The Importance of Combined Antithrombotic Treatment for Capsular Warning Syndrome

A Nomogram Incorporating Intracranial Atherosclerosis Score for Predicting Early Neurological Deterioration in Minor Stroke Patients With Type 2 Diabetes Mellitus

Purpose

Early neurological deterioration (END) frequently complicates acute ischemic stroke (AIS), worsening prognosis, particularly in patients with type 2 diabetes mellitus (T2DM), where hyperglycemia accelerates atherosclerosis, increasing both stroke risk and subsequent END. This study aimed to identify predictors of END in minor stroke patients with T2DM and develop a nomogram integrating these factors with intracranial atherosclerosis (ICAS) scores, evaluating its performance against various machine learning (ML) models.

Methods

We retrospectively analyzed clinical data from 473 minor stroke patients with T2DM treated at our hospital between January 2021 and December 2023. Utilizing LASSO and multivariate logistic regression, we identified characteristic predictors. The cohort was randomly allocated into training (n = 331) and validation (n = 142) groups. Six ML algorithms-SVM, LR, RF, CART, KNN, and Naive Bayes-were assessed, and nomograms were used to visualize the predictive model's performance, evaluated via Area Under the Curve (AUC), calibration plot, and Decision Curve Analysis (DCA).

Results

The ICAS score has been recognized as a pivotal determinant of END, alongside four other significant factors: NIHSS score, low-density lipoprotein cholesterol (LDL-C) levels, presence of branch atheromatous disease (BAD), and stenosis of the responsible vessel ≥50%. The model demonstrated robust predictive capabilities, achieving strong performance in training (AUC = 0.795) and validation (AUC = 0.799) sets. This advanced ML model, which integrates biochemical and imaging indicators, enables accurate risk assessment for END in minor stroke patients with T2DM.

Conclusion

By integrating the ICAS score with the NIHSS score, LDL-C levels, presence of BAD, and stenosis of responsible vessels ≥50%, we developed a clinical model for predicting END in patients with minor stroke and T2DM. This model provides critical decision support for clinicians, facilitating early identification of high-risk patients, personalized treatment, and improved outcomes.

Capsular warning syndrome and its clinical awareness and therapeutic approach: two case reports and a systematic review of the literature

Introduction

Capsular warning syndrome (CWS) is characterized by recurrent stereotyped episodes of unilateral transient motor and/or sensory symptoms affecting the face and upper and lower limbs, without cortical signs in 24 h and with a high risk of developing stroke. Among the possible underlying mechanisms, small perforating artery disease is the most common. The aim was to assess the most common risk factors, the therapeutic alternatives, and the different outcomes in patients with CWS, along with the presentation of two cases treated in our Emergency Department.

Methods

Stroke Code, launched at our institution in January 2017, was triggered 400 times, and by December 2022, 312 patients were admitted as having an acute ischemic stroke. Among them, two of them fulfilled the criteria of CWS. A systematic search was carried out in PubMed, Scopus, and Web of Science databases to seek demography and therapeutic approaches in CWS.

Results

Of 312 cases, two with acute ischemic stroke exhibited CWS. The first patient had six events of right hemiparesis with recovery in 10-30 min; after MRI and digital subtraction angiography (DSA), he received apixaban and clopidogrel; however, a day after admission, he developed ischemic infarction with partial recovery. The second patient presented five transient events of right hemiparesis. After MRI and DSA with an intra-arterial infusion of nimodipine, oral aspirin, and ticagrelor, he presented another event-developing stroke and was discharged with partial recovery. A systematic review found 190 cases of CWS in 39 articles from 1993 to 2022. Most were male subjects (66.4%), and hypertension (60%), smoking (36%), diabetes (18%), and dyslipidemia (55%) were the most common risk factors. Over 50% of the cases were secondary to small perforating artery disease. The most commonly used treatments were dual antiplatelet therapy (DAT), recombinant tissue plasminogen activator, and anticoagulant therapy (ACT), where the combination of DAT plus ACT was linked to the most positive functional outcomes (82.6%).

Conclusion

Our cases fit with the description of patients with partial recovery and risk factors (hypertension, diabetes, and smoking) in male patients. There is a lack of evidence regarding the best treatment option; dual antiplatelet therapy and anticoagulation therapy are strong contenders for a favorable result.

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.

Relationship between the stroke mechanism of symptomatic middle cerebral artery atherosclerotic diseases and culprit plaques based on high-resolution vessel wall imaging

Purpose

For patients with symptomatic middle cerebral artery (MCA) atherosclerotic stenosis, identifying the potential stroke mechanisms may contribute to secondary prevention. The purpose of the study is to explore the relationship between stroke mechanisms and the characteristics of culprit plaques in patients with atherosclerotic ischemic stroke in the M1 segment of the middle cerebral artery (MCA) based on high-resolution vessel wall imaging (HR-VWI).

Methods

We recruited 61 patients with acute ischemic stroke due to MCA atherosclerotic stenosis from Shenzhen Bao'an District People's Hospital. According to prespecified criteria based on infarct topography and magnetic resonance angiography, possible stroke mechanisms were divided into parent artery atherosclerosis occluding penetrating artery (P), artery-to-artery embolism (A), hypoperfusion (H), and mixed mechanisms (M). The correlation between the characteristics of MCA M1 culprit plaque and different stroke mechanisms was analyzed using HR-VWI. The indicators included plaque surface irregularity, T1 hyperintensity, location, plaque burden (PB), remodeling index (RI), enhancement rate, and stenosis rate.

Results

Parental artery atherosclerosis occluding penetrating artery was the most common mechanism (37.7%). The proposed criteria showed substantial to excellent interrater reproducibility (κ, 0.728; 0.593–0.863). Compared with the P group, the surface irregularity, T1 hyperintensity, and obvious enhancement of the culprit plaque in the A group were more common (p < 0.0125). Compared with the other stroke mechanisms, positive remodeling of culprit plaques was more common (p < 0.0125), the RI was greater (p < 0.05), and the PB was the smallest (p < 0.05) in the P group. The enhancement ratio (ER) was smaller in the P group (p < 0.05). Compared with the A group, T1 hyperintensity of the culprit plaque was more common in the H group (p < 0.0125), and the stenosis rate was greater (p < 0.05). After adjustment for clinical demographic factors in the binary logistic regression analysis, the enhancement level (odds ratio [OR] 0.213, 95% CI (0.05–0.91), p = 0.037) and PB of culprit plaque (OR 0, 95% CI (0–0.477), p = 0.034) were negatively associated with P groups.

Conclusion

The culprit plaque characteristics of patients with symptomatic MCA atherosclerotic in different stroke mechanisms may be evaluated using HR-VWI. The plaque characteristics of different stroke mechanisms may have clinical value for the selection of treatment strategies and prevention of stroke recurrence.

Clinical trial registration

Identifier: ChiCTR1900028533.

'Crescendo transient ischemic attack'-an uncommon presentation of a very common disease: a case report on capsular warning syndrome

Capsular warning syndrome is a rare presentation of transient ischaemic attack, which described as recurrent episodes of motor and/or sensory deficits which typically sparring the cortical function. It has a significant risk to progress into a massive stroke with permanent disability, thus important to be recognise early. Here, we report a middle-age gentleman with no known medical illness presented with eight episodes of transient ischaemic attack within the span of 24 h. He was treated with double anti-platelet for 21 days and was not subjected to thrombolysis at time of presentation because it was outside the window period of 4.5 h, and has fully recovered after each episode. The purpose of this case report is to share the uncommon clinical presentation of transient ischaemic attack, which is still not fully understood and warrant more studies especially on the treatment that can affect the progression of the disease.

Pathogenetic mechanisms of ischemic stroke: from verification to secondary prevention

Ischemic stroke is an extremely heterogeneous disease: there are more than 200 causes of cerebral catastrophe. Early identification of the pathogenetic mechanism (subtype) of ischemic stroke allows planning an individual secondary prevention strategy, which includes a wide range of pharmaceutical and surgical methods. The article presents the characteristics of cardioembolic (associated with atrial fibrillation and flutter, prosthetic valves, chronic heart failure, left ventricle thrombus, infective endocarditis, open foramen ovale, etc.), atherothrombotic (due to extra- and intracranial atherosclerosis), lacunar and cryptogenic stroke, as well as less common causes of the disease, in particular cervical or cerebral artery dissection. Issues of secondary prevention of stroke according to the pathogenetic subtype are described and summarized as an algorithm. The article is illustrated with clinical examples.

r-tPA with loading dose of clopidogrel and aspirin therapies for capsular warning syndrome attributed to middle cerebral artery atherosclerotic stenosis: A CARE-compliant case report

RATIONALE

The capsular warning syndrome (CWS) is a rare and special type of transient ischemic attacks (TIAs) syndrome. The pathophysiology of CWS is very complicate, and intracranial atherosclerotic stenosis (ICAS) is rare cause. Moreover, the effective and standard therapy has not yet been established.

PATIENT CONCERNS

A 47-year-old man experienced repeated and exacerbated TIAs of right hemiparesis and dysarthria. Fourteen hours after the first episode of TIAs, he developed more severe right hemiparesis and dysarthria, the National Institute of Health Stroke Scale (NIHSS) score was 12 points, and did not recover in a long time.

DIAGNOSIS

The computed tomography (CT) angiography displayed high stenosis in the M1 segment of the left middle cerebral artery. The patient was diagnosed as CWS with ICAS.

INTERVENTIONS

Loading dose of clopidogrel and aspirin were started but were ineffective, then we used recombinant tissue plasminogen (r-tPA) for thrombolysis therapy after repeat CT scan that showed small acute infarcts in the right putamen and no bleeding.

OUTCOMES

The patient was successfully treated by r-tPA intravenous thrombolysis after loading dose of dual-anti-platelet. He recovered rapidly, and the NIHSS score was 0 point, modified Rankin Scale score was 0 point, and Barthel Index score was 100 points at 3-month follow-up.

LESSONS

r-tPA combined with loading dose of dual antiplatelet appears safe and effective in carefully selected CWS patients with ICAS. The collection of similar cases and further randomized controlled trial research would be desirable.