Large Artery Disease Research Articles

Th17/Treg Imbalance and Atherosclerosis.

Atherosclerosis is nowadays recognized as a chronic inflammatory disease of large arteries. In recent years, cellular and molecular biology studies on atherosclerosis confirmed that the occurrence and development are related to inflammation and autoimmunity. A variety of immune cells, cytokines, and transcription factors are involved in this process. Current studies found that T helper cell 17, regulatory T cells, and their cytokines play an important role in the development of atherosclerosis and vulnerable plaque rupture. Here, we provide a review of the up-to-date applications of T helper cell 17, regulatory T cells, cytokines, and their balance in the prognosis and therapy of atherosclerosis.

Etiological Subtypes of Transient Ischemic Attack and Ischemic Stroke in Chronic Kidney Disease: Population-Based Study.

Chronic kidney disease (CKD) is strongly associated with stroke risk, but the mechanisms underlying this association are unclear and might be informed by subtype-specific analyses. However, few studies have reported stroke subtypes in CKD according to established classification systems, such as the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria. We, therefore, aimed to determine which transient ischemic attack and ischemic stroke subtypes using the TOAST classification occur most frequently in patients with CKD. In a population-based study of all transient ischemic attack and stroke (OXVASC [Oxford Vascular Study]; 2002-2017), all ischemic events were classified by TOAST subtypes (cardioembolism, large artery disease, small vessel disease, undetermined, multiple, other etiology, or incompletely investigated). Logistic regression was used to determine the relationship between CKD (defined as an estimated glomerular filtration rate <60 mL/min per 1.73 m2) and transient ischemic attack/stroke subtypes adjusted for age, sex, and hypertension and then stratified by age and estimated glomerular filtration rate category. Among 3178 patients with transient ischemic attack (n=1167), ischemic stroke (n=1802), and intracerebral hemorrhage (n=209), 1267 (40%) had CKD. Although there was a greater prevalence of cardioembolic events (31.8% versus 21.2%; P<0.001) in patients with CKD, this association was lost after adjustment for age, sex, and hypertension (adjusted odds ratio=1.20 [95% CI, 0.99-1.45]; P=0.07). Similarly, although patients with CKD had a lower prevalence of small vessel disease (8.8% versus 13.6%; P<0.001), undetermined (26.1% versus 39.4%; P<0.001), and other etiology (1.0% versus 3.6%; P<0.001) subtypes, these associations were also lost after adjustment (adjusted odds ratio=0.86 [0.65-1.13]; P=0.27 and 0.73 [0.36-1.43]; P=0.37 for small vessel disease and other defined etiology, respectively) for all but undetermined (adjusted odds ratio=0.81 [0.67-0.98]; P=0.03). There were no independent positive associations between CKD and specific TOAST subtypes, which suggest that renal-specific risk factors are unlikely to play an important role in the etiology of particular subtypes. Future studies of stroke and CKD should report subtype-specific analyses to gain further insights into potential mechanisms.

Post-stroke Cognitive Impairment-Impact of Follow-Up Time and Stroke Subtype on Severity and Cognitive Profile: The Nor-COAST Study.

Background: Post-stroke cognitive impairment (PSCI) is common, but evidence of cognitive symptom profiles, course over time, and pathogenesis is scarce. We investigated the significance of time and etiologic stroke subtype for the probability of PSCI, severity, and cognitive profile.Methods: Stroke survivors (n = 617) underwent cognitive assessments of attention, executive function, memory, language, perceptual-motor function, and the Montreal Cognitive Assessment (MoCA) after 3 and/or 18 months. PSCI was classified according to DSM-5 criteria. Stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS). Stroke subtype was categorized as intracerebral hemorrhage (ICH), large artery disease (LAD), cardioembolic stroke (CE), small vessel disease (SVD), or un-/other determined strokes (UD). Mixed-effects logistic or linear regression was applied with PSCI, MoCA, and z-scores of the cognitive domains as dependent variables. Independent variables were time as well as stroke subtype, time, and interaction between these. The analyses were adjusted for age, education, and sex. The effects of time and stroke subtype were analyzed by likelihood ratio tests (LR).Results: Mean age was 72 years (SD 12), 42% were females, and mean NIHSS score at admittance was 3.8 (SD 4.8). Probability (95% CI) for PSCI after 3 and 18 months was 0.59 (0.51–0.66) and 0.51 (0.52–0.60), respectively and remained constant over time. Global measures and most cognitive domains were assessed as impaired for the entire stroke population and for most stroke subtypes. Executive function and language improved for the entire stroke population (LR) = 9.05, p = 0.003, and LR = 10.38, p = 0.001, respectively). After dividing the sample according to stroke subtypes, language improved for ICH patients (LR = 18.02, p = 0.003). No significant differences were found in the severity of impairment between stroke subtypes except for attention, which was impaired for LAD and CE in contrast to no impairment for SVD (LR = 56.58, p < 0.001).Conclusions: In this study including mainly minor strokes, PSCI is common for all subtypes, both early and long-term after stroke, while executive function and language improve over time. The findings might contribute to personalizing follow-up and offer new insights into underlying mechanisms. Further research is needed on underlying mechanisms, PSCI prevention and treatment, and relevance for rehabilitation.

Luminal and Wall Changes in Intracranial Arterial Lesions for Predicting Stroke Occurrence.

Luminal imaging (degree of stenosis) currently serves as the gold standard to predict stroke recurrence and guide therapeutic strategies in patients with intracranial large artery diseases (ILADs). We comparatively evaluated the importance of vessel wall and luminal changes in predicting stroke occurrence. Consecutive patients with ILAD in the proximal middle cerebral artery or distal internal carotid artery without proximal sources of embolism from the carotid and heart underwent time-of-flight magnetic resonance angiography, high-resolution magnetic resonance imaging, and the ring finger protein 213 (RNF213) gene variant test. Patients were followed up for >3 months. Of the 675 patients, 241 (35.7%) had atherosclerotic ILAD and 434 (64.3%) showed nonatherosclerotic ILAD (315 [46.7%] moyamoya disease cases and 119 [17.6%] dissection cases). The RNF213 variant was detected in 74.9%, 33.6%, and 3.4% patients with moyamoya disease, atherosclerosis, and dissection, respectively. Three hundred (44.4%) patients had asymptomatic ILAD, whereas 375 (55.6%) patients had symptomatic ILAD. Multivariate analysis showed that vessel enhancement and etiological subtypes, not degree of stenosis, determined by high-resolution magnetic resonance imaging and RNF213 gene variant analysis were independently associated with symptomatic ILAD. The presence of the RNF213 variant was also independently associated with recurrent cerebrovascular events. This study demonstrates the prevalence of nonatherosclerotic ILAD in East Asian patients with ILAD. Unlike luminal changes, wall changes determined by high-resolution magnetic resonance imaging and presence of the RNF213 variant could predict stroke occurrence in patients with ILADs.

Characterization of the inflammatory-metabolic phenotype of heart failure with a preserved ejection fraction: a hypothesis to explain influence of sex on the evolution and potential treatment of the disease.

Accumulating evidence points to the existence of an inflammatory‐metabolic phenotype of heart failure with a preserved ejection fraction (HFpEF), which is characterized by biomarkers of inflammation, an expanded epicardial adipose tissue mass, microvascular endothelial dysfunction, normal‐to‐mildly increased left ventricular volumes and systolic blood pressures, and possibly, altered activity of adipocyte‐associated inflammatory mediators. A broad range of adipogenic metabolic and systemic inflammatory disorders – e.g. obesity, diabetes and metabolic syndrome as well as rheumatoid arthritis and psoriasis – can cause this phenotype, independent of the presence of large vessel coronary artery disease. Interestingly, when compared with men, women are both at greater risk of and may suffer greater cardiac consequences from these systemic inflammatory and metabolic disorders. Women show disproportionate increases in left ventricular filling pressures following increases in central blood volume and have greater arterial stiffness than men. Additionally, they are particularly predisposed to epicardial and intramyocardial fat expansion and imbalances in adipocyte‐associated proinflammatory mediators. The hormonal interrelationships seen in inflammatory‐metabolic phenotype may explain why mineralocorticoid receptor antagonists and neprilysin inhibitors may be more effective in women than in men with HFpEF. Recognition of the inflammatory‐metabolic phenotype may improve an understanding of the pathogenesis of HFpEF and enhance the ability to design clinical trials of interventions in this heterogeneous syndrome.

Arterial Stiffness is Associated with Intracranial Arterial Stenosis other than Dolichoectasia in the General Population.

Aims: The relationship between central arterial stiffness and aging-related intracranial arteriopathy is not well investigated in the general population. In a population-based study, we investigated arterial stiffness in relation to intracranial atherosclerotic stenosis and intracranial arterial dolichoectasia.Methods: This study was a cross-sectional analysis on 1,123 subjects (aged 56.0 ± 9.3 years, 37.9% men) of the population-based Shunyi study in China. Arterial stiffness was assessed by measuring brachial-ankle pulse wave velocity (baPWV). Intracranial atherosclerotic stenosis and intracranial arterial dolichoectasia were evaluated via brain magnetic resonance angiography. Multivariate regression models were constructed to investigate the association between baPWV and intracranial large artery diseases.Results: Increased baPWV was significantly associated with higher prevalence of intracranial atherosclerotic stenosis (odds ratio for the highest quartile of baPWV compared with the lowest quartile, 3.66 [95% confidence interval, 1.57–8.54]), after adjustment for cardiovascular risk factors in multivariate analysis. BaPWV was not associated with the presence of basilar artery dolichoectasia and dilation of basilar artery and internal carotid artery. When the diameters of intracranial arteries were regarded as continuous variables, increased baPWV was inversely related to the internal carotid artery diameter in fully adjusted models (β ± SE, −0.083 ± 0.042, p = 0.047).Conclusions: This population-based study demonstrates that arterial stiffness was more likely associated with intracranial stenotic arteriopathy other than intracranial dilative arteriopathy.

Mean platelet volume and mechanical thrombectomy

Background and purposeMean Platelet Volume (MPV) is a marker of platelet activity and it is an independent predictor for long-term outcome in stroke patients. The aim of this study was to evaluate the association between baseline MPV value and clinical outcome at 90-days in anterior circulation stroke and large vessel occlusion (LVO) patients submitted to mechanical thrombectomy (MT). MethodsWe conducted a prospective observational cohort study in acute ischemic stroke (AIS) patients submitted to MT between January 2017 and May 2018. MPV was measured at admission. Patients were initially stratified into two groups according to the mean MPV level. We also compared groups that were stratified according to the MPV cut-off obtained by Peng F et al (10,4 fL) and performed analyses among MPV terciles. ResultsA total of 129 patients were included. Mean level of MPV was 10,9 fL. Patients with embolic stroke of undetermined source (ESUS) had significantly higher rates of good outcome at 3 months compared with large-artery atherosclerotic disease and cardioembolism [(82,9%) vs (78,3%) vs (55,2%); p=0,009]. There were no statistically significant differences in the mean MPV value (p=0,222), successful recanalization (p=0,464) and mortality (p=0,343) when evaluated for all TOAST etiologies. There were no statistically significant differences between the two groups according to the MPV level (10,4 and 10,9 fL) or between the terciles (lowest tertile <10,3 fL, median 10,3 – 11,3 fL, highest >11,3fL) concerning functional outcome at 3 months (p=0,357; p=0,24 and p=0,558, respectively), successful recanalization (p=0,108; p=0,582 and p=0,899, respectively) or mortality at 3 months (p=0,465; p=0,061 and p=0,484, respectively). ConclusionOur study did not find an association between elevated MPV and worse outcome at 3 months in patients with acute anterior circulation stroke and LVO treated with MT. Since ischemic strokes have different pathophysiologic mechanisms, MPV may have distinct prognostic value according to each stroke etiology.

Coronary artery bypass surgery independently associates with retinal vascular oxygen saturation.

The retinal vasculature is the only part of the microcirculation that can be directly studied by non-invasive imaging. Based on the hypothesis that the systemic circulation is reflected in retinal vessels, we investigated if coronary artery bypass grafting (CABG) is related to changes in retinal vascular oxygen saturation (rSatO2 ). Retinal metabolism was evaluated by Oxymap T1, which simultaneously captures two retinal images at different wavelengths measuring the retinal arteriolar (raSatO2 ) and venular (rvSatO2 ) oxygen saturation. Three to 4days after surgery, we measured the median rSatO2 after CABG in 38 patients and in 39 healthy controls (operated for cataract). Coronary artery bypass grafting patients had higher raSatO2 (median±standard deviation 93.1±6.7% versus 90.5±11.2%, p=0.001) and rvSatO2 (57.4±8.3% versus 53.5±15.4%, p=0.048) compared to healthy controls. In multivariable linear regression models, raSatO2 independently associated with CABG (coefficient+3.6% in CABG patients, p=0.007), and rvSatO2 correlated with gender (coefficient+9.4% for females, p=0.001) and CABG (coefficient+8.2% in patients with CABG, p=0.001). Comparing patients with and without cardiovascular disease, raSatO2 and rvSatO2 positively and independently associated with CABG, suggesting their potential as non-invasive markers for coronary large artery disease.

Abstract TP416: Comparative Effectiveness of Addition of Antiplatelet to Oral Anticoagulant in Acute Ischemic Stroke With Atrial Fibrillation

Introduction: Atrial fibrillation (AF) and large artery diseases (LAD) share several risk factors and often coexist in the same patient. Optimal treatments for acute ischemic stroke (AIS) patients with concomitant AF and LAD have not been extensively studied so far. Objective: This study aimed to compare the effectiveness of the addition of antiplatelet (AP) to oral anticoagulant (OAC) with that of OAC alone in AIS with AF according to the LAD. Methods: Using a multicenter stroke registry, acute (within 48h of onset) and mild-to-moderate (NIHSS score ≤15) stroke patients with AF were identified. Propensity scores using IPTW were used to adjust baseline imbalances between the OAC+AP group and the OAC alone group in all patients and in each subgroup by LAD. The primary outcome was major vascular events, defined as the composite of recurrent stroke, MI, and all-cause mortality at up to 3 months after index stroke. Results: Among the 5469 patients (age, 72±10yrs; male, 54.9%; initial NIHSS score, 4 [2-9]), 79.0% (n=4323) received OAC alone, and 21.0% (n=1146) received OAC+AP. By weighted Cox proportional hazards analysis, a tendency of increasing the risk of 3-months primary composite events in the OAC+AP group vs the OAC alone (HR 1.36 [0.99-1.87], p=0.06), with significant interaction with treatments and LAD (Pint=0.048). Briefly, among patients with moderate-to-severe large artery stenosis, tendency of decrease in 3-months primary composite events of the OAC+AP group, compared with OAC alone group, was observed (HR 0.54 [0.17-1.70]), whereas among patients with complete occlusion, the OAC+AP group markedly increased the risk of 3-months composite events (HR 2.00 [1.27-3.15]), compared with the OAC alone group. No interaction between direct oral anticoagulant and warfarin on outcome was observed (Pint=0.35). Conclusion: In conclusion, treatment with addition of AP to OAC had a tendency to increase the risk of 3-months vascular events, compared with OAC alone in AIS with AF. However, the effects of antithrombotic treatment could be modified according to the LAD, with substantial benefits of OAC alone in subgroup of large artery occlusion. Our results address the need for the further study to tailor the optimal treatment in AIS with concomitant AF and LAD.

Abstract WP223: Evolution of Ischemic Stroke Subtypes: An Observational Study Over 15 Years

Introduction: In the face of population ageing and contemporary cardiovascular risk factor control, understanding the evolution of ischemic stroke mechanisms may inform stroke prevention strategy and guide resources allocation. Method: Through a registry-based observational study in a regional hospital in Hong Kong, we studied the evolution of stroke mechanisms by TOAST classification over a 15-year period (2004-2018). We retrieved demographic data, pre-defined cardiovascular risks, use of medications, intensity of risk factor control and clinical outcomes (2-year recurrence and 3-month mortality and disability) from the stroke registry. We defined stroke mechanisms by clinical signs and symptoms, cardiovascular risk profile and infarct topography. We compared the trends of stroke mechanisms by Chi-square test for trend and continuous variables by one-way ANOVA test with post-hoc Bonferroni test. Interobserver reliability was assessed by kappa statistics. Results: We included 5982 patients over the 15-year period. The number of atrial fibrillation (AF)-related stroke increased by 213% (p&lt;0.001) and large-artery-disease (LAD)-related stroke decreased by 47.7% (p&lt;0.001). AF-related stroke had the highest mean age (77.4±11, p&lt;0.001) and National Institute of Health Stroke Scale on admission (14.8±10.8, p&lt;0.001). Within the AF-related stroke patients, the number of strokes as first presentation of AF increased by 200%. 2-year recurrence of stroke or transient ischemic attack of patients with symptomatic intracranial atherosclerosis (ICAS) decreased from 20.7% to 9.3%. Conclusion: We observed a huge increase in AF-related stroke and newly diagnosed AF at presentation. Our results demanded an enhanced surveillance in detecting AF, primary prevention and thrombectomy facilities given the high morbidity and mortality associated with AF-related strokes. The decline in ICAS-related stroke and its recurrence may underscore the importance of intensive risk factor management in the Asia-Pacific region where ICAS remained prevalent.

Abstract WMP63: The Yield of Inpatient Cardiac Telemetry in Ischemic Stroke Patients With Ipsilateral Large Artery Stenosis

Introduction: The detection of atrial fibrillation (AF) is a crucial component of ischemic stroke secondary prevention. Inpatient cardiac telemetry is part of the structured inpatient workup for ischemic stroke but the yield of telemetry is unknown when ipsilateral, hemodynamically-significant large artery atherosclerosis is identified at the time of initial presentation. Methods: We performed a single-center, retrospective, cohort study utilizing data from an institutional quality improvement database. We identified consecutive patients with acute ischemic stroke presenting between July 2015 and September 2017. We included patients with hemodynamically-significant (&gt;50%) large artery stenosis in the arterial territory subserving the region of infarct. We excluded patients with a known history of AF. We determined the yield of an electrocardiogram, inpatient telemetry and outpatient cardiac event monitoring in detecting new AF. Groups with and without AF were compared using unpaired student’s T-test for continuous variables and Chi 2 test for categorical variables. Results: We identified 1435 patients presenting to our institution during the study period of whom 209 (14.6%) met inclusion criteria. Patients were aged 69.37±12.6 years and 33% were female. Of these patients, 19 (9.1%) were found to have new AF during their hospitalization and a further 2 (1%) were found to have AF on extended cardiac monitoring. Thirty seven patients had 30-day cardiac monitoring performed after hospitalization and the yield on this was 5.4% for the detection of AF. Patients with AF were older (76.29±11.31 years vs. 68.60±12.58 years, p=0.008) and had higher rates of hypertension (94% vs. 75%, p=0.04) and hyperlipidemia (72% vs. 52%, p=0.09). In all patients, anticoagulation was planned after the discovery of AF. Discussion: Inpatient cardiac telemetry detects new atrial fibrillation in 9.1% of patients known to have hemodynamically-significant large artery disease at the time of initial presentation. The yield of further outpatient cardiac monitoring is lower (5%). This hypothesis-generating study is limited by its retrospective nature and the potential for selection bias.

Abstract WP270: Etiopathologies of Symptomatic and Asymptomatic Intracranial Large Arterial Disease: The Results of HR-MRI and Genetic Studies

Introduction: Intracranial large arterial disease (ILAD) is common, especially in Asians. We compared clinical, genetic, and imaging features between symptomatic and asymptomatic ILAD. Methods: We conducted a prospective study of patients with acute symptomatic ILAD and subjects with asymptomatic ILAD diagnosed during medical checkups. Patients who had steno-occlusive lesions on the middle cerebral artery and/or distal internal carotid artery underwent high-resolution MRI (HR-MRI) and RNF213 (p.Arg4810Lys variant) gene studies. We excluded patients who had proximal embolic sources in ipsilateral carotid and heart. A presumptive etiology of ILAD was made based on HR-MRI and RNF213 gene studies. Patients were classified into intracranial atherosclerosis (ICAS) when relevant plaques existed on HR-MRI; moyamoya disease (MMD) when patients had RNF213 variant and HR-MRI showed no plaque but characteristic features of MMD (negative remodeling and basal collaterals); and intracranial arterial dissection (ICAD) when pathognomic features (intimal flap/double lumen or mural hematoma) exist on HR-MRI. Results: Among 224 patients analyzed, 124 were symptomatic and 100 were asymptomatic. ICAS-type was more common in symptomatic ILAD than in asymptomatic ILAD (61.4% vs. 45.0%, p=0.009). The RNF213 variant was observed in one third of ICAS-type ILAD (37.0% in asymptomatic and 38.6% in symptomatic). Similarly, the proportion of MMD-type was similar between asymptomatic (33, 21.3%) and symptomatic (32, 19.0%) ILAD. Multivariate testing showed that symptomatic ILAD was associated with the presence of intracranial plaque on HR-MRI, regardless of the presence of the RNF213 variant, site of ILAD, and number of tandem stenosis. Conclusions: While various etiopathologies can cause ILAD, ICAS is an important pathology of symptomatic ILAD and should be target for medical management.

Abstract TP225: Coated-Platelet Levels Are Associated With Chronic Hyperglycemia and Systemic Inflammation in Acute Ischemic Stroke

Introduction: Elevated levels of coated-platelets (a subset of procoagulant platelets) are often associated with acute ischemic stroke (AIS). Diabetes mellitus (DM) and chronic inflammation are both known risks factor for AIS. Elevated neutrophil-lymphocyte-ratio (NLR) and platelet-lymphocyte-ratio (PLR) are also often seen in the setting of acute myocardial infarction and AIS. However, the relationship between prothrombotic, dysglycemic and proinflammatory states in AIS is incompletely characterized. Hypothesis: To investigate whether elevated coated-platelet levels in AIS patients with chronic hyperglycemia is associated with proinflammatory states. Methods: The present cohort consists of patients with AIS or transient ischemic attack (TIA) due to large-artery disease over the period of one year. Coated-platelet levels were assayed upon admission. Glycated hemoglobin (HbA1c) and leukocyte count with differential were obtained through retrospective chart review. Study population was subcategorized into DM (HbA1c &gt;6.4 and/or history of DM), prediabetic (PD, HbA1c 5.7-6.4) and non-diabetic (ND, HbA1c &lt;5.7). Inter-relationship was assessed using linear regression models. Results: We recruited 47 AIS/TIA patients, with an average age of 67.3±8.1 years and 17/47 (36.2%) being current smokers. Thirty of 47 patients (63.8%) were diabetic with 23 patients having HbA1c levels &gt;6.4. Higher coated-platelet levels were associated with higher lymphocyte count for the entire group (r=+0.375; p=0.0094) and also for the patients with HbA1c &gt;6.4 (r=+0.516; p=0.012; n=23). Although PLR and HbA1c &gt;6.4 showed a positive correlation (r=+0.42; p=0.046; n=23) in DM patients, this was not observed among DM patients with HbA1c &lt;6.4. Conclusion: Our study demonstrates positive correlations between elevated coated-platelets and lymphocyte count and between PLR and HbA1c in AIS/TIA patients with HbA1c &gt;6.4. This alludes to a synergistic role for procoagulant and proinflammatory states in chronically dysglycemic AIS/TIA patients.

Usefulness of the ACTEL Score to Predict Atrial Fibrillation in Patients with Cryptogenic Stroke

Introduction: To assess the probability of undetected atrial fibrillation (AF) in patients with ischemic stroke, we previously compared patients who were first diagnosed with AF with patients with large or small artery disease and obtained the MrWALLETS 8-item scoring system. In the present study, we utilized cryptogenic strokes (CS) as the control group, as AF is normally sought among CS patients. Methods: We retrospectively examined 191 ischemic stroke patients (72.5 ± 12.6 years), 68 with first diagnosed AF and 123 with CS, who had undergone 2 brain CT scans, echocardiography, carotid/vertebral ultrasound, continuous electrocardiogram monitoring and anamnestic/laboratory search for cardiovascular risk factors. Results: In logistic regression, 5 variables were independently associated with AF, forming the “ACTEL” score: Age ≥75 years (OR 2.42, 95% CI 1.18–4.96, p = 0.02; +1 point); hyperCholesterolemia (OR 0.38, 95% CI 0.18–0.78, p = 0.009; –1 point); Tricuspid regurgitation ≥ mild-to-moderate (OR 4.99, 95% CI 1.63–15.27, p = 0.005; +1 point); left ventricular End-diastolic volume <65 mL (OR 7.43, 95% CI 2.44–22.6, p = 0.0004; +1 point); Left atrium ≥4 cm (OR 4.57, 95% CI 1.97–10.62, p = 0.0004; +1 point). The algebraic sum of these points may range from –1 to +4. For AF identification, the area under the receiver operating characteristic curve was 0.80 (95% CI 0.73–0.87). With a cutoff of ≥2, positive predictive value was 80.8%, specificity 92.7% and sensitivity 55.9%. Conclusions: The ACTEL score, a simplified and improved version of the MrWALLETS score, allows the identification of patients with first diagnosed AF, in the context of CSs, with a high positive predictive value.

Association between Enlarged Perivascular Spaces and Internal Carotid Artery Stenosis: A Study in Patients Diagnosed by Digital Subtraction Angiography

Objective: An enlarged perivascular space (EPVS) is an imaging marker of cerebral small vessel disease, and its relationship with large artery disease is elusive. We investigated the EPVS in patients with internal carotid artery stenosis (ICAS) with the use of digital subtraction angiography (DSA) and tested the relationship between the degree of EPVS and the degree of ICAS; as well as the relationship between the degree of EPVS and white matter hyperintensity (WMH). Method: A total of 202 patients with or without ICAS diagnosed by DSA were enrolled. The maximal ICAS rates, the degrees of EPVS and WMH were measured. The patients’ clinical characteristics and laboratory parameters were recorded. Univariable analysis and multivariable regression were used to test their correlations. In a unilateral stenosis subgroup, the EPVSs in the ipsilateral hemisphere of stenosis and in the contralateral hemisphere were compared. Results: According to univariable analysis, there were significant differences in age (P = .000), Hg1bc (P = .035) and folic acid (P = .008) among the subgroups based on the degrees of EPVS in the basal ganglia (BG). Age (P = .000) and the level of fibrinogen (P = .018) differed statistically among the subgroups based on the degrees of EPVS in the white matter (WM). The correlation between the degrees of WM-EPVS and the ICAS levels was tested with a gamma test: G = .280, P = .001. The ordinal multivariable regression model showed that age was independently associated with both BG-EPVSs and WM-EPVSs. A current smoker status was also independently associated with WM-EPVSs. ICAS level was associated with the severity of WM-EPVSs after adjusting for other risk factors. The degree of BG-EPVS was not correlated with the degree of stenosis. (P = .101). In 59 patients with unilateral ICAS, as tested by the Wilcoxon signed ranks test, the WM-EPVS scores in the ipsilateral hemisphere of stenosis were higher than those in the contralateral hemisphere. (P = .004), but there was no difference in BG-EPVSs (P = .070). Both BG-EPVSs and WM-EPVSs were independently correlated with WMH. Conclusions: BG-EPVSs and WM-EPVSs have different risk factors. WM-EPVSs but not BG-EPVSs are correlated with ICAS.

Influence of Sex Difference on Distribution of Risk Factors and Etiologic Subtypes of Acute Ischemic Stroke: Reality of Facts.

Sex-related differences have been documented in risk factors distribution, etiologic subtypes, diagnostic evaluation, offered management, and outcome of patients with acute ischemic stroke (AIS) from all over the world. Nevertheless, studies from Saudi Arabia are lacking. This study aimed to investigate the influence of sex on distribution of risk factors and etiologic subtype of AIS in patients admitted to our hospital. Record of patients admitted to King Fahd Hospital of the University between 2010 and 2017 with ischemic stroke (IS) were reviewed. Base line characteristics, risk factors, and etiologic subtypes according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification were compared between men and women. Among 453 patients with IS, 300 (66.2%) were men and 153 (33.7%) were women. The mean age of all patients was 61.5 ± 14.5 years. Women were older than men (P = 0.00). Hypertension (P = 0.00), atrial fibrillation (P = 0.00), and past history of stroke (P = 0.03) were more frequent in women compared to men. Fewer carotid Doppler studies (47.1 vs. 68.3%, P = 0.00) and echocardiogram (75.1 vs. 83%, P = 0.01) were done in women as compared to men. Cardioembolic etiologic subtype (26.1 vs. 17.7%) was found more frequently, whereas small vessel occlusive (23.5 vs. 31%) and large artery disease less (10.5 vs. 16.3%) frequently in women. Significant sex-related differences were found in risk factors and subtypes of AIS in our cohort of patients. Findings of our study are in general comparable with studies from all over the world.

Clinical Factors Associated with Deep Vein Thrombosis in Rehabilitation Patients Suspected of Thromboembolism after Cerebral Infarction.

The aim of this study is to investigate the association between characteristics of cerebral infarction lesion (vascular territory, etiology, and size), functional status and the occurrence of thromboembolism in patients suspected of having thromboembolism in a rehabilitation setting after cerebral infarction. Cerebral infarction patients who were suspected of having thromboembolism and who had undergone deep vein thrombosis (DVT) evaluation were included in analyses. Of the total 916 cerebral infarction patients, 65 patients were suspected of having DVT; 27 patients belonged to the DVT group and 38 patients belonged to the non-DVT group. The DVT (+) group was more likely to have a higher ratio of female, previous DVT history, middle cerebral artery (MCA) infarction, large arterial disease, modified Rankin Scale (mRS) score 5, abnormal speech and higher D-dimer. In multivariate logistic regression analysis, female sex, MCA infarction and mRS score 5 were significantly associated with the occurrence of thromboembolism in patients suspected of having thromboembolism. In contrast, other functional status, cerebral infarction etiology (Trial of ORG 10172 in Acute Stroke Treatment [TOAST] classification), and infarct volume were not associated with the occurrence of thromboembolism. In this study, female gender, MCA infarction, and mRS score 5 could be potential risk factors for thromboembolism in rehabilitation patients after cerebral infarction.

A Study of Clinical Profile of Large Artery Disease in Ischemic Stroke Patients

A Study of Clinical Profile of Large Artery Disease in Ischemic Stroke Patients

Unusual case of a myxoma atrial left presenting with recurrent monoparesis

Usually, embolism is described from cardiac or large artery disease. Atrial fibrillation is the most common cause of cardiogenic emboli in stroke. Myxoma is responsible in only a few cases. We describe here a case of a patient who presented with recurrent pure left brachial monoparesis as a manifestation of a cardiac myxoma.

Reader response: Atrial cardiopathy in patients with embolic strokes of unknown source and other stroke etiologies

We read with great interest the article by Jalini et al.,1 which demonstrated a higher prevalence of atrial cardiopathy in patients with embolic strokes of undetermined source (ESUS) compared with patients with large artery and small vessel disease strokes.