The Pathophysiological Mechanism Is an Independent Predictor of Long-Term Outcome in Stroke Patients with Large Vessel Atherosclerosis.
BACKGROUND
Etiopathological mechanisms underlying ischemic stroke play a crucial role in long-term prognosis. We aimed to investigate the association between the mechanism of stroke due to large vessel disease, and long-term outcome.


METHODS
All consecutive patients registered in the Athens Stroke Registry with atherosclerotic stroke between 1993 and 2010 were included in the analysis. The patients were subdivided into 3 groups according to the presumed underlying mechanism: low-flow infarcts, artery-to-artery embolism, and intrinsic atherosclerosis. They were followed up for up to 10 years or until death. The end points of the study were 10-year all-cause mortality, stroke recurrence, and composite cardiovascular events.


RESULTS
Five hundred two patients were classified as follows: 156 (31%) as low-flow (watershed) strokes, 256 (51%) as artery-to-artery embolic strokes, and 90 (18%) as intrinsic atherosclerotic strokes. The cumulative probability of 10-year mortality rate was similar between groups of patients with different stroke mechanisms: 49.9% (95% confidence interval [CI], 38.5-61.3) for patients with low-flow mechanism, 47.6% (95% CI, 39.4-55.8) for patients with artery-to-artery embolism, and 48.5% (95% CI, 34.0-63.0) for patients with intrinsic atherosclerosis. Patients in the intrinsic atherosclerosis group had significantly higher risks of recurrence (adjusted hazard ratio [HR] = 2.1; 95% CI, 1.19-3.73) compared with those in the artery-to-artery embolism group. Moreover, patients in the intrinsic atherosclerosis and low-flow groups had significantly higher risks of composite cardiovascular events compared with those in the artery-to-artery embolism group (adjusted HR = 1.94; 95% CI, 1.26-3.00; and adjusted HR = 1.64; 95% CI, 1.13-2.38, respectively).


CONCLUSIONS
Low-flow and intrinsic atherosclerosis strokes are associated with a high risk for future cardiovascular events and stroke recurrence. However, long-term mortality is similar across different subgroups.
Department of Neurology, Mediterraneo Hospital, Glyfada, Athens, Greece. Electronic address: apsychoyio@yahoo.gr.
Klearchos
K
Psychogios
Department of Neurology, G. Genimatas General Hospital, Athens, Greece.
Panos
P
Stathopoulos
Department of Neurology, Mediterraneo Hospital, Glyfada, Athens, Greece.
Konstantinos
K
Takis
Acute Stroke Unit, Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece.
Anastasia
A
Vemmou
Acute Stroke Unit, Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece.
Efstathios
E
Manios
Department of Neurology, Eginition Hospital, University of Athens Medical School, Athens, Greece.
Konstantinos
K
Spegos
Acute Stroke Unit, Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece; Stroke Division, Hellenic Cardiovascular Research Society, Athens, Greece.
Konstantinos
K
Vemmos
D000368:Aged; D050197:Atherosclerosis / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D004617:Embolism / Q000209:etiology; D005260:Female; D006115:Greece; D006801:Humans; D053208:Kaplan-Meier Estimate; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000150:complications* / Q000175:diagnosis / Q000401:mortality
Atherosclerosis; Borderzone infarct; Cerebral infarction; Embolism; Prognosis; Stroke; Stroke mechanism