Etiological classification of ischemic stroke in young patients: a comparative study of TOAST, CCS, and ASCO

Association between Triglyceride-Glucose Index and Early Neurological Outcomes after Thrombolysis in Patients with Acute Ischemic Stroke

BACKGROUND

The triglyceride-glucose (TyG) index is a novel biomarker of insulin resistance which might plausibly influence endogenous fibrinolysis and thus early neurological outcomes in patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis using recombinant tissue-plasminogen activator.

METHODS

We included consecutive AIS patients within 4.5 h of symptom onset undergoing intravenous thrombolysis between January 2015 and June 2022 in this multi-center retrospective observational study. Our primary outcome was early neurological deterioration (END), defined as ≥2 (END₂) or ≥ 4 (END₄) National Institutes of Health Stroke Scale (NIHSS) score worsening compared to the initial NIHSS score within 24 h of intravenous thrombolysis. Our secondary outcome was early neurological improvement (ENI), defined as a lower NIHSS score at discharge. TyG index was calculated using the log scale of fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2. We evaluated the association of END and ENI with TyG index using a logistic regression model.

RESULTS

A total of 676 patients with AIS were evaluated. The median age was 68 (Interquartile range, IQR (60-76) years old), and 432 (63.9%) were males. A total of 89 (13.2%) patients developed END₂, 61 (9.0%) patients developed END₄, and 492 (72.7%) experienced ENI. In multivariable logistic regression analysis, after adjustment for confounding factors, TyG index was significantly associated with increased risks of END₂ (categorical variable, vs. lowest tertile, medium tertile odds ratio [OR] 1.05, 95% confidence interval, CI 0.54-2.02, highest tertile OR 2.94, 95%CI 1.64-5.27, overall p < 0.001) and END₄ (categorical variable, vs. lowest tertile, medium tertile OR 1.21, 95%CI 0.54-2.74, highest tertile OR 3.80, 95%CI 1.85-7.79, overall p < 0.001), and a lower probability of ENI (categorical variable, vs. lowest tertile, medium tertile OR 1.00, 95%CI 0.63-1.58, highest tertile OR 0.59, 95%CI 0.38-0.93, overall p = 0.022).

CONCLUSIONS

Increasing TyG index was associated with a higher risk of END and a lower probability of ENI in patients with acute ischemic stroke treated with intravenous thrombolysis.

Fasting Blood-Glucose Level and Clinical Outcome in Anterior Circulation Ischemic Stroke of Different Age Groups After Endovascular Treatment

OBJECTIVE

We aimed to analyze the association between fasting blood-glucose (FBG) level and 3-month functional outcome in anterior circulation ischemic stroke in different age groups after endovascular treatment (EVT).

METHODS

We retrospectively analyzed the consecutive patients with acute ischemic stroke (AIS) receiving EVT from our department between July 2015 and March 2021. The patients were categorized into the older (≥60 years) and younger (<60 years) groups, and patients in each age group were dichotomized into favorable versus unfavorable outcomes according to the 3-month modified Rankin Scale (mRS) score.

RESULTS

A total of 504 patients (286 males and 218 females) were included in our study. Three hundred ninety-two patients (77.8%) belonged to the group aged ≥60 years, and 112 (22.2%) belonged to the group aged <60 years. At the end of the study, 222 (56.6%) patients developed unfavorable outcomes in the older group and 31 (27.7%) showed unfavorable outcomes in the younger group. FBG level of the younger patients was significantly lower than that of older patients. In the older group, FBG level independently predicted a 3-month clinical unfavorable outcome with an odds ratio of 1.242 (95% confidence interval, 1.096-1.407; p = 0.001). However, the association was not found in the younger group (p = 0.376).

CONCLUSION

Higher FBG level is an independent risk factor for 3-month unfavorable outcome in the AIS patients aged ≥60 years receiving EVT, but no similar effect was seen in the group aged <60 years.

Cryptogenic Stroke and Embolic Stroke of Undetermined Source: Risk Factors and Approaches for Detection of Atrial Fibrillation

BACKGROUND

Stroke is a problem worldwide because of its high mortality and disability rates. Almost 90% of strokes are ischemic, and more than half of the deaths are caused by an ischemic stroke. Most risk factors for stroke are manageable so that it can be avoided with proper prevention. Despite the success in determining the causes of stroke in recent years, selectively, the "culprit" causing stroke remains unsolved. In such cases, a diagnosis of undetermined etiology (cryptogenic stroke) or embolic stroke of undetermined source (ESUS) is generated, resulting the prevention of a recurrent cerebrovascular occurrence impossible. Atrial fibrillation (AF) can be a cause of stroke by causing blood clots in the chambers of the heart.

PURPOSE

The aim was to determine the optimal method of heart rate monitoring in patients with ischemic stroke, as methods and approaches for detecting AF are very diverse, but there is still no single opinion, which would be universal.

PROCEDURES

In our review, we consider epidemiology, risk factors for the stroke of undetermined etiology, as well as analytical methods for detecting heart rhythm disturbances in this category of patients.

FINDINGS

Atrial fibrillation (AF) is detected by thorough monitoring of heart rate of patients with cryptogenic stroke and ESUS can be diagnosed in up to 46% of patients. .

CONCLUSION

After AF detection, consideration should be given to prescribing anticoagulants, instead of antiplatelet agents, for the secondary prevention of stroke.

Estonian young stroke registry: High burden of risk factors and high prevalence of cardiomebolic and large-artery stroke

Background and aims

The aim of the present study was to assess the risk factor burden and stroke etiology of young stroke patients in Estonia and to compare the results with similar cohorts from other countries.

Methods

This study includes ischemic stroke patients aged 18-54 years from the prospective Estonian Young Stroke Registry between 2013 and 2020. All patients were managed in a stroke unit following a prespecified detailed protocol. Data on stroke risk factors, etiology, and stroke severity were analyzed.

Results

A total of 437 patients (mean age 44.7 ± 8.3 years; 62% males) were included in the registry during the 8-year study period. A total of 50.2% of patients had ≥ 3 well-documented risk factors (higher for men: odds ratio (OR) 3.8; 95% cardiac index confidence interval (CI) 1.8-8.3; p < .001) and 6.2% of patients had ≥ 3 less well-documented risk factors. While 42% of patients had undetermined cause of stroke (34% of them cryptogenic), the second most frequent etiologies were large-artery atherosclerosis and cardioembolism (both 19%). 60 percent of cardioembolic strokes were due to high-risk causes. Large-artery atherosclerosis was more prevalent in men (OR 1.8; 95% CI 1-3.3; p = .05) and among older patients (OR 6.2; 95% CI 1.8-21.4; p = .008). The median National Institutes of Health Stroke Scale score on admission was 3 (interquartile ranges 2-6), stroke was more severe in men (p = .05).

Conclusions

Our study revealed that young patients with stroke in Estonia have higher burden of well-documented risk factors, higher prevalence of high-risk cardioembolic causes and higher prevalence of large-artery stroke compared to other young stroke cohorts.

Characteristics of cerebral ischemic stroke based on moyamoya disease and atherosclerosis-associated intracranial arterial stenosis

PURPOSE

To analyze the characteristics of acute ischemic stroke (AIS) resulting from moyamoya disease (MMD) and intracranial large artery atherosclerotic stenosis (LAS).

METHOD

This real-world case control study enrolled imaging-confirmed AIS patients owing to MMD or LAS hospitalized from January 2015 through September 2020 consecutively. The features of risk factors, peripheral blood, and imaging presentations were compared between the two cohorts.

RESULTS

A total of 191 eligible patients entered into final analysis, including 70 cases with MMD stroke and 121 with LAS stroke. LAS stroke vs. MMD stroke, the ratios of hyperlipidemia, hypertension, diabetes, and hyperhomocysteinemia were higher in the former (65.3 vs.12.9%, 65.3% vs. 4.3%, 39.7% vs. 2.9%, and 43.8% vs.12.9%; all p < 0.01) as well as baseline plasma arachidonic acid (AA) and adenosine diphosphate (ADP)-stimulated maximum platelet aggregation rates (75.3% vs. 60.8% and 73.1% vs.64.9%, respectively, all p < 0.01), which were positively correlated with triglycerides and cholesterol levels, blood glucose, age, and platelet counts (all p < 0.01). Classical watershed infarction (WSI) accounted for 87.14% in MMD stroke and 40.49% in LAS stroke, respectively (p < 0.01). Almost all of the patients with LAS showed plaques in arterial walls on CTA maps and non-homogeneous thickening with irregular luminal narrowing on HRMRI, while plaques were seldom found in MMD besides homogeneous thickening with regular luminal narrowing.

CONCLUSIONS

Differing from LAS stroke, MMD stroke mainly presents with WSI and does not feature with platelet hyper-aggregation and fragmentation of ulcer plaque. Whereby, focusing on perfusion improvement rather than antiplatelets and statins may be the predominant step in MMD-stroke correction.

A Comparative Study of Carotid Magnetic Resonance Plaque Imaging in Predicting the Early Progression of Acute Anterior Circulation Mild Stroke

To analyze the biological properties of carotid lumen stenosis and plaque before and after bifurcation of the bilateral carotid arteries in patients with acute anterior circulation mild stroke (AACMS) by 3.0 T high-resolution magnetic resonance imaging (HR-MRI) with the aim to clarify the predictive effect of 3.0 T HR-MRI on early progression and poor prognosis in patients with AACMS. Random division of 96 patients with AACMS into a stroke progression group and a non-progression group. The bilateral cervical vessels of the patients were detected by HR-MRI. The degree of carotid artery stenosis before and after bilateral carotid bifurcation was evaluated using a vascular plaque imaging diagnostic system. There were significant differences in the maximum and average wall standardization index, maximum wall thickness, maximum wall area, plaque composition, proportion of plaque fibrous cap rupture, and proportion of VI complex plaques in the progressive group. There was no significant difference in the related indexes of bilateral vessels in the non-progressive group (P >0.05). There are significant differences in MRI morphological characteristics of bilateral carotid plaques in patients with AACMS progression. Through a comparative analysis of the plaque load and plaque composition of bilateral carotid arteries using 3.0 T HR-MRI in patients with early-stage AACMS, the type and stability of complex plaques can be identified, which serve as prognostic factors in predicting the early progression of stroke and guiding clinical treatment.

Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke: A Review

IMPORTANCE

Stroke is the fifth leading cause of death and a leading cause of disability in the United States, affecting nearly 800 000 individuals annually.

OBSERVATIONS

Sudden neurologic dysfunction caused by focal brain ischemia with imaging evidence of acute infarction defines acute ischemic stroke (AIS), while an ischemic episode with neurologic deficits but without acute infarction defines transient ischemic attack (TIA). An estimated 7.5% to 17.4% of patients with TIA will have a stroke in the next 3 months. Patients presenting with nondisabling AIS or high-risk TIA (defined as a score ≥4 on the age, blood pressure, clinical symptoms, duration, diabetes [ABCD2] instrument; range, 0-7 [7 indicating worst stroke risk]), who do not have severe carotid stenosis or atrial fibrillation, should receive dual antiplatelet therapy with aspirin and clopidigrel within 24 hours of presentation. Subsequently, combined aspirin and clopidigrel for 3 weeks followed by single antiplatelet therapy reduces stroke risk from 7.8% to 5.2% (hazard ratio, 0.66 [95% CI, 0.56-0.77]). Patients with symptomatic carotid stenosis should receive carotid revascularization and single antiplatelet therapy, and those with atrial fibrillation should receive anticoagulation. In patients presenting with AIS and disabling deficits interfering with activities of daily living, intravenous alteplase improves the likelihood of minimal or no disability by 39% with intravenous recombinant tissue plasminogen activator (IV rtPA) vs 26% with placebo (odds ratio [OR], 1.6 [95% CI, 1.1-2.6]) when administered within 3 hours of presentation and by 35.3% with IV rtPA vs 30.1% with placebo (OR, 1.3 [95% CI, 1.1-1.5]) when administered within 3 to 4.5 hours of presentation. Patients with disabling AIS due to anterior circulation large-vessel occlusions are more likely to be functionally independent when treated with mechanical thrombectomy within 6 hours of presentation vs medical therapy alone (46.0% vs 26.5%; OR, 2.49 [95% CI, 1.76-3.53]) or when treated within 6 to 24 hours after symptom onset if they have a large ratio of ischemic to infarcted tissue on brain magnetic resonance diffusion or computed tomography perfusion imaging (modified Rankin Scale score 0-2: 53% vs 18%; OR, 4.92 [95% CI, 2.87-8.44]).

CONCLUSIONS AND RELEVANCE

Dual antiplatelet therapy initiated within 24 hours of symptom onset and continued for 3 weeks reduces stroke risk in select patients with high-risk TIA and minor stroke. For select patients with disabling AIS, thrombolysis within 4.5 hours and mechanical thrombectomy within 24 hours after symptom onset improves functional outcomes.

[Cerebrovascular diseases: matching ICD-10 and ICD-11 codes]

A comparison of the codes and wording of the ICD-11 with the previous version of the classification was carried out. It seems necessary to develop a new revision of the domestic classification of cerebrovascular pathology, consistent with the ICD-11 codes.

Stroke in young adults: Current trends, opportunities for prevention and pathways forward

Cardiovascular disease remains a major contributor to morbidity and mortality in the US and elsewhere, and stroke is a leading cause of disability worldwide. Despite recent success in diminishing stroke incidence in the general US population, in parallel there is now a concerning propensity for strokes to happen at younger ages. Specifically, the incidence of stroke for US adults 20-44 years of age increased from 17 per 100,000 US adults in 1993 to 28 per 100,000 in 2015. Occurrence of strokes in young adults is particularly problematic as these patients are often affected by physical disability, depression, cognitive impairment and loss of productivity, all of which have vast personal, social and economic implications. These concerning trends among young adults are likely due to increasing trends in the prevalence of modifiable risk factors amongst this population including hypertension, hyperlipidemia, obesity and diabetes, highlighting the importance of early detection and aggressive prevention strategies in the general population at early ages. In parallel and compounding to the issue, troublesome trends are evident regarding increasing rates of substance abuse among young adults. Higher rates of strokes have been noted particularly among young African Americans, indicating the need for tailored prevention and social efforts targeting this and other vulnerable groups, including the primordial prevention of risk factors in the first place, reducing stroke rates in the presence of prevalent risk factors such as hypertension, and improving outcomes through enhanced healthcare access. In this narrative review we aim to emphasize the importance of stroke in young adults as a growing public health issue and increase awareness among clinicians and the public health sector. For this purpose, we summarize the available data on stroke in young adults and discuss the underlying epidemiology, etiology, risk factors, prognosis and opportunities for timely prevention of stroke specifically at young ages. Furthermore, this review highlights the gaps in knowledge and proposes future directions moving forward.

Young cryptogenic ischemic stroke: A descriptive analysis of clinical and laboratory characteristics, outcomes and stroke recurrence

BACKGROUND AND PURPOSE

Ischemic strokes (IS) occur also in young adults and despite an extensive work-up the cause of IS remains very often cryptogenic. Thus, effectiveness of secondary prevention may be unclear. We aimed to analyze a relationship among vascular risk factors (VRF), clinical and laboratory parameters, outcomes and recurrent IS (RIS) in young cryptogenic IS (CIS) patients.

SUBJECTS AND METHODS

The study set consisted of young acute IS patients < 50 years enrolled in the prospective HISTORY (Heart and Ischemic STrOke Relationship studY) study registered on ClinicalTrials.gov (NCT01541163). All analyzed patients underwent transesophageal echocardiography, 24-h and 3-week ECG-Holter to assess cause of IS according to the ASCOD classification. Recurrent IS (RIS) was recorded during a follow-up (FUP).

RESULTS

Out of 294 young enrolled patients, 208 (70.7%, 113 males, mean age 41.6 ± 7.2 years) were identified as cryptogenic. Hyperlipidemia (43.3%), smoking (40.6%) and arterial hypertension (37.0%) were the most frequent VRF. RIS occurred in 7 (3.4%) patients during a mean time of FUP 19 ± 23 months. One-year risk of RIS was 3.4% (95%CI: 1.4-6.8%). Patients with RIS were older (47.4 vs. 41.1 years, p = 0.007) and more often obese (71.4 vs. 19.7%, p = 0.006), and did not differ in any of other analyzed parameters and VRF. Multivariate logistic regression analysis showed obesity (OR: 9.527; 95%CI: 1.777-51.1) and the previous use of antiplatelets (OR: 15.68; 95%CI: 2.430-101.2) as predictors of recurrent IS.

CONCLUSION

Despite a higher presence of VRF in young CIS patients, the risk of RIS was very low. Obesity and previous use of antiplatelet therapy were found the only predictors of RIS.

Cryptogenic stroke: Contemporary trends, treatments, and outcomes in the United States

Background

Nationwide data on patients with cryptogenic stroke (CS) are lacking. We evaluated patient and hospital characteristics, in-hospital treatments, and discharge outcomes among patients with CS compared with other subtypes in the Get With The Guidelines (GWTG)-Stroke registry.

Methods

We identified patients with ischemic stroke (IS) admitted to GWTG-Stroke participating hospitals between January 1, 2016, and September 30, 2017, with documented National Institutes of Health Stroke Scale (NIHSS) scale and stroke etiology (cardioembolic [CE], large artery atherosclerosis [LAA], small vessel occlusion [SVO], other determined etiology [OTH], or CS). Using multivariable logistic regression, we compared hospital treatments and discharge outcomes by subtype, adjusted for patient and hospital characteristics.

Results

Among 316,623 patients from 1,687 hospitals, there were 63,301 (20.0%) patients with CS. In multivariable analysis, patients with CS received IV thrombolysis more often than other subtypes and had lower mortality than CE, LAA, and OTH but higher mortality than SVO. They were more likely to be discharged home than all other subtypes and be independent at discharge than LAA, OTH, or SVO.

Conclusions

In a large contemporary nationwide registry, CS accounted for 20% of ISs among patients with a documented stroke etiology. Patients with CS had a distinct profile of treatments and outcomes relative to other subtypes. Improved subtype documentation and further research into CS are warranted to improve care and outcomes for patients with stroke.

The Underlying Stroke Etiology: A Comparison of Two Classifications in a Rural Setup

Introduction This study compares the Trial of Org 10172 in Acute Stroke Treatment (TOAST) and the atherothrombosis, small vessel disease, cardiac pathology, other causes, and dissection (ASCOD) classification performed in a rural hospital setup. Stroke is the second leading cause of death after ischemic heart disease with over 9.5 million new cases of ischemic stroke in 2016. Stroke is a complex disease with numerous contributing factors. India needs a standardized stroke classification system, as without one it becomes difficult to collect data on stroke patients, perform follow-ups, and provide appropriate secondary prevention. A standardized stroke classification system would also help in building a nationwide database in order to note epidemiological trends of ischemic stroke. This would also create greater awareness regarding stroke in rural parts of India where healthcare is difficult to access.  Aims and objectives Our aim was to review all admitted stroke patients' data and classify their etiology and mechanism based on the TOAST and ASCOD classification systems. The ASCOD classification has yet to be utilized in the Indian population. The two classifications are then compared in order to gain a better insight into which classification is a better fit for the Indian population. Both are based on the etiology of ischemic stroke but the ASCOD classification differs because it gives suitable secondary prevention measures based on the diseases linked to stroke. ASCOD also gives a proper indication of the patient's present causative factor (similar to TOAST) and other factors that can possibly lead to further recurrences. This is different from TOAST, which denotes only a single cause for stroke and eliminates the possibility of other involved contributing factors. Materials and methods All patients involved in the study were admitted to a rural Indian hospital from January 2014 to July 2016. All the relevant clinical details of each patient were then retrieved from the hospital's electronic medical record system for the study. We then classified all the patients based on the TOAST and ASCOD classification criteria. Results Using the ASCOD classification, we found that 179 (86%) patients out of 209 had either atherothrombosis or small vessel disease. The ASCOD classification also showed substantial evidence that the determined stroke mechanism/etiology is interconnected to multiple causal factors in over 50% of patients. In contrast, the TOAST classification had identified a larger number of ischemic stroke patients as having an etiology of other and undetermined causes as compared to the ASCOD classification. Conclusion The ASCOD classification is better to use in patients and helps decide the secondary prevention appropriately.

Circadian rhythms may not influence the outcomes of thrombolysis in patients with ischemic stroke: A study from China

Circadian rhythms can affect physical or mental activities as well as the time of stroke onset. The impact of circadian rhythms on acute ischemic stroke (AIS) patients treated by recombinant alteplase (rt-PA) is still incongruent. This study aims to consider whether the outcomes of thrombolysis differ depending on stroke onset time and rt-PA infusion time in patients with AIS. A total of 447 AIS patients, who underwent rt-PA intravenous infusion within 4.5 hours after stroke onset, were enrolled in this study consecutively from June 2010 through December 2016. All of the patients were grouped based on the stroke onset time and rt-PA infusion time into two exact 12-hour intervals as daytime (06:01-18:00) and nighttime (18:01-06:00) and further divided into four subgroups at 6-hour time intervals (00:01-06:00, 06:01-12:00, 12:01-18:00 and 18:01-24:00). Major neurological improvement at 1 hour, 24 hours and 7 days, 7-day mortality rate and 24-hour hemorrhage transformation was recorded. The results showed that a total of 295 patients (66.4%) appeared with AIS and 252 (56.4%) were treated during daytime. Higher NIHSS at admission was observed when stroke occurred in nighttime, especially during 00:01-06:00. Patients with stroke onset in nighttime especially during 18:01-24:00 had a significant shorter onset-door time and onset-needle time. No differences of the major neurological improvement at 1 hour, 24 hours and 7 days, 24-hour hemorrhagic transformation and 7-day fatality rate were found among either 12-hour time frames or 6-hour time frames according to the time of stroke onset or rt-PA infusion. In conclusion, there was no evidence to predict that circadian rhythms could influence the outcomes of AIS patients treated with rt-PA in China, although stroke onset during nighttime might aggravate neurological impairment before treatment. Further, multicenter and prospective clinical trials with larger number of subjects are still needed to draw more reliable conclusions.

Point-of-Care-Testing in Acute Stroke Management: An Unmet Need Ripe for Technological Harvest

Stroke, the second highest leading cause of death, is caused by an abrupt interruption of blood to the brain. Supply of blood needs to be promptly restored to salvage brain tissues from irreversible neuronal death. Existing assessment of stroke patients is based largely on detailed clinical evaluation that is complemented by neuroimaging methods. However, emerging data point to the potential use of blood-derived biomarkers in aiding clinical decision-making especially in the diagnosis of ischemic stroke, triaging patients for acute reperfusion therapies, and in informing stroke mechanisms and prognosis. The demand for newer techniques to deliver individualized information on-site for incorporation into a time-sensitive work-flow has become greater. In this review, we examine the roles of a portable and easy to use point-of-care-test (POCT) in shortening the time-to-treatment, classifying stroke subtypes and improving patient's outcome. We first examine the conventional stroke management workflow, then highlight situations where a bedside biomarker assessment might aid clinical decision-making. A novel stroke POCT approach is presented, which combines the use of quantitative and multiplex POCT platforms for the detection of specific stroke biomarkers, as well as data-mining tools to drive analytical processes. Further work is needed in the development of POCTs to fulfill an unmet need in acute stroke management.