TAB-TICI Score: Successful Recanalization Score After Endovascular Thrombectomy in Acute Stroke

Background and Purpose: Successful reperfusion therapy is supposed to be comprehensive and validated beyond the grade of recanalization. This study aimed to develop a novel scoring system for defining the successful recanalization after endovascular thrombectomy.Methods: We analyzed the data of consecutive acute stroke patients who were eligible to undergo reperfusion therapy within 24 h of onset and who underwent mechanical thrombectomy using a nationwide multicenter stroke registry. A new score was produced using the predictors which were directly linked to the procedure to evaluate the performance of the thrombectomy procedure.Results: In total, 446 patients in the training population and 222 patients in the validation population were analyzed. From the potential components of the score, four items were selected: Emergency Room-to-puncture time (T), adjuvant devices used (A), procedural intracranial bleeding (B), and post-thrombectomy reperfusion status [Thrombolysis in Cerebral Infarction (TICI)]. Using these items, the TAB-TICI score was developed, which showed good performance in terms of discriminating early neurological aggravation [AUC 0.73, 95% confidence interval (CI) 0.67–0.78, P < 0.01] and favorable outcomes (AUC 0.69, 95% CI 0.64–0.75, P < 0.01) in the training population. The stability of the TAB-TICI score was confirmed by external validation and sensitivity analyses. The TAB-TICI score and its derived grade of successful recanalization were significantly associated with the volume of thrombectomy cases at each site and in each admission year.Conclusion: The TAB-TICI score is a valid and easy-to-use tool to more comprehensively define successful recanalization after endovascular thrombectomy in acute stroke patients with large vessel occlusion.

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Title: Significance of D-dimer in acute ischemic stroke patients with large vessel occlusion accompanied by active cancer

10.21203/rs.3.rs-512754/v1 ◽

2021 ◽

Author(s):

Kwang Hyun Pan ◽

Jaeyoun Kim ◽

Jong-Won Chung ◽

Keon Ha Kim ◽

Oh Young Bang ◽

...

Keyword(s):

Acute Stroke ◽

Large Vessel ◽

Lesion Volume ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Stroke Registry ◽

D Dimer ◽

Active Cancer

Abstract Background: This study aimed to investigate clinical outcome predictors of acute stroke patients with large vessel occlusion and active cancer and validate the significance of d-dimer levels for endovascular thrombectomy decisions.Methods: We analyzed a prospectively collected hospital-based stroke registry to determine clinical EVT outcomes of acute stroke patients within 24 hours with following criteria: age≥18 years, NIHSS≥6, and internal carotid artery or middle cerebral artery lesion. All patients were classified into EVT and non-EVT groups. Patients were divided into two groups by initial d-dimer level. We explored variables potentially associated with successful recanalization as well as 3-month functional outcomes and mortality rates. Results: Among 68 patients, 36 were treated with EVT, with successful recanalization in 55.6%. The low d-dimer group showed a higher rate of successful recanalization and favorable outcome than the high d-dimer group. The mortality rate was higher in the high d-dimer group. EVT and high d-dimer level were independent predictors of mortality, whereas lesion volume and low d-dimer level were independently associated with favorable outcomes.Conclusions: d-dimer level is a prognostic factor in acute LVO stroke patients with active cancer, and its high value for EVT decisions provisionally supports its testing in this patient population.

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Abstract P84: Covid-19 and Stroke in the Latin American Stroke Registry (LASE)

Stroke ◽

10.1161/str.52.suppl_1.p84 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Virginia Pujol-Lereis ◽

Alan F Flores ◽

Antonio Arauz ◽

Carlos Abanto ◽

Pablo Amaya ◽

...

Keyword(s):

Latin America ◽

Ischemic Stroke ◽

Latin American ◽

Clinical Characteristics ◽

Hemorrhagic Stroke ◽

Reperfusion Therapy ◽

Infection Frequency ◽

Stroke Patients ◽

Vessel Occlusion ◽

Stroke Registry

Background: Ischemic stroke has been reported to occur in approximately 5% of COVID-19 patients, although some reports are contradictory. Proposed mechanisms of this association are hypercoagulable state, vasculitis and cardiomyopathy, together with traditional vascular risk factors. We analyzed the frequency and clinical characteristics of COVID-19 positive stroke cases during the first months of the pandemic in Latin America. Methods: A multinational study (7 countries, 18 centers) of patients admitted during the pandemic outbreak (March - June 2020). We assessed acute stroke cases associated to COVID-19 infection. Clinical characteristics, stroke etiology and severity, acute care and functional outcomes, were compared between non-COVID-19 and COVID-19 cases. Results: There were a total of 1037 stroke cases; sixty-two of them (6.0%) were diagnosed with COVID-19 infection. This group consisted of 38 men [61.3%], with a median age of 68 years [IQR 59-79 years]. From these cases, 80.6% were ischemic stroke, 16.1% hemorrhagic stroke, and 1.6% transient ischemic attack and cerebral venous thrombosis respectively. The most common etiology reported for ischemic cases was atherosclerotic large vessel occlusion (30.6% vs. 12.7% in non-COVID cases, p<0.001), and undetermined etiology for hemorrhagic stroke (55.6%). Median NIHSS for COVID-stroke patients was higher (7 IQR 2-16 vs. 5 IQR 2-11, p=0.05). Five (8.1%) patients received acute reperfusion therapy, with no differences in door-to-CT, door-to-needle and door-to-groin times, compared to non-COVID cases. Most characteristics did not differ from those of COVID-19 negative patients. Mortality was higher in COVID-stroke cases (20.9% vs. 9.6%, p<0.001). Conclusions: COVID-19 infection frequency in stroke patients in Latin America is similar to that reported in several series worldwide, with a higher frequency of atherosclerotic ischemic strokes and mortality compared to non COVID-19 strokes

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Association of CT-Based Hypoperfusion Index With Ischemic Core Enlargement in Patients With Medium and Large Vessel Stroke

Neurology ◽

10.1212/wnl.0000000000012855 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012855

Author(s):

Ali Z Nomani ◽

Joseph Kamtchum Tatuene ◽

Jeremy L Rempel ◽

Thomas Jeerakathil ◽

Ian Winship ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Reperfusion Therapy ◽

Stroke Onset ◽

Progression Rate ◽

Stroke Patients ◽

Infarct Core ◽

Vessel Occlusion ◽

Slow Progressors

Objective:The rate of infarct core progression in patients with acute ischemic stroke is variable and affects outcome of reperfusion therapy. We evaluated hypoperfusion index (HI) to estimate the initial rate of core progression in patients with medium-vessel-occlusion (MeVO) compared to large-vessel-occlusion (LVO) stroke and within a larger time frame since stroke onset.Methods:Core progression was assessed in 106 patients with acute stroke and CT perfusion. Using reperfusion trial core-time criteria, fast progressors had core>70-mL within 6-hours of stroke onset and slow progressors had core ≤70mL, mismatch ≥15mL and mismatch-to-core-ratio ≥1.8 within 6-24-hours. The relationship between HI and infarct core progression (core/time) was examined using receiver-operating-characteristics to determine optimal HI cut-off. The HI cut-off was then tested in overall cohort, compared between MeVO and LVO, and evaluated in patients up to 24-hours from stroke onset to differentiate fast from slow rate of core progression. HI threshold was assessed in a second independent cohort of 110 acute ischemic stroke patients.Results:In 106 patients with acute stroke, 6.6% were fast progressors, 27.4% were slow progressors, and 66% were not classified as fast or slow progressor by reperfusion trial core-time criteria. HI>0.5 was associated with fast progression and able to distinguish fast from slow progressors (AUC=0.94;95%CI=0.80-0.99). In MeVO patients (n=26) HI>0.5 had a core progression of 0.30-mL/min compared to 0.03-mL/min with HI≤0.5 (p<0.001). In LVO patients (n=80), HI>0.5 had a core progression of 0.26-mL/min compared to 0.02-mL/min with HI≤0.5 (p<0.001). In patients not classified as fast or slow progressor by reperfusion trial criteria, those with HI>0.5 had progression rate of 0.21-mL/min compared to 0.03-mL/min with HI≤0.5 (p<0.001). Validation in a second cohort of patients with acute ischemic stroke (n=110; MeVO n=42, LVO n=68) yielded similar results for HI>0.5 to distinguish fast and slow core progression with an AUC of 0.84(95%CI=0.72-0.97).Conclusions:HI can differentiate fast from slow core progression in MeVO and LVO patients within the first 24-hours of acute ischemic stroke. Consideration of core progression rate at time of stroke evaluation may have implications in the selection of MeVO and LVO stroke patients for reperfusion therapy that warrant further study.

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Effects of state-wide implementation of the Los Angeles Motor Scale for triage of stroke patients in clinical practice

Neurological Research and Practice ◽

10.1186/s42466-021-00128-x ◽

2021 ◽

Vol 3 (1) ◽

Author(s):

Stefanie Behnke ◽

Thomas Schlechtriemen ◽

Andreas Binder ◽

Monika Bachhuber ◽

Mark Becker ◽

...

Keyword(s):

Los Angeles ◽

Acute Stroke ◽

Unsolved Problem ◽

Standard Operating Procedure ◽

Stroke Management ◽

Stroke Patients ◽

Vessel Occlusion ◽

Standard Operating ◽

Los Angeles Motor Scale ◽

Triage Decisions

Abstract Background The prehospital identification of stroke patients with large-vessel occlusion (LVO), that should be immediately transported to a thrombectomy capable centre is an unsolved problem. Our aim was to determine whether implementation of a state-wide standard operating procedure (SOP) using the Los Angeles Motor Scale (LAMS) is feasible and enables correct triage of stroke patients to hospitals offering (comprehensive stroke centres, CSCs) or not offering (primary stroke centres, PSCs) thrombectomy. Methods Prospective study involving all patients with suspected acute stroke treated in a 4-month period in a state-wide network of all stroke-treating hospitals (eight PSCs and two CSCs). Primary endpoint was accuracy of the triage SOP in correctly transferring patients to CSCs or PSCs. Additional endpoints included the number of secondary transfers, the accuracy of the LAMS for detection of LVO, apart from stroke management metrics. Results In 1123 patients, use of a triage SOP based on the LAMS allowed triage decisions according to LVO status with a sensitivity of 69.2% (95% confidence interval (95%-CI): 59.0–79.5%) and a specificity of 84.9% (95%-CI: 82.6–87.3%). This was more favourable than the conventional approach of transferring every patient to the nearest stroke-treating hospital, as determined by geocoding for each patient (sensitivity, 17.9% (95%-CI: 9.4–26.5%); specificity, 100% (95%-CI: 100–100%)). Secondary transfers were required for 14 of the 78 (17.9%) LVO patients. Regarding the score itself, LAMS detected LVO with a sensitivity of 67.5% (95%-CI: 57.1–78.0%) and a specificity of 83.5% (95%-CI: 81.0–86.0%). Conclusions State-wide implementation of a triage SOP requesting use of the LAMS tool is feasible and improves triage decision-making in acute stroke regarding the most appropriate target hospital.

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In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

CardioVascular and Interventional Radiology ◽

10.1007/s00270-020-02727-8 ◽

2020 ◽

Author(s):

Juha-Pekka Pienimäki ◽

Jyrki Ollikainen ◽

Niko Sillanpää ◽

Sara Protto

Keyword(s):

Clinical Outcome ◽

Acute Stroke ◽

Mechanical Thrombectomy ◽

Clinical Laboratory ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Ordinal Logistic Regression Analysis ◽

Stroke Center

Abstract Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

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Abstract W P211: Clinical Characteristics of Pseudo Negative Cases in Prehospital Triage for Stroke

Stroke ◽

10.1161/str.46.suppl_1.wp211 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Shuichi Tonomura

Keyword(s):

Acute Stroke ◽

Clinical Characteristics ◽

Stroke Onset ◽

The Other ◽

Small Vessel ◽

Stroke Patients ◽

Vessel Occlusion ◽

Stroke Subtypes ◽

Prehospital Triage ◽

Prehospital Diagnosis

Objective: The accuracy of prehospital diagnosis for stroke by emergency medical services (EMS) is improved using instruments for symptom recognition. On the other hand, prehospital misdiagnosis for stroke and subsequent delay in presentation to a hospital with stroke expertise play a critical role in the exclusion of potential therapeutic candidates. Our study aims to investigate the clinical characteristics of pseudo-negative cases in prehospital triage for stroke/TIA by EMS. Methods: From April 2013 to April 2014, consecutive 644 acute stroke patients were transferred by EMS to our hospital. We investigated prehospital diagnosis, Cincinnati prehospital stroke scale (CPSS) by EMS, neurological symptoms and complaints of patients themselves at stroke onset. We also examined activity of daily life (ADL) and cognitive impairments before stroke onset, and stroke subtypes in final diagnoses. Results: Among 644 acute stroke patients, 36 patients (22 men, mean 72.5±4.4 years old) were pseudo-negative cases in prehospital triage for stroke and had no abnormalities in CPSS by EMS. When EMS arrived at emergency site, 12 patients (33%) had loss of consciousness. Before stroke onset, 6 patients (17%) had impaired ADL (modified Rankin Scale >2), and 5 (14%) cognitive impairment. Among the stroke subtypes, the proportion of small vessel occlusion (22.4%, p=0.0025) and transient ischemic attack (TIA) (25%, p=0.0021) was significant higher in pseudo negative cases in prehospital triage; on the other hand, intracranial hemorrage (11%, p=0.0028) was lower. In complaint of patients themselves at stroke onset, weakness in one or two extremities was reported in 20 patients (56%), abnormal speech/language in 13 (36%), however all of them were not clarified by EMS. Conclusion: This study showed that small vessel occlusion and TIA tend to be misdiagnosed in a prehospital triage by EMS. The complaint of patients themselves at stroke onset is important to prehospital diagnoses by EMS.

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Abstract P327: Utilizing Iodine Contrast Extravasation Post Reperfusion and Dual Energy Ct Imaging to Predict Risk of Hemorrhagic Conversion in Acute Stroke Patients

Stroke ◽

10.1161/str.52.suppl_1.p327 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Tri Huynh* ◽

Niran Vijayaraghavan* ◽

Hannah Branstetter ◽

Natalie Buchwald ◽

Justin De Prey ◽

...

Keyword(s):

Acute Stroke ◽

Infarct Volume ◽

Reperfusion Therapy ◽

Dual Energy ◽

Ct Imaging ◽

Dual Energy Ct ◽

Stroke Patients ◽

Post Intervention ◽

Contrast Extravasation ◽

Post Contrast

Introduction: Hyperintense acute reperfusion marker (HARM) has been identified on post-contrast magnetic resonance imaging (MRI) to be a marker of hemorrhagic conversion (HC) post reperfusion therapy in acute stroke patients. We have previously described a case where MRI HARM was mimicked on post contrast computed topography (CT) imaging in an acute stroke patient post reperfusion. Dual-Energy (DECT) allows for differentiation between acute blood and iodine contrast extravasation (ICE), and thus can have utility when ICE is present. Here we sought to validate whether post-intervention ICE/CT hyperdensity reperfusion maker (CT HARM), and contrast subtracted on DECT is associated with HC in acute stroke patients. Method: Data was obtained from our Institutional Review Board approved stroke admission database from January 2017 to November 2019, including ischemic stroke patients that received thrombolysis or thrombectomy, had evaluable images within 24 hours of admission, and received a DECT. Ischemic volumes of the stroke was measured on diffusion-weighted image (DWI). ICE was measured on CT head and DECT using the freehand 3D region of interest tool on the Visage Imaging PACS System. Susceptibility weighted MRI sequences were used to grade HC. Data analysis was conducted with regression modeling. Results: A total of 82 patients were included, 49% women, median age 73 (interquartile range (IQR), 61- 77), admission NIHSS 12 (IQR, 7 - 21), 24 hour change in NIHSS 4 (IQR, 0 -13), glucose 125 (IQR, 106 -158), creatinine 1.0 (IQR, 0.8 - 1.2), infarct volume 50.6 ± 7.1 mL, 48% treated with thrombectomy, 7% with PH-1 or PH-2 identified on MRI, and 56% with MCA infarcts. ICE volume was 2.6 ± 1.0 mL and DECT volume was 2.2 ± 1.1mL. ICE increased the likelihood of MRI confirmed PH-1 or PH-2 hemorrhagic conversion (odds ratio (OR) 14.34, 95% confidence interval (CI) 5.74 - 22.94) and decreased likelihood of increase in NIHSS at 24 hours (OR 0.20, 95% CI 0.01 to 0.40). There were no other significant associations with ICE or DECT volumes. Conclusion: Our results are supportive of our proposed association between CT HARM and risk of HC. More studies are needed to study whether quantitative of DECT can be predictive of stroke outcomes post reperfusion therapy.

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Abstract P355: Real-Word Performance of Two Automated Software Platforms for Identification of Salvageable Tissue in Stroke Patients: A Single Center Experience

Stroke ◽

10.1161/str.52.suppl_1.p355 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Angelos Katramados ◽

Horia Marin ◽

Maximilian Kole ◽

Owais Alsrouji ◽

Pala Varun ◽

...

Keyword(s):

Ct Perfusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Significant Discrepancy ◽

Endovascular Thrombectomy ◽

Stroke Treatment ◽

Software Platforms ◽

Automated Software ◽

Selection Of Patients ◽

Selection Of

Background and purpose: Modern stroke treatment has been revolutionized by image-guided selection of patients for endovascular thrombectomy. Current automated platforms allow for real-time identification of large vessel occlusion and salvageable brain tissue. We sought to evaluate the performance of these platforms with regard to identification of infarcted and salvageable tissue. Methods: We studied all patients that presented to Henry Ford Health System hospitals over a period of 6 weeks, received CT perfusion imaging of the brain upon initial presentation. The images were processed with two automated software platforms. We prospectively measured volumes of tissue with cerebral blood flow (CBF) < 30% of contralateral hemisphere, Tmax >6 secs, and hypoperfusion indices (defined as the ratio of volumes Tmax>10 secs and Tmax>6 secs). We compared the outputs of the two platforms and analyzed the performance of each platform. Results: 66 scans were included in our study. Both platforms were able to image all stroke patients within their FDA-approved indications. With regard to all scans, both platforms were noted to demonstrate comparable CBF<30% volumes (6.32 ml. vs 4.97 ml, p=0.276), and hypoperfusion indices (0.278 vs 0.338, p=0.344). However, there was statistically significant discrepancy in the volumes of tissue with Tmax>6 secs (23.96 vs 14.18 ml, p=0.023). Analysis of a subset of 12 scans, with evidence of LVO or severe symptomatic stenosis on corresponding CTA, showed again comparable CBF<30% volumes (12.84 ml vs 13.67 ml, p=0.725), and hypoperfusion indices (0.344 vs 0.314, p=0.699). However, the Tmax>6 secs volume discrepancy was greater and still statistically significant (75.54 ml vs 39.58 ml, p=0.048) Conclusions: Automated software platforms are an invaluable aid in the identification of salvageable tissue, and selection of patients for endovascular thrombectomy in the 6-24 hour window. However, the substantial difference in the identified volumes of hypoperfused tissue-at-risk may result in largely different clinical decisions and patient outcomes. Further validation efforts (and harmonization of algorithms) are required. Stroke teams should be aware of the limitations of automated analysis and need for expert review.

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Abstract T P267: Development of an EMS Interfacility Ground Transport Protocol for Patients During/After IV tPA Administration for Acute Ischemic Stroke

Stroke ◽

10.1161/str.45.suppl_1.tp267 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Kerrin Connelly ◽

Rishi Gupta ◽

Raul Nogueira ◽

Arthur Yancey ◽

Alexander Isakov ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Transport Protocol ◽

Stroke Patients ◽

Stroke Registry ◽

The Public ◽

State Office ◽

Stroke Center ◽

Iv Tpa

Purpose: To standardize the care of acute stroke patients who receive IV tPA being transported by ground EMS from a treating hospital to a stroke center. Background: National consensus guidelines exist for the hospital management of patients receiving IV tPA for acute ischemic stroke. Such patients require close monitoring and management to minimize risk of clinical deterioration. Although patients are often emergently transported from local hospitals to a stroke center, there are no treatment specific national guidelines for managing such patients enroute. As a result, there is a need to develop and implement a standardized approach to guide EMS personnel, particularly in states like Georgia where the public health burden of stroke is high. Methods: In 2012, the “Georgia EMS Interfacility Ground Transport Protocol for Patients during/after IV tPA Administration for Acute Ischemic Stroke” was developed in conjunction with the Georgia Coverdell Acute Stroke Registry, the Georgia State Office of EMS, a representative group of Georgia hospitals and EMS providers. Stakeholders were brought together with the goal of creating a unified statewide protocol. The intent was to create a streamlined protocol which could be readily implemented by pre-hospital care providers. Results: Stakeholders discussed challenges and opportunities to change the process of pre-hospital care. Challenges included recognition of the broad diversity of EMS providers representing over 250 agencies in the state. Opportunities included establishing the framework for greater collaboration across organizations and providers. The final protocol was endorsed by both the Georgia Coverdell Acute Stroke Registry and the State Office of EMS, and distributed to all EMS regions in Georgia. EMS agencies are currently implementing the protocol. Conclusion: Engaging a diverse group of statewide stakeholders to develop a new treatment protocol enhances success in implementation and serves to further the public health mission of improving care of acute stroke patients.

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Abstract TP205: Clinical Aspects Of First-ever Stroke In Patients With Permanent Pacemaker

Stroke ◽

10.1161/str.44.suppl_1.atp205 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Jiro Kitayama ◽

Hiroshi Nakane ◽

Hiromi Ishikawa ◽

Masahiro Shijo ◽

Masahiro Kamouchi ◽

...

Keyword(s):

Acute Stroke ◽

Pacemaker Implantation ◽

The United States ◽

Permanent Pacemaker ◽

Stroke Onset ◽

Clinical Aspects ◽

Stroke Patients ◽

Stroke Treatment ◽

Stroke Registry ◽

History Of

OBJECTIVES: Recently, increasing numbers of patients take pacemaker implantation: almost sixty thousands in Japan, and no less than two hundreds of thousands in the United States per year. Previous reports have indicated that prevalence of atrial fibrillation (Af) is high, and several coagulation markers are elevated in those with pacemaker. However, the precise features of stroke with implanted device are not clear. We, thus, examined the clinical aspects of stroke in pacemaker patients. METHODS: For the present study, we analyzed data from the Fukuoka Stroke Registry that is a multicenter epidemiological study database on acute stroke. From June 1999 to May 2011, 11376 ischemic stroke patients (72±12 years of age, female/male=4613/6763) who admitted to the hospital within seven days after onset were enrolled in the registry. Stroke subtypes were classified according to the diagnostic criteria of TOAST (Trial of Org 10172 in Acute Stroke Treatment). RESULTS: A total of 207 patients (1.8% of registered stroke patients) were with pacemaker. Among them, 130 patients had no history of any stroke. They appeared to be a mean age of 81±9 (range 42 to 97) years, and female/male ratio of 77/53. Mean duration from pacemaker implantation to stroke onset was 8±7 (median 6, quartile 3-11) years. 32 patients (25%) were given oral anticoagulant prior to stroke onset; 60 (46%) were on antiplatelet. Prevalence of Af in pacemaker patients was 48% (n=63). In those with Af, 48 patients (76%) were diagnosed as cardioembolic stroke, but only 22 (35%) were on anticoagulation before onset. Even in those without Af, 33 cases (49%) were also diagnosed as cardioembolic. The percentage of subjects with increased plasma D-dimer (≥1.5 μg/ml) was significantly higher in pacemaker group than no-pacemaker group, regardless of the presence or absence of Af (75% vs. 45% with Af; p<0.0001, 74% vs. 25% without Af; p<0.0001). CONCLUSIONS: In our current study, stroke in pacemaker patients revealed to have higher incidence of cardiogenic embolism, with or without Af. In addition, the majority was elderly, and failed to receive anticoagulant prior to stroke. It is needed to re-consider therapeutic strategy, including anticoagulation, for prevention of stroke in those with permanent pacemaker.

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