Risk Of Future Cerebrovascular Events Research Articles

Managing Recurrent Ischemic Cerebrovascular Events in Patients with Atrial Fibrillation Compliant with Oral Anticoagulant Therapy (P6-5.001)

<h3>Objective:</h3> To evaluate if oral anticoagulant therapy change (OAC change) or adding antiplatelet therapy to anticoagulation (AC+AP) in patients with nonvalvular atrial fibrillation (AF) and acute ischemic stroke (AIS) or transient ischemic attack (TIA) despite OAC compliance, is associated with lower risk of recurrent cerebrovascular events compared to patients that continued the same anticoagulant regimen. <h3>Background:</h3> Patients with AF still have an appreciable risk of AIS or TIA despite compliance with OAC. Yet little is known about the best management options in this population. <h3>Design/Methods:</h3> We reviewed all consecutive patients with AF on OAC that presented with AIS/TIA to our tertiary academic stroke center between 2011–2021. Baseline characteristics, type of index event, antithrombotic therapy before and after index event, subsequent recurrent AIS/TIA or major bleeding events were extracted. Fisher’s exact or Log-rank tests and logistic regression models were used to compare outcomes between OAC unchange vs OAC change, and AC+AP vs AC only groups. <h3>Results:</h3> 185 patients (mean age 78.3 ± 12 years) were included. 61% were males and 79 (42.7%) had AIS at index event. 17 (9%) had OAC change and 100 (79%) received AP+AC. 39 (21.15%) had recurrent AIS/TIA, and 28 (15.1%) had major bleeding following the index event. No significant difference was observed between OAC unchange versus OAC change groups regarding recurrent AIS/TIA (HR = 0.607, 95% CI: 0.229–1.609, p = 0.316) or major bleeding events (OR = 1.541, 95% CI: 0.391–10.299, p = 0.586). Additionally, no significant difference was observed between AC+AP versus AC groups regarding recurrent AIS/TIA (HR= 0.863, 95% CI: 0.430–1.732, p = 0.679) or major bleeding events (OR= 0.894, 95% CI: 0.377–2.135, p = 0.798). <h3>Conclusions:</h3> In patients with AF and acute ischemic cerebrovascular events despite OAC compliance, changing anticoagulant or adding antiplatelet agent may not decrease risk of future cerebrovascular events. <b>Disclosure:</b> Dr. Harahsheh has nothing to disclose. Mr. Elshaigi has nothing to disclose. Dr. Alhayek has nothing to disclose. Vanesa Vanderhye has nothing to disclose. Dr. O’Carroll has nothing to disclose. Dr. Dumitrascu has nothing to disclose.

Long-term outcomes of moyamoya disease versus atherosclerosis-associated moyamoya vasculopathy using high-resolution MR vessel wall imaging

ObjectivesWe aimed to compare the long-term outcomes and surgical benefits between moyamoya disease (MMD) and atherosclerosis-associated moyamoya vasculopathy (AS-MMV) using high-resolution MRI (HRMRI).MethodsMMV patients were retrospectively included and divided into...

Abstract 142: Higher Risk Of Stroke Recurrence In Elderly With Prediabetes: A Nationwide Analysis Of Over 200,000 Hospitalizations From 2016 To 2019

Background: Prediabetes (preDM) is known to double the risk of strokes and also predicts poor functional outcomes. With rising prevalence of preDM among the elderly population in the US, this study aimed to analyze the risk and trends in secondary stroke in elderly with preDM. Methods: We queried the National Inpatient Sample (2016-2019) to identify secondary stroke (with prior stroke/transient ischemic attack, TIA) hospitalizations in elderly population (≥65 years) with vs. without preDM by using ICD-10 codes after excluding patients with diabetes mellitus. Trends and risk of recurrent stroke events, demographics, comorbidities, and outcomes were compared between two cohorts (preDM+ vs. preDM-). Results: Overall prevalence of secondary stroke in geriatric preDM population for 2016-2019 was 2.01% (4045/201120, 50.8% female, 68.4% white) with preDM+ cohort often consisting of younger (median 77 vs 81yrs), male vs females (49.2% vs 44.8%), blacks (14.7% vs 10.7%), Hispanics (8.9% vs 5.4%), Asian/Pacific Islanders (7.2% vs 2.6%) (p&lt;0.001). There were declining trends in recurrent any/ischemic strokes among overall/preDM- cohort but nondeclining in preDM+ cohort Table 1a . The preDM+ cohort often had higher rates of hypertension, hyperlipidemia, obstructive sleep apnea, obesity and peripheral vascular disease. Multivariate analysis adjusted for confounders showed higher odds of any stroke (aOR:1.74, 95%CI:1.58-1.92) and ischemic strokes (aOR:1.83, 95%CI:1.64-2.03) (p&lt;0.001) in preDM+ cohort vs. preDM- cohort [Table 1b] with prior history of stroke/TIA. The rates of transfer to short term hospitals and home health care requirements were higher among preDM+ cohort (3.2% vs. 2.9% &amp; 18.7% vs. 17%). Conclusion: The study shows an increased risk of recurrent/secondary strokes (mainly ischemic) among elderly patients with preDM. Findings emphasize the need for strategies to achieve tighter glycemic control to mitigate risk of future cerebrovascular events.

Stroke Risk and Antithrombotic Treatment During Follow-up of Patients With Ischemic Stroke and Cortical Superficial Siderosis.

In patients with ischemic stroke (IS) or transient ischemic attack (TIA) and cortical superficial siderosis (cSS), there are few data regarding the risk of future cerebrovascular events and also about the benefits and safety of antithrombotic drugs for secondary prevention. We investigated the associations of cSS and stroke risk in patients with recent IS or TIA. We retrospectively analyzed the Microbleeds International Collaborative Network (MICON) database. We selected patients with IS or TIA from cohorts who had MRI-assessed cSS, available data on antithrombotic treatments, recurrent cerebrovascular events (intracranial hemorrhage [ICrH], IS, or any stroke [ICrH or IS]), and mortality. We calculated incidence rates (IRs) and performed univariable and multivariable Cox regression analyses. Of 12,669 patients (mean age 70.4 ± 12.3 years, 57.3% men), cSS was detected in 273 (2.2%) patients. During a mean follow-up of 24 ± 17 months, IS was more frequent than ICrH in both cSS (IR 57.1 vs 14.6 per 1,000 patient-years) and non-cSS (33.7 vs 6.3 per 1,000 patient-years) groups. Compared with the non-cSS group, cSS was associated with any stroke on multivariable analysis {IR 83 vs 42 per 1,000 patient-years, adjusted hazard ratio [HR] for cSS 1.62 (95% CI: 1.14-2.28; p = 0.006)}. This association was not significant in subgroups of patients treated with antiplatelet drugs (n = 6,554) or with anticoagulants (n = 4,044). Patients with cSS who were treated with both antiplatelet drugs and anticoagulants (n = 1,569) had a higher incidence of ICrH (IR 107.5 vs 4.9 per 1,000 patient-years, adjusted HR 13.26; 95% CI: 2.90-60.63; p = 0.001) and of any stroke (IR 198.8 vs 34.7 per 1,000 patient-years, adjusted HR 5.03; 95% CI: 2.03-12.44; p < 0.001) compared with the non-cSS group. Patients with IS or TIA with cSS are at increased risk of stroke (ICrH or IS) during follow-up; the risk of IS exceeds that of ICrH for patients receiving antiplatelet or anticoagulant treatment alone, but the risk of ICrH exceeds that of IS in patients receiving both treatments. The findings suggest that either antiplatelet or anticoagulant treatment alone should not be avoided in patients with cSS, but combined antithrombotic therapy might be hazardous. Our findings need to be confirmed by randomized clinical trials.

Spectral analysis of ultrasound backscatter for non-invasive measurement of plaque composition

Carotid atherosclerotic plaque composition may be an important indication of patient risk for future cerebrovascular events. Ultrasound spectral analysis has the potential to provide a robust measure of plaque composition in vivo if the backscatter transfer function can be sufficiently isolated from the effects of attenuation from overlying tissue, receive and transmit transfer functions from the ultrasound system and transducer, and diffraction. This study examines the usefulness of the nonlinearly generated second harmonic portion of the backscatter signal and the effects of a variety of attenuation compensation techniques for noninvasively characterizing human carotid plaque using spectral analysis and machine learning. Post-beamformed ultrasound backscatter radiofrequency (RF) data were acquired from 6 normal subjects and 119 carotid endarterectomy patients prior to surgery. Plaque obtained following surgery was histologically processed, and regions of interest (ROI) corresponding to homogenous tissue types (fibrous/fibro-lipidic, hemorrhagic and/or necrotic core and calcified) were selected from RF data. Both the harmonic and fundamental power spectra for each ROI was obtained and normalized by data from a uniform phantom (0.5 dB/cm-MHz slope of attenuation). Additional attenuation compensation approaches were compared to simply using the reference phantom: (1) optimum power spectral shift estimation, (2) one-step adventitial, or (3) two-step adventitial. Spectral parameters extracted from both the fundamental and harmonic estimates of the backscatter transfer function of 363 ROI’s from 152 plaque specimens were used to train and test random forest and support vector machine classification models. The best results came from using spectral parameters derived from both the fundamental and second harmonic bands with a predictive accuracy of 65–68%, kappa statistic of 0.49–0.54, and accuracies of 84% for fibrous, 68–74% for hemorrhagic and/or necrotic core, and 78–81% for calcified ROI’s. The result indicated that the nonlinearly generated second harmonic portion of backscatter is useful for carotid plaque tissue characterization and that a reference phantom approach with a 0.5 dB/cm-MHz slope of attenuation works as well as more complicated approaches.

Risk of cerebrovascular events in intracerebral haemorrhage survivors with atrial fibrillation: the Danish Stroke Registry

Abstract Background In patients with atrial fibrillation (AF), who have suffered an intracerebral haemorrhage (ICH), the optimal stroke prevention strategy is unclear. The PRESTIGE-AF trial is a multinational randomized controlled trial designed to investigate the optimal stroke prevention strategy in patients with AF who have recently suffered an ICH. Until the results of the PRESTIGE-AF trial becomes available, data on the risk of future cerebrovascular events in AF patient surviving an ICH are important to gain knowledge on the risk in this patient group and to support the clinician in this challenging situation. Purpose To investigate the risk of cerebrovascular events in a study population of ICH survivors with AF resembling the expected trial population of the PRESTIGE-AF trial. Methods We used the Danish nationwide registries to identify all patients presenting with incident ICH and prevalent AF between 2003–2018. To resemble the expected trial population of the PRESTIGE-AF trial, key inclusion and exclusion criteria of the PRESTIGE-AF trial were applied [Flowchart]. Patients were followed for up to one year in the Danish Stroke Registry, and outcomes (recurrent ICH, cerebrovascular ischaemic event, and all-cause death) were reported according to initiation/resumption of oral anticoagulant therapy (OAC) during follow-up. Results A total of 1,885 patients were included in the study. At one year after the incident ICH, we observed 40 recurrent ICH, 63 cerebrovascular ischaemic events, 88 all strokes, and 650 all-cause deaths [Figure]. When splitting the follow-up period according to initiation/resumption of OAC during follow-up, 526 patients initiated/resumed OAC during follow-up. The median time to initiation/resumption of OAC was 5.3 months (IQR: 1.1–12.0). For the subpopulation of patients not initiating/resuming OAC during follow-up, we observed a 2.6% risk of cerebrovascular ischaemic events, a 1.5% risk of recurrent ICH, and a 30.3% risk of all-cause death at one year after the incident ICH. For the subpopulation of patients initiating/resuming OAC during follow-up, we observed a 2.8% risk of recurrent ICH, a 3.2% risk of cerebrovascular ischaemic events, and a 22.0% risk of all-cause death at one year after the incident ICH. Conclusion In this observational cohort study, we identified a population of ICH survivors with concomitant AF mirroring the expected PRESTIGE-AF trial population. One year after the incident ICH, we observed more cerebrovascular ischaemic events than recurrent ICH events, which was also evident for the subpopulation of patients initiating/resuming OAC during follow-up. The results of the PRESTIGE-AF trial are warranted to determine optimal stroke prevention among ICH survivors with concomitant AF. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This study has received funding from the European Union's Horizon 2020 research and innovation programme. FlowchartFigure

Ultrasound Elastography: another piece in the puzzle of carotid plaque vulnerability?

Recent literature has shown that various carotid plaque features, other than stenosis, contribute to plaque vulnerability. Features such as surface morphology and plaque composition with distinct components (e.g. intraplaque hemorrhage, lipid core) have been associated with the increased risk of future cerebrovascular events. Ultrasonography constitutes the first line modality for the assessment of carotid disease and has traditionally been used to grade stenosis with high accuracy. Recenttechnological advances such as contrast-enhanced ultrasound and elastography increased the diagnostic yield of ultrasound in assessing the morphology of carotid plaques. The purpose of this review is to present the available literature on ultrasound elastography of the atherosclerotic carotid. Strain and shear wave elastography allow for the characterization of plaque components, thus indicating its nature and importantly, the plaque's vulnerability. Shear wave elastography indices appear morerobust than Strain indices. Overall, elastography is a feasible method to distinguish vulnerable carotid plaques. There is, however, a need for larger and longer prospective controlled clinical studies in order to validate elastography as an imaging modality used for the detection of unstable carotid plaques.

Editors' note: Prognostic value of “tissue-based” definitions of TIA and minor stroke: Population-based study

In their post hoc analysis of the Oxford Vascular Study, Dr. Hurford and colleagues echoed the prognostic importance of the modern, “tissue-based” definition of acute stroke. The investigators observed that adult patients with diffusion-weighted imaging (DWI) changes were more likely to develop a subsequent cerebral infarction when compared with patients without DWI changes, regardless of the initial clinical diagnosis (TIA vs stroke). Compared to patients without DWI changes, those with DWI changes were also more likely to die by 90 days or to die at later follow-up. Although most patients (65%) were imaged within 5 days of symptoms, Dr. Cao et al. emphasized that some DWI lesions may be transient or reversible with antithrombotic or fibrinolytic therapy and some may not indicate true tissue ischemia. The authors of the OxVasc study agree that there is a declining appearance of DWI abnormalities with delayed scans; however, such patients with negative delayed scans may have a significantly lower risk of subsequent cerebral infarction as well. Also worth noting is that the diagnosis of “TIA” has long been plagued by a heterogeneous collection of mysterious mechanisms, in spite of the most sophisticated examination scales and neuroimaging. Drs. Gocan et al. question the final diagnoses of the more than 700 patients who were excluded from the OxVasc study because of a final diagnosis being one other than TIA. The authors affirm that all final diagnoses were validated by an experienced vascular neurologist using the criteria established by the World Health Organization. Irrespective of how one might define TIA, we may conclude that any new DWI lesion would be concerning in a patient with transient neurologic deficits because it may portend a significant risk of future cerebrovascular events and mortality. In their post hoc analysis of the Oxford Vascular Study, Dr. Hurford and colleagues echoed the prognostic importance of the modern, “tissue-based” definition of acute stroke. The investigators observed that adult patients with diffusion-weighted imaging (DWI) changes were more likely to develop a subsequent cerebral infarction when compared with patients without DWI changes, regardless of the initial clinical diagnosis (TIA vs stroke). Compared to patients without DWI changes, those with DWI changes were also more likely to die by 90 days or to die at later follow-up. Although most patients (65%) were imaged within 5 days of symptoms, Dr. Cao et al. emphasized that some DWI lesions may be transient or reversible with antithrombotic or fibrinolytic therapy and some may not indicate true tissue ischemia. The authors of the OxVasc study agree that there is a declining appearance of DWI abnormalities with delayed scans; however, such patients with negative delayed scans may have a significantly lower risk of subsequent cerebral infarction as well. Also worth noting is that the diagnosis of “TIA” has long been plagued by a heterogeneous collection of mysterious mechanisms, in spite of the most sophisticated examination scales and neuroimaging. Drs. Gocan et al. question the final diagnoses of the more than 700 patients who were excluded from the OxVasc study because of a final diagnosis being one other than TIA. The authors affirm that all final diagnoses were validated by an experienced vascular neurologist using the criteria established by the World Health Organization. Irrespective of how one might define TIA, we may conclude that any new DWI lesion would be concerning in a patient with transient neurologic deficits because it may portend a significant risk of future cerebrovascular events and mortality.

Risk factors for new ischaemic cerebral lesions after carotid artery stenting: protocol for a systematic review and meta-analysis

IntroductionNew ischaemic cerebral lesions (NICL) detected by diffusion-weighted imaging MRI are common after carotid artery stenting (CAS), with an occurrence rate ranging from 18% to 57%. Many studies reported occurrence...

Serum tumor necrosis factor α levels are associated with new ischemic brain lesions after carotid artery stenting

ObjectiveNew diffusion-weighted imaging (DWI) lesions on magnetic resonance imaging (MRI) after carotid artery stenting (CAS) are associated with an increased risk of future cerebrovascular events. Therefore, we evaluated the association between the expression levels of serum inflammatory markers and new DWI lesions after CAS and the presence of intraplaque hemorrhage (IPH). We also explored the mechanisms underlying this association. MethodsA total of 225 inpatients with severe carotid artery stenosis were consecutively enrolled in this cohort study. Serum inflammatory marker levels were detected in all patients by enzyme-linked immunosorbent assay. In the final analysis, 128 patients who underwent CAS and received pretreatment and post-treatment MRI scans were enrolled. DWI was performed to detect new ischemia brain lesions. T1-weighted, T2-weighted, and time-of-flight sequences were also conducted to identify IPH. ResultsSerum tumor necrosis factor α (TNF-α) levels were significantly higher in symptomatic patients as well as in IPH+ patients identified by carotid MRI. New DWI lesions were identified in 50% of patients after CAS. Univariate analysis showed that DWI+ patients after CAS exhibited older mean age, higher mean TNF-α levels, and more IPH on preoperative MRI and were less likely to have right carotid stenosis than DWI− patients. Multivariate logistic regression analyses revealed that serum TNF-α concentrations were associated with new DWI lesions after CAS (odds ratio, 1.245; 95% confidence interval, 1.068-1.451; P = .005). Finally, the specificity and sensitivity of serum TNF-α levels in predicting DWI+ patients after CAS were 0.828 and 0.453, respectively. ConclusionsHigher serum TNF-α levels are associated with a higher likelihood of new DWI lesions after CAS and the presence of IPH. Therefore, TNF-α is a potentially valuable predictor of acute ischemic cerebral lesions after CAS and the presence of IPH.

The Presence of Previous Cerebral Microbleeds Has a Negative Effect on Hypertensive Intracerebral Hemorrhage Recovery.

Background and Purpose: Cerebral microbleeds are an intracerebral microangiopathy with bleeding tendency found in intracerebral hemorrhage patients. However, studies about cerebral microbleed effects on the prognosis of hypertensive intracerebral hemorrhage patients are rare. We performed a prospective study to discuss not only the risk factors of cerebral microbleed incidence in hypertensive intracerebral hemorrhage patients but also the relevance of cerebral microbleeds with silent brain infarction, hemorrhage and prognosis.Methods: This study enrolled 100 patients diagnosed with hypertensive intracerebral hemorrhage within 3 days after onset. Magnetic resonance imaging including susceptibility-weighted imaging and diffusion-weighted imaging (DWI) were utilized to examine patients on the fifth day after onset. Regular follow-ups were performed to examine the following clinical cerebrovascular events and vascular deaths in 1 year.Results: Cerebral microbleeds were observed in 55 (55%) patients. Multiple logistic regression analysis showed that over-aging, elevation of serum creatinine, and leukoaraiosis were independently associated with cerebral microbleeds. In addition, higher silent brain infarction prevalence was observed in patients with cerebral microbleeds. In contrast, none of the cerebral microbleed patients exhibited cerebral microbleeds ≥5, which is an independent risk factor of poor 3-month neurological function recovery. During the 1-year follow-up, 14 subjects presented clinical cerebrovascular events or vascular death. The Cox proportional hazards model implicated that atrial fibrillation, cerebral microbleeds ≥5 and silent brain infarction were independent predictive factors for these events.Conclusions: Over-aging combined with an elevation of serum creatinine and leukoaraiosis were independent risk factors of cerebral microbleeds. Patients with cerebral microbleeds were more likely to exhibit silent brain infarction. Poor recovery of 3-month neurological function was observed in hypertensive intracerebral hemorrhage patients with cerebral microbleeds ≥5. Cerebral microbleeds ≥5 or silent brain infarction might also indicate an elevated risk of future cerebrovascular events and vascular death.

Risk of Stroke After the International Classification of Diseases-Ninth Revision Discharge Code Diagnosis of Hypertensive Encephalopathy.

Although chronic hypertension is a well-established risk factor for stroke, little is known about stroke risk after hypertensive encephalopathy (HE), when neurologic sequelae of hypertension become evident. Therefore, we evaluated the risk of stroke after a diagnosis of HE. We identified all patients discharged from California, New York, and Florida emergency departments and acute care hospitals between 2005 and 2012 with a primary International Classification of Diseases, Ninth Edition, Clinical Modification discharge diagnosis of HE (437.2). Patients discharged with a primary diagnosis of seizure (345.x) served as negative controls, whereas patients with a primary diagnosis of transient ischemic attack (435.x) were positive controls. Our primary outcome was the composite of subsequent ischemic stroke or intracerebral hemorrhage. Kaplan-Meier survival statistics were used to calculate cumulative outcome rates, and Cox proportional hazard analysis was used to examine the association between index disease types and outcomes while adjusting for vascular risk factors. We identified 8233 patients with HE, 191 091 with seizure, and 308 680 with transient ischemic attack. The 1-year cumulative rate of ischemic stroke or intracerebral hemorrhage after HE was 4.90% (95% confidence interval [CI], 4.45-5.40) when compared with 0.92% (95% CI, 0.88-0.97) after seizure and 4.49% (95% CI, 4.42-4.57) after transient ischemic attack. The risk of intracerebral hemorrhage was significantly elevated in those with HE (hazard ratio, 2.0; 95% CI, 1.7-2.5) but not in those with transient ischemic attack (hazard ratio, 1.0; 95% CI, 0.9-1.1), when compared with seizure patients. Patients discharged with a diagnosis of HE face a high risk of future cerebrovascular events, particularly intracerebral hemorrhage.

Markers of inflammation associated with plaque progression and instability in patients with carotid atherosclerosis.

Atherosclerosis is the focal expression of a systemic disease affecting medium- and large-sized arteries, in which traditional cardiovascular risk factor and immune factors play a key role. It is well accepted that circulating biomarkers, including C-reactive protein and interleukin-6, reliably predict major cardiovascular events, including myocardial infarction or death. However, the relevance of biomarkers of systemic inflammation to atherosclerosis progression in the carotid artery is less established. The large majority of clinical studies focused on the association between biomarkers and subclinical atherosclerosis, that is, carotid intima-media thickening (cIMT), which represents an earlier stage of the disease. The aim of this work is to review inflammatory biomarkers that were associated with a higher atherosclerotic burden, a faster disease progression, and features of plaque instability, such as inflammation or neovascularization, in patients with carotid atherosclerotic plaque, which represents an advanced stage of disease compared with cIMT. The association of biomarkers with the occurrence of cerebrovascular events, secondary to carotid plaque rupture, will also be presented. Currently, the degree of carotid artery stenosis is used to predict the risk of future cerebrovascular events in patients affected by carotid atherosclerosis. However, this strategy appears suboptimal. The identification of suitable biomarkers could provide a useful adjunctive criterion to ensure better risk stratification and optimize management.

Recurrent stroke and patent foramen ovale: a systematic review and meta-analysis.

Recurrent cerebrovascular events are frequent in medically treated patients with patent foramen ovale (PFO), but it still remains unclear whether PFO is a causal or an incidental finding. Further uncertainty exists on whether the size of functional shunting could represent a potential risk factor. The aim of the present study was to evaluate if the presence of PFO is associated with an increased risk of recurrent stroke or transient ischemic attack and to investigate further if this relationship is related to the shunt size. We conducted a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines of all available prospective studies reporting recurrent cerebrovascular events defined as cryptogenic stroke and transient ischemic attacks in medically treated patients with PFO diagnosed by echocardiography or transcranial sonography. We identified 14 eligible studies including a total of 4251 patients. Patients with stroke with PFO did not have a higher risk of the combined outcome of recurrent stroke/transient ischemic attack (risk ratio=1.18; 95% confidence interval=0.78-1.79; P=0.43) or in the incidence of recurrent strokes (risk ratio =0.85; 95% confidence interval=0.59-1.22; P=0.37) in comparison with stroke patients without PFO. In addition, PFO size was not associated with the risk of recurrent stroke or transient ischemic attack. We also documented no evidence of heterogeneity across the included studies. Our findings indicate that medically treated patients with PFO do not have a higher risk for recurrent cryptogenic cerebrovascular events, compared with those without PFO. No relation between the degree of PFO and the risk of future cerebrovascular events was identified.

MRI Plaque Imaging Detects Carotid Plaques with a High Risk for Future Cerebrovascular Events in Asymptomatic Patients

PurposeThe aim of this study was to investigate prospectively whether MRI plaque imaging can identify patients with asymptomatic carotid artery stenosis who have an increased risk for future cerebral events. MRI plaque imaging allows categorization of carotid stenosis into different lesion types (I–VIII). Within these lesion types, lesion types IV–V and VI are regarded as rupture-prone plaques, whereas the other lesion types represent stable ones.MethodsEighty-three consecutive patients (45 male (54.2%); age 54–88 years (mean 73.2 years)) presenting with an asymptomatic carotid stenosis of 50–99% according to ECST-criteria were recruited. Patients were imaged with a 1.5-T scanner. T1-, T2-, time-of-flight-, and proton-density weighted studies were performed. The carotid plaques were classified as lesion type I–VIII. Clinical endpoints were ischemic stroke, TIA or amaurosis fugax. Survival analysis and log rank test were used to ascertain statistical significance.ResultsSix out of 83 patients (7.2%) were excluded: 4 patients had insufficient MR image quality; 1 patient was lost-to-follow-up; 1 patient died shortly after the baseline MRI plaque imaging. The following results were obtained by analyzing the remaining 77 patients. The mean time of follow-up was 41.1 months.During follow-up, n = 9 (11.7%) ipsilateral ischemic cerebrovascular events occurred. Only patients presenting with the high-risk lesion types IV–V and VI developed an ipsilateral cerebrovascular event versus none of the patients presenting with the stable lesion types III, VII, and VIII (n = 9 (11.7%) vs. n = 0 (0%) during follow-up). Event-free survival was higher among patients with the MRI-defined stable lesion types (III, VII, and VIII) than in patients with the high-risk lesion types (IV–V and VI) (log rank test P<0.0001).ConclusionsMRI plaque imaging has the potential to identify patients with asymptomatic carotid stenosis who are particularly at risk of developing future cerebral ischemia. MRI could improve selection criteria for invasive therapy in the future.

Intraplaque stretch in carotid atherosclerotic plaque--an effective biomechanical predictor for subsequent cerebrovascular ischemic events.

BackgroundStretch is a mechanical parameter, which has been proposed previously to affect the biological activities in different tissues. This study explored its utility in determining plaque vulnerability.MethodsOne hundred and six patients with mild to moderate carotid stenosis were recruited in this study (53 symptomatic and 53 asymptomatic). High resolution, multi-sequence magnetic resonance (MR) imaging was performed to delineate various plaque components. Finite element method was used to predict high stretch concentration within the plaque.ResultsDuring a two-year follow-up, 11 patients in symptomatic group and 3 in asymptomatic group experienced recurrent cerebrovascular events. Plaque stretch at systole and stretch variation during one cardiac cycle was greater in symptomatic group than those in the asymptomatic. Within the symptomatic group, a similar trend was observed in patients with recurrent events compared to those without.ConclusionPlaques with high stretch concentration and large stretch variation are associated with increased risk of future cerebrovascular events.

013 Differences in Arterial Stiffness Pre- and Post-Carotid Endarterectomy: Does History of Cardiovascular Disease Matter?

very rare complication of coronary artery bypass grafting (CABG). Our objective was to determine the clinical features and management options for aortocoronary SVGAs in an effort to develop an approach to identifying and managing patients with this complication. METHODS/RESULTS: We performed a systematic review of published cases in MEDLINE and SCOPUS between 1966 and December 2010. Standardized data were extracted by two independent reviewers. We identified 209 reported cases of aortocoronary SVGAs in 168 articles. Patients were predominantly male (86.6%) and had a mean age of 65.3 10.6 years. SVGAs were identified on average 13.1 6.0 years after CABG with a mean diameter of 60.7 31.8 mm. Mechanical complications were reported in 34.0% of cases at presentation. Though most patients presented with chest pain (43.5%), SVGAs were commonly identified incidentally on imaging (35.4%). The most commonly employed investigations were cardiac catheterization (66.5%) and computed tomography (60.3%). In cases in which serial follow-up were described, nearly all aneurysms continued to increase in size. Surgical management was reported in 58.4% of cases, percutaneous intervention in 15.8%, and conservative therapy in 20.1% with short-term mortality rates of 13.9%, 6.1%, and 23.8%, respectively. CONCLUSIONS: SVGAs represent a rare but increasingly recognized complication of CABG most often seen remotely from the surgery. A large subset of patients with SVGAs are asymptomatic. It is hypothesized that the aneurysms continue to grow over time albeit at variable rates. Though further study is required, both surgical and percutaneous interventions appear to have favourable outcomes. In select patients, percutaneous management offers an alternative to repeat sternotomy.

Carotid Disease and Stroke

Carotid Disease and Stroke. Stroke is a major cause of disability, mortality, dementia, and depression in the world. Carotid atherosclerosis is recognized as an important cause of stroke and a modifiable factor for the risk reduction of subsequent stroke. Randomized clinical trials have shown efficacy of carotid endarterectomy (CEA) in secondary stroke prevention. Carotid stenting has emerged as a new and less invasive alternative to CEA. Continuous advances in medical therapy have made remarkable success in stroke risk reduction. These new treatment modalities were not widely applied in most interventional trials, making extrapolation of an optimal intervention strategy evermore complex in patients with symptomatic and asymptomatic carotid disease. The determination between “symptomatic” and “asymptomatic” carotid stenosis is a pivotal determinant of management of carotid disease. This special issue provides an updated synopsis of risk factors, imaging modalities, and different treatment options of atherosclerotic carotid disease. Some of the highlights are included in the following: In the basic science rat model, the neurotrophic effect of an immunosuppressant agent after transient global cerebral ischemia is presented by Z. N. Sharifi et al. A paper of S. Kovacic and M. Bakran provides a discussion of the main genetic investigations associated with human atherosclerotic vascular diseases. The paper by A. Chatzikonstantinou et al. summarizes the literature of the natural history of the carotid disease and provides evidence that carotid stenosis is a sensitive marker of systemic atherosclerosis. The causal relationship between stroke-free patients with advanced carotid stenosis and cognitive decline is presented in the paper by I. Martinic-Popovic et al. The paper by V. Vukovic-Cvetkovic presents a comprehensive review of (microembolic signal) MES detection and stroke risk by transcranial doppler (TCD)—an important ultrasound technique shown to successfully stratify asymptomatic patients at high risk for future cerebrovascular events. The paper by M. Roje-Bedekovic et al. explores the visual evoked response in patients with severe carotid stenosis, a marker which serves as an important preoperative functional assessment of intracranial circulation. The paper by L. Pedrini et al. discusses near infrared spectroscopy (NIRS) during CEA as a reliable method in detection of clamping ischemia and in the prevention of clamping-related neurologic deficits during CEA. In the paper by H. Koerner et al., periprocedural ischemic lesions on diffusion-weighted imaging (DWI) during stenting procedures of supra-aortal arteries are discussed. The level of platelet inhibition is presented as an intriguing approach to determining the relationship between nonresponders to clopidogrel and clinically silent microembolization. The paper by F. Sallustio et al. presents a case series data suggesting that early carotid artery stenting may be considered as a safe alternative to CEA after IV thrombolysis in selected patients who are at high risk of stroke recurrence. The primary and secondary stroke prevention approaches are exciting clinical topics in evolution with many opportunities and options for both current treatment and future discoveries. Innovations in genetics, pharmacogenomics, and vascular imaging will likely provide specific pathophysiological targets, tailored treatments, and personalized medical management for individuals with atherosclerotic carotid disease. We hope that this special issue will serve as an overview of the accomplishments, current practices, and controversies in the field as well as a useful reference for management of patients with carotid disease and future research opportunities. Arijana Lovrencic-Huzjan Tatjana Rundek Michael J. Katsnelson

Decreased Kidney Function Is a Significant Factor Associated with Silent Cerebral Infarction and Periventricular Hyperintensities

Background/Aims: Silent cerebral lacunar infarction (SCI) and periventricular hyperintensities (PVH) have been reported to be markers of ischemic cerebral small-vessel disease and risk factors for future cerebrovascular events in the general population. The relationship between CKD and SCI/PVH is examined. Methods: In this cross-sectional study, brain magnetic resonance imaging was performed with a 1.5-T system in 324 predialysis CKD patients and in 60 normal subjects. Results: SCI was found in 103 CKD patients (31.8%), and PVH was found in 174 CKD patients (53.7%). SCI/PVH were more prevalent in patients with higher blood pressure, advanced age and decreased kidney function. There was a significant association between the prevalence of SCI/PVH and the CKD stage, with greater prevalence of SCI/PVH as the CKD stage advanced (p < 0.0001). PVH grade also advanced as the CKD stage advanced. The estimated glomerular filtration rate was a significant factor associated with the presence of SCI/PVH, independent of any other factors. There was a strong association between the prevalence of SCI/PVH (p < 0.0001). Conclusion: In CKD patients, decreased kidney function is a significant factor associated with SCI/PVH, both of which are significantly associated with each other. These results suggest that CKD patients with SCI/PVH are at greater risk of future cerebrovascular events.

MRI-plaqueimaging detects carotid plaques with a high risk for future cerebrovascular events

Background: High-Resolution Magnetic Resonance Imaging (MRI) represents a new technique for risk classification of carotid plaque features. MRI-Plaqueimaging allows categorization of carotid artery stenosis (CS) in distinct lesion types (I-VIII) according to a modified histological scheme based on American Heart Association (AHA) criteria. Lesion types IV-V and VI are regarded as high risk, rupture prone plaques.