1
|
Colangelo G, Ribo M, Montiel E, Dominguez D, Olivé-Gadea M, Muchada M, Garcia-Tornel Á, Requena M, Pagola J, Juega J, Rodriguez-Luna D, Rodriguez-Villatoro N, Rizzo F, Taborda B, Molina CA, Rubiera M. PRERISK: A Personalized, Artificial Intelligence-Based and Statistically-Based Stroke Recurrence Predictor for Recurrent Stroke. Stroke 2024; 55:1200-1209. [PMID: 38545798 DOI: 10.1161/strokeaha.123.043691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 01/31/2024] [Indexed: 04/24/2024]
Abstract
BACKGROUND Predicting stroke recurrence for individual patients is difficult, but individualized prediction may improve stroke survivors' engagement in self-care. We developed PRERISK: a statistical and machine learning classifier to predict individual risk of stroke recurrence. METHODS We analyzed clinical and socioeconomic data from a prospectively collected public health care-based data set of 41 975 patients admitted with stroke diagnosis in 88 public health centers over 6 years (2014-2020) in Catalonia-Spain. A new stroke diagnosis at least 24 hours after the index event was considered as a recurrent stroke, which was considered as our outcome of interest. We trained several supervised machine learning models to provide individualized risk over time and compared them with a Cox regression model. Models were trained to predict early, late, and long-term recurrence risk, within 90, 91 to 365, and >365 days, respectively. C statistics and area under the receiver operating characteristic curve were used to assess the accuracy of the models. RESULTS Overall, 16.21% (5932 of 36 114) of patients had stroke recurrence during a median follow-up of 2.69 years. The most powerful predictors of stroke recurrence were time from previous stroke, Barthel Index, atrial fibrillation, dyslipidemia, age, diabetes, and sex, which were used to create a simplified model with similar performance, together with modifiable vascular risk factors (glycemia, body mass index, high blood pressure, cholesterol, tobacco dependence, and alcohol abuse). The areas under the receiver operating characteristic curve were 0.76 (95% CI, 0.74-0.77), 0.60 (95% CI, 0.58-0.61), and 0.71 (95% CI, 0.69-0.72) for early, late, and long-term recurrence risk, respectively. The areas under the receiver operating characteristic curve of the Cox risk class probability were 0.73 (95% CI, 0.72-0.75), 0.59 (95% CI, 0.57-0.61), and 0.67 (95% CI, 0.66-0.70); machine learning approaches (random forest and AdaBoost) showed statistically significant improvement (P<0.05) over the Cox model for the 3 recurrence time periods. Stroke recurrence curves can be simulated for each patient under different degrees of control of modifiable factors. CONCLUSIONS PRERISK is a novel approach that provides a personalized and fairly accurate risk prediction of stroke recurrence over time. The model has the potential to incorporate dynamic control of risk factors.
Collapse
Affiliation(s)
- Giorgio Colangelo
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Nora Health, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., E.M.)
| | - Marc Ribo
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Estefanía Montiel
- Nora Health, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., E.M.)
| | - Didier Dominguez
- Programa d'Analítica de Dades per a la Recerca i la Innovació en Salut, Agència de Qualitat i Avaluació Sanitàries de Catalunya, Departament de Salut, Generalitat de Catalunya, Carrer de Roc Boronat, Barcelona, Spain (D.D.)
| | - Marta Olivé-Gadea
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Marian Muchada
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Álvaro Garcia-Tornel
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Manuel Requena
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Jorge Pagola
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Jesús Juega
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - David Rodriguez-Luna
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Noelia Rodriguez-Villatoro
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Federica Rizzo
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Belén Taborda
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Carlos A Molina
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| | - Marta Rubiera
- Vall d'Hebron Research Institute, Passeig de la Vall d'Hebron, Barcelona, Spain (G.C., M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
- Hospital Universitari Vall d'Hebron, Stroke Unit, Neurology Department, Passeig de la Vall d'Hebron, Barcelona, Spain (M. Ribo, M.O.-G., M.M., Á.G.-T., M. Requena, J.P., J.J., D.R.-L., N.R.-V., F.R., B.T., C.A.M., M. Rubiera)
| |
Collapse
|
2
|
Wang Y, Zhou Y, Hu H, Liu C, Wang P, Zhang L, Chu J, Lu Z, Guo Z, Jing W, Liu H. Development and validation of a clinical prediction model for ischemic stroke recurrence after successful stent implantation in symptomatic intracranial atherosclerotic stenosis. J Clin Neurosci 2024; 123:137-147. [PMID: 38574685 DOI: 10.1016/j.jocn.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/18/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE This study aimed to analyze the risk factors for recurrent ischemic stroke in patients with symptomatic intracranial atherosclerotic stenosis (ICAS) who underwent successful stent placement and to establish a nomogram prediction model. METHODS We utilized data from a prospective collection of 430 consecutive patients at Jining NO.1 People's Hospital from November 2021 to November 2022, conducting further analysis on the subset of 400 patients who met the inclusion criteria. They were further divided into training (n=321) and validation (n=79) groups. In the training group, we used univariate and multivariate COX regression to find independent risk factors for recurrent stroke and then created a nomogram. The assessment of the nomogram's discrimination and calibration was performed through the examination of various measures including the Consistency index (C-index), the area under the receiver operating characteristic (ROC) curves (AUC), and the calibration plots. Decision curve analysis (DCA) was used to evaluate the clinical utility of the nomogram by quantifying the net benefit to the patient under different threshold probabilities. RESULTS The nomogram for predicting recurrent ischemic stroke in symptomatic ICAS patients after stent placement utilizes six variables: coronary heart disease (CHD), smoking, multiple ICAS, systolic blood pressure (SBP), in-stent restenosis (ISR), and fasting plasma glucose. The C-index (0.884 for the training cohort and 0.87 for the validation cohort) and the time-dependent AUC (>0.7) indicated satisfactory discriminative ability of the nomogram. Furthermore, DCA indicated a clinical net benefit from the nomogram. CONCLUSIONS The predictive model constructed includes six predictive factors: CHD, smoking, multiple ICAS, SBP, ISR and fasting blood glucose. The model demonstrates good predictive ability and can be utilized to predict ischemic stroke recurrence in patients with symptomatic ICAS after successful stent placement.
Collapse
Affiliation(s)
- Yanhong Wang
- School of Clinical Medicine, Jining Medical University, Shandong, China
| | - Yafei Zhou
- Department of Neurology, Jining No.1 People's Hospital, Shandong, China
| | - Haibo Hu
- Emergency Department, Jining No.3 People's Hospital (Yanzhou District People's Hospital of Jining City), Shandong, China
| | - Chaolai Liu
- Department of Neurology, Jining No.1 People's Hospital, Shandong, China
| | - Peng Wang
- Department of Neurology, Jining No.1 People's Hospital, Shandong, China
| | - Lei Zhang
- Department of Neurology, Jining No.1 People's Hospital, Shandong, China
| | - Jianfeng Chu
- Department of Neurology, Jining No.1 People's Hospital, Shandong, China
| | - Zhe Lu
- Department of Neurology, Jining No.1 People's Hospital, Shandong, China
| | - Zhipeng Guo
- School of Clinical Medicine, Jining Medical University, Shandong, China
| | - Wenjun Jing
- School of Clinical Medicine, Jining Medical University, Shandong, China
| | - Huakun Liu
- Department of Neurology, Jining No.1 People's Hospital, Shandong, China.
| |
Collapse
|
3
|
Axford D, Sohel F, Abedi V, Zhu Y, Zand R, Barkoudah E, Krupica T, Iheasirim K, Sharma UM, Dugani SB, Takahashi PY, Bhagra S, Murad MH, Saposnik G, Yousufuddin M. Development and internal validation of machine learning-based models and external validation of existing risk scores for outcome prediction in patients with ischaemic stroke. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2024; 5:109-122. [PMID: 38505491 PMCID: PMC10944684 DOI: 10.1093/ehjdh/ztad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/14/2023] [Accepted: 10/30/2023] [Indexed: 03/21/2024]
Abstract
Aims We developed new machine learning (ML) models and externally validated existing statistical models [ischaemic stroke predictive risk score (iScore) and totalled health risks in vascular events (THRIVE) scores] for predicting the composite of recurrent stroke or all-cause mortality at 90 days and at 3 years after hospitalization for first acute ischaemic stroke (AIS). Methods and results In adults hospitalized with AIS from January 2005 to November 2016, with follow-up until November 2019, we developed three ML models [random forest (RF), support vector machine (SVM), and extreme gradient boosting (XGBOOST)] and externally validated the iScore and THRIVE scores for predicting the composite outcomes after AIS hospitalization, using data from 721 patients and 90 potential predictor variables. At 90 days and 3 years, 11 and 34% of patients, respectively, reached the composite outcome. For the 90-day prediction, the area under the receiver operating characteristic curve (AUC) was 0.779 for RF, 0.771 for SVM, 0.772 for XGBOOST, 0.720 for iScore, and 0.664 for THRIVE. For 3-year prediction, the AUC was 0.743 for RF, 0.777 for SVM, 0.773 for XGBOOST, 0.710 for iScore, and 0.675 for THRIVE. Conclusion The study provided three ML-based predictive models that achieved good discrimination and clinical usefulness in outcome prediction after AIS and broadened the application of the iScore and THRIVE scoring system for long-term outcome prediction. Our findings warrant comparative analyses of ML and existing statistical method-based risk prediction tools for outcome prediction after AIS in new data sets.
Collapse
Affiliation(s)
- Daniel Axford
- Department of Information Technology, Mathematics and Statistics, College of Science, Health, Engineering and Education, Murdoch University, Murdoch, Australia
| | - Ferdous Sohel
- Department of Information Technology, Mathematics and Statistics, College of Science, Health, Engineering and Education, Murdoch University, Murdoch, Australia
| | - Vida Abedi
- Department of Public Health Science, Penn State College of Medicine, Hershey, PA, USA
| | - Ye Zhu
- Robert D. and Patricia E. Kern Centre for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA
| | - Ramin Zand
- Neuroscience Institute, Geisinger Health System, 100 North Academy Ave, Danville, PA 17822, USA
- Neuroscience Institute, The Pennsylvania State University, Hershey, PA 17033, USA
| | - Ebrahim Barkoudah
- Internal Medicine/Hospital Medicine, Brigham and Women’s Hospital, Harvard University, Boston, MA, USA
| | - Troy Krupica
- Internal Medicine/Hospital Medicine, West Virginial University, Morgantown, WV, USA
| | - Kingsley Iheasirim
- Internal Medicine/Hospital Internal Medicine, Mayo Clinic Health System, Mankato, MN, USA
| | - Umesh M Sharma
- Hospital Internal Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Sagar B Dugani
- Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Sumit Bhagra
- Endocrinology, Diabetes and Metabolism, Mayo Clinic Health System, Austin, MN, USA
| | - Mohammad H Murad
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Gustavo Saposnik
- Stroke Outcomes and Decision Neuroscience Research Unit, Division of Neurology, Department of Medicine and Li Ka Shing Knowledge Institute, St.Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Yousufuddin
- Hospital Internal Medicine, Mayo Clinic Health System, 1000 1st Drive NW, Austin, MN 55912, USA
| |
Collapse
|
4
|
Daghlas I, Johnston SC, Easton D, Kim AS. Baseline Stroke Risk and Efficacy of Dual-Antiplatelet Therapy: A Post Hoc Analysis of the POINT Trial. Stroke 2024; 55:385-391. [PMID: 38174567 PMCID: PMC10857750 DOI: 10.1161/strokeaha.123.044927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/29/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND High-risk transient ischemic attacks and minor ischemic strokes are followed by a variable risk of ischemic stroke. We aimed to determine how baseline stroke risk modified the efficacy of clopidogrel-aspirin (referred to here as dual-antiplatelet therapy [DAPT]) for transient ischemic attack and minor ischemic stroke. METHODS We performed an unplanned secondary analysis of the POINT trial (Platelet-Oriented Inhibition in New Transient Ischemic Attack and Minor Ischemic Stroke). We first evaluated the associations of the CHA2DS2-VASc and stroke prognosis instrument II (SPI-II) scores with the risk of incident ischemic stroke and major hemorrhage (intracranial hemorrhage or major systemic hemorrhage). We then tested for heterogeneity of the relative and absolute treatment effect of DAPT relative to aspirin across low- and high-risk patient subgroups. RESULTS A total of 4841 trial participants were included in this analysis, with 2400 participants assigned to treatment with short-term DAPT and 2430 participants to treatment with aspirin and placebo. The dichotomized SPI-II score, but not the CHA2DS2-VASc score (P=0.18), was associated with the risk of incident ischemic stroke. A high-risk SPI-II score (>3) was associated with greater risk of incident ischemic stroke (hazard ratio of incident ischemic stroke relative to low-risk SPI-II score of 1.84 [95% CI, 1.44-2.35]; P<0.001) and numerically greater risk of major hemorrhage though not meeting statistical significance (hazard ratio, 1.80 [95% CI, 0.90-3.57]; P=0.10). The relative risk reduction with DAPT was similar across SPI-II strata (Pinteraction=0.31). The absolute risk reduction for ischemic stroke with DAPT compared with aspirin was nearly 4-fold higher (2.80% versus 0.76%; number needed to treat, 31 versus 131) in the high-risk SPI-II stratum relative to the low-risk stratum. The absolute risk increase for major hemorrhage with DAPT compared with aspirin was 3-fold higher (0.84% versus 0.30%; number needed to harm, 119 versus 331) in the high-risk SPI-II stratum relative to the low-risk stratum. CONCLUSIONS Stratification by baseline stroke risk identifies a patient subgroup that derives greater absolute benefit from treatment with DAPT. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00991029.
Collapse
Affiliation(s)
- Iyas Daghlas
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - S. Claiborne Johnston
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
- Harbor Health, Austin, TX
| | - Donald Easton
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Anthony S. Kim
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
5
|
Chen M, Qian D, Wang Y, An J, Meng K, Xu S, Liu S, Sun M, Li M, Pang C. Systematic Review of Machine Learning Applied to the Secondary Prevention of Ischemic Stroke. J Med Syst 2024; 48:8. [PMID: 38165495 DOI: 10.1007/s10916-023-02020-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
Ischemic stroke is a serious disease posing significant threats to human health and life, with the highest absolute and relative risks of a poor prognosis following the first occurrence, and more than 90% of strokes are attributable to modifiable risk factors. Currently, machine learning (ML) is widely used for the prediction of ischemic stroke outcomes. By identifying risk factors, predicting the risk of poor prognosis and thus developing personalized treatment plans, it effectively reduces the probability of poor prognosis, leading to more effective secondary prevention. This review includes 41 studies since 2018 that used ML algorithms to build prognostic prediction models for ischemic stroke, transient ischemic attack (TIA), and acute ischemic stroke (AIS). We analyzed in detail the risk factors used in these studies, the sources and processing methods of the required data, the model building and validation, and their application in different prediction time windows. The results indicate that among the included studies, the top five risk factors in terms of frequency were cardiovascular diseases, age, sex, national institutes of health stroke scale (NIHSS) score, and diabetes. Furthermore, 64% of the studies used single-center data, 65% of studies using imbalanced data did not perform data balancing, 88% of the studies did not utilize external validation datasets for model validation, and 72% of the studies did not provide explanations for their models. Addressing these issues is crucial for enhancing the credibility and effectiveness of the research, consequently improving the development and implementation of secondary prevention measures.
Collapse
Affiliation(s)
- Meng Chen
- School of Life Science and Technology, Changchun University of Science and Technology, Jilin Province, Changchun, 130022, People's Republic of China
| | - Dongbao Qian
- School of Life Science and Technology, Changchun University of Science and Technology, Jilin Province, Changchun, 130022, People's Republic of China
| | - Yixuan Wang
- Union Hospital of Jilin University, Jilin Province, Neurosurgery, Changchun, 130033, People's Republic of China
| | - Junyan An
- Union Hospital of Jilin University, Jilin Province, Neurosurgery, Changchun, 130033, People's Republic of China
| | - Ke Meng
- Union Hospital of Jilin University, Jilin Province, Neurosurgery, Changchun, 130033, People's Republic of China
| | - Shuai Xu
- School of Life Science and Technology, Changchun University of Science and Technology, Jilin Province, Changchun, 130022, People's Republic of China
| | - Sheng Liu
- School of Life Science and Technology, Changchun University of Science and Technology, Jilin Province, Changchun, 130022, People's Republic of China
| | - Meiyan Sun
- Union Hospital of Jilin University, Jilin Province, Neurosurgery, Changchun, 130033, People's Republic of China
| | - Miao Li
- School of Life Science and Technology, Changchun University of Science and Technology, Jilin Province, Changchun, 130022, People's Republic of China.
- Union Hospital of Jilin University, Jilin Province, Neurosurgery, Changchun, 130033, People's Republic of China.
| | - Chunying Pang
- School of Life Science and Technology, Changchun University of Science and Technology, Jilin Province, Changchun, 130022, People's Republic of China.
| |
Collapse
|
6
|
Suo Y, Jing J, Meng X, Li Z, Pan Y, Yan H, Jiang Y, Liu L, Zhao X, Wang Y, Li H, Wang Y. Intracranial arterial stenosis and recurrence in stroke patients with different risk stratifications by Essen stroke risk score. Neurol Res 2023; 45:1069-1078. [PMID: 37724803 DOI: 10.1080/01616412.2023.2257415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 07/29/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVES We sought to investigate whether the prognostic value of intracranial arterial stenosis (ICAS) is consistent across different risk stratifications using the Essen Stroke Risk score (ESRS). METHODS We derived data from the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events trial. Patients without complete baseline brain imaging data were excluded. Participants were categorized into different risk groups based on ESRS (low risk, 0-2, and high risk ≥ 3). The main outcome was stroke recurrence within 3 and 12 months. Hazard ratios (HRs) and 95% confidence intervals (95%CIs) of ICAS, and other factors associated with stroke recurrence within 3 and 12 months were estimated using the Cox regression method. RESULTS During the 3-month follow-up, 54 patients (7.9%) had recurrent stroke in the low-risk group, and 39 patients (9.6%) had recurrent stroke in the high-risk group. ICAS was associated with a higher risk of stroke within 3 months (HR = 2.761; 95%CI = 1.538-4.957; P < 0.001) in the low-risk group, but not in the high-risk group (HR = 1.501; 95%CI = 0.701-3.213; P = 0.296). ICAS was independently associated with higher recurrent risk in the low-risk group (HR = 2.540; 95%CI = 1.472-4.381; P < 0.001), but not in the high-risk group (HR = 1.951; 95%CI = 0.977-3.893; P = 0.058) within 12 months. CONCLUSION ICAS was an independent predictor of both 3- and 12-month stroke recurrence in low-risk but not high-risk patients with minor ischemic stroke or transient ischemic attack according to ESRS stratification.
Collapse
Affiliation(s)
- Yue Suo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Tiantan Neuroimaging Center of Excellence, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China
| |
Collapse
|
7
|
Zhao J, Wang D, Liu X, Wang Y, Zhao X. The Predictive Value of Essen and SPI-II on the Risk of 5-Year Recurrence in Chinese Patients with Acute Ischemic Stroke. Neuropsychiatr Dis Treat 2023; 19:2251-2260. [PMID: 37900671 PMCID: PMC10612507 DOI: 10.2147/ndt.s433383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/18/2023] [Indexed: 10/31/2023] Open
Abstract
Background The risk prediction score for stroke recurrence is an important tool for stratifying patients based on the risk of cerebrovascular events and selecting potential preventive treatments. Objective The study aimed to validate the Essen Stroke Risk Score (ESRS) and Stroke Prognosis Instrument II (SPI-II) for predicting long-term risk of stroke recurrence and combined vascular events in Chinese patients with acute ischemic stroke (AIS). Methods A total of 876 consecutive patients with non-atrial fibrillation AIS were recruited. The Kaplan-Meier (KM) method was used to estimate the cumulative incidence of stroke recurrence and combined vascular events in different subgroups stratified by the ESRS and SPI-II scores. The area under the receiver operating characteristic curve (AUC) was calculated to evaluate the predictive value of the two scores for stroke recurrence and combined vascular events. Results The KM estimate for 5-year cumulative incidence of stroke recurrence and combined vascular events was 28.7% (95% confidence interval [CI], 25.4-32.0) and 35.6% (95% CI, 32.3-38.9), respectively, in Chinese AIS patients. The risk of stroke recurrence and combined vascular events were increased significantly with increasing ESRS and SPI-II scores. The ESRS and SPI-II scores had similar predictive accuracy for stroke recurrence (AUC 0.57 [95% CI 0.52-0.64] vs 0.59 [95% CI 0.55-0.64]) and combined vascular events (AUC 0.59 [95% CI 0.55-0.63] vs 0.62 [95% CI 0.58-0.66]) at 5 years. Conclusion In Chinese patients with AIS, both ESRS and SPI-II scores were able to stratify the risk of 5-year recurrent stroke and combined vascular events. The predictive power of the two scores were modest and a prediction model suitable for Chinese IS populations is needed.
Collapse
Affiliation(s)
- Jing Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Dandan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xinmin Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yu Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Department of Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, People’s Republic of China
| |
Collapse
|
8
|
Li J, Han M, Chen Y, Wu B, Wu Y, Jia W, Liu J, Luo H, Yu P, Tu J, Kuang J, Yi Y. Prediction of recurrent ischaemic stroke using radiomics data and machine learning methods in patients with acute ischaemic stroke: protocol for a multicentre, large sample, prospective observational cohort study in China. BMJ Open 2023; 13:e076406. [PMID: 37816554 PMCID: PMC10565242 DOI: 10.1136/bmjopen-2023-076406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/20/2023] [Indexed: 10/12/2023] Open
Abstract
INTRODUCTION Stroke is a leading cause of mortality and disability worldwide. Recurrent strokes result in prolonged hospitalisation and worsened functional outcomes compared with the initial stroke. Thus, it is critical to identify patients who are at high risk of stroke recurrence. This study is positioned to develop and validate a prediction model using radiomics data and machine learning methods to identify the risk of stroke recurrence in patients with acute ischaemic stroke (AIS). METHODS AND ANALYSIS A total of 1957 patients with AIS will be needed. Enrolment at participating hospitals will continue until the required sample size is reached, and we will recruit as many participants as possible. Multiple indicators including basic clinical data, image data, laboratory data, CYP2C19 genotype and follow-up data will be assessed at various time points during the registry, including baseline, 24 hours, 7 days, 1 month, 3 months, 6 months, 9 months and 12 months. The primary outcome was stroke recurrence. The secondary outcomes were death events, prognosis scores and adverse events. Imaging images were processed using deep learning algorithms to construct a programme capable of automatically labelling the lesion area and extracting radiomics features. The machine learning algorithms will be applied to integrate cross-scale, multidimensional data for exploratory analysis. Then, an ischaemic stroke recurrence prediction model of the best performance for patients with AIS will be established. Calibration, receiver operating characteristic and decision curve analyses will be evaluated. ETHICS AND DISSEMINATION This study has received ethical approval from the Medical Ethics Committee of the Second Affiliated Hospital of Nanchang University (medical research review No.34/2021), and informed consent will be obtained voluntarily. The research findings will be disseminated through publication in journals and presented at conferences. TRIAL REGISTRATION NUMBER ChiCTR2200055209.
Collapse
Affiliation(s)
- Jingyi Li
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Province Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, Jiangxi, China
| | - Mengqi Han
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Province Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, Jiangxi, China
| | - Yongsen Chen
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Province Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, Jiangxi, China
| | - Bin Wu
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Province Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, Jiangxi, China
| | - Yifan Wu
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Province Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, Jiangxi, China
| | - Weijie Jia
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Province Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, Jiangxi, China
| | - JianMo Liu
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Haowen Luo
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Pengfei Yu
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jianglong Tu
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jie Kuang
- Jiangxi Province Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, Jiangxi, China
| | - Yingping Yi
- Department of Medical Big Data Research Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| |
Collapse
|
9
|
Kongwatcharapong J, Sornkhamphan A, Kaveeta C, Nathisuwan S. Validation and comparison of the stroke prognosis instrument (SPI-II) and the essen stroke risk score (ESRS) in predicting stroke recurrence in Asian population. BMC Neurol 2023; 23:287. [PMID: 37528418 PMCID: PMC10391888 DOI: 10.1186/s12883-023-03329-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 07/12/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Currently, there are limited data on the accuracy of available risk scores to predict stroke recurrence in the Asian population. METHOD A single-center, retrospective cohort study was conducted among patients with acute ischemic stroke during January 2014 - December 2018. Longitudinal data with three years of follow-up among these patients were collected and validated through both electronic and manual chart review. The area under the receiver-operating curve (AUROC) method or C-statistic and calibration plot were used to evaluate and compare the Stroke Prognosis Instrument II (SPI-II) and the Essen Stroke Risk Score (ESRS) in predicting the long-term risk of recurrent ischemic stroke. The predictive performances of the two scores were compared using DeLong's method. RESULTS The study cohort consisted of 543 patients, including 181 and 362 patients with and without recurrent events. There were no significant differences in mean age and gender between the two groups. Recurrence cases tended to have significant more risk factors compared to those without events. Among cases with recurrent events, 134 (74.03%) and 65.74% (119) cases were classified as high-risk based on SPI-II and ESRS, respectively. The AUROC curve of the SPI-II and ESRS score was 0.646 (95% CI, 0.594-0.697) and 0.614 (95%CI, 0.563-0.665), respectively (p = 0.394). Based on the calibration plot, the SPI-II and ESRS scores showed similar moderate predictive performance on recurrence stroke with a C statistic (95% CI) of 0.655 (95% CI: 0.603-0.707) and 0.631 (95% CI 0.579-0.684), respectively. CONCLUSION Both ESRS and SPI-II scores had moderate predictive performance in Thai population.
Collapse
Affiliation(s)
- Junporn Kongwatcharapong
- Pharmaceutical Care in Inpatient unit, Department of Pharmacy, Siriraj Hospital, Bangkok, Thailand
| | - Akaporn Sornkhamphan
- Pharmaceutical Care in Inpatient unit, Department of Pharmacy, Siriraj Hospital, Bangkok, Thailand
| | - Chitapa Kaveeta
- Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Surakit Nathisuwan
- Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri-Ayutthaya Road, Ratchathewi, Bangkok, 10400, Thailand.
| |
Collapse
|
10
|
Shao K, Zhang F, Li Y, Cai H, Paul Maswikiti E, Li M, Shen X, Wang L, Ge Z. A Nomogram for Predicting the Recurrence of Acute Non-Cardioembolic Ischemic Stroke: A Retrospective Hospital-Based Cohort Analysis. Brain Sci 2023; 13:1051. [PMID: 37508983 PMCID: PMC10377670 DOI: 10.3390/brainsci13071051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/26/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
Non-cardioembolic ischemic stroke (IS) is the predominant subtype of IS. This study aimed to construct a nomogram for recurrence risks in patients with non-cardioembolic IS in order to maximize clinical benefits. From April 2015 to December 2019, data from consecutive patients who were diagnosed with non-cardioembolic IS were collected from Lanzhou University Second Hospital. The least absolute shrinkage and selection operator (LASSO) regression analysis was used to optimize variable selection. Multivariable Cox regression analyses were used to identify the independent risk factors. A nomogram model was constructed using the "rms" package in R software via multifactor Cox regression. The accuracy of the model was evaluated using the receiver operating characteristic (ROC), calibration curve, and decision curve analyses (DCA). A total of 729 non-cardioembolic IS patients were enrolled, including 498 (68.3%) male patients and 231 (31.7%) female patients. Among them, there were 137 patients (18.8%) with recurrence. The patients were randomly divided into training and testing sets. The Kaplan-Meier survival analysis of the training and testing sets consistently revealed that the recurrence rates in the high-risk group were significantly higher than those in the low-risk group (p < 0.01). Moreover, the receiver operating characteristic curve analysis of the risk score demonstrated that the area under the curve was 0.778 and 0.760 in the training and testing sets, respectively. The nomogram comprised independent risk factors, including age, diabetes, platelet-lymphocyte ratio, leukoencephalopathy, neutrophil, monocytes, total protein, platelet, albumin, indirect bilirubin, and high-density lipoprotein. The C-index of the nomogram was 0.752 (95% CI: 0.705~0.799) in the training set and 0.749 (95% CI: 0.663~0.835) in the testing set. The nomogram model can be used as an effective tool for carrying out individualized recurrence predictions for non-cardioembolic IS.
Collapse
Affiliation(s)
- Kangmei Shao
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Provincial Neurology Clinical Medical Research Center, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Fan Zhang
- Department of Oncology Surgery, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Hongbin Cai
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Provincial Neurology Clinical Medical Research Center, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Ewetse Paul Maswikiti
- Department of Oncology Surgery, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Mingming Li
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Provincial Neurology Clinical Medical Research Center, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Xueyang Shen
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Provincial Neurology Clinical Medical Research Center, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Longde Wang
- Expert Workstation of Academician Wang Longde, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Zhaoming Ge
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou 730030, China
- Gansu Provincial Neurology Clinical Medical Research Center, Lanzhou University Second Hospital, Lanzhou 730030, China
| |
Collapse
|
11
|
Xiong Y, Wang S, Li Z, Fisher M, Wang L, Jiang Y, Huang X, Zhao X, Meng X, Wang Y. Thirteen-year trends in risk scores predictive values for subsequent stroke in patients with acute ischemic event. Brain Behav 2023; 13:e2962. [PMID: 36978218 PMCID: PMC10176011 DOI: 10.1002/brb3.2962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 01/31/2023] [Accepted: 02/28/2023] [Indexed: 03/30/2023] Open
Abstract
INTRODUCTION A high residual risk of subsequent stroke suggested that the predictive ability of Stroke Prognosis Instrument-II (SPI-II) and Essen Stroke Risk Score (ESRS) may have changed over the years. AIM To explore the predictive values of the SPI-II and ESRS for 1-year subsequent stroke risk in a pooled analysis of three consecutive national cohorts in China over 13 years. RESULTS In the China National Stroke Registries (CNSRs), 10.7% (5297/50,374) of the patients had a subsequent stroke within 1 year; area under the curve (AUC) of SPI-II and ESRS was .60 (95% confidence interval [CI]: .59-.61) and .58 (95% CI: .57-.59), respectively. For SPI-II, the AUC was .60 (95% CI: .59-.62) in CNSR-I, .60 (95% CI: .59-.62) in CNSR-II, and .58 (95% CI: .56-.59) in CNSR-III over the past 13 years. The declining trend was also found in ESRS scale (CNSR-I: .60 [95% CI: .59-.61]; CNSR-II: .60 [95% CI: .59-.62]; and CNSR-III: .56 [95% CI: .55-.58]). CONCLUSIONS The predictive power of the traditional risk scores SPI-II and ESRS was limited and gradually decreased over the past 13 years, thus the scales may not be useful for current clinical practice. Further derivation of risk scales with additional imaging features and biomarkers may be warranted.
Collapse
Affiliation(s)
- Yunyun Xiong
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- Chinese Institute for Brain ResearchBeijingChina
| | - Shang Wang
- Neurocardiology Center, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Zixiao Li
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- Chinese Institute for Brain ResearchBeijingChina
- National Center for Healthcare Quality Management in Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Marc Fisher
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Liyuan Wang
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Yong Jiang
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xinying Huang
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xing‐Quan Zhao
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xia Meng
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Yongjun Wang
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- National Center for Healthcare Quality Management in Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- Advanced Innovation Center for Human Brain ProtectionCapital Medical UniversityBeijingChina
| |
Collapse
|
12
|
Abstract
Stroke is a leading cause of long-term disability and fifth leading cause of death. Acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, the 3 subtypes of strokes, have varying treatment modalities. Common themes in management advocate for early interventions to reduce morbidity and mortality but not all perception is supported through randomized controlled trials. Each stroke subtype has varying premorbid-related and ictus-related outcome predictive models that have differing sensitivities and specificities.
Collapse
|
13
|
Huang Z, Cheng XQ, Liu YN, Bi XJ, Deng YB. Value of Intraplaque Neovascularization on Contrast-Enhanced Ultrasonography in Predicting Ischemic Stroke Recurrence in Patients With Carotid Atherosclerotic Plaque. Korean J Radiol 2023; 24:338-348. [PMID: 36907591 PMCID: PMC10067694 DOI: 10.3348/kjr.2022.0977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/22/2023] Open
Abstract
OBJECTIVE Patients with a history of ischemic stroke are at risk for a second ischemic stroke. This study aimed to investigate the relationship between carotid plaque enhancement on perfluorobutane microbubble contrast-enhanced ultrasonography (CEUS) and future recurrent stroke, and to determine whether plaque enhancement can contribute to risk assessment for recurrent stroke compared with the Essen Stroke Risk Score (ESRS). MATERIALS AND METHODS This prospective study screened 151 patients with recent ischemic stroke and carotid atherosclerotic plaques at our hospital between August 2020 and December 2020. A total of 149 eligible patients underwent carotid CEUS, and 130 patients who were followed up for 15-27 months or until stroke recurrence were analyzed. Plaque enhancement on CEUS was investigated as a possible risk factor for stroke recurrence and as a possible adjunct to ESRS. RESULTS During follow-up, 25 patients (19.2%) experienced recurrent stroke. Patients with plaque enhancement on CEUS had an increased risk of stroke recurrence events (22/73, 30.1%) compared to those without plaque enhancement (3/57, 5.3%), with an adjusted hazard ratio (HR) of 38.264 (95% confidence interval [CI]:14.975-97.767; P < 0.001) according to a multivariable Cox proportional hazards model analysis, indicating that the presence of carotid plaque enhancement was a significant independent predictor of recurrent stroke. When plaque enhancement was added to the ESRS, the HR for stroke recurrence in the high-risk group compared to that in the low-risk group (2.188; 95% CI, 0.025-3.388) was greater than that of the ESRS alone (1.706; 95% CI, 0.810-9.014). A net of 32.0% of the recurrence group was reclassified upward appropriately by the addition of plaque enhancement to the ESRS. CONCLUSION Carotid plaque enhancement was a significant and independent predictor of stroke recurrence in patients with ischemic stroke. Furthermore, the addition of plaque enhancement improved the risk stratification capability of the ESRS.
Collapse
Affiliation(s)
- Zhe Huang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xue-Qing Cheng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ya-Ni Liu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiao-Jun Bi
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - You-Bin Deng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| |
Collapse
|
14
|
Morrison HW, White MM, Rothers JL, Taylor-Piliae RE. Examining the Associations between Post-Stroke Cognitive Function and Common Comorbid Conditions among Stroke Survivors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13445. [PMID: 36294026 PMCID: PMC9603222 DOI: 10.3390/ijerph192013445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 10/03/2022] [Accepted: 10/15/2022] [Indexed: 06/16/2023]
Abstract
A considerable complication for stroke survivors is the subsequent development of cognitive decline or dementia. In this study, the relationship between the inflammation-centered comorbidity burden on post-stroke cognitive function among community-dwelling stroke survivors capable of independent living was examined. Data for this secondary analysis were collected from stroke survivors (n = 97) participating in a randomized clinical trial. Participants provided baseline responses, regarding cognitive function (mini-mental status exam, MMSE; Montreal cognitive assessment, MoCA), history of stroke comorbid conditions, and the Stroke Prognosis Instrument-II (SPI-II), an index of stroke comorbidity and recurrent stroke risk within the next two years. Relationships and differences between groups were tested for significance using Spearman's correlation, Kruskal-Wallis, or Mann-Whitney U tests. Most stroke survivors (69%) had multiple comorbidities. Total SPI-II scores were negatively correlated to both MoCA and MMSE scores (r = -0.25, p = 0.01; r = -0.22, p = 0.03, respectively), and differences in MoCA scores among SPI-II risk groups (low, medium, high) were evident (p = 0.05). In contrast, there were no differences in MoCA or MMSE scores when comorbid conditions were examined individually. Lastly, no gender differences were evident in cognitive assessments. Our data support the premise that comorbidity's burden impacts post-stroke cognitive decline, more than a single comorbid condition. Inflammation may be an important component of this comorbidity burden. Future studies that operationalize this concept will better illuminate the complex phenomenon of post-stroke cognitive decline for improved clinical rehabilitation modalities.
Collapse
Affiliation(s)
| | - Melissa M. White
- El Paso Veteran’s Administration Healthcare System, El Paso, TX 79930, USA
| | - Janet L. Rothers
- BIO5 Institute Statistics Consulting Lab, The University of Arizona, Tucson, AZ 85721, USA
| | | |
Collapse
|
15
|
Yang F, Yan S, Wang W, Li X, Chou F, Liu Y, Zhang S, Zhang Y, Liu H, Yang X, Gu P. Recurrence prediction of Essen Stroke Risk and Stroke Prognostic Instrument-II scores in ischemic stroke: A study of 5-year follow-up. J Clin Neurosci 2022; 104:56-61. [PMID: 35963065 DOI: 10.1016/j.jocn.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/04/2022] [Accepted: 07/13/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To evaluate the predictive accuracy of the Essen Stroke Risk Score and the Stroke Prognostic Instrument II score on the long-term recurrence in Chinese patients with acute ischemic stroke. METHODS Patients with acute ischemic stroke were enrolled and had completed ESRS and SPI-II scores. Patients were stratified according to the Essen Stroke Risk Score and Stroke Prognostic Instrument II score and were followed until stroke recurrence or composite endpoint event (stroke recurrence, myocardial infarction or cardiovascular death). We estimated stratified incidence rates and calculated the cumulative risks at 5 years using Kaplan-Meier estimates. We used receiver operating characteristic (ROC) curves to compare the predictive ability of the Essen Stroke Risk Score and Stroke Prognostic Instrument II score. RESULTS A total of 578 patients completed the follow-up. The cumulative 5-year event rates were 32.3% (95% CI, 28.2% to 36.4%) for recurrent stroke and 37.9% (95% CI: 33.8%-42.0%) for composite endpoint event. The cumulative risk of all outcomes increased with increasing risk scores. AUC for ESRS and SPI-II risk scores were 0.613 (95% CI: 0.565-0.661) and 0.613 (95% CI: 0.564-0.662) for 5-year stroke recurrence respectively and correspondingly 0.622 (95% CI: 0.576-0.668) and 0.627 (95% CI: 0.581-0.674) for composite endpoint events. CONCLUSION In Chinese patients with acute ischemic stroke, both Essen Stroke Risk Score and Stroke Prognostic Instrument II scores could equally stratify the risk of 5-year recurrent stroke and combined vascular events.
Collapse
Affiliation(s)
- Fan Yang
- Department of Neurology, the First Hospital of Hebei Medical University, Shijiazhaung 050031, Hebei, China
| | - Shuangmei Yan
- Department of Neurology, the First Hospital of Hebei Medical University, Shijiazhaung 050031, Hebei, China
| | - Wenting Wang
- Department of Neurology, the First Hospital of Hebei Medical University, Shijiazhaung 050031, Hebei, China
| | - Xiang Li
- Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing 100049, China
| | - Fucheng Chou
- Department of Neurology, the First Hospital of Hebei Medical University, Shijiazhaung 050031, Hebei, China
| | - Yihan Liu
- Department of Neurology, the First Hospital of Hebei Medical University, Shijiazhaung 050031, Hebei, China
| | - Sai Zhang
- Department of Neurology, the First Hospital of Hebei Medical University, Shijiazhaung 050031, Hebei, China
| | - Yongzhi Zhang
- Department of Neurology, the First Hospital of Hebei Medical University, Shijiazhaung 050031, Hebei, China
| | - Huimiao Liu
- Department of Neurology, the First Hospital of Hebei Medical University, Shijiazhaung 050031, Hebei, China
| | - Xu Yang
- Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing 100049, China.
| | - Ping Gu
- Department of Neurology, the First Hospital of Hebei Medical University, Shijiazhaung 050031, Hebei, China.
| |
Collapse
|
16
|
Zhang S, Ren Y, Wang J, Song B, Li R, Xu Y. GSTCNet: Gated spatio-temporal correlation network for stroke mortality prediction. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2022; 19:9966-9982. [PMID: 36031978 DOI: 10.3934/mbe.2022465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Stroke continues to be the most common cause of death in China. It has great significance for mortality prediction for stroke patients, especially in terms of analyzing the complex interactions between non-negligible factors. In this paper, we present a gated spatio-temporal correlation network (GSTCNet) to predict the one-year post-stroke mortality. Based on the four categories of risk factors: vascular event, chronic disease, medical usage and surgery, we designed a gated correlation graph convolution kernel to capture spatial features and enhance the spatial correlation between feature categories. Bi-LSTM represents the temporal features of five timestamps. The novel gated correlation attention mechanism is then connected to the Bi-LSTM to realize the comprehensive mining of spatio-temporal correlations. Using the data on 2275 patients obtained from the neurology department of a local hospital, we constructed a series of sequential experiments. The experimental results show that the proposed model achieves competitive results on each evaluation metric, reaching an AUC of 89.17%, a precision of 97.75%, a recall of 95.33% and an F1-score of 95.19%. The interpretability analysis of the feature categories and timestamps also verified the potential application value of the model for stroke.
Collapse
Affiliation(s)
- Shuo Zhang
- School of Computer and Artificial Intelligence, Zhengzhou University, Zhengzhou 450000, China
- Cooperative Innovation Center of Internet Healthcare, Zhengzhou University, Zhengzhou 450000, China
| | - Yonghao Ren
- School of Computer and Artificial Intelligence, Zhengzhou University, Zhengzhou 450000, China
- Cooperative Innovation Center of Internet Healthcare, Zhengzhou University, Zhengzhou 450000, China
| | - Jing Wang
- School of Computer and Artificial Intelligence, Zhengzhou University, Zhengzhou 450000, China
- Cooperative Innovation Center of Internet Healthcare, Zhengzhou University, Zhengzhou 450000, China
| | - Bo Song
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
- NHC Key Laboratory of Prevention and Treatment of Cerebrovascular Diseases, Zhengzhou 450000, China
| | - Runzhi Li
- Cooperative Innovation Center of Internet Healthcare, Zhengzhou University, Zhengzhou 450000, China
| | - Yuming Xu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
- NHC Key Laboratory of Prevention and Treatment of Cerebrovascular Diseases, Zhengzhou 450000, China
| |
Collapse
|
17
|
Kim JT, Kim NR, Choi SH, Oh S, Park MS, Lee SH, Kim BC, Choi J, Kim MS. Neural network-based clustering model of ischemic stroke patients with a maximally distinct distribution of 1-year vascular outcomes. Sci Rep 2022; 12:9420. [PMID: 35676413 PMCID: PMC9177616 DOI: 10.1038/s41598-022-13636-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 05/17/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractClustering stroke patients with similar characteristics to predict subsequent vascular outcome events is critical. This study aimed to compare several clustering methods, particularly a deep neural network-based model, and identify the best clustering method with a maximally distinct 1-year outcome in patients with ischemic stroke. Prospective stroke registry data from a comprehensive stroke center from January 2011 to July 2018 were retrospectively analyzed. Patients with acute ischemic stroke within 7 days of onset were included. The primary outcomes were the composite of all strokes (either hemorrhagic or ischemic), myocardial infarction, and all-cause mortality within one year. Neural network-based clustering models (deep lifetime clustering) were compared with other clustering models (k-prototype and semi-supervised clustering, SSC) and a conventional risk score (Stroke Prognostic Instrument-II, SPI-II) to obtain a distinct distribution of 1-year vascular events. Ultimately, 7,650 patients were included, and the 1-year primary outcome event occurred in 13.1%. The DLC-Kuiper UB model had a significantly higher C-index (0.674), log-rank score (153.1), and Brier score (0.08) than the other cluster models (SSC and DLC-MMD) and the SPI-II score. There were significant differences in primary outcome events among the 3 clusters (41.7%, 13.4%, and 6.5% in clusters 0, 1, and 2, respectively) when the DLC-Kuiper UB model was used. A neural network-based clustering model, the DLC-Kuiper UB model, can improve the clustering of stroke patients with a maximally distinct distribution of 1-year vascular outcomes among each cluster. Further studies are warranted to validate this deep neural network-based clustering model in ischemic stroke.
Collapse
|
18
|
Zhang R, Wang J. Machine Learning-Based Prediction of Subsequent Vascular Events After 6 Months in Chinese Patients with Minor Ischemic Stroke. Int J Gen Med 2022; 15:3797-3808. [PMID: 35418774 PMCID: PMC9000551 DOI: 10.2147/ijgm.s356373] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/23/2022] [Indexed: 11/25/2022] Open
Abstract
Background To develop and validate a machine learning model for predicting subsequent vascular events (SVE) 6 months after mild ischemic stroke (MIS) in Chinese patients. Methods A retrospective analysis was performed on 495 newly diagnosed MIS patients by collecting their basic information, past medical history, initial NIHSS score, symptoms, obstruction sites of MIS, and MRI results. According to the ratio of 7:3, the dataset was divided into a training set (n=346) and a testing set (n=149) through stratified random sampling. In the training set, the recursive feature elimination (RFE) was used to select the optimal combination of features, and two machine learning algorithms, including the logistic regression (LR) and support vector machines (SVM), were used to build the prediction model, which was further validated by using 5-fold cross-validation. The receiver operating characteristic (ROC) curve was used on the testing set to evaluate the model’s performance, and the area under the curve (AUC), sensitivity, specificity, and accuracy were calculated. The calibration curve and decision curve of the two models were further compared. Results SVE occurred in 56 cases (11.3%) of 495 patients with MIS during the 6-month follow-up. Finally, the best 15 predictive features were selected, and the top three predictive features were diabetes, posterior cerebral artery lesion, and fasting blood glucose in order. In the testing set, the AUC of the LR model was 0.929 (95% CI: 0.875–0.964), and its accuracy, sensitivity, and specificity were 0.832, 0.765, and 0.841, respectively. The AUC of the SVM model was 0.992 (95% CI: 0.962–1.000), and its accuracy, sensitivity, and specificity were 0.966, 0.824, and 0.985, respectively. The SVM model’s discrimination, calibration, and clinical validity are better than those of the LR model. Conclusion The predictive models developed using machine learning methods can predict the risk of SVE after 6 months following MIS in Chinese patients.
Collapse
Affiliation(s)
- Rong Zhang
- Department of Neurology, Traditional Chinese Medicine Hospital of Kunshan, Suzhou, 215300, People’s Republic of China
| | - Jingfeng Wang
- Department of Neurology, The Second People’s Hospital of Kunshan, Suzhou, 215300, People’s Republic of China
- Correspondence: Jingfeng Wang, Department of Neurology, The Second People’s Hospital of Kunshan, Suzhou, 215300, People’s Republic of China, Tel +86-15962508528, Fax +86-512-57557843, Email
| |
Collapse
|
19
|
Maier IL, Herpertz GU, Bähr M, Psychogios MN, Liman J. What is the added value of CT-angiography in patients with transient ischemic attack? BMC Neurol 2022; 22:7. [PMID: 34980008 PMCID: PMC8722154 DOI: 10.1186/s12883-021-02523-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 12/13/2021] [Indexed: 12/03/2022] Open
Abstract
Background Transient ischemic attack (TIA) is an important predictor for a pending stroke. Guidelines recommend a workup for TIA-patients similar to that of stroke patients, including an assessment of the extra- and intracranial arteries for vascular pathologies with direct therapeutic implications via computed tomography angiography (CTA). Aim of our study was a systematic analysis of TIA-patients receiving early CTA-imaging and to evaluate the predictive value of TIA-scores and clinical characteristics for ipsilateral vascular pathologies and the need of an invasive treatment. Methods We analysed clinical and imaging data from TIA patients being admitted to a tertiary university hospital between September 2015 and March 2018. Following subgroups were identified: 1) no- or low-grade vascular pathology 2) ipsilateral high-risk vascular pathology and 3) high-risk findings that needed invasive, surgical or interventional treatment. We investigated established TIA-scores (ABCD2-, the ABCD3- and the SPI-II score) and various clinical characteristics as predictive factors for ipsilateral vascular pathologies and the need for invasive treatment. Results Of 812 patients, 531 (65.4%) underwent initial CTA in the emergency department. In 121 (22.8%) patients, ipsilateral vascular pathologies were identified, of which 36 (6.7%) needed invasive treatment. The ABCD2-, ABCD3- and SPI-II-scores were not predictive for ipsilateral vascular pathologies or the need for invasive treatment. We identified male sex (OR 1.579, 95%CI 1.049–2.377, p = 0.029), a short duration of symptoms (OR 0.692, 95% CI 0.542–0.884, p = 0.003), arterial hypertension (OR 1.718, 95%CI 0.951–3.104, p = 0.073) and coronary heart disease (OR 1.916, 95%CI 1.184–3.101, p = 0.008) as predictors for ipsilateral vascular pathologies. As predictors for the need of invasive treatment, a short duration of symptoms (OR 0.565, 95%CI 0.378–0.846, p = 0.006), arterial hypertension (OR 2.612, 95%OR 0.895–7.621, p = 0.079) and hyperlipidaemia (OR 5.681, 95%CI 0.766–42.117, p = 0.089) as well as the absence of atrial fibrillation (OR 0.274, OR 0.082–0.917, p = 0.036) were identified. Conclusion More than every fifth TIA-patient had relevant vascular findings revealed by acute CTA. TIA-scores were not predictive for these findings. Patients with a short duration of symptoms and a vascular risk profile including coronary heart disease, arterial hypertension and hyperlipidaemia most likely might benefit from early CTA to streamline further diagnostics and therapy. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02523-y.
Collapse
Affiliation(s)
- Ilko L Maier
- Department of Neurology, University Medicine Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
| | - Gerrit U Herpertz
- Department of Anesthesiology, Klinikum Bremerhaven-Reinkenheide, Bremerhaven, Germany
| | - Mathias Bähr
- Department of Neurology, University Medicine Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| | - Marios-Nikos Psychogios
- Department of diagnostic and interventional Neuroradiology, University Clinic Basel, Basel, Switzerland
| | - Jan Liman
- Department of Neurology, University Medicine Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
| |
Collapse
|
20
|
Del Brutto VJ, Rundek T, Sacco RL. Prognosis After Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
21
|
Adams HP. Clinical Scales to Assess Patients With Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
22
|
Marilyn ML, Gordon G, Stephen P, Nicholas G, Wanda F, Kara T, Chris T, Howard W, Sharon S, David M, Gail E, Fiona P, Chris B, Judy D. Program of Rehabilitative Exercise and Education to Avert Vascular Events After Non-Disabling Stroke or Transient Ischemic Attack (PREVENT Trial): A Randomized Controlled Trial. Neurorehabil Neural Repair 2021; 36:119-130. [PMID: 34788569 PMCID: PMC9066689 DOI: 10.1177/15459683211060345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Non-disabling stroke (NDS) and transient ischemic attack (TIA) herald the possibility of future, more debilitating vascular events. Evidence is conflicting about potency of exercise and education in reducing risk factors for second stroke. Methods Three-site, single-blinded, randomized controlled trial with 184 participants <3 months of NDS or TIA (mean age, 65 years; 66% male) randomized to usual care (UC) or UC + 12-week program of exercise and education (PREVENT). Primary (resting systolic blood pressure) and secondary outcomes (diastolic blood pressure [DBPrest], high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], total cholesterol [TC], TC/HDL, triglycerides, fasting glucose, and body mass index) were assessed at baseline, post-intervention, and 6- and 12-month follow-up. Peak oxygen consumption (VO2peak) was measured at baseline, post-intervention, 12-month assessments. Results Significant between-group differences at post-intervention favored PREVENT group over UC: DBPrest (mean difference [MD]: −3.2 mmHg, 95% confidence interval [CI]: −6.3, −.2, P = .04) and LDL-C (MD: −.31 mmol/L, 95% CI: −.42, −.20, P = .02). Trends of improvement in PREVENT group were noted in several variables between baseline and 6-month follow-up but not sustained at 12-month follow-up. Of note, VO2 peak did not change over time in either group. Conclusion Impact of PREVENT on vascular risk factor reduction was more modest than anticipated, possibly because several outcome variables approximated normative values at baseline and training intensity may have been sub-optimal. Further investigation is warranted to determine when exercise and education programs are viable adjuncts to pharmaceutical management for reduction of risk factors for second stroke. Clinical Trial Registration-URL:http://www.clinicaltrials.gov. Unique identifier: #NCT00885456
Collapse
Affiliation(s)
- MacKay-Lyons Marilyn
- School of Physiotherapy, 3688Dalhousie University, Halifax, NS, Canada.,Physical Medicine, Nova Scotia Health Authority, 3688Dalhousie University, Halifax, NS, Canada
| | - Gubitz Gordon
- Neurology, 3688Dalhousie University, Halifax, NS, Canada
| | | | - Giacomantonio Nicholas
- QEII Health Sciences Centre, Halifax, NS, Canada.,Cardiac Rehabilitation, QEII Community Cardiovascular Hearts-in-Motion, Halifax, NS, Canada
| | - Firth Wanda
- Cardiac Rehabilitation, QEII Community Cardiovascular Hearts-in-Motion, Halifax, NS, Canada
| | - Thompson Kara
- Nova Scotia Health, Research Methods Unit, Halifax, NS, Canada
| | - Theriault Chris
- Nova Scotia Health, Research Methods Unit, Halifax, NS, Canada
| | - Wightman Howard
- Cardiology Associates, Valley Regional Hospital, Kentville, NS, Canada
| | - Slipp Sharon
- Cardiac Rehabilitation, Valley Regional Hospital, Kentville, NS, Canada
| | - Marsters David
- Internal Medicine, Valley Regional Hospital, Kentville, NS, Canada
| | - Eskes Gail
- Physical Medicine, Nova Scotia Health Authority, Halifax, NS, Canada.,Psychiatry, 3688Dalhousie University, Halifax, NS, Canada.,Medicine, Nova Scotia Health, Halifax, NS, Canada
| | - Peacock Fiona
- Cardiac Specialty Clinic, Valley Regional Hospital, Kentville, Canada
| | | | - Dewolfe Judy
- Cardiac Specialty Clinic, Valley Regional Hospital, Kentville, Canada
| |
Collapse
|
23
|
Zhang S, Wang J, Pei L, Liu K, Gao Y, Fang H, Zhang R, Zhao L, Sun S, Wu J, Song B, Dai H, Li R, Xu Y. Interpretability analysis of one-year mortality prediction for stroke patients based on deep neural network. IEEE J Biomed Health Inform 2021; 26:1903-1910. [PMID: 34714758 DOI: 10.1109/jbhi.2021.3123657] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Clinically, physicians collect the benchmark medical data to establish archives for a stroke patient and then add the follow up data regularly. It has great significance on prognosis prediction for stroke patients. In this paper, we present an interpretable deep learning model to predict the one-year mortality risk on stroke. We design sub-modules to reconstruct features from original clinical data that highlight the dissimilarity and temporality of different variables. The model consists of Bidirectional Long Short-Term Memory (Bi-LSTM), in which a novel correlation attention module is proposed that takes the correlation of variables into consideration. In experiments, datasets are collected clinically from the department of neurology in a local AAA hospital. It consists of 2,275 stroke patients hospitalized in the department of neurology from 2014 to 2016. Our model achieves a precision of 0.9414, a recall of 0.9502 and an F1-score of 0.9415. In addition, we provide the analysis of the interpretability by visualizations with reference to clinical professional guidelines.
Collapse
|
24
|
Gynnild MN, Hageman SHJ, Dorresteijn JAN, Spigset O, Lydersen S, Wethal T, Saltvedt I, Visseren FLJ, Ellekjær H. Risk Stratification in Patients with Ischemic Stroke and Residual Cardiovascular Risk with Current Secondary Prevention. Clin Epidemiol 2021; 13:813-823. [PMID: 34566434 PMCID: PMC8456548 DOI: 10.2147/clep.s322779] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/20/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose Suboptimal secondary prevention in patients with stroke causes a remaining cardiovascular risk desirable to reduce. We have validated a prognostic model for secondary preventive settings and estimated future cardiovascular risk and theoretical benefit of reaching guideline recommended risk factor targets. Patients and Methods The SMART-REACH (Secondary Manifestations of Arterial Disease-Reduction of Atherothrombosis for Continued Health) model for 10-year and lifetime risk of cardiovascular events was applied to 465 patients in the Norwegian Cognitive Impairment After Stroke (Nor-COAST) study, a multicenter observational study with two-year follow-up by linkage to national registries for cardiovascular disease and mortality. The residual risk when reaching recommended targets for blood pressure, low-density lipoprotein cholesterol, smoking cessation and antithrombotics was estimated. Results In total, 11.2% had a new event. Calibration plots showed adequate agreement between estimated and observed 2-year prognosis (C-statistics 0.63, 95% confidence interval 0.55–0.71). Median estimated 10-year risk of recurrent cardiovascular events was 42% (Interquartile range (IQR) 32–54%) and could be reduced to 32% by optimal guideline-based therapy. The corresponding numbers for lifetime risk were 70% (IQR 63–76%) and 61%. We estimated an overall median gain of 1.4 (IQR 0.2–3.4) event-free life years if guideline targets were met. Conclusion Secondary prevention was suboptimal and residual risk remains elevated even after optimization according to current guidelines. Considerable interindividual variation in risk exists, with a corresponding variation in benefit from intensification of treatment. The SMART-REACH model can be used to identify patients with the largest benefit from more intensive treatment and follow-up.
Collapse
Affiliation(s)
- Mari Nordbø Gynnild
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Department of Stroke, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Torgeir Wethal
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Department of Stroke, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Department of Geriatrics, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Department of Stroke, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| |
Collapse
|
25
|
Xu H, Pang J, Zhang W, Li X, Li M, Zhao D. Predicting Recurrence for Patients With Ischemic Cerebrovascular Events Based on Process Discovery and Transfer Learning. IEEE J Biomed Health Inform 2021; 25:2445-2453. [PMID: 33705325 DOI: 10.1109/jbhi.2021.3065427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The recurrence of Ischemic cerebrovascular events (ICE) often results in a high rate of mortality and disability. However, due to the lack of labeled follow-up data in hospitals, prediction methods using traditional machine learning are usually not available or reliable. Therefore, we propose a new framework for predicting the long-term recurrence risk in patients with ICE after discharge from hospitals based on process mining and transfer learning, to point out high-risk patients for intervention. First, process models are discovered from clinical guidelines for analyzing the similarity of ICE population data collected by different medical institutions, and the control flow found are taken as added characteristics of patients. Then we use the in-hospital data (target domain) and the national stroke screening data (source domain), to develop risk prediction models applying instance filter and weight-based transfer learning method. To verify our method, 205 cases from a tertiary hospital and 2954 cases from the screening cohort (2015-2017) are tested. Experimental results show that our framework can improve the performance of three instance-based transfer algorithms. This study provides a comprehensive and efficient approach for applying transfer learning, to alleviate the limitation of insufficient labeled follow-up data in hospitals.
Collapse
|
26
|
Prediction of Long-Term Stroke Recurrence Using Machine Learning Models. J Clin Med 2021; 10:jcm10061286. [PMID: 33804724 PMCID: PMC8003970 DOI: 10.3390/jcm10061286] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 01/01/2023] Open
Abstract
Background: The long-term risk of recurrent ischemic stroke, estimated to be between 17% and 30%, cannot be reliably assessed at an individual level. Our goal was to study whether machine-learning can be trained to predict stroke recurrence and identify key clinical variables and assess whether performance metrics can be optimized. Methods: We used patient-level data from electronic health records, six interpretable algorithms (Logistic Regression, Extreme Gradient Boosting, Gradient Boosting Machine, Random Forest, Support Vector Machine, Decision Tree), four feature selection strategies, five prediction windows, and two sampling strategies to develop 288 models for up to 5-year stroke recurrence prediction. We further identified important clinical features and different optimization strategies. Results: We included 2091 ischemic stroke patients. Model area under the receiver operating characteristic (AUROC) curve was stable for prediction windows of 1, 2, 3, 4, and 5 years, with the highest score for the 1-year (0.79) and the lowest score for the 5-year prediction window (0.69). A total of 21 (7%) models reached an AUROC above 0.73 while 110 (38%) models reached an AUROC greater than 0.7. Among the 53 features analyzed, age, body mass index, and laboratory-based features (such as high-density lipoprotein, hemoglobin A1c, and creatinine) had the highest overall importance scores. The balance between specificity and sensitivity improved through sampling strategies. Conclusion: All of the selected six algorithms could be trained to predict the long-term stroke recurrence and laboratory-based variables were highly associated with stroke recurrence. The latter could be targeted for personalized interventions. Model performance metrics could be optimized, and models can be implemented in the same healthcare system as intelligent decision support for targeted intervention.
Collapse
|
27
|
Kauw F, van Ommen F, Bennink E, Cramer MJ, Kappelle LJ, Takx RA, Velthuis BK, Viergever MA, Wouter van Es H, Schonewille WJ, Coutinho JM, Majoie CB, Marquering HA, de Jong HW, Dankbaar JW. Early detection of small volume stroke and thromboembolic sources with computed tomography: Rationale and design of the ENCLOSE study. Eur Stroke J 2021; 5:432-440. [PMID: 33598562 PMCID: PMC7856586 DOI: 10.1177/2396987320966420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/21/2020] [Indexed: 01/01/2023] Open
Abstract
Background Computed tomography is the most frequently used imaging modality in acute stroke imaging protocols. Detection of small volume infarcts in the brain and cardioembolic sources of stroke is difficult with current computed tomography protocols. Furthermore, the role of computed tomography findings to predict recurrent ischemic stroke is unclear. With ENCLOSE, we aim to improve (1) the detection of small volume infarcts with thin slice computed tomography perfusion (CTP) images and thromboembolic source with cardiac computed tomography techniques in the acute stage of ischemic stroke and (2) prediction of recurrent ischemic stroke with computed tomography-derived predictors. Methods/design: ENCLOSE is a prospective multicenter observational cohort study, which will be conducted in three Dutch stroke centers (ClinicalTrials.gov Identifier: NCT04019483). Patients (≥18 years) with suspected acute ischemic stroke who undergo computed tomography imaging within 9 h after symptom onset are eligible. Computed tomography imaging includes non-contrast CT, CTP, and computed tomography angiography (CTA) from base of the heart to the top of the brain. Dual-energy CT data will be acquired when possible, and thin-slice CTP reconstructions will be obtained in addition to standard 5 mm CTP data. CTP data will be processed with commercially available software and locally developed model-based methods. The post-processed thin-slice CTP images will be compared to the standard CTP images and to magnetic resonance diffusion-weighted imaging performed within 48 h after admission. Detection of cardioembolic sources of stroke will be evaluated on the CTA images. Recurrence will be evaluated 90 days and two years after the index event. The added value of imaging findings to prognostic models for recurrent ischemic stroke will be evaluated. Conclusion The aim of ENCLOSE is to improve early detection of small volume stroke and thromboembolic sources and to improve prediction of recurrence in patients with acute ischemic stroke.
Collapse
Affiliation(s)
- Frans Kauw
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Fasco van Ommen
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Edwin Bennink
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Maarten J Cramer
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Utrecht University, The Netherlands
| | - L Jaap Kappelle
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Richard Ap Takx
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Max A Viergever
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - H Wouter van Es
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | | | | | - Henk A Marquering
- Department of Neurology, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Hugo Wam de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan W Dankbaar
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
28
|
Risk Factor Control in Stroke Survivors with Diagnosed and Undiagnosed Diabetes: A Ghanaian Registry Analysis. J Stroke Cerebrovasc Dis 2020; 29:105304. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105304] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/23/2020] [Accepted: 09/03/2020] [Indexed: 01/04/2023] Open
|
29
|
Garg A, Limaye K, Shaban A, Leira EC, Adams HP. Risk of Ischemic Stroke after an Inpatient Hospitalization for Transient Ischemic Attack in the United States. Neuroepidemiology 2020; 55:40-46. [PMID: 33260176 DOI: 10.1159/000511829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/26/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION A diagnosis of transient ischemic attack (TIA) must be followed by prompt investigation and rapid initiation of measures to prevent stroke. Prior studies evaluating the risk of stroke after TIA were conducted in the emergency room or clinic settings. Experience of patients admitted to the hospital after a TIA is not well known. We sought to assess the early risk of ischemic stroke after inpatient hospitalization for TIA. METHODS We used the 2010-2015 Nationwide Readmissions Database to identify all hospitalizations with the primary discharge diagnosis of TIA and investigated the incidence of ischemic stroke readmissions within 90 days of discharge from the index hospitalization. RESULTS Of 639,569 index TIA admissions discharged alive (mean ± SD age 70.4 ± 14.4 years, 58.7% female), 9,131 (1.4%) were readmitted due to ischemic stroke within 90 days. Male sex, head/neck vessel atherosclerosis, hypertension, diabetes, atrial flutter/fibrillation, previous history of TIA/stroke, illicit drug use, and higher Charlson Comorbidity Index score were independently associated with readmissions due to ischemic stroke. Ischemic stroke readmissions were associated with excess mortality, discharge disposition other than to home, and elevated cost. CONCLUSIONS Patients hospitalized for TIA have a lower risk of ischemic stroke compared to that reported in the studies based on the emergency room and/or outpatient clinic evaluation. Among these patients, those with cardiovascular comorbidities remain at a higher risk of readmission due to ischemic stroke despite undergoing an inpatient evaluation and should therefore be the target for future preventive strategies.
Collapse
Affiliation(s)
- Aayushi Garg
- Departments of Neurology, University of Iowa, Iowa City, Iowa, USA,
| | - Kaustubh Limaye
- Departments of Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Amir Shaban
- Departments of Neurology, University of Iowa, Iowa City, Iowa, USA
| | - Enrique C Leira
- Departments of Neurology, University of Iowa, Iowa City, Iowa, USA.,Departments of Neurosurgery, University of Iowa, Iowa City, Iowa, USA.,Departments of Epidemiology, University of Iowa, Iowa City, Iowa, USA
| | - Harold P Adams
- Departments of Neurology, University of Iowa, Iowa City, Iowa, USA.,Departments of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
30
|
Strambo D, Zachariadis A, Lambrou D, Schwarz G, Sirimarco G, Aarnio K, Putaala J, Ntaios G, Vemmos K, Michel P. A score to predict one-year risk of recurrence after acute ischemic stroke. Int J Stroke 2020; 16:602-612. [PMID: 32878590 DOI: 10.1177/1747493020932787] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND An acute ischemic stroke carries a substantial risk of further recurrences. We aimed at developing and validating a prognostic tool to predict one-year stroke recurrence after acute ischemic stroke. METHODS An integer score was derived by Cox regression analysis on a hospital-referred cohort of 3246 acute ischemic stroke patients from Switzerland, and tested for external validity in three similar independent cohorts from Athens (n = 2495), Milan (n = 1279), and Helsinki (n = 714) by means of calibration and discrimination. RESULTS In the derivation cohort, the recurrence rate was 7% (n = 228/3246). We developed a nine-point score comprising: previous stroke or transient ischemic attack (1-point), stroke mechanism (small vessel disease and unknown mechanism: 0-points; rare stroke mechanism: 3-points; other mechanisms: 1-point), pre-stroke antiplatelets (1-point), active malignancy (2-points), chronic cerebrovascular lesions on imaging (1-point) and absence of early ischemic changes on first imaging (1-point). In the derivation cohort, the one-year risk of re-stroke was 3.0% (95%CI 1.9-4.1) in 932 (29%) patients with a score 0-1, 7.2% (6.1-8.3) in 2038 (63%) with a score 2-4, and 19.2% (14.6-23.9) in 276 (8%) with a score ≥ 5. The score calibrated well in the Athens (recurrences = 208/2495), but not in the Helsinki (recurrences = 15/714) or Milan (recurrences = 65/1279) cohorts. The AUC was 0.67 in the derivation cohort, and 0.56, 0.70, and 0.63 in the Athens, Helsinki, and Milan cohorts, respectively. CONCLUSION We developed a score to predict one-year stroke recurrence risk in patients with acute ischemic stroke. Since the score was not completely validated when applied to external datasets where it displayed poor to fair calibration and discrimination, additional efforts are required to ameliorate our accuracy for predicting stroke recurrence, by better refining this prognostic tool or developing new ones. Clinical and radiological markers of established cerebrovascular disease and stroke etiology were better predictors than the usual demographic vascular risk factors.
Collapse
Affiliation(s)
- Davide Strambo
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland.,Stroke Unit, Department of Neurology and Neurophysiology, San Raffaele Scientific Institute, Milan, Italy
| | | | - Dimitris Lambrou
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Ghil Schwarz
- Stroke Unit, Department of Neurology and Neurophysiology, San Raffaele Scientific Institute, Milan, Italy
| | - Gaia Sirimarco
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Karolinaa Aarnio
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece
| | | | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| |
Collapse
|
31
|
Kauw F, Greving JP, Takx RAP, de Jong HWAM, Schonewille WJ, Vos JA, Wermer MJH, van Walderveen MAA, Kappelle LJ, Velthuis BK, Dankbaar JW. Prediction of long-term recurrent ischemic stroke: the added value of non-contrast CT, CT perfusion, and CT angiography. Neuroradiology 2020; 63:483-490. [PMID: 32857214 PMCID: PMC7966192 DOI: 10.1007/s00234-020-02526-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022]
Abstract
Purpose The aim of this study was to evaluate whether the addition of brain CT imaging data to a model incorporating clinical risk factors improves prediction of ischemic stroke recurrence over 5 years of follow-up. Methods A total of 638 patients with ischemic stroke from three centers were selected from the Dutch acute stroke study (DUST). CT-derived candidate predictors included findings on non-contrast CT, CT perfusion, and CT angiography. Five-year follow-up data were extracted from medical records. We developed a multivariable Cox regression model containing clinical predictors and an extended model including CT-derived predictors by applying backward elimination. We calculated net reclassification improvement and integrated discrimination improvement indices. Discrimination was evaluated with the optimism-corrected c-statistic and calibration with a calibration plot. Results During 5 years of follow-up, 56 patients (9%) had a recurrence. The c-statistic of the clinical model, which contained male sex, history of hyperlipidemia, and history of stroke or transient ischemic attack, was 0.61. Compared with the clinical model, the extended model, which contained previous cerebral infarcts on non-contrast CT and Alberta Stroke Program Early CT score greater than 7 on mean transit time maps derived from CT perfusion, had higher discriminative performance (c-statistic 0.65, P = 0.01). Inclusion of these CT variables led to a significant improvement in reclassification measures, by using the net reclassification improvement and integrated discrimination improvement indices. Conclusion Data from CT imaging significantly improved the discriminatory performance and reclassification in predicting ischemic stroke recurrence beyond a model incorporating clinical risk factors only. Electronic supplementary material The online version of this article (10.1007/s00234-020-02526-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Frans Kauw
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands. .,Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Richard A P Takx
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Hugo W A M de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | | | - Jan A Vos
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - L Jaap Kappelle
- Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jan W Dankbaar
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | | |
Collapse
|
32
|
Hendrix P, Sofoluke N, Adams M, Kunaprayoon S, Zand R, Kolinovsky AN, Person TN, Gupta M, Goren O, Kirchner HL, Schirmer CM, Rost NS, Faber JE, Griessenauer CJ. Matrix Gla protein polymorphism rs1800801 associates with recurrence of ischemic stroke. PLoS One 2020; 15:e0235122. [PMID: 32584873 PMCID: PMC7316322 DOI: 10.1371/journal.pone.0235122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/09/2020] [Indexed: 02/06/2023] Open
Abstract
The MGP single nucleotide polymorphism (SNP) rs1800801 has previously been associated with recurrent ischemic stroke in a Spanish cohort. Here, we tested for association of this SNP with ischemic stroke recurrence in a North American Caucasian cohort. Acute ischemic stroke patients admitted between 10/2009 and 12/2016 at three hospitals within a large healthcare system in the northeastern United States that were enrolled in a healthcare system-wide exome sequencing program were retrospectively reviewed. Patients with recurrent stroke within 1 year after index event were compared to those without recurrence. Of 9,348 suspected acute ischemic strokes admitted between 10/2009 and 12/2016, 1,727 (18.5%) enrolled in the exome-sequencing program. Among those, 1,068 patients had exome sequencing completed and were eligible for inclusion. Recurrent stroke within the first year of stroke was observed in 79 patients (7.4%). In multivariable analysis, stroke prior to the index stroke (OR 9.694, 95% CI 5.793-16.224, p ≤ 0.001), pro-coagulant status (OR = 3.563, 95% CI 1.504-8.443, p = 0.004) and the AA genotype of SNP rs1800801 (OR = 2.408, 95% CI 1.079-4.389, p = 0.004) were independently associated with recurrent stroke within the first year. The AA genotype of the MGP SNP rs1800801 is associated with recurrence within the first year after ischemic stroke in North American Caucasians. Study of stroke subtypes and additional populations will be required to determine if incorporation of allelic status at this SNP into current risk scores improves prediction of recurrent ischemic stroke.
Collapse
Affiliation(s)
- Philipp Hendrix
- Department of Neurosurgery, Geisinger, Danville, PA, United States of America
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Nelson Sofoluke
- Department of Neurosurgery, Geisinger, Danville, PA, United States of America
| | - Matthew Adams
- Geisinger Commonwealth School of Medicine, Scranton, PA, United States of America
| | - Saran Kunaprayoon
- Geisinger Commonwealth School of Medicine, Scranton, PA, United States of America
| | - Ramin Zand
- Department of Neurology, Geisinger, Danville, PA, United States of America
| | - Amy N. Kolinovsky
- Geisinger Health System Phenomic Analytics and Clinical Data Core, Danville, PA, United States of America
| | - Thomas N. Person
- Geisinger Health System Phenomic Analytics and Clinical Data Core, Danville, PA, United States of America
| | - Mudit Gupta
- Geisinger Health System Phenomic Analytics and Clinical Data Core, Danville, PA, United States of America
| | - Oded Goren
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - H. Lester Kirchner
- Biomedical and Translational Informatics, Geisinger Health System, Danville, PA, United States of America
| | - Clemens M. Schirmer
- Department of Neurosurgery, Geisinger, Danville, PA, United States of America
| | - Natalia S. Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - James E. Faber
- Department of Cell Biology and Physiology, University of North Carolina, Chapel Hill, NC, United States of America
| | - Christoph J. Griessenauer
- Department of Neurosurgery, Geisinger, Danville, PA, United States of America
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| |
Collapse
|
33
|
Sarfo FS, Ovbiagele B. Prevalence and predictors of statin utilization among patient populations at high vascular risk in Ghana. J Neurol Sci 2020; 414:116838. [PMID: 32325358 DOI: 10.1016/j.jns.2020.116838] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Inadequate implementation of evidence-based preventive measures for individuals at high risk of cardiovascular disease (CVD) will only worsen the current epidemic of CVDs in sub-Saharan Africa. We assessed rates and predictors of statin utilization among two high CVD risk patient populations, people with type 2 diabetes mellitus (T2DM) and those with stroke, encountered across five hospitals in Ghana. METHODS A cross-sectional study among 1427 patients with T2DM and 159 stroke survivors encountered at 5 hospitals (1 primary-level, 2 secondary level and 2 tertiary level) in Ghana between July 2015 and June 2018. We collected baseline demographic and clinical details including statin prescription from medical records. Factors associated with statin prescription among T2DM for primary prevention and stroke survivors for secondary prevention were evaluated using multivariate logistic regression analysis. RESULTS Among patients with T2DM without CVDs, 240 (16.8%) were on statins for primary prevention. Factors associated with statin use among diabetics expressed as aOR (95% CI) were being treated at a tertiary level hospital 5.86 (3.22-10.68), hypertension comorbidity 1.80 (1.25-2.60), and lower income 0.43 (0.26-0.70). Among 159 stroke survivors, 22 (14.0%) were on statins with the following associated factors: lower income 0.16 (0.03-0.77), secondary level vs. tertiary level education 0.21 (0.05-0.97) and having T2DM 4.69 (1.63-13.49). CONCLUSION Approximately 1 in 6 individuals with T2DM without CVD and 1 in 7 stroke survivors are prescribed statins in Ghana. Efforts to bridge this practice gap and improve access to life saving preventative medications for CVD risk reduction in low-and-middle income countries are urgently warranted.
Collapse
Affiliation(s)
- Fred Stephen Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, USA
| |
Collapse
|
34
|
O'Connor KP, Hathidara MY, Danala G, Xu C, McCoy TM, Sidorov EV, Zheng B, Bohnstedt BN, Ray B. Predicting Clinical Outcome After Mechanical Thrombectomy: The GADIS (Gender, Age, Diabetes Mellitus History, Infarct Volume, and Sex) Score. World Neurosurg 2020; 134:e1130-e1142. [DOI: 10.1016/j.wneu.2019.11.127] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 11/28/2022]
|
35
|
Wang Y, Qin W, Hu W. An analysis of the risk of perioperative ischemic stroke in patients undergoing non-cardiovascular and non-neurological surgeries. Neurol Res 2020; 42:55-61. [PMID: 31903867 DOI: 10.1080/01616412.2019.1709140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives: This study aimed to assess the preoperative risk factor for perioperative ischemic stroke (PIS) in patients undergoing non-cardiovascular and non-neurological surgeries.Methods: Patients were retrospectively enrolled and grouped into two groups at a ratio of 1:2 according to their PIS status, i.e. patients with PIS in disease group, and patients without PIS in control group. Univariate analysis and multivariate logistic regression analysis were performed on admission laboratory test indices and preoperative risk factors for stroke. The pooled cohort equation (PCE), Essen Stroke Risk Score (ESRS), and Stroke Prognostic Instrument II (SPI-II) were used to separately assess the risk of stroke in patients with or without a history of stroke.Results: There were significant differences between the two groups in the levels of high-density lipoprotein cholesterol (HDL-C), prealbumin, renal insufficiency, dyslipidemia, coronary heart disease, anemia, and hemoglobin; the incidence of electrolyte disturbance; and previous histories of smoking, drinking, and stroke. Multivariate logistic regression analysis showed that renal insufficiency, histories of smoking and stroke, and decreased HDL-C can increase the risk of PIS. There were no significant differences between the disease group and the control group in ESRS or SPI-II score in patients with stroke history. There was a significant difference between the two groups in the risk of PIS evaluated by PCE in patients without stroke history.Conclusions: History of stroke and smoking, renal insufficiency, and low HDL-C are independent risk factors for PIS. It is feasible to assess the risk of stroke in preoperative patients using PCE in clinical practice.
Collapse
Affiliation(s)
- Yun Wang
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Wei Qin
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Wenli Hu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
36
|
Kamtchum-Tatuene J, Jickling GC. Blood Biomarkers for Stroke Diagnosis and Management. Neuromolecular Med 2019; 21:344-368. [PMID: 30830566 PMCID: PMC6722038 DOI: 10.1007/s12017-019-08530-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 02/19/2019] [Indexed: 12/20/2022]
Abstract
Biomarkers are objective indicators used to assess normal or pathological processes, evaluate responses to treatment and predict outcomes. Many blood biomarkers already guide decision-making in clinical practice. In stroke, the number of candidate biomarkers is constantly increasing. These biomarkers include proteins, ribonucleic acids, lipids or metabolites. Although biomarkers have the potential to improve the diagnosis and the management of patients with stroke, there is currently no marker that has demonstrated sufficient sensitivity, specificity, rapidity, precision, and cost-effectiveness to be used in the routine management of stroke, thus highlighting the need for additional work. A better standardization of clinical, laboratory and statistical procedures between centers is indispensable to optimize biomarker performance. This review focuses on blood biomarkers that have shown promise for translation into clinical practice and describes some newly reported markers that could add to routine stroke care. Avenues for the discovery of new stroke biomarkers and future research are discussed. The description of the biomarkers is organized according to their expected application in clinical practice: diagnosis, treatment decision, and outcome prediction.
Collapse
Affiliation(s)
- Joseph Kamtchum-Tatuene
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, 4-120 Katz Building, 114 Street & 87 Avenue, Edmonton, AB, T6G 2E1, Canada.
| | - Glen C Jickling
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, 4-120 Katz Building, 114 Street & 87 Avenue, Edmonton, AB, T6G 2E1, Canada
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| |
Collapse
|
37
|
Chaudhary D, Abedi V, Li J, Schirmer CM, Griessenauer CJ, Zand R. Clinical Risk Score for Predicting Recurrence Following a Cerebral Ischemic Event. Front Neurol 2019; 10:1106. [PMID: 31781015 PMCID: PMC6861423 DOI: 10.3389/fneur.2019.01106] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/02/2019] [Indexed: 12/30/2022] Open
Abstract
Introduction: Recurrent stroke has a higher rate of death and disability. A number of risk scores have been developed to predict short-term and long-term risk of stroke following an initial episode of stroke or transient ischemic attack (TIA) with limited clinical utilities. In this paper, we review different risk score models and discuss their validity and clinical utilities. Methods: The PubMed bibliographic database was searched for original research articles on the various risk scores for risk of stroke following an initial episode of stroke or TIA. The validation of the models was evaluated by examining the internal and external validation process as well as statistical methodology, the study power, as well as the accuracy and metrics such as sensitivity and specificity. Results: Different risk score models have been derived from different study populations. Validation studies for these risk scores have produced conflicting results. Currently, ABCD2 score with diffusion weighted imaging (DWI) and Recurrence Risk Estimator at 90 days (RRE-90) are the two acceptable models for short-term risk prediction whereas Essen Stroke Risk Score (ESRS) and Stroke Prognosis Instrument-II (SPI-II) can be useful for prediction of long-term risk. Conclusion: The clinical risk scores that currently exist for predicting short-term and long-term risk of recurrent cerebral ischemia are limited in their performance and clinical utilities. There is a need for a better predictive tool which can overcome the limitations of current predictive models. Application of machine learning methods in combination with electronic health records may provide platform for development of new-generation predictive tools.
Collapse
Affiliation(s)
- Durgesh Chaudhary
- Neuroscience Institute, Geisinger Health System, Danville, PA, United States
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Weis Center for Research, Geisinger Health System, Danville, PA, United States.,Biocomplexity Institute, Virginia Tech, Blacksburg, VA, United States
| | - Jiang Li
- Department of Molecular and Functional Genomics, Weis Center for Research, Geisinger Health System, Danville, PA, United States
| | - Clemens M Schirmer
- Neuroscience Institute, Geisinger Health System, Danville, PA, United States.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Neuroscience Institute, Geisinger Health System, Danville, PA, United States.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Ramin Zand
- Neuroscience Institute, Geisinger Health System, Danville, PA, United States
| |
Collapse
|
38
|
Bravata DM, Myers LJ, Arling G, Miech EJ, Damush T, Sico JJ, Phipps MS, Zillich AJ, Yu Z, Reeves M, Williams LS, Johanning J, Chaturvedi S, Baye F, Ofner S, Austin C, Ferguson J, Graham GD, Rhude R, Kessler CS, Higgins DS, Cheng E. Quality of Care for Veterans With Transient Ischemic Attack and Minor Stroke. JAMA Neurol 2019; 75:419-427. [PMID: 29404578 DOI: 10.1001/jamaneurol.2017.4648] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Importance The timely delivery of guideline-concordant care may reduce the risk of recurrent vascular events for patients with transient ischemic attack (TIA) and minor stroke. Although many health care organizations measure stroke care quality, few evaluate performance for patients with TIA or minor stroke, and most include only a limited subset of guideline-recommended processes. Objective To assess the quality of guideline-recommended TIA and minor stroke care across the Veterans Health Administration (VHA) system nationwide. Design, Setting, and Participants This cohort study included 8201 patients with TIA or minor stroke cared for in any VHA emergency department (ED) or inpatient setting during federal fiscal year 2014 (October 1, 2013, through September 31, 2014). Patients with length of stay longer than 6 days, ventilator use, feeding tube use, coma, intensive care unit stay, inpatient rehabilitation stay before discharge, or receipt of thrombolysis were excluded. Outlier facilities for each process of care were identified by constructing 95% CIs around the facility pass rate and national pass rate sites when the 95% CIs did not overlap. Data analysis occurred from January 16, 2016, through June 30, 2017. Main Outcomes and Measures Ten elements of care were assessed using validated electronic quality measures. Results In the 8201 patients included in the study (mean [SD] age, 68.8 [11.4] years; 7877 [96.0%] male; 4856 [59.2%] white), performance varied across elements of care: brain imaging by day 2 (6720/7563 [88.9%]; 95% CI, 88.2%-89.6%), antithrombotic use by day 2 (6265/7477 [83.8%]; 95% CI, 83.0%-84.6%), hemoglobin A1c measurement by discharge or within the preceding 120 days (2859/3464 [82.5%]; 95% CI, 81.2%-83.8%), anticoagulation for atrial fibrillation by day 7 after discharge (1003/1222 [82.1%]; 95% CI, 80.0%-84.2%), deep vein thrombosis prophylaxis by day 2 (3253/4346 [74.9%]; 95% CI, 73.6%-76.2%), hypertension control by day 90 after discharge (4292/5979 [71.8%]; 95% CI, 70.7%-72.9%), neurology consultation by day 1 (5521/7823 [70.6%]; 95% CI, 69.6%-71.6%), electrocardiography by day 2 or within 1 day prior (5073/7570 [67.0%]; 95% CI, 65.9%-68.1%), carotid artery imaging by day 2 or within 6 months prior (4923/7685 [64.1%]; 95% CI, 63.0%-65.2%), and moderate- to high-potency statin prescription by day 7 after discharge (3329/7054 [47.2%]; 95% CI, 46.0%-48.4%). Performance varied substantially across facilities (eg, neurology consultation had a facility outlier rate of 53.0%). Performance was higher for admitted patients than for patients cared for only in EDs with the greatest disparity for carotid artery imaging (4478/5927 [75.6%] vs 445/1758 [25.3%]; P < .001). Conclusions and Relevance This national study of VHA system quality of care for patients with TIA or minor stroke identified opportunities to improve care quality, particularly for patients who were discharged from the ED. Health care systems should engage in ongoing TIA care performance assessment to complement existing stroke performance measurement.
Collapse
Affiliation(s)
- Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis.,Department of Neurology, Indiana University School of Medicine, Indianapolis.,Regenstrief Institute, Indianapolis, Indiana
| | - Laura J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
| | - Greg Arling
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,Purdue University School of Nursing, West Lafayette, Indiana
| | - Edward J Miech
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Regenstrief Institute, Indianapolis, Indiana.,Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Teresa Damush
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis.,Regenstrief Institute, Indianapolis, Indiana
| | - Jason J Sico
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Alan J Zillich
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana
| | - Zhangsheng Yu
- Department of Biostatistics, Indiana University School of Medicine, Indiana University-Purdue University, Indianapolis
| | - Mathew Reeves
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,Department of Epidemiology, Michigan State University, East Lansing
| | - Linda S Williams
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Department of Neurology, Indiana University School of Medicine, Indianapolis.,Regenstrief Institute, Indianapolis, Indiana
| | - Jason Johanning
- VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha.,Department of Surgery, University of Nebraska, Omaha
| | - Seemant Chaturvedi
- Department of Neurology, Miami VA Medical Center, Miami, Florida.,Department of Neurology, University of Miami School of Medicine, Miami, Florida
| | - Fitsum Baye
- Department of Biostatistics, Indiana University School of Medicine, Indiana University-Purdue University, Indianapolis
| | - Susan Ofner
- Department of Biostatistics, Indiana University School of Medicine, Indiana University-Purdue University, Indianapolis
| | - Curt Austin
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
| | - Jared Ferguson
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.,Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Glenn D Graham
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,Specialty Care Services, Department of Veterans Affairs, Washington, DC.,Department of Neurology, University of California, San Francisco (UCSF) School of Medicine, San Francisco
| | - Rachel Rhude
- VA Inpatient Evaluation Center, Cincinnati, Ohio
| | - Chad S Kessler
- Specialty Care Services, VA Central Office, Washington, DC.,Department of Emergency Medicine, Durham VA Medical Center, Durham, North Carolina
| | - Donald S Higgins
- Specialty Care Services, Department of Veterans Affairs, Washington, DC.,Department of Neurology, Stratton VA Medical Center, Albany, New York
| | - Eric Cheng
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC.,Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Neurology, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
| |
Collapse
|
39
|
Xu J, Wang A, Wangqin R, Mo J, Chen Z, Dai L, Meng X, Zhao X, Wang Y, Li H, Chen W, Xian Y, Wang Y. Efficacy of clopidogrel for stroke depends on CYP2C19 genotype and risk profile. Ann Neurol 2019; 86:419-426. [PMID: 31237713 DOI: 10.1002/ana.25535] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Jie Xu
- Department of Neurology, Beijing Tiantan HospitalCapital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of StrokeBeijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of StrokeBeijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Runqi Wangqin
- Department of NeurologyDuke University Medical Center Durham NC
| | - Jinglin Mo
- Department of Neurology, Beijing Tiantan HospitalCapital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of StrokeBeijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Zimo Chen
- Department of Neurology, Beijing Tiantan HospitalCapital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of StrokeBeijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Liye Dai
- Department of Neurology, Beijing Tiantan HospitalCapital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of StrokeBeijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan HospitalCapital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of StrokeBeijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan HospitalCapital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of StrokeBeijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of StrokeBeijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Hao Li
- Department of Neurology, Beijing Tiantan HospitalCapital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of StrokeBeijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | - Wei Chen
- Department of Epidemiology, School of Public Health and Tropical MedicineTulane University New Orleans LA
| | - Ying Xian
- Department of NeurologyDuke University Medical Center Durham NC
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Center of StrokeBeijing Institute for Brain Disorders Beijing China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease Beijing China
| | | |
Collapse
|
40
|
Bravata DM, Myers LJ, Reeves M, Cheng EM, Baye F, Ofner S, Miech EJ, Damush T, Sico JJ, Zillich A, Phipps M, Williams LS, Chaturvedi S, Johanning J, Yu Z, Perkins AJ, Zhang Y, Arling G. Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke. JAMA Netw Open 2019; 2:e196716. [PMID: 31268543 PMCID: PMC6613337 DOI: 10.1001/jamanetworkopen.2019.6716] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. OBJECTIVE To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019. MAIN OUTCOMES AND MEASURES Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. RESULTS Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk. CONCLUSIONS AND RELEVANCE Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible.
Collapse
Affiliation(s)
- Dawn M. Bravata
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Laura J. Myers
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Mathew Reeves
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Department of Epidemiology, Michigan State University, East Lansing
| | - Eric M. Cheng
- Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles
| | - Fitsum Baye
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Susan Ofner
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Edward J. Miech
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Teresa Damush
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Jason J. Sico
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
| | - Alan Zillich
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana
| | - Michael Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Linda S. Williams
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
- Department of Neurology, Indiana University School of Medicine, Indianapolis
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Jason Johanning
- Omaha Division, VA Nebraska-Western Iowa Health Care System, Omaha
- Department of Surgery, University of Nebraska, Lincoln
| | - Zhangsheng Yu
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
| | - Anthony J. Perkins
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
| | - Ying Zhang
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
| | - Greg Arling
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Purdue University School of Nursing, Lafayette, Indiana
| |
Collapse
|
41
|
Drozdowska BA, Singh S, Quinn TJ. Thinking About the Future: A Review of Prognostic Scales Used in Acute Stroke. Front Neurol 2019; 10:274. [PMID: 30949127 PMCID: PMC6437031 DOI: 10.3389/fneur.2019.00274] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/01/2019] [Indexed: 11/25/2022] Open
Abstract
Background: There are many prognostic scales that aim to predict functional outcome following acute stroke. Despite considerable research interest, these scales have had limited impact in routine clinical practice. This may be due to perceived problems with internal validity (quality of research), as well as external validity (generalizability of results). We set out to collate information on exemplar stroke prognosis scales, giving particular attention to the scale content, derivation, and validation. Methods: We performed a focused literature search, designed to return high profile scales that use baseline clinical data to predict mortality or disability. We described prognostic utility and collated information on the content, development and validation of the tools. We critically appraised chosen scales based on the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies (CHARMS). Results: We chose 10 primary scales that met our inclusion criteria, six of which had revised/modified versions. Most primary scales used 5 input variables (range: 4–13), with substantial overlap in the variables included. All scales included age, eight included a measure of stroke severity, while five scales incorporated pre-stroke level of function (often using modified Rankin Scale), comorbidities and classification of stroke type. Through our critical appraisal, we found issues relating to excluding patients with missing data from derivation studies, and basing the selection of model variable on significance in univariable analysis (in both cases noted for six studies). We identified separate external validation studies for all primary scales but one, with a total of 60 validation studies. Conclusions: Most acute stroke prognosis scales use similar variables to predict long-term outcomes and most have reasonable prognostic accuracy. While not all published scales followed best practice in development, most have been subsequently validated. Lack of clinical uptake may relate more to practical application of scales rather than validity. Impact studies are now necessary to investigate clinical usefulness of existing scales.
Collapse
Affiliation(s)
- Bogna A Drozdowska
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Sarjit Singh
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, United Kingdom
| |
Collapse
|
42
|
Saengsuwan J, Suangpho P. Self-perceived and Actual Risk of Further Stroke in Patients with Recurrent Stroke or Recurrent Transient Ischemic Attack in Thailand. J Stroke Cerebrovasc Dis 2019; 28:632-639. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 10/29/2018] [Accepted: 11/03/2018] [Indexed: 01/30/2023] Open
|
43
|
Zheng S, Yao B. Impact of risk factors for recurrence after the first ischemic stroke in adults: A systematic review and meta-analysis. J Clin Neurosci 2019; 60:24-30. [DOI: 10.1016/j.jocn.2018.10.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 10/05/2018] [Indexed: 11/26/2022]
|
44
|
Sarfo FS, Sarfo-Kantanka O, Adamu S, Obese V, Voeks J, Tagge R, Sethi V, Ovbiagele B. Stroke Minimization through Additive Anti-atherosclerotic Agents in Routine Treatment (SMAART): study protocol for a randomized controlled trial. Trials 2018. [PMID: 29540234 PMCID: PMC5853072 DOI: 10.1186/s13063-018-2564-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background There is an unprecedented rise in the prevalence of stroke in sub-Saharan Africa (SSA). Secondary prevention guidelines recommend that antihypertensive, statin and antiplatelet therapy be initiated promptly after ischemic stroke and adhered to in a persistent fashion to achieve optimal vascular-risk reduction. However, these goals are seldom realized in routine clinical care settings in SSA due to logistical challenges. We seek to assess whether a polypill containing fixed doses of three antihypertensive agents, a statin and antiplatelet therapy taken once daily per os for 12 months among recent stroke survivors would result in carotid intimal thickness regression compared with usual care (UC). Methods The Stroke Minimization through Additive Anti-atherosclerotic Agents in Routine Treatment (SMAART) trial is a phase 2, open-label, evaluator-blinded trial involving 120 Ghanaian recent-ischemic-stroke survivors. Using a computer-generated sequence, patients will be randomly allocated 1:1 into either the intervention arm or UC. Patients in the intervention arm will receive Polycap DS® (containing aspirin, 100 mg; atenolol, 50 mg; ramipril, 5 mg; thiazide, 12.5 mg; simvastatin, 20 mg) taken as two capsules once daily. Patients in the UC will receive separate, individual secondary preventive medications prescribed at the physician’s discretion. Both groups will be followed for 12 months to assess changes in carotid intimal thickness regression – a surrogate marker of atherosclerosis – as primary outcome measure. Secondary outcome measures include adherence to therapy, safety and tolerability, health-related quality of life, patient satisfaction, functional status, depression and cognitive dysfunction. Discussion An efficacy-suggesting SMAART trial could inform the future design of a multi-center, double-blinded, placebo-controlled, parallel-group, randomized controlled trial comparing the clinical efficacy of the polypill strategy for vascular risk moderation among stroke survivors in SSA. Trial registration ClinicalTrials.gov, ID: NCT03329599. Registered on 11 February 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2564-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Fred Stephen Sarfo
- Division of Neurology, Department of Medicine, Kwame Nkrumah University of Science and Technology, P.M. B, Kumasi, Ghana. .,Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | | | | | - Vida Obese
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Jennifer Voeks
- Department of Neurology, Medical University of South Carolina, South Carolina, USA
| | - Raelle Tagge
- Department of Neurology, Medical University of South Carolina, South Carolina, USA
| | | | - Bruce Ovbiagele
- Department of Neurology, Medical University of South Carolina, South Carolina, USA
| |
Collapse
|
45
|
Uehara T, Ohara T, Minematsu K, Nagatsuka K, Toyoda K. Predictors of Stroke Events in Patients with Transient Ischemic Attack Attributable to Intracranial Stenotic Lesions. Intern Med 2018; 57:295-300. [PMID: 29093423 PMCID: PMC5827305 DOI: 10.2169/internalmedicine.9447-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective The purpose of this study was to identify the predictors of subsequent ischemic stroke events in patients with transient ischemic attack (TIA) attributable to intracranial arterial occlusive lesions. Methods The study population included 82 patients (55 men; mean age, 69.3±12.1 years) with TIA caused by intracranial arterial occlusive lesions who were admitted to our stroke care unit within 48 h of the onset of a TIA between April 2008 and November 2015. TIA was diagnosed if focal neurological symptoms ascribable to a vascular etiology lasted less than 24 h, irrespective of the presence of ischemic insults on imaging. The primary endpoint was an ischemic stroke event within 90 days of the onset of a TIA. Results The 90-day risk of ischemic stroke after the onset of a TIA was 14.6% [95% confidence interval (CI): 8.6-23.9%]. Cox proportional hazards multivariate analyses revealed that diffusion-weighted imaging (DWI) positivity [hazard ratio (HR), 8.73; 95%CI, 2.20-41.59; p=0.002], prior ischemic stroke (HR, 4.03; 95%CI, 1.07-15.99; p=0.040), and a high serum level of alkaline phosphatase (ALP) on admission (HR, 1.15; 95%CI, 1.05-1.26; p=0.002, for every +10 U/L) were significant independent predictors of ischemic stroke within 90 days after the onset of a TIA. Conclusion Our results suggested that patients with a TIA attributable to intracranial artery disease who showed DWI lesions, prior ischemic stroke, or high serum levels of ALP on admission were at high risk of subsequent ischemic stroke events.
Collapse
Affiliation(s)
- Toshiyuki Uehara
- Departments of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Tomoyuki Ohara
- Departments of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Kazuo Minematsu
- Departments of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Kazuyuki Nagatsuka
- Departments of Neurology, National Cerebral and Cardiovascular Center, Japan
| | - Kazunori Toyoda
- Departments of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| |
Collapse
|
46
|
Ling X, Yan SM, Shen B, Yang X. A modified Essen Stroke Risk Score for predicting recurrent ischemic stroke at one year. Neurol Res 2018; 40:204-210. [PMID: 29369004 DOI: 10.1080/01616412.2018.1428389] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Xia Ling
- Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Shuang-Mei Yan
- Peking University Aerospace School of Clinical Medicine, Beijing, China
| | - Bo Shen
- Department of Neurology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Xu Yang
- Peking University Aerospace School of Clinical Medicine, Beijing, China
| |
Collapse
|
47
|
Kernan WN, Viscoli CM, Dearborn JL, Kent DM, Conwit R, Fayad P, Furie KL, Gorman M, Guarino PD, Inzucchi SE, Stuart A, Young LH. Targeting Pioglitazone Hydrochloride Therapy After Stroke or Transient Ischemic Attack According to Pretreatment Risk for Stroke or Myocardial Infarction. JAMA Neurol 2017; 74:1319-1327. [PMID: 28975241 DOI: 10.1001/jamaneurol.2017.2136] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance There is growing recognition that patients may respond differently to therapy and that the average treatment effect from a clinical trial may not apply equally to all candidates for a therapy. Objective To determine whether, among patients with an ischemic stroke or transient ischemic attack and insulin resistance, those at higher risk for future stroke or myocardial infarction (MI) derive more benefit from the insulin-sensitizing drug pioglitazone hydrochloride compared with patients at lower risk. Design, Setting, and Participants A secondary analysis was conducted of the Insulin Resistance Intervention After Stroke trial, a double-blind, placebo-controlled trial of pioglitazone for secondary prevention. Patients were enrolled from 179 research sites in 7 countries from February 7, 2005, to January 15, 2013, and were followed up for a mean of 4.1 years through the study's end on July 28, 2015. Eligible participants had a qualifying ischemic stroke or transient ischemic attack within 180 days of entry and insulin resistance without type 1 or type 2 diabetes. Interventions Pioglitazone or matching placebo. Main Outcomes and Measures A Cox proportional hazards regression model was created using baseline features to stratify patients above or below the median risk for stroke or MI within 5 years. Within each stratum, the efficacy of pioglitazone for preventing stroke or MI was calculated. Safety outcomes were death, heart failure, weight gain, and bone fracture. Results Among 3876 participants (1338 women and 2538 men; mean [SD] age, 63 [11] years), the 5-year risk for stroke or MI was 6.0% in the pioglitazone group among patients at lower baseline risk compared with 7.9% in the placebo group (absolute risk difference, -1.9% [95% CI, -4.4% to 0.6%]). Among patients at higher risk, the risk was 14.7% in the pioglitazone group vs 19.6% for placebo (absolute risk difference, -4.9% [95% CI, -8.6% to 1.2%]). Hazard ratios were similar for patients below or above the median risk (0.77 vs 0.75; P = .92). Pioglitazone increased weight less among patients at higher risk but increased the risk for fracture more. Conclusions and Relevance After an ischemic stroke or transient ischemic attack, patients at higher risk for stroke or MI derive a greater absolute benefit from pioglitazone compared with patients at lower risk. However, the risk for fracture is also higher. Trial Registration clinicaltrials.gov Identifier: NCT00091949.
Collapse
Affiliation(s)
- Walter N Kernan
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Catherine M Viscoli
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Robin Conwit
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Pierre Fayad
- Department of Neurological Sciences, University of Nebraska Medical School, Omaha
| | - Karen L Furie
- Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Peter D Guarino
- Statistical Center for HIV/AIDS Research Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Silvio E Inzucchi
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Amber Stuart
- University of Connecticut School of Medicine, Farmington
| | - Lawrence H Young
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | |
Collapse
|
48
|
Abstract
Significant advances in our understanding of transient ischemic attack (TIA) have taken place since it was first recognized as a major risk factor for stroke during the late 1950's. Recently, numerous studies have consistently shown that patients who have experienced a TIA constitute a heterogeneous population, with multiple causative factors as well as an average 5–10% risk of suffering a stroke during the 30 days that follow the index event. These two attributes have driven the most important changes in the management of TIA patients over the last decade, with particular attention paid to effective stroke risk stratification, efficient and comprehensive diagnostic assessment, and a sound therapeutic approach, destined to reduce the risk of subsequent ischemic stroke. This review is an outline of these changes, including a discussion of their advantages and disadvantages, and references to how new trends are likely to influence the future care of these patients.
Collapse
Affiliation(s)
- Camilo R Gomez
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Michael J Schneck
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Jose Biller
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| |
Collapse
|
49
|
Epstein KA, Viscoli CM, Spence JD, Young LH, Inzucchi SE, Gorman M, Gerstenhaber B, Guarino PD, Dixit A, Furie KL, Kernan WN. Smoking cessation and outcome after ischemic stroke or TIA. Neurology 2017; 89:1723-1729. [PMID: 28887378 DOI: 10.1212/wnl.0000000000004524] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/14/2017] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To assess whether smoking cessation after an ischemic stroke or TIA improves outcomes compared to continued smoking. METHODS We conducted a prospective observational cohort study of 3,876 nondiabetic men and women enrolled in the Insulin Resistance Intervention After Stroke (IRIS) trial who were randomized to pioglitazone or placebo within 180 days of a qualifying stroke or TIA and followed up for a median of 4.8 years. A tobacco use history was obtained at baseline and updated during annual interviews. The primary outcome, which was not prespecified in the IRIS protocol, was recurrent stroke, myocardial infarction (MI), or death. Cox regression models were used to assess the differences in stroke, MI, and death after 4.8 years, with correction for adjustment variables prespecified in the IRIS trial: age, sex, stroke (vs TIA) as index event, history of stroke, history of hypertension, history of coronary artery disease, and systolic and diastolic blood pressures. RESULTS At the time of their index event, 1,072 (28%) patients were current smokers. By the time of randomization, 450 (42%) patients had quit smoking. Among quitters, the 5-year risk of stroke, MI, or death was 15.7% compared to 22.6% for patients who continued to smoke (adjusted hazard ratio 0.66, 95% confidence interval 0.48-0.90). CONCLUSION Cessation of cigarette smoking after an ischemic stroke or TIA was associated with significant health benefits over 4.8 years in the IRIS trial cohort.
Collapse
Affiliation(s)
- Katherine A Epstein
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Catherine M Viscoli
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - J David Spence
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Lawrence H Young
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Silvio E Inzucchi
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Mark Gorman
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Brett Gerstenhaber
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Peter D Guarino
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Anand Dixit
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Karen L Furie
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Walter N Kernan
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI.
| | | |
Collapse
|
50
|
Nam KW, Kwon HM, Lim JS, Han MK, Lee YS. Clinical relevance of abnormal neuroimaging findings and long-term risk of stroke recurrence. Eur J Neurol 2017; 24:1348-1354. [DOI: 10.1111/ene.13391] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/04/2017] [Indexed: 11/29/2022]
Affiliation(s)
- K.-W. Nam
- Department of Neurology; Seoul Metropolitan Government-Seoul National University Boramae Medical Center; Seoul
| | - H.-M. Kwon
- Department of Neurology; Seoul Metropolitan Government-Seoul National University Boramae Medical Center; Seoul
| | - J.-S. Lim
- Department of Neurology; Hallym University Sacred Heart Hospital; Anyang
| | - M.-K. Han
- Department of Neurology; Seoul National University Bundang Hospital; Seong-nam si Korea
| | - Y.-S. Lee
- Department of Neurology; Seoul Metropolitan Government-Seoul National University Boramae Medical Center; Seoul
| |
Collapse
|