Differences in vascular risk factors between etiological subtypes of ischemic stroke: importance of population-based studies

Efficacy and safety of antiplatelet therapy for secondary prevention of small subcortical infarction: A systematic review and network meta-analysis

PURPOSE

Small subcortical infarction (SSI) accounts for approximately 25% of ischemic strokes and shares a comparable recurrence rate of cardiovascular events with other stroke subtypes. This study aimed to evaluate the efficacy and safety of various antiplatelet for secondary prevention of SSI by network meta-analysis (NMA).

METHODS

We systematically searched Medline, Embase, Cochrane Library, and Web of Science from inception to October 2024 for randomized controlled trials (RCTs). Efficacy outcomes included: incidence of major adverse cardiovascular events (MACEs), rates of any stroke and ischemic stroke recurrence. Safety outcomes included: incidence of intracranial hemorrhage, severe bleeding, any bleeding events, and mortality.

FINDINGS

A total of 24 RCTs involving 47,507 SSI patients were included in systematic review. The NMA included 19 RCTs (39,137 patients). The NMA demonstrated that Cilostazol showed the best efficacy in preventing MACEs (surface under the cumulative ranking curve (SUCRA): 90.0%). cilostazol significantly reduced the incidence of MACEs compared to aspirin (OR, 0.66; 95% CI, 0.49-0.89), ticlopidine (OR, 0.65; 95% CI, 0.43-1.00), dipyridamole (OR, 0.61; 95% CI, 0.42-0.90), vorapaxar (OR, 0.51; 95% CI, 0.35-0.74), Sarpogrelate (OR, 0.62; 95% CI, 0.40-0.97), and placebo (OR, 0.51; 95% CI, 0.37-0.71). Regarding safety, aspirin plus clopidogrel and vorapaxar was associated with a significantly increased risk of severe bleeding events compared to the control.

DISCUSSION AND CONCLUSIONS

Cilostazol may be the most effective agent for preventing cardiovascular event recurrence. Aspirin plus clopidogrel and vorapaxar may be not recommended due to heightened bleeding risks.

REGISTRATION

International prospective register of systematic reviews (PROSPERO) - CRD42024607819.

Reassessing the Association of Sedentary Behavior and Physical Activity with Ischemic Stroke: A Mendelian Randomization Study

PURPOSE

Findings from previous Mendelian randomization (MR) studies disagreed with the current scientific consensus regarding the role of physical activity (PA) and sedentary behavior in ischemic stroke (IS). We reassessed these associations with a focus on etiological subtypes of IS and the potential mediating roles of cardiometabolic traits and brain imaging-derived phenotypes (IDPs).

METHODS

We performed MR analyses using summary statistics from genome-wide association studies of sedentary behavior and PA ( n = 88,411 ~ 608,595), cardiometabolic traits ( n = 393,193 ~ 694,649), brain IDPs ( n = 33,224), and the latest IS data (62,100 cases and 1,234,808 controls). Inverse-variance weighted regression was used as the primary method, complemented by several sensitivity analyses. A two-step MR approach was employed to assess the mediating effects of cardiometabolic traits and brain IDPs.

RESULTS

Genetic liability to leisure-time moderate-to-vigorous PA (MVPA) and higher overall PA (OPA) were associated with reduced risks of IS and small vessel stroke (Benjamini-Hochberg adjusted P < 0.05). Suggestive associations were observed between longer leisure-screen time and higher IS risk and between higher OPA and lower cardioembolic stroke risk ( P < 0.05). The isotropic volume fraction in the anterior limb of the left internal capsule, as well as some cardiometabolic metrics, partially mediated these associations. There was no evidence for causal effects of overall MVPA, overall light-intensity PA, or overall sedentary duration on IS.

CONCLUSIONS

Longer leisure screen time, less OPA, and not engaging in MVPA during leisure time were associated with higher risk of IS. The associations between PA and IS depended on different subtypes and were mediated by changes in anterior limb of the left internal capsule and cardiometabolic biomarkers.

Association of Vascular Risk With Severe vs Non-Severe Stroke: An Analysis of the INTERSTROKE Study

BACKGROUND AND OBJECTIVES

Acute stroke is associated with a spectrum of functional deficits. The objective of this analysis was to explore whether the importance of individual risk factors differ by stroke severity, which may be of relevance to public health strategies to reduce disability.

METHODS

INTERSTROKE is an international case-control study of risk factors of first acute stroke (recruitment 2007-August 2015) in 32 countries. Stroke severity was measured using the modified Rankin Scale (mRS) score within 72 hours of admission to hospital. Severe stroke is defined as mRS scores of 4-6 (and non-severe stroke, score of 0-3). We used multinomial logistic regression to estimate comparative odds ratios (ORs; 95% CIs) for severe and non-severe stroke and tested for heterogeneity (pheterogeneity). We also conducted a matched case-case analysis (matched for age, sex, country, and primary stroke subtype) to determine whether the prevalence of risk factors differed significantly between severe and non-severe stroke. A significant difference in the association of a risk factor of severe stroke compared with non-severe stroke was defined as p < 0.05 for both pheterogeneity and pcase-case.

RESULTS

Of patients with acute stroke (n = 13,460), 64.0% (n = 8,612) were reported to have mRS scores of 0-3 and 36.0% (n = 4,848) scores of 4-6. The mean age was 61.7 years for patients with non-severe stroke and 62.9 years for patients with severe stroke (p = 0.72). 38.1% (n = 3,278) of patients with non-severe stroke and 44.6% (n = 2,162) of patients with severe stroke were female. Hypertension (OR 3.21; 95% CI 2.97-3.47 for severe stroke, OR 2.87; 95% CI 2.69-3.05 for non-severe stroke; pheterogeneity = 0.03; pcase-case < 0.001), atrial fibrillation (OR 4.70; 95% CI 4.05-5.45 for severe stroke, OR 3.61; 95% CI 3.16-4.13 for non-severe stroke; pheterogeneity = 0.009; pcase-case < 0.001), and smoking (OR 1.87; 95% CI 1.72-2.03 for severe stroke, OR 1.65; 95% CI 1.54-1.77 for non-severe stroke; pheterogeneity = 0.02; pcase-case < 0.001) had a stronger association with severe stroke, compared with non-severe stroke. The waist-to-hip ratio had a stronger association with non-severe stroke compared with severe stroke (pheterogeneity < 0.001; pcase-case < 0.001).

DISCUSSION

Hypertension, atrial fibrillation, and smoking had a stronger magnitude of association with severe stroke (compared with non-severe stroke) while the increased waist-to-hip ratio had a stronger magnitude of association with non-severe stroke.

Age- and Sex-Specific Analysis of Stroke Hospitalization Rates, Risk Factors, and Outcomes From German Nationwide Data

BACKGROUND

Significant age and sex differences have been reported at each stage of the stroke pathway, from risk factors to outcomes. However, there is some uncertainty in previous studies with regard to the role of potential confounders and selection bias. Therefore, using German nationwide administrative data, we aimed to determine the magnitude and direction of trends in age- or sex-specific differences with respect to admission rates, risk factors, and acute treatments of ischemic and hemorrhagic stroke.

METHODS

We obtained and analyzed data from the Research Data Centres of the Federal Statistical Office for the years 2010 to 2020 with regard to all acute stroke hospitalizations, risk factors, treatments, and in-hospital mortality, stratified by sex and stroke subtype. This database provides a complete national-level census of stroke hospitalizations combined with population census counts. All hospitalized patients ≥15 years with an acute stroke (diagnosis code: I60-64) were included in the analysis.

RESULTS

Over the 11-year study period, there were 3 375 157 stroke events; 51.2% (n=1 728 954) occurred in men. There were higher rates of stroke admissions in men compared with women for both ischemic (378.1 versus 346.7/100 000 population) and hemorrhagic subtypes (75.6 versus 65.5/100 000 population) across all age groups. The incidence of ischemic stroke admissions peaked in 2016 among women (354.0/100 000 population) and in 2017 among men (395.8/100 000 population), followed by a consistent decline from 2018 onward. There was a recent decline in hemorrhagic stroke admissions observed for both sexes, reaching its nadir in 2020 (68.9/100 000 for men; 59.5/100 000 for women). Female sex was associated with in-hospital mortality for both ischemic (adjusted odds ratio, 1.11 [1.09-1.12]; P<0.001) and hemorrhagic stroke (adjusted odds ratio, 1.18 [95% CI, 1.16-1.20]; P<0.001).

CONCLUSIONS

Despite improvements in stroke prevention and treatment pathways in the past decade, sex-specific differences remain with regard to hospitalization rates, risk factors, and mortality. Better understanding the mechanisms for these differences may allow us to develop a sex-stratified approach to stroke care.

Dynamic Perviousness Has Predictive Value for Clot Fibrin Content in Acute Ischemic Stroke

Dynamic perviousness is a novel imaging biomarker, with clot density measurements at multiple timepoints to allow longer contrast to thrombus interaction. We investigated the correlations between dynamic perviousness and clot composition in the setting of acute ischemic stroke. Thirty-nine patients with large vessel occlusion (LVO) undergoing mechanical thrombectomy (MT) were analyzed. Patients received a three-phase CT imaging pre-thrombectomy and histopathological analysis of retrieved clots. Clot densities for every phase and change in densities between phases were calculated, leading to four patterns of dynamic perviousness: no contrast uptake, early contrast uptake with and without washout and late uptake. Clots were categorized into three groups based on dominant histologic composition: red blood cell (RBC)-rich, fibrin/platelet-rich and mixed. Clot composition was correlated with dynamic perviousness using the Kruskal-Wallis test and Pearson's correlation analysis. The dynamic perviousness categories showed a significant difference between fibrin-rich clots when compared to RBC-rich plus mixed groups. The uptake without washout category had significantly fewer fibrin clots compared to the uptake with washout (p = 0.036), and nearly significantly fewer fibrin clots when compared to the no uptake category (p = 0.057). Contrast uptake with different patterns of contrast washout showed significant differences of the likelihood for fibrin-rich clots.

Examining the Prevalence of Left Atrial Appendage Thrombus in a Cohort of Acute Stroke Patients with an Extended Computed Tomography Angiographic Protocol

INTRODUCTION

Current guidelines recommend transthoracic echocardiography (TTE) for routine screening of cardiac emboli; however, the visualization of the left atrial appendage (LAA) where the thrombi are commonly found is poor. Transesophageal echocardiography (TEE) would provide better detectability of LAA thrombus, but it is a time-consuming and semi-invasive method. Extending non-gated carotid computed tomography angiography (CTA) examination to the LAA could reliably detect thrombi and could also aid treatment and secondary prevention of stroke.

METHODS

We extended the CTA scan range of acute stroke patients 4 cm below the carina to include the left atrium and appendage. During the review, we evaluated LAA thrombi based on contrast relations. We then used gradient boosting to identify the most important predictors of LAA thrombi from a variety of different clinical parameters.

RESULTS

We examined 240 acute stroke patients' extended CTA scans. We detected LAA thrombi in eleven cases (4.58%), eight of them had atrial fibrillation. 23.75% of all patients (57 cases) had recently discovered or previously known atrial fibrillation. Windsack morphology was the most commonly associated morphology with filling defects on CTA. According to the gradient-boosting analysis, LAA morphology showed the most predictive value for thrombi.

CONCLUSION

Our extended CTA scans reliably detected LAA thrombi even in cases where TTE did not and showed that 2 patients' LAA thrombus would have been untreated based on electrocardiogram monitoring and TTE. We also showed that the benefits of CTA outweigh the disadvantages arising from the slight amount of excess radiation.

Ischemic stroke subtypes: risk factors, treatments, and 1-month prognosis - The Lille, France Stroke Registry

OBJECTIVES

First, this registry-based study aimed to comprehensively analyze patients' medical histories and treatments based on ischemic strokes' etiology. We focused on the management of atrial fibrillation among patients diagnosed with cardioembolic stroke. Then, our objective was to identify prognostic factors associated with 28-day mortality.

MATERIALS AND METHODS

All ischemic strokes occurring in adults between 2014 and 2021 in Lille, France, were categorized using the TOAST classification. Comparative analyses of patients' medical characteristics were conducted across subtypes. Survival rates within 28 days post-stroke were assessed, and factors influencing mortality were identified using a multivariate Cox model.

RESULTS

1912 ischemic strokes were recorded, due to cardioembolism (36%), large-artery atherosclerosis (9%), small-artery occlusion (9%), other determined causes (6%), or undetermined causes (39%). The median NIHSS score after cardioembolic stroke (6, IQR: 3-13) was twice that after small-artery occlusion (3, IQR: 2-5). Among patients with cardioembolic stroke, 26% were diagnosed post-admission with atrial fibrillation. For the 42% diagnosed pre-admission, only 54% had prior prescriptions for oral anticoagulants. Reperfusion therapies were administered in 21% of cases, with significant variations across subtypes. Mortality rates were higher after cardioembolic strokes (17%) than after small-artery occlusions (3%). Prognostic factors included etiology, high NIHSS score, atrial fibrillation, and previous heparin prescription.

CONCLUSIONS

While atrial fibrillation was underdiagnosed and undertreated, patients with cardioembolic stroke exhibited high severity and elevated mortality rates. Etiology emerged as an independent predictor of early mortality, regardless of NIHSS score upon admission. These findings underscore the importance of targeted prevention to improve patient outcomes after ischemic stroke.

Circadian and Diurnal Regulation of Cerebral Blood Flow

Circadian and diurnal variation in cerebral blood flow directly contributes to the diurnal variation in the risk of stroke, either through factors that trigger stroke or due to impaired compensatory mechanisms. Cerebral blood flow results from the integration of systemic hemodynamics, including heart rate, cardiac output, and blood pressure, with cerebrovascular regulatory mechanisms, including cerebrovascular reactivity, autoregulation, and neurovascular coupling. We review the evidence for the circadian and diurnal variation in each of these mechanisms and their integration, from the detailed evidence for mechanisms underlying the nocturnal nadir and morning surge in blood pressure to identifying limited available evidence for circadian and diurnal variation in cerebrovascular compensatory mechanisms. We, thus, identify key systemic hemodynamic factors related to the diurnal variation in the risk of stroke but particularly identify the need for further research focused on cerebrovascular regulatory mechanisms.

A smart devices based secondary prevention program for cerebrovascular disease patients

Background

Commercially available health devices are gaining momentum and represent a great opportunity for monitoring patients for prolonged periods. This study aimed at testing the feasibility of a smart device-based secondary prevention program in a cohort of patients with cryptogenic stroke.

Methods

In this proof-of-principle study, patients with non-disabling ischemic stroke and transient ischemic attacks (TIA) in the subacute phase were provided with a smartwatch and smart devices to monitor several parameters - i.e., oxygen saturation, blood pressure, steps a day, heart rate and heart rate variability - for a 4-week period (watch group). This group was compared with a standard-of-care group. Our primary endpoint was the compliance with the use of smart devices that was evaluated as the number of measures performed during the observation period.

Results

In total, 161 patients were recruited, 87 in the WATCH group and 74 in the control group. In the WATCH group, more than 90% of patients recorded the ECG at least once a day. In total, 5,335 ECGs were recorded during the study. The median blood pressure value was 132/78 mmHg and the median oxygen saturation value was 97%. From a clinical standpoint, although not statistically significant, nine atrial fibrillation episodes (10.3%) in the WATCH group vs. 3 (4%) in the control group were detected.

Conclusion

Our study suggests that prevention programs for cerebrovascular disease may benefit from the implementation of new technologies.

Antiplatelet therapy for secondary prevention of lacunar stroke: a systematic review and network meta-analysis

PURPOSE

To comprehensively compare the efficacy of different antiplatelet therapies for secondary prevention of lacunar stroke (LS).

METHODS

The relevant studies were identified by searching PubMed, EMBASE, Web of Science, and Cochrane Collaboration Database up to May 2022. Cardiovascular and cerebrovascular events were chosen to evaluate the efficacy of antiplatelet therapy for secondary prevention. Loop-specific approach and node-splitting analysis were used to evaluate consistency and inconsistency, respectively. The value of the surface under the cumulative ranking (SUCRA) was calculated and ranked. Funnel-plot symmetry was used to evaluate publication bias. The meta-analysis was performed by using STATA 16.0.

RESULTS

Thirteen studies with a total of 33,011 subjects were included in this network meta-analysis. Compared with placebo, aspirin, clopidogrel, cilostazol, ticlopidine, aspirin plus dipyridamole, and aspirin plus clopidogrel were associated with reducing cardiovascular and cerebrovascular events. The SUCRA estimated relative ranking of treatments showed that cilostazol may be the most effective (RR 0.56, 95% CI 0.42-0.74, SUCRA 95.8). No significant inconsistency or publication bias was found in the study.

CONCLUSIONS

This meta-analysis suggests that cilostazol may be a priority option for secondary prevention of patients with LS. These findings still need further study in the future.

Effect of Intensive Blood Pressure Control on Incident Stroke Risk in Patients With Mild Cognitive Impairment

BACKGROUND

Patients with mild cognitive impairment may be at higher risk of incident stroke, but the effect of intensive blood pressure (BP) control on that risk has not been explored.

METHODS

We performed a post hoc analysis of SPRINT (Systolic Blood Pressure Intervention Trial) and included patients with a baseline Montreal Cognitive Assessment score of 19 to 25 and without a prior history of stroke. The primary outcome was incident stroke (ischemic and hemorrhagic) during follow-up. We report the unadjusted cumulative risk of our primary outcome by SPRINT randomization arm (intensive versus standard BP control) and also fit Cox models to the primary outcome and adjusted for patient age at randomization, race/ethnicity, sex, baseline BP, atrial fibrillation, diabetes, and smoking.

RESULTS

We included 5091 patients (mean age 68.2, 44% female, 56.7% non-Hispanic White, and 50.2% randomized to intensive BP control), of which 95/5091 (1.9%) had an incident stroke during a mean of 3.8±0.9 years of follow-up. The risk of incident stroke in patients randomized to standard BP control was 57/2536 (2.3%) and to intensive BP control was 38/2555 (1.5%; P=0.045). In the adjusted Cox model, the hazard ratio for incident stroke events with intensive BP control was 0.65 (95% CI, 0.43-0.98; P=0.040).

CONCLUSIONS

Although the SPRINT trial failed to show a reduction in stroke with intensive BP control for all subjects, those with a Montreal Cognitive Assessment score consistent with mild cognitive impairment at baseline had an association between intensive BP control and lower risk of incident stroke. Future trials of primary prevention of stroke may benefit from enrichment using baseline vascular biomarkers of elevated risk, such as mild cognitive impairment.

Can weather help explain 'why now?': The potential role of hourly temperature as a stroke trigger

BACKGROUND

While evidence suggests that daily ambient temperature exposure influences stroke risk, little is known about the potential triggering role of ultra short-term temperature.

METHODS

We examined the association between hourly temperature and ischemic and hemorrhagic stroke, separately, and identified any relevant lags of exposure among adult New York State residents from 2000 to 2015. Cases were identified via ICD-9 codes from the New York Department of Health Statewide Planning and Reearch Cooperative System. We estimated ambient temperature up to 36 h prior to estimated stroke onset based on patient residential ZIP Code. We applied a time-stratified case-crossover study design; control periods were matched to case periods by year, month, day of week, and hour of day. Additionally, we assessed effect modification by leading stroke risk factors hypertension and atrial fibrillation.

RESULTS

We observed 578,181 ischemic and 164,755 hemorrhagic strokes. Among ischemic and hemorrhagic strokes respectively, the mean (standard deviation; SD) patient age was 71.8 (14.6) and 66.8 (17.4) years, with 55% and 49% female. Temperature ranged from -29.5 °C to 39.2 °C, with mean (SD) 10.9 °C (10.3 °C). We found linear relationships for both stroke types. Higher temperature was associated with ischemic stroke over the 7 h following exposure; a 10 °C increase over 7 h was associated with 5.1% (95% Confidence Interval [CI]: 3.8, 6.4%) increase in hourly stroke rate. In contrast, temperature was negatively associated with hemorrhagic stroke over 5 h, with a 5-h cumulative association of -6.2% (95% CI: 8.6, -3.7%). We observed suggestive evidence of a larger association with hemorrhagic stroke among patients with hypertension and a smaller association with ischemic stroke among those with atrial fibrillation.

CONCLUSION

Hourly temperature was positively associated with ischemic stroke and negatively associated with hemorrhagic stroke. Our results suggest that ultra short-term weather influences stroke risk and hypertension may confer vulnerability.

Is the TOAST Classification Suitable for Use in Personalized Medicine in Ischemic Stroke?

Pathophysiologic classification of ischemic stroke is essential to a personalized approach to stroke treatment. The Trial of Org 101072 in Acute Stroke Treatment (TOAST) classification is the most frequently used tool to classify index ischemic strokes. We aimed to assess presence of small and large vessel disease markers across the TOAST groups. In an observational study, 99 ischemic stroke patients were consecutively included and classified according to TOAST. The assessment was supplemented with cerebral small vessel disease (SVD) score, based on Magnetic Resonance Imaging (MRI), and tests for carotid atherosclerosis, ankle−brachial index (ABI), estimated glomerular filtration rate (eGFR), and peripheral reactive hyperemia index (RHI). Markers of small and large vessel disease were present in all TOAST groups. Carotid stenosis and atrial fibrillation were associated with their respective TOAST groups (p = 0.023 and p < 0.001, respectively). We found no association between the SVD score and the small vessel occlusion TOAST group (p = 0.59), and carotid atherosclerosis (p = 0.35), RHI (p = 0.39), ABI (p = 0.20), and eGFR (p = 0.79) were not associated with TOAST groups. The TOAST classification does not provide differential information on the pathophysiologies of the ischemic stroke. An operational classification that contains quantification of each vascular pathophysiology in the individual patient is pivotal for future research and development of personalized medicine.

Diabetes and Ischemic Stroke: An Old and New Relationship an Overview of the Close Interaction between These Diseases

Diabetes mellitus is a comprehensive expression to identify a condition of chronic hyperglycemia whose causes derive from different metabolic disorders characterized by altered insulin secretion or faulty insulin effect on its targets or often both mechanisms. Diabetes and atherosclerosis are, from the point of view of cardio- and cerebrovascular risk, two complementary diseases. Beyond shared aspects such as inflammation and oxidative stress, there are multiple molecular mechanisms by which they feed off each other: chronic hyperglycemia and advanced glycosylation end-products (AGE) promote 'accelerated atherosclerosis' through the induction of endothelial damage and cellular dysfunction. These diseases impact the vascular system and, therefore, the risk of developing cardio- and cerebrovascular events is now evident, but the observation of this significant correlation has its roots in past decades. Cerebrovascular complications make diabetic patients 2-6 times more susceptible to a stroke event and this risk is magnified in younger individuals and in patients with hypertension and complications in other vascular beds. In addition, when patients with diabetes and hyperglycemia experience an acute ischemic stroke, they are more likely to die or be severely disabled and less likely to benefit from the one FDA-approved therapy, intravenous tissue plasminogen activator. Experimental stroke models have revealed that chronic hyperglycemia leads to deficits in cerebrovascular structure and function that may explain some of the clinical observations. Increased edema, neovascularization, and protease expression as well as altered vascular reactivity and tone may be involved and point to potential therapeutic targets. Further study is needed to fully understand this complex disease state and the breadth of its manifestation in the cerebrovasculature.

The Hype Surrounding Patent Foramen Ovale Closure and Cryptogenic Stroke: A Walk Through History

Cryptogenic stroke (CS) represents one-third of all ischaemic strokes. Studies have shown approximately that half of patients with CS have concomitant patent foramen ovale (PFO), with clear data supporting paradoxical embolization as an aetiology of CS. This article is the first of a multi-part review and will detail the history of PFO closure and the clinical trials that have evaluated the efficacy of PFO device closure. Data favour PFO closure in CS for reducing stroke in appropriate patients and should be considered as a treatment modality.

Vascular Dementia and Crosstalk Between the Complement and Coagulation Systems

Vascular Dementia (VaD) is a neurocognitive disorder caused by reduced blood flow to the brain tissue, resulting in infarction, and is the second most common type of dementia. The complement and coagulation systems are evolutionary host defence mechanisms activated by acute tissue injury to induce inflammation, clot formation and lysis; recent studies have revealed that these systems are closely interlinked. Overactivation of these systems has been recognised to play a key role in the pathogenesis of neurological disorders such as Alzheimer's disease and multiple sclerosis, however their role in VaD has not yet been extensively reviewed. This review aims to bridge the gap in knowledge by collating current understanding of VaD to enable identification of complement and coagulation components involved in the pathogenesis of this disorder that may have their effects amplified or supressed by crosstalk. Exploration of these mechanisms may unveil novel therapeutic targets or biomarkers that would improve current treatment strategies for VaD.

Cross-sectional area of the vagus nerve on carotid duplex ultrasound and atrial fibrillation in acute stroke: A retrospective analysis

Introduction

The autonomic nervous system, including the vagus nerve, is associated with the development of atrial fibrillation (AF). However, the association between the cross-sectional area (CSA) of the vagus nerve on ultrasound and the presence of AF has not been fully clarified. This study investigated the association between vagus nerve CSA and the presence of AF in patients with acute stroke.

Methods

We retrospectively reviewed 150 consecutive patients with ischemic stroke or transient ischemic attack. Vagus nerve CSA was evaluated by carotid ultrasonography on the axial view at the thyroid gland level. Univariate and multivariable analyses were performed to examine the association between vagus nerve CSA and AF.

Results

Of 133 patients included in the analysis, 31 (23.3%) were diagnosed with AF before hospital discharge. The median right vagus nerve CSA was significantly smaller in patients with AF than in patients without AF (p = 0.03). However, there was no significant difference in median left vagus nerve CSA. Multivariable logistic regression analysis revealed that log transformed and quintiled brain natriuretic peptide level (odds ratio [OR], 5.03; 95% confidence interval [CI], 2.43-10.40) and right vagus nerve CSA (OR, 0.33; 95% CI, 0.12-0.91) were independent predictors of AF.

Discussion/conclusion

Smaller right vagus nerve CSA in carotid ultrasonography was an independent predictor of AF in patients with ischemic stroke or transient ischemic attack, suggesting that patients with small right vagus nerve CSA should be closely monitored for development of AF.

Causal effect of insulin resistance on small vessel stroke and Alzheimer's disease: A Mendelian randomization analysis

BACKGROUND AND PURPOSE

The causal effect of insulin resistance on small vessel stroke and Alzheimer's disease (AD) was controversial in previous studies. We therefore applied Mendelian randomization (MR) analyses to identify the causal effect of insulin resistance on small vessel stroke and AD.

METHODS

We selected 12 single-nucleotide polymorphisms (SNPs) associated with fasting insulin levels and five SNPs associated with "gold standard" measures of insulin resistance as instrumental variables in MR analyses. Summary statistical data on SNP-small vessel stroke and on SNP-AD associations were derived from studies by the Multi-ancestry Genome-Wide Association Study of Stroke consortium (MEGASTROKE) and the Psychiatric Genomics Consortium-Alzheimer Disease Workgroup (PGC-ALZ) in individuals of European ancestry. Two-sample MR estimates were conducted with inverse-variance-weighted, robust inverse-variance-weighted, simple median, weighted median, weighted mode-based estimator, and MR pleiotropy residual sum and outlier (MR-PRESSO) methods.

RESULTS

Genetically predicted higher insulin resistance had a higher odds ratio (OR) of small vessel stroke (OR 1.23, 95% confidence interval [CI] 1.05-1.44, p = 0.01 using fasting insulin; OR 1.25, 95% CI 1.07-1.46, p = 0.006 using gold standard measures of insulin resistance) and AD (OR 1.13, 95% CI 1.04-1.23, p = 0.004 using fasting insulin; OR 1.02, 95% CI 1.00-1.03, p = 0.03 using gold standard measures of insulin resistance) using the inverse-variance-weighted method. No evidence of pleiotropy was found using MR-Egger regression.

CONCLUSION

Our findings provide genetic support for a potential causal effect of insulin resistance on small vessel stroke and AD.

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.

Chronic Kidney Disease and Cerebrovascular Disease: Consensus and Guidance From a KDIGO Controversies Conference

The global health burden of chronic kidney disease is rapidly rising, and chronic kidney disease is an important risk factor for cerebrovascular disease. Proposed underlying mechanisms for this relationship include shared traditional risk factors such as hypertension and diabetes, uremia-related nontraditional risk factors, such as oxidative stress and abnormal calcium-phosphorus metabolism, and dialysis-specific factors such as cerebral hypoperfusion and changes in cardiac structure. Chronic kidney disease frequently complicates routine stroke risk prediction, diagnosis, management, and prevention. It is also associated with worse stroke severity, outcomes and a high burden of silent cerebrovascular disease, and vascular cognitive impairment. Here, we present a summary of the epidemiology, pathophysiology, diagnosis, and treatment of cerebrovascular disease in chronic kidney disease from the Kidney Disease: Improving Global Outcomes Controversies Conference on central and peripheral arterial disease with a focus on knowledge gaps, areas of controversy, and priorities for research.

Non-Coding RNAs Based Molecular Links in Type 2 Diabetes, Ischemic Stroke, and Vascular Dementia

This article reviews recent advances in the study of microRNAs (miRNAs), long non-coding RNAs (lncRNAs), and their functions in type 2 diabetes mellitus (T2DM), ischemic stroke (IS), and vascular dementia (VaD). miRNAs and lncRNAs are gene regulation markers that both regulate translational aspects of a wide range of proteins and biological processes in healthy and disease states. Recent studies from our laboratory and others have revealed that miRNAs and lncRNAs expressed differently are potential therapeutic targets for neurological diseases, especially T2DM, IS, VaD, and Alzheimer's disease (AD). Currently, the effect of aging in T2DM, IS, and VaD and the cellular and molecular pathways are largely unknown. In this article, we highlight results from the works on the molecular connections between T2DM and IS, and IS and VaD. In each disease, we also summarize the pathophysiology and the differential expressions of miRNAs and lncRNAs. Based on current research findings, we hypothesize that 1) T2DM bi-directionally and age-dependently induces IS and VaD, and 2) these changes are precursors to the onset of dementia in elderly people. Research into these hypotheses is required to examine further whether research efforts on reducing T2DM, IS, and VaD may affect dementia and/or delay the AD disease process in the aged population.

Large disparities in 28-day case fatality by stroke subtype: data from a French stroke registry between 2008 and 2017

BACKGROUND AND PURPOSE

The objectives of the present analysis were to assess 28-day stroke case fatality according to the stroke aetiology and to identify associated factors.

METHODS

All stroke events in adults aged ≥35 years between 2008 and 2017 were collected in a population-based stroke registry in northern France.

RESULTS

Out of a total of 2933 strokes, there were 479 (16%) haemorrhagic strokes and 2454 (84%) ischaemic strokes; the 28-day case fatality rates were 48% and 15%, respectively. Three-quarters of the 28-day case fatalities occurred within 6 days of the event for haemorrhagic strokes and within 16.5 days for ischaemic strokes. After an ischaemic stroke, the case fatality rate was higher for women (18%) than for men (12%, p < 0.0001); however, this difference disappeared after adjustment for age. Cardioembolic strokes (34%) and strokes of undetermined cause (33%) were the most common ischaemic subtypes, with case fatality rates of 16% and 18%, respectively. Large artery atherosclerosis (11%) and lacunar strokes (10%) were less common, and both types had a case fatality rate of 3%. Age at the time of the event and stroke severity were both significantly associated with case fatality. For some types of stroke, a history of cardiovascular events and residence in a nursing home were associated with a poor prognosis. Medical care in a neurology ward was inversely associated with case fatality, for all stroke subtypes.

CONCLUSIONS

In northern France, post-stroke case fatality remains high, especially for haemorrhagic stroke. Being treated in a neurology ward improved survival by around 80%.

Significance of serum neuron-specific enolase in transient global amnesia

Neuron-specific enolase (NSE) is a glycolytic enzyme, which is associated with neuronal cell dysfunction in the brain. This study evaluated the role of serum NSE levels of patients with transient global amnesia (TGA). In addition, the relationship between serum NSE levels and the clinical features of TGA was explored. Forty-eight patients with TGA were prospectively included, and their serum NSE levels were measured. We investigated serum NSE levels in patients with TGA. In addition, we analyzed the differences in clinical characteristics between patients with elevated and normal serum NSE levels. Of the 48 patients with TGA, 16 patients (33.3%) had elevated serum NSE levels (25.0 ± 11.5 ng/mL), whereas 32 patients (66.7%) showed normal serum NSE levels (12.8 ± 2.1 ng/mL). The patients with elevated serum NSE levels exhibited higher levels of cognitive impairment than those with normal serum NSE levels (4/16 vs. 1/32, p = 0.036). The serum NSE levels showed a relatively high discrimination (AUC 0.684) between patients with and without cognitive impairment, with 80.0% sensitivity and 74.4% specificity at a cut-off value 17.3 ng/mL. A third of all patients with TGA carry elevated serum NSE levels, which suggests that the neuronal cell dysfunction could be associated with TGA pathogenesis. In addition, it might be correlated with cognitive impairment.

Endovascular therapy in patients with large vessel occlusion due to cardioembolism versus large-artery atherosclerosis

Background and aims:

To investigate whether stroke aetiology affects outcome in patients with acute ischaemic stroke who undergo endovascular therapy.

Methods:

We retrospectively analysed patients from the Bernese Stroke Centre Registry (January 2010–September 2018), with acute large vessel occlusion in the anterior circulation due to cardioembolism or large-artery atherosclerosis, treated with endovascular therapy (±intravenous thrombolysis).

Results:

The study included 850 patients (median age 77.4 years, 49.3% female, 80.1% with cardioembolism). Compared with those with large-artery atherosclerosis, patients with cardioembolism were older, more often female, and more likely to have a history of hypercholesterolaemia, atrial fibrillation, current smoking (each p < 0.0001) and higher median National Institutes of Health Stroke Scale (NIHSS) scores on admission (p = 0.030). They were more frequently treated with stent retrievers (p = 0.007), but the median number of stent retriever attempts was lower (p = 0.016) and fewer had permanent stent placements (p ⩽ 0.004). Univariable analysis showed that patients with cardioembolism had worse 3-month survival [72.7% versus 84%, odds ratio (OR) = 0.51; p = 0.004] and modified Rankin scale (mRS) score shift (p = 0.043) and higher rates of post-interventional heart failure (33.5% versus 18.5%, OR = 2.22; p < 0.0001), but better modified thrombolysis in cerebral infarction (mTICI) score shift (p = 0.025). Excellent (mRS = 0–1) 3-month outcome, successful reperfusion (mTICI = 2b–3), symptomatic intracranial haemorrhage and Updated Charlson Comorbidity Index were similar between groups. Propensity-matched analysis found no statistically significant difference in outcome between stroke aetiology groups. Stroke aetiology was not an independent predictor of favourable mRS score shift, but lower admission NIHSS score, younger age and independence pre-stroke were (each p < 0.0001). Stroke aetiology was not an independent predictor of heart failure, but older age, admission antithrombotics and dependence pre-stroke were (each ⩽0.027). Stroke aetiology was not an independent predictor of favourable mTICI score shift, but application of stent retriever and no permanent intracranial stent placement were (each ⩽0.044).

Conclusion:

We suggest prospective studies to further elucidate differences in reperfusion and outcome between patients with cardioembolism and large-artery atherosclerosis.

Early detection of small volume stroke and thromboembolic sources with computed tomography: Rationale and design of the ENCLOSE study

Background

Computed tomography is the most frequently used imaging modality in acute stroke imaging protocols. Detection of small volume infarcts in the brain and cardioembolic sources of stroke is difficult with current computed tomography protocols. Furthermore, the role of computed tomography findings to predict recurrent ischemic stroke is unclear. With ENCLOSE, we aim to improve (1) the detection of small volume infarcts with thin slice computed tomography perfusion (CTP) images and thromboembolic source with cardiac computed tomography techniques in the acute stage of ischemic stroke and (2) prediction of recurrent ischemic stroke with computed tomography-derived predictors.

Methods/design: ENCLOSE is a prospective multicenter observational cohort study, which will be conducted in three Dutch stroke centers (ClinicalTrials.gov Identifier: NCT04019483). Patients (≥18 years) with suspected acute ischemic stroke who undergo computed tomography imaging within 9 h after symptom onset are eligible. Computed tomography imaging includes non-contrast CT, CTP, and computed tomography angiography (CTA) from base of the heart to the top of the brain. Dual-energy CT data will be acquired when possible, and thin-slice CTP reconstructions will be obtained in addition to standard 5 mm CTP data. CTP data will be processed with commercially available software and locally developed model-based methods. The post-processed thin-slice CTP images will be compared to the standard CTP images and to magnetic resonance diffusion-weighted imaging performed within 48 h after admission. Detection of cardioembolic sources of stroke will be evaluated on the CTA images. Recurrence will be evaluated 90 days and two years after the index event. The added value of imaging findings to prognostic models for recurrent ischemic stroke will be evaluated.

Conclusion

The aim of ENCLOSE is to improve early detection of small volume stroke and thromboembolic sources and to improve prediction of recurrence in patients with acute ischemic stroke.

Incidence of Stroke and Ischemic Stroke Subtypes: A Community-Based Study in Brno, Czech Republic

BACKGROUND

There are few contemporary epidemiological data on stroke for Central Europe. We performed a population-based study evaluating the incidence of stroke, stroke types, and ischemic stroke (IS) subtypes in Brno, the second biggest city in the Czech Republic (CR).

METHODS

Using the National Registry of Hospitalized Patients, and hospital databases, we identified all patients hospitalized with a stroke diagnosis in Brno hospitals in 2011. For Brno residents with validated stroke diagnosis, we calculated (a) the overall incidence of hospitalized stroke, (b) incidence rates for IS, subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH), and (c) incidence rates for IS subtypes. We calculated the average annual age- and sex-standardized incidence (European Standard Population and World Health Organization), to compare our results with other studies.

RESULTS

The overall crude incidence of stroke in Brno was 213/100,000 population. The incidence of stroke for stroke types were as follows: SAH, 6.9; ICH, 26.4; and IS, 180 cases per 100,000 population, respectively. The WHO-standardized annual stroke incidence was 107 for all strokes and 88 for IS, 14.4 for ICH, and 5 for SAH. For IS subtypes, the WHO-standardized incidence was large artery atherosclerosis 25.8, cardioembolism 27.8, lacunar 21.6, other determined etiology 6.2, and undetermined etiology 6.5 cases per 100,000 population.

CONCLUSIONS

The stroke incidence is lower than that previously reported for the CR and Eastern Europe probably reflecting socioeconomic changes in post-communistic countries in the region. These findings could contribute to stroke prevention strategies and influence health policies.

Coronary Calcium Score and Stratification of Coronary Artery Disease Risk in Patients with Atherosclerotic and Non-Atherosclerotic Ischemic Stroke

BACKGROUND

Ischemic Stroke (IS) and Coronary Artery Disease (CAD) frequently coexist and share atherosclerotic disease risk factors. According to the American Heart Association, IS subtypes may be considered CAD risk equivalents, but the evidence for non-atherosclerotic IS is uncertain. Additionally, the Coronary Calcium Score (CCS) is an accurate marker to address CAD risk; however, CCS distribution between IS subtypes is not well characterized.

OBJECTIVES

To compare the CCS between atherosclerotic and non-atherosclerotic IS groups; and to determine which covariates were associated with high CCS in IS.

METHODS

This cross-sectional design included all patients with IS, 45 to 70 years of age at the time of the stroke, consecutively admitted to a rehabilitation hospital between August 2014 and December 2016, without prevalent CAD. All patients underwent CT scanning for CCS measurement. CCS≥100 was considered a high risk for CAD, with a significance level of p<0.05.

RESULTS

From the 244 studied patients (mean age 58.4±6.8 years; 49% female), 164 (67%) had non-atherosclerotic etiology. The proportions of CCS≥100 were similar between the atherosclerotic and the non-atherosclerotic groups (33% [n=26] x 29% [n=47]; p= 0.54). Among all IS patients, only age ≥60 years was independently associated with CCS≥100 (OR 3.5; 95%CI 1.7-7.1), accounting for hypertension, dyslipidemia, diabetes, sedentarism, and family history of CAD.

CONCLUSION

Atherosclerotic IS did not present a greater risk of CAD when compared to non-atherosclerotic IS according to CCS. Only age ≥60 years, but not etiology, was independently associated with CCS≥100.

Left atrial mechanics for secondary prevention from embolic stroke of undetermined source

Aims 

Anticoagulation is not justified unless atrial fibrillation (AF) is detected in cryptogenic stroke (CS) patients. We sought to explore whether left atrial (LA) remodelling is associated with embolic stroke of undetermined source (ESUS).

Methods and results 

In this prospective study, we evaluated consecutively 186 patients in sinus rhythm who presented with an acute ischaemic stroke (embolic and non-embolic) and sex- and age-matched controls. We performed continuous electrocardiogram (ECG) monitoring to capture paroxysmal AF episodes as recommended by the guidelines. After 12 months of follow-up, continuous ECG monitoring was repeated in patients with undetected AF episodes. We quantified LA reservoir and contraction strain (LASr and LASct) by speckle-tracking, LA volumes by 3D echocardiography. Out of 186 patients, 149 were enrolled after comprehensive investigation for the source of ischaemic stroke and divided into other cause (OC) (n = 52) and CS (n = 97) groups. CS patients were also subdivided into AF (n = 39) and ESUS (n = 58) groups. Among CS patients, LA strain predicted AF independently from CHARGE-AF score and LA volume indices. ESUS group, despite no captured AF, had significantly worse LA metrics than OC and control groups. AF group had the worst LA metrics. Moreover, LASr predicted both CS (embolic stroke with and without AF) and ESUS (embolic stroke with no detected AF) independently from LAVImax and CHA2DS2-VASc score. LASr &gt;26% yielded 86% sensitivity, 92% specificity, 92% positive, and 86% negative predictive values for the identification of ESUS (areas under curve: 0.915, P &lt; 0.0001, 95% confidence interval: 0.86–0.97).

Conclusion 

Echocardiographic quantification of LA remodelling has great potential for secondary prevention from ESUS.

Estimation of the LDL subclasses in ischemic stroke as a risk factor in a Chinese population

Background

Acute ischemic stroke (AIS) is one of the leading causes of mortality and long-term disability worldwide. Our study aims to clarify the role of low-density lipoproteins (LDL) subclasses in the occurrence of AIS and develop a risk xprediction model based on these characteristics to identify high-risk people.

Methods

Five hundred and sixty-six patients with AIS and 197 non-AIS controls were included in this study. Serum lipids and other baseline characteristics including fasting blood glucose (GLU), serum creatinine (Scr), and blood pressure were investigated in relation to occurrence of AIS. The LDL subfractions were classified and measured with the Lipoprint System by a polyacrylamide gel electrophoresis technique.

Results

Levels of LDL-3, LDL-4 and LDL-5 subclasses were significantly higher in the AIS group compared to the non-AIS group and lower level of LDL-1 was prevalent in the AIS patients. Consistently, Spearman correlation coefficient demonstrated that sd-demonevels, especially LDL-3 and LDL-4 levels, were significantly positively correlated with AIS. Furthermore, there is a significant positive correlation between small dense LDL (sd-LDL, that is LDL-3 to 7) levels and serum lipids including total cholesterol (TC), Low density lipoprotein cholesterol (LDL-C), and Triglyceride (TG). Increased LDL-3 and LDL-4 as well as decreased LDL-1 and LDL-2 were correlated to the occurrence of AIS, even in the people with normal LDL-C levels. A new prediction model including 12 variables can accurately predict the AIS risk in Chinese patients (AUC = 0.82 ± 0.04).

Conclusions

Levels of LDL subclasses should be considered in addition to serum LDL-C in assessment and management of AIS. A new prediction model based on clinical variables including LDL subtractions can help clinicians identify high of AIS, even in the people with norm.

CIMT as a risk factor for stroke subtype: A systematic review

INTRODUCTION

An increase in the common carotid artery intima-media thickness (CCA-IMT) is generally considered an early marker of atherosclerosis and is a well-established predictor of cardiovascular disease (CVD). An association between changes in CCA-IMT and risk of stroke has been reported but has conflicting findings.

OBJECTIVE

The present meta-analysis was aimed to clarify the association between CCA-IMT with the risk of stroke and its subtype by estimating pooled analysis of published literature.

METHODS

Comprehensive search for all published articles was performed in electronic databases including PubMed, Embase, Cochrane Library, Trip Databases, Worldwide Science, CINAHL and Google Scholar from 01 January 1950 to 30 April 2020.

RESULTS

In our meta-analysis, a total of 19 studies, of which sixteen studies involving 3475 ischaemic stroke (IS) cases and 11 826 controls; six studies with 902 large vessel disease (LVD) and 548 small vessel disease (SVD) of IS subtypes; five studies with 228 intracerebral haemorrhage (ICH) and 1032 IS cases, were included. Our findings suggest a strong association between increased CCA-IMT with risk of IS as compared to control subjects [SMD = 1.46, 95% CI = 0.90-2.02]. However, there is an increased risk of LVD as compared to the SVD subtype of IS [SMD = 0.36, 95% CI = 0.19-0.52] and more chance of occurrence of IS rather than ICH [SMD = 0.71, 95% CI = 0.28-1.41].

CONCLUSIONS

Carotid intima thickness measurements are found to be associated with the risk of stroke along with its subtypes and may be used as a diagnostic marker for predicting the risk of stroke events.

The management of carotid restenosis: a comprehensive review

Carotid artery stenosis (CS) is a major medical problem affecting approximately 10% of the general population 80 years or older and causes stroke in approximately 10% of all ischemic events. In patients with symptomatic, moderate-to-severe CS, carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS), has been used to lower the risk of stroke. In primary CS, CEA was found to be superior to best medical therapy (BMT) according to 3 large randomized controlled trials (RCT). Following CEA and CAS, restenosis remains an unsolved problem involving a large number of patients as the current treatment recommendations are not as clear as those for primary stenosis. Several studies have evaluated the risk of restenosis, reporting an incidence ranging from 5% to 22% after CEA and an in-stent restenosis (ISR) rate ranging from 2.7% to 33%. Treatment and optimal management of this disease process, however, is a matter of ongoing debate, and, given the dearth of level 1evidence for the management of these conditions, the relevant guidelines lack clarity. Moreover, the incidence rates of stroke and complications in patients with carotid stenosis are derived from studies that did not use contemporary techniques and materials. Rapidly changing guidelines, updated techniques, and materials, and modern medical treatments make actual incidence rates barely comparable to previous ones. For these reasons, RCTs are critical for determining whether these patients should be treated with more aggressive treatments additional to BMT and identifying those patients indicated for surgical or endovascular treatments. This review summarizes the current evidence and controversies concerning the risks, causes, current treatment options, and prognoses in patients with restenosis after CEA or CAS.

Etiological Subtypes of Transient Ischemic Attack and Ischemic Stroke in Chronic Kidney Disease: Population-Based Study

BACKGROUND AND PURPOSE

Chronic kidney disease (CKD) is strongly associated with stroke risk, but the mechanisms underlying this association are unclear and might be informed by subtype-specific analyses. However, few studies have reported stroke subtypes in CKD according to established classification systems, such as the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria. We, therefore, aimed to determine which transient ischemic attack and ischemic stroke subtypes using the TOAST classification occur most frequently in patients with CKD.

METHODS

In a population-based study of all transient ischemic attack and stroke (OXVASC [Oxford Vascular Study]; 2002-2017), all ischemic events were classified by TOAST subtypes (cardioembolism, large artery disease, small vessel disease, undetermined, multiple, other etiology, or incompletely investigated). Logistic regression was used to determine the relationship between CKD (defined as an estimated glomerular filtration rate <60 mL/min per 1.73 m2) and transient ischemic attack/stroke subtypes adjusted for age, sex, and hypertension and then stratified by age and estimated glomerular filtration rate category.

RESULTS

Among 3178 patients with transient ischemic attack (n=1167), ischemic stroke (n=1802), and intracerebral hemorrhage (n=209), 1267 (40%) had CKD. Although there was a greater prevalence of cardioembolic events (31.8% versus 21.2%; P<0.001) in patients with CKD, this association was lost after adjustment for age, sex, and hypertension (adjusted odds ratio=1.20 [95% CI, 0.99-1.45]; P=0.07). Similarly, although patients with CKD had a lower prevalence of small vessel disease (8.8% versus 13.6%; P<0.001), undetermined (26.1% versus 39.4%; P<0.001), and other etiology (1.0% versus 3.6%; P<0.001) subtypes, these associations were also lost after adjustment (adjusted odds ratio=0.86 [0.65-1.13]; P=0.27 and 0.73 [0.36-1.43]; P=0.37 for small vessel disease and other defined etiology, respectively) for all but undetermined (adjusted odds ratio=0.81 [0.67-0.98]; P=0.03).

CONCLUSIONS

There were no independent positive associations between CKD and specific TOAST subtypes, which suggest that renal-specific risk factors are unlikely to play an important role in the etiology of particular subtypes. Future studies of stroke and CKD should report subtype-specific analyses to gain further insights into potential mechanisms.

Tremor in Vascular Cognitive Impairment Raises the Possibility of Mixed Pathology With Lewy Body Disease

Objectives

Tremor is common in patients with Lewy body disease (LBD) and not rare in normal individuals. Prevalence of tremor in patients with vascular cognitive impairment (VCI) and its association with other comorbidities are seldom studied. The aim of this study was to investigate the patient characteristics of VCI associated with tremor and to evaluate the possibility of mixed pathology with LBD in these patients.

Methods

Retrospective analysis of a large population with VCI registered in the database of a regional healthcare system was performed. VCI patients were divided into tremor and non-tremor groups. The associated characteristics including demographics, clinical features in motor and non-motor domains, vascular risk factors, and neuroimaging features were compared between the tremor group and the non-tremor group.

Results

Among 1337 patients with VCI, 292 (21.8%) had tremor, while 1045 (78.2%) did not have tremor. The tremor group had significantly higher prevalence of all motor and non-motor LBD clinical features than the non-tremor group. The tremor group also demonstrated more severe neuropsychiatric symptoms. Among patients with tremor, patients having tremor onset earlier than stroke onset showed significantly higher prevalence of rapid eye movement sleep behavior disorder. All comparisons were adjusted for age and severity of dementia.

Conclusion

Tremor is a common comorbidity of VCI. VCI patients with tremor had a higher prevalence of motor and non-motor LBD features. These findings raised the possibility of VCI patients with tremor having high possibility of mixed pathology with LBD.

Endothelial Dysfunction May Link Interatrial Septal Abnormalities and MTHFR-Inherited Defects to Cryptogenic Stroke Predisposition

We explored the significance of the L-Arginine/asymmetric dimethylarginine (L-Arg/ADMA) ratio as a biomarker of endothelial dysfunction in stroke patients. To this aim, we evaluated the correlation, in terms of severity, between the degree of endothelial dysfunction (by L-Arg/ADMA ratio), the methylene tetrahydrofolate reductase (MTHFR) genotype, and the interatrial septum (IAS) phenotype in subject with a history of stroke. Methods and Results: L-Arg, ADMA, and MTHFR genotypes were evaluated; the IAS phenotype was assessed by transesophageal echocardiography. Patients were grouped according to the severity of IAS defects and the residual enzymatic activity of MTHFR-mutated variants, and values of L-Arg/ADMA ratio were measured in each subgroup. Of 57 patients, 10 had a septum integrum (SI), 38 a patent foramen ovale (PFO), and 9 an ostium secundum (OS). The L-Arg/ADMA ratio differed across septum phenotypes (p ≤ 0.01), and was higher in SI than in PFO or OS patients (p ≤ 0.05, p ≤ 0.01, respectively). In the PFO subgroup a negative correlation was found between the L-Arg/ADMA ratio and PFO tunnel length/height ratio (p ≤ 0.05; r = - 0.37; R2 = 0.14). Interestingly, the L-Arg/ADMA ratio varied across MTHFR genotypes (p ≤ 0.0001) and was lower in subgroups carrying the most impaired enzyme with respect to patients carrying the conservative MTHFR (p ≤ 0.0001, p ≤ 0.05, respectively). Consistently, OS patients carried the most dysfunctional MTHFR genotypes, whereas SI patients the least ones. Conclusions: A low L-Arg/ADMA ratio correlates with impaired activity of MTHFR and with the jeopardized IAS phenotype along a severity spectrum encompassing OS, PFO with long/tight tunnel, PFO with short/large tunnel, and SI. This infers that genetic MTHFR defects may underlie endothelial dysfunction-related IAS abnormalities, and predispose to a cryptogenic stroke. Our findings emphasize the role of the L-Arg/ADMA ratio as a reliable marker of stroke susceptibility in carriers of IAS abnormalities, and suggest its potential use both as a diagnostic tool and as a decision aid for therapy.

Validation of Risk Prediction Models to Detect Asymptomatic Carotid Stenosis

Background Significant asymptomatic carotid stenosis (ACS) is associated with higher risk of strokes. While the prevalence of moderate and severe ACS is low in the general population, prediction models may allow identification of individuals at increased risk, thereby enabling targeted screening. We identified established prediction models for ACS and externally validated them in a large screening population. Methods and Results Prediction models for prevalent cases with ≥50% ACS were identified in a systematic review (975 studies reviewed and 6 prediction models identified [3 for moderate and 3 for severe ACS]) and then validated using data from 596 469 individuals who attended commercial vascular screening clinics in the United States and United Kingdom. We assessed discrimination and calibration. In the validation cohort, 11 178 (1.87%) participants had ≥50% ACS and 2033 (0.34%) had ≥70% ACS. The best model included age, sex, smoking, hypertension, hypercholesterolemia, diabetes mellitus, vascular and cerebrovascular disease, measured blood pressure, and blood lipids. The area under the receiver operating characteristic curve for this model was 0.75 (95% CI, 0.74-0.75) for ≥50% ACS and 0.78 (95% CI, 0.77-0.79) for ≥70% ACS. The prevalence of ≥50% ACS in the highest decile of risk was 6.51%, and 1.42% for ≥70% ACS. Targeted screening of the 10% highest risk identified 35% of cases with ≥50% ACS and 42% of cases with ≥70% ACS. Conclusions Individuals at high risk of significant ACS can be selected reliably using a prediction model. The best-performing prediction models identified over one third of all cases by targeted screening of individuals in the highest decile of risk only.

TOAST classification and risk factors of ischemic stroke in Lebanon

OBJECTIVES

Ischemic stroke is a common cause of morbidity and mortality especially in the increasingly older population. The variability in ischemic stroke subtypes and its risk factors across different populations suggest that more effort is needed to describe the stroke characteristics in order to develop a more tailored management for each population. We aim to describe the demographic characteristics, risk factors, and subtype distribution of subjects with ischemic stroke in the Lebanese population.

MATERIALS AND METHODS

We conducted a cross-sectional study based on chart review on patients with ischemic stroke/transient ischemic attack at the American University of Beirut Medical center between 2015 and 2017.

RESULTS

A total of 284 cases were included with a mean age of 72 years, and 58% male gender. The most commonly identified risk factors were hypertension (77%), dyslipidemia (62%), and diabetes mellitus (42%), while atrial fibrillation was only found in 27% of cases. The cohort distribution according to TOAST classification was as follows: 15% large artery stroke, 31% cardioembolic stroke, 17% small artery stroke, 10% stroke of other determined causes, and 27% stroke of unknown cause.

CONCLUSION

This is the first study to address ischemic stroke characteristics in Lebanon.

CT angiography vs echocardiography for detection of cardiac thrombi in ischemic stroke: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Cardiac thrombi are an important cause of embolic stroke. We studied the diagnostic yield and diagnostic accuracy of cardiac CT angiography (CTA) compared to echocardiography for detection of cardiac thrombi in ischemic stroke patients.

METHODS

We performed a systematic review and meta-analysis of the literature on cardiac CTA versus echocardiography for detection of cardiac thrombi in ischemic stroke patients. We included studies (N ≥ 20) in which both cardiac CTA (index test) and echocardiography (reference test) were performed and data on cardiac thrombi were reported. Results were stratified for type of echocardiography: transesophageal (TEE) vs transthoracic (TTE).

RESULTS

Out of 1530 studies, 14 were included (all single center cohort studies), with data on 1568 patients. Mean age varied between 52 and 69 years per study and 66% were men. Reported time intervals ranged from 0 to 21 days between stroke and first test, and from 0 to 199 days between tests. In ten studies that compared CTA to TEE, CTA detected cardiac thrombi in 87/1385 (6.3%) patients versus 68/1385 (4.9%) on TEE (p < 0.001). In four studies comparing CTA to TTE, CTA detected thrombi in 23/183 (12.5%) patients versus 12/183 (6.6%) on TTE (p = 0.010). Pooled sensitivity and specificity of CTA versus TEE were 86.0% (95% CI 65.6-95.2) and 97.4% (95% CI 95.0-98.7), respectively.

CONCLUSIONS

CTA may be a promising alternative to echocardiography for detection of cardiac thrombi in patients with ischemic stroke, especially now that CTA is standard care for patient selection for endovascular treatment. However, studies were too heterogeneous and of insufficient methodological quality to draw firm conclusions. Large, prospective studies on this topic are warranted.

Cryptogenic stroke and atrial fibrillation in a real-world population: the role of insertable cardiac monitors

The incidence of atrial fibrillation (AF) in cryptogenic stroke (CS) patients has been studied in carefully controlled clinical trials, but real-world data are limited. We investigated the incidence of AF in clinical practice among CS patients with an insertable cardiac monitor (ICM) placed for AF detection. Patients with CS admitted to our Stroke Unit were included in the study; they received an ICM and were monitored for up to 3 years for AF detection. All detected AF episodes of at least 120 sec were considered. From March 2016 to March 2019, 58 patients (mean age 68.1 ± 9.3 years, 67% male) received an ICM to detect AF after a CS. No patients were lost to follow-up. AF was detected in 24 patients (41%, AF group mean age 70.8 ± 9.4 years, 62% male) after a mean time of 6 months from ICM (ranging from 2 days to 2 years) and 8 months after CS (ranging from 1 month to 2 years). In these AF patients, anticoagulant treatment was prescribed and nobody had a further stroke. In conclusion, AF episodes were detected via continuous monitoring with ICMs in 41% of implanted CS patients. AF in CS patients is asymptomatic and difficult to diagnose by strategies based on intermittent short-term recordings. Therefore, we suggest that ICMs should be part of daily practice in the evaluation of CS patients.

Causal Effects of Sleep Traits on Ischemic Stroke and Its Subtypes: A Mendelian Randomization Study

BACKGROUND

Unfavorable sleep habits have been linked with ischemic stroke in observational studies, but the causality remains unclear. The aim of this study is to investigate the potential causal role of three sleep traits, including sleep duration, insomnia, and chronotype, in ischemic stroke and its subtypes.

METHODS

We conducted two-sample Mendelian randomization (MR) analysis using single nucleotide polymorphisms associated with sleep duration, insomnia, and chronotype as instruments to estimate causal associations with ischemic stroke and its subtypes, among 34,217 ischemic stroke cases and 406,111 controls from the MEGASTROKE consortium. Inverse-variance weighted method was used as the main analyses. Alternative MR methods and sensitivity analyses were further performed.

RESULTS

We found suggestive evidence that per doubling of genetic liability for short sleep duration (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.01-1.58) and frequent insomnia symptoms (OR, 1.19; 95% CI, 1.00-1.41) were associated with a modest increase in risk of large artery stroke (LAS) but not with small vessel stroke, cardioembolic stroke, or any ischemic stroke. The association of frequent insomnia symptoms with LAS was stronger after the exclusion of the outlier (OR, 1.25; 95% CI, 1.04-1.50). No significant association was observed for chronotype with any ischemic stroke subtype. Results were overall robust to sensitivity analyses, and there was little evidence of horizontal pleiotropy.

CONCLUSION

We provided suggestive evidence for a potential causal role of short sleep duration and insomnia symptoms in LAS. Future researches are required to investigate whether improved sleep habits could help to mitigate LAS risk.

Risk Factors in Ischemic Stroke Subtypes: A Community-Based Study in Brno, Czech Republic

BACKGROUND

It is not known if risk factors differ between ischemic stroke (IS) subtypes in Central and Eastern Europe.

AIMS

We performed a community-based analysis of risk factors in patients admitted with IS over a 1 year period in Brno, the second largest city in the Czech Republic (CR).

METHODS

Based on the National Register of Hospitalized Patients, all patients with IS admitted in Brno in 2011 were identified. Comprehensive discharge summaries from hospital admissions were collected and reviewed. IS subtype and relevant risk factors were ascertained for all patients. The age- and sex-adjusted association of risk factors with IS subtypes was determined.

RESULTS

Overall, 682 patients with IS were admitted in 2011 to Brno hospitals. The distribution of IS subtypes was: 35% cardioembolism, 28% large-artery atherosclerosis, 23% small-artery occlusion, 7% stroke of undetermined etiology, 7% stroke of other determined etiology. Several of the risk factors showed high prevalence in the overall sample - e.g. hypertension (84%) and hyperlipidemia (61%). Cardioembolism as compared to other subtypes was positively associated with a history of myocardial infarction, cardiac failure, and atrial fibrillation. Small-artery occlusion was positively associated with history of dementia. No significant association was found between IS subtypes and history of IS, hypertension, diabetes, obesity, alcohol abuse or smoking.

CONCLUSIONS

We found high frequency of stroke risk factors in all IS subtypes. These findings have implications for stroke prevention strategies in the CR and across Central Europe.

Cardiac diagnostic work-up of ischaemic stroke

Cardioembolic sources account for 20-30% of ischaemic strokes and are important to identify considering their prognostic and therapeutic implications. During the past years, new developments have been made in the cardiac diagnostic evaluation and management of patients with ischaemic stroke, especially regarding strokes of unknown aetiology. These recent advances have had a major impact on our understanding of embolic strokes, their diagnostic work-up, and clinical management. Herein, we propose a cardiac diagnostic work-up scheme for patients with ischaemic stroke from definite cardioembolic sources and embolic strokes of undetermined source.

Potential Utility of Neurosonology in Paroxysmal Atrial Fibrillation Detection in Patients with Cryptogenic Stroke

Background: Occult paroxysmal atrial fibrillation (PAF) is a common and potential treatable cause of cryptogenic stroke (CS). We sought to prospectively identify independent predictors of atrial fibrillation (AF) detection in patients with CS and sinus rhythm on baseline electrocardiogram (ECG), without prior AF history. We had hypothesized that cardiac arrhythmia detection during neurosonology examinations (Carotid Duplex (CDU) and Transcranial Doppler (TCD)) may be associated with higher likelihood of AF detection. Methods: Consecutive CS patients were prospectively evaluated over a six-year period. Demographics, clinical and imaging characteristics of cerebral ischemia were documented. The presence of arrhythmia during spectral waveform analysis of CDU/TCD was recorded. Left atrial enlargement was documented during echocardiography using standard definitions. The outcome event of interest included PAF detection on outpatient 24-h Holter ECG recordings. Statistical analyses were performed using univariate and multivariate logistic regression models. Results: A total of 373 patients with CS were evaluated (mean age 60 ± 11 years, 67% men, median NIHSS-score 4 points). The rate of PAF detection of any duration on Holter ECG recordings was 11% (95% CI 8%–14%). The following three variables were independently associated with the likelihood of AF detection on 24-h Holter-ECG recordings in both multivariate analyses adjusting for potential confounders: age (OR per 10-year increase: 1.68; 95% CI: 1.19–2.37; p = 0.003), moderate or severe left atrial enlargement (OR: 4.81; 95% CI: 1.77–13.03; p = 0.002) and arrhythmia detection during neurosonology evaluations (OR: 3.09; 95% CI: 1.47–6.48; p = 0.003). Conclusion: Our findings underline the potential utility of neurosonology in improving the detection rate of PAF in patients with CS.

Does Chronic Kidney Disease Predict Stroke Risk Independent of Blood Pressure?: A Systematic Review and Meta-Regression

Background and Purpose- Chronic kidney disease is strongly associated with stroke with various purported mechanisms proposed. Low glomerular filtration rate appears to be a risk factor for stroke independent of cardiovascular risk factors in epidemiological studies, but there has been no systematic assessment of the impact of more complete adjustment for blood pressure on the association. Methods- We did a systematic review to February 2018 (MEDLINE/EMBASE) for cohort studies or randomized controlled trials that reported stroke incidence in adults according to baseline estimated glomerular filtration rate. Study and participant characteristics and relative risks (RR) were extracted. Estimates were combined using a random-effects model. Heterogeneity was assessed by x2 statistics and I2 and by subgroup strata and meta-regression. Results- We identified 168 studies reporting data on 5 611 939 participants with 115 770 stroke outcomes. Eighty-five studies (3 417 098 participants; 72 996 strokes) provided adequate data for meta-analysis of estimated glomerular filtration rate and stroke risk. Incident stroke risk was increased among participants with estimated glomerular filtration rate <60 mL/min per 1.73 m2 (RR=1.73; 95% CI, 1.57-1.90; P<0.001), but there was substantial heterogeneity between studies (P<0.0001; I2, 78.5%). Moreover, the association was reduced after adjustment for cardiovascular risk factors, with progressive attenuation on more thorough adjustment for hypertension: single baseline blood pressure measure (RR=1.63; CI, 1.34-1.99; P<0.001); history or treated hypertension (RR=1.35; CI, 1.24-1.46; P<0.001); multiple blood pressure measurements over months to years (RR=1.10; CI, 1.02-1.18; P=0.01). Conclusions- The association between chronic kidney disease and stroke appears to be highly dependent on the method of adjustment for hypertension. The apparently independent relationship between chronic kidney disease and stroke may be confounded by their shared association with long-term prior blood pressure.

Cerebral White Matter Hyperintensity as a Healthcare Quotient

To better understand the risk factors and optimal therapeutic strategies of cerebral white matter hyperintensity (WMH), we examined a large population of adults with and without various vascular risk factors (VRFs) or vascular risk conditions (VRCs), such as hypertension (HT), diabetes mellitus (DM), and dyslipidemia (DLP), including the comorbidities. We assessed two participant groups having no medical history of stroke or dementia that underwent brain checkup using magnetic resonance imaging (MRI): 5541 participants (2760 men, 2781 women) without VRCs and 1969 participants (1169 men, 800 women) who had received drug treatments for VRCs and the combination of comorbidities. For data analysis, we constructed WMH-brain healthcare quotient (WMH-BHQ) based on the percentile rank of WMH volume. This metric has an inverse relation to WMH. Multiple linear regression analysis of 5541 participants without VRCs revealed that age, systolic blood pressure (SBP), Brinkman index (BI), and female sex were significant factors lowering WMH-BHQ, whereas body mass index (BMI), male sex, fasting blood sugar, and triglyceride levels were increasing factors. The Kruskal–Wallis test and Dunn tests showed that WMH-BHQs significantly increased or decreased with BMI or SBP and with BI classification, respectively. Regarding the impact of impaired fasting glucose and abnormal lipid metabolism, there were almost no significant relationships. For 1969 participants who had HT, DM, and DLP, as well as their comorbidities, we found that DLP played a substantial role in increasing WMH-BHQ for some comorbidities, whereas the presence of HT and DM alone tended to decrease it. Cerebral WMH can be used as a healthcare quotient for quantitatively evaluating VRFs and VRCs and their comorbidities.

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.