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H MG-CoA reductase inhibitors (ie, statins) constitute a cornerstone in primary and secondary prevention of ischemic stroke.1 In addition to dose-dependent cholesterol-lowering effects, statins have dose-dependent pleiotropic effects, including antithrombotic properties, and were shown to modify fibrinolytic balance toward a more profibrinolytic state.2 These properties may contribute to the beneficial impact of statins on outcome after ischemic stroke, which was recently confirmed in a large meta-analysis. 3 However, studies on patients receiving intravenous thrombolysis (IVT) reported conflicting results, and the effects on outcome seemed to be attenuated. [3][4][5] Rather, there has been a discussion that patients with previous statin use might be more likely to develop symptomatic intracerebral hemorrhage (sICH) after IVT. [5][6][7] A recently published meta-analysis showed a positive association of statins with IVT-related sICH, but the statistical significance was lost if only studies with adjusted analyses were included. 5Previous studies investigating the impact of statins on outcome and sICH after IVT lacked information about statin dose. Using pooled data from 2 large European thrombolysis registries, we aimed to analyze the effects of statin dose on risk of sICH and outcome after IVT.Background and Purpose-The aim of our study was to assess whether statins have dose-dependent effects on risk of symptomatic intracerebral hemorrhage (sICH) and outcome after intravenous thrombolysis for ischemic stroke. Methods-We pooled data from 2 European intravenous thrombolysis registries. Statin doses were stratified in 3 groups according to the attainable lowering of cholesterol levels (low dose: simvastatin 20 mg or equivalent; medium dose: simvastatin 40 mg or equivalent; and high dose: simvastatin 80 mg or equivalent). sICH was defined according to the European Cooperative Acute Stroke Study. Modified Rankin Scale score 0 to 2 at 3 months was considered a favorable outcome. Results-Among 1446 patients analyzed (median age, 75 years; median initial National Institutes of Health Stroke Scale score, 11; 54% men), 317 (22%) used statins before intravenous thrombolysis. Of them, 120 patients had low-dose, 134 medium-dose, and 63 high-dose statin therapy. sICH occurred in 4% of patients (n=53). Frequency of sICH was 2%, 6%, and 13% in patients with low-, medium-, and high-dose statin treatment, respectively (P<0.01). Adjusted odds ratio (OR) for sICH was 2. 4,9,10 All patients were treated in a specialized stroke unit for ≥24 hours. The registries were approved by the respective ethics committees.Baseline characteristics, including age, sex, and medical history (atrial fibrillation, coronary artery disease, current smoking, diabetes mellitus, hypertension, and previous stroke), were collected. Stroke severity was assessed via the National Institutes of Health Stroke Scale (NIHSS) by certified raters. Moreover, onsetto-treatment time and blood pressure on admission were recorded. Laboratory measures included glucose l...

A first episode of AF is detected in up to one third of cryptogenic stroke and in up to one fourth of ESUS patients during long-term monitoring. AF prevalence correlates to patient selection, duration, and quality of ECG monitoring. Higher rates of AF were reported in stroke patients with left atrial pathology, specific ECG alterations, or increased natriuretic peptides. While AF detection impacts on medical stroke prevention in the vast majority of patients, patient selection for prolonged monitoring is largely left at the physician's discretion. AF detection after cryptogenic stroke or ESUS is a frequent, potentially causal condition. Whether subsequent oral anticoagulation may improve outcome remains open.

All patients with stroke who received iv-tPA within 4.5 hours of symptom onset at our institution between January 2005 and August 2012 were included. Iv-tPA was administered according to European license. The register has been described in detail elsewhere.7 Serum creatinine levels (mmol/L) were measured for each patient on admission. Renal function was assessed by estimated GFR using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula.8 Patients on dialysis were excluded. GFR values were dealt with as (1) centered data (cGFR) to test for linear association, (2) centered and squared data (csGFR) to test for curvilinear association, and (3) dichotomized data. Categorization was according to International Classification of Diseases for RI: no RI (GFR ≥90 mL/min), mild RI (GFR=60-89 mL/min), moderate RI (GFR=30-59 mL/min), and severe RI (GFR <30 mL/min). For univariate comparisons, GFR was dichotomized at 90 mL/min (any RI) and 30 mL/min (severe RI).Sociodemographic data, vascular risk factors, laboratory data, medication, OTT, and NIHSS were collected from the medical records. Outcome measures were sICH defined according to the European Cooperative Acute Stroke Study (ECASS) criteria (any Background and Purpose-Patients with renal impairment (RI) have an increased risk of both thrombotic and hemorrhagic events. We aimed to clarify whether RI increases the risk of intracerebral hemorrhage (ICH) after intravenous thrombolysis with recombinant tissue plasminogen activator. Methods-Patients who received intravenous thrombolysis with recombinant tissue plasminogen activator within 4.5 hours of symptom onset were retrospectively analyzed. Creatinine levels on admission served to calculate glomerular filtration rate (GFR) to estimate RI according to International Classification of Diseases criteria. Effect of RI on symptomatic ICH (sICH) was assessed using dichotomized (GFR <90 and <30 mL/min) and continuous GFR (centered data to test for linear and centered and squared data to test for curvilinear association). Results-Of the 740 patients included, 83% had any RI (GFR <90 mL/min) and 5% had severe RI (GFR <30 mL/mL); 4.6% experienced sICH. Univariate comparisons revealed higher prevalence of sICH in patients with severe RI (P<0.01) but not with any RI. GFR as a continuous variable (centered and squared) was also associated with sICH (P=0.02), but GFR on its own was not. Severe RI and GFR (centered and squared) remained independently associated with sICH in multiple regression analyses. Conclusions-Severe RI (GFR <30 mL/min) is associated with sICH after intravenous thrombolysis with recombinant tissue plasminogen activator. The association is curvilinear. Severe RI must be taken into account when balancing the risk-benefit ratio of intravenous thrombolysis with recombinant tissue plasminogen activator. (Stroke. 2013;44:3217-3219.)

Background and purpose Relative signal intensity of acute ischemic stroke lesions in fluid-attenuated inversion recovery (FLAIR-rSI) magnetic resonance imaging is associated with time elapsed since stroke onset with higher intensities signifying longer time intervals. In the randomized controlled WAKE-UP trial, intravenous alteplase was effective in patients with unknown onset stroke selected by visual assessment of DWI-FLAIR mismatch, i.e., in those with no marked FLAIR hyperintensity in the region of the acute DWI lesion. In this post-hoc analysis, we investigated if quantitatively measured FLAIR-rSI modifies treatment effect of intravenous alteplase. Methods FLAIR-rSI of stroke lesions was measured relative to signal intensity in a mirrored region in the contralesional hemisphere. The relationship between FLAIR-rSI and treatment effect on functional outcome assessed by the modified Rankin Scale (mRS) after 90 days was analysed by binary logistic regression using different endpoints, i.e., favourable outcome defined as mRS 0-1, independent outcome defined as mRS 0-2, ordinal analysis of mRS scores (shift analysis). All models were adjusted for NIHSS at symptom onset and stroke lesion volume. Results FLAIR-rSI was successfully quantified in stroke lesions in 433 patients (86% of 503 patients included in WAKE-UP). Mean FLAIR-rSI was 1.06 (SD 0.09). Interaction of FLAIR-rSI and treatment effect was not significant for mRS 0-1 (p=0.169) and shift analysis (p=0.086), but 2 reached significance for mRS 0-2 (p=0.004). We observed a smooth continuing trend of decreasing treatment effects in relation to clinical endpoints with increasing FLAIR-rSI. Conclusion In patients in whom no marked parenchymal FLAIR hyperintensity was detected by visual judgement in the WAKE-UP trial, higher FLAIR-rSI of DWI lesions was associated with decreased treatment effects of intravenous thrombolysis. This parallels the known association of treatment effect and elapsing time of stroke onset.