A cross-sectional feasibility study of neurovascular ultrasound in Malawian adults with acute stroke-like syndrome.

Joseph Kamtchum-Tatuene,Henry C Mwandumba,Laura A Benjamin,Tom Solomon,Noel Kayange,Gloria Mwangalika Kachingwe,Laura J Bonnett

doi:10.1371/journal.pone.0229033

Abstract

BackgroundIn sub-Saharan Africa, there is a dearth of epidemiologic data on the burden of cerebral atherosclerosis. This is explained by the limited availability and the high cost of standard vascular imaging techniques. Neurovascular ultrasound is portable, cheaper and non-invasive and could, therefore, represent a reasonable alternative to fill this knowledge gap. We explored the feasibility of neurovascular ultrasound in Malawian adults with acute stroke-like syndrome to inform the design of future large stroke studies comparing its diagnostic performance to that of gold standard vascular imaging techniques in sub-Saharan Africa.MethodsWe enrolled consecutive patients diagnosed with acute stroke-like syndrome based on the World Health Organization definition. Clinical and demographic data were recorded, and a comprehensive neurovascular ultrasound was performed. Fisher’s exact and Kruskal-Wallis tests were used to study the relationship between atherosclerosis and potential risk factors.ResultsSixty-six patients were enrolled (mean age: 58.7 years). The frequency of extracranial atherosclerosis was 39.4% (n = 26, 95% CI: 28.6–52.2). There were 12 patients with abnormal carotid intima media thickness (18.2%, 95% CI: 9.8–29.6) and 14 patients with a carotid plaque (21.2%, 95% CI: 12.1–33.0). The frequency of intracranial atherosclerosis was 19.2% (95%CI: 6.6–39.4) in 26 patients with successful transcranial insonation. Hypertension (80.8 versus 52.5%, p = 0.03) and hypercholesterolemia (11.5 versus 0.0%, p = 0.05) were more prevalent in patients with extracranial atherosclerosis.ConclusionsThis study demonstrates the feasibility of neurovascular ultrasound to assess cervical arteries in adults with stroke-like syndrome in sub-Saharan Africa. There is a high rate of transcranial insonation failure in this setting, highlighting the need for echocontrast agents.

Highlights

Intracranial atherosclerosis is responsible for 8%-10% of ischemic strokes in the western world and 30%-50% of ischemic strokes in Asia [1, 2]
We explored the feasibility of neurovascular ultrasound in Malawian adults with acute stroke-like syndrome to inform the design of future large stroke studies comparing its diagnostic performance to that of gold standard vascular imaging techniques in sub-Saharan Africa
This study demonstrates the feasibility of neurovascular ultrasound to assess cervical arteries in adults with stroke-like syndrome in sub-Saharan Africa

Summary

Introduction

Intracranial atherosclerosis is responsible for 8%-10% of ischemic strokes in the western world and 30%-50% of ischemic strokes in Asia [1, 2]. Intracranial arterial calcifications represent an integral part of the atherosclerotic process though they do not necessarily correspond to clinically significant disease Another pilot autopsy study in the same country identified intracranial atherosclerosis in 45% of 44 patients but the cause of death and the proportion of stroke cases was not specified [4]. The data collected would inform the design of future large stroke studies comparing the diagnostic performance of neurovascular ultrasound to that of gold standard vascular imaging techniques in sub-Saharan Africa. In sub-Saharan Africa, there is a dearth of epidemiologic data on the burden of cerebral atherosclerosis This is explained by the limited availability and the high cost of standard vascular imaging techniques.

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Conclusion