Pre-stroke anticoagulation for atrial fibrillation in primary English speakers and non-primary English speakers: a multicentre retrospective cohort study.

BACKGROUND: Anticoagulation can prevent most strokes in individuals with atrial fibrillation (AF); however, many people presenting with stroke and known AF are not anticoagulated. Language barriers and poor health literacy have previously been associated with decreased patient medication adherence. The association between language barriers and initiation of anticoagulation therapy for AF is uncertain. AIMS: The aims of this study were to determine whether demographic factors, including non-English primary language, were (1) associated with not being initiated on anticoagulation for known AF prior to admission with stroke, and (2) associated with non-adherence to anticoagulation in the setting of known AF prior to admission with stroke. METHODS: A multicentre retrospective cohort study was conducted for consecutive individuals admitted to the three South Australian tertiary hospitals with stroke units over a 5-year period. RESULTS: There were 6829 individuals admitted with stroke. These cases included 5835 ischaemic stroke patients, 1333 of whom had pre-existing AF. Only 40.0% presenting with ischaemic stroke in the setting of known pre-existing AF were anticoagulated. When controlling for demographics, socioeconomic status and past medical history (including the components of the CHADS2VASC score and anticoagulation contraindications), having a primary language other than English was associated with a lower likelihood of having been commenced on anticoagulant for known pre-stroke AF (odds ratio: 0.52, 95% confidence interval: 0.36-0.77, P = 0.001), but was not associated with a differing likelihood of anticoagulation adherence. CONCLUSIONS: A significant proportion of patients with stroke have pre-existing unanticoagulated AF; these rates are substantially higher if the primary language is other than English. Targeted research and interventions to minimise evidence-treatment gaps in this cohort may significantly reduce stroke burden.

Association of tirofiban treatment with outcomes following endovascular therapy in cardioembolic stroke: insights from the RESCUE BT randomized trial.

BACKGROUND AND PURPOSE: The efficacy and safety of tirofiban in endovascular therapy for cardioembolic ischemic stroke patients remain controversial. This study aimed to evaluate the role of intravenous tirofiban before endovascular therapy in cardioembolic stroke. METHODS: This post hoc analysis utilized data from the RESCUE BT (Endovascular Treatment With versus Without Tirofiban for Patients with Large Vessel Occlusion Stroke) trial, which was an investigator-initiated, randomized, double-blind, placebo-controlled trial. Participants were randomized to receive either tirofiban or a placebo in a 1:1 ratio before undergoing endovascular therapy. The study included patients aged 18 years or older, presenting with occlusion of the internal carotid artery or middle cerebral artery (MCA) M1/M2 within 24 h of the last known well time, and with a stroke etiology of cardioembolism. The primary efficacy outcome was global disability at 90 days, assessed using the modified Rankin Scale (mRS). The safety outcome included symptomatic intracranial hemorrhage (sICH) within 48 h and mortality within 90 days. RESULTS: A total of 406 cardioembolic stroke patients were included in this study, with 212 assigned to the tirofiban group and 194 assigned to the placebo group. Tirofiban treatment did not correlate with a favorable shift towards a lower 90-day mRS score (adjusted common odds ratio [OR], 0.91; 95% CI 0.64-1.3; p = 0.617). However, the tirofiban group had a significantly higher risk of symptomatic intracranial hemorrhage (sICH) within 48 h (adjusted OR, 3.26; 95% CI 1.4-7.57; p = 0.006) compared to the placebo group. The adjusted odds ratio (aOR) for mortality within 90 days was 1.48 (95% CI 0.88-2.52; p = 0.143). CONCLUSIONS: Tirofiban treatment was not associated with a lower level of disability and increased the incidence of sICH after endovascular therapy in cardioembolic stroke patients.

Patterns of Infarction on MRI in Patients With Acute Ischemic Stroke and Cardio-Embolism: A Systematic Review and Meta-Analysis.

Background: Cardioembolic strokes are common however atrial fibrillation, the most common cause, is often asymptomatic and difficult to detect. There is evidence that infarct topography and volume on magnetic resonance imaging may be associated with specific stroke etiologies. Aim: A systematic review and meta-analysis were undertaken to summarize the available evidence on the association between stroke etiology, infarct topography, and volume. Methods: A systematic review was conducted using Medline (OVID), Embase (OVID), and PubMed databases. Hand searches of the gray literature and of reference lists in relevant articles were also performed. A quality assessment was undertaken, based on the STROBE checklist. For each study, the number of patients with and without a CE source of stroke and infarct topography was collected and outcomes presented as odds ratios (OR) with 95% CI and p-values. Results: Four thousand eight hundred and seventy-three patients with ischemic stroke were included, of whom 1,559 were determined to have a CE source. Bilateral infarcts (OR 3.41; 95% CI 2.20-5.29; p < 0.0001) and multiple territory infarcts (OR 1.57; 95% CI 1.12-2.21; p = 0.009) were more common in patients with a CE source of stroke, than patients without a CE source. Lacunar infarcts (OR 0.49; 95% CI 0.31-0.80; p = 0.004) were more likely to occur in patients without a CE source. No significant difference between the frequency of multiple infarcts (OR 0.96; 95% CI 0.57-1.61; p = 0.87) anterior circulation (OR 1.45; 95% CI 0.83-2.53; p = 0.19) or posterior circulation infarcts (OR 1.06; 95% CI 0.72-1.57; p = 0.75), between the two groups were identified. Three out of four studies examining volume, found a significant association between increased infarct volume and CE source of stroke. A sensitivity analysis with cryptogenic and undetermined stroke sources assumed to be cardioembolic, did not alter the associations observed. Conclusion: The findings of this systematic review and meta-analysis are broadly consistent with previous literature and provide more robust evidence on the association between infarct topography, volume and stroke etiology. Our findings may assist with refining cardiac investigations for patients with cryptogenic stroke, based on infarct topography.

Etiologies of simultaneous cerebral infarcts in multiple arterial territories: A simple literature-based pooled analysis.

INTRODUCTION: Acute multiple infarcts in multiple cerebral circulations are thought to suggest the presence of cardioembolic sources. However, several studies have shown other etiologies for simultaneous cerebral infarcts in multiple arterial territories. METHODS: We conducted a systematic review of the literature using PubMed, Scopus, Embase, Clinicaltrial.gov, WHO International Clinical Trials Registry Platform (ICTRP), and Cochrane library. Studies reporting multiple acute strokes in more than one arterial territory based on diffusion-weighted imaging (DWI) findings were reviewed and included. Studies were excluded if they had limited inclusion criteria, performed limited subgroup analysis, did not use diffusion weighted imaging (DWI), and were not published in English. RESULTS: Out of 15056 stroke patients from 21 studies included in this study, 1914 (13%) patients had acute multiple infarcts in multiple cerebral circulations. One hundred and ninety-nine patients were excluded as their workup and diagnosis were not reported. Out of 1715 patients, 472 (27.6%) patients had an undetermined etiology. Cardioembolism was the most common cause of stroke in multiple arterial territories [37.2%, 95% confidence interval (CI): 36-40%] followed by large artery atherosclerosis including aortic arch atheroma (25.7%, 95% CI: 21-25%). Hematological disorders were found to be the cause of cerebral infarcts in 36 (2.1%, 95% CI: 2-4%) patients. Other etiologies for stroke in multiple arterial territories were small vessel pathologies and intracranial small vessel atherosclerosis (1.8%), inflammatory disorders such as vasculitis and infection (0.2%), and iatrogenic causes (0.1%). CONCLUSION: Acute multiple infarcts in multiple cerebral circulations occur among 13% of stroke patients. Although cardioembolism is the most common cause, there are several other etiologies that require a different workup and secondary prevention strategy.

The safety of antithrombotic therapy in patients with cerebral microbleeds and cardiogenic cerebral embolism due to nonvalvular atrial fibrillation.

BACKGROUND: The impact of cerebral microbleeds on the safety of antithrombotic therapy has recently received considerable attention. We investigated the safety of antithrombotic therapy in patients with cerebral microbleeds and cardiogenic cerebral embolism caused by nonvalvular atrial fibrillation. METHODS: This retrospective study enrolled patients with acute cardiogenic cerebral embolism due to nonvalvular atrial fibrillation in the stroke unit of the Department of Neurology at the Beijing Tiantan Hospital, the Capital Medical University, from January 2015 to January 2018. General clinical data, magnetic resonance imaging data, and data regarding the use of antithrombotic medications were collected. The main adverse events were cerebral hemorrhage and all-cause death. RESULTS: According to the susceptibility-weighted imaging sequence, patients were divided into a cerebral microbleeds group and a non-cerebral microbleeds group. Patients with cerebral microbleeds were more likely to be male and to have a history of hypertension and diabetes, and they were less likely to have received anticoagulant therapy (49.1% vs. 71.3%, P = 0.001). However, no significant differences were found in the event-free time, the occurrence of cerebral hemorrhage events and all-cause death. Cox regression analysis showed that the risk of all-cause death in patients with a cerebral hemorrhage history and cerebral microbleeds increased 2.773-fold (HR = 2.773, 95%CI 1.056-7.280, P = 0.019), and the risk of a cerebral hemorrhage event in patients with cerebral microbleeds and a hypertension history (HR = 3.451, 95%CI 1.947-6.119, P = 0.045) or a cerebral hemorrhage history (HR = 2.443, 1.078-5.536, P = 0.006) was increased 3.451-fold and 2.443-fold, respectively. CONCLUSIONS: Antithrombotic therapy in patients with CMBs and cardiogenic cerebral embolism due to nonvalvular atrial fibrillation did not have increased risks of a cerebral hemorrhage event and all-cause death. CMBs were probably not a crucial predictor of whether patients were prescribed antithrombotic medicine. Patients with CMBs and a hypertension history or cerebral hemorrhage history should receive a close follow-up after antithrombotic therapy.

Brain natriuretic peptide: a relevant marker to rule out delayed atrial fibrillation in stroke patient.

Detection of new atrial fibrillation (AF) after ischemic stroke is challenging. The aim of the TARGET-AF study was to identify relevant markers for ruling out delayed AF in stroke patients. Early and prolonged Holter electrocardiography (ECG) monitoring during hospitalization was performed systematically in consecutive acute stroke patients naive to AF (no history of AF or no AF on baseline ECG). All clinical and paraclinical data for routine etiologic assessment were collected. The diagnostic value of all parameters significantly associated with AF was assessed by comparison of area under the receiver operating characteristic curve (AUC). Of the 300 stroke patients enrolled (mean age, 62.5 ± 15.5 years; sex ratio: 1.7; mean National Institutes of Health Stroke Scale score, 7.1 ± 7.9, median duration of Holter ECG monitoring, 6.8 days), 52 (17.3%) had newly diagnosed AF. Parameters significantly associated with AF were classified by increasing AUC: anterior circulation localization (AUC, 0.604; 95% confidence interval [CI], 0.546-0.660), P-wave initial force (AUC, 0.608; 95% CI, 0.545-0.669), left atrial dilatation (AUC, 0.657; 95% CI, 0.600-0.711), National Institutes of Health Stroke Scale score (AUC, 0.667; 95% CI, 0.611-0.720), sex (AUC, 0.683; 95% CI, 0.627-0.736), age (AUC, 0.755; 95% CI, 0.707-0.797), CHA2DS2-VASc score (AUC, 0.796; 95% CI, 0.746-0.841), STAF (score for the targeting of AF) score (AUC, 0.842; 95% CI, 0.796-0.882), and plasma brain natriuretic peptide (BNP) level (AUC, 0.868; 95% CI, 0.825-0.904). The use of all parameters combined (AUC, 0.910; 95% CI, 0.872-0.940) was not significantly more efficient in diagnosing AF than BNP alone (P = .248). At the Youden plot, the diagnostic properties for BNP >131 pg/mL were sensitivity, 98.1% (95% CI, 89.7-99.7); specificity, 71.4% (95% CI, 65.3-76.9); and negative predictive value, 99.4% (95% CI, 96.9-99.9). Our data indicate that a BNP level ≤ 131 pg/mL might rule out delayed AF in stroke survivors and could be included in algorithms for AF detection.

Utility of Transthoracic Echocardiography and Carotid Doppler Ultrasound in Differential Diagnosis and Management of Ischemic Stroke in a Developing Country.

OBJECTIVE: We sought to describe findings, diagnostic yield, cost effectiveness of transthoracic echocardiography (TEE) and Carotid doppler ultrasound (CDU) in ischemic stroke. METHODS: Cross sectional study at Mulago hospital, Uganda. Institutional ethical approval, patient consent was obtained. Patients eighteen years and above with ischemic stroke confirmed by brain computerized tomography (CT) scan and met inclusion criteria were selected. TTE and CDU were done as part of comprehensive assessment for stroke risk factors. Data was analyzed using SPSS 14. Univariate analysis was done for social-demographics, abnormalities on cardiac imaging and diagnostic yield using TOAST criteria. Bivariate analysis for association between stroke risk factors, cardio-embolic stroke and other ischemic subtypes (diagnosed using clinical and CT scan features). Statistical significance was set at P<0.05. RESULTS: Of 139 screened patients with suspected stroke, 127 underwent brain CT scan as 12 died before CT. Eighty five were confirmed stroke by CT scan with 66 (77.6%) ischemic stroke, mean age 62 years (SD+16.6), 53% were male. Out of 66, 62 (93.9%) underwent both TTE and CDU. Although only 7 (11.3%) reported history of heart disease, 43 (69.3%) had abnormal findings on TTE with left atrial enlargement commonest in 21 (48.8%). Thirty eight (61.3%) had abnormal finding on CDU with atherosclerosis commonest in 28 (45.2%). Using clinical and CT scan features, atherosclerotic stroke was the commonest subtype in 29 (46.8%) then cardio-embolic 18 (27.3%). Only 6 (9.7%) patients had abnormal findings on TTE suggesting possible cardio-embolism by TOAST criteria. None had stenosis >50% on CDU. Multiple valvular lesions P<0.001, severe valvular lesions P=0.001 were associated with cardio-embolic stroke. CONCLUSIONS: Majority of ischemic stroke patients without previous history of heart disease had abnormal findings on TTE and CDU. Diagnostic yield for cardio-embolic stroke by TOAST criteria was very low given the high cost involved for a developing country.