Carotid Territory Stroke Research Articles

Reliability and validity of the Slovenian Translation of the Functional Oral Intake Scale (FOIS-SI)

Background: It is crucial that each and every stroke patient gets a systematic assessment of swallowing disorders, performed by a dysphagia specialist. Therefore, there is a need to use a standardized scale among professionals. The aim of this study was to translate, adapt, and obtain the statistical characteristics of the Functional Oral Intake Scale (FOIS), which is an observer-rated dysphagia severity scale primarily developed for stroke patients, into the Slovenian language.
 Methods: We performed a 5-step translation and adaptation process. Six speech and language pathologists had evaluated 30 clinical records of patients with an acute ischemic stroke in the carotid artery territory with the Slovenian translation of the Functional Oral Intake Scale (FOIS-SI). Every clinical record included a speech and language clinical bedside assessment of dysphagia, the sex, age, National Institutes of Health Stroke Scale (NIHSS), comorbidities of patients and lesion location. We examined interrater and intrarater reliability and additionally convergent validity of FOIS-SI with the theoretically related IDDSI-Functional Diet Scale (IDDSI-FDS).
 Results: The average measure Intraclass Correlation Coefficient (ICC) for the interrater reliability (ICC=0.959) and the intrarater reliability (ICC=0.979 and ICC=0.991) for both raters was excellent. The FOIS-SI scores correlated very high with the IDDSI-FDS (rs=0.927).
 Conclusion: The results of this study show that the Slovenian translation of the FOIS has an excellent interrater and intrarater reliability and very high validity, which implies the FOIS-SI can be used as a tool to quantitatively assess the severity of dysphagia in clinical practice and research in patients with stroke in carotid artery territory across the country in all medical and care settings.

Idiopathic recurrent spasm of the extracranial internal carotid artery – An unusual cause of stroke in a young woman

We report a case of a young female with recurrent stroke-like episodes who developed disabling cerebral infarction which, after extensive aetiological investigation, was found to be caused by internal carotid artery (ICA) vasospasm. This rare condition is difficult to diagnose but has treatment implications and should be considered in the differential for idiopathic carotid territory stroke in young patients.

THE ROLE OF CAROTID ECHO DOPPLER IN TREATMENT AND PREVENTION OF CEREBROVASCULAR DISEASE IN NON DIABETIC AND DIABETIC POPULATION AT HIGH RISK

Abstract Objective: Stroke, the third leading cause of death is a cardiovascular disease that affects the blood vessels supplying blood to the brain. Diabetes mellitus which is one of the main risk factors of cerebrovascular disease (CVD). Aim: Echo Doppler evaluation of arteries in diabetic and non-diabetic elderly patients. Design and method: Patient selection: We selected 112 patients admitted in Neurology Clinic of Vlad Voiculescu Cerebrovascular Institute Bucharest: 63 non diabetics mean age 63 years with acute ischemic stroke (CT scan confirmed)in carotid territory or a TIA and 59 diabetic patients with risk factors: obesity and arterial hypertension mean age 62.8 included into this study, independently from the presence or absence of acute ischemic stroke investigated by CT/MRI. Results: The carotid Echo-Doppler examination applying a 4 MHz transducer for extracranial and transcranial vascular Doppler investigation performed in both groups of patients revealed that simple carotid plaques, bilateral carotid stenoses (CS), and unilateral CS associated with contralateral carotid occlusion (CO) occurred with higher frequency in the non-diabetic patients, than in diabetic ones. On the other hand, the remaining other findings, such as unilateral CS, unilateral CO, S/O of intracranial carotid artery (ICA) and vertebral/subclavian S were more frequent in the diabetic group. Conclusions: The findings allow us to conclude that the correct and early treatment of diabetes as well as a possible lowering of the risks for cerebrovascular disease are obligatory steps in the primary and secondary prevention of the cerebral ischemic events in diabetic patients with carotid atheromatous lesions. There are several approaches to reduce the risk of stroke in diabetics and physical exercise is a low cost with maximum benefit upon health status contributing to lowering of high blood pressure, and of HDL. This consideration may help the physicians to have a deeper understanding of the pathophysiology, and to implement the necessary treatment and prevention of CVD in the diabetic population of high-risk.

Atherothrombotic stroke in women: blood thrombogenicity and the vascular wall

Introduction. Haemostasis and functional changes of the vascular wall are the strategic and actively developing aspects in the study of ischaemic stroke pathogenesis. The aim of current work was to examine the relationship between hormonal status, thrombogenic blood factors, and the structural and functional changes in the vascular wall in women after atherothrombotic stroke in the internal carotid territory. Materials and methods . Twenty-nine women (mean age 55 years) in the first 3 months after atherothrombotic stroke, diagnosed using the international TOAST criteria, were included in the study. The severity of neurological impairment was evaluated using the NIH Stroke Scale. The follicular stimulating hormone (FSH) and homocysteine levels, along with haemostasis parameters and rheological properties of red blood cells were examined. Ultrasound of the major arteries of the head, assessment of the elastic properties and mural shear stress in the common carotid artery, as well as evaluation of the vasomotor function of the brachial artery endothelium were conducted. Results. Clinical differences in the atherosclerotic stroke were found in women depending on their FSH levels: moderate and severe neurological impairments were noted when the FSG level was ³30 mIU/mL, while mild impairments were present when the FSG level was <30 mIU/mL. It was found that a high FSH level in women is associated with significant arterial hypertension, obesity and type 2 diabetes mellitus. The group of women with high FSH levels had elevated fibrinogen, homocysteine, von Willebrand factor, erythrocyte aggregation amplitude, along with the accelerated formation of 3D aggregates and increased erythrocyte aggregate strength. In women with insufficient estrogen production in the ovaries (FSH ³30 mIU/mL), the stiffness index of the common carotid artery wall was significantly higher, while the mural shear stress and endothelial vasomotor function were lower than in the group of women with preserved ovarian function. Conclusions. A link between menopause, increased blood thrombogenicity, and structural and functional changes in the vascular wall (increased stiffness, reduced mural shear stress and endothelial vasomotor function) was found in women after atherothrombotic stroke.

Effectiveness of complex rehabilitation in post-stroke patients treated with cellex

To evaluate the effectiveness of comprehensive rehabilitation using cellex in post-stroke patients in the late recovery period and the period of residual disorders in a prospective long-term study. Clinical examination and comprehensive rehabilitation treatment of 115 patients, aged 27-69 years (mean 50,47±11,20 years), with ischemic stroke and stroke in the carotid territory (n=78, 67,8%) and hemorrhagic stroke (n=37, 32, 2%) was carried out in the inpatient Department of GBU «NORCI». Patients who received rehabilitation measures were divided into two groups depending on the medication. The main study group consisted of 56 patients (48,7%) who received a course of cellex in the rehabilitation complex, the comparison group (n=59, 51,6%) underwent treatment without medication. The complex multi-course rehabilitation treatment using cellex in patients in the late recovery period and in the period of consequences of ischemic stroke, who have speech and motor disorders, is highly effective, and demonstrate good results despite the age of the disease.

3048PARADIGM-Extend prospective academic trial: Accumulating long-term evidence for MicroNet-covered stent safety and stroke prevention efficacy

Abstract Aims To provide long-term clinical (incl neurologic) and duplex ultrasound (DUS) evaluation of the CGuard MicroNet-covered embolic prevention stent system (EPS) routine use to perform CAS in all-comer (no exclusion criteria) patients with symptomatic or increased-stroke-risk asymptomatic carotid stenosis recommended for revascularization by the NeuroVascular Team. Methods and results PARADIGM-Extend is a non-industry-funded, prospective academic study in all-referrals-tracked symptomatic and asymptomatic carotid stenosis. In asymptomatic lesions, intervention is mandated only in case of increased-stroke-risk features. There is first-line consideration to use the study device, with EPD choice according to tailored-CAS algorithm. Independent neurologist evaluation and DUS are performed before CAS, at 48h, 30 days, and then every 12 months. There is external source data verification, external angiographic corelab, and external statistical analysis. Currently 325 patients (48–87 years, 54.2% symptomatic) crossed the 1st follow-up window. There has been 100% CGuardEPS use. Angiographic DS was reduced from 84±8% to only 6.9±5% (p&lt;0.001, “CEA-like” effect of CAS). Peri-procedural death or major stroke rate was 0%. One event was CEC-adjudicated as minor stroke (0.3%), and there was one (type2) MI (0.3%). By 30 days there was one haemorrhagic transformation leading to death (0.3%) and one bleeding-related death (0.3%). Thus total death/major stroke/minor stroke rate at 30 days was 0.9%, and total death/major stroke/minor stroke/MI rate at 30 days was 1.2%. At 1- 12 months were no strokes or stroke-related deaths (0%). At 12–24 months there was one cerebellar stroke in an AFib patient that was confirmed on MRI imaging but no carotid-territory stroke or stroke deaths (0%). By 24 and 36 months there was one posterior circulation (cerebellal) infarct but no cerebral infarctions. Post-procedural in-stent velocities were normal and remained normal throughout the 36-month follow-up period (peak-systolic/end-diastolic velocity 0.69±0.29/0.18±0.09 m/s at 30 days, 0.82±0.47/0.22±0.13m/s at 12 months, 0.73±0.31/0.19±0.09m/s at 24months and 0.80±0.31/0.21±0.11 at 24months), indicating normal device healing. Conclusions PARADIGM-Extend accumulating 36-month clinical and DUS evidence is consistent with unprecedented, sustained safety and cerebral embolism prevention efficacy of the CGuard™ MicroNET-covered embolic prevention stent system used routinely for stroke prevention in symptomatic and increased-stroke-risk asymptomatic subjects with carotid stenosis. Acknowledgement/Funding K/ZDS/007819 Jagiellonian University Medical College

Transcarotid Approach for Retrograde Stenting of Proximal Innominate and Common Carotid Artery Stenosis

To evaluate the hybrid treatment of severe stenosis or occlusion of the proximal innominate artery (IA) and common carotid artery (CCA) via surgical cutdown of the CCA and distal clamping for cerebral protection against thromboembolic events during retrograde stenting. Consecutive patients undergoing retrograde stenting of proximal IA and CCA stenosis or occlusion via surgical cutdown of the CCA and with distal clamping for prevention of embolization, with or without concomitant endarterectomy of the carotid bifurcation, between April 1999 and August 2015 were reviewed. Perioperative and long-term outcomes were assessed. Thirty-five patients underwent a total of 36 successful interventions. One patient underwent staged bilateral stenting. Additional concomitant carotid endarterectomy was performed in 13 patients (36%). No new neurological symptoms neither perioperatively nor in-hospital were recorded. Thirty-day follow-up revealed 1 new ipsilateral and 1 new contralateral stroke (6%) with completely patent stents, no reinterventions, and 2 unrelated deaths (6%). Median follow-up was 56months (range: 1-197). After 5 and 10years, the Kaplan-Meier estimated overall survival rate was 85% and 52%. Primary assisted patency rate was 94% during follow-up. Overall freedom from reintervention was 91%. Three reinterventions were performed during the first postoperative year. Three new neurological events occurred during follow-up, 1ipsilateral (3%) and 2 contralateral (6%). The ipsilateral event occurred during the first year and both contralateral events during the second year postoperatively. The retrograde hybrid approach to proximal IA and CCA disease is a safe procedure with surgical outflow control preventing perioperative stroke in ipsilateral carotid territory. Most relevant in-stent stenoses/occlusions and new neurological events occurred within the first 2 years, suggesting these patients should undergo regular monitoring early postoperatively. High patency rates without further neurological events can be expected thereafter.

Intracranial stents in the endovascular treatment of acute ischemic stroke

ObjectiveTo evaluate the efficacy and safety of intracranial stenting as a rescue therapy after failed mechanical thrombectomy in patients with acute ischemic stroke. Material and methodsWe retrospectively studied 42 patients treated with intracranial stenting after failed mechanical thrombectomy between December 2008 and January 2016. We compared outcomes before and after the incorporation of stentrievers. We assessed the degree of recanalization in the carotid and basilar territories (modified TIMI score), prognostic factors, and outcome (modified Rankin scale at 3 months). Safety was evaluated in function of the appearance of symptomatic intracranial hemorrhage (SICH). ResultsMedian NIHSS was 17 in patients with carotid territory strokes and 26 in those with vertebrobasilar territory strokes. Median time from onset of symptoms to treatment was 225min in carotid territory strokes and 390min in vertebrobasilar territory strokes. A total of 10 patients underwent intravenous fibrinolytic therapy before treatment with stentrievers. Two patients developed SICH; both had undergone intravenous fibrinolytic therapy (p=0.0523). Recanalization was effective in 30 (71.4%) in the entire series: in 7 (50%) of 14 patients treated before the incorporation of stentrievers and in 23 (82.1%) of 28 treated after the incorporation of stentrievers (p=0.0666). Outcome at 3 months was good in 2 (14.3%) patients in the earlier group and in 14 (50%) patients in the later group (p=0.042). We found significant associations between recanalization and outcome (p=0.0415) and between shorter time to treatment and outcome (p=0.002). Outcome was good in 14 (48.3%) of the 29 patients with carotid territory strokes and in 2 (15.4%) of the 13 patients with vertebrobasilar territory strokes (p=0.078). ConclusionsIntracranial stenting is the rescue treatment when the usual treatment fails. Stentrievers must be used to eliminate the clot burden before stenting. In our study, antiplatelet treatment did not seem to increase the risk of SICH except in patients with prior intravenous fibrinolytic therapy.

Uso del stent intracraneal en el tratamiento endovascular en agudo del ictus

ObjectiveTo evaluate the efficacy and safety of intracranial stenting as a rescue therapy after failed mechanical thrombectomy in patients with acute ischemic stroke. Material and methodsWe retrospectively studied 42 patients treated with intracranial stenting after failed mechanical thrombectomy between December 2008 and January 2016. We compared outcomes before and after the incorporation of stentrievers. We assessed the degree of recanalization in the carotid and basilar territories (modified TIMI score), prognostic factors, and outcome (modified Rankin Score at 3 months). Safety was evaluated in function of the appearance of symptomatic intracranial hemorrhage (SICH). ResultsMedian NIHSS was 17 in patients with carotid territory strokes and 26 in those with vertebrobasilar territory strokes. Median time from onset of symptoms to treatment was 225minutes in carotid territory strokes and 390minutes in vertebrobasilar territory strokes. A total of 10 patients underwent intravenous fibrinolytic therapy before treatment with stentrievers. Two patients developed SICH; both had undergone intravenous fibrinolytic therapy (p=0.0523). Recanalization was effective in 30 (71.4%) in the entire series: in 7 (50%) of 14 patients treated before the incorporation of stentrievers and in 23 (82.1%) of 28 treated after the incorporation of stentrievers (p=0.0666). Outcome at 3 months was good in 2 (14.3%) patients in the earlier group and in 14 (50%) patients in the later group (p=0.042). We found significant associations between recanalization and outcome (p=0.0415) and between shorter time to treatment and outcome (p=0.002). Outcome was good in 14 (48.3%) of the 29 patients with carotid territory strokes and in 2 (15.4%) of the 13 patients with vertebrobasilar territory strokes (p=0.078). ConclusionsIntracranial stenting is the rescue treatment when the usual treatment fails. Stentrievers must be used to eliminate the clot burden before stenting. In our study, antiplatelet treatment did not seem to increase the risk of SICH except in patients with prior intravenous fibrinolytic treatment.

Abstract TP128: Prognosis and Stratification of High-risk Patients with Mild (&lt;50%), but Unstable Stenosis of Internal Carotid Artery - Multi-center Observational Study in Japan

Background and Purpose: Previous clinical trials have shown that clinical benefits of carotid endarterectomy (CEA) are unclear in symptomatic mild (&lt;50%) stenosis of the internal carotid artery. However, it is not rare that the patients with mild carotid stenosis repeat TIA or ischemic stroke in spite of the best medical treatments. Although only the degree of stenosis have been accepted as “gold standard” in deciding treatment strategy, recent development of non-invasive MR imaging enables us to identify unstable plaque. Therefore, we have designed “ M ild, but U nstable S tenosis of I nternal C arotid artery (MUSIC) Study” in Japan. The objectives of this nation-wide, multicenter prospective study are to clarify the prognosis of patients with symptomatic mild carotid stenosis and identify the predictors for the patients at higher risk for recurrent TIA and ischemic stroke in spite of the best medical treatments. Impact of CEA is also evaluated in those refractory to the best medical treatments. Methods and Results: MUSIC Study is conducted in Japan, using a multi-center prospective observational design (UMIN000023635). The MUSIC Study Group is composed of 28 hospitals. This study will register totally 250 patients who are 20 years or older, experience TIA, ischemic stroke, or retinal ischemia in the ipsilateral carotid territory, have mild (&lt;50%) stenosis in the ipsilateral cervical carotid artery, and are independent in daily life (modified Rankin scale=0-2). Using MRI, plaque components are precisely evaluated in all patients. After informed consent is obtained, their clinical and radiological data are registered. They are followed up for two years and MRI/MRA examinations are repeated at 6, 12, and 24 months after the enrollment. Primary endpoint includes the incidence of ischemic stroke in the ipsilateral carotid territory. Secondary endpoints include the incidence of all-ischemic stroke, ipsilateral or all TIA, ipsilateral or all retina ischemia, all stroke, all death, de novo silent cerebral infarct, and progression of carotid stenosis. Conclusion: In this conference, we emphasize the importance to identify the patients at higher risk for recurrent ischemic events due to symptomatic mild carotid stenosis in spite of the best medical treatments.

Clinical analysis of carotid angioplasty stenting for high-grade extracranial carotid artery stenosis combined with severe tortuosity

To observe the feasibility and safety of carotid angioplasty stenting (CAS) for high-grade extracranial carotid artery stenosis combined with severe tortuosity. Twenty patients diagnosed with high-grade extracranial carotid artery stenosis combined with severe tortuosity by cerebral angiography, who were in hospital in neurology department of China-Janpan friendship from June 2011 to June 2014. Twelve of these patients were symptomatic. All cases weren't suit for or disagreed with carotid endarterectomy (CEA) to accept CAS. We retrospectively discussed the rates of technical success, the perioperative complications and clinical improvement. During the follow-up for 4 to 40 months we observed the events of cured carotid artery territory stroke and death, and record the plaque hyperplasia in stent, in-stent restenosis, stent deformation or fracture by color doppler ultrasonography or craniocervical CT angiography. (1) The results of operation: the rate of technical success was 19/20 and the rate of the distal protection device placement was 18/20. One stent and 2 distal protection device were difficult to pass the tortuous access vessels. The kinking was the most common in circuity classification of internal carotid artery. The stenosis was significantly improved after stenting, and the mean degree of stenosis was reduced from (82% ± 9%) before stenting to (7% ± 6%) after stenting. Although 5 patients were with perioperative complications, all symptoms disappeared within 1 weeks, and there was no stent related death and disability. There were 4 cases with vascular spasm, one of them was combined with carotid sinus reaction, and anther with transient ischemic attack (TIA) during operation. There was one with ipsilateral carotid territory minor stroke. (2) The results of prognosis and follow up: The clinical symptoms from 12 symptomatic patients were improved significantly on discharge, and the average NIHSS scores on admission were reduced from (4 ± 4) to (2 ± 2) on discharge. One patient experienced ipsilateral carotid territory minor stroke and another patient experienced ipsilateral carotid territory TIA during the follow-up for an average of 19 months, and there were 5 cases with mild plaque hyperplasia in stent and no in-stent restenosis, stent deformation or fracture. The severe tortuosity of extracranial carotid artery may affect the using of intervention materials and increase the complexity of CAS, but for the patients who disagree with CEA or were with the contraindications to CEA, CAS may be still a relatively safe, effective and alternative treatment.

Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification and vascular territory of ischemic stroke lesions diagnosed by diffusion-weighted imaging.

BackgroundThe association between the location and the mechanism of a stroke lesion remains unclear. A diffusion‐weighted imaging study may help resolve this lack of clarity.Methods and ResultsWe studied a consecutive series of 2702 acute ischemic stroke patients whose stroke lesions were confirmed by diffusion‐weighted imaging and who underwent a thorough etiological investigation. The vascular territory in which an ischemic lesion was situated was identified using standard anatomic maps of the dominant arterial territories. Stroke subtype was based on the Trial of ORG 10172 in Acute Stroke Treatment, or TOAST, classification. Large‐artery atherosclerosis (37.3%) was the most common stroke subtype, and middle cerebral artery (49.6%) was the most frequently involved territory. Large‐artery atherosclerosis was the most common subtype for anterior cerebral, middle cerebral, vertebral, and anterior and posterior inferior cerebellar artery territory infarctions. Small vessel occlusion was the leading subtype in basilar and posterior cerebral artery territories. Cardioembolism was the leading cause in superior cerebellar artery territory. Compared with carotid territory stroke, vertebrobasilar territory stroke was more likely to be caused by small vessel occlusion (21.4% versus 30.1%, P<0.001) and less likely to be caused by cardioembolism (23.2% versus 13.8%, P<0.001). Multiple‐vascular‐territory infarction was frequently caused by cardioembolism (44.2%) in carotid territory and by large‐artery atherosclerosis (52.1%) in vertebrobasilar territory.ConclusionsInformation on vascular territory of a stroke lesion may be helpful in timely investigation and accurate diagnosis of stroke etiology.

Tissue Window in Stroke Thrombolysis Study (TWIST): A Safety Study

Stroke thrombolysis is limited by the "last-seen well" principle, which defines stroke onset time. A significant minority of stroke patients (~15%) awake with their symptoms and are by definition ineligible for thrombolysis because they were "last-seen well" at the time they went to bed implying an interval that is most often greater than three hours. A single-centre prospective, safety study was designed to thrombolyse 20 subjects with stroke-on-awakening. Patients were eligible for inclusion if they were last seen well less than 12 hours previously, specifically including those who awoke from sleep with their stroke deficits. They had a baseline computed tomogram (CT) scan with an ASPECTS score greater than 5, no evidence of well-evolved infarction and a CT angiogram / Trans-cranial Doppler ultrasound study demonstrating an intracranial arterial occlusion. Patients fulfilled all other standard criteria for stroke thrombolysis. The primary outcome was safety defined by symptomatic ICH or death. Among 89 screened patients, 20 were treated with thrombolysis. Two patients (10%) died due to massive carotid territory stroke and two patients (10%) died of stroke complications. Two patients (10%) showed asymptomatic intracerebral hemorrhage (ICH) (petechial hemorrhage) and none symptomatic ICH. Reasons for exclusion were: (a) ASPECTS ≤ 5 (29); (b) well-evolved infarcts on CT (19); (c) historical mRS > 2 (17); (d) no demonstrable arterial occlusion or were too mild to warrant treatment (10). Patients who awake with their deficits can be safely treated with thrombolysis based upon a tissue window defined by NCCT and CTA/TCD.

Vestibular function in carotid territory stroke patients

Stroke patients may present otoneurological symptoms. ObjectiveTo assess the vestibular function of subjects with a history of carotid territory stroke. MethodThis historical cohort cross-sectional study enrolled 40 patients; subjects answered the Dizziness Handicap Inventory, were interviewed and submitted to ENT examination and vector electronystagmography. ResultsMild saccadic movement anomalies were seen in 20 patients (50.0%); nine complained of imbalance and dizziness. Abnormal smooth pursuit gain was seen in 17 cases (42.5%); six subjects reported imbalance and one complained of dizziness. Abnormal directional preponderance during rotational nystagmus was seen in two cases (5.0%), who also reported imbalance. Three patients (7.5%) and two subjects (5.0%) were found to have abnormal labyrinthine predominance and abnormal nystagmus directional preponderance respectively; all five individuals reported imbalance. Ten of the 11 patients without complaints of disordered balance had altered saccadic and smooth pursuit eye movements, while one had unaltered vestibular function. ConclusionPatients with a history of carotid territory stroke may suffer from dizziness or imbalance and present signs of compromised eye motility and vestibular function.

Relationship Between Plasma Homocysteine and the Morphological and Immunohistochemical Study of Carotid Plaques in Patients With Carotid Stenosis Over 70%

Several clinical and epidemiological studies describe hyperhomocysteinemia as an independent cardiovascular risk factor. Implication of cellular immunity in atherosclerosis also seems clear. This study aimed to analyze the association among plasma hyperhomocysteinemia, neurological clinical events, and the morphology and immunocytology of carotid plaques in patients with carotid stenosis >70% receiving surgical treatment. Sixty-two patients with carotid stenosis >70% receiving surgical treatment were studied; 58% had a history of stroke in the ipsilateral carotid territory. Plasma homocysteine concentrations were determined by considering pathological values >12.4 μmol/L. Histopathological (stable and unstable plaques) and immunohistochemical (macrophages, T lymphocytes, and active T lymphocytes counts) studies were performed. Hyperhomocysteinemia prevalence was calculated in this population, as were the possible relationships between homocysteine plasma concentrations, and the carotid plaque type and the cell types in it. The relationship between this risk factor and the presence of a neurological event relating to carotid stenosis was also investigated. Hyperhomocysteinemia prevalence was 43.5%, with a mean value of 11.8 μmol/L (median; range = 2-41.8 μmol/L). No significant differences were found between homocysteine levels and the plaque's morphological characteristics, or between the cell types analyzed. Elevated concentrations of homocysteine were not significantly higher in patients with a history of stroke. The present study confirms high hyperhomocysteinemia prevalence in patients with extracranial cerebrovascular disease, although no relationship between plaque complication phenomena and this cardiovascular risk factor was observed.

Clinical usefulness of the visibility of the transcerebral veins at 3T on T2*-weighted sequence in acute stroke patients

The objective of this work was to investigate the clinical usefulness of the visibility of the transcerebral veins (VTV) in acute ischemic stroke patients at 3T. Sixty consecutive carotid artery territory stroke patients were included retrospectively. Two readers categorized the VTV on T2*-weighted sequence at 3T for each hemisphere, and asymmetry of this sign was assessed between each hemisphere by an asymmetry index (AI) using a three-item scale. The VTV and AI were correlated with clinical and radiological covariates. Particular interest was focused on patients for whom initial diffusion-weighted imaging alone was inconclusive. VTV were detected in the stroke hemisphere in 58.3% (n = 35) and in the contralateral side in 10% (n = 6, p<0.0001). Asymmetry of the VTV between ischemic and contralateral hemispheres was present in 53.3% (n = 32). Intracranial artery occlusion, final infarct volume and symptomatic hemorrhagic transformation were correlated with a higher AI at baseline (ρ = 0.563, ρ = 0.291, and ρ = 0.285, p<0.05, respectively). Three hyperacute stroke patients with subtle DWI high signal intensity at admission demonstrated VTV. The pathological value of the VTV seems to reside in its asymmetry between hemispheres, as it was correlated with important clinical parameters. This study also suggests that the VTV could be a supportive finding in stroke diagnosis, especially when DWI is unreliable.

Part One: For the Motion Carotid Disease is Rarely Responsible for Stroke after Coronary Bypass Surgery

Part One: For the Motion Carotid Disease is Rarely Responsible for Stroke after Coronary Bypass Surgery

Early ADC changes in motor structures predict outcome of acute stroke better than lesion volume

The lesion volume assessed from diffusion-weighted imaging (DWI) within the first six hours to first week following stroke onset has been proposed as a predictor of functional outcome in clinical studies. However, the prediction accuracy decreases when the DWI lesion volume is measured during the earliest stages of patient evaluation. In this study, our hypothesis was that the combination of lesion location (motor-related regions) and diffusivity measures (such as Apparent Diffusion Coefficient [ADC]) at the acute stage of stroke predict clinical outcome. Seventy-nine consecutive acute carotid territory stroke patients (median age: 62 years) were included in the study and outcome at three months was assessed using the modified Rankin scale (good outcome: mRS 0-2; poor outcome: mRS 3-5). DWI was acquired within the first six hours of stroke onset (H2) and the following day (D1). Apparent Diffusion Coefficient (ADC) values were measured in the corticospinal tract (CST), the primary motor cortex (M1), the supplementary motor area (SMA), the putamen in the affected hemisphere, and in the contralateral cerebellum to predict stroke outcome. Prediction of poor vs. good outcome at the individual level at H2 (D1, respectively) was achieved with 74% accuracy, 95%CI: 53-89% (75%, 95% CI: 61-89%, respectively) when patients were classified from ADC values measured in the putamen and CST. Prediction accuracy from DWI volumes reached only 62% (95%CI: 42-79%) at H2 and 69% (95%CI: 50-85%) at D1. We therefore show that measures of ADC at the acute stage in deeper motor structures (putamen and CST) are better predictors of stroke outcome than DWI lesion volume.

T2*-Weighted MRI versus Oxygen Extraction Fraction PET in Acute Stroke

Background: Mapping high oxygen extraction fraction (OEF) in acute stroke is of considerable interest to depict the at-risk tissue. Being sensitive to deoxyhemoglobin, T2*-weighted MRI has been suggested as a potential marker of high OEF. Methods: We compared T2*-weighted images from pre-contrast arrival perfusion scans against quantitative positron emission tomography in 5 patients studied 7–21 h after onset of carotid territory stroke. OEF and T2* signal were obtained in the voxels with significantly high OEF. Results: All patients showed increased OEF. No significant relationship between OEF and T2*-weighted signal was found either within or between subjects. Conclusion: We found no indication that T2*-weighted MRI in the way implemented in this investigation was sensitive to high OEF in acute stroke.

Long-Term Outcome After Angioplasty and Stenting for Symptomatic Vertebral Artery Stenosis Compared With Medical Treatment in the C arotid A nd V ertebral A rtery T ransluminal A ngioplasty S tudy (CAVATAS)

The long-term outcome of endovascular intervention compared with best medical management of patients with symptomatic vertebral artery stenosis is uncertain. We therefore compared these treatments in a randomized trial with long-term follow-up. In the international, multicenter Carotid And Vertebral Artery Transluminal Angioplasty Study, 16 patients with symptomatic vertebral artery stenosis were randomized in equal proportions to receive endovascular therapy (balloon angioplasty or stenting) or best medical treatment alone. An independent neurologist followed up the patients for as long as 8 years. Endovascular intervention was technically successful in all 8 patients, but 2 patients experienced transient ischemic attack at the time of endovascular treatment. There were no deaths or strokes in any arterial territory within the first 30 days. During a mean follow-up period of 4.7 years, no patient in either treatment group experienced a vertebrobasilar territory stroke, but 3 patients in each treatment arm died of myocardial infarction or carotid territory stroke, and 1 endovascular patient had a nonfatal carotid territory stroke. Patients with vertebral artery stenosis were more likely to have carotid territory stroke and myocardial infarction during follow-up than have recurrent vertebrobasilar stroke. The trial failed to show a benefit of endovascular treatment of vertebral artery stenosis, but the numbers of patients included was small. Larger randomized trials are required to determine whether vertebral artery stenting is justified in patients at higher risk of vertebrobasilar stroke. Treatment of patients with vertebral artery stenosis should focus on global reduction of vascular risk, including prevention of carotid territory stroke and myocardial infarction.