Muhib Khan

BACKGROUND: Cervical artery dissection (CeAD) may result in dissecting aneurysm (DA) formation. We aimed to characterize risk factors and clinical outcomes associated with DA in a large, international CeAD cohort. METHODS: We performed a secondary analysis of STOP-CAD (Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection), an international, multicenter, retrospective cohort. Patients with spontaneous CeAD were assessed for DA at baseline and de novo DA formation. Significant covariates in univariable analysis were included in multivariable regression models aiming to identify factors associated with DA formation. Logistic regression and Cox proportional hazards models evaluated the association of DA with ischemic and hemorrhagic outcomes. RESULTS: Among 4008 patients with CeAD, 546 (13.6%) had a DA at baseline, and 221/2938 (7.5%) patients developed a de novo DA during follow-up, of which 172/221 (78.2%) were detected in the first 180 days. Patients with DA had a mean age of 47 years, and 383 (49.9%) were women. Baseline or de novo DA was associated with a history of connective tissue disorder (adjusted odds ratio [aOR], 2.02 [95% CI, 1.22–3.36]), fibromuscular dysplasia (aOR, 1.69 [95% CI, 1.28–2.25]), and multiple vessel dissection (aOR, 1.53 [95% CI, 1.19–1.98]). Lower odds of DA were seen in Hispanic ethnicity (aOR, 0.64 [95% CI, 0.43–0.97]) and ischemic stroke presentation (aOR, 0.41 [95% CI, 0.34–0.49]). Fibromuscular dysplasia was associated with de novo DA formation (aOR, 2.30 [95% CI, 1.52–3.49]). DA was not associated with ischemic stroke (hazard ratio, 0.71 [95% CI, 0.44–1.16]; P =0.173) or intracranial hemorrhage (HR, 1.09 [95% CI, 0.42–2.84]; P =0.86) by day 180. CONCLUSIONS: DAs are relatively common manifestations of CeAD, typically occurring within 6 months of CeAD diagnosis. DA was not associated with an increased risk of subsequent ischemic stroke or intracranial hemorrhage.

BACKGROUND: Intracranial atherosclerosis (ICAS) is associated with an increased risk of early recurrent ischemic stroke. We evaluated whether biomarkers of impaired distal perfusion—specifically, anterior circulation borderzone infarct, and hypoperfusion mismatch volume—were associated with recurrent ischemic stroke within 90 days. METHODS: The BIORISK ICAS (Biomarkers and Recurrence Risk in Symptomatic Intracranial Atherosclerosis) is a multicenter retrospective international study (35 sites) that included hospitalized patients with symptomatic ICAS (50%–99% luminal stenosis of the intracranial vertebral, basilar, distal internal carotid, or proximal middle cerebral artery) from January 2019 to June 2024. The primary outcome was recurrent ischemic stroke in the territory of the symptomatic artery within 90 days. In the primary analysis, the exposure was an acute anterior circulation borderzone infarct. In secondary analysis of the subset with presentation within 72 hours of last known normal and perfusion imaging completed, the exposure of interest was prespecified as hypoperfusion mismatch volume at T _max (time to maximum) threshold of 6 seconds, dichotomized at the Youden index. We performed multivariable Cox regression to test associations between exposure variables and the outcome, adjusting for clinically relevant variables and those associated with the outcome ( P <0.1). RESULTS: Of 2050 patients with symptomatic ICAS, 1737 (84.7%) presented within 72 hours of symptom onset, among whom 509 (29.3%) underwent perfusion imaging. The primary analysis included 1891 patients; 174 (9.2%) patients had recurrent ischemic stroke in the symptomatic arterial territory. In adjusted Cox regression models, there was an association between anterior circulation borderzone infarct and recurrent ischemic stroke at 90 days (adjusted hazard ratio, 1.40 [95% CI, 1.02–1.93]). In the perfusion imaging analysis, hypoperfusion mismatch of ≥10 mL was associated with recurrent ischemic stroke (adjusted hazard ratio, 1.83 [95% CI, 1.03–3.28]). CONCLUSIONS: Biomarkers of impaired distal perfusion, anterior circulation borderzone infarct, and hypoperfusion mismatch were associated with increased risk of recurrent ischemic stroke. These findings support the use of perfusion imaging in ICAS as well as future trials investigating early reperfusion in high-risk patients with ICAS.

Background Patent foramen ovale (PFO) closure is recommended for patients younger than 60 years with cryptogenic stroke, including embolic stroke of undetermined source (ESUS). However, the role of PFO closure in patients older than 60 years remains uncertain. We aim to investigate the benefits of PFO closure in young-older patients (aged between 60 and 70 years) with cryptogenic stroke. Methods Patients older than 60 years with cryptogenic stroke from large tertiary hospitals who received a PFO closure after a multidisciplinary brain-heart case conference, compared to an age-matched cohort of patients with cryptogenic stroke. Demographcis, vascular risk factors, and risk of paradoxical embolism (RoPE) score were collected for comparison between two groups. The primary outcome included recurrent ischemic stroke that occurred up to 5 years following PFO closure between the two groups. The safety outcome was the occurrence of any complications after PFO closure, including new-onset atrial fibrillation (AF). Results A total of 102 patients with cryptogenic stroke were included (mean age 66±4), 56 male (55%), who had a PFO closure. Procedure-related complications, including new onset transient AF, were low (1%). There was no statistical difference between two groups in patients demographic and clinical characteristics, but the RoPE score was significantly higher in the PFO closure group than in the control group. After a median follow-up of 54 months, patients in the PFO closure group demonstrated a relatively low incidence of recurrent ischemic stroke (3.9%, 4/102), compared to an age-matched control cohort with a median follow-up of 51 months, which had a higher recurrence rate (8.2%, 8/97). Conclusions In patients with cryptogenic stroke who are older than 60 years, PFO closure demonstrated safety profiles with a trend of reducing recurrent ischemic stroke compared to their age-matched counterparts. Prospective randomized trials are warranted in this young-older population with cryptogenic stroke and PFO.

Background and Purpose: Corticospinal tract (CST) integrity is an imaging biomarker for predicting upper extremity motor recovery, but data are limited in acute ischemic stroke patients. Our study aimed to assess the impact of CST disruption on upper extremity motor recovery after acute ischemic stroke. Methods: We enrolled patients with upper extremity motor deficits within 7 days of stroke onset. Patients’ clinical status was assessed for the upper extremity Fugl–Meyer assessment motor component (UE‐FM) within 7 days of stroke and at 15, 30, and 90 days. MRI with tractography was performed within 7 days of stroke. Diffusion tensor images (DTI) were processed to produce maps of fractional anisotropy (FA), apparent diffusion, axial, radial, and mean diffusivity. FA maps were used to assess CST asymmetry index (CST‐AI). Fisher's exact tests for categorical variables, two‐sample t ‐tests for normally distributed numerical data, and Wilcoxon rank sums for non‐normally distributed numeric data were used. Results: A total of 21 patients were enrolled in the study with a mean age of 66 (±14) years and median baseline upper extremity motor component score (UE‐FM) of 42 (median) [range: 23, 53]. Baseline UE‐FM was not predictive of a 10‐point change at 90 days ( p = 0.4469). CST‐AI was predictive of recovery at 15 days ( p = 0.0373), and axial diffusivity was predictive of recovery at 90 days ( p = 0.0402). All other imaging variables did not predict recovery. Conclusion: Our data suggest that upper extremity motor recovery after acute ischemic stroke is impacted by CST integrity. Further studies are needed to validate our findings.

BACKGROUND: Patients presenting with cervical artery dissection (CAD) are at risk for subsequent ischemic events. We aimed to identify characteristics that are associated with increased risk of ischemic stroke after initial presentation of CAD and to evaluate the differential impact of anticoagulant versus antiplatelet therapy in these high-risk individuals. METHODS: This was a preplanned secondary analysis of the STOP-CAD study (Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection), a multicenter international retrospective observational study (63 sites from 16 countries in North America, South America, Europe, Asia, and Africa) that included patients with CAD predominantly between January 2015 and June 2022. The primary outcome was subsequent ischemic stroke by day 180 after diagnosis. Clinical and imaging variables were compared between those with versus without subsequent ischemic stroke. Significant factors associated with subsequent stroke risk were identified using stepwise Cox regression. Associations between subsequent ischemic stroke risk and antithrombotic therapy type (anticoagulation versus antiplatelets) among patients with identified risk factors were explored using adjusted Cox regression. RESULTS: In all, 4023 patients (mean age was 47.4 years; 44.5% were women) were included. By day 180, subsequent ischemic stroke occurred in 5.3% of the cohort. In adjusted Cox regression, factors associated with increased risk of subsequent ischemic stroke were prior history of ischemic stroke (adjusted hazard ratio [aHR], 7.31 [95% CI, 1.61–33.13]; P =0.010), presentation within 7 days from first symptoms (aHR, 3.04 [95% CI, 1.04–8.91]; P =0.043), infarct on baseline imaging (aHR, 9.85 [95% CI, 3.65–26.58]; P P =0.043). Only patients with occlusive dissection demonstrated a reduced risk of subsequent ischemic stroke when treated with anticoagulation versus antiplatelets (aHR, 0.36 [95% CI, 0.16–0.80]; P =0.01). CONCLUSIONS: In this post hoc analysis of the STOP-CAD study, several factors associated with subsequent ischemic stroke were identified among patients with CAD. Furthermore, we identified a potential benefit of anticoagulation in patients with CAD with occlusive dissection. These findings require validation by meta-analyses of prior studies to formulate optimal treatment strategies for specific high-risk CAD subgroups.

Background and ObjectivesCervical artery dissection (CeAD) is a common cause of acute ischemic stroke (AIS), especially in patients younger than 55 years, but data regarding trends and subsequent A...

Background: Although intravenous thrombolysis (IVT) is safe and effective in populations with general stroke, its impact on cervical artery dissection–related acute ischemic stroke (CeAD‐AIS) remains unclear. This retrospective study used the National Inpatient Sample to compare outcomes in patients with CeAD‐AIS treated with and without IVT. Methods: We included adult patients with concurrent CeAD and AIS diagnoses ( International Classification of Diseases, Tenth Revision [ ICD‐10 ], codes) hospitalized from 2016 to 2019. The primary outcome was home discharge; safety outcomes included inpatient death and intracerebral hemorrhage. We performed survey‐weighted multivariable logistic regressions comparing IVT versus no IVT, followed by interaction analyses to examine effect modifications based on age, medical history, stroke severity, carotid artery involvement, and endovascular treatment. Results: Between 2016 and 2019, 1360 (12.1%) of 11 285 patients with CeAD‐AIS received IVT. IVT‐treated patients had higher median National Institutes of Health Stroke Scale scores (median [interquartile range], 8 [4–17] versus 3 [1–11]; P 4) and carotid artery involvement. Conclusions: IVT improves the likelihood of home discharge in patients with CeAD‐AIS without increasing the risk of inpatient death or intracerebral hemorrhage.

Introduction: Dynamic vertebral artery insufficiency is a rare vascular phenomenon characterized by insufficient flow of the posterior cerebral circulation induced by dynamic motion of the head. Prior case reports have been limited to vertebral artery occlusion by cervical osteophytes or other structural impingements. Case Report: In this case report, we discuss the unusual case of a 61-year-old female with a history of vertigo, diplopia, nystagmus, and left subclavian stenosis admitted to the hospital for syncope elicited by a left head turn and left shoulder raise. Transcranial Doppler (TCD) ultrasound and angiography showed evidence of dynamic vertebrobasilar insufficiency elicited by a left-head turn. Percutaneous stenting of the left subclavian artery led to the resumption of normal vessel flow as assessed by TCD and the resolution of the patient’s symptoms. Conclusions: This case highlights an unusual cause of dynamic vertebrobasilar insufficiency induced by head turn and/or left shoulder raise due to subclavian stenosis, diagnosed by TCD and angiography, and successfully treated with subclavian artery stenting.