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WorldStrokeAcademy Profile picture
@WorldStrokeEd
Jul 4, 2021 • 8 tweets • 13 min read • Read on X
Scrolly
#WeekendLecture
#ESUS
In most studies ~25% of ischemic stroke are classified as #cryptogenic
In 2014 the Embolic Stroke of Undetermined Source clinical construct was introduced, as a subset from cryptogenics
Criteria & diagnostic assessment were proposed

thelancet.com/journals/laneu… ImageImage
#WeekendLecture
#ESUS

Although a long list of causes was described, covert AF was conceived as perhaps the most important underlying mechanism
It was hypothesized that oral #anticoagulation may⏬ the risk of stroke recurence in #ESUS Image
#WeekendLecture
#ESUS

A systematic review in 2017 (from several authors of the pivotal paper) showed:
👉Frequency: 17% (9-25%) of IS
👉Mean age: 65
👉Recurrence: 4.5% per year
👉Younger, lower freq of vascular RFs and milder stroke vs non-ESUS IS

ahajournals.org/doi/10.1161/st… Image
#WeekendLecture
#ESUS

Benefits from #anticoagulation hypothesis was studied in 2 RCT
👉#NAVIGATE_ESUS 2018
nejm.org/doi/10.1056/NE…
👉#RESPECT_ESUS 2019
nejm.org/doi/10.1056/NE…

☝️Oral anticoagulation was not associated with lower rates of stroke recurrence compared with aspirin ImageImage
#WeekendLecture
#ESUS

Researchers have been highlighting other possible #ESUS etiologies, relationship with AF, & subanalysis trying to identify pts who could benefit from specific therapies
ie:
Carotid Plaques n.neurology.org/content/92/23/…
Atrial Cardiopathy
onlinelibrary.wiley.com/doi/10.1002/br… Image
#WeekendLecture
#ESUS

Currently #ongoing RCTs are using more strict criteria, recruiting subgroups that may respond better to anticoagulation
👉#ARCADIA
journals.sagepub.com/doi/abs/10.117…
👉#ATTICUS journals.sagepub.com/doi/abs/10.117… ImageImage
#WeekendLecture
#ESUS

Recently, a group of experts made a "reexamination" of #ESUS construct, and proposed to #refine its definition, based on current evidence, ie, from #longterm monitoring, imaging, #atrial cardiopathy.

👉ahajournals.org/doi/10.1161/ST…
#WeekendLecture
#ESUS

If you want to go deeper in #ESUS we suggest you to read this 2 reviews
👉From @hoomankamel co-PI from ARCADIA, via @JAMANeuro
jamanetwork.com/journals/jaman…
👉From @GeorgeNtaios from NAVIGATE via @JACCJournals
sciencedirect.com/science/articl…

Thank you!!
#NeuroTwitter Image

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More from @WorldStrokeEd

WorldStrokeAcademy Profile picture
Feb 14, 2022
#WeekendLecture
#ISC22
Highlights

300 invited talks
Nearly 200 oral abstracts
>1000 posters
Here we review some of trials and presentation from Main Events at #ISC22
#ISC22 Highlights
#RESCUE_Japan LIMIT
EVT for acute LVO with #large ischemic #Core

NIHSS>6, #ASPECT 3-5 , CT or MRI (~85%)
<6hr, or DWI/FLAIR mismatch <24hr
🚶mRS 0-3 at 90d: 31 vs 12.8%, RR 2.43🩸sICH,<48hr: 9 vs 4.9% NS
⚫️Death: 18 vs 23.5%, NS

nejm.org/doi/full/10.10…
#ISC22 Highlights
#Rescue-BT EVT with or w/o #tirofiban in LVO stroke
GPIIb/IIIa-R inhibitor could ⏬reocclusion after MT
55🏥in🇨🇳AIS<24hr, no IVT, ASPECT≥6
950pts
🚶mRS at 90d: 3 vs 3
🩸sICH: 9.7 vs 6.4%, NS
⚫️Death: 18.1 vs 16.9%
Treatment effect modification in LAA subgroup
Read 12 tweets
WorldStrokeAcademy Profile picture
Nov 27, 2021
#WeekendLecture
#HistoryofEVT

It’s no secret that #EVT for AIS has been a complete game changer for the field resulting in dramatic reduction in death & disability

Join us to explore the #history of EVT in collaboration with @SVINJournal, to celebrate the inaugural issue Image
Many thanks to @Mahmoudneuro, #RaulNogueira and @DiogoHaussen whose review entitled:
👉“Tx Advancements in the Endovascular Management of Stroke” celebrates the advances in #ETV

🆓 #openaccess

✅ahajournals.org/doi/full/10.11…
1st #Fun fact: Interventional treatment of AIS dates all the way back to 1950s‼️
Sussman & Fitch reported 3 cases of IA infusion of fibrinolytics
Didn’t work 😫. Probably because they were performed in a non-hyperacute fashion
But this laid the foundation for years of refinement Image
Read 21 tweets
WorldStrokeAcademy Profile picture
Oct 17, 2021
#WeekendLecture
#Tenecteplase #TNK
Part 1
✅3rd generation rtPA
🧬Targeted genetic upgrade
3 specific alterations to #alteplase molecule:
👉⬆️Half life
👉⬆️Binding affinity for #fibrin
👉⬆️Resistance to inactivation by #PAI-1
bit.ly/3pqbEb1 Image
#WeekendLecture
#TNK

👉⬆️T1/2 allows single bolus dosing and⬆️clot exposure to TNK
👉Higher affinity to fibrin-rich clots & + potent/faster clot #lysis vs alteplase
👉 < consumption of fibrinogen/plasminogen/ a2- antiplasmin👉⬇️systemic fibrinolytic effect👉⏬risk for bleeding Image
#WeekendLecture
#TNK
First analysis in stroke patients was a #dose-scalation safety study
There was no #symptomatic ICHs in dosis of 0.1-0.2-0.4mg/kg, and 15% (2 of 13) in 0.5mg/kg
No differences in clinical outcomes
bit.ly/3DNHamV ImageImage
Read 11 tweets
WorldStrokeAcademy Profile picture
Oct 11, 2021
#WeekendLecture
Intracranial Atherosclerotic Disease #ICAD

#ICAD leads to changes ranging from minor wall thickening to #hemodynamically significant luminal stenosis and is one of the most #common causes of #stroke worldwide
ahajournals.org/doi/10.1161/CI…

🧵 Image
#WeekendLecture
#ICAD

✅10% of stroke, based on autopsy studies
bit.ly/3v6Lhrd
✅More prevalent in #African Americans, #Hispanics, and #Asians as compared with whites
bit.ly/3AuSiDt

Other risk factors in table Image
#WeekendLecture
#ICAD

In postmortem studies
👉degree of luminal #stenosis
👉% of the plaques containing >40% #lipid area
👉prevalence of intraplaque #hemorrhage, #neovasculature and #thrombus,
were higher in those #plaques associated with #infarct
🔹karger.com/Article/Abstra… Image
Read 13 tweets
WorldStrokeAcademy Profile picture
Oct 4, 2021
#WeekendLecture
#GeneticsAndStroke

#Genetics is involved in several #stroke related conditions, such as small vessel disease #SVD, aneurysms, dissections, cavernomas, and intracranial #hemorrhages

Check this 🧵!
Prepared by @J_Rosales_MD
Edited by @interneurona Image
#Weekendlecture

#Genetic & #SVD
🧬🧠

✅1,5% of cerebral #SVD are #monogenic disorders
✅AR, AD or X-linked
☝🏼Absence of family history doesn't rule out diagnosis because of
👉de novo mutation
👉reduced expression or
👉incomplete penetrance
✅ahajournals.org/doi/10.1161/ST…
#Weekendlecture

#Genetic & #SVD

When to #suspect?🕵️‍♀️

✅early onset stroke without vascular RFs
✅systemic features and neuroimaging of an specific monogenic disorder
✅consanguinity
✅negative work up for other causes of SVD

👉ahajournals.org/doi/10.1161/ST… Image
Read 15 tweets
WorldStrokeAcademy Profile picture
Aug 29, 2021
#WeekendLecture
#CarotidArteryDisease #CAD

#CAD causes ~ 10-20% of #strokes
Atherosclerosis occurs most frequently at carotid #bifurcation, an area of low vessel-wall shear stress and oscillatory/turbulent blood flow

Welcome to this mini review!
#WeekendLecture
#CAD
Endothelial dysfunction
⬇️
Inflammatory response to Lp retention in arterial wall
⬇️
Accelerated accumulation of Lp in subendothelial matrix
⬇️
Macrophages
⬇️
VSCM migrate/proliferate to fibroblast-like cells👉 production of EC matrix
atm.amegroups.com/article/view/7…
#WeekendLecture
#CAD
Stroke Mechanisms
✅#artery_to_artery embolization: retinal (amaurosis fugax) or cerebral circulation
✅#thrombosis in situ
✅#Flow reduction in high grade stenosis: #watershed infarcts, repetitive and brief TIAs (ie limb shaking)

nejm.org/doi/full/10.10…
Read 12 tweets

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