Stroke (Stroke)

Publications in this journal

• Article: Statin Therapy Should be Discontinued in Patients With Intracerebral Hemorrhage.

  Larry B Goldstein
  Stroke 06/2013;
• Article: Early New Diffusion-Weighted Imaging Lesions Appear More Often in Stroke Patients With a Multiple Territory Lesion Pattern.

  Tim Bastian Braemswig, Tatiana Usnich, Fredrik N Albach, Peter Brunecker, Ulrike Grittner, Jan F Scheitz, Jochen B Fiebach, Christian H Nolte
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  ABSTRACT: BACKGROUND AND PURPOSE: New diffusion-weighted imaging (DWI) lesions are common in patients with acute ischemic stroke. They are associated with an initial nonsingle lesion pattern. Previous studies have not analyzed this association in detail. We differentiated nonsingle lesions in 1 vascular supply territory only (scattered lesion pattern) from nonsingle lesions in ≥2 vascular supply territory (multiple territory lesion -pattern). METHODS: Patients with an acute ischemic stroke underwent 3 MRI (3T) examinations: on admission, on the following day, and 4 to 7 days after symptom onset. First, DWI lesions were delineated manually by raters blinded to clinical details. Second, DWI images were coregistered and analyzed visually for new hyperintensities. The initial lesion pattern was categorized as single, scattered, or multiple territory. RESULTS: Of 340 patients enrolled, 43% had a single lesion pattern, 40% had a scattered lesion pattern, and 17% had a multiple territory lesion pattern. In multivariable analysis, the categorical variable lesion pattern was independently associated with new DWI lesions (odds ratiomultiple territory lesion pattern, 3.64 [95% confidence interval, 1.75-7.58]; odds ratioscattered lesion pattern, 1.96 [95% confidence interval, 1.09-3.56]). Patients with multiple territory lesion pattern had significantly more often diabetes mellitus, and their new lesions were more often located remotely from the initial area of hypoperfusion compared with patients with scattered lesion pattern. CONCLUSION: Lesion pattern on initial image is an independent risk factor for new DWI lesions. The risk for new DWI lesions is highest in patients with multiple territory lesion pattern.
  Stroke 06/2013;
• Article: Statin Therapy Should Not be Discontinued in Patients With Intracerebral Hemorrhage.

  Alejandro Bustamante, Joan Montaner
  Stroke 06/2013;
• Article: Continued Statin Treatment After Acute Intracranial Hemorrhage: Fighting Fire With Fire.

  Carlos A Molina, Magdy H Selim
  Stroke 06/2013;
• Article: Protamine Does Not Increase Risk of Stroke in Patients With Elective Carotid Stenting.

  Jennifer S McDonald, David F Kallmes, Giuseppe Lanzino, Harry J Cloft
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  ABSTRACT: BACKGROUND AND PURPOSE: Reversal of anticoagulation with protamine might predispose to a higher risk of stroke in patients with carotid stenting. We evaluated a national, multihospital patient database to examine the risk of stroke in patients with carotid stenting receiving protamine compared with those who did not. METHODS: The Premier Perspective database was used to identify patients who were electively hospitalized for carotid stenting from 2006 through 2011. The incidence of in-hospital mortality and morbidity was compared between patients who did and did not receive protamine after propensity score adjustment via 1:1 matching to reduce selection bias. RESULTS: Of 6664 patients with carotid stenting treated at 193 hospitals, 556 (8%) received protamine on the day of the procedure. After matching by propensity score, patients who received protamine had a similar likelihood of stroke or transient ischemic attack (P=0.77), in-hospital mortality (P=0.12), discharge to long-term care (P=0.15), and access site complications (P=0.90) as compared with patients who did not receive protamine. CONCLUSIONS: Protamine administration is not associated with additional risk of adverse events after carotid stenting.
  Stroke 06/2013;
• Article: Timing-Invariant Imaging of Collateral Vessels in Acute Ischemic Stroke.

  Ewoud J Smit, Evert-Jan Vonken, Tom van Seeters, Jan Willem Dankbaar, Irene C van der Schaaf, L Jaap Kappelle, Bram van Ginneken, Birgitta K Velthuis, Mathias Prokop
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  ABSTRACT: BACKGROUND AND PURPOSE: Although collateral vessels have been shown to be an important prognostic factor in acute ischemic stroke, patients with lack of collaterals on standard imaging techniques may still have good clinical outcome. We postulate that in these cases collateral vessels are present though not visible on standard imaging techniques that are based on a single time frame. METHODS: This study included 40 consecutive patients with acute ischemic stroke with a large-vessel occlusion. Standard computed tomography angiography (CTA, single time frame) and CT perfusion (multiple time frames) were obtained at admission and timing-invariant (TI)-CTA was created from the CT perfusion data. Clinical outcome data (modified Rankin Scale) were assessed at 3-month follow-up. Four experienced observers independently assessed collateral status twice on both standard CTA and TI-CTA in an independent, blinded, randomized manner. Collateral status was rated as good if ≥50% and poor if <50% of collaterals were present compared with the contralateral hemisphere. RESULTS: Collateral status was rated higher on TI-CTA (good in 84%) compared with standard CTA (good in 49%; P<0.001). Thirty-one percent of patients with poor collateral status on standard CTA still had good clinical outcome. All of those patients, however, showed good collaterals on TI-CTA. All cases with poor collateral status rated on TI-CTA had poor clinical outcome. CONCLUSIONS: Collateral vessels may not always be visible on standard single time-frame CTA because of delayed contrast arrival. Future prognostic studies in acute stroke should consider delay-insensitive techniques, such as TI-CTA, instead of standard single time-frame imaging, such as standard CTA.
  Stroke 06/2013;
• Article: Association of Prestroke Statin Use and Lipid Levels With Outcome of Intracerebral Hemorrhage.

  Satu Mustanoja, Daniel Strbian, Jukka Putaala, Atte Meretoja, Sami Curtze, Elena Haapaniemi, Tiina Sairanen, Ronja Hietikko, Joonas Sirén, Markku Kaste, Turgut Tatlisumak
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  ABSTRACT: BACKGROUND AND PURPOSE: It is unclear whether blood lipid profiles and statin use before intracerebral hemorrhage (ICH) are associated with its outcome. METHODS: The Helsinki ICH Study, a single-center observational registry of consecutive ICH patients, was used to study the associations between premorbid statin use, baseline lipid levels, and clinical outcome. RESULTS: The registry includes 964 ICH patients. Statin users (n=187; 19%) were significantly older, had more frequent comorbidities and medication, lower lipid levels, and higher admission Glasgow Coma Scale compared with nonusers. Modified Rankin Scale at discharge or mortality did not differ between statin users and nonusers. Compared with survivors, significantly lower total cholesterol and low-density lipoprotein cholesterol levels were observed in patients who died in hospital (median, 4.1 mmol/L [interquartile range, 3.6-4.4] versus 4.5 [3.8-5.1]; P<0.01; 1.9 mmol/L [1.4-2.5] versus 2.4 [1.8-3.0]; P<0.001, respectively), at 3 or 12 months. After adjusting for known ICH prognostic factors based on univariate analysis that is, age, National Institutes of Health Stroke Scale, Glasgow Coma Scale, ICH volume, and intraventricular location, lower low-density lipoprotein levels were independently associated with in-hospital mortality (odds ratio, 0.54 [95% confidence interval, 0.31-0.93]; P=0.028). CONCLUSIONS: Premorbid statin use did not affect the outcome of ICH, but lower low-density lipoprotein levels were associated with higher in-hospital mortality.
  Stroke 06/2013;
• Article: Impact of Diffusion-Weighted Imaging Lesion Volume on the Success of Endovascular Reperfusion Therapy.

  Jean-Marc Olivot, Pascal J Mosimann, Julien Labreuche, Manabu Inoue, Elena Meseguer, Jean-Philippe Desilles, Aymeric Rouchaud, Isabelle F Klein, Matus Straka, Roland Bammer, Michael Mlynash, Pierre Amarenco, Gregory W Albers, Mikael Mazighi
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  ABSTRACT: BACKGROUND AND PURPOSE: Diffusion-weighted imaging (DWI) lesion volume is associated with poor outcome after thrombolysis, and it is unclear whether endovascular therapies are beneficial for large DWI lesion. Our aim was to assess the impact of pretreatment DWI lesion volume on outcomes after endovascular therapy, with a special emphasis on patients with complete recanalization. METHODS: We analyzed data collected between April 2007 and November 2011 in a prospective clinical registry. All acute ischemic stroke patients with complete occlusion of internal carotid artery or middle cerebral artery treated by endovascular therapy were included. DWI lesion volumes were measured by the RAPID software. Favorable outcome was defined by modified Rankin Scale of 0 to 2 at 90 days. RESULTS: A total of 139 acute ischemic stroke patients were included. Median DWI lesion volume was 14 cc (interquartile range, 5-43) after a median onset time to imaging of 110 minutes (interquartile range, 77-178). Higher volume was associated with less favorable outcome (adjusted odds ratio, 0.55; 95% confidence interval, 0.31-0.96). A complete recanalization was achieved in 65 (47%) patients after a median onset time of 238 minutes (interquartile range, 206-285). After adjustment for volume, complete recanalization was associated with more favorable outcome (adjusted odds ratio, 6.32; 95% confidence interval, 2.90-13.78). After stratification of volume by tertiles, complete recanalization was similarly associated with favorable outcome in the upper 2 tertiles (P<0.005). CONCLUSIONS: Our results emphasize the importance of initial DWI volume and recanalization on clinical outcome after endovascular treatment. Large DWI lesions may still benefit from recanalization in selected patients.
  Stroke 06/2013;
• Article: Policy Implications of the Changing Epidemiology of Chagas Disease and Stroke.

  Francisco Javier Carod-Artal
  Stroke 06/2013;
• Article: Urgent Best Medical Therapy May Obviate the Need for Urgent Surgery in Patients With Symptomatic Carotid Stenosis.

  Saeid Shahidi, Alan Owen-Falkenberg, Ulrik Hjerpsted, Amrit Rai, Karsten Ellemann
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  ABSTRACT: BACKGROUND AND PURPOSE: The purpose of this study was to analyze the 30-day outcome after introduction of a rapid carotid endarterectomy (CEA) program. Reasons for delay in CEA and the incidence of early recurrence neurological symptoms were recorded. METHODS: This is a prospective population-based study of delays to CEA and 30-day outcome in patients with symptomatic carotid stenosis. Neurological recurrence (NR) rate was determined after initiation of urgent best medical treatment (loading dose aspirin/clopidogrel and duel therapy with aspirin plus clopidogrel with a statin) until CEA and compared with NR ≤90 days prior index event. RESULTS: Of a total of 4905 (transient ischemic attack/ischemic stroke, and ocular events) patients, 115 symptomatic patients underwent CEA, 42% within 14 days of the index event and 99% within 14 days of surgical referral. The overall NR from index event to CEA in symptomatic carotid stenosis patients was significantly lower (2.5% [95% confidence interval, 1%-6%]) after best medical treatment when compared with NR ≤90 days in those before referral to a stroke clinic (29% [95% confidence interval, 22%-37%]; P<0.00001). There were no significant differences in outcomes among 48 early (<14 days), 46 intermediate (14-30 days), and 21 delayed (>30 days) CEAs. CONCLUSIONS: CEA can be performed in the subacute period without significantly increasing the operative risk. The urgent best medical treatment was associated with significant reduction in the risk of early NR in CEA patients. It seems that urgent aggressive best medical treatment may obviate the need for urgent CEA.
  Stroke 06/2013;
• Article: Homocysteine Improves Risk Stratification in Patients Undergoing Endarterectomy for Asymptomatic Internal Carotid Artery Stenosis.

  Nikolaus Duschek, Samarth Ghai, Fahrudin Sejkic, Jürgen Falkensammer, Edda Skrinjar, Kurt Huber, Johann Wojta, Thomas Waldhör, Wolfgang Hübl, Afshin Assadian
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  ABSTRACT: BACKGROUND AND PURPOSE: A limited life expectancy reduces the benefit from carotid endarterectomy (CEA) for treatment of asymptomatic internal carotid artery stenosis. The aim of this study was to assess homocysteine as stratifying biomarker to improve prediction of postoperative survival. METHODS: This was a prospective, nonrandomized case series from 2003 to 2012. Two hundred and fourteen consecutive patients (<75 years, n=130; ≥75 years, n=84) undergoing CEA for their asymptomatic internal carotid artery stenosis were observed for 8.5 years for the occurrence of death after CEA as primary end point (EC-nr: 04-067-0604). Homocysteine and major cardiovascular risk factors were used for computation of prognostic indices. Cumulative survival of prognostic indices-based quintiles was estimated by Kaplan-Meier curves. RESULTS: Total homocysteine had a significant effect on postoperative survival (P<0.0001). Total homocysteine-based quintiles of prognostic indices showed a better prediction of the survival of the patients than age alone. This caused reclassification of 17 patients (20.2%) >75 years as fit for surgery, but also indicated a high risk for 19 patients (14.6%) <75 years. In the majority (79.8%) of patients aged >75 years, statistically, CEA could not be advised because of a significantly reduced 5-year survival rate. CONCLUSIONS: High plasma homocysteine levels suggest that older patients with asymptomatic carotid stenosis might rather benefit from intensive medical therapy than from CEA.
  Stroke 06/2013;
• Article: MR RESCUE: Is the Glass Half-Full or Half-Empty?

  Mark W Parsons, Gregory W Albers
  Stroke 06/2013;
• Article: Effects of Microvascular Permeability Changes on Contrast-Enhanced T1 and Pharmacokinetic MR Imagings After Ischemia.

  Hua-Shan Liu, Hsiao-Wen Chung, Ming-Chung Chou, Michelle Liou, Chao-Ying Wang, Hung-Wen Kao, Shih-Wei Chiang, Chun-Jung Juan, Guo-Shu Huang, Cheng-Yu Chen
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  ABSTRACT: BACKGROUND AND PURPOSE: Brain enhancement on contrast-enhanced T1-weighted imaging (CET1-WI) after ischemic stroke is generally accepted as an indicator of the blood-brain barrier disruption. However, this phenomenon usually starts to become visible at the subacute phase. The purpose of this study was to evaluate the time-course profiles of K(trans), cerebral blood volume (vp), and CET1-WI with early detection of blood-brain barrier changes on K(trans) maps and their role for prediction of subsequent hemorrhagic transformation in acute middle cerebral arterial infarct. METHODS: Twenty-six patients with acute middle cerebral arterial stroke and early spontaneous reperfusion, whose MR images were obtained at predetermined stroke stages, were included. T2*-based MR perfusion-weighted images were acquired using the first-pass pharmacokinetic model to derive K(trans) and vp. Parenchymal enhancement observed on maps of K(trans), vp, and CET1-WI at each stage was compared. Association among these measurements and hemorrhagic transformation was analyzed. RESULTS: K(trans) map showed significantly higher parenchymal enhancement in ischemic parenchyma as compared with that of vp map and CET1-WI at early stroke stages (P<0.05). The increased K(trans) at acute stage was not associated with parenchymal enhancement in CET1-WI at the same stage. Parenchymal enhancement in CET1-WI started to occur at the late subacute stage and tended to be luxury reperfusion-dependent. Patients with hemorrhagic transformation showed higher mean K(trans) values as compared with patients without hemorrhagic transformation (P=0.02). CONCLUSIONS: Postischemic brain enhancement on routine CET1-WI seems to be closely related to the luxury reperfusion at the late subacute stage and is not dependent on microvascular permeability changes at the acute stage.
  Stroke 06/2013;
• Article: Life's Simple 7 and Risk of Incident Stroke: The Reasons for Geographic and Racial Differences in Stroke Study.

  Ambar Kulshreshtha, Viola Vaccarino, Suzanne E Judd, Virginia J Howard, William M McClellan, Paul Muntner, Yuling Hong, Monika M Safford, Abhinav Goyal, Mary Cushman
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  ABSTRACT: BACKGROUND AND PURPOSE: The American Heart Association developed Life's Simple 7 (LS7) as a metric defining cardiovascular health. We investigated the association between LS7 and incident stroke in black and white Americans. METHODS: The Reasons for Geographic And Racial Differences in Stroke (REGARDS) is a national population-based cohort of 30 239 blacks and whites, aged ≥45 years, sampled from the US population from 2003 to 2007. Data were collected by telephone, self-administered questionnaires, and an in-home examination. Incident strokes were identified through biannual participant contact followed by adjudication of medical records. Levels of the LS7 components (blood pressure, cholesterol, glucose, body mass index, smoking, physical activity, and diet) were each coded as poor (0 point), intermediate (1 point), or ideal (2 points) health. An overall LS7 score was categorized as inadequate (0-4), average (5-9), or optimum (10-14) cardiovascular health. RESULTS: Among 22 914 subjects with LS7 data and no previous cardiovascular disease, there were 432 incident strokes over 4.9 years of follow-up. After adjusting for demographics, socioeconomic status, and region of residence, each better health category of the LS7 score was associated with a 25% lower risk of stroke (hazard ratios, 0.75; 95% confidence interval, 0.63-0.90). The association was similar for blacks and whites (interaction P value=0.55). A 1-point higher LS7 score was associated with an 8% lower risk of stroke (hazard ratios, 0.92; 95% confidence interval, 0.88-0.95). CONCLUSIONS: In both blacks and whites, better cardiovascular health, on the basis of the LS7 score, is associated with lower risk of stroke, and a small difference in scores was an important stroke determinant.
  Stroke 06/2013;
• Article: Displacement of Sensory Maps and Disorganization of Motor Cortex After Targeted Stroke in Mice.

  Thomas C Harrison, Gergely Silasi, Jamie D Boyd, Timothy H Murphy
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  ABSTRACT: BACKGROUND AND PURPOSE: Recovery from stroke is hypothesized to involve the reorganization of surviving cortical areas. To study the functional organization of sensorimotor cortex at multiple time points before and after stroke, we performed longitudinal light-based motor mapping of transgenic mice expressing light-sensitive channelrhodopsin-2 in layer 5 cortical neurons. METHODS: Pulses of light stimulation were targeted to an array of cortical points, whereas evoked forelimb motor activity was recorded using noninvasive motion sensors. Intrinsic optical signal imaging produced maps of the forelimb somatosensory cortex. The resulting motor and sensory maps were repeatedly generated for weeks before and after small (0.2 mm(3)) photothrombotic infarcts were targeted to forelimb motor or sensory cortex. RESULTS: Infarcts targeted to forelimb sensory or motor areas caused decreased motor output in the infarct area and spatial displacement of sensory and motor maps. Strokes in sensory cortex caused the sensory map to move into motor cortex, which adopted a more diffuse structure. Stroke in motor cortex caused a compensatory increase in peri-infarct motor output, but did not affect the position or excitability of sensory maps. CONCLUSIONS: After stroke in motor cortex, decreased motor output from the infarcted area was offset by peri-infarct excitability. Sensory stroke caused a new sensory map to form in motor cortex, which maintained its center position, despite becoming more diffuse. These data suggest that surviving regions of cortex are able to assume functions from stroke-damaged areas, although this may come at the cost of alterations in map structure.
  Stroke 06/2013;
• Article: Ultra-Sensitive Molecular MRI of Vascular Cell Adhesion Molecule-1 Reveals a Dynamic Inflammatory Penumbra After Strokes.

  Maxime Gauberti, Axel Montagne, Oscar A Marcos-Contreras, Audrey Le Béhot, Eric Maubert, Denis Vivien
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  ABSTRACT: BACKGROUND AND PURPOSE: Our aim was to assess the spatiotemporal evolution of the cerebrovascular inflammation occurring after ischemic and hemorrhagic strokes using a recently developed, fast, and ultra-sensitive molecular MRI method. METHODS: We first assessed longitudinally the cerebrovascular inflammation triggered by collagenase-induced hemorrhage and by permanent/transient middle cerebral artery occlusion in mice, using MRI after injection of microparticles of iron oxide targeted to vascular cell adhesion molecule-1 (MPIOs-αVCAM-1). Thereafter, we used this method to study the anti-inflammatory effects of celecoxib, atorvastatin, and dipyridamole after stroke. RESULTS: Using multiparametric MRI, we demonstrated that the level and the kinetics of cerebrovascular VCAM-1 expression depend on several parameters, including stroke pathogenesis, the natural history of the disease, and the administration of inflammation-modulating drugs. Interestingly, in transient middle cerebral artery occlusion and intracranial hemorrhage models, VCAM-1 expression was maximal at 24 hours and almost returned to baseline 5 days after stroke onset. In contrast, after permanent middle cerebral artery occlusion, VCAM-1 overexpression was sustained between 24 hours and 5 days, and was particularly significant in the peri-infarct areas. Our results suggest that these perilesional areas expressing VCAM-1 constitute an inflammatory penumbra that is recruited by the ischemic core during the subacute phase. Using MPIOs-αVCAM-1-enhanced imaging, we also provided evidence that celecoxib and atorvastatin (but not dipyridamole) alleviate VCAM-1 overexpression after stroke and prevent formation of the inflammatory penumbra. CONCLUSIONS: MPIOs-αVCAM-1-enhanced imaging seems to be promising in the detection of individuals presenting with severe cerebrovascular responses after stroke, which could therefore benefit from anti-inflammatory treatments.
  Stroke 06/2013;
• Article: Spatiotemporal Uptake Characteristics of [18]F-2-Fluoro-2-Deoxy-D-Glucose in a Rat Middle Cerebral Artery Occlusion Model.

  Hong Yuan, Jonathan E Frank, Yonglong Hong, Hongyu An, Cihat Eldeniz, Jingxin Nie, Adomas Bunevicius, Dinggang Shen, Weili Lin
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  ABSTRACT: BACKGROUND AND PURPOSE: Alterations of cerebral glucose metabolism are well anticipated during cerebral ischemia. However, detailed spatiotemporal characteristics of disturbed cerebral glucose metabolism during acute ischemia remain largely elusive. This study aims to delineate spatiotemporal distributions of [(18)]F-2-fluoro-2-deoxy-d-glucose (FDG) uptake using positron emission tomography imaging, particularly at the peri-ischemic zone, and its correlation with tissue outcome. METHODS: The intraluminal suture middle cerebral artery occlusion model was used to induce focal cerebral ischemia in rats (n=48). All animals underwent sequential MRI and FDG positron emission tomography imaging at different times (30-150 minutes) after middle cerebral artery occlusion. MR and positron emission tomography images were coregistered. FDG uptake in the peri-ischemic zone was assessed in relation to middle cerebral artery occlusion duration, cerebral blood flow, apparent diffusion coefficient, and 24-hour T2 lesions. RESULTS: Elevated FDG uptake was consistently observed at the peri-ischemic zone surrounding the presumed ischemic core with low FDG uptake. Both the spatial volume and the uptake level of the hyper-uptake region were inversely correlated with the duration of middle cerebral artery occlusion. The hyper-uptake regions exhibited a mild reduction of cerebral blood flow (28.2±3.2%) and apparent diffusion coefficient (9.1±1.4%) when compared with that in the contralateral hemisphere. Colocalization analysis revealed that, with reperfusion, an average of 12.1±1.7% of the hyper-uptake volume was recruited into final infarction. CONCLUSIONS: Elevated FDG uptake at the peri-ischemic zone is consistently observed during acute cerebral ischemia. The region with elevated FDG uptake likely reflects viable tissues that can be salvaged with reperfusion. Therefore, acute FDG positron emission tomography imaging might hold promise in the management of patients with acute stroke.
  Stroke 06/2013;