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Wolfe J, Kamen S, Koneru M, Vigilante N, Rana A, Penckofer M, Hester T, Oak S, Patel K, Thau L, Sprankle K, Kim K, Thomas K, Zhang L, Siegler JE. Subcortical infarcts in patients with nonstenotic cervical atherosclerotic disease. J Stroke Cerebrovasc Dis 2023; 32:107264. [PMID: 37586218 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107264] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/12/2023] [Accepted: 07/16/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Prior studies have elucidated a relationship between nonstenotic plaque in patients with cryptogenic embolic infarcts with a largely cortical topology, however, it is unclear if nonstenotic cervical internal carotid artery (ICA) plaque is relevant in subcortical cryptogenic infarct patterns. METHODS A nested cohort of consecutive patients with anterior, unilateral, and subcortical infarcts without an identifiable embolic source were identified from a prospective stroke registry (September 2019 - June 2021). Patients with extracranial stenosis >50% or cardiac sources of embolism were excluded. Patients with computed tomography angiography were included and comparisons were made according to the infarct pattern being lacunar versus non-lacunar. Prevalence estimates for cervical internal carotid artery (ICA) plaque presence were estimated with 95% confidence intervals (CI), and differences in plaque thickness and features were compared between sides. RESULTS Of the 1684 who were screened, 141 met inclusion criteria (n=80 due to small vessel disease, n=61 cryptogenic). The median age was 66y (interquartile range, IQR 58-73) and the National Institutes of Health Stroke Scale score was 3 (IQR 1-5). There was a higher probability of finding excess plaque ipsilateral to the stroke (41.1%, 95% CI 33.3-49.3%) than finding excess contralateral plaque (29.1%, 95% CI 22.2-37.1%; p=0.03), but this was driven by patients with non-lacunar infarcts (excess ipsilateral vs. contralateral plaque frequency of 49.2% vs. 14.8%, p<0.001) rather than lacunar infarcts (35.0% vs. 40.0%, p=0.51). CONCLUSIONS The probability of finding ipsilateral, nonstenotic carotid plaque in patients with subcortical cryptogenic strokes exceeds the probability of contralateral plaque and is driven by larger subcortical infarcts, classically defined as being cryptogenic. Approximately 1 in 3 unilateral anterior subcortical infarcts may be due to nonstenotic ICA plaque.
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Affiliation(s)
- Jared Wolfe
- Cooper Medical School of Rowan University, Camden, NJ, United States.
| | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Manisha Koneru
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | | | - Ankit Rana
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Mary Penckofer
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Taryn Hester
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Solomon Oak
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Karan Patel
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Lauren Thau
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Kenyon Sprankle
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Kelly Kim
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Kavya Thomas
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Linda Zhang
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - James E Siegler
- Cooper Medical School of Rowan University, Camden, NJ, United States; Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
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Siegler JE. Nonstenotic intracranial atherosclerosis as an emerging mechanism in cryptogenic cerebral embolism. Eur J Neurol 2023; 30:565-566. [PMID: 36484559 DOI: 10.1111/ene.15662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Affiliation(s)
- James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
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Embolic infarct topology differs between atrial fibrillation subtypes and embolic stroke of undetermined source. J Stroke Cerebrovasc Dis 2022; 31:106782. [PMID: 36130470 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/07/2022] [Accepted: 09/10/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The lack of superiority of anticoagulation over antiplatelet therapy in embolic stroke of undetermined source (ESUS) may be in part due to the misclassification of radiographic ESUS patterns as cardioembolic. In this imaging analysis, we sought to differentiate clinical and radiographic patterns of ESUS patients from patterns in patients with a highly probable cardioembolic source. MATERIALS & METHODS A prospective registry of consecutive adults with acute infarction on diffusion-weighted magnetic resonance imaging was queried. Patients with infarctions due to small vessel disease, large vessel disease, and other causes were excluded. Multivariable logistic regression was used to identify independent predictors of two potentially embolic patterns: (1) multifocal and (2) cortical lesions, comparing patients with ESUS against those with atrial fibrillation (AF). RESULTS Among 1243 screened patients, 343 (27.6%) experienced strokes due to ESUS or AF. Prior to the index stroke, patients with AF as compared to ESUS were older (median 75 vs. 65, p<0.01) and had more heart failure (25.9% vs. 8.4%, p<0.01). The odds of multifocal infarction were the same between patients with ESUS and both AF subtypes (p>0.05), however, cortical involvement was more associated with both AF versus ESUS (77.7% vs. 65.7%, P=0.02). A higher Fazekas grade of white matter disease was inversely associated with cortical infarction among included patients (aOR 0.77, 95% CI 0.62-0.96). CONCLUSION Cortical infarctions were twice as common among patients with AF versus ESUS. Subcortical infarct topography was strongly associated with chronic microvascular ischemic changes and therefore may not represent embolic phenomena. Larger-scale investigations are warranted to discern whether large or multifocal subcortical infarcts ought to be excluded from the ESUS designation.
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