E Murat Arsava1, Gyeong-Moon Kim2, Jamary Oliveira-Filho3, Levent Gungor4, Hyun Jin Noh2, Morgana de Jesus Lordelo5, Ross Avery6, Ilko L Maier7, Hakan Ay8. 1. Department of Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey. 2. Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. 3. Stroke Service, Federal University of Bahia, Salvador, Brazil. 4. Department of Neurology, On Dokuz Mayis University Faculty of Medicine, Samsun, Turkey. 5. Post-Graduate Program in Health Sciences, Federal University of Bahia, Salvador, Brazil. 6. A. A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston. 7. Department of Neurology, Georg-August University of Göttingen, Göttingen, Germany. 8. A. A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston8Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.
Abstract
IMPORTANCE: Approximately half of recurrent strokes occur within days and weeks of an ischemic stroke. It is imperative to identify patients at imminent risk of recurrent stroke because recurrent events lead to prolonged hospitalization, worsened functional outcome, and increased mortality. OBJECTIVE: To test the validity of a prognostic score that was exclusively developed to predict early risk of stroke recurrence in a multicenter setting. DESIGN, SETTING, AND PARTICIPANTS: This hospital-based cohort study examined patients with and without magnetic resonance imaging-confirmed recurrent stroke within 90 days after an ischemic stroke. The study was performed at 3 teaching hospitals in the United States, Brazil, and South Korea and comprised adult patients admitted within 72 hours of symptom onset with a magnetic resonance imaging-confirmed diagnosis of acute ischemic stroke. Recruitment to the US cohort was performed from June 1, 2009, through April 30, 2011. Recruitment to the Korean and Brazilian cohorts was performed from January 1, 2007, through December 31, 2011. Data analysis was performed from June 1, 2013, to December 31, 2014. MAIN OUTCOMES AND MEASURES: The primary outcome was recurrent ischemic stroke as defined by a clinical incident that was clearly attributable to a new area of brain infarction occurring within the 90 days of index infarction. An investigator who was masked to the patient's recurrence status calculated the Recurrence Risk Estimator (RRE) score for each patient based on information available after initial line of testing in the emergency department. We assessed the predictive performance of the RRE by computing the area under the receiver operating characteristic curve. RESULTS: The study included 1468 consecutive patients with 59 recurrent ischemic stroke events. The median age of the patients was 69 (interquartile range, 58-79) years, and 633 (43.1%) were female. The cumulative 90-day recurrence rate was 4.2% (95% CI, 3.2%-5.2%). The mean RRE score was 2.2 (95% CI, 1.9-2.5) in patients with recurrence and 1.0 (95% CI, 1.0-1.1) in patients without. The risk of recurrence increased with a higher RRE score (log-rank test, P < .001). The area under the receiver operating characteristic curve for discrimination was 0.76 (95% CI, 0.70-0.82). The RRE identified 710 patients (48.4%) in the study population as high risk (>10%) or low risk (<1%). The sensitivity and specificity were 38% and 93% for identifying low-risk subsets and 41% and 90% for identifying high-risk subsets, respectively. CONCLUSIONS AND RELEVANCE: This study confirms the validity of the RRE score in a multicenter cohort of patients with diverse characteristics. Our findings suggest that the RRE could be useful in identifying high- and low-risk patients for targeted stroke prevention.
IMPORTANCE: Approximately half of recurrent strokes occur within days and weeks of an ischemic stroke. It is imperative to identify patients at imminent risk of recurrent stroke because recurrent events lead to prolonged hospitalization, worsened functional outcome, and increased mortality. OBJECTIVE: To test the validity of a prognostic score that was exclusively developed to predict early risk of stroke recurrence in a multicenter setting. DESIGN, SETTING, AND PARTICIPANTS: This hospital-based cohort study examined patients with and without magnetic resonance imaging-confirmed recurrent stroke within 90 days after an ischemic stroke. The study was performed at 3 teaching hospitals in the United States, Brazil, and South Korea and comprised adult patients admitted within 72 hours of symptom onset with a magnetic resonance imaging-confirmed diagnosis of acute ischemic stroke. Recruitment to the US cohort was performed from June 1, 2009, through April 30, 2011. Recruitment to the Korean and Brazilian cohorts was performed from January 1, 2007, through December 31, 2011. Data analysis was performed from June 1, 2013, to December 31, 2014. MAIN OUTCOMES AND MEASURES: The primary outcome was recurrent ischemic stroke as defined by a clinical incident that was clearly attributable to a new area of brain infarction occurring within the 90 days of index infarction. An investigator who was masked to the patient's recurrence status calculated the Recurrence Risk Estimator (RRE) score for each patient based on information available after initial line of testing in the emergency department. We assessed the predictive performance of the RRE by computing the area under the receiver operating characteristic curve. RESULTS: The study included 1468 consecutive patients with 59 recurrent ischemic stroke events. The median age of the patients was 69 (interquartile range, 58-79) years, and 633 (43.1%) were female. The cumulative 90-day recurrence rate was 4.2% (95% CI, 3.2%-5.2%). The mean RRE score was 2.2 (95% CI, 1.9-2.5) in patients with recurrence and 1.0 (95% CI, 1.0-1.1) in patients without. The risk of recurrence increased with a higher RRE score (log-rank test, P < .001). The area under the receiver operating characteristic curve for discrimination was 0.76 (95% CI, 0.70-0.82). The RRE identified 710 patients (48.4%) in the study population as high risk (>10%) or low risk (<1%). The sensitivity and specificity were 38% and 93% for identifying low-risk subsets and 41% and 90% for identifying high-risk subsets, respectively. CONCLUSIONS AND RELEVANCE: This study confirms the validity of the RRE score in a multicenter cohort of patients with diverse characteristics. Our findings suggest that the RRE could be useful in identifying high- and low-risk patients for targeted stroke prevention.
Authors: E Murat Arsava; Johanna Helenius; Ross Avery; Mine H Sorgun; Gyeong-Moon Kim; Octavio M Pontes-Neto; Kwang Yeol Park; Jonathan Rosand; Mark Vangel; Hakan Ay Journal: JAMA Neurol Date: 2017-04-01 Impact factor: 18.302
Authors: Shadi Yaghi; Ava L Liberman; Nils Henninger; Brian Mac Grory; Amre Nouh; Erica Scher; James Giles; Angela Liu; Muhammad Nagy; Ashutosh Kaushal; Idrees Azher; Hiba Fakhri; Kiersten Brown Espaillat; Syed Daniyal Asad; Hemanth Pasupuleti; Heather Martin; Jose Tan; Manivannan Veerasamy; Charles Esenwa; Natalie Cheng; Khadean Moncrieffe; Iman Moeini-Naghani; Mithilesh Siddu; Tushar Trivedi; Koto Ishida; Jennifer Frontera; Aaron Lord; Karen Furie; Salah Keyrouz; Adam de Havenon; Eva Mistry; Christopher R Leon Guerrero; Muhib Khan Journal: J Stroke Cerebrovasc Dis Date: 2020-05-13 Impact factor: 2.136
Authors: Nina Buchtele; Michael Schwameis; James C Gilbert; Christian Schörgenhofer; Bernd Jilma Journal: Thromb Haemost Date: 2018-05-30 Impact factor: 5.249
Authors: Aleksandra Yakhkind; Ryan A McTaggart; Mahesh V Jayaraman; Matthew S Siket; Brian Silver; Shadi Yaghi Journal: Front Neurol Date: 2016-06-10 Impact factor: 4.003