Cimen Erol, Ng Kelvin, Buck Brian H, Field Thalia, Coutts Shelagh B, Gioia Laura C, Hill Michael D, Miller Jodi, Benavente Oscar R, Sharma Mukul, Butcher Ken
School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.
Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
BMJ Open. 2025 Jan 9;15(1):e087704. doi: 10.1136/bmjopen-2024-087704.
To evaluate the relationship between infarct pattern, inferred stroke mechanism and risk of recurrence in patients with ischaemic stroke. The question is clinically relevant to optimise secondary stroke prevention investigations and treatment.
We conducted a retrospective analysis of the dabigatran treatment of acute stroke II (DATAS II) trial (ClinicalTrials.gove NCT NCT02295826), in which patients underwent diffusion-weighted imaging (DWI) at baseline and 30 days after randomisation to one of two antithrombotic therapies. Patients were classified as embolic, isolated small subcortical infarcts or transient ischaemic attack TIA (no infarct) at baseline and day 30. Stroke mechanism was determined by traditional and modified (based on DWI lesion findings) Trial of Org 10 172 in Acute Stroke Treatment (TOAST) criteria (DWI-TOAST).
Multicentre (6) tertiary acute stroke treatment hospitals.
305 adults with minor ischaemic stroke (National Institutes of Health Stroke Scale (NIHSS) score≤9).
Of 305 patients, 148 had embolic pattern infarcts, 93 were isolated small subcortical infarcts and 64 had no infarct on baseline MRI (TIA). In the absence of DWI, TOAST classification indicated the mechanism was cryptogenic in 147 patients (48.2%), and small-vessel occlusion in 127 (41.6%). Using, DWI-TOAST, the number of cryptogenic strokes decreased to 123 (40.3%), and the number of small-vessel occlusion strokes increased to 151 (49.5%). Recurrent infarcts were seen in 13% of patients with an MRI-defined embolic infarct pattern and cryptogenic mechanism on DWI-TOAST. The relative risk of recurrent infarction in patients with undetermined aetiology was increased compared with other categories (standardised coefficient=1.0 (0.1, 1.9), p=0.029). The topography of recurrent infarcts was most often embolic (60.9%), but in 39.1% an isolated small subcortical infarct was seen.
Definitive identification of infarct topography with DWI has a significant impact on infarct mechanism classification. The variable relationship between baseline infarct patterns, clinical presentation and recurrent infarct distribution is a challenge to both the lacunar and embolic stroke of uncertain source (ESUS) concepts. Irrespective of aetiological classification, patients with MRI-defined cryptogenic embolic pattern infarcts are at high risk for recurrent events.
Linked to the DATAS II trial.
gov ID NCT02295826.
评估缺血性脑卒中患者的梗死模式、推测的卒中机制与复发风险之间的关系。该问题对于优化二级卒中预防的检查和治疗具有临床相关性。
我们对达比加群治疗急性卒中II（DATAS II）试验（ClinicalTrials.gov NCT NCT02295826）进行了回顾性分析，在该试验中，患者在基线时以及随机分配至两种抗血栓治疗之一后的30天接受了扩散加权成像（DWI）检查。患者在基线和第30天时被分类为栓塞性、孤立性小皮质下梗死或短暂性脑缺血发作（TIA，无梗死）。卒中机制根据传统的和改良的（基于DWI病变结果）急性卒中治疗中Org 10172试验（TOAST）标准（DWI-TOAST）确定。
多中心（6家）三级急性卒中治疗医院。
305例轻度缺血性脑卒中成人患者（美国国立卫生研究院卒中量表（NIHSS）评分≤9）。
在305例患者中，148例有栓塞性梗死模式，93例为孤立性小皮质下梗死，64例在基线MRI上无梗死（TIA）。在没有DWI的情况下，TOAST分类显示147例患者（48.2%）的机制为隐源性，127例（41.6%）为小血管闭塞。使用DWI-TOAST，隐源性卒中数量降至123例（40.3%），小血管闭塞性卒中数量增至151例（49.5%）。在DWI-TOAST上具有MRI定义的栓塞性梗死模式和隐源性机制的患者中，13%出现了复发性梗死。病因未明患者复发性梗死的相对风险与其他类别相比有所增加（标准化系数=1.0（0.1，1.9），p=0.029）。复发性梗死的部位最常见为栓塞性（60.9%），但39.1%为孤立性小皮质下梗死。
用DWI明确梗死部位对梗死机制分类有重大影响。基线梗死模式、临床表现和复发性梗死分布之间的可变关系对腔隙性卒中和不明来源栓塞性卒中（ESUS）概念均构成挑战。无论病因分类如何，MRI定义的隐源性栓塞性模式梗死患者复发事件风险高。
与DATAS II试验相关。
gov标识符NCT02295826。
