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

Stroke ◽  
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.

Abstract TP73: Lower Prehospital Blood Pressure Is Not Associated with Larger Infarct Volumes in Non-lacunar Ischemic Stroke Patients

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Rahel T Zewude ◽  
Laura C Gioia ◽  
Mahesh Kate ◽  
Kim Liss ◽  
Brian Rowe ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Infarct Volume ◽  
Cryptogenic Stroke ◽  
Final Diagnosis ◽  
Large Artery ◽  
Stroke Etiology ◽  
Artery Disease ◽  
Suspected Stroke

Background: Although prehospital blood pressure (BP)-lowering trials in acute stroke have begun, concerns persist that hypotension may exacerbate hypoperfusion and increase infarct volumes, particularly in non-lacunar stroke. We tested the hypothesis that lower prehospital BP is associated with larger infarct volumes in non-lacunar ischemic stroke. Methods: We conducted a retrospective study of consecutive patients with suspected stroke transported by Emergency Medical Services (EMS) during an 18-month period. Serial prehospital BP data were obtained from a centralized EMS database. Hospital charts and neuroimaging were reviewed. Stroke etiology was classified using TOAST criteria. Infarct volumes were measured on follow-up MRI or CT using semi-automated thresholding planimetric techniques by two independent raters, blinded to prehospital BP. Results: Of a total 960 patients transported by EMS, 367 had a final diagnosis of ischemic stroke. Stroke etiology was large artery disease in 51 patients, cardioembolic in 140, lacunar in 44, other determined etiology in 22, and cryptogenic in 110 patients. Follow-up imaging was available in 315 patients (163 MR, 152 CT) at a median (IQR) 1(1) days. The overall median non-lacunar infarct volume was 16.5 (49.6) ml, median NIHSS was 7(10), and mean prehospital SBP was 153 ± 25 mmHg. Mean prehospital SBP was lower in patients with other determined etiology (133.2 ± 26.1 mmHg, p<0.01) than cardioembolic (150.9 ± 25.5 mmHg), large artery disease (157.1 ± 26.1 mmHg) and cryptogenic stroke (157.7 ± 22.9 mmHg). Median infarct volume was similar across categories of stroke etiology (large artery disease (16.3 (60.3) ml), cardioembolic (19.9 (76.2) ml), other determined etiology (23.9 (33.6) ml), and cryptogenic stroke (11.5 (35.9) ml), p=0.12). There was no correlation between mean prehospital SBP and mean infarct volume (r =-0.06, p=0.33). NIHSS score was correlated with mean infarct volume (r=0.6, p<0.001), but not mean prehospital SBP (r=-0.07, p=0.24). Conclusion: These data provide no evidence to suggest that lower prehospital BP is associated with larger infarct volumes in patients with non-lacunar ischemic stroke. The effect of BP reduction on infarct volumes should be assessed as part of randomized trials.

scholarly journals Circulating Vitamin K1 Levels in Relation to Ischemic Stroke and Its Subtypes: A Mendelian Randomization Study

Nutrients ◽  
2018 ◽  
Vol 10 (11) ◽  
pp. 1575 ◽  
Author(s):  
Susanna Larsson ◽  
Matthew Traylor ◽  
Hugh Markus
Keyword(s):  
Ischemic Stroke ◽  
Mendelian Randomization ◽  
Cardioembolic Stroke ◽  
Small Vessel ◽  
Large Artery ◽  
Vitamin K1 ◽  
Nucleotide Polymorphisms ◽  
Single Nucleotide ◽  
Level Data ◽  
Increased Risk

Vitamin K plays a crucial role in blood coagulation, and hypercoagulability has been linked to atherosclerosis-related vascular disease. We used the Mendelian randomization study design to examine whether circulating vitamin K1 (phylloquinone) levels are associated with ischemic stroke. Four single-nucleotide polymorphisms associated with vitamin K1 levels were used as instrumental variables. Summary-level data for large artery atherosclerotic stroke (n = 4373 cases), small vessel stroke (n = 5386 cases), cardioembolic stroke (n = 7193 cases), and any ischemic stroke (n = 34,217 cases and 404,630 non-cases) were available from the MEGASTROKE consortium. Genetically-predicted circulating vitamin K1 levels were associated with large artery atherosclerotic stroke but not with any other subtypes or ischemic stroke as a whole. The odds ratios per genetically predicted one nmol/L increase in natural log-transformed vitamin K1 levels were 1.31 (95% confidence interval (CI) 1.12–1.53; p = 7.0 × 10−4) for large artery atherosclerotic stroke, 0.98 (95% CI 0.85–1.12; p = 0.73) for small vessel stroke, 1.01 (95% CI 0.90–1.14; p = 0.84) for cardioembolic stroke, and 1.05 (95% CI 0.99–1.11; p = 0.11) for any ischemic stroke. These findings indicate that genetic predisposition to higher circulating vitamin K1 levels is associated with an increased risk of large artery atherosclerotic stroke.

scholarly journals A Mendelian randomization analysis of the relationship between cardioembolic risk factors and ischemic stroke

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Danyang Tian ◽  
Linjing Zhang ◽  
Zhenhuang Zhuang ◽  
Tao Huang ◽  
Dongsheng Fan
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Mendelian Randomization ◽  
P Wave ◽  
Cardioembolic Stroke ◽  
Large Artery ◽  
Weighted Analysis ◽  
Inverse Variance ◽  
Weighted Median ◽  
Genetically Determined

AbstractObservational studies have shown that several risk factors are associated with cardioembolic stroke. However, whether such associations reflect causality remains unknown. We aimed to determine whether established and provisional cardioembolic risk factors are causally associated with cardioembolic stroke. Genetic instruments for atrial fibrillation (AF), myocardial infarction (MI), electrocardiogram (ECG) indices and N-terminal pro-brain natriuretic peptide (NT-pro BNP) were obtained from large genetic consortiums. Summarized data of ischemic stroke and its subtypes were extracted from the MEGASTROKE consortium. Causal estimates were calculated by applying inverse-variance weighted analysis, weighted median analysis, simple median analysis and Mendelian randomization (MR)-Egger regression. Genetically predicted AF was significantly associated with higher odds of ischemic stroke (odds ratio (OR): 1.20, 95% confidence intervals (CI): 1.16–1.24, P = 6.53 × 10–30) and cardioembolic stroke (OR: 1.95, 95% CI: 1.85–2.06, P = 8.81 × 10–125). Suggestive associations were found between genetically determined resting heart rate and higher odds of ischemic stroke (OR: 1.01, 95% CI: 1.00–1.02, P = 0.005), large-artery atherosclerotic stroke (OR: 1.02, 95% CI: 1.00–1.04, P = 0.026) and cardioembolic stroke (OR: 1.02, 95% CI: 1.00–1.04, P = 0.028). There was no causal association of P‐wave terminal force in the precordial lead V1 (PTFVI), P-wave duration (PWD), NT-pro BNP or PR interval with ischemic stroke or any subtype.

EXPRESS: Evolving Ischemic Stroke Subtypes in 15 years: A hospital-based observational study

2021 ◽  
pp. 174749302110059
Author(s):  
Yiu Ming Bonaventure Ip ◽  
Lisa Au ◽  
Yin Yan Anne Chan ◽  
Florence Fan ◽  
Hing Lung Ip ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Recurrence Rate ◽  
Small Vessel Disease ◽  
Mainland China ◽  
Cardioembolic Stroke ◽  
Large Artery ◽  
Risk Factor Control ◽  
Stroke Subtypes ◽  
Artery Disease ◽  
Ischemic Attack

Background: Depicting the time trends of ischemic stroke subtypes may inform healthcare resource allocation on etiology-based stroke prevention and treatment. Aim: To reveal the evolving ischemic stroke subtypes from 2004 to 2018. Methods: We determined the stroke etiology of consecutive first-ever transient ischemic attack or ischemic stroke patients admitted to a regional hospital in Hong Kong from 2004 to 2018. We analyzed the age-standardized incidences and the 2-year recurrence rate of major ischemic stroke subtypes. Results: Among 6940 patients admitted from 2004 to 2018, age-standardized incidence of ischemic stroke declined from 187.0 to 127.4 per 100,000 population (p<0.001), driven by the decrease in large artery disease (43.0 to 9.67 per 100,000 population (p<0.001)) and small vessel disease (71.9 to 45.7 per 100,000 population (p<0.001)). Age-standardized incidence of cardioembolic stroke did not change significantly (p=0.2). Proportion of cardioembolic stroke increased from 20.4% in 2004-2006 to 29.3% in 2016-2018 (p<0.001). 2-year recurrence rate of intracranial atherothrombotic stroke reduced from 19.3% to 5.1% (p<0.001) with increased prescriptions of statin (p<0.001) and dual anti-platelet therapy (<0.001). In parallel with increased anticoagulation use across the study period (p<0.001), the 2-year recurrence of AF-related stroke reduced from 18.9% to 6% (p<0.001). Conclusion: Etiology-based risk factor control might have led to the diminishing stroke incidences related to atherosclerosis. To tackle the surge of AF-related strokes, arrhythmia screening, anticoagulation usage and mechanical thrombectomy service should be reinforced. Comparable preventive strategies might alleviate the enormous stroke burden in mainland China.

Patient Demographics, Characteristics, and Intrahospital Mortality of Different Ischemic Stroke Subtypes in a Tertiary Hospital during Five-Year Period

2021 ◽  
Vol 6 (1) ◽  
pp. 6
Author(s):  
Sintija Strautmane ◽  
Kristaps Jurjāns ◽  
Estere Zeltiņa ◽  
Evija Miglāne ◽  
Andrejs Millers
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Reperfusion Therapy ◽  
Cardioembolic Stroke ◽  
Study Group ◽  
Large Artery ◽  
Patient Demographics ◽  
Stroke Subtypes ◽  
Female Predominance ◽  
Study Population

Background and Objectives. Ischemic stroke (IS) is one of the leading causes of disability, morbidity, and mortality worldwide. The goal of the study was to evaluate patient demographics, characteristics, and intrahospital mortality among different ischemic stroke subtypes. Materials and Methods. A retrospective observational non-randomized study was conducted, including only ischemic stroke patients, admitted to Pauls Stradins Clinical university hospital, Riga, Latvia, from January of 2016 until December 2020. Ischemic stroke subtypes were determined according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria as a stroke due to (1) large-artery atherosclerosis (atherothrombotic stroke (AS)), (2) cardioembolism (cardioembolic stroke (CS)), (3) small-vessel occlusion (lacunar stroke (LS)), (4) stroke of other determined etiology (other specified stroke (OSS)), and (5) stroke of undetermined etiology (undetermined stroke (US)). The data between different stroke subtypes were compared. Results. There was a slight female predominance among our study population, as 2673 (56.2%) patients were females. In our study group, the most common IS subtypes were cardioembolic stroke (CS), 2252 (47.4%), and atherothrombotic stroke (AS), 1304 (27.4%). CS patients were significantly more severely disabled on admission, 1828 (81.4%), and on discharge, 378 (16.8%), p < 0.05. Moreover, patients with CS demonstrated the highest rate of comorbidities and risk factors. This was also statistically significant, p < 0.05. Differences between the total patient count with no atrial fibrillation (AF), paroxysmal AF, permanent AF, and different IS subtypes among our study population demonstrated not only statistical significance but also a strong association, Cramer’s V = 0.53. The majority of patients in our study group were treated conservatively, 3389 (71.3%). Reperfusion therapy was significantly more often performed among CS patients, 770 (34.2%), p < 0.05. The overall intrahospital mortality among our study population was 570 (12.0%), with the highest intrahospital mortality rate noted among CS patients, 378 (66.3%), p < 0.05. No statistically significant difference was observed between acute myocardial infarction and adiposity, p > 0.05. Conclusions. In our study, CS and AS were the most common IS subtypes. CS patients were significantly older with slight female predominance. CS patients demonstrated the greatest disability, risk factors, comorbidities, reperfusion therapy, and intrahospital mortality.

Penumbra Consumption Rates Based on Time-to-Maximum Delay and Reperfusion Status: A Post Hoc Analysis of the DEFUSE 3 Trial

Stroke ◽  
2021 ◽  
Author(s):  
Shadi Yaghi ◽  
Eytan Raz ◽  
Seena Dehkharghani ◽  
Howard Riina ◽  
Ryan McTaggart ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Infarct Volume ◽  
Interquartile Range ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Post Hoc Analysis ◽  
Consumption Rates ◽  
Post Hoc

Background and Purpose: In patients with acute large vessel occlusion, the natural history of penumbral tissue based on perfusion time-to-maximum (T max ) delay is not well established in relation to late-window endovascular thrombectomy. In this study, we sought to evaluate penumbra consumption rates for T max delays in patients with large vessel occlusion evaluated between 6 and 16 hours from last known normal. Methods: This is a post hoc analysis of the DEFUSE 3 trial (The Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke), which included patients with an acute ischemic stroke due to anterior circulation occlusion within 6 to 16 hours of last known normal. The primary outcome is percentage penumbra consumption, defined as (24-hour magnetic resonance imaging infarct volume–baseline core infarct volume)/(T max 6 or 10 s volume–baseline core volume). We stratified the cohort into 4 categories based on treatment modality and Thrombolysis in Cerebral Infarction (TICI score; untreated, TICI 0-2a, TICI 2b, and TICI3) and calculated penumbral consumption rates in each category. Results: We included 141 patients, among whom 68 were untreated. In the untreated versus TICI 3 patients, a median (interquartile range) of 53.7% (21.2%–87.7%) versus 5.3% (1.1%–14.6%) of penumbral tissue was consumed based on T max >6 s ( P <0.001). In the same comparison for T max >10 s, we saw a difference of 165.4% (interquartile range, 56.1%–479.8%) versus 25.7% (interquartile range, 3.2%–72.1%; P <0.001). Significant differences were not demonstrated between untreated and TICI 0-2a patients for penumbral consumption based on T max >6 s ( P =0.52) or T max >10 s ( P =0.92). Conclusions: Among extended window endovascular thrombectomy patients, T max >10-s mismatch volume may comprise large volumes of salvageable tissue, whereas nearly half the T max >6-s mismatch volume may remain viable in untreated patients at 24 hours.

Abstract T P153: Women and Men with Ischemic Stroke in SiGN Have Different Subtype Distributions and Risk Factors

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Kathryn M Rexrode ◽  
Braxton D Mitchell ◽  
Kathleen A Ryan ◽  
Steven J Kittner ◽  
Hakan Ay ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Stroke Risk ◽  
Cardioembolic Stroke ◽  
Relative Distribution ◽  
Large Artery ◽  
Stroke Risk Factors ◽  
Stroke Subtypes ◽  
Small Artery Occlusion ◽  
Ischemic Stroke Risk

Introduction: The relative distribution of stroke risk factors, as well as ischemic stroke subtypes, in women compared with men is not well described. Hypothesis: We hypothesized that the distribution of ischemic stroke risk factors and subtypes would differ by sex, with a later onset in women and greater proportion of comorbidities. Methods: The NINDS Stroke Genetics Network (SiGN) consortium was established to evaluate genetic risk factors for ischemic stroke. A total of 23 separate studies performed Causative Classification of Stroke (CCS) typing using standardized criteria on ischemic stroke cases and contributed data on risk factors. We compared the distribution of ischemic stroke risk factors and CCS phenotypes between men and women with ischemic stroke. Results: Of the 16,228 ischemic strokes in SiGN, 8005 (49.3%) occurred in women. Median age at stroke was older in female than male stroke cases (73 vs. 66 years) (p=<0.0001). Among stroke cases, women were more likely than men cases to have hypertension or atrial fibrillation and less likely to have diabetes or coronary artery disease, or to smoke (p <0.003 for all). The distribution of stroke subtypes also differed by sex, with women less likely than men to have large artery infarction and small artery occlusion, and more likely to have cardioembolic stroke and undetermined stroke due to incomplete work-up (p values all <0.0001; see Table). Results were similar when the distribution of stroke subtypes was examined for those <70 years and ≥70 years, except for cardioembolic stroke remaining more common only among women ≥70. Conclusions: In this large group of carefully phenotyped ischemic strokes, the distribution of ischemic stroke subtypes and risk factor profiles differ significantly by sex. Evaluation of the causes of these differences may highlight areas for improved prevention and risk reduction in both genders.

Abstract NS6: To Rest or Mobilize... When to Start Early Mobilization in Acute Stroke: a Systematic Review

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Michelle Whaley ◽  
Wendy Dusenbury ◽  
Andrei V Alexandrov ◽  
Georgios Tsivgoulis ◽  
Anne W Alexandrov
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Early Mobilization ◽  
Future Research ◽  
Cochrane Central Register ◽  
Large Artery ◽  
Stroke Subtype ◽  
Vascular Insufficiency ◽  
The Impact

Background: Recent nursing initiatives encourage early mobilization of neurocritical care patients, but whether this intervention can be safely generalized to acute stroke is debatable. We performed a systematic review of findings from recent studies to provide direction for patient management and future research. Methods: An exhaustive literature search was performed in Medline, SCOPUS and the Cochrane Central Register of Controlled Trials to identify published clinical trial research using a very early mobility intervention (within 24 hours) in acute ischemic stroke patients. The primary efficacy outcome supporting the search was neurologic disability reduction or improved functional outcomes, and the primary safety outcome was neurologic deterioration. Studies were critically reviewed for inclusion by 3 separate investigators, findings were synthesized, and an overall recommendation for very early mobilization use in acute stroke was assigned according to GRADE criteria. Results: We initially identified 12 papers focused on early mobilization in acute stroke; of these, 6 observational studies were excluded, 1 study was excluded due to an ambiguous population, and 3 studies were excluded due to first initial mobilization out of bed occurring greater than 24 hours after admission. Two prospective randomized outcome blinded evaluation (PROBE) studies were retained, consisting of a total 2160 patients; ischemic stroke subtype was not disclosed in either study, limiting an understanding of the impact of very early mobilization on small versus large artery occlusion. Slower mobilization occurring beyond the first 24 hours was associated with higher rates of favorable outcome (mRS 0-2) at 90 days, whereas very early mobilization within the first 24 hours was associated with a number needed to harm of 25. Conclusions: In acute stroke, evidence supports a rested approach to care within the first 24 hours of hospitalization (GRADE: Strong recommendation, high quality of evidence). Similar to acute myocardial infarction, vascular insufficiency experienced in stroke likely warrants a more guarded approach to mobility. Additional studies exploring timing beyond 24 hours and dose of mobility interventions are warranted in discreet populations.

Abstract WP227: Risk Factors for Pathophysiologic Subtypes of Ischemic Stroke Among West Africans: Findings From the SIREN Study

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Fred S Sarfo ◽  
Bruce Ovbiagele ◽  
Onoja M Akpa ◽  
Rufus Akinyemi ◽  
Albert Akpalu ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Vegetable Consumption ◽  
Conditional Logistic Regression ◽  
Meat Consumption ◽  
Small Vessel ◽  
Large Artery ◽  
Green Vegetable ◽  
Catchment Areas ◽  
West Africans

Background: The risk factors associated with the occurrence of the distinct pathophysiologic subtypes of ischemic stroke are unknown among indigenous Africans. Objective: To identify and quantify the contributions of risk factors for occurrence of ischemic stroke and its etiologic subtypes among West Africans. Methods: The Stroke Investigative Research and Educational Network (SIREN) is a multicenter, case-control study involving 15 sites in Nigeria and Ghana. Cases included adults aged >18 years with CT/MRI confirmed stroke and ischemic strokes were etiologically subtyped using the TOAST protocol. Controls were age-and-gender matched stroke-free adults recruited from the communities in catchment areas of cases. Comprehensive evaluation for vascular, lifestyle and psychosocial factors was performed using standard instruments. We used conditional logistic regression to estimate odds ratios (OR) with 95% CIs. Results: There were 1,721 ischemic stroke cases with a mean age of 62.19 ± 14.03 vs 60.86 ± 13.71 for controls. Using the TOAST etiologic scheme, 867 (50.3%) were small vessel occlusions, 425(24.7%) were large-artery atherosclerotic, 181(10.5%) were cardio-embolic, 204(11.9%) were undetermined and 44(2.6%) were of other determined etiology. The 7 dominant risk factors for ischemic strokes aOR (95%CI) were hypertension 10.76(7.15-16.20), dyslipidemia 5.30(3.86-7.29), diabetes 3.61(2.72-4.80), psychosocial stress 1.68(1.20-2.35), cardiac disease 1.94 (1.25-3.02), meat consumption 2.02(1.54-2.65), green vegetable consumption 0.44(0.33-0.59). Hypertension, dyslipidemia, diabetes, meat consumption and green vegetable intake were confluent factors shared by small-vessel, large-vessel and cardio-embolic ischemic stroke subtypes. Conclusion: We provide empiric evidence of risk factors to be targeted for stroke prevention. Our findings open a vista into future studies aimed at elucidating the genetic factors linked with pathophysiologic subtypes of stroke among Africans.

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