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Webb AJ, Birks JS, Feakins KA, Lawson A, Dawson J, Rothman AM, Werring DJ, Llwyd O, Stewart CR, Thomas J. Cerebrovascular Effects of Sildenafil in Small Vessel Disease: The OxHARP Trial. Circ Res 2024; 135:320-331. [PMID: 38832504 PMCID: PMC11227301 DOI: 10.1161/circresaha.124.324327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/20/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Vascular cognitive impairment due to cerebral small vessel disease is associated with cerebral pulsatility, white matter hypoperfusion, and reduced cerebrovascular reactivity (CVR), and is potentially improved by endothelium-targeted drugs such as cilostazol. Whether sildenafil, a phosphodiesterase-5 inhibitor, improves cerebrovascular dysfunction is unknown. METHODS OxHARP trial (Oxford Haemodynamic Adaptation to Reduce Pulsatility) was a double-blind, randomized, placebo-controlled, 3-way crossover trial after nonembolic cerebrovascular events with mild-moderate white matter hyperintensities (WMH), the most prevalent manifestation of cerebral small vessel disease. The primary outcome assessed the superiority of 3 weeks of sildenafil 50 mg thrice daily versus placebo (mixed-effect linear models) on middle cerebral artery pulsatility, derived from peak systolic and end-diastolic velocities (transcranial ultrasound), with noninferiority to cilostazol 100 mg twice daily. Secondary end points included the following: cerebrovascular reactivity during inhalation of air, 4% and 6% CO2 on transcranial ultrasound (transcranial ultrasound-CVR); blood oxygen-level dependent-magnetic resonance imaging within WMH (CVR-WMH) and normal-appearing white matter (CVR-normal-appearing white matter); cerebral perfusion by arterial spin labeling (magnetic resonance imaging pseudocontinuous arterial spin labeling); and resistance by cerebrovascular conductance. Adverse effects were compared by Cochran Q. RESULTS In 65/75 (87%) patients (median, 70 years;79% male) with valid primary outcome data, cerebral pulsatility was unchanged on sildenafil versus placebo (0.02, -0.01 to 0.05; P=0.18), or versus cilostazol (-0.01, -0.04 to 0.02; P=0.36), despite increased blood flow (∆ peak systolic velocity, 6.3 cm/s, 3.5-9.07; P<0.001; ∆ end-diastolic velocity, 1.98, 0.66-3.29; P=0.004). Secondary outcomes improved on sildenafil versus placebo for CVR-transcranial ultrasound (0.83 cm/s per mm Hg, 0.23-1.42; P=0.007), CVR-WMH (0.07, 0-0.14; P=0.043), CVR-normal-appearing white matter (0.06, 0.00-0.12; P=0.048), perfusion (WMH: 1.82 mL/100 g per minute, 0.5-3.15; P=0.008; and normal-appearing white matter, 2.12, 0.66-3.6; P=0.006) and cerebrovascular resistance (sildenafil-placebo: 0.08, 0.05-0.10; P=4.9×10-8; cilostazol-placebo, 0.06, 0.03-0.09; P=5.1×10-5). Both drugs increased headaches (P=1.1×10-4), while cilostazol increased moderate-severe diarrhea (P=0.013). CONCLUSIONS Sildenafil did not reduce pulsatility but increased cerebrovascular reactivity and perfusion. Sildenafil merits further study to determine whether it prevents the clinical sequelae of small vessel disease. REGISTRATION URL: https://www.clinicaltrials.gov/study/NCT03855332; Unique identifier: NCT03855332.
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Affiliation(s)
- Alastair J.S. Webb
- Wolfson Centre for Prevention of Stroke and Dementia (A.J.S.W., K.A.F., A.L., O.L., C.R.S., J.T.), University of Oxford, United Kingdom
- Department of Brain Sciences, Imperial College London, United Kingdom (A.J.S.W.)
| | - Jacqueline S. Birks
- Centre for Statistics in Medicine, Botnar Research Centre (J.S.B.), University of Oxford, United Kingdom
| | - Karolina A. Feakins
- Wolfson Centre for Prevention of Stroke and Dementia (A.J.S.W., K.A.F., A.L., O.L., C.R.S., J.T.), University of Oxford, United Kingdom
| | - Amy Lawson
- Wolfson Centre for Prevention of Stroke and Dementia (A.J.S.W., K.A.F., A.L., O.L., C.R.S., J.T.), University of Oxford, United Kingdom
| | - Jesse Dawson
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom (J.D.)
| | - Alexander M.K. Rothman
- Department of Cardiovascular Science, University of Sheffield, United Kingdom (A.M.K.R.)
| | - David J. Werring
- Research Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, United Kingdom (D.J.W.)
| | - Osian Llwyd
- Wolfson Centre for Prevention of Stroke and Dementia (A.J.S.W., K.A.F., A.L., O.L., C.R.S., J.T.), University of Oxford, United Kingdom
| | - Catriona R. Stewart
- Wolfson Centre for Prevention of Stroke and Dementia (A.J.S.W., K.A.F., A.L., O.L., C.R.S., J.T.), University of Oxford, United Kingdom
| | - James Thomas
- Wolfson Centre for Prevention of Stroke and Dementia (A.J.S.W., K.A.F., A.L., O.L., C.R.S., J.T.), University of Oxford, United Kingdom
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Ishii D, Maeda Y, Kuwabara M, Hosogai M, Kume S, Hara T, Kondo H, Horie N. Pulsatility index of superficial temporal artery was associated with cerebral infarction after direct bypass surgery for moyamoya disease. J Stroke Cerebrovasc Dis 2023; 32:107346. [PMID: 37708702 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107346] [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: 08/21/2023] [Revised: 09/03/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVE Direct bypass surgery by superficial temporal artery (STA) - middle cerebral artery anastomosis is an established procedure for moyamoya disease (MMD). However, some patients may develop cerebral infarction (CI) due to the watershed shift phenomenon after the surgery. This study sought to investigate the correlation between the postoperative changes of STA flow as well as cerebral blood flow (CBF) and the incidence of CI after direct bypass surgery for MMD. METHODS We conducted a retrospective study of 62 hemispheres in 50 subjects who underwent direct bypass surgery for MMD. All subjects underwent pre- and post-operative MR imaging, ultrasound evaluation of STA, and single-photon emission computed tomography. The presence of CI was correlated with preoperative CBF, the delta difference of each value of the STA between before and after the surgery, and the postoperative increase ratio of CBF. RESULTS All bypass procedures were patent, and CI was observed in 4 cases (6.4%). There was no significant association between the incidence of CI and both pre- and post-operative CBF. However, there was a significant difference in delta pulsatility index (PI) of the STA between cases with or without CI (-0.38±0.22 and -0.87±0.63, respectively, p=0.03). Whereas, other factors did not show any significant differences between those with or without CI. CONCLUSIONS A relatively high postoperative PI of the STA was significantly associated with the incidence of CI after direct bypass surgery for MMD. A larger study is needed to confirm these findings.
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Affiliation(s)
- Daizo Ishii
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Yuyo Maeda
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masashi Kuwabara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masahiro Hosogai
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Kume
- Department of Clinical Laboratory, Hiroshima University Hospital, Hiroshima, Japan
| | - Takeshi Hara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Kondo
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Webb AJ, Wartolowska KA, Li L, Rothwell PM. Low Heart Rate Is Associated with Cerebral Pulsatility after TIA or Minor Stroke. Ann Neurol 2022; 92:909-920. [PMID: 36054225 PMCID: PMC9804869 DOI: 10.1002/ana.26480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/12/2022] [Accepted: 08/12/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Beta-blockers are beneficial in coronary artery disease but less so in stroke prevention and dementia, potentially due to reduced heart rate (HR). Cerebral pulsatility is strongly associated with cerebral small vessel disease (SVD) and may be increased by lower diastolic pressures resulting from longer cardiac cycles. METHODS Patients 4-6 weeks after TIA or non-disabling stroke (Oxford Vascular Study) underwent 5 minutes continuous monitoring of blood pressure (BP), electrocardiogram (ECG), and middle cerebral artery flow velocity (transcranial ultrasound). Beat-to-beat relationships between HR, blood pressure and Gosling's pulsatility index (MCA-PI) are reported as beta-coefficients from general linear models for each individual. RESULTS Across 759 patients, average MCA-PI during monitoring was associated with lower HR and diastolic BP (DBP) and greater systolic BP (SBP) (∆MCA-PI per 10 bpm/mmHg: -0.02, -0.04, 0.03, all p < 0.001), with HR particularly associated with low end-diastolic cerebral velocity (0.86, p = 0.014). Beat-to-beat HR was strongly associated with concurrent low DBP and high SBP, potentially mediating the association with greater beat-to-beat cerebral pulsatility (average ∆MCA-PI vs HR/DBP/SBP unadjusted: -0.062, -0.052, 0.0092; adjusted for concurrent BP: -0.039, -0.11, 0.041). The beat-to-beat association between HR and MCA-PI increased with age, beta-blockers, arterial stiffness, low HR (age > 70 + HR < 65 vs age < 70 + HR > 65: -0.081 vs -0.024, interaction p < 0.001), and severe SVD on MRI (age > 70 + severe vs age < 70 + none: -0.087 vs -0.047, interaction p = 0.03), with interactions between age, severe SVD, and low HR synergistically increasing MCA-PI. INTERPRETATION Low HR is associated with greater cerebral pulsatility in patients with SVD, potentially mediated by lower diastolic blood flow and representing a novel potential treatment target. ANN NEUROL 2022;92:909-920.
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Affiliation(s)
- Alastair J.S. Webb
- Wolfson Centre for Prevention of Stroke and DementiaUniversity of OxfordOxfordUK
| | | | - Linxin Li
- Wolfson Centre for Prevention of Stroke and DementiaUniversity of OxfordOxfordUK
| | - Peter M. Rothwell
- Wolfson Centre for Prevention of Stroke and DementiaUniversity of OxfordOxfordUK
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Webb AJS, Wartolowska KA, Li L, Mazzucco S, Rothwell PM. Consistencies and Differences in Intermediate Physiological Phenotypes of Vascular Ageing between Ischaemic Stroke Aetiologies. Cerebrovasc Dis 2022; 52:194-201. [PMID: 35998558 PMCID: PMC7615998 DOI: 10.1159/000525764] [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: 11/22/2021] [Accepted: 03/24/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Arterial stiffness, cerebral pulsatility, and beat-to-beat blood pressure variability partly mediate the relationship between hypertension and stroke, but it is unknown if these intermediate phenotypes of vascular ageing differ between stroke aetiologies. We therefore aimed to characterize differences in these intermediate cardiovascular phenotypes between patients presenting with strokes of different aetiologies. METHODS In consecutive patients on best medical management 1 month after TIA or nondisabling stroke (Oxford Vascular Study), arterial stiffness (PWV) was measured by applanation tonometry (Sphygmocor), middle cerebral blood flow velocity, and pulsatility index (MCA-PI) were measured by transcranial ultrasound (TCD, DWL Doppler Box), and beat-to-beat BP variability was measured with a Finometer. Differences between patients with large artery (LAS), small vessel (SVD), cardioembolic (CE), or undetermined events were derived, including adjustment for cardiovascular risk factors. Relationships were characterized by mixed linear models. RESULTS In 909 eligible patients, MCA-PI, PWV, and SBPV were all positively skewed. Mean values were greatest in LAS than CE and lowest in SVD (p < 0.001). However, after adjustment for age, sex, and risk factors, PI was greatest in LAS and lowest in CE stroke, whilst PWV was greatest in SVD and undetermined stroke (p < 0.001). In multivariate linear models, age was more strongly associated with PWV and PI in patients with small vessel stroke than other aetiologies, particularly under the age of 65, but SBPV was only weakly associated with demographic indices in all stroke subtypes. CONCLUSIONS Intermediate cardiovascular phenotypes of vascular ageing had similar demographic associations between stroke aetiologies, but these were particularly strong in patients with small vessel stroke under the age of 65, implying a potential role of these phenotypes in increasing stroke risk in this patient group.
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Affiliation(s)
| | | | - Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Sara Mazzucco
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
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Webb AJ, Lawson A, Wartolowska K, Mazzucco S, Rothwell PM. Aortic Stiffness, Pulse Pressure, and Cerebral Pulsatility Progress Despite Best Medical Management: The OXVASC Cohort. Stroke 2022; 53:1310-1317. [PMID: 34852644 PMCID: PMC7612543 DOI: 10.1161/strokeaha.121.035560] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/26/2021] [Accepted: 10/06/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Increased cerebral arterial pulsatility is associated with cerebral small vessel disease, recurrent stroke, and dementia despite the best medical treatment. However, no study has identified the rates and determinants of progression of arterial stiffness and pulsatility. METHODS In consecutive patients within 6 weeks of transient ischemic attack or nondisabling stroke (OXVASC [Oxford Vascular Study]), arterial stiffness (pulse wave velocity [PWV]) and aortic systolic, aortic diastolic, and aortic pulse pressures (aoPP) were measured by applanation tonometry (Sphygmocor), while middle cerebral artery (MCA) peak (MCA-PSV) and trough (MCA-EDV) flow velocity and Gosling pulsatility index (PI; MCA-PI) were measured by transcranial ultrasound (transcranial Doppler, DWL Doppler Box). Repeat assessments were performed at the 5-year follow-up visit after intensive medical treatment and agreement determined by intraclass correlation coefficients. Rates of progression and their determinants, stratified by age and sex, were determined by mixed-effects linear models, adjusted for age, sex, and cardiovascular risk factors. RESULTS In 188 surviving, eligible patients with repeat assessments after a median of 5.8 years. PWV, aoPP, and MCA-PI were highly reproducible (intraclass correlation coefficients, 0.71, 0.59, and 0.65, respectively), with progression of PWV (2.4%; P<0.0001) and aoPP (3.5%; P<0.0001) but not significantly for MCA-PI overall (0.93; P=0.22). However, PWV increased at a faster rate with increasing age (0.009 m/s per y/y; P<0.0001), while aoPP and MCA-PI increased significantly above the age of 55 years (aoPP, P<0.0001; MCA-PI, P=0.009). Higher aortic systolic blood pressure and diastolic blood pressure predicted a greater rate of progression of PWV and aoPP, but not MCA-PI, although current MCA-PI was particularly strongly associated with concurrent aoPP (P<0.001). CONCLUSIONS Arterial pulsatility and aortic stiffness progressed significantly after 55 years of age despite the best medical treatment. Progression of stiffness and aoPP was determined by high blood pressure, but MCA-PI predominantly reflected current aoPP. Treatments targetting cerebral pulsatility may need to principally target aortic stiffness and pulse pressure to have the potential to prevent cerebral small vessel disease.
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Affiliation(s)
- Alastair J.S. Webb
- Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom
| | - Amy Lawson
- Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom
| | - Karolina Wartolowska
- Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom
| | - Sara Mazzucco
- Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom
| | - Peter M. Rothwell
- Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom
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Abstract
Despite advances in acute management and prevention of cerebrovascular disease, stroke and vascular cognitive impairment together remain the world's leading cause of death and neurological disability. Hypertension and its consequences are associated with over 50% of ischemic and 70% of hemorrhagic strokes but despite good control of blood pressure (BP), there remains a 10% risk of recurrent cerebrovascular events, and there is no proven strategy to prevent vascular cognitive impairment. Hypertension evolves over the lifespan, from predominant sympathetically driven hypertension with elevated mean BP in early and mid-life to a late-life phenotype of increasing systolic and falling diastolic pressures, associated with increased arterial stiffness and aortic pulsatility. This pattern may partially explain both the increasing incidence of stroke in younger adults as well as late-onset, chronic cerebrovascular injury associated with concurrent systolic hypertension and historic mid-life diastolic hypertension. With increasing arterial stiffness and autonomic dysfunction, BP variability increases, independently predicting the risk of ischemic and intracerebral hemorrhage, and is potentially modifiable beyond control of mean BP. However, the interaction between hypertension and control of cerebral blood flow remains poorly understood. Cerebral small vessel disease is associated with increased pulsatility in large cerebral vessels and reduced reactivity to carbon dioxide, both of which are being targeted in early phase clinical trials. Cerebral arterial pulsatility is mainly dependent upon increased transmission of aortic pulsatility via stiff vessels to the brain, while cerebrovascular reactivity reflects endothelial dysfunction. In contrast, although cerebral autoregulation is critical to adapt cerebral tone to BP fluctuations to maintain cerebral blood flow, its role as a modifiable risk factor for cerebrovascular disease is uncertain. New insights into hypertension-associated cerebrovascular pathophysiology may provide key targets to prevent chronic cerebrovascular disease, acute events, and vascular cognitive impairment.
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Affiliation(s)
- Alastair J S Webb
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom (A.J.S.W.)
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom (D.J.W.)
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