Blood Pressure and Heart Rate Measures Associated With Increased Risk of Covert Brain Infarction and Worsening Leukoaraiosis in Older Adults

Epimedium flavonoids improve cerebral white matter lesions by inhibiting neuroinflammation and activating neurotrophic factor signal pathways in spontaneously hypertensive rats

Cerebral small vessel disease (CSVD) is one of the most common nervous system diseases. Hypertension and neuroinflammation are considered important risk factors for the development of CSVD and white matter (WM) lesions. We used the spontaneously hypertensive rat (SHR) as a model of early-onset CSVD and administered epimedium flavonoids (EF) for three months. The learning and memorization abilities were tested by new object recognition test. The pathological changes of WM were assessed using magnetic resonance imaging, transmission electron microscopy (TEM), Luxol fast blue and Black Gold staining. Oligodendrocytes (OLs) and myelin basic protein were detected by immunohistochemistry. The ultrastructure of the tight junctions was examined using TEM. Microglia and astrocytes were detected by immunofluorescence. RNA-seq was performed on the corpus callosum of rats. The results revealed that EF could significantly improve the learning and memory impairments in SHR, alleviate the injury and demyelination of WM nerve fibers, promote the differentiation of oligodendrocyte precursor cells (OPCs) into mature OLs, inhibit the activation of microglia and astrocytes, inhibit the expression of p38 MAPK/NF-κB p65/NLRP3 and inflammatory cytokines, and increase the expression of tight-junction related proteins ZO-1, occludin, and claudin-5. RNA-seq analysis showed that the neurotrophin signaling pathway played an important role in the disease. RT-qPCR and WB results showed that EF could regulate the expression of nerve growth factor and brain-derived neurotrophic factor and their downstream related proteins in the neurotrophin signaling pathway, which might explain the potential mechanism of EF's effects on the cognitive impairment and WM damage caused by hypertension.

Cognitive impairment in cerebral small vessel disease induced by hypertension

ABSTRACT

Hypertension is a primary risk factor for the progression of cognitive impairment caused by cerebral small vessel disease, the most common cerebrovascular disease. However, the causal relationship between hypertension and cerebral small vessel disease remains unclear. Hypertension has substantial negative impacts on brain health and is recognized as a risk factor for cerebrovascular disease. Chronic hypertension and lifestyle factors are associated with risks for stroke and dementia, and cerebral small vessel disease can cause dementia and stroke. Hypertension is the main driver of cerebral small vessel disease, which changes the structure and function of cerebral vessels via various mechanisms and leads to lacunar infarction, leukoaraiosis, white matter lesions, and intracerebral hemorrhage, ultimately resulting in cognitive decline and demonstrating that the brain is the target organ of hypertension. This review updates our understanding of the pathogenesis of hypertension-induced cerebral small vessel disease and the resulting changes in brain structure and function and declines in cognitive ability. We also discuss drugs to treat cerebral small vessel disease and cognitive impairment.

Association between Resting Heart Rate and Machine Learning-Based Brain Age in Middle- and Older-Age

BACKGROUND

Resting heart rate (RHR), has been related to increased risk of dementia, but the relationship between RHR and brain age is unclear.

OBJECTIVE

We aimed to investigate the association of RHR with brain age and brain age gap (BAG, the difference between predicted brain age and chronological age) assessed by multimodal Magnetic Resonance Imaging (MRI) in mid- and old-aged adults.

DESIGN

A longitudinal study from the UK Biobank neuroimaging project where participants underwent brain MRI scans 9+ years after baseline.

SETTING

A population-based study.

PARTICIPANTS

A total of 33,381 individuals (mean age 54.74 ± 7.49 years; 53.44% female).

MEASUREMENTS

Baseline RHR was assessed by blood pressure monitor and categorized as <60, 60-69 (reference), 70-79, or ≥80 beats per minute (bpm). Brain age was predicted using LASSO through 1,079 phenotypes in six MRI modalities (including T1-weighted MRI, T2-FLAIR, T2*, diffusion-MRI, task fMRI, and resting-state fMRI). Data were analyzed using linear regression models.

RESULTS

As a continuous variable, higher RHR was associated with older brain age (β for per 1-SD increase: 0.331, 95% [95% confidence interval, CI]: 0.265, 0.398) and larger BAG (β: 0.263, 95% CI: 0.202, 0.324). As a categorical variable, RHR 70-79 bpm and RHR ≥80 bpm were associated with older brain age (β [95% CI]: 0.361 [0.196, 0.526] / 0.737 [0.517, 0.957]) and larger BAG (0.256 [0.105, 0.407] / 0.638 [0.436, 0.839]), but RHR< 60 bpm with younger brain age (-0.324 [-0.500, -0.147]) and smaller BAG (-0.230 [-0.392, -0.067]), compared to the reference group. These associations between elevated RHR and brain age were similar in both middle-aged (<60) and older (≥60) adults, whereas the association of RHR< 60 bpm with younger brain age and larger BAG was only significant among middle-aged adults. In stratification analysis, the association between RHR ≥80 bpm and older brain age was present in people with and without CVDs, while the relation of RHR 70-79 bpm to brain age present only in people with CVD.

CONCLUSION

Higher RHR (>80 bpm) is associated with older brain age, even among middle-aged adults, but RHR< 60 bpm is associated with younger brain age. Greater RHR could be an indicator for accelerated brain aging.

Development and validation of a predictive model for white matter lesions in young- and middle-aged people

Background

White matter lesion (WML) is an age-related disorder associated with stroke and cognitive impairment. This study aimed to investigate the risk factors and build a predictive model of WML in young- and middle-aged people.

Methods

We performed a second analysis of the data from the Dryad Digital Repository. We selected those people who are <60 years old and randomly divided them into the training group and the validation group. We investigated the risk factors of WML in the training group with logistic regression analysis and built a prediction nomogram based on multivariate logistic regression analysis; finally, the performance of the prediction nomogram was evaluated for discrimination, accuracy, and clinical utility.

Results

There were 308 people in the training group and 723 people in the validation group. Multivariate regression analysis showed that the age (OR = 1.49, 95% CI: 1.31-1.70), diastolic blood pressure (OR = 1.02, 95% CI: 1.00-1.03), carotid plaque score (OR = 1.31, 95% CI: 1.14-1.50), female gender (OR = 2.27, 95% CI: 1.56-3.30), and metabolic syndrome (OR = 2.12, 95% CI: 1.22-3.70) were significantly associated with white matter lesions. The area under the curve value (AUC) of the receiver operating curve (ROC) was 0.734 for the training group and 0.642 for the validation group. The calibration curve and clinical impact curve showed that the prediction nomogram has good accuracy and clinical application value.

Conclusion

Age, diastolic blood pressure, carotid plaque score, female gender, and metabolic syndrome were risk factors in young- and middle-aged people <60 years old with WML, and the nomogram based on these risk factors showed good discrimination, accuracy, and clinical utility.

Leukoaraiosis severity is related to increased risk of early neurological deterioration in acute ischemic stroke: a retrospective observational study

OBJECTIVES

The relationship between leukoaraiosis and early neurological deterioration in acute cerebral infarction patients remains controversial. We tried to determine whether an association existed between leukoaraiosis and early neurological deterioration in patients with acute ischemic stroke.

MATERIALS AND METHODS

We retrospectively enrolled acute cerebral infarction patients admitted to our our department within 4.5-72.0 h of symptom onset between January 2016 and March 2022. On the basis of the van Swieten scale, leukoaraiosis was evaluated as supratentorial white matter hypoattenuation on admission head CT and graded as 0 (absent), 1 (mild), 2 (moderate) and 3-4 (severe). Early neurological deterioration was defined as an increase in the National Institute of Health Stroke Scale score by >  = 2 points in the total score, or >  = 1 point in motor power within the first seven days after admission.

RESULTS

Among 736 patients, 522 (70.9%) patients had leukoaraiosis, and of these, 332 (63.6%) had mild leukoaraiosis, 41 (7.9%) had moderate leukoaraiosis, and 149 (28.5%) had severe leukoaraiosis. 118 (16.0%) patients experienced early neurological deterioration: 20 of the 214 (9.5%) patients without leukoaraiosis and 98 of the 522 (18.8%) patients with leukoaraiosis. In multiple regression analysis, we found van Swieten scale predicted early neurological deterioration independently (OR = 1.570; 95% CI: 1.226-2.012).

CONCLUSIONS

Leukoaraiosis is common in acute cerebral infarction patients and leukoaraiosis severity is related to increased risk of early neurological deterioration in the patients.

Educational and Clinical Associations With Longitudinal Cognitive Function and Brain Imaging in American Indians: The Strong Heart Study

BACKGROUND AND OBJECTIVES

Little is known about incidence of vascular and Alzheimer dementias in American Indians.

METHODS

We conducted a large, heterogeneous, population-based, longitudinal cohort study of brain aging in community-dwelling American Indians aged 64-95 years from 11 tribes across 3 states, with neurologic examinations, 1.5T MRI, and extensive cognitive testing. Visit 1 in 2010-2013 (n = 817) and visit 2 in 2017-2019 (n = 403) included all willing, surviving participants. Standardized cognitive tests at both visits included Modified Mini-Mental Status Examination (MMSE), Wechsler Adult Intelligence Scale digit symbol coding (WAIS), Controlled Oral Word Association (COWA), and California Verbal Learning Test short form (CVLT). Test materials added at follow-up included Wide Range Achievement (reading) Test (WRAT) and National Alzheimer Coordinating Center Uniform Data Set cognitive battery (v3 form C2), including Montreal Cognitive Assessment (MoCA). MRI neuroradiologists coded infarcts, hemorrhages, white matter hyperintensities, sulcal atrophy, and ventricle enlargement.

RESULTS

The mean time between examinations was 6.7 years (SD 1.1, range 3.8-9.1 years). Years of formal education had modest correlation with WRAT reading score (r = 0.45). Prevalence and incidence (respectively) of infarcts were 32% and 12.8/1,000 person-years (PYs) hemorrhages 6% and 4.4/1000 PY worsening sulci 74% and 19.0/1000 PY worsening ventricle 79% and 30.1/1000 PY worsening leukoaraiosis 44% and 26.1/1000 PY. Linear losses per year in cognitive scores were 0.6% MMSE, 1.2% WAIS, 0.6% COWA, and 2.2% CVLT. The mean MoCA scores were 18.9 (SD 4.3).

DISCUSSION

These are the first data on longitudinal cognitive and imaging changes in American Indians and first reports of Alzheimer disease-related features. The mean scores in MoCA were similar or lower than standard cutoffs used to diagnose dementia in other racial/ethnic groups, suggesting that standardized cognitive tests may not perform well in this population. Test validation, adaptation, and score adjustment are warranted. Years of education were a poor proxy for premorbid function, suggesting novel methods for cognitive score contextualization is also needed in this population. Evaluation of selective survival suggests attrition from death, and frailty should be accounted for in causal analyses. Overall, these data represent a unique opportunity to examine neurology topics of critical importance to an understudied population.

Impact of the Soundscape on the Physical Health and the Perception of Senior Adults in Senior Care Facilities

Purpose:

To explore the impact of different acoustic stimuli of varying sound pressure levels on physical responses and the perception of senior adults.

Background:

Noise-related health problems have been gaining increased attention as studies have shown an association with negative impacts on physiological parameters resulting in cardiovascular morbidity and mortality. However, a gap in knowledge exists in exploring the impact of exposure to sound recordings in the actual environment on physiological measurements.

Methods:

Five acoustic stimuli were recorded in real life and 120 senior adults listened to them in a sound treated room to analyze the impacts of low-, middle-, and high-decibel sounds on their heart rate, blood pressure, and perception. The physical responses, heart rate, and blood pressure were measured during the sound exposure, and questionnaires were administered afterward.

Results:

Exposure to different sounds resulted in fluctuations and an inconsistent trend in heart rate, systolic pressure, and diastolic pressure. According to the physical measures and subjective evaluations, sport sounds and traffic noise were given the lowest rating for preference, while music was perceived as the most comfortable.

Conclusions:

A sound pressure level below 55–65 dB(A) correlates with increased comfort and less increase in heart rate and blood pressure. Senior adults with normal hearing preferred and were most comfortable with music, while those with severe hearing impairment preferred entertainment sounds the most.

Correlation between 24-Hour Ambulatory Blood Pressure Variability and White Matter Lesions in Patients with Cerebral Small Vascular Disease: A Cross-Sectional Study

Objective

The goals of this study are to assess the correlation between 24-hour ambulatory blood pressure (BP) variability and white matter lesions (WML) in patients with cerebral small vascular disease (CSVD) and to provide guidance for the prevention of WML.

Methods

A total of 136 patients diagnosed with CSVD and essential hypertension were recruited and divided into two groups. The Fazekas scale was used to quantify the severity of WML. The basic information, BP levels, BP variability, and circadian rhythm changes across these groups were recorded and compared.

Results

The control group consisted of 40 subjects without WML (Fazekas score = 0), and the WML group was composed of 96 patients with WML (Fazekas score ≥ 1). Patients in the WML group were then divided into three subgroups: mild WML (n = 43, Fazekas score = 1), moderate WML (n = 24, Fazekas score = 2), and severe WML (n = 29, Fazekas score = 3–4). Age, history of diabetes, and serum uric acid levels were significantly increased between the WML and control groups (P < 0.05). The levels of 24-hour mean diastolic BP (F = 3.158, P = 0.026) and daytime mean systolic BP (F = 3.526, P = 0.017) were significantly increased between the control and WML groups. There was no significant difference in the rhythmic classification of BP among all groups (P > 0.05). An ordered multinomial logistic regression analysis revealed that age, triglyceride levels, and nondipper BP were independent risk factors in WML.

Conclusion

Age, history of diabetes, serum uric acid levels, 24-hour mean systolic level, and daily mean systolic BP level were significantly increased between the WML and control groups. Age, triglyceride levels, and nondipper BP were independent risk factors in WML in patients with CSVD, while the 24-hour dynamic blood pressure standard deviation and 24-hour dynamic blood pressure coefficient of variation were not associated with the occurrence of WML.

Association of Cerebral Oxygenation During Exercise With Target Organ Damage in Middle-Aged Hypertensive and Normotensive Individuals

BACKGROUND

The brain is one of the main target organs affected by hypertension. Impaired cerebral oxygenation during exercise is an indicator of cerebral dysfunction. We aimed to investigate whether cerebral oxygenation during exercise correlates with subclinical markers of early target organ damage in a population of middle-aged, newly diagnosed hypertensive and healthy individuals.

METHODS

Carotid intima-media thickness (cIMT) was measured using ultrasound, arterial stiffness was estimated measuring the augmentation index and pulse wave velocity, and retinal vessel diameter was assessed via the central retinal-arteriolar and vein equivalent and retinal-arteriovenous ratio. Participants (n = 93) performed a 3-minute isometric handgrip exercise. Cerebral prefrontal oxygenation was measured continuously using near infrared spectroscopy. The average exercise responses in oxygenated hemoglobin (O2Hb), deoxygenated hemoglobin (HHb), and total hemoglobin (tHb) were assessed. Univariate analyses were performed; partial correlation was used to account for traditional cardiovascular risk factors to identify independent associations between cerebral-oxygenation indices and early markers of target organ damage.

RESULTS

Mean cIMT was negatively correlated with the average exercise response in cerebral oxygenation (rhoO2Hb = -0.348, PO2Hb = 0.001; rhotHb = -0.253, Pthb = 0.02). Augmentation index was negatively correlated with cerebral oxygenation during exercise (rhoO2Hb = -0.374, P < 0.001; rhotHb = -0.332, P = 0.02), whereas no significant correlation was observed between pulse wave velocity and cerebral-oxygenation indices. In the adjusted analysis, cerebral oxygenation was correlated with central retinal arteriolar diameter (CRAE r = 0.233, P = 0.043).

CONCLUSIONS

Our novel findings suggest that indices of lower cerebral oxygenation during a submaximal physical task are associated with markers of early, subclinical target organ damage, namely increased cIMT, arterial stiffness, and arteriolar retinal narrowing in newly diagnosed, untreated, hypertensive individuals.

Risk Factors for Silent Brain Infarcts and White Matter Disease in a Real-World Cohort Identified by Natural Language Processing

OBJECTIVE

To assess the frequency of silent brain infarcts (SBIs) and white matter disease (WMD) and associations with stroke risk factors (RFs) in a real-world population.

PATIENTS AND METHODS

This was an observational study of patients 50 years or older in the Kaiser Permanente Southern California health system from January 1, 2009, through June 30, 2019, with head computed tomography or magnetic resonance imaging for nonstroke indications and no history of stroke, transient ischemic attack, or dementia. A natural language processing (NLP) algorithm was applied to the electronic health record to identify individuals with reported SBIs or WMD. Multivariable Poisson regression estimated risk ratios of demographic characteristics, RFs, and scan modality on the presence of SBIs or WMD.

RESULTS

Among 262,875 individuals, the NLP identified 13,154 (5.0%) with SBIs and 78,330 (29.8%) with WMD. Stroke RFs were highly prevalent. Advanced age was strongly associated with increased risk of SBIs (adjusted relative risks [aRRs], 1.90, 3.23, and 4.72 for those aged in their 60s, 70s, and ≥80s compared with those in their 50s) and increased risk of WMD (aRRs, 1.79, 3.02, and 4.53 for those aged in their 60s, 70s, and ≥80s compared with those in their 50s). Magnetic resonance imaging was associated with a reduced risk of SBIs (aRR, 0.87; 95% CI, 0.83 to 0.91) and an increased risk of WMD (aRR, 2.86; 95% CI, 2.83 to 2.90). Stroke RFs had modest associations with increased risk of SBIs or WMD.

CONCLUSION

An NLP algorithm can identify a large cohort of patients with incidentally discovered SBIs and WMD. Advanced age is strongly associated with incidentally discovered SBIs and WMD.

The Effects of Mean of Visit-to-Visit Blood Pressure on Incident Brain Vascular Lesions and Functional-Cognitive Decline

BACKGROUND

Cerebrovascular disease (CeVD) is an underlying cause of cognitive impairment and dementia. Hypertension is a known risk factor of CeVD, but the effects of mean of visit-to-visit blood pressure (BP) on incident CeVD and functional-cognitive decline remains unclear.

OBJECTIVE

To determine the association between mean of visit-to-visit BP with the incidence and progression of CeVD [white matter hyperintensities (WMH), infarcts (cortical infarcts and lacunes), cerebral microbleeds (CMBs), intracranial stenosis, and hippocampal volume] as well as functional-cognitive decline over 2 years of follow-up.

METHODS

373 patients from a memory-clinic underwent BP measurements at baseline, year 1, and year 2. The mean of visit-to-visit systolic BP, diastolic BP, pulse pressure, and mean arterial pressure were calculated. Baseline and year 2 MRI scans were graded for WMH, infarcts, CMBs, intracranial stenosis, and hippocampal volume. Functional-cognitive decline was assessed using locally validated protocol. Logistic and linear regression models with odds ratios, mean difference, and 95%confidence interval were constructed to analyze associations of visit-to-visit BP on CeVD incidence and progression as well as functional-cognitive decline.

RESULTS

Higher mean of visit-to-visit diastolic BP was associated with WMH progression. Higher tertiles of diastolic BP was associated with WMH progression and incident CMBs. There was no association between mean of visit-to-visit BP measures with incident cerebral infarcts, intracranial stenosis, change in hippocampal volume, and functional-cognitive decline.

CONCLUSION

These findings suggest the possibility of hypertension-related vascular brain damage. Careful monitoring and management of BP in elderly patients is essential to reduce the incidence and progression of CeVD.

Telmisartan use and risk of dementia in type 2 diabetes patients with hypertension: A population-based cohort study

BACKGROUND

Angiotensin receptor blockers (ARBs) may have protective effects against dementia occurrence in patients with hypertension (HTN). However, whether telmisartan, an ARB with peroxisome proliferator-activated receptor γ (PPAR-γ)-modulating effects, has additional benefits compared to other ARBs remains unclear.

METHODS AND FINDINGS

Between 1997 and 2013, 2,166,944 type 2 diabetes mellitus (T2DM) patients were identified from the National Health Insurance Research Database of Taiwan. Patients with HTN using ARBs were included in the study. Patients with a history of stroke, traumatic brain injury, or dementia were excluded. Finally, 65,511 eligible patients were divided into 2 groups: the telmisartan group and the non-telmisartan ARB group. Propensity score matching (1:4) was used to balance the distribution of baseline characteristics and medications. The primary outcome was the diagnosis of dementia. The secondary outcomes included the diagnosis of Alzheimer disease and occurrence of symptomatic ischemic stroke (IS), any IS, and all-cause mortality. The risks between groups were compared using a Cox proportional hazard model. Statistical significance was set at p < 0.05. There were 2,280 and 9,120 patients in the telmisartan and non-telmisartan ARB groups, respectively. Patients in the telmisartan group had a lower risk of dementia diagnosis (telmisartan versus non-telmisartan ARBs: 2.19% versus 3.20%; HR, 0.72; 95% CI, 0.53 to 0.97; p = 0.030). They also had lower risk of dementia diagnosis with IS as a competing risk (subdistribution HR, 0.70; 95% CI, 0.51 to 0.95; p = 0.022) and with all-cause mortality as a competing risk (subdistribution HR, 0.71; 95% CI, 0.53 to 0.97; p = 0.029). In addition, the telmisartan users had a lower risk of any IS (6.84% versus 8.57%; HR, 0.79; 95% CI, 0.67 to 0.94; p = 0.008) during long-term follow-up. Study limitations included potential residual confounding by indication, interpretation of causal effects in an observational study, and bias caused by using diagnostic and medication codes to represent real clinical data.

CONCLUSIONS

The current study suggests that telmisartan use in hypertensive T2DM patients may be associated with a lower risk of dementia and any IS events in an East-Asian population.

Transcriptome Sequencing Identifies Potential Biomarker for White Matter Lesions Diagnosis in the Hypertension Population

Hypertension is confirmed to be one of the major risk factors of leukoaraiosis (LA). However, the pathogenesis of LA is not completely understood and there is no reliable indicator for the early diagnosis of LA in the hypertensive population. This study was designed to explore the potential biomarker for LA diagnosis in patients with hypertension. And it serves as the basis for the further study of LA mechanism. In this study, This study included 110 subjects, including 50 in the LA group and 60 in the control group. First, we performed transcriptome sequencing and quantitative PCR (qPCR) in four samples from the LA group, and three from the control group (seven people) to identify relevant long non-coding RNAs (long ncRNAs or lncRNA). The 103 samples were used for qPCR validation of relevant lncRNAs and the results were consistent with the sequencing. In-depth bioinformatics analysis were performed on differentially expressed (DE) lncRNAs and mRNAs. Go-functional enrichment analysis was performed on DE mRNAs. Some DE mRNA were enriched to biological processes associated with LA, And some lncRNAs related to DE mRNAs were traceable through cis/trans analysis, suggesting that they might be regulated in some way. Additionally, potential biomarkers for LA diagnosis in the hypertension population were identified via RT-qPCR and receive operating characteristic curve (ROC) analysis of lncRNA. One lncRNA, AC020928.1, has been demonstrated to be potential biomarkers for LA diagnosis in the hypertension population. The results of the present study indicated that the lncRNA may have an important role in the pathogenesis of LA and may be a novel target for further research. As the relationship between lncRNAs and LA is just beginning to be unraveled, their specific mechanisms require further investigation.

Cognitive declines after perioperative covert stroke: Recent advances and perspectives

PURPOSE OF REVIEW

With the aging of the population, there are increasing number of aged patients who require surgical interventions. Perioperative covert stroke is emerging as an important health threat and social burden that could affect patients' long-term neurological outcomes.

RECENT FINDINGS

Recent findings of the association between perioperative covert stroke with long-term cognitive declines of surgical patients highlighted the significance of the silent cognitive function killer-perioperative covert stroke. Considering the devastating long-term consequence of the asymptomatic covert stroke, early diagnosis and prevention are turning out as crucial problems to tackle. The evolving brain imaging techniques, such as multimodel MRI sequences are not only able to detect early, small and subtle injuries of the acute ischemic lesions, but also quite advantageous in capturing the preexisting brain vascular diseases that are considered as important risk factors of covert stroke. However, effective predictive markers are still lacking to identify high risk patients for perioperative covert stroke, rendering an unmet need of investigations in this regard.

SUMMARY

The present review will summarize recent findings in perioperative covert stroke and highlight future perspectives of its early diagnosis and the impact of postoperative cognitive impairments.

Heart Rate, Brain Imaging Biomarkers and Cognitive Impairment in Older (≥63 years) Women

Evidence on the relations between heart rate, brain morphology, and cognition is limited. We examined the associations of resting heart rate (RHR), visit-to-visit heart rate variation (VVHRV), brain volumes and cognitive impairment. The study sample consisted of postmenopausal women enrolled in the Women's Health Initiative Memory Study and its ancillary MRI sub-studies (WHIMS-MRI 1 and WHIMS-MRI 2) without a history of cardiovascular disease, including 493 with one and 299 women with 2 brain magnetic resonance imaging (MRI) scans. HR readings were acquired annually starting from baseline visit (1996-1998). RHR was calculated as the mean and VVHRV as standard deviation of all available HR readings. Brain MRI scans were performed between 2005 and 2006 (WHIMS-MRI 1), and approximately 5 years later (WHIMS-MRI 2). Cognitive impairment was defined as incident mild cognitive impairment or probable dementia until December 30, 2017. An elevated RHR was associated with greater brain lesion volumes at the first MRI exam (7.86 cm3 [6.48, 9.24] vs 4.78 cm3 [3.39, 6.17], p-value <0.0001) and with significant increases in lesion volumes between brain MRI exams (6.20 cm3 [4.81, 7.59] vs 4.28 cm3 [2.84, 5.73], p-value = 0.0168). Larger ischemic lesion volumes were associated with a higher risk for cognitive impairment (Hazard Ratio [95% confidence interval], 2.02 [1.18, 3.47], p-value = 0.0109). Neither RHR nor VVHRV were related to cognitive impairment. In sensitivity analyses, we additionally included women with a history of cardiovascular disease to the study sample. The main results were consistent to those without a history of cardiovascular disease. In conclusion, these findings show an association between elevated RHR and ischemic brain lesions, probably due to underlying subclinical disease processes.

White Matter Hyperintensity, Immediate Antihypertensive Treatment, and Functional Outcome After Acute Ischemic Stroke

Background and Purpose- It remains unknown that whether white matter hyperintensity (WMH) severity influences the effect of antihypertensive treatment in acute ischemic stroke. We aimed to investigate the effects of early antihypertensive treatment on death and disability among patients with acute ischemic stroke according to WMH severities. Methods- This study was a secondary analysis of the data from CATIS (China Antihypertensive Trial in Acute Ischemic Stroke). Severity of WMH was evaluated using Fazekas rating scale score among 303 participants with available magnetic resonance imaging data and was categorized into none-mild WMH (Fazekas score 0-2) and moderate-severe WMH (Fazekas score 3-6). Functional outcome was death or major disability (modified Rankin Scale score of ≥3) at 14 days or hospital discharge and within 3 months. Results- WMH severity was significantly associated with an increased risk of death or major disability. Each 1 score increase in Fazekas score was associated with an adjusted odds ratio (95% CI) of 1.25 (1.03-1.51) for 14 days or hospital discharge and 1.39 (1.12-1.72) for 3-month functional outcome. There were no significant interactions between antihypertensive treatment and WMH severity (both P>0.1) on functional outcome at 14 days or hospital discharge and within 3 months. The neutral effects of immediate antihypertensive treatment were observed both in patients with moderate-severe WMH and none-mild WMH. Conclusions- Participants with higher WMH burden had increased risk of death or major disability after acute ischemic stroke. Early antihypertensive treatment had a neutral effect on clinical outcomes among acute ischemic stroke patients with a variety of WMH severities. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT01840072.

Cholesterol Variability and Cranial Magnetic Resonance Imaging Findings in Older Adults: The Cardiovascular Health Study

Background and Purpose- Serum cholesterol variability, independent of mean, has been associated with stroke, white matter hyperintensities on cranial magnetic resonance imaging (MRI), and other cardiovascular events. We sought to assess the relationship between total serum cholesterol (TC) variability and cranial MRI findings of subclinical or covert vascular brain injury in a longitudinal, population-based cohort study of older adults. Methods- In the Cardiovascular Health Study, we assessed associations between intraindividual TC mean, trend, and variability over ≈5 years with covert brain infarction (CBI) and white matter grade (WMG) on cranial MRI. Mean TC was calculated for each study participant from 4 annual TC measurements between 2 MRI scans. TC trend was calculated as the slope of the linear regression of the TC measurements, and TC variability was calculated as the SD of the residuals from the linear regression. We evaluated the association of intraindividual TC variability with incident CBI and worsening WMG between 2 MRI scans in primary analyses and with prevalent CBI number and WMG on the follow-up MRI scan in secondary analyses. Results- Among participants who were eligible for the study and free of clinical stroke before the follow-up MRI, 17.9% of 1098 had incident CBI, and 27.8% of 1351 had worsening WMG on the follow-up MRI. Mean, trend, and variability of TC were not associated with these outcomes. TC variability, independent of mean and trend, was significantly associated with the number of CBI (β=0.009 [95% CI, 0.003-0.016] P=0.004; N=1604) and was associated with WMG (β, 0.009 [95% CI, -0.0002 to 0.019] P=0.055; N=1602) on the follow-up MRI. Conclusions- Among older adults, TC variability was not associated with incident CBI or worsening WMG but was associated with the number of prevalent CBI on cranial MRI. More work is needed to validate and to clarify the mechanisms underlying such associations.

Association Between Blood Pressure Variability and Cerebral Small-Vessel Disease: A Systematic Review and Meta-Analysis

Background

Research links blood pressure variability (BPV) with stroke; however, the association with cerebral small‐vessel disease (CSVD) remains unclear. As BPV and mean blood pressure are interrelated, it remains uncertain whether BPV adds additional information to understanding cerebrovascular morphological characteristics.

Methods and Results

A systematic review was performed from inception until March 3, 2019. Eligibility criteria included population, adults without stroke (<4 weeks); exposure, BPV quantified by any metric over any duration; comparison, (1) low versus high or mean BPV and (2) people with versus without CSVD; and outcomes, (1) CSVD as subcortical infarct, lacunae, white matter hyperintensities, cerebral microbleeds, or enlarged perivascular spaces; and (2) standardized mean difference in BPV. A total of 27 articles were meta‐analyzed, comprising 12 309 unique brain scans. A total of 31 odds ratios (ORs) were pooled, indicating that higher systolic BPV was associated with higher odds for CSVD (OR, 1.27; 95% CI, 1.14–1.42; I²=85%) independent of mean systolic pressure. Likewise, higher diastolic BPV was associated with higher odds for CSVD (OR, 1.30; 95% CI, 1.14–1.48; I²=53%) independent of mean diastolic pressure. There was no evidence of a pairwise interaction between systolic/diastolic and BPV/mean ORs (P=0.47), nor a difference between BPV versus mean pressure ORs (P=0.58). Fifty‐four standardized mean differences were pooled and provided similar results for pairwise interaction (P=0.38) and difference between standardized mean differences (P=0.70).

Conclusions

On the basis of the available studies, BPV was associated with CSVD independent of mean blood pressure. However, more high‐quality longitudinal data are required to elucidate whether BPV contributes unique variance to CSVD morphological characteristics.

Blood Pressure Variability and Cerebral Small Vessel Disease: A Systematic Review and Meta-Analysis of Population-Based Cohorts

Background and Purpose- Blood pressure (BP) variability may increase the risk of stroke and dementia. It remains inconclusive whether BP variability is associated with cerebral small vessel disease, a common and potentially devastating subclinical disease that contributes significantly to both stroke and dementia. Methods- A systematic review and meta-analysis of prospective cohort studies that examined the association between BP variability and the presence or progression of established markers of cerebral small vessel disease, including white matter hyperintensities, lacunes, and microbleeds on magnetic resonance imaging. We searched MEDLINE, EMBASE, and Web of Science. Ten studies met the criteria for qualitative synthesis and 7 could be included in the meta-analysis. Data were synthetized using random-effect models. Results- These studies included a total of 2796 individuals aged 74 (mean) ±4 (SD) years, with a median follow-up of 4.0 years. A one SD increase in systolic BP variability was associated with increased odds of the presence or progression of white matter hyperintensities (odds ratio, 1.26 [95% CI, 1.06-1.50]). The association of systolic BP variability with the presence of lacunes (odds ratio, 0.93 [95% CI, 0.74-1.16]) and the presence of microbleeds (odds ratio, 1.13 [95% CI, 0.89-1.44]) were not statistically significant. Conclusions- A larger BP variability may be associated with a higher risk of having a higher burden of white matter hyperintensities. Targeting large BP variability has the potential to prevent cerebral small vessel disease and thereby reducing the risk of stroke and dementia. The potential issue of reverse causation and the heterogeneity in the assessment of cerebral small vessel disease markers should be better addressed in future studies.

Expression and short-term prognostic value of miR-126 and miR-182 in patients with acute stroke

Expression and short-term prognostic value of miR-126 and miR-182 in patients with acute stroke were investigated. In total, 153 patients with acute stroke admitted to the Second Affiliated Hospital of Soochow University from February 2016 to February 2018 were enrolled into the observation group as group A [88 patients with acute cerebral infarction (AIS)] or group B [65 patients with cerebral hemorrhage (ICH)]. Furthermore, 69 healthy people receiving physical examinations in the hospital were enrolled into the control group. The relative expression of miR-126 and miR-182 in all subjects were measured and their correlation with the National Institute of Health stroke scale (NIHSS) and activities of daily living (ADL) scores was analyzed. After 3 months of follow-up, the correlation of miR-126 and miR-182 with the Modified Rankin Scale (MRS) score of patients was investigated. The receiver operating characteristic (ROC) curve was employed to explore the value of miR-126 and miR-182, alone or in combination, in predicting the prognosis of acute stroke patients. Subjects in the control group had markedly higher miR-126 expression and lower miR-182 expression than those in group A and group B in the observation group (P<0.05). Pearson's correlation analysis suggested a notable correlation of miR-126 and miR-182 with NIHSS and ADL scores. Patients with a mild condition or good prognosis had higher miR-126 expression and lower miR-182 expression than patients with a severe condition or poor prognosis (P<0.05). Both miR-126 and miR-182 predicted the prognosis of acute stroke, and the combination of miR-126 and miR-182 presented better accuracy. The expression levels of miR-126 and miR-182 are associated with the neurological function, self-care ability, and prognosis in patients with acute stroke is highly valuable for predicting the prognosis of patients.

Sex-specific association of metabolic risk factors with brain ischemic lesions by severity and location

Background

Males and females exhibit significant differences in metabolism and in brain ischemic stroke and different features of brain ischemic lesions are related to different health outcomes. It is critical to understand sex differences in their associations to optimize prevention and intervention for both sexes. We aimed to investigate the sex-specific association of metabolic risk factors with brain ischemic lesions by severity and location.

Methods

Five thousand seven hundred ninety-one participants who underwent comprehensive health examinations between Jan. 1, 2017, and Dec. 31, 2017, were enrolled. Clinical and laboratory data about metabolic risk factors were obtained. Brain ischemic lesions were further categorized by severity (mild ischemic lesions or severe infarct lesions) and location (strictly lobar or deep brain/infratentorial areas) based on brain magnetic resonance imaging reports. Sex- and age-specific detected rates were calculated, and generalized linear models and multinomial logistic regression were used to analyze the associations between metabolic risk factors and the presence, severity, and location of ischemic lesions stratified by sex.

Results

A total of 2712 (46.8%) participants had at least one brain ischemic lesions. Age (adjusted OR, 1.10 [1.10–1.11], p < 0.001) and hypertension (adjusted OR, 1.42 [1.22–1.64], p < 0.001) were generally associated with higher risks of brain ischemia in both sexes. Metabolic syndrome was associated with greater adjusted ORs for brain ischemia with different severity and location in men (adjusted ORs between 1.23 and 1.49) but not in women. Overweight and obesity were related to lesions located strictly in lobar in men (adjusted OR, 1.23 and 1.33, respectively) and lesions located in deep brain/infratentorial areas in women (adjusted OR, 1.57 and 2.26, respectively).

Conclusions

Metabolic syndrome was associated with brain ischemic lesions in men but not in women. Higher body mass index was related to ischemic lesions located in lobar in men and in deep brain/infratentorial areas in women. Its mechanisms remain to be further investigated.

Assessment of cerebrovascular reserve impairment using the breath-holding index in patients with leukoaraiosis

Many studies have demonstrated that leukoaraiosis is associated with impaired cerebrovascular reserve function. However, the definitive hemodynamic changes that occur in leukoaraiosis are not clear, and there are many controversies. This study aimed to investigate hemodynamic changes in symptomatic leukoaraiosis using transcranial Doppler ultrasonography and the breath-holding test in a Chinese Han population, from northern China. A total of 203 patients who were diagnosed with ischemic stroke or clinical chronic progressive ischemic symptoms were enrolled in this study, including 97 males and 106 females, with an age range of 43–93 years. The severity of leukoaraiosis was evaluated according to the Fazekas grading scale, and patients were divided into four groups accordingly. Grade 0 was no leukoaraiosis, and grades I, II, and III were mild, moderate, and severe leukoaraiosis, respectively, with 44, 79, 44, and 36 cases in each group. Transcranial Doppler ultrasonography and the breath-holding test were performed. The mean blood flow velocity of the bilateral middle cerebral artery was measured and the breath-holding index was calculated. The breath holding index was correlated with leukoaraiosis severity and cognitive impairment. Patients with a low breath holding index presented poor performance in the Montreal Cognitive Assessment (MoCA) and executive function tests. That is, the lower the breath holding index, the lower the scores for the MoCA and the higher for the trail-making test Parts A and B. These results indicate that the breath-holding index is a useful parameter for the evaluation of cerebrovascular reserve impairment in patients with leukoaraiosis. In addition, the breath-holding index can reflect cognitive dysfunction, providing a new insight into the pathophysiology of leukoaraiosis. This study was approved by the Ethics Committee of the Fifth People’s Hospital of Shenyang, China (approval No. 20160301) and registered in the Chinese Clinical Trial Registry (registration number: ChiCTR1800014421).