Low concentration of serum total cholesterol is associated with multifocal signal loss lesions on gradient-echo magnetic resonance imaging: analysis of risk factors for multifocal signal loss lesions

Association of LDL-cholesterol <1.8 mmol/L and statin use with the recurrence of intracerebral hemorrhage

BACKGROUND

Recent intensive low-density lipoprotein cholesterol (LDL-C) lowering trials, including FOURIER, ODYSSEY OUTCOMES, and Treat Stroke to Target (TST) trials, have mostly refuted the concern surrounding statin use, LDL-C lowering, and intracerebral hemorrhage (ICH) risk. However, the results from these trials may not be fully applied to ICH survivors, as the populations studied were mainly patients without prior ICH, in whom the inherent ICH risk is more than 10 times lower than that of ICH survivors. Although available literature on statin use after ICH has demonstrated no excess risk of recurrent ICH, other potential factors that may modify ICH risk, especially hypertension control and ICH etiology, have not generally been considered. Notably, data on LDL-C levels following ICH are lacking.

AIMS

We aim to investigate the association between LDL-C levels and statin use with ICH risk among ICH survivors, and to determine whether the risk differed with patients' characteristics, especially ICH etiology.

METHODS

Follow-up data of consecutive spontaneous ICH survivors enrolled in the University of Hong Kong prospective stroke registry from 2011 to 2019 were retrospectively analyzed. ICH etiology was classified as cerebral amyloid angiopathy (CAA) using the modified Boston criteria or hypertensive arteriopathy, while the mean follow-up LDL-C value was categorized as <1.8 or ⩾1.8 mmol/L. The primary endpoint was recurrent ICH. The association of LDL-C level and statin use with recurrent ICH was determined using multivariable Cox regression. Pre-specified subgroup analyses were performed, including based on ICH etiology and statin prescription. Follow-up blood pressure was included in all the regression models.

RESULTS

In 502 ICH survivors (mean age = 64.2 ± 13.5 years, mean follow-up LDL-C = 2.2 ± 0.6 mmol/L, 28% with LDL-C <1.8 mmol/L), 44 had ICH recurrence during a mean follow-up of 5.9 ± 2.8 years. Statin use after ICH was not associated with recurrent ICH (adjusted hazard ratio (AHR) = 1.07, 95% confidence interval (CI) = 0.57-2.00). The risk of ICH recurrence was increased for follow-up LDL-C <1.8 mmol/L (AHR = 1.99, 95% CI = 1.06-3.73). This association was predominantly observed in ICH attributable to CAA (AHR = 2.52, 95% CI = 1.06-5.99) and non-statin users (AHR = 2.91, 95% CI = 1.08-7.86).

CONCLUSION

The association between post-ICH LDL-C <1.8 mmol/L and recurrent ICH was predominantly observed in CAA patients and those with intrinsically low LDL-C (non-statin users). While statins can be safely prescribed in ICH survivors, LDL-C targets should be individualized and caution must be exercised in CAA patients.

Deep and infratentorial cerebral microbleeds are related to wake-up stroke by large-artery atherosclerosis and cardioembolism

BACKGROUND AND AIMS

Circadian variability of blood pressure (BP) and hypercoagulation in the morning have been proposed as underlying mechanisms of wake-up stroke (WUS). The aim was to determine the impact of cerebral microbleeds (CMBs), showing BP fluctuation and background hypercoagulability, on WUS.

METHODS

Consecutive patients with acute ischemic stroke onset-to-door time within one week were screened. WUS was defined as an ischemic stroke that occurred during sleep at night. CMBs were categorized into three: "strictly Lobar", "strictly Deep (D) and/or Infratentorial (I)", and "Mixed". Moderate to severe CMBs were defined as having more than three in total. First, whether CMBs are associated with WUS was examined. Second, the same analysis was performed according to the stroke subtype classified as large-artery atherosclerosis (LAA), cardioembolism (CE), and small-vessel occlusion (SVO).

RESULTS

A total of 1477 patients (1059 [72%] male, median age 69 years) were included, and WUS was observed in 363 (25%) patients. On Poisson regression analysis with a robust variance estimator in the total cohort, moderate to severe strictly D and/or I CMBs (PR 1.505, 95% CI 1.154-1.962, p = 0.003) were associated with WUS. From the perspective of stroke subtype, the same result was confirmed in LAA (PR 2.223, 95% CI 1.036-4.768, p = 0.040) and CE (PR 1.668, 95% CI 1.027-2.709, p = 0.039), not SVO.

CONCLUSIONS

The presence of moderate to severe strictly D and/or I CMBs might be associated with the development of WUS. By stroke subtype, the same result was confirmed in LAA and CE.

Prevalence and risk factors for cerebral microbleeds in elderly Chinese patients with arteriosclerotic cardiovascular diseases: A single-center study

OBJECTIVES

People with arteriosclerotic cardiovascular diseases (ASCVD) frequently use antithrombotic agents and statins. The objective of the study was to explore the prevalence and risk factors of cerebral microbleeds (CMBs) in elderly (≥ 65 years old) Chinese people with ASCVD.

MATERIALS AND METHODS

We prospectively included 755 eligible participants with complete MRI data, and CMBs were discerned on the SWI sequence. Multivariate logistic regression was performed to analyze risk factors associated with CMBs.

RESULTS

The average age was 74.9 ± 9.5 years, and the prevalence of CMBs was 37.9% (286/755). Of those with CMBs, 65.0% (186/286) had strictly lobar CMBs, 35.0% (100/286) had deep or infratentorial CMBs with or without lobar CMBs. We divided CMBs into two groups according to their locations, lobar CMBs group (strictly lobar CMBs) and deep CMBs group (with or without lobar CMBs). Age per 10 years (odds ratio (OR) 1.42, 95% confidence interval (CI) 1.17-1.72, p < 0.001), statin use (OR 1.54, 95% CI 1.05-2.26, p = 0.03), and lacunes (OR 1.70, 95% CI 1.09-2.68, p = 0.02) were associated with any CMBs. Age per 10 years (OR 1.33, 95% CI 1.10-1.63, p < 0.001), statin use (OR 1.67, 95% CI 1.12-2.50, p = 0.01), and white matter hyperintensities (OR 1.71, 95% CI 1.17-2.51, p < 0.01) were associated with lobar CMBs. Only lacunes were associated with deep CMBs (OR 3.29, 95% CI 1.85-5.87, p < 0.001).

CONCLUSIONS

In elderly people with risk factors of ASCVD, antithrombotic drug use was not associated with any CMBs, lobar CMBs, or deep CMBs. Statin use was correlated with lobar CMBs but not deep CMBs.

The correlation between the severity of cerebral microbleeds and serum HMGB1 levels and cognitive impairment in patients with cerebral small vessel disease

Objective

The study investigated the correlation and predictive value between the severity of cerebral microbleeds (CMBs) and the level of serum High Mobility Group Protein B1 (HMGB1) and the occurrence of cognitive impairment in patients with cerebral small vessel disease (CSVD).

Methods

A total of 139 patients with CSVD admitted to the Department of Neurology of the First Affiliated Hospital of Xinxiang Medical University from December 2020 to December 2022 were selected as study subjects. The Montreal Cognitive Assessment (MoCA) scale was used to assess the cognitive function and was divided into the cognitive impairment group and the cognitive normal group. Magnetic Resonance Imaging (MRI) and Susceptibility Weighted Imaging (SWI) were used to screen and assess the severity of CMBs. Serum HMGB1 levels of CSVD patients were measured by enzyme linked immunosorbent assay (ELISA). Multivariable logistic regression analysis was used to explore risk factors for cognitive impairment and CMBs. Pearson correlation analysis was used to investigate the correlation between HMGB1 and cognitive function. Receiver Operating Characteristics (ROC) curves were used to assess the predictive value of HMGB1 for the occurrence of cognitive impairment in patients with CMBs.

Results

High Mobility Group Protein B1, uric acid (UA), glycosylated hemoglobin (HbA1c), CMBs, lacunar cerebral infarction (LI), years of education, and history of hypertension were risk factors for cognitive impairment (P < 0.05); HMGB1 was significantly and negatively associated with total MoCA score, visuospatial/executive ability, and delayed recall ability (P < 0.05). HMGB1 was significantly and positively correlated with the number of CMBs (P < 0.05). The area under the ROC curve for HMGB1 predicting cognitive impairment in patients with CMBs was 0.807 (P < 0.001).

Conclusion

Serum HMGB1 levels are associated with the development of cognitive impairment in CSVD patients, and serum HMGB1 levels have a high predictive value for the development of cognitive impairment in CSVD patients with combined CMBs, which can be used for early clinical identification and intervention of vascular cognitive impairment.

A multicenter, prospective, randomized controlled trial of intracranial hemorrhage risk of intensive statin therapy in patients with acute ischemic stroke combined with cerebral microbleeds (CHRISTMAS): Study protocol

Background

Low serum levels of major lipid markers have been proved to be significantly associated with increased risks of hemorrhagic stroke (HS) and cerebral microbleeds (CMBs). However, there is no lipid modification guideline telling us how to maintain a balance between the prevention of ischemic stroke recurrence and the prevention of hemorrhagic events, especially in patients with acute ischemic stroke (AIS) and CMBs.

Aim

The Intracranial Hemorrhage Risk of Intensive Statin Therapy in Patients with Acute Ischemic Stroke combined with Cerebral Microbleeds (CHRISTMAS) trial evaluates the risk of intracranial hemorrhage (i.e., HS and CMBs) of high-dose statin therapy in patients with AIS combined with CMBs.

Methods and design

This is an investigator-initiated, multicenter, prospective, randomized controlled clinical trial design. Up to 344 eligible patients will be consecutively randomized to receive high-dose or low-dose atorvastatin in 1:1 ratio in 5 stroke centers in China.

Outcomes

CHRISTMAS trial has co-primary outcomes, namely, hemorrhage risk: the incidence of HS and the changes in degree of CMBs until the end of 36-month follow-up.

Discussion

The primary hypothesis of this study is that an excessive reduction in serum lipid levels by an intensive statin therapy in AIS patients with CMBs can increase the risk of intracranial hemorrhage. This study will shed light on new clinical decisions regarding the long-term serum lipid management in these patients with dilemma in clinical practice.

Clinical trial registration

Clinicaltrials.gov, identifier: NCT05589454.

Role of LDL-C level alteration in increased mortality risks in spontaneous intracerebral hemorrhage patients: Systematic review and meta-analysis

Background

Current studies indicate a contradictory relationship between decreased mortality risks of spontaneous intracerebral hemorrhage (sICH) and elevated low-density lipoprotein cholesterol (LDL-C) levels. Thus, this meta-analysis was designed to examine the involvement of high LDL-C levels in a lower mortality risk of sICH patients.

Methods

PubMed, Cochrane, and Embase databases were searched up to the date of August 3rd, 2022. Pooled odds ratio (OR) with a 95% confidence interval (CI) was estimated for the higher vs. lower serum LDL-C level groups. Subgroup and sensitivity analyses were also carried out. Egger's test was applied to detect any potential publication bias.

Results

Of 629 citations reviewed, 8 eligible cohort studies involving 83,013 patients were enrolled in this meta-analysis. Compared with lower serum LDL-C levels containing patients, higher serum LDL-C patients exhibited significantly decreased risks of 3-month mortality (OR: 0.51; 95%CI: 0.33-0.78; I² = 47.8%); however, the LDL-C level change wasn't significantly associated with in-hospital mortality risks (OR: 0.92; 95%CI: 0.63-1.33; I² = 91.4%) among sICH subjects. All studies included were classified as high-quality investigations.

Conclusions

This meta-analysis suggests a higher LDL-C level may decrease the mortality risk in sICH patients. LDL-C level increase is inversely associated with the 3-month mortality risks in these patients but not significantly correlated with the in-hospital mortality risks. Further well-designed prospective studies with extended follow-up periods are needed to confirm these findings and explore underlying cross-talks.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022318318, identifier: PROSPERO 2022 CRD42022318318.

Association between non-HDLC and 1-year prognosis in patients with spontaneous intracerebral haemorrhage: a prospective cohort study from 13 hospitals in Beijing

OBJECTIVES

Previous studies suggested an inverse association between lipoprotein cholesterols and bleeding risk, while limited data were available about the predictive value of lipoproteins on intracerebral haemorrhage (ICH). Our recent research series showed that higher non-high-density lipoprotein cholesterol (non-HDLC) was an independent predictor of favourable 3-month outcome in ICH patients, we thus aimed to further investigate the association between non-HDLC levels and 1-year functional outcomes after ICH.

DESIGN

Prospective multicentre cohort study.

SETTING

13 hospitals in Beijing, China.

PARTICIPANTS

A total of 666 ICH patients were included between December 2014 and September 2016.

METHODS

Non-HDLC was calculated by subtracting HDL-C from total cholesterol. Patients were then grouped by non-HDLC levels into three categories: <3.4 mmol/L, 3.4-4.2 mmol/L and ≥4.2 mmol/L. Both the univariate and multivariate logistic regressions were used to assess the association between non-HDLC levels and 1-year unfavourable functional outcomes (modified Rankin Scale ≥3) in ICH patients. Moreover, sensitivity analysis was performed in ICH patients without statin use after admission.

RESULTS

There were 33.5% (223/666) ICH patients identified with unfavourable functional outcomes at 1-year follow-up. In the univariate analysis, patients who achieved non-HDLC levels above 4.2 mmol/L had a 49% decreased risk of 1-year poor prognosis (OR 0.51, 95% CI 0.33 to 0.81). However, non-HDLC did not retain its independent prognostic value in multivariate analysis, the fully adjusted OR values were 1.00 (reference), 1.06 (0.63, 1.79) and 0.83 (0.45, 1.54) from the lowest to the highest non-HDLC group. Moreover, statin use after ICH onset made no difference to the long-term prognosis.

CONCLUSIONS

Non-HDLC was not an independent predictor for 1-year functional outcome in ICH patients, irrespective of poststroke statin use. The predictive value of well-recognised confounding factors was more dominant than non-HDLC on long-term prognosis.

Associations of HDL-C/LDL-C with myocardial infarction, all-cause mortality, haemorrhagic stroke and ischaemic stroke: a longitudinal study based on 384 093 participants from the UK Biobank

OBJECTIVE

To explore the correlations of high-density lipoprotein cholesterol (HDL-C)/low-density lipoprotein cholesterol (LDL-C) with myocardial infarction (MI), all-cause mortality, haemorrhagic stroke and ischaemic stroke, as well as the joint association of genetic susceptibility and HDL-C/LDL-C with the MI risk.

METHODS AND RESULTS

This study selected 384 093 participants from the UK Biobank (UKB) database. First, restricted cubic splines indicated non-linear associations of HDL-C/LDL-C with MI, ischaemic stroke and all-cause mortality. Second, a Cox proportional-hazards model indicated that compared with HDL-C/LDL-C=0.4-0.6, HDL-C/LDL-C<0.4 and >0.6 were correlated with all-cause mortality (HR=0.97 for HDL-C/LDL-C<0.4, 95% CI=0.939 to 0.999, p<0.05; HR=1.21 for HDL-C/LDL-C>0.6, 95% CI=1.16 to 1.26, p<0.001) after full multivariable adjustment. HDL-C/LDL-C<0.4 was correlated with a higher MI risk (HR=1.36, 95% CI=1.28 to 1.44, p<0.05) and ischaemic stroke (HR=1.12, 95% CI=1.02 to 1.22, p<0.05) after full multivariable adjustment. HDL-C/LDL-C>0.6 was associated with higher risk haemorrhagic stroke risk after full multivariable adjustment (HR=1.25, 95% CI=1.03 to 1.52, p<0.05). Third, after calculating the coronary heart disease Genetic Risk Score (CHD-GRS) of each participant, the Cox proportional-hazards model indicated that compared with low CHD-GRS and HDL-C/LDL-C=0.4-0.6, participants with a combination of high CHD-GRS and HDL-C/LDL-C<0.4 were associated with the highest MI risk (HR=2.45, 95% CI=2.15 to 2.8, p<0.001). Participants with HDL-C/LDL-C<0.4 were correlated with a higher MI risk regardless of whether they had a high, intermediate or low CHD-GRS.

CONCLUSION

In UKB participants, HDL-C/LDL-C ratio of 0.4-0.6 was correlated with lower MI risk, all-cause mortality, haemorrhagic stroke and ischaemic stroke. Participants with HDL-C/LDL-C<0.4 were correlated with a higher MI risk regardless of whether they had a high, intermediate or low CHD-GRS. The clinical significance and impact of HDL-C/LDL-C need to be further verified in future studies.

Lacunes and type 2 diabetes mellitus have a joint effect on cognitive impairment: a retrospective study

Objective

To evaluate the joint effects of cerebral small vessel disease (CSVD)-related imaging biomarkers in patients of type 2 diabetes mellitus (T2DM) with cognitive impairment.

Methods

This study is a retrospective cohort study. A total of 227 participants (115 patients with T2DM and 112 healthy control subjects) were enrolled in this study. Cognitive function assessments were evaluated using the Mini-Mental State Examination and the Montreal Cognitive Assessment. The burden of CSVD markers, including the lacunes, white matter hyperintensities (WMH), cerebral microbleeds (CMBs), and enlarged perivascular spaces (PVS), was identified by magnetic resonance imaging and evaluated using small vessel disease (SVD) scores (0-4). The subjects were divided into two groups based on the results of the cognitive function assessments. The synergy index was used to estimate the biological interactions between T2DM and lacunes.

Results

There was a significant correlation between T2DM and cognitive impairment (p < 0.001, χ² test). In patients with diabetes, cognitive impairment was significantly associated with both the presence of lacunes (p < 0.01, χ² test) and increased total SVD burden scores (p < 0.01, χ² test). Regarding CMBs, only the existence of lobar CMBs was correlated with cognitive impairment (p < 0.05, χ² test). The joint effect tended to be larger than the independent effects of T2DM and lacunes on cognitive impairment (adjusted odds ratio [OR]: 7.084, 95% CI [2.836-17.698]; synergy index: 10.018, 95% CI [0.344-291.414]).

Conclusions

T2DM and the presence of lacunes are significantly correlated with cognitive impairment. There was a joint effect of T2DM and lacunes on cognitive impairment.

The Association between Low Levels of Low Density Lipoprotein Cholesterol and Intracerebral Hemorrhage: Cause for Concern?

Excessive levels of low-density lipoprotein cholesterol (LDL-C) in the blood are a known risk factor for atherosclerosis, and a common target of treatment for primary and secondary prevention of cerebrocardiovascular disease. As lipid lowering agents including statins, ezetimibe and anti-proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have shown good therapeutic results, the guidelines are constantly lowering the "optimal" LDL-C goals. However, old and new data point towards an association between low LDL-C and total cholesterol and intracerebral hemorrhage (ICH). In this review we aimed to shed light on this troubling association and identify the potential risk factors of such a potential adverse reaction. With respect to the data presented, we concluded that in patients with high risk of ICH, a cautious approach and individualized therapy strategy are advised when considering aggressive LDL reduction.

White matter changes, duration of hypertension, and age are associated with cerebral microbleeds in patients with different stages of hypertension

BACKGROUND

We aimed to investigate risk factors for the presence and number of cerebral microbleeds (CMBs) in patients with different stages of hypertension stages, with an emphasis on the relationship between white matter changes (WMCs) and CMBs.

METHODS

Since 2016, participants aged 40 years or more have been evaluated for the presence of CMBs using enhanced 3D multiecho GE T2*-weighted angiography (ESWAN) sequences. The Mann-Whitney U test and Pearson χ² test were used to compare the clinical characteristics between the CMB and no-CMB patient groups. Furthermore, we used Spearman's rank correlation analysis to examine the associations between the degree of CMB severity and other important factors.

RESULTS

CMBs were detected in 110 (36.7%) of 300 participants. Among patients with stage 2 hypertension, the majority also had CMBs (61.8%, 68/110). CMBs were positively correlated with age, hypertension stage, duration of hypertension, WMCs, and silent cerebral infarction. Patients with grade 3 WMCs were significantly more likely to have CMBs than those without WMCs; this association was true for both patients with stage 1 and those with stage 2 hypertension. In patients with stage 1 or stage 2 hypertension lasting longer than 20 years, the majority had CMBs (69.0%, 29/42; 69.1%, 47/68). The results of binary logistic regression indicated that a more severe hypertension stage, longer duration of hypertension, aging, having silent cerebral infarction and higher values of WMC increase the likelihood of the occurrence of CMBs.

CONCLUSIONS

CMBs detected in hypertensive patients were more likely to occur in deep structures, and the grade of WMCs and duration of hypertension were more closely associated with the CMB degree than with age.

Low serum lipid levels, use of statin and cerebral microbleeds: A systematic review and meta-analysis

INTRODUCTION

Previous studies have shown that low serum lipids and statins may be related to cerebral hemorrhage. We made the meta-analysis to evaluate the associations between serum lipid levels or statins treatment and cerebral microbleeds (CMBs) to identify whether the similar correlation also existed.

METHOD

We comprehensively searched the Medline, Embase, Cochrane library, Web of Science, only included English journal articles, and systematically collected the observational studies and randomized controlled trials (RCTs) from September 1975 to August 2021. Random-effects model was used to pool data. Statistical heterogeneity was assessed by I² statistic and chi-square. 11 items checklists recommended by the Agency for Healthcare Research and Quality (AHRQ), Newcastle-Ottawa Scale (NOS), and Cochrane Risk of Bias tool (ROB) were used to evaluate the methodological quality of cross-sectional studies, cohort studies and randomized controlled trial, respectively.

RESULTS

Five cohort studies, two RCTs, and ten cross-sectional studies, including 16,637 subjects and 2663 CMBs patients, were included in our quantitative synthesis. Our study found that after adjusting the covariates, total cholesterol (TC) was significantly inversely correlated with the prevalent CMBs in any location, while total triglycerides (TG) and High-density lipoprotein (HDL) were significantly inversely associated with prevalent deep CMBs. Low-density lipoprotein (LDL) was negatively associated with incident CMBs after adjusted confounders. We did not found statistical differences between statin and CMBs after adjusted covariates.

CONCLUSION

Serum major lipid (TC TG HDL LDL) levels may be inversely associated with CMBs. Currently, no sufficient evidence proves that statin therapy is the risk factor of CMBs.

Impact of stroke history on the presence of cerebral microbleeds in hemodialysis patients

Introduction

Cerebral microbleeds (CMBs) are detected on gradient-echo T2*-weighted magnetic resonance imaging (MRI). Clinically, CMBs are often detected after stroke, including in cases of intracerebral hemorrhage and ischemic cerebrovascular disease. Hemodialysis (HD) patients are widely known to have a high incidence of stroke, and HD patients without stroke history have been reported to have a high prevalence of CMBs. In this study, we investigated whether history of stroke affects the prevalence of CMBs in HD patients.

Methods

A cross-sectional study was performed in 241 HD patients who underwent brain T2*-weighted MRI. We compared the prevalence of CMBs between the patients with and without a history of stroke. Moreover, the relationship between history of stroke and presence of CMBs was examined by multivariate logistic regression analysis.

Results

Among these patients, 22 (9.1%) had a history of stroke. CMBs were detected in 70 patients (29.0%). The prevalence of CMBs was significantly higher in patients with a history of stroke compared to those without this history (54.5 vs. 26.5%, p = 0.012). In the multivariable analysis adjusted for background characteristics, history of stroke was a significant and independent factor related to CMBs (OR: 3.24, 95%CI: 1.18–8.89, p = 0.02).

Discussion/conclusions

As has been reported for non-dialysis patients, our results showed a high prevalence of CMBs in HD patients with a history of stroke, and indicated that a history of stroke is significantly and independently associated with CMBs in HD patients.

Borderzone Infarction and Small Vessel Disease in a Sample of Egyptian Stroke Patients: Differences and Similarities

Background

The anatomical location of white matter hyperintense lesions in small vessel disease are apparently similar to those of borderzone infarction. The objective of this study is to find clinical and radiological points of differentiation between the two vascular disorders in a sample of Egyptian patients which might have an impact on primary and secondary prevention.

Methods

Ischemic stroke patients with white matter lesions were categorized into two groups: small vessel disease and borderzone infarctions. NIHSS was done on admission. Risk factor profile was reported, and investigations done including: HbA1C, lipid profile, CRP, ECG, echocardiography, carotid duplex, brain MRI, MRA and MR perfusion study.

Results

46 patients completed the study, 29 with SVD and 17 with BZI. Smoking, hypertension and recurrent stroke were more common in borderzone infarctions, but only diabetes was significantly higher (p = 0.047). Limb shaking was more observed in borderzone infarctions (p = 0.049). Radiologically: lacunar pattern was observed more in small vessel disease, while rosary pattern was more in borderzone infarctions (p = 0.04). FLAIR symmetrical lesions and microbleeds were more significant in small vessel disease (p = <0.001; 0.048, respectively). Perfusion study time to peak denoted evidence of significant hypoperfusion in all regions of interest in borderzone infarctions.

Conclusion

Limb shaking, retinal claudication or syncope, with MRI showing rosary pattern of white matter hyperintensity, few microbleeds and markedly impaired perfusion favor the diagnosis of borderzone infarctions. On the other hand, presence of lacunae, FLAIR showing symmetrical WMH and microbleeds with minimal or no perfusion deficit suggests the diagnosis of small vessel disease.

Role of Blood Lipid Levels and Lipid-Lowering Therapy in Stroke Patients with Different Levels of Cerebral Artery Diseases: Reconsidering Recent Stroke Guidelines

Hyperlipidemia is an important risk factor for ischemic stroke; the Stroke Prevention by Aggressive Reduction in Cholesterol Level and Treat Stroke to Target studies have shown that statins are beneficial for patients with stroke and that a low target for low-density lipoprotein cholesterol (LDL-C) concentration may maximize this benefit. Based on these results, recent guidelines have emphasized the application of "high-intensity statins" and "low LDL-C target" strategies in patients with stroke. However, it should be kept in mind that the role of blood lipids as a risk factor and benefit of lipid-lowering therapy are different among patients with different levels of cerebral arterial diseases. Studies have suggested that hypolipidemia, but not hyperlipidemia, is a risk factor for small vessel diseases (SVDs) such as intracerebral hemorrhages, microbleeds, white matter hyperintensities, and perhaps, lacunar infarction. Although lipid-lowering agents might benefit certain patients with SVD, high-intensity statin and low LDL-C target strategies cannot be applied. In contrast, these strategies are important in patients with extracranial atherosclerosis, such as internal carotid disease, considering ample evidence of the benefits of lipid-lowering agents. Imaging studies have shown that statins stabilize vulnerable plaques in these patients. Although lipid-lowering agents are likely to benefit patients with intracranial atherosclerosis, the degree of their benefit and appropriate target LDL-C level for these patients remain unclear. More studies are needed to elucidate the appropriate lipid-modifying strategies in patients with stroke with different levels of cerebral artery disease.

Statin treatment and cerebral microbleeds: A systematic review and meta-analysis

Although statins have been associated with increased risk of spontaneous intracerebral hemorrhage, their relationship with cerebral microbleeds (CMBs) formation is poorly understood. We systematically reviewed previously published studies reporting on the association between CMBs presence and current statin use. We performed a systematic search in MEDLINE and SCOPUS databases on October 24, 2019 to identify all cohorts from randomized-controlled clinical trials or observational studies reporting on CMB prevalence and statin use. We extracted cross-sectional data on CMBs presence, as provided by each study, in association to the history of current statin use. Random effects model was used to calculate the pooled estimates. We included 7 studies (n = 3734 participants): unselected general population [n = 1965], ischemic stroke [n = 849], hemorrhagic stroke [n = 252] and patients with hypertension over the age of 60 [n = 668]. Statin use was not associated with CMBs presence in either unadjusted (OR = 1.15, 95%CI: 0.76-1.74) or adjusted analyses (OR = 1.09, 95%CI: 0.64-1.86). Statin use was more strongly related to lobar CMB presence (OR = 2.01, 95%CI: 1.48-2.72) in unadjusted analysis. The effect size of this association was consistent, but no longer statistically significant in adjusted analysis that was confined to two eligible studies (OR = 2.26, 95%CI: 0.86-5.91). Except for the analysis on the unadjusted probability of lobar CMBs presence, considerable heterogeneity was present in all other analyses (I² > 60%). Our findings suggest that statin treatment seems not to be associated with CMBs overall, but may increase the risk of lobar CMB formation. This hypothesis deserves further investigation within magnetic resonance imaging ancillary studies of randomized trials.

Association Between Non-high-density Lipoprotein Cholesterol and 3-Month Prognosis in Patients With Spontaneous Intracerebral Hemorrhage

Background: Previous studies have indicated a significant correlation between cholesterol levels and the incidence and outcomes of intracerebral hemorrhage (ICH), However, the association between non-high-density lipoprotein cholesterol (non-HDLC) levels and ICH functional outcomes are still unclear.

Method: We included 654 consecutive spontaneous ICH patients who were enrolled in a prospective registry. We collected clinical, demographic, and laboratory data using standardized forms, and non-HDLC levels and 3-month modified Rankin Scale (mRS) scores were recorded. We performed multivariate logistic regression and interaction analyses to explored the association between non-HDLC levels and ICH functional outcomes.

Results: Of 654 patients included in the study, 281 (42.9%) had poor functional outcome. Univariate analysis showed that high non-HDLC level was associated with good functional outcome at 90 days (p = 0.001). After adjustment for confounding factors, a high non-HDLC level (≥154.89 mg/dl) remained as an indicator of good functional outcome at 90 days [multivariate-adjusted odds ratios (OR) 0.50, 95%CI 0.27–0.92; p-value for trend = 0.043], and was stronger for female patients (OR: 0.13, 95%CI: 0.03–0.50).

Conclusion: ICH patients with higher non-HDLC levels had a decreased prevalence of poor functional outcome at 90 days, and a high non-HDLC level is an independent indicator of good functional outcome at 90 days from onset, especially in females.

Cerebral microbleeds are associated with blood pressure levels in individuals with hypertension

Objective: Cerebral microbleeds (CMBs), which appear as small dot-like hypointense lesions, are strongly associated with cerebrovascular disease. Recently, numerous investigations have suggested that hypertension and age are risk factors for CMBs; however, whether blood pressure grade and age rank are related to the severity of CMBs remains unclear. The purpose of this research was to assess the association between cerebral microbleeds and blood pressure levels.Methods: In total, 460 consecutive hypertension patients (214 males and 246 females; aged 44-96 years, mean age 60.95 ± 6.82 years) from Lishui Central Hospital were enrolled and classified as CMB or non-CMB patients according to magnetic resonance imaging (MRI). Gradient echo T2*-weighted MRI was used to detect CMBs. Differences in blood pressure, CMB severity, and other patient characteristics were compared between the two groups. Multifactorial logistic regression was used to analyze the correlation between blood pressure and microbleeds.Results: In our study, CMB lesions were identified in 123 patients (26.7%), including 39 patients with CMB lesions located deep in the brain. In the hypertensive population, smoking is an independent risk factor for CMBs. Additionally, systolic blood pressure (SBP), diastolic blood pressure (DBP) and age are also independent risk factors for CMBs. Furthermore, a modest correlation was noted between the number of microbleeds and grade of hypertension.Conclusions: This study provides novel evidence that microbleed severity is associated with hypertension grade. This conclusion emphasizes the importance of antihypertensive therapy in hypertension patients to avoid an increase in CMBs.

Improved quantification of amyloid burden and associated biomarker cut-off points: results from the first amyloid Singaporean cohort with overlapping cerebrovascular disease

PURPOSE

The analysis of the [¹¹C]PiB-PET amyloid images of a unique Asian cohort of 186 participants featuring overlapping vascular diseases raised the question about the validity of current standards for amyloid quantification under abnormal conditions. In this work, we implemented a novel pipeline for improved amyloid PET quantification of this atypical cohort.

METHODS

The investigated data correction and amyloid quantification methods included motion correction, standardized uptake value ratio (SUVr) quantification using the parcellated MRI (standard method) and SUVr quantification without MRI. We introduced a novel amyloid analysis method yielding 2 biomarkers: Aβ_L which quantifies the global Aβ burden and ns that characterizes the non-specific uptake. Cut-off points were first determined using visual assessment as ground truth and then using unsupervised classification techniques.

RESULTS

Subject's motion impacts the accuracy of the measurement outcome but has however a limited effect on the visual rating and cut-off point determination. SUVr computation can be reliably performed for all the subjects without MRI parcellation while, when required, the parcellation failed or was of mediocre quality in 10% of the cases. The novel biomarker Aβ_L showed an association increase of 29.5% with the cognitive tests and increased effect size between positive and negative scans compared with SUVr. ns was found sensitive to cerebral microbleeds, white matter hyperintensity, volume, and age. The cut-off points for SUVr using parcellated MRI, SUVr without parcellation, and Aβ_L were 1.56, 1.39, and 25.5. Finally, k-means produced valid cut-off points without the requirement of visual assessment.

CONCLUSION

The optimal processing for the amyloid quantification of this atypical cohort allows the quantification of all the subjects, producing SUVr values and two novel biomarkers: Aβ_L, showing important increased in their association with various cognitive tests, and ns, a parameter sensitive to non-specific retention variations caused by age and cerebrovascular diseases.

Low-Density Lipoprotein Cholesterol and Risk of Hemorrhagic Stroke: a Systematic Review and Dose-Response Meta-analysis of Prospective Studies

PURPOSE OF REVIEW

To systematically examine the association between low-density lipoprotein cholesterol (LDL-C) and risk of hemorrhagic stroke.

RECENT FINDINGS

A previous meta-analysis of prospective studies published in 2013 showed that higher concentrations of LDL-C were associated with lower risk of hemorrhagic stroke. Recently, seven large cohort studies were published examining LDL-C and risk of hemorrhagic stroke in different populations. Twelve prospective studies with 476,173 participants and 7587 hemorrhagic stroke cases were included in the current meta-analysis. The results showed that a 10 mg/dL increase in LDL-C was associated with 3% lower risk of hemorrhagic stroke (pooled relative risk [RR] 0.97, 95% confidence interval [CI] 0.95-0.98). The association appeared to be more pronounced in Asians (pooled RR 0.95, 95% CI 0.92-0.98), relative to Caucasians (pooled RR 0.98, 95% CI 0.97-1.00), with a p heterogeneity of 0.05 between two ethnic groups. Further genetic studies and clinical trials with a stricter safety monitoring strategy are warranted to understand the underlying pathogenesis and determine the treatment target of LDL-C range with the lowest risk of hemorrhagic stroke in different population groups.

Low-density lipoprotein cholesterol and risk of intracerebral hemorrhage: A prospective study

OBJECTIVE

To prospectively examine the association between low-density lipoprotein (LDL) cholesterol (LDL-C) concentrations and intracerebral hemorrhage (ICH) risk.

METHODS

The current cohort study included 96,043 participants (mean age 51.3 years) who were free of stroke, myocardial infarction, and cancer at baseline (2006). Serum LDL-C concentrations were assessed in 2006, 2008, 2010, and 2012. Cumulative average LDL-C concentrations were calculated from all available LDL-C data during that period. Incident ICH was confirmed by review of medical records.

RESULTS

We identified 753 incident ICH cases during 9 years of follow-up. The ICH risk was similar among participants with LDL concentrations of 70 to 99 mg/dL and those with LDL-C concentrations ≥100 mg/dL. In contrast, participants with LDL-C concentrations <70 mg/dL had a significantly higher risk of developing ICH than those with LDL-C concentrations of 70 to 99 mg/dL; adjusted hazard ratios were 1.65 (95% confidence interval [CI] 1.32-2.05) for LDL-C concentrations of 50 to 69 mg/dL and 2.69 (95% CI 2.03-3.57) for LDL-C concentrations <50 mg/dL.

CONCLUSIONS

We observed a significant association between lower LDL-C and higher risk of ICH when LDL-C was <70 mg/dL, and the association became nonsignificant when LDL-C ≥70 mg/dL. These data can help determination of the ideal LDL range in patients who are at increased risk of both atherosclerotic disease and hemorrhagic stroke and guide planning of future lipid-lowering studies.

Cerebral microbleeds in patients with ischemic cerebrovascular disease taking aspirin or clopidogrel

Cerebral microbleeds (CMBs) may be markers of intracerebral bleeding risk in patients receiving antithrombotic drugs. This study aimed to analyze CMBs and white matter hyperintensities (WMHs) in patients taking aspirin or clopidogrel.This retrospective study included patients with ischemic cardiovascular disease administered 75 mg/day aspirin (n = 150) or clopidogrel (n = 150, matched for age and gender) for >1 year (Affiliated Hospital of Inner Mongolia Medical University, China, from July, 2010 to July, 2015). Patients underwent T2-weighted imaging, T1-weighted imaging, diffusion-weighted imaging (DWI) and enhanced T2*-weighted angiography (ESWAN) imaging (3.0-Tesla scanner). Baseline vascular risk factors for CMBs and macroscopic bleeding (MB) were evaluated using univariate and multivariate analyses.The aspirin and clopidogrel groups did not differ significantly in baseline characteristics or prevalences of CMBs or MB. The odds of MB were higher in patients with CMBs than in patients without CMBs in both the aspirin (odds ratio, 95% confidence interval: 4.09, 1.93-8.68; P < .001) and clopidogrel (6.42, 2.83-14.57; P < .001) groups. The odds of WMHs were also higher in patients with CMBs in both the aspirin (3.28, 1.60-6.71; P = .001) and clopidogrel (4.09, 1.91-8.75; P < .001) groups. Patients receiving treatment for >5 years showed elevated risk of CMBs in the aspirin (0.17; 0.09-0.36; P < .001) and clopidogrel (0.15, 0.07-0.33; P < .001) groups as well as higher odds of MB in the aspirin (0.34, 0.16-0.71; P = .004) and clopidogrel (0.37, 0.17-0.80; P = .010) groups.The WMHs and MB were associated with CMBs in patients taking aspirin or clopidogrel for >1 year, and long-term use increased the risks of CMB and bleeding.

Clinical Characteristics of Borderzone Infarction in Egyptian Population

OBJECTIVES

In this research we wanted to highlight the importance of defining Borderzone infarctions (BZI) as a separate subtype in stroke classifications. We thus studied cases of isolated BZI, small vessel disease (SVD), and large vessel disease (LVD), to identify their points of similarities and difference in a sample of Egyptian patients.

METHODS

This is a cross-sectional (observational) study. Consecutive 637 acute ischemic stroke patients were recruited over a 2 year period, from 2 stroke units of Ain Shams University hospitals in Egypt. Medical history and laboratory investigations were done to identify risk factors. National Institute of Health Stroke Scale (NIHSS) was performed on admission, and modified Rankin scale (mRS) on admission, and after 3 months. MRI brain was done to identify stroke subtype; MRA and carotid duplex were used to define vascular status.

RESULTS

Among the studied group of patients, 72 (11.3%) had BZI, 145 (22.8%) had SVD, 165 (26%) had LVD, and 255 were excluded as they had either undetermined, or mixed etiology. BZI showed significantly older age, early confluent lesions, more disease severity by NIHSS, and worst outcome by mRS (P < 0.05). SVD had more microbleeds than BZI and LVD. LVD showed lower prevalence of hypertension and lower high-density lipoprotein levels.

CONCLUSIONS

Isolated BZI, SVD, and LVD infarctions have characteristic risk factors and clinical patterns. Further studies are needed to identify if they are different from cases with mixed pathology. This could have an impact on the selection of primary and secondary preventive measures appropriate to each type.

Low-density lipoprotein level on admission is not associated with postintravenous thrombolysis intracranial hemorrhage in patients with acute ischemic stroke

Intravenous thrombolysis with the tissue plasminogen activator (tPA) is the gold standard for acute ischemic stroke. However, its application is limited because of the concern of the post-tPA intracranial hemorrhage (ICH). Low low-density lipoprotein (LDL) has been speculated to increase the risk of hemorrhagic transformation after ischemic stroke. However, whether LDL is associated with post-tPA ICH remains controversial. The present study obtained the medical records from Shuang Ho Hospital and retrospectively reviewed for the period between August 2009 and December 2016 to investigate the association between LDL and the risk of post-tPA ICH. The differences were analyzed using the Student's t-test, Fisher's exact test, the univariate and stepwise multiple regression model, and p<0.05 was considered statistically significant. Among 218 patients, post-tPA ICH was noted in 23 (10.5%) patients. Patients with post-tPA ICH tended to have a lower LDL level (ICH group: 102.00±24.56, non-ICH group: 117.02±37.60 mg/dL, p=0.063). However, after adjustment for the factors might affect the risk of post-tPA ICH, such as stroke severity, onset-to-treatment time interval, and atrial fibrillation (AF), LDL level was not associated with post-tPA ICH whereas AF was the only significant factor increased the risk of post-tPA ICH (adjusted OR: 1.177, 95% CI 1.080 to 1.283). In addition, patients with AF had significant lower LDL level and for patients without AF, LDL was not associated with the post-tPA ICH. In conclusion, LDL level is not associated with the risk of post-tPA ICH in Taiwanese patients with stroke.

Cerebral Microbleeds in an Acute Ischemic Stroke as a Predictor of Hemorrhagic Transformation

Background

Cerebral microbleeds are small, round hypointensities of <10 mm in diameter, evident on T2* gradient-recall echo (GRE) or susceptibility-weighted (SWI) magnetic resonance imaging (MRI) sequences.

Objective

In this study, our objective was to determine the number and location of cerebral microbleeds in ischemic stroke and to identify the predictive role of microbleeds for hemorrhagic transformation.

Materials and methods

This was a retrospective cohort study. Microbleeds were visually rated on SWI scans of patients who presented with an ischemic stroke and had an SWI scan within 24 hours of onset and a computed tomography (CT)/MRI scan during follow up. Microbleeds were graded as Grades I-IV.

Results

Out of 575 stroke patients, 121 did not have an SWI scan and 336 had no follow-up scan. A total of 118 patients were included for a final analysis (75 males, 43 females) out of which 30 had a hemorrhagic transformation. Most microbleeds were in the parietal region (n=46) with 50% transformation (p-value <0.001). The size and grade of microbleeds had a statistical association with hemorrhagic transformation with p-value 0.001 and p-value <0.001, respectively; 33% of patients with Grade 3 microbleeds aging 55-65 years had transformations. Of the patients, 93.3% with Grade 4 microbleeds had a hemorrhagic transformation. 30% of transformations were detected in the first 24 hours while 30% were detected during the first week. Age, gender, comorbidity, and anticoagulant use had no statistical association of conversion of microbleeds into hemorrhagic transformation.

Conclusion

Microbleeds detected on an SWI scan is a relevant and accurate predictor of hemorrhagic transformations in acute ischemic infarcts and should be added to MRI stroke protocols.

Hypertriglyceridemia Is Associated with Reduced Leukoaraiosis Severity in Patients with a Small Vessel Stroke

Intracranial hemorrhage or microbleeds and leukoaraiosis have an overlap in biology. Hyperlipidemia may reduce the risk of ICH or cerebral microbleeds; studies focusing on the relationship between different lipid profiles and severity of periventricular hyperintensities (PVH) and subcortical white matter lesions (SWMLs) in the cerebral small vessel disease are limited. Methods. Patients with recent first lacunar infarct were recruited. PVH and SWMLs were accessed on MRI with the Fazekas scale, and lipid levels were measured. Univariate and multivariable regression analyses were used to assess the relation between different lipid profiles and severity of PVH and SWMLs. Results. In univariate analyses, advancing age was correlated with increasing severity of leukoaraiosis (P < 0.001). There was an inverse relationship between hypertriglyceridemia (hyper-TG) (≥1.7 mmol/l) and severity of leukoaraiosis (P < 0.05). In the multivariable analysis, after controlling for age, sex, and significant risk factors in the univariate and age-adjusted analyses, hyper-TG demonstrated a protective effect on the severity of PVH and SWMLs (P < 0.05). Higher total cholesterol (TC), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) were not associated with leukoaraiosis. Conclusions. Hyper-TG is associated with the severity of leukoaraiosis independent of other risk factors, and it might be a protective role in cerebral small vessel disease.

Statins do not increase Markers of Cerebral Angiopathies in patients with Cardioembolic Stroke

We investigated whether pre-treatment with statins is associated with surrogate markers of amyloid and hypertensive angiopathies in patients who need to start long-term oral anticoagulation therapy. A prospective multicenter study of patients naive for oral anticoagulants, who had an acute cardioembolic stroke. MRI was performed at admission to evaluate microbleeds, leukoaraiosis and superficial siderosis. We collected data on the specific statin compound, the dose and the statin intensity. We performed bivariate analyses and a logistic regression to investigate variables associated with microbleeds. We studied 470 patients (age 77.5 ± 6.4 years, 43.7% were men), and 193 (41.1%) of them received prior treatment with a statin. Microbleeds were detected in 140 (29.8%), leukoaraiosis in 388 (82.5%) and superficial siderosis in 20 (4.3%) patients. The presence of microbleeds, leukoaraiosis or superficial siderosis was not related to pre-treatment with statins. Microbleeds were more frequent in patients with prior intracerebral hemorrhage (OR 9.7, 95% CI 1.06–90.9) and in those pre-treated antiplatelets (OR 1.66, 95% CI 1.09–2.53). Prior treatment with statins was not associated with markers of bleeding-prone cerebral angiopathies in patients with cardioembolic stroke. Therefore, previous statin treatment should not influence the decision to initiate or withhold oral anticoagulation if these neuroimaging markers are detected.

Correlation between antiplatelet therapy in secondary prevention of acute cerebral infarction and cerebral microbleeds: A susceptibility-weighted imaging (SWI) study

OBJECTIVE

To investigate the clinical significance of antiplatelet aggregation therapy for patients diagnosed with acute cerebral infarction (ACI) complicated with the cerebral microbleeds (CMBs).

METHODS

Thirty patients with ACI and 36 patients with intracerebral hemorrhage (ICH) were included in this research. Two groups, studied by susceptibility-weighted imaging (SWI), were compared in terms of the number, location, and severity of CMBs. Then, 30 cases of ACI patients were divided into CMBs sub-group and non-CMBs sub-group. Univariate analysis between these two sub-groups was performed to determine the risk factors regarding the incidence of CMBs. For ACI patients, the number of CMBs before and after applying anti-platelet treatment were compared to examine the impacts of anti-platelet treatment on hemorrhagic transformation.

RESULTS

CMBs were found to be more prevalent and severe in ICH patients than in ACI patients. CMBs in patients with ICH were more severe than in patients with ischemic stroke (IS), which indicates that CMBs closely relate to ICH. Hypertension and leukoaraiosis were found to have significant effects on the incidence of CMBs. After anti-platelet treatment, patients with CMBs (≥5) increased the number of CMB, whereas there was no obvious effect on patients with the CMBs less than 5 or no CMBs.

CONCLUSIONS

The number of CMBs increased significantly among ACI patients with 5 or more CMBs before the anti-platelet treatment. CMBs are more frequently found in patients with hemorrhagic stroke than in patients with ischemic stroke, and more severe than the latter, which suggests that the clinical impact of higher association between the increase of the number of the CMBs and the hemorrhagic stroke.

Higher low-density lipoprotein cholesterol levels are associated with decreased mortality in patients with intracerebral hemorrhage

BACKGROUND AND AIMS

The relationship between lipoprotein levels, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and clinical outcome after intracerebral hemorrhage (ICH) remains controversial. We sought to evaluate the association of lipoprotein cholesterol levels and statin dosage with clinical and neuroimaging outcomes in patients with ICH.

METHODS

Data on consecutive patients hospitalized with spontaneous acute ICH was prospectively collected over a 5-year period and retrospectively analyzed. Demographic characteristics, clinical severity documented by NIHSS-score and ICH-score, neuroimaging parameters, pre-hospital statin use and doses, and LDL-C and HDL-C levels were recorded. Outcome events characterized were hematoma volume, hematoma expansion, in-hospital functional outcome, and in-hospital mortality.

RESULTS

A total of 672 patients with acute ICH [(mean age 61.6 ± 14.0 years, 43.6% women, median ICH score 1 (IQR: 0-2)] were evaluated. Statin pretreatment was not associated with neuroimaging or clinical outcomes. Higher LDL-C levels were associated with several markers of poor clinical outcome and in-hospital mortality. LDL-C levels were independently and negatively associated with the cubed root of hematoma volume (linear regression coefficient -0.021, 95% CI: -0.042--0.001; p = 0.049) on multiple linear regression models. Higher admission LDL-C (OR 0.88, 95% CI 0.77-0.99; p = 0.048) was also an independent predictor for decreased hematoma expansion. Higher admission LDL-C levels were independently (p < 0.001) associated with lower likelihood of in-hospital mortality (OR per 10 mg/dL increase 0.68, 95% CI: 0.57-0.80) in multivariable logistic regression models.

CONCLUSIONS

Higher LDL-C levels at hospital admission were an independent predictor for lower likelihood of hematoma expansion and decreased in-hospital mortality in patients with acute spontaneous ICH. This association requires independent confirmation.

Serum Lipid Fractions and Cerebral Microbleeds in a Healthy Japanese Population

Background: Cerebral microbleeds (CMBs) are associated with focal hemosiderin deposits and represent a form of cerebral small vessel disease. To date, indefinite and inconsistent reports are available regarding the association between serum lipid fractions and CMBs. In addition, these previous studies did not include Asian populations, who may have a higher risk of cerebral hemorrhage. The purpose of this study was to examine the associations between serum lipid fractions and CMBs in healthy Japanese subjects. Methods: We performed a cross-sectional study involving 4,024 neurologically normal Japanese subjects (mean age 61.6 years). All the participants underwent 1.5-Tesla magnetic resonance imaging scan, and CMBs were classified into 3 groups based on their locations. The concentrations of lipid fractions were categorized into quartiles and the association between the lipid fractions and CMBs were investigated using logistic regression analysis. Results: CMBs were observed in 164 (4.1%) of participants. Of these participants with CMBs, 33 (20.1%) had lobar CMBs and 91 (55.5%) had deep CMBs. Subjects with deep CMBs had lower total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C) levels. After adjusting for confounding factors, lower TC and HDL-C levels were still associated with the presence of deep CMBs (OR for the highest vs. the lowest quartiles of TC and HDL-C was 2.28 [95% CI 1.05-4.94], and 1.93 [95% CI 1.02-3.65], respectively). The presence of subcortical infarcts and periventricular hyperintensities was more frequently observed in deep CMBs, whereas white matter hyperintensities were more frequently observed in lobar CMBs. Conclusions: Our results suggest that low serum TC and HDL-C levels are closely associated with deep CMBs.

Interaction of incidental microbleeds and prior use of antithrombotics with early hemorrhagic transformation: Causative or protective?

BACKGROUND

Gradient echo (GRE) sequence of magnetic resonance imaging (MRI) is a sensitive tool to detect hemorrhagic transformation (HT) and old cerebral microbleeds (CMBs). Presence of CMBs and prior use of antithrombotics pose a risk of HT in ischemic stroke. We evaluated the association of CMBs and antithrombotic use with resultant HT in acute ischemic stroke (AIS).

METHODS

This retrospective study included AIS patients admitted to our center between January 2009 and August 2010 who underwent GRE-weighted MRI within 48 h of admission. Demographic and clinical data including diabetes mellitus, hypertension, hyperlipidemia, prior intake of antiplatelets/anticoagulants/statins, and presence of CMBs at admission were collected and compared between patients who developed HT and those who did not. We did a multivariate analysis using logistic regression to assess the effect of CMBs and prior use of antithrombotic agents on the risk of development for early HT in ischemic stroke.

RESULTS

Of 529 AIS patients, 81 (15%) were found to have HT during the initial hospital course. CMBs were found in only 9 of 81 patients (11%) with HT and in 40 out of remaining 448 patients (9%) who did not develop HT. The presence of CMBs was not associated with increased risk of HT (P = 0.53). However, prior use of antiplatelets (33% vs. 47% in the patients without HT, P = 0.02) was associated with decreased risk of HT in ischemic stroke.

CONCLUSION

Presence of incidental CMBs was not associated with increased risk for early HT of an ischemic stroke. Interestingly, the prior intake of antiplatelets was found to be protective against HT of ischemic stroke.

Endothelial Nitric Oxide Synthase (-786T>C) and Endothelin-1 (5665G>T) Gene Polymorphisms as Vascular Dysfunction Risk Factors in Sickle Cell Anemia

Sickle cell anemia (SCA) patients have vascular complications, and polymorphisms in endothelin-1 (ET-1) and endothelial nitric oxide synthase (eNOS) genes were associated with ET-1 and nitric oxide disturbance. We investigate the association of ET-1 5665G>T and eNOS −786T>C polymorphisms with soluble adhesion molecules (sVCAM-1 and sICAM-1), biochemical markers, and medical history. We studied 101 SCA patients; carriers of eNOS minor allele (C) had the highest levels of sVCAM-1, and carriers of ET-1 minor allele had more occurrence of acute chest syndrome (ACS). The multivariate analysis suggested the influence of the ET-1 gene on ACS outcome and an association of the eNOS gene with upper respiratory tract infection. We suggest that eNOS and ET-1 gene polymorphisms can influence SCA pathophysiology and that eNOS variant in SCA patients might be important to nitric oxide activity and vascular alteration. We found an association of the ET-1 minor allele in ACS, showing the importance of genetic screening in SCA.

Management of intracerebral hemorrhage--use of statins

Intracerebral hemorrhage (ICH) is a neurologic injury resulting in significant morbidity and mortality. Statins play a significant role in primary and secondary prevention of cardiovascular and cerebrovascular ischemic events. Despite clear benefits of statins in ischemic stroke, post hoc analyses of some studies suggest there may be a link between statin therapy and development of ICH. Direct pharmacologic effects of decreased serum levels of total cholesterol and low-density lipoproteins in conjunction with pleiotropic effects are thought to be linked to this possible increase in ICH risk. In the face of the potential of statins to increase the risk of ICH, recent evidence suggests that statins may also have beneficial effects on patient outcomes when continued or initiated following an ICH. This discordance in findings and the overall lack of well-designed prospective clinical trials increase the complexity of clinical decision making when utilizing statin therapy in patients with, or at risk for, ICH. This review evaluates the pharmacologic effects of statin therapy and describes how these effects translate to both risks and benefits in ICH. The current literature regarding the effects of statin therapy on clinical outcomes in ICH is evaluated to help guide clinicians with decisions regarding initiation, continuation, or discontinuation of statin therapy in patients with ICH.

Statins in Intracerebral Hemorrhage

While statins play an indisputable role in primary and secondary prevention of ischemic cardiovascular and cerebrovascular disease, a concern exists regarding a possible association between low lipoprotein levels and statin use on the risk of intracerebral hemorrhage (ICH). While these data may incline physicians to discontinue statins after ICH, an increasing amount of preclinical and clinical evidence suggests that statins might have a beneficial effect on outcome and recovery in this context that goes beyond lipid lowering effects. Different etiologies of ICH and the related risk of recurrence should also be taken into account when deciding about statin use/avoidance in patients with high risk of ICH. The problem is compounded by paucity of data from randomized controlled trials and well-designed prospective observational studies. This review will discuss the existing evidence on potential interactions between statins and risk of ICH as well as outcomes in order to provide practical recommendations for clinical decision-making.

Predictors of New Cerebral Microbleeds in Patients with Antiplatelet Drug Therapy

BACKGROUND

Cerebral microbleeds (CMB) are associated with an increased risk for ischemic and especially hemorrhagic stroke. The aim of the present study is to identify patients at high risk for the development of new CMB after initiation of an antiplatelet drug therapy.

METHODS

Patients received magnetic resonance imaging (MRI) within 1 week after initiation of an antiplatelet drug treatment due to a first ischemic stroke (n = 58) and after a follow-up period of 6 months (n = 40). We documented the presence and the number of CMB at baseline and follow-up and analyzed the influence of possible risk factors including vascular risk factors, stroke etiology, and number of CMB at baseline using stepwise logistic regression and Spearman's correlation coefficient. We compared progression rates of CMB in relation to each risk factor using the Mann-Whitney U-test.

RESULTS

The logistic regression model could correctly predict the presence of CMB in 70.7% of patients at baseline and 80% at follow-up. The model correctly identified 85% of patients with new CMB. We observed progression of CMB in 40% of the patients. The overall progression rate was .8 CMB per patient. The progression rate was significantly influenced by age more than 70 years and atherothrombotic stroke. The number of new CMB correlated significantly with the number of CMB at baseline.

CONCLUSIONS

We found several predictors of CMB after initiation of antiplatelet drug therapy. The results help to identify patients who need closer monitoring and thorough control of risk factors in order to lower the risk of new CMB and associated complications.

Lipid Control and Beyond: Current and Future Indications for Statin Therapy in Stroke

OPINION STATEMENT

Statins are a group of lipid-lowering agents that are competitive inhibitors of the enzyme 3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase that have been used to reduce cholesterol levels and prevent cardiovascular events. Statins have been also shown to reduce the risk of stroke. In this review, we cover the role of statins in cerebrovascular disease through lipid-lowering mechanisms and other "pleiotropic" effects that provide protection against cerebrovascular events and potentially contribute to improve functional outcome after stroke.

Genetic loci for serum lipid fractions and intracerebral hemorrhage

BACKGROUND

Serum total cholesterol and its fractions are inversely associated with intracerebral hemorrhages (ICH) and their potential subclinical precursor, cerebral microbleeds. To ascertain whether there is a genetic basis for this inverse association, we studied established genetic loci for serum total, LDL, and HDL cholesterol, and triglycerides in their association with ICH and microbleeds.

METHODS

Data on 161 genetic variants for serum lipids was collected in 9011 stroke-free participants (mean age 65.8, SD 10.2; 57.9% women) of the population-based Rotterdam Study. Participants were followed from baseline (1997-2005) up to 2013 for the occurrence of ICH. A subset of 4179 participants underwent brain MRI for microbleed assessment between 2005 and 2011. We computed genetic risk scores (GRS) for the joint effect of lipid variants. Cox proportional hazards and logistic regression models were used to investigate the association of GRS of lipid fractions with ICH and microbleeds.

RESULTS

After a mean follow-up of 8.7 (SD 4.1) years, 67 (0.7%) participants suffered an ICH. Microbleed prevalence was 19.6%. Higher genetic load for high serum total and LDL cholesterol was associated with an increased risk of ICH. Higher genetic load for high serum LDL cholesterol was borderline associated with a higher prevalence of multiple lobar microbleeds.

CONCLUSIONS

Genetic susceptibility for high serum total and LDL cholesterol is positively associated with incident ICH and borderline associated with multiple lobar microbleeds. We did not find a genetic basis for the previously reported inverse association between serum lipid levels and ICH.

Silent New Brain Lesions: Innocent Bystander or Guilty Party?

With the advances in magnetic resonance imaging, previously unrecognized small brain lesions, which are mostly asymptomatic, have been increasingly detected. Diffusion-weighted imaging can identify small ischemic strokes, while gradient echo T2* imaging and susceptibility-weighted imaging can reveal tiny hemorrhagic strokes (microbleeds). In this article, we review silent brain lesions appearing soon after acute stroke events, including silent new ischemic lesions and microbleeds appearing 1) after acute ischemic stroke and 2) after acute intracerebral hemorrhage. Moreover, we briefly discuss the clinical implications of these silent new brain lesions.

Risk Factors Associated With Incident Cerebral Microbleeds According to Location in Older People: The Age, Gene/Environment Susceptibility (AGES)-Reykjavik Study

IMPORTANCE

The spatial distribution of cerebral microbleeds (CMBs), which are asymptomatic precursors of intracerebral hemorrhage, reflects specific underlying microvascular abnormalities of cerebral amyloid angiopathy (lobar structures) and hypertensive vasculopathy (deep brain structures). Relatively little is known about the occurrence of and modifiable risk factors for developing CMBs, especially in a lobar location, in the general population of older people.

OBJECTIVE

To investigate whether lifestyle and lipid factors predict new CMBs in relation to their anatomic location.

DESIGN, SETTING, AND PARTICIPANTS

We enrolled 2635 individuals aged 66 to 93 years from the population-based Age, Gene/Environment Susceptibility (AGES)-Reykjavik Study in a brain imaging study. Participants underwent a baseline magnetic resonance imaging (MRI) examination of the brain from September 1, 2002, through February 28, 2006, and returned for a second MRI examination from April 1, 2007, through September 30, 2011.

EXPOSURES

Lifestyle and lipid factors assessed at baseline included smoking, alcohol consumption, body mass index, and serum levels of total cholesterol, high- and low-density lipoprotein cholesterol, and triglycerides.

MAIN OUTCOMES AND MEASURES

Incident CMBs detected on MRIs, which were further categorized as exclusively lobar or as deep.

RESULTS

During a mean follow-up of 5.2 years, 486 people (18.4%) developed new CMBs, of whom 308 had lobar CMBs only and 178 had deep CMBs. In the multivariate logarithm-binomial regression model adjusted for baseline cardiovascular risk factors, including blood pressure, antihypertensive use, prevalent CMBs, and markers of cerebral ischemic small-vessel disease, heavy alcohol consumption (vs light to moderate consumption; relative risk [RR], 2.94 [95% CI, 1.23-7.01]) was associated with incident CMBs in a deep location. Baseline underweight (vs normal weight; RR, 2.41 [95% CI, 1.21-4.80]), current smoking (RR, 1.47 [95% CI, 1.11-1.94]), an elevated serum level of high-density lipoprotein cholesterol (RR per 1-SD increase, 1.13 [95% CI, 1.02-1.25]), and a decreased triglyceride level (RR per 1-SD decrease in natural logarithm-transformed triglyceride level, 1.17 [95% CI, 1.03-1.33]) were significantly associated with an increased risk for lobar CMBs exclusively but not for deep CMBs.

CONCLUSIONS AND RELEVANCE

Lifestyle and lipid risk profiles for CMBs were similar to those for symptomatic intracerebral hemorrhage and differed for lobar and deep CMBs. Modification of these risk factors could have the potential to prevent new-onset CMBs, particularly those occurring in a lobar location.

Prevention and Management of Cerebral Small Vessel Disease

Lacunar infarcts/lacunes, white matter hyperintensities (WMH), and cerebral microbleeds (CMBs) are considered various manifestations of cerebral small vessel disease (SVD). Since the exact mechanisms of these manifestations differ, their associated risk factors differ. High blood pressure is the most consistent risk factor for all of these manifestations. However, a "J curve" phenomenon in terms of blood pressure probably exists for WMH. The association between cholesterol levels and lacunar infarcts/lacunes or WMH was less consistent and sometimes conflicting; a low cholesterol level probably increases the risk of CMBs. Homocysteinemia appears to be associated with WMH. It is noteworthy that the risk factors profile may also differ between different lacunar patterns and CMBs located at different parts of the brain. Thrombolysis, antihypertensives, and statins are used to treat patients with symptomatic lacunar infarction, just as in those with other stroke subtypes. However, it should be remembered that bleeding risks increase in patients with extensive WMH and CMBs after thrombolysis therapy. According to the Secondary Prevention of Small Subcortical Strokes trial results, a blood pressure reduction to <130 mmHg is recommended in patients with symptomatic lacunar infarction. However, an excessive blood pressure decrease may induce cognitive decline in older patients with extensive WMH. Dual antiplatelet therapy (aspirin plus clopidogrel) should be avoided because of the excessive risk of intracerebral hemorrhage. Although no particular antiplatelet is recommended, drugs such as cilostazol or triflusal may have advantages for patients with SVD since they are associated with less frequent bleeding complications than aspirin.

Clinical associations of cerebral microbleeds on magnetic resonance neuroimaging

Susceptibility-weighted and gradient-recalled echo T2* magnetic resonance imaging have enabled the detection of very small foci of blood within the brain, which have been termed "cerebral microbleeds." These petechial intraparenchymal hemorrhages have begun to emerge as diagnostically and prognostically useful markers in a variety of disease states. Severe hypertension and cerebral amyloid angiopathy are perhaps the best established microhemorrhagic conditions from neuroimaging literature; however, many others are also recognized including cerebral autosomal dominant arteriopathy, subcortical infarcts, and leukoencephalopathy (CADASIL), moyamoya disease, fat embolism, cerebral malaria, and infective endocarditis. Microbleeds are also a common finding in the setting of trauma and stroke. The purpose of this review is to broadly describe the neuroimaging of cerebral microbleeds in a wide variety of conditions, including the differences in their appearance and distribution in different disease states. In a few situations, the presence of microbleeds may influence clinical management, and we discuss these situations in detail. The major importance of this emerging field in neuroimaging is the potential to identify microvascular pathology at an asymptomatic or minimally symptomatic stage and create a window of therapeutic opportunity.

Regarding long-term statin therapy: are we trading stronger hearts for weaker brains?

Ideally, the benefits of long-term statin therapy should outweigh the risks in all populations. However, some data suggest that long-term statin therapy might promote cerebral small vessel disease and impair myelination, perhaps resulting from cholesterol depletion and pleiotropic effects on amyloid-β metabolism and oligodendrocyte function. The clinical ramifications can be problematic and have a negative impact on the quality of life. Questions are proposed and the answers should be found by analysis of randomized prospective trials specifically investigating the effects of statin therapy on brain structure and function. Those trials should not be funded by drug companies and the investigators should not have financial ties to the pharmaceutical industry. The relevance of the aforementioned is amplified in light of the new cardiovascular guidelines that might culminate in more than a billion people receiving statin therapy worldwide.

New oral anticoagulants may be particularly useful for asian stroke patients

Atrial fibrillation (AF) is an emerging epidemic in both high-income and low-income countries, mainly because of global population aging. Stroke is a major complication of AF, and AF-related ischemic stroke is more disabling and more fatal than other types of ischemic stroke. However, because of concerns about bleeding complications, particularly intracranial hemorrhage, and the limitations of a narrow therapeutic window, warfarin is underused. Four large phase III randomized controlled trials in patients with non-valvular AF (RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE-AF-TIMI 48) demonstrated that new oral anticoagulants (NOACs) are superior or non-inferior to warfarin as regards their efficacy in preventing ischemic stroke and systemic embolism, and superior to warfarin in terms of intracranial hemorrhage. Among AF patients receiving warfarin, Asians compared to non-Asians are at higher risk of stroke or systemic embolism and are also more prone to develop major bleeding complications, including intracranial hemorrhage. The extra benefit offered by NOACs over warfarin appears to be greater in Asians than in non-Asians. In addition, Asians are less compliant, partly because of the frequent use of herbal remedies. Therefore, NOACs compared to warfarin may be safer and more useful in Asians than in non-Asians, especially in stroke patients. Although the use of NOACs in AF patients is rapidly increasing, guidelines for the insurance reimbursement of NOACs have not been resolved, partly because of insufficient understanding of the benefit of NOACs and partly because of cost concerns. The cost-effectiveness of NOACs has been well demonstrated in the healthcare settings of developed countries, and its magnitude would vary depending on population characteristics as well as treatment cost. Therefore, academic societies and regulatory authorities should work together to formulate a scientific healthcare policy that will effectively reduce the burden of AF-related stroke in this rapidly aging society.