MRI-based Algorithm for Acute Ischemic Stroke Subtype Classification

Park

Choi

et al. 2017

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Background and Purpose-We compared baseline characteristics and outcomes at 3 months between patients with minor anterior circulation infarction (ACI) versus minor posterior circulation infarction (PCI), including the influence of large vessel disease on outcomes. Methods-This study is an analysis of a prospective multicenter registry database in South Korea. Eligibility criteria were patients with ischemic stroke admitted within 7 days of stroke onset, lesions in either anterior or posterior circulation, and National Institutes of Health Stroke Scale score of ≤4 at baseline. Patients were divided into 4 groups for further analysis: minor ACI with and without internal carotid artery/middle cerebral artery large vessel disease and minor PCI with and without vertebrobasilar large vessel disease. Results-A total of 7178 patients (65.2±12.6 years) were analyzed in this study, and 2233 patients (31.1%) had disability (modified Rankin Scale score 2-6) at 3 months. Disability was 32.3% in minor PCI and 30.3% in minor ACI (P=0.07), and death was 1.3% and 1.5%, respectively (P=0.82). In a multivariable logistic regression analysis, minor PCI was significantly associated with disability at 3 months when compared with minor ACI (odds ratio, 1.23; 95% confidence interval, 1.09-1.37; P<0.001). In pairwise comparisons, minor PCI with vertebrobasilar large vessel disease was independently associated with disability at 3 months, compared with the other 3 groups. Conclusions-Our study showed that minor PCI exhibited more frequent disability at 3 months than minor ACI. Especially, the presence of vertebrobasilar large vessel disease in minor PCI had a substantially higher risk of disability. Our results suggest that minor PCI with vertebrobasilar large vessel disease could require more meticulous care and are important targets for further study.

Section: Data Collectionmentioning

confidence: 99%

Clinical Outcomes of Posterior Versus Anterior Circulation Infarction With Low National Institutes of Health Stroke Scale Scores

Park

Choi

et al. 2017

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“…The eligibility criteria for this study were as follows: (1) acute ischemic stroke with admission to a participating center within 48 hours of stroke onset between April 2008 and July 2013, (2) noncardioembolic ischemic stroke subtype according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria with minor modifications, 14,15 and (3) aspirin intake within 7 days before stroke onset for prevention of vascular events. We excluded patients who had anticoagulants during hospitalization or at discharge and who had no antithrombotic therapy at discharge.…”

Section: Subjectsmentioning

confidence: 99%

“…Baseline data, including the National Institutes of Health Stroke Scale (NIHSS) score, were collected from all patients, and the stroke subtypes were stratified according to the TOAST criteria after complete diagnostic profiling. 14,15 Data collection was described further in the online-only Data Supplement. The study subjects were divided into 3 groups according to antiplatelet therapy regimen at discharge; maintaining aspirin monotherapy (MA group), switching aspirin to nonaspirin antiplatelet agents (SA group), and adding other antiplatelet agents to aspirin (AA group).…”

Section: Data Collectionmentioning

confidence: 99%

Different Antiplatelet Strategies in Patients With New Ischemic Stroke While Taking Aspirin

Park

Choi

et al. 2016

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A spirin is a first line antiplatelet agent for the secondary prevention of ischemic stroke or transient ischemic attack.1 In addition, aspirin is recommended in national guidelines for primary prevention of vascular events in patients with multiple cardiovascular risk factors. 2,3With its low cost and easy accessibility, prophylacticBackground and Purpose-Selecting among different antiplatelet strategies when patients experience a new ischemic stroke while taking aspirin is a common clinical challenge, currently addressed by a paucity of data. Methods-This study is an analysis of a prospective multicenter stroke registry database from 14 hospitals in South Korea.Patients with acute noncardioembolic stroke, who were taking aspirin for prevention of ischemic events at the time of onset of stroke, were enrolled. Study subjects were divided into 3 groups according to the subsequent antiplatelet therapy strategy pursued; maintaining aspirin monotherapy (MA group), switching aspirin to nonaspirin antiplatelet agents (SA group), and adding another antiplatelet agent to aspirin (AA group). The primary study end point was the composite of stroke (ischemic and hemorrhagic), myocardial infarction, and vascular death up to 1 year after stroke onset. Results-A total of 1172 patients were analyzed for this study. Antiplatelet strategies pursued in study patients were MA group in 212 (18.1%), SA group in 246 (21.0%), and AA group in 714 (60.9%). The Cox proportional hazards regression analysis showed that, compared with the MA group, there was a reduction in the composite vascular event primary end point in the SA group (hazard ratio, 0.50; 95% confidence interval, 0.27-0.92; P=0.03) and in the AA group (hazard ratio, 0.40; 95% confidence interval, 0.24-0.66; P<0.001). Conclusions-This study showed that, compared with maintaining aspirin, switching to or adding alternative antiplatelet agents may be better in preventing subsequent vascular events in patients who experienced a new ischemic stroke while taking aspirin. Kim et al Antiplatelet Strategies in Prior Aspirin Users 129aspirin use is frequent in the middle-aged and elderly population. [4][5][6] Therefore, patients who suffer a new ischemic stroke while taking aspirin are frequently encountered in a daily practice. Antiplatelet management options in these patients are to maintain aspirin monotherapy, replace aspirin with other antiplatelet agents, such as clopidogrel, or add other antiplatelet agents to aspirin.1,7-10 However, both randomized trial and large-scale registry data to guide this decision are sparse. Accordingly, the most recent American Heart Association/American Stroke Association guideline states that there is no evidence that switching or combining antiplatelet agents reduces the risk of subsequent vascular events in patients who have had stroke while receiving aspirin (Class IIb, Level of Evidence C). 1A post hoc analysis of 838 patients, who have had a recent lacunar stroke while taking aspirin from the Secondary Prevention of Small Subcortical Strok...

“…The form included information on recanalization treatment (intravenous thrombolysis, endovascular treatment, or combined treatment) and antithrombotic treatment during hospitalization (antiplatelet agents, warfarin, low-molecular-weight heparin, or intravenous heparin) and after discharge (antiplatelet agents, warfarin, or novel oral anticoagulant). Demographics, vascular risk factors, prestroke medications, and stroke characteristics including stroke subtypes according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria with minor modifications 18 were obtained from the registry database.…”

Section: Ascertainment Of Information On Patient Characteristics and mentioning

confidence: 99%

Impact of Guidelines on Clinical Practice

Chung

Han

et al. 2016

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Background and Purpose-Since its introduction, controversy has existed about the administration of intravenous heparin for the treatment of acute ischemic stroke. We studied trends in the intravenous heparin use during a 6-year time period and the potential influence of clinical guidelines in national language on intravenous heparin administration in Korea. Methods-On the basis of a prospective nationwide multicenter stroke registry, we collected data on patients with acute ischemic stroke who arrived within 7 days of symptom onset during the time period 2008 to 2013. We studied patient demographics, prestroke medical history, stroke characteristics, and stroke treatment. Data from a total of 23 425 patients from 12 university hospitals or regional stroke centers were analyzed. Results-The administration of intravenous heparin steadily decreased throughout the study period: 9.7% in 2008, 10.9% in 2009, 9.4% in 2010, 6.0% in 2011, 4.7% in 2012, and 4.3% in 2013 (P for trend <0.001). The reduced intravenous heparin use was associated with moderate stroke severity, atrial fibrillation, and stroke of cardioembolic, other-, and undetermined etiology. In a multivariable logistic model, increase of 1 calendar year (odds ratio, 0.89; 95% confidence interval, 0.84-0.95; P<0.001) and release of clinical practice guidelines in Korean (odd ratio, 0.74; 95% confidence interval, 0.59-0.91; P<0.01) were independent factors associated with reduction in the frequency of intravenous heparin use. Conclusions-Use of intravenous heparin for acute ischemic stroke treatment has decreased in Korea, and this change may be attributable to the spread and successful implementation of regional clinical practice guidelines. (Stroke.