Background: Optimal antithrombotic regimens to prevent recurrent stroke in patients with ischemic stroke due to AF and atherosclerotic large-vessel stenosis remains unknown. Aims: This study aimed to evaluate the effect of multiple antithrombotic therapies on outcomes at 1-year after ischemic stroke due to two or more causes. Methods: Based on the linked data, we identified 862 patients with ischemic stroke due to AF and large artery atherosclerosis in the relevant arteries. These patients were categorized into three groups, according to their antithrombotic therapies at discharge after ischemic stroke: those receiving 1) antiplatelet agents, 2) oral anticoagulants (OAC), and 3) antiplatelet agents plus OAC. The study outcomes were recurrent ischemic stroke, composite outcomes, including ischemic stroke, myocardial infarction, intracerebral hemorrhage and death, and major bleeding after 1 year. Inverse probability of treatment weighting (IPTW) was used to balance the three groups using propensity scores. Results: Among 862 patients (mean age: 72.6 years, men: 58.4%), 169 (19.6%) were treated with antiplatelet agents, 405 (47.0%) were treated with OAC, and 288 (33.4%) were treated with antiplatelet agents and OAC. After applying IPTW, only OAC had a significant beneficial effect on the 1-year composite outcome (hazard ratio [HR]: 0.37, 95% confidence interval [CI]: 0.23–0.60, P < 0.001) and death (HR: 0.35, [95% CI: 0.19–0.63], P < 0.001). Patients treated with a combination of antiplatelet agents and OAC had an increased risk of major bleeding complications (HR: 5.27, [95% CI: 1.31–21.16], P = 0.019) compared with those treated with antiplatelet agents alone. However, there was no significant difference in the risk of 1-year recurrent stroke among the three groups. Conclusion: This study demonstrated that OAC monotherapy was associated with lower risks of composite outcome and death in patients at 1-year after ischemic stroke due to AF and atherosclerotic stenosis. In addition, the combination of an antiplatelet agent and OAC had a high risk of major bleeding.

Transcranial Doppler Monitoring in Subarachnoid HemorrhagCerebral vasospasm and delayed cerebral ischemia are common complications associated with subarachnoid hemorrhage (SAH) outcomes. Various modalities can be used to evaluate and detect cerebral vasospasm after SAH. Transcranial Doppler (TCD) ultrasonography can be used as an appropriate bedside dynamic monitoring tool to screen for the presence and progression of cerebral vasospasm in patients with SAH. This article briefly reviewed the severity of SAH and pathophysiology of vasospasm. In addition, information regarding the use of TCD for monitoring cerebral vasospasm, several variables measured by TCD to monitor vasospasm detection, and differentiating vasospasm from physiological conditions in the clinical setting following SAH were presented in this article.

Background Marked protein catabolism is common in patients with critical illness. We hypothesized that optimal protein supplementation using nitrogen balance might be associated with better clinical outcomes in patients in the neurointensive care unit (NICU).Methods A retrospective observational analysis was performed among patients admitted to the NICU between July 2017 and December 2018. Nitrogen balance was measured within 72 hours after NICU admission and measurements were repeated after 10 days in those who stayed in the NICU for more than 7 days. Nitrogen balance was calculated using a standard formula: total protein intake (grams)/6.25 – (urine urea nitrogen + 4 grams). Included patients were categorized into two groups (positive or negative) based on the initial nitrogen balance results. The rate of neurological worsening, defined by a worsening of ≥2 in the Glasgow Coma Scale (GCS) score, and in-hospital mortality were compared between patients who achieved the improvement of nitrogen balance on a follow-up measurement and those who failed to.Results A total of 175 patients were included, and 140 (80.0%) had a negative nitrogen balance on the initial assessment. The negative nitrogen balance group had a lower GCS, longer NICU stay, more events of neurological worsening, and higher in-hospital mortality. Among the 77 patients (44.0%) who underwent a follow-up measurement of nitrogen balance (on a median day of 10), 39 (50.6%) showed an improvement in nitrogen balance and thus received a higher amount of protein (1.94 g/kg/day) than those who did not show this improvement (1.28 g/kg/day) ( P < 0.001). The improvement group had fewer events of neurological worsening (15.4% vs. 36.8%, P = 0.032) and lower in-hospital mortality (12.8% vs. 31.6%, P = 0.047). However, there were no significant differences in baseline nitrogen balance, GCS, and the development of acute kidney injury between the two groups.Conclusions This study demonstrated that a significant proportion of patients in NICU were under protein hypercatabolism. An adequate provision of protein was associated with improved outcomes, suggesting the importance of protein supplementation in neurocritically ill patients.

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