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Yamamoto Y, Nagakane Y. [Identification of potential embolic source and consideration for ischemic lesion formation using the consecutive patient registry of acute embolic stroke]. Rinsho Shinkeigaku 2025; 65:203-210. [PMID: 40010713 DOI: 10.5692/clinicalneurol.cn-002054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2025]
Abstract
We investigated the 992 consecutive patients with acute embolic stroke and identified potential embolic sources (PES) for 88.3% applying transesophageal echocardiography (TEE). We classified patients into 3 groups, the Group A (n = 560): PES were identified after general examinations, the Group B (n = 366): PES were identified after TEE or long-term EEG monitoring and the Group C (n = 66): TEE could not be performed. In Group A, continuous atrial fibrillation (cAf) was most prevalent (n = 464, 82.8%), succeeded by myocardial infarction (n = 39, 6.9%) and Trousseau syndrome (n = 27, 4.8%), etc. In Group B, paroxysmal atrial fibrillation (pAf) was most prevalent (n = 168, 45.9%), succeeded by paradoxical embolism (n = 77, 21.0%) and aorto-embolism (n = 77, 19.3%). We investigated the association of topographic diffusion-weighted imaging patterns (DWI) with PES. DWI was determined based on the arterial supply. Middle cerebral arteries were particularly divided into 4 segments, i.e., M1~M4. Moreover, M2 segments were subdivided into superior and inferior branches. The infarcts of larger caliber arteries such as internal carotid artery, M1 and M2, and multiple cortical branches were mostly associated with atrial fibrillation including cAf and pAf. Striatocapsular infarction were significantly associated with paradoxical embolism. Multiple small scattered infarcts were predominant in aorto-embolism as well as paradoxical embolism, Trousseau syndrome and thrombocytosis. The associations of DWI with different PES have their distinctive characteristics and may help predict PES in patients with embolic stroke of undetermined source. DWI pattern may be determined by the composition of thrombi and hydrodynamics of cerebral vasculature.
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Esnaola Barriola I, Escriche Gorospe E, Miguel Navas P, Martínez Campos E, Molina Goicoechea M, Capell Pascual F, Jiménez Delgado A, Muñoz Arrondo R. Suprasternal aortic arch echocardioscopy as a potential tool in detection and follow-up of mobile thrombi in patients with ischemic stroke. Front Neurol 2025; 15:1528325. [PMID: 39845932 PMCID: PMC11752908 DOI: 10.3389/fneur.2024.1528325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2024] [Accepted: 12/16/2024] [Indexed: 01/24/2025] Open
Abstract
Introduction Severe or complicated atheromatosis of the aortic arch represents an important and often underdiagnosed embolic source in patients with ischemic stroke. The presence of a floating thrombus has significant clinical relevance, as it is associated with a high risk of early recurrence. The aim of this study was to analyze the potential of echocardiographic examination through the suprasternal window in both the detection of embolic sources and the monitoring of the response to anticoagulant treatment in patients with mobile thrombi. Methods This case series study included ten consecutive patients with a mobile floating aortic arch thrombus associated with an atheromatous plaque, detected by focused echocardiography and confirmed by Computed Tomography Angiography (CTA). Epidemiological, clinical, radiological, and ultrasound characteristics were analyzed. Clinical and ultrasound follow-up was performed after initiation of anticoagulation as secondary prevention to assess the efficacy and safety of this treatment. Results Ten patients (seven female) with a mean age of 76 years were identified. After anticoagulation, a complete resolution of the mobile thrombus was observed in eight of them during ultrasound follow-up. One patient suffered an ischemic recurrence. Two patients receiving associated antiplatelet therapy presented severe hemorrhagic complications, one of which was fatal. Once the disappearance of the mobile thrombus was detected, anticoagulation was discontinued, and no further ischemic recurrences were observed. Discussion Floating thrombus of the aortic arch is an underdiagnosed but clinically relevant condition. The study of the aortic arch with echocardiography through the suprasternal window is a highly available and harmless technique, that may be highly useful for the detection and monitoring of response to treatment of this pathology. Furthermore, early anticoagulation could be an effective and safe treatment in these patients.
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Jung JW, Baik M, Jeong J, Lee IH, Kim KH, Yun J, Shim CY, Hong GR, Kim YD, Heo JH, Nam HS. Prognosis of ischemic stroke patients with both aortic atheroma and cardioembolic sources. Sci Rep 2024; 14:12656. [PMID: 38825610 PMCID: PMC11144702 DOI: 10.1038/s41598-024-60294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/21/2024] [Indexed: 06/04/2024] Open
Abstract
This study aimed to investigate the relationship between complex aortic plaque (CAP) and short-term as well as long-term outcomes following cardioembolic stroke. CAP is a known risk factor for occurrence and recurrence of ischemic stroke. However, the association of CAP on cardioembolic stroke remains unclear. This was retrospective study using prospective cohort of consecutive patients with cardioembolic stroke who underwent transesophageal echocardiography. The functional outcome was evaluated using the modified Rankin Scale score at 3 months, and long-term outcomes were assessed by recurrence of ischemic stroke and occurrence of major adverse cardiovascular events (MACE). Among 759 patients with cardioembolic stroke, 91 (12.0%) had CAP. Early ischemic stroke recurrence within 3 months was associated with CAP (p = 0.025), whereas CAP was not associated with functional outcome at 3 months (odd ratio 1.01, 95% confidence interval [CI] 0.57-1.84, p = 0.973). During a median follow-up of 3.02 years, CAP was significantly associated with ischemic stroke recurrence (hazard ratio = 2.68, 95% CI 1.48-4.88, p = 0.001) and MACE occurrence (hazard ratio = 1.61, 95% CI 1.03-2.51, p = 0.039). In conclusion, CAP was associated with early ischemic stroke recurrence and poor long-term outcomes in patients with cardioembolic stroke. It might be helpful to consider transesophageal echocardiography for patients with cardioembolic stroke to identify CAP.
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Affiliation(s)
- Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Minyoul Baik
- Department of Neurology, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, Korea
| | - JaeWook Jeong
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Il Hyung Lee
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Kwang Hyun Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Jaeseob Yun
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Chi Young Shim
- Department of Cardiology, Yonsei University College of Medicine, Seoul, Korea
| | - Geu-Ru Hong
- Department of Cardiology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Korea.
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Yamamoto Y, Nagakane Y, Tanaka E, Yamada T, Fujinami J, Ohara T. How Topographic Diffusion-Weighted Imaging Patterns can Predict the Potential Embolic Source. Clin Neuroradiol 2024; 34:363-371. [PMID: 38169002 DOI: 10.1007/s00062-023-01366-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/09/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE To develop an imaging prediction model for patients with embolic stroke of undetermined source (ESUS), we investigated the association of topographic diffusion-weighted imaging (DWI) patterns with potential embolic sources (PES) identified by transesophageal echocardiography. METHODS From a total of 992 consecutive patients with embolic stroke, 366 patients with the ESUS group were selected. ESUS was defined as no atrial fibrillation (Af) within 24h from admission and no PES after general examination. Clinical variables include age (> 80years, 70-80 years), sex, vascular risk factors and left atrial diameter > 4 cm. Age, sex and vascular risk factors adjusted odds ratio of each DWI for the different PESs were calculated. DWI was determined based on the arterial territories. Middle cerebral arteries were divided into 4 segments, i.e., M1-M4. Moreover, M2 segments were subdivided into superior and inferior branches. RESULTS The 366 patients consisted of 168 with paroxysmal Af (pAf), 77 with paradoxical embolism, 71 with aortic embolism and 50 with undetermined embolism after transesophageal echocardiography. The variables adjusted odds ratio (OR) of internal carotid artery (OR: 12.1, p = 0.037), M1 (4.2, p = 0.001), inferior M2 (7.5, p = 0.0041) and multiple cortical branches (12.6, p < 0.0001) were significantly higher in patients with pAf. Striatocapsular infarction (12.5, p < 0.0001) and posterior inferior cerebellar artery infarcts (3.6, p = 0.018) were significantly associated with paradoxical embolism. Clinical variables adjusted OR of multiple small scattered infarcts (8.3, p < 0.0001) were significantly higher in patients with aortic embolism. CONCLUSION The associations of DWI with different PES have their distinctive characteristics and DWI along with clinical variables may help predict PES in patients with ESUS.
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Affiliation(s)
- Y Yamamoto
- Department of Neurology, Kyoto Katsura Hospital, 615-8256. 17 Yamada Hiraocho, Nishikyoku, Kyoto, Japan.
| | - Y Nagakane
- Department of Neurology, Kyoto Second Red Cross Hospital, 602-8026. 355-5 Haruobi-cho, Kamigyo-ku, Kyoto, Japan
| | - E Tanaka
- Department of Neurology, Kyoto Prefectural University of Medicine, 602-8566. 465 Kajiicho Kamigyoku, Kyoto, Japan
| | - T Yamada
- Department of Neurology and Stroke Treatment, Japanese Red Cross Kyoto Daiichi Hospital, 605-0981. 15-749 Honmachi, Higashiyama, Kyoto, Japan
| | - J Fujinami
- Department of Neurology, Kyoto Second Red Cross Hospital, 602-8026. 355-5 Haruobi-cho, Kamigyo-ku, Kyoto, Japan
| | - T Ohara
- Department of Neurology, Kyoto Prefectural University of Medicine, 602-8566. 465 Kajiicho Kamigyoku, Kyoto, Japan
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Sebök M, Germans MR, Niftrik CHBV, Kulcsár Z, Regli L, Fierstra J. More pronounced hemodynamic alterations in patients with brain arteriovenous malformation–associated epilepsy. Neurosurg Focus 2022; 53:E4. [DOI: 10.3171/2022.4.focus22117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Epileptic seizures in patients with brain arteriovenous malformations (bAVMs) may be caused by hemodynamic alterations due to the complex angioarchitecture of bAVMs. In particular, an arterial steal phenomenon and venous outflow disruption may play an etiological role in seizure development but remain challenging to demonstrate quantitatively. Blood oxygenation level–dependent (BOLD) cerebrovascular reactivity (CVR) imaging is an emerging technique that can measure both arterial steal phenomenon (as a paradoxical BOLD signal decrease during a vasodilatory stimulus) and impaired perinidal BOLD-CVR (which has been found in the presence of venous congestion on conventional angiography in bAVM patients with epilepsy). By applying this innovative BOLD-CVR technique, the aim is to better study CVR patterns and their correlation with morphological features on conventional angiography in patients with bAVM with and without epilepsy.
METHODS
Twenty-two patients with unruptured and previously untreated bAVMs (8 with and 14 without epilepsy) were included in this case-control study. Quantitative CVR measurements were derived from BOLD functional MRI volumes using a novel standardized and precise hypercapnic stimulus (i.e., % BOLD/mm Hg CO2). In addition, 22 matched healthy controls underwent an identical BOLD-CVR study. Evaluation of venous congestion was performed on conventional angiography for all patients with bAVM.
RESULTS
Patients with bAVM-associated epilepsy showed impaired whole-brain BOLD-CVR compared to those in the nonepilepsy group, even after correction for AVM volume and AVM grade (epilepsy vs nonepilepsy group: 0.17 ± 0.07 vs 0.25 ± 0.07, p = 0.04). A BOLD-CVR–derived arterial steal phenomenon was observed in 2 patients with epilepsy (25%). Venous congestion was noted in 3 patients with epilepsy (38%) and in 1 patient without epilepsy (7%; p = 0.08).
CONCLUSIONS
These data suggest that whole-brain CVR impairment, and more pronounced hemodynamic alterations (i.e., arterial steal phenomenon and venous outflow restriction), may be more present in patients with bAVM-associated epilepsy. The association of impaired BOLD-CVR and bAVM-associated epilepsy will need further investigation in a larger patient cohort.
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Affiliation(s)
- Martina Sebök
- Department of Neurosurgery,
- Clinical Neuroscience Center, and
| | | | | | - Zsolt Kulcsár
- Clinical Neuroscience Center, and
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery,
- Clinical Neuroscience Center, and
| | - Jorn Fierstra
- Department of Neurosurgery,
- Clinical Neuroscience Center, and
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Jiang M, Wu H, Zhang H, Su F, Cao L, Ren X, Tatenda G, Hu J, Cheng M, Wen Y. Association between the Triglyceride-Glucose Index and the Risk of Large Artery Atherosclerotic Stroke. Int J Clin Pract 2022; 2022:5191581. [PMID: 36304978 PMCID: PMC9578805 DOI: 10.1155/2022/5191581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/18/2022] [Accepted: 08/09/2022] [Indexed: 11/22/2022] Open
Abstract
The aim of this study is to evaluate the value of the triglyceride-glucose (TyG) index and the risk of large artery atherosclerotic (LAA) stroke. Information on general demographic and clinical characteristics, magnetic resonance angiography (MRA) examination, and blood biochemical index determination were obtained. Based on age stratification, three models to evaluate the odds ratio (OR) and the 95% confidence interval (95% CI) were employed to determine the correlation between the TyG index and the risk of LAA stroke. The most effective TyG index threshold in predicting a high risk of LAA stroke was identified using receiver operating characteristic (ROC) curve analysis. Logistic regression verified the association between the risk of LAA stroke and the TyG index. Both with and without age stratification, logistic regression analysis showed that the TyG index was a significant predictor of the occurrence of LAA stroke (P < 0.05). The maximum Youden index for determining a high risk of LAA stroke was found at a TyG index of 4.60. The area under the ROC curve was 0.69 (95% CI: 0.646-0.742, P < 0.05), sensitivity was 78.0%, and specificity was 63.4%. An elevated TyG index was remarkably associated with a high risk of LAA stroke.
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Affiliation(s)
- Mingfei Jiang
- Department of Diagnostics, Clinical School of Medicine, Wannan Medical College, Anhui, Wuhu 214002, China
| | - Huan Wu
- Department of Prevention Medical, School of Laboratory Medicine, Wannan Medical College, Anhui, Wuhu 214002, China
| | - Huiping Zhang
- Stroke Research Center, Department of Ultrasound, Ma'anshan People's Hospital, Anhui, Ma'anshan 243000, China
| | - Fan Su
- Department of Prevention Medical, School of Public Health, Wannan Medical College, Anhui, Wuhu 214002, China
| | - Lei Cao
- Department of Prevention Medical, School of Public Health, Wannan Medical College, Anhui, Wuhu 214002, China
| | - Xia Ren
- Department of Prevention Medical, School of Public Health, Wannan Medical College, Anhui, Wuhu 214002, China
| | - Grace Tatenda
- Department of Prevention Medical, School of Public Health, Wannan Medical College, Anhui, Wuhu 214002, China
| | - Jian Hu
- Department of Prevention Medical, School of Public Health, Wannan Medical College, Anhui, Wuhu 214002, China
| | - Mingjia Cheng
- Department of Diagnostics, Clinical School of Medicine, Wannan Medical College, Anhui, Wuhu 214002, China
| | - Yufeng Wen
- Department of Prevention Medical, School of Public Health, Wannan Medical College, Anhui, Wuhu 214002, China
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Aubry P, Hamidouche F, Alqudwa A, Naoum-Nehme A, Maiga B, Camara N, Manchon E, Poulos N. [Cryptogenic stroke management : where are we ?]. Ann Cardiol Angeiol (Paris) 2021; 70:373-379. [PMID: 34742466 DOI: 10.1016/j.ancard.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/02/2021] [Indexed: 10/19/2022]
Abstract
Cryptogenic stroke is an old definition that designates an ischemic stroke with no identifiable cause. The term of the embolic stroke of undetermined source was then introduced to identify non-lacunar strokes in whom thromboembolism was the likely mechanism. This subgroup of cryptogenic strokes remains heterogeneous with many potential and possibly associated embolic causes. Covert atrial fibrillation is probably less often involved than initially expected, in contrast to intracranial and extracranial atherosclerosis. The cardiologist should be involved in the search of underlying causes of ischemic stroke by helping the neurologist to identify the most likely diagnosis. Further research is necessary to select populations that may benefit from more effective and individualized treatment.
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Affiliation(s)
- P Aubry
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse; Département de cardiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Bichat-Claude-Bernard, 75018 Paris.
| | - F Hamidouche
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - A Alqudwa
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - A Naoum-Nehme
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - B Maiga
- Service de neurologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - N Camara
- Service de neurologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - E Manchon
- Service de neurologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - N Poulos
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse
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Lee YK, Gwak BC, Yoon BA, Kim DH, Cha JK. Atrial Cardiopathy Biomarkers and MRI-Based Infarct Patterns in Patients with Embolic Strokes of Undetermined Source. J Stroke Cerebrovasc Dis 2021; 30:105933. [PMID: 34157668 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/12/2021] [Accepted: 05/31/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The study aimed to investigate whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentration and/or left atrial volume index (LAVI), as atrial cardiopathy biomarkers, were associated with infarct patterns on diffusion-weighted imaging in patients with embolic strokes of undetermined source (ESUS). MATERIALS AND METHOD We retrospectively evaluated patient with ESUS from our stroke registry between January 2018 and November 2019. Cut-off values for atrial cardiopathy biomarkers were defined as >250 pg/mL for NT-proBNP and >34 mL/m2 for LAVI. Eligible patients were then assigned to 3 groups and infarct patterns were compared according to their atrial cardiopathy markers: Group 1 (no atrial cardiopathy markers), Group 2 (one marker), and Group 3 (both markers). RESULTS Among 194 eligible patients with ESUS (76 women; mean age, 69.2 years), simultaneous increases of NT-proBNP concentration and LAVI were identified in 39 (20.1%). Group 3 had a significantly larger infarct volume, relative to Group 1 and Group 2 (P=0.043) Multivariable logistic regression analyses revealed that these patients (Group 3) were significantly more likely to have multi-territorial infarcts (adjusted odds ratio [aOR]: 3.03, 95% confidence interval [CI]: 1.05-8.72; P=0.04), a maximal lesion diameter >15mm (aOR: 4.51, 95% CI: 1.70-11.93; P=0.001), and large cortical infarctions (aOR: 4.17, 95% CI: 1.75-9.96; P=0.001). CONCLUSION We found that simultaneously increased values for NT-proBNP concentration and LAVI were independently associated with multi-territorial and large cortical infarct patterns in patients with ESUS. These findings suggest that NT-proBNP and LAVI may be useful biomarkers for identifying cardioembolic subtypes and guiding treatment selection in patients with ESUS.
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Affiliation(s)
- Yoon-Kyung Lee
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea; Department of Neurology, College of Medicine, Dong-A University, Busan, Republic of Korea.
| | - Byung-Cheol Gwak
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea; Department of Neurology, College of Medicine, Dong-A University, Busan, Republic of Korea.
| | - Byeol-A Yoon
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea; Department of Neurology, College of Medicine, Dong-A University, Busan, Republic of Korea.
| | - Dae-Hyun Kim
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea; Department of Neurology, College of Medicine, Dong-A University, Busan, Republic of Korea.
| | - Jae-Kwan Cha
- Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea; Department of Neurology, College of Medicine, Dong-A University, Busan, Republic of Korea.
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Sebök M, van Niftrik CHB, Winklhofer S, Wegener S, Esposito G, Stippich C, Luft A, Regli L, Fierstra J. Mapping Cerebrovascular Reactivity Impairment in Patients With Symptomatic Unilateral Carotid Artery Disease. J Am Heart Assoc 2021; 10:e020792. [PMID: 34102856 PMCID: PMC8477889 DOI: 10.1161/jaha.121.020792] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Comprehensive hemodynamic impairment mapping using blood oxygenation‐level dependent (BOLD) cerebrovascular reactivity (CVR) can be used to identify hemodynamically relevant symptomatic unilateral carotid artery disease. Methods and Results This prospective cohort study was conducted between February 2015 and July 2020 at the Clinical Neuroscience Center of the University Hospital Zurich, Zurich, Switzerland. One hundred two patients with newly diagnosed symptomatic unilateral internal carotid artery (ICA) occlusion or with 70% to 99% ICA stenosis were included. An age‐matched healthy cohort of 12 subjects underwent an identical BOLD functional magnetic resonance imaging examination. Using BOLD functional magnetic resonance imaging with a standardized CO2 stimulus, CVR impairment was evaluated. Moreover, embolic versus hemodynamic ischemic patterns were evaluated on diffusion‐weighted imaging. Sixty‐seven patients had unilateral ICA occlusion and 35 patients unilateral 70% to 99% ICA stenosis. Patients with ICA occlusion exhibited lower whole‐brain and ipsilateral hemisphere mean BOLD‐CVR values as compared with healthy subjects (0.12±0.08 versus 0.19±0.04, P=0.004 and 0.09±0.09 versus 0.18±0.04, P<0.001) and ICA stenosis cohort (0.12±0.08 versus 0.16±0.05, P=0.01 and 0.09±0.09 versus 0.15±0.05, P=0.01); however, only 40 (58%) patients of the cohort showed significant BOLD‐CVR impairment. Conversely, there was no difference in mean BOLD‐CVR values between healthy patients and patients with ICA stenosis, although 5 (14%) patients with ICA stenosis showed a significant BOLD‐CVR impairment. No significant BOLD‐CVR difference was discernible between patients with hemodynamic ischemic infarcts versus those with embolic infarct distribution (0.11±0.08 versus 0.13±0.06, P=0.12). Conclusions Comprehensive BOLD‐CVR mapping allows for identification of hemodynamically relevant symptomatic unilateral carotid artery stenosis or occlusion.
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Affiliation(s)
- Martina Sebök
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
| | - Christiaan Hendrik Bas van Niftrik
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
| | - Sebastian Winklhofer
- Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland.,Department of Neuroradiology University Hospital ZurichUniversity of Zurich Switzerland
| | - Susanne Wegener
- Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland.,Department of Neurology University Hospital ZurichUniversity of Zurich Switzerland
| | - Giuseppe Esposito
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
| | - Christoph Stippich
- Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland.,Neuroradiology and Radiology Schmieder Clinic Allensbach Germany
| | - Andreas Luft
- Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland.,Department of Neurology University Hospital ZurichUniversity of Zurich Switzerland.,Cereneo Center for Neurology and Rehabilitation Vitznau Switzerland
| | - Luca Regli
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery University Hospital ZurichUniversity of Zurich Switzerland.,Clinical Neuroscience Center University Hospital ZurichUniversity of Zurich Switzerland
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10
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Viedma-Guiard E, Guidoux C, Amarenco P, Meseguer E. Aortic Sources of Embolism. Front Neurol 2021; 11:606663. [PMID: 33519684 PMCID: PMC7843443 DOI: 10.3389/fneur.2020.606663] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/25/2020] [Indexed: 12/15/2022] Open
Abstract
Aortic arch atheroma is a frequent finding in ischemic stroke patients. Its role as a source of cerebral emboli or a marker of atherosclerosis is unclear. Transesophageal echography is considered the gold standard for its detection, whereas computed tomography angiography is a good alternative; magnetic resonance and positron emission tomography could be proposed to better analyze plaque vulnerability. Despite the interest in this condition, the optimal antithrombotic treatment remains uncertain, while intensive lipid-lowering therapy should be recommended. This review aims to offer guidance on patients with aortic arch atheroma, about its causal role in stroke, diagnosis, and treatment based on current available evidence.
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Affiliation(s)
- Elena Viedma-Guiard
- Department of Neurology and Stroke Center, APHP Bichat Hospital, Paris, France Université de Paris, LVTS, Inserm U1148, Paris, France
| | - Celine Guidoux
- Department of Neurology and Stroke Center, APHP Bichat Hospital, Paris, France Université de Paris, LVTS, Inserm U1148, Paris, France
| | - Pierre Amarenco
- Department of Neurology and Stroke Center, APHP Bichat Hospital, Paris, France Université de Paris, LVTS, Inserm U1148, Paris, France
| | - Elena Meseguer
- Department of Neurology and Stroke Center, APHP Bichat Hospital, Paris, France Université de Paris, LVTS, Inserm U1148, Paris, France
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11
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Kulesh AA, Drobakha VE, Shestakov VV. Cryptogenic stroke. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2019. [DOI: 10.14412/2074-2711-2019-4-14-21] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The paper considers the epidemiology and general etiological characteristics of cryptogenic stroke (CS). It discusses the concept of embolic stroke with an unknown source of embolism. It also characterizes the most significant causes of CS, such as paroxysmal atrial fibrillation, atrial cardiopathy, aortic atheroma, non-stenotic cerebral atherosclerotic plaques, and malignant neoplasms. The paper describes approaches to the diagnosis and secondary prevention of CS and proposes etiological and neuroimaging diagnostic algorithms for CI. Clinical cases are also presented.
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Affiliation(s)
- A. A. Kulesh
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia;
City Clinical Hospital Four
| | - V. E. Drobakha
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia;
City Clinical Hospital Four
| | - V. V. Shestakov
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
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Xu F, Wang F, Liu YS. Brachiocephalic artery stenting through the carotid artery: A case report and review of the literature. World J Clin Cases 2019; 7:2644-2651. [PMID: 31559305 PMCID: PMC6745338 DOI: 10.12998/wjcc.v7.i17.2644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/14/2019] [Accepted: 08/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND As the population ages and people's living standards gradually improve, the incidence of cerebrovascular disease in China is increasing annually, posing a serious threat to people's health. The incidence of brachiocephalic artery stenosis in ischemic cerebrovascular disease is relatively low, accounting for 0.5% to 2% of patients, but its consequences are very serious. Herein, we report a case of brachiocephalic artery stenting through the carotid artery. CASE SUMMARY The patient was a 66-year-old man. He came to our hospital because of repeated dizziness and was diagnosed with ischemic cerebrovascular disease (stenosis at the beginning of the brachiocephalic artery). Cerebral angiography suggested that the stenosis of the brachiocephalic artery had almost occluded it. Contrast agent threaded a line through the stenosis, and there was reversed blood flow through the right vertebral artery to compensate for the subclavian steal syndrome in the right subclavian artery. To improve the symptoms, we placed an Express LD (8 mm × 37 mm) balloon expanding stent in the stenosis section. After the operation, the patient's dizziness significantly improved. However, after 6 mo, the patient was re-admitted to the hospital due to dizziness. A computed tomography scan of the head revealed multiple cerebral infarctions in bilateral basal ganglia and the right lateral ventricle. An auxiliary examination including computerized tomography angiography of the vessels of the head and cerebral angiography both showed severe stenosis in the brachiocephalic artery stent. During the operation, the guidewire and catheter were matched to reach the opening of the brachiocephalic artery. Therefore, we decided to use a right carotid artery approach to complete the operation. We sutured the neck puncture point with a vascular stapler and then ended the operation. After the operation, the patient recovered well, his symptoms related to dizziness disappeared, and his right radial artery pulsation could be detected. CONCLUSION In patients with brachial artery stenosis, when the femoral artery approach is difficult, the carotid artery is an unconventional but safe and effective approach. At the same time, the use of vascular suturing devices to suture a carotid puncture point is also commendable. Although it is beyond the published scope of the application, when used cautiously, it can effectively avoid cerebral ischemia caused by prolonged artificial compression, and improper suturing can lead to stenosis of the puncture site and improper blood pressure, resulting in the formation of a hematoma. Finally, satisfactory hemostasis can be achieved.
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Affiliation(s)
- Fang Xu
- Department of Interventional Therapy, The First Affiliated Hospital of Dalian Medical University, Dalian 116000, Liaoning Province, China
| | - Feng Wang
- Department of Interventional Therapy, The First Affiliated Hospital of Dalian Medical University, Dalian 116000, Liaoning Province, China
| | - Yong-Sheng Liu
- Department of Interventional Therapy, The First Affiliated Hospital of Dalian Medical University, Dalian 116000, Liaoning Province, China
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