J Clin Neurol.  2016 Apr;12(2):129-136. 10.3988/jcn.2016.12.2.129.

Considerations When Subtyping Ischemic Stroke in Asian Patients

• Bang OY

• KMID: 2354131
• DOI: http://doi.org/10.3988/jcn.2016.12.2.129

Abstract

Both the incidence and prevalence of stroke in Asia are steadily increasing, and the burden of stroke is particularly high in Asian countries. Although strokes in Asians and Caucasians share many common features, there are some differences that are probably due to differences in lifestyle and genetic background. While there have been advances in the stroke classification system, the assignment of Asian stroke patients to etiological categories has received little attention. The current classification system may not be well suited to Asian patients with ischemic stroke because the proportions and relative importance of stroke subtypes may differ with race and ethnicity. This review addresses concerns about the use of the current stroke classification system in Asian patients with ischemic stroke, and proposes a classification system that is more specific to the Asian population, in conjunction with discussing advances in diagnostic techniques.

Keyword

stroke; ischemic stroke; subtype; Asian; classification

MeSH Terms

Asia
Asian Continental Ancestry Group*
Classification
Continental Population Groups
Humans
Incidence
Life Style
Prevalence
Stroke*

Figure

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  Fig. 1 Stroke subtypes by racial and ethnic groups. *Data from southern Californians (Modified from Bang et al.8), †Data from South Koreans. AF: atrial fibrillation.

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  Fig. 2 Recurrent infarcts with progression of intracranial stenosis. A 32-year-old female experienced recurrent left middle cerebral artery (MCA) infarcts (three times) within 2 years. Serial time-of-flight magnetic resonance angiography (MRA) showed the progression of stenosis in the left MCA. Transfemoral cerebral angiography (TFCA) showed no stenosis in the distal internal carotid artery or basal collaterals suggestive of moyamoya disease (MMD) (arrow). However, high-resolution (HR) MRI revealed a smaller outer diameter, concentric enhancement, and the absence of focal plaques in the stenotic segment (circle). A genetic investigation revealed that the RNF213 mutation was associated with MMD (p.Arg4810Lys). CE: contrast enhanced.

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  Fig. 3 Subcortical infarction but no significant stenosis. A 48-year-old female experienced left hemiparesis. Diffusion-weighted imaging (DWI) shows a deep infarct in the right basal ganglia and corona radiata. MRA shows no significant stenosis in the relevant vessels. TFCA and high-resolution (HR) MRA show a small plaque in the superior half of the middle cerebral artery (arrow). CE: contrast enhanced, MRA: magnetic resonance angiography, PD: proton density, TFCA: transfemoral cerebral angiography, TOF: time of flight, 3D: three dimensional.

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  Fig. 4 A 59-year-old male presented with right hemiparesis. Diffusion-weighted imaging shows a small acute lacunar infarct in the left corona radiata. The magnetic resonance angiography findings were normal. Gradient-echo imaging shows multiple cerebral microbleeds in deep regions bilaterally. Two years later he was readmitted to the Department of Neurosurgery due to intracranial bleeding while taking dual antiplatelet agents.

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  Fig. 5 Typical cases of atrial fibrillation (AF)-related stroke (A), AF-unrelated stroke (B), and no-AF stroke (C). Left panel, DWI. Middle panel, MRA. Right panel, multidetector cardiac computed tomography. A: AF-related stroke with a larger left atrial appendage (LAA) orifice diameter (32.1 mm) and larger LAA volume (16.8 mL). This patient had an infarction and occlusion in the right MCA territory, but no stenosis or occlusion in other intra- and extracranial vessels was noted. B: AF-unrelated stroke with a smaller LAA diameter (23.1 mm) and smaller LAA volume (9.8 mL). This patient had a rightsided border zone infarction with severe right cervical carotid occlusion. C: No-AF stroke with a smaller LAA orifice diameter (22.9 mm) and smaller LAA volume (4.6 mL). This patient had left cortical small infarcts with left MCA stenosis. DWI: diffusion-weighted imaging, MCA: middle cerebral artery, MRA: magnetic resonance angiography.

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