Extracranial Atherosclerosis Research Articles

Ảnh hưởng của bệnh đi kèm trên kết cục đột quỵ thiếu máu não cấp

Background: Comorbidities that help predict poor outcomes in patients with acute ischemic stroke play a part in treatment planning and provide necessary information for patients and their families. Objective: Identify comorbidities that can predict poor outcomes 90 days after the onset of acute ischemic stroke. Subjects and methods: Prospective study including 150 acute ischemic stroke patients at Trieu An Hospital, Ho Chi Minh City. Subjects recruited upon admission were collected NIHSS score and comorbidities. Subjects had modified Rankin scores collected 90 days after disease onset. Univariate analysis and multivariate regression analysis were used to determine the role of variables on stroke outcomes. Results: The mean age was 65, male accounts for 62.0%. There were 8 factors univariately associated with poor outcome after 90 days of acute ischemic stroke onset: NIHSS, age, atrial fibrillation, valvular heart disease, coronary artery disease, heart failure, extracranial atherosclerosis and dementia. Among them, dementia is an independent prognostic factor for poor outcomes through multivariate analysis. The number of comorbidities is closely related to poor outcomes, the number of comorbidities ≥ 3 predicts patients with poor outcomes after 90 days of disease onset with a sensitivity of 96.6%; Specificity was 88.0%; The area under the curve was 96.3%. Conclusion: In acute ischemic stroke patients with comorbidities ≥ 3, the patient's prognosis is poor. In addition, dementia is an independent prognostic factor of poor outcome after 90 days from disease onset.

Duration of Benefit and Risk of Dual Antiplatelet Therapy up to 72 Hours After Mild Ischemic Stroke and Transient Ischemic Attack.

Clopidogrel-aspirin initiated within 72 hours of symptom onset is effective in patients with mild ischemic stroke or transient ischemic attack (TIA) in the Intensive Statin and Antiplatelet Therapy for Acute High-risk Intracranial or Extracranial Atherosclerosis (INSPIRES) trial. Uncertainties remain about the duration of the treatment effect. This study aimed to assess duration of benefit and risk of clopidogrel-aspirin in these patients. The INSPIRES trial was a 2*2 factorial placebo-controlled randomized trial conducted in 222 hospitals in China. The 2 treatments did not interact and were evaluated separately. In this study, we performed secondary analyses based on antiplatelet treatment. All patients with mild stroke or TIA of presumed atherosclerotic cause within 72 hours of symptom onset enrolled in the trial were included. Patients were randomly assigned to receive clopidogrel-aspirin on days 1-21 followed by clopidogrel on days 22-90 or aspirin alone for 90 days. The primary efficacy outcome was major ischemic event which included the composite of ischemic stroke and nonhemorrhagic death. The primary safety outcome was moderate-to-severe bleeding. We estimated the risk difference between the 2 treatments for each stratified week. All 6,100 patients in the trial were included (3,050 in each group). The mean age was 65 years, and 3,915 patients (64.2%) were men. Compared with aspirin alone, the reduction of major ischemic events by clopidogrel-aspirin mainly occurred in the first week (absolute risk reduction [ARR] 1.42%, 95% CI 0.53%-2.32%) and remained in the second week (ARR 0.49%, 95% CI 0.09%-0.90%) and the third week (ARR 0.29%, 95% CI -0.05% to 0.62%). Numerical higher risk of moderate-to-severe bleedings in the clopidogrel-aspirin group was observed in the first 3 weeks (absolute risk increase 0.05% [95% CI -0.10% to 0.20%], 0.10% [95% CI -0.09% to 0.29%], and 0.18% [95% CI -0.03% to 0.40%] in the first, second, and third weeks, respectively). Among patients with mild ischemic stroke or high-risk TIA of presumed atherosclerotic cause, the net benefit of clopidogrel-aspirin initiated within 72 hours of symptom onset was pronounced in the first week and continued to a lesser degree in the following 2 weeks, outweighing the low, but ongoing hemorrhagic risk. ClinicalTrials.gov Identifier: NCT03635749. This study provides Class II evidence that among patients with mild ischemic stroke or high-risk TIA of presumed atherosclerotic cause, the net benefit of clopidogrel-aspirin initiated within 72 hours of symptom onset was pronounced in the first week and continued to a lesser degree in the following 2 weeks, outweighing the low but ongoing hemorrhagic risk.

Rare RNF213 variants is related to early-onset intracranial atherosclerosis: A Chinese community-based study

BackgroundThe relationship between rare variants in Ring finger protein 213 (RNF213) and intracranial atherosclerosis (ICAS) remained unelucidated. Using whole-exome sequencing (WES) and high-resolution magnetic resonance imaging (HR-MRI), this study aimed at investigating the association between rare RNF213 variants and ICAS within a Chinese community-dwelling population. MethodsThe present study included 821 participants from Shunyi cohort. Genetic data of rare RNF213 variants were acquired by WES and were categorized by functional domains. Intracranial and extracranial atherosclerosis were assessed by brain HR-MRI and carotid ultrasound, respectively. Logistic regression and generalized linear regression were applied to evaluate the effects of rare RNF213 variants on atherosclerosis. Stratification by age were conducted with 50 years old set as the cutoff value. ResultsNinety-five participants were identified as carriers of rare RNF213 variants. Carotid plaques were observed in 367 (44.7 %) participants, while ICAS was identified in 306 (37.3 %). Rare variants of RNF213 was not associated with ECAS. Employing HR-MRI, both the presence of rare variants (β = 0.150, P = 0.025) and numerical count of variants (β = 0.182, P = 0.003) were significantly correlated with ICAS within the group of age ≤50 years. Both variant existence (β = 0.154, P = 0.014) and variant count (β = 0.188, P = 0.003) were significantly associated with plaques in middle cerebral arteries within younger subgroup, rather than basilar arteries. Furthermore, a significant association was observed between variants that located outside the N-arm domain and ICAS in the younger subgroup (OR = 2.522, P = 0.030). Statistical results remained robust after adjusted for age, gender, and cardiovascular risk factors. ConclusionsRare variants of RNF213 is associated with age-related ICAS in general Chinese population, highlighting the potential role of RNF213 as a genetic contributor to early-onset ICAS.

Immediate- or Delayed-Intensive Statin in Acute Cerebral Ischemia

Comparisons are limited for immediate-intensive and delayed-intensive statin for secondary stroke prevention and neuroprotection in patients with acute mild ischemic stroke or transient ischemic attack (TIA) from atherosclerosis. To estimate whether immediate-intensive statin therapy is safe and can lower the risk of recurrent stroke compared with delayed-intensive statin in patients with acute mild ischemic stroke or high-risk TIA from atherosclerosis. The Intensive Statin and Antiplatelet Therapy for High-Risk Intracranial or Extracranial Atherosclerosis (INSPIRES) trial, a double-blind, placebo-controlled, 2 × 2 factorial, randomized clinical trial enrolled patients from September 2018 to October 2022. The trial was conducted at 222 hospitals in China. Patients aged 35 to 80 years with mild ischemic stroke or high-risk TIA of presumed atherosclerosis within 72 hours of symptom onset were assessed. Patients were randomly assigned to receive immediate-intensive atorvastatin (80 mg daily on days 1-21; 40 mg daily on days 22-90) or 3-day delayed treatment (placebo for days 1-3, followed by placebo and atorvastatin, 40 mg daily on days 4-21, and then atorvastatin, 40 mg daily on days 22-90). The primary efficacy outcome was new stroke within 90 days, and a secondary efficacy outcome was poor functional outcome. Moderate to severe bleeding was the primary safety outcome. A total of 11 431 patients were assessed for eligibility, and 6100 patients (median [IQR] age, 65 [57-71] years; 3915 men [64.2%]) were enrolled, with 3050 assigned to each treatment group. Within 90 days, new stroke occurred in 245 patients (8.1%) in the immediate-intensive statin group and 256 patients (8.4%) in the delayed group (hazard ratio, 0.95; 95% CI, 0.80-1.13). Poor functional outcome occurred in 299 patients (9.8%) and 348 patients (11.4%) in the immediate-intensive and delayed-intensive statin groups, respectively (odds ratio, 0.83; 95% CI, 0.71-0.98). Moderate to severe bleeding occurred in 23 of 3050 patients (0.8%) and 17 of 3050 patients (0.6%), in the immediate-intensive and delayed-intensive statin groups, respectively. Immediate-intensive statin initiated within 72 hours did not reduce the risk of stroke within 90 days and may be associated with improved functional outcomes without significant difference in moderate to severe bleeding, compared with 3-day delayed-intensive statin in Chinese patients with acute mild ischemic stroke or TIA from atherosclerosis. ClinicalTrials.gov Identifier: NCT03635749.

Recent Translational Research Models of Intracranial Atherosclerotic Disease.

Intracranial atherosclerotic disease (ICAD) is a leading cause of ischemic stroke worldwide. However, research on the pathophysiology of ICAD is scarce due to the relative inaccessibility of histology samples and the lack of comprehensive experimental models. As a result, much of the current understanding of ICAD relies on research on extracranial atherosclerosis. This approach is problematic as intracranial and extracranial arteries are anatomically, structurally, physiologically, and metabolically distinct, indicating that intracranial and extracranial atherosclerosis likely develop through different biologic pathways. The current standard of care for ICAD treatment relies predominantly on therapeutics developed to treat extracranial atherosclerosis and is insufficient given the alarmingly high risk of stroke. To provide a definitive treatment for the disease, a deeper understanding of the pathophysiology underlying ICAD is specifically required. True mechanistic understanding of disease pathogenesis is only possible using robust experimental models. In this review, we aim to identify the advantages and limitations of the existing in vivo and in vitro models of ICAD and basic atherosclerotic processes, which may be used to inform better models of ICAD in the future and drive new therapeutic strategies to reduce stroke risk.

Review and targeted lipidomic biomarkers in atherosclerosis

Ischemic cardiovascular events (ischemic stroke, myocardial infarction) are the most common complications of cardiovascular diseases. One of the leading mechanisms of these complications is atherosclerosis. Lipids play an important role in plaque development. Recently, the lipidome has been of greatest interest, since it may have a prognostic value in atherosclerosis development. With an increase in the circulation of proatherogenic lipidomic biomarkers, the risk of atheroscle­rosis destabilization and ischemic complications increases.The conducted studies made it possible to create additional risk stratification scales, for example, Cardiovascular Event Risk Test (CERT) 1 and 2. They make it possible to estimate the residual risk in patients taking statins. The lipidome examination in extracranial artery atherosclerosis can identify those plaques that have signs of instability, and therefore are dangerous for ischemic stroke development.The review describes the features of plasma lipidome in various cardiovascular diseases associated with atherosclerosis.

Rare Variants of RNF213 Are Related to Intracranial Atherosclerosis but Not to Extracranial Atherosclerosis: A Study in a Chinese Community-dwelling Population (S6.002)

Rare Variants of RNF213 Are Related to Intracranial Atherosclerosis but Not to Extracranial Atherosclerosis: A Study in a Chinese Community-dwelling Population (S6.002)

Sex differences in clot, vessel and tissue characteristics in patients with a large vessel occlusion treated with endovascular thrombectomy.

To improve our understanding of the relatively poor outcome after endovascular treatment (EVT) in women we assessed possible sex differences in baseline neuroimaging characteristics of acute ischemic stroke patients with large anterior vessel occlusion (LVO). We included all consecutive patients from the MR CLEAN Registry who underwent EVT between 2014 and 2017. On baseline non-contrast CT and CT angiography, we assessed clot location and clot burden score (CBS), vessel characteristics (presence of atherosclerosis, tortuosity, size, and collateral status), and tissue characteristics with the Alberta Stroke Program Early Computed Tomography Score (ASPECTS). Radiological outcome was assessed with the extended thrombolysis in cerebral infarction score (eTICI) and functional outcome with the modified Rankin Scale score (mRS) at 90 days. Sex-differences were assessed with multivariable regression analyses with adjustments for possible confounders. 3180 patients were included (median age 72 years, 48% women). Clots in women were less often located in the intracranial internal carotid artery (ICA) (25%vs 28%, odds ratio (OR) 0.85;95% confidence interval: 0.73-1.00). CBS was similar between sexes (median 6, IQR 4-8). Intracranial (aOR 0.73;95% CI:0.62-0.87) and extracranial (aOR 0.64;95% CI:0.43-0.95) atherosclerosis was less prevalent in women. Vessel tortuosity was more frequent in women in the cervical ICA (aOR 1.89;95% CI:1.39-2.57) and women more often had severe elongation of the aortic arch (aOR 1.38;95% CI:1.00-1.91). ICA radius was smaller in women (2.3vs 2.5 mm, mean difference 0.22;95% CI:0.09-0.35) while M1 radius was essentially equal (1.6vs 1.7 mm, mean difference 0.09;95% CI:-0.02-0.21). Women had better collateral status (⩾50% filling in 62%vs 53% in men, aOR 1.48;95% CI:1.29-1.70). Finally, ASPECT scores were equal between women and men (median 9 in both sexes, IQR 8-10vs 9-10). Reperfusion rates were similar between women and men (acOR 0.94;95% CI:0.83-1.07). However, women less often reached functional independence than men (34%vs 46%, aOR 0.68;95% CI:0.53-0.86). On baseline imaging of this Dutch Registry, men and women with LVO mainly differ in vessel characteristics such as atherosclerotic burden, extracranial vessel tortuosity, and collateral status. These sex differences do not result in different reperfusion rates and are, therefore, not likely to explain the worse functional outcome in women after EVT.

Abstract WP239: Apolipoprotein E4 Allele Effect on the Prevalence of Intracranial Large Artery Stenosis

Introduction: Apolipoprotein E4 (ApoE4) allele is linked to increased LDL-Cholesterol, one of the main risk factors for intracranial large artery stenosis (ICAS). Evidence shows that in diabetic men, intima-media thickness is significantly higher in those with ApoE4 than those with ApoE3. While the link between ApoE4 and extracranial atherosclerosis and vascular risk factors is established, the association of these vascular factors with ICAS is unknown. This study investigates the relationship between ApoE4 carrier status and ICAS and whether vascular risk factors influence this relationship. Methods: We rated intracranial large arteries on MR-angiography for their degree of stenosis as 0=no stenosis, 1=<50% stenosis, 2=50-69%, 3=70% or flow gap. We added the score of each of the 11 intracranial arteries to reflect a composite measure of the severity of ICAS. We then related ApoE4 carrier status to the ICAS score using generalized linear models with a Poisson link, adjusting for demographics, vascular risk factors, and cohort. We ran pre-specified interaction models with demographics and vascular risk factors. Results: 4099 individuals from six cohorts were included; 58% were women, the prevalence of hypertension was 76%, diabetes 31%, dyslipidemia 64%, and current smoking 13% (Table). There was no association between ApoE4 carrier and ICAS score (B= 0.08+0.06, p=0.19), but we found statistical interactions between ApoE4 carrier and male sex (p=<0.001), current smoking (p=0.05), and hypertension (p=0.003). ApoE4 carrier status was associated with higher ICAS score among hypertensive men (B=0.52±0.11, P=<0.001) and hypertensive people who smoke (B=0.58±0.20, p=0.01. Conclusion: ApoE4 carrier status was not associated with ICAS overall, but there were associations in subgroups defined by sex, hypertension, and smoking. Whether these interactions influence the risk of stroke and dementia should be further investigated.

Abstract TP142: Perfusion Profiles to Identify Acute Extracranial Internal Carotid Artery Atherosclerosis-Related Stroke Prior to Endovascular Therapy

Introduction: Perfusion imaging has been used to assess collateral status in patients with acute ischemic stroke secondary to anterior large-vessel occlusion. We aimed to evaluate the hypoperfusion intensity ratio (HIR), a surrogate of collateral status, in acute stroke secondary to extracranial atherosclerosis disease (AD) compared with extracranial non-AD etiologies prior to EVT. Methods: We retrospectively reviewed the data of consecutive EVT stroke patients in our prospectively collected registry from January 2019 to December 2022. Inclusion criteria: patients with anterior circulation stroke with concomitant extracranial internal carotid artery (ICA) disease with 70-100% stenosis per NASCET criteria and patients who underwent computed tomography perfusion (CTP) before EVT. Patients were divided into those with extracranial AD and non-AD based on clinical and radiological characteristics. HIR was calculated as the volume of ischemic brain tissue with a Tmax>10s divided by a Tmax>6s. A relative CBF<30% was also obtained. Multivariable regression was used to identify the HIR independently associated with extracranial ICA AD-related stroke; adjusted odds ratio with 95%CIs were calculated using the non-AD group as a reference. Results: Among all 624 EVT patients, 79 met inclusion criteria. Of these patients (21 women [36.2%]; median age 67 [60-75] years), 58 (72.5%) had extracranial ICA AD. Patients in the AD group had significantly lower CBF<30% (median 8ml [0-17] vs 19ml [9-36]), lower Tmax>10s (median 29ml [11-69] vs 68ml [38-117]), and lower HIR (median 0.27 [0.13-0.45] vs 0.49 [0.42-0.59]). There was no significant difference in time from last know well to CTP between groups. Lower HIR was independently associated with AD after adjusting for variables related to AD (Figure1). Conclusions: Low HIR values was a predictor of stroke secondary to extracranial ICA AD and could be helpful to differentiate from other non-AD etiologies prior to EVT.

Triglyceride-Related Parameters and Symptomatic Atherosclerotic Lesions in Patients With Ischemic Stroke.

Recently, evidence has suggested that the pathophysiology and risk factors of intracranial atherosclerosis (ICAS) differs from those of extracranial atherosclerosis (ECAS). In addition, novel parameters reflecting metabolic conditions, such as insulin resistance or atherogenic dyslipidemia, based on triglycerides (TG) and other biomarkers, have emerged. In this study, we evaluated the association between TG-related parameters and symptomatic cerebral atherosclerosis in patients with acute ischemic stroke resulting from large artery atherosclerosis (LAA). We assessed consecutive acute LAA-stroke patients between January 2010 and December 2020. Based on the radiological findings, we classified the relevant symptomatic arteries that caused the index stroke into LAA-ICAS and LAA-ECAS. As TG-related parameters, the atherogenic index of plasma (AIP) and TG-glucose (TyG) index were calculated according to the following formulas: AIP = log10 (TG Level/High-density Lipoprotein Cholesterol Level), TyG Index = Ln (TG Level × Glucose Level/2). A total of 519 patients with LAA-stroke were evaluated. In multivariable logistic regression analysis to identify predictors of LAA-ICAS, AIP was significantly associated with LAA-ICAS (adjusted odds ratio [aOR], 3.60; 95% confidence interval [CI], 1.60-8.06). TyG index also showed a statistically significant relationship with LAA-ICAS (aOR, 1.60; 95% CI, 1.11-2.32). However, TG per se did not show a statistical association with LAA-ECAS. TG-related parameters were more closely associated with stroke by ICAS than by ECAS. The metabolic conditions reflected by the AIP or TyG index, rather than hypertriglyceridemia itself, may play a greater role in determining the relevant vessel causally involved in a stroke.

Prognostic value of diagnostic criteria for familial hypercholesterolemia in men and women with dyslipidemia

Aim. To analyze the prognostic value of the Dutch Lipid Clinic Network (DLCN) and Simon Broome Register (SBR) screening criteria for familial hypercholesterolemia (FH) in men and women with dyslipidemia.Material and methods. The study included 1233 patients with dyslipidemia.Biomaterial samples from 421 patients were studied using Next Generation Sequencing (NGS) to identify FH-associated genes. Statistical analysis was carried out using the StatTech v program. 3.1.6 (OOO Stattekh, Russia).Results. The most significant factors for predicting the FH in men are the level of low-density lipoprotein cholesterol (LDL-C) (1,77 times), positive family history for coronary artery disease (CAD) (6,26 times), multivessel coronary artery disease (4,05 times); in women before menopause — LDL-C (1,77 times per 1 mmol/l) and/or family history of coronary artery disease (3,31 times), in menopausal women — total cholesterol level (1,79 times per 1 mmol/l), coronary artery disease (6,52 times) and/or family history of stroke (6,04 times), xanthomas (4,24 times). Acute myocardial infarction and/or coronary stenting, arcus senilis, extracranial artery atherosclerosis did not prove to be prognostically significant for FH diagnosis.Conclusion. Diagnostic criteria for potential FH vary among patient populations. Its diagnostic significance depends on sex, and in women, reproductive status.

Computed tomography angiography-based radiomics model to identify high-risk carotid plaques.

Extracranial atherosclerosis is one of the major causes of stroke. Carotid computed tomography angiography (CTA) is a widely used imaging modality that allows detailed assessments of plaque characteristics. This study aimed to develop and test radiomics models of carotid plaques and perivascular adipose tissue (PVAT) to distinguish symptomatic from asymptomatic plaques and compare the diagnostic value between radiomics models and traditional CTA model. A total of 144 patients with carotid plaques were divided into symptomatic and asymptomatic groups. The traditional CTA model was built by the traditional radiological features of carotid plaques measured on CTA images which were screened by univariate analysis and multivariable logistic regression. We extracted and screened radiomics features from carotid plaques and PVAT. Then, a support vector machine was used for building plaque and PVAT radiomics models, as well as a combined model using traditional CTA features and radiomics features. The diagnostic value between radiomics models and traditional CTA model was compared in identifying symptomatic carotid plaques by Delong method. The area under curve (AUC) values of traditional CTA model were 0.624 and 0.624 for the training and validation groups, respectively. The plaque radiomics model and PVAT radiomics model achieved AUC values of 0.766, 0.740 and 0.759, 0.618 in the two groups, respectively. Meanwhile, the combined model of plaque and PVAT radiomics features and traditional CTA features had AUC values of 0.883 and 0.840 for the training and validation groups, respectively, and the receiver operating characteristic curves of combined model were significantly better than those of traditional CTA model in the training group (P<0.001) and validation group (P=0.029). The combined model of the radiomics features of carotid plaques and PVAT and the traditional CTA features significantly contributes to identifying high-risk carotid plaques compared with traditional CTA model.

Association of insulin resistance with intra- and extra-cranial atherosclerotic burden in the nondiabetic community population

AimsFew population-based studies have investigated the association between insulin resistance and atherosclerotic burden in intra- and extra-cranial arteries. The purpose of this study is to explore the relationship between insulin resistance and intra- and extra-cranial atherosclerotic burden in community-based nondiabetic participants. MethodsThis is a cross-sectional analysis from a population-based prospective cohort-PolyvasculaR Evaluation for Cognitive Impairment and vaScular Events (PRECISE) study in China. The homeostasis model assessment of insulin resistance (HOMA-IR) and insulin sensitivity indices (ISI0–120) were stratified by the quartiles, respectively. The atherosclerotic presence of plaques and burden was evaluated by high-resolution MRI. Binary or ordinal logistic regression was performed to assess the association between HOMA-IR or ISI0–120 and the presence and burden of atherosclerosis. ResultsAmong the 2754 participants, the mean age was 60.9 ± 6.6 years, and 1296 (47.1%) were males. Compared with the lowest quartile of HOMR-IR, the highest quartile of HOMA-IR (indicating a higher level of insulin resistance) was associated with an increased presence of plaques (OR:1.54, 95% CI:1.14–2.08), and atherosclerotic burden (OR:1.53, 95%CI:1.14–2.07) in intracranial arteries. Meanwhile, we observed a similar relationship between HOMA-IR and the presence or burden in extracranial atherosclerosis. The first (indicating a higher level of insulin resistance) quartiles of ISI0–120 were associated with the intracranial plaques (Q1, OR:1.56, 95%CI:1.16–2.11) and atherosclerotic burden (Q1, OR:1.57, 95%CI:1.17–2.12), but not extracranial plaques or atherosclerotic burden, compared with the fourth quartile of ISI0–120. ConclusionsInsulin resistance was associated with an increased intra-and extra-cranial atherosclerotic burden in the nondiabetic elderly Chinese population.

Update on Biomarkers Associated with Large-Artery Atherosclerosis Stroke.

Intracranial and extracranial large-artery atherosclerosis (LAA) are a main cause of ischemic stroke. Biomarkers may aid in the diagnosis of LAA and help to stratify patients' risk of stroke. We performed a narrative review of the literature, mainly published in the last five years, with the aim of identifying biomarkers associated either with intracranial or extracranial LAA in humans. Several potential biomarkers of LAA, mainly related to lipidic pathways and inflammation, have been studied. Diagnostic biomarkers of LAA were evaluated by measuring biomarkers levels in patients with LAA stroke and other stroke etiologies. Some biomarkers were associated with the functional prognosis of LAA stroke patients. Increased levels of IL-6 and sLOX-1 were associated with a risk of progression of carotid atherosclerotic disease. Findings support the notion that the immune system plays a central role in the pathogenesis of LAA. Overall, in most studies, results were not externally validated. In the future, biomarkers could be useful for the selection of patients for clinical trials. To adopt these biomarkers in clinical practice, we will need robust multicentric studies proving their reproducibility and a clear practical applicability for their use.

Patient with non-cardioembolic ischemic stroke or high-risk transient ischemic attack. Part 2. Secondary prophylaxis

Non-cardioembolic ischemic stroke (IS) of high and very high risk includes three groups of patients: with severe extracranial atherosclerosis, with any intracranial atherosclerosis, and with aortic arch atheromatosis. This risk is also characteristic of patients with aggressive transient ischemic attack (TIA) phenotypes. Effectiveness of secondary prophylaxis can be raised by these strategies: short-term dual antiplatelet therapy using a combination of acetylsalicylic acid with clopidogrel or ticagrelor in minor IS or high-risk TIA; long-term dual antithrombotic therapy with acetylsalicylic acid and low doses of rivaroxaban for multifocal atherosclerosis with low hemorrhagic risk and non-lacunar stroke; early surgical revascularization (carotid endarterectomy or stenting) for non-disabling IS and urgent revascularization for high-risk TIA; intensive, including combined, lipid-lowering therapy with high doses of statins, ezetimibe, PCSK9 inhibitors, or inclisiran to achieve low-density lipoprotein levels &lt;1.4 mmol/L ; antidiabetic therapy using type 2 glucose-sodium cotransporter inhibitors and type 1 glucagon-like peptide agonists with glycosylated hemoglobin level of &lt;7%; prescribing antihypertensive therapy and achieving target blood pressure level.

A novel etiological classification in patients with intracranial large vessel occlusion and endovascular treatment: discordance with the classic and SSS TOAST systems: A retrospective cohort study

Purpose: Among patients with acute ischemic stroke (AIS), those with intracranial large vessel occlusion (LVO) should undertake endovascular treatment (EVT) based on mechanical thrombectomy. Although the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification system has been used in overall population of patients with AIS, especially for secondary prevention. In the current study, a new classification system for the LVO population is proposed.Methods: The classic TOAST and Stop Stroke Study TOAST (SSS TOAST) were applied to the LVO population. Based on discordance with those systems, a new LVO classification system was developed and applied to the LVO population. The new system comprised extracranial atherosclerosis (ECAS), intracranial atherosclerosis (ICAS), cardioembolism (CE), cryptogenic embolism, stroke of undetermined etiology (SUE; two or more etiologies), and stroke of other determined etiology (SOE) where small artery occlusion was removed.Results: The LVO classification system comprised 43 ECAS (6.52%), 141 ICAS (21.36%), 303 CE (45.91%), 75 cryptogenic embolism (11.36%), 75 SUE (11.36%; cardioembolic source in 98.67%), and 23 SOE (3.48%) patients. The ICAS group had a significantly longer median onset-to-puncture time than the other groups. In the ICAS group, 102 of 141 (72.34%) remained partial recanalization after EVT.Conclusion: The LVO classification system differentiating ECAS and ICAS in patients with large artery atherosclerosis and classifying cryptogenic embolism is more suitable for patients with EVT for intracranial LVO. Further studies for predicting underlying ICAS and planning treatment strategy should be performed.

Intracranial Atherosclerosis and Postoperative Stroke Following Coronary Artery Bypass Surgery: A Literature Review

Stroke is a devastating complication of cardiac surgery. Extracranial carotid atherosclerosis (ECAS) is a risk factor for postoperative stroke, but there is limited insight into the effect of intracranial atherosclerosis (ICAS). It is believed that this is the first literature review investigating ICAS and postoperative stroke in a cardiac surgery patient cohort. This review aimed to explore the prevalence and predictors of intracranial ICAS, association with postoperative stroke, and treatment options in patients with ICAS undergoing cardiac surgery.

Rational clinical approach to transient ischaemic attack, stroke and associated mimics: A retrospective cohort study.

The present study was performed to identify the individual clinical features and risk factors most strongly associated with the diagnosis of transient neurological symptoms with a cerebrovascular cause (transient ischaemic attack (TIA) or stroke), as compared to common TIA mimics (including retinal ischaemia, migraine and seizure). In a retrospective cohort study, consecutive patients presenting with transient neurological symptoms to TIA clinic in Royal Adelaide Hospital were included. Clinical features and risk factors were recorded in a standardised form, categorised into subgroups, and analysed using descriptive statistics and diagnostic performance indicators, such as sensitivity, specificity and likelihood ratios. For 218/1273 individuals diagnosed with stroke, the three features with the highest positive likelihood ratio were the presence of diffusion weighted imaging positive lesion on magnetic resonance imaging (23.66, 95% confidence interval (CI) 14.35-51.08), extracranial carotid atherosclerosis (3.98, 95% CI 1.19-6.87) and a history of peripheral vascular disease (3.33, 95% CI 1.64-6.27). For TIA, the three features with the highest positive likelihood ratio were extracranial carotid atherosclerosis (3.98, 95% CI 1.19-8.27), presence of atrial fibrillation (2.43, 95% CI 1.54-3.46) and pre-existing anticoagulant therapy (2.39, 95% CI 1.61-3.29). For stroke and TIA, the respective features with the lowest negative likelihood ratios were limb weakness (0.71, 95% CI 0.65-0.77) and hypertension (0.66, 95% CI 0.49-0.84). The present study demonstrated that specific clinical features and risk factors were associated with the final diagnosis at TIA clinic. These clinical features may assist with diagnosis of TIA in centres without access to a vascular neurologist.

Study of Risk Factors and Outcome Evaluation in Patients with Stroke with Intracranial versus Extracranial Atherosclerotic Arterial Disease (P14-5.020)

<h3>Objective:</h3> To study the differences in risk factors between stroke caused by intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS) in the Indian population. <h3>Background:</h3> Stroke is a multi-factorial disease occurs due to the combination of risk-factors. Pathogenic mechanism of intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS) vary, hence exploring the risk factors of these subtypes is essential for targeting preventive therapy and to influence choice of management. <h3>Design/Methods:</h3> 100 patients presenting with acute ischemic stroke with clinically significant atherosclerosis in intra-cranial/extra-cranial arteries were compared with respect to their risk factors, presentation, progression and outcomes. <h3>Results:</h3> There were 35 ICAS, 52 ECAS and 13 with both ICAS &amp; ECAS. Mean age of the patients, gender, body mass index was not associated with their stroke type. Medical history of IHD and CKD was more common in patients with ICAS. Median (IQR) NIHSS of our study cohort was 12.97 (4.23) at 3 months. It was significantly higher in ICAS group (median = 16.26) as compared to that in the ECAS group (median = 10.92). Anterior circulation strokes were observed in 78% of patients, more commonly occurring in ECAS stroke group. Median (IQR) mRS score of the study cohort at 3 months was 1 (1.00), four patients died (mRS = 6) three of ICAS and one patients with both ICAS &amp; ECAS. ECAS group had significantly more proportion of patients with favorable mRS as compared to ICAS group. After adjusting for all possible confounders, only increasing NIHSS at admission was significantly associated with poor outcomes at 3 months. Stroke type did not significantly affect the the clinical outcome at 3 months. <h3>Conclusions:</h3> Although ICAS and ECAS shared similar risk factors, differences still existed between them as far as clinical outcomes are concerned. With higher NIHSS at admission, ICAS patients are at an increased risk for poor clinical outcome. <b>Disclosure:</b> Dr. Patel has nothing to disclose. Dr. Ponda has nothing to disclose.