Use of carotid intima-media thickness to identify patients with ischemic stroke and transient ischemic attack with low yield of cardiovascular sources of embolus on transesophageal echocardiography

Bubble Test and Carotid Ultrasound to Guide Indication of Transesophageal Echocardiography in Young Patients With Stroke

Background and Purpose

Indication of transesophageal echocardiography (TEE) in patients ≤60 years with brain ischemia is uncertain.

Methods

This prospective double-blinded study included patients with cryptogenic acute ischemic stroke or transient ischemic attack (TIA) ≥18 and ≤60 years. After routine diagnostics, all patients underwent patent foramen ovale (PFO) screening by transcranial Doppler (TCD) bubble test, carotid ultrasound for atherosclerosis screening (intima-media-thickness >0.90 mm or plaques), and TEE. We calculated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) of the combined non-invasive ultrasound to predict therapy-relevant TEE findings.

Results

We included 240 consecutive patients (median 51 years, 39% women) of which 68 (28.3%) had both a negative bubble test and no carotid atherosclerosis. Of these, 66 (97.1%) had unremarkable TEE findings; in one patient a small PFO was found and closed subsequently, in another patient a 4.9 mm thick aortic atheroma was found, and double platelet inhibition initiated. Of the other 172 (71.7%) patients, 93 (54%) had PFO and 9 (5.2%) complex aortic plaques. No other therapy-relevant findings were present in both groups. Non-invasive ultrasound had a sensitivity of 98.0%, specificity of 47.8%, NPV of 97.1%, and PPV of 58.1% for therapy-relevant TEE findings.

Conclusions

Bubble test and carotid ultrasound could be used for the individual decision for/against TEE in patients with cryptogenic stroke ≤60 years. If they are unremarkable, TEE can be omitted with high safety regarding secondary prevention. If bubble test is positive and/or carotid ultrasound shows atherosclerosis, TEE should be carried out if PFO or aortic atheroma are potentially relevant for further patient management.

Low CD4 Cell Counts Are Associated with Carotid Plaque and Intima-Media Thickness in Virologically Suppressed HIV-Infected Asians Older Than 50 Years

Information about the prevalence, and risk factors for subclinical atherosclerosis in an Asian HIV-infected population is limited. Carotid intima-media thickness (cIMT) is one predictor for the risk of cardiovascular disease (CVDs) and mortality. We evaluated the prevalence and risk factors related to carotid atherosclerosis among well-suppressed HIV-infected adults receiving long-term ART from Thailand. This was a cross-sectional study of HIV-infected adults >50 years of age and free from CVDs from Thailand during 1 March 2016 and 30 May 2017. Ultrasonography of the carotid was performed and read by cIMT experienced neurologists who were blinded from the patient care. Subclinical atherosclerosis was defined by carotid plaque or cIMT of the common carotid artery (CCA) >0.9 mm. Totally 316 HIV-infected adults (61% males) were included. Median age was 54.4 years and 15.8% were diabetic, 40.2% had hypertension, and 12.7% were current smokers. The median duration of ART was 16.3 years and 32% were currently on boosted protease inhibitor. The mean overall cIMT of the common carotid arteries were 0.63 (IQR 0.55-0.72) mm. Men had higher cIMT than women, 0.64 (IQR 0.56-0.76) vs. 0.60 (IQR 0.53-0.70), p = .03. Overall, 3.8% had cIMT >0.9 mm and 24.4% had carotid plaque. From the multivariate logistic regression analysis, age per 1 year increase [odds ratio (OR) 1.06; 95% confidence interval (CI) 1.003-1.12; p = .04] and nadir CD4 < 200 cells/mm³ (OR 1.8; 95%CI 1.02-3.18, p = .04) were significantly associated with subclinical atherosclerosis. High-sensitivity C-reactive protein was not associated with subclinical atherosclerosis. In this well-suppressed HIV-infected Aging Asian cohort with relatively low prevalence of current smokers, 26.9% of them had subclinical atherosclerosis. Advanced age and low nadir CD4 cell count were significantly associated with subclinical atherosclerosis. Given that approximately a quarter of the patients had carotid plaques, longitudinal studies to evaluate the development of future overt coronary artery disease and stroke are warranted.

Ultrasonic assessment of carotid intima-media thickness in migraine: a meta-analysis

Objective

Migraine is believed to be a risk factor for cerebrovascular diseases, and previous studies have indicated an association between migraine and cerebral atherosclerosis. Carotid artery intima-media thickness (IMT) is considered to be a biomarker of atherosclerosis pathology. This study aimed to investigate the relationship between carotid IMT and migraine by conducting a meta-analysis.

Methods

We searched Web of Science, PubMed, and the Cochrane Library for eligible studies assessing carotid IMT in patients with migraine and controls. Data were extracted independently by two reviewers and analyzed using Review Manager 5.3 software.

Results

The meta-analysis included seven articles with 555 subjects (279 migraine patients, 276 controls). Carotid IMT was significantly greater in patients with migraine compared with controls. However, there were no significant differences in IMT between patients with migraine with aura (MA) and controls, migraine without aura (MO) and controls, and patients with MA and MO.

Conclusion

Patients with migraine have greater carotid IMT than individuals without migraine, suggesting an association between atherosclerosis and migraine. However, further studies with more samples are needed to confirm this finding.

Atherosclerosis in intracranial, extracranial, and coronary arteries with aortic plaques in patients with ischemic stroke of undetermined etiology

OBJECTIVE

We investigated the association of cerebral and coronary artery atherosclerosis with the presence, burden and type of atherosclerotic plaques of the aorta (AP) in patients with ischemic stroke of undetermined etiology.

METHODS

48 consecutive patients (32 males, mean age 68 ± 11 years) with acute ischemic stroke of unknown etiology after thorough stroke workup were investigated using ECG-gated CT-Angiography (CTA) for the detection of embolic AP. Intima media thickness (IMT), presence of carotid plaques and stenosis ≥ 50% and intracranial stenosis were assessed as parameters of cerebral atherosclerosis, the Agatston score (AS) and coronary artery stenosis ≥ 50% (CAS) in CTA as parameters of coronary atherosclerosis. Plaque burden was classified as mild or severe and plaque types were classified according to their morphology in calcified, non-calcified or mixed.

RESULTS

APs were found in 36 patients (75%). AP presence was associated with higher IMT values (p = 0.029), intracranial stenosis (p = 0.047), CAS (p = 0.033) and AS (p = 0.026). Twenty-three of 31 (74.2%) patients with both carotid atherosclerosis and AP revealed plaque calcification (p = 0.041). Ten of 14 (71.4%) patients with AP and intracranial stenosis had calcified plaques (p = 0.030). AP in more than one aortic segment was found in patients with bilateral carotid stenosis ≥ 50% (p = 0.038), intracranial stenosis (p = 0.042), high IMT (p = 0.040) and higher AS (p = 0.019).

CONCLUSIONS

Aortic atherosclerotic plaques are common in patients with ischemic stroke of undetermined etiology and in particular those with carotid, intracranial and coronary atherosclerosis or high IMT values. In these patients, CTA of aorta should be seriously considered.

Different locations but common associations in subcortical hypodensities of presumed vascular origin: cross-sectional study on clinical and neurosonologic correlates

BACKGROUND

Subcortical hypodensities of presumed vascular etiology (SHPVO) are a clinical, radiological and neuropathological syndrome with a still largely unexplained pathophysiology. Parallel to the clinical heterogeneity, there is also recognised cerebral topographical diversity with undetermined etiological implications. Our aim is to assess clinical and neurosonological predictors of SHPVO according to their location.

METHODS

Cross sectional analysis of consecutive patients that underwent neurosonologic evaluation and head CT within one month, during a one year period. We excluded patients with absent temporal sonographic window, any pathology with a possible confounding effect on cerebral arterial pulsatility, atrial fibrillation and other etiologies of white matter diseases. The mean pulsatility index (PI) of both middle cerebral arteries was measured in the middle third of the M1 segment; intima media thickness was evaluated in the far wall of both common carotid arteries. SHPVO were rated by analysis of head CT in deep white matter (DWMH), periventricular white matter (PVWMH) and basal ganglia (BGH). We conducted a multivariate ordinal logistic regression model including all clinical, demographic and ultrasonographic characteristics to determine independent associations with SHPVO.

RESULTS

We included 439 patients, mean age 63.47 (SD: 14.94) years, 294 (67.0%) male. The independent predictors of SHPVO were age (OR = 1.067, 95% CI: 1.047-1.088, p < 0.001 for DWMH; OR = 1.068, 95% CI: 1.049-1.088, p < 0.001 for PVWMH; OR = 1.05, 95% CI: 1.03-1.071, p < 0.001 for BGH), hypertension (OR = 1.909, 95% CI: 1.222-2.981, p = 0.004 for DWMH; OR = 1.907, 95% CI: 1.238-2.938, p = 0.003 for PVWMH; OR = 1.775, 95% CI: 1.109-2.843, p = 0.017 for BGH) and PI (OR = 17.994, 95% CI: 6.875-47.1, p < 0.001 for DWMH; OR = 5.739, 95%CI: 2.288-14.397, p < 0.001 for PVWMH; OR = 11.844, 95% CI: 4.486-31.268, p < 0.001 for BGH) for all locations of SHPVO.

CONCLUSIONS

Age, hypertension and intracranial pulsatility are the main independent predictors of SHPVO across different topographic involvement and irrespective of extracranial atherosclerotic involvement.

Carotid artery atherosclerotic profile as a predictor of the aorta atherosclerotic profile in patients with cerebrovascular events

BACKGROUND

It is well known that the presence of atheroma of the thoracic aorta is a risk factor for cerebrovascular events. We sought to evaluate whether the presence and the morphology of atherosclerotic plaque in the carotid artery detected by duplex ultrasonography is associated with disease in the proximal aorta visualized by transesophageal echocardiogram in patients with a cerebrovascular event.

METHODS

We carried out a cross-sectional prospective study including 147 consecutive patients with prior stroke or transient ischemic attack (TIA). Neurological evaluations were performed by an expert neurologist using clinical and tomographic diagnostic criteria including the definition of etiology and whether the patient suffered from stroke or TIA. Transthoracic and transesophageal echocardiograms and carotid artery duplex ultrasonography were performed by the same examiner. Patients with and without plaque in the carotid artery were compared using Student's t test or the χ2 test. Regression analysis was used to determine whether the presence of plaque in the carotid artery was predictive of the presence of plaque in the proximal aorta and to analyze the relationship between the echogenicity of carotid and aortic plaques. The significance level was set at p < 0.05.

RESULTS

All 147 patients (95 men) were included in the analysis. Patients' ages ranged from 23 to 85 years (65 ± 12.4 years). Most of the patients (58.5%) were Caucasian, while 41.5% were African-Brazilian. Arterial hypertension, diabetes and tobacco use were more frequent among patients with atherosclerotic plaque in the aorta. A normal carotid intima-media thickness halved the risk of atherosclerotic plaque in the aorta [odds ratio (OR) 0.46, 95% confidence interval (CI) 0.23-0.91; p = 0.026]. The presence of carotid plaque increased the risk of aortic plaque by 70-fold (OR 73.2, 95% CI 25.6-2,018.6; p < 0.001) in univariate analysis. The absence of atherosclerotic plaque in the carotid artery reduced the risk of plaque in the aorta to almost 0 (OR 0.014, 95% CI 0.004-0.041; p < 0.001). Considering the 86 patients with both aortic and carotid plaques, the presence of hypoechoic plaque in the carotid artery was a predictor of hypoechoic plaque in the aorta (OR 10.1, 95% CI 3.3-31.2; p < 0.001).

CONCLUSIONS

The carotid artery atherosclerotic profile defined by ultrasonography is a strong predictor of the atherosclerotic profile of the proximal aorta. This should be taken into consideration before referring patients with acute cerebrovascular events for transesophageal echocardiogram.

A retrospective case-control study of modifiable risk factors and cutaneous markers in Indian patients with young coronary artery disease

OBJECTIVE

Indians have the highest risk rates for coronary artery disease (CAD) among all ethnic groups. There is a paucity of data on the risk factors and clinical markers associated with premature CAD. We aimed to determine whether young CAD is due to preventable lifestyle-related factors and cutaneous clinical markers are useful in identifying at-risk patients.

DESIGN

Single-centre retrospective study.

SETTING

Tertiary care center.

PARTICIPANTS

A total of 292 patients (age ≤40 years) who presented with acute CAD between January 2005 and June 2009 and 92 age, and gender-matched controls.

MAJOR OUTCOME MEASURES

Details of smoking, family history of premature CAD, waist size, blood sugar and lipid profile. Clinical evidence of arcus juvenilis, premature greying of hair and premature baldness sought.

RESULTS

Dyslipidaemia (91%), smoking (74.3%), low high-density lipoprotein cholesterol (HDL-C) (68.9%), central obesity (47.7%) and greying of hair (34.9%) were the most commonly associated factors. Compared with male patients, females had greater prevalence of dyslipidaemia, low HDL-C, central obesity, hypertension, diabetes and family history of premature CAD. The presence of cutaneous markers was significantly associated with premature CAD.

CONCLUSIONS

CAD in young Indian people is multifactorial; dyslipidaemia, low HDL-C, smoking, hypertension, central obesity and family history of premature CAD are the most common risk factors. Smoking in men and central obesity in women are the most prevalent factors. Clinicians should be highly suspicious of patients with presence of cutaneous markers, and they should be followed intensively for lifestyle modifications.

Carotid artery wall thickness and leukoaraiosis: preliminary results using multidetector row CT angiography

BACKGROUND AND PURPOSE

LA is a condition caused by chronic cerebral ischemia and it represents an independent risk for stroke. The purpose of this work was to determine whether CAWT studied by using MDCTA is correlated with LA and its severity.

MATERIALS AND METHODS

Ninety-eight patients ≥60 years of age were retrospectively studied by using multidetector row CT. Supra-aortic vessel analysis and brain CT were performed in the same procedure. In each patient, CAWT was measured with an internal digital caliper, and the presence and severity of LA were assessed. Correlation coefficients by using Spearman statistics and ROC curves were calculated. A P value < .05 was considered statistically significant.

RESULTS

Measurements of the distal common CAWT ranged from 0.5 to 1.53 mm. A correlation between LA and increased CAWT was observed (Pearson correlation, 0.33; P < .001). On the basis of a threshold of 0.9 mm, an important statistical association between increased CAWT and LA (P < .0001) was found. With the same threshold, ROC curve analysis indicated a sensitivity of 55% and a specificity of 75% for LA.

CONCLUSIONS

The results of this study show a statistically significant correlation between increased CAWT and LA (and its severity).

Carotid artery wall thickness and risk of stroke subtypes: the atherosclerosis risk in communities study

BACKGROUND AND PURPOSE

Understanding associations of carotid atherosclerosis with stroke subtypes may contribute to more effective prevention of stroke.

METHODS

Between 1987 and 1989, 13 560 men and women aged 45 to 64 years and free of clinical stroke took part in the first examination of the Atherosclerosis Risk in Communities (ARIC) study. Incident strokes were ascertained by hospital surveillance.

RESULTS

During an average follow-up of 15.7 years, 82 incident hemorrhagic and 621 incident ischemic strokes (131 lacunar, 358 nonlacunar, and 132 cardioembolic strokes) occurred. The incidence rates of hemorrhagic and ischemic strokes were greater across higher carotid intima-media thickness levels. Although this positive association was observed for all stroke subtypes, the age-, gender-, and race-adjusted risk ratios were higher for cardioembolic and nonlacunar strokes than for hemorrhagic and lacunar strokes. Compared with participants in the lowest quintile (<0.61 mm), the adjusted risk ratios for those in the highest quintile (≥0.85 mm) of intima-media thickness were 2.55 (95% CI, 1.09-5.94) for hemorrhagic, 2.89 (95% CI, 1.50-5.54) for lacunar, 3.61 (95% CI, 2.33-5.99) for nonlacunar, and 6.12 (95% CI, 2.71-13.9) for cardioembolic stroke. The risk ratios were attenuated by additional adjustment for covariates but remained statistically significant for nonlacunar and cardioembolic strokes (P for trend <0.001, respectively). The association between carotid intima-media thickness and lacunar stroke was somewhat stronger in blacks than in whites (P for interaction=0.07).

CONCLUSIONS

Carotid atherosclerosis was associated with increased risk of all stroke subtypes, but the association of carotid atherosclerosis with stroke may vary by subtypes.

Carotid atherosclerosis in ischemic cerebrovascular patients

Background

Cerebral emboli resulting from atherosclerosis at the carotid bifurcation is a major cause of ischemic stroke. A convenient and prompt evaluation is necessary for secondary prevention and treatment.

Methods

In this study, one hundred and thirty eight patients with cerebral ischemic events were enrolled; 100 patients with nonischemic cerebral diseases were enrolled as controls. Noninvasive ultrasound was used to measure the atherosclerotic plaques and intima-media thickness (IMT) of carotid and femoral artery.

Results

Our results showed that patients in study group had higher incidence and severity of carotid and femoral plaques, and higher mean intima-media thickness (IMT) at both the carotid and femoral sites compared with that of controls (p < 0.01). Carotid atherosclerosis were highly prone to have instability plaques in study group(p < 0.001).

Conclusions

This cross-sectional study showed that, the prevalence of carotid atherosclerosis and the unstable plaques were higher in cerebral ischemic patients.

Keywords

Carotid artery; Atherosclerosis; Intima-media thickness; Cerebral ischemic stroke