Prevalence of extracranial carotid stenosis in Thai ischemic stroke/TIA patients

Stroke is a leading cause of death and morbidity in Thailand. The purpose of this study was to look for prevalence of significant extracranial carotid stenosis (ECCS) in Thai ischemic stroke/transient ischemic attack (TIA) patients and baseline characteristics of this subgroup.

Methods

All acute/subacute ischemic stroke/TIA patients who were treated at Thammasat hospital and had carotid duplex done, during August 2006–July 2007, were included. Carotid duplex studies were performed in all clinically stable patients. The degree of stenosis was defined according to the standard velocity criteria. Stroke subtypes were classified by TOAST criteria: large-artery atherosclerosis (LAA), cardioembolism (CE), small-artery occlusion (SAO), stroke of other determined cause (OC) and stroke of undetermined cause (UND).

Results

One-hundred and eighty-four cases were included. Prevalence of significant ECCS was 9.2%. SAO subtype was the most common stroke subtype in our study (45%). Significant ECCS was found in 18.4%, 6% and 8.3% patients with LAA, SAO and CE stroke subtype, respectively.

Conclusion

Significant ECCS in Thai ischemic stroke/TIA patients is uncommon. Low prevalence of coronary artery disease and peripheral artery disease in Thai stroke patients and/or high SAO stroke subtype in our patients may explain this.     

Association between metabolic syndrome and previous ischemic lesions in patients with intracranial atherosclerotic stroke

Objectives

To elucidate the relationship between MetS and ischemic stroke, we evaluated the association of MetS and individual components with frequency of ischemic stroke lesions and investigated the independent associations between them in acute ischemic stroke patients.

Patients and methods

We evaluated 370 acute ischemic stroke patients who underwent brain magnetic resonance (MR) imaging and MR angiography. The stroke subgroups were categorized as intracranial large artery atherosclerosis (IC-LAA, n = 151), extracranial large artery atherosclerosis (EC-LAA, n = 35), and nonatherosclerosis (NA, n = 184). MetS was defined using the criteria of the International Diabetes Federation.

Results

Patients with IC-LAA group showed a higher rate of MetS and previous ischemic lesions (predominantly deep gray/white matter) than those with EC-LAA and NA (all P < 0.001). The number of previous ischemic lesions showed a tendency to increase as the number of MetS components increased in the IC-LAA group (P = 0.004). In the IC-LAA group, age (OR, 1.04) and MetS (OR, 3.28) were independently associated with previous ischemic lesions (all P < 0.001), which was prominent with more severe MetS components after adjustment for risk factors (P < 0.001). Among the component conditions, high blood pressure, impaired fasting glucose, and abdominal obesity were more associated with previous ischemic lesions (all P < 0.001) than low high-density lipoprotein and high triglyceride levels (P = 0.010 and 0.028, respectively).

Conclusion

Our study showed a strong association between MetS and previous ischemic lesions, more in patients with IC-LAA.     

Different infarction patterns in patients with aortic atheroma compared to those with cardioembolism or large artery atherosclerosis

Aortic atheroma is a known cause of ischemic stroke. However, it is unclear whether ischemic stroke is caused by emboli from aortic atheroma or by accompanying atherosclerosis. In this study, we evaluated lesion patterns of patients with complex aortic plaque (CAP) to assume the underlying pathophysiology. Acute ischemic stroke patients who underwent transesophageal echocardiography were included. CAP was defined as a plaque in the proximal aorta ≥ 4 mm thick or with a mobile component. The diffusion-weighted imaging lesion patterns of patients with CAP were compared to those with large arterial atherosclerosis (LAA) or cardioembolism (CE). A total of 64 CAP patients, 127 LAA patients, and 80 CE patients were included. Small cortical pattern was more common in the CAP group (45.3%) than in the LAA (7.9%, p < 0.001) or the CE group (23.8%, p = 0.018). A large cortical pattern was more common in the CE group than in the CAP group (p < 0.001), whereas subcortical only pattern tended to be more common in the CAP group than in the CE group (p = 0.057). In multinominal analysis, the CAP group was more likely to have a small cortical lesion than the LAA group [odds ratio (OR) 14.63; 95% confidence interval (CI) 4.67–45.85] or the CE (OR 3.69, 95% CI 1.19–11.39) group. In conclusion, patients with CAP frequently had small cortical lesions or subcortical single lesion. These findings imply that ischemic stroke in aortic atheroma patients is associated with either small emboli or small artery disease.     

Early recurrent ischemic lesions on diffusion-weighted imaging in symptomatic intracranial atherosclerosis

BACKGROUND: Prior observations have shown that early recurrent ischemic lesions (ERILs) on diffusion-weighted imaging occur frequently within the first week after an index stroke. OBJECTIVE: To investigate differential patterns of ERILs among stroke subtypes, particularly intracranial large-artery atherosclerosis (IC-LAA). DESIGN: Retrospective study. SETTING: Tertiary university hospital. PATIENTS: We included 133 patients who experienced an acute ischemic stroke and who underwent initial diffusion-weighted imaging within 24 hours and subsequent diffusion-weighted imaging within 7 days after onset, and whose stroke subtype was IC-LAA, extracranial LAA (EC-LAA), or cardioembolism (CE). MAIN OUTCOME MEASURE: Early recurrent ischemic lesions were defined as new ischemic lesions on follow-up diffusion-weighted imaging, separate from the index stroke lesion. RESULTS: Early recurrent ischemic lesions were observed in the following proportions: 50.9% (28/55) in the IC-LAA group, 47.4% (9/19) in the EC-LAA group, and 44.1% (26/59) in the CE group. Early recurrent ischemic lesions in the IC-LAA group had the following characteristics: (1) they occurred mostly (27 [96.4%] of 28) in the pial area of the same vascular territory as the index stroke; (2) they were more frequently observed in a higher grade of stenosis than in milder stenosis (P<.001), whereas ERILs in the EC-LAA group were not related to the degree of stenosis; (3) they were not associated with subsequent recanalization, whereas ERILs in the CE group were mostly associated with subsequent recanalization (P<.001); and (4) they were more closely associated with clinical recurrence than in the EC-LAA or CE group (P=.02). CONCLUSION: Early recurrent ischemic lesions in the IC-LAA group are relatively frequent and have different patterns than in the EC-LAA or CE group.     

人尿激肽原酶治疗TOAST分型急性脑梗死的效果

目的分型探讨人尿激肽原酶(尤瑞克林)治疗急性脑梗死的临床疗效。方法对169例急性脑梗死住院患者给予尤瑞克林治疗(除常规治疗外,静滴尤瑞克林0.15PNA单位/d)14d,结合TOAST分型观察各组治疗前后中心区及半暗带区脑灌注成像相对比值,对比各组治疗效果及治疗前后神经功能缺损评分(NIHSS)。同时进行颈动脉、椎动脉和心脏彩色多普勒超声,心电图(动态心电图),以及头颅和颈部MRI/MRA等检查;并行血常规、血糖、血脂、肝功能、肾功能、心肌酶谱、凝血常规等检测。结果大动脉粥样硬化性脑梗死(LAA)中心区及半暗带区的脑血容量(CBV)、脑血流量(CBF)、达峰时间(TTP)均明显高于治疗前(P0.05),与小动脉闭塞性(SAO)、心源性(CE)、其他原因(SOE)及不明原因(SUE)组相比,微循环灌注改善程度和NIHSS评分差异有统计学意义(P0.05),且无明显不良反应。结论尤瑞克林对LAA患者的疗效明显优于SAO、CE、SOE、SUE患者。     

The value of the use of plasma B-type natriuretic peptide among acute ischemic stroke patients in a Chinese emergency department

Objective

To determine the value of the use of plasma B-type natriuretic peptide (BNP) among acute ischemic stroke patients in a Chinese emergency department (ED).

Materials and methods

In our ED, the emergency physicians prospectively assessed consecutive adult patients with acute phase of ischemic stroke and measured plasma BNP by Biosite Triage^®BNP POCT platform on admission, then followed up these patients. And the stroke neurologists evaluated patients’ functional outcome at hospital discharge, and also made discharge diagnosis and stroke etiologic subtypes according to TOAST criteria: large-artery atherosclerosis (LAA), cardioembolism (CE), small-artery occlusion (SAO), stroke of other determined etiology (SOE) and stroke of other undetermined etiology (SUE).

Results

In this study, 142 of 238 acute ischemic stroke patients met the study criteria [mean age 70.84 ± 11.48 years, 74 (52.11%) female]. Of the 142 patients, 35.92% were diagnosed with LAA at discharge, 25.35% with CE, 27.46% with SAO, 11.27% with SOE or SUE. Age, previous cardiac disease, atrial fibrillation, the length of hospital stays, SSS score on admission ≤ 25 and mRS ≥ 3 or death at discharge were all significantly higher in the CE patients compared to other subtypes (p < 0.01). And the mean BNP concentration was significantly higher in the CE group than in other three subtypes (p < 0.001). The optimal cut-off concentration, sensitivity and specificity of the plasma BNP concentration suitable to distinguish CE from non-CE were 66.50 pg/ml, 75.0% and 88.7%, respectively.

Conclusions

Plasma BNP level is significantly higher in CE patients than in other TOAST subtypes, and by using Biosite Triage^®BNP POCT platform, emergency physicians should strongly consider CE subtype with the plasma BNP level of over 66.50 pg/ml. However, the single BNP biomarker panel cannot be used to confidently rule out or identify stroke subtypes as a diagnosis and must be taken in context with clinical assessment and judgment before making management decisions in the ED.     

Ischemic stroke subtypes: risk factors, functional outcome and recurrence

The etiology of ischemic stroke affects its prognosis, outcome and management. Our aims were to determine risk factors, clinical and imaging variables and prognostic differences in acute ischemic stroke subtypes. In this study, we prospectively investigated 264 consecutive patients with acute ischemic stroke between 1996 and 2000. All of the patients were categorized to one of four major ischemic stroke subtype based on TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. The mean age was greater in patients with stroke of undetermined etiology (SUE). Prevalence of hypertension was higher in patients with lacunar infarct (LAC) than other subtypes. Smoking was less frequent in patients with cardioembolism (CARD). The mean infarct size was largest in patients with large artery atherosclerosis (LAA) while there were no differences in location or conversion of the infarct into hemorrhage. The proportion of the patients with milder neurological deficits at entry was higher in patients with LAC subtype. The rate of independent patients were different between subtypes: 62% in LAC, 43% in CARD, 38% in SUE, 35% in LAA at discharge (p=0.01), and 91% in LAC, 69% in CARD, 59% in SUE, 60% in LAA at 6 months (p<0.001). Recurrence rates were not different between groups. We conclude that risk factors, clinical imaging variables are different among ischemic stroke subtypes and that neurological status on admission and during follow-up strongly favors LAC. Received: 20 June 2001 / Accepted in revised form: 30 October 2001     

血清Hcy和hs-CRP与缺血性卒中各亚型关系的临床研究

目的探讨血清同型半胱氨酸(homocysteine,Hcy)、超敏C-反应蛋白(high sensitivity C-reactive protein,hs-CRP)在大动脉粥样硬化型(large artery atherosclerotic,LAA)、小血管闭塞型(small artery occlusion,SAO)缺血性卒中(ischemic stroke,IS)中的差异,以及二者与完全性、进展性卒中的关系。方法入组患者按急性卒中治疗Org 10 172试验(trial of org 10 172 in acute stroke treatment,TOAST)分型分为LAA及SAO卒中共217例,LAA 130例,其中进展性卒中58例;SAO 87例,其中进展性卒中12例。检测并比较血清Hcy和hs-CRP水平。结果 (1)Hcy(P0.019)、hs-CRP(P=0.021)、低密度脂蛋白(low density lipoprotein,LDL)(P=0.012)在LAA组及SAO组经Logistic回归分析纠正混杂因素后差异显著,LAA组血清Hcy和hs-CRP、LDL显著高于SAO组。(2)Hcy(P0.001)、hs-CRP(P=0.017)、LAA(P=0.023)在进展性和完全性卒中中纠正混杂因素后比较,差异仍有统计学意义,全部进展性卒中患者血清Hcy、hs-CRP、LAA明显高于完全性卒中患者。(3)LAA组中,进展性与完全性两亚组患者血清Hcy无明显差异,而进展性卒中亚组hs-CRP水平明显高于完全性卒中患者。结论血清Hcy、hs-CRP、LDL是LAA卒中的独立危险因素,血清Hcy和hs-CRP可作为IS病因分型的参考指标之一;高Hcy、hs-CRP、LAA是进展性卒中的独立危险因素。     

缺血性脑卒中患者动脉粥样硬化分布的临床研究

目的探讨急性缺血性脑卒中不同亚型与颈动脉粥样硬化分布的相关性。方法通过经颅多普勒超声(TCD)和颈动脉彩色多普勒血流成像(CDFI)方法检测颅内、外动脉粥样硬化程度,并结合病史、生化指标及影像学提示的病变部位进行综合分析。结果411例急性缺血性脑卒中患者,颅内动脉狭窄率为38.93%(160/411),颈动脉颅外段狭窄率24.09%(99/411)。颈动脉颅外段狭窄者年龄大、吸烟比例高,与无狭窄者比较差异有统计学意义(P=0.020,0.013);而颅内动脉狭窄者糖尿病发病率明显高于无狭窄者(P=0.005)。411例中皮质梗死49例、皮质下梗死108例、腔隙性梗死72例和短暂性脑缺血发作30例,颈动脉颅外段狭窄者以皮质梗死为主(P=0.001),并且动脉内-中膜层厚度明显增加(P=0.020);而颅内动脉狭窄者以腔隙性梗死更多见(P=0.016)。颅内、外动脉狭窄者的年龄、性别、血糖及血脂之间差异无统计学意义(均P>0.05)。结论临床和影像学检查所确定的急性缺血性脑卒中亚型与颅内、外动脉粥样硬化的病变部位相关,提示发病的原因可能不同。糖尿病与吸烟是引起颅内、外动脉病变的重要原因。     

青年缺血性卒中病因分型特点及相关危险因素分析

目的探讨青年缺血性卒中患者的病因分型构成特点和相关危险因素。方法回顾性分析北京市海淀医院神经内科2010年1月~2014年6月连续登记的120例青年首发缺血性卒中患者,同时选取同期住院的中老年缺血性卒中患者136例作为对照,收集所有研究对象的临床资料,根据中国缺血性卒中亚型(China Ischemic Stroke Subclassification,CISS)明确所有研究对象的病因分型及其危险因素,比较两组患者的病因分型特点及相关危险因素特点。结果青年缺血性卒中组男性82例(68.3%),女性38例(31.7%);中老年组男性76例(55.9%),女性60例(44.1%)。两组性别相比差异具有显著性(χ2=4.183,P=0.041)。CISS分型青年组依次为大动脉粥样硬化(large artery atherosclerosis,LAA)25.8%,原因不明(stroke of other undetermined etiology,SUE)22.5%,穿支动脉闭塞(perforating branch artery occlusion,PAO)20.8%,心源性(cardioembolism,CE)19.2%,其他病因(stroke of other etiology,SOE)11.7%。中老年组依次为LAA 40.5%,PAO 33.8%,CE 21.3%,SOE 2.9%,SUE 1.5%。青年缺血性卒中和中老年缺血性卒中两组间病因分型除CE差异无显著性外,LAA、PAO、SOE、SUE两组比较均差异具有显著性(P0.05)。其中青年组SOE、SUE病因分型比例明显高于中老年组,差异有显著性(P0.05)。青年组排前5位的危险因素分别是吸烟48.3%,高血压44.2%,高脂血症40.8%,饮酒36.7%,卒中家族史23.3%。而中老年组分别是高血压57.4%,糖尿病47.1%,高脂血症43.4%,颈动脉粥样硬化37.5%,吸烟35.3%。两组间相关危险因素比较,青年组吸烟、饮酒、卒中家族史明显高于中老年组,两组比较差异有显著性(P0.05)。结论青年缺血性卒中病因分型构成特点和相关危险因素与中老年患者分布不同。早期明确病因分型和发现危险因素有利于青年缺血性卒中的防治。