White Matter Hyperintensities Improve Ischemic Stroke Recurrence Prediction

10.1159/000450962 â—½  
2016 â—½  
Vol 43 (1-2) â—½  
pp. 17-24 â—½  
Author(s):  
Søren Due Andersen â—½  
Torben Bjerregaard Larsen â—½  
Anders Gorst-Rasmussen â—½  
Yousef Yavarian â—½  
Gregory Y.H. Lip â—½  
...  
Keyword(s):  
Ischemic Stroke â—½  
White Matter â—½  
Risk Score â—½  
White Matter Hyperintensities â—½  
Stroke Risk â—½  
Risk Scores â—½  
Stroke Recurrence â—½  
Cerebral White Matter â—½  
Clinical Scores â—½  
Recurrence Prediction

Background: Nearly one in 5 patients with ischemic stroke will invariably experience a second stroke within 5 years. Stroke risk stratification schemes based solely on clinical variables perform only modestly in non-atrial fibrillation (AF) patients and improvement of these schemes will enhance their clinical utility. Cerebral white matter hyperintensities are associated with an increased risk of incident ischemic stroke in the general population, whereas their association with the risk of ischemic stroke recurrence is more ambiguous. In a non-AF stroke cohort, we investigated the association between cerebral white matter hyperintensities and the risk of recurrent ischemic stroke, and we evaluated the predictive performance of the CHA2DS2VASc score and the Essen Stroke Risk Score (clinical scores) when augmented with information on white matter hyperintensities. Methods: In a registry-based, observational cohort study, we included 832 patients (mean age 59.6 (SD 13.9); 42.0% females) with incident ischemic stroke and no AF. We assessed the severity of white matter hyperintensities using MRI. Hazard ratios stratified by the white matter hyperintensities score and adjusted for the components of the CHA2DS2VASc score were calculated based on the Cox proportional hazards analysis. Recalibrated clinical scores were calculated by adding one point to the score for the presence of moderate to severe white matter hyperintensities. The discriminatory performance of the scores was assessed with the C-statistic. Results: White matter hyperintensities were significantly associated with the risk of recurrent ischemic stroke after adjusting for clinical risk factors. The hazard ratios ranged from 1.65 (95% CI 0.70-3.86) for mild changes to 5.28 (95% CI 1.98-14.07) for the most severe changes. C-statistics for the prediction of recurrent ischemic stroke were 0.59 (95% CI 0.51-0.65) for the CHA2DS2VASc score and 0.60 (95% CI 0.53-0.68) for the Essen Stroke Risk Score. The recalibrated clinical scores showed improved C-statistics: the recalibrated CHA2DS2VASc score 0.62 (95% CI 0.54-0.70; p = 0.024) and the recalibrated Essen Stroke Risk Score 0.63 (95% CI 0.56-0.71; p = 0.031). C-statistics of the white matter hyperintensities score were 0.62 (95% CI 0.52-0.68) to 0.65 (95% CI 0.58-0.73). Conclusions: An increasing burden of white matter hyperintensities was independently associated with recurrent ischemic stroke in a cohort of non-AF ischemic stroke patients. Recalibration of the CHA2DS2VASc score and the Essen Stroke Risk Score with one point for the presence of moderate to severe white matter hyperintensities led to improved discriminatory performance in ischemic stroke recurrence prediction. Risk scores based on white matter hyperintensities alone were at least as accurate as the established clinical risk scores in the prediction of ischemic stroke recurrence.

Risks of Stroke Recurrence and Mortality After First and Recurrent Strokes in Denmark: A Nationwide Registry Study

Neurology â—½  
2021 â—½  
pp. 10.1212/WNL.0000000000013118
Author(s):  
Nils Skajaa â—½  
Kasper Adelborg â—½  
Erzsébet Horváth-Puhó â—½  
Kenneth J Rothman â—½  
Victor W. Henderson â—½  
...  
Keyword(s):  
Ischemic Stroke â—½  
Intracerebral Hemorrhage â—½  
Risk Score â—½  
Recurrent Stroke â—½  
Recurrent Event â—½  
Risk Scores â—½  
Stroke Recurrence â—½  
Stroke Severity â—½  
Risk Of Death â—½  
First Time

Background and Objectives:To examine risks of stroke recurrence and mortality after first and recurrent stroke.Methods:Using Danish nationwide health registries, we included patients (age ≥18 years) with first-time ischemic stroke (N = 105,397) or intracerebral hemorrhage (N = 13,350) during 2004–2018. Accounting for the competing risk of death, absolute risks of stroke recurrence were computed separately for each stroke subtype and within strata of age groups, sex, stroke severity, body mass index, smoking, alcohol, the Essen stroke risk score, and atrial fibrillation. Mortality risks were computed after first and recurrent stroke.Results:After adjusting for competing risks, the overall 1-year and 10-year risks of recurrence were 4% and 13% following first-time ischemic stroke and 3% and 12% following first-time intracerebral hemorrhage. For ischemic stroke, the risk of recurrence increased with age, was higher for men and following mild than more severe stroke. The most marked differences were across Essen risk scores, for which recurrence risks increased with increasing scores. For intracerebral hemorrhage, risks were similar for both sexes and did not increase with Essen risk score. For ischemic stroke, the 1-year and 10-year risks of all-cause mortality were 17% and 56% after a first-time stroke and 25% and 70% after a recurrent stroke; corresponding estimates for intracerebral hemorrhage were 37% and 70% after a first-time event and 31% and 75% after a recurrent event.Conclusion:The risk of stroke recurrence was substantial following both subtypes, but risks differed markedly among patient subgroups. The risk of mortality was higher after a recurrent than first-time stroke.

Abstract 18538: The ATRIA Stroke Risk Score Predicts Ischemic Stroke Better than CHADS2 and CHA2DS2-VASc in a large Swedish Cohort of Patients with Atrial Fibrillation

Circulation â—½  
2014 â—½  
Vol 130 (suppl_2) â—½  
Author(s):  
Sara Aspberg â—½  
Yuchiao Chang â—½  
Daniel Singer
Keyword(s):  
Atrial Fibrillation â—½  
Ischemic Stroke â—½  
Risk Score â—½  
Stroke Risk â—½  
Anticoagulation Therapy â—½  
Bleeding Risk â—½  
Risk Scores â—½  
Cut Points â—½  
Net Clinical Benefit â—½  
Better Than

Introduction: Atrial fibrillation (AF) is a major risk factor for acute ischemic stroke (AIS). Anticoagulation therapy (OAC) effectively prevents AIS, but increases bleeding risk. There is a need for better AIS risk prediction to optimize the anticoagulation decision in AF. The ATRIA stroke risk score (ATRIA) (table) was superior to CHADS2 and CHA2DS2-VASc in two large California community AF cohorts. We now report the performance of the 3 scores in a very large Swedish AF cohort. Methods: The cohort consisted of all Swedish patients hospitalized with a diagnosis of AF from July 1, 2005 to December 31, 2008. Predictor variables and the outcome, AIS, were obtained from inpatient ICD-10 codes. Warfarin use was determined from National Pharmacy Database. Risk scores were assessed via c-index (C) and net reclassification index (NRI). Results: The cohort included 158,370 AF patients off warfarin who contributed 340,332 person-years of follow-up, and 11,823 incident AIS, for an overall AIS rate of 3.47%/yr, higher than the 2%/yr seen in the California cohorts. Using the entire point score, ATRIA had a good C of 0.712 (0.708-0.716), significantly better than CHADS2, 0.694 (0.689-0.698), or CHA2DS2-VASc, 0.697 (0.693-0.702). Using published cut-points for Low/Moderate/High AIS risk, C deteriorated for all scores but ATRIA and CHADS2 were superior to CHA2DS2-VASc. NRI favored ATRIA; 0.16 (0.15-0.18) versus CHADS2; 0.22 (0.21-0.24) versus CHA2DS2-VASc. However, NRI decreased to near-zero when cut-points were altered to better fit the cohort’s stroke rates. Conclusion: Findings in this large Swedish AF cohort validate those in the California AF cohorts, with the ATRIA score predicting stroke risk better than CHADS2 or CHA2DS2-VASc. However, relative performance of the categorical scores varied by population stroke risk. Knowledge about this population risk may be needed to optimize cut-points on the multipoint scores to achieve better net clinical benefit from OAC.

Multiple Silent Lacunes Are Associated with Recurrent Ischemic Stroke

10.1159/000445196 â—½  
2016 â—½  
Vol 42 (1-2) â—½  
pp. 73-80 â—½  
Author(s):  
Søren Due Andersen â—½  
Flemming Skjøth â—½  
Yousef Yavarian â—½  
Flemming W. Bach â—½  
Gregory Y.H. Lip â—½  
...  
Keyword(s):  
Ischemic Stroke â—½  
White Matter â—½  
Cardiovascular Events â—½  
White Matter Hyperintensities â—½  
Incidence Rates â—½  
Common Finding â—½  
Stroke Recurrence â—½  
Proportional Hazard â—½  
Risk Of Death â—½  
Cox Proportional Hazard

Background: Silent lacunes are a common finding on brain imaging in ischemic stroke patients, but the prognostic significance of these lesions is uncertain. We aimed at investigating the association of silent lacunes and the risk of ischemic stroke recurrence, death, and cardiovascular events in a cohort of patients with incident ischemic stroke and no atrial fibrillation (AF). Methods: We included 786 patients (mean age 59.5 (SD 14.0); 42.9% females) in a registry-based, observational cohort study on patients with first-ever ischemic stroke. On brain MRI we assessed the number of silent lacunes as none, single, or multiple and we calculated stratified incidence rates of the outcomes. Cox proportional hazard ratios (HRs) adjusted for age, gender, congestive heart failure, hypertension, diabetes, and vascular disease were calculated with no silent lacunes as reference. In additional analyses, we further adjusted for white matter hyperintensities. Patients were followed up until death or recurrence of ischemic stroke. Results: In 81 (10.3%) patients, a single silent lacune was present, and in 87 (11.1%) patients, multiple silent lacunes were present. Patients with at least one silent lacune were older (mean age 66.1 vs. 57.7, p < 0.001) and were more often hypertensive (60.1 vs. 43.4%, p < 0.001) compared to patients with no silent lacunes. During a median follow-up time of 2.9 (interquartile range 3.1) years, we observed 53 recurrent ischemic strokes, 76 deaths, and 96 cardiovascular events. Incidence rates per 100 person-years of ischemic stroke recurrence were 1.6, 2.5, and 5.0 for none, single, and multiple silent lacunes respectively. Corresponding incidence rates were 2.6, 2.4, and 4.4 for death, and 3.4, 4.0, and 6.6 for cardiovascular events respectively. Adjusted HRs of ischemic stroke recurrence were 1.53 (0.67-3.49) and 2.52 (1.25-5.09) for a single and multiple silent lacunes, respectively. Further adjustment for white matter hyperintensities maintained positive association although not significant. Corresponding adjusted HRs were 0.56 (0.25-1.25) and 0.65 (0.33-1.25) for death and 1.16 (0.61-2.22) and 1.51 (0.86-2.66) for cardiovascular events. Conclusions: In this large cohort of patients with incident ischemic stroke and no AF, an increasing number of silent lacunes was associated with increasing incidence rates of ischemic stroke recurrence. In the adjusted Cox proportional hazard analyses, the presence of multiple silent lacunes was significantly associated with an increased risk of ischemic stroke recurrence. The risk of death or cardiovascular events was not significantly influenced by the presence of silent lacunes.

scholarly journals Sustained Opening of the Blood-Brain Barrier with Progressive Accumulation of White Matter Hyperintensities Following Ischemic Stroke

Brain Sciences â—½  
2019 â—½  
Vol 9 (1) â—½  
pp. 16 â—½  
Author(s):  
Imama Naqvi â—½  
Emi Hitomi â—½  
Richard Leigh
Keyword(s):  
Ischemic Stroke â—½  
White Matter â—½  
Acute Stroke â—½  
Blood Brain Barrier â—½  
White Matter Hyperintensities â—½  
Brain Barrier â—½  
Common Finding â—½  
Blood Brain â—½  
History Of â—½  
Iv Tpa

Objective: To report a patient in whom an acute ischemic stroke precipitated chronic blood-brain barrier (BBB) disruption and expansion of vascular white matter hyperintensities (WMH) into regions of normal appearing white matter (NAWM) during the following year. Background: WMH are a common finding in patients with vascular risk factors such as a history of stroke. The pathophysiology of WMH is not fully understood; however, there is growing evidence to suggest that the development of WMH may be preceded by the BBB disruption in the NAWM. Methods: We studied a patient enrolled in the National Institutes of Health Natural History of Stroke Study who was scanned with magnetic resonance imaging (MRI) after presenting to the emergency room with an acute stroke. After a treatment with IV tPA, she underwent further MRI scanning at 2 h, 24 h, 5 days, 30 days, 90 days, 6 months, and 1-year post stroke. BBB permeability images were generated from the perfusion weighted imaging (PWI) source images. MRIs from each time point were co-registered to track changes in BBB disruption and WMH over time. Results: An 84-year-old woman presented after acute onset right hemiparesis, right-sided numbness and aphasia with an initial NIHSS of 13. MRI showed diffusion restriction in the left frontal lobe and decreased blood flow on perfusion imaging. Fluid attenuated inversion recovery (FLAIR) imaging showed bilateral confluent WMH involving the deep white matter and periventricular regions. She was treated with IV tPA without complication and her NIHSS improved initially to 3 and ultimately to 0. Permeability maps identified multiple regions of chronic BBB disruption remote from the acute stroke, predominantly spanning the junction of WMH and NAWM. The severity of BBB disruption was greatest at 24 h after the stroke but persisted on subsequent MRI scans. Progression of WMH into NAWM over the year of observation was detected bilaterally but was most dramatic in the regions adjacent to the initial stroke. Conclusions: WMH-associated BBB disruption may be exacerbated by an acute stroke, even in the contralateral hemisphere, and can persist for months after the initial event. Transformation of NAWM to WMH may be evident in areas of BBB disruption within a year after the stroke. Further studies are needed to investigate the relationship between chronic BBB disruption and progressive WMH in patients with a history of cerebrovascular disease and the potential for acute stroke to trigger or exacerbate the process leading to the development of WMH.

Pre-Admission CHADS2 and CHA2DS2-VASc Scores on Early Neurological Worsening

10.1159/000513396 â—½  
2021 â—½  
pp. 1-8
Author(s):  
Ki-Woong Nam â—½  
Chi Kyung Kim â—½  
Sungwook Yu â—½  
Jong-Won Chung â—½  
Oh Young Bang â—½  
...  
Keyword(s):  
Ischemic Stroke â—½  
Stroke Risk â—½  
Multivariable Analysis â—½  
National Institutes Of Health â—½  
Risk Scores â—½  
Stroke Patients â—½  
Nihss Score â—½  
Early Neurological Deterioration â—½  
Close Relationship â—½  
The Relationship

<b><i>Background:</i></b> Stroke risk scores (CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>-VASc) not only predict the risk of stroke in atrial fibrillation (AF) patients, but have also been associated with prognosis after stroke. <b><i>Objective:</i></b> The aim of this study was to evaluate the relationship between stroke risk scores and early neurological deterioration (END) in ischemic stroke patients with AF. <b><i>Methods:</i></b> We included consecutive ischemic stroke patients with AF admitted between January 2013 and December 2015. CHADS<sub>2</sub> and CHA<sub>2</sub>DS<sub>2</sub>-VASc scores were calculated using the established scoring system. END was defined as an increase ≥2 on the total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 on the motor NIHSS score within the first 72 h of admission. <b><i>Results:</i></b> A total of 2,099 ischemic stroke patients with AF were included. In multivariable analysis, CHA<sub>2</sub>DS<sub>2</sub>-VASc score (adjusted odds ratio [aOR] = 1.17, 95% confidence interval [CI] = 1.04–1.31) was significantly associated with END after adjusting for confounders. Initial NIHSS score, use of anticoagulants, and intracranial atherosclerosis (ICAS) were also found to be closely associated with END, independent of the CHA<sub>2</sub>DS<sub>2</sub>-VASc score. Multivariable analysis stratified by the presence of ICAS demonstrated that both CHA<sub>2</sub>DS<sub>2</sub>-VASc (aOR = 1.20, 95% CI = 1.04–1.38) and CHADS<sub>2</sub> scores (aOR = 1.24, 95% CI = 1.01–1.52) were closely related to END in only patients with ICAS. In patients without ICAS, neither of the risk scores were associated with END. <b><i>Conclusions:</i></b> High CHA<sub>2</sub>DS<sub>2</sub>-VASc score was associated with END in ischemic stroke patients with AF. This close relationship is more pronounced in patients with ICAS.

scholarly journals Arterial stiffness and progression of cerebral white matter hyperintensities in patients with type 2 diabetes and matched controls: a 5-year cohort study

2021 â—½  
Vol 13 (1) â—½  
Author(s):  
Kristian L. Funck â—½  
Esben Laugesen â—½  
Pernille Høyem â—½  
Brian Stausbøl-Grøn â—½  
Won Y. Kim â—½  
...  
Keyword(s):  
Type 2 Diabetes â—½  
Cohort Study â—½  
White Matter â—½  
Arterial Stiffness â—½  
White Matter Hyperintensities â—½  
Cerebrovascular Diseases â—½  
Study Data â—½  
Cerebral White Matter â—½  
Intracranial Volume

Abstract Background Stroke is a serious complication in patients with type 2 diabetes (T2DM). Arterial stiffness may improve stroke prediction. We investigated the association between carotid-femoral pulse wave velocity [PWV] and the progression of cerebral white matter hyperintensities (WMH), a marker of stroke risk, in patients with T2DM and controls. Methods In a 5-year cohort study, data from 45 patients and 59 non-diabetic controls were available for analysis. At baseline, participants had a mean (± SD) age of 59  ±  10 years and patients had a median (range) diabetes duration of 1.8 (0.8–3.2) years. PWV was obtained by tonometry and WMH volume by an automated segmentation algorithm based on cerebral T2-FLAIR and T1 MRI (corrected by intracranial volume, cWMH). High PWV was defined above 8.94 m/s (corresponding to the reference of high PWV above 10 m/s using the standardized path length method). Results Patients with T2DM had a higher PWV than controls (8.8  ±  2.2 vs. 7.9  ±  1.4 m/s, p  <  0.01). WMH progression were similar in the two groups (p  =  0.5). One m/s increase in baseline PWV was associated with a 16% [95% CI 1–32%], p  <  0.05) increase in cWMH volume at 5 years follow-up after adjustment for age, sex, diabetes, pulse pressure and smoking. High PWV was associated with cWMH progression in the combined cohort (p  <  0.05). We found no interaction between diabetes and PWV on cWMH progression. Conclusions PWV is associated with cWMH progression in patients with type 2 diabetes and non-diabetic controls. Our results indicate that arterial stiffness may be involved early in the pathophysiology leading to cerebrovascular diseases.

Development and validation of morphological segmentation of age-related cerebral white matter hyperintensities

NeuroImage â—½  
2009 â—½  
Vol 47 (1) â—½  
pp. 199-203 â—½  
Author(s):  
Richard Beare â—½  
Velandai Srikanth â—½  
Jian Chen â—½  
Thanh G. Phan â—½  
Jennifer Stapleton â—½  
...  
Keyword(s):  
White Matter â—½  
White Matter Hyperintensities â—½  
Cerebral White Matter â—½  
Morphological Segmentation â—½  
Age Related â—½  
Development And Validation

Cerebral white matter Hyperintensities in HIV–positive patients

2018 â—½  
Vol 14 (1) â—½  
pp. 10-18 â—½  
Author(s):  
Alice Trentalange â—½  
Adolfo Prochet â—½  
Daniele Imperiale â—½  
Jessica Cusato â—½  
Mariacristina Tettoni â—½  
...  
Keyword(s):  
White Matter â—½  
White Matter Hyperintensities â—½  
Cerebral White Matter â—½  
Hiv Positive
Sign in / Sign up

Export Citation Format

Share Document