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Ariko TA, Aimagambetova B, Gardener H, Gutierrez J, Elkind MSV, Wright CB, Zhao W, Rundek T. Estimated Pulse-Wave Velocity and Magnetic Resonance Imaging Markers of Cerebral Small-Vessel Disease in the NOMAS. J Am Heart Assoc 2024; 13:e035691. [PMID: 39023069 DOI: 10.1161/jaha.124.035691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/24/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Pulse-wave velocity is a measure of arterial stiffness and a risk factor for cardiovascular disease. Recently, an estimated pulse-wave velocity (ePWV) was introduced that was predictive of increased risk of cardiovascular disease. Our objective was to determine whether ePWV was associated with cerebral small-vessel disease on magnetic resonance imaging. METHODS AND RESULTS We included 1257 participants from the NOMAS (Northern Manhattan Study). The ePWV values were calculated using a nonlinear function of age and mean arterial blood pressure. The association between ePWV and white matter hyperintensity volume was assessed. Modification by race and ethnicity was evaluated. Associations between ePWV and other cerebral small-vessel disease markers, covert brain infarcts, cerebral microbleeds, and enlarged perivascular spaces, were explored as secondary outcomes. Mean±SD age of the cohort was 64±8 years; 61% were women; 18% self-identified as non-Hispanic Black, 67% as Hispanic, and 15% as non-Hispanic White individuals. Mean±SD ePWV was 11±2 m/s in the total NOMAS population and was similar across race and ethnic groups. The ePWV was significantly associated with white matter hyperintensity volume (β=0.23 [95% CI, 0.20-0.26]) after adjustment. Race and ethnicity modified the association between ePWV and white matter hyperintensity volume, with stronger associations in Hispanic and non-Hispanic Black individuals. Significant associations were found between ePWV and covert brain infarcts, cerebral microbleeds, and perivascular spaces after adjustment. CONCLUSIONS The ePWV function may provide a vascular mechanism for deleterious cerebrovascular outcomes in individuals with cerebral small-vessel disease and is particularly apparent in the racial and ethnic minorities represented in the NOMAS cohort.
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Affiliation(s)
- Taylor A Ariko
- Evelyn F. McKnight Brain Institute, University of Miami Miami FL
- Department of Biomedical Engineering University of Miami Miami FL
| | - Botagoz Aimagambetova
- Evelyn F. McKnight Brain Institute, University of Miami Miami FL
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Hannah Gardener
- Evelyn F. McKnight Brain Institute, University of Miami Miami FL
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Jose Gutierrez
- Department of Neurology, Vagelos College of Physicians and Surgeons Columbia University New York NY
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons Columbia University New York NY
- American Heart Association Dallas TX
| | - Clinton B Wright
- National Institute of Neurological Disorders and Stroke Bethesda MD
| | - Weizhao Zhao
- Department of Biomedical Engineering University of Miami Miami FL
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | - Tatjana Rundek
- Evelyn F. McKnight Brain Institute, University of Miami Miami FL
- Department of Biomedical Engineering University of Miami Miami FL
- Department of Neurology University of Miami Miller School of Medicine Miami FL
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Roh DJ, Murguia-Fuentes R, Gurel K, Khasiyev F, Rahman S, Bueno PP, Kozii K, Spagnolo-Allende AJ, Cottarelli A, Simonetto M, Ji R, Guo J, Spektor V, Hod EA, Burke DJ, Konofagou E, Rundek T, Wright CB, Marshall RS, Elkind MSV, Gutierrez J. Relationships of Hematocrit With Chronic Covert and Acute Symptomatic Lacunar Ischemic Lesions. Neurology 2024; 102:e207961. [PMID: 38165319 PMCID: PMC10870744 DOI: 10.1212/wnl.0000000000207961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/11/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Red blood cell (RBC) concentrations are known to associate with ischemic stroke. It is unclear whether RBC concentrations associate specifically with small vessel disease lacunar infarcts. We investigated the hypothesis that RBC concentrations associate with both chronic covert and acute symptomatic brain MRI lacunar infarcts. METHODS A cross-sectional observational analysis was performed across 2 cohorts with available hematocrit (as the assessment of RBC concentration exposure) and MRI outcome data. The primary setting was a population-based cohort of stroke-free, older adult (>50 years) participants from the Northern Manhattan Study (NOMAS) enrolled between 2003 and 2009. A second replication sample consisted of patients admitted with acute stroke and enrolled into the Columbia Stroke Registry (CSR) between 2005 and 2020. Associations of hematocrit with (1) chronic, covert lacunar infarcts and (2) symptomatic (i.e., acute) lacunar strokes were separately assessed from the NOMAS and CSR cohorts, respectively, using general additive models after adjusting for relevant covariates. RESULTS Of 1,218 NOMAS participants analyzed, 6% had chronic, covert lacunar infarcts. The association between hematocrit and these covert lacunar infarcts was U-shaped (χ2 = 9.21 for nonlinear associations; p = 0.03), with people with hematocrit extremes being more likely to have covert lacunar infarcts. Of the 1,489 CSR patients analyzed, 23% had acute lacunar strokes. In this sample, only the relationships of increased hematocrit concentrations and lacunar strokes were replicated (adjusted coefficient β = 0.020; SE = 0.009; p = 0.03). DISCUSSION We identified relationships of hematocrit with MRI lacunar infarcts in both stroke-free and ischemic stroke cohorts, respectively. The relationship between increased hematocrit concentrations with lacunar infarcts was replicated in both cohorts. Further studies are required to clarify the mechanisms behind the relationships of hematocrit with ischemic cerebral small vessel disease.
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Affiliation(s)
- David J Roh
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Ricardo Murguia-Fuentes
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Kursat Gurel
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Farid Khasiyev
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Salwa Rahman
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Pedro Paiva Bueno
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Khrystyna Kozii
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Antonio J Spagnolo-Allende
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Azzurra Cottarelli
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Marialaura Simonetto
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Robin Ji
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Jia Guo
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Vadim Spektor
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Eldad A Hod
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Devin J Burke
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Elisa Konofagou
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Tatjana Rundek
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Clinton B Wright
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Randolph S Marshall
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Mitchell S V Elkind
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Jose Gutierrez
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
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Khatri P. Anticoagulants to prevent recurrent non-cardioembolic stroke. Lancet Neurol 2024; 23:3-5. [PMID: 38101895 DOI: 10.1016/s1474-4422(23)00464-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 11/23/2023] [Accepted: 11/23/2023] [Indexed: 12/17/2023]
Affiliation(s)
- Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH 45208, USA.
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Gurel K, Khasiyev F, Spagnolo-Allende A, Rahman S, Liu M, Kulick ER, Boehme A, Rundek T, Sv Elkind M, Marshall RS, Bos D, Gutierrez J. The role of intracranial artery calcification (IAC) in stroke subtype and risk of vascular events. J Stroke Cerebrovasc Dis 2023; 32:107185. [PMID: 37186970 PMCID: PMC10524441 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/01/2023] [Accepted: 05/10/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE To test the hypothesis that intracranial arterial calcification (IAC) is associated with intracranial large artery stenosis (ILAS) and a higher risk of vascular events and mortality. METHOD We leveraged data from two cohorts, the New York-Presbyterian Hospital/Columbia University Irving Medical Center Stroke Registry Study (NYP/CUIMC-SRS) and the Northern Manhattan Study (NOMAS) to test our hypotheses. We measured IAC using CT scans of participants in both cohorts and expressed IAC as present (vs not) and in tertiles. For the CUIMC-SRS, demographic, clinical and ILAS status was collected retrospectively. In NOMAS, we used research brain MRI and MRA to define asymptomatic ILAS and covert brain infarcts(CBI). We built models adjusted for demographics and vascular risk factors for cross-sectional and longitudinal analyses. RESULTS Cross-sectionally, IAC was associated with ILAS in both cohorts (OR 1.78, 95% CI: 1.16-2.73 for ILAS-related stroke in the NYP/CUIMC-SRS and OR 3.07, 95%CI 1.13-8.35 for ILAS-related covert brain infarcts in NOMAS). In a meta-analysis of both cohorts, IAC in the upper (HR 1.25, 95%CI 1.01-1.55) and middle tertile (HR 1.27, 95%CI 1.01-1.59) was associated with higher mortality compared with participants with no IAC. There were no longitudinal associations between IAC and risk of stroke or other vascular events. CONCLUSION In these multiethnic populations, IAC is associated with symptomatic and asymptomatic ILAS as well as higher mortality. IAC may be a useful marker of higher mortality, the role of IAC as an imaging marker of risk of stroke is less certain.
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Affiliation(s)
- Kursat Gurel
- Florence Irving Assistant Professor of Neurology, Department of Neurology, Irving Medical Center, Vagelos College of Physicians and Surgeons, Columbia University, 710 W 168th Street, 6th floor, Suite 639, New York, NY 10032, United States
| | - Farid Khasiyev
- Department of Neurology, Saint Louis University, Saint Louis, MI, United States
| | - Antonio Spagnolo-Allende
- Florence Irving Assistant Professor of Neurology, Department of Neurology, Irving Medical Center, Vagelos College of Physicians and Surgeons, Columbia University, 710 W 168th Street, 6th floor, Suite 639, New York, NY 10032, United States
| | - Salwa Rahman
- Florence Irving Assistant Professor of Neurology, Department of Neurology, Irving Medical Center, Vagelos College of Physicians and Surgeons, Columbia University, 710 W 168th Street, 6th floor, Suite 639, New York, NY 10032, United States
| | - Minghua Liu
- Florence Irving Assistant Professor of Neurology, Department of Neurology, Irving Medical Center, Vagelos College of Physicians and Surgeons, Columbia University, 710 W 168th Street, 6th floor, Suite 639, New York, NY 10032, United States
| | - Erin R Kulick
- Department of Epidemiology and Biostatatistics, Temple University College of Public Health, Philadelphia, PA, United States
| | - Amelia Boehme
- Florence Irving Assistant Professor of Neurology, Department of Neurology, Irving Medical Center, Vagelos College of Physicians and Surgeons, Columbia University, 710 W 168th Street, 6th floor, Suite 639, New York, NY 10032, United States
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, United States; Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, United States; Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Mitchell Sv Elkind
- Florence Irving Assistant Professor of Neurology, Department of Neurology, Irving Medical Center, Vagelos College of Physicians and Surgeons, Columbia University, 710 W 168th Street, 6th floor, Suite 639, New York, NY 10032, United States; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Randolph S Marshall
- Florence Irving Assistant Professor of Neurology, Department of Neurology, Irving Medical Center, Vagelos College of Physicians and Surgeons, Columbia University, 710 W 168th Street, 6th floor, Suite 639, New York, NY 10032, United States
| | - Daniel Bos
- Department of Epidemiology, Erasmus MC University Medical Center Rotterdam, the Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Jose Gutierrez
- Florence Irving Assistant Professor of Neurology, Department of Neurology, Irving Medical Center, Vagelos College of Physicians and Surgeons, Columbia University, 710 W 168th Street, 6th floor, Suite 639, New York, NY 10032, United States.
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Bilski AE, Aparicio HJ, Gutierrez J, de Leeuw FE, Hilkens N. Antiplatelet Therapy or Not for Asymptomatic/Incidental Lacunar Infarction. Stroke 2023; 54:1954-1959. [PMID: 37191009 PMCID: PMC10421561 DOI: 10.1161/strokeaha.122.040444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/11/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Amanda E Bilski
- Department of Neurology, New York Presbyterian Hospital/ Columbia University Irving Medical Center
| | - Hugo J. Aparicio
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine
- Boston Medical Center
| | - Jose Gutierrez
- Department of Neurology, New York Presbyterian Hospital/ Columbia University Irving Medical Center
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Nina Hilkens
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
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Lucci C, Rissanen I, de Jong PA, Kappelle LJ, Hendrikse J, Geerlings MI. Ischemic stroke recurrence and mortality in different imaging phenotypes of ischemic cerebrovascular disease: The SMART-MR Study. Eur Stroke J 2023; 8:522-531. [DOI: 10.1177/23969873231162122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Background: Diagnosis of cerebrovascular disease is based on both clinical and radiological findings, however, they do not always correlate. Aims: To investigate ischemic stroke recurrence and mortality in patients with different imaging phenotypes of ischemic cerebrovascular disease. Methods: Within the SMART-MR study, a prospective patient cohort with arterial disease, cerebrovascular diseases of participants at baseline were classified as no cerebrovascular disease (reference group, n = 828), symptomatic cerebrovascular disease ( n = 204), covert vascular lesions ( n = 156), or imaging negative ischemia ( n = 90) based upon clinical and MRI findings. Ischemic strokes and deaths were collected at 6 month-intervals up to 17 years of follow-up. With Cox regression, relationships between phenotype and ischemic stroke recurrence, cardiovascular mortality, and non-vascular mortality were studied adjusted for age, sex, and cardiovascular risk factors. Results: Compared to reference group risk for recurrent ischemic stroke was increased not only in the symptomatic cerebrovascular disease (HR 3.9, 95% CI 2.3–6.6), but also in the covert vascular lesion (HR 2.5, 95% CI 1.3–4.8) and the imaging negative ischemia groups (HR 2.4, 95% CI 1.1–5.5). Risk for cardiovascular mortality was increased in the symptomatic cerebrovascular disease (HR 2.2, 95% CI 1.5–3.2) and covert vascular lesions groups (HR 2.3, 95% CI 1.5–3.4), while the risk was less strong but also increased in the imaging negative ischemia group (HR 1.7, 95% CI 0.9–3.0). Conclusions: People with all imaging phenotypes of cerebrovascular disease have increased risk of recurrent ischemic stroke and mortality compared to other arterial diseases. Strict preventive measures should be performed even when imaging findings or clinical symptoms are absent. Data access statement: For use of anonymized data, a reasonable request has to be made in writing to the UCC-SMART study group and the third party has to sign a confidentiality agreement.
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Affiliation(s)
- Carlo Lucci
- Department of Radiology, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Ina Rissanen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Department of Neurology, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Mirjam I Geerlings
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
- Department of General Practice, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging & Later Life, and Personalized Medicine, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep, Amsterdam, The Netherlands
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7
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Kim DY, Han SG, Jeong HG, Lee KJ, Kim BJ, Han MK, Choi KH, Kim JT, Shin DI, Cha JK, Kim DH, Kim DE, Ryu WS, Park JM, Kang K, Kim JG, Lee SJ, Oh MS, Yu KH, Lee BC, Park HK, Hong KS, Cho YJ, Choi JC, Sohn SI, Hong JH, Park TH, Lee KB, Kwon JH, Kim WJ, Lee J, Lee JS, Lee J, Gorelick PB, Bae HJ. Covert Brain Infarction as a Risk Factor for Stroke Recurrence in Patients With Atrial Fibrillation. Stroke 2023; 54:87-95. [PMID: 36268719 DOI: 10.1161/strokeaha.122.038600] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND We aimed to evaluate covert brain infarction (CBI), frequently encountered during the diagnostic work-up of acute ischemic stroke, as a risk factor for stroke recurrence in patients with atrial fibrillation (AF). METHODS For this prospective cohort study, from patients with acute ischemic stroke hospitalized at 14 centers between 2017 and 2019, we enrolled AF patients without history of stroke or transient ischemic attack and divided them into the CBI (+) and CBI (-) groups. The 2 groups were compared regarding the 1-year cumulative incidence of recurrent ischemic stroke and all-cause mortality using the Fine and Gray subdistribution hazard model with nonstroke death as a competing risk and the Cox frailty model, respectively. Each CBI lesion was also categorized into either embolic-appearing (EA) or non-EA pattern CBI. Adjusted hazard ratios and 95% CIs of any CBI, EA pattern CBI only, non-EA pattern CBI only, and both CBIs were estimated. RESULTS Among 1383 first-ever stroke patients with AF, 578 patients (41.8%) had CBI. Of these 578 with CBI, EA pattern CBI only, non-EA pattern CBI only, and both CBIs were 61.8% (n=357), 21.8% (n=126), and 16.4% (n=95), respectively. The estimated 1-year cumulative incidence of recurrent ischemic stroke was 5.2% and 1.9% in the CBI (+) and CBI (-) groups, respectively (P=0.001 by Gray test). CBI increased the risk of recurrent ischemic stroke (adjusted hazard ratio [95% CI], 2.91 [1.44-5.88]) but did not the risk of all-cause mortality (1.32 [0.97-1.80]). The EA pattern CBI only and both CBIs elevated the risk of recurrent ischemic stroke (2.76 [1.32-5.77] and 5.39 [2.25-12.91], respectively), while the non-EA pattern only did not (1.44 [0.40-5.16]). CONCLUSIONS Our study suggests that AF patients with CBI might have increased risk of recurrent stroke. CBI could be considered when estimating the stroke risk in patients with AF.
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Affiliation(s)
- Do Yeon Kim
- Department of Neurology and Cerebrovascular Center (D.Y.K., S.-G.H., H.-G.J., K.-J.L., B.J.K., M.-K.H., H.-J.B.), Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Seok-Gil Han
- Department of Neurology and Cerebrovascular Center (D.Y.K., S.-G.H., H.-G.J., K.-J.L., B.J.K., M.-K.H., H.-J.B.), Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Han-Gil Jeong
- Department of Neurology and Cerebrovascular Center (D.Y.K., S.-G.H., H.-G.J., K.-J.L., B.J.K., M.-K.H., H.-J.B.), Seoul National University College of Medicine, Seongnam, Republic of Korea.,Department of Neurosurgery, Seoul National University Bundang Hospital (H.-G.J.), Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Keon-Joo Lee
- Department of Neurology and Cerebrovascular Center (D.Y.K., S.-G.H., H.-G.J., K.-J.L., B.J.K., M.-K.H., H.-J.B.), Seoul National University College of Medicine, Seongnam, Republic of Korea.,Department of Neurology, Korea University Guro Hospital, Seoul, Republic of Korea (K.-J.L.)
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center (D.Y.K., S.-G.H., H.-G.J., K.-J.L., B.J.K., M.-K.H., H.-J.B.), Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center (D.Y.K., S.-G.H., H.-G.J., K.-J.L., B.J.K., M.-K.H., H.-J.B.), Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (K.-H.C., J.-T.K.)
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea (K.-H.C., J.-T.K.)
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea (D.-I.S.)
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Republic of Korea (J.K.C., D.H.K.)
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Republic of Korea (J.K.C., D.H.K.)
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (D.-E.K., W.-S.R.)
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea (D.-E.K., W.-S.R.).,Artificial Intelligence R&D, JLK Corp, Seoul, Republic of Korea (W.-S.R.)
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Republic of Korea (J.-M.P.)
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Republic of Korea (K.K.)
| | - Jae Guk Kim
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., S.J.L.)
| | - Soo Joo Lee
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Republic of Korea (J.G.K., S.J.L.)
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.)
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.)
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea (M.-S.O., K.-H.Y., B.-C.L.)
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea (H.-K.P., K.-S.H., Y.-J.C.,)
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea (H.-K.P., K.-S.H., Y.-J.C.,)
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea (H.-K.P., K.-S.H., Y.-J.C.,)
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea (J.C.C.)
| | - Sung Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea (S.I.S., J.-H.H.)
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea (S.I.S., J.-H.H.)
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Republic of Korea (T.H.P.)
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, Republic of Korea (K.B.L.)
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University Hospital, Ulsan University College of Medicine, Republic of Korea (J.-H.K., W.-J.K.)
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University Hospital, Ulsan University College of Medicine, Republic of Korea (J.-H.K., W.-J.K.)
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Republic of Korea (J.L.)
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Republic of Korea (J.S.L.)
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea (J.L.)
| | - Philip B Gorelick
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL (P.B.G.)
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center (D.Y.K., S.-G.H., H.-G.J., K.-J.L., B.J.K., M.-K.H., H.-J.B.), Seoul National University College of Medicine, Seongnam, Republic of Korea
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Gutierrez J, Turan TN, Hoh BL, Chimowitz MI. Intracranial atherosclerotic stenosis: risk factors, diagnosis, and treatment. Lancet Neurol 2022; 21:355-368. [DOI: 10.1016/s1474-4422(21)00376-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/14/2021] [Accepted: 10/19/2021] [Indexed: 12/13/2022]
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9
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Schilter M, Epstein A, Vynckier J, Mujanovic A, Belachew NF, Beyeler M, Siepen B, Goeldlin M, Scutelnic A, Seiffge DJ, Jung S, Gralla J, Dobrocky T, Arnold M, Kaesmacher J, Fischer U, Meinel TR. Chronic cerebral infarctions and white matter lesions link to long-term survival after a first ischemic event: A cohort study. J Neuroimaging 2022; 32:1134-1141. [PMID: 35922890 PMCID: PMC9804158 DOI: 10.1111/jon.13033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/15/2022] [Accepted: 07/23/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE To investigate the association of different phenotypes, count, and locations of chronic covert brain infarctions (CBI) with long-term mortality in patients with first-ever manifest acute ischemic stroke (AIS) or transient ischemic attack (TIA). Additionally, to analyze their potential interaction with white matter hyperintensities (WMH) and predictive value in addition to established mortality scores. METHODS Single-center cohort study including consecutive patients with first-ever AIS or TIA with available MRI imaging from January 2015 to December 2017. Blinded raters adjudicated CBI phenotypes and WMH (age-related white matter changes score) according to established definitions. We compared Cox regression models including prespecified established predictors of mortality using Harrell's C and likelihood ratio tests. RESULTS A total of 2236 patients (median [interquartile range] age: 71 [59-80] years, 43% female, National Institutes of Health Stroke Scale: 2 [1-6], median follow-up: 1436 days, 21% death during follow-up) were included. Increasing WMH (per point adjusted Hazard Ratio [aHR] = 1.29 [1.14-1.45]), but not CBI (aHR = 1.21 [0.99-1.49]), were independently associated with mortality. Neither CBI phenotype, count, nor location was associated with mortality and there was no multiplicative interaction between CBI and WMH (p > .1). As compared to patients without CBI or WMH, patients with moderate or severe WMH and additional CBI had the highest hazards of death (aHR = 1.62 [1.23-2.13]). The Cox regression model including CBI and WMH had a small but significant increment in Harrell's C when compared to the model including 14 clinical variables (0.831 vs. 0.827, p < .001). DISCUSSION WMH represent a strong surrogate biomarker of long-term mortality in first-ever manifest AIS or TIA patients. CBI phenotypes, count, and location seem less relevant. Incorporation of CBI and WMH slightly improves predictive capacity of established risk scores.
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Affiliation(s)
- Marina Schilter
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Alessandra Epstein
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Jan Vynckier
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Adnan Mujanovic
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Nebiyat Filate Belachew
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Bernhard Siepen
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Martina Goeldlin
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - David Julian Seiffge
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Urs Fischer
- Department of NeurologyBasel University Hospital, University of BaselBernSwitzerland
| | - Thomas Raphael Meinel
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
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Covert Brain Infarcts in Patients with Philadelphia Chromosome-Negative Myeloproliferative Disorders. J Clin Med 2021; 11:jcm11010013. [PMID: 35011753 PMCID: PMC8745571 DOI: 10.3390/jcm11010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/10/2021] [Accepted: 12/17/2021] [Indexed: 11/28/2022] Open
Abstract
Backgrounds and Purpose. Philadelphia chromosome-negative myeloproliferative disorders (Ph-negative MPD) are a rare group of hematological diseases, including three distinct pathologies: essential thrombocythemia (ET), polycythemia vera (PV), and primary myelofibrosis (PMF). They most often manifest with thrombotic complications, including cerebrovascular events. Covert brain infarcts (CBIs) are defin ed as predominantly small ischemic cerebral lesions that are detected using magnetic resonance imaging (MRI) in the absence of clinical stroke events. The relationship between MPD and CBIs remains unclear. Methods. Included in the study were 103 patients with the diagnosis of Ph-MPD (according to WHO 2016 criteria) (median age—47 (35; 54) years; 67% female). In total, 38 patients had ET, 42 had PV, and 23 had PMF. They underwent clinical examination, routine laboratory analyses (complete blood count), brain MRI, ultrasound carotid artery, flow-mediated dilatation (as a measure of endothelial dysfunction—FMD). Results. Overall, 23 patients experienced an ischemic stroke (as per MRI and/or clinical history), of which 16 (15.5%) could be classified as CBIs. The rate of CBIs per MPD subtype was statistically non-significant between groups (p = 0.35): ET–13.2%, PV–21.4%, and PMF–8.7%. The major vascular risk factors, including arterial hypertension, carotid atherosclerosis, and prior venous thrombosis, were not associated with CBIs (p > 0.05). Age was significantly higher in patients with CBIs compared to patients without MRI ischemic lesions: 50 (43; 57) years vs. 36 (29; 48) (p = 0.002). The frequency of headaches was comparable between the two groups. CBIs were associated with endothelial dysfunction (OR - 0.71 (95% CI: 0.49–0.90; p = 0.02)) and higher hemoglobin levels (OR—1.21 (95% CI: 1.06–1.55); p =0.03). Conclusions. CBIs are common in patients with Ph-negative MPD. Arterial hypertension and carotid atherosclerosis were not associated with CBIs in this group of patients. The most significant factors in the development of CBIs were endothelial dysfunction (as measured by FMD) and high hemoglobin levels. Patients with Ph-negative MPD and CBIs were older and had more prevalent endothelial dysfunction.
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11
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Automated detection and segmentation of intracranial hemorrhage suspect hyperdensities in non-contrast-enhanced CT scans of acute stroke patients. Eur Radiol 2021; 32:2246-2254. [PMID: 34773465 PMCID: PMC8921016 DOI: 10.1007/s00330-021-08352-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/03/2021] [Accepted: 09/22/2021] [Indexed: 01/01/2023]
Abstract
Objectives Artif
icial intelligence (AI)–based image analysis is increasingly applied in the acute stroke field. Its implementation for the detection and quantification of hemorrhage suspect hyperdensities in non-contrast-enhanced head CT (NCCT) scans may facilitate clinical decision-making and accelerate stroke management. Methods NCCTs of 160 patients with suspected acute stroke were analyzed regarding the presence or absence of acute intracranial hemorrhages (ICH) using a novel AI-based algorithm. Read was performed by two blinded neuroradiology residents (R1 and R2). Ground truth was established by an expert neuroradiologist. Specificity, sensitivity, and area under the curve were calculated for ICH and intraparenchymal hemorrhage (IPH) detection. IPH-volumes were segmented and quantified automatically by the algorithm and semi-automatically. Intraclass correlation coefficient (ICC) and Dice coefficient (DC) were calculated. Results In total, 79 of 160 patients showed acute ICH, while 47 had IPH. Sensitivity and specificity for ICH detection were 0.91 and 0.89 for the algorithm; 0.99 and 0.98 for R1; and 1.00 and 0.98 for R2. Sensitivity and specificity for IPH detection were 0.98 and 0.89 for the algorithm; 0.83 and 0.99 for R1; and 0.91 and 0.99 for R2. Interreader reliability for ICH and IPH detection showed strong agreements for the algorithm (0.80 and 0.84), R1 (0.96 and 0.84), and R2 (0.98 and 0.92), respectively. ICC indicated an excellent (0.98) agreement between the algorithm and the reference standard of the IPH-volumes. The mean DC was 0.82. Conclusion The AI-based algorithm reliably assessed the presence or absence of acute ICHs in this dataset and quantified IPH volumes precisely. Key Points • Artificial intelligence (AI) is able to detect hyperdense volumes on brain CTs reliably. • Sensitivity and specificity are highest for the detection of intraparenchymal hemorrhages. • Interreader reliability for hemorrhage detection shows strong agreement for AI and human readers. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08352-4.
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Sharma M, Smith EE, Pearce LA, Shoamanesh A, Perera KS, Coutts SB, Damgaard D, Ameriso SF, Rha JH, Modrau B, Yoon BW, Romano M, Messé SR, Barlinn J, Lambeck J, Saad F, Berkowitz SD, Mundl H, Connolly SJ, Hart RG. Frequency and Patterns of Brain Infarction in Patients With Embolic Stroke of Undetermined Source: NAVIGATE ESUS Trial. Stroke 2021; 53:45-52. [PMID: 34538089 DOI: 10.1161/strokeaha.120.032976] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE The spectrum of brain infarction in patients with embolic stroke of undetermined source (ESUS) has not been well characterized. Our objective was to define the frequency and pattern of brain infarcts detected by magnetic resonance imaging (MRI) among patients with recent ESUS participating in a clinical trial. METHODS In the NAVIGATE ESUS trial (New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial Versus ASA to Prevent Embolism in Embolic Stroke of Undetermined Source), an MRI substudy was carried out at 87 sites in 15 countries. Participants underwent an MRI using a specified protocol near randomization. Images were interpreted centrally by those unaware of clinical characteristics. RESULTS Among the 918 substudy cohort participants, the mean age was 67 years and 60% were men with a median (interquartile range) of 64 (26-115) days between the qualifying ischemic stroke and MRI. On MRI, 855 (93%) had recent or chronic brain infarcts that were multiple in 646 (70%) and involved multiple arterial territories in 62% (401/646). Multiple brain infarcts were present in 68% (510/755) of those without a history of stroke or transient ischemic attack before the qualifying ESUS. Prior stroke/transient ischemic attack (P<0.001), modified Rankin Scale score >0 (P<0.001), and current tobacco use (P=0.01) were associated with multiple infarcts. Topographically, large and/or cortical infarcts were present in 89% (757/855) of patients with infarcts, while in 11% (98/855) infarcts were exclusively small and subcortical. Among those with multiple large and/or cortical infarcts, 57% (251/437) had one or more involving a different vascular territory from the qualifying ESUS. CONCLUSIONS Most patients with ESUS, including those without prior clinical stroke or transient ischemic attack, had multiple large and/or cortical brain infarcts detected by MRI, reflecting a substantial burden of clinical stroke and covert brain infarction. Infarcts most frequently involved multiple vascular territories. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02313909.
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Affiliation(s)
- Mukul Sharma
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada (M.S, A.S., K.S.P.)
| | - Eric E Smith
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada (E.E.S.)
| | - Lesly A Pearce
- Biostatistics Consultant, St. Catharines, Ontario, Canada (L.A.P.)
| | - Ashkan Shoamanesh
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada (M.S, A.S., K.S.P.)
| | - Kanjana S Perera
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada (M.S, A.S., K.S.P.)
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, University of Calgary, Alberta, Canada. (S.B.C.)
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, Denmark (D.D.)
| | | | - Joung-Ho Rha
- Inha University Hospital, Incheon, Korea (J.-H.R.)
| | - Boris Modrau
- Department of Neurology, Aalborg University Hospital, Denmark (B.M.)
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University Hospital, Korea (B.-W.Y.)
| | - Marina Romano
- Department of Neurology, Centro Estudios Medicos e Invest. Clinicas "Dr. N. Quirno", Buenos Aires, Argentina (M.R.)
| | - Steven R Messé
- Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.)
| | - Jessica Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universitat Dresden, Germany (J.B.)
| | - Johann Lambeck
- Department of Neurology and Clinical Neurophysiology, Universitätsklinikum Freiburg, Germany (J.L.)
| | - Feryal Saad
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada. (F.S.)
| | | | | | - Stuart J Connolly
- Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada (R.G.H., S.J.C.)
| | - Robert G Hart
- Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada (R.G.H., S.J.C.)
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Gutierrez J, Porras TN, Yoo-Jeong M, Khasiyev F, Igwe KC, Laing KK, Brickman AM, Pavol M, Schnall R. Cerebrovascular Contributions to Neurocognitive Disorders in People Living With HIV. J Acquir Immune Defic Syndr 2021; 88:79-85. [PMID: 34397745 PMCID: PMC8371714 DOI: 10.1097/qai.0000000000002729] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 04/07/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND To investigate a comprehensive array of magnetic resonance imaging (MRI)-based biomarkers of cerebrovascular disease (CVD) in a cohort of people living with HIV (PLWH) and relate these imaging biomarkers to cognition. SETTINGS Cross-sectional, community-based study. METHODS Participants were PLWH in New York City, aged 50 years or older. They underwent a brain magnetic resonance angiography or MRI to ascertain 7 MRI markers of CVD: silent brain infarcts, dilated perivascular spaces, microhemorrhages, white matter hyperintensity volume, white matter fractional anisotropy and mean diffusivity (measures of white matter integrity), and intracranial large artery stenosis. Participants underwent a battery of neurocognitive tests to obtain individual and global cognitive scores representative of various aspects of cognition. RESULTS We included 85 participants (mean age 60 ± 6 years, 48% men, 78% non-Hispanic Black), most of them with well-controlled HIV (75% with CD4 cell count > 200 cells/mm3 and viral load < 400 copies/mL at or near the time of the MRI scan). Silent brain infarcts, intracranial large artery stenosis, and poor white matter integrity were associated with poorer performance in at least one cognitive domain, but the sum of these 3 MRI markers of CVD was associated with lower working memory (B = -0.213, P = 0.028), list learning (B = -0.275, P = 0.019), and global cognition (B = -0.129, P = 0.007). CONCLUSIONS We identified silent brain infarcts, intracranial large artery stenosis, and poor white matter integrity as exposures that may be modifiable and may, therefore, influence cognitive decline. In addition, these MRI markers of CVD may help in identifying PLWH at higher risk of cognitive decline, which may be more amenable to targeted therapies.
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Affiliation(s)
- Jose Gutierrez
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
- Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Tiffany N Porras
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Moka Yoo-Jeong
- School of Nursing, Bouvé College of Health Sciences, Northeastern University, Boston, MA
| | - Farid Khasiyev
- Department of Neurology, Saint Louis University, Saint Louis, MI
| | - Kay C Igwe
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | - Krystal K Laing
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | - Adam M Brickman
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
- Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
- Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University Irving Medical Center, New York, NY
| | - Marykay Pavol
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | - Rebecca Schnall
- School of Nursing, Columbia University Irving Medical Center, New York, NY; and
- Department of Population and Family Health, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
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14
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Gutierrez J, Khasiyev F, Liu M, DeRosa JT, Tom SE, Rundek T, Cheung K, Wright CB, Sacco RL, Elkind MSV. Determinants and Outcomes of Asymptomatic Intracranial Atherosclerotic Stenosis. J Am Coll Cardiol 2021; 78:562-571. [PMID: 34353533 DOI: 10.1016/j.jacc.2021.05.041] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/30/2021] [Accepted: 05/18/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Intracranial atherosclerotic stenosis (ICAS) is one of the most common causes of stroke worldwide and confers a high risk of stroke recurrence, despite aggressive management of risk factors. OBJECTIVES This study identified the role of risk factors and risk of vascular events in subjects with asymptomatic ICAS for improved risk stratification. METHODS Stroke-free participants in the NOMAS (Northern Manhattan Study) trial, prospectively followed since 1993, underwent a brain magnetic resonance angiogram from 2003 to 2008. The study rated stenosis in 11 brain arteries as: 0: no stenosis; 1: <50% or luminal irregularities; 2: 50%-69%; and 3: ≥70% stenosis or flow gap. The study ascertained vascular events during the post-magnetic resonance imaging (MRI) period. Proportional odds regression quantified the association of pre-MRI exposures, and proportional hazard adjusted models were built to identify the risk of events in the post-MRI period. RESULTS The included sample included 1,211 participants from NOMAS (mean age: 71 ± 9 years; 59% women; 65% Hispanic; 45% had any stenosis). Older age (OR: 1.02 per year; 95% CI: 1.01 to 1.04), hypertension duration (OR: 1.01 per year; 95% CI: 1.00 to 1.02), higher number of glucose-lowering drugs (OR: 1.64 per each medication; 95% CI: 1.24 to 2.15), and high-density lipoprotein (OR: 0.96 per mg/dL; 95% CI: 0.92 to 0.99) were associated with ICAS. The highest event risk was noted among participants with ICAS ≥70% (5.5% annual risk of vascular events; HR: 2.1; 95% CI:1.4 to 3.2; compared with those with no ICAS). CONCLUSIONS ICAS is an imaging marker of established atherosclerotic disease in stroke-free subjects, and incidental diagnosis of ICAS should trigger a thorough assessment of vascular health.
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Affiliation(s)
- Jose Gutierrez
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA.
| | - Farid Khasiyev
- Department of Neurology, Saint Louis University, Saint Louis, Missouri, USA
| | - Minghua Liu
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Janet T DeRosa
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sarah E Tom
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA; Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA; Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ken Cheung
- Department of Biostatistics, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York, USA
| | - Clinton B Wright
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Ralph L Sacco
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA; Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA; Evelyn F. McKnight Brain Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mitchell S V Elkind
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York, USA
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15
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Ho WM, Wu YY, Chen YC. Genetic Variants behind Cardiovascular Diseases and Dementia. Genes (Basel) 2020; 11:genes11121514. [PMID: 33352859 PMCID: PMC7766236 DOI: 10.3390/genes11121514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/15/2022] Open
Abstract
Cardiovascular diseases (CVDs) and dementia are the leading causes of disability and mortality. Genetic connections between cardiovascular risk factors and dementia have not been elucidated. We conducted a scoping review and pathway analysis to reveal the genetic associations underlying both CVDs and dementia. In the PubMed database, literature was searched using keywords associated with diabetes mellitus, hypertension, dyslipidemia, white matter hyperintensities, cerebral microbleeds, and covert infarctions. Gene lists were extracted from these publications to identify shared genes and pathways for each group. This included high penetrance genes and single nucleotide polymorphisms (SNPs) identified through genome wide association studies. Most risk SNPs to both diabetes and dementia participate in the phospholipase C enzyme system and the downstream nositol 1,4,5-trisphosphate and diacylglycerol activities. Interestingly, AP-2 (TFAP2) transcription factor family and metabolism of vitamins and cofactors were associated with genetic variants that were shared by white matter hyperintensities and dementia, and by microbleeds and dementia. Variants shared by covert infarctions and dementia were related to VEGF ligand-receptor interactions and anti-inflammatory cytokine pathways. Our review sheds light on future investigations into the causative relationships behind CVDs and dementia, and can be a paradigm of the identification of dementia treatments.
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Affiliation(s)
- Wei-Min Ho
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan; (W.-M.H.); (Y.-Y.W.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Yah-Yuan Wu
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan; (W.-M.H.); (Y.-Y.W.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Yi-Chun Chen
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 33305, Taiwan; (W.-M.H.); (Y.-Y.W.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Correspondence: ; Tel.: +886-3-3281200 (ext. 8433)
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16
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Abstract
Numerous epidemiological studies have demonstrated stroke disparities across race and ethnic groups. The goal of the NOMAS (Northern Manhattan Study) was to evaluate race and ethnic differences in stroke within a community with 3 different race-ethnic groups. Starting as a population-based incidence and case-control study, the study evolved into a cohort study. Results from NOMAS have demonstrated differences in stroke incidence, subtypes, risk factors, and outcomes. Disparities in ideal cardiovascular health can help explain many differences in stroke incidence and call for tailored risk factor modification through innovative portals to shift more diverse subjects to ideal cardiovascular health. The results of NOMAS and multiple other studies have provided foundational data to support interventions. Conceptual models to address health disparities have called for moving from detecting disparities in disease incidence, to determining the underlying causes of disparities and developing interventions, and then to testing interventions in human populations. Further actions to address race and ethnic stroke disparities are needed including innovative risk factor interventions, stroke awareness campaigns, quality improvement programs, workforce diversification, and accelerating policy changes.
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Affiliation(s)
- Ralph L Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, FL
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17
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Sharma M, Hart RG, Smith EE, Bosch J, Eikelboom JW, Connolly SJ, Dyal L, Reeh KW, Casanova A, Diaz R, Lopez-Jaramillo P, Ertl G, Störk S, Dagenais GR, Lonn EM, Ryden L, Tonkin AM, Varigos JD, Bhatt DL, Branch KR, Probstfield JL, Kim JH, O’Donnell M, Vinereanu D, A.A. Fox K, Liang Y, Liu L, Zhu J, Pogosova N, Maggioni AP, Avezum A, Piegas LS, Keltai K, Keltai M, Berkowitz SD, Yusuf S. Rivaroxaban for Prevention of Covert Brain Infarcts and Cognitive Decline. Stroke 2020; 51:2901-2909. [DOI: 10.1161/strokeaha.120.029762] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background and Purpose:
Covert brain infarcts are associated with cognitive decline. It is not known whether therapies that prevent symptomatic stroke prevent covert infarcts. COMPASS compared rivaroxaban with and without aspirin with aspirin for the prevention of stroke, myocardial infarction, and vascular death in participants with stable vascular disease and was terminated early because of benefits of rivaroxaban 2.5 mg twice daily plus aspirin over aspirin. We obtained serial magnetic resonance imagings and cognitive tests in a consenting subgroup of COMPASS patients to examine treatment effects on infarcts, cerebral microbleeds, and white matter hyperintensities.
Methods:
Baseline and follow-up magnetic resonance imagings were completed in 1445 participants with a mean (SD) interval of 2.0 (0.7) years. Whole-brain T1, T2 fluid-attenuated inversion recovery, T2* sequences were centrally interpreted by blinded, trained readers. Participants had serial measurements of cognition and function. The primary end point was the proportion of participants with incident covert infarcts. Secondary end points were the composite of clinical stroke and covert brain infarcts, cerebral microbleeds, and white matter hyperintensities.
Results:
At baseline, 493 (34.1%) participants had infarcts. Incident covert infarcts occurred in 55 (3.8%) participants. In the overall trial rivaroxaban plus aspirin reduced ischemic stroke by 49% (0.7% versus 1.4%; hazard ratio [95% CI], 0.51 [0.38–0.68]). In the magnetic resonance imaging substudy the effects of rivaroxaban+aspirin versus aspirin were: covert infarcts: 2.7% versus 3.5% (odds ratio [95% CI], 0.77 [0.37–1.60]); Covert infarcts or ischemic stroke: 2.9% versus 5.3% (odds ratio [95% CI], 0.53 [0.27–1.03]). Incident microbleeds occurred in 6.6% of participants and 65.7% of participants had an increase in white matter hyperintensities volume with no effect of treatment for either end point. There was no effect on cognitive tests.
Conclusions:
Covert infarcts were not significantly reduced by treatment with rivaroxaban and aspirin but estimates for the combination of ischemic stroke and covert infarcts were consistent with the effect on ischemic stroke in the overall trial.
Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT01776424.
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Affiliation(s)
- Mukul Sharma
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada (M.S., R.G.H., J.B., J.W.E., S.J.C., L.D., K.W.R., A.C., E.M.L., S.Y.)
| | - Robert G. Hart
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada (M.S., R.G.H., J.B., J.W.E., S.J.C., L.D., K.W.R., A.C., E.M.L., S.Y.)
| | - Eric E. Smith
- Hotchkiss Brain Institute, University of Calgary, AB, Canada (E.E.S.)
| | - Jacqueline Bosch
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada (M.S., R.G.H., J.B., J.W.E., S.J.C., L.D., K.W.R., A.C., E.M.L., S.Y.)
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada (J.B.)
| | - John W. Eikelboom
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada (M.S., R.G.H., J.B., J.W.E., S.J.C., L.D., K.W.R., A.C., E.M.L., S.Y.)
| | - Stuart J. Connolly
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada (M.S., R.G.H., J.B., J.W.E., S.J.C., L.D., K.W.R., A.C., E.M.L., S.Y.)
| | - Leanne Dyal
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada (M.S., R.G.H., J.B., J.W.E., S.J.C., L.D., K.W.R., A.C., E.M.L., S.Y.)
| | - Kevin W Reeh
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada (M.S., R.G.H., J.B., J.W.E., S.J.C., L.D., K.W.R., A.C., E.M.L., S.Y.)
| | - Amparo Casanova
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada (M.S., R.G.H., J.B., J.W.E., S.J.C., L.D., K.W.R., A.C., E.M.L., S.Y.)
| | - Rafael Diaz
- Estudios Clinicos Latino America and Instituto Cardiovascular de Rosario, Argentina (R.D.)
| | | | - Georg Ertl
- Comprehensive Heart Failure Center, University and University Hospital, Würzburg, Germany (G.E., S.S.)
| | - Stefan Störk
- Comprehensive Heart Failure Center, University and University Hospital, Würzburg, Germany (G.E., S.S.)
| | - Gilles R. Dagenais
- Institut Universitaire de Cardiologie et Pneumologie de Quebec, Quebec City, Canada (G.R.D.)
| | - Eva M. Lonn
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada (M.S., R.G.H., J.B., J.W.E., S.J.C., L.D., K.W.R., A.C., E.M.L., S.Y.)
| | - Lars Ryden
- Karolinska Institutet, Stockholm, Sweden (L.R.)
| | | | | | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard, Medical School, Boston, MA (D.L.B.)
| | - Kelley R.H. Branch
- University of Washington Medical Centre, Seattle (K.R.H.B.)
- University of Washington, Seattle (K.R.H.B., J.L.P.)
| | | | - Jae-Hyung Kim
- The Catholic University of Korea, Seoul, Korea (J.-H.K.)
| | | | - Dragos Vinereanu
- University of Medicine and Pharmacology Carol Davila University and Emergency Hospital, Bucharest, Romania (D.V.)
| | - Keith A.A. Fox
- Centre for Cardiovascular Science, University of Edinburgh, Scotland, United Kingdom (K.A.A.F.)
| | - Yan Liang
- FuWai Hospital, Beijing, China (Y.L., L.L., J.Z.)
| | - Lisheng Liu
- FuWai Hospital, Beijing, China (Y.L., L.L., J.Z.)
| | - Jun Zhu
- FuWai Hospital, Beijing, China (Y.L., L.L., J.Z.)
| | - Nana Pogosova
- National Medical Research Center of Cardiology, Moscow, Russia (N.P.)
| | | | - Alvaro Avezum
- Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil (A.A.)
| | | | | | - Matyas Keltai
- Semmelweis University, Budapest, Hungary (K.K., M.K.)
| | | | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada (M.S., R.G.H., J.B., J.W.E., S.J.C., L.D., K.W.R., A.C., E.M.L., S.Y.)
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18
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Cognitive declines after perioperative covert stroke: Recent advances and perspectives. Curr Opin Anaesthesiol 2020; 33:651-654. [PMID: 32796168 DOI: 10.1097/aco.0000000000000903] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Thomas Raphael Meinel
- Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology (L.R.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
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20
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McCarron MO, Wade C, McKee J, McVerry F. Stroke scan agnosia - What radiologists may not see. Clin Neurol Neurosurg 2020; 195:106052. [PMID: 32683231 DOI: 10.1016/j.clineuro.2020.106052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/09/2020] [Accepted: 06/27/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Neuroimaging helps neurologists make accurate diagnoses. We used a multidisciplinary review system to search for perceptual discrepancies in stroke lesions. We sought to identify recurrent pitfalls in the detection of neuroimaging stroke lesions. PATIENTS AND METHODS Patients were selected from a neuroimaging database of second opinions if cerebrovascular lesions had been missed at initial reporting. Patient demographics, scanning modality and stroke type were recorded. RESULTS A neuroradiologist second opinion was provided for 1336 patients. Forty-four patients, 18 women and 26 men, mean age 59.9 (SD 14.2) years, were identified in whom a vascular lesion was not detected on initial reporting. The lesions included cerebellar infarcts in 17 patients (bilateral in 7), pontine infarction/ischaemia (n=5), pontine and cerebellar lesions (n=1) and spinal infarction (n=1). Supratentorial infarction occurred in 10 patients of which 3 were thalamic infarcts. Vessel abnormalities were present in 8 patients (hyperdense vessel n=3, dissection n=3, middle cerebral artery occlusion on CTA n=1 and cerebral venous sinus thrombosis n=1). Convexity subarachnoid hemorrhage was missed and a subdural hematoma was not identified in one patient. In 10 (23 %) patients the missed lesions occurred solely on CT brain scanning. The missed lesions were symptomatic in 28 (64 %) patients and presentations were acute in 14 (32 %) patients. CONCLUSION Some cerebrovascular lesions are prone to perceptual errors with CT and MRI brain scanning. Radiologists and neurologists should be aware that posterior fossa lesions (particularly in the cerebellum and pons) and hyperdense vessel signs may be missed. Better identification of radiological cerebrovascular lesions should enhance management of acute and chronic stroke patients.
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Affiliation(s)
- Mark O McCarron
- Department of Neurology and Stroke Service, Altnagelvin Hospital, Derry, N. Ireland, BT47 6SB, UK.
| | - Carrie Wade
- Department of Neurology, Altnagelvin Hospital, Derry, N. Ireland, BT47 6SB, UK
| | - Jacqueline McKee
- Stroke Service, Altnagelvin Hospital, Derry, N. Ireland, BT47 6SB, UK
| | - Ferghal McVerry
- Department of Neurology and Stroke Service, Altnagelvin Hospital, Derry, N. Ireland, BT47 6SB, UK
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21
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Maestrini I, Altieri M, Di Piero V. Letter by Maestrini et al Regarding Article, “Classification of Covert Brain Infarct Subtype and Risk of Death and Vascular Events”. Stroke 2020; 51:e81. [DOI: 10.1161/strokeaha.119.028835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ilaria Maestrini
- Department of Human Neurosciences, ‘Sapienza’ University of Rome, Italy
| | - Marta Altieri
- Department of Human Neurosciences, ‘Sapienza’ University of Rome, Italy
| | - Vittorio Di Piero
- Department of Human Neurosciences, ‘Sapienza’ University of Rome, Italy
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Gutierrez J, Di Tullio MR, Rundek T, Sacco RL, Wright CB, Elkind MS. Response by Gutierrez et al to Letter Regarding Article, "Classification of Covert Brain Infarct Subtype and Risk of Death and Vascular Events". Stroke 2020; 51:e82. [PMID: 32200758 DOI: 10.1161/strokeaha.120.028937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Tatjana Rundek
- Department of Neurology, University of Miami, Miller School of Medicine, FL
| | - Ralph L Sacco
- Department of Neurology, University of Miami, Miller School of Medicine, FL
| | - Clinton B Wright
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
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Affiliation(s)
- Hugues Chabriat
- From the Department of Neurology, Groupe Hospitalier Saint-Louis-Lariboisière, Assistance Publique des Hôpitaux de Paris (APHP), Université Denis Diderot and DHU NeuroVasc Sorbonne Paris-Cité (INSERM U1141), France
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