Cardioembolic vs. noncardioembolic strokes in atrial fibrillation: frequency and effect of antithrombotic agents in the stroke prevention in atrial fibrillation studies

BACKGROUND: While atrial fibrillation (AF) increases the risk of cardioembolic stroke, some ischemic strokes in AF patients are noncardioembolic. OBJECTIVES: To assess ischemic stroke mechanisms in AF and to compare their responses to antithrombotic therapies. METHODS: On-therapy analyses of ischemic strokes occurring in 3,950 participants in the Stroke Prevention in Atrial Fibrillation I-III clinical trials. Strokes were classified by presumed mechanism according to specified neurologic features by neurologists unaware of antithrombotic therapy. RESULTS: Of 217 ischemic strokes, 52% were classified as probably cardioembolic, 24% as noncardioembolic, and 24% as of uncertain cause (i.e., 68% of classifiable infarcts were deemed cardioembolic). Compared to those receiving placebo or no antithrombotic therapy, the proportion of cardioembolic stroke was lower in patients taking adjusted-dose warfarin (p = 0.02), while the proportion of noncardioembolic stroke was lower in those taking aspirin (p = 0.06). Most (56%) ischemic strokes occurring in AF patients taking adjusted-dose warfarin were noncardioembolic vs. 16% of strokes in those taking aspirin. Adjusted-dose warfarin reduced cardioembolic strokes by 83% (p < 0.001) relative to aspirin. Cardioembolic strokes were particularly disabling (p = 0.05). CONCLUSIONS: Most ischemic strokes in AF patients are probably cardioembolic, and these are sharply reduced by adjusted-dose warfarin. Aspirin in AF patients appears to primarily reduce noncardioembolic strokes. AF patients at highest risk for stroke have the highest rates of cardioembolic stroke and have the greatest reduction in stroke by warfarin.     

Antithrombotic agents’ use in patients with atrial fibrillation and acute cerebral ischemia

Background although trials suggest a benefit of aspirin, and not of anticoagulation (AC), in the acute stage of cerebral ischemia associated with atrial fibrillation (AF), many neurologists still use heparin. Objective to evaluate how antithrombotic agents were used at the acute stage of cerebral ischemia in AF patients after the publication of trials and guidelines. Methods we reviewed the charts of all patients with AF who were admitted between 1996 and 2002 as primary care patients, within 48 hours after onset of an ischemic stroke (IS) or transient ischemic attacks (TIAs). We recorded the first antithrombotic treatment prescribed at admission. Results in 763 consecutive patients (42% men; median age 79 years), the use of AC on admission decreased over time from 70% to 22% (p<0.001), while antiplatelet agents increased from 27% to 78% (p<0.001). Patients who received AC were more likely to be younger, to have a Barthel index >60, no hemorrhagic changes, and to have been admitted in 1996 or 1997. Results were similar between patients with IS and TIAs and in patients who were not under AC before. In patients who were under oral AC before, AC use at admission did not decline over time (p=0.366). Conclusion there was a clear decrease in AC use during the study period, except in patients who were already under AC before, and in TIA patients. Funding: grant EA 2691 and EA 1046 from the French Ministry of Education, Research and Technology. Received in revised form: 23 October 2005     

Detection of atrial fibrillation in patients with acute stroke

Atrial fibrillation (AF) and paroxysmal AF (PAF) are common causes of stroke which may not be detected by a single electrocardiogram (EKG). We conducted a prospective study to determine if 48 hours of telemetry monitoring increased the rate of detection of AF in patients with acute stroke and thus identified patients requiring anticoagulation. One hundred and fifty consecutive patients with acute ischemic stroke were placed on telemetry monitoring for 48 hours. Thirty-five patients had AF related strokes. There were 12 patients with AF related stroke who did not have a previous history of AF and were found to have AF following the stroke. Six of these 12 patients were found to have AF on their admission EKG. The remaining six patients had normal admission EKGs and were diagnosed with AF only during telemetry monitoring for 48 hrs. Patients with AF were older, had larger strokes, which were more likely to be non-lacunar, than patients without AF. Our study suggests that AF is sometimes undiagnosed until a stroke occurs. Improved methods of detection of AF are needed in high-risk patients for primary stroke prevention. Patients older than 65 years of age with non-lacunar strokes should have 48 hours of telemetry monitoring to detect previously undiagnosed AF.     

Preceding Antithrombotic Treatment is Associated With Acute Ischemic Stroke Severity and Functional Outcome at 90 Days Among Patients With Atrial Fibrillation

BackgroundAntithrombotic therapies are known to prevent ischemic stroke (IS) for patients with atrial fibrillation (AF), but are often underused in clinical practice. The aim of present study was to investigate the prevalence of patients with acute IS with known history of AF who were not receiving antithrombotic treatment before stroke and to evaluate the association of preceding antithrombotic treatment with stroke severity and outcomes at 90 days after admission.Materials and MethodsThis was a retrospective, multi-center, observational study of 748 patients with acute IS and known history of AF admitted to 6 participating hospitals between March 2016 and October 2017. The primary outcome was stroke severity at admission as assessed using National Institutes of Health Stroke Scale (NIHSS) score. The secondary outcome was functional outcome at 90 days after admission as measured by modified Rankin Scale (mRS) score.ResultsA total of 748 patients, 54 (7.2%) were receiving therapeutic warfarin (international normalized ratio [INR] ≥ 2) and 100 (13.4%) had subtherapeutic warfarin anticoagulation (INR < 2), 340 (45.5%) were receiving antiplatelet treatment, and 254 (34.0%) were not receiving any antithrombotic treatment prior to stroke. Compared with no antithrombotic treatment, therapeutic warfarin (OR: 0.64; 95% CI: 0.52-0.82; P = .022), and antiplatelet therapy only (OR: 0.89; 95% CI: 0.76-0.96; P = .041) were associated with lower odds ratio of moderate or severe stroke (NIHSS ≥ 16). Patients receiving preceding therapeutic warfarin (OR: 1.32; 95% CI: 1.22-3.57; P = .025), antiplatelet therapy only (OR: 1.13; 95% CI: 1.07-2.59; P = .043), and subtherapeutic warfarin with INR 1.5 to 1.99 (OR: 1.15; 95% CI: 1.10-2.66; P = .042) had higher odds ratio of better functional outcome (mRS ≤ 2) at 90 days.ConclusionsAmong patients with AF who had experienced an acute IS, inadequate therapeutic warfarin preceding the stroke was very prevalent in China. Therapeutic warfarin was associated with less severe stroke and better functional outcome at 90 days.     

Preceding direct oral anticoagulant administration reduces the severity of stroke in patients with atrial fibrillation – K-PLUS registry

BackgroundStroke severity can be mitigated by preceding anticoagulant administration in acute ischemic stroke patients with atrial fibrillation (AF). We investigated if such mitigative effects are different between warfarin and direct oral anticoagulants (DOACs).Material and methodsWe collected data from a regional multicenter stroke registry. Ischemic stroke or transient ischemic attack patients with AF were included. Background characteristics, National Institutes of Health Stroke Scale (NIHSS) score on admission, lesion characteristics, and in-hospital death were analyzed according to preceding antithrombotic agents at onset.ResultsA total of 2173 patients had AF; 628 were prescribed warfarin, 272 DOACs, 429 antiplatelets alone, and 844 no antithrombotics. The NIHSS score on admission was lowest in the DOACs group compared to the other groups. In neuroimaging analysis, small ischemic lesions were observed more frequently in the DOACs group, while large ischemic lesions were less frequent in this group. When the no antithrombotics group was used as a reference, the adjusted odds ratio for moderate to severe stroke was 0.56 (95% confidence interval, 0.40–0.78) in the DOACs group, while it was 0.98 (0.77–1.24) in the warfarin group and 0.94 (0.72–1.22) in the antiplatelets group. In-hospital mortality was lowest in the DOACs group compared to the other groups.ConclusionPreceding DOAC administration might mitigate the severity of stroke in AF patients more strongly than other antithrombotics, possibly leading to a better outcome in patients with stroke.     

Outcomes in patients with ischaemic stroke undergoing endovascular thrombectomy: Impact of atrial fibrillation

ObjectivesEndovascular thrombectomy (EVT) is associated with good clinical outcomes in ischaemic stroke, but the risk of intracerebral haemorrhage (ICH) and mortality remains common following ischaemic stroke. The effect of concomitant atrial fibrillation (AF) on clinical outcomes following acute ischaemic stroke in patients receiving EVT remains unclear. The aim is to investigate associations between AF and intracerebral haemorrhage and all-cause mortality at 90 days in patients with ischaemic stroke undergoing EVT.Materials and MethodsA retrospective cohort was conducted using TriNetX, a global health research network. The network was searched for people aged ≥18 years with ischaemic stroke, EVT and AF recorded in electronic medical records between 01/09/2018 and 01/09/2021. These patients were compared to controls with ischaemic stroke, EVT and no AF. Propensity score matching for age, sex, race, comorbidities, National Institutes of Health Stroke Scale (NIHSS) scores, and prior use of anticoagulation was used to balance the cohorts with and without AF.ResultsIn total 3,106 patients were identified with history of ischaemic stroke treated by EVT. After propensity-score matching, 832 patients (mean age 68 ± 13; 47% female) with ischaemic stroke, EVT and AF, were compared to 832 patients (mean age 67 ± 12; 47% female) with ischaemic stroke, EVT and no history of AF. In the cohort with AF, 11.5% (n = 96) experienced ICH within 90 days following EVT, compared with 12.3% (n = 103) in patients without AF (Odds Ratio (OR) 0.92, 95% confidence interval (CI) 0.68-1.24; p = 0.59). In the patients with AF, mortality within 90 days following EVT was 18.7% (n = 156), compared with 22.5% in patients without AF (n = 187) (OR 0.79, 95% CI 0.63-1.01; p = 0.06).ConclusionIn patients with ischaemic stroke undergoing EVT, AF was not significantly associated with intracerebral haemorrhage or all‐cause mortality at 90‐day follow‐up.     

Recommendations for the use of new oral anticoagulants (NOACs) after TIA or stroke caused by atrial fibrillation (AF), after a consensus conference among Italian neurologists (the Venice group)

Vascular neurologists of Veneto and Friuli Venezia Giulia, north-east regions of Italy, have sought an agreement on the two following questions: (A) what prophylactic treatment should we recommend to patients with a stroke ascribed to atrial fibrillation (AF), who were not previously on antithrombotic treatment, to prevent further strokes? (B) What should we do in the event of an ischemic or hemorrhagic stroke associated with AF in patients who were already on antithrombotic treatment? There was a unanimous consensus for preferring the new oral anticoagulants (NOACs) in patients not taking any antithrombotics and in cases treated with antithrombotic drugs (coumadin and/or antiplatelets), due to a lower incidence of intracranial bleeding complications and a noninferiority for recurrent stroke or TIA. Even after intracranial bleeding complications, when it is useful or necessary to continue anticoagulant treatment, the group of experts preferred the NOACs, suggesting, however, to be very cautious in cases with widespread leukoaraiosis or microbleeds, practice frequent monitoring of creatinine clearance (CrCl) and avoid using NOACs when CrCl is <30 mL/min.     

Factors associated with ischemic stroke during aspirin therapy in atrial fibrillation: analysis of 2012 participants in the SPAF I-III clinical trials. The Stroke Prevention in Atrial Fibrillation (SPAF) Investigators.

BACKGROUND AND PURPOSE: Nonvalvular atrial fibrillation (AF) is a strong, independent risk factor for stroke, but the absolute rate of stroke varies widely among AF patients, importantly influencing the potential benefit of antithrombotic prophylaxis. We explore factors associated with ischemic stroke in AF patients taking aspirin. METHODS: We performed multivariate logistic regression analysis of 2012 participants given aspirin alone or in combination with low, inefficacious doses of warfarin in the Stroke Prevention in Atrial Fibrillation I-III trials followed for a mean of 2.0 years, during which 130 ischemic strokes were observed. RESULTS: Age (relative risk [RR]=1.8 per decade, P<0.001), female sex (RR=1.6, P=0.01), history of hypertension (RR=2.0, P<0.001), systolic blood pressure >160 mm Hg (RR=2.3, P<0.001), and prior stroke or transient ischemic attack (RR=2.9, P<0.001) were independently associated with increased stroke risk. Regular consumption of >/=14 alcohol-containing drinks per week was associated with reduced stroke risk (adjusted RR=0.4, P=0.04). Among SPAF III participants, estrogen hormone replacement therapy was associated with a higher risk of ischemic stroke (adjusted RR=3.2, P=0.007). With the use of these variables, a risk stratification scheme for primary prevention separated participants into those with high (7.1%/y, 22% of the cohort), moderate (2.6%/y, 37% of the cohort), and low (0.9%/y, 41% of the cohort) rates of stroke. Ischemic strokes in low-risk participants were less often disabling (P<0.001). CONCLUSIONS: Patients with AF who have high and low rates of stroke during treatment with aspirin can be identified. However, validation of our risk stratification scheme is necessary before it can be applied with confidence to clinical management. Postmenopausal estrogen replacement therapy and moderate alcohol consumption may additionally modify the risk of stroke in AF, but these findings require confirmation.     

Antithrombotic therapy for ischaemic stroke patients with AF/RHD in West China daily practice

Abstract

Background and Objective:

Although, current evidence-based guidelines advocate anticoagulation as a strong recommendation in IS patients with AF/RHD, the underuse of anticoagulation in IS patients with AF/RHD has been found in clinical practice worldwide. Nevertheless, there was little information about implementation of antithrombotic therapy to prevent stroke for patients with AF and/or RHD in daily practice in West China. Our study determined to clarify the patterns, adherence and comparative effect of antithrombotic treatment during 1-year follow-up in IS patients with AF and/or RHD.

Method:

Consecutive patients with acute IS and AF/RHD admitted to Department of Neurology, West China Hospital from November 2010 to October 2011 were included in the study.

Results:

155 consecutive patients were analysed in this study. One hundred thirteen patients have been diagnosed as AF and/or RHD before admission. Of these, 49 (43.4%) patients were receiving antithrombotic therapy before the time of admission, including nine (8.0%) patients receiving warfarin. At 12?months after stroke onset, 109 (81.3%) patients were on antithrombotics, and 46 (34.3%) patients were on warfarin alone. The persistence rate of warfarin use at 1?year was 77.8%. Moreover, there were 80 (81.6%) patients never starting to use warfarin. Compared with no antithrombotic therapy, anti-platelets and warfarin reduced death risk significantly during 1-year after stroke onset (P?=?0.005).

Conclusion:

Our study suggests that overall real-world use of warfarin in IS patients with AF and/or RHD is low before and after admission in West China. Implementation study on this respect should be conducted in this area to improve the daily practice.     

Predictors of atrial fibrillation detection and features of recurrent strokes in patients after cryptogenic stroke

Background and purposeUse of implantable cardiac monitors (ICMs) has increased diagnosis of atrial fibrillation (AF) in cryptogenic stroke (CS) patients. Identifying AF predictors may enhance the yield of AF detection. Recurrent strokes after CS are not well described. We aimed to assess the predictors for AF detection and the characteristics of recurrent strokes in patients after CS.MethodsWe reviewed electronic medical records of CS patients who were admitted between February 2014 and September 2017 and underwent ICM placement with minimum one-year follow-up. Patient demographics, stroke characteristics, pre-defined risk factors as well as recurrent strokes were compared between patients with and without AF detection.Results389 patients with median follow-up of 548 days were studied. AF was detected in 102 patients (26.2%). Age (per decade increase, OR 2.10, CI 1.64–2.68, with vs. without AF) and left atrium diameter (per 5 mm increase, OR 1.91, CI 1.33–2.74) were identified as AF predictors. Intracranial large vessel stenosis >50% irrelevant to the index strokes was associated with AF detection within 30 days (OR 0.24, CI 0.09–0.69, >30 vs. <30 days). Recurrent strokes occurred in 14% patients with median follow-up about 2.5 years. Topography of these strokes resembled embolic pattern and was comparable between patients with and without AF. Among recurrent strokes in patients with AF, the median time to AF detection was much shorter (90 vs. 251 days), and the median time to first stroke recurrence was much longer (422 vs. 76 days) in patients whose strokes recurred after AF detection than those before AF detection.ConclusionsOlder age and enlarged left atrium are predictors for AF detection in CS patients. Intracranial atherosclerosis is more prevalent in patients with early AF detection within 30 days. Recurrent strokes follow the embolic pattern, and early AF detection could delay the stroke recurrence.     

Case Fatality Decline from 2009 to 2013 among Medicare Beneficiaries with Ischemic Stroke

ObjectivesThis study aimed to examine the temporal trend of 30-day and 1-year mortality among U.S. Medicare beneficiaries who were hospitalized for ischemic stroke, with special focus on the mortality among subgroup of patients in relation to acute reperfusion therapies including intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT).MethodsWe evaluated Medicare fee-for-service beneficiaries age 65 years or older who were hospitalized for ischemic stroke between 2009 and 2013. Multivariable Cox proportional hazards models were generated to analyze the trend of adjusted mortality.ResultsA total of 1,070,574 patients were included in the study. The 30-day mortality did not change among patients who were not treated with IVT or EVT. It decreased by 13% among patients treated with IVT but not EVT (HR = .87, 95% CI .82-.92), 25% among patients treated with EVT but not IVT (HR = .75, 95% CI .59-.95), and 37% among patients treated with both IVT and EVT (HR = .63, 95% CI .52-.77). One-year mortality decreased by 19% among patients who were not treated with IVT nor EVT (HR = .81, 95% CI .80-.83), 22% among those treated with IVT but not EVT (HR = .78, 95% CI .75-.81), 33% among those treated with EVT but not IVT (HR = .67, 95% CI .55-.81), and 38% among those treated with both IVT and EVT (HR = .62, 95% CI .53-.73).ConclusionsFrom 2009 to 2013, the 30-day stroke case fatality decreased only among the patients received reperfusion therapy. The 1-year mortality declined among all the stroke patients, with the greatest decline among those treated with both IVT and EVT.     

COVID-19 and Stroke: Incidence and Etiological Description in a High-Volume Center

BackgroundAn increased rate of thrombotic events has been associated to Coronavirus Disease 19 (COVID-19) with a variable rate of acute stroke. Our aim is to uncover the rate of acute stroke in COVID-19 patients and identify those cases in which a possible causative relationship could exist.MethodsWe performed a single-center analysis of a prospective mandatory database. We studied all patients with confirmed COVID-19 and stroke diagnoses from March 2^nd to April 30^th. Demographic, clinical, and imaging data were prospectively collected. Final diagnosis was determined after full diagnostic work-up unless impossible due to death.ResultsOf 2050 patients with confirmed SARS-CoV-2 infection, 21 (1.02%) presented an acute ischemic stroke 21 and 4 (0.2%) suffered an intracranial hemorrhage. After the diagnostic work-up, in 60.0% ischemic and all hemorrhagic strokes patients an etiology non-related with COVID-19 was identified. Only in 6 patients the stroke cause was considered possibly related to COVID-19, all of them required mechanical ventilation before stroke onset. Ten patients underwent endovascular treatment; compared with patients who underwent EVT in the same period, COVID-19 was an independent predictor of in-hospital mortality (50% versus 15%; Odds Ratio, 6.67; 95% CI, 1.1-40.4; p 0.04).ConclusionsThe presence of acute stroke in patients with COVID-19 was below 2% and most of them previously presented established stroke risk factors. Without other potential cause, stroke was an uncommon complication and exclusive of patients with a severe pulmonary injury. The presence of COVID-19 in patients who underwent EVT was an independent predictor of in-hospital mortality.     

Predictors and outcome of malignant cerebral edema after successful reperfusion in anterior circulation stroke

Background and objectiveRisk factors and predictors of malignant cerebral edema (MCE) after successful endovascular thrombectomy (EVT) were not fully explored. This study aimed to evaluate the incidence and risk factors of MCE after successful reperfusion.MethodsWe retrospectively analyzed consecutive ischemic stroke patients who underwent EVT in our institution from November 2015 to April 2022. Patients who failed to achieve successful reperfusion (modified thrombolysis in cerebral infarction [mTICI]<2b) were excluded. Based on multivariate logistic models, the best-fit monogram was established. The discriminative performance was assessed by the receiver operating characteristics curve (ROC).ResultsA total of 307 patients were included and 48 (15.6%) were diagnosed with MCE after successful reperfusion. Patients with MCE after successful reperfusion had a lower 3-month favorable outcome (15.2% versus 59.6%; p<0.001), a lower 3-month good outcome (17.4% versus 68.4%; p<0.001), and a higher rate of mortality at 3-month (54.3% versus 8.8%; p<0.001) compared with patients without MCE. Predictors of MCE after successful reperfusion included admission glucose level, baseline National Institutes of Health Stroke Scale (NIHSS) score, stroke etiology, occlusion site and puncture-to-reperfusion (PTR) time>120 min. The area under the curve (AUC) of the nomogram was 0.805 (95% CI, 0.756-0.847).ConclusionsMCE after successful reperfusion is associated with poor outcome and mortality. A nomogram containing admission glucose level, baseline NIHSS score, stroke etiology, occlusion site and PTR time>120 min may predict the risk of MCE after successful reperfusion in patients with acute ischemic stroke and treated successfully with EVT.     

Workflow and Outcomes of Endovascular Thrombectomy for In-Hospital Stroke a Systematic Review and Meta-Analysis

Background and PurposeAcute strokes due to large vessel occlusion in hospitalized patients is not uncommon. We performed a systematic review and meta-analysis to investigate the timing and outcome of endovascular thrombectomy (EVT) for in-hospital stroke.MethodsWe conducted a meta-analysis of clinical studies published in English until September 2020 in the MEDLINE and Cochrane databases. Studies reporting original data on the characteristics and outcomes of in-hospital stroke patients treated with EVT were included. We extracted data on the time-metrics from last known well (LKW) until reperfusion was achieved. We also collected data on procedural and functional outcomes.ResultsOut of 5093 retrieved studies, 8 were included (2,622 patients). The median age was 71.4 years and median NIHSS score on admission was 16. Patients were mostly admitted to the cardiology service (27.3%). The pooled time from LKW to recognition by staff was 72.9 min (95% CI: 40.7 to 105 min). 25.6% received IV tPA. The mean time from stroke recognition to arterial puncture was 134.5 min (95% CI: 94.9 to 174.1). Successful reperfusion occurred in 82.8.% with a pooled mean time from detection to reperfusion of 193.1 min (95% CI: 139.5 to 246.7). The 90-day independent functional outcome was reported in 42% of patients (95% CI 29 to 55%).ConclusionEVT can be performed safely and successfully for in-hospital strokes. Noticeable delays from LKW to detection and then to puncture are noted. This calls for better stroke pathways to identify and treat these patients.BackgroundStroke in hospitalized patients, referred to as in-hospital stroke (IHS), accounts for 2.2–17% of all strokes.¹ The majority of these are ischemic while intracranial hemorrhage represents 2–11% of all IHS.¹ These patients are expected to have a rapid diagnosis and treatment given the ongoing medical supervision, and therefore favorable outcomes.^1–3 However, existing studies report poor outcomes in patients with IHS with a mortality risk that exceeds that of community-onset stroke (COS): 24.7% vs 9.6%.⁴ Surviving IHS patients are also less likely to be discharged home compared to COS (27.7% vs 49.9%) and to be functionally independent at 3 months (31.0% vs 50.4%).^1–4     

Burden of Premature Atrial Complexes and Risk of Recurrent Stroke and Death in Patients with Mild to Moderate Ischemic Stroke

BackgroundPremature atrial complexes (PACs) meet increased attention as a potential intermediary between sinus rhythm and atrial fibrillation (AF). Patients with even high numbers of PACs do not fulfill current guidelines for oral anticoagulation treatment though an associated stroke risk is suspected. Objective: We aimed to determine whether a high number of PACs or runs of AF less than 30 seconds in 2-day continuous electrocardiogram (ECG) recording was associated with risk of recurrent ischemic stroke/transient ischemic attack (TIA) or death in a large cohort of patients with acute ischemic stroke or TIA and no prior AF.MethodsWe performed 48 hours continuous ECG recording within 1 week after ischemic stroke/TIA. PACs were reported as mean number of PACs per hour. Patients were followed in Danish Stroke Registry, Danish Civil Registration System, and Danish National Patient Registry. Cox Regression analysis was used to calculate hazard ratios.ResultsWe included 1507 patients with TIA (40%) or ischemic stroke (60%), of which 98.7% had mild to moderate strokes. Mean age was 72.9 (7.8) years, 43.4% were females. Follow-up was 2.3 (1.3) years. Hazard ratio for recurrent stroke/TIA or death did not differ between quartiles of PAC burden, nor did any of the 2 components of this composite endpoint. Nonsustained AF less than 30 seconds was not associated with higher risk of recurrent stroke/TIA or death.ConclusionsIn a large cohort of patients with recent ischemic stroke or TIA, burden of PACs or nonsustained AF less than 30 seconds were not associated to higher risk of recurrent stroke/TIA or death.     

Adequate Adherence to Direct Oral Anticoagulant is Associated with Reduced Ischemic Stroke Severity in Patients with Atrial Fibrillation

BackgroundThe impact of adherence to direct oral anticoagulants (DOACs) is unknown. We aimed to assess the effects of preceding anticoagulation treatment on neurologic severity at admission and functional outcomes at discharge in patients with atrial fibrillation (AF) who developed acute ischemic stroke.MethodsWe retrospectively assessed consecutive patients with acute ischemic stroke and AF. Adherence to DOACs was assessed using the 4-item Morisky Medication Adherence Scale. Associations between preceding DOAC treatment and stroke severity at admission and functional outcomes at hospital discharge were examined.ResultsOf 387 patients with AF and acute ischemic stroke, 248 (64.1%) were not administered an anticoagulant before stroke onset, 95 (24.5%) had subtherapeutic warfarin with an international normalized ratio less than 2 at the time of stroke, 16 (4.1%) had therapeutic warfarin, 6 (1.6%) had DOACs with nonadherence, and 22 (5.7%) had DOACs with adequate adherence. Multivariate analysis showed that DOAC treatment with adequate adherence was associated with lower odds of severe stroke (National Institute of Health Stroke Scale ≥10 at admission) (odds ratio, .24; 95% confidence interval, .03-.98; P = .04) and higher odds of excellent recovery (modified Rankin Scale score, 0-1 at discharge) (odds ratio, 4.89; 95% confidence interval, 1.51-20.6; P < .01) compared with no anticoagulation therapy.ConclusionsPreceding DOAC treatment with adequate adherence has beneficial effects on stroke severity at admission and functional outcome at discharge in patients with AF. Hence, our results encourage an increased effort to bolster adherence to DOACs in patients with AF.     

Neurological Deficits in Stroke Patients that May Impede the Capacity to Provide Informed Consent for Endovascular Treatment Trials

BackgroundWe assessed the occurrence of neurological deficits that may impede the capacity to provide consent for trial participation in patients with an acute stroke, who are eligible for endovascular treatment (EVT).MethodsWe used data from the Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry, a prospective observational cohort study. We included 1526 patients with an anterior large vessel occlusion, undergoing EVT between March 2014 and June 2016. We based our assessment of decision-making capacity for trial participation on neurological symptoms influencing conditions concerning informed consent as stated in the declaration of Helsinki. We formulated a strict and a mild capacity assessment rule, using 2 different cut points in item scores on the National Institutes of Health Stroke Scale (NIHSS).ResultsApplying the strict and mild rule, respectively 1469 (96%) and 1220 (80%) patients deemed not capable of decision-making for trial participation on admission, and 1077 (79%) and 825 (60%) patients at 24-48 hours after admission. Highest frequencies of predefined scores suggesting incapacity based on the strict rule were on the NIHSS items “Level of Consciousness Questions” (59%), "Best Gaze" (68%), and “Best Language” (58%). Patients who were considered incapable were older (median 71 versus 66 years, P = .043), had higher NIHSS scores (median 16 versus 8, P < .001), and had more often left hemisphere strokes (55% versus 28%, P < .001) than patients who were presumably capable.ConclusionsIn the majority of patients with an anterior circulation stroke who are eligible for EVT, neurological deficits are present that may impede the capacity to provide informed consent for trial participation.     

Adherence to Guidelines for Antithrombotic Therapy in Patients with Atrial Fibrillation According to CHADS2 Score before and after Stroke: A Multicenter Observational Study from Korea

MethodsAIS patients with AF hospitalized within 7 days of onset were identified from a prospective nine-center stroke registry database. Two cohorts were defined: patients diagnosed with AF prior to the stroke event (admission cohort) and patients diagnosed with AF at discharge from hospital (discharge cohort). Any of the following conditions were regarded as nonadherence to guidelines in this study: use of anticoagulant or nonuse of antithrombotics with CHADS2 score=0, nonuse of antithrombotics with CHADS2 score=1, or nonuse of anticoagulant with CHADS2 score ≥2.ResultsOverall, 406 patients were enrolled in the admission cohort and 518 in the discharge cohort. The rates of nonadherence before a stroke event and at discharge were 77.8% and 33.3%, respectively. These rates varied widely for both cohorts, with interhospital differences being statistically significant. Multivariable analysis revealed that old age, stroke history, and congestive heart failure were associated with nonadherence before stroke. At discharge, males, coronary heart disease, inappropriate antithrombotic use before stroke, and functional disability at discharge were associated with nonadherence.ConclusionsThis study shows that antithrombotic use in AIS patients with AF might be not optimal before and after stroke in Korea.     

Associations of Neutrophil-Lymphocyte Ratios with Reperfusion and Functional Outcomes in Ischemic Stroke after Endovascular Therapy

ObjectivesTreatment of ischemic stroke with endovascular thrombectomy (EVT) leads to improved outcomes compared to IV tPA. The neutrophil-lymphocyte ratio (NLR), a marker of inflammation, has been proposed to predict outcomes in ischemic stroke patients and may be used to identify patients at risk for poor outcomes after EVT.Materials and MethodsThis was a retrospective study of adult ischemic stroke patients undergoing EVT between 1/1/2018 and 12/31/2020. Outcomes were successful reperfusion (TICI score ≥2B), favorable discharge NIHSS (≤4), favorable discharge and 3-month mRS (≤2), and symptomatic intracranial hemorrhage (sICH). The primary exposure was NLR, measured pre- and post-EVT. Other variables collected included demographics and timing of stroke onset, arrival, groin puncture, tPA, and recanalization.ResultsA total of 592 patients were included. The most common vessel involved was the middle cerebral artery (73%). Lower admission NLR was associated with favorable discharge NIHSS and favorable discharge and 3-month mRS (all P < 0.01). NLRs measured after EVT were associated with all the primary outcomes. Improvements in NLR after EVT were associated with favorable discharge (P = 0.02) and 3-month mRS (P = 0.02) and lower incidence of sICH (P = 0.01).ConclusionsBecause of the long-term functional deficits that can persist after ischemic stroke, it is vital to identify patients with higher probability for these outcomes. The results from this study showed that favorable NLR measures, as well as favorable trends in NLR over time, are associated with improved outcomes, indicating that NLR is a useful marker to identify patients at risk for poor functional outcomes.