Principal Investigator: Adam  DeHavenon
Keywords: Stroke , Cryptogenic Stroke , Stroke in Young , Vessel Wall MRI Department: Neurology
IRB Number: 00131084
Specialty: Neurology, Neurology
Sub Specialties: Neuroimaging, Stroke
Recruitment Status: Recruiting

Contact Information

Ka-Ho Wong

Brief Summary

Every year 100,000 young Americans (<55 years old) suffer ischemic stroke, resulting in significant mortality and long-term disability. While stroke incidence in older adults has declined, it is on the rise in the young. Diagnostic testing fails to identify a stroke etiology, so-called cryptogenic stroke, in up to 40% of young stroke patients, a prevalence higher than in older patients. Cryptogenic stroke prevents personalized treatment and patients struggle with anxiety from the diagnostic uncertainty. Although the yearly recurrence rate for young cryptogenic stroke patients is 1-2%, their longer lifespan results in a high lifetime risk of stroke recurrence. Following recurrence, 30% of young stroke patients die within 5 years and 50% within 12 years. Improved diagnostic accuracy will lead to more successful personalized treatment and reduced risk of stroke recurrence. The goal of the proposed project is to evaluate whether the novel vessel wall MRI (vwMRI) technique can improve diagnosis of stroke etiology in young patients.

Older patients who are initially diagnosed with cryptogenic stroke often have an underlying cardioembolic etiology, while younger cryptogenic patients are far more likely to harbor an arterial etiology. Our data show that vwMRI excels at identifying subtle arterial pathology. Compared to traditional luminal angiographic techniques, vwMRI images not only the arterial lumen but also, by suppressing MRI blood signal, the vessel wall itself. This increases diagnostic accuracy for arterial pathology without overt luminal irregularities, such as mild atherosclerosis, dissection, or vasculitis – all more common in young stroke patients. However, it is unknown if vwMRI is a suitable diagnostic test of stroke etiology in young patients. Prior vwMRI research has focused on the head or neck in isolation, which is incomplete and inefficient for clinical diagnosis. We have an innovative vwMRI protocol, which permits vwMRI from the aortic arch to distal intracranial vessels in a single scan.

Aim: Increase diagnostic accuracy with our vwMRI protocol. We will perform vwMRI on 20 patients aged 18-54 with cryptogenic stroke within 90 days. We will test if vwMRI improves diagnosis of stroke etiology. To determine etiology (Trial of Org. in Acute Stroke Treatment classification) and diagnostic confidence, for each patient 3 vascular neurologist raters will be randomized to standard data (clinical presentation, diagnostic testing and imaging) and 3 to standard data plus vwMRI. This is to help us further understand if there are other underline cause of cryptogenic stroke and decreases the chance of cryptogenic stroke. To understand that, a validated standardized vwMRI protocol will be use to investigate if these patients has an accurate cryptogenic stroke diagnosis. 

Expected Outcome: The addition of vwMRI will increase inter-rater agreement and diagnostic confidence and decrease cryptogenic stroke.

The anticipated result of these aims is identifying a specific cause and personalized treatment for cryptogenic young stroke patients, who would have the reassurance of a defined diagnosis. Our data will support an R01 study of vwMRI in young stroke patients to measure if the improved accuracy of vwMRI can reduce recurrent stroke in the young and if vwMRI can be used to explain the rise in stroke in the young.

Inclusion Criteria

  1. Adult patients, 18-54 years old, with acute ischemic stroke on diffusion-weighted imaging (DWI) MRI.

  2. Cryptogenic stroke etiology at the completion of the initial stroke workup.

  3. Enrollment within 90 days of stroke onset.

Exclusion Criteria

  1. Inability to tolerate or contraindication to MRI based on the American College of Radiology

  2. Glomerular filtration rate <30, serum creatinine >1.5 mg/dl, or end-stage renal disease on dialysis.

  3. Positive pregnancy test or currently breastfeeding.