Correlation between ASPECTS and Core Volume on CT Perfusion: Impact of Time since Stroke Onset and Presence of Large-Vessel Occlusion

BACKGROUND AND PURPOSE: Both ASPECTS and core volume on CTP are used to estimate infarct volume in acute ischemic stroke. To evaluate the potential role of ASPECTS for acute endovascular treatment decisions, we studied the correlation between ASPECTS and CTP core, depending on the timing and the presence of large-vessel occlusion. MATERIALS AND METHODS: We retrospectively reviewed all MCA acute ischemic strokes with standardized reconstructions of CTP maps entered in the Acute STroke Registry and Analysis of Lausanne (ASTRAL) registry. Correlation between ASPECTS and CTP core was determined for early (,6 hours) versus late (6–24 hours) times from stroke onset and in the presence versus absence of large-vessel occlusion. We used correlation coefficients and adjusted multiple linear regression models. RESULTS: We included 1046 patients with a median age of 71.4 years (interquartile range, IQR ¼ 59.8–79.4 years), an NIHSS score of 12 (IQR, 6–18), an ASPECTS of 9 (IQR, 7–10), and a CTP core of 13.6 mL (IQR, 0.6–52.8 mL). The overall correlation between ASPECTS and CTP core was moderate (r ¼ –0.49, P , .01) but significantly stronger in the late-versus-early window (r ¼ –0.56 and r ¼ – 0.48, respectively; P ¼ .05) and in the presence versus absence of large-vessel occlusion (r ¼ –0.40 and r ¼ –0.20, respectively; P , .01). In the regression model, the independent association between ASPECTS and CTP core was confirmed and was twice as strong in late-arriving patients with large-vessel occlusion (b ¼ –0.21 per 10 mL; 95% CI, 0.27 to –0.15; P , .01) than in the overall population (b ¼ –0.10; 95% CI, 0.14 to –0.07; P , .01). CONCLUSIONS: In a large cohort of patients with acute ischemic stroke, we found a moderate correlation between ASPECTS and CTP core. However, this was stronger in patients with large-vessel occlusion and longer delay from stroke onset. Our results could support the use of ASPECTS as a surrogate marker of CTP core in late-arriving patients with acute ischemic stroke with large-vessel occlusion

Prévention de l’AVC chez les patients avec une fibrillation auriculaire [Stroke prevention in patients with atrial fibrillation]

Oral anticoagulation with vitamin K antagonists (VKA) was the cornerstone of stroke prevention in atrial fibrillation (AF). This review article presents the state of the art, with regard to the treatment options developed over the past few years, the new oral anticoagulants (NOAC). A search in PubMed for relevant published studies has been performed. Dabigatran and apixaban were superior to warfarin to reduce stroke risk or systemic embolism ; dabigatran, rivaroxaban and edoxaban were non-inferior. All NOAC are globally non-inferior to warfarin for stroke prevention in non-valvular AF and they have a superior safety profile, with a reduced intracranial bleeding risk. They are now the first choice for treatment

Skiing Associated Stroke: Causes, Treatment, and Outcome.

Previous studies have described ischemic stroke temporally related to specific triggers, but only 1 series collected patients with acute ischemic stroke (AIS) following downhill skiing and all caused by cervical artery dissections. Here we describe our series of AIS temporally associated to ski practice, focusing on the frequency, pathogenesis, clinical presentation, and prognosis. We maintained a prospective list of Skiing Associated Strokes (SASs) from 2003 to 2017. From all AIS patients included in our stroke registry Acute Stroke Registry and Analysis of Lausanne (ASTRAL) over the same period, we identified a comparison group of non-SAS patients, matched for age and gender. In the 12-year observation period, we identified 17 SASs (4 females, median age 51 years) and 51 matched control patients with nonski-associated strokes. Vascular risk factors, stroke features, and outcome were similar between the 2 groups. Stroke mechanism was arterial dissection in 11 of 17 SASs (65%) and in 7 of 51 control patients (14%, chi-square test: P < .05). In the other 6 cases of ski-associated stroke, etiology was cardiac embolism from atrial fibrillation in 2 patients, large vessel atherosclerosis with stenosis >50% in 1 patient, and undetermined in 3. Among the 11 patients with SAS caused by dissection, 8 reported minor falls while skiing, 1 had a major head trauma without loss of consciousness, and 2 had no traumatism (compared to preceding trauma in 29 of 147 [20%] of all other AIS caused by arterial dissection in ASTRAL, P < .01). Arterial dissection was a significantly more frequent stroke mechanism in SAS compared to matched controls, but other mechanisms occurred as well. Minor or moderate skiing-related trauma preceded most SAS with dissections

Extracranial and intracranial sonographic findings in vertebral artery diseases

Objective. The aim of this review is to illustrate the sonographic features that can be detected in vertebral artery (VA) diseases. Methods. We conducted a review of sonographic findings in VA diseases. Results. Various VA diseases are described, and sonographic techniques and features are discussed. Conclusions. Posterior circulation vascular imaging can be performed by means of various neuroimaging techniques. Intra-arterial angiography remains the reference standard. The use of this technique has become even more widespread since it has become possible to perform endovascular procedures; it is, however, an invasive procedure that is associated with a not irrelevant level of risk. Computed tomographic angiography and magnetic resonance angiography with and without contrast agents have been proposed as less invasive alternatives, although these techniques can only be performed in the radiology unit and may not be readily available in daily clinical management. Sonography, which combines an extracranial and intracranial evaluation, is highly suited to the assessment of the vertebrobasilar system on account of its widespread availability and its unique capacity to study real-time hemodynamics. Furthermore, new sonographic applications and sonographic contrast agents have improved the sensitivity and specificity of this technique with regard to diagnostic accuracy for the posterior circulation

Embolic Stroke of Undetermined Source and Patent Foramen Ovale: Risk of Paradoxical Embolism Score Validation and Atrial Fibrillation Prediction

Background and Purpose: The Risk of Paradoxical Embolism (RoPE) score stratifies patients with stroke according to the probability of having a patent foramen ovale (PFO), which (through Bayes theorem and simple assumptions) can be used to estimate the probability that a PFO is pathogenic in a given subgroup of patients with specific features (ie, a given RoPE score value): A higher PFO prevalence corresponds to a higher probability that a PFO is pathogenic. Among alternative mechanisms in embolic stroke of undetermined source (ESUS), the actual stroke cause may be covert atrial fibrillation. We aimed to validate the RoPE score in a large ESUS population and investigate the rate of stroke recurrence and new incident atrial fibrillation during follow-up according to PFO status and RoPE score. Methods: We pooled data of consecutive patients with ESUS from 3 prospective stroke registries. We assessed RoPE score's calibration and discrimination for the presence of PFO (and consequently for the probability that it is pathogenic). Multivariate logistic regression analysis was performed to identify factors associated with PFO. Results: Among 455 patients with ESUS (median age 59 years), 184 (40%) had PFO. The RoPE score's area under the receiver operating characteristic curve was 0.75. In addition to RoPE score variables, absence of left ventricular hypertrophy, absence of atherosclerosis, and infratentorial lesions were independently associated with PFO. In patients with PFO and RoPE 7 to 10, PFO and RoPE 0 to 6, and without PFO, new incident atrial fibrillation rate was 3.1%, 20.5%, and 31.8%, respectively (log-rank test=6.28, P=0.04). Stroke recurrences in patients with likely pathogenic PFO were not statistically different from other patients. Conclusions: This multicenter study validates the RoPE score to predict the presence/absence of PFO in patients with ESUS, which strongly suggests that RoPE score is helpful in identifying patients with ESUS with pathogenic versus incidental PFOs. Left ventricular hypertrophy, atherosclerosis, and infratentorial stroke may further improve the score. Low RoPE scores were associated with more incidental atrial fibrillation during 10-year follow-up. © 2021 Georg Thieme Verlag. All rights reserved

Embolic Stroke of Undetermined Source and Patent Foramen Ovale: Risk of Paradoxical Embolism Score Validation and Atrial Fibrillation Prediction.

[Figure: see text]

Intravenous thrombolysis in acute ischemic stroke due to intracranial artery dissection: a single-center case series and a review of literature.

Efficacy and safety of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) due to intracranial artery dissection (IAD) are currently not established. We aimed to present a single-center experience on IAD-related AIS treated by IVT. We selected all consecutive patients with IAD-related AIS treated by IVT from a prospectively constructed single-center acute stroke registry from 2003 to 2017. We reviewed demographical, clinical and neuroimaging data and recorded hemorrhagic complications, mortality within 7 days and modified Rankin Scale at 3-months. Out of 181 AISs related to cervicocephalic dissections, 10 (5.5%) were due to IAD and five of these patients received IVT. Among these five patients, median age was 62 years; hypertension and dyslipidemia were the most frequent vascular risk factors. IAD locations were distal internal carotid artery, middle cerebral artery (M1), anterior cerebral artery (A2), and, in two cases, the basilar artery. All anterior circulation IADs were occlusive or subocclusive, while the two basilar artery IADs caused arterial stenosis. After IVT, there were no subarachnoid or symptomatic intracranial hemorrhages. One patient had an asymptomatic hemorrhagic infarct type 1. Two patients died within 7 days from ischemic mass effect. The other three patients had favorable clinical outcomes at 3-months. In this small single-center case series of IAD-related AIS, thrombolysis seemed relatively safe. However, IVT efficacy and the likelihood of arterial recanalization are still uncertain in this context. Further studies are needed to assess the safety and efficacy of IVT in these patients

Efficacy and safety of endovascular treatment in acute ischemic stroke due to cervical artery dissection: A 15-year consecutive case series.

Limited observational data are available on endovascular treatment in acute ischemic stroke due to cervical artery dissection. Three studies comparing endovascular treatment with standard medical therapy or intravenous thrombolysis in cervical artery dissection-related acute ischemic stroke did not demonstrate superiority of endovascular treatment. Efficacy and the choice of endovascular treatment technique in this setting remain to be established. To assess the potential efficacy and safety of endovascular treatment compared to intravenous thrombolysis alone or to no revascularization treatment in our center. We selected all consecutive patients with cervical artery dissection-related acute ischemic stroke and intracranial occlusion from the Acute STroke Registry and Analysis of Lausanne between 2003 and 2017. We compared clinical and neuroimaging data of patients treated by endovascular treatment versus patients receiving intravenous thrombolysis or patients without revascularization treatment. Safety analysis included symptomatic intracranial hemorrhage, major radiological hemorrhages (parenchymal hematoma 1, parenchymal hematoma 2, and subarachnoid hemorrhage) and mortality within seven days. We assessed favorable clinical outcome (modified Rankin Scale 0-2) at three months using a binary logistic regression model. Of the 109 patients included, 24 had endovascular treatment, 38 received intravenous thrombolysis alone, and 47 had no revascularization treatment. Endovascular treatment patients had a higher rate of recanalization at 24 h. Major radiological hemorrhages occurred more often in endovascular treatment patients (all with bridging therapy) than in patients without revascularization treatment (p = 0.026), with no differences in symptomatic intracranial hemorrhage or mortality within seven days. Favorable clinical outcome at three months did not differ between groups (endovascular treatment versus intravenous thrombolysis p = 0.407; endovascular treatment versus no revascularization treatment p = 0.580). In this single-center cohort of cervical artery dissection-related acute ischemic stroke with intracranial occlusion, endovascular treatment with prior intravenous thrombolysis may increase the risk of major radiological but not symptomatic intracranial hemorrhage. Despite the lack of clear superiority in our cohort, endovascular treatment should currently not be withheld in these patients