Prediction of Recurrent Stroke or Transient Ischemic Attack After Noncardiogenic Posterior Circulation Ischemic Stroke

Different patterns of multiple acute infarctions and long-term prognosis in minor posterior circulation stroke

OBJECTIVES

Different classification of multiple acute infarctions (MAIs) existed in minor posterior circulation stroke (PCS). We aimed to explore the association between different patterns of MAIs and long-term prognosis in minor PCS.

MATERIALS AND METHODS

We derived data from Chinese Intracranial Atherosclerosis (CICAS) study. We analyzed the clinical features and outcomes in MAIs among anterior circulation stroke (ACS) and PCS. The patterns of MAIs in PCS were further classified into multiple infarcts, multilevel infarcts, or multiterritorial infarcts. The long-term prognosis included ischemic events recurrence and poor functional outcome (modified Rankin Scale, mRS=2-6) in 1 year. Multivariable Cox and logistic regression were adopted respectively to evaluate the correlation of different patterns of MAIs with recurrence and poor functional outcome.

RESULTS

We totally enrolled 802 patients with minor stroke in CICAS study, including 484 ACS and 318 PCS. In univariate analysis, MAIs were significantly associated with recurrence in ACS (P<0.01), but were significantly correlated with poor functional outcome in PCS (P=0.044). Among the PCS patients, there were 90 patients with multiple infarcts, 32 patients with multilevel infarcts and 36 patients with multiterritorial infarcts. Multivariable Cox regression showed that multiterritorial infarcts were independently associated with ischemic events recurrence (HR, 3.083; 95 % CI, 1.078-8.813). In multivariable logistic regression, significant correlation with poor functional outcome in 1 year was revealed in multilevel infarcts (OR, 2.788; 95 % CI, 1.144-6.797).

CONCLUSIONS

Different patterns of MAIs provide different predictive performances for PCS prognosis. It is imperative to perform more detailed image interpretation of MAIs in PCS.

Predictive value of whole-brain CT perfusion combined with ABCD3 score for short-term secondary cerebral infarction after TIA

Objective

To investigate the predictive value of Whole Brain CT Perfusion (WB-CTP) combined with the ABCD3 score in patients with transient ischemic attack (TIA).

Methods

A total of 336 TIA patients with TIA underwent WB-CTP and ABCD3 score assessment within 48 h of admission. Spearman correlation test was performed to analyze the relationship between the degree of vascular stenosis, relative perfusion values, and ABCD3 score. Logistic regression analysis was used to identify independent risk factors for secondary cerebral infarction. Receiver operating characteristic (ROC) curves were generated to evaluate the predictive value of relative cerebral blood flow (rCBF), degree of vascular stenosis, ABCD3 score, and the WB-CTP-ABCD3 combined model for secondary cerebral infarction after TIA. Calibration curves and H-L tests were used to evaluate the predictive efficacy of the model.

Results

Among the 336 TIA patients, 143 showed abnormal perfusion areas and 146 had responsible vessel stenosis. The degree of vascular stenosis, relative time-to-maximum (rTmax), and relative mean transit time (rMTT) were positively correlated with the ABCD3 score, while rCBF and relative cerebral blood volume (rCBV) were negatively correlated with the ABCD3 score. ROC curve analysis identified a cutoff value of 0.8205 for rCBF, with a sensitivity of 84.10% and specificity of 58.10% for distinguishing the cerebral infarction group from the non-cerebral infarction group. Furthermore, rCBF ≤ 0.8205, degree of vascular stenosis, and ABCD3 score > 6 were identified as independent risk factors for secondary cerebral infarction in TIA patients within 90 days in TIA patients. The AUC of the WB-CTP-ABCD3 combined model for predicting secondary cerebral infarction within 90 days was 0.836. The model risk was assessed by plotting calibration curves. The value of p for the H-L goodness of fit test was 0.366 (p > 0.05), which indicated that the difference between the obtained model and the perfect model were statistically insignificant.

Conclusion

The combined model of WB-CTP-ABCD3 shows promise as a valuable method for predicting secondary cerebral infarction within 90 days following TIA.

Association between red blood cell distribution width and ischemic stroke recurrence in patients with acute ischemic stroke: a 10-years retrospective cohort analysis

Numerous studies have reported that a higher red blood cell distribution width (RDW) level was associated with adverse outcomes in patients with the first stroke. However, no studies have examined the association between RDW and recurrent ischemic stroke. We performed a population-based cohort data analysis from 2007 to 2017. Baseline RDW was measured in 6402 first ischemic stroke participants, who were followed for about five years on average. During 62 months of median follow-up, 205 participants (3.20%) reported a recurrence (self-reported). RDW showed a nonlinear relationship with the risk of ischemic stroke recurrence. When RDW was assessed as quartiles (quartile 1, RDW<12.4; quartile 2, 12.4 to 12.8; quartile 3,12.8 to 13.3, quartile4, RDW>13.3), compared with the reference group (quartile 1), the hazard ratios (HRs) of ischemic stroke recurrence were 1.372 (95% confidence interval [CI]=0.671-2.805, P=0.386) in quartile 2, 1.835 (95% CI=1.222-2.755, P=0.003) in quartile 3, and 1.732 (95% CI=1.114-2.561, P<0.001) in quartile 4. The trend test was significant (P<0.001). When quartiles 3 and 4 were combined, the adjusted HR of ischemic stroke recurrence was 1.439 (95% CI=1.330-1.556, P<0.001) compared with the combined quartiles 1 and 2 subgroups. This study demonstrated that elevated RDW levels were positively associated with an increased risk of recurrent ischemic stroke. RDW can provide a new perspective for initial risk assessment and identify high-risk patients early. Further research is required to confirm our results.

Association of periprocedural perfusion non-improvement with recurrent stroke after endovascular treatment for Intracranial Atherosclerotic Stenosis

Background

Predictors of recurrent stroke after endovascular treatment for symptomatic intracranial atherosclerotic stenosis (ICAS) remain uncertain.

Objectives

Among baseline characteristics, lesion features, and cerebral perfusion changes, we try to explore which factors are associated with the risk of recurrent stroke in symptomatic ICAS after endovascular treatment.

Design

Consecutive patients with symptomatic ICAS of 70-99% receiving endovascular treatment were enrolled. All patients underwent whole-brain computer tomography perfusion (CTP) within 3 days before and 3 days after the endovascular treatment. Baseline characteristics, lesion features, and cerebral perfusion changes were collected.

Methods

Cerebral perfusion changes were evaluated with RAPID software and calculated as preprocedural cerebral blood flow (CBF) < 30%, time to maximum of the residue function (Tmax) > 6 s, and Tmax > 4 s volumes minus postprocedural. Cerebral perfusion changes were divided into periprocedural perfusion improvement (>0 ml) and non-improvement (⩽ 0 ml). Recurrent stroke within 180 days was collected. The Cox proportional hazards analysis analyses were performed to evaluate factors associated with recurrent stroke.

Results

From March 2021 to December 2021, 107 patients with symptomatic ICAS were enrolled. Of the 107 enrolled patients, 30 (28.0%) patients underwent balloon angioplasty alone and 77 patients (72.0%) underwent stenting. The perioperative complications occurred in three patients. Among CBF < 30%, Tmax > 6 s, and Tmax > 4 s volumes, Tmax > 4 s volume was available to evaluate cerebral perfusion changes. Periprocedural perfusion improvement was found in 77 patients (72.0%) and non-improvement in 30 patients (28.0%). Nine patients (8.4%) suffered from recurrent stroke in 180-day follow-up. In Cox proportional hazards analysis adjusted for age and sex, perfusion non-improvement was associated with recurrent stroke [hazards ratio (HR): 4.472; 95% CI: 1.069-18.718; p = 0.040].

Conclusion

In patients with symptomatic ICAS treated with endovascular treatment, recurrent stroke may be related to periprocedural cerebral perfusion non-improvement.

Registration

http://www.chictr.org.cn. Unique identifier: ChiCTR2100052925.

Association of Proton Pump Inhibitor Prophylaxis on Clinical Outcome in Acute Ischemic Stroke in China: A Multicenter Retrospective Cohort Study

BACKGROUND

Overtreatment with proton pump inhibitors (PPIs) in acute ischemic stroke (AIS) patients continues to grow. We aimed to investigate the frequency of PPI prophylaxis without an appropriate indication in AIS patients in China and clarify the association between PPI prophylaxis and long-term prognosis.

METHODS

Based on a multicenter stroke registry database, neurological outcomes, stroke events, recurrent ischemic strokes, and all-cause death were compared between patients with and without PPI prophylaxis.

RESULTS

A total of 4542 AIS were included, and 3335 (73.4%) received PPI prophylaxis. Patients with PPI prophylaxis were more likely to have a poor outcome at 1 year than those without PPI prophylaxis (33.3% vs. 25.8%, OR 1.321; 95% CI 1.102-1.584; p = 0.003). No significant differences were found in all-cause death, stroke event, or recurrent ischemic stroke at 1 year between the two groups. After propensity score matching, PPI prophylaxis was still independently associated with a higher rate of poor outcome (30.9% vs. 25.8%, OR 1.432; 95% CI 1.151-1.780; p = 0.001). Sensitivity analysis also showed that PPI prophylaxis increased the rate of a poor outcome in minor strokes or at different durations of PPI prophylaxis.

CONCLUSIONS

Approximately 3/4 of AIS patients were given PPI prophylaxis during hospitalization, which was associated with a poor long-term outcome.

Collateral Flow in Magnetic Resonance Angiography: Prognostic Value for Vertebrobasilar Stenosis With Stroke Recurrence

Background and Purpose

Intracranial vertebrobasilar atherosclerotic stenosis (IVBAS) is a major cause of posterior circulation stroke. Some patients suffer from stroke recurrence despite receiving medical treatment. This study aimed to determine the prognostic value of a new score for the posterior communicating artery and the P1 segment of the posterior cerebral artery (PCoA-P1) for predicting stroke recurrence in IVBAS.

Methods

We retrospectively enrolled patients with severe IVBAS (70%–99%). According to the number of stroke recurrences, patients were divided into no-recurrence, single-recurrence, and multiple-recurrences groups. We developed a new 5-point grading scale, with the PCoA-P1 score ranging from 0 to 4 based on magnetic resonance angiography, in which primary collaterals were dichotomized into good (2–4 points) and poor (0 or 1 point). Stroke recurrences after the index stroke were recorded. Patients who did not experience stroke recurrence were compared with those who experienced single or multiple stroke recurrences.

Results

From January 2012 to December 2019, 176 patients were enrolled, of which 116 (65.9%) had no stroke recurrence, 35 (19.9%) had a single stroke recurrence, and 25 (14.2%) had multiple stroke recurrences. Patients with single stroke recurrence (odds ratio [OR]=4.134, 95% confidence interval [CI]=1.822–9.380, p=0.001) and multiple stroke recurrences (OR=6.894, 95% CI=2.489–19.092, p<0.001) were more likely to have poor primary collaterals than those with no stroke recurrence.

Conclusions

The new PCoA-P1 score appears to provide improve predictions of stroke recurrence in patients with IVBAS.

Duplex Ultrasonography for the Evaluation of Extracranial Vertebral Artery: A Prospective Comparison With Digital Subtraction Angiography

Background and Objective

Patients with symptomatic vertebral artery stenosis are at high risk of stroke recurrence, especially ≥70% stenosis. Revascularization may be considered for extracranial vertebral artery stenosis in patients with recurrent ischemic events despite optimal medical management. Currently, there is a lack of consensus on the ultrasonic evaluation of extracranial vertebral artery stenosis in clinical practice. This study aimed to validate the efficiency of duplex ultrasonography and assess the optimal sonographic thresholds for predicting extracranial vertebral artery stenosis.

Methods

This is a prospective study of all patients with symptomatic posterior circulation stroke/transient ischemic attack who were scheduled to undergo digital subtraction angiography from April 2020 to October 2021. A total of 544 vertebral arteries with a normal lumen or extracranial stenosis confirmed with digital subtraction angiography were included in the study. The peak systolic velocity at the V1 segment (PSVv1) and the V2 segment (PSVv2) were measured and the PSVv1/PSVv2 and PSVv2/PSVv1 ratios were calculated. The cutoff values were determined using receiver operating characteristic analysis.

Results

The areas under the receiver operating characteristic curve of all the velocity parameters to predict extracranial vertebral artery stenosis were >0.80. The cutoff values for predicting ≥50% and ≥70% V1 segment stenosis were PSVv1 ≥146 cm/s (sensitivity 76.2%, specificity 86.3%) and PSVv1/PSVv2 ratio ≥2.2 (sensitivity 84.3%, specificity 77.6%), and PSVv1 ≥184 cm/s (sensitivity 80.8%, specificity 87.1%) and PSVv1/PSVv2 ratio ≥3.5 (sensitivity 79.5%, specificity 90.5%), respectively. The cutoff values for predicting ≥50% and ≥70% V2 segment stenosis were PSVv2 ≥80 cm/s (sensitivity 75.0%, specificity 91.0%) and PSVv2/PSVv1 ratio ≥1.2 (sensitivity 75.0%, specificity 94.8%), and PSVv2 ≥111 cm/s (sensitivity 81.0%, specificity 95.0%) and PSVv2/PSVv1 ratio ≥1.7 (sensitivity 81.0%, specificity 96.6%), respectively.

Conclusion

Symptomatic patients with the ultrasonic parameters of PSVv1 ≥146 cm/s and PSVv1/PSVv2 ratio ≥2.2 at V1 segment or PSVv2 ≥80 cm/s and PSVv2/PSVv1 ratio ≥1.2 at V2 segment need to be considered for further verification by digital subtraction angiography to seek revascularization. If the parameters increase to PSVv1 ≥184 cm/s and PSVv1/PSVv2 ratio ≥3.5 at the V1 segment or PSVv2 ≥111 cm/s and PSVv2/PSVv1 ratio ≥1.7 at the V2 segment, these patients have an increased risk of recurrent stroke and are more likely to need revascularization. The results can be used as a reference for the assessment and long-term management of patients with extracranial VA stenosis.

Prediction of Recurrent Ischemic Stroke Using Registry Data and Machine Learning Methods: The Erlangen Stroke Registry

BACKGROUND

There have been multiple efforts toward individual prediction of recurrent strokes based on structured clinical and imaging data using machine learning algorithms. Some of these efforts resulted in relatively accurate prediction models. However, acquiring clinical and imaging data is typically possible at provider sites only and is associated with additional costs. Therefore, we developed recurrent stroke prediction models based solely on data easily obtained from the patient at home.

METHODS

Data from 384 patients with ischemic stroke were obtained from the Erlangen Stroke Registry. Patients were followed at 3 and 12 months after first stroke and then annually, for about 2 years on average. Multiple machine learning algorithms were applied to train predictive models for estimating individual risk of recurrent stroke within 1 year. Double nested cross-validation was utilized for conservative performance estimation and models' learning capabilities were assessed by learning curves. Predicted probabilities were calibrated, and relative variable importance was assessed using explainable artificial intelligence techniques.

RESULTS

The best model achieved the area under the curve of 0.70 (95% CI, 0.64-0.76) and relatively good probability calibration. The most predictive factors included patient's family and housing circumstances, rehabilitative measures, age, high calorie diet, systolic and diastolic blood pressures, percutaneous endoscopic gastrotomy, number of family doctor's home visits, and patient's mental state.

CONCLUSIONS

Developing fairly accurate models for individual risk prediction of recurrent ischemic stroke within 1 year solely based on registry data is feasible. Such models could be applied in a home setting to provide an initial risk assessment and identify high-risk patients early.

Vertebral artery stenosis predicts cerebrovascular diseases following radiotherapy for nasopharyngeal carcinoma

PURPOSE

Radiotherapy for nasopharyngeal carcinoma (NPC) may induce cerebrovascular diseases including ischemic stroke and transient ischemic attack (TIA), which can cause severe disability. However, information on the incidence and predictors of cerebrovascular diseases is scarce. This study aimed to estimate the incidence of cerebrovascular diseases following NPC, and attempts to ascertain the predictors of cerebrovascular diseases to facilitate early prevention.

METHODS

We performed a retrospective cohort study on 655 NPC patients who received radiotherapy between 2006 and 2018 in a medical center. This study analyzed the incidence, clinical and imaging presentation of patients with cerebrovascular diseases. Cox proportional hazard model was used to identify risk factors associated with cerebrovascular diseases following radiotherapy.

RESULTS

There were 14 patients who developed an ischemic stroke, and 3 patients developed a TIA after a mean follow-up of 5.8 years. Most ischemic events were from large-artery atherosclerosis (76.5%), and the most common symptom of ischemic stroke was unilateral limb weakness (57.1%). The cumulative incidence of ischemic stroke or TIA 15 years after radiotherapy was 9.1% (95% confidence interval [CI] = 4.7-17.2%). Multivariate Cox regression identified vertebral artery stenosis (HR: 18.341; 95% CI = 3.907-86.100; P < 0.001), atrial fibrillation (HR: 13.314; 95% CI = 1.306-135.764; P = 0.029), and hypertension (HR: 7.511; 95% CI = 1.472-38.320; P = 0.015) as independent predictors of ischemic stroke or TIA.

CONCLUSION

Our study found that NPC patients with vertebral artery stenosis, atrial fibrillation, or hypertension carry a higher risk for ischemic stroke or TIA. Regular assessment of vertebral artery after radiotherapy was suggested.

Non-invasive Detection of Diffuse Intracranial Vertebrobasilar Artery Stenosis: A Prospective Comparison with Digital Subtraction Angiography

The aim of this study was to prospectively evaluate diffuse intracranial vertebrobasilar artery stenosis by ultrasonic examination with digital subtraction angiography as the reference. Five hundred forty-one vertebrobasilar arteries with a normal lumen or intracranial stenosis were enrolled. Peak systolic velocity, mean flow velocity and end-diastolic velocity (EDV) at the intracranial vertebrobasilar arteries and extracranial vertebral arteries (VAs) were measured. The resistance index (RI) at extracranial VAs and the difference between the RI of extracranial VAs and the RI of the extracranial internal carotid artery (RI_ica) were calculated. Compared with normal arteries, all stenotic arteries were divided into the high-velocity group (focal stenosis, multiple-segment stenosis and multiple-artery stenosis) and low-velocity group (critical stenosis and long stenosis). The consistency between ultrasonic examination and digital subtraction angiography for evaluation of vertebrobasilar arteries with multiple-segment stenosis and multiple-artery stenosis was not favorable when applying the widely used Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis criteria (κ = 0.442 and 0.438, respectively). The optimal low-velocity criteria for identifying intracranial vertebrobasilar arteries with critical stenosis and long stenosis were determined by receiver operating characteristic curve analysis and were as follows: EDV ≤15 cm/s and RI ≥0.68 at the extracranial VA and RIica ≥0.10.

A clinical characteristic analysis of five cases of rare bilateral cerebral peduncular infarction (BCPI) with the 'Mickey Mouse ears' sign

Objective: To investigate the clinical manifestations, magnetic resonance imaging (MRI) features, and prognosis of patients diagnosed with bilateral cerebral peduncular infarction (BCPI) with the 'Mickey Mouse ears' sign.Methods: This study, retrospectively summarized the clinical features, MRI and magnetic resonance angiography (MRA) manifestations, and prognosis of 5 patients diagnosed with BCPI and with the 'Mickey Mouse ears' sign from our hospital. In the meantime, we also systematically analyzed and summarized the clinical and imaging features, and prognosis in combination with relevant cases from the national and international literature that had been reported.Results: In our study, five cases presented tetraplegia whereas 4 cases presented disturbance of consciousness. In all cases, the 'Mickey Mouse ears' sign was observed in the mid-brain level using a diffusion-weighted imaging (DWI) cross-section. The MRA images showed thrombosis on either the basilar artery (BA), posterior cerebral artery (PCA), or superior cerebellar artery (SCA). All the studied patients received standardized treatment for cerebral infarction. However, three patients died and the remaining two were left in a locked-in syndrome state.Conclusions: BCPI is a very rare stroke disease and its main clinical manifestations are locked-in syndrome and persistent vegetative states. However, the obtained imaging features on the brain-MRI of patients diagnosed with BCPI with the 'Mickey Mouse ears' sign can predict a bad prognosis.

Evaluating the Efficacy of VitalStim Electrical Stimulation Combined with Swallowing Function Training for Treating Dysphagia following an Acute Stroke

OBJECTIVES

This study explored the clinical efficacy of VitalStim electrical stimulation combined with swallowing function training for patients with dysphagia following an acute stroke.

METHODS

Seventy-two patients with dysphagia following an acute stroke were admitted to our hospital and were further divided into two groups using prospective research methods. There were 36 cases in each group according to the random number table method. The control group received conventional medical treatment and swallowing function training while the experimental group received conventional medical treatment and VitalStim electrical stimulation combined with swallowing function training.

RESULTS

The overall response rate of the experimental group (94.44%) was higher than that of the control group (77.78%), and the difference was statistically significant (p<0.05). Compared with before treatment, the upward and forward movement speeds of the hyoid bone, anterior movement speed, the grading score of the Kubota drinking water test, Caiteng's grading score, serum superoxide dismutase, 5-hydroxytryptamine, and norepinephrine levels, Fugl-Meyer Assessment score, and multiple quality of life scores of the two groups showed improvement after treatment. While the standard swallowing assessment score, serum malondialdehyde level, and National Institutes of Health Stroke Scale score decreased, the aforementioned indices showed a significant improvement in the experimental group (p<0.05).

CONCLUSION

The results of this study indicate that VitalStim electrical stimulation combined with swallowing function is effective for treating dysphagia following an acute stroke. It can effectively improve swallowing, neurological, and limb motor functions, reduce complications, promote physical recovery, and improve overall quality of life of patients.

Risk factors for in-hospital mortality among acute ischemic stroke patients in China: a nationwide prospective study

Objective: We aimed to investigate factors related to in-hospital mortality (IHM) in acute ischemic stroke (AIS) patients.Methods: We prospectively investigated 827,314 patients who were admitted within 7 days of AIS between August 2015 and July 2019. Demographic characteristics, risk factors, and clinical and laboratory characteristics of patients were assessed. Univariate and multivariate logistic regression analyses were performed to identify predictors associated with IHM.Results: The IHM rate in this study was 0.5% in women and 0.3% in men. Factors associated with IHM in AIS included diabetes (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.03-1.43), female (OR 0.84, 95%CI 0.74-0.96), hypertension (OR 1.16, 95%CI 1.01-1.34), atrial fib/flutter (OR 1.51, 95%CI 1.29-1.77), other heart disease (OR1.43, 95%CI 1.23-1.67), prior myocardial infarction (OR 2.00, 95%CI 1.54-2.60), antiplatelet therapies (OR 0.71, 95%CI 0.60-0.84), gastrointestinal bleeding (OR 3.54, 95%CI 2.83-4.44), pulmonary embolism (OR 2.53, 95%CI1.41-4.53), dysphagia(OR7.32, 95%CI6.23-8.61), glycosylated hemoglobin (OR1.05, 95%CI 1.02-1.09), serum creatinine (OR 1.001, 95%CI 1.001-1.002), urea nitrogen (OR 1.10, 95%CI 1.08-1.12), National Institutes of Health Stroke Scale (NIHSS) score (4-5 vs. 0-4: OR 3.58; ≥15 vs. 0-4: OR 8.78), stroke rehabilitation (OR 0.27, 95%CI 0.23-0.30), age (third IQR vs. first IQR: OR 1.57; fourth IQR vs. first IQR: OR 2.23), and in-hospital stroke/TIArecurrence (OR 2.38, 95%CI 2.03-2.78).Conclusions: The findings from this study may help clinicians control the risk of IHM better for patients with AIS.

Concurrent intracranial and extracranial artery stenosis and the prognosis of transient ischaemic symptoms or imaging-negative ischaemic stroke

BACKGROUND AND PURPOSE

Transient ischaemic attack (TIA), transient symptoms with infarction (TSI) and diffusion-weighted imaging (DWI)-negative acute ischaemic stroke (AIS) share similar aetiologies but are considered to have a rather benign prognosis. We intended to investigate the association between intracranial atherosclerotic stenosis (ICAS), extracranial atherosclerotic stenosis (ECAS) and the prognosis of patients with TIA, TSI and DWI-negative AIS.

METHODS

Clinical and imaging data of eligible participants were derived from the Chinese Intracranial Atherosclerosis study, according to symptom duration, acute infarction on DWI and discharge diagnosis. Based on the severity and location of arterial atherosclerosis, we categorised the study population into four groups: no or <50% ICAS and no ECAS; ≥50% ICAS but no ECAS; no or <50% ICAS with ECAS; and concurrent ≥50% ICAS and ECAS. Using multivariable Cox regression models, we analysed the relationship between the severity and distribution of large artery atherosclerosis and the prognosis of TIA, TSI and DWI-negative AIS.

RESULTS

A total of 806 patients were included, 67.3% of whom were male. The median age of the study participants was 63 years. Patients in the concurrent ≥50% ICAS and ECAS subgroup had both a significantly higher 1-year recurrence rate (adjusted HR 3.4 (95% CI 1.15 to 10.04), p=0.027) and a higher risk of composite vascular events (adjusted HR 3.82 (95% CI 1.50 to 9.72), p=0.005).

CONCLUSIONS

Concurrent ICAS and ECAS is associated with a higher possibility of 1-year recurrent stroke or composite vascular events. Large artery evaluation is necessary to assess patients with transient ischaemic symptoms or DWI-negative AIS. Progress in shortening the time interval between symptom onset and large vessel evaluation is needed.

Arterial culprit plaque characteristics revealed by magnetic resonance Vessel Wall imaging in patients with single or multiple infarcts

PURPOSE

To investigate characteristics of intra- and extracranial arterial culprit plaques between patients with single infarct and multiple-infarcts by a head-neck combined high resolution magnetic resonance vessel wall imaging (HR-MRVWI).

MATERIALS AND METHODS

Forty-three patients with recent ischemic stroke due to large artery atherosclerosis were enrolled. The head-neck combined HR-MRVWI was performed in all patients both pre- and post-contrast administration. Based on diffusion weighted imaging findings, patients were divided into single-infarction and multiple-infarction groups. For patients with anterior circulation ischemic stroke, they were also divided into perforating artery infarction (PAI) and non-PAI groups. Patient demographics, number and location of culprit plaques, artery stenosis percentage, intraplaque hemorrhage, and plaque enhancement were evaluated and compared between single-infarction and multiple-infarction groups, as well as between PAI and non-PAI groups.

RESULTS

A total of 83 culprit plaques were identified. The artery stenosis degree was more severe and plaque enhancement more prominent in multiple-infarction group than in single-infarction group. Patients with multiple infarcts also had more culprit plaques per patient than those with single infarct, which contributed to the occurrence of multiple infarcts. For comparison of PAI and non-PAI groups, a higher artery stenosis percentage was observed in non-PAI group, and patients with non-PAI had more culprit plaques per patient, which contributed to a variety of infarct manifestations.

CONCLUSION

A higher stenosis grade and higher number of culprit plaques seem to be associated with a higher number of cerebral infarcts in patients with large artery atherosclerosis.

Risk Factors of Recurrent Ischemic Events after Acute Noncardiogenic Ischemic Stroke

Background:

A considerable proportion of acute noncardiogenic ischemic stroke patients continue to experience recurrent ischemic events after standard therapy.

Aim:

We aimed to identify risk factors for recurrent ischemic event prediction at an early stage.

Methods :

286 non-cardioembolic ischemic stroke patients with the onset of symptoms within 24 hours were enrolled. Vascular risk factors, routine laboratory data on admission, thromboelastography test seven days after clopidogrel therapy and any recurrent events within one year were assessed. Patients were divided into case group (patients with clinical adverse events, including ischemic stokes, transient ischemic attack, myocardial infarction and vascular related mortality) and control group (events-free patients). The risk of the recurrent ischemic events was determined by the receiver operating characteristic curve and multivariable logistic regression analysis.

Results:

Clinical adverse events were observed in 43 patients (case group). The mean levels of Mean Platelet Volume (MPV), Platelet/Lymphocyte Ratio (PLR), Lymphocyte Count (LY) and Fibrinogen (Fib) on admission were significantly higher in the case group as compared to the control group (P<0.001). Seven days after clopidogrel therapy, the ADP-induced platelet inhibition rate (ADP%) level was lower in the case group, while the Maximum Amplitude (MA) level was higher in the case group as compared to the control group (P<0.01). The Area Under the Curve (AUC) of receiver operating characteristic(ROC) curve of LY, PLR, , Fib, MA, ADP% and MPV were 0.602, 0.614, 0.629, 0.770, 0.800 and 0.808, respectively. The logistic regression analysis showed that MPV, ADP% and MA were indeed predictive factors.

Conclusion:

MPV, ADP% and MA were risk factors of recurrent ischemic events after acute noncardiogenic ischemic stroke. Urgent assessment and individual drug therapy should be offered to these patients as soon as possible.

Wall shear stress can improve prediction accuracy for transient ischemic attack

BACKGROUND

Early prediction of transient ischemic attack (TIA) has important clinical value. To date, systematic studies on clinical, biochemical, and imaging indicators related to carotid atherosclerosis have been carried out to predict the occurrence of TIA. However, their prediction accuracy is limited.

AIM

To explore the role of combining wall shear stress (WSS) with conventional predictive indicators in improving the accuracy of TIA prediction.

METHODS

A total of 250 patients with atherosclerosis who underwent carotid ultrasonography at Naval Military Medical University Affiliated Gongli Hospital were recruited. Plaque location, plaque properties, stenosis rate, peak systolic velocity, and end diastolic velocity were measured and recorded. The WSS distribution map of the proximal and distal ends of the plaque shoulder was drawn using the shear stress quantitative analysis software, and the average values of WSS were recorded. The laboratory indicators of the subjects were recorded. The patients were followed for 4 years. Patients with TIA were included in a TIA group and the remaining patients were included in a control group. The clinical data, laboratory indicators, and ultrasound characteristics of the two groups were analyzed. Survival curves were plotted by the Kaplan-Meier method. Receiver operating characteristic curves were established to evaluate the accuracy of potential indicators in predicting TIA. Logistic regression model was used to establish combined prediction, and the accuracy of combined predictive indicators for TIA was explored.

RESULTS

The intraclass correlation coefficients of the WSS between the proximal and distal ends of the plaque shoulder were 0.976 and 0.993, respectively, which indicated an excellent agreement. At the end of the follow-up, 30 patients suffered TIA (TIA group) and 204 patients did not (control group). Hypertension (P = 0.037), diabetes (P = 0.026), homocysteine (Hcy) (P = 0.022), fasting blood glucose (P = 0.034), plaque properties (P = 0.000), luminal stenosis rate (P = 0.000), and proximal end WSS (P = 0.000) were independent influencing factors for TIA during follow-up. The accuracy of each indicator for predicting TIA individually was not high (area under the curve [AUC] < 0.9). The accuracy of the combined indicator including WSS (AUC = 0.944) was significantly higher than that of the combined indicator without WSS (AUC = 0.856) in predicting TIA (z = 2.177, P = 0.030). The sensitivity and specificity of the combined indicator including WSS were 86.67% and 92.16%, respectively.

CONCLUSION

WSS at plaque surface combined with hypertension, diabetes, Hcy, blood glucose, plaque properties, and stenosis rate can significantly improve the accuracy of predicting TIA.

Recurrent risk of ischemic stroke due to Vertebrobasilar Dolichoectasia

Background

Patients with vertebrobasilar dolichoectasia usually have persistent hemodynamic abnormalities, and therefore, may bear an increased risk of stroke. This study aimed to identify risk factors for stroke recurrence in patients with vertebrobasilar dolichoectasia.

Methods

Patients with acute ischemic stroke were screened and evaluated for eligibility. Enrolled patients were followed via scheduled clinical visits or telephone interviews. Ischemic stroke recurrence was proposed with clinical symptoms and confirmed with cranial Magnetic Resonance Imaging or Computerized Tomography scans. Baseline characteristics and vascular geometry were compared between patients with and without stroke recurrence. Significant parameters were introduced into COX proportional hazard model to detect possible predictors of stroke recurrence.

Results

A total of 115 stroke patients with vertebrobasilar dolichoectasia were enrolled, of which 22 (19.1%) had recurrence during 22 ± 6 months follow-up. Basilar artery diameter ≥ 5.3 mm (HR = 4.744; 95% CI, 1.718–13.097; P = 0.003), diffuse intracranial dolichoectasia (HR = 3.603; 95% CI, 1.367–9.496; P = 0.010) and ischemic heart disease history (HR = 4.095; 95% CI, 1.221–13.740; P = 0.022) had increased risk of recurrence.

Conclusions

Stroke patients with vertebrobasilar dolichoectasia may have a high risk of recurrence. Larger basilar artery diameter or diffuse intracranial dolichoectasia may increase the risk of recurrence.

Recent advances in the management of transient ischemic attacks

Significant advances in our understanding of transient ischemic attack (TIA) have taken place since it was first recognized as a major risk factor for stroke during the late 1950's. Recently, numerous studies have consistently shown that patients who have experienced a TIA constitute a heterogeneous population, with multiple causative factors as well as an average 5-10% risk of suffering a stroke during the 30 days that follow the index event. These two attributes have driven the most important changes in the management of TIA patients over the last decade, with particular attention paid to effective stroke risk stratification, efficient and comprehensive diagnostic assessment, and a sound therapeutic approach, destined to reduce the risk of subsequent ischemic stroke. This review is an outline of these changes, including a discussion of their advantages and disadvantages, and references to how new trends are likely to influence the future care of these patients.

Baseline platelet parameters for predicting early platelet response and clinical outcomes in patients with non-cardioembolic ischemic stroke treated with clopidogrel

Purpose

The present study investigated whether routine baseline platelet parameters(BPPs) detected before clopidogrel therapy in acute non-cardioembolic ischemic stroke(NCIS) could predict early platelet response and future clinical outcomes.

Results

The CYP2C19 polymorphisms constituted independent risk factors for LCR. The number of female patients, the incidence of diabetes mellitus (DM), the level of low-density lipoprotein(LDL) cholesterol, and the neutrophil-to-lymphocyte ratio(NLR) were significantly high in the clinical clopidogrel resistance (CCR) group. However, none of the BPPs had a significant association with laboratory clopidogrel resistance (LCR) or discriminated with the cut-off values regarding LCR or CCR. The patients were divided into two groups according to the average mean platelet volume(MPV) or platelet count(PC). We found that the HbA1c level, the number of female patients, and the CCR were higher in the groups with elevated MPV (≥ 10.6fL) and PC (≥ 235 × 10⁹/L); the LCR, the NIHSS score at discharge, and elevated MPV and PC were risk predictors for CCR.

Materials and Methods

This study included 196 patients with acute NCIS who underwent routine blood tests upon admission, were treated with clopidogrel, and were followed up for 6 months. Early platelet response was assessed and the CYP2C19 genetic variants were screened for. All participants were categorized into either laboratory clopidogrel resistance(LCR) or clinical clopidogrel resistance (CCR) groups.

Conclusions

Elevated baseline MPV and PC before clopidogrel therapy, as well as CYP2C19 gene variants, should be included in a risk algorithm for NCIS. Furthermore, other nongenetic clinical risk factors should be assessed for optimal prediction of the risk for thrombotic events because of individual variability in platelet response to clopidogrel.