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Papanikolaou P, Antonopoulos AS, Mastorakou I, Angelopoulos A, Kostoula E, Mystakidi XV, Simantiris S, Galiatsatos N, Oikonomou E, Tousoulis D. Antithrombotic Therapy in Carotid Artery Disease. Curr Pharm Des 2020; 26:2725-2734. [PMID: 32418521 DOI: 10.2174/1381612826666200518111359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/08/2020] [Indexed: 12/19/2022]
Abstract
The management of asymptomatic atherosclerotic carotid artery disease and the role of antithrombotic therapy is of increasing importance for stroke prevention. Non-invasive imaging of carotid plaques can identify high-risk plaque features that are associated with the risk of plaque rupture. Carotid plaque necrosis, hemorrhage, fibrous cap thinning, and the presence of foam cells have all been correlated with the risk of rupture and onset of neurological symptoms in patients with carotid stenosis. Antiplatelets are currently recommended for patients with a history of ischemic stroke and/or significant carotid artery stenosis, with aspirin and clopidogrel being the most widely used and studied agents. The role of dual antiplatelet therapy remains controversial. Moreover, there is scarce evidence on the role of newer anticoagulant agents in stable patients with carotid artery stenosis. In this review article, we discuss the pathophysiology of carotid atherosclerosis, the use of non-invasive imaging for detecting the vulnerable carotid plaque and summarize the existing clinical evidence on the use of antiplatelet and antithrombotic agents in carotid artery disease.
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Affiliation(s)
- Paraskevi Papanikolaou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Alexios S Antonopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Irene Mastorakou
- Imaging Department - Onassis Cardiac Surgery Centre, Athens, Greece
| | - Andreas Angelopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | | | - Xara-Vasiliki Mystakidi
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Spyros Simantiris
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Nikolaos Galiatsatos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Evangelos Oikonomou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
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Xu YY, Li ML, Gao S, Jin ZY, Sun ZY, Chen J, Hou B, Zhou HL, Feng F, Xu WH. Etiology of intracranial stenosis in young patients: a high-resolution magnetic resonance imaging study. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:319. [PMID: 28861416 DOI: 10.21037/atm.2017.06.31] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Using high-resolution magnetic resonance imaging (HRMRI), we sought to investigate the underlying etiology of intracranial stenosis in young patients. METHODS We retrospectively studied 122 Chinese young adult patients (from 18 to 45 years old, mean age 36.2±7.5 years) with unilateral middle cerebral artery (MCA) stenosis based on a prospectively established HRMRI database. The eccentricity, degree of stenosis, and remodeling types of MCA lesions were analyzed. The MCA lesions were classified as eccentric (presumed atherosclerosis) or concentric stenosis (presumed non-atherosclerosis). The clinical data and vessel wall properties were compared between the patients >35 years old and the patients ≤35 years old. RESULTS Eccentric stenosis was observed in 98 (80.3%) patients and concentric stenosis in 24 (19.7%) patients. The patients with eccentric stenosis were older (37.5±6.8 vs. 31.4±8.4 years old, P<0.001) and more likely had atherosclerosis risk factors (56.1% vs. 25.0%, P=0.006). The patients >35 years old had higher prevalence (90.1% vs. 66.7%, P=0.001) of eccentric stenosis and atherosclerosis factors (60.6% vs. 35.3%, P=0.006) than the patients ≤35 years old. Most of the patients with concentric stenosis were ≤35 years old (17/24, 70.8%) and were female (16/24, 66.7%). Binary Logistic analysis suggested smoking (OR =3.171; 95% CI, 1.210-8.314) and remodeling ratio (OR =1.625; 95% CI, 1.001-2.636) were independent predictive factors for symptomatic stenosis. CONCLUSIONS Atherosclerosis is the most common cause of intracranial stenosis in Chinese young patients. Non-atherosclerosis disease is an important etiology in young female, especially in the patients aged 35 years old or younger.
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Affiliation(s)
- Yu-Yuan Xu
- Departments of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ming-Li Li
- Departments of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Shan Gao
- Departments of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Zheng-Yu Jin
- Departments of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Zhao-Yong Sun
- Departments of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jie Chen
- Departments of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Bo Hou
- Departments of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Hai-Long Zhou
- Departments of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Feng Feng
- Departments of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei-Hai Xu
- Departments of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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Bulder MMM, Braun KPJ, Leeuwis JW, Lo RTH, van Nieuwenhuizen O, Kappelle LJ, Klijn CJM. The course of unilateral intracranial arteriopathy in young adults with arterial ischemic stroke. Stroke 2012; 43:1890-6. [PMID: 22550051 DOI: 10.1161/strokeaha.112.653212] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Unilateral intracranial focal nonprogressive arteriopathy is often found in children with arterial ischemic stroke. We aimed to investigate the course of unilateral intracranial arteriopathy in young adults. METHODS We searched the Utrecht Stroke Database for patients between 16 and 50 years of age diagnosed with anterior circulation arterial ischemic stroke and a nonatherosclerotic, unilateral intracranial large-artery arteriopathy between 1991 and 2005. We assessed clinical features, potential causes, risk factors, extent of infarction and arteriopathy at presentation, long-term angiographic course, and clinical outcome. RESULTS Of 356 patients with anterior circulation arterial ischemic stroke, 17 (5%) had a documented unilateral intracranial arteriopathy, of whom 14 could be included for follow-up investigations (median age, 34 years; range, 27-49 years). Median duration of follow-up was 8.8 years (range, 1.7-12.8 years). In 11 patients, onset of symptoms was not abrupt. The arteriopathy normalized completely in 5 and improved in 3 patients; in none of the patients did the arteriopathy worsen. Two of 14 patients had recurrent symptoms. Ten patients (71%) had a good outcome (modified Rankin Scale score≤2). CONCLUSIONS In young adults, arterial ischemic stroke is rarely caused by a unilateral intracranial arteriopathy. Similar to children, onset of symptoms in young adults is often not abrupt and the arteriopathy may improve over time. Late recurrences were rare. Possibly, a monophasic inflammatory process, as has been suggested for childhood intracranial focal nonprogressive arteriopathies, also occurs in young adults.
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Affiliation(s)
- Marcel M M Bulder
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, HP G03.228, PO Box 85500, 3508 GA Utrecht, The Netherlands.
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Kim YO, Son YJ, Woo YJ, Yun SJ. Spontaneous intracranial internal carotid artery dissection in a child with psoriasis. KOREAN JOURNAL OF PEDIATRICS 2009. [DOI: 10.3345/kjp.2009.52.9.1044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Young Ok Kim
- Department of Pediatrics, School of Medicine, Chonnam National University, Gwangju, Korea
| | - Young Jun Son
- Department of Pediatrics, School of Medicine, Chonnam National University, Gwangju, Korea
| | - Young Jong Woo
- Department of Pediatrics, School of Medicine, Chonnam National University, Gwangju, Korea
| | - Sook Jung Yun
- Department of Dermatology, School of Medicine, Chonnam National University, Gwangju, Korea
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Ay H, Benner T, Arsava EM, Furie KL, Singhal AB, Jensen MB, Ayata C, Towfighi A, Smith EE, Chong JY, Koroshetz WJ, Sorensen AG. A Computerized Algorithm for Etiologic Classification of Ischemic Stroke. Stroke 2007; 38:2979-84. [PMID: 17901381 DOI: 10.1161/strokeaha.107.490896] [Citation(s) in RCA: 320] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The SSS-TOAST is an evidence-based classification algorithm for acute ischemic stroke designed to determine the most likely etiology in the presence of multiple competing mechanisms. In this article, we present an automated version of the SSS-TOAST, the Causative Classification System (CCS), to facilitate its utility in multicenter settings.
Methods—
The CCS is a web-based system that consists of questionnaire-style classification scheme for ischemic stroke (http://ccs.martinos.org). Data entry is provided via checkboxes indicating results of clinical and diagnostic evaluations. The automated algorithm reports the stroke subtype and a description of the classification rationale. We evaluated the reliability of the system via assessment of 50 consecutive patients with ischemic stroke by 5 neurologists from 4 academic stroke centers.
Results—
The kappa value for inter-examiner agreement was 0.86 (95% CI, 0.81 to 0.91) for the 5-item CCS (large artery atherosclerosis, cardio-aortic embolism, small artery occlusion, other causes, and undetermined causes), 0.85 (95% CI, 0.80 to 0.89) with the undetermined group broken into cryptogenic embolism, other cryptogenic, incomplete evaluation, and unclassified groups (8-item CCS), and 0.80 (95% CI, 0.76 to 0.83) for a 16-item breakdown in which diagnoses were stratified by the level of confidence. The intra-examiner reliability was 0.90 (0.75–1.00) for 5-item, 0.87 (0.73–1.00) for 8-item, and 0.86 (0.75–0.97) for 16-item CCS subtypes.
Conclusions—
The web-based CCS allows rapid analysis of patient data with excellent intra- and inter-examiner reliability, suggesting a potential utility in improving the fidelity of stroke classification in multicenter trials or research databases in which accurate subtyping is critical.
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Affiliation(s)
- Hakan Ay
- AA Martinos Center for Biomedical Imaging and Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Room 2301, Charlestown, MA 02129, USA.
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Guimarães J, Fonseca R, Azevedo E. Cryptogenic multi-infarcts and cortico-subcortical dementia in a young adult. J Neurol Sci 2007; 257:255-7. [PMID: 17349661 DOI: 10.1016/j.jns.2007.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Etiology of stroke and dementia in young adults are challenging clinical problems, and these diseases often have devastating consequences. We present a case where a final etiologic diagnosis is not possible, in spite of an exhaustive study. CASE REPORT A 34-year-old man presented with a 5-year history of transient neurological deficits. Examination disclosed a cortico-subcortical dementia, but no other deficits. Laboratory evaluation was unremarkable, including the basic vascular study, homocystein, immunologic study, ACE, serology for Lyme, syphilis and HIV, tests for mitochondrial cytopathy, CADASIL and Fabry's disease, and CSF study. Prothrombotic study was normal except for a heterozygous mutation for factor V Leiden and for methylene tetrahydrofolate reductase. Cardiac exams (electrocardiogram, transesophagic echocardiography and 24 h-ECG) were normal. Cervical and transcranial duplex ultrasound and magnetic resonance angiography (MRA)-were normal, except for a hypoplasic right vertebral artery. Brain magnetic resonance imaging revealed corticosubcortical atrophy and multiple infarcts. The patient was prescribed antiplatelet and statin therapy, and is presently clinically stabilized after 3 years of follow-up, scoring 2 in modified Rankin scale. DISCUSSION Differential diagnosis of young onset vascular dementia is wide, including a number of rare sporadic and hereditary diseases. Although our case has a heterozygotic mutation for factor V Leiden, this might not explain the whole clinical picture; furthermore, there is no history of other vascular events, as venous thrombosis. An extensive investigation did not lead to a final etiological diagnosis. Nevertheless, even in these cases prevention with antiplatelet and statin might lead to clinical stabilization.
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Affiliation(s)
- J Guimarães
- Department of Neurology, Hospital São João, University of Porto, Portugal.
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