Original Paper Received: December 12, 2014 Accepted: March 1, 2015 Published online: April 15, 2015

Eur Neurol 2015;73:271–277 DOI: 10.1159/000381336

Impact of Intracranial Atherosclerotic Stenosis on the Prognosis in Acute Ischemic Stroke Patients with Cardioembolic Source Seung-Jae Lee a Dong-Geun Lee a Dal-Soo Lim b Sukkeun Hong b  

 

 

 

Departments of a Neurology and b Cardiology, Sejong General Hospital, Bucheon, South Korea  

 

Key Words Intracranial atherosclerosis · Stroke · Cardioembolism

2.920, p = 0.042). Conclusions: In acute ischemic stroke patients with cardioembolic source, IAS may be considered a marker of a high risk of stroke recurrence or death. © 2015 S. Karger AG, Basel

© 2015 S. Karger AG, Basel 0014–3022/15/0736–0271$39.50/0 E-Mail [email protected] www.karger.com/ene

Introduction

Intracranial atherosclerotic stenosis (IAS) is frequently encountered among non-white stroke patients of Asian, black, or Hispanic ethnic groups [1]. It constitutes one of the main causes of stroke in these people. Its clinical significance in ischemic stroke has increased as a result of accumulating studies in the literature [2]. Previous studies have shown that it is related to stroke recurrence and death in the total patient population with acute ischemic stroke [3–5]. In addition, higher vascular risk factor profiles such as metabolic syndrome have been commonly found in these patients [6, 7]. However, the clinical significance of IAS in stroke patients with cardioembolic source is not yet established. Because cardioembolism may be the main etiological factor of stroke in these patients, the relationship between IAS and the outcome of the patients might be insignificant. To the best of our knowledge, no study to Dr. Seung-Jae Lee Department of Neurology, Sejong General Hospital 91–121 Sosabon2-dong Sosa-gu, Bucheon-si, Gyeonggi-do, 422–711 (South Korea) E-Mail neurosj @ catholic.ac.kr

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Abstract Background and Aim: In recent days, intracranial atherosclerotic stenosis (IAS) has been reportedly related to recurrent stroke and mortality in the total patient population with ischemic stroke. However, its impact on the prognosis of the patients with cardioembolic source is not yet established. This study attempted to investigate whether IAS was associated with poor outcome in stroke patients with cardioembolic source. Methods: Overall, 223 patients with acute ischemic stroke and cardioembolic source were included in this study. IAS was defined as ≥50% stenosis on enhanced MRA, and cardioembolic sources were detected by ECG and echocardiography. Follow-up data were obtained from outpatient medical records and/or telephone interviews. Results: Overall, 60 major clinical events causing poor outcome occurred in 58 patients (26.0%). Patients with IAS had significantly higher rates of death and stroke recurrence than those without IAS (p = 0.015 and 0.046 each by log rank test). The multivariate Cox proportional hazards regression analysis showed that IAS was significantly related to the poor outcome (hazard ratio 1.725, 95% confidence interval 1.020–

Table 1. Prevalence of major and minor sources of cardioembolism in the 223 study patients

Major source

n (%)

Minor source

n (%)

Atrial fibrillation Mitral stenosis LA thrombus Mechanical prosthetic valve Dilated cardiomyopathy Sick sinus syndrome MI within 4 weeks LV thrombus Akinetic LV segment or aneurysm Atrial myxoma Infective endocarditis

142 (63.7) 16 (7.2) 11 (4.9) 18 (8.1) 5 (2.2) 6 (2.7) 12 (5.4) 6 (2.7) 44 (19.7) 4 (1.8) 4 (1.8)

Mitral valve prolapse or regurgitation Mitral annular calcification Spontaneous echo contrast Atrial septal aneurysm PFO or ASD Bioprosthetic valve Congestive heart failure Hypokinetic LV segment 4 weeks< MI 90 mm Hg demonstrated on repeated examinations at least one month after presentation with a stroke), diabetes mellitus (defined as a fasting blood glucose level >126 mg/dl or a history of being treated for diabetes mellitus), and hyperlipidemia (defined as a total cholesterol level >200 mg/dl or a low-density lipoprotein cholesterol >130 mg/dl at the time of presentation or a history of treatment). In addition, current cigarette smoking, a previous history of stroke, and ischemic heart disease (defined as a known history or clinical demonstration of myocardial infarction or angina pectoris) were noted. Brain Vessel Evaluation All the included patients underwent 1.5-T MR imaging on admission. The MR imaging consisted of diffusion-weighted image, gradient echo image, fluid-attenuated inversion recovery image, three-dimensional time-of-flight intracranial MR angiography (MRA), and contrast-enhanced MRA, including extracra-

Lee/Lee/Lim/Hong

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date has addressed this topic within this patient population. In this study, we attempted to evaluate the prevalence of IAS in acute ischemic stroke patients with a cardioembolic source and to investigate whether IAS was associated with poor clinical outcome (stroke recurrence and death) in these patients.

Data Analysis Statistical analyses were performed with SPSS software, version 18.0 (SPSS Inc., Chicago, Ill., USA). The independent t-test or Chisquare test was used to compare the difference between the patient groups with and without IAS. Kaplan-Meier survival curves were computed according to the distribution pattern of stenosis. Differences in survival and outcome were also estimated using the log rank test. Cox proportional hazards model was used to perform univariate and multivariate analyses for stroke recurrence and mortality. Unadjusted and adjusted hazard ratio (HR) and 95% confidence interval (CI) were obtained. p values 65 88 (58.3) Male 76 (50.3) Hypertension 80 (53.0) Diabetes 30 (19.9) Hyperlipidemia 66 (43.7) Current smoking 26 (17.2) Previous history of stroke 30 (19.9) Ischemic heart disease 28 (18.5) Atrial fibrillation 108 (71.5) Valvular heart disease 59 (39.1) Ischemic stroke 118 (78.1) Transient ischemic attack 33 (21.9) Initial modified rankin scale ≥3 82 (54.3) Initial national institutes of health stroke scale 6.7±8.4 Extracranial atherosclerotic stenosis 25 (16.6) Medications before index stroke Antiplatelet 72 (47.7) Warfarin 41 (27.2) Statin 38 (25.2)

IAS (n = 72)

p

52 (72.2) 0.044 28 (38.9) 0.109 58 (80.6)

Impact of Intracranial Atherosclerotic Stenosis on the Prognosis in Acute Ischemic Stroke Patients with Cardioembolic Source.

In recent days, intracranial atherosclerotic stenosis (IAS) has been reportedly related to recurrent stroke and mortality in the total patient populat...
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