Abstract W MP67: Etiology-Specific Clinical and Imaging Features in Ischemic Stroke

Background: Identification of clinical and imaging characteristics of ischemic stroke that can predict the underlying etiology is critical for accurate stroke subtyping. We sought to investigate the relationship between stroke characteristics and stroke etiology in 7,591 patients in the NINDS Stroke Genetics Network Study. Methods: We determined the probability of having a major etiology in the presence of certain stroke characteristics that were previously linked to specific stroke mechanisms. We excluded patients with multiple competing major etiologies. All patients had brain imaging, intra- and extra-cranial vascular imaging, and complete cardiac assessment. We defined major etiologies according to the Causative Classification of Stroke System Criteria without reference to the stroke characteristics under study. Results: History of 1 ipsilateral ischemic events within the last month, the presence of internal watershed infarcts or multiple, ipsilateral, unilateral, and temporally separate infarcts were associated with large artery atherosclerosis (Table). Multiple acute infarcts in different cerebral circulations were more common in patients with major cardiac source of embolism as well as in those with uncommon/cryptogenic causes. Stereotypic lacunar TIAs within the last week and lacunar syndrome were associated with lacunar infarction Discussion: Clinical and imaging stroke characteristics appear to predict stroke etiologies. This information may find utility in developing algorithms for a guided stroke evaluation as well as help identify the most likely causative etiology in the presence of multiple competing etiologies.

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Abstract TP201: The Relationship Between Chronic Kidney Diseases and the Presence of Cerebral Small Vessel Disease in Patients With Acute Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.tp201 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Kana Ueki ◽

Asako Nakamura ◽

Masahiro Yasaka ◽

Takahiro Kuwashiro ◽

Seiji Gotoh ◽

...

Keyword(s):

Ischemic Stroke ◽

White Matter ◽

Acute Ischemic Stroke ◽

White Matter Lesion ◽

Kidney Diseases ◽

Univariate Analysis ◽

Small Vessel ◽

Chronic Kidney Diseases ◽

History Of ◽

The Relationship

Introduction: Cerebral small vessel diseases (SVDs) i.e. white matter lesion and cerebral microbleeds (CMBs) are related to the patients with stroke more deeply than those without. In general population, in addition to age, hypertension, diabetes chronic kidney diseases (CKD) is well known to be related to SVDs, but it remains unclear in patients with stroke. We investigated the relationship between CKD and the presence of SVDs in patients with acute ischemic stroke. Methods: We enrolled 493 patients with acute ischemic stroke patients or transient ischemic attack patients (mean age 71; 60% male) who had undergone 1.5T MR imaging within a week of the index events from April 2013 to march 2015. We evaluated kidney function by estimated glomerular filtration rate (eGFR) with the modification of diet in Renal Disease. CKD was defined as an eGFR less than 60mil/min/1.73m 2 . CMBs were defined as focal areas of very low signal intensity smaller than 10mm. White matter lesion as Periventricular hyper intensity (PVH)>grade 2 and Deep and Subcortical White Matter Hyper intensity (DSWMH)> grade 2 were defied as advanced PVH and advanced DSWMH, respectively. We investigated relationship between CKD and CMBs, advanced PVH and advanced DSWMH using a logistic regression analysis. Results: We noted CMBs in 173 patients (35%), PVH in 81 (16%), and DSWMH in 151 (31%). An univariate analysis revealed that the age, CKD, history of stroke, and antiplatelet agents were associated with presence of CMBs, advanced PVH and severe DSWMH . The multivariate analysis revealed that CMBs, advanced PVH and advanced DSWMH were associated with age (CMBs: odds ratio(OR) ; 1.32 ; 95% confidence interval(CI), 1.10-1.60, p=0.004, advanced PVH : OR ; 3.00 ; 95% CI, 2.17-4.26, p<0.01, advanced DSWMH: OR ; 1.94; 95% CI, 1.56-2.45, p<0.01 ), history of stroke(CMBs : OR ; 2.01 ; 95% CI, 1.21-3.34, p=0.007, advanced PVH : OR ; 2.25 ; 95% CI, 1.18-4.27, p=0.01, advanced DSWMH: OR ; 1.78 ; 95% CI, 1.03-3.06, p=0.038). CKD was associated with CMBs (OR ; 1.62 ; 95% CI, 1.04-2.52, p=0.03), but PVH and DSWMH were not. Conclusions: It seems that age and history of stroke are related to CMBs, advanced PVH and advanced DSWMH, and that CKD is associates with CMBs but not with either advanced PVH or advanced DSWMH.

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Clinical and Imaging Predictors of Recurrent Ischemic Stroke: A Systematic Review and Meta-Analysis

Cerebrovascular Diseases ◽

10.1159/000490422 ◽

2018 ◽

Vol 45 (5-6) ◽

pp. 279-287 ◽

Cited By ~ 8

Author(s):

Frans Kauw ◽

Richard A.P. Takx ◽

Hugo W.A.M. de Jong ◽

Birgitta K. Velthuis ◽

L. Jaap Kappelle ◽

...

Keyword(s):

Ischemic Stroke ◽

Lower Risk ◽

Meta Analysis ◽

Cochrane Library ◽

Large Artery ◽

Cortical Lesions ◽

Level Of Evidence ◽

Risk Of Recurrence ◽

Increased Risk ◽

History Of

Background: Predictors of recurrent ischemic stroke are less well known in patients with a recent ischemic stroke than in patients with transient ischemic attack (TIA). We identified clinical and radiological factors for predicting recurrent ischemic stroke in patients with recent ischemic stroke. Methods: A systematic search in PubMed, Embase, Cochrane Library, and CINAHL was performed with the terms “ischemic stroke,” “predictors/determinants,” and “recurrence.” Quality assessment of the articles was performed and the level of evidence was graded for the articles included for the meta-analysis. Pooled risk ratios (RR) and heterogeneity (I2) were calculated using inverse variance random effects models. Results: Ten articles with high-quality results were identified for meta-analysis. Past medical history of stroke or TIA was a predictor of recurrent ischemic stroke (pooled RR 2.5, 95% CI 2.1–3.1). Small vessel strokes were associated with a lower risk of recurrence than large vessel strokes (pooled RR 0.3, 95% CI 0.1–0.7). Patients with stroke of an undetermined cause had a lower risk of recurrence than patients with large artery atherosclerosis (pooled RR 0.5, 95% CI 0.2–1.1). We found no studies using CT or ultrasound for the prediction of recurrent ischemic stroke. The following MRI findings were predictors of recurrent ischemic stroke: multiple lesions (pooled RR 1.7, 95% CI 1.5–2.0), multiple stage lesions (pooled RR 4.1, 95% CI 3.1–5.5), multiple territory lesions (pooled RR 2.9, 95% CI 2.0–4.2), chronic infarcts (pooled RR 1.5, 95% CI 1.2–1.9), and isolated cortical lesions (pooled RR 2.2, 95% CI 1.5–3.2). Conclusions: In patients with a recent ischemic stroke, a history of stroke or TIA and the subtype large artery atherosclerosis are associated with an increased risk of recurrent ischemic stroke. Predictors evaluated with MRI include multiple ischemic changes and isolated cortical lesions. Predictors of recurrent ischemic stroke concerning CT or ultrasound have not been published.

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Abstract TP175: Migraines and the Risk of Hemorrhagic Stroke

Stroke ◽

10.1161/str.48.suppl_1.tp175 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Muhammad Umar Farooq ◽

Kathie Thomas

Keyword(s):

Ischemic Stroke ◽

Medical History ◽

Hemorrhagic Stroke ◽

The United States ◽

Future Studies ◽

History Of ◽

Medical Histories ◽

Get With The Guidelines ◽

The Relationship ◽

Sample Set

Background and Objectives: Migraine is a common neurological disorder affecting 38 million people in the United States. Hemorrhagic stroke accounts for 13% of all stroke cases and the risk of having a hemorrhagic stroke is 94 in 100,000 or 0.94%. There are two types of hemorrhagic stroke; intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Previous research has investigated the association between migraine and vascular disease, with several studies demonstrating a possible link between migraines and ischemic stroke. The relationship between migraine and hemorrhagic stroke remains unclear. Methods: A retrospective review from January 2012-December 2014 of hemorrhagic stroke patients (n=3682) from 30 Michigan hospitals using a Get With the Guidelines (GWTG) database was conducted. Stroke subtypes and patient medical histories were examined. This sample set was comprised of 46.95% males and 53.05% females. Results: It was found that the risk for hemorrhagic stroke increased from 0.94% to 2.12% with a medical history of migraines. The risk of ICH with a history of migraine in this study was 1.41%, while the risk of SAH with a history of migraine was 3.11%. The median age for a hemorrhagic stroke in this sample set was 67 years. A patient with a medical history that included migraines, had a median hemorrhagic stroke age of 55 years. Of these patients with a history of migraine who developed a hemorrhagic stroke, 74.7% were female and 25.3% were male. Conclusions: This study demonstrated that a higher risk of hemorrhagic stroke is associated with a history of migraines. The median age for an individual with a hemorrhagic stroke and history of migraine was significantly lower (12 years) than the median age of the sample, which indicates that migraines as a risk factor for stroke might be more significant in middle age. Additionally, this risk seemed to impact females much more than males. A limitation of this study is that GWTG Stroke does not include whether the patient has a migraine with or without aura. Migraine with aura has been associated at a higher rate with ischemic stroke than migraine without aura. It would be beneficial for future studies regarding migraine and hemorrhagic stroke to include whether the migraine was associated with or without aura.

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Abstract 2919: Do Premature Ventricular Contractions Play a Role in the Etiologic Subtypes of Ischemic Stroke?

Stroke ◽

10.1161/str.43.suppl_1.a2919 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

JUN LEE ◽

Na-Young Kim

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Cryptogenic Stroke ◽

Holter Monitoring ◽

Median Number ◽

Large Artery ◽

Vessel Occlusion ◽

Premature Ventricular Contractions ◽

Ordinal Logistic Regression Analysis ◽

The Relationship

Background The relationship between stroke and non-atrial fibrillation cardiac arrhythmias remains unclear. Frequent premature ventricular contractions (PVCs) are associated with impaired ventricular relaxation and may increase the risk of clot formation and subsequent embolization. This study investigated the relationship between frequency of PVCs and etiologic subtypes of ischemic stroke. Methods Consecutive ischemic stroke patients admitted within 7 days of onset who underwent 24-hour Holter monitoring were enrolled (n=451). Subtypes of ischemic stroke were defined according to the SSS-TOAST classification as Large artery atherosclerosis (LAD), cardioembolic stroke (CE), small vessel occlusion (SVO), other causes (OC), and cryptogenic stroke (CS). Risk factors, demographic information, and 24-hour Holter recordings were compared between the subtypes of ischemic stroke. Results There were 182 women and 269 men (191 LAD, 90 CE, 93 SVO, 13 OC, 64 CS), with a mean age of 66 years (median 68). PVCs were seen in 305 patients (67.5%) on 24-hour Holter monitoring (median 3, IQR 0-48). CE had a higher median number of PVCs (median 24, IQR 0-258) than LAD (median 2, p=0.01), SVO (median 1, p<0.001), OC (median 0, p=0.013), and CS (median 4, p=0.2). The proportions of frequent PVCs (>50 in a 24-hour Holter monitoring) were higher in CE (43.3%) compared with the other groups (20.9% in LAD, 15.1% in SVO, 15.4% in OC, and 23.4% in CS; p<0.001). Compared with the SVO, the upper 3 quartiles of PVCs were associated with CE (OR 2.93; 95% CI, 1.69 to 5.06) and CS (OR 1.86; 95% CI, 1.07 to 3.2) in ordinal logistic regression analysis after adjustment for traditional risk factors. Conclusions The number of PVCs detected by 24-hour Holter monitoring is associated with CE and CS. The presence of high frequency of PVC may help in stratifying patients with different stroke subtypes, particularly embolic stroke. The role of these arrhythmias as a risk marker for ischemic stroke deserves further investigation.

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Abstract WP213: Comparison of Clinical and Imaging Characteristic of Cryptogenic Stroke to Known Ischemic Subtypes

Stroke ◽

10.1161/str.48.suppl_1.wp213 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Tyler P Behymer ◽

Achala Vagal ◽

Heidi Sucharew ◽

Vineeth Yeluru ◽

Arjun Minhas ◽

...

Keyword(s):

Ischemic Stroke ◽

Infarct Volume ◽

Cryptogenic Stroke ◽

Large Vessel ◽

Cardioembolic Stroke ◽

Small Vessel ◽

White Matter Hyperintensity ◽

Large Artery ◽

Imaging Characteristics ◽

The Impact

Introduction: Cryptogenic stroke is defined as not attributable to an identified source despite standard evaluation. The absence of small vessel or large artery disease in such evaluation suggests that cryptogenic stroke may be largely cardioembolic. We hypothesized that cryptogenic stroke would be similar to cardioembolic stroke in clinical and imaging characteristics. Methods: The Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) is a population-based study that tracks the regional incidence of stroke. A convenient subsample from the 2010 GCNKSS ischemic stroke cohort (N= 368) was selected for detailed neuroimaging analysis. The study physician subtyped cases based on clinical, radiographic and laboratory findings (carotid ultrasound, echocardiography, vascular imaging). Subtypes included cryptogenic, cardioembolic, large-vessel, small-vessel, undetermined, and other. Three radiologists performed imaging analysis including number of acute infarcts, location and white matter hyperintensity (WMH). Infarct volume was segmented using manual tracing. Results: Of 368 ischemic stroke cases with imaging data, subtypes were 26.4% cryptogenic, 16.3% large vessel, 15.5% small vessel, 24.7% cardioembolic, 5.4% undetermined, and 11.7% other. Compared to cardioembolic, cryptogenic stroke patients were younger, had less hypertension, higher alcohol use, smaller infarct volume and differed in location of stroke. Cryptogenic stroke had more clinical and radiological features in common with large and small-vessel stroke (Table). Undetermined and other had no significant differences to cryptogenic. Conclusion: Contrary to our hypothesis, cryptogenic stroke was different from cardioembolic stroke and appeared more similar to large vessel stroke in clinical and radiological characteristics. Further testing on a larger sample size to evaluate the impact of cardiac event monitoring on subtype distribution is needed.

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Effect of Edaravone on Neurological Symptoms in Real-World Patients With Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.118.024351 ◽

2019 ◽

Vol 50 (7) ◽

pp. 1805-1811 ◽

Cited By ~ 6

Author(s):

Susumu Kobayashi ◽

Shingo Fukuma ◽

Tatsuyoshi Ikenoue ◽

Shunichi Fukuhara ◽

Shotai Kobayashi ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Neurological Symptoms ◽

Small Vessel ◽

Large Artery ◽

Stroke Subtype ◽

Vessel Occlusion ◽

Nihss Score ◽

Ischemic Stroke Subtype ◽

History Of

Background and Purpose— In Japan, nearly half of ischemic stroke patients receive edaravone for acute treatment. The purpose of this study was to assess the effect of edaravone on neurological symptoms in patients with ischemic stroke stratified by stroke subtype. Methods— Study subjects were 61 048 patients aged 18 years or older who were hospitalized ≤14 days after onset of an acute ischemic stroke and were registered in the Japan Stroke Data Bank, a hospital-based multicenter stroke registration database, between June 2001 and July 2013. Patients were stratified according to ischemic stroke subtype (large-artery atherosclerosis, cardioembolism, small-vessel occlusion, and cryptogenic/undetermined) and then divided into 2 groups (edaravone-treated and no edaravone). Neurological symptoms were evaluated using the National Institutes of Health Stroke Scale (NIHSS). The primary outcome was changed in neurological symptoms during the hospital stay (ΔNIHSS=NIHSS score at discharge−NIHSS score at admission). Data were analyzed using multivariate linear regression with inverse probability of treatment weighting after adjusting for the following confounding factors: age, gender, and systolic and diastolic blood pressure at the start of treatment, NIHSS score at admission, time from stroke onset to hospital admission, infarct size, comorbidities, concomitant medication, clinical department, history of smoking, alcohol consumption, and history of stroke. Results— After adjusting for potential confounders, the improvement in NIHSS score from admission to discharge was greater in the edaravone-treated group than in the no edaravone group for all ischemic stroke subtypes (mean [95% CI] difference in ΔNIHSS: −0.46 [−0.75 to −0.16] for large-artery atherosclerosis, −0.64 [−1.09 to −0.2] for cardioembolism, and −0.25 [−0.4 to −0.09] for small-vessel occlusion). Conclusions— For any ischemic stroke subtype, edaravone use (compared with no use) was associated with a greater improvement in neurological symptoms, although the difference was small (<1 point NIHSS) and of limited clinical significance.

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High ABCD2 Scores and In-Hospital Interventions following Transient Ischemic Attack

Cerebrovascular Diseases Extra ◽

10.1159/000450692 ◽

2016 ◽

Vol 6 (3) ◽

pp. 76-83 ◽

Cited By ~ 4

Author(s):

Shawna Cutting ◽

Elizabeth Regan ◽

Vivien H. Lee ◽

Shyam Prabhakaran

Keyword(s):

Ischemic Stroke ◽

Transient Ischemic Attack ◽

Heart Association ◽

Reperfusion Therapy ◽

Large Artery ◽

Increased Risk ◽

Risk Patients ◽

Abcd2 Score ◽

Ischemic Attack ◽

Ischemic Events

Background and Purpose: Following transient ischemic attack (TIA), there is increased risk for ischemic stroke. The American Heart Association recommends admission of patients with ABCD2 scores ≥3 for observation, rapid performance of diagnostic tests, and potential acute intervention. We aimed to determine if there is a relationship between ABCD2 scores, in-hospital ischemic events, and in-hospital treatments after TIA admission. Methods: We reviewed consecutive patients admitted between 2006 and 2011 following a TIA, defined as transient focal neurological symptoms attributed to a specific vascular distribution and lasting <24 h. Three interventions were prespecified: anticoagulation for atrial fibrillation, carotid or intracranial revascularization, and intravenous or intra-arterial reperfusion therapies. We compared rates of in-hospital recurrent TIA or ischemic stroke and the receipt of interventions among patients with low (<3) versus high (≥3) ABCD2 scores. Results: Of 249 patients, 11 patients (4.4%) had recurrent TIAs or strokes during their stay (8 TIAs, 3 strokes). All 11 had ABCD2 scores ≥3, and no neurological events occurred in patients with lower scores (5.1 vs. 0%; p = 0.37). Twelve patients (4.8%) underwent revascularization for large artery stenosis, 16 (6.4%) were started on anticoagulants, and no patient received intravenous or intra-arterial reperfusion therapy. The ABCD2 score was not associated with anticoagulation (p = 0.59) or revascularization (p = 0.20). Conclusions: Higher ABCD2 scores may predict early ischemic events after TIA but do not predict the need for intervention. Outpatient evaluation for those with scores <3 would potentially have delayed revascularization or anticoagulant treatment in nearly one-fifth of ‘low-risk' patients.

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Some problems in interpreting Anglo-Saxon coinage

Anglo-Saxon England ◽

10.1017/s0263675100000843 ◽

1976 ◽

Vol 5 ◽

pp. 173-224 ◽

Cited By ~ 12

Author(s):

Stewart Lyon

Keyword(s):

Economic History ◽

Economic Life ◽

Documentary Evidence ◽

Anglo Saxon ◽

The Past ◽

History Of ◽

The Times ◽

The Relationship ◽

Dividing Line

This discussion of Anglo-Saxon coinage attempts to look beyond the detail of numismatic classification in order to consider the relationship between the underlying variations and the economic life of the times. Those parts of it which deal with the classification of the coinage and analyse the observed metrology are intended to be a critical summary of the numismatic research carried out in the past thirty years. Other parts, in which I seek to relate the metrology to such documentary evidence as is known to me – and thus trespass across the vague dividing line between numismatics, of which I have some knowledge, and economic history, of which I have little – are aimed at stimulating awareness and discussion of the problems involved. Finally, a section is devoted to numismatic methods because it is important that their use and limitations be generally understood.

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Correlation of imaging and histopathology of thrombi in acute ischemic stroke with etiology and outcome: a systematic review

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012391 ◽

2016 ◽

Vol 9 (6) ◽

pp. 529-534 ◽

Cited By ~ 92

Author(s):

Waleed Brinjikji ◽

Sharon Duffy ◽

Anthony Burrows ◽

Werner Hacke ◽

David Liebeskind ◽

...

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Treatment Strategies ◽

Hounsfield Unit ◽

Large Artery ◽

Vessel Occlusion ◽

Stroke Etiology ◽

Imaging Characteristics ◽

Significant Difference

Background and purposeStudying the imaging and histopathologic characteristics of thrombi in ischemic stroke could provide insights into stroke etiology and ideal treatment strategies. We conducted a systematic review of imaging and histologic characteristics of thrombi in acute ischemic stroke.Materials and methodsWe identified all studies published between January 2005 and December 2015 that reported findings related to histologic and/or imaging characteristics of thrombi in acute ischemic stroke secondary to large vessel occlusion. The five outcomes examined in this study were (1) association between histologic composition of thrombi and stroke etiology; (2) association between histologic composition of thrombi and angiographic outcomes; (3) association between thrombi imaging and histologic characteristics; (4) association between thrombi imaging characteristics and angiographic outcomes; and (5) association between imaging characteristics of thrombi and stroke etiology. A meta-analysis was performed using a random effects model.ResultsThere was no significant difference in the proportion of red blood cell (RBC)-rich thrombi between cardioembolic and large artery atherosclerosis etiologies (OR 1.62, 95% CI 0.1 to 28.0, p=0.63). Patients with a hyperdense artery sign had a higher odds of having RBC-rich thrombi than those without a hyperdense artery sign (OR 9.0, 95% CI 2.6 to 31.2, p<0.01). Patients with a good angiographic outcome had a mean thrombus Hounsfield unit (HU) of 55.1±3.1 compared with a mean HU of 48.4±1.9 for patients with a poor angiographic outcome (mean standard difference 6.5, 95% CI 2.7 to 10.2, p<0.001). There was no association between imaging characteristics and stroke etiology (OR 1.13, 95% CI 0.32 to 4.00, p=0.85).ConclusionsThe hyperdense artery sign is associated with RBC-rich thrombi and improved recanalization rates. However, there was no association between the histopathological characteristics of thrombi and stroke etiology and angiographic outcomes.

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Overview of species of the Clinopodium sections Calamintha and Ellementha (Lamiaceae) in the flora of the Caucasus and adjacent territories

Novitates Systematicae Plantarum Vascularium ◽

10.31111/novitates/2020.51.79 ◽

2020 ◽

pp. 79-112

Author(s):

D. G. Melnikov

Keyword(s):

New Species ◽

Morphological Traits ◽

The Caucasus ◽

History Of ◽

New Varieties ◽

Trichome Types ◽

The Relationship

The article briefly discusses the history of the study of species from the relationship Clinopodium calamintha (L.) Kuntze s. l. in the Caucasus, now included in the sections Calamintha (Mill.) Melnikov and Ellementha Melnikov. A number of new morphological traits to distinguish the species of these sections are presented, and a classification of the trichome types found in this group is given. 17 new species and 4 new varieties are described. For the flora of the Caucasus, 16 species are recorded, and 3 more species are possible to find growing in the regions adjacent to the Caucasus (in Turkey and Iran). A key has been compiled to identify the species and varieties of these two sections in the Caucasus.

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