Clinical Sciences

Burden and Outcome of Prevalent Ischemic Brain

Disease in a National Acute Stroke Registry
Silvia Koton, PhD; Rakefet Tsabari, MD; Noa Molshazki, MSc; Moshe Kushnir, MD;
Radi Shaien, MD; Anda Eilam, MD; David Tanne, MD; on behalf of the NASIS Investigators

Background and Purpose—Previous overt stroke and subclinical stroke are frequent in patients with stroke; yet, their
clinical significance and effects on stroke outcome are not clear. We studied the burden and outcome after acute ischemic
stroke by prevalent ischemic brain disease in a national registry of hospitalized patients with acute stroke.
Methods—Patients with ischemic stroke in the National Acute Stroke Israeli prospective hospital-based registry (February to
March 2004, March to April 2007, and April to May 2010) with information on previous overt stroke and subclinical stroke
per computed tomography/MRI (n=3757) were included. Of them, a subsample (n=787) was followed up at 3 months.
Logistic regression models were computed for outcomes in patients with prior overt stroke or subclinical stroke, compared
with patients with first stroke, adjusting for age, sex, vascular risk factors, stroke severity, and clinical classification.
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Results—Two-thirds of patients had a prior overt stroke or subclinical stroke. Death rates were similar for patients with and
without prior stroke. Adjusted odds ratios (OR; 95% confidence interval [CI]) for disability were increased for patients
with prior overt stroke (OR, 1.31; 95% CI, 1.03–1.66) and subclinical stroke (OR, 1.45; 95% CI, 1.16–1.82). Relative
odds of Barthel Index ≤60 for patients with prior overt stroke (OR, 2.04; 95% CI , 1.14–3.68) and with prior subclinical
stroke (OR, 2.04; 95% CI, 1.15–3.64) were twice higher than for patients with a first stroke. ORs for dependency were
significantly increased for patients with prior overt stroke (OR, 1.95; 95% CI, 1.19–3.20) but not for those with subclinical
stroke (OR, 1.36; 95% CI, 0.84–2.19).
Conclusions—In our national cohort of patients with acute ischemic stroke, nearly two thirds had a prior overt stroke
or subclinical stroke. Risk of poor functional outcomes was increased for patients with prior stroke, both overt and
subclinical.   (Stroke. 2013;44:3293-3297.)
Key Words: follow-up ◼ ischemic stroke ◼ mortality ◼ national registry ◼ outcome ◼ silent brain infarction
◼ subclinical stroke

A lthough rates of stroke death have substantially decreased

in the past decade, stroke remains a major burden of dis-
ease still ranking fourth among causes of death.1 In January
2013, the American Heart Association reported an overall
stroke prevalence of 2.8%.1 According to the World Health
Organization in today’s world, 1 in 6 people worldwide will
have a stroke in their lifetime.2
Stroke survivors show high rates of disability,3,4 high risk
of recurrent stroke, and dementia.5–7 The burden of stroke is
magnified by the fact that, in addition to the patients diag-
nosed with stroke, in population-based studies, subclinical
or silent cerebral infarction has been reported to be present
in 8% to 28% of the population.8 Subclinical infarcts are fre-
quent in patients with stroke8; yet, their clinical significance
and impact on stroke outcome are not clear. They are more
common in older population groups; therefore, their preva-
lence is expected to increase in the future as the proportion
of elderly people globally increases. Silent cerebral infarc-
tions are asymptomatic or at least unidentified; however, they
are associated with increased risk of subsequent stroke and
dementia,9,10 thus taking into account both overt stroke and
subclinical stroke allows for a more accurate evaluation of the
burden of stroke. We aim to study the burden and outcome of
prevalent ischemic brain disease in a national stroke registry
of hospitalized patients with acute stroke.
Subjects and Methods
Study Setting
The National Acute Stroke Israeli is a prospective hospital-based
registry, including all patients with consecutive acute stroke hospi-
talized during February to March 2004, March to April 2007, and
April to May 2010. The registry was approved by the ethical com-
mittees of the participating medical centers. Details on the registry’s
methods have been published.11–13 Overall, 6279 patients with acute
stroke were included in National Acute Stroke Israeli; 4452 of them
diagnosed with ischemic stroke. The present observational study
included 3757 patients with ischemic stroke with information on pri-
or overt stroke per history and subclinical stroke, based on brain com-
puted tomography (CT) or MRI. A subsample, including all patients

Received May 18, 2013; final revision received August 16, 2013; accepted August 19, 2013.
From the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (S.K., D.T.); Department of Neurology, Chaim Sheba Medical Center, Tel-
Hashomer, Israel (R.T., N.M., D.T.); Department of Neurology, Kaplan Medical Center, Rechovot, Israel (M.K., A.E.); and Department of Neurology,
Rivka Ziv Medical Center, Zefat, Israel (R.S.).
Correspondence to David Tanne, MD, Sagol Neuroscience Center, Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel. E-mail tanne@post.tau.ac.il
© 2013 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.113.002174

3293
 3294  Stroke  December 2013

with ischemic stroke hospitalized during the National Acute Stroke
Israeli 2007 and 2010 periods in 8 hospitals, was followed up at 3
months. These hospitals were chosen to include various geographical
areas, managing agents (government and the largest health fund), and
hospital size. In total, 850 patients with ischemic stroke hospitalized
at baseline in these 8 hospitals survived for the first 3 months after
stroke, 787 of them (92.6%) were included in the follow-up.
Data Collection and Study Variables
A structured form was used for collection of data on patients’ charac-
teristics, clinical diagnoses, stroke management, in-hospital compli-
cations, and outcome at discharge.
To assure completeness of data, a coordinating physician at each
medical center was assigned who was responsible for data collection
in all the hospital wards. Data checks for completeness and consis-
tency were performed at a central coordinating center, on the basis
of discharge medical reports and through computerized data queries.
The occurrence of stroke before the present event was reported on
the form. Old brain infarcts were identified with head CT/MRI on
admission. Severity of stroke was categorized into 3 categories ac-
cording to the National Institutes of Health Stroke Scale score; stroke
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as stroke severity, causes, clinical classification, medications at dis-
charge, and outcomes.
Logistic regression models were computed for outcome variables,
and odds ratios (ORs; 95% confidence interval [CI]) were presented
for patients with prior overt stroke and patients with prior subclinical
stroke, compared with patients with no prior infarction. Three models
were studied: model 1, adjusting for age and sex; model 2, further
adjusting for National Institutes of Health Stroke Scale, hyperten-
sion, ischemic heart disease, diabetes mellitus, atrial fibrillation,
chronic kidney disease, prior disability (modified Rankin Scale, ≥2),
peripheral artery disease, dementia; and model 3, adjusting also for
Oxfordshire classiffication of stroke. Analyses were performed with
SAS 9.2 (SAS; SAS Institute, Cary, NC).
Results
Baseline Characteristics
In our national registry, prevalence of ischemic brain disease
posed a significant health burden: approximately two thirds of
patients with ischemic stroke had a prior overt stroke or subclin-

subtype was defined with the Trial of Org 10172 in Acute Stroke
Treatment (TOAST) classification, and the Oxfordshire classifica-
tion was used for the clinical classification of stroke. Follow-up data
were collected from survivors at 3 months through a telephone in-
terview conducted using a form specially designed for this purpose.
Definition of Stroke Outcomes
At discharge, we assessed in-hospital death, complications, dis-
charge to a nursing home, and disability defined as modified Rankin
Scale ≥2 at discharge. Three months after stroke, disability (Barthel
Index≤60) and dependency (by 2-simple questions) were assessed in
patients who survived the hospitalization period, and total mortality
during the first 3 months was reported.
Statistical Analysis
Characteristics of patients, risk factors, and comorbidities on admis-
sion were presented for patients with no prior infarction, prior overt
stroke, and subclinical stroke. Differences in age between the groups
were studied with ANOVA, and χ2 test was used for the comparison
of the distribution of sex, vascular risk factors, comorbidities, as well
ical stroke. The proportions of prior overt stroke and subclinical
stroke were similar. The distribution of patients’ characteristics
by group is shown in Table 1. Patients with prior ischemic brain
damage were aged >4 years than those with no prior infarc-
tion. The distribution of sex was similar in all groups. Atrial
fibrillation, dyslipidemia, ischemic heart disease, and chronic
kidney disease were more common in patients with prior isch-
emic brain damage, both subclinical stroke and overt stroke,
compared with those with no prior infarction. Significant dif-
ferences in rates of hypertension, diabetes mellitus, dementia,
prior disability (P<0.001 for all), and peripheral artery disease
(P=0.001) were present, with rates lowest in patients with first
stroke, higher in patients with prior subclinical stroke, and high-
est for patients with prior overt stroke. Minor neurological defi-
cits (National Institutes of Health Stroke Scale, 0–5) were less
common in patients with prior stroke (Table 2). Management
of stroke differed by group: patients with prior ischemic brain
damage underwent less vascular imaging while statins and

Table 1.  Baseline Characteristics of Patients With Ischemic Stroke by Prior Stroke Status, n=3757
First Stroke, Prior Subclinical Stroke, Prior Overt Stroke,
n=1329 (35.4) n=1136 (30.2) n=1292 (34.4) P Value
Age (SD), y 68.2 (13.8) 73.4 (12.1) 72.3 (11.9) <0.001
Women 612 (46.0) 503 (44.3) 573 (44.3) 0.59
Hypertension 918 (69.4) 917 (80.8) 1088 (84.5) <0.001
Atrial fibrillation 214 (16.2) 226 (20.0) 267 (21.1) 0.004
Diabetes mellitus 483 (36.4) 467 (41.1) 617 (48.0) <0.001
Current smoking 296 (22.5) 227 (20.1) 235 (18.7) 0.05
Dyslipidemia 666 (50.2) 695 (61.3) 807 (62.9) <0.001
Carotid stenosis >50% 25 (1.9) 21 (1.9) 74 (5.9) <0.001
Chronic heart failure 170 (12.9) 161 (14.3) 194 (15.3) 0.21
Ischemic heart disease 338 (25.7) 347 (30.7) 454 (35.6) <0.001
Peripheral artery disease 76 (5.8) 82 (7.3) 121 (9.6) 0.001
Chronic kidney disease 118 (8.9) 176 (15.5) 226 (17.7) <0.001
Dementia 74 (5.8) 112 (10.2) 173 (13.9) <0.001
Prior disability (mRS≥2) 259 (19.9) 329 (29.6) 664 (52.8) <0.001
Data represent number of patients and percentage unless otherwise specified. Atrial fibrillation by history of chronic or paroxysmal
atrial fibrillation or diagnosed during hospitalization. Ischemic heart disease includes history of MI, angina pectoris, coronary artery
bypass grafting, or percutaneous coronary intervention for revascularization. mRS indicates modified Rankin Scale.
 Koton et al   Burden of Prevalent Ischemic Brain Disease    3295

blood pressure control treatment were more often recom-
mended to them at discharge (Table 2).
Stroke Outcome at Discharge
Two-hundred fourteen patients (5.7%) died during hospital-
ization. Similar death rates were observed for patients with
first stroke, prior subclinical stroke, and prior overt stroke
(P=0.1). However, after adjustment for age and sex, death
risk estimates were decreased for patients with prior overt
stroke (OR, 0.65; 95% CI, 0.47–0.90) and prior subclinical
stroke (OR, 0.54; 95% CI, 0.38–0.78) compared with those
with first stroke. Findings were consistent after further adjust-
ment (Table 3). Proportions of in-hospital complications were
also similar for all study groups (≈28%; P=0.90), and no
significant increase in risk of complications was found after
adjustment for risk factors (Table 3). Unadjusted rates of dis-
charge to a nursing home and disability at discharge were low-
est in patients with first stroke, higher in patients with prior
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Adjusted estimates for disability were increased for patients
with prior overt stroke (OR, 1.31; 95% CI, 1.03–1.66) and
prior subclinical stroke (OR, 1.45; 95% CI, 1.16–1.82) com-
pared with those with first stroke (Table 3).
Stroke Outcome 3 Months After Stroke
Adjusted ORs (95% CIs) for poor outcomes at 3-month follow-
up are presented in Table 4. No significant differences in rates of
death at 3 months were found between the groups, and adjusted
risk estimates were not significantly increased for patients with
prior overt stroke (OR, 0.70; 95% CI, 0.41–1.19) and with prior
subclinical stroke (OR, 0.70; 95% CI, 0.41–1.22). The groups
differed in rates of functional outcomes at 3 months: rates of
disability and dependency were higher for patients with prior
ischemic brain damage than for those without. Among patients
with prior ischemic brain damage, those with prior overt stroke
showed higher rates of poor functional outcomes than those
with prior subclinical stroke. The estimated risk of Barthel

subclinical stroke, and highest for patients with prior overt Index ≤60 for patients with both prior overt stroke (OR, 2.04;
stroke (P<0.001). Adjusted ORs for discharge to a nursing 95% CI, 1.14–3.68) and prior subclinical stroke (OR, 2.04;
home were significantly increased for patients with prior overt 95% CI, 1.15–3.64) were twice higher than for patients with
stroke but not for those with prior subclinical stroke (Table 3). a first stroke. Adjusted ORs (95% CI) for dependency were

Table 2.  Stroke Characteristics and In-hospital Management by Prior Stroke Status, n=3757
First Stroke, Prior Subclinical Stroke, Prior Overt Stroke,
n=1329 (35.4) n=1136 (30.2) n=1292 (34.4) P Value
Stroke characteristics
 NIHSS score <0.001
  
NIHSS 0–5 719 (54.3) 611 (53.8) 574 (44.5)
  
NIHSS 6–10 301 (22.7) 298 (26.3) 409 (31.7)
NIHSS ≥11
   305 (23.0) 226 (19.9) 306 (23.7)
 Stroke subtype
  
Cardioembolic 253 (19.0) 221 (19.5) 240 (18.6) 0.86
  Large vessel atherosclerosis 110 (8.3) 99 (8.7) 100 (7.7) 0.68
  Small vessel occlusive 393 (29.6) 354 (31.2) 369 (28.6) 0.37
  Other determined cause 16 (1.2) 10 (0.9) 16 (1.2) 0.66
Procedure related
   20 (1.5) 10 (0.9) 5 (0.4) 0.01
  
Undetermined 555 (41.8) 457 (40.2) 569 (44.0) 0.16
 Oxfordshire classification <0.001
  Total anterior circulation 127 (10.1) 79 (7.3) 100 (8.2)
  Partial anterior circulation 537 (42.6) 445 (41.1) 533 (43.5)
Posterior circulation
   316 (25.0) 229 (21.1) 286 (23.3)
  
Lacunar 282 (22.3) 331 (30.5) 307 (25.0)
In-hospital diagnostic tests
 Vascular imaging 567 (42.7) 433 (38.1) 411 (31.8) <0.001
 Echocardiography 327 (24.6) 252 (22.2) 197 (15.2) <0.001
Medications at discharge
 Statins 610 (48.1) 613 (55.6) 722 (58.0) <0.001
 Clopidogrel 200 (15.7) 308 (27.9) 521 (41.8) <0.001
 Blood pressure control 909 (71.7) 914 (82.9) 1056 (84.5) <0.001
 Anticoagulants in atrial fibrilation 100 (49.3) 88 (40.7) 109 (42.9) 0.19
patients
Data represent number of patients and percentage unless otherwise specified. Vascular imaging includes transcranial doppler,
computed tomography/MR angiography, carotid duplex, cerebral angiography. Echocardiography includes transthoracic or
transesophageal echocardiography. Blood pressure control: β-blockers, diuretics, angiotensin-converting enzyme inhibitors,
angiotensin II receptor blockers, Ca-antagonists. NIHSS indicates National Institutes of Health Stroke Scale.
 3296  Stroke  December 2013

Table 3.  Risk Estimates for Poor Outcome at Discharge Table 4.  Risk Estimates for Poor Outcome 3 Months After
for Patients With Prior Subclinical Stroke or Overt Stroke Stroke for Patients With Prior Subclinical Stroke or Overt
Compared With First Stroke, n=3757 Stroke Compared With First Stroke, n=787
OR (95% CI) OR (95% CI)
First Stroke Prior Subclinical Stroke Prior Overt Stroke First Stroke Prior Subclinical Stroke Prior Overt Stroke
In-hospital death Death ≤3 mo
 Model 1 1 0.54 (0.38–0.78) 0.65 (0.47–0.90)  Model 1 1 0.58 (0.36–0.87) 0.75 (0.49–1.14)
 Model 2 1 0.57 (0.37–0.87) 0.52 (0.34–0.78)  Model 2 1 0.67 (0.39–1.16) 0.67 (0.40–1.14)
 Model 3 1 0.60 (0.39–0.92) 0.54 (0.36–0.82)  Model 3 1 0.70 (0.41–1.22) 0.70 (0.41–1.19)
In-hospital complications Barthel Index ≤60
 Model 1 1 0.86 (0.71–1.03) 0.91 (0.76–1.09)  Model 1 1 1.38 (0.89–2.15) 1.90 (1.23–2.94)
 Model 2 1 0.97 (0.79–1.21) 0.82 (0.66–1.02)  Model 2 1 2.09 (1.19–3.66) 1.97 (1.11–3.49)
 Model 3 1 1.01 (0.82–1.26) 0.84 (0.68–1.05)  Model 3 1 2.04 (1.15–3.64) 2.04 (1.14–3.68)
Discharge to a nursing home Dependency by 2 simple questions
 Model 1 1 1.00 (0.68–1.46) 2.10 (1.53–3.01)  Model 1 1 1.06 (0.71–1.59) 2.19 (1.46–3.28)
 Model 2 1 1.03 (0.65–1.62) 1.51 (1.00–2.29)  Model 2 1 1.29 (0.81–2.06) 1.94 (1.19–3.15)
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 Model 3 1 1.04 (0.66–1.65) 1.56 (1.02–2.37)
Disability (mRS≥2 at discharge)
 Model 1 1 1.25 (1.05–1.50) 2.04 (1.71–2.44)
 Model 2 1 1.43 (1.14–1.78) 1.28 (1.01–1.62)
 Model 3 1 1.45 (1.16–1.82) 1.31 (1.03–1.66)
Model 1: adjusted for age and sex; model 2: adjusted for age, sex, National
Institutes of Health Stroke Scale, hypertension, ischemic heart disease, diabetes
mellitus, atrial fibrillation, chronic kidney disease, prior disability (mRS≥2),
peripheral artery disease, dementia; model 3: adjusted for age, sex, National
Institutes of Health Stroke Scale, hypertension, ischemic heart disease, diabetes
mellitus, atrial fibrillation, chronic kidney disease, prior disability (mRS≥2),
peripheral artery disease, dementia, Oxfordshire classiffication. CI indicates
confidence interval; mRS, modified Rankin Scale; and OR, odds ratio.
significantly increased for patients with prior overt stroke (OR,
1.95; 95% CI, 1.19–3.20) but not for those after subclinical
stroke (OR, 1.36; 95% CI, 0.84–2.19; Table 4).
Discussion
National data show that, among unselected patients hospi-
talized for acute ischemic stroke, one third has a prior overt
stroke and one third has a prior subclinical infarction by head
CT. Patients with prior ischemic brain disease have higher
prevalence of risk factors and comorbidities than those with no
prior infarction. Mortality rates were similar for patients with
and without prior infarction. However, risk of poor functional
outcome at discharge and 3 months after stroke was increased
for patients with prior stroke, both overt and subclinical.
Although mortality rates were similar for the 3 groups,
and no significant difference in the adjusted risk of death at
3 months was evident, adjusted risk estimates for death dur-
ing hospitalization were reduced for patients with prior stroke
(overt and subclinical) compared with those with a first stroke.
Lower stroke severity in patients with a preceding transient
ischemic attack has been reported14; however, our findings do
not show significant higher rates of severe stroke in patients
with no history of overt stroke or subclinical stroke. It could
also be claimed that medical treatment before the stroke influ-
enced our findings; however, this possible effect was studied
using multivariable models, including treatment with anti-
thrombotics, statins, and antihypertensives. Our findings were
 Model 3 1 1.36 (0.84–2.19) 1.95 (1.19–3.20)
Dependency by 2 simple questions: odds ratios calculated for dependent.
The reference group was independent and recovered or independent. Model 1:
adjusted for age and sex; model 2: adjusted for age, sex, National Institutes of
Health Stroke Scale, hypertension, ischemic heart disease, diabetes mellitus,
atrial fibrillation, chronic kidney disease, prior disability (modified Rankin
Scale, ≥2), peripheral artery disease, dementia; model 3: adjusted for age, sex,
National Institutes of Health Stroke Scale, hypertension, ischemic heart disease,
diabetes mellitus, atrial fibrillation, chronic kidney disease, prior disability
(modified Rankin Scale, ≥2), peripheral artery disease, dementia, Oxfordshire
classiffication. CI indicates confidence interval; and OR, odds ratio.
consistent after adjustment for medical treatment (data not
shown). Lower mortality in patients with prior stroke (overt
and subclinical) compared with patients with a first stroke is
an interesting finding warranting further research.
Comparison With Previous Studies
The reported prevalence of silent infarctions varies according
to the definition of infarction and to the population studied.
Previous studies based on CT reported 11% to 38% prevalence
of silent stroke in patients with stroke8; our study supports
these previous findings. Subclinical infarcts are not necessar-
ily silent. They could be present in those that were clinically
diagnosed, but the patient failed to report the prior stroke,
and in those with subtle symptoms that were not reported or
diagnosed by the physician. They have been associated with
physical functional decline,15 frailty,16 impaired cognition, and
visual field deficits.17 Furthermore, in population-based stud-
ies, patients with silent infarcts have a significantly increased
risk of stroke9,10 and of dementia,18 independent of other risk
factors. Taking in account the potential impact of silent infarc-
tion, its prevalence should be taken into account when esti-
mating the overall burden of stroke.
Regarding the significance of prevalent silent infarctions for
patients with acute stroke, previous studies have not reported in
associations with stroke outcome.19,20 Our findings differ from
those reports: we found that risks of short- and long-term dis-
ability for patients with ischemic stroke with prior subclinical
stroke are similar to those with prior overt stroke. On the basis
of our national data, we found that subclinical stroke should be
considered an important cause of functional disability in the
 Koton et al   Burden of Prevalent Ischemic Brain Disease    3297
adult population, similar to overt strokes. The effect of sub-
clinical stroke on the global burden of stroke is expected to
increase with the increase in the proportion of elderly popula-
tions. It has been suggested previously to consider clinically
diagnosed stroke as the tip of the iceberg of cerebrovascular
disease.21 Subclinical stroke, transient ischemic attack, and
overt strokes are all forms of atherothombotic vascular dis-
ease22 and should all be taken in account in the implementation
of preventive strategies aimed at reducing the burden of stroke.
Strengths and Limitations
Our study is based on national data on unselected patients hos-
pitalized with acute ischemic stroke throughout all hospitals
nationwide. A coordinating physician at each medical center
was assigned who was responsible for complete data collection.
Patients not admitted were not included and it is possible that
some minor strokes were misdiagnosed or missed, but selec-
tion bias because of exclusion of hospitalized patients is not
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reasonable in our study. Experienced physicians defined prior
infarctions on the basis of CT/MRI on admission. However,
only 1.8% of patients underwent MRI, thus categorization of
subclinical infarction was based mostly on CT. Because the
sensitivity to detect infarcts is lower for CT than for MRI,8
the reported frequency of subclinical infarctions likely under-
estimates their true prevalence in patients with acute stroke.
Follow-up data on stroke survivors were not available for the
entire cohort; however, hospitals selected for collection of fol-
low-up data were chosen to include various geographical areas,
managing agents, and hospital size; 92.6% of the survivors in
these hospitals consented to be followed up. Finally, because no
information is collected in our registry on patients not hospital-
ized, it is important to assess the generalizability of our findings
for patients not admitted because of acute ischemic stroke.
Conclusions
In an unselected national cohort of patients with acute ischemic
stroke, nearly two thirds had a prior overt stroke or subclini-
cal stroke by CT. Poor functional outcomes were more com-
mon in patients with prior stroke, both overt and subclinical.
These findings are of particular importance, given the updated
definition of stroke for the 21st century.23 Preventive strategies
should be similar for patients with prior ischemic brain damage
irrespective of the reported presence of stroke symptoms.
Sources of Funding
The National Acute Stroke Israeli Project is supported by the Israeli
Center for Disease Control, Israeli Ministry of Health and by MSD,
Novo-Nordisk, Pfizer, Sanofi-Aventis, Rafa Laboratories and Teva.
Disclosures
None.
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 Burden and Outcome of Prevalent Ischemic Brain Disease in a National Acute Stroke
Registry
Silvia Koton, Rakefet Tsabari, Noa Molshazki, Moshe Kushnir, Radi Shaien, Anda Eilam and
David Tanne
on behalf of the NASIS Investigators
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Stroke. 2013;44:3293-3297; originally published online September 24, 2013;

doi: 10.1161/STROKEAHA.113.002174
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