Small-artery Occlusion Subtype Research Articles

Polymorphisms of the Matrix Metalloproteinase Genes are Associated with Acute Ischemic Stroke in Chinese Han Population.

Studies have shown that matrix metalloproteinase (MMP-2,3,9) plays an important role in the pathologic process of ischemic stroke (IS). The aim of this study was to investigate the relationship between C1306T, 1612-5A/6A, C-1562T polymorphisms of MMP-2,3,9 genes and IS in Chinese Han population. The polymorphisms of MMP-2(C1306T), -3(1612-5A/6A), -9(C-1562T) gene were detected by PCR-RFLP and SNaPshot sequencing. Then, stratified analysis was used to study the relationship between IS subtypes and MMP-2,3,9 polymorphisms. For the MMP-2 gene C1306T polymorphism, TT genotype and T allele were significantly associated with a reduced risk of IS (P = 0.015, P = 0.003, respectively). T allele was significantly associated with a reduced risk of small artery occlusion (SAO) subtype compared with the control group (P = 0.012, OR = 0.550, 95% CI = 0.065-1.291). For the MMP-3 gene-1612 (5A/6A) polymorphism, 5A/5A genotype was significantly increased in the IS group (P = 0.011, OR = 0.370, 95% CI = 0.168-0.814), especially in the large-artery atherosclerosis (LAA) subtype (P = 0.001, OR = 2.345) as compared to the control group. Our study suggested that the T allele of MMP-2 may be a protective factor of IS, especially in SAO subtype, while the 5A/5A gene of MMP-3 may increase the risk of IS, especially in LAA subtype in Chinese Han population.

Clinical features, risk factors and prognosis of idiopathic dilated cardiomyopathy complicated by ischemic stroke

Objective: To analyze the clinical features, risk factors and prognosis of idiopathic dilated cardiomyopathy (DCM) complicated with ischemic stroke (IS) (DCM-IS). Methods: The clinical data of patients with idiopathic DCM (n=613) in Beijing Anzhen Hospital, Liangxiang Hospital and Fuxing Hospital from January 2016 to December 2020 were retrospectively collected, and among them, 123 cases were DCM-IS. Clinical features of patients with DCM-IS were summarized and multivariate logistic regression model was utilized to analyze the independent risk factors of DCM-IS. Furthermore, 1-year follow-up was conducted and Kaplan-Meier curve was adopted to analyze the prognosis of DCM, using all-cause death and heart transplantation as adverse outcomes. Results: Among the 70 patients with DCM-IS, 6 patients (8.6%, 6/70) were in accordance with the subtype of large artery atherosclerosis, and 47 patients (67.1%, 47/70) were in line with the subtype of cardiogenic embolism, and small artery occlusion subtype (ie, lacunar infarction) were detected in 17 cases (24.3%, 17/70). Hypertension [odds ratio (OR)=1.617, 95% confidence interval (CI): 1.049-2.491, P=0.029], hyperlipidemia (OR=1.918, 95%CI: 1.198-3.073, P=0.007), atrial fibrillation (AF) (OR=1.617, 95%CI: 1.016-2.572, P=0.043), lower estimated glomerular filtration rate (eGFR) (OR=0.986, 95%CI: 0.977-0.996, P=0.005) and a higher incidence of intracardiac thrombus (OR=6.127, 95%CI: 3.174-11.827, P<0.001) were risk factors for DCM-IS. The overall 1-year survival rate was lower in DCM-IS patients (70.7%) than DCM patients without stroke (83.6%, P=0.004), and the main causes of death included obstinate heart failure (3 cases of DCM-IS, and 5 cases of non-DCM-IS) and malignant arrhythmia (DCM-IS) (22 cases of DCM-IS, and 18 cases of non-DCM-IS). Conclusions: Among IS patients with idiopathic DCM, cardioembolism is the most common, followed by lacunar infarction, and the large-artery atherosclerotic subtype is the least common.Hypertension, hyperlipidemia, AF, lower eGFR value and higher incidence of intracardiac thrombus are risk factors for DCM-IS. DCM patients complicated with IS have poor short-term prognosis, and obstinate heart failure and malignant arrhythmia are their main causes of death.

Nontraditional Risk Factors for Residual Recurrence Risk in Patients with Ischemic Stroke of Different Etiologies

Background and Objective: With the popularization of guideline-based secondary prevention based on traditional risk factors, rates of stroke recurrence reduced greatly after ischemic stroke (IS) or transient ischemic attack (TIA), but the residual risk still exists. We aim to evaluate which IS subtype benefits the most from the current secondary prevention and to evaluate nontraditional risk factors for residual recurrence risk of different IS etiologies. Methods: The study included IS/TIA patients who participated in both biomarker substudy and imaging substudy of the Third China National Stroke Registry. We used 5 guideline-recommended interventions (antiplatelet, statins, anticoagulant, antihypertensive, and antidiabetic therapies) to document the performance of secondary prevention care. Residual risk was defined as the risk of stroke recurrence despite adherence to these 5 guideline-based secondary prevention strategies. Risk factors associated with stroke recurrence were analyzed by using Cox regression models. Results: In total, 9,733 patients were included in this study. At 3 months, 4,186 (43.0%) patients adhered to 5 secondary prevention strategies, and the residual risk of recurrence was 5.1%. According to Trial of Org 10172 in Acute Stroke Treatment subtypes, cardioembolism benefited the most from current secondary prevention (relative risk reduction: 65.2%), followed by large-artery atherosclerosis (LAA) (29.0%) and small-artery occlusion (SAO) (20.0%). Despite adhering to secondary prevention strategies, high sensitivity C-reactive protein, interleukin-6 (IL-6) levels, and impaired renal function were independent risk factors for the residual recurrence risk of LAA subtype, while IL-6 and trimethylamine N-oxide significantly contributed to the residual risk of SAO subtype. Conclusions: LAA and SAO subtypes own the specific nontraditional risk factors while inflammation is a common risk factor for residual recurrence risk of both.

Night-time diastolic blood pressure variability relates to stroke recurrence in patients who had ischaemic stroke with small artery occlusion

Background and purposeThe association between blood pressure variability (BPV) and stroke recurrence among patients who had ischaemic stroke (IS) remains unclear. This study aimed to investigate the association between BPV...

Trimethylamine N-Oxide and Stroke Recurrence Depends on Ischemic Stroke Subtypes.

Trimethylamine N-oxide (TMAO) has been recognized as a risk factor for cardiovascular disease. However, the role of TMAO in ischemic stroke remains unclear. As we know, ischemic stroke is a heterogeneous disease with variable pathogenesis. Hence, we aimed to investigate the association between TMAO and stroke recurrence according to etiology subtypes. A total of 10 756 ischemic stroke/transient ischemic attack patients from the Third China National Stroke Registry were enrolled, and 1-year follow-up data for stroke recurrence were analyzed. TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria was used to classify the etiology subtypes. Plasma TMAO levels were quantified by liquid chromatography-mass spectrometry. The association between TMAO and stroke outcomes was analyzed using Cox regression models. We also conducted a meta-analysis on the association of TMAO levels and stroke risk. Elevated TMAO level was independently associated with the risk of stroke recurrence (Q4 versus Q1: adjusted hazard ratio, 1.37 [95% CI, 1.15-1.64]) in multivariate Cox regression model. After stratification by TOAST subtypes, there was a significant association between TMAO and stroke recurrence in small artery occlusion subtype (adjusted hazard ratio, 1.43 [95% CI, 1.03-2.00]) but not in the others subtype (large-artery atherosclerosis, 1.19 [0.95-1.48]; cardioembolism, 1.54 [0.95-2.48]; others, 1.19 [0.98-1.44]). The meta-analysis reported on stroke recurrence for the highest versus lowest TMAO levels with a pooled hazard ratio of 1.66 (95% CI, 0.91-3.01) and similarly found an increased risk of stroke recurrence. Elevated TMAO level is associated with increased risk of stroke recurrence in patients with small artery occlusion subtype, but this association seems to be attenuated in large-artery atherosclerosis, cardioembolism, and others subtypes.

Causal associations of insulin resistance with coronary artery disease and ischemic stroke: a Mendelian randomization analysis

IntroductionThe relationship between insulin resistance (IR) and cardiovascular diseases is unclear. We aimed to examine the causal associations of IR with cardiovascular diseases, including coronary artery disease, myocardial infarction, ischemic...

Association of DIAPH1 gene polymorphisms with ischemic stroke.

DIAPH1 is a formin protein involved in actin polymerization with important roles in vascular remodeling and thrombosis. To investigate potential associations of DIAPH1 single-nucleotide polymorphisms (SNPs) with hypertension and stroke, 2,012 patients with hypertension and 2,210 controls, 2,966 stroke cases [2,212 ischemic stroke (IS), 754 hemorrhagic stroke (HS)] and 2,590 controls were enrolled respectively in the case-control study. A total of 4,098 individual were included in the cohort study. DIAPH1 mRNA expression was compared between 66 IS [43 small artery occlusion (SAO) and 23 large-artery atherosclerosis (LAA)] and 58 controls. Odds ratio (OR), hazard ratio (HR) and 95% confidence interval (CI) were calculated by logistic and cox regression analysis. Rs7703688 T>C variation was significantly associated with an increased risk of IS [OR (95% CI) was 1.721 (1.486-1.993), P=4.139×10-12]. Association of rs7703688 with stroke risk was further validated in the cohort study [adjusted HRs (95% CIs) for additive and recessive models were 1.385 (1.001-1.918), P=0.049, and 2.882 (1.038-8.004), P=0.042, respectively)]. DIAPH1 mRNA expression was significantly downregulated in IS. In SAO stroke subtype, DIAPH1 expression has an increased trend among rs251019 genotypes (Ptrend=0.048). These novel findings suggest that DIAPH1 variation contributes to genetic susceptibility to stroke risk, especially the SAO subtype of IS.

Artificially Sweetened Beverages and Stroke, Coronary Heart Disease, and All-Cause Mortality in the Women's Health Initiative.

Background and Purpose- We examine the association between self-reported consumption of artificially sweetened beverages (ASB) and stroke and its subtypes, coronary heart disease, and all-cause mortality in a cohort of postmenopausal US women. Methods- The analytic cohort included 81 714 women from the Women's Health Initiative Observational Study, a multicenter longitudinal study of the health of 93 676 postmenopausal women of ages 50 to 79 years at baseline who enrolled in 1993 to 1998. This prospective study had a mean follow-up time of 11.9 years (SD of 5.3 years.) Participants who completed a follow-up visit 3 years after baseline were included in the study. Results- Most participants (64.1%) were infrequent consumers (never or <1/week) of ASB, with only 5.1% consuming ≥2 ASBs/day. In multivariate analyses, those consuming the highest level of ASB compared to never or rarely (<1/wk) had significantly greater likelihood of all end points (except hemorrhagic stroke), after controlling for multiple covariates. Adjusted models indicated that hazard ratios and 95% confidence intervals were 1.23 (1.02-1.47) for all stroke; 1.31 (1.06-1.63) for ischemic stroke; 1.29 (1.11-1.51) for coronary heart disease; and 1.16 (1.07-1.26) for all-cause mortality. In women with no prior history of cardiovascular disease or diabetes mellitus, high consumption of ASB was associated with more than a 2-fold increased risk of small artery occlusion ischemic stroke hazard ratio =2.44 (95% confidence interval, 1.47-4.04.) High consumption of ASBs was associated with significantly increased risk of ischemic stroke in women with body mass index ≥30; hazard ratio =2.03 (95% confidence interval, 1.38-2.98). Conclusions- Higher intake of ASB was associated with increased risk of stroke, particularly small artery occlusion subtype, coronary heart disease, and all-cause mortality. Although requiring replication, these new findings add to the potentially harmful association of consuming high quantities of ASB with these health outcomes.

Retrospective analysis of prognosis and risk factors of patients with stroke by TOAST.

To determine differences in 90-day mortality and identify risk factors among different etiological classifications of ischemic stroke using the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification.Our retrospective analysis included 538 ischemic stroke patients. The cause of stroke was categorized according to the TOAST criteria, and 90-day mortality rates were obtained through the patient follow-up. Age, sex, previous medical history, and clinical features were used in the analysis of potential risk factors.There were 38 deaths during the 90-day follow-up period. Patients in the undetermined cause subgroups experienced significantly higher mortality rate than those in subgroups with small artery occlusion and large artery atherosclerosis. Factors independently associated with 90-day mortality for patients with the large artery atherosclerosis stroke subtype were age (95% confidence interval [CI], 1.010–1.192, P = .028), history of hypertension (95% CI, 3.030–99.136, P = .001), high blood glucose (95% CI, 1.273–2.354, P < .001), high cholesterol (95% CI, 0.017–0.462, P = .004), high uric acid (95% CI, 2.360–64.389, P = .003), and National Institute of Health Stroke Scale(95% CI, 1.076–1.312, P = .001). Age (95% CI, 1.012–1.358, P = .034) and high cholesterol (95% CI, 0.011–0.496, P = .007) were independently associated with 90-day mortality for patients with the small artery occlusion subtype of stroke.Our analysis identified that certain risk factors and 90-day mortality differ significantly among different stroke subtypes, as classified by the TOAST criteria. These risk factors must be considered carefully to provide the best clinical management of these patients and thus reduce mortality.

The role of high-sensitivity C-reactive protein levels in functional outcomes in patients with large-artery atherosclerosis and small-artery occlusion

Background: High-sensitivity C-reactive protein (hs-CRP) is an inflammatory marker that is associated with the outcomes of ischemic stroke. However, the role of hs-CRP levels in the functional outcomes after large-artery atherosclerosis (LAA) and small-artery occlusion (SAO) is poorly understood. Methods: We recruited 1299 patients diagnosed as having LAA and 453 patients diagnosed as having SAO from 1 January 2009 to 31 December 2013, from the Department of Neurology, Tianjin Huanhu Hospital. The hs-CRP values were classified into two groups based on the significant threshold of hs-CRP level in the receiver operating characteristic (ROC) curve (≥3.215 mg/L in LAA and ≥1.72 mg/L in SAO). We examined the relationship between hs-CRP levels on admission and the modified Rankin scale scores using univariate and multivariate analyses. Results: Patients with LAA had a higher hs-CRP mean value than patients with SAO (7.69 vs. 4.12 mg/L). The ROC curve showed a significant hs-CRP threshold value at 3.215 mg/L in patients with LAA and at 1.72 mg/L in patients with SAO. Logistic regression analyses showed that patients with LAA with hs-CRP levels ≥3.215 mg/L had a significant risk of poor outcome compared with those with hs-CRP levels <3.215 mg/L (odds ratio [OR], 1.545; 95% confidence interval [CI], 1.155–2.067; p = 0.003). Meanwhile, patients with SAO with hs-CRP levels ≥1.72 mg/L had a significant risk of poor outcome compared with those with hs-CRP levels <1.72 mg/L (OR, 1.97; 95% CI, 1.02–3.801; p = 0.043). Moreover, combining hs-CRP with National Institutes of Health Stroke Scale could predict outcome with satisfying clinical accuracy both in LAA and SAO subtype. Conclusions: Patients with LAA with hs-CRP levels <3.215 mg/L and patients with SAO with hs-CRP levels <1.72 mg/L on admission had favorable functional outcomes at 3 months after stroke onset.

Validation of the Essen Stroke Risk Score in different subtypes of ischemic stroke

Objective: Predictive scores are important tools for stratifying patients based on their risk of future vascular events and for selecting preventive therapies. The aim of this study is to validate the Essen Stroke Risk Score (ESRS) for stratifying stroke recurrence in different subtypes of non-atrial fibrillation ischemic stroke in a large Chinese cohort.Methods: Data were derived from the Blood pressure and clinical Outcome in Stroke Survivors registry, which includes a cohort of 2204 stroke patients. All patients were further classified according to the TOAST (Trial of Org 10 172 in Acute Stroke Treatment) criteria. We stratified one-year cumulative rates for stroke and composite vascular events using the ESRS. The predictive power of the ESRS was assessed using the area under the receiver–operator curves (AUC).Results: Among 1699 patients included in the study, the AUC of ESRS was 0.58 (95% CI: 0.52–0.64) for recurrent stroke, whereas 0.59 (95% CI: 0.53–0.64) for composite vascular events at 1 year. In patients with large-artery atherosclerosis (LAA) subtype of stroke, the AUC of ESRS was both 0.61 (95% CI: 0.54–0.68) for recurrent stroke and composite vascular events. However, no significant AUC was observed in patients with small-artery occlusion subtype of stroke.Conclusions: In patients with LAA subtype of non-atrial fibrillation stroke, the ESRS has moderate accuracy in stratifying the risk of both recurrent strokes and major vascular events within the first year. However, the ESRS couldn’t accurately stratify the risk of recurrent strokes in patients with small-artery atherosclerosis subtype of non-atrial fibrillation stroke.

Association of Diabetes and Prognosis of Minor Stroke and Its Subtypes: A Prospective Observational Study.

BackgroundThe association between diabetes mellitus (DM) and prognosis of minor stroke is unclear. The aim of this study is to investigate whether DM contributes to the prognosis of minor stroke or its specific subtype.MethodsAll minor ischemic stroke patients were derived from the China National Stroke Registry and classified into 5 subtypes according to the TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. DM was defined as either self-reported physician diagnosis of diabetes or use of hypoglycemic medications during hospitalization or at discharge. Patients were followed up for 1 year for clinical outcomes of recurrent stroke, death and functional outcome. Poor functional outcomes were defined as a score of 2–6 for modified Rankin Score. Associations between DM and prognosis of minor stroke and its subtypes were analyzed by univariable and multivariable logistic regression.ResultsOf 4,548 patients with minor stroke, 1,230(27.0%) patients had DM, 1,038(22.8%) had poor outcomes and 570(13.0%) of 4,401 patients had recurrent stroke at 1 year. In multivariable analyses, DM were significantly associated with 1-year stroke recurrence (Odds Ratio [OR], 1.31; 95% confidence interval [CI]: 1.08–1.59) and poor outcome (OR, 1.51; 95%CI: 1.28–1.77). Among the subtypes of minor stroke, DM was only significantly associated with 1-year stroke recurrence (OR, 1.63; 95%CI: 1.07–2.50) and poor outcome (OR, 1.73; 95%CI: 1.22–2.45) in the small-artery occlusion subtype.ConclusionsDM significantly increased the risk of stroke recurrence and poor outcome in the small-artery occlusion subtype, but not in other subtypes of minor stroke.

Interactions among Candidate Genes Selected by Meta-Analyses Resulting in Higher Risk of Ischemic Stroke in a Chinese Population.

Ischemic stroke (IS) is a multifactorial disorder caused by both genetic and environmental factors. The combined effects of multiple susceptibility genes might result in a higher risk for IS than a single gene. Therefore, we investigated whether interactions among multiple susceptibility genes were associated with an increased risk of IS by evaluating gene polymorphisms identified in previous meta-analyses, including methylenetetrahydrofolate reductase (MTHFR) C677T, beta fibrinogen (FGB, β-FG) A455G and T148C, apolipoprotein E (APOE) ε2–4, angiotensin-converting enzyme (ACE) insertion/deletion (I/D), and endothelial nitric oxide synthase (eNOS) G894T. In order to examine these interactions, 712 patients with IS and 774 controls in a Chinese Han population were genotyped using the SNaPshot method, and multifactor dimensionality reduction analysis was used to detect potential interactions among the candidate genes. The results of this study found that ACE I/D and β-FG T148C were significant synergistic contributors to IS. In particular, the ACE DD + β-FG 148CC, ACE DD + β-FG 148CT, and ACE ID + β-FG 148CC genotype combinations resulted in higher risk of IS. After adjusting for potential confounding IS risk factors (age, gender, family history of IS, hypertension history and history of diabetes mellitus) using a logistic analysis, a significant correlation between the genotype combinations and IS patients persisted (overall stroke: adjusted odds ratio [OR] = 1.57, 95% confidence interval [CI]: 1.22–2.02, P < 0.001, large artery atherosclerosis subtype: adjusted OR = 1.50, 95% CI: 1.08–2.07, P = 0.016, small-artery occlusion subtype: adjusted OR = 2.04, 95% CI: 1.43–2.91, P < 0.001). The results of this study indicate that the ACE I/D and β-FG T148C combination may result in significantly higher risk of IS in this Chinese population.

Elevation of serum CXCL16 level correlates well with atherosclerotic ischemic stroke

IntroductionCurrently there are no reliable biological markers for ischemic stroke. The novel chemokine CXCL16 is known to be involved in the development of atherosclerosis. Nevertheless, the real role of CXCL16 in atherosclerotic disorders remains uncertain. The goal of our study was to investigate the associations between serum-soluble CXCL16 level and atherosclerotic ischemic stroke, including large artery atherosclerosis (LAA) and small artery occlusion (SAO) subtypes, and to explore whether elevation in CXCL16 levels is correlated with the severity of large arterial stenosis.Material and methodsThe study recruited 227 subjects, including 74 controls and 153 consecutive patients with acute ischemic stroke from atherosclerosis of the carotid artery. The etiology of the acute ischemic strokes was classified into LAA (n = 86) subtype and SAO (n = 67) subtype according to the TOAST criteria, and the severity of carotid artery stenosis was assessed by the NASCET criteria. Serum-soluble CXCL16 concentration was measured by enzyme-linked immunosorbent assay.ResultsSerum CXCL16 concentrations were significantly increased in both LAA (2.36 ng/ml) and SAO subtypes (2.13 ng/ml) when compared to that of the controls (2.04 ng/ml, p < 0.01 and p < 0.05, respectively), and it was significantly elevated in LAA subtype than in SAO subtype (p < 0.05). However, significant differences in CXCL16 levels between the high-grade stenosis group (2.36 ng/ml) and moderate-grade stenosis group (2.24 ng/ml) of LAA subtype were not found (p > 0.05). A correlation of serum levels of CXCL16 with serum levels of hs-CRP, fibrinogen and lipid parameters was not observed (p > 0.05).ConclusionsIncreased serum level of soluble CXCL16 was independently associated with atherosclerotic ischemic stroke, particularly LAA subtype.

Association of thromboxane A2 receptor gene polymorphisms with cerebral infarction in a Chinese population

Platelet aggregation is crucial for the development of cerebral infarction (CI) and it is markedly increased due to the binding of thromboxane A2 (TXA2) to its receptor (TXA2R). Therefore, TXA2R plays a central role in the pathogenesis of atherosclerosis and thrombosis. This study aimed to investigate the relationship between human TXA2R gene single nucleotide polymorphisms (SNPs) and non-cardiogenic CI in a Chinese cohort. Two SNPs, rs768963 and rs4523, located in the regulatory and coding regions of TXA2R gene, respectively, were examined in DNA samples from 407 Chinese patients with CI and 270 controls. 407 CI was categorized into subtypes using Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. There was no significant association between rs4523 variants and CI. However, there was a significant difference in the overall distribution of genotypes and dominant/recessive models of rs768963 between CI and control groups. In addition, multiple logistic regression analysis revealed that the C allele of rs768963 was significantly associated with total CI (P = 0.023), large artery atherosclerosis subtype (P = 0.009), small artery occlusion subtype (P = 0.044) after adjusting for confounding factors (odds ratio = 1.533, 1.918 and 1.573, respectively). We conclude that TXA2R rs768963 polymorphism is associated with CI in a Chinese population.

Association of Hypertension With Stroke Recurrence Depends on Ischemic Stroke Subtype

The association between hypertension (HTN) and stroke recurrence is unclear, but may be influenced by different subtypes of stroke. This study aims to explore whether HTN contributes to the recurrence of certain subtypes of ischemic stroke (IS). Data from the China National Stroke Registry was examined and 1-year follow-up data for stroke recurrence was analyzed. Trial of Org 10172 in Acute Stroke Treatment criteria was used to classify the subtypes of all IS. HTN was defined when resting blood pressure was ≥ 140/90 mm Hg on repeated measurements during hospitalization or a patient had been on antihypertensive medication. Recurrent stroke was defined as a new neurological deficit compatible to IS or intracerebral hemorrhage. The association between HTN and stroke recurrence in patients with different IS subtypes was analyzed by using univariable and multivariable logistic regression models. Of 11 560 patients with IS, 8409 (72.7%) had HTN and 2050 (17.7%) experienced a recurrent stroke within 1 year. Patients with HTN had an insignificantly higher stroke recurrence rate than those without (18.0% versus 17.0%; P=0.21). After stratification by Trial of Org 10172 in Acute Stroke Treatment subtypes, multivariable analysis revealed a significant association between HTN and stroke recurrence in small-artery occlusion subtype (odds ratio, 1.52; 95% confidence interval, 1.03-2.31), but not in the other subtypes (large-artery atherosclerosis: odds ratio, 0.99; 95% confidence interval, 0.81-1.21; cardioembolic: odds ratio, 1.14; 95% confidence interval, 0.75-1.73; other: odds ratio, 0.88; 95% confidence interval, 0.71-1.09). Our results showed that HTN is specifically related to the recurrent strokes in patients with small-vessel diseases, not other subtypes of IS.

Early and intermediate prognosis of intravenous thrombolytic therapy in acute ischemic stroke subtypes according to the causative classification of stroke system

Objectives: Intravenous thrombolytic therapy has established acceptable results in treating ischemic stroke. However, there is little information on treatment outcome especially in different subtypes. The aim of current study was to evaluate early and intermediate prognosis in intravenous thrombolytic therapy for acute ischemic stroke subtypes. Methodology: Forty eligible patients (57.5% male with mean age of 63.18±13.49 years) with definite ischemic stroke who were admitted to emergency department of Imam Reza University Hospital, in the first 180 minutes after occurrence received recombinant tissue plasminogen activator. All investigation findings were recorded and stroke subtypes were determined according to the Causative Classification of Stroke System. Stroke severity forms including modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) scores were recorded for all patients in first, seven and 90 days after stroke and disease outcome was evaluated. Results: The etiology of stroke was large artery atherosclerosis in 20%, cardio-aortic embolism in 45%, small artery occlusion in 17.5% and undetermined causes in 17.5%. NIHSS and mRS scores were significantly improved during time (P < 0.001 in both cases). Three months mortality rate was 25%. Among the etiologies, patients with small artery occlusion and then cardio-aortic embolism had lower NIHSS score at arrival (P = 0.04). Caplan-meier analysis showed that age, sex and symptom to needle time could predict disease outcome. Conclusion: Intravenous thrombolytic therapy is accompanied by good early and intermediate outcome in most patients with ischemic stroke. Small artery occlusion subtype had less disease severity and higher improvement.

Prevalence of extracranial carotid stenosis in Thai ischemic stroke/TIA patients

Stroke is a leading cause of death and morbidity in Thailand. The purpose of this study was to look for prevalence of significant extracranial carotid stenosis (ECCS) in Thai ischemic stroke/transient ischemic attack (TIA) patients and baseline characteristics of this subgroup. All acute/subacute ischemic stroke/TIA patients who were treated at Thammasat hospital and had carotid duplex done, during August 2006-July 2007, were included. Carotid duplex studies were performed in all clinically stable patients. The degree of stenosis was defined according to the standard velocity criteria. Stroke subtypes were classified by TOAST criteria: large-artery atherosclerosis (LAA), cardioembolism (CE), small-artery occlusion (SAO), stroke of other determined cause (OC) and stroke of undetermined cause (UND). One-hundred and eighty-four cases were included. Prevalence of significant ECCS was 9.2%. SAO subtype was the most common stroke subtype in our study (45%). Significant ECCS was found in 18.4%, 6% and 8.3% patients with LAA, SAO and CE stroke subtype, respectively. Significant ECCS in Thai ischemic stroke/TIA patients is uncommon. Low prevalence of coronary artery disease and peripheral artery disease in Thai stroke patients and/or high SAO stroke subtype in our patients may explain this.

Serum Creatinine Does Not Improve Early Classification of Ischemic Stroke Caused by Small Artery Occlusion

Accurate subtyping of ischemic stroke in the acute setting is a potentially important but very difficult task. Microvascular disease is a systemic disorder, and we hypothesized that impaired renal function, which is most commonly a result of microvascular disease, would correlate with the subtype of small-artery occlusion (SAO) in patients with acute ischemic stroke. This was a retrospective cohort study of consecutive patients with ischemic stroke. Clinical and laboratory data at admission were analyzed and compared with the final determination of stroke subtype. We determined whether serum creatinine level at admission was independently associated with final determination of the SAO stroke subtype. There was no correlation between elevated baseline creatinine (>/=1.5 mg/dL) and SAO (odds ratio = 0.38, 95% confidence interval 0.01-2.98, P = .38). The most helpful predictor of a final SAO subtype was lacunar syndrome on initial examination, but only in patients with diabetes (positive predictive value = 67%, 95% confidence interval 30%-93%). Laboratory evidence of impaired renal function does not aid the early identification of the SAO stroke subtype in patients with acute stroke. In addition, an initial lacunar syndrome only effectively identifies SAO among patients with diabetes, not the general stroke population.