Are morphologic features of recent small subcortical infarcts related to specific etiologic aspects?

Background: Recent small subcortical infarcts (RSSIs) mostly result from the occlusion of a single, small, brain artery due to intrinsic cerebral small-vessel disease (CSVD). Some RSSIs may be attributable to other causes such as cardiac embolism or large-artery disease, and their association with coexisting CSVD and vascular risk factors may vary with morphological magnetic resonance imaging (MRI) features. Methods: We retrospectively identified all inpatients with a single symptomatic MRI-confirmed RSSI between 2008 and 2013. RSSIs were rated for size, shape, location (i.e. anterior: basal ganglia and centrum semiovale posterior cerebral circulation: thalamus and pons) and MRI signs of concomitant CSVD. In a further step, clinical data, including detailed diagnostic workup and vascular risk factors, were analyzed with regard to RSSI features. Results: Among 335 RSSI patients (mean age 71.1 ± 12.1 years), 131 (39%) RSSIs were >15 mm in axial diameter and 66 (20%) were tubular shaped. Atrial fibrillation (AF) was present in 44 (13.1%) and an ipsilateral vessel stenosis > 50% in 30 (9%) patients. Arterial hypertension and CSVD MRI markers were more frequent in patients with anterior-circulation RSSIs, whereas diabetes was more prevalent in posterior-circulation RSSIs. Larger RSSIs occurred more frequently in the basal ganglia and pons, and the latter were associated with signs of large-artery atherosclerosis. Patients with concomitant AF had no specific MRI profile. Conclusion: Our findings suggest the contribution of different pathophysiological mechanisms to the occurrence of RSSIs in the anterior and posterior cerebral circulation. While there appears to be some general association of larger infarcts in the pons with large-artery disease, we found no pattern suggestive of AF in RSSIs

Liver Fibrosis-4 index indicates atrial fibrillation in acute ischemic stroke

BACKGROUND: Non-alcoholic fatty liver disease and particularly liver fibrosis is related to cardiovascular disease and may indicate an increased risk for atrial fibrillation (AF), but this association has not yet been systematically investigated in a cohort of ischemic stroke patients. METHODS: We analyzed data from a prospective single-center study enrolling all consecutive ischemic stroke patients admitted to our stroke unit over a one-year-period. All patients received a thorough etiological work-up. For evaluation of liver fibrosis, we determined the FIB-4 index, a well-established noninvasive liver fibrosis test. Laboratory results were analyzed from a uniform blood sample taken at stroke unit admission. RESULTS: Of 414 included patients (mean age 70.2 years, 57.7% male), FIB-4 indicated advanced liver fibrosis in 92 (22.2%). AF as the underlying stroke mechanism was present in 28.0% (large vessel disease: 25.6%, small vessel disease: 11.4%, cryptogenic: 29.2%). Patients with FIB-4 ≥2.67 had higher rates of AF (53.3% vs. 20.8%, p<0.001), this association remained significant after correction for established AF risk factors (Odds Ratio 2.53, 95% confidence interval 1.44-4.46, p=0.001). FIB-4 was further associated with worse functional outcome three months (p<0.001) and higher mortality four years post-stroke (p<0.02), but these relationships were no longer present after correction for age and initial stroke severity. Moreover, FIB-4 did not associate with long-term recurrent vascular events. CONCLUSIONS: Liver fibrosis assessed by the FIB-4 index is independently associated with AF in acute ischemic stroke patients. Further studies should evaluate whether adding the FIB-4 index to AF risk scores increases their precision

Association of Presence and Pattern of MRI Markers of Cerebral Small Vessel Disease With Recurrent Intracerebral Hemorrhage.

BACKGROUND Assessing the risk of recurrent intracerebral hemorrhage (ICH) is of high clinical importance. MRI-based cerebral small vessel disease (SVD) markers may help establish ICH etiological subtypes (including cryptogenic ICH) relevant for recurrence risk. METHODS We investigated the risk of recurrent ICH in a large cohort of consecutive ICH survivors with available MRI at baseline. Patients with macrovascular, structural or other identified secondary causes (other than SVD) were excluded. Based on MRI findings, ICH etiology was defined as probable cerebral amyloid angiopathy (CAA) according to the Boston 2.0 criteria, arteriolosclerosis (non-lobar ICH and additional markers of arteriolosclerosis, absent lobar hemorrhagic lesions), mixed SVD (mixed deep and lobar hemorrhagic changes) or cryptogenic (no MRI markers of SVD). Recurrent ICH was determined using electronic health records and confirmed by neuroimaging. Data from an independent multi-center cohort (CROMIS-2 ICH) was used to confirm core findings. RESULTS Of 443 patients with ICH (mean age 67±13 years, 41% female), ICH etiology was mixed SVD in 36.7%, arteriolosclerosis in 23.6%, CAA in 23.0%, and cryptogenic in 16.7%. During a median follow-up period of 5.7 years (IQR 2.9-10.0, 2682 patient-years), recurrent ICH were found in 59 individual patients (13.3%). The highest recurrence rate per 100 person-years was detected in patients with CAA (8.5, 95% CI 6.1-11.7), followed by mixed SVD (1.8, 95% CI 1.1-2.9) and arteriolosclerosis (0.6, 95% CI 0.3-1.5). No recurrent ICH occurred in patients with cryptogenic ICH during 510 person-years follow-up (97.5% CI, 0-0.7); this finding was confirmed in an independent cohort (CROMIS-2 ICH, n=216), in which there was also no recurrence in patients with cryptogenic ICH. In patients with CAA, cortical superficial siderosis was the imaging feature strongest related with ICH recurrence (hazard ratio 5.7, 95% CI 2.4-13.6). CONCLUSIONS MRI-based etiological subtypes are helpful in determining the recurrence risk of ICH; while the highest recurrence risk was found in CAA, recurrence risk was low for arteriolosclerosis, and negligible for cryptogenic ICH

Association of Presence and Pattern of MRI Markers of Cerebral Small Vessel Disease With Recurrent Intracerebral Hemorrhage

BACKGROUND: Assessing the risk of recurrent intracerebral hemorrhage (ICH) is of high clinical importance. MRI-based cerebral small vessel disease (SVD) markers may help establish ICH etiological subtypes (including cryptogenic ICH) relevant for recurrence risk. METHODS: We investigated the risk of recurrent ICH in a large cohort of consecutive ICH survivors with available MRI at baseline. Patients with macrovascular, structural or other identified secondary causes (other than SVD) were excluded. Based on MRI findings, ICH etiology was defined as probable cerebral amyloid angiopathy (CAA) according to the Boston 2.0 criteria, arteriolosclerosis (non-lobar ICH and additional markers of arteriolosclerosis, absent lobar hemorrhagic lesions), mixed SVD (mixed deep and lobar hemorrhagic changes) or cryptogenic (no MRI markers of SVD). Recurrent ICH was determined using electronic health records and confirmed by neuroimaging. Data from an independent multi-center cohort (CROMIS-2 ICH) was used to confirm core findings. RESULTS: Of 443 patients with ICH (mean age 67±13 years, 41% female), ICH etiology was mixed SVD in 36.7%, arteriolosclerosis in 23.6%, CAA in 23.0%, and cryptogenic in 16.7%. During a median follow-up period of 5.7 years (IQR 2.9-10.0, 2682 patient-years), recurrent ICH were found in 59 individual patients (13.3%). The highest recurrence rate per 100 person-years was detected in patients with CAA (8.5, 95% CI 6.1-11.7), followed by mixed SVD (1.8, 95% CI 1.1-2.9) and arteriolosclerosis (0.6, 95% CI 0.3-1.5). No recurrent ICH occurred in patients with cryptogenic ICH during 510 person-years follow-up (97.5% CI, 0-0.7); this finding was confirmed in an independent cohort (CROMIS-2 ICH, n=216), in which there was also no recurrence in patients with cryptogenic ICH. In patients with CAA, cortical superficial siderosis was the imaging feature strongest related with ICH recurrence (hazard ratio 5.7, 95% CI 2.4-13.6). CONCLUSIONS: MRI-based etiological subtypes are helpful in determining the recurrence risk of ICH; while the highest recurrence risk was found in CAA, recurrence risk was low for arteriolosclerosis, and negligible for cryptogenic ICH

Global Outcome Assessment Life-long after stroke in young adults initiative-the GOAL initiative : study protocol and rationale of a multicentre retrospective individual patient data meta-analysis

Introduction Worldwide, 2 million patients aged 18-50 years suffer a stroke each year, and this number is increasing. Knowledge about global distribution of risk factors and aetiologies, and information about prognosis and optimal secondary prevention in young stroke patients are limited. This limits evidence-based treatment and hampers the provision of appropriate information regarding the causes of stroke, risk factors and prognosis of young stroke patients. Methods and analysis The Global Outcome Assessment Life-long after stroke in young adults (GOAL) initiative aims to perform a global individual patient data meta-analysis with existing data from young stroke cohorts worldwide. All patients aged 18-50 years with ischaemic stroke or intracerebral haemorrhage will be included. Outcomes will be the distribution of stroke aetiology and (vascular) risk factors, functional outcome after stroke, risk of recurrent vascular events and death and finally the use of secondary prevention. Subgroup analyses will be made based on age, gender, aetiology, ethnicity and climate of residence.Peer reviewe

Repeated Endovascular Treatment of Early Recurrent Proximal Middle Cerebral Artery Occlusion: Case Report and Brief Review of the Literature

Mechanical thrombectomy (MT) is the gold standard treatment for large vessel occlusion (LVO) stroke of the anterior circulation. Whether MT can also be effectively and safely performed in early recurrent LVO is largely unclear. We present the case of a middle-aged patient who was successfully treated by MT for right proximal middle cerebral artery (MCA) occlusion with excellent outcome. One day after discharge (9 days after the first MT), the patient was readmitted with wake-up stroke. MRI again revealed right proximal MCA occlusion with severe diffusion–perfusion mismatch. Repeat MT was performed and once more led to almost full recovery. The recurrent strokes were attributed to ulcerated non-stenosing plaques in the ipsilateral internal carotid artery, which prompted thromboendarterectomy. In an 18-months follow-up period, no further vascular events occurred. In conclusion, repeated MT for early recurrent LVO appears feasible in carefully selected patients. The collection of similar cases via registries would be desirable

Comparison of Boston Criteria v2.0/v1.5 for Cerebral Amyloid Angiopathy to Predict Recurrent Intracerebral Hemorrhage

BACKGROUND: Intracerebral hemorrhage (ICH) caused by cerebral amyloid angiopathy (CAA) has a high recurrence risk. The Boston criteria, while not designed to predict recurrence, are commonly used for in vivo diagnosis of CAA and have recently been revised to the version 2.0 (v2.0), introducing nonhemorrhagic white matter features. We investigated whether the new v2.0 criteria change ICH recurrence risk in patients with probable CAA. METHODS: We assessed ICH recurrence risk in consecutive patients with ICH and available brain magnetic resonance imaging. Patients with macrovascular or structural causes were excluded. Recurrent ICH was determined using electronic health records and confirmed by neuroimaging. We compared ICH recurrence risk for Boston criteria v2.0 versus v1.5 for probable CAA using survival analysis. RESULTS: Fifty-nine of 443 patients (13.3%) had recurrent ICH over a median follow-up of 5.7 years (2682 patient-years). Thirty-seven out of one hundred two patients (36.3%) with probable CAA according to the Boston criteria v2.0 had recurrent ICH compared with 36/82 patients (43.9%) according to the v1.5 criteria. Patients with probable CAA according to the Boston v1.5 criteria had a higher ICH recurrence rate (10.9 per 100 person-years [95% CI, 7.8-15.1]) compared with those diagnosed by the v2.0 criteria (8.5 per 100 person-years [95% CI, 6.1-11.7]). The 20 patients defined as probable CAA only by the v2.0 criteria had a very low recurrence rate (0.9 per 100 person-years [95% CI, 0.1-6.7]), lower than those diagnosed using the v1.5 criteria (P<0.001). CONCLUSIONS: Our findings suggest a wide spectrum of ICH recurrence risk in patients with probable CAA. Patients with ICH diagnosed with CAA based only on the nonhemorrhagic white matter markers introduced in the Boston v2.0 criteria had a much lower risk of recurrence than those diagnosed with the previous Boston criteria v1.5, comparable to that of patients with ICH not fulfilling any probable CAA criteria

VA-ECMO and thrombus aspiration in a pulmonary embolism patient with cardiac arrest and contraindications to thrombolytic therapy

A 57-year-old male patient with a history of proximal deep vein thrombosis on vitamin K antagonist therapy, suffered a recent hypertensive intracranial hemorrhage without significant neurological deficit. Three weeks later he presented with bilateral central pulmonary embolism. He had witnessed cardiac arrest and was put on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Endovascular thrombectomy with an Aspirex device led to a significant improvement of hemodynamics. VA-ECMO was terminated after one day, an IVC filter was inserted, and he was discharged from ICU after 15 days. In conclusion, VA-ECMO and endovascular therapy are rescue strategies in patients with contraindications for thrombolysis