Internal carotid artery dissection among younger and older patients with acute ischemic stroke.

Purpose/Aim of the study: Carotid artery dissection (CAD) is a known causative factor in the etiology of acute ischemic stroke in young patients. However, the significance of CAD in older patients with acute ischemic stroke is unclear with only a few prior clinical studies. In order to isolate the influence of CAD as an independent factor, we performed multivariate analyses of common covariables in acute ischemic stroke patients in northern Israel. MATERIALS AND METHODS: Three hundred and forty-seven consecutive patients who suffered from acute ischemic stroke had initial CT angiography (CTA) ordered from the emergency room. We reviewed the CTAs for radiologic signs of CAD, and recorded patients' demographic and clinical data from the hospital's computerized information system. RESULTS: Eighteen of the 347 patients (5.19%) had CTA evidence of CAD, with no statistically significant differences based on age, gender or ethnicity. A statistically significant inverse association between hypertension and a lower rate of CAD was found before and after stepwise logistic regression, while hyperlipidemia showed a trend toward a similar inverse association that was borderline for statistical significance. CONCLUSIONS: Our study shows that CAD is an independent and significant causative factor for acute ischemic stroke. Therefore, diagnostic imaging is indicated to rule out CAD not only in young patients, but rather in all patients with acute ischemic stroke. The inverse correlation between common vascular risk factors (i.e. hypertension and hyperlipidemia) and CAD points to CAD as an independent nonatherosclerotic causative factor in the etiology of acute ischemic stroke.

Microembolic signals in patients with acute nonembolic stroke.

BACKGROUND: The nature of microembolic signals (MES) in patients without apparent sources of embolism remains elusive. We hypothesize that MES in acute stroke patients without an embolic source may represent a transient phenomenon related to blood rheology or clot dissolving, in which case the characteristics of such MES would differ from those with definitive sources of emboli. METHODS: We compared the intensity and duration of 250 MES in 62 acute nonembolic stroke patients (stroke group) and 217 MES in 57 patients with asymptomatic carotid stenosis (≥50%; carotid group). RESULTS: The duration of MES was significantly different between the 2 groups (24.86 ± 0.89 ms in the carotid group v 18.8 ± 0.83 in the stroke group; P < .001). When comparing the groups for MES with an intensity higher than 6 dB, a highly significant difference in the duration of MES was found (27.87 ± 1.26 ms in the carotid group v 18.57 ± 1.29 ms in the stroke group; P < .0001). A strong linear relationship between the duration and intensity of MES was found for the carotid group, but not for the stroke group. CONCLUSIONS: There are significant differences between the characteristics of MES in acute stroke patients as compared with MES in patients with carotid plaques. There is a strong correlation between the intensity and duration of MES from a definitive embolic source, which is absent from MES in patients with nonembolic stroke. These findings may point to the different mechanisms of MES origin in the examined groups.

Are there disparities in acute stroke treatment between the Jewish and Arab populations in Israel? Results from the National Acute Stroke Israeli registry.

BACKGROUND: According to the latest reported data from the National Acute Stroke Israeli Survey (NASIS), around 18,000 strokes occur annually in Israel. Data regarding disparities in stroke care between the Jewish and the Arab populations in Israel are lacking. AIMS: We wished to compare demographics, comorbidities, stroke characteristics and outcomes between Jewish and Arab stroke patients in Israel that were acutely treated with intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT), in order to test if there are disparities or any ethnic-specific parameters. METHODS: The National Acute Stroke Israeli registry of patients undergoing revascularization (NASIS-REVASC) prospectively enrolled patients in six comprehensive stroke centers between 1/2014 and 3/2016. In this observational research, we compared demographics, comorbidities, time metrics, stroke characteristics and outcomes between Jewish and Arab patients enrolled. RESULTS: NASIS-REVASC included 1432 patients out of which 143 (10%) were of Arab ethnicity and 1289 (90%) of Jewish ethnicity. Arab patients were significantly younger (66 ± 14 vs. 73 ± 29, p = 0·004), exhibited higher rates of smoking and diabetes (31% vs. 18% and 57% vs. 34%, p < 0·001 for both), and were less often treated with systemic thrombolysis (48% vs. 59%, p = 0·012). However, the rates of any interventional treatment with either intravenous thrombolysis or endovascular thrombectomy as well as the rates of favorable outcomes and mortality were comparable between groups. CONCLUSIONS: Despite several baseline differences between Arab and Jewish Israeli stroke patients, treatment allocations, survival and functional outcomes were similar indicating lack of disparity in stroke care among patients treated acutely with IVT and/or EVT in Israel. DATA ACCESS STATEMENT: Full data is available following a formal request to the NASIS-REVASC registry at the Israeli Health Ministry.

Ethnic disparities in first primary intracerebral hemorrhage in northern Israel.

BACKGROUND: Ethnic differences among first primary intracerebral hemorrhage (PICH) patients in an Israeli biethnic population have not yet been studied. PATIENTS AND METHODS: We included in the study 546 patients (counting warfarin-related hemorrhages) hospitalized during the period from December 1999 through June 2008. RESULTS: The mean age was 71.1 +/- 14 years for the Jewish patients and 63.3 +/- 13.9 years for the Arab patients (p < 0.0001). Diabetes and smoking were significantly more frequent among the Arab patients. No difference was found between groups by location, extent, or ventricular involvement of PICH. Although the in-hospital mortality rate was significantly higher among the Jewish patients, adjustment of the model combining multiple risk factors for PICH eliminated this difference. CONCLUSIONS: There are differences in the demographic and vascular risk factor profiles between Arab and Jewish PICH patients, with the Arabs found to be younger and to suffer more from diabetes. The location and extent of intracerebral hemorrhage as well as functional outcome were similar between the two groups. The apparent higher in-hospital mortality in the group of Jewish patients was eliminated when the influence of multiple covariates other than ethnicity, main vascular risk factors and international normalized ratio level were taken into consideration.

Ethnic differences in ischemic stroke of working age in northern Israel.

BACKGROUND: There are currently no comparative data about ethnic differences in ischemic stroke in Arab and Jewish populations. METHODS: Data on 727 consecutive Arab and Jewish patients of working age (

The effect of TEE on treatment change in patients with acute ischemic stroke.

BACKGROUND AND PURPOSE: Ischemic stroke is a widespread disease carrying high morbidity and mortality. Transesophageal echocardiography (TEE) is considered an important tool in the work-up of patients with acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients; its utility is limited by a semi-invasive nature. The purpose of this study was to evaluate the probability of treatment change due to TEE findings (yield) in the work-up of AIS and TIA patients. METHODS: Retrospective data on patients with AIS or TIA who underwent TEE examination between 2000-2013 were collected from the institutional registry. RESULTS: The average age of 1284 patients who were included in the study was 57±10.4, 66% of patients were male. The most frequent TEE findings included aortic plaques in 54% and patent foramen ovale (PFO) in 15%. TEE findings led to treatment change in 135 (10.5%) patients; anticoagulant treatment was initiated in 110 of them (81%). Most common etiology for switch to anticoagulation was aortic plaques (71 patients); PFO was second most common reason (26 patients). Significant TEE findings (thrombus, endocarditis, tumor) were found in 1.9% of patients, they were more common in young patients (<55; 56% of the patients). CONCLUSIONS: The beginning of anticoagulation treatment in patients with thick and complicated plaques was found frequently in our study. Significant TEE findings, were infrequent, constituted an absolute indication for treatment change and were more common in younger patients.

Effect of time from onset to endovascular therapy on outcomes: the National Acute Stroke Israeli (NASIS)-REVASC registry.

BACKGROUND: Endovascular therapy (EVT) is currently the most effective treatment for emergent large vessel occlusion (ELVO) stroke. Earlier treatment is associated with a better clinical outcome. Our aim was to examine the association between onset-to-EVT (OTE) time and clinical outcomes using real-world nationwide data from the National Acute Stroke ISraeli (NASIS)-REVASC registry. METHODS: Stroke patients undergoing EVT within the Endovascular Capable Centres (ECCs) in Israel between January 2014 and March 2016 were prospectively included. Several clinical and radiological outcomes were evaluated. The association between OTE time and outcomes was analyzed with logistic regression models using time as a continuous variable and then by OTE groups of <2, 2-4, 4-6, and >6 hours. RESULTS: 299 patients with acute stroke were included in the analysis. OTE time was significantly associated with favorable outcomes. ORs for each hour of delay in EVT were 0.84 (95% CI 0.71 to 0.99) for significant early recovery, 0.80 (95% CI 0.68 to 0.94) for discharge to home, 0.80 (95% CI 0.66 to 0.95) for freedom from disability at discharge, and 0.78 (95% CI 0.67 to 0.91) for excellent reperfusion (Thrombolysis in Cerebral Ischemia 3). The <2 OTE group was significantly associated with better outcomes than the ≥2 OTE group including significant early recovery (OR 3.3, 95% CI 1.2 to 9.1), discharge to home (OR 3.32, 95% CI 1.3 to 8.5), and excellent reperfusion (OR 4.6, 95% CI 1.3 to 29.5). The same trend was observed for freedom from disability at discharge and 3 months (OR 2.08, 95% CI 0.7 to 5.7 and OR 2.57, 95% CI 0.8 to 8.3, respectively). Only 1% of transferred patients achieved an OTE time of <2 hours. CONCLUSIONS: Nationwide real-life registry data indicate that benefit from EVT is strongly associated with OTE time and is most prominent within the 'two golden hours' from stroke onset. This time goal may not be applicable in inter-hospital transfer patients.

Impact of previous stroke on outcome after thrombectomy in patients with large vessel occlusion.

BACKGROUND: Many patients with large vessel occlusion (LVO) who are otherwise candidates for endovascular treatment (EVT) have had previous strokes. We aimed to examine the effect of previous stroke on outcome after EVT. METHODS: Consecutive patients with LVO were prospectively entered into a National Acute Stroke registry of patients undergoing EVT. Patients treated with EVT were divided into those with and without previous strokes. The rates of favorable reperfusion status, mortality, and excellent outcome at 90 days post-stroke as well as symptomatic intracranial hemorrhage (sICH) were evaluated. RESULTS: A total of 390 underwent EVT and 35 had previous strokes. Patients with previous strokes were significantly older; more frequently had a history of prior myocardial infarction and more often had pre-existing functional disability. Favorable target vessel recanalization was less frequently achieved in patients with previous strokes (60% vs. 82%; p = 0.005) and ordinal regression analysis for functional outcome revealed higher frequency of deterioration at three months in patients with previous strokes. Nevertheless, 9% of these patients maintained their previous disability state and sICH rates did not differ between the groups. Mortality rates at one year post stroke were significantly higher in patients with previous strokes (37% vs. 16%; p = 0.005). CONCLUSIONS: Previous strokes are associated with higher likelihoods of mortality and unfavorable outcome in patients with LVO undergoing EVT. However, because some of these patients maintain their previous disability state, the presence of previous stroke should not be used as an exclusion criterion from EVT.

Microemboli in MCA ipsilateral to occluded common carotid artery: an observation and short review of the literature.

Sixty-five years old patient suffering from acute stroke was treated by rTPA intravenously. TCD monitoring of both middle cerebral arteries (MCA) was carried out simultaneously with administration of rTPA. Seven microemboli were found in right and four in left MCA. Duplex ultrasound, CT angiography and digital subtractional angiography revealed occlusion of left common carotid artery (CCA) and moderate to severe stenosis of right internal carotid artery (ICA). The case presented here is, to the best of our knowledge, the first description of MCA microemboli signals in patient with occlusion of ipsilateral CCA. This location of occlusion eliminates the possibility of microemboli passage from carotid bulb proximally to the site of occlusion through the ipsilateral external carotid artery or from the distal stump of occluded ICA. The possibility of emboli from contralateral stenosed ICA through the patent anterior communicating artery (ACoA) or from the distal stump of occluded CCA seems to be the most probable explanation.

Ischemic middle cerebral artery stroke missing the tissue plasminogen activator time window: transcranial Doppler evaluation.

We investigated the interconnection between natural history of middle cerebral artery (MCA) recanalization by transcranial Doppler (TCD) and stroke severity in patients not treated by fibrinolysis. A total of 54 patients with an acute MCA stroke were examined within the first 24 hours and again within 120 hours after stroke onset. The first TCD examination detected 16 patients (29.6%) with complete occlusion, 27 patients (50%) with partial occlusion, and 11 patients (20.4%) with patent MCA. There were no significant differences among groups according to mean National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale values. The second examination revealed 7 patients (13.2%) with complete occlusion, 31 patients (58.5%) with partial occlusion, and 15 patients (28.3%) with patent MCA. The mean NIHSS score in patients with total occlusion was significantly higher than in patients without occlusion or with partial occlusion. There was no significant difference in mean NIHSS value between patients with and without improvement on the second TCD examination. We conclude that MCA occlusion by TCD is associated with more severe stroke than that of patients without occlusion or with only a partial occlusion. A later MCA recanalization is not accompanied by significant improvement of neurologic or functional status.

Direct Thrombectomy versus Bridging for Patients with Emergent Large-Vessel Occlusions.

BACKGROUND AND AIMS: Patients with emergent large-vessel occlusion (ELVO) that present earlier than 4 h from onset are usually treated with bridging systemic thrombolysis followed by endovascular thrombectomy (EVT). Whether direct EVT (dEVT) could improve the chances of favorable outcome remains unknown. METHODS: Consecutively, prospectively enrolled patients with ELVO presenting within 4 h of onset were entered into a National Acute Stroke Registry of patients undergoing revascularization. Patients treated with bridging were compared to those treated with dEVT. Excellent outcome was defined as having a modified Rankin Scale score ≤1 at 90 days following stroke. RESULTS: Out of 392 patients that underwent thrombectomy, 270 (68%) presented within 4 h and were included. Of those, 159 (59%) underwent bridging and 111 (41%) underwent dEVT. Atrial fibrillation and congestive heart failure were more common in the dEVT group (43 vs. 30%, p = 0.04 and 20 vs. 8%, p = 0.009, respectively), but other risk factors, demographics, stroke severity and subtypes as well as baseline vessel patency state and time metrics did not differ. Excellent target vessel recanalization defined as TICI 3 (thrombolysis in cerebral infarction score) was more common in the dEVT group (75 vs. 61%, p = 0.03), but in-hospital mortality, discharge destinations, short- and long-term excellent outcome rates did not differ. On multivariate regression analysis, treatment modality did not significantly modify the chances of excellent outcome at discharge (OR 0.7; 95% CI 0.3-1.5) or at 3 months (OR 0.78 95% CI 0.4-1.4). CONCLUSIONS: The chances of attaining excellent functional outcomes are similar in ELVO patients undergoing dEVT or bridging.

Pre-admission CHA2DS2-VASc score and outcome of patients with acute cerebrovascular events.

BACKGROUND: The CHA2DS2-VASc score has been recommended for the assessment of thromboembolic risk in patients with atrial fibrillation. Data regarding the association between the pre-admission CHA2DS2-VASc score and the outcome of patients with stroke and TIA are scarce. We aimed to assess the predictive value of pre-admission CHA2DS2-VASc score for early risk stratification of patients with acute cerebrovascular event. METHODS: The study group consisted of 8309 patients (53% males, mean age of 70±13.3years) with acute stroke and TIA included in the prospective National Acute Stroke Israeli (NASIS) registry. The two-primary end-points were in-hospital mortality and severe disability at discharge. We divided the study population into 4 groups according to their pre-admission CHA2DS2-VASc score (0-1, 2-3, 4-5, >5). RESULTS: Following a multivariate analysis odds ratios (OR) for all-cause mortality increased for CHA2DS2-VASc score >1 (OR=2.1 95% CI=1.2-3.6, OR=1.8 95% CI=1.1-3.2, OR=1.8 95% CI 1.1-3.3, for patients with CHA2DS2-VASc score of 2-3, 4-5 and >5, respectively, p<0.001). OR for severe disability (mRS 4-5) at discharge increased significantly in direct association with the CHA2DS2-VASc score (OR=1.55 95% CI=1.14-2.12, OR=2.42 95% CI=1.8-3.3, OR=3 95% CI 2.19-4.27, for patients with CHA2DS2-VASc score of 2-3, 4-5 and >5, respectively as compared with 0-1, p<0.001). Each 1-point increase in the CHA2DS2-VASc score was associated with a 21% increase in the risk for severe disability. CONCLUSIONS: High-risk pre-admission CHA2DS2-VASc score among patients with acute cerebrovascular events is associated with higher in-hospital mortality and severe disability at discharge.

Distribution of artificial cerebral microemboli in stroke patients with patent foramen ovale.

OBJECTIVES: Patent foramen ovale (PFO) is considered as an important risk factor for cerebrovascular diseases. Nevertheless, the relationship between the distribution of high-intensity transient signals (HITS), resulting from injection of air mixed with saline and detected by transcranial Doppler (TCD), and clinical cerebrovascular syndromes in these patients has not been investigated. METHODS: Using TCD, we screened 40 patients with stroke or transient ischemic attack (TIA), in whom PFO was proven by transesophageal echocariography (TEE). Of these, 30 patients (75%) with artificially produced HITS either in the middle cerebral artery (MCA) or the basilar artery (BA) were included in the analysis. RESULTS: Nineteen patients had a stroke or TIA in the carotid territory and 11 patients in the vertebro-basilar territory. HITS were found in the MCA in all 30 patients and in 21 of the 30 patients in the BA. Of the latter, ten patients were in the carotid group and 11 patients were in the veretebro-basilar group, p = 0.011. CONCLUSION: There is a significant association between the distribution of artificial HITS and the clinical cerebrovascular syndromes.

Velocity of microemboli and transit time from the heart to the brain in patients with patent foramen ovale and artificial heart valves.

There is no information about the physical behavior of microemboli en route from their source to the cerebral vessels. Microemboli could abide to a certain laminae, and have a consistent velocity, or wander between different laminae, and keep changing their velocity. Two hundred and seventy four microemboli were recorded by transcranial Doppler (TCD) in six patients with artificial valves, and 119 microemboli were recorded in response to i.v. injection of saline agitated with air in eight patent foramen ovale (PFO) patients. Transit time of microemboli, calculated based on their arrival time at the cerebral vessel (site of monitoring) was explored as a possible function of their measured velocity at the detection point. In the PFO group, the relation between embolus velocity and transit time was: embolus velocityPFO = -41.8 * transit time + 100.6, whereas for the artificial heart valve group it was: embolus velocityValve = -22.6 * transit time + 67.1. Transit time, in both clinical groups, was inversely related to velocity (p < 0.001), thus, early appearing emboli had higher velocity and vice versa. The inverse relation between transit time and measured terminal velocity implies a consistent velocity per microemboli en route, in both groups. Thus, a flow abided to a certain laminae seems to characterize microemboli.

The positions of the patients in the diagnosis of patent foramen ovale by transcranial Doppler.

BACKGROUND AND PURPOSE: There is no information about the optimal position of a patient for the performance of a transcranial Doppler (TCD) examination to detect patent foramen ovale (PFO). Such information is important to improving the sensitivity of the test in comparison to the gold standard of transesophageal echocardiography (TEE). METHODS: Thirty-four patients with TEE-proved PFO were examined by contrast TCD. Examinations were done in both the sitting and supine positions in random order. RESULTS: Eight hundred ninety-two microemboli were recorded. Patients' positions and the sequence of testing did not affect the number of microemboli detected. Yet for each individual, 1 of the 2 positions was more sensitive. CONCLUSIONS: To improve the sensitivity of TCD in the detection of PFO, it is recommended, in the case of a first negative test, to change the patient's position for a repeated TCD examination.

Clinical and imaging findings in patients with neurosyphilis: a study of a cohort and review of the literature.

BACKGROUND: Most patients with neurosyphilis are considered asymptomatic. The diagnosis is challenging and the role of neuroimaging is not yet well established. The present study was conducted to focus on the clinical findings and further characterize the imaging features of the disease, along with a review of the pertinent literature. METHODS: Six male patients with neurosyphilis based on abnormal cerebrospinal fluid findings, five of whom were asymptomatic at presentation, underwent cranial computerized tomography (CT) and magnetic resonance imaging (MRI). They also underwent a complete physical, neurological, and ophthalmological examination, with special attention paid to atherosclerotic vascular risk factors. In addition, all were examined for cardiac involvement using electrocardiography and cardiac ultrasound. RESULTS: The meticulous neurological and ophthalmological examination revealed abnormalities in five patients, most commonly cranial nerve involvement (three patients) and hemiparesis (two patients). The CT and MRI studies revealed abnormalities in five of the six patients, and in all six patients, respectively. The most common findings were brain infarcts, which were demonstrated in four of the six patients. MRI was found to be more sensitive than CT in detecting these brain infarcts, as expected. CONCLUSIONS: Vascular insult was the most common neuroimaging finding in our patients with neurosyphilis, probably due to meningovascular endarteritis. Neurosyphilis should always be considered in young patients with unexplained brain infarcts.

Gender differences in characteristics, management and outcome at discharge and three months after stroke in a national acute stroke registry.

BACKGROUND: The importance of gender as an independent risk factor for poor outcome is not clear. We examined gender differences in patients' characteristic, management and outcome at discharge and 3-months after acute stroke in a national hospital-based registry. METHODS: Data were derived from the triennial two-month national Acute Stroke Israeli Registry (Feb-March 2004, March-April 2007, April-May 2010). Unselected patients in all Israeli hospitals (n = 28) were included. Outcome at 3-month was assessed in a sub-sample. Logistic regression models were used in the study of gender as an independent risk factor for poor outcome. RESULTS: In total, 5034 patients (88.5% ischemic stroke, 9.6% ICH and 1.9% undetermined stroke) were included, of them 2285 (45.4%) women. Follow-up at 3-month was completed for 1040 patients, 41.9% women. Women showed higher rates of cardiovascular risk factors in-hospital death (p = 0.007) and poor functional outcome (p < 0.0001). Following adjustment for age, prior disability, NIHSS, prior stroke and risk factors, risk estimates (ORs, 95%CI) for women compared to men were 0.72 (0.55-0.96) for in-hospital death, 1.03 (0.83-1.29) for discharge to a nursing home or death, and 1.01 (0.86-1.20) for disability. Poor outcomes at 3-month were significantly more common in women; however, adjusted risk estimates were not significantly increased: OR 0.95 (95%CI 0.50-1.81) for death at 3-months, 1.41 (0.99-2.01) for Barthel Index ≤ 60, 1.24 (0.90-1.72) for dependency and 0.88 (0.55-1.39) for living in a nursing home or death. CONCLUSION: Gender-differences in risk of death and poor functional outcome after stroke are mainly explained by dissimilarities in patients' characteristics and stroke severity.

Aortic atheromas in acute ischemic stroke patients in northern Israel.

AIM: There are currently no data on ethnic differences in aortic atherosclerosis in Arab and Jewish patients from northern Israel with acute ischemic stroke. METHODS: Data on demographic and risk factors alongside transesophageal echocardiography (TEE) data and treatment details for 509 patients with acute ischemic stroke were included in the study. RESULTS: The patients with aortic atheromas were older and had significantly more frequent vascular risk factors (hypertension, hyperlipidemia, and smoking), as well as vascular disease (ischemic heart disease, peripheral vascular disease, and carotid plaques). They were also treated with statins more often than those without aortic atheroma. Logistic regression analysis showed that age, smoking, ethnicity, and the presence of carotid plaques were independent predictors for aortic atheromas. Aortic plaques were found more frequently in Jewish patients than Arab patients (160 (41.9%) vs. 35 (27.3%); p= 0.003). This finding did not change after adjustment for age, sex, all vascular risk factors, and type of antithrombotic treatment. We did not find any difference between Arab and Jewish patients in the distribution of plaques by location or complexity before and after adjustment for age, sex, all vascular risk factors, or type of antithrombotic or lipid-lowering treatment. CONCLUSIONS: Our findings emphasize the influence of ethnicity on the prevalence of aortic atheromas in acute ischemic stroke patients in northern Israel. The search for genetic, cultural, socioeconomic, and other factors explaining these ethnic differences should be the topic of future studies.