Recurrent Cerebral Ischemia Research Articles

Changing or Retaining Direct Oral Anticoagulant After Ischemic Stroke Despite Direct Oral Anticoagulant Treatment.

The optimal antithrombotic strategies for patients with atrial fibrillation who experience ischemic stroke (IS) despite direct oral anticoagulant (DOAC) therapy remain inconclusive. This study compared outcomes for patients with DOAC treatment failure who changed or retained their prestroke DOAC. This retrospective cohort study analyzed data from the National Health Insurance Research Database from 2012 to 2020. Patients with atrial fibrillation who experienced IS during DOAC therapy were assigned to either (1) the DOAC-change group: changing prestroke DOAC or (2) the DOAC-retain group: retaining prestroke DOAC. The primary outcome was a composite of recurrent IS and transient ischemic attack. The secondary outcomes included intracranial hemorrhage, major bleeding, systemic thromboembolism, and all-cause death. Propensity score-based inverse probability of treatment weighting was applied to balance the baseline characteristics between the DOAC-change and DOAC-retain groups. The Cox proportional hazards model compared the risk of outcomes between the 2 groups. In total, 1979 patients were enrolled (609 DOAC-change patients and 1370 DOAC-retain patients). The incidence rates of recurrent IS or transient ischemic attack were 7.20 and 6.56 per 100 person-years in the DOAC-change and DOAC-retain groups, respectively (hazard ratio [HR], 1.07 [95% CI, 0.87-1.30]). A nonsignificantly higher incidence rate of intracranial hemorrhage was observed in the DOAC-change group compared with the DOAC-retain group (0.75 versus 0.53 per 100-person-years; HR, 1.49 [95% CI, 0.78-2.83]). The systemic thromboembolism, major bleeding, and death rates were comparable between the DOAC-change and DOAC-retain groups. Changing prestroke DOAC does not reduce the risk of recurrent cerebral ischemia in patients with atrial fibrillation who develop IS during DOAC therapy. However, future studies should continue to observe the potential trends of increased intracranial hemorrhage risk.

Symptomatic carotid artery intraluminal thrombus: risk of medical management failure and distal embolization

BackgroundCarotid artery intraluminal thrombus (ILT), or free-floating thrombus, is an uncommon cerebrovascular entity with considerable equipoise regarding its clinical management. Likewise, in patients treated with medical management (MM), distal embolization...

Predictors of recurrent cerebral ischemia after patent foramen ovale closure: A single center observational study

ObjectivesTranscatheter patent foramen ovale closure lowers recurrent stroke in patients with cryptogenic stroke or transient ischemic attack with an indication for closure. However, the incidence of recurrent stroke is not negligible and underlying pathophysiology remains largely unknown. We sought to evaluate the prevalence of recurrent ischemic neurological events and to assess its predictors after transcatheter patent foramen ovale closure. MethodsWe enrolled consecutive patients who underwent patent foramen ovale closure for secondary prevention of neurological ischemic events at the University Hospital of Parma between 2006 and 2021. Clinical and procedure-related features were collected for each patient. The incidence of recurrent ischemic neurological events was assessed at follow-up. ResultsWe enrolled a total of 169 patients with mean Risk of Paradoxical Embolism score at hospital admission of 6.4 ± 1.5. The primary indication was previous cryptogenic stroke (94 [55.6 %] subjects), followed by transient ischemic attack (75 [44.4 %]). Among patients with complete outcome data (n= 154), after a median follow-up of 112 months, recurrent cerebral ischemia occurred in 13 [8.4 %], with an annualized rate of 0.92/100 patients. The presence of obesity [OR 5.268, p = 0.018], Risk of Paradoxical Embolism score < 7 [OR 5.991, p = 0.035] and migraine [OR = 5.932 p = 0.012] were independent positive predictors of recurrent stroke/ transient ischemic attack after patent foramen ovale closure. ConclusionsThe presence of obesity, Risk of Paradoxical Embolism score < 7 and migraine were independent positive predictors of recurrent ischemic neurological events after patent foramen ovale closure.

P466 PREDICTORS OF RECURRENT CEREBRAL ISCHEMIA AFTER PATENT FORAMEN OVALE CLOSURE: A SINGLE CENTER EXPERIENCE WITH A LONG–TERM FOLLOW–UP

Abstract Aims Transcatheter patent foramen ovale (PFO) closure has been shown to lower recurrent stroke in patients with cryptogenic stroke (CS) or transient ischemic attack (TIA) with an indication for closure. However, the incidence of recurrent stroke is not negligible and underlying pathogenic mechanisms remain largely unknown. We sought to evaluate the prevalence of recurrent CS/TIA and to assess its predictors after transcatheter PFO closure. Methods We enrolled consecutive patients who underwent PFO closure for secondary prevention of neurological ischemic events at the University Hospital of Parma between 2006 and 2021. For each subject, CS/TIA index event was diagnosed after exclusion of alternative etiologies, PFO features were characterized by transesophageal echocardiography (TEE), the Risk of Paradoxical Embolism (ROPE) score was retrospectively assessed and the presence of migraine was investigated. Clinical follow–up was scheduled with outpatient visits at 3 – 12 months and yearly thereafter device implantation; the primary outcome was the recurrence of any ischemic neurological event. Results We enrolled a total of 169 patients with mean Risk of Paradoxical Embolism (ROPE) score at hospital admission of 6.4 ± 1.5. The primary indication for PFO closure was previous CS (94 [55.6%] subjects), followed by TIA (75 [44.4%]). Among patients with complete outcome data (n= 154), after a median follow–up of 112 months, recurrent cerebral ischemia occurred in 13 [8.4%], with an annualized rate of 0.92/100 patients. The presence of obesity [OR 5.268, p = 0.018], ROPE score &amp;lt; 7 [OR 5.991, p = 0.035] and migraine [OR = 5.932 p = 0.012] were independent positive predictors of recurrent stroke/TIA after PFO closure. Conclusion In our study, recurrent cerebral events after PFO closure were not negligible, with an annualized rate of 0.92/100 patients, consistent with prior research. Multiple heterogeneous predictors were identified: the presence of obesity, ROPE score &amp;lt; 7 and migraine were independent positive predictors of recurrent stroke/TIA after PFO closure

A non-linear relationship between lesion length and risk of recurrent cerebral ischemia after stenting for symptomatic intracranial stenosis with hemodynamic impairment.

Stent placement can be an effective treatment for patients with symptomatic intracranial stenosis (sICAS) and hemodynamic impairment (HI). However, the association between lesion length and the risk of recurrent cerebral ischemia (RCI) after stenting remains controversial. Exploring this association can help predict patients at higher risk for RCI and develop individualized follow-up schedules. In this study, we provided a post-hoc analysis of a prospective, multicenter registry study on stenting for sICAS with HI in China. Demographics, vascular risk factors, clinical variables, lesions, and procedure-specific variables were recorded. RCI includes ischemic stroke and transient ischemic attack (TIA), from month 1 after stenting to the end of the follow-up period. Smoothing curve fitting and segmented Cox regression analysis were used to analyze the threshold effect between lesion length and RCI in the overall group and subgroups of the stent type. The non-linear relationship between lesion length and RCI was observed in the overall population and subgroups; however, the non-linear relationship differed by subgroup of stent type. In the balloon-expandable stent (BES) subgroup, the risk of RCI increased 2.17-fold and 3.17-fold for each 1-mm increase in the lesion length when the lesion length was <7.70 mm and >9.00 mm, respectively. In the self-expanding stent (SES) subgroup, the risk of RCI increased 1.83-fold for each 1-mm increase in the lesion length when the length was <9.00 mm. Nevertheless, the risk of RCI did not increase with the length when the lesion length was >9.00mm. A non-linear relationship exists between lesion length and RCI after stenting for sICAS with HI. The lesion length increases the overall risk of RCI for BES and for SES when the length was <9.00 mm, while no significant relationship was found when the length was >9.00 mm for SES.

215 PREDICTORS OF RECURRENT CEREBRAL ISCHEMIA AFTER PATENT FORAMEN OVALE CLOSURE: A SINGLE CENTER OBSERVATIONAL STUDY

Abstract Background Transcatheter patent foramen ovale (PFO) closure is an effective therapy in patients with cryptogenic stroke (CS) or transient ischemic attack (TIA) and evidence of PFO. However, the incidence of recurrent cerebral ischemia is not negligible and underlying pathogenic mechanisms remain largely unknown. We sought to evaluate the magnitude of the problem and to assess predictors of recurrent stroke/TIA after transcatheter PFO closure. Methods We enrolled non-randomized consecutive patients who underwent PFO closure for secondary prevention of neurological ischemic events at the University Hospital of Parma between 2004 and 2021. Clinical, echocardiographic and procedure-related features were collected for each patient. The incidence of recurrent ischemic neurological events was assessed at follow-up. Results We enrolled a total of 154 patients. The primary indication for PFO closure was previous stroke (85 [55.2%] subjects) and a third of patients (51 [33.1%]) suffered from migraine, 22 [14.3%] with and 29 [18.8%] without aura. Moreover, mean Risk of Paradoxycal Embolism (ROPE) score at hospital admission was 6.4 ± 1.5. After a median follow-up of 112 months, the incidence of recurrent cerebral ischemia occurred in 13 [8.4%] patients, with an annualized rate of 0.92/100 patients. The presence of migraine, obesity and ROPE &amp;lt; 7 were independent positive predictors of recurrent stroke/TIA. Conclusion The presence of obesity, a familiar history of CVD, ROPE &amp;lt; 7 and migraine were independent positive predictors of recurrent ischemic neurological events after PFO closure.

Only transesophageal echocardiography guided patentforamen ovale closure: Asingle-center experience.

BackgroundAn increasing number of studies have proved that patent foramen ovale (PFO) occlusion could reduce the incidence of recurrent stroke more than drug therapy alone under certain conditions. Which is the “best” guidance technique still remains to be discussed.MethodsA single center retrospective study enrolled 120 patients (mean age 52.51 ± 14.29 years) who underwent PFO closure between April 2019 and March 2021. 87 patients (72.5%) had suffered cryptogenic stroke (CS) at least one time, and 24 patients (20%) had repetitive episodes of hemicrania unsourced. 65 patients were in the transesophageal echocardiography (TEE) guidance group (T-group), and the other 55 patients were in the angiographic guidance group (A-group).ResultsThere were no significant differences in crucial clinical characteristics between the two groups. In T-group, the procedural success rate was higher (100% vs. 92.7%, P = 0.028), and the procedural time was shorter (23.15 ± 13.87 vs. 25.75 ± 7.19, P = 0.001). No difference was detected in the procedural complication rate. Follow-up were performed at least 12 months. At 12 months, new atrial fibrillation occurred in 1 patient (1.5%) in the T-group and in 1 patient (1.8%) in the A-group (P = 0.905). Residual shunt occurred in 1 patient (1.5%) in the T-group and in 3 patients (5.5%) in the A-group (P = 0.236). Recurrent cerebral ischemia occurred in 2 patient (3.1%) in the T-group and in 2 patients (3.6%) in the A-group (P = 0.865).ConclusionThe use of only intra-procedural TEE guidance for PFO closure is safe and effective. The whole procedure can be performed without fluoroscopy and contrast medium. The short and medium follow-up results are satisfactory, especially in the residual shunt.

Increased frequency of CYP2C19 loss-of-function alleles in clopidogrel-treated patients with recurrent cerebral ischemia.

Clopidogrel is used as secondary prevention after cerebral ischaemia. Previous, mainly Asian, studies have shown that genetic variations in CYP2C19 are associated with an increased risk of recurrent stroke in clopidogrel-treated patients. Evidence on the impact of this drug-gene interaction in European neurology patients is currently limited. The aim of this study is to compare the prevalence of CYP2C19 loss-of-function (LoF) alleles in a population with recurrent cerebral ischaemia to two reference groups from the same region. CYP2C19-genotyping (*2 and *3) was performed in clopidogrel-treated patients who presented with a recurrent ischaemic stroke/transient ischaemic attack (TIA). Genotype distributions were compared with two reference groups; a cohort of consecutive patients who underwent elective coronary stent implantation and a cohort of healthy Dutch volunteers. In total, 188 cases with a recurrent ischaemic event were identified, of whom 38 (20.2%) experienced an early recurrent event (24 hours to 90 days after the previous event). Among the total case group, 43.6% of the patients carried at least one CYP2C19 LoF allele, compared with 27.6% and 24.7% in respectively the cardiology and the healthy volunteers reference groups (P < .001 for both comparisons). Among the cases with an early recurrent event, 55.3% of patients were carriers of at least one CYP2C19 LoF allele (P < .0001). In this clopidogrel-treated population with recurrent cerebral ischaemia, the frequency of CYP2C19 LoF alleles was significantly higher than in reference groups, especially in early recurrent events. This study adds to the growing body of evidence that genotype-guided antiplatelet therapy could improve patient outcomes.

Abstract P569: Adherence to Preventive Therapy and Early Recurrent Cerebral Ischemia in Patients With Symptomatic Intracranial Atherosclerotic Disease: Analysis of the Myriad Study

Background: Intracranial atherosclerotic disease (IAD) is a common cause of stroke with high rate of early recurrence despite maximal medical therapy. We sought to determine adherence to secondary preventive therapy and its association with early recurrent ischemia in patients with symptomatic IAD. Methods: The Mechanisms of Early Recurrence in Intracranial Atherosclerotic Disease (MyRIAD) study included patients with recent stroke or transient ischemic attack due to moderate-to-severe IAD. Although MyRIAD did not mandate treatment, patients were recommended to follow standard secondary preventive management including antiplatelet therapy, lipid-lowering medications, antihypertensives for blood pressure (BP) goal &lt;140/90 mmHg, smoking cessation and regular physical activity. Patients underwent 6-8 weeks assessment for medication adherence, smoking status, and physical activity compliance. Adherence to preventive therapy was correlated with new infarcts in the affected vessel territory on brain MRI. Results: Eighty-nine out of 105 patients enrolled in MyRIAD completed 6-8 weeks clinical and brain MRI assessment (mean age 64 +/- 12 years; 57% men). During follow up, 99% were on antiplatelets, 89% on lipid-lowering medications, 81% on antihypertensives, 48% had systolic BP at goal, 79% had diastolic BP at goal, 93% were not active smokers, and 47% were compliant with physical activity. Overall, new infarcts on brain MRI were found in 25% patients. Although no significant differences were found, patients with uncontrolled BP, active smokers and those not compliant with physical activity had a higher frequency of new infarcts in the affected vessel territory (Table). Conclusions: Medication adherence was high after IAD-related stroke. However, a noteworthy fraction of patients had uncontrolled BP, continue to smoke, and were not compliant with physical activity. The latter may represent important therapeutic targets to prevent early recurrent ischemia.

Patent foramen ovale closure in non-lacunar cryptogenic ischemic stroke: where are we now?

Patent foram ovale (PFO) is the most common anatomical cause of an interarterial shunt. It is usually asymptomatic but may cause paradoxical embolism and is a risk factor for non-lacunar cryptogenic cerebral ischemia in young adults. Although the first clinical trials did not show a significant superiority of PFO closure in the secondary prevention of cerebral ischemia as compared with standard antithrombotic treatment, six subsequent randomized clinical trials (CLOSURE I, PC Trial, RESPECT, CLOSE, REDUCE, and DEFENSE-PFO) performed in a sample of cryptogenic stroke in patients aged 60 years or younger provided evidence of a significant reduction of recurrent cerebral ischemia after percutaneous PFO closure. However, the use of percutaneous PFO closure cannot be generalized to the entire population of patients with cerebral ischemia and PFO, but it is indicated in highly selected patients with non-lacunar cryptogenic cerebral infarction with a large right-to-left shunt, an atrial septal aneurysm and no evidence of atrial fibrillation, as well as in association with antithrombotic treatment for an optimal secondary prevention of cerebral ischemia.

Increased platelet procoagulant potential predicts recurrent stroke and TIA after lacunar infarction

BackgroundMean levels of coated‐platelets, a subset of highly procoagulant platelets, are decreased in patients with lacunar as compared to those with non‐lacunar stroke. Elevated coated‐platelets are associated with increased risk for recurrent infarction in non‐lacunar stroke and predict incident stroke after transient ischemic attack (TIA). ObjectiveWe investigated if coated‐platelet levels are predictive of recurrent cerebral ischemia following lacunar stroke. MethodsCoated‐platelet levels were assayed in consecutive patients with acute lacunar stroke, who were followed for up to 12 months. Cox proportional hazards regression analysis was used to estimate the combined risk of stroke and TIA at 12 months according to initial coated‐platelet levels. ResultsWe enrolled a total of 109 lacunar stroke patients. Eight events were recorded over a mean follow‐up period of 10.8 months. A cut‐off of 42.6% for coated‐platelet levels yielded a sensitivity of 0.75 (0.35‐0.97; 95% confidence interval [CI]), specificity of 0.92 (0.85‐0.97), positive predictive value of 0.43 (0.26‐0.62), and a negative predictive value of 0.98 (0.93‐0.99) for recurrent stroke/TIA. The adjusted hazard ratio for recurrent stroke/TIA in patients with coated‐platelet levels ≥ 42.6% was 23.9 (95% CI: 4.26‐134.4) when compared to those with levels < 42.6%. ConclusionsIdentification of increased platelet procoagulant potential may improve our ability to identify patients at higher risk of recurrent stroke/TIA following a lacunar stroke. Further study of mechanisms involved is warranted and may yield novel targets for prevention and treatment.

Clinical Risk Score for Predicting Recurrence Following a Cerebral Ischemic Event.

Introduction: Recurrent stroke has a higher rate of death and disability. A number of risk scores have been developed to predict short-term and long-term risk of stroke following an initial episode of stroke or transient ischemic attack (TIA) with limited clinical utilities. In this paper, we review different risk score models and discuss their validity and clinical utilities.Methods: The PubMed bibliographic database was searched for original research articles on the various risk scores for risk of stroke following an initial episode of stroke or TIA. The validation of the models was evaluated by examining the internal and external validation process as well as statistical methodology, the study power, as well as the accuracy and metrics such as sensitivity and specificity.Results: Different risk score models have been derived from different study populations. Validation studies for these risk scores have produced conflicting results. Currently, ABCD2 score with diffusion weighted imaging (DWI) and Recurrence Risk Estimator at 90 days (RRE-90) are the two acceptable models for short-term risk prediction whereas Essen Stroke Risk Score (ESRS) and Stroke Prognosis Instrument-II (SPI-II) can be useful for prediction of long-term risk.Conclusion: The clinical risk scores that currently exist for predicting short-term and long-term risk of recurrent cerebral ischemia are limited in their performance and clinical utilities. There is a need for a better predictive tool which can overcome the limitations of current predictive models. Application of machine learning methods in combination with electronic health records may provide platform for development of new-generation predictive tools.

57-Year-Old Man With Vertigo

57-Year-Old Man With Vertigo

Six-Month Outcome of Transient Ischemic Attack and Its Mimics

Background and Objective: Although the risk of recurrent cerebral ischemia is higher after a transient ischemic attack (TIA), there is limited data on the outcome of TIA mimics. The goal of this study is to compare the 6-month outcome of patients with negative and positive diffusion-weighted imaging (DWI) TIAs (DWI-neg TIA vs. DWI-pos TIA) and also TIA mimics.Methods: We prospectively studied consecutive patients with an initial diagnosis of TIA in our tertiary stroke centers in a 2-year period. Every included patient had an initial magnetic resonance (MR) with DWI and one-, three-, and six-month follow-up visits. The primary outcome was defined as the composition of intracerebral hemorrhage, ischemic stroke, TIA, coronary artery disease, and death.Results: Out of 269 patients with the initial diagnosis of TIA, 259 patients (mean age 70.5 ± 15.0 [30–100] years old, 56.8% men) were included in the final analysis. Twenty-one (8.1%, 95% confidence interval [CI] 5.1-12.1%) patients had a composite outcome event within the six-month follow-up. Five (23.8%) and 13 (61.9%) composite outcome events occurred in the first 30 and 90 days, respectively. Among patients with DWI-neg TIA, the one- and six-month ischemic stroke rate was 1.5 and 4.6%, respectively. The incidence proportion of composite outcome event was significantly higher among patients who had the diagnosis of DWI-neg TIA compared with those who had the diagnosis of TIA mimics (12.2 vs. 2.1%—relative risk 5.9; 95% CI, 1.4–25.2). In our univariable analysis among patients with DWI-neg TIA and DWI-pos TIA, age (P = 0.017) was the only factor that was significantly associated with the occurrence of the composite outcome.Conclusion: Our study indicated that the overall six-month rate of the composite outcome among patients DWI-neg TIA, DWI-pos TIA, and TIA mimics were 12.2, 9.7, and 2.1%, respectively. Age was the only factor that was significantly associated with the occurrence of the composite outcome.

Exercise and cognitive function in patients with end-stage kidney disease.

In this review we summarize the research pertaining to the role of exercise in preventing cognitive decline in patients with end-stage kidney disease (ESKD). Impairment in cognitive function, especially in executive function, is common in patients with ESKD, and may worsen with maintenance dialysis as a result of retention of uremic toxins, recurrent cerebral ischemia, and high burden of inactivity. Cognitive impairment may lead to long-term adverse consequences, including dementia and death. Home-based and intradialytic exercise training (ET) are among the nonpharmacologic interventions identified to preserve cognitive function in ESKD. Additionally, cognitive training (CT) is an effective approach recently identified in this population. While short-term benefits of ET and CT on cognitive function were consistently observed in patients undergoing dialysis, more studies are needed to replicate these findings in diverse populations including kidney transplant recipients with long-term follow-up to better understand the health and quality of life consequences of these promising interventions. ET as well as CT are feasible interventions that may preserve or even improve cognitive function for patients with ESKD. Whether these interventions translate to improvements in quality of life and long-term health outcomes, including dementia prevention and better survival, are yet to be determined.

Abstract WP72: Recurrent Cerebral Ischemic Events in Symptomatic Carotid Stenosis are Related to Plaque Inflammation

Background and Aims: Severity of symptomatic carotid stenosis often determines the treatment approach. However, severity explains only the regional hypoperfusion as the mechanism of cerebral ischemia. Artery-to-artery embolisation remains an important pathogenic mechanism in patients with high-risk carotid plaques. Inflammation is considered as the initiating event for plaque rupture and cerebral embolism. Using 18F-fluorodeoxyglucose positron-emission tomography (FDG-PET)/computed tomography (CT) and high-resolution magnetic resonance imaging (HR-MRI), we investigated the role of plaque imaging in stroke recurrence in our patients with recently symptomatic carotid stenosis. Methods: This prospective study included consecutive patients within 30-days of recent stroke and ipsilateral carotid stenosis (≥50%). FDG uptake was quantified as mean standardized uptake values (SUV, g/ml). The ratio of T1 hyperintensity of carotid plaque to the ipsilateral sternocleidomastoid muscle (SCM) was recorded on T1-weighted fat suppressed HR-MRI. Patients were followed-up for stroke recurrence within 90-days. Results: Of the 115 patients included in the study, 17 (15%) suffered from recurrent cerebral ischemic event in the stenosed carotid territory within 90-days. Compared to patients who remained asymptomatic, patients with recurrent cerebral ischemia showed higher mean T1 carotid-SCM ratio (2.19 versus 1.38; p&lt;0.0001) and higher mean SUV value in the carotid plaque (3.04g/ml versus 1.25g/ml; p&lt;0.0001). Higher T1 carotid-SCM ratio on HR-MRI (OR 3.215, 95%CI 1.304-5.927; p&lt;0.0001) and higher mean SUV on FDG-PET (OR 3.601, 95%CI 2.924-7.628; p=0.005) were independent predictors of recurrent cerebral ischemia. Conclusions: FDG-PET/CT and HR-MRI of carotid stenosis are useful tools for risk stratification and may aid in better therapeutic decision-making.

Atrial Fibrillation and Risk of Dementia: Epidemiology, Mechanisms, and Effect of Anticoagulation.

Atrial fibrillation (AF) is one of the cardiovascular risk factors for dementia. Several longitudinal studies have reported an association between AF and dementia independently of stroke history. Although the mechanisms underlying this association are not fully understood, proposed mechanisms include cerebral hypoperfusion, inflammation, genetic factors, cerebral microbleeds, and recurrent silent cerebral ischemia. Oral anticoagulation can be used to minimize risk of cognitive decline and dementia, given that brain insults can be caused by chronic microemboli or microbleeds. However, controversy on the effects of warfarin and direct oral anticoagulants on this risk exists. This article will address these aspects, with data on the studies already published and a critical view on this subject.

Flow-diverter Stents for Internal Carotid Artery Reconstruction Following Spontaneous Dissection: ATechnical Report.

Extracranial internal carotid artery (ICA) dissection is an important cause of ischemic stroke in younger adults. The optimal medical and surgical strategies for managing these lesions have not been well established. We report acase series of extracranial ICA reconstruction using overlapping flow-diverter stents as arescue therapy for the treatment of symptomatic ICA dissection in patients presenting with recurrent ischemic stroke and/or severe hemispheric hypoperfusion who failed medical management. Consecutive patients undergoing endovascular reconstruction of either occluded or severely narrowed ICA due to dissection and presenting with symptoms of recurrent cerebral ischemia or cerebral hypoperfusion were included. Data were collected on demographic characteristics, antiplatelet management, clinical presentation, imaging findings, treatment characteristics, complications and stroke recurrence rates. A total of 7patients were included. The mean age was 47years, 4 patients were male and 3 were female. All patients were symptomatic presenting with ipsilateral recurrent ischemia with or without cerebral hemodynamic compromise and necessitated reconstructive treatment. Patients were placed on dual antiplatelet therapy with aspirin and either ticagrelor or clopidogrel prior to the procedure. In cases where patients were not preloaded with dual antiplatelets intravenous abciximab was used as a bridging therapy. Post-stenting angioplasty was performed if deemed necessary. There were no symptomatic ischemic or hemorrhagic complications. No patients had recurrent ischemic events. Reconstruction of the ICA as arescue strategy for extracranial carotid dissection using flow-diverter stents is feasible and was performed without adverse events in this small series.

Determinants and outcome of multiple and early recurrent cervical artery dissections.

To assess putative risk factors and outcome of multiple and early recurrent cervical artery dissection (CeAD). We combined data from 2 multicenter cohorts and compared patients with multiple CeAD at initial diagnosis, early recurrent CeAD within 3 to 6 months, and single nonrecurrent CeAD. Putative risk factors, clinical characteristics, functional outcome, and risk of recurrent ischemic events were assessed. Of 1,958 patients with CeAD (mean ± SD age 44.3 ± 10 years, 43.9% women), 1,588 (81.1%) had single nonrecurrent CeAD, 340 (17.4%) had multiple CeAD, and 30 (1.5%) presented with single CeAD at admission and had early recurrent CeAD. Patients with multiple or early recurrent CeAD did not significantly differ with respect to putative risk factors, clinical presentation, and outcome. In multivariable analyses, patients with multiple or early recurrent CeAD more often had recent infection (odds ratio [OR] 1.81, 95% confidence interval [CI] 1.29-2.53), vertebral artery dissection (OR 1.82, 95% CI 1.34-2.46), family history of stroke (OR 1.55, 95% CI 1.06-2.25), cervical pain (OR 1.36, 95% CI 1.01-1.84), and subarachnoid hemorrhage (OR 2.85, 95% CI 1.01-8.04) at initial presentation compared to patients with single nonrecurrent CeAD. Patients with multiple or early recurrent CeAD also had a higher incidence of cerebral ischemia (hazard ratio 2.77, 95% CI 1.49-5.14) at 3 to 6 months but no difference in functional outcome compared to patients with single nonrecurrent CeAD. Patients with multiple and early recurrent CeAD share similar risk factors, clinical characteristics, and functional outcome. Compared to patients with single nonrecurrent CeAD, they are more likely to have recurrent cerebral ischemia at 3 to 6 months, possibly reflecting an underlying transient vasculopathy.

A Rare Cause of Recurrent Cerebral Ischemia and Syncope: Eagle Syndrome

Eagle syndrome is defined as symptomatic elongation of the styloid process or calcification of the stylohyoid and stilomandibular ligament. The syndrome was described by WW Eagle in 1937. The styloid process is located between the internal and external carotid arteries and laterally in the tonsillar fossa. Patients with cerebrovascular ischemia causing syncope or hemiparesia due to Eagle syndrome are rarely published in the literature. The authors presented a patient with recurrent cerebrovascular attacks due to long styloid process.