Neuroimaging features of antiphospholipid antibody-related stroke compared with atrial fibrillation-related stroke

Abstract

Recognizing the lesion pattern of antiphospholipid antibody-related stroke (aPL-stroke) may contribute to establishing the cause in patients with cryptogenic stroke. We aimed to describe the neuroimaging features of aPL-stroke compared with atrial fibrillation-related stroke (AF-stroke), a major hidden cause of cryptogenic stroke. Using a prospective stroke registry, we identified consecutive aPL- and AF-stroke patients without other potential causes of stroke. Neuroimaging features based on diffusion-weighted imaging and angiographic findings at admission were compared. A total of 56 and 333 patients were included in the aPL- and AF-stroke groups, respectively. aPL-stroke patients more often presented with single small lesions (aPL-stroke, 30.4% vs. AF-stroke, 7.5%, p < 0.001), while the predominant pattern in AF-stroke patients was large territorial lesions (26.8% vs. 56.5%, p < 0.001). aPL-stroke patients had smaller infarct volume (1.58 mL [0.45; 9.41] vs. 11.32 mL [2.82; 33.08], p < 0.001) and less experience of relevant artery occlusion (17.9% vs. 54.7%, p < 0.001). The proportion of multi-territory lesions, an embolic pattern, was similar between the two groups (28.6% vs. 22.8%, p = 0.44). In comparison only including patients with multi-territory lesions as well, aPL-stroke patients showed small lesion dominance and smaller infarct volume. Multivariate analyses showed independent associations between mild neuroimaging features (small lesion prevalence, smaller infarct volume, and absence of relevant artery occlusion) and aPL-stroke. Patterns of small lesion prevalence, small infarct volume, and absence of relevant artery occlusion were suggestive of aPL-stroke rather than AF-stroke. Cryptogenic stroke patients with such neuroimaging features may benefit from aPL testing for a precise diagnosis.

Conflict of interest statement

The authors declare no competing interests.

© 2022. The Author(s).

Figures

Figure 1

Flowchart of patient inclusion and exclusion. AF atrial fibrillation, AF-stroke atrial fibrillation-related stroke, AIS acute ischemic stroke, aPL antiphospholipid antibody, aPL-stroke antiphospholipid antibody-related stroke, MRI magnetic resonance imaging.

Figure 2

Neuroimaging features of aPL- and AF-stroke patients. (a) Lesion pattern based on the size and distribution of aPL- and AF-stroke patients. A single small lesion, solitary lesion ≤ 15 mm; small scattered lesion in a single territory, multiple scattered lesions with the largest lesion size ≤ 15 mm; large territorial lesion, lesion > 15 mm involving single vascular territory; and multi-territory lesion, multiple lesions involving multiple vascular territories. (b) Comparison of representative lesion patterns in aPL- and AF-stroke patients. (c) Total DWI lesion volumes of aPL- and AF-stroke patients. DWI lesion volume is presented on the y-axis as a log scale. ***p < 0.001. AF-stroke atrial fibrillation-related stroke, aPL-stroke antiphospholipid antibody-related stroke, DWI diffusion-weighted imaging.

Figure 3

Proportion of patients who experienced relevant artery occlusion among aPL- and AF-stroke patients. Intracranial branch vessel occlusion, occlusion of the ACA, PCA, M2 or distal segments of the MCA, or SCA; intracranial main vessel occlusion, occlusion of the distal ICA, M1 segment of the MCA, distal VA, or BA; and extracranial large vessel occlusion, occlusion of the CCA, proximal ICA, or proximal VA. ***p < 0.001; **p < 0.01; ns no significant difference. ACA anterior cerebral artery, AF-stroke atrial fibrillation-related stroke, aPL-stroke antiphospholipid antibody-related stroke, BA basilar artery, CCA common carotid artery, ICA internal carotid artery, MCA middle cerebral artery, PCA posterior cerebral artery, SCA superior cerebellar artery, VA vertebral artery.

Figure 4

DWI lesion pattern and total lesion volume of aPL- and AF-stroke patients with a multi-territory lesion. (a) Lesion pattern based on the largest lesion size (≤ 15 mm or > 15 mm) of aPL- and AF-stroke patients with multi-territory lesions. (b) Total DWI lesion volumes of aPL- and AF-stroke patients with multi-territory lesions. DWI lesion volume is presented on the y-axis as a log scale. **p < 0.01. AF-stroke atrial fibrillation-related stroke, aPL-stroke antiphospholipid antibody-related stroke, DWI diffusion-weighted imaging.