Background: the construct Embolic Stroke of Undetermined Source (ESUS) defines a non-lacunar ischemic stroke (IS) without >50% stenosis in the artery supplying the ischemic area, high-risk cardioembolic sources, and other determined causes. Despite the hypothesis that occult atrial fibrillation was the most common embolic source, now non-stenosing complicated atherosclerotic plaques are considered a major source of embolism. The etiological diagnosis in ESUS is necessary for providing patients with appropriate secondary prevention strategies. Vessel Wall Magnetic Resonance Imaging (VW MRI) with black-blood sequences is an advanced imaging technique that is able to detect high risk intracranial plaques and other intracranial vasculopathies that can cause arterial embolism and stroke. However, the role of VW MRI in ESUS patients is still not defined. Materials and methods: we prospectively enrolled ESUS patients admitted to our Stroke Unit from 17 May 2022 to 30 April 2023. Patients with single-territory embolic stroke and no other potential embolic sources were included. VW MRI with gadolinium administration was performed within one month from the index event. Follow-up visits were performed at three months. Results: the results from the first 31 enrolled patients are presented. Adequate VW MRI images were obtained form 30 patients. A culprit atherosclerotic lesion was identified in 9/30 patients (30%). One patient was diagnosed with intracranial vertebral artery dissection which was not visible on conventional luminal techniques. Age >70 years (OR 7.50, 95% CI 1.32-51.97, p=0.0278), hypertension (OR 13.00, 95% CI 1.88-265.52, p=0.0260), and smoking status (OR 7.00, 95% CI 1.30-56.19, p=0.0356) were associated with intracranial atherosclerosis in univariate logistic regression model. Conclusions: VW MRI detected a culprit complicated atherosclerotic plaque in a significant percentage of ESUS patients, decreasing the proportion of cryptogenic strokes. Age >70 years, hypertension, and smoking status are associated with intracranial atherosclerosis.
Introduzione: il costrutto ESUS (Embolic Stroke of Undetermined Source) identifica quei pazienti con stroke ischemico criptogenico non lacunare senza la presenza di una stenosi ≥50% in un’arteria che irrora l’area ischemica, fonti cardioemboliche ad alto rischio. L’ipotesi iniziale considerava la fibrillazione atriale occulta come il meccanismo responsabile nella maggior parte dei casi; successivi studi hanno dimostrato il ruolo fondamentale delle placche aterosclerotiche complicate non stenosanti. Il raggiungimento di una diagnosi eziologica nel paziente ESUS è fondamentale per garantire un’adeguata terapia di prevenzione secondaria. La risonanza magnetica con studio delle pareti dei vasi (Vessel Wall Magnetic Resonance Imaging, VW MRI) è una metodica avanzata in grado di rilevare placche aterosclerotiche intracraniche ad alto rischio e altre vasculopatie intracraniche. Tuttavia, il ruolo della VW MRI nel percorso diagnostico del paziente ESUS non è ancora definito. Materiali e metodi: sono stati arruolati in modo prospettico i pazienti ESUS ricoverati nella nostra Stroke Unit dal 17 Maggio 2022 al 30 Aprile 2023. I pazienti che presentavano una lesione ischemica monoterritoriale in assenza di potenziali fonti emboliche sono stati inclusi nello studio. Entro un mese dall’evento ischemico, i pazienti arruolati sono stati sottoposti all’esame VW MRI mediante somministrazione di mezzo di contrasto. Un follow-up clinico è stato programmato a 3 mesi. Risultati: sono stati analizzati i dati relativi ai primi 31 pazienti arruolati. Immagini soddisfacenti delle sequence black-blood sono state ottenute in 30 pazienti. In 9 pazienti su 30 (30%) è stata identificata una placca aterosclerotica ad alto rischio. Ad un paziente è stata diagnosticata una dissecazione arteriosa coinvolgente il tratto intracranico di una arteria vertebrale, non diagnosticabile con le metodiche di imaging tradizionali. Un’età maggiore di 70 anni (OR 7.50, 95% CI 1.32-51.97, p=0.0278), la presenza di ipertensione arteriosa (OR 13.00, 95% CI 1.88-265.52, p=0.0260), e l’esposizone al fumo di sigaretta (OR 7.00, 95% CI 1.30-56.19, p=0.0356) sono stati associati alla malattia aterosclerotica intracranica non stenosante sintomatica in un modello di regressione logistica univariata. Conclusioni: la VW MRI è in grado di identificare placche aterosclerotiche intracraniche non stenosanti complicate in una percentuale significativa di pazienti ESUS, riducendo la percentuale di pazienti con ictus criptogenico. Età più avanzata, ipertensione arteriosa e fumo sono risultati associati a patologia aterosclerotica intracranica sintomatica.
The diagnostic value of Vessel Wall Magnetic Resonance Imaging in Embolic Stroke of Undetermined Source: a prospective study
DEL BELLO, BEATRICE
2022/2023
Abstract
Background: the construct Embolic Stroke of Undetermined Source (ESUS) defines a non-lacunar ischemic stroke (IS) without >50% stenosis in the artery supplying the ischemic area, high-risk cardioembolic sources, and other determined causes. Despite the hypothesis that occult atrial fibrillation was the most common embolic source, now non-stenosing complicated atherosclerotic plaques are considered a major source of embolism. The etiological diagnosis in ESUS is necessary for providing patients with appropriate secondary prevention strategies. Vessel Wall Magnetic Resonance Imaging (VW MRI) with black-blood sequences is an advanced imaging technique that is able to detect high risk intracranial plaques and other intracranial vasculopathies that can cause arterial embolism and stroke. However, the role of VW MRI in ESUS patients is still not defined. Materials and methods: we prospectively enrolled ESUS patients admitted to our Stroke Unit from 17 May 2022 to 30 April 2023. Patients with single-territory embolic stroke and no other potential embolic sources were included. VW MRI with gadolinium administration was performed within one month from the index event. Follow-up visits were performed at three months. Results: the results from the first 31 enrolled patients are presented. Adequate VW MRI images were obtained form 30 patients. A culprit atherosclerotic lesion was identified in 9/30 patients (30%). One patient was diagnosed with intracranial vertebral artery dissection which was not visible on conventional luminal techniques. Age >70 years (OR 7.50, 95% CI 1.32-51.97, p=0.0278), hypertension (OR 13.00, 95% CI 1.88-265.52, p=0.0260), and smoking status (OR 7.00, 95% CI 1.30-56.19, p=0.0356) were associated with intracranial atherosclerosis in univariate logistic regression model. Conclusions: VW MRI detected a culprit complicated atherosclerotic plaque in a significant percentage of ESUS patients, decreasing the proportion of cryptogenic strokes. Age >70 years, hypertension, and smoking status are associated with intracranial atherosclerosis.È consentito all'utente scaricare e condividere i documenti disponibili a testo pieno in UNITESI UNIPV nel rispetto della licenza Creative Commons del tipo CC BY NC ND.
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https://hdl.handle.net/20.500.14239/15962