Early Menopause and the Risk of Silent Brain Infarction in Community-Dwelling Elderly Subjects: The Sefuri Brain MRI Study

Insulin resistance and muscle weakness are synergistic risk factors for silent lacunar infarcts: the Bunkyo Health Study

Insulin resistance and muscle weakness are risk factors for silent lacunar infarcts (SLI), but it is unclear whether they are still independent risk factors when adjusted for each other. In addition, the effect of their combination on SLI is completely unknown. We evaluated SLI, insulin sensitivity, and knee extensor muscle strength by magnetic resonance imaging, PREDIM, and dynamometer, respectively, in 1531 elderly people aged 65–84 years living in an urban area of Tokyo. Among the study subjects, 251 (16.4%) had SLI. Impaired insulin sensitivity (High; 1.00 [reference], Medium; 1.53 [95% confidence interval (CI) 0.94–2.48], Low; 1.86 [1.02–3.39], p for trend 0.047) and reduced muscle strength (High; 1.00 [reference], Medium; 1.40 [0.98–2.02], Low; 1.49 [1.04–2.15], p for trend 0.037) were independently associated with increased risk for SLI in the fully adjusted model. In terms of combined, subjects classified as having the lowest insulin sensitivity and lowest strength were 4.33 times (95% CI 1.64–11.45) more likely to have a SLI than those classified as having the highest insulin sensitivity and highest strength. Impaired insulin sensitivity and reduced muscle strength were independently associated with higher risk of SLI in elderly subjects, and their combination synergistically increased this risk.

The selective estrogen receptor modulator tamoxifen protects against subtle cognitive decline and early markers of injury 24 h after hippocampal silent infarct in male Sprague-Dawley rats

Silent infarcts (SI) are subcortical cerebral infarcts occurring in the absence of typical ischemia symptoms and are linked to cognitive decline and dementia development. There are no approved treatments for SI. One potential treatment is tamoxifen, a selective estrogen receptor modulator. It is critical to establish whether treatments effectively target the early consequences of SI to avoid progression to complete injury. We induced SI in the dorsal hippocampal CA1 of rats and assessed whether tamoxifen is protective 24 h later against cognitive deficits and injury responses including gliosis, apoptosis, inflammation and changes in estrogen receptors (ERs). SI led to subtle cognitive impairment on the object place task, an effect ameliorated by tamoxifen administration. SI did not lead to detectable hippocampal cell loss but increased apoptosis, astrogliosis, microgliosis and inflammation. Tamoxifen protected against the effects of SI on all measures except microgliosis. SI increased ERα and decreased ERβ in the hippocampus, which were mitigated by tamoxifen. Exploratory data analyses using scatterplot matrices and principal component analysis indicated that SI rats given tamoxifen were indistinguishable from controls. Further, SI rats were significantly different from all other groups, an effect associated with low levels of ERα and increased apoptosis, gliosis, inflammation, ERβ, and time spent with the unmoved object. The results demonstrate that tamoxifen is protective against the early cellular and cognitive consequences of hippocampal SI 24 h after injury. Tamoxifen mitigates apoptosis, gliosis, and inflammation and normalization of ER levels in the CA1, leading to improved cognitive outcomes after hippocampal SI.

Early menopause is associated with increased risk of arterial hypertension: A systematic review and meta-analysis

OBJECTIVE

Menopausal transition has been associated with an increased risk of cardiovascular disease (CVD), mainly attributed to atherogenic dyslipidaemia, central obesity and insulin resistance. Whether arterial hypertension (AH) also contributes to menopause-associated CVD is currently unknown. The aim of this study was to systematically investigate and meta-analyze the best available evidence regarding the association between early menopause (EM) and AH risk.

METHODS

A comprehensive search was conducted in PubMed, CENTRAL and Scopus databases, up to January 20th, 2020. Data were expressed as odds ratio (OR) with 95 % confidence intervals (CI). The I² index was employed for heterogeneity.

RESULTS

Ten studies were included in the quantitative analysis (273,994 postmenopausal women, 76853 cases with AH). Women with EM (age at menopause <45 years) were at higher AH risk compared with those of normal age at menopause (>45 years) (OR 1.10, 95 % CI 1.01-1.19, p = 0.03; I² 79 %). The direction or the magnitude of this association remained significant when the analysis was restricted to studies including groups matched for potential confounders, such as age, BMI, smoking or the use of menopausal hormone therapy or oral contraceptives.

CONCLUSIONS

Women with EM have an increased risk for AH compared with those of normal age at menopause.

Enlarged Perivascular Spaces and Cerebral Small Vessel Disease in Spontaneous Intracerebral Hemorrhage Patients

Background: Cerebral small vessel disease (SVD) is associated with cognitive decline, depression, increased mortality, and disability in stroke patients. MRI-visible perivascular spaces (PVS) are a sensitive neuroimaging marker of SVD. We aimed to explore the risk factors and associations with other SVD markers of PVS in two topographical regions (in the basal ganglia [BG] and centrum semiovale [CS]) in a cohort of spontaneous intracerebral hemorrhage (ICH) patients.

Method: We included 306 consecutive patients from a prospective spontaneous ICH cohort. We rated PVS, white matter hyperintensities (WMH), cerebral microbleeds (CMB), and lacunes with validated visual rating scale. We collected clinical information using standardized forms. We predefined severe PVS as score > 2 and examined associations between PVS in both BG and CS regions and clinical and imaging markers of SVD by logistic regression.

Results: In the multivariable logistic regression, increasing age (OR = 1.075; 95% CI = 1.038–1.113, p < 0.001), high CS PVS degrees (OR = 6.906; 95% CI = 3.024–15.774, p < 0.001), extensive periventricular WMH (OR = 2.878; 95% CI = 1.298–6.379, p = 0.009), and the presence of CMB (OR = 4.073, 95% CI = 1.869–8.877, p < 0.001) were independently associated with BG PVS severity. Alcohol-drinking habit (OR = 2.805; 95% CI = 1.451–5.422, p = 0.002), hyperlipidemia history (OR = 3.782; 95% CI = 1.582–8.783, p = 0.003), high BG PVS degrees (OR = 6.293; 95% CI = 2.755–14.371, p < 0.001) and the presence of strictly lobar CMB (OR = 2.556, 95% CI = 1.285–5.085, p = 0.008) were independent predictors of increased CS PVS severity.

Conclusion: MRI-visible PVS in BG and CS regions are inter-related and have different risk factors in spontaneous ICH patients. Further studies are needed to explore the mechanism and clinical importance of PVS, with possible implications for cerebrovascular disease prevention and effective treatments.

Parity As a Protective Biomarker Against Silent Brain Infarction in Community-Dwelling Older Adults: The Sefuri Study

BACKGROUND

Although several studies have reported an association between parity and increased risk of stroke, this relationship remains controversial.

AIMS

The present study aimed to determine whether parity is associated with silent brain infarction (SBI), independent of other confounders.

METHODS

We analyzed the brain magnetic resonance imaging findings in 576 of community-dwelling older adults with a mean age of 72.1 years. All female participants were asked to provide information regarding the total number of live births, their age at the last parity, and their age at menopause.

RESULTS

The prevalence of SBI and the number of infarcts per participant were higher in men than in women. Although all women who had given birth (0, 1-2, 3-4, or 5+ times) exhibited lower age-adjusted odds ratios (ORs) for SBI than men, a significant difference was observed between women with ≧5 births and men after adjustment for common vascular risk factors (OR: .348, 95% confidence interval [95% CI]: .123-.986). Among women who had given birth, the relationship between fertility and SBI was attenuated, but was enhanced after adjustment for age at the last parity (OR: .300, 95% CI: .102-.886).

CONCLUSIONS

Our findings indicate that fertile women may be protected against SBI or cerebral small vessel disease via the biological effects associated with reproductive activity, and that high fertility may be a marker of protection against SBI. However, late childbearing may blunt protective effects of fertility against SBI.

Atrial fibrillation and silent stroke: links, risks, and challenges

Atrial fibrillation (AF) is the most common cardiac arrhythmia, with a projected number of 1 million affected subjects in Germany. Changes in age structure of the Western population allow for the assumption that the number of concerned people is going to be doubled, maybe tripled, by the year 2050. Large epidemiological investigations showed that AF leads to a significant increase in mortality and morbidity. Approximately one-third of all strokes are caused by AF and, due to thromboembolic cause, these strokes are often more severe than those caused by other etiologies. Silent brain infarction is defined as the presence of cerebral infarction in the absence of corresponding clinical symptomatology. Progress in imaging technology simplifies diagnostic procedures of these lesions and leads to a large amount of diagnosed lesions, but there is still no final conclusion about frequency, risk factors, and clinical relevance of these infarctions. The prevalence of silent strokes in patients with AF is higher compared to patients without AF, and several studies reported high incidence rates of silent strokes after AF ablation procedures. While treatment strategies to prevent clinically apparent strokes in patients with AF are well investigated, the role of anticoagulatory treatment for prevention of silent infarctions is unclear. This paper summarizes developments in diagnosis of silent brain infarction and its context to AF.

Leisure-Time Physical Inactivity Associated with Vascular Depression or Apathy in Community-Dwelling Elderly Subjects: The Sefuri Study

BACKGROUND

Although physical inactivity is a major public health problem, the causative factors for physical inactivity per se are poorly understood. To address this issue, we investigated the relationship between deep white matter lesions (DWMLs) on magnetic resonance imaging, apathy, and physical activities using structural equation modeling (SEM).

METHODS

We examined 317 community-dwelling elderly subjects (137 men and 180 women with a mean age of 64.5 years) without dementia or clinically apparent depression. Physical activity was assessed with a questionnaire consisting of 3 components (leisure-time, work, and sport activities).

RESULTS

The mean score from the apathy scale (a visual analogue version of Starkstein's apathy scale) of the Grades 2-3 DWML group was 420 (95% confidence interval [CI] 379-461), which was lower (more apathetic) than the Grade 0 DWML group score of 478 (95% CI 463-492) after adjustment for education as a covariate. SEM showed that the direct paths from DWMLs or education to apathy were significant, and the direct path from apathy to leisure-time activity was highly significant (β = .25, P < .001). The degree of apathetic behavior was negatively associated with sport activity in female subjects and positively associated with TV watching in male subjects.

CONCLUSIONS

The results of the study show that DWMLs are one of the major factors that cause apathetic behavior and that apathy has significant negative effects on leisure-time physical activity in community-dwelling elderly subjects. Even a minor level of apathy without major depression would have a significant impact on activities of daily living and quality of life.

Prevention and management of stroke in women

Stroke is the leading cause of acquired disability and the third leading cause of death in women worldwide. Sex differences in risk factors, treatment response and quality of life after stroke complicate stroke management in women. Women have an increased lifetime incidence of stroke compared to men, largely due to a sharp increase in stroke risk in older postmenopausal women. Women also have an increased lifetime prevalence of stroke risk factors, including hypertension and atrial fibrillation in postmenopausal women, as well as abdominal obesity and metabolic syndrome in middle-aged women. Controversy continues over the risks of oral contraceptives, hormone therapy and surgical intervention for carotid stenosis in women. Pregnancy and the postpartum period represent a time of increased risk, presenting challenges to stroke management. Recognition of these issues is critical to improving acute care and functional recovery after stroke in women.

The epidemiology of silent brain infarction: a systematic review of population-based cohorts

BACKGROUND

Cerebral infarction is a commonly observed radiological finding in the absence of corresponding, clinical symptomatology, the so-called silent brain infarction (SBI). SBIs are a relatively new consideration as improved imaging has facilitated recognition of their occurrence. However, the true incidence, prevalence and risk factors associated with SBI remain controversial.

METHODS

Systematic searches of the Medline and EMBASE databases from 1946 to December 2013 were performed to identify original studies of population-based adult cohorts derived from community surveys and routine health screening that reported the incidence and prevalence of magnetic resonance imaging (MRI)-determined SBI.

RESULTS

The prevalence of SBI ranges from 5% to 62% with most studies reported in the 10% to 20% range. Longitudinal studies suggest an annual incidence of between 2% and 4%. A strong association was seen to exist between epidemiological estimates of SBI and age of the population assessed. Hypertension, carotid stenosis, chronic kidney disease and metabolic syndrome all showed a strong association with SBI. Heart failure, coronary artery disease, hyperhomocysteinemia and obstructive sleep apnea are also likely of significance. However, any association between SBI and gender, ethnicity, tobacco or alcohol consumption, obesity, dyslipidemia, atrial fibrillation and diabetes mellitus remains unclear.

CONCLUSIONS

SBI is a remarkably common phenomenon and endemic among older people. This systematic review supports the association of a number of traditional vascular risk factors, but also highlights disparities between clinically apparent and silent strokes, potentially suggesting important differences in pathophysiology and warranting further investigation.

Dual task walking reveals cognitive dysfunction in community-dwelling elderly subjects: the Sefuri brain MRI study

The aim of our study was to investigate the effects of subclinical brain lesions and cognitive function on gait performance with or without concurrent cognitive task in community-dwelling elderly subjects. Participants without dementia (92 men and 109 women with a mean age of 67.8 years) underwent brain magnetic resonance imaging, neuropsychologic tests, and gait measurements. Impaired gait velocity of the Timed Up and Go test was associated with deep white matter lesions (odds ratio [OR], 2.338; 95% confidence interval [CI], 1.120-4.880) and diabetes mellitus (OR, 2.725; 95% CI, 1.120-6.630) after adjusted for age, sex, education, and cognitive function tests. Impaired gait velocity of dual task walking was associated with age and the score of Rivermead Behavioral Memory Test (OR, .899/1 point higher; 95% CI, .813-.994), whereas deep white matter lesions were not significantly associated with dual task walking. The present study showed that gait represents not only physical functioning but also subclinical cognitive dysfunction particularly memory impairment in healthy elderly subjects.