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Background We recently described the association between periodontal disease (PD) and stroke risk. Purpose The purpose of this study was to test the association between PD, dental care utilization and incident atrial fibrillation (AF), as well as AF as a mediator to PD- stroke association. Methods In dental cohort of the Atherosclerosis Risk in Communities Study (ARIC), participants without prior AF underwent full-mouth periodontal measurements. PD was defined on an ordinal scale as healthy (referent), mild, moderate and severe. In ARIC main cohort, participants were classified as regular or episodic dental care users. These patients were followed for AF, over 17 years. Cox proportional hazards models adjusted for AF risk factors were used to study relationships between PD severity, dental care utilization and AF. Mediation analysis was used to test if AF mediated the PD- stroke association. Results In dental ARIC cohort, 5,958 were assessed without prior AF, 754 were found to have AF. Severe PD was associated with AF on both univariable (crude HR, 1.54; 95% CI, 1.26-1.87) and multivariable (adjusted HR, 1.31, 95% CI, 1.06-1.62) analyses. Mediation analysis suggested AF mediates the association between PD and stroke. In the main ARIC cohort, 9,666 participants without prior AF were assessed for dental care use, 1558 were found to have AF. Compared with episodic users, regular users had a lower risk for AF on univariable (crude HR, 0.82, 95% CI, 0.74-0.90) and multivariable (adjusted HR, 0.88, 95% CI, 0.78-0.99) analyses. Conclusions PD is associated with AF. The association may explain the PD-stroke risk. Regular users had a lower risk of incident AF compared with episodic users.

BACKGROUND: Stroke remains more common in the “buckle” of the stroke belt, and disproportionately impacts African Americans. The reasons for this racial disparity are poorly understood and are not entirely explained by traditional stroke risk factors. The PeRiodontal treatment to Eliminate Minority InEquality and Rural disparities in Stroke (PREMIERS) study will evaluate the effect of periodontal treatment on recurrent vascular events and stroke risk factors among ischemic stroke and transient ischemic attack patients. DESIGN: Eligibility for the trial includes a non-disabling stroke confirmed by neuroimaging or Transient Ischemic Attack (TIA), being at least 18 years of age, having ≥ 5 natural teeth with ≥ 2 interproximal sites with ≥ 4 mm of clinical attachment loss and at least 2 sites with probing depth of ≥ 5 mm, and who are able to provide written informed consent. Within 90 days of the index event, patients are randomly assigned to intensive or initial standard cycle of supragingival mechanical scaling, polishing, and oral health instruction and followed for 1 year. The primary outcome is a composite of death, myocardial infarction and stroke or TIA. Secondary outcomes include A1C, fasting lipid profile, triglycerides, high sensitivity C-reactive protein, carotid intimal medial thickness, and blood pressure. A five year enrollment period followed by an addition one year of follow-up is planned.

Introduction: Craniocervical artery dissection (CeAD) is a leading cause of stroke in the young patient population. Recent studies reported a low rate of major adverse cardiac events (MACEs) in patients with CeAD, with no significant difference between patients randomized to anticoagulation or antiplatelet therapy. Objective: To compare the effectiveness of anticoagulation and antiplatelet therapy in patients with CeAD. Methods: All CeAD patients from 2015 to 2017 were consecutively identified by an electronic medical record-based application and enrolled in this prospective longitudinal registry. CeAD was confirmed by imaging and graded using the Denver scale for blunt cerebrovascular injury. Patients were followed for 12 months for MACE defined as stroke, transient ischemic attack (TIA), or death. Results: The cohort included 111 CeAD patients (age 53 ± 15.9 years, 56% Caucasian, 50% female). CeAD was detected by magnetic resonance (5%), computed tomography (88%), or catheter angiography (7%). CeAD was noted in the carotid (59%), vertebral (39%), and basilar (2%) arteries, 82% of which were extracranial dissections. CeAD was classified as grade I, II, III, and IV in 16, 33, 19, and 32%, respectively. A total of 40% of dissections were due to known trauma. A predisposing factor was noted in the majority (78%) of patients, including violent sneezing (21%), carrying a heavy load (19%), sports/recreational activity (11%), chiropractic manipulation (9%), abrupt/prolonged rotation of head (9%), and prolonged phone use (9%). At presentation, 41% had a stroke, 5% had TIA, 39% had headache, and 36% were asymptomatic. Favorable outcome defined as a modified Rankin Scale score of 0–2 was noted in 68% at 3 months and 71% at 12 months. The rate of MACEs at 3 and 12 months was 11 and 14%, respectively, with more events observed in patients who were not receiving anticoagulation/antiplatelet therapy due to contraindications (p = 0.008). Conclusions: We report diagnostic characteristics, as well as short- and long-term outcomes of CeAD. A high MACE rate was observed within the first 2 weeks of CeAD diagnosis, notably in patients not initiated on anticoagulation or antiplatelet therapy.

Introduction: Spontaneous craniocervical artery dissection (CeAD) occurs commonly in healthy individuals without known risk factors for stroke, whereas traumatic CeAD varies widely from penetrating trauma to motor vehicle crashes to minor movements of the neck. Headache (HA) and cervical pain occur in up to 75% of patients with CeAD. Yet, there are limited data on the incidence of new HA in CeAD patients after diagnosis. Methods: All patients from January 2015 to May 2017 consecutively identified by an electronic medical record-based application were enrolled in this prospective longitudinal registry. CeAD was confirmed by imaging during acute hospital visits. Patients were consented and followed for 12 months for HA status and HA Impact Test-6 (HIT-6) score (little to no impact: 49 or less, some impact: 50-55, substantial impact: 56-59, severe impact 60+). Results: The cohort included 111 CeAD patients (age 53 ± 15.9 years, 56% Caucasian, 50% female). Prevalence of reported HA at baseline was 40% (n=44) of enrolled patients; yet, there was no reportable difference between HA and no HA based on dissection location (carotid n=62; vertebral n=41; or basilar n=2; p=0.445). At baseline, 43% of patients categorized their HA as severely impacting their lives based on HIT-6. At the 3-month follow up, there was an incidence of 16% (n=11) who now reported HA but had no HA at baseline. At 3 months, 57% of patients categorized their HA as severely impacting on their life. At the 12-month follow up, there was an incidence of 7% (n=4) who now reported HA but no previous HA at baseline or 3 months. At 12 months, 58% of patients were classified into the severe impact category determined using HIT-6 calculations. HA status was not found to be associated with stroke or traumatic brain injury from CeAD (p = non-significant). Conclusions: We report the incidence and prevalence of HA within the CeAD population over a 12-month period. A high prevalence level was observed (40%) within the baseline history of CeAD diagnosis, with incremental incidence of new HA (16% and 7%) reported at 3 months and 12 months, respectively. There was no association found between HA status and stroke, dissection location or traumatic brain injury.

Introduction: Craniocervical artery dissection (CeAD) is a leading cause of stroke in the young. Recent studies reported a low rate of major adverse cardiac events (MACE) in patients with CeAD, with no significant difference between patients randomized to antiplatelet or anticoagulation. Methods: All patients from 2015-2017 consecutively identified by an electronic medical record-based application were enrolled in this prospective longitudinal registry. CeAD was confirmed by imaging and graded using the Denver scale for blunt cerebrovascular injury. Patients were followed for 12 months for MACE (stroke/transient ischemic attack [TIA]/death). Results: The cohort included 111 CeAD patients, (age 53 ±15.9 years, 56% white, 50% female) detected by magnetic resonance (5%), computed tomography (88%) and catheter (7%) angiography. CeAD was noted in the carotid (66%), vertebral (42%) and basilar (2%) arteries, with 83% of them being extracranial. CeAD was classified as grade 1, 2, 3 and 4 in 16%, 33%, 19%, and 32%, respectively. A total of 40% of dissections were due to known trauma. A predisposing factor was noted in the majority (78%), including 21% violent sneezing, 19% carrying heavy load, 11% sports/recreation activity, 9% chiropractic manipulation, 9% abrupt/prolonged rotation of head, and 9% prolonged phone use. At presentation, 41% had stroke, 39% had headache, 5% had TIA, and 15% were asymptomatic. Favorable outcome defined as modified Rankin score of 0-2 was noted in 68% at 3 months and 71% at 12 months. Rate of MACE was 14%, with more events observed in patients not on antiplatelet/anticoagulant therapy due to contraindications (p=0.008, Fig 1). Conclusions: We report diagnostic characteristics and short- and long-term outcomes of CeAD. A high MACE rate was observed within the first week of CeAD diagnosis, especially in patients not initiated on antiplatelet/anticoagulant therapy.

Introduction: Multiple trials have validated thrombectomy as a viable option in acute stroke patients with Anterior Large Vessel Occlusion (LVO). As a consequence, there has been a dire need for proper routing of patients. Currently, there are established prehospital scales but limited evidence for late window LVO screening. Methods: We assessed 748 patients, from June 2016 to June 2018, who presented within a 24 hour last known well time (LKWT) and were assessed with RAPID neuroimaging and CT angiography. An analysis was completed of patients with LVOs versus those without a LVO. Patient’s medical records were reviewed to obtain their baseline presenting NIHSS, which was used to derive 14 corresponding LVO stroke scale values. Patients excluded had absent NIHSS values and unknown LKWT. LVO stroke scales excluded evaluated history of seizures, seizure at onset, grip strength, or age > 45 as criteria. Results: A total of 748 consecutive patients (67 years, 51% male, 49% African American) were analyzed with 110 confirmed anterior LVO, 476 patients in the 0-6-hour (hr) window, and 272 in the 6-24-hr window. In the 0-6-hr window, the top three scales in sensitivity were ranked in order of C-STAT (0.83) > MaPSS (0.81) > VAN (0.80). In the 6-24-hr window, the top three scales that ranked equally in sensitivity were MaPSS (0.75), VAN (0.75), and C-STAT (0.75). In the 0-6-hr window, the top three scales in specificity were ranked in order of 3-ISS (0.88) > MiPSS (0.76) > FPSS (0.72) = sNIHSS-8 (0.72). In the 6-24-hr window, the top three scales in specificity were ranked in order of 3-ISS (0.90) > MiPSS (0.84) > FPSS (0.83). (See Table 1). Conclusion: To correctly identify as many patients as possible in the pre-hospital setting with the available scales, the data suggests that C-STAT, VAN, and MaPSS are effective within the early and late windows. To reduce routing of incorrect prehospital LVO identification, the data suggests that 3-ISS, MiPSS, and FPSS are effective in the early and late windows

Introduction: Migraine with visual aura (MA) has been associated with the risk of cardioembolic stroke (CES). Low heart rate variability (HRV), a marker of cardiac autonomic dysfunction, has been shown to be associated with atrial fibrillation (AF) and risk of stroke. We investigated the association between low HRV and MA. We also examined whether the MA associated CES risk can be explained by a low HRV. Methods: Participants in the Atherosclerosis Risk in Communities cohort were interviewed for migraine history in 1993-1995; during a subsequent follow-up visit (1996-1998) HRV was measured using 6-minute EKG. HRV indices were calculated using the standard deviation of RR intervals (SDNN), the mean of all normal RR intervals (MeanNN), the root mean square of successive differences of RR intervals (RMSSD), low (LF) and high (HF) frequency power, and the LF/HF ratio. All HRV measures were categorized into quintiles. Logistic regression models were used to estimate ORs adjusted for sociodemographic and comorbid confounders. Mediation analysis was conducted to test if HRV was a mediator of MA associated CES risk, using Barron-Kenny’s causal step tests. Results: Of 11,939 participants assessed for headache 426 reported MA. A total of 164 incident CES occurred over a 20-year follow-up period. After covariate adjustment, there was a strong evidence of an association between low HRV and MA. The lowest HRV quintile was associated with higher odds of MA compared with the highest quintile for SDNN (OR, 1.5, 95% CI, 1.1–2.3), RMSSD (OR, 1.4; 95% CI, 1.1–2.1), LF (OR, 1.3; 95% CI, 1.0–1.8), HF (OR, 1.5; 95% CI, 1.1–2.1), and LF/HF ratio (OR, 1.5; 95% CI, 1.1–2.0). The data also suggests HRV may be a potential mediator between MA and CES. Conclusion: MA was associated with low HRV, suggestive of chronic autonomic dysfunction among this population. Alongside prior findings showing HRV-AF, HRV-Stroke and AF-Stroke link, the association may provide the missing link between MA and Stroke (Figure).

Introduction and Hypothesis: Approximately a third of stroke/TIA events occur in patients taking daily Aspirin. We studied the comparative effectiveness of FDA approved antiplatelet agents (Aspirin, Clopidogrel, and Aspirin-dipyridamole or ASA+DP) in prevention of recurrent vascular events in stroke/TIA patients on Aspirin. Methods: Consecutive patients identified as having stroke or TIA were screened and enrolled into this prospective longitudinal registry. Patients on dual antiplatelet therapy or oral anticoagulants were excluded. Patient’s etiological stroke subtype, medication history, medication compliance and Aspirin Platelet Function Test were assessed at baseline. Changes in antiplatelet regimen including Aspirin dose, Clopidogrel, ASA+DP, changes in statin therapy were recorded. Follow up 6 and 12 month phone visits were conducted to assess primary outcomes (stroke/TIA, MI, death), adjudicated by chart review. Results: A total of 183 subjects (mean age 68+12, 58% males, 50% white, 44% African-American) were enrolled over a 24 month period on Aspirin. Majority (63%) had ischemic stroke (NIHSS: 0-21) and remaining (37%) had TIA (ABCD 2 : 2-7). Ischemic strokes were attributed to penetrating artery disease (41%), large artery atherosclerosis (35%), other/undetermined (18%), and cardiogenic (6%). After 12-months, 4.9% of participants on Clopidogrel, 15.1% of participants on aspirin and 35.3% of participants on ASA+DP had a primary outcome (p=0.006), depicted in the Kaplan-Meier curve. Changes in Aspirin dose from 81mg to 325mg or statin therapy regimen did not appear to impact primary outcome. Conclusions: This study shows a significant difference in secondary vascular event within 12 months of stroke/TIA on Aspirin, with effectiveness recorded in the order: Clopidogrel>Aspirin>ASA+DP. A larger randomized pragmatic trial may help ascertain this finding and clarify if specific subtype benefit from specific antiplatelet agent. Figure

Goal: Significant proportions of stroke/transient ischemic attack events occur in patients taking daily aspirin. We studied the comparative effectiveness of Food and Drug Administration approved antiplatelet agents (aspirin, clopidogrel, and aspirin-dipyridamole combination) in prevention of recurrent vascular events in stroke/transient ischemic attack patients on aspirin.Materials and Methods: Consecutive patients having stroke or transient ischemic attack were screened and enrolled into this registry. Patients on long-term dual antiplatelet therapy or oral anticoagulants were excluded. Patient’s etiological stroke subtype, medication history, medication compliance, and Aspirin Platelet Function Test were assessed at baseline. Changes in antiplatelet regimen and statin therapy were also recorded. Follow up 6 and 12-month phone visits were conducted to assess primary outcomes of major adverse cardiovascular events that included a composite of death, myocardial infarction and stroke or transient ischemic attack.Result: One-hundred-eighty subjects (mean age ± SD= 68 ± 12 years, 59% male, 51% white, 49% African-American) were enrolled over 24-months. Majority (64%) had ischemic stroke (NIHSS: 0-21) and remaining (36%) had transient ischemic attack (ABCD2: 2-7). Within 12-months of the index cerebrovascular event, 3 (5.9%) participants on clopidogrel, 21 (18.8%) participants on aspirin and 7 (41.2%) participants on aspirin-dipyridamole combination had a composite vascular event (Log rank p=0.0011).Conclusion: This study shows a significant difference in major adverse cardiovascular event within 12 months of stroke/ transient ischemic attack on Aspirin, with effectiveness recorded in the order: clopidogrel>aspirin> aspirin-dipyridamole combination. A larger randomized pragmatic trial may help ascertain this finding and clarify if specific stroke subtypes benefit from specific antiplatelet agents.