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ABSTRACT: The risk of recurrent stroke in the modern era of secondary stroke prevention is not well defined. Several prediction models, including the Stroke Prognostic Instrument-II (SPI-II), have been created to identify patients at highest risk, but their performance in modern populations has been infrequently tested. We aimed to assess the 1-year risk of recurrence after hospital discharge in a recent, large, community-based cohort of patients with ischemic stroke and to validate the SPI-II prediction model in this cohort.
From 2004 through 2006, 5575 patients with acute ischemic stroke were prospectively identified and followed for recurrent events. Kaplan-Meier statistics were used to analyze the cumulative incidence of recurrent ischemic stroke. Harrell c-statistic was calculated to determine the performance of SPI-II in predicting stroke or death at 1 year, and the log-rank test was used to compare the differences among low-, middle-, and high-risk groups.
Among 5575 patients with ischemic stroke, recurrence was observed in 221 during the subsequent year. Kaplan-Meier estimates of cumulative rates of recurrent stroke were 2.5%, 3.6%, and 4.8% at 3, 6, and 12 months, respectively. Rates of stroke or death for SPI-II in the low-, middle-, and high-risk groups were 8.2%, 24.5%, and 35.6%, respectively (trend, P=0.001). The c-statistic for SPI-II was 0.62 (95% CI, 0.61-0.64).
The modern 1-year rate of recurrent stroke after hospital discharge is low but still substantial at 4.8%. SPI-II is a modestly effective tool in identifying patients with ischemic stroke at highest risk of developing recurrence or death.
Stroke 09/2011; 42(12):3392-6. · 5.73 Impact Factor
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ABSTRACT: Stroke is the fourth killer and number one cause of adult disability in the United States. The estimated direct and indirect costs of stroke care in this country are $68.9 billion for 2009. The prevalence of stroke and its cost will undoubtedly rise as the aging population increases. In addition, stroke incidence and mortality are increasing in less developed countries in which the lifestyles and population restructuring are rapidly changing. More population-based research to assess incidence, risk factors, and outcomes are needed in these countries. Epidemiologic studies can help identify groups of individuals or regions at higher risk for stroke. They can also help us better understand the natural history of certain conditions and therefore push the direction of therapeutic investigations. Furthermore, the study of trends across different time periods and different populations can help investigators evaluate the effects of stroke care programs and treatment options.
Journal of the American Society for Experimental NeuroTherapeutics 06/2011; 8(3):319-29. · 5.38 Impact Factor
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Yilong Wang,
Xiaoling Liao,
Xingquan Zhao,
David Z Wang,
Chunxue Wang, Mai N Nguyen-Huynh,
Yong Zhou,
Liping Liu,
Xianwei Wang,
Gaifen Liu,
Hao Li,
Yongjun Wang
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ABSTRACT: Little is known about intravenous recombinant tissue plasminogen activator (rtPA) use in China. By accessing the Chinese National Stroke Registry (CNSR), the rate of intravenous rtPA use was reviewed. We specifically examined the issues of prehospital and in-emergency department delay and compared them with the published data from developed countries.
Funded by Chinese government, CNSR is the only nationwide stroke registry that includes 132 urban hospitals. All patients eligible for intravenous rtPA were included for analysis. We then compared the onset-to-needle time and door-to-needle time in the emergency department in China with those in developed countries.
From September 2007 to August 2008, 14,702 patients with ischemic stroke were entered into CNSR. Among 11,675 patients with known time of stroke onset, 2514 (21.5%) presented to the emergency department within 3 hours, 1469 (12.6%) were eligible for thrombolytic treatment, and 284 (2.4%) were finally treated, 181 (1.6%) of them with intravenous rtPA. The median onset-to-needle time was 180 (interquartile range, 150 to 228) minutes; the median door-to-needle time was 116 (interquartile range, 70 to 150) minutes; the median imaging-to-needle time was 90 (interquartile range, 60 to 129) minutes. Patients who were younger, presented to the emergency department quicker, with higher National Institutes of Health Stroke Scale scores, having higher income, and better education had a better chance of receiving intravenous rtPA.
Approximately 1 in 5 patients with stroke presenting within 3 hours received thrombolytic therapy. The onset-to-needle time, door-to-needle time, and especially imaging-to-needle time were significantly longer than those in developed countries. Reducing prehospital and in-emergency department response time would help increase intravenous rtPA use in China.
Stroke 06/2011; 42(6):1658-64. · 5.73 Impact Factor
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Yongjun Wang,
Liying Cui,
Xunming Ji,
Qiang Dong,
Jinsheng Zeng,
Yilong Wang,
Yong Zhou,
Xingquan Zhao,
Chunxue Wang,
Liping Liu, Mai N Nguyen-Huynh,
S Claiborne Johnston,
Lawrence Wong,
Hao Li
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ABSTRACT: As a leading cause of severe disability and death, stroke places an enormous burden on the health care system in China. There are limited data on the pattern of current medical practice and quality of care delivery for stroke patients at the national level.
The nation-wide prospective registry, China National Stroke Registry, will be considered with regard to its design, progress, geographic coverage, and hospital and patient characteristics.
Between September 2007 and August 2008, the China National Stroke Registry recruited consecutive patients with diagnoses of acute cerebrovascular events from 132 hospitals that cover all 27 provinces and four municipalities (including Hong Kong region) in China. Clinical data were collected prospectively using paper-based registry forms. Patients were followed for clinical and functional outcomes through phone interviews at three, six, 12, 18, and 24 months after disease onset.
These patients (n=21,902) were 63.8 years of age on average, and 39% were females. Ischaemic stroke was predominant (66.4%), and the other subtypes were intracerebral haemorrhage (23.4%), subarachnoid haemorrhage (3.4%), and transient ischaemic attack (6.2%).
The China National Stroke Registry is a large-scale nationwide registry in China. Rich data collected from this prospective registry may provide the opportunity to evaluate the quality of care for stroke patients in China.
International Journal of Stroke 02/2011; 6(4):355-61. · 2.38 Impact Factor
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ABSTRACT: clinical scores help predict outcome after transient ischemic attack (TIA), and imaging studies may improve the accuracy of predictions. Intracranial large vessel occlusion (LVO) predicts poor outcome after stroke, but the natural history of symptomatic intracranial LVO in patients with TIA is unknown.
we studied patients presenting with TIA in the STOP Stroke Study, a prospective imaging-based study of stroke outcomes. All patients underwent brain CTA. If an intracranial vascular occlusion was found in an appropriate territory to account for clinical findings, then it was judged to be a symptomatic LVO. Baseline characteristics, follow-up events, and outcomes were collected. Characteristics of patients with and without LVO were compared using χ(2) and t tests. Predictors of LVO were analyzed by univariate and multivariate analysis. LVO was assessed as a predictor of asymptomatic outcome (modified Rankin scale [mRS] score, 0), poor outcome (mRS score ≤ 3), and increase in mRS score over the study period.
of 97 patients with TIA, 13 (13%) had symptomatic intracranial LVO. Patients with LVO had higher baseline NIHSS on emergency department arrival, which was an independent predictor of LVO (OR, 1.15 per point; 95% CI, 1.02-1.29; P=0.02). Patients with LVO were more likely to have an increase in mRS score during the 90-day follow-up (P=0.03). LVO independently predicted an increase in mRS score (OR, 4.76; 95% CI, 1.23-18.43; P=0.02) and was a borderline predictor of poor outcome (mRS score ≥ 3; OR, 5.07; 95% CI, 0.92-28.03; P=0.06).
LVO is found in >1 in 10 patients presenting with TIA and predicts a decline in functional status, likely attributable to new brain ischemia.
Stroke 01/2011; 42(1):44-7. · 5.73 Impact Factor
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ABSTRACT: Gender differences in carotid endarterectomy (CEA) rates after transient ischemic attack are not well studied, although some reports suggest that eligible men are more likely to have CEA than women after stroke.
We retrospectively identified all patients diagnosed with transient ischemic attack and >or=70% carotid stenosis on ultrasound in 2003 to 2004 from 19 emergency departments. Medical records were abstracted for clinical data; 90-day follow-up events, including stroke, cardiovascular events, or death; CEA within 6 months; and postoperative 30-day outcomes. We assessed gender as a predictor of CEA and its complications adjusting for demographic and clinical variables as well as time to CEA between groups.
Of 299 patients identified, 47% were women. Women were older with higher presenting systolic blood pressure and less likely to smoke or to have coronary artery disease or diabetes. Fewer women (36.4%) had CEA than men (53.8%; P=0.004). Reasons for withholding surgical treatment were similar in women and men, and there were no differences in follow-up stroke, cardiovascular event, postoperative complications, or death. Time to CEA was also significantly delayed in women.
Women with severe carotid stenosis and recent transient ischemic attack are less likely to undergo CEA than men, and surgeries are more delayed.
Stroke 09/2010; 41(9):1891-5. · 5.73 Impact Factor
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ABSTRACT: 1. Little is known about the prevention of secondary stroke in China. In the present study, we assessed the status of antithrombotic management of stroke patients in clinics across China. 2. A cross-sectional survey was conducted in 19 urban neurological clinics. All subjects diagnosed with ischaemic stroke (IS) or transient ischaemic attack (TIA) were enrolled consecutively in the study. Face-to-face interviews were conducted by research assistants using questionnaires on the day of enrollment. The data recorded included demographic and clinical characteristics, medication and reasons for not using medication. Independent predictors for the prescription of antiplatelet drugs were determined using multivariate logistic regression models. 3. Of the 2283 patients with IS or TIA enrolled in the study (34.7% women; mean ( +/- SD) age 65.8 +/- 11.6 years), 1719 (75.3%) had a prescription for antiplatelet therapy. Of the 108 patients with atrial fibrillation, only 14 (13.0%) were receiving warfarin therapy. The main independent factors significantly associated with being on antiplatelet therapy were having basic health insurance (odds ratio (OR) 1.47; 95% confidence interval (CI) 1.09-1.99), government insurance and labour insurance (OR 1.63; 95% CI 1.03-2.59) and a monthly income of > 500 yuan (US$66.70; OR 2.14; 95% CI 1.51-3.03). Being older (OR 0.70; 95% CI 0.50-0.99) and having a severe disability (OR 0.68; 95% CI 0.49-0.97) were associated with lower odds of receiving antiplatelet therapy. 4. Based on the survey results, adherence to guidelines for antithrombotic management in neurological clinics in China is poor. The main reasons contributing to the less than optimal management of stroke patients include negative attitudes among neurologists, a lack of medical insurance, a lower income and being elderly and/or severely disabled.
Clinical and Experimental Pharmacology and Physiology 04/2010; 37(8):775-81. · 1.85 Impact Factor
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ABSTRACT: Digital subtraction angiography (DSA) is regarded as the gold standard in assessing degree of stenosis in intracranial vessels. However, it is invasive and can only be carried out at specialized centers. We sought to compare CT angiography (CTA) to DSA for detection and measurement of stenosis in large intracranial arteries.
We identified all subjects admitted with ischemic stroke or transient ischemic attack and with CTA and DSA studies of good quality completed within 30 days of each other between April 2000 and May 2006 at a single medical center. Two readers blinded to clinical information reviewed each CTA and DSA independently. Each reader located and measured stenosis of 15 prespecified large intracranial arterial segments per study at the same level of magnification. These stenotic lesions were most likely atherosclerotic in etiology. All measurements were made with Wiha digiMax 6" digital calipers. The degree of stenosis was calculated using the published method for the Warfarin-Aspirin Symptomatic Intracranial Disease study. All disagreements of greater than 10% were reviewed by a third reader who decided between the 2 prior measurements. Segments were excluded from analyses if they were judged to be congenitally hypoplastic or seen only through collaterals or cross-filling. Intraclass correlation, sensitivity, and specificity were calculated using DSA as the reference standard.
Forty-one pairs of CTA and DSAs from 41 patients were reviewed. CTAs were completed within 28 days before 13 days after DSA, with a median of 1 day. A total of 475 pairs of major intracranial arterial segment were analyzed. Intraclass correlation between degree of stenosis based on CTA and DSA for all segments was 0.98 (P=0.001). CTA detected large arterial occlusion with 100% sensitivity and specificity. For detection of >or=50% stenosis, CTA had 97.1% sensitivity and 99.5% specificity. To detect all lesions >or=50% as determined by DSA, the cut off point on CTA appeared to be at >or=30%, with a false-positive rate of 2.4%.
Compared to DSA, CTA has high sensitivity and specificity for detecting >or=50% stenosis of large intracranial arterial segments. CTA is minimally invasive and may be a useful screening tool for intracranial arterial disease and occlusion.
Stroke 04/2008; 39(4):1184-8. · 5.73 Impact Factor
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ABSTRACT: Stroke and transient ischemic attack (TIA) share similar risk factors and methods of evaluation and secondary prevention. As neurological symptoms resolve after TIA, however, there has been a widely held perception that urgent evaluation and treatment following TIA are unnecessary. In actual fact, it is becoming increasingly clear that the short-term stroke risk after TIA is very high. Recent studies have identified independent predictors that indicate which patients are at highest risk of recurrent ischemic events. These risk scores could enable physicians to target appropriate patients for urgent care. In this Review, we summarize the recent literature on stroke risk after TIA and risk stratification, and recently published guidelines on evaluation and treatment.
Nature Clinical Practice Cardiovascular Medicine 07/2007; 4(6):310-8. · 7.04 Impact Factor
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ABSTRACT: We aimed to validate two similar existing prognostic scores for early risk of stroke after transient ischaemic attack (TIA) and to derive and validate a unified score optimised for prediction of 2-day stroke risk to inform emergency management.
The California and ABCD scores were validated in four independent groups of patients (n=2893) diagnosed with TIA in emergency departments and clinics in defined populations in the USA and UK. Prognostic value was quantified with c statistics. The two groups used to derive the original scores (n=1916) were used to derive a new unified score based on logistic regression.
The two existing scores predicted the risk of stroke similarly in each of the four validation cohorts, for stroke risks at 2 days, 7 days, and 90 days (c statistics 0.60-0.81). In both derivation groups, c statistics were improved for a unified score based on five factors (age >or=60 years [1 point]; blood pressure >or=140/90 mm Hg [1]; clinical features: unilateral weakness [2], speech impairment without weakness [1]; duration >or=60 min [2] or 10-59 min [1]; and diabetes [1]). This score, ABCD(2), validated well (c statistics 0.62-0.83); overall, 1012 (21%) of patients were classified as high risk (score 6-7, 8.1% 2-day risk), 2169 (45%) as moderate risk (score 4-5, 4.1%), and 1628 (34%) as low risk (score 0-3, 1.0%).
Existing prognostic scores for stroke risk after TIA validate well on multiple independent cohorts, but the unified ABCD(2) score is likely to be most predictive. Patients at high risk need immediate evaluation to optimise stroke prevention.
The Lancet 01/2007; 369(9558):283-92. · 38.28 Impact Factor
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S Claiborne Johnston, Mai N Nguyen-Huynh,
Miriam E Schwarz,
Kate Fuller,
Christina E Williams,
S Andrew Josephson,
Graeme J Hankey,
Robert G Hart,
Steven R Levine,
Jose Biller, [......],
Ralph L Sacco,
L Jaap Kappelle,
Peter J Koudstaal,
Julien Bogousslavsky,
Louis R Caplan,
Jan van Gijn,
Ale Algra,
Peter M Rothwell,
Harold P Adams,
Gregory W Albers
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ABSTRACT: Transient ischemic attacks are common and important harbingers of subsequent stroke. Management varies widely, and most published guidelines have not been updated in several years. We sought to create comprehensive, unbiased, evidence-based guidelines for the management of patients with transient ischemic attacks.
Fifteen expert panelists were selected based on objective criteria, using publication metrics that predicted nomination by practitioners in the field. Prior published guidelines were identified through systematic review, and recommendations derived from them were rated independently for quality by the experts. Highest quality recommendations were selected and subsequently edited by the panelists using a modified Delphi approach with multiple iterations of questionnaires to reach consensus on new changes. Experts were provided systematic reviews of recent clinical studies and were asked to justify wording changes based on new evidence and to rate the final recommendations based on level of evidence and quality. No expert was allowed to contribute to recommendations on a topic for which there could be any perception of a conflict of interest.
Of 257 guidelines documents identified by systematic review, 13 documents containing 137 recommendations met all entry criteria. Six iterations of questionnaires were required to reach consensus on wording of 53 final recommendations. Final recommendations covered initial management, evaluation, medical treatment, surgical treatment, and risk factor management.
The final recommendations on the care of patients with transient ischemic attacks emphasize the importance of urgent evaluation and treatment. The novel approach used to develop these guidelines is feasible, allows for rapid updating, and may reduce bias.
Annals of Neurology 10/2006; 60(3):301-13. · 11.09 Impact Factor
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PhD S. Claiborne Johnston MD, Mai N. Nguyen-Huynh MD,
Miriam E. Schwarz BS,
Kate Fuller MA,
MS Christina E. Williams BA,
S. Andrew Josephson MD,
MD Graeme J. Hankey MBBS,
Robert G. Hart MD,
Steven R. Levine MD,
Jose Biller MD, [......],
MS Ralph L. Sacco MD,
L. Jaap Kappelle MD,
Peter J. Koudstaal MD,
Julien Bogousslavsky MD,
Louis R. Caplan MD,
Jan van Gijn MD,
Ale Algra MD,
PhD Peter M. Rothwell MD,
Harold P. Adams MD,
Gregory W. Albers MD
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ABSTRACT: Objective
Transient ischemic attacks are common and important harbingers of subsequent stroke. Management varies widely, and most published guidelines have not been updated in several years. We sought to create comprehensive, unbiased, evidence-based guidelines for the management of patients with transient ischemic attacks.Methods
Fifteen expert panelists were selected based on objective criteria, using publication metrics that predicted nomination by practitioners in the field. Prior published guidelines were identified through systematic review, and recommendations derived from them were rated independently for quality by the experts. Highest quality recommendations were selected and subsequently edited by the panelists using a modified Delphi approach with multiple iterations of questionnaires to reach consensus on new changes. Experts were provided systematic reviews of recent clinical studies and were asked to justify wording changes based on new evidence and to rate the final recommendations based on level of evidence and quality. No expert was allowed to contribute to recommendations on a topic for which there could be any perception of a conflict of interest.ResultsOf 257 guidelines documents identified by systematic review, 13 documents containing 137 recommendations met all entry criteria. Six iterations of questionnaires were required to reach consensus on wording of 53 final recommendations. Final recommendations covered initial management, evaluation, medical treatment, surgical treatment, and risk factor management.InterpretationThe final recommendations on the care of patients with transient ischemic attacks emphasize the importance of urgent evaluation and treatment. The novel approach used to develop these guidelines is feasible, allows for rapid updating, and may reduce bias. Ann Neurol 2006
Annals of Neurology 08/2006; 60(3):301 - 313. · 11.09 Impact Factor
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ABSTRACT: A 24-hour hospitalization for TIA could be cost-effective simply by increasing the likelihood that patients will receive tissue plasminogen activator if a stroke occurs. The authors performed a cost-utility analysis of 24-hour hospitalization for patients diagnosed with recent TIA. The overall cost-effectiveness ratio was 55,044 dollars per quality-adjusted life-year, a value considered borderline cost-effective. For patients with higher risk of stroke, admission was cost-effective.
Neurology 01/2006; 65(11):1799-801. · 8.31 Impact Factor
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ABSTRACT: Classically, a transient ischemic attack (TIA) has been defined as an acute episode of neurologic symptoms lasting less than 24 hours attributed to focal ischemia in a vascular distribution of the brain or retina. Stroke and TIA share similar risk factors, evaluation, and secondary prevention. However, evaluation of patients with TIA has traditionally lacked the same urgency that has been directed to acute stroke, probably because patients with TIA are at baseline neurologically when the diagnosis is made. Recently, several studies have found a high risk of stroke shortly after TIA. Furthermore, recent evidence suggests that early recovery from ischemia actually is associated with greater instability. Identifying patients with the highest risk of recurrent ischemic events for urgent evaluation and intervention is key in secondary stroke prevention. This article reviews the current literature on new concepts about TIA, subsequent risk of stroke, and guidelines on evaluation and treatment.
Current Neurology and Neuroscience Reports 03/2005; 5(1):13-20. · 3.45 Impact Factor
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ABSTRACT: In Asia, stroke incidence varies dramatically from country to country. Little is known about stroke incidence in Asians/Pacific Islanders in the US, where regional heterogeneity in Asian/Pacific Islander sub-populations is great. We sought to characterize both the national and regional incidences of first and recurrent hospitalized acute ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage in Asians/Pacific Islanders compared to non-Hispanic whites.
We used the National Inpatient Sample of the 1997 Healthcare Cost and Utilization Project. It is a 20% stratified sample of hospitalizations to nonfederal hospitals in the US. National and regional projections were made using sampling weights specific for patients and hospitals. We identified stroke subtypes using previously validated ICD-9 codes. Age-adjusted incidence rates were calculated using the direct method with the US population in 2000 as the standard.
There were 169,386 stroke hospitalizations in the database. Nationally, compared to whites, Asians/Pacific Islanders were more likely to have subarachnoid hemorrhage (incidence rate ratio {RR} female: 1.53, 95% CI 1.41-1.65; male RR: 1.13, 95% CI 1.00-1.27) and intracerebral hemorrhage (female RR 1.29, 95% CI 1.22-1.36; male RR: 1.58, 95% CI 1.50-1.67). However, when examined by geographic regions, Asians/Pacific Islanders had higher incidence rates of subarachnoid hemorrhage and intracerebral hemorrhage predominantly in the West, and lower rates of stroke elsewhere.
Stroke incidence varies 3-fold among Asians/Pacific Islanders residing in different US regions. Geographic variation is less dramatic in whites. Whether genetic or cultural differences are responsible for dramatic heterogeneity among Asian/Pacific Islander populations is unclear and deserves further study.
BMC Neurology 02/2005; 5:21. · 2.17 Impact Factor
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Neurology 12/2003; 61(10):1455-6. · 8.31 Impact Factor
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ABSTRACT: Spontaneous recanalization of an acutely occluded internal carotid artery (ICA) is an important phenomenon, the natural history and incidence of which have been incompletely studied. Although conventional catheter arteriography remains the gold standard for distinguishing total arterial occlusion from hairline residual lumen, CT angiography (CTA) is able to make this distinction noninvasively and more sensitively than either unenhanced MR angiography or ultrasound. The purpose of this report is to raise awareness of spontaneous recanalization and to demonstrate the possible use of CTA in following up cases of ICA occlusion.
We describe here 2 cases of acute cervical ICA occlusion seen on CTAs done at our institution.
Follow-up CTAs in both cases showed spontaneous recanalization of the ICA requiring ipsilateral carotid endarterectomy within 1 month of the initial presentation.
CTA, an accurate, rapid, and less invasive modality than conventional catheter arteriography, can be used to serially monitor anticoagulated patients with new-onset ICA occlusion for potential spontaneous vascular recanalization. The ability to conveniently assess ICA patency not only may influence management of individual patients but also could help us better establish the true incidence of spontaneous carotid recanalization in future studies.
Stroke 05/2003; 34(4):1032-4. · 5.73 Impact Factor
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Editorial Team,
S Claiborne Johnston, Mai N Nguyen-Huynh,
Miriam E Schwarz,
Kate Fuller,
Christina E Williams,
S Andrew Josephson,
Graeme J Hankey,
Robert G Hart,
Steven R Levine, [......],
Ralph L Sacco,
L Jaap Kappelle,
Peter J Koudstaal,
Julien Bogousslavsky,
Louis R Caplan,
Jan Van Gijn,
Ale Algra,
Peter M Rothwell,
Harold P Adams,
Gregory W Albers
01/2002;
