Stroke recurrences

The abciximab in Acute Ischemic Stroke trial was a randomized, placebo-controlled dose-escalation study to examine the safety of abciximab in acute stroke. It randomized 74 patients within 24 hours of stroke onset to receive one of four doses of abciximab (by bolus with or without additional infusion, 54 patients) or placebo (20 patients). The median baseline National Institute of Health Stroke Scale (NIHSS) score was 15. The rates of asymptomatic ICH were 19% in the intervention group compared to 5% in the placebo group p = 0.07). Most (9 of 11) of the asymptomatic ICH patients had more severe stroke (NIHSS >14). No cases of symptomatic ICH or major systemic bleeding occurred. There was a trend toward a lower rate of stroke recurrence (2% vs. 5%) and a higher rate of functional recovery at 3 months in the group treated with abciximab than with placebo. 

Acute Anticoagulation for AF-associated Stroke HAEST and 1ST provided valuable data on relatively large numbers (449 in HAEST, 3169 in 1ST) of patients with AF-associated ischemic stroke treated with acute anticoagulation (danaparoid in HAEST, UFH in 1ST). HAEST found no reduction in early stroke recurrence or effect on late functional outcome in the LMWH arm. In contrast, 1ST found a dose-dependent reduction in early recurrence rates, but no late functional benefit associated with UFH. However, this was offset by an increase in rates of sICH among patients with AF receiving UFH, with no net benefit in the composite outcome of recurrence stroke and sICH combined. The reasons for the discrepancy between trials is unclear. 

Acute anticoagulation is widely used in the acute setting of arterial dissection. Once again, the rationale is to prevent propagation of local thrombosis and formation of new thrombus at the site of the injured arterial wall, which is beheved to reduce the likelihood of early stroke recurrence. This practice, while rational, is based on anecdotal evidence and case series, as randomized controlled trials have... 

Develop an appropriate therapeutic plan for outpatient management of a patient with ischemic stroke, including an appropriate agent to prevent stroke recurrence. 

Chronic transfusion therapy is warranted to prevent serious complications from SCD, including stroke and recurrence. Especially in children, chronic transfusions have been shown to decrease stroke recurrence from approximately 50% to 10% over 3 years. Without chronic transfusions, approximately 70% of ischemic stroke patients will have another stroke. Chronic transfusion therapy also may be used to prevent vaso-occlusive pain and ACS, as well as prevent progression of... 

The goals of treatment for acute stroke are to (1) reduce the ongoing neurologic injury and decrease mortality and long-term disability (2) prevent complications secondary to immobility and neurologic dysfunction and (3) prevent stroke recurrence. 

Elevated blood pressure is common after ischemic stroke, and its treatment is associated with a decreased risk of stroke recurrence. The Joint National Committee and AHA/ASA guidelines recommend an angiotensin-converting enzyme inhibitor and a diuretic for reduction of blood pressure in patients with stroke or TIA after the acute period (first 7 days). Angiotensin II receptor blockers have also been shown to reduce the risk of stroke and should be considered in patients unable to tolerate angiotensinconverting enzyme inhibitors after acute ischemic stroke. 

Chronic transfusion is indicated to prevent stroke and stroke recurrence in children. Transfusion frequency is usually every 3 to 4 weeks and should be adjusted to maintain HbS of less than 30% of total hemoglobin. The optimal duration is unknown. Risks include alloimmunization, hyperviscosity, viral transmission (requiring hepatitis A and B vaccination), volume and iron overload, and transfusion reactions. 

Imaizumi T, Horita Y, Hashimoto et al. (2004). Dotlike haemosiderin spots on Tj-weighted magnetic resonance imaging as a predictor of stroke recurrence a prospective study. Journal of Neurosurgery 101 915-920. 

Nadareishvili ZG, Li H, Wright V, Marie D, Warach S, Hallenbeck JM, Dambrosia J, Barker JL, Baird AE (2004) Elevated pro-inflammatory CD4 + CD28- lymphocytes and stroke recurrence and death. Neurology 63 1446-1451. 

Statin therapy is recommended for all ischemic stroke patients, regardless of baseline cholesterol, to reduce stroke recurrence. 

Transfusions play an important role in the management of SCD. In acute illness, transfusions can be life-saving and will be discussed in a later section. Maintenance transfusion programs are used to prevent serious complications of SCD. The primary indication for chronic transfusion is stroke prevention. Chronic transfusions help prevent stroke and stroke recurrence in children. 

In children who had a stroke, chronic transfusions are successful in reducing stroke recurrence from approximately 50% to about 10% over 3 years. ° Since the first stroke in SCD is usually devastating, transfusions have been used to prevent the first stroke. In one trial, prophylactic transfusions significantly reduced the incidence of first stroke over a 2-year period in children 2 to 16 years of age with abnormal transcranial Doppler (TCD) ultrasonography. Stroke occurrence rate was reduced from 16% in patients receiving standard care to 2% in those who received prophylactic transfusions. ... 

Several hematologic disorders and hemostatic defects increase risk of ischemic stroke. Inherited thrombophilias (such as factor V Leiden protein S, protein C, or antithrombin III deficiency or the prothrombin G20210A mutation) rarely contribute to stroke in adults, but may play a larger role in pediatric stroke. Antiphospholipid antibody syndrome consists of venous and arterial occlusive disease in multiple organs, miscarriages, and livedo reticularis [7]. The association between antiphospholipid antibodies and stroke in the absence of antiphospholipid antibody syndrome is strongest for young adults. In the Antiphospholipid Antibodies in Stroke substudy of WARSS (WARSS/ APASS), antiphospholipid antibodies were detected in 40.7% of stroke patients, but they had no effect on the risk of stroke recurrence (see Table 2.5) [88]. Thrombotic thrombocytopenic purpura (TTP) has... 

CAPITAL MI 170 None Tenecteplase FDL FDL + PCI UFH Death + MI + stroke + recurrent ischemia at 30 days Completed... 

Dipyridamole treatment in patients with prior stroke or transient ischaemic attack substantially reduced stroke recurrence, with a beneficial effect comparable to and additive with that induced by acetylsa-licylic acid (Diner 1996). In vitro, dipyridamole behaved. as an antioxidant twice as effective as a-tocopherol in inhibiting lipid peroxidation of methyl linoleate (Iuliano et al. 1995), and in the oxidation of low-density lipoprotein induced chemically and by endothelial cells (Iuliano et al. 1996). Kusmic et al. (2000) during cerebral hypoperfusion with human carotid endarterectomy could attenuate cerebral oxidative stress by pre-treatment with oral dipyridamole. 

Hey levels and the risk of stroke recurrence and allcause mortality in a large prospective stroke population... 

After adjustment for age, gender and other cardiovascular risk factors, a high Hey concentration was associated with an increased risk of 1.74-fold for stroke recurrence and 1.75-fold for all-cause mortality when highest and lowest categories were compared. This study suggest that elevated Hey concentrations can predict the risk of stroke recurrence and mortality in patients with stroke. 

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