Prevalence of high-risk aortic arch atherosclerosis features on computed tomography angiography in embolic stroke of undetermined source.

INTRODUCTION: Embolic stroke of undetermined source (ESUS) comprises a heterogenous group. There is a need to further identify etiologies within this group to guide management strategies. We examined the prevalence of aortic arch atherosclerosis (AAA) on CT angiography (CTA) in patients with embolic stroke of undetermined source (ESUS) to characterize high-risk plaque features. METHODS: All patients from two prospective multicenter acute ischemic stroke studies (INTERRSeCT and PRove-IT) were included if the CTA adequately imaged the proximal aortic arch and the stroke etiology was recorded. Three readers blinded to stroke etiology analyzed the following AAA plaque features on baseline CTA at the time of stroke: 1) thickness in millimetres (mm); 2) morphology (none, smooth, ulcerated, or protruding); 3) location within the aortic arch (proximal, transverse, or distal); and 4) calcification (none, single small, multiple small, single large, or diffuse extensive). RESULTS: We included 1063 patients, of which 293 (27.6%) had ESUS (mean age 67.5 years; 46.4% men; median NIHSS 12; 80.6% large vessel occlusion). Mean AAA thickness was significantly larger in ESUS patients (3.8 mm) compared to non-ESUS patients (3.0 mm; p<0.0001) and to a subgroup of patients with large artery atherosclerosis (2.9 mm; p=0.003). ESUS patients had a significantly higher proportion of ulcerated or protruding plaques (17.4% vs 10.3%; risk ratio 1.7, 95% C.I. 1.2-2.4, p=0.002). The location of AAA in the ESUS group was the ascending aorta in 37.9%, transverse arch in 42.3%, and descending aorta in 84.6%. Although AAA was mostly located in the distal aortic arch, ulcerated or protruding plaques were least common in the distal arch (p=0.002). There was no difference between ESUS and non-ESUS patients in plaque location (p=0.23) or calcification grade (p=0.092). CONCLUSION: ESUS patients in our study had thicker AAA and a higher prevalence of ulcerated or protruding plaques located more proximally within the aortic arch. High-risk plaque features may suggest a causal role of AAA in the ESUS population with visible intracranial occlusions.

Basilar artery stenting in hyperacute stroke: A systematic review of published cases.

BACKGROUND AND PURPOSE: Basilar artery stenting is a rescue therapy in the management of hyperacute stroke. Published data on efficacy and safety are limited. METHODS: A systematic review of published studies was performed in accordance with PRISMA guidelines. Inclusion criteria were adult patients with ischemic stroke with permanent basilar artery stent placement within 48 h of onset. Data were extracted by two independent reviewers. Additional cases from our institution were identified via a local stroke registry. RESULTS: Of 212 screened articles, patient-level data was reported in 35 studies (87 individuals) and six additional patients were included from our registry. Patients (n = 93, 63 % male; median age 64) most often presented with mid-basilar occlusion (52 %) and 76 % received treatment within 12 hours of onset. Favorable angiographic results occurred in 67 %. The final modified Rankin Scale score (mRS) was 0-3 for 56 % of patients; mortality was 29 %. Those with complete flow post-procedure were more likely to have a final mRS of 0-3 (p = 0.05). CONCLUSIONS: In 93 cases of basilar stenting in hyperacute stroke, favourable angiographic and functional outcomes were reported in 67 % and 56 % of patients, respectively. International multicenter registries are required to establish benefit and identify patient and technical factors that predict favorable outcomes.

Transcultural Adaptation and Validation of Kannada version of the National Institute of Health Stroke Scale (NIHSS).

Background and Purpose: The National Institute of Health Stroke Scale (NIHSS) is widely used in clinical practice to evaluate stroke-related neurological deficits. The aim of this study was to develop Kannada language version of the NIHSS (Ka-NIHSS) and determine its validity and reliability. Materials and Methods: In the first phase of the study, Ka-NIHSS was adapted based on cultural and linguistic peculiarities. In the next phase, 51 acute stroke patients were prospectively enrolled in the study. The concurrent validity of the Ka-NIHSS was evaluated by comparison with the Glasgow Coma Scale (GCS) and the modified Rankin Scale (mRS). The predictive validity was assessed by comparison with Barthel Index (BI) score and mRS at a 90-day telephonic follow-up. The reliability was evaluated using the kappa statistics for inter-rater agreement between two independent raters and intra-class correlation coefficient (ICC) analysis. The inter-rater agreement of videotaped assessment of items 9 and 10 between four independent raters was evaluated using kappa statistics. Results: Ka-NIHSS scores highly correlated with GCS (P = -0.74 P < 0.001) and mRS (P = 0.85, P < 0.001) at baseline. It moderately correlated with mRS (P = 0.67, P < 0.001) and BI (P = -0.64, P < 0.001) at 90 days follow up. Inter-rater reliability was high between the two examiners, with kappa values ranging from 0.66 to 0.95. The inter-rater agreements of the video assessment of items 9 and 10 for nine patients among four raters were 0.81 and 1 respectively. Conclusions: Ka-NIHSS is a valid and reliable tool for assessing neurological deficits in Kannada-speaking stroke patients.