Causes, Risk Factors, and Clinical Outcomes of Stroke in Korean Young Adults: Systemic Lupus Erythematosus is Associated with Unfavorable Outcomes

Rare combo: moyamoya and lupus in men

Moyamoya syndrome (MMS) is a rare, chronic, progressive cerebrovascular disorder characterized by stenosis at the apices of the intracranial internal carotid arteries, including the proximal anterior cerebral arteries and middle cerebral arteries. Cerebral angiography images are used for detection through measurement. Systemic lupus erythematosus (SLE) is an autoimmune disease that can cause multisystemic involvement. The coexistence of SLE and MMS has been rarely reported in the literature. A 46-year-old male patient with malar rash, Raynaud phenomenon presented to the hospital with a complaint of weakness in the left lower extremity, which began 3 days before the date of the visit. In the diffusion magnetic resonance imaging, multiple diffusion restrictions were observed in the right frontal region. The patient underwent MR angiography, revealing stenosis in the terminal and supraclinoid segments of the right internal carotid artery, which made us consider moyamoya disease. This patient, with a malar rash and Raynaud's, a positive antibody profile, was diagnosed as a male with SLE accompanied by MMS.

Hypointense signal lesion on susceptibility-weighted imaging as a potential indicator of vertebral artery dissection in medullary infarction

Vertebral artery dissection (VAD) is often associated with medullary infarction; however, an underlying cause may be underestimated. This study aimed to assess the diagnostic potential of hypointense signal lesions along the arterial pathways using susceptibility-weighted imaging (SWI) as a feasible indicator of VAD in medullary infarction. A retrospective analysis was conducted using clinical data, brain magnetic resonance imaging, and angiography records of 79 patients diagnosed with medullary infarction between January 2014 and December 2021. Patients were categorized into an angiography-confirmed dissection group and a non-dissection group based on imaging findings. A new possible dissection group was identified using SWI, including cases with hypointense signals along the arteries without calcification or cardioembolism. We compared the clinical characteristics of the two groups before and after the addition of the hypointense signal as a marker of VAD. The angiography-confirmed dissection group included 12 patients (15%). Among patients lacking angiographic VAD evidence, 14 subjects displayed hypointense signals on SWI: nine patients along the vertebral artery and five subjects at the posterior inferior cerebellar artery without calcification or cardioembolism. The newly classified dissection group was younger, had a lower prevalence of diabetes mellitus and stroke history, and revealed increased headaches compared to the non-dissection group. Hypointense signal detection on SWI in medullary infarctions shows promise as a diagnostic indicator for VAD. Suspicion of VAD is needed when the hypointense signal on SWI is noted, and considering different treatment strategies with angiographic follow-up will be helpful.

A nested case-control study investigating short-term prognosis, clinical and imaging features in acute ischemic stroke patients with systemic lupus erythematosus

OBJECTIVES

To investigate acute ischemic stroke (AIS) patients with systemic lupus erythematosus (SLE) clinical and imaging features, and to explore the impact of SLE on the short-term prognosis of AIS patients.

METHODS

A nested case-control study was conducted in The First Affiliated Hospital of Zhengzhou University between October 1, 2019, and May 31, 2021. The case group consisted of 28 AIS patients diagnosed with SLE, and 112 AIS patients without SLE were selected by incidence density sampling as a control group.

RESULTS

Among 140 patients, the mean age was (48.4 ± 15.6) years, and 130 (92.9%) were females. Higher levels in low-density lipoprotein cholesterol (LDL-C) (2.5 mmol/L vs. 2.1 mmol/L; P = 0.049), D-dimer (DDi) (0.7 mg/L vs. 0.3 mg/L; P = 0.02), and C-reactive protein (CRP) (13.2 mg/L vs. 6.3 mg/L; P = 0.002) were observed in the case group. On imaging, the case group was more prevalent in simultaneous involvement of the anterior and posterior circulation (42.9% vs. 17.0%; P = 0.004), multiple infarcts (46.4% vs. 20.5%; P = 0.008) and stroke of other undetermined etiologies (SUE) (28.6% vs. 6.3%; P = 0.002) than the control group. SLE (OR 5.94, 95%CI [1.04-34.39]; P = 0.045) was an independent risk factor for a poor short-term prognosis of AIS patients.

CONCLUSIONS

Higher levels of LDL-C, CRP, and DDi, multiple infarcts and simultaneous involvement of the anterior, and posterior circulation were more prevalent in the AIS patients with SLE. Further, SLE was also found as an independent risk factor for AIS patients' poor short-term prognosis.

Long Sleep Duration and Dissatisfaction with Sleep Quality Are Associated with Ischemic Stroke in Young Patients

INTRODUCTION

Suboptimal sleep duration and poor sleep quality have been proposed to increase stroke risk. However, their significance in young ischemic stroke is unclear. We aimed to investigate the importance of sleep duration and quality on young ischemic stroke patients.

METHODS

A multicenter matched case-control study was performed to evaluate under-recognized risk factors in young (<45 years) ischemic stroke patients in 8 tertiary hospitals in Korea. A total of 225 patients and 225 age- and sex-matched controls were enrolled in the same period. Detailed information about patients' demographics, socioeconomic state, and traditional and nontraditional risk factors including sleep-related factors were obtained using structured questionnaires. Risk of ischemic stroke was estimated using conditional logistic regression analysis.

RESULTS

Although average sleep duration was similar in patients and controls, patients were more likely to have long (≥9 h) or extremely short (<5 h) sleep durations. In addition, the proportion of subjects with dissatisfaction with sleep quality was higher in patients than controls (66.2 vs. 49.3%, p < 0.001). In multivariable conditional logistic regression analysis, long sleep duration (OR: 11.076, 95% CI: 1.819-67.446, p = 0.009) and dissatisfaction with sleep quality (OR: 2.116, 95% CI: 1.168-3.833, p = 0.013) were independently associated with risk of ischemic stroke.

CONCLUSIONS

Long sleep duration and dissatisfaction with sleep quality may be associated with increased risk of ischemic stroke in young adults. Improving sleep habit or quality could be important for reducing the risk of ischemic stroke.

Predictors for the prognosis and recurrence of ischaemic stroke among young Chinese patients: a cohort study

OBJECTIVE

To identify predictors of young Chinese patients with ischaemic stroke outcome and recurrence of stroke.

DESIGN

Through considered the risk factors, neuroimaging findings, distribution, vascular stenosis, and the post-stroke treatment of young Chinese patients with ischemic stroke.

SETTING

The First Hospital of Jilin University.

PARTICIPANTS

We enrolled 579 patients (median age 45 years, range 15-49, men 81.0%) treated for the first occurrence of ischaemic stroke between January 2014 and December 2017.

MAIN OUTCOME MEASURES

We assessed stroke outcome based on the modified Rankin Scale (mRS) scores and recurrence of cerebrovascular events at 12 months. Multivariate logistic regression was used to identify the independent predictors of unfavourable outcomes (mRS score ≥2) and recurrence.

RESULTS

We observed stenosis in 295 patients (50.9%)-middle cerebral artery stenosis was the most common (18.1%). Of all 579 included patients, normal or mild, moderate and severe stenoses or occlusions were observed in 51.8%, 6.0% and 42.1% of patients, respectively. Unfavourable outcomes were observed in 91 patients (15.7%), including 10 patients (1.7%) who died. The rate of stroke recurrence was 7.9%. Independent predictors of unfavourable outcomes included a high National Institutes of Health Stroke Scale score (OR 1.151, 95% CI 1.094 to 1.210; p<0.001) and severe vascular stenosis or occlusion (OR 1.867, 95% CI 1.181 to 2.952; p=0.008). Predictors of recurrence included age of ≥45 years (OR 2.072, 95% CI 1.066 to 4.025; p=0.032) and atrial fibrillation (OR 15.207, 95% CI 4.273 to 54.120; p<0.001).

CONCLUSIONS

Our research shows that when developing prevention strategies for young people, measures that focus on mitigating risk factors should be considered. In addition, vascular screening of young populations is also of vital importance for stroke prevention and poor prognosis prediction.

Successful treatment with rituximab in a patient with lupus cerebritis and posterior reversible encephalopathy syndrome: a case report

Background: Neuropsychiatric systemic lupus erythematosus (NPSLE) has a diverse and broad spectrum of severity and prognosis, with some devastating manifestations. However, its diagnosis and treatment remain unclear and controversial. Case Report: A 19-year-old woman with SLE presented with fever, headache, quadriparesis, and tremor. Brain magnetic resonance imaging (MRI) showed sulcal enhancement in the cortical sulcus, and intravenous methylprednisolone (500 mg/day) and immunoglobulin (2 g/kg for 5 days) were started under the suspicion of aseptic lupus meningitis. However, the patient’s neurologic symptoms worsened; brain MRI showed a newly developed brain parenchymal lesion, suggesting lupus cerebritis and posterior reversible encephalopathy syndrome. Two cycles of rituximab (850 mg/day, 1-week interval) were administered for the treatment of refractory NPSLE. Her neurologic symptoms gradually improved after the second cycle, and she was discharged with minimal neurologic symptoms. Conclusion: Rituximab may be a therapeutic option for refractory lupus cerebritis. Further research is needed to accurately determine its efficacy.

Progression in Moyamoya Disease: Clinical Feature, Neuroimaging Evaluation and Treatment

Moyamoya disease (MMD) is a chronic cerebrovascular disease characterized by progressive stenosis of the arteries of the circle of Willis, with the formation of collateral vascular network at the base of the brain. Its clinical manifestations are complicated. Numerous studies have attempted to clarify the clinical features of MMD, including its epidemiology, genetic characteristics, and pathophysiology. With the development of neuroimaging techniques, various neuroimaging modalities with different advantages have deepened the understanding of MMD in terms of structural, functional, spatial, and temporal dimensions. At present, the main treatment for MMD focuses on neurological protection, cerebral blood flow reconstruction, and neurological rehabilitation, such as pharmacological treatment, surgical revascularization, and cognitive rehabilitation. In this review, we discuss recent progress in understanding the clinical features, in the neuroimaging evaluation and treatment of MMD.