Importance of infarct topography in determination of stroke mechanism and recurrence risk: a post-hoc analysis of the dabigatran acute treatment of stroke trial
Objective 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.Design We conducted a retrospective analysis of...
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BMJ Publishing Group
2025-01-01
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| author | Michael D Hill Ken Butcher Kelvin Ng Mukul Sharma Shelagh B Coutts Brian H Buck Thalia Field Erol Cimen Laura C Gioia Jodi Miller Oscar R Benavente |
| author_facet | Michael D Hill Ken Butcher Kelvin Ng Mukul Sharma Shelagh B Coutts Brian H Buck Thalia Field Erol Cimen Laura C Gioia Jodi Miller Oscar R Benavente |
| author_sort | Michael D Hill |
| collection | DOAJ |
| description | Objective 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.Design 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).Setting Multicentre (6) tertiary acute stroke treatment hospitals.Participants 305 adults with minor ischaemic stroke (National Institutes of Health Stroke Scale (NIHSS) score≤9).Results 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.Conclusions 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.Trial registration number Linked to the DATAS II trial. ClinicalTrials.gov ID NCT02295826. |
| format | Article |
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| institution | Kabale University |
| issn | 2044-6055 |
| language | English |
| publishDate | 2025-01-01 |
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| spelling | doaj-art-b48d51fd3558470f92f2d68a38d7f6012025-01-10T07:05:14ZengBMJ Publishing GroupBMJ Open2044-60552025-01-0115110.1136/bmjopen-2024-087704Importance of infarct topography in determination of stroke mechanism and recurrence risk: a post-hoc analysis of the dabigatran acute treatment of stroke trialMichael D Hill0Ken Butcher1Kelvin Ng2Mukul Sharma3Shelagh B Coutts4Brian H Buck5Thalia Field6Erol Cimen7Laura C Gioia8Jodi Miller9Oscar R Benavente105 Department of Clinical Neruosciences, University Calgary, Calgary, Alberta, Canada1 School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia2 Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada2 Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada5 Department of Clinical Neruosciences, University Calgary, Calgary, Alberta, Canada3 Department of Medicine, Univ Alberta, Edmonton, Alberta, Canada4 Department of Neurology, University of British Columbia, Vancouver, British Columbia, Canada1 School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia6 University of Montreal, Montreal, Québec, Canada2 Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada4 Department of Neurology, University of British Columbia, Vancouver, British Columbia, CanadaObjective 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.Design 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).Setting Multicentre (6) tertiary acute stroke treatment hospitals.Participants 305 adults with minor ischaemic stroke (National Institutes of Health Stroke Scale (NIHSS) score≤9).Results 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.Conclusions 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.Trial registration number Linked to the DATAS II trial. ClinicalTrials.gov ID NCT02295826.https://bmjopen.bmj.com/content/15/1/e087704.full |
| spellingShingle | Michael D Hill Ken Butcher Kelvin Ng Mukul Sharma Shelagh B Coutts Brian H Buck Thalia Field Erol Cimen Laura C Gioia Jodi Miller Oscar R Benavente Importance of infarct topography in determination of stroke mechanism and recurrence risk: a post-hoc analysis of the dabigatran acute treatment of stroke trial BMJ Open |
| title | Importance of infarct topography in determination of stroke mechanism and recurrence risk: a post-hoc analysis of the dabigatran acute treatment of stroke trial |
| title_full | Importance of infarct topography in determination of stroke mechanism and recurrence risk: a post-hoc analysis of the dabigatran acute treatment of stroke trial |
| title_fullStr | Importance of infarct topography in determination of stroke mechanism and recurrence risk: a post-hoc analysis of the dabigatran acute treatment of stroke trial |
| title_full_unstemmed | Importance of infarct topography in determination of stroke mechanism and recurrence risk: a post-hoc analysis of the dabigatran acute treatment of stroke trial |
| title_short | Importance of infarct topography in determination of stroke mechanism and recurrence risk: a post-hoc analysis of the dabigatran acute treatment of stroke trial |
| title_sort | importance of infarct topography in determination of stroke mechanism and recurrence risk a post hoc analysis of the dabigatran acute treatment of stroke trial |
| url | https://bmjopen.bmj.com/content/15/1/e087704.full |
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