Cause Of Acute Ischemic Stroke Research Articles

Anterior Circulation Acute Ischemic Stroke Associated with Atherosclerotic Lesions of the Cervical ICA: A Nosologic Entity Apart.

Mechanical thrombectomy for patients with acute ischemic stroke with tandem occlusions has been shown to present varying reperfusion successes and clinical outcomes. However, the heterogeneity of tandem occlusion etiology has been strongly neglected in previous studies. We retrospectively investigated patients with acute ischemic stroke atherothrombotic tandem occlusion. All consecutive patients with acute ischemic stroke with atherothrombotic tandem occlusions treated with mechanical thrombectomy in our center between September 2009 and April 2015 were analyzed. They were compared with patients with acute ischemic stroke with dissection-related tandem occlusion and isolated intracranial occlusion treated during the same period. Comparative univariate and multivariate analyses were conducted, including demographic data, safety, and rates of successful recanalization and good clinical outcome. Despite comparable baseline severity of neurologic deficits and infarct core extension, patients with atherothrombotic tandem occlusions were older (P < .001), were more frequently smokers (P < .001), and had globally more cardiovascular risk factors (P < .001) than the other 2 groups of patients. The patients with atherothrombotic tandem occlusions had significantly longer procedural times (P < .001), lower recanalization rates (P = .004), and higher global burden of procedural complications (P < .001). In this group, procedural complications (OR = 0.15, P = .02) and the TICI 2b/3 reperfusion scores (OR = 17.76, P = .002) were independently predictive factors of favorable clinical outcome. Our study suggests that atherothrombotic tandem occlusions represent a peculiar and different nosologic entity compared with dissection-related tandem occlusions. This challenging cause of acute ischemic stroke should be differentiated from other etiologies in patient management in future prospective studies.

Serum cystatin C is associated with large cerebral artery stenosis in acute ischemic stroke.

Large cerebral artery stenosis is a major cause of acute ischemic stroke (AIS); however, the correlation between serum cystatin C (CysC) and the stenosis of large cerebral arteries in patients with AIS has not been established. We performed a retrospective review of acute ischemic stroke patients, who were examined by cerebral digital subtraction angiography(DSA). Participants (252 cases) included 131 patients without stenosis and 121 patients with large cerebral artery stenosis. Serum CysC levels in patients with large cerebral artery stenosis were much higher than that of control subjects (p<0.001). However, serum CysC levels were not related to the location of stenosis. Further, logistic regression analyses showed that increased serum CysC was an independent risk factor of large cerebral artery stenosis in patients with acute ischemic stroke. Total participants were subdivided into quintiles based on serum CysC levels. Compared with the first quintile, the odds ratios of risk for large cerebral artery stenosis in the fourth and the fifth quintile were 1.26 (p<0.05) and 4.71(p<0.05) respectively, after the adjustment for age, sex, and smoking, hypertension, type 2 diabetes mellitus(DM), dyslipidemia, creatinine(Cr), urea, uric acid, and C reactive protein(CRP). Therefore, a significant positive correlation was observed between elevated serum CysC levels and large cerebral artery stenosis in patients with acute ischemic stroke. In summary, our findings provide new insights into the correlation between increased serum CysC and large cerebral artery stenosis in patients with acute ischemic stroke.

One swallow does not a summer make but many swallows do: accumulating clinical evidence for nearly-eliminated peri-procedural and 30-day complications with mesh-covered stents transforms the carotid revascularisation field.

Atherosclerotic carotid artery stenosis (CS) continues to be a common cause of acute ischaemic stroke. Optimised medical therapy (OMT), the first-line treatment modality in CS, may reduce or delay – but it does not abolish – CS-related strokes. As per current AHA/ASA and ESC/ESVS/ESO guidelines, carotid artery stenting (CAS) is a less-invasive alternative to carotid endarterectomy (CEA) for CS revascularisation in primary and secondary stroke prevention.Ten-year follow-up from the CREST trial in patients with symptomatic and asymptomatic CS confirmed equipoise of CAS and CEA in the primary endpoint. Nevertheless CAS – using a widely open-cell, first-generation stent and first-generation (distal/filter) neuroprotection – has been criticised for its relative excess of (mostly minor) strokes by 30 days, a significant proportion of which were post-procedural.Atherosclerotic plaque protrusion through conventional carotid stent struts, confirmed on intravascular imaging, has been implicated as a leading mechanism of the relative excess of strokes with CAS vs. CEA, including delayed strokes with CAS. Different designs of mesh-covered carotid stents have been developed to prevent plaque prolapse. Several multi-centre/multi-specialty clinical studies with CGurad MicroNet-Covered Embolic Prevention Stent System (EPS) and RoadSaver/Casper were recently published and included routine DW-MRI cerebral imaging peri-procedurally and at 30 days (CGuard EPS).Data from more than 550 patients in mesh-covered carotid stent clinical studies to-date show an overall 30-day complication rate of ~1% with near-elimination of post-procedural events. While more (and long-term) evidence is still anticipated, these results – taken together with optimised intra-procedural neuroprotection in CAS (increased use of proximal systems including trans-carotid dynamic flow reversal) and the positive 12-month mesh-covered stent data reports in 2017 – are transforming the carotid revascularisation field today.Establishing effective algorithms to identify the asymptomatic subjects at stroke risk despite OMT, and large-scale studies with mesh-covered stents including long-term clinical and duplex ultrasound outcomes, are the next major goals.

Rapid Identification of Type A Aortic Dissection as a Cause of Acute Ischemic Stroke

Patients with acute aortic dissection (AAD) sometimes present predominantly with neurological symptoms from cerebral ischemia. Such stroke patients must not receive thrombolysis therapy, which can be fatal. However, patients remain at risk if there is a failure to notice concurrent AAD. We aimed to clarify the characteristics of AAD patients with stroke to identify markers for early AAD detection before thrombolysis. Using the single-center database of Stanford type A-AAD patients between 2007 and 2013, we selected those presenting with acute focal neurological deficits, presumably due to cerebral ischemia. Results of physical, radiological, and blood examinations were assessed in AAD patients with stroke. Of 226 AAD patients, 23 (10%) had stroke secondary to AAD. Of the 23 patients, 21 (91%) were primarily examined by stroke physicians and 2 (9%) by cardiologists. Thirteen patients (57%) were potential candidates for intravenous thrombolysis. Only 11 patients (48%) complained of chest/back pain. Positive findings indicating AAD included occlusion or intimal flap of the common carotid artery on carotid ultrasound in 18 (90%) of 20 patients, elevated serum d-dimer values (≥6.9 µg/mL) in 18 (78%) of 23, left hemiparesis as a neurological symptom in 17 (74%) of 23, systolic blood pressure differential above 20 mmHg between the arms in 15 (71%) of 21 patients, and mediastinal widening on chest radiograph in 10 (67%) of 15 patients. All 14 patients who underwent complete evaluation showed 2 or more positive diagnostic findings. The combination of physical, radiological, and laboratory findings may be a useful rapid-screening method for AAD as a cause of acute ischemic stroke.

Abstract TP7: Intraarterial Treatment for Acute Ischemic Stroke due to Dissection: Retrospective Series of 24 Cases

Introduction: Cervical artery dissection is a recognized cause of acute ischemic stroke (AIS). Intra-arterial treatment (IAT) may be a complementary option to IV tPA and antithrombotic therapy. Hypothesis/Purpose: To describe a large series of patients with dissection treated with IAT. Methods: Demographics, clinical characteristics, treatment, and outcomes were summarized for all dissection patients treated with IAT from 1/2010 - 5/2015. Outcomes included functional independence (modified Rankin score ≤ 2 at 90 days or discharge, or discharge home), recanalization, procedural complications, sICH, and mortality. Data are presented as median (interquartile range) or (n). Results: Of 161 patients with dissection, 24 (15%) were managed with IAT and comprise our population, which was primarily male (75%) aged 52 (42-59.5) and NIHSS of 13 (12 -16). Internal carotid artery dissections (ICAD, 18) were more common than vertebral artery dissections (VAD, 6); three patients had bilateral dissections (1 ICAD, 2 VAD). In all but two patients there was associated intracranial embolus. Dissections were idiopathic (17), traumatic (5) or cough-related (2). Eleven patients were treated with IV tPA. IAT techniques included thrombectomy (19), IA thrombolysis (17), stent (13), and angioplasty (7). The majority of patients had multiple techniques: 2 (2 -3). Functional independence was achieved in 63% (12/19). There were four deaths, none were attributable to IAT. There was one sICH and three procedural complications (2 groin pseudoaneurysm, one catheter induced acute dissection). Among the 6 VADs, 2 were left untreated and the remaining 4 were successfully recanalized (100%). All 6 VADs had a basilar artery occlusion; recanalization was successful in 2 and partial in 4 cases. Among the 18 ICADs, 6 were left untreated and the remaining 12 were successfully recanalized (100%). Sixteen of 18 ICADs had middle cerebral artery occlusion; recanalization was successful in 4, partial in 10, and unsuccessful in 2 cases. Conclusions: Despite the additional intravascular risk, outcomes appear to be similar to those presented in large RCTs with stroke from all causes, suggesting utility of IAT when performed in patients with dissection.

Abstract TP16: Intraarterial Treatment for Acute Ischemic Stroke: Analysis of Outcomes of Dissection vs. Non-Dissection Mechanism in 445 patients

Introduction: The safety and efficacy of intraarterial treatment (IAT) for acute ischemic stroke (AIS) due to cervical artery dissection (CAD, carotid and vertebral) has not been studied in a controlled trial. Hypothesis: There will be no differences in safety and efficacy of IAT for AIS due to CAD compared to non-CAD mechanism. Methods: We studied consecutive admissions with AIS who received IAT between 1/2010 - 4/2015 and compared outcomes for AIS patients who presented with CAD mechanism vs. other causes. Outcomes included in-hospital mortality, symptomatic intracerebral hemorrhage (sICH), procedural complications, and functional independence (Modified Rankin Score ≤ 2 at 90-days or discharge, or discharge home). Outcomes were univariately analyzed with Chi-square tests. Co-primary outcomes of functional independence and sICH were analyzed with multivariate logistic regression. Results: Of 3,671 patients with AIS, 445 patients received IAT and comprise our study population: 24 with CAD (5%: 18 carotid, 6 vertebral) and 421 with another cause. Patients with CAD were younger (median age: 52 vs. 70, p &lt; 0.001) with less severe stroke (median NIHSS: 13 vs. 18, p=0.03) than those with another cause of AIS. Unadjusted outcomes were similar by AIS cause (Table 1). After adjustment for NIHSS and age, the odds of achieving functional independence (OR: 0.58 [0.19-1.78], p=0.34) and sICH (OR: 0.57 [0.07-4.66], p=0.60) were not significantly different in patients with CAD vs. other mechanism. Conclusions: Intraarterial treatment appears to be as safe and effective when used in patients with ischemic stroke due to CAD as in AIS patients with other causes. Following the major advances in IAT for AIS in the general population, IAT should be considered in patients with AIS due to a CAD.

Advances in the Detection and Monitoring of Atrial Fibrillation for Patients with Cryptogenic Ischemic Stroke.

Atrial fibrillation (AF) is a significant etiologic cause of acute ischemic stroke (AIS) that leads to disabling deficits as well as significant morbidity and mortality in this population. Approximately 25 % of AIS is considered to be cryptogenic with no etiology ascertained at the time of the index event. Recent advances from the EMBRACE and CRYSTAL-AF trial have improved detection and treatment of AF and subsequently lead to changes in guidelines. However, with improved detection rates, the duration and frequency cutoffs for treating AF are currently being investigated to ensure optimization of patient selection and subsequent treatment.

Symptomatic focal cerebral arteriopathy in a young man

Arteriopathy is the leading cause of acute ischemic stroke in children and young adults, with intracranial arterial dissection (IAD) and transient cerebral arteriopathy (TCA) most commonly reported. The etiology and pathophysiology of childhood cerebral arteriopathies are not completely understood. The diagnosis is mainly based on clinical presentation and neuroimaging findings with considerable overlapping and discrepancy between diagnoses. We report the case of a young man who presented with an acute right basal ganglia infarct, and was found to have a focal cerebral arteriopathy of the intracranial right internal carotid artery that fluctuated clinically but resolved in four weeks with conservative management. The diagnoses of IAD and TCA were considered. We review and discuss the literature and the difficulties with the current terminology and classifications. In order to better understand the natural history and management there is a need to standardize the terminology and classifications of cerebral arteriopathies of the children and young adults.

Abstract W P312: Secular Trends of Intravenous Heparin Use for Acute Ischemic Stroke in Korea: From 2008 To 2013

Background: Since the introduction of intravenous (IV) heparin for the treatment of acute ischemic stroke in 1941, its use has been an area of great controversy among neurologists. Current American Heart Association guideline does not recommend IV heparin for the treatment of acute ischemic stroke. We sought to obtain updated information regarding the practices of Korean neurologists with regard to acute heparin use. Methods: Based on a prospective multicenter stroke registry database (CRCS-5), we collected patients with acute ischemic stroke, arrived within 7 days of symptom onset, from 2008 to 2013. Patient’s demographics, medical history and stroke characteristics were compared between IV heparin user and non-user. Results: Total of 23,425 patients from 12 regional stroke centers or university hospitals across the nation was analyzed. The mean age was 67.8 years and 58.1% was male. Median initial NIHSS score was 4 (interquartile range, 2 - 9). Large artery atherosclerosis was the most common cause of acute ischemic stroke (37.1%), followed by cardioembolism (21.9%), and small-vessel occlusion (18.9%). During the study period, use of IV heparin decreased; 9.7% in 2008; 10.9% in 2009; 9.4% in 2010; 6.0% in 2011; 4.7% in 2012; 4.3% in 2013 (p for trend &lt; 0.001). The most prominent reduction was observed between 2010 and 2011, just after the first release of the Korean Stroke Guidelines in October, 2009. Cardioembolism (17.1%) and stroke of two or more causes (15.3%) were associated with IV heparin, and the decrease of IV heparin use in these stroke subtypes was a major contributor of the decrease in general. Age (age ≥ 75, 7.5%; age &lt;75, 6.6%; p = 0.014), initial stroke severity (NIHSS &lt; 5, 5.4%; NIHSS 5 - 24, 8.7%; NIHSS ≥ 25, 9.5%; p &lt; 0.001), and atrial fibrillation on electrocardiogram (atrial fibrillation, 19.9%; non-atrial fibrillation, 4.2%; p &lt; 0.001) were also associated with IV heparin. Conclusions: Use of IV heparin for patients with acute ischemic stroke is decreasing in Korea, and this change may be explained by the development and spread of the national stroke guidelines in the Korean language.

Abstract 169: IV t-PA May Result in Better Outcomes than Conservative Care in Patients with Mild Acute Ischemic Stroke and Large Vessel Occlusion

Introduction: Most patients with mild acute ischemic stroke (AIS) symptoms are excluded from acute stroke therapy (AST). Studies have shown that patients presenting with large vessel occlusions (LVO) and low NIH stroke scale (NIHSS) may have poorer outcomes than previously presumed. The optimal treatment strategy in this population is unknown. Methods: A retrospective chart review of patients with AIS presenting to our tertiary care center between 2010 and 2013 was carried out. Inclusion criteria included LVO as cause of AIS and initial NIHSS &lt; 8. Patients presenting &gt;24 hours after last known normal were excluded. Patient demographics, administered therapies and short-term clinical outcomes were analyzed. For patients lost to follow up, last known values were imputed. Favorable 30-day outcomes were defined as mRS 2, NIHSS 1 or at least 4 point decrease in NIHSS. Results: A total of 121 patients (56.19% males; mean age 63.85±14.08) met inclusion criteria. Anterior circulation was involved in 69.4% cases [MCA (46.28%), ICA (16.52%), ACA (2.47%), ICA-MCA (4.13%)] vs 33.88% posterior circulation cases [PCA (8.26%), Ba (5.7%), V (19%)]. Median admission NIHSS and pre-admission mRS were 4 &amp; 0 respectively, which were statistically significant predictors of favorable outcome. Only 23 patients (19%) received AST [IV t-PA: 13, intrarterial (IA) therapy: 6, IV + IA: 4]. AST patients had shorter time from onset of symptoms to evaluation (mean: 3.7 vs. 9.9 hours, p &lt; 0.001), higher NIHSS on arrival (median: 5 vs. 3, p = 0.024), and were more likely to have a history of stroke (39% vs. 18%, p = 0.049). The odds of a 30-day favorable mRS were 1.7 times higher in the treated group, although not statistically significant (95% CI: 0.58, 5.7; p = 0.333). Numbers in the subgroup analysis remained too small to reach statistical significance, but 85% of patients who received IV t-PA (and 70% with any treatment) had a favorable 30-day outcome versus 62% of patients with conservative care.Conclusion: Our study suggests that qualifying patients with LVO and mild AIS presenting early may have better outcomes if treated with IV t-PA. We propose that rapid evaluation of vessel status may support more aggressive treatment considerations in patients with mild AIS. Further prospective data is needed.

Predictors of poor hospital discharge outcome in acute stroke due to atrial fibrillation.

Atrial fibrillation (AF) is a frequent cause of acute ischemic stroke that results in severe neurological disability and death despite treatment with intravenous thrombolysis (intravenous recombinant tissue plasminogen activator [rtPA]). We performed a retrospective review of a single-center registry of patients treated with intravenous rtPA for stroke. The purposes of this study were to compare intravenous rtPA treated patients with stroke with and without AF to examine independent predictors of poor hospital discharge outcome (in-hospital death or hospital discharge to a skilled nursing facility, long-term acute care facility, or hospice care). A univariate analysis was performed on 144 patients receiving intravenous rtPA for stroke secondary to AF and 190 patients without AF. Characteristics that were significantly different between the two groups were age, initial National Institutes of Health Stroke Scale score, length of hospital stay, gender, hypertension, hyperlipidemia, smoking status, presence of large cerebral infarct, and hospital discharge outcome. Bivariate logistic regression analysis indicated that patients with stroke secondary to AF with a poor hospital discharge outcome had a greater likelihood of older age, higher initial National Institutes of Health Stroke Scale scores, longer length of hospital stay, intubation, and presence of large cerebral infarct compared with those with good hospital discharge outcome (discharged to home or inpatient rehabilitation or signed oneself out against medical advice). A multivariate logistic regression analysis showed that older age, longer length of hospital stay, and presence of large cerebral infarct were independent predictors of poor hospital discharge outcome. These predictors can guide nursing interventions, aid the multidisciplinary treating team with treatment decisions, and suggest future directions for research.

入院時に塞栓源不明の脳塞栓症と考えられた患者における病型診断

Objective: The cause of acute ischemic stroke is unknown in many patients at the time of admission. We aimed to determine the current status of diagnostic test performance and definitive diagnosis at hospital discharge in patients with embolic strokes of unknown source on admission.Methods: Between July 2012 and June 2013, 623 patients with acute ischemic stroke were admitted to our hospital within 7 days from onset. Among them, patients with non-lacunar strokes, excluding those with occlusive atherosclerosis or high-risk sources of cardioembolism, were enrolled. We evaluated the execution rates of examinations and their findings as well as the definitive stroke subtypes of patients at discharge.Results: In total, 147 patients (59 women; mean age: 73 ± 14 years) were enrolled. The execution rate of each examination was: electrocardiogram monitoring in 100%; Holter electrocardiogram in 76%; transthoracic echocardiography in 72%; and transesophageal echocardiography in 68% of patients. Paroxysmal atrial fibrillation and patent foramen ovale were detected in 20% and 46% of patients, respectively, representing the majority of the embolic sources. Stroke subtypes were determined to be: cardioembolism in 54% (High-risk 24%, Medium-risk 30%); Large-artery atherosclerosis in 9%; other determined etiology in 4%; and undetermined etiology in 33% of patients at discharge.Conclusions: Cardioembolic stroke was diagnosed in one-half of patients with embolic stroke, whereas an embolic source could not be detected in one-third of patients. Embolic stroke of undetermined source (ESUS) was found in 13% of total ischemic strokes at discharge. Further studies are needed to investigate the diagnostic characteristics of ESUS.

Management of pediatric craniocervical arterial dissections.

Craniocervical arterial dissections (CCADs) represent a preventable cause of acute ischemic stroke (AIS). Our objective was to describe clinical presentation, imaging features, treatment strategies, and report clinical and imaging outcomes of CCADs at a large pediatric tertiary referral center. Electronic medical records were queried using variations of the word dissection for patients under 25 years of age with neuroimaging over a 13-year period. Medical and imaging records were reviewed to identify carotid, vertebral, or intracranial dissections. Demographics, presenting symptoms, presence of AIS, mechanism of injury, dissection location, dissection treatment, and complications stemming from treatment were collected. Clinical outcome was classified according to modified Rankin Scale (mRS) score. Imaging follow-up was obtained until the dissection healed or stabilized. A total 6,289 patients met initial search criteria. Of the 42 (0.7%) patients with CCADs, 23 (54.8%) had internal carotid artery (ICA) dissections, and 17 (40.5%) had vertebrobasilar (VB) dissections. More females had ICA dissections (p = 0.002), and more males had VB dissections (p = 0.01). CCADs associated with traumatic presentation occurred in 34 patients (81.0%), while 8 (19.0%) were spontaneous. Good outcomes (mRS 0-3) were noted for 36 patients, and 5 had poor outcomes (mRS 4-6). In the 17 patients with vessel occlusion, 50.0% had partial or complete recanalization at a mean follow-up of 23.9 months. CCAD is commonly related to trauma and presents with AIS. The majority of patients experience good clinical outcome. Recanalization of initial vessel occlusion occurs in half of cases at 2 years.

Endovascular treatment of tandem vascular occlusions in acute ischemic stroke

Background and purposeTandem vascular occlusions are an important cause of acute ischemic stroke (AIS) and present unique treatment challenges. We report our experience of managing a subset of AIS patients...

Abstract T P92: Paraoxonase Gene Polymorphism and Carotid Atherosclerosis in Acute Ischemic Stroke

Background: Atherosclerosis in the carotid artery is one of the main causes of acute ischemic stroke. Lipid oxidation has been known to play an important role in the pathogenesis of atherosclerosis. Paraoxonase (PON) is involved in lipid oxidation and has anti-atherogenic activity. PON single-nucleotide polymorphism (SNP) is associated with serum concentration, the activity of paraoxonase, and an increased risk of vascular disease. The purpose of this study was to investigate the association between four genetic variations of PON SNPs and carotid atherosclerosis (CA) in Korean stroke patients. Methods: Acute stroke patients with cardioembolism, other etiologies, and undermined etiologies were excluded to avoid mistaking embolic occlusive lesion for true atherosclerotic lesion. We included 656 subjects who met the inclusion criteria among acute ischemic stroke patients. One hundred and eighty-six subjects had LAA subtype of stroke, and 468 had SVO stroke. All subjects were categorized four subgroups based on the angiographic findings as follows: (1) the No ECIC+ICIC group (those without significant stenosis in the intracranial and extracranial carotid arteries); (2) the ECIC group (those with significant stenosis in the extracranial carotid arteries, but with no significant stenosis in the intracranial carotid arteries); (3) the ICIC group (those with significant stenosis in the intracranial carotid arteries, but with no significant stenosis in the extracranial carotid arteries); and (4) the ECIC+ICIC group (those with significant stenosis in the intracranial and extracranial carotid arteries). All enrolled patients were genotyped with the four genetic variations of PON SNPs (PON1 L55M, PON1 Q192R, PON2 A1148G, and PON2 C311S). Results: There were no significant associations between the four PON SNPs of each subgroups according to CA. In cases of LAA stroke, patients with CA had a significantly higher frequency of the PON2 148 AA and PON2 311 CC genotype than those without CA (p=0.021). Conclusion: We found an association between PON SNPs and carotid atherosclerosis in LAA stroke. But there was no significant difference in distributions of PON SNPs between intracranial CA and extracranial CA.

MRI-based Algorithm for Acute Ischemic Stroke Subtype Classification.

Background and PurposeIn order to improve inter-rater reliability and minimize diagnosis of undetermined etiology for stroke subtype classification, using a stroke registry, we developed and implemented a magnetic resonance imaging (MRI)-based algorithm for acute ischemic stroke subtype classification (MAGIC).MethodsWe enrolled patients who experienced an acute ischemic stroke, were hospitalized in the 14 participating centers within 7 days of onset, and had relevant lesions on MR-diffusion weighted imaging (DWI). MAGIC was designed to reflect recent advances in stroke imaging and thrombolytic therapy. The inter-rater reliability was compared with and without MAGIC to classify the Trial of Org 10172 in Acute Stroke Treatment (TOAST) of each stroke patient. MAGIC was then applied to all stroke patients hospitalized since July 2011, and information about stroke subtypes, other clinical characteristics, and stroke recurrence was collected via a web-based registry database.ResultsThe overall intra-class correlation coefficient (ICC) value was 0.43 (95% CI, 0.31-0.57) for MAGIC and 0.28 (95% CI, 0.18-0.42) for TOAST. Large artery atherosclerosis (LAA) was the most common cause of acute ischemic stroke (38.3%), followed by cardioembolism (CE, 22.8%), undetermined cause (UD, 22.2%), and small-vessel occlusion (SVO, 14.6%). One-year stroke recurrence rates were the highest for two or more UDs (11.80%), followed by LAA (7.30%), CE (5.60%), and SVO (2.50%).ConclusionsDespite several limitations, this study shows that the MAGIC system is feasible and may be helpful to classify stroke subtype in the clinic.

Cerebral air embolism from angioinvasive cavitary aspergillosis.

Background. Nontraumatic cerebral air embolism cases are rare. We report a case of an air embolism resulting in cerebral infarction related to angioinvasive cavitary aspergillosis. To our knowledge, there have been no previous reports associating these two conditions together. Case Presentation. A 32-year-old female was admitted for treatment of acute lymphoblastic leukemia (ALL). Her hospital course was complicated by pulmonary aspergillosis. On hospital day 55, she acutely developed severe global aphasia with right hemiplegia. A CT and CT-angiogram of her head and neck were obtained demonstrating intravascular air emboli within the left middle cerebral artery (MCA) branches. She was emergently taken for hyperbaric oxygen therapy (HBOT). Evaluation for origin of the air embolus revealed an air focus along the left lower pulmonary vein. Over the course of 48 hours, her symptoms significantly improved. Conclusion. This unique case details an immunocompromised patient with pulmonary aspergillosis cavitary lesions that invaded into a pulmonary vein and caused a cerebral air embolism. With cerebral air embolisms, the acute treatment option differs from the typical ischemic stroke pathway and the provider should consider emergent HBOT. This case highlights the importance of considering atypical causes of acute ischemic stroke.

Therapeutic Decision Making in Acute Stroke due to Carotid Artery Dissection: A Potential Role for Percutaneous Vascular Intervention following Intravenous Thrombolysis

Internal carotid artery dissection (ICAD) is an important cause of acute ischemic stroke in younger patients. Potential acute treatments include anticoagulation, intravenous thrombolysis (IVT), and endovascular thrombectomy (ET). We report a case where the use of IVT followed by ET resulted in a good clinical outcome in a patient with tandem internal carotid and middle cerebral artery occlusion following ICAD.

Stroke Outcomes of Japanese Patients With Major Cerebral Artery Occlusion in the Post-Alteplase, Pre-MERCI Era

This study examined outcomes of patients with acute ischemic stroke (AIS) with major cerebral artery occlusion after the approval of intravenous recombinant tissue-type plasminogen activator (IV rt-PA) but before approval of the MERCI retriever. We retrospectively enrolled 1170 consecutive patients with AIS and major cerebral artery occlusion (496 women; mean age, 73.9 ± 12.3 years) who were admitted within 24 hours after the onset of symptoms to 12 Japanese stroke centers between October 2005 and June 2009. Cardioembolism was a leading cause of AIS in this group (68.2%). The occlusion sites of the major cerebral arteries included the common carotid artery and internal carotid artery (ICA; 29.6%), middle cerebral artery (52.2%), and basilar artery (7.6%). Recanalization therapy (RT) was performed in 32.0% of patients (IV rt-PA, 20.0%; neuroendovascular therapy, 9.4%; combined, 2.5%). Symptomatic intracerebral hemorrhage within 36 hours with a ≥ 1-point increase in the National Institutes of Health Stroke Scale score occurred in 5.3% of the patients. At 3 months (or at hospital discharge), 29.3% of the patients had a favorable outcome (based on a modified Rankin scale score of 0-2), 23.8% were bedridden, and 15.6% died. After multivariate adjustment, RT was positively associated with a favorable outcome and negatively associated with death, whereas age, baseline National Institutes of Health Stroke Scale score, and ICA occlusion were negatively associated with a favorable outcome and positively associated with death. One-third of the patients with AIS and major cerebral artery occlusion were treated with RT, which was independently associated with favorable outcomes and death. However, 40% of the patients became bedridden or died during the post-alteplase, pre-MERCI era in Japan.

Carotid disease in acute ischemic stroke patients of northern Israel

Carotid disease complicated by thrombosis or embolism is a frequent cause of acute ischemic stroke. The aim of the study was to determine factors associated with carotid disease in patients suffering from acute ischemic stroke in northern Israel. Participants were 1378 acute ischemic stroke patients, including 671 patients with and 707 patients without carotid plaques, as defined by cervical ultrasound. Logistic regression analysis of possible predictors revealed that age, male gender, diabetes, hyperlipidemia, and smoking were independent predictors for the presence of carotid plaque. Male gender was independently associated with the increased prevalence of carotid stenosis of 50% or more, as well as with symptomatic carotid plaques. Age was found to be the only independent factor influencing the extent (bilateral vs unilateral) of carotid disease among acute ischemic stroke patients in northern Israel. Although ethnicity was initially found to have an influence on the prevalence of carotid plaques (higher among Jews than Arabs), no such influence was found after logistic regression. Our findings emphasize that demographic characteristics (age, gender) and vascular risk factors (diabetes, smoking and hyperlipidemia) rather than ethnic disparities are important determinants of carotid disease in acute ischemic stroke patients in northern Israel.