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Sagris D, Korompoki E, Strambo D, Mavraganis G, Michel P, Eskandari A, Vemmos K, Lastras C, Rodriguez-Pardo J, Fuentes B, Díez-Tejedor E, Tiili P, Lehto M, Putaala J, Cuadrado-Godia E, Farington-Terrero E, Arauz A, Kamel H, Soledad Rosales J, Rodriguez Perez MS, Gomez Schneider M, Barboza M, Tsiskaridze A, Ntaios G. Prevalence and Factors Associated with Carotid Stenosis in Acute Ischemic Stroke Patients with Atrial Fibrillation. Neuroepidemiology 2024:1-10. [PMID: 38981461 DOI: 10.1159/000539693] [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: 10/03/2023] [Accepted: 03/26/2024] [Indexed: 07/11/2024] Open
Abstract
INTRODUCTION Among stroke patients with atrial fibrillation (AF), it is not uncommon to identify carotid atherosclerosis. This study aimed to estimate the prevalence of, and factors associated with, carotid atherosclerosis among patients with AF and acute ischemic stroke. PATIENTS AND METHODS Prospectively collected data from consecutive patients with anterior ischemic stroke and AF who underwent carotid imaging from 10 stroke registries were categorized retrospectively according to the degree of stenosis in: no atherosclerosis, stenosis <50%, stenosis ≥50%, and occlusion. Logistic regression analysis was used to identify factors associated with ipsilateral carotid atherosclerosis. RESULTS Among 2,955 patients with ischemic stroke and AF, carotid atherosclerosis was evident in 1,022 (34.6%) patients, while carotid stenosis ≥50% and occlusion were identified in 204 (6.9%) and 168 (5.7%) patients, respectively. Ipsilateral carotid stenosis ≥50% or occlusion was associated with higher age (OR: 1.15, 95% CI: 1.01-1.32, per decade), previous ischemic stroke or transient ischemic attack (OR: 1.70, 95% CI: 1.29-2.25), peripheral artery disease (OR: 1.85, 95% CI: 1.23-2.78), coronary artery disease (OR: 1.53, 95% CI: 1.16-2.04), and statin treatment on admission (OR: 1.30, 95% CI: 1.01-1.67). Patients with lacunar stroke had a lower likelihood of stenosis ≥50% or occlusion (OR: 0.29, 95% CI: 0.13-0.68). Compared to the absence of atherosclerotic disease, atherosclerosis in one and two arterial beds was associated with the identification of ipsilateral carotid stenosis (OR: 1.49, 95% CI: 1.22-2.98 and OR: 3.18, 95% CI: 1.85-5.49, respectively). CONCLUSION Among acute ischemic stroke patients with AF, 1 out of 3 had ipsilateral carotid atherosclerosis, and 1 out of 8 had ipsilateral carotid stenosis ≥50% or occlusion. Atherosclerosis in two arterial beds was the most important predictor for the identification of ipsilateral carotid stenosis. Among ischemic stroke patients with AF, carotid atherosclerosis is common, while carotid imaging should not be overlooked, especially in those with coronary or/and peripheral artery disease.
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Affiliation(s)
- Dimitrios Sagris
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece,
| | - Eleni Korompoki
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece
| | - Davide Strambo
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Georgios Mavraganis
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece
| | - Patrik Michel
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Ashraf Eskandari
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Konstantinos Vemmos
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece
| | - Clara Lastras
- Department of Neurology and Stroke Center, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Jorge Rodriguez-Pardo
- Department of Neurology and Stroke Center, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Blanca Fuentes
- Department of Neurology and Stroke Center, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Exuperio Díez-Tejedor
- Department of Neurology and Stroke Center, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital-Universidad Autónoma de Madrid), Madrid, Spain
| | - Paula Tiili
- Department of Neurology, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Mika Lehto
- Department of Cardiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Elisa Cuadrado-Godia
- Department of Neurology, Neurovascular Research Group, Institut Hospital del Mar d'Investigació Biomèdica, Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Esmirna Farington-Terrero
- Stroke Clinic, Instituto Nacional de Neurologıa y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Antonio Arauz
- Stroke Clinic, Instituto Nacional de Neurologıa y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Julieta Soledad Rosales
- Department of Neurology, Institute for Neurological Research, FLENI, Buenos Aires, Argentina
| | | | - Maia Gomez Schneider
- Department of Neurology, Institute for Neurological Research, FLENI, Buenos Aires, Argentina
| | - Miguel Barboza
- Neurosciences Department, Hospital Dr. Rafael A. Calderon Guardia, CCSS, University of Costa Rica, San José, Costa Rica
| | - Alexander Tsiskaridze
- Department of Neurology, Ivane Javakhishvili Tbilisi State University, Tbilisi, Georgia
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Wen S, Naqvi TZ. 3-D transesophageal echocardiography aids in assessment of embolic stroke due to aortic atherosclerotic plaque: A case series. Echocardiography 2024; 41:e15799. [PMID: 38516862 DOI: 10.1111/echo.15799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/23/2024] Open
Abstract
Atherosclerosis is the most common cause of heart disease and stroke. Plaque thickness ≥4 mm in the ascending aorta or aortic arch is strongly correlated with cerebral embolic events and ischemic stroke. However, despite imaging workup, the cause of embolic stroke remains unidentified in many patients. Transesophageal echocardiography (TEE) is the preferred echocardiographic method for the evaluation of cardiac source of emboli. 2D TEE imaging evaluates aortic root and aortic arch in a single plane or two planes with biplane imaging. However, 2D TEE often fails to detect mobile or complex components in the ascending aorta and aortic arch plaques. The routine availability of 3D TEE in current ultrasound systems may significantly improve the assessment of aortic plaques as a potential embolic source. In this case series, we present four consecutive patients with stroke who underwent TEE by a single cardiologist for possible cardioembolic source. Some of these patients may have been labelled as "cryptogenic stroke" or "embolic stroke of undetermined source" (ESUS) due to the presence of insignificant or nonmobile ascending aortic or aortic arch plaques on 2D TEE imaging. In our four consecutive patients with ESUS who underwent TEE by a single operator, 3D TEE showed complex aortic arch plaques with ulceration with mobile components and established these plaques as the likely source of embolic stroke.
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Affiliation(s)
- Songnan Wen
- Department of Cardiovascular Medicine, Division of Echocardiography, Mayo Clinic, Scottsdale, USA
| | - Tasneem Z Naqvi
- Department of Cardiovascular Medicine, Division of Echocardiography, Mayo Clinic, Scottsdale, USA
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Luo N, Shang Z, Tao L, Yang B, Chen H. Atherosclerosis as a Potential Cause of Deep Embolic Stroke of Undetermined Source: A 3T High‐Resolution Magnetic Resonance Imaging Study. J Am Heart Assoc 2022; 11:e026737. [DOI: 10.1161/jaha.122.026737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
The potential causes or sources of embolic stroke of undetermined source (ESUS) vary. This study aimed to investigate the main cause of deep ESUS by evaluating nonstenotic intracranial atherosclerotic plaque.
Methods and Results
We retrospectively screened consecutive patients with unilateral anterior circulation ESUS. After excluding the patients with possible embolism from an extracranial artery such as aortic arch plaque, carotid plaque, and so on, the enrolled patients with ESUS were categorized into 2 groups: deep ESUS and cortical with/without deep ESUS. All patients underwent intracranial high‐resolution magnetic resonance imaging to assess the characteristics of nonstenotic intracranial atherosclerotic plaque. Biomarkers of atrial cardiopathy (ie, P‐wave terminal force in lead V1 on ECG, NT‐proBNP [N‐terminal pro–brain natriuretic peptide] and left atrial diameter) were collected. A total of 155 patients with ipsilateral nonstenotic intracranial atherosclerotic plaque were found, with 76 (49.0%) in deep ESUS and 79 (51.0%) in cortical with/without deep ESUS. We found more prevalent plaque in the M1 segment of the middle cerebral artery and the ostia of the perforator, with a smaller remodeling index plaque burden, and less frequent occurrence of complicated plaque in deep ESUS versus cortical with/without deep ESUS. Higher BNP (brain natriuretic peptide) levels and a higher prevalence of atrial cardiopathy in cortical with/without deep ESUS versus deep ESUS. Moreover, the discrimination of vulnerable plaque for predicting ESUS was significantly enhanced after adjusting for or further excluding patients with deep ESUS.
Conclusions
The current study provides the first high‐resolution magnetic resonance imaging evidence that cortical with/without deep ESUS and deep ESUS should be 2 distinct entities and that atherosclerosis, not embolism, might be the main cause of deep ESUS.
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Affiliation(s)
- Na Luo
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Zi‐Yang Shang
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Lin Tao
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Ben‐Qiang Yang
- Department of Radiology General Hospital of Northern Theater Command Shenyang China
| | - Hui‐Sheng Chen
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
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Shang ZY, Tao L, Li XQ, Yang BQ, Ntaios G, Chen HS. The characteristics of intracranial plaques of unilateral, anterior circulation embolic stroke of undetermined source: an analysis of different subtypes based on high-resolution imaging. Eur J Neurol 2022; 29:2654-2663. [PMID: 35593148 DOI: 10.1111/ene.15409] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the characteristics of non-stenotic intracranial plaque (NSIP) among embolic stroke of undetermined source (ESUS) subtypes by high-resolution magnetic resonance imaging (HR-MRI). METHODS we retrospectively enrolled consecutive patients with ESUS who were mandatory for HR-MRI. Based the location and arterial supply of the infarct, ESUS were categorized into three types: cortical ESUS, subcortical ESUS and mixed ESUS. The NSIP parameters including plaque location, morphology (plaque distribution, remodeling index and plaque burden) and composition (thick fibrous cap, discontinuity of plaque surface, intraplaque hemorrhage and complicated plaque) were evaluated among subtypes. RESULTS Among 243 patients, there were 87 (35.8%) cortical ESUS, 127 (52.3%) subcortical ESUS and 29 (11.9%) mixed ESUS. We found significant differences in plaque location (P < 0.001), plaque quadrant (P < 0.001), remodeling index (P < 0.001), plaque burden (P < 0.001), discontinuity of plaque surface (P < 0.001), intraplaque hemorrhage (P = 0.001) and complicated plaque (P < 0.001) of ipsilateral NISP among different ESUS subtypes, except for fibrous cap (P = 0.135). But we found no differences among contralateral NISP. In addition, the clinical characteristics of the differences among ESUS subtypes were striking, including age (P = 0.004), initial National Institute of Health Stroke Scale (P < 0.001), coronary artery disease (P = 0.039), serum urea (P = 0.011) and creatinine (P = 0.002). CONCLUSION This is the first report of significantly heterogeneous characteristics of ipsilateral NSIP and clinical findings among ESUS subtypes, which may suggest their different underlying mechanisms.
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Affiliation(s)
- Zi-Yang Shang
- Department of Neurology, General Hospital of Northern Theater Command, China
| | - Lin Tao
- Department of Neurology, General Hospital of Northern Theater Command, China
| | - Xiao-Qiu Li
- Department of Neurology, General Hospital of Northern Theater Command, China
| | - Ben-Qiang Yang
- Radiology, General Hospital of Northern Theater Command, China
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, China
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Ntaios G, Korompoki E. Embolic stroke of undetermined source and atrial cardiopathy: Towards a personalized antithrombotic strategy for secondary stroke prevention. Eur J Intern Med 2022; 99:24-25. [PMID: 35193782 DOI: 10.1016/j.ejim.2022.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 11/18/2022]
Affiliation(s)
- George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Thessaly 41110, Greece; Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece.
| | - Eleni Korompoki
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Thessaly 41110, Greece; Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
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Alokley AA, Albakr A, Almansori M. Absent Left Anterior Descending Coronary Artery as a Potential Cause of Ischemic Stroke: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931109. [PMID: 34252070 PMCID: PMC8286803 DOI: 10.12659/ajcr.931109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Embolic stroke of undetermined source (ESUS) represents 20-30% of ischemic strokes, with a high risk of recurrence. It usually requires an extensive diagnostic evaluation to address the potential etiologies. Coronary artery anomaly (CAA) of the left anterior descending artery (LAD) is uncommon, and it is known to be linked to myocardial complications. The association of this anomaly with ischemic strokes has not been reported yet. Here, we report on a rare case of a young patient with hypoplastic LAD complicated by an impaired ventricular function that resulted in left ventricular (LV) thrombus formation as a source of recurrent ischemic strokes. CASE REPORT A 36-year-old man had a 4-year history of recurrent strokes despite maintaining antiplatelet treatment. He had no pre-existing vascular risk factors or relevant family history. The initial stroke etiology work-up was inconclusive. A transesophageal echocardiogram showed moderate ventricular hypokinesia. A coronary angiogram was initiated, and a hypoplastic (LAD) artery anomaly was found. At first, the antiplatelet therapy was maintained. Later on, he presented with transient focal neurological symptoms indicative of a transient ischemic attack. Repeated echocardiograms detected left ventricular thrombus. Apixaban was started, with successful thrombus resolution in a one-month follow-up echocardiogram. He has not had a further recurrent ischemic event for 18 months. CONCLUSIONS This case suggests that CAAs might be considered as an associated etiology of ESUS in a young patient with recurrent cerebral events. In a clinical setting, we encourage early use of advanced cerebral and cardiac imaging modalities to accurately determine the stroke etiology, target the appropriate treatment, and prevent a further neurological sequel.
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Affiliation(s)
- Alia Ali Alokley
- Department of Neurology, King Fahad Hospital of the University, Al-Khobar, Saudi Arabia.,Department of Neurology, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Aishah Albakr
- Department of Neurology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammed Almansori
- Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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The Value of Combined Detection of D-dimer and CD62p in Judging the Severity of Acute Cerebral Infarction and Short-Term Prognosis. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6620311. [PMID: 33532490 PMCID: PMC7834744 DOI: 10.1155/2021/6620311] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/02/2021] [Accepted: 01/07/2021] [Indexed: 12/25/2022]
Abstract
Objective To explore the value of combined detection of peripheral blood P-selectin (CD62p) and D-dimer (D-dimer) in the judgment of acute cerebral infarction severity and short-term prognosis. Methods 268 patients with acute cerebral infarction from February 2015 to February 2019 were selected as the observation group. According to the National Institute of Health stroke scale, there were 90 cases (SCI group), 88 cases (MOCI group), and 90cases (MICI group) in the severe, moderate, and mild cerebral infarction groups, respectively. In the same period, 80 cases of healthy people served as the Normal group. Use flow cytometry to detect CD62p in peripheral blood and magnetic bead method to detect D-dimer level within 24 hours of onset. Logistic regression was used to analyze whether the two are factors affecting the short-term prognosis of acute cerebral infarction, and the ROC curve was drawn to evaluate the value of the combined detection of the two in the short-term prognosis of patients with acute cerebral infarction. Results Peripheral blood D-dimer and CD62p levels (2.95 ± 0.76 ng/l, 34.03 ± 5.29 ng/l) in the SCI group were higher than those in the MOCI group (2.30 ± 0.51 ng/l, 27.58 ± 5.56 ng/l) and the MICI group (1.87 ± 0.40 ng/l, 19.60 ± 3.98 ng/l); the difference between the groups was statistically significant (P < 0.05). Logistic regression analysis showed that D-dimer and CD62p were independent risk factors affecting the poor prognosis of patients with acute cerebral infarction (OR values were 3.752 and 1.213, and 95% CI were 1.612-7.934 and 1.093-1.342, respectively, both P < 0.05). The AUC of D-dimer combined with CD62p for predicting poor prognosis of acute cerebral infarction is 0.859, which is better than D-dimer and CD62p alone. Conclusion Peripheral blood D-dimer combined with CD62p detection is helpful for the risk stratification and short-term prognosis assessment of patients with acute cerebral infarction. Clinical detection is of great significance for the prevention and monitoring of disease development.
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