Cerebral microembolism in patients with stroke or transient ischaemic attack as a risk factor for early recurrence

Valton, Luc; Larrue, Vincent; Traon, Anne Pavy-Le; Géraud, G

doi:10.1136/jnnp.63.6.784

Cited by 27 publications

(17 citation statements)

References 18 publications

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“…Consistent with our findings, the Stroke Data Bank investigators found that the 30-day cumulative rate of early recurrence was highest in the group of patients with large-vessel atherothrombotic stroke and lowest in the group with smallvessel lacunar infarction, with intermediate rates for cardioembolic and cryptogenic stroke subtypes. 9 The higher rate of early recurrence in patients with large-vessel atherosclerosis compared with other infarct subtypes may be the result of cerebral microembolism 38,39 from plaque ulceration and lumen thrombus. 40 While we did not distinguish between extracranial and intracranial atherosclerosis in our classification of large-vessel disease, such a distinction may be important, given that patients with intracranial atherosclerosis are also at increased risk of early recurrence.…”

Section: Discussionmentioning

confidence: 99%

Risk Factors for Early Recurrence After Ischemic Stroke

Moroney

Bagiella

Paik

et al. 1998

Stroke

150

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Background and Purpose-Information regarding risk factors for early recurrence is limited. Our aim was to identify the clinical predictors of early recurrence after ischemic stroke. Methods-We prospectively examined 297 patients (mean age, 72.0Ϯ8.4 years) hospitalized with ischemic stroke to identify recurrent strokes occurring within 90 days of the index stroke. Survival free of recurrence was estimated using Kaplan-Meier analysis stratified by demographic variables; vascular risk factors; stroke syndrome, subtype, vascular territory, and severity; scores on the Barthel Index and Mini-Mental State Examination during hospitalization; blood pressure on admission; and selected laboratory data. We estimated the relative risk (RR) of early recurrence associated with those variables using proportional hazards analysis. Results-We identified 22 recurrent events in the first 90 days after the index stroke, resulting in an early stroke recurrence rate of 7.4%, and death occurred immediately after recurrence in 6 of the 22 patients. A major hemispheric stroke syndrome (RRϭ2.9; 95% confidence interval [CI]ϭ1.2 to 7.1), atherothrombotic stroke mechanism (RRϭ3.3; CIϭ1.3 to 8.3), and atrial fibrillation (RRϭ2.2; CIϭ0.8 to 6.1) were independent predictors of early recurrence, after adjustment for demographic variables. Conclusions-Early recurrence was frequent and resulted in increased mortality. Attention to the clinical features of the index stroke, including the presenting syndrome and the ischemic mechanism, and the recognition of atrial fibrillation may help in the selection of patients for the initiation of targeted interventions to prevent early recurrence and subsequent mortality. (Stroke. 1998;29:2118-2124.)

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Section: Discussionmentioning

confidence: 99%

Risk Factors for Early Recurrence After Ischemic Stroke

Moroney

Bagiella

Paik

et al. 1998

Stroke

150

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“…As covered in the introduction, in patients with carotid stenosis, a large number of studies suggest that asymptomatic embolic signals have clinical significance. 6 -10 Prospective studies in patients with symptomatic carotid stenosis 8,10 and in patients with asymptomatic carotid stenosis 24 have found embolic signals to be an independent predictor of combined stroke and transient ischemic attack risk. Their high frequency compared with the clinical end points of stroke and transient ischemic attack, combined with their clinical significance, suggest that they may be useful surrogate markers for the evaluation of new antithromboembolic agents.…”

Section: Kaposzta Et Al Switching Off Embolization From Plaquementioning

confidence: 99%

“…Furthermore, the presence of embolic signals in the ipsilateral middle cerebral artery independently predicts future stroke and risk of transient ischemic attack in patients with symptomatic carotid stenosis. 8,10 The current treatment of choice for symptomatic carotid stenosis Ն70% is carotid endarterectomy. 1,2 In patients with 50% to 70% stenosis there is still an increased stroke risk, but the benefits of operation are unclear.…”

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confidence: 99%

Switching off Embolization From Symptomatic Carotid Plaque Using S -Nitrosoglutathione

2002

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Background-Current antiplatelet regimens fail to prevent the majority of recurrent strokes. Asymptomatic circulating emboli can be detected by transcranial Doppler ultrasound, are frequent in patients with symptomatic carotid stenosis, and predict recurrent stroke risk. S-Nitrosoglutathione (GSNO) is a nitric oxide donor that appears to have relative platelet specificity. We evaluated its effectiveness in reducing embolization in patients with symptomatic carotid stenosis who already were taking aspirin. Methods and Results-Twenty patients with Ն50% internal carotid artery stenosis and with Ն3 embolic signals detected during a half-hour screening recording were recruited. All had taken aspirin for at least 7 days. They were randomly assigned in a double-blind fashion to either GSNO (4.4 mmol/kg per minute) or saline placebo for 90 minutes. Transcranial Doppler recordings were made from the ipsilateral middle cerebral artery for 1 hour before treatment and at 0 to 3, 6, and 24 hours after treatment. Before treatment, the mean (range) of embolic signals per hour was 6.9 (3 to 13) in the GSNO group and 7.3 (4 to 12) in the placebo group (Pϭ0.68). GSNO resulted in a rapid reduction in the frequency of embolic signals of 84% at 0 to 3 hours, 95% at 6 hours, and 100% at 24 hours (PϽ0.0001, Pϭ0.003, and PϽ0.0001 versus placebo, respectively). Conclusions-Continued embolization is common in patients with carotid stenosis despite aspirin therapy. GSNO was highly effective in rapidly reducing the frequency of embolic signals in this patient group. Despite its short administration time and its short half-life, it resulted in therapeutic effects lasting 24 hours. Key Words: ultrasonics Ⅲ drugs Ⅲ platelets Ⅲ carotid arteries Ⅲ nitric oxide S ymptomatic carotid stenosis is associated with a markedly increased risk of stroke on the order of 15% in the first year. 1,2 In contrast, asymptomatic carotid stenosis of the same degree is associated with a much lower risk of only Ϸ2% per year. 3,4 The mechanisms by which the asymptomatic plaque becomes symptomatic are incompletely understood, but plaque surface irregularity and ulceration resulting in the adherence of platelets and subsequent thromboembolism appears to play an important role. 5 The role of embolization is supported by recent studies demonstrating that asymptomatic cerebral microemboli (embolic signals) are frequent in patients with symptomatic carotid stenosis but less common in patients with asymptomatic carotid stenosis. 6,7 That these embolic signals have clinical significance is supported by the finding that they are more common in symptomatic patients with recent events, 7 with increasing degrees of stenosis, 8 and in the presence of plaque ulceration, 8,9 all of which are associated with an increased stroke risk. Furthermore, the presence of embolic signals in the ipsilateral middle cerebral artery independently predicts future stroke and risk of transient ischemic attack in patients with symptomatic carotid stenosis. 8,10 The current treatment of choice for sym...

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“…12 A few studies have suggested that microembolism may be a risk factor for early ischemic recurrence (EIR). [13][14][15] However, none of their designs permitted them to control for the effect of potential confounding variables, such as severe carotid stenosis or thick AAA. The purpose of our study was to assess the independent contribution of microembolism to the risk of EIR in patients with cerebral ischemia of presumed arterial origin.…”

mentioning

confidence: 99%

Microembolic Signals and Risk of Early Recurrence in Patients With Stroke or Transient Ischemic Attack

Valton¹,

Larrue²,

Traon³

et al. 1998

Stroke

148

107

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Background and Purpose-Asymptomatic microembolic signals (MES) can be demonstrated in patients with cerebral ischemia using transcranial Doppler (TCD) ultrasonographic monitoring of the middle cerebral artery. However, the clinical relevance of MES remains uncertain. The purpose of this study was to estimate the independent contribution of microembolism to the risk of early ischemic recurrence (EIR) in patients with stroke or transient ischemic attack (TIA) of presumed arterial origin. Methods-We studied the incidence of EIR in 73 consecutive patients with carotid stroke or TIA in whom TCD scanning of the symptomatic middle cerebral artery was performed within 7 days from the onset of symptoms. Patients with a potential cardiac source of embolism were excluded from the study. Results-Eight patients had EIR during a meanϮSD follow-up of 10Ϯ8 days. The incidence of EIR was 4.3 per 100 patient-days in patients with MES and only 0.5 per 100 patient-days in patients without MES.

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Cerebral microembolism in patients with stroke or transient ischaemic attack as a risk factor for early recurrence

Cited by 27 publications

References 18 publications

Risk Factors for Early Recurrence After Ischemic Stroke

Risk Factors for Early Recurrence After Ischemic Stroke

Switching off Embolization From Symptomatic Carotid Plaque Using S -Nitrosoglutathione

Microembolic Signals and Risk of Early Recurrence in Patients With Stroke or Transient Ischemic Attack

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