Prevalence of Intracranial Aneurysm in Patients With Aortic Disease in Korea: A Nationwide Population-Based Study

Outcomes of Bypass Surgery in Adult Moyamoya Disease by Onset Type

Importance

Moyamoya disease (MMD) is a rare chronic cerebrovascular disease, and the outcomes of bypass management in adult patients remain controversial.

Objective

To categorize adult MMD based on asymptomatic, ischemic, and hemorrhagic onset and compare the outcomes (death, hemorrhagic stroke [HS], and ischemic stroke [IS]) of bypass surgery (direct or indirect) with those of conservative management.

Design, Setting, and Participants

This retrospective, nationwide, population-based longitudinal cohort study used Korean National Health Insurance Research data to identify adults (aged ≥15 years) with MMD who were diagnosed between January 1, 2008, and December 31, 2020, and followed up until December 31, 2021 (median follow-up, 5.74 [IQR, 2.95-9.42] years). A total of 19 700 participants (3194 with hemorrhagic, 517 with ischemic, and 15 989 with asymptomatic MMD) were included. Data were analyzed from January 2 to April 1, 2023.

Exposures

Bypass surgery and conservative management.

Main Outcomes and Measures

Death constituted the primary outcome; secondary outcomes consisted of HS or IS. Kaplan-Meier survival curve and Cox proportional hazards regression analysis were applied. The propensity score-matching and stratified analyses were performed to control covariate effects.

Results

A total of 19 700 patients (mean [SD] age, 45.43 [14.98] years; 12 766 [64.8%] female) were included. Compared with conservative management, bypass was associated with a reduced risk of death (adjusted hazard ratio [AHR], 0.50 [95% CI, 0.41-0.61]; P < .001) and HS (AHR, 0.36 [0.30-0.40]; P < .001) in hemorrhagic MMD; reduced risk of IS (AHR, 0.55 [95% CI, 0.37-0.81]; P = .002) in ischemic MMD; and reduced risk of death (AHR, 0.74 [95% CI, 0.66-0.84]; P < .001) in asymptomatic MMD. However, bypass was associated with an increased risk of HS (AHR, 1.76 [95% CI, 1.56-2.00]; P < .001) in asymptomatic MMD. Both direct and indirect bypass demonstrated similar effects in hemorrhagic and asymptomatic MMD, except only direct bypass was associated with a reduced risk of IS (AHR, 0.52 [95% CI, 0.33- 0.83]; P = .01) in ischemic MMD. After stratification, bypass was associated with a reduced risk of death in patients younger than 55 years with ischemic (AHR, 0.34 [95% CI, 0.13- 0.88]; P = .03) and asymptomatic (AHR, 0.69 [95% CI, 0.60-0.79]; P < .001) MMD, but an increased risk of HS in patients 55 years or older with ischemic MMD (AHR, 2.13 [95% CI, 1.1-4.16]; P = .03).

Conclusions and Relevance

The findings of this cohort study of bypass outcomes for patients with MMD emphasize the importance of tailoring management strategies in adult patients based on onset types.

Low and Borderline Ankle-Brachial Index Is Associated With Intracranial Aneurysms: A Retrospective Cohort Study

BACKGROUND AND OBJECTIVES

A low ankle-brachial index (ABI) has been linked to systemic inflammation and an elevated risk of cardiovascular events, most notably myocardial infarction and stroke. Intracranial aneurysms (IAs) share similar risk factors with other cardiovascular diseases. However, the association between low ABI and IAs has not been sufficiently investigated. Our objective was to investigate the potential connection between ABI values and the prevalence of unruptured IAs.

METHODS

This retrospective cohort study reviewed 2751 patients who had ABI measurements at a public tertiary hospital from January 2011 to December 2013. Patients with available cerebrovascular imaging or a diagnosis of ruptured IA were included in the study (n = 776) to examine the association between ABI and saccular IAs. The patients were classified into 4 groups: low ABI (≤0.9, n = 464), borderline ABI (0.91-0.99; n = 47), high ABI (>1.4, n = 57), and normal ABI (1.00-1.40; n = 208).

RESULTS

The prevalence of IAs was 20.3% (18.1% unruptured IAs) in the low ABI group, 14.9% (12.8% unruptured IAs) in the borderline ABI group, 7.0% (5.3% unruptured IAs) in the high ABI group, and 2.4% (1.9% unruptured IAs) in the normal ABI group (P < .001). There were no significant differences in the prevalence of ruptured IAs between the ABI groups (P = .277). Sex- and age-adjusted multinomial regression, including clinically relevant variables, revealed that low ABI (odds ratio [OR], 13.02; 95% CI, 4.01-42.24), borderline ABI (OR, 8.68; 95% CI, 2.05-36.69), and smoking history (OR, 2.01; 95% CI, 1.07-3.77) were associated with unruptured IAs.

CONCLUSION

The prevalence of unruptured IAs was 9-fold higher in the low ABI group and nearly 7-fold higher in the borderline ABI group when compared with the normal ABI group. ABI measurements could be clinically relevant for identifying individuals at higher risk of IAs and may help guide screening and preventive strategies.

Prevalence of aortic aneurysms and dissections in patients with systemic vessel aneurysms and dissections; matched case-control study using a national sample cohort

Objective

Aneurysms in systemic arteries are rare, and little is known about their relationship with aortic aneurysms. In this study, we aimed to evaluate the prevalence of aortic aneurysms and dissections (AAD) in patients with other systemic vessel aneurysms and dissections (OVAD) and identify their potential risk factors.

Methods

This cross-sectional study used a nationwide representative cohort sample from the Korea National Health Insurance Service-National Sample Cohort database. We defined OVAD as systemic vessel aneurysms and dissections excluding intracranial and aortic dissections and aneurysms. With a total of 690 OVAD patients and 2,760 non-OVAD matched controls, we investigated the prevalence of AAD in patients with OVAD and potential risk factors for their concurrence using the χ2 test and logistic regression.

Results

The prevalence of AAD in patients with OVAD was 10.6% (73/690) and 0.3% (9/2,760) in patients with non-OVAD. The adjusted odds ratio (OR) for having concurrent AAD with OVAD was 37.56 (95% CI: 18.29-77.12, p < 0.001) after stratification by sex, age, income, region of residence and after adjustment for hypertension, diabetes mellitus, dyslipidemia, and extent of disability. The adjusted ORs of AAD were significantly higher in females [adjusted OR = 47.63 (95% CI: 10.72-211.55)], and individuals aged ≥60 years [adjusted OR = 28.18 (95% CI: 13.42-59.17)], as well as those without hypertension [adjusted OR = 95.44 (95% CI: 18.21-500.23)], diabetes mellitus [adjusted OR = 46.39 (95% CI: 18.85-114.17)], without dyslipidemia [adjusted OR = 60.99 (95% CI: 20.83-178.56), p < 0.001 for all]. The prevalence of AAD significantly differed by according to specific sites of OVAD in carotid artery, upper extremity artery, iliac artery, lower extremity artery, and splanchnic artery (p < 0.001 for all).

Conclusions

The prevalence of AAD in patients with OVAD was 37.56 times higher than that in the matched population. We may approach aneurysms as systemic diseases and further investigations of pathophysiology would help to clarify the relationships between AAD and OVAD.

Long‐Term Risks of Stroke in Patients With Type A Aortic Dissection: A Nationwide Cohort Study

Background

Patients with type A aortic dissection (TAAD) have a high short‐term risk of stroke. However, whether patients with TAAD have an increased long‐term risk of stroke is still undetermined, and our study aims to address this knowledge gap.

Methods and Results

A nationwide retrospective cohort study was conducted using Taiwan's National Health Insurance Research Database. We included patients with TAAD as well as age‐ and sex‐matched aortic disease–free individuals between 2003 and 2016. Inverse probability of treatment weighting was performed to balance patient characteristics between the groups. The primary outcome was the development of stroke, regardless of subtype; the secondary outcomes were the risk of developing either ischemic or hemorrhagic stroke. The hazard ratios (HRs) of stroke were estimated using the Cox proportional hazards model. After inverse probability of treatment weighting, 3556 and 7023 patients were categorized into the TAAD and aortic disease–free cohorts, respectively. The mean follow‐up period was 5.71 years. The HRs for overall, ischemic, and hemorrhagic strokes in the TAAD cohort were 3.01 (95% CI, 2.40–3.78), 3.18 (95% CI, 2.47–4.10), and 2.32 (95% CI, 1.58–3.41), respectively, compared with the aortic disease–free cohort. Consistent trends of higher stroke risk in patients with TAAD were revealed in the analyses stratified by age; sex; antiplatelet use; and history of hypertension, diabetes, or dyslipidemia.

Conclusions

Our study findings revealed that patients with TAAD had an increased long‐term risk of both ischemic and hemorrhagic strokes. Further studies are warranted to establish optimal strategies for stroke prevention in these patients.

Impact of obstructive sleep apnea on aortic disease occurrence: a meta-analysis

Objective

Aortic diseases, mainly including aortic dilatation, aortic aneurysm (AA) and aortic dissection (AD), have high morbidity and mortality. Many studies have suggested that obstructive sleep apnea (OSA) acts as a candidate risk factor for aortic diseases. Thus, we performed a meta-analysis to explore comprehensively the effect of OSA on the risk of aortic disease occurrence.

Methods

We searched PubMed, Embase and Cochrane Library databases from inception to February 2022 to identify studies investigating the association between OSA and aortic diameter dilatation, the prevalence of OSA in individuals with or without AA/AD and the incidence of AA/AD in individuals with or without OSA. The Newcastle-Ottawa Scale (NOS) and the Agency for Healthcare Research and Quality (AHRQ) were respectively used to evaluate the quality of the included cohort and cross-sectional studies. A random or fixed effect model was used to generate pooled effects according to interstudy heterogeneity. Sensitivity analyses were performed to test the robustness of the results.

Results

We identified 10 observational publications with 214,127 participants in this meta-analysis. OSA was significantly associated with increased aortic diameter (WMD = 1.46, 95% CI, 1.10–1.83, p < 0.001). OSA prevalence was higher in patients with AA/AD compared to their counterparts without AA/AD (OR = 1.90, 95% CI, 1.30–2.76, p = 0.001). No significant difference in the incidence of AA/AD was observed in individuals with or without OSA (RR = 0.85, 95% CI, 0.62–1.16, p = 0.307). Sensitivity analyses did not modify these results.

Conclusions

This meta-analysis suggests that OSA is associated with aortic diameter dilatation but does not affect AA/AD occurrence.

Prevalence of Intracranial Aneurysm in Patients With Aortic Disease in Korea: A Nationwide Population-Based Study

Background Patients with aortic disease (AD) might have a higher prevalence of intracranial aneurysm (IA). The present study evaluated the prevalence of IA in patients with AD and identified potential risk factors of IA using nationwide representative cohort sample data. Methods and Results We defined AD as both aortic dissections and aortic aneurysms. This study used a nationwide representative cohort sample from the Korea National Health Insurance Service-National Sample Cohort database from 1.1million patients. Using χ² or Fisher's exact tests, the prevalence of the IA in patients with AD and potential risk factors for their concurrence were analyzed. The prevalence of IA in patients with AD was 6.8% (155/2285). The adjusted odds ratios (OR) for having concurrent IA in patients with AD was 3.809 (95% CI, 3.191-4.546; P<0.01). Patients with AD and hypertension were >19 times more likely to be affected by IA (adjusted OR, 18.679; 95% CI, 16.555-21.076; P<0.01). Patients with AD and diabetes mellitus, old age (>60 years), and male sex were >4, 3, and 2 times more likely to be affected by IA, respectively (adjusted OR, 4.291, 3.469, and 1.983, respectively; 95% CI, 3.914-4.704, 3.152-3.878, and 1.779-2.112, respectively). Subgroup analysis with socioeconomic status or disability revealed that the prevalence of IA was significantly higher in all groups. Conclusions In the current population-based study, the prevalence of IA in patients with AD was quadrupled compared with that in the general population. Early IA screening might be considered among patients with AD for appropriate management.