A critical assessment of the current pharmacotherapy for the treatment of embolic strokes of undetermined source

Features of non-stenotic carotid plaque on computed tomographic angiography in patients with embolic stroke of undetermined source

Purpose

Embolic stroke of undetermined source (ESUS) is a subset of cryptogenic stroke constituting a large proportion of acute ischemic strokes. This study aimed to assess the features of non-stenotic carotid plaque (<50%) on computed tomographic angiography (CTA) and to evaluate the association between non-stenotic carotid plaque and ESUS.

Methods

From January 1 to December 31, 2019, a total of 60 consecutive patients with primary unilateral ESUS and <50% carotid artery stenosis, as determined using screening ultrasonography, were hospitalized in the Department of Neurology of our hospital. All enrolled patients underwent CTA to determine the composition and morphological features of non-stenotic carotid plaques using consecutive sections in both carotid arteries. The features of these plaques with and without ipsilateral stroke in patients with ESUS were compared.

Results

Sixty ESUS images were included in the study, with 85 plaques. Forty-five (52.9%) of these plaques were ipsilateral and 40 (47.1%) were contralateral to the stroke. Compared to that of the contralateral plaque group, the maximum carotid plaque thickness and plaque length of the ipsilateral group were greater (2.1 mm vs. 1.5 mm, p = 0.03; 20.8 mm vs. 12.1 mm, p = 0.02); however, there were no significant differences in the degree of luminal stenosis, presence of soft plaque and calcified plaque, and the number of ulcers on the plaque surface between the two groups. Similarly, the number of plaques with thickness >3 mm in the ipsilateral group was greater than in the contralateral group (30 vs. 13, p = 0.01). A lipid core was more common in individuals with ipsilateral strokes than in those with contralateral strokes (19 vs. 7, p = 0.02). Regression analysis showed that plaque lipid core area was an independent risk factor for ESUS (odds ratio, 1.92; 95% confidence interval, 1.22–3.04; p = 0.03).

Conclusions

Non-stenotic carotid plaques could be an etiology of acute ischemic strokes classified as ESUS. The presence of a lipid core was a risk factor in individuals with non-stenotic carotid plaques.

Markers of Atrial Cardiopathy in Severe Embolic Strokes of Undetermined Source

Background and Purpose

The current definition of embolic strokes of undetermined source (ESUS) seems to be too broad, including strokes due to heterogeneous mechanisms, such as atrial cardiopathy and other occult cardiac conditions, aortic arch plaques, and non-stenosing atherosclerosis, that can be differently associated with clinical stroke severity at the time of presentation. The aim of our study was to assess the possible association between neurological deficit severity and presence of markers of atrial cardiopathy in ESUS.

Methods

We retrospectively reviewed the medical records of a cohort of 226 ESUS patients (105 M, 121 F), that were divided into two groups according to the severity of neurological deficit (99 mild strokes with NIHSS ≤ 5 and 127 severe strokes with NIHSS >5). The following indices of atrial cardiopathy were evaluated: P wave dispersion, P wave max, P wave min, P wave mean, P wave index, P wave axis, left atrial size.

Results

Patients with severe ESUS were significantly older (74 ± 12 vs. 67 ± 14 years, P < 0.001) and female sex was prevalent (67 vs. 36%, P > 0.001); they had higher values of P-wave-dispersion (51 ± 14 vs. 46 ± 13, P = 0.01), P-wave-max (131 ± 20 vs. 125 ± 15 ms, P = 0.01), P-wave-index (16 ± 5 vs. 15 ± 5 ms, P = 0.01), left atrial size (20 ± 6 vs. 18 ± 4 cm², P = 0.01), left atrial volume index (31 ± 14 vs. 27 ± 11 ml/m², P = 0.04), in comparison with mild ESUS. An abnormal P wave axis was detected more frequently in severe ESUS (21 vs. 9%, P = 0.01). Furthermore, multivariate logistic regression showed that age (OR = 1.21 for each 5-year increase, 95% CI 1.09–1.35), sex (OR = 3.24 for female sex, 95% CI 1.82–5.76) and PWD (OR = 1.32 for each 10-ms increase, 95% CI 1.07–1.64) were the best subset of associated variables for severe ESUS.

Conclusions

Our findings shed light on specific clinical characteristics of severe ESUS including the presence of atrial cardiopathy that could play a pathogenic role in this subgroup of patients. Searching for atrial fibrillation in these patients is especially important to perform the most appropriate therapy.