Incidence of silent lacunar lesion in normal adults and its relation to cerebral blood flow and risk factors

Clinical characteristics of elderly hip fracture patients with chronic cerebrovascular disease and construction of a clinical predictive model for perioperative pneumonia

INTRODUCTION

The recovery of cerebrovascular disease (CVD) will increase the incidence of perioperative pneumonia (POP). However, there is limited research on POP in elderly patients with hip fractures complicated by CVD. Therefore, our research focuses on the following two issues: (1) What are the clinical features of elderly patients with hip fractures combined with CVD? (2) What are the predictive factors for the occurrence of POP in such patients?

HYPOTHESIS

Male, femoral neck fracture and hypoalbuminemia can be predictive factors for the development of POP after hip fracture in CVD patients.

MATERIAL AND METHODS

This is a nested case-control study that included patients aged 65 to 105 years with CVD who had a hip fracture between January 2021 and January 2023. According to the occurrence of POP, they were divided into case group and control group. Collecting data includes demographic information, clinical data, and surgical information. Least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression analyses were used to select variables. The constructed predictive model was transformed into a nomogram. Predictive performance was assessed using the area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA).

RESULTS

We ultimately included 714 patients, 69.3% female, with a median age of 80 years. Asymptomatic cerebral infarction (ACI) is the most common CVD (55.7%). More patients developed intertrochanteric fractures than femoral neck fractures (57.1 vs. 42.9%). In total, 606 patients (84.9%) underwent surgery. The most common perioperative complications were anemia (76.9%) and hypoalbuminemia (71.8%). POP (20.0%) was more common preoperatively (89.5%). Factors such as fracture type, surgical wait time, implant used for surgery, and anesthesia type did not differ between the presence or absence of postoperative pneumonia. 143 patients with POP served as the case group. Five hundred and seventy one patients did not develop POP and served as the control group. The predictors of POP were male (OR 1.699,95%CI 1.150-2.511, p<0.05), femoral neck fracture (OR 2.182,95%CI 1.491-3.192, p<0.05), and hypoalbuminemia (OR 3.062, 95%CI 1.833-5.116, p<0.05). This model has good discrimination, calibration, and clinical practicality.

DISCUSSION

In this study, we constructed a clinical prediction model for the occurrence of POP in CVD combined with hip fracture in the elderly, with risk factors including gender, fracture type and perioperative hypoproteinemia. Therefore, we can take effective preventive measures against the occurrence of POP in patients with these factors in our clinical work.

LEVEL OF PROOF

IV; nested case-control study.

Management of covert brain infarction survey: A call to care for and trial this neglected population

BACKGROUND

Covert brain infarction (CBI) is highly prevalent and linked with stroke risk factors, increased mortality, and morbidity. Evidence to guide management is sparse. We sought to gain information on current practice and attitudes toward CBI and to compare differences in management according to CBI phenotype.

METHODS

We conducted a web-based, structured, international survey from November 2021 to February 2022 among neurologists and neuroradiologists. The survey captured respondents' baseline characteristics, general approach toward CBI and included two case scenarios designed to evaluate management decisions taken upon incidental detection of an embolic-phenotype and a small-vessel-disease phenotype.

RESULTS

Of 627 respondents (38% vascular neurologists, 24% general neurologists, and 26% neuroradiologists), 362 (58%) had a partial, and 305 (49%) a complete response. Most respondents were university hospital senior faculty members experienced in stroke, mostly from Europe and Asia. Only 66 (18%) of respondents had established institutional written protocols to manage CBI. The majority indicated that they were uncertain regarding useful investigations and further management of CBI patients (median 67 on a slider 0-100, 95% CI 35-81). Almost all respondents (97%) indicated that they would assess vascular risk factors. Although most would investigate and treat similarly to ischemic stroke for both phenotypes, including initiating antithrombotic treatment, there was considerable diagnostic and therapeutic heterogeneity. Less than half of respondents (42%) would assess cognitive function or depression.

CONCLUSIONS

There is a high degree of uncertainty and heterogeneity regarding management of two common types of CBI, even among experienced stroke physicians. Respondents were more proactive regarding the diagnostic and therapeutic management than the minimum recommended by current expert opinions. More data are required to guide management of CBI; meantime, more consistent approaches to identification and consistent application of current knowledge, that also consider cognition and mood, would be promising first steps to improve consistency of care.

Language patterns in Japanese patients with Alzheimer disease: A machine learning approach

AIM

The authors applied natural language processing and machine learning to explore the disease-related language patterns that warrant objective measures for assessing language ability in Japanese patients with Alzheimer disease (AD), while most previous studies have used large publicly available data sets in Euro-American languages.

METHODS

The authors obtained 276 speech samples from 42 patients with AD and 52 healthy controls, aged 50 years or older. A natural language processing library for Python was used, spaCy, with an add-on library, GiNZA, which is a Japanese parser based on Universal Dependencies designed to facilitate multilingual parser development. The authors used eXtreme Gradient Boosting for our classification algorithm. Each unit of part-of-speech and dependency was tagged and counted to create features such as tag-frequency and tag-to-tag transition-frequency. Each feature's importance was computed during the 100-fold repeated random subsampling validation and averaged.

RESULTS

The model resulted in an accuracy of 0.84 (SD = 0.06), and an area under the curve of 0.90 (SD = 0.03). Among the features that were important for such predictions, seven of the top 10 features were related to part-of-speech, while the remaining three were related to dependency. A box plot analysis demonstrated that the appearance rates of content words-related features were lower among the patients, whereas those with stagnation-related features were higher.

CONCLUSION

The current study demonstrated a promising level of accuracy for predicting AD and found the language patterns corresponding to the type of lexical-semantic decline known as 'empty speech', which is regarded as a characteristic of AD.

Relationship between obstructive sleep apnoea syndrome and silent brain infarction

BACKGROUND

The relationship between obstructive sleep apnea syndrome (OSAS) and ischaemic stroke is less known.

OBJECTIVES

This study aimed to investigate the relationship between OSAS and silent brain infarcts (SBI).

METHODS

Patients who applied to our clinic with the complaint of snoring, respiratory arrest during sleep, that underwent polysomnography were included. All patients were undergone cranial magnetic resonance imaging to detect SBI.

RESULTS

SBI was found in 176 (51.5%) of 270 patients in the group with OSAS and 94 (34.8%) patients without OSAS. The patients were evaluated according to their Apnea-Hypopnea Index(AHI) ratio, and those with were found to be significant in terms of SBI. SBI was detected in 56.56% in the moderate and severe (AHI ˃15) stage group and 39.94% in the normal and mild (AHI ≤15) OSAS group (p=0.009).

CONCLUSIONS

SBI was found to be significantly higher in patients with moderate and severe stage OSAS compared to the normal and mild OSAS group. Desaturations during sleep may influence the formation of these infarcts. Therefore, this study reported that patients with moderate and severe sleep apnea syndrome may have a higher risk of developing ischaemic cerebrovascular disease and that the treatment of these patients should be planned in this respect.

Risk assessment of lacunar infarct associated with oral conditions: A case control study focused on radiographic bone loss and Eichner classification

PURPOSE

This study aimed to evaluate whether lacunar infarcts can be predicted from occlusal support and periodontal stage on images.

METHODS

Seventy patients with lacunar infarcts and 300 participants without lacunar infarcts who underwent cerebral checkups at our university hospital were retrospectively reviewed. Lacunar infarcts were assessed using magnetic resonance images by a neuroradiologist. The number of teeth, occlusal support, and severity of radiographic bone loss (RBL) were evaluated using computed tomography. Occlusal support was classified according to the Eichner classification. Additionally, patient characteristics were investigated using medical charts and blood test reports. Records of clinical periodontal parameters, such as clinical attachment loss and bleeding on probing, were also evaluated.

RESULTS

The severity of RBL and Eichner classification in patients with lacunar infarcts was significantly higher than that in individuals without lacunar infarcts (P<.01). Receiver operating characteristic analysis revealed that the cut-off values for predicting lacunar infarct were ≥ III in the severity of RBL and ≥B1 in the Eichner classification. The corresponding areas under the curve were 0.75 and 0.70, respectively. In multivariate analysis, the factors affecting the severity of RBL (≥ III) (odds ratio [OR], 8.1; 95% confidence interval [CI], 4.1-16.3; P ‹.001), and Eichner classification ( ≥B1) (OR, 1.9; 95% CI, 0.86-4.1; P ‹.05) were significantly associated with the occurrence of lacun ar infarcts.

CONCLUSIONS

The severity of RBL and the Eichner classification may be helpful in predicting lacunar infarcts. Therefore, proper periodontal treatment and prosthodontic rehabilitation of missing teeth may prevent lacunar infarcts.

Relationship Between Olfactory Disturbance After Acute Ischemic Stroke and Latent Thalamic Hypoperfusion

Odor detection, recognition, and identification were assessed in 19 acute ischemic stroke patients who had no magnetic resonance imaging-detectable thalamic lesions but in whom technetium-99m ethyl cysteinate dimer single photon emission tomography revealed thalamic hypoperfusion. Although these patients were unaware of reduced olfactory function, they exhibited significantly lower scores in tests for odor identification and recognition threshold as compared with 9 ischemic stroke controls that had normal thalamic hypoperfusion. However, absolute odor detection thresholds were similar in the 2 groups. These results demonstrate the usefulness of cerebral perfusion scintigraphy in assessing sensory loss after ischemic stroke and provide further evidence for the role of the thalamus in olfaction.

Early detection of cognitive impairments with the Montreal Cognitive Assessment in patients with uncomplicated and complicated mild traumatic brain injury

OBJECTIVES

The Montreal Cognitive Assessement (MoCA) is a brief and standardized cognitive screening tool that has been used with several clinical populations. The aim of this study was to screen the early cognitive status of patients following mild traumatic brain injury (mTBI) with the MoCA.

METHODS

The MoCA was administered within the first 2 weeks post-injury to 42 patients with uncomplicated mTBI, 92 patients with complicated mTBI and 50 healthy controls.

RESULTS

Patients with complicated mTBI had a significantly lower performance (more impairments) on the total score of the MoCA than both the group with uncomplicated mTBI and the control group. Also, the group with uncomplicated mTBI had a significantly lower performance than controls. Moreover, age, education and TBI severity had a significant effect on the MoCA total score where younger, more educated and patients with less severe (higher GCS score) mTBI performed significantly better.

CONCLUSIONS

The MoCA may be clinically useful to acutely screen cognition following mTBI.

Prognostic Relationships between Microbleed, Lacunar Infarction, White Matter Lesion, and Renal Dysfunction in Acute Ischemic Stroke Survivors

BACKGROUND

It is well known that renal dysfunction and cerebral small-vessel disease (SVD), including microbleed, lacunar infarction, and white matter lesion (WML), are associated with poor prognosis after ischemic stroke. However, the prognostic relationship between renal dysfunction and SVD has not been well evaluated in acute ischemic stroke survivors. Therefore, in this study, we evaluated the prognostic relationships between estimated glomerular filtration rate (eGFR) and cerebral SVD after acute ischemic stroke.

METHODS

We retrospectively reviewed the clinical and radiological data of acute ischemic stroke survivors with decreased eGFR (<60 mL/min/1.73 m², n = 128) and controls (eGFR ≥60 mL/min/1.73 m², n = 128). The presence of SVD was evaluated according to magnetic resonance imaging performed on admission. Mortality data were obtained from medical chart reviews and telephone interviews.

RESULTS

Patients with silent lacunar infarction, WML, or microbleed had lower eGFR than patients without such lesions (60.4 ± 34.8 versus 87.5 ± 28.4 mL/min/1.73 m², 60.5 ± 37.1 versus 73.9 ± 33.3 mL/min/1.73 m², and 57.6 ± 33.3 versus 73.9 ± 32.9 mL/min/1.73 m², respectively). In addition, the multivariate adjusted odds ratio for the presence of SVD increased inversely with eGFR. Three-year survival was lower in patients with renal dysfunction and each type of SVD. The presence of WML was an independent risk factor for cardiovascular death.

CONCLUSIONS

Renal impairment was associated with the presence of SVD in acute ischemic stroke survivors. Both renal impairment and the presence of SVD were predictors of poor poststroke survival.

Cerebral blood flow in small vessel disease: A systematic review and meta-analysis

White matter hyperintensities are frequent on neuroimaging of older people and are a key feature of cerebral small vessel disease. They are commonly attributed to chronic hypoperfusion, although whether low cerebral blood flow is cause or effect is unclear. We systematically reviewed studies that assessed cerebral blood flow in small vessel disease patients, performed meta-analysis and sensitivity analysis of potential confounders. Thirty-eight studies (n = 4006) met the inclusion criteria, including four longitudinal and 34 cross-sectional studies. Most cerebral blood flow data were from grey matter. Twenty-four cross-sectional studies (n = 1161) were meta-analysed, showing that cerebral blood flow was lower in subjects with more white matter hyperintensity, globally and in most grey and white matter regions (e.g. mean global cerebral blood flow: standardised mean difference-0.71, 95% CI -1.12, -0.30). These cerebral blood flow differences were attenuated by excluding studies in dementia or that lacked age-matching. Four longitudinal studies (n = 1079) gave differing results, e.g., more baseline white matter hyperintensity predated falling cerebral blood flow (3.9 years, n = 575); cerebral blood flow was low in regions that developed white matter hyperintensity (1.5 years, n = 40). Cerebral blood flow is lower in subjects with more white matter hyperintensity cross-sectionally, but evidence for falling cerebral blood flow predating increasing white matter hyperintensity is conflicting. Future studies should be longitudinal, obtain more white matter data, use better age-correction and stratify by clinical diagnosis.

Carotid atherosclerosis, silent ischemic brain damage and brain atrophy: A systematic review and meta-analysis

BACKGROUND

The widespread use of brain imaging has led to increased recognition of subclinical brain abnormalities, including white matter hyperintensities (WMH) and silent brain infarctions (SBI), which have a vascular origin, and have been associated to a high risk of stroke, disability and dementia. Carotid atherosclerosis (CA) may be causative in the development of WMH, SBI and eventually brain atrophy. Aim of the present systematic review and meta-analysis was to assess the existing evidence linking CA to WMH, SBI and brain atrophy.

METHODS

The relation between CA and WMH, SBI and brain atrophy was investigated through the systematic search of online databases up to September 2015 and manual searching of references and related citations. Pooled estimates were calculated by random-effects model, using restricted maximum likelihood method with inverse variance weighting method.

RESULTS

Of the 3536 records identified, fifteen were included in the systematic review and 9 were found to be eligible for the meta-analysis. CA was significantly associated with the presence of WMH (Odds Ratio, OR 1.42, confidence interval, CI 1.22-1.66, p<0.0001) and of SBI (OR 1.89, CI 1.46-2.45, p<0.0001). No meta-analysis could be performed for the relation between CA and brain atrophy due to the lack of suitable studies.

CONCLUSIONS

CA was found to be associated to WMH and SBI. While no causative association can be inferred from the available data, the presence of carotid plaque may be considered a significant risk factor for subclinical cerebral damage.

Neuroanatomical Changes Associated with Unipolar Major Depression

There is increasing evidence for structural brain changes associated with unipolar re current major depression. Many depressed patients have comorbid physical illnesses, producing a high rate of subcortical white matter changes and brain damage to key structures involved in the modulation of emotion. This is especially true in the case of late-onset depression, which typically occurs in the setting of age-related illnesses, such as Parkinson's disease, Alzheimer's disease, poststroke syndromes, and myocardial in farction. In addition, there is now evidence for brain changes associated with early-onset major depression. Volume decreases have been reported in the hippocampus, amygdala, caudate, putamen, and frontal cortex. These structures are extensively interconnected and are part of a neuroanatomical circuit that has been termed the limbic-cortical-striatal pallidal-thalamic tract. Possible mechanisms for tissue loss include neuronal loss through exposure to repeated episodes of hypercortisolemia or glial cell loss, resulting in in creased vulnerability to glutamate neurotoxicity. Studies combining the anatomical and morphological information of MRI studies with functional studies have the potential to localize abnormalities in blood flow, metabolism, and neurotransmitter receptors and provide a better integrated model of depression. NEUROSCIENTIST 4:331-334, 1998

Prevalence of and risk factors for silent ischemic stroke in patients with atrial fibrillation as determined by brain magnetic resonance imaging

Varied silent ischemic stroke (SS) prevalence occurs in patients with atrial fibrillation (AF). Stroke history is worth 2 points in the CHADS2 scoring system. An unknown proportion of patients with AF with a CHADS2 score of 0 or 1 have been undertreated for stroke prevention. We investigated SS risk factors using magnetic resonance imaging and estimated SS impact on clinical outcomes in patients with AF. We analyzed a total of 1,200 patients (400 with AF and 800 with sinus rhythm) who had brain magnetic resonance imaging performed for routine health checkups. Clinical outcomes including symptomatic stroke, dementia, and cognitive disorder were also evaluated in patients with AF (follow-up duration: 66.7 ± 35.9 months; range 10 to 162). SS was observed in 113 patients with AF (28.3%), which was significantly higher than that in 53 subjects (6.6%) with sinus rhythm (p <0.001, odds ratio [OR] 5.549). Independent risk factors for SS in patients with AF were age (OR 1.049), hypertension (OR 2.086), dyslipidemia (OR 2.073), and valvular AF (OR 3.157). Symptomatic stroke incidence during the follow-up was significantly greater in patients with AF with SS than without SS (5.6% vs 2.7% per year, respectively; p = 0.022, hazard ratio 1.787, 95% confidence interval 1.089 to 2.933). Using current scoring systems without correcting for subclinical stroke, clinicians have likely underestimated the stroke risk in low-risk patients with AF; thus many patients with AF might not receive optimal anticoagulation treatment. In conclusion, a screening tool for detecting SS could be considered for stroke risk evaluation in patients with AF, especially those with valvular AF, elderly patients, and patients with dyslipidemia or hypertension.

Shear rate specific blood viscosity and shear stress of carotid artery duplex ultrasonography in patients with lacunar infarction

Background

This study describes a new method for determining site-specific vascular shear stress using dynamic measures of shear rate and blood viscosity (BV) in the carotid arteries, and examines characteristics of carotid arterial shear stress among patients with lacunar infarction.

Methods

Vascular shear stress measurements were conducted in 37 patients (17 lacunar infarction patients and 20 control subjects) using duplex ultrasonography. Vessel wall diameters and velocities were measured in each arterial segment at peak-systolic (PS) and end-diastolic (ED) phases, for calculation of PS/ED shear rates. PS/ED shear stresses [dyne/cm²] were determined with PS/ED shear rates and shear-rate dependent BV values. For comparison, both values of hematocrit-derived BV and BV measurements at 300 s^-1 were used for calculation of shear stress.

Results

All cardiovascular disease (CVD) risk factors including BV values were similar between the two groups. In both common carotid arteries, PS and ED shear stresses were significantly lower in the patients with lacunar infarction than in controls in multivariate models that included age, sex, and other major CVD risk factors. PS and ED shear stresses using the shear rate specific BV were 4.5% lower and 7.3% higher than those using the two other BVs, respectively.

Conclusion

Lacunar infarction was associated with reduced carotid arterial shear stress. The use of estimated BV for calculating carotid arterial shear stress provides more accurate assessment of the hemodynamic contribution of shear stress than previous models that have arbitrarily assigned a constant value to this dynamic flow property.

Risk factors for cerebral arteriosclerosis in Parkinson's disease

A previous study showed a lower incidence of ischemic stroke in patients with Parkinson's disease (PD) than in controls. It has been speculated that this may be related to less severe atherosclerosis in PD. In this study we examined the magnetic resonance imaging (MRI) and blood chemistry in 106 parkinsonian patients and compared the data with those from control cases. Abnormal MRI findings (état criblé, lacunar infarctions or periventricular hyperintensity) were found in 55.7% of cases. No case of cortical artery infarction was found. In comparison with a control population, the PD group showed a lower frequency of hypercholesterolemia, a higher frequency of low HDL cholesterol and a lower frequency of obesity. These results suggest that patients with PD have a reduction in risk factors for cortical artery infarction.

Occult cerebrovascular disease and late-onset epilepsy: could loss of neurovascular unit integrity be a viable model?

Late-onset epilepsy (LOE) first occurs after 60 years of age and may be due to occult cerebrovascular disease (CVD) which confers an increased risk of stroke. However, patients with late-onset epilepsy are not currently consistently investigated or treated for cerebrovascular risk factors. We discuss how abnormalities of neurovascular unit function, namely, changes in regional cerebral blood flow and blood brain barrier disruption, may be caused by occult cerebrovascular disease but present clinically as late-onset epilepsy. We describe novel magnetic resonance imaging methods to detect abnormal neurovascular unit function in subjects with LOE and controls. We hypothesise that occult CVD may cause LOE as a result of neurovascular unit dysfunction.

Age-related changes in white matter lesions, hippocampal atrophy, and cerebral microbleeds in healthy subjects without major cerebrovascular risk factors

Although cumulative evidence indicates that risk factors for arteriosclerosis have an impact on age-related changes in brain pathology, the influence of aging without major risk factors on changes in brain structures has not yet been fully elucidated. We used magnetic resonance imaging (MRI) to study how aging affects structural changes in the brain (eg, white matter lesions, hippocampal atrophy [HA], microbleeds) in normal subjects without major risk factors for cerebrovascular diseases. We studied 1108 subjects who underwent voluntary brain screening and had no cerebrovascular risk factors, such as hypertension, diabetes mellitus, or hyperlipidemia. We examined the conventional and T2-weighted MRI to define white matter hyperintensities, HA, and cerebral microbleeds in addition to all physical parameters, blood biochemical data, and neuropsychiatric symptoms. We found that the prevalence of white matter lesions and HA increased significantly with age (P < .001). Logistic analysis showed that periventricular hyperintensity was significantly related to age (P < .0001) and depressive state (P < .01). A linear relation was found between white matter lesions and HA (P < .05). Cerebral microbleeds also increased with age, and their presence was associated with HA (P < .001). White matter lesions, HA, and cortical microbleeds were associated with one another in healthy elderly subjects, and these changes were affected by the aging process independent of any cerebrovascular risk factors. Cerebral amyloid angiopathy may underlie these age-related brain changes.

Association of methylenetetrahydrofolate reductase (MTHFR 677C>T and 1298A>C) polymorphisms and haplotypes with silent brain infarction and homocysteine levels in a Korean population

PURPOSE

Methylenetetrahydrofolate reductase (MTHFR) is the main regulatory enzyme for homocysteine metabolism. In the present study, we evaluated whether the MTHFR 677C>T and 1298A>C gene polymorphisms are associated with SBI and plasma homocysteine concentration in a Korean population.

MATERIALS AND METHODS

We enrolled 264 patients with SBI and 234 healthy controls in South Korea. Fasting plasma total homocysteine (tHcy) concentrations were measured, and genotype analysis of the MTHFR gene was carried out.

RESULTS

The plasma tHcy levels were significantly higher in patients with SBI than in healthy controls. Despite a significant association between the MTHFR 677TT genotype and hyperhomocysteinemia, the MTHFR 677C>T genotypes did not appear to influence susceptibility to SBI. However, odds ratios of the 1298AC and 1298AC + CC genotypes for the 1298AA genotype were significantly different between SBI patients and normal controls. The frequencies of 677C-1298A and 677C-1298C haplotypes were significantly higher in the SBI group than in the control group.

CONCLUSION

This study demonstrates that the MTHFR 1298A>C polymorphism is a risk factor for SBI in a Korean population. The genotypes of 677C>T and 1298A>C polymorphisms interact additively, and increase the risk of SBI in Korean subjects.

An analysis of risk factors for asymptomatic cerebral infarction

OBJECTIVE

The aim of this study is to identify risk factors for asymptomatic cerebral infarction (ACI) in the general Japanese population.

MATERIALS AND METHODS

A total of 634 subjects (272 men aged 55.4+/-8.8 years and 362 women aged 55.2+/-8.5 years) who visited the Health Management Center at Aoyama Hospital (Tokyo, Japan) from January 2004 through January 2005 for an annual brain dry dock examination were analyzed. We evaluated 21 risk factors for ACI by multivariate logistic regression analysis.

RESULTS

Abnormal or potentially abnormal conditions were detected in 258 subjects (40.7% of all subjects who had an annual check-up program for brain disease). The most frequent abnormal finding was ACI, which was observed in 208 subjects. The significant risk factors for ACI, as determined by multivariate logistic analysis, were age (P <0.01), hypertension (P <0.01), and hypertensive vascular changes in the fundus (P <0.05).

CONCLUSION

The hypertensive vascular abnormalities in the fundus might be a risk factor for ACI independent of age and hypertension.

Effect of the Ca Antagonist Nilvadipine on Stroke Occurrence or Recurrence and Extension of Asymptomatic Cerebral Infarction in Hypertensive Patients with or without History of Stroke (PICA Study)

BACKGROUND

We examined the effect of a Ca antagonist (nilvadipine) on the occurrence or recurrence of symptomatic stroke in hypertensive patients with MRI-defined asymptomatic cerebral infarction (ACI), periventricular hyperintensity (PVH), and deep and subcortical white matter hyperintensity (DSWMH), with or without a history of stroke, and evaluated the effect of long-term treatment on the lesions.

METHODS

Patients with hypertension and incidental ACI were divided into those with (group B, 235 patients) or without (group A, 181 patients) a history of symptomatic stroke, and were given nilvadipine 4-8 mg/day for 3 years. Primary evaluation points were occurrence of symptomatic ischemic stroke and development or extension of asymptomatic ischemic lesions.

RESULTS

Male sex, hyperuricemia, diabetes, maximum diameter of infarction and PVH severity were stronger risk factors for group B. Numbers of cerebral infarctions were 31 +/- 28 (group A) and 42 +/- 32 (group B) at enrollment (p < 0.001). Infarctions were larger and located more frequently on the internal capsule, putamen, thalamus and brainstem in group B. The severity of PVH and DSWMH paralleled the number of cerebral infarctions in both groups.

CONCLUSION

The study design and status of asymptomatic ischemic brain lesions in hypertensive subjects at enrollment are presented.

Silent Brain Infarction and Subcortical White Matter Lesions Increase the Risk of Stroke and Mortality: A Prospective Cohort Study

Silent brain infarction (SBI) and white matter lesions (periventricular hyperintensity [PVH] and subcortical white matter lesions [SWML] are detected in both stroke patients and normal elderly persons. We prospectively examined the association between these lesions and the risk of subsequent stroke and mortality in neurologically normal adults. Magnetic resonance imaging scans were performed in 2,684 neurologically normal subjects with no history of stroke (mean age, 58 +/- 7 years old at entry) who underwent our health screening of the brain. After the brain screening, we obtained information about clinical stroke onset and death using a questionnaire sent annually to all subjects. When a subject suffered from medical events, we confirmed the detailed information in a telephone interview and by asking the attending physician. SBI was defined as a focal T2-hyperintensity and T1-hypointensity lesion > 3 mm. PVH and SWML were graded according to their severity. The average follow-up period was 6.3 years. Stroke occurred in 102 subjects (3.8%), and 93 subjects died during follow-up. The incidence of clinical stroke was significantly higher in the subjects with SBI than in those without SBI. Marked PVH and marked SWML independently increased the risk of stroke (for SBI, stroke risk factor-adjusted odds ratio [OR] = 3.66, 95% confidence interval [CI] = 2.28-5.89; for marked PVH, stroke risk factor-adjusted OR = 2.08, 95% CI = 1.04-4.17; for marked SWML, stroke risk factor-adjusted OR = 2.73, 95% CI = 1.32-5.63). Regarding mortality, SBI and marked PVH increased the risk of death (for SBI, stroke risk factor-adjusted OR = 1.95, 95% CI = 1.16-3.29; for PVH, stroke risk factor-adjusted OR = 4.01, 95% CI = 1.91-8.45). Death attributable to stroke occurred more frequently in those subjects with SBI, marked PVH, and marked SWML. We conclude that SBI, marked PVH, and marked SWML are important risk factors for clinical stroke and that SBI and marked PVH also increase the risk of mortality.

Lymphotoxin-alpha gene 252G allelic variant is a risk factor for large-vessel-associated ischemic stroke

A direct role of lymphotoxin-alpha (LTA) in promoting atherosclerotic plaque growth has been demonstrated recently. The different protein transcripts of the naturally occurring genetic variants of the LTA gene have been demonstrated to exhibit affected functions, and an allelic difference in binding to transcription factor(s) has also been suggested. The homozygous variant of LTA characterized by the intron 1 252A-->G (252G) transition, which naturally coexists with an exon 3 804C-->A (804A) single-nucleotide polymorphism (SNP), has been reported as a susceptibility gene for myocardial infarction. Because the atherosclerotic process is also an integral component in the pathogenesis of certain types of vascular stroke, we investigated the possible significance of the above SNPs in 353 ischemic stroke patients and 180 healthy controls. The homozygous LTA allele with the 252G and 804C SNPs occurred more frequently in stroke patients (13.9%) than in controls (7.20%, p<0.025). Specific subclassification of the patients revealed an accumulation of these SNPs in large-vessel, pathology-associated cerebral infarction (18.2%); multivariate logistic regression analysis of the data confirmed this association, with an odds ratio of 2.1 (95% confidence interval, 1.3-6.2; p<0.005). Elimination of all subjects with a history or evidence of ischemic heart disease, including myocardial infarction, did not affect this association. These data show that besides the role in the development of myocardial infarction, the homozygous carriage of the LTA allele with 252G and 804A SNPs is a novel susceptibility factor for largevesselassociated ischemic stroke.

A revised mathematical model of cerebral microischemia

Cerebral microinfarcts (lacunes) are considered to cause dementia. Experimental studies of this kind of infarct may bring us closer to an understanding of, and thus, a treatment for, cerebral infarction. However, the study of experimental cerebral microischemia is complex because of the high resolution needed. Comparing experimental with theoretical results should improve our knowledge of the subject. In the present work, a theoretical model of cerebral microischemia was improved and some results are presented. This study confirms that the glucose supply in some cases limits the energy turnover. Furthermore, the results show that increasing the oxygen supply (increasing Khem, and increasing the partial pressure of oxygen in blood) should at maximum only improve the energy turnover by about 5%. The present model may be an aid in the interpretation of experimental results and may be used to predict benefits of various treatments.

Atherosclerotic changes in intracranial and extracranial large arteries in apparently healthy persons with asymptomatic lacunar infarction

To clarify the relationship between large-vessel disease and asymptomatic cerebral infarction (ACI), we evaluated atherosclerotic changes in intracranial and extracranial arteries in adults with and without ACI. Subjects were 142 apparently healthy persons with ACI on magnetic resonance imaging (MRI) (ACI group) and 605 age matched persons without cerebral infarction on MRI. The 605 age-matched persons were divided into 380 persons with cerebrovascular risk factors (RF group) and 225 persons without cerebrovascular risk factors (NC group). Intracranial arteries (internal carotid artery, main trunks of the middle cerebral artery, and basilar artery) were examined by magnetic resonance angiography (MRA), and extracranial carotid arteries were investigated using B-mode ultrasonography. Stenosis of 25% to 49% in intracranial arteries detected on MRA was significantly more frequent in the ACI group (16%) than in the RF group (8%) or NC group (4%) (P < .05 and P < .001, respectively). On B mode ultrasonography, the prevalences of <25% stenosis (29%) and 25% to 49% stenosis (7%) in extracranial carotid arteries in the ACI group were significantly greater than those in the NC group (16% and 2% respectively, P < .05), whereas >/=50% stenosis was significantly more frequent in the ACI group (6%) than in the RF group (2%; P < .05). There was no statistically significant difference in prevalence of stenosis in intracranial and extracranial large arteries between persons with ipsilateral stenosis and infarction and persons with contralateral stenosis and infarction. We conclude that potential major cerebral vessel disease frequently coexists in persons with asymptomatic lacunar infarction.

Silent cerebral infarction in patients with type 2 diabetic nephropathy. Effects of antiplatelet drug dilazep dihydrochloride

BACKGROUND

To determine whether diabetic nephropathy is a risk factor for silent cerebral infarction and whether antiplatelet drug dilazep dihydrochloride decreases the occurrence of silent cerebral infarction in type 2 diabetes patients with microalbuminuria.

METHODS

Two hundred four type 2 diabetes patients (124 men, 80 women; age, median 56 years, range 42-74 years) and 60 healthy age-matched subjects (no diabetes, normal renal function) were recruited for brain magnetic resonance imaging. The diabetes patients included 40 without nephropathy (group A), 42 with microalbuminuria (20-200 microg/min) (group B), 44 with macroalbuminuria (>200 microg/min) and normal renal function (blood creatinine <132.7 micromol/L) (group C), 33 with chronic renal failure but not undergoing haemodialysis (blood creatinine >132.7 micromol/L; mean creatinine 335.9 micromol/L) (group D) and 45 undergoing haemodialysis (duration; median 4 years, range 3-6 years) (group E).

RESULTS

Silent cerebral infarction was found in 20, 29, 34, 45, 53 and 8% of group A, B, C, D, E and control patients respectively. The incidence of silent cerebral infarction was increased with diabetic nephropathy. Thirty group B patients with no silent cerebral infarction were divided into two groups: (B1) 15 treated with dilazep dihydrochloride and (B2) 15 not treated with dilazep dihydrochloride. Treatment continued for 24 months. The incidence of silent cerebral infarction was significantly lower in the dilazep-treated patients (6.7%) than in the untreated patients (33.3%) (p < 0.01).

CONCLUSIONS

These data suggest that diabetic renal dysfunction increases the risk of silent cerebral infarction and that dilazep dihydrochloride prevents its onset in early type 2 diabetic nephropathy patients.

Neuroimaging studies of mood disorder effects on the brain

Studies of early-onset recurrent depression, late life depression associated with neurologic disorders, and bipolar illness have revealed structural brain changes within a neuroanatomical circuit. This circuit, originally described by, has been termed the limbic-cortical-striatal-pallidal-thalamic tract and is comprised of structures which are extensively interconnected. In three-dimensional magnetic resonance imaging studies of affective illness, many of the structures that comprise this tract have been found to have volume loss or structural abnormalities. Mechanisms proposed to explain volume loss in depression include glucocorticoid neurotoxicity, decreased brain-derived growth factor, decreased neurogenesis, and loss of plasticity.

Increased prevalence of platelet glycoprotein IIb/IIIa PLA2 allele in ischaemic stroke associated with large vessel pathology

INTRODUCTION

Platelet glycoprotein IIb/IIIa is a membrane receptor with a central function in the platelet adhesion and ultimately in the thrombus formation. Two major variants of the gene encoding the IIIa subunit, called PLA1 (A1) and PLA2 (A2), have been identified in the general population. There are indications that the A2 allele can also be associated with acute thrombosis or stroke. The purpose of this study was to study the distribution of the A2 allele in different vascular subtypes of stroke disease.

MATERIALS AND METHODS

A total of 638 consecutive patients were analyzed and classified as having large vessel pathology (n=168) or a small vessel infarct (n=210). Localization of the vascular occlusions was deducted from analysis of the magnetic resonance imaging (MRI) scan results in stroke patients. The remainder patients were listed into a mixed vascular pathology group (n=167). Patients with other or poorly characterized stroke etiology were excluded from the study (n=93).

RESULTS

In the small vessel and mixed vascular pathology groups, the PLA2 allele frequency was similar to that in the controls. By contrast, PLA2 allele frequency was approximately two-fold higher in patients with large vessel pathology (23.3%) than in the stroke-free control subjects (11.7%, p<0.0005). Multivariate logistic regression analysis of data confirmed this association with an odds ratio (OR) of 2.9 (95% confidence interval [CI]: 1.6-4.9, p<0.0005).

CONCLUSIONS

These data suggest that the PLA2 allele is more frequent in brain infarcts associated with large-vessel occlusion.

Functional evaluation of cerebral microembolization in the rat

This study investigates the effects of cerebral microembolism on motor performance and risk assessment behavior in the rat. Cerebral infarcts were produced in rats by injecting small plastic beads into the left heart ventricle under short-acting anesthesia. The functional outcome was tested 24 h later by subjecting the animals to a series of consecutive behavioral tests. Thereafter, the rats were anesthetized and underwent magnetic resonance imaging. On average about seven infarcts per brain were found. The volume of the individual infarcts was largest in the hippocampus (mean=4.26 mm(3)) and smallest in the white matter (mean=0.83 mm(3)). Embolized animals performed spontaneous and evident locomotion. The activity was, however, significantly decreased compared to rats treated with vehicle. More specific tests for motor ability revealed reduced gait capacity and muscular strength. A significant relationship was found between behaviors reflecting motor ability and the total volume of infarcted tissue in the brain stem, cortex and cerebellum. Also the behavioral profile of risk and benefit assessment was found to be altered by the microembolization. It is concluded that the combination of the microembolization method and behavioral tests provides a valuable tool for further studies of the pathophysiology of, and potential treatment for, cerebral infarction.

Olprinone: a phosphodiesterase III inhibitor with positive inotropic and vasodilator effects

Olprinone is a newly developed phosphodiesterase III inhibitor characterized by several properties. First, olprinone has positive inotropic and vasodilator actions and improves myocardial mechanical efficiency. Second, olprinone augments cerebral blood flow by a direct vasodilatory effect on cerebral arteries. The cerebrovascular reactivity to olprinone is marked in patients with impaired cerebral circulation. Third, olprinone selectively improves carotid artery distensibility, which may be attributable to differences in the arterial structural components or the reactivity of smooth muscle cells to olprinone. Fourth, olprinone improves inadequate redistribution of brain perfusion and may prevent cerebral metabolic abnormalities in heart failure.

Stroke vs. chronic progressive cerebrovascular disease: a magnetic resonance imaging study of symptomatic outpatients

Stroke is the main manifestation of cerebrovascular disease (CVD). Few studies report the insidious and progressive development of CVD. The aim of this study was the characterization of a CVD form without stroke in association with vascular subtypes and risk factors (VRF). From 105 CVD patients, 65 had stroke (62%), 13 of them had more than one stroke (20%), and 40 patients had a chronic progressive form (CPF) (38%). Mean evolution times up to maximum neurological deficiency were 1.57+/-0.94 and 344.25+/-210.96 days, respectively. Group results significantly associated with VRFs: hypertension (p=0.0046), hyperlipemia (p=0.0046) and atrial fibrillation (p=0.0173); with clinical manifestations: aphasia (p=0.0018), pyramidal syndrome (p=0.0000001) and small vessel disease (SVD) (p=0.0000001); and with MRI: bilateral infarctions (p=0.00009) and incomplete white matter lesions (IWMLs) (p=0.0061). Within the CPF group, dysarthria and complete infarctions were associated (p=0.00036). Most neurological disorders associated with CVD are related to CPF. The significant correlations of SVD, bilateral infarcts, IWMLs, dysarthria, several VRFs and the strong difference in evolution time up to maximum neurological deficiency values characterize CPF as a separate entity within CVD.

Why do treated hypertensives suffer strokes? An internist's perspective

Despite widespread treatment of hypertension, stroke continues to be the third leading cause of death in the United States. Antihypertensive therapy is more effective in preventing hemorrhagic strokes than ischemic strokes. In order to understand the reasons why antihypertensive therapy is only partially successful in the eradication of ischemic strokes, differences in the pathogenesis and treatment of subtypes of stroke must be considered. There are three main stroke subtypes of ischemic strokes: small-vessel arteriopathic (lacunar), large-artery atherothrombotic, and cardioembolic. Hypertension is the major cause of lacunar strokes but plays a lesser role in the pathogenesis of atherothrombotic strokes. Antihypertensive therapy prevents the majority of lacunar strokes but may not have a major impact on the occurrence of atherothrombotic strokes. Due to impaired cerebral autoregulation, overtreatment of hypertension, especially in the elderly and in patients with previous strokes, may paradoxically lead to stroke (J-curve). Assuming that the majority of lacunar strokes are prevented by judicious antihypertensive therapy, future therapeutic efforts should concentrate on the prevention of atherothrombotic and cardioembolic strokes. In this regard, refinement of surgical techniques, pharmacologic approaches aimed at plaque stabilization, and the application of transesophageal echocardiography for the diagnosis of embolic strokes (and anticoagulation for a probable source) are promising. Besides the obvious reasons of noncompliance and inadequate therapy, overly aggressive treatment of hypertension in the elderly and stroke mechanisms unrelated to blood pressure may explain the occurrence of strokes despite our efforts to treat hypertension.

Carotid turbulent flow observed by convergent color Doppler flowmetry in silent cerebral infarction

AIM

A newly developed convergent color Doppler (CCD) was used for evaluating the possible relationship of the flow dynamics of the internal carotid artery to silent cerebral infarction (SCI).

METHODS

In 108 patients (65+/-8 years) with stroke risk factors, the CCD simultaneously images information, on both flow direction and Doppler signal energy. The relation between turbulent flow and the incidence of brain lesions of SCI as identified by magnetic resonance imaging was investigated in 212 vessels, excluding four occluded vessels. Percent area stenosis was measured as (vessel area - lumen area)/(vessel area) on cross-sectional echo image of stenotic site.

RESULTS

Incidence of turbulent flow in SCI patients with 50-70% or 70-90% stenosis was higher (76.5 or 59.1%) than that in non-SCI patients (17.4 or 33.3%, both p < 0.0001).

CONCLUSION

Non-invasive assessment of flow dynamics by CCD imaging can be useful for proposing the early stages of brain damage even in patients free from neurological deficits.

Silent cerebral infarction and cognitive function in middle-aged neurologically healthy subjects

We sought to clarify whether apparently silent cerebral infarcts and periventricular hyperintensities are associated with depressed cognitive function in middle-aged subjects. Subjects were 84 middle-aged neurologically normal adults who wished to undergo a screening examination of the brain. We performed magnetic resonance imaging (MRI) of the brain and neuropsychologic tests in all subjects. Silent cerebral infarcts and periventricular hyperintensities, respectively, were detected in 21 and 14 of 84 subjects. Mini-mental state (MMS) and Raven's colored progressive matrices (RCPM) scores were significantly lower in subjects with than without silent cerebral infarcts. By two-factor analysis of variance, MMS score was affected by silent cerebral infarcts or periventricular hyperintensities, with interactions between the two lesion types (P < 0.05). Silent cerebral infarcts may be an independent factor in the pathogenesis of intellectual dysfunction, but truly independent analysis is difficult because many subjects with silent cerebral infarcts also have periventricular hyperintensities.

Silent brain infarction in patients with rheumatic mitral stenosis

Silent brain infarction (SBI) is defined as asymptomatic infarction areas detected in computerized tomography (CT) scans in patients without a history of stroke. The incidence of SBI is increased in CT or magnetic resonance imaging in patients with carotid stenosis and with atrial fibrillation (AF), but its relation with rheumatic mitral stenosis (MS), another major source of emboli, is uncertain. The aim of this study was to investigate the incidence of SBI in patients with MS. Fifty-three patients with MS (44 females and 9 males; range 25-52 years; mean age 38 +/- 7 years) diagnosed by transthoracic echocardiography (TTE) were enrolled in the study. Mitral valve calcification, left atrium (LA) dimension, and the presence of associating mitral regurgitation on TTE were recorded. Electrocardiographic evaluation was done for rhythm analysis and neurologic examination was performed prior to cerebral CT. Carotid artery Doppler examination was carried out in patients with SBI to exclude carotid artery lesions. Patients with a history of hypertension, diabetes mellitus, anticoagulant drug usage, presence of thrombus in LA, left ventricular segmental or systolic dysfunction, or other valve diseases were excluded from the study. The incidence of SBI was found to be 24.5% in patients with MS (47% cortical, 53% lacunar). SBI was observed to be significantly high in patients with LA dimension > 4 cm or in patients with AF (p < 0.05). The SBI incidence was markedly higher if AF was found with enlarged LA when compared with patients having sinus rhythm and small LA (p < 0.01). When moderate to severe mitral regurgitation was associated with MS, the SBI incidence was found to be lower (p < 0.05). Although SBI was higher in patients with MVA < 1.5 cm2, it was not statistically significant (p > 0.05). No significant correlation was found between calcific and noncalcific valves for SBI (p > 0.05). Our data suggest that SBI may be expected in about 1/4 of patients with MS. The presence of LA enlargement and AF increase the incidence of SBI in patients with MS, whereas the presence of moderate to severe mitral regurgitation decreases the incidence of SBI.

Effects of Choto-san on hemorheological factors and vascular function in stroke-prone spontaneously hypertensive rats

Choto-san is a formula used for the treatment of headache and vertigo. Recently it has often also been used for hypertension and dementia. One of the mechanisms involved is thought to be the improvement of blood circulation, but the details are still unclear. In this study, the effect of Chotosan was studied on nitric oxide (NO) function, hemorheological factors and endothelial function in stroke-prone spontaneously hypertensive rats (SHR-SP). Rats were given Choto-san in drinking water for eight weeks. Body weight, blood pressure, serum NO2-/NO3-, lipid peroxides, blood viscosity, erythrocyte deformability and endothelium-dependent/-independent relaxation were measured. The results indicated that Choto-san caused a decrease in blood pressure and an increase in erythrocyte deformability and NO function. Blood viscosity was not changed. Furthermore, endothelium-dependent relaxation by acetylcholine was significantly increased as compared to control. In this study, it was supposed that Choto-san had a protective effect on the endothelium. SHR-SP is a useful model for human brain stroke, and Choto-san showed a protective effect against cerebral vascular injury in the susceptible rat.

Late-onset depression: can EEG abnormalities help in clinical sub-typing?

BACKGROUND

The purpose of this study was to determine the frequency of EEG abnormalities indicative of mild cerebrovascular dysfunction in patients with late-onset depression and to correlate these abnormalities with clinical features.

METHODS

The subjects, aged > or = 50 years, were 51 outpatients with major depression diagnosed according to DSM-IV criteria. They were living in the community and prospectively selected at their initial consultation for mostly mild-moderate depression. We also included 32 normal age-matched controls. We examined basic rhythms and temporal slow waves on EEG and determined the Hamilton Rating Scale for Depression (HAMD) as a scale for the severity of psychiatric symptoms.

RESULTS

Temporal slow waves were more common in depressed patients (47%) than in normal controls (22%). Depressed patients with temporal slow waves had significantly lower frequency of family history of mood disorders (P<0.05). There was no difference in the total score of HAMD between patients with and without temporal slow waves, however, each score of HAMD in patients with temporal slow waves showed a significantly lower score for "feeling of guilt" (P<0.01) and a significantly higher score for "general somatic symptoms" (P<0.01) and "hypochondriasis" (P<0.01).

CONCLUSIONS

Our EEG study suggested that temporal slow waves, which were probably associated with subtle cerebrovascular lesions, might reflect vulnerability to late-onset depression. In addition, depressed patients with temporal slow waves could be classified as a subgroup of heterogeneous late-onset depression based on the clinical findings. These results must be interpreted within the limitations of the sample selection procedure.

Associations of plasma endothelin concentration with carotid atherosclerosis and asymptomatic cerebrovascular lesions in patients with essential hypertension

We studied the association of endothelin (ET)-1 with carotid atherosclerosis and asymptomatic cerebrovascular lesions in patients with essential hypertension. Neurologically normal patients with essential hypertension (n=293; 138 male, 155 female; mean age, 65 years) and age-matched control subjects (n=242) were studied with B-mode ultrasonography of the common and internal carotid arteries and magnetic resonance imaging of the brain. Plasma ET-1 was measured by enzyme immunoassay. Hypertensive patients were divided into groups with carotid plaques and low ET-1 concentrations (< 0.75 pg/ml; PL group); carotid plaques and mid-range ET-1 (0.75 to 1.55 pg/ml; PM group); carotid plaques and high ET-1 (> or = 1.55 pg/ml; PH group); no plaques and low ET-1 (NPL); no plaques and mid-range ET-1 (NPM); and no plaques and high ET-1 (NPH). Overall, ET-1 concentrations were significantly higher in patients than in control subjects. Carotid plaque prevalence was significantly related to ET-1 in hypertensive patients. ET-1 showed a significant positive relationship with the number of asymptomatic lacunar infarcts of the brain in hypertensive patients with carotid plaques (rho=0.48, p<0.001). No significant relationship was seen between ET-1 and periventricular hyperintensity scores in patients with plaques. ET-1 did not show a relationship to either brain lesion type in patients without carotid plaques. Thus, ET-1 may foster asymptomatic lacunar cerebral infarcts by promoting carotid atherosclerosis in patients with essential hypertension.

Effects of Choto-san on microcirculation, serum nitric oxide and lipid peroxides in patients with asymptomatic cerebral infarction

The effects of Choto-san on microcirculation, serum nitric oxide and lipid peroxides were investigated. Fifteen patients with asymptomatic cerebral infarction were investigated before and after a four-week administration of Choto-san. The variables of microcirculation of the bulbar conjunctiva, which were the internal diameter of vessels, flow velocity and flow volume rate, were increased. Serum NO2(-)/NO3(-) tended to increase and lipid peroxides were decreased. Total serum cholesterol was also decreased. These results suggest that Choto-san may improve microcirculation affected by endothelial function and fat metabolism.

A controlled study of MRI signal hyperintensities in older depressed patients with and without hypertension

OBJECTIVES

To compare the frequency/severity of signal hyperintensities--likely markers of cerebrovascular disease--in the subcortical gray and deep white matter on magnetic resonance imaging (MRI) scans of brains of hypertensive and normotensive older depressed and nondepressed comparison subjects.

DESIGN

Between-groups comparison of cross-sectional MRI data employing analyses of covariance controlling for the effects of age, gender, and height.

SETTING

A comprehensive inpatient-outpatient geriatric psychiatry service in a university hospital.

PARTICIPANTS

Nondemented older depressed (n = 81) and nondepressed comparison (n = 70) subjects divided into four groups (hypertensive depressed (n = 40), hypertensive normals (n = 21), normotensive depressed (n = 41), normotensive normals (n = 49)).

MEASUREMENTS

Signal hyperintensities were rated on T-2 weighted MRI scans blind to patient diagnoses employing two standardized hyperintensity rating systems (Fazekas, Boyko).

RESULTS

Hypertensive depressives had significantly more- severe hyperintensity ratings in both subcortical gray and deep white matter than did normotensive depressives and controls (P < .05) and significantly more-severe hyperintensity ratings only in subcortical gray matter (P < .05) than did hypertensive controls. Hypertensive controls had significantly more-severe ratings in deep white matter than either normotensive group (P < .05).

CONCLUSIONS

Findings suggest a relationship between deep white matter hyperintensities and hypertension (regardless of depressive state), and a particular role of subcortical gray matter hyperintensities (possibly interacting with more-severe deep white matter lesions) in older depressed hypertensives, as compared with older depressed normotensives of similar ages and severity of depression. These data support possible heterogeneous pathogenic contributions in late-life depression subgroups, one of which appears to be influenced by cerebrovascular disease.

Time course of changes in jugular venous oxygen saturation during hypothermic or normothermic cardiopulmonary bypass in patients with diabetes mellitus

BACKGROUND

Preexisting diabetic mellitus is a risk factor determining postoperative neurological disorders. The present study assesses the effects of normothermic and hypothermic cardiopulmonary bypass (CPB) on jugular venous oxygen saturation (SjvO2)in patients with preexisting diabetic mellitus.

METHODS

Sixteen diabetic patients who underwent elective coronary artery bypass grafting surgery were randomly divided into two groups: Group DN (n=8, diabetic patients) underwent normothermic CPB (>35 degrees C), and group DH (n=8, diabetic patients) underwent hypothermic CPB (32 degrees C). Controls were 16 age-matched non-diabetic patients (normothemic group, CN: n=8; hypothemic group, CH: n=8). A 4.0 F fiberoptic oximetry oxygen saturation catheter was inserted into the right jugular bulb to continuously monitor SjvO2 values. Hemodynamic parameters and arterial and jugular venous blood gases were measured seven times.

RESULTS

Cerebral desaturation, which was defined as SjvO2 values below 50%, was observed during normothermic CPB in diabetic patients (at the onset of CPB: 46+/-3%, at 20 min after onset of CPB: 49+/-3%, means+/-SD, respectively). No cerebral desaturation occurred in diabetic and control patients during hypothermic CPB.

CONCLUSIONS

Patients with preexisting diabetes mellitus experienced cerebral desaturation during normothermic CPB.

Magnetic resonance imaging findings and postoperative neurologic dysfunction in elderly patients undergoing coronary artery bypass grafting

BACKGROUND

Small cerebral infarctions are common in elderly patients, but the association between the magnetic resonance imaging finding and neurologic dysfunction after coronary artery bypass grafting has not been evaluated.

METHODS

We determined, prospectively, whether varying degrees of abnormal findings on magnetic resonance images of the brain increased the incidence of preoperative cognitive decline, postoperative neuropsychological dysfunction, and stroke in 421 elderly patients (> or = 60 years) undergoing coronary artery bypass grafting.

RESULTS

Control patients (almost normal or leukoaraiosis, n = 212) had rates of postoperative neuropsychological dysfunction (7%) and stroke (1.4%); the small infarctions group (some small infarctions, n = 126) had rates of 13% and 5.6%, respectively; whereas patients with multiple infarctions (multiple small infarctions or broad infarctions, n = 83) had rates of 20% and 8.4%, respectively (p = 0.004, p = 0.013). In the group with multiple infarctions, 49 patients (59%) were asymptomatic and 21 patients (25%) had cognitive decline. Stepwise logistic regression analysis demonstrated that the significant predictors of multiple small infarctions or large infarctions were history of cerebrovascular disease, renal insufficiency, cognitive decline, and cerebral arteriosclerosis.

CONCLUSIONS

Multiple infarctions significantly increase the risk of neurologic dysfunction after coronary artery bypass grafting. Routine screening for preoperative cognitive decline should be performed to detect underlying ischemic cerebral disease in elderly patients.