Clinical Features of Embolic Stroke of Undetermined Source

Association Between Spotty Calcification in Nonstenosing Extracranial Carotid Artery Plaque and Ipsilateral Ischemic Stroke

Background Small spotty calcifications in the coronary arteries are associated with an increased risk of myocardial infarction. We examined the association between spotty calcifications near the carotid bifurcations and ipsilateral ischemic stroke in patients with <50% luminal stenosis of the extracranial carotid arteries. Methods and Results We used data from the CAESAR (Cornell Acute Stroke Academic Registry), a prospective registry of all patients with acute ischemic stroke admitted to our institution. We included patients who met criteria for cryptogenic stroke and underwent computed tomography angiography and brain magnetic resonance imaging. Patients with extracranial carotid artery stenosis ≥50% and patients with posterior or bilateral anterior circulation infarcts were excluded. We examined the carotid bifurcations for spotty calcifications, defined as ≥1 contiguous regions of luminal calcification ≤3 mm along the long axis of the vessel. We also measured low-density plaque and maximum plaque thickness. The eligible cohort consisted of 117 patients with a mean age of 66.7±1.65 years with a median National Institute of Health Stroke Scale stroke at the time of arrival of 6 (range, 3-13). The number of spotty calcifications present within a low-density plaque was significantly associated with ipsilateral infarction (0.3±0.8 versus 0.1±0.4, P=0.02). Maximum plaque thickness was also significantly associated with ipsilateral infarction (1.4 mm ±1.5 versus 1.0 mm ±1.1, P=0.004). Conclusions Spotty calcifications associated with low-density plaque and maximum plaque thickness were associated with ipsilateral ischemic stroke in patients with nonstenotic carotid atherosclerosis, suggesting a role as imaging markers of high-risk plaque.

Demographic characteristics and types of stroke in Southwestern Saudi Arabia, and the potential demand of neuro endovascular specialists

OBJECTIVES

To identify demographic characteristics, and types of stroke in Southwestern (Aseer) Region, Saudi Arabia.

METHODS

This study is a retrospective and hospital-based. The data of all stroke patients (n=562) admitted to the tertiary care hospital in the province, Aseer Central Hospital (ACH) within the period from January 2016 until December 2017 are included.

RESULTS

The mean ± SD of stoke patients' age was 62.6 ± 17.0 years. Male patients were more than female patients (62.6% and 37.4%, respectively). The majority (93.2%) were Saudi, while 91.5% had below university education and 6.4% were smokers. Interestingly, only 2% of patients had a family history of stroke, while 68.1% were diabetic, 80.4% were hypertensive, 91.6% had high serum cholesterol level, and 10.7% had history of transient ischemic attacks (TIA). Despite the lack of awareness, and leading to delay in reaching health care facility, 58.1% of stroke patients, were arriving to emergency department (ED) in less than 24 hours (potential endovascular therapeutic window).

CONCLUSIONS

In Aseer Region, Saudi Arabia, stroke affects mainly those who are older, less educated, diabetic, hypertensive, with hypercholesterolemia and previous history of TIA. Associated factors for stroke differ significantly according to their nationality.

Diagnosis and Treatment for embolic stroke of undetermined source: Consensus statement from the Taiwan stroke society and Taiwan society of cardiology

Cryptogenic stroke comprises about one-quarter of ischemic strokes with high recurrence rate; however, studies specifically investigating the features and treatment of this stroke subtype are rare. The concept of 'embolic stroke of undetermined source' (ESUS) may facilitate the development of a standardized approach to diagnose cryptogenic stroke and improve clinical trials. Since recent large randomized control trials failed to demonstrate a reduction in stroke recurrence with anticoagulants, anti-platelet agents remain the first-line treatment for ESUS patients. Nevertheless, patients with high risk of stroke recurrence (e.g., those with repeated embolic infarcts despite aspirin treatment) require a more extensive survey of stroke etiology, including cardiac imaging and prolonged cardiac rhythm monitoring. Anticoagulant treatments may still benefit some subgroups of high-risk ESUS patients, such as those with multiple infarcts at different arterial territories without aortic atheroma, the elderly, or patients with high CHA₂D₂-VASc or HOVAC scores, atrial cardiopathy or patent foramen ovale. Several important ESUS clinical trials are ongoing, and the results are anticipated. With rapid progress in our understanding of ESUS pathophysiology, new subcategorizations of ESUS and assignment of optimal treatments for each ESUS subgroup are expected in the near future.