Large Artery Atherothrombosis Research Articles

Evaluation of the relationship between thrombophilia gene mutations and demographic data, imaging findings and stroke subtypes in young patients followed up with a diagnosis of stroke

Aims: A stroke is defined as a focal or generalized neurological deficit that develops suddenly, lasts for more than 24 hours, or ends in death within this period, with a cause other than a vascular cause. Stroke is among the leading causes of morbidity and mortality in the general population. In our study, we examined the prevalence of all prothrombotic gene mutations observed in patients with and without predisposing risk factors for young patients with stroke and discussed their roles in stroke formation in the context of existing literature. Methods: In the present study, we conducted a retrospective review of the medical records of 300 patients aged 18 to 49 years who were hospitalized in the neurology clinic of our hospital between June 2023 and June 2024 and diagnosed with acute arterial ischemic stroke based on anamnesis, neurological examination, and radiological imaging (CT and MRI) results. The study cohort comprised 47 patients (23 males, 24 females) aged between 18 and 49 years with a diagnosis of ischemic stroke. In our study, we examined ischemic stroke-related gene polymorphisms in patients with early-onset ischemic stroke (before the age of 50 years). This study aims to investigate the prevalence of Factor V-Leiden, prothrombin-G20210A, methylenetetrahydrofolate reductase (MTHFR) C677T, MTHFR A1298C, SERPIN 1, and Factor II polymorphisms in young patients with ischemic stroke. Results: A total of 47 patients, comprising 23 males and 24 females, were included in the study. The mean age of the patients was 40.34 ± 6.37 years. According to the TOAST classification system, 17 patients (36.2%) were diagnosed with large artery atherothrombosis, one patient (2.1%) had a cardioembolic infarction, and 29 patients (61.7%) had a small artery occlusion. In our study, when evaluating the thrombophilia mutation subtypes in young ischemic stroke patients, 23.4% (n=11) of the patients were found to be heterozygous for the FVL mutation, while 76.6% (n=36) had no mutation. Concerning the SERPIN 1 mutation, 40.4% (n=19) of the patients were heterozygous, 23.4% (n=11) were homozygous, and 36.2% (n=17) exhibited no mutation. The distribution of patients according to MTHFR C677T mutation revealed that 57.4% (n=27) were heterozygous, 19.1% (n=9) were homozygous, and 23.4% (n=11) had no mutation. Considering the distribution of patients according to the MTHFR A1298C gene mutation, a total of 38.3% (n=18) of the patients were heterozygous, 14.9% (n=7) were homozygous, and 46.9% (n=22) had no mutation. Upon analysis of the distribution of patients according to factor XIII mutation, it was identified that 19.1% (n=9) were heterozygous, 2.1% (n=1) were homozygous, and 78.7% (n=37) of the patients exhibited no mutation. Upon analysis of the distribution of patients according to prothrombin (Factor II) mutation, it was identified that 8.5% (n=4) were heterozygous, while 91.5% (n=43) exhibited no mutation. Conclusion: Although stroke is less prevalent in young adults, the underlying etiology is highly varied. Further research, including the investigation of genetic and prothrombotic mutations, is vital for the prevention of recurrent strokes in young adults.

Probability of Cardioembolic vs. Atherothrombotic Pathogenesis of Cryptogenic Strokes in Older Patients

Some clinical, laboratory, ECG, and echocardiographic parameters could provide useful indications to assess the probability of cardioembolism or atherothrombosis in cryptogenic strokes. We retrospectively examined 290 patients with ischemic stroke aged ≥60years, divided into 3 groups: strokes originating from large artery atherothrombosis (n=92), cardioembolic strokes caused by paroxysmal atrial fibrillation (n=88) and cryptogenic strokes (n=110). In addition to echocardiographic and routine clinical-laboratory variables, neutrophil:lymphocyte ratio, red blood cell distribution width, mean platelet volume, P wave and PR interval duration and biphasic inferior P waves, both on admission and after 7 to 10days, were also considered. By multiple logistic regression, cardioembolic strokes were compared with large artery atherothrombosis strokes, and beta coefficients were rounded to produce a scoring system. Late PR interval ≥188ms, left atrium ≥4cm, left ventricular end-diastolic volume <65ml, and posterior circulation syndrome were associated with paroxysmal atrial fibrillation (positive scores). In contrast, male gender, hypercholesterolemia, and initial platelet count ≥290×109/L were associated with atherothrombosis of large arteries (negative scores). The algebraic sum of these scores produced values indicative of cardioembolism if >0 (positive predictive value 89.1%), or of atherothrombosis, if ≤0 (positive predictive value 72.5%). The area under the receiver operating characteristic curve was 0.85. Among cryptogenic strokes, 41.5% had a score >0 (probable atrial fibrillation) and 58.5% had a score ≤0 (possible atherothrombosis). In conclusion, a scoring system based on electrocardiogram, laboratory, clinical and echocardiographic parameters can provide useful guidance for further investigations and secondary prevention in older patients with cryptogenic stroke.

Admission hyperglycemia, stroke subtypes, outcomes in acute ischemic stroke

AimsWhether admission hyperglycemia is differentially associated with early vascular outcomes in acute ischemic stroke (AIS) depending on stroke subtype has been incompletely delineated. MethodsIn a multicenter, prospective stroke registry, patients with AIS were categorized based on admission glucose levels into normoglycemia, moderate hyperglycemia, and severe hyperglycemia (<140mg/dl, 140–179mg/dl, and ≥180mg/dl, respectively) groups. Multivariate analysis assessed the interaction between the hyperglycemia and ischemic stroke subtypes of large artery atherothrombosis (LAA), cardioembolism (CE), and small vessel occlusion (SVO) and early vascular outcomes (3-month stroke, all-cause mortality, and composite of stroke, MI, and all-cause mortality). ResultsAmong the 32,772 patients (age:69.0±12.6yrs, male:58.4%) meeting eligibility criteria, 61.9% were in the normoglycemia group, 19.5% were in the moderate hyperglycemia group, and 18.7% were in the severe hyperglycemia group. Substantial interactions between hyperglycemia groups and stroke subtypes were observed for 3-month stroke (Pinteraction = 0.003) and composite of stroke, MI, and all-cause mortality (Pinteraction = 0.001), with differential recurrence strongest among CE, intermediate among LAA, and least among SVO. ConclusionsHyperglycemia was differently associated with the risk of 3-month stroke by ischemic stroke subtype. The associations of hyperglycemia with 3-month stroke were greatest in CE subtype but not in SVO subtype. These results suggest that the effect of glucose-lowering treatment after AIS may differ according to stroke subtype.

Abstract 85: Periodontal Disease Association With Large-Artery Atherothrombotic Stroke

Introduction: Periodontal disease (PD) is associated with incident and recurrent ischemic stroke. We investigated whether PD is associated with specific stroke subtype. Methods: In this cross-sectional study, PD was assessed in ischemic stroke and TIA patients. Moderate-severe PD was determined by full-mouth examination by a dentist. Clinical information including stroke etiological subtype (TOAST) was collected at admission. Based on vascular imaging, strokes caused by large-artery atherothrombosis were further analyzed to distinguish those caused by either intracranial atherosclerosis (ICAS) or extracranial atherosclerosis (ECAS). They were also classified as anterior or posterior circulation disease. Results: Consecutive patients (N=265) were enrolled (age 64 ± 12.8, 49% white, 46% black, 5% other and 56% male) between 2015-17. A third (N=87) were found to have PD. Twenty percent (N=42) of strokes were caused by large-artery atherothrombosis. In this group, there was a significantly higher proportion of patients with PD compared with those without PD (24% vs.12%, X 2 p=0.01). Patients with PD also had a significantly higher proportion (12% vs 5%) of stroke due to posterior circulation disease (crude OR 3.0, 95% CI 1.1-7.9, p=0.03), not anterior circulation disease (14% vs. 7%; crude OR 2.2, 95% CI 0.9-5.2, p=0.08). This association with posterior circulation disease persisted after adjustment for age, race, hypertension, diabetes, hyperlipidemia, smoking status, coronary artery disease, atrial fibrillation, and hemoglobin A1C (adjusted OR 3.1 95% CI 1.04-9.1, p=0.004). In addition, those with PD had a significantly higher rate of stroke due to ICAS compared to those without PD (20% vs. 8%; crude OR 2.6, 95% CI 1.3-5.6, p=0.01), while there was no significant difference between the groups for strokes due to ECAS (9% vs. 3%; crude OR 2.2, 95% CI 1.0-8.7, p=0.06). PD remained significantly associated with ICAS after adjustment for the same covariates (adjusted OR 2.6, 95% CI 1.1-5.8, p=0.004). Conclusion: We report a significantly higher proportion of stroke due to large-artery atherothrombosis in patients with PD compared to those without PD. We report an independent association between PD and ICAS, as well as posterior circulation disease.

P5351In-Flight Stroke in Korea

Abstract Background During flight, atmospheric pressure drop, low humidity and restricted motion occur. The environmental change can evoke the stroke occurrence. However, description of in-flight stroke case series has been limited until now. We investigated the clinical and flight trip characteristics of in-flight stroke cases in Korea. Method Since the opening of Incheon international airport, which is used by about 50 million people a year, in 2001, our hospital branch has been located at the airport and all the emergency stroke patients have been referred to our hospital. We performed retrospective review of the prospectively collected stroke registry and the information about the flight from January 2001 to December 2018. Results During the study period, 31 in-flight stroke cases were identified among total 1,452 ischemic stroke patients (17 men, 62±15 years old). Twenty-six patients had cerebral infarction, and four patients had transient ischemic attack. On etiological classification of cerebral infarction, 19 large artery atherothrombosis (61.3%), 1 septic embolism, 3 cryptogenic stroke, 3 cardioembolism (9.7%) and 1 cerebral venous thrombosis were identified. Six patients had Patent Foramen Ovale. Twenty-two patients reported to experience symptom around landing. Fourteen patients had flight for six hours or longer. Compared to the patients with long flight time (≥6 hrs), those with short flight time had the higher incidence of stroke occurrence around landings (32 vs 68%) and low incidence of unclear stroke onset. Poor outcome, defined as mRS 4 or higher, was associated with old age, unclear stroke onset, and early neurologic deterioration. Conclusion In-flight stroke is uncommon, and can easily be neglected during flight, which result in poor outcome. The stroke risk seems to be relatively high around landing, especially in the travelers with short flight time. The possibility of paradoxical embolism related to motion restriction seems low for stroke occurrence. Old age and unclear stroke onset are associated with poor outcomes.

Abstract TP204: Characteristics of in Flight Stroke in Korea

Background: During flight, low humidity, atmospheric pressure drop, and restricted motion occur. These environmental changes can precipitate the stroke occurence. However, description of in-flight stroke case series has been limited. We investigated the clinical characteristics of in-flight stroke cases in Korea. Method: Since the opening of Incheon international airport in 2001, which is used by about 50 million people a year, our hospital branch has been set up at the airport and all the emergency stroke patients have been referred to our hospital. We performed retrospective review of the prospectively collected stroke registry and the information about the flight from January 2001 to July 2018. Results: During the study period, 24 in-flight stroke cases were identified among total 9782 admitted ischemic stroke patients in our hospital (18 men, 58±12 years old): 22 cerebral infarction, and 2 TIA. One patient was diagnosed as cerebral venous thrombosis. On etiological classification, 15 large artery atherothrombosis, 1 septic embolism, 3 cryptogenic stroke, and 3 cardioembolism were identified. Thirteen patients reported to experience symptom during or immediately before (within 10 minutes) landing. Fifteen patients had flight for six hours or more. Compared to the patients with long flight time (≥6hrs), those with short flight time (&lt;6hrs) had the higher incidence of stroke occurrence around landings (24 vs 85%). Seven patients were found as unconscious state after landing. These patients all had long flight time over 6 hours, and showed very poor outcomes. Among them, mismatch between FLAIR and DWI was observed in five patients. PFO was detected in eight patients and deep vein thrombosis was not found in any patients. Seven patients with clear onset during landing could receive intravenous thrombolysis or mechanical thrombectomy. Conclusion: In-flight stroke is uncommon, and can easily be neglected during flight, which result in poor outcome. The stroke risk seems to be relatively high around landing, especially for the passengers with short flight time and the mechanism needs to be investigated. The possibility of paradoxical embolism related to motion restriction seems low for stroke occurrence.

Study on the risk factors for hemorrhagic transformation of the different subtypes of acute cerebral infarction in elderly patients

Objective To investigate the risk factors for hemorrhagic transformation(HT)of different subtypes of acute cerebral infarction in elderly patients. Methods A total of 415 elderly hospitalized patients aged ≥60 years with acute cerebral infarction were selected from a hospital in Changsha from January 2014 to December 2016 for the study.Among them, 56 had hemorrhagic transformation(observation group)and 359 had no hemorrhage transformation(control group). The general demographic information, past medical history, physical examination and laboratory indicators, cranial CT/MRI examination, admission treatment and the National Institutes of Health Stroke Scale(NIHSS)score on admission were analyzed and compared between two different subtypes.Multivariate Logistic regression was used to analyze the influencing factors for HT of different subtypes of acute cerebral infarction in elderly patients. Results The incidence of HT was 26.61%(29/109)for large-artery atherothrombosis, 47.50%(19/40)for cardiac embolism and 3.12%(8/257)for small-artery occlusion with a statistically significant differences among the three subtypes(χ2=77.923, P=0.000). The incidence of HT was 0%(0/7)for unknown type, and 0%(0/2)for other types.Multivariate logistic regression showed that female was the protective factor(OR=0.171, 95%CI: 0.037-0.790), but high level of glycated haemoglobin A1c(HbA1c)and large infarct size were the risk factors(OR=5.949 and 20.619, 95%CI: 1.199-29.509 and 2.869-148.207)for HT due to large-artery atherothrombosis.A high score of NIHSS and high level of matrix metalloproteinase-9(MMP-9)were the risk factors for HT due to cardioembolism(OR=20.254 and 91.200, 95%CI: 1.605-255.625 and 4.044-2056.710, respectively). A high level of homocysteine(Hcy)and large infarct size were the risk factors for HT due to small-artery occlusion(OR=10.231 and 15.251, 95%CI: 1.202-87.108 and 3.371-68.995, respectively). Conclusions The incidence of HT due to cardioembolism is the highest.Influencing factors for HT due to different subtypes of acute cerebral infarction are different in the elderly.It is important for clinicians to know that gender, HbA1c levels and infarct size are associated with HT due to large-artery atherothrombosis, NIHSS score on admission and MMP-9 concentration associated with HT due to cardioembolism, and Hcy level and infarct size associated with HT due to small-artery occlusion. Key words: Brain infarction; Cerebral hemorrhage; Factor analysis, statistical

Epidemiology of Stroke in Costa Rica: A 7-Year Hospital-Based Acute Stroke Registry of 1319 Consecutive Patients

Limited data on stroke exist for Costa Rica. Therefore, we created a stroke registry out of patients with stroke seen in the Acute Stroke Unit of the Hospital Calderon Guardia. We analyzed 1319 patients enrolled over a 7-year period, which incorporated demographic, clinical, laboratory, and neuroimaging data. The mean age of patients with stroke was 68.0 ± 15.5 years. Seven hundred twenty-five were men and the age range was 13-104 years. The most prevalent risk factors were hypertension (78.8%), dyslipidemia (36.3%), and diabetes (31.9%). Fifteen percent had atrial fibrillation and 24.7% had a previous stroke or transient ischemic attack. Prevalence of hypertension and atrial fibrillation increased with age; however, younger patients were more associated with thrombophilia. We documented 962 (72.9%) ischemic and 270 (20.5%) hemorrhagic strokes. Of the ischemic strokes, 174 (18.1%) were considered secondary to large-artery atherothrombosis, 175 (18.2%) were due to cardiac embolism, 19 (2.0%) were due to lacunar infarcts, and 25 (2.6%) were due to other determined causes. Five hundred sixty-nine (59.1%) remained undetermined. Atherothrombotic strokes were mostly associated with dyslipidemia, diabetes, metabolic syndrome, and obesity, whereas lacunar infarcts were associated with hypertension, smoking, sedentary lifestyle, and previous stroke or transient ischemic attack. Of our patients, 69.9% scored between 0 and 9 in the initial National Institutes of Health Stroke Scale (NIHSS). We found differences in sociodemographic features, risk factors, and stroke severity among stroke subtypes. Risk factor prevalence was similar to other registries involving Hispanic populations.

Sex differences in long-term outcomes among acute ischemic stroke patients with diabetes in China.

BackgroundDiabetes has been shown to be significantly associated with poor outcome after stroke. However, the sex differences in stroke outcome among patients with diabetes are unknown. Therefore, we aimed to assess the sex differences in long-term prognosis among acute ischemic stroke patients with diabetes.MethodsThe ischemic stroke patients with diabetes were recruited to this study between May 2005 and September 2014 in Tianjin, China. Sex differences in mortality, dependency (modified rank scale > 2), and recurrence at 3, 12, and 36 months after stroke were analyzed.ResultsA total of 2360 patients were recruited in this study. The age of stroke onset, National Institute of Health stroke scale (NIHSS), and modified rank scale (mRS) on admission were greater in women than in men (P < 0.05). Women were more likely to have hypertension, obesity, atrial fibrillation, and dyslipidemias. In contrast, men were more likely to have artery stenosis, current smoking, and alcohol consumption (P < 0.001). There was higher mortality in women than in men at 3 months (7.9 % vs 5.2 %), 12 months (12.2 % vs 8.2 %), and 36 months (21.9 % vs 16.1 %) after stroke; but no differences were found in dependency and recurrence. Sex differences were found in associated factors of outcomes by time-point. Trial of Org 10172 in Acute Stroke Treatment (TOAST) of large artery atherothrombosis (LAA), cardioembolism (CE), and smoking were risk factors of outcomes in women at short term and medium term; but atrial fibrillation (AF), obesity, and alcohol were risk factors of outcomes in men at medium term and long term.ConclusionsThese findings suggest that it is crucial to establish the individual scheme of therapy for every patient by different risk factors of stroke, strengthen the rehabilitation of stroke, and carry on the health education early for the secondary prevention of stroke in patients with diabetes mellitus (DM).

One-year follow-up in patients with brainstem infarction due to large-artery atherothrombosis.

BackgroundPosterior circulation infarction accounts for approximately 25% of the ischemic strokes. A number of different conditions may be associated with the development of brainstem infarction. Prognosis and recurrence rate of brainstem infarction due to large-artery atherothrombosis is still controversial.MethodsA total of 826 patients with ischemic stroke were admitted to our clinic during a 15-month period. Patients with clinical and radiological evidence of brainstem infarction were comprehensively assessed with appropriate vascular imaging modalities and for cardiological causes. Subjects with an established diagnosis of large-artery atherothrombosis were followed up for 1 year in terms of prognosis and recurrence rates.ResultsOf the 101 patients with an established brainstem infarction, the diagnostic work-up indicated the presence of large-artery atherothrombosis as the causative factor in 53. A recurrent stroke was detected in the posterior circulation within the first 3 months in 5.8% and within 1 year in 9.8% of these individuals. The 1-year mortality rate was 11.7%. All patients with recurrent stroke had intracranial vascular narrowing at baseline.ConclusionOur findings demonstrate a particularly high rate of recurrence and mortality at 1 year among patients who have a brainstem infarction due to intracranial arterial stenosis.

Abstract W P120: Effect of Prior Aspirin Use on Initial Stroke Severity and Hemorrhagic Transformation

Background and Purpose: The effect of prior aspirin use on the severity and safety of index ischemic stroke have not been well investigated. We studied the effect of prior aspirin use on initial stroke severity and also on the hemorrhagic transformation in initial MRI. Methods: Using a prospective multicenter stroke registry, patients who were hospitalized due to ischemic stroke and had relevant lesions on MRI were selected. Patients who were on anticoagulants or whose stroke subtype was categorized as stroke of other determined etiology or undetermined etiology were excluded. Baseline stroke severity was measured using the NIHSS scores at presentation, and was compared between no prior aspirin (non-PA) users and prior aspirin (PA) users with stratification by stroke subtypes. Prevalence of the hemorrhagic transformation in initial GRE-MRI was also compared between those two groups. Results: Among the 11,183 patients, a total of 2,664 (23.2%) patients reported use of an aspirin within a week of stroke onset. In crude analysis, the overall baseline NIHSS score was lower in non-PA group than PA group (5.69 vs. 6.08, P=0.005). The interaction between prior aspirin use and stroke subtype was significant (P = 0.031) in a multivariable analysis. When the study subjects were stratified by stroke subtype, the baseline NIHSS in PA groups was significantly lower in large artery atherothrombosis group (5.77 vs. 5.21, P=0.001), but not in those with cardioembolism as well as small-vessel occlusion before and after adjustments. Hemorrhagic transformation in initial GRE-MRI was more frequently observed in PA groups (4.3% vs. 7.6%, P&lt;0.001) irrespective of stroke subtypes. Conclusions: Our study suggests that the reduction of initial stroke severity in the prior aspirin users may differ by stroke mechanism, which was only significant in patients with large artery atherothrombotic stroke.

Types of Stroke Recurrence in Patients with Ischemic Stroke: A Substudy from the PRoFESS Trial

Risk profiles for stroke recurrence are poorly characterized. We determined the variation in the risk and type of recurrent stroke among index ischemic stroke subtypes, and whether index stroke subtype and conventional stroke risk factors were predictors of stroke recurrence. Patients enrolled in the Prevention Regimen for Effectively Avoiding Second Strokes trial were included in this study. In 1794 patients' recurrent stroke subtypes were the same as the index stroke in: 48·3% of patients with large artery atherothrombosis stroke; 50% of patients with cardioembolic stroke; 48·7% of patients with small artery occlusion stroke; 8·1% of patients with stroke of other etiology, and 45·3% of patients with undetermined etiology stroke. Patients with cardioembolic stroke, who were unwilling or unable to take oral anticoagulants, had the greatest risk of stroke recurrence. Predictors of stroke recurrence in multivariable analysis were: older age and previous stroke among large artery atherothrombosis strokes; older age, male sex, previous stroke, previous transient ischemic attack, hypertension, diabetes, and tobacco use among small artery occlusion strokes; older age among cardioembolic strokes; atrial fibrillation and anti-diabetic medications among other etiology strokes; older age, previous stroke and atrial fibrillation among undetermined etiology strokes. Predictors of brain hemorrhage as recurrent stroke were index small artery occlusion stroke, older age, previous stroke, and antiplatelet treatment with aspirin plus extended-release dipyridamole. Risk predictors for stroke recurrence and for brain hemorrhage differ by index ischemic stroke subtype, information that is important when initiating secondary prevention therapy.

Factors associated with use of emergency medical services in patients with acute stroke

PurposesThe aim of this study was to investigate the factors associated with use of emergency medical services (EMS) in patients with acute stroke. MethodsProspective data on consecutive patients with acute stroke who presented to the emergency department of a university medical center from January 1, 2010, to July 31, 2011, were analyzed. Patients were excluded if they had an unknown residence, had onset of stroke at a nursing home or hospital, or were transferred from another hospital. Variables for all patients with stroke and ischemic stroke who did and did not use EMS were compared. ResultsIn total, 1344 patients (60% male; mean age, 68.7 years) were included. Use of EMS (n = 409; 30.4%) was significantly associated with a higher level of education (≧6 years vs <6 years; odds ratio [OR], 1.69; 95% confidence interval [CI], 1.25-2.29), a higher National Institutes of Health Stroke Scale score (OR, 1.08; 95% CI, 1.05-1.11), altered consciousness (OR, 1.88; 95% CI, 1.25-2.84), and atrial fibrillation (OR, 2.43; 95% CI, 1.71-3.44) after adjustment. For patients with ischemic stroke, use of EMS was significantly higher in cases of cardioembolism (OR, 3.04; 95% CI, 1.40-6.60) and large artery atherothrombosis (OR, 2.10; 95% CI, 1.22-3.62) than lacunar infarction. ConclusionPatients with stroke who have altered consciousness, a higher level of education, a higher National Institutes of Health Stroke Scale score, atrial fibrillation, and cardioembolic stroke were more likely to use EMS.

Efficacy of Cilostazol in Preventing Aspiration Pneumonia in Acute Cerebral Infarction

This retrospective study examined the effectiveness of cilostazol in preventing aspiration pneumonia in patients with acute cerebral infarction. The 189 subjects ranged in age from 31 to 95 years and included 57 with small-artery occlusion, 107 with large-artery atherothrombosis, and 25 with other disorders. Patients with cardiogenic cerebral embolism or preexisting pneumonia at the time of hospital admission were excluded from the analysis. Neurologic symptoms, cognitive function, and swallowing function were assessed at the first clinical examination, and the ability to perform activities of daily living was assessed at both hospital admission and discharge. Outcome and food intake status were also assessed at hospital discharge. Pneumonia was detected in 27 of 189 subjects (14.3%), in 20 subjects during nasogastric tube feeding implemented because of oral intake difficulties (fasting group) and in 7 subjects after initiation of oral feeding (oral intake group). Cilostazol was administered to 48 of the 189 subjects (25.4%). The incidence of pneumonia was 6.3% (3 of 48) in patients who received cilostazol, compared with 17% (24 of 141) in those who did not receive cilostazol. Our data suggest that cilostazol appears to prevent the occurrence of pneumonia in both the chronic and acute stages of cerebral infarction.

Clinical Features and Functional Outcome of Stroke After Transient Ischemic Attack

Transient ischemic attacks (TIAs) greatly increase the risk of stroke, but few reports have examined subsequent stroke in patients with history of TIA. This retrospective, hospital-based study included 506 consecutive patients with acute ischemic stroke who were admitted to our hospital. The clinical features and prognosis were compared between patients with and without TIA. Multiple logistic regression analysis was also performed to identify predictors for poor outcome. Of 506 patients, 114 (22.5%) had a history of TIA. Compared to patients without previous TIAs (non-TIA group), patients with previous TIAs (TIA group) were significantly more likely to have hypertension (76.3% vs 64.3%; P = .016), dyslipidemia (57.0% vs 41.1%; P = .003), chronic kidney disease (28.1% v 15.1%; P = .001), intracranial major artery stenosis (51.8% vs 36.2%; P = .018), and large artery atherothrombosis (43.9% vs 28.3%; P = .002). There was no difference in the previous use of antithrombotic medications between the groups (36.0% vs 35.2%; P = .881). Although stroke severity on admission was similar, poor functional outcome (modified Rankin Scale score ≥4) was significantly more frequent in the TIA group, and history of TIA was an independent determinant of unfavorable outcome on multiple logistic regression analysis (odds ratio 1.46; 95% confidence interval 1.02-2.10; P = .041). Atherothrombotic stroke with concomitant vascular risk factors were more frequent in the stroke patients with than without previous TIA. Antithrombotic therapy was conducted only in one-third of the patients even after TIA. The stroke patients with history of TIA were at great risk of disabling stroke.

Combined diffusion- and perfusion-weighted imaging: a new way for the assessment of hemispheric transient ischemic attack patients

Abnormalities in diffusion-weighted and perfusion-weighted magnetic resonance images not only occur in stroke patients but also in transient ischemic attack patients. We found magnetic resonance images were abnormal in 28 patients (68%): 15 had diffusion-weighted imaging abnormalities, 7 had both diffusion-weighted imaging and perfusion-weighted imaging defects and 6 had an isolated perfusion-weighted imaging abnormality. Patients with shorter onset to magnetic resonance imaging, large artery atherothrombosis, coronary artery disease, hyperlipidemia and hemiparesis were more likely to show perfusion-weighted imaging abnormalities. Compared with patients who had a good prognosis, in poor prognosis patients, the relative cerebral blood flow and relative cerebral blood volume was significantly higher. The data suggest that transient ischemic attack patients are more likely to have a poor prognosis when white matter of the symptomatic side shows hyperperfusion within 24h of symptom onset; however, patients are more likely to have a good prognosis when white matter of the symptomatic side shows hypoperfusion.

Differential Effect of Previous Antiplatelet Use on Stroke Severity According to Stroke Mechanism

The effect of previous antiplatelet use on stroke severity is controversial. We assume that this controversy is attributable to its difference according to the stroke mechanism. Using a prospective stroke registry, patients who were hospitalized because of ischemic stroke and had relevant lesions on MRI were selected. Patients who were using anticoagulants or whose stroke subtype was categorized as stroke of other determined etiology or undetermined etiology were excluded. Baseline stroke severity was measured using the National Institutes of Health Stroke Scale scores at presentation and was compared between no previous antiplatelet users and previous antiplatelet users with stratification by stroke subtypes. Among the 1622 patients, a total of 490 (30.2%) patients reported use of an antiplatelet within 1 week of stroke onset. The baseline National Institutes of Health Stroke Scale score showed no difference between the nonantiplatelet and antiplatelet groups by crude comparison. However, the interaction between previous antiplatelet use and stroke subtype was significant (P=0.023) in a multivariable analysis; when the study subjects were stratified by stroke subtype, the difference in baseline National Institutes of Health Stroke Scale between the nonantiplatelet and platelet groups was significant in the large artery atherothrombosis group but not in those with cardioembolism and small-vessel occlusion before and after adjustments. Our study suggests that the reduction of initial stroke severity in the previous antiplatelet users may differ by stroke mechanism.

Low Levels of Low-Density Lipoprotein Cholesterol Increase Hemorrhagic Transformation but Not Parenchimal Hematoma in Large Artery Atherothrombosisis

To the Editor: We read with interest the article by Kim and colleagues1 reporting on the effect of low level of total cholesterol and low low-density lipoprotein cholesterol (LDLC) on hemorrhagic transformation (HT) after acute ischemic stroke. The authors found that low levels of LDLC are independently associated with the risk of HT after acute ischemic stroke attributable to large artery atherothrombosis (LAA) but not to cardioembolism (CE). The authors commented on the results saying that they should be interpreted with caution in consideration of several points: …

Low Level of Low-Density Lipoprotein Cholesterol Increases Hemorrhagic Transformation in Large Artery Atherothrombosis but Not in Cardioembolism

Low cholesterol level is known to be associated with increased cerebral hemorrhage. However, the associations of hemorrhagic transformation (HTf) after acute ischemic stroke and the low levels of total cholesterol (TC) or low-density lipoprotein cholesterol (LDLC) are largely undiscovered. Of the 1034 patients with acute ischemic stroke who were consecutively admitted to our hospital, 377 patients with stroke attributable to large artery atherothrombosis (LAA; n=210) or cardioembolism (n=167) were selected for this study. Demographic and clinical information was collected and HTf was evaluated through follow-up T2*-weighted gradient-echo MRI performed usually within 1 week after stroke. Measurement of lipid parameters included TC, LDLC, high-density lipoprotein cholesterol, and triglyceride. Of the 377 patients, HTf was noted in 74 patients (19.6%). When patients were divided into 4 groups according to their TC and LDLC levels, the incidence of HTf was significantly elevated in the lowest quartile of each TC (P<0.01) and LDLC (P<0.01) level in LAA subgroup, but not in cardioembolism. After adjusting covariates, a low level of LDLC (OR, 0.46 per 1 mmol/L-increase; 95% CI, 0.22-0.98) was independently associated with HTf in LAA, but not in cardioembolism. There was no significant association between low levels of TC (OR, 0.63 per 1 mmol/L-increase; 95% CI, 0.35-1.15) and HTf in LAA. Low levels of LDLC, and possibly TC, are associated with greater risk of hemorrhagic transformation after acute ischemic stroke attributable to LAA.

Does microbleed predict haemorrhagic transformation after acute atherothrombotic or cardioembolic stroke?

Objectives: Cerebral microbleeds (MBs) are known to be indicative of bleeding-prone microangiopathy and may predict incident intracerebral haemorrhage. However, there is controversy concerning the causal relationship between the presence of...