Prevalence of patent foramen ovale in patients with ischemic stroke compared with control groups: a transcranial doppler study

Introduction: Patent foramen ovale (PFO) closure in patients with cryptogenic stroke (CS) is an effective secondary prevention strategy. However, optimal selection criteria for PFO closure candidates are still under investigation. The Risk of Paradoxical Embolism (RoPE) score calculates the probability that patent foramen ovale (PFO) is causally related to stroke (PFO attributable fraction, PFOAF), based on PFO prevalence in patients with CS compared with that in the general population. The latter has been estimated at 25% based on autopsy and transesophageal echocardiography studies; however, PFO prevalence in nonselected populations varies widely. Methods: Since PFO prevalence in Greece remains unknown, we evaluated it and we calculated PFOAF stratified by RoPE score in a cohort of patients with CS ≤55 years-old. PFO was detected according to the international consensus transcranial Doppler (TCD) criteria in 124 healthy subjects (H), in 102 patients with CS, in 56 patients with stroke of known cause (nonCS) and in 78 patients with multiple sclerosis (MS). Each subject underwent unilateral middle cerebral artery recording after infusion of agitated saline, at rest and after a controlled Valsalva maneuver. We characterized PFO-associated right-to-left cardiac shunt (RLS) as large (>20 microbubbles or curtain), moderate (11-20) and small (≤10). Results: Mean age was 37.2 in H, 42.1 in CS, 45.7 in nonCS and 38.1 in MS. PFO was numerically higher in CS compared with H (49% vs 42,7%, aOR: 1.38, 95% CI: 0.8-2.4, p=0.25). Conversely, PFO was significantly less frequent in nonCS compared with H (25% vs 42.7%, aOR: 0.42, 95% CI: 0.20-0.89, p=0.024). MS patients had PFO prevalence comparable to nonCS (29,5% vs 25%) but significantly lower than H (aOR: 0.54, 95% CI: 0.31-0.95, p=0.032). Large RLS was significantly higher in H (19.4%, p=0.036) and in CS (28.4%, p=0.002) compared with nonCS (7.1%) and MS (5.1%). Large RLS was only numerically higher in CS compared with H (28.4% vs 19.4%). Prevalence of moderate and small RLS did not differ among the four subgroups of participants. The median RoPE score in patients with CS and PFO was 7 (quartiles: 6-8). Even patients with very high RoPE score (9-10) had moderate PFOAF (57%). For any individual stratum up to RopE score 8, PFOAF was 20 μικροεμβολικά σήματα, MES), μέτριο (11-20 MES) και μικρό (≤10 MES). Αποτελέσματα: Η μέση ηλικία στους ΥΕ ήταν 37,2 έτη, στους ασθενείς με CS 42,1 έτη, στους nonCS 45,7 έτη και στους ασθενείς με ΠΣ 38,1 έτη. Στους ασθενείς με CS, το ΑΩΤ ήταν αριθμητικώς συχνότερο σε σχέση με τους ΥΕ (49% έναντι 42,7%, σταθμισμένο OR: 1,38, 95% CI: 0,8-2,4, p=0,25). Αντιθέτως, στους ασθενείς με nonCS το ΑΩΤ ήταν στατιστικώς λιγότερο συχνό συγκριτικώς με τους ΥΕ (25% έναντι 42.7%, σταθμισμένο OR: 0,42, 95% CI: 0,20-0,89, p=0,024). Οι ασθενείς με ΠΣ εμφάνιζαν συχνότητα ΑΩΤ συγκρίσιμη με αυτή των ασθενών με nonCS (29,5% έναντι 25%) και στατιστικώς μικρότερη συγκριτικώς με το γενικό πληθυσμό (σταθμισμένο OR: 0,54, 95% CI: 0,31-0,95, p=0,032). Μεγάλη RLS διαπιστώθηκε σημαντικά συχνότερα στους ΥΕ (19,4%, p=0,036) και στους CS (28,4%, p=0,002) συγκριτικώς με τους nonCS (7,1%) και τους ασθενείς με ΠΣ (5,1%). Μεταξύ της ομάδας των CS και των ΥΕ υπήρχε αριθμητική μόνο υπεροχή υπέρ της πρώτης ως προς την ύπαρξη μεγάλης RLS (28,4% έναντι 19,4%). Η συχνότητα ύπαρξης της μέτριας και μικρής RLS δεν διέφερε μεταξύ των τεσσάρων ομάδων των συμμετεχόντων. Στους CS η διάμεση τιμή του RoPE score ήταν 7 (τεταρτημόρια: 6, 8). Ακόμη και ασθενείς με πολύ υψηλό RoPE score (≥9) είχαν μέτριο PFOAF (57%). Για κάθε βαθμίδα της κλίμακας RoPE έως το 8, το PFOAF ήταν <33%. Συμπεράσματα: Η συχνότητα του ΑΩΤ φαίνεται πως υπερβαίνει κατά πολύ το «καθιερωμένο» ποσοστό του 25%. Το ΑΩΤ αποτελεί την αιτία του επεισοδίου σε έναν εκ των εννέα Ελλήνων ασθενών με CS. Μεταξύ των Ελλήνων ασθενών με CS που έχουν ΑΩΤ, αυτό είναι παθολογικό μόνο σε έναν εκ των πέντε. Το καθιερωμένο όριο ≥7 στην κλίμακα RoPE ενδέχεται να υπερεκτιμά την αιτιότητα σε ασθενείς που προέρχονται από πληθυσμούς με υψηλή συχνότητα ΑΩΤ, όπως ο Ελληνικός

Off-label intravenous thrombolysis for early recurrent brain embolism associated with aortic arch thrombus.

Safety data of intravenous thrombolysis (IVT) in presence of aortic arch thrombus is scant. Furthermore, IVT is debatable in patients with prior recent stroke. We present a 51-year-old woman with recurrent major infarction 5 days after a minor left MCA territory stroke. She had a floating aortic arch thrombus and she was treated safely and effectively with off-label IVT. Patients with small infarct volumes and mild/no residual neurological deficits after an initial stroke might be considered for IVT in case of early recurrence. IVT may be reasonable in a context of acute severely disabling stroke associated with aortic arch thrombus

Advances in Noninvasive Carotid Wall Imaging with Ultrasound: A Narrative Review

Carotid atherosclerosis is a major cause for stroke, with significant associated disease burden morbidity and mortality in Western societies. Diagnosis, grading and follow-up of carotid atherosclerotic disease relies on imaging, specifically ultrasound (US) as the initial modality of choice. Traditionally, the degree of carotid lumen stenosis was considered the sole risk factor to predict brain ischemia. However, modern research has shown that a variety of other imaging biomarkers, such as plaque echogenicity, surface morphology, intraplaque neovascularization and vasa vasorum contribute to the risk for rupture of carotid atheromas with subsequent cerebrovascular events. Furthermore, the majority of embolic strokes of undetermined origin are probably arteriogenic and are associated with nonstenosing atheromas. Therefore, a state-of-the-art US scan of the carotid arteries should take advantage of recent technical developments and should provide detailed information about potential thrombogenic (/) and emboligenic arterial wall features. This manuscript reviews recent advances in ultrasonographic assessment of vulnerable carotid atherosclerotic plaques and highlights the fields of future development in multiparametric arterial wall imaging, in an attempt to convey the most important take-home messages for clinicians performing carotid ultrasound

sj-docx-1-eso-10.1177_23969873241234238 – Supplemental material for Risk of major adverse cardiovascular events and stroke associated with treatment with GLP-1 or the dual GIP/GLP-1 receptor agonist tirzepatide for type 2 diabetes: A systematic review and meta-analysis

Supplemental material, sj-docx-1-eso-10.1177_23969873241234238 for Risk of major adverse cardiovascular events and stroke associated with treatment with GLP-1 or the dual GIP/GLP-1 receptor agonist tirzepatide for type 2 diabetes: A systematic review and meta-analysis by Maria-Ioanna Stefanou, Aikaterini Theodorou, Konark Malhotra, Diana Aguiar de Sousa, Mira Katan, Lina Palaiodimou, Aristeidis H Katsanos, Ioanna Koutroulou, Vaia Lambadiari, Robin Lemmens, Sotirios Giannopoulos, Andrei V Alexandrov, Gerasimos Siasos and Georgios Tsivgoulis in European Stroke Journal</p

The Experience of a Tertiary Reference Hospital in the Study of Rare Neurological Diseases

Background and Objectives: Rare diseases (RDs) are life-threatening or chronically impairing conditions that affect about 6% of the world’s population. RDs are often called ‘orphan’ diseases, since people suffering from them attract little support from national health systems. Aim: The aim of this study is to describe the clinical characteristics of, and the available laboratory examinations for, patients who were hospitalized in a tertiary referral center and finally received a diagnosis associated with a Rare Neurological Disease (RND). Materials and Methods: Patients that were hospitalized in our clinic from 1 January 2014 to 31 March 2022 and were finally diagnosed with an RND were consecutively included. The RND classification was performed according to the ORPHAcode system. Results: A total of 342 out of 11.850 (2.9%) adult patients admitted to our department during this period received a diagnosis associated with an RND. The most common diagnosis (N = 80, 23%) involved an RND presenting with dementia, followed by a motor neuron disease spectrum disorder (N = 64, 18.7%). Family history indicative of an RND was present in only 21 patients (6.1%). Fifty-five (16%) people had previously been misdiagnosed with another neurological condition. The mean time delay between disease onset and diagnosis was 4.24 ± 0.41 years. Conclusions: Our data indicate that a broad spectrum of RNDs may reach a tertiary Neurological Center after a significant delay. Moreover, our data underline the need for a network of reference centers, both at a national and international level, expected to support research on the diagnosis and treatment of RND

Global impact of the COVID-19 pandemic on subarachnoid haemorrhage hospitalisations, aneurysm treatment and in-hospital mortality: 1-year follow-up

Background: Prior studies indicated a decrease in the incidences of aneurysmal subarachnoid haemorrhage (aSAH) during the early stages of the COVID-19 pandemic. We evaluated differences in the incidence, severity of aSAH presentation, and ruptured aneurysm treatment modality during the first year of the COVID-19 pandemic compared with the preceding year. Methods: We conducted a cross-sectional study including 49 countries and 187 centres. We recorded volumes for COVID-19 hospitalisations, aSAH hospitalisations, Hunt-Hess grade, coiling, clipping and aSAH in-hospital mortality. Diagnoses were identified by International Classification of Diseases, 10th Revision, codes or stroke databases from January 2019 to May 2021. Results: Over the study period, there were 16 247 aSAH admissions, 344 491 COVID-19 admissions, 8300 ruptured aneurysm coiling and 4240 ruptured aneurysm clipping procedures. Declines were observed in aSAH admissions (-6.4% (95% CI -7.0% to -5.8%), p=0.0001) during the first year of the pandemic compared with the prior year, most pronounced in high-volume SAH and high-volume COVID-19 hospitals. There was a trend towards a decline in mild and moderate presentations of subarachnoid haemorrhage (SAH) (mild: -5% (95% CI -5.9% to -4.3%), p=0.06; moderate: -8.3% (95% CI -10.2% to -6.7%), p=0.06) but no difference in higher SAH severity. The ruptured aneurysm clipping rate remained unchanged (30.7% vs 31.2%, p=0.58), whereas ruptured aneurysm coiling increased (53.97% vs 56.5%, p=0.009). There was no difference in aSAH in-hospital mortality rate (19.1% vs 20.1%, p=0.12). Conclusion: During the first year of the pandemic, there was a decrease in aSAH admissions volume, driven by a decrease in mild to moderate presentation of aSAH. There was an increase in the ruptured aneurysm coiling rate but neither change in the ruptured aneurysm clipping rate nor change in aSAH in-hospital mortality

Global Impact of the COVID-19 Pandemic on Stroke Volumes and Cerebrovascular Events: One-Year Follow-up.

BACKGROUND AND OBJECTIVES Declines in stroke admission, intravenous thrombolysis, and mechanical thrombectomy volumes were reported during the first wave of the COVID-19 pandemic. There is a paucity of data on the longer-term effect of the pandemic on stroke volumes over the course of a year and through the second wave of the pandemic. We sought to measure the impact of the COVID-19 pandemic on the volumes of stroke admissions, intracranial hemorrhage (ICH), intravenous thrombolysis (IVT), and mechanical thrombectomy over a one-year period at the onset of the pandemic (March 1, 2020, to February 28, 2021) compared with the immediately preceding year (March 1, 2019, to February 29, 2020). METHODS We conducted a longitudinal retrospective study across 6 continents, 56 countries, and 275 stroke centers. We collected volume data for COVID-19 admissions and 4 stroke metrics: ischemic stroke admissions, ICH admissions, intravenous thrombolysis treatments, and mechanical thrombectomy procedures. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases. RESULTS There were 148,895 stroke admissions in the one-year immediately before compared to 138,453 admissions during the one-year pandemic, representing a 7% decline (95% confidence interval [95% CI 7.1, 6.9]; p<0.0001). ICH volumes declined from 29,585 to 28,156 (4.8%, [5.1, 4.6]; p<0.0001) and IVT volume from 24,584 to 23,077 (6.1%, [6.4, 5.8]; p<0.0001). Larger declines were observed at high volume compared to low volume centers (all p<0.0001). There was no significant change in mechanical thrombectomy volumes (0.7%, [0.6,0.9]; p=0.49). Stroke was diagnosed in 1.3% [1.31,1.38] of 406,792 COVID-19 hospitalizations. SARS-CoV-2 infection was present in 2.9% ([2.82,2.97], 5,656/195,539) of all stroke hospitalizations. DISCUSSION There was a global decline and shift to lower volume centers of stroke admission volumes, ICH volumes, and IVT volumes during the 1st year of the COVID-19 pandemic compared to the prior year. Mechanical thrombectomy volumes were preserved. These results suggest preservation in the stroke care of higher severity of disease through the first pandemic year. TRIAL REGISTRATION INFORMATION This study is registered under NCT04934020