Etiology Of Ischemic Stroke Research Articles

Abstract TP225: Socioeconomic Status And Etiologies Of Ischemic Stroke In Peru

Background: Studies have reported an association between lower socioeconomic status (SES) and an elevated risk of ischemic stroke. It is unclear whether low SES is correlated with a specific etiology of ischemic stroke. Few studies have investigated the relationship in LMIC nations with wide disparities in SES. We analyzed data from a hospital-based stroke registry in Lima, Peru to determine the association between level of education as an indicator of SES and ischemic stroke etiology. Methods: All patients hospitalized with ischemic stroke at the National Institute of Neurologic Sciences from 2015-2018 were prospectively collected in a registry including demographics, risk factors, highest attained level of education, and diagnosed etiology of stroke by TOAST criteria. Association between ordinal level of education and stroke etiology was assessed after adjusting for differences in demographics and comorbidities by a multinomial multivariate logistic regression model. Results: A total of 461 cases of ischemic stroke were ascertained with 38.4% female and a mean age of 66.2 (SD 13.0). Stroke etiology was composed of 7.5% atherosclerotic, 29.7% cardioembolic, 14.2% small vessel disease, 24.7% cryptogenic, and 24.0% with incomplete evaluation. Higher education level strata had more men, younger mean age, and lower rates of hypertension. After multivariate adjustment, lower level of education was associated with an increased odds of large artery atherosclerosis compared to all non-cardioembolic etiologies (OR=2.27; 95% CI, 1.12-4.55). There was no significant association with level of education and odds of cardioembolic stroke after multivariate adjustment. Conclusion: Lower SES is associated with an increased odds of atherosclerotic etiology in patients with non-cardioembolic ischemic stroke. The associated between SES and stroke may be attributed to a higher burden of atherosclerotic disease in lower SES.

Abstract WP228: Normal Left Atrial Diameter Is Associated With Better Performance On A Telephone Cognition Screening Tool Among Ischemic Stroke Survivors

Background: Cardiac structure and function are important in determining ischemic stroke (IS) etiology, but whether there is an association with cognition post IS is unknown. Methods: IS patients admitted to Johns Hopkins Hospital (2017-2019) underwent transthoracic echocardiography. IS was classified (TOAST) by a masked reviewer. Parasternal short axis left atrial (LA) diameter was evaluated as a continuous variable with a spline at 4cm (normal ≤4cm versus enlarged >4cm); left ventricle ejection fraction (LVEF) was evaluated as a nonlinear continuous variable with two spline knots at 40% and 65%. Cognition was assessed by telephone using the Six Item Screener (SIS), which tests orientation (day, month, year) and recall (grass, paper, shoe) and was dichotomized into low (0-3, worse score) and high (4-6, better score), and conservatively imputing low category scores for non-answerers. Multivariable logistic regression determined the association of SIS category with LA or LVEF, each, adjusted for covariates. Results: Participants (N=119) were on average 60 (18-89) years, 60% male, and 59% Black. Mean LA diameter was 3.9cm ( SD =0.8) and mean LVEF 61.4% ( SD =10.5). For LA diameter ≤4cm, each 1cm increase was associated with 5.93 greater odds (95% CI=1.49-23.65) of scoring in the high SIS category, while for LA diameter >4cm each 1cm increase was associated with lower odds (OR=0.88, 95% CI=0.39-1.99) of scoring in the high SIS category (Figure 1). Decreased (OR=0.91, 95% CI=0.74-1.11), normal (OR=0.98, 95% CI=0.91-1.06) or hyperdynamic LVEF (OR=1.02, 95% CI=0.90-1.14) showed no relationship with SIS category. Conclusions: In this study, a 1cm change in LA diameter was significantly associated with a higher score on a telephone cognition screening test, if patients had a LA diameter within normal range, but without the same association with SIS if the LA diameter was >4cm. We cautiously suggest that LA function may be associated with cognition post-stroke.

Abstract WP74: An Automated, Electronic Health Record-based Algorithm To Classify Ischemic Stroke Etiology

Introduction: Determining acute ischemic stroke (AIS) etiology is central to secondary stroke prevention, but can be diagnostically challenging. We built a stroke etiology classification model using electronic health record (EHR) data from non-cryptogenic AIS hospitalization encounters. Methods: We studied discharge summaries of non-cryptogenic AIS patients hospitalized at 2 academic, Comprehensive Stroke Centers from 2015-2020. The outcome was stroke etiology encoded in each institution’s stroke registry, abstracted from the discharge attending’s impression. We engineered variables including 1) clinical features from Unified Medical Language System concepts identified by a text mining tool, MetaMap , and 2) neuroimaging, echocardiographic, and laboratory features by regular expression operations. XGBoost classifier models were generated (80% training set, 20% testing set). A grid search of 36 model parameter value combinations and 10-fold cross validation were performed. We assessed variable importance in the optimized algorithm by calculating each feature’s Shapley value, the absolute value of the variable’s mean impact in predicting each specific stroke etiology. Results: The cohort was comprised of 1,993 patients (mean age 69 years, 55% male). We engineered a total of 2,004 features. Mean cross-validated accuracies of the best model in the training and validation sets were: 73.0% and 65.5%, respectively. Validation precision, recall, and F1 weighted scores were 66.2%, 65.5%, and 64.1% (mean cross-validated). The top 20 features contributing to etiology prediction are in Figure 1. Conclusion: We developed an EHR-based, automated tool to replicate a discharging attending’s stroke etiology diagnosis in non-cyptogenic patients. With further training in representative cohorts of non-cryptogenic and cryptogenic patients with an eventually diagnosed etiology, this algorithm may aide stroke etiology diagnosis before hospital discharge.

Abstract 47: Project TURNIP: Teleproctoring Of Rural Stroke Patients With Advanced Nurse Practitioner

Introduction: Prisma Health Tuomey (PHT) is a rural-based spoke hospital, with advanced Nurse Practitioners (ANP). Prisma Health Richland (PHR) is an urban-based hub hospital with access to vascular neurologists. In this ongoing project we evaluated the effectiveness of Zeriscope, a web-based, HIPAA compliant, teleproctoring platform, for ANP evaluation of etiology of ischemic stroke. Methods: PHT uses a web-based, HIPAA compliant, telemedicine platform, Zeriscope, to provide a live interactive video stream to PHR, a certified Comprehensive Stroke Center 45 miles away. Zeriscope uses a mobile exam headset, comprised of a camera attached to a cellphone and an audio headset, to provide two-way audio and visual communication between an APP and a board-certified vascular neurologist (Figure). The care was provided in inpatient setting with full access to neuroimaging, vascular imaging, cardiac imaging, and long-term monitoring. Patients evaluated directly by teleneurology platform in the PHT emergency room for TPA and thrombectomy were transferred to PHR and excluded from the teleproctoring assessment. Results: Fifty-two ischemic stroke and TIA patients (age 67.8 ± 12.7, 52 % African American, 69 % Males) were evaluated and treated in 4-month period from April to August 2021. Patients underwent a standardized stroke work-up to determine stroke etiology, which was classified by TOAST criteria (11.8% LAA, 19.6% Cardioembolic, 27.5% Lacunar, 39.2% Cryptogenic and 1.9% Undetermined). All patients received best medical management based on the secondary stroke prevention guidelines. To date, no patients experienced complications or were readmitted or needed transfer to a stroke center. Conclusion: Tele-proctoring is a feasible method of delivering stroke care that has not been previously implemented in a rural hospital. The use of Zeriscope was practical and effective in determination of ischemic stroke etiology and implementation of best practice guidelines.

Abstract TMP62: Carotid Web Stenting Is Comparable To Atherosclerotic Stenting With Lower Procedural Risk

Introduction: Carotid Web (CaW) is an underrecognized etiology for ischemic stroke. This entity has been shown to be amenable to endovascular stenting, similar to carotid atherosclerotic stenosis (CAS). We aimed to assess procedural characteristics of stenting for CaW as compared to CAS. Methods: We retrospectively analyzed a cohort of patients at a single comprehensive stroke center from October 2014 to March 2021 who had undergone endovascular stent placement for symptomatic CAS or CaW. Patients who received other intervention (e.g. thrombectomy, aneurysm repair) on the same day as stent placement were excluded. Baseline patient characteristics, procedural data, periprocedural complications, and follow-up statistics were analyzed. Results: In total, 105 patients underwent stent placement status post ischemic stroke or transient ischemic attack; 79 patients had CAS and 26 patients had CaW. Patients with CAS were older on average (CAS 63 vs CAS 53.5 years, p < 0.001 ) and less likely to be female (OR 0.116; 95% CI 0.041 to 0.326, p <0.001). CAS patients were more likely to have vascular risk factors such as hypertension, hyperlipidemia, and Diabetes ( Table ). Radiation, need for angioplasty, and filter time were significantly lower in CaW procedures. No significant difference was found between the two pathologies in periprocedural complications such as hypotension, need for vasopressors, or bradycardia. However, post-procedural restenosis only occurred in CAS stents. Conclusion: Stenting for CaW is comparable to stenting for CAS in terms of vasovagal side effects, but associated with lower filter times, lower radiation dose, lower need for angioplasty, and lower rates of restenosis.

Abstract WP114: Elevated Troponin Is Associated With Mortality In Patients With Acute Cardioembolic Stroke And Atrial Fibrillation

Introduction: Stroke is the fifth leading cause of death in the US and a major cause of disability. Atrial fibrillation (AF) increases the risk of ischemic stroke fivefold. Cardioembolic stroke in patients with AF is associated with high mortality. The association of elevated cardiac troponin with mortality in patients with acute ischemic stroke has been studied previously; however, there is limited data in subgroups of ischemic stroke etiology. We sought to determine the association of troponin elevation at presentation with 90-day all-cause mortality in patients with acute ischemic stroke and AF. Methods: The I nitiation of A nticoagulation after C ardioembolic Stroke (IAC) study is a multicenter cohort drawn from eight US Stroke Centers. We included consecutive patients hospitalized with acute ischemic stroke and AF between 2015-2018, who had an initial baseline cardiac troponin I (bcTnI) obtained at presentation. The primary outcome was all-cause mortality at 90 days from stroke onset. We undertook multivariable logistic regression to determine the association between elevated bcTnl (≥0.1 ng/mL) and 90-day mortality. Results: Of the 2084 patients enrolled in IAC, 1889 patients had 90-day follow-up of which 1461 patients had bcTnI available. 239 of the included patients (16.4%) had an elevated bcTnl, and death within 90-days occurred in 323 patients (22.1%). Elevated bcTnI was associated with 90-day mortality in univariable analysis (49.4% vs 24.9%; OR 1.71, 95% CI 1.17-2.50, p<0.001). This association persisted after adjusting for potential confounders: age, NIHSS, coronary artery disease, congestive heart failure and initial systolic blood pressure (OR 1.71, 95% CI 1.17-2.50, p=0.006); and in sensitivity analysis adding CrCl to the adjusted model above (OR 1.57, 95% CI 1.03-2.39, p=0.037). Conclusion: In acute ischemic stroke patients with AF, elevated bcTnI was independently associated with 90-day all-cause mortality.

A Systemic Review of the Integral Role of TRPM2 in Ischemic Stroke: From Upstream Risk Factors to Ultimate Neuronal Death.

Ischemic stroke causes a heavy health burden worldwide, with over 10 million new cases every year. Despite the high prevalence and mortality rate of ischemic stroke, the underlying molecular mechanisms for the common etiological factors of ischemic stroke and ischemic stroke itself remain unclear, which results in insufficient preventive strategies and ineffective treatments for this devastating disease. In this review, we demonstrate that transient receptor potential cation channel, subfamily M, member 2 (TRPM2), a non-selective ion channel activated by oxidative stress, is actively involved in all the important steps in the etiology and pathology of ischemic stroke. TRPM2 could be a promising target in screening more effective prophylactic strategies and therapeutic medications for ischemic stroke.

Impact of COVID-19 Pandemic on Developmental Service Delivery in Children With a History of Neonatal Seizures

BackgroundChildren with a history of acute provoked neonatal seizures are at high risk for disability, often requiring developmental services. The coronavirus disease 2019 (COVID-19) pandemic has led to widespread changes in how health care is delivered. Our objective was to determine the magnitude of service interruption of among children born between October 2014 and December 2017 and enrolled in the Neonatal Seizure Registry (NSR), a nine-center collaborative of pediatric centers in the United States. MethodsThis is a prospective cohort study of children with acute provoked seizures with onset ≤44 weeks' gestation and evaluated at age three to six years. Parents of children enrolled in the NSR completed a survey about their child's access to developmental services between June 2020 and April 2021. ResultsAmong 144 children enrolled, 72 children (50%) were receiving developmental services at the time of assessment. Children receiving services were more likely to be male, born preterm, and have seizure etiology of infection or ischemic stroke. Of these children, 64 (89%) experienced a disruption in developmental services due to the pandemic, with the majority of families (n = 47, 73%) reporting that in-person services were no longer available. ConclusionsHalf of children with acute provoked neonatal seizures were receiving developmental services at ages three to six years. The COVID-19 pandemic has led to widespread changes in delivery of developmental services. Disruptions in services have the potential to impact long-term outcomes for children who rely on specialized care programs to optimize mobility and learning.

Cerebral border zone infarctions: An etiologic study

Background: Cerebral border zone infarctions (BZIs) are a subtype of acute ischemic stroke that occur at the junction between two major cerebral arterial territories. Internal and external BZIs are defined based on the known patterns in brain magnetic resonance imaging (MRI). However, the etiology and pathophysiology of these two types of BZI are still debated. This study aimed to determine the etiologic differences of two types of BZI to guide tailor appropriate treatment strategies for these patients. Methods: In this prospective study, patients with BZIs were enrolled from patients with acute ischemic stroke admitted to the hospitals affiliated with Tabriz University of Medical Sciences, Tabriz, Iran, from 2017 to 2019. Appropriate clinical and laboratory workups were applied to determine possible etiologies of ischemic stroke according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification system. Results: The study included 106 patients with BZI, 53 patients in each group. Both types of BZI were more frequent in males. However, there was no significant difference between the two types concerning sex, age, and profile of major stroke risk factors. The results showed no correlation between the type of BZI and hemodynamic factors (P = 0.086). However, large artery atherosclerosis (LAA) was the most frequent etiology within each subtype of BZI; LAA in internal (P = 0.016) and cardioembolism (P = 0.046) in external BZI were more frequent etiologic subtypes of cerebral infarction. Conclusion: LAA might be the most common etiology for internal and external cerebral BZIs. Cardioembolism might have a more important etiologic role in the external subtype.

The association of arterial stiffness index with cerebrovascular and cardiometabolic disease: A Mendelian randomization study.

Arterial stiffness index (ASI) is a potential risk factor for cerebrovascular and cardiometabolic diseases, but the causal links between them are inconclusive. The aim is to evaluate the causal effects of ASI on cerebrovascular and cardiometabolic diseases by Mendelian randomization (MR). Two-sample MR analysis was performed to infer causal links. Genetic variants significantly associated with ASI were extracted. The inverse variance weighted method was used for estimating the effects. Sensitivity analysis was performed to test heterogeneity or pleiotropy. MR analysis indicated an effect of genetically predicted ASI on the risk of ischemic stroke (IS) of all causes (OR = 1.894, 95% CI 1.210-2.965, p = 0.005). No links were identified between genetically predicted ASI and other cerebrovascular or cardiometabolic diseases (all p > 0.05). Subgroup analysis of IS etiologies found a suggestive association between genetically predicted ASI and large artery atherosclerosis stroke (LAS) (OR = 3.726, 95% CI 1.230-11.286, p = 0.020). There were no effects of ASI on IS due to cardioembolism or small vessel occlusion. The current MR analysis suggested that genetically predicted ASI was associated with higher risk of IS of all causes. The results and the underlying pathways or mechanisms between ASI and IS needs further investigation.

Association between serum irisin concentration and ischemic stroke: From etiology to clinic.

To investigate the relationship between irisin levels in serum and classification of subtype of acute ischemic stroke, National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Score (mRS) at the time of discharge from the hospital in Turkish patients who had their first acute ischemic stroke (AIS). Serum irisin levels were measured using enzyme linked immunosorbent assay (ELISA) 180 patients who applied to emergency department with the diagnosis of AIS from May 2021 to November 2021. A significant relationship was found between serum irisin levels and ischemic stroke aetiological factors (TAOST) (p=0.017). Increased serum irisin levels were detected in patients without neurological deficits with localization value than those with it (p<0.01). Serum irisin levels also have a negative correlation with high-density lipoprotein (HDL) value in ischemic stroke (r: -0.272, p<0.01). High serum irisin levels found in patients with stroke attributed to small vessel disease and in patients with ischemic stroke in whom we did not find any neurological deficits with a localization value. The results of the study show that serum irisin levels have an important role in the etiology of ischemic stroke. Although the question how the irisin is involved in the course of ischemic stroke and what the clinical reflection has not been answered, these findings are a pioneering study on this subject.

Endovascular evaluation of intracranial atherosclerotic stenosis in a sample of Egyptian patients presented with ischemic stroke

Background and aim Intracranial atherosclerosis is an important etiology of ischemic stroke and is associated with multiple vascular risk factors. Endovascular evaluation is used for assessing patterns and distributions of intracranial atherosclerotic stenosis in a sample of Egyptian patients presented with ischemic stroke. Patients and methods A total of 50 patients with ischemic stroke or transient ischemic attack were included. Assessment of the state of cerebral vessels before the procedure was done by duplex ultrasound, magnetic resonance angiography, and/or computed tomography angiography to confirm any stenosis in intracranial vessels. Neurological assessment was done before and after the procedure using the National Institutes of Health Stroke Scale score. Digital subtraction angiography was done to evaluate the degrees and patterns of stenosis. Results A total of 50 participants (29 males and 21 females) were included. Their ages ranged from 30 to 78 years. The major risk factors were dyslipidemia (62.0%), hypertension (60.0%), diabetes mellitus (54.0%), smoking (48.0%), and atrial fibrillation (22.0%). The procedure was performed on 50 patients. A total of 39 (78.0%) patients had angiographic findings of vessel stenosis in either extracranial or intracranial vessels or both. In those 39 patients, 32 (64.0%) patients had arterial stenosis, and seven (14.0%) patients were found to have total occlusion. A total of 18 (36.0%) patients had angiographic findings of intracranial atherosclerotic stenosis. Of these 18 patients, 14 (28.0%) patients had arterial stenosis, and four (8.0%) patients were found to have total occlusion. The most common site of intracranial stenosis was middle cerebral artery (33.3%). Conclusion Endovascular evaluation of patients with ischemic stroke is yielding, informative, safe, and easy to be done.

Ischemic Stroke Genetics: What Is New and How to Apply It in Clinical Practice?

The etiology of ischemic stroke is multifactorial. Although receiving less emphasis, genetic causes make a significant contribution to ischemic stroke genesis, especially in early-onset stroke. Several stroke classification systems based on genetic information corresponding to various stroke phenotypes were proposed. Twin and family history studies, as well as candidate gene approach, are common methods to discover genetic causes of stroke, however, both have their own limitations. Genome-wide association studies and next generation sequencing are more efficient, promising and increasingly used for daily diagnostics. Some monogenic disorders, despite covering only about 7% of stroke etiology, may cause well-known clinical manifestations that include stroke. Polygenic disorders are more frequent, causing about 38% of all ischemic strokes, and their identification is a rapidly developing field of modern stroke genetics. Current advances in human genetics provide opportunity for personalized prevention of stroke and novel treatment possibilities. Genetic risk scores (GRS) and extended polygenic risk scores (PRS) estimate cumulative contribution of known genetic factors to a specific outcome of stroke. Combining those scores with clinical information and risk factor profiles might result in better primary stroke prevention. Some authors encourage the use of stroke gene panels for stroke risk evaluation and further stroke research. Moreover, new biomarkers for stroke genetic causes and novel targets for gene therapy are on the horizon. In this article, we summarize the latest evidence and perspectives of ischemic stroke genetics that could be of interest to the practitioner and useful for day-to-day clinical work.

Global Differences in Risk Factors, Etiology, and Outcome of Ischemic Stroke in Young Adults-A Worldwide Meta-analysis: The GOAL Initiative.

There is a worldwide increase in the incidence of stroke in young adults, with major regional and ethnic differences. Advancing knowledge of ethnic and regional variation in causes and outcomes will be beneficial in implementation of regional health care services. We studied the global distribution of risk factors, causes, and 3-month mortality of young patients with ischemic stroke, by performing a patient data meta-analysis from different cohorts worldwide. We performed a pooled analysis of individual patient data from cohort studies that included consecutive patients with ischemic stroke aged 18-50 years. We studied differences in prevalence of risk factors and causes of ischemic stroke between different ethnic and racial groups, geographic regions, and countries with different income levels. We investigated differences in 3-month mortality by mixed-effects multivariable logistic regression. We included 17,663 patients from 32 cohorts in 29 countries. Hypertension and diabetes were most prevalent in Black (hypertension, 52.1%; diabetes, 20.7%) and Asian patients (hypertension 46.1%, diabetes, 20.9%). Large vessel atherosclerosis and small vessel disease were more often the cause of stroke in high-income countries (HICs; both p < 0.001), whereas "other determined stroke" and "undetermined stroke" were higher in low and middle-income countries (LMICs; both p < 0.001). Patients in LMICs were younger, had less vascular risk factors, and despite this, more often died within 3 months than those from HICs (odds ratio 2.49; 95% confidence interval 1.42-4.36). Ethnoracial and regional differences in risk factors and causes of stroke at young age provide an understanding of ethnic and racial and regional differences in incidence of ischemic stroke. Our results also highlight the dissimilarities in outcome after stroke in young adults that exist between LMICs and HICs, which should serve as call to action to improve health care facilities in LMICs.

Intracranial Atherosclerotic Disease: Current Concepts in Medical and Surgical Management.

This article reviews the current concepts in intracranial atherosclerotic disease (ICAD) as a common etiology of ischemic stroke; pathophysiologic mechanisms of ischemic stroke; diagnostic evaluation; and therapeutic modalities, including maximal medical therapy (MMT), percutaneous transluminal angioplasty and stenting (PTAS), and bypass surgery. Data from recent studies demonstrate that proper patient selection and timing of procedure and standardized PTAS techniques by experienced operators resulted in acceptably low periprocedural adverse events for patients who failed MMT. ICAD is a common cause of ischemic stroke. Complex pathology and high rates of recurrent and disabling ischemic strokes despite currently available treatments make ICAD the most challenging to treat of all ischemic stroke etiologies. Randomized trials previously showed that MMT, which involves the use of combinations of antiplatelet medications, targeted control of hypertension and serum low-density lipoprotein cholesterol, and adequate management of body weight through lifestyle modification, was superior to PTAS in decreasing rates of recurrent ischemic strokes from symptomatic ICAD. MMT performed better than expected, while periprocedural complications were significantly higher than expected in PTAS. Meanwhile, high rates of recurrent ischemic stroke despite MMT remain a great challenge. New clinical evidence continues to emerge on a safer application of PTAS, which is currently offered to a subset of patients who present with recurrent ischemic strokes despite MMT.

Abstract 1122‐000005: Plasminogen Activator Inhibitor‐1 5G/5G Polymorphism – Do We Know All About It?

Introduction : The etiology of ischemic stroke is heterogeneous, and it has been proposed that different stroke subtypes might have different genetic architecture 1,2. The plasminogen activator inhibitor‐1 (PAI‐1) has been of particular interest due to its role in thrombotic diseases. Several polymorphisms have been found for this gene, with some having protective effect while others increase the risk of ischemic and hemorrhagic strokes 3,4. The protective role appears to be due to the role of PAI‐1 in fibrinolytic cascade and that PAI‐1 also inhibit plasmin‐dependent metalloproteinases activation. We hereby, present a case of ischemic stroke in young adult and its association with our gene of interest. Methods : Case: We present a case of 43‐year‐old woman with past medical history significant for Acetylcholine Receptor (AChR) antibody positive Myasthenia Gravis diagnosed in 1993 status post thymectomy (1994), currently on prednisone and intravenous immunoglobulin every two weeks (failed cyclosporine and mycophenolate mofetil). She had two events in 2018 where she reported episodic right sided numbness and weakness that lasted for few hours. Stroke workup was done, and she was found to have focal moderate to severe stenosis of the left middle cerebral artery (MCA) on CT angiography (figure 1) with very subtle left hypoperfusion in the MCA on the brain single‐photon emission computerized tomography scan. She underwent catheter angiogram (figure 1) showing severe stenosis involving the mid and distal M1 segment of the left MCA and nondominant proximal A1 segment left anterior cerebral artery (ACA). There were robust leptomeningeal collaterals from the left anterior and left posterior cerebral arteries. She also reported history of two miscarriages in the first trimester. Hypercoagulable workup was done and all of those were negative including: SLE profile, Lupus anticoagulant, ANA comprehensive panel, Cryoglobulin, Anticardiolipin antibody, Antithrombin III, Antithrombin antigen, protein C, protein S, Factor VIII activity, Factor V Leiden. She also had rheumatoid arthritis factor, Homocysteine, sedimentation rate, and C‐reactive protein done which were unremarkable. Genetic workup showed that she is PAI‐1 5G/5G homozygous. She has been stable since 2018 without new focal neurological events and is on Aspirin monotherapy and Statin. Results : The genetics for stroke disease are very complicated and yet to be discovered fully. The association between PA‐1 5G/5G and intracranial stenosis has not been reported previously. New genetic associations will need to be increasingly considered as we assess our cerebrovascular diseases and stroke patients Conclusions : • With the current knowledge, ischemic stroke have polygenic basis but no single common “stroke gene” has been identified yet. • Here we present a case suggesting that PAI‐1 5G/5G genotype is may be associated with an independent risk of intracranial atherosclerosis.

Fibromuscular Dysplasia/Carotid Web in Angio-CT Imaging: A Rare Cause of Ischemic Stroke.

Background and Objectives: Carotid web (CaW) is an intimal variant of fibromuscular dysplasia and may constitute as one of rare causes of acute ischemic stroke (AIS). The objective of this study was to determine the prevalence of CaW in patients with AIS or transient ischemic attack (TIA) based on head/neck CT angiography (CTA) in a Polish cohort study. Materials and Methods: A retrospective study was performed by analyzing 1480 electronic clinical and imaging data regarding patients with AIS or TIA, hospitalized in the years 2018–2020 in the authors’ institution. The final sample consisted of 181 patients who underwent head/neck CTA; aged 67.81 ± 13.51 years (52% were women). All head/neck CTA studies were independently evaluated by two radiologists. The patient’s clinical condition was assessed with the National Institutes of Health Stroke Scale (NIHSS, 5.76 ± 4.05 and 2.88 ± 3.38 at admission and at discharge, respectively). Results: 27 patients were identified with CaW. The prevalence of CaW in the final sample (181 pts with good quality CTA) was 14.9%. In the CaW group, 89% patients had AIS, including 26% diagnosed with recurrent and 11% with cryptogenic strokes. There were no significant differences between the presence of CaW and gender, age, NIHSS score, recurrent or cryptogenic stroke. Conclusions: Our study demonstrated that CaW may be an underrecognized entity leading to cerebrovascular events. The diagnosis of CaW depends on a high level of awareness and a comprehensive analysis of the neuroimaging studies. Our findings support the hypothesis that it is worthwhile to perform CTA to determine the etiology of ischemic stroke, particularly if predicting factors were not identified.

Relationships of Ischemic Stroke Occurrence and Outcome with Gene Variants Encoding Enzymes of Tryptophan Metabolism.

Ischemic stroke is among the leading causes of mortality and long-term disability worldwide. Among stroke risk factors the importance of genetic background is gaining interest. There is a growing body of evidence of changes of metabolite levels and enzyme activities involved in the conversion of Trp during the course of cerebral ischemia. We compared the frequencies of ten SNPs of five genes related to Trp metabolism between groups of 122 ischemic stroke patients and 120 control individuals. Furthermore, we examined the mRNA levels of TPH1, IDO1 and KYAT1 genes in peripheral venous blood with the aim of assessing (i) whether there are changes in their expression during the course of stroke and (ii) does any of their investigated SNPs have an impact on gene expression. In seven cases out of ten studied polymorphisms we detected significant differences in frequencies in relation to ischemic stroke occurrence, etiology, and clinical parameters. We also detected changes in the expression of TPH1 and IDO1 genes during the course of the disease. We found that those IDO1 variants which show a trend towards elevated mRNA level are more frequent in stroke patients than in controls. Our results are important novel observations which suggest a causal relationship between elevated IDO1 expression and stroke etiology.

Women and Stroke: Different, yet Similar

Background: The impact of gender on acute ischemic stroke, in terms of presentation, severity, etiology, and outcome, is increasingly getting recognized. Here, we analyzed the gender-related differences in etiology and outcome of ischemic stroke in South India. Methods: Patients with first ever ischemic stroke within 1 week of onset presenting to the Comprehensive Stroke Care Centre, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India, were included in our study. Clinical and risk factor profile was documented. The stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) at onset, and stroke subtype classification was done using Trial of Org 10172 in Acute Ischemic Stroke criteria. The 3-month functional outcome was assessed using the modified Rankin Scale (mRS) with excellent outcome defined as an mRS ≤2. Results: Of the 742 patients, 250 (33.7%) were females. The age, clinical profile, and rate of reperfusion therapies did not differ between the genders. Women suffered more severe strokes (mean NIHSS 9.5 vs. 8.4, p = 0.03). While large artery atherosclerosis was more common in men (21.3% vs. 14.8%, p = 0.03), cardioembolic strokes secondary to rheumatic heart disease were more common in women (27.2% vs. 19.7%, p = 0.02). Men had a better 3-month functional outcome compared to women (68.6% vs. 61.2%, p = 0.04), but was not statistically significant after adjusting for confounders. Conclusion: Our data, from a single comprehensive stroke unit from South India, suggest that stroke in women are different, yet similar in many ways to men. Guideline-based treatment can result in comparable short-term outcomes, irrespective of admission stroke severity.

Reclassifications of ischemic stroke patterns due to variants of the Circle of Willis.

BackgroundVariants of the Circle of Willis (vCoW) may impede correct identification of ischemic lesion patterns and stroke etiology. We assessed reclassifications of ischemic lesion patterns due to vCoW.MethodsWe analyzed vCoW in patients with acute ischemic stroke from the 1000+ study using time-of-flight magnetic resonance angiography (TOF MRA) of intracranial arteries. We assessed A1 segment agenesis or hypoplasia in the anterior circulation and fetal posterior cerebral artery in the posterior circulation. Stroke patterns were classified as one or more-than-one territory stroke pattern. We examined associations between vCoW and stroke patterns and the frequency of reclassifications of stroke patterns due to vCoW.ResultsOf 1000 patients, 991 had evaluable magnetic resonance angiography. At least one vCoW was present in 37.1%. VCoW were more common in the posterior than in the anterior circulation (33.3% vs. 6.7%). Of 238 patients initially thought to have a more-than-one territory stroke pattern, 20 (8.4%) had to be reclassified to a one territory stroke pattern after considering vCoW. All these patients had fetal posterior cerebral artery and six (30%) additionally had carotid artery disease. Of 753 patients initially presumed to have a one-territory stroke pattern, four (0.5%) were reclassified as having more-than-one territory pattern.ConclusionsVCoW are present in about one in three stroke patients and more common in the posterior circulation. Reclassifications of stroke lesion patterns due to vCoW occurred predominantly in the posterior circulation with fetal posterior cerebral artery mimicking multiple territory stroke pattern. Considering vCoW in these cases may uncover symptomatic carotid disease.