Blood pressure variability in acute stroke: Risk factors and association with functional outcomes at 1 month

BACKGROUND AND PURPOSE

Blood pressure variability, in acute stroke, may be an important modifiable determinant of functional outcome after stroke. In a large international cohort of participants with acute stroke, it was sought to determine the association of blood pressure variability (in the early period of admission) and functional outcomes, and to explore risk factors for increased blood pressure variability.

PATIENTS AND METHODS

INTERSTROKE is an international case-control study of risk factors for first acute stroke. Blood pressure was recorded at the time of admission, the morning after admission and the time of interview in cases (median time from admission 36.7 h). Multivariable ordinal regression analysis was employed to determine the association of blood pressure variability (standard deviation [SD] and coefficient of variance) with modified Rankin score at 1-month follow-up, and logistic regression was used to identify risk factors for blood pressure variability.

RESULTS

Amongst 13,206 participants, the mean age was 62.19 ± 13.58 years. When measured by SD, both systolic blood pressure variability (odds ratio 1.13; 95% confidence interval 1.03-1.24 for SD ≥20 mmHg) and diastolic blood pressure variability (odds ratio 1.15; 95% confidence interval 1.04-1.26 for SD ≥10 mmHg) were associated with a significant increase in the odds of poor functional outcome. The highest coefficient of variance category was not associated with a significant increase in risk of higher modified Rankin score at 1 month. Increasing age, female sex, high body mass index, history of hypertension, alcohol use, and high urinary potassium and low urinary sodium excretion were associated with increased blood pressure variability.

CONCLUSION

Increased blood pressure variability in acute stroke, measured by SD, is associated with an increased risk of poor functional outcome at 1 month. Potentially modifiable risk factors for increased blood pressure variability include low urinary sodium excretion.

Tobacco use and risk of acute stroke in 32 countries in the INTERSTROKE study: a case-control study

Background

Smoking is a major risk factor for the global burden of stroke. We have previously reported a global population attributable risk (PAR) of stroke of 12.4% associated with current smoking. In this study we aimed to explore the association of current tobacco use with different types of tobacco exposure and environmental tobacco smoke (ETS) exposure on the risk of stroke and stroke subtypes, and by regions and country income levels.

Methods

The INTERSTROKE study is a case-control study of acute first stroke and was undertaken with 13,462 stroke cases and 13,488 controls recruited between January 11, 2007 and August 8, 2015 in 32 countries worldwide. Association of risk of tobacco use and ETS exposure were analysed with overall stroke, ischemic and intracerebral hemorrhage (ICH), and with TOAST etiological stroke subtypes (large vessel, small vessel, cardioembolism, and undetermined).

Findings

Current smoking was associated with an increased risk of all stroke (odds ratio [OR] 1.64, 95% CI 1.46-1.84), and had a stronger association with ischemic stroke (OR 1.85, 95% CI 1.61-2.11) than ICH (OR 1.19 95% CI 1.00-1.41). The OR and PAR of stroke among current smokers varied significantly between regions and income levels with high income countries (HIC) having the highest odds (OR 3.02 95% CI 2.24-4.10) and PAR (18.6%, 15.1-22.8%). Among etiological subtypes of ischemic stroke, the strongest association of current smoking was seen for large vessel stroke (OR 2.16, 95% CI 1.63-2.87) and undetermined cause (OR 1.97, 95% CI 1.55-2.50). Both filtered (OR 1.73, 95% CI 1.50-1.99) and non-filtered (OR 2.59, 95% CI 1.79-3.77) cigarettes were associated with stroke risk. ETS exposure increased the risk of stroke in a dose-dependent manner, exposure for more than 10 h per week increased risk for all stroke (OR 1.95, 95% CI 1.69-2.27), ischemic stroke (OR 1.89, 95% CI 1.59-2.24) and ICH (OR 2.00, 95% CI 1.60-2.50).

Interpretation

There are significant variations in the magnitude of risk and PAR of stroke according to the types of tobacco used, active and ETS exposure, and countries with different income levels. Specific strategies to discourage tobacco use by any form and to build a smoke free environment should be implemented to ease the global burden of stroke.

Funding

The Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, and through unrestricted grants from several pharmaceutical companies with major contributions from Astra Zeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MERCK, Sharp and Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke.

Variations in the prevalence of atrial fibrillation, and in the strength of its association with ischemic stroke, in countries with different income levels: INTERSTROKE case-control study

BACKGROUND

The contribution of atrial fibrillation (AF) to the etiology and burden of stroke may vary by country income level.

AIMS

We examined differences in the prevalence of AF and described variations in the magnitude of the association between AF and ischemic stroke by country income level.

METHODS

In the INTERSTROKE case-control study, participants with acute first ischemic stroke were recruited across 32 countries. We included 10,363 ischemic stroke cases and 10,333 community or hospital controls who were matched for age, sex, and center. Participants were grouped into high-income (HIC), upper-middle-income (subdivided into two groups-UMIC-1 and UMIC-2), and lower-middle-income (LMIC) countries, based on gross national income. We evaluated the risk factors for AF overall and by country income level, and evaluated the association of AF with ischemic stroke.

RESULTS

AF was documented in 11.9% (n = 1235) of cases and 3.2% (n = 328) of controls. Compared to HIC, the prevalence of AF was significantly lower in UMIC-2 (aOR 0.35, 95% CI 0.29-0.41) and LMIC (aOR 0.50, 95% CI 0.41-0.60) on multivariable analysis. Hypertension, female sex, valvular heart disease, and alcohol intake were stronger risk factors for AF in lower-income countries, and obesity a stronger risk factor in higher-income countries. The magnitude of association between AF and ischemic stroke was significantly higher in lower-income countries compared to higher-income countries. The population attributable fraction for AF and stroke varied by region and was 15.7% (95% CI 13.7-17.8) in HIC, 14.6% (95% CI 12.3-17.1) in UMIC-1, 5.7% (95% CI 4.9-6.7) in UMIC-2, and 6.3% (95% CI 5.3-7.3) in LMIC.

CONCLUSION

Risk factors for AF vary by country income level. AF contributes to stroke burden to a greater extent in higher-income countries than in lower-income countries, due to a higher prevalence and despite a lower magnitude of odds ratio.

Implications of ACC/AHA Versus ESC/EAS LDL-C Recommendations for Residual Risk Reduction in ASCVD: A Simulation Study From DA VINCI

PURPOSE

Low-density lipoprotein cholesterol (LDL-C) recommendations differ between the 2018 American College of Cardiology/American Heart Association (ACC/AHA) and 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for patients with atherosclerotic cardiovascular disease (ASCVD) (< 70 vs. < 55 mg/dl, respectively). In the DA VINCI study, residual cardiovascular risk was predicted in ASCVD patients. The extent to which relative and absolute risk might be lowered by achieving ACC/AHA versus ESC/EAS LDL-C recommended approaches was simulated.

METHODS

DA VINCI was a cross-sectional observational study of patients prescribed lipid-lowering therapy (LLT) across 18 European countries. Ten-year cardiovascular risk (CVR) was predicted among ASCVD patients receiving stabilized LLT. For patients with LDL-C ≥ 70 mg/dl, the absolute LDL-C reduction required to achieve an LDL-C of < 70 or < 55 mg/dl (LDL-C of 69 or 54 mg/dl, respectively) was calculated. Relative and absolute risk reductions (RRRs and ARRs) were simulated.

RESULTS

Of the 2039 patients, 61% did not achieve LDL-C < 70 mg/dl. For patients with LDL-C ≥ 70 mg/dl, median (interquartile range) baseline LDL-C and 10-year CVR were 93 (81-115) mg/dl and 32% (25-43%), respectively. Median LDL-C reductions of 24 (12-46) and 39 (27-91) mg/dl were needed to achieve an LDL-C of 69 and 54 mg/dl, respectively. Attaining ACC/AHA or ESC/EAS goals resulted in simulated RRRs of 14% (7-25%) and 22% (15-32%), respectively, and ARRs of 4% (2-7%) and 6% (4-9%), respectively.

CONCLUSION

In ASCVD patients, achieving ESC/EAS LDL-C goals could result in a 2% additional ARR over 10 years versus the ACC/AHA approach.

Pleocytosis in cerebrospinal fluid attributed to ischemic stroke: A review of the literature

INTRODUCTION

Lumbar puncture is generally performed in stroke settings when infectious or inflammatory diseases are suspected to be the etiology. This review aimed to assess the prevalence of pleocytosis in the cerebrospinal fluid following ischemic stroke without inflammatory or infectious etiology.

METHODS

We searched PubMed for studies with mentions of "[ischemic stroke] AND [cerebrospinal fluid]". We included only studies written in English, including patients with a primary diagnosis of either ischemic stroke or transient ischemic attack (TIA), and where white blood cell count in the spinal fluid was presented. Studies investigating common etiologies for pleocytosis, was excluded. Study and patient characteristics, white blood cell count and time to lumbar puncture were presented in tables, and the prevalence of pleocytosis were reported and plotted graphically.

RESULTS

We included 15 studies with 1607 patients, 1522 with ischemic stroke and 85 with TIA. The prevalence of pleocytosis was between 0% to 28,6% and a mean of 11.8%. The highest white blood cell count found with common etiologies for pleocytosis ruled out was 56 cells/mm3. A mean white blood cell count of 4.0 was based on the three studies where this was available.

DISCUSSION

The included studies were methodologically heterogenous and few had pleocytosis as primary outcome. Pleocytosis following ischemic stroke is uncommon and should prompt further investigations.

Capillary transit time heterogeneity inhibits cerebral oxygen metabolism in patients with reduced cerebrovascular reserve capacity from steno-occlusive disease

The healthy cerebral perfusion demonstrates a homogenous distribution of capillary transit times. A disruption of this homogeneity may inhibit the extraction of oxygen. A high degree of capillary transit time heterogeneity (CTH) describes that some capillaries have very low blood flows, while others have excessively high blood flows and consequently short transit times. Very short transit times could hinder the oxygen extraction due to insufficient time for diffusion of oxygen into the tissue. CTH could be a consequence of cerebral vessel disease. We examined whether patients with cerebral steno-occlusive vessel disease demonstrate high CTH and if elevation of cerebral blood flow (CBF) by administration of acetazolamide (ACZ) increases the cerebral metabolic rate of oxygen (CMRO₂), or if some patients demonstrate reduced CMRO₂ related to detrimental CTH. Thirty-four patients and thirty-one healthy controls participated. Global CBF and CMRO₂ were acquired using phase-contrast MRI. Regional brain maps of CTH were acquired using dynamic contrast-enhanced MRI. Patients with impaired cerebrovascular reserve capacity demonstrated elevated CTH and a significant reduction of CMRO₂ after administration of ACZ, which could be related to high CTH. Impaired oxygen extraction from CTH could be a contributing part of the declining brain health observed in patients with cerebral vessel disease.

High-intensity training in patients with lacunar stroke: A one-year follow-up

OBJECTIVES

Physical inactivity is a major risk factor for stroke. It is a challenge for patients to initiate and adhere to regular exercise post-stroke. Early initiation of home-based high-intensity interval training (HIIT) may engage patients in physical activity, improve cardiorespiratory fitness, and reduce risk of recurrent stroke.

MATERIALS AND METHODS

Post-intervention follow-up of patients with lacunar stroke, randomized to three-months HIIT including weekly motivational calls, or usual care. At follow-up (six- and 12-months post-stroke), we investigated changes in cardiorespiratory fitness, physical activity, fatigue, depression, mental well-being, stress, cognition, cardiovascular function, and recurrent stroke.

RESULTS

We included 71 patients of whom 59 patients (mean age: 63.9 ± 8.8 years) completed six- and 12-month follow-up. No change was detected in cardiorespiratory fitness between groups from baseline to 12-months follow-up. At six months, vigorous-intensity activity (median hours/week [interquartile range]) was maintained in the intervention group (baseline, 0[0;2]; post-intervention, 2[0;3]; six-month, 2[0;4]) and increased in the usual care group (baseline, 0[0;1]; post-intervention, 1[0;2]; six-month, 1[0;3]), with no difference between groups. Vigorous-intensity activity declined to baseline levels at 12-months in both groups. Secondary outcomes improved from baseline to 12-months with no significant differences between groups. Similar rate of recurrent stroke (n=3) occurred in each group with a three-month delay in the intervention group.

CONCLUSIONS

Early initiated HIIT did not increase long-term cardiorespiratory fitness, but increased time spent doing vigorous-intensity activities post-stroke. Decline to baseline activity level at 12 months warrants identification of motivators to initiate and sustain physical activity post-stroke.

Association of Psychosocial Stress With Risk of Acute Stroke

IMPORTANCE

Psychosocial stress is considered a modifiable risk factor for stroke. Given the prevalence of chronic and acute exposure to stress, it represents a potentially attractive target for population-health interventions.

OBJECTIVES

To determine the association of psychosocial stress with the risk of acute stroke and explore factors that might modify the association of stress with risk of acute stroke in a large international population.

DESIGN, SETTING, AND PARTICIPANTS

INTERSTROKE is an international retrospective case-control study of risk factors for first acute stroke in 32 countries in Asia, North and South America, Europe, Australia, the Middle East, and Africa. A total of 13 462 patients with stroke and 13 488 matched controls were recruited between January 11, 2007, and August 8, 2015. The present analyses were performed from June 1 to 30, 2021, and included 13 350 cases and 13 462 controls with available data on psychosocial stress.

EXPOSURES

Psychosocial stress and occurrence of stressful life events within the preceding year were measured using a standardized questionnaire of self-reported stress at home and work.

MAIN OUTCOMES AND MEASURES

The association of stress with acute stroke and its subtypes was examined using multivariable conditional logistic regression and factors that might modify the association, particularly self-reported locus of control.

RESULTS

Among 26 812 participants included in the analysis, the mean (SD) age of cases was 62.2 (13.6) years; that of controls, 61.3 (13.3) years; 7960 cases (59.6%) and 8017 controls (59.6%) were men. Several periods of stress and permanent stress were reported for 2745 cases (20.5%) and 1933 controls (14.4%), with marked regional variation in prevalence, with the lowest in China (201 of 3981 [5.0%] among controls and 364 of 3980 [9.1%] among cases) and highest in South East Asia (233 of 855 [26.1%] among controls and 241 of 782 [30.8%] among cases). Increased stress at home (odds ratio [OR], 1.95 [95% CI, 1.77-2.15]) and at work (OR, 2.70 [95% CI, 2.25-3.23]) and recent stressful life events (OR, 1.31 [95% CI, 1.19-1.43]) were associated with an increased risk of acute stroke on multivariable analyses (vs no self-reported stress). Higher locus of control at home was associated with a reduced odds of all stroke (OR, 0.73 [95% CI, 0.68-0.79]), and higher locus of control both at work and at home were associated with a lower odds of acute stroke and significantly diminished the association with stress at work (OR, 2.20 [95% CI, 1.88-2.58]; P = .008 for interaction) and home (OR, 1.69 [95% CI, 1.44-1.98]; P < .001 for interaction) for acute stroke.

CONCLUSIONS AND RELEVANCE

Psychosocial stress is a common risk factor for acute stroke. The findings of this case-control study suggest that higher locus of control is associated with lower risk of stroke and may be an important effect modifier of the risk associated with psychosocial stress.

Immigration status and utilization of secondary preventive treatment after ischemic stroke

Introduction:

The objective of the study was to assess use and persistence of secondary preventive treatment after ischemic stroke comparing immigrants and Danish-born residents.

Patients and methods:

A cohort of patients discharged with ischemic stroke (IS) diagnosis ( n = 106,224) by immigration status was identified from the Danish Stroke Registry between 2005 and 2018. We investigated use (claiming at least one prescription in 180 days post-discharge according to information from the Register of Medicinal Products Statistics) and persistence of treatment within 180 days thereafter using multivariable logistic regression and Fine and Gray models.

Results:

Overall, 82,078 Danish-born residents (80.6%) and 3589 (80.7%) immigrants with IS used at least one of the recommended preventive medications post-discharge. Immigrants had lower odds of use of anticoagulants and angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARB) (odds ratio (OR), 0.66; 95% confidence interval (CI), 0.53–0.82 and OR, 0.87; 95% CI, 0.75–0.98, respectively) but had higher odds of use of beta-blockers (OR, 1.25; 95% CI, 1.02–1.53) than Danish-born residents after adjustment for age at stroke, sex, sociodemographic factors, duration of residence, stroke severity, and comorbidities. The odds were most evident among immigrants originating from non-Western countries. Persistence of medication use did not differ between immigrants and Danish-born residents after adjustment for sociodemographic factors and comorbidities.

Conclusion:

Modest disparities in use of standard guideline recommended secondary preventive medications were observed when comparing immigrants and Danish-born residents with ischemic stroke. Furthermore, no differences in persistence of medication therapy were observed.

Role of Proxy Respondents in International Stroke Research: Experience of the INTERSTROKE Study

Introduction Measuring patient-reported information in stroke research is challenging. To overcome this, use of proxy respondents is often a necessary strategy. In this study, we report on use and effect of proxy respondents on patient case-mix in a large international epidemiologic stroke study (INTERSTROKE). Methods This was a cross-sectional study of 13,458 cases of acute first stroke in 32 countries. A standardised study questionnaire recording behavioural cardiovascular risk factors was administered to the patient, and if unable to communicate adequately, a valid proxy, or both. We used logistic regression to evaluate the association of age, sex, education, occupation, stroke severity and region with need for proxy respondent, and report odds ratio (OR) with 95%CI. Results Among 13,458 participants with acute stroke, questionnaires were completed by patients alone in 41.4% (n=5573), combination of patient and proxy together in 21.7% (n=2,918) and proxy alone in 36.9% (n=4967). Use of proxy alone was greater in participants with severe stroke (4.7% with modified-Rankin score of 0 versus 80.5% in those with score 5; OR 187.13; 95% CI 119.61-308.22) older persons (43.8% of those aged 80 years and over versus 33.2% of those aged less than 40 years; age per decade OR 1.09; 95% CI 1.06-1.12), women (40.7% versus 34.3% of men; OR 1.32 95% CI 1.22-1.43); and those less educated (58.9% of those never educated versus 25.7% of those who attended third level education; OR 7.84; 95% CI 6.78-9.08). Conclusion Use of proxy respondents enhances the generalisability of international research studies of stroke, by increasing representation of women, patients with severe stroke, older age, and lower education.

Association of Lipids, Lipoproteins, and Apolipoproteins with Stroke Subtypes in an International Case Control Study (INTERSTROKE)

Background and Purpose The association of dyslipidemia with stroke has been inconsistent, which may be due to differing associations within etiological stroke subtypes. We sought to determine the association of lipoproteins and apolipoproteins within stroke subtypes.Methods Standardized incident case-control STROKE study in 32 countries. Cases were patients with acute hospitalized first stroke, and matched by age, sex and site to controls. Concentrations of total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein A1 (apoA1), and apoB were measured. Non-HDL-C was calculated. We estimated multivariable odds ratio (OR) and population attributable risk percentage (PAR%). Outcome measures were all stroke, ischemic stroke (and subtypes), and intracerebral hemorrhage (ICH).Results Our analysis included 11,898 matched case-control pairs; 77.3% with ischemic stroke and 22.7% with ICH. Increasing apoB (OR, 1.10; 95% confidence interval [CI], 1.06 to 1.14 per standard deviation [SD]) and LDL-C (OR, 1.06; 95% CI, 1.02 to 1.10 per SD) were associated with an increase in risk of ischemic stroke, but a reduced risk of ICH. Increased apoB was significantly associated with large vessel stroke (PAR 13.4%; 95% CI, 5.6 to 28.4) and stroke of undetermined cause. Higher HDL-C (OR, 0.75; 95% CI, 0.72 to 0.78 per SD) and apoA1 (OR, 0.63; 95% CI, 0.61 to 0.66 per SD) were associated with ischemic stroke (and subtypes). While increasing HDL-C was associated with an increased risk of ICH (OR, 1.20; 95% CI, 1.14 to 1.27 per SD), apoA1 was associated with a reduced risk (OR, 0.80; 95% CI, 0.75 to 0.85 per SD). ApoB/A1 (OR, 1.38; 95% CI, 1.32 to 1.44 per SD) had a stronger magnitude of association than the ratio of LDL-C/HDL-C (OR, 1.26; 95% CI, 1.21 to 1.31 per SD) with ischemic stroke (<i>P</i><0.0001). Conclusions The pattern and magnitude of association of lipoproteins and apolipoproteins with stroke varies by etiological stroke subtype. While the directions of association for LDL, HDL, and apoB were opposing for ischemic stroke and ICH, apoA1 was associated with a reduction in both ischemic stroke and ICH. The ratio of apoB/A1 was the best lipid predictor of ischemic stroke risk.

Melatonin profile in healthy, elderly subjects - A systematic literature review

Melatonin plays an important role in regulation and maintaining of the circadian rhythm. In the elderly population, an array of disturbances of circadian rhythm and sleep can be observed; however the current knowledge within the group of healthy, elderly is scarce. This systematic literature review of studies on the melatonin profile measured in the blood of healthy, elderly individuals included 519 studies, found in the primary search on PubMed. After reviewing the title and abstract, 47 studies were found eligible for full text review. The inclusion criteria were defined as follows: healthy, elderly individuals, with a mean or average age over 65 years and analysis done in blood or plasma. In addition to the primary search, three studies were directly identified by the reference lists of already included studies. A final total of 23 studies were included in the systematic literature review. In reviewing the literature, a clear circadian melatonin profile with a nocturnal peak at 3 am and lower daytime levels was observed in the healthy, elderly population. In elderly over 75 years of age, the nocturnal level of melatonin may be lower; however, the circadian rhythmicity is maintained. In the comparison of elderly, independently living individuals and individuals living in care facilities, the latter group had lower levels of nocturnal melatonin peak as well as higher daytime levels; however one can wonder if elderly in care facilities are healthy. The 23 included studies in the systematic literature review had varying primary objectives and generally the term "healthy" within this population group proves difficult to clearly define. As a result of this, an obvious interstudy variability existed, which is a limitation of this systematic literature review. However, the graphs depicted represent the best possible estimation of the melatonin profile in a healthy, elderly population. Future research in the melatonin profile within this population should focus on clearly defined healthy elderly to ensure a valid normal material in this age group.

Sex-Differences in Oral Anticoagulant-Related Intracerebral Hemorrhage

Introduction and Aim

Data remain limited on sex-differences in patients with oral anticoagulant (OAC)-related intracerebral hemorrhage (ICH). We aim to explore similarities and differences in risk factors, acute presentation, treatments, and outcome in men and women admitted with OAC-related ICH.

Method

This study was a retrospective observational study based on 401 consecutive patients with OAC-related ICH admitted within 24 h of symptom onset. The study was registered on osf.io. We performed logarithmic regression and cox-regression adjusting for age, hematoma volume, Charlson Comorbidity Index (CCI), and pre-stroke modified Ranking Scale (mRS). Gender and age were excluded from CHA₂DS₂-VASc and CCI was not adjusted for age.

Results

A total of 226 men and 175 women were identified. More men were pre-treated with vitamin K-antagonists (73.5% men vs. 60.6% women) and more women with non-vitamin K-antagonist oral anticoagulants (26.5% men vs. 39.4% women), p = 0.009. Women were older (mean age 81.9 vs. 76.9 years, p < 0.001). CHA₂DS₂-VASc and CCI were similar in men and women.

Hematoma volumes (22.1 ml in men and 19.1 ml in women) and National Institute of Health Stroke Scale (NIHSS) scores (13 vs. 13) were not statistically different, while median Glasgow Coma Scale (GCS) was lower in women, (14 [8;15] vs. 14 [10;15] p = 0.003).

Women's probability of receiving reversal agents was significantly lower (adjusted odds ratio [aOR] = 0.52, p = 0.007) but not for surgical clot removal (aOR = 0.56, p = 0.25). Women had higher odds of receiving do-not-resuscitate (DNR) orders within a week (aOR = 1.67, p = 0.04). There were no sex-differences in neurological deterioration (aOR = 1.48, p = 0.10), ability to walk at 3 months (aOR = 0.69, p = 0.21) or 1-year mortality (adjusted hazard ratio = 1.18, p = 0.27).

Conclusion

Significant sex-differences were observed in age, risk factors, access to treatment, and DNRs while no significant differences were observed in comorbidity burden, stroke severity, or hematoma volume. Outcomes, such as adjusted mortality, ability to walk, and neurological deterioration, were comparable. This study supports the presence of sex-differences in risk factors and care but not in presentation and outcomes.

Use of reperfusion therapy and time delay in patients with ischemic stroke by immigration status: a register-based cohort study in Denmark

Background and purpose

Reperfusion therapy is the mainstay of treatment for acute ischaemic stroke (AIS); however, little is known about the use of reperfusion therapy and time delay amongst immigrants.

Methods

This is a Danish nationwide register‐based cohort study of patients with AIS aged ≥18 years (n = 49,817) recruited from 2009 to 2018. Use of reperfusion therapy (intravenous thrombolysis and/or mechanical thrombectomy) and time delay between immigrants and Danish‐born residents were compared using multivariable logistics and quantile regression.

Results

Overall, 10,649 (39.8%) Danish‐born residents and 452 (39.0%) immigrants with AIS were treated with reperfusion therapy in patients arriving <4.5 h following stroke onset. Compared with Danish‐born residents, immigrants had lower odds of receiving reperfusion therapy after adjustment for prehospital delay, age, sex, stroke severity, sociodemographic factors and comorbidities (adjusted odds ratio 0.67; 95% confidence interval 0.49‒0.92, p = 0.01). The lowest odds were observed amongst immigrants originating from Poland and non‐Western countries. Similarly, immigrants had a longer prehospital delay than Danish‐born residents in the fully adjusted model in patients arriving <4.5 h after stroke onset (15 min; 95% confidence interval 4‒26 min, p = 0.03). No evidence was found that system delay and clinical outcome differed between immigrants and Danish‐born residents in patients eligible for reperfusion therapy after adjustment for sociodemographic factors and comorbidities.

Conclusion

Immigration status was significantly associated with lower chances of receiving reperfusion therapy and there may be differences in patient delay between immigrants and Danish‐born residents in patients arriving to a stroke unit <4.5 h after stroke onset.

Atrial fibrillation after closure of patent foramen ovale in the REDUCE clinical study

OBJECTIVES

To describe the occurrence of postprocedural atrial fibrillation (AF) among patients with cryptogenic stroke undergoing patent foramen ovale (PFO) closure in the REDUCE clinical study and analyze for potential risk factors for the development of postprocedural AF.

BACKGROUND

AF is an adverse event that might potentially counterbalance the stroke prevention benefit from PFO closure. Data on AF after transcatheter PFO closure are sparse.

METHODS

We evaluated data from patients having PFO closure (Gore HELEX or Gore Cardioform Septal Occluder) in the REDUCE clinical trial (n = 408) in at post hoc explorative analysis. Median follow-up was 5.0 years.

RESULTS

AF occurred in 30 patients (7.4%) after PFO closure with a total of 34 AF events. Most were reported as non-serious (68%), detected within 45 days post-procedure (79%), and resolved within 2 weeks of onset (63%). One subject with AF had recurrent stroke. Postprocedural AF occurred more frequently among subjects with higher age and large device sizes. Male sex was the only independent predictor of postprocedural AF. We found no association between the type of occluder (HELEX or Gore Cardioform Septal Occluder) or PFO anatomical characteristics and post-procedural AF.

CONCLUSION

In the REDUCE clinical study, postprocedural atrial fibrillation was mostly early onset, transient and with no later recurrence. Postprocedural AF occurred more frequently among patients with higher age and larger devices. Male sex was the only independent predictor of postprocedural AF.

Clinical outcomes of light therapy in hospitalized patients - A systematic review

Light therapy and the effects on biological function have been known and investigated for decades. Light therapy is used to compensate for the lack of exposure to sunlight, which is thought to be linked to major depressive disorder with seasonal patterns. It is applied as sessions with bright light mimicking natural sunlight. Lack of bright light during daytime is not the only factor to maintain the circadian rhythm, also lack of exposure to bright light at night is important. A new modality called naturalistic light shows promise, mimicking daylight by dynamically changing intensity and wavelengths throughout the day. Evidence of clinical effects, besides bright light effects on depression, is still limited, especially in hospital populations, and present review aims to extract results of the effect of any optical light intervention on hospitalized patients. Through database search, 29 trials were included, of which 8 trials used a variation of naturalistic light. Trials were heterogeneous regarding designs, populations, interventions, methods and outcomes. In 14 out of 17 studies investigating sleep duration, quality and circadian alignment, along with decreased fatigue and improved mood in daytime, light therapy had a significant effect. Circadian rhythm and rhythmicity were affected as well. The effect on mood and cognition was inconsistent across studies. Trials showed more significant outcomes when conducted in non-intensive care units and with duration >5 days. Lux was reported in and compared across 24 studies and did not appear to be correlated to outcome, rather the distribution of wavelengths should be considered when conducting trials in the future. Of the 8 trials investigating naturalistic light, 4 trials had significant outcomes and 3 had adverse outcomes compared to one in the standard light regime. The overall effect of light therapy is beneficial, but evidence for the effect of naturalistic light is still insufficient to be recommended before other modalities. Future research in this area should be conducted in facilities where naturalistic light is installed, with a focus on the spectral distribution.

Patent Foramen Ovale Closure Decreases the Incidence but Not the Size of New Brain Infarction on Magnetic Resonance Imaging: An Analysis of the REDUCE Trial

Background and Purpose

Randomized patent foramen ovale closure trials have used open-label end point ascertainment which increases the risk of bias and undermines confidence in the conclusions. The Gore REDUCE trial prospectively performed baseline and follow-up magnetic resonance imaging (MRIs) for all subjects providing an objective measure of the effectiveness of closure.

Methods

We performed blinded evaluations of the presence, location, and volume of new infarct on diffusion-weighted imaging of recurrent clinical stroke or new infarct (>3 mm) on T2/fluid attenuated inversion recovery from baseline to follow-up MRI at 2 years, comparing closure to medical therapy alone. We also examined the effect of shunt size and the development of atrial fibrillation on infarct burden at follow-up.

Results

At follow-up, new clinical stroke or silent MRI infarct occurred in 18/383 (4.7%) patients who underwent closure and 19/177 (10.7%) medication-only patients (relative risk, 0.44 [95% CI, 0.24–0.81], P=0.02). Clinical strokes were less common in closure patients compared with medically treated patients, 5 (1.3%) versus 12 (6.8%), P=0.001, while silent MRI infarcts were similar, 13 (3.4%) versus 7 (4.0%), P=0.81. There were no differences in number, volumes, and distribution of new infarct comparing closure patients to those treated with medication alone. There were also no differences of number, volumes, and distribution comparing silent infarcts to clinical strokes. Infarct burden was also similar for patients who developed atrial fibrillation and for those with large shunts.

Conclusions

The REDUCE trial demonstrates that patent foramen ovale closure prevents recurrent brain infarction based on the objective outcome of new infarcts on MRI. Only clinical strokes were reduced by closure while silent infarctions were similar between study arms, and there were no differences in infarct volume or location comparing silent infarcts to clinical strokes.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT00738894.

Impact of the circadian clock on fibrinolysis and coagulation in healthy individuals and cardiovascular patients - A systematic review

INTRODUCTION

Human body functions exhibit a circadian rhythm generated in peripheral cells and synchronized by the suprachiasmatic nucleus (SCN), which mostly is entrained by the daily light/dark cycles. Activity, meals and posture are capable of interfering with the endogenous circadian rhythm of coagulation parameters. An increasing number of human disorders show a circadian component, and epidemiological studies find cardiovascular events to peak in the morning hours. The aim was to review the circadian rhythms impact on fibrinolysis and coagulation in healthy individuals and cardiovascular patients.

MATERIALS AND METHODS

A total number of 25 studies were identified where 8 enrolled cardiovascular patients with or without healthy individuals. Using a MeSH-search in MEDLINE PubMed. Only original peer-reviewed papers were included.

RESULTS

Results showed substantial variance with respect to exhibition of circadian rhythms and/or peak/trough times. Circadian rhythms of fibrinolysis were less pronounced in cardiovascular patients than in healthy individuals with decreased levels in the morning hours compared to healthy inducing higher risk of blood clotting.

CONCLUSIONS

Because of small studied group sizes and failure to control for entraining factors, larger studies are needed to fully establish the effects of the circadian rhythm on especially coagulation. The findings of chronobiologic rhythms in coagulation and fibrinolysis could suggest a need for a chrono-pharmacological approach when treating/preventing cardiovascular diseases.

Assessment of patients with a suspected cardioembolic ischemic stroke. A national consensus statement

OBJECTIVES

Several cardiovascular, structural, and functional abnormalities have been considered as potential causes of cardioembolic ischemic strokes. Beyond atrial fibrillation, other sources of embolism clearly exist and may warrant urgent action, but they are only a minor part of the many stroke mechanisms and strokes that seem to be of embolic origin remain without a determined source. The associations between stroke and findings like atrial fibrillation, valve calcification, or heart failure are confounded by co-existing risk factors for atherosclerosis and vascular disease. In addition, a patent foramen ovale which is a common abnormality in the general population is mostly an innocent bystander in patients with ischemic stroke. For these reasons, experts from the national Danish societies of cardiology, neurology, stroke, and neuroradiology sought to develop a consensus document to provide national recommendations on how to manage patients with a suspected cardioembolic stroke. Design: Comprehensive literature search and analyses were done by a panel of experts and presented at a consensus meeting. Evidence supporting each subject was vetted by open discussion and statements were adjusted thereafter. Results: The most common sources of embolic stroke were identified, and the statement provides advise on how neurologist can identify cases that need referral, and what is expected by the cardiologist. Conclusions: A primary neurological and neuroradiological assessment is mandatory and neurovascular specialists should manage the initiation of secondary prophylactic treatment. If a cardioembolic stroke is suspected, a dedicated cardiologist experienced in the management of cardioembolism should provide a tailored clinical and echocardiographic assessment.

Workforce Attachment after Ischemic Stroke - The Importance of Time to Thrombolytic Therapy

OBJECTIVES

The ability to remain in employment addresses an important consequence of stroke beyond the usual clinical parameters. However, data on the association between time to intravenous thrombolysis and workforce attachment in patients with acute ischemic stroke are sparse.

MATERIALS AND METHODS

In this nationwide cohort study, stroke patients of working age (18-60 years) treated with thrombolysis (2011-2016) who were part of the workforce prior to admission and alive at discharge were identified using the Danish Stroke Registry. The association between time to thrombolysis and workforce attachment one year later was examined with multivariable logistic regression.

RESULTS

The study population comprised 1,329 patients (median age 51 years [25^th-75^th percentile 45-56], 67.3% men). The median National Institutes of Health Stroke Scale score at presentation was 4 (25^th-75^th percentile 2-8), and the median time from symptom-onset to initiation of thrombolysis was 140min (25^th-75^th percentile 104-196min). The proportion of patients who were part of the workforce at one-year follow-up was 64.6%, 64.3%, 64.9%, and 60.0% in patients receiving thrombolysis within 90min, between 91-180min, between 181-270min, and after 270min, respectively. In adjusted analysis, time to thrombolysis between 91-180min, 181-270min, and >270min was not significantly associated with workforce attachment compared with thrombolysis received ≤90min of symptom-onset (ORs 0.89 [95%CI 0.60-1.31], 0.93 [0.66-1.31], and 0.80 [0.43-1.52], respectively).

CONCLUSIONS

In patients of working age admitted with stroke and treated with thrombolysis, two out of three were part of the workforce one year after discharge. There was no graded relationship between time to thrombolysis and the likelihood of workforce attachment.

Trends in incidence of oral anticoagulant-related intracerebral hemorrhage and sales of oral anticoagulants in Capital Region of Denmark 2010-2017

Introduction

Non-vitamin K-antagonist oral anticoagulants (NOAC) have become first choice oral anticoagulant (OAC) with decreasing use of vitamin K antagonists (VKA), partly due to lower risk of intracerebral hemorrhage (ICH). Aim: to identify trends in sale of OACs and relate them to trends in OAC-related ICH (OAC-ICH).

Patients and methods

Study was based on the population in the Capital Region of Denmark (1.8 million inhabitants). We identified all patients admitted with a non-traumatic OAC-ICH in 2010-2017 and ascertained diagnosis and drug use through medical charts. We used information available in the public domain on sale of defined daily doses (DDD) of OAC in the Capital Region of Denmark.

Results

453 patients with OAC-ICH out of a total of 2877 ICH-events were identified. From 2010 to 2017 sale of NOAC rose from 0.1 to 11.8 DDD/1000 inhabitants/day (p < 0.001); while VKA sale decreased from 7.6 to 5.2 DDD/1000 inhabitants/day (p < 0.001). The total number of ICH events was stable between 2010 and 2017, but the proportion of OAC-ICH events increased from 13% in 2010 to 22% in 2017 (p < 0.001). The proportion of ICH events related to NOAC had a significant increasing trend (p < 0.001), whereas a decreasing trend was observed for VKA (p = 0.04).

Discussion

In Denmark, the population on OACs has increased; resulting from increased use of NOACs. Parallel to this development, the proportion of OAC-ICH overall has increased based on an increasing trend in NOAC-related ICH.

Conclusion

Our findings document a need for further research on prevention and treatment of this complication.

Renal Impairment and Risk of Acute Stroke: The INTERSTROKE Study

BACKGROUND

Previous studies reported an association of renal impairment with stroke, but there are uncertainties underpinning this association.

AIMS

We explored if the association is explained by shared risk factors or is independent and whether there are regional or stroke subtype variations.

METHODS

INTERSTROKE is a case-control study and the largest international study of risk factors for first acute stroke, completed in 27 countries. We included individuals with available serum creatinine values and calculated estimated glomerular filtration rate (eGFR). Renal impairment was defined as eGFR <60 mL/min/1.73 m2. Multivariable conditional logistic regression was used to determine the association of renal function with stroke.

RESULTS

Of 21,127 participants, 41.0% were female, the mean age was 62.3 ± 13.4 years, and the mean eGFR was 79.9 ± 23.5 mL/min/1.73 m2. The prevalence of renal impairment was higher in cases (22.9% vs. 17.7%, p < 0.001) and differed by region (p < 0.001). After adjustment, lower eGFR was associated with increased odds of stroke. Renal impairment was associated with increased odds of all stroke (OR 1.35; 95% CI: 1.24-1.47), with higher odds for intracerebral hemorrhage (OR 1.60; 95% CI: 1.35-1.89) than ischemic stroke (OR 1.29; 95% CI: 1.17-1.42) (pinteraction 0.12). The largest magnitudes of association were seen in younger participants and those living in Africa, South Asia, or South America (pinteraction < 0.001 for all stroke). Renal impairment was also associated with poorer clinical outcome (RRR 2.97; 95% CI: 2.50-3.54 for death within 1 month).

CONCLUSION

Renal impairment is an important risk factor for stroke, particularly in younger patients, and is associated with more severe stroke and worse outcomes.

Urinary Sodium and Potassium, and Risk of Ischemic and Hemorrhagic Stroke (INTERSTROKE): A Case-Control Study

BACKGROUND

Although low sodium intake (<2 g/day) and high potassium intake (>3.5 g/day) are proposed as public health interventions to reduce stroke risk, there is uncertainty about the benefit and feasibility of this combined recommendation on prevention of stroke.

METHODS

We obtained random urine samples from 9,275 cases of acute first stroke and 9,726 matched controls from 27 countries and estimated the 24-hour sodium and potassium excretion, a surrogate for intake, using the Tanaka formula. Using multivariable conditional logistic regression, we determined the associations of estimated 24-hour urinary sodium and potassium excretion with stroke and its subtypes.

RESULTS

Compared with an estimated urinary sodium excretion of 2.8-3.5 g/day (reference), higher (>4.26 g/day) (odds ratio [OR] 1.81; 95% confidence interval [CI], 1.65-2.00) and lower (<2.8 g/day) sodium excretion (OR 1.39; 95% CI, 1.26-1.53) were significantly associated with increased risk of stroke. The stroke risk associated with the highest quartile of sodium intake (sodium excretion >4.26 g/day) was significantly greater (P < 0.001) for intracerebral hemorrhage (ICH) (OR 2.38; 95% CI, 1.93-2.92) than for ischemic stroke (OR 1.67; 95% CI, 1.50-1.87). Urinary potassium was inversely and linearly associated with risk of stroke, and stronger for ischemic stroke than ICH (P = 0.026). In an analysis of combined sodium and potassium excretion, the combination of high potassium intake (>1.58 g/day) and moderate sodium intake (2.8-3.5 g/day) was associated with the lowest risk of stroke.

CONCLUSIONS

The association of sodium intake and stroke is J-shaped, with high sodium intake a stronger risk factor for ICH than ischemic stroke. Our data suggest that moderate sodium intake-rather than low sodium intake-combined with high potassium intake may be associated with the lowest risk of stroke and expected to be a more feasible combined dietary target.

Specialized Outpatient Clinic vs Stroke Unit for TIA and Minor Stroke: A Cohort Study

OBJECTIVE

To evaluate the effects of an outpatient clinic setup for minor stroke/TIA using subsequent admission of patients at high risk of recurrent stroke.

METHODS

We performed a cohort study of all patients with suspected minor stroke/TIA seen in an outpatient clinic at Aarhus University Hospital, Denmark, between September 2013 and August 2014. Patients with stroke were compared to historic (same hospital) and contemporary (another comparable hospital) matched, hospitalized controls on nonprioritized outcomes: length of stay, readmissions, care quality (10 process-performance measures), and mortality. Patients with TIA were compared to contemporary matched, hospitalized controls. Following complete diagnostic workup, patients with stroke/TIA were classified into low/high risk of recurrent stroke ≤7 days.

RESULTS

We analyzed 1,076 consecutive patients, of whom 253 (23.5%) were subsequently admitted to the stroke ward. Stroke/TIA was diagnosed in 215/171 patients, respectively. Fifty-six percent (121/215) of the patients with stroke were subsequently admitted to the stroke ward. Comparison with the historic stroke cohort (n = 191) showed a shorter acute hospital stay for the strokes (median 1 vs 3 days; adjusted length of stay ratio 0.49; 95% confidence interval 0.33-0.71). Thirty-day readmission rate was 3.2% vs 11.6% (adjusted hazard ratio 0.23 [0.09-0.59]), and care quality was higher, with a risk ratio of 1.30 (1.15-1.47). The comparison of stroke and TIAs to contemporary controls showed similar results. Only one patient in the low risk category and not admitted experienced stroke within 7 days (0.6%).

CONCLUSIONS

An outpatient clinic setup for patients with minor stroke/TIA yields shorter acute hospital stay, lower readmission rates, and better quality than hospitalization in stroke units.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that a neurovascular specialist-driven outpatient clinic for patients with minor stroke/TIA with the ability of subsequent admission is safe and yields shorter acute hospital stay, lower readmission rates, and better quality than hospitalization in stroke units.

Variations in knowledge, awareness and treatment of hypertension and stroke risk by country income level

OBJECTIVE

Hypertension is the most important modifiable risk factor for stroke globally. We hypothesised that country-income level variations in knowledge, detection and treatment of hypertension may contribute to variations in the association of blood pressure with stroke.

METHODS

We undertook a standardised case-control study in 32 countries (INTERSTROKE). Cases were patients with acute first stroke (n=13 462) who were matched by age, sex and site to controls (n=13 483). We evaluated the associations of knowledge, awareness and treatment of hypertension with risk of stroke and its subtypes and whether this varied by gross national income (GNI) of country. We estimated OR and population attributable risk (PAR) associated with treated and untreated hypertension.

RESULTS

Hypertension was associated with a graded increase in OR by reducing GNI, ranging from OR 1.92 (99% CI 1.48 to 2.49) to OR 3.27 (2.72 to 3.93) for highest to lowest country-level GNI (p-heterogeneity<0.0001). Untreated hypertension was associated with a higher OR for stroke (OR 5.25; 4.53 to 6.10) than treated hypertension (OR 2.60; 2.32 to 2.91) and younger age of first stroke (61.4 vs 65.4 years; p<0.01). Untreated hypertension was associated with a greater risk of intracerebral haemorrhage (OR 6.95; 5.61 to 8.60) than ischaemic stroke (OR 4.76; 3.99 to 5.68). The PAR associated with untreated hypertension was higher in lower-income regions, PAR 36.3%, 26.3%, 19.8% to 10.4% by increasing GNI of countries. Lifetime non-measurement of blood pressure was associated with stroke (OR 1.80; 1.32 to 2.46).

CONCLUSIONS

Deficits in knowledge, detection and treatment of hypertension contribute to higher risk of stroke, younger age of onset and larger proportion of intracerebral haemorrhage in lower-income countries.

Ethnic differences in incidence and mortality of stroke in Denmark

Background

Stroke is a leading cause of disability and mortality worldwide. However, studies on incidence and mortality of stroke hereof among ethnic minorities compared with local born are still limited.

Methods

We conducted a Danish nationwide register-based cohort study between 2004 and 2018. All cases of first ever stroke aged 18-95 years were included. Country of birth was used to construct ethnic groups. Age standardized incidence rate ratio (IRR) of stroke stratified by country of birth and sex were estimated with the Danish born as a reference group. Ethnic minorities were grouped as Western and Non-western for mortality hazard ratio (HR) estimates.

Results

In overall, ethnic minorities had a higher risk of stroke compared with Danish born. Particularly, the IRR of all stroke was estimated to be 8.3 times higher among Polish men compared to Danish born men (IRR, 8.32; 95% CI, 6.89-10.05). Compared with Danish born women, Pakistan women had the highest risk of all stroke (IRR, 2.89; 95% CI, 2.46-3.39). By contrast, Swedish women had reduced risk of hemorrhagic stroke (IRR, 0.40; 95% CI, 0.18-0.89) and Norwegian women had reduced risk of ischemic stroke (IRR, 0.87; 95% CI, 0.72-1.06). Compared with Danish born men, all-cause 1-year mortality hazard for Non-western men was (HR, 1.61; 95% CI, 1.13-2.29) while for Western men was (HR, 1.07; 95% CI, 0.90-1.29) among ischemic stroke patients. Among hemorrhagic stroke patients, 1-year mortality hazard for Non-western men was (HR, 0.75; 95% CI, 0.39-1.47) whereas Western men had (HR, 1.48; 95% CI, 1.04-2.10). Among women, we observed reduced all cause 1-year mortality hazard in Non-western (HR, 0.32; 95% CI, 0.13-0.80) for hemorrhagic stroke whereas no difference in mortality hazard was observed for ischemic stroke.

Conclusions

Incidence and post stroke mortality appear to vary among ethnic minorities in comparison to Danish born. It may depend on the type of stroke and sex.

Key messages

The study contributes knowledge in migration and health. With good quality registers, we are in unique position to establish findings in Denmark, which has a growing migrant population.

EU-Wide Cross-Sectional Observational Study of Lipid-Modifying Therapy Use in Secondary and Primary Care: the DA VINCI study

Aims

To provide contemporary data on the implementation of European guideline recommendations for lipid-lowering therapies (LLTs) across different settings and populations and how this impacts low-density lipoprotein cholesterol (LDL-C) goal achievement.

Methods and results

An 18 country, cross-sectional, observational study of patients prescribed LLT for primary or secondary prevention in primary or secondary care across Europe. Between June 2017 and November 2018, data were collected at a single visit, including LLT in the preceding 12 months and most recent LDL-C. Primary outcome was the achievement of risk-based 2016 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) LDL-C goal while receiving stabilized LLT; 2019 goal achievement was also assessed. Overall, 5888 patients (3000 primary and 2888 secondary prevention patients) were enrolled; 54% [95% confidence interval (CI) 52–56] achieved their risk-based 2016 goal and 33% (95% CI 32–35) achieved their risk-based 2019 goal. High-intensity statin monotherapy was used in 20% and 38% of very high-risk primary and secondary prevention patients, respectively. Corresponding 2016 goal attainment was 22% and 45% (17% and 22% for 2019 goals) for very high-risk primary and secondary prevention patients, respectively. Use of moderate–high-intensity statins in combination with ezetimibe (9%), or any LLT with PCSK9 inhibitors (1%), was low; corresponding 2016 and 2019 goal attainment was 53% and 20% (ezetimibe combination), and 67% and 58% (PCSK9i combination).

Conclusion

Gaps between clinical guidelines and clinical practice for lipid management across Europe persist, which will be exacerbated by the 2019 guidelines. Even with optimized statins, greater utilization of non-statin LLT is likely needed to reduce these gaps for patients at highest risk.

SiPP (Stroke in Pregnancy and Postpartum): A prospective, observational, international, multicentre study on pathophysiological mechanisms, clinical profile, management and outcome of cerebrovascular diseases in pregnant and postpartum women

Rationale

Cerebrovascular diseases associated with pregnancy and postpartum period are uncommon; however, they can have an important impact on health of both women and foetus or newborn.

Aims

To evaluate the frequency, characteristics and management of cerebrovascular events in pregnant/postpartum women, to clarify pathophysiological mechanisms underlying the occurrence of these events including biomolecular aspects, and to assess the short- and long-term cerebrovascular and global cardiovascular outcome of these patients, their predictors and infant outcome.

Methods and design

This is an observational, prospective, multicentre, international case-control study. The study will include patients with cerebrovascular events during pregnancy and/or within six months after delivery. For each included case, two controls will be prospectively recruited: one pregnant or puerperal subject without any history of cerebrovascular event and one non-pregnant or non-puerperal subject with a recent cerebrovascular event. All controls will be matched by age, ethnicity and type of cerebrovascular event with their assigned cases. The pregnant controls will be matched also by pregnancy weeks/trimester. Follow-up will last 24 months for the mother and 12 months for the infant.

Summary

To better understand causes and outcomes of uncommon conditions like pregnancy/postpartum-related cerebrovascular events, the development of multisite, multidisciplinary registry-based studies, such as the Stroke in Pregnancy and Postpartum study, is needed in order to collect an adequate number of patients, draw reliable conclusions and give definite recommendations on their management.

Characteristics and Outcomes in Patients With COVID-19 and Acute Ischemic Stroke: The Global COVID-19 Stroke Registry

Supplemental Digital Content is available in the text.

Recent case-series of small size implied a pathophysiological association between coronavirus disease 2019 (COVID-19) and severe large-vessel acute ischemic stroke. Given that severe strokes are typically associated with poor prognosis and can be very efficiently treated with recanalization techniques, confirmation of this putative association is urgently warranted in a large representative patient cohort to alert stroke clinicians, and inform pre- and in-hospital acute stroke patient pathways. We pooled all consecutive patients hospitalized with laboratory-confirmed COVID-19 and acute ischemic stroke in 28 sites from 16 countries. To assess whether stroke severity and outcomes (assessed at discharge or at the latest assessment for those patients still hospitalized) in patients with acute ischemic stroke are different between patients with COVID-19 and non-COVID-19, we performed 1:1 propensity score matching analyses of our COVID-19 patients with non-COVID-19 patients registered in the Acute Stroke Registry and Analysis of Lausanne Registry between 2003 and 2019. Between January 27, 2020, and May 19, 2020, 174 patients (median age 71.2 years; 37.9% females) with COVID-19 and acute ischemic stroke were hospitalized (median of 12 patients per site). The median National Institute of Health Stroke Scale was 10 (interquartile range [IQR], 4–18). In the 1:1 matched sample of 336 patients with COVID-19 and non-COVID-19, the median National Institute of Health Stroke Scale was higher in patients with COVID-19 (10 [IQR, 4–18] versus 6 [IQR, 3–14]), P=0.03; (odds ratio, 1.69 [95% CI, 1.08–2.65] for higher National Institute of Health Stroke Scale score). There were 48 (27.6%) deaths, of which 22 were attributed to COVID-19 and 26 to stroke. Among 96 survivors with available information about disability status, 49 (51%) had severe disability at discharge. In the propensity score-matched population (n=330), patients with COVID-19 had higher risk for severe disability (median mRS 4 [IQR, 2–6] versus 2 [IQR, 1–4], P<0.001) and death (odds ratio, 4.3 [95% CI, 2.22–8.30]) compared with patients without COVID-19. Our findings suggest that COVID-19 associated ischemic strokes are more severe with worse functional outcome and higher mortality than non-COVID-19 ischemic strokes.

Review on motor imagery based BCI systems for upper limb post-stroke neurorehabilitation: From designing to application

Strokes are a growing cause of mortality and many stroke survivors suffer from motor impairment as well as other types of disabilities in their daily life activities. To treat these sequelae, motor imagery (MI) based brain-computer interface (BCI) systems have shown potential to serve as an effective neurorehabilitation tool for post-stroke rehabilitation therapy. In this review, different MI-BCI based strategies, including "Functional Electric Stimulation, Robotics Assistance and Hybrid Virtual Reality based Models," have been comprehensively reported for upper-limb neurorehabilitation. Each of these approaches have been presented to illustrate the in-depth advantages and challenges of the respective BCI systems. Additionally, the current state-of-the-art and main concerns regarding BCI based post-stroke neurorehabilitation devices have also been discussed. Finally, recommendations for future developments have been proposed while discussing the BCI neurorehabilitation systems.

An exploratory investigation of the effect of naturalistic light on fatigue and subjective sleep quality in stroke patients admitted for rehabilitation: A randomized controlled trial

BACKGROUND

Daylight entrains the central circadian pacemaker to the 24-hour day and is crucial for optimal alertness and sleep-quality. Rehabilitation patients tend to lack exposure to sufficient natural light.

OBJECTIVE

Installed diurnal naturalistic light may reduce the known disrupted sleep quality and fatigue seen in post stroke patients.

METHODS

Stroke patients were randomized to either an intervention rehabilitation unit (IU) equipped with naturalistic lighting (artificial sunlight spectrum) or to a control rehabilitation unit (CU) with standard indoor lighting. At inclusion and discharge, fatigue and subjective sleep quality were measured.

RESULTS

Ninety stroke patients were included between May 2014, and June 2015. At discharge, patients from the IU experienced less fatigue than the CU patients, based on the Multidimensional Fatigue Inventory questionnaire general (IU, n = 28; CU, n = 30; diff - 20.6%, 95% confidence interval (CI) [- 35.0%; - 3.0%]; P = 0.025) and the Rested Statement (IU, n = 28; CU, n = 30; diff + 41.6%, 95% CI [+4.6%; +91.8%]; P =  0.025). No differences were detected between groups in sleepiness or subjective sleep quality by the Pittsburgh Sleep Quality Index.

CONCLUSIONS

Fatigue was significantly reduced in rehabilitation patients exposed to naturalistic lighting during admission.

Motor Imagery based Brain Computer Interface Paradigm for Upper Limb Stroke Rehabilitation

Motor Imagery (MI) based Brain Computer Interface (BCI) systems have shown potential to serve as a tool for neurorehabilitation for post stroke patients to complement the standard therapy. The aim of this study was to develop an MI based BCI system that could potentially be used in neurorehabilitation of hand motor function in stroke patients. Two co-adaptive, three-class MI based BCI systems for realtime processing were developed and compared using the publicly available data from the BCI Competition III Dataset V as well as our own data. The first algorithm utilizes the Filterbank Common Spatial Pattern (FBCSP) for feature extraction, and the other utilizes the Separable Common Spatio-Spectral Pattern (SCSSP) - both combined with a Multi-layer Perceptron (MLP) for classification. The proposed system proved successful when using the competition data showing an average accuracy of 64.71 % for the SCSSP compared to 60.48% for the FBCSP. This proved superior to a related study using the same feature extraction methods, but with other classification methods. The proposed system, however did show results around chance level for the 3-class MI experimental data that we have collected in our laboratory. Further studies needs to be conducted to improve the performance as well as to realize such a system to put in use.

Multiple Soluble Components of the Glycocalyx Are Increased in Patient Plasma After Ischemic Stroke

Background and Purpose—

The GLX (glycocalyx) is a protein/polysaccharide meshwork at the cellular surface. Consisting largely of glycosaminoglycans and proteoglycans, the GLX can shed in response to stress. In this study, we assay 11 components of the GLX in plasma from patients with ischemic stroke from a longitudinal cohort.

Methods—

Plasma samples from healthy individuals (N=8), and patients with ischemic stroke day ≥3, day 7, and day 90 (N=9–14) were immunoassayed for diverse components of the GLX.

Results—

Median stroke severity was mild (National Institutes of Health Stroke Scale 2.0 (range, 0–6) at day ≤3). Three (keratan-chondroitin-heparan-sulfate) of 4 glycosaminoglycans and CD44 (proteoglycan) were increased at day 7 and returned to baseline at day 90. Proteoglycan syndecan (Syn)-3 increased and Syn-2 levels decreased, significantly.

Conclusions—

Individual GLX components are often assayed as stand-alone biomarkers for endothelial health. This study suggests a full assessment of GLX components is more indicative of the endothelial health of an individual and represents a complex GLX signature that may be valuable as a composite biomarker of disease.

An exploratory investigation of the effect of naturalistic light on depression, anxiety, and cognitive outcomes in stroke patients during admission for rehabilitation: A randomized controlled trial

BACKGROUND

Patients admitted for rehabilitation often lack sufficient natural light to entrain their circadian rhythm.

OBJECTIVE

Installed diurnal naturalistic light may positively influence the outcome of depressive mood, anxiety, and cognition in such patients.

METHODS

A quasi-randomized controlled trial. Ninety stroke patients in need of rehabilitation were randomized between May 1, 2014, and June 1, 2015 to either a rehabilitation unit equipped entirely with always on naturalistic lighting (IU), or to a rehabilitation unit with standard indoor lighting (CU).Examinations were performed at inclusion and discharge. The following changes were investigated: depressive mood based on the Hamilton Depression scale (HAM-D6) and Major Depression Inventory scale (MDI), anxiety based on the Hospital Anxiety and Depression Scale (HADS), cognition based on the Montreal Cognitive Assessment (MoCA) and well-being based on the Well-being Index (WHO-5).

RESULTS

Depressive mood (MDI p = 0.0005, HAM-D6 p = 0.011) and anxiety (HADS anxiety p = 0.045) was reduced, and well-being (WHO-5 p = 0.046) was increased, in the IU at discharge compared to the CU. No difference was found in cognition (MoCA p = 0.969).

CONCLUSIONS

This study is the first to demonstrate that exposure to naturalistic light during admission may significantly improve mental health in rehabilitation patients. Further studies are needed to confirm these findings.

Effect of Home-Based High-Intensity Interval Training in Patients With Lacunar Stroke: A Randomized Controlled Trial

Background: High-intensity interval training (HIIT) is superior to moderate-intensity continuous training in improving cardiorespiratory fitness in patients with cardiovascular disease, but is it safe, feasible and effective in patients with stroke? We investigated feasibility and effect of early, home-based HIIT in patients with lacunar stroke combined with usual care vs. usual care, only. Methods: Patients with minor stroke (severity: 55/58 point on the Scandinavian Stroke Scale) were randomized to HIIT or usual care in a randomized, controlled trial. We measured the following outcomes at baseline and post-intervention: cardiorespiratory fitness monitored as power output from the Graded Cycling Test with Talk Test (GCT-TT; primary outcome), physical activity, fatigue, depression, well-being, stress, cognition, endothelial function, blood pressure, body mass index, and biomarkers. Results: We included 71 patients (mean age 63.7 ± 9.2), 49 men, 31 in intervention group. Home-based HIIT was feasible with no reported adverse events in relation to the intervention. No significant change between the groups in GCT-TT power output was detected (p = 0.90). The change in time spent on vigorous-intensity activity was 2 h/week and 0.6 h/week, intervention and usual care, respectively (p = 0.045). There were no significant differences between groups in the remaining secondary outcomes. Conclusion: HIIT was feasible and safe in patients with lacunar stroke. Patients can engage early in home-based HIIT when involved in choosing exercise modality and guided by weekly motivational phone calls. Within 3 months, HIIT did, however, not yield effect on cardiorespiratory fitness. We await further evaluation of long-term effects of this intervention on continued regular physical exercise and cardiovascular event. Clinical Trial Registration: https://clinicaltrials.gov, identifier NCT02731235.

Self-Reported Physical Activity and Cardiovascular Disease Risk Factors in Patients with Lacunar Stroke

BACKGROUND

Physical inactivity is a major modifiable risk factor for stroke. The aim was to explore if stroke patients admitted with lacunar stroke adhere to the international recommendations on physical activity prestroke (≥150 minutes of moderate-intensity activity, or ≥75 minutes of vigorous-intensity activity, or an equivalent combination). Further, to assess association between prestroke physical activity and cardiovascular disease (CVD) risk factors.

METHODS

A cross-sectional study, including patients with lacunar stroke according to the Trial of Org 10172 in Acute Stroke Treatment criteria. Data collected included prestroke physical activity using the self-reported Physical Activity Scale. Cardiorespiratory fitness was estimated as the power output from the Graded Cycling Test with Talk Test and sociodemographic factors including age, sex, education, and CVD risk factors including pre-existing diabetes, history of hypertension, body mass index, and lipids were assessed.

RESULTS

We included 19 women and 52 men (mean age 64 years). Overall, 79% of the recruited patients adhered to the physical activity recommendations prestroke, but only 35% did vigorous-intensity activity. Prestroke physical activity was associated with a history of hypertension.

CONCLUSIONS

A high proportion of the lacunar stroke patients reported to adhere to the recommendations on physical activity prestroke; however, only one third engaged in vigorous-intensity activity. Studies are warranted to investigate if vigorous-intensity activity is effective as secondary prevention in patients with a lacunar stroke.

Abstract WP191: Short-term Follow-up After Early Home-based High-intensity Interval Training in Stroke

Background: High-intensity interval training (HIIT) is superior to moderate-intensity continuous training (MICE) in improving aerobic fitness in patients with cardiovascular disease. Few studies have investigated the effect of HIIT in patients with stroke and none specifically in patients with small vessel disease stroke (SVDS).

Purpose: We aimed to investigate the short-term effect of 12-weeks home-based HIIT post stroke in addition to usual care, versus usual care only.

Methods: We included 71 patients with SVDS in a randomised controlled trial, intervention vs. control 1:1. At baseline and after 3 months we assessed: aerobic fitness (power output from the Graded Cycling Test with Talk Test (GCT-TT)), physical activity, fatigue, depression, well-being, stress, cognition, endothelial function, blood pressure, body mass index, and blood biomarkers.

Results: We found that the patients in the intervention group spent more time on vigorous-intensity activity than the usual care group. Home-based HIIT was feasible, with no adverse events reported. No significant difference was detected in GCT-TT power output between groups. Further, we found no significant differences between the groups in general well-being (depression, stress, fatigue, cognition, and quality of life). Insulin levels decreased slightly in the active group (p=0.048).

Conclusion: Importantly, this study shows that patients with SVDS can engage in home-based HIIT when encouraged weekly by phone, and provided either a stationary bicycle or choosing a high intensity activity of their own interest. However, increased activity was not reflected in short-term effect on aerobic fitness. This may be due to a lower than requested intensity or duration of activity. We need more investigations on long-term effects, and how to further increase physical activity and aerobic fitness.

The Effects of Naturalistic Light on Diurnal Plasma Melatonin and Serum Cortisol Levels in Stroke Patients during Admission for Rehabilitation: A Randomized Controlled Trial

Background: Stroke patients admitted for rehabilitation often lack sufficient daytime blue light exposure due to the absence of natural light and are often exposed to light at unnatural time points. We hypothesized that artificial light imitating daylight, termed naturalistic light, would stabilize the circadian rhythm of plasma melatonin and serum cortisol levels among long-term hospitalized stroke patients. Methods: A quasi-randomized controlled trial. Stroke patients in need of rehabilitation were randomized between May 1, 2014, and June 1, 2015 to either a rehabilitation unit equipped entirely with always on naturalistic lighting (IU), or to a rehabilitation unit with standard indoor lighting (CU). At both inclusion and discharge after a hospital stay of at least 2 weeks, plasma melatonin and serum cortisol levels were measured every 4 hours over a 24-hour period. Circadian rhythm was estimated using cosinor analysis, and variance between time-points. Results: A total of 43 were able to participate in the blood collection. Normal diurnal rhythm of melatonin was disrupted at both inclusion and discharge. In the IU group, melatonin plasma levels were increased at discharge compared to inclusion (n = 23; median diff, 2.9; IQR: -1.0 to 9.9, p = 0.030) and rhythmicity evolved (n = 23; p = 0.007). In the CU group, melatonin plasma levels were similar between discharge and inclusion and no rhythmicity evolved. Overall, both patient groups showed normal cortisol diurnal rhythms at both inclusion and discharge. Conclusions: This study is the first to demonstrate elevated melatonin plasma levels and evolved rhythmicity due to stimulation with naturalistic light.

An adaptive CSP filter to investigate user independence in a 3-class MI-BCI paradigm

This paper describes the implementation of a Brain Computer Interface (BCI) scheme using a common spatial patterns (CSP) filter in combination with a Recursive Least Squares (RLS) approach to iteratively update the coefficients of the CSP filter. The proposed adaptive CSP (ACSP) algorithm is made more robust by introducing regularization using Diagonal Loading (DL), and thus will be able to significantly reduce the length of training sessions when introducing new patients to the BCI system. The system is tested on a 4-class multi-limb motor imagery (MI) data set from the BCI competition IV (2a), and a more complex single limb 3-class MI dataset recorded in-house. The latter dataset is produced to mimic an upper limb rehabilitation session, e.g., after stroke. The findings indicate that when extensive calibration data is available, the ACSP performs comparably to the CSP (kappa value of 0.523 and 0.502, respectively, for the 4-class problem); for reduced calibration sessions, the ACSP significantly improved the performance of the system (up to 4-fold). The proposed paradigm proved feasible and the ACSP algorithm seems to enable a user or semi user independent scenario, where the need for long system calibration sessions without feedback is eliminated.

Strengthening the role and functions of nursing staff in inpatient stroke rehabilitation: developing a complex intervention using the Behaviour Change Wheel

Purpose: Over the past two decades, attempts have been made to describe the nurse’s role and functions in the inpatient stroke rehabilitation; however, the nursing contribution is neither clear nor well-defined. Previous studies have highlighted the need for research aimed at developing interventions in the neuro-nursing area. The objective of this paper was to describe the development of a nursing intervention aimed at optimising the inpatient rehabilitation of stroke patients by strengthening the role and functions of nursing staff.

Method: A systematic approach was used, consistent with the framework for developing and evaluating complex interventions by the UK’s Medical Research Council (MRC). Based on qualitative methods and using the Behaviour Change Wheel’s (BCW) stepwise approach, we sought behaviours related to nursing staffs’ roles and functions.

Results: We conducted a behavioural analysis to explain why nursing staff were or were not engaged in these behaviours. The nursing staff’s Capability, Opportunity and Motivation were analysed with regard to working systematically with a rehabilitative approach and working deliberately and systematically with the patient’s goals.

Conclusion: We developed the educational intervention Rehabilitation 24/7. Following the MRC and the BCW frameworks is resource-consuming, but offers a way of developing a practical, well-structured intervention that is theory- and evidence based.

Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): an international observational study

BACKGROUND

Stroke disproportionately affects people in low-income and middle-income countries. Although improvements in stroke care and outcomes have been reported in high-income countries, little is known about practice and outcomes in low and middle-income countries. We aimed to compare patterns of care available and their association with patient outcomes across countries at different economic levels.

METHODS

We studied the patterns and effect of practice variations (ie, treatments used and access to services) among participants in the INTERSTROKE study, an international observational study that enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. We supplemented patient data with a questionnaire about health-care and stroke service facilities at all participating hospitals. Using univariate and multivariate regression analyses to account for patient casemix and service clustering, we estimated the association between services available, treatments given, and patient outcomes (death or dependency) at 1 month.

FINDINGS

We obtained full information for 12 342 (92%) of 13 447 INTERSTROKE patients, from 108 hospitals in 28 countries; 2576 from 38 hospitals in ten high-income countries and 9766 from 70 hospitals in 18 low and middle-income countries. Patients in low-income and middle-income countries more often had severe strokes, intracerebral haemorrhage, poorer access to services, and used fewer investigations and treatments (p<0·0001) than those in high-income countries, although only differences in patient characteristics explained the poorer clinical outcomes in low and middle-income countries. However across all countries, irrespective of economic level, access to a stroke unit was associated with improved use of investigations and treatments, access to other rehabilitation services, and improved survival without severe dependency (odds ratio [OR] 1·29; 95% CI 1·14-1·44; all p<0·0001), which was independent of patient casemix characteristics and other measures of care. Use of acute antiplatelet treatment was associated with improved survival (1·39; 1·12-1·72) irrespective of other patient and service characteristics.

INTERPRETATION

Evidence-based treatments, diagnostics, and stroke units were less commonly available or used in low and middle-income countries. Access to stroke units and appropriate use of antiplatelet treatment were associated with improved recovery. Improved care and facilities in low-income and middle-income countries are essential to improve outcomes.

FUNDING

Chest, Heart and Stroke Scotland.

Abstract 102: Consistency of Efficacy of PFO Closure in the Gore Reduce Trial

Background: The Gore REDUCE Clinical Study (REDUCE) demonstrated superiority of PFO closure in conjunction with antiplatelet therapy over antiplatelet therapy alone in reducing the risk of recurrent clinical ischemic stroke or new silent brain infarct in patients with cryptogenic stroke.

Methods: We randomized 664 subjects with cryptogenic stroke at 63 multinational sites in a 2:1 ratio to either antiplatelet therapy plus PFO closure (with Gore HELEX Septal Occluder or Gore CARDIOFORM Septal Occluder) or antiplatelet therapy alone. Co-primary endpoints were freedom from recurrent clinical ischemic stroke through ≥2 years and incidence of new brain infarct (defined as the composite of clinical ischemic stroke and silent brain infarct) at 2 years. Primary analyses were performed on the intention-to-treat (ITT) population. Per-protocol (PP) analysis included only subjects randomized and treated according to critical protocol requirements (excluding those who violated key eligibility criteria, did not receive the therapy to which they were randomized, or did not comply with protocol-required medical regimen). As-treated (AT) analysis assessed all subjects based on treatment received, regardless of study assignment.

Results: PFO closure was associated with a highly consistent reduction in risk compared to medical therapy alone in all three analytic cohorts (Table).

Conclusions: Among selected patients with cryptogenic stroke and PFO, closure of the PFO plus antiplatelet therapy was superior to antiplatelet therapy alone for reducing the risk of subsequent ischemic stroke.

P2Y12 Receptor Antagonist, Clopidogrel, Does Not Contribute to Risk of Osteoporotic Fractures in Stroke Patients

Background: Stroke is a leading cause of mortality and morbidity. It is associated with excessive bone loss and risk of fracture in stroke patients is high. The P2Y12R antagonist and platelet inhibitor, clopidogrel, is widely used for secondary prevention after a stroke. However, recent studies have shown that clopidogrel has negative effects on bone and that long-term clopidogrel use is associated with increased fracture risk. The purpose of the current study was therefore to investigate the association of clopidogrel treatment with risk of fractures in stroke and TIA patients.

Methods: The study was a cohort study including all subjects who were prescribed clopidogrel between 1996 and 2008 in Denmark (n = 77,503). Age- and gender matched controls (n = 232,510) were randomly selected from the background population. The study end-points were occurrence of stroke or TIA and occurrence of fracture. Clopidogrel use was primary exposure.

Results: Ischemic stroke increased risk of fracture by 50% while haemorrhagic stroke and TIA increased the risk by 30%. However, after adjusting for multiple confounders only patients with ischemic stroke and haemorrhagic stroke had increased fracture risk. Clopidogrel use was not associated with increased fracture risk in subjects with ischaemic stroke or TIA. In contrast, after adjusting for multiple confounders clopidogrel treatment was associated with a 10–35% reduced risk of fracture.

Conclusion: Patients with stroke have increased risk of osteoporotic fractures, but clopidogrel treatment does not increase fracture risk. In contrast, patients less adherent to the treatment have lower risk of fractures than non-users and patients with high adherence. However, based on the increased risk in stroke patients, clinicians should consider evaluation of bone status of these patients.

Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke

BACKGROUND

The efficacy of closure of a patent foramen ovale (PFO) in the prevention of recurrent stroke after cryptogenic stroke is uncertain. We investigated the effect of PFO closure combined with antiplatelet therapy versus antiplatelet therapy alone on the risks of recurrent stroke and new brain infarctions.

METHODS

In this multinational trial involving patients with a PFO who had had a cryptogenic stroke, we randomly assigned patients, in a 2:1 ratio, to undergo PFO closure plus antiplatelet therapy (PFO closure group) or to receive antiplatelet therapy alone (antiplatelet-only group). Imaging of the brain was performed at the baseline screening and at 24 months. The coprimary end points were freedom from clinical evidence of ischemic stroke (reported here as the percentage of patients who had a recurrence of stroke) through at least 24 months after randomization and the 24-month incidence of new brain infarction, which was a composite of clinical ischemic stroke or silent brain infarction detected on imaging.

RESULTS

We enrolled 664 patients (mean age, 45.2 years), of whom 81% had moderate or large interatrial shunts. During a median follow-up of 3.2 years, clinical ischemic stroke occurred in 6 of 441 patients (1.4%) in the PFO closure group and in 12 of 223 patients (5.4%) in the antiplatelet-only group (hazard ratio, 0.23; 95% confidence interval [CI], 0.09 to 0.62; P=0.002). The incidence of new brain infarctions was significantly lower in the PFO closure group than in the antiplatelet-only group (22 patients [5.7%] vs. 20 patients [11.3%]; relative risk, 0.51; 95% CI, 0.29 to 0.91; P=0.04), but the incidence of silent brain infarction did not differ significantly between the study groups (P=0.97). Serious adverse events occurred in 23.1% of the patients in the PFO closure group and in 27.8% of the patients in the antiplatelet-only group (P=0.22). Serious device-related adverse events occurred in 6 patients (1.4%) in the PFO closure group, and atrial fibrillation occurred in 29 patients (6.6%) after PFO closure.

CONCLUSIONS

Among patients with a PFO who had had a cryptogenic stroke, the risk of subsequent ischemic stroke was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone; however, PFO closure was associated with higher rates of device complications and atrial fibrillation. (Funded by W.L. Gore and Associates; Gore REDUCE ClinicalTrials.gov number, NCT00738894 .).