Welcome to the WSC 2022 Interactive Program

Background and Aims

Prediabetes is a risk factor for ischemic stroke in atrial fibrillation (AF) patients. However, the association between prediabetes and recurrent stroke in AF patients remains understudied.

Methods

We identified hospitalizations with prior stroke/TIA with concomitant AF from the National Inpatient Sample (2018) and divided them into prediabetes and non-prediabetes (excluding DM). We compared frequency/odds of recurrent stroke in patients with prior stroke/TIA and concurrent AF with vs without prediabetes and associated outcomes.

Results

Of 18905 non-diabetic AF patients hospitalized for recurrent strokes, 480 were prediabetic (2.5%, median 78 years [69-84]) and 18425 were non-prediabetics (median 82 years [73-88]). The prediabetic cohort often had males (50% vs 45.9%) and blacks (15.6% vs 9.4%) than the non-prediabetic cohort (p<0.001). Prediabetes in AF patients hospitalized with prior stroke/TIA independently predicted two times higher risk of recurrent stroke on unadjusted (OR 2.14, 95CI 1.72-2.66) and adjusted (Adjusted for sociodemographics/comorbidities, OR 2.09, 95CI 1.65-2.64) regression analyses (p<0.001). The prediabetes group often consisted of higher Medicaid enrollees, Northeastern/Western region admissions and had higher rates of hyperlipidemia (74.0% vs 59.3%), smoking (43.7% vs 37.4%,), PVD (17.7% vs 13.0%), obesity (18.7% vs 8.0%) and COPD (21.9% vs 18.2%) (all p<0.05). The prediabetes cohort often required home health care (22.9 vs 17.3%) and had higher hospital costs. However, adjusted odds of all-cause mortality were not statistically significant in prediabetics vs. non-prediabetics (OR 0.55, 95CI 0.19-1.56, p=0.260).

Conclusions

Prediabetes independently increased the risk of recurrent stroke in hospitalized AF patients with prior stroke with no association to subsequent in-hospital mortality.

Background and Aims

Cholesterol makes up about 10% of atheroma plaque. High blood cholesterol is correlated with the incidence of coronary disease but less so (ischaemic) stroke. High intensity statin therapy is recommended in Guidelines but is not supported by convincing clinical trial evidence.

Methods

We analysed all of the relevant long term clinical trials which randomised patients to statin or placebo and recruited more than 2,000 patients.

Results

In SPARCL, the largest secondary prevention study of cholesterol-lowering after stroke, atorvastatin, (80 mg daily), the highest available clinical dose, reduced low density lipoprotein (LDL)-cholesterol by 57% compared to placebo and ischaemic stroke by 20% (p<0.05), there was a 66% increase in cerebral haemorrhage (p=0.01) and a (non-significant) 25% increase in non-cardiovascular deaths.

In HPS, the largest randomised placebo-controlled statin clinical trial to date, 40 mg of simvastatin daily reduced LDL-cholesterol by a substantial 30%, ischaemic stroke by 28% (p < 0.0001), cerebral haemorrhage by 5% (non-significant) and total mortality by 13% (p = 0.0003).

The greatest reported risk reduction in total mortality in the many placebo-controlled RCTs was observed with just 40 mg of pravastatin in the LIPID study.

Conclusions

Any incremental reduction in cardiovascular events has not been shown to be associated with a reduction in total mortality. Being an enzyme (HMG CoA reductase) antagonist, statin efficacy plateaus with increased dose, whilst a wide range of adverse events continue to increase, likely to contribute to the failure to reduce mortality rates. Statins are indicated after stroke but higher doses appear potentially harmful and usually unnecessary.

Background and Aims

To investigate the best NOACs choices in ischaemic stroke patient who is non valvular AF and anaemia, Thrombocytosis or none surgically treated carotid stenosis

Methods

A literature search of PubMed, EMBASE and internal/external databases up to February , 2022 using keyword search terms ‘atrial fibrillation’ AND ‘thrombocytosis’ AND ‘non-vitamin K oral anticoagulant/NOAC’, OR ‘direct oral anticoagulant/DOAC’ did not retrieve any publications regarding patients with NVAF on DOACs presenting thrombocytosis. A broader literature search of PubMed, EMBASE and internal/external databases using keyword search terms ‘thrombocytosis’ “anaemia” “carotid disease “AND ‘non-vitamin K oral anticoagulant/NOAC’ OR ‘direct oral anticoagulant/DOAC’ retrieved few publications regarding patients on DOACs presenting with above groups.

Results

There are 41 cases who treated for different reasons includes DVT, Budd Chari syndrome, Pulmonary embolism who was treated with NOACs and found to have his platelet is high. There were no further information we found support our study groups with thrombocytosis.

In regard, patient with diseased internal carotid arteries anon surgically treated and a known ischaemic stroke and atrial fibrillation. There was no supportive studies that we can find in our research. Except of randomised trial on revascularization of diseased carotid arteries.

In anaemia categories, we found seldom studies in our study group, however, there are retrospective cohort study investigating the safety and effectiveness of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and anaemia in Taiwan

Conclusions

We could not find an enough evidence to support our best practice in such subgroup of ischaemic stroke patients.

Background and Aims

The aim of the study is to assess the usefulness of elastography in the diagnosis of atherosclerotic plaque stability as an element of secondary stroke prevention.

Methods

The research involved the studies of 42 patients aged ca. 67 +/- 7 years, without significant stenosis of the carotid arteries, with a documented history of ischemic stroke and with the presence of atherosclerotic plaque in the B-mode USG examination.

The elastographic examination was performed using the Shear-Wave-Elastography protocol, assessing the direction and type of transverse wave propagation, with simultaneous evaluation of the stiffness of the atherosclerotic plaque and its elements.

The CEUS (contrast enhanced ultrasound) examination was used as the reference study.

Results

It was found that the difference in the propagation velocity of the transverse (shear) wave in the hypoechoic elements of the examined atherosclerotic plaque compared to the propagation velocity above 30% allows for the suspicion of plaque instability.

The study shows much lower speed of shear wave propagation in the plaques assessed in the B-mode test and in CEUS as unstable plaques, while the plaques assessed as stable both in the CEUS examination and in B-Mode as well as their elements were found to be of increased stiffness.

(SWE / CEUS: unstable plaque 91%, plaque 81.2% -p <0.05).

Conclusions

Elastographic examination in correlation with the CEUS examination may prove to be a useful and convenient tool in the assessment of carotid plaque stability, essential for indicating the risk of a secondary ischemic stroke and optimizing its prevention.

Background and Aims

Physicians worldwide witnessed an unprecedented situation during the COVID-19 pandemic. Anticoagulants were required in COVID-19 patients that presented with high D-dimer levels. We present such a case where the decision-making was difficult due to the fact that the patient had suffered a recent intramural massive esophageal hemorrhage and while in the recovery phase she got infected with a severe form of COVID-19.

Methods

Blood reports of a COVID-19 positive 75-year-old female patient having a recent massive esophageal hemorrhage were evaluated. D-dimer levels were noted, in order to decide if anticoagulant therapy should be initiated or not.

Results

The patient suffered a massive esophageal intramural hemorrhage, leaving a large 13 cm long hematoma, presenting yet with melena. She was found to be positive for COVID-19 on the 10^th day of the hemorrhagic event on the esophagus. She was on Clopidogrel 75 mg/day and Aspirin 100 mg/day, for previous coronary stenting, which was momentarily kept on hold due to the intramural bleed of unknown etiology. Dyslipidemia and diabetes mellitus type II with poor control by oral anti-diabetic medications were noted. On the 4^th day of COVID-19, the D-dimmer levels were 1200. It was decided to keep the patient admitted and to start low dose Apixaban, 2.5 mg twice daily for two weeks, and reevaluate. Favorable outcomes were noted.

Conclusions

NOACs play an important role when treating such complicated cases. Especially because of their low possibility to generate hemorrhagic events. Which in the case of Acenocoumarol is quite high.

Background and Aims

Managing stroke is a major challenge, but the prevention of stroke by timely initiation of anticoagulant therapy is even more difficult. The CHA2DS2-VASc score and the HAS-BLED scores are considered the best predictors worldwide for evaluating the risk of stroke and bleeding, respectively, in atrial fibrillation (AF) patients. Hypertension plays a pivotal role in stroke. The aim of our study was to identify if the stroke risk increases with the increase in severity of hypertension or remains the same in different grades of hypertension.

Methods

Medical records of AF patients were evaluated to assess the risk of future stroke events based on their CHA2DS2-VASc scores. Grades of hypertension were taken into consideration. Stroke events occurring in the first year, from the initiation of the study were noted, and statistical analysis was performed.

Results

Among the cases selected for the study, the occurrence of stroke was observed only in patients with grade 3 and grade 4 hypertension during the first year. Based on the scores, all qualifying patients were kept on NOACs and the suitable classes of antihypertensive medications.

Conclusions

Further studies on a larger sample should be performed to ascertain the correlation between the grades of hypertension and the augmented risk of a future stroke event in AF patients. Our results demonstrate the need for revising the CHA2DS2-VASc scores based on the severity of hypertension.

Background and Aims

The purpose of this study is to investigate the association between clinical outcomes and direct oral anticoagulants (DOAC) concentration among atrial fibrillation (AF) patients in real-world.

Methods

Patients aged ≥20 years, had AF, and used DOAC for more than 3 days were enrolled. Trough blood sample was collected and measured with ultrahigh-performance liquid chromatography with tandem mass spectrometry. The DOAC concentration was compared to the expected range reported in clinical trials to define higher, within or lower than range. The Cox proportional hazard model was used to investigate the association between concentration and outcomes.

Results

A total of 781 patients were enrolled, included 189 (24.2%) dabigatran users, 197 (25.2%) rivaroxaban users, 268 (34.3%) apixaban users and 127 (16.3%) edoxaban users. Compared to clinical trials, 127 (16.3%) of DOAC concentrations were lower and 79 (10.1%) of concentrations were higher than the expected range. The incidence of stroke and systemic thromboembolism (SSE) was 1.55 per 100-person years. Low trough concentration was the only significant factor to predict SSE (HR=3.20 [1.32, 7.80]). The incidence of major bleeding was 1.74 per 100-person years. Congestive heart failure is the only factor to predict occurrence of major bleeding (HR=5.92 [2.70, 12.99]). Factors associated with low trough concentration included creatinine clearance (OR=1.02 [1.01, 1.03]), CHA₂DS₂-VASc score (OR=0.85 [0.72, 0.99]), off-label under-dose regimen (OR=1.95 [1.27, 2.99]) and poor adherence (OR=2.50 [1.41, 4.42]).

Conclusions

During DOAC therapy, low drug concentration is associated with SSE. In addition, off label underdose regimen and poor adherence leads to low drug concentration.

Background and Aims

It is unclear what neurologists' real attitudes toward early antiplatelet therapy, statins, and even thrombolytic therapy in acute minor stroke. Our study focused on this topic, particularly dual antiplatelet therapy.

Methods

The Shanxi Stroke Association (SSA) conducted a national cross-sectional questionnaire online from July 2019 to October 2019, and 1274 neurologists responded to the questionnaire.

Results

The total response rate was 79.3%. Approximately 84.9% of neurologists considered an NIHSS score ≤ 3 to indicate a minor stroke, while 23.1% thought that NIHSS scores ≤ 5 indicated a minor stroke. Approximately 93.7% of neurologists chose DAPT for patients with acute minor ischemic stroke as recommended by the guideline, and 52.2% of neurologists selected DAPT for patients with NIHSS scores 3-5. Most neurologists (90.9%) used aspirin due to its effectiveness as the first choice for long-term maintenance therapy after 21 days of DAPT. Approximately 88.5% of doctors would give statins to patients in the acute phase. Neurologists are more likely to choose atorvastatin as the first option, and the universal dosage is 40 mg for atorvastatin. About 82.7% of physicians choose to give intravenous thrombolytic (rt-PA) therapy for minor strokes, and 69.8% of doctors will use dual antiplatelet therapy to patients who accepted rt-PA after 24 hours.

Conclusions

Most neurologists follow the guidelines for using secondary therapy. Nevertheless, there are many choices beyond the guidelines. Especially for DAPT in patients with NIHSS scores above 3 points and an onset time within 24 hours, moderate statins and DAPT were used after thrombolysis for 24 hours.

Background and Aims

Ontario SPCs held primarily in-person visits prior to COVID-19, then suddenly changed to telephone or video visits, enabling service continuity. This change affected service quality and patient experiences.

This study sought to understand patients' perception of Ontario SPCs’ rapid transition to teleconsultation during COVID-19. Two research questions explored (1) patient-identified factors and service-quality dimensions, and (2) factors affecting patient dissatisfaction.

Methods

Using a cross-sectional service performance (SERVPERF) model, we surveyed patients who had a telephone or video consultation at one of two Ontario SPCs in 2021. Concurrent mixed methods, including ordinal regression and thematic analysis, analyzed patients’ perceptions.

Results

The quantitative analysis was based on 110 responses and the qualitative analysis on 98. The online survey response rate was 36.1% and telephone 44.4%. The mean global satisfaction score for teleconsultation was 3.95 (SD=.975). Three SERVPERF dimensions were statically significantly associated with global satisfaction scores: responsiveness (p<.001), assurance (p=.010), and empathy (p=.004). Two demographic factors, travel distance ((p=.035) and language barrier (p=.040) were statistically significantly related to global satisfaction scores. Patients with low global satisfaction scores had the most negative perception of assurance (n=26), reliability (n=13), and empathy (n=10). The main subdomains were missing clinical activities, inadequate communication, lack of follow-through in the administrative process, and absence of personal connection.

Conclusions

We identified three service-quality dimensions and two demographic factors statistically significantly associated with patients' satisfaction, and four important subdomains affecting patients' perceptions. All could be considered when designing a hybrid service model to enhance patient experiences of stroke prevention care.

Background and Aims

Antithrombotic treatment for patients with prior antiplatelet or anticoagulant presenting with acute minor stroke (NIHSS ≤5) or transient ischaemic attack (TIA) is unclear. We aim to explore how these patients are treated by stroke physicians.

Methods

Eighty stroke physicians in Malaysia participated in an online survey where participants answered scenario-based multiple-choice questions. Participants were also given the choice to describe their treatment plan if it was not one of the choices given.

Results

95% (76/80) participants would treat antithrombotic-naïve patients presenting with minor stroke or TIA with dual antiplatelet consisting of aspirin plus either clopidogrel (72, 90%) or ticagrelor (4, 5%) for 14 to 21 days followed by clopidogrel or ticagrelor long term. When a patient on clopidogrel presented with minor stroke/TIA, the treatment strategies include dual antiplatelet excluding clopidogrel (aspirin/dipyridamole=2, 2.5%; aspirin/ticagrelor 15, 18.8%), dual antiplatelet of aspirin/clopidogrel (43, 53.8%), switch to aspirin (7, 8.8%) or deferring decision till platelet function test (13, 16.3%). In a patient with atrial fibrillation on direct oral anticoagulant (DOAC) presenting with minor stroke, treatment options include continue with same DOAC (21, 26.3%), switch to alternative DOAC (18, 22.5%), switch to aspirin temporarily (4, 5%), adding on aspirin (21, 26.3%) or clopidogrel (16, 20%) to existing DOAC. Six participants (7.5%) have tests for antiplatelet resistance available at their centres, whilst 5 (6.3%) use the tests routinely or occasionally.

Conclusions

The practice of antithrombotics in perceived antithrombotic failure varies widely. Future studies incorporating antiplatelet resistance testing may help determine optimal strategy.

Background and Aims

BACKGROUND

The validity of platelet aggregation studies in predicting future adverse vascular events in patient on aspirin is controversial.

AIM

To determine the reliability and the significance of aspirin responsiveness status assessed by light transmission aggregometry in predicting the recurrence of vascular events in patients after acute ischemic stroke.

Methods

We conducted a prospective cohort study in Ischemic stroke patients of age between 20-70 years, who were on a daily dose of 150mg of aspirin. Aspirin responsiveness status was assessed using light transmittance aggregometry (LTA) induced by arachidonic acid (AA) and adenosine diphosphate (ADP). Patients were followed up for recurrent vascular events, sudden death, and all-cause mortality.

Results

The study enrolled 174 patients. LTA was repeated in 78 patients on follow-up. 56.8% were responders, 34.5% semi responders, and 8.6% were non-responders to aspirin. There was no difference in the responder status on follow-up testing. The median distribution of serum thromboxane was 1.23 ng/ml in responders and 5.03 ng/ml in non-responders. In ADP semi-responders the median serum thromboxane value was 0.9 ng/ml, while in AA-semi-responders the median was 2.55 ng/ml. The groups were assessed for clinical endpoints of recurrent vascular events and sudden death. . HR for aspirin non-responders and AA semi responders was 18.8 while those for aspirin responders and ADP semi responders were 2.3.

Conclusions

Platelet responsiveness to aspirin assessed using light transmission aggregometry is reliable on repeat assessment. The combined group of aspirin non-responders and AA semireponders has worse vascular event-free survival than aspirin responders and ADP semiresponders.

Background and Aims

Recurrent stroke, cardiovascular morbidity and mortality, primarily due to non-adherence to stroke prevention management, lead to poor outcomes in post-stroke patients. SPRINT provides patient education with positive reinforcements to support sustainable behavior change and prevent stroke recurrence. As part of this multipronged package, stroke prevention workbook was developed in English following formative, acceptability and implementation stage process and translated into 11 regional languages. This 11-chapter workbook (covering stroke, risk factors and life after stroke) having 15 activities, was provided to intervention arm to be completed in 6 weeks, with monthly revisions until one year. Feedback questionnaire was collected at 1 year.

Methods

Used patient workbooks were recalled from all 30 centers across India with English translations of activities. Those who could not return physical workbook were asked to send pictures of activities, which were analyzed as PDFs. Activities were graded in Excel according to Likert scale based on level of completeness and responses were analyzed. Activities were grouped into objective (close-ended) and subjective (open-ended).

Results

Of 1010 workbooks analyzed, number of patients who attempted activities at 1, 2, 3, 4, 5 and 6 weeks were 908 (89.90%), 833 (82.48%), 805 (79.70%), 592 (58.61%), 662 (65.54%) and 548 (54.26%) respectively. More than half (76.83%) of the patients plan to or have improved their lifestyle. There was statistically significant (p<0.001) difference between response rates for objective (93.27%) versus subjective activities (58.71%).

Conclusions

Interventions for lifestyle modification should be designed in predominantly objective pattern, while recognizing that response rates steadily decrease as time from index event increases.

Background and Aims

Blunt cerebrovascular injuries (BCVIs) are an uncommon complication of trauma but associated with high risk of ischemic stroke (IS), particularly in the young. Detecting BCVI is challenging as most patients are either asymptomatic or unexaminable. Extended screening criteria and modern non-invasive imaging have improved the timely detection of BCVIs. We studied the incidence of BCVIs and associated IS in a major, Level 1 trauma centre in Australia.

Methods

This was a single centre, retrospective, cohort study of all adult major trauma patients admitted to The Alfred hospital from January 2014 to June 2021. BCVIs were confirmed on imaging by independent, blinded neuroradiologists prior to study inclusion. Demographics, injury mechanism and associated injuries as well as outcomes including IS were recorded.

Results

There were 23,775 trauma calls recorded, out of which 20,954 were blunt trauma. Initially there were 369 patients reported as having a BCVI, however after independent review, 306 patients were confirmed and those were selected for analyses. The median age was 51 and 65% were men. The incidence of BCVI was 1.4% (306/20,954). 43 patients had IS (14%) of which 13 presented on arrival and 30 (10%) occurred during admission.

Conclusions

Despite a low and stable incidence of BCVI, the frequency of IS in adult, blunt, major trauma patients remains high. About 2/3^rd of IS occur as an inpatient and thus can potentially be targeted by preventative treatment strategies. Detecting BCVIs early is critical to the identification of patients at risk and to the tailoring of individual therapies.

Background and Aims

Shexiang Baoxin Pill (SBP) is a proprietary Chinese medicine initially used to treat cardiovascular diseases. The purpose of this study was to explore whether SBP had the potential in preventing and alleviating ischemic stroke-induced neuropsychiatric sequelae and the underlying mechanisms in cultured neural cells with oxygen glucose deprivation and reoxygenation (OGD/R) and rat model of cerebral ischemia/reperfusion with middle cerebral artery occlusion (MCAO).

Methods

Cultured neural cells with oxygen glucose deprivation and reoxygenation (OGD/R) and rat model of cerebral ischemia/reperfusion with middle cerebral artery occlusion (MCAO) were used in this study.

Results

MCAO rats received two doses of oral SBP (28 or 56 mg/kg) starting at 1 h of MCAO and once daily thereafter for 2 weeks. SBP significantly reduced cerebral infarction size at the early stage of stroke. SBP also alleviated ischemic stroke-induced depression- and anxiety-behavior. SBP-treated rats had much less cognitive and locomotor impairment compared to control rats. SBP downregulated apoptosis, and upregulated the expression of p-Akt/Akt and p-GSK3β/GSK3β signal pathway in both cultured cells and rat brain regional tissues.

Conclusions

These results suggest that SBP may be an effective agent in the prevention and alleviation of neuropsychiatric sequelae of ischemic stroke.

Background and Aims

Hypertension is common in patients with acute ischemic stroke. Most studies have shown that elevated baseline blood pressure is associated with poor clinical prognosis. Antihypertensive therapy may be safe, but whether patients can benefit from it is controversial.Stroke type and the choice of antihypertensive time may affect the effect of antihypertensive therapy. Our aim is to explore whether lowering blood pressure has a consistent effect on in-hospital outcomes in acute minor ischemic stroke patients with and without intracranial atherosclerotic stenosis.

Methods

This is a retrospective study based on the real-world, enrolling minor stroke patients from three centers. All patients accepted MRA to evaluate whether ICAS existed. Patients with/without ICAS were divided into three groups according to the antihypertensive time (non-antihypertensive, early antihypertensive within 24 hours and delayed antihypertensive after 24 hours). The primary outcome was in-hospital recurrent stroke, and secondary outcome was early neurologic deterioration(END). Regression models were used to determine the relationship between blood pressure lowering time and outcomes.

Results

Among 1342 enrolled patients, there were 580 patients with ICAS. Antihypertensive therapy after 24 hours of onset might increase the risk of in-hospital stroke recurrence in patients without ICAS ( adjusted HR 1.81,95 % CI 0.94-3.48 ; p = 0.076 ). While for patients with ICAS, antihypertensive therapy after 24 hours of onset reduced the risk of early neurological deterioration ( adjusted HR 0.06,95 % CI 0.01-0.65 ; p = 0.021 ).

Conclusions

Acute minor ischemic stroke patients with ICAS can delay the time of antihypertensive therapy appropriately, and patients without ICAS are more likely to recommend early antihypertensive therapy.

Background and Aims

Discontinuation of non-vitamin K antagonist oral anticoagulants (NOACs) may induce a hypercoagulable state, leading to severe stroke and poor outcomes. To compare stroke outcomes between NOACs withdrawal and other prior medication status in patients with non-valvular atrial fibrillation (NVAF).

Methods

Consecutive patients who had pre-existing NVAF and were admitted for an acute ischemic stroke or transient ischemic attack at five hospitals between January 2017 and December 2020 were included. Prior medication status was categorized into seven groups such as no antithrombotics, antiplatelet-only, warfarin with subtherapeutic intensity, warfarin with therapeutic intensity, NOAC, warfarin withdrawal, and NOAC withdrawal. We compared initial National Institute of Health Stroke Scale (NIHSS) scores between groups.

Results

Among 825 patients with NVAF, The median NIHSS score at admission was 5 (IQR 1-13). The NOAC withdrawal group had the highest median NIHSS scores at stroke onset (16, interquartile range, IQR [4-20]), followed by the warfarin withdrawal group (11, IQR [3-17]), the no antithrombotic group (5, IQR [2-16]), and the warfarin with subtherapeutic intensity group (5, IQR [2-13]). Multivariable analysis demonstrated that NOAC withdrawal was independently associated with higher NIHSS scores at stroke onset (B 4.645, 95% confidence interval 0.384–8.906, P=0.033). The median interval from drug withdrawal to ischemic stroke or TIA was 7 days (IQR 4-15) in the NOAC group.

Conclusions

Stroke occurred after discontinuing oral anticoagulants, particularly NOAC, was independently associated with severe stroke at presentation.