Background: White matter disease (WMD) and microhemorrhages (MH) present at the time of stroke have been linked to outcome, yet few have investigated changes in the time leading up to stroke. Magnetic Resonance Imaging (MRI) characteristics before a stroke may shed light on the severity of outcomes following stroke. Methods: We retrospectively identified patients admitted to our institution for ischemic stroke between 5/16-12/17 who had an MRI in the 1-24 months prior to their stroke. After collecting clinical and demographic data, automatic segmentations of gray and white matter volumes and manual segmentation of WMD and MH (size<10mm) were completed using 3D Slicer 4.5 and 4.9, respectively. Groups were created based on modified Rankin Scale score (mRS) at 90 days; an mRS of 3-6 was considered a poor outcome. Univariate analyses and multivariate regression models were performed to determine factors associated with poor outcome. Results: Among the 48 patients in our study (mean age 68, 50% female), 29 patients (60%) had poor outcome. Poor outcome was associated with pre-existing WMD volume (21.9+/-23.6 vs 6.1+/-5.7mL, p= 0.002), and WMD volume at time of stroke (26.4+/-24.9 vs 8.8+/-6.0mL, p=0.001). There was a trend towards poor outcome in older patients (p=0.073), women (p=0.075), higher NIHSS score (p=0.066), and need for thrombectomy (p=0.065). History of prior stroke was not associated with poor outcome (p=0.74), larger pre-existing WMD volumes (14.3+/-19.3 vs 19.5+/-22.6mL, p=0.47) or larger WMD volumes at time of stroke (18.7±22.5 vs 21.5±18.8mL, p=0.67). After adjusting for confounders, pre-existing WMD volume showed a trend to predict poor outcome (adjusted OR 1.086 per one point increase, 95% CI 0.987-1.195, p=0.09), as did WMD volume at the time of stroke (adjusted OR 1.103 per one point increase, 95% CI 0.992-1.226, p=0.07). Conclusions: Greater volume of WMD at time of and prior to admission for stroke may be independent predictors of poor outcome. These results should be validated in subsequent studies.
Introduction: Headache and anxiety are poorly described in children with moyamoya vasculopathy following revascularization. Hypothesis: Headache and anxiety in pediatric moyamoya patients are common co-morbidities and result in frequent healthcare utilization. Methods: In this single-center retrospective cohort study, children (<18 years of age) with moyamoya syndrome or disease who underwent EC-IC bypass between 2007-2020 were identified from a UCSF registry. Data regarding headache or anxiety were abstracted from medical records of inpatient, outpatient and emergency (ED) encounters using standardized forms. ED encounters were attributed to headache or anxiety when they occurred in the absence of stroke or TIA and documented as the likely cause of symptoms for that visit. Summary statistics were used to describe outcomes. Results: We identified 32 children (63% female, 53% white, 22% Hispanic) who underwent initial revascularization surgery at a median age of 8.3 years (range 0.8-17.4). Two or more EC-IC surgeries were completed in 84% of patients. During follow-up after surgery (median 6.7 years, interquartile range 3.2 - 8.2 years), 81% of patients reported headache and 53% reported anxiety (Table). Headaches led to 27 ED encounters among 10 patients (31%). Headache rescue medications were prescribed to 21 patients (66%), and headache prophylaxis was prescribed in 37.5%. Six patients (19%) were referred to a headache specialist. Symptoms attributed to anxiety led to six ED encounters among three patients, and 19% (6/32) reported panic attacks. A referral to mental health services was provided to 44% (14/32) of patients. Conclusions: Headaches and anxiety are common symptoms among children with moyamoya after revascularization and may lead to significant healthcare consumption. Symptoms and prevention measures should be explored in future studies to improve quality of life and decrease healthcare utilization.
Background: Patients are more likely to develop white matter disease (WMD) and microhemorrhage (MH) after ischemic stroke. Little is known about whether stroke patients had an increased prevalence of these findings before a stroke compared to patients who did not go on to develop a stroke. Methods: We retrospectively identified patients admitted to our institution with ischemic stroke between 5/16 - 12/17 who had magnetic resonance imaging (MRI) of the brain between 30 days-2 years prior to their stroke. Age and gender-matched controls for the initial MRI were identified for pair-wise comparison. Automatic segmentations of gray and white matter volumes and manual segmentation of WMD and MH (size<10mm) were completed using 3D Slicer 4.5 and 4.9, respectively. Univariate analyses and multivariate models were performed to determine factors associated with stroke. This included demographic factors and traditional vascular risk factors. Results: Among the 96 patients in our study, stroke patients (n=48, mean age 68, 50% female) had lower rates of cancer (p=0.03) but higher rates of hyperlipidemia (p=0.024) compared to controls. Stroke patients exhibited greater WMD volume (15.7±20.2 vs 7.3±10.4 mL, p= 0.012) compared to controls, but not MH number (p=0.29) or total MH volume (p=0.26). Although history of stroke was associated with new presentation of stroke (72.9% vs 22.9%, p<0.001), prior stroke was not linked to an overall difference in WMD volume (13.7±17.6 vs 9.4±15.3mL, p=0.20), gray to white matter ratio (1.27±0.54 vs 1.21±0.74 mL, p=0.68), MH number (p=0.36) or total MH volume (p=0.39). After adjusting for confounders, pre-existing WMD volume remained an independent predictor of stroke (adjusted OR 1.042 per one point increase, 95% CI 1.001-1.086, p=0.046). Conclusion: Increased volume of white matter disease correlates with a greater risk of future ischemic stroke. These results should be validated in subsequent studies.
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