XVII. European Stroke Conference
Nice, France

Oral Session:

Heart & brain 
Date: Wednesday 14 May 2008  
Time: 16:30 - 16:40 -  Room: Calliope
Chair: J.L. Marti-Vilalta, Spain and K. Muir, United Kingdom

01
Population-based comparison of risk factors for ischaemic stroke versus acute coronary syndromes: identical twins or distant relatives?
A. Banerjee    L.E.Silver    C. Heneghan    S.J.V. Welch    Z. Mehta    P.M.Rothwell                            
 

Stroke Prevention Research Unit. Department of Clinical Neurology. University of Oxford

UNITED KINGDOM

BACKGROUND: Previous studies of risk factors for stroke versus acute coronary syndromes (ACS) are conflicting, and all have been potentially biased by selective ascertainment of cases. We performed the first ever population-based comparison, with complete case-ascertainment and no exclusion by age. METHODS: All incident or recurrent ischaemic strokes and TIA and all ACS (unstable angina and myocardial infarction) were identified in a prospective, population-based cohort (Oxford Vascular Study) from 2002-2007. The prevalence of known risk factors, co-morbid vascular disease and family history were compared. RESULTS: Among 1105 patients with TIA or ischaemic stroke and 948 with ACS, diabetes (OR 1.88, 95%CI 1.47-2.40, p<0.0001), hypercholesterolaemia (1.81, 1.49-2.20, p<0.0001) and current smoking (2.42, 1.91-3.07, p<0.0001) were more frequent in ACS, and hypertension (1.32, 1.11-1.57, p=0.001), atrial fibrillation (1.86, 1.45-2.40, p<0.0001) and family history of diabetes (4.00, 2.50-6.42, p<0.0001) were more frequent in stroke. Peripheral vascular disease was also more common in TIA and stroke than in ACS (2.78, 1.82-4.24, p<0.0001). All of these differences remained significant after adjustment for age and sex, and after restriction of the analysis to incident events only. DISCUSSION: In a prospective, population-based study, without exclusion by age, we found major differences in risk factors, co-morbid vascular disease and family history between acute ischaemic cerebral and coronary events. These findings have implications for prediction of vascular risk in primary prevention and for understanding differences in aetiology, and highlight the need for caution in interpreting composite outcomes for stroke and ACS in clinical trials and epidemiological studies.

Heart & brain 
Date: Wednesday 14 May 2008  
Time: 16:40 - 16:50 -  Room: Calliope
Chair: J.L. Marti-Vilalta, Spain and K. Muir, United Kingdom

02
Myocardial Scars are an Underestimated Cardiovascular Burden in Patients with ICA Stenosis
J.B.Fiebach    S. Goericke    P. Hunold    M. Lowitsch    J. Barkhausen    G. Sabin    M. Forsting    O. Bruder              
 

Charité - Universitätsmedizin Berlin

GERMANY

Background: Patients with internal carotid artery (ICA) stenosis have an increased incidence of coronary heart disease. Evidence about the incidence of clinically silent myocardial infarction (MI) in these patients is limited. Contrast-enhanced cardiac magnetic resonance (CMR) imaging allows for the detection of minor myocardial damage. Objective: We tested whether patients with ICA stenosis exhibit a relevant incidence of silent MI when assessed by CMR. Methods: In a single-center study, 77 consecutive patients (age 68 ±7 years) with suspected ICA stenosis were imaged prospectively with a combined MRI protocol including T1, T2, DWI, FLAIR, and CEMRA imaging of the brain and a short (11 minute) CMR protocol with left ventricular function and late gadolinium enhancement imaging. Blinded to any clinical information, two readers evaluated the cardiac and neuroradiologic examinations. Results: Of 154 imaged ICA, 85 presented with stenosis and 17 were occluded. In 7 patients, the suspected ICA stenosis could not be confirmed by CEMRA. In the remaining 70 patients with ICA stenosis, 34.3% had cerebral lesions (15.7% with a homodynamic pattern,18.6% with territorial infarction). CMR detected MI in 29 (41%) patients whereas ECG and medical history enabled diagnosis in only 7 (10%) patients. Conclusions: ICA stenosis patients have a higher incidence of myocardial scars proving silent MI when detected by contrast-enhanced CMR than clinicaly expected. Whether presence and extent of silent myocardial infarctions detected by CMR affect periinterventional risk and prognosis of ICA stenosis patients remains to be evaluated in a large patient cohort with long-term follow-up.

Heart & brain 
Date: Wednesday 14 May 2008  
Time: 16:50 - 17:00 -  Room: Calliope
Chair: J.L. Marti-Vilalta, Spain and K. Muir, United Kingdom

03
Microembolic signals (MES) are more frequent in Chagas disease than other causes of congestive heart failure (CHF): a transcranial Doppler study.
P.A.Jesus    I.S.N.Ribeiro    R.M.Vieira-de-Melo    C.C.S.Santos    D.M.Fonseca    D.F.Pereira    F.J.F.B.Reis    J. Oliveira-Filho              
 

Federal University of Bahia

BRAZIL

Background: Embolism is the major cause of stroke in patients with CHF. Chagas disease (CD) is an endemic disease in Latin America, where 18 million persons are infected and have CHF as the main presentation. In this study we aimed to determine the frequency of MES by transcranial Doppler (TCD) in patients with CHF due to CD (CHF-C) and compare to CHF from other etiologies (CHF-O). Methods: Case-control study, where patients with CHF from a specialty Cardiomyopathy Clinic, who were not receiving anticoagulant therapy, underwent a general clinical evaluation, neurologic scales (Mini Mental State Exam and NIH Stroke Scale), echocardiogram and electrocardiogram. TCD monitorization was then performed in all patients looking for MES in the middle cerebral artery during 60 minutes, by a single examiner who was blinded to all clinical, echocardiographic and electrocardiographic data. Multivariable logistic regression analysis was performed searching for predictors of MES in this population. Results: We studied 116 patients, 56.0% male, mean age 54 (+/-12) years (range 24 to 90 years), 47.4% with CHF-C. The mean ejection fraction was similar between patients with CHF-C and CHF-O (39.4% vs. 37.0% respectively, P=0.255). Patients with and without MES had similar mean ejection fraction (38.1% and 38.2%, respectively, p=0.708). MES occurred in 7 (13.2%) patients with CHF-C and only one (1.7%) with CHF-O (p= 0.026). In the multivariable analysis, CHF-C (OR=17.0; 95% CI=1.2-250.0, p=0.038) and stroke history (OR=7.9; 95% CI=1.2-53.8) were independently associated with the presence of MES. Discussion: MES occurrence is frequent in patients with CHF-C and was associated with history of stroke, suggesting that MES occurrence on TCD is a possible risk factor for stroke in these patients.

Heart & brain 
Date: Wednesday 14 May 2008  
Time: 17:00 - 17:10 -  Room: Calliope
Chair: J.L. Marti-Vilalta, Spain and K. Muir, United Kingdom

04
Immunoinflammatory predictors of stroke in patients with chronic non valvular atrial fibrillation (NVAF)
A. Pinto    A.  Tuttolomondo    D. Di Raimondo    A.  Casuccio    R.  Di Sciacca    G.  Licata                            
 

Biomedical Department of Internal and Specialist Medicine, University of Palermo

ITALY

Introduction: It is well-established that patients with nonvalvular atrial fibrillation (NVAF) are at risk for embolism, especially when their conditions are complicated with risk factors for embolism. Moreover inflammation and hypercoagulability markers are present in patients with NVAF. On this basis we hypothesized that increased plasma levels of citokines, selectins, adhesion molecules and Von Willebrand factor would be associated with an increased risk of stroke in patients with NVAF. To test our hypothesis, we undertook a prospective study to determine rates of stroke in patients with non valvular atrial fibrillation and compared plasma levels of these inflammatory variables to the occurrence of stroke during a three years follow-up. Matherials and methods : Patients with chronic NVAF admitted to our Department of Internal Medicine from 2000 to 2006 were consecutively enrolled. Blood samples were drawn within 72 hours from admission. We evaluated plasma levels of IL-1β, TNF-α, IL-6, IL-10, E-selectin, P-selectin, ICAM-1 and VCAM-1. Patient events (stroke at follow-up) were monitored. Results : We enrolled 373 (M/F: 237/136) consecutive patients with chronic NVAF. IL6 TNF-α, vWF and IL1β plasma levels at admission were significantly associated with new onset stroke at follow-up. At multivariate analysis high levels of IL6, TNF-α and vWF remained a significant predictor of an higher risk to experience ischemic stroke at follow-up. Moreover , IL6 and vWF showed a significative area under the ROCplasma values of TNF- curve Discussion: In our study we showed as baseline plasma levels of TNF-β, IL-6 and vWF are predictors of new onset ischemic stroke at follow-up in patients with chronic non valvular atrial fibrillation (NVAF) with a significatively higher predictive value than other laboratory and clinical variables.

Heart & brain 
Date: Wednesday 14 May 2008  
Time: 17:10 - 17:20 -  Room: Calliope
Chair: J.L. Marti-Vilalta, Spain and K. Muir, United Kingdom

05
PREvalence of asymptomatic CORonary disease in ISchemic stroke/TIA patients
D. Calvet    E. Touzé    O. Varenne    S. Weber    JL Sablayrolles    J.-L.Mas                            
 

Hôpital Sainte-Anne

FRANCE

Background The prevalence and predictors of asymptomatic coronary artery disease (CAD) in stroke/TIA patients are not well known. Methods We assessed the prevalence of asymptomatic CAD in consecutive patients (45–75 years) with recent non cardioembolic stroke/TIA and no history of symptomatic CAD, using 64-slice CT scanner. Asymptomatic CAD was defined by at least one coronary stenosis ≥ 50%. All stenosis ≥50% were confirmed by coronary angiography. Cervical/cerebral artery atherosclerosis was assessed by MR angiography and ultrasounds and classified as: absent, plaques, 20-49% stenosis and ≥50% stenosis. Results Preliminary analysis of 154 patients showed that 32 (21%) had asymptomatic CAD≥50%, 26 (17%) had plaques and 11 (7%) had 30-49% stenosis. Male gender (p<0.0001), smoking (p=0.013) and age (p=0.009) were associated with a higher prevalence of asymptomatic CAD. Asymptomatic CAD was 31% in patients with large artery atherosclerosis (TOAST), 17% in those with small vessel disease and 19% in those with undetermined cause (p=0.31). The prevalence of asymptomatic CAD≥50% was 4% in patients with no cervical/cerebral atherosclerosis, 11% in those with plaques only, 36% in those with at least one 20-49% stenosis and 32% in those with at least one ≥ 50% stenosis (p<0.0001). After adjustment for age, gender and smoking, the presence of at least one ≥ 20% cervical/cerebral artery stenosis (OR=5.3, 1.8-15.5), but not its severity, remained strongly associated with asymptomatic CAD ≥50%. Discussion About one fifth of ischemic stroke or TIA patients have asymptomatic CAD≥50%. In addition to traditional risk factors, the presence (but not the severity) of cervical/ cerebral artery stenosis is a strong predictor of CAD.

Heart & brain 
Date: Wednesday 14 May 2008  
Time: 17:20 - 17:30 -  Room: Calliope
Chair: J.L. Marti-Vilalta, Spain and K. Muir, United Kingdom

06
Frequency of atrial septal abnormalities in older patients with cryptogenic ischemic stroke or transient ischemic attack
M. Force    P. Massabuau    V. Larrue                                                 
 

CHU de Toulouse Hopital Rangueil

FRANCE

Objective To evaluate the association of atrial septal abnormalities – patent foramen ovale (PFO), atrial septal aneurysm (ASA), or the combination of both (PFO+ASA) – with cryptogenic stroke or transient ischemic attack (TIA) in older patients. Methods We examined the prevalences of PFO, ASA, and PFO+ASA in 132 consecutive patients aged 55 years or more who underwent transesophageal echocardiography (TEE) for evaluation of ischemic stroke or TIA. We compared patients with cryptogenic stroke/TIA and those with stroke/TIA of known cause. Results PFO+ASA was more common in patients with cryptogenic stroke/TIA than in patients with stroke/TIA of known cause (12/62 or 19 % vs 2/70 or 3 %; odds ratio adjusted for age, 9.6; 95 % CI 1.9 to 48.9). Differences between groups for isolated PFO, and isolated ASA were not significant. The association of PFO+ASA with cryptogenic stroke/TIA was confirmed in the subgroup of patients aged 75 years or more (odds ratio, 15.0; 95 % CI, 1.5 to 146.7) Conclusion This study indicates a significant association of PFO+ASA with cryptogenic stroke or TIA in older patients.