Stroke Alert: A Review of Current Clinical Stroke Literature
Secondary Prevention after Acute Ischemic Stroke
By Matthew E. Fink, MD, Professor and Chairman, Department of Neurology, Weill Cornell Medical College, and Neurologist-in-Chief, New York Presbyterian Hospital.
Closure of Patent Foramen Ovale in Selected Patients with Cryptogenic Stroke May Be Better Than Medical Therapy Alone
Source: Carroll JD, et al, for the RESPECT Investigators. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013;368:1092-1100.
Up to one-third of all Ischemic strokes do not have a defined etiology and are referred to as cryptogenic, and about one-half of those have a patent foramen ovale (PFO). It is uncertain if closure of a PFO is effective in preventing recurrent stroke or is better than medical therapy. The CLOSURE I trial evaluated the STARFlex Septal Closure System and failed to show superiority of closure over medical therapy alone.1 The investigators in the Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment (RESPECT) trial evaluated the effectiveness of the Amplatzer PFO Occluder to prevent recurrent stroke and compared this intervention to standard medical therapy with antiplatelet and antithrombotic medications.
A total of 980 patients (mean age = 45.9 years) were enrolled and randomized in a 1:1 ratio to medical therapy alone or closure of the PFO. The medical therapy group received one or more antiplatelet medications (74.8%) or warfarin (25.2%). The closure group was followed over 1375 patient-years and the medical group over 1184 patient-years, with a higher dropout rate in the medical group. In the intention-to-treat analysis, recurrent stroke occurred in nine patients in the closure group and 16 patients in the medical group (hazard ratio with closure, 0.49; 95% confidence interval [CI], 0.22-1.11; P = 0.08). In the prespecified, per-protocol cohort (six events in the closure group vs 14 events in the medical group), the hazard ratio was 0.37 (95% CI, 0.14-0.96; P = 0.03). Serious adverse events occurred in 23% of patients in the closure group and in 21.6% in the medical therapy group. Procedure-related adverse events occurred in 21 of 499 patients in the closure group (4.2%), but the rate of atrial fibrillation or device thrombus was not increased.
In the primary intention-to-treat analysis, there was no significant benefit associated with closure of the PFO in adults who had a cryptogenic ischemic stroke, but closure was superior to medical therapy, alone, in a prespecified, per-protocol cohort in the “as-treated” analysis.
1. Furlan AJ, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012;366:991-999.
Use of Ischemic Stroke Scores May Aid in the Prediction of Risk of Early Recurrence
Source: Maier IL, et al. Risk prediction of very early recurrence, death and progression after acute ischemic stroke. Eur J Neurol 2013;20:599-604.
The investigators studied the utility of three common stroke risk scores to determine the risk of early recurrence after acute ischemic stroke: Essen Stroke Risk Score (ESRS),1 the ABCD2 score,2 and the Recurrence Risk Estimator at 90 days (RRE-90).3 Clinical and radiographic data were analyzed from 1727 consecutive patients admitted to the stroke unit at the University of Gottingen, Germany, and evaluated retrospectively. The predictive value of three stroke scores was tested for early recurrence within 7 days, as well as death and progressive stroke.
Early recurrent stroke occurred in 56 patients (3.2%), 40 patients (2.3%) died, and 125 patients (7.2%) had progressive stroke within the first 7 days. The ESRS was not predictive for early recurrence, death, or progressive stroke. The ABCD2 score was predictive for death (P < 0.001) and progressive stroke (P < 0.001), and the RRE-90 was predictive for early recurrent stroke (P < 0.001), early death (P < 0.001), and progressive stroke (P < 0.001).
The ABCD2 score and the RRE-90 show promise in predicting early recurrence, as well as death and progression in the first 7 days following acute ischemic stroke. Further validation of these findings in other stroke cohorts should be performed.
1. Fitzek S, et al. The Essen Stroke Risk Score in one-year follow-up acute ischemic stroke patients. Cerebrovasc Dis 2011;31:400-407.
2. Chandratheva A, et al. ABCD2 score predicts severity rather than risk of early recurrent events after transient ischemic attack. Stroke 2010;41:851-856.
3. Ay H, et al. A score to predict early risk of recurrence after ischemic stroke. Neurology 2010;74:128-135.