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.

Differences in characteristics between patients from Egypt and Germany presenting with lacunar stroke

Despite the enormous health burden of lacunar stroke, data from low- and middle-income countries on lacunar stroke characteristics and its comparison with that of high-income countries are scarce. Thus, we aimed to investigate and compare the variable characteristics and vascular status in patients from Egypt and Germany suffering lacunar stroke. Two cohorts of lacunar stroke patients from Ain Shams University Hospital, Egypt and Goethe University Hospital Frankfurt, Germany were retrospectively collected between January 2019 and December 2020 and analyzed for demographics, risk factors, mode of presentation, neuroimaging features, treatment protocols and outcomes. MRI showed a different distribution pattern of lacunar strokes between cohorts, detecting posterior circulation lacunar infarctions preponderantly in patients from Egypt and anterior circulation lacunar infarctions preponderantly in patients from Germany. Complementary MR/CT angiography revealed a significantly higher proportion of intracranial and combined intracranial and extracranial arterial stenosis in patients from Egypt than in patients from Germany, suggesting differences in pathological processes. Younger age, higher NIHSS on admission, and posterior circulation lacunar infarction were predictors of Egyptian origin, whereas hypertension was a predictor of German origin. Our results support the idea of clinical and neuroimaging phenotype variations in lacunar stroke, including different sources of lacunar stroke in patients of different populations and geographical regions. This implies that guidelines for management of lacunar stroke might be tailored to these differences accordingly.

Prevalence and distribution of lacunar stroke in China: a cross-sectional study using self-reported survey data

OBJECTIVES

To report the prevalence and distribution of lacunar stroke in different regions of China, as well as the demographical characteristics of symptomatic and asymptomatic lacunar stroke.

DESIGN

Cross-sectional study.

SETTING

Data were derived from NESS-China Study that was conducted in 157 sites covering all 31 provinces, including 64 urban and 93 rural areas in mainland China between 1 September 2013 and 31 December 2013. Lacunar stroke was defined as being previously diagnosed according to the participants' medical history. Patients were further divided into symptomatic or asymptomatic groups, depending on whether they were initially diagnosed with neurological symptoms.

PARTICIPANTS

458 833 participants aged ≥20 years were enrolled in this study.

RESULTS

A total of 7520 participants (1.63%) were diagnosed with lacunar stroke. The peak rate of diagnosis was between the ages of 70 and 79 years in both men and women. Geographically, the age-standardised and sex-standardised prevalence was highest in Northeast China (2495.3/100 000 persons) and lowest in Southeast China (599.7/100 000 persons), showing a geographical disparity. Over 90% of patients with lacunar stroke were diagnosed in secondary or tertiary hospitals. Patients with symptomatic lacunar stroke had significantly different demographic characteristics in age, sex and geographical regions compared with those who were asymptomatic.

CONCLUSIONS

In this study, the prevalence and distribution of lacunar stroke were reported at population level across China. Special attention and prevention should be given to the age, sex and geographical groups that are vulnerable to lacunar stroke.

Correlation between silent lacunar strokes and retinopathies seen on fundus among patients hospitalized for lacunar strokes: An observational study at the neurology department of Befelatanana University Hospital

Retinal and cerebral arterioles have similar characteristics. Silent infarcts are associated with a risk of incident lacunar stroke and dementia. The objective of our study was to determine the correlation between silent lacunar strokes and retinopathy in patients hospitalized in our department for lacunar strokes. This is an observational, retrospective study, from July 2018 to December 2019, of patients diagnosed with lacunar stroke at the neurology department of Befelatanana Hospital, Antananarivo. Stroke was diagnosed with brain CT scan and retinopathy was classified according to fundus examination. The correlation between the presence of silent lacunar stroke and different types and stages of retinopathy was studied. Silent lacunar lesions were discovered on imaging in 70.59% of patients with lacunar strokes. All patients with symptomatic lacunar stroke, with or without associated silent lacunar lesions, were hypertensives. No statistical difference was found between patients with or without associated silent lacunar lesions according to age and gender. Among patients with silent lacunar lesions, dysexecutive syndrome was more prevalent as compared to patients without silent lesions (52.63% vs. 47.36%, P=0.03). Arteriolopathy was more prevalent in patients with silent lacunar lesions (85.71% vs. 14.28%, P=0.047). Silent lacunar lesions were unique in 72% of cases (P=0.022). The presence of stage II hypertensive retinopathy was significantly correlated with the presence of silent lacunar lesions (OR 5.20 [1.02-267] [1.02-26.47], P=0.018). Upon discovery of stage II hypertensive retinopathy on fundus examination, brain imaging should be performed for silent lacunar stroke screening to optimize hypertension management. This management is expected to prevent the incidence of lacunar stroke and vascular dementia.

Factors associated with higher falling risk in elderly diabetic patients with lacunar stroke

PURPOSE

The aim of this study is to explore the factors associated with the fall risk in type 2 diabetes (T2D) patients with a lacunar stroke.

MATERIALS AND METHODS

We compiled data of 146 T2D patients (mean age 68 years), including the Morse fall scale data (MFS), nutrition score, self-care scale, laboratory data, and data from continuous glucose monitoring system (CGMS) from 2019 to 2021 in Shanghai Pudong Hospital. Thereby, we evaluated the associations between MFS and other clinical parameters.

RESULTS

The analyses showed that there were significantly increased size and numbers of lacunar infarction (p < 0.05). Furthermore, the greater risk group had an older mean age (p < 0.05), and significant decreased estimated glomerular filtration rate (eGFR), total triglyceride (TG), while increased microalbuminuria, magnesium, lipoprotein A (LP(a)), anti-thyroid peroxidase antibody (TPOAb) (p < 0.05). However, the time in range (TIR) was very comparable (p > 0.05). The correlational study revealed the higher score of MFS was associated with the age (r = 0.41), number of lacunar infarction (r = 0.18), nutrition score (r = 0.20), self-care score (r = - 0.43), serum creatine level (r = 0.19), eGFR (r = - 0.26) (p < 0.05). The total numbers of lacunar infarction were associated with age (r = 0.36), eGFR (r = - 0.40), homocysteine level (r = 0.33) (p < 0.05).

CONCLUSIONS

Age, nutrition, self-care ability, and renal function are all critical factors associated with the risk of fall in T2D with lacunar infarction. The age, eGFR, and homocysteine are closely associated with lacunar infarction, suggesting that in T2D, evaluation of kidney dysfunction, homocysteine level in the elderly can predict lacunar infarcts and falls.

Effect of folic acid combined with pravastatin on arteriosclerosis in elderly hypertensive patients with lacunar infarction

ABSTRACT

This study aimed to assess the effect of folic acid combined with pravastatin on atherosclerosis-related indexes in elderly patients with hypertension complicated with lacunar cerebral infarction.A total of 134 elderly hypertensive patients with lacunar cerebral infarction were randomly divided into 3 groups using the random number table method. Group A, the folic acid group, had 45 cases and received low-dose folic acid (0.8 mg/d) treatment on the basis of antihypertensive treatment. Group B, the pravastatin group, had 45 cases and received pravastatin (20 mg/d) treatment on the basis of antihypertensive treatment. Group C, the folic acid combined with the pravastatin group, had 44 cases. Members of this group received pravastatin (20 mg/d) and low-dose folic acid (0.8 mg/d) based on antihypertensive treatment. Levels of folic acid, homocysteine (Hcy), tumor necrosis factor alpha (TNF-a), matrix metallopeptidase 9 (MMP-9), cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C) were measured by ELISA before treatment in all 3 groups. Carotid intima-media thickness (IMT) was measured using ultrasound, and systolic and diastolic blood pressure were measured with a mercury column. After 8 weeks of treatment, the levels of folic acid, Hcy, TNF-a, MMP-9, TC, LDL-C, and systolic and diastolic blood pressure were compared among the 3 groups. IMT levels were measured at 12 weeks of treatment.After 8 weeks of treatment, compared with group B, patients in groups A and C had folic acid levels significantly higher than baseline levels, with significantly lower Hcy levels (both P < .05). Patients in group C presented significantly decreased TNF-a, MMP-9, TC, and LDL-C levels and systolic and diastolic blood pressure after 8 weeks of treatment, compared with those in groups A and B (both P < .05). These patients also showed significantly decreased IMT levels compared with those in the other groups (P < .05).Low-dose folic acid combined with pravastatin in elderly patients with lacunar cerebral infarction can reduce the level of homocysteine, improve the degree of carotid atherosclerosis, protect vascular endothelium, and reduce blood lipids and blood pressure, presenting better benefits than pravastatin alone.

Genetic basis of lacunar stroke: a pooled analysis of individual patient data and genome-wide association studies

BACKGROUND

The genetic basis of lacunar stroke is poorly understood, with a single locus on 16q24 identified to date. We sought to identify novel associations and provide mechanistic insights into the disease.

METHODS

We did a pooled analysis of data from newly recruited patients with an MRI-confirmed diagnosis of lacunar stroke and existing genome-wide association studies (GWAS). Patients were recruited from hospitals in the UK as part of the UK DNA Lacunar Stroke studies 1 and 2 and from collaborators within the International Stroke Genetics Consortium. Cases and controls were stratified by ancestry and two meta-analyses were done: a European ancestry analysis, and a transethnic analysis that included all ancestry groups. We also did a multi-trait analysis of GWAS, in a joint analysis with a study of cerebral white matter hyperintensities (an aetiologically related radiological trait), to find additional genetic associations. We did a transcriptome-wide association study (TWAS) to detect genes for which expression is associated with lacunar stroke; identified significantly enriched pathways using multi-marker analysis of genomic annotation; and evaluated cardiovascular risk factors causally associated with the disease using mendelian randomisation.

FINDINGS

Our meta-analysis comprised studies from Europe, the USA, and Australia, including 7338 cases and 254 798 controls, of which 2987 cases (matched with 29 540 controls) were confirmed using MRI. Five loci (ICA1L-WDR12-CARF-NBEAL1, ULK4, SPI1-SLC39A13-PSMC3-RAPSN, ZCCHC14, ZBTB14-EPB41L3) were found to be associated with lacunar stroke in the European or transethnic meta-analyses. A further seven loci (SLC25A44-PMF1-BGLAP, LOX-ZNF474-LOC100505841, FOXF2-FOXQ1, VTA1-GPR126, SH3PXD2A, HTRA1-ARMS2, COL4A2) were found to be associated in the multi-trait analysis with cerebral white matter hyperintensities (n=42 310). Two of the identified loci contain genes (COL4A2 and HTRA1) that are involved in monogenic lacunar stroke. The TWAS identified associations between the expression of six genes (SCL25A44, ULK4, CARF, FAM117B, ICA1L, NBEAL1) and lacunar stroke. Pathway analyses implicated disruption of the extracellular matrix, phosphatidylinositol 5 phosphate binding, and roundabout binding (false discovery rate <0·05). Mendelian randomisation analyses identified positive associations of elevated blood pressure, history of smoking, and type 2 diabetes with lacunar stroke.

INTERPRETATION

Lacunar stroke has a substantial heritable component, with 12 loci now identified that could represent future treatment targets. These loci provide insights into lacunar stroke pathogenesis, highlighting disruption of the vascular extracellular matrix (COL4A2, LOX, SH3PXD2A, GPR126, HTRA1), pericyte differentiation (FOXF2, GPR126), TGF-β signalling (HTRA1), and myelination (ULK4, GPR126) in disease risk.

FUNDING

British Heart Foundation.

Lacunes, Microinfarcts, and Vascular Dysfunction in Cerebral Amyloid Angiopathy

OBJECTIVE

To analyze the relationship of lacunes with cortical cerebral microinfarcts (CMIs), to assess their association with vascular dysfunction, and to evaluate their effect on the risk of incident intracerebral hemorrhage (ICH) in cerebral amyloid angiopathy (CAA).

METHODS

The count and topography of lacunes (deep/lobar), CMIs, and white matter hyperintensity (WMH) volume were retrospectively analyzed in a prospectively enrolled CAA cohort that underwent high-resolution research MRIs. The relationship of lacunes with CMIs and other CAA-related markers including time to peak (TTP) of blood oxygen level-dependent signal, an established measure of vascular dysfunction, was evaluated in multivariate models. Adjusted Cox regression models were used to investigate the relationship between lacunes and incident ICH.

RESULTS

The cohort consisted of 122 patients with probable CAA without dementia (mean age, 69.4 ± 7.6 years). Lacunes were present in 31 patients (25.4%); all but one were located in lobar regions. Cortical CMIs were more common in patients with lacunes compared to patients without lacunes (51.6% vs 20.9%, p = 0.002). TTP was not associated with either lacunes or CMIs (both p > 0.2) but longer TTP response independently correlated with higher WMH volume (p = 0.001). Lacunes were associated with increased ICH risk in univariate and multivariate Cox regression models (p = 0.048 and p = 0.026, respectively).

CONCLUSIONS

Our findings show a high prevalence of lobar lacunes, frequently coexisting with CMIs in CAA, suggesting that these 2 lesion types may be part of a common spectrum of CAA-related infarcts. Lacunes were not related to vascular dysfunction but predicted incident ICH, favoring severe focal vessel involvement rather than global ischemia as their mechanism.

Microvascular Brain Disease Progression and Risk of Stroke: The ARIC Study

BACKGROUND AND PURPOSE

Data on the significance of combined white matter hyperintensities (WMH)/lacunar brain infarcts, and their progression over time for the prediction of stroke are scarce. We studied associations between the progression in combined measures of microvascular brain disease and risk of stroke in the ARIC study (Atherosclerosis Risk in Communities).

METHODS

Prospective analysis of 907 stroke-free ARIC participants who underwent a brain magnetic resonance imaging (MRI) in 1993 to 1995, a second brain MRI in 2004 to 2006, and were subsequently followed for stroke incidence through December 31, 2017 (median [25%-75%] follow-up 12.6 [8.9-13.4] years). A combined measure of microvascular brain disease was defined at each visit and categorized by progression from first to second brain MRI as no progression; mild progression (increase of ≥1 unit in WMH grade or new lacune), and moderate progression (increase of ≥1 unit in WMH grade and new lacune). All definite/probable ischemic or hemorrhagic incident strokes occurring after this second MRI, and through 2017, were included. Associations between microvascular brain disease, progression in the combined measures, and stroke incidence were studied with Cox proportional hazard models, adjusting for age, sex, race, education level, time from first to second MRI, body mass index, smoking, hypertension, diabetes mellitus, and coronary heart disease.

RESULTS

At the second brain MRI (mean age 72), the distribution of the combined measure was 37% WMH grade <2 and no lacune; 57% WMH grade ≥2 or lacune; and 6% WMH grade ≥2 and lacune. No progression in the combined measures was observed in 38% of participants, 57% showed mild progression and 5% showed moderate progression. Sixty-four incident strokes occurred during the follow-up period. Compared with no change in the combined measure, moderate progression of microvascular brain disease was significantly associated with higher risk of stroke (adjusted hazard ratio, 3.00 [95% CI, 1.30-6.94]).

CONCLUSIONS

Progression of microvascular brain disease, manifesting as both new lacunes and increase in WMHs grade, is related to substantial increase in long-term risk of stroke.

The study on analysis of risk factors for severity of white matter lesions and its correlation with cerebral microbleeds in the elderly with lacunar infarction

This study aimed to explore the risk factors for severity of white matter lesions and its correlation with in the elderly with lacunar infarction.Patients (range, 70-85 years) with lacunar infarction treated in a hospital in China from 2016 to 2017were enrolled. Fazekas rating scale (0-6 points) was used to assess severity of white matter lesions. Risk factors for the severity of white matter lesions and correlation between cerebral microbleeds and white matter lesions in the elderly with lacunar infarction were studied.The elderly (81-85 years' old, odds ratio [OR]: 2.423, 95% confidence interval [CI]: 1.795-3.271, P = .018; 76∼80 years' old, OR: 3.113, 95% CI: 1.723-5.625, P = .043), carotid atherosclerosis (OR: 3.062, 95% CI:1.715-5.468, P < .001), history of hypertension (OR: 3.694, 95% CI: 2.031-6.717, P < .001) were risk factors for the severity of white matter lesions. The white matter lesions score increased corresponding to increase in the cerebral microbleeds grade (P < .001). The white matter lesions score was higher in the cerebral microbleeds combined with the white matter lesions group than in the white matter lesions group (P < .01). After correcting the effects of age, there was a correlation between white matter lesions and cerebral microbleeds (P < .001). Logistic analysis revealed that the patients' age (81-85 years' old, OR: 2.722, 95% CI: 1.985-3.734, P = .019; 76∼80 years' old, OR: 1.857, 95% CI: 1.075-3.207, P = .031), history of hypertension (OR: 2.931, 95% CI: 1.136-7.567, P = 0.0.036), systolic blood pressure (OR: 1.049, 95% CI: 1.015-1.084, P = .007), high-sensitivity C-reactive protein (OR: 1.504, 95% CI: 1.254-1.803, P < .001), homocysteine (OR: 1.076, 95% CI: 1.020-1.136, P = .009), and carotid atherosclerosis (OR: 1.389, 95% CI: 1.103-1.748, P = .010) were significant risk factors for combined cerebral microbleeds with white matter lesions in patients with lacunar infarction.The elderly, carotid atherosclerosis, history of hypertension were risk factors for the severity of white matter lesions. Cerebral microbleeds were positively correlated with the severity of white matter lesions.

Plasma brain natriuretic peptide is a biomarker for screening ischemic cerebral small vessel disease in patients with hypertension

Plasma brain natriuretic peptide (BNP), a diagnostic marker of cardiovascular diseases, has been previously linked to cerebrovascular diseases. Our goal was to determine whether plasma BNP level is helpful for identifying high-risk individuals who are likely to present with the 3 main subtypes of cerebral small vessel diseases (CSVDs), namely, white matter lesions, lacunar infarcts, and cerebral microbleeds, on magnetic resonance imaging (MRI) in patients with hypertension.Three hundred forty-six consecutive hypertensive patients presenting at our cardiology or neurology clinic were investigated. Plasma BNP level was measured by chemiluminescent microparticle immunoassay. The presence of CSVD was assessed by 1.5-T brain MRI. Multivariate linear regression was used to determine whether individual or combined MRI-defined CSVD subtypes were associated with BNP level, after adjustment for several covariates.The mean age of patients was 69.1 ± 9.8 years, and 44.2% were female. The highest quartile BNP group was positively associated with advanced age, female sex, clinically manifesting cardiac diseases, and ischemic CSVD (white matter lesions and lacunar infarcts) and no association with cerebral microbleeds. According to multivariate linear regression, white matter lesions [β = 0.722; 95% confidence interval (95% CI), 0.624-0.819] and lacunar infarcts (β = 0.635; 95% CI, 0.508-0.762) were independently associated with BNP level, even after controlling for vascular risk factors and clinically manifesting cardiac diseases. Combined white matter lesions and lacunar infarcts were more strongly associated with BNP level than each subtype alone. With the cutoff value of 106.4 pg/mL, BNP level had a sensitivity, a specificity, and an area under the curve of 95.2%, 64.9%, and 0.799, respectively, for white matter lesions, whereas the values were 143.0 pg/mL, 81.6%, 73.5%, and 0.848, respectively, for lacunar infarcts.Plasma BNP level, which is independently correlated with individual or combined white matter lesions and lacunar infarcts, is a useful molecular marker for identifying ischemic CSVD in patients with hypertension.

Time course of blood pressure control prior to lacunar TIA and stroke: Population-based study

OBJECTIVE

To determine the age-specific temporal trends in blood pressure (BP) before acute lacunar vs nonlacunar TIA and stroke.

METHODS

In a population-based study of TIA/ischemic stroke (Oxford Vascular Study), we studied 15-year premorbid BP readings from primary care records in patients with lacunar vs nonlacunar events (Trial of Org 10172 in Acute Stroke Treatment [TOAST]) stratified by age (<65, ≥65 years).

RESULTS

Of 2,085 patients (1,250 with stroke, 835 with TIA), 309 had lacunar events. In 493 patients <65 years of age, the prevalence of diagnosed hypertension did not differ between lacunar and nonlacunar events (46 [48.4%] vs 164 [41.2%], p = 0.20), but mean/SD premorbid BP (44,496 BP readings) was higher in patients with lacunar events (15-year records: systolic BP [SBP] 138.5/17.7 vs 133.3/15.0 mm Hg, p = 0.004; diastolic BP [DBP] 84.1/9.6 vs 80.9/8.4 mm Hg, p = 0.001), mainly because of higher mean BP during the 5 years before the event (SBP 142.6/18.8 vs 134.6/16.6 mm Hg, p = 0.0001; DBP 85.2/9.7 vs 80.6/9.0 mm Hg, p < 0.0001), with a rising trend (ptrend = 0.006) toward higher BP leading up to the event (<30-day pre-event SBP: 152.7/16.1 vs 135.3/23.1 mm Hg, p = 0.009; DBP 87.9/9.4 vs 80.8/12.8 mm Hg, p = 0.05; mean BP ≤1 year before the event 145.8/22.0 vs 134.7/16.1 mm Hg, p = 0.001; 86.1/10.7 vs 80.4/9.8 mm Hg, p = 0.0001). Maximum BP in the 5 years before the event was also higher in patients with lacunar events (SBP 173.7/26.6 vs 158.6/23.2 mm Hg, p = 0.0001; DBP 102.3/12.9 vs 94.2/11.2 mm Hg, p < 0.0001), as was persistently elevated BP (≥50% SBP >160 mm Hg, odd ratio 4.95, 95% confidence interval 1.99-12.31, p = 0.0002). However, no similar differences in BP were observed in patients ≥65 years of age.

CONCLUSION

Recent premorbid BP control is strongly temporarily related to acute lacunar events at younger ages, suggesting a direct role of BP in accelerating causal pathology and highlighting the need to control hypertension quickly.

Plasma Aβ (Amyloid-β) Levels and Severity and Progression of Small Vessel Disease

BACKGROUND AND PURPOSE

Cerebral small vessel disease (SVD) is a frequent pathology in aging and contributor to the development of dementia. Plasma Aβ (amyloid β) levels may be useful as early biomarker, but the role of plasma Aβ in SVD remains to be elucidated. We investigated the association of plasma Aβ levels with severity and progression of SVD markers.

METHODS

We studied 487 participants from the RUN DMC study (Radboud University Nijmegen Diffusion Tensor and Magnetic Resonance Imaging Cohort) of whom 258 participants underwent 3 MRI assessments during 9 years. We determined baseline plasma Aβ38, Aβ40, and Aβ42 levels using ELISAs. We longitudinally assessed volume of white matter hyperintensities semiautomatically and manually rated lacunes and microbleeds. We analyzed associations between plasma Aβ and SVD markers by ANCOVA adjusted for age, sex, and hypertension.

RESULTS

Cross-sectionally, plasma Aβ40 levels were elevated in participants with microbleeds (mean, 205.4 versus 186.4 pg/mL; P<0.01) and lacunes (mean, 194.8 versus 181.2 pg/mL; P<0.05). Both Aβ38 and Aβ40 were elevated in participants with severe white matter hyperintensities (Aβ38, 25.3 versus 22.7 pg/mL; P<0.01; Aβ40, 201.8 versus 183.3 pg/mL; P<0.05). Longitudinally, plasma Aβ40 levels were elevated in participants with white matter hyperintensity progression (mean, 194.6 versus 182.9 pg/mL; P<0.05). Both Aβ38 and Aβ40 were elevated in participants with incident lacunes (Aβ38, 24.5 versus 22.5 pg/mL; P<0.05; Aβ40, 194.9 versus 181.2 pg/mL; P<0.01) and Aβ42 in participants with incident microbleeds (62.8 versus 60.4 pg/mL; P<0.05).

CONCLUSIONS

Plasma Aβ levels are associated with both presence and progression of SVD markers, suggesting that Aβ pathology might contribute to the development and progression of SVD. Plasma Aβ levels might thereby serve as inexpensive and noninvasive measure for identifying individuals with increased risk for progression of SVD.

Age-Specific Associations of Renal Impairment With Magnetic Resonance Imaging Markers of Cerebral Small Vessel Disease in Transient Ischemic Attack and Stroke

Supplemental Digital Content is available in the text.

Background and Purpose—

It has been hypothesized that cerebral small vessel disease (SVD) and chronic renal impairment may be part of a multisystem small-vessel disorder, but their association may simply be as a result of shared risk factors (eg, hypertension) rather than to a systemic susceptibility to premature SVD. However, most previous studies were hospital based, most had inadequate adjustment for hypertension, many were confined to patients with lacunar stroke, and none stratified by age.

Methods—

In a population-based study of transient ischemic attack and ischemic stroke (OXVASC [Oxford Vascular Study]), we evaluated the magnetic resonance imaging markers of cerebral SVD, including lacunes, white matter hyperintensities, cerebral microbleeds, and enlarged perivascular space. We studied the age-specific associations of renal impairment (estimated glomerular filtration rate <60 mL/min per 1.73 m²) and total SVD burden (total SVD score) adjusting for age, sex, vascular risk factors, and premorbid blood pressure (mean blood pressure during 15 years preevent).

Results—

Of 1080 consecutive patients, 1028 (95.2%) had complete magnetic resonance imaging protocol and creatinine measured at baseline. Renal impairment was associated with total SVD score (odds ratio [OR], 2.16; 95% confidence interval [CI], 1.69–2.75; P<0.001), but only at age <60 years (<60 years: OR, 3.97; 95% CI, 1.69–9.32; P=0.002; 60–79 years: OR, 1.01; 95% CI, 0.72–1.41; P=0.963; ≥80 years: OR, 0.95; 95% CI, 0.59–1.54; P=0.832). The overall association of renal impairment and total SVD score was also attenuated after adjustment for age, sex, history of hypertension, diabetes mellitus, and premorbid average systolic blood pressure (adjusted OR, 0.76; 95% CI, 0.56–1.02; P=0.067), but the independent association of renal impairment and total SVD score at age <60 years was maintained (adjusted OR, 3.11; 95% CI, 1.21–7.98; P=0.018). Associations of renal impairment and SVD were consistent for each SVD marker at age <60 years but were strongest for cerebral microbleeds (OR, 5.84; 95% CI, 1.45–23.53; P=0.013) and moderate–severe periventricular white matter hyperintensities (OR, 6.28; 95% CI, 1.54–25.63; P=0.010).

Conclusions—

The association of renal impairment and cerebral SVD was attenuated with adjustment for shared risk factors at older ages, but remained at younger ages, consistent with a shared susceptibility to premature disease.

Basilar Artery Dolichoectasia: Prevalence and Correlates With Markers of Cerebral Small Vessel Disease in Community-Dwelling Older Adults

BACKGROUND

Basilar artery (BA) dolichoectasia has been associated with cerebral small vessel disease (SVD). However, studies have focused on stroke patients, and results cannot be extrapolated to the population at large. In this study, we aimed to assess prevalence of BA dolichoectasia and its association with SVD in community-dwelling older adults living in rural Ecuador.

METHODS

Atahualpa residents aged ≥60 years underwent brain magnetic resonance imaging and magnetic resonance angiography of intracranial vessels. Following Smoker's criteria, the mean BA diameter plus 2 standard deviation defined ectasia. In addition, a location lateral to the lateral margin of the clivus of dorsum sellae or a bifurcation at the third ventricle floor or higher defined dolichosis. Associations between BA abnormalities and imaging markers of SVD were assessed by the use of regression models adjusted for demographics and cardiovascular risk factors.

RESULTS

Of 346 participants, 11 (3.2%) had ectasia, 40 (11.6%) had dolichosis, and 47 (13.6%) had dolichoectasia (ectasia, dolichosis, or both). BA diameter was only associated with severity of white matter hyperintensities (P = .038). Dolichosis was associated with deep cerebral microbleeds (P = .002) but not with white matter hyperintensities. Dolichoectasia was associated with both white matter hyperintensities (P = .031) and cerebral microbleeds (P = .001). There were no associations with lacunar infarcts or enlarged perivascular spaces in any model.

CONCLUSIONS

Prevalence of BA dolichoectasia in this rural setting is similar to that reported in other populations. Associations with imaging markers of SVD differ according to whether the subject has ectasia or dolichosis.

Differences between patients with unilateral and bilateral internal carotid kinking in age distribution, risk factors and clinical relevance

BACKGROUND

Clinical differences between patients with and without internal carotid kinking (ICK) were frequently discussed in previous literatures. However, studies comparing patients with unilateral and bilateral ICK for their characteristics are scarce. The purpose of this study was to identify the differences between these patients in age distribution, risk factors and clinical relevance.

METHODS

From November 1, 2013 to January 30, 2014, all the patients who underwent carotid CT angiography and skull MRI for various medical reasons in our hospital were consecutively enrolled. Patient data were assessed simultaneously according to medical records. Then, age distribution, risk factors and prevalence of subcortical ischemic change in patients with unilateral ICK (unilateral group) and those with bilateral ICK (bilateral group) were compared statistically.

RESULTS

A total of 13.5% and 14.9% study patients had unilateral and bilateral ICK, respectively. Age distribution of ICK prevalence was similar between the two groups. Compared to the unilateral group, being female was the only independent risk factor related to bilateral ICK, in both univariate (χ2=11.76, P=0.001) and logistic regression (OR =1.34, 95% CI: 1.1.18-1.65, P=0.001) analyses. Moreover, the prevalence rates of leukoaraiosis (72.1 vs. 54.8%, P=0.004) and multiple lacunar infarct (62.3 vs. 42.9%, P=0.009) in the bilateral group were significantly higher compared with the values obtained for the unilateral group.

CONCLUSIONS

Compared to patients with unilateral ICK, female gender is the only risk factor associated with bilateral ICK, and subcortical ischemic change is significantly more prevalent in patients with bilateral ICK.

Effect of Intensive Versus Usual Blood Pressure Control on Kidney Function Among Individuals With Prior Lacunar Stroke: A Post Hoc Analysis of the Secondary Prevention of Small Subcortical Strokes (SPS3) Randomized Trial

BACKGROUND

The effect of intensive blood pressure (BP) lowering on kidney function among individuals with established cerebrovascular disease and preserved estimated glomerular filtration rate (eGFR) is not established.

METHODS AND RESULTS

Among 2610 participants randomized to a lower (<130 mm Hg) versus higher (130-149 mm Hg) systolic BP target with repeated measures of serum creatinine, we evaluated differences by study arm in annualized eGFR decline and rapid decline (eGFR decline >30%) using linear mixed models and logistic regression, respectively. We assessed associations of both treatment and kidney function decline with stroke, major vascular events, and the composite of stroke, death, major vascular events, or myocardial infarction using multivariable Cox regression, separately and jointly including a test for interaction. Analyses were conducted by treatment arm. Mean age was 63±11 years; 949 participants (36%) were diabetic; and mean eGFR was 80±19 mL·min(-1)·1.73 m(-2). At 9 months, achieved systolic BP was 137±15 versus 127±14 mm Hg in the higher versus lower BP group, and differences were maintained throughout follow-up (mean, 3.2 years). Compared with the higher target, the lower BP target had a -0.50-mL·min(-1)·1.73 m(-2) per year (95% confidence interval [CI], -0.79 to -0.21) faster eGFR decline. Differences were most pronounced during the first year (-2.1 mL·min(-1)·1.73 m(-2); 95% CI, -0.97 to -3.2), whereas rates of eGFR decline did not differ after year 1 (-0.095; 95% CI, -0.47 to 0.23). A total of 313 patients (24%) in the lower BP group had rapid kidney function decline compared with 247 (19%) in the higher BP group (odds ratio, 1.4; 95% CI, 1.1-1.6). Differences in rapid decline by treatment arm were apparent in the first year (odds ratio, 1.4; 95% CI, 1.1-1.8) but were not significant after year 1 (odds ratio, 1.0; 95% CI, 0.73-1.4). Rapid decline was associated with higher risk for stroke, major vascular events, and composite after full adjustment among individuals randomized to the higher BP target (stroke hazard ratio, 1.93; 95% CI, 1.15-3.21) but not the lower BP arm (stroke hazard ratio, 0.93; 95% CI, 0.50-1.75; all P for interaction <0.06).

CONCLUSIONS

In patients with prior lacunar stroke and relatively preserved kidney function, intensive BP lowering was associated with a greater likelihood of rapid kidney function decline. Differences were observed primarily during the first year of antihypertensive treatment. Rapid kidney function decline was not associated with increased risk for clinical events among those undergoing intensive BP lowering.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicalTrials.gov. Unique identifier: NCT00059306.

Association between Serum Alkaline Phosphatase Level and Cerebral Small Vessel Disease

BACKGROUND

Serum alkaline phosphatase (ALP) is a marker of vascular calcification. A high serum ALP level is associated with an increase in cardiovascular events, and predicts poor functional outcome in patients with stroke. We investigated whether serum ALP was associated with cerebral small vessel disease (cSVD) and large cerebral artery stenosis (LCAS).

METHODS

We evaluated vascular risk factors, brain magnetic resonance images (MRIs), and MR angiograms from 1,011 neurologically healthy participants. The presence of silent lacunar infarction (SLI) and moderate-to-severe cerebral white matter hyperintensities (MS-cWMH) were evaluated as indices of cSVD on brain MRIs. Findings of extracranial arterial stenosis (ECAS) or intracranial arterial stenosis (ICAS) were considered to be indices of LCAS on MR angiograms.

RESULTS

Subjects with SLI (odds ratio [OR]: 2.09; 95% confidence interval [CI]: 1.27-3.42; p = 0.004) and MS-cWMH (OR: 1.48; 95% CI; 1.03-2.13, p = 0.036) were significantly more likely to have ALP levels in the third tertile (ALP ≥ 195 IU/L) than the first tertile (ALP ≤ 155 IU/L), after adjusting for cardiovascular risk factors. The mean serum ALP level was significantly higher in patients with SLI or MS-cWMH compared to patients without those findings. After adjustment for confounding factors, the multivariate model found that the statistical significance of serum ALP remained when the presence of SLI (OR: 1.05 per 10 IU/L increase in ALP; 95% CI: 1.02-1.08; p = 0.003) or MS-cWMH (OR: 1.03 per 10 IU/L increase in ALP; 95% CI: 1.00-1.06; p = 0.025) were added to the model. There were no differences in the proportions of patients with LCAS, ICAS, and ECAS across the serum ALP tertiles.

CONCLUSIONS

Our study of neurologically healthy participants found a positive association between serum ALP level and indicators of cSVD, but no association between serum ALP level and the indicators of LCAS.

Contribution of Deep Microbleeds to Stroke Recurrence: Differences between Patients with Past Deep Intracerebral Hemorrhages and Lacunar Infarctions

BACKGROUND

This study investigated the contribution of deep cerebral microbleeds (MBs) to stroke recurrences in patients with histories of deep intracerebral hemorrhages (ICHs) or lacunar infarctions (LIs).

METHODS

We prospectively analyzed stroke recurrences in patients admitted to our hospital who were treated for deep ICHs or LIs between April 2004 and December 2011. The number of deep MBs was counted on admission. Stroke recurrence-free rate curves were generated with the Kaplan-Meier method using the log-rank test. The odds ratios (ORs) for recurrent strokes were derived using multivariate logistic regression models, based on deep MBs and risk factors.

RESULTS

We evaluated magnetic resonance images or the recurrences of 231 deep-ICH patients (92 women, 68.0 ± 12.0 years old) and 309 LI patients (140 women, 70.7 ± 11.7 years old). The incidences of deep ICHs (1.5%/year) and LIs (2.1%/year) presenting as stroke recurrences were significantly larger in LI patients with deep MBs than in those without (.01 [P = .0001] and .08%/year [P = .005], respectively). However, there was no significant difference between deep-ICH patients with and without MBs in terms of incidence of recurrences. Multivariate analyses revealed that deep MBs independently and significantly elevated the rate of deep ICHs (OR, 19.0; P = .007) or LIs (OR, 3.62; P = .008) presenting as recurrences in LI patients, but not in deep-ICH patients, when adjusted for stroke risk factors.

CONCLUSIONS

There may be differences between patients with deep ICHs and those with LIs in terms of the contribution of deep MBs to stroke recurrence.

Clinical characteristics of acute lacunar stroke in women: emphasis on gender differences

There are few studies analyzing features of ischemic stroke subtypes in women. We assessed gender differences in lacunar stroke subtype based on data collected from a prospective stroke registry in Barcelona, Spain. Lacunar ischemic stroke was diagnosed in 310 (8.1 %) women and 423 (11.1 %) men of a total of 3,808 consecutive stroke patients included in a prospective hospital-based stroke registry, in Barcelona, Catalonia (Spain), over a period of 19 years. Independent factors for lacunar stroke in women were assessed by multivariate analysis. Women accounted for 42 % of all lacunar stroke patients (n = 733) in the registry and 11.4 % of all patients with ischemic stroke (n = 2,704). Very old age (85 years or older) was found in 20.3 % in women versus 11.1 % in men (P < 0.0001). In the logistic regression analysis, obesity [odds ratio (OR) = 4.24], prolonged hospital stay (>12 days) (OR = 1.59), arterial hypertension (OR = 1.50), and age (OR = 1.06) were significant variables independently associated with lacunar stoke in women, whereas peripheral vascular disease (OR = 0.51), chronic obstructive pulmonary disease (OR = 0.46), renal dysfunction (OR = 0.13), and heavy smoking (OR = 0.04) were independent variables for lacunar stroke in men. Women with lacunar stroke were remarkably older and presented with obesity and hypertension more frequently than did men. Lacunar stroke severity was similar in men and women. These findings in lacunar stroke patients could be explained by differences in gender for ischemic stroke in general.

Predicting symptomatic intracerebral hemorrhage versus lacunar disease in patients with longstanding hypertension

BACKGROUND AND PURPOSE

Hypertension results in a spectrum of subcortical cerebrovascular disease. It is unclear why some individuals develop ischemia and others develop hemorrhage. Risk factors may differ for each population. We identify factors that predispose an individual to subcortical symptomatic intracerebral hemorrhage (sICH) compared with ischemia.

METHODS

Demographic and laboratory data were prospectively collected for hypertensive patients presenting with ischemic stroke or sICH during an 8.5-year period. Neuroimaging was retrospectively reviewed for acute (subcortical lacunes [<2.0 cm] versus subcortical sICH) and chronic (periventricular white matter disease and cerebral microbleeds) findings. We evaluated the impact of age, race, sex, serum creatinine, erythrocyte sedimentation rate, low-density lipoprotein, presence of periventricular white matter disease or cerebral microbleeds, and other factors on the risk of sICH versus acute lacune using multivariate logistic regression.

RESULTS

Five hundred seventy-one patients had subcortical pathology. The presence of cerebral microbleeds (adjusted odds ratio [OR], 3.39; confidence interval [CI], 2.09-5.50) was a strong predictor of sICH, whereas severe periventricular white matter disease predicted ischemia (OR, 0.56 risk of sICH; CI, 0.32-0.98). This association was strengthened when the number of microbleeds was evaluated; subjects with >5 microbleeds had an increased risk of sICH (OR, 4.11; CI, 1.96-8.59). It remained significant when individuals with only cortical microbleeds were removed (OR, 1.77, CI, 1.13-2.76). An elevated erythrocyte sedimentation rate (OR, 1.19 per 10 mm/h increase; CI, 1.06-1.34) was significantly associated with sICH, whereas low-density lipoprotein was associated with ischemic infarct (OR, 0.93 risk of sICH per 10 mg/dL increase; CI, 0.86-0.99).

CONCLUSIONS

Subclinical pathology is the strongest predictor of the nature of subsequent symptomatic event. Low-density lipoprotein and erythrocyte sedimentation rate may also have a role in risk stratification.

[Lacunar stroke and cerebral small vessel disease: advocacy for a recognition]

Cerebral small vessel disease (cSVD) represents the sum of lesions which define a rather new clinical entity. Indeed, lacunar infarcts which are acute events of cSVD, represent 25% of all ischemic strokes. However, only few studies have dealt with acute and long term management of such stroke. Despite its rather early description around the XIXth century, the "lacune", the cardinal anatomopathological lesion of cSVD, remains only partially explained and pathogenesis is still debated. The purpose of this paper is to better define the anatomical lesions, to discuss physiopathological hypotheses and to present the most salient clinical features. Once identified cSVD should not be further overlooked.

Predictors of stroke recurrence in patients with recent lacunar stroke and response to interventions according to risk status: secondary prevention of small subcortical strokes trial

BACKGROUND

Among participants in the Secondary Prevention of Small Subcortical Strokes randomized trial, we sought to identify patients with high versus low rates of recurrent ischemic stroke and to assess effects of aggressive blood pressure control and dual antiplatelet therapy according to risk status.

METHODS

Multivariable analyses of 3020 participants with recent magnetic resonance imaging-defined lacunar strokes followed for a mean of 3.7 years with 243 recurrent ischemic strokes.

RESULTS

Prior symptomatic lacunar stroke or transient ischemic attack (TIA) (hazard ratio [HR] 2.2, 95% confidence interval [CI] 1.6, 2.9), diabetes (HR 2.0, 95% CI 1.5, 2.5), black race (HR 1.7, 95% CI 1.3, 2.3), and male sex (HR 1.5, 95% CI 1.1, 1.9) were each independently predictive of recurrent ischemic stroke. Recurrent ischemic stroke occurred at a rate of 4.3% per year (95% CI 3.4, 5.5) in patients with prior symptomatic lacunar stroke or TIA (15% of the cohort), 3.1% per year (95% CI 2.6, 3.9) in those with more than 1 of the other 3 risk factors (27% of the cohort), and 1.3% per year (95% CI 1.0, 1.7) in those with 0-1 risk factors (58% of the cohort). There were no significant interactions between treatment effects and stroke risk status.

CONCLUSIONS

In this large, carefully followed cohort of patients with recent lacunar stroke and aggressive blood pressure management, prior symptomatic lacunar ischemia, diabetes, black race, and male sex independently predicted ischemic stroke recurrence. The effects of blood pressure targets and dual antiplatelet therapy were similar across the spectrum of independent risk factors and recurrence risk.

Microvascular retinal abnormalities in acute intracerebral haemorrhage and lacunar infarction

BACKGROUND

Retinal microvascular changes have been previously associated with cerebral MRI markers of small vessel disease (SVD). Whether retinal changes differ between patient with intracerebral haemorrhage (ICH) and patients with lacunar infarction (LI) caused by small vessel disease has been poorly investigated.

OBJECTIVE

The study aims to compare the frequency of retinal changes between patients with LI and patients with ICH at the acute stage of stroke-related SVD.

METHODS

Microvascular wall signs (arteriolar occlusion, arteriovenous nicking, focal arterial narrowing) and retinopathy lesions (microanevrysms, cotton wool spots, retinal haemorrhages, hard exudates) were assessed by retinography up to three months after stroke onset.

RESULTS

Forty-eight non-diabetic patients with acute stroke-related to SVD (26 LI, 22 ICH) were recruited prospectively in the study. Retinal wall signs (arteriovenous nicking, and focal arterial narrowing) were found in more than three quarters of subjects and most often bilaterally in both groups. Retinopathy lesions (cotton wool spots, retinal haemorrhages) were found more frequently in ICH patients than in LI patients (22.2% vs. 15.4%, 50% vs. 34% respectively, P>0.005). The frequency of bilateral cotton wool spots and of bilateral retinal haemorrhages was significantly higher in ICH patients than in LI patients (12.5% vs. 0%, P=0.012, 41.2% vs. 7.7%, P=0.029 respectively).

CONCLUSION

These results confirm the high frequency of microvascular alterations in patients with hypertension-related SVD leading to LI or ICH and suggest that retinal tissue alterations are more frequent in ICH than in LI. Further investigations are needed to investigate the mechanisms underlying this difference.

Hyperglycaemia in acute lacunar stroke: a Chinese hospital-based study

Admission hyperglycaemia is very common in acute ischaemic stroke (IS) patients and is associated with worse outcome in non-lacunar infarction, but its association with lacunar infarction remains controversial. We investigated the association between hyperglycaemia and clinical outcome in patients with acute lacunar stroke in a hospitalised Chinese population. Consecutive patients with acute IS were enrolled and classified into lacunar and non-lacunar stroke groups based on clinical criteria according to the Oxfordshire Community Stroke Project (OCSP) and findings on brain computed tomography (CT) or magnetic resonance imaging (MRI) scan. Hyperglycaemia was defined as blood glucose > 6.1 mmol/L. Univariate and multivariate analyses were used to examine the association between hyperglycaemia and outcomes in diabetic and non-diabetic groups. The main outcome measure was a poor outcome [defined as modified Rankin Scale (mRS) score ≥ 3] at 12 months after stroke. Of the 2020 acute ISs, 689 (34.1%) were acute lacunar strokes, of which 159 (23%) were diabetic and the other 530 (77%) were non-diabetic. In non-lacunar stroke, admission hyperglycaemia was independently associated with increased risk of poor outcome at 1 year (odds ratio (OR) = 1.782; 95% confidence interval (CI) = 1.340-2.370, p = 0.0005). In lacunar stroke, hyperglycaemia was not associated with functional outcome (OR = 1.337; 95% CI = 0.939-1.093, p = 0.086) irrespective of the diabetic status.

Cognitive impairment in lacunar strokes: the SPS3 trial

OBJECTIVE

Lacunar strokes are a leading cause of cognitive impairment and vascular dementia. However, adequate characterization of cognitive impairment is lacking. The aim of this study was to estimate the prevalence and characterize the neuropsychological impairment in lacunar stroke patients.

METHODS

All English-speaking participants in the Secondary Prevention of Small Subcortical Strokes (SPS3) trial (National Clinical Trial 00059306) underwent neuropsychological testing at baseline. Raw scores were converted to z scores using published norms. Those with impairment (z ≤ -1.5) in memory and/or nonmemory domains were classified as having mild cognitive impairment (MCI).

RESULTS

Among the 1,636 participants, average z scores on all tests were < 0, with the largest deficits seen on tests of episodic memory (range of means, -0.65 to -0.92), verbal fluency (mean, -0.89), and motor dexterity (mean, -2.5). Forty-seven percent were classified as having MCI (36% amnestic, 37% amnestic multidomain, 28% nonamnestic). Of those with modified Rankin score 0-1 and Barthel score = 100, 41% had MCI. Younger age (odds ratio [OR] per 10-year increase, 0.87), male sex (OR, 1.3), less education (OR, 0.13-0.66 for higher education levels compared to 0-4 years education), poststroke disability (OR, 1.4), and impaired activities of daily living (OR, 1.8) were independently associated with MCI.

INTERPRETATION

In this large, well-characterized cohort of lacunar stroke patients, MCI was present in nearly half, including many with minimal or no physical disabilities. Cognitive dysfunction in lacunar stroke patients may commonly be overlooked in clinical practice but may be as important as motor and sensory sequelae.

[Epidemiology of the subtypes of stroke in hospitalised patients attended by neurologists: results of the EPICES registry (I)]

INTRODUCTION

Hospital-based population studies are a good way to determinate the number and features of strokes that occur in a given society. The major stroke subtypes have different patterns of incidence and outcome, for that reason information on the natural history of stroke subtypes is essential.

AIM

To determine the incidence of the stroke subtypes and the prevalence of the major risk factors in the Spanish population.

PATIENTS AND METHODS

EPICES is an observational, multicenter and prospective study. Methodology includes systematic review of consecutive medical records of hospitalized stroke patients in neurological care. 6,197 patients were included during the period April 2008 and January 2009. 3,544 (57.2%) were men. Mean age was 71.4 ± 12.8 years.

RESULTS

Intracerebral haemorrhage was diagnosed in 771 patients (12.4%) and ischemic stroke in 5,426 (87.6%). 1,543 (28.4%) were classified as large-artery atherosclerosis, cardioembolic 1,424 (26.2%), small-vessel occlusion 1,202 (22.5%), undetermined etiology 1,125 (20.7%). Stroke of other uncommon origin was founded in 132 (2.4%). Hypertension is the most common risk factor in both ischemic stroke (67%) and intracerebral haemorrhage (69.1%). The different types of ischemic and hemorrhagic stroke showed differences in risk factors prevalence.

CONCLUSIONS

The overall distribution of stroke subtypes are not significantly different from those of most Western countries. The frequency of vascular risk factors differs between stroke subtypes. Hypertension remains the most important modifiable risk factor.

Relation of carotid intima-media thickness and silent cerebral infarction to cardiovascular events and all-cause mortality in chronic hemodialysis patients

OBJECTIVE

Silent cerebral infarction (SCI) and increased carotid intima-media thickness (IMT) have been found to be associated with future stroke in the general population. We investigated whether a combination of SCI and increased IMT is a predictor of cardiovascular events and all-cause mortality in chronic hemodialysis (HD) patients.

METHODS

We performed a retrospective cohort study of 70 HD patients who had one or more risk factors for atherosclerosis but no history of cardiovascular disease. We performed cranial magnetic resonance imaging (MRI) and measured carotid IMT at baseline, and then evaluated the risks of cardiovascular events and all-cause mortality by using Cox proportional hazards models. The Kaplan-Meier method and a log-rank test were used to compare event-free survival.

RESULTS

SCI was present in 25 patients (35.7%) at baseline. During an average follow-up of 46.3 ± 14.3 months (range: 19 to 56 months), 15 patients (21.4%) died and 16 (22.9%) experienced a new cardiovascular event. The presence of SCI in combination with increased carotid IMT at baseline was independently associated with cardiovascular events and all-cause mortality after adjustment for age, sex, duration of dialysis, and traditional vascular risk factors.

CONCLUSION

SCI, similar to carotid IMT, is an independent predictor of cardiovascular events and all-cause mortality in chronic HD patients.

Leptin, adiponectin and ghrelin, new potential mediators of ischemic stroke

OBJECTIVES

Fat tissue is an important endocrine organ that produces a number of hormones and cytokines (leptin, adiponectin, resistin, plasminogen activator inhibitor-1, Tumour necrosis factor TNF α) with essential roles in regulation of many physiological functions.

METHODS

We targeted implications of adipokines in ischemic stroke patients. Patients with acute stroke were examined (n=145) and the results were compared with the control group (n=68). We have examined potential associations between leptin, adiponectin and ghrelin, and different types of stroke and traditional risk factors.

RESULTS

Significantly higher levels of leptin and lower levels of adiponectin and ghrelin were confirmed in the stroke group. The level of leptin in women with stroke was three-times higher than in men, and the leptin levels positively correlated with obesity in both sexes. Ghrelin levels correlated mildly with triglyceride levels, and were dominant in men with cardioembolic stroke. Adiponectin levels were not different between men and women with acute stroke, and correlated with atherothrombotic and lacunar stroke types in men.

CONCLUSIONS

Adipokines and ghrelin play an important role in ischemic stroke, but their function in stroke subtypes seems to be different and sex influenced. More research is required to confirm our results.