year recurrence risk was 14.6%, and mortality risk was 19.2%. Not having a PCP was associated with higher recurrence risk (adjusted hazard ratio 1.75, 95% confidence interval 1.02–3.02). Having a PCP was not associated with mortality. Sensitivity analyses showed that results were robust to different ways to adjust for chronic conditions.ConclusionThis study found lower rates of stroke recurrence among those with a PCP at the time of first stroke. Future studies could determine the value of establishing a PCP before stroke hospital discharge for secondary stroke prevention.

Abstract WP400: Causes of Death in a Longitudinal Analysis of Spontaneous Intracerebral Hemorrhage Survivors

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Lindsey R Kuohn ◽  
Audrey C Leasure ◽  
Julian N Acosta ◽  
Kevin N Vanent ◽  
Santosh B Murthy ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Longitudinal Analysis ◽  
Causes Of Death ◽  
Primary Diagnosis ◽  
Spontaneous Intracerebral Hemorrhage ◽  
Risk Of Death ◽  
History Of ◽  
First Time

Introduction: With improvements in acute care, more patients are surviving a first-time spontaneous intracerebral hemorrhage (ICH). In the growing survivor population, little is known about effective secondary stroke prevention strategies or long-term causes of illness and death. This study aims to determine the cause of death in first-time ICH survivors. Methods: We performed a longitudinal analysis of prospectively collected claims data. We used data collected on all hospitalizations from California (2005-2011) and New York (2005-2014). State residents admitted with a primary diagnosis of non-traumatic ICH (ICD-9-CM code 431) who survived to discharge were included in the study. Patients were followed for a primary outcome of any readmission event resulting in death. Cause of death was defined as the primary diagnosis assigned at discharge. Kaplan-Meier survival analysis was used to estimate the risk of in-hospital death during follow-up. Cox proportional hazards and multinomial logistic regression were used to determine factors associated with the risk and cause for death. Subgroup analyses stratified by a history of atrial fibrillation (AF) were performed. Results: Of 56,593 identified ICH survivors (mean age 69 [SD 15], 49% female), 6,931 (14%) died during a median follow-up period of 3.6 years (IQR 1.5-5.9). The one-year risk of death was 7% (95% CI 7.0-7.4) and the median time to death was 0.7 years (IQR 0.1-2.3). Patients who died were older (74 vs. 68, p<0.001) and more likely to have history of AF (24% vs. 16%, p<0.001), congestive heart disease (15% vs. 8%, p<0.001), and diabetes (32% vs. 26%, p<0.001). The leading causes of death were infection (29%), recurrent ICH (12%), cardiac causes (8%), respiratory failure (7%), and ischemic stroke (4%). Patients with AF were at an increased the risk of death from ischemic stroke (OR 2.04, 95% CI 1.56-2.68, p<0.001) and cardiac causes (OR 1.49, 95% CI 1.19-1.87, p=0.002) compared to those without AF. Conclusions: The leading causes of inpatient death in ICH survivors are infection, recurrent ICH, and cardiac causes while survivors with AF are at an elevated risk for death by recurrent stroke. These findings may represent interventional targets in the effort to extend improved outcomes in ICH survivors.

scholarly journals Racial differences in recurrent ischemic stroke risk and recurrent stroke case fatality

Neurology ◽  
2018 ◽  
Vol 91 (19) ◽  
pp. e1741-e1750 ◽  
Author(s):  
Karen C. Albright ◽  
Lei Huang ◽  
Justin Blackburn ◽  
George Howard ◽  
Michael Mullen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Racial Differences ◽  
Recurrent Stroke ◽  
Case Fatality ◽  
Stroke Recurrence ◽  
Adjusted Relative Risk ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Day Case ◽  
Risk Of Death

ObjectiveTo determine black-white differences in 1-year recurrent stroke and 30-day case fatality after a recurrent stroke in older US adults.MethodsWe conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries with fee-for-service health insurance coverage who were hospitalized for ischemic stroke between 1999 and 2013. Hazard ratios for recurrent ischemic stroke and risk ratios for 30-day case fatality comparing blacks to whites were calculated with adjustment for demographics, risk factors, and competing risk of death when appropriate.ResultsAmong 128,789 Medicare beneficiaries having an ischemic stroke (mean age 80 years [SD 8 years], 60.4% male), 11.1% were black. The incidence rate of recurrent ischemic stroke per 1,000 person-years for whites and blacks was 108 (95% confidence interval [CI], 106–111) and 154 (95% CI 147–162) , respectively. The multivariable-adjusted hazard ratio for recurrent stroke among blacks compared with whites was 1.36 (95% CI 1.29–1.44). The case fatality after recurrent stroke for blacks and whites was 21% (95% CI 21%–22%) and 16% (95% CI 15%–18%), respectively. The multivariable-adjusted relative risk for mortality within 30 days of a recurrent stroke among blacks compared with whites was 0.82 (95% CI 0.73–0.93).ConclusionThe risk of stroke recurrence among older Americans hospitalized for ischemic stroke is higher for blacks compared to whites, while 30-day case fatality after recurrent stroke remains lower for blacks.

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

2017 ◽  
Vol 12 (3) ◽  
pp. 302-320 ◽  
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.

Abstract 181: Determinants of Intracranial Atherosclerotic Enhancement on Vessel Wall MRI in Patients with Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Adam de Havenon ◽  
Nabeel Chauhan ◽  
Jennifer Majersik ◽  
David Tirschwell ◽  
Ka-Ho Wong ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Vessel Wall ◽  
Recurrent Stroke ◽  
Pulse Sequences ◽  
High Rate ◽  
Stroke Recurrence ◽  
Anterior Circulation ◽  
Post Contrast

Introduction: Enhancing intracranial atherosclerotic plaque on high-resolution vessel wall MRI (vwMRI) is a reliable marker of recent thromboembolism, and confers a recurrent stroke risk of up to 30% a year. Post-contrast plaque enhancement (PPE) on vwMRI is thought to represent inflammation, but studies have not fully examined the clinical, serologic or radiologic factors that contribute to PPE. Methods: Inpatients with acute ischemic stroke due to intracranial atherosclerosis were prospectively enrolled at a single center from 2015-16. vwMRI was performed on a 3T Siemens Verio and included 3D DANTE pulse sequences, pre- and post-contrast (for PPE identification). Three experienced neuroradiologists interpreted vwMRI using a validated multicontrast technique. The Chi-squared, Fisher’s Exact, and Student’s t-test were used for intergroup differences, and logistic regression was fitted to the primary outcome of PPE. Results: Inclusion criteria were met by 35 patients. Atherosclerotic plaques were in the anterior circulation in 21/35 (60%) and PPE was diagnosed in 20/35 (57%) of stroke parent arteries. PPE predictors are shown in Table 1 with logistic regression in Table 2 . Conclusion: PPE is associated with stenosis, which was expected, but the association with HgbA1c is novel. All patients with HgbA1c >8 had PPE and a one point HgbA1c rise increased the odds of PPE 3-fold. Hyperglycemia induces vascular oxidative stress by generating reactive oxygen species, quenching nitric oxide, and triggering an inflammatory cascade. Given the high rate of stroke recurrence in PPE patients, aggressive HgbA1c reduction may be a viable treatment target and warrants additional study.

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