Stroke Of Other Determined Etiology Research Articles

Abstract TP189: Outcome Differences Between Endovascular Thrombectomy and Medical Management Based on Underlying Stroke Etiology: A Secondary Analysis of SELECT2 Trial

Introduction: In patients with large core ischemic stroke, potential heterogeneity in EVT treatment effect based on underlying etiology is an important question. We explored differences in clinical outcomes and successful recanalization rates between EVT and MM. Methods: From SELECT2 randomized clinical trial, patients were categorized based on Stroke etiology: Large-artery atherosclerosis (LAA), Cardioembolism (CE), Stroke of other determined etiology (SOE), and Stroke of undetermined etiology (SUE). Procedure success, clinical outcomes and EVT treatment effect was compared based on stroke etiology. Results: Cardioembolic stroke was most frequently observed etiology across the trial (41%), followed by stroke of undetermined etiology (29%), large artery atherosclerosis (23%) and stroke of other determined etiology (6%). Proportion of patients achieving successful reperfusion (mTICI 2b-3) after EVT differed significantly across the categories (CE: 87%, LAA: 82%, SOE: 73%, SUE: 66%, p=0.040). However, treatment effect estimates favored EVT across categories of stroke etiology without significant heterogeneity - CE (ref): aGenOR: 1.83 (1.30-2.59) vs LAA: aGenOR: 2.04 (1.24-3.37), p-int: 0.87 vs SOE: aGenOR: 2.06 (0.80-5.28), p-int: 0.79 vs SUE: aGenOR: 1.20 (0.77-1.88), p-int: 0.17. Conclusion: In patients with large core ischemic stroke, proportion of patients achieving successful reperfusion differed based on stroke etiology. However, EVT was associated with better outcomes without evidence of significant heterogeneity. Further optimization of procedure techniques may help improve successful reperfusion rates and clinical outcomes in patients with SUE. Clinicaltrials.gov registration: NCT03876457

A novel etiological classification in patients with intracranial large vessel occlusion and endovascular treatment: discordance with the classic and SSS TOAST systems: A retrospective cohort study

Purpose: Among patients with acute ischemic stroke (AIS), those with intracranial large vessel occlusion (LVO) should undertake endovascular treatment (EVT) based on mechanical thrombectomy. Although the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification system has been used in overall population of patients with AIS, especially for secondary prevention. In the current study, a new classification system for the LVO population is proposed.Methods: The classic TOAST and Stop Stroke Study TOAST (SSS TOAST) were applied to the LVO population. Based on discordance with those systems, a new LVO classification system was developed and applied to the LVO population. The new system comprised extracranial atherosclerosis (ECAS), intracranial atherosclerosis (ICAS), cardioembolism (CE), cryptogenic embolism, stroke of undetermined etiology (SUE; two or more etiologies), and stroke of other determined etiology (SOE) where small artery occlusion was removed.Results: The LVO classification system comprised 43 ECAS (6.52%), 141 ICAS (21.36%), 303 CE (45.91%), 75 cryptogenic embolism (11.36%), 75 SUE (11.36%; cardioembolic source in 98.67%), and 23 SOE (3.48%) patients. The ICAS group had a significantly longer median onset-to-puncture time than the other groups. In the ICAS group, 102 of 141 (72.34%) remained partial recanalization after EVT.Conclusion: The LVO classification system differentiating ECAS and ICAS in patients with large artery atherosclerosis and classifying cryptogenic embolism is more suitable for patients with EVT for intracranial LVO. Further studies for predicting underlying ICAS and planning treatment strategy should be performed.

Stroke of Other Determined Etiology: Results From the Nationwide Multicenter Stroke Registry

Stroke of other determined etiology (OE) includes patients with an uncommon cause of stroke. We described the general characteristics, management, and outcomes of stroke in OE and its subgroups. This study is a retrospective analysis of a prospective, multicenter, nationwide registry, the Clinical Research Center for Stroke-Korea-National Institutes of Health registry. We classified OE strokes into 10 subgroups according to the literature and their properties. Each OE subgroup was compared according to clinical characteristics, sex, age strata, lesion locations, and management. Moreover, 1-year composites of stroke and all-cause mortality were investigated according to the OE subgroups. In total, 2119 patients with ischemic stroke with OE types (mean age, 55.6±16.2 years; male, 58%) were analyzed. In the Clinical Research Center for Stroke-Korea-National Institutes of Health registry, patients with OE accounted for 2.8% of all patients with stroke. The most common subtypes were arterial dissection (39.1%), cancer-related coagulopathy (17.3%), and intrinsic diseases of the arterial wall (16.7%). Overall, strokes of OE were more common in men than in women (58% versus 42%). Arterial dissection, intrinsic diseases of the arterial wall and stroke associated with migraine and drugs were more likely to occur at a young age, while disorders of platelets and the hemostatic system, cancer-related coagulopathy, infectious diseases, and hypoperfusion syndromes were more frequent at an old age. The composite of stroke and all-cause mortality within 1 year most frequently occurred in cancer-related coagulopathy, with an event rate of 71.8%, but least frequently occurred in stroke associated with migraine and drugs and arterial dissection, with event rates of 0% and 7.2%, respectively. This study presents the different characteristics, demographic findings, lesion locations, and outcomes of OE and its subtypes. It is characterized by a high proportion of arterial dissection, high mortality risk in cancer-related coagulopathy and an increasing annual frequency of cancer-related coagulopathy in patients with stroke of OE.

Clinical Characteristics and Analysis of Lung Cancer- Associated Acute Ischemic Stroke

IntroductionThe incidence of lung cancer and acute ischemic stroke remains high in recent years, both of which occur mostly in people over 60 years old. In the present study, we aimed to further clarify the pathogenesis of lung cancer-associated acute ischemic stroke (LCA-AIS) by comparing and analyzing clinical characteristics of stroke patients with or without lung cancer. MethodsA total of 51 patients with lung cancer were selected as the case group (LCSG), and 78 patients without cancer history were adopted as the control group (SG). The data collected in this study included sex, age, traditional cerebrovascular disease risk factors (TCDRFs), blood test index, imaging findings, etiological typing, and prognosis evaluation. SPSS21.0 software was used for statistical analysis. Normally distributed data were analyzed by t-test, and count data were analyzed by chi-square test or exact probability method. P < 0.05 was considered statistically significant. ResultsIn the case group, the levels of plasma D-dimer, fibrinogen degradation products (FDPs) and NIHSS, as well as the mRS score and mortality of patients, were higher, while the levels of RBC, Hb and Hcy were lower compared with the control group. Imaging findings showed that multivessel involvement was more common in the case group, and the infarcts were more likely to be multiple and involved in both the anterior and posterior circulations. The TOAST classification of LCSG was dominated by stroke of undetermined etiology (SUE) and stroke of other determined etiology (SOE). Statistical analysis showed that the patients were more likely to suffer from acute ischemic stroke within 1 year after the diagnosis of lung cancer (41 cases, 80.39%). ConclusionsHypercoagulability and acute multiple brain infarcts were more common in patients with LCA-AIS, and hypoproteinemia and hyponatremia were more likely to occur in these patients, leading to worse prognosis. Patients were most likely to have a stroke within 1 year after the diagnosis of lung cancer.

An investigation on prevalence and severity of cerebral microbleeds in patients with different stroke classifications of cerebral infarction

Objective To investigate the prevalence and severity of cerebral microbleeds(CMBs) in patients with different stroke classifications of cerebral infarction. Methods From October 2016 to December 2017, the clinical data of patients with acute cerebral infarction in the Second Affiliated Hospital of Xuzhou Medical University were collected through the prospective study.The SWI technique was used to screen the CMBs.According to the TOAST and OCSP classifications, the prevalence and severity of CMBs in patients with different stroke classifications of cerebral infarction were analyzed. Results A total of 254 patients with cerebral infarction were enrolled, there were 136 patients(53.54%) in CMBs group and 118 patients(46.46%) in no CMBs group.The prevalence of CMBs in patients with different TOAST classifications was large artery atherosclerosis(54.29%), small-artery occlusion(64.15%), cardioembolism(40.43%), stroke of other determined etiology(33.33%), stroke of undetermined etiology(38.46%), and the difference was statistically significant(χ2=12.206, P=0.016). The prevalence of CMBs in patients with different OCSP classifications was total anterior circulation infarcts(43.75%), partial anterior circulation infarcts(51.19%), posterior circulation infarcts(49.18%), lacunar infarcts(67.53%), and the difference was statistically significant(χ2=8.944, P=0.030). The severity of CMBs in patients with different TOAST classifications was large artery atherosclerosis[mild(55.26%), moderate(26.32%), severe(15.79%)], small-artery occlusion[mild(25.00%), moderate(33.82%), severe(41.18%)], cardioembolism[mild(57.89%), moderate(26.32%), severe(15.79%)), stroke of other determined etiology[mild(50.00%), moderate(33.33%), severe(16.67%)], stroke of undetermined etiology[mild(60.00%), moderate(20.00%), severe(20.00%)], and the difference was statistically significant(Fisher exact test, P=0.025). The severity of CMBs in patients with different OCSP classifications was total anterior circulation infarcts[mild(57.14%), moderate(28.57%), severe(14.29%)], partial anterior circulation infarcts[mild(52.50%), moderate(32.50%), severe(15.00%)], posterior circulation infarcts[mild(50.00%), moderate(33.33%), severe(16.67%)], lacunar infarcts[mild(25.00%), moderate(32.69%), severe(42.31%)], and the difference was statistically significant(Fisher exact test, P=0.023). Conclusion The prevalence and severity of CMBs in patients with different stroke classifications of cerebral infarction are variable.The prevalence of CMBs in small-artery occlusion and lacunar infarcts are the highest and give first place to severe CMBs(number of lesions≥10). We should pay attention to these two stroke classifications by early recognition and taking targeted clinical strategies. Key words: Stroke; Cerebral infarction; Cerebral hemorrhage; Prevalence; Magnetic resonance imaging

Biomarkers for ischemic stroke subtypes: A protein-protein interaction analysis

According to the Trial of Org 10172 in Acute Stroke Treatment, ischemic stroke is classified into five subtypes. However, the predictive biomarkers of ischemic stroke subtypes are still largely unknown. The utmost objective of this study is to map, construct and analyze protein-protein interaction (PPI) networks for all subtypes of ischemic stroke, and to suggest the predominant biological pathways for each subtypes. Through 6285 protein data retrieved from PolySearch2 and STRING database, the first PPI networks for all subtypes of ischemic stroke were constructed. Notably, F2 and PLG were identified as the critical proteins for large artery atherosclerosis (LAA), lacunar, cardioembolic, stroke of other determined etiology (SOE) and stroke of undetermined etiology (SUE). Gene ontology and DAVID analysis revealed that GO:0030193 regulation of blood coagulation and GO:0051917 regulation of fibrinolysis were the important functional clusters for all the subtypes. In addition, inflammatory pathway was the key etiology for LAA and lacunar, while FOS and JAK2/STAT3 signaling pathways might contribute to cardioembolic stroke. Due to many risk factors associated with SOE and SUE, the precise etiology for these two subtypes remained to be concluded.

Five-year readmission and mortality differ by ischemic stroke subtype

BackgroundIschemic stroke subtype may influence the risk of readmission and mortality after ischemic stroke (IS) and transient ischemic attack (TIA) due to differences in comorbidity, risk factors, and stroke severity. We aimed to study the five-year incidence and risk of all-cause readmission, cause-specific readmission and mortality after IS or TIA by stroke subtype. MethodsThe medical records of 1453 patients admitted with IS or TIA to the stroke unit at Haukeland University Hospital, Norway, between 2007 and 2012 were reviewed for identification of unplanned readmissions within five years after discharge. Stroke etiology was classified as large-artery atherosclerosis (LAA), cardioembolism (CE), small vessel occlusion (SVO), stroke of other determined etiology (SOE), multiple etiologies (ME), or cryptogenic stroke (CS). Kaplan-Meier estimates and Cox regression analyses were used to determine incidences and risk of readmission and death. ResultsThe five-year incidence of all-cause readmission was 72.6% (74% LAA, 81% CE, 65% SVO, 55% SOE, 71% ME, and 67% CS), with infections, cardiac disease, stroke-related events and fractures as the most frequent causes. Compared to patients with other subtypes, SVO subtype had a 21% lower risk of all-cause readmission and a 48% lower risk of death, whereas CE had a 25% higher risk of all cause readmission and a 34% higher risk of death. CE subtype also had a 75% higher risk of readmission due to cardiac disease, whereas CS subtype had a 44% lower risk of readmission with cardiac disease. ConclusionThe five-year incidence of readmission and mortality varied among the stroke subtypes. The risk of readmission and death are especially high in patients with CE subtype, and lowest for patients with SVO subtype.

Thirty-day recurrence after ischemic stroke or TIA.

BackgroundIncidence of recurrent stroke is highest within 30 days after the initial ischemic stroke (IS) or TIA, but knowledge about early recurrence is lacking. We aimed to identify etiological groups with highest risk of early recurrence and assess how the TOAST classification identified index stroke etiology.MethodsMedical records of 1874 IS and TIA patients in the Bergen NORSTROKE registry were retrospectively reviewed for identification of recurrent IS or TIA within 30 days after index IS or TIA. Stroke etiology was determined by review of electronical medical journals. Logistic regression was used to calculate odds ratios (OR) for 30‐day recurrence.ResultsThirty‐three patients (1.8%) were readmitted with recurrent IS or TIA within 30 days after index stroke. By using TOAST, 12 patients were initially classified with stroke of unknown etiology (SUE). Etiologies behind recurrent IS or TIA were after the recurrent episode identified as extracranial large artery atherosclerosis (LAA) in 14 patients (42.4%), intracranial arterial pathology in seven patients (21.2%), active malignancy in six patients (18.2%), and cardio embolism in four patients (12.1%). Small vessel occlusion and SUE were the causes in one patient each. Logistic regression showed that patients with stroke of other determined etiology (SOE) and LAA had increased risk of 30‐day recurrence (OR = 9.72, 95% CI 1.84–51.3, p < 0.01 and OR = 4.36, 95% CI 2.01–9.47, p < 0.01, respectively).ConclusionPatients with LAA and SOE had increased risk of recurrent IS or TIA within 30 days. TOAST was inadequate at identifying exact etiologies behind recurrent stroke at index event.

Risk factors and etiological subtype analysis of brainstem infarctions

ObjectiveTo evaluate the features of risk factors and etiological subtypes of brainstem infarctions (BSIs) patients in China. MethodsOne hundred and ninety-nine cerebral infarction patients with brainstem involvement were categorized into five groups according to Trial of Org 10172 in Acute Stroke Treatment classification: large artery disease (LAD), cardioembolism (CE), small vessel disease (SVD), stroke of other determined etiology (SOE) or stroke of undetermined etiology (SUE). The risk factors and percentage of the different etiological subtypes were assessed. ResultA total of 199 patients were enrolled in this study. The number and percentage of patients in SVD, LAD, SUE, CE and SOE were 77 (38.7%), 74 (37.2%), 25 (12.6%), 23 (11.6%) and 0, respectively. There were significantly different incidences of hypertension, diabetes and coronary heart disease (CHD) without atrial fibrillation (AF) among different stroke subtypes (P=0.006, P=0.002, P=0.016, respectively). Hypertension was more prevalent in LAD than in SVD and CE (P=0.001 and P=0.039, respectively) while the incidence of diabetes in LAD was higher than those in SVD and CE (P<0.001 and P=0.015, respectively). CHD without AF was more prevalent in CE than in SVD and LAD (P=0.044 and P=0.012, respectively). LAD was significantly associated with hypertension (OR=3.18, P=0.009) and diabetes (OR=2.84, P=0.003) in BSIs. ConclusionThe pattern of etiological subtypes of BSIs in China has its own characteristics. It might result from the features of risk factors in Chinese patients.

TOAST classification of isolated pontine infarction

Background Through the analysis of various imaging and angiography data, including computed tomography angiography (CTA), magnetic resonance angiography (MRA) and digital subtraction angiography (DSA), this article aims to understand the relation between pontine infarction and posterior circulation lesions, classify different types of causes of isolated pontine infarction, and compare the clinical characteristics of different classification methods. Methods Eighty-five cases with first-onset isolated pontine infarction were selected. On the basis of imaging examinations, they were divided into the following categories: vertebrobasilar large-artery disease (VLAD); basal artery branch disease (BABD); small artery disease (SAD); type of other reasons and type of uncertain causes. According to Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification standard, all patients were divided into the following categories: large artery atherosclerosis (LAA), small artery occlusion (SAO), cardiac embolism (CE), stroke of other determined etiology (SOE), stroke of undetermined etiology (SUE). Results According to imaging classification, BABD was the most common type, accounting for 50.59% (43/85); SAD accounted for 28.23% (24/85); VLAD accounted for 14.12% (12/85); type of uncertain causes accounted for 7.06% (6/85); type of other reasons was not found. Based on the TOAST classification, SAO was the most common type, accounting for 67.06% (57/85); LAA accounted for 30.59% (26/85); SUE accounted for 2.35% (2/85); CE and SOE were not found. Conclusion Based on the TOAST classification, small artery occlusion is the most common etiology of isolated pontine infarction. It is favorable for formulating specific treatment to make TOAST classification based on a variety of imaging data.

The value of the use of plasma B-type natriuretic peptide among acute ischemic stroke patients in a Chinese emergency department

ObjectiveTo determine the value of the use of plasma B-type natriuretic peptide (BNP) among acute ischemic stroke patients in a Chinese emergency department (ED). Materials and methodsIn our ED, the emergency physicians prospectively assessed consecutive adult patients with acute phase of ischemic stroke and measured plasma BNP by Biosite Triage®BNP POCT platform on admission, then followed up these patients. And the stroke neurologists evaluated patients’ functional outcome at hospital discharge, and also made discharge diagnosis and stroke etiologic subtypes according to TOAST criteria: large-artery atherosclerosis (LAA), cardioembolism (CE), small-artery occlusion (SAO), stroke of other determined etiology (SOE) and stroke of other undetermined etiology (SUE). ResultsIn this study, 142 of 238 acute ischemic stroke patients met the study criteria [mean age 70.84±11.48 years, 74 (52.11%) female]. Of the 142 patients, 35.92% were diagnosed with LAA at discharge, 25.35% with CE, 27.46% with SAO, 11.27% with SOE or SUE. Age, previous cardiac disease, atrial fibrillation, the length of hospital stays, SSS score on admission≤25 and mRS≥3 or death at discharge were all significantly higher in the CE patients compared to other subtypes (p<0.01). And the mean BNP concentration was significantly higher in the CE group than in other three subtypes (p<0.001). The optimal cut-off concentration, sensitivity and specificity of the plasma BNP concentration suitable to distinguish CE from non-CE were 66.50pg/ml, 75.0% and 88.7%, respectively. ConclusionsPlasma BNP level is significantly higher in CE patients than in other TOAST subtypes, and by using Biosite Triage®BNP POCT platform, emergency physicians should strongly consider CE subtype with the plasma BNP level of over 66.50pg/ml. However, the single BNP biomarker panel cannot be used to confidently rule out or identify stroke subtypes as a diagnosis and must be taken in context with clinical assessment and judgment before making management decisions in the ED.

Risk factors in various subtypes of ischemic stroke according to TOAST criteria.

To identify the frequency of risk factors in various subtypes of acute ischemic stroke according to TOAST criteria. Cross-sectional, observational study. Ziauddin Hospital, Karachi, from January to December 2007. Patients with acute ischemic stroke were enrolled. Studied variables included demographic profile, history of risk factors, physical and neurological examination, and investigations relevant with the objectives of the study. Findings were described as frequency percentages. Proportions of risk factors against subtypes was compared using chi-square test with significance at p < 0.05. Out of the 100 patients with acute ischemic stroke, mean age at presentation was 63.5 years. Risk factor distribution was hypertension in 85%, Diabetes mellitus in 49%, ischemic heart disease in 30%, dyslipedemia in 22%, smoking in 9%, atrial fibrillation in 5%, and previous history of stroke in 29%. The various subtypes of acute ischemic stroke were lacunar infarct in 43%, large artery atherosclerosis in 31%, cardioembolic type in 8%, stroke of other determined etiology in 1% and stroke of undetermined etiology in 18%. Hypertension and Diabetes were the most important risk factors in both large and small artery atherosclerosis. In patients with cardio-embolic stroke significant association was found with ischemic heart disease (p=0.01). Importance and relevance of risk factors evaluated for subtypes rather than ischemic stroke as a whole should be reflected in preventive efforts against the burden of ischemic stroke.