Large vessel cardioembolic stroke and embolic stroke of undetermined source share a common profile of matrix metalloproteinase‐9 level and susceptibility vessel sign length

Abstract

Background Embolic stroke of undetermined source (ESUS) accounts for up to 25% of ischemic strokes. Identification of biomarkers that could improve the prediction of stroke subtype and subsequently of stroke prevention still remains a major issue. Methods The HIBISCUS‐STROKE cohort includes ischemic stroke patients with large vessel occlusion treated with mechanical thrombectomy following admission magnetic resonance imaging. Presence and length of susceptibility vessel sign (SVS) were assessed by gradient‐recalled echo T2*‐weighted imaging. Matrix metalloproteinase‐9 (MMP‐9) was measured on sera collected at admission. A multiple logistic regression model was performed to detect independent markers distinguishing cardioembolic (CE) from large‐artery atherosclerosis (LAA) subtype. Results A total of 147 patients were included, of them the etiology was distributed as follows: 86 (58.5%) CE, 26 (17.7%) LAA, and 35 (23.8%) ESUS. The optimal cutoff for differentiating CE from LAA subtype was 14.5 mm for SVS length (sensitivity, 79.7%; specificity, 72.7%) and 1110 ng/ml for admission MMP‐9 level (sensitivity, 85.3%; specificity, 52.2%). Multivariate analysis revealed that current smoking (odds ratio [OR] 0.07, 95% confidence interval [CI] 0.01–0.93), tandem occlusion (OR 0.01, 95% CI 0.01–0.21), SVS length (OR 0.78, 95% CI 0.63–0.97), and admission MMP‐9 level (OR 0.99, 95% CI 0.99–1.00) were inversely associated with CE subtype. SVS length and MMP‐9 level did not differ between ESUS and CE subtypes. Conclusion SVS length and admission MMP‐9 level may improve the prediction of CE subtype whose profile is close to ESUS, thus suggesting a common cardiac embolic source.

Susceptibility vessel sign in patients with subacute ischemic stroke

“…Another prominent finding of our study was that patients with the LAA subtype had a longer SVS compared to those with CE subtype, aligning with the recent findings reported by Alhazmi et al ( 19 ). Moreover, a CT study found non-cardioembolic stroke to be associated with longer thrombus duration compared to stroke caused by CE ( 22 ).…”

“…Furthermore, the activation of the fibrinolytic system and spontaneous recanalization of occluded intracranial arteries poststroke could also impact the presence of SVS during the subacute stage. Compared to other stroke subtypes, CE has the highest spontaneous recanalization rate, which ranges from 18.8% to 72% in the literature ( 19 - 21 ). This phenomenon may contribute to the lower presence of SVS in the CE subtype during the subacute stage.…”

Positive Susceptibility Vessel Sign on SWI-MRI Sequence Imaging Might Differentiate Patients Had Silent Brain Ischemia among Apparently Neurologically-Free Patients

“…In support of the accuracy of SVS for detection of cerebral insults, Alhazmi et al (19) found the SVS length can differentiate cardioembolic from large-artery atherosclerosis subtype of embolic stroke of undetermined source with sensitivity and specificity rates of 79.7% and 72.7%, respectively. Also, Guenego et al (20) reported that clot shape in SVS as determined on T2 * imaging in patients presenting with proximal middle cerebral occlusion can predict the success of reperfusion during mechanical thrombectomy.…”

Biochemical, biomechanical and imaging biomarkers of ischemic stroke: Time for integrative thinking

“…A study showed that the growth differentiation factor-15 level is associated with the severity of cerebral damage and can be used as a prognostic marker for patients who underwent intraarterial thrombectomy following an ischemic stroke (Jeong et al, 2020). Another study utilizing gradient echo T2*W imaging found that susceptibility vessel sign and admission MMP-9 levels can be used to differentiate between subtypes of stroke (Alhazmi et al, 2021). In a 3D MR vessel wall imaging study, type 2 diabetes mellitus was found to be associated with an increased number of intracranial plaques (Li et al, 2021).…”