Extracranial Stenosis Research Articles

Abstract TMP106: Relationship Between Smoking and the Development of Extracranial and Intracranial Arteriosclerotic Stenosis

Background and purpose: to investigate the relationship between active cigarette smoking and the occurrence of extracranial (ECAS) and intracranial atherosclerotic stenosis (ICAS). Methods: We analyzed patients enrolled in the Chinese Intracranial atherosclerosis (CICAS), which was a prospective, multicenter, hospital-based cohort study. Smoking status was classified into never, former and current smoking. ICAS was evaluated with 3-dimentional time-of-flight MRA and ECAS was evaluated with cervical ultrasonography or contrast-enhanced MRA. Multivariable Logistic regression was performed to identify the association between smoking status and the occurrence of ECAS and ICAS. Results: A total of 2656 patients (92.7%) of acute ischemic stroke and 208 (7.3%) of transient ischemic attack were analyzed. The mean age was 61.9±11.2 and 67.8% were male. There were 141 (4.9%) patients had only ECAS, 1074 (37.5%) had only ICAS, and 261 (9.1%) had both ECAS and ICAS. Current smoking was significantly associated with the occurrence of ECAS (adjusted OR=1.47, 95% CI=1.09-1.99, P<0.01). In addition, with one year of smoking increment, the risk of ECAS increased by 1.1% (adjusted OR=1.011; 95% CI=1.003-1.019; P=0.005); with one cigarette smoked per day increment, the risk of ECAS increased by 1.0% (adjusted OR=1.010; 95% CI=1.001-1.020; P=0.03); and with one pack year of smoking increment, the risk of ECAS increased by 0.7% (adjusted OR=1.007; 95% CI=1.002-1.012; P<0.01). However, no similar significant association was found between smoking status and the occurrence of ICAS. Conclusion: A paradoxical dose-response relationship between cigarette smoking and the occurrence of ECAS and ICAS was identified. Further studies on molecular mechanisms were warranted. <!--EndFragment-->

Abstract WP228: Clinical Characteristics of Hmong Patients Presenting with Acute Ischemic Stroke

Introduction: Hmong people are originally from the mountainous areas of Southeastern China, Northern Vietnam, Laos, and Thailand. Large numbers have migrated to the USA. In response to a request from leaders of the Hmong community and given the lack of literature, this study was conducted to describe ischemic stroke in the Hmong patients at our comprehensive stroke center. Methods: Institutional GWTG database and charts for years 2010-2015 were retrospectively reviewed. Hmong patients were identified by their last names (18 clans) provided by the Hmong community leaders. Different demographic, social, and clinical aspects were reported and compared to white patients in a univariate analysis. Results: Forty-one Hmong and 1510 White were included in the analysis. Compared to Whites, Hmong patients were significantly younger (60±2.16 vs. 70±0.39 years # ), predominantly women (66% vs. 48%; p=0.03), less frequently covered by medical insurance (68% vs. 87% # ) and less frequently brought by ambulance (44% vs. 54% # ). Onset-to-door time, door-to-needle time, NIHSS at admission, and incidence of vascular risk factors was similar between the two groups; however, Hmong patients seemed to have poorly controlled risk factors with mean A1C 11±0.9% in diabetics (n=13) and mean LDL 116±6.4 mg/dL in hyperlipidemics (n=16). The most common stroke mechanisms were small vessel (31%) and intracranial atherosclerotic diseases (27%). Based on imaging in Hmong patients; 56% had intracranial arterial calcification, 53% had microaniopathic disease, 46% had intracranial stenosis, and 18% extracranial stenosis. On echocardiogram, 68% of Hmong had left ventricular hypertrophy, 54% had dilated left atrium, one patient had hypokinesis, and none had low ejection fraction. The length of stay and the rate of independent ambulation on discharge were not different between Hmong and Whites, however, a larger proportion of Hmong were discharged home (59% vs. 46%; p=0.05). # p≤0.0005 Conclusion: In this study population, Hmong patients suffered from poorly controlled risk factors, had high incidence of small vessel and intracranial atherosclerotic disease, low incidence of carotid disease and heart failure and utilized fewer resources than Whites.

Abstract WP201: Sub-analysis of Japanese Versus Non-japanese on Background Characteristics and One-year Outcomes in Tiaregistry.org

Background and Purpose: TIAregistry.org is an international prospective registry in patients with TIA or minor stroke (mRS 0 or 1) within 7 days after the onset. Main analysis of one-year follow-up data have been reported (N Engl J Med 2016;374:1533-42). We performed Japanese vs non-Japanese sub-analysis on the baseline and one-year follow-up data. Methods: Patients were classified into two groups according to their countries of origin (Japanese and non-Japanese). All comparisons between the two groups were adjusted on age, sex and mRS. Variables included demographic characteristics, intracranial and extracranial arterial stenosis, acute infarcts, TOAST classification, ABCD 2 score, and time to first contact. We compared the 1-year event rates of cardiovascular death, non-fatal stroke, and non-fatal acute coronary syndrome between the two groups using Cox proportional hazard models. Results: A total of 4,583 patients were included in the analysis. From them, 345 (7.5%) were Japanese. Proportion of patients with mRS 1 was higher in Japanese (58.5% vs 27.9%, p <0.001). The prevalence of acute infarct was higher for Japanese (73.9% vs 29.8%, p <0.001). Intracranial arterial stenosis >50% was more common in Japanese (19.6% vs 12.9%, p = 0.01). Distribution of ABCD 2 score was also different between Japanese and non-Japanese (20.1% vs 33.5% in scores 0-3, 28.6% vs 18.3% in scores 6 and 7, p = 0.02 in total). Time to first contact <24 hours was fewer in Japanese (80.0% vs 88.2%, P <0.001). Composite event rate of cardiovascular death, nonfatal stroke, nonfatal acute coronary syndrome was 7.7% in Japanese and 6.0% in non-Japanese (p = 0.18), while nonfatal stroke rate was higher for the Japanese patients (7.5% vs 4.4%, p = 0.008). Conclusions: Higher risk conditions in baseline characteristics as well as delay of time to contact, and a higher one-year stroke rate were identified in Japanese patients enrolled in this registry.

A lower baseline glomerular filtration rate predicts high mortality and newly cerebrovascular accidents in acute ischemic stroke patients.

Chronic kidney disease (CKD) is gradually recognized as an independent risk factor for cardiovascular and cardio-/cerebrovascular disease. This study aimed to examine the association of the estimated glomerular filtration rate (eGFR) and clinical outcomes at 3 months after the onset of ischemic stroke in a hospitalized Chinese population.Totally, 972 patients with acute ischemic stroke were enrolled into this study. Modified of Diet in Renal Disease (MDRD) equations were used to calculate eGFR and define CKD. The site and degree of the stenosis were examined. Patients were followed-up for 3 months. Endpoint events included all-cause death and newly ischemic events. The multivariate logistic model was used to determine the association between renal dysfunction and patients’ outcomes.Of all patients, 130 patients (13.4%) had reduced eGFR (<60 mL/min/1.73 m2), and 556 patients had a normal eGFR (≥90 mL/min/1.73 m2). A total of 694 patients suffered from cerebral artery stenosis, in which 293 patients only had intracranial artery stenosis (ICAS), 110 only with extracranial carotid atherosclerotic stenosis (ECAS), and 301 with both ICAS and ECAS. The patients with eGFR <60 mL/min/1.73m2 had a higher proportion of death and newly ischemic events compared with those with a relatively normal eGFR. Multivariate analysis revealed that a baseline eGFR <60 mL/min/1.73 m2 increased the risk of mortality by 3.089-fold and newly ischemic events by 4.067-fold. In further analysis, a reduced eGFR was associated with increased rates of mortality and newly events both in ICAS patients and ECAS patients. However, only an increased risk of newly events was found as the degree of renal function deteriorated in ICAS patients (odds ratio = 8.169, 95% confidence interval = 2.445–14.127).A low baseline eGFR predicted a high mortality and newly ischemic events at 3 months in ischemic stroke patients. A low baseline eGFR was also a strong independent predictor for newly ischemic events in ICAS patients.

Abstract WMP63: Prevalence of Occult Paroxysmal Atrial Fibrillation in Non-Cryptogenic Ischemic Stroke Patients

Background: Paroxysmal atrial fibrillation (PAF) is often asymptomatic and is more prevalent than persistent AF in patients with ischemic stroke (IS). Long-term monitoring with insertable cardiac monitors (ICM) yields an up to 30% PAF detection rate in cryptogenic IS patients. Yet, the prevalence of PAF in patients with a presumed stroke etiology other than AF remains unknown. Methods: Prospective cohort study of non-cryptogenic IS patients implanted within 10 days of stroke onset with the Reveal LINQ ICM (n=47 enrolled, 45/47 (95.7%) implanted). Patients were monitored until PAF detection (adjudicated by study cardiologist) or minimum of 12 months. Inclusion required a defined stroke etiology other than AF based on standard stroke evaluation (including ≥24 hour cardiac telemetry), age≥40, and either a virtual CHADS2 score ≥3, or ≥2 PAF related comorbidities (COPD, hyperthyroidism, obesity, prior MI, PR interval &gt;175ms, or renal impairment). Patients with high-risk cardiac sources, recent MI or cardiac bypass surgery, pacemaker or defibrillator, permanent anticoagulation indication or contraindication, and pregnancy were excluded. Results: Mean age 64.8 years (range 40-88 years), 15/47 (31.9%) female, mean virtual CHADS2 score 3.5 (range 3 to 5), mean CHA2DS2-VASc score 4.5 (range 3 to 8), and 8/47 (17.0%) had ≥2 PAF comorbidities. Lacunar stroke etiology predominated (n=33), followed by extracranial atherosclerotic stenosis (n=4), cardioembolic (n=3), arch atheroembolic (n=3), intracranial atherosclerosis (n=4), and extracranial dissection (n=2). Five had multiple potential sources. Interim analysis (mean monitoring 264 days, range 0 to 642 days) demonstrates 3/45 (6.7%) implanted patients have PAF (range of longest AF episode: 0.3 to 18.7 hours). Mean time to PAF diagnosis 162.7 days (range 9-356 days). All were started on anticoagulation. There was 1 device related complication (skin erosion) and 1 patient had recurrent stroke. Conclusions: Occult PAF in non-cryptogenic IS patients is infrequent and may reflect the background prevalence of PAF in this demographic. Despite this, long-term cardiac monitoring may promote optimization of stroke prevention therapy for a small but unanticipated proportion of these patients.

Abstract WP177: Retinal Nerve Fiber Layer Thickness and Risk Factors of Stroke

Background and Purpose: We aimed to find the relationship between retinal nerve fiber layer (RNFL) thickness and the relevant risk factors of different stroke subtypes of TOAST classification, in order to make a better primary prevention of stroke. Method: The study population came from the first follow- up of the Asymptomatic Polyvascular Abnormalities Community study (APAC) population. We finished the questionnaire of epidemiological information and medical history during the baseline time, and finished the physical and laboratory examination, transcranial doppler, carotid ultrasound, cognitive functional scale and ophthalmological optical coherence tomography (OCT) examination to measure the thickness of RNFL and whether there exists intracranial artery stenosis (ICAS), extracranial artery stenosis (ECAS) or cognitive impairment. Then we discuss the association between RNFL thickness and the risk factors of stroke mentioned above. Results: We included 5440 participants at baseline and 3376 finished the follow- up eventually. The average thickness of RNFL was 101.89± 10.53 μm. As RNFL became thinner, the percentage of older age, male sex and hypertension became higher (P&lt;0.001). We also found out that ICAS and ECAS, especially ECAS increased as RNFL become thinner (OR:0.982,95% CI:0.969- 0.996,P= 0.011), and the severity of ECAS became worse when RNFL was thinner (P=0.001), and retinal central arteriolar was narrower (P=0.003). What is more, RNFL thickness is associated with cognitive impairment as well (P&lt; 0.05). Conclusion: The thickness of RNFL is associated with stroke risk factors, such as older age, male sex and hypertension. As RNFL became thinner, the prevalence of ICAS and ECAS, which are the main cause of LAA stroke, became higher, and the severity of ECAS became worse. The thinner RNFL was also relevant with cognitive impairment, which is common in the SAO stroke. The results provide a new point of view on stroke classification and prevention.

Effect of stenting for the proximal atherosclerotic extracranial vertebral artery stenosis

Objective: To evaluate the effect of stenting for proximal atherosclerotic extracranial vertebral artery stenosis. Methods: A total of 204 proximal atherosclerotic extracranial vertebral artery stenosis patients underwent stent implantation at Fuwai Hospital were enrolled consecutively between August 2007 and June 2014 prospectively. Medical records were collected and the clinical results were obtained through outpatient and telephone follow up. Results: (1) The patients were (64.1±7.9) years old, and 179 were male (87.7%). (2) Stent implantation was performed on 210 proximal atherosclerotic extracranial vertebral artery stenosis lesions with 210 stents (156 on the left, 54 on the right), and 6 patients received both sides stent implantations. Technical success rate was 100%(210/210). The stenosis of the lesions was decreased from (85.1±6.4) % to (6.5±3.2) % after the stent implantation (P<0.01). (3) Three (1.5%) patients experienced transient ischemic attack during the procedure, and two (1.0%) patients suffered from minor posterior circulation ischemic strokes on the 2nd and 10th day after the procedure, respectively. (4)The median follow-up was 1.5 (0.8-2.5) years. Three(1.5%) patients died (two non-vacular deaths, and the other one due to sudden cardiac death). Three (1.5%) patients developed stroke (one case ipsilateral posterior circulation stroke, and two cases unrelated area stroke). Four (2.0%) patients experienced transient ischemic attack. One patient suffered nonfatal myocardial infraction. In-stent restenosis occurred in thirty nine (19.4%) patients, of which fourteen (35.9%) patients were totally occluded and four (10.3%) patients with symptomatic restenosis. Kaplan-Meier survival curve showed that the primary patency rate of the vertebral artery were 85.6%, 78.6%, 72.2% and 64.4% at 1, 2, 3 and 5 years, respectively. Conclusions: Stenting for proximal atherosclerotic extracranial vertebral artery stenosis is safe and feasible, with a good middle to long-term patency rate. However, further trials are required to validate the effective results found in this patients cohort.

Multiple factor analysis of symptomatic intracranial arterial stenosis

Objective To discuss the correlation among intracranial arterial stenosis and its risk factors. Methods A total of 486 patients with transient ischemic attack (TIA) or ischemic cerebral infarction were examined using color doppler flow imaging (CDFI) and transcranial doppler ultrosonography (TCD).According to the degrees of extracranial arterial stenosis, patients with mild-to-moderate extracranial stenosis were classified into group A (435 cases) while those with constant severe stenosis or occlusion were classified into group B (51 cases).The differences between the two groups of risk factors were compared, and the multi-factor logistic regression analysis of risk factors associated with moderately severe intracranial arterial stenosis was performed. Results ① The risk factors that were significantly associated with intracranial arterial stenosis included age ( P =0.034) and gender ( P =0.044).② Intracranial artery stenosis was observed in both anterior and posterior cerebral arteries in patients with hypertension, diabetes, and coronary heart disease respectively ( P P =0.000), with a higher proportion of men ( P =0.037), and the intracranial arterial stenosis degrees were significantly higher ( P =0.013).â'£ Multi-factor logistic regression analysis showed that diabetes is a risk factor for moderately severe intracranial arterial stenosis ( P P =0.012). Conclusions Age, gender, hypertension, diabetes, coronary heart disease, and smoking are risk factors for the distribution of intracranial arterial stenosis.The degrees of intracranial arterial stenosis are related with extracranial arterial stenosis.Diabetes is a risk factor for moderately severe intracranial arterial stenosis while hyperlipidemia is a protective factor.

Progression or Regression of Intracranial or Extracranial Arterial Stenosis: Role of Ultrasound

Atherosclerosis of intracranial or extracranial artery is a major cause of ischemic stroke, which may be a dynamic lesion with progression or regression. Ultrasound examinations are useful and important tools for the diagnosis of progression or regression of intracranial or extracranial arterial stenosis. Progression of intracranial stenosis may increase the risk of stroke, therefore adequate diagnosis is important. Transcranial Doppler sonography (TCD) may be useful for this purpose, however, optimal diagnostic criteria have not been defined well. According to our subgroup analysis from the prospective clinical trial, which had evaluated the efficacy of cilostazol combined with aspirin in symptomatic intracranial stenosis, sensitivity of TCD criteria ranged 23-42% for progression and 13-67% for regression, while specificity ranged 83-92% for progression and 91-97% for regression. Among the criteria validated, Δ20cm/s increment or decrement criteria had the highest sensitivity (42% for progression and 67% for regression) and specificity (90% for progression and 96% for regression). With these criteria, we compared long-term TCD changes with MRA in patients with intracranial stenosis. Among 164 patients included (84 males, mean age 64 years, mean follow-up period 35 months), progression was observed in 5.7% among MCA and 5.0% among BA. With diagnosis of progression, more aggressive medical management (BP control, blood glucose and lipid lowering, antiplatelet agents, etc.) is indicated and higher-dose statin may be recommended. Carotid duplex ultrasound (CDU) has an important role for the screening of asymptomatic carotid stenosis (ACS), detection of vulnerable plaques, or monitoring of progression or regression of arterial stenosis. With qualified examination and optimal diagnostic criteria, the sensitivity and specificity has been reported up to 90% and 94% for the detection of stenosis of 70% or greater. In addition to the degree of stenosis, CDU also reveal the morphology and distribution of the plaques. Natural course of ACS also has been studied with CDU and several factors related to the progression/regression of ACS have been reported. Recent advance of medical treatment diminished the risk of stroke (< 1%/year) compared with carotid revascularization in ACS. Therefore, current issue is to identify “high-risk” patients who will get more benefit from the carotid revascularization. With optimal criteria, CDU may diagnose progression of arterial stenosis, which is an important predictor for future stroke. TCD is also useful for the detection of microembolic signals (MES), which is potently associated with the risk of stroke in ACS. In summary, adequate ultrasound examination is useful for the diagnosis of intracranial or extracranial arterial stenosis, progression/regression of stenosis, and possibly for the identification of the “high risk” patients, therefore is useful for the adequate clinical decision making.

Prevalence and prognosis of intracranial stenosis in acute ischemic stroke; a single center registry from Turkey

Background/aim: Intracranial stenosis (ICS) is identified in 2.2%?70.4% of patients with ischemic stroke and transient ischemic attack. This study aimed to determine the prevalence of ICS in a single center registry from Turkey. Materials and methods: We reviewed the charts of 619 patients with acute ischemic stroke. ICS was defined as any ICS > 50% on cerebrovascular imaging. The demographic data, risk factors, NIHSS scores and C reactive protein level at admission, mortality in hospital, recurrent stroke, and mRS in the follow-up period were recorded. Results: A total of 72 (11.6%) patients with ICS (45 males (62.5%); mean age 68.3 ± 12.6 years) were included. Sixty-seven patients (10.8%) had symptomatic ICS and 44 patients (7.1%) had ICS without extracranial stenosis. Diabetes mellitus (DM) was significantly higher in the ICS group compared to the others (P = 0.017). Disability was significantly better in patients with ICS compared to the others (P < 0.001). On logistic regression analysis, DM and follow up mRS were significantly associated with ICS (P < 0.05). Conclusion: ICS was seen in 11.6% of acute ischemic stroke cases in our registry. DM appears to be the major risk factor for ICS. Disability was better in patients with ICS. Ethnicity could be a factor causing better disability.

Stroke prevention

Patients who have had a stroke are at high risk for recurrent stroke, myocardial infarction, and vascular death. Prevention of these events should be initiated promptly after stroke, because many recurrent events occur early, and should be tailored to the precise cause of stroke, which may require specific treatment. Lifestyle advice including abstinence from smoking, regular exercise, Mediterranean-style diet, and reduction of salt intake and alcohol consumption are recommended for all patients with stroke. For most patients with ischemic stroke or TIA, control of risk factors, including lowering blood pressure under 140/90mmHg and LDL cholesterol under 1g/L, together with antiplatelet or oral anticoagulant therapy, depending on the cause of stroke, have been shown to decrease the risk of recurrent stroke and cardiovascular events. Aspirin, clopidogrel, or the combination of aspirin and dipyridamole, are all acceptable options for secondary prevention in patients with ischemic stroke or TIA of arterial origin. Dual therapy with aspirin and clopidogrel might be considered for 3weeks after a minor ischemic stroke or TIA and for 3months in patients with stroke due to severe intracranial stenosis. Oral anticoagulants are very effective to prevent cardioembolic stroke. Non-VKA oral anticoagulants have a favorable risk-benefit profile compared with VKAs, with significant reductions in stroke, intracranial hemorrhage, mortality, with similar major bleeding, but increased gastrointestinal bleeding. Carotid endarterectomy reduces the risk of ipsilateral stroke in patients with recent (<6months) non disabling ischemic stroke or TIA in the territory and severe carotid artery stenosis. Carotid stenting is a potential alternative to surgery in patients younger than ≈70years or patients with greater risk of surgery due to anatomic or medical conditions or specific circumstances such as radiation-induced stenosis or restenosis after surgery. For patients with hemorrhagic stroke due to hypertension-associated small vessel disease or cerebral amyloid angiopathy, strict control of blood pressure is essential. Restarting oral anticoagulants in patients after intracranial hemorrhage is a difficult decision that should weigh the risks of recurrent ischemic and hemorrhage stroke with and without oral anticoagulants. Several areas of uncertainty persist including the optimal target of blood pressure in patients with cerebrovascular disease, the benefit of PFO closure in patients with PFO-associated stroke, of stenting procedures in patients with atherosclerotic intracranial artery or extracranial vertebral artery stenosis, and of interventional procedures in patients with brain arteriovenous or cavernous malformations.

Comparison of Four Methods calculating Ankle Brachial Indexes for Coexistent Intracranial and Extracranial Artery Stenoses in the Patients with Ischemic Stroke

Comparison of Four Methods calculating Ankle Brachial Indexes for Coexistent Intracranial and Extracranial Artery Stenoses in the Patients with Ischemic Stroke

The urgent need for contemporary clinical trials in patients with asymptomatic carotid stenosis.

Asymptomatic extracranial internal carotid artery atherosclerotic stenosis increases with age and is more common in men. Studies performed more than 2 decades ago showed that carotid endarterectomy reduced the rate of stroke in carefully selected patients with asymptomatic carotid stenosis compared with medical therapy in the long term. Those trials were completed more than 20 years ago and with advances in the treatment of atherosclerotic disease, the question has been raised to as to whether endarterectomy is still of value for patients with asymptomatic narrowing. Perioperative risk of carotid revascularization procedures has also declined. Due to improvements in both medical and surgical treatments for carotid artery stenosis, it is timely to reevaluate the efficacy of carotid intervention relative to medical treatment for patients with asymptomatic stenosis.

Asymptomatic Extracranial Artery Stenosis and the Risk of Cardiovascular and Cerebrovascular Diseases.

Asymptomatic extracranial artery stenosis (ECAS) is a well-known risk factor for stroke events, but it remains unclear whether it has the same role in predicting cardiovascular and cerebrovascular diseases, especially in China. We investigated the potential associations between ECAS, carotid plaque and carotid intima-media thickness and the new occurrence of cardiovascular and cerebrovascular diseases in the study. Out of 5440 study participants, 364 showed an asymptomatic ECAS at baseline, and 185 had come up to the final vascular events (brain infarction, intracerebral hemorrhage, subarachnoid hemorrhage, coronary heart disease and death due to the vascular diseases). During the follow- up. ECAS, carotid plaque and its instability and increased CIMT have associated with vascular events significantly (P < 0.05). After adjusting relevant vascular risk factors, ECAS still has a strong relationship with the new occurrence of vascular events, especially the brain infarction (HR: 2.101; 95% CI: 1.027–4.298; P = 0.042). We observed a clear relationship between ECAS and the new occurrence of cardiovascular and cerebrovascular disease, especially the brain infarction event. Carotid plaque and its instability and increased CIMT have all relevant with the occurrence of vascular events. Our findings provide direct evidence for the importance of ECAS in vascular events occurrence.

CT Angiographic Evaluation of Pattern and Distribution of Stenosis and its Association with Risk Factors Among Indian Ischemic Stroke Patients.

SummaryBackgroundStroke is the major cause of disability and third major cause of death. Ischemia causes about 80% of stroke cases; stenosis and occlusion are the predominant cause of stroke. Our purpose for this study was to evaluate the pattern and distribution of stenosis and its association with risk factors in Indian ischemic stroke patients and in other countries, for comparison.Material/MethodsWe evaluated 60 patients after ischemic stroke with CT angiography. The degree of stenosis was measured by the North American Symptomatic Carotid Endarterectomy Trial (NASCET). The results were analyzed by descriptive statistics and chi-square test.ResultsOut of 60 cases, 32 cases were positive for significant stenosis and a total number of stenotic segments was 45. Out of 45 stenotic segments, 29 were single stenotic segments (16 intracranial and 13 extracranial) and 16 were multiple stenotic segments (8 intracranial and 8 extracranial). In the total number of stenotic segments (single and multiple), there were 24 (53.33%) intracranial and 21 (46.67%) extracranial. The most commonly involved intracranial stenosis segment was MCA, present in 10 (41.6%) out of 24 intracranial segments. Most commonly involved extracranial stenosis segment was ICA, present in 14 (66.6%) out of 21 extracranial segments. Diabetes is found to be the most common risk factor of intracranial stenosis while hypertension and hypercholesterolemia are the major risk factors of extracranial stenosis.ConclusionsIn the Indian population, intracranial stenosis is more common than extracranial one, anterior circulation stenosis is more common than posterior circulation stenosis; single stenosis is more common than multiple stenosis.

Association of Inter-arm Blood Pressure Difference with Asymptomatic Intracranial and Extracranial Arterial Stenosis in Hypertension Patients.

Inter-arm blood pressure (BP) difference has been associated with ischemic stroke. Local atherosclerosis of stroke differ among vulnerable individuals, whereas intracranial arterial stenosis (ICAS) is more frequently affected Asians, and extracranial arterial stenosis (ECAS) is more prevalent among whites. We hereby sought to explore the association of inter-arm BP difference with ICAS and ECAS in stroke-free hypertensive patients in Chinese population. All the 885 subjects were evaluated of ICAS and ECAS through computerized tomographic angiography. Both arm BP was measured simultaneously by Vascular Profiler-1000 device. In the continuous study, ICAS was significantly associated with age, male, average brachial SBP, diabetes, anti-hypertensive treatment and inter-arm DBP difference. ECAS was associated with age, inter-arm SBP and LDL. In the categorical study, subjects with the top quartile of inter-arm DBP difference (≥4 mmHg) showed significantly higher risk of ICAS (OR = 2.109; 95% CI, 1.24–3.587). And the participants with the top quartile of inter-arm SBP difference (≥6 mmHg) showed significantly higher risk of ECAS (OR = 2.288; 95% CI, 1.309–3.998). In conclusion, we reported a diverse association of inter-arm SBP/DBP difference with the ICAS/ECAS. Inter-arm DBP difference might be the early symbol of ICAS in Chinese population, which need further verification in long-term cohort study.

P.067 Incidence of tissue-defined stroke and large vessel occlusion in acute stroke alerts in a non-teaching hospital system

Background: Stroke alerts are used to triage patients with acute neurologic change for rapid imaging evaluation. CTA has been advocated to rapidly triage stroke patients for endovascular therapy. However, the yield of this approach is not well established. We evaluated the stroke alert yield in a non-teaching hospital system. Methods: A retrospective review of radiology reports for stroke alerts using PACS archive. Cases were then followed for 72 hours to determine the types of advanced imaging obtained and the findings of those studies. Results: From January to March 2014, 269 stroke alert head CTs were performed. Subsequent imaging included 128 MRIs (48%), 25 CTAs (9%) and 2 angiograms (0.7%). There were 58 (22%) tissue-defined strokes and 16 were non-lacunar (6% stroke alerts). 61% of stroke alert head CTs were negative or reported microvascular change. Other findings included large vessel occlusion (5%), intracranial stenosis (1.5%), extracranial stenosis(1.5 %), intracranial hemorrhage (9%) and masses (13%). Conclusions: Most stroke alerts were negative for tissue-defined stroke. Based on this data, universal use of CTA in the ER to triage patients with acute neurologic symptoms may not be appropriate. An updated triage system to facilitate endovascular rescue is being analyzed for changes to advanced imaging utilization and yield.

One-Year Risk of Stroke after Transient Ischemic Attack or Minor Stroke

BackgroundPrevious studies conducted between 1997 and 2003 estimated that the risk of stroke or an acute coronary syndrome was 12 to 20% during the first 3 months after a transient ischemic attack (TIA) or minor stroke. The TIAregistry.org project was designed to describe the contemporary profile, etiologic factors, and outcomes in patients with a TIA or minor ischemic stroke who receive care in health systems that now offer urgent evaluation by stroke specialists.MethodsWe recruited patients who had had a TIA or minor stroke within the previous 7 days. Sites were selected if they had systems dedicated to urgent evaluation of patients with TIA. We estimated the 1-year risk of stroke and of the composite outcome of stroke, an acute coronary syndrome, or death from cardiovascular causes. We also examined the association of the ABCD2 score for the risk of stroke (range, 0 [lowest risk] to 7 [highest risk]), findings on brain imaging, and cause of TIA or minor stroke with the risk of recurrent stroke over a period of 1 year.ResultsFrom 2009 through 2011, we enrolled 4789 patients at 61 sites in 21 countries. A total of 78.4% of the patients were evaluated by stroke specialists within 24 hours after symptom onset. A total of 33.4% of the patients had an acute brain infarction, 23.2% had at least one extracranial or intracranial stenosis of 50% or more, and 10.4% had atrial fibrillation. The Kaplan–Meier estimate of the 1-year event rate of the composite cardiovascular outcome was 6.2% (95% confidence interval, 5.5 to 7.0). Kaplan–Meier estimates of the stroke rate at days 2, 7, 30, 90, and 365 were 1.5%, 2.1%, 2.8%, 3.7%, and 5.1%, respectively. In multivariable analyses, multiple infarctions on brain imaging, large-artery atherosclerosis, and an ABCD2 score of 6 or 7 were each associated with more than a doubling of the risk of stroke.ConclusionsWe observed a lower risk of cardiovascular events after TIA than previously reported. The ABCD2 score, findings on brain imaging, and status with respect to large-artery atherosclerosis helped stratify the risk of recurrent stroke within 1 year after a TIA or minor stroke. (Funded by Sanofi and Bristol-Myers Squibb.)

Intracranial and Extracranial Stenosis interact with White Matter Disease in the Pathogenesis of Post Stroke Dementia (P5.210)

Intracranial and Extracranial Stenosis interact with White Matter Disease in the Pathogenesis of Post Stroke Dementia (P5.210)

Silent Brain Infarction in Patients With Asymptomatic Carotid Artery Atherosclerotic Disease.

The relationship between carotid atherosclerosis and ipsilateral silent brain infarction (SBI) is unclear. We tested the hypothesis that extracranial internal carotid artery (ICA) stenosis is associated with a greater prevalence of SBI in the cerebral hemisphere ipsilateral to ICA disease compared with the unaffected, contralateral side. We identified patients with unilateral extracranial ICA stenosis ≥50% on angiography by standard imaging criteria. We included patients with recent brain magnetic resonance imaging who had no previous history of stroke or transient ischemic attack. Blinded readers ascertained the presence of anterior circulation SBIs. SBI was defined as either a cavitary lacunar infarction in the white or deep gray matter or cortical infarction defined by T2 hyperintense signal in cortical gray matter. The Wilcoxon signed-rank test was used to compare SBI in the cerebral hemispheres and Cohen κ to assess inter-rater reliability of SBI evaluation. Among 104 patients, we found a higher prevalence of SBIs ipsilateral to ICA disease (33%) compared with the contralateral side (20.8%; P=0.0067). There was no significant difference in the prevalence of lacunar SBIs (including both white and deep gray matter) between hemispheres (P=0.109), but there was a significantly higher prevalence of cortical SBIs occurring downstream from ICA disease (P=0.0045). High inter-rater reliability was observed (κ=0.818). Patients with asymptomatic ICA disease demonstrate a higher prevalence of SBI downstream from their ICA atherosclerotic disease compared with the contralateral side but only of the cortical and not lacunar SBI subtype.