Homocysteine and C-reactive protein associated with progression and prognosis of intracranial branch atheromatous disease

Prognostic study of intracranial branch atheromatous disease in the blood-supplying areas of the lenticulostriate and paramedian pontine arteries

INTRODUCTION

Branch atheromatous disease (BAD) is prone to early neurological deterioration (END), leading to a poor prognosis. The most common arteries causing END are the lenticulostriate arteries (LSA) and the paramedian pontine arteries (PPA). To gain insight into the characteristics of symptomatic plaques and their association with poor prognosis in patients with BAD, we conducted a prospective study using high-resolution magnetic resonance imaging (HRMRI).

METHODS

A total of 75 patients with BAD in the vascular range of LSA or PPA were recruited for this study. The vascular and plaque features of the carrier middle cerebral artery (MCA) and basilar artery (BA) were evaluated through the application of HRMRI, and the local cerebral blood flow (CBF) of the lesion was assessed through pseudo-continuous arterial spin-labeling (pCASL), and the number and location of cerebral microbleeds (CMBs) were documented by susceptibility-weighted imaging (SWI). Univariable and multivariable logistic regression analyses were performed to analyze the factors that affected the prognosis.

RESULTS

A poor prognosis was observed in 24 patients (32%) with BAD. A total of 28 patients (37%) developed END. Multifactorial analysis showed statistically significant differences in the dorsal plaque of BA (OR: 19.15, 95% CI 1.72-385.37, p=0.028), male (OR: 26.22, 95% CI 3.18-406.31, p=0.007), and NIHSS at 7 days of onset (OR: 2.24, 95% CI 1.4-4.45, p=0.004).

CONCLUSIONS

In patients with BAD in LSA and PPA areas, the dorsal plaque of BA, male, and NIHSS at 7 days of onset were independent risk factors for poor prognosis.

Clinical and Prognostic Characteristics of Acute BAD-Related Stroke: A Multicenter MRI-Based Prospective Study

BACKGROUND

Branch atheromatous disease (BAD)-related stroke has emerged as a meaningful subtype of ischemic stroke yet remained understudied. We aimed to investigate the demographic, clinical, therapeutic, and prognostic characteristics of BAD-related stroke.

METHODS

The BAD-study was a nationwide, multicenter, prospective, observational cohort study in 20 Chinese hospitals from June 2021 to June 2023, enrolling patients aged 18 to 80 years with BAD-related stroke within 72 hours of onset. Eligible single subcortical infarct in the territory of lenticulostriate artery and paramedian pontine artery was included. Clinical, laboratory, and treatment data were collected at baseline. The primary outcome was a proportion of good outcomes (modified Rankin Scale score, 0-2) at 90 days. Main secondary outcomes included early neurological deterioration (END), cerebrovascular event, major bleeding, and excellent outcome (modified Rankin Scale score, 0-1) during 90-day follow-up.

RESULTS

We finally enrolled 476 patients, with a median age of 60 (interquartile range, 53-68) years, and 70.2% were male. The median National Institutes of Health Stroke Scale score was 3 (interquartile range, 2-6) at enrollment. Involvement of the lenticulostriate artery was more common than the paramedian pontine artery (60.7% versus 39.3%). END occurred in 14.7% of patients, with a median time from onset of 38 (interquartile range, 22-62) hours. The rates of good and excellent outcomes were 86.5% and 72%, respectively. Its 90-day stroke recurrence rate was 1.9%. Acute-phase therapy (from onset to 7 days of enrollment) showed heterogeneity and was not associated with prognosis. Multivariable logistic regression analysis identified the National Institutes of Health Stroke Scale score ≥4 at admission and END as negative predictors and extracranial artery stenosis as a positive predictor of good outcomes. Age ≥60 years, National Institutes of Health Stroke Scale score ≥4 at admission, and END were negative predictors of excellent outcomes.

CONCLUSIONS

With distinct demographic, clinical, and prognostic characteristics, along with a high incidence of END and a low risk of stroke recurrence, BAD-related stroke could be categorized as a separate disease entity. Moreover, its acute-phase treatment strategies were undetermined, awaiting further high-quality studies.

A one-year relapse prediction model for acute ischemic stroke (AIS) based on clinical big data

Objective

To develop and evaluate a nomogram prediction model for recurrence of acute ischemic stroke (AIS) within one year.

Method

Patients with AIS treated at the second affiliated hospital of Xuzhou Medical University from August 2017 to July 2019 were enrolled. Clinical data such as demographic data, risk factors, laboratory tests, TOAST etiological types, MRI features, and treatment methods were collected. Cox regression analysis was done to determine the parameters for entering the nomogram model. The performance of the model was estimated by receiver operating characteristic curves, decision curve analysis, calibration curves, and C-index.

Result

A total of 645 patients were enrolled in this study. Side of hemisphere (SOH, Bilateral, HR = 0.35, 95 % CI = 0.15-0.84, p = 0.018), homocysteine (HCY, HR = 1.38, 95 % CI = 1.29-1.47, p < 0.001), c-reactive protein (CRP, HR = 1.04, 95 % CI = 1.01-1.07, p = 0.013) and stroke severity (SS, HR = 3.66, 95 % CI = 2.04-6.57, p < 0.001) were independent risk factors. The C-index of the nomogram model was 0.872 (se = 0.016). The area under the receiver operating characteristic (ROC)curve at one-year recurrence was 0.900. Calibration curve, decision curve analysis showed good performance of the nomogram. The cutoff value for low or high risk of recurrence score was 1.73.

Conclusion

The nomogram model for stroke recurrence within one year developed in this study performed well. This useful tool can be used in clinical practice to provide important guidance to healthcare professionals.

The "island sign" on diffusion-weighted imaging predicts early neurological deterioration in penetrating artery territory infarctions: a retrospective study

BACKGROUND

Early neurological deterioration (END) sometimes occurs in patients with penetrating artery territory infarction (PATI) and leads to poor prognosis. In this study, we analyzed clinical and neuroimaging characteristics of PATI, and focused on the infarct patterns on diffusion-weighted imaging (DWI). We tried to investigate whether the "island sign" pattern is associated with END.

METHODS

We enrolled consecutive patients admitted with acute PATI within 48 h after onset from May 2020 to July 2022. They were divided into with and without the "island sign" pattern on DWI. According to infarct location, all the patients were classified into two groups: the territories of the lenticulostriate arteries (LSA) and paramedian pontine arteries (PPA). The patients in each group were further divided into two groups according to whether they developed END or not. Through analyzing the clinical and neuroimaging characteristics of the patients, we tried to identify the factors that might associated with the "island sign" pattern and the potential predictors of END within the LSA and PPA groups.

RESULTS

Out of the 113 patients enrolled in this study, END was found in 17 patients (27.9%) in the LSA group and 20 patients (38.5%) in the PPA group. The "island sign" was found in 26 (23%) patients. In the multivariate analysis, the independent predictors of END in the LSA group were the "island sign" (OR 4.88 95% CI 1.03-23.2 P = 0.045) and high initial National Institute of Health Stroke Scale (NIHSS) (OR 1.79 95% CI 1.08-2.98 P = 0.024) and in the PPA group was the presence of lesions extending to the ventral pontine surface (OR 7.53 95% CI 1.75-32.37 P = 0.007).

CONCLUSIONS

The predictive factors for END were different in the LSA and PPA groups. The "island sign" was particularly associated with END in the LSA group.

Clinical features of ischemic stroke in patients with nonvalvular atrial fibrillation combined with intracranial atherosclerotic stenosis

BACKGROUND

Nonvalvular atrial fibrillation (NVAF) and intracranial atherosclerotic stenosis (ICAS) are major causes of ischemic stroke. Relatively few studies have focused on the risk factors and clinical features of ischemic stroke caused by NVAF combined with ICAS.

METHOD

We retrospectively evaluated NVAF and/or ICAS in patients with acute ischemic stroke admitted within 72 h after stroke. All patients with acute ischemic stroke underwent diffusion-weighted magnetic resonance imaging (DWI), magnetic resonance angiography (MRA), computed tomography angiography (CTA), and/or digital subtraction angiography (DSA). NVAF was detected by routine electrocardiogram or 24-h Holter examination, Doppler echocardiography, and contrast echocardiography of the right heart.

RESULTS

Among the 635 enrolled patients, NVAF, ICAS, and NVAF+ICAS were diagnosed in 170 (26.77%), 255 (40.16%), and 210 (33.07%) patients, respectively. Patients in the NVAF+ICAS group were older (p < .001), specifically aged ≥75 years (p < .001). The admission time of the NVAF+ICAS group was shorter (p < .001) than that of the ICAS group. The admission NIHSS score of the NVAF group was higher than that of the NVAF+ICAS group (p < .001). HsCRP, NTpro-BNP, and LEVF levels were significantly different among the three groups (p < .001). NVAF+ICAS ischemic stroke occurred mainly in the right hemisphere (52.4%).

CONCLUSION

NVAF with ICAS ischemic stroke is more likely to occur in older patients. Infarctions occurred mainly in the right cerebral hemisphere. Neurological deficits in NVAF are more severe than those in NVAF combined with ICAS and in simple ICAS ischemic strokes. HsCRP, LEVF, andNTpro-BNP seem to be closely associated with NVAF+ICAS ischemic stroke.

Culprit Plaques of Large Parent Arteries, Rather than Cerebral Small Vessel Disease, Contribute to Early Neurological Deterioration in Stroke Patients with Intracranial Branch Atheromatous Disease

INTRODUCTION

Intracranial branch atheromatous disease (BAD) has been applied to occlusions that occur at the origin of large caliber penetrating arteries due to the microatheromas or large parent artery plaques. This study aimed to explore the association between culprit plaques of large parent arteries, neuroimaging markers of cerebral small vessel disease (CSVD), and the risk of early neurological deterioration (END) in stroke patients with BAD.

METHODS

A total of 97 stroke patients with BAD in the vascular territories of the lenticulostriate arteries or paramedian pontine arteries, diagnosed using high-resolution magnetic resonance imaging, were prospectively recruited in this observational study. A culprit plaque in the middle cerebral artery was defined as the only arterial plaque on the ipsilateral side of an infarction visible on diffusion-weighted imaging. A culprit plaque in the basilar artery (BA) was identified when it was observed within the same axial slices of an infarction or on the adjacent upper or lower slice, whereas a plaque within the BA located in the ventral region was considered non-culprit. If more than one plaque was present in the same vascular territory, the most stenotic plaque was chosen for the analysis. Four CSVD neuroimaging markers, including white matter hyperintensity, lacunes, microbleeds, and enlarged perivascular spaces, were evaluated in accordance with the total CSVD score. The associations between neuroimaging features of lesions within large parent arteries, neuroimaging markers of CSVD, and the risk of END in stroke patients with BAD were investigated using logistic regression analysis.

RESULTS

END occurred in 41 stroke patients (42.27%) with BAD. The degree of large parent artery stenosis (p < 0.001), culprit plaques of large parent arteries (p < 0.001), and plaque burden (p < 0.001) were significantly different between the END and non-END groups in stroke patients with BAD. In logistic regression analysis, culprit plaques of large parent arteries (odds ratio, 32.258; 95% confidence interval, 4.140-251.346) were independently associated with the risk of END in stroke patients with BAD.

CONCLUSIONS

Culprit plaques of large parent arteries could predict the risk of END in stroke patients with BAD. These results suggest that lesions in the large parent arteries, rather than damage to the cerebral small vessels, contribute to END in stroke patients with BAD.

The neutrophil-to-lymphocyte ratio is an important indicator correlated to early neurological deterioration in single subcortical infarct patients with diabetes

Background and purpose

This study aimed to investigate the relationship between neutrophil-to-lymphocyte ratio (NLR) and early neurological deterioration (END) among cases suffering from single subcortical infarction (SSI) and diabetes.

Methods

We collected the data of patients with SSI admitted to our hospital between January 2019 and December 2020 retrospectively. A score of ≥2 elevations in overall National Institutes of Health Stroke Scale (NIHSS) score or ≥1 increase in motor NIHSS score in 5-day post-admission was considered END. Furthermore, logistic regression was used to analyze the relationship between NLR and END among SSI cases.

Results

Altogether, we enrolled 235 consecutive SSI cases, of which 53 (22.5%) were diagnosed with END, while 93 (39.5%) were diabetic. In patients with diabetes, the value of NLR increased markedly among the patients with END (median, 3.59; IQR, 2.18–4.84) compared to patients without END (median, 2.64; IQR, 1.89–3.18; P = 0.032). Meanwhile, in patients without diabetes, NLR was not significantly associated with END. In the multivariate analysis, NLR values were positively related to END (adjusted odds ratio (OR), 1.768; 95% CI, 1.166–2.682, P = 0.007) upon adjusting age, SSI type, lesion diameter, initial NIHSS, fasting blood glucose (FBG), 2-h postprandial blood glucose (2hPBG), and estimated glomerular filtration rate (eGFR). The subgroup analysis showed that the relationship between NLR and END was more pronounced in the branch atheromatous disease (BAD) (adjusted OR, 1.819; 95% CI, 1.049–3.153, P = 0.033) and anterior SSI subgroups (adjusted OR, 2.102; 95% CI, 1.095–4.037, P = 0.026).

Conclusion

NLR value was significantly related to END among SSI patients with diabetes and was recognized as an independent factor in predicting the risk of END.

Branch atheromatous disease and treatment

Branch atheromatous disease (BAD) is a subtype of ischemic stroke caused by perforating arteries occlusion due to proximal atherosclerosis of the arteries. Early neurological deterioration and recurrent stereotyped transient ischemic attacks are typical clinical manifestations of BAD. The optimal treatment for BAD has not been determined. This article explores a possible mechanism of BAD and effective treatment measures to prevent early progression and attack of transient ischemic events. This article explains the current status of intravenous thrombolysis, tirofiban, and argatroban for BAD and subsequent prognosis.

Risk factors for early neurological deterioration in acute isolated pontine infarction without any causative artery stenosis

BACKGROUND

This study aimed to investigate the risk predictors for early neurological deterioration (END) in isolated acute pontine infarction without any causative artery stenosis.

METHODS

In this retrospective study, patients with isolated acute pontine infarction within 72 h of symptom onset were enrolled between October 2017 and December 2021. END was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score ≥ 2 points within the first week postadmission. Patients were divided into the END and the non-END groups. Multiple logistic regression analysis was used to evaluate independent predictors of END in patients with isolated acute pontine infarction.

RESULTS

A total of 153 patients were included in the final study (62 females; mean age, 67.27 ± 11.35 years), of whom 28.7% (47 of 153) experienced END. Multiple logistic regression analyses showed that infarct volume (adjusted odds ratio [aOR], 1.003; 95% CI, 1.001-1.005; P = 0.002) and basilar artery branch disease  (aOR, 3.388; 95% CI, 1.102-10.417; P = 0.033) were associated with END. The combined ROC analysis of the infarct volume and basilar artery branch disease for predicting END showed that the sensitivity and specificity were 80.9% and 72.6%, respectively.

CONCLUSION

Basilar artery branch disease and infarct volume were associated with END in acute isolated pontine infarction and may be useful prognostic factors for neurological progression.

Carotid Siphon Calcification Predicts the Symptomatic Progression in Branch Artery Disease With Intracranial Artery Stenosis

Arterial calcification in the aortic arch, carotid bifurcation, or siphon on computed tomography was associated with cardiovascular disease. The association between arterial calcification prevalence and progression of branch atheromatous disease (BAD) in intracranial artery atherosclerosis was little investigated.

Elevated ESRS, serum FIB, Hcy and stroke history were independent risk factors to PAIS

Background: The aim of this study was to investigate the diagnostic performance of serum homocysteine (Hcy) and Essen stroke risk score (ESRS) in prediction of progressing acute ischemic stroke (PAIS).

Methods One hundred and thirty two acute ischemic stroke (AIS) patients were retrospectively recruited from Daping Hospital, Third Military Medical University from February 2016 to January 2018. The 132 AIS patients were divided into PAIS and non-progressing AIS (NPAIS) groups according to the definition of PAIS. The clinical characteristics, serum Hcy concentration, and ESRS were compared between the PAIS and NPAIS groups. The independent risk factors for PAIS were evaluated by logistic regression analysis. The prediction sensitivity, specificity and area under the ROC curve (AUC) of serum Hcy and ESRS for PAIS were calculated using STATA11.0 software.

Results: The elevated ESRS (OR=1.82, p<0.05), serum fibrinogen (FIB) (OR=1.18, p<0.05), Hcy (OR=1.21, p<0.05) and personal stroke history (OR=1.74, p<0.05) were independent risk factors for PAIS. The serum Hcy of the PAIS and NPAIS groups were 24.59±9.24 (μmol/L) and 18.20±8.29 (μmol/L) respectively with a statistical significance of p<0.05. The ESRS were 3.43±1.09 and 2.60±0.92 for the PAIS and NPAIS groups respectively, with a significance of p<0.05. The prediction sensitivity, specificity and AUC were 76.24%, 67.74% and 0.73 (95%CI:0.63-0.83), respectively, for serum Hcy. For ESRS, the prediction sensitivity, specificity and AUC were 69.99%, 64.52% and 0.74 (95%CI:0.63-0.84) respectively. Correlation between serum Hcy and ESRS was evaluated by a Pearson correlation test. Significant positive correlation between serum Hcy and ESRS was found in PAIS (r=0.54, p<0.05), and NPAIS patients (r=0.78, p<0.01).

Conclusion: Patients with elevated ESRS, serum FIB, Hcy and stroke history had an elevated risk of developing PAIS.

Characteristics of paramedian pontine arteries disease and its association with hemoglobinA1c

Objectives

The association of branch atherosclerotic disease (BAD) and diabetes mellitus (DM) in the territory of posterior circulation is rarely discussed. Intracranial BAD was divided into two different types: paramedian pontine arteries (PPA) disease (PPD) and lenticulostriate arteries (LSA) disease. The goal of the study was to evaluate the clinical characteristics of PPD and its association with hemoglobinA1c (HbA1c) in China.

Materials and Methods

Radiologically confirmed PPD was defined as an isolated unilateral infarction extending to the ventral surface of the pons. Small deep cerebral infarctions are usually caused by two different pathological changes of arteries: BAD and lipohyalinotic degeneration (LD). We compared the vascular risk factors between BAD and LD in PPA territory. A total of 159 stroke patients were analyzed (PPD, n = 75; LD, n = 84). Patients with PPD were also categorized into two groups according to follow-up modified Rankin Scale (FmRS) scores. Logistic regression analyses were used for the evaluation of independent risk factors of PPD and prognosis.

Results

Comparison between PPD and LD revealed statistical significance in fasting glucose, HbA1c, estimated glomerular filtration rate (eGFR), and uric acid (p = .011, p = .005, p = .027, p = .018, respectively). Compared with LD, PPD was only related to HbA1c (p = .011) in logistic regression analysis. There were statistically significant differences between the two groups based on the stratification of FmRS scores in fasting glucose, HbA1c, homocysteine, eGFR, and the occurrence of DM. After multivariate analysis, only HbA1c was related with poor prognosis of PPD (p = .002).

Conclusions

The subtypes and prognosis of small deep brain infarcts are significantly influenced by elevated HbA1c level in PPA territory. DM might play an important role in the pathogenesis of PPD.

Mean Platelet Volume Is Associated with Early Neurological Deterioration in Patients with Branch Atheromatous Disease: Involvement of Platelet Activation

BACKGROUND

The most attentive clinical problem in patients with branch atheromatous disease (BAD) is early neurological deterioration (END). Although the platelet activation (PA) is involved in pathogenesis, the relationship between PA and END has remained unclear. We investigated clinical data including mean platelet volume (MPV, fL) as a marker for PA to identify clinically useful biomarkers for END.

METHODS

A total of 64 patients with BAD were investigated retrospectively, and divided into 2 groups based on whether neurologic symptoms deteriorated or not: BAD with and without END (END and non-END). The END was defined as patients with point increase of 1 or greater in the National Institutes of Health Stroke Scale (NIHSS); non-END was defined as those without such increase. Clinical features such as NIHSS, modified Rankin scale (mRS), laboratory data including MPV, lesion size (LS, mm) on admission, and treatments were compared between the 2 groups.

RESULTS

Of 64 patients, 17 cases had an END. The median values of NIHSS, mRS, MPV, and LS on admission were significantly greater in END than in non-END (P < .05, respectively). There was no correlation of MPV with NIHSS, mRS and LS, respectively. The median values of MPV were significantly higher in END than in non-END and control (P < .05, respectively). A receiver operating characteristic curve indicated a value of 10.1 as cutoff level for MPV to discriminate between END and non-END.

CONCLUSIONS

High MPV values on admission may be an independent biomarker for END. Physicians should pay more careful attention to END in BAD showing MPV values higher than 10.1 on admission.

An Elevated High-Sensitivity C-Reactive Protein Level Is Associated with Unfavorable Functional Outcomes of Small-Artery Occlusion in Patients without Diabetes

BACKGROUND

High-sensitivity C-reactive protein (hs-CRP) is associated with a risk of causing diabetes mellitus and ischemic stroke. However, the association between hs-CRP levels and functional outcome after small-artery occlusion (SAO) is unknown.

METHODS

Data for 836 patients diagnosed with SAO were collected from the Department of Neurorehabilitation of Huanhu Hospital. Hs-CRP values were classified according to quartiles (<0.67, 0.67 to <1.46, 1.46 to <3.46, and ≥3.46 mg/L). We examined the relationship between hs-CRP levels on admission and modified Rankin Scale (mRS) scores using univariate and multivariate analyses. We further performed subgroup analyses of patients with and without diabetes.

RESULTS

Patients in the highest hs-CRP quartile had a significantly higher risk of an unfavorable outcome. In the non-diabetes subgroup, the elevated hs-CRP quartiles were associated with higher mRS scores. In the diabetes subgroup, no statistically significant association was observed between hs-CRP levels and mRS.

CONCLUSIONS

Elevated hs-CRP level on admission was associated with a poor functional outcome 3 months after SAO, especially among nondiabetes patients. However, no significant associations were observed in patients with diabetes.

Lipid and hyperglycemia factors in first-ever penetrating artery infarction, a comparison between different subtypes

BACKGROUND

The pathogenesis and progression of branch atheromatous disease (BAD), which differs from lipohyalinotic degeneration (LD), remains controversial. Few studies have investigated the lipid indices and glycometabolism status factors for BAD in first-ever penetrating artery infarction (PAI).

METHODS

We retrospectively examined acute stroke patients with PAI admitted within 3 days after stroke. All patients underwent diffusion weight magnetic resonance imaging (DWI) and magnetic resonance angiography (MRA) and/or computed tomography angiography (CTA). Progression was defined as an increase by 2 point or higher in the National Institutes of Health Stroke Scale score. The characteristics, clinical data were statistically analyzed.

RESULTS

BAD and LD were diagnosed in 142 (57%) and 107 (43%) patients, respectively. Patients with BAD had higher low-density lipoprotein cholesterol (LDL-C) compared with those with LD (p = .013). Elevated LDL-C was related to early neurological deterioration in patients with BAD (p = .045). The percentage of lenticulostriate arterial (LSA) infarction was greater than that of the pontine penetrating arterial (PPA) infarction in acute PAI (75.1% vs. 24.9%; p < .001). PPA infarction was more prevalent in the BAD group compared with the LD group (34.5% vs. 12.1%, p < .001). The PPA infarction had older age at onset and higher HbA1c concentrations than those with the LSA infarction (p = .014, p = .036 respectively) in the BAD and LD patients, respectively.

CONCLUSION

LDL-C may be associated with both the pathogenesis and progression of intracranial BAD. The LSA infarction was the most frequently subtypes in PAI. Age at onset and HbA1c seem to be closely associated with the PPA infarction of first-ever PAI.

The Impact of Homocysteine, Vitamin B12, and Vitamin D Levels on Functional Outcome after First-Ever Ischaemic Stroke

We explored the relationship between acute ischaemic stroke (IS) early functional outcome and serum levels of homocysteine, vitamin B12, and D in a noninterventional prospective clinical study. We enrolled 50 patients with first-ever IS and performed laboratory tests and functional assessment at three time points: on admission and three and six months after stroke. Modified Rankin Scale (mRS), NIHSS scale, and Barthel index (BI) scores were assessed in all participants by trained examiner blinded to laboratory data. Patients did not receive treatment that might alter laboratory data. Admission NIHSS correlated with homocysteine levels (r = 0.304, p < 0.05), B12 level (r = −0.410, p < 0.01), and vitamin D levels (r = −0.465, p < 0.01). Functional outcome measures (BI and mRS) did not significantly correlate with homocysteine and vitamin D3 levels at 3 and 6 months. However, a positive correlation with vitamin B12 levels was detected for BI both at 3 and 6 months and mRS at 6 months. Higher serum vitamin B12 levels were associated with better functional outcome at follow-up.

A retrospective study of branch atheromatous disease: Analyses of risk factors and prognosis

The theory of branch atheromatous disease (BAD) has been commonly underused in clinical practice and research since it was proposed in 1989. In this study, we sought to explore clinical characteristics of its substypes and biomarkers for prognosis of BAD. A total of 176 consecutive patients with BAD were classified into two groups: paramedianpontine artery group (PPA group, n=70) and lenticulostriate artery group (LSA group, n=106). Bivariate analyses were used to explore the relationship between white matter hyperintensities (WMHs), National Institutes of Health Stroke Scale (NIHSS) scores and prognosis evaluated by the modified Rank Scale (mRS) at 6th month after stroke. The differences in prevalence of diabetes mellitus and a history of ischemic heart disease were statistically significant between PPA group and LSA group (χ 2=8.255, P=0.004; χ 2=13.402, P<0.001). The bivariate analyses demonstrated a positive correlation between NIHSS and poor prognosis in patients with BAD and in the two subtype groups, and a positive correlation between WMHs and poor prognosis in the PPA group. It is concluded that a significantly higher prevalence of diabetes mellitus and a history of ischemic heart disease exist in the PPA group than in the LSA group. In addition, high grades of NIHSS scores imply poor prognosis in patients with BAD and in the two subtype groups. Moreover, WMHs are a positive predictor for poor prognosis in patients in the PPA group.

Blood/Brain Biomarkers of Inflammation After Stroke and Their Association With Outcome: From C-Reactive Protein to Damage-Associated Molecular Patterns

Stroke represents one of the most important causes of disability and death in developed countries. However, there is a lack of prognostic tools in clinical practice to monitor the neurological condition and predict the final outcome. Blood biomarkers have been proposed and studied in this indication; however, no biomarker is currently used in clinical practice. The stroke-related neuroinflammatory processes have been associated with a poor outcome in stroke, as well as with poststroke complications. In this review, we focus on the most studied blood biomarkers of this inflammatory processes, cytokines, and C-reactive protein, evaluating its association with outcome and complications in stroke through the literature, and performing a systematic review on the association of C-reactive protein and functional outcome after stroke. Globally, we identified uncertainty with regard to the association of the evaluated biomarkers with stroke outcome, with little added value on top of clinical predictors such as age or stroke severity, which makes its implementation unlikely in clinical practice for global outcome prediction. Regarding poststroke complications, despite being more practical scenarios in which to make medical decisions following a biomarker prediction, not many studies have been performed, although there are now some candidates for prediction of poststroke infections. Finally, as potential new candidates, we reviewed the pathophysiological actions of damage-associated molecular patterns as triggers of the neuroinflammatory cascade of stroke, and their possible use as biomarkers.

The Relationship between C-Reactive Protein Level and Discharge Outcome in Patients with Acute Ischemic Stroke

Previous studies showed that C-reactive protein (CRP), an inflammatory marker, was associated with stroke severity and long-term outcome. However, the relationship between the acute-phase CRP level and discharge outcome has received little attention. We prospectively studied 301 patients with acute ischemic stroke (over a period of two weeks) from two hospital stroke wards and one rehabilitation department in Henan, China. Patients’ demographic and clinical data were collected and evaluated at admission. Poor discharge outcome was assessed in patients at discharge using the Modified Rankin Scale (MRS > 2). Multivariate logistic regression analysis was performed to determine the risk factors of poor discharge outcome after adjusting for potential confounders. Poor discharge outcome was observed in 78 patients (25.9%). Univariate analyses showed that factors significantly influencing poor discharge outcome were age, residence, recurrent acute ischemic stroke, coronary heart disease, the National Institutes of Health Stroke Scale (NIHSS) score at admission, non-lacunar stroke, time from onset of stroke to admission, CRP, TBIL (total bilirubin), direct bilirubin (DBIL), ALB (albumin), FIB (fibrinogen) and D-dimer (p < 0.05). After adjusting for age, residence, recurrent ischemic stroke, coronary heart disease, NIHSS score at admission, lacunar stroke, time from onset of stroke to admission, CRP, TBIL, DBIL, ALB, FIB and D-dimer, multivariate logistic regression analyses revealed that poor outcome at discharge was associated with recurrent acute ischemic stroke (OR, 2.115; 95% CI, 1.094–4.087), non-lacunar stroke (OR, 2.943; 95% CI, 1.436–6.032), DBIL (OR, 1.795; 95% CI, 1.311–2.458), and CRP (OR, 4.890; 95% CI, 3.063–7.808). In conclusion, the CRP level measured at admission was found to be an independent predictor of poor outcome at discharge. Recurrent acute ischemic stroke, non-lacunar stroke and DBIL were also significantly associated with discharge outcome in acute ischemic stroke.

Carotid artery intima-media thickness associated with prognosis of intracranial branch atheromatous disease

BACKGROUND AND PURPOSE

Small deep brain infarcts are often caused by two different vascular pathologies: branch atheromatous disease (BAD) and lipohyalinotic degeneration (LD). In this study, we compare the clinical characteristics of BAD and LD and investigate the role of C-reactive protein (CRP), homocysteine (Hcy), and carotid artery intima-media thickness (IMT) in the prognosis of patients with BAD and LD.

METHODS

Of 262 adult patients with small deep infarcts, 104 were considered BAD and 158 were considered LD. Data compared included clinical information, prevalence of lacune and leukoaraiosis, Hcy, CRP, carotid artery IMT, deterioration during admission, and recurrence of ischemic stroke (IS) within 1 year.

RESULTS

Patients with LD have severe leukoaraiosis and higher prevalence of lacune and intracerebral hemorrhage compared with those with BAD. Patients with BAD have higher initial National Institutes of Health Stroke Scale scores and incidence of progressive motor deficits compared with those with LD; CRP is associated with the progression in both groups. There is no statistical difference of recurring risk of IS within 1 year between the two groups; by multivariable logistic regression analysis, carotid artery IMT was an independent risk factor for recurrence of IS in 1 year in patients with BAD.

CONCLUSION

BAD as an independent clinical entity has different clinical and radiological characteristics compared with LD. Carotid artery IMT is an independent risk factor for recurrence of IS in patients with BAD.

Infarct Size May Distinguish the Pathogenesis of Lacunar Infarction of the Middle Cerebral Artery Territory

Background

Lacunar infarctions are caused by small vessel disease (SVD) and branch atheromatous disease (BAD). Lacunar infarction may be classified as proximal vessel lacunar infarction (BAD) or distal vessel lacunar infarction (SVD) according to its location within the middle cerebral artery (MCA) territory in patients with normal MCA. Studies found that the lenticulostriate arteries may exist different ways and that the size of lacunar infarction may be dependent on the branching order. We investigated whether lacunar infarction size can differentiate between SVD and BAD in patients with normal MCA.

Material/Methods

We retrospectively studied 312 patients with lacunar infarction who had normal MCA on MR angiography. We found the normal flow void of the MCA on MR T2-weighted images, and the same layer on DWI was considered the level 0. The median of lowest layer of infarction lesions and the mean of lesion size were considered the cutoff point. We divided lacunar infarction into 2 groups according to cutoff point of lesion location and size. Data compared between the 2 groups included clinical information, radiography, and National Institutes of Health Stroke Scale score.

Results

Of all the 312 patients, the median of lowest layer of infarction lesions was the 3^rd level. Compared to patients with BAD, according to infarct location, patients with SVD were older, more often had a history of hypertension and smoking, and had more severe leukoaraiosis and smaller infarct lesions. The mean length of lesions was 11.1 mm on DWI images. Patients with SVD, according to infarct size, had lower NIHSS scores at admission. The mean lesion height was 12.26 mm on FLAIR images. Patients with SVD were more often male, had higher prevalence of smoking, and had more severe leukoaraiosis and lower NIHSS scores at admission. The lacunar infarction diameter on DWI and FLAIR images was negatively correlated with the level of lowest layer of infarction lesions.

Conclusions

Our data suggest that infarct lesion size may be used as a method to distinguish SVD and BAD in lacunar infarction patients with normal MCA.

Comparative analysis of general characteristics of ischemic stroke of BAD and non-BAD CISS subtypes

Based on the recently proposed Chinese ischemic stroke subclassification (CISS) system, intracranial branch atheromatous disease (BAD) is divided into large artery atherosclerosis (LAA) and penetrating artery disease (PAD). In the current retrospective analysis, we compared the general characteristics of BAD-LAA with BAD-PAD, BAD-LAA with non-BAD-LAA and BAD-PAD with non-BAD-PAD. The study included a total of 80 cases, including 45 cases of BAD and 35 cases of non-BAD. Subjects were classified using CISS system: BAD-LAA, BAD-PAD, non-BAD-LAA and non-BAD-PAD. In addition to analysis of general characteristics, the correlation between the factors and the two subtypes of BAD was evaluated. The number of cases included in the analysis was: 32 cases of BAD-LAA, 13 cases of BAD-PAD, 21 cases of non-BAD-LAA, and 14 cases of non-BAD-PAD. Diabetes mellitus affected more non-BAD-LAA patients than BAD-LAA patients (P=0.035). In comparison with non-BAD-PAD, patients with BAD-PAD were younger (P=0.040), had higher initial NIHSS score (P<0.001) and morbidity of ischemic heart disease (P=0.033). Within patients with BAD, the PAD subtype was associated with smoking (OR=0.043; P=0.011), higher low-density lipoprotein (OR=5.339; P=0.029), ischemic heart disease (OR=9.383; P=0.047) and diabetes mellitus (OR=12.59; P=0.020). It was concluded that large artery atherosclerosis was the primary mechanism of BAD. The general characteristics showed no significant differences between the CISS subtypes of LAA and PAD within BAD, as well as between the BAD and non-BAD within LAA subtype. Several differences between PAD subtypes of BAD and non-BAD were revealed.