Large Artery Atherosclerosis Research Articles

Correlation Between MMP9 Promoter Methylation and Transient Ischemic Attack/Mild Ischemic Stroke with Early Cognitive Impairment.

Dyskinesia caused by transient ischemic attack (TIA) and mild ischemic stroke (MIS) is mild and short-lived; however, cognitive impairment (CI) can occur in the acute phase and be easily overlooked. DNA methylation is an epigenetic phenomenon that can affect gene expression through gene silencing. Blood levels of matrix metalloproteinase (MMP) 9 are elevated in ischemic stroke patients and is associated with the destruction of the blood-brain barrier and the occurrence of CI. No studies have investigated the relationship between MMP9 gene methylation and TIA/MIS with early cognitive impairment (ECI). As such, the purpose of the present study was to investigate the correlation between MMP9 gene methylation and TIA/MIS with ECI. Data from 112 subjects were collected, including 84 with TIA/MIS (National Institutes of Health Stroke Scale <5 points) and 28 non-stroke control subjects. Patients were evaluated within 7 days of TIA/MIS onset according to four single-domain cognitive scales. Whole blood DNA methylation was detected using MethylTarget sequencing technology. Comparison of MMP9 gene methylation levels among subgroups was performed using statistical methods. The site S33-79 in the TIA/MIS group was hypomethylated compared with the control group, and sites S33-25 and S33-30 in TIA/MIS with ECI was hypomethylated compared with TIA/MIS without ECI. Compared with the small artery occlusion group, MMP9 gene, S33-25, 30, 39, 53, 58, 73, 79, 113 and 131 sites in the large artery atherosclerosis group were hypomethylated. MMP9 gene hypomethylation sites were associated with TIA/MIS and TIA/MIS with ECI, and there was a strong correlation between MMP9 gene hypomethylation and atherosclerotic TIA/MIS. MMP9 gene methylation can reflect the severity of TIA/MIS. MMP9 gene hypomethylation sites may be used as potential biomarkers and therapeutic targets for TIA/MIS and TIA/MIS with ECI.

Exploring the Causality of Type 1 Diabetes and Stroke Risk: A Mendelian Randomization Study and Meta-analysis.

Type II diabetes was causally related to stroke, which is a risk factor for stroke. However, the causal relationship between type I diabetes(T1D) and stroke, especially its subtypes, remains unclear. To determine whether T1D has a genetic causal link to stroke and its subtypes, we undertook this mendelian randomization (MR) study. The genome-wide association studies (GWAS) of T1D was the source of exposure. The outcomes were strokes and their subtypes, including ischemic stroke (IS), small vessel stroke (SVS), cardioembolic stroke (CES), large artery atherosclerosis stroke (LAS), intracerebral hemorrhage (ICH), lobar intracerebral hemorrhage (LICH), and non-lobar intracerebral hemorrhage (NLICH). We used outcome GWAS conducted by ISGC consortium for the initial phase and GWAS from MEGASTROKE consortium as the data for the replication phase to confirm the causal association. Besides, we conducted a meta-analysis of the causal association from ISGC and MEGASTROKE databases to confirm robust causality. Inverse-variance weighting (IVW) was utilized as the primary method to estimate the causality between T1D and stroke. The Cochran's Q test and the MR-PRESSO global test were used to examine the sensitivity. We discovered the causal relationship between T1D and SVS (OR = 1.17, 95% CI: 1.07-1.28, p = 6.0 × 10- 4), CES (OR = 1.11, 95%CI: 1.03-1.21, p = 0.0080) in initial stage. The replication phase validated T1D has a causal relationship with SVS (OR = 1.12, 95% CI: 1.06-1.18, p = 4.0 × 10- 5), but not with stroke and other subtypes. The meta-analysis of initial and replication stage again supported the causal link between T1D and SVS (OR = 1.13, 95% CI: 1.08-1.18, p < 0.05). However, no causal relationship was found between T1D and other stroke subtypes. The sensitivity analysis also supported the robust of these results. In conclusion, T1D was causally associated with SVS, but not with other subtypes of stroke. More investigation is needed to understand the underlying biology mechanism.

Poststroke neutrophil count is predictive of the outcomes of large-artery atherosclerotic stroke and associated with craniocervical atherosclerosis

Elevation of the neutrophil count is detrimental to the outcome of patients with stroke. The effect of poststroke neutrophil count on the outcome of patients with large-artery atherosclerosis (LAA) stroke is unclear. This study aims to explore the relationship of poststroke neutrophil count with the functional outcome of patients with LAA stroke, and the relationship of poststroke neutrophil count and craniocervical atherosclerotic stenosis (AS) number in these patients. The AS was defined as ≥ 50% stenosis or occlusion attributed to atherosclerosis on craniocervical large arteries. A total of 297 participants were enrolled in the cohort. In multivariable analyses, neutrophil count [adjusted relative risk (aRR) = 1.23, 95% confidence interval (CI) 1.09–1.40, p = 0.001] was an independent predictor of 90-day poor functional outcome [modified Rankin Scale (mRS) > 2 points]. The neutrophil count was significantly associated with the craniocervical AS number in a multivariable ordinal logistic regression analysis [adjusted odds ratio (aOR) = 1.41, 95% CI 1.16–1.72, p = 0.001]. The poststroke neutrophil count is a valuable predictor of 90-day poor functional outcome of patients with LAA stroke. The poststroke neutrophil count is positively correlated with the craniocervical AS number in these patients.

The value of serum Lp-PLA2 combined with MPO in the diagnosis of cerebral infarction caused by large artery atherosclerosis

ObjectiveTo explore the value of serum lipoprotein-associated phospholipase A2（Lp-PLA2）combined with myeloperoxidase（MPO）for the diagnosis of large artery atherosclerosis(LAA) cerebral infarction. MethodsBaseline data were collected from patients with first-ever acute cerebral infarction, serum Lp-PLA2 and MPO levels were measured. The etiology of cerebral infarction was classified according to the Chinese Ischemic Stroke Subtype Classification Standard. The risk factors associated with LAA cerebral infarction were identified by univariate and multivariate regression analysis. The diagnostic value of serum Lp-PLA2 and MPO for LAA cerebral infarction was assessed by the area under the receiver-operating characteristic (ROC) curve. ResultsOverall 368 patients were involved, 148 patients (40.22 %) were LAA. The serum La-PLA2 and MPO levels were higher in the LAA group than those in non-LAA group (23.06 ± 3.39 ng/mL versus 17.48 ± 3.26 ng/mL; 93.60 ± 9.58 ng/mL versus 75.98 ± 15.53 ng/mL; P < 0.001 for both). Multivariate analysis showed that elevated levels of serum Lp-PLA2 (OR 1.742, 95 %CI 1.499–2.025; P < 0.001) and MPO (OR 1.060, 95 % CI 1.026–1.096; P = 0.001) were the independent risk factors of LAA cerebral infarction. The area under curve of the serum Lp-PLA2 combined with MPO for the diagnosis of LAA cerebral infarction was 0.896 [0.866 ∼ 0.927] (P < 0.001). ConclusionSerum Lp-PLA2 combined with MPO could be valued as a predictor of acute cerebral infarction caused by large artery atherosclerosis.

Demographics, Risk Factors, and Etiology of Posterior Cerebral Artery Stroke Causing Homonymous Hemianopia.

Posterior cerebral artery (PCA) strokes account for up to 10% of all ischemic strokes, often presenting with homonymous hemianopia. The proportion of these strokes attributed to various etiologies varies widely in previously published studies, owing largely to differing patient populations, definitions of stroke pathogenesis, and vascular territories involved. The Causative Classification System (CCS), an automated version of the Stop Stroke Study (SSS) Trial of Org 10,172 in Acute Stroke Treatment (TOAST) system, allows for a more rigorous assignment of stroke etiology. We excerpted clinical and imaging data on 85 patients who had PCA stroke with homonymous hemianopia examined at the University of Michigan. We compared the stroke risk factor profile of our PCA cohort with that of 135 patients with stroke in the distribution of the internal carotid artery (ICA) and middle cerebral artery (MCA) in an unpublished University of Michigan registry. We applied the CCS web-based calculator to our PCA cohort to determine stroke etiology. In our PCA cohort, 80.0% had at least 2 conventional stroke risk factors and 30.6% had 4 risk factors, most commonly systemic hypertension. The risk factor profile of our PCA cohort resembled that of our ICA/MCA cohort except that the mean age of our PCA cohort was more than a decade younger and had a significantly lower frequency of atrial fibrillation (AF) than our ICA/MCA cohort. In nearly half of the patients with AF in our PCA cohort, AF was diagnosed after the stroke. Among stroke etiologies in our PCA cohort, 40.0% were of undetermined cause, 30.6% were from cardioaortic embolism, 17.6% were from other determined causes, and only 11.8% were from supra-aortic large artery atherosclerosis. Strokes after endovascular or surgical interventions were prominent among other determined causes. Most patients in our PCA cohort had multiple conventional stroke risk factors, a finding not previously documented. Mean age at stroke onset and AF frequency were lower than in our ICA/MCA cohort, in agreement with previous studies. As some other studies have found, nearly 1/3 of strokes were attributed to cardioaortic embolism. Within that group, AF was often a poststroke diagnosis, a finding not previously highlighted. Compared with earlier studies, a relatively high portion of strokes were of undetermined etiology and of other determined etiologies, including stroke after endovascular or surgical interventions. Supra-aortic large artery atherosclerosis was a relatively uncommon explanation for stroke.

The impact of competing stroke etiologies in patients with atrial fibrillation.

Data on the impact of competing stroke etiologies in stroke patients with atrial fibrillation (AF) are scarce. We used prospectively obtained data from an observational registry (Novel-Oral-Anticoagulants-in-Ischemic-Stroke-Patients-(NOACISP)-LONGTERM) of consecutive AF-stroke patients treated with oral anticoagulants. We compared the frequency of (i) the composite outcome of recurrent ischemic stroke (IS), intracerebral hemorrhage (ICH) or all-cause death as well as (ii) recurrent IS alone among AF-stroke patients with versus without competing stroke etiologies according to the TOAST classification. We performed cox proportional hazards regression modeling adjusted for potential confounders. Furthermore, the etiology of recurrent IS was assessed. Among 907 patients (median age 81, 45.6% female), 184 patients (20.3%) had competing etiologies, while 723 (79.7%) had cardioembolism as the only plausible etiology. During 1587 patient-years of follow-up, patients with additional large-artery atherosclerosis had higher rates of the composite outcome (adjusted HR [95% CI] 1.64 [1.11, 2.40], p = 0.017) and recurrent IS (aHR 2.96 [1.65, 5.35 ], p < 0.001), compared to patients with cardioembolism as the only plausible etiology. Overall 71 patients had recurrent IS (7.8%) of whom 26.7% had a different etiology than the index IS with large-artery-atherosclerosis (19.7%) being the most common non-cardioembolic cause. In stroke patients with AF, causes other than cardioembolism as competing etiologies were common in index or recurrent IS. Concomitant presence of large-artery-atherosclerosis seems to indicate an increased risk for recurrences suggesting that stroke preventive means might be more effective if they also address competing stroke etiologies in AF-stroke patients. NCT03826927.

Posterior Circulation Strokes – Clinico-Radiological Features and Predictors of Outcome at 6 Months

Introduction: Posterior circulation stroke (PCS) is often diagnosed late and long-term outcomes have not been described in South India. We wished to study clinical features, long-term outcomes, and independent predictors of the same. Materials and Methods: We conducted a prospective cohort study in PCS patients from January 2014 to May 2017. Morbidity and mortality at discharge, at 3 months and 6 months was studied. Univariate and multivariate analysis of predictors of poor outcome as well as the survival analysis was computed. Results: We recruited 291 PCS during the study period; prevalence of PCS among all strokes was 12.9% in 2014. The mean age was 53.34 years (standard deviation 13.34). Young strokes constituted 28.8%. The common comorbidities were hypertension 72%, diabetes mellitus 52.6%, smoking 38.5%, and dyslipidemia 32.6%. The common presenting symptoms were giddiness 79%, unsteadiness 75.35%, ataxia 56%, motor deficits 48.8% and nausea and vomiting 43%. Most were Ischemic strokes (86.5%); 10.3% gave a history of preceding TIAs. Common arteries involved were posterior cerebral 45%, posterior inferior cerebellar 38%, and basilar artery 19.2%. Among ischemic strokes, large artery atherosclerosis was 50.8%. Dysphagia was seen in 32.6% and sepsis in 19.2%; post stroke pain in 23%, followed by cognition decline in 10.3%. Bad outcome (modifies Rankins score 4–6) was 16.8% at discharge, 16.4% at 1 month, 14.4% at 3 months, and 13.8% at 6 months. Independent predictors of bad outcomes at 6 months were baseline National Institute of Health Stroke Scale (NIHSS) score (Odds ratio [OR] 1615.59 confidence interval [CI] 27.64–94447.7), invasive ventilation (OR 7.77 CI 1.57–38.43), sepsis (OR 17.22 CI 1.45–204.08), and basilar artery involvement (OR 19.98 CI 1.67–238.81). Baseline NIHSS scores between 0 and 5 suggest a good outcome while scores more than 13 suggest a bad outcome at 6 months. At 6 months, half are unemployed. Conclusions: The prevalence, clinical features, and comorbidities were also similar to previous studies. There was good survival at 6 months. NIHSS score is useful in predicting poor outcomes.

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.

Increased plasma levels of circPTP4A2 and circTLK2 are associated with stroke injury.

Accumulating studies have shown that circulating circular RNAs (circRNAs) represent novel biomarkers for many human diseases. We investigated whether plasma circPTP4A2 and circTLK2 levels are associated with stroke severity, infarct volume, stroke etiology, and functional outcome in acute ischemic stroke (AIS) patients. We applied quantitative real-time PCR (qPCR) to measure plasma circPTP4A2 and circTLK2 levels of 236 AIS patients within 72 h of symptoms onset and 136 healthy controls. We further assessed the National Institutes of Health Stroke Scale (NIHSS), infarct size, the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification and the 90-day modified Rankin scale (mRS) for each patient. At admission, plasma circPTP4A2 and circTLK2 levels in patients with moderate to severe stroke were significantly higher compared to those with mild stroke. Logistic regression and receiver-operating characteristic (ROC) curve analyses indicated that they might function as predictive biomarkers for moderate to severe stroke. We also observed a medium positive correlation between these two circRNAs and NIHSS. Plasma circPTP4A2 and circTLK2 levels were slight positively correlated with cerebral infarct volume only in anterior circulation infarction (ACI) patients. Levels of both circPTP4A2 and circTLK2 were closely related with large artery atherosclerosis (LAA) stroke. Moreover, changes within 7 days after admission in circPTP4A2 and circTLK2 were able to predict unfavorable clinical outcome 90 days after AIS. These results demonstrate that plasma circPTP4A2 and circTLK2 strongly correlated with severity, subtypes and prognosis of AIS, and they could serve as promising biomarkers.

The Trial of Org 10172 of Acute Stroke Treatment pada Era Pandemi COVID-19

Background and Objective: The Trial of Org 10172 of Acute Stroke Treatment (TOAST) classification was introduced to classify ischemic stroke based on potential etiological mechanisms. The purpose of this study was to assess the characteristics of acute ischemic stroke patients based on the TOAST classification during the COVID-19 pandemic era. Subject and Methods: This research was a descriptive cross-sectional study from the medical records of acute ischemic stroke patients who were treated in Neurology ward of Hasan Sadikin Hospital in 2021. Results: A total of 136 acute ischemic stroke patients were involved in this study. Large-artery atherosclerosis (LAA) was the most common stroke subtype (30.1%) and hypertension is the most common risk factor (97%). The risk factors for hypercoagulation were found to be 79% in the Undetermined etiology classification and 100% in the Other etiology classification. Conclusion: In the COVID-19 pandemic era, hypercoagulation was found as the dominant risk factor in the Undetermined etiology and Other etiology classifications. The coagulopathy mechanism in COVID-19 could increase the risk of stroke in affected person who have conventional stroke risk factors.

A Study on the Efficacy of Thrombectomy in Patients with Atherosclerotic and Cardioembolic Basilar Artery Occlusion.

Background Studies on basilar artery occlusion are relatively few compared with those of anterior circulation stroke. The aim of the present study was to compare the efficacy of endovascular therapy (EVT) in patients with basilar artery occlusion classified as large artery atherosclerosis (LAA) and cardioembolism (CE), and to analyze the independent risk factors affecting the prognosis of EVT. Methods A total of 123 people were assigned to the LAA and CE groups (97 to the LAA and 26 to the CE). The primary outcome was a modified Rankin Scale (mRS) score of 2 or lower at 90 days. The primary safety outcome was mortality at 90 days. Secondary safety endpoints included the rates of symptomatic intracranial hemorrhage and reinfarction. Multiple logistic regression was used to screen out independent risk factors for EVT prognosis of the LAA and CE groups. Results In the analysis, the patients with LAA stroke had better collateral circulation (American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology [SIR] score of 2-4; 61.9 vs. 19.2%, p = 0.000), and higher angioplasty rate (32.0 vs. 3.8%, p = 0.002). The proportions of patients with a 90-day mRS score of 0 to 2 and 90-day mortality were not found to be statistically significant between the two groups. Multivariate logistic regression analysis indicated that age, SIR, white blood cell, blood glucose, and modified thrombolysis in cerebral infarction were independent risk factors for the poor prognosis of EVT in the LAA group. Conclusion Although there were differences in clinical characteristics and imaging features between LAA and CE, there was no evidence of a significant difference in prognosis after EVT. In addition, the National Institutes of Health Stroke Scale score was not among the independent risk factors affecting the prognosis of the LAA group.

Sex disparity in stroke outcomes in a multicenter prospective stroke registry in Viet Nam.

Although men have a higher rate of stroke than women, it is not clear whether women have a worse outcome after adjusting for confounders such as vascular risk factors, age, stroke severity, and reperfusion therapy. We evaluated sex differences on 90-day functional outcomes after stroke in a multicenter study in Vietnam. We recruited patients presenting with ischemic or hemorrhagic stroke at 10 stroke centers in Vietnam for a period of 1 month from August 1, 2022, to August 31, 2022. We reviewed the patient's clinical demographics, time from symptom onset to hospital admission, stroke classification, stroke subtype, stroke severity, characteristics of reperfusion therapy, and 90-day clinical outcome. We compared functional outcomes and predisposing factors at day 90 between men and women after an ischemic and hemorrhagic stroke. Poor outcome was defined as mRS 3-6. There were 2,300 stroke patients included. Men accounted for 61.3% (1,410) of participants. Compared with men, women were older (67.7±13.9 vs. 63.7±13.3, P<0.001), had a higher rate of diabetes mellitus (21.1% vs.15.3%, P<0.001), a lower rate of smoking (1.0 % vs. 23.6%, P<0.001), and a lower BMI (21.4 ± 2.70 vs. 22.0 ± 2.72, P<0.001). There was a higher rate of ICH in men (21.3% vs.15.6%, P=0.001), whereas the rate of subarachnoid hemorrhage was higher in women (6.2% vs.3.0%, P<0.001). For ischemic stroke, door-to-needle time (36.9±17.6 vs. 47.8±35.2 minutes, P=0.04) and door-to-recanalization time (113.6±51.1 vs.134.2±48.2, p=0.03) were shorter in women.There was no difference in 90-day functional outcomes between sexes. Factors associated with poor outcomes included age ≥ 50 years (adjusted OR, aOR 1.75; 95% CI, 1.16 to 2.66), history of stroke (aOR 1.50; 95% CI, 1.15 to 1.96), large artery atherosclerosis (aOR 5.19; 95% CI, 3.90 to 6.90), and cardioembolism (aOR 3.21; 95% CI, 1.68 to 6.16). Factors associated with mortality in patients with acute ischemic stroke included a history of coronary artery disease (aOR 3.04; 95% CI, 1.03 to 8.92), large artery atherosclerosis (aOR 3.37; 95% CI, 2.11 to 5.37), and cardioembolism (aOR 3.15; 95%CI, 1.20 to 8.27). There were no sex differences in the clinical outcome of stroke and ischemic stroke in this prospective cohort of hospitalized Vietnamese patients.

Association of Homocysteine with Acute Stroke and Its Subtypes in the Chinese Population.

Homocysteine (Hcy) is recognized as a risk factor for stroke. Our study examined the relationship between plasma Hcy levels and stroke, along with its subtypes, among Chinese patients who experienced an acute stroke episode. We retrospectively enrolled patients with acute stroke and age- and sex-matched healthy controls admitted to the First Affiliated Hospital of Xi'an Jiaotong University from October 2021 to September 2022. Ischemic stroke subtypes were classified using the modified TOAST criteria. Multivariate logistic regression models were employed to probe the associations of plasma Hcy levels with total stroke, ischemic stroke and its subtypes, and hypertensive intracerebral hemorrhage (HICH), and the correlation between plasma Hcy levels and the National Institute of Health Stroke Scale (NIHSS). The mean age of the total group was 63 years, with women representing 30.6% (246 individuals). Elevated Hcy levels were significantly associated with total stroke (OR 1.054, 95% CI: 1.038-1.070), HICH (OR 1.040, 95% CI: 1.020-1.060), ischemic stroke (OR 1.049, 95% CI: 1.034-1.065), and the TOAST subtypes of ischemic stroke in large-artery atherosclerosis (LAA) (OR 1.044, 95% CI: 1.028-1.062) and small-artery occlusion (SAO) (OR 1.035, 95% CI: 1.018-1.052), but not with cardioembolic (CE) stroke. Moreover, only in the case of SAO stroke were the Hcy levels positively correlated with the NIHSS score (B=0.030, 95% CI: 0.003-0.056, P=0.030). Plasma Hcy levels were found to be positively correlated with the risk of stroke, particularly in the context of LAA, SAO stroke, and HICH. Additionally, Hcy levels demonstrated a positive correlation with stroke severity in patients presenting with SAO stroke. These findings suggest potential clinical implications in stroke prevention, particularly for ischemic stroke (LAA, SAO subtypes) and HICH by employing homocysteine-lowering therapies. Future investigations are warranted to fully elucidate these associations.

Predictive factors for clinical outcomes in Filipino patients with watershed infarction: A single center study.

Watershed infarcts denote ischemic lesions involving the distal territories of two major arteries. For years, hypotheses on its pathophysiological mechanisms have been proposed. Yet, the cause is still widely debated. This study aimed to determine the mechanism of watershed strokes and compare their clinical outcomes to acute ischemic stroke from other causes and predict the factors affecting clinical outcomes in patients with watershed infarcts. This single-center, comparative, six-years retrospective cohort study included patients with a diagnosis of Acute Ischemic Stroke. Patients were classified under watershed group or acute ischemic stroke based on their neuroimaging findings. Stroke mechanisms were determined between groups as well as the factors associated with clinical outcomes in watershed strokes. Among the 424 patients included in the study, large artery atherosclerosis was seen in greater frequency in patients with watershed infarcts regardless of the type (EWIs: n=68, 73% vs IWIs: n=89, 75%). No differences observed in the clinical outcomes between groups. Multiple variable analysis showed that age, female sex, high NIHSS score and presence of underlying malignancy were associated with clinical outcomes. Clinical outcomes between watershed infarcts and acute ischemic strokes were similar. Hemodynamic compromise in the setting of severe stenosis is the underlying mechanism for both types of watershed strokes thus, the goal of treatment is to maintain adequate perfusion. High baseline NIHSS score, increased age, female gender and underlying malignancy were all poor predictors of clinical outcomes in patients with watershed strokes.

Exploration of the etiology of single small subcortical infarctions using high-resolution vessel wall MRI.

We aimed to explore imaging indicators for diagnosing the etiology of single small subcortical infarctions (SSI) using high-resolution vessel wall imaging (HR-VWI). Patients with acute isolated subcortical cerebral infarction were prospectively enrolled and classified as having large artery atherosclerosis (LAA), stroke of undetermined etiology (SUD), or small artery disease (SAD). The infarct information, the cerebral small vessel disease (CSVD) score, morphological characteristics of the lenticulostriate arteries (LSAs), and plaque characteristics were compared between the three groups. Seventy seven patients were enrolled (30 LAA, 28 SUD, and 19 SAD). The total CSVD score of the LAA (P = 0.001) and SUD groups (P = 0.017) was significantly lower than that of the SAD group. The number and total length of LSA branches in the LAA and SUD groups were shorter than in the SAD group. Moreover, the total length laterality index (LI) of the LSAs in the LAA and SUD groups was greater than in the SAD group. The total CSVD score and LI of total length were independent predictors for the SUD and LAA groups. The remodeling index of the SUD group was significantly higher than that of the LAA group (P = 0.002); positive remodeling was dominant in the SUD group (60.7%), whereas remodeling in the LAA group was primarily non-positive (83.3%). SSI with and without plaques on the carrier artery may have different modes of pathogenesis. Patients with plaques may also have a coexisting mechanism of atherosclerosis.

Ischaemic stroke despite antiplatelet therapy: Causes and outcomes.

Ischaemic stroke may occur despite antiplatelet therapy (APT). We aimed to investigate frequency, potential causes and outcomes in patients with ischaemic stroke despite APT. In this cohort study, we enrolled patients with imaging-confirmed ischaemic stroke from the Swiss Stroke Registry (01/2014-07/2022). We determined the frequency of prior APT, assessed stroke aetiology (modified TOAST classification) and determined the association of prior APT with unfavourable functional outcome (modified Rankin Scale score 3-6) and recurrent ischaemic stroke at 3 months using regression models. Among 53,352 patients, 27,484 (51.5%) had no prior antithrombotic treatment, 17,760 (33.3%) were on APT, 7039 (13.2%) on anticoagulation and 1069 (2.0%) were on APT + anticoagulation. In patients with a history of ischaemic stroke/TIA (n = 11,948; 22.4%), 2401 (20.1%) had no prior antithrombotic therapy, 6594 (55.2%) were on APT, 2489 (20.8%) on anticoagulation and 464 (3.9%) on APT + anticoagulation. Amongst patients with ischaemic stroke despite APT, aetiology was large artery atherosclerosis in 19.8% (n = 3416), cardiac embolism in 23.6% (n = 4059), small vessel disease in 11.7% (n = 2011), other causes in 7.4% (n = 1267), more than one cause in 6.3% (n = 1078) and unknown cause in 31.3% (n = 5388). Prior APT was not independently associated with unfavourable outcome (aOR = 1.06; 95% CI: 0.98-1.14; p = 0.135) or death (aOR = 1.10; 95% CI: 0.99-1.21; p = 0.059) at 3-months but with increased odds of recurrent stroke (6.0% vs 4.3%; aOR 1.26; 95% CI: 1.11-1.44; p < 0.001). One-third of ischaemic strokes occurred despite APT and 20% of patients with a history of ischaemic stroke had no antithrombotic therapy when having stroke recurrence. Aetiology of breakthrough strokes despite APT is heterogeneous and these patients are at increased risk of recurrent stroke.

Plasma lncRNA LIPCAR Expression Levels Associated with Neurological Impairment and Stroke Subtypes in Patients with Acute Cerebral Infarction: A Prospective Observational Study with a Control Group.

This prospective observational study with a control group aimed to compare the plasma levels of long non-coding RNA (lncRNA) LIPCAR between patients with acute cerebral infarction (ACI) and healthy controls, and to assess the prognostic abilities of LIPCAR for adverse outcomes of patients with ACI at 1-year follow-up. Eighty patients with ACI, of whom 40 had large artery atherosclerosis (LAA) and 40 had cardioembolism (CE) and who were hospitalized at Xi'an No. 1 Hospital from July 2019 to June 2020, were selected as the case group. Age- and sex-matched non-stroke patients from the same hospital throughout the same time period were chosen as the control group. Real-time quantitative reverse transcription polymerase chain reaction was used to measure the levels of plasma lncRNA LIPCAR. The correlations of LIPCAR expression among the LAA, CE, and control groups were assessed using Spearman's correlation analysis. Curve fitting and multivariate logistic regression were used to analyze the LIPCAR levels and 1-year adverse outcomes of patients with ACI and its subtypes. The expression of plasma LIPCAR in the case group was noticeably higher than that of the control group (2.42±1.49 vs. 1.00±0.47, p<0.001). Patients with CE had considerably higher levels of LIPCAR expression than those with LAA. The National Institute of Health Stroke Scale score and modified Rankin scale score on admission were significantly positively correlated with LIPCAR expression in patients with CE and LAA. Furthermore, the correlation was stronger in patients with CE than in those with LAA, with correlation coefficients of 0.69 and 0.64, respectively. Curve fitting revealed a non-linear correlation between LIPCAR expression levels, 1-year recurrent stroke, all-cause mortalities, and poor prognoses, with a cut-off value of 2.2. The expression level of lncRNA LIPCAR may play a potential role in the identification of neurological impairment and CE subtype in patients with ACI. Increased 1-year risk of adverse outcomes may be associated with high levels of LIPCAR expression.

Incidence and Association of Seizures in Stroke Patients Undergoing Endovascular Therapies

Background: Endovascular therapies have revolutionized the treatment of stroke, but post-stroke seizures continued as significant complication that impacted morbidity. Objectives: We examined the incidence and association of seizures in stroke patients undergoing endovascular therapy (EVT). Methods: Investigation included 384 hospitalized patients with acute ischemic or hemorrhagic stroke undergoing EVT. To distinguish and investigate the stroke, and to identify subtypes of stroke using the TOAST classification, the incidence of seizures was determined in stroke patients following EVT through brain imaging. Results: We analyzed the demographic and clinical characteristics of 384 stroke patients who underwent EVT and had seizures. Seizures were found to occur in 6.51% of EVT patients (p&gt;0.05). Occurrence of seizures was non-substantially affected by comorbidities like hypertension, cardiac maladies and diabetes. Majority of stroke patients (82.81%) suffered from ischemic strokes, while only 17.18% had hemorrhagic strokes. Large artery atherosclerosis was the most prevalent subtype of stroke associated with seizures following EVT. The severity of the stroke and existing of cortical involvement were not significantly associated with seizures (p&lt;0.05), whereas lower age and early seizures after EVT were associated with a marginally increased risk of experiencing seizures. Overall, study indicated that incidence of seizures following EVT was relatively low and influenced by particular factors. Practical implication: This study emphasized the need for personalized patient care strategies, including vigilant surveillance for seizures and preventative interventions, to enhance the outcomes of stroke patients undergoing endovascular therapy. Conclusion: Seizures are a significant complication of EVT for stroke patients. Stroke severity and etiology may influence seizure risk, highlighting the significance of vigilant monitoring and proactive management to reduce the incidence of seizures in this patient population. Keywords: Endovascular treatment; Epidemiology; Epilepsy; Hemorrhage; Seizures; Thrombectomy.

Texture analysis of apparent diffusion coefficient maps in predicting the clinical functional outcomes of acute ischemic stroke.

To investigate texture analysis (TA) based on apparent diffusion coefficient (ADC) map in predicting acute ischemic stroke (AIS) prognosis and discriminating TA features in stroke subtypes. This retrospective study included patients with AIS between January 2018 and April 2021. The patients were assigned to the favorable [modified Rankin Scale (mRS) score ≤ 2] and unfavorable (mRS score > 2) outcome groups. All patients underwent stroke subtyping according to the Trial of Org 10,172 in Acute Stroke Treatment (TOAST) classification. The TA features were extracted from infarction lesions on the ADC map. The demographic characteristics, clinical characteristics, and texture features were used to construct prediction models with recurrent neural network (RNN). The receiver operating characteristic (ROC) curves were implemented to evaluate the performance of the predictive models. A total of 1,003 patients (682 male; mean age 65.90 ± 12.44) with AIS having documented the 90-day mRS score were identified, including 840 with favorable outcomes. In the validation set, the area under the curve (AUC) of the predictive model using only clinical characteristics achieved an AUC of 0.56, texture model 0.77, the model combining both clinical and texture features showed better with an AUC of 0.78. The texture feature profiles differed between large artery atherosclerosis (LAA) and small artery occlusion (SAO) subtypes (all p < 0.05). The AUC of combined prediction models for LAA and SAO subtypes was 0.80 and 0.81. Texture analysis based on ADC map could be useful as an adjunctive tool for predicting ischemic stroke prognosis.

A randomized trial of Trendelenburg position for acute moderate ischemic stroke

We aim to explore the effect of head-down position (HDP), initiated within 24 hours of onset, in moderate anterior circulation stroke patients with probable large artery atherosclerosis (LAA) etiology. This investigator-initiated, multi-center trial prospective, randomized, open-label, blinded-endpoint, multi-center and phase-2 trial was conducted in China and completed in 2021. Eligible patients were randomly assigned (1:1) into the HDP group receiving −20° Trendelenburg, or control group receiving standard care according to national guideline. The primary endpoint was proportion of modified Rankin Scale (mRS) of 0 to 2 at 90 days, which is a scale for measuring the degree of disability after stroke. 90-day mRS was assessed by a certified staff member who was blinded to group assignment. A total of 96 patients were randomized (47 in HDP group and 49 in control group) and 94 (97.9%) patients were included in the final analysis: 46 in HDP group and 48 in control group. The proportion of favorable outcome was 65.2% (30/46) in the HDP group versus 50.0% (24/48) in the control group (unadjusted: OR 2.05 [95%CI 0.87-4.82], P = 0.099). No severe adverse event was attributed to HDP procedures. This work suggests that the head-down position seems safe and feasible, but does not improve favorable functional outcome in acute moderate stroke patients with LAA. This trial was registered with ClinicalTrials.gov, NCT03744533.