Smokers with Elevated Glycated Albumin Could Not Benefit from Dual Antiplatelet Therapy after Minor Stroke or Transient Ischemic Attack.

INTRODUCTION: The aim of this study was to investigate the impact of smoking on dual antiplatelet therapy in patients with minor stroke or transient ischemic attack (TIA) under different glycated albumin (GA) levels. METHODS: We analyzed data from the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial. A subgroup of 3,044 patients with baseline GA levels was included and categorized by smoking status and GA levels. The primary efficacy outcome was a new stroke within 90 days. The safety outcome was any bleeding event at 90 days. The interaction of smoking status with antiplatelet therapy was calculated by Cox proportional hazards regression model. RESULTS: In patients with GA levels ≤15.5%, the proportion of smokers was 37.7% (719/1,908), while in patients with GA levels >15.5%, it was 51.6% (586/1,136). During the 3-month follow-up period, 299 (9.9%) patients had a new stroke occurrence. In patients with elevated GA levels, both smokers and nonsmokers could not benefit from dual antiplatelet therapy (smokers, adjusted hazard ratio [HR] 0.70, 95% confidence interval [CI]: 0.42-1.17; nonsmokers, adjusted HR 0.82, 95% CI: 0.57-1.18). In patients with normal GA levels, dual antiplatelet therapy reduced the risk of stroke recurrence in smokers by 72% (adjusted HR 0.28, 95% CI: 0.14-0.56) and in nonsmokers by 53% (adjusted HR 0.47, 95% CI: 0.26-0.86). However, whether the GA level was elevated or normal, there was no significant interaction between smoking status and antiplatelet therapy. CONCLUSIONS: Smokers with elevated GA levels could not benefit from dual antiplatelet therapy after minor stroke or TIA.

Early dual antiplatelet therapy in patients with minor ischemic stroke after intravenous thrombolysis.

OBJECTIVES: Minor stroke is defined by a score of 5 or less on the National Institutes of Health Stroke Scale (NIHSS). Prior trials have shown efficacy of short term dual antiplatelet therapy (DAPT) in secondary prevention of stroke among patients with transient ischemic attack (TIA) or minor ischemic stroke, but no randomized clinical trials have studied this benefit after intravenous thrombolysis (IVT). Our aim was to investigate the safety of DAPT within 90 days after IVT in patients with acute minor ischemic stroke. PATIENTS AND METHODS: We reviewed medical records of patients older than 18 years that received IVT between January 2015 and December 2022. Patients had a diagnosis of acute minor stroke or averted stroke (complete recovery and negative image on follow-up). Single or dual antiplatelet treatment was started 24 hours after thrombolysis according to the physician's judgment. Patients were divided in two groups: single and dual antiplatelet therapy. We assessed clinical outcome using the modified Rankin scale (mRS), symptomatic intracranial hemorrhage (SICH) and mortality at 90 days. RESULTS: Fifty-three patients met the inclusion criteria, 68% men aged 64±16,5 years. Seventy five percent had an ischemic stroke and 25% had an averted stroke. Median door-to-needle time was 50 minutes. Fifty one percent were in the single antiplatelet group and 49% in the dual antiplatelet therapy group. There were no differences in demographic and clinical characteristics between groups. The 90-day mRS did not show significant difference between groups. No patients had SICH nor died during follow-up. One patient in the single antiplatelet group had stroke recurrence. CONCLUSIONS: Dual antiplatelet therapy after IVT with rtPA for acute minor ischemic stroke appears not to increase the risk of bleeding and mortality compared to single antiplatelet therapy in the first three months after the event. This is the first study to assess this subject in a Latin American population.

The use of dual antiplatelet therapy for ischemic cerebrovascular events.

In the last 10 years, the use of dual antiplatelet therapy (DAPT) in the neurological ambit has been explored in patients with non-cardioembolic ischemic stroke, transient ischemic attack (TIA), and intracranial atherosclerotic disease. Two clinical trials (CHANCE and POINT) showed that in patients with minor non-cardioembolic ischemic stroke or high-risk TIA, the addition of clopidogrel to aspirin reduces the risk of stroke recurrence. Another trial (THALES) evaluated the association of ticagrelor and aspirin in mild-to-moderate non-cardioembolic ischemic stroke or high-risk TIA, showing a reduced risk of subsequent stroke compared to aspirin alone. Finally, the use of DAPT has been assessed in the treatment of stroke associated with atherosclerotic intracranial stenosis in the SAMMPRIS trial, showing a favorable profile compared to percutaneous angioplasty and stenting. The aim of this article is, after a review the major trials evaluating DAPT in patients with ischemic cerebrovascular events and the ways they have been implemented in Italian, European, and USA guidelines, to provide a practical algorithm to help clinicians in their everyday clinical practice and to outline possible caveats in the practical implementation of guidelines. Possible limitations and gaps in knowledge regarding specific conditions (e.g., the use of DAPT after acute phase therapies) are also underlined.

IV thrombolysis plus thrombectomy versus IV thrombolysis alone for minor stroke with anterior circulation large vessel occlusion from the IRETAS and Italian SITS-ISTR cohorts.

INTRODUCTION: The aim of this study was to compare the outcomes of patients treated with intravenous thrombolysis (IVT) <4.5 h after symptom onset plus mechanical thrombectomy (MT) <6 h with those treated with IVT alone <4.5 h for minor stroke (NIHSS ≤5) with large vessel occlusion (LVO) in the anterior circulation. PATIENTS AND METHODS: Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analyzed. RESULTS: Among the patients with complete data on 24-h ICH type, 236 received IVT plus MT and 382 received IVT alone. IVT plus MT was significantly associated with unfavorable shift on 24-h ICH types (from no ICH to PH-2) (OR, 2.130; 95% CI, 1.173-3.868; p=0.013) and higher rate of PH (OR, 4.363; 95% CI, 1.579-12.055; p=0.005), sICH per ECASS II definition (OR, 5.527; 95% CI, 1.378-22.167; p=0.016), and sICH per NINDS definition (OR, 3.805; 95% CI, 1.310-11.046; p=0.014). Among the patients with complete data on 3-month mRS score, 226 received IVT plus MT and 262 received IVT alone. No significant difference was reported between IVT plus MT and IVT alone on mRS score 0-1 (72.1% versus 69.1%), mRS score 0-2 (79.6% versus 79%), and death (6.2% versus 6.1%). CONCLUSIONS: Compared with IVT alone, IVT plus MT was associated with unfavorable shift on 24-h ICH types and higher rate of 24-h PH and sICH in patients with minor stroke and LVO in the anterior circulation. However, no difference was reported between the groups on 3-month functional outcome measures.

Transient ischemic attack and minor stroke as "surgeons affairs": a narrative review.

OBJECTIVE: The scope of this paper is to review the subtypes of transient ischemic attack (TIA) and minor stroke (mS) in which a surgical treatment is needed, discussing the importance and the timing of a multidisciplinary approach, in order to achieve an optimized management and prevent major strokes or other critical complications. MATERIALS AND METHODS: The keywords "transient ischemic attack," "minor stroke," "surgical treatment," "vascular surgery," "heart surgery," "neurosurgery," and "multidisciplinary" were searched using MEDLINE, EMBASE, and Scopus. Relevant search results were discussed by the authors for references inclusion. RESULTS: Notwithstanding that best medical therapy is usually the first choice for the most part of cases, there are specific but recurrent etiologies that must be properly recognized because of a potential surgical approach, even in urgency. In fact, symptomatic carotid stenosis, or particular cases of hemodynamic cerebrovascular events, should be promptly referred to vascular surgeon, since increasing evidences highlighted a benefit from an early artery revascularization. In addition, beyond arrhythmic causes, cardioembolic events due to bacterial endocarditis and atrial myxoma should be quickly diagnosed, possibly in emergency department, because they are a presumptive urgency for heart surgery. In addition to the above-mentioned conditions, in patients suffering from vertebrobasilar TIA or mS, clinicians should keep in mind the Bow Hunter disease, because surgical artery decompression can represent the only suitable treatment in selected cases. CONCLUSIONS: TIA and mS require a multidisciplinary in order to discuss therapeutic options, comparing risks and benefits and determining the best timing for an optimized management.

Effect of Hypertension on Efficacy and Safety of Ticagrelor-Aspirin Versus Clopidogrel-Aspirin in Minor Stroke or Transient Ischemic Attack.

BACKGROUND: Hypertension is a risk factor of poor stroke outcomes and associated with antiplatelet resistance. This study aimed to explore the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in patients with different hypertension status, using randomized trial data from the CHANCE-2 trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events-II). METHODS: A total of 6412 patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles were enrolled and randomized to either ticagrelor-aspirin or clopidogrel-aspirin group. Hypertension status were classified into no, newly diagnosed, and previously diagnosed hypertension according to medical history, blood pressure, and antihypertensive medications during hospitalization. The primary efficacy and safety outcomes were stroke recurrence and moderate to severe bleeding risk within 90-day follow-up. RESULTS: Ticagrelor-aspirin was associated with reduced risk of new stroke in patients without hypertension (32 [4.8%] versus 60 [7.2%]; hazard ratio, 0.55 [95% CI, 0.35-0.86]), but not in those with a newly diagnosed hypertension (20 [5.3%] versus 36 [9.1%]; hazard ratio 0.59 [95% CI, 0.33-1.07]), or those with a previously diagnosed hypertension (139 [7.0%] versus 147 [7.4%]; hazard ratio, 0.93 [95% CI, 0.74-1.18]) compared with clopidogrel-aspirin (P=0.04 for interaction). The risk of bleeding for ticagrelor-aspirin was not associated with hypertension status (0.1% versus 0.4%; 0.3% versus 0.5%, 0.4% versus 0.3%, P=0.50 for interaction). All the efficacy and safety outcomes between treatments did not differ by blood pressure levels on admission. CONCLUSIONS: In the CHANCE-2 trial, patients without hypertension received a significantly greater benefit from ticagrelor- aspirin than those with previous hypertension after minor stroke or transient ischemic attack, and a similar benefit trend was observed in those with newly diagnosed hypertension. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT04078737.

Minor stroke in large vessel occlusion: A matched analysis of patients from the German Stroke Registry-Endovascular Treatment (GSR-ET) and patients from the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Register (SITS-ISTR).

BACKGROUND AND PURPOSE: Reperfusion treatment in patients presenting with large vessel occlusion (LVO) and minor neurological deficits is still a matter of debate. We aimed to compare minor stroke patients treated with endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) or IVT alone. METHODS: Patients enrolled in the German Stroke Registry-Endovascular Treatment (GSR-ET) and the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR) between June 2015 and December 2019 were analyzed. Minor stroke was defined as National Institutes of Health Stroke Scale (NIHSS) score ≤5, and LVO as occlusion of the internal carotid, carotid-T, middle cerebral, basilar, vertebral or posterior cerebral arteries. GSR-ET and SITS-ISTR IVT-treated patients were matched in a 1:1 ratio using propensity-score (PS) matching. The primary outcome was good functional outcome at 3 months (modified Rankin Scale score 0-2). RESULTS: A total of 272 GSR-ET patients treated with EVT and IVT (age 68.6 ± 14.0 years, 43.4% female, NIHSS score 4 [interquartile range 2-5]) were compared to 272 IVT-treated SITS-ISTR patients (age 69.4 ± 13.7, 43.4% female, NIHSS score 4 [2-5]). Good functional outcome was seen in 77.0% versus 82.9% (p = 0.119), mortality in 5.9% versus 7.9% (p = 0.413), and intracranial hemorrhage in 8.8% versus 12.5% (p = 0.308) of patients in the GSR-ET versus the SITS-ISTR IVT group, respectively. In a second PS-matched analysis, 624 GSR-ET patients (IVT rate 56.7%) and 624 SITS-ISTR patients (IVT rate 100%), good outcome was more often observed in the SITS-ISTR patients (68.2% vs. 80.9%; p < 0.001), and IVT independently predicted good outcome (odds ratio 2.16, 95% confidence interval 1.43-3.28). CONCLUSIONS: Our study suggests similar effectiveness of IVT alone compared to EVT with or without IVT in minor stroke patients. There is an urgent need for randomized controlled trials on this topic.

Predictive values of baseline matrix metalloproteinase 9 levels in peripheral blood on 3-month outcomes of high-risk patients with minor stroke or transient ischemic attack.

BACKGROUND AND PURPOSE: To explore the relationship between baseline levels of matrix metalloproteinase 9 (MMP9) in peripheral blood and the outcomes in patients with acute minor stroke and transient ischemic attack (TIA). METHODS: We assessed data from patients with acute minor ischemic stroke or TIA who were included in the CHANCE (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events) trial. Baseline level of MMP9 in peripheral blood is classified into five quintiles. We assessed the relationship between the baseline MMP9 and outcomes of stroke recurrence, composite vascular events, and poor functional outcomes within 90 days after stroke onset. RESULTS: Of the 3014 patients included, 295 (9.79%) had recurrent stroke, 289 (9.59%) had recurrent ischemic stroke, 297 (9.85%) had combined vascular events, and 199 (6.64%) had poor functional outcomes within 90 days. We used MMP9 concentrations near hazard ratio (HR) = 1 (Q3) in restricted cubic splines as the reference. The result showed that, compared to patients in the Q3 group, patients in the highest quintile (Q5 group) had an increased risk of poor functional outcomes at 90 days after adjusting the risk factors and confounders (p = 0.030), which may be associated with an increased risk of combined vascular events (p = 0.052). Using Cox regression models or logistic regression models with restricted cubic spline, we also observed that higher MMP9 ratios were associated with an increased risk of stroke recurrence, combined events, and poor functional outcomes at a range of concentrations. CONCLUSIONS: For patients with acute minor stroke or TIA, higher baseline MMP9 level was associated with an increased risk of poor functional outcomes, which might be related to stroke recurrence and combined vascular events.

Machine learning is an effective method to predict the 90-day prognosis of patients with transient ischemic attack and minor stroke.

OBJECTIVE: We aimed to investigate factors related to the 90-day poor prognosis (mRS≥3) in patients with transient ischemic attack (TIA) or minor stroke, construct 90-day poor prognosis prediction models for patients with TIA or minor stroke, and compare the predictive performance of machine learning models and Logistic model. METHOD: We selected TIA and minor stroke patients from a prospective registry study (CNSR-III). Demographic characteristics,smoking history, drinking history(≥20g/day), physiological data, medical history,secondary prevention treatment, in-hospital evaluation and education,laboratory data, neurological severity, mRS score and TOAST classification of patients were assessed. Univariate and multivariate logistic regression analyses were performed in the training set to identify predictors associated with poor outcome (mRS≥3). The predictors were used to establish machine learning models and the traditional Logistic model, which were randomly divided into the training set and test set according to the ratio of 70:30. The training set was used to construct the prediction model, and the test set was used to evaluate the effect of the model. The evaluation indicators of the model included the area under the curve (AUC) of the discrimination index and the Brier score (or calibration plot) of the calibration index. RESULT: A total of 10967 patients with TIA and minor stroke were enrolled in this study, with an average age of 61.77 ± 11.18 years, and women accounted for 30.68%. Factors associated with the poor prognosis in TIA and minor stroke patients included sex, age, stroke history, heart rate, D-dimer, creatinine, TOAST classification, admission mRS, discharge mRS, and discharge NIHSS score. All models, both those constructed by Logistic regression and those by machine learning, performed well in predicting the 90-day poor prognosis (AUC >0.800). The best performing AUC in the test set was the Catboost model (AUC=0.839), followed by the XGBoost, GBDT, random forest and Adaboost model (AUCs equal to 0.838, 0, 835, 0.832, 0.823, respectively). The performance of Catboost and XGBoost in predicting poor prognosis at 90-day was better than the Logistic model, and the difference was statistically significant(P<0.05). All models, both those constructed by Logistic regression and those by machine learning had good calibration. CONCLUSION: Machine learning algorithms were not inferior to the Logistic regression model in predicting the poor prognosis of patients with TIA and minor stroke at 90-day. Among them, the Catboost model had the best predictive performance. All models provided good discrimination.

Factors influencing follow-up care post-TIA and minor stroke: a qualitative study using the theoretical domains framework.

BACKGROUND: Follow-up care after transient ischaemic attack (TIA) and minor stroke has been found to be sub-optimal, with individuals often feeling abandoned. We aimed to explore factors influencing holistic follow-up care after TIA and minor stroke. METHODS: Qualitative semi-structured interviews with 24 healthcare providers (HCPs): 5 stroke doctors, 4 nurses, 9 allied health professionals and 6 general practitioners. Participants were recruited from three TIA clinics, seven general practices and one community care trust in the West Midlands, England. Interview transcripts were deductively coded using the Theoretical Domains Framework and themes were generated from coded data. RESULTS: There was no clear pathway for supporting people with TIA or minor stroke after rapid specialist review in hospital; consequently, these patients had limited access to HCPs from all settings ('Environmental context and resources'). There was lack of understanding of potential needs post-TIA/minor stroke, in particular residual problems such as anxiety/fatigue ('Knowledge'). Identification and management of needs was largely influenced by HCPs' perceived role, professional training ('Social professional role and identity') and time constraints ('Environmental context and resources'). Follow-up was often passive - with onerous on patients to seek support - and predominantly focused on acute medical management ('Intentions'/'Goal'). CONCLUSIONS: Follow-up care post-TIA/minor stroke is currently sub-optimal. Through identifying factors which influence follow-up, we can inform guidelines and practical strategies to improve holistic healthcare.

Longitudinal white matter hyperintensity changes and cognitive decline in patients with minor stroke.

BACKGROUND AND OBJECTIVE: As reported, both minor stroke and white matter hyperintensities (WMHs) are associated with an increased risk of cognitive impairment and dementia. The underlying factors for dynamic changes in WMH volume and cognitive performances in patients with minor stroke remain poorly understood. A 2-year longitudinal study was designed to investigate the factors associated with the changes in white matter hyperintensity (WMH) volume on brain MRI and cognitive decline in patients with minor stroke. METHODS: A group of eligible patients with minor ischemic stroke was recruited in a row. At the initial and 2-year follow-up visits, all the participants underwent routine examinations, multimodal MRI, and cognitive assessment. Using a lesion prediction algorithm tool, we were able to automate the measurement of the change in WMH volume. During the 2-year follow-up, cognitive function was evaluated using Telephone Interview for Cognitive Status-Modified (TICS-m). Participants' demographic, clinical, and therapeutic data were collected and statistically analyzed. Regression analyses were used to test the relationships between risk factors and changes in WMH volume and cognitive decline. RESULTS: Finally, we followed up with 225/261 participants for 2 years, with a mean age of 65.67 ± 10.73 years (65.6% men). WMH volume was observed to be increased in 113 patients, decreased in 74 patients, and remained stable in 58 patients. Patients with WMH progression were more often had a history of hypertension (p = 0.006) and a higher CSVD burden both at baseline and follow-up visit (p < 0.05). Longitudinally, the proportion of patients taking antihypertension medications on a regular basis in the regression group was higher than in the stable group (p = 0.01). When compared to the stable group, the presence of lacunes (OR 9.931, 95% CI 1.597-61.77, p = 0.014) was a stronger predictor of progression in WMH volume. 87 subjects (38.6%) displayed incident cognitive impairment. The progression of WMH volume was a significant risk factor for cognitive decline (p < 0.001). CONCLUSIONS: The longitudinal change of WMH is dynamic. The regressive WMH volume was associated with the use of antihypertensive medications on a regular basis. The presence of lacunes at the initial visit of the study was a stronger predictor of WMH progression. The progression of WMH volume could be useful in predicting cognitive decline in patients with minor stroke.

Defining Minor Intracerebral Hemorrhage.

BACKGROUND AND PURPOSE: The minor stroke concept has not been analyzed in intracerebral hemorrhage (ICH) patients. Our purpose was to determine the optimal cut point on the NIH Stroke Scale (NIHSS) for defining a minor ICH (mICH) in patients with primary ICH. METHODS: An ICH was considered minor if associated with a favorable 3-month outcome (modified Rankin Scale score ≤2). For supratentorial ICH, the discovery cohort consisted of 478 patients prospectively admitted at University Hospital del Mar. Association between NIHSS at admission and 3-month outcome was evaluated with area under the curve-receiver operating characteristics (AUC-ROC) and Youden's index to identify the optimal NIHSS cutoff point to define mICH. External validation was performed in a cohort of 242 supratentorial ICH patients from University Hospital Sant Pau. For infratentorial location, patients from both hospitals (n = 85) were analyzed together. RESULTS: The best -NIHSS cutoff point defining supratentorial-mICH was 6 (AUC-ROC = 0.815 [0.774-0.857] in the discovery cohort and AUC-ROC = 0.819 [0.756-0.882] in the external validation cohort). For infratentorial ICH, the best cutoff point was 4 (AUC-ROC = 0.771 [0.664-0.877]). Using these cutoff points, 40.5% of all primary ICH cases were mICH. Of these, 70.2% were living independently at 3-month follow-up (72% for supratentorial ICH and 56.1% for infratentorial ICH) and 6.5% had died (5.3% for supratentorial ICH, and 14.6% for infratentorial ICH). For patients identified as non-mICH, good 3-month outcome was observed in 11.3% of cases; mortality was 51%. CONCLUSIONS: The definition of mICH using the NIHSS cutoff point of 6 for supratentorial ICH and 4 for infratentorial ICH is useful to identify good outcome in ICH patients.

The length of susceptibility vessel sign predicts early neurological deterioration in minor acute ischemic stroke with large vessel occlusion.

BACKGROUND: Patients with acute large vessel occlusion (LVO) presenting with minor stroke are at risk of early neurological deterioration (END). The present study aimed to evaluate the frequency and potential predictors of END in patients with medical management and LVO presenting with minor stroke. The relationship between SVS length and END was also investigated. METHODS: This was a prospective multicenter study. Consecutive patients were collected with anterior circulation. LVO presented with minor stroke [National Institutes of Health Stroke Scale (NIHSS) ≤ 4] within 24 h following onset. END was defined as a deterioration of NIHSS ≥4 within 24 h, without parenchymal hemorrhage. The length of the susceptibility vessel sign (SVS) was measured using the T2* gradient echo imaging. RESULTS: A total of 134 consecutive patients with anterior circulation LVO presenting with minor stroke were included. A total of 27 (20.15%) patients experienced END following admission. Patients with END exhibited longer SVS and higher baseline glucose levels compared with subjects lacking END (P < 0.05). ROC curve analysis indicated that the optimal cutoff point SVS length for END was SVS ≥ 9.45 mm. Multivariable analysis indicated that longer SVS [adjusted odds ratio (aOR), 2.03; 95% confidence interval (CI), 1.45-2.84; P < 0.001] and higher baseline glucose (aOR,1.02; 95% CI, 1.01-1.03; P = 0.009) levels were associated with increased risk of END. When SVS ≥ 9.45 mm was used in the multivariate logistic regression, SVS ≥ 9.45 mm (aOR, 5.41; 95%CI, 1.00-29.27; P = 0.001) and higher baseline glucose [aOR1.01; 95%CI, 1.00-1.03; P = 0.021] were associated with increased risk of END. CONCLUSIONS: END was frequent in the minor stroke patients with large vessel occlusion, whereas longer SVS and higher baseline glucose were associated with increased risk of END. SVS ≥ 9.45 mm was a powerful independent predictor of END.

Factors Associated with Level of Physical Activity After Minor Stroke.

OBJECTIVES: To explore factors from the acute phase, and after three and 12 months, associated with level of self-reported physical activity 12 months after a minor ischemic stroke with National Institutes of Health Stroke Scale (NIHSS) score ≤ 3 in persons 70 years or younger. MATERIALS AND METHOD: In this longitudinal cohort study patients were recruited consecutively from two stroke units. Activity level were measured with three sets of questions addressing the average number of frequency (times exercising each week), the average intensity, and duration (the average time), and a sum score was constructed. The association between physical activity 12 months after stroke and sociodemographic factors, NIHSS, body mass index, balance, and neuropsychiatric symptoms were explored using multiple linear regression. RESULTS: This study included 101 patients, with mean age (SD) 55.5 (11.4) years, NIHSS median (Q1, Q3) 0.0 (0.0, 1.0), and 20 % were female. Multiple linear regression analyses showed sick leave status at stroke onset, balance at three and 12 months, and anxiety, depression, apathy, and fatigue at 12 months to be factors associated with physical activity at 12 months after stroke. CONCLUSION: We found that pre-stroke sick leave, post-stroke balance, and neuropsychiatric symptoms were associated with the level of physical activity one year after minor stroke. This might be of importance when giving information about physical activity and deciding about post-stroke follow-up.

Under Treatment of High-Risk TIA Patients with Clopidogrel-Aspirin in the Emergency Setting.

BACKGROUND: Treating high-risk transient ischemic attack (TIA) with dual antiplatelet therapy (DAPT) reduces subsequent ischemic stroke risk yet current rates of clopidogrel-aspirin treatment are uncertain. MATERIALS AND METHODS: We conducted a retrospective cohort study of consecutive TIA patients who presented to any of the four emergency departments (ED) of a single urban health system from 1/1/2018-3/1/2020. Medical record review was used to describe the cohort and assess clopidogrel-aspirin treatment. Patient eligibility for clopidogrel-aspirin was determined using relevant criteria from the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trial. Comparisons among eligible patients who received versus did not receive clopidogrel-aspirin were conducted using t-test, chi-squared, and Mann-Whitney as indicated. RESULTS: We identified 248 TIA patients of whom 95 met eligibility criteria for clopidogrel-aspirin treatment. Among these 95 patients, mean age was 69.5 (SD: 12), 68.4% were women, and median ABCD2 score was 5 (IQR: 4-6). A total of 26/95 (27.4%) eligible patients received clopidogrel-aspirin within 24 hours of symptom onset. Appropriate clopidogrel-aspirin use was associated with having a stroke code called upon ED arrival (88.5% vs. 34.8%; P<0.001), being evaluated by a vascular neurologist (88.5% vs. 21.1%; P<0.001), and not presenting to the community ED site wherein only a single patient received clopidogrel-aspirin. CONCLUSIONS: In a multisite, single health system study, nearly three-fourths of high-risk TIA patients eligible for clopidogrel-aspirin treatment did not receive it. Appropriate clopidogrel-aspirin use was highest among patients seen by vascular neurologists and lowest at the community ED, though under treatment was evident at all sites.

Quickly home again: patients' experiences of early discharge after minor stroke.

BACKGROUND: Patients with minor stroke experience some of the same issues as patients experiencing stroke of increased severity such as fatigue, anxiety and cognitive symptoms. It is current practice that patients with minor stroke receive accelerated treatment and care, yet studies indicate that patients find it difficult to return to their everyday lives after being discharged. We aimed to explore how patients with minor stroke experience the transitional period from the hospital through the first 2-4 weeks after an accelerated care pathway with discharge within 72 hours after stroke onset. METHODS: A qualitative study consisting of semi-structured interviews with 11 patients experiencing first-time stroke 2-4 weeks after discharge. RESULTS: The patients struggled to identify themselves as having had a stroke. They strived to find a new everyday life, but were challenged by existential concerns, mental fatigue and the fear of having a stroke again. Unresolved questions and misunderstandings arose, and the patients expressed a need for health professionals to support them and discuss unclear issues after discharge. Patients searched for others with similar issues in order to find a new sense of self. CONCLUSION: Patients with minor stroke struggle with everyday life after discharge. There is a need for support after discharge from healthcare professionals with specialised knowledge of stroke. Patients also requested an opportunity to meet other patients with minor stroke.

Higher early recurrence risk and potential benefit of dual antiplatelet therapy for minor stroke with watershed infarction: subgroup analysis of CHANCE.

BACKGROUND AND PURPOSE: The aim was to explore the risk of early stroke recurrence within 3 months after watershed infarction and to investigate whether early dual antiplatelet therapy is more effective in decreasing such risk. METHODS: Patients enrolled in the Clopidogrel in High-risk Patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial and who had acute infarction on diffusion-weighted imaging were included in this subgroup analysis. All magnetic resonance images were read centrally by two neurologists who were blinded to the patients' baseline and outcome information. The primary outcome was any stroke recurrence within 3 months. The hazard ratios were adjusted by known predictors of stroke recurrence. RESULTS: Of the 1089 patients with magnetic resonance imaging data enrolled in CHANCE, 834 (76.58%) patients had acute infarcts on diffusion-weighted imaging. The median and range of duration from randomization to stroke recurrence was 1.5 (1-6) days. Patients with watershed infarction had higher risk of stroke recurrence than those without (17.20% vs. 6.34%) within the first week after initial stroke; the hazard ratio (95% confidence interval) was 2.799 (1.536-5.101) adjusted by age, sex, smoking, body mass index, medical history, time to randomization, open-label aspirin dose at first day, single or dual antiplatelet therapy, National Institutes of Health Stroke Scale score at randomization, in-hospital treatment and white matter lesions, P < 0.001. There was no interaction between antiplatelet therapy and the presence of watershed infarction (P = 0.544). CONCLUSIONS: Minor stroke with watershed infarction has high recurrent risk in the first week. Dual antiplatelet therapy may be safely implemented, yet watershed infarction mechanisms of hypoperfusion and emboli may not be addressed.

Endovascular treatment decision-making in acute ischemic stroke patients with large vessel occlusion and low National Institutes of Health Stroke Scale: insights from UNMASK EVT, an international multidisciplinary survey.

PURPOSE: Many stroke patients with large vessel occlusion present with a low National Institutes of Health Stroke Scale (NIHSS). There is currently no level 1A recommendation for endovascular treatment (EVT) for this patient subgroup. From a physician's standpoint, the deficits might only be slight, but they are often devastating from a patient perspective. Furthermore, early neurologic deterioration is common. The purpose of this study was to explore endovascular treatment attitudes of physicians in acute ischemic stroke patients presenting with low admission NIHSS. METHODS: In an international cross-sectional survey among stroke physicians, participants were presented the scenario of a 76-year-old stroke patient with an admission NIHSS of 2. Survey participants were then asked how they would treat the patient (A) given their current local resources, and (B) under assumed ideal conditions, i.e., without external (monetary or infrastructural) constraints. Overall, country-specific and specialty-specific decision rates were calculated and clustered multivariable logistic regression performed to provide adjusted measures of effect size. RESULTS: Two hundred seventy-five participants (150 neurologists, 84 interventional neuroradiologists, 30 neurosurgeons, 11 affiliated to other specialties) from 33 countries provided their treatment approach to this case scenario. Most physicians favored an endovascular treatment approach, either combined with intravenous alteplase (55.3% under assumed ideal and 52.0% under current working conditions) or as single treatment (11.3% under assumed ideal and 8.4% under current conditions). CONCLUSION: Despite the limited evidence for endovascular therapy in acute stroke patients with low NIHSS, most physicians in this survey decided to proceed with endovascular therapy. A randomized controlled trial seems warranted.

Effect of alteplase versus aspirin plus clopidogrel in acute minor stroke.

Background and purpose: The optimal treatment for acute ischemic stroke with mild neurologic deficits is unclear. We aimed to compare the efficacy and safety of alteplase versus dual-antiplatelet therapy in acute minor stroke.Methods: We performed a retrospective cohort study of patients with minor ischemic stroke and National Institutes of Health Stroke Scale scores ≤5 presenting within 24 h from last seen normal. Patients were divided into intravenous alteplase or dual-antiplatelet therapy group. The primary outcome was a modified Rankin Scale (mRS) score of 0 or 1 at 90 days. Secondary outcomes included mRS score at 7 days, and composite outcome of vascular events within 90 days. The safety outcome was any intracranial hemorrhage (ICH) according to the ECASS II criteria. Clinical outcomes were compared using a multivariable logistic regression after adjusting for confounding factors. We then performed the propensity score matching as a sensitivity analysis.Results: Two hundred twenty-eight patients met the eligibility criteria were included for analysis between January 2015 and September 2018. In the aspirin-clopidogrel group, 109 patients (91.6%) achieved a favorable functional outcome at 3-month versus 85(78.0%) in the alteplase group (OR 4.463, 95%CI 1.708-11.662, p = .002). The difference of the composite outcome of vascular events were not statistical significance between the two groups (p > .05). Asymptomatic ICH occurred in 0.8% patients who received aspirin-clopidogrel, as compared with 3.7% patients in alteplase group (p = .030).Conclusions: Patients treated with dual-antiplatelet therapy with acute minor ischemic stroke had greater functional outcome at 3 months compared with patients who received alteplase therapy.Classification of evidence: This study provides Class IV evidence that dual-antiplatelet therapy is superior to alteplase for achieving a better functional outcome and does not increase the risk of hemorrhage in acute minor ischemic stroke.

Early Cognitive Impairment after Minor Stroke: Associated Factors and Functional Outcome.

OBJECTIVES: Evaluation of cognitive status is not performed routinely in the acute stroke setting. This study aimed to evaluate the frequency of early cognitive impairment in patients with minor ischemic stroke, analyze the factors associated with early cognitive impairment, and assess functional outcomes. METHODS: In this prospective study, 112 consecutive patients with acute minor ischemic stroke were enrolled. Neuroimages were assessed for semiquantitative evaluation of brain atrophy and small vessel disease (SVD) markers. Cognitive performance was measured within 5 days of onset using Montreal Cognitive Assessment (MoCA) scores. Functional outcome analyses were adjusted for demographic variables, premorbid cognitive status, education level, vascular risk factors, neuroimaging characteristics, stroke severity, and MoCA scores. RESULTS: The median MoCA score was 22, and 63% of patients had cognitive impairment. Factors independently associated with cognitive impairment were education (odds ratios [OR], .79; confidence intervals [CI], .63-.99), smoking (OR, .26; 95%CI, .073-.89), and temporal horn atrophy (OR, 4.73; 95% CI, 1.66-13.49). Factors independently associated with poor functional outcome were total MoCA score (OR, .78; 95%CI, .62-.95) and the sum of 4 MoCA subscores (visuospatial/executive, attention, language, and orientation; OR, .72; 95%CI, .53-.92). The cutoff value of the sum of 4 MoCA subscores for predicting poor outcome was 13 points with 76.5% sensitivity and 81.1% specificity. CONCLUSIONS: Early cognitive impairment was common after minor ischemic stroke and was associated with preexisting temporal horn atrophy but not SVD markers. The sum of 4 MoCA subscores was useful in predicting the functional outcome.