Effects of intracranial atherosclerosis and atrial fibrillation on the prognosis of ischemic stroke with active cancer

Background In ischemic stroke patients with active cancer, cryptogenic stroke has worse prognosis than stroke by conventional mechanisms. However, the individual effects of intracranial atherosclerosis (ICAS) or atrial fibrillation (AF) on the prognosis of these patients have not been studied. Aims Therefore, we aimed to investigate the effects of ICAS and AF on the prognosis of ischemic stroke patients with active cancer. Methods We included ischemic stroke patients with active cancer between 2010 and 2020. Early neurological deterioration (END) was defined as an increase of ≥ 1 in the motor NIHSS score, or ≥ 2 in the total NIHSS score within 72 hours of admission. Unfavorable outcomes were defined as a score of ≥ 3 on the 3-month modified Rankin Scale. Results In total, 116 ischemic stroke patients with active cancer were evaluated. In multivariable analysis, ICAS was positively associated with END (adjusted odds ratio [aOR] = 4.56, 95% confidence interval [CI]: 1.52–13.70), and this association showed a quantitative relationship according to the degree of stenosis of ICAS (stenosis group: aOR = 4.24, 95% CI: 1.31–13.72; occlusion group, aOR = 5.74, 95% CI: 1.05–31.30). ICAS was also closely related to unfavorable outcomes (aOR = 6.33, 95% CI: 1.15–34.79). In contrast, AF showed no significant association with END or unfavorable outcomes. Our data showed that patients with ICAS had larger and more severe initial stroke lesions, and poorer prognosis than those without. Conclusions ICAS, but not AF, was closely associated with poor prognosis in ischemic stroke patients with active cancer.

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Effects of cerebral small vessel disease on the outcomes in cryptogenic stroke with active cancer

Scientific Reports ◽

10.1038/s41598-021-97154-1 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Ki-Woong Nam ◽

Hyung-Min Kwon ◽

Yong-Seok Lee ◽

Jeong-Min Kim ◽

Sang-Bae Ko

Keyword(s):

Small Vessel Disease ◽

Multivariable Analysis ◽

Cryptogenic Stroke ◽

Unfavorable Outcome ◽

Small Vessel ◽

White Matter Hyperintensity ◽

Stroke Patients ◽

Nihss Score ◽

Point Increase ◽

Active Cancer

AbstractCerebral small vessel diseases (cSVDs) affect the prognosis of various types of ischemic stroke. Therefore, we evaluated the association between cSVD and the prognosis of cryptogenic stroke patients with active cancer. We enrolled patients diagnosed with cryptogenic stroke and active cancer from 2010 to 2016. Early neurological deterioration (END) was defined as a ≥ 2-point increase in the total NIHSS score or a ≥ 1-point increase in the motor NIHSS score within the first 72 h. We defined an unfavorable outcome as the modified Rankin Scale (mRS) score ≥ 3 points. We analyzed cSVD separately for each subtype including white matter hyperintensity (WMH), silent brain infarct (SBI), and cerebral microbleed (CMB). A total of 179 cryptogenic stroke patients with active cancer were evaluated. In the multivariable analysis, SBI was significantly associated with END (adjusted odds ratio = 3.97, 95% confidence interval: 1.53–10.33). This close relationship between SBI and END increased proportionally with an increase in SBI burden. However, WMH and CMB showed no significant association with END. None of the cSVD subtypes showed a statistically significant relationship with the 3-month unfavorable outcome. SBI was the only parameter closely associated with END in cryptogenic stroke patients with active cancer.

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Pre-Admission CHADS2 and CHA2DS2-VASc Scores on Early Neurological Worsening

Cerebrovascular Diseases ◽

10.1159/000513396 ◽

2021 ◽

pp. 1-8

Author(s):

Ki-Woong Nam ◽

Chi Kyung Kim ◽

Sungwook Yu ◽

Jong-Won Chung ◽

Oh Young Bang ◽

...

Keyword(s):

Ischemic Stroke ◽

Stroke Risk ◽

Multivariable Analysis ◽

National Institutes Of Health ◽

Risk Scores ◽

Stroke Patients ◽

Nihss Score ◽

Early Neurological Deterioration ◽

Close Relationship ◽

The Relationship

Background: Stroke risk scores (CHADS2 and CHA2DS2-VASc) not only predict the risk of stroke in atrial fibrillation (AF) patients, but have also been associated with prognosis after stroke. Objective: The aim of this study was to evaluate the relationship between stroke risk scores and early neurological deterioration (END) in ischemic stroke patients with AF. Methods: We included consecutive ischemic stroke patients with AF admitted between January 2013 and December 2015. CHADS2 and CHA2DS2-VASc scores were calculated using the established scoring system. END was defined as an increase ≥2 on the total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 on the motor NIHSS score within the first 72 h of admission. Results: A total of 2,099 ischemic stroke patients with AF were included. In multivariable analysis, CHA2DS2-VASc score (adjusted odds ratio [aOR] = 1.17, 95% confidence interval [CI] = 1.04–1.31) was significantly associated with END after adjusting for confounders. Initial NIHSS score, use of anticoagulants, and intracranial atherosclerosis (ICAS) were also found to be closely associated with END, independent of the CHA2DS2-VASc score. Multivariable analysis stratified by the presence of ICAS demonstrated that both CHA2DS2-VASc (aOR = 1.20, 95% CI = 1.04–1.38) and CHADS2 scores (aOR = 1.24, 95% CI = 1.01–1.52) were closely related to END in only patients with ICAS. In patients without ICAS, neither of the risk scores were associated with END. Conclusions: High CHA2DS2-VASc score was associated with END in ischemic stroke patients with AF. This close relationship is more pronounced in patients with ICAS.

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Abstract TP315: D-dimer is Associated With 30-day Mortality in Acute Ischemic Stroke With Active Cancer

Stroke ◽

10.1161/str.48.suppl_1.tp315 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Ki Woong Nam ◽

Chi Kyung Kim ◽

Tae Jung Kim ◽

Sang Joon An ◽

Kyungmi Oh ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Infarct Volume ◽

Hemorrhagic Transformation ◽

Stroke Patients ◽

Nihss Score ◽

Patients With Cancer ◽

Advanced Stages ◽

D Dimer ◽

Active Cancer

Background: Stroke in cancer patients is not rare, but is a devastating event with high mortality. However, the predictors of mortality in stroke patients with cancer have not been well addressed. D-dimer could be a useful predictor because it can reflect both thromboembolic events and advanced stages of cancer. In this study, we evaluate the possibility of D-dimer as a predictor of 30-day mortality in stroke patients with active cancer. Methods: We included 210 ischemic stroke patients with active cancer. The data of 30-day mortality were collected by reviewing medical records. We also collected follow-up D-dimer levels in 106 (50%) participants to evaluate the effects of treatment response on D-dimer levels. Results: Of the 210 participants, 30-day mortality occurred in 28 (13%) patients. Higher initial NIHSS score, D-dimer levels, CRP levels, frequent cryptogenic mechanism, systemic metastasis, multiple vascular territory lesion, hemorrhagic transformation, and larger infarct volume were related to 30-day mortality. In the multivariate analysis, D-dimer [adjusted OR (aOR) = 2.19; 95% CI, 1.46-3.28, P < 0.001] predicted 30-day mortality after adjusting for confounders. Initial NIHSS score (aOR = 1.07; 95% CI, 1.00-1.14, P = 0.043) and hemorrhagic transformation (aOR = 3.02; 95% CI, 1.10-8.29, P = 0.032) were also significant independently from D-dimer levels. In the analysis of D-dimer changes after treatment, the mortality group showed no significant decrease of D-dimer levels, despite treatment, while the survivor group showed opposite responses. Conclusions: D-dimer levels may predict 30-day mortality in acute ischemic stroke patients with active cancer.

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Hemorrhagic transformation predictors in ischemic stroke patients from a Stroke Unit

10.5327/1516-3180.659 ◽

2021 ◽

Author(s):

Fernanda Ferreira de Abreu ◽

Vinícius Bessa Mendez ◽

Ivã Taiuan Fialho Silva ◽

Alice Monteiro Soares Cajaíba ◽

Pedro Antonio Pereira de Jesus

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Ct Scan ◽

Computer Tomography ◽

Prospective Cohort ◽

Stroke Unit ◽

Hemorrhagic Transformation ◽

Stroke Patients ◽

Nihss Score ◽

Toast Classification

Background: Hemorrhagic transformation (HT) is an aggravating factor to patients with ischemic stroke. For patients’ best care, it’s essential to know its predictors. Objective: To describe HT in patients with ischemic stroke. Design and setting: Prospective cohort with ischemic stroke patients from a Stroke Unit, admitted between 2017 to 2019. Methods: All patients performed a brain computer tomography (CT) scan on arrival and 24-hours later. Patients with or without HT were compared for predictors. Results: 363 patients were included, with a mean age of 63,14 (±13,92), 53,1% were male and 9,9% (n= 38) had HT. Thrombolysis didn’t increase the risk of HT [(55,3% vs 42,5%); p= 0,132]. Patients with atrial fibrillation [(31,6% vs 12,6%); p= 0,002], and cardioembolic etiology according with TOAST classification [(57,6% vs 21,7%); p< 0,001] had higher risk of HT. Patients with HT had lower ASPECTS scores on their initial CT [8 (6-9) vs 9 (8-10); p< 0,001] and higher NIHSS scores [12 (9-15) vs 8 (5-12); p< 0,001]. Cardioembolic strokes [OR= 4,67; (IC95% 2,01-10,84)] and higher NIHSS [OR= 1,11; (IC95% 1,01-1,22)] were independently associated with HT after multivariate adjustments, considering ASPECTS and thrombolysis. Conclusion: Cardioembolic etiology and higher NIHSS score were independently associated with HT. It’s essential to know HT predictors due to worse outcomes associated with its occurrence.

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Determinants of Use of Long-term Continuous Electrocardiographic Monitoring for Acute Ischemic Stroke Patients without Atrial Fibrillation at Baseline

Current Neurovascular Research ◽

10.2174/1567202617666200423092025 ◽

2020 ◽

Vol 17 (3) ◽

pp. 224-231

Author(s):

Jiann-Der Lee ◽

Yen-Chu Huang ◽

Meng Lee ◽

Tsong-Hai Lee ◽

Ya-Wen Kuo ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Triglyceride Level ◽

Detection Rate ◽

Transaminase Level ◽

Aspartate Transaminase ◽

Multivariate Logistic Regression ◽

Stroke Patients ◽

Nihss Score

Background: Atrial fibrillation (AF) is the most common cardiac rhythm disorder associated with stroke. Increased risk of stroke is the same regardless of whether the AF is permanent or paroxysmal. However, detecting paroxysmal AF is challenging and resource intensive. We aimed to develop a predictive model for AF in patients with acute ischemic stroke, which could improve the detection rate of paroxysmal AF. Methods: We analyzed 10,034 adult patients with acute ischemic stroke. Differences in clinical characteristics between the patients with and without AF were analyzed in order to develop a predictive model of AF. The associated factors for AF were analyzed using multivariate logistic regression and classification and regression tree (CART) analyses. We used another dataset, which enrolled 860 acute ischemic stroke patients without AF at baseline, to test whether the developed model could improve the detection rate of paroxysmal AF. Among the study population, 1,658 patients (16.5%) had AF. Results: Multivariate logistic regression revealed that sex, age, body weight, hypertension, diabetes mellitus, hyperlipidemia, pulse rate at admission, respiratory rate at admission, systolic blood pressure at admission, diastolic blood pressure at admission, National Institute of Health Stroke Scale (NIHSS) score at admission, total cholesterol level, triglyceride level, aspartate transaminase level, and sodium level were major factors associated with AF. CART analysis identified NIHSS score at admission, age, triglyceride level, and aspartate transaminase level as important factors for AF to classify the patients into subgroups. Conclusions: When selecting the high-risk group of patients (with an NIHSS score >12 and age >64.5 years, or with an NIHSS score ≤12, age >71.5 years, and triglyceride level ≤61.5 mg/dL) according to the CART model, the detection rate of paroxysmal AF was approximately double in the acute ischemic stroke patients without AF at baseline.

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Abstract 25: Paroxysmal Atrial Fibrillation is Common in Patients With Defined Etiology for Stroke: Prolonged Monitoring of Cardiac Rhythm for Detection of Atrial Fibrillation After a Cerebral Ischemic Event (PEAACE) Study

Stroke ◽

10.1161/str.45.suppl_1.25 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Esseddeeg M Ghrooda ◽

Peter Dobrowolski ◽

Ghazala Basir ◽

Ibrahim Yaseen ◽

Nazim khan ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Cardiac Rhythm ◽

Previous History ◽

Cryptogenic Stroke ◽

Predictive Score ◽

Stroke Patients ◽

Similar Frequency ◽

Stroke Team ◽

Rhythm Monitoring

Introduction: Atrial fibrillation (AF) related cardioembolic stroke accounts for over 20% of ischemic stroke. Recent reports using prolonged cardiac rhythm monitoring (PCRM) in cryptogenic stroke reveal paroxysmal AF (PAF) in an additional 20% of patients. We report our findings with PCRM in patients with and without cryptogenic stroke patients in whom an initial 24-h Holter was negative. Methods: Patients admitted to the stroke service with no previous history of AF and no AF on Holter monitoring were enrolled for 3 weeks of PCRM. We used a PAF predictive score to determine the risk of the arrhythmia. All studies were interpreted by the stroke team prior to final review by the cardiologist. Results: Between Sept 2012 and June 2013, 96 patients were evaluated. Over all PAF was diagnoses in 37.5 % of patients. PAF was diagnosed in 32% of patients with cryptogenic stroke and 36 % of patients where an additional etiology may account for the stroke diagnosis. The AF prediction score was not useful in the recognition of patients that were more likely to be at risk for AF. 96 of 98 recordings were correctly identified by the stroke team prior to final diagnosis by the cardiologist. Interpretation: PAF is more common in stroke patients than was previously suspected. It occurs with similar frequency in patients with and without cryptogenic stroke. Our data strongly supports the need for prolonged cardiac rhythm monitoring in all stroke patients to diagnose this important preventable cause of ischemic stroke.

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Abstract W MP65: Moderate to Severe Left Atrial Enlargement is Associated with Cardioembolic or Cryptogenic Stroke Recurrence in a Multiethnic Cohort: The Northern Manhattan Study

Stroke ◽

10.1161/str.46.suppl_1.wmp65 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Shadi Yaghi ◽

Yeseon P Moon ◽

Consuelo Mora-McLaughlin ◽

Joshua Z Willey ◽

Marco R Di Tullio ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Left Atrial ◽

Recurrent Stroke ◽

Cryptogenic Stroke ◽

Cardioembolic Stroke ◽

Stroke Recurrence ◽

Stroke Patients ◽

Stroke Subtypes ◽

Multiethnic Cohort

Background: While left atrial (LA) enlargement increases incident stroke risk, the association with recurrent stroke is unclear. Our aim was to determine the association of LA enlargement (LAE) with stroke recurrence risk and recurrent stroke subtypes likely related to embolism (cryptogenic or cardioembolic). Methods: We enrolled 655 first ischemic stroke patients in the Northern Manhattan Stroke Study. LA size was measured by two-dimensional echocardiogram as part of the clinical evaluation and patients were followed annually for up to 5 years. LA size adjusted for sex and body surface area was categorized into three groups: normal (52.7%), mild LAE (31.6%), and moderate to severe LAE (15.7%). The outcomes were total recurrent stroke, and recurrent combined cryptogenic or cardioembolic stroke. Cox proportional hazard models assessed the association between LA size and risk of stroke recurrence. Results: Of 655 patients, LA size data was present in 529 (81%). Mean age was 69 ± 13 years; 46% were male and 18% had atrial fibrillation. Over a median of 4 years, recurrent stroke occurred in 83 patients (16%), 29 were cardioembolic or cryptogenic stroke. After adjusting for baseline demographics and risk factors including atrial fibrillation and congestive heart failure, compared to normal LA size, moderate to severe LAE was associated with greater risk of recurrent combined cardioembolic or cryptogenic stroke (adjusted HR 2. 99, 95% CI 1. 10 to 8.13), but not with risk of total stroke recurrence (adjusted HR 1.18, 95% CI 0.60 to 2.32). Mild LAE was not associated with either total stroke recurrence or the combined recurrent cryptogenic or cardioembolic stroke subtypes. Conclusion: Moderate to severe LAE is an independent marker of recurrent cardioembolic or cryptogenic stroke in a multiethnic cohort of ischemic stroke patients. Future research is needed to determine if anticoagulant use reduces the risk of recurrence in ischemic stroke patients with moderate to severe LAE.

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Presence of Atrial Fibrillation in Stroke Patients With Patent Foramen Ovale: Systematic Review and Meta-Analysis

Frontiers in Neurology ◽

10.3389/fneur.2021.613758 ◽

2021 ◽

Vol 12 ◽

Author(s):

Jessie Ze-Jun Chen ◽

Vincent N. Thijs

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Confidence Interval ◽

Lower Risk ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

Stroke Patients ◽

Loop Recorder ◽

Cross Sectional

Purpose: Patent foramen ovale (PFO) is associated with ischemic stroke, especially in patients with embolic stroke of undetermined source. This study aims to evaluate the presence of atrial fibrillation (AF) in ischemic stroke patients with PFO.Methods: We systematically searched EMBASE and MEDLINE databases on May 21, 2020 for studies that analyzed the presence of AF in patients with PFO. The primary outcome was the presence of AF in patients with PFO compared with those without. Outcomes were pooled using a random-effects model using the method of DerSimonian and Laird. We recorded demographic characteristics and the methods used for AF detection in the studies included (unspecified, history/medical records review, ECG, Holter monitor, or loop recorder).Results: A total of 14 studies and 13,245 patients fulfilled the entry criteria. The average age was 61.2 years and 41.3% of the participants were female. There was a lower risk of AF in patients with PFO compared with those without (RR 0.52, 95% confidence interval, 0.41–0.63, p < 0.001). There was no evidence of heterogeneity. The lower risk of AF was found in cross-sectional and longitudinal studies and in studies stratified by average age (<60 or ≥60) and in cryptogenic stroke. Meta-regression by PFO detection technique suggested that studies using transoesophageal echocardiogram for PFO detection reported higher risk of AF (1.39, 95% confidence interval 1.14–1.70, p = 0.004).Conclusion: The presence of a PFO in patients with ischemic stroke/TIA may be associated with a lower risk of AF. Few studies have estimated the risk of future AF in patients with PFO.

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Abstract WP255: Can Normal Electrocardiogram Rule Out Newly Diagnosed Atrial Fibrillation in Ischemic Stroke Patients

Stroke ◽

10.1161/str.51.suppl_1.wp255 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Joshua Santucci ◽

Takashi Shimoyama ◽

Ken Uchino

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Cryptogenic Stroke ◽

Cardiac Monitoring ◽

Large Artery ◽

Newly Diagnosed ◽

Stroke Patients ◽

Stroke Subtype ◽

History Of

Introduction: Electrocardiogram (ECG) findings of premature atrial contraction and prolonged PR interval are associated with risk of onset atrial fibrillation (AF) in cryptogenic stroke. We sought to see if normal ECG and AF incidence is incompletely understood. Methods: From a prospective single-hospital stroke registry from 2018, we identified ischemic stroke patients who had ECG done on admission for review. We excluded patients with AF on admission ECG, history of AF, and implanted device with cardiac monitoring capability. Normal ECG was interpreted based on the standardized reporting guidelines for ECG studies evaluating risk stratification of emergency department patients. Stroke subtype was diagnosed according to the TOAST classification: large artery atherosclerosis (LAA), small vessel occlusion (SVO), cardioembolism, others/undetermined and embolic stoke of undetermined source (ESUS) criteria. We compared the incidence of newly diagnosed AF during hospitalization and from outpatient cardiac event monitoring between normal and abnormal ECG. Results: Of the 558 consecutive acute ischemic stroke patients, we excluded 135 with AF on admission ECG or history of AF and 9 with implanted devices. Of the remaining 414 patients that were included in the study, ESUS (31.2%) was the most frequent stroke subtype, followed by LAA (30.0%), SVO (14.0%), others/undetermined (15.7%), and cardioembolism (9.2%). Normal ECG was observed in 125 patients (30.2%). Cardioembolic subtype was less frequent in the normal versus abnormal ECG group (1.6% vs. 12.5%, p<0.001). New AF was detected in 17/414 patients (4.1%) during hospitalization. Of these 17 patients, none had normal ECG (0/125) and all had abnormal ECG (17/289, 5.9%) (p=0.002). After discharge, of 111 patients undergoing 4-week outpatient cardiac monitoring, new AF was detected in 16 (14.4%). Of these 16 patients, only 1 had a normal ECG (1/35, 2.9%) while 15 had abnormal ECG (15/76, 19.7%) (p=0.02). Conclusions: Normal ECG at admission for acute ischemic stroke is associated with low likelihood of detection of new atrial fibrillation in either the inpatient or outpatient setting.

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Abstract WP256: Atrial Fibrillation Predicting Factors in Transient and Minor Stroke Patients

Stroke ◽

10.1161/str.51.suppl_1.wp256 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Marian Muchada Lopez ◽

Jorge Pagola ◽

Jesus Juega ◽

Jaume Francisco-Pascual ◽

Alejandro Bustamante ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Left Atrial ◽

Cryptogenic Stroke ◽

Volume Index ◽

Minor Stroke ◽

Stroke Patients ◽

Left Atrial Strain ◽

Minor Ischemic Stroke ◽

Atrial Strain

Introduction and Purpose: Our aim was to review the characteristics of transient ischemic attack (TIA) and minor ischemic stroke patients monitored for atrial fibrillation (AF) epidoses detection within the first 4weeks after stroke to assess AF predictors. Materials and Methods: TIA and minor ischemic stroke patients (nihss≤ 5) were selected from CRYPTO-AF database. CRYPTO-AF is a prospective multicentre registry of patients with cryptogenic stroke older of 55 year-old. Monitoring started within the first 72 hours from stroke symptoms onset and was prolonged for 4 weeks. Clinical, cardiographic and blood test parameters of patients included were reviewed. Fisher exact and Mann Whitney tests were used to analyze categorical and continuous data. Results: In our cohort of 152 transient and minor ischemic stroke patients, 55.9% were men, mean age 73.18±10.24 and median NIHSS score was 2.31(0-5). A total of 30 patients (20.3%) were diagnosed with AF in the first month of monitoring, 6 patients (5.7%) within the first 3 days, 14 patients (13.3%) between 3 days and to 2 weeks of monitoring, and 14 partientes (12.4%) between the second and the fourth week. In these transient and minor ischemic stroke patients, age (p< 0.031), left atrial volume index (p< 0.023), the appearance of isolated extrasystoles during monitoring (p< 0.021), Type B natriuretic peptide (p< 0.011) and the longitudinal strain (p< 0.019) appeared as independet precitors of AF. However in the multivariate analysis adjusted for the above variables, only left atrial strain (OR 0.89, 95% CI: 0.797-0.991, p< 0.034) independently predicts AF detection. Conclusions: In our serie, only the left atrial strain appeared as a indepent predictor of AF. Given the known pathophysiology of TIA and minor ischemic stroke, the description of AF predictors would help to identify those patients who would benefit from completing a longer monitoring. More studies are needed to identify these predictors.

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