Comparison Study of ASCO and TOAST Classification System in Chinese Minor Stroke Patients.

BACKGROUND: Precise subtype classification based on underlying pathophysiology is important to prevent recurrent attack in minor stroke patients. A newly developed Atherosclerosis, Small vessel disease, Cardiac source, Others (ASCO) phenotypic classification system aims to characterize patients using different grades of evidence for stroke subtypes. However, this system has not been specifically applied to minor stroke population. In our study, the impact of using the newer ASCO criteria on minor stroke etiologies was investigated, and compared with that of Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. METHODS: Consecutive patients with minor ischemic stroke (NIHSS ≤3) were assessed and subtyped by the ASCO and TOAST systems. Stroke etiologies were presented and compared. The McNemar test and k statistic were used to analyze the difference and concordance between the 2 algorithms, respectively. RESULTS: A total of 604 first-ever minor stroke patients were analyzed in the present study. Using TOAST classification, large artery atherosclerosis was the most frequent subtype (281, 46.5%), followed by small artery occlusion category (165, 27.3%). When ASCO was applied, 37 different profiles of stroke etiologies were identified. Using grade 1 of evidence, atherosclerosis (A1) was the most frequent subtype (308, 51.0%), followed by small vessel disease (S1, 178, 29.5%). Under consideration of grades 1 and 2, 239 (39.6%) patients were classified into more than 1 category. The ASCO system revealed determined etiologies in 104 of the 137 patients classified to cause undetermined subtype by TOAST classification. Good to very good accordance was observed between ASCO grade 1 and TOAST schemes across etiologic subtypes (κ = 0.719-0.832) except cause undetermined category (κ = 0.470). CONCLUSION: Application of ASCO decreased the proportion of patients assigned to cause undermined category compared to TOAST system. Comprehensive characteristics of ASCO system might be helpful in the personalized therapy or secondary prevention for individual patients in the future.

Outcomes after diagnosis of mild cognitive impairment in a large autopsy series.

OBJECTIVE: To determine clinical and neuropathological outcomes following a clinical diagnosis of mild cognitive impairment (MCI). METHODS: Data were drawn from a large autopsy series (N = 1,337) of individuals followed longitudinally from normal or MCI status to death, derived from 4 Alzheimer Disease (AD) Centers in the United States. RESULTS: Mean follow-up was 7.9 years. Of the 874 individuals ever diagnosed with MCI, final clinical diagnoses were varied: 39.2% died with an MCI diagnosis, 46.8% with a dementia diagnosis, and 13.9% with a diagnosis of intact cognition. The latter group had pathological features resembling those with a final clinical diagnosis of MCI. In terms of non-AD pathologies, both primary age-related tauopathy (p < 0.05) and brain arteriolosclerosis pathology (p < 0.001) were more severe in MCI than cognitively intact controls. Among the group that remained MCI until death, mixed AD neuropathologic changes (ADNC; ≥1 comorbid pathology) were more frequent than "pure" ADNC pathology (55% vs 22%); suspected non-Alzheimer pathology comprised the remaining 22% of cases. A majority (74%) of subjects who died with MCI were without "high"-level ADNC, Lewy body disease, or hippocampal sclerosis pathologies; this group was enriched in cerebrovascular pathologies. Subjects who died with dementia and were without severe neurodegenerative pathologies tended to have cerebrovascular pathology and carry the MCI diagnosis for a longer interval. INTERPRETATION: MCI diagnosis usually was associated with comorbid neuropathologies; less than one-quarter of MCI cases showed "pure" AD at autopsy. Ann Neurol 2017;81:549-559.

High Blood Pressure Increases the Risk of Poor Outcome at Discharge and 12-month Follow-up in Patients with Symptomatic Intracranial Large Artery Stenosis and Occlusions: Subgroup analysis of the CICAS Study.

AIMS: The purpose of this study was to discuss the relationship between blood pressure and prognosis of patients with symptomatic intracranial arterial stenosis. METHODS: Data on 2426 patients with symptomatic intracranial large artery stenosis and occlusion who participated in the Chinese Intracranial Atherosclerosis (CICAS) study were analyzed. According to the JNC 7 criteria, blood pressure of all patients was classified into one of the four subgroups: normal, prehypertension, hypertension stage I, and hypertension stage II. Poor outcomes were defined as death and functional dependency (mRS 3-5) at discharge or at 1 year. RESULTS: For patients with intracranial stenosis of 70% to 99%, the rate of poor outcome at discharge was 19.3%, 23.5%, 26.8%, and 39.8% (P = 0.001) for each blood pressure subgroup. For patients with intracranial large artery occlusion, the rates were 17.6%, 22.1%, 29.5%, and 49.8%, respectively (P < 0.0001). The rate of poor outcome at 12-month follow-up was 12.6%, 15.3%, 28.5%, and 27.9% (P = 0.0038) in patients with stenosis of 70% to 99% for each blood pressure subgroup and 11.6%, 21.5%, 23.9%, 35.1% (P < 0.0001) in patients with occlusion. CONCLUSIONS: For patients with severe intracranial arterial stenosis or occlusion, higher hypertension stages are associated with an increased risk of poor outcome at discharge and 12-month follow-up.

Characterization of intracranial atherosclerotic stenosis using high-resolution MRI study--rationale and design.

BACKGROUND: Intracranial atherosclerosis is a leading cause of stroke, but little is known about the composition of the intracranial atherosclerotic lesion and how intracranial plaque morphology is related to the risk of stroke. High-resolution magnetic resonance imaging (HR MRI) has been used in patients with extracranial carotid atherosclerosis as an in vivo tool to identify, with high-interrater agreement, histologically defined plaque components (i.e., intraplaque hemorrhage, fibrous cap, and lipid core), which have been shown to be predictors of recurrent stroke. With careful imaging the components of atherosclerotic plaque can be visualized in the intracranial arteries using HR MRI, but there are no reports of reproducibility or interrater reliability. METHODS/STUDY DESIGN: The Characterization of intracranial atherosclerotic stenosis using high-resolution MRI (CHIASM) study is a single-center NIH-funded prospective observational study, to (1) demonstrate high -interrater agreement for identifying intracranial plaque components on HR MRI, (2) determine the frequency of these components in symptomatic versus asymptomatic plaques, and (3) estimate the 1-year rate of stroke in the territory of high-risk plaque components. CHIASM will recruit 90 patients with 50-99% intracranial atherosclerosis to undergo HRMRI of the intracranial artery plaque at enrollment and 1-year follow-up. Both symptomatic and asymptomatic subjects will be recruited. CONCLUSION: Determination of good interrater reliability is an important first step in the development of HR MRI as a tool to predict risk in patients with intracranial atherosclerosis. This study will inform the design of future multicenter studies to determine the prevalence and prognosis of intracranial atherosclerotic plaque components. Such studies could lead to new understanding of the pathophysiological mechanisms of cerebral ischemia in patients with atherosclerotic intracranial stenosis, improvements in risk stratification, and potentially to new treatments of this common and serious disease.

Association of imaging classification of intracranial cerebral atherosclerotic vascular stenosis in ischemic stroke and renalase gene polymorphisms.

Cerebral atherosclerosis vascular stenosis is a common etiology for ischemic stroke and a major factor in recurrent stroke and vascular mortality. Recent studies suggest that renalase plays a role in hypertension and ischemic stroke, and may be involved in atherosclerosis. The aim of the present study was to investigate whether there were correlations between single-nucleotide polymorphisms (SNPs) in the renalase gene and severity of intracranial cerebral atherosclerotic vascular stenosis in ischemic stroke patients as determined by imaging. A total of 212 ischemic stroke patients and 244 healthy controls from the north Chinese Han population were enrolled in this study. Polymerase chain reaction and ligase detection reaction were used for SNP analysis. We classified the case samples by severity of the intracranial cerebral atherosclerotic vascular stenosis. Allele, genotype, and haplotype were analyzed in cases and controls, and logistic regression was used to adjust for bias due to conventional stroke risk factors. The allele and the genotype of rs10887800 in the renalase gene were both associated with severe intracranial cerebral atherosclerotic vascular stenosis (p = 0.013 and p = 0.049, respectively). No association was observed with severity for SNP rs2576178 or SNP rs2296545. Our findings show that the SNP rs10887800 in the renalase gene is closely associated with severe intracranial cerebral atherosclerotic vascular stenosis in ischemic stroke patients of north Chinese Han origin.

ASCO classification in clinical practice.

ASCO (Atherosclerosis, Small vessel disease, Cardiac source, Other cause) is a new of classification of ischemic cerebrovascular diseases. This classification categorizes the data of the patients according to all underlying diseases and allows the clinician to grade the severity of cause (Each of the four phenotypes can be graded 1, 2, or 3). It is suggested to use ASCO classification in large epidemiologic studies but this classification may be used in daily practice. In this study we aimed to analyze the clinical features of patients with ischemic stroke and to investigate results of ASCO classification of these patients and data of 35 patients with ischemic stroke is analyzed. Use of ASCO classification is discussed with the special example cases. Patients' etiology of stroke was classified according to ASCO as known, unknown, completely unknown and unclassifiable group. Percentile of the patients classified as "known" was 71.4% (n = 25), "unknown" was 17.1% (n = 6), "completely unknown" was 5.7% (n = 2) and "unclassifiable group" was 5.7% (n = 2). We think that the ASCO classification which is thought to be more useful in large epidemiologic studies may be used in clinical follow-up period of the stroke patients. Further studies, from different neurology centers and stroke units, are needed to expand our experiences about use of ASCO classification in clinical practice.

Incidence and risk factors of intracranial atherosclerotic stroke: the Northern Manhattan Stroke Study.

BACKGROUND: To assess the prevalence of risk factors as determinants of intracranial atherosclerosis (IATH)-related stroke in a multi-ethnic community-based cohort. METHODS: The Northern Manhattan Stroke Study included a population-based incidence study and a nested case-control study. Incident cases of first ischemic stroke were 1:2 when matched to community controls by age, sex, and race/ethnicity. Vascular risk factors were assessed among controls and compared against the following stroke subtypes: IATH, extracranial atherosclerosis (EATH), and non-atherosclerotic (NATH: cardioembolic, lacunar, and cryptogenic). Conditional logistic-regression was used to determine the association between risk factors and stroke subtypes. RESULTS: The crude incidence of IATH was 8/100,000 per year and the relative incidence of IATH was higher than that of EATH in blacks (5.9 vs. 3.2/100,000 per year) and in Hispanics (5.0 vs. 1.7/100,000 per year). The IATH group had a higher prevalence of diabetes mellitus (DM; 67% IATH, 60% EATH, 48% NATH, and 23% controls; p < 0.05 IATH vs. control) and of metabolic syndrome (62% IATH, 40% EATH, 40% NATH, and 35% controls; p < 0.05 IATH vs. control). In multivariate analysis, DM conferred a higher risk for IATH versus NATH stroke (OR, 10.8; 95% CI, 2.0-57 vs. OR, 2.7; 95% CI, 1.9-3.9; p < 0.05) and much lower for EATH (OR, 6.2; 95% CI, 1.2-32). The metabolic syndrome conferred a higher risk for IATH stroke subtype (OR, 4.6; 95% CI, 1.1-18.7) when compared to EATH (OR, 2.3; CI, 0.6-9.1) and NATH (OR, 2.4; CI, 1.7-3.3). CONCLUSIONS: DM is a more important determinant for IATH-related stroke than EATH or NATH.

MR mismatch profiles in patients with intracranial atherosclerotic stroke: a comprehensive approach comparing stroke subtypes.

Most clinical trials have focused on the presence of perfusion- and diffusion-weighted imaging (PWI-DWI) mismatch by more than 20%, and different stroke subtypes were lumped together. We hypothesized that intracranial large artery atherosclerotic stroke (IC-LAA) would show different PWI-DWI and magnetic resonance angiography (MRA)-DWI mismatch profiles, compared with other stroke subtypes. Consecutive patients underwent pretreatment multiparametric magnetic resonance imaging for the acute middle cerebral artery infarcts within 6 h of symptom onset. We assessed the difference in the DWI-PWI mismatch ratio, severity of hypoperfusion, and MRA-DWI mismatch among the stroke subtypes. Of 86 patients, 19 (22.1%) had IC-LAA; 42 (48.8%) cardioembolic stroke, 15 (17.4%) extracranial-LAA, and 10 (11.6%) had cryptogenic embolic stroke. Although the volume of the penumbra was not different among the groups, the mismatch ratio was higher (P=0.003) and the severity of hypoperfusion was lower in the IC-LAA group (P=0.001). The MRA-DWI mismatch was more prevalent in the IC-LAA group than in other groups (P<0.001). Collateral grading, assessed in 41 patients, was more likely to be intermediate/excellent in the IC-LAA group (P<0.001). Multivariate testing revealed that a larger mismatch ratio and less severe hypoperfusion, and MRA-DWI mismatch were independently associated with IC-LAA. Our data show that patients with IC-LAA had different mismatch profiles, which were related to better collaterals, compared with other subtypes.

Classic risk factors for atherosclerosis are not major determinants for location of extracranial or intracranial cerebral atherosclerosis.

BACKGROUND: The prevalence of extracranial (EC) and intracranial (IC) atherosclerosis varies among races. Although several studies have sought to identify specific vascular risk factors that are associated with EC or IC atherosclerosis, the exact relationships are uncertain. This study aimed to determine if there are any specific risk factors for EC or IC atherosclerosis. METHODS: For this study, we considered 3,349 consecutive patients who had been entered into a stroke registry between January 1999 and June 2007. After the exclusion of patients who had not undergone angiography, patients with cardiac sources of embolism or other causes of stroke, and non-Koreans, we had a total of 2,169 patients of single ethnicity with an angiographic analysis. Patients with atherosclerosis in both the IC and EC arteries (856 patients) were excluded. Finally, we identified 1,313 patients who had EC atherosclerosis (EC group, n = 256), IC atherosclerosis (IC group, n = 566) or normal angiographic findings (no-lesion group, n = 488). The frequency of risk factors and the demographic parameters were compared among these groups. RESULTS: When compared to the normal group, the IC group was associated with older age and hypertension, and the EC group was associated with older age, higher initial blood sugar and low-density lipoprotein cholesterol levels. However, in a direct comparison between the IC and EC groups, we did not observe any significant risk factors or variables except for a higher frequency of males and higher total cholesterol levels in the EC group. CONCLUSIONS: Vascular risk factors may not be major determinants of location for atherosclerosis in the EC or IC arteries.

Stenting of symptomatic M1 stenosis of middle cerebral artery: an initial experience of 40 patients.

OBJECTIVE: To assess the safety and clinical efficacy of stenting for patients with symptomatic M1 stenosis of middle cerebral artery (MCA), and to assess the significance of classification based on location, morphology, and access of intracranial stenosis (LMA classification) in MCA stenting. METHODS: Forty patients with 42 symptomatic M1 stenoses refractory to medical therapy were enrolled in this study. The lesions were situated at M1 trunk (n=13), M1 origin (n=12), and M1 bifurcation (n=17), respectively, which were classified into type N (nonbifurcation lesions, n=13) and type A (prebifurcation, n=11), B (postbifurcation, n=14), C (lesion across the nonstenotic ostium of its branch, n=1), D (across the stenotic ostium of its branch, n=2), F (combinative lesions of prebifurcation and its small branch ostium, n=1) locations, morphologically into type A (n=15), B (n=23) and C (n=4) lesions, and into type I (mild-to-moderate tortuosity and smooth access, n=17), II (severe tortuosity and/or irregular arterial wall, n=18), and III (excessively severe tortuosity, n=7) accesses. RESULTS: The technical successful rate was 97.6% for total lesions and 100%, 100%, and 85.7% for types I, II, and III accesses, respectively. The total complication rate was 10%. The mortality was 2.5% (1/40 patients), and 0%, 0%, and 25% for types A, B, and C lesions, respectively. During the median 10 months follow-up, there was no recurrence of transient ischemic attack or stroke in 38 available patients. Among 8 stenting vessels of seven patients with six-month follow-up angiography, 7 showed good patency and one showed restenosis. CONCLUSIONS: Stenting appears to be an effective and feasible therapy for symptomatic M1 stenoses, but also appears to have the higher periprocedural complications, which need strict procedural and periprocedural management to reduce the mortality and morbidity. The LMA classification seems to be helpful to work out the individual therapy and predict the results of stenting. A further study is needed to confirm the benefits of stenting of MCA stenosis.

Relationship between the Oxfordshire Community Stroke Project classification and vascular abnormalities in patients with predominantly intracranial atherosclerosis.

BACKGROUND: The Oxfordshire Community Stroke Project (OCSP) classification is a stroke classification based on clinical features collected at bedside. Previous studies reported good correlation between vascular abnormalities and OCSP mainly in populations not at risk of intracranial atherosclerosis. There have been limited data on the relationship between intracranial atherosclerosis and the OCSP classification. METHODS: Consecutive Chinese patients admitted to a regional hospital with acute ischemic stroke were studied in Hong Kong. Stroke subtype was classified as total or partial anterior circulation infarct (TACI or PACI), posterior circulation infarct (POCI), or lacunar infarct (LACI), according to the OCSP method. Transcranial Doppler (TCD) was performed whenever possible to evaluate the intracranial arteries as well as the carotid arteries. National Institute of Health Stroke Scale (NIHSS) was used to assess the severity of stroke on admission. RESULTS: Six hundred and ninety-nine consecutive patients were studied. On admission, 24 patients were classified as TACI (3.4%), 96 PACI (13.7%), 111 POCI (15.9%), and 468 LACI (67.0%). Of the 345 patients who had TCD evidence of intracranial or carotid artery abnormalities, 75% had intracranial involvement only, 5% extracranial involvement only and 20% had both intracranial and extracranial involvement. The frequencies of arterial abnormalities were found in 58% of TACIs, 48% of PACIs, 48% of POCIs and 50% of LACIs. There was no evidence that the frequencies of arterial abnormalities were different between the OCSP groups (P=0.8). Middle cerebral artery velocity was abnormal in 9 TACIs (38%), 32 PACIs (33%), 35 POCIs (32%) and 177 LACIs (38%) (P=0.6). Vertebrobasilar velocities were abnormal in 4 TACIs (17%), 20 PACIs (21%), 29 (26%) and 87 LACIs (19%) (P=0.3). The OCSP subtypes were associated with POCIs the severity of stroke. NIHSS score of > or =9 was found in 83% of TACIs, 18% of PACIs, 9% of POCIs, and 12% of LACIs (P<0.0001). CONCLUSIONS: OCSP classification is not significantly related to the presence of vascular abnormalities among patients with predominantly intracranial atherosclerosis.

Follow-up study after intracranial percutaneous transluminal cerebral balloon angioplasty.

BACKGROUND AND PURPOSE: Our objective was to find the specific angiographic characteristics of atherosclerotic lesions that indicate suitability for intracranial percutaneous transluminal cerebral balloon angioplasty (PTCBA). METHODS: Forty-two clinically symptomatic patients with 42 hemodynamically significant intracranial lesions (>70% stenosis) were treated by PTCBA between January 1992 and May 1996. Before treatment, the patients were assigned to three groups according to the angiographic characteristics of the lesions, as follows: type A, short (5 mm or less in length) concentric or moderately eccentric lesions less than totally occlusive; type B, tubular (5 to 10 mm in length), extremely eccentric or totally occluded lesions, less than 3 months old; and type C, diffuse (more than 10 mm in length), extremely angulated (>90 degrees) lesions with excessive tortuosity of the proximal segment, or totally occluded lesions, and 3 months old or older. The patients were followed up for a period of 1 month to 6 years to compare the results of PTCBA treatment among the three groups. Primary end points were death, stroke, or bypass surgery. RESULTS: The clinical success rates for the type A, B, and C groups were 92%, 86%, and 33%, respectively. Cumulative risks of fatal or nonfatal ischemic stroke or ipsilateral bypass surgery in type A, B, and C groups were 8%, 26%, and 87%, respectively. The cumulative risk of 8% among patients in the type A group appeared to be smaller than in studies reported in the literature. CONCLUSION: PTCBA for intracranial simple (type A) lesions yields a favorable clinical outcome for symptomatic patients.

[Ultrasonic diagnosis of patients with circulatory encephalopathy]. / Ul'trazvukovaia diagnostika u bol'nykh s distsirkuliatornoi éntsefalopatiei.

The paper describes the results of examining intracerebral blood flow in patient with different stages of dyscirculatory encephalopathies. Transcranial Doppler was applied. Ultrasound examination of the great arteries of the head was made by determining the linear and volumetric velocities of blood flow. Progressive cerebral atherosclerosis was found to result in an earlier decrease in cerebrovascular blood flow.

[Brain function in patients with atherosclerotic circulatory encephalopathy]. / Funktsional'nyi stan holovnoho mozku u khvorykh na aterosklerotychnu dystsyrkuliatornu entsefalopatiiu.

Based on the analysis of findings from clinical and paraclinical investigations (ultrasonic vascular diagnosis, electroencephalography, computerized tomography, angiography) in 244 patients with atherosclerotic dyscirculatory encephalopathy, functional status was studied as were structural alterations in the brain tissue in stenosing lesions of precerebral arteries. The first clinical manifestations of atherosclerotic dyscirculatory encephalopathy in the presence of damage to the vestibular-basilar system were found to be dysfunction of column structures of vestibular apparatus, reticular formation and posterior longitudinal fascicle, and, in the presence of damage to the carotid area, -- dysfunction of cortex of frontal, parietal and temporal lobes of the brain.

[The clinico-instrumental characteristics of the lesions of the precerebral arteries in patients with atherosclerotic circulatory encephalopathy]. / Kliniko-instrumental'na kharakterystyka urazhennia pretserebral'nykh arterii u khvorykh na aterosklerotychnu dystsyrkuliatornu entsefalopatiu.

Results have been analysed of comprehensive evaluation of 175 patients with discirculatory encephalopathy of atherosclerotic genesis, consisting of inspection of the neck vessels projection, study of neurological status, ultrasonic investigation of the major brain arteries structure and hemodynamics, their angiographic features. At stage I discirculatory encephalopathy subjective complaints predominated, being caused by syndrome of thoracic outlet, steal syndrome, stenosing lesions of brachiocephalic arteries. Encountered more frequently in the middle-aged and elderly patients were affections of several major brain arteries. Specific weight of correlation between ultrasonic investigation and angiography in stenosing lesions of brachiocephalic arteries in patients with discirculatory encephalopathy constituted 84-100%. Therefore patients with discirculatory encephalopathy of atherosclerotic genesis require ultrasonic investigation of brachiocephalic arteries with the purpose of finding out exactly the pathological process and choosing the tactics of treatment.

[Tactics of treatment of patients with atherosclerotic circulatory encephalopathy]. / Taktyka likuvannia khvorykh na aterosklerotychnu dystsyrkuliatornu entsefalopatiiu.

Immediate and late follow-up results of nonoperative and operative treatment of 244 patients with atherosclerotic dyscirculatory encephalopathy (ADE) were analyzed. The effectiveness of operative treatment is 1.9 times the non-operative one. Surgical correction of ADE of the I-II stages is mostly prognostically favourable. Operative intervention in patients with ADE of the III stage is justified if the operation risk is lower than the risk of disease progress. Indications for the operative treatment in patients with ADE caused by stenosing lesions of the main head arteries are elaborated.

Computer based pattern recognition of carotid arterial disease using pulsed Doppler ultrasound.

A minicomputer based system has been developed for studying carotid artery blood flow data obtained for a combined B-mode, pulsed Doppler ultrasound scanner. The goals of this work are to devise and improve techniques for estimating the extent of atherosclerosis at the carotid artery bifurcation. Features are automatically extracted from spectrum analyzed Doppler blood flow data. Five statistical pattern recognition algorithms are compared, with cross validation being used to improve the estimate of classification accuracy. A data collection protocol has been devised in which four sites are studied along each carotid arterial system. Classification of unknowns is done using a hierarchy of three decisions.