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Of the 230 included patients, 155 (67%) were clinically stable, 47 (20%) were clinically unstable and 28 (12%) were clinically highly unstable. Patients with stroke or retinal artery occlusion as presenting event were more often clinically stable than patients with TIA or amaurosis fugax as presenting event (p = 0.004, chi-squared test), see Figure 1. Patients in the intermediate age group (65–74 years) tended to be less often clinically stable than younger (<65 years) or older (≥75 years) patients (p = 0.060, chi-squared test). The delay between the presenting event and CEA, and hence the observation time, is presented in Table 1.
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Figure 1.
Prevalence of additional ipsilateral events. Numbers inside bars denotes number of patients. PE = presenting event; RAO = retinal artery occlusion; Afx = amaurosis fugax; LAA = large artery atherosclerosis
Additional Events and Risk of Recurrent Ipsilateral Ischemic Stroke
Thirty-two patients suffered a none-fatal and one patient suffered a fatal recurrent ipsilateral ischemic stroke within 90 days of the presenting event. Eighteen patients suffered a recurrent ipsilateral ischemic stroke within 7 days after the presenting event. Twelve (67%) of these patients were clinically stable, 4 (22%) were clinically unstable, and 2 (11%) were clinically highly unstable, see Table 2. The risk of ipsilateral ischemic stroke was not statistically significantly affected by if the patient was clinically stable, unstable or highly unstable (Table 2, Figure 2). We analyzed the risk of recurrent ipsilateral ischemic stroke based additional events before the presenting event and after the presenting event separately: we found non-significant trends that 1 additional ipsilateral event within 7 days before the presenting event incurred a higher risk of recurrent ipsilateral ischemic stroke than 0 or ≥2 events (Figure 3, Table 2); whereas the opposite pattern was observed in patients with 1 additional event after the presenting event (Figure 4, Table 2). After adjustment for age, sex, degree of symptomatic carotid stenosis and type of presenting event using Cox Regression, all tendencies were weaker or similar, see Table 3.
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Figure 2.
Kaplan Meier analysis of the risk of recurrent ipsilateral stroke after the presenting event with patients divided by number of events within 7 days before and/or after the presenting event: Clinically stable (0 events), clinically unstable (1 event), and clinically highly unstable (≥2 events). CEA was used a censor.
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Figure 3.
Kaplan Meier analysis of the risk of recurrent ipsilateral stroke after the presenting event with patients divided by number of additional events within 7 days before the presenting event. CEA was used a censor.
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Figure 4.
Kaplan Meier analysis of the risk of recurrent ipsilateral stroke after the presenting event with patients divided by number of additional events within 7 days after the presenting event. CEA was used a censor.
We also conducted explorative analyses: We explored the association between type of presenting event and clinical stability regarding the 18 recurrent ipsilateral ischemic strokes that occurred within 7 days of the presenting event, see Figure 5. We found no interaction for the risk of recurrent ipsilateral ischemic stroke for clinical stability and type of presenting event (p = 0.76; Cox Regression). We further repeated the Kaplan Meier analysis of the risk of recurrent ipsilateral ischemic stroke based on additional events within 7 days before the presenting event, but limited to the 70 patients with TIA (excluding amaurosis fugax) as the presenting event. The findings were similar to those for the entire study with a tendency that 1 additional event before the presenting event incurred a higher risk of recurrent ipsilateral ischemic stroke than 0 or ≥2 events (p = 0.08; log rank test). We also repeated the Kaplan Meier analyses for all patients, but grouped the patients based on if additional ipsilateral events occurred within 90 days (not 7 days) before and/or after the presenting event. All associations were similar or weaker compared to the original analyses.
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Figure 5.
Type of presenting event among the patients with recurrent ipsilateral ischemic stroke within 7 days divided between clinically stable, unstable and highly unstable. Numbers inside bars denotes number of patients.
Patients With Several Additional Events
Fourteen patients (6%) had ≥3 additional ipsilateral events within 7 days before and/or after the presenting event. Of these patients, 7 (50%) had 3–6 additional ipsilateral events and 7 (50%) had 7–11 additional ipsilateral events. Including the presenting event, 5 (36%) had only amaurosis fugax events, 4 (29%) had only TIA events, and 5 (36%) had a mix of stroke, TIA, and amaurosis fugax events. One (7%) of these patients suffered a recurrent ipsilateral ischemic stroke two days after the presenting event. Eight patients (3%) had ≥10 (range 12–30) additional ipsilateral events within 90 days before and/or after the presenting event. Including the presenting event, 3 (38%) had only amaurosis fugax events, 2 (25%) had only TIA events, and 3 (38%) had a mix of stroke, TIA, and amaurosis fugax events. None of these eight patients suffered a recurrent ipsilateral ischemic stroke after the presenting event.
Patients With Only Cerebral Events or Retinal Events
We analyzed how often patients suffer only cerebral events (stroke and TIA) or only retinal events (retinal artery occlusion and amaurosis fugax). First, we considered the 110 patients with additional ipsilateral events (including endpoint events) within 90 days before and/or after the presenting event. In 62/70 (89%) patients with a cerebral presenting event, all the additional events were cerebral. In 31/40 (78%) patients with a retinal presenting event, all the additional events were retinal. Then, we further analyzed the 33 patients that reached the endpoint. In 29/30 (97%) patients with ipsilateral ischemic stroke as the endpoint event, all preceding events were cerebral. In 1/3 (33%) patients with recurrent ipsilateral retinal artery occlusion as the endpoint event, all preceding events were retinal; while, one patient had a single TIA and one had several TIAs as preceding events.
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