Silent Lacunar Infarcts Research Articles

Association of obesity and metabolic health status with cerebral small vessel disease in stroke-free individuals

Abstract Background It remains unclear whether obesity itself or metabolic abnormalities coexisting with obesity, are associated with stroke. Purpose We aimed to investigate the association of obesity and metabolic health status with cerebral small vessel disease (SVD) in stroke-free participants from a brain health check-up. Methods We conducted a cross-sectional study of 6088 stroke-free participants who underwent brain magnetic resonance imaging at a brain check-up between 2013 and 2020. Participants were categorised according to sex-specific waist circumference and metabolic health status. A metabolically healthy status was defined as the absence of components of metabolic syndrome other than a large waist circumference, such as high blood pressure, hyperglycaemia, and dyslipidaemia. The total SVD score was derived from four magnetic resonance imaging markers: silent lacunar infarcts, cerebral microbleeds, moderate-to-severe white matter hyperintensities, and enlarged perivascular spaces. Results The mean age of the participants was 55±12 years and 46% were women. The prevalence of metabolically healthy obesity was 650 (11%) and the proportion of metabolically healthy obesity among individuals with obesity was 24%. The prevalence of metabolically unhealthy obesity was 2043 (34%), and the proportion of metabolically unhealthy obesity among individuals with metabolically unhealthy individuals was 58%. The prevalence of moderate-to-severe SVD scores (≥2) was 348 (6%), which was higher in metabolically unhealthy individuals, regardless of obesity status. Compared with the metabolically healthy non-obesity group, the metabolically unhealthy non-obesity (odds ratio 2.22 [95% CI, 1.44–3.42]) and metabolically unhealthy obesity (odds ratio, 2.76 [95% CI, 1.80–4.24]) groups had a significantly higher multivariable-adjusted risk for a total SVD score of ≥2. Further sensitivity analyses using BMI-defined obesity instead of waist circumference-defined obesity yielded similar results. Conclusions Abdominal and general obesity alone are not associated with higher total SVD scores in stroke-free individuals. Unhealthy metabolic components, especially high blood pressure and hyperglycaemia, are important risk factors for SVD.

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

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). 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. 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. 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.

Exploring the Role of Insulin Resistance in Fueling Stroke Vulnerability and Worsening Post-stroke Prognosis: A Narrative Review of Current Literature.

Stroke remains one of the world's greatest causes of disability and death. Insulin resistance (IR) impairs insulin's beneficial effects on the brain and can change the course of illness in post-stroke patients. This review aims to find sufficient evidence to support the causal association of IR in ischemic stroke and with post-stroke prognosis (PSP). The review will also list probable mechanisms to better understand how IR affects stroke pathology. Various articles from PubMed Central, MEDLINE, and PubMed databases were reviewed, and then after careful consideration, 17 articles were selected. The studies, using various genetic and metabolic markers, have linked IR to increased incidence of ischemic stroke. Among the various types of strokes investigated from this standpoint, silent lacunar infarct stands out as a widely researched subtype. Even though the exact pathogenesis is still unclear, current evidence shows an interplay of atherosclerosis, embolism, and platelet dysfunction. The development of early neurological decline (END) in post-stroke patients has been used to link IR to poor PSP. It is also acknowledged to have contributed in some way to poor three-month outcomes. Modifying inflammatory pathways and developing glucotoxicity are some of the pathways by which IR affects PSP. After reviewing the studies, significant evidence was found to support the role of IR in causing ischemic stroke as well as in poor PSP. Additional investigation is required to assess its influence on three-month prognosis and its significance in various stroke subcategories.

Metabolic Syndrome: A Strange Companion of Atrial Fibrillation; A Blessing in Disguise from the Neuropsychiatric Point of View.

Background: The concept of metabolic syndrome (MetSy) brings together components that individually represent a risk factor for cardiovascular diseases, which over time can prove to be more harmful if a combined effect of these is exhibited. Method: A single-centre retrospective study in an academic medical unit was conducted. We analysed the link between the MetSy and the occurrence of neuropsychic complications among atrial fibrillation (AF) patients. We sifted through the files of the patients admitted during 2015-2016 to the Municipal Emergency University Hospital Timisoara, Romania, with the diagnosis of AF. We divided these AF patients into two groups: the first group comprised patients with atrial fibrillation and MetSy (267 patients), while the second group comprised AF patients without MetSy (843 patients). We analysed the occurrence of neuropsychic changes (stroke, Parkinson's disease, dementia, cognitive impairment, and silent lacunar infarction) among the two groups. Results: Cognitive impairment (p-value = 0.0081) and dementia (p-value < 0.0001) were less frequent in patients with AF and MetSy than in those with AF without MetSy. Regarding the presence of stroke and Parkinson's disease (PD), we could not demonstrate the existence of any statistically significant difference between the two groups. Using logistic regression (enter test), we found that MetSy might have a protective effect (OR = 0.4040, 95% CI [0.2132; 0.7654], p-value = 0.0054) for the occurrence of dementia in those patients. Furthermore, obesity was the only factor with a possible protective effect from all the constituents of the MetSy when analysed together (with a significance level of p-value = 0.0004 for the logistic regression). The protective effect of MetSy against stroke occurrence was supplementarily proven by a longer period of survival without stroke from the AF diagnosis (3.521 years, p = 0.0304) compared to patients with AF without MetSy (3.286 years to first stroke occurrence). Conclusions: Metabolic syndrome might offer protection against the occurrence of dementia among patients with AF, but no effect was noted when compared with the presence of stroke. Further studies on larger cohorts can help us reach a conclusion regarding the positive effects of the metabolic syndrome.

The Association between Pulmonary Function and Cerebral Small Vessel Diseases (S49.003)

<h3>Objective:</h3> This study investigated the association between pulmonary function(PFT) and cerebral small vessel diseases (SVD) in neurologically asymptomatic screening adults <h3>Background:</h3> SVD is considered as precursor lesions of many clinical outcomes including stroke. Pulmonary disease, such as chronic obstructive pulmonary disease is an independent risk factor of stroke. However, few studies have examined the association between pulmonary function and the presence of cerebral SVD in healthy adults. <h3>Design/Methods:</h3> We conducted a cross-sectional study of 3,096 neurologically asymptomatic adults (mean age 56.0±9.4; 1,690 men), who underwent screening health checkups including brain magnetic resonance imaging (MRI) and PFT (forced expiratory volume in the first second [FEV1] and forced vital capacity [FVC]) at the Seoul National University Hospital Health Promotion Center in Seoul, South Korea. Possible clinical risk factors for SVD, anthropometric parameters and clinical information were obtained from a structured questionnaire, interview by a family physician, measurement and blood samples in an at least 12-hour overnight fasting state. The presence of silent lacunar infarct (SLI), cerebral microbleeds (CMBs), and the volume of white matter hyperintensity (WMH) were assessed through axial MRI. Each subject’s PFT was conducted according to the recommendation by the American Thoracic Society guideline <h3>Results:</h3> SLI and CMBs were evident in 229 (7.4%) and 128 (4.1%) subjects, respectively. The mean volume of WMH was 2.7±6.7mm³. In multivariable logistic analysis, FVC had a significant negative correlation with the presence of SLI (adjusted odds ratio [aOR] 0.63, 95% confidence interval [CI] 0.45–0.88), and FEV1/FVC ratio was positively associated with the presence of SLI (aOR 1.03, 95% CI 1.00–1.05). The presence of CMBs and the volume of WMH were not associated with any factor of pulmonary function tests after adjustment. <h3>Conclusions:</h3> Lower pulmonary function, especially FVC and FEV1/FVC ratio, is an independent risk factor of SLI in neurologically healthy adults. <b>Disclosure:</b> Dr. Park has nothing to disclose. Mrs. MIN has nothing to disclose.

Abstract 131: Brain Mri Biomarkers Of Impaired Balance And Slow Walk Speed: Atherosclerosis Risk In Communities And UK Biobank Studies

Background and Objectives: Vascular brain injury (VBI) may contribute to imbalance and slow walk speed, but this is uncertain. We hypothesize that MRI biomarkers of VBI associate with impaired balance and slow walk speed. Methods: We performed separate, cross-sectional analyses in the Atherosclerosis Risk in Communities (ARIC) and UK Biobank (UKB) studies. Eligible participants had no prior clinical stroke and underwent a brain MRI and balance and walk speed ascertainment. MRI biomarkers of VBI analyzed were: ventricular volume, white matter hyperintensity volume (WMH), non-lacunar infarction, lacunar infarction, microhemorrhage in ARIC; ventricular volume, brain volume, WMH, fractional anisotropy (FA), mean diffusivity (MD), intra-cellular volume fraction, isotropic free water volume fraction in UKB. Quantitative biomarker levels were classified into tertiles, the unhealthiest tertile designated as the exposure. Our outcomes were poor balance and slow walk speed. We constructed multivariable logistic regression models to examine the associations between each MRI biomarker and the outcomes, adjusting for demographics and clinical history. Results: We included 1,626 ARIC participants (mean age 76.2 years; 23.4% impaired balance, 25.0% slow walk speed) and 40,098 UKB participants (mean age 55 years; 15.8% impaired balance, 2.8% slow walk speed). In ARIC, impaired balance was associated with 4 of 5 MRI measures of VBI in adjusted analysis (all p-values &lt;0.05). The strongest association was with WMH (OR 1.36; 95% C.I. 1.04-1.76). Slow walk speed in ARIC was significantly associated with 4 of 5 MRI measures; the strongest association was with silent lacunar infarcts (OR 2.17; 95% C.I. 1.61-2.93). In UKB, poor balance was associated with all MRI biomarkers except WMH. The strongest association was with FA (OR 1.16; 95% C.I. 1.08-1.24). Slow walking speed was associated with WMH, FA, and MD. The strongest association was with FA (OR 1.42; 95% C.I. 1.21-1.67). Conclusions: We demonstrate that MRI measures of VBI are independently associated with impaired balance and slow walk speed in two studies of community-dwelling adults with no history of clinical stroke. Consequences of VBI may extend beyond clinically apparent stroke to also include mobility.

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

Previous studies have proposed the estimated pulse wave velocity (ePWV) as a simple and cost-effective measure of arterial stiffness. Since arterial stiffness plays a role in the progression of silent lacunar infarct (SLI), our present work aims to evaluate the association between ePWV and the presence of SLI. The present work was based on a cross-section study. Our study included 1,011 neurologically healthy Korean participants. The SLI was evaluated using brain magnetic resonance images (MRI). The ePWV was derived from a published equation using age and mean blood pressure (MBP). Logistic regression analyses were performed to investigate the association between ePWV and SLI. The linear relationship and robustness were evaluated using smooth curve fitting and subgroup analyses, respectively. The prevalence of SLI was 11.87%. After fully adjusting for covariates, per 1 m/s increase of ePWV casted 31% additional risk for SLI (P = 0.009). When dividing the ePWV into quartiles, the top quartile had 4.01 times risk compared with the bottom quartile. The increasing trend across the quartiles was statistically significant (P for trend < 0.001). Consistently, smooth curve fitting revealed that the risk of SLI elevated linearly with the increase of ePWV. Finally, subgroup analysis suggested that the association was robust in several sub-populations divided by age, sex, smoking, hypertension, diabetes mellitus (DM), coronary artery occlusive disease (CAOD), hyperlipidemia, and statin medication (all P for interaction > 0.05). The current study revealed an independent and positive association between ePWV and the presence of SLI in a neurologically healthy Korean population.

PS-BPP03-6: HIGHER ARTERIAL STIFFNESS IS ASSOCIATED WITH SILENT CEREBRAL SMALL VESSEL DISEASE IRRESPECTIVE OF BLOOD PRESSURE

Objectives: Arterial stiffness and hypertension are important risk factors for cerebral small vessel diseases (CSVD). Arterial stiffness assessed by pulse wave velocity (PWV) is closely related with hypertension. Higher PWV represents an organ damage from hypertension. However, there are hypertensive patients with lower PWV and non-hypertensive subjects with higher PWV in clinical practice. The aim of the study is to determine the impact of PWV on CSVD in non-hypertensive and hypertensive individuals. Design and method: An observational cross-sectional study was conducted in 1894 stroke-free participants who underwent a brain magnetic resonance imaging and brachial-ankle PWV (baPWV) at a health checkup between 2013 and 2020. baPWV were measured using an automatic oscillometric device. The presence of CSVD, including white matter hyperintensities, cerebral microbleeds, silent lacunar infarcts, and dilated periventricular spaces, were determined by brain magnetic resonance imaging. Participants were divided into 4 groups according to blood pressure (BP, 120/80 mmHg) and baPWV (14.63 m/s, a cutoff value that predicted the presence of CSVD). Results: The mean age was 57 years (41% women). The prevalence of CSVD was 718 (38%), and it was higher in low BP with high baPWV group (56%) and high BP with high baPWV group (55%) compared to high BP with low baPWV group (24%) and low BP with low baPWV group (22%). Both low BP with high baPWV group (odds ratio 1.89; 95% CI, 1.00–3.56) and high BP with high baPWV group (odds ratio 2.12; 95% CI, 1.41–3.21), but not high BP with low baPWV group (odds ratio 1.19, 95% CI 0.76–1.86), had significantly higher odds ratio for the presence of CSVD compared with low BP with low baPWV group, after adjustment for age, sex, and other conventional risk factors, and use of any agents for hypertension, dyslipidemia, and diabetes. Conclusions: Individuals with high baPWV had higher prevalence of CSVD, irrespective of BP status. It is likely that higher arterial stiffness is an important risk for CSVD in stroke-free healthy populations.

Annual exposure to PM10 is related to cerebral small vessel disease in general adult population

Ambient air pollution is one of the most important global health issues. Although several studies have been reported the associations between air pollution and brain function or structure, impact of the air pollution on cerebral small vessel disease (cSVD) have rarely been explored in Asian adult population. We evaluated the association between exposure to air pollutants and cSVD in Korean asymptomatic adults. This cross-sectional study included 3257 participants of a health screening program from January 2006 to December 2013. All participants performed brain magnetic resonance imaging. To assess the cSVD, we considered three features such as white matter hyperintensities (WMH), silent lacunar infarction (SLI), and cerebral microbleeds (CMBs). The annual average exposure to air pollutants [particulate matter ≤ 10 μm in aerodynamic diameter (PM10), nitrogen dioxide (NO2), sulfur dioxide (SO2), and carbon monoxide (CO)] was generated. The mean [standard deviation (SD)] age of the total 3257 participants was 56.5 (9.5) years, and 54.0% of them were male. Among all the included participants, 273 (8.4%) had SLI and 135 (4.1%) had CMBs. The mean volume (± SD) of WMH was 2.72 ± 6.57 mL. In result of linear regression analysis, the volume of WMH was associated with various potential factors including age, height, weight, smoking and alcohol consumption status, blood pressure (BP), hypertension, and diabetes mellitus. SLI-positive group, compared to the SLI-negative group, was older, shorter, and had higher BP as well as higher frequency of hypertension and diabetes mellitus. After adjusting for covariates, the annual average concentration of PM10 was significantly associated with the volume of WMH [β (95% CI) for Model 1 = 0.082 (0.038- 0.125), p < 0.001; β (95% CI) for Model 2 = 0.060 (0.013, 0.107), p = 0.013]. CMBs were not associated with the annual average concentration of PM10. No significant associations of NO2, SO2, and CO with cSVD were observed. In conclusion, PM10 exposure is associated with significant increases in brain WMH’ volume and silent lacunar infarcts in asymptomatic adults.

Total Burden of Cerebral Small Vessel Disease on MRI May Predict Cognitive Impairment in Parkinson's Disease.

(1) Objective: to investigate the association between the total burden of cerebral small vessel disease (CSVD) and cognitive function in Parkinson’s disease (PD). (2) Methods: this retrospective study compared clinical and neuroimaging characteristics of 122 PD patients to determine the association between cognitive decline and total burden of CSVD in PD. All patients underwent brain MRI examinations, and their total CSVD burden scores were evaluated by silent lacunar infarction (SLI), cerebral microbleeds (CMB), white matter hyperintensities (WMH), and enlarged perivascular spaces (EPVS). The cognitive function was assessed by administering Mini-Mental State Examination (MMSE). Receiver-operating characteristic (ROC) curve and the area under the ROC curve (AUC) were performed to quantify the accuracy of the total burden of CSVD and PVH in discriminating PD patients with or without cognitive impairment. (3) Results: the PD patients with cognitive impairment had a significantly higher SLI, CMB, periventricular hyperintensities (PVH), deep white matter hyperintensities (DWMH), enlarged perivascular spaces of basal ganglia (BG-EPVS), and the total CSVD score compared with no cognitive impairment. Total CSVD score and MMSE had a significant negative correlation (r = −0. 483). Furthermore, total burden of CSVD and PVH were the independent risk factors of cognitive impairment in PD, and their good accuracy in discriminating PD patients with cognitive impairment from those with no cognitive impairment was confirmed by the results of ROC curves. (4) Conclusions: total burden of CSVD tightly linked to cognitive impairment in PD patients. The total burden of CSVD or PVH may predict the cognitive impairment in PD.

Diagnostic accuracy of major stroke types in Chinese adults: A clinical adjudication study involving 40,000 stroke cases

SummaryBackgroundWidespread use of brain imaging in suspected stroke cases in Chinese adults has prompted the need for clinical adjudication studies of stroke types. We conducted a clinical adjudication study to assess the reporting and diagnostic accuracy of major stroke types.MethodsThe prospective China Kadoorie Biobank recruited >512,000 adults (mean age 52 years, 59% women) from 10 urban and rural areas in China during 2004–2008, and recorded 45,859 first-ever incident stroke cases during an 11-year follow-up. Medical records were retrieved in ∼85%, and clinical details were recorded using a handheld computer for specialist physician adjudicators who applied conventional WHO clinical criteria for diagnosis of stroke. The positive predictive value (PPV) for reported and adjudicated stroke cases was examined for major stroke types (ischaemic stroke [IS], intracerebral haemorrhage [ICH], subarachnoid haemorrhage [SAH]), calendar year, area, and hospital type.FindingsOf 38,823 cases with retrieved medical records, the PPV for reported strokes was 91%. Among 29,952 adjudicated cases, the PPV for adjudicated cases was 81%, with higher PPV for ICH (n = 3391; 98%) and SAH (364; 98%) than for IS (20,473; 79%). Of 5504 cases with a verified IS diagnosis that was refuted on adjudication, 3763 (68%) had silent lacunar infarcts (LACI). The proportion of cases with silent LACI increased from 7.1% in 2004–2008 to 18.2% in 2016–2017. If cases with silent LACI were classified as IS, as advocated by new International Classification of Diseases (ICD-11) diagnostic criteria for stroke involving imaging and clinical rather than clinical criteria alone, the PPV increased to 93%.InterpretationWhile the overall reporting and diagnostic accuracy of stroke types in Chinese adults is high, the recent implementation of new diagnostic criteria for IS has important implications for contemporary clinical practice and research on stroke in Chinese populations.FundingKadoorie Charitable Foundation, Hong Kong, China, UK Wellcome Trust (212946/Z/18/Z, 202922/Z/16/Z, 104085/Z/14/Z, 088158/Z/09/Z), Chinese National Natural Science Foundation (91843302), and the National Key Research and Development Program of China (2016YFC0900500, 2016YFC0900501, 2016YFC0900504, 2016YFC1303904). British Heart Foundation, and UK Medical Research Council, and Cancer Research UK.

Hospital management of major stroke types in Chinese adults: a population-based study of 20 000 hospitalised stroke cases

ObjectivesTo compare hospital treatments for major stroke types in Chinese adults by stroke pathological types, sex, age, calendar year, hospital tier, region and other factors.DesignCross-sectional analysis of medical records retrieved...

Insulin resistance and muscle weakness are synergistic risk factors for silent lacunar infarcts: the Bunkyo Health Study

Insulin resistance and muscle weakness are risk factors for silent lacunar infarcts (SLI), but it is unclear whether they are still independent risk factors when adjusted for each other. In addition, the effect of their combination on SLI is completely unknown. We evaluated SLI, insulin sensitivity, and knee extensor muscle strength by magnetic resonance imaging, PREDIM, and dynamometer, respectively, in 1531 elderly people aged 65–84 years living in an urban area of Tokyo. Among the study subjects, 251 (16.4%) had SLI. Impaired insulin sensitivity (High; 1.00 [reference], Medium; 1.53 [95% confidence interval (CI) 0.94–2.48], Low; 1.86 [1.02–3.39], p for trend 0.047) and reduced muscle strength (High; 1.00 [reference], Medium; 1.40 [0.98–2.02], Low; 1.49 [1.04–2.15], p for trend 0.037) were independently associated with increased risk for SLI in the fully adjusted model. In terms of combined, subjects classified as having the lowest insulin sensitivity and lowest strength were 4.33 times (95% CI 1.64–11.45) more likely to have a SLI than those classified as having the highest insulin sensitivity and highest strength. Impaired insulin sensitivity and reduced muscle strength were independently associated with higher risk of SLI in elderly subjects, and their combination synergistically increased this risk.

Natural history of silent lacunar infarction: 10-year follow-up of a community-based prospective study of 0.5 million Chinese adults

BackgroundWidespread use of brain imaging in China has resulted in an increased prevalence of silent lacunar infarct (LACI) in addition to symptomatic LACI, but their clinical relevance is not fully understood. MethodsWe compared the 5-year risks of recurrent stroke and all-cause mortality for silent LACI vs symptomatic LACI in a prospective study of 489,597 Chinese adults with no history of stroke or ischemic heart disease at baseline. Data on recurrent stroke and all-cause mortality were obtained by linkage with local stroke and mortality registries and health insurance records for all hospital admissions. FindingsAmong 12,150 cases with an adjudicated diagnosis of first-ever LACI, 4,134 (34%) had silent LACI and 8,016 (66%) had symptomatic LACI. All cases had brain imaging, but only 33% of silent LACI and 40% of symptomatic LACI cases had brain magnetic resonance imaging (MRI). The standardized event rates for silent LACI were 2-fold greater in urban than rural areas, but the ratios of silent LACI vs symptomatic LACI were similar in all areas. Cases with silent LACI vs symptomatic LACI had comparable 5-year risks of recurrent stroke (38% vs 43%) and all-cause mortality (11% vs 14%), respectively. For both silent and symptomatic LACI cases, most cases of recurrent stroke had non-LACI (70% vs 72%). While the relative risks of recurrent stroke did not differ by age, sex and area, the absolute risks of all-cause mortality varied by sex, age and area. InterpretationThe prognosis of cases with silent LACI was comparable with symptomatic LACI, and the results highlight the need for further randomized trials assessing the efficacy and safety of established treatments for ischemic stroke in cases with silent LACI. FundingWellcome Trust (212946/Z/18/Z, 202922/Z/16/Z, 104085/Z/14/Z, 088158/Z/09/Z) and National Key Research and Development Program of China (2016YFC0900500, 2016YFC0900501, 2016YFC0900504, 2016YFC1303904) and National Natural Science Foundation of China (91843302); UK Medical Research Council (MC_UU_00017/1,MC_UU_12026/2 MC_U137686851), Cancer Research UK (C16077/A29186; C500/A16896) and British Heart Foundation (CH/1996001/9454). ZH was supported West China Hospital, Sichuan University (ZYGD18009 and 2016YFC1300505) for a visiting scholarship to the University of Oxford, UK, during 2018-19.

Management tactics in patients with chronic cerebral ischemia during COVID-19 pandemic

The article describes the current state of evidence of hypertension and diabetes mellitus roles in the pathophysiology of chronic cerebral ischemia (CCI). CCI is mediated by cerebral microangiopathy, which develops due to vascular remodeling, increased arterial stiffness, endothelial dysfunction, impaired cerebrovascular reactivity, and neuroinflammation. All those mechanisms lead to white matter lesions and cognitive impairment. Arteriolosclerosis is the primary morphological process that damages perforating arteries and arterioles. COVID-19 pandemic can modify CCI progression due to similar pathophysiology. In particular, COVID-19-associated coagulopathy can lead to silent lacunar infarctions and lacunar stroke development. Treatment features of patients with CCI during the COVID-19 pandemic are reviewed. It is concluded that special attention in this group of patients should be paid to primary and secondary cardiovascular prevention issues, an essential element of which is the use of dipyridamole since it has a pleiotropic effect.

Triglyceride/HDL-Cholesterol Ratio as an Index of Intracranial Atherosclerosis in Nonstroke Individuals.

Background: Triglyceride (TG)/high-density lipoprotein cholesterol ratio (THR) is a marker of dyslipidemia, and high THR is associated with an increase in cardiovascular events. In the present study, whether THR was associated with various markers of cerebral vascular pathologies, atherosclerosis of major cerebral arteries, including large artery atherosclerosis (LAA) and cerebral small vessel disease (SVD), in neurologically healthy individuals was investigated.Methods: Vascular risk factors, brain magnetic resonance imaging (MRI) scans, and MR angiograms of 851 study subjects were evaluated. Findings of extracranial atherosclerosis (ECAS) and intracranial atherosclerosis (ICAS) were considered indices of LAA based on brain MR angiograms. The presence of silent lacunar infarct (SLI) and white matter hyperintensities (WMHs) were evaluated as indices of SVD based on brain MRIs.Results: Subjects with ICAS (odds ratio, 1.83; 95% confidence interval, 1.06–3.16; P = 0.03) were significantly more likely to have high THR tertile (THR > 2.06) than low THR tertile (THR < 1.37) after adjusting for cardiovascular risk factors. THR was higher in subjects with multiple ICAS lesions than in those with single ECAS or without ICAS lesions. Associations among THR tertiles in ECAS, SLI, and WMHs were not significant.Conclusion: In the present study, a positive association between high THR and the development of ICAS was observed in neurologically healthy participants.

Cerebral magnetic resonance imaging of coincidental infarction and small vessel disease in retinal artery occlusion

There are several reports in the literature on the association between non-arteritic retinal artery occlusion (NA-RAO) and acute ischemic stroke. We investigated the burden of small vessel disease (SVD) and cerebral coincident infarction observed on cerebral magnetic resonance imaging (MRI) in patients with newly diagnosed NA-RAO. In this retrospective, observational, case-series study, consecutive patients with NA-RAO who underwent cerebral MRI within one month of diagnosis between September 2003 and October 2018 were included. The classification of NA-RAO was based on ophthalmologic and systemic examinations. We also investigated the co-incident infarction and burden of underlying SVD, which were categorized as white matter hyperintensity lesion (WMH), cerebral microbleeds (CMB), and silent lacunar infarction (SLI). Among the 272 patients enrolled in the study, 18% presented co-incident infarction and 73% had SVD, which included WMH (70%), CMB (14%), and SLI (30%). Co-incident infarction, WMH, and SLI significantly increased with age: co-incident infarction was observed in 8% of young (< 50 years) patients and 30% of old (≥ 70 years) patients. The embolic etiology of RAO (large artery atherosclerosis, cardioembolism, and undetermined etiology) was significantly associated with the prevalence of SVD (82%: 70%: 64%, P = 0.002) and co-incident infarction (30%: 19%: 8%; P = 0.009). Therefore, high co-incidence of acute cerebral infarction and underlying SVD burden warrant careful neurologic examination and appropriate brain imaging, followed by management of NA-RAO. Urgent brain imaging is particularly pertinent in elderly patients with NA-RAO.

Blood Neutrophil/Lymphocyte Ratio Is Associated With Cerebral Large-Artery Atherosclerosis but Not With Cerebral Small-Vessel Disease

Background and Objective: The blood neutrophil/lymphocyte ratio (NLR) is a marker of peripheral inflammation, with a high NLR associated with an increased risk of cardiovascular events and poor prognosis in ischemic stroke. However, few data are available on the differential impact of the blood NLR on different silent cerebral vascular pathologies, including cerebral large-artery atherosclerosis (LAA) and cerebral small-vessel disease (CSVD), in neurologically healthy individuals.Methods: We evaluated cardiovascular risk factors, brain magnetic resonance imaging (MRI), and MR angiography of 950 individuals without any neurological diseases. The study participants were divided into three groups according to NLR tertile (low, middle, and high). The presences of extracranial (EC) and intracranial (IC) atherosclerosis were considered to indicate LAA on brain MR angiography. The presences of silent lacunar infarction (SLI) and cerebral white matter hyperintensities (WMHs) were analyzed as indices of CSVD on brain MRI.Results: In univariate analysis, the high NLR tertile group showed a high prevalence of old age, hyperlipidemia, and renal dysfunction and higher fasting glucose. Multivariable logistic regression analysis revealed that indices of LAA (EC atherosclerosis [odds ratio: 1.88; 95% confidence interval: 1.14–3.09; p = 0.01] and IC atherosclerosis [odds ratio: 1.87; 95% confidence interval: 1.15–3.06; p = 0.01]) were more prevalent in the highest NLR tertile group than in the lowest NLR tertile group after adjustment for cardiovascular risk factors. However, no significant differences were found in the prevalence of CSVD indices (SLI and WMHs) among the three NLR tertile groups.Conclusions: A high NLR is associated with the development of cerebral LAA but not CSVD.

Noninvasive model for predicting future ischemic strokes in patients with silent lacunar infarction using radiomics

BackgroundThis study aimed to investigate integrating radiomics with clinical factors in cranial computed tomography (CT) to predict ischemic strokes in patients with silent lacunar infarction (SLI).MethodsRadiomic features were extracted from baseline cranial CT images of patients with SLI. A least absolute shrinkage and selection operator (LASSO)–Cox regression analysis was used to select significant prognostic factors based on ModelC with clinical factors, ModelR with radiomic features, and ModelCR with both factors. The Kaplan–Meier method was used to compare stroke-free survival probabilities. A nomogram and a calibration curve were used for further evaluation.ResultsRadiomic signature (p < 0.01), age (p = 0.09), dyslipidemia (p = 0.03), and multiple infarctions (p = 0.02) were independently associated with future ischemic strokes. ModelCR had the best accuracy with 6-, 12-, and 18-month areas under the curve of 0.84, 0.81, and 0.79 for the training cohort and 0.79, 0.88, and 0.75 for the validation cohort, respectively. Patients with a ModelCR score < 0.17 had higher probabilities of stroke-free survival. The prognostic nomogram and calibration curves of the training and validation cohorts showed acceptable discrimination and calibration capabilities (concordance index [95% confidence interval]: 0.7864 [0.70–0.86]; 0.7140 [0.59–0.83], respectively).ConclusionsRadiomic analysis based on baseline CT images may provide a novel approach for predicting future ischemic strokes in patients with SLI. Older patients and those with dyslipidemia or multiple infarctions are at higher risk for ischemic stroke and require close monitoring and intensive intervention.

PM Association Between Silent Lacunar Infarcts And Muscle Strength: The Bunkyo Health Study

Silent lacunar infarcts by definition, lack clinically overt stroke-like symptom, are occasionally found by brain magnetic resonance imaging (MRI) scan in asymptomatic elderly individuals. A previous study revealed that more than 25% of elderly people have silent lacunar infarcts. The main risk factors for lacunar infarcts and stroke were reported as aging, hypertension, and smoking. While a recent study showed that low muscle strength is also a risk factor for cerebrovascular events, it remains unclear whether low muscle strength is a risk factor for silent lacunar infarcts. PURPOSE: To investigate the association between muscle strength and silent lacunar infarcts in the elderly people living in urban community. METHODS: This study included 1,536 elderly people without past history of cerebral vascular events, aged 65-84 years living in an urban area of Tokyo, Japan (Bunkyo Health Study). All participants underwent brain MRI scan and silent lacunar infarcts were defined as the presence of 1 or more lacunar infarcts. Isokinetic muscle strength of knee extensors was evaluated at angular velocity of 60 degree per seconds using dynamometer. Subjects was categorized tertiles (high, medium, and low) by muscle strength, and compared the prevalence of silent lacunar infarcts. RESULTS: Mean age of subjects was 73.0±5.4 years old and 58.9% were female. Two hundred fifty-two (16.4%) subjects were diagnosed as silent lacunar infarcts, and the subjects categorized as lower muscle strength showed higher prevalence of silent lacunar infarcts (high: 12.3%, medium: 17.7%, and low: 19.3%, p for trend 0.003), while skeletal muscle indices among the groups were similar. After multivariate adjustment by age, sex, body mass index, smoking status, physical activity, hypertension, diabetes, and dyslipidemia, the trend was still significant and the odds ratio for having silent lacunar infarcts was significantly higher in the lowest muscle strength tertile compared to the highest tertile [(High: 1.00 (reference), medium: 1.42 (95%CI: 0.98-2.04), Low: 1.48 (1.02-2.14), p for trend 0.043]. CONCLUSIONS: In the elderly people living in urban community, lower muscle strength of knee extensors was associated with higher prevalence of silent lacunar infarcts independent of other established risk factors.