Stroke phenotype in cannabis users among young adults with ischemic stroke.

BACKGROUND AND PURPOSE: Incidence of ischemic stroke in young adults has been steadily increasing over the past 20 years. One hypothesis to explain this phenomenon is the increase in the use of illicit drugs, including cannabis. However, the mechanisms and the clinical presentation of ischemic stroke associated with cannabis use are unclear. The objective of this study was to describe the phenotype of ischemic stroke in cannabis users compared to nonusers among a population of young adults with a first-ever ischemic stroke. METHODS: Patients aged 18-54 years consecutively hospitalized in a university department of neurology for a first-ever ischemic stroke from January 2017 to July 2021 were included. Drug use over the past year was assessed by a semistructured interview, and the stroke phenotype was described using the ASCOD classification. RESULTS: A total of 691 patients, including 78 of 691 (11.3%) cannabis users, were included. Cannabis use was independently associated with potential A1 (odds ratio [OR] = 3.30, 95% confidence interval [CI] = 1.45-7.5, p = 0.004) and uncertain A2 (OR = 13.1, 95% CI = 2.89-59.4, p < 0.001) atherosclerotic cause of stroke after adjustment for vascular risk factors including tobacco and other drug use. Moreover, the association of atherosclerosis and cannabis use was significant for frequent (OR = 3.13, 95% CI = 1.07-8.6, p = 0.030) and daily cannabis use (OR = 4.43, 95% CI = 1.40-13.4, p = 0.008), but not for occasional use. CONCLUSIONS: We found a significant, independent, and graded association of cannabis use with the atherosclerotic stroke phenotype.

Migraine and large artery atherosclerosis in young adults with ischemic stroke.

INTRODUCTION: Migraine is a risk factor for ischemic stroke, but the mechanisms of stroke associated with migraine are debated. The aim of this study was to investigate the association between migraine and large artery atherosclerosis (LAA) in young adults with ischemic stroke. METHODS: Patients aged between 18 and 54 years consecutively treated for first acute ischemic stroke in a university hospital stroke unit between January 2017 and December 2019 were included in this cross-sectional study. Migraine status was systematically assessed by the same headache specialist. Stenotic and nonstenotic LAA of extracranial and intracranial cerebral arteries were evaluated and graded using the ASCOD (atherosclerosis, small-vessel disease, cardiac pathology, other causes, dissection) criteria. We adjusted the association between migraine and LAA for traditional risk factors. RESULTS: A total of 415 patients were included (mean age [standard deviation], 43.9 [8.7] years; 258/415 [62.2%] men). Migraine with aura (MWA) was diagnosed in 76 patients, and migraine without aura (MWoA) in 68 patients. Patients with migraine had fewer traditional cardiovascular risk factors. Stenotic LAA (10/144 [6.9%] vs. 42/271 [15.5%]; p < 0.001) and LAA of any grade (35/144 [24.3%] vs. 138/271 [50.9%]; p < 0.001) were significantly less frequent in patients with migraine than in patients without migraine, respectively. Multivariable analysis adjusting for age, sex, overweight, tobacco use, hypertension, diabetes, and hyperlipidemia showed a negative association between migraine and LAA of any grade (odds ratio [OR] = 0.44, 95% confidence interval [CI: 0.254-0.78], p = 0.005). This negative association was found for both MWoA (OR = 0.42, 95% CI [0.204-0.88], p = 0.020) and MWA (OR = 0.47, 95% CI [0.228-0.96], p = 0.037) compared to no migraine. CONCLUSION: In this study of young adults with ischemic stroke, migraine had a negative association with LAA. This negative association was independent of traditional vascular risk factors and was found for both MWA and MWoA.

Carotid Ultrasound for Assessment of Nonobstructive Carotid Atherosclerosis in Young Adults with Cryptogenic Stroke.

BACKGROUND: The role of nonobstructive (<50% stenosis) carotid atherosclerosis (NOCA) in young adults with ischemic stroke is not well understood. In the present study, we investigated the prevalence and the ultrasonic characteristics of NOCA in a consecutive series of young adults with cryptogenic stroke (CS). METHODS: Patients aged 18-54, consecutively treated in a tertiary hospital for first-ever CS (defined as an ischemic stroke without ASCOD (A: atherosclerosis; S: small-vessel disease; C: cardiac pathology; O: other causes) grade 1 potential cause) in the carotid artery territory, were prospectively enrolled. NOCA was assessed using carotid duplex ultrasonography. RESULTS: Of 148 patients with first-ever ischemic stroke, 70 had CS, including 44 patients with carotid CS. NOCA was found in 22 of 44 (50%) patients. All but 1 plaque were echolucent. NOCA was bilateral in 15 patients and unilateral in 7 patients. All unilateral plaques were on the symptomatic side (P = .02). Plaque thickness, plaque length, and plaque volume were greater on the symptomatic side than on the asymptomatic side (P = .001, P < .001, and P < .001, respectively). Discrimination between the symptomatic and the asymptomatic side using any of these plaque metrics was good with areas under the curve (95% confidence interval) of .82 (.69-0.95), .85 (.74-0.96), and .87 (.75-0.99) for plaque thickness, plaque length, and plaque volume, respectively. CONCLUSIONS: NOCA is frequent in young adults with CS. Measurement of the plaque burden with carotid duplex may help to identify symptomatic NOCA.

Tobacco Use and Cryptogenic Stroke in Young Adults.

OBJECTIVE: Cryptogenic stroke is the leading subtype of ischemic stroke in the young. We sought to evaluate the association between traditional cardiovascular risk factors and cryptogenic stroke by using a case-control study. METHODS: Patients aged 18-54 years, consecutively treated for first-ever cryptogenic ischemic stroke in an academic stroke unit, were compared with subjects from the general population living in the same geographic area. Control subjects were matched for age and sex with patients. We further evaluated the association between significant risk factors and nonobstructive (<50% stenosis) carotid plaque and thrombus among patients with cryptogenic stroke. Odds ratios [OR] were calculated using logistic regression analysis. RESULTS: A total of 155 patients with cryptogenic stroke (66.4% men, mean age 43.5 years [SD 8.4]) were included in the study. Cryptogenic stroke was associated with current tobacco use (42.6% in patients versus 23.9% in control subjects; OR = 2.38, 95% confidence interval [CI] 1.40-4.05, P = .002). Current tobacco use was associated with nonobstructive carotid plaque (OR = 6.22; 95% CI, 2.43-15.9; P = .001) and nonobstructive carotid thrombus (OR = 13.7; 95% CI, 1.42-132.7; P = .03) among the patients. CONCLUSION: Our case-control study showed a strong link between current tobacco use and cryptogenic stroke in young adults.

Ultrasound characteristics of carotid web.

BACKGROUND AND PURPOSE: Carotid web (CaW) is a cause of recurrent ischemic stroke that remains underdiagnosed using Duplex ultrasound (DUS). Improved methods and description of its ultrasound's features could allow better detection of CaW. Ultrasound microflow imaging (MFI) is a blood flow imaging technique sensitive to slow flow that could increase CaW detection. This study aimed to describe ultrasound features of CaW using B-mode imaging and MFI. METHODS: In a retrospective monocentric study, patients with CaW on CT angiography who underwent DUS examination of carotid arteries were included. DUS was performed by two nonblinded experienced neurosonologists. The specificity of CaW ultrasound features was evaluated using a group of patients with carotid atherosclerotic plaque (AP). RESULTS: Twenty-four patients with CaW were included. Mean age (standard deviation) was 48 years (11). Seventeen (71%) were females. Fifteen (63%) CaWs were symptomatic. MFI was available for 22 patients. B-mode imaging demonstrated the characteristic CaW appearance in 19/24 (79%) patients as a protruding triangular iso-hypoechoic lesion on longitudinal view. CaW were detected on axial view in only 9/24 (38%) patients. MFI displayed slow blood flow above CaW during systole and allowed it delineation, appearing as a thin triangular endoluminal defect in 18/22 (82%) cases. Based on MFI and B-mode, 21/22 (95%) CaWs were visible, including three CaWs only with MFI. These ultrasound features were not found among 24 patients with AP. CONCLUSION: We report the ultrasound features from a series of 24 CaW. The use of MFI in addition to B-mode imaging improved the detection rate of CaW.

Lipoprotein (a) and carotid atherosclerosis in young patients with stroke.

BACKGROUND AND PURPOSE: Elevated lipoprotein (a) concentration is associated with carotid atherosclerosis in middle-aged and older patients with ischemic stroke. This association has not been explored in young patients with stroke. METHODS: A retrospective analysis of data from patients aged 16 to 54 years consecutively treated for acute ischemic stroke in a tertiary stroke unit during 4.5 years was performed. We graded carotid atherosclerosis using carotid duplex as: no atherosclerosis (A); plaque without stenosis (B); or stenosis≥50% (C). RESULTS: One hundred ninety-six patients were included (male/female: 119/77; mean age±SD: 44.3±8.6 years): 115 in Group A; 67 in Group B; and 14 in Group C. Multivariate analysis using polynomial logistic regression showed a graded association of lipoprotein (a) plasma concentration with carotid atherosclerosis (P<0.001). CONCLUSIONS: Our results showed a positive association of lipoprotein (a) plasma concentration with carotid atherosclerosis in young adults with ischemic stroke. This association was strong, graded, and independent of traditional risk factors including cholesterol.

Restenosis is more frequent after carotid stenting than after endarterectomy: the EVA-3S study.

BACKGROUND AND PURPOSE: Carotid angioplasty and stenting (CAS) may be more often associated with residual or recurrent stenosis than carotid endarterectomy (CEA). We compared the rates of restenosis in patients treated with CAS or CEA in the EVA-3S trial. METHODS: Five hundred seven patients (242 treated by CAS and 265 by CEA) had carotid ultrasound follow-up (mean carotid ultrasound follow-up, 2.1 years) according to a predefined protocol. Carotid restenosis of 50% to 69% was diagnosed on planimetry, whereas carotid restenosis of ≥70% or occlusion was diagnosed using either planimetry or velocity criteria. RESULTS: The rate of carotid restenosis of ≥50% or occlusion was significantly higher after CAS (12.5%) than after CEA (5.0%; time ratio, 0.16; 95% CI, 0.03-0.76; P=0.02). The rates of severe restenosis of ≥70% or occlusion were low and did not differ significantly between the 2 groups (3-year rates are 3.3% in the CAS group and 2.8% in the CEA group). Age at baseline was the only vascular risk factor significantly associated with carotid restenosis. Our study could not detect any effect of carotid restenosis on ipsilateral stroke. CONCLUSIONS: The short-term rate of carotid restenosis of ≥50% or occlusion is ≈2.5-times more common after CAS than after CEA, a difference accounted for by an excess risk in moderate restenosis. More data with longer follow-up are needed to assess the rates of late severe restenosis and to determine the relation between restenosis and recurrent stroke over time.

Cardiovascular autonomic neuropathy and other complications in type 1 diabetes.

OBJECTIVE AND METHODS: This study deals with cardiovascular autonomic neuropathy (CAN) in type 1 diabetic patients and its association with other complications. We searched for CAN in 684 patients (age, 47 +/- 12 years; diabetes duration, 22 +/- 11 years) by cardiovascular responses to deep breathing and standing. Patients considered as positive had laboratory evaluation: "Ewing" tests (deep breathing, Valsalva, stand test, hand grip); heart rate variability (HRV) [low frequency (LF) and high frequency (HF) power] and spontaneous baroreflex slope (SBS). Logistic regression was used to identify the combination of patient characteristics, including other complications, most associated with CAN severity according to Ewing Score (ES 0-5). RESULTS: 66.2% presented no significant abnormality (ES 0-0.5), 21.5 % had mild abnormalities (ES 1-2), and 12.3% had confirmed autonomic failure (ES > 2). Decrease in LF, HF and SBS was highly correlated to CAN severity. In the stepwise regression, age, retinopathy, nephropathy, bladder dysfunction, erectile dysfunction, peripheral neuropathy and hypertension remained correlated with CAN, whereas digestive neuropathy, BMI and HbA1c were excluded. Despite a small number of events, we found a significant association between coronary disorders and CAN severity. CONCLUSIONS: Simple bedside tests can detect CAN. HRV and SBS provide additional elements on CAN severity. Diabetes duration did not discriminate sufficiently patients with CAN. The association with retinopathy is in favor of the role of poor glycemic control in CAN development. This study shows the interest of CAN detection and the need to look for extracardiac autonomic neuropathy and silent myocardial ischemia in patients with confirmed CAN.