Optimizing the Definitions of Stroke, Transient Ischemic Attack, and Infarction for Research and Application in Clinical Practice

Retrospective Analysis of a Novel Grading System for Evaluating the Long-Term Benefit of Revascularization on Carotid Artery Stenosis

BACKGROUND

To estimate revascularization benefit for carotid artery stenosis, with a novel grading system containing symptoms, stenosis, plaque, and collateral compensation (SSPC grading system).

METHODS

A retrospective multicenter study examined 945 consecutive patients diagnosed with carotid stenosis from January 2013 to December 2017. The cohort was classified into 2 groups: the revascularization group and the best medical therapy (BMT) group. Demographic, clinical, and lesion characteristics of all patients were recorded and 5-year nonprocedural stroke survival was calculated using Kaplan-Meier curve analyses.

RESULTS

Of the 945 patients, 514 underwent carotid revascularization (483 for carotid endarterectomy and 31 for transfemoral-carotid artery stenting) and 431 patients were treated with BMT. Patients in the revascularization group had a significantly higher proportion of preprocedural stroke/transient ischemic attack (TIA) and grades of stenosis. Of the patients in the revascularization group, 3.1% were classified as SSPC I, 10.3% as SSPC II, 41.4% as SSPC III, and 45.1% as SSPC IV. Meanwhile, 17.9% were classified as SSPC I, 19.7% as SSPC II, 49.2% as class III, and 13.2% had class IV in the BMT group. Procedural stroke developed in 13 patients (2.5%) following revascularization (10 of them were non-disabling). The overall rate of freedom from any nonprocedural stroke was 94.1 ± 1.1% in the revascularization group and 89.5 ± 1.6% in the BMT group (P = 0.01). Subgroup analysis was conducted for asymptomatic carotid stenosis (ACS) and carotid near-occlusion (CNO) patients. Nonsignificance was noted in the rate of freedom from any nonprocedural stroke between revascularization and BMT in both ACS and CNO subgroups (P = 0.09 and 0.12, respectively). Of note, in ACS patients graded as SSPC III, a significant difference in stroke survival was found between the revascularization and BMT group (96.0 ± 2.0% vs. 89.1 ± 2.4%, P = 0.04). Meanwhile, in symptomatic CNO patients, similar results were found regarding SSPC classification (94.8 ± 3.6% vs. 63.8 ± 14.9%, P = 0.01).

CONCLUSIONS

The SSPC grading system stratifies the patients with carotid artery stenosis and predicts the long-term benefits of revascularization. Meanwhile, potential revascularization benefits could be better attained via SSPC classes in specific patients with ACS and CNO.

Next-generation transcarotid artery revascularization: TransCarotid flOw Reversal Cerebral Protection And CGUARD MicroNET-Covered Embolic Prevention Stent System To Reduce Strokes - TOPGUARD Study

BACKGROUND

Stent-assisted carotid artery revascularization employing surgical cutdown for transcervical access and dynamic flow reversal (TCAR) is gaining popularity. TCAR, despite maximized intra-procedural cerebral protection, shows a marked excess of 30-day neurologic complications in symptomatic vs. asymptomatic stenoses. The TCAR conventional single-layer stent (free-cell area 5.89mm2) inability to seal embologenic lesions may be particularly relevant after the flow reversal neuroprotection is terminated.

METHODS

We evaluated peri-procedural and 30-day major adverse cerebral and cardiac events (MACCE) of TCAR (ENROUTE, SilkRoad Medical) paired with MicroNET-covered neuroprotective stent (CGuard, InspireMD) in consecutive patients at elevated risk of complications with transfemoral/transradial filter-protected stenting (increased lesion-related and/or access-related risk). CGuard (MicroNET free cell area ≈0.02-0.03 mm2) has level-1 evidence for reducing intra- and abolishing post-procedural lesion-related cerebral embolism.

RESULTS

One hundred and six increased-risk patients (age 72 [61-76] years, median [Q1-Q3]; 60.4% symptomatic, 49.1% diabetic, 36.8% women, 61.3% left-sided index lesion) were enrolled in three vascular surgery centers. Angiographic stenosis severity was 81 (75-91)%, lesion length 21 (15-26)mm, increased-risk lesional characteristics 87.7%. Study stent use was 100% (no other stent types). 74.5% lesions were predilated; post-dilatation rate was 90.6%. Flow reversal duration was 8 (5-11)min. One stroke (0.9%) occurred in an asymptomatic patient prior to establishing neuroprotection (index lesion disruption with the sheath insertion wire); there were no other peri-procedural MACCE. No further adverse events occurred by 30-days. 30-day stent patency was 100% with normal velocities and absence of any in-stent material by Duplex Doppler.

CONCLUSIONS

Despite a high proportion of increased-risk lesions and clinically symptomatic patients in this study, TCAR employing the MicroNET-covered anti-embolic stent showed 30-day MACCE rate <1%. This suggests a clinical role for combining maximized intra-procedural prevention of cerebral embolism by dynamic flow reversal with anti-embolic stent prevention of peri- and post-procedural cerebral embolism (TOPGUARD NCT04547387).

ABCD2-I Score Predicts Unplanned Emergency Department Revisits within 72 Hours Due to Recurrent Acute Ischemic Stroke

BACKGROUND

the ABCD2 score is valuable for predicting early stroke recurrence after a transient ischemic attack (TIA), and Doppler ultrasound can aid in expediting stroke triage. The study aimed to investigate whether combining the ABCD2 score with carotid duplex results can enhance the identification of early acute ischemic stroke after TIA.

METHODS

we employed a retrospective cohort design for this study, enrolling patients diagnosed with TIA who were discharged from the emergency department (ED). The modified ABCD2-I (c50) score, which incorporates a Doppler ultrasound assessment of internal carotid artery stenosis > 50%, was used to evaluate the risk of acute ischemic stroke within 72 h. Patients were categorized into three risk groups: low risk (with ABCD2 and ABCD2-I scores = 0-4), moderate risk (ABCD2 score = 4-5 and ABCD2-I score = 5-7), and high risk (ABCD2 score = 6-7 and ABCD2-I score = 8-9).

RESULTS

between 1 January 2014, and 31 December 2019, 1124 patients with new neurological deficits were screened, with 151 TIA patients discharged from the ED and included in the analysis. Cox proportional hazards analysis showed that patients in the high-risk group, as per the ABCD2-I (c50) score, were significantly associated with revisiting the ED within 72 h due to acute ischemic stroke (HR: 3.12, 95% CI: 1.31-7.41, p = 0.0102), while the ABCD2 alone did not show significant association (HR: 1.12, 95% CI: 0.57-2.22, p = 0.7427).

CONCLUSION

ABCD2-I (c50) scores effectively predict early acute ischemic stroke presentations to the ED within 72 h after TIA.

Expression of Tie2 (angiopoietin receptor) on the monocyte subpopulations from ischemic stroke patients: Histological and flowcytometric studies

INTRODUCTION

Different subpopulations of monocytes play roles in phagocytosis, inflammation, and angiogenic processes e.g., Tie2-expressing monocytes (TEMs). The brain is flooded with macrophages that are derived from monocytes within 3-7 days after a stroke. This study aimed to determine the expression level of Tie2 (an angiopoietin receptor) on monocytes and their subpopulations in ischemic stroke patients using the histological and immunohistological study of bone marrow biopsies and blood flow cytometry examination.

METHODS

Ischemic stroke patients within two days were selected. Participants in the control group were healthy volunteers of matched age and gender. Sample collection was performed within 24 to 48 hours after medical consultants confirmed the stroke diagnosis. An iliac crest bone marrow biopsy was obtained and fixed for histological and immunohistological staining with antiCD14 and antiCD68. Flow cytometry was used to determine the total monocyte population, monocyte subpopulations, and TEMs after staining with monoclonal antibodies to CD45, CD14, CD16, and Tie2.

RESULTS

Post-stroke patients' bone marrow cells were hypercellular. There was an apparent increase in CD68 and CD14-positive cells. Ischemic stroke patients exhibited low percentages of nonclassical monocytes CD14lowCD16++, with an increase in intermediate monocytes CD14highCD16+. Moreover, ischemic stroke patients had significantly higher levels of TEMs than control group.

CONCLUSIONS

The results of this study demonstrate dysregulation of angiogenesis in monocyte subsets in ischemic stroke patients, which could be used as an early diagnostic marker of neurovascular damage and may need angiogenic therapy or improved medications to prevent further damage of blood vessels.

Role of carotid duplex in the assessment of carotid artery restenosis after endarterectomy or stenting

Introduction

Redo carotid endarterectomy (CEA) and carotid stenting (CAS) are often performed when there is evidence of post-procedural restenosis. The incidence of restenosis after carotid reconstruction is not negligible, ranging from 5 to 33%. The diagnosis of significant internal carotid artery (ICA) restenosis is usually based on duplex ultrasound (US) criteria, mostly on peak-systolic flow velocity (PSV). However, there have been no generally accepted duplex US criteria for carotid restenosis after CAS or CEA.

Methods

In this systematic review, the PubMed/ Medline and Scopus databases were screened to find trials that reported duplex US criteria for significant restenosis after CEA and/or CAS. Only those reports were analyzed in which the restenoses were also assessed by CT/MR or digital subtraction angiography as comparators for duplex US.

Results

Fourteen studies met the predetermined search criteria and were included in this review. In most studies, PSV thresholds for significant in-stent ICA restenosis after CAS were higher than those for significant stenosis in non-procedurally treated (native) ICA. Many fewer studies investigated the US criteria for ICA restenosis after CEA. Despite the heterogeneous data, there is a consensus to use higher flow velocity thresholds for assessment of stenosis in stented ICA than in native ICA; however, there have been insufficient data about the flow velocity criteria for significant restenosis after CEA. Although the flow velocity thresholds for restenosis after CAS and CEA seem to be different, the large studies used the same duplex criteria to define restenosis after the two procedures. Moreover, different studies used different flow velocity thresholds to define ICA restenosis, leading to variable restenosis rates.

Discussion

We conclude that (1) further examinations are warranted to determine appropriate duplex US criteria for restenosis after CAS and CEA, (2) single duplex US parameter cannot be used to reliably determine the degree of ICA restenosis, (3) inappropriate US criteria used in large studies may have led to false restenosis rates, and (4) studies are required to determine if there is a benefit from redo carotid artery procedure, such as redo-CEA or redo-CAS, starting with prospective risk stratification studies using current best practice non-invasive care alone.

Neuroimaging biomarkers of cognitive recovery after ischemic stroke

Post-stroke cognitive impairment affects more than one-third of patients after an ischemic stroke (IS). Identifying markers of potential cognitive recovery after ischemic stroke can guide patients' selection for treatments, enrollment in clinical trials, and cognitive rehabilitation methods to restore cognitive abilities in post-stroke patients. Despite the burden of post-stroke cognitive impairment, biomarkers of cognitive recovery are an understudied area of research. This narrative review summarizes and critically reviews the current literature on the use and utility of neuroimaging as a predictive biomarker of cognitive recovery after IS. Most studies included in this review utilized structural Magnetic Resonance Imaging (MRI) to predict cognitive recovery after IS; these studies highlighted baseline markers of cerebral small vessel disease and cortical atrophy as predictors of cognitive recovery. Functional Magnetic Resonance Imaging (fMRI) using resting-state functional connectivity and Diffusion Imaging are potential biomarkers of cognitive recovery after IS, although more precise predictive tools are needed. Comparison of these studies is limited by heterogeneity in cognitive assessments. For all modalities, current findings need replication in larger samples. Although no neuroimaging tool is ready for use as a biomarker at this stage, these studies suggest a clinically meaningful role for neuroimaging in predicting post-stroke cognitive recovery.

Caregiver Burden in Caregivers of Stroke Survivors: A Hospital-Based Study

Background

A principal caregiver (CG) is directly affected by the patient's health problems leading to CG strain. In the present study, we evaluated the different factors related to increased CG burden in stroke survivors and assessed the relationship between patient's personal and clinical characteristics and CG's stress.

Material and Methods

In this prospective, follow-up study, a total of 141 principle CGs of 164 First-ever stroke (FES) survivors were subjected to the Caregivers Strain Index (CSI) and Oberst Caregiving Burden Scale (OCBS) at 30 days (n = 141), 90 days (n = 129), and 6 months (n = 119) after informed consent. Patients were subjected to modified Rankin Scale (mRS) and Barthel index score assessment at the end of 30 days.

Results

The mean age of CG was 49.8 ± 21.0 years, approximately 20 years lesser than that of the patients. 102 (72.34%) CGs were females. Urinary incontinence (p < 0.006) morbidity at 30 days, mRS (p = 0.004), and moderate to the severe neurological deficit on admission (p = 0.003) were the patient factors in FES cases leading to significant CGs stress. CG factors responsible for major stress were long caregiving hours (P < 0.001), anxiety (P < 0.001), disturbed night sleep (P < 0.001), financial stress (P < 0.001), younger age (P = 0.002), and CGs being daughters-in-law (P = 0.039).

Conclusion

CG burden increases with increased severity of stroke. Integrated stroke rehabilitation services should also address CGs issues along with patients.

Stroke Scales as Assessment Tools in Emergency Settings: A Narrative Review

In the last 20 years, substantial improvements have been made in stroke recanalization treatment. Good outcomes after modern reperfusion treatment require the rapid and accurate identification of stroke patients. Several stroke rating scales are available or have been proposed for the early recognition of stroke and the evaluation of stroke severity and outcome. This review aims to provide an overview of commonly used stroke scales in emergency and clinical settings. The most commonly used scale in a prehospital setting for stroke recognition is the Face, Arms, Speech, Time (FAST) test. Among many prehospital stroke scales, the Los Angeles Prehospital Stroke Screen has the highest sensitivity and specificity for confirming stroke diagnosis. The National Institutes of Health Stroke Scale (NIHSS) is the most recommended tool for the evaluation of stroke patients in hospital settings and research, and it has two variants: the shortened NIHSS for Emergency Medical Service and the modified NIHSS. The evaluation of comatose patients usually involves assessment with the Glasgow Coma Scale, which is very useful in patients with hemorrhagic stroke or traumatic brain injury. In patients with subarachnoid hemorrhage, the outcome is usually accessed with the Hunt and Hess scale. A commonly used tool for stroke outcome evaluation in clinical/hospital settings and research is the modified Rankin scale. The tools for disability evaluation are the Barthel Index and Functional Independence Measure.

Long term survival after a first transient ischaemic attack in England: A retrospective matched cohort study

OBJECTIVE

Transient ischaemic attacks (TIA) serve as warning signs for future stroke, and the impact of TIA on long term survival is uncertain. We assessed the long-term hazards of all-cause mortality following a first episode of a transient ischaemic attack (TIA).

DESIGN

Retrospective matched cohort study.

METHODS

Cohort study using electronic primary health care records from The Health Improvement Network (THIN) database in the United Kingdom. Cases born in or before 1960, resident in England, with a first diagnosis of TIA between January 1986 and January 2017 were matched to three controls on age, sex and general practice. The primary outcome was all-cause mortality. The hazards of all-cause mortality were estimated using a time-varying Double-Cox Weibull survival model with a random frailty effect of general practice, while adjusting for different socio-demographic factors, medical therapies, and comorbidities.

RESULTS

20,633 cases and 58,634 controls were included. During the study period, 24,176 participants died comprising of 7,745 (37.5%) cases and 16,431(28.0%) controls. In terms of hazards of mortality, cases aged 39 to 60 years at the first TIA event had the highest hazard ratio (HR) of mortality compared to their 39-60 years matched controls (HR = 3.04 (2.91 - 3.18)). The HR for cases aged 61-70 years, 71-76 years and 77+ years were 1.98 (1.55 - 2.30), 1.79 (1.20 - 2.07) and 1.52 (1.15 - 1.97) compared to their same-aged matched controls. Cases aged 39-60 at TIA onset who were prescribed aspirin were associated with reduced HR of 0.93 (0.84 - 1.01), 0.90 (0.82 - 0.98) and 0.88 (0.80 - 0.96) at 5, 10 and 15 years respectively, compared to the same aged cases who were not prescribed any antiplatelet. Statistically significant reductions in hazard ratios were observed with aspirin at 10 and 15 years in all age groups. Hazard ratio point estimates for other antiplatelets (dipyridamole or clopidogrel) and dual antiplatelet therapy were very similar to aspirin at 5, 10 and 15 years but with wider confidence intervals that included 1. There was no survival benefit associated with antiplatelet prescription in controls.

CONCLUSIONS

The overall risk of death was considerably elevated in all age groups after a first-ever TIA event. Aspirin prescription was associated with a reduced risk. These findings support the use of aspirin in secondary prevention for people with a TIA. The results do not support the use of antiplatelet medication in people without TIA.

Efficacy of mechanical thrombectomy in stroke patients with large vessel involvement

Ischemic stroke is a common disease worldwide and leads to a significant rate of mortality and disability in patients every year, and imposes high costs on the health care system. The aim of this study was to evaluate the efficacy of the invasive method of mechanical thrombectomy for rapid intervention in ischemic stroke patients with large vessel involvement. Patients suspected of having a stroke, who were referred to Imam Hossein Hospital, were examined, and the diagnosis of stroke was confirmed. In the next stage, patients' MRS index was measured and the possibility of emergency thrombectomy was evaluated in patients. Patients who underwent thrombectomy were considered as the case group and the other patients were contemplated as the control group; then, the cases of the two groups were evaluated and compared. The mean age of patients was 66.63 ± 12.26 years. the use of emergency thrombectomy in the study group significantly reduced the MRS index of patients after 90 days (p <0.001), while a significant increase in the mean scores of the MRS index was seen in patients receiving pharmacological treatments. Also, there was no significant difference in terms of gender between the group of patients undergoing thrombectomy and the group receiving other treatments (p = 0.375). Emergency mechanical thrombectomy significantly reduces disability in stroke patients in the long term and can be a good alternative to conventional drug treatments..

Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence

Background and Purpose

Carotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, such as surgery (endarterectomy) and stenting, for lowering the stroke risk associated with carotid stenosis. Meanwhile, the improving and predominant value of medical intervention (lifestyle coaching and medication) continues to be underappreciated.

Methods and Results

This article aims to be an objective presentation and discussion of the scientific literature critical for decision making when the primary goal is to optimize patient outcome. This compilation follows from many years of author scrutiny to separate fact from fiction. Common sense conclusions are drawn from factual statements backed by original citations. Detailed research methodology is given in cited papers. This article has been written in plain language given the importance of the general public understanding this topic. Issues covered include key terminology and the economic impact of carotid stenosis. There is a summary of the evidence-base regarding the efficacy and safety of procedural and medical (non-invasive) interventions for both asymptomatic and symptomatic patients. Conclusions are drawn with respect to current best management and research priorities. Several "furphies" (misconceptions) are exposed that are commonly used to make carotid stenting and endarterectomy outcomes appear similar. Ongoing randomized trials are mentioned and why they are unlikely to identify a routine practice indication for carotid artery procedures. There is a discussion of relevant worldwide guidelines regarding carotid artery procedures, including how they should be improved. There is an outline of systematic changes that are resulting in better application of the evidence-base.

Conclusion

The cornerstone of stroke prevention is medical intervention given it is non-invasive and protects against all arterial disease complications in all at risk. The "big" question is, does a carotid artery procedure add patient benefit in the modern era and, if so, for whom?

Lessons From ACST-2

The recent 130-center, international, second ACST trial (Asymptomatic Carotid Surgery Trial) involving 3625 patients found that regardless of whether a patient underwent stenting or endarterectomy, the periprocedural risk of disabling or fatal stroke was about 1% and the 5-year estimated risk of nonprocedural disabling or fatal stroke was 2.5%. With advances in technique, technology, and patient selection, stenting done by appropriately trained and experienced operators can achieve safety and efficacy comparable to endarterectomy for asymptomatic patients. The ongoing CREST-2 trial (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) will clarify whether revascularization, by either stenting or endarterectomy, remains an important therapeutic goal in the setting of modern intensive medical therapy.

Direct Medical Cost of Stroke and the Cost-Effectiveness of Direct Oral Anticoagulants in Atrial Fibrillation-Related Stroke: A Cross-Sectional Study

BACKGROUND

Stroke has significant direct medical costs, and direct oral anticoagulants (DOACs) are better alternatives to warfarin for stroke prevention in atrial fibrillation (AF). This study aimed to determine the direct medical costs of stroke, with emphasis on AF stroke and the cost-effectiveness of DOACs among stroke patients in a tertiary hospital in Malaysia.

METHODS

This study utilised in-patient data from the case mix unit of Universiti Kebangsaan Malaysia Medical Centre (UKMMC) between 2011 and 2018. Direct medical costs of stroke were determined using a top-down costing approach and factors associated with costs were identified. Incremental cost effectiveness ratio (ICER) was calculated to compare the cost-effectiveness between DOACs and warfarin.

RESULTS

The direct medical cost of stroke was MYR 11,669,414.83 (n = 3689). AF-related stroke cases had higher median cost of MYR 2839.73 (IQR 2269.79-3101.52). Regression analysis showed that stroke type (AF versus non-AF stroke) (p = 0.013), stroke severity (p = 0.010) and discharge status (p < 0.001) significantly influenced stroke costs. DOACs were cost-effective compared to warfarin with an ICER of MYR 19.25.

CONCLUSIONS

The direct medical cost of stroke is substantial, with AF-stroke having a higher median cost per stroke care. DOACs were cost effective in the treatment of AF-related stroke in UKMMC.

Stroke and Pneumonia: Mechanisms, Risk Factors, Management, and Prevention

A stroke is a cerebrovascular medical emergency characterized by the sudden loss of neurological function due to interruption to the blood supply. A serious and common complication of stroke is pneumonia. This review article outlined various studies in order to understand the pathogenesis pathways that lead to the development of stroke-associated pneumonia, as well as therapeutic and preventive options to reduce pneumonia. The article looked for risk factors that increase the risk of developing pneumonia among stroke patients. In addition, it has reviewed various therapeutic modalities, such as postural modifications, pharmacological treatment, and other unique treatments, in an attempt to find which of them are efficient to decrease the occurrence of pneumonia and which of them are not. The article also attempts to emphasize the importance of early screening for dysphagia among stroke patients and demonstrates the importance of preventive strategies that can be easily implemented, such as routine oral care and behavioral modifications.

Stroke and Athletes: A Scoping Review

Stroke (i.e., cerebrovascular accident) affects one in 10,000 people between the ages of 14 and 45; however, very little is known about the frequency and type of stroke that occurs in athletes. The risk of injury to the neurovascular structures may depend on the type of sport involvement, although, sport-specific incidence rates are not known. Therefore, the goal of our scoping review was to provide some guidance to better inform the development of a context-fit stroke model by summarizing studies on a broad research topic related to stroke or cerebrovascular accident in sport based on a strict athlete definition. We used the guidance of Arksey and O'Malley's five-stage-process for a scoping review. Databases included MEDLINE(R) Epub Ahead of Print, In-Process & Other Non- Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), and Embase (OVID databases); CINAHL Plus with Full Text, SportDiscus with Full Text (Ebsco databases); and Scopus. Publication dates were from 1979-2020 across nine different countries resulting in 39 individual cases of stroke with an athlete age range of 14-56 years (95% male). The major inciting event(s) prior to stroke onset were headaches (38.4%), head trauma (30.7%), and neck injury and/or vertebral artery dissection (20.5%). Several sporting activities were represented with American football as the most prevalent (30.7%). In summary, we found that sports with an aspect of impact, collision, or microtrauma can lead to subsequent stroke. These sport-related traumatic events were often difficult to diagnose because of the longer interval before ischemia occurred. Therefore, health care providers should be particularly attuned to the possibility of stroke when evaluating athletes presenting with or without neurological deficit.

Hypothesis of "stroke-stop" formula: a tool for risk index determination in development of acute cerebrovascular disease in asymptomatic individuals with carotid stenosis

Background

Extracranial carotid artery disease is considered a risk factor for developing acute cerebrovascular diseases. The paper suggests the “Stroke-Stop” formula as hypothesis for the determination of the risk of developing stroke in asymptomatic individuals with carotid stenosis. The formula is based on a mathematical calculation of the major risk factors for stroke: the degree of ICA (internal carotid artery) stenosis, the morphological structure of the atherosclerotic plaque and the level of lipoprotein-associated phospholipase A2 (Lp-PLA2) concentration.

Methods

The cross sectional study included 70 patients with atherosclerotic ICA stenosis. Among vascular inflammatory markers, Lp-PLA2 was determined with concentration 252.7–328.6 mg/l. The obtained results were evaluated using descriptive statistics (the frequency, percentage ratio) as well as the one-way analysis of variance (ANOVA) and chi-square test.

Results

The risk of stroke development is eminently increasing with the progression of ICA stenosis and elevation of Lp-PLA2 levels. In patients with echolucent plaque, the risk of stroke development was significantly higher in correlation with patients with echogenic plaque. Based on calculations using “Stroke-Stop” formula, three main groups were generated: low (< 70 points), medium (70–100 points) and high (> 100 points) risk of stroke development.

Conclusions

Hypothesis of “Stroke-Stop” formula is proposed for better selection of patients who should be indicated for surgical treatment and will be evaluated in prospective study. In order to verify this hypothesis, we plan to do prospective study using “Stroke-Stop” formula for ipsilateral annual stroke rate in asymptomatic individuals with carotid stenosis who receive conservative therapy.

Stenosis, ulceration of the atherosclerotic plaque and Lp-PLA2 concentration are calculated

3 groups of stroke risk development were set (low, medium and high)

Proposed formula form personalized approach to the diagnosis and prevention of stroke

Pharmacotherapy Pattern and Treatment Outcomes of Stroke Patients Admitted to Jimma University Medical Center, Ethiopia

Background

Despite the fact that stroke has been reported as one of the top three leading causes of death and morbidity in Ethiopia, there are limited data regarding the management of stroke and clinical outcomes. Hence, the present study aimed to evaluate the pharmacotherapy of stroke and factors associated with poor treatment outcomes.

Methods

A retrospective cross-sectional study was conducted at Jimma University Medical Center (JUMC) among adult stroke patients managed from 2014 to 2017. Clinical characteristics, treatment, and outcomes data were analyzed by using SPSS version 21. Multivariable logistic regression was performed to identify the predictors of poor treatment outcomes. Two-sided P < 0.05 was accepted as statistically significant.

Results

A total of 153 illegible patient cases were included in this study. The majority, 111 (72.5%), were male and the mean age of the patients was 57±13.7 years. Among 153 stroke patients, 112 (73.2%) patients presented with ischemic stroke. Aspirin and statins (78.6%) were the most commonly used treatment among ischemic stroke patients, whereas enalapril was used in about (43%) of stroke patients to treat high blood pressure. About 61 (40%) stroke patients had poor treatment outcomes; of this, 36 (23.5%) died in hospital. Older age (AOR = 1.034; 95% CI: 1.003–1.069), history of heart failure (AOR = 4.26; 95% CI: 1.58–11.48), loss of consciousness diabetes (AOR = 3.05 95% CI: 1.25–7.44), and aspiration pneumonia (AOR = 5.94; 95% CI: 2.46–14.32) were significantly associated with poor treatment outcomes.

Conclusion

Overall, treatment of stroke patients was sub-optimal and almost half of the patients had poor treatment outcomes. Availing of thrombolytic therapy, devising appropriate preventive measures of risk factors (hypertension), and decreasing preventable complication such as aspiration pneumonia could improve patient outcomes.

The significance of the oxidative stress markers in the one-year prognosis of patients with acute ischemic stroke: a case-control study

Background

Stroke is a major cause of mortality and morbidity. Also, free radicals and oxidative stress are deleterious factor in the stroke progression. We aimed to evaluate the association between oxidative stress markers and odds of having risk factor for stroke or developing stroke.

Methods

The present case-control study was conducted on 556 participants in Imam-Reza hospital, Tabriz, Iran. Subjects were divided into three group, including individuals with acute ischemic stroke, those who were at risk of stroke, and healthy controls. All enrolled participants except for controls underwent neurological examinations and brain magnetic resonance imaging (MRI). Stroke-related disability and stroke severity were evaluated by modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS), respectively. Serum malondialdehyde (MDA) level and total antioxidant capacity (TAC) were measured within 48 h of the initiation of stroke. One-way ANOVA and Chi-square tests were used for comparing characteristics between groups. Multivariable logistic regression was implemented for odds of stroke based on MDA and TAC quartiles. Also, Spearman’s correlation was utilized.

Results

Serum MDA, systolic and diastolic blood pressure, cholesterol, and triglyceride were significantly higher in the stroke group than controls. High levels of MDA were associated with increased development of stroke (P-value < 0.001), however TAC and MDA were not associated with having risk factors for stroke (P-value = 1.00 and 0.27, respectively). Also, TAC level was negatively associated with baseline (ρ = − 0.28; P-value = 0.04) and follow-up (ρ = − 0.31; P-value = 0.03) NIHSS scores. Moreover, MDA was correlated with mRS score at follow-up (ρ = − 0.26; P-value = 0.04).

Conclusions

The balance between antioxidants and oxidants markers might reveal a new approach in this context. Further studies are warranted to identify the source of oxidative stress as well as cessation of the production of oxygen radicals in stroke.

Multimodality Imaging in Acute Ischemic Stroke

Stroke is the most common cause of mortality and morbidity worldwide. The prognosis of stroke depends upon the area affected and its early treatment. Time is of the essence in the care of stroke patients as it is estimated that approximately 1.9 million neurons, 14 billion synapses, and 12 km myelinated nerve fibers are lost per minute. Therefore, early diagnosis and prompt treatment are necessary. The primary goal of imaging in acute stroke is to diagnose the underlying cause, estimate the area affected, predict response towards thrombolytic therapy and to exclude the conditions mimicking stroke. With advancements in radiology, multiple imaging modalities are available for diagnosis and predicting prognosis. None of them is considered alone to be perfect. In this era of multimodality imaging, the decision of choosing appropriate techniques depends upon purpose and availability. Non-Contrast Computed Tomography is time effective, and helps in excluding other causes, Trans Cranial Doppler is time-effective and cost-effective with wide availability, however, is operator dependent and less sensitive. It holds a great future in sonothrombolysis. Magnetic Resonance Imaging is so far considered to be the most superior one in terms of early diagnosis, planning for interventional treatment and predicting the response of treatment. However, it is limited due to high cost and lack of availability. The current review gives a detailed account of all imaging modalities available for imaging stroke and their associated pros and cons.

The Moyamoya Health Behavior Scale for Adolescent Patients: Measurement Tool Development and Psychometric Evaluation

Clinical practitioners treating moyamoya disease recognize the need for a systematic approach to better manage the disease in adolescent patients with the disease. Methods: This study aimed to develop and evaluate the validity and reliability of a disease scale which measures the health-related behaviors of adolescents with moyamoya disease. Results: The final 12-item Moyamoya-HB Scale for adolescents was categorized by three sub-domains: implementation of treatment for moyamoya disease (four items); health promoting behavior for moyamoya disease (four items); and health coping behavior for moyamoya disease (four items). Overall, these factors explained 68.97% of the total variance. The results of the confirmative factor analysis supported the construct, convergent and discriminant validity of the three sub-domains. The Moyamoya-HB Scale for adolescents also demonstrated a concurrent validity with the Korean Adolescents’ Health Behaviors Tool (r = 0.59, p < 0.001). Reliability analysis showed an acceptable-to-high Cronbach’s alpha of 0.865 in total, and the subscales ranged from 0.800 to 0.841. Conclusions: Initial findings support the Moyamoya-HB Scale as a reliable and valid measure of health behaviors in adolescents with moyamoya disease.

Strategies adopted to manage physical and psychosocial challenges after returning home among people with stroke: A qualitative study

Stroke survivors encounter various physical and psychosocial challenges after hospital discharge. Systematic reviews consistently suggest the importance of self-management in promoting post-stroke recovery. However, stroke survivors' performance of self-management behaviors after returning home is poorly understood. This study was conducted to explore how stroke survivors manage their life after returning home from the hospital. This was a qualitative study with individual, semi-structured interviews. We recruited a purposive sample of adults who had a first or recurrent ischemic or hemorrhagic stroke and currently lived at home. Participants were asked about their post-stroke experiences, challenges encountered, and strategies adopted for managing post-stroke conditions. Data were transcribed verbatim and analyzed using thematic analysis. A total of 30 stroke survivors (mean age = 61.97 years, SD = 10.20) were interviewed. Most were men (n = 18), married (n = 25), and retired (n = 21). Two-thirds had experienced an ischemic stroke. Five key themes emerged: pursuing lifelong learning to live well after a stroke; reinterpreting unpleasant experiences as new learning opportunities; engaging in life activities to better adapt to post-stroke challenges; being confident in oneself to persevere in self-management behaviors; and continuing to accept the current self and explore the new self. Participants regarded learning as a prerequisite for improving their affected functions and managing uncertainties in recovery. Learning requires self-participation, building self-efficacy and positive outcome expectations, testing and adapting strategies to one's own health conditions, and engaging in leisure or social activities. These findings will guide future development of interventions for enhancing stroke survivors' recovery outcomes.

Multinational Survey of Current Practice from Imaging to Treatment of Atherosclerotic Carotid Stenosis

BACKGROUND

In the last 20-30 years, there have been many advances in imaging and therapeutic strategies for symptomatic and asymptomatic individuals with carotid artery stenosis. Our aim was to examine contemporary multinational practice standards.

METHODS

Departmental Review Board approval for this study was obtained, and 3 authors prepared the 44 multiple choice survey questions. Endorsement was obtained by the European Society of Neuroradiology, American Society of Functional Neuroradiology, and African Academy of Neurology. A link to the online questionnaire was sent to their respective members and members of the Faculty Advocating Collaborative and Thoughtful Carotid Artery Treatments (FACTCATS). The questionnaire was open from May 16 to July 16, 2019.

RESULTS

The responses from 223 respondents from 46 countries were included in the analyses including 65.9% from academic university hospitals. Neuroradiologists/radiologists comprised 68.2% of respondents, followed by neurologists (15%) and vascular surgeons (12.9%). In symptomatic patients, half (50.4%) the respondents answered that the first exam they used to evaluate carotid bifurcation was ultrasound, followed by computed tomography angiography (CTA, 41.6%) and then magnetic resonance imaging (MRI 8%). In asymptomatic patients, the first exam used to evaluate carotid bifurcation was ultrasound in 88.8% of respondents, CTA in 7%, and MRA in 4.2%. The percent stenosis upon which carotid endarterectomy or stenting was recommended was reduced in the presence of imaging evidence of "vulnerable plaque features" by 66.7% respondents for symptomatic patients and 34.2% for asymptomatic patients with a smaller subset of respondents even offering procedural intervention to patients with <50% symptomatic or asymptomatic stenosis.

CONCLUSIONS

We found heterogeneity in current practices of carotid stenosis imaging and management in this worldwide survey with many respondents including vulnerable plaque imaging into their decision analysis despite the lack of proven benefit from clinical trials. This study highlights the need for new clinical trials using vulnerable plaque imaging to select high-risk patients despite maximal medical therapy who may benefit from procedural intervention.

White matter hyperintensity determines ischemic stroke severity in symptomatic carotid artery stenosis

INTRODUCTION

The aim of this study is to investigate the influence of white matter hyperintensity (WMH) on stroke severity and prognosis in patients with symptomatic carotid artery stenosis.

METHODS

Patients with symptomatic carotid artery stenosis were retrieved from the Samsung Medical Center stroke registry from January 2011 to December 2016. Stroke severity was categorized into three levels according to National Institutes of Health Stroke Scale (NIHSS): transient ischemic attack (TIA) or transient symptoms with infarction (TSI), mild stroke, and moderate to severe stroke. WMH volume was measured with medical image processing and visualization. The clinical outcome was assessed using the modified Rankin scale on the 90th day from which the latest onset of the neurological symptom. Logistic regression was used to predict stroke severity, and ordinal regression was used to compare the clinical outcome.

RESULTS

Among 158 patients, the numbers of patients with TIA or TSI, mild stroke, and moderate to severe stroke were 48 (30.4%), 59 (37.3%), and 51 (32.3%), respectively. The larger WMH volume was associated with moderate to severe strokes (TIA/TSI vs. moderate to severe strokes, odds ratio (OR) 2.318, 95% confidence interval (CI) 1.194-4.502, p = 0.007; mild vs. moderate to severe strokes, OR 1.972, 95% CI 1.118-3.479, p = 0.013). Patients with larger volume of WMH showed poorer clinical outcome (cutoff value: 9.71 cm³, OR 2.099, 95% CI 1.030-4.311, p = 0.042).

CONCLUSION

Our study showed that larger WMH volume is associated with more severe stroke and poorer prognosis in patients with symptomatic carotid artery stenosis.

Innovative Multiparametric Characterization of Carotid Plaque Vulnerability by Ultrasound

OBJECTIVE

The degree of stenosis of a carotid plaque is a well-established risk factor for ischemic stroke. Nevertheless, the risk of ipsilateral stroke in asymptomatic carotid stenosis remains low and new imaging markers are needed to better target which patients would benefit most from endarterectomy or intensive medical therapy. Ultrafast ultrasound imaging offers parameters helping at characterizing the carotid plaque by shear wave elastography and Ultrafast Doppler (UFD). We aimed at using these techniques to characterize 3 different ultrasound biomarkers: plaque stiffness heterogeneity, wall shear stress (WSS) and intraplaque micro-flows and to correlate these biomarkers with findings on computed tomography angiography (CTA) and the pathological examination.

METHODS

We present the case of a multimodal evaluation of a carotid plaque using ultrasound. Elastography has been coupled to the WSS assessment and the detection of intraplaque micro-flows by UFD. The data have been compared to CTA and to the pathology examination of the tissue after carotid endarterectomy.

RESULTS

Elastography allowed at identifying stiff areas corresponding to calcifications, as well as a soft area corresponding to an intraplaque hemorrhage. The flow evaluation with UFD showed an increase of the WSS along the plaque and identified the presence of a plaque rupture, confirmed by the pathologist.

CONCLUSION

Ultrafast ultrasound imaging is an innovative, easily accessible technique that provides imaging modalities on top of the conventional B-mode. Ultrafast ultrasound biomarkers such as plaque stiffness heterogeneity, WSS and intraplaque micro-flows could help to define the vulnerability of the carotid plaque in order to stratify patients that could benefit most from endarterectomy or intensive medical therapy.

Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis

BACKGROUND

Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal.

METHODS

We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017.

RESULTS

Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit for ACS only for selected average surgical risk men aged less than 75 to 80 years with 60% or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with ACS using medical intervention alone are overall lower than for those who had CEA or CAS in randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention.

CONCLUSIONS

Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure.

The Association Between an Antecedent of Transient Ischemic Attack Prior to Onset of Stroke and Functional Ambulatory Outcome

BACKGROUND

Specific clinical risk factors linked to transient ischemic attack (TIA) could affect functional ambulatory outcome following thrombolytic therapy in patients having ischemic stroke with a prior TIA (TIA-ischemic stroke). This issue was investigated in this study.

METHODS

We retrospectively analyzed data from 6379 ischemic stroke patients of which 1387 presented with an antecedent TIA prior to onset of stroke. We used logistic regression model to identify demographic and clinical risk factors that are associated with functional ambulatory outcome in patients with TIA-ischemic stroke treated with thrombolytic therapy.

RESULTS

In a population of TIA-ischemic stroke who received recombinant tissue plasminogen activator, patients with a history of stroke (odds ratio [OR] = 3.229, 95% confidence interval [CI] = 1.494-6.98, P = .003) were associated with increasing odds of improvement in functional ambulation, while the female gender (OR = 0.462, 95% CI = 0.223-0.956, P = .037) was associated with reducing odds of improvement. In the non-TIA group, dyslipidemia (OR = 1.351, 95% CI = 1.026-1.781, P = .032) and blood glucose (OR = 1.003, 95% CI = 1.0-1.005, P = .041) were associated with the increasing odds of improvement while older patients (OR = 0.989, 95% CI = 0.98-0.999, P = .029) with heart failure (OR = 0.513, 95% CI = 0.326-0.808, P = .004) and higher lipid level (OR = 0.834, 95% CI = 0.728-0.955, P = .009) were associated with reducing odds of improvement in ambulation.

CONCLUSION

In a population of TIA-ischemic stroke with thrombolytic therapy and a clearly defined TIA without focal ischemic injury, regardless of associated clinical risk factors, a TIA prior to a stroke is not associated with reducing odds of improved ambulatory outcome, except in female patients with TIA-ischemic stroke.

Assessment of Carotid Intraplaque Neovascularization Using Superb Microvascular Imaging in High Risk of Stroke Individuals: Results From a Community-Based Study

Background: Improved stroke risk stratification may improve stroke prevention. We aimed to study the value of a novel Doppler method, superb microvascular imaging (SMI), in correlating plaque thickness and evidence of intra-plaque neovascularization with a history stroke and TIA involving any cerebrovascular territory among community residents considered at high stroke risk.

Methods: We selected residents aged at least 40 years from the Donghuashi community in China who had at least three stroke risk factors (including a history of stroke or TIA) and carotid plaque thickness of at least 1.5 mm (but without heavy calcification) and no history of carotid endarterectomy or stenting. In this cross-sectional study, each subject underwent carotid plaque examination with standard ultrasound and SMI. SMI evidence of plaque neovascularization was categorized as none or mild (Grade 1) or moderate or marked (Grade 2) and correlated with past history of stroke or TIA.

Results: A total of 131 individuals (mean age 69 ± 8 years, 63% male) met the study inclusion criteria. SMI revealed no or mild neovascularization in 74 subjects (56.5%) and moderate or marked neovascularization in 57 subjects (43.5%). Subjects with moderate or marked neovascularization were more likely to have a history of any territory stroke or TIA, 43.9 vs. 17.6% (P = 0.001). Multivariate logistic regression analyses showed a thicker plaque (odds ratio: 2.272, 95% CI: 1.351–3.822, P = 0.002) and a history of stroke or TIA (odds ratio: 4.017, 95% CI: 1.719–9.387, P = 0.001) significantly correlated with evidence of moderate to marked intra-plaque neovascularization.

Conclusions: Moderate to marked intraplaque neovascularization detected by SMI was more likely in subjects with a history of any territory stroke or TIA or thicker plaque. This indicates a potential new role of SMI in stratifying future risk of stroke or other arterial disease complications.

Magnetic Resonance Imaging Identified Brain Ischaemia in Symptomatic Patients Undergoing Carotid Endarterectomy Is Related to Histologically Apparent Intraplaque Haemorrhage

OBJECTIVE

Intraplaque haemorrhage (IPH) has been independently associated with a higher risk of future ipsilateral stroke in patients with carotid artery stenosis. Evaluation of plaque characteristics may contribute to risk assessment of recurrent (silent) cerebrovascular events in order to prioritise patients for timing of treatment. It is unknown if patients showing histologically apparent IPH also have increased risk of silent ischaemic brain lesions in the waiting period between index event and revascularisation.

METHODS

A retrospective analysis was performed based on prospectively collected data of patients included simultaneously in the magnetic resonance imaging (MRI) substudy of the International Carotid Stenting Study and Athero-Express biobank. Patients randomised for carotid endarterectomy (CEA) underwent surgery between 2003 and 2008. Brain MRI was performed one to seven days prior to CEA. Plaques were histologically examined for presence of IPH. The primary outcome parameter was presence of silent ipsilateral brain ischaemia on magnetic resonance diffusion weighted imaging (MR-DWI) appearing hypo or isointense on apparent diffusion coefficient.

RESULTS

Fifty-three patients with symptomatic carotid stenosis meeting the study criteria were identified, of which 13 showed one or more recent ipsilateral DWI lesion on pre-operative scan. The median time between latest ipsilateral neurological event and revascularisation was 45 days (range 6-200) in DWI negative patients vs. 34 days (range 6-74, p = .16) in DWI positive patients. IPH was present in 24/40 (60.0%) DWI negative patients vs. 12/13 (92.3%) DWI positive patients (OR 8.00; 95% CI 0.95-67.7, p = .06). Multivariable logistic regression analysis correcting for age and type of index event revealed that IPH was independently associated with DWI lesions in the waiting period till surgery (OR 10.8; 95% CI 1.17-99.9, p = .04).

CONCLUSION

Symptomatic patients with ipsilateral carotid stenosis and silent brain ischaemia on pre-operative MR-DWI, more often showed pathological evidence of IPH compared with those without ischaemic lesions. This identifies carotid IPH as a marker for patients at risk of silent brain ischaemia and possibly for future stroke and other arterial disease complications. Such patients may be more likely to benefit from CEA than those without evidence of ipsilateral carotid IPH.

Symptomatic vs. Asymptomatic 20-40% Internal Carotid Artery Stenosis: Does the Plaque Size Matter?

Background: Around 9–15% of ischemic strokes are related to internal carotid artery (ICA)-stenosis ≥50%. However, the extent to which ICA-stenosis <50% causes ischemic cerebrovascular events is uncertain. We examined the relation between plaque cross-sectional area and length and the risk of ischemic stroke or TIA among patients with ICA-stenosis of 20–40%.

Methods: We retrospectively identified patients admitted to the Department of Neurology, University Hospital of Würzburg, from January 2011 until September 2016 with ischemic stroke or TIA and concomitant ICA-stenosis of 20–40%, either symptomatic or asymptomatic. Plaque length and cross-sectional area were assessed on ultrasound scans.

Results: We identified 41 patients with ischemic stroke or TIA and ICA-stenosis of 20–40%; 14 symptomatic and 27 asymptomatic. The plaque cross-sectional area was significantly larger among symptomatic than asymptomatic ICA-stenosis; median values (IQR) were 0.45 (0.21–0.69) cm² and 0.27 (0.21–0.38) cm², p = 0.03, respectively. A plaque cross-sectional area ≥0.36 cm² had a sensitivity of 71% and a specificity of 76% for symptomatic compared with asymptomatic ICA-stenosis. In a sex-adjusted multivariate logistic regression, a plaque cross-sectional area ≥0.36 cm² and a plaque length ≥1.65 cm were associated with an OR (95% CI) of 5.54 (1.2–25.6), p = 0.028 and 1.78 (0.36–8.73), p = 0.48, respectively, for symptomatic ICA-stenosis.

Conclusion: Large plaques might increase the risk of ischemic stroke or TIA among patients with low-grade ICA-stenosis of 20–40%. Sufficiently powered prospective longitudinal cohort studies are needed to definitively test the stroke risk stratification value of carotid plaque length and cross-sectional area in the setting of current optimal medical treatment.

Asymptomatic Carotid Stenosis Is Associated With Circadian and Other Variability in Embolus Detection

Background and Purpose: Variability in transcranial Doppler (TCD) detection of embolic signals (ES) is important for risk stratification. We tested the effect of time of day on ES associated with 60–99% asymptomatic carotid stenosis.

Materials and Methods: Subjects were from the Asymptomatic Carotid Stenosis Embolus Detection (ASED) Study such that half were previously ES-positive and half ES-negative with 6-monthly 60-min TCD monitoring. All underwent bilateral TCD monitoring for two 12-h sessions separated by 24 h. ES detection rates were calculated using 6 and 4-h intervals from midnight and effective TCD monitoring time.

Results: Ten subjects (8 male, mean age 79.5 years) were monitored. Over 24 h, 5/10 study arteries with 60–99% asymptomatic carotid stenosis were ES-positive (range 1–28 ES/artery, 56 total ES from 177.9 total effective monitoring hours). The remaining five study arteries and all eight successfully monitored contralateral arteries were ES-negative. Using 6-h intervals the mean ES detection rate peaked at 0600-midday (0.64/h) and was lowest 1800-midnight (0.09/h) with an incidence rate ratio of 7.26 (95% CI 2.52–28.64, P ≤ 0.001). Using 4-h intervals the mean ES detection rate peaked at 0800-midday (0.64/h) and was lowest midnight-0400 (0.12/h) with an incidence rate ratio of 5.51 (95% CI 1.78–22.67, P = 0.001).

Conclusions: Embolism associated with asymptomatic carotid stenosis shows circadian variation with highest rates 4–6 h before midday. This corresponds with peak circadian incidence of stroke and other vascular complications. These and ASED Study results show that monitoring frequency, duration, and time of day are important in ES detection.

Extracranial Artery Stenosis Is Associated With Total MRI Burden of Cerebral Small Vessel Disease in Ischemic Stroke Patients of Suspected Small or Large Artery Origins

Background and Purpose: Extracranial artery stenosis (ECAS) is related to individual imaging markers of cerebral small vessel disease (cSVD). However, little has been reported on the association between ECAS and the total burden of cSVD as assessed by magnetic resonance imaging (MRI). The purpose of this study was to investigate the relationship between ECAS and cSVD burden in patients with ischemic stroke of suspected small or large artery origin.

Methods: We reviewed consecutive patients with ischemic stroke of suspected small or large artery origin who underwent color Doppler ultrasonography and brain MRI. Bilateral extracranial cerebral arteries including common carotid artery, internal carotid artery (ICA), and proximal vertebral artery (VA, ostium, V2–3 segments) were assessed using color Doppler ultrasonography. ECAS severity was classified as no/mild stenosis, moderate stenosis, severe stenosis, or occlusion. The total cSVD score was assessed by awarding one point according to the load of each of these cSVD markers as determined using MRI; lacunar infarction, white matter hyperintensities, cerebral microbleeds, and enlarged perivascular spaces. The relationship between ECAS severity and cSVD burden according to MRI was examined.

Results: Two hundred and twenty one patients were included in this study (mean age 61 ± 12 years, 75.6% male). Hypertension, current smoking, hyperlipidaemia, and diabetic mellitus were frequent among the patients (67.4, 45.7, 43.9, and 36.7%, respectively), while the other vascular risk factors including previous stroke or TIA and alcohol excess were less frequent (19.0 and 15.4%, respectively). Patients with higher total cSVD burden was significantly older and had severer ECAS. The frequency of hypertension was significantly higher in patients with higher total cSVD burden. This analysis indicated that that increasing ECAS severity (from no stenosis through to 100%) was independently associated with increasing total cSVD score after adjusting for other vascular risk factors (odds ratio 1.76, 95% CI [1.16–2.69]).

Conclusions: In this study, high levels of ECAS from ultrasound evidence were associated with coexisting advanced cerebral cSVD in ischemic stroke patients of suspected small or large artery origin. Further studies are required to determine if and how extracranial arterial imaging helps reduce cSVD burden or improves cognitive function.

Radiotherapy Exposure in Cancer Patients and Subsequent Risk of Stroke: A Systematic Review and Meta-Analysis

Background: Cancer patients who have undergone radiotherapy may have an increased risk of subsequent stroke. A clear and detailed understanding of this risk has not been established. Methods: A search for research articles published from January 1990 to November 2017 in the English language was conducted. Subsequent stroke risk in cancer survivors was compared using relative risk (RR) and 95% confidence intervals (CI) according to whether or not radiotherapy was given. Results: A total of 12 eligible studies were identified including 57,881 total patients. All studies were retrospective, as no prospective studies were identified. The meta-analysis revealed a higher overall risk of subsequent stroke in cancer survivors/patients given radiotherapy compared to those not given radiotherapy (RR: 2.09, 95% CI: 1.45, 3.16). In addition, compared to patients not given radiotherapy, there was an increased risk of subsequent stroke for radiotherapy treated patients with Hodgkin's lymphoma (RR: 2.81, 95% CI: 0.69, 4.93) or head/neck/brain/nasopharyngeal cancer (RR: 2.16, 95% CI: 1.16, 3.16), for patients younger than 40 years (RR: 3.53, 95% CI: 2.51, 4.97) or aged 40-49 years (RR: 1.23, 95% CI: 1.09, 1.45) and for patients treated in Asia (RR: 1.88, 95% CI: 1.48, 2.29), the United States (RR: 1.62, 95% CI: 1.01, 2.23), or in Europe (RR: 4.11, 95% CI 2.62, 6.45). Conclusions: The available literature indicates an approximate overall doubling of the subsequent stroke risk in cancer patients given radiotherapy. The elevated risk was generally statistically significant according to cancer type, baseline patient age and region or country where treatment was given. Caution is required in interpreting these findings due to the heterogeneity of populations represented and lack of standardization and completeness across published studies. Further, if real, we cannot conclude the extent to which patient, treatment and/or investigational factors are responsible for this apparent elevated risk. An objective and more detailed understanding of the risks of radiotherapy, and how to prevent them, is urgently required. It is the responsibility of all who provide cancer services to ensure that the experience of all their patients is documented and analyzed using quality registries.

Pre-existing White Matter Hyperintensity Lesion Burden and Diagnostic Certainty of Transient Ischemic Attack

GOALS

There are no validated biomarkers that allow for reliable distinction between TIA and other transient neurological symptoms that mimic TIA. We sought to determine whether the degree of pre-existing white matter hyperintensity (WMH) lesion burden relates to the diagnostic certainty of TIA in a cohort of patients presenting with transient neurological symptoms.

MATERIALS AND METHODS

We retrospectively analyzed 144 consecutive patients with available brain MRI to quantify and normalize the WMH volume for brain atrophy (adjusted white matter hyperintensity [aWMHV]). We first stratified subjects to probable (n = 62) versus possible (n = 82) TIA as per existing guidelines. Receiver-operating characteristic curves were used to determine a critical aWMHV-threshold (7.8 mL) that best differentiated probable from possible TIA. We then further stratified patients with possible TIA to likely (n = 52) versus unlikely (n = 30) TIA after independent chart review and adjudication. Finally, multivariable logistic and multinomial regression was used to determine whether the defined aWMHV independently related to probable and likely TIA after adjustment for pertinent confounders.

FINDINGS

With the exception of age (P < .001) and use of antiplatelets (P = .017), baseline characteristics were similar between patients with probable, likely, and unlikely TIA. In the fully adjusted multinomial model, the aWMHV cut-off greater than 7.8 mL (odds ratio 3.8, 95% confidence interval 1.3-10.9, P = .012) was significantly more frequent in patients with a probable TIA as compared to those with an unlikely TIA diagnosis.

CONCLUSIONS

We provide proof-of-principle that WMH may serve as a neuroimaging marker of diagnostic certainty of TIA after neurological workup has been completed.