Cerebral small vessel disease: a review of clinical, radiological, and histopathological phenotypes

Assessing stroke recurrence in sICAS: a study on mCSVD score and culprit plaque magnetic resonance characteristics

Background

Recurrent ischemic stroke in patients with symptomatic intracranial atherosclerotic stenosis (sICAS) can be attributed to two main causes: intracranial atherosclerotic stenosis (ICAS) and cerebral small vessel disease (CSVD). This study investigates the potential associations between stroke recurrence and the modified cerebral small vessel disease (mCSVD) burden score, as well as the characteristics of culprit plaques related to intracranial artery high-resolution vessel wall imaging (HR-VWI).

Methods

A total of 145 patients presenting sICAS underwent intracranial artery HR-VWI and routine cranial MRI at two large Chinese hospitals from December 2019-2022 were participants of this retrospective analysis. Standard MRI scans were used to calculate the mCSVD score. Following a 12-month observation period, the patients were categorized into two distinct groups depending on whether or not they experienced a subsequent stroke.

Results

Within 12 months, 32 patients experienced stroke recurrence. The recurrence group's mCSVD score was higher compared to the non-recurrence group (p < 0.001). Their luminal stenosis and culprit plaque thickness and burden were also higher (p < 0.05). Additionally, higher rates of diabetes, T1WI hyperintensity of culprit plaques, and significant plaque enhancement were observed in the recurrence group (p < 0.05). The adjusted Cox regression model indicated that the mCSVD score (HR = 1.730, 95% CI 1.021-2.933, p = 0.042) and T1WI hyperintensity of the culprit plaque (HR = 6.568, 95% CI 1.104-39.059, p = 0.039) remained significantly independent risk variables. The combination of the mCSVD score and T1WI hyperintensity of the culprit plaque demonstrated the highest efficacy in predicting stroke recurrence (z = 2.678, p < 0.05).

Conclusion

The mCSVD score, associated with T1WI hyperintensity of culprit plaque, effectively predicts stroke recurrence and can be easily obtained, offering high clinical value.

Outcome of intravenous thrombolysis in acute ischemic stroke patients with small vessel disease

INTRODUCTION

Lacunar stroke (LS) subtype accounts for a quarter of ischemic strokes. Intravenous thrombolysis (IVT) is known to improve overall stroke outcomes. Very few studies have focused on the outcome of IVT in lacunar strokes.

AIM

To detect the outcome of IVT in LS patients compared to non-thrombolysed LS patients.

METHODS

Fifty patients presenting with LS received the standard protocol of IVT (Group I). They were compared to fifty matched LS patients who presented beyond the time window and were selected as the control group (Group II). Clinical outcome was measured using NIHSS within 24 h, NIHSS at discharge, and MRS after 3 months. Risk factors that could have affected clinical outcomes were compared in the thrombolysis group.

RESULTS

The short-term clinical outcome of Group I showed statistically significant improvement of NIHSS after 24 hrs compared to Group II (mean NIHSS = 5.52±3.89 and 7.44±1.82 respectively), as well as on discharge (mean NIHSS = 3.88±3.50 and 5.78±2.97) respectively. For long-term outcomes, 94 % of GroupⅠ reached MRS 0, 1, and 2 (n = 47/50) versus 74 % (n = 36/50) in Group II. Longer door-to-needle time, severe WMCs (Fazekas score), and pneumonia were shown to be significant predictor factors for the worst outcome.

CONCLUSION

IVT has improved short- and long-term outcomes in LS patients. Longer door-to-needle time, severe WMCs, and pneumonia were shown to be significant predictor factors for the worst outcome.

Pathogenesis of Cerebral Small Vessel Disease: Role of the Glymphatic System Dysfunction

Cerebral small vessel disease (CSVD) is a group of pathologies that affect the cerebral blood vessels. CSVD accounts for 25% of strokes and contributes to 45% of dementia. However, the pathogenesis of CSVD remains unclear, involving a variety of complex mechanisms. CSVD may result from dysfunction in the glymphatic system (GS). The GS contains aquaporin-4 (AQP-4), which is in the perivascular space, at the endfeet of the astrocyte. The GS contributes to the removal of waste products from the central nervous system, occupying perivascular spaces and regulating the exchange and movement of cerebrospinal fluid and interstitial fluid. The GS involves astrocytes and aquaporin channels, which are components of the blood-brain barrier, and problems with them may constitute the pathogenesis of CSVD. Vascular risk factors, including diabetes, dilate the perivascular space, disrupting the glymphatic system and the active regulation of AQP-4. CSVD exacerbation due to disorders of the GS is associated with multiple vasculopathies. Dysfunction of the glymphatic system and AQP-4 interferes with the functioning of the blood-brain barrier, which exacerbates CSVD. In a long-term follow-up of CSVD patients with microbleeds, lacunar infarcts, and white matter hyperintensity, several vascular risk factors, including hypertension, increased the risk of ischemic stroke. Dysfunction of the GS may be the cause of CSVD; however, the underlying treatment needs to be studied further.

Taxonomy of Acute Stroke: Imaging, Processing, and Treatment

Stroke management employs a variety of diagnostic imaging modalities, image processing and analysis methods, and treatment procedures. This work categorizes methods for stroke imaging, image processing and analysis, and treatment, and provides their taxonomies illustrated by a state-of-the-art review. Imaging plays a critical role in stroke management, and the most frequently employed modalities are computed tomography (CT) and magnetic resonance (MR). CT includes unenhanced non-contrast CT as the first-line diagnosis, CT angiography, and CT perfusion. MR is the most complete method to examine stroke patients. MR angiography is useful to evaluate the severity of artery stenosis, vascular occlusion, and collateral flow. Diffusion-weighted imaging is the gold standard for evaluating ischemia. MR perfusion-weighted imaging assesses the penumbra. The stroke image processing methods are divided into non-atlas/template-based and atlas/template-based. The non-atlas/template-based methods are subdivided into intensity and contrast transformations, local segmentation-related, anatomy-guided, global density-guided, and artificial intelligence/deep learning-based. The atlas/template-based methods are subdivided into intensity templates and atlases with three atlas types: anatomy atlases, vascular atlases, and lesion-derived atlases. The treatment procedures for arterial and venous strokes include intravenous and intraarterial thrombolysis and mechanical thrombectomy. This work captures the state-of-the-art in stroke management summarized in the form of comprehensive and straightforward taxonomy diagrams. All three introduced taxonomies in diagnostic imaging, image processing and analysis, and treatment are widely illustrated and compared against other state-of-the-art classifications.

Association of ADAMTS13 activity with cerebral deep medullary vein: A community-based cross-sectional study

Objectives

This study aims to investigate whether circulating ADAMTS13 activity can offer insights into the mechanism of pathophysiological changes in deep medullary veins (DMVs).

Methods

This study was conducted on a community cohort of elderly individuals in Shanghai. Plasma von Willebrand factor (VWF) levels and ADAMTS13 activity were measured. A validated DMV score described the overall burden of DMV on the brain. Through ordinal regression models, we investigated the correlation between VWF levels, ADAMTS13 activity, and increasing severity of DMV score while adjusting for demographics and cardiovascular risk factors.

Results

The study enrolled 262 subjects according to the inclusion criteria. The mean VWF level (1.35 ± 0.25) was higher in the DMV group than in the group without DMV (1.25 ± 0.30) (p = 0.025), and ADAMTS13 activity (83.76 ± 7.96) was relatively lower. After adjusting for age, sex, alcohol consumption, smoking, hypertension, and diabetes, reduced ADAMTS13 activity [β = -7.78; 95 % CI (-10.21, -5.35) p < 0.01] was associated with DMV. Moreover, correlation analysis indicated that ADAMTS13 activity was negatively correlated with the DMV score (Kendall's tau-b = -0.53, p < 0.001).

Discussion

In summary, there was an inverse correlation observed between ADAMTS13 activity and the DMV score, which may provide some clinical clues for exploring the potential pathogenesis of DMV.

Identifying Leukoaraiosis with Mild Cognitive Impairment by Fusing Multiple MRI Morphological Metrics and Ensemble Machine Learning

Leukoaraiosis (LA) is strongly associated with impaired cognition and increased dementia risk. Determining effective and robust methods of identifying LA patients with mild cognitive impairment (LA-MCI) is important for clinical intervention and disease monitoring. In this study, an ensemble learning method that combines multiple magnetic resonance imaging (MRI) morphological features is proposed to distinguish LA-MCI patients from LA patients lacking cognitive impairment (LA-nCI). Multiple comprehensive morphological measures (including gray matter volume (GMV), cortical thickness (CT), surface area (SA), cortical volume (CV), sulcus depth (SD), fractal dimension (FD), and gyrification index (GI)) are extracted from MRI to enrich model training on disease characterization information. Then, based on the general extreme gradient boosting (XGBoost) classifier, we leverage a weighted soft-voting ensemble framework to ensemble a data-level resampling method (Fusion + XGBoost) and an algorithm-level focal loss (FL)-improved XGBoost model (FL-XGBoost) to overcome class-imbalance learning problems and provide superior classification performance and stability. The baseline XGBoost model trained on an original imbalanced dataset had a balanced accuracy (Bacc) of 78.20%. The separate Fusion + XGBoost and FL-XGBoost models achieved Bacc scores of 80.53 and 81.25%, respectively, which are clear improvements (i.e., 2.33% and 3.05%, respectively). The fused model distinguishes LA-MCI from LA-nCI with an overall accuracy of 84.82%. Sensitivity and specificity were also well improved (85.50 and 84.14%, respectively). This improved model has the potential to facilitate the clinical diagnosis of LA-MCI.

Cerebral white matter hyperintensities indicate severity and progression of coronary artery calcification

Cerebral white matter hyperintensities (WMH) have been associated with subclinical atherosclerosis including coronary artery calcification (CAC). However, previous studies on this association are limited by only cross-sectional analysis. We aimed to explore the relationship between WMH and CAC in elderly individuals both cross-sectionally and longitudinally. The study population consisted of elderly stroke- and dementia-free participants from the community-based Austrian Stroke Prevention Family Study (ASPFS). WMH volume and CAC levels (via Agatston score) were analyzed at baseline and after a 6-year follow-up period. Of 324 study participants (median age: 68 years), 115 underwent follow-up. Baseline WMH volume (median: 4.1 cm3) positively correlated with baseline CAC levels in multivariable analysis correcting for common vascular risk factors (p = 0.010). While baseline CAC levels were not predictive for WMH progression (p = 0.447), baseline WMH volume was associated CAC progression (median Agatston score progression: 27) in multivariable analysis (ß = 66.3 ± 22.3 [per cm3], p = 0.004). Ten of 11 participants (91%) with severe WMH (Fazekas Scale: 3) at baseline showed significant CAC progression > 100 during follow-up. In this community-based cohort of elderly individuals, WMH were associated with CAC and predictive of its progression over a 6-year follow-up. Screening for coronary artery disease might be considered in people with more severe WMH.

Stride length and cerebellar regulation: Key features of early gait disorder in cerebral small vessel disease

OBJECTIVES

Gait disorder (GD) is a common problem in cerebral small vessel disease (CSVD). This study aimed to determine (1) the early characteristics of GD in CSVD, (2) cerebellar neuroimaging features related to GD in CSVD, and (3) the association of cognitive impairment with GD.

METHODS

In total, 183 subjects were enrolled in this study: patients with CSVD with normal cognitive function (CSVD-NC) group (64 subjects), patients with CSVD with mild cognitive impairment (CSVD-MCI) group (66 subjects), and a healthy control (HC) group (53 subjects). The GD patterns were evaluated using the ReadyGo three-dimensional motion balance testing system. Meanwhile, we analyzed the cerebrum and cerebellum structurally and functionally. Correlation analyses were conducted among gait indicators, neuroimaging features, and neuropsychological tests.

RESULTS

Both the CSVD-NC and CSVD-MCI groups had a reduced stride length, cortical atrophy in the left cerebellum VIIIb, and decreased functional connectivity between the left cerebellum VIIIb and left SFGmed compared with the HC group. In the correlation analysis, the gray matter probability of the left cerebellum VIIIb was closely related to stride length in the HC group. In the CSVD-MCI group, linguistic function, memory, and attention were significantly correlated with gait performance.

CONCLUSION

Decreased stride length was the earliest characteristic of GD in CSVD. Structural and functional regulation of the left cerebellum VIIIb could play a particularly important role in early GD in CSVD.

Performance of the walking trail making test in older adults with white matter hyperintensities

BACKGROUND

Several studies have reported that the walking trail making test (WTMT) completion time is significantly higher in patients with developmental coordination disorders and mild cognitive impairments. We hypothesized that WTMT performance would be altered in older adults with white matter hyperintensities (WMH).

AIM

To explore the performance in the WTMT in older people with WMH.

METHODS

In this single-center, observational study, 25 elderly WMH patients admitted to our hospital from June 2019 to June 2020 served as the WMH group and 20 participants matched for age, gender, and educational level who were undergoing physical examination in our hospital during the same period served as the control group. The participants completed the WTMT-A and WTMT-B to obtain their gait parameters, including WTMT-A completion time, WTMT-B completion time, speed, step length, cadence, and stance phase percent. White matter lesions were scored according to the Fazekas scale. Multiple neuropsychological assessments were carried out to assess cognitive function. The relationships between WTMT performance and cognition and motion in elderly patients with WMH were analyzed by partial Pearson correlation analysis.

RESULTS

Patients with WMH performed significantly worse on the choice reaction test (CRT) (0.51 ± 0.09 s vs 0.44 ± 0.06 s, P = 0.007), verbal fluency test (VFT, 14.2 ± 2.75 vs 16.65 ± 3.54, P = 0.012), and digit symbol substitution test (16.00 ± 2.75 vs 18.40 ± 3.27, P = 0.010) than participants in the control group. The WMH group also required significantly more time to complete the WTMT-A (93.00 ± 10.76 s vs 70.55 ± 11.28 s, P < 0.001) and WTMT-B (109.72 ± 12.26 s vs 82.85 ± 7.90 s, P < 0.001). WTMT-A completion time was positively correlated with CRT time (r = 0.460, P = 0.001), while WTMT-B completion time was negatively correlated with VFT (r = -0.391, P = 0.008). On the WTMT-A, only speed was found to statistically differ between the WMH and control groups (0.803 ± 0.096 vs 0.975 ± 0.050 m/s, P < 0.001), whereas on the WTMT-B, the WMH group exhibited a significantly lower speed (0.778 ± 0.111 vs 0.970 ± 0.053 m/s, P < 0.001) and cadence (82.600 ± 4.140 vs 85.500 ± 5.020 steps/m, P = 0.039), as well as a higher stance phase percentage (65.061 ± 1.813% vs 63.513 ± 2.465%, P = 0.019) relative to controls.

CONCLUSION

Older adults with WMH showed obviously poorer WTMT performance. WTMT could be a potential indicator for cognitive and motor deficits in patients with WMH.

Deep Medullary Vein and MRI Markers Were Related to Cerebral Hemorrhage Subtypes

BACKGROUND

To explore the performance of deep medullary vein (DMV) and magnetic resonance imaging (MRI) markers in different intracerebral hemorrhage (ICH) subtypes in patients with cerebral small vessel disease (CSVD).

METHODS

In total, 232 cases of CSVD with ICH were included in this study. The clinical and image data were retrospectively analyzed. Patients were divided into hypertensive arteriopathy (HTNA)-related ICH, cerebral amyloid angiopathy (CAA)-related ICH, and mixed ICH groups. The DMV score was determined in the cerebral hemisphere contralateral to the ICH.

RESULTS

The DMV score was different between the HTNA-related and mixed ICH groups (p < 0.01). The MRI markers and CSVD burden score were significant among the ICH groups (p < 0.05). Compared to mixed ICH, HTNA-related ICH diagnosis was associated with higher deep white matter hyperintensity (DWMH) (OR: 0.452, 95% CI: 0.253-0.809, p < 0.05) and high-degree perivascular space (PVS) (OR: 0.633, 95% CI: 0.416-0.963, p < 0.05), and CAA-related ICH diagnosis was associated with increased age (OR: 1.074; 95% CI: 1.028-1.122, p = 0.001). The DMV score correlated with cerebral microbleed (CMB), PVS, DWMH, periventricular white matter hyperintensity (PWMH), and CSVD burden score (p < 0.05) but not with lacuna (p > 0.05). Age was an independent risk factor for the severity of DMV score (OR: 1.052; 95% CI: 0.026-0.076, p < 0.001).

CONCLUSION

DMV scores, CSVD markers, and CSVD burden scores were associated with different subtypes of ICH. In addition, DMV scores were associated with the severity of CSVD and CSVD markers.

Effects of Acupuncture upon cerebral hemodynamics in cerebral small vessel disease: A pilot study

Background and aims

Recent preclinical studies and meta-analysis of clinical trials suggested that acupuncture may improve cognition in cerebral small vessel disease (CSVD). We investigated the cerebral hemodynamics of acupuncture in subjects with CSVD and compared its impact upon the cerebral hemodynamics in normal elderly subjects.

Methods

10 subjects with CSVD (CSVD group) and 10 aged-matched control subjects who had no or insignificant CSVD (control group) were recruited. A single session of acupuncture was applied for 30 min in both groups. We assessed the effect of our acupuncture intervention on cerebral hemodynamics by transcranial Doppler ultrasound (TCD). Peak systolic velocity (PSV) and pulsatility index (PI) of the middle cerebral artery (MCA) were assessed.

Results

We observed that PSV increased by a maximum of 39% at 20 min (p<0.05), while there was no significant change in PI in the CSVD group during the acupuncture session. In the control group, although we observed no significant change in PSV during the acupuncture session, there was a significant decrease in PI by a maximum of 22% at 20 min (p<0.05). No adverse events were reported during or after the procedure.

Conclusion

This study suggested that our acupuncture prescription was associated with an increase in cerebral blood flow in subjects with established moderate to severe CSVD yet without apparent impact on distal vascular resistance. While, in subjects with no or insignificant CSVD, it may reduce cerebral small vessel distal vascular resistance. A larger study is needed to confirm our findings.

Motoric Cognitive Risk Syndrome Among Chinese Older Adults with White Matter Lesions: A Cross-Sectional Observational Study

Brain aging is characterized by the declines in motor and cognitive features. The present study is to detect motor cognitive risk syndrome (MCRS) in older adults with white matter lesions (WML). 134 WML aged patients were recruited and diagnosed with the criteria for MCRS. Numerous cognitive function tests and walking tests were performed. The frequency of MCRS is 28.35%. Verbal fluency test, Mini-Mental State Examination, and dual-task walking speed were independent risk factor of MCRS. These findings indicated that MCRS was common in WML seniors. MCRS was associated with the pathologies of WML in older adults.

The relevance of serum macrophage migratory inhibitory factor and cognitive dysfunction in patients with cerebral small vascular disease

Cerebral small vascular disease (CSVD) is a common type of cerebrovascular disease, and an important cause of vascular cognitive impairment (VCI) and stroke. The disease burden is expected to increase further as a result of population aging, an ongoing high prevalence of risk factors (e.g., hypertension), and inadequate management. Due to the poor understanding of pathophysiology in CSVD, there is no effective preventive or therapeutic approach for CSVD. Macrophage migration inhibitory factor (MIF) is a multifunctional cytokine that is related to the occurrence and development of vascular dysfunction diseases. Therefore, MIF may contribute to the pathogenesis of CSVD and VCI. Here, reviewed MIF participation in chronic cerebral ischemia-hypoperfusion and neurodegeneration pathology, including new evidence for CSVD, and its potential role in protection against VCI.

Is the female sex associated with an increased risk for long-term cognitive decline after the first-ever lacunar stroke? Prospective study on small vessel disease cohort

Background

Sex is a significant determinant of survival and functional outcome after stroke. Long-term cognitive outcome after acute lacunar stroke in the context of sex differences has been rarely reported.

Methods

A cohort of small vessel disease (SVD) patients presenting with first-ever acute lacunar stroke and normal cognitive status has been evaluated 4 years after the qualifying event for the presence of cognitive impairment (CI) with a comprehensive neuropsychological battery. Differences in baseline clinical and neuroimaging characteristics were compared between sexes in relation to cognitive status.

Results

A total of 124 female and 150 male patients were analyzed. No difference was detected between the groups regarding age (p = 0.932) or frequency of common vascular risk factors (p > 0.1 for all). At the baseline assessment, women had more disabilities compared to men with a mean modified Rankin scale (mRS) score of 2.5 (1.5 in men, p < 0.0001). Scores of white matter hyperintensities (WMH) of presumed vascular origin and a total number of lacunes of presumed vascular origin on brain MRI were higher in women compared to men (p < 0.0001 for all). As many as 64.6% of patients had CI of any severity on follow-up, women more frequently (77.4%) than men (54.0%; p < 0.0001). Univariate logistic regression analysis showed that female sex, higher NIHSS and mRS scores, presence of depression, and increasing WMH severity were associated with an increased risk for CI. Multivariate regression analysis indicated that only depression (OR 1.74, 95%CI 1.25-2.44; p = 0.001) and WMH severity (OR 1.10, 95%CI 1.03-1.17; p = 0.004) were independently associated with the CI.

Conclusion

At the long-term follow-up, women lacunar stroke survivors, compared to men, more frequently had CI in the presence of more severe vascular brain lesions, but this association was dependent on the occurrence of depression and severity of WMH, and could not be explained by differences in common vascular risk factors.

Posterior white matter hyperintensities are associated with reduced medial temporal lobe subregional integrity and long-term memory in older adults

White matter hyperintensities are a marker of small vessel cerebrovascular disease that are strongly related to cognition in older adults. Similarly, medial temporal lobe atrophy is well-documented in aging and Alzheimer's disease and is associated with memory decline. Here, we assessed the relationship between lobar white matter hyperintensities, medial temporal lobe subregional volumes, and hippocampal memory in older adults. We collected MRI scans in a sample of 139 older adults without dementia (88 females, mean age (SD) = 76.95 (10.61)). Participants were administered the Rey Auditory Verbal Learning Test (RAVLT). Regression analyses tested for associations among medial temporal lobe subregional volumes, regional white matter hyperintensities and memory, while adjusting for age, sex, and education and correcting for multiple comparisons. Increased occipital white matter hyperintensities were related to worse RAVLT delayed recall performance, and to reduced CA1, dentate gyrus, perirhinal cortex (Brodmann area 36), and parahippocampal cortex volumes. These medial temporal lobe subregional volumes were related to delayed recall performance. The association of occipital white matter hyperintensities with delayed recall performance was fully mediated statistically only by perirhinal cortex volume. These results suggest that white matter hyperintensities may be associated with memory decline through their impact on medial temporal lobe atrophy. These findings provide new insights into the role of vascular pathologies in memory loss in older adults and suggest that future studies should further examine the neural mechanisms of these relationships in longitudinal samples.

New Horizons-Cognitive Dysfunction Associated With Type 2 Diabetes

The prevalence of type 2 diabetes (T2D) and cognitive dysfunction increases with age. As society ages, clinicians will be increasingly tasked with managing older people who have both T2D and cognitive dysfunction. T2D is associated with an increased risk of cognitive dysfunction and hence there is increasing interest in whether T2D is a causal factor in the pathogenesis of cognitive decline and dementia. Recent advances in the use of sensitive measures of in vivo brain dysfunction in life-course studies can help understand potential mechanistic pathways and also help guide recommendations for clinical practice. In this article we will describe new horizons in the understanding of cognitive dysfunction associated with T2D. Coming from a clinical perspective, we discuss potential mechanisms and pathways linking the 2 conditions and the contribution of multimodal neuroimaging and study designs to advancing understanding in the field. We also highlight the important issues on the horizon that will need addressing in clinical identification, management, and risk reduction for people with coexistent T2D and cognitive dysfunction.

Endometrial carcinoma: Angiogenesis and review of the role of vascular endothelial growth factor

Endometrial carcinomas (EC) represent the most common malignant tumors of the female reproductive system and the sixth most common in the female population with an increased incidence of morbidity and mortality over the past three decades. In addition to stage, grade and type of tumor, these are the most significant prognostic factors of the biological behavior of EC and in current clinical practice are based on pathohistological examination. The shortcomings of the current histological classification are cited as one of the key limiting factors in further research, as well as in the understanding of EC carcinogenesis and improving therapeutic protocols. A new molecular classification of EC was formulated, based on the analysis of molecular biological features, recognized as highly related to the specific clinical course. Considerable efforts have been made to understand the process of angiogenesis as one of the key processes in tumor growth. The vascular endothelial growth factor (VEGF) family is a group of proangiogenic ligands that play a central role in the process of physiological and pathological angiogenesis. This factor is the most widely investigated angiogenic one as a potential biomarker and target for targeted therapy. After vast research, clinical studies have shown significant advances in the development of anti-angiogenic therapy directed at VEGF, predominantly in the form of combined therapy. In defining therapeutic groups, this therapy relies on the molecular classification of EC. Antiangiogenic therapy is limited to small specific groups of patients, associated with side effects, and numeorus patients who initially responded to targeted therapy develop resistance over time, which indicates the further need for a better understanding of the mechanisms and factors involved in the angiogenic process of EC. Potentially promising advances in the development of targeted therapeutic options for EC can be expected within the integration of molecular features of EC as a factor in the context of histological classification.

Diagnostic Values of Serum Levels of Homocysteine, Heat Shock Protein 70 and High-Sensitivity C-Reactive Protein for Predicting Vascular Cognitive Impairment

INTRODUCTION

Vascular cognitive impairment is one of the main clinical manifestations of cerebral small vessel disease (CSVD). Reliable molecular markers are needed urgently to predict cognitive impairments in CSVD patients. This study aimed to investigate the possible diagnostic values of serum levels of Hcy, Hsp70 and hs-CRP for predicting vascular cognitive impairment in patients with CSVD.

METHODS

According to the presence of CSVD and cognitive impairment (CI), healthy patients and CSVD patients were divided into three groups. Serum Hcy, HSP70 and hs-CRP were abnormal in the CI group. Clinical characteristics and MOCA cognitive function score statistics were performed for the three groups: the control group, CSVD without cognitive impairment group and CSVD with cognitive impairment group. Finally, Hcy, HSP70 and hs-CRP were correlated with MOCA to analyze the correlation between serum Hcy, HSP70 and hs-CRP and cognitive dysfunction caused by CSVD.

RESULTS

The levels of serum Hcy, Hsp70, and hsCRP had significantly higher expression in the CSVD groups than those in the control group (p<0.05). Moreover, basic clinical characteristics, cardiovascular risk factors and other clinical details had no significantly differences among the three groups. Serum Hcy, Hsp70 and hs-CRP levels were negatively correlated with MoCA total scores.

CONCLUSION

Serum levels of Hcy, HSP70 and hs-CRP were negatively correlated with cognitive impairment caused by CSVD, which could be used as a predictor to predict the risk of cognitive impairment caused by CSVD.

Risk factors of cerebral small vessel disease: A systematic review and meta-analysis

BACKGROUND

Cerebral small vessel disease (CSVD) is a common neurological disease under the effect of multiple factors. Although some literature analyzes and summarizes the risk factors of CSVD, the conclusions are controversial. To determine the risk factors of CSVD, we conducted this meta-analysis.

METHODS

Five authoritative databases of PubMed, Embase, Cochrane Library, CNKI, and Wan Fang were searched to find related studies published before November 30, 2020. The literature was screened according to the inclusion and exclusion criteria. We used RevMan 5.4 software to analyze the data after extraction.

RESULTS

A total of 29 studies involving 16,587 participants were included. The meta-analysis showed that hypertension (odds ratio [OR] 3.16, 95% confidence interval [CI] 2.22-4.49), diabetes (OR 2.15, 95% CI 1.59-2.90), hyperlipidemia (OR 1.64, 95% CI 1.11-2.40), smoking (OR 1.47, 95% CI 1.15-1.89) were significantly related to the risk of lacune, while drinking (OR 1.03, 95% CI 0.87-1.23) was not. And hypertension (OR 3.31, 95% CI 2.65-4.14), diabetes (OR 1.66, 95% CI 2.65-1.84), hyperlipidemia (OR 1.88, 95% CI 1.08-3.25), smoking (OR 1.48, 95% CI 1.07-2.04) were significantly related to the risk of white matter hyperintensity, while drinking (OR 1.41, 95% CI 0.97-2.05) was not.

CONCLUSIONS

This study suggested that hypertension, diabetes, hyperlipidemia, and smoking are risk factors of CSVD, and we should take measures to control these risk factors for the purpose of preventing CSVD.

Non-Simultaneous Bilateral Ischemic Optic Neuropathy Related to High Altitude and Airplane Flight in a Patient with Cerebral Small Vessel Disease

Non-arteritic anterior ischemic optic neuropathy (NA-AION) is considered the most frequent type of acute optic neuropathy. A 61-year-old woman presented with a NA-AION in her right eye within 24 h following an airplane flight. One year later, after driving for 10 days with a daily accumulated altitude of 1500 m, she developed a NA-AION in her left eye. Systemic disorders were investigated, and cerebral small vessel disease was observed via cranial computed tomography. An inadequate response to hypoxia, in a patient with individual susceptibility, could lead to reduced blood supply to the optic nerve head, which could represent an underlying cause of NA-AION.

Inpatient Management of Acute Stroke and Transient Ischemic Attack

This article focuses on the inpatient evaluation and management of ischemic stroke and transient ischemic attack (TIA). We describe foundational principles including quality metrics, TIA, and stroke as emergencies, TIA/minor stroke management, and standard assessments before discussing tailored evaluation and management strategies by stroke type.

The Potential Utility of Prebiotics to Modulate Alzheimer's Disease: A Review of the Evidence

The gut microbiome has recently emerged as a critical modulator of brain function, with the so-called gut-brain axis having multiple links with a variety of neurodegenerative and mental health conditions, including Alzheimer's Disease (AD). Various approaches for modulating the gut microbiome toward compositional and functional states that are consistent with improved cognitive health outcomes have been documented, including probiotics and prebiotics. While probiotics are live microorganisms that directly confer beneficial health effects, prebiotics are oligosaccharide and polysaccharide structures that can beneficially modulate the gut microbiome by enhancing the growth, survival, and/or function of gut microbes that in turn have beneficial effects on the human host. In this review, we discuss evidence showing the potential link between gut microbiome composition and AD onset or development, provide an overview of prebiotic types and their roles in altering gut microbial composition, discuss the effectiveness of prebiotics in regulating gut microbiome composition and microbially derived metabolites, and discuss the current evidence linking prebiotics with health outcomes related to AD in both animal models and human trials. Though there is a paucity of human clinical trials demonstrating the effectiveness of prebiotics in altering gut microbiome-mediated health outcomes in AD, current evidence highlights the potential of various prebiotic approaches for beneficially altering the gut microbiota or gut physiology by promoting the production of butyrate, indoles, and secondary bile acid profiles that further regulate gut immunity and mucosal homeostasis, which are associated with beneficial effects on the central immune system and brain functionality.

Emerging role of white matter lesions in cerebrovascular disease

White matter lesions have been implicated in the setting of stroke, dementia, intracerebral haemorrhage, several other cerebrovascular conditions, migraine, various neuroimmunological diseases like multiple sclerosis, disorders of metabolism, mitochondrial diseases and others. While much is understood vis a vis neuroimmunological conditions, our knowledge of the pathophysiology of these lesions, and their role in, and implications to, management of cerebrovascular diseases or stroke, especially in the elderly, are limited. Several clinical assessment tools are available for delineating white matter lesions in clinical practice. However, their incorporation into clinical decision-making and specifically prognosis and management of patients is suboptimal for use in standards of care. This article sought to provide an overview of the current knowledge and recent advances on pathophysiology, as well as clinical and radiological assessment, of white matter lesions with a focus on its development, progression and clinical implications in cerebrovascular diseases. Key indications for clinical practice and recommendations on future areas of research are also discussed. Finally, a conceptual proposal on putative mechanisms underlying pathogenesis of white matter lesions in cerebrovascular disease has been presented. Understanding of pathophysiology of white matter lesions and how they mediate outcomes is important to develop therapeutic strategies.

Association of Left Ventricular Hypertrophy and Atrial Fibrillation with Hemorrhagic Evolution of Small Vessel Disease

OBJECTIVES

Cerebral small vessel disease (SVD) is often associated with hypertension and may evolve towards intracerebral hemorrhage (ICH) or lacunar ischemic stroke. However, the factors favoring the evolution towards ICH or lacunar stroke are not well understood.

MATERIALS AND METHODS

This retrospective study included 326 consecutive patients (71.1±13.2 years, 38% women): 143 with deep ICH and 183 with lacunar lesions (LL) <2 cm, which were visible in a deep location on brain CT scan. Among LL patients, 143 had a small-artery occlusion (SAO) stroke according to the TOAST classification. Clinical characteristics plus laboratory and neuroradiological variables of these patients had been prospectively collected and a subgroup underwent echocardiography.

RESULTS

In multivariate analysis, ICH patients (97% hypertensive), compared to SAO patients (89% hypertensive), had greater left ventricular wall thickness (LVWT; OR 4.15, 95%CI 1.64-10.53, for those with LVWT ≥ 1.4 cm, 70% of whom were hemorrhagic) and lower prevalence of white matter lesions (OR 0.30, 95%CI 0.13-0.70), ever smokers (OR 0.39, 95%CI 0.18-0.82) and diabetics (OR 0.29, 95% CI 0.10-0.84). Moreover, ICH patients had a greater prevalence of atrial fibrillation than LL patients (OR 3.14, 95%CI 1.11-8.93), and so they were more often anticoagulated.

CONCLUSIONS

Most SVD patients were hypertensive, but those evolving towards ICH were characterized by organ damage at the cardiac level (increase in LVWT and atrial fibrillation), while those evolving towards lacunar stroke were characterized by a higher prevalence of smokers and diabetics, and by organ damage at the cerebral level (white matter lesions).

Acupuncture for patients recovering from lacunar infarction: A protocol for systematic review and meta-analysis

BACKGROUND

Lacunar infarction (LI) is the mild type in the classification of ischemic stroke, mostly occurs in the middle-aged and elderly, with mild hemiplegia and partial sensory disorder as the main manifestations. In the treatment of LI, acupuncture is often regarded as dominant therapy in the convalescence period. However, acupuncture for treatment of LI in the recovery period lacks high-quality reports and evidence-based medical evidence. Thus, we aim to evaluate the curative effect and safety of acupuncture for LI objectively.

METHODS

Pubmed, Cochrane Library, Web of Science, EBSCO, Springer, China National Knowledge Infrastructure, Chinese Scientific and Technical Journals Database (VIP), Wan-fang Database, Chinese Biomedical Literature Database, Chinese Science Citation Database, and other electronic databases will be retrieved from the inception to May, 2021. Randomized controlled trials related to this subject will be searched. The inclusion criteria are established and a detailed literature search strategy is designed through discussion. Article retrieval, screening, excluding repetitive studies, assessment of quality, and data processing will be conducted by 2 reviewers independently using EndNote (X9) and Review Manager (5.3.5). The outcome measures include primary outcome measures (total effective rate, National Institute of Health Stroke Scale score, and Fugl-Meyer Assessment score), secondary outcome measures (blood pressure, plasma glucose, and blood lipid), and safety outcome measures. We will perform a meta-analysis, descriptive analysis, and subgroup analysis based on data conditions.

RESULTS

The study of total effective rate, National Institute of Health Stroke Scale score, Fugl-Meyer Assessment score, blood pressure, plasma glucose, blood lipid, and adverse effects will provide evidenced outcome for high-quality synthesis and descriptive analysis.

CONCLUSION

This systematic review will kindly provide evidence of whether acupuncture is an effective and safe intervention for LI in the recovery period.

INPLASY REGISTRATION NUMBER

INPLASY202150060 (DOI:10.37766/inplasy2021.5.0060).

Loss of Integrity of Corpus Callosum White Matter Hyperintensity Penumbra Predicts Cognitive Decline in Patients With Subcortical Vascular Mild Cognitive Impairment

Loss of white matter (WM) integrity contributes to subcortical vascular mild cognitive impairment (svMCI). Diffusion tensor imaging (DTI) has revealed damage beyond the area of WM hyperintensity (WMH) including in normal-appearing WM (NAWM); however, the functional significance of this observation is unclear. To answer this question, in this study we investigated the relationship between microstructural changes in the WMH penumbra (WMH-P) and cognitive function in patients with svMCI by regional tract-based analysis. A total of 111 patients with svMCI and 72 patients with subcortical ischemic vascular disease (SIVD) without cognitive impairment (controls) underwent DTI and neuropsychological assessment. WMH burden was determined before computing mean values of fractional anisotropy (FA) and mean diffusivity (MD) within WMHs and WMH-Ps. Pearson’s partial correlations were used to assess the relationship between measurements showing significant intergroup differences and composite Z-scores representing global cognitive function. Multiple linear regression analysis was carried out to determine the best model for predicting composite Z-scores. We found that WMH burden in the genu, body, and splenium of the corpus callosum (GCC, BCC, and SCC respectively); bilateral anterior, superior, and posterior corona radiata; left sagittal stratum was significantly higher in the svMCI group than in the control group (p < 0.05). The WMH burden of the GCC, BCC, SCC, and bilateral anterior corona radiata was negatively correlated with composite Z-scores. Among diffusion parameters showing significant differences across the 10 WM regions, mean FA values of WMH and WMH-P of the BCC were correlated with composite Z-scores in svMCI patients. The results of the multiple linear regression analysis showed that the FA of WMH-P of the BCC and WMH burden of the SCC and GCC were independent predictors of composite Z-score, with the FA of WMH-P of the BCC making the largest contribution. These findings indicate that disruption of the CC microstructure—especially the WMH-P of the BCC—may contribute to the cognitive deficits associated with SIVD.

4D flow MRI for non-invasive measurement of blood flow in the brain: A systematic review

The brain's vasculature is essential for brain health and its dysfunction contributes to the onset and development of many dementias and neurological disorders. While numerous in vivo imaging techniques exist to investigate cerebral haemodynamics in humans, phase-contrast magnetic resonance imaging (MRI) has emerged as a reliable, non-invasive method of quantifying blood flow within intracranial vessels. In recent years, an advanced form of this method, known as 4D flow, has been developed and utilised in patient studies, where its ability to capture complex blood flow dynamics within any major vessel across the acquired volume has proved effective in collecting large amounts of information in a single scan. While extremely promising as a method of examining the vascular system's role in brain-related diseases, the collection of 4D data can be time-consuming, meaning data quality has to be traded off against the acquisition time. Here, we review the available literature to examine 4D flow's capabilities in assessing physiological and pathological features of the cerebrovascular system. Emerging techniques such as dynamic velocity-encoding and advanced undersampling methods, combined with increasingly high-field MRI scanners, are likely to bring 4D flow to the forefront of cerebrovascular imaging studies in the years to come.

Comparison of plaque characteristics of small and large subcortical infarctions in the middle cerebral artery territory using high-resolution magnetic resonance vessel wall imaging

Background

The characteristics of plaque that ultimately lead to different subcortical infarctions remain unclear. We explored the differences in plaque characteristics between patients with small subcortical infarction (SSI) and large subcortical infarction (LSI) of the middle cerebral artery (MCA) using high-resolution magnetic resonance vessel wall imaging (HR-MRVWI).

Methods

The study group comprised 71 patients (mean age, 47.49±11.5 years; 55 male) with MCA territory ischemic stroke. Whole-brain HR-MRVWI was performed using a three-dimensional T1-weighted variable-flip-angle turbo spin echo (SPACE) sequence. Patients were divided into SSI and LSI groups based on routine MRI images. Plaque distribution was classified as the superior, inferior, ventral, or dorsal wall of the MCA. The number of quadrants with plaque formation, location of plaque, plaque burden (PB), arterial remodeling pattern (positive or negative), and degree of stenosis were analyzed and compared between groups.

Results

Of the 71 patients, 43 (60.6%) and 28 (39.4%) were identified as the SSI and LSI groups, respectively. The proportion of plaques involving only one quadrant was significantly higher in the SSI group, and these plaques were located in the superior or dorsal MCA vessel wall. There was no significant difference between groups in the proportion of plaques involving two or more quadrants, plaque distribution, or PB. Most plaques in both groups showed positive remodeling, and the percentage of remodeling pattern was similar. A significantly higher incidence of low-grade stenosis (<50%) was observed in the SSI group.

Conclusions

Both SSI and LSI may be associated with major intracranial artery atherosclerosis, but patients with SSI showed relatively fewer quadrants with plaque formation and a lesser degree of stenosis.

Human Brain Atlases in Stroke Management

Stroke is a leading cause of death and a major cause of permanent disability. Its management is demanding because of variety of protocols, imaging modalities, pulse sequences, hemodynamic maps, criteria for treatment, and time constraints to promptly evaluate and treat. To cope with some of these issues, we propose novel, patented solutions in stroke management by employing multiple brain atlases for diagnosis, treatment, and prediction. Numerous and diverse CT and MRI scans are used: ARIC cohort, ischemic and hemorrhagic stroke CT cases, MRI cases with multiple pulse sequences, and 128 stroke CT patients, each with 170 variables and one year follow-up. The method employs brain atlases of anatomy, blood supply territories, and probabilistic stroke atlas. It rapidly maps an atlas to scan and provides atlas-assisted scan processing. Atlas-to-scan mapping is application-dependent and handles three types of regions of interest (ROIs): atlas-defined ROIs, atlas-quantified ROIs, and ROIs creating an atlas. An ROI is defined by atlas-guided anatomy or scan-derived pathology. The atlas defines ROI or quantifies it. A brain atlas potential has been illustrated in four atlas-assisted applications for stroke occurrence prediction and screening, rapid and automatic stroke diagnosis in emergency room, quantitative decision support in thrombolysis in ischemic stroke, and stroke outcome prediction and treatment assessment. The use of brain atlases in stroke has many potential advantages, including rapid processing, automated and robust handling, wide range of applications, and quantitative assessment. Further work is needed to enhance the developed prototypes, clinically validate proposed solutions, and introduce them to clinical practice.

Intracranial Pulsatility in Relation to Severity and Progression of Cerebral White Matter Hyperintensities

Background and Purpose:

Previous studies suggested an association between increased intracranial arterial pulsatility and the severity of microangiopathic white matter hyperintensities (WMH). However, possible confounders such as age and hypertension were seldomly considered and longitudinal data are lacking. We here aimed to explore whether increased middle cerebral artery pulsatility is associated with baseline severity and progression of cerebral small vessel disease–related WMH in elderly individuals.

Methods:

The study population consisted of elderly participants from the community-based ASPS (Austrian Stroke Prevention Study). Baseline and follow-up assessment comprised transcranial Doppler sonography, brain magnetic resonance imaging, and clinical/laboratory examination of vascular risk factors. Pulsatility index on transcranial Doppler sonography was averaged from baseline indices of both middle cerebral arteries and was correlated with baseline WMH severity and WMH progression over a median follow-up period of 5 years in uni- and multivariable analyses. WMH severity was graded according to the Fazekas scale, and WMH load was quantified by semiautomated volumetric assessment.

Results:

The study cohort comprised 491 participants (mean age: 60.7±6.9 years; female: 48.5%). Pulsatility index was increased in participants with more severe WMH at baseline ( P <0.001) but was not associated with WMH progression during follow-up (r s : 0.097, P =0.099). In multivariable analyses, only arterial hypertension remained significantly associated with baseline severity ( P =0.04) and progression ( P =0.008) of WMH, although transcranial Doppler sonography pulsatility index was not predictive ( P >0.1, respectively).

Conclusions:

This community-based cohort study of elderly individuals does not support the pulsatility index of the middle cerebral artery on transcranial Doppler sonography as an independent marker of microangiopathic WMH severity and progression over time.

Twenty-Four-Hour Ambulatory Blood Pressure Variability Associated With Cerebral Small Vessel Disease MRI Burden and Its Progression in Inpatients With Cerebrovascular Disease

Background: Lacunar infarcts, white matter lesions, cerebral microbleed, enlarged perivascular space and brain atrophy are regarded as magnetic resonance imaging (MRI) manifestations of cerebral small vessel disease (cSVD). 24-hour blood pressure variability (BPV) has been reported to relate with cerebral small vessel disease, but the impact of 24-h BPV on the total MRI cSVD burden and its progression in inpatients with cerebrovascular disease has not been investigated yet. Methods: We enrolled inpatients with cerebrovascular disease, who underwent the 24-h ambulatory blood pressure monitoring (ABPM) and the brain MRI scan at baseline and had the follow-up brain MRI images stored in the clinical information system of our hospital. BPV was quantified by the calculation of standard deviation (SD), coefficient of variation (CV), weighted standard deviation (wSD) of blood pressure record. We evaluated the total cSVD score on baseline MRI and the MRI followed-up to obtain the total burden of cSVD. The cSVD burden progression was estimated through the comparison of the total cSVD score on the two MRIs. Results: A total of 140 patients with an average age of 65.6 years were finally enrolled, 82.9% (116/140) of whom had one or more cSVD markers. After a median of 4.4 years follow-up, cSVD score progression were found in 50.7% (71/140) of the patients. Both SD and CV of SBP and DBP during 24-h and daytime as well as the SBP wSD differed significantly among different total cSVD score groups. The SBP SD and CV during 24-h and daytime, the SBP SD in nighttime, the DBP SD and CV during the daytime were significantly higher in the cSVD progression group than those in the cSVD no-progression group. The SBP wSD and the DBP wSD were significantly higher in the cSVD progression group than those in the cSVD no-progression group. Logistic regression analyses revealed that daytime SBP SD and SBP wSD were independent risk factors for total cSVD burden [daytime SBP SD: OR = 1.628, 95% CI = 1.105-2.398 (per 5 mmHg increase in SD), P = 0.014; SBP wSD: OR = 2.248, 95% CI = 1.564-3.230 (per 5 mmHg increase in wSD), P < 0.001)] and SBP wSD was a significant predictor for cSVD progression [OR = 2.990, 95% CI = 1.053-8.496 (per 5 mmHg increase in wSD), P = 0.040]. Conclusion: Higher BPV were significantly related with total cSVD burden in inpatients with cerebrovascular disease. SBP SD during daytime and SBP wSD were independent risk factor for total cSVD burden and SBP wSD was an predictive factor for cSVD progression.

Association between red blood cell distribution width and white matter hyperintensities: A large-scale cross-sectional study

BACKGROUND

Red blood cell distribution width (RDW) is a strong prognostic marker for various medical conditions, such as ischemic strokes. However, the relationships between higher RDW and the subtypes of white matter hyperintensities (WMHs) remain unclear. Hence, this study aimed to thoroughly evaluate the relationships between RDW and the subtypes of WMHs.

PATIENTS AND METHODS

This cross-sectional study was a retrospective analysis of hospital database (Dongguan Medical System, from April 2015 to February 2017). The presence and subtypes of WMHs were evaluated using Fazekas score with the T2WI-FLAIR brain images from a 1.5-T MRI system. The overall sample was randomly split in half. One of the two split-half samples was used for determining the optimal cutoff value of higher RDW and another for further statistical analyses.

RESULTS

A total of 555 subjects with WMHs and 642 controls were recruited. The optimal cutoff value of higher RDW was 13.25%. Logistic regression revealed that higher RDW (≥13.25%) was positively associated with periventricular WMHs (adjusted OR = 1.81, 95% CI: 1.16-2.82, p = .009). However, higher RDW was not associated with total WMHs (adjusted OR = 1.52, 95% CI: 0.99-2.33, p = .057) and deep WMHs (adjusted OR = 1.21, 95% CI: 0.76-1.94, p = .426).

CONCLUSION

Our findings suggested that higher RDW may be independently associated with periventricular WMHs, but not with total WMHs and deep WMHs.

Assessing the effectiveness of statin therapy for alleviating cerebral small vessel disease progression in people ≥75 years of age

BACKGROUND

Statins have been recommended by several guidelines as the primary prevention medication for cardiovascular diseases. However, the benefits of statin therapy for cerebral small vessel disease (CSVD), particularly in adults ≥75 years of age, have not been fully evaluated.

METHODS

We analyzed the data from a prospective population-based cohort study and a randomized, double-blind, placebo-controlled clinical trial to determine whether statin therapy might aid in slowing the progression of CSVD in adults ≥75 years of age. For the cohort study, 827 participants were considered eligible and were included in the baseline analysis. Subsequently, 781 participants were included in follow-up analysis. For the clinical trial, 227 participants were considered eligible and were used in the baseline and follow-up analyses.

RESULTS

The white matter hyperintensities (WMH) volume, the WMH-to-intracranial volume (ICV) ratio, the prevalence of a Fazekas scale score ≥ 2, lacunes, enlarged perivascular spaces (EPVS), and microbleeds were significantly lower in the statin group than the non-statin group at baseline in the cohort study (all P < 0.05). During the follow-up period, in both the cohort and clinical trial studies, the WMH volume and WMH-to-ICV ratio were significantly lower in the statin/rosuvastatin group than the non-statin/placebo group (all P < 0.001). Statin therapy was associated with lower risk of WMH, lacunes, and EPVS progression than the non-statin therapy group after adjustment for confounders (all P < 0.05). There was no statistically significant difference in the risk of microbleeds between the statin and non-statin therapy groups (all, P > 0.05).

CONCLUSIONS

Our findings indicated that statin therapy alleviated the progression of WMH, lacunes, and EPVS without elevating the risk of microbleeds. On the basis of the observed results, we concluded that statin therapy is an efficient and safe intervention for CSVD in adults ≥75 years of age.

TRIAL REGISTRATION

Chictr.org.cn: ChiCTR-IOR-17013557 , date of trial retrospective registration November 27, 2017 and ChiCTR-EOC-017013598 , date of trial retrospective registration November 29, 2017.

Association between Low-Density Lipoprotein Cholesterol Levels and Proximal Single Subcortical Infarction in Comparison with Distal Single Subcortical Infarction

PURPOSE

Single subcortical infarction (SSI) in the middle cerebral artery (MCA) territory can be classified into proximal SSI (pSSI) and distal SSI (dSSI) based on the heterogeneous pathogenesis. It is hypothesized that pSSI is more relevant with atherosclerosis, as low-density lipoprotein cholesterol (LDL-C) is the major atherogenic lipoprotein, we conducted the present study to investigate the association between LDL-C levels and pSSI in comparison with dSSI.

PATIENTS AND METHODS

This study is a subset of the Chinese Intracranial Atherosclerosis study. A total of 380 with SSI in the MCA territory classified as small artery occlusion stroke were enrolled in this study. 3.0-T magnetic resonance imaging (MRI) was performed to categorize the participants into two groups, pSSI (extending to the basal surface of MCA) and dSSI (not extending to the basal surface of MCA).

RESULTS

Out of the 380 enrolled participants (273 men and 107 women), the proportion of pSSI and dSSI were 53.2% (202/380) versus 46.8% (178/380) based on MRI. The results of univariate and multivariate logistic regression were both at the borderline level of statistical significance. Further stratified analyses revealed that age is an interaction factor (P = 0.03), the association between LDL-C levels and the pSSI in participants aged over 65 had a significant positive relation (OR: 1.56; 95%CI: 1.14-2.12).

CONCLUSION

LDL-C level is an independent risk factor for pSSI in patients aged over 65. Our result is in accordance with the hypothesis that pSSI is more relevant with atherosclerosis, thus appropriate treatment should be applied differently to pSSI and dSSI.

Association between Ankle Brachial Index, Brachial-Ankle Pulse Wave Velocity, and Mild Cognitive Impairment in Patients with Acute Lacunar Infarction

BACKGROUND

The link between arterial stiffness and mild cognitive impairment (MCI) is receiving increasing attention, and the goal of this study was to explore the relationship among the ankle brachial index (ABI), brachial-ankle pulse wave velocity (Ba-PWV), and MCI in patients with acute lacunar infarction (ALI).

METHODS

A total of 103 hospitalized patients with ALI were divided into a non-MCI group (n = 41) and an MCI group (n = 62) according to their Montreal Cognitive Assessment (MoCA) scores. A binary logistic regression model was used to assess the association among ABI, Ba-PWV, and MCI after adjusting for confounding factors. Spearman correlation was utilized to analyse the correlations between ABI, Ba-PWV, and MoCA total scores and sub-scores in ALI patients.

RESULTS

Participants with cognitive impairment had significantly higher Ba-PWV and lower ABI than those with normal cognition. Correlation analysis suggested that Ba-PWV (r = -0.854, p < 0.05) and ABI (r = 0.734, p < 0.05) were correlated with MoCA total scores; of all MoCA sub-scores, visuospatial/executive function was the most strongly correlated with the vascular variables. In the binary logistic regression analysis, Ba-PWV (odds ratio [OR] = 4.507, 95% confidence interval [CI] = 2.152-9.441) and ABI (OR = 1.124, 95% CI = 1.015-1.254) were significantly associated with MCI, even after adjusting for lipoprotein (a) and systolic and diastolic blood pressure.

CONCLUSION

The present study suggested that a higher Ba-PWV and a lower ABI were independent risk factors for MCI in patients with ALI.

Association of Circadian Rhythm of Blood Pressure and Cerebral Small Vessel Disease in Community-Based Elderly Population

BACKGROUND

Although it is accepted that the etiology of cerebral small vessel disease (CSVD) is associated with cardiovascular risk factors, the association between CSVD and the circadian rhythm of blood pressure (BP) is unclear. We aimed to determine if such an association existed in the elderly population.

METHOD

White matter hyperintensities (WMHs), lacunes, microbleeds, nocturnal dipping pattern (NDP), and morning surge in systolic blood pressure (SBP) were assessed in 2,091 participants ≥60 years of age.

RESULTS

During an average of 63 months of follow-up, WMH and the WMH-to-intracranial volume ratio were significantly increased in extreme dippers, nondippers, and reverse dippers than those in dippers (p < .001). For new-incident Fazekas scale ≥2, the hazard ratios were 1.77 (95% confidence interval [CI], 1.09-2.86) for extreme dippers, 2.20 (95% CI, 1.48-3.28) for nondippers, and 2.43 (95% CI, 1.59-3.70) for reverse dippers compared with dippers, and 1.04 (95% CI, 0.81-1.35) for higher morning surge compared with lower morning surge. Nondippers and reverse dippers were associated with higher risks of new-incident lacunes and microbleeds than dippers (p < .05). Higher morning surge was associated with a higher risk of new-incident microbleeds than lower morning surge (p < .05).

CONCLUSION

NDPs in SBP played an important role in CSVD, and the morning surge in SBP was associated with cerebral microbleeds in community-based elderly population beyond the average SBP level.

Different Influences of Statin Treatment in Preventing At-Risk Stroke Subtypes: A Post Hoc Analysis of J-STARS

Aims: To understand the different influences of statins on the incidence rate of each stroke subtype in association with low-density lipoprotein (LDL) cholesterol levels, we performed a post hoc analysis on the data from the Japan Statin Treatment Against Recurrent Stroke (J-STARS) study.

Methods: Subjects (n = 1,578) were divided into three groups according to their mean postrandomized LDL cholesterol level (< 100, 100–120, and ≥ 120 mg/dL) until the last observation before the event or the end of follow-up. A Cox proportional hazard model for time to events was used for calculating adjusted hazard ratios, 95% confidence intervals, and the trend tests.

Results: The event rates for atherothrombotic stroke did not decrease in accordance with the postrandomized LDL cholesterol level subgroups of either the control or the pravastatin group (p = 0.15 and 0.33 for the trend, respectively). In the control group, however, no atherothrombotic stroke event was observed in the subgroup of the low postrandomized LDL cholesterol level (less than 100 mg/dL). The event rates for atherothrombotic stroke were lower in the middle postrandomized LDL cholesterol level subgroup (100–120 mg/dL) of the pravastatin group than that of the control group. The event rates for lacunar stroke decreased in the lower postrandomized LDL cholesterol level subgroup of the control group but not of the pravastatin group (p = 0.004 and 0.06 for the trend, respectively).

Conclusions: Statins showed different influences on the risks of atherothromobotic and lacunar stroke according to postrandomized LDL cholesterol levels.

[Current concepts about small vessel disease]

Small vessel disease is a very common pathological process, which plays a key role in the development of stroke and cognitive impairment and, at the same time, affects other organs. The search for optimal drugs for prevention and treatment of small vessel disease has been continuing. The results of new studies enable further development of new treatment strategies. Currently, the drugs with neurotrophic properties become more and more important.

Coexistence of Cerebral Microbleeds and Amyloid Pathology in Patients with Cognitive Complaints

Background and Purpose

We investigated the prevalence of amyloid positivity and cerebral microbleeds (CMBs) in subjects with cognitive complaints with the aim of identifying differences in clinical parameters and cognitive function according to the pattern of coexistence.

Methods

We retrospectively enrolled 200 subjects with memory impairment and applied both standardized ¹⁸F-florbetaben PET and brain MRI, including susceptibility-weighted imaging. The amyloid burden was visually classified as positive or negative, and the number and location of CMBs were also analyzed visually. Descriptive analysis was performed for the prevalence of amyloid positivity and CMBs. The relationship between the coexisting pattern of those two findings and clinical parameters including the results of neuropsychiatric tests was analyzed.

Results

Positive amyloid PET scans were exhibited by 102 (51.5%) of the 200 patients, and 51 (25.5%) of them had CMBs, which were mostly located in lobar areas in the patients with positive amyloid scans. The patients with CMBs were older and had a higher burden of white-matter hyperintensities than the patients without CMBs. The patients with CMBs also performed worse in confrontation naming and frontal/executive function. When classified by topographical region, parietal CMBs (odds ratio=3.739, p=0.024) were significantly associated with amyloid positivity.

Conclusions

The prevalence of CMBs was higher in patients with cognitive decline than in the general population. CMBs play distinctive roles in affecting clinical parameters and neuropsychological profiles according to the coexistence of amyloid pathology.

Association Between Endothelial Cell Stabilizing Medication and Small Vessel Disease Stroke: A Case-Control Study

Increasing evidence suggests a role for endothelial cell (EC) dysfunction in pathogenesis of cerebral small vessel disease. Commonly used medications including certain antihypertensives and statins have EC-stabilizing effects. We used individual patient data from completed acute stroke trials to assess whether prior exposure to EC-stabilizing medications was associated with lacunar stroke, using lacunar stroke as a clinical proxy for cerebral small vessel disease. Across 12,002 patients with relevant data, 2,855 (24%) had a lacunar stroke presentation. Univariable analyses suggested potential confounding from vascular diseases treated with EC-stabilizing medications. Initial multivariable logistic regression gave conflicting results when describing the independent association of exposure to EC-stabilizing medication and lacunar stroke in the complete population (O.R. 0.87, 95% C.I.: 0.77– 0.98) and limited to those taking any antihypertensive (O.R. 1.51, 95% C.I.: 1.21–1.88). Re-running the analyses including statins in the EC-stabilizing category suggested a beneficial effect of EC-stabilizing medication exposure on lacunar stroke incidence (O.R. 0.83, 95% C.I.: 0.73–0.93). These results align with recent pre-clinical data and would support interventional trials of EC-stabilizing medication for preventing cerebral small vessel disease. Our results also suggest that analyses of EC-stabilizing interventions need to adjust for potential endothelial effects of other co-prescribed medication.

Genetic Factors of Cerebral Small Vessel Disease and Their Potential Clinical Outcome

Cerebral small vessel diseases (SVD) have been causally correlated with ischemic strokes, leading to cognitive decline and vascular dementia. Neuroimaging and molecular genetic tests could improve diagnostic accuracy in patients with potential SVD. Several types of monogenic, hereditary cerebral SVD have been identified: cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL), cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), cathepsin A-related arteriopathy with strokes and leukoencephalopathy (CARASAL), hereditary diffuse leukoencephalopathy with spheroids (HDLS), COL4A1/2-related disorders, and Fabry disease. These disorders can be distinguished based on their genetics, pathological and imaging findings, clinical manifestation, and diagnosis. Genetic studies of sporadic cerebral SVD have demonstrated a high degree of heritability, particularly among patients with young-onset stroke. Common genetic variants in monogenic disease may contribute to pathological progress in several cerebral SVD subtypes, revealing distinct genetic mechanisms in different subtype of SVD. Hence, genetic molecular analysis should be used as the final gold standard of diagnosis. The purpose of this review was to summarize the recent discoveries made surrounding the genetics of cerebral SVD and their clinical significance, to provide new insights into the pathogenesis of cerebral SVD, and to highlight the possible convergence of disease mechanisms in monogenic and sporadic cerebral SVD.

Treatment Approaches to Lacunar Stroke

Lacunar strokes are appropriately named for their ability to cavitate and form ponds or "little lakes" (Latin: lacune -ae meaning pond or pit is a diminutive form of lacus meaning lake). They account for a substantial proportion of both symptomatic and asymptomatic ischemic strokes. In recent years, there have been several advances in the management of large vessel occlusions. New therapies such as non-vitamin K antagonist oral anticoagulants and left atrial appendage closure have recently been developed to improve stroke prevention in atrial fibrillation; however, the treatment of small vessel disease-related strokes lags frustratingly behind. Since Fisher characterized the lacunar syndromes and associated infarcts in the late 1960s, there have been no therapies specifically targeting lacunar stroke. Unfortunately, many therapeutic agents used for the treatment of ischemic stroke in general offer only a modest benefit in reducing recurrent stroke while adding to the risk of intracerebral hemorrhage and systemic bleeding. Escalation of antithrombotic treatments beyond standard single antiplatelet agents has not been effective in long-term lacunar stroke prevention efforts, unequivocally increasing intracerebral hemorrhage risk without providing a significant benefit. In this review, we critically review the available treatments for lacunar stroke based on evidence from clinical trials. For several of the major drugs, we summarize the adverse effects in the context of this unique patient population. We also discuss the role of neuroprotective therapies and neural repair strategies as they may relate to recovery from lacunar stroke.

Low carotid endothelial shear stress associated with cerebral small vessel disease in an older population: A subgroup analysis of a population-based prospective cohort study

BACKGROUND AND AIMS

The association between carotid wall shear stress (WSS) and cerebral small vessel disease has yet to be fully elucidated. The major purpose of this study was to investigate this association in older subjects.

METHODS

Common carotid artery WSS, endothelial function, white matter hyperintensities (WMH), lacunes, and microbleeds were assessed in 1396 older adults. Participants were followed-up for an average of 69.7 months.

RESULTS

Mean (M) and peak (P) WSS and changes in endothelial function were independently associated with changes in WMH volume and fraction, lacune counts, and microbleed counts (all p < 0.05). The risks of new-incident Fazekas scale ≥2 [hazard ratio (HR) with 95% confidence interval (CI): 2.141 (1.469-3.119), p = 0.005 and 1.731 (1.197-2.505), p = 0.004, respectively], lacunes [HR (95% CI): 2.034 (1.369-3.022), p < 0.001 and 1.693 (1.151-2.490), p = 0.003, respectively], and microbleeds [HR (95% CI): 2.311 (1.509-3.541), p < 0.001 and 2.208 (1.299-3.751), p < 0.001, respectively] were significantly higher in the lowest quartile group than in the higher quartile group, as classified by either MWSS or PWSS, after adjustment for confounders.

CONCLUSIONS

Low carotid WSS is an independent risk factor for the progression of cerebral small vessel disease in older adults.

Pathophysiology of Lacunar Stroke: History's Mysteries and Modern Interpretations

Since the term "lacune" was adopted in the 1800s to describe infarctions from cerebral small vessels, their underlying pathophysiological basis remained obscure until the 1960s when Charles Miller Fisher performed several autopsy studies of stroke patients. He observed that the vessels displayed segmental arteriolar disorganization that was associated with vessel enlargement, hemorrhage, and fibrinoid deposition. He coined the term "lipohyalinosis" to describe the microvascular mechanism that engenders small subcortical infarcts in the absence of a compelling embolic source. Since Fisher's early descriptions of lipohyalinosis and lacunar stroke (LS), there have been many advancements in the understanding of this disease process. Herein, we review lipohyalinosis as it relates to modern concepts of cerebral small vessel disease (cSVD). We discuss clinical classifications of LS as well as radiographic definitions based on modern neuroimaging techniques. We provide a broad and comprehensive overview of LS pathophysiology both at the vessel and parenchymal levels. We also comment on the role of biomarkers, the possibility of systemic disease processes, and advancements in the genetics of cSVD. Lastly, we assess preclinical models that can aid in studying LS disease pathogenesis. Enhanced understanding of this highly prevalent disease will allow for the identification of novel therapeutic targets capable of mitigating disease sequelae.

Are morphologic features of recent small subcortical infarcts related to specific etiologic aspects?

Background:

Recent small subcortical infarcts (RSSIs) mostly result from the occlusion of a single, small, brain artery due to intrinsic cerebral small-vessel disease (CSVD). Some RSSIs may be attributable to other causes such as cardiac embolism or large-artery disease, and their association with coexisting CSVD and vascular risk factors may vary with morphological magnetic resonance imaging (MRI) features.

Methods:

We retrospectively identified all inpatients with a single symptomatic MRI-confirmed RSSI between 2008 and 2013. RSSIs were rated for size, shape, location (i.e. anterior: basal ganglia and centrum semiovale posterior cerebral circulation: thalamus and pons) and MRI signs of concomitant CSVD. In a further step, clinical data, including detailed diagnostic workup and vascular risk factors, were analyzed with regard to RSSI features.

Results:

Among 335 RSSI patients (mean age 71.1 ± 12.1 years), 131 (39%) RSSIs were >15 mm in axial diameter and 66 (20%) were tubular shaped. Atrial fibrillation (AF) was present in 44 (13.1%) and an ipsilateral vessel stenosis > 50% in 30 (9%) patients. Arterial hypertension and CSVD MRI markers were more frequent in patients with anterior-circulation RSSIs, whereas diabetes was more prevalent in posterior-circulation RSSIs. Larger RSSIs occurred more frequently in the basal ganglia and pons, and the latter were associated with signs of large-artery atherosclerosis. Patients with concomitant AF had no specific MRI profile.

Conclusion:

Our findings suggest the contribution of different pathophysiological mechanisms to the occurrence of RSSIs in the anterior and posterior cerebral circulation. While there appears to be some general association of larger infarcts in the pons with large-artery disease, we found no pattern suggestive of AF in RSSIs.

Clinical and research applications of magnetic resonance imaging in the study of CADASIL

Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is an inherited small vessel disease that leads to early cerebrovascular events and functional disability. It is the most common single-gene disorder leading to stroke. Magnetic resonance imaging (MRI) is a central component of the diagnosis and monitoring of CADASIL. Here we provide a descriptive review of the literature on three important aspects pertaining to the use of MRI in CADASIL. First, we review past research exploring MRI markers for this disease. Secondly, we describe results from studies investigating associations between neuroimaging abnormalities and neuropathology in CADASIL. Finally, we discuss previous findings relating MRI markers to clinical symptoms. This review thus provides a summary of the current state of knowledge regarding the use of MRI in CADASIL as well as suggestions for future research.

Characterizing the Penumbras of White Matter Hyperintensities and Their Associations With Cognitive Function in Patients With Subcortical Vascular Mild Cognitive Impairment

Normal-appearing white matter (NAWM) surrounding white matter hyperintensities (WMHs), frequently known as the WMH penumbra, is associated with subtle white matter injury and has a high risk for future conversion to WMHs. The goal of this study was to define WMH penumbras and to further explore whether the diffusion and perfusion parameters of these penumbras could better reflect cognitive function alterations than WMHs in subjects with subcortical vascular mild cognitive impairment (svMCI). Seventy-three svMCI subjects underwent neuropsychological assessments and 3T MRI scans, including diffusion tensor imaging (DTI) and arterial spin labeling (ASL). To determine the extent of cerebral blood flow (CBF) and DTI penumbras. A NAWM layer mask was generated for periventricular WMHs (PVWMHs) and deep WMHs (DWMHs) separately. Mean values of CBF, fractional anisotropy (FA), mean diffusivity (MD) within the WMHs and their corresponding NAWM layer masks were computed and compared using paired t-tests. Pearson's partial correlations were used to assess the relations of the mean CBF, FA, and MD values within the corresponding penumbras with composite z-scores of global cognition and four cognitive domains controlling for age, sex, and education. For both PVWMHs and DWMHs, the CBF penumbras were wider than the DTI penumbras. Only the mean FA value of the PVWMH-FA penumbra was correlated with the composite z-scores of global cognition before correction (r = 0.268, p = 0.024), but that correlation did not survive after correcting the p-value for multiple comparisons. Our findings showed extensive white matter perfusion disturbances including white matter tissue, both with and without microstructural alterations. The imaging parameters investigated, however, did not correlate to cognition.