Recurrent Ischemic Stroke - A Systematic Review and Meta-Analysis

J Stroke Cerebrovasc Dis. 2021 Aug;30(8):105935. doi: 10.1016/j.jstrokecerebrovasdis.2021.105935. Epub 2021 Jun 18.


Objectives: Recurrent stroke remains a challenge though secondary prevention is initiated immediately post-stroke. Stroke subtype may determine the risk of recurrent stroke and require specific preventive measures. We aimed to identify subtype-specific stroke recurrence and associated risk factors over time.

Methods and materials: A systematic review was performed using PubMed and Embase for studies including adults >18 years, first-ever ischemic stroke in population-based observational studies or registries, documented TOAST-criteria and minimum 1-year follow-up. Meta-analysis on stroke recurrence rate was performed. Final search: November 2019.

Results: The search retrieved 26 studies (between 1997 and 2019). Stroke recurrence rate ranged from 5.7% to 51.3%. Recurrent stroke was most frequent in large artery atherosclerosis (LAA) and cardioembolic (CE) stroke with recurrent stroke similar to index stroke subtype. We identified a lower recurrence rate for small vessel occlusion (SVO) stroke with recurrence frequently of another stroke subtype. Based on a meta-analysis the summary proportion recurrence rate of recurrent stroke in studies using TOAST-criteria = 0.12 and = 0.14 in studies using TOAST-like criteria. Hypertension, diabetes mellitus, atrial fibrillation previous transient ischemic attack, and high stroke severity were independent risk factors for recurrence.

Conclusion: Stroke recurrence rates seem unchanged over time despite the use of secondary prevention. The highest recurrence rate is in LAA and CE stroke eliciting same subtype recurrent stroke. A lower recurrence rate is seen with SVO stroke with a more diverse recurrence pattern. Extensive workup is important in all stroke subtypes - including SVO stroke. Future research needs to identify better preventive treatment and improve compliance to risk factor prevention to reduce stroke recurrence.

Keywords: Secondary prevention; Stroke recurrence; Stroke subtype; TOAST-criteria.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cerebral Small Vessel Diseases / diagnosis
  • Cerebral Small Vessel Diseases / epidemiology*
  • Cerebral Small Vessel Diseases / prevention & control
  • Comorbidity
  • Embolic Stroke / diagnosis
  • Embolic Stroke / epidemiology*
  • Embolic Stroke / prevention & control
  • Female
  • Humans
  • Intracranial Arteriosclerosis / diagnosis
  • Intracranial Arteriosclerosis / epidemiology*
  • Intracranial Arteriosclerosis / prevention & control
  • Ischemic Stroke / diagnosis
  • Ischemic Stroke / epidemiology*
  • Ischemic Stroke / prevention & control
  • Male
  • Middle Aged
  • Prevalence
  • Prognosis
  • Recurrence
  • Risk Assessment
  • Risk Factors
  • Secondary Prevention
  • Time Factors