Anterior Stroke Research Articles

Timing of initiation of oral anticoagulants in patients with acute ischemic stroke and atrial fibrillation comparing posterior and anterior circulation strokes.

The aim of this study in patients with acute posterior ischaemic stroke (PS) and atrial fibrillation (AF) was to evaluate (1) the risks of recurrent ischaemic event and severe bleeding and (2) these risks in relation with oral anticoagulant therapy (OAT) and its timing. Patients with PS were prospectively included; the outcome events of these patients were compared with those of patients with anterior stroke (AS) which were taken from previous registries. The primary outcome was the composite of stroke recurrence, transient ischaemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding and major extracranial bleeding occurring within 90 days from acute stroke. A total of 2470 patients were available for the analysis: 473 (19.1%) with PS and 1997 (80.9%) with AS. Over 90 days, 213 (8.6%) primary outcome events were recorded: 175 (8.7%) in patients with AS and 38 (8.0%) in those with PS. In patients who initiated OAT within 2 days, the primary outcome occurred in 5 out of 95 patients (5.3%) with PS compared to 21 out of 373 patients (4.3%) with AS (OR 1.07; 95% CI 0.39-2.94). In patients who initiated OAT between days 3 and 7, the primary outcome occurred in 3 out of 103 patients (2.9%) with PS compared to 26 out of 490 patients (5.3%) with AS (OR 0.54; 95% CI 0.16-1.80). our findings suggest that, when deciding the time to initiate oral anticoagulation, the location of stroke, either anterior or posterior, does not predict the risk of outcome events. Patients with PS or AS and AF appear to have similar risks of ischaemic or haemorrhagic events at 90 days with no difference concerning the timing of initiation of OAT.

The relationship between the platelet to leukocyte ratio and mechanical thrombectomy outcomes in acute ischemic stroke patients

ABSTRACT Background and purpose The predictive effect of blood cell ratio on ischemic event has been widely confirmed. Whether PWR and PNR can assess the risk of endovascular treatment (EVT) is largely unclear. This study aimed to investigate the prognostic value of PNR and PWR in acute ischemic stroke patients treated with EVT. Methods Poor functional outcome was defined as Modified Rankin Scale (mRS) of 3-6 at 3 months, Symptomatic intracranial hemorrhage (sICH) was diagnosed based on CT scan and classified according to the criterial of Heidelberg Bleeding Classification. Binary logistical regression was used to analyze the relationship of PWR, PNR with functional outcome and symptomatic intracranial hemorrhage (sICH). Results Patients with good prognosis had higher PNR and PWR value (29 vs. 24, P=0.002) (22 vs. 19, P=0.009), a lower rate of sICH (2.9% vs. 24.9%, P<0.001). In model 1, the lower PNR significantly associated with poor functional outcome (OR, 0.48; 95% CI 0.26-0.88; P=0.018), and sICH (OR, 0.42; 95% CI 0.19-0.91; P=0.028). The lower PWR only significantly associated with poor prognosis (OR, 0.97; 95% CI 0.94-1.00; P=0.038), and had a trend relation with sICH (OR, 0.98; 95% CI 0.94-1.02; P=0.328). In model 2 lower PNR still significantly associated with poor functional outcome (OR, 0.53; 95% CI 0.29-0.99; P=0.047), but showed a trend for predicting sICH (OR, 0.56; 95% CI 0.25-1.25; P=0.158). Conclusion Platelet to leukocyte ratio may be use to assess the risk of functional outcome and sICH in patients with acute anterior circulation occlusion stroke undergoing endovascular treatment in real world China.

The Relation Between Aortic Arch Branching Types and the Laterality of Cardio-Embolic Stroke

Background and purposeThe trajectory of cardiogenic emboli could be affected by anatomical and flow characteristics of the aortic arch. We aimed to study the relation between the different aortic arch patterns and the laterality of cardiogenic emboli. Methods192 cardioembolic strokes were classified into 3 groups according to the type of the aortic arch; type 1 (n = 69), type 2 (n = 49), type 3 (n = 74). The side and site of the cerebral vessels occlusion were divided into anterior and posterior circulation strokes, and anterior strokes were further subdivided into right or left internal carotid, middle or anterior cerebral arteries occlusion. ResultsOverall, the anterior circulation embolic occlusions were more common than the posterior, and middle cerebral artery more commonly affected than internal carotid artery. The left side propensity was higher either in the total patients’ pool or after segregation into atrial fibrillation (AF) and non AF cardio-embolic cases in all types of aortic arch except for type 1 aortic arch in the non AF cases. This propensity tended to get higher with advancement of the aortic arch types but failed to show statistically significant difference between the 3 arch types, however combination of type 2 and 3 arches into a single group showed statistically significant rise in the left side propensity in the total cardioembolic cases (P = 0.039) and in the non AF cardioembolic cases (P = 0.029). The bovine arch also showed increased left side propensity. ConclusionCardioemboli tends to have left anterior cerebrovascular predilection especially with AF. Different geometrical patterns of aortic arch branching seem to affect the laterality of cardioemboli and increase its left side predilection.

First Case of an Anterior Spinal Artery Stroke in Neurosarcoidosis: A case report and review of literature (666)

First Case of an Anterior Spinal Artery Stroke in Neurosarcoidosis: A case report and review of literature (666)

Abstract WP225: Fetal-Type Posterior Cerebral Artery: A Not So Benign Anatomical Variant?

Introduction: The fetal-type of the posterior cerebral artery (ftPCA) is a remnant of the embryonic cerebral vasculature and describes a predominant supply of the PCA territory by a branch of the internal carotid artery. It is usually considered a benign anatomical variant with a prevalence ranging between 3% and 40%. Given the larger supply of the brain parenchyma by the anterior circulation in this variant, ftPCA is often associated with a hypoplastic basilar artery and thus a reduced vertebrobasilar blood flow. Hypothesis: Attenuated blood flow through the vertebrobasilar system in patients with a ftPCA is associated with an increased risk of infratentorial ischemic stroke. Methods: We prospectively analyzed 625 consecutive acute stroke patients from our comprehensive stroke center. Cerebral MRI was used to identify stroke location. PCA territory blood supply was classified in 5 subcategories using CT or MRI angiography: 1) total ftPCA (i.e. complete supply via PCOM); 2) predominant ftPCA; 3) balanced PCA (supply via PCOM and P1); 4) predominant P1, and 5) complete P1 supply. Variants 1) and 2) were considered ftPCA for further analysis. We compared the frequencies of anterior, posterior, infratentorial, and multiple territories strokes between patients with and without ftPCA. Results: There were 215 patients (34%) with ftPCA. Patients with ftPCA were significantly more likely to suffer from an infratentorial stroke than those without the ftPCA variant (20% vs 12.2%, P = 0.009). In contrast, anterior, posterior, and multiple territories stroke did not differ between groups. When posterior territory strokes were attributed to the corresponding P1 or PCOM supply, there was no difference in the frequency of vertebrobasilar stroke (i.e. infratentorial plus P1-PCA) between patients with and without ftPCA (P=0.864). Mean cross sectional area of the basilar artery was significantly lower in patients with ftPCA compared to those without ftPCA (6.6mm2 vs. 9.7mm2, P&lt;0.001). Conclusion: Fetal-type PCA is associated with a higher frequency of infratentorial stroke and a lower cross sectional area of the basilar artery. Possibly, hemodynamic factors influence infratentorial stroke risk in patients with ftPCA.

Hypertrophic Cardiomyopathy Is Associated with Altered Left Ventricular 3D Blood Flow Dynamics.

To employ four-dimensional (4D) flow MRI to investigate associations between hemodynamic parameters with systolic anterior motion (SAM), mitral regurgitation (MR), stroke volume, and cardiac mass in patients with hypertrophic cardiomyopathy (HCM). A total of 13 patients with HCM (51 years ± 16 [standard deviation]; 10 men) and 11 age-matched healthy control subjects (54 years ± 15; eight men) underwent cardiac 4D flow MRI data analysis including calculation of peak systolic and diastolic control-averaged left ventricular (LV) velocity maps to quantify volumes of elevated velocity (EVV) in the left ventricle. Standard-of-care cine imaging was performed in short-axis, LV outflow tract (LVOT), and two-, three-, and four-chamber views on which the presence of SAM, presence of MR, total stroke volume, and cardiac mass were assessed. Systolic EVV in patients with HCM was 7 mL ± 5, which was significantly associated with elevated aortic peak velocity (R = 0.87; P < .001), decreased LVOT diameter (R = 0.68; P = .01), and increased cardiac mass (R = 0.62; P = .02). In addition, EVV differed significantly between patients with and those without SAM (10 mL ± 4.7 vs 3 mL ± 2.3; P = .03) and those with and those without MR (9.9 mL ± 4.8 vs 4.0 mL ± 3.2; P < .05). In the atrial systolic phase, peak diastolic velocity in the LV correlated with septal thickness (R = 0.66; P = .01). Quantification and visualization of EVV in the LV is feasible and may provide further insight into the clinical manifestations of altered hemodynamics in HCM.© RSNA, 2020.

Risk Stratification for Endovascular Treatment in Acute Anterior Circulation Occlusive Stroke

Objective: To develop and validate a novel scoring system for risk stratification in acute anterior circulation large vessel occlusion stroke patients undergoing endovascular treatment. Methods: Subjects were included from a multicenter registry on acute ischemic stroke undergoing thrombectomy in China. Two thirds of the patients were used as the derivation group and the other one third of the patients as the validation group. Multivariable logistic regression was used to generate the scoring system. The area under the receiver operating characteristic curve and Hosmer-Lemeshow goodness-of-fit test were used to assess model discrimination and calibration, respectively. Results: The Risk strAtification for eNdovascular treatment in acute anterior circulation occlusive stroKe (RANK) scale (total score ranges from −11 to 14) showed good discrimination in the derivation cohort (AUC = .79; 95% confidence interval [CI], .74-.84) and validation cohorts (AUC = .74; 95% CI, .68-.81), as well as good calibration (Hosmer-Lemeshow test) in the validation cohort (P = .54). We categorized the RANK score into 5 predictive groups for an unfavorable functional outcome, less than or equal to −8 (very low risk), –7 to –4 (low risk), –3 to 0 (intermediate), 1-5 (high risk), and greater than or equal to 6 (very high risk). In the very high risk group, only 3.3% (1 of 30, 95% CI: .08%-.2%) of patients in the derivation group and 5.5% (1 of 18, 95% CI: .1%-.3%) of patients in the validation group achieved a good functional outcome at day 90. Conclusions: The novel scale is a valid tool for risk stratification for endovascular stroke treatment in anterior circulation large vessel occlusions.

Effect of mode of anesthesia on radiation exposure in patients undergoing endovascular recanalization of anterior circulation embolic stroke

PurposeTo determine the effect of general anesthesia (GA) versus conscious sedation (CS) on radiation exposure (RE), procedure time (PT), and fluoroscopy time (FT) in patients receiving endovascular stroke treatment (EST)...

Ultrasonic quantification of cerebral perfusion in acute anterior circulation occlusive stroke-A comparative challenge of the refill- and the bolus-kinetics approach.

PurposeTo prospectively evaluate the potential of semi-quantitative evaluation of cerebral perfusion in acute ischemic stroke by comparing two established ultrasound approaches.Materials and methodsConsecutive inclusion of patients with acute occlusion of middle cerebral artery (MCA) confirmed by either magnetic resonance imaging (MRI) or computed tomography (CT) perfusion imaging qualifying for interventional therapy. Comparison of bilateral high mechanical index (MI) bolus-kinetics (HighMiB) and unilateral low MI refill-kinetics (LowMiR) performed before specific treatment.ResultsIn 16/31 patients HighMiB was eligible, in 8/31 patients LowMiR was eligible. In six out of these eight patients both HighMiB and LowMiR were eligible for direct comparison. In MR/CT perfusion imaging of the 16 patients eligible for HighMiB, 29/48 cortical regions of interest (ROIs) (60%) displayed hypoperfusion or ischemia, areas inadequately accessible by LowMiR. These ROIs made up 49% of the 59 ROIs displaying hypoperfusion or ischemia, altogether. Matching of parameters in normal and impaired ROIs between LowMiR and MRI/CT perfusion imaging was significantly poorer than in HighMiB.ConclusionLowMiR using refill-kinetics potentially has the advantage of real time imaging and better resolution. The diagnostic impact, however, proves inferior to HighMiB both with respect to imaging quality and semi-quantitative evaluation.

Acute Ischemic Stroke with Vessel Occlusion—Prevalence and Thrombectomy Eligibility at a Comprehensive Stroke Center

Introduction: Endovascular thrombectomy (ET) for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) can prevent severe disability and mortality. There is currently limited data on the epidemiology of LVO strokes and ET eligibility. We aim to determine the incidence of intracranial vessel occlusion (IVO) strokes eligible for ET per 2018 American Heart Association (AHA) guidelines and characteristics of an AHA ineligible population at a comprehensive stroke center (CSC). Methods: Retrospective chart review of all consecutive AISs at a CSC between November 2014 and February 2017. Demographic, clinical, and radiographic data were analyzed to determine ET eligibility per AHA guidelines and characteristics of ineligible patients were investigated. Results: Twenty-four percent of AIS harbor an IVO. Thirty percent of IVO strokes and 47% of anterior circulation LVO strokes are thrombectomy eligible per AHA guidelines. Most common reasons for thrombectomy ineligibility among IVO strokes are presence of IVO other than anterior circulation LVO (35%, n = 224), presence of large stroke burden (15%, n = 93), baseline modified Rankin scale greater than or equal to 2 (14%, n = 89), and NIHSS score less than 6 (15%, n = 96). Conclusions: At a CSC, 1 in 4 AISs harbor an IVO. Seven in 100 acute ischemic strokes, 3 in 10 strokes with vessel occlusion, and 1 in 2 strokes with internal carotid or middle cerebral artery M1 occlusion are thrombectomy eligible per AHA 2018 guidelines. These data highlight that current guidelines render a majority of strokes thrombectomy ineligible and a large window of opportunity exists for clinical investigation.

Prevalence of Nonstenotic Carotid Plaque in Stroke Due to Atrial Fibrillation Compared to Embolic Stroke of Undetermined Source

Background: Embolic stroke of undetermined source (ESUS) accounts for about 20% of strokes. Nonstenotic cervical arterial plaque may be a mechanism of stroke in a subset of these patients. Methods: A cohort of consecutive patients with ischemic stroke was retrospectively identified from a stroke registry. Patients with unilateral anterior circulation embolic stroke due to atrial fibrillation (AF) or consistent with ESUS who underwent computed tomographic neck angiography were included. The prespecified primary outcome was a comparison of the prevalence of carotid plaque greater than or equal to 3 mm thickness ipsilateral versus contralateral to the infarct side. Results: Of 772 screened patients, 96 patients with ESUS and 99 patients with AF were included. Plaque greater than or equal to 3 mm was more frequently ipsilateral than contralateral to the infarct in patients with ESUS (41% versus 29%, P = .03), and plaque thickness was greater ipsilateral compared to contralateral (median 2.5 versus 2.2 mm, P = .02). No significant differences in plaque characteristics ipsilateral compared to contralateral were found in patients with AF. The prevalence of ipsilateral versus contralateral plaque was greater in ESUS patients less than or equal to 65 years old (48% versus 19%, P < .01), but no different in patients greater than 65 years old (35% versus 39%, P = .57). Conclusions: Nonstenotic cervical carotid plaque is more common ipislateral to the infarction in patients with ESUS, but not in patients with AF, supporting an underlying atheroembolic mechanism in a subset of ESUS patients. This association might be greater in younger ESUS patients.

Distribution of ischemic strokes in patients with atrial fibrillation: The FibStroke Study.

We aimed to determine the relative frequency of affected cerebrovascular territories in patients with atrial fibrillation (AF) suffering an ischemic stroke. Altogether, 1,976 patients who suffered their first-ever ischemic stroke during 2003-2012 and were diagnosed with AF either before or within 30 days after the event were included in this retrospective multicenter cohort study. Strokes were classified radiographically to be located either within the anterior or the posterior cerebrovascular territory, and the effect of the CHA2DS2-VASc score, oral anticoagulant (OAC) use, and timing of AF diagnosis on lesion localization was determined. The median age of the patients was 78.4 (interquartile range: 71.7-84.2) years, 1,137 (57.5%) of them were women, their mean CHA2DS2-VASc score was 3.5 (95% confidence interval: 3.4-3.5), 656 (33.2%) were receiving OAC drugs, and altogether, 1,450 (73%) had a previous AF diagnosis. The localization of ischemic lesions between the anterior and the posterior cerebrovascular territories was not affected by the timing of AF diagnosis (p = 0.46), use of OACs (p = 0.70), or the CHA2DS2-VASc score (p = 0.10). Within the anterior territory, altogether 774 strokes (53.2%) were located in the left hemisphere and 3 (0.2%) were bilateral. The timing of AF diagnosis (p = 0.84), use of OACs (p = 0.90), or the CHA2DS2-VASc score (p = 0.21) did not affect the location of the ischemic lesion between the hemispheres. The timing of AF diagnosis, use of OAC drugs, or the CHA2DS2-VASc score did not affect the distribution of ischemic strokes. Anterior territory strokes were slightly more often located within the left hemisphere.

Impact of Procedure Time on Outcomes of Thrombectomy for Stroke

BackgroundEndovascular thrombectomy (ET) for acute ischemic stroke is the current standard of care. Although successful ET has high efficacy in improving functional outcomes, the decision to abort a long procedure remains a challenge. Longer procedure time (PT) has been associated with lower rates of functional independence. ObjectivesThe objective of this study was to evaluate the impact of PT on outcomes and complications after ET using different techniques at a multicenter level and to define the risk of procedure extension in different patient cohorts. MethodsPatients undergoing ET with a stent retriever (SR) or a direct aspiration at first pass technique at 7 U.S. centers between June 2013 and February 2018 were reviewed from prospectively maintained databases that include baseline variables and technical and clinical outcomes. Multivariate analyses were used to assess impact of PT on 90-day modified Rankin scores, successful recanalization, post-procedural symptomatic hemorrhage (sICH), and complications. ResultsThe study included 1,359 patients and demonstrated a decreased likelihood of good functional outcomes (modified Rankin score 0 to 2) when PT extended beyond 30 min (p < 0.01). Rates of sICH and complications increased exponentially with PT (doubling rates of 26 and 50 min, respectively). The cumulative rate of successful recanalization and good outcomes plateaued after 60 min of PT. In patients with PT >30 min, fewer attempts predicted the success of ET and good outcomes (p < 0.01). Successful recanalization was achieved faster with the direct aspiration at first pass technique than in SR. The direct aspiration technique was more sensitive to PT than SR, and posterior stroke was more sensitive to PT than anterior stroke. ConclusionsLonger ET procedures lead to lower rates of functional independence and higher rates of sICH and complications. Exceeding 60 min or 3 attempts should trigger careful assessment of futility and risks of continuing the procedure.

Abstract WP34: ASPIRE: Aspiration Thrombectomy as the Primary Modality in Endovascular Stroke Treatment: Pooled Analysis of the 3D Stent-Retriever, ASTER, THERAPY, COMPASS and MR CLEAN Trials

Background: Given the overwhelming evidence for the benefit of stent-retriever thrombectomy, a future trial of primary aspiration thrombectomy (PAT) against best medical therapy (BMT) alone has become unethical and impractical. Therefore, alternative approaches are needed to further investigate the impact of PAT in the outcomes in large vessel occlusion (LVO) strokes. The aim of this project is to assess the effectiveness of PAT plus BMT (including IV t-PA if indicated) compared to BMT alone in patients with anterior circulation LVO strokes. Methods: A systematic search of the medical literature and trial registries (EMBASE, Pubmed Medline, Cochrane trial registry, clinical trials.gov and ISRCTN) was conducted to trace randomized clinical trials (RCT) that evaluated PAT as a first treatment approach for LVO strokes. Four prospective RCTs employing aspiration thrombectomy as a primary treatment modality in one arm were identified: THERAPY (n=108; 55 PAT), Penumbra 3D Stent-Retriever (n=198; 100 PAT), ASTER (n=381; 192 PAT) and COMPASS (n=270; 134 PAT). Data from the PAT arms from these four RCTs and controls from the MR CLEAN (n=500; 267 controls) and THERAPY (53 controls) trials will be pooled. Treatment effect on the primary outcome (90-day mRS ordinal shift analysis) will be analyzed with multivariable ordinal regression analysis in the propensity matched dataset, after adjusting for remaining differences in distribution of baseline prognostic factors, to increase power. Adjustments will be made for age, sex, baseline NIHSS, collateral score, pre-treatment ASPECTS, admission glucose levels, time from stroke onset to qualifying imaging. The effect will be expressed as an adjusted common odds ratio, with 95% confidence interval. Treatment effects for secondary outcomes will be estimated in a similar approach, with the appropriate regression method. Results: The data will be analyzed by an independent statistical group (Erasmus MC, University Medical Center Rotterdam, the Netherlands). The results will be available and reported at the time of the ISC 2019. Conclusion: This pooled data project will provide unique and high-level evidence concerning the effect of aspiration thrombectomy on functional outcome after acute ischemic stroke.

Abstract WMP15: Flat Panel Detector CT Assessment in Stroke to Reduce Times to Intra-Arterial Treatment (FAST-IA): A Study of Multi-Phase CTA in the Angiography Suite to Bypass Conventional Imaging

Background: Bypassing the emergency department (ED) and the CT suite by directly transporting to the neuroangiography suite for imaging assessment and treatment may shorten reperfusion times while maintaining proper patient selection. Methods: Single-center prospective study of consecutive patients with anterior circulation LVO strokes transferred to our facility for consideration of endovascular therapy (ET) from 5/2016 to 12/2017. Those with basilar strokes and/or presenting to the ED were excluded. Patients were categorized into two groups: (1) F lat-Panel Detector CT A ssessment in S troke to Reduce T imes to I ntra- A rterial Treatment (FAST-IA) group, with patients transferred directly to the suite for Flat-Panel Detector multiphase CT angiography (FD-mCTA); and (2) Patients undergoing standard protocol including CT+/-CTA/CTP. The groups were matched for age, baseline NIHSS and pre-treatment glucose. Baseline characteristics, time metrics and outcomes were compared. Results: Out of 419 patients that underwent ET over the study period, 210 patients fit inclusion criteria, with 54 (25.7%) in the FAST-IA group. After matching, 49 FAST-IA/Control pairs were generated and analyzed. Baseline characteristics were well-balanced. FAST-IA patients had significantly shorter median door-to-puncture (33[26.5-47] vs 55[44.5-66] minutes, p&lt;0.001), door-to-reperfusion (85[57.5-115.5]vs110[80-153],p=0.005) and picture-to-puncture (18[13.5-22.5]vs 42[32-47.5]minutes, p&lt;0.001)times. There were no differences in rates of successful reperfusion (mTICI 2b-3, 95.9% vs 100%, p=0.5), parenchymal hematomas type-2 (4.1% vs 2%, p=1.00), good outcome (90-day mRS-0-2, 44.9% vs 40.8%, p=0.68) and 90-day mortality (14.3% vs 22.4%,p=0.30). Conclusions: Directly transferring patients to angiography and using FD-mCTA to determine eligibility for ET is safe and results in significant reduction in treatment times. Future larger studies are warranted.

High Variability in Neuronal Loss.

Background and Purpose- In the setting of acute ischemic stroke because of large-vessel occlusion (LVO) there is progressive loss of brain tissue which occurs in a time-dependent fashion previously quantified to be ≈1.9 million neurons per minute. However, this number represents an average and accumulating evidence suggests large individual variation. In this study, we aim to quantify the distribution and range in the rate of loss brain tissue across the entire spectrum of clinical phenotypes of anterior circulation LVO strokes encountered in clinical practice. Methods- Retrospective review of a prospectively acquired database of consecutive patients with anterior circulation stroke because of proximal LVO and appropriate ischemic core imaging was performed. Ischemic core volume was measured using automated software processing and time from last known well to imaging was recorded. Applying previously published methodology for brain loss quantification, we computed rate of brain tissue elements loss in proximal LVO stroke patients. Results- We studied 415 patients with internal carotid artery or middle cerebral artery (M1 segment) occlusion. Mean ischemic core volume was 50.4 mL and mean time to imaging from time from last known well (TLKW) was 8.7 hours, which is similar to previously published data, translates into a mean loss per minute of 2.03 million neurons, 14.8 billion synapses, and 12.8 km of myelinated fibers. However, the distribution of neuron loss was highly variable, ranging from <35 000 to >27 million cells per minute. Conclusions- Widely spread rates of infarct growth are observed in acute ischemic stroke because of proximal LVO with rate of neuron loss per minute ranging from <35 000 per minute in slow progressors to >27 million per minute in fast progressors, with a mean and median of 2 million and 0.9 million, respectively.

Large but Nonstenotic Carotid Artery Plaque in Patients With a History of Embolic Stroke of Undetermined Source.

Background and Purpose- This study's objective is to determine if nonstenotic carotid plaque of <50% luminal narrowing predominantly develops ipsilateral rather than contralateral to the stroke site. Methods- This was a cross-sectional observational study. We identified consecutive patients with anterior circulation embolic stroke of undetermined source (ESUS), excluding stroke in multiple vascular territories. Using ultrasonography, we measured the internal carotid plaque size and stenosis for each patient. We dichotomized the plaque size at several predefined thresholds and calculated the frequency of the plaque size and morphology above each threshold ipsilateral versus contralateral to the stroke site. Results- We included 53 patients with unilateral anterior circulation ESUS. Initially, we found that plaque with a thickness ≥1.5 mm was present ipsilateral to the stroke site in 59% of the patients, and present contralateral to the stroke site in 42% of the patients (31/53 versus 22/53 patients; P=0.049). Plaque with low echo likewise had a similar prevalence when present ipsilateral (9%) and contralateral (4%) to the stroke site (5/53 versus 2/53; P=0.25). Conclusions- Internal carotid artery plaque with a thickness ≥1.5 mm but that is nonstenotic (<50%) is considerably more common when ipsilateral to the ESUS site than when contralateral to the ESUS site, especially in plaque with a thickness ≥2.6 mm. Large but nonstenotic carotid artery plaque is associated with anterior circulation ESUS.

Nonstenotic Carotid Plaque in Patients with Anterior Circulation Embolic Stroke of Undetermined Source

Characteristics of nonstenotic (<50%) carotid plaque in embolic stroke of undetermined source (ESUS) are unclear. This study aimed to clarify the size and properties of carotid plaque in patients with ESUS. We retrospectively analyzed the results of carotid ultrasonography in 17 consecutive patients with anterior circulation ESUS and compared the size and morphology of carotid plaque on the ipsilateral and contralateral sides of the stroke lesion. The mean plaque thickness did not significantly differ between both sides (2.13 vs 1.86 mm, p = 0.54), but the mean noncalcified plaque thickness was greater on the ipsilateral side than on the contralateral side (1.15 vs 0.23mm, p = 0.025). Noncalcified plaque with thickness≥2.5mm was observed on the ipsilateral side in five of 17 patients, but not on the contralateral side, suggesting that noncalcified plaque with thickness≥2.5mm is a potential source of ESUS. (Received January 29, 2018; Accepted July 21, 2018; Published November 1, 2018).

Return to work after ischemic stroke in young adults: A registry-based follow-up study.

ObjectiveWe aimed to investigate the proportion of young patients not returning to work (NRTW) at 1 year after ischemic stroke (IS) and during follow-up, and clinical factors associated with NRTW.MethodsPatients from the Helsinki Young Stroke Registry with an IS occurring in the years 1994–2007, who were at paid employment within 1 year before IS, and with NIH Stroke Scale score ≤15 points at hospital discharge, were included. Data on periods of payment came from the Finnish Centre for Pensions, and death data from Statistics Finland. Multivariate logistic regression analyses assessed factors associated with NRTW 1 year after IS, and lasagna plots visualized the proportion of patients returning to work over time.ResultsWe included a total of 769 patients, of whom 289 (37.6%) were not working at 1 year, 323 (42.0%) at 2 years, and 361 (46.9%) at 5 years from IS. When adjusted for age, sex, socioeconomic status, and NIH Stroke Scale score at admission, factors associated with NRTW at 1 year after IS were large anterior strokes, strokes caused by large artery atherosclerosis, high-risk sources of cardioembolism, and rare causes other than dissection compared with undetermined cause, moderate to severe aphasia vs no aphasia, mild and moderate to severe limb paresis vs no paresis, and moderate to severe visual field deficit vs no deficit.ConclusionsNRTW is a frequent adverse outcome after IS in young adults with mild to moderate IS. Clinical variables available during acute hospitalization may allow prediction of NRTW.

Clinical Outcomes of Valvular versus Nonvalvular Atrial Fibrillation in Acute Anterior Circulation Occlusive Stroke Undergoing Endovascular Treatment

BackgroundThrombectomy is the first choice for cardioembolism due to atrial fibrillation (AF), however, whether valvular AF and nonvalvular AF had different safety and functional outcomes has not been reported yet. We aimed to investigate the differences between patients with valvular AF and patients with nonvalvular AF on safety and functional outcomes in acute large artery occlusion undergoing thrombectomy. MethodsValvular AF refers to patients with mitral stenosis or artificial heart valves and valve repair. Rate of symptomatic intracerebral hemorrhage [sICH], modified Rankin Scale Score (mRS), and death at 90 days were compared between valvular AF and nonvalvular AF groups. Univariate and multivariable logistic regression was performed to identify the predictors for unfavorable functional outcome (mRS 3-6). Results18.8% (51/271) of AF were valvular AF. The valvular AF group had significantly higher proportion of mRS 0-2 (49% [25/51] versus 33.3% [73/219], P = .04) and less death (21.6% [11/51] versus 38.4% [84/219], P = .02) comparing with nonvalvular AF group. The rates of sICH between both groups were nonsignificantly different (21.5% [47/219] for nonvalvular AF versus 13.7% [7/51] for valvular AF, P = .46). Valvular AF was not an independent predictor for unfavorable functional outcome (odds ratio .67, 95% confidence interval: .24-1.84) with age, collateral flow, chronic heart failure, NIHSS at admission, recanalization status, glucose at admission, occlusion site, ASPECTS, and ICH as covariates. ConclusionsValvular AF and nonvalvular AF have similar safety and functional outcomes in patients with acute anterior circulation large artery occlusion undergoing thrombectomy.