Symptomatic Intracranial Atherosclerosis: Natural History of Medical Management Beyond the Hyperacute Stage of Ischemic Stroke in the Post-SAMMPRIS Era

Background: A major cause of ischemic stroke (IS) worldwide, especially in Asia, is intracranial atherosclerotic stenosis (ICAS), which is also associated with the high risk of recurrent stroke. Objective: The aim of our study was to determine the natural history of symptomatic ICAS ischemic stroke (ICAS IS) patients. Materials and Methods: We collected data on acute ICAS IS patients beyond the hyperacute IS phase to determine stroke recurrence and mortality at a tertiary care neurology hospital. Data were collected on basic demographics and traditional risk factors such as hypertension, coronary artery disease, diabetes mellitus, tobacco abuse, and hyperlipidemia, and statistical analysis was done. The primary endpoint was to measure the unfavorable outcome as defined by recurrent stroke or death from any cause. Results: The mean follow-up time for the total 87 patients was 24.5 months. Nine patients (10.3%) had an unfavorable outcome in the follow-up period; 2 (2.3%) of them had recurrent IS. Age was a predictor of the unfavorable outcome ( P = .0025), whereas hyperlipidemia was present more in patients with the favorable outcome ( P = .033). There was a tendency for patients with poor outcomes to have a higher National Institutes of Health Stroke Scale at their onset of stroke. Conclusions: Aggressive medical treatment was associated with a relatively low risk of recurrent stroke in our ICAS IS population. This study provides groundwork for larger studies that can take into account clinical and newer imaging techniques to improve secondary prevention in ICAS IS patients.

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Unruptured intracranial aneurysms in children: 18 years’ experience in a tertiary care pediatric institution

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.4.peds18703 ◽

2019 ◽

Vol 24 (2) ◽

pp. 184-189 ◽

Cited By ~ 1

Author(s):

Daniel-Alexandre Bisson ◽

Peter Dirks ◽

Afsaneh Amirabadi ◽

Manohar M. Shroff ◽

Timo Krings ◽

...

Keyword(s):

Carotid Artery ◽

Natural History ◽

Internal Carotid Artery ◽

Intracranial Aneurysms ◽

Internal Carotid ◽

Tertiary Care ◽

Unruptured Intracranial Aneurysms ◽

History Of ◽

Mean Size

OBJECTIVEThere are little data in the literature on the characteristics and natural history of unruptured intracranial aneurysms in children. The authors analyzed their experience with unruptured intracranial aneurysms in the pediatric population at their tertiary care pediatric institution over the last 18 years. The first objective was to assess the imaging characteristics and natural history of these aneurysms in order to help guide management strategies in the future. A second objective was to evaluate the frequency of an underlying condition when an incidental intracranial aneurysm was detected in a child.METHODSThe authors conducted a Research Ethics Board–approved retrospective review of incidental intracranial aneurysms in patients younger than 18 years of age who had been treated at their institution in the period from 1998 to 2016. Clinical (age, sex, syndrome) and radiological (aneurysm location, type, size, thrombus, mass effect) data were recorded. Follow-up imaging was assessed for temporal changes.RESULTSSixty intracranial aneurysms occurred in 51 patients (36 males, 15 females) with a mean age of 10.5 ± 0.5 years (range 9 months–17 years). Forty-five patients (88.2%) had a single aneurysm, while 2 and 3 aneurysms were found in 3 patients each (5.8%). Syndromic association was found in 22 patients (43.1%), most frequently sickle cell disease (10/22 [45.5%]). Aneurysms were saccular in 43 cases (71.7%; mean size 5.0 ± 5.7 mm) and fusiform in the remaining 17 (28.3%; mean size 6.5 ± 2.7 mm). Thirty-one aneurysms (51.7%) arose from the internal carotid artery (right/left 1.4), most commonly in the cavernous segment (10/31 [32.3%]). Mean size change over the entire follow-up of 109 patient-years was a decrease of 0.6 ± 4.2 mm (range −30.0 to +4.0 mm, rate −0.12 ± 9.9 mm/yr). Interval growth (2.0 ± 1.0 mm) was seen in 8 aneurysms (13.3%; 4 saccular, 4 fusiform). An interval decrease in size (8.3 ± 10.7 mm) was seen in 6 aneurysms (10%). There was an inverse relationship between aneurysm size and growth rate (r = −0.82, p < 0.00001). One aneurysm was treated endovascularly with internal carotid artery sacrifice.CONCLUSIONSUnruptured pediatric intracranial aneurysms are most frequently single but can occur in multiples in a syndromic setting. None of the cases from the study period showed clinical or imaging signs of rupture. Growth over time, although unusual and slow, can occur in a proportion of these patients, who should be identified for short-term imaging surveillance.

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Abstract MP86: Effects of Immediate Blood Pressure Reduction on Death and Major Disability in Acute Ischemic Stroke Patients by History of Hypertension and Use of Antihypertensive Medications

Circulation ◽

10.1161/circ.131.suppl_1.mp86 ◽

2015 ◽

Vol 131 (suppl_1) ◽

Author(s):

Tan Xu ◽

Yonghong Zhang ◽

Yingxian Sun ◽

Chung-Shiuan Chen ◽

Jing Chen ◽

...

Keyword(s):

Ischemic Stroke ◽

Treatment Group ◽

Acute Ischemic Stroke ◽

Hospital Discharge ◽

Odds Ratio ◽

Recurrent Stroke ◽

Stroke Patients ◽

Antihypertensive Medications ◽

History Of

Introduction: The effects of blood pressure (BP) reduction on clinical outcomes among acute stroke patient remain uncertain. Hypothesis: We tested the effects of immediate BP reduction on death and major disability at 14 days or hospital discharge and 3-month follow-up in acute ischemic stroke patients with and without a previous history of hypertension or use of antihypertensive medications. Methods: The China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) randomly assigned patients with ischemic stroke within 48 hours of onset and elevated systolic BP (SBP) to receive antihypertensive treatment (N=2,038) or to discontinue all antihypertensive medications (N=2,033) during hospitalization. Randomization was stratified by participating hospitals and use of antihypertensive medications. Study outcomes were assessed at 14 days or hospital discharge and 3-month post-treatment follow-up. The primary outcome was death and major disability (modified Rankin Scale score≥3), and secondary outcomes included recurrent stroke and vascular events. Results: Mean SBP was reduced 12.7% in the treatment group and 7.2% in the control group within 24 hours after randomization (P<0.001). Mean SBP was 137.3 mmHg in the treatment group and 146.5 in the control group at day 7 after randomization (P<0.001). At 14 days or hospital discharge, the primary and secondary outcomes were not significantly different between the treatment and control groups by subgroups. At the 3-month follow-up, recurrent stroke was significantly reduced in the antihypertensive treatment group among patients with a history of hypertension (odds ratio 0.43, 95% CI 0.24-0.75, P=0.003) and among patients with a history of use of antihypertensive medications (odds ratio 0.41, 95% CI 0.20-0.84, P=0.01). All-cause mortality (odds ratio 2.84, 95% CI 1.11-7.27, P=0.03) was increased among patients without a history of hypertension. Conclusion: Immediate BP reduction lowers recurrent stroke among acute ischemic stroke patients with a previous history of hypertension or use of antihypertensive medications at 3 months. On the other hand, BP reduction increases all-cause mortality among patients without a history of hypertension.

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Abstract P684: Treatment of Hypercoagulability-Induced New Neurovascular Events Using Enoxaparin vs DOACs (THINNED): A Retrospective Study

Stroke ◽

10.1161/str.52.suppl_1.p684 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Danielle Golub ◽

Sakinah Sabadia ◽

Shadi Yaghi ◽

Aneek Patel ◽

Christopher Hernandez ◽

...

Keyword(s):

Ischemic Stroke ◽

Cancer Patients ◽

Metastatic Disease ◽

Recurrent Stroke ◽

Antiplatelet Agent ◽

Retrospective Chart Review ◽

Initial Study ◽

Stroke Recurrence ◽

Vessel Infiltration

Introduction: The incidence of stroke is higher in patients with malignancy, especially within a few months of diagnosis and in more aggressive cancers. This phenomenon may be explained by an inherent hypercoagulable state, tumor embolism, vessel infiltration, or as a side effect from cancer treatment. Notably, stroke in cancer patients is associated with poor functional outcomes and reduced survival. Currently, however, there are no clear guidelines for antithrombotic management for prevention of recurrent strokes in these patients. Methods: We conducted a single-center retrospective chart review from 2013-2019. All adult patients with an ischemic stroke occurring with active malignancy and who then received either a direct oral anticoagulant (DOAC) or low molecular weight heparin (LMWH) were included. Patients with hemorrhagic stroke, an intracranial malignancy, or who were immediately admitted to hospice were excluded. Results: A total of 55 patients were included with a mean age of 71.8 years (range 28-96), 60% females, 87.3% first-time strokes, and 54.9% with metastatic disease. After stroke, 25 patients received a DOAC and 30 received LMWH for anticoagulation with a mean follow-up of 403 days. Between these two groups, most presentation and treatment characteristics were similar except for baseline hypertension, hyperlipidemia, additional initiation of an antiplatelet, and follow-up time. There was no difference in either stroke recurrence (DOAC vs LMWH: OR 2.61 [0.51-13.45], p=0.252) or time to recurrent stroke (DOAC vs LMWH: HR 1.68, p=0.446), but both analyses required adjustment for additional initiation of an antiplatelet—which was significantly protective regardless of anticoagulation choice (p=0.021* and p=0.017*, respectively). There was a trend towards improved survival if placed on a DOAC (HR 0.27, p=0.051), even after adjusting for metastatic disease. Conclusions: In this initial study of cancer patients with ischemic stroke, anticoagulation choice made no difference on stroke recurrence; however, addition of an antiplatelet agent was significantly protective. There was also a trend towards improved survival on a DOAC. Additional prospective data incorporating a larger sample size could further validate these findings.

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Prognosis of carotid dissecting aneurysms

Neurology ◽

10.1212/wnl.0000000000003617 ◽

2017 ◽

Vol 88 (7) ◽

pp. 646-652 ◽

Cited By ~ 14

Author(s):

Susanna C. Larsson ◽

Alice King ◽

Jeremy Madigan ◽

Christopher Levi ◽

John W. Norris ◽

...

Keyword(s):

Natural History ◽

Stroke Risk ◽

Recurrent Stroke ◽

Anticoagulation Therapy ◽

Artery Dissection ◽

Cervical Artery Dissection ◽

Cervical Artery ◽

History Of ◽

Age And Sex

Objective:To determine the natural history of dissecting aneurysm (DA) and whether DA is associated with an increased recurrent stroke risk and whether type of antithrombotic drugs (antiplatelets vs anticoagulants) modifies the persistence or development of DA.Methods:We included 264 patients with extracranial cervical artery dissection (CAD) from the Cervical Artery Dissection in Stroke Study (CADISS), a multicenter prospective study that compared antiplatelet with anticoagulation therapy. Logistic regression was used to estimate age- and sex-adjusted odds ratios. We conducted a systematic review of published studies assessing the natural history of DA and stroke risk in patients with non-surgically-treated extracranial CAD with DA.Results:In CADISS, DA was present in 24 of 264 patients at baseline. In 36 of 248 patients with follow-up neuroimaging at 3 months, 12 of the 24 baseline DAs persisted, and 24 new DA had developed. There was no association between treatment allocation (antiplatelets vs anticoagulants) and whether DA at baseline persisted at follow-up or whether new DA developed. During 12 months of follow-up, stroke occurred in 1 of 48 patients with DA and in 7 of 216 patients without DA (age- and sex-adjusted odds ratio 0.84; 95% confidence interval 0.10–7.31; p = 0.88). Published studies, mainly retrospective, showed a similarly low risk of stroke and no evidence of an increased stroke rate in patients with DA.Conclusions:The results of CADISS provide evidence suggesting that DAs may have benign prognosis and therefore medical treatment should be considered.

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Abstract TMP110: Antithrombotic Therapy and Risk of Stroke Recurrence in Children With Congenital and Acquired Cardiac Disease

Stroke ◽

10.1161/str.51.suppl_1.tmp110 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Elizabeth Pulcine ◽

Mike Seed ◽

Leonardo Brandao ◽

Mahmoud Slim ◽

Manohar Shroff ◽

...

Keyword(s):

Ischemic Stroke ◽

Antithrombotic Therapy ◽

Recurrent Stroke ◽

Hemorrhagic Transformation ◽

Palliative Surgery ◽

Left Ventricular ◽

Stroke Recurrence ◽

Inclusion Criteria ◽

Arterial Ischemic Stroke

Background: Antithrombotic therapy (ATT) is currently recommended for stroke prevention in pediatric cardioembolic arterial ischemic stroke (CE-AIS) where the risk of recurrence is high. Methods: We conducted a retrospective study of a prospectively enrolled cohort of neonates and children with radiologically-confirmed cardioembolic arterial ischemic stroke (CE-AIS) from January 2003 - December 2017. We evaluated the clinical and radiographic predictors of hemorrhagic transformation (HT) and stroke recurrence to assess the safety and efficacy of ATT. Results: Eighty-two children met inclusion criteria [53.7% males and 28% neonates; median age 0.43 (IQR: 0.08 - 4.23) years]. Stroke recurred in 11 children at a median of 32 days (IQR: 5.5 - 93) from the index event. Most recurrent infarcts were silent (n=6; 54.5%) and found on follow-up neuroimaging with an average follow-up interval of 4.1 ±3 .5 years. Procedure-related recurrence took place in 1 (9.1%) child. Ten (90.9%) children were receiving antithrombotic therapy at the time of recurrence: 8 (72.7%) were on anticoagulant therapy (ACT) and 2 (18.2%) were on a combination of antiplatelet (ATP) and ACT. HT occurred in 20 of 82 children (24.4%), all of whom were receiving ACT, 5 (6.1%) of whom were symptomatic. Four (4.9%) had systemic hemorrhage. There was no difference in the frequency of stroke recurrence between those with and without HT [3 (15.0%) vs. 8 (12.9%); p=1.00]. Children with univentricular physiology were less likely to have HT [15% vs. 43.5%; p=0.03] and had higher rates of recurrent stroke, prior to definitive cardiac repair, despite receiving ATT. Stroke recurrence was highest in those with cyanotic congenital heart disease (CHD) pre-surgery (3/11), cyanotic CHD post-palliative surgery with residual right-to-left-shunt (3/11) and in those with cardiomyopathy (4/11). HT was not associated with ATP vs. ACT use nor combination therapy. Conclusion: ATT appears to be relatively safe in children with CE-AIS. However, ATT warrants further optimization to prevent stroke recurrence, particularly in those with single ventricle physiology and reduced left ventricular function.

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Abstract 1122‐000169: The Carotid Web and Ischemic Stroke ‐ A Case Report

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000169 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Aravind Reddy ◽

Neil Suryadevara ◽

Hesham Masoud ◽

Palma Shaw ◽

Karen Albright

Keyword(s):

Ischemic Stroke ◽

Case Report ◽

Carotid Artery ◽

Literature Review ◽

Medical Therapy ◽

Systematic Literature Review ◽

Recurrent Stroke ◽

Stroke Recurrence ◽

Patient Case

Introduction : Case report: 63 year old African American woman with history of hypertension presented with acute onset of expressive aphasia. Her neurologic exam and NIHSS was significant for moderate aphasia with paraphasic errors and impairment of repetition. She was outside the treatment window for IV thrombolytic therapy. CT angiography of the head and neck in the ED showed moderate 60–70% stenosis of the left internal carotid artery secondary to a carotid web. She was admitted to the stroke service and started on DAPT with ASA and clopidogrel. MRI brain was obtained, which confirmed a small acute infarct in the posterior margin of the left sylvian fissure. Methods : Intervention and Follow‐up: Vascular surgery and interventional neurology were consulted to discuss the treatment options for the patient’s carotid web. Give the unique nature of the patient’s web with its triple lumen appearance, carotid endarterectomy (CEA) was favored over stenting, and the patient underwent left CEA. There were no immediate complications, and she was continued on DAPT for 21 days, then ASA monotherapy. One month follow‐up carotid dopplers of the left ICA showed patent flow without significant stenosis. On follow‐up evaluations at 3 and 12 months, the patient’s speech deficits had improved significantly and she reported no new stroke‐like symptoms. Results : Literature Review: Carotid webs (CaW) may be a potentially underrecognized cause of ischemic strokes. CaW are thin, fibrous tissue that extends from the wall of the carotid artery into the lumen in a shelf‐like projection. It is believed to be a variant of fibromuscular dysplasia. It is hypothesized that blood stasis on the downstream surface of the web may result in thrombus formation and thromboembolic stroke. The optimal treatment for CaW remains unclear, however there is some evidence to suggest that antiplatelet therapy alone may be insufficient to prevent recurrent stroke, with rates of recurrent stroke of 30–50% from a systematic literature review. Furthermore, there have been no reports of CaW positive remodeling over time, so patients likely remain at elevated risk for ischemic stroke without intervention. Conclusions : Discussion: Case series as well as systematic literature review have shown high rates of stroke recurrence in CaW patients treated with medical therapy alone. Data is still limited, however, CEA and carotid artery stenting (CAS) appear to be safe and effective revascularization procedures for CaW, with potentially significant reduction in recurrent stroke risk. CEA was preferred in our patient case due to the triple‐lumen appearance of the carotid web (Figure). CaW is a relatively underappreciated cause of ischemic strokes and the optimal management is not well‐established, however medical therapy alone appears to be sub‐optimal with high rates of stroke recurrence. Our patient case shows that carotid revascularization can be safe may be effective in preventing stroke recurrence.

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896 THE NATURAL HISTORY OF IDIOSYNCRATIC DRUG-INDUCED LIVER INJURY (DILI): FOLLOW-UP IN A COHORT OF PATIENTS IDENTIFIED IN A SINGLE TERTIARY CARE CENTRE

Journal of Hepatology ◽

10.1016/s0168-8278(08)60898-3 ◽

2008 ◽

Vol 48 ◽

pp. S336 ◽

Cited By ~ 1

Author(s):

B. Garcia-Munoz ◽

S. Lopez-Ortega ◽

Y. Borraz ◽

A. Fernandez Castaner ◽

M.C. Lopez-Vega ◽

...

Keyword(s):

Liver Injury ◽

Natural History ◽

Tertiary Care ◽

Care Centre ◽

Tertiary Care Centre ◽

Drug Induced ◽

Drug Induced Liver Injury ◽

History Of

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Analysis and natural history of pituitary incidentalomas

Acta Endocrinologica ◽

10.1530/eje-16-0041 ◽

2016 ◽

Vol 175 (1) ◽

pp. 1-9 ◽

Cited By ~ 15

Author(s):

Syed Ali Imran ◽

Churn-Ern Yip ◽

Netee Papneja ◽

Khaled Aldahmani ◽

Syed Mohammad ◽

...

Keyword(s):

Natural History ◽

Tertiary Care ◽

Population Based ◽

Post Surgery ◽

Surgery Group ◽

High Prevalence ◽

History Of ◽

Ischemic Attack ◽

Epidemiological Characteristics

Objectives Pituitary incidentalomas (PI) are frequently found on brain imaging. Despite their high prevalence, little is known about their long-term natural history and there are limited guidelines on how to monitor them. Methods We conducted a retrospective study to compare epidemiological characteristics at presentation and the natural history of PI in population-based vs referral-based registries from two tertiary-care referral centers in Canada. Results A total of 328 patients with PI were included, of whom 73% had pituitary adenomas (PA) and 27% had non-pituitary sellar masses. The commonest indications for imaging were headache (28%), dizziness (12%) and stroke/transient ischemic attack (TIA) (9%). There was a slight female preponderance (52%) with a median age of 55 years at diagnosis; 71% presented as macroadenomas (>10mm). Of PA, 25% were functioning tumors and at presentation 36% of patients had evidence of secondary hormonal deficiency (SHD). Of the total cohort, 68% were treated medically or conservatively whereas 32% required surgery. Most tumors (87% in non-surgery and 68% in post-surgery group) remained stable during follow-up. Similarly, 84% of patients in the non-surgery and 73% in the surgery group did not develop additional SHD during follow-up. The diagnosis of non-functioning adenoma was a risk factor for tumor enlargement and a change in SHD status was associated with a change in tumor size. Conclusions Our data suggest that most PI seen in tertiary-care referral centers present as macroadenomas and may frequently be functional, often requiring medical or surgical intervention.

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