Letter re: Risks and benefits of clopidogrel–aspirin in minor stroke or TIA: Time course analysis of CHANCE

Gutiérrez, José Javier Querol; Lekic, Tim

doi:10.1212/wnl.0000000000004654

Cited by 1 publication

(1 citation statement)

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“…Among individuals with intracranial LAA who present with ipsilateral strokes, dual antiplatelet may be more effective than among those with isolated artery disease, 22 especially early in the disease course. 23,24 The difference in antiplatelet benefit may be related to the pathophysiology of atherosclerosis-related strokes, which is attributed to plaque rupture and platelet-driven in-situ thrombosis 25 whereas the pathophysiology related to small artery disease relates more to endothelial dysfunction. 26 Distal cryptogenic strokes are the most numerous of all CBI subtypes, and perhaps offer the greatest opportunities to uncover the underlying etiology that may, or not, have a specific treatment.…”

Section: Discussionmentioning

confidence: 99%

Classification of Covert Brain Infarct Subtype and Risk of Death and Vascular Events

Gutierrez

Gil-Guevara

Ramaswamy

et al. 2020

Stroke

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Background and Purpose— To test the hypothesis that covert brain infarcts (CBIs) are more likely to be located in noneloquent brain areas compared with clinical strokes and that CBI etiological subtypes carry a differential risk of vascular events compared with people without CBI. Methods— We used brain magnetic resonance imaging from 1290 stroke-free participants in the NOMAS (Northern Manhattan Study) to evaluate for CBI. We classified CBI as cardioembolic (ie, known atrial fibrillation), large artery atherosclerosis (extracranial and intracranial), penetrating artery disease, and cryptogenic (no apparent cause). CBI localized in the nonmotor areas of the right hemisphere were considered noneloquent. We then evaluated risk of events by CBI subtype with adjusted Cox proportional models. Results— At the time of magnetic resonance imaging, 236 participants (18%) had CBI (144 [61%] distal cryptogenic, 29 [12%] distal cardioembolic, 26 [11%] large artery atherosclerosis, and 37 [16%] penetrating artery disease). Smaller (per mm, odds ratio, 0.8 [0.8–0.9]) and nonbrain stem infarcts (odds ratio, 0.2 [0.1–0.6]) were more likely to be covert. During the follow-up period (10.4±3.1 years), 398 (31%) died (162 [13%] of vascular death) and 117 (9%) had a stroke (99 [85%]) were ischemic. Risks of events varied by CBI subtype, with the highest risk of stroke (hazard ratio, 2.2 [1.3–3.7]) and vascular death (hazard ratio, 2.24 [1.29–3.88]) noted in participants with intracranial large artery atherosclerosis-related CBI. Conclusions— CBI can be classified into subtypes that have differential outcomes. Certain CBI subtypes such as those related to intracranial large artery atherosclerosis have a high risk of adverse vascular outcomes and could warrant consideration of treatment trials.

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