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

Chatzikonstantinou, Anastasios; Krissak, Radko; Schaefer, Anne‐Kristin; Schoenberg, Stefan O.; Fink, Christian; Hennerici, Michael G.

doi:10.1159/000339945

Cited by 15 publications

(17 citation statements)

References 24 publications

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“…Vascular risk factors influence both small‐vessel occlusion and large‐artery atherosclerosis 25, 26. In our study population, all risk factors (except smoking and diabetes mellitus) increased consistently throughout the lifetime, but most distinctly among middle‐aged patients.…”

Section: Discussionmentioning

confidence: 60%

“…Hypertension plays a particular role in small‐vessel occlusion 25 and is also frequently present in large‐artery atherosclerosis 18, 22. There are some indications that large‐artery atherosclerosis and small‐vessel occlusion are coexisting subtypes of stroke 26, supporting the partly atherosclerotic aetiology of small‐vessel occlusion. However, small‐vessel occlusion is an imprecise subtype, which besides occlusions due to small artery microatheroma, lipohyalinosis and fibrinoid necrosis, most likely also includes misinterpreted occlusions due to embolic sources 28, 29, 30, 31, 32.…”

Section: Discussionmentioning

confidence: 99%

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Age dependency of ischaemic stroke subtypes and vascular risk factors in western Norway: the Bergen Norwegian Stroke Cooperation Study

et al. 2015

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ObjectivesAge dependency of acute ischaemic stroke aetiology and vascular risk factors have not been adequately evaluated in stroke patients in Norway. Aims of this study were to evaluate how stroke subtypes and vascular risk factors vary with age in a western Norway stroke population.Materials and methodsPatients aged 15–100 years consecutively admitted to our neurovascular centre with acute ischaemic stroke between 2006 and 2012 were included. The study population was categorized as young (15–49 years), middle‐aged (50–74 years) or elderly (≥75 years). Stroke aetiology was defined by TOAST criteria. Risk factors and history of cardiovascular disease were recorded.ResultsIn total, 2484 patients with acute cerebral infarction were included: 1418 were males (57.3%). Mean age was 70.8 years (SD ± 14.9), 228 patients were young, 1126 middle‐aged, and 1130 were elderly. The proportion of large‐artery atherosclerosis and of small‐vessel occlusion was highest among middle‐aged patients. The proportion of cardioembolism was high at all ages, especially among the elderly. The proportion of stroke of other determined cause was highest among young patients. Some risk factors (diabetes mellitus, active smoking, angina pectoris, prior stroke and peripheral artery disease) decreased among the elderly. The proportions of several potential causes increased with age.ConclusionThe proportion of stroke subtypes and vascular risk factors are age dependent. Age 50–74 years constitutes the period in life where cardiovascular risk factors become manifest and stroke subtypes change.

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Section: Discussionmentioning

confidence: 60%

Section: Discussionmentioning

confidence: 99%

Age dependency of ischaemic stroke subtypes and vascular risk factors in western Norway: the Bergen Norwegian Stroke Cooperation Study

et al. 2015

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“…Compared to other stroke-subtyping classifications that categorize ischemic stroke in rigid groups into known cause of stroke and undetermined or cryptogenic stroke, ignoring other underlying diseases not deemed to be causally related, ASCOD grades all diseases present in a given patient, captures the overlap between the diseases, and weights the potentially causal relationship between every disease detected and the ischemic stroke [3,4,5,6,7]. …”

Section: Discussionmentioning

confidence: 99%

“…Based on experience with ASCO during the past few years [3,4,5,6,7,8,9,10,11,12], we now propose an updated version called ASCOD phenotyping. …”

Section: Introductionmentioning

confidence: 99%

The ASCOD Phenotyping of Ischemic Stroke (Updated ASCO Phenotyping)

et al. 2013

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ASCO phenotyping (A: atherosclerosis; S: small-vessel disease; C: cardiac pathology; O: other causes) assigns a degree of likelihood of causal relationship to every potential disease (1 for potentially causal, 2 for causality is uncertain, 3 for unlikely causal but the disease is present, 0 for absence of disease, and 9 for insufficient workup to rule out the disease) commonly encountered in ischemic stroke describing all underlying diseases in every patient. In this new evolution of ASCO called ASCOD, we have added a ‘D' for dissection, recognizing that dissection is a very frequent disease in young stroke patients. We have also simplified the system by leaving out the ‘levels of diagnostic evidence', which has been integrated into grades 9 and 0. Moreover, we have also changed the cutoff for significant carotid or intracranial stenosis from 70% to more commonly used 50% luminal stenosis, and added a cardiogenic stroke pattern using neuroimaging. ASCOD captures and weights the overlap between all underlying diseases present in ischemic stroke patients.

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“…Indeed, after echocardiography, only 9 high-risk findings in 140 patients were found and this number rose to 25 high-risk findings after performing both echocardiography and CT. This increasing sensitivity helps to identify a subtype of stroke and it reduces the number of patients with cryptogenic stroke that has shown to be relatively high in stroke registries [14,15,16]. The main explanation for the increasing sensitivity was the higher number of previous myocardial infarctions found by CACC-CT but also ventricular thrombus and aortic thrombus, and more aortic arch atheromatous plaque were found after CACC-CT evaluation.…”

Section: Discussionmentioning

confidence: 99%

Computed Tomography and Echocardiography together Reveal More High-Risk Findings than Echocardiography Alone in the Diagnostics of Stroke Etiology

et al. 2013

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Background: Cardioembolic stroke carries a major risk of stroke recurrence, which can be markedly reduced by early initiation of appropriate secondary prevention. Weinvestigate whether combined examination of the heart, aorta, and cervicocranial arteries with computed tomography (CACC-CT) may improve the diagnosis of stroke etiology. Methods: Patients with suspected cardiogenic ischemic stroke or transient ischemic attack (n = 140; mean age 60 ± 10 years; 95 males) underwent CACC-CT and standard diagnostics including transthoracic and transesophageal echocardiography (TTE/TEE). Patients with atrial fibrillation were excluded because cardiac imaging will not affect to anticoagulant treatment. Imaging findings with a potential cardioembolic source were analyzed. Aortic and cardiac risk findings were evaluated independently. Consensus reading of 2 experts using the findings of both approaches and complemented by cardiac MRI when needed served as the reference standard. Results: In 101 patients (72%) the clinical diagnosis was stroke, and transient ischemic attack was confirmed in the remaining patients. Imaging findings associated with highly increased cardioembolic risk were detected in 22 patients (16%). Nine high-risk findings in 140 patients were found by TTE/TEE and this number rose to 25 high after performing both echocardiography and CACC-CT. No difference was found between CACC-CT and TTE/TEE in detecting patients with of at least one high-risk findings (sensitivity 68 vs. 41%, p = 0.052; specificity 98 vs. 99%; overall accuracy 94 vs. 90%). Combined use of CACC-CT and TTE/TEE was more sensitive than TTE/TEE alone for detecting patients with at least one cardiac or aortic high-risk finding (sensitivity 91 vs. 41%, p < 0.001; specificity 98 vs. 99%; overall accuracy 97 vs. 90%). TTE/TEE was insufficient for diagnosing myocardial infarction with left ventricular aneurysm, whereas the accuracy of CACC-CT was high. In 9 patients (6%) with normal or mild hypokinesia in TTE/TEE, CACC-CT and MRI showed myocardial infarction large enough to indicate anticoagulant therapy. In contrast, CACC-CT was not suitable for diagnosing small left artrial thrombi, patent foramen ovale or to measure left ventricular ejection fraction. Conclusion: CACC-CT and TTE/TEE alone show limited accuracy for the diagnostics of stroke etiology. Therefore, CACC-CT could be a valuable tool in patients with cryptogenic stroke despite standard stroke diagnostics.

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

Cited by 15 publications

References 24 publications

Age dependency of ischaemic stroke subtypes and vascular risk factors in western Norway: the Bergen Norwegian Stroke Cooperation Study

Age dependency of ischaemic stroke subtypes and vascular risk factors in western Norway: the Bergen Norwegian Stroke Cooperation Study

The ASCOD Phenotyping of Ischemic Stroke (Updated ASCO Phenotyping)

Computed Tomography and Echocardiography together Reveal More High-Risk Findings than Echocardiography Alone in the Diagnostics of Stroke Etiology

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