Incidence and risk factors of intracranial atherosclerotic stroke: the Northern Manhattan Stroke Study

Anti-thyroid peroxidase antibody in stroke localization: exordium doorway of preliminary findings in thyroidology?

OBJECTIVE

Stroke is a chronic health problem that affects all areas of life. The presence of thyroid autoantibodies can augment the severity of stroke. The aim of this work is to investigate whether there is a relationship between the site of stroke involvement and the anti-thyroid peroxidase antibody (anti-TPO) or not. This is the first study in the English-language literature.

METHODS

A total of 39 patients with a diagnosis of acute ischemic stroke were included, and the cases under 18 years of age with an infection and the ones with autoimmune diseases other than Hashimoto's thyroiditis were excluded from the study design. The patients' age, gender, smoking status, comorbid conditions, and stroke localization in brain imaging were recorded. The region involving the anterior circulation area originating from the internal carotid artery was evaluated as anterior, and the region possessing the vertebrobasilar circulation area from the vertebral arteries was considered posterior involvement. Thyroid-stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), triglyceride, high-density lipoprotein (HDL), low-density lipoprotein (LDL), C-reactive protein (CRP), sedimentation, and anti-TPO were retrospectively analyzed.

RESULTS

As a consequence, gender distribution, smoking, comorbid conditions, TSH, T3, T4, triglyceride, HDL, LDL, CRP, and sedimentation did not differ significantly, while the age of the posterior-located stroke was lower than that of the cases with the anterior. The anti-TPO value was significantly lower in posterior-located strokes than in the anterior system.

CONCLUSION

In summary, the anti-TPO value was recognized as higher in the anterior stroke localization. Thyroiditis and accompanying anti-TPO autoantibody positivity are conditions that should not be ignored by thyroidologists and thyroid-health providers.

Progression of arterial calcifications: what, where, and in whom?

OBJECTIVES

There is a lack of information on the development of arteriosclerosis over time. This study aims to assess long-term sex-specific changes in arterial calcifications in five arteries, and the influence of cardiovascular risk factors hereon.

METHODS

From a population-based cohort, 807 participants (mean baseline age, 65.8; SD, 4.2) underwent a non-contrast computed tomography (CT) examination between 2003 and 2006, and after a median follow-up of 14 years. We assessed incidences and changes in volumes of coronary artery calcification (CAC), aortic arch calcification (AAC), extracranial (ECAC) and intracranial carotid artery calcification (ICAC), and vertebrobasilar artery calcification (VBAC). We investigated the simultaneous presence of severe progression (upper quartile of percentual change volumes). Associations of cardiovascular risk factors with changes in calcification volumes were assessed using multivariate linear regression models.

RESULTS

The difference in AAC was most substantial; the median volume (mm3) increased from of 129 to 916 in men and from 93 to 839 in women. For VBAC, no change in volumes was observed though more than a quarter of participants without baseline VBAC developed VBAC during follow-up. Severe progression was most often observed in only one artery at the same time. Hypertension was most consistently associated with increase in calcifications. Associations of diabetes, hypercholesterolemia, and smoking with changes in calcifications varied across arteries and sex.

CONCLUSIONS

We found a considerable incidence and increase in volumes of calcifications in different arteries, over a 14-year time interval. Cardiovascular risk factors were associated with increase of calcifications with sex-specific differential effects across arteries.

CLINICAL RELEVANCE STATEMENT

There is a considerable incidence and increase in volumes of calcifications in different arteries, over a 14-year time interval. Cardiovascular risk factors are associated with increase of calcifications with sex-specific differential effects across arteries; thus, assessing changes in only one artery may thus not provide a good reflection of the systemic development of arteriosclerosis.

KEY POINTS

• Assessing change in arterial calcification in only one artery does not reflect the systemic development of arterial calcification. • Cardiovascular risk factors are associated with progression of arterial calcifications. • Progression of arterial calcification is sex and artery-specific.

Common and distinct risk profiles of asymptomatic extra- and intracranial atherosclerosis in the Nagahama cohort

BACKGROUND AND PURPOSE

Atherosclerotic burden increases the risk of both extracranial internal carotid artery stenosis (ICS) and intracranial large artery disease (ICAD). However, the differences in risk profiles have not been thoroughly investigated.

METHODS

Participants were recruited from the Nagahama study cohort in Japan. Individuals over 60 years old who underwent 1.5-T head and neck magnetic resonance angiography (MRA) between July 2013 and February 2017 were included. ICAD was defined as WASID ≥ 50%, and ICS was defined as NSCET ≥ 30%. The prevalence and association of risk factors, including proatherogenic and proinflammatory factors, and the p.R4810K variant in the RNF213 gene, were investigated. Multivariable logistic regression analyses were performed.

RESULTS

A total of 3089 individuals participated in the study, with a mean age of 68.1 ± 5.3 years, and 36.0% were males. Among them, 52 (1.7%) had ICS, 119 (3.8%) had ICAD, and 15 (0.49%) had both conditions. Alopecia areata was an independent predictor for both ICS (Odds ratio [OR] 3.5; 95% CI 1.3-8.3) and ICAD (OR 2.1; 95% CI 1.0-3.9). Diabetes (OR 3.7; 95% CI 2.0-7.0) and older age (OR 2.4; 95% CI 1.2-4.5) were associated only with ICS, while the RNF213 variant was associated with only ICAD (OR 5.7; 95% CI 1.6-16.0). ICS and ICAD were also independently associated with each other.

CONCLUSIONS

In this MRA-based large scale study, alopecia areata, known as a systemic inflammatory disease, was shown to be a common risk factor for ICS and ICAD. While conventional atherosclerotic factors were associated with ICS, non-atherosclerotic factors appear to contribute to ICAD in Japan.

Use of the neuroform atlas for stenting of intracranial atherosclerotic disease: Clinical and angiographic outcomes

BACKGROUND

Intracranial atherosclerotic disease (ICAD) is a potential cause of ischemic stroke. Treatment of ICAD can include intracranial stenting. There are specifically designed stents for this use-case; however, less is known about the off-label use of the Neuroform Atlas stent. In this study, we describe the outcomes of the Neuroform Atlas stent for treatment of ICAD.

METHODS

Adult patients with symptomatic ICAD failing best medical treatment undergoing elective intracranial stenting using the Neuroform Atlas stent between November 2018 and March 2021 were included. Patient demographics, procedure-related details and clinical and imaging outcomes were analyzed.

RESULTS

Eighteen patients met the inclusion criteria, with a mean follow-up duration of 9.6 ± 6.8 (standard deviation) months. There were two procedure-related mortalities (one massive intracranial hemorrhage and one groin site complication with sepsis). Fifteen patients were alive at the 6-month follow-up, all with satisfactory stent patency on follow-up imaging without any new ischemic events. Modified Rankin Scale at latest follow-up was 1.9 (interquartile range 5).

CONCLUSION

In this single-center consecutive series, intracranial stenting with the Neuroform Atlas stent was a safe and effective treatment for symptomatic ICAD patients failing best medical management.

Exploring Gender Disparities in the Prevalence and Clinical Characteristics of Atherosclerotic Cranial Stenosis

Background Atherosclerotic cranial stenosis (ACS) is a significant contributor to vascular events, including ischemic strokes. While early clinical studies suggested a divergence in the distribution of intracranial and extracranial stenosis between genders, recent evidence has highlighted the complexity of these disparities. Therefore, this study aims to investigate gender differences in the prevalence and clinical characteristics of atherosclerotic cranial stenosis in patients admitted with stroke. Methods This cross-sectional study was conducted at a tertiary care hospital located in the Southern Region of Saudi Arabia between June 2022 and December 2022. It included patients of all age groups who had been diagnosed with an ischemic stroke during the study period. Data were collected from electronic health records and medical archives, and data analysis was performed using Statistical Package for the Social Sciences (SPSS version 26, IBM Inc., Chicago, IL, USA). Results In our study, 201 stroke patients were analyzed, with 161 (80.09%) identified as having atherosclerotic stenosis. Of these, 57.8% were male, and 42.2% were female. Gender disparities were evident, with higher stenosis prevalence in males (46.27% vs. 33.83% in females). Significant gender differences were observed in dyslipidemia (p = 0.013), metabolic syndrome (p = 0.019), and smoking habits (p < 0.001). Males exhibited higher rates of extracranial stenosis (p = 0.012) and combined stenosis (p = 0.009) compared to females; however, females exhibited higher rates of intracranial stenosis (p = 0.013). Further analyses revealed significant associations in dyslipidemia (adjusted odd ratio (AOR): 0.245, p = 0.004), metabolic syndrome (AOR: 5.159, p = 0.006), obesity (AOR: 8.085, p = 0.016), smoking habits (AOR: 0.002, p < 0.001), and intracranial stenosis (AOR: 5.667, p = 0.005) within the female cohort. Conversely, age, hypertension, diabetes mellitus, ischemic heart disease, and extracranial stenosis did not show statistically significant associations in females (p > 0.05). Conclusion We observed a substantial presence of atherosclerotic cranial stenosis, with males showing higher rates, and identified significant gender-related variations in dyslipidemia, metabolic syndrome, and smoking habits as important factors. This highlights the necessity of tailoring ACS assessment and treatment by considering gender-specific risk factors and clinical characteristics for improved patient care and stroke management.

Relationship between Serum Testosterone Level and Carotid Intima-Media Thickness among Korean Men and Postmenopausal Women

Background

Given that the role of serum testosterone on incident cardiovascular disease has been uncertain, it is necessary to find out the relationship between serum testosterone and carotid atherosclerosis.

Methods

The study participants included 1,302 Korean adults (873 men and 429 postmenopausal women) who participated in the Healthy Twin Study and were not receiving androgen deprivation therapy. The participants were classified into three groups: men aged <40 and ≥40 years and postmenopausal women. Total testosterone (TT) and sex hormone-binding globulin (SHBG) concentrations were measured using electrochemiluminescence immunoassays, and free testosterone (cFT) levels were calculated using Vermeulen’s method. Carotid intima-media thickness (IMT) was measured at three levels using a high-resolution B-mode ultrasound equipped with a 7-MHz linear transducer. The associations between sex hormone concentrations and carotid IMT were evaluated using a mixed linear regression analysis.

Results

After adjusting for cardiovascular risk factors, TT was found to be inversely associated with common carotid IMT in men aged ≥40 years, with a 4.5% decrease in common carotid IMT for every one-standard deviation increase in TT concentration (P=0.0063). In contrast, TT was not significantly associated with carotid IMT in all segments in men aged <40 years and postmenopausal women. Additionally, SHBG and cFT were not associated with carotid IMT in any segment.

Conclusion

The significant association between TT level and common carotid IMT in men aged ≥40 years suggests that decreased testosterone levels are involved in the development of atherosclerosis in men.

Demographic and risk factors profile of intracranial atherosclerotic stenosis in the Kingdom of Bahrain

Background

Intracranial atherosclerotic stenosis (ICAS) is one of the most common causes of stroke worldwide. This study aimed to analyze the demographic and risk factor profiles of ICAS in the Kingdom of Bahrain. The study population included 477 patients who were hospitalized in the Neurology Department from March 1, 2018, to September 1, 2020 because of acute ischemic stroke and underwent arterial brain imaging (CTA or MRA) examination during their hospitalization.

Results

Of 477 patients, 123 (25.7%) had ICAS. A history of stroke/transient ischemic attack was significantly higher in patients with intracranial stenosis (P = 0.012). Patients with ICAS had significant concurrent extracranial arterial stenosis (ECAS) (P = 0.00). In Bahraini patients, dyslipidemia was associated with a higher percentage of developing ICAS, but this was statistically nonsignificant (p = 0.06).

Conclusions

An independent and significant correlation was found between ICAS and stroke recurrence. In addition, a concurrent existence of ECAS and ICAS was noted.

Incidence of arterial steno-occlusive disease and related factors in patients undergoing coronary artery bypass graft surgery

Background: Patients who undergo coronary artery bypass graft (CABG) surgery receive regular physical examinations and medications on an outpatient basis. However, these patients are at risk of developing other vascular diseases, such as postoperative arterial steno-occlusive disease (SOD). This study investigated the incidence of SOD and related factors.Methods: In total, 246 patients who underwent CABG surgery from January 1, 2017 to December 31, 2021 were investigated. The incidence and risk factors of vascular disease were analyzed by dividing the included patients into SOD and non-SOD groups. Laboratory tests, medical history, surgical information, and family history were investigated through an electronic chart review.Results: Data from 193 patients who met the criteria were analyzed. SOD occurred in 19.1% of patients, and the cerebral artery (38%) was the most common artery involved, followed by the peripheral artery (32%), the coronary artery (22%), and the retinal artery (8%). Risk factors for the development of SOD included estimated glomerular filtration rate (eGFR; odds ratio [OR]=0.977, p=0.008), cholesterol (OR=1.020, p=0.001), and patients with diabetes complications (OR=5.077, p=0.010). The 3-year cumulative incidence rate was 21.6%, and the risk factors for cumulative occurrence were a low eGFR, elevated cholesterol, and complications of diabetes.Conclusions: Low eGFR, high cholesterol, and the presence of diabetic complications before CABG surgery may be associated with postoperative vascular disease. In these cases, close monitoring, proper drug administration, and patient warnings may be required.

Intracranial Large Artery Stenosis and Past Infectious Exposures: Results From the NOMAS Cohort

BACKGROUND

Intracranial large artery stenosis (ILAS) is an important contributor to ischemic stroke in the United States and worldwide. There is evidence to suggest that chronic exposure to certain infectious agents may also be associated with ILAS. We aimed to study this association further in an ethnically diverse, prospective, population-based sample of Northern Manhattan.

METHODS

We enrolled a random sample of stroke-free participants from an urban, racially, and ethnically diverse community in 1993. Participants have been followed prospectively and a subset underwent brain magnetic resonance angiograms from 2003 to 2008. Intracranial stenoses of the circle of Willis and vertebrobasilar arteries were scored as 0=no stenosis, 1≤50% (or luminal irregularities), 2=50% to 69%, 3≥70% stenosis, and 4=flow gap. We summed the individual score of each artery to produce a global ILAS score (possible range, 0-44). Past infectious exposure to Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus, and herpes simplex virus 1 and 2 was determined using serum antibody titers.

RESULTS

Among 572 NOMAS (Northern Manhattan Study) participants (mean age 71.0±8.0 years, 60% women, 68% Hispanic) with available magnetic resonance angiogram and serological data, herpes simplex virus 2 (beta=0.051, P<0.001) and cytomegalovirus (beta=0.071, P<0.05) were associated with ILAS score after adjusting for demographics and vascular risk factors. Stratifying by anterior and posterior circulations, herpes simplex virus 2 remained associated with the anterior circulation (beta=0.055 P<0.01) but not with posterior circulation ILAS score.

CONCLUSIONS

Chronic infectious exposures, specifically herpes simplex virus 2 and cytomegalovirus were associated with asymptomatic ILAS as seen on magnetic resonance angiogram imaging. This may represent an additional target of intervention in the ongoing effort to stem the substantial global burden of strokes related to ILAS.

Rehabilitation of Upper Limb Motor Impairment in Stroke: A Narrative Review on the Prevalence, Risk Factors, and Economic Statistics of Stroke and State of the Art Therapies

Stroke has been one of the leading causes of disability worldwide and is still a social health issue. Keeping in view the importance of physical rehabilitation of stroke patients, an analytical review has been compiled in which different therapies have been reviewed for their effectiveness, such as functional electric stimulation (FES), noninvasive brain stimulation (NIBS) including transcranial direct current stimulation (t-DCS) and transcranial magnetic stimulation (t-MS), invasive epidural cortical stimulation, virtual reality (VR) rehabilitation, task-oriented therapy, robot-assisted training, tele rehabilitation, and cerebral plasticity for the rehabilitation of upper extremity motor impairment. New therapeutic rehabilitation techniques are also being investigated, such as VR. This literature review mainly focuses on the randomized controlled studies, reviews, and statistical meta-analyses associated with motor rehabilitation after stroke. Moreover, with the increasing prevalence rate and the adverse socio-economic consequences of stroke, a statistical analysis covering its economic factors such as treatment, medication and post-stroke care services, and risk factors (modifiable and non-modifiable) have also been discussed. This review suggests that if the prevalence rate of the disease remains persistent, a considerable increase in the stroke population is expected by 2025, causing a substantial economic burden on society, as the survival rate of stroke is high compared to other diseases. Compared to all the other therapies, VR has now emerged as the modern approach towards rehabilitation motor activity of impaired limbs. A range of randomized controlled studies and experimental trials were reviewed to analyse the effectiveness of VR as a rehabilitative treatment with considerable satisfactory results. However, more clinical controlled trials are required to establish a strong evidence base for VR to be widely accepted as a preferred rehabilitation therapy for stroke.

Determinants and Outcomes of Asymptomatic Intracranial Atherosclerotic Stenosis

BACKGROUND

Intracranial atherosclerotic stenosis (ICAS) is one of the most common causes of stroke worldwide and confers a high risk of stroke recurrence, despite aggressive management of risk factors.

OBJECTIVES

This study identified the role of risk factors and risk of vascular events in subjects with asymptomatic ICAS for improved risk stratification.

METHODS

Stroke-free participants in the NOMAS (Northern Manhattan Study) trial, prospectively followed since 1993, underwent a brain magnetic resonance angiogram from 2003 to 2008. The study rated stenosis in 11 brain arteries as: 0: no stenosis; 1: <50% or luminal irregularities; 2: 50%-69%; and 3: ≥70% stenosis or flow gap. The study ascertained vascular events during the post-magnetic resonance imaging (MRI) period. Proportional odds regression quantified the association of pre-MRI exposures, and proportional hazard adjusted models were built to identify the risk of events in the post-MRI period.

RESULTS

The included sample included 1,211 participants from NOMAS (mean age: 71 ± 9 years; 59% women; 65% Hispanic; 45% had any stenosis). Older age (OR: 1.02 per year; 95% CI: 1.01 to 1.04), hypertension duration (OR: 1.01 per year; 95% CI: 1.00 to 1.02), higher number of glucose-lowering drugs (OR: 1.64 per each medication; 95% CI: 1.24 to 2.15), and high-density lipoprotein (OR: 0.96 per mg/dL; 95% CI: 0.92 to 0.99) were associated with ICAS. The highest event risk was noted among participants with ICAS ≥70% (5.5% annual risk of vascular events; HR: 2.1; 95% CI:1.4 to 3.2; compared with those with no ICAS).

CONCLUSIONS

ICAS is an imaging marker of established atherosclerotic disease in stroke-free subjects, and incidental diagnosis of ICAS should trigger a thorough assessment of vascular health.

Role of Brain Arterial Remodeling in HIV-Associated Cerebrovascular Outcomes

As the life expectancy of people living with HIV (PLWH) on combination antiretroviral therapy (cART) increases, so does morbidity from cerebrovascular disease and neurocognitive disorders. Brain arterial remodeling stands out as a novel investigational target to understand the role of HIV in cerebrovascular and neurocognitive outcomes. We therefore conducted a review of publications in PubMed, EMBASE, Web of Science and Wiley Online Library, from inception to April 2021. We included search terms such as HIV, cART, brain, neuroimmunity, arterial remodeling, cerebrovascular disease, and neurocognitive disorders. The literature shows that, in the post-cART era, PLWH continue to experience an increased risk of stroke and neurocognitive disorders (albeit milder forms) compared to uninfected populations. PLWH who are immunosuppressed have a higher proportion of hemorrhagic strokes and strokes caused by opportunistic infection and HIV vasculopathy, while PLWH on long-term cART have higher rates of ischemic strokes, compared to HIV-seronegative controls. Brain large artery atherosclerosis in PLWH is associated with lower CD4 nadir and higher CD4 count during the stroke event. HIV vasculopathy, a form of non-atherosclerotic outward remodeling, on the other hand, is associated with protracted immunosuppression. HIV vasculopathy was also linked to a thinner media layer and increased adventitial macrophages, suggestive of non-atherosclerotic degeneration of the brain arterial wall in the setting of chronic central nervous system inflammation. Cerebrovascular architecture seems to be differentially affected by HIV infection in successfully treated versus immunosuppressed PLWH. Brain large artery atherosclerosis is prevalent even with long-term immune reconstitution post-cART. HIV-associated changes in brain arterial walls may also relate to higher rates of HIV-associated neurocognitive disorders, although milder forms are more prevalent in the post-cART era. The underlying mechanisms of HIV-associated pathological arterial remodeling remain poorly understood, but a role has been proposed for chronic HIV-associated inflammation with increased burden on the vasculature. Neuroimaging may come to play a role in assessing brain arterial remodeling and stratifying cerebrovascular risk, but the data remains inconclusive. An improved understanding of the different phenotypes of brain arterial remodeling associated with HIV may reveal opportunities to reduce rates of cerebrovascular disease in the aging population of PLWH on cART.

Association Between Metabolic Syndrome and Asymptomatic Cerebral Arterial Stenosis: A Cross-Sectional Study in Shandong, China

Metabolic syndrome (MetS) can worsen cerebral arterial atherosclerosis stenosis in patients with stroke; however, its effect on patients without stroke remains ambiguous. This study explored the association of MetS and its individual components with asymptomatic intracranial arterial stenosis (aICAS) and asymptomatic extracranial arterial stenosis (aECAS) among older Chinese adults. A total of 1988 participants from the Kongcun Town study aged ≥40 years and without a history of stroke were enrolled. The baseline data were obtained via face-to-face interviews. MetS was defined according to International Diabetes Federation criteria. Detection of aICAS was conducted using transcranial Doppler ultrasound, followed by diagnosis via magnetic resonance angiography. The evaluation of aECAS was performed using bilateral carotid ultrasonography. The aICAS and aECAS groups were 1:1 matched separately to the non-stenosis group by age and sex. The association between MetS and aICAS or aECAS was analyzed using multivariate logistic regression. Among the 1988 participants, 909 were diagnosed with MetS. The prevalence of MetS was higher in the aICAS group than in the non-stenosis group (P <0.001), but did not differ significantly between the aECAS and non-stenosis groups. The prevalence of aICAS increased with the number of MetS components from 3.4% in the ≤ 1 component group to 12.7% in the ≥4 components group (P for trend <0.001). After adjusting for confounding factors, MetS components associated with aICAS included central obesity, elevated triglyceride levels, and elevated blood pressure. None of the MetS components was associated with aECAS. MetS was positively associated with aICAS, but not with aECAS. Further, different components play different roles in the pathological process leading to aICAS.

Stroke Disparities: From Observations to Actions: Inaugural Edward J. Kenton Lecture 2020

Numerous epidemiological studies have demonstrated stroke disparities across race and ethnic groups. The goal of the NOMAS (Northern Manhattan Study) was to evaluate race and ethnic differences in stroke within a community with 3 different race-ethnic groups. Starting as a population-based incidence and case-control study, the study evolved into a cohort study. Results from NOMAS have demonstrated differences in stroke incidence, subtypes, risk factors, and outcomes. Disparities in ideal cardiovascular health can help explain many differences in stroke incidence and call for tailored risk factor modification through innovative portals to shift more diverse subjects to ideal cardiovascular health. The results of NOMAS and multiple other studies have provided foundational data to support interventions. Conceptual models to address health disparities have called for moving from detecting disparities in disease incidence, to determining the underlying causes of disparities and developing interventions, and then to testing interventions in human populations. Further actions to address race and ethnic stroke disparities are needed including innovative risk factor interventions, stroke awareness campaigns, quality improvement programs, workforce diversification, and accelerating policy changes.

Gastrointestinal Disorders and Risk of First-Ever Ischemic Stroke

BACKGROUND AND PURPOSE

Recent studies suggest that alteration of the normal gut microbiome contributes to atherosclerotic burden and cardiovascular disease. While many gastrointestinal diseases are known to cause disruption of the normal gut microbiome in humans, the clinical impact of gastrointestinal diseases on subsequent cerebrovascular disease remains unknown. We conducted an exploratory analysis evaluating the relationship between gastrointestinal diseases and ischemic stroke.

METHODS

We performed a retrospective cohort study using claims between 2008 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. We included only beneficiaries ≥66 years of age. We used previously validated diagnosis codes to ascertain our primary outcome of ischemic stroke. In an exploratory manner, we categorized gastrointestinal disorders by anatomic location, disease chronicity, and disease mechanism. We used Cox proportional hazards models to examine associations of gastrointestinal disorder categories and ischemic stroke with adjustment for demographics and established vascular risk factors.

RESULTS

Among a mean of 1 725 246 beneficiaries in each analysis, several categories of gastrointestinal disorders were associated with an increased risk of ischemic stroke after adjustment for established stroke risk factors. The most notable positive associations included disorders of the stomach (hazard ratio, 1.17 [95% CI, 1.15-1.19]) and functional (1.16 [95% CI, 1.15-1.17]), inflammatory (1.13 [95% CI, 1.12-1.15]), and infectious gastrointestinal disorders (1.13 [95% CI, 1.12-1.15]). In contrast, we found no associations with stroke for diseases of the anus and rectum (0.97 [95% CI, 0.94-1.00]) or neoplastic gastrointestinal disorders (0.97 [95% CI, 0.94-1.00]).

CONCLUSIONS

In exploratory analyses, several categories of gastrointestinal disorders were associated with an increased risk of future ischemic stroke after adjustment for demographics and established stroke risk factors.

The Therapeutic Effects of Endovascular Therapy with mTICI2b and 3 Recanalization for Acute Anterior Circulation Stroke Patients

BACKGROUND AND PURPOSE

Modified Thrombolysis in Cerebral Infarction (mTICI)2b/3 has been considered the criterion for successful reperfusion in endovascular treatment. This study aimed to compare the therapeutic safety and efficacy of mTICI2b and mTICI3 recanalization, and to analyze the factors related to outcomes in everyday clinical practice.

MATERIALS AND METHODS

This is a single-center retrospective analysis of 224 patients who underwent successful thrombectomy (achieving a mTICI score ≥2b). The primary outcomes included a modified Rankin score (mRS) of 0-2 at 90-day, mortality, and symptomatic intracranial hemorrhage.

RESULTS

A total of 111 patients achieved mTICI2b status (49.6%), and 113 achieved mTICI3 status (50.4%). The comparison between mTICI2b and 3 reperfusions showed no differences in short-term outcomes, 90-day mRS, complications, and mortality. There was a trend toward more passes in mTICI2b patients, although the difference was not significant. The univariate analysis showed that poor outcomes after endovascular treatment were associated with older age, previous history of coronary heart disease, atrial fibrillation, diabetes, tandem occlusions, high National Institutes of Health Stroke Scale (NIHSS) score on admission, and general anesthesia. A previous history of coronary heart disease, a high NIHSS score on admission, and the use of general anesthesia were independent factors that affected the therapeutic effects.

CONCLUSION

The superiority (efficacy and safety) of mTICI3 reperfusion was not significant compared with that of mTICI2b reperfusion. Prolonged efforts to achieve mTICI3 after achieving mTICI2b should be considered prudently for those with difficulty achieving 100% reperfusion.

Carotid Artery Angioplasty and Stenting for Carotid Stenosis: A Single-Center Experience from Saudi Arabia

Purpose

Atherosclerotic stenosis of the extracranial carotid artery accounts for approximately 20% of all strokes. Both carotid artery endarterectomy and carotid artery angioplasty with stenting (CAAS) are recommended for symptomatic patients with 50% or more stenosis or asymptomatic patients with 70% or more stenosis. CAAS is under-reported in Saudi Arabia, as evidenced by a thorough literature search. In this article, we aim to share our experience of CAAS to call for the necessity of conducting more research on stroke and emphasize the local need of utilizing more endovascular treatments like CAAS.

Materials and Methods

A retrospective single-center observational study was conducted at King Abdulaziz Medical City in Jeddah, Saudi Arabia. The inclusion criteria consisted of all adult patients (18 years and above) with carotid stenosis who were treated with CAAS.

Results

A total of 16 patients were included in the study. The mean age of the participants was 66.9±13.5 years (range 30–87 years). All patients were symptomatic (had a previous stroke or transient ischemic attack). The procedure was successful in 14 patients (87.5%), while it failed in 2 patients (12.5%) due to technical reasons. All patients had no stroke or myocardial infarction within 30 days of the procedure.

Conclusion

Despite the advancement in medicine with free healthcare services in Saudi Arabia, the interventional procedures for secondary prevention of strokes are underutilized. Collaboration between different hospitals will be extremely helpful since few centers in each city are providing such treatments by an expert neurointerventionist and/or strokologist. The good selection of candidates, optimal management of comorbid conditions, and multidisciplinary care may improve outcomes and reduce mortality.

Frequency and Characteristics of Metabolic Syndrome in Patients With Ischemic Stroke Admitted to a Tertiary Care Hospital in Karachi

Introduction

Metabolic syndrome (MetS) is defined as a syndrome of truncal obesity, insulin resistance, hypertension, hypertriglyceridemia, and dyslipidemia. It is well known that MetS increases the risk of cardiovascular disease and adverse events. Each of its components is associated with an increased risk of cardiovascular disease, but data on the association with ischemic stroke are scarce. At the international level, a significant body of research has been conducted on this issue, but the situation is very different in Pakistan. Very little data are present on the subject matter. This study is an endeavor in this direction, generating data, that can be used in early identification and developing treatment services for patients with ischemic stroke having MetS.

Aims

To determine the frequency of MetS in ischemic stroke patients admitted to a tertiary care hospital in Karachi, Pakistan.

Methods

This six-month observational and cross-sectional study was conducted at Medical Unit I, Jinnah Postgraduate Medical Centre from July 1, 2019, to December 31, 2019. Patients with a diagnosis of acute ischemic stroke were enrolled. Detailed history, physical examination, and biochemical measurements were noted. The presence of MetS was defined in accordance with the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III)/American Heart Association (AHA) guidelines.

Results

A total of 224 patients fulfilling the inclusion criteria were inducted into this study. The mean age of presentation was 61.04 ± 14.72 years, and more than two-thirds of the patients were ≥60 years of age. A total of 150 (66.96%) patients with ischemic stroke also had MetS. The male-to-female ratio in this group was 2:1. The most common variables constituting the MetS were truncal obesity, hypertension, and dyslipidemia. The median MetS score was 3.

Conclusions

MetS is highly prevalent in patients presenting with ischemic stroke irrespective of age or gender. The three most deranged and common components of MetS in these patients are truncal obesity, hypertension, and dyslipidemia.

Genetic Risk Factors of Intracranial Atherosclerosis

PURPOSE OF REVIEW

Intracranial atherosclerosis (ICAS) is the most common cause of stroke throughout the world. It also increases the risk of recurrent stroke and dementia. As a complex and multifactorial disease, ICAS is influenced by multiple genetic, biological, and environmental factors. This review summarizes the candidate gene and genome-wide studies aimed at discovering genetic risk factors of ICAS.

RECENT FINDINGS

Numerous studies have focused on the association between single-nucleotide polymorphisms (SNPs) of atherosclerosis-related genes and the risk of ICAS. Variants in adiponectin Q (ADIPOQ), ring finger protein 213 (RNF213), apolipoprotein E (APOE), phosphodiesterase 4D (PDE4D), methylenetetrahydrofolate reductase (MTHFR), lipoprotein lipase (LPL), α-adducin (ADD1) genes, angiotensin-converting enzyme (ACE), and other genes related to renin-angiotensin-aldosterone system have been associated with ICAS. We review the available evidences on the candidate genes and SNPs associated with genetic susceptibility to ICAS, and point out future developments of this field. Genetic discoveries could have clinical implications for intracranial atherosclerotic disease.

Comparison of Risk Factors, Treatment, and Outcome in Patients with Symptomatic Intracranial Atherosclerotic Disease in India and the United States

BACKGROUND AND AIMS

Intracranial atherosclerotic disease (ICAD) is common in the Asian population, but less studied in South Asians compared to East Asians. We compared risk factors, treatments, and outcomes among consecutive patients with symptomatic ICAD from India with a mixed-ethnic cohort from Chicago, Illinois.

METHODS

Consecutive patients with symptomatic ICAD were enrolled at 2 academic medical centers in Kerala, India and Chicago, United States. Data on demographics, risk factors, initial stroke severity (National Institute of Health Stroke Scale score [NIHSS]), recurrent stroke, and 3-month functional outcome (modified Rankin Scale [mRS]) were prospectively collected. Recurrent stroke was defined as symptomatic recurrence of focal neurologic deficits associated with radiographic evidence of new cerebral infarction within 3 months of index admission.

RESULTS

329 patients (117 from Kerala, 212 from Chicago) were included. Indian patients were younger (61 vs. 68, P < 0.001), less frequently had prior stroke history (15.4 vs. 32.5%, P = 0.001) and coronary artery disease (11.1 vs. 22.2%, P = 0.013) but had higher initial NIHSS score (median 6 vs. 3, P < 0.001). Both groups received reperfusion therapy in similar proportions (8.5 vs. 7.1%, P = 0.630) but at discharge, 90.6% of Indian patients compared to 59.0% of Chicago patients were treated with dual antiplatelet therapy. More recurrent strokes occurred in Chicago patients (21.7 vs. 1.9%, P < 0.001) but functional outcome did not differ significantly.

CONCLUSION

Compared to patients in US with symptomatic ICAD, Indian patients were younger and had more severe strokes. However, Indian patients had lower rates of recurrent stroke, perhaps due to greater use of dual antiplatelet therapy.

Intracranial Atherosclerotic Stenoses: Pathophysiology, Epidemiology, Risk Factors and Current Therapy Options

Intracranial atherosclerotic stenoses (ICAS) are one of the most common causes of first and recurrent cerebrovascular ischaemic events worldwide, with highest prevalence in Asian, Hispanic and African populations. Clinical trials have improved the understanding of epidemiology, risk factors and imaging characteristics of patients with ICAS. Current therapeutic approaches concerning these patients include management of risk factors, best medical therapy, potentially endovascular and rarely surgical therapy. In our review, we elucidate the current epidemiology and evidence in evaluation of risk factors and therapeutic options for providing favourable outcome for patients with ICAS.

Relationship Between Brain Arterial Pathology and Neurocognitive Performance Among Individuals With Human Immunodeficiency Virus

Background

Human immunodeficiency virus-positive (HIV+) individuals have higher rates of cognitive impairment and cerebrovascular disease compared with uninfected populations. We hypothesize that cerebrovascular disease, specifically brain large artery disease, may play a role in HIV-associated neurocognitive disorders (HAND).

Methods

Participants (N = 94) in the Manhattan HIV Brain Bank study were followed on average 32 ± 33 months with repeated neuropsychological examinations until death. We used five cognitive domains (motor, processing speed, working memory, verbal fluency, and executive functioning) to assess ante mortem performance. We quantified the diameter of the lumen and arterial wall thickness obtained during autopsy. The diagnoses of HAND were attributed using the American Academy of Neurology nosology. We used generalized linear mixed model to account for repeated measures, follow-up time, and codependence between arteries. Models were adjusted for demographics, viral loads, CD4 counts, history of opportunistic infections, and vascular risks.

Results

We included 94 HIV+ individuals (mean age 56 ± 8.3, 68% men, 54% African American). In adjusted models, there was an association between arterial wall thickness and global cognitive score (B = -0.176, P value = .03), processing speed (B = -0.175, P = .05), and verbal fluency (B = -0.253, P = .02). Participants with incident or worsening HAND had thicker brain arterial walls (B = 0.523 ± 0.234, P = .03) and smaller arterial lumen (B = -0.633 ± 0.252, P = .01).

Conclusions

We report here a novel association between brain arterial wall thickening and poorer ante mortem cognitive performance and diagnosis of incident or worsening HAND at death. Strategies to preserve the arterial lumen or to prevent wall thickening may impact HAND.

Intracranial Hemorrhage Due to Secondary Hypertension from Intracranial Large Vessel Occlusion

Simultaneous hemorrhagic and ischemic strokes have been previously reported in the literature. Typically, these occur in patients secondary to dialysis, cerebral amyloid angiopathy, or thrombotic thrombocytopenic purpura.1,2,3 However, this is the unique case of a 62-year-old Asian female who presented with a hemorrhagic stroke suspected to be secondary to refractory hypertension from intracranial large vessel atherosclerotic flow limiting stenosis, with rapid subsequent large vessel occlusion and ischemic stroke. Questions arise such as ideal blood pressure parameters for dual management, timeliness of computed tomography angiography imaging in the emergency department for detection of large vessel occlusion during intracranial hemorrhage, and subsequent selection of treatment plan in the dual-lesion patient population.

Frequency, risk factors, and outcomes in patients with significant carotid artery disease admitted to King Abdulaziz Medical City, Riyadh with Ischemic Stroke

OBJECTIVE

To determine the frequency, risk factors, and outcomes of significant carotid artery disease (CAD) in patients with ischemic stroke.

METHODS

The frequency of significant CAD in patients admitted to the Stroke Unit between January 2014 and December 2015 was determined from radiological data. Outcomes were determined clinically and radiologically.

RESULTS

Among 435 patients, 273 were men (62.8%), with a mean age of 57.4+/-12.2 years. Significant CAD was found in 48 vessels in 40 (9.2%) patients, of which 30 patients were symptomatic. Nine of these patients were treated with carotid artery stenting, one underwent carotid endarterectomy, and 3 underwent an urgent thrombectomy, without stenting. Seventeen symptomatic patients were not treated for the following reasons: patient/family refusal (n=2), contraindications (n=5), and complete occlusion (n=10). One (7.7%) of the 13 treated patients had an ipsilateral stroke on follow up, one (7.7%) had contralateral transient ischemic attack (TIA), 9 (69.2%) had no recurrence, and no clinical data were available for 2 patients. Among the 17 untreated patients, one (5.9%) had an ipsilateral stroke, 7 (41.2%) had no recurrence, and 9 (52.9%) were lost to follow up.

CONCLUSION

Significant carotid artery disease is uncommon in our cohort found in less than 10% of patients. Vascular risk factors are more or less similar between patients with or without CAD except obesity which appears to have inverse relation with CAD. A small number of patients received carotid intervention with no recurrence of stroke at limited follow up.

Correlation between Metabolic Syndrome and Intracranial versus Extracranial Arteriosclerosis among Chinese Patients with Stroke

BACKGROUND

We aimed to explore the correlation between metabolic syndrome and intracranial and extra-cranial arteriosclerosis. Overall, 318 over 60-yr-old patients with cerebral infarction or TIA who were examined by digital subtraction angiography (DSA) in our hospital were enrolled in the study.

METHODS

Overall, 192 patients with intracranial and extracranial arteriosclerosis were admitted to the case group (the intracranial and extracranial arteriosclerosis group). Also, 196 patients, suffering from the same condition, were selected from our outpatient clinic and enrolled in the control group.

RESULTS

The prevalence of metabolic syndrome was 31.4%. The prevalence of each metabolic syndrome component in the intracranial arteriosclerosis group was higher than those of the extracranial arteriosclerosis and the control groups. The average component values in the intracranial arteriosclerosis group was higher than those observed in other groups. The prevalence rate of metabolic syndrome had no significant difference among different degrees of stenosis for extracranial arteriosclerosis group. There was a remarkable correlation between intracranial arteriosclerosis and metabolic syndrome (P<0.001), while no correlation was detected between extracranial arteriosclerosis and metabolic syndrome (P<0.001). We concluded that metabolic syndrome may increase the prevalence risk of intracranial arteriosclerosis. There was a significant correlation between intracranial arteriosclerosis and metabolic syndrome components including hyperglycemia and hypertension. Also, there was a significant correlation between extracranial arteriosclerosis and metabolic syndrome components including hyperglycemia.

CONCLUSION

We believe that at least three components of metabolic syndrome can obviously increase the risk of intracranial arteriosclerosis.

Prevalence and Risk Factors of Brain Infarcts and Associations With Cognitive Performance in Tenants of Marginal Housing

Background Homeless and vulnerably housed individuals are at increased risk for multimorbidity compared with the general population. We assessed prevalence of brain infarcts on neuroimaging and associations with vascular risk factors and cognitive performance in a prospective study of residents living in marginal housing. Methods and Results Two hundred twenty-eight participants underwent structured clinical interviews, targeted clinical, laboratory, and neuropsychological assessments, and magnetic resonance imaging with T1, T2-fluid-attenuated inversion recovery and susceptibility-weighted images. Subjects underwent cognitive testing to assess premorbid IQ , verbal learning and memory, inhibition, sustained attention, mental flexibility, and decision making. In this sample (mean age 44.0 years [ SD 9.4], 77% male), prevalence of conventional vascular risk factors was lower than in the general population apart from tobacco use (94%). Ten-year Framingham risk for any cardiovascular event was 11.4%±9.2%. Brain infarcts were present in 25/228 (11%). All were ischemic (40% cortical, 56% lacunar, 4% both). Participants with infarcts were older than those without (48.9±9.4 versus 43.4±9.2, P=0.006). In a multivariable regression analysis, only age remained a significant predictor of brain infarcts (odds ratio 1.08, 95% CI 1.02-1.14, P=0.004). After controlling for age and education, the presence of infarct was a significant predictor of impaired decision making on the Iowa Gambling Task of decision making (β -28.2, 95% CI -42.7 to -14.1, P<0.001). Conclusions Prevalence of infarcts on neuroimaging in this disadvantaged, community-dwelling cohort was much higher than expected for age and was associated with impaired decision making. Further research is needed to identify individuals at highest risk who may benefit from targeted preventative strategies.

Urine albumin-to-creatinine ratio and asymptomatic intracranial atherosclerotic stenosis in hypertensive patients

Intracranial atherosclerotic stenosis (ICAS) contributes to nearly 50% of stroke in China, especially in patients with hypertension. Urine albumin-to-creatinine ratio (ACR) has been related to stroke and other atherosclerotic cardiovascular diseases. However, there is limited information about the association of ACR and early impairment of cerebral vessels. Hereby we assessed the association of ICAS with ACR, estimated glomerular filtration rate (eGFR), and dipstick proteinuria in a stroke-free hypertensive population. We included 889 hypertension patients aged ≥60 years without prior stroke. Computed tomography angiography was performed to detect ICAS. ACR and dipstick proteinuria were tested from a random spot urine. eGFR was calculated using the CKD-EPI equation. Logistic regression was carried out to analyze the association of renal function with the presence, extent, and lesion number of ICAS. Elevated ACR (≥30 mg/g) was associated with ICAS after adjustment of confounding factors (odds ratio (OR) = 1.66, 95% confidence interval (CI): 1.21-2.29). Patients with elevated ACR were more prone to develop moderate-to-severe stenosis (OR = 1.57, 95% CI: 1.16-2.14) and more lesions (OR = 1.58, 95% CI: 1.16-2.15). Such association was independent of previously identified cardiovascular risk factors. No significant association was detected between ICAS and dipstick proteinuria or eGFR after adjustment. Our findings suggested that elevated ACR was associated with asymptomatic ICAS in an aged stroke-free hypertensive population.

Risk factors for intracranial atherosclerosis: A systematic review and meta-analysis

BACKGROUND AND AIMS

Intracranial atherosclerosis (ICAS) is a predictable and preventable condition, but existing evidence concerning its risk factors has not been quantitatively assessed. The aim of this meta-analysis is to identify the non-modifiable and modifiable risk factors for ICAS.

METHODS

PubMed and EMBASE were searched (1995-May 15, 2018) for cross-sectional and longitudinal studies exploring risk factors for ICAS. The risk estimates and 95% confidence intervals (CIs) in multivariate analysis were aggregated using random-effect models.

RESULTS

Thirty-four studies comprising 59,736 subjects met the inclusion criteria for the systematic review involving thirty-one risk or protective factors. Seven factors were associated with ICAS, as suggested by the meta-analysis, including advanced age (odds ratio (OR) 1.05, 95% CI 1.03-1.08), metabolic syndrome (OR 2.13, 95% CI 1.35-3.37), diabetes mellitus (OR 1.98, 95% CI 1.69-2.31), hypertension (OR 1.97, 95% CI 1.69-2.31), dyslipidemia (OR 1.29, 95% CI 1.04-1.59), high levels of low-density lipoprotein cholesterol (OR 1.06, 95% CI 1.00-1.12) and high levels of apolipoprotein A1 (OR 0.34, 95% CI 0.15-0.75). The subgroup analysis for study populations indicated advanced age, metabolic syndrome, diabetes mellitus and hypertension as an elevated risk of ICAS among community subjects and stroke patients; according to the subgroup analysis for ethnicity, similar associations remained in Asians, but only metabolic syndrome and diabetes mellitus were correlated with ICAS in Caucasians.

CONCLUSIONS

Individuals with advanced age, metabolic syndrome, diabetes mellitus, hypertension and dyslipidemia might have a higher risk of ICAS, whereas high levels of apolipoprotein A1 might protect against ICAS.

Diabetes mellitus inhibits complete recanalization in patients with middle cerebral artery occlusion

Methods: This was a retrospective cohort study. Data from 165 patients, with middle cerebral occlusion before t-PA therapy (from the YAMATO study databank), were retrospectively evaluated. Patients were classified into diabetic (D) or non-diabetic (ND) groups based on the history of diabetes mellitus (DM) or hemoglobin A1c levels of ≥ 6.5%. Arterial recanalization was assessed using magnetic resonance angiography or digital subtraction angiography at 2 points: 1) early recanalization, within 2 h; 2) delayed complete recanalization at 24 h. Good clinical outcome was defined as modified Rankin Scale score 0-2 at 3 months. Results: A total of 33 (21%) were classified into the D and 127 (79%) in the ND groups. Early recanalization was similarly in the D and ND groups (61% vs. 52%, p = 0.434). However, complete recanalization at 24 h was infrequent in the D group (13% vs. 43%, p = 0.002). Among patients with early recanalization, 4 (22%) of 18 patients in the D group and 32 (56%) of 57 patients in the ND group had complete recanalization at 24 h (p = 0.015); while among those without early recanalization, 17 (30%) in the ND and none in the D groups had complete recanalization at 24 h (p = 0.028). Multivariate regression analysis showed DM was one of the independent negative factors for complete recanalization at 24 h (odds ratio 0.113, 95%CI: 0.027-0.472, p = 0.003). At 3 months, group with complete recanalization at 24 h achieved higher frequency of good outcome (67% vs. 49%, p = 0.046). Conclusion: Diabetes might be a risk factor of incomplete recanalization at 24 h regardless of early recanalization.

Dyslipidaemia was correlated to the posterior circulation infarction in non-diabetic populations

Background

Diabetes mellitus (DM) was prone to happening in posterior circulation infarction (POCI) and DM also has the impact on the lipids, our study was to investigate the correlation between lipid compositions and POCI.

Methods

Data was collected from the patients with acute ischemic stroke (AIS) hospitalization in Affiliated Drum Tower Hospital of Nanjing University Medical School from October 2008 to May 2012. Lipids and other risk factors in the different populations were investigated in relation to occurrence of POCI based on the infarction location.

Results

Six hundred ten patients with AIS were included in this study, which had 428 with anterior circulation infarction (ACI) and 182 with POCI. Elevated Triglyceride (TG) and decreased High density lipoprotein cholesterol (HDL-C) were seen in the POCI of total populations and AIS without DM compared to the ACI, but not in the populations of AIS with DM, so did the elevated TG/HDL-C ratios. Also, the percent of low HDL-C level and high TG level were higher in POCI group than that in ACI group. Furthermore, single factors logistic regression demonstrated that TG, HDL-C and TG/HDL-C ratio were correlated to the POCI whatever in the total populations or AIS without DM, but this kind of trend just maintained in the populations of AIS without DM after adjusting by relative interference factors.

Conclusion

Dyslipidaemia was prone to happening in POCI compared to ACI in the non-diabetic populations, which was correlated to the pathogenesis of POCI.

Low HDL-C levels are associated with cervicocerebral atherosclerotic stenosis in Southern Chinese patients with large artery atherosclerotic ischemic stroke

OBJECTIVES

The aim of this study is to investigate the association of HDL-C with CCAS, as well as its intracranial or extracranial location in the Southern Chinese population.

PATIENTS AND METHODS

123 Southern Chinese patients with large-artery atherosclerotic(LAA) ischemic stroke were enrolled for the final analysis. Based on the stenosis severity defined by digital subtraction angiography, the patients were categorized into CCAS and non-CCAS groups. The degree of artery stenosis among patients of CCAS was classified into three grades. CCAS were further categorized into intracranial AS (ICAS), Extracranial AS (ECAS) and combined intra-/extra-cranial AS (IECAS).

RESULTS

It was showed that patients with CCAS had a lower HDL-C level compared to NCCAS, and HDL-C levels were correlated to the degree of artery stenosis among CCAS. After adjusting for multiple potential confounders, low HDL-C level remained independently associated with CCAS(adjusted OR = 2.860). Patients with the lowest HDL-C quartile had a significantly increased risk for CCAS(adjusted OR: 5.771), referred to the highest quartile. But HDL-C levels in patients with ICAS, ECAS and IECAS were not significantly different, and there was no significant correlation between HDL-C levels and ICAS.

CONCLUSION

Our data indicate that low HDL-C level is associated with CCAS in Southern Chinese patients with LAA ischemic stroke. But the effects of HDL-C on the distribution of CCAS is required to be further explored.

Endovascular Treatment of Intracranial Aneurysms Concomitant with Severe Adjacent Atherosclerotic Stenosis

PURPOSE

To investigate the effect and safety of endovascular treatment of intracranial aneurysms concomitant with severe adjacent atherosclerotic stenosis.

MATERIALS AND METHODS

Twenty-six patients with aneurysms and adjacent stenosis were prospectively enrolled. The characteristics of the aneurysm, parent artery, atherosclerotic stenosis and endovascular treatment methods were analyzed.

RESULTS

All aneurysms were successfully embolized (100%), with stent-assisted coiling in 14 (53.8%) cases, coiling alone in 10 (38.5%), double microcatheter coiling in 1 (3.8%), and balloon-assisted coiling in the remaining 1 (3.8%). Immediately after embolization, complete occlusion was achieved in 10 cases (38.5%), nearly complete occlusion in 6 (23.1%) and non-complete occlusion in 10 (38.5%). Ten aneurysms were type I and were managed with coiling alone in 8 cases and stent-assisted coiling in the remaining 2 cases, with complete occlusion achieved in 6 cases (60%), nearly complete in 2 (20%), and noncomplete in the other 2 (20%). Sixteen aneurysms were type II and treated with stent-assisted coiling in 12 cases (75%), single coiling in 2 (12.5%), double microcatheters in 1 (6.3%), and balloon-assisted coiling in the remaining aneurysm (6.3%). Aneurysm occlusion was complete in 4 cases (25%), nearly complete in 4 (25%), and noncomplete in the other 8 (50%). Clinical follow-up of 2 months to 5 years (mean 26 ± 11 months) demonstrated no rebleeding, with the modified Rankin scale score of 0-2 in 20 patients, 3 in 4, and 6 in the remaining 2.

CONCLUSIONS

Intracranial aneurysms concomitant with severe adjacent atherosclerotic stenosis can be successfully treated endovascularly, and careful evaluation of the characteristics of the aneurysm, parent artery, stenosis and collateral circulation can help reducing complications.

The association between serum uric acid and asymptomatic intracranial arterial stenosis in middle-aged Koreans

BACKGROUND AND AIMS

Intracranial arterial stenosis (ICAS) is one of the most common causes of stroke, especially in Asians. Hyperuricemia has been associated with an increased risk of comorbidities such as metabolic syndrome or cardiovascular diseases. However, there are few studies focusing on the association between serum uric acid (SUA) levels and asymptomatic ICAS. The aim of this study was to explore the association between SUA and the prevalence of ICAS in middle-aged Korean health screening examinees.

METHODS AND RESULTS

A cross-sectional study was performed on 9417 males and 7755 females who underwent a comprehensive health examination including transcranial Doppler (TCD) ultrasonography. The association of SUA and ICAS was analyzed using multivariate logistic regression. The prevalence of ICAS among the total examinee population was 3.55%. In females, the multivariate-adjusted odds ratio for ICAS was 1.52 (confidence interval 1.13-2.04) in the 3rd quartile of SUA and 1.45 (1.05-2.00) in the highest quartile, compared to the reference (P for trend 0.008). This trend was evident in all clinically relevant subgroups evaluated, including women with low inflammation status. SUA was not significantly associated with the prevalence of ICAS among males. In a sensitivity analysis, the multivariate-adjusted odds ratio of middle cerebral artery stenosis in females was 1.60 (1.09-2.37) in the highest quartile compared to the reference (P for trend 0.023).

CONCLUSIONS

Higher SUA level was associated with increased risk of ICAS among middle-aged females but not males. A further cohort study is warranted to elucidate the effect of SUA on asymptomatic ICAS.

Recently Uncontrolled Glycemia in Diabetic Patients Is Associated with the Severity of Intracranial Atherosclerosis

BACKGROUND AND PURPOSE

Diabetes mellitus is a specific risk factor for intracranial atherosclerosis (ICAS) regardless of race. However, it is largely unknown whether poor glycemic control is associated with the severity of ICAS in diabetic patients.

METHODS

We selected diabetic patients with acute ischemic stroke who were prospectively registered between March 2005 and December 2015. The patients who had a high-risk source of cardiogenic embolism were excluded. ICAS was graded from 0 to 3 by the number of significant (≥50%) stenoses on intracranial magnetic resonance angiography, and was divided into 4 types: unilateral anterior, bilateral anterior, posterior, and anterior plus posterior. Ordinal and multinomial regression tests were applied for the factors influencing the number and types of ICAS.

RESULTS

A total of 774 patients with noncardioembolic acute ischemic stroke with diabetes were enrolled. The multiplicity of ICAS was independently associated with age (odds ratio [OR], 1.035 per 1 year, 1.018-1.052; P < .001), hypertension (OR, 1.992, 1.336-2.965; P = .001), and glycated hemoglobin (HbA1c; OR, 1.207 per 1%, 1.089-1.338; P < .001) in the ordinal regression model. In multinomial regression, bilateral anterior stenosis tended to be correlated with age (OR, 1.042, 1.008-1.077; P = .016) and HbA1c (OR, 1.201 per 1%, .991-1.520; P = .057). Both anterior and posterior stenoses were significantly associated with age (OR, 1.056, 1.029-1.084; P < .001), hypertension (OR, 2.584, 1.404-4.762; P = .002), and HbA1c (OR, 1.272, 1.070-1.511; P = .006).

CONCLUSIONS

Age, concomitant hypertension, and HbA1c were factors associated with multiple intracranial stenoses. Further study is warranted to elucidate whether poor glycemic control facilitates ICAS in diabetic patients.

Pathologic Study of Intracranial Large Artery Atherosclerosis in 7260 Autopsy Cases

BACKGROUND

Atherosclerotic changes in the cerebral arteries may differ with era of birth. Herein, we analyzed the chronological changes of intracranial atherosclerosis in consecutive autopsy cases.

METHODS

A total of 7260 autopsy cases from 1972 to 2014 were analyzed. Severity of atherosclerosis was classified using a semi-quantitative scale of pathologic observation of each artery after formalin fixation: 0 = no stenosis; .5 = fatty streaks but no stenosis; 1 = <50% stenosis; 2 = 50%-90% stenosis; 3 = ≥90% stenosis. The bilateral vertebral, anterior, middle, and posterior cerebral arteries and the basilar artery were scored. The sum of each individual was defined and compared by age at death, sex, and era of birth.

RESULTS

The atherosclerosis score increased with age at death, as follows: age in the 50s, 0 [0-2]; 60s, 3 [.5-7]; 70s, 5 [2-9.5]; 80s, 6.5 [3.5-11.5]; 90s, 7.75 [4-12]; and 100s, 8 [5.5-13.5] (median value [interquartile range], P< .0001). The percentage of cases with a score of 2 or 3 in each artery also increased with age (P< .0001). Atherosclerosis score was higher in men than women in their 60s at death, and was higher in women than men in their 80s and 90s at death. In each age at death group (from 60s to 100s), the score declined with later year of birth (P < .05).

CONCLUSIONS

Intracranial atherosclerosis advances with age and is more severe in subjects born earlier.

Microbleeds in the Secondary Prevention of Small Subcortical Strokes Trial: Stroke, mortality, and treatment interactions

OBJECTIVE

To characterize cerebral microbleeds (CMBs) in lacunar stroke patients in the Secondary Prevention of Small Subcortical Strokes (SPS3) trial and to assess their relationship with recurrent stroke and death, and response to assigned treatment.

METHODS

SPS3 is a randomized, clinical trial conducted between 2003 and 2011. Patients with recent magnetic resonance imaging (MRI)-documented lacunar infarcts were randomly assigned in a factorial design to target levels of systolic blood pressure (130-149mmHg vs <130mmHg; open label) and to antiplatelet treatment (aspirin/clopidogrel vs aspirin/placebo; double-blinded). The current analysis involves 1,278 trial participants who had a baseline axial T2*-weighted gradient echo MRI sequence allowing for CMB detection.

RESULTS

CMBs were present in 30% of 1,278 patients (mean age = 63 years). Male gender (odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.3-2.3), history of hypertension (OR = 1.6, 95% CI = 1.2-2.3), increased systolic blood pressure (1.2 per 20mmHg, 95% CI = 1.1-1.4), nondiabetic status (OR = 1.4, 95% CI = 1.1-1.9), multiple old lacunar infarcts (OR = 1.9, 95% CI = 1.5-2.5), and moderate (OR = 1.7, 95% CI = 1.2-2.3) or severe (OR = 4.2, 95% CI = 3.0-5.9) white matter hyperintensities on MRI were independently associated with CMBs. During a mean follow-up of 3.3 years, overall stroke recurrence was 2.5% per patient-year. Patients with CMBs had an adjusted 2-fold increased risk of recurrent stroke (hazard ratio = 2.1, 95% CI = 1.4-3.1). CMBs were not a risk factor for death. There were no statistically significant interactions between CMBs and treatment assignments.

INTERPRETATION

Patients with lacunar stroke and CMBs likely harbor a more advanced form of cerebral small vessel disease in need of efficacious therapeutic strategies. Ann Neurol 2017;82:196-207.

Prevalence and risk factors of intracranial and extracranial artery stenosis in asymptomatic rural residents of 13 villages in China

Background

The present study aimed to investigate the prevalence and risk factors for extracranial carotid artery stenosis (ECAS) and intracranial carotid artery stenosis (ICAS) simultaneously in asymptomatic Chinese pure rural population.

Methods

We analyzed 2589 asymptomatic subjects aged over 30 yr. by ultrasonography and transcranial Doppler simultaneously in 13 isolated villages by door-to-door investigation. Both ECAS and ICAS were defined as more than 50% stenosis. Demographics, medical history documentation, and investigation of biochemical results were performed for each subject. Univariate and multivariate logistic regression analyses were employed to assess the risk factors associated with ECAS and ICAS, respectively.

Results

One hundred twenty-two (4.7%) residents with ICAS and 56 (2.2%) with ECAS were found in 2589 subjects. Three factors emerged as independent risk factors for ICAS: age (95% confidence interval [CI] = 1.01–1.04, odds ratio [OR] = 1.07), hypertension (95% CI = 1.98–4.37, OR = 2.94), and diabetes mellitus (95% CI = 1.72–4.38, OR = 2.75). As for ECAS, five factors presented as independent risk factors: age (95% CI = 1.09–1.11, OR = 1.10), male sex (95% CI = 1.01–1.02, OR = 1.01), diabetes mellitus (95% CI = 1.10–2.12, OR = 1.53), systolic blood pressure (95% CI = 1.95–2.88, OR = 2.37), and total cholesterol (95% CI = 1.00–1.13, OR = 1.06).

Conclusions

ICAS and ECAS were relatively common among asymptomatic rural Chinese subjects. Although they shared similar risk factors, differences still existed between them.

Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery for Refractory Symptomatic Intracranial Atherosclerotic Stenosis

OBJECTIVE

To evaluate blood flow changes after bypass surgery for refractory symptomatic intracranial atherosclerotic stenosis (ICAS).

METHODS

We examined a cohort of consecutive patients with symptomatic ICAS. Superficial temporal artery-middle cerebral artery (MCA) bypass was performed in refractory patients with poor perfusion. Angiograms were graded systematically for antegrade, collateral, and bypass flow, and clinical variables were collected preoperatively, at 7 days postoperatively, and 3, 6, and 12 months postoperatively.

RESULTS

Among 185 consecutive cases with ICAS, 15 patients who were unsuitable for or did not respond to the best medical therapy or stenting underwent bypass surgery. No patients had new ischemic deficits within 7 days postoperatively. The mean follow-up period was 30.2 ± 12.3 months. Within this period, all anastomoses were patent by methods of ultrasound or computed tomography angiography. In 2 patients, stenotic lesions exhibited early postoperative occlusion conversion at 7 days on digital subtraction angiography. In 2 patients, stenotic lesions showed progression of occlusion at 6 and 8 months. The 2 lesions with early occlusion were both located in the MCA. The extent of retrograde blood flow via bypass anastomosis was correlated with early occlusion conversion.

CONCLUSIONS

For refractory ICAS in patients with compromised hemodynamics, direct bypass might induce early occlusion of a stenotic area. MCA lesions may have a greater tendency toward early occlusion conversion.

Impact of MCA stenosis on the early outcome in acute ischemic stroke patients

Background

Asians have higher frequency of intracranial arterial stenosis. The present study aimed to compare the clinical features and outcomes of ischemic stroke patients with and without middle cerebral artery (MCA) stenosis, assessed by transcranial sonography (TCS), based on the Taiwan Stroke Registry (TSR).

Methods

Patients with acute ischemic stroke or transient ischemic attack registered in the TSR, and received both carotid duplex and TCS assessment were categorized into those with stenosis (≥50%) and without (<50%) in the extracranial internal carotid artery (ICA) and MCA, respectively. Logistic regression analysis, Kaplan-Meier method and Cox proportional hazard model were applied to assess relevant variables between groups.

Results

Of 6003 patients, 23.3% had MCA stenosis, 10.1% ICA stenosis, and 3.9% both MCA and ICA stenosis. Patients with MCA stenosis had greater initial NIHSS, higher likelihood of stroke-in-evolution, and more severe disability than those without (all p<0.001). Patients with MCA stenosis had higher prevalence of hypertension, diabetes and hypercholesterolemia. Patients with combined MCA and extracranial ICA stenosis had even higher NIHSS, worse functional outcome, higher risk of stroke recurrence or death (hazard ratio, 2.204; 95% confidence intervals, 1.440–3.374; p<0.001) at 3 months after stroke than those without MCA stenosis.

Conclusions

In conclusion, MCA stenosis was more prevalent than extracranial ICA stenosis in ischemic stroke patients in Taiwan. Patients with MCA stenosis, especially combined extracranial ICA stenosis, had more severe neurological deficit and worse outcome.

A lower baseline glomerular filtration rate predicts high mortality and newly cerebrovascular accidents in acute ischemic stroke patients

Chronic kidney disease (CKD) is gradually recognized as an independent risk factor for cardiovascular and cardio-/cerebrovascular disease. This study aimed to examine the association of the estimated glomerular filtration rate (eGFR) and clinical outcomes at 3 months after the onset of ischemic stroke in a hospitalized Chinese population.Totally, 972 patients with acute ischemic stroke were enrolled into this study. Modified of Diet in Renal Disease (MDRD) equations were used to calculate eGFR and define CKD. The site and degree of the stenosis were examined. Patients were followed-up for 3 months. Endpoint events included all-cause death and newly ischemic events. The multivariate logistic model was used to determine the association between renal dysfunction and patients' outcomes.Of all patients, 130 patients (13.4%) had reduced eGFR (<60 mL/min/1.73 m), and 556 patients had a normal eGFR (≥90 mL/min/1.73 m). A total of 694 patients suffered from cerebral artery stenosis, in which 293 patients only had intracranial artery stenosis (ICAS), 110 only with extracranial carotid atherosclerotic stenosis (ECAS), and 301 with both ICAS and ECAS. The patients with eGFR <60 mL/min/1.73m had a higher proportion of death and newly ischemic events compared with those with a relatively normal eGFR. Multivariate analysis revealed that a baseline eGFR <60 mL/min/1.73 m increased the risk of mortality by 3.089-fold and newly ischemic events by 4.067-fold. In further analysis, a reduced eGFR was associated with increased rates of mortality and newly events both in ICAS patients and ECAS patients. However, only an increased risk of newly events was found as the degree of renal function deteriorated in ICAS patients (odds ratio = 8.169, 95% confidence interval = 2.445-14.127).A low baseline eGFR predicted a high mortality and newly ischemic events at 3 months in ischemic stroke patients. A low baseline eGFR was also a strong independent predictor for newly ischemic events in ICAS patients.

Risk Factors, Vascular Lesion Distribution, Outcome and Recurrence of Strokes Due to Intracranial Atherosclerosis: One Year Data from Hyderabad Stroke Registry

Background:

Intracranial atherosclerotic stenosis (ICAS) is a common cause of ischemic stroke in Asian countries and probably in India.

Aim:

The aim of this study was to describe the risk factors, distribution of vascular lesions, recurrence and outcome of stroke due to ICAS.

Methodology:

A total of 100 consecutive patients of ischemic stroke due to ICAS were enrolled prospectively from January 1, 2015, to December 31, 2015, and followed for 1 year for treatment compliance and recurrence. The details about demographics, risk factors, and vascular lesions were noted.

Results:

There were 68 males and 32 females. Hypertension (HTN), diabetes, alcohol, smoking, hyperlipidemia, and hyperhomocysteinemia was present in 82%, 52%, 34%, 33%, 28%, and 23%, respectively. The number of arteries involved were middle cerebral artery, 53 (37.3%); posterior cerebral artery, 24 (16.9%); internal cerebral artery, 21 (14.8%); vertebral artery, 18 (12.7%); basilar artery, 6 (4.2%); and anterior cerebral artery, 6 (4.2%). Seventeen (17%) patients had a recurrent stroke during 1 year follow-up. The presence of uncontrolled HTN and diabetes mellitus after discharge were significantly associated with stroke recurrence (P < 0.05). The use of dual antiplatelet agents and statins was found to have a significant effect in the prevention of recurrent stroke (P < 0.05). Severe stroke at presentation and presence of hemiparesis were the predictors for unfavorable outcome at 3 months (P < 0.05).

Conclusion:

Risk factors, distribution of vascular lesions and high recurrence of stroke due to ICAS in this study is similar to that reported from other Asian countries. Aggressive medical management and risk factor control remains the best strategy for preventing recurrence.

A comparison of risk factors and prognosis between intra and extracranial acute atherosclerotic stroke in the Turkish population: a prospective study

BACKGROUND

The aim of this study was to compare the differences in risk factors and prognosis between acute stroke caused by definitive intracranial atherosclerosis (ICAS) or extracranial atherosclerosis (ECAS) in the Turkısh population.

METHODS

This study was prospectively designed in a single centre and conducted with patients who were hospitalised due to acute ischaemic stroke. Inclusion criteria were the diagnosis of atherosclerotic ischaemic stroke, defined as more than 50% stenosis or occlusion in the arterial structure supplying the ischaemic area, having excluded other possible causes.

RESULTS

Information on 58 ICAS and 57 ECAS stroke patients was collected in a 13-month period. The ECAS patients had male gender predominance (p = 0.003). Ageing, stroke history and hyperlipidaemia were related with stroke severity in ECAS, and gender was associated with severity in ICAS. Hypertension and being female were related with poor prognosis in ICAS (p = 0.081 vs. 0.087). Congestive heart failure (p = 0.002) was associated with poor prognosis and alcohol with a favourable outcome (p = 0.087) in ECAS. Stroke severity was related with poor prognosis in both groups (p < 0.001).

CONCLUSIONS

The prevalence of risk factors differs between ICAS and ECAS, and their influence differs for stroke severity and prognosis.

Location of cerebral atherosclerosis: Why is there a difference between East and West?

Intracranial atherosclerosis is more prevalent in Asian patients, whereas extracranial atherosclerosis is more common in individuals from western countries. The reasons for this discrepancy remain unknown. We reviewed the relevant literature and discussed the currently available information. Although the study population, diagnostic modality, and risk factor definitions differ between studies, hypercholesterolemia is more correlated with extracranial atherosclerosis than intracranial atherosclerosis. The difference in hypercholesterolemia prevalence is one of the main reasons for racial differences. Intracranial arteries contain higher antioxidant level than extracranial arteries and may be more vulnerable to risk factors for antioxidant depletion (e.g., metabolic syndrome and diabetes mellitus). Intracranial arteries may be vulnerable to factors associated with hemodynamic stress (e.g., advanced, salt-retaining hypertension and arterial tortuosity) because of a smaller diameter, thinner media and adventitia, and fewer elastic medial fibers than extracranial arteries. Additionally, non-atherosclerotic arterial diseases (e.g., moyamoya disease) that commonly occur in the intracranial arteries of East Asians may contaminate the reports of intracranial atherosclerosis cases. Genes, including RNF 213 or those associated with high salt sensitivity, may also explain racial differences in atherosclerotic location. To understand racial differences, further well-designed studies on various risk and genetic factors should be performed in patients with cerebral atherosclerosis. Additionally, improvements in diagnostic accuracy via advancements in imaging technologies and increased genetic data will aid in the differentiation of atherosclerosis from non-atherosclerotic intracranial diseases.