Risk Factors for Silent Lacunar Infarction in Patients with Transient Ischemic Attack

Progression of enlarged perivascular spaces contributes to occurrence of silent lacunar infarction in the elderly

INTRODUCTION

This study aims to assess the effect of enlarged perivascular spaces (EPVS) in patients using the methods of scale score and 3D volume quantification and to determine whether EPVS progression is related to the occurrence of silent lacunar infarction (SLI).

METHOD

Three hundred sixty-seven elderly patients with EPVS were screened by MRI on the day of admission and 2 years later; 295 patients were included in the final study, among which 136 patients had EPVS with SLI (EL); and 159 patients had EPVS without SLI (EOL). Both scale score and 3D volume quantification method were used to evaluate EPVS. The 295 patients were divided into three groups based on EPVS progression state: Group 1 (no progression), Group 2 (0-50% EPVS progression), and Group 3 (≥ 50% EPVS progression). Multiple logistic regression analysis was used to analyze the risk of occurrence of SLI.

RESULTS

The EPVS scores and ΔEPVS scores were not significantly different between the EL and EOL groups (p > 0.05). EPVS volumes and their progression were significantly higher in EL compared with EOL (p < 0.001). The incidence of SLI was increased in Groups 2 and 3 compared with those in Group 1, and the trend test showed statistically significant (p = 0.032). Multiple logistic regression analysis showed that the risk of occurrence of SLI was significantly increased in Group 2 (OR 2.24; p = 0.024) and Group 3 (OR 3.31; p = 0.037) versus that in Group 1.

CONCLUSION

3D volume quantification allows for a more sensitive assessment of EPVS changes, and the progression of EPVS volume may contribute to the occurrence of SLI.

Genotype-Guided Dual Antiplatelet Therapy in Minor Stroke or Transient Ischemic Attack With a Single Small Subcortical Infarction

BACKGROUND AND OBJECTIVES

Single small subcortical infarction (SSSI) is an important stroke subtype. The optimal antiplatelet medication for patients with ischemic stroke with an SSSI is still unclear. We aimed to test the efficacy and safety of ticagrelor-aspirin in preventing stroke recurrence among patients with SSSI in the Ticagrelor or Clopidogrel with Aspirin in High-Risk Patients with Acute Nondisabling Cerebrovascular Events II (CHANCE-2) trial.

METHODS

In the CHANCE-2 trial, patients with a minor stroke or TIA who carried CYP2C19 loss-of-function (LOF) alleles were randomly assigned within 24 hours after symptom onset, to either ticagrelor-aspirin (placebo clopidogrel plus a 180 mg loading dose of ticagrelor on day 1, followed by 90 mg twice daily on days 2-90) or clopidogrel-aspirin (placebo ticagrelor plus a 300 mg loading dose of clopidogrel on day 1, followed by 75 mg daily on days 2-90). Aspirin was applied during the first 21 days. Patients who had an SSSI (diffusion-weighted imaging lesion diameter ≤20 mm) were included in this analysis and further categorized into 2 types according to whether they had the responsible intracranial artery stenosis (ICAS): SSSI + ICAS and SSSI - ICAS. The primary efficacy outcome was a new stroke at 90 days.

RESULTS

Among 2,143 eligible patients, 340 had the responsible ICAS, and 1,803 did not. Ticagrelor-aspirin reduced stroke recurrence among all patients with SSSI (hazard ratio [HR]: 0.55; 95% CI 0.38-0.78; p = 0.001) compared with clopidogrel-aspirin. Stroke recurrence occurred in 35/901 (3.9%) patients with SSSI - ICAS on ticagrelor-aspirin and in 72/902 (8.0%) on clopidogrel-aspirin (hazard ratio [HR]: 0.45; 95% CI 0.29-0.68; p < 0.001). In patients with SSSI + ICAS, the corresponding event rates were 14/176 (8.0%) and 13/164 (7.9%), respectively (HR: 1.20; 95% CI 0.45-3.23; p = 0.71; p for interaction = 0.08). The risk of severe or moderate bleeding only occurred in patients with SSSI - ICAS (5/901 [0.6%] vs 5/902 [0.6%]).

DISCUSSION

In this prespecified substudy, ticagrelor-aspirin was superior to clopidogrel-aspirin in reducing the risk of stroke at 90 days among patients with SSSI who carried CYP2C19 LOF allele(s). Although there was no treatment-by-heterogeneous etiology interaction, a greater absolute risk reduction of stroke was observed in patients with SSSI - ICAS than in those with SSSI + ICAS.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that ticagrelor and aspirin reduced the risk of stroke recurrence compared with clopidogrel with aspirin in adult patients with acute minor SSSI.

Association between estimated pulse wave velocity and silent lacunar infarct in a Korean population

Aims

Previous studies have proposed the estimated pulse wave velocity (ePWV) as a simple and cost-effective measure of arterial stiffness. Since arterial stiffness plays a role in the progression of silent lacunar infarct (SLI), our present work aims to evaluate the association between ePWV and the presence of SLI.

Methods

The present work was based on a cross-section study. Our study included 1,011 neurologically healthy Korean participants. The SLI was evaluated using brain magnetic resonance images (MRI). The ePWV was derived from a published equation using age and mean blood pressure (MBP). Logistic regression analyses were performed to investigate the association between ePWV and SLI. The linear relationship and robustness were evaluated using smooth curve fitting and subgroup analyses, respectively.

Results

The prevalence of SLI was 11.87%. After fully adjusting for covariates, per 1 m/s increase of ePWV casted 31% additional risk for SLI (P = 0.009). When dividing the ePWV into quartiles, the top quartile had 4.01 times risk compared with the bottom quartile. The increasing trend across the quartiles was statistically significant (P for trend < 0.001). Consistently, smooth curve fitting revealed that the risk of SLI elevated linearly with the increase of ePWV. Finally, subgroup analysis suggested that the association was robust in several sub-populations divided by age, sex, smoking, hypertension, diabetes mellitus (DM), coronary artery occlusive disease (CAOD), hyperlipidemia, and statin medication (all P for interaction > 0.05).

Conclusion

The current study revealed an independent and positive association between ePWV and the presence of SLI in a neurologically healthy Korean population.

Effect of Ibandronate Therapy on Serum Chemerin, Vaspin, Omentin-1 and Osteoprotegerin (OPG) in Postmenopausal Osteoporotic Females

Osteoporosis is a condition in which bone mineral density is reduced due to altered bone microstructure, which results in increased skeletal fragility and incidence of various types of fractures. Adipokines such as chemerin, vaspin, omentin-1 and osteoprotegerin are involved in bone remodeling. The current study was designed to determine the changes in circulating chemerin, vaspin, omentin-1, and osteoprotegerin levels after treatment with oral ibandronate 150 mg in postmenopausal osteoporotic females. The present study enrolled 107 postmenopausal osteoporotic females from a tertiary care hospital in Faisalabad, Pakistan, based on stringent inclusion and exclusion criteria. Sixty-six healthy postmenopausal, non-osteoporotic females with no systemic illness were chosen from the general population. The assessment of bone mineral density (BMD) was done using a DEXA scan. Serum levels of chemerin, vaspin, omentin-1 and osteoprotegerin were estimated using commercially available enzyme-linked immunosorbent assay kits. The collected data were analyzed with the Statistical Package for Social Sciences (SPSS) version 24. Following 6 months of ibandronate treatment, there was a significant decrease of 24.24% (p < .033) in serum chemerin levels, as well as a significant increase in serum vaspin levels 343.32% (p < .001) and osteoprotegerin levels 19.57% (p < .001), with no significant change in omentin-1 levels. Thus, an increase in serum chemerin levels and a decrease in serum vaspin and osteoprotegerin levels could be implicated in osteoporosis.

Prevalence and Consequences of Cerebral Small Vessel Diseases: A Cross-Sectional Study Based on Community People Plotted Against 5-Year Age Strata

PURPOSE

To study the variation tendency of cerebral small vessel disease (CSVD) imaging markers and total burden with aging and to research the relationship between aging, CSVD markers and cognitive function.

METHODS

Participants in local urban communities were recruited for neuropsychological and magnetic resonance imaging assessments. Montreal Cognitive Assessment (MoCA), Mini-mental State Examination (MMSE), Number Connection Test A (NCT-A) and Digital Symbol Test (DST) were adopted as neuropsychological scale. Age was stratified at 5-year intervals, and the variation tendency of imaging markers and variables of neuropsychological scales in different age groups was studied. We further studied the relationship between aging, image markers and neuropsychological scales by multi-linear regression.

RESULTS

Finally, a total of 401 stroke-free participants (age, 54.83±7.74y; 45.9% were male) were included in the present analysis. With the increase of age, the incidence of imaging markers of CSVD were increased with aging except cerebral microbleeds. The performance results of NCT-A and DST were significant difference in 6 age groups (P < 0.001). In addition, linear decline of the neuropsychological function reflected by NCT-A and DST variables was observed. Linear regression found that age was an independent factor affecting the neuropsychological function reflected by NCT-A and DST variables, and the standard correction coefficients among different age groups increased gradually with age. In addition, brain atrophy is an independent factor affecting neuropsychological variables (odds ratio: -2.929, 95% CI: [-5.094 to -0.765]). There was no correlation between the number of neuroimaging markers and neuropsychological variables after full adjustment.

CONCLUSION

There are many CVSD markers even in younger people, the incidence rate and CVSD marker numbers increase with age. Aging and CSVD may eventually affect cognitive function through brain atrophy.

Acupuncture for patients recovering from lacunar infarction: A protocol for systematic review and meta-analysis

BACKGROUND

Lacunar infarction (LI) is the mild type in the classification of ischemic stroke, mostly occurs in the middle-aged and elderly, with mild hemiplegia and partial sensory disorder as the main manifestations. In the treatment of LI, acupuncture is often regarded as dominant therapy in the convalescence period. However, acupuncture for treatment of LI in the recovery period lacks high-quality reports and evidence-based medical evidence. Thus, we aim to evaluate the curative effect and safety of acupuncture for LI objectively.

METHODS

Pubmed, Cochrane Library, Web of Science, EBSCO, Springer, China National Knowledge Infrastructure, Chinese Scientific and Technical Journals Database (VIP), Wan-fang Database, Chinese Biomedical Literature Database, Chinese Science Citation Database, and other electronic databases will be retrieved from the inception to May, 2021. Randomized controlled trials related to this subject will be searched. The inclusion criteria are established and a detailed literature search strategy is designed through discussion. Article retrieval, screening, excluding repetitive studies, assessment of quality, and data processing will be conducted by 2 reviewers independently using EndNote (X9) and Review Manager (5.3.5). The outcome measures include primary outcome measures (total effective rate, National Institute of Health Stroke Scale score, and Fugl-Meyer Assessment score), secondary outcome measures (blood pressure, plasma glucose, and blood lipid), and safety outcome measures. We will perform a meta-analysis, descriptive analysis, and subgroup analysis based on data conditions.

RESULTS

The study of total effective rate, National Institute of Health Stroke Scale score, Fugl-Meyer Assessment score, blood pressure, plasma glucose, blood lipid, and adverse effects will provide evidenced outcome for high-quality synthesis and descriptive analysis.

CONCLUSION

This systematic review will kindly provide evidence of whether acupuncture is an effective and safe intervention for LI in the recovery period.

INPLASY REGISTRATION NUMBER

INPLASY202150060 (DOI:10.37766/inplasy2021.5.0060).

Differential Characteristics of Ischemic and Hemorrhagic Stroke in Patients with Cerebral Small Vessel Disease

Background

Small vessel disease (SVD) is the underlying anatomical substrate for both lacunar infarction and subcortical hemorrhage.

Aim

To assess predictive factors of ischemic or hemorrhagic stroke in patients with cerebral SVD.

Materials and Methods

Prospective hospital-based stroke registry ("The Sagrat Cor Hospital of Barcelona Stroke Registry") in an acute-care teaching hospital in Barcelona, Spain. From 4597 acute stroke patients included in the stroke registry over a 24-year period, 440 cases of lacunar stroke and 210 of subcortical intracerebral hemorrhage were selected. Demographics, clinical characteristics, risk factors, and early outcome were compared. Predictors of lacuna versus subcortical hemorrhage were assessed by multivariate analyses.

Results

In a logistic regression model based on demographics, risk factors, clinical features and outcome, dyslipidemia (odds ratio [OR] 2.06 (95% confidence interval (CI) 1.17-3.62) and diabetes (OR 1.97, 95% CI 1.19-3.26) were independent risk factors for lacunar infarction. Anticoagulation therapy (OR 0.05, 95% CI 0.01-0.28), sudden onset (OR 0.51, 95% CI 0.33-0.78), motor symptoms (OR 0.44, 95% CI 0.26-0.76), headache (OR 0.23, 95% CI 0.12-0.41), altered consciousness (OR 0.10, 95% CI 0.05-0.21), respiratory complications (OR 0.19, 95% CI 0.08-0.46), and in-hospital death (OR 0.08, 95% CI 0.02-0.36) were predictors of subcortical hemorrhage.

Conclusion

Identification of differential clinical and prognostic profile between ischemic and hemorrhagic consequences of underlying cerebral SVD is useful for risk stratification in the current process pursuing precision medicine.

Correlation of serum uric acid, cystatin C and high-sensitivity C-reactive protein with cognitive impairment in lacunar cerebral infarction

OBJECTIVE

To study the correlation of serum uric acid (UA), cystatin C (Cys-C) and high-sensitivity C-reactive protein (hs-CRP) with cognitive impairment in lacunar cerebral infarction.

METHODS

Total 198 patients with lacunar cerebral infarction were selected and divided into 4 groups according to their cognitive function, with 65 cases in the normal group, 72 cases in the mild cognitive impairment group, 38 cases in the moderate cognitive impairment group and 23 cases in the severe cognitive impairment group. The hs-CRP, serum UA, Cys-C and Montreal Cognitive Assessment (MoCA) were measured upon admission.

RESULTS

There were statistical differences in hs-CRP, UA and Cys-C among the four groups (all P<0.001). MoCA was negatively correlated with hs-CRP, UA and Cys-C (all P<0.001). Multivariate logistic regression analysis showed that elevated levels of hs-CRP, UA and Cys-C were the influencing factors of cognitive impairment in patients with lacunar cerebral infarction (all P<0.05).

CONCLUSION

The levels of hs-CRP, UA and Cys-C in patients with lacunar cerebral infarction increase with the aggravation of cognitive impairment, and high hs-CRP, UA and Cys-C are independent risk factors of cognitive impairment in patients with lacunar cerebral infarction.

Relation between left atrial structure and lacunar infarction in patients with hypertension

A lacunar infarction (LACI) can cause damage to the surrounding brain tissue and place an individual at greater risk for future major stroke. LACI is associated with hypertension and hypertension is associated with left atrial enlargement. It is important to identify a high-risk patient who is more vulnerable to suffering a LACI in hypertensive group. So, we studied whether left atrium size is an independent risk predictor for LACI in hypertensive patients. We performed cross-sectional analysis of 365 patients with hypertension at Shanghai Ninth People's Hospital from January 2016 to January 2017. The results showed that left atrial diameter(LAD), left atrial volume (LAV) and the ratio of left atrial diameter to left ventricular diameter (LAD/LVD) were significantly associated with LACI in hypertensive patients. Based on the ROC curve analysis, the area under the ROC curve (AUC) of LAV used to predict LACI was 0.737 (95% CI: 0.686 - 0.788), and the AUC of LAD/LVD was 0.784 (95% CI: 0.737 - 0.830). The optimal cut-off value for LAV was 30.14, and the sensitivity and specificity were 72% and 63%, respectively. The optimal cut-off value for LAD/LVD was 0.757, and the sensitivity and specificity were 77% and 70%, respectively. LAV or LAD/LVD played an important role in LACI with hypertension and could be an independent risk factor in hypertensive patients.

Hypertension-Induced Cerebral Small Vessel Disease Leading to Cognitive Impairment

Objective:

Alzheimer's disease and vascular dementia are responsible for more than 80% of dementia cases. These two conditions share common risk factors including hypertension. Cerebral small vessel disease (CSVD) is strongly associated with both hypertension and cognitive impairment. In this review, we identify the pathophysiological changes in CSVD that are caused by hypertension and further explore the relationship between CSVD and cognitive impairment.

Data Sources:

We searched and scanned the PubMed database for recently published literatures up to December 2017. We used the keywords of “hypertension”, “cerebral small vessel disease”, “white matter lesions”, “enlarged perivascular spaces”, “lacunar infarcts”, “cerebral microbleeds”, and “cognitive impairment” in the database of PubMed.

Study Selection:

Articles were obtained and reviewed to analyze the hypertension-induced pathophysiological changes that occur in CSVD and the correlation between CSVD and cognitive impairment.

Results:

In recent years, studies have demonstrated that hypertension-related changes (e.g., small vascular lesions, inflammatory reactions, hypoperfusion, oxidative stress, damage to autoregulatory processes and the blood-brain barrier, and cerebral amyloid angiopathy) can occur over time in cerebral small vessels, potentially leading to lower cognitive function when blood pressure (BP) control is poor or lacking. Both isolated and co-occurrent CSVD can lead to cognitive deterioration, and this effect may be attributable to a dysfunction in either the cholinergic system or the functionality of cortical and subcortical tracts.

Conclusions:

We explore the currently available evidence about the hypertensive vasculopathy and inflammatory changes that occur in CSVD. Both are vital prognostic indicators of the development of cognitive impairment. Future studies should be performed to validate the relationship between BP levels and CSVD progression and between the numbers, volumes, and anatomical locations of CSVD and cognitive impairment.

The Association between Carotid Artery Atherosclerosis and Silent Brain Infarction: A Systematic Review and Meta-analysis

BACKGROUND

Carotid atherosclerosis is responsible for ~20% of ischemic strokes, but it is unclear whether carotid disease is associated with the presence of downstream silent brain infarction (SBI). We performed a systematic review and meta-analysis to study the relationship between SBI and 2 separate manifestations of carotid atherosclerosis, carotid intima-media thickening (IMT) and luminal stenosis.

METHODS

Ovid MEDLINE, Ovid Embase, and the Cochrane Library Database were searched with an additional search of references and citing articles of target studies. Articles were included if they reported an association between carotid IMT or stenosis and magnetic resonance imaging-defined SBI, excluding SBIs found after carotid intervention.

RESULTS

We pooled 7 studies of carotid IMT reporting on 1469 subjects with SBI and 5102 subjects without SBI. Subjects with SBI had a larger mean IMT than subjects without SBI (pooled standardized mean difference, .37; 95% confidence interval [CI], .23-.51; P < .0001). We pooled 11 studies of carotid stenosis reporting on 12,347 subjects (2110 subjects with carotid stenosis and 10,237 subjects without carotid stenosis). We found a higher prevalence of SBI among subjects with carotid stenosis (30.4% versus 17.4%). Our pooled random-effects analysis showed a significant positive relationship between carotid stenosis and SBI (odds ratio, 2.78; 95% CI, 2.19-3.52; P < .0001).

CONCLUSIONS

Two forms of atherosclerotic disease, carotid IMT and stenosis, are both significantly associated with SBI. This review highlights a lack of consistent definitions for carotid disease measures and little evidence evaluating SBI prevalence downstream from carotid stenosis.

Insulin Resistance Is a Risk Factor for Silent Lacunar Infarction

Background and Purpose—

This study aims to investigate the association between insulin resistance (IR) and silent lacunar infarction (SLI) in healthy adults.

Methods—

We recruited 2326 healthy Korean adults who took health checkups, including a brain magnetic resonance imaging. SLI was defined as an infarction measuring 0.3 to 1.5 cm in diameter that was localized in the territory of perforating branches of cerebral arteries, as seen in the brain magnetic resonance imaging. The homeostasis model assessment–estimated insulin resistance index was used for IR estimation, and the cutoff value for its diagnosis for Koreans was 2.56.

Results—

The mean age of the study population was 56.2 years (range, 40–79 years), and 1279 subjects (55.0%) were male. The prevalence of SLI and IR was 8.1% and 18.1%, respectively. In multivariate logistic analysis, after adjusting for traditional SLI-associated risk factors, IR was positively associated with the prevalence of SLI (adjusted odds ratio, 1.69; 95% confidence interval, 1.16–2.46). The proportion of subjects with multiple SLI lesions (≥2) was also higher in the IR (+) group than that in the IR (−) group (4.3% versus 1.7%; P <0.001). In ordered logistic regression, IR was positively associated with an increase in SLI severity (adjusted odds ratio, 1.76; 95% confidence interval, 1.21–2.56).

Conclusions—

IR is an independent risk factor of SLI presence and its severity in Koreans. Whether improvement of IR might prevent SLI occurrence needs to be addressed by clinical trials.

The prevalence of lacunar infarct decreases with aging in the elderly: a case-controlled analysis

Background and purpose

Lacunar infarct (LI) is well known as a heterogeneous primary disorder of cerebral small vessel. Compelling results have demonstrated that age is a risk factor to the prevalence of LI. However, the relationship between age and the prevalence of LI remains obscure. It is essential to note the relationship between age and the prevalence of LI through more clinical data.

Methods

A total of 3,500 patients were included in the case-controlled study. All data were collected from the Examination Center of Magnetic Resonance Imaging, Lu’an People’s Hospital from January 2014 to December 2015. A primary discharge diagnosis of LI was done, and all subjects were evaluated as retrospective data. The relationship between the risk factors and the prevalence of diabetes and the relationship between age and the prevalence of diabetes was analyzed. A chi-square test was used to analyze the associations between different variables. A one-way analysis of variance was used to test the equality of three or more means at one time by using variances. Statistical significance was defined as a P-value of <0.05.

Results

The one-way analysis of variance demonstrated that the prevalence of LI increased with age before 60 years and decreased with age after 69 years. The same results were found in both the male and the female subjects. These results showed that the age-related risk factors (hypertension, diabetes, cerebral infarct, cardiovascular diseases, smoking, and drinking) have no relationship with the prevalence of LI on the basis of age. There is a significant difference among the different age ranges (P=0.0006). Two-tailed P-value (unpaired t-test) showed the mean significant difference between 30–39 years and 40–49 years (P=0.009) and between 70–79 years and 80–100 years (P=0.0196). F-test (to compare variances) demonstrated that the variances of the different age ranges are significantly different between 30–39 years and 40–49 years (P=0.0002), between 40–49 years and 50–59 years (P=0.0424), and between 70–79 years and 80–100 years (P=0.0003).

Conclusion

The age-related risk factors (hypertension, diabetes, cerebral infarct, cardiovascular diseases, smoking, and drinking) have no relationship with the prevalence of LI on the basis of age. A decreasing prevalence of LI with aging occurs in the elderly, while the prevalence of LI increases with aging in the young and in adults. This investigation implicates that age is not a risk factor for LI in the elderly.