Colchicine for stroke prevention in patients with coronary artery disease: a systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Although clinical trials suggest that colchicine may reduce the risk of vascular events in patients with a history of coronary artery disease, its effect on the prevention of cerebrovascular events still remains unclear. METHODS: A systematic review and meta-analysis was performed of all available randomized controlled trials (RCTs) reporting on incident strokes during the follow-up of patients with a history of cardiovascular disease randomized to colchicine treatment or control (placebo or usual care). RESULTS: Four RCTs were identified, including a total of 5553 patients (mean age 61 years, 81% males), with a follow-up ranging from 1 to 36 months. Colchicine treatment was associated with a significantly lower risk of incident stroke during follow-up compared to control (risk ratio 0.31, 95% confidence interval 0.13-0.71), without heterogeneity across included studies (I2  = 0%). Based on the pooled incident stroke rate of control groups (0.9%) in the included RCTs, it was estimated that administration of low-dose colchicine to 161 patients with coronary artery disease would prevent one stroke during a follow-up of 23 months. CONCLUSION: Colchicine treatment decreases stroke risk in patients with a history of coronary artery disease. The effect of colchicine in secondary stroke prevention is currently being evaluated in an ongoing RCT.

[Availability of mechanical thrombectomy for acute stroke : Analysis of the health care reality in Germany]. / Verfügbarkeit der mechanischen Thrombektomie bei akutem Hirninfarkt : Analyse der Versorgungsrealität in Deutschland.

BACKGROUND: Mechanical thrombectomy (MT) has become an evidence-based therapy for stroke patients with proximal vessel occlusion of the anterior cerebral circulation. Nationwide availability of MT for all eligible patients within the shortest possible time window is a major challenge. AIM OF THE STUDY: Nationwide analysis of the rates of systemic thrombolysis (STL) and MT in Germany according to region and hospital-based evaluation. METHODS: The evaluation involved data analysis of the diagnosis-related groups (DRG) statistics and structured quality reports of hospitals for 2010 and 2014. The rates and changes of STL and MT were evaluated in the 413 German districts with reference to the corresponding case number of patients with acute ischemic stroke. RESULTS: Nationwide recanalization treatment rates increased from 2010 to 2014 both for STL (from 8.0% to 11.6%) and MT (from 0.7% to 2.3%). High variations were observed depending on the patient's place of residence (STL = 3.4-36.7%, MT = 0-7.4%). In 2014 a total of 5526 MT were coded in a total of 244,757 ischemic strokes. A total of 134 hospitals with more than 2 MT per year were identified; however, 21% of the nationwide MTs were performed in only 7 hospitals with more than 100 MT/year. In 308 (75%) of the 413 districts, not a single MT was performed. CONCLUSION: Due to a narrow net of certified stroke units with nationwide availability of STL, excellent structural conditions for treatment of acute stroke patients are already established in Germany. With regard to the nationwide availability of MT, there is still a need for optimization. Despite the increasing number of hospitals providing MT as an emergency procedure, a trend toward large intervention centers with supraregional catchment areas can be observed.

[Treatment reality of internal carotid artery stenosis in Germany : requirement and reality in international comparison and in light of the current S3 guidelines]. / Versorgungsrealität von Karotisstenosen in Deutschland : Forderung und Wirklichkeit im internationalen Vergleich und im Lichte der aktuellen S3-Leitlinie.

BACKGROUND: Severe atherosclerotic extracranial carotid artery stenosis accounts for 5-10 % of all ischemic strokes. Currently, therapeutic recommendations are undergoing changes, particularly regarding the treatment of asymptomatic stenosis. Consolidated knowledge on the indications, nationwide distribution and numbers of cases are not available. Moreover, the impact and grade of implementation of the recently published national S3 guidelines on the reality of medical treatment remain unclear. METHODS: Analysis of administrative hospital data involving the diagnosis-related groups (DRG) statistics and structured quality reports for 2010 and 2013 to evaluate the procedural therapy trends concerning operative and interventional approaches for symptomatic and asymptomatic carotid artery stenoses. RESULTS: In Germany approximately 37,000 carotid endarterectomies (CEA) and approximately 5,000 carotid angioplasties with stenting (CAS) are carried out per year. Approximately 94 % of CEA and 62 % of CAS are performed in centers with more than 25 procedures per year. Only 33 % of CEA and 39 % of CAS are related to symptomatic stenosis. CONCLUSION: Mathematically, an undertreatment of symptomatic and an overtreatment of asymptomatic carotid artery stenoses become apparent. Efforts should be made to achieve inpatient medical treatment conforming to the national S3 guidelines, in particular to adequately reduce the risk of stroke recurrence in patients with atherosclerotic symptomatic carotid artery stenosis.

B-type natriuretic peptide predicts stroke of presumable cardioembolic origin in addition to coronary artery calcification.

BACKGROUND AND PURPOSE: B-type natriuretric peptide (BNP) is a marker of cardiac dysfunction that is released from myocytes in response to ventricular wall stress. Previous studies suggested that BNP predicts stroke events in addition to classical risk factors. It was suggested that the BNP-associated risk results from coronary atherosclerosis or atrial fibrillation. METHODS: Three thousand six hundred and seventy five subjects from the population-based Heinz Nixdorf Recall study (45-75 years; 47.6% men) without previous stroke, coronary heart disease, myocardial infarcts, open cardiac valve surgery, pacemakers and defibrillators were followed up over 110.1 ± 23.1 months. Cox proportional hazards regressions were used to examine BNP as a stroke predictor in addition to vascular risk factors (age, gender, systolic blood pressure, low-density lipoprotein, high-density lipoprotein, diabetes, smoking), renal insufficiency, atrial fibrillation/known heart failure and coronary artery calcification. RESULTS: Eighty-nine incident strokes occurred (80 ischaemic, 9 hemorrhagic). Subjects suffering stroke had significantly higher BNP values at baseline than the remaining subjects [26.3 (Q1; Q3 = 12.9; 51.0) vs. 17.4 (9.4; 31.4); P < 0.001]. In a multivariable regression, log10 BNP was an independent stroke predictor [hazard ratio 1.96, 95% confidence interval (CI) 1.13-3.41; P = 0.017] in addition to age (1.24 per 5 years, CI 1.04-1.49; P = 0.016), systolic blood pressure (1.25 per 10 mmHg, CI 1.14-1.38; P < 0.001), smoking (2.05, CI 1.24-3.39; P = 0.005), atrial fibrillation/heart failure (2.25, CI 1.05-4.83; P = 0.037) and computed-tomography-based log10 (coronary artery calcification + 1) (1.47, CI 1.15-1.88; P = 0.002). Log10 BNP predicted stroke in men but not women, both in subjects ≤65 and >65 years. In subsequent analyses, BNP discriminated the incidence of cardioembolic stroke (P for trend = 0.001), but not stroke of macroangiopathic (P = 0.555), microangiopathic (P = 0.809) or unknown (P = 0.367) origin. CONCLUSIONS: BNP predicts presumable cardioembolic stroke independent of coronary calcification.

[New aspects of stroke medicine]. / Neues aus der Schlaganfallmedizin.

Systemic thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) remains the only effective and approved medical treatment of acute ischemic stroke. Several studies have demonstrated the importance of rapid recanalization. The efficacy of thrombectomy has so far not been sufficiently shown in randomized clinical trials; therefore, inclusion of suitable patients in one of the currently ongoing randomized trials is of great importance. The early treatment with magnesium after acute ischemic stroke during the pre-hospital phase did not prove to be neuroprotective. Intermittent pneumatic compression of the lower extremities in immobilized stroke patients effectively prevents deep venous thrombosis and pulmonary embolism. In patients with lacunar stroke the combination of aspirin and clopidogrel is not superior to aspirin alone and causes more bleeding complications. The novel oral anticoagulants are superior to warfarin in secondary prevention and carry a lower risk of intracranial and systemic bleeding complications. New studies will investigate whether dabigatran or rivaroxaban are superior to aspirin in secondary prevention after cryptogenic stroke.

New recommendations on cerebral venous and dural sinus thrombosis from the German consensus-based (S2k) guideline.

Over the last years, new evidence has accumulated on multiple aspects of diagnosis and management of cerebral venous and dural sinus thrombosis (CVT) including identification of new risk factors, studies on interventional treatment as well as treatment with direct oral anticoagulants. Based on the GRADE questions of the European Stroke Organization guideline on this topic, the new German guideline on CVT is a consensus between expert representatives of Austria, Germany and Switzerland. New recommendations include:• CVT occurring in the first weeks after SARS-CoV-2 vaccination with vector vaccines may be associated with severe thrombocytopenia, indicating the presence of a prothrombotic immunogenic cause (Vaccine-induced immune thrombotic thrombocytopenia; VITT).• D-dimer testing to rule out CVT cannot be recommended and should therefore not be routinely performed.• Thrombophilia screening is not generally recommended in patients with CVT. It should be considered in young patients, in spontaneous CVT, in recurrent thrombosis and/or in case of a positive family history of venous thromboembolism, and if a change in therapy results from a positive finding.• Patients with CVT should preferably be treated with low molecular weight heparine (LMWH) instead of unfractionated heparine in the acute phase.• On an individual basis, endovascular recanalization in a neurointerventional center may be considered for patients who deteriorate under adequate anticoagulation.• Despite the overall low level of evidence, surgical decompression should be performed in patients with CVT, parenchymal lesions (congestive edema and/or hemorrhage) and impending incarceration to prevent death.• Following the acute phase, oral anticoagulation with direct oral anticoagulants instead of vitamin K antagonists should be given for 3 to 12 months to enhance recanalization and prevent recurrent CVT as well as extracerebral venous thrombosis.• Women with previous CVT in connection with the use of combined hormonal contraceptives or pregnancy shall refrain from continuing or restarting contraception with oestrogen-progestagen combinations due to an increased risk of recurrence if anticoagulation is no longer used.• Women with previous CVT and without contraindications should receive LMWH prophylaxis during pregnancy and for at least 6 weeks post partum.Although the level of evidence supporting these recommendations is mostly low, evidence from deep venous thrombosis as well as current clinical experience can justify the new recommendations.This article is an abridged translation of the German guideline, which is available online.

Use of paracetamol in ischaemic stroke patients: evidence from VISTA.

OBJECTIVES: Paracetamol is frequently prescribed for pain and fever control in acute stroke patients, but its effect on stroke outcome is unclear. The aim was to investigate the safety and benefit of paracetamol administration in the acute phase of ischaemic stroke. METHODS: We analysed the impact of paracetamol exposure on functional outcome at 90 days among ischaemic stroke patients registered in a clinical trials archive. We used an adjusted Cochran-Mantel-Haenszel test to test for significance (P) followed by proportional odds logistic regression analysis to estimate the odds ratios (OR) for more favourable modified Rankin Scale score. RESULTS: Data were available for 6015 patients, of whom 2435 had received paracetamol. No association of paracetamol-use with overall stroke outcome could be detected among those patients who experienced pain and/or fever (OR 1.03, 95% CI 0.86-1.20, P = 0.931). In patients without recorded pain and/or fever events and a baseline temperature below 37°C, in whom paracetamol was started within 3 days of stroke, paracetamol was associated with worse outcome (OR 0.58, 95% CI 0.47-0.72, P = <0.001). CONCLUSION: This retrospective analysis is discouraging for prophylactic use of paracetamol in acute stroke patients, but underlines the need for a sufficiently powered randomized controlled trial.

Recurrent stroke after lobar and deep intracerebral hemorrhage: a hospital-based cohort study.

BACKGROUND: Recurrent stroke rates after intracerebral hemorrhage (ICH) vary widely between observational studies due to differences in ICH etiology and risk for thromboembolic events. We therefore aimed to assess the patient characteristics and prognosis after deep and lobar ICH in a well-characterized, multicenter, hospital-based cohort. METHODS: Patients were prospectively documented in 13 German neurological stroke centers. Of 744 patients with spontaneous ICH discharged alive, 516 (69.4%) gave informed consent and 496 (66.7%) could be followed up by central telephone interview over a mean duration of 2 years. RESULTS: In patients with deep ICH, the Kaplan-Meier estimate for stroke during the first year was 5.8% (95% CI 2.9-8.7) and the overall annual rate (calculated over a 3-year period) was 2.9% (95% CI 1.6-4.1). In patients with lobar ICH, the Kaplan-Meier estimate for stroke during the first year was 7.8% (95% CI 3.1-12.5) and the overall annual rate was 7.2% (95% CI 3.8-10.6). At the last follow-up before recurrent stroke or end of study, 141 patients (28.4%) overall received antiplatelet agents, and 12 (2.4%) received oral anticoagulation. No difference could be found for recurrent ICH under antiplatelet agents versus no antithrombotic medication. CONCLUSION: The risk of recurrent stroke after lobar ICH remains high beyond the first year, whereas it decreases after 1 year in patients with deep ICH. Antiplatelets are prescribed in a considerable number of patients even though the risk-benefit ratio after ICH remains unknown.

Why do acute ischemic stroke patients with a preceding transient ischemic attack present with less severe strokes? Insights from the German Stroke Study.

BACKGROUND: The effect of ischemic preconditioning (IP) is well established in animal models of brain ischemia. There are conflicting data from human observational studies whether IP is also induced by a preceding transient ischemic attack (TIA) resulting in a lower stroke severity in these patients. METHODS: Data from 7,611 consecutive patients with first-ever acute ischemic stroke from the prospective German Stroke Study Collaboration were analyzed. A multivariate linear regression analysis was used to evaluate whether a preceding TIA was associated with a lower National Institutes of Health Stroke Scale (NIH-SS) score at admission. Furthermore, stroke severity was stratified by the latency between a preceding TIA and subsequent acute ischemic stroke (≤7 days vs. >7 days and ≤72 h vs. >72 h). RESULTS: A previous TIA was documented in 452 (5.9%) patients, and a significantly lower NIH-SS score at admission was found in these patients compared with patients without TIA. A previous TIA remained significantly associated with a lower NIH-SS score in multivariate analysis corrected for the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, cardiovascular risk factors, age, sex and premorbid disability. The NIH-SS score at admission did not significantly differ in 96 patients with a TIA within 7 days compared with 137 patients with a TIA more than 7 days before ischemic stroke. Similarly, there were no significant differences in stroke severity in patients with a TIA within 72 h. CONCLUSIONS: The significantly lower stroke severity observed in patients with a preceding TIA is not confounded by stroke etiology in our large-scale observational study. Data on latency between the TIA and subsequent ischemic stroke do not support a neuroprotective effect caused by TIA-induced IP in human ischemic stroke.

Worse blood pressure control in patients with cerebrovascular or peripheral arterial disease compared with coronary artery disease.

OBJECTIVES: Poor blood pressure (BP) control is common amongst patients with symptomatic atherothrombotic disease. It is unclear whether BP control and management differ across atherothrombotic disease subtypes. METHODS: We analysed the baseline data of 44,984 patients with documented coronary artery disease (CAD) only (n = 30,414), cerebrovascular disease (CVD) only (n = 11,359) and peripheral arterial disease (PAD) only (n = 3211) from the international REduction of Atherothrombosis for Continued Health Registry and investigated the impact of atherothrombotic disease subtype on BP control and use of antihypertensive drugs. RESULTS: The proportion of patients with BP controlled (<140/90 mmHg) was higher in CAD (58.1%) than in CVD (44.8%) or PAD (38.9%) patients (P < 0.001). Amongst patients with treated hypertension, CAD patients were more likely to have BP controlled than were CVD patients [odds ratio (OR) = 1.67; 95% confidence interval (CI) = 1.59-1.75] or PAD (OR = 2.30; 95% CI = 2.10-2.52). These differences were smaller in women than in men and decreased with age. Amongst treated patients, CAD patients were more likely to receive > or =3-drug combination therapies than were CVD (OR = 1.73; 95% CI = 1.64-1.83) or PAD (OR = 1.64; 95% CI = 1.49-1.80) patients. Adjustment for age, gender, waist obesity, diabetes, education level and world region did not alter the results. CONCLUSIONS: Coronary artery disease patients are more likely than CVD or PAD patients to have BP controlled and to receive antihypertensive drugs, particularly combination therapies. Promotion of more effective BP control through combination antihypertensive therapies could improve secondary prevention and therefore prevent complications in CVD and PAD patients.

Symptomatic intracranial atherosclerotic stenoses: prevalence and prognosis in patients with acute cerebral ischemia.

BACKGROUND: In Caucasian patients with acute stroke or transient ischemic attack (TIA) due to symptomatic intracranial atherosclerotic stenoses (ICAS), only limited data on the recurrent stroke rate and its associated risk factors have been reported. In view of the increasing options for endovascular interventions, we sought to investigate the prevalence, risk for recurrent stroke and mortality in these patients. METHODS: A total of 304 consecutive patients with acute ischemic stroke or TIA due to 50-99% ICAS were prospectively documented in 19 German stroke centers. In 201 patients (68.1% of the survivors), a central biannual telephone follow-up could assess recurrent stroke and mortality up to a median of 2 years after the index event. RESULTS: An ischemic cerebrovascular event attributable to symptomatic ICAS was found in 2.24% of the consecutively admitted patients. The overall cumulative recurrent stroke rate after admission was 17.9% (95% CI = 13.4-23.5) for the first year and 23.3% (95% CI = 17.8-29.8) over 3 years. After correction for age and sex, only previous stroke (HR = 2.11, 95% CI = 1.14-3.91) and diabetes (HR = 2.41, 95% CI = 1.33-4.37) were significantly associated with recurrent stroke. CONCLUSION: Although the prevalence of this etiology seems very low in patients admitted to German stroke centers, we found a high risk of recurrent stroke in patients with symptomatic ICAS. Whether endovascular interventions can reduce this high risk needs to be determined in a randomized trial.

Correction to: Features of intracranial hemorrhage in cerebral venous thrombosis.

The original version of this article unfortunately contained mistakes. The correct information is given below.

Features of intracranial hemorrhage in cerebral venous thrombosis.

BACKGROUND: Cerebral venous thrombosis (CVT) is associated with intracranial hemorrhage. AIM: To identify clinical and imaging features of CVT-associated intracranial hemorrhage. We hypothesized that higher clot burden would be associated with a higher risk of intracranial hemorrhage. METHODS: We performed a retrospective analysis of an international, multicenter cohort of patients with confirmed cerebral venous thrombosis who underwent computed tomography within 2 weeks of symptom onset. Clinical and imaging features were compared between patients with and without intracranial hemorrhage. Clot burden was assessed by counting the number of thrombosed venous sinuses and veins on confirmatory imaging. RESULTS: We enrolled 260 patients from 10 institutions in Europe and Mexico. The mean age was 42 years and 74% were female. Intracranial hemorrhage was found in 102 (39%). Among them parenchymal hemorrhage occurred in 64 (63%), in addition, small juxta-cortical hemorrhage was found in 30 (29%), subarachnoid hemorrhage in 24 (24%) and subdural hemorrhage in 11 (11%). Multiple concomitant types of hemorrhage occurred in 23 (23%). Older age and superior sagittal thrombosis involvement were associated with presence of hemorrhage. The number of thrombosed venous sinuses was not associated with intracranial hemorrhage (median number IQRInterquartile ratio] of sinuses/veins involved with hemorrhage 2 (1-3) vs. 2 (1-3) without hemorrhage, p = 0.4). CONCLUSION: The high rate of intracranial hemorrhage in cerebral venous thrombosis is not explained by widespread involvement of the venous sinuses. Superior sagittal sinus involvement is associated with higher bleeding risk.

Current management and risk of recurrent stroke in cerebrovascular patients with right-to-left cardiac shunt.

BACKGROUND: Right-to-left cardiac shunt (RLS) is considered a risk factor for stroke, especially in patients aged <55 years. We aimed to investigate the current management and prognosis in consecutive patients with RLS and otherwise cryptogenic cerebrovascular events. METHODS: In total, 1,126 patients with cryptogenic stroke or TIA were included from 17 German neurology departments. During a mean follow-up of 28.4 months, we assessed current antithrombotic medication, percutaneous device closure (PDC) and recurrent cerebrovascular events in 899 patients (79.8%). Stroke recurrence was compared between 548 patients without RLS and 351 patients with RLS under various prevention regimens. RESULTS: RLS was detected in 35.9% of cryptogenic cerebrovascular patients, but could not be evaluated as an independent predictor for recurrent stroke (adjusted HR 1.6, 95% CI: 0.9-2.7). In RLS-positive patients, the Kaplan-Meier estimate for stroke during the first year was 4.1% (95% CI: 1.9-6.3%) and 1.7% (95% CI: 0.9-2.4%) per year thereafter. At the last follow-up before recurrent stroke or end of study, 117 RLS-positive patients (33.3%) had received a PDC, 154 (43.9%) were receiving antiplatelets, 63 (17.9%) received anticoagulation, and 17 (4.8%) received none of the above. No association with recurrent stroke was found for the secondary preventive regime. CONCLUSION: Our multicenter hospital-based cohort study confirmed low recurrent event rates in RLS patients with otherwise cryptogenic stroke or TIA, as well as a great heterogeneity of current management. Despite the lack of scientific evidence, a substantial number of RLS-positive patients underwent PDC for secondary stroke prevention.

Antiplatelet agents in stroke prevention: acute and long-term treatment strategies.

In primary prevention, aspirin reduces the risk of stroke but not of myocardial infarction in women while in men only the risk of myocardial infarction but not stroke could be significantly reduced. Only aspirin has been shown to be safe and effective in large randomized trials in the first 48 hours after ischemic stroke. Aspirin/dipyridamole and clopidogrel both reduce the risk of a combined cardiovascular outcome in long-term secondary prevention compared to aspirin alone. More potent antiplatelet drugs or combination of aspirin and clopidogrel prevent more ischemic events, but also lead to more bleeding complications. No benefit of oral anticoagulants could be shown in patients with non-cardioembolic stroke. In patients with atrial fibrillation oral anticoagulation is more effective than aspirin in stroke prevention. The choice between oral anticoagulants and aspirin in these patients depends on age and the individual risk factor profile. Patients with symptomatic intracranial stenosis have a higher risk of intracerebral bleeding with oral anticoagulation compared to high dose aspirin. Aspirin is the recommended treatment in stroke patients with a patent foramen ovale.

Predictive value of the Essen Stroke Risk Score and Ankle Brachial Index in acute ischaemic stroke patients from 85 German stroke units.

BACKGROUND: Risk stratification can contribute to individualised optimal secondary prevention in patients with cerebrovascular disease. OBJECTIVE: To prospectively investigate the prediction of the Essen Stroke Risk Score (ESRS) and a pathological Ankle Brachial Index (ABI) in consecutive patients hospitalised with acute ischaemic stroke or transient ischaemic attack (TIA) in 85 neurological stroke units throughout Germany. METHODS: 852 patients were prospectively documented on standardised case report forms, including assessment of ESRS and ABI. After 17.5 months, recurrent cerebrovascular events, functional outcome or death could be assessed in 729 patients predominantly via central telephone interview. RESULTS: After discharge from the documenting hospital, recurrent stroke occurred in 41 patients (5.6%) and recurrent TIA in 15 patients (2.1%). 52 patients (7.1%) had died, 33 (4.5%) from cardiovascular causes. Patients with an ESRS > or = 3 (vs <3) had a significantly higher risk of recurrent stroke or cardiovascular death (9.7% vs 5.1%; odds ratio (OR) 2.00, 95% confidence interval (CI) 1.08 to 3.70) and a higher recurrent stroke risk (6.9% vs 3.7%; OR 1.93, 95% CI 0.95 to 3.94). Patients with an ABI < or = 0.9 (vs > 0.9) had a significantly higher risk of recurrent stroke or cardiovascular death (10.4% vs 5.5%; OR 2.00, 95% CI 1.12 to 3.56) and a higher recurrent stroke risk (6.6% vs 4.6%; OR 1.47, 95% CI 0.76 to 2.83). CONCLUSION: Our prospective follow-up study shows a significantly higher rate of recurrent stroke or cardiovascular death and a clear trend for a higher rate of recurrent stroke in patients with acute cerebrovascular events classified as high risk by an ESRS > or = 3 or a pathological ABI.

Adherence and quality of oral anticoagulation in cerebrovascular disease patients with atrial fibrillation.

BACKGROUND/AIMS: Low rates and poor quality of oral anticoagulation (OAC) have been reported in patients with atrial fibrillation (AF). We therefore sought to investigate the prescription patterns at discharge, adherence and quality of OAC in cerebrovascular disease patients with AF. METHODS: Consecutive ischemic stroke (IS) and transient ischemic attack (TIA) patients were prospectively documented in 11 German stroke centers. A central telephone follow-up after 1-2 years assessed the current antithrombotic medication and results of coagulation checks. RESULTS: Of 1,463 surviving patients with AF, 30.5% were discharged on OAC and 13.9% on high-dose heparin. Of 329 AF patients discharged on OAC and with consent for follow-up, 88.7% of surviving patients were still on OAC at the follow-up. Of these, 52.7% reported coagulation values out of the therapeutic range during the preceding 3 months. A recurrent IS was seen in 9 patients (2.1%/year) and an intracranial hemorrhage in 2. CONCLUSION: We found an important underuse of OAC following TIA or IS mainly in older patients and with greater stroke-related disability. Although the reported coagulation checks showed an only moderate rate within therapeutic ranges, safety and efficacy of OAC in this cohort seem comparable to previous randomized and observational trials in AF patients.

Headache associated with ischemic cerebrovascular disease.

Headache often accompanies acute ischemic stroke. Observational studies indicate that 15 to 40% of patients with acute ischemic stroke report headache in close temporal relation to the event. The onset headache is more often seen in posterior circulation strokes than in strokes in other vascular territories. Transient ischemic attacks (TIA) can also lead to headache. The pathophysiology of headache associated with acute ischemic stroke includes edema, hemorrhagic transformation, and changes in the trigeminovascular system.