From the Department of Internal Medicine (G.N., K.P., E. Karagkiozi, V.P., K.M.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Department of Clinical Therapeutics (G.G., A.V., E. Koroboki, E.M., K.V.), Medical School of Athens, Alexandra Hospital, Greece; Stroke Center and Neurology Service (G.S., D.S., A.E., S.N., P.M.), Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Switzerland; Department of Neurology (E.K.), National and Kapodistrian University of Athens, Greece; Division of Brain Sciences (E.K.), Department of Stroke Medicine, Imperial College, London, UK; Stroke Unit (A.R.-C., E.C.-G., J.R.), Department of Neurology, Hospital del Mar, Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona, Spain; Stroke Unit (V.A., V.C., M.P.), University of Perugia, Italy; Department of Neurology and Stroke Center (E.D.-T., B.F., J.R.P., S.S.-V.), La Paz University Hospital-Autónoma University of Madrid, IdiPAZ Health Research Institute, Spain; Stroke Clinic (A.A.), Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico; Department of Neurology (S.F.A., L.P., M.G.-S., M.A.H.), Institute for Neurological Research, FLENI, Buenos Aires, Argentina; Neurosciences Department (M.A.B.), Hospital Dr. Rafael A. Calderón Guardia, CCSS, University of Costa Rica; Vascular Neurology Section (B.C.C., A.M.I.M., A.G.P., A.G.-N.), Stroke Center, Hospital General Universitario Gregorio Marañón, IiSGM Health Research Institute, Universidad Complutense de Madrid, Spain; Department of Neurology (J.P., T.T.), Helsinki University Central Hospital and University of Helsinki, Finland; Department of Clinical Neurosciences (T.T.), Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg; Department of Neurology (T.T.), Sahlgrenska University Hospital, Gothenburg, Sweden; Stroke Service (V.P.), Department of Neurosciences, Leeds Teaching Hospitals NHS Trust and Medical School, University of Leeds, UK; and Department of Neurology (F.B.), S. Paolo Hospital, Savona, Italy.
Neurology. 2019 Dec 3;93(23):e2094-e2104. doi: 10.1212/WNL.0000000000008571. Epub 2019 Oct 29.
A tool to stratify the risk of stroke recurrence in patients with embolic stroke of undetermined source (ESUS) could be useful in research and clinical practice. We aimed to determine whether a score can be developed and externally validated for the identification of patients with ESUS at high risk for stroke recurrence.
We pooled the data of all consecutive patients with ESUS from 11 prospective stroke registries. We performed multivariable Cox regression analysis to identify predictors of stroke recurrence. Based on the coefficient of each covariate of the fitted multivariable model, we generated an integer-based point scoring system. We validated the score externally assessing its discrimination and calibration.
In 3 registries (884 patients) that were used as the derivation cohort, age, leukoaraiosis, and multiterritorial infarct were identified as independent predictors of stroke recurrence and were included in the final score, which assigns 1 point per every decade after 35 years of age, 2 points for leukoaraiosis, and 3 points for multiterritorial infarcts (acute or old nonlacunar). The rate of stroke recurrence was 2.1 per 100 patient-years (95% confidence interval [CI] 1.44-3.06) in patients with a score of 0-4 (low risk), 3.74 (95% CI 2.77-5.04) in patients with a score of 5-6 (intermediate risk), and 8.23 (95% CI 5.99-11.3) in patients with a score of 7-12 (high risk). Compared to low-risk patients, the risk of stroke recurrence was significantly higher in intermediate-risk (hazard ratio [HR] 1.78, 95% CI 1.1-2.88) and high-risk patients (HR 4.67, 95% CI 2.83-7.7). The score was well-calibrated in both derivation and external validation cohorts (8 registries, 820 patients) (Hosmer-Lemeshow test χ: 12.1 [ = 0.357] and χ: 21.7 [ = 0.753], respectively). The area under the curve of the score was 0.63 (95% CI 0.58-0.68) and 0.60 (95% CI 0.54-0.66), respectively.
The proposed score can assist in the identification of patients with ESUS at high risk for stroke recurrence.
为了便于研究和临床实践，开发并验证一种针对不明原因栓塞性卒中（ESUS）患者卒中复发风险分层的工具可能具有重要意义。本研究旨在确定能否制定一种评分系统来识别 ESUS 患者中具有高卒中复发风险的患者。
我们汇总了 11 个前瞻性卒中登记处中所有连续的 ESUS 患者的数据。我们采用多变量 Cox 回归分析来确定卒中复发的预测因子。根据拟合多变量模型中每个协变量的系数，我们生成了一个基于整数的评分系统。我们通过评估其区分度和校准度对该评分进行了外部验证。
在用作推导队列的 3 个登记处（884 例患者）中，年龄、脑白质病变和多灶性梗死被确定为卒中复发的独立预测因子，并被纳入最终评分中，其中每 10 年增加 1 分（35 岁后），脑白质病变得 2 分，多灶性梗死（急性或陈旧性非腔隙性梗死）得 3 分。评分 0-4 分（低危）的患者卒中复发率为 2.1/100 患者年（95%置信区间 [CI]：1.44-3.06），评分 5-6 分（中危）的患者卒中复发率为 3.74（95% CI：2.77-5.04），评分 7-12 分（高危）的患者卒中复发率为 8.23（95% CI：5.99-11.3）。与低危患者相比，中危（风险比 [HR]：1.78，95% CI：1.1-2.88）和高危（HR：4.67，95% CI：2.83-7.7）患者的卒中复发风险显著更高。该评分在推导队列和外部验证队列（8 个登记处，820 例患者）中均具有良好的校准度（Hosmer-Lemeshow 检验 χ2：12.1[=0.357]和 χ2：21.7[=0.753]）。评分的曲线下面积分别为 0.63（95% CI：0.58-0.68）和 0.60（95% CI：0.54-0.66）。
所提出的评分有助于识别 ESUS 患者中具有高卒中复发风险的患者。
