Single Infarction Research Articles

Interactions Between Acute Infarcts and Cerebrovascular Pathology Predict Poststroke Dementia.

Chronic cerebrovascular pathology accelerates the incidence of poststroke dementia (PSD). Whether the risk of PSD varies according to different types of chronic cerebrovascular pathology remains unclear. We investigated whether PSD is associated with a unique pattern of interactions between chronic cerebrovascular pathologies and acute stroke lesions. In this case-control study of acute mild stroke patients (n=185), cases included patients who developed PSD at a 6-month poststroke follow-up, and controls included patients who remained nondemented at 6 months, matched on prestroke cognitive status. Magnetic resonance imaging was performed at initial stroke presentation; neuropsychological assessments were performed 6 months after the stroke. White matter hyperintensities (WMH), chronic lacunes, microbleeds, and acute infarcts were not associated with PSD after controlling for demographics, cardiovascular risk, and global cortical atrophy. The risk of PSD was largest for patients with acute large subcortical infarcts (>15 mm) and concomitant periventricular WMH compared with patients with large subcortical infarcts and punctate/absent periventricular WMH [odds ratio (OR)=5.85, 95% confidence interval (CI)=1.85-40.04]. A moderate risk of PSD was observed for patients with acute multiple small infarcts (3 to 15 mm) and concomitant lacunes (OR=2.48, 95% CI=0.94-6.51) or concomitant lobar microbleeds (OR=2.20, 95% CI=0.89-5.41), compared with patients with acute multiple small infarcts and absent lacunes or microbleeds. Single small infarcts did not interact with cerebrovascular pathology to affect PSD. The risk of PSD varies depending on the presence of chronic cerebrovascular pathologies and type of acute infarcts. Clinical implications support a precision medicine approach for stratifying those at highest risk of PSD.

Donepezil Improves Gait Performance in Patients with an Acute Cerebral Infarction: A Prospective Observational Cohort Study.

Hemiplegia is a common symptom after acute cerebral infarction. This study aimed to explore the influence factors of gait performance and investigate whether donepezil could improve gait performance in patients with an acute cerebral infarction. A total of 107 patients who experienced unilateral paresis after an acute cerebral infarction incident were enrolled in this prospectively observational study. Participants underwent a 3- month assessment. At the study's conclusion, patients were divided into 2 groups-those who received donepezil daily (observation Group) and those who did not (Control Group). There was a significant difference (t=3.269, P=0.001) of Wisconsin Gait Scale (WGS) score between single site infarction (27.11±6.65) and multiple sites infarction (31.54±6.42). For gender, smoking, drinking, hypertension, hyperlipidemia and diabetes, there was no difference in WGS scores between subgroups (P>0.05), respectively. The patient's admission National Institute of Health Stroke Scale(NIHSS) score had a strongly positive correlation with WGS score (r=0.850, P<0.001). Besides, age (r=0.218, P=0.024), glycosylated hemoglobin (r=0.274, P=0.004), MMSE (r=-0.261, P=0.007) and Montreal Cognitive Assessment (MoCA) (r=-0.272, P=0.005) had a weak correlation with WGS scores. Multivariate analysis showed age (95% CI: 0.042~0.188, P=0.002), admission NIHSS score (95% CI: 2.405~3.137, P<0.001) and multiple sites infarction (95% CI: 0.044~2.983, P=0.044) were independent risk factors of WGS scores. WGS scores of both observation and control groups gradually decreased after admission (P<0.001). At 3 months after admission, WGS score of the observation group was significantly lower than the control group (t=2.468, P=0.015). There were no significant differences between observation and control group at admission and 1 month after admission (P>0.05) and WGS scores of both single site and multiple sites infarction gradually decreased at one month and three months after admission (P<0.001), while there was no significant difference between two groups (P>0.05). Admission NIHSS score, age and multiple sites infarction were independent risk factors of WGS score. Donepezil could improve gait performance in patients with acute cerebral infarction.

Characteristics of single subcortical small infarction in the middle cerebral artery territory

Objective: To investigate the characteristics and possible mechanisms of differtent stroke patterns of single subcortical small infarction (SSSI) in the middle cerebral artery (MCA) territory. Methods: The clinical and imaging data of patients with acute SSSI in MCA territory admitted to the Neurology Department of People's Hospital of Zhengzhou City from January 2016 to December 2017 were retrospectively analyzed. According to the presence of MCA stenosis and whether the lesion sites on axial DWI-MRI involved the lowest basal ganglia, SSSl were divided into different patterns. The clinical and imaging characteristics of patients with different stroke patterns were compared. Results: Of the 91 patients, 24 (26.37%) were SSSI with parental artery disease (SSSIPAD), 28 (30.77%) were proximal SSSI without PAD (pSSSI-PAD) and 39 (42.86%) were distal SSSI without PAD (dSSSI-PAD). There were significant differences in age, hypertension, diabetes mellitus, smoking, NIHSS score, low density lipoprotein cholesterin (LDL-C) level, infarct layers ≥3, lesion diameter, white matter hyperintensity, lacunar infarction, enlarged perivascular space, cerebral microbleed, concomitant intracranial and extracranial atherosclerotic stenosis among the three groups (all P<0.05). Compared with SSSIPAD(-), patients with SSSIPAD(+) had significantly higher prevalence of smoking, proximal SSSI, ICAS, ECAS, NIHSS score, LDL-C level and larger lesion diameter (all P<0.05). Conclusions: The clinical characteristics and imaging features were different among different SSSI stroke patterns. SSSIPAD is an important infarct type. pSSSI-PAD may showed intermediate features of SSSIPAD and dSSSI-PAD, and evidence of atherosclerosis should be carefully searched for such patients.

Assessment of intracranial and extracranial atherosclerosis in patients presenting with acute ischaemic stroke

Background: Few Indian studies are available which have examined the risk factors and extracranial and intracranial vascular observations in patients with stroke.Methods: We prospectively studied the burden of intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS) in patients (n = 300) with acute ischaemic stroke and study the vascular disease to the outcome of the patients.Results: Their mean age was 57.8 ± 14.2 years; there were 183 (61%) males. The frequency of risk factors were hypertension (73%), diabetes mellitus (46%), tobacco smoking (34%), dyslipidaemia (39.3%), alcoholism (27%), previous stroke (21%), chronic kidney disease (CKD) (9%) and hyperhomocystinaemia (15%). Multiple and single territory infarction was evident in 103 (34.3%) and 197 (65.7%), respectively. Both ICAS and ECAS were evident in 117 (39%), whereas 111 (37%) had ICAS and 36 (12%) had ECAS. On univariate analysis, the presence of CKD (P = 0.01), previous stroke (P = 0.02), ICAS and combined ICAS plus ECAS were associated with unfavourable outcome (P = 0.0001). On multivariable analysis, age >58 years (odds ratio [OR] 1.04, 95% confidence intervals [CI] 0.71–0.89, P < 0.0001), female gender (OR 0.6, 95% CI 0.41–0.87, P = 0.008), National Institutes of Health Stroke Scale score >18 (OR 0.75, 95% CI (0.71–0.80, P < 0.0001) were associated poor functional outcome.Conclusions: ICAS was more common than ECAS. ICAS and combined ICAS plus ECAS were associated with unfavourable outcome.

Determinants of infarction patterns in posterior cerebral circulation

Background Ischemic stroke is defined as focal or global neurological dysfunction lasting longer than 24 h or leading to death that is caused by vascular insult, either stricture or occlusion of a specific vascular territory. Aim of the study This study aimed to determine the relationship between different risk factors and different infarction patterns in posterior circulation such single small lacunar lesion, single large lesion, and multiple scattered lesions. Patients and methods This study included 60 patients recruited from the stroke unit of Ain Shams University and El Sahel Teaching Hospitals during the period from April to October 2018 with the diagnosis of posterior circulation ischemic stroke. The study population was divided into three groups according to the infarction pattern. Infarction patterns were categorized into a single small lacunar lesion (20 patients) (group I), a single large lesion (20 patients) (group II), and multiple scattered lesions (20 patients) (group III). Results There was no significant difference between the three groups in the presence of vascular risk factors such as hypertension (P = 0.153), diabetes (P = 0.317), dyslipidemia (P = 0.420), presence of cardiac diseases (P = 0.180), and smoking (P = 0.931). The only significant difference in terms of vascular risk factors was atrial fibrillation (AF). AF was present in six patients in group II and six patients in group III, and not present in group I patients (P = 0.024). Conclusion Different vascular risk factors such as hypertension, diabetes, dyslipidemia, and smoking are present in all infarction patterns of posterior cerebral circulation, either single or multiple infarctions, and there were no significant differences in the presence of these vascular risk factors in relation to the type of the vascular lesion. AF and significant vertebrobasilar stenosis were mostly associated with large and multiple infarct lesion patterns. Small-vessel disease was the most common stroke etiology for a single small lacunar lesion, whereas large artery atherosclerosis was mostly present in a single large lesion and multiple lesions. Strict control of vascular risk factors is highly recommended in all infarction patterns of posterior circulation.

Branch atheromatous disease diagnosed as embolic stroke of undetermined source: A sub-analysis of NAVIGATE ESUS

Branch atheromatous disease (BAD) is distinctive from large and small arterial diseases, which is single subcortical infarction larger than lacunar stroke in the territories of deep perforators without relevant arterial stenosis. BAD meets the current criteria of embolic stroke of undetermined source. We performed an exploratory analysis of BAD in patients recruited to NAVIGATE embolic stroke of undetermined source, a randomized controlled trial to compare rivaroxaban and aspirin in embolic stroke of undetermined source patients. Among 3972 stroke patients in cerebral hemispheres with intracranial arterial imaging, 502 (12.6%) patients met the criteria for BAD. BAD was associated with younger age (years; OR: 0.97, 95% CI: 0.96-0.98), race (Asian; OR: 1.78, 95% CI: 1.44-2.21), region (Eastern Europe; OR: 2.49, 95% CI: 1.87-3.32), and higher National Institute of Health Stroke Scale (OR: 1.17, 95% CI: 1.12-1.22) at randomization. During follow-up, stroke or systemic embolism (2.5%/year vs. 6.2%/year, p = 0.0022), stroke (2.1%/year vs. 6.2%/year, p = 0.0008), and ischemic stroke (2.1%/year vs. 5.9%/year, p = 0.0013) occurred less frequently in BAD than non-BAD patients. There were no differences in annual rates of stroke or systemic embolism (2.5%/year vs. 2.5%/year, HR: 1.01, 95% CI: 0.33-3.14) or major bleeding (1.3%/year vs. 0.8%/year, HR: 1.51, 95% CI: 0.25-9.05) between rivaroxaban and aspirin groups among BAD patients. BAD was relatively common, especially in Asian and from Eastern Europe among embolic stroke of undetermined source patients. Stroke severity was higher at randomization but recurrence of stroke was fewer in BAD than non-BAD patients. The efficacy and safety of rivaroxaban and aspirin did not differ among BAD patients.

Consecutive Slides on Axial View Is More Effective Than Transversal Diameter to Differentiate Mechanisms of Single Subcortical Infarctions in the Lenticulostriate Artery Territory.

Objective: Lipohyalinosis or atherosclerosis might be responsible for single subcortical infarctions (SSIs); however, ways of differentiating between the two clinically remain uncertain. We aimed to investigate whether consecutive slides on axial view or transversal diameter is more effective to differentiate mechanisms by comparing their relationships with white matter hyperintensities (WMHs).Methods: All the participants from the Standard Medical Management in Secondary Prevention of Ischemic stroke in China (SMART) cohort who had SSIs in the lenticulostriate artery territory were included and categorized according to consecutive slides on axial view (≥4 consecutive slices or not) and transversal diameter (≥15 mm or not). The associations between the severity of WMHs and the different categories were analyzed.Results: Among the 3,821 patients of the SMART study, 281 had diffusion-weighted image-proven SSIs in the lenticulostriate artery territory. When classified by consecutive slides on axial view, SSIs on ≥4 slices were significantly associated with the severity of the WMHs, both in deep WMH (DWMH) (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.11–0.97; p = 0.04) and periventricular hyperintensity (PVH) (OR, 0.37; 95% CI, 0.17–0.78; p = 0.01). No such association was found on the basis of the transversal diameter (p > 0.1).Conclusion: Consecutive slides on axial view (≥4 consecutive slices) might be more effective than transversal diameter to identify the atherosclerotic mechanisms of SSIs in the lenticulostriate artery territory.Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT00664846

Clinical and imaging features of cerebral infarction in children

To summarize and analyze the etiology, clinical manifestations and imaging features of children with cerebral infarction. A retrospective analysis was performed for the clinical data of 54 children with cerebral infarction, including etiology, clinical manifestations, distribution of infarcts, type of infarcts and clinical outcome. Of the 54 children, 93% had a clear cause, among whom 46% had the coexistence of multiple factors, and the top three causes were infection (54%), vascular disease (40%) and trauma (26%). Major clinical manifestations included limb paralysis (85%), pyrexia (20%), disturbance of consciousness (19%) and convulsion (17%). As for the location of infarcts, 80% of the infarcts were located in the cerebral cortex and 52% in the basal ganglia. Major types of infarcts were small-area infarcts (74%) and multifocal infarcts (56%). Viral encephalitis was the most common cause of cerebral infarction caused by infection, with the cerebral cortex as the most common location of infarcts (21/23, 91%) and multiple infarcts as the most common type of infarcts (13/23, 57%). Among the 12 children with cerebral infarction caused by nonspecific endarteritis, 10 (83%) had infarcts located in the basal ganglia and only one child had multiple infarcts. Among the five children with cerebral infarction caused by moyamoya disease, four children (80%) had infarcts located in the cerebral cortex, and large-area infarction (4/5, 80%) and multifocal infarction (4/5, 80%) were the major types of infarcts. Among the children with traumatic cerebral infarcts, 92% had infarcts located in the basal ganglia, and small-area infarcts (92%) and single infarcts (85%) were the major types of infarcts. Among the 46 children with limb paralysis, 34 (74%) had infarcts located in the basal ganglia; 50% of the children with disturbance of consciousness had infarcts located in the basal ganglia. Subcortical infarcts were observed in all six children with epilepsy. Seventy-five percent of the infarcts located in the cerebral cortex and 87% of the infarcts located in the basal ganglia had a good prognosis. Among the two children with cerebral infarcts located in the brainstem, one had the sequela of hemiplegia and the other had the sequela of cognitive impairment. Eighty-eight percent of the children with cerebral infarction caused by infection and 82% of the children with traumatic cerebral infarction tended to have a good prognosis, and 83% of the children with cerebral infarction caused by nonspecific endarteritis had good prognosis. Recurrence was observed in all three children with cerebral infarction caused by vascular malformations. Of the five children with cerebral infarction caused by moyamoya disease, one child died and four children survived with the sequela of localized brain atrophy, among whom one child also had the sequela of epilepsy. Infection, vascular disease and trauma are the most common causes of cerebral infarction in children, and limb paralysis is the most common clinical manifestation. Cerebral cortex is the most common infarct site, and small-area infarcts and multifocal infarcts are the most common types of infarcts, which tend to have a better prognosis.

Cardioembolic Sources in Patients With Small Single Subcortical Infarcts.

Transthoracic echocardiogram (TTE) is widely used as part of the work-up for ischemic stroke. However, the added utility of TTE in the management of small single subcortical infarcts (SSSI) has not been extensively evaluated. Therefore, we aimed to determine the frequency of high-risk and medium-risk cardioembolic sources diagnosed by TTE in SSSI patients, and whether the findings altered clinical management. We performed a retrospective analysis of a prospective cohort of patients with confirmed acute ischemic stroke enrolled in a single-center observational registry between August 2012 and July 2014. We assessed infarct topography on brain magnetic resonance imaging, blinded to final stroke subtype and treatment, to identify patients with SSSI. We defined SSSI as lesions in the corona radiata, basal ganglia, thalamus, or brainstem measuring <1.5 cm in maximal diameter. We excluded patients with atrial fibrillation and large artery stenosis >50%, and assessed the frequency of cardioembolic sources found by TTE in the remaining patients. Among 908 patients, 75 (8.3%) had SSSI, of which 4 (5.3%) had atrial fibrillation and 6 (8%) had symptomatic large artery stenosis. TTE revealed cardiac abnormalities in 46% of the remaining patients (mean age: 65.1 y, 52% female, 58% white). The most common findings were dilated left atrium (29%), patent foramen ovale (14%), and atrial septal aneurysm (7.7%). Anticoagulants were prescribed in 3 (4.6%) patients on the basis of TTE results. TTE identified potential cardioembolic sources in almost half of the patients, but altered antithrombotic management in only 5% of patients with SSSI.

The Relationship between Diffusion-Weighted Magnetic Resonance Imaging Lesions and 24-Hour Rhythm Holter Findings in Patients with Cryptogenic Stroke.

Background and objectives: Cranial magnetic resonance imaging findings of patients considered to be cryptogenic stroke may be useful in determining the clinical and prognostic significance of arrhythmias, such as atrial premature beats and atrial run attacks, that are frequently encountered in rhythm Holter analysis. This study was conducted to investigate the relationship between short atrial runs and frequent premature atrial contractions detected in Holter monitors and infarct distributions in cranial magnetic resonance imaging of patients diagnosed with cryptogenic stroke. Materials and Methods: We enrolled the patients with acute ischemic stroke whose etiology were undetermined. We divided the patients in two groups according to diffusion-weighted magnetic resonance imaging as single or multiple vascular territory acute infarcts. The demographic, clinical, laboratory, echocardiographic, and rhythm Holter analyses were compared. Results: The study investigated 106 patients diagnosed with cryptogenic stroke. Acute cerebral infarctions were detected in 31% of the investigated patients in multiple territories and in 69% in a single territory. In multivariate logistic regression analysis, the total premature atrial contraction count (OR = 1.002, 95% CI: 1.001–1.004, p = 0.001) and short atrial run count (OR = 1.086, 95% CI: 1.021–1.155, p = 0.008) were found as independent variables that could distinguish between infarctions in a single or in multiple vascular territories. Conclusions: Rhythm Holter monitoring of patients with infarcts detected in multiple vascular territories showed significantly higher premature atrial contractions and short atrial run attacks. More effort should be devoted to the identification of cardioembolic etiology in cryptogenic stroke patients with concurrent acute infarcts in the multiple vascular territories of the brain.

Combining Diffusion-Weighted Imaging Patterns with ABCD2 Score Predicts Stroke Risk after Transient Ischemic Attack.

Recent studies indicated that multiple acute infarctions on Diffusion- Weighted Imaging (DWI) were associated with a higher risk of stroke. The study aims to estimate the association of different infarction patterns and ABCD2 score with the prognosis of Transient Ischemic Attack (TIA). We prospectively analyzed the data from TIA database of the First Affiliated Hospital of Zhengzhou University. The predictive outcome was a 90-day ischemic stroke. Cox proportional hazards model was used to evaluate the predictive value of risk factors associated with stroke. The receiver-operating characteristics curves were plotted, and the predictive value was assessed by computing the Area Under the Curve (AUC). A total of 1376 eligible patients were enrolled. DWI patterns were significant predictors for stroke (single acute infarction: hazard ratio [HR] =2.942, p <0.001; multiple acute infarctions: HR =5.552, p <0.001, in comparison with no acute infarction). Patients with both multiple infarctions and ABCD2 ≥4 were associated with approximately 15.5-fold risk of stroke at 90 days (28.8% vs. 2.1%, HR =15.455, 95% confidence interval [CI], 7.946-30.057, p <0.001), compared with those with no infarction or ABCD2 <4. The ABCD2+ DWI patterns showed a better discrimination with an AUC of 0.765 (95% CI, 0.741-0.787) than the ABCD2 score (AUC =0.651; 95% CI, 0.625-0.676; Z =4.777; p <0.0001) and ABCD3-I score (AUC =0.724; 95% CI, 0.700- 0.748; Z =2.697; p =0.007). Combining infarction patterns with ABCD2 score could enhance the predictive value for early stroke risk in TIA.

Does all single infarction have lower risk of stroke recurrence than multiple infarctions in minor stroke?

BackgroundSingle acute infarction (SAI) usually had lower risk of stroke recurrence than multiple acute infarctions (MAIs) in minor stroke. To evaluate whether all SAI had lower risk of stroke recurrence than MAIs in minor stroke.MethodsWe derived data from the imaging subgroup of the Clopidogrel in High-risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial. Minor stroke were categorized into SAI and MAIs by infarction numbers in diffusion weighted imaging. SAI were classified as lacunar infarction and non-lacunar infarction. The outcome was stroke recurrence within one-year follow-up. We assessed the associations between infarction patterns and stroke recurrence using multivariable Cox regression models.ResultsOverall, 834 patients with minor stroke were included in this subgroup, 553 SAI (381 lacunar infarction, 172 non-lacunar infarction) and 281 MAIs. The rate of stroke recurrence was 7.6%, 15.1% and 15.3% in lacunar infarction of SAI, non-lacunar infarction of SAI and MAIs at one year, respectively. Compared with MAIs, lacunar infarction of SAI had lower risk of stroke recurrence (hazard ratio [HR] 0.41, 95% confidence interval [CI] 0.21–0.80, P = 0.009), but not in non-lacunar infarction of SAI (HR 1.01, 95% CI 0.60–1.69, P = 0.98).ConclusionsLacunar infarction of SAI have lower risk of stroke recurrence than MAIs, while non-lacunar infarction of SAI might have similar risk as MAIs. Except for the number of infarctions, size and location should also be considered to stratify risk of stroke recurrence in minor stroke.Trial registrationhttp://www.clinicaltrials.gov Unique identifier: NCT00979589. Date of registration: September 2009.

Infarction Patterns in Posterior Cerebral Circulation: Etiology and Prognosis

Study Objectives: About a quarter of strokes and transient ischemic attacks occur in the vertebrobasilar distribution. Vertebrobasilar stroke is particularly prone to devastating consequences especially brain stem infarctions due to damage of the regional brain tissues that contain vital centers, and is associated with high rates of death and disability. Study Design: This was across sectional observational prospective hospital-based study conducted on 60 patients with first-ever acute posterior circulation ischemic stroke. The aim of the current study was to determine the relationship between different risk factors and different infarction patterns in posterior circulation; single small lacunar lesion, single large lesion, or multiple scattered lesions. Diagnosis of ischemic stroke and stroke subtypes were defined using the Trial of ORG 10,172 in Acute Stroke Treatment (TOAST) criteria as well as clinical and brain imaging features. Stroke severity using National Institutes of Health Stroke Scale (NIHSS) score was done on admission, after 24 hours from admission, and at 7 days from onset of symptoms. The patients functional status was assessed by modified Rankin scale (mRS) done on admission and on discharge from hospital and at 7-day follow up from onset of symptoms. Patients were classified according to infarction patterns into a single small lacunar lesion (group I), a single large lesion (group II), and multiple scattered lesions (group III) 20 patients in each group. Results: There was no significant difference between the three groups as regard the presence of vascular risk factors and the only significant difference as regard vascular risk factors was atrial fibrillation (AF). There was significant difference between the three groups as regard the occurrence of previous transient ischemic attacks (TIA). There was significant difference between the three groups as regard NIHSS score on admission, after 24 hours, and at 7 days from admission. There were significant differences between the three groups as regard mRS score at discharge and at 7-day follow up from the onset of symptoms and the degree of improvement from admission to discharge. There was significant difference between the three groups as regard volume of infarction in Brain magnetic resonance imaging (MRI). Group II and group III patients had larger volumes of infarction when compared to group I patients. There was no significant difference between the three groups as regard presence of significant intracranial stenosis in magnetic resonance angiography (MRA). There was significant difference between the three groups as regard stroke etiology. It was found that largeartery atherosclerosis (LAA) was the most common stroke etiology in posterior circulation being present in (53.3%) of the patient group and was common in group II and III in contrast to group I patients. Conclusions: Different vascular risk factors such as hypertension, diabetes, dyslipidemia, and smoking are present in all infarction patterns of posterior circulation ischemic stroke either single or multiple infarctions. However, AF and significant vertebrobasilar stenosis were mostly associated with large and multiple infarct lesion patterns. Small vessel disease was the most common stroke etiology for single small lacunar lesion while large artery atherosclerosis was associated with single large lesion and multiple lesions in the posterior circulation. Early MRI and MRA help in define type and prognosis of posterior circulation infarcts. Early diagnosis and control of potentially modifiable risk factors and comorbid conditions are an important aspect in the early management of patients with infarction in the posterior circulation.

The Additional Value of PET in the Assessment of Cerebral Small Vessel Disease.

The diagnosis of cerebral small vessel disease (SVD) is difficult because there is no consensus on clinical criteria, and therefore imaging is important for diagnosis. Most patients undergo brain imaging by CT, which is able to detect ischemic strokes, hemorrhages, and brain atrophy and may also indicate white matter changes. MRI remains the key neuroimaging modality and is preferred to CT in vascular cognitive impairment (VCI) because it has higher sensitivity and specificity for detecting pathologic changes. These modalities for imaging morphology permit detection of vascular lesions traditionally attributed to VCI in subcortical areas of the brain, single infarction or lacunes in strategic areas (thalamus or angular gyrus), or large cortical-subcortical lesions reaching a critical threshold of tissue loss. In SVD, multiple punctuate or confluent lesions can be seen in the white matter by MRI and were called leukoaraiosis. Another major neuroimaging finding of SVD in VCI are microhemorrhages. However, whereas CT and MRI are able to detect morphologic lesions, these modalities cannot determine functional consequences of the underlying pathologic changes. PET can support the clinical diagnosis by visualizing cerebral functions in typically affected brain regions. In SVD, 18F-FDG PET can clearly differentiate scattered areas of focal cortical and subcortical hypometabolism that differ from the typical metabolic pattern seen in Alzheimer dementia (AD) with marked hypometabolism affecting the association areas. Additional PET tracers can further support the diagnosis of a type of dementia and also yield information on the underlying pathophysiology.

Clinical analysis of young and middle-aged stroke patients with patent foramen ovale

Objective: To investigate the pathogenesis of young and middle-aged stroke patients with patent foramen ovale (PFO) by analyzing clinical characteristics. Methods: Data of 298 consecutive young and middle-aged patients diagnosed as stroke were retrospectively collected from Department of Neurology, Beijing Anzhen Hospital from January 2010 to January 2017.Patients were divided into cryptogenic stroke (CS) group and not-CS group.Risk factors, characteristics of PFO and infarct of imaging were analyzed between two groups. Results: PFO was confirmed in 88 patients among 298 young and middle-aged stroke patients.The prevalence of PFO was 29.6%. Forty-six patients were assigned into CS group and 42 patients were assigned into not-CS group.The ratio of atrial fibrillation and internal carotid artery stenosis in CS group was lower than that in not-CS group (0 vs 12, 4 vs 22, P<0.05). The concentration of homocysteine was lower in CS group than that in not-CS group [(10.4±1.1) mmol/L vs(14.6±2.4) mmol/L, P<0.05]. The difference of migraine and scores of scale of Risk of Paradoxical Embolism (RoPE) in CS group were significantly higher than those in not-CS group [18 vs 4, (6.8±2.5)vs (5.5±1.4), P<0.05]. The prevalence of big PFO, constant right-to-left shunt and atrial septal aneurysm (ASA) in CS group was higher than that in not-CS group (26 vs 6, 36 vs 18, 5 vs 0, P<0.05). Post-circulation location, single cortex infarction and multiple infarctions in multiple vascular areas are indicative of PFO (25 vs 18, 15 vs 7, 20 vs 8, P<0.05). Conclusion: Migraine, high scores of RoPE, big PFO, constant RLS and ASA are indicative of important role of PFO in cryptogenic stroke in young and middle-aged patients.The imaging characteristics of CS with PFO should be emphasized.

Dysphagia in supratentorial recent small subcortical infarcts results from bilateral pyramidal tract damage.

Background Dysphagia occurs in up to 20% of patients with a recent small subcortical infarct, even when excluding brainstem infarcts. Aim To examine the impact of lesion topography and concomitant cerebrovascular lesions on the occurrence of dysphagia in patients with a single supratentorial recent small subcortical infarct. Methods We retrospectively identified all inpatients with magnetic resonance imaging-confirmed supratentorial recent small subcortical infarcts over a five-year period. Dysphagia was determined by speech-language therapists. Recent small subcortical infarcts were compiled into a standard brain model and compared using lesion probability maps. Furthermore, magnetic resonance imaging scans were reviewed for the combination of both acute and old cerebrovascular lesions. Results A total of 243 patients with a recent small subcortical infarct were identified (mean age 67.9 ± 12.2 years). Of those, 29 had mild and 18 moderate-to-severe dysphagia. Lesion probability maps suggested no recent small subcortical infarct location favoring the occurrence of moderate-to-severe dysphagia. However, patients with moderate-to-severe dysphagia more frequently showed combined damage to both pyramidal tracts by the recent small subcortical infarct and a contralateral old lesion (lacune: 77.8% vs. 19.9%, p < 0.001; lacune or confluent white matter hyperintensities: 100% vs. 57.7%, p < 0.001) than patients without swallowing dysfunction. Comparable results were obtained when analyzing patients with any degree of dysphagia. Conclusions Preexisting contralateral vascular pyramidal tract lesions are closely related to the occurrence of moderate-to-severe dysphagia in patients with supratentorial recent small subcortical infarcts.

Plaque Distribution and Characteristics in Low-Grade Middle Cerebral Artery Stenosis and Its Clinical Relevance: A 3-Dimensional High-Resolution Magnetic Resonance Imaging Study

The significance of atherosclerotic plaques in the parental artery with low-grade stenosis remains undetermined. We used three-dimensional high-resolution magnetic resonance imaging (3D HR-MRI) to investigate plaque distribution and characteristics of low-grade middle cerebral artery (MCA) stenosis and its clinical relevance with stroke events. We retrospectively studied 22 symptomatic patients and 24 asymptomatic patients with low-grade MCA stenosis (<50%). By 3D HR-MRI, each identified plaque was classified as either culprit (plaque on the ipsilateral side of a stroke) or nonculprit (plaques in asymptomatic patients or not within the vascular territory of a stroke). Plaque enhancement grades and distribution were assessed and compared between the groups. The association between plaque enhancement and distribution and ischemic stroke was evaluated. We identified 22 culprit plaques and 31 nonculprit plaques. More culprit plaques showed contrast enhancement compared to the nonculprit plaques (95.5% versus 29.0%, P <.001). Culprit plaques were more frequently superiorly distributed than the nonculprit plaques (46.9% versus 17.5%, P <.01). Contrast enhancement (odds ratio [OR] 17.0, 95% confidence interval [CI] 3.7-77.4) and superior distribution (OR 4.2, 95% CI 1.4-12.1) of a plaque were associated with a recent ischemic stroke, of which single subcortical infarctions accounted for the largest percentage (50%). Contrast enhancement and superior distribution may serve as indicators of culprit plaques in low-grade MCA stenosis, and they were significantly related to a recent ischemic stroke.

Acute Unilateral Audiovestibulopathy due to Embolic Labyrinthine Infarction.

Labyrinthine infarction is a cause of acute audiovestibulopathy, but can be diagnosed only in association with other infarctions involving the brainstem or cerebellar areas supplied by the anterior inferior cerebellar artery (AICA) since current imaging techniques cannot visualize an infarction confined to the labyrinth. This case series aimed to establish embolic labyrinthine infarction as a mechanism of isolated acute audiovestibulopathy. We analyzed clinical features, imaging findings, and mechanisms of embolism in 10 patients (8 men, age range: 38-76) who had developed acute audiovestibulopathy in association with an obvious source of embolism and concurrent acute embolic infarctions in the non-anterior inferior cerebellar artery territories. The presence of audiovestibulopathy was defined when bedside or laboratory evaluation documented unilateral vestibular (head-impulse tests or caloric tests) or auditory loss (audiometry). Six patients showed combined audiovestibulopathy while three had isolated vestibulopathy. One patient presented isolated hearing loss. Audiovestibular findings were the only abnormalities observed in nine patients. In all patients, MRIs documented single or multiple infarctions in the cerebellum (n = 5) or cerebral hemispheres (n = 5). Especially three patients showed single or scattered foci of tiny acute infarctions only in the cerebral hemispheres. Cardiac sources of embolism were found in eight, and artery-to-artery embolism was presumed in two patients. Selective embolism to the labyrinth may be considered in patients with acute unilateral audiovestibulopathy and concurrent acute infarctions in the non-AICA territories.

High resolution magnetic resonance imaging in pathogenesis diagnosis of single lenticulostriate infarction with nonstenotic middle cerebral artery, a retrospective study

BackgroundIt is usually difficult to identify stroke pathogenesis for single lenticulostriate infarction with nonstenotic middle cerebral artery (MCA). Our aim is to differentiate the two pathogeneses, non-branch atheromatous small vessel disease and branch atheromatous disease (BAD) by high-resolution magnetic resonance imaging (HR-MRI).MethodsThirty-two single lenticulostriate infarction patients with nonstenotic MCA admitted to the China-Japan Friendship Hospital from December 2014 to August 2017 were enrolled for retrospective analysis. National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), atherosclerotic risk factors, imaging features, and the characteristic of MCA vessel wall in HR-MRI were evaluated.ResultsMCA plaques were detected in 15(46.9%) patients which implied BAD and 8 of 15 (53.3%) patients had plaques location in upper dorsal side of the vessel wall. Patients with HR-MRI identified plaques had a significantly larger infarction lesion length (1.95 ± 0.86 cm versus 1.38 ± 0.55 cm; P = 0.031) and larger lesion volume (2.95 ± 3.94 cm3 versus 0.90 ± 0.94 cm3; P = 0.027) than patients without plaques. Patients with HR-MRI identified plaques had a significant higher percentage of proximal lesions than patients without plaques (P = 0.055). However, according to the location of MCA plaques, there were no significant differences in terms of imaging features, NIHSS and mRS.ConclusionWe demonstrated high frequency of MCA atheromatous plaques visualized in single lenticulostriate infarction patients with nonstenotic MCA by using HR-MRI. Patients with HR-MRI identified plaque presented larger infarction lesions and more proximal lesions than patients without plaque, which were consistent with imaging features of BAD. HR-MRI is an important and effective tool for identifying stroke etiology in patients with nonstenotic MCA.

Dual Antiplatelet Therapy in Transient Ischemic Attack and Minor Stroke With Different Infarction Patterns

Infarction patterns may serve as important imaging markers to assess the probability of stroke recurrence in transient ischemic attack (TIA) and minor stroke. However, it is unclear whether patients with different infarction patterns benefit differently from dual antiplatelet therapy. To investigate whether infarction patterns can stratify the risk of recurrent stroke and whether the efficacy and safety of clopidogrel plus aspirin vs aspirin alone are consistent in different infarction patterns after TIA or minor stroke. In this prespecified imaging substudy of the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) randomized clinical trial, a total of 1342 patients with noncardioembolic TIA or minor stroke at 45 sites of CHANCE from October 1, 2009, to July 30, 2012, were included in this substudy. The final analysis was conducted on July 30, 2016, and included 1089 patients with required magnetic resonance imaging sequences. Infarction patterns were grouped into multiple acute infarctions (MAIs), single acute infarction (SAI), and no acute infarction (NAI) according to diffusion-weighted imaging. Primary and secondary efficacy outcomes were stroke recurrence and new clinical vascular event after 3 months, respectively. The safety outcome was moderate to severe bleeding risk after 3 months. Among 1089 patients, the mean (SD) age was 63.1 (10.7) years and 731 patients (65%) were men. Patients with MAIs (hazard ratio [HR], 5.8; 95% CI, 2.2-15.1; P < .001) and SAI (HR, 3.9; 95% CI, 1.5-10.5; P = .007) had higher risk of recurrent stroke than those with NAI after adjustment for potential confounders at 3-month follow-up. Stroke recurrence occurred in 15 (10.1%) and 25 (18.8%) of patients with MAIs administered clopidogrel plus aspirin and placebo plus aspirin, respectively (HR, 0.5; 95% CI, 0.3-0.96; P = .04), 24 (8.9%) and 24 (8.5%) of patients with SAI administered clopidogrel plus aspirin and placebo plus aspirin, respectively (HR, 1.1; 95% CI, 0.6-2.0; P = .71), and 3 (2.6%) and 2 (1.4%) of patients with NAI administered clopidogrel plus aspirin and placebo plus aspirin, respectively (HR, 1.7; 95% CI, 0.3-11.1; P = .56), with P = .04 for treatment × infarction pattern interaction effect. Clopidogrel plus aspirin did not increase moderate to severe bleeding risk. Infarction patterns can efficiently stratify the risk of recurrent stroke within 3 months of noncardioembolic TIA or minor ischemic stroke. Patients with MAIs received the most pronounced clinical benefit from dual antiplatelet therapy without increasing the risk of moderate to severe bleeding. However, even if after dual antiplatelet treatment, patients with MAIs still had a risk of stroke recurrence as high as those with SAI. clinicaltrials.gov Identifier: NCT00979589.