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      Call for Papers: Sex and Gender in Neurodegenerative Diseases

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      About Neurodegenerative Diseases: 1.9 Impact Factor I 5.9 CiteScore I 0.648 Scimago Journal & Country Rank (SJR)

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      Coexisting Large and Small Vessel Disease in Patients with Ischemic Stroke of Undetermined Cause

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          Background and Purpose: Large artery atherosclerosis (LAA) and small vessel disease (SVD) share common risk factors for stroke. We aimed at investigating the association of SVD with cerebral LAA as well as with atherosclerosis in patients with stroke likely to originate from aortic plaques. Methods: We investigated 71 consecutive patients (48 men, mean age 64.2 ± 13 years) with ischemic stroke of undetermined cause according to the ASCO classification, who received ECG-triggered CT angiography for best available atherosclerotic plaque detection in the aorta. Results: Aortic atherosclerotic plaques were detected in 54 patients (76.1%). The presence of SVD significantly correlated with the presence of aortic plaques (p < 0.001), as well as LAA (p < 0.001) and risk factors such as arterial hypertension (p = 0.032) and diabetes mellitus (p = 0.017). Conclusions: Aortic plaques are common in patients with stroke of undetermined cause. If so, SVD and LAA are often coexisting, which demonstrates the close link of macro- and microangiopathy, at least in cases of severe risk factors of atherosclerosis.

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          New Approach to Stroke Subtyping: The A-S-C-O (Phenotypic) Classification of Stroke

          P Amarenco, J Bogousslavsky, L.R. Caplan … (2009)
          We now propose a new approach to stroke subtyping. The concept is to introduce a complete ‘stroke phenotyping’ classification (i.e. stroke etiology and the presence of all underlying diseases, divided by grade of severity) as distinguished from past classifications that subtype strokes by characterizing only the most likely cause(s) of stroke. In this phenotype-based classification, every patient is characterized by A-S-C-O: A for atherosclerosis, S for small vessel disease, C for cardiac source, O for other cause. Each of the 4 phenotypes is graded 1, 2, or 3. One for ‘definitely a potential cause of the index stroke’, 2 for ‘causality uncertain’, 3 for ‘unlikely a direct cause of the index stroke (but disease is present)’. When the disease is completely absent, the grade is 0; when grading is not possible due to insufficient work-up, the grade is 9. For example, a patient with a 70% ipsilateral symptomatic stenosis, leukoaraiosis, atrial fibrillation, and platelet count of 700,000/mm 3 would be classified as A1-S3-C1-O3. The same patient with a 70% ipsilateral stenosis, no brain imaging, normal ECG, and normal cardiac imaging would be identified as A1-S9-C0-O3. By introducing the ‘level of diagnostic evidence’, this classification recognizes the completeness, the quality, and the timing of the evaluation to grade the underlying diseases. Diagnostic evidence is graded in levels A, B, or C: A for direct demonstration by gold-standard diagnostic tests or criteria, B for indirect evidence or less sensitive or specific tests or criteria, and C for weak evidence in the absence of specific tests or criteria. With this new way of classifying patients, no information is neglected when the diagnosis is made, treatment can be adapted to the observed phenotypes and the most likely etiology (e.g. grade 1 in 1 of the 4 A-S-C-O phenotypes), and analyses in clinical research can be based on 1 of the 4 phenotypes (e.g. for genetic analysis purpose), while clinical trials can focus on 1 or several of these 4 phenotypes (e.g. focus on patients A1-A2-A3).
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            Autopsy prevalence of intracranial atherosclerosis in patients with fatal stroke.

            Charles Duyckaerts, Fernando Rivera, Jean-Jacques Hauw … (2008)
            The objective of this study was to determine the prevalence of intracranial plaques and stenoses and their causal role in patients with fatal stroke. Intracranial atherosclerosis is considered to be a rare condition with a severe prognosis. However, disease prevalence may be underestimated due to lack of appropriate diagnostic procedures. We performed a systematic analysis of intra- and extracranial arteries, the aortic arch, and the heart in 339 consecutive autopsies of patients with stroke. Clinical history, risk factors, imaging data, and general autopsy reports were analyzed. Patients with brain hemorrhage (n=80) were used as control subjects. Intracranial plaques and stenoses occurred in 62.2% (95% CI, 56.3 to 68.1) and 43.2% (95% CI, 37.2 to 49.3) of patients with brain infarction, respectively, compared with 48.8% (P 30%, the stenosis was considered to be causal in 5.8% of cases (n=15) because of superimposed clot on ulcerated plaques; 27% of these patients had stenoses graded 30% to 75%. In multivariate analyses, diabetes and male sex were significantly associated with intracranial plaques and stenosis. History of myocardial infarction was significantly associated with intracranial plaques and previous stroke was associated with intracranial stenosis. Intracranial plaques and stenoses are highly prevalent in fatal stroke, and stenoses graded 30% to 75% may be causal. New arterial wall imaging techniques should be used to reevaluate the frequency and role of intracranial artery plaques in living patients with stroke.
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              CT Angiography of the Aorta Is Superior to Transesophageal Echocardiography for Determining Stroke Subtypes in Patients with Cryptogenic Ischemic Stroke

              A Chatzikonstantinou, R Krissak, S. Flüchter … (2012)
              Background: The etiology of ischemic strokes remains cryptogenic in about one third of patients, even after extensive workup in specialized centers. Atherosclerotic plaques in the aorta can cause thromboembolic events but are often overlooked. They can elude standard identification by transesophageal echocardiography (TEE), which is invasive or at best uncomfortable for many patients. CT angiography (CTA) can be used as an alternative or in addition to TEE if this technique fails to visualize every part of the aorta and in particular the aortic arch. Methods: We prospectively studied 64 patients (47 men, age 60 ± 13 years) classified as having cryptogenic stroke after standard and full workup [including brain MRI and 24-hour electrocardiogram (ECG)] with ECG-triggered CTA of the aorta in search of plaques and compared the results with those of TEE. Investigators were blinded to the results of both techniques. Plaques were graded on CTA according to their presence (0 = not present; 1 = mild; 2 = severe) and degree of calcification (1a or 2a = noncalcified; 1b or 2b = calcified). Associations with risk factors and infarct localization were also assessed. Results: Only 21 of 64 patients (32.8%) had aortic plaques identified by TEE, compared to 43 of 64 (67.2%) with CTA (p < 0.05). The plaque localization was as follows (TEE vs. CTA): ascending aorta, 10 vs. 20 (p < 0.05); aortic arch, 10 vs. 40 (p < 0.05), and descending aorta, 20 vs. 34 (p < 0.05). Grade 1 plaques were most commonly found in the aortic arch (25; 39%), while grade 2 plaques were most often detected in the aortic arch (15; 23.4%) and the descending aorta (14; 21.9%). There was no significant correlation between plaque location, infarct territory or vascular risk profile, except for hypertension (p = 0.003), which was significantly associated with the presence of plaques. Conclusions: CTA identifies more plaques throughout the aortic arch and around the origins of the major cerebral arteries in particular compared to TEE. These may represent potential embolic sources of acute ischemic stroke. Better plaque detection may have an impact on the best available secondary prevention regimen in individual patients if proximal embolic sources are suspected.
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                Author and article information

                Journal
                Journal ID (publisher-id): ENE
                Journal ID (nlm-ta): Eur Neurol
                Journal ID (doi): 10.1159/issn.0014-3022
                Title: European Neurology
                Publisher: S. Karger AG
                ISSN (Print): 0014-3022
                ISSN (Electronic): 1421-9913
                Publication date Subscription-year: 2012
                Publication date (Print): September 2012
                Publication date (Electronic): 14 August 2012
                Volume: 68
                Issue: 3
                Pages: 162-165
                Affiliations
                aDepartment of Neurology and bInstitute of Radiology and Nuclear Medicine, UniversitätsMedizin Mannheim, University of Heidelberg, Mannheim, Germany
                Author notes
                *Anastasios Chatzikonstantinou, MD, Department of Neurology, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1–3, DE–68167 Mannheim (Germany), Tel. +49 621 383 2885, E-Mail anastasios.chatzikonstantinou@umm.de
                Article
                Publisher ID: 339945 Other ID: Eur Neurol 2012;68:162–165
                DOI: 10.1159/000339945
                PubMed ID: 22906845
                SO-VID: ef1a24d1-c7ff-4b84-96a8-f835f7523ac1
                Copyright © © 2012 S. Karger AG, Basel
                License:

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Date received : 20 March 2012
                Date accepted : 29 May 2012
                Page count
                Tables: 1, Pages: 4
                Categories
                Subject: Original Paper

                ScienceOpen disciplines: Geriatric medicine,Neurology,Cardiovascular Medicine,Neurosciences,Clinical Psychology & Psychiatry,Public health
                Keywords: Small vessel disease,Atherosclerosis,Stroke,CT angiography
                Data availability:
                ScienceOpen disciplines: Geriatric medicine, Neurology, Cardiovascular Medicine, Neurosciences, Clinical Psychology & Psychiatry, Public health
                Keywords: Small vessel disease, Atherosclerosis, Stroke, CT angiography

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