Diagnostic and Therapeutic Gaps in Recurrent Stroke Management: Real-World Insights from a Ghanaian Hospital-based Registry.

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Priscilla Abrafi Opare-Addo, Fred Stephen Sarfo, Minas Aikins, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8489763/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Recurrent strokes account for up to 1 out of 4 strokes in Low-and-Middle-Income-Countries (LMICs), culminating in worsening of outcomes. International guidelines recommend subtype-specific etiological workup to help tailor strategies for prevention of recurrence after an index stroke. However, huge gaps in secondary stroke prevention persist in LMICs. Objectives We aimed to assess the extent of diagnostic evaluation (for risk-factor and underlying etiological identification) and treatment approaches among recurrent stroke patients in a Ghanaian tertiary hospital. Methods This was a cross-sectional study among recurrent stroke cases admitted to Komfo Anokye Teaching Hospital between 2023 and 2024. The data was analyzed using SPSS Version 28. Results Recurrent strokes accounted for 17.8% of all stroke admissions over 2 years, with ischemic stroke comprising 76.2% of these recurrent events. Hypertension was the most dominant modifiable risk factor among both ischemic and hemorrhagic subtypes, 96.1% and 92.1% respectively, (p = 0.297). Most ischemic strokes had no diagnostic evaluation to determine etiology beyond classification as lacunar/ non-lacunar. Only 7.9% of hemorrhagic strokes underwent Computed tomography angiography (CTA)/ Magnetic resonance angiography (MRA) to evaluate for structural causes. The majority of ischemic stroke patients were prescribed a statin and an antiplatelet. However, anticoagulant therapy was used only in a minority of patients (3.91%). Carotid endarterectomy or carotid stenting was not performed for any of the ischemic stroke patients. Conclusion Our findings highlight significant gaps in recurrent stroke evaluation and management in the Ghanaian setting. Standardized algorithms for secondary stroke prevention and treatment are urgently needed to prevent recurrence. Recurrent Stroke Secondary prevention Risk-factors Etiologies Sub-Saharan Africa Introduction Up to 25% of stroke survivors in Low-Middle-Income-Countries (LMICs) suffer recurrence within the first 5 years of an index stroke. 1 , 2 Stroke recurrence is frequently associated with dismal functional outcomes, longer hospital stays, greater healthcare costs, and higher case fatality rates. 3 This has serious global health and economic implications. 4 Structured systems for prevention are required to avert such dire repercussions. The specific strategies for the prevention of recurrence after stroke heavily depend on the particular stroke subtype. International guidelines, therefore, recommend an extensive diagnostic workup after index stroke, where possible, to define associated risk and etiological factors. 5 , 6 This approach informs the tailoring of treatments to effectively target and interrupt the underlying pathophysiological mechanism. However, despite holding the highest population of stroke survivors globally, huge gaps in secondary stroke prevention persist in LMICs. 7 , 8 Considering that recurrent strokes are highly preventable if appropriately mitigated, understanding the routine practices in real-world LMIC settings could inform future initiatives to improve and standardize secondary stroke prevention. 2 , 5 This study sought to assess the extent of diagnostic evaluation (for risk-factor and underlying etiological identification) and treatment approaches to mitigation among recurrent stroke patients in a Ghanaian tertiary hospital. Methods Study design This was a cross-sectional study among recurrent stroke cases admitted to Komfo Anokye Teaching Hospital. Study settings This study was conducted at the Komfo Anokye Teaching Hospital (KATH), which is the second-largest tertiary referral institution in Ghana, serving an estimated population of over 12 million and receiving referrals from 10 out of 16 administrative regions in Ghana. KATH is located in Kumasi, the capital city of the Ashanti region. Study population The cases included patients with recurrent strokes, aged 18 years and above. Cases were recruited from September 2023 to September 2025. Data collection Demographic variables included age and sex, type of domicile, and National Health Insurance (NHIS) status, while clinical features included frequency of stroke recurrence, outcome of admission, and complications. Stroke risk factors included hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, cigarette smoking, alcohol use, and the number of previous strokes. Hypertension was based on a self-reported history of hypertension, or use of antihypertensive before stroke onset, or with confirmed medical records, or a BP cut-off of at least 140/90 mm Hg. Diabetes mellitus was defined based on a history of diabetes mellitus, use of antidiabetic medications, confirmed medical records, or an HbA1c > 6.5%. 9 Dyslipidaemia was defined as fasting total cholesterol ≥ 5.2 mmol/L, HDL-C (high-density lipoprotein cholesterol) ≤ 1.03 mmol/L, triglyceride ≥ 1.7 mmol/L, or LDL-C (low-density lipoprotein cholesterol) ≥ 3.4 mmol/L or use of lipid-lowering drug prior to stroke onset. 10 Etiological classification for ischemic stroke was based on the TOAST Classification (Trial of Org 10,172 in Acute Stroke Treatment). Etiologies included cardio-embolic, large-artery, small vessel, and ischemic stroke of undetermined etiology. 11 For ICH, etiological classification was based on SMASH U, comprising Structural, Medication, Amyloid Angiopathy, Systemic diseases, Hypertension, and Undetermined. 12 Stroke treatment, including antihypertensives, antiplatelets, statins, oral hypoglycaemics, and anticoagulants, and interventions such as carotid endarterectomy and stenting, was recorded. Recurrent stroke was defined as a new focal neurological deficit occurring after an index stroke with imaging evidence of infarction consistent with symptoms, OR lasting > 24 hours without imaging evidence, AND not attributable to a non-ischemic etiology; AND acute extravasation of blood into the brain parenchyma, subarachnoid or intraventricular space, judged to be non-traumatic and identified as the cause of new neurologic symptoms. 13 ICH severity was assessed with the National Institutes of Health Stroke Scale (NIHSS) score. 14 Lacunar stroke was defined by the presence of a lacunar syndrome or subcortical stroke measuring < 1.5 cm in diameter on CT or MRI. 15 Data Analysis The data extracted from case report forms was entered into a predesigned database using Microsoft Excel 2021. The data was subsequently cleaned and double-checked for errors and then exported to SPSS Version 28 for further validation and analysis. Categorical variables were summarized as frequencies and percentages. Mean with standard deviation will be used for numerical variables with a normal distribution, while median with interquartile range will be used for those that were skewed. To compare variables across stroke types, the ANOVA-test or Kruskal Wallis test was used for normally or non-normally distributed continuous variables, respectively. Chi-square/Fisher’s Exact tests were used for categorical variables. P-values less than 0.05 were considered to indicate statistical significance for all statistical analyses. Results Socio-demographic and clinical characteristics of recurrent stroke patients Recurrent strokes accounted for 17.8% (302 out of 1701) of all stroke admissions over the 2 years, with ischemic stroke comprising 76.16% of these recurrent events. The mean age of participants was 63.20 ± 13.26 years, and 52.3% were males. Most patients were enrolled in the National Health Insurance Scheme (NHIS) (68.87%). The majority were semi-urban (64.2%) and urban dwellers (25.5%). The median NIHSS score at presentation for recurrent ischemic stroke was 15 (IQR 11), compared to 18 (13.5) for recurrent hemorrhagic strokes (p = 0.027). Among patients with recurrent ischemic strokes, most of the index events were also ischemic (78%). In contrast, only 44.4% of patients with recurrent hemorrhagic strokes had an index hemorrhagic event (p = 0.000). The median length of hospital stay was 9 days (IQR 8). Aspiration pneumonia was the most common in-hospital complication, occurring in 43.6% of patients with ischemic, 46.0% of patients with hemorrhagic, and 66.67% of patients with recurrent untyped strokes (p = 0.491). Generally, in-hospital Case Fatality among patients with recurrent stroke was 25.8%; however, this was highest among patients with untyped recurrent events (57.1%), p = 0.000. (Table I) Table I Socio-demographics and Clinical Characteristics Variables, n (%) All recurrent strokes n = 302 Ischemic recurrent strokes n = 230 Hemorrhagic recurrent strokes n = 63 Untyped recurrent strokes n = 9 p-value Age, mean ± SD 63.20± 13.26 65.26± 12.71 55.10± 12.47 67.86± 10.84 0.000* Gender (Male) 158 (52.3) 119 (51.3) 34 (54.0) 5 (71.4) 0.551 Domicile 0.692 Rural 31 (10.2) 21 (9.0) 9 (14.3) 1 (14.3) Semi-urban 194 (64.2) 149 (64.2) 41 (65.1) 4(57.1) Urban 77 (25.5) 62 (26.7) 13 (20.6) 2 (28.6) National health Insurance Status (Insured) 208 (68.87) 159 (69.13) 43 (68.25) 6 (66.67) 0.535 NIHSS, median (IQR) 16 (12) 15 (11) 18 (13.5) 21 (5) 0.027* Index stroke type 0.000* Ischemic 214 (70.9) 181 (78.0) 30 (47.6 ) 3 (42.9) Hemorrhagic 61 (20.2) 32 (13.8) 28 (44.4) (14.3) Unknown 27 (8.4) 19 (8.2) 5 (7.9) 3 (42.9) Complications of acute stroke Aspiration Pneumonia 136 (45.03) 101 (43.6) 29 (46.0) 6 (66.67) 0.049* UTI 74 (24.50) 59 (25.5) 14 (22.2) 1 (14.3) 0.992 DVT 12 (4.0) 7 (3.04) 4 (6.35) 1 (14.3) 0.893 PE 4 (1.33) 4 (1.74) 0 (0) 0 (0) 0.968 Decubitus ulcers 28 (9.27) 22 (9.5) 6 (9.5) 0 (0) 0.966 Post stroke seizures 53 (17.55) 44 (19.0) 8 (12.6) 1 (14.3) 0.674 Duration of Hospital admission 9 (IQR 8) 8.5 (IQR 9) 9 (IQR 8) 6 (IQR 3) 0.176 In-Hospital Case Fatality 78 (25.8) 51 (22.0) 23 (36.5) 4 (57.1) 0.000* Risk Profile of Recurrent Stroke Patients Among the recurrent stroke patients, 90.1% were admitted with the first episode of recurrence, while 8.9% had experienced two recurrent strokes, and the rest had experienced at least two. Hypertension was the most dominant modifiable risk factor among both ischemic and hemorrhagic subtypes, 96.1% and 92.1%, respectively (p=0.297). Diabetes was identified as a modifiable vascular risk factor in the majority of untyped recurrent stroke (77.78%), while dyslipidemia was mainly identified among patients with recurrent ischemic stroke (p=0.000). Atrial fibrillation was diagnosed in 5.65% of patients with ischemic strokes (p=0.003). Alcohol use was reported in 21.9%, while cigarette smoking (0.3%) and recreational drug use (1%) were uncommon. Compared to recurrent hemorrhagic strokes (69.8%), the majority of recurrent ischemic (85.8%) and untyped stroke patients (85.7%) engaged in <150 minutes of low-moderate intensity/ week physical activity per week (p=0.013). (Table II) Table II Risk Profile of recurrent stroke patients Variables n (%) All recurrent strokes n= 302 Ischemic recurrent strokes n=230 Hemorrhagic recurrent strokes n=63 Untyped recurrent strokes n=9 p-value Alcohol use 66 (21.9) 47 (20.43) 17 (26.98) 2 (28.6) 0.632 Recreational drug use 1(0.3) 1 (0.44) 0 (0) 0 (0) 0.860 Cigarette Smoking 8 (2.7) 7 (3.04) 1 (1.58) 0 (0) 0.762 Hypertension 288(95.4) 223 (96.1) 58 (92.1) 7 (77.78) 0.297 Diabetes 78 (25.8) 67 (29.8) 2 (3.2) 7 (77.78) 0.000* Dyslipidemia 104 (34.44) 96(41.74) 7 (11.11) 1 (11.11) 0.000* Atrial Fibrillation 13 (4.30) 13 (5.65) 0 (0) 0 (0) 0.003* HIV infection 1 (0.33) 1 (0.43) 0 (0) 0 (0) 0.472 Frequency of recurrence 0.059 1 st time 272 (90.1) 205 (88.4) 62 (98.4) 5 (71.4) 2 nd time 27 (8.9) 24 (10.3) 1 (1.6) 2 (28.6) >2 nd time 3 (1) 3 (1.3) 0 (0) 0 (0) Level of physical activity <150 mins low-mod intensity/ week 249 (82.5) 199 (85.8) 44 (69.8) 6 (85.7) 0.013* Gaps diagnostic workup Among patients with recurrent Ischemic strokes, 94.8% had a lipid profile, while 69.1% HBA1c measured (p=0.000). For ischemic non-lacunar strokes, only 28.9% had 12-Lead ECG, 16.4% had Transthoracic echocardiograms, 14.1% underwent Carotid Doppler, 1.56% had Computerized Tomographic (CT) or Magnetic Resonance (MR) Angiography. No participant had 24-72-hour Holter ECG, Transesophageal echocardiography, nor Implantable loop recorder studies performed (Supplementary Tables S1). Only 7.9% of hemorrhagic strokes underwent Computed tomography angiography (CTA)/ Magnetic resonance angiography (MRA). Digital subtraction angiography (DSA) was not performed for any hemorrhagic stroke patients. Gradient echo sequences (GRE )/ Susceptibility weighted imaging (SWI) sequence MRI were not done for any of the hemorrhagic strokes to evaluate for Cerebral Amyloid Angiopathy (CAA). (Table III) Table III Extent of risk and etiological evaluation done for recurrent stroke patients Diagnostic evaluation n(%) All recurrent strokes n= 302 Ischemic recurrent strokes n=230 Hemorrhagic recurrent strokes n=63 Untyped recurrent strokes n=9 p-value Lipid Profile 264 (87.42) 218 (94.78) 43 (68.25) 3 (33.33) 0.000* Hemoglobin A1c 187 (61.92) 159 (69.13) 27 (42.86) 1 (11.11) 0.000* Renal Function 290 (96.03) 226 (98.26) 58 (92.06) 6 (66.67) 0.000* HIV screening 6 (1.99) 5 (2.17) 2 (3.17) 0 (0) 0.80 FBC 300 (99.34) 229 (99.57) 63 (100.0) 8 (88.89) 0.010* Sickle Cell screening 4 (1.32) 4 (1.74) 0 (0) 0 (0) 0.380 Clotting profile 3 (0.99) 0 (0) 3 (4.76) 0 (0) 0.090* 12-Lead ECG 50 (16.56) 43 (18.70) 6 (9.52) 1 (11.1) 0.450 24- 72-hour Holter ECG 0 (0) 0 (0) 0 (0) 0 (0) NA TTE Echo 22 (7.28) 22 (9.57) 0 (0) 0 (0) 0.000* Carotid Doppler 18 (5.96) 18 (7.83) 0 (0) 0 (0) 0.000* CTA/MRA 7 (2.32) 2 (0.87) 5 (7.94) 0 (0) 0.060* DSA 0 (0) 0 (0) 0 (0) 0 (0) NA GRE/SWI MRI 0 (0) 0 (0) 0 (0) 0 (0) NA TEE Echo 0 (0) 0 (0) 0 (0) 0 (0) NA Implantable loop recorder 0 (0) 0 (0) 0 (0) 0 (0) NA APS panel 1 (0.43) 1 (0.43) 0 (0) 0 (0) 0.600 Patterns of Etiological Designation Most non-Lacunarischemic recurrent stroke (88.28%) were presumed to be large vessel arterosclerotic etiology, while the remaining were designated as cardioembolic. Nearly all lacunar strokes (99.02%) were designated as small vessel disease, except one, which was found be due to vertebral dissection. All non-lobar bleeds in hypertensive patients were designated as hypertensive bleeds. The majority of Lobar hemorrhages (83.33%) were attributed to CAA, while 24.99% were confirmed to be from structural causes. (Supplementary Tables S2) S econdary preventi ve therapy in place before stroke recurrence As shown in Supplementary Table 3, the majority of patients were already receiving antihypertensive therapy at the time of recurrent stroke onset, including (55.6%) Calcium Channel Blockers (CCBs), 16.2% on Angiotensin Receptor Blockers (ARB), 5.6% on Thiazides, and 3% on beta blockers. Among patients with prior ischemic stroke, only 3.3% of were on statin therapy, 5.1% were on aspirin, and 0.9% were on Dual Antiplatelet therapy (DAPT) comprising aspirin and clopidogrel. Anticoagulant use was observed in only 3.3% of patients with prior ischemic stroke. None of the patients with prior ischemic stroke had undergone Carotid endarterectomy or Carotid stenting following the index ischemic event. S econdary prevention t reatments and interventions during recurrent stroke The majority of recurrent stroke patients received antihypertensive treatments, including (89.2%) Calcium Channel Blockers (CCBs), and 70.7% on Angiotensin Receptor Blockers (ARB) during the recurrent stroke admission. Among ischemic stroke, 93.1% were prescribed a statin during admission, 80.6% received aspirin, and 14.7% were on clopidogrel. 10.87% of ischemic stroke patients received. Dual Antiplatelet therapy (DAPT). Anticoagulant therapy was used in 3.91% of ischemic strokes. None of the patients underwent Carotid endarterectomy or Carotid stenting (Table IV). Table IV Treatments and interventions received by recurrent stroke patients Medications n (%) All recurrent strokes n= 302 Ischemic recurrent strokes n=230 Hemorrhagic recurrent strokes n=63 Untyped recurrent strokes n=9 P-value Medications CCB 274 (90.7) 207 (89.2) 61 (96.8) 6 (66.7) 0.030* ARB 220 (72.8) 164 (70.7) 52 (82.5) 4 (57.2) 0.120 ACEI 52 (17.2) 36 (15.6) 14 (22.2) 2 (28.6) 0.330 Thiazide 121 (40.1) 78 (33.6) 41 (65.1) 2 (28.6) 0.001* Beta Blocker 153 (50.7) 102 (44.0) 44 (76.2) 3 (42.9) 0.002* Alpha adrenergic receptor 2 (0.6) 1 (0.4) 1 (1.6) 0 (0) 0.471 Methyldopa 21 (7.0) 13 (5.6) 8 (12.7) 0 (0) 0.032* Anticoagulant 10 (3.3) 9 (3.9) 1 (1.6) 0 (0) 0.598 Aspirin 191 (63.3) 187 (80.6) 4 (6.3) 0 (0) 0.000* Clopidogrel 35 (11.6) 34 (14.7) 1 (1.6) 0 (0) 0.005* DAPT 25 (8.28) 25 (10.87) 0 (0) 0 (0) 0.000* Statin 255 (84.5) 216 (93.1) 36 (57.1) 3 (42.9) 0.000* Oral Hypoglycemic agents 58 (19.2) 53 (22.8) 3 (4.8) 2 (28.6) 0.001* Interventions n (%) Carotid endarterectomy 0 (0) 0 (0) 0 (0) 0 (0) NA Carotid stenting 0 (0) 0 (0) 0 (0) 0 (0) NA Discussion Our study has evaluated critical diagnostic and treatment gaps in recurrent stroke management, in a real-life setting in Ghana, on a backdrop of an existing National Health Insurance Scheme (NHIS), and provides very important insights for LMICs. Among our cohort, we found that almost a fifth of stroke cases were recurrent strokes, which is much higher than what was reported in the SIREN study in 2022. 16 This highlights a rising burden of recurrent strokes in Ghana, contrary to the trend in High-Income Countries (HICs) where recurrent strokes are on a decline due to intensification of secondary prevention measures. 17 Ischemic stroke accounted for 76.16% of the recurrent events, which is consistent with the pattern in other SSA countries. 7 , 16 , 18 , 19 Additionally, recurrent strokes were associated with a longer length of hospital stay (median (IQR) of 9 days (IQR 8)) compared to that reported to the index stroke in our setting (median (IQR) of 6 days (IQR 5)). 20 Aspiration pneumonia remained the predominant in-hospital complication, occurring in almost half of patients. 20 In-Hospital Case Fatality among patients with recurrent stroke was 25.8%, which is relatively lower than rates reported in other LMICs. 21 , 22 A plausible explanation may be the incremental improvement in stroke services in our setting over the past few years. We observed a high prevalence of modifiable vascular risk factors, particularly hypertension, diabetes, and dyslipidemia, consistent with other studies in LMICs. 2 , 22 These findings suggest that these risk factors may be the major drivers of stroke recurrence in our setting, underscoring an urgent need to strengthen approaches to mitigation. Recurrent strokes constitute a very high-risk population, requiring careful evaluation to inform strategies for prevention. 23 A key finding that stood out in our study was the limited adherence to recommended etiological and risk evaluation. 5 , 24 Although basic laboratory tests such as Lipid profiles and HbA1c were performed, the workup was remarkably sparse for cardioembolic etiologies. Though readily available, only a minority received 12- lead ECGs and transthoracic echocardiograms. Also, in cases where ECGs were negative, Holter monitoring and implantable cardiac loop monitors were never utilized. Transesophageal echocardiograms were not done in any of the patients. Advanced neurimaging modalities such as CT/ MRI angiograms were sparingly used, and DSA were nonexistent. These gaps underscore substantial constraints in diagnostic capacity. These deficiencies may be driven by multiple barriers, including financial limitations, clinician inertia, absence of structured protocols and systems. Stroke recurrence suggests a possible failure of the initial attempt at interrupting the underlying pathophysiology, making mechanistic profiling highly important, as it has direct consequences for the rate of stroke recurrence. Etiological designation amongst our cohort of recurrent strokes seemed to rely heavily on clinical judgement rather than a comprehensive diagnostic workup. While this approach is generally acceptable for lacunar ischemic strokes, most of which were attributed to small vessel disease, non-lacunar ischemic strokes require a comprehensive etiological workup to rule out potential cardioembolic sources and also confirm other possible etiologies. In our cohort, cardiac evaluation was very limited. This raises concerns about the possibility of underdiagnosis of cardioembolic strokes in our setting. 25 Similarly, vascular imaging was sparingly performed to assess for intracranial and extracranial large vessel atherosclerosis. Given the limited depth of diagnostic evaluation, it is difficult to meaningfully apply the concepts of cryptogenic or Embolic Strokes of Undetermined Source (ESUS) in our setting. Both diagnoses require a thorough minimum workup, including extended cardiac monitoring and vascular evaluation. 5 All non-lobar bleeds in hypertensive patients were designated as hypertensive bleeds. The majority of Lobar hemorrhages were attributed to CAA, without any GRE/SWI sequence MRI. The overreliance on clinical judgement without essential tests could potentially lead to missed opportunities for targeted prevention. There was also a clear mismatch between stroke risk factors, etiologies, and the secondary prevention strategies implemented. 17 , 26 Anticoagulant use among our cohort was strikingly low, including even atrial fibrillation patients with recurrent stroke. Similary no one underwent carotid endarterectomy or carotid stenting. This highlights important challenges in accessing evident based interventions. Limitations This study employed a cross-sectional design, which limits its ability to draw causal inferences. It, however, has some limitations. It was also a single-center study, which limits its external validity. Future directions Pragmatic initiatives incorporating structured risk/ etiological profiling and standardized therapeutic protocols, driven by strong national policies, are required for improved recurrent stroke prevention in Ghana and other resource constrained setting. Substantial effort is required to strengthen stroke care services, expand diagnostic capacity, and build the human resources to adequately mitigate recurrent stroke risk in LMICs. Conclusion Our findings highlight significant gaps in recurrent stroke evaluation and management in Ghana. Standardized prevention models are urgently needed to overcome existing bottlenecks. Non-standard Abbreviations and Acronyms ARB Angiotensin Receptor Blockers CAA Cerebral Amyloid Angiopathy CCBs Calcium Channel Blockers DAPT Dual Antiplatelet therapy GRE Gradient echo sequences LMICs Low-and-Middle-Income-Countries NHISS National Institutes of Health Stroke Scale SIREN Stroke Investigative Research and Educational Network SSA Sub-Saharan Africa SPSS Statistical Package for the Social Sciences SWI Susceptibility weighted imaging TOAST Trial of Org 10,172 in Acute Stroke Treatment Declarations Ethics approval and consent to participate : Ethical approval was obtained from the Committee on Human Research and Publication Ethics, Kwame Nkrumah University of Science and Technology (CHRPE/AP/936/23). This study was conducted in compliance with the Helsinki Declaration. Participants were provided informed consent. However, in instances when subjects were not capable of providing informed consent for their participation due to altered level of consciousness or aphasia, their legal authorized representatives were contacted to provide informed consent to participate on their behalf. Consent to Publish declaration : Not applicable Availability of data and materials: De-identified datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interest: The authors declare no competing interest. Funding Information: None Author contributions: PAOA and FSS contributed to the conception and design of the study; PAOA wrote the first draft of the manuscript; FSS, MA, EA, MN, NOAD, JMH, GM contributed to editing of the text and preparing the figures; PAOA, FSS and EA performed analysis of data, all co-authors have reviewed the manuscript and agree to its submission. Clinical trial number : Not applicable. Acknowledgement statement: None Author information: Directorate of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana Priscilla Abrafi Opare-Addo, Fred Stephen Sarfo, Minas Aikins, Maxwell Nyenaah, Nana Osei Asibey Derkyi, Jessey Mahama Holu, Gordon Manu. Department of Internal Medicine, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Priscilla Abrafi Opare-Addo, Fred Stephen Sarfo and Enock Asante. References Han J, Mao W, Ni J, Wu Y, Liu J, Bai L, et al. Rate and Determinants of Recurrence at 1 Year and 5 Years After Stroke in a Low-Income Population in Rural China. Front Neurol. 2020;11:2. Mbalinda SN, Kaddumukasa M, Najjuma JN, Kaddumukasa M, Nakibuuka J, Burant CJ, et al. Stroke Recurrence Rate and Risk Factors Among Stroke Survivors in Sub-Saharan Africa: A Systematic Review. NDT. 2024;20:783–91. Hardie K, Hankey GJ, Jamrozik K, Broadhurst RJ, Anderson C. Ten-Year Risk of First Recurrent Stroke and Disability After First-Ever Stroke in the Perth Community Stroke Study. Stroke. 2004;35(3):731–5. Yang M, Ju KJ, Chen P, Zhong LL. Risk Factors for Recurrent Stroke and the Impact of Targeted Health Management. Risk Manag Healthc Policy. 2025;18:2759–67. Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021 July;52(7):e364–467. Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022 July;53(7):e282–361. Kolmos M, Christoffersen L, Kruuse C. Recurrent Ischemic Stroke – A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis. 2021;30(8):105935. Opare-Addo PA, Sarfo FS, Berchie PO, Aikins M, Ovbiagele B. Participation by patients from low- and middle-income countries (LMICs) in trial evidence supporting secondary stroke prevention guideline recommendations. J Neurol Sci. 2023;448:120641. American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2018. Diabetes Care. 2017;41(Supplement_1):S13–27. Lorenzo C, Williams K, Hunt KJ, Haffner SM. The National Cholesterol Education Program–Adult Treatment Panel III, International Diabetes Federation, and World Health Organization Definitions of the Metabolic Syndrome as Predictors of Incident Cardiovascular Disease and Diabetes. Diabetes Care. 2007;30(1):8–13. Adams HP, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35–41. Meretoja A, Strbian D, Putaala J, Curtze S, Haapaniemi E, Mustanoja S, et al. Smash-u Stroke. 2012;43(10):2592–7. Wang Y, Xu J, Zhao X, Wang D, Wang C, Liu L, et al. Association of hypertension with stroke recurrence depends on ischemic stroke subtype. Stroke. 2013;44(5):1232–7. Kwah LK, Diong J. National Institutes of Health Stroke Scale (NIHSS). J Physiother. 2014;60(1):61. Gore M, Bansal K, Khan Suheb MZ, Lui F, Asuncion RMD. Lacunar Stroke. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 Dec 8]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK563216/ Akpalu A, Sarfo FS, Akinyemi J, Wahab K, Komolafe M, Obiako R, et al. Frequency & factors associated with recurrent stroke in Ghana and Nigeria. J Neurol Sci. 2022;439:120303. Flach C, Muruet W, Wolfe CDA, Bhalla A, Douiri A. Risk and Secondary Prevention of Stroke Recurrence: A Population-Base Cohort Study. Stroke. 2020;51(8):2435–44. Massi DG, Nyassinde J. Risk factors of stroke recurrence in a low income country: case of Senegal (P6.289). Neurology. 2017;88(16supplement):P6289. Dabilgou AA, Dravé A, Kyelem JMA, Zoungrana R, Napon C, Millogo A, et al. Frequency of recurrent stroke in Burkina Faso: an observational hospital based study of 6 months. Pan Afr Med J. 2021;40:108. Sarfo FS, Acheampong JW, Appiah LT, Oparebea E, Akpalu A, Bedu-Addo G. The Profile of Risk Factors and In-Patient Outcomes of Stroke in Kumasi, Ghana. Ghana Med J. 2014 Sept;48(3):127–34. Nutakki A, Chomba M, Chishimba L, Zimba S, Gottesman RF, Bahouth MN, et al. Characteristics of adults with first-ever stroke vs. recurrent stroke at the university teaching Hospital in Lusaka, Zambia. J Neurol Sci. 2025;472:123473. Lekoubou A, Nkoke C, Dzudie A, Kengne AP. Recurrent Stroke and Early Mortality in an Urban Medical Unit in Cameroon. J Stroke Cerebrovasc Dis. 2017;26(8):1689–94. Kolmos M, Christoffersen L, Kruuse C. Recurrent Ischemic Stroke - A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis. 2021;30(8):105935. Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022 July;53(7):e282–361. Adebayo O, Akpa O, Asowata OJ, Fakunle A, Sarfo FS, Akpalu A, et al. Determinants of First-Ever Stroke Severity in West Africans: Evidence From the SIREN Study. J Am Heart Association. 2023 June;20(12):e027888. Wang Y. Residual recurrence risk of ischaemic cerebrovascular events: concept, classification and implications. Stroke Vasc Neurol. 2021;6(2):155–7. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8489763","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":578594755,"identity":"c4cc069e-c323-472b-9e6f-7772d3fd7ce5","order_by":0,"name":"Priscilla Abrafi Opare-Addo","email":"data:image/png;base64,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","orcid":"","institution":"Komfo Anokye Teaching Hospital","correspondingAuthor":true,"prefix":"","firstName":"Priscilla","middleName":"Abrafi","lastName":"Opare-Addo","suffix":""},{"id":578594756,"identity":"0b9ae0b6-ffc8-4170-a6ce-ab20a8ffc7b4","order_by":1,"name":"Fred Stephen Sarfo","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Fred","middleName":"Stephen","lastName":"Sarfo","suffix":""},{"id":578594757,"identity":"737a0d2e-7345-46c4-957d-5289ce2acf48","order_by":2,"name":"Minas Aikins","email":"","orcid":"","institution":"Komfo Anokye Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Minas","middleName":"","lastName":"Aikins","suffix":""},{"id":578594758,"identity":"32b9fa8f-03a9-4c2e-8239-579e55193505","order_by":3,"name":"Enock Asante","email":"","orcid":"","institution":"Kwame Nkrumah University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Enock","middleName":"","lastName":"Asante","suffix":""},{"id":578594760,"identity":"40c53c90-ab8e-445f-b396-cb62b6268f8e","order_by":4,"name":"Maxwell Nyanaah","email":"","orcid":"","institution":"Komfo Anokye Teaching 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14:11:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1361551,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8489763/v1/73b5401b-7040-4579-a105-41c4ba3937bd.pdf"},{"id":100989939,"identity":"b2323d9d-7f6c-4e4f-b5be-7f08847b7653","added_by":"auto","created_at":"2026-01-23 14:10:59","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21819,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8489763/v1/2531d28977fc00292563b9eb.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDiagnostic and Therapeutic Gaps in Recurrent Stroke Management: Real-World Insights from a Ghanaian Hospital-based Registry.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eUp to 25% of stroke survivors in Low-Middle-Income-Countries (LMICs) suffer recurrence within the first 5 years of an index stroke.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Stroke recurrence is frequently associated with dismal functional outcomes, longer hospital stays, greater healthcare costs, and higher case fatality rates.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e This has serious global health and economic implications.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Structured systems for prevention are required to avert such dire repercussions.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe specific strategies for the prevention of recurrence after stroke heavily depend on the particular stroke subtype. International guidelines, therefore, recommend an extensive diagnostic workup after index stroke, where possible, to define associated risk and etiological factors.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e This approach informs the tailoring of treatments to effectively target and interrupt the underlying pathophysiological mechanism. However, despite holding the highest population of stroke survivors globally, huge gaps in secondary stroke prevention persist in LMICs.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Considering that recurrent strokes are highly preventable if appropriately mitigated, understanding the routine practices in real-world LMIC settings could inform future initiatives to improve and standardize secondary stroke prevention.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study sought to assess the extent of diagnostic evaluation (for risk-factor and underlying etiological identification) and treatment approaches to mitigation among recurrent stroke patients in a Ghanaian tertiary hospital.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis was a cross-sectional study among recurrent stroke cases admitted to Komfo Anokye Teaching Hospital.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy settings\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study was conducted at the Komfo Anokye Teaching Hospital (KATH), which is the second-largest tertiary referral institution in Ghana, serving an estimated population of over 12\u0026nbsp;million and receiving referrals from 10 out of 16 administrative regions in Ghana. KATH is located in Kumasi, the capital city of the Ashanti region.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe cases included patients with recurrent strokes, aged 18 years and above. Cases were recruited from September 2023 to September 2025.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eDemographic variables included age and sex, type of domicile, and National Health Insurance (NHIS) status, while clinical features included frequency of stroke recurrence, outcome of admission, and complications.\u003c/p\u003e \u003cp\u003eStroke risk factors included hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, cigarette smoking, alcohol use, and the number of previous strokes.\u003c/p\u003e \u003cp\u003eHypertension was based on a self-reported history of hypertension, or use of antihypertensive before stroke onset, or with confirmed medical records, or a BP cut-off of at least 140/90 mm Hg.\u003c/p\u003e \u003cp\u003eDiabetes mellitus was defined based on a history of diabetes mellitus, use of antidiabetic medications, confirmed medical records, or an HbA1c\u0026thinsp;\u0026gt;\u0026thinsp;6.5%.\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDyslipidaemia was defined as fasting total cholesterol\u0026thinsp;\u0026ge;\u0026thinsp;5.2 mmol/L, HDL-C (high-density lipoprotein cholesterol)\u0026thinsp;\u0026le;\u0026thinsp;1.03 mmol/L, triglyceride\u0026thinsp;\u0026ge;\u0026thinsp;1.7 mmol/L, or LDL-C (low-density lipoprotein cholesterol)\u0026thinsp;\u0026ge;\u0026thinsp;3.4 mmol/L or use of lipid-lowering drug prior to stroke onset.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEtiological classification for ischemic stroke was based on the TOAST Classification (Trial of Org 10,172 in Acute Stroke Treatment). Etiologies included cardio-embolic, large-artery, small vessel, and ischemic stroke of undetermined etiology. \u003csup\u003e11\u003c/sup\u003e For ICH, etiological classification was based on SMASH U, comprising Structural, Medication, Amyloid Angiopathy, Systemic diseases, Hypertension, and Undetermined.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eStroke treatment, including antihypertensives, antiplatelets, statins, oral hypoglycaemics, and anticoagulants, and interventions such as carotid endarterectomy and stenting, was recorded.\u003c/p\u003e \u003cp\u003eRecurrent stroke was defined as a new focal neurological deficit occurring after an index stroke with imaging evidence of infarction consistent with symptoms, OR lasting\u0026thinsp;\u0026gt;\u0026thinsp;24 hours without imaging evidence, AND not attributable to a non-ischemic etiology; AND acute extravasation of blood into the brain parenchyma, subarachnoid or intraventricular space, judged to be non-traumatic and identified as the cause of new neurologic symptoms.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e ICH severity was assessed with the National Institutes of Health Stroke Scale (NIHSS) score.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eLacunar stroke was defined by the presence of a lacunar syndrome or subcortical stroke measuring\u0026thinsp;\u0026lt;\u0026thinsp;1.5 cm in diameter on CT or MRI.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe data extracted from case report forms was entered into a predesigned database using Microsoft Excel 2021. The data was subsequently cleaned and double-checked for errors and then exported to SPSS Version 28 for further validation and analysis.\u003c/p\u003e \u003cp\u003eCategorical variables were summarized as frequencies and percentages. Mean with standard deviation will be used for numerical variables with a normal distribution, while median with interquartile range will be used for those that were skewed. To compare variables across stroke types, the ANOVA-test or Kruskal Wallis test was used for normally or non-normally distributed continuous variables, respectively. Chi-square/Fisher\u0026rsquo;s Exact tests were used for categorical variables. P-values less than 0.05 were considered to indicate statistical significance for all statistical analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic and clinical characteristics of recurrent stroke patients\u003c/h2\u003e \u003cp\u003eRecurrent strokes accounted for 17.8% (302 out of 1701) of all stroke admissions over the 2 years, with ischemic stroke comprising 76.16% of these recurrent events. The mean age of participants was 63.20 \u0026plusmn; 13.26 years, and 52.3% were males. Most patients were enrolled in the National Health Insurance Scheme (NHIS) (68.87%). The majority were semi-urban (64.2%) and urban dwellers (25.5%). The median NIHSS score at presentation for recurrent ischemic stroke was 15 (IQR 11), compared to 18 (13.5) for recurrent hemorrhagic strokes (p\u0026thinsp;=\u0026thinsp;0.027). Among patients with recurrent ischemic strokes, most of the index events were also ischemic (78%). In contrast, only 44.4% of patients with recurrent hemorrhagic strokes had an index hemorrhagic event (p\u0026thinsp;=\u0026thinsp;0.000). The median length of hospital stay was 9 days (IQR 8). Aspiration pneumonia was the most common in-hospital complication, occurring in 43.6% of patients with ischemic, 46.0% of patients with hemorrhagic, and 66.67% of patients with recurrent untyped strokes (p\u0026thinsp;=\u0026thinsp;0.491). Generally, in-hospital Case Fatality among patients with recurrent stroke was 25.8%; however, this was highest among patients with untyped recurrent events (57.1%), p\u0026thinsp;=\u0026thinsp;0.000. (Table I)\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable I Socio-demographics and Clinical Characteristics\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll recurrent strokes n\u0026thinsp;=\u0026thinsp;302\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIschemic recurrent strokes\u003c/p\u003e \n\u003cp\u003en\u0026thinsp;=\u0026thinsp;230\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHemorrhagic\u003c/p\u003e \u003cp\u003erecurrent strokes\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;63\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUntyped\u003c/p\u003e \u003cp\u003erecurrent strokes\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean \u0026plusmn; SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.20\u0026plusmn; 13.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.26\u0026plusmn; 12.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.10\u0026plusmn; 12.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.86\u0026plusmn; 10.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Male)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158 (52.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e119 (51.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (54.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.551\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDomicile\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.692\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (10.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (9.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSemi-urban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e194 (64.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e149 (64.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41 (65.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4(57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (20.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNational health Insurance Status (Insured)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e208 (68.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e159 (69.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43 (68.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (66.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.535\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNIHSS, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (13.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.027*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndex stroke type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIschemic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e214 (70.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e181 (78.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (47.6\u003c/p\u003e \u003cp\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemorrhagic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (20.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplications of acute stroke\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspiration Pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136 (45.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101 (43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (46.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (66.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.049*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (24.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.992\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDVT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (3.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (6.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.893\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (1.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.968\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecubitus ulcers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (9.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.966\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost stroke seizures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (17.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.674\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of Hospital admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (IQR 8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.5 (IQR 9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (IQR 8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (IQR 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.176\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-Hospital Case Fatality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (25.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (22.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (36.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eRisk Profile of Recurrent Stroke Patients\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the recurrent stroke patients, 90.1% were admitted with the first episode of recurrence, while 8.9% had experienced two recurrent strokes, and the rest had experienced at least two. Hypertension was the most dominant modifiable risk factor among both ischemic and hemorrhagic subtypes, 96.1% and 92.1%, respectively (p=0.297). Diabetes was identified as a modifiable vascular risk factor in the majority of untyped recurrent stroke (77.78%), while dyslipidemia was mainly identified among patients with recurrent ischemic stroke (p=0.000). Atrial fibrillation was diagnosed in 5.65% of patients with ischemic strokes (p=0.003). Alcohol use was reported in 21.9%, while cigarette smoking (0.3%) and recreational drug use (1%) were uncommon. Compared to recurrent hemorrhagic strokes (69.8%), the majority of recurrent ischemic (85.8%) and untyped stroke patients (85.7%) engaged in \u0026lt;150 minutes of low-moderate intensity/ week physical activity per week (p=0.013). (Table II)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable II Risk Profile of recurrent stroke patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll recurrent strokes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en= 302\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIschemic recurrent strokes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=230\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemorrhagic\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003erecurrent strokes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=63\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUntyped\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003erecurrent strokes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAlcohol use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e66 (21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47 (20.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (26.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.632\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eRecreational drug use\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1(0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (0.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.860\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eCigarette Smoking\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e8 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (3.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (1.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.762\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eHypertension\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e288(95.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e223 (96.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58 (92.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (77.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.297\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e78 (25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e67 (29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (77.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eDyslipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e104 (34.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;96(41.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 (11.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (11.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAtrial Fibrillation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e13 (4.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (5.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eHIV infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1 (0.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (0.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.472\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency of recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e272 (90.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e205 (88.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62 (98.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e27 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24 (10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026gt;2\u003csup\u003end\u003c/sup\u003e time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eLevel of physical activity \u0026lt;150 mins low-mod intensity/ week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e249 (82.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e199 (85.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44 (69.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.013*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eGaps diagnostic workup\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong patients with recurrent Ischemic strokes, 94.8% had a lipid profile, while 69.1% HBA1c measured (p=0.000). For ischemic non-lacunar strokes, \u0026nbsp;only 28.9% had 12-Lead ECG, 16.4% had Transthoracic echocardiograms, 14.1% underwent Carotid Doppler, 1.56% had Computerized Tomographic (CT) or Magnetic Resonance (MR) Angiography. No participant had 24-72-hour Holter ECG, Transesophageal echocardiography, nor Implantable loop recorder studies performed (Supplementary Tables S1). Only 7.9% of hemorrhagic strokes underwent\u0026nbsp;Computed tomography angiography (CTA)/\u0026nbsp;Magnetic resonance angiography\u0026nbsp;(MRA).\u0026nbsp; Digital subtraction angiography\u0026nbsp;(DSA)\u0026nbsp;was not performed for any hemorrhagic stroke patients.\u0026nbsp;\u003cem\u003eGradient echo sequences (GRE\u003c/em\u003e)/\u0026nbsp;Susceptibility weighted imaging (SWI)\u0026nbsp;\u0026nbsp;sequence MRI were not done for any of the hemorrhagic strokes to evaluate for Cerebral Amyloid Angiopathy (CAA). (Table\u0026nbsp;III)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable III Extent of risk and etiological evaluation done for recurrent stroke patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnostic \u0026nbsp;evaluation n(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll recurrent strokes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en= 302\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIschemic recurrent strokes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=230\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemorrhagic\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003erecurrent strokes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=63\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUntyped\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003erecurrent strokes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eLipid Profile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e264 (87.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e218 (94.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43 (68.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eHemoglobin A1c\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e187 (61.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e159 (69.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27 (42.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (11.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eRenal Function\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e290 (96.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e226 (98.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58 (92.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (66.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eHIV screening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e6 (1.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (2.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (3.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eFBC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e300 (99.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e229 (99.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e63 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (88.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.010*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eSickle Cell screening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4 (1.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (1.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.380\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eClotting profile\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3 (0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (4.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.090*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12-Lead ECG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e50 (16.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43 (18.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (9.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.450\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e24- 72-hour Holter ECG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eTTE Echo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e22 (7.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (9.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eCarotid Doppler\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e18 (5.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (7.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eCTA/MRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e7 (2.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (7.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.060*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eDSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eGRE/SWI MRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eTEE Echo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eImplantable loop recorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAPS panel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1 (0.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (0.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.600\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePatterns of Etiological Designation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost non-Lacunarischemic recurrent stroke (88.28%) were presumed to be large vessel arterosclerotic etiology, while the remaining were designated as cardioembolic. Nearly all lacunar strokes (99.02%) were designated as small vessel disease, except one, which was found be due to vertebral dissection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll non-lobar bleeds in hypertensive patients were designated as hypertensive bleeds. The majority of Lobar hemorrhages (83.33%) were attributed to CAA, while 24.99% were confirmed to be from structural causes. (Supplementary Tables S2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eS\u003c/strong\u003e\u003cstrong\u003eecondary preventi\u003c/strong\u003e\u003cstrong\u003eve\u003c/strong\u003e\u003cstrong\u003etherapy in place before stroke recurrence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Supplementary Table 3, the\u0026nbsp;majority of patients were already receiving antihypertensive therapy at the time of recurrent stroke onset, including (55.6%) Calcium Channel Blockers (CCBs), 16.2% on Angiotensin Receptor Blockers (ARB), 5.6% on Thiazides, and 3% on beta blockers. Among patients with prior ischemic stroke, only 3.3% of were on statin therapy, 5.1% were on aspirin, and 0.9% were on Dual Antiplatelet therapy (DAPT) comprising aspirin and clopidogrel. Anticoagulant use was observed in only 3.3% of patients with prior ischemic stroke. None of the patients with prior ischemic stroke had undergone Carotid endarterectomy or Carotid stenting following the index ischemic event.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eS\u003c/strong\u003e\u003cstrong\u003eecondary prevention\u003c/strong\u003e \u003cstrong\u003et\u003c/strong\u003e\u003cstrong\u003ereatments and interventions\u003c/strong\u003e\u003cstrong\u003eduring recurrent stroke\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of recurrent stroke patients received antihypertensive treatments, including (89.2%) Calcium Channel Blockers (CCBs), and 70.7% on Angiotensin Receptor Blockers (ARB) during the recurrent stroke admission. Among ischemic stroke, 93.1% were prescribed a statin during admission, 80.6% received aspirin, and 14.7% were on clopidogrel. 10.87% of ischemic stroke patients received. Dual Antiplatelet therapy (DAPT). Anticoagulant therapy was used in 3.91% of ischemic strokes. None of the patients underwent Carotid endarterectomy or Carotid stenting (Table IV).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable IV Treatments and interventions received by recurrent stroke patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedications n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll recurrent strokes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en= 302\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIschemic recurrent strokes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=230\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemorrhagic\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003erecurrent strokes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=63\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUntyped\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003erecurrent strokes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedications\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eCCB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;274 (90.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e207 (89.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61 (96.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.030*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eARB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e220 (72.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e164 (70.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52 (82.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (57.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.120\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eACEI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e52 (17.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.330\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eThiazide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e121 (40.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78 (33.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41 (65.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eBeta Blocker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e153 (50.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e102 (44.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44 (76.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAlpha adrenergic receptor\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.471\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMethyldopa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e21 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.032*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAnticoagulant\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e10 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.598\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAspirin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e191 (63.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e187 (80.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eClopidogrel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e35 (11.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.005*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eDAPT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e25 (8.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25 (10.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eStatin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e255 (84.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e216 (93.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOral Hypoglycemic agents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e58 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53 (22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterventions n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eCarotid endarterectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eCarotid stenting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study has evaluated critical diagnostic and treatment gaps in recurrent stroke management, in a real-life setting in Ghana, on a backdrop of an existing National Health Insurance Scheme (NHIS), and provides very important insights for LMICs.\u003c/p\u003e \u003cp\u003eAmong our cohort, we found that almost a fifth of stroke cases were recurrent strokes, which is much higher than what was reported in the SIREN study in 2022.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e This highlights a rising burden of recurrent strokes in Ghana, contrary to the trend in High-Income Countries (HICs) where recurrent strokes are on a decline due to intensification of secondary prevention measures.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Ischemic stroke accounted for 76.16% of the recurrent events, which is consistent with the pattern in other SSA countries.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Additionally, recurrent strokes were associated with a longer length of hospital stay (median (IQR) of 9 days (IQR 8)) compared to that reported to the index stroke in our setting (median (IQR) of 6 days (IQR 5)).\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Aspiration pneumonia remained the predominant in-hospital complication, occurring in almost half of patients.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e In-Hospital Case Fatality among patients with recurrent stroke was 25.8%, which is relatively lower than rates reported in other LMICs.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e A plausible explanation may be the incremental improvement in stroke services in our setting over the past few years. We observed a high prevalence of modifiable vascular risk factors, particularly hypertension, diabetes, and dyslipidemia, consistent with other studies in LMICs.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e These findings suggest that these risk factors may be the major drivers of stroke recurrence in our setting, underscoring an urgent need to strengthen approaches to mitigation.\u003c/p\u003e \u003cp\u003eRecurrent strokes constitute a very high-risk population, requiring careful evaluation to inform strategies for prevention.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e A key finding that stood out in our study was the limited adherence to recommended etiological and risk evaluation.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Although basic laboratory tests such as Lipid profiles and HbA1c were performed, the workup was remarkably sparse for cardioembolic etiologies. Though readily available, only a minority received 12- lead ECGs and transthoracic echocardiograms. Also, in cases where ECGs were negative, Holter monitoring and implantable cardiac loop monitors were never utilized. Transesophageal echocardiograms were not done in any of the patients. Advanced neurimaging modalities such as CT/ MRI angiograms were sparingly used, and DSA were nonexistent. These gaps underscore substantial constraints in diagnostic capacity. These deficiencies may be driven by multiple barriers, including financial limitations, clinician inertia, absence of structured protocols and systems.\u003c/p\u003e \u003cp\u003eStroke recurrence suggests a possible failure of the initial attempt at interrupting the underlying pathophysiology, making mechanistic profiling highly important, as it has direct consequences for the rate of stroke recurrence. Etiological designation amongst our cohort of recurrent strokes seemed to rely heavily on clinical judgement rather than a comprehensive diagnostic workup. While this approach is generally acceptable for lacunar ischemic strokes, most of which were attributed to small vessel disease, non-lacunar ischemic strokes require a comprehensive etiological workup to rule out potential cardioembolic sources and also confirm other possible etiologies. In our cohort, cardiac evaluation was very limited. This raises concerns about the possibility of underdiagnosis of cardioembolic strokes in our setting.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Similarly, vascular imaging was sparingly performed to assess for intracranial and extracranial large vessel atherosclerosis. Given the limited depth of diagnostic evaluation, it is difficult to meaningfully apply the concepts of cryptogenic or Embolic Strokes of Undetermined Source (ESUS) in our setting. Both diagnoses require a thorough minimum workup, including extended cardiac monitoring and vascular evaluation.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e All non-lobar bleeds in hypertensive patients were designated as hypertensive bleeds. The majority of Lobar hemorrhages were attributed to CAA, without any GRE/SWI sequence MRI. The overreliance on clinical judgement without essential tests could potentially lead to missed opportunities for targeted prevention.\u003c/p\u003e \u003cp\u003eThere was also a clear mismatch between stroke risk factors, etiologies, and the secondary prevention strategies implemented.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Anticoagulant use among our cohort was strikingly low, including even atrial fibrillation patients with recurrent stroke. Similary no one underwent carotid endarterectomy or carotid stenting. This highlights important challenges in accessing evident based interventions.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study employed a cross-sectional design, which limits its ability to draw causal inferences. It, however, has some limitations. It was also a single-center study, which limits its external validity.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eFuture directions\u003c/h2\u003e \u003cp\u003ePragmatic initiatives incorporating structured risk/ etiological profiling and standardized therapeutic protocols, driven by strong national policies, are required for improved recurrent stroke prevention in Ghana and other resource constrained setting. Substantial effort is required to strengthen stroke care services, expand diagnostic capacity, and build the human resources to adequately mitigate recurrent stroke risk in LMICs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur findings highlight significant gaps in recurrent stroke evaluation and management in Ghana. Standardized prevention models are urgently needed to overcome existing bottlenecks.\u003c/p\u003e"},{"header":"Non-standard Abbreviations and Acronyms","content":"\u003cp\u003e \u003cb\u003eARB\u003c/b\u003e Angiotensin Receptor Blockers\u003c/p\u003e \u003cp\u003e \u003cb\u003eCAA\u003c/b\u003e Cerebral Amyloid Angiopathy\u003c/p\u003e \u003cp\u003e \u003cb\u003eCCBs\u003c/b\u003e Calcium Channel Blockers\u003c/p\u003e \u003cp\u003e \u003cb\u003eDAPT\u003c/b\u003e Dual Antiplatelet therapy\u003c/p\u003e \u003cp\u003e \u003cb\u003eGRE\u003c/b\u003e Gradient echo sequences\u003c/p\u003e \u003cp\u003e \u003cb\u003eLMICs\u003c/b\u003e Low-and-Middle-Income-Countries\u003c/p\u003e \u003cp\u003e \u003cb\u003eNHISS\u003c/b\u003e National Institutes of Health Stroke Scale\u003c/p\u003e \u003cp\u003e \u003cb\u003eSIREN\u003c/b\u003e Stroke Investigative Research and Educational Network\u003c/p\u003e \u003cp\u003e \u003cb\u003eSSA\u003c/b\u003e Sub-Saharan Africa\u003c/p\u003e \u003cp\u003e \u003cb\u003eSPSS\u003c/b\u003e Statistical Package for the Social Sciences\u003c/p\u003e \u003cp\u003e \u003cb\u003eSWI\u003c/b\u003e Susceptibility weighted imaging\u003c/p\u003e \u003cp\u003e \u003cb\u003eTOAST\u003c/b\u003e Trial of Org 10,172 in Acute Stroke Treatment\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Ethical approval was obtained from the Committee on Human Research and Publication Ethics, Kwame Nkrumah University of Science and Technology (CHRPE/AP/936/23). This study was conducted\u0026nbsp;in compliance with the Helsinki Declaration.\u0026nbsp;Participants were provided informed consent. However, in instances when subjects were not\u0026nbsp;capable of providing informed consent for their participation\u0026nbsp;due to altered level of consciousness or aphasia, their legal authorized representatives were contacted\u0026nbsp;to provide informed consent to participate on their behalf.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e De-identified datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest:\u003c/strong\u003e The authors declare no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Information:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003ePAOA and FSS contributed to the conception and design of the study; PAOA wrote the first draft of the manuscript; FSS, MA, EA, MN, NOAD, JMH, GM contributed to editing of the text and preparing the figures; PAOA, FSS and EA performed analysis of data, all co-authors have reviewed the manuscript and agree to its submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement statement:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDirectorate of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana\u003c/p\u003e\n\u003cp\u003ePriscilla Abrafi Opare-Addo, Fred Stephen Sarfo, Minas Aikins, Maxwell Nyenaah, Nana Osei Asibey Derkyi, Jessey Mahama Holu, Gordon Manu.\u003c/p\u003e\n\u003cp\u003eDepartment of Internal Medicine, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana\u003c/p\u003e\n\u003cp\u003ePriscilla Abrafi Opare-Addo, Fred Stephen Sarfo and Enock Asante.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHan J, Mao W, Ni J, Wu Y, Liu J, Bai L, et al. Rate and Determinants of Recurrence at 1 Year and 5 Years After Stroke in a Low-Income Population in Rural China. Front Neurol. 2020;11:2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMbalinda SN, Kaddumukasa M, Najjuma JN, Kaddumukasa M, Nakibuuka J, Burant CJ, et al. Stroke Recurrence Rate and Risk Factors Among Stroke Survivors in Sub-Saharan Africa: A Systematic Review. NDT. 2024;20:783\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHardie K, Hankey GJ, Jamrozik K, Broadhurst RJ, Anderson C. Ten-Year Risk of First Recurrent Stroke and Disability After First-Ever Stroke in the Perth Community Stroke Study. Stroke. 2004;35(3):731\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang M, Ju KJ, Chen P, Zhong LL. Risk Factors for Recurrent Stroke and the Impact of Targeted Health Management. Risk Manag Healthc Policy. 2025;18:2759\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021 July;52(7):e364\u0026ndash;467.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022 July;53(7):e282\u0026ndash;361.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKolmos M, Christoffersen L, Kruuse C. Recurrent Ischemic Stroke \u0026ndash; A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis. 2021;30(8):105935.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOpare-Addo PA, Sarfo FS, Berchie PO, Aikins M, Ovbiagele B. Participation by patients from low- and middle-income countries (LMICs) in trial evidence supporting secondary stroke prevention guideline recommendations. J Neurol Sci. 2023;448:120641.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes\u0026mdash;2018. Diabetes Care. 2017;41(Supplement_1):S13\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorenzo C, Williams K, Hunt KJ, Haffner SM. The National Cholesterol Education Program\u0026ndash;Adult Treatment Panel III, International Diabetes Federation, and World Health Organization Definitions of the Metabolic Syndrome as Predictors of Incident Cardiovascular Disease and Diabetes. Diabetes Care. 2007;30(1):8\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdams HP, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeretoja A, Strbian D, Putaala J, Curtze S, Haapaniemi E, Mustanoja S, et al. Smash-u Stroke. 2012;43(10):2592\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Xu J, Zhao X, Wang D, Wang C, Liu L, et al. Association of hypertension with stroke recurrence depends on ischemic stroke subtype. Stroke. 2013;44(5):1232\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwah LK, Diong J. National Institutes of Health Stroke Scale (NIHSS). J Physiother. 2014;60(1):61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGore M, Bansal K, Khan Suheb MZ, Lui F, Asuncion RMD. Lacunar Stroke. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 Dec 8]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/books/NBK563216/\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/books/NBK563216/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkpalu A, Sarfo FS, Akinyemi J, Wahab K, Komolafe M, Obiako R, et al. Frequency \u0026amp; factors associated with recurrent stroke in Ghana and Nigeria. J Neurol Sci. 2022;439:120303.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlach C, Muruet W, Wolfe CDA, Bhalla A, Douiri A. Risk and Secondary Prevention of Stroke Recurrence: A Population-Base Cohort Study. Stroke. 2020;51(8):2435\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMassi DG, Nyassinde J. Risk factors of stroke recurrence in a low income country: case of Senegal (P6.289). Neurology. 2017;88(16supplement):P6289.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDabilgou AA, Drav\u0026eacute; A, Kyelem JMA, Zoungrana R, Napon C, Millogo A, et al. Frequency of recurrent stroke in Burkina Faso: an observational hospital based study of 6 months. Pan Afr Med J. 2021;40:108.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarfo FS, Acheampong JW, Appiah LT, Oparebea E, Akpalu A, Bedu-Addo G. The Profile of Risk Factors and In-Patient Outcomes of Stroke in Kumasi, Ghana. Ghana Med J. 2014 Sept;48(3):127\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNutakki A, Chomba M, Chishimba L, Zimba S, Gottesman RF, Bahouth MN, et al. Characteristics of adults with first-ever stroke vs. recurrent stroke at the university teaching Hospital in Lusaka, Zambia. J Neurol Sci. 2025;472:123473.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLekoubou A, Nkoke C, Dzudie A, Kengne AP. Recurrent Stroke and Early Mortality in an Urban Medical Unit in Cameroon. J Stroke Cerebrovasc Dis. 2017;26(8):1689\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKolmos M, Christoffersen L, Kruuse C. Recurrent Ischemic Stroke - A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis. 2021;30(8):105935.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022 July;53(7):e282\u0026ndash;361.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdebayo O, Akpa O, Asowata OJ, Fakunle A, Sarfo FS, Akpalu A, et al. Determinants of First-Ever Stroke Severity in West Africans: Evidence From the SIREN Study. J Am Heart Association. 2023 June;20(12):e027888.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y. Residual recurrence risk of ischaemic cerebrovascular events: concept, classification and implications. Stroke Vasc Neurol. 2021;6(2):155\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Recurrent Stroke, Secondary prevention, Risk-factors, Etiologies, Sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-8489763/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8489763/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRecurrent strokes account for up to 1 out of 4 strokes in Low-and-Middle-Income-Countries (LMICs), culminating in worsening of outcomes. International guidelines recommend subtype-specific etiological workup to help tailor strategies for prevention of recurrence after an index stroke. However, huge gaps in secondary stroke prevention persist in LMICs.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eWe aimed to assess the extent of diagnostic evaluation (for risk-factor and underlying etiological identification) and treatment approaches among recurrent stroke patients in a Ghanaian tertiary hospital.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a cross-sectional study among recurrent stroke cases admitted to Komfo Anokye Teaching Hospital between 2023 and 2024. The data was analyzed using SPSS Version 28.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eRecurrent strokes accounted for 17.8% of all stroke admissions over 2 years, with ischemic stroke comprising 76.2% of these recurrent events. Hypertension was the most dominant modifiable risk factor among both ischemic and hemorrhagic subtypes, 96.1% and 92.1% respectively, (p\u0026thinsp;=\u0026thinsp;0.297). Most ischemic strokes had no diagnostic evaluation to determine etiology beyond classification as lacunar/ non-lacunar. Only 7.9% of hemorrhagic strokes underwent Computed tomography angiography (CTA)/ Magnetic resonance angiography (MRA) to evaluate for structural causes. The majority of ischemic stroke patients were prescribed a statin and an antiplatelet. However, anticoagulant therapy was used only in a minority of patients (3.91%). Carotid endarterectomy or carotid stenting was not performed for any of the ischemic stroke patients.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur findings highlight significant gaps in recurrent stroke evaluation and management in the Ghanaian setting. Standardized algorithms for secondary stroke prevention and treatment are urgently needed to prevent recurrence.\u003c/p\u003e","manuscriptTitle":"Diagnostic and Therapeutic Gaps in Recurrent Stroke Management: Real-World Insights from a Ghanaian Hospital-based Registry.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-23 14:08:50","doi":"10.21203/rs.3.rs-8489763/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-02T05:16:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-27T19:47:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-08T10:26:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61666703138448275711079283421433479611","date":"2026-01-27T09:49:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80763832165127109618888105197705828557","date":"2026-01-22T07:37:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-22T06:29:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-22T06:20:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-06T02:45:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-05T22:00:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2026-01-05T21:53:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e415b22b-9da6-4560-bc87-1be15d0f67b8","owner":[],"postedDate":"January 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T20:38:15+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-23 14:08:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8489763","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8489763","identity":"rs-8489763","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}