XVII. European Stroke Conference
Nice, France
XVII. European Stroke Conference
Nice, France
Poster Session: Etiology of stroke
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Impact of Cardiac Evaluation in the SOS-TIA Clinic
T. Slaoui
P.C.Lavallee
J. Labreuche
C. Guidoux
E. Meseguer
L. Cabrejo
H. Abboud
M. Mazighi
E. Brochet
P. Amarenco
Service de Neurologie du Pr Pierre Amarenco
Hopital Bichat
Rue Henri-Huchard
75018 Paris
FRANCE
Background: The cause of transient ischemic attack (TIA) or minor stroke is unknown in up to 40% of patients. Major cardiac sources of embolism (MCSE) and aortic arch atherosclerosis (AAA) are potential causes. Methods: 1,085 consecutive patients with a suspicion of TIA were admitted to the SOS-TIA clinic with round-the-clock access, immediate evaluation and multifactorial therapeutic intervention. We studied the prevalence of cardiac abnormalities and MCSE (TOAST criteria) in 701 patients with definite TIA or minor stroke. Electrocardiography (ECG), transthoracic and transesophageal echocardiography (TTE, TEE) were available in 96% (n=674), and 77% (n=537) of patients, respectively. Results: Admission ECG detected abnormalities in 11% of 674 patients. Overall, 10% (n=67) of patients had atrial fibrillation (AF) of which 30 were new diagnosis (16 at admission and 14 during the follow-up). Cardiac abnormalities were detected in 68% of 479 patients with both TTE and TEE, and in 50% of 58 patients with TTE only (p<0.01). Significant AAA (plaque > 4 mm or thrombus) was detected in 14% and MCSE other than AF in 2% (3 mural thrombus, 3 dilated cardiomyopathy, 3 fibroleslatoma, 2 mitral stenosis, 1 thrombus on prosthetic heart valve). Overall, MCSE other than AF (including 5 patients with a history of prosthetic valve and 1 recent myocardial infarction) were found in 3%. Atrial septal abnormalities (PFO and/or ASA) were detected in 19% of patients. There was no difference in the prevalence of cardiac abnormalies between groups with minor stroke, TIA with brain tissue damage, or TIA without brain tissue damage. Conclusions: In addition to atrial fibrillation, AAA, atrial septal abnormalities and MCSE were common. The therapeutic impact of these findings remains to be evaluated.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Variants in the VKORC1 gene are not associated with cerebral ischemia or white matter disease
R. Lemmens
W. Robberecht
A. Goris
V. Thijs
KULeuven, Leuven
BELGIUM
Background: Common variants within the gene encoding the vitamin K epoxide reductase complex subunit 1 (VKORC1) have recently been implicated in susceptibility to arterial and venous disease. We investigated whether these variants were also associated with transient ischemic attack (TIA) or stroke and with white matter disease in a case-control study in a Belgian population. Methods: A total of 317 TIA or ischemic stroke patients and 564 controls were genotyped for VKORC1 SNP +2255 (rs2359612), a SNP differentiating between common functional VKORC1 haplotypes. Patients were imaged using brain magnetic resonance imaging (MRI) scans and white matter disease was examined on fluid attenuated inversion recovery (FLAIR) MRI using a semiquantitative rating scale. Results: Allele frequencies for the proposed risk allele C did not differ between cases and controls, 60.2% and 62.0% respectively (P=0.46). Similarly, no association with cerebrovascular disease was observed after correcting for age and gender nor when considering genotype frequencies. Furthermore, variation in the VKORC1 gene was not associated with white matter disease (OR: 1.11; 95%CI 0.61-2.00). Conclusions: In a Belgian study population, we were unable to replicate the association between VKORC1 genotype and cerebrovascular disease that has previously been reported. Moreover, we did not observe an association between white matter disease and variants in the VKORC1 gene. We additionally performed a meta-analysis of the different studies in venous and arterial diseases and found no association of variants in the VKORC1 gene and vascular disease. Ethnical differences in genetic risk factors may be at play to explain the results in various populations.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Thrombin generation is higher in young patients with cryptogenic stroke
F.O.Lima
M.K.Parides
D.M.Greer
G.S.Silva
K.L.Furie
Massachusetts General Hospital, Boston-MA
USA
Background: The etiology of stroke in young patients is often due to unusual mechanisms. Many young patients do not have a clear stroke subtype (e.g. large artery or cardioembolic) identified, and are classified as “cryptogenic”. A hypercoagulable state is often considered in the course of the evaluation of these patients, but is rarely found. We measured prothrombin fragment F1.2 level to evaluate the degree of thrombin generation in young patients with cryptogenic stroke. Methods: Nine hundred and eighteen consecutive ischemic stroke cases presenting to a single academic medical center were enrolled in a stroke biomarker study. Detailed clinical data concerning stroke characteristics, demographics, medical history, and medications were obtained at baseline, discharge, and at 6 month follow-up. Bloods were drawn at baseline and 6 months. We measured prothrombin fragment F1.2 using an ELISA method in the 6-month samples. Results: We identified 101 patients age 50 years and younger. Of these, 65 (65%) had no identifiable mechanism and were classified as “cryptogenic”. F1.2 was significantly higher in subjects with cryptogenic stroke (0.8 nmol/L) compared with non-cryptogenic (0.29 nmol/L) mechanism (p=.03). Discussion: Younger patients with cryptogenic stroke have higher levels of thrombin formation, suggesting an underlying prothrombotic tendency. F1.2 may be useful in the diagnosis and management of young cryptogenic stroke patients. Additional data are needed to determine if higher levels are associated with increased risk of stroke recurrence.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Infarct pattern on diffusion weighted image in cardioembolic stroke: Atrial Fibrillation vs. Patent Foramen Ovale
J.H.Rha
J. Lee
K.H.Ji
Inha University Medical College
SOUTH KOREA
Background and Purposes: Atrial fibrillation (AF) is an established source of cardioembolism, but the exact mechanism of cerebral infarct in the patent foramen ovale (PFO) is still controversial. To find the differences between these two cardiac conditions, we compared the acute infarct pattern. Method: Acute ischemic stroke patients were screened to have PFO by transcranial Doppler right to left shunt study. MRI including diffusion weighted image (DWI) were performed in all the patients. The infarct pattern was classified as: TIA (no DWI lesion), Lacune (single, deep infarct < 2 cm), SVTI (single vascular territory infarct, infarct can be either single or multiple within the territory), MVTI (multiple vascular territory infarct, not explained by single vessel lesion, such as bilateral infarct or both anterior and posterior circulation infarct). Symptomatic stenosis or occlusion of relevant (underlying or proximal tandem) artery was also investigated by MR angiography. Presence of atrial fibrillation was determined by electrocardiography. Transthoracic echocardiography was also performed in all the patients. Result: From June 2004 to July 2007, 1653 acute ischemic strokes were screened and 133 PFO and 156 AF patients were identified. The infarct pattern of PFO was: TIA 16%, Lacune 20%, SVTI 43%, MVTI 22% and that of AF was: TIA 2%, Lacune 2%, SVTI 57%, MVTI 39% respectively (p<0.01). SVTI with no relevant arterial stenosis/occlusion and MVTI and were regarded as cardioembolic pattern, and the proportion were 55/133 (41%) in PFO and 101/156 (65%) in AF (p<0.01). Conclusion: In AF, cardioembolism is the major cause of cerebral infarct, but in PFO, though substantial portion shows cardioembolic pattern, mechanism other than the paradoxical embolism should be also considered.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Atrial fibrillation detection in paced patients, a multicentric retrospective study
F.-Corea
G. Silvestrelli
S. Micheli
M. Paciaroni
M. Spinelli
M. Venti
A. Baldi
G. Agnelli
P. Previdi
G. Comi
INSPE, IRCCS San Raffaele Milano
ITALY
Introduction: Worldwide, millions of people with cardiac arrhythmias have been treated with pacemakers. The prevalence of AF is particularly high in patients with permanent pacemaker. ECG recognition of the underlying rhythm in patients who have dual chamber pacing can be difficult without a switching off the device. The growth in use of cardiac pacing will increase the need of awareness for the possibility of unrecognised AF. Objective: Objective of our study was to test the detection of AF on ECG at the admission in paced patients in different types of device Method: Inclusion criteria were suffering for a TIA or stroke and having an implanted device. The pre-stroke therapy together with ECG findings at admission, vascular risk factors as well as secondary prevention therapy were recorded. For this purpose the databases of a 2-year period were retrospectively reviewed in 3 centres (Mantova, Milano, Perugia). Results: Seventy-six patients were included: 46 were males the median age was 77 ranging from 56 to 92. Fifty-two subjects (68.4%) were hypertensive, 11 (14%) had diabetes, 31 (40.7%) AF history. Before the index event 32 (42%) were treated with aspirin, 10 (13.1%) with anticoagulants, 5 (6.5%) with other antiplatelet agents. In the study population 54 subjects (71%) suffered from an ischemic stroke, 4 (5.2%) a hemorrhagic stroke and 16 (21%) a TIA. AF was observed at admission in 24 (31%) cases: 5 AF out of 24 subjects with dual chamber pacing (DDD), and in 19 out of 39 subjects on single chamber pacing (VVI). At the univariate analysis we found baseline ECG-detected AF as associated with VVI pacing (p<0.05). The use of anticoagulants at discharge was found associated only to AF history (p<0.05). Conclusions: In our study AF is found associated to VVI pacing. Presumably DDD patients are not spared by AF episodes, they simply need a deeper test of the device to asses the real underlying rhythm. A tailored analysis of cardiac rhythm could provide indication for the use of anticoagulation.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
POSTPARTUM CEREBRAL ANGIOPATHY ASSOCIATED WITH CARBEGOLINE THERAPY.
P. Cardona Portela
R. Velasco
L. Bau
A. Escrig
J. Sanchez
C. Majos
F. Rubio
Bellvitge University Hospital. Department of Neurology. IDIBELL. Barcelona
SPAIN
INTRODUCTION Postpartum cerebral angiopathy (PCA) is a rare reversible cerebrovascular disorder . Drugs as ephedrine or bromocriptine has been related with PCA associated to vasospastic effect. Carbegoline also may induce cerebral angiopathy PATIENTS We report two cases of postpartum women who presented with headaches, seizures and visual disturbances. Carbegoline was prescribed to prevent postpartum breast engorgement, 3 to 4 days before initial symptoms. MRAngiogram excluded cerebral venous thrombosis(CVT), brain MR revealed multiple abnormal areas of increased signal in the cortex and basal ganglia. Occipital and parietal lobes showed most number of cortical signals. Brain stem and cerebellum were also affected in both patients. Transcranial doppler showed diffusely elevated velocities suggesting vasoconstriction. Treatment with nimodipine was initiated to improve possible vasospasm. Radiological and clinical abnormalities were reversible 10-14 days after admission. DISCUSSION The presenting symptoms of PCA occurs within the early postpartum period and includes recurrent headaches, altered conscienciousness and focal neurological signs. Diagnosis requires reversible radiological and clinical findings and exclusion of alternative diagnosis such as eclampsia or CVT. The pathogenesis of PCA is unknown, it is suggest a form of reversible cerebral vasoconstriction. Recently ergotics as bromocriptine or ergovine has been associated to PCA and heart attack, and therefore is avoided during postpartum, but there aren´t any reports of carbegoline. CONCLUSION PCA is a reversible cerebral arterial vasoconstriction syndrome and it´s a diagnosis of exclusion. Carbegoline used for lactation suppression is associated with PCA. It can precipitate or aggravate vasospasm in early postpartum.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Unruptured Intracranial Artery Aneurysm Revealed by Cerebral Ischemia
L. Calviere
A. Viguier
N.A.da Silva
V. Larrue
University hospital Rangueil Toulouse
FRANCE
Background and purpose: The discovery of unruptured intracranial aneurysms in patients with ischemic stroke often raises a diagnostic and therapeutic challenge due to the difficulty to affirm a causal relationship between aneurysm and cerebral ischemia. Methods: From September 1999 to September 2007 we prospectively analyzed consecutive patients with transient ischemic attack (TIA) or ischemic stroke, unruptured aneurysm of the symptomatic cerebral artery, and no other potential cause of cerebral ischemia. All patients had magnetic resonance imaging (MRI) and/or conventional angiography. Transcranial doppler continuous monitoring of the symptomatic middle cerebral artery for microembolic signal (MES) detection was performed in 10 patients. Results: 15 patients (5 men and 10 women) were included. Mean age was 49.7 y (range, 37 to 80 y). Five patients presented with TIA and 10 with stroke. Six aneurysms were located on the middle cerebral artery, 2 on the anterior cerebral artery, and 7 on the internal carotid artery. The median diameter of aneurysm was 7.5 mm (range, 2.5 to 23 mm). Aneurysm thrombosis was found in 10 (66.6%) patients. Aneurysm thrombosis was partial in 7 patients and complete in 3 patients. MES were detected in 2/10 patients. The aneurysm was treated in 8 patients (embolization in 6 patients, surgery in 2 patients). The seven remaining patients were given antiplatelet agents. Mean follow-up was 607 days. There was no ischemic recurrence. Partial or complete recanalization of aneurysm thrombosis on repeat MRI or angiography occurred in 7 patients (70%). Two patients, both with initial aneurysmal thrombosis, experienced aneurysm rupture at day 6 and 182, respectively. Conclusion: Unruptured cerebral artery aneurysm can be revealed by cerebral ischemia. Aneurysm thrombosis is a dynamic process with frequent partial or complete recanalization. Risk of ischemic recurrence seems to be low. In contrast, aneurysm rupture may occur despite initial thrombosis. Thus, early treatment of aneurysm should be considered in these patients.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Is cerebral vasospasm the cause of “crack” cocaine-related ischemic strokes?
M.A.TAQI
E.A.GIRALDO
UNIVERSITY OF TENNESSEE
USA
Objective: To study the mechanism and prognosis of ”crack”cocaine-related ischemic strokes. Methods: Retrospective chart review of stroke patients admitted at the Regional Medical Center of Memphis. Results: Charts of 1219 consecutive stroke patient admitted between Jan 2001 and May 2006 were reviewed. 57 patients had ischemic stroke in the setting of recent cocaine abuse. 65% were male and the mean age was 48 years. Based on clinical and imaging findings, 75.4% had “other” stroke subtype, 8.8% had large-artery atherosclerosis, 7% had cardioembolic stroke, and 3.5% had small-artery occlusion. According to the OCSP classification of brain infarction, 72.2% had partial anterior circulation infarcts (PACI) and 20.4% had lacunar infarcts (LACI). In terms of arterial distribution, about 88% of patients had stroke in the middle cerebral artery (MCA) territory. The functional outcome scales used in the study indicate that these strokes were mild (mean admission NIHSS=5.5) except for 2 deaths and few patients with NIHSS > 18 in this group of patients. Conclusion: Strokes related to “crack” cocaine abuse are prevalent in our population. These results suggest that large or small artery diseases are not common in this cohort. CNS vasculitis although cannot be ruled out completely without brain biopsy but based on symptomatology and normal imaging findings, it is a very unlikely cause of stroke in “crack” cocaine abusers. Cardio-embolic source is another potential etiology but again none of these patients had bilateral or multifocal infarct and none of the patient had arrhythmias on telemetry, to suggest cardioembolic source as a potential cause. Based on these findings, we suggest that the most likely cause of stroke in these patients is cerebral vasospasm. This hypothesis is supported by the fact that most ischemic strokes were in the MCA distribution without evidence of arterial occlusion, and patients had mild strokes with low NIHSS, and therefore, good functional outcome without rt-PA use.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Vascular imaging follow-up of 14 young adults with stroke and unilateral intracranial large-artery arteriopathy
M.M.Bulder
J.W.Leeuwis
T.H.Lo
L.J.Kappelle
O. van Nieuwenhuizen
K.P.Braun
C.J.Klijn
Departments of Neurology and Child Neurology, University Medical Center Utrecht
THE NETHERLANDS
Background: The majority of children with arterial ischemic stroke (AIS) suffer from non-atherosclerotic arteriopathies, of which most are unilateral, intracranial and non-progressive (transient cerebral arteriopathy (TCA)). TCA is often preceded by chickenpox and is presumably caused by monophasic arterial wall inflammation. In young adults, causes, course and outcome of unilateral intracranial large-artery arteriopathy are unknown. Methods: We screened all young adults (age 16-50) with anterior circulation AIS, registered in the Utrecht Stroke Database between 1991 and 2005, for the presence of unilateral intracranial large-artery arteriopathy. Clinical and radiological characteristics of the stroke were reviewed. Long-term angiographic course of arteriopathy was studied by repeated MRA of the circle of Willis, and clinical outcome was assessed. Results: Eighteen of 357 patients (5%) fulfilled the inclusion criteria, of whom 14 could be included. Mean age at the time of AIS was 37 years (range 27-49), 6 patients were male and the mean follow-up duration was 108 months (range 20-153). In 8 patients the arteriopathy involved only the proximal MCA. Involvement of the terminal ICA occurred in 1 patient. Both MCA and ICA were involved in 1 patient and all three arteries in 4 patients. Repeated MRA revealed improvement of the arteriopathy in 10 of 14 patients (71%), of whom 3 showed complete normalization. Two had recurrent stroke or TIA within 1 month after AIS, none had late recurrences. Eleven patients (79%) had a good outcome with a modified Rankin Score of ≤2. Discussion: In contrast to children, AIS in young adults is rarely caused by a unilateral intracranial arteriopathy. In the majority of patients, in contrast to what would be expected from atherosclerotic lesions, arteriopathy improved over time. Late recurrences did not occur and clinical outcome was good. Possibly, an inflammatory process (similar to childhood TCA) may also cause unilateral intracranial arteriopathies in young adults.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Patent Foramen Ovale is not associated with Embolic Lesion Pattern in MRI
R. Feurer
S. Sadikovic
L. Esposito
K. Holzer
A. Bockelbrink
D. Sepp
P. Heider
B. Hemmer
H. Poppert
Technical University Munich
GERMANY
Background – Despite numerous preceding studies the role of Patent Foramen Ovale (PFO) as a risk factor for stroke due to paradoxical embolism is still controversially discussed. Based on the assumption that specific lesion patterns and in particular multiple acute ischemic lesions on diffusion-weighted magnetic resonance imaging (DWI-MRI) indicate an cardioembolic origin, we compared the MRI findings in stroke patients with right-to-left shunt (RLS) and those without. Different prevalences of further known causes of cardiac embolism like atrial fibrillation in both groups would bias our results. These data were therefore also analyzed and considered in our calculations. Methods – The records of 486 consecutive patients with definite diagnosis of stroke who were investigated between January 1997 and December 2005 at our institution were reviewed. For detection of right-to-left shunt contrast-enhanced transcranial Doppler (c-TCD) was carried out in all patients. Stroke origin was subtyped using the TOAST classification criteria. An MRI scan of the brain was performed using a superconducting magnet at a field strength of either 1.0 T or 1.5 T. Affected vascular territories were divided into anterior cerebral artery, middle cerebral artery, posterior cerebral artery, brain stem, cerebellar, and strokes occurring in more than one territory. Results – We did not find a specific difference in neuroradiological lesion patterns in patients with RLS compared with patients without. In particular 23 patients (4.7%) with RLS showed multiple ischemic lesions in MRI in comparison with 45 patients (9.3%) without RLS (p = 0.98). Furthermore we did not find a significant difference in prevalence of atrial fibrillation between both groups (p = 0.93). Conclusion – There was no association between an ischemic lesion pattern that is considered as being typical for stroke due to cardiac embolism and the existence of PFO. Therefore our data provide a strong argument against the common theory of paradoxical embolism as a major cause of stroke in PFO carriers.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Ischemic Lesion Patterns in Stroke Patients with Right-to-Left Shunt compared with Patients having Atrial Fibrillation
J.-H.Lee
H.-K.Song
J.-H.Shin
W.-K.Kim
D.-J.Oh
K.-R.Han
D.-G.Park
J.-H.Lee
D.-H.Yoon
S.-E.Kim
College of Medicine, Hallym University
SOUTH KOREA
Background: Right-to-left shunt (RLSh) such as patent foramen ovale (PFO) may a possible cause of embolic stroke. Diffusion weighted imaging (DWI) is helpful in understanding of stroke mechanism. The aim of this study was to compare ischemic lesion patterns on DWI in stroke patients having RLSh with them in patients with atrial fibrillation (AF). Methods: 236 consecutive patients with ischemic stroke were investigated by use of DWI. Transthoracic echocardiography with second harmonic imaging was performed for the evaluation of RLSh. We excluded patients with stenosis ≥ 50% or occlusion in the clinically relevant extracranial or intracranial arteries. In the remaining 165 patients, we selected 25 patients with AF and 69 with RLSh only, and analyzed their lesion patterns on DWI. Infarct lesions were classified as non-embolic pattern (single infarct < 2cm in the territory of perforating arteries, lacunar infarct pattern) and embolic pattern (other single infarct, scattered infarcts in one vascular territory, or multiple infarcts in multiple vascular territories). Results: The incidence of embolic lesion pattern was higher in patients with AF than patients with RLSh only (80% vs. 53.6%, p=0.021). The incidence of hypertension was significantly higher in patients with non-embolic lesion pattern (lacunar infarct pattern) than patients with embolic pattern (91.9% vs. 59.6%, p<0.01). Age, sex, smoking, diabetes, and hyperlipidemia were not correlated with ischemic lesion patterns. Discussion: This study suggests RLSh including PFO may have much lower embolic burden than AF. Small vessel disease may be common stroke mechanism in patients with RLSh.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Young women’s stroke etiology differs from that in young men. An analysis of 511 patients.
M. Hoffmann
L. Benes Cases
University of South Florida, Tampa, Florida
USA
Background: Women have particular heterogeneity in stroke etiology. Without accurate causal determination more strokes are likely to follow. Aim: Young women’s stroke etiology incorporating contemporary brain and cardiac imaging. Methods: Young stroke people (18-49y) tested by multimodality MR imaging, angiography, cardiac echo, stroke blood investigations, cause classified by an expanded TOAST classification and neurological deficit by NIH stroke scores. Results: In 511 young stroke patients, (women, n=269, 53%, mean age 39.8 y, CI: 39.1;40.7), the etiological categories (women; men, Chi-square p-value) included 1. small vessel disease (30/55;25/55, p=NS), 2. cardioembolic (16/42;26/42, 3.9, p=0.05), 3. large vessel disease (24/43;19/43, p=NS), the “other” category (132/226; 91/226, p=0.01), which included, 4. substance abuse (15/41; 26/41, p=0.05), 5. prothrombotic states (22/37;15/37, p=NS), 6. dissection (11/30;19/30, p=NS), 7. cerebral venous thrombosis (15/19; 4/19, p=0.001), 8. vasculitis (8/12; 4/12, p=0.001), 9. migraine related (10/11, 1/11, p=0.02), 10. miscellaneous vasculopathy (38/52;14/52, p=0.01), 11. intracerebral hemorrhage (43/106; 63/106, p=0.01) and 12. undetermined etiology (6/10; 4/10, p=NS). Mean NIHSS in women, men (4.7; 6.0 t=1.8, p=0.03). Conclusion: Young women’s stroke differs from men in 8/12 etiological categories and 4 unique subtypes require specific management.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Ischemic lesions in patients with migrainous stroke are underestimated: a DWI/ADC study
M.E.Wolf
K. Szabo
M. Griebe
A. Förster
A. Gass
M.G.Hennerici
R. Kern
Universitätsklinikum Mannheim, University of Heidelberg
GERMANY
Background: Migrainous infarction is considered a rare complication of migraine with aura, particularly in young women. However, good imaging studies are scarce and the distribution of acute lesions is unknown. Methods: We studied 8 patients (7 women, 1 man, mean age 31.5+/-10.6 years) presenting with acute migrainous stroke according to the diagnostic criteria of the International Headache Society (IHS). MRI including diffusion weighted imaging (DWI/ADC) was analyzed to characterize infarct patterns (size, number and location of the lesions). In 6 of 8 cases MR perfusion imaging (PI) was additionally evaluated. Risk factors including screening for PFO were obtained. Results: Acute ischemic lesions were predominantly located in the posterior circulation territory (5/8 cases in the PCA territory with additional lesions in the brainstem or in the cerebellum in 2 cases). In 3/8 patients the MCA territory was affected. 2 patients had severe territorial PCA infarctions extending in large parts of the territory with signs of hypoperfusion on PI. All others were punctuate. 4 patients had multiple DWI lesions. A PFO was detected in 5/8 cases. Conclusions: This study supports previous observations that migrainous infarctions mostly occur in the posterior circulation. Cardiac embolism (PFO) causes tiny and multiple lesions that may remain undetected using conventional imaging. DWI is useful in the discrimination between aura symptoms and migrainous stroke.
http://www.eurostroke.org/ni_graphics/g_aid530.htm
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Multiple vertebro-basilar infarcts and Erdheim-Chester disease
G. GODENECHE
P. ARDILOUZE
V. AUCHE
J.P.NEAU
CHU POITIERS
FRANCE
Erdheim-Chester disease (ECD) is a rare non Langerhans form of histiocytosis of unknown origin, characterized by systemic manifestations (osteosclerosis, cardiovascular and neurological involvement). In April 2007, a 59-year old woman developed a severe arterial hypertension due to bilateral stenoses of renal arteries treated by angioplasty and aorto-renal bypass. Since 2002, she suffered from a moderate hypertension and had a persistent biologic inflammation of unknown origin. In August 2007, she was referred to our neurological department for sudden cortical blindness associated with memory impairment. Cerebral-MRI revealed multiple vertebro-basilar ischemic stroke, due to a severe narrowing of the basilar artery (median part). She had a severe biologic inflammation (first-hour ESR =114mm). Cardiovascular explorations (transoesophageal echocardiography, CT scan and MRI) revealed a periaortic infiltration, a pericardial effusion, and a right atrial tumour. ECD was suspected and a 99Tc bone scintigraphy showed bilateral symmetrical abnormal increased labelling of the long bones of the lower limbs. The diagnosis was histologically confirmed by sinuses biopsy and alpha interferon treatment was initiated. Three months later, clinical outcome was favourable. The biological abnormalities decreased to a nearly normal range. Cardiovascular explorations showed partial regression of atrial infiltration and complete regression of periatrial effusion. Cerebral MRI showed important regression of basilar stenosis (50% versus prethrombotic). This observation is the first reported case of ECD revealed by a cerebral infarct associated with basilar stenosis. The improvement of the basilar stenosis under specific treatment confirmed that it was due to xanthogranulomatous infiltration.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Coagulation Activation, Fibrinolysis and Inflammation in Ischaemic Stroke Subtypes.
F.N.Doubal
A. Rumley
G.D.Lowe
M.S.Dennis
J.M.Wardlaw
University of Edinburgh
UNITED KINGDOM
Introduction: Lacunar stroke accounts for 25% of all ischaemic stroke. The aetiology remains unclear but may be related to microvessel endothelial activation or inflammation. We examined plasma markers of coagulation activation, fibrinolysis and inflammation, in the chronic phase, to see if lacunar differed from large artery stroke. Methods: We prospectively recruited patients with lacunar or mild cortical stroke, diagnosed and subtyped based on clinical assessment by an experienced stroke physician and magnetic resonance imaging (which were also rated for leukoaraosis with the Fazekas method). Blood samples were taken at least 1 month after stroke to avoid the acute phase. We measured thrombin anti thrombin III complex (TAT), von-Willebrands factor (vWF), D-dimer, fibrinogen, F1+2, tissue plasminogen factor (t-PA), tumour necrosis factor alpha (TNF alpha), C-reactive protein (CRP) and interleukin-6 (IL-6) as markers of coagulation, fibrinolysis and inflammation respectively. All patients gave written informed consent and the study had ethical approval. Results: We recruited 110 patients (53 cortical, 57 lacunar), mean age 66 years (SD 11). The cortical stroke patients were older (mean 69.4 yrs SD 10 v 64.1 SD 12, cortical v lacunar, p=0.01) but there were no differences in time to blood sampling (median 55 v 58 days), hypertension (66% v 61%) or leukoaraiosis (chi square test for trend p=0.7). Plasma t-PA was significantly higher in cortical versus lacunar stroke (median: cortical 8.04, lacunar 6.63, difference 1.14, 95% CI 0.11-2.25, p=0.03 Mann Whitney U). There were no differences between subgroups in vWF, D-dimer, fibrinogen, F1+2, TNF alpha, CRP or IL-6 levels. Conclusion: t-PA is raised in large artery compared with lacunar stroke but other markers do not differ suggesting that at a median of 55 days post ischaemic stroke there is no difference in either inflammation or coagulation activation. T-PA levels reflect vascular injury suggesting that vascular injury may be more prominent in cortical than lacunar stroke patients.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Frequent Atrial Premature Beats and carotid circulation Diffusion abnormality predict Paroxysmal Atrial Fibrillation on Transtelephonic ECG after Cerebral ischemic events
N. Gaillard
S. Deltour
B. Vilotijevic
A. Hornych
S. Crozier
A. Leger
R. Frank
Y. Samson
University Hospital Pitié Salpétrière, Paris
FRANCE
Objective:to identify predicting factors associated with paroxysmal atrial fibrillation (PAF) on Transtelephonic ECG monitoring (TTECG) in patients after a cerebral ischemic event (CIE).Background: PAF is underdiagnosed after a CIE because Holter is poorly sensitive and we previously investigated the sensitivity of TTECG, which is an ambulatory patient-activated hand-held electrocardiograph, not requiring permanently attached electrodes, in stroke patients. We therefore aimed to identify both predicting factors associated with PAF diagnosed on TTECG after a CIE, and a high risk subgroup of patients requiring a further TTECG monitoring when conventional etiological investigations are negative. Methods:9 patients (9.2%) out of 98 consecutive patients after a CIE with no prior history of PAF and a negative standard and 24-hour holter ECG and no other cardioembolic condition had PAF on TTECG ambulatory monitoring (median duration of 1 month and number of TTECG of 25). We then conducted a uni- and multi-variate analysis to identify predicting factors associated with PAF on TTECG among 78 patients with ischemic stroke (n =63) or transient ischemic attack (n=15), including the 9 patients with PAF.Results: In a stepwise logistic regression analysis including three univariate independent variables (DWI carotid abnormality; > 100 atrial premature beats (APB) / 24h, and > 1 episode of >3 consecutive AEB on Holter), predictive factors were a DWI carotid abnormality (OR=22.2; 95 % CI: 2.2-227, p = 0.009), and > 100 APB on Holter (OR=21.1; CI: 3.2-137, p=0.001). We then tested a simple scoring system ranging from 0 to 2, with one point for DWI carotid abnormality and one point for > 100 APB. The ROC curve had an AUC of 0.860 (95 % CI: .763-.928, p=0.0001). Score 1 had a 17.3 % PPV and a 100 % NPV, and score 2 had a 54.5 % PPV and a 95.5 % NPV. Conclusion: DWI acute abnormality in the carotid artery territory and/or more than 100 APB on Holter are associated with a high risk of PAF on TTECG after a CIE. These patients should therefore especially benefit from TTECG monitoring.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Analysis of hepatic lipase gene promoter 514C/T polymorphism in Shanghai Han patients with cerebral infarction by using PCR-RFLP
Y. Fu
P.H.Ni
Y.Y.Ying
J.R.Liu
S.D.Chen
Department of Neurology，Ruijin Hospital，School of Medicine，Shanghai Jiaotong University
CHINA
Objective To investigate the correlation between hepatic lipase gene promoter 514C/T polymorphism and cerebral infarction in Shanghai Han population. Methods The genotype of the hepatic lipase gene promoter 514C/T was detected in 133 patients with cerebral infarction in Shanghai, Chinese Han and 75 healthy elders by using the polymerase chain reaction-restricted fragments length polymorphism technique (PCR-RFLP). The effect of the gene polymorphism on serum lipid level was also studied. Results The significant difference was found in the frequencies of the genotypes and the alleles between cerebral infarction and healthy elders. In the group of cerebral infarction, the serum triglyceride levels in individuals with T allele were higher than those in individuals without T allele(2.21±1.45 mmol/L vs 1.68±0.72 mmol/L), but the serum high-density lipoprotein cholesterol levels were lower(1.17±0.26 mmol/L vs 1.29±0.33 mmol/L, P<0.05). The serum triglyceride levels in the group of cerebral infarction with T allele were higher than those in the group of healthy elders with T allele(2.21±1.45 mmol/L vs 1.69±0.61 mmol/L), and the serum low-density lipoprotein cholesterol levels in the group of cerebral infarction without T allele were higher than those in the group of healthy elders without T allele(3.30±1.00 mmol/L vs 2.87±0.82 mmol/L). Logistic regression analysis showed that systolic pressure, serum glucose and T allele were independent risk factors for cerebral infarction. Conclusion Hepatic lipase gene promoter 514C/T polymorphism is directly related to cerebral infarction. In addition, －514C/T gene polymorphism in patients with cerebral infarction may influence triglyceride and high-density lipoprotein cholesterol levels, which proves that the hyperlipemia has close relationship with some gene mutations in cerebral infarction.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Lacunar Stroke is Associated with Increased Blood Brain Barrier Permeability.
F.N.Doubal
M.S.Dennis
J.M.Wardlaw
University of Edinburgh
UNITED KINGDOM
Introduction The exact aetiology of lacunar stroke is uncertain but might occur subsequent to, or be associated with increased blood brain barrier (BBB) permeability. Magnetic resonance (MR) Fluid Attenuated Inversion Recovery (FLAIR) imaging after intravenous gadolinium (Gd) is very sensitive to BBB leak by showing visible cerebrospinal fluid (CSF) enhancement. Methods We prospectively recruited patients presenting with lacunar or cortical stroke. Stroke was diagnosed and subtyped by an expert stroke physician based on clinical information and diagnostic MRI. Gd enhanced FLAIR MR was performed at least one month after stroke to avoid BBB changes due to acute stroke. CSF enhancement on FLAIR was graded as definitely/possibly/not present by an experienced neuroradiologist blind to stroke subtype. We coded white matter disease scores with the Fazekas method. All patients provided written informed consent and the study had local ethical approval. Results We included 16 patients (9 lacunar, 7 cortical), mean age 65 years (SD 10) and mean NIHSS score of 3. White matter disease scores, age and presence of hypertension and diabetes did not differ between the 2 groups. CSF enhancement on FLAIR post Gd was not associated with time to scan or white matter disease score. Significantly more lacunar stroke patients had CSF enhancement on FLAIR post Gd than did those with cortical stroke. Of the 9 patients with lacunar stroke 4 had definite and 5 possible CSF enhancement and of the 7 cortical patients one had possible and 5 had no CSF enhancement (likelihood ratio chi square value 8.4 – p=0.01). Conclusion These results show an association between lacunar stroke and increased contrast entering CSF, providing further evidence that a generalised BBB permeability defect may underlie lacunar stroke.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
ARTERIO-ARTERIAL EMBOLISM AS A CAUSE OF LACUNAR STROKE
O. Vinogradov
National Center of Cerebrovascular Disorders
RUSSIAN FEDERATION
Background. According to «lacunar» hypothesis the cause of lacunar stroke (LS) is cerebral microangiopathy owing to arterial hypertension. However, authors reported, about embolism in the perforant arteries as a cause of LS. The purpose of this study was to determine could LS be the result of arterio-arterial embolism. Material and methods. We have examined 216 patients with acute LS. We used diffusion-weighted MRI (Giroscan INTERA NOVA, Holland), transthoracic or transesophageal echocardiography, carotid duplex sonography (VIVID 7, USA), transcranial Doppler sonography with microembolic detection (Sonomed-300, Russia). Patients were parted on 2 groups: I – patients without stenosis of carotid artery >70% (n=178); II – patients with stenosis of carotid artery >70% (n=38). Results. Diffusion-weighted MRI data in 24 (63,2%) patients of the group II discovered multiple LS, that was more frequent, than in patients of the group I –11 (6,2%), р<0,001. In the group II the incident of microembolic signals registration in a middle cerebral artery was also higher – in 28 patients (73,7%), as compared to the group I – 25 patients (14,0%), р<0,001. In the group II carotid stenosis was more frequent ipsilaterally to the affected hemisphere – 26 patients (68,4%), then contralaterally – 12 patients (31,6%), р<0,01. Conclusions. Causes of LS are heterogeneous. Arterio-arterial embolism can be one of causes of LS.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Cockayne syndrome and stroke : a case report
A. Ferrier
C. Sarret
P.P.Derost
P. Clavelou
CHU Gabriel Montpied, Clermont-Ferrand
FRANCE
Introduction : Cockayne syndrome (CS) is a rare autosomal recessive disease, characterized by short stature, photosensitivity and premature aging. Cognitive impairment are well known, but stroke appears very rare. Observation : A 21-year-old woman with a CS developed a sudden right hemiparesia with right facial palsy, right hemianopsia and aphasia. A brain magnetic resonance imaging (MRI) revealed a recent ischemia in left middle cerebral artery (MCA) territory. During the first 24 hours she was admitted in intensive care because of drowsiness and fever. Then the clinical outcome was favourable. To explain this stroke we only found a left internal carotid irregularity, without significative stenosis. No other cause was found in spite of an extensive check-up. Discussion : It was the first case of a non transient ischemic stroke in an adult with a CS. Patients with CS have defects in DNA nucleotide excision repair and can develop early atherosclerosis. Our patient didn’t have any significative carotid atheroma. Conclusion : This is a notable observation because this patient with a CS confirmed by molecular biology, and complication by ischemic stroke, has finally a good recovery.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
The Etiology of Subarachnoid Hemorrhage: Genetic Predisposition, Environmental Factors or Inflammation?
B. Krischek
C. Roder
H. Kasuya
I. Inoue
M. Tatagiba
University of Tuebingen
GERMANY
Background: Although the incidence of other kinds of stroke has declined in the last three decades the frequency of subarachnoid hemorrhage due to a ruptured intracranial aneurysm has remained the same. The etiology of intracranial aneurysm formation and rupture remains mostly unknown, but lately several studies have increasingly supported the role of genetic factors. In this study, we present results of our extensive genetic research on intracranial aneurysms, as well as the conclusions that we draw from the obtained information. Methods: Multiple linkage and candidate gene analyses using DNA of large cohorts of different ethnicity were performed. Microarray analyses using tissue of the dome of ruptured intracranial aneurysms and control cerebral arteries were compared with immunohistochemical staining of aneurysmal tissue. Results: Several linkage regions on several chromosomes such as 5q22-13, 7q11 and 14q22 in a Japanese cohort were detected. Other linkage regions such as chromosome 17cen could not be replicated. Single nucleotide polymorphisms of candidate genes that play a role in the vessel wall formation were found to be significantly altered in patients with intracranial aneurysms. The microarray analysis and immunohistochemical results showed evidence for MHC class II gene overexpression in intracranial aneurysm tissue and the in creased presence of antigen presenting cells (macrophages, monocytes). Discussion: In addition to the well-published environmental factors, such as alcohol intake, hypertension and smoking, only the recent progress in molecular genetics enables us to investigate the possible genetic determinants of this disease. Multiple genetic susceptibilities in conjunction with the environmental factors and immune response mechanisms are considered to act together in the disease’s etiology. The continuing development of computational and genetic analyses will enable further detection of gene-gene and gene-environment interaction.
Session:
Poster Session I
Date:
Wednesday 14 May 2008
Time:
12:30 - 14:00
Room:
Agora 2
Stroke in young. 31 cases from saudi arabia.
H.H.Hatoum
King Faisal Specialist Hospital and Research Center
SAUDI ARABIA
Background and purpose: Stroke in young differ from that in the elderly by its life-long tragic impact, and different etiologies. We studied the risk profile, etiology and outcome of ischemic stroke in young adults at a tertiary care center, King Faisal Specialist Hospital & Research center Jeddah. Methods: We reviewed retrospectively, the medical records of 31 patients aged 15-45y, with ischemic stroke. We further divided them into 2 subgroups; Group I (15y-30y) and Group II (31y-45y. We elected to classify patients into 7 etiological groups based on the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria, modified and accommodated for stroke in young highlighting the importance of the hematological/ hypercoagulable and the non-atherosclerotic vasculopathy group seen not uncommonly in the young stroke victims: (1) large-artery atherosclerosis (2) small-vessel occlusion or lacunes (3) embolism (4) Hematological/ hypercoagulable (5) non-atherosclerotic vasculopathy (6) Other determined causes (7) undetermined. Patients were also categorized according to their stroke functional outcome into 5 classes. Results: We were able to find a likely diagnosis of stroke in almost 84% of our series, and only 16% of undetermined etiology 60% of which with incomplete investigation. Hematological/ hypercoagulable diseases represented 32% of the etiology. Isolated elevation of Antiβ2 antiglycoprotein I was seen in 8 cases with normal otherwise anticardiolipin antibodies and lupus anticoagulant. No disability or minor sequels were present in 77% with better prognosis for the younger group. Conclusions: Young stroke victims deserve a tailored etiologic classification, highlighting the importance of a group of diseases rarely encountered in the aged stroke.. Etiological Diagnosis can be reached most of the time with extensive evaluation. Antib2 glycoprotein seems to play a role in some cases. . Outcome was generally good with better outcome seen in the younger group. These findings support the need for additional prospective controlled studies.
