Nonlacunar Stroke Research Articles

Main features of ischemic stroke in patients with acute immune-mediated thrombotic thrombocytopenic purpura

BackgroundImmune-mediated thrombotic thrombocytopenic purpura (iTTP) is a microangiopathy often characterized by acute neurological involvement including ischemic stroke (IS). The characteristics of IS in iTTP remain largely unknown. AimsTo evaluate the epidemiology, neuroimaging patterns and risk factors of IS in iTTP patients. MethodsWe performed a cross-sectional study of patients enrolled in the Milan TTP Registry presenting with neurological signs/symptoms and underwent neuroimaging evaluation during their first acute iTTP episode. ResultsSeventy-eight patients were enrolled, the majority of patients were female (72 %), with a median age of 46 years. Computed tomography (CT) was performed in all patients, and magnetic resonance (MRI) was performed in 38 % of patients. IS was confirmed in 18 out of 78 patients (23 %), most of whom (70 %) showed a non-lacunar pattern with multifocal involvement. In the subgroup of patients who had MRI (n = 30), IS was identified in 12 patients (40 %) and of them 6 (50 %) had a false negative result with CT scan. Patients with IS were slightly older than those without, whereas the prevalence of cardiovascular risk factors and iTTP-related parameters were comparable between the two groups. Conclusion23 % of patients presenting with neurological manifestations at their first acute TTP episode, showed brain IS. As expected, MRI showed higher sensitivity in detecting ischemic lesions underscoring its usefulness over CT in this setting. An unexpected prevalence of non-lacunar and multifocal stroke patterns warrants further investigation. Cardiovascular risk factors and iTTP-related clinical and laboratory parameters were similarly distributed in patients with and without IS.

Association of Retinal Biomarkers With the Subtypes of Ischemic Stroke and an Automated Classification Model.

Retinal microvascular changes are associated with ischemic stroke, and optical coherence tomography angiography (OCTA) is a potential tool to reveal the retinal microvasculature. We investigated the feasibility of using the OCTA image to automatically identify ischemic stroke and its subtypes (i.e. lacunar and non-lacunar stroke), and exploited the association of retinal biomarkers with the subtypes of ischemic stroke. Two cohorts were included in this study and a total of 1730 eyes from 865 participants were studied. A deep learning model was developed to discriminate the subjects with ischemic stroke from healthy controls and to distinguish the subtypes of ischemic stroke. We also extracted geometric parameters of the retinal microvasculature at different retinal layers to investigate the correlations. Superficial vascular plexus (SVP) yielded the highest areas under the receiver operating characteristic curve (AUCs) of 0.922 and 0.871 for the ischemic stroke detection and stroke subtypes classification, respectively. For external data validation, our model achieved an AUC of 0.822 and 0.766 for the ischemic stroke detection and stroke subtypes classification, respectively. When parameterizing the OCTA images, we showed individuals with ischemic strokes had increased SVP tortuosity (B = 0.085, 95% confidence interval [CI] = 0.005-0.166, P = 0.038) and reduced FAZ circularity (B = -0.212, 95% CI = -0.42 to -0.005, P = 0.045); non-lacunar stroke had reduced SVP FAZ circularity (P = 0.027) compared to lacunar stroke. Our study demonstrates the applicability of artificial intelligence (AI)-enhanced OCTA image analysis for ischemic stroke detection and its subtypes classification. Biomarkers from retinal OCTA images can provide useful information for clinical decision-making and diagnosis of ischemic stroke and its subtypes.

Stroke heart injury: the effect of cerebral reperfusion treatment.A 3-year retrospective study.

Cardiac involvement following an acute stroke (Stroke Heart Syndrome-SHS) is an established complication and it is linked to the involvement of sympathetic activation, inflammation, and neuro-endocrine response. Troponin "rise and fall pattern" > 30% is one marker of SHS. The aim of this study was to evaluate the role of reperfusion treatments in the prevention/pathogenesis of SHS with different stroke sizes and locations (OCSP classification). We retrospectively analyzed data of 890 patients admitted to the Stroke Unit of Trieste (Italy) between 2018 and 2020. Out of them, 411 met the inclusion criteria (acute ischemic non-lacunar stroke). Clinical data were collected for each patient, imaging characteristics, and markers of cardiac injury [troponin I (TnI), NT-proBNP, "rise and fall pattern" > 30%]. We compared different stroke subtypes according to OCSP, while evaluating any differences in patients with and without SHS. In treatedtotal anterior circulation infarct (TACI) patients, the rate of SHS is lower than in non-treated TACI. Similar SHS rate was found in partial anterior (PACI) and posterior stroke (POCI), and between treated and non-treated patients. Focusing on TACI group, we compared SHS-TACI and non-SHS-TACI, we performed a univariate and multivariate analysis; treatment (OR 0.408 CI95% 0.185-0.900; p = 0.026) and diabetes (OR 2.618 CI95% 1.181-5.803; p = 0.018) were significantly associated to SHS. No clear insular effect was found in SHS development. In severe anterior stroke (TACI), reperfusion treatment may be effective in preventing SHS. Conversely, diabetes is an independent risk factor for SHS. PACI and POCI have similar troponin elevation rate.

MRI in the Evaluation of Cryptogenic Stroke and Embolic Stroke of Undetermined Source.

Cryptogenic stroke refers to a stroke of undetermined etiology. It accounts for approximately one-fifth of ischemic strokes and has a higher prevalence in younger patients. Embolic stroke of undetermined source (ESUS) refers to a subgroup of patients with nonlacunar cryptogenic strokes in whom embolism is the suspected stroke mechanism. Under the classifications of cryptogenic stroke or ESUS, there is wide heterogeneity in possible stroke mechanisms. In the absence of a confirmed stroke etiology, there is no established treatment for secondary prevention of stroke in patients experiencing cryptogenic stroke or ESUS, despite several clinical trials, leaving physicians with a clinical dilemma. Both conventional and advanced MRI techniques are available in clinical practice to identify differentiating features and stroke patterns and to determine or infer the underlying etiologic cause, such as atherosclerotic plaques and cardiogenic or paradoxical embolism due to occult pelvic venous thrombi. The aim of this review is to highlight the diagnostic utility of various MRI techniques in patients with cryptogenic stroke or ESUS. Future trends in technological advancement for promoting the adoption of MRI in such a special clinical application are also discussed.

Individual Patient Data Meta-Analysis of Dynamic Cerebral Autoregulation and Functional Outcome After Ischemic Stroke.

The relationship between dynamic cerebral autoregulation (dCA) and functional outcome after acute ischemic stroke (AIS) is unclear. Previous studies are limited by small sample sizes and heterogeneity. We performed a 1-stage individual patient data meta-analysis to investigate associations between dCA and functional outcome after AIS. Participating centers were identified through a systematic search of the literature and direct invitation. We included centers with dCA data within 1 year of AIS in adults aged over 18 years, excluding intracerebral or subarachnoid hemorrhage. Data were obtained on phase, gain, coherence, and autoregulation index derived from transfer function analysis at low-frequency and very low-frequency bands. Cerebral blood velocity, arterial pressure, end-tidal carbon dioxide, heart rate, stroke severity and sub-type, and comorbidities were collected where available. Data were grouped into 4 time points after AIS: <24 hours, 24 to 72 hours, 4 to 7 days, and >3 months. The modified Rankin Scale assessed functional outcome at 3 months. Modified Rankin Scale was analyzed as both dichotomized (0 to 2 versus 3 to 6) and ordinal (modified Rankin Scale scores, 0-6) outcomes. Univariable and multivariable analyses were conducted to identify significant relationships between dCA parameters, comorbidities, and outcomes, for each time point using generalized linear (dichotomized outcome), or cumulative link (ordinal outcome) mixed models. The participating center was modeled as a random intercept to generate odds ratios with 95% CIs. The sample included 384 individuals (35% women) from 7 centers, aged 66.3±13.7 years, with predominantly nonlacunar stroke (n=348, 69%). In the affected hemisphere, higher phase at very low-frequency predicted better outcome (dichotomized modified Rankin Scale) at <24 (crude odds ratios, 2.17 [95% CI, 1.47-3.19]; P<0.001) hours, 24-72 (crude odds ratios, 1.95 [95% CI, 1.21-3.13]; P=0.006) hours, and phase at low-frequency predicted outcome at 3 (crude odds ratios, 3.03 [95% CI, 1.10-8.33]; P=0.032) months. These results remained after covariate adjustment. Greater transfer function analysis-derived phase was associated with improved functional outcome at 3 months after AIS. dCA parameters in the early phase of AIS may help to predict functional outcome.

Abstract TP249: A Real World Study of PFO Closure in Young Patients With Ischemic Stroke

Introduction: Over the past decade, the concept of Patent Foreman Ovale (PFO)-related stroke has been evolving. Current guidelines recommend PFO closure in young patients who had a non-lacunar ischemic stroke of undetermined cause and related to a high-risk PFO. Whereas there remains a discrepancy in patient selection for PFO closure among providers and institutions in real-world practice. The retrospective study comprehensively examined patient characteristics, clinical assessments, and outcomes among young stroke patients who underwent PFO closure to gauge the current clinical process in selecting PFO candidates. Methods: Adult ischemic stroke patients (age &gt;18) who underwent PFO closure from 1/2018 to 12/2022 at the single center were identified from the cardiology PFO closure database. Patients were characterized into PFO-Associated Stroke Causal Likelihood (PASCAL)-probable; PASCAL-possible, and PASCAL-unlikely categories for comparison. Descriptive statistics was conducted due to the small sample size. Results: The mean age of qualified 78 patients was 47 years old when receiving PFO closure; the majority were males (64%) and Caucasians (75%). High risk PFO was identified in 55% of patients, and 63% of patients had high Risk of Paradoxical Embolism score ≥7. The patients were determined as PASCAL- probable (53%); PASCAL-possible (33%), and PASCAL-unlikely (15%), respectively. Among all the patients, the rate of successful device implantation was 96.0%, rate of closure related adverse events were 15.8% with post closure atrial fibrillation rate of 7.9%. Compared to PASCAL possible and unlikely patients, PASCAL-probable patients had the highest rate of successful device implantation and the lowest closure-related adverse events rate, including post-procedure atrial fibrillation. During a median follow-up of 3.4 years after PFO closure, three patients (one PASCAL-unlikely and two PASCAL-possible) had a recurrent stroke. Conclusions: The findings of real-world data confirmed that PASCAL-probable patient most likely benefit from PFO closure with the least procedure-related adverse events.

Serum erythropoietin in acute ischemic stroke: preliminary findings

Ischemic stroke is the most common stroke, caused by occlusion of cerebral vessels and leading causes of disability. Erythropoietin (EPO) has non-hematopoietic effects as a neuroprotectant after ischemic event. This study aimed to learn the serum level of EPO in acute ischemic stroke. This cross-sectional study of ischemic stroke patients with onset < 24 h and consecutive sampling was used to collect the data from medical records review, physical examinations, head CT, 24-h EPO, 24-h and seventh-day NIHSS. A total of 47 patients consisting of 59.6% women, with a median age of 53 years old (21–70). The median 24 h EPO level was 808.6 pg/mL (134.2–2988.9). The relationship between 24 h-EPO and 24-h NIHSS were not significant (r = 0.101; p = 0.250), nor to 7th day NIHSS (r = − 0.0174; p = 0.121) and to delta NIHSS (r = 0.186; p = 0.106). The relationship of blood collection time (hour) and EPO was significant (r = − 0.260; p = 0.039). There was a statistically significant difference between serum EPO levels in ischemic stroke patients with lacunar stroke compared to non-lacunar stroke (288.5 vs. 855.4 ng/mL; p = 0.021). There was a relationship between the time of collection of blood and the level of EPO and also there was difference EPO level in lacunar stroke subtype compared with non-lacunar. The relationship between EPO and NIHSS lost significance after analysis. There is a need for a future study comparing each stroke risk factor and the same blood collection time.

Abstract WP238: Efficacy of Dual Antiplatelet Therapy After Lacunar versus Non-Lacunar Syndromes in the POINT Trial

Introduction: About 20% of ischemic strokes are lacunar infarcts, the pathophysiology of which differs from that of other stroke etiological subtypes. The POINT trial demonstrated the efficacy of dual antiplatelet therapy (DAPT) for secondary stroke prevention in patients with minor ischemic stroke and high-risk TIA, but it remains unknown whether this benefit differed in lacunar versus non-lacunar strokes. Method: In a secondary analysis of POINT trial data, we compared the efficacy of DAPT in patients with an index lacunar syndrome versus not. A lacunar syndrome was defined based on common classic lacunar syndromes (e.g., pure motor hemiparesis, clumsy-hand dysarthria) and ascertained using subcomponents of the National Institutes of Health Stroke Scale documented at baseline. Our primary efficacy outcome was ischemic stroke and the safety outcome was intracranial hemorrhage. We used survival analysis and tests of interaction to compare the effect of DAPT between the lacunar and non-lacunar subgroups. Result: Among 4,881 patients enrolled in the study, 1,083 (22.1%) were classified as having an index lacunar syndrome. The effect of DAPT on the risk of ischemic stroke did not vary significantly after a lacunar syndrome (HR, 0.76; 95% CI, 0.52-1.09) versus after a non-lacunar syndrome (HR, 0.69; 95% CI, 0.50-0.95) (P value for interaction, 0.70). Similarly, the effect of DAPT on the risk of intracranial hemorrhage did not vary significantly after a lacunar syndrome (HR, 2.82; 95% CI, 0.29-27.1) versus after a non-lacunar syndrome (HR, 2.10; 95% CI, 0.63-6.99) (P for interaction, 0.82). Conclusion: In a post hoc secondary analysis of the POINT trial, we found no evidence of a lesser benefit of DAPT after a minor ischemic stroke or TIA in patients presenting with a lacunar syndrome compared to other stroke subtypes.

CHARACTERISTICS OF COGNITIVE FUNCTIONS DURING THE RECOVERY PERIOD AFTER ISCHEMIC STROKES IN PATIENTS WITH IMPAIRED CARDIAC RHYTHM AND CONDUCTION

Introduction. Disturbances of cardiac rhythm and conduction are risk factors for cognitive impairments.&#x0D; Aim: to determine peculiarities of the cognitive status in patients with impaired heart rhythm and conduction during the recovery period after ischemic non-lacunar strokes.&#x0D; Material and methods. This study included 52 patients with atrial fibrillation, 18 patients with atrioventricular block 2-3 degrees, and 24 patients with sinus rhythm who had an ischemic non-lacunar stroke during the last 6 months. Cognitive status was measured using the MMSE, MoCA, ADAS-cog scales, the Clock Drawing Test, the “5 Words” test, and the frontal assessment battery.&#x0D; Results. According to the MoCA scale, patients with atrial fibrillation and atrioventricular block were significantly more often diagnosed with post-stroke cognitive impairments (71.2% and 77.8%, respectively) compared with patients having sinus rhythm (37.5%). Among patients with cognitive impairments by the MoCA scale, the presence of atrial fibrillation was associated with a significant decrease in MoCA scale scores, compared with sinus rhythm (18.0 (17.0-22.0) versus 22.0 (18.0-23.0)). In patients with sinus rhythm, the clock-drawing test had higher scores (8.0 (7.0-9.0)) compared to cases with atrial fibrillation (7.0 (5.8-8.0)). Patients with sinus rhythm had higher values of the frontal assessment battery (15.0 (14.0-15.0)) compared to atrial fibrillation (13.0 (12.0-14.0)) and atrioventricular blocks (14.0 (13.0- 15.0)).&#x0D; Conclusions. During the first 6 months after schemic non-lacunar strokes, patients with impaired heart rhythm and conduction demonstrated a significant prevalence of cognitive impairments by the MoCA scale and significantly worse scores of cognitive tests for executive functions.

Abstract 13142: Prediction of Embolic Stroke in People Without Atrial Fibrillation and Prior Stroke Using Measures of Atrial Myopathy: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: There is no effective way to predict embolic stroke (ES) in people without atrial fibrillation (AF). Atrial myopathy—characterized by left atrial (LA) remodeling—is associated with ES independent of AF. Hypothesis: An ES prediction model for people without AF or stroke can be developed with measures of atrial myopathy. Methods: ARIC study participants without AF, stroke, or anticoagulation at visit 5 (2011-13) were followed for 5 years. Covariates included CHA 2 DS 2 VASc variables, P-wave indices, echocardiographic measures of LA function and size, and N-terminal B-type Natriuretic Peptide (NTproBNP). The primary outcome was ischemic stroke. A secondary outcome of possible embolic stroke (PES) was defined as non-lacunar strokes and strokes with new AF within 1 year of stroke. Cox proportional hazards models were created for 5-year ischemic stroke (model A) and PES (model B) risk. Stepwise backwards selection (inclusion threshold P&lt;0.20) generated parsimonious models. Model discrimination and calibration were evaluated by the c-statistic and Hosmer-Lemeshow χ 2 statistic, respectively. Results: 91 ischemic strokes (53 PES) were identified in 4154 participants (59.9% female, mean age 75.1(5.0) years). Age, sex, peripheral arterial disease, hypertension, abnormal P-wave axis, and left atrial reservoir strain were included in model A. Model B added NTproBNP. The C-statistics for models A and B were 0.653 (0.596-0.709) and 0.744 (0.680-0.808), respectively. Both models were well calibrated. Conclusions: Prediction of ES may be achieved using measures of atrial myopathy in people without AF and prior stroke. Validation of our model is needed.

The left atrial morphologic and functional parameters as predictors of paroxysmal atrial fibrillation in patients after ischemic stroke

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiogenic source of embolism is the most common cause of non-lacunar ischemic stroke (IS). Identifying the patients with undiagnosed paroxysmal atrial fibrillation (PAF) may reduce the risk of recurrent cardiogenic strokes. Reliable predictors of PAF seems to be crucial for selection the patients to prolonged ECG monitoring after IS. Purpose To assess the feasibility of echocardiography in selecting the patients with highest risk of PAF. Methods We present the preliminary data of prospective cohort study of patients after IS or transient ischemic attack of unknown aetiology and possible cardiogenic origin. The examined group comprises of 40 consecutive patients without history of AF, capable to perform ECG recording. All patients included in the study had transthoracic echocardiography (TTE) prior the monitoring period. An offline analysis including left atrial functional and morphologic assessment was performed. Every patient enrolled in the study was equipped for 2 weeks with a mobile, on demand 1-minute single lead ECG recorder and was asked for at least two exams per day. After two weeks all recorded ECGs were checked for AF occurrence. The level of statistical significance was set at p&amp;lt;0.05. Results From 40 patients (aged 64,5 yrs in average) included in the study 45% were males; (n=18). 15% (n=6) of patients were diagnosed with PAF during ECG monitoring and comprised PAF subgroup, the rest of patients formed non PAF subgroup (nPAF). Mean number of ECG records was 56,5 per patient, during the monitoring period. There were no significant differences between PAF/nPAF in age, past medical history, and left ventricular (LV) size or systolic function. Patients from PAF group have statistically significant higher values of left atrial (LA) area and volume see table 1. PAF group has significantly lower (in absolute values) left atrial contraction strain – (LASct). There were no differences in conduit and reservoir LA (LASr) strains nor in LA ejection fraction. The highest PAF diagnosis efficacy according to area under the curve (AUC) of ROC curves was noted for parameters of: LA size: LA atrium volume index (LAVI) in 4 chamber view (AUC=0,82) and LA area index (0,81) LA contraction function: LASct (Avg) (AUC =0,80) LV diastolic function: E/E’ (0,81) For the threshold of 100% sensitivity the highest specificity was found for LA volume before active atrial contraction in 4 chamber view with cut-off value of &amp;gt;=37,6 ml (specificity 64,7%) (Figure 1.) and LASct (Avg) with cut-off value &amp;lt;=17% in absolute values (specificity 47,1%). Conclusions Both functional and morphologic parameters of LA can predict PAF diagnosis during ECG monitoring after IS. TTE after IS can be used to select patients who would benefit the most from prolonged ECG monitoring. High PAF detectability (100% sensitivity) with approximately 1/2 negative results of ECG monitoring can be achieved by both LA volumetric (LAV preA) and strain (LASct) analysis.

Amide proton transfer-weighted MRI features of acute ischemic stroke subtypes.

Stroke is a highly heterogeneous disorder with distinct subtypes, and the stroke subtype influences the outcome. Amide proton transfer-weighted (APTW) MRI has been demonstrated to be promising in stroke patients, but the image characteristics of stroke subtypes have not been sufficiently investigated. The purpose of this study was to investigate the APTW MRI features of different subtypes of acute ischemic stroke (AIS). Ninety-two AIS patients presenting within 96 h of symptom onset were enrolled and examined with a 3.0-T MRI system. Patients were grouped into four subtypes: lacunar circulation infarcts (LACI, n = 33); total anterior circulation infarcts (TACI, n = 9); partial anterior circulation infarcts (PACI, n = 28); and posterior circulation infarcts (POCI, n = 22). APTW values in the lesion (APTWlesion ) and the contralateral normal-appearing region (APTWcontral ) were measured. The change in APTW values between the acute ischemic lesion and the contralateral normal-appearing region (APTWles-con ) was calculated. A two-sample t-test, one-way ANOVA, and the Chi-square method were used. There were significant differences between APTWlesion and APTWcontral in the three categories of nonlacunar strokes (TACI, PACI, and POCI, all p < 0.01), but not for lacunar strokes (LACI, p = 0.080). TACI patients had the lowest APTWlesion and APTWles-con in all groups (p < 0.05). In the POCI group, patients with supratentorial infarcts showed significant differences between APTWlesion and APTWcontral (p = 0.001), while the differences were not significant for infratentorial infarcts (p = 0.135). Our results suggest that the APT effect was heterogeneous in different stroke subtypes, and that APTW MRI gave an excellent performence in depicting nonlacunar AIS in supratentorial locations.

Cardiac Disorders in Patients with Ischemic Stroke

INTRODUCTION Worldwide cardioembolic strokes account for one third of non-lacunar strokes and almost half of all risk factors of ischemic stroke in Nepal. This study was done to describe the types of cardiac disorders and their associations with younger and older patients with ischemic stroke. MATERIAL AND METHODS In this prospective observational study, data were collected by convenience sampling and analyzed by the Statistical Package for the Social Sciences version 26. Cardiac disorders were divided into rhythm disturbances and structural disorders. Patients were divided into younger (≤ 50 years) and older (&gt; 50 years) patients based on standard definition. The associations were analyzed by using Chi-square test. Other data were expressed as frequencies and percentages. RESULTS Of 145 patients were included, cardiac disorders were present in 88.3%. Cardiac structural disorders were present in 86.2% out of which the commonest were left ventricular hypertrophy (26.2%), left ventricular diastolic dysfunction (23.4%) and mitral stenosis (13.8%). Cardiac rhythm abnormalities were present in 42.1% and atrial fibrillation (17.2%), atrial ectopics (14.5%) and ventricular ectopics (4.8%) were the commonest. When considered in total, there was no statistically significant differences in the distribution of these disorders between young and old patients. However, mitral stenosis was strongly associated with young patients (p=0.001). Atrial fibrillation and older patients were also significantly associated (p=0.04). CONCLUSION Though common, cardiac disorders in total were not significantly associated with young and older patients with ischemic stroke; however, mitral stenosis was significantly associated with young patients and atrial fibrillation with older patients.

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 relationship between LDL-c and platelet count with lacunar stroke findings on brain MRI

Objectives. Lacunar stroke or cerebral small vessel disease accounts for 15-30% of all ischemic stroke. The golden standard to identify lacunar stroke is by using MR imaging with diffusion-weighted imaging (DWI) sequence. In prior studies LDL-c and platelet count were described as contributing factors in lacunar stroke event. The aim of this study is to examine whether LDL-c and platelet value may have a contribution in lacunar stroke finding. Methods. In cross-sectional study, we consecutively collected patients older than 18 years old who had undergone brain MRI and had their LDL-c and platelet count laboratory results and we also took their history of diabetes mellitus and hypertension to evaluate risk factor association. Outcomes. We collected 93 patients who underwent brain MRI obtained lacunar stroke in 20 patients (21.5%) and non-lacunar stroke findings in 78.5%. We found no significant association between LDL-c and platelets with lacunar stroke findings in brain MRI. However we found that lacunar stroke findings had significant association with hypertension with P &lt; 0.05. Conclusion. LDL-c and platelets were not statistically significant in lacunar stroke findings in brain MRI, while hypertension was the risk factor associated with lacunar stroke event.

Intracranial carotid artery calcification morphology differs in patients with lacunar and nonlacunar acute ischemic strokes.

Intracranial carotid artery calcifications (ICACs) are a common finding on noncontrast computed tomography (NCCT) and have been associated with an increased risk of ischemic stroke. However, no data are available about the association between ICAC patterns and stroke etiology. We investigated the association between ICAC patterns and etiological subtypes of ischemic stroke. We retrospectively analyzed a single center cohort of patients admitted for ischemic stroke with known etiology. Each carotid artery was evaluated separately on NCCT scans to define the ICAC pattern (intimal, medial, mixed). The association between ICAC patterns and stroke etiology was investigated using logistic regression models adjusting for relevant confounders. A total of 485 patients were included (median age=78 [interquartile range (IQR) = 70-85] years, 243 [50%] female, median National Institutes of Health Stroke Scale=6 [IQR=3-12]). Frequencies of ICAC patterns were: intimal, n= 96 (20%); medial, n= 273 (56%); mixed, n= 51 (11%), indistinct/absent, n= 65 (13%) patients. Intimal pattern was more frequent in lacunar compared with nonlacunar (33% vs. 16%, p< 0.001) stroke etiology, whereas medial pattern was less frequent in lacunar compared with nonlacunar stroke (36% vs. 62%, p< 0.001). After adjustment for confounders, intimal ICAC predominant pattern remained associated with lacunar stroke etiology in two multivariate models (Model 1: adjusted odds ratio [aOR]=2.08, 95% confidence interval [CI]=1.20-3.56; Model 2: aOR=2.01, 95% CI=1.16-3.46). Our study suggests that intimal ICAC pattern is associated with lacunar stroke and may serve as a marker for lacunar stroke etiology, possibly strengthening the relation between endothelial dysfunction and lacunar stroke.

Abstract WP91: Pre-stroke Sulfonylurea Exposure Leads To Worse Outcomes

Introduction: Sulfonylurea medications may reduce cerebral edema following ischemic stroke. Prior retrospective studies evaluated the impact of pre-stroke sulfonylurea exposure on outcome metrics yielding inconclusive results and have not provided results based on stroke subtype. We hypothesize that exposure to pre-stroke sulfonylureas would have a better outcome than unexposed regardless of stroke etiology. Methods: We performed a post-hoc analysis of the Stroke Hyperglycemia Insulin Network Effort (SHINE) dataset. Only those with pre-enrollment diabetes mellitus were included. The primary exposure was pre-stroke sulfonylurea usage. The primary outcome was 90-day functional outcome by mRS 0 - 2 (good) versus 3 - 6 (poor). Ischemic stroke was categorized as lacunar or non-lacunar. Standard descriptive and logistic regression analyses were used for data interpretation. Results: A total of 919 individuals met inclusion criteria: mean age 65 years, 58% male, 256 (28%) being sulfonylurea exposed. Lacunar stroke was diagnosed in 220 (24%) of the cohort. Pre-stroke sulfonylurea exposure was reported in 256 participants (lacunar: 59 vs. non-lacunar: 197, p = 0.69). Amongst the whole cohort, exposed individuals were more likely to have a poor outcome (OR 1.7, 95%CI 1.25 - 2.32, p = &lt;0.001). The association between sulfonylurea exposure and poor outcome remains in those with non-lacunar stroke (OR 1.67, 95%CI 1.19 - 2.32, p = 0.003) as opposed to lacunar stroke (OR 0.60, 95%CI 0.43 - 0.84, p = 0.003) (pinteraction 0.1). Conclusion: Patients with pre-stroke sulfonylurea exposure were more likely to have a poor outcome at 90 days. Current trials investigating sulfonylurea infusion for cerebral edema, though these data suggest chronic oral administration may mitigate this response. Limitations exist including potential unaccounted differences amongst the cohort. This is a hypothesis generating study with future studies needed expand and corroborate our findings.

Abstract TMP102: Differences In Platelet Procoagulant Potential Between Lobar And Deep Microbleeds In Patients With Non-lacunar Stroke - A Potential Clue To Mechanisms?

Introduction: Coated-platelets are a subset of highly procoagulant platelets observed upon dual-agonist stimulation with collagen and thrombin. Coated-platelet levels are elevated in patients with ischemic stroke and associated with stroke recurrence. Lower levels of coated-platelets are present in ischemic stroke patients with early hemorrhagic transformation or in those with microbleeds. We now investigate if the number and location of microbleeds are associated with coated-platelet levels following non-lacunar stroke. Methods: Coated-platelet levels, reported as percent of cells converted to coated-platelets, were assayed in consecutive stroke patients. The number and location of microbleeds (deep vs lobar/mixed) on 1.5 T MRI was recorded by two independent reviewers. Correlations between number of microbleeds and demographics, vascular risk factors, stroke subtype, medications and laboratory values (platelet count, MPV, Hgb, WBC, CRP) were calculated using the Spearman correlation coefficient. Logistic regression was used to identify factors independently associated with location. Results: There were 249 stroke patients analyzed, with a mean age of 65.7 years (range 42 to 91). Microbleeds were present in 72/249 patients (29%), ranged from 1 to 14 lesions and were classified as deep (47) or lobar/mixed (25) distribution. Inter-rater agreement was excellent (91%). The number of microbleeds correlated negatively with coated-platelet levels (adjusted r = -0.41, p &lt; 0.001) after adjusting for age (r = 0.11, p = 0.09). Variables independently associated with lobar/mixed as opposed to deep location of microbleeds included coated-platelet levels (47.0±35.0% vs 26.7±10.2%, p = 0.005) and prior stroke (10/25 vs 9/47, p = 0.028). Conclusions: Lower levels of coated-platelets are associated with increased number of microbleeds. In addition, coated-platelet levels are higher in patients with lobar/mixed as compared to those with deep distribution of microbleeds, a finding possibly linked to amyloid metabolism abnormalities described in this subset of procoagulant platelets. These data support a role for differential involvement of platelet procoagulant potential in mechanisms leading to development of cerebral microbleeds.

Pathophysiology of cryptogenic stroke identified by transesophageal echocardiography multicenter study : CHALLENGE ESUS/CS registry

Cryptogenic stroke is not uncommon. In 2014, embolic stroke of undetermined source (ESUS) was advocated, two clinical trials for ESUS comparing the efficacy of direct oral anticoagulants (DOACs) and aspirin have failed to show any benefits of DOACs over aspirin, possibly due to heterogeneous embolic mechanisms in ESUS. Transesophageal echocardiography (TEE) is useful to screen for potential embolic sources such as patent foramen ovale, atrial septal aneurysm, and aortic arch plaques in ESUS/cryptogenic stroke. The Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for Embolic Stroke of Undetermined Source/Cryptogenic Stroke (CHALLENGE ESUS/CS) registry is a multicenter registry enrolling consecutive patients with CS who underwent TEE among 8 hospitals in Japan between April 2014 and December 2016. Inclusion criteria were: 1) ≥ 20 years of age within 7 days of stroke onset; 2) non-lacunar stroke on neuroradiological imaging; 3) absence of arterial stenosis ≥ 50% or occlusion in a corresponding large artery; 4) absence of major embologenic cardiac diseases; and 5) absence of other determined stroke etiologies. In this paper, results from CHALLENGE ESUS/CS are reviewed, and the pathomechanisms of cryptogenic stroke are discussed.

Vertigo in Acute Stroke Is a Predictor of Brain Location but Is Not Related to Early Outcome: The Experience of Sagrat Cor Hospital of Barcelona Stroke Registry.

Vertigo is an uncommon symptom among acute stroke victims. Knowledge about the clinical profile, the brain location, and the early outcome in stroke patients with cerebrovascular diseases and vertigo remains limited. In this study, the effects of vertigo on cerebral topography and early prognosis in cerebrovascular diseases were investigated. A comparative analysis in terms of demographics, risk factors, clinical characteristics, stroke subtypes, cerebral and vascular topography, and early outcome was performed between patients with presence or absence of vertigo on a sample of 3743 consecutive acute stroke patients available from a 24-year ongoing single-center hospital-based stroke registry. Vertigo was present in 147 patients (3.9%). Multiple logistic regression analysis showed that variables independently associated with vertigo were: location in the cerebellum (OR 5.59, CI 95% 3.24-9.64), nausea or vomiting (OR 4.48, CI 95% 2.95-6.82), medulla (OR 2.87, CI 95% 1.31-6.30), pons (OR 2.39, CI 95% 1.26-4.51), basilar artery (OR 2.36, CI 95% 1.33-4.17), ataxia (OR 2.33, CI 95% 1.41-3.85), and headache (OR 2.31, CI 95% 1.53-3.49). The study confirmed that the presence of vertigo was not related with increased in-hospital mortality or poor prognosis at hospital discharge. Vertigo is mainly related to non-lacunar vertebrobasilar stroke with topographic localization in the cerebellum and/or brainstem.