Extracranial Artery Stenosis Research Articles

Relation of Ideal Cardiovascular Health Metrics to Asymptomatic Polyvascular Disease in a Chinese Population

Atherosclerosis is a systemic disease with manifestations in multiple vascular beds. Ideal cardiovascular health (CVH) metrics relate to cardiovascular and cerebrovascular disease. However, the relation between ideal CVH metrics and asymptomatic polyvascular disease (polyVD) is unknown. We collected information on the 7 CVH metrics among 5,224 participants aged ≥40years from 2010 to 2011. Intracranial artery stenosis, extracranial artery stenosis, and lower extremity artery disease were detected by transcranial Doppler, duplex sonography, and by calculating ankle-brachial index. Ordinal logistic regression and linear models were used to analyze the relation between ideal CVH metrics and polyVD. PolyVD was identified in 158 (3%) participants. We observed a significant inverse gradient relation between the number of ideal CVH metrics and prevalence of polyVD after adjustment for potential confounders. The adjusted odds ratios and 95% confidence intervals were 0.824 (0.657 to 1.032), 0.641 (0.511 to 0.804), 0.538 (0.423 to 0.684), 0.583 (0.442 to 0.769), and 0.530 (0.348 to 0.808) for those having 2, 3, 4, 5, and 6 or 7 ideal CVH metrics, respectively, compared with those having 0 or 1 ideal CVH metric (p-trend <0.0001). Similarly, a larger number of ideal CVH metrics was associated with a lower prevalence of polyVD in the linear models (adjusted β coefficient-0.030, 95% confidence interval-0.041 to-0.020). Stratification for gender and age yielded consistent results in all subgroups except for women subgroup. In conclusion, we observed a significant inverse gradient association between the number of ideal CVH metrics and prevalence of asymptomatic polyVD.

Asymptomatic polyvascular disease and the risks of cardiovascular events and all-cause death

Background and aimsAtherosclerosis is a diffuse and systemic disease. We aimed to assess prevalence and outcome of extracoronary polyvascular disease (polyVD) in the asymptomatic Chinese community population. MethodsA random sample of 5440 participants aged 40 years or older were enrolled in the Asymptomatic Polyvascular Abnormalities Community Study from 2010 to 2011. Intracranial artery stenosis, extracranial artery stenosis, and lower extremity artery disease were detected by transcranial Doppler and duplex sonography, and by calculating the ankle brachial index. The study endpoints included the first occurrence of stroke, myocardial infarction (MI) and all-cause death. ResultsPolyVD (two or three affected vascular territories) was found in 3.0% of the participants, and was significantly higher in men (4.3%). Over a median follow-up of 4.1 years, we identified a total of 247 events (4.7%), including 83 strokes (68 ischemic), 45 MIs and 134 all-cause deaths. After adjusting for age, gender and other potential confounders, we found a significant increase in risk of major cardiovascular events as well as all-cause death in participants with polyVD. In multivariate Cox regression analyses, the adjusted hazard ratios (HR) (95% confidence interval, CI) for the composite of stroke, MI and all-cause death for single and poly-vascular disease (compared with 0 vascular disease) increased from 1.58 (1.19–2.12) to 1.95 (1.26–3.03). Similarly, the adjusted HR (95% CI) for all-cause death for single and poly-vascular disease increased from 1.53 (1.03–2.29) to 2.22 (1.27–3.86). ConclusionsPolyVD significantly increased the risk of major cardiovascular events and all-cause death in the asymptomatic community population. Performing invasive screening tests for polyVD is useful in the high-risk asymptomatic population.

Differential impact of serum total bilirubin level on cerebral atherosclerosis and cerebral small vessel disease.

BackgroundA low serum total bilirubin (T-bil) level is associated with an increased risk of atherosclerosis. However, the differential impact of the serum T-bil level on cerebral atherosclerosis and cerebral small vessel disease (SVD) is still unclear.MethodsWe evaluated serum T-bil levels from 1,128 neurologically healthy subjects. Indices of cerebral atherosclerosis (extracranial arterial stenosis [ECAS] and intracranial arterial stenosis [ICAS]), and indices of SVD (silent lacunar infarct [SLI], and moderate-to-severe white matter hyperintensities [msWMH]) were evaluated by the use of brain magnetic resonance imaging (MRI) and MR angiography.ResultsIn logistic regression analysis after adjusting for confounding variables, subjects within middle T-bil (odds ratio [OR]: 0.63; 95% CI: 0.41–0.97) and high T-bil tertiles (OR: 0.54; 95% CI: 0.33–0.86) showed a lower prevalence of ECAS than those in a low T-bil tertile. Although subjects with a high T-bil tertile had a lower prevalence of ICAS than those with a low T-bil tertile, the statistical significance was marginal after adjusting for confounding variables. There were no significant differences in the proportions of subjects with SLI and msWMH across serum T-bil tertile groups.ConclusionsThe serum T-bil level is negatively associated with cerebral atherosclerosis, especially extracranial atherosclerosis, but not with SVD.

Abstract WP177: Retinal Nerve Fiber Layer Thickness and Risk Factors of Stroke

Background and Purpose: We aimed to find the relationship between retinal nerve fiber layer (RNFL) thickness and the relevant risk factors of different stroke subtypes of TOAST classification, in order to make a better primary prevention of stroke. Method: The study population came from the first follow- up of the Asymptomatic Polyvascular Abnormalities Community study (APAC) population. We finished the questionnaire of epidemiological information and medical history during the baseline time, and finished the physical and laboratory examination, transcranial doppler, carotid ultrasound, cognitive functional scale and ophthalmological optical coherence tomography (OCT) examination to measure the thickness of RNFL and whether there exists intracranial artery stenosis (ICAS), extracranial artery stenosis (ECAS) or cognitive impairment. Then we discuss the association between RNFL thickness and the risk factors of stroke mentioned above. Results: We included 5440 participants at baseline and 3376 finished the follow- up eventually. The average thickness of RNFL was 101.89± 10.53 μm. As RNFL became thinner, the percentage of older age, male sex and hypertension became higher (P&lt;0.001). We also found out that ICAS and ECAS, especially ECAS increased as RNFL become thinner (OR:0.982,95% CI:0.969- 0.996,P= 0.011), and the severity of ECAS became worse when RNFL was thinner (P=0.001), and retinal central arteriolar was narrower (P=0.003). What is more, RNFL thickness is associated with cognitive impairment as well (P&lt; 0.05). Conclusion: The thickness of RNFL is associated with stroke risk factors, such as older age, male sex and hypertension. As RNFL became thinner, the prevalence of ICAS and ECAS, which are the main cause of LAA stroke, became higher, and the severity of ECAS became worse. The thinner RNFL was also relevant with cognitive impairment, which is common in the SAO stroke. The results provide a new point of view on stroke classification and prevention.

Abstract WP201: Sub-analysis of Japanese Versus Non-japanese on Background Characteristics and One-year Outcomes in Tiaregistry.org

Background and Purpose: TIAregistry.org is an international prospective registry in patients with TIA or minor stroke (mRS 0 or 1) within 7 days after the onset. Main analysis of one-year follow-up data have been reported (N Engl J Med 2016;374:1533-42). We performed Japanese vs non-Japanese sub-analysis on the baseline and one-year follow-up data. Methods: Patients were classified into two groups according to their countries of origin (Japanese and non-Japanese). All comparisons between the two groups were adjusted on age, sex and mRS. Variables included demographic characteristics, intracranial and extracranial arterial stenosis, acute infarcts, TOAST classification, ABCD 2 score, and time to first contact. We compared the 1-year event rates of cardiovascular death, non-fatal stroke, and non-fatal acute coronary syndrome between the two groups using Cox proportional hazard models. Results: A total of 4,583 patients were included in the analysis. From them, 345 (7.5%) were Japanese. Proportion of patients with mRS 1 was higher in Japanese (58.5% vs 27.9%, p &lt;0.001). The prevalence of acute infarct was higher for Japanese (73.9% vs 29.8%, p &lt;0.001). Intracranial arterial stenosis &gt;50% was more common in Japanese (19.6% vs 12.9%, p = 0.01). Distribution of ABCD 2 score was also different between Japanese and non-Japanese (20.1% vs 33.5% in scores 0-3, 28.6% vs 18.3% in scores 6 and 7, p = 0.02 in total). Time to first contact &lt;24 hours was fewer in Japanese (80.0% vs 88.2%, P &lt;0.001). Composite event rate of cardiovascular death, nonfatal stroke, nonfatal acute coronary syndrome was 7.7% in Japanese and 6.0% in non-Japanese (p = 0.18), while nonfatal stroke rate was higher for the Japanese patients (7.5% vs 4.4%, p = 0.008). Conclusions: Higher risk conditions in baseline characteristics as well as delay of time to contact, and a higher one-year stroke rate were identified in Japanese patients enrolled in this registry.

Effect of stenting for the proximal atherosclerotic extracranial vertebral artery stenosis

Objective: To evaluate the effect of stenting for proximal atherosclerotic extracranial vertebral artery stenosis. Methods: A total of 204 proximal atherosclerotic extracranial vertebral artery stenosis patients underwent stent implantation at Fuwai Hospital were enrolled consecutively between August 2007 and June 2014 prospectively. Medical records were collected and the clinical results were obtained through outpatient and telephone follow up. Results: (1) The patients were (64.1±7.9) years old, and 179 were male (87.7%). (2) Stent implantation was performed on 210 proximal atherosclerotic extracranial vertebral artery stenosis lesions with 210 stents (156 on the left, 54 on the right), and 6 patients received both sides stent implantations. Technical success rate was 100%(210/210). The stenosis of the lesions was decreased from (85.1±6.4) % to (6.5±3.2) % after the stent implantation (P<0.01). (3) Three (1.5%) patients experienced transient ischemic attack during the procedure, and two (1.0%) patients suffered from minor posterior circulation ischemic strokes on the 2nd and 10th day after the procedure, respectively. (4)The median follow-up was 1.5 (0.8-2.5) years. Three(1.5%) patients died (two non-vacular deaths, and the other one due to sudden cardiac death). Three (1.5%) patients developed stroke (one case ipsilateral posterior circulation stroke, and two cases unrelated area stroke). Four (2.0%) patients experienced transient ischemic attack. One patient suffered nonfatal myocardial infraction. In-stent restenosis occurred in thirty nine (19.4%) patients, of which fourteen (35.9%) patients were totally occluded and four (10.3%) patients with symptomatic restenosis. Kaplan-Meier survival curve showed that the primary patency rate of the vertebral artery were 85.6%, 78.6%, 72.2% and 64.4% at 1, 2, 3 and 5 years, respectively. Conclusions: Stenting for proximal atherosclerotic extracranial vertebral artery stenosis is safe and feasible, with a good middle to long-term patency rate. However, further trials are required to validate the effective results found in this patients cohort.

Progression or Regression of Intracranial or Extracranial Arterial Stenosis: Role of Ultrasound

Atherosclerosis of intracranial or extracranial artery is a major cause of ischemic stroke, which may be a dynamic lesion with progression or regression. Ultrasound examinations are useful and important tools for the diagnosis of progression or regression of intracranial or extracranial arterial stenosis. Progression of intracranial stenosis may increase the risk of stroke, therefore adequate diagnosis is important. Transcranial Doppler sonography (TCD) may be useful for this purpose, however, optimal diagnostic criteria have not been defined well. According to our subgroup analysis from the prospective clinical trial, which had evaluated the efficacy of cilostazol combined with aspirin in symptomatic intracranial stenosis, sensitivity of TCD criteria ranged 23-42% for progression and 13-67% for regression, while specificity ranged 83-92% for progression and 91-97% for regression. Among the criteria validated, Δ20cm/s increment or decrement criteria had the highest sensitivity (42% for progression and 67% for regression) and specificity (90% for progression and 96% for regression). With these criteria, we compared long-term TCD changes with MRA in patients with intracranial stenosis. Among 164 patients included (84 males, mean age 64 years, mean follow-up period 35 months), progression was observed in 5.7% among MCA and 5.0% among BA. With diagnosis of progression, more aggressive medical management (BP control, blood glucose and lipid lowering, antiplatelet agents, etc.) is indicated and higher-dose statin may be recommended. Carotid duplex ultrasound (CDU) has an important role for the screening of asymptomatic carotid stenosis (ACS), detection of vulnerable plaques, or monitoring of progression or regression of arterial stenosis. With qualified examination and optimal diagnostic criteria, the sensitivity and specificity has been reported up to 90% and 94% for the detection of stenosis of 70% or greater. In addition to the degree of stenosis, CDU also reveal the morphology and distribution of the plaques. Natural course of ACS also has been studied with CDU and several factors related to the progression/regression of ACS have been reported. Recent advance of medical treatment diminished the risk of stroke (< 1%/year) compared with carotid revascularization in ACS. Therefore, current issue is to identify “high-risk” patients who will get more benefit from the carotid revascularization. With optimal criteria, CDU may diagnose progression of arterial stenosis, which is an important predictor for future stroke. TCD is also useful for the detection of microembolic signals (MES), which is potently associated with the risk of stroke in ACS. In summary, adequate ultrasound examination is useful for the diagnosis of intracranial or extracranial arterial stenosis, progression/regression of stenosis, and possibly for the identification of the “high risk” patients, therefore is useful for the adequate clinical decision making.

Multiple factor analysis of symptomatic intracranial arterial stenosis

Objective To discuss the correlation among intracranial arterial stenosis and its risk factors. Methods A total of 486 patients with transient ischemic attack (TIA) or ischemic cerebral infarction were examined using color doppler flow imaging (CDFI) and transcranial doppler ultrosonography (TCD).According to the degrees of extracranial arterial stenosis, patients with mild-to-moderate extracranial stenosis were classified into group A (435 cases) while those with constant severe stenosis or occlusion were classified into group B (51 cases).The differences between the two groups of risk factors were compared, and the multi-factor logistic regression analysis of risk factors associated with moderately severe intracranial arterial stenosis was performed. Results ① The risk factors that were significantly associated with intracranial arterial stenosis included age ( P =0.034) and gender ( P =0.044).② Intracranial artery stenosis was observed in both anterior and posterior cerebral arteries in patients with hypertension, diabetes, and coronary heart disease respectively ( P P =0.000), with a higher proportion of men ( P =0.037), and the intracranial arterial stenosis degrees were significantly higher ( P =0.013).â'£ Multi-factor logistic regression analysis showed that diabetes is a risk factor for moderately severe intracranial arterial stenosis ( P P =0.012). Conclusions Age, gender, hypertension, diabetes, coronary heart disease, and smoking are risk factors for the distribution of intracranial arterial stenosis.The degrees of intracranial arterial stenosis are related with extracranial arterial stenosis.Diabetes is a risk factor for moderately severe intracranial arterial stenosis while hyperlipidemia is a protective factor.

Stroke prevention

Patients who have had a stroke are at high risk for recurrent stroke, myocardial infarction, and vascular death. Prevention of these events should be initiated promptly after stroke, because many recurrent events occur early, and should be tailored to the precise cause of stroke, which may require specific treatment. Lifestyle advice including abstinence from smoking, regular exercise, Mediterranean-style diet, and reduction of salt intake and alcohol consumption are recommended for all patients with stroke. For most patients with ischemic stroke or TIA, control of risk factors, including lowering blood pressure under 140/90mmHg and LDL cholesterol under 1g/L, together with antiplatelet or oral anticoagulant therapy, depending on the cause of stroke, have been shown to decrease the risk of recurrent stroke and cardiovascular events. Aspirin, clopidogrel, or the combination of aspirin and dipyridamole, are all acceptable options for secondary prevention in patients with ischemic stroke or TIA of arterial origin. Dual therapy with aspirin and clopidogrel might be considered for 3weeks after a minor ischemic stroke or TIA and for 3months in patients with stroke due to severe intracranial stenosis. Oral anticoagulants are very effective to prevent cardioembolic stroke. Non-VKA oral anticoagulants have a favorable risk-benefit profile compared with VKAs, with significant reductions in stroke, intracranial hemorrhage, mortality, with similar major bleeding, but increased gastrointestinal bleeding. Carotid endarterectomy reduces the risk of ipsilateral stroke in patients with recent (<6months) non disabling ischemic stroke or TIA in the territory and severe carotid artery stenosis. Carotid stenting is a potential alternative to surgery in patients younger than ≈70years or patients with greater risk of surgery due to anatomic or medical conditions or specific circumstances such as radiation-induced stenosis or restenosis after surgery. For patients with hemorrhagic stroke due to hypertension-associated small vessel disease or cerebral amyloid angiopathy, strict control of blood pressure is essential. Restarting oral anticoagulants in patients after intracranial hemorrhage is a difficult decision that should weigh the risks of recurrent ischemic and hemorrhage stroke with and without oral anticoagulants. Several areas of uncertainty persist including the optimal target of blood pressure in patients with cerebrovascular disease, the benefit of PFO closure in patients with PFO-associated stroke, of stenting procedures in patients with atherosclerotic intracranial artery or extracranial vertebral artery stenosis, and of interventional procedures in patients with brain arteriovenous or cavernous malformations.

Comparison of Four Methods calculating Ankle Brachial Indexes for Coexistent Intracranial and Extracranial Artery Stenoses in the Patients with Ischemic Stroke

Comparison of Four Methods calculating Ankle Brachial Indexes for Coexistent Intracranial and Extracranial Artery Stenoses in the Patients with Ischemic Stroke

Asymptomatic Extracranial Artery Stenosis and the Risk of Cardiovascular and Cerebrovascular Diseases.

Asymptomatic extracranial artery stenosis (ECAS) is a well-known risk factor for stroke events, but it remains unclear whether it has the same role in predicting cardiovascular and cerebrovascular diseases, especially in China. We investigated the potential associations between ECAS, carotid plaque and carotid intima-media thickness and the new occurrence of cardiovascular and cerebrovascular diseases in the study. Out of 5440 study participants, 364 showed an asymptomatic ECAS at baseline, and 185 had come up to the final vascular events (brain infarction, intracerebral hemorrhage, subarachnoid hemorrhage, coronary heart disease and death due to the vascular diseases). During the follow- up. ECAS, carotid plaque and its instability and increased CIMT have associated with vascular events significantly (P < 0.05). After adjusting relevant vascular risk factors, ECAS still has a strong relationship with the new occurrence of vascular events, especially the brain infarction (HR: 2.101; 95% CI: 1.027–4.298; P = 0.042). We observed a clear relationship between ECAS and the new occurrence of cardiovascular and cerebrovascular disease, especially the brain infarction event. Carotid plaque and its instability and increased CIMT have all relevant with the occurrence of vascular events. Our findings provide direct evidence for the importance of ECAS in vascular events occurrence.

Association of Inter-arm Blood Pressure Difference with Asymptomatic Intracranial and Extracranial Arterial Stenosis in Hypertension Patients.

Inter-arm blood pressure (BP) difference has been associated with ischemic stroke. Local atherosclerosis of stroke differ among vulnerable individuals, whereas intracranial arterial stenosis (ICAS) is more frequently affected Asians, and extracranial arterial stenosis (ECAS) is more prevalent among whites. We hereby sought to explore the association of inter-arm BP difference with ICAS and ECAS in stroke-free hypertensive patients in Chinese population. All the 885 subjects were evaluated of ICAS and ECAS through computerized tomographic angiography. Both arm BP was measured simultaneously by Vascular Profiler-1000 device. In the continuous study, ICAS was significantly associated with age, male, average brachial SBP, diabetes, anti-hypertensive treatment and inter-arm DBP difference. ECAS was associated with age, inter-arm SBP and LDL. In the categorical study, subjects with the top quartile of inter-arm DBP difference (≥4 mmHg) showed significantly higher risk of ICAS (OR = 2.109; 95% CI, 1.24–3.587). And the participants with the top quartile of inter-arm SBP difference (≥6 mmHg) showed significantly higher risk of ECAS (OR = 2.288; 95% CI, 1.309–3.998). In conclusion, we reported a diverse association of inter-arm SBP/DBP difference with the ICAS/ECAS. Inter-arm DBP difference might be the early symbol of ICAS in Chinese population, which need further verification in long-term cohort study.

Intracranial Artery Stenting May Not Improve Cognitive Function: A Preliminary Study.

Intracranial Artery Stenting May Not Improve Cognitive Function: A Preliminary Study.

Risk score to predict concurrent extracranial and intracranial artery stenosis in acute ischemic stroke

ObjectiveThe aim of this study was to develop and validate a risk score for predicting combined extracranial and intracranial artery stenosis (EICAS) in acute ischemic stroke patients. MethodsPatients with acute ischemic stroke were consecutively and prospectively enrolled in this study. Eligible patients were randomly divided into derivation and validation cohorts.Variables collected at presentation were used for predicting EICAS after acute ischemic stroke. Multivariable logistic regression was used to identify independent risk factors. Points for EICAS were generated by β-coefficients. Sensitivity and specificity of the risk score was assessed by the area under the receiver operating characteristic curve (AUROC). Cutoff value for predicting EICAS was determined by maximum Youden index. ResultsThere were 629 patients with EICAS and 352 patients without cranial artery stenosis. Among EICAS, 321 patients were in the derivation cohort and 308 in the validation cohort. Five independent predictors including age, diabetes mellitus, hypertension, Low density lipoprotein (LDL) and heart disease were used to develop a 10-point score. The score was termed ADLH2 (age, diabetes mellitus, hypertension, LDL, heart disease).The ADLH2 showed good discrimination in the derivation (AUROC 0.695; 95% confidence interval, 0.656–0.735) and validation (AUROC 0.672; 95% confidence interval, 0.631–0.712) cohort. The cutoff value at maximum Youden index was 4 with the sensitivity 0.479 and specificity 0.719. Stroke patients with ADLH2 score≥4 need further examination and therapy for EICAS. ConclusionsThe ADLH2 score is a valid risk score to identify high-risk EICAS individuals who need further investigation and treatment.

THE ROLE OF MULTIFOCAL ATHEROSCLEROSIS IN DEVELOPMENT OF UNFAVORABLE CARDIOVASCULAR OUTCOMES IN PATIENTS AFTER CORONARY BYPASS GRAFTING

Background: The number of disorders caused by atherosclerosis of various arterial tree is constantly increasing worldwide. Multifocal atherosclerosis (MFA) remains to be an important problem limiting effectiveness of coronary bypass grafting. Aim: To compare one-year rates of unfavorable cardiovascular events in patients, who underwent coronary bypass grafting, depending on the degree of non-coronary stenoses (stenoses of extracranial arteries and lower limb arteries). Materials and methods: Two hundred and thirty two patients, that underwent coronary bypass graft surgery in 2006 due to clinical manifest coronary atherosclerosis, were included into the study. Oneyear outcome (10–12 months) was assessed with the following endpoints: coronary and non-coronary death, myocardial infarction, stroke, angina pectoris and severe chronic heart failure (III–IV functional classes). One-year combined outcome after coronary bypass grafting was considered unfavorable if these events were registered. Results: After initial assessment, patients were divided into 2 groups depending on the degree of coronary atherosclerosis; thereafter, each group was subdivided into subgroups depending on presence or absence of MFA. Compared to patients without MFA, those with hemodynamically significant stenosis (≥ 50%) of non-coronary arteries had higher rates of unfavorable one-year outcomes (р = 0.001). They had higher rates of stroke (20% (5) and 5.8% (12) of patients, respectively, р = 0.03) and of recurrent angina (р = 0.001). Patients with hemodynamically non-significant stenoses (≥ 30%) also had significantly higher rates of unfavorable events, compared to patients without stenoses: myocardial infarction, in 12 (11%) and 3 (2%), respectively (p = 0.006), stroke, in 14 (13%) and 3 (2%) (p = 0.001). Eighty four (79%) patients with MFA had clinical manifestations of angina pectoris, whereas among those without MFA, only 23 (18%) of patients (p = 0.0001). Severe chronic heart failure was significantly more frequent in the MFA group, than in patients with isolated coronary atherosclerosis (38 (36%) and 21 (17%) patients, respectively, p = 0.002). In the MFA group, 10 (9%) patients died, while in the group without MFA there was one death (0.8%) (p = 0.003). Conclusion: Taking into account non-coronary stenoses of ≥ 30%, compared to only hemodynamically significant stenoses of ≥ 50%, produces more significant differences in clinical and historical characteristics of patients.

Abstract TP127: Prevalence and Clinical Significance of Asymptomatic Extracranial Vertebral Artery Disease in Patients With Symptomatic Internal Carotid Artery Stenosis: Analysis of Stent-protected Angioplasty versus Carotid Endarterectomy (SPACE) Trial

Background: Extracranial vertebral artery disease is seen in patients with internal carotid artery stenosis although the clinical significance not well understood. Methods: We analyzed data that was collected as part of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) trial which recruited patients with recently symptomatic internal carotid artery stenosis. We used Cox proportional hazards analysis to compare the relative risk of various endpoints between the three categories of extracranial vertebral artery disease (normal/hypoplastic, moderate/severe stenosis, and occlusion). The multivariate analyses were adjusted for age, gender, basic demographics and severity of carotid stenosis. Results: Of the 1181 subjects who had extracranial vertebral artery ultrasound evaluation, moderate to severe stenosis and occlusion of one of both extracranial vertebral arteries was diagnosed in 152(12.9%) and 57(4.8%) subjects, respectively. During the mean follow up period (±SD) of 22.1±7.1 months 102(8.6%) and 60(5.1%) experienced a stroke or died, respectively. Compared with subjects with normal or hypoplastic vertebral artery, there was a non-significant 30% higher risk of any stroke among subjects with moderate to severe vertebral artery stenosis (relative risk [RR]1.3, 95% confidence interval [CI]0.7-2.3) after adjusting for potential confounders. There was a 40% and 50% higher risk of ipsilateral stroke (RR 1.4, 95% CI0.7-2.5) and death (RR 1.5, 95% CI 0.7-3.1) among subjects with moderate to severe vertebral artery stenosis after adjusting for potential confounders. In Kaplan Meir analysis, the estimated 1 and 2 year stroke free survival for subjects with moderate to severe vertebral artery stenosis was 88% (standard error [SE]2.6%). In comparison, the estimated 1 and 2 year stroke free survival for subjects with normal or hypoplastic vertebral artery was 92.5%(SE0.8%)and 91.6%(SE0.9), respectively. Conclusions: There appears to be an increased risk of stroke and death in patients with symptomatic internal carotid artery stenosis with concurrent asymptomatic extracranial vertebral artery stenosis.

Distinguishable Distribution of Cerebral Artery Stenoses: Ultrasonographic Evidence from a North-East Chinese Cohort

Background: Cerebral artery stenosis is an important risk factor for ischemic strokes. Racial predilection with reference to stenosed artery distribution has been recognized. Intracranial artery stenosis was more frequently detected in Asians, blacks and hispanics with ischemic strokes. However, distribution of intraand extra-cranial artery stenosis with reference to age and sex has not been clarified. This study aims to explore intracranial and extracranial artery stenosis in a large northeast Chinese cohort by utilizing transcranial Doppler (TCD) and carotid duplex ultrasound. Methods: We recruited 14793 outpatients and hospitalized patients to identify artery stenosis distribution. Artery stenosis screening was done with TCD for intracranial arteries and carotid duplex ultrasound for extracranial arteries. Findings: More patients with intracranial than with extracranial artery stenoses were identified (4255 versus 2809, i.e. 28.8% versus 19.0%, P<0.05). Similarly, mere intracranial stenosis was significantly more common than extracranial artery stenosis in this cohort (2632 versus 1186, i.e. 17.8% versus 8%, P<0.05). Among all identified intracranial arteries stenoses, the proportion of middle cerebral artery (MCA) stenosis was the highest. More intracranial than extracranial artery stenoses was seen within each age group, and rates of both increased with age. Intracranial and/or extracranial artery stenosis was more frequently identified in males than females, and intracranial artery stenosis in both groups was respectively more common compared to extracranial stenosis. Interpretation: Incidence of cerebral artery stenosis in the population increases with age. Intracranial artery stenosis is more common than extracranial artery stenosis and the MCA stenosis accounted for the highest proportion among cerebral artery stenoses, within each age group. More males suffer from intracranial or extracranial artery stenosis than females.

The restoration of speech in patients with aphasia depending on the manifestations of carotid atherosclerosis in stroke

To study an effect of stenosing lesions of carotid arteries on the recovery of speech functions in acute stroke patients. Medical histories of 253 patients (median age 58 [52,63]) with acute left hemispheric ischemic and hemorrhagic stroke and motor or sensorimotor aphasia were analyzed. The severity of atherosclerotic lesion of brachiocephalic arteries was assessed using color duplex scanning. According to the results of duplex scanning, patients were divided into 3 groups: 1 - without stenosis of extracranial arteries; 2 - with ≤50% stenosis of carotid arteries; 3 - with >50% stenosis of carotid arteries. Stenosis greater than 50% (group 3) was a predictor of the poor recovery of speech function while stenosis less than 50% (groups 1 and 2) had no effect on the outcome. The severe atherosclerosis of carotid arteries had a negative effect on speech recovery in acute stroke patients.

Clinical usefulness of ankle brachial index and brachial-ankle pulse wave velocity in patients with ischemic stroke.

Ankle brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) are widely used noninvasive modalities to evaluate atherosclerosis. Recently, evidence has increased supporting the use of ABI and baPWV as markers of cerebrovascular disease. This study sought to examine the relationship between ABI and baPWV with ischemic stroke. This study also aimed to determine which pathogenic mechanism, large artery disease (LAD) or small vessel disease (SVD), is related to ABI or baPWV. Retrospectively, 121 patients with ischemic stroke and 38 subjects with no obvious ischemic stroke history were recruited. First, ABI and baPWV were compared between the groups. Then, within the stroke group, the relevance of ABI and baPWV with regard to SVD and LAD, which were classified by brain magnetic resonance image (MRI) and magnetic resonance angiography (MRA) or computed tomography angiography (CTA) findings, was assessed. The baPWV was higher in the stroke group than non-stroke group (1,944.18±416.6 cm/s vs. 1,749.76±669.6 cm/s, P<0.01). Regarding LAD, we found that mean ABI value was lower in the group with extracranial large artery stenosis (P<0.01), and there was an inverse linear correlation between ABI and the grade of extracranial large artery stenosis (P<0.01). For SVD, there was a significant correlation between SVD and baPWV (2,057.6±456.57 cm/s in the SVD (+) group vs. 1,491±271.62 cm/s in the SVD (-) group; P<0.01). However, the grade of abnormalities detected in SVD did not correlate linearly with baPWV. These findings show that baPWV is a reliable surrogate marker of ischemic stroke. Furthermore, baPWV and ABI can be used to indicate the presence of small vessel disease and large arterial disease, respectively.

Association between Serum Alkaline Phosphatase Level and Cerebral Small Vessel Disease.

BackgroundSerum 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).MethodsWe 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.ResultsSubjects 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.ConclusionsOur 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.