Nonlacunar Infarcts Research Articles

Sex differences in cognitive functioning in patients with heart failure

BackgroundCognitive impairment is common in patients with heart failure (HF) and impacts patients' life. Sex differences in HF-characteristics are well-established. We hypothesized that women and men with HF also differ in cognitive functioning and that this may be related to sex differences in HF-characteristics and vascular brain injury. MethodsIn the Heart-Brain Connection Study, 162 clinically stable HF patients (mean age 69.7 ± 10.0, 33 % women) underwent neuropsychological assessments and brain-MRI. Test results were standardized into z-scores for memory, language, attention/speed, executive functioning, and global cognition. Using linear models adjusted for age and education, we calculated sex differences (women-to-men: W-M∆) in cognitive functioning and examined effects of HF- and vascular brain injury-characteristics on these differences. ResultsMen more often had an ischemic cause of HF and lower NYHA-classes, whereas women more often had preserved left ventricular ejection fractions (LVEF). Women had a higher volume of white matter hyperintensities (WMHs) whereas non-lacunar infarcts and microbleeds were more prevalent in men. Women performed better on global cognition than men (W-M∆ in z-score 0.20, 95 %CI 0.03–0.37), predominantly on memory (0.40, 0.02–0.78). These differences were associated with ischemic HF-etiology, as adjustment attenuated these sex differences. After adjustment for non-lacunar infarcts, global cognition difference persisted, but the difference in memory functioning attenuated. Adjustments for NYHA-class, LVEF, WMHs, and microbleeds did not change the results. ConclusionWomen and men with HF differ in cognitive functioning, predominantly in memory functioning, these differences were related to some sex differences in HF-characteristics and vascular brain injury, but not to all.

Lower Coated-platelet Potential is Associated with Major Hemorrhagic Complications After Discharge in Patients with Non-lacunar Brain Infarction (P2-5.030)

Lower Coated-platelet Potential is Associated with Major Hemorrhagic Complications After Discharge in Patients with Non-lacunar Brain Infarction (P2-5.030)

Abstract 97: Acute Ischemic Stroke Despite Anticoagulant Use: The Neuro-AFib Study

Background: Acute ischemic stroke (AIS) admissions in patients with atrial fibrillation (AF) using anticoagulants (AIS-despite-AC) are commonly seen in stroke units but data on their frequency, causes, and outcomes are scarce. Methods: The Neuro-AFib study is a multicenter effort geared toward elucidating the causes and consequences of strokes in a contemporary AF cohort. Detailed clinical, laboratory and multimodal imaging data from known AF patients consecutively admitted to 20 stroke centers with an IS between 1/2018-12/2019 were used to define characteristics of AIS-despite-AC and compared to AIS-off-AC. Results: Out of 4456 patients with known AF prior to the AIS, 2051 (46%) were using anticoagulants. Patients who had AIS-despite-AC were younger (76.8 + 11 vs 77.8 + 12, p=0.007), had higher mean CHA 2 DS 2 -VASc scores (4.57 + 1.7 vs 4.21 + 1.7, p<0.001), and they were more likely to have permanent AF (23.5% vs 19.6%, p=0.002) and a past-history of stroke/TIA (36% vs 25%, p<0.001) when compared to non-AC group. Chronic embolic (non-lacunar) infarcts on imaging were more common among AIS-despite-AC (34.5% vs 26.7%, p<0.001). Acute large vessel occlusion (LVO) was common among AIS-despite-AC (48%). The pattern of the acute infarcts (numbers, embolic features) was not different. The calculated acute infarct volume was large (34ml) and mean NIHSS was 10.4 for AIS-despite-AC. Intravenous thrombolysis was used much less commonly for AIS-despite-AC (10.5% vs 32.1%, p<0.001). Symptomatic carotid disease was suspected in 2.4%, a hypercoagulable condition in 5.7%, whereas acute lacunar infarct was found in 6.5% of all patients. Death or significant disability (mRS 3-5) at hospital discharge were common in AIS on vs off AC (70.6% vs 75.2%, p<0.001). Conclusions: Based on a large multicenter cohort, AF patients who have AIS-despite-AC have higher AF load and risk scores, most don't have a concurrent etiology and they are more likely to have recurrent embolic events. The stroke severity, common presence of LVO, infarct size, and poor outcomes are alarming features, and most patients are unable to receive thrombolysis because of AC use. Overall, detection of AF patients at risk of AIS-despite-AC and development of specific preventive modalities should be priorities.

Impaired mobility and MRI markers of vascular brain injury: Atherosclerosis Risk in Communities and UK Biobank studies

BackgroundVascular brain injury (VBI) may be an under-recognised contributor to mobility impairment. We examined associations between MRI VBI biomarkers and impaired mobility.MethodsWe separately analysed Atherosclerosis Risk in Communities (ARIC) and...

Subcortical infarcts in patients with nonstenotic cervical atherosclerotic disease

BackgroundPrior studies have elucidated a relationship between nonstenotic plaque in patients with cryptogenic embolic infarcts with a largely cortical topology, however, it is unclear if nonstenotic cervical internal carotid artery (ICA) plaque is relevant in subcortical cryptogenic infarct patterns. MethodsA nested cohort of consecutive patients with anterior, unilateral, and subcortical infarcts without an identifiable embolic source were identified from a prospective stroke registry (September 2019 - June 2021). Patients with extracranial stenosis >50% or cardiac sources of embolism were excluded. Patients with computed tomography angiography were included and comparisons were made according to the infarct pattern being lacunar versus non-lacunar. Prevalence estimates for cervical internal carotid artery (ICA) plaque presence were estimated with 95% confidence intervals (CI), and differences in plaque thickness and features were compared between sides. ResultsOf the 1684 who were screened, 141 met inclusion criteria (n=80 due to small vessel disease, n=61 cryptogenic). The median age was 66y (interquartile range, IQR 58-73) and the National Institutes of Health Stroke Scale score was 3 (IQR 1-5). There was a higher probability of finding excess plaque ipsilateral to the stroke (41.1%, 95% CI 33.3-49.3%) than finding excess contralateral plaque (29.1%, 95% CI 22.2-37.1%; p=0.03), but this was driven by patients with non-lacunar infarcts (excess ipsilateral vs. contralateral plaque frequency of 49.2% vs. 14.8%, p<0.001) rather than lacunar infarcts (35.0% vs. 40.0%, p=0.51). ConclusionsThe probability of finding ipsilateral, nonstenotic carotid plaque in patients with subcortical cryptogenic strokes exceeds the probability of contralateral plaque and is driven by larger subcortical infarcts, classically defined as being cryptogenic. Approximately 1 in 3 unilateral anterior subcortical infarcts may be due to nonstenotic ICA plaque.

Outcome of Lacunar vs Non-lacunar Infarcts in a Prospective Stroke Database (P14-5.029)

<h3>Objective:</h3> To prospectively compare recovery outcomes, presentation with NIH stroke scale and modified ranking scale (MRS) in the study population with follow up at discharge. <h3>Background:</h3> Earlier studies suggested lacunar stroke has a better prognosis compared to other strokes, but recent studies show prognosis of lacunar stroke is simiar or worse when compared to large strokes. <h3>Design/Methods:</h3> We prospectively collected demographic information, admission NIH stroke scale, and modified ranking scale with serial measurements during hospitalized course in single tertiary care hospital in six-month period(n=74). We also collected information on discharge disposition between lacunar and non-lacunar stroke groups. Two groups adjusted for sex and race. Independent t-test is used for comparing continuous variables and chi-square test for comparing categorical variables. <h3>Results:</h3> There were 30 lacunar stroke patients and 44 non-lacunar stroke patients with mean age of 60 years for lacunar stroke patients and 70 for non-lacunar stroke patients. Mean admission NIH stroke scale was 11 in the non-lacunar group with MRS of 0.4 compared to 6 (p= 0.009) and 1(p=0.006), respectively in the lacunar group. Discharge NIH and MRS values were 7 and 2.3 respectively for the non-lacunar group compared to 4(p=0.03) and 2.2(p=0.88) for the lacunar group. ΔNIH (admit-discharge) is 4 and 2 for non-lacunar and lacunar group, respectively. ΔMRS (admit-discharge) is −1.9 and −1.3 for non-lacunar and lacunar group, respectively. Discharge to home was 46.7% &amp; 37% (p=0.03) in non-lacunar group and lacunar group, respectively. Discharge to Skilled nursing facility was 13.3% and 18.5%(p=0.03) in non-lacunar group and lacunar group, respectively. <h3>Conclusions:</h3> Despite the relatively small volume of infarct associated with lacunar stroke compared to typically large infarcts seen with non-lacunar stroke, we found that the outcome was similar if not worse in terms of recovery for lacunar type stroke based upon prospective information collected in our six-month database extending from May 2021 to November <b>Disclosure:</b> Dr. Buchhanolla has nothing to disclose. Dr. PANDEY has nothing to disclose. Dr. Bir has nothing to disclose. Dr. Javalkar has nothing to disclose. Dr. Kelley has nothing to disclose.

The Prognostic Significance of Early Glycemic Profile in Acute Ischemic Stroke Depends on Stroke Subtype.

It is still unclear whether early glycemic profile after admission for acute ischemic stroke (IS) has the same prognostic significance in patients with lacunar and non-lacunar infarction. Data from 4011 IS patients admitted to a Stroke Unit (SU) were retrospectively analyzed. Lacunar IS was diagnosed by clinical criteria. A continuous indicator of early glycemic profile was calculated as the difference of fasting serum glucose (FSG) measured within 48 h after admission and random serum glucose (RSG) measured on admission. Logistic regression was used to estimate the association with a combined poor outcome defined as early neurological deterioration, severe stroke at SU discharge, or 1-month mortality. Among patients without hypoglycemia (RSG and FSG > 3.9 mmol/L), an increasing glycemic profile increased the likelihood of a poor outcome for non-lacunar (OR, 1.38, 95%CI, 1.24-1.52 in those without diabetes; 1.11, 95%CI, 1.05-1.18 in those with diabetes) but not for lacunar IS. Among patients without sustained or delayed hyperglycemia (FSG < 7.8 mmol/L), an increasing glycemic profile was unrelated to outcome for non-lacunar IS but decreased the likelihood of poor outcome for lacunar IS (OR, 0.63, 95%CI, 0.41-0.98). Early glycemic profile after acute IS has a different prognostic significance in non-lacunar and lacunar patients.

Cognitive phenotypes and factors associated with cognitive decline in a cohort of older patients with atrial fibrillation: The Strat-AF study.

The multifactorial relationship between atrial fibrillation (AF) and cognitive impairment needs to be elucidated. The aim of this study was to assess, in AF patients on oral anticoagulants (OACs), the prevalence of cognitive impairment, defined according to clinical criteria or data-driven phenotypes, the prevalence of cognitive worsening, and factors associated with cognitive outcomes. The observational prospective Strat-AF study enrolled AF patients aged ≥ 65 years who were receiving OACs. The baseline and 18-month protocol included clinical, functional, and cognitive assessment, and brain magnetic resonance imaging. Cognitive outcomes were: empirically derived cognitive phenotypes; clinical diagnosis of cognitive impairment; and longitudinal cognitive worsening. Out of 182 patients (mean age 77.7 ± 6.7 years, 63% males), 82 (45%) received a cognitive impairment diagnosis, which was associated with lower education level and functional status, and higher level of atrophy. Cluster analysis identified three cognitive profiles: dysexecutive (17%); amnestic (25%); and normal (58%). Compared to the normal group, the dysexecutive group was older, and had higher CHA2 DS2 -VASc scores, while the amnestic group had worse cognitive and functional abilities, and medial temporal lobe atrophy (MTA). Out of 128 followed-up patients, 35 (27%) had cognitive worsening that was associated with lower education level, worse cognitive efficiency, CHA2 DS2 -VASc score, timing of OAC intake, history of stroke, diabetes, non-lacunar infarcts, white matter hyperintensities and MTA. In multivariate models, belonging to the dysexecutive or amnestic group was a main predictor of cognitive worsening. In our cohort of older AF patients, CHA2 DS2 -VASc score, timing of OAC intake, and history of stroke influenced presence, type and progression of cognitive impairment. Empirically derived cognitive classification identified three groups with different clinical profiles and better predictive ability for cognitive worsening compared to conventional clinical diagnosis.

Abstract 131: Brain Mri Biomarkers Of Impaired Balance And Slow Walk Speed: Atherosclerosis Risk In Communities And UK Biobank Studies

Background and Objectives: Vascular brain injury (VBI) may contribute to imbalance and slow walk speed, but this is uncertain. We hypothesize that MRI biomarkers of VBI associate with impaired balance and slow walk speed. Methods: We performed separate, cross-sectional analyses in the Atherosclerosis Risk in Communities (ARIC) and UK Biobank (UKB) studies. Eligible participants had no prior clinical stroke and underwent a brain MRI and balance and walk speed ascertainment. MRI biomarkers of VBI analyzed were: ventricular volume, white matter hyperintensity volume (WMH), non-lacunar infarction, lacunar infarction, microhemorrhage in ARIC; ventricular volume, brain volume, WMH, fractional anisotropy (FA), mean diffusivity (MD), intra-cellular volume fraction, isotropic free water volume fraction in UKB. Quantitative biomarker levels were classified into tertiles, the unhealthiest tertile designated as the exposure. Our outcomes were poor balance and slow walk speed. We constructed multivariable logistic regression models to examine the associations between each MRI biomarker and the outcomes, adjusting for demographics and clinical history. Results: We included 1,626 ARIC participants (mean age 76.2 years; 23.4% impaired balance, 25.0% slow walk speed) and 40,098 UKB participants (mean age 55 years; 15.8% impaired balance, 2.8% slow walk speed). In ARIC, impaired balance was associated with 4 of 5 MRI measures of VBI in adjusted analysis (all p-values &lt;0.05). The strongest association was with WMH (OR 1.36; 95% C.I. 1.04-1.76). Slow walk speed in ARIC was significantly associated with 4 of 5 MRI measures; the strongest association was with silent lacunar infarcts (OR 2.17; 95% C.I. 1.61-2.93). In UKB, poor balance was associated with all MRI biomarkers except WMH. The strongest association was with FA (OR 1.16; 95% C.I. 1.08-1.24). Slow walking speed was associated with WMH, FA, and MD. The strongest association was with FA (OR 1.42; 95% C.I. 1.21-1.67). Conclusions: We demonstrate that MRI measures of VBI are independently associated with impaired balance and slow walk speed in two studies of community-dwelling adults with no history of clinical stroke. Consequences of VBI may extend beyond clinically apparent stroke to also include mobility.

Abstract 33: Risk Scores And Brain Mri Markers In Distinguishing Ischemic Stroke And Intracerebral Hemorrhage Risk Among Atrial Fibrillation Patients: The Neuro-Afib Study

Background: Recent studies cast doubt on the accuracy of the most-commonly used risk scores (CHA 2 DS 2 -VASC and HAS-BLED) in differentiating the risk of acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) among patients with fibrillation (AF). Because of the importance of AIS/ICH risk determination for choice of proper preventive approaches, we aimed to compare the value of these risk scores and brain MRI markers to differentiate the occurrence of AIS and ICH in a large cohort of AF-related strokes. Methods: The Neuro-AFib study is a multicenter effort to elucidate the causes and consequences of AIS and ICH in AF patients. Demographics, CHA 2 DS 2 -VASC and HAS-BLED scores, and ischemic/hemorrhagic brain MRI markers were compared between AF patients admitted with AIS and ICH to 15 academic stroke centers in the US between 1/2018-12/2019. Results: Of 5694 stroke admissions with AF, 4826 (84.8%) had AIS and 868 (15.2%) ICH. Mean age was similar between groups (75.9±11.5 vs 76.6±11.9, p=0.1), more ICH patients were male (57% vs 50%). Pre-index event CHA 2 DS 2 -VASC (4.14±1.6 vs 4.22±1.6) and HAS-BLED (2.71±1.09 vs 2.68±1.13) were similar between groups [both p&gt;0.2]. Cerebral microbleeds (CMB, 56% vs 33.5%), cortical superficial siderosis (cSS, 15% vs 9.4%), and moderate-to-severe leukoaraiosis (41% vs 33.4%) were more commonly found among ICH patients compared to AIS (all p&lt;0.001). Chronic lacunar infarcts (43.5% vs 39.5%, p=0.03) and chronic non-lacunar infarcts (29% vs 18%, p&lt;0.001) were more commonly found in AIS. In a multivariable logistic regression model that included all variables above, male sex, presence of CMBs, cSS, moderate-to-severe leukoaraiosis were associated with ICH, chronic non-lacunar infarcts with AIS (all p&lt;0.005), while CHA 2 DS 2 -VASC (p=0.9) and HAS-BLED (p=0.9) were not related to the stroke type. Conclusions: Data from our multicenter study confirm the lack of specificity of CHA 2 DS 2 -VASC and HAS-BLED to categorize the risk of AIS vs ICH in AF patients. The chronic MRI findings (CMB, cSS, moderate-to-severe leukoaraiosis, chronic infarcts) should be incorporated into risk scores, and their predictive value for AIS and ICH should be investigated in prospective studies to select optimal stroke prevention methods in AF patients.

712 INFLAMMATION, HAEMOSTASIS AND EXTRACELLULAR MATRIX IN THE STRATIFICATION OF BLEEDING AND THROMBOTIC RISK OF ATRIAL FIBRILLATION ON ORAL ANTICOAGULANT THERAPY: INSIGHTS FROM STRAT-AF STUDY

Abstract Background In anticoagulated atrial fibrillation patients, the validity of models recommended for the stratification of the risk ratio between benefits and hemorrhage risk is limited. We hypothesize that biological markers – both circulating and neuroimaging-based – and their possible interaction, might improve the prediction of bleeding risk in atrial fibrillation patients under treatment with any type of oral anticoagulant. Methods The Strat-AF study is an observational, prospective, single-center hospital-based study enrolling patients with atrial fibrillation, aged 65 years or older, and with no contraindications to undergo magnetic resonance imaging. Recruited patients are evaluated by means of a comprehensive protocol, with clinical, cerebral magnetic resonance imaging and circulating biomarkers assessment. The main outcomes are the evaluation of cerebral microangiopathy using MRI (lacunar infarcts, non-lacunar infarcts, microbleeds, hyperintensity of the white matter, SVDs [small vessel disease score]) and the onset of ischemic or hemorrhagic stroke related to the levels of circulating biomarkers of inflammation (IL-6, IL-8, TNFα, IL-4, IL-10, CCL2, CXCL10, ICAM-1, VCAM-1, VEGF), haemostasis (PAI-1, CLT, vWF) and extracellular matrix remodeling (MMP-2,-7,-8,-9,-12, TIMP-1,-2,-3,-4). Starting from September 2017, 191 patients (mean age 78.1±6.7, range 65-97; 65.3% males) were enrolled. 56 patients (29.3%) were on vitamin K antagonists, and 135 (70.7%) were on direct oral anticoagulants. Follow-up clinical evaluation and brain MRI were performed at 18 months. Results At multivariate analysis, adjusted for age, sex, CHA2DS2-VASc, HAS-BLED and type of anticoagulant, independent predictors were: low levels of vWF and elevated levels of TIMP-2 for microbleeds [OR:0.62 95%CI(0.42-0.89), p=0.011and OR:1.25 (1.01-1.77), p=0.049 respectively]; elevated levels of IL-6 and TIMP-4 for hyperintensity of white matter [OR: 1.55 (1.01-2.58), p=0.049 and OR: 1.44 (1.01-2.07), p=0.047 respectively]; elevated levels of MMP-2 and of TIMP-1 and TIMP-2 for lacunar infarcts [OR: 1.33 (1.01-1.89), p=0.049, OR: 1.48(1.01-2.18), p=0.048 and 1.50 (1.05-2.16), p=0.028 respectively]; elevated levels of TIMP-1, TIMP-2, TIMP-3 for the appearance of at least 1 new lesion according to the SVD score [OR: 1.48 (1.01-2.19), p=0.046, OR:1.53 (1.05-2.23), p=0.028 and OR: 1.58 (1.09-2.31), p=0.016 respectively]. Conclusions The Strat-AF study may be an essential step towards the exploration of the role of a combined clinical biomarker or multiple biomarker models in predicting stroke risk in atrial fibrillation and might sustain the incorporation of such new markers in the existing stroke prediction schemes by the demonstration of a greater incremental value in predicting stroke risk and improvement in clinical outcomes in a cost-effective fashion.

Characterization of the Retinal Microvasculature and FAZ Changes in Ischemic Stroke and Its Different Types.

PurposeThis study aimed to assess morphological changes in the retinal microvasculature and foveal avascular zone (FAZ) in patients with ischemic stroke and its different subtypes.MethodsThirty-three patients with ischemic stroke (14 with nonlacunar infarction and 19 with lacunar infarction) and 27 control participants were enrolled in this study. Based on optical coherence tomography angiography (OCTA), three vascular parameters, including vascular area density, vascular fractal dimension (VFD), and vascular orientation distribution (VOD), and four FAZ-related parameters, including FAZ area, FAZ axis ratio (FAR), FAZ circularity (FC), and FAZ roundness, in the superficial capillary plexus (SCP) and deep capillary plexus (DCP) were extracted and analyzed.ResultsLogistic regression results showed that worse best-corrected visual acuity (odds ratio [OR], 0.21), higher FAR (OR, 2.77) and lower FC (OR, 0.36) of the DCP were associated with ischemic stroke. Furthermore, lower VOD of the SCP was significantly associated with lacunar infarction compared with nonlacunar infarction.ConclusionsOur study shows that the FAR and FC of the DCP may be potential biomarkers of ischemic stroke. Moreover, we demonstrated that OCT showed specific damage patterns in retinal microvascular and macular morphology in different subtypes of ischemic stroke.Translational RelevanceThis work lays the foundation for the pathophysiological characteristics of cerebrovascular diseases assisted by retinal imaging and artificial intelligence.

Prevalence and risk factors of MRI-defined brain infarcts among Chinese adults.

BackgroundFew studies have explored the prevalence and risk factors of brain infarcts (BI) detected by magnetic resonance imaging (MRI) in China. The purpose was to evaluate the prevalence and risk factors of brain infarcts (BI) detected by magnetic resonance imaging (MRI) in 1.4 million Chinese adults.MethodsThis was a multicenter cross-sectional study conducted on 1,431,527 participants aged ≥18 years (mean age: 46.4 years) who underwent MRI scans in health examinations from 28 provinces of China in 2018. MRI-defined BI was defined as focal parenchymal lesions ≥3 mm. Multivariable logistic regression analyses were performed to evaluate risk factors associated with MRI-defined BI.ResultsThe age- and sex-standardized prevalence of MRI-defined BI, lacunar and non-lacunar infarcts were 5.79% (5.75–5.83%), 4.56% (4.52–4.60%), and 1.23% (1.21–1.25%), respectively. The sex-standardized prevalence of MRI-defined BI ranged from 0.46% among those aged 18–29 years to 37.33% among those aged ≥80 years. Men (6.30%) had a higher age-standardized prevalence of MRI-defined BI than women (5.28%). The highest age- and sex-standardized prevalence of MRI-defined BI was observed in the Northwest (8.34%) and Northeast (8.02%) regions, while the lowest prevalence was observed in the Southwest (4.02%). A higher risk of MRI-defined BI was associated with being male [odd ratio (OR) 1.17, 95% CI 1.15–1.19], older age (OR per 10-year increments 2.33, 2.31–2.35), overweight (1.12, 1.10–1.14) or obesity (1.18, 1.16–1.21), hypertension (1.80, 1.77–1.83), diabetes (1.24, 1.21–1.26), and dyslipidemia (1.07, 1.05–1.08).ConclusionMRI-defined BI is highly prevalent in China, even among young adults. MRI-defined BI was associated with being male, older age, living in the northern region, and metabolic conditions.

Can CHA2DS2-VASc and HAS-BLED Foresee the Presence of Cerebral Microbleeds, Lacunar and Non-Lacunar Infarcts in Elderly Patients With Atrial Fibrillation? Data From Strat-AF Study.

Anticoagulants reduce embolic risk in atrial fibrillation (AF), despite increasing hemorrhagic risk. In this context, validity of congestive heart failure, hypertension, age ≥ 75 years, diabetes, stroke, vascular disease, age 65–74 years and sex category (CHA2DS2-VASc) and hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly (HAS–BLED) scales, used to respectively evaluate thrombotic and hemorrhagic risks, is incomplete. In patients with AF, brain MRI has led to the increased detection of “asymptomatic” brain changes, particularly those related to small vessel disease, which also represent the pathologic substrate of intracranial hemorrhage, and silent brain infarcts, which are considered risk factors for ischemic stroke. Routine brain MRI in asymptomatic patients with AF is not yet recommended. Our aim was to test predictive ability of risk stratification scales on the presence of cerebral microbleeds, lacunar, and non-lacunar infarcts in 170 elderly patients with AF on oral anticoagulants. Ad hoc developed R algorithms were used to evaluate CHA2DS2-VASc and HAS–BLED sensitivity and specificity on the prediction of cerebrovascular lesions: (1) Maintaining original items' weights; (2) augmenting weights' range; (3) adding cognitive, motor, and depressive scores. Accuracy was poor for each outcome considering both scales either in phase 1 or phase 2. Accuracy was never improved by the addition of cognitive scores. The addition of motor and depressive scores to CHA2DS2-VASc improved accuracy for non-lacunar infarcts (sensitivity = 0.70, specificity = 0.85), and sensitivity for lacunar–infarcts (sensitivity = 0.74, specificity = 0.61). Our results are a very first step toward the attempt to identify those elderly patients with AF who would benefit most from brain MRI in risk stratification.

Abstract WP184: The Risk Of Stroke Recurrence According To Neuroimaging Parameters In Patients With Acute Ischemic Stroke And Atrial Fibrillation

Purpose: The usefulness of the existing risk stratification tools for atrial fibrillation (AF) is limited in predicting stroke recurrence in patients with acute ischemic stroke (AIS). Neuroimaging parameters obtained from diagnostic work-up of AIS could offer more elaborate prediction. Methods: A multicenter prospective cohort of AIS patients with AF recruited from 14 university hospitals or regional stroke centers were followed up for recurrent ischemic stroke (RIS) and a composite of all stroke and TIA. Neuroimaging features were derived from acute and chronic infarction patterns, and SVD markers such as lacunes, CMBs, and WMH. Cumulative incidences according to each neuroimaging parameter were estimated and compared using the Kaplan-Meier method with log-rank test and multivariable cause-specific hazard models with death as a competing risk. Results: A total of 2,270 patients were followed up for 431 days (IQR, 365-735), during which 111 RISs and 130 composite outcomes occurred. In unadjusted analysis, lesion multiplicity among acute infarction patterns, the presence of chronic non-lacunar infarction, and the presence of lacunes among SVD markers increased the risk of RIS significantly (Table). Other neuroimaging features such as territory multiplicity and location, confluency, topography, and size of acute lesions, lesion multiplicity, territory multiplicity, confluency, topography, and size of chronic infarction, number of lacunes, presence of CMBs, and WMH did not affect the incidence of RIS. The adjusted hazard ratios of lesion multiplicity of acute infarction, chronic infarction and lacunes were 1.45 (95% CI, 0.99-2.11), 1.57 (1.06-2.34) and 1.97 (1.30-2.98) for RIS, respectively. Similar findings were obtained for the composite outcome. Conclusions: Several neuroimaging markers were associated with recurrent ischemic stroke in AIS with AF. This could pave the way to a new stratification scheme for AF including neuroimaging parameters.

Vascular Cognitive Impairment and cognitive decline; a longitudinal study comparing different types of vascular brain injury - The TRACE-VCI study.

Little is known about the trajectories of cognitive decline in relation to different types of vascular brain injury in patients presenting at a memory clinic with Vascular Cognitive Impairment (VCI). We included 472 memory clinic patients (age 68 (±8.2) years, 44% female, MMSE 25.9 (±2.8), 210 (44.5%) dementia) from the prospective TRACE-VCI cohort study with possible VCI, defined as cognitive complaints and vascular brain injury on MRI and at least 1 follow-up cognitive assessment (follow-up time 2.5 (±1.4) years, n=1172 assessments). Types of vascular brain injury considered lacune(s) (≥1; n = 108 patients (23%)), non-lacunar infarct(s) (≥1; n = 54 (11%)), white matter hyperintensities (WMH) (none/mild versus moderate/severe (n = 211 patients (45%)) and microbleed(s) (≥1; n = 202 patients (43%)). We assessed cognitive functioning at baseline and follow-up, including the Rey Auditory Verbal Learning Test (RAVLT), Trail Making Test (TMT) A and B, category naming task and MMSE. The association of different types of vascular brain injury with cognitive decline was evaluated with linear mixed models, including one type of vascular brain injury (dichotomized), time and vascular brain injury*time, adjusted for sex, age, dementia status (yes/no), education (Verhage scale) and medial temporal lobe atrophy (MTA) score (dichotomized as ≥ 1.5). Across the population, performance declined over time on all tests. Linear mixed models showed that lacune(s) were associated with worse baseline TMTA (Beta(SE)) (8.3 (3.8), p=.03) and TMTB (25.6 (10.3), p = .01), albeit with a slower rate of decline on MMSE, RAVLT and category naming. By contrast, patients with non-lacunar infarct(s) showed a steeper rate of decline on TMTB (29.6 (7.7), p = .00), mainly attributable to patients with dementia (62.9 (15.5), p = .00). Although different types of vascular brain injury have different etiologies and different patterns, they show little differences in cognitive trajectories depending on type of vascular brain injury.

Early argatroban and antiplatelet combination therapy in acute non-lacunar single subcortical infarct associated with mild intracranial atherosclerosis

BackgroundPatients with acute non-lacunar single subcortical infarct (SSI) associated with mild intracranial atherosclerosis (ICAS) have a relatively high incidence of early neurological deterioration (END), resulting in unfavorable functional outcomes. Whether the early administration of argatroban and aspirin or clopidogrel within 6–12 h after symptom onset is effective and safe in these patients is unknown.MethodsA review of the stroke database of Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University and Qingdao Center Hospital, Qingdao University Medical College in China was undertaken from May 2017 to January 2020 to identify all patients with non-lacunar SSI caused by ICAS within 6–12 h of symptom onset based on MRI screening. Patients were divided into two groups, one comprising those who received argatroban and mono antiplatelet therapy with aspirin or clopidogrel on admission (argatroban group), and the other those who received dual antiplatelet therapy (DAPT) with aspirin and clopidogrel during hospitalization (DAPT group). The primary outcome was recovery by 90 days after stroke based on a modified Rankin scale (mRS) score (0 to 1). The secondary outcome was END incidence within 120 h of admission. Safety outcomes were intracranial hemorrhage (ICH) and major extracranial bleeding. The probability of clinical benefit (mRS score 0–1 at 90 days) was estimated using multivariable logistic regression analysis.ResultsA total of 304 acute non-lacunar SSI associated with mild ICAS patients were analyzed. At 90 days, 101 (74.2%) patients in the argatroban group and 80 (47.6%) in the DAPT group had an mRS score that improved from 0 to 1 (P < 0.001). The relative risk (95% credible interval) for an mRS score improving from 0 to 1 in the argatroban group was 1.50 (1.05–2.70). END occurred in 10 (7.3%) patients in the argatroban group compared with 37 (22.0%) in the DAPT group (P < 0.001). No patients experienced symptomatic hemorrhagic transformation.ConclusionsEarly combined administration of argatroban and an antiplatelet agent (aspirin or clopidogrel) may be beneficial for patients with non-lacunar SSI associated with mild ICAS identified by MRI screening and may attenuate progressive neurological deficits.Trial registrationOur study is a retrospectively registered trial.

Sex and Cardiovascular Function in Relation to Vascular Brain Injury in Patients with Cognitive Complaints.

Emerging evidence shows sex differences in manifestations of vascular brain injury in memory clinic patients. We hypothesize that this is explained by sex differences in cardiovascular function. To assess the relation between sex and manifestations of vascular brain injury in patients with cognitive complaints, in interaction with cardiovascular function. 160 outpatient clinic patients (68.8±8.5 years, 38% female) with cognitive complaints and vascular brain injury from the Heart-Brain Connection study underwent a standardized work-up, including heart-brain MRI. We calculated sex differences in vascular brain injury (lacunar infarcts, non-lacunar infarcts, white matter hyperintensities [WMHs], and microbleeds) and cardiovascular function (arterial stiffness, cardiac index, left ventricular [LV] mass index, LV mass-to-volume ratio and cerebral blood flow). In separate regression models, we analyzed the interaction effect between sex and cardiovascular function markers on manifestations of vascular brain injury with interaction terms (sex*cardiovascular function marker). Males had more infarcts, whereas females tended to have larger WMH-volumes. Males had higher LV mass indexes and LV mass-to-volume ratios and lower CBF values compared to females. Yet, we found no interaction effect between sex and individual cardiovascular function markers in relation to the different manifestations of vascular brain injury (p-values interaction terms > 0.05). Manifestations of vascular brain injury in patients with cognitive complaints differed by sex. There was no interaction between sex and cardiovascular function, warranting further studies to explain the observed sex differences in injury patterns.

Clinical and neuroimaging analysis of carotid infarction in the acute ischemic stroke

Background. The assessment of clinical manifestations in patients with acute pre-circular infarction is important for verification of the lesion, the choice of the treatment program, prediction of the stroke consequences. The purpose is to investigate the clinical, neurological, and neuroimaging features of lacunar and non-lacunar carotid infarctions in acute ischemic stroke and to assess their short-term consequences. Materials and methods. There was performed a clinical and radiological analysis of carotid infarction in 540 patients with acute ischemic stroke, which were divided into two groups: 155 patients were verified for infarcts in the cortex and white matter of the brain in the vasculature of the anterior and middle cerebral artery; in 385 patients, infarct foci were found in the area of the deep hemispheres of the brain (subcortical-capsular infarcts). Results. Clinical neuroimaging analysis of patients with ischemic stroke in the vasculature of the cortical branches of the anterior and middle cerebral arteries of the anterior circulatory basin showed that acute cerebral circulatory disorders caused the development of small cortical infarctions in 89 (57.4 %) patients and 65 (41 %) — lacunar infarction, in one patient (0.7 %) with occlusion of the proximal anterior cerebral artery — total infarction. The neurological clinical picture of infarcts of varying localization, which was determined by the location and size of the lesion, was described. Conclusions. The obtained results showed that the consequences of anterior circular infarctions depended on the localization of the lesion of the arterial area, the caliber of the infarction of the dependent artery, the size of the infarct locus. For the most part, these factors determined the background severity of neurological deficit after the development of acute ischemic stroke.

Detection and prevalence of intra-cardiac thrombus in patients with embolic stroke of undetermined source

Abstract Background Embolic Stroke of Undetermined Source (ESUS) is defined as non-lacunar brain infarct without proximal arterial stenosis or known cardioembolic source (including atrial arrythmias). Little is known about the prevalence of intra-cardiac thrombus as a potential source of embolism in patients presenting with ESUS. Objectives To examine the use of contrast-enhanced electrocardiogram-gated computed tomography (CT) to elucidate the prevalence of intra-cardiac thrombus in patients suspected of ESUS. Methods We retrospectively investigated 101 consecutive patients who presented to our hospital with ESUS between January 2019 and March 2021 and underwent 2D echocardiography and CT as part of stroke etiology evaluation. Results In our study population (73.2±9.98 years, 41% female), CT detected intra-cardiac thrombus in 19 (18.8%) patients. Left ventricular thrombus (LVT) was found in 10 (9.9%) patients and left atrial/left atrial appendage in 8 patients. All of cases of LVT were detected by cardiac CT, while 2D echocardiography was able to detect only four of these cases. All cases of LVT were associated with significant coronary obstructive disease, while in 2 out of 10 patients, a previous history of ischemic heart disease was unknown. Using CT 2 patients after transcatheter aortic valve implantation were diagnosed with hypoattenuated leaflet thickening, and 3 patients with concomitant pulmonary embolism. In total, the finding of CT resulted in change of management, indication for anticoagulation instead of antiplatelets drugs, in 23 (22.7%) patients. Conclusion CT may help to improve the detection of intra-cardiac thrombus in patients presenting with ESUS and therefore provide relevant information for anticoagulation therapy and need of further coronary evaluation and intervention. The high prevalence of intra-cardiac thrombus in ESUS patients make the use of complementary 3D imaging important. Funding Acknowledgement Type of funding sources: None.