Reduction in Early Stroke Risk in Carotid Stenosis With Transient Ischemic Attack Associated With Statin Treatment
Patients with transient ischemic attack (TIA) and carotid stenosis have a high risk of stroke. Current recommendations call for early carotid endarterectomy, preferably within 14 days, for symptomatic carotid stenosis. Despite these recommendations, only a minority of patients undergo early carotid endarterectomy, and thus, aggressive medical therapy is warranted in this early period to prevent recurrent stroke. The current study was a multicenter effort of patients from TIA registries from 11 centers aimed to look at the effects of the early use of statins in the risk of stroke after TIA in patients with carotid stenosis. Patients included in this study had TIA, defined as an acute loss of focal cerebral or ocular function lasting <24 hours attributed to embolic or thrombotic vascular disease and ≥50% narrowing of the internal carotid artery. A total of 43.5% of patients were prescribed a statin before the TIA and 87.7% after the index TIA. Despite a higher rate of use of preventative medications in carotid stenosis patients, nonprocedural 7-day stroke risk was 8.3% when compared with 2.7% in those without stenosis (P<0.0001). In patients with carotid stenosis, nonprocedural 7-day stroke risk was 3.8% with statin pretreatment at TIA onset when compared with 13.2% in those not statin pretreated (P=0.01; 90-day risks 8.9% versus 20.8%; P=0.01). Statin pretreatment was associated with reduced stroke risk in patients with carotid stenosis (odds ratio for 7-day stroke, 0.26 and for 90-day stroke, 0.37). No benefit was observed in patients with TIA without carotid stenosis. On multivariable logistic regression (adjusting for ABCD2 score, smoking, and antiplatelet treatment), the statin and carotid stenosis interaction remained significant for early stroke. These results, although not from randomized data, support the benefits of early statin use in this patient population. Statins in patients with symptomatic severe carotid stenosis should not be used in lieu of surgical revascularization in appropriately indicated patients. However, these results support early statin use until further randomized trials can be performed. See p 2814.
Lesion Location Predicts Transient and Extended Risk of Aspiration After Supratentorial Ischemic Stroke
Dysphagia and the risk of aspiration are very common after ischemic stroke. The risk of aspiration has previously been demonstrated in brain stem infarcts. The present study aimed to determine an association between lesion location and risk of aspiration and to establish MRI-based predictors of transient versus extended risk of aspiration after supratentorial ischemic stroke. Ninety-four patients from a longitudinal cohort were included in this study. Most of the patients were evaluated by a speech language pathologist within 48 hours of admission. The risk of aspiration was determined by the 2 of 6 scale, which consisted of 6 features: dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, cough after swallow, and voice change after swallow. The presence of ≥2 features on this scale indicated an elevated risk of aspiration, and <2 features indicated no risk of aspiration. Patients with acute risk of aspiration were tested in follow-up 7 to 9 days later and subclassified as transient risk of aspiration if their score became 0 to 1 or as extended risk of aspiration in the early subacute phase if their swallow did not recover and their score remained 2 to 6. After correcting for stroke volume and National Institutes of Health Stroke Scale with a multiple logistic regression model, significant adjusted odds ratios (aORs) in favor of acute risk of aspiration were demonstrated for the internal capsule (aOR, 6.2; P<0.002) and the insular cortex (aOR, 4.8; P<0.003). In multivariate logistic regression model adjusted for National Institutes of Health Stroke Scale and lesion size (Table 4), ischemic infarction of the frontal operculum remained the single independent predictor of extended risk of aspiration (aOR, 33.8; P<0.008). The authors calculated an equal aOR of prolonged dysphagia for a compound variable (simultaneous lesion of the insular cortex and the frontal operculum; aOR, 33.8; P<0.008) after adjusting for stroke severity and lesion size. These results demonstrate the importance of these anatomic areas in swallowing and their subsequent infarction result in increased risk of aspiration. Practitioners must consider patients with infarctions in these locations and consider early use of enteral feeding in these cases. See p 2760.
Thrombolysis for Ischemic Stroke Associated With Infective Endocarditis: Results From the Nationwide Inpatient Sample
Ischemic stroke from septic embolism is a frequent complication of infective endocarditis (IE) and is associated with high rates of death and disability. Previous trials of the use of intravenous tissue-type plasminogen activator in acute ischemic stroke (AIS), such as the National Institutes of Neurological Disorders and Stroke trial (NINDS thrombolysis study), excluded patients with IE. The present study sought to determine the rates and outcomes of patients with AIS with IE treated with intravenous thrombolysis using data from the Nationwide Inpatient Sample from 2002 to 2010. A total of 222 patients were treated with intravenous thrombolysis for AIS secondary to IE and 134 048 patients who were treated for AIS without IE. The rate of post-thrombolytic intracerebral hemorrhage was significantly higher in patients with IE compared with non-IE patients with AIS (20% versus 6.5%; P=0.006). There was also a significantly lower rate of favorable outcome in the IE group (10% versus 37%; P=0.01) when compared with that of the non-IE AIS-treated group. Current guidelines do not exclude patients with IE and acute ischemic stroke from receiving intravenous thrombolysis. However, the use of intravenous tissue-type plasminogen activator in this subgroup is controversial because of the increased risk of hemorrhagic transformation of infarcts demonstrated in this study and others. Although no randomized data exist, these results argue strongly for caution in the use of intravenous tissue-type plasminogen activator in patients with ischemic stroke and IE. See p 2917.
- © 2013 American Heart Association, Inc.
- Reduction in Early Stroke Risk in Carotid Stenosis With Transient Ischemic Attack Associated With Statin Treatment
- Lesion Location Predicts Transient and Extended Risk of Aspiration After Supratentorial Ischemic Stroke
- Thrombolysis for Ischemic Stroke Associated With Infective Endocarditis: Results From the Nationwide Inpatient Sample
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