Displaying One Session

e-Poster Discussion
Session Type
e-Poster Discussion
Room
Station 7 (E-Poster Area)
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM

EFFICACY AND SAFETY OF ASPIRIN FOR PATIENTS WITH ATHEROTHROMBOTIC STROKE : PORCELAIN STUDY SUB-ANALYSIS.

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 7 (E-Poster Area)
Lecture Time
06:30 PM - 06:35 PM

Abstract

Background And Aims

We are investigating the utility of low-dose aspirin for secondary stroke prevention in patients with non-cardioembolic stroke. We found that the efficacy and safety of aspirin was differ among stroke subtypes. In this sub-study, we analyzed the utility profile of aspirin for patients with atherothrombotic stroke.

Methods

PORCELAIN study included three randomized, double-blinded, aspirin-comparator study conducted in Japan, i.e. S-ACESS study (2008; vs sarpogrelate), CSPS 2 study (2010; vs cilostazol) and JASAP study (2011; vs Aggrenox). All three studies enrolled only patients with non-cardioembolic stroke. We pooled the patients who were randomized to aspirin-arm from each studies and reanalyzed. In this sub-analysis, we limited the patients who were diagnosed atherothrombotic stroke as an index stroke and evaluated the efficacy and safety according to background patients' profiles.

Results

From total 2726 cases, 835 patients with atherothrombotic stroke were included (female 28.5%, mean age 64.1 y/o). All cases were administrated 81mg aspirin. During 715 days mean observation period, 69 ischemic stroke recurrence (4.2%/year) and eight intracranial hemorrhage (0.49%/year) were documented. After multivariate logistic regression analysis, we found that age and systolic blood pressure at the registration were positive predictor (p=0.0008 and 0.012 respectively), whereas the history of dyslipidemia was the only negative predictor (p=0.015) of ischemic stroke recurrence. There was no significant predictor for intracranial hemorrhage.

Conclusions

Because most of patients with dyslipidemia were treated with statins, we speculated that the positive influence of dyslipidemia depended on the synergy effect of aspirin and statin for the plaque stabilization, besides of an antiinflammatory effect of aspirin.

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COMPARISON OF MRI IMAGES IN PATIENTS WITH LOW-GRADE CAROTID STENOSIS BETWEEN PRESYMPTOMATIC AND SYMPTOMATIC PHASES

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 7 (E-Poster Area)
Lecture Time
06:35 PM - 06:40 PM

Abstract

Background And Aims

The process by which asymptomatic carotid stenosis becomes symptomatic and the determinants of exacerbation risk in asymptomatic patients are unclear. Our aim was to identify the risk factors by comparing the MRI images between the presymptomatic and symptomatic phases.

Methods

The study sample consisted of 20 patients with symptomatic low-grade carotid stenosis (NASCET <50%) undergoing carotid MRI for any reason before and after symptom development. The outcome measures were defined as stenosis, plaque-to-muscle signal intensity ratio (PMSIR), and volume of T1-hyperintense plaques (PMSIR >1.2).

Results

The average interval between MRI images taken before and after symptom development was 37 months. At the presymptomatic phase, all patients had plaques, 15 (75%) of whom had hyperintense plaques. At the symptomatic phase, all patients had hyperintense plaques, 9 patients (45%) had an increased stenosis rate, 18 patients (90%) had an increased PMSIR, 18 patients (90%) had an increased volume of T1-hyperintense plaques, and a significant increase was found in mean PMSIR (1.34±0.29 vs. 1.73±0.25, p<0.01) and mean volume of T1-hyperintense plaques (287±308 mm3 vs. 622±251 mm3, p<0.01).

Conclusions

In patients with asymptomatic low-grade carotid stenosis, increased plaque signal intensity and increased volume of T1-hyperintense plaques are highly predictive of ischemic events during the follow-up period.

Trial Registration Number

Not applicable

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BURDEN OF ILLNESS FOR UNITED STATES MEDICARE BENEFICIARIES WITH NON-CARDIOEMBOLIC MINOR ISCHEMIC STROKE OR HIGH RISK TRANSIENT ISCHEMIC ATTACK: A RETROSPECTIVE ANALYSIS

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 7 (E-Poster Area)
Lecture Time
06:40 PM - 06:45 PM

Abstract

Background And Aims

There is a substantial gap in knowledge about longitudinal outcomes for patients with non-cardioembolic (NCE) minor ischemic stroke (IS) or high-risk transient ischemic attack (TIA), a population that may benefit from potent antiplatelet regimens. We examined outcomes among US Medicare beneficiaries following NCE minor IS (NIHSS ≤5) or high-risk TIA (ABCD2 score ≥6) with disease characteristics similar to those enrolled in the THALES clinical trial.

Methods

Patients aged >65 years were identified using GWTG-Stroke registry data linked with Medicare claims for index hospitalization discharges between January, 2011 to December, 2014. Outcomes included cumulative incidence of IS, hemorrhagic stroke, all-cause mortality and a composite of the three.

Results

figure 1.jpgWe identified 62,518 patients from 1,471 hospitals with NCE minor IS or high-risk TIA. Mean (SD) age was 78.6 (7.8) years; 45.3% were male. Comorbidities included 79.9% hypertension, 32.4% diabetes, 26.7% CAD/prior MI, and 26.1% previous stroke/TIA. Antiplatelet therapy was prescribed to 96.2% patients at hospital discharge. Cumulative incidences at 30 days, 90 days and 1 year were 2.3%, 3.9% and 6.9% for IS; 0.1%, 0.2%, and 0.5% for hemorrhagic stroke; 1.6%, 4.3% and 11.5% for all-cause mortality; and 3.8%, 7.7% and 17.3% for the composite outcome (Figure 1).

Conclusions

There was a notable and early risk of stroke and death after hospital discharge among a nation-wide sample of Medicare beneficiaries admitted with NCE minor IS or high-risk TIA. This substantial burden of illness suggests an important unmet need for more efficient treatment options targeted to improve longitudinal cerebrovascular outcomes.

Trial Registration Number

Not Applicable

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COST EFFECTIVENESS OF CYP2C19 GENETIC TESTING IN GUIDING ANTIPLATELET CHOICE IN PATIENTS WITH ISCHEMIC STROKE – AN ASIAN PERSPECTIVE.

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 7 (E-Poster Area)
Lecture Time
06:45 PM - 06:50 PM

Abstract

Background And Aims

Patients with ischemic stroke are often treated with clopidogrel monotherapy as part of secondary stroke prevention. The prevalence of loss of function (LOF) mutations in the CYP2C19 gene is higher in Asians than in Western populations. Patients with LOF mutations are at risk for poorer secondary outcomes when prescribed clopidogrel. We aimed to determine the cost effectiveness of genetic testing with the aim to prescribe ticagrelor as an alternative to patients with LOF mutations.

Methods

Markov models were developed to look at the cost effectiveness of genetic testing of CYP2C19, with patients who screened positive for LOF alleles being switched to ticagrelor compared to universal clopidogrel treatment. Effect ratios were obtained from the literature and incidence rates and costs were obtained from the national data published by the Ministry of Health. Lifetime costs and QALYs were calculated. The primary endpoints were the incremental cost-effectiveness ratios (ICERs).

Results

The prevalence of the LOF mutations were 61% in the population, with 65% of Chinese, 60% of Indians, and 53% of Malays having LOF mutations. Based on these prevalence, the overall ICER of genetic testing was $33,839/QALY with ICERS of $30,755/QALY , $33,177/QALY, and $41,470/QALY for Chinese, Indians, and Malays respectively.

Conclusions

This study suggests that it is cost effective to screen for LOF mutations in the CYP2C19 gene in Asian ischemic stroke populations prior to treatment with clopidogrel, with ticagrelor as a substitute in those with LOF mutations. Genetic testing is more cost effective for Chinese and Indian patients as compared to Malay patients.

Trial Registration Number

Not applicable

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SYMPTOMATIC CAROTID WEB IN PATIENTS TREATED BY ENDOVASCULAR TREATMENT: CLINICAL, RADIOLOGICAL AND HISTOLOGICAL FINDINGS.

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 7 (E-Poster Area)
Lecture Time
06:50 PM - 06:55 PM

Abstract

Background And Aims

To determine demographic, clinical characteristics, radiological profile, outcome and histological features of the retrieved thrombi in patients symptomatic carotid web (SCW) and acute ischemic stroke (AIS) treated by endovascular treatment (EVT)

Methods

We reviewed our monocentric prospectively collected EVT database of patients with AIS from January 2016 to April 2019 and SCW and no other causes of ischemic stroke according to the TOAST criteria. A good outcome was defined as a 3-month modified Rankin Scale score ≤ 2

Results

12 patients were found for a prevalence of 0.77% (12/1561). CW patients had the following characteristics: Seven were women (58%); mean age was 45 years old; 58% originated from sub-Saharan Africa; 10 had no cardiovascular risk factors; median NIHSS was 16; median DWI ASPECT was 7.5; 10/12 patients had proximal middle cerebral artery occlusion on cerebral angiography and treated by EVT associated with IV thrombolysis in 6 cases. All patients had TICI › 2b at the end of the procedure; Histological analysis of endovascular thrombectomy-retrieved thrombi which was performed in 4 patients found fibrin rich and platelet rich thrombi and poor red blood cells in favour of older thrombi. For secondary stroke prevention 8 patients had carotid artery stenting and one patient had carotid endarterectomy artery. 11/ 12 patients had good outcome.

Conclusions

EVT in ischemic stroke related to SCW is effective and carotid stenting appears to be a good therapeutic option. Radiological findings and histologic analysis of thrombi are in favour of embolic mechanism of AIS.

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PREVALENCE, PREDICTORS AND PROGNOSIS OF SYMPTOMATIC INTRACRANIAL STENOSIS IN PATIENTS WITH TIA AND MINOR STROKE: POPULATION-BASED VALIDATION OF RANDOMISED TRIALS

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 7 (E-Poster Area)
Lecture Time
06:55 PM - 07:00 PM

Abstract

Group Name

Oxford Vascular Study

Background And Aims

Recent trials (SAMMPRIS and VISSIT) have failed to show superiority of stenting symptomatic intracranial stenosis (ICS) over intensive medical management alone. The generalisability of the results has been brought into question given the young trial cohorts and lower than expected rate of recurrent stroke without stenting. We aimed to validate the trials’ findings in a population-based cohort of patients with TIA/minor stroke on intensive medical management alone.

Methods

From 2011-2018, all TIA/minor ischaemic stroke (NIHSS≤3) patients recruited to the population-based Oxford Vascular Study, irrespective of age, underwent intracranial vascular imaging, preferentially with 3.0T MR angiography. We determined the age-specific prevalence of ≥50% symptomatic ICS and the associated stroke risk by follow-up to 2019 on standard medical treatment without stenting.

Results

Of 1368 eligible patients, 261 had a total of 424 symptomatic or asymptomatic ICS. The prevalence of symptomatic ICS increased with age, reaching 21.2% at age ≥90 years (ptrend <0.0001). Of 106 patients with symptomatic ICS, 14 had recurrent ischaemic strokes during mean follow-up of 3.2 years. Although recently symptomatic ICS conveyed an increased risk of ischaemic stroke compared to no ICS (adjusted HR=1.47, 95%CI=1.09-1.98), the risk of same-territory ischaemic stroke (2-year: 7.5%,1.6-13.8) tended to be less than those reported in the non-stenting arms of the trials.

Conclusions

The prevalence of ≥50% ICS increases steeply with age in patients with TIA/minor stroke, but the risk of recurrent stroke on intensive medical treatment is consistent with randomised trials in younger cohorts, supporting their generalisability to routine practice.

Trial Registration Number

Not applicable

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QUANTIFICATION OF CAROTID PLAQUE COMPOSITION WITH MULTI-CONTRAST ATHEROSCLEROSIS CHARATERIZATION (MATCH) VERSUS MULTISEQUENCE CAROTID MRI

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 7 (E-Poster Area)
Lecture Time
07:00 PM - 07:05 PM

Abstract

Background And Aims

Multisequence magnetic resonance imaging (MRI) is commonly used for quantification of carotid atherosclerotic composition.1 Limitation are long scan time and image mis-registration errors. Multi-contrast Atherosclerosis Characterization (MATCH) was developed to overcome these limitations.2

Aim: To compare MATCH with multisequence MRI for the characterization of carotid plaque components.

Methods

Eighteen symptomatic patients with ≥ 2 mm plaque underwent carotid multisequence and MATCH MRI on a 3.0T. Image analysis of the MATCH images was performed independently of the multisequence images.

Results

One total or nearly occluded artery was excluded. The mean quality scores of the MATCH images were lower than multisequence images (p< 0.01). The scan time for MATCH and multisequence MRI was 4:44 and 10:84 minutes, respectively. Excellent agreement between the two protocols was obtained for identification of lipid-rich necrotic core (LRNC) (κ = 0.82), substantial for intraplaque haemorrhage (IPH) (κ= 0.77) (Fig.1) and slight agreement for calcifications (κ= 0.39) (Table 1).

figure 1. .jpg

table 1 .jpg

No significant differences between MATCH and multisequence MRI were found in volume of LRNC, IPH and calcifications There was a small but significant difference in total volume of vessel wall (1269.07±333.89 versus 1295.32±329.81 mm³; P=0.041) and total volume of fibrous tissue (1131.4±370.31 versus 1371.6±502.04 mm³; P=0.013) (Fig.2).

figure 2.jpg

Conclusions

We demonstrated excellent to substantial agreement between MATCH and multisequence MRI for the identification and quantification of LRNC and IPH. There was only slight agreement for scoring presence of calcifications. Although MATCH images showed a lower mean image quality score, short scan time and perfect co-registration are major advantages of MATCH.

Trial Registration Number

''Not applicable''

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ASSOCIATION BETWEEN CUMULATIVE EXPOSURE TO LOW-DENSITY LIPOPROTEIN AND THE PREVALENCE OF ASYMPTOMATIC INTRACRANIAL ATHEROSCLEROTIC STENOSIS

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 7 (E-Poster Area)
Lecture Time
07:05 PM - 07:10 PM

Abstract

Background And Aims

Low-density lipoprotein cholesterol (LDL-C) has not been a well-established factor that might be associated with asymptomatic intracranial atherosclerotic stenosis (ICAS). We performed this study to characterize the association of cumulative exposure to increased LDL-C with prevalence of asymptomatic ICAS.

Methods

In this study, we included 4523 participants with LDL-C measured at 3 examinations in 2006, 2008, and 2010 respectively. Cumulative exposure to LDL-C was calculated as following: LDL-C burden2006-2008 = [(LDL-C2006-1.8) + (LDL-C2008-1.8)] / 2 * time2006-2008; LDL-C burden = LDL-C burden2006-2008 + LDL-C burden2008-2010. Participants were classified into four groups (Q1, Q2, Q3 and Q4) according to the interquartile range of LDL-C burden. Transcranial doppler ultrasonography (TCD) was carried out in 2010 for the detection of ICAS. Univariate and Multivariate regression analysis were used to assess the association of LDL-C burden with prevalence of ICAS.

Results

Of the 4523 patients, 12.8% (580/4523) were diagnosed with ICAS. The study showed a dose-response pattern with risk of ICAS as the LDL-C burden increases. In comparison with participants in the Q1 group, Participants in the Q2, Q3 and Q4 groups had significantly increased risk of ICAS with odds ratio (95% confidence interval) of 1.30 (0.99–1.70), 1.34 (1.03–1.76) and 2.10 (1.63–2.70) respectively (P<0.05). The significant associations were also observed in multivariate analysis after adjustment for potential confounding factors, with respective odds ratio (95% confidence interval) of 1.32 (1.00–1.74), 1.40 (1.06–1.85), and 2.01 (1.55– 2.61).table 1.png

table 2.png

Conclusions

Cumulative exposure to LDL-C is dose dependently associated with increased risk of asymptomatic ICAS prevalence.

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REGIONAL HIGH WALL SHEAR STRESS ASSOCIATED WITH REGRESSION OF LUMINAL STENOSIS IN SYMPTOMATIC INTRACRANIAL ATHEROSCLEROTIC DISEASE: A COMPUTATIONAL FLUID DYNAMICS STUDY

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 7 (E-Poster Area)
Lecture Time
07:10 PM - 07:15 PM

Abstract

Background And Aims

Understanding the mechanisms underlying progression/regression of symptomatic intracranial atherosclerotic stenosis (sICAS) will inform secondary prevention of the patients. Focal wall shear stress (WSS) may play an important role, which, however, had seldom been investigated.

Methods

Patients with acute ischemic stroke or transient ischemic attack (TIA) attributed to 50-99% ICAS were recruited. All patients underwent cerebral CT angiography (CTA) at baseline and a computational fluid dynamics model was built based on CTA to simulate blood flow and quantify WSS in the vicinity of the sICAS lesion (Figure 1). All patients received optimal medical treatment and a 2nd CTA at 1 year. The change in the luminal stenosis from baseline to 1 year in sICAS was defined as progression (increased >10%), quiescence (±10%), or regression (decreased >10%). Associations between baseline WSS metrics and sICAS regression were analyzed.

figure 1. wss distribution in a case.png

Results

Among 39 patients (mean age 61 years; 27 males), sICAS luminal stenosis progressed, remained quiescent and regressed in 6 (15.4%), 15 (38.5%) and 18 (46.2%) cases, respectively (Figure 2). A higher maximum WSS and larger high-WSS area, throughout the sICAS lesion or obtained separately in the proximal and distal parts of the lesion, were independently associated with regression of luminal stenosis in sICAS over 1 year.

figure 2. icas progression over 1 year.png

Conclusions

A majority of sICAS lesions regress or stay quiescent in the luminal stenosis over 1 year after stroke under optimal medical treatment, when higher focal WSS may facilitate stenosis regression. Further studies of the effects of hemodynamics including WSS in altering plaque vulnerability and stroke risks are needed.

Trial Registration Number

Not applicable

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FREQUENCY, SITES AND PREDICTORS OF BLEEDING IN PATIENTS WITH EMBOLIC STROKES OF UNDETERMINED SOURCE

Session Type
e-Poster Discussion
Date
07.11.2020, Saturday
Session Time
06:30 PM - 07:30 PM
Room
Station 7 (E-Poster Area)
Lecture Time
07:15 PM - 07:20 PM

Abstract

Background And Aims

Risks, sites and predictors of major bleeding during antithrombotic therapies have not been well defined for patients with recent embolic stroke of undetermined source (ESUS).

Methods

Exploratory analysis of major bleeds defined by International Society of Thrombosis and Hemostasis criteria occurring among 7213 participants in international NAVIGATE ESUS randomized trial comparing rivaroxaban 15mg daily with aspirin 100mg daily.

Results

During a median follow-up of 11 months, 85 major bleeds occurred. The most frequent site was gastrointestinal (38%), followed by intracranial (29%). Assignment to rivaroxaban (HR 2.7, 95% CI 1.7, 4.3), East Asia region (HR 2.5, 95% CI 1.6, 3.9), systolic blood pressure >160 mmHg (HR 2.2, 95%CI 1.2, 3.8) and reduced estimated glomerular filtration rate (eGFR) (HR 1.2 per 10 mL/min/1.73m2 decrease, 95% CI 1.0, 1.3) were independently associated with presence of major bleeds. Five (6%) were fatal. Among 15 patients with intracerebral hemorrhage, two (13%) were fatal. There was no evidence of an early high-risk period following initiation of rivaroxaban. The annualized rate of intracerebral hemorrhage was six-fold higher among East Asian participants (0.67%) vs. all other regions (0.11%) (HR 6.3, 95% CI 2.2, 18.0). Distribution of bleeding sites was similar for rivaroxaban and aspirin.

Conclusions

Among ESUS patients independent predictors of major bleeding were assignment to rivaroxaban, East Asia region, increased systolic blood pressure and impaired renal function. East Asia as a region was strongly associated with risk of intracerebral hemorrhage. eGFR should be a consideration for stratifying bleeding risk.

Trial Registration Number

NCT02313909

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