Silent brain infarct in migraine: Systematic review and meta-analysis

BACKGROUND

While migraine, particularly migraine with aura, is a recognized risk factor for ischemic stroke, the association of migraine with silent brain infarction is a matter of debate, as studies on this topic have yielded conflicting results.

METHODS

A systematic review of the literature was conducted of studies reporting migraine and silent brain infarction, assessed by magnetic resonance imaging, between January 1980 and April 2022, by consulting Medline and Embase databases. Studies with a control group were included in a meta-analysis of population-based studies. An exploratory meta-analysis of both population-based and clinical-based studies was further performed to test the association between migraine with aura and silent brain infarction.

RESULTS

A total of 2,408 articles were identified, among which 24 were included in the systematic review and 10 in the meta-analysis. The meta-analysis of population-based studies showed no association of migraine with silent brain infarction (odds ratio (OR)=1.32 [95% CI 0.92;1.90], P=0.13) and migraine with aura with silent brain infarction (OR=1.56 [0.74;3.30], P=0.24). However, in the exploratory meta-analysis of population-based and clinical-based studies, migraine with aura was significantly associated with silent brain infarction (OR=1.91 [1.02;3.59], P=0.04) and to silent cerebellar infarcts (OR=2.57 [1.01;6.56], P=0.05).

CONCLUSION

In this updated systematic review and meta-analysis of population-based studies, migraine and migraine with aura were not associated with silent brain infarction.

Stroke phenotype in cannabis users among young adults with ischemic stroke

INTRODUCTION

Incidence of ischemic stroke in young adults has been steadily increasing over the last 20 years. One hypothesis to explain this phenomenon is the increase in the use of illicit drugs, including cannabis. However, the mechanisms and the clinical presentation of ischemic stroke associated with cannabis use are unclear. The objective of this study was to describe the phenotype of ischemic stroke in cannabis users compared to non-users among a population of young adults with a first-ever ischemic stroke.

METHODS

Patients aged 18 to 54 years consecutively hospitalized in a university department of neurology for a first-ever ischemic stroke from January 2017 to July 2021 were included. Drug use over the past year was assessed by a semi-structured interview and the stroke phenotype was described using the ASCOD classification.

RESULTS

A total of 691 patients, including 78/691 (11.3%) cannabis users were included. Cannabis use was independentely associated with potential A1 (OR = 3.30, 95% CI [1.45-7.5], p = 0.004) and uncertain A2 (OR = 13.1, 95% CI [2.89-59.4], p < 0.001) atherosclerotic cause of stroke after adjustment for vascular risk factors including tobacco and other drug use. Moreover, the association of atherosclerosis and cannabis use was significant for frequent, (OR = 3.13, IC 95% [1.07-8.6], p = 0.030), and daily cannabis use (OR = 4.43, IC 95% [1.40-13.4], p = 0.008), but not for occasional use.

CONCLUSION

We found a significant, independent and graded association of cannabis use with the atherosclerotic stroke phenotype.

Insular functional connectivity in migraine with aura

Introduction

Insula plays an integrating role in sensory, affective, emotional, cognitive and autonomic functions in migraine, especially in migraine with aura (MA). Insula is functionally divided into 3 subregions, the dorsoanterior, the ventroanterior and the posterior insula respectively related to cognition, emotion, and somatosensory functions. This study aimed at investigating functional connectivity of insula subregions in MA.

Methods

Twenty-one interictal patients with MA were compared to 18 healthy controls (HC) and 12 interictal patients with migraine without aura (MO) and were scanned with functional MRI during the resting state. Functional coupling of the insula was comprehensively tested with 12 seeds located in the right and left, dorsal, middle, ventral, anterior and posterior insula, by using a seed-to-voxel analysis.

Results

Seed-to-voxel analysis revealed, in MA, a strong functional coupling of the right and left antero-dorsal insula with clusters located in the upper cerebellum. The overlap of these cerebellar clusters corresponded to the vermis VI. These functional couplings were not correlated to duration of MA, frequency of MA attacks nor time since last MA attack, and were not found in MO.

Discussion

The anterior insula and superior cerebellum, including vermis VI, are components of the central Autonomic Nervous System (ANS) network. As these regions are involved in the control of cardiovascular parasympathetic tone, we hypothesize that this connectivity may reflect the cardiovascular features of MA.

Conclusion

The anterior dorsal insula is connected with vermis VI in MA patients in the resting state. This connectivity may reflect the cardiovascular features of MA.

Trial registration

NCT02708797.

Ultrasound characteristics of carotid web

BACKGROUND AND PURPOSE

Carotid web (CaW) is a cause of recurrent ischemic stroke that remains underdiagnosed using Duplex ultrasound (DUS). Improved methods and description of its ultrasound's features could allow better detection of CaW. Ultrasound microflow imaging (MFI) is a blood flow imaging technique sensitive to slow flow that could increase CaW detection. This study aimed to describe ultrasound features of CaW using B-mode imaging and MFI.

METHODS

In a retrospective monocentric study, patients with CaW on CT angiography who underwent DUS examination of carotid arteries were included. DUS was performed by two nonblinded experienced neurosonologists. The specificity of CaW ultrasound features was evaluated using a group of patients with carotid atherosclerotic plaque (AP).

RESULTS

Twenty-four patients with CaW were included. Mean age (standard deviation) was 48 years (11). Seventeen (71%) were females. Fifteen (63%) CaWs were symptomatic. MFI was available for 22 patients. B-mode imaging demonstrated the characteristic CaW appearance in 19/24 (79%) patients as a protruding triangular iso-hypoechoic lesion on longitudinal view. CaW were detected on axial view in only 9/24 (38%) patients. MFI displayed slow blood flow above CaW during systole and allowed it delineation, appearing as a thin triangular endoluminal defect in 18/22 (82%) cases. Based on MFI and B-mode, 21/22 (95%) CaWs were visible, including three CaWs only with MFI. These ultrasound features were not found among 24 patients with AP.

CONCLUSION

We report the ultrasound features from a series of 24 CaW. The use of MFI in addition to B-mode imaging improved the detection rate of CaW.

Peri-Operative Outcomes of Carotid Endarterectomy are Not Improved on Dual Antiplatelet Therapy vs. Aspirin Monotherapy: A Systematic Review and Meta-Analysis

OBJECTIVE

A systematic review and meta-analysis of the peri-operative outcomes of carotid endarterectomy (CEA) on dual antiplatelet therapy (DAPT) vs. aspirin monotherapy was carried out, to determine optimal peri-operative management with these antiplatelet agents.

DATA SOURCES

The Web of Science, Pubmed, and Embase databases were searched from inception to July 2021. The corresponding authors of excluded articles were contacted to obtain additional data for possible inclusion.

REVIEW METHODS

The main outcomes included ischaemic complications (stroke, transient ischaemic attack [TIA], and transcranial Doppler [TCD] measured micro-emboli), haemorrhagic complications (haemorrhagic stroke, neck haematoma, and re-operation for bleeding), and composite outcomes. Pooled estimates using odds ratios (ORs) were combined using a random or fixed effects model based on the results of the chi square test and calculation of I².

RESULTS

In total, 47 411 patients were included in 11 studies, with 14 345 (30.2%) receiving DAPT and 33 066 (69.7%) receiving aspirin only. There was no significant difference in the rates of peri-operative stroke (OR 0.87, 95% confidence interval [CI] 0.72 - 1.05) and TIA (OR 0.78, 95% CI 0.52 - 1.17) despite a significant reduction in TCD measured micro-emboli (OR 0.19, 95% CI 0.10 - 0.35) in the DAPT compared with the aspirin monotherapy group. Subgroup analysis did not reveal any significant difference in ischaemic stroke risk between patients with asymptomatic and symptomatic carotid artery stenosis. DAPT was associated with an increased risk of neck haematoma (OR 2.79, 95% CI 1.87 - 4.18) and re-operation for bleeding (OR 1.98, 95% CI 1.77 - 2.23) vs. aspirin. Haemorrhagic stroke was an under reported outcome in the literature.

CONCLUSION

This meta-analysis found that CEA while on DAPT increased the risk of haemorrhagic complications, with similar rates of ischaemic complications, vs. aspirin monotherapy. This suggests that the risks of performing CEA on DAPT outweigh the benefits, even in patients with symptomatic carotid stenosis. The overall quality of studies was low, and improved reporting of CEA outcomes in the literature is necessary.

Cryptogenic Ischemic Stroke in Migraine: Role of Patent Foramen Ovale

Introduction

Migraine with aura (MWA) has been associated with cryptogenic ischemic stroke (CIS) after adjustment for the presence of a patent foramen ovale (PFO) assessed by a transcranial Doppler. This study aimed at evaluating the association of MWA with causal PFO assessed by Transesophageal echocardiography (TEE) in CIS.

Methods

Patients aged 18–54 years consecutively treated for first acute ischemic stroke in a university hospital stroke unit, between January 2017 and December 2019, were included in this cross-sectional study. Associations between migraine subtypes and PFO were tested for all PFO, possibly causal PFO (PFO with large shunt and/or atrial septal aneurysm [ASA]), and the probably causal PFO subset (large shunt and/or ASA, plus risk of paradoxical embolism [RoPE] score ≥ 7). We adjusted the association between migraine subtypes and possibly causal PFO, which included the probably causal subset for age, sex, large artery atherosclerosis, and small vessel disease.

Results

A total of two hundred and two patients with CIS were included, of whom 42/202 (20%) had MWA, 32/202 (15%) had migraine without aura, and 128/202 (63%) had no migraine. MWA was associated with possibly causal PFO (OR = 4.0, 95%CI [1.78–9.3], P < 0.001) and with probably causal PFO (OR = 5.4, 95%CI [2.37–13], P < 0.001). In a multinomial logistic regression analysis, MWA remained associated with possibly causal PFO (OR = 3.24, 95% CI [1.45–7.2], P = 0.004).

Conclusion

In a young adult population with CIS, MWA was strongly associated with possibly causal PFO, i.e., with a large shunt or combined with an interatrial septal aneurysm.

Large artery intracranial stenosis in young adults with ischaemic stroke

Large artery intracranial stenosis (ICS) is a common finding in stroke patients, but is much less prevalent in Western countries than in Asia and in young adults than in the elderly. We investigated the prevalence and causes of ICS among French young adults with ischaemic stroke. Clinical and radiological data of patients aged 18-54 years treated consecutively for acute ischaemic stroke in the anterior circulation at a tertiary stroke centre were analysed retrospectively. Patients with>50% ICS were identified. ICS was evaluated using TOF-MRA, vessel wall-MRI, digital subtraction angiography and CT-angiography. A total of 316 patients were included. ICS was diagnosed in 29 patients, resulting in a prevalence of 9.2% (95% CI, 6.2 to 13.3). The leading cause of ICS was atherosclerosis (n=13), ahead of moyamoya disease (n=4), dissection (n=2), vasculitis (n=2), and reversible cerebral vasoconstriction syndrome (n=1). The cause of ICAS could not be determined in 7 patients. ICS was found in nearly one in 10 ischaemic strokes among French young adults. Atherosclerosis was the leading cause of ICS. The cause of ICS could not be determined in almost a quarter of the patients.

Sonothrombolysis in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: An Individual Patient Data Meta-Analysis

BACKGROUND AND PURPOSE

Evidence about the utility of ultrasound-enhanced thrombolysis (sonothrombolysis) in patients with acute ischemic stroke (AIS) is conflicting. We aimed to evaluate the safety and efficacy of sonothrombolysis in patients with AIS with large vessel occlusion, by analyzing individual patient data of available randomized-controlled clinical trials.

METHODS

We included all available randomized-controlled clinical trials comparing sonothrombolysis with or without addition of microspheres (treatment group) to intravenous thrombolysis alone (control group) in patients with AIS with large vessel occlusion. The primary outcome measure was the rate of complete recanalization at 1 to 36 hours following intravenous thrombolysis initiation. We present crude odds ratios (ORs) and ORs adjusted for the predefined variables of age, sex, baseline stroke severity, systolic blood pressure, and onset-to-treatment time.

RESULTS

We included 7 randomized controlled clinical trials that enrolled 1102 patients with AIS. A total of 138 and 134 confirmed large vessel occlusion patients were randomized to treatment and control groups respectively. Patients randomized to sonothrombolysis had increased odds of complete recanalization compared with patients receiving intravenous thrombolysis alone (40.3% versus 22.4%; OR, 2.17 [95% CI, 1.03-4.54]; adjusted OR, 2.33 [95% CI, 1.02-5.34]). The likelihood of symptomatic intracranial hemorrhage was not significantly different between the 2 groups (7.3% versus 3.7%; OR, 2.03 [95% CI, 0.68-6.11]; adjusted OR, 2.55 [95% CI, 0.76-8.52]). No differences in the likelihood of asymptomatic intracranial hemorrhage, 3-month favorable functional and 3-month functional independence were documented.

CONCLUSIONS

Sonothrombolysis was associated with a nearly 2-fold increase in the odds of complete recanalization compared with intravenous thrombolysis alone in patients with AIS with large vessel occlusions. Further study of the safety and efficacy of sonothrombolysis is warranted.

Leptomeningeal enhancement on post-contrast FLAIR images for early diagnosis of Susac syndrome

BACKGROUND

Leptomeningeal enhancement (LME) is a key feature of Susac syndrome (SuS) but is only occasionally depicted on post-contrast T1-weighted images (T1-WI).

OBJECTIVE

As post-contrast fluid-attenuated inversion recovery (FLAIR) may be more sensitive, our aim was to assess LME in SuS on this sequence.

METHODS

From 2010 to 2020, 20 patients with definite SuS diagnosis were retrospectively enrolled in this multicentre study. Two radiologists independently assessed the number of LME on post-contrast FLAIR and T1-WI acquisitions performed before any treatment. A chi-square test was used to compare both sequences and the interrater agreement was calculated.

RESULTS

Thirty-five magnetic resonance imagings (MRIs) were performed before treatment, including 19 post-contrast FLAIR images in 17 patients and 25 post-contrast T1-WI in 19 patients. In terms of patients, LME was observed on all post-contrast FLAIR, contrary to post-contrast T1-WI (17/17 (100%) vs. 15/19 (79%), p < 0.05). In terms of sequences, LME was observed on all post-contrast FLAIR, contrary to post-contrast T1-WI (19/19 (100%) vs. 16/25 (64%), p < 0.005). LME was disseminated at both supratentorial (19/19) and infratentorial (18/19) levels on post-contrast FLAIR, contrary to post-contrast T1-WI (3/25 and 9/25, respectively). Interrater agreement was excellent for post-contrast FLAIR (κ = 0.95) but only moderate for post-contrast T1-WI (κ = 0.61).

CONCLUSION

LME was always observed and easily visible on post-contrast FLAIR images prior to SuS treatment. In association with other MRI features, it is highly indicative of SuS.

PI3KC2β inactivation stabilizes VE-cadherin junctions and preserves vascular integrity

Endothelium protection is critical, because of the impact of vascular leakage and edema on pathological conditions such as brain ischemia. Whereas deficiency of class II phosphoinositide 3-kinase alpha (PI3KC2α) results in an increase in vascular permeability, we uncover a crucial role of the beta isoform (PI3KC2β) in the loss of endothelial barrier integrity following injury. Here, we studied the role of PI3KC2β in endothelial permeability and endosomal trafficking in vitro and in vivo in ischemic stroke. Mice with inactive PI3KC2β showed protection against vascular permeability, edema, cerebral infarction, and deleterious inflammatory response. Loss of PI3KC2β in human cerebral microvascular endothelial cells stabilized homotypic cell-cell junctions by increasing Rab11-dependent VE-cadherin recycling. These results identify PI3KC2β as a potential new therapeutic target to prevent aggravating lesions following ischemic stroke.

Atrial fibrillation and migraine with aura in young adults with ischemic stroke

BACKGROUND

Migraine is associated with an increased risk of ischemic stroke. The associations are stronger in migraine with aura than in migraine without aura, in women than in men, and in younger subjects. However, the mechanisms by which migraine might increase the risk of ischemic stroke are debated.

METHODS

We analysed the associations between migraine without aura and migraine with aura and the causes of ischemic stroke in patients aged 18-54 years treated consecutively in a university hospital stroke center.

RESULTS

A total of 339 patients (mean/SD age 43.8/8.8 years, 62.83% male) were included. Migraine with aura was diagnosed in 58 patients, and migraine without aura in 54 patients. Patients with migraine with aura were younger and had fewer traditional cardiovascular risk factors than patients with no migraine. Migraine with aura was strongly associated with atrial fibrillation (odds ratio, 5.08; 95% confidence interval, 1.24-21.92; p = 0.011) and negatively associated with atherosclerosis (odds ratio, 0.29; 95% confidence interval, 0.05-0.97; p = 0.033) and small vessel disease (odds ratio, 0.13; 95% confidence interval, 0.00-0.87; p = 0.022). No other cause of stroke was significantly associated with migraine. The most common cause of stroke was atherosclerosis in no-migraine patients, dissection in migraine without aura patients and patent foramen ovale in migraine with aura patients. Atrial fibrillation was, together with dissection, the second leading cause of stroke in migraine with aura patients, accounting for 10.34% of cases in this subgroup.

CONCLUSION

We showed that atrial fibrillation was a common cause of ischemic stroke in young adults with migraine with aura.

Left Atrial Function in Young Patients With Cryptogenic Stroke and Patent Foramen Ovale: A Left Atrial Longitudinal Strain Study

Background: The study of left atrial (LA) longitudinal strain by speckle tracking is a reliable method for analyzing LA function that could provide relevant information in young patients with cryptogenic stroke (CS). The aim of this study was to investigate whether the presence of a patent foramen ovale (PFO) impacts the LA longitudinal strain in a population of young patients with first CS.

Methods and Results: Patients aged 18 to 54 years, treated consecutively in a university hospital for first CS, were included in this study. The presence of a PFO and an atrial septal aneurysm (ASA) was investigated using transesophageal echocardiography and transcranial Doppler. Speckle tracking analysis was performed on transthoracic echocardiography, allowing the measurement of global, passive, and active longitudinal LA strain, corresponding to the reservoir, conduit, and contractile function, respectively. A total of 51 patients were included in the study. In a multivariable analysis, overweight was associated with reduced global and passive LA longitudinal strain (P = 0.013 and P = 0.018, respectively), and hypertension was associated with reduced active LA longitudinal strain (P = 0.049). LA longitudinal strain was not different between patients with PFO or PFO plus ASA and patients without PFO.

Conclusion: LA longitudinal strain in young subjects with CS was impaired in the presence of overweight and hypertension, but not of PFO or PFO plus ASA.

Neuromelanin Locus Coeruleus MRI Contrast in Migraine With Aura

INTRODUCTION

The locus coeruleus (LC) is one of the brainstem nuclei that may be activated during migraine attack. As LC contains neuromelanin, a by-product of norepinephrine synthesis, it can be delineated in vivo using neuromelanin sensitive magnetic resonance imaging (MRI). The neuromelanin content in LC has been suggested to reflect previous LC activation. We investigated LC MRI contrast in patients with migraine with aura (MWA) and its correlation with migraine features.

METHODS

This matched cohort study compared 23 MWA patients aged 30-55 and without comorbidity, to 23 sex- and age-matched healthy controls. The study was conducted in a University Hospital. LC contrast was measured with T1 neuromelanin-sensitive-weighted 3T MRI. Voxels were manually selected by 2 independent researchers and comparison was made twice using intersection and union of the voxels selected by the 2 observers.

RESULTS

No difference was found in neuromelanin LC contrast between MWA patients and controls with both the INTER method (0.224 ± 0.042 vs 0.228 ± 0.048; difference: 0.0001 (95%CI: -0.032 to 0.026), P = .799) and UNION method (0.218 ± 0.043 vs 0.222 ± 0.047; difference: -0.0012 (95%CI: -0.031 to 0.026), P = .775). Global LC volume was also similar between the 2 groups with INTER method (15.087 ± 3.965 vs 13.739 ± 3.583; difference: 2 (95%CI: -1 to 4), P = .233) and UNION method (17.522 ± 4.440 vs 16.087 ± 4.274; difference: 1 (95%CI: -2 to 4), P = .270). Moreover, no correlations were found between neuromelanin LC contrast and migraine features (duration of migraine and frequency of attacks).

CONCLUSION

These negative findings do not support the use of neuromelanin LC contrast as a biomarker of MA.

Abstract 106: Safety and Efficacy of Sonothrombolysis in Acute Ischemic Stroke Patients With Large Vessel Occlusion: International Collaborative Individual Patient Data Meta-Analysis

Introduction: Conflicting evidence has been published regarding the safety and efficacy of ultrasound-enhanced thrombolysis (sonothrombolysis) in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO).

Methods: We conducted an individual participant data meta-analysis of available randomized controlled trials (RCTs) comparing sonothrombolysis with or without addition of microspheres (treatment group) to intravenous thrombolysis alone (control group) in AIS patients with LVO.

Results: We included 6 in total RCTs that enrolled 1077 AIS patients. A total of 138 and 134 confirmed LVO patients were randomized to treatment and control groups respectively (median age 68 years, 58% men, median baseline NIHSS score 16). Patients randomized to sonothrombolysis had increased odds of complete recanalization compared to patients receiving intravenous thrombolysis alone (40.3% vs. 22.4%; OR=2.30, 95%CI: 1.05-5.02; adjusted OR=2.33, 95%CI: 1.02-5.34). They also tended to have increased odds of any (complete or partial recanalization (66.4% vs. 53.0%; OR=1.78, 95%CI: 0.95-3.33; adjusted OR=1.85, 95%CI: 0.97-3.53). The likelihood of symptomatic intracranial hemorrhage did not differ between the two groups (7.3% vs. 3.7%, OR=2.52, 95%CI: 0.77-8.29; adjusted OR=2.55, 95%CI: 0.76-8.52). No differences in the likelihood of asymptomatic intracranial hemorrhage (adjusted OR: 1.30, 95%CI: 0.38-4.39), three-month mortality (adjusted OR: 1.23, 95%CI: 0.25-6.05), three-month favorable functional outcome (mRS-scores of 0-1; adjusted OR: 1.43, 95%CI: 0.64-3.19) and three-month functional independence (mRS-scores of 0-2; adjusted OR: 1.43, 95%CI: 0.77-2.64) were documented.

Conclusion: Sonothrombolysis was associated with a two-fold increase in the odds of complete recanalization compared to intravenous thrombolysis alone in AIS patients with LVOs. Further study of the safety and efficacy of sonothrombolysis is warranted.

Standard Diffusion-Weighted Imaging in the Brain Can Detect Cervical Internal Carotid Artery Dissections

BACKGROUND AND PURPOSE

The ICA is the most common site of cervical artery dissection. Prompt and reliable identification of the mural hematoma is warranted when a dissection is clinically suspected. The purpose of this study was to assess to capacity of a standard DWI sequence acquired routinely on the brain to detect dissecting hematoma related to cervical ICA dissections.

MATERIALS AND METHODS

This was a retrospective study of a cohort of 110 patients younger than 55 years of age (40 women; mean age, 46.79 years) admitted at the acute phase of a neurologic deficit, headache, or neck pain and investigated by at least a standard 3T diffusion-weighted sequence of the brain. Among them were 50 patients (14 women; mean age, 46.72 years) with subsequently confirmed ICA dissection. In the whole anonymized cohort, both a senior and junior radiologist separately assessed, on the DWI sequences only, the presence of a crescent-shaped or circular hypersignal projecting on the subpetrosal segment of the ICA arteries, assuming that it would correspond to a mural hematoma related to an ICA dissection.

RESULTS

The senior radiologist found 46 subpetrosal hyperintensities in 43/50 patients with ICA dissection and none in patients without dissection (sensitivity, 86%; specificity, 100%). The junior radiologist found 48 subpetrosal hyperintensities in 45/50 patients with dissection and none in patients without dissection (sensitivity, 90%; specificity, 100%).

CONCLUSIONS

In our cohort, a standard DWI sequence performed on the brain at the acute phase of a stroke or for a clinical suspicion of dissection detected nearly 90% of cervical ICA dissections.

Functional connectivity of hypothalamus in chronic migraine with medication overuse

OBJECTIVE

To investigate the functional connectivity of the hypothalamus in chronic migraine compared to interictal episodic migraine in order to improve our understanding of migraine chronification.

METHODS

Using task-free fMRI and ROI-to-ROI analysis, we compared anterior hypothalamus intrinsic connectivity with the spinal trigeminal nucleus in patients with chronic migraine (n = 25) to age- and sex-matched patients with episodic migraine in the interictal phase (n = 22). We also conducted a seed-to-voxel analysis with anterior hypothalamus as a seed.

RESULTS

All patients with chronic migraine had medication overuse. We found a significant connectivity (T = 2.08, p = 0.024) between anterior hypothalamus and spinal trigeminal nucleus in the chronic group, whereas these two regions were not connected in the episodic group. The strength of connectivity was not correlated with pain intensity (rho: 0.09, p = 0.655). In the seed-to-voxel analysis, three regions were more connected with the anterior hypothalamus in the chronic group: The spinal trigeminal nuclei (MNI coordinate x = 2, y = -44, z = -62), the right dorsal anterior insula (MNI coordinate x = 10, y = 10, z = 18), and the right caudate (MNI coordinate x = 12, y = 28, z = 6). However, these correlations were no longer significant after whole brain FWE correction.

CONCLUSION

An increased functional connectivity between the anterior hypothalamus and the spinal trigeminal nucleus, as previously reported in preictal episodic migraine, was demonstrated in chronic migraine with medication overuse. This finding confirms a major role of the anterior hypothalamus in migraine and suggests that chronic migraineurs are locked in the preictal phase.

Cerebral autoregulation in migraine with aura: A case control study

BACKGROUND

Migraine with aura is independently associated with increased risk of ischemic stroke, especially in younger subjects. This association might be related to an impairment of cerebral autoregulation, which normally maintains cerebral blood flow independent of arterial blood pressure variations.

METHODS

Patients aged 30-55, fulfilling ICHD-3 beta criteria for migraine with aura, were prospectively enrolled and compared with gender- and age-matched healthy controls without a history of migraine. Patients and controls with a history of stroke or any disease potentially impairing cerebral autoregulation were excluded. We assessed cerebral autoregulation with two different methods: Transfer function analysis, and the correlation coefficient index Mx. The transfer function phase and gain reflect responses of cerebral blood flow velocities to relatively fast fluctuations of arterial blood pressure, whereas Mx also reflects responses to slower arterial blood pressure fluctuations.

RESULTS

A total of 22 migraine with aura patients (median age [IQR]: 39.5 [12.5] years) and 22 controls (39 [9.75] years) were included. Transfer function parameters and Mx were not different between patients and controls. However, Mx was inversely correlated with age in patients (ρ = -0.567, p = 0.006) and not in controls (ρ = -0.084, p = 0.509). Mx was also inversely correlated with migraine with aura duration (ρ = -0.617, p = 0.002), suggesting improvement of cerebral autoregulation efficiency with disease duration.

CONCLUSIONS

Cerebral autoregulation did not differ between patients and controls aged 30-55. However, cerebral autoregulation efficiency was strongly correlated with migraine with aura duration. Further studies in younger patients are needed to determine whether cerebral autoregulation is impaired early in the course of disease.

TRIAL REGISTRATION

NCT02708797.

Changes in Activated Thrombin-Activatable Fibrinolysis Inhibitor Levels Following Thrombolytic Therapy in Ischemic Stroke Patients Correlate with Clinical Outcome

BACKGROUND AND PURPOSE

Thrombin-activatable fibrinolysis inhibitor (TAFI) activation following thrombolysis may affect thrombolysis effectiveness in acute ischemic stroke (AIS). To support this hypothesis, we propose to study the relationship between TAFI consumption, activated/inactivated TAFI (TAFIa/ai) and stroke severity and outcome in 2 groups of AIS patients, one treated and one untreated with intravenous recombinant tissue type plasminogen activator (rt-PA).

METHODS

In this prospective, longitudinal, multicenter, observational study, we aimed to study the association between TAFIa/ai and stroke outcome. TAFI levels were sequentially measured in patients treated with intravenous rt-PA thrombolysis (T), and in patients not given any thrombolytic therapy (NT). Baseline reference values were established in healthy subjects matched for age and gender. The National Institutes of Health Stroke Scale (NIHSS) score assessed at baseline and on day 2 was dichotomized into 2 severity groups (0-7 vs. >7). The modified Rankin Scale (mRS) score at day 90 was dichotomized for favorable (0-1) and unfavorable (2-6) outcomes.

RESULTS

A total of 109 patients were included, with 41 receiving rt-PA. At admission, patients had higher TAFIa/ai levels than reference. A significant increase in TAFIa/ai levels was observed at the end of thrombolysis (mean change from baseline of 963%) and lasted up to 4 h (191%). Higher TAFIa/ai levels were associated with a more severe day 2 NIHSS score (p = 0.0098 at T2h post thrombolysis) and an unfavorable mRS score from T48h (p = 0.0417) to day 90 (p = 0.0046). In NT patients, higher TAFIa/ai levels at admission were associated with a more severe stroke, as assessed by day 2 NIHSS score (p = 0.0026) and mRS score (p = 0.0003).

CONCLUSION

These data demonstrate a consistent relationship between TAFI levels and early clinical severity during rt-PA treatment.

Acute Convexity Subarachnoid Hemorrhage Related to Cerebral Amyloid Angiopathy: Clinicoradiological Features and Outcome

BACKGROUND

The specificities of acute convexity subarachnoid hemorrhage (cSAH) related to cerebral amyloid angiopathy (CAA) and its evolution are not well known. We aimed to describe the clinicoradiological pattern, the magnetic resonance imaging (MRI) evolution, and the risk of recurrent bleeding in such patients.

METHODS

Among consecutive patients with an acute nontraumatic cSAH, subjects with available MRI who meet the modified Boston criteria for probable CAA were included. Review of medical records, MRI findings, and follow-up data was performed.

RESULTS

Twenty-three patients (14 women; mean age ± standard deviation: 75.9 ± 7.3 years) were included. cSAH was revealed by transient focal neurological episodes (TFNEs) in 18 of 23 (78.3%) patients. In all patients, acute cSAH appeared as a sulcal fluid-attenuated inversion recovery hyperintensity and GRE T2 hypointensity. Cortical superficial siderosis and cortical microbleeds, respectively, were observed in 21 (91.3%) and 20 (86.9%) patients. Twenty patients (87%) had available follow-up data with a mean duration of 29.8 ± 20.2 months. Recurrent TFNEs occurred in 40% of patients. Acute cSAH evolved into cortical superficial siderosis in all patients. New subarachnoid bleedings defined by recurrent acute cSAH (n = 8) or extension of siderosis (n = 14) were detected in 83.3% of the patients. Lobar intracerebral hemorrhage (ICH) occurred in 7 patients (35%).

CONCLUSION

CAA-related cSAH has a specific pattern defined by a high prevalence of TFNEs and cortical superficial siderosis, with a high risk of recurrent bleeding, either cSAH or lobar ICH. The systematic evolution from cSAH to focal cortical superficial siderosis reveals data on siderosis physiopathology.

Abstract WMP95: Cerebral Amyloid Angiopathy Patients With Convexity Subarachnoid Hemorrhage Present Higher Risk of Subsequent Hemorrhage Than Those With Lobar Intracranial Hemorrhage

Background: Acute convexity subarachnoid hemorrhage (cSAH) is increasingly recognized as a marker of cerebral amyloid angiopathy (CAA). Little is known about the risk of subsequent hemorrhage in such CAA presentation, whereas CAA-related lobar intracranial hemorrhage (ICH) is associated with a high risk of recurrence. The aim of this study was to compare clinical outcome among patients with an acute CAA related- cSAH to those with an acute CAA-related lobar ICH.

Hypothesis: We hypothesized that the risk of subsequent hemorrhage is different between patients with acute cSAH and lobar ICH related to CAA.

Methods: We retrospectively reviewed the clinical outcomes (death, subsequent transient focal neurological episodes (TFNE), rates of ICH and acute cSAH) of 45 consecutive patients (75 ± 7 years) with an acute cSAH related to probable CAA compared to 70 consecutive patients (78 ± 7 years) with an acute lobar ICH meeting the Boston criteria for probable CAA.

Results: cSAH-patients presented essentially with TFNE (84.4% vs 0%; p<0.001) whereas ICH-patients had a persistent neurological deficit (98.6% vs 15.6%; p<0.001). Five patients with lobar ICH died in the first days. Thirty nine cSAH-patients and 60 lobar ICH-patients had available follow-up data. The mean time of follow-up (± SD) was 364 ± 358 days. Mortality did not differ between cSAH-patients and ICH-patients who survived (10.2 % vs 16.7%; p = 0.38). Patients with cSAH had a higher rate of TFNE (48.7 % vs 0 %; p<0.001) and acute cSAH recurrence (20.5 % vs 1.7 %; p = 0.002). In the other hand, 20.5 % of cSAH-patients presented a subsequent ICH, not different from patients with acute ICH (15.0 %; p = 0.45).

Conclusions: In the context of CAA, patients with acute cSAH present more clinical recurrences than lobar ICH-patients, due to higher risk of subsequent TFNE and acute cSAH. Although the clinical presentation of cSAH-patients may appear benign, their outcome regarding the risk of incident ICH and mortality, does not seem different from CAA-related lobar ICH survivors.

Abstract WP362: Subarachnoid and Subdural Hemorrhages Concomitant to Acute Lobar Intracerebral Hematoma are Markers of Cerebral Amyloid Angiopathy

Background: Convexity subarachnoid hemorrhage (cSAH) or subdural Hematoma (SDH) are occasionally described on CT or MRI in the area of acute lobar intracerebral hematoma (ICH). The prevalence and the etiologic significance of this association are not well known.

Hypothesis: We hypothesized that cSAH and SDH were more frequent in Cerebral Amyloid Angiopathy (CCA)-related lobar ICH.

Methods: Using our electronic database, we retrospectively reviewed the clinical and MRI characteristics of 165 consecutive patients (mean age 70 ± 13 years) admitted for acute lobar ICH. The presence of cSAH and SDH was assessed by 2 reviewers on a brain MRI performed within 10 days after ICH onset.

Results: SDH and cSAH were present in respectively 28.5 and 54.5 % of all patients. Among patients with acute lobar ICH meeting the modified Boston criteria for probable CAA, the frequency was 37.5 % (27/72) for SDH and 73 % (53/72) for cSAH, which is significantly higher than among patients with hematoma of other causes ( 21.5 and 39.8 %; p=0.03 and p<0.001 respectively). The association remained significant considering patients meeting the modified Boston criteria for probable or possible CAA versus others causes.

Conclusions: Using MRI for evaluation of acute lobar ICH, cSAH and SDH were very frequent and associated with CCA. This is consistent with the involvement of leptomeningeal arteries in this disease. The presence of subarachnoid or subdural hemorrhage should be systematically assessed and could be added to diagnostic criteria for CAA.

Abstract WMP93: Cortical Superficial Siderosis in Cerebral Amyloid Angiopathy: Higher Prevalence Among Convexity Subarachnoid Hemorrhage Than Among Intracerebral Hemorrhage

Introduction: Cerebral amyloid angiopathy (CAA) is a major cause of both lobar intracerebral hemorrhage (ICH) and cerebral microbleeds (CMB), especially in the elderly. Recently, acute convexity subarachnoid hemorrhage (cSAH) and cortical superficial siderosis (cSS) has been identified as markers of CAA. Although the clinical feature and the increased risk of future lobar ICH of cSS is well established, little is known about the specific pattern of CAA-related cSAH.

Hypothesis: We hypothesized that clinical and imaging characteristics of CAA-related cSAH differ from CAA-related lobar ICH.

Methods: We retrospectively analyzed clinical and MRI data of a monocentric cohort of 45 consecutive patients with an acute cSAH related to probable CAA and a comparison group of 70 consecutive patients presenting with an acute lobar ICH meeting Boston criteria for probable CAA.

Results: cSAH patients were younger than ICH patients (mean age +/-SD: 75 +/-7 vs 78 +/-7; p=0.046). Transient focal neurological episodes (TFNE) were common among cSAH patients (84.4% vs 0%; p<0.001). Persistent focal neurological deficits were frequent among ICH patients (15.6% vs 98.6%; p<0.001). Prevalence of cSS was significantly higher among cSAH patients than among ICH patients (88.9% vs 60%; p<0.001) especially disseminated (66.7% vs 37.1%; p=0.002) and bilateral cSS (48.9% vs 28.6%; p=0.027). Number of lobar macrobleeds (median number [IQR]: 0 [0-1] vs 1[1-2]; p=0.07) and lobar CMB (median number [IQR]: 3 [1-6] vs 6 [2-14.75]; p=0.405) did not differ between the two groups.

Conclusions: In CAA, patients presenting with cSAH are characterized by a younger age, TFNE as presenting symptoms and a higher prevalence of cSS than those presenting with Lobar ICH. These findings suggest that restricted hemorrhage into the subarachnoid space may play a crucial role in cSS physiopathology.

Clinical Spectrum of Encephalitis Associated With Antibodies Against the α-Amino-3-Hydroxy-5-Methyl-4-Isoxazolepropionic Acid Receptor: Case Series and Review of the Literature

IMPORTANCE

The clinical features of autoimmune encephalitis associated with antibodies against the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR-Abs) remain poorly defined.

OBJECTIVES

To describe 7 patients with encephalitis and AMPAR-Abs and to provide a review of the literature on this disease entity.

DESIGN, SETTING, AND PARTICIPANTS

The setting was the Centre National de Référence pour les Syndromes Neurologiques Paranéoplasiques (Lyon, France), and participants were 7 consecutive patients diagnosed as having encephalitis and AMPAR-Abs between January 1, 2010, and December 1, 2014. Patients' clinical data were analyzed, with a median follow-up period of 12 months (range, 2-31 months). Relevant articles were identified in the MEDLINE database using the keywords autoimmune encephalitis and AMPA receptor antibodies until February 15, 2015.

MAIN OUTCOMES AND MEASURES

Modes of onset, full clinical presentations, and cancer prevalence.

RESULTS

The patients included 4 women and 3 men (median age, 56 years). Four main modes of encephalitis onset were observed, including confusion (3 patients), epileptic (1 patient), amnestic (1 patient), and a severe form of fulminant encephalitis (2 patients). In contrast with previous reports, we observed only 1 patient with seizures. Two patients had cancer (1 lung carcinoma and the other thymic carcinoma). Analysis of the literature identified 35 published cases of encephalitis and AMPAR-Abs, including 18 with clinical data. The same modes of encephalitis onset were observed, including confusion (12 patients), epileptic (1 patient), amnestic (3 patients), and fulminant encephalitis (2 patients). Eleven patients were initially seen with a neoplasm (lung, breast, thymoma, or ovary).

CONCLUSIONS AND RELEVANCE

The clinical spectrum of AMPAR encephalitis is variable. Cancer was found in 13 of 27 patients (48%) with known cancer status. Most patients are seen with symptoms suggestive of autoimmune limbic encephalitis, although they can be paucisymptomatic or may manifest severe panencephalitis that evolves to a minimally conscious state and diffuse cortical atrophy. Patients suspected of having autoimmune encephalitis should undergo screening for serum and cerebrospinal fluid AMPAR-Abs.

Tobacco Use and Cryptogenic Stroke in Young Adults

OBJECTIVE

Cryptogenic stroke is the leading subtype of ischemic stroke in the young. We sought to evaluate the association between traditional cardiovascular risk factors and cryptogenic stroke by using a case-control study.

METHODS

Patients aged 18-54 years, consecutively treated for first-ever cryptogenic ischemic stroke in an academic stroke unit, were compared with subjects from the general population living in the same geographic area. Control subjects were matched for age and sex with patients. We further evaluated the association between significant risk factors and nonobstructive (<50% stenosis) carotid plaque and thrombus among patients with cryptogenic stroke. Odds ratios [OR] were calculated using logistic regression analysis.

RESULTS

A total of 155 patients with cryptogenic stroke (66.4% men, mean age 43.5 years [SD 8.4]) were included in the study. Cryptogenic stroke was associated with current tobacco use (42.6% in patients versus 23.9% in control subjects; OR = 2.38, 95% confidence interval [CI] 1.40-4.05, P = .002). Current tobacco use was associated with nonobstructive carotid plaque (OR = 6.22; 95% CI, 2.43-15.9; P = .001) and nonobstructive carotid thrombus (OR = 13.7; 95% CI, 1.42-132.7; P = .03) among the patients.

CONCLUSION

Our case-control study showed a strong link between current tobacco use and cryptogenic stroke in young adults.

Baroreflex and cerebral autoregulation are inversely correlated

BACKGROUND

The relative stability of cerebral blood flow is maintained by the baroreflex and cerebral autoregulation (CA). We assessed the relationship between baroreflex sensitivity (BRS) and CA in patients with atherosclerotic carotid stenosis or occlusion.

METHODS AND RESULTS

Patients referred for assessment of atherosclerotic unilateral >50% carotid stenosis or occlusion were included. Ten healthy volunteers served as a reference group. BRS was measured using the sequence method. CA was quantified by the correlation coefficient (Mx) between slow oscillations in mean arterial blood pressure and mean cerebral blood flow velocities from transcranial Doppler. Forty-five patients (M/F: 36/9), with a median age of 68 years (IQR:17) were included. Thirty-four patients had carotid stenosis, and 11 patients had carotid occlusion (asymptomatic: 31 patients; symptomatic: 14 patients). The median degree of carotid steno-occlusive disease was 90% (IQR:18). Both CA (P=0.02) and BRS (P<0.001) were impaired in patients as compared with healthy volunteers. CA and BRS were inversely and strongly correlated with each other in patients (rho=0.58, P<0.001) and in healthy volunteers (rho=0.939; P<0.001). Increasing BRS remained strongly associated with impaired CA on multivariate analysis (P=0.004).

CONCLUSIONS

There was an inverse correlation between CA and BRS in healthy volunteers and in patients with carotid stenosis or occlusion. This might be due to a relative increase in sympathetic drive associated with weak baroreflex enhancing cerebral vasomotor tone and CA.

Long-term follow-up study of endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis trial

BACKGROUND AND PURPOSE

We aimed at comparing the long-term benefit-risk balance of carotid stenting versus endarterectomy for symptomatic carotid stenosis.

METHODS

Long-term follow-up study of patients included in Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S), a randomized, controlled trial of carotid stenting versus endarterectomy in 527 patients with recently symptomatic severe carotid stenosis, conducted in 30 centers in France. The main end point was a composite of any ipsilateral stroke after randomization or any procedural stroke or death.

RESULTS

During a median follow-up of 7.1 years (interquartile range, 5.1-8.8 years; maximum 12.4 years), the primary end point occurred in 30 patients in the stenting group compared with 18 patients in the endarterectomy group. Cumulative probabilities of this outcome were 11.0% (95% confidence interval, 7.9-15.2) versus 6.3% (4.0-9.8) in the endarterectomy group at the 5-year follow-up (hazard ratio, 1.85; 1.00-3.40; P=0.04) and 11.5% (8.2-15.9) versus 7.6% (4.9-11.8; hazard ratio, 1.70; 0.95-3.06; P=0.07) at the 10-year follow-up. No difference was observed between treatment groups in the rates of ipsilateral stroke beyond the procedural period, severe carotid restenosis (≥70%) or occlusion, death, myocardial infarction, and revascularization procedures.

CONCLUSIONS

The long-term benefit-risk balance of carotid stenting versus endarterectomy for symptomatic carotid stenosis favored endarterectomy, a difference driven by a lower risk of procedural stroke after endarterectomy. Both techniques were associated with low and similar long-term risks of recurrent ipsilateral stroke beyond the procedural period.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00190398.

The role of sonolysis and sonothrombolysis in acute ischemic stroke: a systematic review and meta-analysis of randomized controlled trials and case-control studies

OBJECTIVES

To assess the evidence on the safety and efficacy of sonothrombolysis in acute stroke.

SEARCH METHODS

Electronic databases and grey literature were searched under different MeSH terms from 1970 to present.

SELECTION CRITERIA

Randomized control trials (RCTs) and case control studies (CCSs) on sonolysis and sonothrombolysis alone or with microsphere in acute stroke patients (>18 old). Outcome measures included complete recanalization (CR) at 1-2 and 24 hours, 3 months modified Rankin Scale (mRS), and symptomatic intracerebral hemorrhage (sICH). Data was extracted to Review Manager software.

RESULTS

Fifty-seven studies were retrieved and analyzed. Ten studies (7 RCTs and 3 CCSs) were included in our meta-analysis, which revealed that sonolysis and sonothrombolysis are safe (OR of sICH: 1.14; 95% confidence interval (CI): 0.56- 2.34;P=0.71) and effective (OR of CR at 1-2 hours: 2.95;95% CI: 1.81-4.81;P<0.00001) and have more than two-fold higher likelihood of favourable long-term outcome (3-month mRS 0-2; OR: 2.20; CI:1.52-3.19;P<0.0001). Further subgroup analysis based on the presence of microsphere revealed that it is safe (OR of sICH: 1.18; CI:0.433.24;P=0.75) and effective (OR of CR: 2.61; CI: 1.36-4.99;P=0.004). Subgroup analysis based on sonolysis revealed to be safe and effective.

CONCLUSIONS

This novel treatment appears safe and effective. The evidence of microsphere as an enhancement of sonothrombolysis is evolving.

Abstract TP425: Clinical and Radiological Spectrum of Nontraumatic Cortical Subarachnoid Hemorrhages : A Consecutive Series of 62 Patients

Non-traumatic cortical subarachnoid hemorrhage (cSAH) is an unusual location of SAH not related to aneurysmal rupture. Several causes have been described in small cohorts. We report the characteristics and the follow-up of a large cohort of such patients.

Methods: During 4 years, consecutive patients admitted in our institution with a cSAH revealed by neurological symptoms were included in a registry. Retrospective review of medical records, neuroimaging studies, and follow-up data was performed.

Results: Sixty two patients (37 women; mean age ± SD : 66 ± 14 years) were included. The main clinical presentation was a transient deficit in 50 % of cases. Headache was present in only 39 % of cases. Cerebral amyloid angiopathy (CAA) accounted for 50 % of cases. The main other etiologies were reversible vasoconstriction syndrome (13 %), endocarditis (11 %), severe intracranial or cervical arterial stenoses (8 %) and cerebral venous thrombosis (5 %). Patients with CAA were older (p < 0.001) and suffered essentially from transient deficit (80 vs 18 %; p < 0.001) without headache (18 % vs 58 %; p = 0.002). Cortical hemosiderosis on MRI was strongly associated with CAA (77 % vs 0 %; p < 0.001). Follow up data were available in 55 patients (28 with CAA). Forty eight patients underwent an imaging follow up (25 with CAA). Recurrent hemorrhages (cSAH or hematoma) occurred in 52 % of CAA cases against 12 % in other origins (p = 0.01).

Conclusions: Our data show that CCA is clearly the main etiology of cSAH with a specific pattern associating transient neurological deficit without headache and cortical hemosiderosis on MRI. Many origins can be found in younger patients to whom the diagnosis is guided by imaging findings and clinical background. The risk of recurrence is high in CAA contrary to other etiologies.

Abstract 55: Prediction of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage Using Variations of Dynamic Cerebral Autoregulation

The risk of delayed cerebral ischemia (DCI) after cerebral aneurysm rupture is increased in patients with large cerebral artery vasospasm (VS). The predictive value of VS is, however, far to be optimal. Assessment of cerebral microcirculation impairment using dynamic cerebral autoregulation (DCA) measurement might improve our ability to predict DCI in these patients.

Methods. We included consecutive patients with low-grade aneurysmal subarachnoid hemorrhage (SAH) (WFNS 1 to 3) within 4 days of aneurysm rupture. DCA was evaluated using the moving correlation coefficient Mx calculated from spontaneous fluctuations of cerebral blood flow velocities and arterial blood pressure. Impairment of DCA was defined as Mx ≥ 0.3. Transcranial colour-coded sonography was performed every 48 hours to look for VS. Diagnosis of VS was based on a Lindegaard ratio >3 (MCA), or mean flow velocities > 130 cm/s (ACA). DCI was defined as neurologic deterioration caused by brain ischemia confirmed by brain imaging.

Results. Thirty patients (19 women; mean age ± SD: 44.7 ± 12.1 years) were included. Twenty (66.7%) patients had VS. DCI occurred in six (20%) patients after a median delay of 10 days (range 8 to 13 days). Mx (mean ± SD) was heightened at baseline (0.43 ± 0.2) and at day 7 (0.46 ± 0.2), then decreased at day 14 (0.37 ± 0.18 (p = 0.034). Isolated measures of VS and Mx were not associated with DCI. However, the elevation of Mx between baseline and day 7 in patients with VS was predictive of subsequent DCI (positive likelihood ratio=5.01; negative likelihood ratio=0.19; P=0.005).

Conclusion. Findings suggest that DCA assessment may help to predict better the risk of DCI after cerebral aneurysm rupture than the simple recordings of mean flow velocities.

Intracranial artery stenosis or occlusion predicts ischemic recurrence after transient ischemic attack

BACKGROUND AND PURPOSE

Patterns of DWI findings that predict recurrent ischemic events after TIA are well-established, but similar assessments of intracranial MRA findings are not available. We sought to determine the imaging characteristics of MRA that are predictive of early recurrent stroke/TIA in patients with TIA.

MATERIALS AND METHODS

We performed a retrospective analysis of 129 consecutive patients with a clinical diagnosis of TIA in whom MR imaging was done within 24 hours of symptom onset. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of >50% stenosis or occlusion of symptomatic intracranial arteries for recurrent stroke/TIA at 7 days after TIA. We used logistic regression analysis to adjust for the clinical ABCD(2) score. We performed this analysis for symptomatic steno-occlusive lesions at any site and symptomatic steno-occlusive lesions on proximal large intracranial arteries (internal carotid artery, vertebral artery, basilar artery, and circle of Willis).

RESULTS

Forty-two (32.5%) patients had acute ischemic lesions on DWI; 16 (12.4%) had significant MRA lesions, of which 11 (8.5%) were on proximal vessels. Nine patients had early recurrence (TIA, 7; minor stroke, 2). Only patients with proximal MRA lesions were at higher risk of early recurrence independent of the ABCD(2) score (adjusted odds ratio, 5.5; 95% confidence interval, 1.1-27.8; P = .04).

CONCLUSIONS

Proximal lesions of cerebral arteries seen on MRA were predictive of recurrent stroke/TIA at 7 days. These findings suggest that MRA could be used to improve the selection of patients with TIA at high risk of early recurrent stroke/TIA.

Executive dysfunction in adults with moyamoya disease is associated with increased diffusion in frontal white matter

BACKGROUND AND PURPOSE

Alteration of the cerebrovascular reserve (CVR) in the frontal lobes has been associated with cognitive dysfunction in adults with moyamoya disease (MMD). Elevation of the apparent diffusion coefficient (ADC) in normal-appearing white matter on conventional MRI may occur as a consequence of chronic haemodynamic failure. In the present study, the authors examined the relation of ADC with CVR and cognitive dysfunction in adults with MMD.

METHODS

The authors measured ADC and CVR in the normal-appearing frontal white matter. CVR was calculated using dynamic susceptibility contrast-enhanced MRI and the acetazolamide challenge. A standardised and validated neuropsychological assessment test battery focusing on executive function was used.

RESULTS

14 patients, 9 women and 5 men (mean age 36.6±12.9 years), were included. The authors found executive dysfunction in 7 of 13 tested patients. ADC and CVR were negatively correlated (Spearman coefficient: -0.46; p=0.015). Elevation of ADC predicted executive dysfunction (area under receiver operating characteristic curve (95% CI): 0.85 (0.59 to 1.16); p=0.032).

CONCLUSION

Elevation of ADC in the normal-appearing frontal white matter of adults with MMD was associated with reduced CVR and executive dysfunction. This preliminary study suggests that measurement of ADC might be used to detect patients at risk for cerebral ischaemia and cognitive impairment.

Patent foramen ovale and ischemic stroke

Patent foramen ovale (PFO) is a common finding in healthy subjects and has not been associated with increased risk of ischemic stroke in population-based cohort studies. Nevertheless, case-control studies have consistently shown an increased prevalence of PFO in cryptogenic stroke, suggesting that PFO might be a cause of stroke. The risk of stroke recurrence in patients with cryptogenic stroke and PFO is low under aspirin therapy but may be substantially higher in patients with an associated atrial septal aneurysm (ASA). The mechanisms of stroke associated with PFO or ASA are uncertain. Paradoxical embolism through the PFO is rarely documented. The optimal treatment for secondary prevention in patients with cryptogenic stroke and PFO is still uncertain and debated. A randomized controlled trial failed to demonstrate the superiority of transcatheter PFO closure over medical therapy. Whether anticoagulation is superior to aspirin should be tested in a randomized controlled trial.

Lipoprotein (a) and carotid atherosclerosis in young patients with stroke

BACKGROUND AND PURPOSE

Elevated lipoprotein (a) concentration is associated with carotid atherosclerosis in middle-aged and older patients with ischemic stroke. This association has not been explored in young patients with stroke.

METHODS

A retrospective analysis of data from patients aged 16 to 54 years consecutively treated for acute ischemic stroke in a tertiary stroke unit during 4.5 years was performed. We graded carotid atherosclerosis using carotid duplex as: no atherosclerosis (A); plaque without stenosis (B); or stenosis≥50% (C).

RESULTS

One hundred ninety-six patients were included (male/female: 119/77; mean age±SD: 44.3±8.6 years): 115 in Group A; 67 in Group B; and 14 in Group C. Multivariate analysis using polynomial logistic regression showed a graded association of lipoprotein (a) plasma concentration with carotid atherosclerosis (P<0.001).

CONCLUSIONS

Our results showed a positive association of lipoprotein (a) plasma concentration with carotid atherosclerosis in young adults with ischemic stroke. This association was strong, graded, and independent of traditional risk factors including cholesterol.

Etiologic investigation of ischemic stroke in young adults

OBJECTIVES

We attempted to classify causes of ischemic stroke in young adults using a progressive diagnostic algorithm and the ASCO (atherosclerosis, small-vessel disease, cardiac source, other cause) classification system.

METHODS

Patients aged 16-54 years consecutively treated for acute ischemic stroke in a tertiary stroke unit were included in this retrospective analysis. Causes of stroke were classified using the ASCO system, which assigns a graded level of likelihood to each potential cause in individual patients. The initial etiologic workup included brain imaging, magnetic resonance or CT angiography of cerebral and cervical vessels, EKG, and routine blood studies. Patients without a definite cause of ischemic stroke after initial evaluation underwent transesophageal echocardiography.

RESULTS

We included 318 patients (195 men and 123 women); 131 patients were aged 16-44 years, and 187 were aged 45-54 years. A definite cause of stroke (ASCO grade 1) could be identified in 145 patients (45.5%). An uncertain cause of stroke (ASCO grade 2) was found in 59 (18.5%) further patients. Most (130 of 145) definite causes were identified by initial evaluation. The 2 major definite or uncertain causes of stroke were patent foramen ovale associated with atrial septal aneurysm (PFO-ASA) (20 of 131 [15.3%]) and dissection of the cervical or cerebral artery (19 of 131 [14.5%]) in patients aged 16-44 years and large-vessel atherosclerosis (37 of 187 [19.8%]) and PFO-ASA (23 of 187 [12.3%]) in patients aged 45-54 years.

CONCLUSIONS

Our findings suggest that PFO-ASA may be a major cause of ischemic stroke in young adults.