Prevalence of Systemic Atherosclerosis Burdens and Overlapping Stroke Etiologies and Their Associations With Long-term Vascular Prognosis in Stroke With Intracranial Atherosclerotic Disease

Encephaloduroarteriosynangiosis for Symptomatic Intracranial Atherosclerotic Arterial Steno-Occlusive Disease: Clinical and Radiological Outcomes

BACKGROUND

This study investigated the long-term clinical and angiographic outcomes of encephaloduroarteriosynangiosis treatment for symptomatic intracranial atherosclerotic arterial steno-occlusive disease to further evaluate the potential therapeutic role of encephaloduroarteriosynangiosis in this population.

METHODS AND RESULTS

A total of 152 adult patients with symptomatic intracranial atherosclerotic arterial steno-occlusive disease who were treated with encephaloduroarteriosynangiosis and intensive medical management across 3 tertiary centers in China between January 2011 and September 2019 were retrospectively included. The primary outcomes were defined as postoperative cerebrovascular events, including ischemic and hemorrhagic stroke. The postoperative neovascularization was analyzed qualitatively and quantitatively by using angiography. Clinical, radiological, and long-term follow-up data were analyzed using Cox regression, logistic regression, and linear regression analyses. Primary outcome rates were 3.2% (5/152) within 30 days, 6.6% (10/152) within 2 years, 9.2% (14/152) within 5 years, and 11.1% (17/152) during a median 9.13 years follow-up. Initial infarction symptoms were positively associated with recurrent ischemic stroke. Additionally, posterior circulation involvement and coexisting cardiac disease indicated poorer neurological status, whereas encephaloduroarteriosynangiosis neovascularization efficacy was negatively associated with older age and vascular risk factors but positively associated with posterior circulation involvement.

CONCLUSIONS

Encephaloduroarteriosynangiosis plus intensive medical management appears efficacious and safe for symptomatic intracranial atherosclerotic arterial steno-occlusive disease, with low perioperative risk and favorable long-term results. Further prospective trials are needed to verify its efficacy and determine the optimal patient selection criteria.

The association between hyperhomocysteinemia and the prevalence of bilateral carotid atherosclerotic plaques in a middle-aged population

OBJECTIVE

We conducted a cross-sectional study to investigate the impact of hyperhomocysteinemia (HHcy) on the prevalence of CASP among middle-aged individuals, aiming to provide insights for CASP prevention.

METHODS

1105 subjects were categorized into HHcy group or normal tHcy group based on their plasma total homocysteine (tHcy). All participants underwent carotid artery ultrasonography to assess the presence of unilateral and bilateral CASP. Comparative analyses of demographic and clinical data were conducted between the two groups. Logistic regression and prespecified subgroup analyses were performed to determine whether HHcy independently contributed to bilateral CASP.

RESULTS

132 individuals exhibited bilateral CASP. The prevalence of bilateral CASP was significantly higher in the HHcy group compared to the normal tHcy group (21.55 % vs. 10.82 %, p = 0.003). Univariate logistic analysis showed a significant association between HHcy and the prevalence of bilateral CASP (OR = 2.056, 95 %CI 1.089-3.881, p = 0.026). In all four models of multivariate logistic analysis, HHcy consistently emerged as an independent risk factor for bilateral CASP, with odd ratios of 1.958, 2.047, 2.023, and 2.186. This association remained significant across all five subgroups stratified by age, sex, hypertension, diabetes, and BMI.

CONCLUSION

Our studies demonstrated HHcy was an independent risk factor for the prevalence of bilateral CASP in the middle-aged population. Theses results emphasized the importance of addressing HHcy in preventive strategies aimed at mitigating the burden of CASP among middle-aged individuals.

Small-Vessel Disease and Intracranial Large Artery Disease in Brain MRI Predict Dementia and Acute Coronary Syndrome, Respectively: A Prospective, Observational Study in the Population at High Vascular Risk

BACKGROUND

We aimed to clarify the predictive value of cerebral small-vessel disease and intracranial large artery disease (LAD) observed in magnetic resonance imaging of the brain and magnetic resonance angiography on future vascular events and cognitive impairment.

METHODS AND RESULTS

Data were derived from a Japanese cohort with evidence of cerebral vessel disease on magnetic resonance imaging. This study included 862 participants who underwent magnetic resonance angiography after excluding patients with a modified Rankin Scale score >1 and Mini-Mental State Examination score <24. We evaluated small-vessel disease such as white matter hyperintensities and lacunes in magnetic resonance imaging and LAD with magnetic resonance angiography. Outcomes were incident stroke, dementia, acute coronary syndrome, and all-cause death. Over a median follow-up period of 4.5 years, 54 incident stroke, 39 cases of dementia, and 27 cases of acute coronary syndrome were documented. Both small-vessel disease (white matter hyperintensities and lacunes) and LAD were associated with stroke; however, only white matter hyperintensities were related to dementia. In contrast, only LAD was associated with acute coronary syndrome. Among the 357 patients with no prior history of stroke, coronary or peripheral artery disease, or atrial fibrillation, white matter hyperintensities emerged as the sole predictor of future stroke and dementia, while LAD was the sole predictor of acute coronary syndrome.

CONCLUSIONS

Among cerebral vessels, small-vessel disease could underlie the cognitive impairment while LAD was associated with coronary artery disease as atherosclerotic vessel disease.

Characteristics and outcomes of large artery occlusion-related stroke due to intracranial atherostenosis: An experience from a single center in Saudi Arabia

BACKGROUND

Literature on the frequency, response to treatment, and outcomes of acute ischemic stroke (AIS) due to intracranial atherostenosis (ICAS)-related intracranial large artery occlusion (ILAO) from Saudi Arabia is scarce. The aim of this study was to identify the percentage, describe the characteristics, and observe the treatment response in patients with AIS attributed to ICAS-related ILAO.

MATERIALS AND METHODS

This cross-sectional study included all adult patients from 2017-2021 who fulfilled the inclusion criteria for the diagnosis of ICAS-related AIS. Patients were dichotomized based on ILAO. Mortality and functional outcomes (FOCs) based on 90 days' dependence level were compared between the two groups. The association between ILAO and other variables was assessed using the Chi-squared test, odds ratios (OR), and 95% confidence interval (CI).

RESULTS

ILAO was found in 38.7% of patients with ICAS-related AIS. Men comprised three-fourths of the cohort and were more frequent in the ILAO group. Smoking was associated with increased (P = 0.04) likelihood of ILAO. Patients with ILAO had more severe strokes (P ≤ 0.001) than patients without. Middle cerebral artery was the most common occluded vessel (52%). Functional dependence (P = 0.003, OR = 2.87, CI = 1.42-5.77), malignant transformation (P = 0.001, OR = 8.0, CI = 1.82-35.9), and mortality (P ≤ 0.001, OR = 7.67, CI = 2.40-24.5) were significantly higher among ILAO group. Patients with ILAO with unfavorable FOC were older than those who achieved better FOC (P ≤ 0.001). Thrombolysis (P = 0.02, OR = 2.50, CI = 1.15-5.41) and mechanical thrombectomy (MT) improved FOC in patients with ILAO (P = 0.04, OR = 2.33, CI = 1.10-4.92).

CONCLUSION

ILAO is common in patients with ICAS-related AIS. Timely hyperacute stroke treatment can help improve the FOC of otherwise disabling stroke due to ILAO. Raising awareness of the community about stroke is needed, so that a higher number of patients can arrive at hospital within the golden hours. Further data from the region are required to recognize the efficacy of MT in ICAS-related ILAO.

A bibliometric analysis of the 100 most-cited clinical articles in the research of intracranial artery stenosis and intracranial atherosclerosis

Background

Intracranial arterial stenosis (ICAS), caused by intracranial atherosclerosis, is one of the major causes of ischemic stroke. This study identified the top 100 most-cited publications on ICAS through a bibliometric analysis.

Methods

Two independent authors conducted a search in the Web of Science database for clinical articles on ICAS published between 1993 and 2022. The top 100 most-cited articles were then extracted. For each article, the analysis covered the title, author, country of origin/affiliation, journal, total number of citations, number of citations per year, and type of study.

Results

The top 100 most-cited papers in the ICAS were authored by 565 authors from 12 countries and published in 29 journals. In terms of the 5-year trend, the largest number of papers were published between 2003 and 2007 (n = 31). The median number of citations for the 100 papers was 161 (range 109-1,115). The journal with the highest proportion of the 100 most published articles was Stroke, accounting for 41% of articles and 37% of the citations. According to country of origin, the United States of America accounted for the largest number of articles, followed by China, Japan, and South Korea, with these four countries together accounting for 81% of the total number of articles and 88% of the citations. Trends in the past five years included the use of terms such as acute ischemic stroke and mechanical thrombectomy.

Conclusion

The findings of this study provide novel insight into this field and will facilitate future research endeavors.

Safety and effectiveness assessment of endovascular recanalization for non-acute middle cerebral artery occlusion

BACKGROUND

Endovascular treatment for patients with symptomatic nonacute middle cerebral artery occlusion remains clinically challenging, and proof of a beneficial effect on functional outcome is lacking. We aim to evaluate the effectiveness and safety of endovascular recanalization for patients with symptomatic nonacute middle cerebral artery occlusion.

METHODS

Ninety-eight patients with symptomatic atherosclerotic nonacute middle cerebral artery occlusion were divided into drug treatment groups (42) and endovascular treatment groups (56). The rate of recanalization, peri-procedural complications, and follow-up results were evaluated.

RESULTS

Among the 56 patients who received endovascular treatment, 53 (94.6%) achieved successful recanalization. The rate of peri-procedural complications was 7.1% (4/56), and the death rate was 1.8% (1/56). Any stroke within 90 days was 7.1% (4/56). Among the 42 patients in drug treatment group, any stroke within 90 days was 19.0% (8/42), death rate was 0.

CONCLUSION

Among patients with symptomatic nonacute middle cerebral artery occlusion with a short length of occlusion and a moderate-to-good collateral circulation, endovascular treatment seems to be safe. And endovascular treatment could reduce the recurrence rate of stroke.

The Impact of Atherosclerotic Burden on Vascular Outcomes in Patients with Stroke and Atrial Fibrillation: The ATHENA study

Introduction: Patients with ischemic stroke (IS) and atrial fibrillation (AF) face a higher risk of recurrent vascular events. This study evaluates the impact of atherosclerotic vascular disease burden across different vascular territories on the risk of vascular events in patients with recent ischemic stroke and AF within 90 days. Patients and Methods: We included patients with IS and AF from the International RAF network in a prospective 90-day follow-up. Atherosclerotic vascular disease was identified by at least one of the following: Symptomatic ischemic heart disease, symptomatic peripheral artery disease, internal carotid stenosis ≥50%, or the presence of plaques in the aorta. The primary outcome was a composite of stroke, transient ischemic attack, systemic embolism, cerebral bleeding, and major extracranial bleeding within 90 days postacute stroke. Patients were categorized into 5 groups based on the number of affected atherosclerotic vascular territories, with those with no atherosclerotic vascular disease as the reference. Kaplan-Meier curves were generated and compared using the log-rank test to determine the predictive value of the number of diseased territories for the risk of events. Data analysis was performed with SPSS/PC Win Package 25.0. Results: Of the 2148 patients (mean age 77.59; 53.86% female), 744 (34.60%) had atherosclerosis. Multivariable analysis revealed that involvement of 3 (hazard ratio [HR] 2.80, 95% confidence interval [CI]: 1.20-6.53) or 4 (HR 6.81, 95% CI: 1.02-36.24) vascular territories was significantly associated with the risk of combined events. Conclusions: In patients with recent ischemic stroke and AF, atherosclerosis across multiple territories correlates with a higher risk of future vascular events.

Central arterial stiffening and intracranial atherosclerosis: the atherosclerosis risk in communities neurocognitive study (ARIC-NCS): Aortic stiffness & intracranial atherosclerosis

OBJECTIVES

Previous studies suggest an association between central arterial stiffness (CAS) and intracranial atherosclerotic disease (ICAD) among Asian participants with stroke or hypertension; this association has not been evaluated in United States populations. We assessed the cross-sectional association of CAS with ICAD presence and burden in late-life, and differences in association by age, sex, and race.

MATERIALS AND METHODS

We conducted a cross-sectional analysis of 1,285 Atherosclerosis Risk in Communities Study participants [mean age 75 (standard deviation: 5) years, 38 % male, 20  % Black] at Visit 5 (2011-2013). CAS was measured as carotid-femoral pulse wave velocity (cfPWV) using the Omron VP-1000 Plus. ICAD was assessed using high-resolution vessel wall MRI and MR angiography. We evaluated associations of a 1 standard deviation (SD) cfPWV (3.02 m/s) and high vs. non-high cfPWV (≥ 13.57 m/s vs. < 13.57 m/s) with presence of plaques (yes/no) and plaque number (0, 1-2, and >2) using multivariable logistic and ordinal logistic regression models adjusted for covariates.

RESULTS

Each one SD greater cfPWV was associated with higher odds of plaque presence (odds ratio (OR)=1.32, 95 % confidence interval (CI): 1.22, 1.43), and an incrementally higher odds of number of plaques (OR 1-2 vs. 0 plaques = 1.21, 95 % CI: 1.10, 1.33; OR >2 vs. 0 plaques = 1.51, 95 % CI: 1.33,1.71). Results suggested differences by race, with greater magnitude associations among Black participants.

CONCLUSIONS

CAS was positively associated with ICAD presence and burden; cfPWV may be a useful subclinical vascular measure for identification of individuals who are at high risk for cerebrovascular disease.

Comparison of short-term outcomes between patients with extracranial carotid and/or intracranial atherosclerotic disease

OBJECTIVE

To directly compare the 90-day outcomes of patients with symptomatic intracranial atherosclerotic disease (ICAD), extracranial carotid atherosclerotic disease (ECAD), and ICAD with concomitant ECAD.

METHODS

From 2017-2021, patients who had (1) a transient ischemic attack or ischemic stroke within 30 days of admission as evaluated by a stroke neurologist and (2) ipsilateral ICAD and/or ECAD were prospectively enrolled. The cohort was divided into three groups: ICAD, ECAD, and ICAD with concomitant ECAD. The primary outcome assessed was 90-day ischemic stroke recurrence. Secondary outcomes included 90-day myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE, including cardiovascular death, nonfatal MI, and/or nonfatal ischemic stroke).

RESULTS

Of 371 patients included in the analysis, 240 (64.7%) patients had ICAD only, 93 (25.0%) patients had ECAD only, and 38 (10.3%) patients had ICAD with concomitant ECAD. On multivariate time-to-event analysis adjusting for potential confounders and with ICAD as the reference comparator, the risk of 90-day clinical outcomes was highest among patients with ICAD and concomitant ECAD, with adjusted hazard ratios of 4.54 (95% CI=1.45, 14.2; p = 0.006), 9.32 (95% CI=1.58, 54.8; p = 0.014), and 8.52 (95% CI=3.54, 20.5; p < 0.001) for 90-day ischemic stroke, MI, and MACE, respectively.

CONCLUSIONS

Patients with ICAD and concomitant ECAD have a poorer prognosis and are at significantly higher risk for 90-day ischemic stroke, MI, and MACE. Further research should focus on the evaluation of coronary atherosclerotic disease and more intensive medical therapy in this population.

Rescue angioplasty and/or stenting after mechanical thrombectomy: who can benefit?

BACKGROUND

Angioplasty and/or stenting is a rescue therapy for mechanical thrombectomy (MT) in acute intracranial large vessel occlusion. This study was undertaken to determine whether rescue angioplasty and/or stenting improves the outcome after MT and to investigate whether outcomes differ by subgroup of rescue indication.

METHODS

We performed propensity score matching (PSM) with data from a prospective multicenter registry of patients with acute large vessel occlusion receiving endovascular treatment. Patients were divided into the MT alone group and the MT with rescue therapy group. The primary outcome was functional independence (modified Rankin Scale score of 0-2) at 90 days. PSM was also performed in the failed MT (modified Thrombolysis In Cerebral Infarction (mTICI) 0-2a) and the residual severe stenosis (mTICI 2b-3) subgroups, respectively.

RESULTS

326 patients of mean±SD age 62.7±12.0 years (90 women, 27.6%) were matched from 1274 patients. In the matched cohort, functional independence at 90 days was higher in the rescue therapy group than in the MT alone group (44.2% vs 29.5%; OR 1.90, 95% CI 1.18 to 3.06, P=0.008). In the failed MT subgroup with 66 matched pairs, more patients had functional independence in the rescue therapy group than in the MT alone group (39.0% vs 17.0%; OR 3.12, 95% CI 1.29 to 7.59, P=0.01). In the residual stenosis subgroup with 63 matched pairs, functional independence rates were similar in the rescue therapy and the MT alone groups (51.6% vs 55.7%; OR 0.85, 95% CI 0.42 to 1.72, P=0.65).

CONCLUSION

Rescue angioplasty and/or stenting could improve the clinical outcome in patients with acute large vessel occlusion with failed MT, while no benefit was seen in those with residual severe stenosis but substantial reperfusion.

Intracranial Atherosclerosis Disease Associated With Cognitive Impairment and Dementia: Systematic Review and Meta-Analysis

BACKGROUND

Intracranial atherosclerosis disease (ICAD) alters cerebrovascular hemodynamics and brain structural integrity. Multiple studies have evaluated the link between ICAD and cognitive impairment, with mixed results. This study aims to systematically review and summarize the current evidence on this link.

METHODS AND RESULTS

PubMed, EMBASE, PsycInfo, and Web of Science were searched from 2000 to 2023 without language restriction. Cross-sectional and prospective cohort studies as well as postmortem studies were included. Studies containing data on the link between ICAD, defined as at least 50% stenosis in 1 intracranial vessel, and cognitive impairment and dementia were screened by 2 independent reviewers. A total of 22 (17 observational and 5 postmortem) unique studies, comprising 11 184 individuals (average age range, 59.8-87.6 years; 45.7% women; 36.5% Asian race), were included in the systematic review. Seven of 10 cross-sectional studies and 5 of 7 prospective studies showed a significant association between ICAD and cognitive impairment. In the pooled analysis, ICAD was associated with greater cognitive impairment (measure of association, 1.87 [95% CI, 1.49-2.35]). Meta-regression analyses did not show a significant impact of age, sex, and race. All postmortem studies showed that patients with Alzheimer disease and vascular dementia had a higher burden of ICAD compared with controls.

CONCLUSIONS

This study shows that ICAD is associated with cognitive impairment and dementia across age, sex, and race groups. Our findings may underscore the need to develop individualized dementia preventive care plans in patients with ICAD.

Carotid calcium burden derived from computed tomography angiography as a predictor of all-cause mortality after carotid endarterectomy

OBJECTIVE

Carotid endarterectomy (CEA) aims to reduce the risk of stroke in patients with atherosclerotic carotid disease. Preoperative risk assessments that predict complications are needed to optimize the care in this patient group. The current approach, namely relying solely on symptomatology and degree of stenosis, is outdated and calls for innovation. The Agatston calcium score was applied in several vascular specialties to assess cardiovascular risk profile but has been little studied in carotid surgery. It is hypothesized that a higher calcium burden at initial presentation equates to a worse prognosis attributable to an increased cerebrovascular and cardiovascular risk profile. The aim was to investigate the association between preoperative ipsilateral calcium score and postoperative all-cause mortality in patients undergoing CEA.

METHODS

This single-center retrospective cohort study included 89 patients who underwent CEA at a tertiary referral center between 2010 and 2018. Preoperative calcium scores were measured on contrast-enhanced computed tomography images with patient-specific Hounsfield thresholds at the level of the carotid bifurcation. The association between these calcium scores and all-cause mortality was analyzed using multivariable adjusted Cox proportional hazard analysis.

RESULTS

Cox proportional hazard analysis demonstrated a significant association between preoperative ipsilateral carotid calcium score and all-cause mortality (hazard ratio, 1.10; 95% confidence interval, 1.03-1.16; P = .003). After adjusting for age, preoperative estimated glomerular filtration rate, and diabetes mellitus, a significant association remained (hazard ratio, 1.07; 95% confidence interval, 1.00-1.15; P = .05).

CONCLUSIONS

A higher calcium burden was predictive of worse outcome, which might be explained by an overall poorer health status. These results highlight the potential of calcium measurements in combination with other traditional risk factors, for preoperative risk assessment and thus for improved patient education and care.

Co-existing intracranial and extracranial carotid atherosclerosis predicts large-artery atherosclerosis stroke recurrence: a single-center prospective study utilizing combined head-and-neck vessel wall imaging

OBJECTIVES

Intracranial and extracranial plaque features on high-resolution vessel wall imaging (HR-VWI) are associated with large-artery atherosclerosis (LAA) stroke recurrence. However, most studies have focused on a single vascular bed, and the prognostic value of combined intracranial and extracranial plaque features has yet to be studied. This study aimed to investigate the roles of plaque features, plaque number, and co-existing atherosclerosis in predicting stroke recurrence, utilizing combined head-and-neck HR-VWI.

METHODS

From September 2016 to March 2020, participants with acute LAA ischemic strokes were prospectively enrolled and underwent combined head-and-neck HR-VWI. The participants were followed for stroke recurrence for at least 12 months or until a subsequent event occurred. The imaging features at baseline, including conventional and histogram plaque features, plaque number, and co-existing atherosclerosis, were evaluated. Univariable Cox regression analysis and the least absolute shrinkage and selection operator (lasso) method were used for variable screening. Multivariable Cox regression analyses were used to determine the independent risk factors of stroke recurrence.

RESULTS

A total of 97 participants (59 ± 12 years, 63 men) were followed for a median of 30.9 months, and 21 participants experienced recurrent strokes. Multivariable Cox analysis identified co-existing intracranial high signal on T1-weighted fat-suppressed images (HST1) and extracranial carotid atherosclerosis (HR, 6.12; 95% CI, 2.52-14.82; p = 0.001) as an independent imaging predictor of stroke recurrence.

CONCLUSION

Co-existing intracranial HST1 and extracranial carotid atherosclerosis independently predicted LAA stroke recurrence. Combined head-and-neck HR-VWI is a promising technique for atherosclerosis imaging.

CLINICAL RELEVANCE STATEMENT

This prospective study using combined head-and-neck HR-VWI highlighted the necessity of both intracranial culprit plaque evaluation and multi-vascular bed assessment, adding value to the prediction of stroke recurrence.

KEY POINTS

• This study highlighted the necessity of both intracranial culprit plaque evaluation and multi-vascular bed assessment, adding value to the prediction of stroke recurrence. • This prospective study using combined head-and-neck HR-VWI found co-existing intracranial HST1 and extracranial carotid atherosclerosis to be independent predictors of stroke recurrence.

Rescue Stent Placement for Acute Ischemic Stroke with Large Vessel Occlusion Refractory to Mechanical Thrombectomy: A Multiethnic Middle Eastern/African/Asian Cohort

PURPOSE

To investigate the safety and effectiveness of rescue stent placement in patients who experienced acute stroke in whom mechanical thrombectomy failed.

METHODS

This was a retrospective review of a multiethnic stroke database. After stent placement, an aggressive antiplatelet protocol was followed with glycoprotein IIb/IIIa infusion. The primary outcomes were incidence of intracerebral hemorrhage (ICH), recanalization score, and favorable prognosis (modified Rankin score ≤ 2) at 90 days. A comparison was made between patients from the Middle East and North Africa (MENA) region and those from other regions.

RESULTS

Fifty-five patients were included, with 87% being men. The mean age was 51.3 years (SD ±11.8); 32 patients (58%) were from South Asia, 12 (22%) from MENA, 9 (16%) from Southeast Asia, and 2 (4%) from elsewhere. Successful recanalization (modified Thrombolysis in Cerebral Infarction score = 2b/3) was achieved in 43 patients (78%), and symptomatic ICH occurred in 2 patients (4%). A favorable outcome at 90 days was seen in 26 of the 55 patients (47%). Apart from significantly older age-mean, 62.8 years (SD ±13; median, 69 years) versus 48.1 years (SD ±9.3; median, 49 years)-and coronary artery disease burden-4 (33%) versus 1 (2%) (P < .05), patients from MENA had risk factors, stroke severity, recanalization rates, ICH rates, and 90-day outcomes similar to those from South and Southeast Asia.

CONCLUSION

Rescue stent placement showed good outcomes and a low risk of clinically significant bleeding in a multiethnic cohort of patients from MENA and South and Southeast Asia, similar to that in published literature.

Association between glycated hemoglobin and functional outcomes in patients with intracranial large artery atherosclerotic disease-related acute ischemic stroke: identifying the magic number

Objective

This study aimed to investigate the effect of the glycated hemoglobin A1c (HbA1c) level on the functional outcome (FOC) in patients with intracranial large artery atherosclerotic disease (ICLAD)-related acute ischemic stroke (AIS).

Methods

This retrospective study enrolled patients with ICLAD-related AIS who were admitted to King Fahd University Hospital between January 2017 and September 2021. Patients were divided into two groups based on the optimal cutoff HbA1c level determined using receiver operating characteristic curve analysis-those with HbA1c ≤6.9% and those with HbA1c >6.9%. Demographic and other clinical characteristics were compared between the two groups using chi-square tests. The association between HbA1c and 90-day FOC was assessed using the chi-square test and odds ratios (ORs). Multivariate analysis was performed to adjust for confounding factors.

Results

A total of 140 patients were included in the analysis. A significant association was observed between the HbA1c level and FOC. Compared to patients with HbA1c ≤6.9%, patients with HbA1c >6.9% were more likely to have an unfavorable FOC [p = <0.001, OR = 2.05, 95% confidence interval (CI) = 1.33-3.14]. The association between HbA1c >6.9% and unfavorable FOC was sustained even after adjusting for confounding factors (p = 0.008) and atherosclerosis risk factors (p = 0.01). HbA1c >6.9% was also associated with higher ORs for in-hospital complications (p = 0.06, OR = 1.34, 95% CI = 1.02-1.77) and mortality (p = 0.07, OR = 1.42, 95% CI = 1.06-1.92) although these associations did not attain significant p-values.

Conclusion

HbA1c >6.9% was significantly associated with unfavorable FOC in ICLAD-related AIS. However, further studies with larger sample sizes are required to verify whether HbA1c is an independent predictor of poor FOC. Nevertheless, targeting HbA1c <7% should be the goal of physicians when managing patients at high risk of ICLAD.

Atherosclerosis Burden of Brain- and Heart-Supplying Arteries and the Relationship With Vascular Risk in Patients With Ischemic Stroke

Background Atherosclerosis of brain- and heart-supplying arteries (BHAs) are risk indicators for patients with ischemic stroke, but the atherosclerosis burden (AB) of intracranial, cervical, aortic, and coronary arteries in each and in total have not been simultaneously evaluated, and the associations with vascular risk remain unknown. Methods and Results With computed tomography angiography, single-territory AB was triple ranked on the basis of the number of arterial segments with a significant atherosclerotic lesion. The total AB (TAB) of BHAs was triple ranked on the basis of the number of arterial territories with a significant atherosclerotic lesion, or according to the sum of 4 single-territory AB rank-scores. After a 12-month follow-up of 395 patients with ischemic stroke, a composite outcome of ischemic stroke, myocardial infarction, and vascular death occurred in 10.9%. The single-territory AB of intracranial, cervical, aortic, and coronary arteries showed distinct strata patterns and different associations with vascular risk. The score-based TAB of BHAs predicted vascular risk (crude hazard ratios [95% CIs]: per level increase, 2.35 [1.54-3.58]; median versus low, 3.37 [1.45-7.82]; high versus low, 6.00 [2.36-15.24]) independently of vascular risk factors and single-territory AB, providing more prognostic information than the TAB of BHAs measured by the number of significantly atherosclerotic territories. Vascular events occurred in 3.0%, 13.6%, and 22.6% of patients in the low (41.8%), median (44.8%), and high (13.4%) strata of the score-based TAB of BHAs, respectively. Conclusions The single-territory AB of intracranial, cervical, aortic, or coronary arteries might be not reliable for vascular risk stratification in patients with ischemic stroke, and evaluating the TAB of BHAs by quantitatively integrating the single-territory AB is advisable.

Correlation Between MMP9 Promoter Methylation and Transient Ischemic Attack/Mild Ischemic Stroke with Early Cognitive Impairment

Background/Objective

Dyskinesia caused by transient ischemic attack (TIA) and mild ischemic stroke (MIS) is mild and short-lived; however, cognitive impairment (CI) can occur in the acute phase and be easily overlooked. DNA methylation is an epigenetic phenomenon that can affect gene expression through gene silencing. Blood levels of matrix metalloproteinase (MMP) 9 are elevated in ischemic stroke patients and is associated with the destruction of the blood-brain barrier and the occurrence of CI. No studies have investigated the relationship between MMP9 gene methylation and TIA/MIS with early cognitive impairment (ECI). As such, the purpose of the present study was to investigate the correlation between MMP9 gene methylation and TIA/MIS with ECI.

Methods

Data from 112 subjects were collected, including 84 with TIA/MIS (National Institutes of Health Stroke Scale <5 points) and 28 non-stroke control subjects. Patients were evaluated within 7 days of TIA/MIS onset according to four single-domain cognitive scales. Whole blood DNA methylation was detected using MethylTarget sequencing technology. Comparison of MMP9 gene methylation levels among subgroups was performed using statistical methods.

Results

The site S33-79 in the TIA/MIS group was hypomethylated compared with the control group, and sites S33-25 and S33-30 in TIA/MIS with ECI was hypomethylated compared with TIA/MIS without ECI. Compared with the small artery occlusion group, MMP9 gene, S33-25, 30, 39, 53, 58, 73, 79, 113 and 131 sites in the large artery atherosclerosis group were hypomethylated.

Conclusion

MMP9 gene hypomethylation sites were associated with TIA/MIS and TIA/MIS with ECI, and there was a strong correlation between MMP9 gene hypomethylation and atherosclerotic TIA/MIS. MMP9 gene methylation can reflect the severity of TIA/MIS. MMP9 gene hypomethylation sites may be used as potential biomarkers and therapeutic targets for TIA/MIS and TIA/MIS with ECI.

Reclassification and risk stratification of embolic stroke of undetermined source by ASCOD phenotyping

BACKGROUND

Common vascular diseases underlying stroke, including atherosclerosis, small-vessel disease (SVD), and cardioembolic pathology, can be present in patients with embolic stroke of undetermined source (ESUS), although these are not direct causes of stroke.

AIMS

To describe the frequency and degree of the three major diseases using atherosclerosis, SVD, cardiac pathology, other causes, and dissection (ASCOD) phenotyping and to assess their prognostic implications in ESUS.

METHODS

In this prospective observational study, 221 patients with ESUS within 1 week of onset were consecutively enrolled and followed up for 1 year. Vascular diseases associated with stroke were assessed using the ASCOD classification. The primary outcome was a composite of nonfatal stroke, nonfatal acute coronary syndrome, and vascular death.

RESULTS

Among 221 patients (mean age, 69.6 years; male, 59.7%), 135 (61.1%), 102 (46.2%), and 107 (48.4%) had any grade of atherosclerosis (A2 or A3), SVD (S3), and cardiac pathology (C2 or C3), respectively. ESUS patients graded as A2 or A3 (i.e. ipsilateral atherosclerotic plaque, contralateral ⩾ 50% stenosis, or aortic arch plaque) were at a significantly higher risk of composite vascular events than those graded as A0 (i.e. no atherosclerotic disease) (adjusted hazard ratio (95% confidence interval), 2.40 (1.01-5.72). No differences were observed in the event risk between patients with S3 (i.e. magnetic resonance imaging evidence of SVD) and S0 (i.e. no SVD) and between those with C2 or C3 (i.e. presence of any cardiac pathology) and C0 (i.e. no cardiac abnormalities).

CONCLUSIONS

Atherosclerotic diseases corresponding to ASCOD grade A2 or A3 were predictive of recurrent vascular events in ESUS patients. Reclassification of ESUS using ASCOD phenotyping provides important clues for risk prediction and may guide optimal management strategies.

Early identification and treatment for peripheral arterial disease in patients with ischemic cerebrovascular disease

Ischemic cerebrovascular disease (ICVD) is a major cause of mortality and disability worldwide and is often caused by atherosclerosis. As a systemic disease, atherosclerosis usually affects multiple vascular beds, mainly including cerebral, coronary, and peripheral arteries. Therefore, ICVD is easily complicated by lower-extremity peripheral arterial disease (PAD). ICVD patients with PAD have more serious symptoms and a worse prognosis, however, neurologists might neglect the evaluation and management of the coexistent PAD, and there is still a lack of consensuses about the diagnosis and treatment for such patients. By summarizing relevant research progresses, this review showed that duplex ultrasound had more advantages in the early screening and evaluation of PAD in ICVD patients among multiple methods to diagnose PAD. Furthermore, the current evidence seems to support that single-drug antiplatelet can be used as the basic treatment, and new antithrombotic strategies, such as ticagrelor only or aspirin combined with low-dose rivaroxaban are expected to further reduce the incidence of stroke for ICVD patients with PAD. More effective treatments would be explored by large-scale trials to guide the clinical management to prevent secondary stroke for such patients.

Associations between coronary/aortic 18F-sodium fluoride uptake and pro-atherosclerosis factors in patients with multivessel coronary artery disease

BACKGROUND

18F-NaF PET/CT is a novel approach to detect and quantify microcalcification in atherosclerosis. We aimed to explore the underlying systematic vascular osteogenesis in the coronary artery and aorta in patients with multivessel coronary artery disease (CAD).

METHODS

Patients with multivessel CAD prospectively underwent 18F-NaF PET/CT. The coronary microcalcification activity (CMA) and aortic microcalcification activity (AMA) were calculated based on both the volume and intensity of 18F-NaF PET activity. Peri-coronary adipose tissue (PCAT) density was measured in adipose tissue surrounding the coronary arteries and the 18F-NaF tissue-to-blood ratio (TBR) was measured in the coronary arteries.

RESULTS

100 patients with multivessel CAD were prospectively recruited. The CMA was significantly associated with the AMA (r = 0.70; P < .001). After multivariable adjustment, the CMA was associated with the AMA (Beta = 0.445 per SD increase; P < .001). The coronary TBR was also significantly associated with the PCAT density (r = 0.56; P < .001). The PCAT density was independently associated with the coronary TBR after adjusting confounding factors.

CONCLUSIONS

Coronary 18F-NaF uptake was significantly associated with the PCAT density. There was a significant relationship between the coronary and the aortic 18F-NaF uptake. It might indicate an underlying systematic vascular osteogenesis in patients with multivessel CAD.

The Importance of the Plasma Membrane in Atherogenesis

Atherosclerotic cardiovascular diseases are an important medical problem due to their high prevalence, impact on quality of life and prognosis. The pathogenesis of atherosclerosis is an urgent medical and social problem, the solution of which may improve the quality of diagnosis and treatment of patients. Atherosclerosis is a complex chain of events, which proceeds over many years and in which many cells in the bloodstream and the vascular wall are involved. A growing body of evidence suggests that there are complex, closely linked molecular mechanisms that occur in the plasma membranes of cells involved in atherogenesis. Lipid transport, innate immune system receptor function, and hemodynamic regulation are linked to plasma membranes and their biophysical properties. A better understanding of these interrelationships will improve diagnostic quality and treatment efficacy.

Diagnostic Predictive Value of Tryptase, Serum Amyloid A and Lipoprotein-Associated Phospholipase A2 Biomarker Groups for Large Atherosclerotic Cerebral Infarction

Background

There has been a gradual trend towards younger ageing of acute cerebral infarction in recent years. Atherosclerotic plaque rupture followed by dislodgement of emboli and resulting arterial embolism is an important mechanism for the development of acute cerebral infarction. Traditional independent risk factors for cerebral infarction have received attention from clinicians, but the risk factors for large artery atherosclerotic cerebral infarction are still unclear. Various blood biomarkers have an important role in the early diagnosis of large artery atherosclerotic cerebral infarction.

Objective

To assess the diagnostic predictive value of a group of biomarkers for large artery atherosclerotic cerebral infarction.

Methods

Lipoprotein-associated phospholipase A2 (LP-PLA2), trypsin-like protein (TPS), serum amyloid A (SAA), and supersensitive C-reactive protein (hs-CRP) levels were measured in the case group (30 cases) and control group (54 cases), respectively.

Results

The differences in the general data between the two groups were not statistically significant (P > 0.05). Logistic regression and ROC curve analysis showed that Lp-PLA2, TPS, and SAA were positively associated with the diagnosis of large atherosclerotic cerebral infarction (P < 0.05). The area under the ROC curve of the multivariate model for the biomarker group reached 0.995.

Conclusion

Biomarkers are closely associated with the occurrence of large atherosclerotic cerebral infarction and can be used as clinical adjuncts for diagnosis and assessment of prognosis.

Risk factors, infarct patterns and outcome differ between anterior and posterior circulation strokes attributed to intracranial large artery atherosclerotic steno-occlusive disease

BACKGROUND

Intracranial large artery atherosclerotic steno-occlusive disease (ICLAS) is the leading cause of acute ischemic stroke (AIS). The differences between anterior circulation stroke (ACS) and posterior circulation stroke (PCS) based on the TOAST classification have been well studied. However, data on the differences between ACS and PCS related to ICLAS are scarce, particularly from Saudi Arabia (SA). This study aimed to investigate the differences in demographics and clinico-radiological characteristics between patients with ACS and PCS attributed to ICLAS.

METHODS

This retrospective study included data for patients with ICLAS-related AIS grouped into two phenotypes as ACS and PCS. Demographics and clinico-radiological characteristics were compared between defined phenotypes using the chi-square test. The difference in the distribution of risk factors and radiological variables was ascertained by estimating the odds ratios (ORs) and 95 % confidence intervals (CI).

RESULTS

Data pertaining to 147 patients were included. Anterior circulation was involved in 66 % of patients. Territorial infarct pattern (68.7 %) was the most prevalent infarct pattern and artery to artery embolization (49 %) was the most prevalent mechanism for AIS. Watershed infarct pattern due to hemodynamic impairment was more prevalent in ACS than PCS (P = 0.0011). Diabetes mellitus (P = 0.02) and perforator infarct pattern (P = 0.001) were more prevalent in PCS than ACS. Baseline NIHSS, stroke severity and discharge status were statistically different between two phenotypes. Patients with infarction in posterior circulation have better functional outcome than those having in anterior circulation.

CONCLUSION

AIS attributed to ICLAS differs between ACS and PCS. Observed differences in risk factors' distribution, infarct pattern, underlying mechanism and outcome between two phenotypes carry important therapeutic and prognostic implications.

Association between carotid atherosclerosis and presence of intracranial atherosclerosis using three-dimensional high-resolution vessel wall magnetic resonance imaging in asymptomatic patients with type 2 diabetes

AIMS

Carotid atherosclerosis (CAS) is associated with a high risk of cardiovascular diseases. We aimed to investigate whether CAS is associated with the presence of intracranial atherosclerosis (ICAS).

METHODS

A total of 69 asymptomatic patients with type 2 diabetes (36 with CAS and 33 without CAS) who were free of cerebrovascular disease were enrolled in this case-control study. CAS was defined as a mean carotid intima-media thickness ≥ 1.0 mm or carotid plaque. The presence of ICAS was identified using three-dimensional high-resolution vessel wall magnetic resonance imaging.

RESULTS

There was no difference between the case and control groups in baseline characteristics, such as age, the proportion of men, duration of diabetes, and other cardiometabolic risk factors. The prevalence of ICAS was significantly higher in patients with CAS than those without CAS (72.2 % vs 48.5 %, P = 0.044). CAS was significantly associated with the presence of ICAS, even after adjusting other covariates (odds ratio [OR], 3.19; 95 % confidence interval [CI] 1.09-9.33, P = 0.034). In addition, CAS was significantly associated with the presence of multiple ICAS lesions (OR, 5.57; 95 % CI 1.75-17.78, P = 0.004).

CONCLUSIONS

CAS is significantly and independently associated with the presence and extent of ICAS in asymptomatic patients with type 2 diabetes.

Efficacy of metoprolol plus atorvastatin for carotid atherosclerosis and its influence on carotid intima-media thickness and homocysteine level

OBJECTIVE

To analyze the effects of metoprolol (MET) plus atorvastatin (ATO) on carotid intima-media thickness (IMT) and homocysteine (Hcy) level in carotid atherosclerosis (CAS) patients.

METHODS

In this retrospective study, 90 patients with CAS admitted to the Hangzhou Ninth People's Hospital between January 2019 and July 2021 were enrolled, including 40 cases (control group, the Con) treated with MET and 50 cases treated with the combination therapy of MET plus ATO (Research group, the Res). The efficacy and related influencing factors were observed and compared. The clinical effects (IMT, plaque score), Hcy level, inflammatory cytokines (ICs; matrix metalloproteinase-9 [MMP-9], high-sensitivity C-reactive protein [hs-CRP]), blood lipid indices (low-/high- density lipoprotein cholesterol [LDL-C/HDL-C], total cholesterol [TC], triglyceride [TG]) and coagulation markers (thrombin time [TT], prothrombin time [PT], activated partial thromboplastin time [APTT], fibrinogen [FIB]) of the two groups were observed and compared.

RESULTS

The results identified a statistically higher overall response rate in the Res group. Age, coronary heart disease, cerebral infarction and plaque score were confirmed to be closely related to the efficacy of CAS. In addition, statistically lower post-treatment IMT, plaque score, MMP-9, hs-CRP, LDL-C, TG, TC and FIB while higher PT, TT and APTT were determined in the Res group compared with the pre-treatment values and the Con group.

CONCLUSIONS

MET plus ATO can significantly improve efficacy, reduce IMT and plaque score of patients with CAS, as well as improve inflammatory factors, blood lipid indices and coagulation markers, for which it deserves clinical promotion.

Dual anti-platelet therapy for secondary prevention in intracranial atherosclerotic disease: a network meta-analysis

Background:

Intracranial arterial stenosis (ICAS) is a non-marginal cause of stroke/transient ischemic attacks (TIAs) and is associated with high stroke recurrence rate. Some studies have investigated the best secondary prevention ranging from antithrombotic therapy to endovascular treatment (ET). However, no direct comparison between all the possible treatments is currently available especially between single and dual anti-platelet therapies (SAPT and DAPT).

Aim:

To establish whether DAPT is more effective than SAPT in preventing the recurrence of ICAS-related stroke, by means of a network meta-analysis (NMA).

Design:

Systematic review and NMA in accordance to PRISMA guidelines.

Data sources and methods:

We performed a systematic review of trials investigating secondary prevention (SAPT or DAPT, anticoagulant treatment or ET) in patients with symptomatic ICAS available in MEDLINE, Scopus and Web of Science from January 1989 to May 2021. We defined our primary efficacy outcome as the recurrence of ischemic stroke/TIA. We analysed the extracted data with Bayesian NMA approach.

Results:

We identified 815 studies and included 5 trials in the NMA. Sequence generation was adequate in all the selected studies while the allocation concealment method was described in one study. All the included studies reported the pre-specified primary outcomes, and outcome assessment was blinded in all the studies. We used the fixed-effect approach as the heterogeneity was not significant (p > 0.1) according to the Cochran’s Q statistic. DAPT was superior to SAPT and DAPT + ET in preventing stroke/TIA recurrence [respectively, odds ratio (OR), 0.59; confidence interval (CI), 0.39–0.9; and OR, 0.49, CI, 0.26–0.88], while no difference was found between DAPT and oral anticoagulant therapy (OAC). DAPT was safer than OAC (OR, 0.48; CI, 0.26–0.89) and DAPT + ET (OR, 0.50; CI, 0.35–0.71), while no difference was found between DAPT and SAPT.

Conclusion:

DAPT is more effective than SAPT for secondary stroke prevention in patients with symptomatic ICAS, without increasing the risk of haemorrhage.

Registration:

Prospero/CRD42019140033.

The lymphocyte-to-monocyte ratio predicts intracranial atherosclerotic stenosis plaque instability

Background and purpose

Gadolinium enhancement on high-resolution vessel wall imaging (HR-VWI) is an imaging marker of intracranial atherosclerotic stenosis (ICAS) plaque instability. This study aimed to evaluate the relationships between hematological inflammatory indicators and the enhancement of ICAS plaques and to search for hematological indicators that can predict ICAS plaque instability.

Methods

Consecutive adult patients diagnosed with ICAS from April 2018 to December 2021 were recruited retrospectively, and every patient underwent HR-VWI. Plaque enhancement was measured qualitatively and quantitatively. The plaque-to-pituitary stalk contrast ratio (CR) indicated the degree of plaque enhancement. Clinical and laboratory data, including the lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), and systemic immune inflammation index (SII), were recorded. The hematological inflammatory indicators were compared between ICAS patients with and without plaque enhancement and between patients with and without symptomatic plaque. The hematological inflammatory indicators and the CR were compared using linear regression. Furthermore, receiver operating characteristic curve analysis was performed to assess the discriminative abilities of the inflammatory indicators to predict plaque instability.

Results

Fifty-nine patients were included. The NLR, SII and LMR were significantly correlated with plaque enhancement. The LMR was independently associated with plaque enhancement, and a linear negative correlation was observed between the LMR and CR (R = 0.716, P < 0.001). The NLR, LMR, plaque enhancement and CR were significantly associated with symptomatic ICAS, and the LMR and plaque enhancement were independent risk factors for symptomatic ICAS. The optimal cutoff value of the admission LMR to distinguish symptomatic plaque from asymptomatic plaque was 4.0 (80.0% sensitivity and 70.6% specificity).

Conclusion

The LMR was independently associated with ICAS plaque enhancement and showed a linear negative correlation with CR. The LMR and plaque enhancement were independent risk factors for symptomatic ICAS. An LMR ≤ 4.0 may predict ICAS plaque instability.

Present and future avenues of cell-based therapy for brain injury: The enteric nervous system as a potential cell source

Cell therapy is a promising strategy in the field of regenerative medicine; however, several concerns limit the effective clinical use, namely a valid cell source. The gastrointestinal tract, which contains a highly organized network of nerves called the enteric nervous system (ENS), is a valuable reservoir of nerve cells. Together with neurons and neuronal precursor cells, it contains glial cells with a well described neurotrophic potential and a newly identified neurogenic one. Recently, enteric glia is looked at as a candidate for cell therapy in intestinal neuropathies. Here, we present the therapeutic potential of the ENS as cell source for brain repair, too. The example of stroke is introduced as a brain injury where cell therapy appears promising. This disease is the first cause of handicap in adults. The therapies developed in recent years allow a partial response to the consequences of the disease. The only prospect of recovery in the chronic phase is currently based on rehabilitation. The urgency to offer other treatments is therefore tangible. In the first part of the review, some elements of stroke pathophysiology are presented. An update on the available therapeutic strategies is provided, focusing on cell‐ and biomaterial‐based approaches. Following, the ENS is presented with its anatomical and functional characteristics, focusing on glial cells. The properties of these cells are depicted, with particular attention to their neurotrophic and, recently identified, neurogenic properties. Finally, preliminary data on a possible therapeutic approach combining ENS‐derived cells and a biomaterial are presented.

Follow-up assessment of atherosclerotic plaques in acute ischemic stroke patients using high-resolution vessel wall MR imaging

PURPOSE

Data on evolution of intracranial plaques in acute ischemic stroke patients after receiving medical therapy is still limited. We aimed to investigate the plaque features associated with culprit lesions and to explore the plaque longitudinal changes during treatment using high-resolution vessel wall MR imaging (VW-MRI).

METHODS

Twenty-three patients (16 men; mean age, 51.4 years ± 11.1) with acute ischemic stroke underwent 3-T VW-MRI for intracranial atherosclerosis and were taken follow-up assessments. Each identified plaque was retrospectively classified as culprit, probably culprit, or nonculprit. Plaque features were analyzed at both baseline and follow-up and were compared using paired t-test, paired Wilcoxon test, or McNemar's test.

RESULTS

A total of 87 intracranial plaques were identified (23 [26.4%] culprit, 10 [11.5%] probably culprit, and 54 [62.1%] nonculprit plaques). The median time interval between initial and follow-up MRI scans was 8.0 months. In the multiple ordinal logistic regression analysis, plaque contrast ratio (CR) (OR, 1.037; 95% CI, 1.013-1.062; P = 0.002) and surface irregularity (OR, 4.768; 95% CI, 1.064-21.349; P = 0.041) were independently associated with culprit plaques. During follow-up, plaque length, maximum thickness, normalized wall index (NWI), stenosis degree, and CR significantly decreased (all P-values < 0.05) in the culprit plaque group. The plaque NWI and CR dropped in the probably culprit plaques (P = 0.041, 0.026, respectively). In the nonculprit plaque group, only plaque NWI and stenosis degree showed significant decrement (P = 0.017, 0.037, respectively).

CONCLUSION

Follow-up VW-MRI may contribute to plaque risk stratification and may provide valuable insights into the evolution of different plaques in vivo.

Genome-Wide Association Study of Intracranial Artery Stenosis Followed by Phenome-Wide Association Study

The genetic background of intracranial artery stenosis (ICAS), a major cause of ischemic stroke, remains elusive. We performed the world's first genome-wide association study (GWAS) of ICAS using DNA samples from Japanese subjects, to identify the genetic factors associated with ICAS and their correlation with clinical features. We also conducted a phenome-wide association study (PheWAS) of the top variant identified via GWAS to determine its association with systemic disease. The GWAS involved 408 patients with ICAS and 349 healthy controls and utilized an Asian Screening Array of venous blood samples. The PheWAS was performed using genotypic and phenotypic data of the Biobank Japan Project, which contained information on 46 diseases and 60 quantitative trait data from > 150,000 Japanese individuals. The GWAS revealed that the East Asian-specific functional variant of RNF213, rs112735431 (c.14429G > A, p.Arg4810Lys), was associated with ICAS (odds ratio, 12.3; 95% CI 5.5 to 27.5; P = 7.8 × 10^-10). Stratified analysis within ICAS cases demonstrated that clinical features of those with and without the risk allele were different. PheWAS indicated that high blood pressure and angina were significantly associated with RNF213 rs112735431. The first GWAS of ICAS, which stratifies subpopulations within the ICAS cases with distinct clinical features, revealed that RNF213 rs112735431 was the most significant variant associated with ICAS. Thus, RNF213 rs112735431 shows potential as an important clinical biomarker that characterizes pleiotropic risk in various vascular diseases, such as blood pressure and angina, thereby facilitating personalized medicine for systemic vascular diseases in East Asian populations.

Integrated head and neck imaging of symptomatic patients with stroke using simultaneous non-contrast cardiovascular magnetic resonance angiography and intraplaque hemorrhage imaging as compared with digital subtraction angiography

BACKGROUND

Both stenosis rate and intraplaque hemorrhage (IPH) are important predictors of stroke risk. Simultaneous non-contrast angiography and intraplaque hemorrhage (SNAP) cardiovascular magnetic resonance (CMR) imaging can detect both stenosis rate and IPH. We aimed to evaluate consistency between SNAP and digital subtraction angiography (DSA) to assess symptomatic patients with stroke and explore the performance of SNAP to identify IPH and the clinical factors associated with IPH.

METHODS

Eighty-one symptomatic patients with stroke, admitted to Wuhan Union Hospital who underwent CMR high-resolution vessel wall imaging (HR-VWI) and SNAP, were retrospectively identified. For patients who received interventional therapy, the imaging functions of SNAP and HR-VWI were compared with DSA. The diameters of the intracranial and carotid vessels were measured, and stenotic vessels were identified. The consistency of SNAP and HR-VWI in identifying IPH was also examined, and the correlations between IPH and clinical factors were analyzed.

RESULTS

SNAP was more consistent with DSA than HR-VWI in measuring vascular stenosis (intraclass correlation coefficient [ICC]SNAP-DSA = 0.917, ICC HR-VWI-DSA = 0.878). Regarding the diameter measurements of each intracranial and carotid vessel segment, SNAP was superior or similar to HR-VWI, and both were consistent with DSA in the measurement of major intracranial vascular segments. HR-VWI and SNAP exhibited acceptable agreement in identifying IPH (Kappa = 0.839, 95% confidence interval [CI]: 0.704-0.974). Patients who underwent interventional therapy had a higher plaque burden (P < 0.001). Patients with IPH had lower levels of high-density lipoprotein cholesterol (HDL) (P = 0.038) and higher levels of blood glucose (P = 0.007) and cystatin C (P = 0.040).

CONCLUSIONS

CMR SNAP is consistent with DSA in measuring vessel diameters and identifying atherosclerosis stenosis in each intracranial and carotid vessel segment. SNAP is also a potential alternative to HR-VWI in identifying stenosis and IPH.

Prognostic Role of Hypertriglyceridemia in Patients With Stroke of Atherothrombotic Origin

BACKGROUND AND OBJECTIVES

Hypertriglyceridemia is perceived to promote atherosclerotic pathology, but its role in stroke has not been well defined. We aimed to assess the contribution of hypertriglyceridemia to residual vascular risk in patients with atherothrombotic stroke.

METHODS

The Tokyo Women's Medical University Stroke Registry is an ongoing prospective, observational registry, in which 870 patients with acute ischemic stroke or TIA within 1 week of onset were consecutively enrolled and followed up for 1 year. Hypertriglyceridemia was defined as serum triglycerides levels of ≥150 mg/dL under fasting conditions. Significant stenosis of the cervicocephalic arteries was defined as having 50% or greater stenosis or occlusion. The primary outcome was major adverse cardiovascular events, including nonfatal stroke, nonfatal acute coronary syndrome, and vascular death.

RESULTS

Of 870 patients (mean age, 70.1 years; male, 60.9%), 217 (24.9%) had hypertriglyceridemia. High triglycerides levels were significantly associated with an increased prevalence of intracranial artery stenosis, particularly in the anterior circulation, rather than extracranial artery stenosis. Patients with hypertriglyceridemia had a greater risk of major adverse cardiovascular events than those without (annual rate, 20.9% vs. 9.7%; P<0.001), even after adjustment for potential confounders, including baseline low-density lipoprotein cholesterol and statin use (adjusted hazard ratio, 2.46; 95% confidence interval, 1.62-3.74). The higher risk of vascular events in hypertriglyceridemia versus non-hypertriglyceridemia patients was observed among patients with stroke of atherothrombotic origin (n=174; annual rate, 35.1% vs. 14.2%; P=0.001), those with significant intracranial artery stenosis (n=247; annual rate, 29.9% vs. 14.7%; P=0.006), and those with significant extracranial carotid artery stenosis (n=123; annual rate, 23.0% vs. 9.4%; P=0.042). In contrast, hypertriglyceridemia was not predictive of recurrent vascular events in patients with cardioembolic stroke (n=221; annual rate, 19.1% vs. 10.5%; P=0.18).

DISCUSSION

Hypertriglyceridemia is an important modifiable risk factor that drives residual vascular risk in patients with stroke of atherothrombotic origin, even while on statin therapy.

TRIAL REGISTRATION INFORMATION

The Tokyo Women's Medical University Stroke Registry is registered at UMIN000031913 (https://upload.umin.ac.jp).

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that in patients with atherothrombotic stroke, hypertriglyceridemia is associated with an increased risk of major cardiovascular events.

Development and Validation of a Risk Prediction Model for Atherosclerotic Cardiovascular Disease in Japanese Adults: The Hisayama Study

AIM

To develop and validate a new risk prediction model for predicting the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) in Japanese adults.

METHODS

A total of 2,454 participants aged 40-84 years without a history of cardiovascular disease (CVD) were prospectively followed up for 24 years. An incident ASCVD event was defined as the first occurrence of coronary heart disease or atherothrombotic brain infarction. A Cox proportional hazards regression model was used to construct the prediction model. In addition, a simplified scoring system was translated from the developed prediction model. The model performance was evaluated using Harrell's C statistics, a calibration plot with the Greenwood-Nam-D'Agostino test, and a bootstrap validation procedure.

RESULTS

During a median of a 24-year follow-up, 270 participants experienced the first ASCVD event. The predictors of the ASCVD events in the multivariable Cox model included age, sex, systolic blood pressure, diabetes, serum high-density lipoprotein cholesterol, serum low-density lipoprotein cholesterol, proteinuria, smoking habits, and regular exercise. The developed models exhibited good discrimination with negligible evidence of overfitting (Harrell's C statistics: 0.786 for the multivariable model and 0.789 for the simplified score) and good calibrations (the Greenwood-Nam-D'Agostino test: P=0.29 for the multivariable model, 0.52 for the simplified score).

CONCLUSION

We constructed a risk prediction model for the development of ASCVD in Japanese adults. This prediction model exhibits great potential as a tool for predicting the risk of ASCVD in clinical practice by enabling the identification of specific risk factors for ASCVD in individual patients.

Prediction of Mechanosensitive Genes in Vascular Endothelial Cells Under High Wall Shear Stress

Objective: The vulnerability of atherosclerotic plaques is among the leading cause of ischemic stroke. High wall shear stress (WSS) promotes the instability of atherosclerotic plaques by directly imparting mechanical stimuli, but the specific mechanisms remain unclear. We speculate that modulation of mechanosensitive genes may play a vital role in accelerating the development of plaques. The purpose of this study was to find mechanosensitive genes in vascular endothelial cells (ECs) through combining microarray data with bioinformatics technology and further explore the underlying dynamics–related mechanisms that cause the progression and destabilization of atherosclerotic plaques.

Methods: Microarray data sets for human vascular ECs under high and normal WSS were retrieved from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) were identified through the R language. The performance of enrichment analysis and protein–protein interaction (PPI) network presented the biological function and signaling pathways of the DEGs. Hub genes were identified based on the PPI network and validated by GEO data sets. Predicted transcription factor (TF) genes and miRNAs interaction with potential mechanosensitive genes were identified by NetworkAnalyst.

Results: A total of 260 DEGs, 121 upregulated and 139 downregulated genes, were screened between high and normal WSS from GSE23289. A total of 10 hub genes and four cluster modules were filtered out based on the PPI network. The enrichment analysis showed that the biological functions of the hub genes were mainly involved in responses to unfolded protein and topologically incorrect protein, and t to endoplasmic reticulum stress. The significant pathways associated with the hub genes were those of protein processing in the endoplasmic reticulum, antigen processing, and presentation. Three out of the 10 hub genes, namely, activated transcription factor 3 (ATF3), heat shock protein family A (Hsp70) member 6 (HSPA6), and dual specificity phosphatase 1 (DUSP1, also known as CL100, HVH1, MKP-1, PTPN10), were verified in GSE13712. The expression of DUSP1 was higher in the senescent cell under high WSS than that of the young cell. The TF–miRNA–mechanosensitive gene coregulatory network was constructed.

Conclusion: In this work, we identified three hub genes, ATF3, HSPA6, and DUSP1, as the potential mechanosensitive genes in the human blood vessels. DUSP1 was confirmed to be associated with the senescence of vascular ECs. Therefore, these three mechanosensitive genes may have emerged as potential novel targets for the prediction and prevention of ischemic stroke. Furthermore, the TF–miRNA–mechanosensitive genes coregulatory network reveals an underlying regulatory mechanism and the pathways to control disease progression.

Involvement of Fatty Acids and Their Metabolites in the Development of Inflammation in Atherosclerosis

Despite all the advances of modern medicine, atherosclerosis continues to be one of the most important medical and social problems. Atherosclerosis is the cause of several cardiovascular diseases, which are associated with high rates of disability and mortality. The development of atherosclerosis is associated with the accumulation of lipids in the arterial intima and the disruption of mechanisms that maintain the balance between the development and resolution of inflammation. Fatty acids are involved in many mechanisms of inflammation development and maintenance. Endothelial cells demonstrate multiple cross-linkages between lipid metabolism and innate immunity. In addition, these processes are linked to hemodynamics and the function of other cells in the vascular wall, highlighting the central role of the endothelium in vascular biology.

Low Toe-Brachial Index Is Associated With Stroke Outcome Despite Normal Ankle-Brachial Index

Introduction: We investigated whether the toe-brachial index (TBI) is associated with stroke prognosis and evaluated this association in patients with normal ankle-brachial index (ABI). Methods: Acute ischemic stroke patients who underwent TBI measurements were enrolled. Poor functional outcome was defined as modified Rankin Scale score ≥3. Major adverse cardiovascular event (MACE) was defined as stroke recurrence, myocardial infarction, or death. Normal ABI was defined as 0.9 ≤ ABI ≤ 1.4. Results: A total of 1,697 patients were enrolled and followed up for a median 39.7 (interquartile range, 25.7-54.6) months. During the period, 305 patients suffered MACE (18.0%), including 171 (10.1%) stroke recurrences. TBI was associated with hypertension, diabetes, atrial fibrillation, aortic plaque score, ABI, and brachial-ankle pulse wave velocity (all p < 0.05). In multivariable logistic regression, TBI was inversely associated with poor functional outcome in all patients [odds ratio (OR) 0.294, 95% confidence interval (CI) 0.114-0.759], even in patients with normal ABI (OR 0.293, 95% CI 0.095-0.906). In multivariable Cox regression, TBI < 0.6 was associated with stroke recurrence [hazard ratio (HR) 1.651, 95% CI 1.135-2.400], all-cause mortality (HR 2.105, 95% CI 1.343-3.298), and MACE (HR 1.838, 95% CI 1.396-2.419) in all patients. TBI < 0.6 was also associated with stroke recurrence (HR 1.681, 95% CI 1.080-2.618), all-cause mortality (HR 2.075, 95% CI 1.180-3.651), and MACE (HR 1.619, 95% CI 1.149-2.281) in patients with normal ABI. Conclusions: Low TBI is independently associated with poor short- and long-term outcomes in acute ischemic stroke patients despite normal ABI.

Genome sequencing reveals the role of rare genomic variants in Chinese patients with symptomatic intracranial atherosclerotic disease

Objectives

The predisposition of intracranial atherosclerotic disease (ICAD) to East Asians over Caucasians infers a genetic basis which, however, remains largely unknown. Higher prevalence of vascular risk factors (VRFs) in Chinese over Caucasian patients who had a stroke, and shared risk factors of ICAD with other stroke subtypes indicate genes related to VRFs and/or other stroke subtypes may also contribute to ICAD.

Methods

Unrelated symptomatic patients with ICAD were recruited for genome sequencing (GS, 60-fold). Rare and potentially deleterious single-nucleotide variants (SNVs) and small insertions/deletions (InDels) were detected in genome-wide and correlated to genes related to VRFs and/or other stroke subtypes. Rare aneuploidies, copy number variants (CNVs) and chromosomal structural rearrangements were also investigated. Lastly, candidate genes were used for pathway and gene ontology enrichment analysis.

Results

Among 92 patients (mean age at stroke onset 61.0±9.3 years), GS identified likely ICAD-associated rare genomic variants in 54.3% (50/92) of patients. Forty-eight patients (52.2%, 48/92) had 59 rare SNVs/InDels reported or predicted to be deleterious in genes related to VRFs and/or other stroke subtypes. None of the 59 rare variants were identified in local subjects without ICAD (n=126). 31 SNVs/InDels were related to conventional VRFs, and 28 were discovered in genes related to other stroke subtypes. Our study also showed that rare CNVs (n=7) and structural rearrangement (a balanced translocation) were potentially related to ICAD in 8.7% (8/92) of patients. Lastly, candidate genes were significantly enriched in pathways related to lipoprotein metabolism and cellular lipid catabolic process.

Conclusions

Our GS study suggests a role of rare genomic variants with various variant types contributing to the development of ICAD in Chinese patients.

Stroke Aetiology and Collateral Status in Acute Ischemic Stroke Patients Receiving Reperfusion Therapy-A Meta-Analysis

BACKGROUND

The interplay between collateral status and stroke aetiology may be crucial in the evaluation and management of acute ischemic stroke (AIS). Our understanding of this relationship and its level of association remains sub-optimal. This study sought to examine the association of pre-intervention collateral status with stroke aetiology, specifically large artery atherosclerosis (LAA) and cardio-embolism (CE), in AIS patients receiving reperfusion therapy, by performing a meta-analysis.

METHODS

Relevant search terms were explored on Medline/PubMed, Embase and Cochrane databases. Studies were included using the following inclusion criteria: (a) patients aged 18 or above; (b) AIS patients; (c) patients receiving reperfusion therapy; (d) total cohort size of >20, and (e) qualitative or quantitative assessment of pre-intervention collateral status on imaging using a grading scale. Random-effects meta-analysis was performed to investigate the association of aetiology with pre-intervention collateral status, and forest plots of risk ratio (RR) were generated.

RESULTS

A meta-analysis was conducted on seven studies, with a cumulative cohort of 1235 patients, to assess the association of pre-intervention collateral status with stroke aetiology. Patients with LAA were associated significantly with an increased rate of good collaterals (RR 1.24; 95% CI 1.04-1.50; p = 0.020, z = 2.33). Contrarily, CE aetiology was associated significantly with a decreased rate of good collaterals (RR 0.83; 95% CI 0.71-0.98; p = 0.027, z = -2.213).

CONCLUSIONS

This study demonstrates that, in AIS patients receiving reperfusion therapy, LAA and CE aetiologies are associated significantly with collateral status.

Pathogenetic mechanisms of ischemic stroke: from verification to secondary prevention

Ischemic stroke is an extremely heterogeneous disease: there are more than 200 causes of cerebral catastrophe. Early identification of the pathogenetic mechanism (subtype) of ischemic stroke allows planning an individual secondary prevention strategy, which includes a wide range of pharmaceutical and surgical methods. The article presents the characteristics of cardioembolic (associated with atrial fibrillation and flutter, prosthetic valves, chronic heart failure, left ventricle thrombus, infective endocarditis, open foramen ovale, etc.), atherothrombotic (due to extra- and intracranial atherosclerosis), lacunar and cryptogenic stroke, as well as less common causes of the disease, in particular cervical or cerebral artery dissection. Issues of secondary prevention of stroke according to the pathogenetic subtype are described and summarized as an algorithm. The article is illustrated with clinical examples.

Diversity of Lipid Function in Atherogenesis: A Focus on Endothelial Mechanobiology

Atherosclerosis is one of the most important problems in modern medicine. Its high prevalence and social significance determine the need for a better understanding of the mechanisms of the disease's development and progression. Lipid metabolism and its disorders are one of the key links in the pathogenesis of atherosclerosis. Lipids are involved in many processes, including those related to the mechanoreception of endothelial cells. The multifaceted role of lipids in endothelial mechanobiology and mechanisms of atherogenesis are discussed in this review. Endothelium is involved in ensuring adequate vascular hemodynamics, and changes in blood flow characteristics are detected by endothelial cells and affect their structure and function.

Risk Stratification in Patients with Ischemic Stroke and Residual Cardiovascular Risk with Current Secondary Prevention

PURPOSE

Suboptimal secondary prevention in patients with stroke causes a remaining cardiovascular risk desirable to reduce. We have validated a prognostic model for secondary preventive settings and estimated future cardiovascular risk and theoretical benefit of reaching guideline recommended risk factor targets.

PATIENTS AND METHODS

The SMART-REACH (Secondary Manifestations of Arterial Disease-Reduction of Atherothrombosis for Continued Health) model for 10-year and lifetime risk of cardiovascular events was applied to 465 patients in the Norwegian Cognitive Impairment After Stroke (Nor-COAST) study, a multicenter observational study with two-year follow-up by linkage to national registries for cardiovascular disease and mortality. The residual risk when reaching recommended targets for blood pressure, low-density lipoprotein cholesterol, smoking cessation and antithrombotics was estimated.

RESULTS

In total, 11.2% had a new event. Calibration plots showed adequate agreement between estimated and observed 2-year prognosis (C-statistics 0.63, 95% confidence interval 0.55-0.71). Median estimated 10-year risk of recurrent cardiovascular events was 42% (Interquartile range (IQR) 32-54%) and could be reduced to 32% by optimal guideline-based therapy. The corresponding numbers for lifetime risk were 70% (IQR 63-76%) and 61%. We estimated an overall median gain of 1.4 (IQR 0.2-3.4) event-free life years if guideline targets were met.

CONCLUSION

Secondary prevention was suboptimal and residual risk remains elevated even after optimization according to current guidelines. Considerable interindividual variation in risk exists, with a corresponding variation in benefit from intensification of treatment. The SMART-REACH model can be used to identify patients with the largest benefit from more intensive treatment and follow-up.

A systematic review of the correlation between serum asymmetric dimethylarginine, carotid atherosclerosis and ischaemic stroke

OBJECTIVE

To investigate the correlation between serum asymmetric dimethylarginine (ADMA) and the risk of ischaemic stroke and carotid atherosclerosis in adults.

METHODS

We systematically searched PubMed, EMBASE, Web of Science and other databases for relevant studies on serum ADMA and ischaemic stroke or carotid atherosclerosis, which were published from December 1980 to December 2019. The quality of the included studies was evaluated according to the Cochrane system evaluation standard. The difference in serum ADMA level between ischaemic stroke and control group was selected as the effect size (standardized mean difference, SMD). The pooled analysis was performed using Review Manager (V.5.3).

RESULTS

According to the selection criteria, thirteen studies were included in the meta-analysis after screening. Nine studies compared ADMA levels between the ischaemic stroke group and healthy control group, involving a total of 1315 and 880 subjects in the two groups, respectively. Pooled effect sizes were calculated using the random-effects model due to the high heterogeneity (I²  = 93%, P < .00001). The level of serum ADMA in patients with ischaemic stroke was significantly higher than that in healthy people (SDM = 0.69, 95% CI [0.32, 1.06], P = .0002). Seven of the thirteen articles compared ADMA levels between the carotid arteriosclerosis group and the healthy control group, with 559 and 330 subjects in the two groups, respectively. The random-effects model was applied due to the high heterogeneity (I²  = 91%, P < .00001). The level of serum ADMA in patients with carotid arteriosclerosis was significantly higher than that in healthy people (SDM = 1.03, 95% CI [0.49, 1.57], P = .0002).

CONCLUSION

The serum ADMA may be related to ischaemic stroke, and it is a risk factor for carotid atherosclerosis.

Intracranial Atherosclerotic Plaque Characteristics and Burden Associated With Recurrent Acute Stroke: A 3D Quantitative Vessel Wall MRI Study

Background: Intracranial atherosclerotic disease (ICAD) tends to affect multiple arterial segments, and previous studies rarely performed a comprehensive plaque analysis of the entire circle of Willis for the evaluation of recurrent stroke risk. We aimed to investigate the features of circle of Willis ICAD on 3D magnetic resonance vessel wall imaging (MR-VWI) and their relationships with recurrent acute stroke. Methods: Patients with either acute ischemic stroke (within 4 weeks after stroke) or chronic ischemic stroke (after 3 months of stroke) due to intracranial atherosclerotic plaque underwent 3D contrast-enhanced MR-VWI covering major cerebral arteries. Participants were divided into three groups: first-time acute stroke, recurrent acute stroke, and chronic stroke. Culprit plaque (defined as the only lesion or the most stenotic lesion when multiple plaques were present within the same vascular territory of the stroke) and non-culprit plaque characteristics, including total plaque number, plaque thickness, plaque area, plaque burden (calculated as plaque area divided by outer wall area), enhancement ratio (ER), eccentricity, and stenosis, were measured and compared across the three groups. Associations between plaque characteristics and recurrent acute stroke were investigated by multivariate analysis. Results: A total of 176 participants (aged 61 ± 10 years, 109 men) with 702 intracranial plaques were included in this study. There were 80 patients with first-time acute stroke, 42 patients with recurrent acute stroke, and 54 patients with chronic stroke. More intracranial plaques were found per patient in the recurrent acute stroke group than in the first-time acute stroke or chronic stroke group (5.19 ± 1.90 vs. 3.71 ± 1.96 and 3.46 ± 1.33, p < 0.001). Patients in the recurrent acute stroke group had greater culprit plaque burden (p < 0.001) and higher culprit ER (p < 0.001) than the other two groups. After adjustment of clinical demographic factors, in multivariate analysis, coronary artery disease (CAD) (odds ratio, OR = 4.61; p = 0.035), total plaque number (OR = 1.54; p = 0.003), culprit plaque ER (OR = 2.50; p = 0.036), and culprit plaque burden (OR per 10% increment = 2.44; p = 0.010) were all independently associated with recurrent acute stroke compared to the first-time acute stroke. Conclusion: Increased intracranial atherosclerotic plaque number, higher culprit plaque ER, greater culprit plaque burden, and CAD are independently associated with recurrent acute stroke.

Glucose Fluctuation and Severe Internal Carotid Artery Siphon Stenosis in Type 2 Diabetes Patients

The impact of glucose fluctuation on intracranial artery stenosis remains to be elucidated. This study aimed to investigate the association between glucose fluctuation and intracranial artery stenosis. This was a cross-sectional study of type 2 diabetes mellitus (T2DM) patients equipped with the FreeStyle Libre Pro continuous glucose monitoring system (Abbott Laboratories) between February 2019 and June 2020. Glucose fluctuation was evaluated according to the standard deviation (SD) of blood glucose, coefficient of variation (%CV), and mean amplitude of glycemic excursions (MAGE). Magnetic resonance angiography was used to evaluate the degree of intracranial artery stenosis. Of the 103 patients, 8 patients developed severe internal carotid artery (ICA) siphon stenosis (≥70%). SD, %CV, and MAGE were significantly higher in the severe stenosis group than in the non-severe stenosis group (<70%), whereas there was no significant intergroup difference in the mean blood glucose and HbA1c. Multivariable logistic regression analysis adjusted for sex showed that SD, %CV, and MAGE were independent factors associated with severe ICA siphon stenosis. In conclusion, glucose fluctuation is significantly associated with severe ICA siphon stenosis in T2DM patients. Thus, glucose fluctuation can be a target of preventive therapies for intracranial artery stenosis and ischemic stroke.

Effects of Pemafibrate in Patients with Stroke and Hypertriglyceridemia: Baseline Cerebral Artery Diseases and 3-Month Laboratory Outcomes

AIMS

The role of hypertriglyceridemia in stroke is poorly understood. The Pemafibrate for Prevention of Atherosclerotic Diseases in Stroke (PPAR Stroke) study was designed to assess the effects of a novel selective peroxisome proliferator-activated receptor alpha modulator, pemafibrate, on vascular outcomes in stroke patients with hypertriglyceridemia.

METHODS

This was a prospective single-arm study including 74 patients (mean age, 64.1 years; male 75.7%) with stroke and hypertriglyceridemia (defined as fasting serum triglycerides levels of ≥ 150 mg/dL) who were treated with pemafibrate at 0.2 mg or 0.1 mg/day. The present report assessed the association of hypertriglyceridemia with cerebral large and small vessel diseases at baseline and changes in laboratory parameters after a three-month pemafibrate therapy.

RESULTS

Patients with triglycerides levels of ≥ 227 mg/dL (higher than the median) more often presented with intracranial artery atherosclerotic stenosis than those with triglycerides levels of 150-227 mg/dL (44.4% vs. 21.6%, p=0.037). On the other hand, no differences were found in the prevalence of extracranial artery atherosclerosis and cerebral small vessel diseases. Mean triglycerides levels were significantly reduced from 285 mg/dL at baseline to 175 mg/dL at 3 months (p＜0.001). High-density lipoprotein cholesterol levels increased from 48 mg/dL to 53 mg/dL (p＜0.001). In addition, significant reductions in alanine aminotransferase, γ-glutamyl transpeptidase, and interleukin-6 levels were observed (p＜0.001, p=0.002, and p=0.044, respectively).

CONCLUSIONS

Higher triglycerides levels are associated with intracranial artery atherosclerosis. Pemafibrate showed pleiotropic effects not only in ameliorating atherogenic dyslipidemia but also in the reduction of the levels of inflammatory markers and hepatobiliary enzymes.

Association between coexisting intracranial artery and extracranial carotid artery atherosclerotic diseases and ipsilateral cerebral infarction: a Chinese Atherosclerosis Risk Evaluation (CARE-II) study

BACKGROUND

To evaluate the association between coexisting intracranial and extracranial carotid artery atherosclerotic diseases and ipsilateral acute cerebral infarct (ACI) in symptomatic patients by using magnetic resonance (MR) vessel wall imaging.

METHODS

Symptomatic patients were recruited from a cross-sectional, multicentre study of Chinese Atherosclerosis Risk Evaluation (CARE-II). All patients underwent MR imaging for extracranial carotid arterial wall, intracranial artery and brain. Coexisting intracranial stenosis ≥50% and extracranial carotid artery mean wall thickness (MWT) ≥1 mm and plaque compositions at the same side were evaluated and the ipsilateral ACI was identified. The association between coexisting atherosclerotic diseases and ACI was evaluated using logistic regression.

RESULTS

351 patients were recruited. Patients with ipsilateral ACI had significantly greater prevalence of coexisting intracranial stenosis ≥50% and carotid MWT ≥1 mm (20.5% vs 4.9%, p<0.001), calcification (15.1% vs 4.4%, p=0.001) and lipid-rich necrotic core (LRNC) (19.2% vs 7.8%, p=0.002) compared with those without. Coexisting intracranial artery stenosis ≥50% and carotid MWT ≥1 mm (OR 5.043, 95% CI 2.378 to 10.694; p<0.001), calcification (OR 3.864, 95% CI 1.723 to 8.664; p=0.001) and LRNC (OR 2.803, 95% CI 1.455 to 5.401; p=0.002) were significantly associated with ipsilateral ACI. After adjusting for confounding factors, the aforementioned associations remained statistically significant (intracranial stenosis ≥50% coexisting with carotid MWT ≥1 mm: OR 4.313, 95% CI 1.937 to 9.601, p<0.001; calcification: OR 3.606, 95% CI 1.513 to 8.593, p=0.004; LRNC: OR 2.358, 95% CI 1.166 to 4.769, p=0.017).

CONCLUSIONS

Coexistence of intracranial artery severe stenosis and extracranial carotid artery large burden and intraplaque components of calcification and LRNC are independently associated with ipsilateral ACI.

TRIAL REGISTRATION NUMBER

https://www.clinicaltrials.gov/. Unique identifier: NCT02017756.

Prevalence, prognosis, and treatment of atherosclerotic intracranial stenosis in Caucasians

BACKGROUND

Intracranial atherosclerotic stenosis is a highly prevalent cause of stroke worldwide with important ethnic disparities. Widely considered to be a common cause of stroke in Asian and Afro-Caribbean populations, relatively less is known about the burden and significance of intracranial atherosclerotic stenosis in Caucasians.

AIMS

We aim to highlight recent insights and advances into the prevalence, prognosis, and treatment of symptomatic and asymptomatic atherosclerotic intracranial atherosclerotic stenosis in Caucasian patients.

SUMMARY OF REVIEW

We identified 48 articles studying intracranial atherosclerotic stenosis in Caucasian patients with ischemic stroke or transient ischemic attack. Most studies were on hospital-based cohorts of consecutive patients and half were graded as "fair" quality. There was significant variation between studies in the definition of intracranial atherosclerotic stenosis and in the imaging modalities used to detect intracranial atherosclerotic stenosis. Overall, 12.1% of Caucasian patients were found to have any intracranial atherosclerotic stenosis, 6.4% symptomatic intracranial atherosclerotic stenosis and 11.1% asymptomatic intracranial atherosclerotic stenosis, with higher rates at older ages. In studies reporting prognosis, there were 61 and 10 same-territory ischemic strokes in 1000 person-years in patients with symptomatic and asymptomatic intracranial atherosclerotic stenosis, respectively. Percutaneous stenting and angioplasty have not proven superior to intensive medical management in patients with symptomatic intracranial atherosclerotic stenosis.

CONCLUSIONS

Intracranial atherosclerotic stenosis has previously been neglected as a cause of stroke in Caucasians but is highly prevalent at older ages and frequently discovered with the growing use of noninvasive angiography. Intensive medical therapy is the treatment of choice, but there is a need to develop novel treatments or therapeutic approaches to lower the risk of stroke in higher risk patients.

Concurrent intracranial and extracranial artery stenosis and the prognosis of transient ischaemic symptoms or imaging-negative ischaemic stroke

BACKGROUND AND PURPOSE

Transient ischaemic attack (TIA), transient symptoms with infarction (TSI) and diffusion-weighted imaging (DWI)-negative acute ischaemic stroke (AIS) share similar aetiologies but are considered to have a rather benign prognosis. We intended to investigate the association between intracranial atherosclerotic stenosis (ICAS), extracranial atherosclerotic stenosis (ECAS) and the prognosis of patients with TIA, TSI and DWI-negative AIS.

METHODS

Clinical and imaging data of eligible participants were derived from the Chinese Intracranial Atherosclerosis study, according to symptom duration, acute infarction on DWI and discharge diagnosis. Based on the severity and location of arterial atherosclerosis, we categorised the study population into four groups: no or <50% ICAS and no ECAS; ≥50% ICAS but no ECAS; no or <50% ICAS with ECAS; and concurrent ≥50% ICAS and ECAS. Using multivariable Cox regression models, we analysed the relationship between the severity and distribution of large artery atherosclerosis and the prognosis of TIA, TSI and DWI-negative AIS.

RESULTS

A total of 806 patients were included, 67.3% of whom were male. The median age of the study participants was 63 years. Patients in the concurrent ≥50% ICAS and ECAS subgroup had both a significantly higher 1-year recurrence rate (adjusted HR 3.4 (95% CI 1.15 to 10.04), p=0.027) and a higher risk of composite vascular events (adjusted HR 3.82 (95% CI 1.50 to 9.72), p=0.005).

CONCLUSIONS

Concurrent ICAS and ECAS is associated with a higher possibility of 1-year recurrent stroke or composite vascular events. Large artery evaluation is necessary to assess patients with transient ischaemic symptoms or DWI-negative AIS. Progress in shortening the time interval between symptom onset and large vessel evaluation is needed.